Pediatric Gastrointestinal Disorders
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| Unique Characteristics of Digestive System of Children | Decreased emptying time (stomach emptiesa lot quicker in 2.5-3 hrs), Small stomach capacity (holds 10-20mls), Immature relaxed lower esophageal spincter (LES) (spit up reason), Low acidity level (gradully rises in childhood, normal at 6 yrs)
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| Etiology/Risk Factors for short bowel syndrome? What are the common causes of it? | Short Bowel Syndrome is a Malabsorptive Disorder, Common causes- NEC Necrotizing enterocolitis (occurs in premies), intestinal obstructions, & Crohn disease
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| Therapeutic mgt of sort bowel syndrome | Preserving bowel, Nutrition, Stimulate intestinal adaptation (Entral feeding + cath), Minimize complications
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| 3 ____ syndrome nursing interventions; administration and monitoring of nutritional therapy, prepare family for home therapy and developmental and emotional stimulation are | short bowel syndrome
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| adverse effects of long term TPN | liver failure 6 mo, expensive, may not take bottle when done (use pacifier), intenstine cells atrophy and die; central line
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| ____ is when an infant is born without anus, some more ovious than others, put a ____few cm up rectum to make sure ok. | anorectal malformation; Cathether
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| VATER syndrome is associated with imperforated anus, what does VATER stand for? sometimes they add a C. What does the C stand for? | Vertebral(check spine), Anal rectal defect, TE trachealesophigeal fistula, Renal defect or Radius bone missing; C = Cardiac
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| 4 diagnostic studies to determine imperforated anus: | invertogram (inject dye into anal opening to see level of obstruction), ultrasound (need air so wait 24hrs after birth), cardiac evaluation, spinal films
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| imperforate anus therapeutic mgt includes an IV, Possibly a ___, Pt will be NPO for the ____ which include anal dilations and divided sigmoid colostomy and posterior sagittal anorectoplasty | Imperforate anus therapeutic mgmnt includes an IV, Possibly a NG tube, pt will be NPO for the anoplasty
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| position pt in post operative imperforate anus | side-lying prone position with hips elevated so stool is away from surgical site. use sandbags to support
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| A high/intermediate lesion of imperorate anus will include operation for a tempoary ___ | colostomy
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| ____ inflammation or injury to bile ducts>fibrosis>obstruction occurs> impaireddigestion fats> accumulation ___& ___>progress intrahepatic ducts>leads to ___ of the liver | biliary atresia Inflammation or injury to bile ducts>fibrosis>obstruction occurs>impaired digestion fats> accumulation bile in ducts & gallbladder> progressess intrahepatic ducts> leads to Cirrhosis of the liver
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| In biliary atresia the ducts are ____ which causes impaired digestion of fats and accumulation of bile in ducts and gallbladder | obstruction
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| biliary aresia causes fibrosis of the ____ | liver
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| T/F biliary atresia is acquired | False, it is congenital, tetratogenic factors include radiation, drugs, ischemia, and viruses; 15% have associated defects-GI narrowing in the valve of congential heart disease
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| With ____ the infant is normal at birth then presents with jaundice beyond 1 week (10-14 days usually) | biliary atresia
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| With biliary atresia the appearance of skin is greenish bronze as ____ increases | bilirubin
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| stolls became ____ colored and urine ____ within a few weeks after birth of an infant with biliary atresia | clay colored stools and dark urine You WILL NOT see this at birth
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| How long will the liver fail or go into End stage liver failure without surgery of an infant with biliry atresia | 2-3 months
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| ____ is the surgical procedure for biliary atresia which includes dissection and resection of the extrahepatic bile duct within the first ___wks of life had has an 80-90% success rate | Kasai procedure; 10 wks IF not done within the first 10 weeks they will need a hepatic transplant
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| pt with biliary atresia; monitor VS carefully especially ____, look for bleeding tendencies due to liver failure; before surgery you have an active role in diagnosis & treatment | blood pressure
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| pt with biliary atresia; monitor nutritional requirements b/c pt needs _____ more calories, watch for abdominal distention, can affect breathing | one and a half more calories
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| What is the most common craniofacial malformation? Highest incidence in ___ lowest in ___? | cleft lip and cleft palate, highest in japanese and lowest in african americans
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| cleft lip and cleft palate are ____ and ___ ? | genetic-increase incidence in relatives and environmental
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| maternal smoking in 1st trimester is associated with ____ | cleft lip & cleft palate
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| Which position of cleft lip is rare? | midline
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| T/F cleft palate can occure without cleft lip | True
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| T/F clef lip closure is done early to help the infant feed. What is the age for a CL closure? | False it is done early to promote bonding. CL closure at 6 weeks to 4 months of age
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| cleft palate surgical repair is done between 12 - 18 months because: | before child develops faulty speech habits and the palate has more tissue after 12 months.
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| Major nursing intervention for parents with a child born with cleft lip and cleft palate is ____ support | psychosocial
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| cleft lip and cleft palate feeding technique is ESSR method, what does ESSR stand for? Can mom breast feed? | Enlarge nipple, Stimulate such reflex, Swallow fluid appropriately, Rest facial expressions. Mom can possibly breast feed
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| post op care of cleft lip feeding include using what type of instuments to feed | small paper cup, syringe with soft rubber tubing, or lg scoop spoon
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| post op care of cleft lip positioning / restraints include | supine position only (prone for cleft palate post op) and use elbow restraints to avoid bending arms for 4-6 wks (take off every 2 hrs to exercise elbows)and a older child may require a jacket restriant.
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| post op care of cleft lip wound care include | maintain logan's bow over suture line, cleanse any drainage or formula with 1/2 strength H2O2 and rince with saline, & thin layer of antibiotic ointment
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| post op care of cleft palate position and restraints | prone to prevent secretions collecting, observe for respiratory distress (supine for cleft lip) elbow restraints for 4-6 wks. paking is in for 2-3 days (IV fluids given as well)
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| ____ is when the trachea and esosophagus fail to develop seperately | tracheoesophageal fistula
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| therapeutic management of T-E fistula includes gastric or blind ____ decompression | pouch
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| over ____% of T-E fistula pt get GERD after the pulled smaller esophagus after surgery | over 50%
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| ____ is a state of inadequate growth from inability to obtain and or use calories required for growth, it is a symptom - not a diagnosis | Failure to Thrive (FTT)
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| below ___ percentile for age on growth chart is a characterisitc of ____ | 3-5% Failure to Thrive
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| ____ is a catagory of failure to thrive where there is a problem with a body system that increases the need for calories. What test will you need to do to rule out things? | Organic failure to thrive (OFTT) - first do chloride test to R/O cystic fibrosis
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| ____ is a catagory of failure to thrive that includes neglect or lack of knowledge | Nonorganic failure to thrive (NFFT)
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| nursing intervention for failure to thrive include | daily weight with I&O and kcal count, diet high in calories & protein with unlimited feedings, promote positive feeding interaction and promote proper parenting
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| guidelines to promote a positive feeding interaction for pt with failure to thrive | consistent non-stimulating environment, firm but calm schedule, stay with child, consistent care givers and don't force to eat.
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| Hypertrophic pyloric stenosis (HPS)develops when | first few weeks of life
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| grossly enlarged circular muscle of pylorus (severe narrowing pyloric canal) causes | hypertropic pyloric stenosis (HPS)
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| With hypertrophic pyloric stenosis (HPS), overtime inflammation developes, then ____ | obstruction
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| palpable olive-shaped tumor | hypertrophic pyloric stenosis (HPS)
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| hypertrophic pyloric stenosis causes gastric ____, constipation, dehydration and metabolic ____ | gastric peristalsis, constipation, dehydration, metrabolic alkalosis with the palpable olive-shaped tumor
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| To confirm hypertrophic pyloric stenosis, a ____ study is done | barium study
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| Which electrolytes will be up and which ones down with hypertrophic pyloric stenosis (HPS) | Na, K, and Cl down and bicarbonate up - due to loss of gastric secretions and dehydration; Increased pH
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| Need to correct ___ before operation with hypertrophic pyloric stenosis | fluid and electrolytes
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| Surgery to dividing the muscle of the pylorus to open up the gastric outlet to correct hypertrophic pyloric stenosis | pyloromyotomy
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| How long after pyloromyotomy surgery do you want to feed an infant? | 6 hrs, then every 2 hrs, start with clear then 1/2 strength and so on. If vomit go back to previous step prior to vomiting.
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| ____ a malabsorption disorder where there is an intolerance of the protein gluten | celiac disease
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| Patients with celiac disease must avoid the gluten protein what 4 natural items contain gluten? | wheat, barley, rye and oats
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| What does the protein gluten do to the villi in the intestine | damage or destroy
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| T/F celiac disease is inherited | True its rare in Asians or African Americans
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| Early manifestations of celiac disease | stools - frothy & foul odor, growth failure, muscle wasting, distended abdomen, and anemia
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| Late manifestations of celiac disease | failure to thrive, diarrhea, constipation, abdominal pain, vomiting, behavioral changes, dental enamel defects
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| Diagnosis of celiac disease includes a ____ biopsy | jejunum or jejunal biopsy to see if villi is damaged or destroyed; Sometimes a withdrawal of gluten from diet
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| Tx for celiac disease | lifelong gluten free diet. Be sure to look for hidden sources like cheese, salad dressing, some cold cut meat,ketcup, ice cream...
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| T/F manifestations of celiac disease is always present during infancy | False - may go undiagnosed for years
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| nursing intervention of celiac disease includes stressing ___ compliactions | long-range
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| ____ is invagination or telescoping of one portion of the intestine into another | intussusception
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| most frequent cause of intestinal obstruction in children 3mo to 5 yrs | intussusception
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| ____ diverticulum can cause intussusception | Meckel's Diverticulum
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| initial assessment of intussesception includes acute ___ pain, ____ shaped mass in upper right quandrant with ____ stools | acute colickly abdominal pain, sausage shaped mass in URQ and normal stool
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| Later assessment of intussesception includes classic ____ stool, abdomen tender and ____ | classic currant jelly-like stool, abdomen tender and distended.
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| If intussusception is not treated may develope ____ and signs of ____ | fever and signs of PERITONITIS!!!! Chronic picture may occur with diarrhea, anorexia, wt loss, occasional vomiting and periodic pain.
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| diagnostic studies of intussusception include: abdominal radiograph and or ____ will show mass, X-ray looking for ____ escaping perforation and ____ enema | abdominal radiograph and or ultrasound. X-ray looking for air escapng perforation and barium enema
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| T/F intussusception can spontaneous reduce | True - 10% do
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| upon examining stools of an intussusception pt, they are narrow and ____ like with ____ mucus | narrow and ribbon like with bloody mucus.
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| nursing intervention for intussusception includes monitor for sign of complete ____ & perforation | obstruction
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| ____ congenital abnormality - absence of parasympathetic ganglion cells | Hischsprung's disease
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| Hirschsprung's disease affects mostly the ____ colon, stool goes to that area and stops and that area expands | distal
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| Hirschsprung's disease is usualy diagnosed as an ____ with abdominal distention, bilious vomiting (bile, not fresh milk), and constipation | Infant
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| Manifestation of newborn Hirchsprung's disease is delayed passage of ____ | meconium
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| An older child with Hirschsprung's disease will have progressive constipation ___ stools and presence of palpable fecal mass | ribbonlike stools
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| How is Hirschsprung's diagnosed | rectal biopsy and or anorectal manometer
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| Management of Hirschsprung's includes stabalization then tempoary ____. | colostomy - eventually anastomosis of proximal and distal ends of intestines
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| ___ is a normal problem due to immature sphincter | GER (infants will spit up for a few days then stop up to 30% have this - if it doesn't resolve then it becomes a disorder GERD
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| GER is an inappropriate ____ of the lower esophageal spincter | relaxation
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| The tone of the lower esophageal spincter is ___ at birth | low & increases with age 90% 18 mo old = correction GERD
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| an infant with GERD has clinical manifestations of | emesis, FTT, anemia, irritability, gagging during feeding, apnea and recurrent pneumonia
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| an older child with GERD hs clinical manifestations of | emesis, blood in emesis and stool, heartburn, dysphagia, abdominal and chest pain and chronic nocturnal asthma
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| Diagnostic tests for GERD include; ____ swallow, esophageal manometry, esophagoscopy and ___ monitoring | barium swallow, esophageal manometry, esophagoscopy and pH monitoring
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| An infant with GERD is given ____ | Zantec - don't give an antiacid b/c affects absortion
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| A child with GERD has a three step pharmacological managment starting with Maalox or Mylanta then what | progression to H2 antagonist like Zantac, then replace with a proton pump inhibitor like Prilosec or a prokinetic drug like Reglan
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| ____ is usually not given to children under a year unless they have severe GERD with N/V/D | Prilosec - proton pump inhibitor
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| Dietary measures for an infant with GERD | avoid overfeeding, keep upright during and 20min after feeding, always place infant on their back when they sleep w HOB eleved 6 inches NOT in infant seat.
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| An infant who has had surgery to correct GERD doesn't ____ or vomit | burp or vomit b/c the muscles are tight and may have loose stools
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| Why can't the nurse replace the NG tube for an infant who has just had surgery to correct GERD? | The tube goes through a surgical site and only the physican can put the tube through a surgical site - this is the only time a nurse does not put the NG tube back
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| ___ is a functional disorder that involves repeated passage of feces into places that are not appropriate for that purpose | Encopresis
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| Primary encopresis is when a child is not trained yet and secondary encopresis is ___ after a child is trained | regression
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| A child is diagnosed with encopresis when it occures at least once a monthe for ____ months | 6 months
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| Regression of bowel movement - encopresis occures when the child is constipated and the external rectal spincter ____ due to pain | contract
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| abnormal motility of the stomach and small intestine causes the stool to ____ the intestine | stretch - the larger stool is harder to get out
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| Etiology and risk factors of ___ include toilet training techniques, toileting behaviors, stool patterns, stress, trauma, disturbed parent-child relationship, sexual and physical abuse and temperment | encopresis
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| Encopresis has ____ distention where Hirshprungs had ____ distention | encopresis minimal distention and Hirshprungs large distention
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| With encopresis the movable fecal masses are palpable due to ____ | stool not moving
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| ___ manifestation is a large rectum but normal sphincter tone | encopresis
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| First therapeutic management of encopresis is | treat the cause - while this is going on get abdominal x-ray, bowel management program, dietary changes and behavior therapy for child and family
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| Bowel management of encopresis includes ____ enema and giving the child ____ oil 3tsp TID or QID | Fleet enema and mineral oil
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| A child with encopresis should get increased dose of ____ vitamins, high ____ diet and do not pressure child to have stool | increase water soluble vitamins, high roughage diet with increased fluids
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| If both parents are obese then ___% chance child will be obese too. If both parents are normal there is a ____% chance the child will be obese - why | if both are then child 80% if both not 14% chance child will be due to decreased phyusical activity and poor feeding habits
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| Children with obesity should diet to ____ weight | maintain weight while they grow taller
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| Diet and exercise are encouraged for obese chidlren b/c drugs ___ | are not as effective as for adults
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| Last resort for therapeutic management for obese children | surgical techniques due to severe water and electrolyte disorders and affects on liver long term
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| Screening (not a diagnoses) for obesity | BMI over 95% - at risk between 85-95%
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| How do you calculate BMI? (using lbs and inches) | (lbs / inches squared) X 703
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| At some point during a child's course of the disorder, intussusception, a stool is described as | currant jelly
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| The nurse notes on assessment that a one-year-old child is underweight, with abdominal distention, thin legs and arms, and foul-smelling stools. The nurse suspects failure to thrive associated with what disorder? | celiac disease
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| The nurse is teaching parents of a 5-week-old about a pyloromyotomy (dividing the muscle of the pylorus to open up the gastric outlet), she informs the parents that | the prognosis for complete correction with surgery is good.
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| A three-week-old is hospitalized for the repair of a cleft lip. What nursing intervention would be included in a postoperative care plan? | Advance diet from clear liquid to regular formula as tolerated.
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| Which of the following is the most important information to be included in the discharge planning for an infant with gastroesophageal reflux? | Teach the parents how to do infant cardiopulmonary resuscitation (CPR).
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| The nurse caring for a child with a suspected appendicitis would question which of the following physician orders? | Apply K-pad to abdomen prn for pain. Need to keep pt NPO, obtain CBC, start IV of D5/.45 normal saline at 60ml/hr
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| Which of the following orders should the nurse question when caring for a child following surgery for Hirschsprung's disease? | Monitor rectal temperature every 4 hours and report an elevation greater than 38.4 C. Need to assess site for swelling ... Q4H, keep NPO, check bowel sounds, and maintain IV fluids
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| A seven-week-old infant is admitted with a diagnosis of pyloric stenosis. What admission data would the nurse expect to obtain related to the infant's emesis? | Large amounts fresh formula projected - no blood
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| Which of the following nursing diagnoses has highest priority for the child with irritable bowel syndrome? | Pain related to hyperperistalsis
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| In NEC Nectorizing Entercolitis why do the intestines become inflamed? | NEC Intestines becomes inflamed d/t early feeding
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| In Short Bowl syndrome what happens if they have a intestinal obstruction? | It has to be removed
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| A risk factor for Short Bowel syndrome: ______ there is a problem in theintestines, intestines that is left there is a decrease for absorption? | Malabsorptive Disorder
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| When preserving the bowel you need at least ___cm of bowel to function? | Preserving bowel - need at least 15cm of bowel to function
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| TPN within ___ months can damage liver quickly? U also have ___ problems too. | TPN within 6 mo can damage liver quickly. Central line problems too
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| A nursing intervention for short bowel syndrome is administration & monitoring of nutritional therapy. What does this entail? | access F & E status, abdominal distention, they may have to be on continuous feeding they may develop a severe e- disorder. Formula will stimulate the cells inthe intestines. if they are not being feed it will atrophy and die.
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| What do you need to be aware of when preparing the family for hometherapy of a short bowel syndrome pt? | TPN is expensive, Children willfeelisolated, & it puts stress on the family
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| A nursing intervention for short bowel syndrome is developemtnal & emotional stimulation. What do you need to be aware of and do as a nurse? | Don't have extra energy for play, makesure they suck on a pacifier for oral stimulation, if they have not had anything by mouth for 6 months it will be hard for them to have that sucking refles. their cognitive development may be intact
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| In short bowel syndrome if you have less than ___ cm of bowel left, then you need a transplant. You can loose ___ % w/o problem with ___ % you have severe malabsorption? | 50% w/o problem 70% severe malabsorption.
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| T/F Imperforate Anus Is never a thin membrane over anus or very extensive where whole rectum is occulated. | False Can be thin membrane over anus or very extensive where whole rectum is occulated.
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| What is a low anommally imperforate anus? | It is where there is a thin tissue covering the opening of the anus
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| What is a intermediate imperforate anus? | Where the closing is 1/2 way up the rectum
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| What is a high imperforate anus? | Where the closure is the entire rectum
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| T/F In Imperforate Anus there is a slight increase in incidence in males | True
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| Names some other abnormalities Imperforate Anus is associated with? | Congential abnormalities
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| If a child is born with GI defect look at the ___ & the opposite is true? | GU
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| T/F in imperforate Anus a fistula maybe present from the return to the urethra? | True
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| When should a newborn pass their 1st stool? | W/in the first 24hrs
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| JT is a 2hr old full term white male. His wt is 7lbs 3oz. His mother experienced no complications during pregnancy or delivery. Can this child have an imperfortate anus? | Yes as a nurse during his initial physical exam you look to see if he has a visible anus possiblymake sure there is an opening with the use of a cath
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| What are the post-op nursing interventions for a low lesion imperforate anus? | 1. Freuent, gental perineal cleansing 2. Apply protective ointment 3. Place in side-lying prone position w/ hips elevated 4. regular feedins upon hearing bowel sounds 5. Bowel mgmt (may be constipated) 6. Teach parents and dilation
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| Why do we need to teach parents of a low lesion imperforate anus dilations? How long is this done for? | opening has a tendency to close up, teach parent to insert a metal rod in rectum to keep anus open. Done for 4-6 weeks
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| What are the post op nursing interventions for high/intermediate lesion imperforate anus? | 1. IV fluids 2. NG & NPO until peristalsis returns (may take 2-3 days) 3. Colostomy care 4. Family support 5. Final repair/follow up 6. Measure NG tube drainage
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| In an High/Intermediate imperforate anus once repaired, the colostomy is closed at the same time, child may have a ___? | flat bottom
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| When will you see symptoms of biliary atresia? | biliary atresia - see sx after 1 wk old
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| T/F Biliary Atresia is seen more in Females? Occurs 1 in 1000 births | False Males & occurs 1 in 1000 births
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| A pt with biliary Atresia will be ____ at birth, have jaudice beyond ___ week and can have ___ hyptertension? | Normal at birth, Jaundice beyound 1 week, portal HTN
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| In a Kasai procedure for Biliary Atresia can leakage develope? | Yes leakage can develope
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| Hx, Physical findings & lab findings; R/Oother causes cholestasis (an arrest in flow of bile) Abdominal sonogram; liver biopsy & exploratory laparotomy or laparoscopy are all diagnostic evaluations for ____? | Biliary Atresia
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| In Biliary Atresia a nursing intervention is efficient collection of multiple blood samples. What do you need to know as a nurse? | Know the appropriate amount of blood that can be removed in a 24hr period
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| How much does a pt with biliary atresia need to eat? Why? | they need 1.5x the calories. They will have ascities and that will affect their appitite. They are abdominal breathers,they are placed on a formula that is easy for them to absorb.
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| How do you treat pruritus of a biliary atresia pt? | Oat meal baths, trim finger nails. medication will make the child sleepy and you dont want their growth & developemnt obstructed
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| What are the positions that a cleft lip can be in? | Cleft lip can be unilateral, bilateral, and midline-rare
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| the following are risk factors for ____: 1 in 3000 live births; most cases represent accident of embryology; 30-70% have associated malformations; May have Hx of maternal polyhdramnios (excess amount of amniotic fluid) | Tracheoesophageal (T-E) Fistula
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| What are the clinical manifestations of Tracheoesophageal (T-E) Fistula? | Drooling, frequent cough, cyanosis, when fed formula returns through mouth & nose
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| What is the classic manifestation of Tracheoesphageal Fistula? | Not able to swallow secretion is a classic manifestation
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| How is Tracheoesphageal (T-E) Fistula diagnosed? | Diagnosed by passing catheter through esophagus-suspected if you get a catheter more than 10 cm. an ex-ray will be done with the catheter in
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| With a Tracheoesphageal (T-E) Fistula a child may be allowed only ____; the abdomen is often times ___? | Child may be allowed only sterile water; abdomen is often times depressed.
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| Gastricor blind pounch depression (to remove excess air in abdomen; Intermittent/continous suctioning; NPO; IV fluids; Transfer to NICU; Surgical repair (thoracotomy) w/ 24hrs of birth unless they have pneumonia; & ELEVATE THE HOB thearaputic mgmnt for__? | T-E Fistula
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| What are the nursing interventions for T-E Fistula? | Assist with diagnosis 2. Maintain airway 3. monitor IV fluids 4. manage decompression tube 5. provide support care 6 family support-Child will have problems with GERD later on
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| ___ is a catagory of failure to thrive that is unknown origion. What do you need to do as a nurse for this? | Idiopathic failure to thrive; Observe parents feeding the baby and feed the baby also.
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| Therapeutic management of FTT-treatment is directed at ___ malnutrition and is a multidisciplinary team approach-OT, & ___ are involved | treatment directed at reversing malnutrition; multidisciplinary team approach-OT, social services are involved
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| What do you need to assess in FTT? | 1. Physical-sleep patterns, appropriate rest, how pt is fed 2. Psychological-parenting & stress in family 3. Social-poverty, young & single momther lack of employment 4. spiritual - subjective be protective of child
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| T/F leagally you can put a hold on a baby for 24 hrs if you think it is danger. | True
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| If the pt has FTT how much do they need to eat if they are less than 6 months old and how much if they are more than 6 months old? | less than 6 months 200 grams/day; more than 6 months 2.2 kg/month
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| Having a firm calm schedule that is consistent and non stimulating in environement as well as staying with the clild having consistent care givers and dont force the baby to eat are all guidlines for promoting ____? | positive feeding interaction in FTT pts
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| What are some strategies for promoting a positive parenting? | Encourage but dont pressure; teach through example-appropriate play; develop parent feeding plan; offer opportunity for discussion; promote parent self-esteem & confidence; Refer available resources; teach appropriate stimulation & play
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| If a child is not thriving what do you whant to check for? | Cystic fibrosis and celiac disease
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| T/F HPS is recuring? | False it dosent
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| Diet teaching; refere to registered nutritionist; important to stress long-range complications(have increase incidence of lympoma if dont adhear to diet) and family support are all nursing interventions for ____? | Celiac disease
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| ___ IS USED IN INTUSSUSCEPTION-air with or without water-soluble contrast or barium- 75% success | Hydrostatic reduction
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| T/F In intussusception surgical intervention is needed if reduction is unsuccessful or for perforation? | True They will remove the bad area if not perforated.If perforated they will do a temporary colostomy
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| Assist with establishing diagnosis; Monitor for signs of complete obstruction & perforation; & examine stools are nursing interventions for ____? | intussusception
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| How often should a baby have BMs? | every 2-3 days at most
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| How often do you check the pH in GERD pts? | every 20 mins and chart what they ate due to Juices decrease pH and formula increases pH
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| FTT with persistent vomiting after 1-3 months intensive medication & nutrition; recurrent pneumonitis; ALTE; Sever esophagitis are surgical manigment for ___? | GERD
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| What does ALTE stand for? | Adverse Life Threating Episode
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