NCLEX-RN: Pediatric Nursing

Pediatric Nursing: Gastrointestinal System

Focus topic: Pediatric Nursing

The primary function of the alimentary tract is to provide the body with a continual supply of nutrients, fluids, and electrolytes for tissue nourishment. This system has three components: a tract for ingestion and movement of food and fluids; secretion of digestive juices for breaking down the nutrients; and absorption mechanisms for the utilization of foods, water, and electrolytes for continued growth and repair of body tissues.

Pediatric Nursing: Disorders of Motility

Focus topic: Pediatric Nursing

Pediatric Nursing: Acute Diarrhea (Acute Gastroenteritis)

focus topic: Pediatric Nursing

Definition: Diarrhea occurs when there is a disturbance of the intestinal tract that alters motility and absorption, and accelerates the excretion of intestinal contents (3–30 stools per day). Fluids and electrolytes that are normally absorbed are excreted, causing electrolyte imbalances. Most infectious diarrheas in the United States are caused by a virus (usually rotavirus). Bacterial causes include Salmonella groups, Shigella, Yersinia, Campylobacter, and Clostridium difficile. Diarrhea can be a separate disease, or it may be a symptom of another disease. Acute diarrhea becomes chronic if it lasts more than 2 weeks.

Assessment
A. Obtain history; ascertain exposures to allergens, new foods; infectious agents or current medications, exposure to rotavirus. Vaccination against rotavirus during the first year of life has decreased the incidence of gastroenteritis from this cause. Giardia is the pathogen seen in children who attend day care.
B. Assess child’s general state: LOC, activity, and vital signs.
C. Assess quantity and quality of stools.

  •  Assess for increased rate of peristalsis carrying intestinal contents.
    a. Blood, pus, or mucus in stools, which are often green in color.
    b. Increase in frequency of stools of watery consistency.

D. Lab tests ordered when child is moderately to severely dehydrated.

  •  Stool cultures.
  •  Stools examined for ova and parasites if cultures are negative.
  •  CBC, electrolytes, hemoglobin and hematocrit, blood urea nitrogen (BUN), and creatinine indicated if admission is required.

E. Assess amount of dehydration.

Implementation
A. Intravenous fluids begun immediately with severe diarrhea and dehydration. Admission to hospital is usually warranted to replace fluid deficit and correct electrolytes.
B. Provide small, frequent offerings of oral rehydration solutions (ORS) such as Pedialyte throughout course, unless vomiting is severe. The rate of replacement may range from 50–100 mL/kg over a 4–6 hour period, even if the child is vomiting. Give 5–10 mL of ORS every 2 minutes.
C. Breastfeeding should be continued throughout the disease and ORS given to replace ongoing losses.
D. Early reintroduction of the normal diet is becoming common and beneficial in reducing the number of stools and decreasing weight loss.

  •  Discourage the administration of juices, broth, gelatins, or BRAT diet.
  •  Cow’s milk and milk-based formulas are usually included unless clearly not tolerated.

E. Maintain contact isolation until causal organism or other factors are determined in a child who is in diapers or standard precautions as needed.

  •  Encourage careful hand washing at home.
  •  Dispose of stools and diapers in proper containers.

F. Maintain careful ongoing assessment and management of dehydration level and acidosis.
G. Complete accurate recording of the number and consistency of stools.
H. Maintain excellent skin care to prevent excoriation caused by alkaline stools; apply appropriate skin protectants (such as zinc oxide).
I. Explain to parents that antidiarrheals are not indicated for diarrhea in children as it keeps the causative agent in the GI tract longer.

Pediatric Nursing

Pediatric Nursing: Dehydration

Focus topic: Pediatric Nursing

Definition: Dehydration can be isotonic, hypotonic, or hypertonic (loss of water with resulting sodium excess). Fluid volume deficit is the nursing diagnosis used when water and sodium losses are proportional, which is isotonic dehydration. Most losses in children are isotonic; “the sum of all losses” adds up to being isotonic. The type of dehydration can be determined by electrolyte values and subtle clinical manifestations.

Assessment
A. Check for increased heart rate and respiratory rate.
B. Assess for increased irritability and fussiness.
C. Assess for depressed fontanelles and eyes that appear sunken.
D. Assess for dry mucous membranes become dried and cracked.

E. Note dry skin with loss of normal elasticity.
F. Note presence or absence of tears.
G. Assess capillary refill (should be 2–3 seconds).
H. Assess for decreased urine.

  •  Urine may be dark in color (concentrated).
  •  Increase in urine specific gravity (greater than 1.020 in infants).
  •  Acidosis is a common result, with serum CO2 less than 17.

Implementation
A. Maintain strict recording of I&O. Expect > 2–3 mL/kg output in infants and > 1–2 mL/kg in children.
B. Administer oral rehydration therapy (ORT).

  •  See ORS guidelines in section on gastroenteritis.
  •  Do not use Gatorade in infants and young children.
  •  Approximately 60–120 mL ORS/kg per each diarrheal stool for children under 10 kg and 120–240 mL ORS/kg for child over 10 kg.

C. Continue regular diet while rehydrating.
D. Vomiting children should be given ORS in frequent, small amounts.
E. Severe dehydration (loss of 15% circulating volume) must be treated urgently (shock). Treatment is guided by the serum sodium levels.
F. Parenteral IV fluids indicated if child is severely dehydrated, unable to take fluids by mouth, and continuing fluid replacement is needed. Fluid boluses of 10–20 mL/kg are ordered. NaCl 0.9% or lactated Ringer’s solution is ordered.
G. Continue to closely monitor electrolytes.
H. Maintain skin integrity; monitor for diaper rash.
I. Family teaching (hand washing, avoid high-sugar containing fluids to rehydrate, avoid BRAT diet).

Pediatric Nursing: Constipation

Focus topic: Pediatric Nursing

Definition: The infrequent passage of stools associated with difficulty in passing stool, abdominal pain, passage of small, hard stools sometimes streaked with blood over a period of 2 weeks. Constipation may be caused by changes in diet, dehydration, lack of exercise, emotional stress, certain drugs, pain from anal fissures, inadequate or inconsistent toilet training, or excessive milk intake. May be associated with encopresis or fecal incontinence.

Assessment
A. Obtain history of usual bowel habits and characteristics.
B. Assess diet habits, over-the-counter and prescription medications taken recently, and any used for constipation.

C. Observe for passage of meconium in newborns (possible meconium ileus or Hirschsprung’s disease).
D. Closely evaluate diet in constipated infants and older children.
E. Investigate bowel patterns and timing of stools with older children.

Implementation
A. Dietary counseling appropriate to age. May refer to dietitian.

  •  Encourage fluid intake and diet higher in fiber.
  •  Eliminate any foods known to be constipating.

B. Establish regular time for bowel movements.

  •  Encourage child to take time to have bowel movement daily (may use times for child to practice sitting longer).
  •  Establish a routine time for bowel movements (e.g., 10–15 minutes after a meal).

C. If constipation is persistent, then the healthcare provider will initiate treatment.

  •  First disimpaction—enemas, laxatives, or stool softeners.
  •  Education about the causes of constipation.
  •  Maintenance with laxatives—mineral oil, lactulose, or Miralax (polyethylene glycol 3350).
  •  Dietary changes, including limiting milk, increasing water, fiber, and residue.
  •  Changing the retention habit.
  •  Establish a routine.

Pediatric Nursing: Hirschsprung’s Disease (Congenital Aganglionic Megacolon)

Focus topic: Pediatric Nursing

Definition: A disease caused by the congenital absence of parasympathetic nerve ganglion cells in the distal bowel.

Characteristics
A. The distal portion of the bowel is unable to transmit regular peristaltic waves, which are coordinated with the proximal portion of the bowel.
B. When a stool reaches the diseased area, it is not transmitted down the colon, but accumulates in the segment just proximal to this area, forming a functional obstruction.
C. The bowel above the obstructed portion eventually becomes hypertrophied in its attempts to transmit the stool.

Assessment
A. Assess for failure to pass meconium in newborn; may not be diagnosed until later in infancy or childhood.
B. Assess for symptoms of bile-stained vomiting and reluctance to feed.
C. Evaluate for signs of intestinal obstruction.

D. Evaluate for signs of constipation and abdominal distention.
E. Assess for foul odor of breath and stool.
F. Note that in an older infant or child symptoms of constipation, offensive odor, and ribbonlike stools may be present.

Treatment
A. The majority of children require surgical rather than medical treatment. Children beyond the newborn phase may require bowel emptying with enemas and antibiotics to reduce colonic flora preoperatively.
B. The first stage of treatment is usually a transverse or sigmoid colostomy.
C. The child is then brought back to optimal health and nutritional status.
D. The next procedure consists of dissection and removal of the nonfunctional bowel and anastomosis.
E. Final treatment is closure of temporary colostomy.

Implementation
A. Prior to diagnosis, observe carefully for all gastrointestinal manifestations of the disease and report them accurately.
B. Prior to the colostomy procedure.

  •  Cleanse bowel.
    a. Oral antibiotics.
    b. Liquid diet.
    c. Colonic irrigation—saline.
    d. Measure abdominal girth when taking vital signs.
  •  Prepare parents for the procedure.
    a. Clarify the surgical technique.
    b. Describe stoma.
    c. Prepare for care of the child with a colostomy.
    d. Give parents the opportunity to express their feelings about the procedure.

C. Postoperative care.

  •  Maintain optimal nutrition.
  •  Closely observe stools for reestablishment of normal elimination pattern.
  •  Maintain skin care of colostomy and anal areas.
  •  Involve older children in care of ostomy  provide support and referrals to parents in discharge preparations.

Pediatric Nursing: Gastroesophageal Reflux Disease

Focus topic: Pediatric Nursing

Definition: The transfer of gastric contents into the esophagus. A significant problem in approximately 1/300 to 1/1000 children. Occurs as result of relaxation of lower esophageal sphincter.

Assessment
A. Begins in infancy, but only a small percentage continue to have gastroesophageal reflux disease (GERD) after the first year of life as the lower esophageal sphincter matures.
B. History.

  •  Previous TEF surgery, CNS disease, asthma, CF, scoliosis, or developmental delay.
  •  Frequent respiratory symptoms from aspiration.

C. Symptoms.

  •  Stomach contents in esophagus damage the esophageal lining. In some children, the stomach contents go up to the mouth and are swallowed (or potentially aspirated) again.
  •  When refluxed material passes into back of the mouth or enters airway, child may become hoarse, have a raspy voice, or have a chronic cough.
  •  Other symptoms include recurrent pneumonia, wheezing, irritability, choking during feedings, apnea in newborns, difficult or painful swallowing, vomiting, sore throat, weight loss or poor weight gain, and heartburn (in older children).

D. Diagnosed by pH probe test of esophageal acidity, upper GI, endoscopy, and swallowing studies.

Implementation
A. Modify feedings to small and frequent feedings  may use thickening agents.
B. Infants are generally positioned upright or prone during waking hours. (Note placed prone when sleeping because of recommended supine position to prevent SIDS only exception is if risk of aspiration is greater than risk of SIDS). Avoid placing infants in “infant seats” because slumping posture increases reflux.
C. Pharmacologic therapy (most commonly used in children).

  •  H2 blockers: Pepcid (famotidine) or Zantac (ranitidine).
  •  Proton-pump inhibitors (PPIs) often used to block production of stomach acid—Prilosec (omeprazole), Prevacid (lansoprazole), Protonix (pantoprazole).
  •  Prokinetic agents to improve peristalsis and stimulate gastric emptying: Reglan (metoclopramide).

D. Surgery indicated for severe cases (Nissen fundoplication).

  • Often combined with pyloroplasty.
  •  Numerous potential complications.

E. Support and education for family.

  •  Feeding techniques.
    a. Have child eat more frequent smaller meals; avoid eating 2–3 hours before bed.

b. Raise head of child’s bed 6–8 inches by putting blocks of wood under bedposts. Just using extra pillows will not help.
c. Children should avoid carbonated drinks, chocolate, caffeine, and foods that are high in fat or contain a lot of acid (citrus fruits) or spices.

  •  Positioning.
  • Respite care and support for parents.
  •  Continued reinforcement of therapeutic regimen; teach importance of administering medications in proper relation to feedings and therapeutic regimen.
  •  CPR training.
  • Discharge planning and appropriate referrals.

Pediatric Nursing: Inflammatory Diseases

Focus topic: Pediatric Nursing

Pediatric Nursing: Appendicitis

Focus topic: Pediatric Nursing

Pediatric Nursing: Inflammatory Bowel Disease

Focus topic: Pediatric Nursing

Definition: An inflammatory disease of the colon and the rectum in which the mucous membrane becomes hyperemic, bleeds easily, and tends to ulcerate. The exact etiology is unknown; however, the incidence is highest in young adults and middle-age groups. Encompasses ulcerative colitis and Crohn’s disease.

Assessment
A. Assess for diarrhea or bloody diarrhea (ulcerative colitis).
B. Evaluate for weight loss—can be moderate to severe.
C. Assess for rectal bleeding.
D. Evaluate for abdominal pain, anorexia, nausea, and vomiting.
E. Assess for presence of anemia.
F. Assess for fever and dehydration.
G. Assess for oral aphthous ulcers.
H. Evaluate for delayed growth and development.
I. Evaluate for fatigue, joint pain.
J. Assess for fistula formation (Crohn’s).

Implementation
A. Assist with diagnostic procedures; rule out irritable bowel syndrome.

  • Upper GI with small bowel follow-through.
  •  Colonoscopy with tissue biopsy.
  •  Ultrasound or CT of abdomen.
  •  Stool for occult blood and white blood cells (WBCs), ova and parasites, Clostridium difficile.
  •  CBC, electrolytes, calcium and phosphorus, zinc, and magnesium, total protein, albumin, ESR, C–reactive protein, and liver enzymes.
  • Ophthalmic exam (Crohn’s).
  • Serum iron, total iron binding capacity, ferritin (ulcerative colitis).

B. Control inflammation and treat symptoms.

  • Supervise anti-inflammatory medication regimen, which may include (oral, IV, rectal)
    a. Aminosalicylates: Azulfidine (sulfasalazine) or Apriso (mesalamine).
    b. Immunosuppressives: Neoral (cyclosporine), Rowasa (5-ASA), and Imuran (azathioprine).
    c. Corticosteroids.
    d. Remicade (infliximab) therapy (tumor necrosis factor blocker) for Crohn’s.
  •  Antibiotics may be used to prevent or treat infections.
  •  Provide adequate hydration with intravenous therapy and oral fluids as indicated.
  •  Pain medication.
  •  Antidiarrheals.

C. Provide rest to intestinal tract.

  • Observe for amount of bowel activity and symptoms of bleeding and hyperactive peristalsis.
  •  Administer sedatives sparingly; observe for side effects.

D. Support nutrition.

  • Encourage well-balanced, high-protein, highcalorie diet.
  •  May require special formulas, continuous NG feedings at night, especially successful with elemental formulas.
  • Total parenteral nutrition (TPN) may be necessary for complete bowel rest.
  • Record I&O. Institute vitamin therapy, monitor Hgb, Hct,
    iron levels, folic acid.
  • Low fiber, low-residue, low-fat, milk-free diet may be useful (ulcerative colitis).
  • May avoid sharp cheeses, highly spiced foods, smoked or salted meats, fried foods, raw fruits, and vegetables (foods omitted determined by individual).

E. Surgical treatment may be necessary.

  •  Colectomy may be needed in severe cases, is NOT curative in Crohn’s disease.
  •  Variety of procedures possible, some preserve normal defecation.

F. Provide counseling and education to client and family.

  •  Educate child about diet, medication, and
    symptoms of bleeding, management of chronic disease.
  • Observe for signs of psychological problems; adaptation to chronic disease; social isolation and poor self-esteem because of need to be near bathroom; initiate appropriate referral if necessary.

Pediatric Nursing: Intestinal Parasites

Focus topic: Pediatric Nursing

Definition: Worms affect not only the gastrointestinal system, but also are found in the lungs, heart, and other body systems. As parasites, they feed off the host, which leads to a variety of symptoms. More common in children because of frequent hand-to-mouth activity.

Pediatric Nursing: Roundworms (Ascaris Lumbricoides)

Focus topic: Pediatric Nursing

Characteristics
A. Eggs are laid by the worm in the gastrointestinal tract of any host and passed out of the body in feces.
B. After the worms have been ingested, egg batches are laid.
C. Larvae in the host invade lymphatics and venules of the mesentery and migrate to the liver, the lungs, and the heart.
D. Larvae from lungs reach the host’s epiglottis and are swallowed; once in the gastrointestinal tract, the cycle is repeated larvae mature and mate, and the female lays eggs.

Assessment
A. Assess for atypical pneumonia.
B. Assess for gastrointestinal symptoms: nausea, vomiting, anorexia, and weight loss, stooling patterns.
C. Determine if insomnia is present.
D. Evaluate for signs of irritability.
E. Assess for presence of intestinal obstruction, vomiting, and dehydration.
F. Diagnosis confirmed with fecal smear for ova and parasites.

Implementation
A. Prevent infection through the use of a sanitary toilet.
B. Provide hygiene education of the family.
C. Dispose of infected stools carefully.
D. Administer medications: Vermox (mebendazole) or Albenza (albendazole) (treat the entire family).

Pediatric Nursing: Pinworms (Enterobiasis)

Focus topic: Pediatric Nursing

Characteristics
A. A common parasite infection in United States, especially in warm climates.
B. Eggs are ingested or inhaled.
C. Eggs mature in cecum, then migrate to anus.
D. Worms exit at night and lay eggs on host’s skin.

Assessment
A. Assess for acute or subacute appendicitis.
B. Evaluate for eczematous areas of skin.
C. Determine if irritability is present.
D. Ascertain loss of weight and anorexia.

E. Determine if child suffers from insomnia.
F. Diagnose condition by tape test: Place transparent adhesive tape over anus and examine tape for evidence of worms.

Implementation
A. During treatment, maintain meticulous cleansing of skin, particularly anal region, hands, and nails.
B. Ensure that bed linens and clothing are washed in hot water.
C. May use topical ointment to relieve itching.
D. Teach careful hygiene as a preventative measure.
E. Instruct all infected persons living communally that they must be treated simultaneously.
F. Medication: Pin-X (pyrantel pamoate); drug of choice is Vermox.

Pediatric Nursing: Giardiasis

Focus topic: Pediatric Nursing

Definition: The most common intestinal parasitic pathogen in the United States, this condition is caused by the protozoan, Giardia lamblia.

Characteristics
A. Often occurs in children in day care centers (estimates are 9–38%).
B. Major mode of transmission is person-to-person, water (especially mountain lakes and streams), food, and animals.
C. Adults may be asymptomatic, but children usually manifest symptoms.

Assessment
A. Infants and young children.

  •  Diarrhea.
  •  Vomiting and anorexia.
  •  May have failure to thrive.

B. Children over 5 years of age.

  •  Abdominal cramps and flatulence
  •  Loose stools may be intermittent.
  •  Stools may be watery, pale, and smelly.

C. Assess condition through stool for ova and parasites may need six or more over several weeks.

Implementation
A. The most important nursing measure is to teach prevention—meticulous sanitary practices during diaper changes and cleaning of children.

  •  Inform parents of importance of hand washing.
  •  Drink water that is purified, especially when near potentially contaminated streams.

B. Administer drugs available for treatment: Flagyl (metronidazole).

Pediatric Nursing: Hepatic Disorders

Focus topic: Pediatric Nursing

Pediatric Nursing: Hepatitis

Focus topic: Pediatric Nursing

See adult section on hepatitis, Chapter 8. Hepatitis B vaccination is included in vaccination schedule with the first dose given at birth. Hepatitis A vaccination is recommended for all children beginning at age 1 year.

Pediatric Nursing: Biliary Atresia

Focus topic: Pediatric Nursing

Definition: The atresia or absence of bile ducts outside the liver. A progressive inflammatory process causing intrahepatic and extrahepatic bile duct inflammation and obstruction. Affects between 1 in 10,000 and 1 in 25,000 infants without preference to race or sex.

Assessment
A. Diagnosis based on history, physical exam, and diagnostic evaluation.
B. Early signs: jaundice (may be present at birth generally evident by 2–3 weeks), dark urine, light colored stools, hepatomegaly, pruritus, irritability, failure to thrive.
C. Etiology is poorly understood; possibly viral, toxin, or chemical injury or immune mechanism.
D. Gradual deterioration of liver function, loss of intralobular ducts and developing cholestasis, and buildup of bile acids and toxins.

Implementation
A. Early surgery yields highest successes (hepatoportoenterostomy Kasai procedure); segment of small bowel is anastomosed to resected porta hepatis to facilitate bile drainage.
B. Bile drainage achieved in most clients undergoing surgery in first 2 months of life.
C. Large number still have progressive liver failure and go on to require transplantation.
D. Dietary management: medium chain triglycerides (MCT) oil or Polycose added to formula to increase calories; low-salt diet; supplemental vitamins and minerals: vitamins A, D, E, K; calcium, phosphate, zinc.
E. Diuretics.
F. Bile acid binders such as Questran (cholestyramine) aid in excretion of bile salts and decrease in pruritus.  Colloidal oatmeal baths for itching. Wear gloves to prevent scratching.
G. Monitor nutritional intake and growth.
H. Support and education for family.

  •  Multidisciplinary process.
  •  Appropriate community and support group referrals.

Pediatric Nursing: General Disorders

Focus topic: Pediatric Nursing

Pediatric Nursing: Celiac Disease (Gluten-Induced Enteropathy)

Focus topic: Pediatric Nursing

Definition: A chronic disease of intestinal malabsorption precipitated by ingestion of gluten or protein portions of wheat or rye flour.

Characteristics
A. A major cause of malabsorption in children, second only to cystic fibrosis. Appears in children from 1–5 years of age.
B. Highest incidence occurs in Caucasians.
C. Major problem is an intolerance to gluten, a protein found in most grains.
D. Basic defect is believed to be an inborn error of metabolism or an autoimmune response.
E. Primary physiological effect is inadequate fat absorption; as disease progresses, it affects absorption of all ingested elements.
F. Long-term effects can be anemia, poor blood coagulation, osteoporosis, and lymphoma.

Assessment
A. Assess age disease occurs: usually when infant begins to ingest grains at age 9–12 months of age.
B. Assess for diarrhea or loose stools: foul-smelling, pale, and frothy.
C. Check for failure to gain weight (usually below 25th percentile on growth charts for weight).
D. Check for abdominal distention.
E. Assess for anorexia.
F. Evaluate behavioral changes: irritability and restlessness.
G. Diagnosis:

  •  Immunoglobulin A (IgA) antitissue transglutaminase antibody test or the IgA antiendomysial antibody test.
  • Jejunal tissue biopsy is the definitive test.

H. Observe for celiac crisis.

  •  Vomiting and profuse diarrhea (acute and severe).
  •  Acidosis and dehydration.
  •  May be precipitated by respiratory infection, fluid and electrolyte imbalance, emotional upset.
  •  Excessive perspiration.
  • Cold extremities.

Implementation
A. Monitor appropriate diet; “gluten-free” diet necessary.

  •  Wheat and rye gluten, as well as barley and oats, are eliminated. Corn, rice, and millet are substituted grain sources.
  • Consultation with a nutritionist.
  •  Supplemental vitamins and iron.

B. Instruct parents and child how to recognize impending celiac crisis, how to manage diet at home, and deal with school lunches and meals away from home.

  •  Teach primary symptoms of crisis.
  •  Institute medical intervention to correct dehydration and metabolic acidosis.

C. Prevent infection and precipitating events.
D. Provide support and education for child and family.

  • Teach diet.
  • Provide for follow-up by home care nurse and nutritionist for continued teaching and assistance. Assess financial strain of special diet on family.
  •  Explain prognosis: Clinical symptoms decrease with increasing age.
  •  Refer to American Celiac Society, other appropriate community agencies, and support groups.
[sociallocker]

Pediatric Nursing: Obesity

Focus topic: Pediatric Nursing

Definition: The accumulation of body fat resulting from an excess of caloric intake over caloric output, usually from overeating. Often defined as body weight over 120% ideal weight for height, taking into account lean body weight relative to body fat.

Characteristics
A. Obesity is twice as common in adolescents as it was 30 years ago. In the United States, 17% of children and teens are overweight or obese.
B. Most complications of obesity occur in adulthood, but obese school-age and adolescent children are twice as likely to have high blood pressure and type 2 diabetes.
C. Familial tendencies exist, but most childhood and adolescent obesity is attributed to eating too much and exercising too little.
D. Psychosocial causes of overeating should be identified and treated with counseling. Group counseling for overweight children and adolescents is effective, along with dietary and exercise programs. (See anticipatory guidance for appropriate age throughout chapter starting on page 633.)
E. The impact of childhood obesity becomes most obvious at adolescence, when body image and peer approval become important.

Assessment
A. Assess height and weight according to standard growth and development scale.
B. Risk factors: diet (amount and type of food), inactivity, genetics (other family member are overweight), psychosocial factors, poverty.
C. Screening: BMI > 85th–95th percentile, diabetes (type 2), eating and exercise habits, and looking for other health conditions the child may have.

D. Identify possible hormonal or genetic factors related to the child.
E. Evaluate eating patterns and habits, and food types.
F. Assess length of time child has been obese.
G. Acanthosis nigricans–dark, velvety discoloration in body folds and creases.
H. Evaluate child’s and family’s feelings and attitudes about obesity.
I. Considerable cultural implications of body size and usual diet.

Implementation
A. Provide a balanced diet with limited calories.

  • Slow and steady weight loss of 1 pound per week to 1 pound per month.
  •  Set achievable goals and plan for long-term lifestyle and eating changes.
  •  Encourage healthy diet (for the entire family), limiting snacks, fast food, and concentrated sweets, while providing a wide assortment of healthy choices.

B. Set up a routine of daily exercise; frequently, groups for after-school exercise programs can be organized by school nurses.
C. Help the young person work through underlying problems causing or caused by obesity.
D. Provide family counseling family-centered programs have higher success rates.

  •  Examine the eating patterns of the family. Some cultures have a high proportion of starches; others associate large meals with prosperity.
  •  Suggest the use of positive reinforcement for the adolescent rather than shaming the child.
  •  Have family support child by removing high calorie foods from their meals.
  •  Child and family must be motivated for weight loss to occur (use motivational interviewing to set mutual goals).
  •  Incorporate cultural values and diet considerations into nutritional plan.
  •  Decrease screen time and increase physical activity.

E. Complications: Type 2 diabetes, metabolic syndrome, high blood pressure, asthma, sleep apnea, fatty liver disease, hyperlipidemia, early puberty, polycystic ovary disease, menstrual irregularities, acne, gallbladder disease, slipped capital femoral epiphysis, knee pain.
F. Monitor and treat hypertension if dietary and exercise modifications do not result in decreased blood pressure. Obese children should be monitored for hyperlipidemia (lipid panel), type 2 diabetes (fasting glucose and HA1c), thyroid disease (thyroid-stimulating hormone; TSH), and treated with oral antihyperglycemic agents (Glucophage [metformin]) if indicated.

[/sociallocker]

FURTHER READING/STUDY:

Resources:

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.