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: System Assessment

Focus topic: Pediatric Nursing

A. History: family history, perinatal events, prior feeding or stooling disorders, anorexia, emesis, pain, fever, allergies, usual bowel and bladder patterns.

B. Inspection.

  •  Assess symmetry and contour standing and lying (“pot-belly” in the toddler).
  •  Observe umbilicus for evidence of hernia.
  •  Observe for visible peristaltic waves (often indicates obstruction).
  •  Inspect area around anus for fissures or polyps. Inspect skin for diaper rash.

C. Auscultation (be sure to do before palpation).

  •  Listen to all four quadrants.
  •  High-pitched, “tinkling” sounds indicative of diarrhea or gastroenteritis.
  •  Children’s bowel sounds often “hyperactive.”

D. Percussion.

  •  Tympany normally heard throughout abdomen.
  •  Dullness usually along right costal margin to 1–3 cm below.
  •  Dullness around symphysis pubis indicative of full bladder and is normal.

E. Palpation.

  • Palpate last any areas identified as painful.
  •  Ticklish children can place their hand under examiner’s to palpate.
  •  Spleen tip can be felt 1–2 cm below left costal margin during inspiration in infants and young children.
  •  Kidneys may be palpable in neonates, rarely in any other age group.
  •  Sigmoid colon may be felt as a tender, sausage-shaped mass.
  •  Palpate for inguinal and femoral hernias.

F. Assess hydration status.

  •  Skin color, temperature, turgor, fontanelles.
  •  Recent intake and output history.

G. Nutritional status.

  •  Failure to gain weight—evaluate growth patterns on chart.
  •  Abnormal stools, pattern, recent changes.
  •  Usual diet.

 

Pediatric Nursing: Diagnostic Procedures

Focus topic:  Pediatric Nursing

Oropharyngeal Motility (Swallowing) Study
A. Child is given small amounts of a liquid containing barium to drink with a bottle, spoon, or cup.
B. A series of x-rays are taken to evaluate what happens as child swallows the liquid.

Ultrasound
A. High-frequency sound waves create computer generated images of blood vessels, tissues, and organs; used to view internal organs as they function.
B. Helpful in diagnosing appendicitis and structural abnormalities.

Colonoscopy
A. Colonoscope is inserted through the rectum up into the colon.
B. The colonoscope allows the physician to see the lining of the colon, remove tissue for further examination, and possibly treat some problems that are discovered.
C. Client may require conscious sedation.

Endoscopic Retrograde Cholangiopancreatography
A. Procedure allows the physician to diagnose and treat problems in liver, gallbladder, bile ducts, and pancreas.
B. Combines x-ray and use of an endoscope guided through the mouth and throat, esophagus, stomach, and duodenum.

C. Tube is then passed through scope and a dye is injected that allows internal organs to appear on x-ray.

Esophagogastroduodenoscopy (Upper Endoscopy)
A. Esophagogastroduodenoscopy (EGD) allows physician to look at inside of the esophagus, stomach, and duodenum.
B. Endoscope allows physician to view inside of this area of the body and to insert instruments through a scope for removal of a sample of tissue for biopsy (if necessary).

Esophageal pH Monitoring
A. Measure acidity inside of esophagus helpful in evaluating gastroesophageal reflux disease (GERD).

B. A thin plastic tube is placed into a nostril, guided down the throat and then into esophagus. The tube stops just above lower esophageal sphincter.

C. At end of the tube inside the esophagus is a sensor that measures pH or acidity.

D. The other end of the tube (outside body) is connected to a monitor that records the pH levels for a 12- to 24-hour period.

  •  Normal activity is encouraged during the study, and a diary is kept of symptoms experienced or activity that might be suspicious for reflux, such as gagging or coughing.
  • The pH readings are evaluated and compared to child’s activity for that time period.

Anorectal Manometry
A. Helps determine strength of muscles in rectum and anus and is helpful in evaluating anorectal malformations and Hirschsprung’s disease, among other problems.
B. A small tube is placed into rectum, and pressures inside the anus and rectum are measured.

Esophageal Manometry
A. Helps determine strength of the muscles in the esophagus.
B. Useful in evaluating gastroesophageal reflux and swallowing abnormalities

  • Small tube is guided into the nostril, then into the esophagus.
  • The pressure that esophageal muscles produce at rest is then measured.

Barium Enema
A. A procedure in which a barium mixture is placed in the large intestine via a rectal catheter for x-ray visualization of the entire large intestine.

  • B. Nursing responsibilities prior to procedure. Cleanse the bowel through enemas.
  •  Restrict diet (clear fluids for 24 hours).
  •  Prepare child and family through teaching.

C. Nursing responsibilities following procedure.

  •  Avoid impaction from barium.
    a. Provide child with large fluid intake.
    b. Administer laxative or cleansing enemas.
  • Advise parents and child that stools will be white for 24–72 hours following procedure.

Upper Gastrointestinal Radiography
A. Radiographic study of esophagus, stomach, and small bowel using barium contrast.
B. Client must be NPO before procedure.
C. Children often are resistant to swallowing barium.

Small Bowel Follow-Through
A. Radiographic study of lower small intestine using sequential films as barium contrast progresses.
B. Test may take up to 90 minutes depending on intestinal transit time, sequential films taken.

Liver Biopsy
A. Many liver diseases are diagnosable only by direct biopsy.
B. Sample of liver tissue is obtained with large-bore needle.
C. Requires sedation per institutional protocol.
D. Child must have normal coagulation studies or receive vitamin K or fresh frozen plasma with procedure.

Cholangiography
A. Variety of tests to examine gallbladder and biliary tree.
B. Contrast medium may be administered orally and/ or IV, or pushed into biliary tree from duodenal endoscope or directly injected into liver.

 Pediatric Nursing: System Implementation

Focus topic:  Pediatric Nursing

A. Evaluate vital signs.

  • Increased temperature and pulse are signs of infection.
  •  If significant dehydration has occurred, respirations and heart rate may be rapid.

B. Maintain hydration status.

C. Use contact precautions for child with vomiting or diarrhea until the causative organism is identified, then isolate depending on the organism identified.

D. Maintain nutritional status.

  •  Compare child’s growth with standardized growth chart.
  •  Evaluate food intake and meal pattern; vomiting pattern.
  •  Record stooling pattern and reaction to feedings. (If fatty, bulky stools, assess for malabsorption problem.)
  •  Evaluate laboratory results of stool culture.
  •  Determine child’s likes and dislikes and orient diet accordingly.
  • Allow bottle if child regresses and is comforted by sucking.
  •  Allow between-meal snacks that are both nutritious and fun (Popsicles, fruit bars).

E. Provide meticulous skin care, especially if diapered.

Pediatric Nursing: Anatomic Defects

Focus topic:  Pediatric Nursing

Pediatric Nursing: Cleft Lip

Focus topic:  Pediatric Nursing

Definition: A congenital defect that involves a fissure resulting from incomplete merging of embryonic processes that normally form the face or jaws. The development of a cleft lip is usually considered to be of multifactorial origin, but may be familial.

Characteristics
A. The prevalence of cleft lip and/or cleft palate is more common among Asians and Native Americans.
B. Cleft lip is more common in males than females.
C. Incidence of isolated cleft lip (CL) is about 1 in 700–800, may occur with cleft palate.
D. Cleft lip is readily diagnosed through inspection of the lip. Diagnosis may also be made in utero with ultrasound.

Assessment
A. Assess respiratory status.
B. Assess for adequate nutrition.
C. Assess vital signs for baseline data.
D. Assess for parent–child bonding because of the child’s altered appearance.

Implementation
A. Prior to surgical repair.

  •  May use special feeding techniques, obturators, unique nipples and feeders, or a syringe with tubing to administer feeding; may use a regular or soft nipple or a crosscut nipple. Breastfeeding may be possible.
  •  A soft compressible bottle will prevent the child from having to suck vigorously because the milk can be squeezed into the mouth. A longer nipple may allow the milk to be swallowed without entering the nose.
  •  Place nipple on opposite side from cleft.
  •  Feed the child slowly and provide short periods of rest for swallowing. Burp frequently.
  • Advise parents that babies will be “noisy eaters.”
  •  Mouth should be rinsed with water after feeding.

B. Postoperative care. (Surgery usually done by 3 months of age.)

  •  Observe for respiratory distress and swelling of tongue, nostrils, and mouth.
  •  Avoid circumstances that will cause crying.
  •  Watch for hemorrhage.
  •  Use elbow restraints and provide supervised rest periods to exercise arms.
  •  Secure lip-protecting device used to prevent trauma to suture site.
  •  Modify feeding technique to adapt to surgical site, feeding upright, and teaching parents in preparation for home care.
  •  After feeding, keep infant upright to decrease chance of aspiration.
  •  Clean the suture line as directed by the surgeon to prevent crust formation on suture line. Often normal saline is used to rinse followed by antibiotic ointment.
  • Lay infant on unoperated side or back with support; goal is to prevent rubbing suture site on the sheet.

C. Support family and promote bonding.

  •  Provide education and support to families of neonates.
  •  Prepare for discharge needs.

Pediatric Nursing

Pediatric Nursing: Cleft Palate

Focus topic:  Pediatric Nursing

Definition: A birth defect in which the primary and secondary palatine plates—openings between nose and roof of mouth—fail to close properly. It is usually considered hereditary. Types include clefted soft palate, clefted hard palate, and a cleft that infrequently involves the nose.

Characteristics
A. Incidence of cleft palate (CP) (without CL) is approximately 1 in 2000.
B. Cleft palate is more common in females.
C. Diagnosis may be made in utero with ultrasound and by a more complete examination during the immediate newborn period.

Assessment
A. Assess for difficulty in sucking.
B. Formula coming out of the nose; because the volume of liquid with colostrum is only a small amount, breast milk coming out of the nose is not as noticeable.
C. Assess for increase in upper respiratory infections.
D. Evaluate mother–child relationship (e.g., mother feels frustrated and baby is fussy).

Treatment
A. Surgical repairs: Some surgeons prefer to wait until the palate has had the opportunity to grow or child is 9–18 months old. Most prefer to operate prior to the onset of speech.
B. Repair in stages: may be required with extensive defects.
C. Surgical repair usually needs to be followed by treatment from an orthodontist, a speech therapist, and a plastic surgeon.

Implementation
A. Care prior to surgery.

  •  Observe for respiratory infections.
  •  Ensure that child is sitting up when fed.
  • Provide frequent mouth care.
  •  Introduce the method of postoperative feeding; for example, have the child drink from a cup, or feeder to be used after surgery.
  •  Practice arm restraints on the child, so that child becomes familiar with them.
  •  Prepare parents and give them support.
  •  Before surgery, devices such as a Latham device may be placed in the mouth to expand and realign the palate or to decrease the size of a wide lip cleft.

B. Postoperative care.

  •  Immediate postoperative period.
    a. Place child on abdomen to prevent aspiration of mucus or blood.
    b. Observe for signs of airway obstruction and have suction apparatus at the bedside.
    c. Observe for shock or hemorrhage.
    d. Utilize elbow restraints but release every 2 hours for 10–15 minutes one side at a time, while distracting the child.
    e. Rinse suture line frequently.
    f. Oral packing may be in place for 2–3 days.
  •  Second postoperative day prior to discharge.
    a. Start introducing fluids by cup; avoid straws and spoons. Avoid other hard objects (suction catheters,  tongue blades, pacifiers). Do not brush the teeth for 1–2 weeks after surgery.
    b. Advance diet as tolerated. Usually child is discharged on a blenderized or soft diet.
    c. Rinse sutures following feedings.
  •  Provide support and education to families.

 

 Pediatric Nursing: Esophageal Atresia with Tracheoesophageal Fistula

Focus topic:  Pediatric Nursing

 Definition: Failure of the esophagus to be continuous from the pharynx to the stomach. Tracheoesophageal fistula (TEF) is an abnormal connection between the trachea and the esophagus. Defects may occur separately or in combination, and are rapidly fatal if not detected. Characteristics
A. Anomaly occurs during embryonic development. Cause is unknown. (Occurs in about 1 in 3000 births.)
B. There are several different types of esophageal atresia.

  • The most simple type involves the narrowing of the esophagus.
  • The second type involves the upper and lower segments of the esophagus that are not attached to each other, creating two blind pouches.
  • Other types involve fistulas between the upper and/or lower segments of the esophagus and trachea.

C. Fistulas may be present when the esophagus is patent, when it is narrowed, or when it is not joined to its distal portion.
D. Infants at risk for TEF: premature infants and those with polyhydramnios.

Assessment
A. Assess for excessive amounts of mucus with much drooling.
B. Assess for coughing, choking, and cyanosis when fed (the three Cs of TEF).
C. Assess infant status to ingest formula.

  • Early recognition of the defect is imperative to prevent aspiration.
  •  Inability to pass NG tube at birth indicates esophageal atresia.

D. Check to see if food is expelled through the nose immediately following feeding.

  •  Assess severe coughing and choking.
  •  Assess struggling with resulting cyanosis.

E. Evaluate frequent respiratory problems; apnea may occur.
F. Check for abdominal distention caused by inspired air going into the stomach.

Implementation
A. Maintain patent airway; observe for signs of respiratory distress.
B. Prevent aspiration pneumonia.

  •  Discontinue oral fluids immediately (NPO status).
  •  Position infant at 30-degree head elevation to decrease potential of aspiration, depending on the type of esophageal atresia/ fistula.
  •  Change position every 2 hours.
  •  Suction accumulated secretions frequently.

C. Initiate and monitor IV fluids as ordered to prevent dehydration.
D. Prepare for gastrostomy tube insertion (decompresses stomach and prevents aspiration of gastric contents from fistula).

  •  Administer gastrostomy tube feedings.
  •  Observe for patency of all tubes. Do not clamp gastrostomy tube.
  •  Use gentle suctioning of the upper pouch to minimize aspiration of saliva.
  •  Monitor the gastrostomy tube in place until total repair is performed.

 Pediatric Nursing: Postoperative Implementation

Focus topic:  Pediatric Nursing

A. Maintain patent airway.

  • Suction secretions as necessary.
  •  Position for optimal ventilation.
  •  Administer oxygen as needed.
  •  Maintain care of chest tubes.

B. Prevent infection.

  •  Provide meticulous care of operative site.
  •  Observe for signs of inflammation or infection.

C. Maintain fluid and electrolyte balance.

  •  Monitor IV fluids; record intake and output.
  •  Record weight daily.
  •  Measure specific gravity of urine.

D. Maintain infant in radiant warmer with nebulized humidity.
E. Provide adequate nutrition.

  •  Administer gastrostomy feedings (usually after third postoperative day).
  •  Continue until infant tolerates oral feedings, based on condition of child and degree of healing.
  •  Monitor gradual increase in feedings and elevation of gastrostomy tube.
    a. Feed slowly to allow for swallowing and to provide infant rest.
    b. Position upright to prevent aspiration.
    c. Burp frequently.

F. Meet sucking needs by providing a pacifier (if approved by physician).
G. Prepare parents for discharge.

  • Teach techniques parents will need for home care: tube feedings, suctioning, etc.
  •  Educate parents to look for signs of complications such as esophageal constriction: difficulty in swallowing, choking, and breathing difficulties.
  •  Provide support and preparation for future procedures.

 Pediatric Nursing: Imperforate Anus

Focus topic:  Pediatric Nursing

Definition: A congenital abnormality in the formation of the anorectal canal or in the location of the anus, resulting in the rectum ending blindly. A fistula or a severe narrowing of the anal canal.

Assessment
A. Assess patency of anal opening with small finger or soft catheter if the following symptoms are present.

  •  No meconium stool within 24 hours.
  •  Green-tinged urine (presence of meconium in the urine).
  •  Progressive abdominal distention.
  •  Vomiting.
  •  A flat perineum and absence of an intergluteal groove.

B. Assess for presence of other anomalies if imperforate anus is present.
C. Observe for signs of abdominal distress.

Implementation
A. Maintain NPO status when anomaly is diagnosed, monitor IVs.
B. Check vital signs frequently and hydration.

C. Maintain temperature by using Isolette or radiant warmer.
D. Provide postoperative care.

  • Prevent infection of operative site.
  •  Provide colostomy care if colostomy is performed and prevent skin breakdown.
  • Check for return of peristalsis so that oral feedings may be started.

E. Provide supportive care to parents before and after surgery.
F. Provide education and appropriate referrals for follow-up.

 Pediatric Nursing: Obstructive Disorders

Focus topic:  Pediatric Nursing

 Pediatric Nursing: Obstruction of the Bowel

Focus topic:  Pediatric Nursing

Definition: Cause of the obstruction of the bowel could be mechanical or muscular. If congenital intestinal obstruction occurs, may be life-threatening.

Assessment
A. Absent or abnormal stools.
B. Presence of vomiting—may be projectile.
C. Distended abdomen.

  • Presence of slightly protuberant abdomen is normal.
  •  If abdomen is distended or excessively hard, evaluate for possible obstruction.
  •  Monitor respiratory status carefully as abdominal distention impinges on ability to expand diaphragm.

D. Hyperactive bowel sounds above level of obstruction, hypoactive or absent below.

Implementation
A. Passage of meconium should occur during first 3 days after birth.

  •  If not, assess the child for abdominal distention.
  •  If more than 20 mL of gastric contents is aspirated through nasogastric tube, assess for lower intestinal obstruction.
  •  Meconium ileus highly associated with cystic fibrosis.

B. Attempt to insert a nasogastric tube into stomach and aspirate contents as ordered.
C. Evaluate for excessive mucus and choking.
D. Observe for presence of cyanosis and choking on first feeding.
E. Check for projectile vomiting following feedings.

  • Evaluate infant’s diet. (Overfeeding can cause projectile vomiting.)
  •  If vomiting occurs, evaluate for signs of infection or increased intracranial pressure.
  • 3. If these conditions are not present, vomiting may be a sign of an obstruction.

F. Document evidence of abdominal pain.
G. Evaluate for absent or abnormal stooling cycle.

  •  If the child has very harsh intermittent crying or continual crying, evaluate the stool cycle for normal or abnormal stools.
  •  Ribbon-shaped stools; bulky, foul-smelling stools; or other abnormalities can be signs of a gastrointestinal abnormality.

 Pediatric Nursing: Hypertrophic Pyloric Stenosis

Focus topic:  Pediatric Nursing

Definition: The pyloric canal, which is at the distal end of the stomach and connects with the duodenum, is greatly narrowed. This narrowing is believed to be caused by a combination of muscular hypertrophy, spasms, and edema of the mucous membrane. Occurs in about 5 in 1000 males and 1 in 1000 females.

Assessment
A. Assess for vomiting in newborn. Vomiting usually begins 30–60 minutes after feedings.

  •  Progressively increases in frequency and force; usually begins at around 1 week of age.
  •  Projectile vomitus may contain mucus and blood, but usually not bile.
  •  May progress to complete obstruction.

B. Check for constant hunger, fussiness, frequent crying, colicky abdominal pain, and abdominal distention.
C. Palpate epigastrium just right of umbilicus for classic “olive”-shaped mass.
D. Evaluate stools for decrease in size and number, and assess for constipation.
E. Observe for peristaltic waves: frequently noted passing from left to right during or immediately following a feeding.
F. Assess for later symptoms, which may include malnutrition, dehydration, electrolyte imbalance, and alkalosis.
G. Evaluate growth since birth for failure to thrive.

Implementation
A. Monitor infant for metabolic alkalosis, and electrolyte imbalances (decreased sodium, decreased chloride, and decreased potassium) from vomiting
B. Provide preoperative care.

  •  Ensure accurate regulation of IV to prevent dehydration and correct electrolytes.
  •  Accurately record intake and output.
  •  Observe feeding behavior for definitive diagnosis.
  •  Prepare for possible diagnostic procedures (upper GI or abdominal ultrasound).
  • Support mother and infant.

C. Maintain proper insertion and observation of gastric tube for gastric decompression.

  •  Measure length of tube externally on infant from bridge of nose to ear to stomach.
  •  Check position of the tube. Infant should show no sign of respiratory difficulty with external end of tube occluded.
  •  Aspirate gastric contents and check pH. If < 3 (acidic), tube is in stomach.
  •  Keep head of bed flat or slightly elevated.

D. Perform nursing care following surgery. Follow standard postoperative procedures for pyloromyotomy.

  •  Maintain patent airway.
  •  After anesthesia has worn off, place in semi- Fowler’s position.
  •  Begin feedings 4–6 hours after surgery and progress slowly.
  •  Keep a careful record of feeding behavior to assist physician in determining progress of feedings. (Most infants may vomit in first 24–48 hours after surgery.)
  • Do not handle infant excessively after feeding.
  •  Observe for bleeding at wound site or signs of shock.

 Pediatric Nursing: Intussusception

Focus topic:  Pediatric Nursing

Definition: A segment of the bowel telescopes into the portion of bowel immediately distal to it. Probably results from hyperactive peristalsis in the proximal portion of the bowel, with inactive peristalsis in the distal segment. Usually occurs at the junction of the ileum with the colon, generally in children between 3 and 12 months old, or before age 2. Common in children with cystic fibrosis and celiac disease, but usual cause is unknown.

Assessment
A. Assess for sudden onset of acute abdominal pain.
B. Evaluate for sudden onset of vomiting, abdominal pain, and distention; and later, infrequent stools with blood and mucus (appears like currant jelly).
C. Child frequently pulls knees to chest, indicating pain; may appear normal between painful episodes.
D. Assess level of hydration.
E. Abdomen is distended and tender.
F. Sausage-shaped mass palpable in upper right quadrant.
G. Right lower quadrant “empty.”
H. Passage of “normal” brown stool indicates intussusception has reduced.

Implementation
A. Prepare child for barium enema x-ray, which frequently reduces the bowel; making surgery unnecessary if successful.

B. Observe and monitor for recurrence of symptoms. Surgery may need to be performed for bowel reduction.
C. Observe and maintain IV fluid and electrolyte replacement.
D. Perform nasogastric suction to deflate the stomach to prevent vomiting.
E. Gradually reintroduce fluids and foods.
F. Maintain care of operative site following surgery.
G. Prepare family for discharge.

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