NR 602 Week 3 Quiz Assignment

NR 602 Week 3 Quiz

NR 602 Week 3 Quiz

Encopresis

Hernias

Pyloric stenosis

Pinworms

Viral gastroenteritis

Soft tissue trauma (sprains and strains)

Fractures of the lower and upper extremities

Legg-Calve’-Perthes

Oschgood-Schlatter disease

Scoliosis

Slipped capital femoral epiphysis

Genu Valgum and Genu Varum

Nurse Maid’s elbow and other dislocations

Boxer fracture

Jammed fingers or joints

Recognition of more serious conditions, including osteomyelitis, neoplasms of the bones, and juvenile rheumatoid arthritis.

NR 602 Week 3 Quiz

Vomiting and Dehydration

Vomiting is the forceful emptying of gastric contents coordinated by the medullary vomiting center and/or the chemoreceptor trigger zone of the brain. It is differentiated from regurgitation, which is a passive reflux of gastric contents into the oral pharynx. It can be caused by GI or extraintestinal disorders that are either acute or chronic. Vomiting can be classified as projectile (often arising from the central nervous system [CNS]) or non-projectile (often seen in GER), and bilious, bloody, nonbilious, or nonbloody.

The age of the child helps to formulate an appropriate list of potential diagnoses:

• Newborn or young infant—infectious process, congenital GI anomaly, CNS abnormality, or inborn errors of metabolism
• Infants and young children—gastroenteritis, GERD, milk/soy protein allergies, pyloric stenosis or obstructive lesion, inborn errors of metabolism, intussusception, child abuse, intracranial mass lesion
• Older children and adolescents—gastroenteritis, systemic illness, CNS (cyclic vomiting syndrome [CVS], abdominal migraine, meningitis, brain tumor), intussusception, rumination, superior mesenteric artery syndrome, pregnancy

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Dehydration is the loss of water and extracellular fluid. Volume depletion or hypovolemia (loss of extracellular fluid) and dehydration are used interchangeably. Dehydration is classified as mild (less than 3% weight loss when compared with recent current weight in older children and 5% in infants), moderate (6% in older children and 10% in infants), or severe (9% or greater in older children and 15% or greater in infants) (Thomas, 2015).

Vomiting is one of the most common symptoms in childhood. Nonbilious vomit is generally caused by infection, inflammation, and metabolic, neurologic, or psychological problems. An obstructive lesion generally causes bilious vomiting. Bloody vomit accompanies active bleeding in the upper GI tract (gastritis, peptic ulcer disease [PUD]).

Following is a list of potential causes of vomiting by site of origin:

• Oropharynx: Cleft palate and laryngopharyngeal cleft
• Upper GI: Congenital stricture, foreign body, gastritis and/or esophagitis, gastric web, pyloric stenosis, tracheoesophageal fistula, vascular ring, PUD
• Small intestine: Annular pancreas, choledochal cyst, intestinal atresias and stenosis, intestinal malrotation with volvulus, intestinal pseudo-obstruction
• Colon: Hirschsprung disease, intussusception, meconium ileus, necrotizing enterocolitis, fecal impaction
• Hepatobiliary or pancreatic dysfunction
• Infections: Bacterial enteritis, otitis media, sepsis, urinary tract infection (UTI), viral gastroenteritis (VGE), hepatitis
• Neurologic: Congenital anatomic malformation, gray and white matter degenerative disorders, hydrocephalus, kernicterus, brain tumors, migraine headache, head trauma
• Other: Cow’s-milk protein (CMP) allergy (intolerance), inborn errors of metabolism, maternal drug exposure and/or withdrawal, toxic ingestions, appendicitis, cyclic vomiting, pneumonia, drug or alcohol ingestion, eating disorders, pregnancy

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Management

Vomiting

• Identify and alleviate the cause as soon as possible.
• Antiemetics (not recommended in acute gastroenteritis or when cause is unknown) may at times be warranted. Newer medications, such as 5-HT3 receptor antagonists (ondansetron or granisetron) do not have adverse effects on the CNS and may be indicated in children and their use encouraged (Freedman et?al, 2014).
• Refer to specialist for persistent vomiting, recurrent vomiting, or vomiting associated with significant underlying process.image

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Dehydration

• Determine the degree of dehydration.
• If minimal, mild, or moderate, oral rehydration solution (ORS) with 70 to 90?mEq/L sodium, 25?g/L glucose, 20?mEq/L potassium, 30?mEq/L base (in the form of citrate, acetate, or lactate) with a defined osmolarity of 240 to 300?mOsm/L is recommended.
• If severe, immediate and aggressive intervention is needed (e.g., IV fluids).image
• Pediatric subcutaneous rehydration using recombinant human hyaluronidase is an alternate method, effective when used in children with mild to moderate dehydration who require parenteral therapy (Spandorfer et?al, 2012)

Initial rehydration, maintenance of fluids, and replacement of ongoing losses are stages of treatment (Table 33-3). Physiologically sodium and glucose are coupled in transport across the intestinal brush border into systemic circulation to maximize rehydration. Administration of oral fluid should be in frequent, small (5?mL or less) amounts. Larger amounts may be given as tolerated. Plain water, juices, soda, milk, and sports drinks should be avoided, because these liquids are hyperosmolar and do not provide appropriate replacement of sugars and electrolytes. A pediatric emergency department using ORS in children with moderate dehydration showed not only successful rehydration but also a decreased length of stay, less staff use, and more satisfied parents (Bell, 2010). Palatability of ORS does not affect 841the quantity consumed. Homemade solute ions can be used when premade ORS is not available (see rehydrate.org). Refeeding should resume as quickly as possible, because the gut needs nutrition to facilitate mucosal repair following injury.

• Antiemetics: A single dose of an oral disintegrating tablet of ondansetron (2?mg for children 8 to 15?kg, 4?mg for children 15 to 30?kg, and 8?mg for more than 30?kg) reduces vomiting (Freedman et?al, 2014).
• Treat fever and monitor urine output.
• Refer if the child has a toxic appearance, severe dehydration, projectile vomiting, abnormal examination, vomiting for greater than 12 hours, or vomiting of blood, bile, or fecal matter, or significantly decreased urine output.

NR 602 Week 3 Quiz

Gastroesophageal Reflux Disease

Gastroesophageal reflux refers to the passage of gastric contents into the esophagus from the stomach through the LES. It is a normal physiologic process that occurs several times a day in healthy infants, children, and adults. “GERD is present when the reflux causes troublesome symptoms and or complications” (Vandenplas et?al, 2009, p 499). GERD is the most common esophageal disorder in children (Khan and Orenstein, 2011b).

The etiology of GERD is unclear and probably multifactorial. Inappropriate relaxation of the LES with failure to prevent gastric acid reflux into the esophagus, prolonged esophageal clearance of the gastric refluxate, and impaired esophageal mucosal barrier function are the likely causes of most GERD (Loots et?al, 2014). LES function usually is influenced by intraabdominal pressure, hormones, neurologic control, and age. Young infants have increased intraabdominal pressure because of their inability to sit upright. They can also regurgitate when they cough, cry, or strain. In healthy infants, regurgitation is highest in the first month of life (73%) and decreases to 50% by the fifth month of life. During the first 2 months of life, 20% of infants regurgitate more than four times per day. After 1 year old, less than 4% of infants regurgitate daily and nearly all resolve by 2 years old. Weight gain is less in infants who regurgitate more than four times per day and breastfed babies regurgitate less than formula-fed babies (Khan and Orenstein, 2011b).

Alterations in swallowing, pharyngeal coordination, esophageal motility, and delayed gastric emptying are also potential factors related to GERD. Increased muscle tone, chronic supine positioning, and altered GI motility exacerbate GERD. Helicobacter pylori has been associated with GERD. Children with H. pylori are about six times more likely to develop GERD than non–H. pylori-positive children. H. pylori has not been found in infants younger than 1 year old (Polat and Polat, 2012).

The American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS) states that 10% of infants younger than 1 year old with regurgitation develop significant complications (GERD) (AAO-HNS, 2011). Risk factors include prematurity, neurologic impairment, obesity, CF, hiatal hernia, and family history of GERD.

NR 602 Week 3 Quiz

Clinical Findings

Common signs and symptoms by age that should lead the clinician to suspect GERD are found in Table 33-4; 845 although, according to the guidelines, there is no symptom or symptom complex that is diagnostic of GERD or predicts response to therapy. In older children and adolescents, history and physical examination may be sufficient to diagnose GERD. The most common symptom is “heartburn.” Recurrent regurgitation with or without vomiting, weight loss or poor weight gain, ruminative behavior, hematemesis, dysphagia, and respiratory disorders such as, wheezing, stridor, cough, apnea, hoarseness, and recurrent pneumonia are also associated with GERD.

Intussusception

Intussusception involves a section of intestine being pulled antegrade into adjacent intestine with the proximal bowel trapped in the distal segment. The invagination of bowel begins proximal to the ileocecal valve and is usually ileocolic, but it can be ileoileal or colocolic. Intussusception is 859thought to be the most frequent reason for intestinal obstruction in children. Intussusception most commonly occurs between 5 and 10 months of age and is also the most common cause of intestinal obstruction in children 3 months to 6 years old; 80% of the cases occur before 2 years of age. In younger infants, intussusception is generally idiopathic and responds to nonoperative approaches. In some children, there is a known medical predisposing factor, such as polyps, Meckel diverticulum, Henoch-Schönlein purpura, constipation, lymphomas, lipomas, parasites, rotavirus, adenovirus, and foreign bodies. Intussusception may also be a complication of CF. Children older than 3 years are more likely to have a lead point caused by polyps, lymphoma, Meckel diverticulum, or Henoch-Schönlein purpura; therefore, a cause must be investigated. The currently approved rotavirus vaccines have not been associated with an increased risk of intussusception (Kennedy and Liacouras, 2011).

Clinical Findings

History

• The classic triad for intussusception, intermittent colicky (crampy) abdominal pain, vomiting, and bloody mucous stools, are present in fewer than 15% of cases (Kennedy and Liacouras, 2011):
• Paroxysmal, episodic abdominal pain with vomiting every 5 to 30 minutes. Vomiting is nonbilious initially. Some children do not have any pain.
• Screaming with drawing up of the legs with periods of calm, sleeping, or lethargy between episodes.
• Stool, possibly diarrhea in nature, with blood (“currant jelly”).
• A history of a URI is common.
• Lethargy is a common presenting symptom.
• Fever may or may not be present; can be a late sign of transmural gangrene and infarction.
• Severe prostration is possible.

Physical Examination

• Observe the baby’s appearance and behavior over a period of time; often the child appears glassy-eyed and groggy between episodes, almost as if sedated.
• A sausage-like mass may be felt in the RUQ of the abdomen with emptiness in the RLQ (Dance sign); observe the infant when quiet between spasms.
• The abdomen is often distended and tender to palpation.
• Grossly bloody or guaiac-positive stools.

Clinical Findings

History

• The classic triad for intussusception, intermittent colicky (crampy) abdominal pain, vomiting, and bloody mucous stools, are present in fewer than 15% of cases (Kennedy and Liacouras, 2011):
• Paroxysmal, episodic abdominal pain with vomiting every 5 to 30 minutes. Vomiting is nonbilious initially. Some children do not have any pain.
• Screaming with drawing up of the legs with periods of calm, sleeping, or lethargy between episodes.
• Stool, possibly diarrhea in nature, with blood (“currant jelly”).
• A history of a URI is common.
• Lethargy is a common presenting symptom.
• Fever may or may not be present; can be a late sign of transmural gangrene and infarction.
• Severe prostration is possible.

Physical Examination

• Observe the baby’s appearance and behavior over a period of time; often the child appears glassy-eyed and groggy between episodes, almost as if sedated.
• A sausage-like mass may be felt in the RUQ of the abdomen with emptiness in the RLQ (Dance sign); observe the infant when quiet between spasms.
• The abdomen is often distended and tender to palpation.
• Grossly bloody or guaiac-positive stools.

NR 602 Week 3 Quiz

Diagnostic Studies

• An abdominal flat-plate radiograph can appear normal, especially early in the course and reveal intussusceptions in only about 60% of cases (Fig. 33-5). A plain radiograph may show sparse or no intestinal gas or stool in the ascending colon with air-fluid levels and distension in the small bowel only.

Abdominal ultrasound is very accurate in detecting intussusception and is the test of choice (Ross and LeLeiko, 2010). It shows “target sign” and the “pseudo kidney” sign and can also be used to evaluate resolution following air contrast enema.

• An air contrast enema is both diagnostic and a treatment modality.

Differential Diagnosis

The differential diagnosis includes incarcerated hernia, testicular torsion, acute gastroenteritis, appendicitis, colic, and intestinal obstruction.

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Management

• Emergency management and consultation with a pediatric radiologist and a pediatric surgeon is recommended.
• Rehydration and stabilization of fluid status; gastric decompression.
• Radiologic reduction using a therapeutic air contrast enema under fluoroscopy is the gold standard.
• Surgery is necessary if perforation, peritonitis, or hypovolemic shock is suspected or radiologic reduction fails.
• IV antibiotics are often administered to cover potential intestinal perforation.
• A period of observation following radiologic reduction is recommended (12 to 18 hours); clear discharge instructions to return with any recurrence of symptoms are required, and close phone follow-up for up to 72 hours is prudent.

Complications

Swelling, hemorrhage, incarceration, and necrosis of the bowel requiring bowel resection may occur. Perforation, sepsis, shock, and re-intussusception (reported to typically be less than 10%, usually within 72 hours of radiologic reduction but can occur up to 36 months later) can all occur. Recurrence is associated with the lead points described earlier.

NR 602 Week 3 Quiz

Childhood Functional Abdominal Pain and Functional Abdominal Pain Syndrome

Children who have recurrent abdominal pain with no specific organic etiology are said to have functional abdominal pain (FAP), which is also known as recurrent abdominal painand is often a puzzling problem for providers. FAP is much more common than organic reasons for abdominal pain. The Rome III criteria are used as the diagnostic standards (Rasquin et?al, 2006; Rutten et?al, 2014). These criteria include:

• FAP: The following must occur at least once per week for at least 2 months before diagnosis:
• Episodic or continuous abdominal pain
• Insufficient criteria for other functional GI disorders
• No evidence of an inflammatory, anatomic, metabolic, or neoplastic process to explain symptoms
• Functional abdominal pain syndrome (FAPS): One or more of the following must occur at least once per week for at least 2 months before diagnosis and include childhood FAP criteria at least 25% of the time:
• Some loss of daily functioning
• Additional somatic symptoms, such as headache, limb pain, or difficulty sleeping

FAP is a fairly common pediatric complaint. The cause of the pain remains unclear, but the pain is genuine. There is no evidence of visceral hypersensitivity in the rectum (Rasquin et?al, 2006; Rutten et?al, 2014) as occurs with IBS. Affected children have an involuntary predisposition for the development of physiologic pain (e.g., a family history of FAP). Temperament and personality can make the child more vulnerable to environmental stressors (often minor) that precipitate the sensation of pain. Children who are perfectionists and have a tendency toward anxiety are more likely to experience FAP. Stress at school, home, with friends, or because of a novel social situation may be associated with FAP symptoms (Bishop and Ebach, 2015). Positive and negative reinforcement can modify the pain.

Approximately 15% to 35% of children worldwide have recurrent abdominal pain with about one third of those having no specific organic disorder (Gottsegen, 2010). FAP is the most common pain complaint of preschoolers and accounts for 2% of pediatric visits (Scheffer, 2011). The peak incidence of FAP occurs between 7 and 12 years old (Bishop and Ebach, 2015).

NR 602 Week 3 Quiz

Acute Diarrhea

The term acute gastroenteritis was formerly used to describe acute diarrhea, but this term is technically a misnomer because the etiology of diarrhea does not technically involve the stomach (Guandalini and Assiri, 2014). With acute diarrhea, there is a disruption of the normal intestinal net absorptive versus secretory mechanisms of fluids and electrolytes, resulting in excessive loss of fluid into the intestinal lumen. This can lead to dehydration, electrolyte imbalance, and in severe cases, death in those also malnourished. In children younger than 2 years old, this translates to a daily stool volume of more than 10?mL/kg (this definition excludes the normal breastfeeding stooling of five or six stools per day). In children older than 2 years old, diarrheal stooling is described as occurring four or more times in 24 hours. The duration can last up to 14 days.

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Viruses can injure the absorptive surface of mature villous cells, which reduces the amount of fluid absorbed. Some can release a viral enterotoxin (e.g., rotavirus). A loss of water and electrolytes ensues, and there can be volumes of watery diarrhea, even if the child is not being fed. Bacterial and parasitic agents can adhere and/or translocate, causing noninflammatory diarrhea. Bacteria can also damage the anatomy and functional ability of the intestinal mucosa by direct invasion. Some bacteria release endotoxins, whereas others release cytotoxins that result in the excretion of fluid, protein, and cells into the intestinal lumen and an inflammatory response in some cases. Abnormal peristalsis for any reason can result in acute diarrhea. The enteric pathogens are spread through the fecal-oral route and by ingestion of contaminated food or water.

Worldwide, the burden of acute diarrhea is huge, resulting in 3 to 5 billion cases and nearly 2 billion deaths (20% of total child deaths) in children younger than 5 years old (particularly vulnerable) (Bell, 2010; Guandalini and Assiri, 2014; Norman et?al, 2010). Developing countries also see their share of the burden of this disease (approximately 10%), attributable to poor water, sanitation, and hygiene (Norman et?al, 2010). Globally, females have higher rates of Campylobacter species infections and hemolytic uremic syndrome; otherwise the incidence of cases shows no gender preference. Nontyphoidal Salmonella, Shigella, Campylobacter, E. coli organisms (bacteria); rotavirus, norovirus, enteric adenovirus (viruses); and Giardia, Cryptosporidium, and Strongyloides (parasites) cause most disease (Ahmed Bhutta, 2011). Shigella, E. coli, Giardia lamblia, Cryptosporidium parvum, and Entamoeba histolytica are particularly infectious in small amounts. The term “dysentery” is used to indicate infection with specific species of Shigella and Salmonella(e.g., Shigella dysenteriae).

In the United States, those most vulnerable include Native Americans and Native Alaskans, where remote residential locations or living on reservations compomises sanitation and safe water supplies, and where severe rotavirus diarrhea occurs. About 200,000 hospitalizations in the United States occur annually due to diarrheal illness with 300 deaths (Bell, 2010). The most common viral pathogens are noroviruses and rotavirus, followed by adenoviruses and astroviruses. Food-borne bacterial or parasitic diarrheal diseases are most commonly due to Salmonella and Campylobacter species, followed by Shigella, Cryptosporidium, E. coli O157:H7, Yersinia, Listeria, Vibrio (Vibrio cholerae and other species), and Cyclospora species. C. difficile has been associated with pseudomembranous colitis and diarrhea after the use of antibiotics, but it is not the causative agent in most antibiotic-associated diarrhea in children in the United States (Ahmed Bhutta, 2011).

Tables 33-11 and 33-14 discuss the characteristics of diarrheal diseases caused by bacteria, viruses, and parasites that a primary care provider is more likely to encounter and needs to differentiate. Infections due to Cryptosporidium, E. coli O157:H7, Giardia, Listeria, Salmonella, Shigella, and V. cholerae are required to be reported to the CDC. The enteric pathogens encountered more in day care settings include rotavirus, astrovirus, calicivirus, Campylobacter, Shigella, Giardia, and Cryptosporidium species (Guandalini and Assisri, 2014).

NR 602 Week 3 Quiz

Differential Diagnosis

Diarrhea from viral etiology and antibiotic use are the most common causes of diarrhea in all age groups. Systemic infection is a common cause in infants and children, and food poisoning is a common cause in children and adolescents. Overfeeding should also be considered in infants. Rare causes of acute diarrhea in infants include primary disaccharidase deficiency, Hirschsprung toxic colitis, adrenogenital syndrome, and neonate opiate withdrawal; toxic ingestion in children; and hyperthyroidism in adolescents.

Management

The foundation of all treatment of acute diarrhea is fourfold:

• Restore and maintain hydration and correct/maintain electrolyte and acid-base balance. Oral rehydration with an oral electrolyte solution should be attempted when dehydration is assessed between 3% and 9%. Administer parenteral hydration if necessary for the following: impaired circulation and possible shock, weight less than 4 to 5?kg or a child younger than 3 months old, intractable diarrhea, lethargy, anatomic anomalies, or failure to gain weight or continued weight loss despite oral fluids (see Table 33-3).
• Maintain nutrition. Resume early refeeding because contents of the bowel stimulate the growth of enterocytes and help facilitate mucosal repair following injury (see Table 33-3).
• Prescribe antibiotics prudently. Antibiotics are recommended for acute diarrhea caused by G. lamblia, V. cholerae,and Shigella species and can be considered for infections caused by enteropathogenic E. coli (if infection prolonged), enteroinvasive E. coli, Yersinia for those with sickle cell disease, and Salmonella in young infants with fever or positive blood culture findings (Guandalini and Assiri, 2014) (see Tables 33-11 and 33-12). Children with HIV at risk for acute diarrhea may benefit from cotrimoxazole and vitamin A (Humphreys et?al, 2010).