1. ★ GERD (GastroEsophageal Reflux Disease)
|• GERD is the backflow of gastric and duodenal contents into the esophagus.
• Complications of GERD include esophagitis, esophageal strictures, aspiration of gastric contents, and aspiration pneumonia.
|• heartburn, epigastric pain
• dyspepsia, difficulty with swallowing
• nausea, regurgitation
|• Instruct the client to avoid factors that decrease lower esophageal sphincter pressure or cause esophageal irritation such as peppermint, chocolate, coffee, fried or fatty foods, carbonated beverages, alcoholic beverages, and cigarette smoking.
• Instruct the client to eat a low-fat, high-fiber diet and to avoid eating and drinking 2 hours before bedtime and wearing tight clothes. Provide small frequent meals and limit the amounts of liquids taken with meals. Advise the client not to recline for 1 hour after eating. Also, elevate the head of the bed on 6 to 8-inch blocks.
• Instruct the client regarding prescribed medications, such as antacids, H2-receptor antagonists, or proton pump inhibitors. Instruct the client regarding the administration of prokinetic medications, if prescribed, which accelerate gastric emptying.
• Avoid the use of anticholinergics, which delay stomach emptying. Also, NSAIDs and other medications that contain acetylsalicylic acid need to be avoided.
• [Pediatric] Breastfeeding may continue, and the mother may provide more frequent feeding times or express milk for thickening with rice cereal. For infants, the formula may be thickened by adding rice cereal to the formula. For toddlers, feed solids first, followed by liquids. Instruct the parents that the child should avoid vigorous play after feeding and avoid feeding just before bedtime.
|• Gastritis is inflammation of the stomach or gastric mucosa.
• caused by the ingestion of food contaminated with disease-causing microorganisms or food that is irritating or too highly seasoned, the overuse of aspirin or other NSAIDs, excessive alcohol intake, bile reflux, or radiation therapy
|• abdominal discomfort,
heartburn after eating
• anorexia, nausea, vomiting
• vitamin B12 deficiency
|• Foods and fluids may be withheld until symptoms subside. Afterward, and as prescribed, ice chips can be given, followed by clear liquids, and then solid food. Instruct the client to avoid irritating foods, fluids, and other substances, such as spicy and highly seasoned foods, caffeine, alcohol, and nicotine. Bland diet (low fiber).
• Instruct the client in the use of prescribed medications, such as antibiotics and antacids. Provide the client with information about the importance of vitamin B12 injections if a deficiency is present.
3. PUD (Peptic Ulcer Disease)
|• A peptic ulcer is ulceration in the mucosal wall of the stomach, pylorus, duodenum, or esophagus in portions accessible to gastric secretions. Erosion may extend through the muscle.||• bland diet, low fat|
(1) gastric ulcers
|• A gastric ulcer involves ulceration of the mucosal lining that extends to the submucosal layer of the stomach.
• Predisposing factors include stress, smoking, alcohol, caffeine, spicy foods, history of gastritis, family history of gastric ulcers, the use of corticosteroids, NSAIDs, aspirin, or infection with H. pylori.
• Complications include hemorrhage, perforation, and pyloric obstruction.
|• Gnawing, sharp pain in or to the left of the mid-epigastric region occurs 30 to 60 minutes after a meal. Food ingestion accentuates the pain. Pain is not relieved by food or antacid.
• Hematemesis is more common than melena. → absent bowel sound: priority
|• Monitor V/S.
• Monitor for signs of bleeding.
• Administer small, frequent bland feedings during the active phase.
• Administer H2 receptor antagonists or proton pump inhibitors as prescribed to decrease the secretion of gastric acid. Administer antacids to neutralize gastric secretions. Administer anticholinergics to reduce gastric motility. Administer mucosal barrier protectants as prescribed 1 hour before each meal. Administer prostaglandins as prescribed for their protective and antisecretory actions.
• surgical interventions :
total gastrectomy, vagotomy, gastric resection, Billroth 1, Billroth 2, pyloroplasty
• interventions during active bleeding: Monitor vital signs closely. Monitor hemoglobin and hematocrit. Assess for signs of dehydration, hypovolemic shock, sepsis, and respiratory insufficiency. Maintain NPO status and administer IV fluid replacement as prescribed. Monitor intake and output. Administer blood transfusions as prescribed. Prepare to assist with administering medications as prescribed to induce vasoconstriction and reduce bleeding.
(2) duodenal ulcers
|• A duodenal ulcer is a break in the mucosa of the duodenum.||• Burning pain occurs in the mid-epigastric area 1 and 1/2 to 3 hours after a meal and during the night (often awakens the client). Pain is often relieved by the ingestion of food.
• melena: more common than hematemesis
4. ★ dumping syndrome ↔ GERD
|• the rapid emptying of the gastric contents into the small intestine that occurs following gastric resection||• symptoms occurring 30 minutes after eating
• feelings of abdominal fullness and abdominal cramping
• nausea and vomiting
• palpitation and tachycardia
• perspiration (sweating)
• weakness and dizziness
|– client education: Lie down after meals. Eat a low-carbohydrate (simple CHO < complex CHO), high-protein, high-fat diet. Eat small meals and avoid consuming fluids with meals. Fluids between meals. Avoid sugar, salt, and milk (artificial sugar는 가능). Take antispasmodic medications as prescribed to delay gastric emptying.
worst food: milkshake ∵ 달고 차가워서 장의 운동을 촉진하기 때문
5. vitamin B12 deficiency
|• Vitamin B12 deficiency results from an inadequate intake of vitamin B12 or a lack of absorption of ingested vitamin B12 from the intestinal tract. Pernicious anemia results from a deficiency of intrinsic factor, necessary for intestinal absorption of vitamin B 12 (cobalamin).
• Gastric disease or surgery (ex) gastrectomy) can result in a lack of intrinsic factor.
|• sever pallor
• fatigue, disturbance with gait and balance, paresthesia of the hands and feet: neuralgia sign
• weight loss
• smooth, beefy red tongue: anemia sign
• slight jaundice
|• Increase dietary intake of foods rich in vitamin B12 if the anemia is the result of a dietary deficiency.
• Administer vitamin B12 injections as prescribed, weekly initially, and then monthly for lifelong maintenance if the anemia is the result of a deficiency of intrinsic factor or disease or surgery of the ileum.
Cf.) vitamin B1 (티아민) : 에너지 대사에 관여 ∵ 알코올은 티아민 결핍을 야기
Vitamin B12 (액티나마이드) : 혈구 생성에 관여
6. ulcerative colitis
|• an ulcerative and inflammatory disease of the bowel that results in poor absorption of nutrients
• commonly begins in the rectum and spreads upward toward the cecum,
occurs in continuous areas
• characterized by various periods of remissions and exacerbations
• curable with surgery
• colorectal ca. 의 위험요인
|• abdominal tenderness and cramping
• severe diarrhea that may contain blood, mucus, and pus
• anorexia, weight loss, malaise
• malnutrition, dehydration, and electrolyte imbalances
• vitamin K deficiency, anemia
|• Monitor I/O.
• Monitor bowel sounds for abdominal cramping.
• Monitor stools, noting color, consistency, and the presence or absence of blood.
• In the acute phase, maintain NPO status and administer fluids and electrolytes intravenously or via parenteral nutrition as prescribed. Restrict the client’s activity to reduce intestinal activity.
• Following the acute phase, the diet progresses from clear liquids to a low-fiber diet as tolerated. Usually, a low-fiber, low-fat, high-protein diet with vitamins and iron supplements are prescribed. Instruct the client to avoid gas-forming foods, milk products, and foods such as whole wheat grains, nuts, raw fruits and vegetables, pepper, alcohol, and caffeine-containing products.
• Administer medications as prescribed, which may include a combination of medications such as salicylate compounds, corticosteroids, immunosuppressants, and antidiarrheals.
• surgical interventions :
total proctocolectomy with a permanent ileostomy, Kock ileostomy, ileoanal reservoir, ileoanal anastomosis
7. Crohn’s disease
|• an inflammatory disease that can occur anywhere in the GI tract but most often affects the terminal ileum and leads to thickening and scarring, a narrowed lumen, fistulas, ulcerations, and abscesses
• occurs in sporadic areas
• characterized by remissions and exacerbations
• colorectal ca.의 위험요인
|• abdominal distention,
cramp-like and colicky pain after meals
• diarrhea (semi-solid) that may contain mucus and pus, steatorrhea
• anorexia, weight loss
• malnutrition, dehydration, and electrolyte imbalances
|• similar to that for the client with ulcerative colitis|
8. GE (GastroEnteritis)
|• diagnosed by stool|
9. diverticulosis and diverticulitis
|• Diverticulosis is an outpouching or herniation of the intestinal mucosa.
• Diverticulitis is the inflammation of one or more diverticula that occurs from penetration or fecal matter through the thin-walled diverticula.
|• cramp-like pain, left lower quadrant abdominal pain that increases with coughing, straining, or lifting
abdominal distention and tenderness
• nausea, vomiting
• blood in the stools
|• In the acute phase, maintain NPO status. Restrict the client’s activity to reduce intestinal activity. Instruct the client to refrain from lifting, straining, coughing, or bending to avoid increased intraabdominal pressure.
• Instruct the client to increase fluid intake to 2500 to 3000mL daily, unless contraindicated.
• Administer antibiotics, analgesics, and anticholinergics.
• Instruct the client to consume a small amount of bran daily and to take bulk-forming laxatives as prescribed to increase stool mass.
• Introduce a fiber-containing diet gradually to prevent constipation when the inflammation has resolved (when diverticulosis). Instruct the client to eat soft high-fiber foods, such as whole grains. The client should avoid high-fiber foods and eat low-residue foods when inflammation occurs (when diverticulitis) because these foods will irritate the mucosa further.
Instruct the client to avoid gas-forming foods or foods containing indigestible roughage, seeds, or nuts (ex) berries, cucumber, squash, popcorn) because these food substances become trapped in diverticula and cause inflammation.
• surgical intervention: colon resection, temporary or permanent colostomy
|• 우선순위 높음||• sudden severe abdominal pain,
radiated to the right shoulder,
board-like abdominal pain• tenderness, abdomen rigidity,
decreased bowel sound• shock: BP ↓, HR ↑, RR ↑, BT ↑
11. hiatal hernia (esophageal hernia, diaphragmatic hernia)
|• A portion of the stomach herniates through the diaphragm and into the thorax.||• heartburn, epigastric pain
• the feeling of fullness, dysphagia, nausea, regurgitation
|• similar to those for the care of a client with GERD|
12. cholelithiasis and cholecystitis
|• Acute cholecystitis is associated with cholelithiasis (gallstones).
• Cholecystitis is the inflammation of the gallbladder that may occur as an acute or chronic process
|• epigastric pain that radiates to the right scapula 2 to 4 hours after eating fatty foods and may resist for 4 to 6 hours,
pain localized in the right upper quadrant,
positive in Murphy’s sign (cannot take a deep breath when the examiner’s fingers are passed below the hepatic margin because of pain)
rebound tenderness, rigidity• nausea, vomiting, indigestion, diarrhea• low-grade fever• jaundice, pruritus, clay-colored stools, steatorrhea, dark-color urine
|• Maintain NPO status.
Maintain nasogastric decompression as prescribed for severe vomiting.• Administer antiemetics, analgesics, anticholinergics as prescribed.• Instruct the client to eat small, regular, low-fat, and calorie-restricted meals. Instruct the client to avoid gas-forming foods.• surgical intervention :
• care of a T-tube
13. ★ hepatitis
|• inflammation of the liver caused by a virus, bacteria, or exposure to medications or hepatotoxins
• types of hepatitis: HAV (Hepatitis A Virus), HBV, HCV, HDV, HEV
|• pre-icteric stage: flulike symptoms
• icteric stage: jaundice, pruritus, clay-colored stools, dark-color urine
• post-icteric stage: the convalescent stage of hepatitis
• home care instructions for the client with hepatitis: Hand washing must be strict and frequent. Do not share bathrooms unless the client strictly adheres to personal hygiene measures. Individual washcloths, towels, drinking and eating utensils, toothbrushes, and razors must be labeled and identified. The client may maintain normal contact with persons as long as proper personal hygiene is maintained. Close personal contact such as kissing should be discouraged until hepatitis B surface antigen test results are negative. The client is to avoid sexual activity until hepatitis B surface antigen results are negative. The client must not prepare food for other family members. The client should consume small, regular, frequent meals consisting of high- calorie, high-carbohydrate, low-fat foods. The client should increase activity gradually to prevent fatigue. The client should avoid alcohol and over-the-counter medications, particularly acetaminophen (Tylenol) and sedatives because these medications are hepatotoxic. The client is not to donate blood.
1) hepatitis A
|• individual at increased risk: commonly seen in young children, individuals in institutional settings, health care personnel
• transmission: fecal-oral route, parenteral, poorly washed utensils, person-to-person contact
• incubation period: 2 to 6 weeks
• infectious periods: 2 to 3 weeks before and 1 week after the development of jaundice
|• Infection is established by the presence of anti-HAV (HAV antibodies) in the blood.
• IgM and IgG are normally present in the blood, increased levels indicate infection and inflammation.
• Ongoing inflammation of the liver is evidenced by the presence of elevated levels of IgM antibodies, which persist in the blood for 4 to 6 weeks.
• Previous infection is indicated by the presence of elevated levels of IgG antibodies.
|• strict hand washing
Provide enteric precautions for at least 1 week after the onset of jaundice with HAV. P The hospitalized child usually is not isolated in a separate room unless he or she is (fecal) incontinent and items are likely to become contaminated with feces.
• stool and needle precaution
• hepatitis A vaccine (HAVRIX, VAQTA)
• immune globulin: For individuals exposed to HAV who have never received the hepatitis A vaccine, administer immune globulin during the period of incubation and within 2 weeks of exposure.
• Pre-exposure prophylaxis with immunoglobulin is recommended to individuals traveling to countries with poor or uncertain sanitation conditions.
2) hepatitis B
|• individual at increased risk: IV drug users, clients undergoing long-term hemodialysis, health care personnel
• transmission: blood or body fluid contact, parenteral, sexual contact, perinatal period
• incubation period: 6 to 24 weeks
• chronic, fulminant
|• Infection is established by the presence of hepatitis B antigen-antibody systems in the blood.
• The presence of HBsAg is the serological marker establishing the diagnosis of hepatitis B. The client is considered infectious if these antigens are present in the blood. Hepatitis B early antigen (HBeAg) is detected in the blood about 1 week after the appearance of HBsAg and its presence determines the infective state of the client.
• The presence of anti-HBs indicates recovery and immunity to hepatitis B.
|• strict hand washing
• needle precaution
• Avoiding intimate sexual contact if the test for HBsAg is positive.
• testing of all pregnant women
• hepatitis B vaccine (Engerix-B, Recombivax HB)
• Hepatitis B immune globulin is for individuals exposed to HBV through sexual contact or through the percutaneous or transmucosal routes who have never had hepatitis B and have never received the hepatitis B vaccine.
3) hepatitis C
|• individuals at increased risk; same as for HBV
• transmission: same as for HBV, blood or body fluid contact
• incubation period: 5 to 10 weeks
|• Anti-HCV is measured to detect chronic states of hepatitis C.||• strict hand washing
• needle precautions
4) hepatitis D
|• Hepatitis D occurs with hepatitis B and causes infection only in the presence of active HBV infection.
• individuals at increased risk; same as for HBV
• transmission: same as for HBV, blood or body fluid contact
• incubation period: 7 to 8 weeks
|• Serological HDV determination is made by detection of the HDAg early in the course of the infection and by detection of anti-HDV antibody in the later disease stages.||• Because hepatitis D must coexist with hepatitis B, the precautions that help prevent hepatitis B are also useful in preventing hepatitis D.
• vaccine 있음.
5) hepatitis E
|• individuals at increased risk; same as for HAV
• transmission: same as for HAV, fecal-oral route
• incubation period: 2 to 9 weeks
|• Specific serological test for HEV include detection of IgM and IgG antibodies to hepatitis E||• strict hand washing|
14. LC (Liver cirrhosis)
|• A chronic, progressive disease of the liver characterized by diffuse degeneration and destruction of hepatocytes.||• ascites: accumulation of fluid in the peritoneal cavity that results from venous congestion of the hepatic capillaries
• coagulation defects: decreased synthesis of bile fats in the liver prevents the absorption of fat-soluble vitamins
• jaundice: occurs because the liver is unable to metabolize bilirubin and because the edema, fibrosis, and scarring of the hepatic bile ducts interfere with normal bile and bilirubin secretion
|• Weigh the client and measure abdominal girth daily.
• Monitor intake and output and electrolyte balance.
• Monitor coagulation laboratory results.
• If ascites and edema are absent and the client does not exhibit signs of impending coma (when stable LC), a high-protein diet supplemented with vitamins is prescribed. Provide supplemental vitamins (B complex, vitamin A, C, and K, folic acid, and thiamine) as prescribed. Restrict protein, sodium intake, and fluid intake as prescribed. Initiate enteral feedings or parenteral nutrition as prescribed.
• Prepare the client for paracentesis to remove the abdominal fluid.
• Administer diuretics as prescribed.
• Administer blood products as prescribed.
Administer vitamin K if prescribed.
• Avoid medications such as opioids, sedatives, and barbiturates, and any hepatotoxic medications or substances.
15. the complication of LC
|① portal hypertension
• a persistent increase in pressure in the portal vein that develops because of obstruction to flow
|② esophageal varix bleeding
• Esophageal varices are dilated and tortuous veins in the submucosa of the esophagus. Esophageal varices are at high risk for rupture if portal circulation pressure rises.
• Bleeding varices are an emergency.
|• Monitor V/S. Monitor level of consciousness.
• Elevate the head of the bed. Instruct the client to avoid activities that will initiate the vasovagal response.
• Maintain NPO status. Administer fluids intravenously as prescribed to restore fluid volume and electrolyte imbalances.
• Monitor hemoglobin and hematocrit values and coagulation factors.
• Administer blood transfusions or clotting factors as prescribed.
• Prepare to assist with administering medications to induce vasoconstriction and reduce bleeding.
• Assist in inserting a nasogastric tube or a balloon tamponade as prescribed. Balloon tamponade is not used frequently because it is very uncomfortable for the client and its use is associated with complications.
• Prepare the client for endoscopic procedures or surgical procedures as prescribed; endoscopic injection (sclerotherapy), endoscopic variceal ligation, shunting (TIPS, TransJugular Intrahepatic Portosystemic Shunt)
|③ portal-systemic encephalopathy: End-stage hepatic failure characterized by the altered level of consciousness, neurological symptoms, and neuromuscular disturbance. It is caused by the failure of the diseased liver to detoxify neurotoxic agents such as ammonia.||• Monitor level of consciousness. Assess for precoma state (tremors, delirium).
• Administer lactulose (Constulose, Enulose, Generlac) as prescribed, which decreased the pH of the bowel, decreases the production of ammonia by bacteria in the bowel, and facilitates the excretion of ammonia.
|④ hepatorenal syndrome: progressive renal failure associated with hepatic failure|
|• Acute or chronic inflammation of the pancreas, with the associated escape of pancreatic enzymes into the surrounding tissue.||• abdominal pain, including a sudden onset at a mid-epigastric or left upper quadrant location with radiation to the back
pain aggravated by a fatty meal, alcohol, or lying in a recumbent position
• nausea, vomiting
• steatorrhea and foul-smelling stools
• positive Cullen’s sign: the discoloration of the abdomen and periumbilical area
• positive Turner’s sign: the bluish discoloration of the flanks
• elevated serum lipase and amylase level
|• Maintain NPO status.
Administer parenteral nutrition for severe nutritional depletion. Administer supplemental preparations and vitamins and minerals to increase caloric intake if prescribed.
• Maintain the nasogastric tube to decrease gastric distention and suppress pancreatic secretion.
• Maintain hydration with IV fluids as prescribed.
• Administer opiates as prescribed.
• Administer antacids, H2 receptor antagonists, proton pump inhibitors, anticholinergics as prescribed.
• Instruct the client about the importance of avoiding alcohol. Instruct the client on the prescribed dietary measures. Fat and protein intake may be limited. Instruct the client to avoid heavy meals, and instruct the client to eat small, regular, frequent meals.
|• inflammation of the appendix||• pain in the periumbilical area that descends to the right lower quadrant,
abdominal pain that is most intense at McBurney’s point,
client in the side-lying position, with abdominal guarding and legs flexed
• low-grade fever
|• Position the client in a right-side lying or low to semi-Fowler’s position to promote comfort.
• Avoid the application of heat to the abdomen of a client with appendicitis. Heat can cause rupture of the appendix leading to peritonitis, a life-threatening condition. Apply ice packs to the abdomen for 20 to 30 minutes every hour as prescribed.
• surgical interventions: appendectomy
|• inflammation of the peritoneum|
|• dilated varicose veins of the anal canal||• rectal itching, rectal pain
• bright red bleeding with defecation
|• Apply cold packs to the anal rectal area followed by sitz baths as prescribed.
• Apply witch hazel soaks and topical anesthetics as prescribed.
• Encourage a high-fiber diet and fluids to promote bowel movements without straining.
• Administer stool softeners as prescribed.
• surgical interventions: hemorrhoidectomy
1) gastric cancer
2) intestinal tumors
3) pancreatic tumors
21. [Pediatric] vomiting
|• The major concerns when a child is vomiting are the risk of dehydration, the loss of fluid and electrolytes, and the development of metabolic alkalosis. Additional concerns include aspiration and the development of atelectasis or pneumonia.||• Maintain a patent airway.
• Monitor for signs and symptoms of dehydration.
• Provide oral rehydration therapy as tolerated and as prescribed. Begin feeding slowly, with small amounts of fluid at frequent intervals.
22. [Pediatric] diarrhea
|• The major concerns when a child is diarrhea are the risk of dehydration, the loss of fluid and electrolytes, and the development of metabolic acidosis.||• Provide enteric isolation as required.
• For mild to moderate dehydration, provide oral rehydration therapy with Pedialyte or a similar rehydration solution as prescribed. Supply low-fiber meals. Avoid carbonated beverages because they are gas-producing and fluids that contain high amounts of sugar, such as apple juice. For several dehydrations, maintain NPO status to place the bowel at rest and provide fluid and electrolyte replacement by IV route as prescribed. If potassium is prescribed for IV administration, ensure that the child has voided before administering and has an adequate renal function. Reintroduce a normal diet when rehydration is achieved.
23. [Pediatric] constipation and encopresis
|• Constipation is the infrequent and difficult passage of dry, hard stools.
• Encopresis (분변 실금) is constipation with fecal incontinence.
|• Maintain a diet high in fiber and fluids to promote bowel elimination. Decrease sugar and milk intake.
• Administer stool softeners or laxatives as prescribed.
• Administer enemas as prescribed until impaction is cleared. Monitor for hypernatremia or hyperphosphatemia when administering repeated enemas.
• Encourage the child to sit on the toilet for 5 to 10 minutes approximately 20 to 30 minutes after breakfast and dinner to assist with defecation.
• Monitor treatment regimen for severe encopresis for 3 to 6 months.
24. [Pediatric] cleft lip and cleft palate
|• A child with a cleft palate is at risk for developing frequent otitis media.||• Assess the ability to suck, swallow, handle normal secretions, and breathe without distress.
• Monitor daily weight.
• Modify feeding techniques. Plan to use specialized feeding techniques, obturators, and special nipples and feeders. Teach the parents special feeding or suctioning techniques. Teach the parents the ESSR method of feeding (Enlarge the nipple, Stimulate the sucking reflex, Swallow, Rest to allow the infant to finish swallowing what has been placed in the mouth).
• Hold the infant in an upright position and direct the formula to the side and back of the mouth to prevent aspiration. Feed small amounts gradually and burp frequently.
• Keep suction equipment and a bulb syringe at the bedside.
• Encourage parental bonding with the infant, including holding the infant and calling the infant by name.
• Closure of a cleft lip defect precedes closure of the cleft palate and is usually performed by age 3 to 6 months Cleft palate repair is usually performed between 6 and 24 months of age to allow for the palatal changes that occur with normal growth. A cleft palate is closed as early as possible to facilitate speech development.
• cleft lip repair postoperative interventions: Provide lip protection. A metal appliance or adhesive strips may be taped securely to the cheeks to prevent trauma to the suture line. Restraint should be used to prevent the infant from injuring the surgical site. Avoid positioning the infant on the side of the repair or in the prone position. Position on the back upright and position to prevent airway obstruction by secretions, blood, or the tongue. After feeding, gently cleanse the suture line of formula or serosanguineous drainage with a solution such as normal saline (면봉으로 톡톡). Avoid the use of oral suction or placing objects in the mouth such as a tongue depressor, thermometer, straws, spoons, forks, or pacifiers.
• cleft palate repair postoperative interventions: Oral packing may be secured to the palate. Restraint may be used. Instruct the parents to avoid offering hard food items to the child, such as toast or cookies. Feedings are resumed by bottle, breast, or cup. Do not allow the child to brush his or her teeth. After feeding, gently cleanse the suture line of formula or serosanguineous drainage with a solution such as normal saline (면봉으로 톡톡 치면 안됨). Avoid the use of oral suction or placing objects in the mouth such as a tongue depressor, thermometer, straws, spoons, forks, or pacifiers.
• Initiate appropriate referrals such as a dental referral and speech therapy referral.
25. [Pediatric] esophageal atresia and tracheoesophageal fistula
|• esophageal atresia: The esophagus terminates before it reaches the stomach ending in a blind pouch.
• tracheoesophageal fistula: A fistula is present that forms an unnatural connection with the trachea.
|• Maintain a patent airway.
• Prevent aspiration.
• gastric or blind pouch decompression
• surgical repair
26. [Pediatric] hypertrophic pyloric stenosis
|• Hypertrophy of the circular muscles of the pylorus causes narrowing of the pyloric canal between the stomach and the duodenum.||• projectile vomiting
• olive-shaped mass in the epigastrium
|• Keep the VAD.
• Prepare the child and parents for pyloromyotomy if prescribed.
27. [Pediatric] lactose intolerance
|• Inability to tolerate lactose as a result of an absence or deficiency of lactase, an enzyme found in the secretions of the small intestine that is required for the digestion of lactose
• A child with lactose intolerance can develop calcium and vitamin D deficiency.
|• Eliminate the offending dairy products.
Substitute soy-based formulas for cow’s milk formula or human milk. Limit milk consumption to one glass at a time. Instruct the child and family that the child should drink milk with other foods rather than by itself. Encourage consumption of hard cheese, cottage cheese, and yogurt, which contain the inactive lactase enzyme. Encourage consumption of small amounts of dairy foods daily to help colonic bacteria adapt to ingested lactose.
• Administer an enzyme tablet replacement.
28. [Pediatric] celiac disease (gluten enteropathy)
|• Intolerance to gluten, the protein component of wheat, barley, rye, and oats, is characteristic. Celiac disease results in the accumulation of the amino acid glutamine, which is toxic to intestinal mucosal cells. Intestinal villous atrophy occurs, which affects the absorption of ingested nutrients.
• celiac crisis
|• Strict dietary avoidance of gluten minimizes the risk of developing malignant lymphoma of the small intestine and other gastrointestinal malignancies.
• Maintain a gluten-free diet, substituting corn, rice, and millet as grain sources. Instruct the parents and child about lifelong elimination of gluten sources such as wheat, rye, oats, and barley.
• Administer mineral and vitamin supplements, including iron, folic acid, and fat-soluble vitamins A, D, E, and K.
29. [Pediatric] Hirschsprung’s disease (congenital aganglionosis, aganglionic megacolon)
|• The disease occurs as the result of an absence of ganglion cells in the rectum and other areas of the affected intestine. The mechanical obstruction results because of inadequate mobility in an intestinal segment.||• fail to pass a meconium stool
• bile-stained vomitus
• ribbon-like and foul-smelling stools
|• Maintain a low-fiber, high-calorie, high-protein diet. Parenteral nutrition may be necessary for extreme situations.
• surgical management
30. [Pediatric] intussusception
|• Telescoping of one portion of the bowel into another portion. The condition results in obstruction to the passage of intestinal contents.||• colicky abdominal pain
• currant jelly-like stools containing blood and mucus
• a palpable sausage-shaped mass in the upper right quadrant
|• Monitor for the passage of normal, brown stool, which indicates that the intussusception has reduced itself.
• hydrostatic reduction
• surgical management
31. [Pediatric] abdominal wall defects
• Omphalocele refers to herniation of the abdominal contents through the umbilical ring, usually with an intact peritoneal sac.
|• Immediately after birth, the sac is covered with sterile gauze soaked in normal saline to prevent drying of abdominal contents. A layer of plastic wrap is placed over the gauze to provide additional protection against moisture loss.
• surgical management
• Gastroschisis occurs when the herniation of the intestine is lateral to the umbilical ring. No membrane covers the exposed bowel.
|• The exposed bowel is covered loosely in saline-soaked pads, and the abdomen is loosely wrapped in a plastic drape. Wrapping directly around the exposed bowel is contraindicated because if the exposed bowel expands, wrapping could cause pressure and necrosis.
• surgical management
|③ umbilical hernia
• umbilical hernia, inguinal hernia
• incarcerated hernia
• non-communicating hydrocele,
32. [Pediatric] imperforate anus
|• incomplete development or absence of the anus in its normal position in the perineum||• surgical management: After surgery, the preferred position is a side-lying prone position with the hips elevated or a supine position with the legs suspended at a 90-degree angle to the trunk to reduce edema and pressure on the surgical site. Instruct the parents to use only dilator supplied by the HCP and a water-soluble lubricant and to insert the dilator no more than 1 to 2 cm into the anus to prevent damage to the mucosa.|
33. [Pediatric] IBS (Irritable Bowel Syndrome)
|• IBS results from increased motility, which can lead to spasms and pain. Stress and emotional factors may contribute to its occurrence.|