A.

The Child with Nutrition – Elimination Patterns Alterations

1. Acid-Base Imbalances

1.1. Respiratory Acidosis and Alkalosis

1.1.1. Respiratory Acidosis
a. Background
 Results from diminished or inadequate pulmonary
ventilation
 Increase plasma PCO2
 Increase concentration of carbonic acid
 Increase carbonic acid and hydrogen ion concentration
 Compensation:
 Through the kidneys
 increase plasma HCO3-  excrete hydrogen ions
b. Laboratory Finding:
 increase plasma HCO3-
c. Treatment:
 Correcting the underlying cause
 Improving gas exchange (provide more efficient removal of
carbon dioxide)
 Oxygen therapy
 Mechanical ventilation
 Oral sodium bicarbonate = administered in children with
chronic metabolic acidosis
 IV sodium bicarbonate = administered in acute metabolic
acidosis
1.1.2. Respiratory Alkalosis
a. Background
 Increase in the rate and depth of pulmonary ventilation =
large amounts of carbon dioxide being exhaled
 decreased plasma PCO2
 increased plasma pH
 Compensation:
 Performed by the kidneys
 Excretion of carbonic acid with sodium and
potassium  conserve hydrogen ions
b. Laboratory Finding:
 increased plasma pH
 decreased plasma carbonic acid concentration
 increased plasma PCO2
 c. Treatment:
 Treatment of underlying cause
 Preventions of lost anions and potassium deficit
 Rebreathing carbon dioxide
 Oxygen therapy

1.2. Metabolic Acidosis and Alkalosis

1.2.1. Metabolic Acidosis
a. Background
 Caused by gain of nonvolatile acids or loss of bicarbonate
 decreased plasma pH
 Compensation:
 Respiratory
 Kussmaul respiration = breathing is deep and
rapid
b. Laboratory Finding:
 decreased plasma pH
 decreased plasma bicarbonate concentration
 Plasma AG = used in evaluating patients with metabolic
acidosis
c. Treatment:
 Correcting the basic deficit
 Replacing the excessive losses of bicarbonate with sodium
or potassium bicarbonate or sodium lactate
1.2.2. Metabolic Alkalosis
a. Background
 Occurs when there is reduction in hydrogen ion
concentration and an excess of bicarbonate
 Increased plasma pH
 Compensation:
 Theoretically: Respiratory
 Irregular and unpredictable
 Sodium, potassium and chloride loss  kidney will
attempt to conserve sodium and potassium concentration
 elevated urine pH, plasma pH, plasma
bicarbonate; reduced chloride concentration
b. Treatment
 Preventing further loss of acid
 Replacing lost electrolytes

**General Nursing Responsibilities

A. Assessment:
 Observe general appearance
 Drawn expressions
 Dry mucous membranes and lips
 “Look sick”
 Loss of appetite
 Cry of infant
 Child is irritable
B. Diagnosis
 History taking
 Taken from the parent or primary caregiver
 Amount and type of fluid intake and output are important.
o Number and consistency of stools the child passed in the past
24 hours
o Number of times the child voided
o Type and amount of food and fluid ingested of vomited
o Number of wet diapers in the past 24 hours
o History of normal or increased intake of an unusual fluid
 History of gradual weight gain and observations of puffiness
 History of excessive water intake with diminished output
 I/O Measurement
C. Care Management
 Venous Access Device:
 Factors for VAD
o reason for placement of catheter
o patient age
o length of therapy
o risk of patient in placement of catheter
o availability of resources
 Types of central catheters
o Peripheral Intermittent Infusion Device
o Peripherally Inserted Central Catheter
o Long-term Central Venous Access Device
1) Tunneled catheter
2) Groshing Catheter
3) Implanted Parts
 Total Parenteral Nutrition and Total Nutrient Admixture:
 TPN – also known as alimentation
o Provides for the nutritional of infants or children who cannot
consume an adequate amount of nutrients to support physical
growth, positive nitrogen balance and water and electrolyte
homeostasis.
  Parenteral Nutrition – delivered into a large diameter vessel
such as the subclavian vein.
 Total Nutrient Admixture (TNA) - refers to the PN formula
with carbohydrates, lipids, amino acids, vitamins, minerals, water,
trace elements and other additives in a single container with lipids
piggybacked into the administration setup.
 Home Parenteral Nutrition
 Before a home care program can be implemented, a thorough
assessment is made of the family and the home care situation.
 Technical Aspects of the procedure:
a) Psychosocial readiness of the family
o Family support systems
b) Availability of a pharmacy to prepare the parenteral
alimentation solution.
o A practitioner to handle a day-to-day emergency needs.
c) Cooperating insurance company or agency
o Major responsibilities for the child and family with HPN
include assurance that the proper solution is infusing, proper
maintenance of the VAD, prevention of sepsis and other
mechanical complications, monitoring of infusion rate, and
assessment of the patient’s tolerance to the solution.

2. Acute Gastroenteritis

a. Background
 Gastroenteritis is an infection of the gut.
 Viruses that cause gastroenteritis include: rotavirus, noro virus,
and hepatitis A.
 Bacteria that cause gastroenteritis include: salmonella,
campylobacter, bacillus, vibrio, and escherichia coli.
 Bacterial gastroenteritis is caused by food poisoning.
b. Assessment
 Assess recent change in weight
 Assess child of signs of dehydration
 appears unwell
 altered responsiveness
 reduced urine output
 Pale or mottled skin
 Cold extremities
 Sunken eyes
 Dry mucous membranes
 reduced skin turgor
 c. Signs and Symptoms
 Diarrhea
 Nausea and Vomiting
 Fever
 Abdominal pain
d. Diagnostic Procedure
 Stool Exam
e. Treatment
 Probiotics helps reduce the duration of diarrhea
 Analgesics for headache
 Antibiotics are not advisable because they cause diarrhea
 Pedialyte™ or Re-hydration formulas to prevent dehydration
f. Nursing Care Management
 Encourage the child to increase oral fluid intake
 Provide comfort so that the child can recover easily
 Monitor urine output

3. Genitourinary Alterations

1. UTI

a. Background
 Clinical condition that may involve the urethra and bladder (lower
urinary tract) and the ureters, renal pelvis, calyces, and renal
parenchyma (upper urinary tract).
 Females have a 10 to 30 times greater risk for developing UTI than
males.
 Escherichia Coli - most common causative agent.
 Proteus, Pseudomonas, Klebsiella, Staphylococcus Aureus - other
organisms associated with UTI.
b. Clinical Manifestations
 Depends on the child’s age.
 Newborn infants and children less than 2 years of age:
1) Characteristically nonspecific
2) Nearly resemble gastrointestinal infection such as:
 Failure to thrive
 Feeding problem
 Vomiting
 Diarrhea
 Abdominal distention
  Jaundice
3) Other evidence:
 Frequent and infrequent voiding
 Constant squirming and irritability
 Strong-smelling urine
 Abnormal stream
 Persistent diaper rash
 Children more than 2 years of age:
1) Often observable, such as:
 Enuresis or daytime incontinence
 Fever
 Strong or foul-smelling urine
 Increased frequency of urination
 Dysuria or urgency
 Hematuria
2) May complain having abdominal pain.
 Adolescents:
1) Manifestations are MORE specific.
2) Lower Tract Infection symptoms:
 Frequency and painful urination
 Fever is usually absent
 Small amount of turbulent urine that may be glossy
bloody
3) Upper Tract Infection symptoms:
 Fever
 Chills
 Flank pain
 Lower tract symptoms, which may appear 1 or 2 days
after.
c. Diagnostic Procedure
 Bag Urine Specimen - commonly contaminated by perineal and
perianal flora and are usually considered inadequate for a
definitive diagnosis.
 Suprapubic Aspiration - most accurate test of bacterial content
for children less than 2 years of age.
 Properly Performed Bladder Catheterization - most accurate test
of bacterial content as long as the first few millimeters are
excluded from collection.
 Plastic Dipstick and Agar-coated Slide Test - quick and
inexpensive methods for detecting infection before obtaining
final culture results.
  Specific test for the localization of the infection site:
 Ureteral catheterization
 Bladder washout procedures
 Radioisotope renography
 Ultrasonography
 Dimercaptosuccinic Acid Scan
d. Treatment
 Antibiotic Therapy - guided by the laboratory culture and
sensitivity tests.
 Empiric Therapy - may be necessary when fever or systemic
illness complicates UTI.
 Common anti-infective drugs:
1) Penicillins
2) Sulfonamide (including trimethoporin and sulfamethoxazole
in combination)
3) Cephalosporins
4) Nitrofurantoin
5) Tetracyclines
 Urine cultures - usually repeated at monthly intervals for 3
months and at 3-month intervals for another 6 months.
 Renal scarring - can develop during the initial infection,
especially in younger children.
 Aim of therapy:
1) Prevent morbidity
2) Reduce the chance of renal scarring
e. Nursing Care Management
 Nurses should instruct parents to observe regularly for clues
that suggest UTI.
 Careful history regarding voiding habits, stooling patterns, and
episode of unexplained irritability may assist in detecting less
obvious cases of UTI.
 Children who are old enough to understand need an explanation
of the procedure, it purpose, and what they will experience.
 Patients should primarily drink clear liquids.
 Caffeinated or carbonated beverages are avoided because
of their potentially irrigative effect on the bladder mucosa.

2. Enuresis

a. Background
 A common and troublesome disorder that is defined as
intentional or involuntary passage of urine into bed (usu.
 at night) or into clothes during the day the children who are
beyond the age when voluntary bladder control should normally
have been acquired.

 This is more common in boys. Enuresis is an alteration of

neuromuscular bladder function and is often benign and
self-limiting.

b. Assessment
 compute for the normal child’s bladder capacity: Child’s age + 2
= Normal Bladder Capacity

c. Signs and Symptoms

 urgency that is immediate and accompanied by acute
discomfort, restlessness and urinary frequency.
d. Diagnostic Procedure
 To diagnose as enuresis, the child must be at least 5 years
and voiding of urine at least twice a week for at least 3
months.

e. Treatment
1) Drugs

a) Imipramine (Tofranil) – inhibits urination

b) Oxybutynin – reduces uninhibited bladder contractions and

may be helpful for children with daytime urinary frequency

c) Desmopressin (DDAVP) – reduces nighttime urine output to a

volume less than functional bladder capacity

2) Bladder Training

3) Elimination of fluids after every evening meal

4) Interruption of sleep to void

f. Nursing Care Management

 The nurse can both help the children and parent in
understanding the problem, the treatment plan and difficulties
they may encounter in the process.

 The nurse provides consistent support and encouragement to

help sustain them

 And lastly, the children should develop feelings of confidence

and hope that they are helping themselves.
3. Structural Defects

A. Renal Tubular Disorders

 Abnormalities of the following:

 Tubular Transport
 Tubular Reabsorption
 Glomerular Function
 Key Points:
 Edema and hypertension are ABSENT.
 BUN level and routine urinalysis are NORMAL.
 Function
 Proximal Tubules – reabsorption of substances from the
glomerular filtrate – sodium, potassium, chloride,
bicarbonate, glucose, phosphate and amino acids
 Distal Renal Tubules – acidification of urine; potassium
secretion; selective and differential reabsorption of sodium,
chloride, and water – determines the final urinary
concentration.
1) Renal Tubular Acidosis
a) Distal Tubular Acidosis (Type 1)
i. Etiology
 Kidneys inability to establish a normal pH gradient
between tubular cells and tubular contents
ii. Characteristics
 Inability to produce a pH below 6.0 despite the presence of
severe metabolic acidosis
 Primary Disorder
 Hereditary defect; greater penetrance in females
 Secondary Disorder
 Rare
**After the age of 2 = growth failure, history of vomiting,
polyuria, dehydration, anorexia, failure to thrive, bone
demineralization, with occasional formation of urinary calculi
(urolithiasis) in older children.

b) Proximal Tubular Acidosis (Type 2)

i. Etiology
 Impaired bicarbonate reabsorption of the proximal tubule
ii. Characteristics
  Plasma concentration of bicarbonate stabilizes at a lower
level than normal -> Hypercholerimic metabolic acidosis
 *Fanconi syndrome – transport mechanisms are damaged
by the accumulation of toxic metabolites; the tubular
epithelium is damaged by – lead, cadmium or platinum
 Secondary or idiopathic
iii. Clinical manifestation
 Growth failure
 Tachypnea
 Dehydration
 Vomiting
 Episodic fever
 Nephrolithiasis secondary to hypercalciuria
 Muscle weakness
 Severe life-threatening academia
iv. Therapeutic Management
 For both proximal and distal disorders:
 Administration of sufficient carbonate and citrate = to
balance metabolically produced hydrogen ions; To maintain
plasma bicarbonate levels in normal range; And to correct
associated electrolyte disorders.
 For proximal disorders:
 Large volumes by carbonate = to compensate for urinary
losses.
 Best management:
 Mixture of sodium and potassium carbonate = prevent
deficiencies of either cation
 *Shohl solution – effective but uneasily prepared
v. Nursing care management:
 Intensive medical evaluation
 Providing and informing medication plants to parents
 Teaching of the importance of taking medications for long-
term treatment

2) Nephrogenic Diabetic Insipidus

a) Etiology
 Defect in the ability to concentrate
 Distal tubules and collecting ducts – insensitive to ADH action
 Occurs primarily in males; females are carriers of the
defective gene
 May be related to
  Chronic obstructive renal disorders
 Sickle cell disease
 Renal tuberculosis
 Other renal disorders

b) Clinical manifestations
 Newborn
 Vomiting
 Unexplained fever
 Failure to thrive
 Severe recurrent dehydration
 Dehydration with hypernatremia
 Growth retardation related to diminished food intake and
poor general health
c) Diagnosis
 Family history
d) Therapeutic management
 Provision of adequate volumes of water = compensate for
urinary losses
 Low sodium, low solute diet
 Chlorothiazide or ethacrynic acid diuretics = increase
reabsorption of sodium and water
 Supplemental potassium = prevent hypokalemia as a result
of thiazide therapy

e) Nursing care management

 Assist family and children in coping with long-term
convenience
 Teach family to administer medications and help with diet
planning
 Avoid activities that contribute to dehydration
 Early recognition of disease
 Genetic counselling is recommended

4. Acute Glomerulonephritis

a. Etiology
 Pneumococcal, streptococcal and viral infections
 An immune-complex disease (a reaction that occurs as a by-
product of an antecedent streptococcal infection with certain
strains of group A B-hemolytic streptococci
 b. Clinical Manifestations
 Initial Signs
 Edema of the face, especially around the eyes (periorbital
edema)
 Anorexia
 Tea/Dark-colored urine
 Reduced urinary output
 Pale
c. Diagnostic Evaluation
 Urinalysis shows hematuria and proteinuria
 Hypertension
d. Therapeutic and Nursing Care Management
 Record daily weight to assess fluid balance
 Sodium and water restriction is useful when the output is
significantly reduced (< 2 to 3 dl/24hr)
 Diuretics shouldn’t be used if renal failure is severe. However, if
not severe, diuretic therapy is helpful if edema and fluid
overload are present.
 BP should be taken every 4-6 hours
 Limit sodium intake
 Note volume and character of urine

5. Nephrotic Syndrome

a. Definition

 Most common presentation of glomerular injury in children

 Characterized by massive proteinuria, hypoalbuminemia,

hyperlipidemia, and edema

 A clinical manifestation of a large number of distinct glomerular

disorders in which increased glomerular permeability to plasma
protein results in massive urine protein loss

b. Background

 Rare in children younger than 6 months of age

 Uncommon in infants younger than 1 year of age

 Unusual after the age of 8 years

 Occurs more in males than femals 2:1

 In adolescence, the ratio is 1:1

 Types of Nephrotic Syndrome

 Primary Nephrotic Syndrome

o Minimal Change Nephrotic Syndrome (MCNS)

 Secondary Nephrotic Syndrome

 Congenital Nephrotic Syndrome

c. Assessment

 Assess for weight gain greater than previous patterns

 Assess for generalized edema

 Abdomen

 Lower extremities

 Assess for changes in the appearance of the nails

 White (muercke) lines parallel to the lunula

d. Signs and Symptoms

 Periorbital or ankle edema

 Wight gain greater than expected based on previous pattern

 Decreased urinary output

 Pallor

 Fatigue

e. Diagnostic Procedure

 Urinalysis

 Renal biopsy

f. Therapeutic Management

 Objectives

 Reduce the excretion of urinary protein and maintain

protein-free urine
  Prevention or treatment of acute infection

 Control of edema

 Establishment of good nutrition

 Readjustment of any disturbed metabolic processes

 General Measures

 Diet

 Corticosteroid Therapy

 Immunosuppressant Therapy

 Diuretics

g. Nursing Care Management

 Daily monitoring of intake and output

 Examination of urine for albumin

 Monitor daily weight and measurement of abdominal girth

 Monitor vital signs

 Inform parents of possible relapses and side effects that may

occur during the course of treatment

 Reassure parents that relapses can occur but continuation of the

drugs will diminish side effects

6. Renal Failure

 Background
 inability of the kidneys to excrete waste materials, concentrate
urine, and conserve electrolytes.
 can be acute or chronic and affects most systems in the body.
A. Acute Renal Failure
a. Etiology
 result of a large number of related or unrelated clinical
conditions: poor renal perfusion; acute renal injury; or the
final expression of chronic, irreversible renal disease.
b. Clinical Manifestations
  Oliguria
 Anuria
c. Signs and Symptoms
 Drowsiness
 circulatory congestion
 cardiac arrhythmia from hyperkalemia
d. Diagnostic Procedure
 History Taking
e. Nursing Care Management
 treatment of the underlying cause

 management of the complication of renal failure

 provision of supportive therapy within the constraints

imposed by the renal failure

B. Chronic renal failure

a. Etiology
 congenital renal and urinary tract malformations: renal
hypoplasia and dysplasia and obstructive uropathy; and
vesicoureteral reflux.
b. Clinical Manifestations
 loss of normal energy and increased fatigue on exertion
 pale
 growth retardation
c. Signs and Symptoms
 Evidence of difficulty
d. Diagnostic Procedure
 Observation
e. Nursing Care Management
 Children areencouraged to attend to school

 Regulation of diet

7. Bladder Exstophy Epispadia Complex

a. Background
 Bladder Exstrophy is a complex combination of disorders that
occurs during fetal development.
  involves many systems in the body, including the urinary tract,
skeletal muscles and bones, and the digestive system
 the bladder is essentially inside out and exposed on the outside
of the abdomen
 urine constantly trickles onto the skin causing local irritation
b. Clinical Manifestations
 widened pubic bones
 outwardly rotated legs and feet
 triangle-shaped defect in the abdomen and visibility of the
membrane of the bladder which is usually bright pink
 abnormally-shaped abdominal muscles
 displacement of the umbilicus (belly button), usually above the
defect
 umbilical hernia may be present (section of intestine protrudes
through a weakness in the abdominal muscles)
 short, small penis with urethral opening along top of penis
(epispadias)
 narrow vaginal opening, wide labia, and short urethra
c. Diagnostic Procedure
Exstrophy of the bladder can usually be diagnosed by fetal
ultrasound before an infant is born. After the infant is born,
exstrophy can be determined by physical examination. Other
diagnostic procedures may include:
 renal ultrasound - a non-invasive test in which a transducer is
passed over the kidney producing sound waves which bounce
off of the kidney, transmitting a picture of the organ on a video
screen. The test is used to determine the size and shape of the
kidney, and to detect a mass, kidney stone, cyst, or other
obstruction or abnormalities.
 renal scan - a specialized scan that may include injections of a
radioactive substance. A scan is then performed at different
intervals to determine the blood flow through the renal vessels
and urine flow through the kidneys.
d. Treatment
 Modern therapy is aimed at surgical reconstruction of the bladder
and genitalia.
 TRINITY UNIVERSITY OF ASIA
St. Luke’s College of Nursing

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS

in NURSING CARE MANAGEMENT (NCM) LEC
 WRITTEN OUTPUT
THE CHILD WITH NUTRITION – ELIMINATION PATTERNS
ALTERATIONS

SUBMITTED BY:
2NU08
EXALERON

Obar, Jean Kathleen Aynn M.

Ocampo, Rouzele Katherine L.
Omampo, Jennider Andrei B.
Ong, Renz Andrew V.
Oquendo, Rose Ann A.
Orellosa, Diane Emmille E.
Otico, Joseph S.
Paat, Joden Ryan D.
Pacis, Lea Therese R.
Pajaro, Barbrah Allana A.
Palon, Dorelyn Jade P.
Panay, Jason V.
 SUBMITTED TO:
Ms. Julie Ann Gundran, RN
Professor