N303 - Ch 29

Front 1

What represents one of the leading causes of death in children less than 5 years of age throughout the world?

Back 1

Diarrhea

Front 2

What causes diarrhea?

Back 2

Abnormal intestinal water and electrolyte transport

Front 3

What causes acute diarrhea?

Back 3

Viral, bacterial, and parasitic infections

Front 4

What causes chronic diarrhea?

Back 4

Malabsorption syndrome, inflammatory bowel disease, immunodeficiency, food allergy, lactose intolerance, chronic nonspecific diarrhea (CNSD), or result from inadequate management of acute infectious diarrhea

Front 5

What causes secretory diarrhea?

Back 5

Bacterial enterotoxins that stimulate fluid and electrolyte secretion from the mucosal crypt cell, the principal secretory cells of the small intestines

Front 6

What are the characteristics of cytotoxic diarrhea?

Back 6

1. Viral destruction of the mucosal cells of the ville of the small intestine

2. A smaller intestinal surface area, with a decreased capacity for fluid and electrolyte absorption

Front 7

What is osmotic diarrhea?

Back 7

A malabsorption syndrome, such as lactose intolerance, in which the intestines cannot absorb nutrients and electrolytes

Front 8

What is dysenteric diarrhea?

Back 8

1. An inflammation of the mucosa and submucosa in the ileum and colon caused by infectious agents such as Campylobacter, Salmonella, or Shigella organisms

2. Edema, mucosal bleeding, and leukocyte infiltration occur

Front 9

What might acute diarrhea be associated with?

Back 9

Upper respiratory or urinary tract infections

Front 10

How long does acute diarrhea usally last?

Back 10

Less than 14 days

Front 11

What are the major consequences of diarrhea?

Back 11

Dehydration and malnutrition

Front 12

Who are at high risk for the development of dehydration and malnutrition?

Back 12

Infants and young children

Front 13

How is diarrhea acquired or spread?

Back 13

1. Fecal-oral route through contaminated food or water

2. From person-to-person, especially where there is close contact (e.g. daycare centers)

3. Lack of clean water

4. Crowding

5. Poor hygiene

6. Nutritional deficiency

7. Poor sanitation

Front 14

What is the most common pathogen identified as the cause of diarrhea and dehydration in hospitalized young children?

Back 14

Rotavirus

Front 15

What are the non-microorganism causes of diarrhea?

Back 15

1. HIV infection

2. Ingestion of laxatives

3. Excessive ingestion of sorbitol and fructose in common foods such as apple juice or in gum or candy

Front 16

What does excessive ingestion of sorbitol and fructose cause?

Back 16

Osmotic dietary diarrhea from the poorly absorbed carbohydrate

Front 17

How does antibiotics cause diarrhea?

Back 17

By altering the normal intestinal flora, allowing pathogenic ones to grow (such as Clostridium difficile)

Front 18

What are the most serious consequences of acute diarrhea?

Back 18

1. Dehydration
2. Electrolyte disturbances
3. Malnutrition
4. Metabolic acidosis

Front 19

What type of stool suggests sugar intolerance?

Back 19

Watery, explosive stools

Front 20

What type of stool suggests fat malabsorption?

Back 20

Foul-smelling, greasing, bulky stools

Front 21

What does diarrhea that develops after the introduction of cow's milk, fruits, or cereals suggest?

Back 21

An enzyme deficiency or protein intolerance

Front 22

What does the presence of neutrophils or red blood cells in the stool indicate?

Back 22

Bacterial gastroenteritis or inflammatory bowel disease

Front 23

What does the presence of eosinophils in the stool suggest?

Back 23

Protein intolerance or parasitic infection

Front 24

What may indicate carbohydrate intolerance or secondary lactase deficiency?

Back 24

A stool pH of less than 6 and the presence of reducing substances

Front 25

What are the major goals in management of acute diarrhea?

Back 25

1. Assessment of the fluid and electrolyte imbalance
2. Rehydration
3. Maintenance fluid therapy
4. Reintroduction of adequate diet

Front 26

What should be treated first in infants and children with acute diarrhea?

Back 26

Oral rehydration therapy

Front 27

Why is oral rehydration therapy (ORT) preferred over IV rehydration?

Back 27

1. Effective and safer
2. Less painful
3. Less costly

Front 28

What is required for severe dehydration and vomiting?

Back 28

Intravenous fluids - a saline solution containing 5% dextrose in water is usually given. The initial volume should be 20 to 30 ml/kg and should be administered as a bolus. Therapy during the remainder of the first 24 hours should be aimed at completely correcting the remaining fluid and sodium deficits and replacing ongoing abnormal losses

Front 29

Why are antidiarrheal drugs contraindicated in infants and young children?

Back 29

Toxicity and adverse effects, such as worsening of the diarrhea because of the slowing of motility and ileus or decrease in diarrhea with continuing fluid losses and dehydration, may occur

Front 30

What physical assessments should be made for diarrhea?

Back 30

1. Dehydration, such as decreased urinary output and weight
2. Dry mucous membranes
3. Poor skin turgor
4. Sunken fontanel in the infant
5. Pale, cool, dry skin

Front 31

What may indicate impending shock with more severe dehydration?

Back 31

1. Increased pulse and respiration
2. Decreased BP
3. Prolonged capillary refill time (>2 seconds)

Front 32

What early practices are now discouraged for treating diarrhea?

Back 32

1. Withholding feedings
2. Providing clear liquids (juices, broth, or gelatin)
3. Providing a BRAT (Bananas, Rice, Applesauce, and Tea) diet

Front 33

What strict assessments must be documented for hospitalized children with diarrhea?

Back 33

1. Hydration status
2. Daily weights
3. Measurement of intake and output
4. Urine specific gravity
5. Stools examined for blood, pH, and reducing substances

Front 34

Why is extra care needed for children with diarrhea?

Back 34

Because diarrheal stools are highly irritating and the skin in the perianal area needs to be protected from becoming excoriated

Front 35

What is the definition of chronic diarrhea?

Back 35

An increase in stool frequency and increased water content with a duration of more than 14 days

Front 36

What is intractable diarrhea of infancy?

Back 36

A syndrome defined as diarrhea that occurs in the first few months of life, persists for longer than 2 weeks with no recognized pathogens, and is refractory to treatment

(no relief)

Front 37

What is the most common cause of intractable diarrhea of infancy?

Back 37

Acute infectious diarrhea that was not managed adequately in terms of nutrition

Front 38

What causes diarrhea to become intractable?

Back 38

Combination of secondary consequences:
1. Malnutrition deprives the infant of essential nutrients necessary for mucosal regeneration
2. The villi of the small intestine atrophy
3. Secondary digestive and absorptive disorders develop as a result of malnutrition, dysmotility, and overgrowth of bacteria

Front 39

What age group is commonly affected by chronic nonspecific diarrhea (CNSD)?

Back 39

Children between 6 and 54 months of age

Front 40

What are the potential causes of chronic nonspecific diarrhea (CNSD)?

Back 40

1. Disordered small intestine motility
2. Excessive fluid intake
3. Dietary fat restriction
4. Carbohydrate malabsorption

Front 41

What might children with chronic nonspecific diarrhea (CNSD) have?

Back 41

Impaired intestinal motility, which causes rapid intestinal transit and impaired fluid absorption

Front 42

How is chronic nonspecific diarrhea (CNSD) diagnosed?

Back 42

Only by exclusion - a history of prior illnesses and antibiotic use should be obtained. A dietary history, including fluid intake and quantities of fruit and fruit juice ingested, is important.

Front 43

What is the therapeutic management of chronic nonspecific diarrhea (CNSD)?

Back 43

1. Avoidance of foods and liquids containing sorbitol and fructose (prunes, prune juice, pears, pear juice, peaches, apple juice, sugar-free gum and candy)

2. Increased fiber in the diet

3. Increased fat content in the diet

4. Limitation of fluid intake (use fluid maintenance - do not overhydrate)

Front 44

What is vomiting?

Back 44

Forceful ejection of gastric contents through the mouth

Front 45

What is regurgitation?

Back 45

Simpler, more passive, and effortless phenomenon of spitting up

Front 46

What complications can occur in children who have persistent vomiting?

Back 46

1. Dehydration
2. Electrolyte disturbances
3. Malnutrition
4. Aspiration
5. Mallory-Weiss syndrome (small tears in the distal esophageal mucosa)

Front 47

What is Mallory-Weiss syndrome?

Back 47

Small tears in the distal esophageal mucosa caused by persistent vomiting

Front 48

What does green, bilious vomit suggest?

Back 48

Bowel obstruction

Front 49

What does curdled stomach contents, mucus, or fatty foods that are vomited suggest?

Back 49

Poor gastric emptying or high intestinal obstruction

Front 50

What does fever and diarrhea accompanying vomiting suggest?

Back 50

Infection

Front 51

What does constipation associated with vomiting suggest?

Back 51

An anatomical or functional obstruction

Front 52

What does localized abdominal pain and vomiting suggest?

Back 52

1. Appendicitis
2. Panreatitis
3. Peptic ulcer disease (PUD)

Front 53

What does a change in level of consciousness or a headache associated with vomiting suggest?

Back 53

A central nervous system or metabolic disorder

Front 54

What is forceful vomiting assoicated with?

Back 54

Pyloric stenosis

Front 55

What part of the brain controls vomiting?

Back 55

The medulla (with secondary impulses from the chemoreceptor trigger zone)

Front 56

What is nausea?

Back 56

A desire to vomit, with discomfort felt in the throat or abdomen

Front 57

What autonomic symptoms are associated with nausea?

Back 57

Salivation, pallor, sweating, and tachycardia

Front 58

What is retching?

Back 58

A series of spasmodic movements during inspiration, creating a negative intrathoracic pressure, and contraction of the abdominal muscles

(May occur with or without vomiting)

Front 59

What does projectile vomiting accompany?

Back 59

Vigorous peristaltic waves

Front 60

What is evaluated when vomiting occurs?

Back 60

Behavior, symptoms, analysis for urine protein or blood, serum electrolytes, radiographic studies, etc.

Front 61

What is important to consider regarding vomiting?

Back 61

Maintaining hydration or preventing dehydration

Front 62

What is shock?

Back 62

Circulatory failure, a complex clinical syndrome characterized by tissue perfusion that is inadequate to meet the metabolic demands of the body

Front 63

What does shock result in?

Back 63

Cellular dysfunction and eventual organ failure

Front 64

What are the physiologic consequences of shock?

Back 64

1. Hypotension
2. Tissue hypoxia
3. Metabolic acidosis

Front 65

What is the most common type of circulatory failure in children?

Back 65

Hypovolemic shock

Front 66

What is hypovolemic shock?

Back 66

A reduction in circulating blood volume related to blood loss, plasma losses, or extracellular fluid losses beyond the child's physiologic ability to compensate

Front 67

What does cardiogenic shock result from?

Back 67

Impaired cardiac muscle function that leads to decreased cardiac output

Front 68

What is distributive shock?

Back 68

Vasogenic shock, which results from a vascular abnormality that produces maldistribution of blood supply throughout the body

Front 69

What are the types of distributive shock?

Back 69

1. Neurogenic shock
2. Anaphylactic shock
3. Septic shock

Front 70

What is neurogenic shock?

Back 70

Distributive shock characterized by massive vasodilation resulting from loss of sympathetic nervous system tone, which can occur with spinal injuries

Front 71

What is anaphylactic shock?

Back 71

Distributive shock characterized by a hypersensitivity reaction that causes massive vasodilation and capillary leak and may occur with drug or latex allergy, insect stings, or blood transfusion

Front 72

What is septic shock?

Back 72

Distributive shock characterized by a decreased cardiac output and derangements in the peripheral circulation in response to a severe, overwhelming infection

Front 73

What are the stages of shock?

Back 73

1. Compensated
2. Decompensated
3. Irreversible

Front 74

What are the principal differentiating signs at all stages of shock?

Back 74

1. Degree of tachycardia and perfusion to extremities
2. Level of consciousness
3. Blood pressure

Front 75

What is compensated shock?

Back 75

When vital organ function is maintained by intrinsic mechanisms in reaction to shock

Front 76

How does the body respond during compensated shock?

Back 76

1. Cardiac output and systemic arterial BP are usually normal or increased
2. Blood flow generally uneven or maldistributed in the microcirculation

Front 77

What are the early clinical signs of compensated shock?

Back 77

1. Apprehension
2. Irritability
3. Normal BP
4. Narrowing pulse pressure
5. Thirst
6. Pallor
7. Diminished urinary output

Front 78

What are the signs of decompensated shock?

Back 78

1. Tachypnea
2. Moderate metabolic acidosis
3. Oliguria
4. Cool, pale extremities with decreased skin turgor and poor capillary filling

Front 79

What are the outcomes of circulatory failure due to decompensated shock?

Back 79

1. Tissue hypoxia
2. Metabolic acidosis
3. Eventual dysfunction of all organ systems

Front 80

What is irreversible shock?

Back 80

Terminal shock that implies damage to vital organs of such magnitude that the entire system is disrupted regardless of therapeutic intervention

Front 81

What are the signs of irreversible shock?

Back 81

1. Systemic vasoconstriction
2. Hypoxia of visceral and cutaneous circulations
3. Hypotension
4. Acidosis
5. Lethargy or coma
6. Oliguria or anuria
7. Thready, weak pulse
8. Periodic breathing or apnea
9. Possibly death

Front 82

What are signs of impending cardiopulmonary arrest?

Back 82

Stupor or coma

Front 83

What laboratory tests assist in assessment of shock?

Back 83

1. Blood gas measurements
2. pH
3. Sometimes liver function tests
4. Coagulation status (PTT, partial thromboplastin time, platelet count, fibrinogen, fibrin)

Front 84

What are the treatments of shock?

Back 84

1. Ventilation
2. Fluid administration
3. Improvement of the pumping action of the heart (vasopressor support)

Front 85

What is the priority of treating shock?

Back 85

1. Establish an airway and administer oxygen

2. Circulatory stabilization

3. Placement of one or more multilumen central lines, preferably above the diaphragm

Front 86

Which organ in most sensitive to shock?

Back 86

Lungs

Front 87

How is ventilatory support provided?

Back 87

Via endotracheal intubation with positive-pressure ventilation and supplemental oxygen

Front 88

What is monitored frequently during ventilation treatment for shock?

Back 88

1. Blood gases
2. O2 saturation
3. pH

Front 89

What is therapy directed at in patients experiencing shock?

Back 89

Maintaining normal arterial blood gas measurements, normal acid-base balance, and circulation. Efforts are made to remove fluid and prevent accumulation by increasing oncotic pressure and decreasing microvascular hydrostatic pressure.

Front 90

How is elevated oncotic pressure promoted?

Back 90

By diuresis with furomeside or mannitol, colloid administration, or both

Front 91

What is the first choice for fluid replacement?

Back 91

An isotonic crystalloid solution (NS or lactated Ringer's solution)

Front 92

How is the crystalloid solution administered?

Back 92

In intravenous boluses of 10 to 20 ml/kg over 10 to 15 minutes and repeated as necessary

Front 93

What are colloids?

Back 93

Protein-containing fluids that are often administered to children in shock

Front 94

What is the most common colloid?

Back 94

Albumin

Front 95

Why is albumin commonly used?

Back 95

Because it is a protein solution, it stays in the vascular space much longer than crystalloid fluids

Front 96

What agents are principally used to improve cardiac output and circulation during shock?

Back 96

1. Exogenous catecholamines, administered by constant infusion pump

2. Dopamine, which also improves renal perfusion

3. Other agents (dobutamine, isoproterenol, epinephrine) may be used to improve cardiac output

Front 97

What other therapies are a priority when treating shock?

Back 97

Prevention of infection

Front 98

What position is most beneficial to children experiencing shock?

Back 98

Head-down position, which tends to increase ICP, decrease diaphragmatic excursion and lung volume, and decrease venous return to the heart because of the altered thoracic pressure

Front 99

What is the emergency treatment of shock?

Back 99

1. Ventilation - establish airway; be prepared for intubation; administer O2, usually 100% by mask

2. Fluid administration - restore blood or fluid volume as ordered

3. Cardiovascular Support - administer vasopressors (epinephrine 1:1000, 0.01 mg/kg subQ; max dose of 0.5mg; may repeat if needed)

4. General support - keep child flat with legs raised above level of heart; keep child warm and calm

Front 100

What is the first stage of septic shock?

Back 100

Chills, fever, and vasodilation with increased cardiac output, which results in warm, flushed skin that reflects vascular tone abnormalities and hyperdynamic, warm, or hyperdynamic-compensated responses

Front 101

What is the second stage of septic shock?

Back 101

Skin is cool, but pulses and BP are normal, urinary output diminshes, mental state is depressed

Front 102

What is the third stage of septic shock?

Back 102

Hypothermia, cold extremities, weak pulses, hypotension, and oliguria or anuria; patient is severely lethargic or comatose; multiorgan failure is common

Front 103

In which stage does the patient has the best chance of survival?

Back 103

First stage of septic shock

Front 104

Which is the most dangerous stage of septic shock?

Back 104

Third stage