lOMoARcPSD|17706574
NR602 Final Study Guide
October 2022
Week 5
Gastrointestinal
Dehydration:
o A common problem, increased risk of diarrhea
o Infants and young children are at the highest risk
o Body fluids make up 75% of an infant’s body weight
o Infants/toddlers’ high ratio of surface area to weight equals more body loss through
evaporation
Diarrhea:
o Acute diarrhea is typically caused by viruses, like rotavirus, bacteria, and parasites
o Rotavirus is common in infants between 3 and 15 months of age
o Chronic diarrhea can be caused by antibiotic treatment of another condition, poor
absorption of starches and sugars, food allergies, laxative abuse in eating disorders,
hyperthyroidism, or irritable bowel syndrome
o In acute cases, treatment is supportive and includes fluid and electrolyte replacement
and/or antidiarrheals based on age; in chronic cases, treatment is specific to the
underlying conditions
Assessing dehydration:
o History of present illness (HPI): quantity and frequency of fluid intake, vomiting, and/or
diarrhea, urine output or number of wet diapers in 24 hours, duration or degree of fever,
types of medications, underlying diseases
o Weight is the most essential measure in calculating body fluid loss
o Physical exam (PE): vital signs, color, capillary refill, skin turgor, dryness of lips and
mucous membranes, lack of tears, sunken fontanelles, output, and mental status
Treatment of mild to moderate dehydration:
o Commercially available oral hydration solutions (ORS)
o Continue breastfeeding with ORS supplementation
o Offer young children 20 ml/kg per hour
o Offer older children 100 mL of ORS every 5 minutes
o Combine with IV therapy as needed
o Reassess after 4 hours; repeat if needed
o Avoid juice, soft drinks, and sports drinks
Treatment of severe dehydration:
o Evidence of compromised perfusion and severe dehydration
o Intravenous (IV) therapy of Ringer's lactate or normal saline if Ringers not available
o under 1 year, 30 ml/kg over the first hour, 70 ml/kg for the following 6 hours, and
100 ml/kg from 6 to 24 hours.
o over 1 year, 30 ml/kg over the first 30 minutes and 70 ml/kg for the following 3
hours.
o reassess every 15 to 30 minutes
Downloaded by Nicholas Marks ()
, lOMoARcPSD|17706574
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 (<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).
Dehydration is overwhelmingly the result of an infectious process, primarily viral, that often causes
diarrhea. Children are at increased risk due to their higher surface area–to-volume ratios, higher rate
of insensible loss, and in younger children the inability to communicate or actively replenish losses.
Clinical Findings
History
The vomiting history should assess the following:
• Symptoms with the onset of vomiting; duration of vomiting, quality and quantity, presence of blood
or bile, odor, precipitating event; pain; relationship of vomiting to meals, activities, or time of day.
Vomiting early in the morning is indicative of increased intracranial pressure.
• Recent exposure to illness, injury, or stress; recent travel (including camping); swimming activities;
possibility of poisoning or contaminated food
• Medications currently being taken (including over-the-counter, herbal, cultural, and homeopathic
remedies)
• Presence of associated symptoms: Diarrhea, fever, ear pain, UTI symptoms, vision changes, cough,
headache, seizures, high-pitched cry, polydipsia, polyuria, polyphagia, anorexia
• Past history of illnesses, surgeries, or hospitalizations
• Family history of GI disease or fetal or neonatal deaths (metabolic syndrome, congenital anomaly)
The dehydration history should assess the following:
• Mental status and thirst
• Parental concern regarding decreased tearing or urination, or depressed fontanel in infants
Physical Examination
• Growth parameters and vital signs
• Neurologic examination: Nuchal rigidity, decreased level of consciousness, and behavioral changes,
which can include irritability or lethargy. Sensorium remains intact until there is greater than 6%
weight loss as a result of dehydration. Hypotension is a late manifestation of dehydration.
• Abdominal examination: Inspect for distention, abdominal scars from previous surgery (may be
associated with obstruction and/or adhesions), or visible peristaltic waves. Auscultate bowel sounds
(i.e., increased with gastroenteritis, decreased with obstruction, absent with ileus or peritonitis).
Palpate the abdomen for pain and/or rebound tenderness. Assess abdominal organs (liver and
spleen size, masses). Perform a rectal examination as indicated.
Downloaded by Nicholas Marks ()
, lOMoARcPSD|17706574
• Respiratory examination: Tachypnea, decreased oxygen saturation, stridor
• One of the most useful clinical signs of hydration is capillary refill time
Diagnostic Studies
Diagnostic studies are performed as indicated by the probable diagnosis:
• Laboratory studies:
• CBC with differential, blood culture
• Electrolytes, including blood urea nitrogen (BUN) and creatinine, glucose, and liver function tests
• Serum sodium less than 130 (hyponatremic) or greater than 150 (hypernatremic)
• CRP and ESR
• Serum lactate, organic acids, ammonia for metabolic disorders (may only be abnormal during
episodes of vomiting)
• UA and urine culture
• Toxicology screen
• Stool for culture and occult blood, leukocytes, parasites, fat, pH, reducing substances
• Rapid strep test and/or throat culture
• Pregnancy test
Downloaded by Nicholas Marks ()
, lOMoARcPSD|17706574
• Imaging;
• Abdominal radiographs (suspected obstruction or FB ingestion, organomegaly, or a palpable mass)
• Chest radiograph (suspected pneumonia)
• Ultrasound (abscesses, masses, stenoses, cysts, appendicitis, pyloric stenosis)
• Barium swallow or enema (malrotation, pyloric stenosis, GER, masses)
• CT scan or MRI to diagnose masses, inflammation, herniations, perforations, and obstructions
• Other studies
• Endoscopy (obstruction, hemorrhage, infection, collect biopsies)
• Esophageal pH probe analysis, scintiscan
• Electroencephalogram (EEG)
Colic (signs, symptoms, treatment, etc): Colic is defined as crying for no apparent reason that
lasts for 3 hours or more per day and occurs 3 days or more per week in an otherwise healthy infant
younger than 3 months of age. The Period of PURPLE Crying Initiative (www.purplecrying.info) is a
resource for parents to assist them during the developmentally normal fussy period. The term
PURPLE - acronym used to describe specific characteristics of an infant’s cry during this period and
provides parents with knowledge that this is indeed normal and will pass in time.
When difficult-to-soothe crying occurs, a careful history and physical examination including a
thorough gastrointestinal and neurological assessment should be performed. The main management
is an acknowledgement by the provider of the tremendous difficulties the parents are dealing with and
an inquiry about the well-being of the parents. There is no evidence to support changing formulas or
using medications to manage crying.
The use of quiet “white noise”—noise that contains many frequencies with equal intensities—can help
calm infants. Many parents realize their infants calm when the vacuum is running or a ceiling fan is
on. Others notice a car ride provides a variety of noise from the engine, street, to calming music in the
car. Discourage parents from putting the infant in a car seat on the dryer or using a blow dryer, in
order to prevent falls and burns. For infants with colic, mothers may wish to reduce or eliminate
allergenic foods (e.g., cow’s milk, eggs, peanuts, tree nuts, soy, fish, and wheat) in her diet; however,
there is little evidence that elimination of foods is protective against colic symptoms.
Downloaded by Nicholas Marks ()
NR602 Final Study Guide
October 2022
Week 5
Gastrointestinal
Dehydration:
o A common problem, increased risk of diarrhea
o Infants and young children are at the highest risk
o Body fluids make up 75% of an infant’s body weight
o Infants/toddlers’ high ratio of surface area to weight equals more body loss through
evaporation
Diarrhea:
o Acute diarrhea is typically caused by viruses, like rotavirus, bacteria, and parasites
o Rotavirus is common in infants between 3 and 15 months of age
o Chronic diarrhea can be caused by antibiotic treatment of another condition, poor
absorption of starches and sugars, food allergies, laxative abuse in eating disorders,
hyperthyroidism, or irritable bowel syndrome
o In acute cases, treatment is supportive and includes fluid and electrolyte replacement
and/or antidiarrheals based on age; in chronic cases, treatment is specific to the
underlying conditions
Assessing dehydration:
o History of present illness (HPI): quantity and frequency of fluid intake, vomiting, and/or
diarrhea, urine output or number of wet diapers in 24 hours, duration or degree of fever,
types of medications, underlying diseases
o Weight is the most essential measure in calculating body fluid loss
o Physical exam (PE): vital signs, color, capillary refill, skin turgor, dryness of lips and
mucous membranes, lack of tears, sunken fontanelles, output, and mental status
Treatment of mild to moderate dehydration:
o Commercially available oral hydration solutions (ORS)
o Continue breastfeeding with ORS supplementation
o Offer young children 20 ml/kg per hour
o Offer older children 100 mL of ORS every 5 minutes
o Combine with IV therapy as needed
o Reassess after 4 hours; repeat if needed
o Avoid juice, soft drinks, and sports drinks
Treatment of severe dehydration:
o Evidence of compromised perfusion and severe dehydration
o Intravenous (IV) therapy of Ringer's lactate or normal saline if Ringers not available
o under 1 year, 30 ml/kg over the first hour, 70 ml/kg for the following 6 hours, and
100 ml/kg from 6 to 24 hours.
o over 1 year, 30 ml/kg over the first 30 minutes and 70 ml/kg for the following 3
hours.
o reassess every 15 to 30 minutes
Downloaded by Nicholas Marks ()
, lOMoARcPSD|17706574
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 (<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).
Dehydration is overwhelmingly the result of an infectious process, primarily viral, that often causes
diarrhea. Children are at increased risk due to their higher surface area–to-volume ratios, higher rate
of insensible loss, and in younger children the inability to communicate or actively replenish losses.
Clinical Findings
History
The vomiting history should assess the following:
• Symptoms with the onset of vomiting; duration of vomiting, quality and quantity, presence of blood
or bile, odor, precipitating event; pain; relationship of vomiting to meals, activities, or time of day.
Vomiting early in the morning is indicative of increased intracranial pressure.
• Recent exposure to illness, injury, or stress; recent travel (including camping); swimming activities;
possibility of poisoning or contaminated food
• Medications currently being taken (including over-the-counter, herbal, cultural, and homeopathic
remedies)
• Presence of associated symptoms: Diarrhea, fever, ear pain, UTI symptoms, vision changes, cough,
headache, seizures, high-pitched cry, polydipsia, polyuria, polyphagia, anorexia
• Past history of illnesses, surgeries, or hospitalizations
• Family history of GI disease or fetal or neonatal deaths (metabolic syndrome, congenital anomaly)
The dehydration history should assess the following:
• Mental status and thirst
• Parental concern regarding decreased tearing or urination, or depressed fontanel in infants
Physical Examination
• Growth parameters and vital signs
• Neurologic examination: Nuchal rigidity, decreased level of consciousness, and behavioral changes,
which can include irritability or lethargy. Sensorium remains intact until there is greater than 6%
weight loss as a result of dehydration. Hypotension is a late manifestation of dehydration.
• Abdominal examination: Inspect for distention, abdominal scars from previous surgery (may be
associated with obstruction and/or adhesions), or visible peristaltic waves. Auscultate bowel sounds
(i.e., increased with gastroenteritis, decreased with obstruction, absent with ileus or peritonitis).
Palpate the abdomen for pain and/or rebound tenderness. Assess abdominal organs (liver and
spleen size, masses). Perform a rectal examination as indicated.
Downloaded by Nicholas Marks ()
, lOMoARcPSD|17706574
• Respiratory examination: Tachypnea, decreased oxygen saturation, stridor
• One of the most useful clinical signs of hydration is capillary refill time
Diagnostic Studies
Diagnostic studies are performed as indicated by the probable diagnosis:
• Laboratory studies:
• CBC with differential, blood culture
• Electrolytes, including blood urea nitrogen (BUN) and creatinine, glucose, and liver function tests
• Serum sodium less than 130 (hyponatremic) or greater than 150 (hypernatremic)
• CRP and ESR
• Serum lactate, organic acids, ammonia for metabolic disorders (may only be abnormal during
episodes of vomiting)
• UA and urine culture
• Toxicology screen
• Stool for culture and occult blood, leukocytes, parasites, fat, pH, reducing substances
• Rapid strep test and/or throat culture
• Pregnancy test
Downloaded by Nicholas Marks ()
, lOMoARcPSD|17706574
• Imaging;
• Abdominal radiographs (suspected obstruction or FB ingestion, organomegaly, or a palpable mass)
• Chest radiograph (suspected pneumonia)
• Ultrasound (abscesses, masses, stenoses, cysts, appendicitis, pyloric stenosis)
• Barium swallow or enema (malrotation, pyloric stenosis, GER, masses)
• CT scan or MRI to diagnose masses, inflammation, herniations, perforations, and obstructions
• Other studies
• Endoscopy (obstruction, hemorrhage, infection, collect biopsies)
• Esophageal pH probe analysis, scintiscan
• Electroencephalogram (EEG)
Colic (signs, symptoms, treatment, etc): Colic is defined as crying for no apparent reason that
lasts for 3 hours or more per day and occurs 3 days or more per week in an otherwise healthy infant
younger than 3 months of age. The Period of PURPLE Crying Initiative (www.purplecrying.info) is a
resource for parents to assist them during the developmentally normal fussy period. The term
PURPLE - acronym used to describe specific characteristics of an infant’s cry during this period and
provides parents with knowledge that this is indeed normal and will pass in time.
When difficult-to-soothe crying occurs, a careful history and physical examination including a
thorough gastrointestinal and neurological assessment should be performed. The main management
is an acknowledgement by the provider of the tremendous difficulties the parents are dealing with and
an inquiry about the well-being of the parents. There is no evidence to support changing formulas or
using medications to manage crying.
The use of quiet “white noise”—noise that contains many frequencies with equal intensities—can help
calm infants. Many parents realize their infants calm when the vacuum is running or a ceiling fan is
on. Others notice a car ride provides a variety of noise from the engine, street, to calming music in the
car. Discourage parents from putting the infant in a car seat on the dryer or using a blow dryer, in
order to prevent falls and burns. For infants with colic, mothers may wish to reduce or eliminate
allergenic foods (e.g., cow’s milk, eggs, peanuts, tree nuts, soy, fish, and wheat) in her diet; however,
there is little evidence that elimination of foods is protective against colic symptoms.
Downloaded by Nicholas Marks ()
