06.01 Vomiting

Hey guys, in this lesson we are going to talk about vomiting. So you already know a lot about vomiting as a symptom of illness. The point of this lesson isn’t to just repeat what you will already have learned in your adult lessons, what I want to do is just point out a few things that will be a little different in our pediatric patients.

SSo we are just going to jump right in to looking at possible causes of vomiting in our pediatric patients.

Infection is the most common cause and a lot of times this is a virus or maybe bacterial from food poisoning. Rotavirus is a common cause of both vomiting and diarrhea in children and used to be the cause for a lot of hospital admissions for kids because of severe dehydration and electrolyte abnormalities, but now we have an immunization for this and we are seeing a lot fewer admissions for this.

Increased ICP can also cause vomiting. So this may occur in children with brain tumors as the tumor increases in size there may be an increase in ICP which may cause the vomiting. You can also see vomiting due to increased ICP in trauma situations where there is a bleed in the head.

GI obstructions can happen in children as well. Two diagnosis that are specific to the pediatric population are pyloric stenosis and intussusception. Pyloric stenosis is an obstruction in the upper gi system just above the small intestines where the the pyloric sphincter is controlling the flow of food out of the stomach. The sphincter is narrowed blocking food from entering the small intestines. This usually occurs in infants 2 weeks -7 weeks and it causes kids to forcefully vomit their feeds back up. This is treated with surgery. Intussusception can cause an obstruction in the lower GI tract. We have a lesson on this for you so take a look at it if you aren’t sure what intussusception is. Foreign body ingestion can also cause GI obstruction. I’ve seen an abdominal xray of a child with 6 bouncy balls blocking up their intestines! The child thought they were candy! And remember lower gi obstruction usually causes kids (and adults) to vomit up green bile from the stomach.

Our assessment of a patient that’s vomiting is focused on the 3 biggest complications we see with vomiting and they are aspiration, dehydration and electrolyte abnormalities.

Your assessment should really start by assessing their level of consciousness. A patient that has a lower level of consciousness is at greater risk for aspirating and compromising their airway. Signs that they have aspirated are coughing, shortness of breath, foul smelling breath and hypoxia.

Then we need to move on to find out how often they are vomiting, how much is coming up and what the contents look like. This information is important because it can help us figure out how dehydrated they are. Check out the lesson on dehydration for more details on how to assess fluid status and how to treat dehydration.

The most common electrolyte imbalance to be on the look out for is low potassium or hypokalemia - and this is true for any patient that is losing a lot of fluid through their GI system.

Metabolic alkalosis can occur with excessive vomiting because hydrogen ions are being lost everytime the patient vomits up the acidic stomach content. This creates a less acidic more alkaline environment in the body. If this goes untreated the patient will become lethargic and confused. They may experience neuromuscular excitability and can even have seizures. Check out our lessons on ABG’s for more information on acid-base imbalances like metabolic alkalosis.

Therapeutic management is really all about preventing or treating the complications we just talked about. We start with ABC’s to make sure we are keeping that airway protected. So remember a patient with decreased LOC is at a greater risk for aspirating so it’s best to lay the patient on their left side to help prevent the vomit from going into their airway.

Next for management is making sure we are keeping an eye on fluid and electrolyte status- monitoring for dehydration and metabolic alkalosis. If they are in need of fluids we need to rehydrate either with oral rehydration solution or with IV Fluids.

I mentioned earlier that some kids can have a lot of problems secondary to having chronic reflux and most of the time this problem is frequent chest infections from aspirating. If this is the case,they may be a candidate for a procedure called a Nissen Fundoplication. This procedure reinforces that top of the stomach to prevent reflux. You can see in the photo here what that looks like. This severe of reflux is also often associated with poor feeding and weight loss so a lot of times a g-tube is placed when the Nissen is done. I’m sure you’ll come across this during your clinicals as is a really common procedure for our pediatric patients who are living with chronic illnesses.

Your priority nursing concepts for a pediatric patient with comint are gastrointestinal/liver metabolism, fluid and electrolyte balance and nutrition.
Okay guys, remember vomiting in children isn’t all that different from vomiting in adults. There are a few diagnoses to be aware of that you probably won’t come across in your adult patients and those are rotavirus, pyloric stenosis, Intussusception and Reflux.

Primary complications to be on the look out for are aspiration, dehydration and electrolyte imbalances. Our treatment of vomiting centers on these 3 complications- so we are helping maintain a clear airway and providing fluids and electrolytes as needed.

Keep in mind that kids who are chronically ill may have long-term issues from dealing with chronic reflux. These patients are at risk for losing weight and aspirating so they may need a procedure called a nissen fundoplication to stop the reflux from happening all together.

That’s it for our lesson on vomiting in pediatric patients. Make sure you check out all the resources attached to this lesson, as well as the lesson on dehydration and the fluids and electrolyte course. All of those topics should be linking in with this information on vomiting! Now, go out and be your best self today. Happy Nursing!