Transcript Nursing Care of the Child with a Gastrointestinal Disorder

Providing Patient Centered Care
for the Child with a
Gastrointestinal Disorder
Presented by Marlene Meador RN, MSN, CNE
Normal Gastrointestinal System
Disorders
of
Development
Cleft Lip and Cleft Palate
Etiology- Failure of maxillary and median
nasal processes to fuse during embryonic
development
Remember the psycho-social implications
for these children and families
Assessment
Unilateral, bilateral, midline
Treatment
Surgical repair between 3 and 6 months
 Rule of “10”
 Multidisciplinary team
 Reconstruction begins in infancy and can
continue through adulthood.
 Homecare by the family prior to surgery
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Pre-operative Nursing Care
Remind parents that defect is operableshow photographs of corrected clefts
Before
After
Pre-operative Nursing Care
Post-Operative Care
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Prevent trauma to suture line
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Logan’s bow to protect site
Do not allow to suck
Maintain upper arm restraints
Position supine
No hard objects in mouth
Reduce Pain
Prevent Infection
◦ Cleanse suture lines as ordered – rinse with water after
each feeding.
◦ Call Doctor for any swelling or redness
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Referral to appropriate team members
Nursing Care of the Child with
Esophageal Atresia or
Tracheoesophageal Fistula
Malformation from failure of esophagus to develop as a
continuous tube
Upper Esophagus
Trachea
Lower Esophagus
Signs and Symptoms
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Excessive amounts of salivation / mucus, frothy
bubbles
Three “C’s”: Coughing, choking, and cyanosis
when fed
Food may be expelled through the nose
immediately
following the feeding
Rattling respirations and frequent respiratory
problems such as aspiration pneumonia
Gastric distention, if fistula
History of polyhydramnios during pregnancy can
suggest a high gastrointestinal obstruction
Diagnosis and Management
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Early diagnosis
◦ Ultrasound
◦ Radiopaque catheter inserted in the esophagus to
illuminate defect on X-ray
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Surgical repair
◦ Thoracotomy and anastomosis
Pre-Op
Maintain airway
Keep NPO- administer IV fluids
Elevate HOB 30 degrees
Suction PRN
Administer Prophylactic antibiotics
Post-Op
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Maintain airway
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Maintain nutrition
◦ Gastrostomy tube feedings
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Prevent trauma
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Monitor for potential complications
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Monitor weight, growth and developmental
achievements
Imperforate Anus
Incomplete development or
absence of anus in its normal
position in perineum.
Assessment
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Most commonly diagnosed upon Newborn
Assessment
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Symptoms
◦ Absence of anorectal canal
◦ Failure to pass meconium
◦ Presence of anal membrane
Treatment
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Anal stenosis is treated with repeated
anal dilation
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Surgery
Abdominal Wall Defects:
Gastroschisis
Omphalocele
Omphalocele
Herniation of abdominal contents through the umbilical
cord. Contents are covered by a translucent sac.
Gastroschisis
herniation of abdominal viscera outside the
abdominal cavity through a defect in the abdominal
wall to the side of the umbilicus. Not covered.
Diagnosis:
What prenatal testing would detect this
defect?
 Alpha-fetoprotein
 Ultrasound
Treatment and Nursing Care
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Pre-operatively – provide protection of the
contents/sac.
◦ Cover with warm, sterile, saline-soaked dressings
◦ Maintain temperature – esp. with gastroschisis
May choose to replace the gut to the abdomen
gradually over several weeks.
May place silo or silastic
material over bowel until it
returns to the abdomen.
 Surgery used to close defect.
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Post-operative Nursing Care
 Assess
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for ileus
Maintain parenteral feedings
 Provide support to the parents.
Gastroesophageal Reflux
Disease
(GERD)
The cardiac sphincter and lower portion of
the esophagus are weak, allowing regurgitation
of gastric contents back into the esophagus.
Assessment: Infant
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Regurgitation almost immediately after each feeding
when the infant is laid down
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Excessive crying, irritability
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Failure to Thrive
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Life Threatening Risk / Complications:
◦ aspiration pneumonia
◦ apnea
Assessment: Child
Heartburn
 Abdominal pain
 Cough, recurrent pneumonia
 Dysphagia
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Diagnosis
Assess Ph of secretions in esophagus if
<7.0 indicates presence of acid
 Also diagnosed using Barium Swallow and
visualization of esophageal abnormalities
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Management & Nursing Care
Small frequent feedings of predigested formula or thicken the
formula
 Frequent burping
 Positioning --prone position- flat prone or head elevated
prone. Use reflux board to keep head elevated.
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Avoid excessive handling after feedings.
 Nissen Fundoplication
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Reflux board
Medications
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H2 Histamine receptor antagonists – reduce
gastric acidity
◦ Zantac and Pepcid
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Proton-pump inhibitors
◦ Prevacid
◦ Prilosec
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Gastric emptying
◦ Reglan
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Antacids
◦ Gaviscon
Diarrhea
Infectious Gastroenteritis
Diarrhea/Gastroenteritis
Severe
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A disturbance of the intestinal tract that
alters motility and absorption and
accelerates the excretion of intestinal
contents.
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Most infectious diarrheas in this country
are caused by Rotovirus most common
non-viral pathogen is Giardia
Clinical Manifestations
Increase in peristalsis
 Large volume stools
 Increase in frequency of stools
 Nausea, vomiting, cramps
 Increased heart & resp. rate, decreased
tearing and fever
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Diagnosis
Blood Gases
Stool for O&P
Stool Culture
Complications
Dehydration
Metabolic Acidosis
The newborn and infant have a high percentage of body weight comprised of water,
especially extracellular fluid, which is lost from the body easily. Note the small stomach
size which limits ability to rehydrate quickly.
Treatment & Nursing Care
Treat cause
 Fluid and electrolyte balance
 Weigh daily
 Monitor I&O
 Assess for dehydration
 Isolate
 Skin care
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Appendicitis
Inflammation of the lumen of the appendix
which becomes quickly obstructed causing
edema, necrosis and pain.
Management and Nursing Care:
Pre-Operatively
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NPO
IV
Comfort measures – semi-fowlers or R side
lying
Antibiotics
Elimination
Patient education
**Narcotic pain medications are used
minimally so as not mask the signs of
appendicitis.
Clinical Judgment:
What is the most common
symptom indicating that
the appendix may have
ruptured?
Post-operative Nursing Care:
 NPO
 Antibiotics
 Analgesia
 Patient
teaching
Pyloric Stenosis
The pylorus muscle which is at the distal end of the
stomach becomes thickened causing constriction of
the pyloric canal between the stomach and the
duodenum and obstruction of the gastric outlet of
the stomach.
Pyloric Stenosis
Narrowing of the
pyloric spincter
 Delayed emptying of
the stomach
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Assessment
Projectile
vomiting
Distended
Abdomen
Hypertrophied
pylorus
Constan
t hunger
fussiness
Visible
peristaltic
waves
Treatment and Nursing Care
Treatment: Surgery -Pyloromyotomy
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Post Operative Care:
◦I&O
◦ Feeding
 Feeding begins with clear liquids containing glucose and
electrolytes. Regime example: 8 hours NPO, 10cc
sterile hater feed X 2. Increase to 15cc X 2,
progressing to ½ strength formula, then full strength
formula. Observe and record the infant’s response to
feeding.
◦ Position with head elevated
◦ Assess Surgical site to prevent infection
◦ Patient teaching
Clinical Judgment

A 4 week old infant with a history of vomiting
after feeding has been hospitalized with a
tentative diagnosis of pyloric stenosis. What is
the nurse’s priority intervention at this time?
◦ Begin an intravenous infusion
◦ Measure abdominal circumference
◦ Orient family to unit
◦ Weigh infant
Intussuception
Volvulus
Both are forms of bowel obstruction
Intussuception
Most commonly seen in infants 3-12
months
 Bowel “telescopes” within itself
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Volvulus
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A twisting of the
bowel that leads to
a bowel
obstruction.
Assessment
Pain
 Vomiting
 Stools – resemble currant
jelly
 Dehydration
 Serious complications
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Medical Intervention:

Intussuception
◦ Hydrostatic Reduction
◦ Surgery
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Volvulus
◦ Surgery
Hirschsprung’s Disease
Congenital disorder of nerve cells in lower colon
Assessment
*
• Failure to pass meconium
• Ribbon Like stools
*
• Vomiting
• Reluctance to feed
*
• Abdominal distention
• Foul odor of breath
Diagnosis & Management
Diagnosis
 History & Physical
 Barium enema (X-ray)
 Rectal biopsy- absence of ganglionic cells
in bowel mucosa
Management
 Surgical intervention
◦ Colostomy
◦ Resection
Nursing Care
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Pre-op
◦ Cleanse bowel
◦ Patient/parent teaching
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Post-op
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NPO
Vital Signs – never take a rectal temperature
Assessment
Patient/parent teaching
 Colostomy care
 Skin care
 Nutrition
Lactose Intolerance
Inability to tolerate the sugar found in
dairy products as a result of an absence or
deficiency of lactase.
Celiac Disease
inability to digest gliadin which is a
by-product of gluten breakdown.
Signs and Symptoms
The child with celiac disease
commonly demonstrates
failure to grow and wasting of
extremities. The abdomen can
appear large due to intestinal
distension and malnutrition
Complications:
Hypocalcemia, osteomalacia, osteoporosis, depression.
Treatment and Nursing Care
Teach parents DIETARY REGULATIONS:
NO !
Gluten
Free
Diet
Wheat
Rye
Barley
Oats
For questions or clarification please contact
Marlene Meador RN, MNS, CNE
Office # 512-223-5769
Email:
[email protected]