Transcript Care of the Pediatric Patient with Gastrointestinal Problems

Care of the Pediatric
Patient with
Gastrointestinal Problems
Elizabeth Allen RN, MSN
Learning Objectives
1. Review the normal structure and function
of the GI system, including the pediatric
anatomical differences.
2. Review the pharmacological and surgical
measures utilized for the various GI
conditions
3. Recognize dehydration with appropriate
interventions.
4. Select appropriate diet for Celiac disease.
Anatomic and Physiologic
Differences
 Newborn swallowing reflex until 6 weeks
 Newborn stomach small with increased peristalsis
 4-6 months- Insufficient enzymes to aid digestion
 First 2 years- kidneys less efficient regulation of acidbase balance, less able to concentrate urine
 Infants & Children- greater body surface area
 Urine output
 Infants 2 cc/kg/hr.
 Children 1 cc/kg/hr.
Dehydration
 Infants and young
children more
susceptible
 Physiologic differences
 Phototherapy or
overhead warmer
 Insensible losses:
Increased respiratory
rate, fever
 Vomiting and diarrhea
 Drainage or blood loss
 Body Weight Composed
of Water (Especially
extracellular fluid)
 Newborn- 75% total
body water
 Infant- 65% total body
water
 Child/Adolescent- 50%
total body water
Dehydration Assessment
 Level of Consciousness
 Thirst
 Urine output- weigh diapers, Foley
 Urine Specific Gravity (>2 years)
 Skin Turgor
 Fontanelle
 HR, BP
 Capillary Refill
 Skin color, temperature
Degrees of Dehydration
Mild
% of Body
Weight Lost
<5%
Moderate
Severe
6-9%
10% or
more
Urine Output
Usual
<1 ml/kg/hr.
Very
decreased or
absent
Fluid
Replacement
Oral
Oral/IV
IV
IV Fluid bolus with isotonic crystalloid only!!
Pediatric Fluid resuscitation with 20 ml/kg
Degrees of Dehydration
Mild
Moderate
Severe
Level of
Consciousness
Alert
Lethargic, Sleepy, Irritable
(Infants)
Alert, restless (older children)
Lethargy, unresponsiveness (Infant)
Conscious, anxious (older children)
Mucus
Membranes
Moist
dry
Parched, non elastic skin turgor
Normal
Dark and diminished
Markedly decreased or absent
No change
Increased HR BP normal or
slightly decreased
Increased HR, Decreased BP
Warm, Cap
Refill <2 sec
Capillary refill >2 sec
Cool, Discolored
Cap Refill >3-4 sec
No thirst
Thirsty
Greatly Increased unless lethargic
Normal
Slightly sunken, decreased
tears
Sunken, decreased or absent tears
Flat
Sunken
Sunken
Urine
LOC
Extremities
Thirst
Eyes
Fontanelle
(London et al., 2014)
Dehydration
What type of acid-base disturbance
would you expect from prolonged
vomiting and diarrhea?
Respiratory Acidosis
Respiratory Alkalosis
Metabolic Acidosis
Metabolic Alkalosis
Abnormal Motility
Constipation
 Functional Constipation
Normal G&D, Increase fluids, fiber, May
resolve as solid food is added to diet
May treat pharmacologically with
osmotic agent (polyethylene glycol)
Abnormal Motility
Hirshprung Disease
Congenital Aganglionic Megacolon
Lack of peristalsis
Rectum and colon
More often in males
Abnormal Motility
Hirshprung Disease
 Symptoms
Abdominal Distention
Failure to pass meconium in first 48
hours
 Treatment
Chronic progressive constipation
Bloody diarrhea
 Enterocolitis as complication- life
threatening emergency
Abnormal Motility
Hirshprung Disease
 Treatment
 Colectomy of aganglionic section
 Primary Repair
 Placement of temporary colostomy
 Assess for Enterocolitis!
 Colostomy
 Teach proper care to parents
 Monitor for fluid loss
 Post op fecal incontinence or constipation may
persist
Abnormal Motility
GER/GERD
GER affects approximately 50%
infants 0-3 months
More common in
Asthma
Neurological Disorders
CF
Abnormal Motility
GERD Symptoms
 Weight loss or no gain
 Irritable
 Vomiting
GERD Treatment
 H2 blocker
 PPI
 Pro-kinetic agents
 Frequent URI’s
 Upright after feeds- 30
minutes
 Positive pH probe study
 Small frequent feeds
 Thickened formula
 Gastostomy tube
placement
 Fundoplication
Fundoplication
Obstruction
Esophageal Atresia
 Defect occurs in 4th-5th
week gestation
 90% with Esophageal
Atresia also have TEF
 Esophagus ends as dry
pouch or connects to
trachea with fistula
 May have associated
defects
Tracheoesophageal
Fistula (TEF)
 Defect occurs in 4th-5th
week gestation
 Allows oral secretions,
liquids entry to lungs
Obstruction
 Treatment:
 Pre- op
 NPO, position
 Esophageal
Fistula and TEF
 3 Classic signs in Infant:
 Cyanosis
 Choking
 Coughing
 Excessive Drooling,
aspiration, abdominal
distention (air)
 Suction
 NGT insertion, IV
hydration and antibiotics
 Surgery ASAP
 Ligate fistula,
insert
gastrostomy tube
 Anastomosis of
esophagus
 May be a 2 step
process
Obstruction
 Pyloric Stenosis
 Hypertrophy of pyloris muscle causes stenosis
 Difficult passage from stomach to duodenum
 More common in males (4:1)
 Unknown cause
 Symptoms begin 2-8 weeks after birth
 Projectile vomiting immediately after feeds
 Hungry, irritable, unable to gain weight
 May present with dehydration, metabolic alkalosis
 Olive sized mass R upper quadrant
Obstruction
 Pyloric Stenosis
 Treatment
 Fluid replacement
 Correct abnormal
fluid balance,
electrolytes
 Surgical repairLaparoscopic
Pyloromyotomy
Obstruction
 Intussusception
 Telescoping of
intestine into itself
 65% in infants <1
year
 More common in
males
Obstruction
Intussusception
Symptoms
Intussusception
Treatment
 Abrupt onset
 Air enema- works 90%
of cases
 Acute abdominal pain
 Intermittent pain
 Vomiting
 Currant jelly stools- mix
of blood and mucus
 May have palpable
abdominal mass
 Then Barium enema
 NGT
 Surgical repair, removal
of necrotic tissue
Obstruction
 Multidisciplinary
approach
Cleft Lip and Palate
 Lip repair to
improve feeding
 Can occur together or
separately
 Defects occurs at 5-12
weeks gestation
 Often associated with
other defects or
syndromes
 Prone to otitis media
 Speech problems
Obstruction
Cleft Lip and
Palate
 Important to assess
palate in newborn
 Cleft lip repair in first
weeks to 6 months of
life
 Cleft palate repair at
approximately 18
months
Obstruction
Cleft Lip and Palate
 Pre Op Nursing
Care
 Feedings
 Hydration
 Prevent
aspiration
 Post Op Repair
 No sucking for 2
weeks
 Nutrition
 Elbow restraints
 Pain control
Abnormal Absorption/Metabolism
Celiac Disease
 Intolerance to gluten
 Accumulate amino acid glutamine toxic to mucosal
cells and villi
 First affects fat absorption
 Steatorrhea- Large amounts of foul smelling, greasy stools
 Symptoms arise 6 months- 2 years with solid food
introduction- may not be diagnosed until adulthood
 Diagnosis
 Fecal fat content
 Duodenal or jejeunal biopsy
 Gluten free diet- Diagnostic & Treatment
Abnormal Absorption/Metabolism
Pin Worms
 Intestinal parasitic disorder- most common worm
infestation in US
 Untreated water
 Hand to mouth
 Symptoms
 Itching
 Restless
 Clinical Therapy
 Mebendazole, pyrantel pamoate, albendazole
 Household containment
Abnormal Absorption/Metabolism
 Failure to Thrive (FTT)
 Organic versus Non-organic
 Symptoms
 Persistent failure to eat
 No weight gain/or weight loss
 Small size
 Irritable
 Possible developmental delays
 Management
 Assessment
 Growth
 Home
 Referrals