Transcript Nursing Care of the Child with a Gastrointestinal Disorder

Nursing Care of the Child
with a Gastrointestinal
Disorder
Normal Gastrointestinal System
Disorders
of
Development
Cleft Lip and Cleft Palate
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Etiology- Failure of maxillary and median nasal
processes to fuse during embryonic development
Remember the psycho-social implications for these
children and families
Assessment
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Unilateral, bilateral, midline
Treatment
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Surgical repair between 3 and 6 months
Multidisciplinary team - involving many specialists
including plastic surgeons, nurses, ear, nose, and throat
specialists, orthodontists, audiologists, and speech
therapists.
Reconstruction begins in infancy and can continue
through adulthood.
Homecare by the family prior to surgery
Pre-op Nursing Care
Pre-op Nursing Care
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May breast feed if has small cleft lip
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If bottle fed, use compressible bottle, longer nipple,
larger hole in nipple, any other special device for feeding
this infant.
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Feed slowly in upright position and bubble frequently
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Keep bulb syringe and suction equipment at bedside
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Position on side after feeding
Pre-Op Nursing Care
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What are problems that the nurse needs to be alert for
during feedings?
 Lack
of proper seal around nipple to create necessary
suction
 Excessive
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air intake
Use of special feeding techniques
 Feeder with compressible sides
 Syringes with tubing
Pre-op Nursing Care
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Remind parents that defect is operable- show
photographs of corrected clefts
Before
After
Therapeutic Management
Surgical Correction
A number of professionals are involved including
surgeons, nurses, ear, nose, and throat specialists,
audiologists, speech therapist, orthodontists, and
plastic surgeons.
Post-Op Care
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Prevent trauma to suture line
 Logan’s bow to protect site
 Do not allow to suck
 Maintain upper arm restraints
 Position supine
 No hard objects in mouth- straws, pacifiers, spoons
 Do not take temperature orally
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Reduce Pain
 Mild analgesics and sedatives
 Parents to provide, holding, rocking, and parental voices
Post-op Care
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Prevent Infection
 Cleanse suture lines as ordered
 rinse with water after each feeding
 Use cotton swab, use rolling motion vertically down
suture line
 Apply anti-infective ointment as ordered
 Call Doctor for any swelling or redness, bleeding,
drainage, fever
Make early Referrals to appropriate team members
Assess for Complications
 Otitis media, hearing loss, speech difficulties, growth,
altered dentition.
Esophageal Atresia
Malformation from failure of esophagus to develop as
a continuous tube
Upper Esophagus
Trachea
Lower Esophagus
An atresia is the absence or closure of a normal body tubular passage, such
as the esophagus and it ends in a blind pouch.
A tracheoesophageal fistula is when the esophagus connects with the trachea.
Signs and Symptoms
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Excessive amounts of salivation / mucus, frothy bubbles
in the mouth and sometimes nose
Three “C’s” - Coughing, choking, and cyanosis when fed,
overflow may be aspirated
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
 Ultra sound
 Radiopaque catheter inserted in the esophagus to
illuminate defect on X-ray
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Surgical repair
 Thoracotomy and anastomosis
Pre-Op Nursing Care
Maintain airway
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Keep NPO- administer IV fluids
Place in warmer, give humidified O2
Elevate HOB 30 degrees, suction PRN
Give Prophylactic antibiotics
Post-Op Nursing Care
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Maintain airway
Maintain thermoregulation
Maintain nutrition
 Gastrostomy Tube feedings
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Prevent trauma
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Monitor for potential complications
 Constipation or diarrhea
 Blockage of esophagus
 Infection
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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
Omphalocele
Gastroschisis
Omphalocele
Herniation of abdominal contents through the umbilical
cord. Contents are covered by a translucent sac.
Gastroschisis
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herniation of abdominal viscera outside the abdominal
cavity through a defect in the abdominal wall to the side
of the umbilicus. Not covered.
Diagnosis
Alphafetaoprotein
Permit a
early diagnosis
Ultrasound
Pre-op Treatment and Nursing Care
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Focus is on protection of the contents / sac. Cover with
warm, sterile, saline-soaked dressings over the defect.
Maintain temperature – esp. with gastroschisis because it
is not covered and lose of fluids
May choose to replace the gut to the abdomen gradually
over several weeks.
May place silo or silastic material
over gut until it returns to the
abdomen.
Maintain hydration – start IV (NPO)
NG tube to decompress stomach
Oomphalocele Repair
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While the baby is deep asleep and painfree (under general anesthesia) an
incision is made to remove the sac
membrane. The bowel is examined
closely for signs of damage or
additional birth defects.
Damaged or defective portions are
removed and the healthy edges
stitched together.
A tube is inserted into the stomach
(gastrostomy tube) and out through the
skin.
Gastroschisis Repair
Surgical repair of abdominal wall defects
involves replacing the abdomen through
the abdominal wall defect, repairing the
defect if possible, or creating abdominal
organs back into the a sterile pouch to
protect the intestines while they are
gradually pushed back into the abdomen.
Post-op Nursing Care
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Maintaining fluid and electrolyte balance
 TPN via central venous catheter to provide nutrition
while bowel rests and heals
 Progress to oral feedings once bowel motility occurs
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Prevent Infection
 IV antibiotics
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Assess for Complications
 Ileus
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Educate parents
Complications
Thermoregulation
Loss of Fluids
Ileus
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
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Heartburn
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Abdominal pain
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Cough, recurrent pneumonia
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Dysphagia
Signs and Symptoms
Diagnosis
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Assess Ph of secretions in esophagus if <7.0 indicates
presence of acid
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Also diagnosed using Barium Swallow and visualization
of esophageal abnormalities
Management & Nursing Care
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Small frequent feedings of predigested formula or
thicken the formula
Frequent burping
Positioning –keep upright for 30 minutes after feedings.
Use reflux board to keep head elevated.
Reflux board
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Avoid excessive handling after feedings.
Medications
H2 Histamine receptor antagonists – reduce gastric
acidity
 Zantac and Pepcid
 Proton-pump inhibitors
 Prevacid
 Prilosec
 Gastric emptying
 Reglan
 Antacids
 Gaviscon
**be sure to study nursing implications and side effects
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Management and Nursing Care
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If history of apnea, bradycardia, r/t GER—needs
continuous cardiac and apnea monitoring. Arrange for
CPR teaching for caregivers
If infant does not responds to non-invasive therapy, then
a Nissen fundoplication may be done to increase the
competence of the cardiac sphincter.
In a fundoplication, the upper part of the stomach is wrapped around the
lower end of the esophagus and stitched in place, reinforcing the closing
function of the cardiac sphincter.
Post-op Nursing Care
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Assess for pain, abdominal distention, and return of
bowel sounds.
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Teach parents about gastrostomy tube feedings
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:
 Giardia – most commonly seen in daycare centers
 Rotovirus – seen in infants in young children
Clinical Manifestations
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Increase in peristalsis
Large volume stools
Increase in frequency of stools
Nausea, vomiting, cramps
Increased heart & resp. rate, decreased tearing and
fever
Complications:
 Dehydration
 Metabolic acidosis
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.
Dehydration
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Infant
Depressed fontanels
Sunken eye orbits
Fussy, Irritable
Thirsty
Fewer wet diapers
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Child
Decreased tear production
Skin non-elastic
Decreased urinary output
Thirsty
Restless
Treatment & Nursing Care
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Treat cause
Fluid and electrolyte balance
Weigh daily
Monitor I&O
Assess for dehydration
Isolate
Skin care
Oral Rehydration
Avoid fluids that are high in sugar – soft drinks,
jello, fruit drinks, tea
Appendicitis
Inflammation of the lumen of the appendix
which becomes quickly obstructed causing
edema, necrosis and pain.
Clinical Manifestations
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Abdominal cramps and pain
Fever
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Guarding
Abdominal rigidity
Rebound Tenderness
Vomiting
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Elevated WBC - >15,000
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Management and Nursing Care:
Pre-Op
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NPO
IV
Comfort measures – semi-fowlers or R side lying
Antibiotics
Thermal therapy – ice, not heating pads
Elimination
Patient education
**Narcotic pain medications are used minimally so as not
mask the signs of appendicitis.
Appendicitis
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What is the most common
symptom indicating that
the appendix may have
ruptured?
Management and Nursing Care:
Post-Op
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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
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Narrowing of the pyloric
spincter
Delayed emptying of the
stomach
Assessment
Projectile
vomiting
Distended
Abdomen
Hypertrophied
pylorus
Constant
hunger
fussiness
Visible peristaltic
waves
Treatment and Nursing Care
Treatment: Surgery
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Pyloromyotomy
Post Operative Care:
I&O
 Feeding
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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
Critical Thinking
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A 4 week old infant with a history of vomiting
after feeding has been hospitalized with a
tentative diagnosis of pyloric stenosis. Which of
these actions is priority for the nurse?
 Begin
an intravenous infusion
 Measure abdominal circumference
 Orient family to unit
 Weigh infant
Intussuception
Volvulus
Both are forms of bowel obstruction
Intussuception
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Most commonly seen in infants 3-12 months
Bowel “telescopes”
within itself
Volvulus
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A twisting of the bowel
that leads to a bowel
obstruction.
Assessment
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Intussusception
Pain
Vomiting
Stools – resemble currant
jelly, bloody mucus
Sausage shape
abdominal mass
Dehydration
Serious complications
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Shock and sepsis
Volvus
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Pain
Bilious vomiting
Abdominal distention
Tachycardia
Therapeutic Intervention
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Intussuception
 Hydrostatic Reduction
 Surgery
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Volvulus
 Surgery
Nursing Care
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Following Hydrostatic reduction
 Clear liquids and diet is advanced gradually
 Observe for passage of barium and eventually
passage of stool
If reduction is not successful
Surgery
Post-op Care
 Stabilize the child
 NPO and start IV fluids
 NG tube to decompress the bowel
 Pain medications
 Provide information to the parents
Hirschsprung's
Disease
Hirschsprung’s Disease
Congenital disorder of nerve cells in lower colon
Assessment
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• Failure to pass meconium
• Ribbon Like stools
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• Vomiting
• Reluctance to feed
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• Abdominal distention
• Foul odor of breath
Diagnosis
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History & Physical
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Barium enema (X-ray)
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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
 NPO
 Vital Signs – never take a rectal temperature
 Assessment
 Patient/parent teaching
 Colostomy care
 Skin care
 Nutrition
Lactose intolerance
the inability to metabolize lactose, because
of a lack of the required enzyme lactase in
the digestive system.
Lactose Intolerance
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Manifestations
 Diarrhea that is frothy, but not fatty
 Abdominal distention
 Cramping
 Abdominal pain
 Excessive flatus
Lactose Intolerance
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Removal of lactose from the Diet
 Eliminate – milk, formulas that contain dairy products,
ice cream, yogurt, hard cheeses
 Breastfeeding moms – eliminate lactose from their diet
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Medications
 Lactase preparations – Lactaid, Dairy Ease, Lac-Dose
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Obtain calcium from other sources
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