Transcript Gastrointestinal Disorders in Pediatric Patients

Gastrointestinal
Disorders in Pediatric
Patients
Revised, Summer 2009
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 done ASAP
 Rule of 10 > 10#, 10 weeks, 10 HGB
 Multidisciplinary team
 Homecare by the family prior to surgery
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E-enlarge opening in nipple
S-stimulate suck reflex
S-swallow fluids appropriately
R-rest when infant signals
Pre-op Teaching
Remind parents that defect is operableshow photographs of corrected clefts
 Introduce cup, spoon feeding devices (see
your book for feeding tips)
 Explain restraints
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Post-Op
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Prevent trauma to suture line – Do not
allow to suck!
– Facilitate breathing
– Maintain nutrition
Reduce pain to minimize crying
 Prevent infection
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– Cleanse suture lines as ordered
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Referrals to appropriate team members
Esophageal Atresia/
Tracheoesophageal fistula
Failure of the esophagus to totally
differentiate – 4-5th wk gestation
Both are malformations of ESOPHAGUS
Cause is unknown
Assessment
3C’s -coughing, choking, cyanosis when
feeding
 Respiratory difficulties
 Drooling
 Inability to pass suction catheter, NG @
birth
 Abdominal distention if fistula present
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Management
Early diagnosis
Ultra sound
Radiopaque catheter inserted in the esophagus
to illuminate defect on X-ray
Surgical repair- thoracotomy
Anastomose ends of esophagus if possible (may need 2
stage repair)
Ligate fistula
Pre-Op
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Maintain airway
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Keep NPO- administer IV fluids
Elevate HOB 30 degrees
Suction PRN
Gastrostomy for feedings
Prevent aspiration pneumonia
– Suction
– HOB 30 degrees
– Prophylactic antibiotics
Post-Op
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Maintain airway
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Maintain nutrition
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Prevent trauma
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Monitor growth and development
Gastroesophageal Reflux
Disease
(GERD)
The cardiac/lower esophageal sphincter
(AKA LES) and lower portion of the
esophagus are weak, allowing
regurgitation of gastric contents back into
the esophagus.
Assessment: Infant
Regurgitation almost immediately after
each feeding when the infant is laid down
 Excessive crying, irritability
 FTH
 Risk for:
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– aspiration (pneumonia)
– Apnea
– Development of respiratory problems
(asthma)
Assessment: Child
Heartburn
 Abdominal pain
 Cough, recurrent pneumonia
 Dysphagia
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Diagnosis

Ph of secretions in esophagus <7.0=acid
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Barium Swallow and visualization of any
esophageal abnormalities
Management & Nursing Care
Nutritional needs
 Positioning – PRONE (supine worsens GERD)
 Medications
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– H2 receptor antaqgonists (-tidine)
– Cholinergics – metoclopramide (Reglan)
– Proton pump inhibitors – (-prazole)
CPR instruction for parents/caregivers
 Possible Nissen Fundoplication
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Diarrhea/Gastroenteritis
Severe
A disturbance of the intestinal tract that
alters motility and absorption and
accelerates the excretion of intestinal
contents. 3-30 stools/day!!!
 Most infectious diarrheas in this country
are caused by Rotovirus, but can be c.diff
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Clinical Manifestations
Increase in peristalsis
 Large volume stools (loose, watery, green)
 Increase in frequency of stools with
cramps, nausea, vomiting
 Urge with small stool present
 Increased heart & resp. rate, decreased
tearing and fever
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Complications
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Dehydration
– Mucus membranes dried, cracked
– Decreased elasticity of skin
– Depressed fontanels, eyes sunken
– Decreased urinary output, dark
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Metabolic Acidosis
– pH <7.35
– HCO3 =/<22mEq/L
Diagnosis

Stool culture
-causative organism
-O&P
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ABG’s to diagnose Metabolic Acidosis
Treatment & Nursing Care
Contact isolation
 Treat cause
 Weigh daily
 Monitor I&O, assess for dehydration
 Skin care
 Fluid and electrolyte balance
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– Oral rehydration
– IV rehydration (RL or D5NS)
Appendicitis
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Inflammation of the lumen of the
appendix which becomes quickly
obstructed causing edema, necrosis and
pain.
Clinical Manifestations
Pain
– Vague
– Periumbilical
– Rebound tenderness
 No bowels sounds “silent abdomen”
 Anorexia with or without vomiting
 Diarrhea
 Increased temperature
 If ruptures/perforates, there is immediate relief of pain
followed by high fever and dehydration
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Diagnosis
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WBC <15-20,000
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Rebound tenderness at McBurney’s point
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Abdominal ultrasound or xray - fecalith
Management and Nursing Care:
Pre-Op
NPO, IV
 Comfort measures, knee chest position
 Antibiotics
 Thermal therapy – Ice pack
 No elimination
 Patient education for post-op
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– +/- NG tube
– Penrose drain vs open wound bed
Management and Nursing Care:
Post-Op
NPO, IVs
 Antibiotics
 Analgesia
 Patient teaching
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– Wound care
– Open vs laproscopic
– No contact sports, PE, lifting until released by
surgeon
Pyloric Stenosis
Pyloric sphincter
 Incidence
 Possible genetic predisposition
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Assessment
Vomiting: character??
 Constant hunger and fussiness
 Distended upper abdomen
 Visible peristaltic waves
 Hypertrophied pylorus
 No pain
 Weight loss
 Dehydration and electrolyte imbalance
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Diagnosis
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History and physical
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Abdominal ultrasound
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Laboratory data
Pre-op care
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Restore fluid and electrolyte balance
– NPO
–I&O
– Urine specific gravity
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Parental support
– Guilt – think they are “bad parents”
– Emphasize structural problem not parental
feeding technique
Management and
Nursing Care
Pylorotomy via laproscopy
I&O
 Feeding
 Position – HOB elevated slightly
 Surgical site infection free
 Patient teaching – s/s recurrence
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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?
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Begin an intravenous infusion
Measure abdominal circumference
Orient family to unit
Weigh infant
Intussuception
Most commonly seen in infants 3-12
months but can
occur in older child
 Bowel “telescopes”
within itself usually
at ileocecal valve
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Assessment
Pain – colicky, knee chest position
 Vomiting – can contain stool
 Stools – “currant jelly”
 Dehydration
 Serious complications
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Diagnosis
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Abdominal xray = intraperitoneal AIR
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Abdominal ultrasound
Therapeutic Intervention
Hydrostatic
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Surgery
reduction
Post-op care
NPO with NG tube
 Monitor bowel sounds and passage of
stool
 Gradual introduction of fluids and solids
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Hirschsprung’s Disease
Congenital disorder of nerve cells in lower colon
Assessment
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Failure to pass meconium
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Vomiting with reluctance to feed
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Bowel assessment
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Breath
If in older child:
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Constipation
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Offensive ribbon-like stools
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History of REGULAR laxative use
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Palpable fecal mass
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
–One stage = resection
–Two stage
Temporary diverting colostomy
with resection
Re-anastomosis and takedown of colostomy
Nursing Care:
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Pre-op
– Cleanse bowel
– Neomycin per rectum
– Patient/parent teaching re: ostomy
Post-op
– NPO – N/G tube, IV fluids
– No rectal thermometers, monitor VS
– Monitor bowel sounds and abdominal girth
– Patient/parent teaching
 Incision care, s/s infection
 Pain management
 ?colostomy teaching
Volvulus & Malrotation
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Assessment- pain, bilious vomiting, S & S
bowel obstruction
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Treatment- surgery to prevent ischemia
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Nursing Care- same as Intussuception and
Hirschsprung’s
Failure to Thrive (FTH)
Assessment- low growth for age,
developmental delays, apathy
 Diagnosis- History to determine organicvs- non-organic
 Nursing Care- Teaching on nutrition
feeding techniques, feeding
cues, praise
 Community resources
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Celiac Disease
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Assessment- Growth pattern, GI pattern
Treatment- Dietary restrictions
 Nursing Care- monitor for dehydration,
encourage compliance with
dietary restrictions, provide
support groups for patient and
caregiver
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Diagnosis
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Measure fetal fat
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Duodenal biopsy
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Screen IgA
Complications
Hypocalcemia
 Osteomalacia
 Osteoporosis
 Depression
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