Transcript Gastrointestinal Disorders in Pediatric Patients

Nursing Care of the Child
with Gastrointestinal
Disorders
Ann Hearn RNC, MSN
Fall 2009
Cleft Lip and Cleft Palate
Failure of maxillary and median nasal processes
to fuse during embryonic development

Unilateral, bilateral, midline
p
h
o
t
Treatment
Surgical repair done ASAP
 Rule of 10 > 10#, 10 weeks, 10 HGB
 Multidisciplinary team

Pre-op Goals
• Prevent aspiration
• Maintain nutrition
• Provide emotional support to family
Prevent Aspiration / Maintain
Nutrition
Breast feed – small cleft lip
 Bottle feed – special feeding devises

– Special nipples
– Enlarge cross cut hole
Bubble frequently
 Hold upright
 ESSR

Provide Emotional Support
Assist with accepting of defect
 Teach proper feeding
 Point out positive attributes
 Encourage participation in care
 Explain surgical procedure

Pre-op Teaching
Remind parents that defect is operableshow photographs of corrected clefts
 Introduce cup, spoon feeding devices
 Explain elbow restraints
 Explain Logan Bow

Post-Op

Prevent trauma to suture line
– Reduce pain & infection
Cleanse suture lines as ordered
 Facilitate breathing
 Maintain nutrition
 Referral to appropriate team members

Esophageal Atresia
Failure of the esophagus to totally
differentiate during uterine development.
Assessment Findings
Respiratory difficulties
 Drooling
 Coughing, choking, cyanosis
 Gastric distention - if fistula present
 Hx of ??? during pregnancy?

– Polyhydramnios
 gastrointestinal obstruction
 fetus unable to swallow
Management

Early diagnosis
– Ultrasound
– Radiopaque catheter inserted in the
esophagus to illuminate defect on X-ray

Surgical repair
– Thoracotomy and anastomosis
Pre-Op Nursing Priority
Maintain airway
 Prevent aspiration pneumonia
 Keep NPO- administer IV fluids

– Elevate HOB 30 degrees
– Suction PRN
– Prophylactic antibiotics
Post-Op

Maintain nutrition
– TPN
– Gastrostomy

Maintain airway
– Prevent aspiration
Monitor weigh, growth and development
achievements
 Complications

– GERS
– Stricture formation
Teaching Plan: Gastrostomy Tube
Equipment
 Procedure
 Psychosocial needs
 Medication administration
 Stoma care
 Problem solving

Gastroesophagial Reflux Disease
(GERD)
The cardiac sphincter and lower
portion of the esophagus are
weak, allowing regurgitation of
gastric contents back into the
esophagus.
Assessment findings: Infant
Regurgitation almost immediately after
each feeding when the infant is laid down
 Excessive crying, irritability
 Failure to thrive (FTH)
 Complications:

– aspiration pneumonia
– apnea
Assessment findings: Child
Heartburn
 Abdominal pain
 Cough, recurrent pneumonia
 Dysphagia

Diagnosis
Assess pH of • < 7.0
esophageal • acidic
secretions
Baruim
Swallow
• Visualization
of
esophageal
abnormalities
Management & Nursing Care

Nutritional needs
– Small frequent feedings
– Frequent burping

Positioning
– Prone flat or head elevated after feedings
(not for sleep)
Medications
 CPR instruction for parents/caregivers

Surgery
Nissen fundoplication
Post Op Nursing Care
Feedings
 Burping (bubbling)
 Positioning
 Airway
 Medications

Medications
H2 Histamine receptor antagonists – suppress gastric
acid secretions
– Zantac and Pepcid
 Proton-pump inhibitors – reduce gastric acid production
– Prevacid and Prilosec
 Gastric emptying - increases
– Reglan
 Antacids – neutralize gastric acidity
– Gaviscon
**be sure to study nursing implications and side effects

Pyloric Stenosis
Results when the circular area of the
muscle surrounding the pylorus
hypertrophies & obstructs gastric
emptying.
– Incidence: 3 in 1000 births
– Possible genetic predisposition
Pyloric Stenosis


Narrowing of the pyloric
spincter
Delayed emptying of the
stomach
Assessment
Vomiting - projectile
 Constant hunger and fussiness
 Distended upper abdomen
 Hypertrophied pylorus – olive shaped
mass
 Visible peristaltic waves

Diagnosis
History and Physical
 Laboratory values
 X-ray or Ultrasound

Surgery
Fred Ramstedt procedurePyloromyotomy via laparoscopy
 Pre-op
 Hydration and electrolyte balance
 Weigh daily & I and O
 NG tube
 Support of parents
Management and Nursing Care:
Post-Op

NPO until bowel function
– Progressive feeds: Feeding begins with clear liquids
containing glucose and electrolytes. Regime
example: 8 hours NPO, 10cc sterile water 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 for infection - Antibiotics
 Analgesia
 Patient teaching

Critical Thinking

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?
a. Begin an intravenous infusion
b. Measure abdominal circumference
c. Orient family to unit
d. Weigh infant
Gastroschisis
&
Omphalocele
Abdominal Wall Defects
Gastroschisis
Herniation of abdominal viscera outside the abdominal
cavity through a defect in the abdominal wall to the
side of the umbilicus. Content not covered.
Treatment and Nursing Care



Pre-operatively – focus is on protection of the
contents / sac. Cover with warm, sterile,
saline-soaked dressings over the defect.
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.
Surgery used to close defect.
Gastroschisis
Assessment- noted on ultrasound and
obvious at birth
 Treatment - surgical repair in stages
 Nursing care:

– monitor thermoregulation and loss of fluids
– assess for ileus
– maintain parenteral feeding
– provide support to the parents
Omphalocele
Herniation of abdominal contents through the umbilical
cord. Contents are covered by a translucent sac.
Omphalocele

Assessment- ultrasound and at birth

Treatment - surgical repair in stages

Nursing care- same as for Gastroschisis
Intussuception
Invagination of a section of the
intestine, into the distal bowel that
causes bowel obstruction.

Results in inflamed bowel & bleeding
– Leading to necrosis & perforation
Intussuception


Most commonly seen in infants 3-12 months
Bowel “telescopes” within itself
Intussuception: Clinical
Manifestations
Intermittent then constant pain
 Vomiting
 Abdominal distention
 Currant jelly-like stools
 Diarrhea
 Dehydration
Serious complications:
Ischemia, perforation & shock

Volvulus
A twisting of the bowel
that leads to a bowel
obstruction.
Clinical Manifestations
and Assessment
Pain
 Vomiting (fecal material)
 Abdominal distention
 Stools
 Dehydration
 Serious complication: shock

Diagnosis
X-ray
 Abdominal ultrasound

Therapeutic Intervention

Hydrostatic reduction

Laparoscopic Surgery
Post-op Nursing Care:

NPO- NG tube, IV

Assess – V/S, pain

Monitor stools

Re-introduce food
Appendicitis
Inflammation of the lumen of
the appendix at the end of the
cecum which becomes quickly
obstructed causing edema,
necrosis and pain.
Clinical Manifestations






Abdominal pain – McBurney’s point
Silent Abdomen
Anorexia & nausea
Diarrhea
Elevated temperature
IF PERFORATED:
– Sudden pain relief
– Fever
– Dehydration
Diagnosis
History and Physical
 Ultrasound
 X-Ray
 Laboratory values

– increased WBC 15,000 – 20,000
Management and Nursing Care:
Pre-Op
NPO
 IV
 Comfort measures
 Antibiotics
 Thermal therapy
 Elimination
 Patient education


What is the most common symptom
indicating that the appendix may have
ruptured?
Hirschsprung’s Disease
Congenital disorder: absence of
ganglia (nerve cells) in lower colon
leading to an obstruction.
Assessment

Failure to pass meconium

Vomiting

Bowel assessment

Breath

Older child
Diagnosis

History & Physical

Barium enema (X-ray)

Rectal biopsy- absence of ganglionic cells
in bowel mucosa
Management

Surgical intervention
– Colostomy
– Resection
Nursing Care:

Pre-op
– Cleanse bowel
– NPO
– Patient/parent teaching

Post-op
–
–
–
–
NPO
VS (no rectal temperatures)
Assessment
Patient/parent teaching
Diarrhea/Gastroenteritis
Severe
A disturbance of the intestinal tract
that alters motility and absorption,
and accelerates the excretion of
intestinal contents.

Most infectious diarrheas in this country are
caused by Rotovirus but could be C. difficele
Clinical Manifestations
Increase in peristalsis
 Large volume stools
 Increase in frequency of stools
 Nausea, vomiting, cramps
 Metabolic Acidosis:

– Increased heart & resp. rate, decreased B/P,
arrhythmias
– Cold, clammy skin
– Changes in CNS – stupor, lethergy
Diagnosis
Blood gases
Stool O & P
Stool culture
Complications
Dehydration
Little fluid volume reserve in children
Metabolic Acidosis
Increase HR & RR, Decrease BP, Arrhythmias
Hypovolemic Shock
Priority Nursing Interventions
Treat underlying cause
 Restore fluid & electrolyte balance
 Daily weights
 I&O
 Assess for dehydration
 Isolation protocol
 Monitor electrolytes/metabolic acidosis
 Skin care

Oral Rehydration
Critical Thinking
Why is there an increase in incidence of
diarrhea in lower socio-economic
groups?
Why is there and increase in young
children?
Celiac Disease
The inability to digest gliadin which
is a by-product of gluten
breakdown.

This results in the accumulation of the amino
acid glutamine which is toxic to the mucosal
cells in the intestines. Damage to the villi
impairs the ability of the small intestines to
absorb nutrients
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.
Celiac Disease
Assessment - Growth pattern, GI pattern
 Failure to Thrive
 Treatment - Dietary restrictions
 Nursing Care - monitor for dehydration,
encourage compliance with
dietary restrictions, provide
support groups for patient and
caregiver

Diagnostic Findings
Measurement of fat content
 Duodenal or Jejunal biopsy
 Elevated IGA antibodies

Treatment and Nursing Care
Teach parents DIETARY REGULATIONS:
NO !
Gluten
Free
Diet
Wheat
Rye
Barley
Disease specific support groups
The End