The Child with Gastrointestinal Dysfunction PDF

The Child with Gastrointestinal Dysfunction  GI Anatomy GI System Absorb and digest food and fluid Eliminate waste GI Organs Esophagus, stomach, pancreas Large and small intestines Gallbladder, liver, spleen Figure 25-2 The internal ana...

The Child with Gastrointestinal Dysfunction  GI Anatomy GI System Absorb and digest food and fluid Eliminate waste GI Organs Esophagus, stomach, pancreas Large and small intestines Gallbladder, liver, spleen Figure 25-2 The internal anatomic structures of the stomach, including the pancreatic cystic and hepatic ducts, the pancreas, and the gallbladder.  Pediatric Differences Newborn Poor swallowing control Increased peristalsis Enzyme deficiencies Limits in bilirubin conjugation, gluconeogenesis, deamination, plasma protein, and ketone formation  Newborn Period First meconium should be passed within 24 to 36 hours of life; if not assess for: Hirschsprung disease, hypothyroidism Meconium plug, meconium ileus (CF) Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.  GI Problems INFANTILE COLIC in Infancy Nutritional Imbalances Colic Food Sensitivities Failure to Thrive Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.  Structural Defects Head Cleft lip and cleft palate Esophagus and Stomach Esophageal atresia Tracheoesophageal fistula Pyloric stenosis Gastroesophageal reflux  Structural Defects Structural Defects CLEFT LIP/CLEFT PALATE Facial malformations that occur during embryonic development May appear separately or together Etiology and pathophysiology Diagnostic evaluation Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.  CLEFT LIP/CLEFT PALATE (CONT’D) FIG. 24-3 Variations in clefts of lip and palate at birth. A, Notch in vermilion border. B, Unilateral cleft lip and palate. C, Bilateral cleft lip and palate. D, Cleft palate. Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. SURGICAL CORRECTION OF CLEFT LIP Closure of lip defect precedes correction of the palate Z-plasty to minimize retraction of scar Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. SURGICAL CORRECTION OF CLEFT PALATE Typically 6-18 months of age Effect on speech development Prognosis Nursing considerations Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.  CLEFT LIP AND PALATE FEEDING Issues Techniques and interventions Special feeding equipment Breastfeeding issues Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. SpecialNeeds® Feeder (B) both have longer, softer nipples and make it easier for the child to feed from a bottle. A, Photo courtesy of Mead Johnson & Company; B, Courtesy of Medela AG, Switzerland. A the SpecialNeeds® Feeder (B) both have longer, softer nipples and make it easier for the child to feed from a bottle. A, Photo courtesy of Mead Johnson & Company; B, Courtesy of Medela AG, Switzerland. B  Question #1 The best rationale to give parents who are questioning the use of elbow restraints with their child who has had cleft palate repair is:  Question #1 Choices 1. “This device is frequently used postoperatively to protect the IV site in small children.” 2. “The restraints will help us maintain proper body alignment.” 3. “Elbow restraints are used postoperatively to keep their hands away from the surgical site.” 4. “The restraints help us remember that the child is NPO after surgery.”  Question #1 Answer 1. “This device is frequently used postoperatively to protect the IV site in small children.” 2. “The restraints will help us maintain proper body alignment.” 3. “Elbow restraints are used postoperatively to keep their hands away from the surgical site.” 4. “The restraints help us remember that the child is NPO after surgery.”  Question #1 Rationale Elbow restraints are used to keep hands away from the mouth after cleft palate surgery. This precaution will be maintained at home until the palate is healed, usually 4 to 6 weeks. Application level ESOPHAGEAL ATRESIA AND TEF (CONT’D) Failure of esophagus to develop as a continuous passage May occur separately or in combination FIG. 24-4 A-E, Five most common types of esophageal atresia and tracheoesophageal fistula. Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.  Hypertrophic Pyloric Stenosis CONSTRICTION OF THE PYLORIC SPHINCTER WITH OBSTRUCTION OF THE GASTRIC OUTLET Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.  Hypertrophic Pyloric Stenosis Signs & Symptoms: Typically: healthy, male infant: new onset non-bilious vomiting progressing to projectile vomiting, failure to gain weight and signs of dehydration, (dry/pale skin, cool lips, dry mucous membranes, decreased skin turgor, diminished urinary output, concentrated urine, thirst, rapid pulse, sunken eyes) Diagnosis: Palpating the pyloric mass (olive-shaped) Nursing Care: Surgery (Ramstedt pyloromyotomy) Assess dehydration, changes is VS, weight loss & discomfort Preoperative care (NPO, NG tube,) Postoperative care ( maintain fluids & electrolyte balance, feedings, infection, keeping the wound clean & pain relief) Discharge instructions Mosby (care items items and derived of incision, s/s infection, © 2009, 2005 response by Mosby, Inc., to feedings) an affiliate of Elsevier Inc.  Gastroesophageal Reflux (GER) Defined as transfer of gastric contents into the esophagus Occurs in everyone Frequency and persistency may make it abnormal Infants-spitting up, forceful vomiting, excessive crying, respiratory problems, failure to thrive, apnea Children-heartburn, abdominal pain, difficulty swallowing, chronic cough, noncardiac chest pain May occur without GERD GERD may occur without regurgitation Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.  Structural Defects (cont’d) Intestines Omphalocele Gastroschisis Intussusception Volvulus Hirschsprung disease Anus Anorectal malformations Ostomies  Structural Defects: Gastroschisis Child born with a defect in the abdominal wall Stomach, bowel, and liver pushed outside of the abdomen No covering or sac around abdominal contents Signs and symptoms: Visible bowel on the outside of the baby Fluid losses Treatment: Surgery IV OG tube Ventilator for breathing Retrieved from http://www.chla.org/sites/default/files/migrated/NICUGlossary.pdf  Structural Defects: Intussusception Telescoping or invagination of one portion of intestine into another Occasionally due to intestinal lesions Often cause is unknown Sudden abdominal pain, screaming with knees to chest, abdominal mass (sausage-shaped, stools with mixed blood that resemble red currant jelly, vomiting, fever, distended abdomin Diagnostic evaluation Therapeutic management Prognosis Nursing considerations Intussusception  Structural Defects: Volvulus Malrotation is due to abnormal rotation around the superior mesenteric artery during embryonic development Volvulus occurs when intestine is twisted around itself and compromises blood supply to intestines May cause intestinal perforation, peritonitis, necrosis, and death Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.  Hirschsprung Disease Also called congenital aganglionic megacolon Mechanical obstruction from inadequate motility of intestine Incidence: 1 in 5000 live births; more common in males and in Down syndrome Absence of ganglion cells in colon Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.  Hirschsprung Disease Signs & Symptoms: Failure to pass meconium within the first 48 hours of life, vomiting bile, abdominal distention, failure to thrive, poor feeding, chronic constipation, & Down syndrome, Complications: Entercolitis is the most ominous presentation (abrupt onset o foul smelling diarrhea, abdominal distention & fever. Rapid progress may indicate perforation & sepsis Nursing Care: Surgical resection (colostomy) Preoperative care (fluid & electrolyte status, NPO, NG tube, IV fluids) Postoperative care (maintain NG tube, monitor for abdominal distension, Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc. assess for bowel sounds) Teach caregiver how to car for colostomy, s/s of complications)  Hirschsprung Disease CLINICAL MANIFESTATIONS Aganglionic segment usually includes the rectum and proximal colon Accumulation of stool with distention Failure of internal anal sphincter to relax Enterocolitis may occur Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.  Hernias Hernias Umbilical, inguinal, femoral  Anorectal Malformation Imperforate anus Persistent cloaca Cloacal exstrophy Genitalia may be indefinite Diagnostic evaluation Management  Family-Centered Care Child with Cleft Lip/Palate Increased Risk for Impairments Speech Hearing Tooth Development Coordinated, Multidisciplinary Care Necessary Facial deformities can be devastating to a family  Pre-Operative Care Assessing Family Reactions Providing Emotional Support Facilitating Feeding Providing Parent Education Assisting Parents With coordinating care With maintaining healthy environment Making Referrals  Post-Operative Care Airway Management Wound Care Nutrition Management Identify and Address Home/Family Needs Well in Advance of Discharge  Inflammatory Disorders Appendicitis Necrotizing Enterocolitis Meckel’s Diverticulum Inflammatory Bowel Disease Crohn’s Disease and Ulcerative Colitis Peptic Ulcer  Inflammatory Disorders: Appendicitis Signs & Symptoms: Earliest symptom; periumbilical pain, vomiting Followed by: right lower quadrant pain (classic sign) Other signs, rigid abdomen, decreased bowel sounds, lethargy, tachycardia, rapid, shallow breathing, anorexia Clinical Alert: Children who respond yes to being hungry most likely do not have appendicitis Nursing Care: Surgery Postoperative care (monitor intake & output, wound care, pain control, NPO until peristalsis returns, discharged home in 2-3 days) If perforate appendix intravenous antibiotics Mosby are given, items and derived NPO items © withbyNG 2009, 2005 tube Mosby, Inc., an affiliate of Elsevier Inc. until bowel function returns  Question #9 A 10-year-old boy has been admitted with a diagnosis of “rule out appendicitis.” While the nurse was conducting a routine assessment, the boy stated, “It doesn’t hurt anymore.” The nurse suspects that:  Question #9 Choices 1. The boy is afraid of going to surgery. 2. The boy is having difficulty expressing his pain adequately. 3. The appendix has ruptured. 4. This is a method the boy uses to receive attention.  Question #9 Answer 1. The boy is afraid of going to surgery. 2. The boy is having difficulty expressing his pain adequately. 3. The appendix has ruptured. 4. This is a method the boy uses to receive attention.  Question #9 Rationale Signs and symptoms of a ruptured appendix include fever, sudden relief from abdominal pain, guarding, abdominal distention, rapid shallow breathing, pallor, chills, and irritability. Application level  Inflammatory Disorders: Meckel’s Diverticulum MECKEL DIVERTICULUM Expected findings: rectal bleeding, abdominal pain, bloody, mucus stools Most common congenital malformation of the GI tract Occurs in 1% to 3% of population Pathophysiology Diagnostic evaluation Therapeutic management May need blood transfusions antibiotics Nursing considerations Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.  Inflammatory Disorders: Ulcerative ULCERATIVE COLITIS (UC) Colitis Pathophysiology –inflamation in colon and rectum Clinical manifestations – ulceration, bleeding, anorexia, anemia Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.  Inflammatory Disorders: Crohn’s ULCERATIVE COLITIS (UC) Disease Pathophysiology-Crohn's disease is an inflammatory bowel disease (IBD) Clinical manifestations-abdominal pain, severe diarrhea and even malnutrition Extraintestinal manifestations-arthritis, skin problems, fever, anemia Therapeutic management Medical- corticosteriods, Remicade for remission, 6-MP Surgical Nursing considerations – nutritional support, education Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.  Inflammatory Disorders: PEPTIC ULCERPeptic DISEASE Ulcer (PUD) Disease Etiology and pathophysiology -Loss of tissue of mucosal, submucosal, and even muscular layer Diagnostic evaluation – upper GI, endoscopy Therapeutic management Medical – treat increased H.Pylori –PPI, amoxicillin, flagyl Surgical Nursing considerations -stress Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.  Disorders of Motility Gastroenteritis (Acute Diarrhea) Constipation Encopresis  Disorders of Motility: Gastroenteritis/Acute Diarrhea Acute diarrhea is leading cause of illness in children