Unit_5_exam_3_review_.docx.pdf

UNIT 5: GASTROINTESTINAL CONDITIONS ANORECTAL MALFORMATIONS Rectal atresia (Closure of the rectal passage) no stool. Initially, anus may appear to be normal in appearance, but it is later determined as an abnormal situation a...

UNIT 5: GASTROINTESTINAL CONDITIONS ANORECTAL MALFORMATIONS Rectal atresia (Closure of the rectal passage) no stool. Initially, anus may appear to be normal in appearance, but it is later determined as an abnormal situation and is a complete obstruction that precludes the passage of stool. Immediate surgical intervention is mandatory for rectal atresia. Rectal stenosis (Constriction or narrowing of the rectal passage) includes vomiting, abdominal distension, difficulty passing stool. May present with a ribbon-like or narrow stool, which is not always apparent at birth. Imperforate anus (Absence of a rectal opening) no stool. Surgery is required. Failure to pass bowel in first 24 hrs after birth Can appear as a Rectal fistula - rectal connection to vagina or urethra through which stool passes. Surgery is required to close the fistula. The visualization of gas in the bladder or urethra during imaging also indicates the presence of a fistula connection between the bowel and associated structure. Passage of meconium through the vagina, urethra, or an opening under the scrotum is early evidence of an imperforate anus though the presence of a fistula may not be evident at birth. Child will be placed in prone position after surgery or side lying with knees flexed Diagnosis Physical examination Surgical Care: Radiological imaging (x-ray) Visualizing of gas in the bladder or o Repeated manual dilation to treat urethra during imaging also indicates anal stenosis the presence of a fistula connection o Creating a new anal opening for between the bowel and associated structure. rectal atresia – two stages Magnetic resonance imaging (MRI) of  First stage is resection the lumbosacral spinal cord is required and creation of a for all children presenting with an temporary colostomy. imperforate anus to rule out the presence of a tethered spinal cord Ultrasound (outlines the shape of tissues and organs of the abdomen and pelvis). IV pyelogram: (provides information about the structure and function of the   2nd stage involves the closure of the colostomy and anastomosing the blind pouch of the rectum to the anus. Nursing care: o Depends on type of defect and extent of surgical correction. o Child is kept NPO; therefore, the care of the infant before surgery includes parent education and maintenance of IV fluids. o Post-op – pain control and the importance of infection control post surgery for the incision site because of potential fecal or urinary contamination. Also, during post op, nurses monitor VS, I&O’s, fluid maintenance, pain control, and developmentally appropriate play. o Nurse communicates to the family that post op for high anorectal malformations a colostomy is placed and must do colostomy care. o Presence of a colostomy: good skin care & infection control in post operative. o Nasogastric decompression is often required early in post op period and ORAL FEEDINGS ARE GENERALLY INITIATED WITH THE REESTABLISHMENT OF PERISTALSIS AND ONCE STOOLING HAS BEGUN. Education Discharge Information: o Colostomy care, wound care, prevention of infection. o The procedure for anal dilation if appropriate for the defect-may need to do this multiple times. o Adequate fluids o Dietary fiber o Stool softeners or bulking agents o Parents are advised about the potential for delayed toilet training Hypertrophic Pyloric Stenosis Etiology is unknown. Thickening of the pyloric sphincter, causing an obstruction of the pyloric canal. Affects kids 3-6 weeks More common in Caucasian population.  More common in males-especially first born. May reveal an infant in metabolic alkalosis resulting from the loss of large amounts of of gastric hydrochloride acid. Diagnosis  Palpating pyloric mass (olive-shaped) best palpated from the left side and located above and to the right of the umbilicus in the midepigastrium (the superior central portion of the abdomen beneath the liver edge).  Ultrasound usually confirms the Pyloric Stenosis (shows elongation and thickening of the pylorus, which may be confirmed with barium.  An abdominal x-ray film may show an enlarged stomach with diminished or absent gas in the intestine  Confirmation by upper GI series demonstrates S/S: “string sign,” which is caused by barium o Pattern of normal feedings and passing through narrowed pylorus then new onset of non-bilious vomiting containing undigested food. o Projectile vomiting-may occur right after the feed. Then baby wants to eat again. The vomiting usually begins with episodes of regurgitation during the first few weeks of life. o Insatiable appetite o Olive shaped mass (RUQ) o Visible reverse peristalsis in LUQ o Hypochloric (low chloride) o Weight loss o Dehydration o Constipation Surgical Care o Pyloromyotomy (incision and suture of the pyloric sphincter)- laparoscopic procedure with endoscope. o The nurse communicates with the family that it is COMMON for the infant to experience some vomiting in the first 24-36 hours after surgery.  o Whether or not bowel sounds are present, feedings begin 6 hours after surgery. o "Pedialyte 15 mL is given every 2 hours for two consecutive feds, if the baby tolerates this with no vomiting, then His advanced to half- strength formula 15 mL every 2 hours for two consecutive feeds. If no vomiting, then advance to 30 mL for two consecutive feeds, then 45 mL for two consecutive feeds, and finally 60 mL for two consecutive feeds. o If baby were to vomit, then the baby stays at that level until two consecutive feeds are tolerated. Nursing care o The nurse needs to be alert for signs and symptoms of dehydration such as: changes in skin turgor appearance of the mucous membranes depressed fontanelle presence or absence of tears urine output changes in vital signs weight loss evidence of discomfort o Pre-op: Child is NPO, and a gastric tube is inserted to provide gastric decompression. o If dehydration is present before surgery IV fluids is administered of appropriate electrolyte therapy. o Post-op - Maintain IV fluids, monitor V/S frequently, I & O’s, pain mgmt, monitor for s/s of infection, keeping the wound clean and dry and changing diapers is the way to prevent infection of the wound. And providing pain relief. Education & Discharge Instructions o Care of incision and observation for signs of infection o Change diapers frequently o It is important after surgery to let the family know about the importance of saving wet diapers that are weighed to measure output.  o Observe infant’s response to feedings, as some vomiting may still occur within first 48 hours postoperatively o Vomiting beyond 48 hours must be reported to child’s health-care provider. o Tell parents to change diapers as soon as possible for children who are not toilet trained. Cleft Lip & Cleft Palate Birth defect characterized by incomplete formation of the lip (cleft lip) or the roof of the mouth (cleft palate) Maternal age higher than 35 years old American Indian or Alaska Natives Babies with Cleft Palate before surgical correction are more at risk for frequent episodes of acute otitis media due to the opening in their oropharynx. May have increased difficulty with forming a good seal and thus have a poor suck, increasing the risk for feeding difficulties. At risk for otitis media or chronic sinusitis S/S: o Unilateral or bilateral cleft lip o Can occur with or without a cleft of the hard and/or soft palate o Both or either of the palates can have cleft without lip affected o Uvula can also contain cleft Nursing Care o Initial focus is assessment of the infant’s airway and sucking ability. o Infants with a cleft palate cannot effectively suck from a bottle or breast and will require adaptive feeding equipment before surgery, such as a modified shorter nipple that expresses liquid into the mouth but not into the posterior pharynx. o Infants with cleft lip may require a longer nipple but may be able to feed independently from the bottle or breast. o Maintaining adequate nutrition o Breastfeeding possible but may be interrupted for period of time based on the need for surgical repair  o Bottle feeding is initiated with special nipple that is longer than a regular nipple to help prevent aspiration. Has a reservoir to regulate the flow of formula. (Haberman feeder) o Feed in upright position to decrease the incidence of regurgitation (not in infant seat) o After feeding rinse the mouth with water Surgical Care of Cheiloplasty o Surgical repair of Cleft lip is typically done at or before 3 months of age o Surgical repair of Cleft palates is usually repaired before 6-18 months but should be performed before the child begins speaking. o Some repairs may require more than one surgical procedure. Surgical Care of a Cleft Lip o Z-plasty to minimize retraction of scar o Protect suture line with Logan bow or other methods o No-No’s sleeves (keeps elbows locked out to prevent infant from touching the face Education/Discharge Instructions: Educate parents that the things shown below can decrease pregnancy risk for developing cleft lip and palate: o Avoid certain medications such as medicines used to treat seizures, and methotrexate, which is used to treat cancer and other diseases. o Avoiding cigarettes and alcohol. o Taking prenatal multivitamins that contain at least 400 micrograms of folic acid. o Telling the health care provider about the prescription drugs, over the counter medications and supplements. o Cleft palate-position in upright position. Use bottle with one-way flow valve o Cleft lip-Use nipple with wide base, squeeze cheeks together during feeding o Apply petroleum jelly to operative site as directed o Feeding with a syringe or dropper o Avoid use of pacifiers o Nothing in mouth after surgery  A, Haberman feeder. B, Mead-Johnson bottle used to feed infant with cleft lip and palate. C, Pigeon bottle Intussusception Intussusception occurs when one portion of the intestine invaginates or telescopes into another portion, most commonly at the ileocecal valve. It is a condition in which a proximal segment of the bowel prolapses into a distal segment of the bowel. Small intestine goes into the large intestine Most common in 6-36 months of age. Classic symptomatic triad signs: 1. Paroxysmal abdominal pain with vomiting every 5-30 min (pain that comes and goes) 2. screaming and drawing up legs with periods of calm, sleeping, or lethargy between episodes 3. stool with blood (currant-jelly stool or mucous in stool). S/S: o Acute abdominal pain caused by the spasm if the telescoping bowel. Diagnosis o Pain mimics “colicky” infants Based on history of characteristic symptoms and o Infants may pull their legs up to abdomen physical findings during and inconsolable crying. examination o “Currant-jelly” stools – mucous mixed Presence of sausage-shaped mass palpable in RUQ (Dance’s with blood, stool-- possibly diarrheal sign) in nature with blood. Barium enema is gold standard o Fever, vomiting may follow episodes of for intussusception. Air enema is also therapeutic. abdominal pain, weight loss Abdominal ultrasound confirms the diagnosis in most cases  o Dehydration, lethargy, abdominal distention and grunting noises because of pain. Collaborative Care Nursing care for surgery: o Pre-op-: place an NG tube in child, child is placed on NPO, and initiating IV therapy. o Post-op-infection, hydration, pain management o Watch for signs of perforation, (peritonitis inflammation of the abdominal cavity), shock if evidence of increased pain, monitor vital signs o Monitor for the passage of normal, brown stool, which indicates a resolution of the obstruction. o If patient stools before surgery, call MD. Education/Discharge Instructions: o Care of incision o Observation for signs of infection o Teach feeding, dehydration and pain management Failure to Thrive (FTT) Not a diagnosis, but a description of a Identified criteria that is used to determine FTT condition that usually occurs in infancy Weight for length less than 10% and is characterized by failure of the Weight for age and sex less than 5% infant to achieve age-appropriate Length for chronological age and sex less than 5% weight gain Body mass index for chronological age less Child cannot take in enough nutrition than 5% to adequately meet standard growth Developmental delays, withdrawn and weight expectations. behavior Labs will show decrease prealbumin If child drops in weight reweigh them!!! Appendicitis CANNOT BE PROVENTED  IF PAIN STOPS NOTIFY DOCTOR IT COULD MEAN APPENDIX HAS RUPTURED!!! Inflammation of the appendix, which is a small sac-like structure at the end of the cecum. It is the most common abdominal surgical condition in children ages 6-10 years old. In appendicitis, the lumen of the appendix becomes obstructed with fecal matter, lymphoid tissue, tumor, parasite, foreign body, or inspissated- thickened cystic fibrosis secretions, which cause the appendix to become distended and subject to ischemia and necrosis. The characteristic symptoms are caused by the inflammation around the infected with approximately a 36–72-hour maximum window from onset of pain to the rupture of a gangrenous appendix. S/S: o Periumbilical pain (pain around the Diagnosis umbilicus)-earliest symptom Progression of symptoms Laboratory findings may demonstrate an o Right lower quadrant pain (classic elevated WBC sign) (McBurney’s point) Abdominal x-ray revealing fecal matter o Vomiting-generally follows Ultrasound/CT scan – can help to periumbilical pain differentiate the diagnosis o Anorexia o Low Fever or afebrile. o Perforation (occurs in 1/3 of children) Collaborative Care Surgical o Remove the appendix Nursing care: o Pre-op-NPO, IV fluids, Antibiotics o Monitor VS, pain – if pain stops, it could have ruptured-notify physician! o Post-op-Monitor pain, I&O, wound care, infection, NPO for 24 hours or until peristalsis resumes. o IV Antibiotics if perforation is suspected for 7-14 days o Monitor for peritonitis (stiff, tender abdomen) o 1-2 ounces of fluid Education/Discharge Instructions:  o Keep the surgical site clean and dry o Monitor site for signs of infection o Pain management o Progression of activity over a 2-week period o Resumption of normal nutritional intake as tolerated Acute Diarrhea Excessive loss of fluid and electrolytes in the stool, with the disruption occurring in the intestinal tract. Stool loss is considered excessive if it is more than 10g/kg in children less than 2. Stooling is 4 or more times in 24 hours in children older than 2 Multiple causes –Infections, Diet, Medications, or toxic materials Osmotic diarrhea occurs when water is pulled into the bowel due to conditions such as lactose intolerance, overfeeding Secretory diarrhea occurs when there is an increase in the active secretions of fluid or electrolytes into the stool. S/S: Diagnosis o Increased frequency and fluid History-family, day care, medications, food content of stools with or without allergies, recent travel, dietary consumption of associated symptoms poorly cooked food. Physical examination –focus on abdomen and Prevention: perineum, hydration, level of alertness, # of stools, o proper hand washing illness contacts o food handling Culture and sensitivity, serum electrolytes, CBC with diff o diapering Collaborative Care o Mostly supportive, hydration, dietary needs, medications for infections o Nursing Care: o Monitor fluid intake and output, IV fluids o Hydrate o BRAT diet (Bananas, Rice, Applesauce, Toast) o Foods generally well tolerated include vegetables, fruits, yogurt, complex carbohydrates, and lean meat. o Skin care-perineum and buttock areas o Diet as indicated-start with bland, soft foods  o Lactobacillus acidophilus, such as yogurt o RETURNING TO FULL STRENGTH FORMULA IS RECCOMMENDED AS QUICKLY AS POSSIBLE o Observe for signs of dehydration o Offer po fluids –no fruit juices, soda, or sports drinks o Foods generally well tolerated include vegetables, fruits, yogurt, complex carbohydrates, and lean meat. Education/Discharge Instructions: o Preventative measures o Monitoring hydration status o Instruction on good hand hygiene o Care of soiled clothing and diapers Chronic Diarrhea The treatment of chronic diarrhea is change or reduction of fruit juice consumption 3 or more stools passed per day for 14 days or more, though healthy infants may pass 5-8 stools per day. Usually associated with a chronic illness (IBD, lactose intolerance, malabsorption, overfeeding, food allergies) S/S: o Abdominal distention or Diagnosis tenderness Culture and sensitivity, ova and parasites, fecal pH, o Dehydration occult blood, fat stain, Clinitest (determines how well carbs are metabolized) o Hyperactive bowel sound o Signs of weight loss o Presence of undigested food particles in stool o Blood in the stool Collaborative Care: Medical o treat the underlying cause-in toddler’s diarrhea, reduce the child’s intake of fruit juices Nursing care: o Monitor fluid intake and output, IV fluids  o Hydrate o Observe for signs of dehydration o Offer po fluids –no fruit juices, soda, or sports drinks o Skin care-perineum and buttock areas o Diet as indicated-start with bland, soft foods Education/discharge instructions o Preventative measures o Monitoring hydration status o Instruction on good hand hygiene o Care of soiled clothing and diapers o The treatment of chronic diarrhea is change or reduction of fruit juice consumption Gastroesophageal Reflux Medication is given 30 minutes before meals to ensure child gets full dose of med. DO NOT MIX MEDS WITH MILK The return of gastric contents from the stomach through the lower esophageal sphincter into the esophagus S/S: Infant Diagnosis History and physical examination o Spitting up Upper GI series o Crying Barium swallow o Arching of their back 24-hour intra-esophageal pH monitoring study o failure to thrive o respiratory difficulties (cyanotic) o Halitosis o Chronic sinusitis o Otitis media Children o Indigestion o Regurgitation  o chest pain o dysphagia o chronic cough Tx: o Proton-pump inhibitors-given ½ hour before feeds or in the AM daily o Nissan Fundoplication (tightening of sphincter) o Omeprazole (Prilosec) helps with heartburn give 30 minutes before meals daily o Position patient on right side to facilitate gastric emptying Education/discharge instructions: (Dietary modifications) Infants o thicken formulas with cereal o feed upright o offering small amounts more often o burping frequently. Children o Avoid fatty fried foods, Citrus, and spicy foods o remain upright after meals, HOB up o give meds 30 minutes before feeding o Small meals o Pharmacological therapy o Avoid vigorous playing after feeding o Lose weight if necessary Hirschsprung Disease FAILURE TO PASS STOOL IN FIRST 48 HRS OF LIFE Birth defect with the absence of ganglion cells results in lack of motility in segments of the colon resulting in obstruction S/S: Diagnosis o Failure to pass meconium within X-ray evidence of dilated loop of bowel the first 48 hours of life Barium enema o Abdominal distension Rectal biopsy Anorectal manometry o Foul smelling Ribbon like stool  o Failure to thrive/Poor feeding o Constipation o Vomiting bile o Palpable fecal mass Collaborative Care: Medical/surgical o removal of a ganglionic section with colostomy Nursing care o Pre-op o Post-op o NPO o NG tube o Monitor for enterocolitis (fever, bloody diarrhea, abdominal pain) Education/discharge instructions: o Care for temporary colostomy o Teach about symptoms of complications Celiac Disease CANNOT PREVENT BUT CAN REDUCE SYMPTOMS Autoimmune disorder that affects the small bowel mucosa which is damaged as a result of dietary exposure to gluten. This leads to malabsorption of foods. Does not present until gluten products introduced (6 months-2 years) Permanent intolerance to gluten Up to 1% of US population affected Women 3X more likely than men More common in northern European, Type 1 diabetes, Trisomy 21, Turner’s S/S: o Diarrhea Diagnosis Clinical symptoms o Constipation Serological markers o Anorexia/weight loss/anemia Duodenal mucosal biopsy o Lethargy Laboratory studies – show evidence of malabsorption and nutritional deficiencies o Failure to thrive o Steatorrhea  o Abdominal pain o Abdominal distention Prevention: o cannot prevent, but can reduce symptoms by maintaining diet Collaborative Care Medical o Dietary consult, referral to support group Nursing care: o Gluten-free diet (no wheat, rye, barley, and oats) BROW o Corn, rice, and millet are acceptable grains o Assess growth/development on regular basis o Supplementary calories, vitamins, minerals Education/discharge instructions: o Hidden sources of gluten (processed foods) o Read Nutrition labels o Adherence to the gluten-free diet o High calorie, protein, simple carb diet o Adverse symptoms when gluten ingested o Assess growth o Monitoring at intermittent intervals o Periodic measurement of transglutaminase (TTG) o Temporary lactose restriction o High calorie, protein, simple carb diet Dehydration (fluid deficit) Occurs when the amount of fluid lost from the body is greater than the amount of fluid taken in. Three types Isotonic – sodium and water are lost in equal amounts, most common type, hypovolemic shock is the greatest concern Hypotonic – more sodium than water is lost, physical signs are more severe Hypertonic – more water than sodium is lost, most dangerous type, seizures are likely S/S and Diagnosis:  o Decreased skin turgor o Tacky or dry mucous membrane o Poor perfusion o Weight loss o Decreased blood pressure o Tachycardia o Increased respiratory rate o High hematocrit Collaborative Care Medical o IV fluids o determine and treat the cause Nursing o Monitor I&O o Monitor VS o Administer IV fluids, medications o Education Fluid and Electrolyte Imbalance Children are at a greater risk for imbalance Fluid balance – intake and output are approximately the same Fluid deficit usually caused by vomiting, diarrhea, hemorrhage Fluid overload usually caused by kidney disease or CHF, can be caused by too much IV fluids Fluid balance measured by daily weight and monitoring I&O. S/S: o Pulmonary edema (crackles) o Weight gain o Lethargy o Decreased level of consciousness o Slow bounding pulse o Decreased hematocrit Daily maintenance fluid requirements for 24 hours o 0-10 kg – 100ml/kg o 11-20 kg – 1000ml/kg + 50 ml/kg for each kg over 10  o Over 20 kg – 1,500 ml + 20 ml/kg for each kg over 20 Daily output o Infants: 2-3ml/kg per hour o Toddler/Preschooler: 2ml/kg per hour o School age: 1-2ml/kg per hour o Adolescent: 0.5-1ml/kg per hour Collaborative Care Medical o Fluids o Medications o Labs Nursing o Monitor I&O o Monitor IV fluids, po fluids o Daily weight o Assess hydration o Educate Ingestion of Injurious Agents About 3.6 million U.S. families with a child under age 6 years live in a home with one or more conditions that can expose their child to high levels of lead Exposure of lead can lead to multiorgan damage including neurocognitive disease. Reference level of 5 micrograms of lead per deciliter of blood (5μg/dL) Approximately 500,000 children ages 1 to 5 years exceed the reference level Decrease chances of lead intake by wet mopping floors, check for peeling paint/chipped paint. Wash toys and pacifiers often. Lead Poisoning Risk factors are housing before 1978 and home renovations S/S: o Cognitive impairment (↓ IQ scores) o impaired hearing o growth delays  o anemia o Vomiting o fatigue o Serum lead level > 5 mcg/dL o Chelation therapy for serum lead level >45mcg/dL Sources: o Lead-based paint o Soil and dirt in yards o Water o Outdoor air o Manufactured products o Food containers o Hobbies and work exposure Secondary Prevention Nutritional Intervention: o Make sure that at-risk children receive a well-balanced and age- appropriate diet high in calcium, iron and vitamin C, nutrients that may help keep lead from being absorbed Developmental Interventions o Provide regular developmental and behavioral screening, Long-term developmental surveillance, identify emerging difficulties and watch for behaviors that interfere with learning, referral for a thorough diagnostic evaluation Medical Intervention o Chelation therapy Foreign Body Ingestion Diagnosis o History and Physical Prevention: o Imagine o Educate parents/caregivers o Avoid giving nuts, uncooked carrots o Avoid coins, marbles, button eye on stuffed animals  o Age-appropriate toys Nursing Care: o Monitor vital signs o NPO status o Explain procedures o Educate on prevention o Respiratory support o Post-op pain control Medical care: o Instrumental assistance to remove obstruction o Medical management o Potential surgery o Heimlich maneuver