Gi Disorders Final

Assessment:

GI disorders among

children can lead to dehydration especially if vomiting & diarrhea are the presenting symptoms

Assess for poor skin turgor,

dry mucous membranes & lack of tearing

Alert: All children with diarrhea must be seen by a health care provider because of rapid change in fluids & electrolyte levels

Greater percentage of

fluid held extracellularly rather than intracellularly

Vomiting forcible ejection of stomach

contents through the mouth

Etiology: Infections Obstructions Motion sickness

Metabolic alterations Psychological alterations

Allergic reactions Side effects of medications

(chemotherapy) Toxic effects of medications Eating disorders

Manifestations:

Sour milk curds without

green or brown color Undigested food (stomach)

Diagnostic Evaluation:

CBC Electrolyte studies Blood Urea Nitrogen (BUN) Glucose levels Urine tests

Radiographic studies Blood cultures Arterial blood gas analysis

Assessment:

Major concern: Dehydration Fluid & electrolyte imbalance

Accurate monitoring of

intake & output Assess weight Fontanels in infants

Skin turgor Eyes/skin Heart/respiratory rates

Determine/describe type &

force of vomiting (regurgitation, projectile vomiting) Assess amount, color, consistency, time (ACCT)

Nursing diagnoses:

Fluid volume deficit Imbalanced Nutrition: Less

than Body Requirements

Interventions:

Position child upright or

side lying Educate family regarding appropriate feeding techniques (eg. Burping)

Educate family (avoiding

certain foods) fatty foods Minimize stimuli ( stress, anxiety) Avoid unfavorable smelling food

Therapeutic Management:

Oral Rehydration

Treatment (ORT) IV therapy (prolonged vomiting neonates/infants) Anti-emetics

Dehydration

Fluid loss in excess of fluid

intake Can cause fluid & electrolyte deficiencies

Classification:

Isonatremic dehydration – most common type of dehydration in children Water & electrolytes are lost the same proportion they exist in the body

Normal serum Na level

(135-145 mEq./L)

Hyponatremic dehydration – electrolyte loss greater than water loss Serum Na less than 130 mEq./L

Hypernatremic dehydration – water loss is greater than the electrolyte loss Serum Na concentration above 150 mEq./L

Etiology:

GI tract- vomiting,

diarrhea, malabsorption Endocrine system: - fever, DM,

Skin – burns Lungs – tachypnea Kidneys - Renal failure Heart - CHF

Neonates/infants –

vulnerable to the effects of dehydration

Mild dehydration – 4-5%

loss of body weight; fluid volume loss less than 50ml/kg

Moderate dehydration – 6-

10% loss of body weight; fluid volume loss 50-100 ml/kg.

Severe dehydration – 10%

or more loss of body weight; fluid volume loss of 100 ml/kg or more

Signs & symptoms of Dehydration:

Fewer wet diapers (6-8

hours) No tears when crying (if older than 2-4 months) Sticky/dry mouth

Irritability/high pitched

cry Difficulty in awakening Increased RR/DOB

Sunken fontanels/sunken

eyes with dark circles Abnormal skin color, temperature or dryness

Signs of impending shock: Changes in heart rate Changes in sensorium Urine output Skin qualities Fontanels (infants)

Pathophysiology:

Reduced fluid intake Increased fluid loss Vomiting, diarrhea, fever, hyperventilation/burns Trauma, hemorrhage, DM

Rapid ECF loss

Electrolyte imbalance

ICF Loss

Cellular dysfunction

Hypovolemi c shock

Death

Management:

Directed toward correcting

the fluid & electrolyte imbalance & then treating the causative factors

Oral rehydration therapy

(Rehydralyte, Pedialyte, Infalyte) Rehydralyte (WHO’s solution) – best source of oral rehydration

Children (mild to moderate dehydration) 50-100 ml/kg of ORT over 4 hours

Parenteral fluid &

electrolyte therapy Lactated Ringer’s solution/0.9% NaCl

Assessment Parameters:

Intake & output Urine output & Specific

gravity Output < 2-3 ml./kg./hr – infants & toddlers

1-2 ml/kg/hr – preschoolers &

young school- age children 0.5 ml./kg/hr in school-age children or adolescents Specific gravity above 1.020

Weight crucial indicator of

fluid status Stools/vomitus Sweating Skin, Mucous membranes & presence of tears

Anterior fontanel Vital signs/behavior

Nursing diagnosis

Fluid volume deficit

Diarrhea

One of the most common

disorders in childhood Increased in the frequency, fluidity & volume of stools

Gastroenteritis – diarrhea

caused by infection Acute diarrhea can lead to dehydration, electrolyte imbalance & hypovolemic shock

Most common viral pathogens -

rotavirus & adenovirus Bacterial pathogens include – Campylobacter jejuni, Salmonella, Giardia lamblia & Clostridium difficile

Mild Diarrhea Fever, anorectic, irritable & appear unwell 2-10 loose, watery stools per day

Dry mucous membranes,

rapid pulse, warm skin Normal skin turgor, normal urine output

Management: Rest the GI tract; 1 hour after offer OHT Ask parents to wash hands after changing diapers

Continue breastfeeding Notify healthcare provider

if condition worsens

Severe diarrhea Rectal temperature is high

(103-104⁰) F Pulse/RR weak & rapid Skin pale/cool

Depressed fontanelle, sunken

eyes, poor skin turgor Bowel movement every few minutes Liquid green stool, mixed with mucus & blood

Urine output is scanty &

concentrated Elevated hemoglobin, hematocrit & serum protein levels

Treatment: Focus is centered in regulating electrolyte & fluid balance Oral or IV rehydration therapy

Rest the GI tract Identifying the responsible

organism All children with severe diarrhea must have a stool culture taken

IV fluids – NSS or 5%

glucose in NS Nursing diagnosis: Fluid volume deficit

Gastrointestinal Disorders

III. Cleft Lip & Cleft Palate Failure of soft tissue or bony

structure to fuse during embryonic development Abnormal openings in the lip or palate that may occur unilaterally or bilaterally

Causes include genetic, environmental

factors; exposure to radiation or rubella virus; chromosome abnormalities; & teratogenic factors Closure of cleft lip defect precedes that of the palate & is formed usually during the first wks of life

Cleft lip o failure of median & maxillary nasal process to fuse by 5 - 8 weeks of pregnancy common to boys unilateral

Cleft Palate Failure of the palatine shelves to fuse by 9 – 12 weeks of pregnancy  common to girls  unilateral or bilateral

III. Cleft Lip & Cleft Palate

Gastrointestinal Disorders

III. Cleft Lip & Cleft Palate Cleft palate repair is performed

sometime between 12 to 18 months of age ; a cleft palate is closed before the child develops faulty speech habits

Gastrointestinal Disorders

Implementation Assess fluid & calorie intake daily & monitor weight Modify feeding techniques; plan to use specialized feeding techniques, obturators, & special nipples & feeders

Hold the child in an upright position &

direct the formula to the side & back of the mouth to prevent aspiration; feed small amounts gradually (every 3-5 minutes) & burp frequently (2x in the middle & at the end of feeding)

Gastrointestinal Disorders

Implementation Position

on side after feeding Keep suction equipment & bulb syringe at bedside Encourage breastfeeding if appropriate

Teach

the parents special feeding or suctioning techniques Teach the parents the ESSR (enlarge, stimulate sucking, swallow, rest) method of feeding

Gastrointestinal Disorders

Implementation Teach

the parents the ESSR (enlarge, stimulate sucking, swallow, rest) method of feeding Encourage the parents to describe their feelings related to the deformity

Gastrointestinal Disorders

Implementation

Postoperatively Cleft lip repair A

lip protector device may be taped securely to the cheeks

Position the child on the side or on the

back; avoid the prone position to prevent rubbing of the surgical site on the mattress

Gastrointestinal Disorders

Implementation Postoperatively Cleft 

lip repair

After feeding, cleanse the suture line of formula or serosanguinous drainage

w/ a cotton-tipped swab dipped in saline; apply antibiotic ointment if prescribed

Gastrointestinal Disorders

Implementation

Postoperatively Cleft palate repair Child

is allowed to lie on the abdomen

Feedings

are resumed by bottle, breast, or cup Oral packing may be secured to the palate (removed in 2 to 3 days)

Gastrointestinal Disorders Implementation Postoperatively Cleft

palate repair

Do not allow the child to brush his or her teeth Avoid offering hard food items to the child, such as toast or cookies 

Gastrointestinal Disorders

Implementation

Postoperatively Soft

elbow or jacket restraints may be used; remove restraints at least every 2 hours to assess skin integrity & allow for exercising the arms

Avoid

the use of oral suction or placing objects in the mouth such as tongue depressor thermometer, straws, spoons, forks, or pacifiers

Gastrointestinal Disorders Implementation Postoperatively Monitor

for signs of infection at the surgical site, such as redness, swelling, or drainage Initiate appropriate referrals for speech impairment or language-based learning difficulties

Gastrointestinal Disorders

IV. Esophageal Atresia & Tracheoesophageal Fistula The esophagus terminates before it

reaches the stomach &/or a fistula is present that forms an unnatural connection w/ the trachea

An obstruction of the esophagus A fistula occurs between the closed

esophagus & trachea

Five usual types of esophageal atresia: Esophagus ends in a blind pouch-TEF between the distal part of the esophagus & trachea Esophagus ends in a blind pouch-there is no connection in the trachea

Fistula present between a normal

esophagus & trachea Esophagus ends in a blind pouchfistula connects the blind pouch of the proximal esophagus to the trachea

Blind end portion of the esophagus-

fistulas present between both widely spaced segments of the trachea & esophagus

A fistula can allow milk to enter the

trachea causing an aspiration Must be ruled out in any infant born to a woman with hydramnios

Diagnosis: Barium swallow Bronchial endoscopy exam Treatment: Surgery-closing the fistula & & anastomosing the esophageal segments

Causes oral intake to enter the

lungs or a large amount of air to enter the stomach

Gastrointestinal Disorders

IV. Esophageal Atresia & Tracheoesophageal Fistula Aspiration pneumonia & severe

respiratory distress will develop, & death will occur w/out surgical intervention

Gastrointestinal Disorders

Assessment Frothy saliva in the mouth & nose, & drooling Coughing & choking during feedings Unexplained cyanosis

Regurgitation

& vomiting Abdominal distention Inability to pass a small-gauge (no. 5 French) orogastric feeding tube via the mouth into the stomach

Gastrointestinal Disorders

Implementation  Suction

accumulated secretions from the mouth & pharynx  A double-lumen catheter is placed into the upper esophageal pouch & attached to intermittent or continuous low suction to keep the pouch empty secretions  Maintain in an upright position to facilitate drainage

Gastrointestinal Disorders Implementation A

gastrostomy tube may be placed & is left open so that air entering the stomach through the fistula can escape, minimizing the danger of regurgitation

Gastrointestinal Disorders

Implementation

postoperatively Monitor

respiratory status Inspect surgical site Provide care to the chest tube if in place

Assess

for signs of pain Monitor for anastomotic leaks as evidenced by purulent chest drainage, increased temperature, & an increased white blood cell count

Gastrointestinal Disorders

Implementation

postoperatively If

a gastrostomy tube is present, it is attached to gravity drainage until the infant can tolerate feedings (usually the 5th to 7th day postoperatively)

Before oral feedings & removal of the

chest tube, a barium swallow is performed

Gastrointestinal Disorders

Implementation

postoperatively Prior

to feeding, the gastrostomy tube is elevated to allow gastric secretions to pass to the duodenum & swallowed air to escape through the open gastrostomy tube

The gastrostomy tube may be removed

prior to discharge or may be maintained for supplemental feedings at home

Gastrointestinal Disorders

Implementation

postoperatively Assess

cervical esophagostomy site for redness, breakdown, or exudate; remove drainage frequently & apply a protective ointment

If the infant is awaiting esophageal

replacement, nonnutritive sucking is provided by a pacifier; may have difficulty eating by mouth after surgery & develop oral hypersensitivity & food aversion

Gastrointestinal Disorders

Implementation

postoperatively Instruct

parents to identify behaviors that indicate the need of suctioning, signs of respiratory distress, & signs of a constricted esophagus (poor feeding, dysphagia, drooling, or regurgitated undigested food)

Gastrointestinal Disorders

V. Gastroesophageal Reflux Disease (GERD) Backflow of gastric contents into the

esophagus as a result of relaxation or incompetence of the lower esophageal or cardiac sphincter

Complications include esophagitis,

esophageal strictures, aspiration of gastric contents, & aspiration pneumonia

V. Gastroesophageal Reflux (GER)

Gastrointestinal Disorders

Assessment Passive

regurgitation or emesis Hematemesis & melena Heartburn (in older children) Anemia from blood loss

Gastrointestinal Disorders

Implementation Assess

amount & characteristics of

emesis Assess the relation of vomiting to the times of feedings & infant activity

Monitor

breath sounds before & after

feedings Place suction equipment at the bedside

Gastrointestinal Disorders Positioning Place

in either the flat prone position or the head-elevated prone position following feedings & at night

Gastrointestinal Disorders

Diet Provide

small frequent feedings For infants, thicken formula by adding 1 tablespoon of rice cereal per 6 ounces of formula & crosscut the nipple

Breastfeeding

may continue, & the mother may provide more frequent feeding times or express milk for thickening w/ rice cereal

Gastrointestinal Disorders

Diet Burp the infant frequently when feeding & handle the infant minimally after feedings For toddlers, feed solids first, followed by liquids

Avoid

feeding the child fatty foods, chocolate, tomato products carbonated liquids, fruit juices, citrus products, & spicy foods Avoid vigorous play after feeding & avoid feeding just before bedtime

Gastrointestinal Disorders

Medications Antacids

& histamine receptor antagonists as prescribed

Gastrointestinal Disorders

Surgery If

surgery is prescribed, it will require a procedure known as fundoplication A gastrostomy may be performed at the same time as the fundoplication

Fundoplication may be combined w/

pyloroplasty in children w/ GER who also have delayed gastric emptying

Surgery 

fundoplication

Gastrointestinal Disorders

X. Hirschsprung’s Disease A congenital anomaly also known as

congenital aganglionosis or megacolon Congenital Aganglionic Megacolon Absence of ganglion cells in the rectum & upward in the colon

Results in mechanical obstruction May be associated w/ other anomalies,

such as Downs syndrome & genital urinary diarrhea

X. Hirschsprung’s Disease

Gastrointestinal Disorders

X. Hirschsprung’s Disease A rectal biopsy demonstrates histologic evidence The most serious complication is enterocolitis; signs include fever, GI bleeding & explosive watery diarrhea

Gastrointestinal Disorders

X. Hirschsprung’s Disease Initially, in the neonatal period, the

obstruction is relieved by a temporary colostomy to relieve obstruction & allow the normally innervated, dilated bowel to return to its normal size

A complete surgical repair is

performed, when the child weighs approximately 9 kg (20 lbs), via a pullthrough procedure

Gastrointestinal Disorders

Assessment 1. Newborn infants Failure to pass meconium stool Refusal to suck Abdominal distention Bile-stained vomitus

Gastrointestinal Disorders

Assessment

2. Children  Abdominal

distention

 Vomiting  Constipation

alternating w/ diarrhea  Ribbon-like & foul-smelling stools

Gastrointestinal Disorders

Implementation: Medical

management Dietary

management Daily rectal irrigations w/ normal saline to promote adequate elimination

Gastrointestinal Disorders

Surgical management:

preoperative implementation Maintain

NPO status Measure abdominal girth

Avoid

rectal temperatures Monitor for respiratory distress associated w/ abdominal distention

Gastrointestinal Disorders

Implementation

postoperatively Monitor

vital signs, avoiding rectal temperatures Assess surgical site for redness, swelling, & drainage

Assess

the stoma for bleeding or skin breakdown Maintain the NG tube to allow intermittent suction until peristalsis returns

Gastrointestinal Disorders Implementation postoperatively Maintain

the IV until the child tolerates appropriate oral intake; begin the diet w/ clear liquids, advancing to regular as tolerated & as prescribed

Provide the parents w/ instructions

regarding colostomy care & skin care

Gastrointestinal Disorders

XI. Intussusception Telescoping of one portion of the bowel into another portion Results in an obstruction

XI. Intussusception

Gastrointestinal Disorders

Assessment Colicky

abdominal pain that causes the child to scream & draw the knees to the abdomen Currant jelly-like stools containing blood & mucus

Tender distended abdomen, possibly

w/ a palpable sausage-shaped mass in the upper right quadrant

Gastrointestinal Disorders

Implementation Monitor for signs of perforation & shock as evidenced by fever, increased heart rate Prepare for hydrostatic reduction if prescribed (not performed if signs of perforation of shock occur

Monitor

for the passage of normal brown stool, w/c indicates that the intussusception has reduced itself

Gastrointestinal Disorders

Implementation After

hydrostatic reduction Monitor for the return of normal bowel sounds, for the passage of barium, & the characteristics of stool

Gastrointestinal Disorders XIII. Umbilical hernia, Inguinal hernia, or Hydrocele A hernia is a protrusion of the bowel through an abnormal opening in the abdominal wall In children, a hernia most commonly occurs at the umbilicus & through the inguinal canal

Omphalocele – protrusion of abdominal contents

through the abdominal wall at the point of the junction of the umbilical cord & abdomen Incidence: 1 in 5000 live births Diagnosis: Prenatally through a sonogram Inspection after birth

Management: Immediate surgery to replace the bowel back If large apply silver sulfadiazine to prevent infection;

followed by delay surgical exposure

XIII. Umbilical hernia, Inguinal hernia, or Hydrocele

Gastrointestinal Disorders

XIII. Umbilical hernia, Inguinal hernia, or Hydrocele A hydrocele is the presence of abdominal fluid in the scrotal sac

Diagnosis: Prenatal sonogram At birth, scrotum of newborn appears enlarged If uncomplicated, fluid will be gradually reabsorbed

in the body; no treatment necessary

Gastrointestinal Disorders

Assessment 1.Umbilical hernia Soft swelling or protrusion around the umbilicus that is usually reducible w/ the finger

2.Inguinal hernia Painless inguinal swelling that is reducible Swelling may disappear during periods of rest

Gastrointestinal Disorders

Assessment 3.Incarcerated hernia When the descended portion of bowel becomes tightly caught in the hernial sac compromising blood supply

Irritability Tenderness

at site Abdominal distention May lead to complete intestinal obstruction & gangrene

Gastrointestinal Disorders

XVIII. Ingestion of poisons A. Lead Poisoning

Gastrointestinal Disorders

Causes The pathway for exposure may be food, air, or water Dust & soil contaminated w/ lead Poisoning occurs commonly in 2-3 years old age group; all socioeconomic groups

Poisoning can occur from: OTC drugs (vitamins, aspirin, iron compounds or

prescription drugs; antidepressants)

The

most common route is ingestion either from hand to mouth behavior from contaminated objects or from eating loose paint chips It affects the erythrocytes, bones, & teeth, & organs & tissues, including the brain & nervous system

Gastrointestinal Disorders

Universal screening Recommended

in high-risk areas at the age of 1 to 2 yrs Any child between the ages 3 & 6 yrs who has not been screened Common in toddlers. (falls- common to infant)

Gastrointestinal Disorders

Blood lead level (BLL) test BLL

less than 10 ug/dl: Reassess or rescreen in 1 year BLL 10 to 14 ug/dl.: Provide family lead education, follow-up testing, & social service referral

BLL

15 to 19 ug/dL or greater: Provide family lead education, follow-up testing, & social service referral

Gastrointestinal Disorders

Blood lead level (BLL) test BLL

70 ug/dL or greater: medical treatment is immediately provided BLL 20 to 44 ug/dL: A BLL greater than 20 ug/dL is considered acute; clinical management, including treatment, environmental investigation, & lead-hazard control

Principles: Determine substance taken, assess LOC Unless poison is corrosive, caustic

(strong alkali such as LYE) or a hydrocarbon, vomiting is the most effective way to remove poison.

Give syrup of Ipecac to induce

vomiting Ipecac – oral emetic Dose: * 15 ml – adolescent, school age & pre school * 10 ml to infant

Vomiting will occur within 20 minutes after giving

Ipecac If vomiting did not occur within 20-30 minutes; another dose maybe given

UNIVERSAL ANTIDOTE- activated

charcoal either (orally or via NGT),stools appear black, milk of magnesia & burned toast Never administer charcoal before ipecac

For caustic poisoning ( muriatic acid )

neutralize acid by giving vinegar . Don’t vomit instead prepare tracheostomy set Gas - mineral oil will coat intestine

Gastrointestinal Disorders XVIII. Ingestion of poisons B. Acetaminophen (Tylenol)

Gastrointestinal Disorders

Description - Seriousness of ingestion is

determined by the amount ingested & the length of time before intervention - Toxic dose is 150 mg/kg or greater in children

Gastrointestinal Disorders

Assessment GI

effects: nausea, vomiting & thirst from dehydration CNS effects: hyperpnea, confusion, tinnitus, convulsions, coma Hematopoietic effects: bleeding tendencies

Gastrointestinal Disorders

Implementation Induce

vomiting w/ syrup of ipecac or perform gastric lavage Administer activated charcoal to decrease absorption of salicylate

Antidote for Acetaminophen poisoning

– Acetylcystine ( Mucomyst)

Kwashiorkor Diseased caused by CHON

insufficiency Occurs in children 1-3 years old Growth failure – major symptom Edema Muscle wasting

Irritable & disinterested in

environment Lag in motor development compared to other children at same age group Zebra sign – hair shafts develop a striped appearance

Diarrhea Anemia Hepatomegaly

Treatment: Diet high in CHON Fatal if not treated Even if corrected children fail to reach their full potential (cognitive,psychological)

Marasmus Deficiency of all food groups Children affected –younger than 1 year

old

Symptoms: Growth failure Muscle wasting Irritability Iron-deficiency anemia diarrhea

Starving – will suck on anything

offered to them Treatment: Supply with diet rich in all nutrients