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Nursing Care of the Child with Gastrointestinal Disorders. Ann Hearn RNC, MSN Fall 2009. Cleft Lip and Cleft Palate. Unilateral, bilateral, midline. photos. Treatment. Surgical repair done ASAP Rule of 10 > 10#, 10 weeks, 10 HGB Multidisciplinary team. Pre-op Goals.
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Nursing Care of the Child with Gastrointestinal Disorders Ann Hearn RNC, MSN Fall 2009
Cleft Lip and Cleft Palate • Unilateral, bilateral, midline
Treatment • Surgical repair done ASAP • Rule of 10 > 10#, 10 weeks, 10 HGB • Multidisciplinary team
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 operable- show 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
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
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
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 Nissenfundoplication
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 • 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 FredRamstedt procedure- Pyloromyotomy 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
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 • Assessment- ultrasound and at birth • Treatment - surgical repair in stages • Nursing care- same as for Gastroschisis
Intussuception • 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
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
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
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