Caring for Children with Gastrointestinal Dysfunction

1. Caring for children with gastrointestinal dysfunction —Chap 17 壹、評估 貳、小兒常見腸胃道疾病

2. 壹、評估（補） • 診斷性檢查 • 血液檢查、 • 糞便檢查、 • 特殊技術 • （LGI、UGI、 、） • 健康史 進食狀況 營養狀況 家庭狀況 主要照顧者的衛生習慣 排便情形 身體檢查 身體外觀 口腔感染 腹部評估

3. 常見腸胃道疾病 • Intestinal obstruction • Intussusception • Inflammatory disorders • Appendicitis • Disorders of motility • Gastroenteritis（Acute diarrhea） • Dehydration---Chap 10 • Constipation • Feeding disorders • Colic • Disorders of malabsorption • Celiac disease • Lactose Intolerance • Short bowel syndrome

4. Intussusception P602 • Etiology and pathophysiology 第1段 • One portion of the intestine prolapses and then invaginates(陷入) or telescopes (使嵌入) into another.第1行 • One of the most frequent causes of intestinal obstruction during infant • Between the age of 3 months and 6 years • Site：ileocecal valve 第2段 • Telescoping of the Intestine obstructs the passage of stool. • The walls of intestine rub together •  inflammation、edema、decreased blood flow •  necrosis、perforation、hemorrhage、 peritonitis • In infant, intussusception is commonly associated with measles, viral disease, and gastroenteritis syndromes. P603 Fig17-7

5. Clinical manifestationsP603第2段 Onset is abrupt • Acute abdominal pain（periods of comfort between acute episodes of pain） • Vomiting • Passage of brown stool→become red and resemble currant jelly • A palpable mass may be present in the upper right quadrant or mid-upper abdomen • 腹部呈柔軟、膨脹 • 疲倦、虛脫 • 發燒及腹膜炎之其他徵象 • 右下腹區排空（Dance徵象）

6. Diagnosis P603第2段 • History • Radiographs and ultrasound of the abdomen • Barium enema

7. Treatment P603第3段 • Hydrostatic pressure靜水壓—Barium enema • Oxygen（air）、saline、aqueous contrast material • Surgery • Supportive care • 液體補充 • 鼻胃管減壓 • 抗生素

8. Nursing management • Maintain fluid and electrolyte balance • Post OP • Monitoring for early signs of infection • Pain management • Maintain NG tube patency • Assess vital signs、Abdominal distention、 • Listen for bowel sounds every 4 hours • After normal bowel function • Clear liquid feeding half- strength milk and other foods

9. Appendicitis P609 Is an inflammation of the vermiform appendix. Most often in adolescent boys（10-19 y/o）；rarely seen before 2 years of age Etiology and pathophysiology • Result from an obstruction in the appendiceal lumen • Caused by a fecalith，parasitic infestations，stenosis，hyperplasia of lymphoid tissue，or a tumor • Obstructioncontinued secretion of mucus→pressure↑ →ischemia，cellular death，and ulceration • Complication：perforation or rupture → peritonitis → small bowel obstruction，electrolyte imbalances，septicemia，and hypovolemic shock Inflammatory disorders

10. Clinical manifestations • Pain • Fever, vomiting, diarrhea, constipation P610第2段 • Motionless, side-lying position with knees flexed Caution： • Some children • Appendix is in a different locationP609最後1行 • Differentiation P609此段第2行 • Ovulation • Ruptured ectopic pregnancy • Pelvic inflammatory

11. Pain • Periumbilical cramps，abdominal tenderness第1行 → pain in the right lower abdomen become constant第4行 • Most intense halfway between the anterior superior iliac crest and umbilicus → rigidity and rebound tendernessP610第2行 → if sudden relief of pain（ruptured）

12. Signs and symptoms of a ruptured appendix includeP609右上 • Fever • Sudden relief from abdominal pain • Guarding • Abdominal distention • Rapid shallow breathing • Pallor • Chills • Irritability or restlessness

13. Diagnosis— evaluation over several hours P610 • WBC↑（teenagers）第2段 • Abdominal pain • X-ray • Abdominal ultrasound • Focused appendiceal computerized tomography（FACT）

14. Treatment第3段 • Preoperatively • NPO & NG decompression • IV fluids & electrolytes • Antibiotics • Appendectomy • Postoperatively • Antibiotics • If ruptured • Penrose drain • Wound irrigations

15. Nursing management • Promote comfort • Maintain hydration • Provide emotional support • Recognize symptoms of infection • Support respiratory function • Discharge planning and home care teaching

16. Disorders of motility Diarrhea 因消化、吸收及分泌不正常所導致的症狀 特徵： （1）明顯或突然的增加排便次數 （2）含水量增加、性狀的改變 （3）糞便傾向綠色並含有黏液或血液。 可能是急性或慢性、發炎或沒發炎，一般和發炎有關的腹瀉通常被敘述成腸胃炎。 Disorders of motility

17. 急性腹瀉：糞便在次數及性狀上的突然改變，通常是因為傳染性病源所造成的炎症反應所致。急性腹瀉：糞便在次數及性狀上的突然改變，通常是因為傳染性病源所造成的炎症反應所致。 慢性腹瀉：持續兩週以上的腹瀉情形，如 吸收不良症候群。 Disorders of motility

18. Gastroenteritis（Acute diarrhea）P617 • Is an inflammation of the stomach and intestines 第1段 • Vomiting and diarrhea • Infants and small children with gastroenteritis or • diarrhea can quickly become dehydrated and are • at risk for hypovolemic shock . Disorders of motility

19. Etiology and pathophysiology （P617第2行） • Decrease in the absorptive capacity、decrease in surface area for absorption、alteration of parasympathetic innervation • High risk－day-care centers、improper sanitation （第5～6行） • Causes（Table 17-2） Disorders of motility

20. Mild －Slightly increased in number and more liquid Moderate －Several loose or watery stools －Irritability、anorexia、nausea、vomiting －Self-limiting Severe －Continuous watery stools －Fluid and electrolyte imbalance －Cramp、extremely irritable、difficult to console Clinical manifestationsP617

21. Diagnosisclinical therapy之第1段 • History • Physical examination • Laboratory finding－S/R、S/C 、urine sp.gr • Presence of ova, parasite, infectious organisms, viruses, fat, and undigested sugars.

22. TreatmentP618第2段 Depends on the severity of the diarrhea and fluid and electrolyte imbalances. Goal：correct the fluid and electrolyte • Mild to moderate • －Oral rehydration therapy ( Contain water, carbohydrate, sodium, potassium, chloride and lactate P315) • －Carbonated beverages and those containing high amounts of sugar should NOT be given • Severe • －IV（N/S with glucose【one half or one quarter normal • saline】 or L/R）第3段 • －NPO • －Antiemetics and antidiarrheals should generally not be used in • infants and young children. P618左下 • Lactose-free milk, breast milk, half-strength milk. P315倒數第4行

23. Nursing assessmentP618 • Frequency, color, amount and consistency of stools第4行 • The amount and type of vomitus • Observing dehydration • Urine output and specific gravity • Weight • Vital signs ( Febrile ) • Skin integrity

24. Nursing diagnosis & management P619 • Anxiety • Provide Emotional support • Sleep pattern disturbance • 活動無耐力 • Promote rest and comfort • Altered nutrition • Ensure adequate nutrition • CRAM (Complex carbohydrates, Rice and Milk ) P619綠框 • Diarrhea related to infectious process P620 care plan • Fluid volume deficit P620 • Risk for impaired skin integrityP621

25. DehydrationChap 10 --P313 • There is not enough fluid in the extracellular compartment. • The state of body water deficit is called dehydration. • Sodium is generally lost along with water → hyponatremia

26. Etiology and pathophysiology Causes P313 第1段第2行 • Loss of fluid containing sodium are vomiting、diarrhea、nasogastric suction、hemorrhage and burns • Radiant warmers 第2段第2行 • Adrenal insufficiency and overuse of diuretics • Bulimic adolescents

27. Blood urea nitrogen＞25mg/dLclinical therapy第1段第3行 • Serum bicarbonate＞17mEq/L

28. Medical managementP315 同腸胃炎之治療 • Oral rehydration therapy－mild and moderate dehydration • Contain water, carbohydrate, sodium, potassium, chloride and lactate • Lactose-free milk, breast milk, half-strength milk倒數第4行 • IV－severelyP316第1段 • L/R, one half or one quarter normal saline

29. Nursing assessment • Weight • I/O • Urine specific gravity • Consciousness • Pulse rate and quality • Skin turgor and mucous membrane moisture • Respiration • Blood pressure

30. Nursing management • Provide oral rehydration therapy guidelines • Teach parents oral rehydration methods • Monitor intravenous fluid administration • Discharge planning and home care teaching

31. Disorders of malabsorptionP627 包括各種不同程度的消化或吸收不良疾病。 • 消化不良是指消化霉減少或缺乏的狀況，如囊性纖維、Lactose Intolerance 。 • 吸收不良是指腸道運輸系統缺乏的狀況，可能是原發性缺損（如Celiac Disease）或續發性腸道發炎；解剖上之缺損，如short bowel syndrome，因物質運輸時間及吸收表面減少，而影響吸收。

32. Lactose IntoleranceP628 Etiology and pathophysiology • Inability to digest lactose（a disaccharide）第1行 • A congenital or acquired deficiency of the enzyme lactase • Congenital • Rare 第3行 • Acquired • Highest（約100％）among Asian and Native American 第5行

33. Clinical manifestations 第4行 • Abdominal pain • Flatulence • Diarrhea Diagnosis 第2段 History Hydrogen breath test Lactose-free diet for confirming the diagnosis

34. Treatment第2段第4行 • Diet • Infant－soy-based formula • Older children－eliminating lactose-containing foods • Enzyme tablets

35. Nursing management • Support • Explain dietary modifications and discuss alternate sources of calcium P337右下 • Discuss the need for supplementation of calcium and vitamin D • Read food labels

36. Short bowel syndrome（SBS）P628 Etiology and pathophysiology第1段 • It is a decreased ability to digest and absorb a regular diet because of a shortened intestine. • Causes：necrotizing enterocolitis（NEC）、inflammatory disorders、congenital bowel anomaly • The extent and location of the involved bowel determine the severityof the disorder.第2段 • Adaptation period：increases its absorptive surface area 第5行

37. Clinical manifestations第2段 • Watery diarrhea 第4行 Treatment 第2段 • Nutritional support 第6行 • TPN、elemental formula、MCT • Enteral feeding • High-fat, low-carbohydrate diet • Nucleotide, glutamine, polyamine, and fatty acid • Surgical（補）

38. Complication（補） • 缺少50%的腸道（若未缺失遠端迴腸）不會影響健康 • 缺少70%以上的腸道易導致嚴重吸收不良 • 通常死於TPN相關問題，如sepsis or TPN-cholestasis

39. Nursing management • Meeting the child’s nutritional and fluid needs • Oral and enteral feedings are instituted gradually • Feeding pump • Feeding tube • Emotional support • Arrange home visits to monitor the child’s growth and development and observed side effects （fluid and electrolyte imbalance and diarrhea）