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INTERFERENCES WITH ELIMINATION

INTERFERENCES WITH ELIMINATION. CONGENITAL OBSTRUCTIVE INTERFERENCES Anorectal Malformations Definition: malformation of anus and/or rectum minor to severe forms -rectal atresia -imperforate anus . Assessment May Include:

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INTERFERENCES WITH ELIMINATION

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  1. INTERFERENCES WITH ELIMINATION CONGENITAL OBSTRUCTIVE INTERFERENCES Anorectal Malformations Definition: malformation of anus and/or rectum minor to severe forms -rectal atresia -imperforate anus

  2. Assessment May Include: - failure to pass meconium stool ( imperforate anus) - stools in urine ( fistula) - ribbonlike stools (anal stenosis) Inspection of perineal area for abnormalities Insert lubricated rectal thermometer short distance (check protocol of agency)

  3. Interventions - corrective surgery (anoplasty) - perform manual dilation as ordered - instruct parents in proper technique - prevent infection keeping anal area as clean as possible

  4. HIRSCHSPRUNGS DISEASE:AGANGLIONIC MEGACOLON Definition/Pathophysiology autonomic parasympathetic ganglion cells absent in part of the large colon resulting in decreased motility, causing mechanical obstruction -familial disease, more common in boys and associated with Down’s syndrome Diagnosis: - history of bowel patterns - radiographic contrast studies - rectal biopsy to check for ganglion cells

  5. Assessment Newborns: failure to pass meconium, refusal to suck, abdominal distention and bile stained emesis Older Child: failure to gain weight and delayed growth, abdominal distention, constipation alternating with diarrhea and vomiting Treatment/Interventions Surgical removal of aganglionic bowel with a temporary colostomy (in severe cases) Milder case: dietary modification ( low residue), stool softeners -isotonic irrigations to prevent impactions

  6. Nursing Management Identify early through history Monitor fluid & lyte balance; nutrition Patient education - teach ostomy care if needed - teach how to perform irrigations - teach how to prevent skin breakdown - teach proper nutrition Post op care/measures: monitor for infection, pain control, measure abdominal circumference, maintain hydration

  7. VOLVULUS Definition/Pathophysiology: bowel twists upon itself causing obstruction and necrosis Assessment: nausea, vomiting, no bowel sounds, severe gripping pain and a tense distended abdomen Confirmed by x-ray Treatment/Interventions surgical intervention with a bowel resection follow with post op care

  8. INTUSSUSCEPTION Definition/Pathophysiology: - telescoping of the bowel into itself - usually at the ileocecal valve - causes inflammation and edema -blood flow becomes decreased - commonly in boys (2 months to 5 yrs old) -associated with cystic fibrosis and celiac disease

  9. Assessment: abrupt onset with acute abdominal pain, vomiting and the passage of brown stool - as condition worsens stools become red and resemble currant jelly - possibly a palpable mass in R upper quadrant or mid upper abdomen Diagnosis: history of child and radiography, ultra- sound of abdomen and/or barium enema

  10. Treatments -Barium Enema can reduce telescoping by hydro- static pressure -Surgery to reduce invaginated bowel and remove necrotic tissue

  11. Nursing Management for Intussusception • IV’s started immediately • Post Op • -monitor VS, bowel sounds • -monitor abdominal distention • -check for S&S of infection • -manage pain • - maintain NGT patency • PATIENT EDUCATION

  12. Omphalocele Definition/Pathophysiology: -congenital malformation where intra- abdominal contents herniate through the umbilical cord -covered by translucent sac-peritoneum -may have other congenital anomalies Nursing Management -cover with NS soaked gauze & cover with plastic -monitor VS especially temp -NPO with IV’s to maintain fluid & lyte balance

  13. Post Op Care prevent infection maintain fluid & lytes control pain ensure adequate nutritional intake support parents in dealing with crisis

  14. Hernias Definition: -protrusion of viscus from its normal cavity through an abnormal opening Types: Reducible: can be manually placed back into abdominal cavity Irreducible: cannot be placed back into cavity Inguinal: weakness of abdominal wall - spermatic cord emerges in males - round ligament in females Strangulated: irreducible with blood flow cut off

  15. Treatment/Interventions manual reduction use of supports (TRUSS) surgery for strangulated hernia repair Nursing Interventions -Post op prevent bladder distention splint incision site deep breathe Q 2 HR (avoid coughing) ice to scrotal area & support avoid heavy lifting 4-6 weeks report pain or difficulty urinating

  16. INFLAMMATORY INTERFERENCES Necrotizing Enterocolitis -inflammatory disease of the intestinal tract r/t intestinal ischemia, infection, gut immaturity - primarily in premature infants Assessment -feeding intolerance ( vomiting, abdominal distention, irritability) -bloody diarrhea - possible sepsis

  17. Diagnostics -X-rays showing free peritoneal gas -bowel wall thickening Interventions: - NPO and maintain IV’s - NGT to suction - antibiotics - bowel resection - possible ileostomy, colostomy

  18. NURSING MANAGEMENT • ID early (monitor feedings) • Maintain fluid & lyte balance • Comfort infant (holding, pacifier to meet sucking needs) • Patient Education post op

  19. APPENDICITIS Definition - inflammation of the vermiform appendix preventing mucus from passing into the cecum -untreated can cause ischemia, gangrene, rupture and peritonitis (may be caused by mechanical obstruction or anatomical defect) Assessment - low grade fever - Rt. Lower quadrant pain (McBurney’s point) - vomiting, diarrhea, constipation - rebound tenderness - Rovsing’s sign: palpate Lt. abdomen, pain felt on Rt. Diagnostics - increased WBC count - CAT scan

  20. Figure 24–16 Common location of pain in children and adolescents with appendicitis.

  21. TREATMENTS/INTERVENTIONS Pre OpPost Op NPO check VS, monitor incision IV’s IV’s Antibiotics antibiotics NGT (if peritonitis) coughing & deep breathing No laxatives drain (penrose) if ruptured Ruptured Appendix - fever - sudden relief of pain -chills, pallor

  22. NURSING MANAGEMENT -Promote comfort: Rt. Side lying, semi- fowler’s with knees bent, analgesics -Maintain hydration: I&O, skin turgor -Support respiratory function: cough, deep breathe / splint -Check for S&S of infection: check incision, check drainage, change dressing, antibiotics Discharge teaching: -how to check for infection -no strenuous activities

  23. INFLAMMATORY BOWEL DISEASE CROHN’S DISEASE Definition - chronic, inflammatory process along the GI tract - involves all layers of the bowel (deep fissures & ulcerations may develop between loops of bowel or nearby organs) - possible genetic association Assessment - crampy abdominal pain (RLQ) - fever - diarrhea (weight loss ) - ileum involvement ( steatorrhea) (prevalent in individuals of Jewish descent between the ages of 15- 25 yrs. old )

  24. Diagnostics - CBC: increased WBC, decreased H&H - increased ESR - hypoalbumineria - abdominal tenderness - thrombocytosis - radiologic & biopsy examination - lower endoscopy (proctosigmoidoscopy) - barium study of UGI tract - CAT scan

  25. ULCERATIVE COLITIS Definition -chronic disease of colon/rectal mucosa - can involve entire length of bowel -only involves mucosa/submucosa with ulcerations & inflammation - emotional/psychosocial factors may have an effect -peak incidence 15 – 25 yrs & 55- 65 yrs. Old F>M Assessment - bloody/mucus diarrheal stools - lower abdominal pain (cramping) -tenesmus - wt. loss (possible delayed growth & arthralgias) - ID nutritional deficiencies

  26. Diagnostics -ID the extent of involved bowel • - r/o any infectious process (i.e. Shigella) • - radiologic studies & endoscopy with biopsy • - decreased H&H, albumin • -increased WBC

  27. Treatment/Management Medications Salicylate Compounds: Sulfasalazine Corticosteroids: prednisone Immunosuppressants: cyclosporine Antidiarrheals: immodium Antibiotics : ciprofloxacil Nutrition Therapy - low fiber diet - if poor appetite (high protein) -supplemental vitamins, iron, zinc & folic acid -TPN Ulcerative Colitis Crohn’s Temporary colostomy/ileostomy bowel resection

  28. DIFFERENTIAL FEATURES OF U. C. AND CROHN’S

  29. GASTROENTERITIS (ACUTE DIARRHEA) Definition - inflammation of the stomach and intestines -may be accompanied by vomiting and diarrhea (bacterial or parasitic infections) Assessment -mild, moderate or severe diarrhea (loose, watery stools) - irritabilty, cramping - nausea and vomiting - fluid & lyte balance - hx & physical exam of patient - stool examination (ova and parasite)

  30. Treatments/Interventions -ID the causative factor -moderate: maintain fluid & lytes balance -oral replacement therapy (pedialyte, gatorade) -no carbonated or sugar drinks -severe: keep NPO; give IV fluids (NS/ RL) - start with clear liquids - monitor lytes especially potassium for cardiac patients - antidiarrheals for adults

  31. Nursing Interventions -Provide emotional support : allow pt. to talk -Provide rest and comfort: quiet environment -Ensure adequate nutrition: BRAT diet (bananas, rice, applesauce & toast) CRAM (complex carbohydrates rice and milk) milk free for 48 hrs.; caffeine free Discharge planning: teach parents S&S of dehydration

  32. DIVERTICULITIS Definition/Pathophysiology: -a saclike outpouching of the lining of the bowel (If bowel contents are retained in the sac, it becomes inflamed or infected) Assessment: -chronic constipation -abdominal pain (especially LLQ) -fever -abdominal distention/tenderness

  33. Diagnostics: - Ultrasonography -barium enema( not during acute phase) -increased ESR & WBC -decreased H&H -colonoscopy (after acute phase) Complications: -possible peritonitis - abscess formation & bleeding

  34. Treatment/Management Dietary: -Severe stage: NPO, NGT, IV’s -During inflammation: low fiber clear liquids initially -After inflammation: high fiber -Avoid foods with seeds, nuts, alcohol -Rest Medications -Broad spectrum antibiotics (Flagyl, Cipro) - Mild analgesics - Anticholinergics (pro banthine) - Bulk forming laxatives (metamucil)

  35. Surgical Management peritonitis or abscess formations may require surgery - one stage: bowel resection - multistaged: bowel resected and temporary colostomy performed Nursing Management teach pt. about dietary modifications teach pt. about the various meds teach pt. about ostomy care if needed

  36. PARALYTIC ILEUS Definition/Pathophysiology: paralysis of peristaltic movement due to effect of trauma or toxins on the nerves that regulate intestinal movement Assessment -abdominal pain/distention: accumulation of gas/fluid above the obstruction -rigid abdomen: increased distention makes it rigid -vomiting: earliest sign of high obstruction; bile if lower obstruction - constipation -absent bowel sounds: no peristalsis with obstruction -shock: loss of fluid/lytes from the bloodstream into intestines

  37. IRRITABLE BOWEL SYNDROME Definition: functional disorder of intestinal mobility with no irritation (spasms) Assessment: symptoms range from mild to severe in intensity with constipation, diarrhea or both - pain, cramps (LLQ) - bloating, abdominal distention -more females than males

  38. Treatment/Management Dietary modifications: ID food intolerances limiting caffeine and avoiding alcohol -dietary fiber and bulk help stools Medications -bulk forming laxatives (metamucil) -antidiarrheal agents (Lomotil) -anticholinergic agents (Bentyl) -tricyclic antidepressants (Elavil) -5-HT4 (Zelnorm) Stress Management

  39. Diagnostics: CT scan, possible endoscopy Treatment/Interventions NPO NGT Nasointestinal tube (Cantor/Harris tube with mercury) IV’s Pain management Treat shock Nursing Interventions ID early Monitor pt. and all tubes Maintain accurate I&O with monitoring of lytes

  40. Table 24–2 Causes of diarrhea in children.

  41. HEMORRHOIDS Definition/Pathophysiology - hyperplastic areas of vascular tissue in the anal canal - Internal hemorrhoids above the internal sphincter - External hemorrhoids outside the external sphincter. Assessment Internal: prolapse causing discomfort External -itching - pain - bright red bleeding with defecation

  42. Treatment/Interventions Conservative measures: increase fiber diet (fruit, bran, whole grains) -encourage plenty of water -analgesic ointments, suppositories -stool softeners -Sitz baths Teach to avoid irritating laxatives, spicy foods, caffeine, alcohol, nuts Surgery Pre op: enemas & laxatives Post op: monitor rectal bleeding report significant bloody drainage side lying position

  43. Nursing Interventions -flotation pad -pain med before BM -stool softener -increased fiber in diet -sitz bath -perianal care

  44. Table 24–3 Influential factors in childhood constipation.

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