The Child with Gastrointestinal Dysfunction

1. The Child with Gastrointestinal Dysfunction Chapter 25 Christine Limann Dyer, RN, MSN, CPN

2. Gastrointestinal System • Upper portion is responsible for nutrient intake (ingestion) • Includes: • Mouth • Esophagus • Stomach

3. Digestion • Required to convert nutrients into usable energy • Performs excretory function and detoxification • Mechanical digestion • Chemical digestion

4. Gastrointestinal System • Lower portion is responsible for remainder of digestion, absorption & metabolism • Includes: • Small intestine • Large intestine • Rectum • Anus

5. Absorption • Principally from small intestine • Osmosis • Carrier-mediated diffusion • Active energy-driven transport (“pump”) • Large intestine • Absorption of water • Absorption of sodium • Role of colonic bacteria

6. Gastrointestinal System • Accessory Structures: • Liver • Gallbladder • Pancreas

7. Ingestion of Foreign Substances • Pica • Food picas • Nonfood picas • Foreign bodies • Nursing considerations

8. Developmental Aspects(each developmental stage contributes to the promotion of the health of the child) • Infant: • Prevent choking • Suck-swallow • Frequent feedings • Carefully introduce foods about 1 year of age

9. Developmental Aspects • Toddler: • Weight gain (5-6 lbs/year) • Deceased caloric needs • Food “jags”

10. Developmental Aspects • Preschooler: • Eats a full range of food • Appetite fluctuation • School-age: • GI tract stable (digestive system is adult sized) • Stools well formed

11. Structural Gastrointestinal Disorders

12. Umbilical Hernia • Signs & Symptoms: • Soft midline swelling in the umbilical area • Complications: • Incarcerated (strangulated) Nursing Care: • Most resolve spontaneously by 3-5 yrs of age • Surgery (pre-post operative care) • Discharge instructions

13. Anorectal Malformations • Signs & Symptoms: • Rectal atresia (closure) and stenosis (constriction or narrowing of a passage) • Complications: • Depends on the defect and accompanying multisystem involvement • Nursing Care: • Extensive treatment depending on defect and associated organ involvement • Preoperative care (caregiver education & IV fluids) • Postoperative care (pain control, s/s of infection, good skin care, NG tube, oral feedings resumed) • Discharge instructions

14. Obstructive Gastrointestinal Disorders

15. Hypertrophic Pyloric StenosisConstriction of the pyloric sphincter with obstruction of the gastric outlet

16. Hypertrophic Pyloric Stenosis • Signs & Symptoms: • Typically: healthy, male infant: new onset non-bilious vomiting progressing to projectile vomiting • Diagnosis: • Palpating the pyloric mass (olive-shaped) • Nursing Care: • Surgery (Ramstedt pyloromyotomy) • Assess dehydration, changes is VS, weight loss & discomfort • Preoperative care (NPO, NG tube,) • Postoperative care ( maintain fluids & electrolyte balance, feedings, infection, keeping the wound clean & pain relief) • Discharge instructions (care of incision, s/s infection, response to feedings)

17. Intussusception • Telescoping or invagination of one portion of intestine into another • Signs & Symptoms: • Acute abdominal pain, currant jelly stools, fever, dehydration, abdominal distention, lethargy and grunting due to pain • Diagnostic evaluation • Therapeutic management • Prognosis • Nursing considerations

18. Ileocolic Intussusception

19. Malrotation and Volvulus • Malrotation is due to abnormal rotation around the superior mesenteric artery during embryonic development • Volvulus occurs when intestine is twisted around itself and compromises blood supply to intestines • May cause intestinal perforation, peritonitis, necrosis, and death • Complications: • Shock (signs include; tachycardia, tachypnea, hypotension & cool, clammy or cyanotic skin)

20. Inflammatory Disorders

21. Irritable Bowel Syndrome (IBS) • Identified as cause of recurrent abdominal pain in children • Classified as a functional GI disorder • Alternating diarrhea and constipation • Therapeutic management • Nursing considerations

22. Inflammatory Bowel Disease (IBD) • Two types • Crohn’sDisese • Ulcerative Colitis

23. Ulcerative Colitis (UC) • Pathophysiology –inflamation in colon and rectum • Clinical manifestations – ulceration, bleeding, anorexia, anemia

24. Crohn’s Disease • Pathophysiology-Crohn's disease is an inflammatory bowel disease (IBD) • Clinical manifestations-abdominal pain, severe diarrhea and even malnutrition • Extraintestinal manifestations-arthritis, skin problems, fever, anemia • Therapeutic management • Medical- corticosteriods, • Remicade for remission, 6-MP • Surgical • Nursing considerations – nutritional support, education

25. Appendicitis • Signs & Symptoms: • Earliest symptom; periumbilical pain, vomiting • Followed by: right lower quadrant pain (classic sign) • Clinical Alert: • Children who respond yes to being hungry most likely do not have appendicitis • Nursing Care: • Surgery • Postoperative care (monitor intake & output, wound care, pain control, NPO until peristalsis returns, discharged home in 2-3 days) • If perforate appendix intravenous antibiotics are given, NPO with NG tube until bowel function returns

26. Omphalitis • Signs & Symptoms: • Redness & edema of the soft tissue • Diagnosis: • Culture obtained to confirm diagnosis • Nursing Care: • Prevention by good perinatal care & caregiver education • Intravenous broad-spectrum antibiotics

27. Meckel Diverticulum • Most common congenital malformation of the GI tract • Band connecting small intestine to umbilicus • Signs & Symptoms: • Abdominal pain, painless rectal bleeding, stools (bright or dark red with mucus) • Complications: • If undetected severe anemia & shock can occur • Nursing Care: • Surgical removal of the diverticulum or pouch • Postoperative antibiotics • Correct fluid & electrolyte imbalances • Monitor for shock & blood loss • Provide rest • Fluid replacement & NG tube

28. Functional Gastrointestinal Conditions

29. Infantile Colic • Signs & Symptoms: • Persistent, unexplained crying – younger than 3 months • Episodes occur at the same time each day • Diagnosis: • Based on symptoms occurring for more than 3 weeks, for 3 days (2-3 hours a day) • Nursing Care: • Rule out acute conditions • Management strategies (see Box 25-1)

30. Acute Diarrhea • Signs & Symptoms: • Increased frequency & fluid content of the stools with or without associated symptoms • Additional Symptoms: • Caregiver asked about vomiting, fever, pain, number of wet diapers in previous 24-hours) • Nursing Care: • Hydration & dietary needs • Pharmacology treatment not ordered • IV fluids essential with impaired circulation and possible shock

31. Chronic Diarrhea • Signs & Symptoms: • Reflective of underlying pathology • History of the diarrhea; frequency & appearance • Additional Symptoms: • Abdominal distention or tenderness, hyperactive bowel sounds, dehydration & condition of the perineal area • Nursing Care: • Treat the underlying cause • Enteral or TPN is provided for the child who is unable to maintain adequate oral intake • Caregiver educated on prevention

32. Vomiting • Signs & Symptoms: • Assessment includes description of onset, duration quality, quantity, appearance, presence of undigested food and precipitating event • Additional Symptoms: • Fever, diarrhea, ear pain, headache • Nursing Care: • Treatment of the cause & prevent of complications • Bowel is allowed to rest • Rehydration • Bland solids reintroduced • Antiemetic drugs • Dehydration, monitor fluid intake & output • Oral hygiene

33. Cyclic Vomiting Syndrome • Signs & Symptoms: • Recurrent episodic vomiting, usually lasts 24-48 hours. Vomiting occurs at regular intervals, usually every two to four weeks • Diagnosis: • Rule out other conditions • Nursing Care: • Supportive care: fluid replacement, rest, pharmacotherapy & psychiatric evaluation • Calm stress-free environment

34. Constipation • An alteration in the frequency, consistency, or ease of passage of stool • May be secondary to other disorders • Idiopathic (functional) constipation—no known cause • Chronic constipation—may be due to environmental or psychosocial factors

35. Newborn Period • First meconium should be passed within 24 to 36 hours of life; if not assess for: • Hirschsprung disease, hypothyroidism • Meconium plug, meconium ileus (CF)

36. Infancy • Often related to diet • Constipation in exclusively breastfed infant almost unknown • Infrequent stool may occur because of minimal residue from digested breast milk • Formula-fed infants may develop constipation • Interventions - adding cereals, fruits and vegetables may help (after 4 months)

37. Constipation in Childhood • Often due to environmental changes or control over body functions • Encopresis: inappropriate passage of feces, often with soiling • May result from stress • Management

38. Nursing Considerations History of bowel patterns, medications, diet Educate parents and child Dietary modifications (age appropriate)

39. Case Study 2 week old Joey is brought into the clinic by his mom because he hasn’t had a bowel movement in two days. He is not eating and has abdominal distention. She states that he didn’t pass meconium until the day after his birth. 1. Describe the structural anomaly associated with Hirshbrung’s disease. 2. How is Hirshbrung’s diagnosed? 3. List 2 actual NANDA and 1 risk 4. If Joey is diagnosed with Hirsbrung’s Disease, what is the likely surgical intervention? 5. What are possible complications for an older child?

40. Hirschsprung Disease • Also called congenital aganglionic megacolon • Mechanical obstruction from inadequate motility of intestine • Incidence: 1 in 5000 live births; more common in males and in Down syndrome • Absence of ganglion cells in colon

41. Hirschsprung Disease • Signs & Symptoms: • Failure to pass meconium within the first 48 hours of life, failure to thrive, poor feeding, chronic constipation, & Down syndrome • Complications: • Entercolitis is the most ominous presentation (abrupt onset o foul smelling diarrhea, abdominal distention & fever. Rapid progress may indicate perforation & sepsis • Nursing Care: • Surgical resection (colostomy) • Preoperative care (fluid & electrolyte status, NPO, NG tube, IV fluids) • Postoperative care (maintain NG tube, monitor for abdominal distension, assess for bowel sounds) • Teach caregiver how to car for colostomy, s/s of complications)

42. Clinical Manifestations of Hirschprung Disease • Aganglionic segment usually includes the rectum and proximal colon • Accumulation of stool with distention • Failure of internal anal sphincter to relax • Enterocolitis may occur

43. Diagnostic Evaluation • X-ray, barium enema • Anorectal manometric exam • Confirm diagnosis with rectal biopsy

44. Therapeutic Management • Surgery • Two stages • Temporary ostomy • Second stage “pull-through” procedure Preoperative care Postoperative care Discharge care

45. Gastroesophageal Reflux (GER) • Defined as transfer of gastric contents into the esophagus • Occurs in everyone • Frequency and persistency may make it abnormal • May occur without GERD • GERD may occur without regurgitation

46. GER • Diagnostics • Therapeutic management • Nursing considerations

47. Malabsorption Disorders

48. Lactose Intolerance • Signs & Symptoms: • Bloating, cramping, abdominal pain & flatulence • Diagnosis: • Based on history/physical & decrease in symptoms with elimination of lactose from the diet • Nursing Care: • Elimination of dairy products or the use of enzyme replacement • Dietary education (alternative sources of calcium)

49. Celiac Disease • Also called gluten-induced enteropathy and celiac sprue • Four characteristics • Steatorrhea-fatty stool • General malnutrition • Abdominal distention • Secondary vitamin deficiencies

50. Celiac Disease (cont.) • Pathophysiology • Diagnostic evaluation • Therapeutic management • Nursing considerations