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Gastrointestinal Alterations

Gastrointestinal Alterations. NUR 264 Pediatrics Angela J. Jackson, RN, MSN. Developmental Differences. GI system of the newborn very ineffective because of immaturity Sucking and swallowing automatic reflexes until nerves and muscles develop by 6 weeks of age

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Gastrointestinal Alterations

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  1. Gastrointestinal Alterations NUR 264 Pediatrics Angela J. Jackson, RN, MSN

  2. Developmental Differences • GI system of the newborn very ineffective because of immaturity • Sucking and swallowing automatic reflexes until nerves and muscles develop by 6 weeks of age • Newborn stomach capacity 10 -20ml, expanding to 200ml by one month of age and to adult capacity of 2000-3000ml by late adolescence • Peristalsis is greater in the infant, emptying time of the stomach 2-3hrs in the newborn increases to 3-6hrs by one to two months of age

  3. Developmental Differences • Infant’s metabolic rate is faster than an adults. Infant’s require 100calories per kg, adults require 30-40 calories per kg • Regurgitation common in infants (relaxed cardiac sphincter tone) • Length of small intestine is proportionally greater in an infant, six times the body length • Infants secretes more fluids and electrolytes into the intestine than the adult • Large intestines of the infant are proportionately shorter than an adult’s, resulting in less epithelial lining available for absorption of water

  4. Developmental Differences • Liver function is immature at birth. Toxic substances are inefficiently detoxified and medications are inefficiently processed. • Infant’s are deficient in several digestive enzymes, including amylase (carbohydrate digestion), lipase (fat absorption), trypsin (protein digestion) • Infant’s intestines are more permeable to proteins, allowing passage of protein into the bloodstream, increasing susceptibility to food protein allergens

  5. Cleft Lip and Cleft Palate

  6. Cleft Lip and Cleft Palate • Most common craniofacial malformation • Cleft lip: Simple notch in vermillion border of lip to complete opening extending to floor of the nose. May be unilateral or bilateral • Cleft palate: Fissure or small opening to complete opening between mouth and nasal cavity. May be isolated or occur with cleft lip

  7. Cleft Lip and Cleft Palate: Etiology • Mulitfactorial: Genetic – increased incidence in families • Environmental factors: Drugs (anticonvulsants), alcohol, smoking, maternal illness, infection, folic acid deficiency, parental age

  8. Cleft Lip and Cleft Palate: Etiology • Cleft lip with or without palate – more common in males • Cleft palate more common in females

  9. Cleft Lip: Complications • Cleft Lip and Cleft Palate: • Facial disfigurement may cause shock, guilt and grief for the parents and may block parental bonding with the child • Cleft Lip: • Abnormal development of external nose, nasal cartilages, nasal septum, usually nose is flattened • Dental anomalies: missing, malpositioned teeth on side of abnormality

  10. Cleft Palate: Complications • Cleft Palate: • Infants have feeding problems because they are unable to develop suction due to opening between mouth and nasal cavity. • Increases the risk of aspiration: the increased open space in the mouth causes some formula to exit through the nose • Increases the risk of upper respiratory infection and otitis media

  11. Cleft Lip and Cleft Palate: Diagnosis • Prenatal by ultrasound (may be seen by 13 to 16 weeks gestation) • Apparent on assessment at birth • Unable to generate negative pressure in oral cavity to suck and may impair ability to swallow resulting in feeding difficulties

  12. Cleft Lip and Cleft Palate: Therapeutic Management • Multidisciplinary care: plastic surgeon, neurosurgeon, orthodontist, otolaryngologist, speech pathologist, pediatrician • Surgical closure of Cleft Lip: 3 months or 12 pounds • Palate prosthesis may be used prior to surgery for a cleft palate. Cleft palate surgery is done before child develops faulty speech patterns (approximately 12 - 18 months)

  13. Cleft Lip and Cleft Palate: Therapeutic Management • Prevention of complications: infection, speech difficulties, malocclusion problems, hearing problems • Facilitation of parent-child bonding, normal growth and development, speech and language development

  14. Cleft Lip and Cleft Palate: Nursing Management • Newborn assessment: assess ability to suck, swallow and feed • Assess parents reaction to infant • Teach feeding pre and post op: Feed in an upright position, use soft, elongated nipple, frequent burping, prevent aspiration, adequate nutrition, breastfeeding • Monitor weight gain • Postop care: Logan bow, restraints, pain medication, cleansing wound site and mouth, positioning (side or supine for cleft lip, side or prone for cleft palate) • Discharge teaching and Home care planning: feeding, suture care, restraints, pain management and follow-up

  15. Esophageal Atresia (EA) and Tracheoesophageal Fistula (TEF)

  16. EA & TEF • Failure of esophagus to develop as a continuous passage to the stomach and failure of the esophagus and trachea to separate into distinct structures

  17. EA & TEF: Clinical Manifestations • Frothy saliva in mouth • Drooling, coughing and choking • Sudden coughing, gagging at feedings. Feeding comes out of the nose and mouth, becomes cyanotic and stops breathing as feeding is aspirated • When the trachea joins the stomach, the stomach becomes distended with air

  18. EA & TEF: Diagnosis • Polyhydramnios should suggest the possibility of a high gastrointestinal obstruction • Inability to identify fetal stomach bubble on a prenatal ultrasound • Inability to pass a nasogastric tube into the stomach • Radiographic studies: curling of NG tube in upper esophagus, air in the stomach

  19. EA & TEF: Therapeutic Management • Maintain a patent airway • Prevent pneumonia • Gastric or blind pouch decompression • Surgical repair as soon as possible • Preferably, surgical repair is done in one stage, but may have to be done in two stages, based on infants condition: • 1st stage: Close TEF and insert gastrostomy tube • 2nd stage: Connect ends of esophagus

  20. EA & TEF: Nursing Considerations • Preoperative care: • Maintain patent airway: have suction available • Thermoregulation • Insert NG tube for gastric decompression • Keep NPO • Establish IV access to maintain hydration

  21. EA & TEF: Nursing Considerations • Postoperative care: • Maintain patent airway • Prevent trauma to the anastomosis • Elevate gastrostomy tube and keep open to allow gas to escape and gastric secretions to flow into the small intestine • Provide emotional support to family, encourage bonding • Teach parents gastrostomy care, signs of infection, signs of esophageal stricture

  22. Gastroschisis and Omphalocele

  23. Gastroschisis • Extrusion of the large and small intestine through a defect in the abdominal wall to the right of the umbilical cord. The bowel has no covering membrane, and is exposed to the amniotic fluid

  24. Omphalocele • Herniation of abdominal contents through the umbilical cord. The bowel is covered by a protective sac, and the size of the defect is variable, ranging from 1cm to all of the abdominal contents

  25. Gastroschisis and Omphalocele: Diagnosis • Maternal serum alpha-fetoprotein (elevated) • Prenatal Ultrasound

  26. Gastroschisis and Omphalocele: Therapeutic Management • Cover exposed contents loosely with sterile saline-soaked pads and plastic drape to prevent water loss, drying and temperature instability. Gastroschisis: be careful not to wrap around bowel – can cause pressure necrosis as exposed bowel expands • IV fluids • Antibiotics • Surgical closure: primary or staged repair

  27. Gastroschisis and Omphalocele: Surgical Closure • Primary closure: All of the exposed bowel is placed inside the abdominal cavity and the abdomen is closed during a single procedure • Staged repair: When the abdominal cavity is not large enough to contain all of the exposed bowel, the abdominal wall is stretched and a silo is created. The edges of the abdominal wall are sutured to plastic sheeting that is then suspended with mild tension to the top of the incubator. The silo and the suture lines are covered with providone-iodine to prevent infection. The silo is gently compressed on a daily basis until all of the exposed bowel is enclosed in the abdominal cavity. This process takes several days (7-10) to complete. Once all of the exposed bowel is contained within the abdominal cavity, the silo is removed and the abdominal wall is closed

  28. Gastroschisis and Omphalocele:Potential Complications • Postoperative complications: respiratory distress due to increased abdominal pressure, infection, intestinal obstruction, vena cava compression resulting in decreased blood flow to extremities, evisceration, intestinal volvulus

  29. Gastroschisis and Omphalocele: Nursing Considerations • Preoperatively: careful handling and positioning, prevent infection, thermoregulation, assess respiratory status, fluid replacement • Postoperatively: mechanical ventilation, IV fluids, TPN, antibiotics, monitor for signs of complications, assess bowel function • Family support, discharge teaching – parenteral nutrition, oral stimulation, signs of bowel obstruction, follow-up care

  30. Biliary Atresia • Absence of bile duct or obstruction of bile duct prevents flow of bile from the liver to the gallbladder and small intestine • Bile accumulates in the liver and bile plugs form • Inflammation, edema and irreversible liver injury occur, resulting in fibrosis of the liver • Causes excretion of bilirubin and bile salts in the urine

  31. Biliary Atresia: Clinical Manifestations • Jaundice, developing between 2 weeks and 2 months of age • Tea colored urine due to bilirubin and bile salt excretion • Light colored stools due to absence of bile pigments • Hepatomegaly • Abdominal distention • Bruising due to prolonged bleeding time • Intense itching • Failure-to-thrive, malnutrition as fat and fat-soluble vitamins can not be absorbed

  32. Biliary Atresia: Diagnosis and Treatment • Diagnosed by ultrasound, liver biopsy and increased bilirubin levels • Fatal without treatment: • Surgery: hepatic portoenterostomy (Kasai procedure, formation of a substitute duct) –to correct obstruction and allow for drainage of bile from liver into intestines • Surgery is not a cure; end stage liver disease may result in need for liver transplant

  33. Biliary Atresia: Nursing Considerations • Monitor nutrition – fat soluble vitamin supplements, TPN, Intralipids, daily weights • Monitor I&O, stool patterns • Good skin care • Discharge teaching (nutrition, skin care, support groups, signs of rejection)

  34. Diaphragmatic Hernia • Herniation of the abdominal contents through a defect in the diaphragm into the chest cavity and usually develops on the left side • Intestines and abdominal structures enter the thoracic cavity, compressing the lung

  35. Diaphragmatic Hernia: Clinical Manifestations • Severe respiratory distress • Cyanosis, tachypnea, retractions • Decreased or absent breath sounds on the side of the defect • Barrel-shaped chest • Heart sounds shifted to the right • Bowel sounds heard over the chest • Scaphoid abdomen

  36. Diaphragmatic Hernia: Diagnosis • Prenatal ultrasound • Chest x-ray

  37. Diaphragmatic Hernia: Treatment • Respiratory support – O2, intubation, No Bag/Mask ventilation, pulse oximeter • Blood gases to monitor acid-base status • Jet ventilator or High frequency ventilation for severe respiratory distress • ECMO (extra corporeal membrane oxygenation)

  38. Diaphragmatic Hernia: Treatment • Position head and thorax higher than abdomen, place on affected side • IV fluids • NG tube to decompress stomach/intestines • Medications • Opoids (Fentanyl) or paralyzing agents (pancuronium) if agitated • Isotropic (Dopamine) for blood pressure support and improve cardiac output • Surfactant to improve oxygenation • Sodium bicarbonate to prevent acidosis

  39. Diaphragmatic Hernia: Treatment • Surgical repair • Fetal surgery • Post-birth surgery: return abdominal contents to abdomen and close defect in diaphragm

  40. Diaphragmatic Hernia: Nursing Considerations • Preoperative care: stabilization • Postoperative care: • Position on affected side to facilitate expansion of unaffected lung • Maintain respiratory support • IV fluids, fluid and electrolyte balance • Stress reduction • Prevent infection • Pain management • Chest tube care • Family support, promote bonding • Discharge teaching (wound care, feedings, prevention of infection)

  41. Anorectal Malformations • Congenital anomalies of the anus and rectum caused by abnormal development • Imperforate anus: any abnormality without an obvious opening – may have a fistula from rectum to perineum or GI tract

  42. Anorectal Malformation: Clinical Manifestations • No anal opening • Failure to pass meconium within 24 hours after birth • Passing meconium through the urethra or vagina

  43. Anorectal Malformations: Diagnosis • External physical exam • X-rays with contrast • Abdominal ultrasound

  44. Anorectal Malformations: Treatment • Anal stenosis – manual dilations • Imperforate anal membrane – excise membrane and manual dilations • Perineal fistula – Anoplasty and dilations • High or intermediate malformations – Colostomy, repair defects between 6-12 months

  45. Anorectal malformations: Nursing Considerations • Complete assessment at birth • Rectal temperature • Asses for passage of meconium stool • Preoperative care: assist with diagnostic evaluation, IV fluids, gastrointestinal decompression

  46. Anorectal Malformations : Nursing Considerations • Postoperative care: • perineal care, protective ointments and dressings to protect skin • Positioning: side-lying with hips elevated or supine with legs elevated to prevent pressure on perineal sutures • Colostomy care • NG tube for abdominal decompression • IV fluids ( feedings begin when peristalsis returns) • Family support • Discharge teaching: perineal and wound care, prevention of constipation, colostomy care, delayed toilet training, manual dilations, observe for complications, follow-up care

  47. Pyloric Stenosis • An increasing hyperplasia and hypertrophy of the circular muscle at the pylorus, narrows the pyloric canal. Most commonly seen in male infants between ages 1 and 6 months • Hypertrophy eventually obstructs the pylorus opening. Obstruction results in inability of food to pass out of the stomach, causing vomiting

  48. Pyloric Stenosis: Clinical Manifestations • Vomiting beginning at 3-6 weeks of age. Infant begins to regurgitate small amounts of formula immediately after feeding, which progresses to projectile vomiting • Vomiting can occur during feedings, after feedings or several hours later • Infant will be hungry after vomiting and will accept a second feeding • Failure to gain weight • Sign and symptoms of dehydration • Palpable olive-shaped mass in right upper quadrant • Visible peristaltic waves

  49. Pyloric Stenosis: Diagnosis • History and physical • UGI • Ultrasound

  50. Pyloric Stenosis: Treatment • Correct electrolyte imbalances and dehydration • Pyloromyotomy: split the muscle to make the opening larger

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