Gastrointestinal Disorders in Pediatric Patients

1. Gastrointestinal Disorders in Pediatric Patients Revised, Summer 2009

2. Cleft Lip and Cleft Palate • Etiology- Failure of maxillary and median nasal processes to fuse during embryonic development Remember the psycho-social implications for these children and families

3. Assessment • Unilateral, bilateral, midline

4. Treatment • Surgical repair done ASAP • Rule of 10 > 10#, 10 weeks, 10 HGB • Multidisciplinary team • Homecare by the family prior to surgery • E-enlarge opening in nipple • S-stimulate suck reflex • S-swallow fluids appropriately • R-rest when infant signals

5. Pre-op Teaching • Remind parents that defect is operable- show photographs of corrected clefts • Introduce cup, spoon feeding devices (see your book for feeding tips) • Explain restraints

6. Post-Op • Prevent trauma to suture line – Do not allow to suck! • Facilitate breathing • Maintain nutrition • Reduce pain to minimize crying • Prevent infection • Cleanse suture lines as ordered • Referrals to appropriate team members

7. Esophageal Atresia/ Tracheoesophageal fistula Failure of the esophagus to totally differentiate – 4-5th wk gestation Both are malformations of ESOPHAGUS Cause is unknown

8. Assessment • 3C’s -coughing, choking, cyanosis when feeding • Respiratory difficulties • Drooling • Inability to pass suction catheter, NG @ birth • Abdominal distention if fistula present

9. Management Early diagnosis Ultra sound Radiopaque catheter inserted in the esophagus to illuminate defect on X-ray Surgical repair- thoracotomy Anastomose ends of esophagus if possible (may need 2 stage repair) Ligate fistula

10. Pre-Op • Maintain airway • Keep NPO- administer IV fluids • Elevate HOB 30 degrees • Suction PRN • Gastrostomy for feedings • Prevent aspiration pneumonia • Suction • HOB 30 degrees • Prophylactic antibiotics

11. Post-Op • Maintain airway • Maintain nutrition • Prevent trauma • Monitor growth and development

12. Gastroesophageal Reflux Disease(GERD) The cardiac/lower esophageal sphincter (AKA LES) and lower portion of the esophagus are weak, allowing regurgitation of gastric contents back into the esophagus.

13. Assessment: Infant • Regurgitation almost immediately after each feeding when the infant is laid down • Excessive crying, irritability • FTH • Risk for: • aspiration (pneumonia) • Apnea • Development of respiratory problems (asthma)

14. Assessment: Child • Heartburn • Abdominal pain • Cough, recurrent pneumonia • Dysphagia

15. Diagnosis • Ph of secretions in esophagus <7.0=acid • Barium Swallow and visualization of any esophageal abnormalities

16. Management & Nursing Care • Nutritional needs • Positioning – PRONE (supine worsens GERD) • Medications • H2 receptor antaqgonists (-tidine) • Cholinergics – metoclopramide (Reglan) • Proton pump inhibitors – (-prazole) • CPR instruction for parents/caregivers • Possible NissenFundoplication

17. Diarrhea/GastroenteritisSevere • A disturbance of the intestinal tract that alters motility and absorption and accelerates the excretion of intestinal contents. 3-30 stools/day!!! • Most infectious diarrheas in this country are caused by Rotovirus, but can be c.diff

18. Clinical Manifestations • Increase in peristalsis • Large volume stools (loose, watery, green) • Increase in frequency of stools with cramps, nausea, vomiting • Urge with small stool present • Increased heart & resp. rate, decreased tearing and fever

19. Complications • Dehydration • Mucus membranes dried, cracked • Decreased elasticity of skin • Depressed fontanels, eyes sunken • Decreased urinary output, dark • Metabolic Acidosis • pH <7.35 • HCO3 =/<22mEq/L

20. Diagnosis • Stool culture -causative organism -O&P • ABG’s to diagnose Metabolic Acidosis

21. Treatment & Nursing Care • Contact isolation • Treat cause • Weigh daily • Monitor I&O, assess for dehydration • Skin care • Fluid and electrolyte balance • Oral rehydration • IV rehydration (RL or D5NS)

22. Appendicitis • Inflammation of the lumen of the appendix which becomes quickly obstructed causing edema, necrosis and pain.

23. Clinical Manifestations • Pain • Vague • Periumbilical • Rebound tenderness • No bowels sounds “silent abdomen” • Anorexia with or without vomiting • Diarrhea • Increased temperature • If ruptures/perforates, there is immediate relief of pain followed by high fever and dehydration

24. Diagnosis • WBC <15-20,000 • Rebound tenderness at McBurney’s point • Abdominal ultrasound or xray - fecalith

25. Management and Nursing Care: Pre-Op • NPO, IV • Comfort measures, knee chest position • Antibiotics • Thermal therapy – Ice pack • No elimination • Patient education for post-op • +/- NG tube • Penrose drain vs open wound bed

26. Management and Nursing Care: Post-Op • NPO, IVs • Antibiotics • Analgesia • Patient teaching • Wound care • Open vslaproscopic • No contact sports, PE, lifting until released by surgeon

27. Pyloric Stenosis • Pyloric sphincter • Incidence • Possible genetic predisposition

28. Assessment • Vomiting: character?? • Constant hunger and fussiness • Distended upper abdomen • Visible peristaltic waves • Hypertrophied pylorus • No pain • Weight loss • Dehydration and electrolyte imbalance

29. Diagnosis • History and physical • Abdominal ultrasound • Laboratory data

30. Pre-op care • Restore fluid and electrolyte balance • NPO • I & O • Urine specific gravity • Parental support • Guilt – think they are “bad parents” • Emphasize structural problem not parental feeding technique

31. Management and Nursing Care Pylorotomy via laproscopy • I & O • Feeding • Position – HOB elevated slightly • Surgical site infection free • Patient teaching – s/s recurrence

32. 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? • Begin an intravenous infusion • Measure abdominal circumference • Orient family to unit • Weigh infant

33. Intussuception • Most commonly seen in infants 3-12 months but can occur in older child • Bowel “telescopes” within itself usually at ileocecal valve

34. Assessment • Pain – colicky, knee chest position • Vomiting – can contain stool • Stools – “currant jelly” • Dehydration • Serious complications

35. Diagnosis • Abdominal xray = intraperitoneal AIR • Abdominal ultrasound

36. Therapeutic Intervention • Hydrostatic reduction • Surgery

37. Post-op care • NPO with NG tube • Monitor bowel sounds and passage of stool • Gradual introduction of fluids and solids

38. Hirschsprung’s Disease Congenital disorder of nerve cells in lower colon

39. Assessment • Failure to pass meconium • Vomiting with reluctance to feed • Bowel assessment • Breath

40. If in older child: • Constipation • Offensive ribbon-like stools • History of REGULAR laxative use • Palpable fecal mass

41. Diagnosis • History & Physical • Barium enema (X-ray) • Rectal biopsy- absence of ganglionic cells in bowel mucosa

42. Management • Surgical intervention • One stage = resection • Two stage • Temporary diverting colostomy with resection • Re-anastomosis and take-down of colostomy

43. Nursing Care: • Pre-op • Cleanse bowel • Neomycin per rectum • Patient/parent teaching re: ostomy • Post-op • NPO – N/G tube, IV fluids • No rectal thermometers, monitor VS • Monitor bowel sounds and abdominal girth • Patient/parent teaching • Incision care, s/s infection • Pain management • ?colostomy teaching

44. Volvulus & Malrotation • Assessment- pain, bilious vomiting, S & S bowel obstruction • Treatment- surgery to prevent ischemia • Nursing Care- same as Intussuception and Hirschsprung’s

45. Failure to Thrive (FTH) • Assessment- low growth for age, developmental delays, apathy • Diagnosis- History to determine organic- vs- non-organic • Nursing Care- Teaching on nutrition feeding techniques, feeding cues, praise • Community resources

46. Celiac Disease • Assessment- Growth pattern, GI pattern • Treatment- Dietary restrictions • Nursing Care- monitor for dehydration, encourage compliance with dietary restrictions, provide support groups for patient and caregiver

47. Diagnosis • Measure fetal fat • Duodenal biopsy • Screen IgA

48. Complications • Hypocalcemia • Osteomalacia • Osteoporosis • Depression