Child Health Nursing Partnering with Children & Families

1. Child HealthNursingPartnering withChildren & Families Jane W. BallRuth C. Bindler Chapter 30 Alterations in Gastrointestinal Function

2. Let’s Review the GI tract

3. FIGURE 30–1 The internal anatomic structures of the stomach, including the pancreatic, cystic, and hepatic ducts; the pancreas; and the gallbladder. Jane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & Families © 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

4. Pediatric Differences in Anatomy and Physiology • Duodenum: digestion takes place • Enzymes that aid in digestion: • Amylase ( saliva; digests carbs) • Lipase (enhances fat absorption) • Trypsin (which breaks down protein into polypeptides and some amino acids) (Infants are deficient in these enzymes until around 4-6 mos…therefore abdominal distention from gas is common)

5. Pediatric Differences in Anatomy and Physiology • GI sx immature at birth • Process of absorption and secretion do not take place until after birth • Sucking primitive reflex • Voluntary swallow (at 6 weeks) • Newborn’s stomach capacity is small at birth ??? Implications.. • (frequent feedings, freq bowel movements, and intestinal motility is greater than in older kids (peristalsis) therefore greater emptying time)

6. Pediatric Differences in Anatomy and Physiology • Liver function immature at birth and next few weeks • During first year of life • Gluconeogenesis (formation of glycogen from noncarbs) • Plasma protein • Ketone formation • Vitamin storage • Deamination • GI structures in second year of life more mature • Enlarged stomach capacity (to 3m/day) • Sphincter control (mylination of sc)

7. What would be some signs/ symptoms of GI disorders in infants/ children? • Vomiting/ regurgitation • Irritability/ fussiness • Abdominal pain/ distension • FTT • Weight loss • Stool changes • Abdominal pain

8. GI Assessment Techniques • Subjective • Lifestyle and family factors • Including family hx • Diet • ? Gaining weight • Thorough h/o feeding pattern, ? Any problems • Allergies (lactose intolerant, celiac disease) • Elimination patterns • I/O’s • Encorpresis/ constipation

9. GI Assessment Techniques • Objective • Observe • Abdominal distension • Symmetry, bumps, bulges or masses • Umbilicus • Peristaltic waves • Visible rippling waves= bowel obstruction

10. GI Assessment Techniques • Objective (con’t) • Auscultation • Hyper/hypo bowel sounds • Percussion • Tympany vs dullness • Palpation • Light vs deep • Rebound tenderness…peritoneal inflammation • McBurney’s point

11. Disorders of the GI System • Structural defects • Disorders of motility • Intestinal parasitic disorders • Inflammatory disorders • Disorders of malabsorption • Hepatic disorders • Injuries to the GI system

12. Structural Defects • Cleft Lip and Cleft Palate • Esophageal atresia and tracheoesophageal fistula • Pyloric Stenosis • Insussusception • Abdominal Wall Defects • Anorectal malformations • Umbilical hernia

13. Cleft Lip and Cleft Palate • Congenital malformation (failure of the maxillary processes to fuse) occurring during weeks 6-12 gestation • Each abnormality may appear by itself or may be seen together • Varying degrees of severity • Most common craniofacial deformities overall in US • Multifactoral causes

14. Cleft Lip and Cleft Palate • Complication Associated with Cleft Lip or Cleft Palate (see Table 30-1) • Feeding problems • Speech development • Otologic • Dental and orthodontic • Developmental

15. Cleft Lip • Opening between the nose and lip • Apparent at birth • Should be documented during newborn assessment • Assess child’s ability to suck and swallow • Cleft lip repair is performed during first month of life • Special feeding techniques if surgery is delayed

16. FIGURE 30–2A, Unilateral cleft lip. B, Bilateral cleft lip. Courtesy of Dr. Elizabeth Peterson, Spokane, WA. A Jane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & Families © 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

17. FIGURE 30–3A, Repaired unilateral cleft lip (see Figure 30–2A). B, Repaired bilateral cleft lip (see Figure 30–2B). Courtesy of Dr. Elizabeth Peterson, Spokane, WA. A Jane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & Families © 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

18. FIGURE 30–2 (continued)A, Unilateral cleft lip. B, Bilateral cleft lip. Courtesy of Dr. Elizabeth Peterson, Spokane, WA. B Jane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & Families © 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

19. FIGURE 30–3 (continued)A, Repaired unilateral cleft lip (see Figure 30–2A). B, Repaired bilateral cleft lip (see Figure 30–2B). Courtesy of Dr. Elizabeth Peterson, Spokane, WA. B Jane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & Families © 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

20. Cleft Lip • Feeding a Child before Cleft Lip Repair • Bottle with special nipple – longer and narrower • Hold infant in upright position • Large cross-cut hole in nipple to allow the child to get food into back of throat without strong sucking • Stimulate sucking by rubbing nipple on infant’s lower lip • Allow child to swallow and burp frequently • ESSR method – Enlarge nipple, Stimulate sucking, Swallow, Rest

21. Cleft Lip • Surgery for Cleft Lip Repair • Usually done early (first few days to 1st month of life) to improve parental bonding and improve feeding • Plastic surgery with a staggered suture line (often in shape of letter “Z” to minimize scarring) • After surgery Logan Bar over child’s mouth to reduce tension on suture line

22. Logan Bar

23. Cleft Lip Repair • Pre-Op Care of the Child and Parents • Explain pre-op procedures to parents • Provide support and information • Keep accurate record of child’s growth and feeding schedule • Infant: • NPO X 4-6 hours pre-op • IVs

24. Cleft Lip Repair • Nursing Diagnosis • Pre-Op • Imbalanced Nutrition: Less than body requirements • Risk for aspiration • Altered parenting

25. Cleft Lip Repair • Post-Op Care of Child and Family • Encourage rooming-in • Incision care: clean sutures with sterile cotton swab and ½ strength H2O2 followed by saline to prevent crusting (esp. after feeding). May apply antibiotic ointment to suture line • DO NOT DISPLACE LOGAN BAR • Special feeder – syringe with rubber tubing into side of mouth, Breck feeder • Diet advance from clear to diet for age over 48 hours • Elbow restraints

26. Cleft Lip Repair • Nursing Diagnosis • Post-Op • Risk of injury & Infection • Pain • Altered feeding patterns

27. Cleft Palate • Repaired surgically between 6 months to 2 years prior to talking • Parents will care for child at home until surgical repair • Altered dentition and speech dysfunction may also occur • Frequent episodes of otitis media • (due to opening into nasopharynx)

28. Cleft Palate

29. Cleft Palate Repair • Post-op: sutures in child’s mouth • Keep straws, pacifiers, spoons away from child’s mouth for 7-10 days post-op • Elbow restraints and mittens • Feeding – soft foods: baby food. Short nipples may be used • All feeding followed by rinsing mouth with water to clean suture line • No brushing teeth X 1-2 weeks

30. Cleft Palate Repair • Nursing Diagnoses • Pre-Op: • Parental Knowledge Deficit • Risk for Infection • High Risk for Altered Family Processes • Post-Op: • Altered Skin Integrity • Child: Pain

31. Success!!

32. Esophageal Atresia & Tracheoesophageal Fistula (TEF) • Esophageal atresia and TEF • a malformation that results from failure of the esophagus to develop as a continuous tube • Foregut fails to lengthen, separate and fuse into 2 parallel tubes (at 4-5 weeks gestation) • Associated with maternal polyhydramnios

33. FIGURE 30–4 In the most common type of esophageal atresia and tracheoesophageal fistula, the upper segment of the esophagus ends in a blind pouch connected to the trachea; the fistula connects the lower segment to the trachea. Jane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & Families © 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

34. EA and TEF • Signs/Sx: • Apparent in immediate newborn period • Respiratory Distress • Difficulty feeding • Excessive drooling • Choking, coughing • Cyanosis • Esophageal Atresia is a surgical emergency! • Tx: Surgical correction

35. EA and TEF • Diagnosis • Confirmed by attempting to pass an NG Tube into stomach • Usually a 5 or 8 French tube • Nursing Care • ID signs/symptoms of disease • Careful Physical Assessment

36. EA and TEF • Pre- and Post- Operative Care • Pre-Op: • NG tube to suction • Prevent aspiration complication • (increase HOB, NPO) • Establish IV access: IVFs & IV abx • Post-Op: • Care of G-Tube • Family teaching

37. FIGURE 30–5 Children with esophageal atresia and other gastrointestinal disorders often require a gastrostomy tube for feedings. Jane W. Ball and Ruth C. BindlerChild Health Nursing: Partnering with Children & Families © 2006 by Pearson Education, Inc.Upper Saddle River, New Jersey 07458All rights reserved.

38. Pyloric Stenosis • AKA Hypertrophic Pyloric Stenosis • Etiology unknown, but often affects first-born males • Affects males 2-5 X more than females, especially white males • Present at birth • Diagnosis by ultrasound • Stenosis occurs b/t stomach and duodenum

39. Pyloric Stenosis • Pathophysiology: • Obstruction of the pyloric sphincter by hypertrophy of the circular muscle of the pylorus • With the enlarged muscle, there is severe narrowing of the pyloric canal between the stomach and duodenum • With food, the muscle is irritated and becomes further edematous thus causing the opening to become narrower • Usually there is a slow progression of edema and narrowing of the opening into the duodenum

40. Pyloric Stenosis

41. Pyloric Stenosis • Clinical Manifestations: • Initially, regurgitation after meals • Within one week - projectile vomiting • Vomiting occurs shortly after meals • Vomiting is forceful and may spew 2-4 feet • Infant constantly hungry • Fails to gain weight or loses weight • Stools decrease in number • Dehydration results/ electrolyte imbalances

42. Pyloric Stenosis • Clinical Manifestations: • Upper abdomen distended • Olive-shaped mass palpable in RUQ • Left-to-right peristaltic waves noticeable on abdomen • Best time to palpate mass is when infant is relaxed during feeding • S/Sx of dehydration – sunken anterior fontanel, sunken eyes, decreased elasticity of skin (tenting) • Tx: • Surgery – Pyloromyotomy

43. Pyloric Stenosis • Nursing Care Pre- and Post-Op • Fluid and electrolyte management • IV • NG Tube • Analgesics • Prevent Infection • Support family • Teaching

44. Intussusception • Invagination (telescoping) of one portion of intestine into another • (like a sock). • Multifactoral causes • Commonly occurs in children b/t 3 months-6 years • 3x more likely in boys than girls • Common in children w/ CF, Celiac Disease and gastroenteritis

45. Intussusception • Mechanical Bowel Obstruction Occurs: • Walls of the segments of the intestine press against each other causing inflammation, edema and decreased blood flow. • As incarceration occurs, necrosis results with hemorrhage, perforation and peritonitis. • Classic Triad: • Severe episodic pain • “Currant jelly” stool • Transverse tubular abdominal mass

46. Intussusception

47. Intussusception

48. Intussusception • Clinical Manifestations: • Sudden onset of abdominal pain in a healthy child • Child screams and draws knees up to abdomen • Pain is intermittent, child is relaxed between pain intervals - paroxysmal • Vomiting occurs and increases over time • Stool changes from brown to blood-tinged and mucousy - “currant jelly” in 50% of cases

49. Intussusception • Clinical Manifestations: • Most patients (75%) will test + for occult blood in stools • Abdomen tender and distended • Sausage-shaped mass in RLQ (vertically-oriented) • As obstruction progresses, child becomes acutely ill with fever, and signs of peritonitis

50. Intussusception • Diagnosis: • Often based on history and physical examination alone • Barium Enema is definitive (in 75% of cases). It is therapeutic and curative in most cases with less than 24-hour duration. • Digital rectal exam reveals mucous, blood and sometimes the intussusception • Laboratory tests – CBCD, Lytes