Nursing Care of the Child with a Gastrointestinal Disorder

1. Nursing Care of the Child with a Gastrointestinal Disorder

2. Normal Gastrointestinal System

3. Disorders of Development

4. 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

5. Assessment • Unilateral, bilateral, midline

6. Treatment • Surgical repair between 3 and 6 months • Rule of “10” • Multidisciplinary team • Reconstruction begins in infancy and can continue through adulthood. • Homecare by the family prior to surgery

7. Pre-op Nursing Care • Remind parents that defect is operable- show photographs of corrected clefts Before After

8. Pre-op Nursing Care Two Main Goals: 1. Prevention of Aspiration 2. Maintain Nutrition

9. Post-Op • Prevent trauma to suture line • Logan’s bow to protect site • Do not allow to suck • Maintain upper arm restraints • Position supine • No hard objects in mouth • Reduce Pain • Prevent Infection • Cleanse suture lines as ordered – rinse with water after each feeding. • Call Doctor for any swelling or redness • Referral to appropriate team members

10. Esophageal Atresia

11. Malformation from failure of esophagus to develop as a continuous tube Upper Esophagus Trachea Lower Esophagus

12. Signs and Symptoms Excessive amounts of salivation / mucus, frothy bubbles Three “C’s”: Coughing, choking, and cyanosis when fed Food may be expelled through the nose immediately following the feeding Rattling respirations and frequent respiratory problems such as aspiration pneumonia Gastric distention, if fistula History of polyhydramnios during pregnancy can suggest a high gastrointestinal obstruction

13. Diagnosis and Management • Early diagnosis • Ultrasound • Radiopaque catheter inserted in the esophagus to illuminate defect on X-ray • Surgical repair • Thoracotomy and anastomosis

14. Pre-Op

15. Post-Op • Maintain airway • Maintain nutrition • Gastrostomy tube feedings • Prevent trauma • Monitor for potential complications • Monitor weight, growth and developmental achievements

16. Imperforate Anus Incomplete development or absence of anus in its normal position in perineum.

17. Assessment • Most commonly diagnosed upon Newborn Assessment • Symptoms • Absence of anorectal canal • Failure to pass meconium • Presence of anal membrane

18. Treatment Anal stenosis is treated with repeated anal dilation Surgery

19. Abdominal Wall Defects Omphalocele Gastroschisis

20. Omphalocele Herniation of abdominal contents through the umbilical cord. Contents are covered by a translucent sac.

21. Gastroschisis herniation of abdominal viscera outside the abdominal cavity through a defect in the abdominal wall to the side of the umbilicus. Not covered.

22. Diagnosis Provide an early diagnosis Alpha-fetaoprotein Ultrasound

23. Treatment and Nursing Care • Pre-operatively – provide protection of the contents/sac. • Cover with warm, sterile, saline-soaked dressings • Maintain temperature – esp. with gastroschisis • May choose to replace the gut to the abdomen gradually over several weeks. May place silo or silastic material over gut until it returns to the abdomen. • Surgery used to close defect.  

24. Post-op Care • Assess for ileus • Maintain parenteral feedings • Provide support to the parents.

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

26. Assessment: Infant • Regurgitation almost immediately after each feeding when the infant is laid down • Excessive crying, irritability • Failure to Thrive • Life Threatening Risk / Complications: • aspiration pneumonia • apnea

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

28. Diagnosis • Assess Ph of secretions in esophagus if <7.0 indicates presence of acid • Also diagnosed using Barium Swallow and visualization of esophageal abnormalities

29. Management & Nursing Care • Small frequent feedings of predigested formula or thicken the formula • Frequent burping • Positioning --prone position- flat prone or head elevated prone. Use reflux board to keep head elevated. • Avoid excessive handling after feedings. • Nissen Fundoplication Reflux board

30. Medications • H2 Histamine receptor antagonists – reduce gastric acidity • Zantac and Pepcid • Proton-pump inhibitors • Prevacid • Prilosec • Gastric emptying • Reglan • Antacids • Gaviscon

31. Diarrhea Infectious Gastroenteritis

32. Diarrhea/GastroenteritisSevere • A disturbance of the intestinal tract that alters motility and absorption and accelerates the excretion of intestinal contents. • Most infectious diarrheas in this country are caused by Rotovirus but can be C. Difficele

33. Clinical Manifestations • Increase in peristalsis • Large volume stools • Increase in frequency of stools • Nausea, vomiting, cramps • Increased heart & resp. rate, decreased tearing and fever

34. Diagnosis

35. Complications Dehydration Metabolic Acidosis

36. The newborn and infant have a high percentage of body weight comprised of water, especially extracellular fluid, which is lost from the body easily. Note the small stomach size which limits ability to rehydrate quickly.

37. Treatment & Nursing Care • Treat cause • Fluid and electrolyte balance • Weigh daily • Monitor I&O • Assess for dehydration • Isolate • Skin care

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

39. Management and Nursing Care: Pre-Op • NPO • IV • Comfort measures – semi-fowlers or R side lying • Antibiotics • Elimination • Patient education • **Narcotic pain medications are used minimally so as not mask the signs of appendicitis.

40. Appendicitis What is the most common symptom indicating that the appendix may have ruptured?

41. Management and Nursing Care: Post-Op • NPO • Antibiotics • Analgesia • Patient teaching

42. Pyloric Stenosis The pylorus muscle which is at the distal end of the stomach becomes thickened causing constriction of the pyloric canal between the stomach and the duodenum and obstruction of the gastric outlet of the stomach.

43. Pyloric Stenosis • Narrowing of the pyloric spincter • Delayed emptying of the stomach

44. Assessment

45. Treatment and Nursing Care Treatment: Surgery Pyloromyotomy • Post Operative Care: • I & O • Feeding • Feeding begins with clear liquids containing glucose and electrolytes. Regime example: 8 hours NPO, 10cc sterile hater feed X 2. Increase to 15cc X 2, progressing to ½ strength formula, then full strength formula. Observe and record the infant’s response to feeding. • Position with head elevated • Assess Surgical site to prevent infection • Patient teaching

46. 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

47. Intussuception Volvulus Both are forms of bowel obstruction

48. Intussuception • Most commonly seen in infants 3-12 months • Bowel “telescopes” within itself

49. Volvulus A twisting of the bowel that leads to a bowel obstruction.

50. Assessment • Pain • Vomiting • Stools – resemble currant jelly • Dehydration • Serious complications