Nursing Care of the Child with a Gastrointestinal Disorder

Normal Gastrointestinal Normal Gastrointestinal SystemSystem

Disorders of

Development

Cleft Lip and Cleft PalateCleft 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

AssessmentAssessment

Unilateral, bilateral, midline

TreatmentTreatment

Surgical repair between 3 and 6 months Multidisciplinary team - involving many specialists

including plastic surgeons, nurses, ear, nose, and throat specialists, orthodontists, audiologists, and speech therapists.

Reconstruction begins in infancy and can continue through adulthood.

Homecare by the family prior to surgery

Pre-op Nursing CarePre-op Nursing Care

Pre-op Nursing CarePre-op Nursing Care May breast feed if has small cleft lip

If bottle fed, use compressible bottle, longer nipple, larger hole in nipple, any other special device for feeding this infant.

Feed slowly in upright position and bubble frequently

Keep bulb syringe and suction equipment at bedside

Position on side after feeding

Pre-Op Nursing CarePre-Op Nursing Care

What are problems that the nurse needs to be alert for during feedings?

Lack of proper seal around nipple to create necessary suction

Excessive air intake

Use of special feeding techniques Feeder with compressible sides Syringes with tubing

Pre-op Nursing CarePre-op Nursing Care

Remind parents that defect is operable- show photographs of corrected clefts

Before After

Therapeutic Management

Surgical Correction

A number of professionals are involved including surgeons, nurses, ear, nose, and throat specialists, audiologists, speech therapist, orthodontists, and

plastic surgeons.

Post-Op CarePost-Op Care 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- straws, pacifiers, spoons Do not take temperature orally

Reduce Pain Mild analgesics and sedatives Parents to provide, holding, rocking, and parental voices

Post-op CarePost-op Care Prevent Infection

Cleanse suture lines as ordered rinse with water after each feeding Use cotton swab, use rolling motion vertically down suture

line Apply anti-infective ointment as ordered Call Doctor for any swelling or redness, bleeding, drainage, fever

Make early Referrals to appropriate team members Assess for Complications

Otitis media, hearing loss, speech difficulties, growth, altered dentition.

Esophageal Atresia

Malformation from failure of esophagus to Malformation from failure of esophagus to develop as a continuous tubedevelop as a continuous tube

Upper Esophagus

Trachea

Lower Esophagus

An atresia is the absence or closure of a normal body tubular passage, such as the esophagus and it ends in a blind pouch.

A tracheoesophageal fistula is when the esophagus connects with the trachea.

Signs and SymptomsSigns and Symptoms

Excessive amounts of salivation / mucus, frothy bubbles in the mouth and sometimes nose

Three “C’s” - Coughing, choking, and cyanosis when fed, overflow may be aspirated

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

Diagnosis and ManagementDiagnosis and Management

Early diagnosis Ultra sound Radiopaque catheter inserted in the esophagus to

illuminate defect on X-ray

Surgical repair Thoracotomy and anastomosis

Pre-Op Nursing CarePre-Op Nursing Care

Post-Op Nursing CarePost-Op Nursing Care Maintain airway Maintain thermoregulation Maintain nutrition

Gastrostomy Tube feedings

Prevent trauma

Monitor for potential complications Constipation or diarrhea Blockage of esophagus Infection

Monitor weight , growth and developmental achievements

 

Imperforate Anus

Incomplete development or absence of anus in its normal

position in perineum.

AssessmentAssessment

Most commonly diagnosed upon Newborn Assessment

Symptoms Absence of anorectal canal Failure to pass meconium Presence of anal membrane

TreatmentTreatment

Anal stenosis is treated with repeated anal dilation

Surgery

Omphalocele

Gastroschisis

OmphaloceleOmphalocele

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

GastroschisisGastroschisis

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

DiagnosisDiagnosis

Alpha-fetaoprotein

Permit a early diagnosis Ultrasound

Pre-op Treatment and Nursing Pre-op Treatment and Nursing CareCare

Focus is on protection of the contents / sac. Cover with warm, sterile, saline-soaked dressings over the defect.

Maintain temperature – esp. with gastroschisis because it is not covered and lose of fluids

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. Maintain hydration – start IV (NPO) NG tube to decompress stomach

Oomphalocele RepairOomphalocele Repair

While the baby is deep asleep and pain-free (under general anesthesia) an incision is made to remove the sac membrane. The bowel is examined closely for signs of damage or

additional birth defects. Damaged or defective portions are removed

and the healthy edges

stitched together. A tube is inserted into the stomach

(gastrostomy tube) and out through the skin.

Gastroschisis RepairGastroschisis Repair

Surgical repair of abdominal wall defects

involves replacing the abdomen through

the abdominal wall defect, repairing the

defect if possible, or creating abdominal

organs back into the a sterile pouch to

protect the intestines while they are

gradually pushed back into the abdomen.

Post-op Nursing CarePost-op Nursing Care Maintaining fluid and electrolyte balance

TPN via central venous catheter to provide nutrition while bowel rests and heals

Progress to oral feedings once bowel motility occurs

Prevent Infection IV antibiotics

Assess for Complications Ileus

Educate parents

ComplicationsComplications

IleusIleus

Gastroesophageal Reflux Disease(GERD)

The cardiac sphincter and lower portion of the esophagus are weak, allowing

regurgitation of gastric contents back into the esophagus.

Assessment: InfantAssessment: 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

Assessment: ChildAssessment: Child

Heartburn

Abdominal pain

Cough, recurrent pneumonia

Dysphagia

Signs and SymptomsSigns and Symptoms

DiagnosisDiagnosis

Assess Ph of secretions in esophagus if <7.0 indicates presence of acid

Also diagnosed using Barium Swallow and visualization of esophageal abnormalities

Management & Nursing CareManagement & Nursing Care

Small frequent feedings of predigested formula or thicken the formula

Frequent burping Positioning –keep upright for 30 minutes after feedings. Use

reflux board to keep head elevated.

Avoid excessive handling after feedings.

Reflux board

MedicationsMedications H2 Histamine receptor antagonists – reduce gastric acidity

Zantac and Pepcid Proton-pump inhibitors

Prevacid Prilosec

Gastric emptying Reglan

Antacids Gaviscon

**be sure to study nursing implications and side effects

Management and Nursing CareManagement and Nursing Care

If history of apnea, bradycardia, r/t GER—needs continuous cardiac and apnea monitoring. Arrange for CPR teaching for caregivers

If infant does not responds to non-invasive therapy, then a Nissen fundoplication may be done to increase the competence of the cardiac sphincter.

In a fundoplication, the upper part of the stomach is wrapped around the lower end of the esophagus and stitched in place, reinforcing the closing

function of the cardiac sphincter.

Post-op Nursing CarePost-op Nursing Care

Assess for pain, abdominal distention, and return of bowel sounds.

Teach parents about gastrostomy tube feedings

Diarrhea

Infectious Gastroenteritis

Diarrhea/GastroenteritisDiarrhea/GastroenteritisSevereSevere

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:Giardia – most commonly seen in daycare centers Rotovirus – seen in infants in young children

Clinical ManifestationsClinical Manifestations

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

Complications: Dehydration Metabolic acidosis

DiagnosisDiagnosis

ComplicatioComplicationsns

DehydrationDehydration

Metabolic AcidosisMetabolic Acidosis

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.

Dehydration

Infant Depressed fontanels Sunken eye orbits Fussy, Irritable Thirsty Fewer wet diapers

Child Decreased tear production Skin non-elastic Decreased urinary output Thirsty Restless

Treatment & Nursing CareTreatment & Nursing Care

Treat cause Fluid and electrolyte balance Weigh daily Monitor I&O Assess for dehydration Isolate Skin care

Oral RehydrationOral Rehydration

Avoid fluids that are high in sugar – soft drinks, jello, fruit drinks, tea

Appendicitis

Inflammation of the lumen of the appendix which becomes quickly obstructed causing

edema, necrosis and pain.

Clinical ManifestationsClinical Manifestations

Abdominal cramps and pain Fever

Guarding Abdominal rigidity Rebound Tenderness Vomiting

Elevated WBC - >15,000

Management and Nursing Management and Nursing Care: Pre-OpCare: Pre-Op

NPO IV Comfort measures – semi-fowlers or R side lying Antibiotics Thermal therapy – ice, not heating pads Elimination Patient education

**Narcotic pain medications are used minimally so as not mask the signs of appendicitis.

AppendicitisAppendicitis

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

Management and Nursing Management and Nursing Care: Post-OpCare: Post-Op

NPO Antibiotics Analgesia Patient teaching

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.

Pyloric StenosisPyloric Stenosis

Narrowing of the pyloric spincter

Delayed emptying of the stomach

AssessmentAssessment

Treatment and Nursing CareTreatment 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

Critical ThinkingCritical 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

Intussuception

Volvulus

Both are forms of bowel obstruction

IntussuceptionIntussuception

Most commonly seen in infants 3-12 months Bowel “telescopes”

within itself

VolvulusVolvulus

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

 

Assessment

Intussusception Pain Vomiting Stools – resemble currant

jelly, bloody mucus Sausage shape

abdominal mass Dehydration Serious complications

Shock and sepsis

Volvus Pain Bilious vomiting Abdominal distention Tachycardia

Therapeutic Intervention Therapeutic Intervention

IntussuceptionHydrostatic ReductionSurgery

VolvulusSurgery

Nursing CareNursing Care Following Hydrostatic reduction

Clear liquids and diet is advanced gradually Observe for passage of barium and eventually passage of stool

If reduction is not successful Surgery Post-op Care

Stabilize the child NPO and start IV fluids NG tube to decompress the bowel Pain medications

Provide information to the parents

Hirschsprung's Disease

Hirschsprung’s DiseaseHirschsprung’s Disease

Congenital disorder of nerve cells in lower colon

AssessmentAssessment

DiagnosisDiagnosis

History & Physical

Barium enema (X-ray)

Rectal biopsy- absence of ganglionic cells in bowel mucosa

Management Management

Surgical intervention ColostomyResection

Nursing CareNursing Care Pre-op

Cleanse bowel Patient/parent teaching

Post-op NPO Vital Signs – never take a rectal temperature Assessment Patient/parent teaching

Colostomy care Skin care Nutrition

Lactose intolerance

the inability to metabolize lactose, because of a lack of the required enzyme lactase in

the digestive system.

Lactose IntoleranceLactose Intolerance

Manifestations Diarrhea that is frothy, but not fatty Abdominal distention Cramping Abdominal pain Excessive flatus

Lactose IntoleranceLactose Intolerance

Removal of lactose from the Diet Eliminate – milk, formulas that contain dairy products,

ice cream, yogurt, hard cheeses Breastfeeding moms – eliminate lactose from their diet

Medications Lactase preparations – Lactaid, Dairy Ease, Lac-Dose

Obtain calcium from other sources

Celiac Disease

inability to digest gliadin which is a

by-product of gluten breakdown.

Signs and Symptoms Signs and Symptoms

The child with celiac disease commonly demonstrates

failure to grow and wasting of extremities. The abdomen can appear large due to intestinal distension and malnutrition

Complications: Hypocalcemia, osteomalacia, osteoporosis, depression.  

Treatment and Nursing CareTreatment and Nursing CareTeach parents DIETARY REGULATIONS:

Gluten Free Diet

NO !