Nursing Care of the Child with a Gastrointestinal Disorder

Normal Gastrointestinal System

Disorders of Development

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 The tissue that forms the lip ordinarily fuses by 5-6 weeks gestation, and the palate closes between 7-9 weeks gestation.

Assessment Unilateral, bilateral, midline Can be a cleft lip with no problems with the palate or it can be a combination of Lip and palate abnormalities.

Treatment 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

1. Prevention of Aspiration Pre-op Nursing Care Two Main Goals: 1. Prevention of Aspiration 2. Maintain Nutrition 1. What are the two main pre-operative goals for the child with cleft lip and palate? Prevent Aspiration: Assess respiratory status Position on side after feedings Maintain nutrition Feed slowly using adaptive equipment Burp frequently Keep suction equipment at bedside Nutrition: Assess intake and output Weigh daily Facilitate breastfeeding is desired Hold in upright position

Pre-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 2. What nursing interventions does the nurse utilize to achieve these goals? Home care: breastfeeding may be possible if child has a small cleft; compressible bottle will prevent a child from having to suck, longer nipple may allow the milk to be swallowed without entering the nose. Keep child in an upright position during feedings; burp frequently

Pre-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 3. Explain why the nurse would include frequent burping in teaching the parents/caregivers of this infant. Frequent bubbling decreases amount of air in stomach because increase air intake is is a problem. If the air is not removed, causes distention and colic symptoms, increase passing of flatus.

Pre-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 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 4. What are measures to prevent pain, trauma and infection to the suture line post-operatively?

Post-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 develop as a continuous tube Upper Esophagus Trachea Lower Esophagus 5. What is an atresia? Compare esophageal atresia and tracheoesophageal fistula. 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 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 6. What assessment findings indicate esophageal atresia in a newborn? What are the three “C’s” 7. What is the relationship of esophageal atresia to polyhydramnios?

Diagnosis 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 Care Maintain airway Keep NPO- administer IV fluids jlkjfj Keep NPO- administer IV fluids Place in warmer, give humidified O2 Elevate HOB 30 degrees, suction PRN Give Prophylactic antibiotics 8. What is the priority nursing goal pre-operatively? Maintain airway

Post-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   9. What home care instructions would be included in teaching for the infant with a gastrostomy tube. 10. What are potential post-operative complications?

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

Assessment Most commonly diagnosed upon Newborn Assessment Symptoms Absence of anorectal canal Failure to pass meconium Presence of anal membrane 11. When is this disorder most commonly diagnosed? What are symptoms?  

Treatment Anal stenosis is treated with repeated anal dilation Surgery 12. What is the treatment?

Omphalocele Gastroschisis Abdominal Wall Defects Omphalocele Gastroschisis

Omphalocele 13. What is the difference in these two abdominal wall defects - omphalocele and gastroschisis?   Herniation of abdominal contents through the umbilical cord. Contents are covered by a translucent sac.

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

Diagnosis Alpha-fetaoprotein Ultrasound Permit a early diagnosis 14. What prenatal testing is associated with omphalocele and gastroschisis?

Pre-op Treatment and Nursing Care 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 15. Is fluid loss / electrolyte stability and temperature regulation more severe in gastroschisis or omphalocele? 16. What is the treatment for these abdominal wall defects? What is important to include in parent teaching? Immediately after delivery, the exposed organs are covered with warm, moist, sterile dressings. A tube is inserted into the stomach (nasogastric tube, also called NG tube) to keep the stomach empty to prevent choking on or breathing in (aspiration) stomach contents into the lungs. The surgery is done as soon as the infant is stable.

Oomphalocele 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. The infant is cared for post-operatively in a neonatal intensive care unit. The baby is placed in an isolette (incubator) to keep warm and prevent infection. Oxygen is given and mechanical ventilation is often required. Intravenous fluids, antibiotics, and pain medications will be given. A nasogastric tube will be in place to keep the stomach emptied of gastric secretions. Feedings are started by nasogastric tube as soon as bowel function resumes. Feedings are started very slowly and often infants are reluctant to feed. These babies may need feeding therapy and lots of encouragement.

Gastroschisis 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 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

Complications Thermoregulation Loss of Fluids Ileus

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: 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 17. Describe the clinical manifestations of GER. 18. What is the life threatening risk associated with GER?

Assessment: Child Heartburn Abdominal pain Cough, recurrent pneumonia Dysphagia

Signs and Symptoms

Acute Gastric Bleeding Major Complication is Acute Gastric Bleeding A complication of longstanding GER is GI bleeding. Stomach lavage to remove blood.

Diagnosis 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 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. 19. What is the recommended position for a newborn/infant with GER? upright Reflux board

Medications 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 20. What are the medications / classifications / actions utilized in the treatment of GER?

Management 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 Care Assess for pain, abdominal distention, and return of bowel sounds. Teach parents about gastrostomy tube feedings 21. What interventions should the nurse include during post-operative care and when teaching the parents /caregivers about home-care for the infant with GER?  

Diarrhea Infectious Gastroenteritis

Diarrhea/Gastroenteritis Severe 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 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 22. What are symptoms of dehydration that occur in the infant that are different from the older child or adult?

Diagnosis Stool Culture Stool for O&P Blood Gases Most of time stool cultures are not used unless it is severe diarrhea. arterial blood gases reveal decreased pH (under 7.35), a low HCO3 value (near or below 22 mEq/L)

Complications Dehydration Metabolic Acidosis Dehydration: Mucous membranes become dried and cracked Skin dries and loses its normal elasticity, poor skin turgor Fontanels are depressed and eyes appear sunken Urine decreases greatly in amount and becomes dark in color (concentrated) Metabolic Acidosis: Increased heart rate, decreased BP, increased Respirations, arrhythmias Cold, clammy skin 3. Changes in level of consciousness – stupor, lethargy Metabolic 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. 22. What are symptoms of dehydration that occur in the infant that are different from the older child or adult? 23. Why is dehydration more severe in an infant? 24 Severe diarrhea causes what acid-base problem? Explain the pathophysiology. What assessment findings would the nurse report if suspecting metabolic acidosis?

Dehydration Infant Child Depressed fontanels Sunken eye orbits Fussy, Irritable Thirsty Fewer wet diapers Decreased tear production Skin non-elastic Decreased urinary output Thirsty Restless

Treatment & Nursing Care Treat cause Fluid and electrolyte balance Weigh daily Monitor I&O Assess for dehydration Isolate Skin care 25. What are the priority nursing interventions (including assessment) for a client with diarrhea and dehydration?

Oral Rehydration What is oral re-hydration therapy? What fluids should be avoided and why?   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 Manifestations Abdominal cramps and pain Fever Guarding Abdominal rigidity Rebound Tenderness Vomiting Elevated WBC - >15,000 26. What are classic symptoms of appendicitis? 27. What lab work confirms the diagnosis of appendicitis?

Management and Nursing Care: 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. 28. Why would the nurse question the use of analgesics to decrease pain pre-operatively?   Thermal NEVER apply heat…WHY??? May use cold pack to decrease discomfort NO enemas or laxatives- cathartics cause bowel movements, that can increase the risk of rupture through muscle straining. Teach patient and family to notify nurse immediately if sudden relief of pain, and if sudden increase in pain. Teach the use of IV’s post op analgesia, and possibility of NG use.

Appendicitis What is the most common symptom indicating that the appendix may have ruptured? What symptom would suggest the appendix has perforated / ruptured?   Sudden cessation of pain

Management and Nursing Care: Post-Op NPO Antibiotics Analgesia Patient teaching These are becoming more and more, outpatient procedures

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. Explain what stenosis means. (Stenosis is narrowing or constriction)

Pyloric Stenosis Narrowing of the pyloric spincter Delayed emptying of the stomach 29. What is a stenosis?

Assessment Projectile vomiting Constant hunger fussiness Visible peristaltic waves Hypertrophied pylorus Distended Abdomen 29. What is the classic symptoms related to pyloric stenosis? Why is there no pain?   Diagnosis made: History and Physical; Ultrasound; Laboratory values

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 30. Explain the feeding regime following surgical correction of pyloric stenosis. What is the Evidence-Based Nursing related to these feedings?  

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 Weigh the infant – anytime an infant has vomiting and diarrhea, it is important to weigh the infant on admission. This is one of the main ways to assess fluid volume.

Intussuception Volvulus 31. What occurs to the bowel in these anomalies?   Both are forms of bowel obstruction

Intussuception Most commonly seen in infants 3-12 months Bowel “telescopes” within itself 32. Describe the manifestations of each. Telescoping causes obstruction and mesenteric vessels become trapped between the walls of the two layers and ischemia occurs Cause actually unknown, but may follow a viral infection

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

Assessment Intussusception Volvus Pain Vomiting Stools – resemble currant jelly, bloody mucus Sausage shape abdominal mass Dehydration Serious complications Shock and sepsis Pain Bilious vomiting Abdominal distention Tachycardia Describe clinical manifestations of each. Diagnosis is made by xray or abdominal ultrasound

Therapeutic Intervention Intussuception Hydrostatic Reduction Surgery Volvulus How is hydrostatic reduction therapeutic in the treatment of intussusceptions? Barium or air enema until free flow of barium into the terminal ileum is evident. This can be done in approximately 80% of all cases If unsuccessful, continue to monitor for return of normal bowel function because spontaneous resolution could occur, eliminating the need for surgery IV fluids, NG suction, and frequent vial signs

Nursing 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 What are the nurses responsibilities, interventions and assessment findings related to intussusception and volvulus? a. NPO & decompression of the bowel b. Focused assessment c. Passage of stool and barium d. Introduction of p.o. fluids and solids.

Hirschsprung's Disease

Hirschsprung’s Disease Congenital disorder of nerve cells in lower colon 35. What causes the bowel obstructed in Hirshsprung’s? Also known as megacolon. It is the result of an absence of ganglion cells in the rectum and, to varying degrees, upward in the colon. This accounts for 20-25% of all neonatal GI obstructions.

Assessment * Failure to pass meconium Ribbon Like stools Vomiting Reluctance to feed Abdominal distention Foul odor of breath 35. What symptom found during newborn assessment could indicate Hirshsprung’s disease? Failure to pass meconium in first 24-48 hours in the newborn. Vomiting and reluctance to feed, Abdominal distention; Signs of intestinal obstruction; Foul odor of breath and stool Older child – constipation, offensive and ribbon-like stools, history of regular laxative use, palpable fecal mass  

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

Surgical intervention Colostomy Resection Management Surgical intervention Colostomy Resection If diagnosis is made early enough before the bowel becomes severely dilated a one-stage pull-through procedure may be used that eliminates the necessity of a temporary colostomy. If the child is acutely ill on presentation, enterocolitis must be suspected. This is a life-threatening complication and, if it is suspected, must be reported immendiately!

Nursing Care Pre-op Cleanse bowel Patient/parent teaching Post-op NPO Vital Signs – never take a rectal temperature Assessment Colostomy care Skin care Nutrition 36. What nursing interventions and teaching is included in post-operative care, including care of a colostomy? Why would the nurse question an order for rectal temperature or suppository for a child with Hirshsprung’s disease?  

Lactose intolerance the inability to metabolize lactose, because of a lack of the required enzyme lactase in the digestive system.

Lactose Intolerance Manifestations Diarrhea that is frothy, but not fatty Abdominal distention Cramping Abdominal pain Excessive flatus What are the manifestations of lactose intolerance?  

Lactose 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 How is this managed? What teaching is important?

inability to digest gliadin which is a by-product of gluten breakdown. Celiac Disease Explain the etiology related to celiac disease. inability to digest gliadin which is a by-product of gluten breakdown.

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 When do symptoms of celiac disease usually first appear? What are the signs and symptoms of celiac disease? Diarrhea and failure to thrive are the most common. They may also exhibit abdominal distention, vomiting, anemia, irritability, anorexia, muscle wasting, edema.   Complications: Hypocalcemia, osteomalacia, osteoporosis, depression.  

Treatment and Nursing Care Teach parents DIETARY REGULATIONS: NO ! Wheat Rye Barley Oats Gluten Free Diet Discuss the dietary teaching associated with treatment of celiac disease.