Gastrointestinal Disorders in Pediatric Patients Marlene Meador RN, MSN Fall 2006

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

photosphotosphotosphotos

Assessment Unilateral, bilateral, midline Unilateral, bilateral, midline

Treatment Surgical repair done ASAP Surgical repair done ASAP Rule of 10 > 10#, 10 weeks, 10 HGB Rule of 10 > 10#, 10 weeks, 10 HGB Multidisciplinary team Multidisciplinary team

Management Pre-op Maintain nutrition Maintain nutrition Prevent aspiration Prevent aspiration

Pre-op Teaching Remind parents that defect is operable- show photographs of corrected clefts Remind parents that defect is operable- show photographs of corrected clefts Introduce cup, spoon feeding devices (see page 1114 for feeding tips) Introduce cup, spoon feeding devices (see page 1114 for feeding tips) Explain restraints Explain restraints Explain Logan Bow Explain Logan Bow

Post-Op Prevent trauma to suture line Prevent trauma to suture line Facilitate breathing Facilitate breathing Maintain nutrition Maintain nutrition Cleanse suture lines as ordered Cleanse suture lines as ordered Referral to appropriate team members Referral to appropriate team members

Esophageal Atresia Failure of the esophagus to totally differentiate during uterine development.

Assessment Respiratory difficulties Respiratory difficulties Drooling Drooling Coughing, choking Coughing, choking Gastric distention Gastric distention Hx of ??? during pregnancy? Hx of ??? during pregnancy?

Management Early diagnosis Ultra sound Radiopaque catheter inserted in the esophagus to illuminate defect on X-ray Surgical repair- thoracotomy and anastomosis

Pre-Op Maintain airway Maintain airway Keep NPO- administer IV fluids Keep NPO- administer IV fluids Elevate HOB 30 degrees Elevate HOB 30 degrees Suction PRN Suction PRN Prophylactic antibiotics Prophylactic antibiotics

Post-Op Maintain airway Maintain airway Maintain nutrition Maintain nutrition Prevent trauma Prevent trauma

Gastroesophagial Reflux (GER) 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 Regurgitation almost immediately after each feeding when the infant is laid down Excessive crying, irritability Excessive crying, irritability FTH FTH Complications of aspiration pneumonia, apnea Complications of aspiration pneumonia, apnea

Assessment: Child Heartburn Heartburn Abdominal pain Abdominal pain Cough, recurrent pneumonia Cough, recurrent pneumonia Dysphagia Dysphagia

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

Management & Nursing Care Nutritional needs Nutritional needs Positioning Positioning Medications Medications CPR instruction for parents/caregivers CPR instruction for parents/caregivers Surgery Surgery

Diarrhea/Gastroenteritis Severe A disturbance of the intestinal tract that alters motility and absorption and accelerates the excretion of intestinal contents. 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 Most infectious diarrheas in this country are caused by Rotovirus

Critical Thinking Why is there an increase in incidence of diarrhea in lower socio-economic groups? Why is there an increase in incidence of diarrhea in lower socio-economic groups? Why is there and increase in young children? Why is there and increase in young children?

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

Complications Dehydration Dehydration Metabolic Acidosis Metabolic Acidosis

Diagnosis Stool culture Stool culture O&P O&P Diagnose Metabolic Acidosis Diagnose Metabolic Acidosis

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

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

Clinical Manifestations Abdominal pain Abdominal pain Silent abdomen Silent abdomen Anorexia and nausea Anorexia and nausea Diarrhea Diarrhea Elevated temperature Elevated temperature Sudden relief Sudden relief

Diagnosis History and Physical History and Physical Laboratory values Laboratory values X-ray or Ultrasound X-ray or Ultrasound

Management and Nursing Care: Pre-Op NPO NPO IV IV Comfort measures Comfort measures Antibiotics Antibiotics Thermal therapy Thermal therapy Elimination Elimination Patient education Patient education

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

Pyloric Stenosis Pyloric sphincter Pyloric sphincter Incidence Incidence Possible genetic predisposition Possible genetic predisposition

Assessment Vomiting Vomiting Constant hunger and fussiness Constant hunger and fussiness Distended upper abdomen Distended upper abdomen Hypertrophied pylorus Hypertrophied pylorus Visible peristaltic waves Visible peristaltic waves

Diagnosis History and Physical History and Physical Ultrasound Ultrasound Laboratory values Laboratory values

Management and Nursing Care Fred Ramstedt procedure- Pylorotomy via laproscopy

Pre-Op Hydration and electrolyte balance Hydration and electrolyte balance Weigh daily & I and O Weigh daily & I and O Support of parents Support of parents

Post- Op: I & O I & O Feeding Feeding Position Position Surgical site Surgical site Patient teaching Patient teaching

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? 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 Most commonly seen in infants 3-12 months Most commonly seen in infants 3-12 months Typically follows what type of illness? Typically follows what type of illness?

Assessment Pain Pain Vomiting Vomiting Stools Stools Dehydration Dehydration Serious complications Serious complications

Diagnosis X-ray X-ray Abdominal ultrasound Abdominal ultrasound

Therapeutic Intervention Hydrostatic reduction Hydrostatic reduction Surgery Surgery

Nursing Care: NPO- NG NPO- NG Assess Assess Monitor stools Monitor stools Re-introduce food Re-introduce food

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

Assessment Failure to pass meconium Failure to pass meconium Vomiting Vomiting Bowel assessment Bowel assessment Breath Breath Older child Older child

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

Management Surgical intervention Surgical intervention –Colostomy –Resection

Nursing Care: Pre-op Pre-op –Cleanse bowel –Patient/parent teaching Post-op Post-op –NPO –VS –Assessment –Patient/parent teaching

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

Gastroschisis Assessment- noted on ultrasound and obvious at birth Assessment- noted on ultrasound and obvious at birth Treatment- surgical repair in stages Treatment- surgical repair in stages Nursing care- support parents loss of “Perfect Child” Nursing care- support parents loss of “Perfect Child”

Omphalocele Assessment- ultrasound and at birth Assessment- ultrasound and at birth Treatment- surgical repair in stages Treatment- surgical repair in stages Nursing care- same as for Gastroschisis Nursing care- same as for Gastroschisis

Imperforate Anus Assessment- note failure to pass meconium, Ultrasound & CT Assessment- note failure to pass meconium, Ultrasound & CT Treatment- repeated dilation or surgical intervention dependent on extent Treatment- repeated dilation or surgical intervention dependent on extent Nursing Care- note skin dimples or stool in urine or vagina Nursing Care- note skin dimples or stool in urine or vagina

Umbilical Hernia Assessment- abdominal muscle of NB does not meet around umbilical ring Assessment- abdominal muscle of NB does not meet around umbilical ring Treatment- resolve by age 1 yr. Surgical if not resolved by 5 years or becomes strangulated or enlarges Treatment- resolve by age 1 yr. Surgical if not resolved by 5 years or becomes strangulated or enlarges Nursing care- Binding not effective. Monitor for obstruction or strangulation Nursing care- Binding not effective. Monitor for obstruction or strangulation

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

Helminths/Parasitic Disorders Assessment- parasites identified in stool Assessment- parasites identified in stool Treatment- oral medications specific to helminth Treatment- oral medications specific to helminth Nursing care- prevention education, Nursing care- prevention education,

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

Please contact me with any questions or concerns regarding my lectures Marlene Meador RN, MSN