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

Assessment Unilateral, bilateral, midline

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

Pre-op Nursing Care Remind parents that defect is operable- show photographs of corrected clefts BeforeAfter

Pre-op Nursing Care

Latham Device

Post-Op Prevent trauma to suture line  Protect site  Advance diet as tolerated  Maintain upper arm restraints  Position supine  No hard objects in mouth 7-10 days 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

Esophageal Atresia

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

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

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

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

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

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

Treatment Anal stenosis is treated with repeated anal dilation Surgery

Omphalocele Gastroschisis

Omphalocele 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 Provide an early diagnosis Ultrasound

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.

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

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

Assessment: Child Heartburn Abdominal pain Cough, recurrent pneumonia Dysphagia

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 --prone position- flat prone or head elevated prone. Use reflux board to keep head elevated. Avoid excessive handling after feedings. Nissen Fundoplication Reflux board

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

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 Rotovirus but can be C. Difficele

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

Diagnosis Stool Culture Stool for O&P Blood Gases

Complications Dehydration 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.

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

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

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.

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

Management and Nursing Care: 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 Stenosis Narrowing of the pyloric spincter Delayed emptying of the stomach

Assessment Projectile vomiting Constant hunger fussiness Visible peristaltic waves Hypertrophied pylorus Distended Abdomen

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 water 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 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

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

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

Assessment Pain Vomiting Stools – resemble currant jelly Dehydration Serious complications

Therapeutic Intervention Intussuception  Hydrostatic Reduction  Surgery Volvulus  Surgery

Hirschsprung's Disease

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

Assessment * Failure to pass meconium Ribbon Like stools * Vomiting Reluctance to feed * Abdominal distention Foul odor of breath

Diagnosis & Management Diagnosis History & Physical Barium enema (X-ray) Rectal biopsy- absence of ganglionic cells in bowel mucosa Management Surgical intervention  Colostomy  Resection  Colostomy takedown

Nursing 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 Inability to tolerate the sugar found in dairy products as a result of an absence or deficiency of lactase.

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 Complications: Hypocalcemia, osteomalacia, osteoporosis, depression.

Treatment and Nursing Care Wheat Rye Barley Oats Teach parents DIETARY REGULATIONS: Gluten Free Diet NO !