Nursing Care of the Child with Gastrointestinal Disorders Ann Hearn RNC, MSN Spring 2009

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

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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

Pre-op Goals Prevent aspiration / Maintain nutrition Prevent aspiration / Maintain nutrition Provide emotional support to family Provide emotional support to family

Prevent Aspiration / Maintain Nutrition Breast feed – small cleft lip Breast feed – small cleft lip Bottle feed – special feeding devises Bottle feed – special feeding devises –Special nipples –Enlarge cross cut hole Bubble frequently Bubble frequently Hold upright Hold upright ESSR ESSR

Provide Emotional Support Assist with accepting of defect Assist with accepting of defect Teach proper feeding Teach proper feeding Point out positive attributes Point out positive attributes Encourage participation in care Encourage participation in care Explain surgical procedure Explain surgical procedure

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 Introduce cup, spoon feeding devices Explain elbow restraints Explain elbow restraints Explain Logan Bow Explain Logan Bow

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

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

Assessment Findings Respiratory difficulties Respiratory difficulties Drooling Drooling Coughing, choking, cyanosis Coughing, choking, cyanosis Gastric distention - if fistula present Gastric distention - if fistula present Hx of ??? during pregnancy? Hx of ??? during pregnancy? –Polyhydramnios  gastrointestinal obstruction  fetus unable to swallow

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 Priority Maintain airway Maintain airway Prevent aspiration pneumonia Prevent aspiration pneumonia Keep NPO- administer IV fluids Keep NPO- administer IV fluids –Elevate HOB 30 degrees –Suction PRN –Prophylactic antibiotics

Post-Op Maintain nutrition Maintain nutrition –TPN –Gastrostomy Maintain airway Maintain airway –Prevent aspiration Monitor weigh, growth and development achievements Monitor weigh, growth and development achievements Complications Complications –GERS –Stricture formation

Teaching Plan: Gastrostomy Tube Equipment Equipment Procedure Procedure Psychosocial needs Psychosocial needs Medication administration Medication administration Stoma care Stoma care Problem solving Problem solving

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

Assessment findings: 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 Failure to thrive (FTH) Failure to thrive (FTH) Complications: Complications: – aspiration pneumonia – apnea

Assessment findings: 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 Barium Swallow and visualization of esophageal abnormalities Barium Swallow and visualization of esophageal abnormalities

Management & Nursing Care Nutritional needs Nutritional needs –Small frequent feedings –Frequent burping Positioning Positioning – Prone flat or head elevated after feedings (not for sleep) Medications Medications CPR instruction for parents/caregivers CPR instruction for parents/caregivers Surgery: Nissen fundoplication Surgery: Nissen fundoplication

Post Op Nursing Care Feedings Feedings Bubbling Bubbling Positioning Positioning Airway Airway Medications Medications

Medications H2 Histamine receptor antagonists – reduce gastric acidity H2 Histamine receptor antagonists – reduce gastric acidity –Zantac and Pepcid Proton-pump inhibitors Proton-pump inhibitors –Prevacid –Prilosec Gastric emptying Gastric emptying –Reglan Antacids Antacids –Gaviscon **be sure to study nursing implications and side effects

Pyloric Stenosis Results when the circular area of the muscle surrounding the pylorus hypertrophies & obstructs gastric emptying. Results when the circular area of the muscle surrounding the pylorus hypertrophies & obstructs gastric emptying. –Incidence: 3 in 1000 births –Possible genetic predisposition

Pyloric Stenosis Narrowing of the pyloric spincter Narrowing of the pyloric spincter Delayed emptying of the stomach Delayed emptying of the stomach

Assessment Vomiting - projectile Vomiting - projectile Constant hunger and fussiness Constant hunger and fussiness Distended upper abdomen Distended upper abdomen Hypertrophied pylorus – olive shaped mass Hypertrophied pylorus – olive shaped mass Visible peristaltic waves Visible peristaltic waves

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

Management and Nursing Care Fred Ramstedt procedure- Pyloromyotomy via laproscopy

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

Management and Nursing Care: Post-Op NPO until bowel function NPO until bowel function –Progressive feeds: 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 Position with head elevated Assess surgical site for infection - Antibiotics Assess surgical site for infection - Antibiotics Analgesia Analgesia 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? a. Begin an intravenous infusion b. Measure abdominal circumference c. Orient family to unit d. Weigh infant

Gastroschisis Omphalocele Abdominal Wall Defects

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

Treatment and Nursing Care Pre-operatively – focus is on protection of the contents / sac. Cover with warm, sterile, saline-soaked dressings over the defect. Pre-operatively – focus is on protection of the contents / sac. Cover with warm, sterile, saline-soaked dressings over the defect. 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. 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. Surgery used to close defect.

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- Nursing care- – support parents loss of “Perfect Child” – assess for ileus –maintain parenteral feeding

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

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

Intussuception Invagination of a section of the intestine, into the distal bowel that causes bowel obstruction. Invagination of a section of the intestine, into the distal bowel that causes bowel obstruction. –Usually the terminal ileum telescopes into the ascending colon through the ileocecal valve. Inflamed bowel & bleeding Inflamed bowel & bleeding –Leading to necrosis & perforation

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

Intussuception: Clinical Manifestations Intermittent then constant pain Intermittent then constant pain Vomiting Vomiting Abdominal distention Abdominal distention Currant jelly-like stools Currant jelly-like stools Diarrhea Diarrhea Dehydration Dehydration Serious complications: Ischemia, perforation & shock

Volvulus Twisting of the bowel that leads to a bowel obstruction. Twisting of the bowel that leads to a bowel obstruction. Vomiting of fecal material Vomiting of fecal material Abdominal distention Abdominal distention Pain Pain

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

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 Laparoscopic Surgery Laparoscopic Surgery

Nursing Care: NPO- NG tube, IV NPO- NG tube, IV Assess – V/S, pain Assess – V/S, pain Monitor stools Monitor stools Re-introduce food Re-introduce food

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

Clinical Manifestations Abdominal pain – McBurney’s point Abdominal pain – McBurney’s point Silent Abdomen Silent Abdomen Anorexia & nausea Anorexia & nausea Diarrhea Diarrhea Elevated temperature Elevated temperature IF PERFORATED: IF PERFORATED: –Sudden pain relief –Fever –Dehydration

Diagnosis History and Physical History and Physical Ultrasound Ultrasound X-Ray X-Ray Laboratory values Laboratory values – increased WBC 15,000 – 20,000

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

Hirschsprung’s Disease Congenital disorder of absence of ganglia (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 –NPO –Patient/parent teaching Post-op Post-op –NPO –VS (no rectal temperatures) –Assessment –Patient/parent teaching

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

Dehydration Infant: Infant: –Depressed fontanels –Sunken eyes Little fluid volume reserve Little fluid volume reserve Hypovolemic Shock Hypovolemic Shock

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 Metabolic Acidosis: Metabolic Acidosis: –Increased heart & resp. rate, decreased B/P, arrhythmias –Cold, clammy skin –Changes in CNS – stupor, lethergy

Diagnosis Stool sample Stool sample – culture –O&P Blood gases Blood gases – Metabolic Acidosis

Priority Nursing Interventions Treat underlying cause Treat underlying cause Restore fluid & electrolyte balance Restore fluid & electrolyte balance Daily weights Daily weights I&O I&O Assess for dehydration Assess for dehydration Isolation protocol Isolation protocol Monitor electrolytes/metabolic acidosis Monitor electrolytes/metabolic acidosis Skin care Skin care

Oral Rehydration

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?

Celiac Disease Celiac disease results from the inability to digest gliadin which is a by-product of gluten breakdown. Celiac disease results from the inability to digest gliadin which is a by-product of gluten breakdown. – This results in the accumulation of the amino acid glutamine which is toxic to the mucosal cells in the intestines. Damage to the villi impairs the ability of the small intestines to absorb nutrients

Celiac Disease Assessment- Growth pattern, GI pattern Assessment- Growth pattern, GI pattern Failure to Thrive Failure to Thrive 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

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.

Diagnostic Findings Measurement of fat content Measurement of fat content Duodenal or Jejunal biopsy Duodenal or Jejunal biopsy Elevated IGA antibodies Elevated IGA antibodies

Treatment and Nursing Care WheatRyeBarley Teach parents DIETARY REGULATIONS: Gluten Free Diet NO !  Disease specific support groups

The End