3 GI Flashcards
Lower esophageal sphincter is what
Fully developed when
Lower esophageal sphincter is:
-relaxed at birth allowing mild occasional regurgitation (spitting up)
Fully developed at 1 month old
Fluid differences in children
-greater amount of what than adults
-lose more what
-require what
-what occurs faster
Proportionally greater amount of body water than adults:
-lose more water daily than adults do
Require larger fluid intake and excrete more fluids
Dehydration can occur faster because of these things
Fluid differences in children
BSA (body surface area)
Greater amount of skin surface (compared to wt)
Affects insensible fluid loss
(Immeasurable loss of water through skin)
Fluid differences in children
Kidneys
Kidneys cannot fully concentrate urine until child is 2y/o
Greater daily fluid need
Unable to conserve water and electrolytes or fully assist in acid-base balance
Fluid differences in children
Lungs
Insensible losses
Lungs:
-Water is lost thru lungs d/t higher resp rate
Insensible losses:
-Fever
-Increased basal mtabolic rate
-Larger BSA
Threats to fluid balance
Insensible losses
Stressors:
-disease/illness (vomiting/diarrhea/fever)
-exercise in hot weather
Medical tx:
-NPO
-IV fluids
-drainage
-diuretic
Metabolic acidosis
Causes
Ingestion of something act like acid:
-antifreeze, ASA
Body makes too much acid:
-ketoacidosis (diabetes)
-lactic acidosis (sepsis)
Decrease renal acid excretion
Loss of bicarbonate:
-diarrhea
Metabolic alkalosis
Causes
Excessive intake of bicarbonate :
-ingestion of baking soda, antiacids
-large blood transfusions
Excessive loss of acid:
-vomiting
-gastric suction
-diuretic
Peds GI assessment
Hx: freq of bowel/bladder emptying
Calorie counts
I/O
DW/growth patterns
Focus assessment
-assessment of other areas (cardia shows dehydration)
Peds GI assessment
Look
Listen
Feel
Measure
GI symptoms
Visual inspection: flat/round/distended
-s/s of dehydration
Bowel sounds
Palpate: (soft, firm, rigid, tender, guarding)
Abdominal circumference
Gi s/s: N/V/D
What landmark do we use to measure abd circumference
Umbilicus
Acute GI disorders
Dehydrations (vomiting/diarrhea)
Pyloric stenosis
Intussusception
Appendicitis
Dehydration
-what is happening (5)
Rapid reduction of ECF
Loss of ICF
Electrolyte imbalance
Hypovolemic shock
Death
Types of dehydration
Isotonic
Hypotonic
Hypertonic
Isotonic dehydration
H2O and Na lost in equal parts
Blood sodium normal limits
Loss of ECF=reduced volume of circulating fluids
Hypovolemix shock can occur
Hypotonic dehydration
Electrolye loss > H2O loss
Fluid shifts from ECF to ICF
Blood sodium low
Shock likely
Hypertonic dehydration
H2O loss > electrolyte loss
Fluid shifts from ICF to ECF
Blood sodium elevated
Neuro changes:
-change in LOC, irritable, hyperreflexia, SZ
Infectious gastroenteritis
Most commonly what but can be what
What is it
Caused by
Can cause what
Mostly diarrhea but can be vomiting also
Alteration of GI tract resulting in increased motility and rapid emptying of intestinal content
Caused by: virus/bacteria/parasites
-Rotavirus, Ecoli, salmonella, C.diff, C.botulinum, shigellosis
Causes:
-loss of nutrients, electrolytes, water
Infectious gasteroenteritis: rotavirus
Most commonly cause of gasteroenteritis
S/s
What is it
What can lead to what
Tx
Fever
Vomiting
Watery diarrhea
-highly contagious
-diarrhea can lead to severe dehydration/death
TX: support tx, prevention
Dehydration assessment
Monitor early signs
Look at behavior:
-irritable, lethargic, confused
Skin color/oral membranes
Anterior fontanel (sunken)
VS (high HR, low BP)
DW
UOP (weigh wet diapers)
(want 1-2mL/kg/hr)
Dehydration goals
Avoid what
Correct fluid/electrolytes
If child is awake and alert try PO fluids (pedialyte)
If unable to take PO or continues to vomit = IV fluids
AVOID fruit juice
Rehydration:
mild or moderate dehydration
Severe
Mild/moderate:
-PO 1st if not tolerated give IV
Severe:
-isotonic fluid replacement (NS/LR)
-20mL/kg bolus
-continuous IV fluid after bolus
important to monitor for fluid overload
How to measure fluid maintenance for:
10kg and under
11-20kg
Over 20kg
10kg or under:
4mL/kg/hr
11-20kg:
40+ 2mL/kg(over10kg)/hr
20kg over:
60mL + 1mL/kg (over 20kg)/hr
Only up to 100ml
Dehydration:
S/s we see with excessive fluids
Tx
Rapid wt gain
Edema
I/O
Crackles
Tx:
Diuretics
Fluid restriction
Pyloric stenosis
What is it
Presents when
Usually who
Overgrowth (hypertrophy) of the pylorus muscle
-results in obstruction of the pyloric sphinctor—>
-food cant pass (causes vomiting)
Presents around 3-6wks old
Usually male
Pyloric stenosis s/s
Intitially then progression
Palpation
Intitially: infants regurgitate slightly after feed
-parents say baby is a good eater that occasionally vomits
Vomiting becomes more frequent—>
Then becomes projectile as obstruction progresses
Infant is hungry/irritable/fails to gain wt
Fewer/smaller stools
Palpation (movable, firm, olive shaped mass in RUQ)
Pyloric stenosis
Diagnostics
When can we do sx
Ultrasound (for confirmation)
Electrolyte (need to be fixed before sx)
Pyloric stenosis
Pre-op management
NPO
I/O
DW
Fluid/electrolytes correction
Pyloric stenosis
Post-op
Vitals
I/O, DW
Pain
Continue IVF
Nutrients
-small, freq meals of clear liquids (4-6hrs post-op)—>
—> advance to 1/2 strength formula—>
—>then full strenth
Assess incision for signs of infection
Intussusception
What is it
What it causes
Common in what age
Can occur how (tx)
Proximal segment of intestine telescopes into a more distal segment
Causes lymphatic and venous obstruction—> edema
Partial/total bowel obstruction
Younger than 6y/o
Can be episodes where it resolves on its own
—if not surgery required
Intususception
S/s
Hallmark:
-severe abdominal pain (episodic)
-blood/mucus in stool (currant jelly stools)
Normal:
-screaming, drawing knees to abdomen
-vomiting/diarrhea
-bilious emesis (obstruction in biliary)
Intussusception
Evaluation
Xray and ultrasound of abdomen
Barium enema (dye in rectum w/ imaging)
Intussusception
Nursing considerations
Stabilize prior to procedure
-fluids
-prophylactic abx (for sx)
-pain management
-possible NG for gastric decompression
-restoration of fluid and electrolyte balance
Appendicitis
What is it
Most common cause of?
If left untreated could what? Causing?
Inflammation of appendix
Most common cause of emergent abdominal surgery in children
If left untreated: could rupture
—leading to sepsis/death
Appendicitis
S/s
RLQ pain
Tenderness over mc burneys point
N/V
Fever
If abdominal pain suddenly relieved without intervention, suspect rupture and notify provider immediatly (need sx)
Appendicitis
Diagnostics
CT
Abd US
CBC (increase wbc)
CRP
Appendicitis
Surgical removal
How its done
Nonruptured:
-laparoscopic
Ruptured:
-open surgical procedure
Appendicitis
Pre-op and post-op for non ruptured appendix
Pre:
IVF
NG for decompression (ruptured)
Post:
Standard post-op (VS, IV fluid until tolerate PO)
Pain management
Monitor for infection
Assess bowel function
Appendicitis
Pre-op for ruptured appendic
IVF and electrolyte replacement
IV abx
NG for decompression
Appendicitis
Post-op for ruptured appendix
-standard post-op care
-pain management
-monitor surgical site for infection/bleeding
-IVF and ABX
-maintain NPO status
-NG to low continuous suction
-drain care
-monitor for signs of peritonitis (rigid board like abd,fever)
Chronic GI disorders
Constipation
GERD
Hirschsprung’s disease
Constipation
Management
Diet:
-high fiber (peas, lentils, black beans, bananas, raspberries, sweet potatoes
Fluids
Meds:
stool softeners, laxatives, probiotics
Gastroesophageal Reflux
What is it
Appears when and resolves when
Leads to
Complications
Reflux of gastric contents into the esophagus
—appears in 1st wk of life
—self-limtiing and resolves by one year old
GERD is tissue damage from the reflux
Complications:
-recurrent pneumonia, wt loss, FTT
Gastroesophageal Reflux
Risk Factors
Prematurity
CF, asthma
CP
delayed gastric emptying
Over-eating/feeding
Gastroesophageal Reflux
Infant s/s
Spitting up
Irritability (excessive crying, arching back, stiffening)
Apnea
FTT (not gaining wt)
Gastroesophageal Reflux
Older children s/s
Heartburn/Non cardiac chest pain/Abdominal pain
Chronic cough
Difficulty swallowing
Gastroesophageal Reflux
Nursing management
-Positioning (elevate HOB or keep infant upright at least 30min after feedings
-small more frequent feedings
-thickening formula with 1tsp=tbsp rice cereal per oz
-change diet or formula
Gastroesophargeal Reflux
Meds
Sx interventions
Med:
-H2 antagonis: ranitidine (Zantac), famotidine (Pepcid)
-PPIs: omeprazole (Prilosec), esomeprazole (Nexium), pantoprazole (protonix)
-motility- metoclopramide (Reglan)
Sx:
-nissen fundoplication
Hirschsprungs disease
What is it
Cogenital aganglions megacolon:
Absence of ganglion cells in colon—>
—> allows bowel to relax—>
—>results in decreased motility and mechanical obstruction
Hirschsprungs disease
Newborn and infant s/s
Episodes of vomiting bile
Episodes of vomiting/diarrhea/constipation
Abdomenal distention
Failure to pass meconium 24-48 hrs after birth
FTT
Hirschsprungs disease
Older children s/s
Same as infants:
-Abdomenal distention
-Constipation
New:
-undernourished appearance
-visible peristalsis
-palpable fecal mass
-foul-smelling, ribbon like stool
Hirschsprungs disease
Evaluation/diagnosis
Hx
Bowel patterns
Radiographic contrast studies (barium enema)
Rectal biopsy to confirm absence of ganglion cells
Hirschsprungs disease
-surgery rection may require what
Temporary colostomy
Hirschsprungs disease
Preop nursing management
IVF, electrolytes
Bowel prep with saline enemas (clean it out)
Oral abx (prophylactic for sx)
Monitor signs of enterocolitis (inflammation in gut)
Hirschsprungs disease
Post op nursing management
Standard postop care
Pain management
Assess bowel function
Ostomy care if applicable
Monitor signs of enterocolitis (inflammation in gut)
Once recovered encourage adequate:
-oral fluids, high fiber diet, laxatives as prescribed
Hirschsprungs disease
Monitoring enterocolitis (inflammation of gut)
Tx
Monitor vitals and abdominal girth
Abdominal distention
Fever
Signs of sepsis/shock
Tx:
Bowel rest (nothing in gut)
IVFs
Abx
Hirschsprungs disease
Treatment focused on
Resolving inflammation
Prevention bowel perforation
Maintain hydration (IVFs)
Initiating abx therapy
Colostomy, ileostomy if extensive bowel involvement
Structural defects of GI system
-Cleft lip/palate
-Esophageal atresia/TE fistula
-Omphalocele
-Gastroschisis
-Meckels diverticulum
-Anorectal malformations
-Umbilical hernia
Cleft lip vs cleft palate
Repaired when for each
Cleft lip:
-incomplete fusion of oral cavity
-repaired 2-3mo old
Cleft palate:
-incomplete fusion of the palates
-repaired 6-12mo old
Cleft lip and palate
Risk factors/complications
RF:
-family hx
-folate deficiency during pregnancy
-exposure to alcohol, tobacco, anti convulsants, steroids during pregnancy
Complications:
-otitis media/hearing loss
-altered dentition
-speech impairment
Cleft lip and palate
Initial nursing care
Feeding support
Promote parent bond
Monitor resp status while feeding (cyanosis)
Feeding for cleft lip
Encourage breast feeding
Use wide-based nipple for bottle feeding
Feeding for cleft palate (or both lip/palate)
Upright position
Specialized bottle w/ one way valve and a specially cut nipple (prevents milk from flooding them)
Burp frequently
Syringe feeding (if unable to take bottle/nipple)
Postop care
Standard: VS, airway managed, I/O, DW
Pain management
Monitor surgical site for infection
Position (supine/upright/side lying)
Elbow splint (no-no’s): prevent them from touching incision
Post op care
Cleft lip (cheiloplasty)
Resume what
How to clean
Avoid
-Protect incision
-Resume breastfeeding or prior feeding routine
-use water or diluted hydrogen peroxide to clean incision (apply abx ointment/petroleum jelly)
AVOID pacifier
Post op care
Cleft palate
-Positioning
-IVF (until able to eat/drink—>liquid then soft solid diet
NO straws, rigid utensils, hard tipped sippy cups, suction cath (any thing hard in mouth)
Esophageal atresia and tracheoesophageal (TE) fistula
What is it
EA: esophagus just ends and does not attach to stomach
TE fistula: trach and esophagus connect
Esophageal atresia and tracheoesophageal (TE) fistula
S/s
-Copious, frothy mucous in mouth/nose
-Drooling
-Abdominal distention (air into stomach)
-vomiting (atresia backs up)
If feeding may demonstrate 3 C’s (coughing, choking, cyanosis)
Esophageal atresia and tracheoesophageal (TE) fistula
Diagnosis
Prenatal US
Unable to insert NG (coiled on xray)
Lots of air in GI tract if fistual present
(abd distention)
Esophageal atresia and tracheoesophageal (TE) fistula
Tx
Preop care
Surgery (go to nicu until then)
-Maintain airway (o2/suction setup)
-Elevate HOB 30-45 degrees
-Orogastric tube insertion (low suction continuous to remove secretions from blind pouch)
-NPO=IVF
Tracheoesophageal (TE) fistula repair
Surgery stages
Stage 1:
-ligation of fistula w/ g-tube placement
-Gtube feeds/nutrition
Stage 2:
-ends of esophagus are attached to one another
(Leave Gtube to make sure sx is successful)
Omphalocele
What is it
Evisceration of the abdominal contents thru the umbilical cord
Covered by a translucent sack
Omphalocele
Nursing management
Tx
Covered content w/ sterile non-adherent dressing to maintain integrity and prevent infection
Prevent hypothermia = radiant warmer
Maintain perfusion and minimize fluid loss (need fluids)
Tx: surgery
Gastroschisis
What is it
Herniation of abdominal contents thru the abdominal wall
No membrane covering (unlike omphalocele)
Tx: same as omphalocele
(Wrap contents in saran wrap)
Meckels diverticulum
What is it
Complications
Incomplete fusion of the omphalomesenteric duct during embryonic development (connects fetus to yolk sac)
-diverticulum located at terminal ileum
Can contain gastric/pancreatic tissue casuing production of stomach acid (results in ulcers)
Complications:
GI hemorrhage, bowel obstruction
Meckels diverticulum
S/s
Labs/diagnostics
Rectal bleeding/bloody stools
Abdominal pain
Anemia
Test:
-CBC
-occult stool
-meckels scan (imaging)
Meckels diverticulum
Tx
Nursing management
Surgical removal
-IVF/blood products
-IV ABX
-monitor bowel function
Post sx: NPO, standard (ABCs/VS/pain management)
Anorectal malformations
What is it
Imperforated anus or atresia
-without obvious opening
-diagnosis made at birth or newborn assessment
Anorectal malformation
S/s
Absent anal opening
Abdominal distention
Absence of meconium (48hrs)
Anorectal tx
Sx:
NPO—>IVF
Orogastric tube (for gastric decompression)
Umbilical hernia
What is it
Failure of what
Tx
Protrusion of intestine at the umbilicus
-failure of umbilical ring to close completely
Tx:
90% close on their own by 4y/o
(You can try to see if you can push it back in)
