ELIMINATION: PEDIATRIC GI DYSFUNCTION Flashcards
FUNCTIONS OF GI SYSTEM
- ingestion, digestion, and absorption of fluids and nutrients
- metabolism of needed nutrients
- excretion of waste products
- any alteration in GI system deceases body’s ability to obtain nutrients , thus impairing growth
PEDIATRIC DIFERENCES :GI
- GI system immature at birth
- sucking is a primitive reflex
- infant stomach is small
- peristalsis is increased
- digestive enzymes deficient
- liver function immature
NURSING CARE PRIORITIES
- assessment
- establish feeding
- prevent infection
- monitor for serious infection
- protect suture line
- protect airway
CLEFT LIP/CLEFT PALATE (CL/CP): ETIOLOGY AND PATHOPHYSIOLOGY
- occur during 3rd and 12th week of gestation
- occur singly or in combination
- maxillary and nasal processes fail to fuse
- 10-15% cases have other defects (trisomy 13)
-multifactorial cause suspected
environment- maternal smoking and alcohol , phenytoin, genetics
folate- added to breads and cereals in 1998, decreased incidence of clefts
DIAGNOSIS: CLEFT PALATE
- cleft palate without cleft lip may not be detected at birth
- slide a gloved finger directly across the newborn palate
DIAGNOSIS : CLEFT LIP
- detected at birth , or fetal U/S by 13-26 weeks
- size varies a small notch to a complete cleft
- may be unilateral or bilateral
PROBLEMS WITH CLEFT LIP AND PALATE
- recurring OM,TM scarring , hearing loss
- speech impairment /delay
- improper tooth alignment
- long term problems, social adjustment , threat to slef image
EBP: CL/CP AND RISK FOR DENTAL CARIES
- children with cl/cp had higher risk of dental caries
- higher risk factors: poor oral hygiene and higher levels of salivary lactobacilli
- higher risk children had more caries
THERAPEUTIC MANAGMENT
- collaboration of specialists: plastic surgery, ENT, speech therapist, and dentist
- closure of clefts prevention of complications, facilitation of normal growth and development of the child
SURGICAL CORRECTION : CLEFT LIP
- cheiloplasty -surgery
- usually repaired by 3-6 months
- lip sutured together
- protect suture line from tension/trauma
- elbow restraints
SURGICAL CORRECTION: CLEFT PALATE
palatoplasty: -surgery
- CP-repaired by 18 months
- protects tooth buds
- allows for development of normal speech
NURSING MANAGMENT :EMOTIONAL SUPPORT
- may generate negative responses in both nurses and parent
- have a positive regarding surgical correction
- before and after photographs of possible cosmetic improvements
NURSING MANAGMENT: PRE- OP FEEDING
-cleft lip/palate reduces ability to suck
-some cl babies may breast feed
mother’s breast soft, fill gap caused by cleft
Cp makes it difficult to create suction
- food enters nasal cavity through cleft
- bottle feed with expressed breast milk
- hold head in upright position
special feeders; long nipples with enlarged holes, gravity flow nipples with squeezable bottle
NURSING MANAGMENT : POST OP CARE
CLEFT LIP
- clear liquids- dropper or syringe
- formula/breast feeding resumed when tolerated
- aspirate oral/nasal prn
-maintain suture line elbows in soft restraints no prone position minimize crying-pain med prn incision care- antibiotic cream
CLEFT PALATE
- start with clear fluids from syringe or dropper
- advance to formula/breast milk by cup
- protect sutures -no pacifier
- no chewing- pureed diet ,no hard foods
- soft tip suction prn
- pain management
ESOPHAGEAL ATRESIA(EA) AND TRACHEOESOPHAGEAL FISTULA (TEF)
- rare congenital malformations- occur by 4th week of gestation cause unknown
- the foregut fails to lengthen , separate and fuse into two parallel tubes
- esophagus may end up in a build pouch or develop as a pouch connected to the trachea by a fistula
CLINICAL MANIFESTATIONS
- excessive salivation and drooling
- the three C’s of TEF- coughing, choking, cyanosis
- feeding- fluid comes out nose and mouth
- apnea, gasping with frothy sputum
- risk of aspiration and pneumonia
DIAGNOSIS
- established clinically : difficulty feeding, excessive drooling, choking , apnea, coughing, cyanosis
- confirmed by attempting to pass a NGT
- x-ray stomach - air filled pouch
- other tests done to R/O associated defects
abdominal ultrasound
Echo
TREATMENT
- tube inserted to suction the upper pouch
- IVF,IV antibiotics
- surgery- accomplished in stages
- stage 1- ligation of fistula, g tube
- stage 2- 2 ends of esophagus reconnected if possible
- may need repeated surgeries
NURSING MANAGEMENT ; PREOP CARE
- npo/ivf (offer pacifier)
- maintain patent airway -suction , HOB elevated
- continuous or LIS for blind pouch
- constant monitoring of vital signs and condition surgical emergency
NURSING MANAGEMENT - POST OP CARE
- gastric decompression - GT to drain
- GT care teaching
- administer IVF/antibiotics/watch electrolytes
- TPN until G-tube feeds or oral feeding tolerated
- parental support - encourage to hole infant , express emotions
PYLORIC STENOSIS
-hypertrophic obstruction of the circular muscle of the pyloric canal
- occurs in 1-3 per 1000 live births- may be familial
- male to female ratio 6:1
- seen more frequently in first born white males
PATHOPHYSIOLOGY
- pylorus sphincter narrows due to progressive hypertrophy of the circular pylorus muscle
- results in outlet obstruction
CLINICAL MANIFESTATIONS
- 2-6 weeks after birth
- initially infant appears well or regurgitates after feeding
- vomiting progresses to projectile
- vomiting is non- bilious, may be blood tinged
- infant- hungry , irritable, fail to gain weight, fewer and smaller stools
- dehydration, metabolic alkalosis and increased bilirubin
CLINICAL THERAPY -diagnosis
- physical examination- visible peristaltic wave across the abdomen moving from left to right
- olive size mass in left upper quadrant
- pyloric ultrasound
- upper GI series
CLINICAL THERAPY TREATMENT
- surgery pyloromyotomy
- release of muscle fibers allows the passage of food and fluid
- high success rate
NURSING MANAGEMENT
PRE OP
- npo
- ivf
- monitor electrolytes
- ngt
POST OP
- -pain management
- vital signs monitoring
- establish feeding
- involve parents
- discharge teaching
GASTROESPHAGEAL REFLUX (GER)
-return of gastric contents into the esophagus due to relaxation of the lower esophageal or cardiac sphincter
- 50% of FT infants have GER
- higher in premature infants
- males affected 3x more than females
- children with neuro impairments (CP) have increased GER
-peak age is 1-4 months of age ,ogten resolves spontaneously by age 12 months
GERD
- more serious than GER
- spit up any time, even between feedings
- cries and arches back during and after feeds
- eat often but still lose weight
- respiratory problems - cough, wheeze, choking , color changes during feeding
- may aspirate- pneumonia, apnea
- generalized irritability , poor weight gain, weight loss or delayed growth
DIAGNOSIS
- history of feeding , vomiting episodes, pain with feeding
- upper GI series- UGI - check for anatomic abnormalities
- ph probe monitoring
valid and reliable measure of reflux
determines number of reflux episodes
TREATMENT
- depends on severity
- mild- happy spitter
- modification of feeding habits - small frequent feeds , frequent burping
- thicken formula with rice cereal - 1 tsp RC/1oz formula (make nipple hole bigger)
- position - hold child upright after feeds for 20-30 min
- supine while sleeping due to risk of sids OOR
TREATMENT
pharmacological therapy for moderate to severe
-poor weight gain, irritable, no improvement with modification of feeding habits and position
H2 RECEPTOR antagonists
ACTION- decreased gastric acid production
- famotidine -Pepcid
- ranitidine - zantac
PROTON PUMP INHIBITORS
action- blocks acid production by inhibiting proton pumps, increases LEs tone , more effective than H2 receptor agonists
lansoprazole(prevacid)
omeprazole (Prilosec)
SEVERE GERD
- severe gerd with failure to thrive , aspiration
- surgical management -nissen fundoplication - involves a 360 wrap of the fundus of the stomach around the distal esophagus
- gastrostomy tube is inserted during surgery and left in place for 6 weeks or longer
NURSING MANAGEMENT
IN CHILDREN WITH GERD
- observe for respiratory distress , monitor vs
- provide adequate nutrition- small frequent feeds
- position - elevate HOB - prone position with caution (while awake only0
POST OP FUNDOPLICATION
-GT- maintain skin integrity, secure tube, provide pacifier
-educate parent about home care- feeding , position, medication, suctioning
HIRSCHSPRUNG DISEASE
-congenital aganglionic megacolon
decreased motility causes obstruction of the intestines
- incidence 1:5000, males more than females
- familial tendency
- can occur with down syndrome ,congenital heart disease, other syndromes
PATHOPHYSIOLOGY
-absence of ganglion cells in one segment of the colon causes lack of innervation in that segment
- usually rectosigmoid colon
- prevents peristalsis- leads to blockage , and stool builds up behind blockage
- results in constipation, abdominal distention, poor weight gain, poor growth
CLINICAL MANIFESTATIONS
Newborn
- lack of meconium stool
- bilious vomiting
- S/S enterocolitis
Older Child
-chronic constipation alternating with diarrhea, ribbon like stools, abdominal distention, poor weight gain, decreased growth
DIAGNOSIS
-barium enema,abdominal Xray- dilated bowel
- rectal examination - rectum small, no stool
-anal manometry
-rectal biopsy- absence of ganglionic cells
confirms diagnosis
TREATMENT CHILD WITH MILDER DEFECT
- dietary modification - high fiber diet
- stool softeners
- enemas to prevent impaction in children not toilet trained
TREATMENT -INFANCY
- surgical removal of the aganglionic bowel and pull through procedure
- temporary colostomy- closure 2-6 months later
- normal bowel function depends on the amount of bowel involved
- enterocolitis- serious complication
ENTEROCOLITIS
- inflammation of small intestine and colon
- results in ischemia and ulceration of bowel wall
- may occur before or after surgery
- greatest cause of morbidity and mortality in hirschsprungs
ENTEROCOITIS
- presents with abdominal pain, fever, foul smelling and or/bloody stools
- should be suspected if neonate has distended abdomen, feeding intolerance with bilious vomiting and delay of meconium
- if not recognized may progress to sepsis and perforation
- Tx, IVF, antibiotics, NGT, monitor electrolytes and vs
NURSING MANAGEMENT PREOPERATIVE
- dependent on condition
- assess; skin turgor,fontanels,urinary output,MMs
- monitor fluid and electrolyte balance
- maintain nutrition - TPN if NPO
- ensure patent NG tube if NPO
- monitor abdominal circumference
- encourage parent to hold and cuddle infant
NURSING MANAGEMNET POSTOPERATIVE
- po clear or breast milk in several hours
- observe for signs of enterocolitis
- monitor I/O
- avoid pressure on incision -diapering
- provide comfort , pain relief
- encourage parents to partake ininfant’s care
- discharged when tolerating full feeds
INTUSSUSCEPTION
- occurs when one portion of the intestine invaginates or telescopes into another
- one of the most frequent causes of intestinal obstruction in children
- more common in males
- peak age 3-9 months up to 3 yrs
- cause - unknown , viral infection , intestinal polyps, medications, rotasheild vaccine
PATHOPHYSIOLOGY
- most common site is the ileocecal valve
- telescoping of the intestines obstructs the passage of stools
- intestinal walls run together causing inflammation , edema and decreased blood flow
- leads to necrosis, perforation , hemorrhage, peritonitis
CLINICAL MANIFESTATIONS
- sudden onset of abdominal pain - draw legs to chest
- may vomit
- periods of calm between episodes of pain
- abdominal pain and distention
- palpable “sausage shaped mass” in upper right quadrant
- passage of “currant jelly stools “
DIAGNOSIS
- made on subjective findings, history
- abdominal X-ray
- abdominal ultrasound confirms diagnosis
TREATMENT
- may spontaneously reduce without treatment
- hydrostatic reduction by air, saline, or barium enema
- rare- surgery to reduce or to remove necrotic bowel
- NG tube to for gastric decompression
NURSING MANAGEMENT
- preoperative - maintain IVF, fluid and electrolyte balance, NGT for decompression , antibiotic therapy
- postoperative- monitor for infection, pain management , NG tube patency , assess VS, check for abdominal distention , bowel sounds
- discharge when tolerating feeds
- D/C teaching ; can reoccur after enema or surgery, must return for fever , pain , bloody stools
