Exam 3 Peds GI Flashcards
When is an infant’s GI tract mature?
Age 2
Why is the mouth an optimal point of infection entrance?
?
What prevents regurgitation of stomach contents into the esophagus?
Lower esophageal sphincter (LES)
When is the LES developed?
1 month
What is the stomach capacity for newborns?
10-20 mL
What is the stomach capacity for infants?
200 mL
What is the stomach capacity for a 16 year old?
1,500 mL
When do pancreatic enzymes reach adult levels?
2 years
Liver at birth
Large, easily palpated
If infants have small bowel loss what happens?
Chronic problems with absorption and diarrhea
Small intestines at birth
Not fully functionally mature, rapid growth spurts
Physical exam order
Inspect and observe
Auscultation
Percussion
Palpation
2 categories of food sensitivity
Allergy/hypersensitivity
Intolerance
Systemic effects of food sensitivity
Anaphylactic, growth failure
GI effects of food sensitivity
Abdominal pain, vomiting, cramping, diarrhea
Respiratory effects of food sensitivity
Cough, wheezing, rhinitis, infiltrates
Cutaneous effects of food sensitivity
Urticaria, rash, atopic dermatitis
What can help prevent food sensitivity?
Breastfeeding No solids for first 6 mo No whole milk until 12 mo No eggs until 24 mo No peanuts, nuts, fish, seafood for 36 mo
How do you identify possible reactions to food?
Add one new food at 5 day intervals
Cow’s Milk Allergy
Adverse systemic and local GI reaction to cow’s milk protein
When can cow’s milk allergy be seen?
Within the first 4 months of life
What are GI symptoms of cow’s milk allergy?
Diarrhea, committing, colic, abd pain
What are respiratory symptoms of cow’s milk allergy?
Rhinitis, wheezing, sneezing, eczema, excessive crying, pallor
How do you diagnose cow’s milk allergy?
Occult blood
Serum IgE levels
Allergy testing
Milk restriction followed by challenge test
Treatment of cow’s milk allergy
Elimination of cow’s milk based formula
Continue until one year old, then small amounts are reintroduced
Nursing care management for cow’s milk allergy
Prevent and reduce exposure of infants to cow’s milk protein (through exclusive breastfeeding for the first 4-6 months)
Help parents identify signs and symptoms
Teach parents when introduce solid foods to be aware of those that contain milk
Educate on re-introduction of milk products after one year
Happens much more quickly in infants and children than adults due to differences in A&P
Dehydration
Why must dehydration be recognized quickly?
To prevent hypovolemic shock
Occurs whenever the total output of fluid exceeds the total intake
Dehydration
Causes of dehydration
Vomiting/Diarrhea Decreased oral intake High fever DKA Burns, insensible losses Increased renal excretion
Fluid balance and losses compared with older children and adults
Infants have a greater need for water and have more alterations in fluid and electrolyte balance
Expanded extracellular compartment lasts how long?
Age 2
Expanded extracellular compartment
Constitutes more than half of their total body water, causes greater and more rapid water loss
Fluid losses are divided into what 3 types?
- Insensible
- Urinary
- Fecal
Insensible fluid losses
Fever increases fluid loss
Increased Body Surface Area (BSA) in infants and children increase fluid loss
Basal metabolic rate is higher than adults
Kidneys are immature and cannot concentrate urine
Nursing assessment for fluid loss
Mental status
Fontanel
Eyes
Oral mucosa
Skin turgor
Heart rate
Blood pressure
Extremities – capillary refill
Urine output – specific gravity
Table 41-1 – mild vs. moderate vs. severe
*Must accurately measure intake and output
Intake – anything that goes in the mouth/IV/tube feedings
Output – anything that comes out – urine, stool, emesis, sweat, drainage
Nursing care management for insensible fluid loss
Must restore fluid volume
Replace ongoing losses 1:1
Offer at frequent intervals and small amount
Do NOT manage by encouraging intake of clear liquids other than ORS or BRATT diet
IV fluids – used for severe dehydration or shock
Observe for s/s of dehydration
Need at least 1 cc/kg/hr of urine output
Probiotics may decrease the extent of diarrhea
Lactobacillus (Culturelle)
Constipation
Alteration in the frequency, consistency, or ease of passing stool
Passing hard, dry stools, often painful
Liquid stools around hard stools
Bowel habits vary between children
Meconium stools
Assessment signs and symptoms What are normal bowel habits?? Abdominal distention Inspect for any anal fissures Bowel sounds
KUB and stool studies
Nursing care management for constipation
Change dietary habits
Increase high-fiber foods and fluids
Eliminate constipating foods
Behavior modification
Positive reinforcement
Scheduled times to sit on toilet
Hirschprung’s Dz
Absence of ganglion cells in the bowel
Also called congenital aganglionic megacolon
Causes inadequate peristalsis in part of the intestine
Males affected 4x more than females
Associated with Down syndrome
Therapeutic management for Hirschsprung’s Dz
Surgical resection of aganglionic bowel to relieve obstruction and restore normal bowel motility
1st surgery to create ostomy
2nd surgery to “pull-through” the healed intestines to rectum and close ostomy
Nursing care management for Hirschsprung’s Dz
Provide Postoperative Care
Observe for complications of enterocolitis
Provide Ostomy Care Ensure proper function of stoma Daily ostomy care Skin care Diet: avoid foods that produce excess gas and constipation
Patient and Family education
Explain surgical procedure
Educate on stoma care
Medications
GERD
Passage of gastric contents into the esophagus
Occurs during episodes of transient relaxation of LES
Common during first year of life
Nursing assessment for GERD
Assess for signs and symptoms and risk factors
Ask parents what they observed
Physical exam
May appear malnourished
Assess for aspiration and breathing patterns
Diagnosis
Upper GI/EGD
pH probe – gold standard
Hemoccult stool
Therapeutic management for GERD
Modify feeding habits Appropriate positioning Elevate HOB during feeding and for 30 min - 1 hour after Smaller more frequent feeds Thicken feeds with rice cereal Avoid foods known to cause reflux Medications Histamine-2 blockers (Zantac, Pepcid) Proton Pump Inhibitors (Nexium) Prokinetics (Reglan)
Surgical intervention
Nissen fundoplication
Nursing care management for GERD
Promote safe feeding techniques
Monitor vomiting
Weight daily
Maintain patent airway
Risk for aspiration and ALTE
Post-operative care
Parent education Feeding Positioning Medications NG care/Apnea monitor
Hypertrophic Pyloric Stenosis
The circular muscle of the pylorus becomes hypertrophied creating a gastric outlet obstruction
Compensatory dilation, hypertrophy, and hyperperistalsis of stomach
Infant usually presents at 2-5 weeks old with a history of projectile nonbilious vomiting
Other symptoms include:
Hard, moveable “olive” mass is the RUQ, no pain
Hunger soon after vomiting
Wt loss, dehydration, and electrolyte disturbancesCircular muscle thickens severe narrowing of the pyloric canal (olive shaped mass)
obstruction vomiting dehydrated, lethargic, malnourished
Nursing care management for Hypertrophic Pyloric Stenosis
Requires surgical intervention (pyloromyotomy)
Preop care:
Assess laboratory values/physical exam for dehydration
Restore hydration and electrolyte balance
Monitor VS - dehydration
Strict intake and output - NPOPostop care:
May have vomiting, pain
feedings begun 4-6 hours post op (clears then formula)
Monitor tolerance of feedings
Incision site care
Strict intake and output
Provide emotional support for anxious family
Intussusception
Occurs when a proximal segment of bowel “telescopes” into a more distal segment
Pulls the mesentery with it
Most common at ileocecal valve
Can result in lymphatic and venous congestion and bowel wall edema
Leads to obstruction, infarction, and perforation
Venous engorgement leads to leaking of blood and mucous into intestinal lumen
Forms the classic “currant jelly” stools
Nursing assessment for intussusception
Look for common signs and symptoms Sudden onset of intermittent abd pain Child screaming and drawing knees to abdomen but comfortable in between episodes Distended, tender abdomen Vomiting/Diarrhea Currant-jelly stools or bloody
Palpate the abdomen for sausage-shaped mass in the upper-mid abdomen
Ultrasound, Pneumo/Saline/Barium enema
Surgical reduction
Nursing care management for intussusception
IV fluids/NPO
Monitor for adequate hydration and nutrition
May need abx and NG tube before intervention
Monitor for return of normal bowel function after enema or surgery
Passage of a normal brown stool usually indicates that the intussusception has reduced itself
Can d/c home once tolerating feedings
Reoccurs in 1 out of 10 patients
Cleft lip and cleft palate
Facial malformations that occur during embryonic development
Frequently occurs with other anomalies
Can occur individually or together and can be unilateral or bilaterally
Causes include Maternal smoking and alcohol consumption Prenatal infection Medications used during pregnancy- anticonvulsants Advanced maternal age
Involves the care of a multidisciplinary team
Cleft lip
Can involve only the lip or extend into the nostril
Can be diagnosed by prenatal ultrasound or at birth by classic appearance
Significant emotional reaction in parents
Repaired surgically at 2-3 months old
Z-plasty or Millard technique
Cleft palate
Can involve both the hard and soft palate
Not as obvious as cleft lip
Can be seen when mouth examined
Management directed at:
closure of cleft
prevention of complications
normal growth and development
Repaired surgically at 6- 12 months
Nursing care management for cleft lip/palate
Immediate problems related to feeding and parent reaction
Encourage infant-parent bonding, provide emotional support
Feeding can be difficult, must educate parents Infants have a reduced ability to suck Must feed in upright position Need to start feeding as soon as possible after birth Special cleft lip/palate nipple used Burp frequently Breastfeeding usually most effective Risk for aspiration Risk for failure to grow
Preop care for cleft lip/palate
Preoperative
Educate parents on what to expect
Place elbow restraints on infant
Cleft palate postop care
Allowed to lie on abdomen after surgery
May resume feeds after surgery
Usually through syringe or soft sipee cup
Sent home on soft diet
Avoid the use of tongue depressors, thermometers, pacifiers, spoons, or straws
Packing in place – will remove after 2 to 3 days
Watch for respiratory complications, risk for aspiration
Suction with extreme caution!
Elbow restraints in place to prevent injury to mouth and continued for 7-10 days
Pain medication as needed – want to avoid crying
Complications/Prognosis of cleft lip and palate
Feeding difficulties
Upper respiratory infections
Altered dentition
Delayed speech development, will need speech therapy
Chronic otitis media, possible hearing loss
Long-term social adjustment
Ingestion of injurious agents
Very common in pediatrics Cosmetics and personal care products Cleaning products Plants Foreign bodies, toys Medications
Often occur in the home or relatives house
Infants and toddlers explore their environment through oral experimentation
Very curious
Imitation
Emergency tx for ingestion of injurious agents
Call Poison Control Center
Will develop a plan of care
Treat the child first, not the poison
Immediate concern is life support
Vital signs, respiratory, circulation
Gastric Decontamination
Specific antidotes for certain poisons
Would like to originally prevent
Parents need education on how to prevent recurrence
Heavy metal poisoning
Ingestion of a variety of substances
Lead
Iron
Mercury
Treatment involves chelation therapy
Tracheoesophageal Fistula (TEF)
Failure of the trachea and the esophagus to separate
Proximal- ends in a blind pouch
Distal- connected to the trachea or bronchus
Commonly associated with VATER or VACTERL
Biliary Atresia
Inflammatory Process that causes intrahepatic and extrahepatic bile duct fibrosis with eventual obstruction
Biliary Atresia tx
Hepatic portoenterostomy
Intestine anastomosed to help bile drainage
Liver transplant later
Nutrition support
Omphalocele
Protrusion of intra-abdominal viscera- out pouching from umbilical cord- contents covered in peritoneum without skin
Surgical Repair
Nursing care for omphalocele
Protect sac from drying or trauma Keep soaked with saline soaked dressings Maintain temperature Prophylactic antibiotics After surgery- bowel decompression, pain management
Gatroschisis
Protrusion of intra-abdominal contents- no peritoneal sac covering the exposed bowel
Surgical repair
Sometimes requires gradual reduction of contents into the abdomen
Nursing care for Gatroschisis
Same as Omphalocele EXCEPT:
NG decompression
Observe exposed bowel for necrosis or color change
Post op-
Monitor lower extremities- pulses and perfusion
Siloh Pouch
Total Parenteral Nutrition
Why do we need TPN? Side effects/Adverse events Know the patho behind patient’s illness to know what is in the TPN Evaluate patients response Weight gain Bloating Electrolyte imbalance Central access unless less than 12.5% dextrose Sometimes they will add meds Liver testing Other metabolic labs
What is the treatment of choice for mild dehydration?
Oral rehydration treatment
After initial rehydration what may be used as maintenance fluid therapy?
ORS and alternate with formula/breastmilk or regular diet
Meds for fluid loss
If bacteria or parasitic causes may need antibiotics or antiparasitics
Metronidazole, Vancomycin
*Antidiarrheals not recommended
Educate parents- Rotavirus oral vaccine (3 doses at 2, 4, and 6 months)
Meds for constipation
Medications and enemas
Stool Softeners (colace)
Laxatives (Miralax, Milk of Magnesia, Lactulose)
Pediatric Fleets Enema, Milk and Molasses enema
Health history for Hirschsprung’s Dz
Newborn stool patterns
Physical exam for Hirschsprung’s Dz
Inspect and palpate abdomen for distention
Lab and diagnostic tests for Hirschsprung’s Dz
Barium enema
Rectal biopsy to evaluate for absence of ganglion cells Absence of ganglion cells causes contraction which leads to obstruction
Stool collects = distention, leading to ischemia and enterocolitis
GERD clinical manifestations in infants
Spitting up, forceful vomiting
Excessive crying, arching of back
Wt loss, growth failure
Respiratory problems, ALTE
GERD clinical manifestations in children
Heartburn, abdominal pain, non cardiac chest pain
Chronic cough, dysphagia, recurrent PNA
Postoperative CL Repair
Must protect the operative site!!
Place elbow restraints
Prevent infant from rolling onto abdomen
Will be supine immediately after surgery then can go into infant seat
Adequate pain relief – want to avoid crying
Clear liquids once recovered from anesthesia
Clinical manifestations of TEF
Excessive salivation Coughing Choking Cyanosis Apnea/ respiratory distress Abdominal distention Immediately NPO Prone position to aid in the drainage of secretions Low intermittent suction in the blind pouch via a catheter One surgery or several staged surgeries
Clinical manifestations of Biliary Atresia
Jaundice Dark urine Light color (tan) stool Hepatomegaly Poor weight gain Growth retardation Pruritus Irritability
