Gastrointestinal Conditions Flashcards
1. Describe acquired and congenital gastrointestinal problems that interfere with digestion, absorption and elimination. 2. Assess and plan care for a child with vomiting and diarrhea. Plan feeding interventions for a child with anomalies that interfere with ingesting nutrients.
Many GI abnormalities originate when?
During fetal life; they may or may not be detected during the neonatal period.
When obtaining a history for most GI conditions, it is important to obtain information based on:
food habits (what is eaten, how it is prepared, how much is eaten, when does eating occur and with whom), vitamins and nutritional supplements that may be used, and normal bowel habits, including frequency, appearance, and the use of aids, such as laxatives or enemas.
How much does the stomach hold?
The newborn stomach expands from 20 mL at birth as much as 90 mL by the end of the first week of life, the stomach holds up to 3,000 mL by late adolescence.
How is the infant’s gut different during the first year of life?
It is immature; some products cannot be digested and are excreted in the stool, whereas other products may be absorbed more readily, possibly leading to the development of food allergy.
Vomiting
Introduction
- Definition: the forceful emptying of stomach contents through the mouth - usually caused by a GI disorder (such as spasm of the duodenum, reverse peristalsis from blockage of the pylorus, reflux from an incompetent or lax esophageal sphincter, overdistention of the stomach from increased intake, or gastroenteritis), but may result from a non-GI disorder (such as increased intracranial pressure).
- It is controlled by the medulla.
- A “wet burp” or “spit up” involves either dribbling of ndigested liquids from the mouth and esophagus or their expulsion with the force of a burp and should be differentiated from vomiting.
- The most common cause of infant vomiting is overfeeding.
Vomiting
Assessment
- Differentiate vomiting from a wet burp or spitting up.
- Review the child’s history for frequency of episodes.
- Assess for accompanying symptoms, such as fever, nausea, headache, and diarrhea.
- Determine if the vomiting is projectile.
- Determine if the vomiting is related to intake or to other activities.
- Describe the vomitus: blood (hematemesis), bile, undigested or digested food, amount, force.
- Note presence or absence of nausea.
- Note the time since last ingestion of food.
-
Assess abdomen: check for bowel sounds, note distention of abdomen or areas of pain.
a. Measure abdomen with a paper tape at the widest point, usually the umbilicus; mark the point of measurement with a pen. - Assess fluid and electrolyte balance, especially for dehydration (check skin turgor).
- Assess for metabolic alkalosis from the loss of stomach acids.
- Assess nutritional status, including growth and development.
- **Evaluate feeding methods (amount of burping, air in nipple, feeding supine or sitting up).
Vomiting
Interventions
- Prevent aspiration during vomiting by positioning the child on their side; maintain a patent airway; perform nasotracheal or bulb suctioning, if necessary.
- After a period of no vomiting and if an obstruction is not the cause, begin administering frequent small amounts of clear liquids.
a. For infants: give Pedialyte.
b. For older children: give flat noncarbonated ginger ale or cola. - Admin antiemetic meds only to older children; they should not be used in infants; use the rectal or intramuscular route.
- Raise the head of the bed or sit up when feeding; place side-lying on right side or prone after feeding for a child; infants should be placed on their backs.
- Provide skin and mouth care.
- Measure I & Os as well as daily weight.
- Monitor stool status.
Gastroesophageal Reflux (GER)
Introduction
1. GER is the return of gastric contents into the esophagus from an incompetent or poorly developed esophageal sphincter.
2. The condition occurs almost immediately after eating and typically affects infants; it is also seen in infants and young children with spastic cerebral palsy and other conditions with decreased muscle tone.
3. Aspiriation puts them at risk for pneumonia.
Assessment
1. Assess the relationship of vomiting to feedings, positioning, and the activity level immediately after feedings.
2. Assess for failure to thrive/poor weight gain.
3. Assess for aspiration of feedings; note any relationship between apnea and GER (many infants may be placed on apnea monitors).
4. Measure the pH of gastric contents.
Interventions
1. Admin meds 30 minutes before meals to maximize the benefits of the medications.
a. H2 blockers and proton pump inhibitors are drugs used to reduce the amount of gastric acid present in gastric contents, thereby reducing esophagitis.
2. Provide thickened formula (1 tbsp cereal/1 oz formula); will need to enarge hole in nipple or use cross-cut nipple.
3. Feed child in an upright position and keep upright for 30 minutes after feed; avoid car seat sitting position.
4. Give small frequent feedings.
5. Research supports placement of infant with GER on their backs to sleep, as there is no increased risk for aspiration.
6. Prepare for surgery (Nissen fundoplication for hiatal hernia) if necessary.
Diarrhea
Introduction
- Diarrhea is the increased frequency and amount and decreased consistency of stool.
- It occurs when water in the bowel increases from osmotic pull, with electrolyte imbalance, or when peristalsis increases, preventing water from being absorbed.
- It may accompany gastroenteritis, an inflammation of the lining of the stomach and intestines.
- It can result from anatomic changes, malabsorption conditions, GI allergies, or toxins.
- It can lead to metabolic acidosis and dehydration through loss of HCO3 in the stool.
- In infants, rotavirus is a major cause.
- Difficile infection presents with fever, abdominal pain and often bloody diarrhea.
a. It is the most common cause of antimicrobial-associated diarrhea; it is acquired by the fecal-oral route.
What is the most common cause of diarrhea in infants?
Rotavirus
Difficile infection symptoms
fever, abdominal pain, and often bloody diarrhea
Diarrhea
Assessment
- Note the amount, frequency, duration, consistency, appearance, and odor of stool; weigh diapers and note the amount of water loss.
- Test stool for blood and other reducing substances, such as sugars, and for pH; obtain stool cultures, if ordered.
- Assess for the presence of abdominal pain or cramping associated with stooling.
- Assess the relationship between stooling and the time of eating or quality of intake.
- Assess skin integrity around the anus.
- Assess hydration status.
- Assess abdomen; check bowel sounds, palpate for masses, distention, and pain.
Diarrhea
Interventions
- For mild diarrhea, continue regular diet.
a. Avoid fruit juices and soft drinks because of their high osmotic load. - For more serious diarrhea:
a. For infants: Initiate unlimited amounts of Oral Rehydration Solutions (Pedialyte); continue breast feeding or formula.
b. For children > than 1 year: Encourage fluids and increase starchy foods in regular diet (rice cereal, oatmeal, toast, potatoes, carrots, white rice, applesauce, bananas); pretzels and salty crackers help meet sodium needs.
(1) NOTE: The BRAT diet, which is bananas, rice, applcesauce, and toast, is not recommended by the American Academy of Pediatrics due to the lack of protein.
c. IV fluids may be needed. - Use enteric precautions and good hand washing.
- Measure intake and output.
- Provide skin care around anus; apply a skin protectant; change diapers promptly.
- Do not take child’s temperature rectally.
Constipation
Introduction
1. Constipation is a decreased amount and increased consistency of stool compared to the patient’s normal pattern (children do not need to have a daily bowel movement).
2. Constipation is not necessarily synonymous with straining.
3. It may be caused by diet low in liquids or high in fat and protein.
Assessment
1. Note a hard, dry, infrequent stool.
2. Test stool for blood (guaiac test). Melena is dark, tarry stool usually associated with bleeding from the upper GI tract; it may be Hematest-positive from trauma to the rectal tissue from passing a hard mass; assess skin integrity around anus.
3. Ask child about abdominal pain during stooling or intermittent pain throughout the day.
4. Assess the child’s diet for liquids, fiber, carbohydrates, and constipating foods.
5. Measure abdominal girth.
6. Note whether child is reluctant to use the toilet in school or is consciously retaining stool.
7. May present as encopresis/fecal incontinence with involuntary soiling of clothing as impacted stool collects in colon and rectum; may appear as diarrhea as only liquid leaks around the retained stool.
a. Usually occurs after age 4
b. May be due to emotional issues or fear of using toilet and pain
Interventions
1. Lubricate around the anus to ease the passage of hard stool (may have to remove stool digitally).
2. Administer stool softeners: suppositories, mineral oil, and docusate sodium (Colace).
3. Add fiber or prune juice to the diet; increase fluid intake.
4. Administer enemas, if ordered; use isotonic solutions only.
Cleft Lip and Palate
Introduction
- Cleft lip and palate are a failure of the bone and tissue of the upper jaw and palate to fuse completely at the midline.
- Cleft lip and palate are congenital defects, in some cases due to heredity but many other causes are implicated; the defect occurs in the first trimester of pregnancy.
- The defects may be partial or complete, unilateral or bilateral, or may involve just the lip, just the plate, or both.
- The condition requires a long-term tema approach to address speech defects, dental and orthodontic problems, nasal defects, and possible alterations in hearing.
- Because it results in facial disfigurement, the condition may cause shock, guilt, and grief for the parents and may interfere with parental bonding with the child.
- Cleft lip and palate increase the risk of aspiration, because increased open space in the mouth causes some formula to exit through the nose with we burps.
- They also increase the risk of upper respiratory tract infection and otitis media, because the increased open space decreases natural defenses against bacterial invasion.
Cleft Lip and Palate
Assessment
- Visually inspect and palpate the palate.
- Assess the quality of the infant’s suck; determine if the infant can form an airtight seal around a nipple.
- Assess the child’s ability to swallow.
- Assess for abdominal distention from swallowed air.
- Be alert for respiratory distress when feeding.
Cleft Lip and Palate
Interventions for cleft lip (preoperative)
- Feed the infant slowly and in an upright position to decrease the risk of aspiration.
- Burp often during feeding to eliminate swallowed air and decrease the risk of emesis.
- Use a specialized nipple, a cleft palate nipple with a flap across the palate (palatal obturators), a medicine dropper, a syringe with rubber tubing attached to the end (aim nipple toward the side of the mouth), or manual compression to unite the edges of the cleft lip; all encouraging sucking, promote oral muscle development, and enhance the infant’s nutritional status.
- Use gavage feedings if oral feedings are unsuccessful.
- Administer a small amount of water after feedings to prevent formula from accumulating and mecoming a medium for bacterial browth.
- Give small frequent feedings.
- Hold infant while feeding and promote sucking between meals.
- Provide psychological support to the parents; reinforce the likely success of surgery; point out the positive qualities of the infant.
- Tell parents that cleft lips are usually corrected when the infant is 10 weeks old and weighs 10 lb (4.5 kg); the infant must be free of respiratory infections at the time of surgery.
Cheiloplasty
Interventions for postoperative cleft lip repair
CLEFT LIP REPAIR
1. Cheiloplasty unites the lip and gum edges in anticipation of teeth eruption, provides a route for nuturition and sucking, and improves the infant’s appearance, which promotes parent-child bonding.
2. Maintain a patent airway; edema or narrowing of a previously large airway may make the infant appear to be in distress.
3. Observe for cyanosis, as the infant begins to breathe through the nose.
4. Maintain an intact suture line; keep the infant’s hands away from the mouth by using elbow restraints or swaddling the infant with a blanket; Steri-Strips will be used to hold the suture line in place.
5. Prevent tension on the suture line by anticipating the infant’s needs and preventing crying; do not place in prone position to avoid pressure on face.
6. Give extra care and support, because the infant cannot meet emotional needs by sucking.
7. When feeding resumes, use a special cleft lip feeder (e.g., a Haberman feeder) so they may drink from a bottle or a syringe with tubing to administer foods at the side of the mouth; this will prevent trauma to the suture line.
8. After feedings, place infant on right side to prevent aspiration.
9. To prevent crusts and scarring, clean suture line after each feeding with warm water using a Q-Tip and apply antibiotic ointment (Neosporin).
10. Monitor and treat for pain.
Staphylorrhaphy
Interventions for cleft palate (preoperative)
CLEFT PALATE REPAIR
1. Be aware that the infant must be weaned from the bottle or breast before cleft palate surgery; the infant must be able to drink from a cup.
2. Feed infant with a cleft palate nipple or a Teflon implant to enhance nutritional intake.
3. Surgery is usually scheduled before age 1 year to allow for the growth of the palate and before the infant develops speech patterns to prevent speech delays; the infant must be free from ear and respiratory infections.
4. Teach the parents that the infant is susceptible to pathogens and otitis media from the altered position of the Eustachian tube.
Staphylorrhaphy
Interventions for cleft palate (postoperative)
CLEFT PALATE REPAIR
1. Maintain a patent airway; position infant on the abdomen or side.
2. Anticipate edema and a decreased airway from palate closure; this may make the infant appear temporarily dyspneic.
3. Prevent trauma to the suture line by keeping hard or pointed objects (utensils, straws, frozen dessert sticks) away from the mouth; do not use suction catheters, except in emergency (use bulb syringe if necessary).
4. Use a cup to feed; do not use a nipple or pacifier.
5. Use elbow restraints to keep the child’s hands out of the mouth or have parent hold child in shuch a way as to pregent hands going in mouth.
6. Provide soft toys.
7. Start the child on clear liquids and progress to a soft diet; rinse the suture line by giving child a sip of water after each feeding.
8. Distract or hold child to try to keep the tongue away from the roof of the mouth.
Esophageal Atresia (EA) and Tracheoesophageal Fistula (TEF)
Introduction
1. An atresia is the termination of a passageway; it usually refers to a pathologic closure or the absence of a normal anatomic opening.
2. A fistula is a tubelike connection between two structures.
3. These conditions occur alone or in many combinations; they may be associated with other congenital defects, especially cardiac defects; TEF may be part of a syndrome called VACTERL (Vertebral defects, Anorectal malformations, Cardiac anomalies, TEF, EA, Renal defects, and Limb defects).
4. EA occurs when the proximal end of the esophagus ends in a blind pouch; food cannot enter the stomach via the esophagus.
5. TEF occurs when there is a connection between the esophagus and the trachea.
6. TEF may result in the reflux of gastric juice after feeding that can allow acidic stomach contents to cross the fistula, irritating the trachea.
7. EA with TEF occurs when either the distal end of the esophagus ends in a blind pouch and the proximal end of the esophagus is linked to the trachea via a fistula or when the proximal end of the esophagus ends in a blind pouch and the distal portion of the esophagus is connected to the trachea via a fistula; EA with TEF is the most common of these defects with EA alone being second most common.
Assessment of TEF
1. Maternal history of polyhydraminos (excess amniotic fluid, since fetus is unable to swallow it).
2. Newborn may have excessive oral secretions.
3. Assess for choking, coughing, and intermittent cyanosis during feeding from formula that goes through the fistula into the trachea; stop feeding if this occurs.
4. Observe for abdominal distention from air that goes through the fistula into the stomach.
5. Observe for tracheal irritation from gastric acids that reflux across the fistula.
Assessment of EA with TEF
1. Assess for all signs and symptoms of EA.
2. Observe for signs of respiratory distress: coughing, choking, and intermittent cyanosis.
Interventions
1. If EA or TEF is suspected, do not feed orally; a percutaneous endoscopic gastrostomy (PEG) tube may be inserted; keep the tube open and suspended above the child for release of gas.
2. Maintain a patent airway; have suction equipment available.
3. If feeding the child via gastrostomy tube after surgery, anticipate abdominal distention from air; keep the child upright during feedings to reduce the chance to regurgitated stomach contents and aspiration pneumonia, and keep the tub open and elevated before and after feedings.
4. Gastrostomy feeds should be administered either by gravity or by feeding pump.
5. Explain to parents how the surgery ligates the TEF and reanastomoses the esophageal ends; expect a staged repair in many instances.
Pyloric Stenosis
Introduction
1. Pyloric stenosis is an increasing hyperplasia and hypertrophy of the circular muscle at the pylorus, which narrows the pyloric canal as it exits the stomach.
2. The defect is most commonly seen in boys around 4 weeks of life.
3. Emesis may be Hematest positive, but it will not contain bile; it will increase in amount and force as the obstruction increases and will become projectile.
Assessment
1. Be aware that symptoms seldom appear during the first two weeks of life.
2. May palpate for an olive-size bulge below the right costal margin.
3. May observe for projectile emesis during or shortly after feedings (preceded by reverse peristaltic waves [going left to right] but not by nausea).
4. Note that the child will resume eating after vomiting.
5. Evaluate for poor weight gain and symptoms of malnutrition despite the child’s apparent hunger.
6. Assess for metabolic alkalosis and dehydration from frequent emesis.
Interventions
1. Provide small, frequent feedings with the head of the bed elevated; burp the child frequently.
2. Position the child to prevent the aspiration of vomitus, preferably on the right side for children and on their backs for infants with the head of the bed raised 30 degrees.
3. Correct any electrolyte imbalance.
4. An NG tube may be inserted and kept open and elevated for gastric decompression.
5. Prepare for pyloromyotomy, where the overdeveloped muscle around the pyloric valve is split, thereby spreading open the muscle and enlarging the pylorus to relieve the obstruction.
Intussusception
Introduction
1. **Is the telescoping or invagination of a bowel segment into itself, the most common site being the ileocecal valve; it usually occurs between 3 and 24 months. **
2. The condition may result from polyps, hyperactive peristalsis, an abnormal bowel lining, or for no known cause.
3. Initially, it causes inflammation and swelling at the affected site; edema eventually causes obstruction and necrosis from occlusion of the blood supply to the bowel.
4. Intussusception can be acute or chronic. Untreated, it may lead to peritonitis.
Assessment
1. Note a sudden attack of acute abdominal pain in a previously well child; the child shrieks and draws the knees to the chest.
2. Observe for an increase in bile-stained vomitus.
3. Note the passage of a red currant jelly-like stool (red blood and mucus).
4. Assess for a distended and tender abdomen.
5. Note pallor and agitation.
Interventions
1. Prepare for a barium enema or water-soluble contrast with air pressure to confirm the condition and reduce the invagination by hydrostatic pressure.
2. Be aware that, if enemas fail to reduce the invagination, surgery may be required to resect the gangrenous portion; a temporary colostomy may be necessary.
Hirschsprung Disease
Congenital Aganlionic Megacolon
Introduction
1. Parasympathetic ganglionic cells are absent in a segment of the colon (usually at the distal end of the large intestines); the lack of nerve innervation causes a lack of or alteration in peristalsis in the affected part.
2. As stool enters the affected part, it remains there until additional stool pushes it through; the affected part of the colon dialates; a mechanical obstruction may result.
Assessment
1. Observe for liquid or ribbon-like stools; only fluid can pass the obstruction caused by stool.
2. Assess for a distended abdomen from stool impaction.
3. Assess for nausea, vomitus, anorexia, lethargy, weight loss, and failure to thrive.
4. Prepare for barium studies and a biopsy of the large intestines to confirm condition.
5. Be alert for signs and symptoms of enterocolitis, volvulus, and shock, which can occur from this condition.
Interventions
1. Surgery to bypass the affected area or a resection of the aganglionic portion may be done with or without a colostomy
Imperforate Anus
Introduction
1. An imperforate anus is an atresia of the anal opening; the infant may have no anal opening onto the skin wall, or the rectum may end in a blind pouch.
2. A fistula to the vagina in females or to the urethra in males may also be present.
Assessment
1. Observe to see from which orifice stool is excreted.
2. Assess for signs and symptoms of impaction from the inability to pass stool.
3. Measure abdominal girth to evaluate abdominal distention.
Interventions
1. Do not take the infant’s temperature rectally unless stool has been excreted from the rectum, due to risk of perforation.
2. After surgical reconstruction of the anus and the formation of a temporary colostomy, keep the infant prone with the hips elevated.
3. Keep site clean.
Appendicitis
Introduction
1. Inflammation and obstruction of the blind sac at the end of the cecum results in ischemia, gangrene, perforation, and peritonitis.
2. Suggested causes include infections, dietary intake, constipation, and parasites.
3. It is common in school-age children.
Assessment
1. Symptoms are variable, making a quick and accurate diagnosis difficult.
2. Assess for abdominal pain and tenderness that begins as diffuse, then localizes in the LRQ at McBurney’s point.
3. Note rebound tenderness, especially in the LRQ.
4. Note fever, an increased WBC count, and behavioral changes.
5. Assess for decreased bowel sounds, nausea, vomiting, and anorexia.
6. Assess for abdominal distention, abdoninal rigidity, and guarding.
7. Note symptoms of peritonitis if a rupture occurs (fever, sudden relief of pain followed by a diffuse pain); this is a surgical emergency.
Interventions
1. Most cases of appendicitis are now treated with antibiotics rather than surgery.
2. If surgery is planned, position the child preoperatively in a semi-Fowler or right side-lying position.
3. Do not apply heat, as it may cause the appendix to rupture and lead to peritonitis.
4. Child may return from surgery with a drain and an NG tube attached to low intermittent suction.
5. Resume oral nutrition when bowel sounds reappear.
6. Administer antibiotics and pain medicaitons.
Inflammatory Bowel Disease
Introduction
1. Inflammatory bowel disease consists of Crohn’s disease (regional enteritis) and ulcerative colitis.
a. Ulcerative colitis involves contiguous GI ulcers; Crohn’s disease involves patchy lesions.
b. Ulcerative colitis causes more blood loss than Crohn’s disease.
c. Ulcerative colitis attcks the mucuosa of the bowel; Crohn’s disease affects all layers of the bowel wall.
d. Ulcerative colitis usually involves the large intestines; Crohn’s disease can occur at any point along the GI tract.
2. Inflammatory bowel disease is diagnosed on the basis of results of a barium enema, biopsy of the GI mucosa, and stool studies.
3. Edema and inflammation of the bowel produces ulceration, bleeding, diarrhea, and abdominal distention.
4. Chronic exacerbation may delay growth and development, including sexual development.
5. The disease, which commonly occurs in adolescents, is exacerbated by emotional factors, but its cause is unknown.
Assessment
1. Assess for weight loss, anorexia, nausea, and vomiting.
2. Test stool for blood.
3. Observe for diarrhea.
4. Test for anemia and signs of hypovolemia.
5. Assess for pain.
Interventions
1. Administer analgesics and antispasmodics to decrease abdominal pain.
2. Administer corticosteroids to decrease bowel inflammation.
3. Administer immunomodulators (methotrexate and cyclosporine).
4. Promote stress reduction through relaxation, distraction, and enhanced self-image and self-esteem.
5. Withhold food and fluids, using parenteral nutrition in place of feeding to rest the bowel; or provide a high-protein, high-calorie, low-residue, low-fat diet with vitamin supplementation.
6. Be aware that when conditions are not amenable to medical treatment, a colectomy, ileostomy, or ileo-anal pull-through may be performed.
Celiac Disease
Introduction
1. An absence of an enzyme in the intestinal mucosal cells causes the villi of the proximal small intestine to atrophy and decreases intestinal absorption.
2. The disease is a response to gluten intolerance (inability to absorb rye, oat, wheat, and barley glutens).
Assessment
1. Assess for steatorrhea (fatty stools) and chronic diarrhea from fat malabsorption.
2. Assess for generalized malnutrition and failure to thrive from the malabsorption of protein and carbohydrates.
3. Evaluate for osteoporosis and coagulation difficulty from the malabsorption of fat-soluable vitamins.
4. Assess for abdominal pain.
5. Observe for irritability from anemia.
6. Prepare the child for an intestinal biopsy to diagnose the condition.
7. Differentiate celiac disease from a gluten intolerance where no intestinal damage occurs and removing gluten from the diet resolves symptoms.
Interventions
1. Eliminate gluten from the diet.
2. Give the child corn and rice products, soy and potato flour, and all fresh fruits.
3. Replace vitamins and calories; give small frequent meals.
What needs to be evaluated when malabsorption of fat-soluable vitamins is present?
In celiac disease, check for osteoporosis and coagulation.
