Gastrointestinal disorders Flashcards
▪ Protrusion of intraabdominal contents through defect in abdominal wall lateral to umbilical ring which is
never with a peritoneal sac
▪ M. membranes covers the exposed
GASTROSCHISIS
Incomplete fusion of the palate which results in
communication between the mouth and the nose
Cleft Palate
when will cleft palate precede cleft lip
6 – 12 weeks
AE/TEF: A2
Simple esophageal atresia with no fistula (Isolated EA)
signs of Esophageal motility disorders
dysphagia, GER (50%)
- non union of the tissue and bone of the upper lip and hard/soft palate during embryonic development
- Distinct facial defects that occurs singly or in combination
- Malformation of the face that may occur individually or together
- Both occur during embryonic development
CLEFT LIP (HARELIP)/CLEFT PALATE
Type of cleft palate: occurs in midline and may involve soft
and hard palate
CP alone
what is ESSR
▪ Enlarge the nipple (long, soft)
▪ Stimulate the suck reflex
▪ Swallow fluid appropriately
▪ Rest =to allow child to finish what has been placed in the mouth
(-) air in the GIT in EA/TEF meaning
EA without TEF
Type of EA/TEF: Both upper and lower ends of esophagus open into the
trachea by a fistula
EA with double TEF
Rule of 10
10gms Hgb?10lbs?10wks
Restraints for cleft palate
▪ Elbow restraint until palate healed (4-
6 weeks)
How to prevent infection in Cleft lip/palate
- Assess v/s
- Cleanse suture line with normal saline/sterile water if ordered
- Cleanse cleft areas by giving 5-15 cc of water after feeding
- loosen crust
aiding in removal - Antibiotic cream as prescribed
- Careful hand washing and sterile technique
Assessment for Transesophageal Atresia (TEF)
a) 3 Cs - choking, coughing, cyanosis
b) Aspiration pneumonia
c) Distended abdomen
Preop preparation of the infant for surgery in omphalocele
NPO, IVF, NGT for decompression
Major Etiology/Causes of Cleft lip/palate
genetics and environmental
Speech impairment in CL/CP
o Insufficient functioning of the muscle of the soft palate and nasopharynx
o Improper tooth alignment-orthodontics
o Hearing loss
CLINICAL MANIFESTATIONS of EA/TEF
- 3 C’s of TEF = choking, coughing, cyanosis (intermittent)→due to aspiration from overflow of secretions from the blind pouch
- copious, fine white frothy bubbles of mucus in the mouth and nose=EA
- increased respiratory distress after feeding
- Distended abdomen-air from trachea passes through the fistula into the stomach
Structural Defects
- Cleft lip/ cleft palate
- Esophageal Atresia with Transesophageal Fistula
- Omphalocele
Protrusion of intraabdominal contents into the base of umbilicus which is covered by a translucent sac
(peritoneum without skin)→rupture→****
evisceration
position for maintaining patent airway in Cleft lip
upright/infant seat position
How to maintain Airway patency in CP/CL
gentle aspiration (NO SUCTIONING=trauma to the site) of mouth and nasopharyngeal
secretions to prevent aspiration and respiratory complications
Gastrointestinal System of the Newborn
- The infant does not have voluntary control over swallowing until 6 weeks old.
- Stomach capacity is small and intestinal motility is greater than in older children.
- Relaxed cardiac sphincter.
- Deficiency of several enzymes until 4 to 6 months.
- Liver junctions are immature until the first year of life.
How to optimize nutrition in Cleft lip
Rubber tipped syringe on the side of the mouth
incidence of cleft palate
1:2000 live births
week of Fusion of palatal processes
7 – 12th wk AOG
stomach capacity of 2-3 weeks
75-100 ml
postop preparation of the infant for surgery in omphalocele
measures to control pain, prevent infection, fluid and electrolyte balance,
adequate nutritional intake
Gastrostomy tube feedings are elevated and secured to a point above the level of the stomach in how many inches to prevent reflux to the healing esophagus; allows gastric secretions to pass duodenum and swallowed air to escape through open tube
4”
Type of cleft lip: small notch; maybe a little
more than a notching of the vermillion border of the lip and may extend to the nostril
Incomplete
management of EA/TEF
- Prevention of aspiration pneumonia through drug therapy
* →inevitable and appear early
* Broad spectrum antibiotic - Surgery
▪ to repair anomaly→ emergency; closing the fistula and anastomosing esophageal
segments (NGT for feeding until esophagus heals; chest tube)
diagnosis of cleft lip
apparent at birth – detected by Sonogram (while in Utero)
How to protect sac from trauma and infection in omphalocele
▪ Monitor sac and make sure that it is covered with sterile gauze soaked in NSS to prevent drying of abdominal contents
▪ Place dried sterile gauze over sterile moist gauze and cover with plastic wrap to provide additional protection from heat and moisture loss
▪ Monitor vital signs especially temperature because the infant easily loses heat through sac
▪ Monitor for s/s of infection
Pediatric Nursing Gastrointestinal Disorders
A. Structural Defects
B. Disorders of Motility
C. Obstructive Disorders
D. Malabsorption Syndrome
development of larynx, trachea, beginning lung tissue, esophageal
lumen
4th – 8th week
corrective surgeries for EA/TEF
▪ End-to-end anastomosis
▪ Colon transplants for defects
why infant with cleft palate have difficulty feeding
infant is unable to generate a negative pressure and create suction in the oral cavity
incidence of cleft lip
1:800 live births
how to provide adequate nutrition in CL/CP
a. ESSR
b. Upright position when feeding to facilitate swallowing and discourage aspiration
c. Burp frequently because more air is swallowed which can cause regurgitation/vomiting
d. NGT feeding as ordered
▪ Protrusion of intraabdominal contents into the base of umbilicus which is covered by a translucent sac
(peritoneum without skin)→rupture→evisceration
▪ Herniated organs
OMPHALOCELE
Type of cleft lip: extends into the base of the nose and even the gums in which upper teeth are set may also be deformed
Complete
Characteristics of cleft lip
Associated with deformed dental structures
NURSING DIAGNOSIS
Preoperative of CL/CP
- High risk for aspiration (breastmilk, formula or mucus) related to anatomic defect
- High risk for aspiration (breastmilk, formula or mucus) related to anatomic defect
stomach capacity of 3 months
150-200 ml
intestines which include stomach and liver covered by psa
Herniated organs
NURSING CARE of omphalocele
- Protect sac from trauma and infection
- Prepare the infant for surgery
stomach capacity of 2 years
500 ml
Type of EA/TEF: most common
EA with distal TEF
stomach capacity of 1 month
90-150 ml
Pre-op nursing care for EA/TEF
- Maintain open airway
- NPO
- Administer IVF as ordered
- Oxygen to relieve respiratory distress
Other defects associated with cleft lip/palate
omphalocele, TEF
3Cs of TEF
choking, coughing, cyanosis
purposes of cheiloplasty
- early repair avoids oral deprivation, prevents trauma and difficulty for the parents
- its difficult to bond with an infant with deformed face
- Help infant experience the pleasure in sucking
Palliative surgery for EA/TEF:
* Provision of constant drainage of the esophageal
pouch=tube in the mouth to upper pouch
o Esophageal replacement
Esophagostomy
Types of cleft palate
- CP alone
- With CL
Palliative surgery for EA/TEF:
* Several stages – indicated for premature, multiple
anomalies/in poor condition LIGATION OF TEF + PALLIATIVE
MEASURES
* for gastric decompression (placement of a feeding tube,
left open to drain by gravity to keep stomach empty of
secretion and prevent reflux into lung) and jejunostomy
feeding
Gastrostomy
how to observe for bleeding in CL/CP
check for frequent swallowing, increased PR and restlessness
ethnicity where cleft lip/palate is most common
Asians
gender at risk for cleft palate
Females
Palliative surgeries for EA/TEF
▪ Gastrostomy
▪ Esophagostomy
Management of cleft palate
URANOPLASTY
chest tube care (thoracotomy) in EA/TEF
- Check clots
- Keep lower than chest
- Check amount, color, drainage
- Vaselinized gauze at bedside
- Don’t clamp unless ordered
d. Semi-Fowler’s position or right side to prevent gastric juice from flowing to the fistula
Type of cleft lip: generally below the center of one nostril
Unilateral
In CL/CP, why cleanse cleft areas by giving 5-15 cc of water after feeding
to prevent accumulation of carbohydrates
which encourage bacterial growth
How to help parent cope with the impact of the defect in CL/CP
o Encourage them to hold and cuddle the infant
o Explain surgical procedure and expected outcome
o Show pictures before and after surgery
Types of EA/TEF
- Simple esophageal atresia with no fistula (Isolated EA)
- EA with proximal TEF
- EA with distal TEF
- EA with double TEF
- Isolated TEF
postop nursing care for EA/TE
- Promote respiratory function
- Provide optimum nutrition
an alternative to gastrostomy if the 2nd step surgery will be much later
Cervical esophagostomy
risk for EA/TEF
- low birth weight
- prematurity
- occurs with other congenital disorders (VACTERL)
Type of EA/TEF: Upper end of esophagus is blind, lower end
connects into the trachea
EA with distal TEF
when can cheiloplasty be done
on or before 2nd month
nursing responsibilities in oral feeding of postop EA/TEF
- Carefully observe to make sure that infant is able to swallow without choking
- Start with sterile water, followed by small feedings of formula
- May be supplemented with gastrostomy/parenteral nutrition if unable to take sufficient amount by mouth
- Discharged if able to take oral fluids well and gastrostomy tube removed but for palliative surgery,
discharged with gastrostomy tube (EDUCATION)
stomach capacity of NB
10-20ml
cause of EA/TEF
unknown
failure of the maxillary and median
nasal processes to fuse (incomplete
fusion of the lip)
Cleft Lip
AE/TEF: B4
EA with proximal TEF
management of speech impairment
speech therapy
Characteristics of cleft palate
❖ Although these are also through with CL, it is
more with CP
* Difficulty feeding
* Prone to recurrent otitis
media
evidence that cleft lip/palate is inherited
increased incidence in relatives
diagnosis of Cleft lip/palate
physical assessment
what covers omphalocele
peritoneal sac
sex incidence of EA/TEF
equal
How to optimize nutrition in Cleft palate
Paper cup/large hole nipple
How to promote respiratory function in EA/TEF
a. Assessment of respiratory difficulties
b. Suction PRN
c. Provide chest tube care (thoracotomy)
d. Semi-Fowler’s position or right side to prevent gastric juice from flowing to the fistula
e. Gastrostomy returned to gravity drainage
Care for patients in restraint
→ Check site for s/s of irritation
→ Release one at a time at frequent intervals to provide opportunity to exercise arms and for cuddling
position for maintaining patent airway in Cleft palate
lie on abdomen
abnormal connection between the esophagus and the trachea
Tracheoesophageal fistula (TEF)
Nursing Care for Cleft lip/palate
- Help parent cope with the impact of the defect
- Provide adequate nutrition
- Prepare for surgery
- Postoperative care
Type of cleft lip: beneath
both nostril
Bilateral
Obstructive Disorders
- Intususception
- Pyloric Stenosis
- failure of the esophagus to develop a continuous passage
- esophagus ends in a blind pouch with no entry to the stomach
Esophageal atresia (EA)
associated with other congenital anomalies of omphalocele
heart, genitourinary, TEF and imperforate anus
ethnicity where cleft lip/palate is least common
Blacks
congenital disorders associated with EA/TEF
(VACTERL)=vertebral,
anorectal, cardiovascular, tracheoesophageal, renal, limb
abnormalities
Malabsorption Syndrome
Celiac Disease
DIAGNOSTIC TESTS for EA/TEF: (to confirm placement , aspirate stomach contents)
Inability to pass NGT
MANAGEMENT of omphalocele
immediate surgical repair to replace abdominal contents and close abdominal wall
how to loosen crust in CL/CP surgery
use cotton swab to apply a half-strength peroxide solution
Avoid trauma to the operative site in CL/CP
▪ Logan’s bow/butterfly adhesive after surgery to hold in close approximation the suture line
▪ Restraints (elbow pinned to the infant’s clothing) to avoid rubbing the incision with hands
▪ Minimize crying – anticipate needs (produces tension on the suture line)
▪ No to sucking – no pacifiers
▪ No tongue depressor, thermometer, spoons, straws, toothbrushing, hard food items
AE/TEF: E3
Isolated TEF
Type of cleft palate: midline of the soft palate and one orboth sides of the hard palate
With CL
repair for cleft lip (cheiloplasty) is until what age
age 2
Pacifier and NPO purpose is to
prevent food aversion
signs of stricture due to tension
dilatation
DIAGNOSTIC TESTS for EA/TEF
- History (polyhydramnios=EA) and clinical manifestations
- Inability to pass NGT
- Radiography
Management of cleft lip
CHEILOPLASTY
gender at risk for cleft lip
Males
diagnosis of cleft palate
may not be detected without thorough assessment of the mouth (palpate with the finger)
results of otitis media
→fluid can get in the middle ear
→tympanic membrane scarring
→hearing loss
NURSING DIAGNOSIS
Postoperative of CL/CP
- Ineffective breathing pattern related to anesthetic and increased secretions
- Impaired tissue integrity related to surgical correction of cleft
- Knowledge deficit (parent) related to diagnosis, treatment, prognosis and home care needs
- Altered nutrition: less than body requirements related to surgery and feeding difficulties
diagnostic sign of EA without TEF
(-) air in the GIT
Etiology/Causes of Cleft lip/palate
o Genetics
o Environmental
o Family History
o Exposure to certain drugs during pregnancy
o Nutritional deficiencies
o Certain Medical Conditions
Cause of omphalocele
Abdominal contents fail to return when abdominal wall closes by 10th week.
How to Provide optimum nutrition in EA/TEF
a. Gastrostomy tube feedings
b. Oral feeding when anastomosis site healed
c. Maintain IVF
d. Pacifier
e. NPO or no oral stimulation
when can uranoplasty be done
12 – 18 months
COMPLICATIONS OF SURGERY in EA/TEF
- Anastomostic leak
- Stricture due to tension
- Esophageal motility disorders
Assessment for Esophageal Atresia (EA)
a) History of polyhydramnios in mother
b) Inability to pass NG tube
c) Increased drooling & salivation
d) Immediate regurgitation of undigested formula/milk when fed
e) copious, fine white frothy bubbles of mucus in the mouth and nose
signs of anastomostic leak
purulent chest tube drainage, temperature instability and increased WBC
- to take advantage of palatal changes that take place with normal growth and before child develops faulty speech in anticipation of speech development, it is done before the child develops faulty speech habits
URANOPLASTY
on what day will you give gastrostomy tube feedings in postop care for EA/TEF
5th-7th day-post-op feedings
Restraints for cleft lip
▪ Elbow restraint
▪ Jacket restraint for older children to prevent rubbing of site
Type of EA/TEF: Upper end of the esophagus ends into the trachea
EA with proximal TEF
Type of EA/TEF: Upper and lower ends of esophagus are blind, no connection to the trachea
Simple esophageal atresia with no
fistula (Isolated EA)
stomach capacity of 1 week
30-90 ml
Alternative to nipple feeding
rubber tipped medicine dropper or aseptosyringe,
Breck feeder
(large syringe with soft rubber tubing) deposited at the back of the mouth
Cleft lip/palate has higher incidence in
Caucasians
Type of EA/TEF: No Esophageal atresia but with fistula between
normal esophagus and trachea
Isolated TEF
what covers gastroschisis
mucus membranes
Types of cleft lip
- Complete
- Incomplete
- Unilateral
- Bilateral
How to maintain patent airway in EA/TEAF
- Continuous/low intermittent suction to remove secretions from blind pouch
- TEF=supine with HOB elevated on an inclined plane for at least 30 degrees→minimizes reflux of gastric secretions up the distal esophagus into the trachea and bronchi
Disorders of Motility
- Gastrointestinal Reflux Disease
- Hirschprung’s Disease
- Colic
on what day will you give oral feeding in postop care for EA/TEF
when anastomosis site healed (10th day-2nd week)
Postoperative care for cleft lip/palate
a. Maintain Airway patency
b. Observe for Bleeding
c. Avoid trauma to the operative site
d. Minimize pain
e. Optimize nutrition
f. Prevent infection
week of Fusion of maxillary and premaxillary processes
7 – 8th wk AOG
AE/TEF: C1
EA with distal TEF
o may appear alone with cleft lip
o midline of hard & soft palate
o midline of soft palate & one or both
side of hard palate
Cleft Palate
AE/TEF: D4
EA with distal TEF
