Gastrointestinal System - Pedi Flashcards
GASTROINTESTINAL SYSTEM
*Route to ingest, digest, and absorb foods, fluids, vitamins, and nutrients
*Excretion/elimination of solid waste
*GI tract:
*Mouth, esophagus, stomach, pancreas, small intestine, large intestine
*Helper organs:
*Liver, gallbladder, spleen
DIFFERENCES BW PEDI AND ADULT
*Mouth – infants/young children oral phase – risk for infectious agents
*Swallowing - involuntary until 6 weeks
*Esophagus – lower esophageal sphincter matures at 1mos – prior to this regurgitation common
*Stomach capacity – smaller
*2 mos – 200 mLs (most smaller amts)
*16yo – 1500mLs
*Adult – 2000 mLs – 3000 mLs
*Digestive enzymes – deficient until ~6 months
*Small intestine
*~250 cm at birth
*600 cm in adult
*Liver function
*bilirubin conjugation starts at 2-3 weeks of age
*Pancreatic enzymes at adult levels by 2yo
*Palpable at birth – relatively large
*Excretory function – control of defecation (awareness/control 18-24 months)
*Total Body Water: infants/children > adults
PEDIATRIC GI ASSESSMENT (Health History)
*Past history – birth history, hospitalizations
*Present illness – onset? Symptoms? Assoc symptoms?
*Growth and development – gaining/ growing
*Emesis – Spitting up vs vomit, when? Frequency? Color? Volume?
*Stool – color, consistency, passage of meconium, pattern – BF usually with every
feed, Bottle 1-2 per day, size, abdominal pain, leaking/staining
*Nutrition – intake, appetite
*Activity – more sleep? Changes in activity level? Mental status?
*Family hx: IBS? IBD? Food allergies?
PEDIATRIC GI ASSESSMENT, CONT.
(Physical Exam)
*General – lethargic, interactive, active,distress
*Hydration status – MM, tears, fontanelle, turgor, UO
*Weight
*Heart /Perfusion– rate, rhythm; murmur, pulses, cap refill
*Abdomen – Inspect, Auscultate, Palpate
*Stool – Color, consistency, size, frequency, pattern changes
*Assess rectum – tone, fissures
*Skin – color, texture, diaphoretic
GI NURSING GOALS/INTERVENTIONS
*Maintain adequate fluid balance/hydration
*Prevent hypovolemia
*IV fluids, strict I & O, perfusion, daily weight
*Maintain skin integrity
*Appropriate Nutrition
*Treat/prevent infection
*Promote pain relief, comfort & rest
*Administer/manage medications
*Maintain and promote growth and development/milestone achievements
*Provide support to child & parents / Educate
GI/GI TRACT DISORDERS
(Structural anomalies)
*Cleft lip & palate
*Esophageal Atresia (EA)/Tracheoesophageal Fistula (TEF)
*Meckel’s diverticulum
*Omphalocele
*Gastroschisis
*Congenital Diaphragmatic Hernia (CDH)
*Anorectal malformations
*Imperforate anus
*Rectovestibular fistula
*Cloacal exstrophy/malformation
GI/GI TRACT DISORDERS
(Acute GI Disorders)
*Dehydration
*Vomiting
*Gastroenteritis
*Hypertrophic Pyloric Stenosis
*Necrotizing Enterocolitis (NEC)
*Malrotation and Volvulus
*Intusussception
*Appendicitis
*Peptic Ulcer Disease (PUD)
*Rotavirus, Clostridium difficile (c.diff), Giardia
GI/GI TRACT DISORDERS
(Chronic GI disorders)
*Gastroesophageal Reflux (GER)
*Constipation
*Encopresis
*Hirschsprung Disease
*Short Bowel Syndrome
*Inflammatory Bowel Disease
*Crohn’s Disease
*Ulcerative Colitis
*Celiac Disease
GI/GI TRACT DISORDERS
(Hepatobiliary Disorders)
*Pancreatitis
*Hyperbilirubinemia (Jaundice)
*Biliary Atresia
*Hepatitis
*Cirrhosis & Portal Hypertension
STRUCTURAL ANOMALIES
(Cleft Lip and Palate)
Most common congenital craniofacial defect:
frontonasal and/or maxillary processes did not
fuse
*~1 in 700 births
*Unknown cause. Contributing factors:
*Genetics, folic acid deficiency, advanced
maternal age, anticonvulsants, ETOH &
smoking, family hx
*25-30% also have syndrome/other
abnormalities
*Lip tissues fuse 5 – 6 weeks gestation
*Palate closes 7-9weeks gestation
STRUCTURAL ANOMALIES:
Complications cleft lip and palate
- feeding difficulties
- insufficient growth
- altered dentition
- delayed or altered speech
- otitis media with effusion
STRUCTURAL ANOMALIES:
Treatment cleft lip and palate
Tx: Multidisciplinary team: plastic surgeon or
craniofacial specialist, oral surgeon, dentist or
orthodontist, psychologist, otolaryngologist, nurse,
LICSW, audiologist, and speech language pathologist
Surgical repair cleft lip and palate:
*Lip 2-3 months – early repair improves feeding and
appearance
*Palate 6-9 months – essential for speech
development
STRUCTURAL ANOMALIES:
Cleft Lip and Palate Nursing Management
- Promoting adequate nutrition – may need special nipple, burp frequently
- Aspiration risk – prior to repair for palate may have a prosthodontic device
- to act as palate / breastfeeding may be more effective due to the soft breast tissue that is pliable and may cover opening
- Post op some surgeons resume BF immediately / special nipples for bottle fed
STRUCTURAL ANOMALIES:
Cleft lip and palate, nursing management
*Parent – Infant bonding: appearance may affect
*Emotional support
*Post operatively:
*Feeding support, may need restraints to prevent rubbing / touching surgical site,
certain things in mouth may affect repair ie no pacifier, straws, suction catheters
*Avoid vigorous or sustained crying
STRUCTURAL ANOMALIES:
Esophageal Atresia
*proximal and distal ends of esophagus do not communicate
*upper esophagus ends in a pouch / lower portion ends above the
diaphragm
STRUCTURAL ANOMALIES:
Tracheoesophageal Fistula
- abnormal communication between esophagus and trachea
- BOTH Atresia and Fistula typically associated with other abnormalities:
- VACTERL work up
- Vertebral, Anal atresia, Esophagus, Trachea, Renal abnormalities, or limb differences
STRUCTURAL ANOMALIES:
Esophageal Atresia and Tracheoesophageal Fistula
*maternal hx of polyhydramnios
*neonate with copious, frothy bubbles in mouth and nose and drooling
*abdominal distension – air accumulates
*can not insert NGT
*newborn with rattling respirations, excess salivation
*3 C’s: cough, choking and cyanosis with feeding
STRUCTURAL ABNORMALITIES:
Nursing Management Atresia and Fistula
*Preop:
*NPO
*HOB elevated prevent reflux/aspiration
*Orogastric tube – low wall suction / avoid irrigation
*I+O’s – fluid and electrolyte
*Comfort measures avoid crying
*Postop:
*TPN
*Antibiotics
*PO /NGT feeds about a week postop
*No deep suctioning
STRUCTURAL ANOMALIES:
Omphalocele
*Congenital anomaly of anterior abdominal wall
*Defect of umbilical ring
*Vary in size
*Evisceration of abdominal contents into an external peritoneal sac
*Bowel / liver / entire GI tract
STRUCTURAL ANOMALIES:
Gastroschisis
- congenital defect of anterior abdominal wall
- Herniation of abdominal contents thru a defect, typically to left or right of umbilicus
- NO peritoneal sac protecting organs, exposure to amniotic fluid - thickened, edematous and inflamed
STRUCTURAL ANOMALIES:
Nursing Assessment Gastroschisis and Omphalocele
- size of deformity
- appearance of organs
- look for twisting of intestine
- Full exam looking for other deformities ie VACTERL
STRUCTURAL ANOMALIES:
Nursing Management Omphalocele/ Gastroschisis
- Prevent hypothermia
- Prevent fluid loss
- Prevent trauma to exposed contents
- Prevent infection – sterile technique/antibiotics
- NPO / orogastric tube / PN
- Monitor exposed contents for vascular changes
STRUCTURAL ANOMALIES:
Omphalocele/ Gastroschisis
(Treatment, Surgery, Post op)
Treatment:
Surgery: exact way repaired depends on size of defect/size of child/ stability of child
May due primary closure or staged closure
Possibly silo closure
Post op:
monitor closely for respiratory compromise
pain management
fluids
Initiation of feeds
STRUCTURAL ANOMALIES:
Anorectal Malformations
Anomalies Associated with:
* VACTERL syndrome
* Esophageal atresia
* Intestinal atresia
* Malrotation
* Renal agenesis
* Hypospadias
* Vesicoureteral reflux
* Bladder exstrophy
* Cardiac anomalies
* Skeletal anomalies
Anorectal Malformations
**Imperforate Anus
*** Rectum ends in a blind pouch
* Level of defect influences outcome – fecal continence
* Staged repair
* Colostomy while waiting repair
Nursing Assessment Imperforate Anus
- newborn assess for normal anal opening
- passage of meconium stool within 24hours of birth
- assess UO to identify accompanying GU abnormalities
- assess for signs of intestinal obstruction – distension/vomiting
Nursing Management: Imperforate Anus
- Preop: NPO, gastric decompression, hydration status, education
- Postop: pain, NPO maintained, gastric decompression, colostomy care, if needed.
- After intestinal pull thru initially stool will be watery – skin breakdown
STRUCTURAL ANOMALIES:
Meckel’s Diverticulum
Congenital – 3-6 cm outpouching (bulge) of lower segment of small intestine
*Most common birth defect of GI system – 2-3% population
*Most children asymptomatic
*If symptoms, usually age 1-2y
*Painless rectal bleeding
*“brick” or “currant jelly” – very red stool
Can be associated with partial or complete bowel obstruction
*Obstruction – younger children
*Diverticulitis - older children (~ 8y) - looks like appendicitis
Meckel’s Diverticulum:
Common Complications
- Anemia
- Bleeding
- Ulcer
- Obstruction (volvulus / intussusception)
- Typically occur in first 2 years of life
Presentation Meckel’s Diverticulum
- Rectal bleeding, painless
- Abdominal pain
- Bloody, mucusy stools
Meckel’s Diverticulum: Dx
- Meckels Scan (radionuclide scan), CBC and metabolic panel
Meckel’s Nursing Management
- possibly blood products
- IV fluids
- NPO
- Surgery to repair
Inguinal Hernia
- Abdominal or pelvic viscera travel thru inguinal ring into inguinal canal
* Males: bowel
* Females: fallopian tubes/ovaries
- Nursing Assessment: Bulging mass in lower abdomen/groin
- ** Management: ** Surgical repair
- Reduction until surgery/ teach family (NP/MD)
- Education to family about incarcerated hernias and urgency
STRUCTURAL ABNORMALITIES:
Umbilical Hernia
More common: Preterm infants / African Americans
- Incomplete closure of umbilical ring
- Most self resolve by 4yo
- Surgery if large that fail to close by 4 yo
ACUTE GASTROINTESTINAL DISORDERS: Dehydration
*Infants in young children more at risk
*Increased extracellular fluid percentage, increase in body water compared to
adults
*Increased Basal Metabolic Rate
*Immature renal function
*Increased insensible fluid loss thru temp elevation
ACUTE GASTROINTESTINAL DISORDERS: Dehydration Nursing Management:
- Restore fluid volume
- Prevent shock
- Mild to moderate ORT
- Severe IVF
- Refer to Teaching Guidelines 20.1 ORT
- Pedialyte, 50-100mL/kg over 4 hours, reeval
- reg diet after rehydrated
ACUTE GASTROINTESTINAL DISORDERS: Vomiting
*** forceful expulsion of gastric contents thru mouth
- Many different causes – it is a symptom of some other condition
- Infectious: gastroenteritis, OM, pharyngitis, sinusitis, pyelonephritis, meningitis
- GI: intussusception, malrotation, appendicitis, cholecystitis, pancreatitis, GERD, pyloric stenosis
- GU: ureteropelvic junction dysfunction
- Endocrine: Diabetic ketoacidosis
- Neuro: IICP
- Other: food poisoning, toxic ingestion
Vomiting: Nursing Assessment
- Hx
- onset, progression, timing, characteristics
- color – bilious never normal
- bloody – GI bleed or esophageal bleed
- hx of trauma?
- feeding pattern
- assoc symptoms ie fever, diarrhea, abdominal pain
- PE
- hydration/perfusion, mental status, abdomen
Vomiting:
Nursing management
- Simple vomiting: ORT – 0.5 – 2oz ORS every 15 min age and size dependent
- Antinausea meds
- IVF
ACUTE GASTROINTESTINAL DISORDERS, CONT.
Diarrhea
- increase in frequency or decrease in consistency of stool
- Acute vs chronic (more than 2 weeks)
** Acute:** viral – watery, loose, fever, vomiting
* bacterial – bloody stools or mucousy
* Parasites – fever, watery
** Chronic:** infants: milk/soy intolerance, enteritis, hirschprungs, nutrient malabsorption
* toddlers: nonspecific, enteritis, celiac, UC
* school age: IBD, appendiceal abscess, lactase deficiency, constipation with encopresis
Oral Candidiasis (Thrush)
- Fungal infection of the oral mucosa
- Most common infants/newborns
- HR: immune d/o’s, corticosteroid MDIs, antibiotic use
- May be transmitted bw BF mom and baby
Oral Candidiasis (Thrush):
Nursing Management
- Meds and Education
- Nystatin topically younger / swish and swallow older
- Fluconazole – SE’s hepatotoxicity, N/V
- BF mom’s much treat as well
- Keep bottles and pacifiers clean
- Wash toys
Hypertrophic Pyloric Stenosis
- The circular muscle of the pylorus becomes hypertrophied causing thickness in the luminal side of the pyloric canal
- The thickness causes an gastric outlet obstruction
- Nonbilious vomiting 3-6 weeks of life – becomes more frequent and forceful - - projectile
- 2-3.5/1000 live births Males > Females
Hypertrophic Pyloric Stenosis:
Treatment
Pylorotomy
Hypertrophic Pyloric Stenosis:
Nursing Assessment
- Forceful, nonbilious vomiting
- Hunger after vomiting
- Wt loss
- Dehydration
- Hard moveable “olive” mass in RUQ
Intussusception
- Proximal segment of the bowel “telescopes” into a more distal segment
- edema, vascular compromise and partial/total obstruction
- Intermittent telescoping then reduces spontaneously
Intussusception:
Treatment
Barium/Air enema or Surgery
Intusussception:
Nursing Assessment
- Severe pain intermittent (drawing knees up) vomiting, diarrhea, currant-jelly stools, bloody, lethargy, may be able to palpate sausage shaped mass in upper mid abdomen
Intusussception:
Nursing Management
IVF, support for procedure
Malrotation
- occurs from a disruption in embryonic development
- intestine is abnormally attached
- mesentery narrows twisting on itself (volvulus)
- Main symptom: bilious vomiting
- abdominal pain, distension, bloody stools
- Most cases first few weeks of life – but may occur when older
Malrotation:
Therapeutic Management
Surgery - Ladd procedure straighten out intestine and divide the bands that contribute to misalignment
Appendicitis
- Acute inflammation of appendix
- Peaks second decade of life
- Obstruction of the appendix: possibly from fecal matter
- IF it perforates inflammatory fluid and bacteria leak into abdominal cavity = Peritonitis (more common younger children)
- Older children more mature omentum – making an abscess
Nursing Assessment: Appendicitis
- Hx: may be gradual onset
- typically sxs progress but are not intermittent
- vague abdominal pain that localizes to RLQ over hours
- N/V after onset of pain
- Small volume, frequent stools
- Fever (low grade) unless perforation (high grade)
Exam: Appendicitis
- ill appearance/uncomfortable
guarded movements
Pain > at McBurneys point RLQ
Distenstion and diffuse pain - peritonitis
Appendicitis:
Dx
- CBC
- CRP
- US vs CT scan
Appendicitis:
Treatment
- nonruptured, nongangrenous appendix preop antibiotics – no post op antibiotics
- suppurative or gangrenous appendix antibiotics post op 48-72hours perforated – antibiotics possible for 7-14 days (may wait on surgery)
- IF abscess develops post op - drains
GERD
- reflux of gastric contents into esophagus
- occurs during relaxation of LES during swallowing, crying, valsava
- Normal first year of life – outgrow 12-18 mos of age
- Sxs: vomiting, irritability with feeding or posturing after feeds, bradycardia
GERD:
Therapeutic Management
- HOB elevated
- upright 30” after feeds
- small, frequent feeds
- Medications: ie prilosec
Constipation
- Typically presents during TT years
- Painful experience during defecation turns to fear of defecation
- and withholding behaviors
- Organic causes are rare: sign of disease ie spina bifida or sacral agenesis
- affects 30% of pedi population
- Failure to achieve complete evacuation of the lower colon
- BF: stool with each feed, sometimes skip 2-3 days
- Bottle fed: 1-2 per day, may skip 2-3 days
Functional Constipation at least two of the following over 1mos:
- less than 3 BM / week
- at least one episode fecal incontinence/week (post Toilet trained)
- excessive stool retention hx
- hard/painful BM
- large fecal rectal mass
- stool passage volume clogs toilet
- stool withholding behavior (retentive posturing)
Encopresis
soiling of fecal matter into underwear beyond age of expected TT (4-5 yo)
Constipation:
Nursing Management
- Toileting Behaviors: regular toileting times, positive reinforcement for toileting
- Dietary changes
- Medications: suppositories/enema, miralax, colace, senna
Hirschprung Disease (congenital aganglionic megacolon)
- disorder of motility of the intestinal track resulting in obstruction
- most commonly characterized: Failure to pass a meconium within first 24 hours of life
- Lack of ganglion cells in the intestine - inadequate motility
- Can occur anywhere from rectosigmoid colon all the way to small intestine
Hirschprung Disease (congenital aganglionic megacolon): Nursing Assessment
Hx: Passage of meconium
* did require rectal stimulation
* Down syndrome or family hx higher incidence
Exam: Abdominal distension
* may stool with rectal stimulation / typically stool not in rectum until after stimulation
Dx: rectal suction bx – aganglionic cells
Hirschprung Disease (congenital aganglionic megacolon): Therapeutic Management
- initially may do rectal dilations
- Surgery: resection / ostomy while healing
Nursing Management post op:
Hirschprung Disease (congenital aganglionic megacolon):
- Ostomy care, I+O’s, skin care
- Observe for signs and symptoms of enterocolitis: fever, distension, rectal bleeding
Short Bowel Syndrome
- Nutrient malabsorption – excessive intestinal fluid and electrolyte loss
- Occurs after massive small intestinal resection
- Most common causes are NEC, small intestinal atresia, gastroschisis, malrotation or trauma to small intestine
- Goals: minimize bacterial overgrowth and maximize nutrition
- Management: possible antibiotics prophylactically, vitamin and mineral supplementation, antidiarrheals, TPN
Inflammatory Bowel Disease
- Crohns and UC
- Cause: UK
- 15-20% diagnosed in childhood/adolescence
- Exacerbations & remissions; chronic, sometimes debilitating
Crohns
affects large and small intestines (can affect entire alimentary canal, mouth – anus)
- Lesions full thickness, acute and chronic inflammation, noncaseating granulomas, extraintestinal fistulas, abscesses, strictures, and fibrosis
- Abdominal pain, diarrhea with blood if colon involved, perianal disease, fistula, abscess, anorexia
Ulcerativecolitis
- affects only large intestine and rectal mucosa (proctitis)
- guishing features Crohns and UC
- Superficial, acute inflammation of mucosa
- Abdominal pain, bloody diarrhea, urgency, tenesmus
Celiac Disease
- Immunologic Disorder
- Gluten causes damage to the small intestine
- Villi in small intestine damaged d/t immunologic response to
digestion of gluten - Most common chronic GI d/o Europe and US
- Prevalence > 3% - increased if family hx, autoimmune or genetic d/o’s
Celiac
Treatment – Gluten free diet (strict)
Initial presentation: often by age 2
diarrhea, steatorrhea, constipation, FTT/wt loss, Abdominal distention, poor muscle tone, irritability, fatigue, dental d/o’s, anemia, amenorrhea, delayed puberty, nutritional deficiencies
Celiac: Nursing Management
- Gluten free- Diet – Strict
- Dietitian
- Support groups
- Resources
Teaching Guidelines for Dietary Considerations table 20.2
Functional Abdominal Pain
- Approx 2-4 % all pedi outpt visits are r/t recurrent abdominal pain
- Etiology: UK
- May occur as a result of: rectal distension, impaired gastric relaxation in response to pain, or heightened sensitivity to visceral pain
- Psychological responses may occur if pain persistent or recurrent
Functional Abdominal Pain:
Nursing Management
- Typically a battery of tests are completed blood, Xrays, other diagnostics r/t complaints to r/o other organic causes
- Identifying triggers and increasing coping skills
- Return to activities/school – keep routines
Biliary Atresia
- Cause: UK
- Absence of all or some of the major biliary ducts
- resulting in obstruction of bile flow
- Cholestasis occurs
Biliary Atresia:
Nursing Assessment
- Light beige stools (Normal stool color for infants is yellow, green or brown.)
- Dark brown urine
- Distended abdomen
- Hepatosplenomegaly
- Difficulty gaining weight
- Ascites
- Cirrhosis in several mos if untreated
Biliary Atresia:
Management
- Surgery (Kasai procedure) most successful before 45 days old
- if not successful, or later in age, may need liver transplant
- Other D/o’s Hepatitis, Pancreatitis, Gallbladder Disease
