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Pedi Exam #2 > Gastrointestinal System - Pedi > Flashcards

Gastrointestinal System - Pedi Flashcards

1
Q

GASTROINTESTINAL SYSTEM

A

*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

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2
Q

DIFFERENCES BW PEDI AND ADULT

A

*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

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3
Q

PEDIATRIC GI ASSESSMENT (Health History)

A

*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?

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4
Q

PEDIATRIC GI ASSESSMENT, CONT.
(Physical Exam)

A

*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

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5
Q

GI NURSING GOALS/INTERVENTIONS

A

*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

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6
Q

GI/GI TRACT DISORDERS
(Structural anomalies)

A

*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

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7
Q

GI/GI TRACT DISORDERS
(Acute GI Disorders)

A

*Dehydration
*Vomiting
*Gastroenteritis
*Hypertrophic Pyloric Stenosis
*Necrotizing Enterocolitis (NEC)
*Malrotation and Volvulus
*Intusussception
*Appendicitis
*Peptic Ulcer Disease (PUD)
*Rotavirus, Clostridium difficile (c.diff), Giardia

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8
Q

GI/GI TRACT DISORDERS
(Chronic GI disorders)

A

*Gastroesophageal Reflux (GER)
*Constipation
*Encopresis
*Hirschsprung Disease
*Short Bowel Syndrome
*Inflammatory Bowel Disease
*Crohn’s Disease
*Ulcerative Colitis
*Celiac Disease

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9
Q

GI/GI TRACT DISORDERS
(Hepatobiliary Disorders)

A

*Pancreatitis
*Hyperbilirubinemia (Jaundice)
*Biliary Atresia
*Hepatitis
*Cirrhosis & Portal Hypertension

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10
Q

STRUCTURAL ANOMALIES
(Cleft Lip and Palate)

A

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

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11
Q

STRUCTURAL ANOMALIES:
Complications cleft lip and palate

A
  • feeding difficulties
  • insufficient growth
  • altered dentition
  • delayed or altered speech
  • otitis media with effusion
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12
Q

STRUCTURAL ANOMALIES:
Treatment cleft lip and palate

A

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

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13
Q

STRUCTURAL ANOMALIES:
Cleft Lip and Palate Nursing Management

A
  • 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
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14
Q

STRUCTURAL ANOMALIES:
Cleft lip and palate, nursing management

A

*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

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15
Q

STRUCTURAL ANOMALIES:
Esophageal Atresia

A

*proximal and distal ends of esophagus do not communicate
*upper esophagus ends in a pouch / lower portion ends above the
diaphragm

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16
Q

STRUCTURAL ANOMALIES:
Tracheoesophageal Fistula

A
  • 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
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17
Q

STRUCTURAL ANOMALIES:
Esophageal Atresia and Tracheoesophageal Fistula

A

*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

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18
Q

STRUCTURAL ABNORMALITIES:
Nursing Management Atresia and Fistula

A

*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

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19
Q

STRUCTURAL ANOMALIES:
Omphalocele

A

*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

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20
Q

STRUCTURAL ANOMALIES:
Gastroschisis

A
  • 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
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21
Q

STRUCTURAL ANOMALIES:
Nursing Assessment Gastroschisis and Omphalocele

A
  • size of deformity
  • appearance of organs
  • look for twisting of intestine
  • Full exam looking for other deformities ie VACTERL
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22
Q

STRUCTURAL ANOMALIES:
Nursing Management Omphalocele/ Gastroschisis

A
  • 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
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23
Q

STRUCTURAL ANOMALIES:
Omphalocele/ Gastroschisis
(Treatment, Surgery, Post op)

A

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

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24
Q

STRUCTURAL ANOMALIES:
Anorectal Malformations

A

Anomalies Associated with:
* VACTERL syndrome
* Esophageal atresia
* Intestinal atresia
* Malrotation
* Renal agenesis
* Hypospadias
* Vesicoureteral reflux
* Bladder exstrophy
* Cardiac anomalies
* Skeletal anomalies

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25
Q

Anorectal Malformations

A

**Imperforate Anus
*** Rectum ends in a blind pouch
* Level of defect influences outcome – fecal continence
* Staged repair
* Colostomy while waiting repair

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26
Q

Nursing Assessment Imperforate Anus

A
  • 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
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27
Q

Nursing Management: Imperforate Anus

A
  • 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
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28
Q

STRUCTURAL ANOMALIES:
Meckel’s Diverticulum

A

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

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29
Q

Meckel’s Diverticulum:
Common Complications

A
  • Anemia
  • Bleeding
  • Ulcer
  • Obstruction (volvulus / intussusception)
  • Typically occur in first 2 years of life
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30
Q

Presentation Meckel’s Diverticulum

A
  • Rectal bleeding, painless
  • Abdominal pain
  • Bloody, mucusy stools
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31
Q

Meckel’s Diverticulum: Dx

A
  • Meckels Scan (radionuclide scan), CBC and metabolic panel
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32
Q

Meckel’s Nursing Management

A
  • possibly blood products
  • IV fluids
  • NPO
  • Surgery to repair
33
Q

Inguinal Hernia

A
  • 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
34
Q

STRUCTURAL ABNORMALITIES:
Umbilical Hernia

A

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
35
Q

ACUTE GASTROINTESTINAL DISORDERS: Dehydration

A

*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

36
Q

ACUTE GASTROINTESTINAL DISORDERS: Dehydration Nursing Management:

A
  • 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
37
Q

ACUTE GASTROINTESTINAL DISORDERS: Vomiting

A

*** 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
38
Q

Vomiting: Nursing Assessment

A
  • 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
39
Q

Vomiting:
Nursing management

A
  • Simple vomiting: ORT – 0.5 – 2oz ORS every 15 min age and size dependent
  • Antinausea meds
  • IVF
40
Q

ACUTE GASTROINTESTINAL DISORDERS, CONT.
Diarrhea

A
  • 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

41
Q

Oral Candidiasis (Thrush)

A
  • 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
42
Q

Oral Candidiasis (Thrush):
Nursing Management

A
  • 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
43
Q

Hypertrophic Pyloric Stenosis

A
  • 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
44
Q

Hypertrophic Pyloric Stenosis:
Treatment

A

Pylorotomy

45
Q

Hypertrophic Pyloric Stenosis:
Nursing Assessment

A
  • Forceful, nonbilious vomiting
  • Hunger after vomiting
  • Wt loss
  • Dehydration
  • Hard moveable “olive” mass in RUQ
46
Q

Intussusception

A
  • Proximal segment of the bowel “telescopes” into a more distal segment
  • edema, vascular compromise and partial/total obstruction
  • Intermittent telescoping then reduces spontaneously
47
Q

Intussusception:
Treatment

A

Barium/Air enema or Surgery

48
Q

Intusussception:
Nursing Assessment

A
  • 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
49
Q

Intusussception:
Nursing Management

A

IVF, support for procedure

50
Q

Malrotation

A
  • 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
51
Q

Malrotation:
Therapeutic Management

A

Surgery - Ladd procedure straighten out intestine and divide the bands that contribute to misalignment

52
Q

Appendicitis

A
  • 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
53
Q

Nursing Assessment: Appendicitis

A
  • 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)
54
Q

Exam: Appendicitis

A
  • ill appearance/uncomfortable

guarded movements
Pain > at McBurneys point RLQ
Distenstion and diffuse pain - peritonitis

55
Q

Appendicitis:
Dx

A
  • CBC
  • CRP
  • US vs CT scan
56
Q

Appendicitis:
Treatment

A
  • 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
57
Q

GERD

A
  • 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
58
Q

GERD:
Therapeutic Management

A
  • HOB elevated
  • upright 30” after feeds
  • small, frequent feeds
  • Medications: ie prilosec
59
Q

Constipation

A
  • 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
60
Q

Functional Constipation at least two of the following over 1mos:

A
  • 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)
61
Q

Encopresis

A

soiling of fecal matter into underwear beyond age of expected TT (4-5 yo)

62
Q

Constipation:
Nursing Management

A
  • Toileting Behaviors: regular toileting times, positive reinforcement for toileting
  • Dietary changes
  • Medications: suppositories/enema, miralax, colace, senna
63
Q

Hirschprung Disease (congenital aganglionic megacolon)

A
  • 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
64
Q

Hirschprung Disease (congenital aganglionic megacolon): Nursing Assessment

A

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

65
Q

Hirschprung Disease (congenital aganglionic megacolon): Therapeutic Management

A
  • initially may do rectal dilations
  • Surgery: resection / ostomy while healing
66
Q

Nursing Management post op:
Hirschprung Disease (congenital aganglionic megacolon):

A
  • Ostomy care, I+O’s, skin care
  • Observe for signs and symptoms of enterocolitis: fever, distension, rectal bleeding
67
Q

Short Bowel Syndrome

A
  • 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
68
Q

Inflammatory Bowel Disease

A
  • Crohns and UC
  • Cause: UK
  • 15-20% diagnosed in childhood/adolescence
  • Exacerbations & remissions; chronic, sometimes debilitating
69
Q

Crohns

A

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
70
Q

Ulcerativecolitis

A
  • affects only large intestine and rectal mucosa (proctitis)
  • guishing features Crohns and UC
  • Superficial, acute inflammation of mucosa
  • Abdominal pain, bloody diarrhea, urgency, tenesmus
71
Q

Celiac Disease

A
  • 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
72
Q

Celiac

A

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

73
Q

Celiac: Nursing Management

A
  • Gluten free- Diet – Strict
  • Dietitian
  • Support groups
  • Resources

Teaching Guidelines for Dietary Considerations table 20.2

74
Q

Functional Abdominal Pain

A
  • 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
75
Q

Functional Abdominal Pain:
Nursing Management

A
  • 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
76
Q

Biliary Atresia

A
  • Cause: UK
  • Absence of all or some of the major biliary ducts
  • resulting in obstruction of bile flow
  • Cholestasis occurs
77
Q

Biliary Atresia:
Nursing Assessment

A
  • 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
78
Q

Biliary Atresia:
Management

A
  • 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

Pedi Exam #2 (5 decks)

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