GI Flashcards
Functions of GI System
- ingestion, digestion, and absorption of fluids and nutrients
- metabolism of needed nutrients
- excretion of waste products
Any alteration in GI system…
decreases body’s ability to obtain nutrients, thus impairing growth
(difference in peds)
Pediatric Differences: GI
- GI system immature at birth
- sucking is a primitive reflex
- infant stomach is small
- peristalsis is increased
- digestive enzymes deficient
- liver function immature
Nursing Care Priorities: GI
- assessment
- establish feeding
- prevent infection
- monitor for serious infection
- protect airway
- protect suture line
Cleft Lip/Cleft Palate
(CL/CP)
- occur during 3rd and 12th week of gestation
- occur singly or in combination, must more together
- maxillary and nasal processes fail to fuse
- 10-50% cases have other defects (Trisomy 13)
Cause of Cl/CP
- multifactoral
- environment: maternal smoking and alcohol, phenytoin, genetics
- folate: added to breads and cereals in 1998, deceased incidence of clefts
Diagnosis: Cleft Palate
-cleft palate without cleft lip may not be detected at birth
slide a gloved finger directly across the newborn palate
Diagnosis: Cleft Lip
- detected at birth or fetal U/S by 13-26 weeks
- size varies a small notch to a complete cleft
- may be unilateral or bilateral
Problems with cleft lip and palate
- recurring OM, Tempanic Membrane scarring, hearing loss
- speech impairment/delay
- improper tooth alignment
- long term problems, social adjustment, threat to self image
EBP: CL/CP and risk for dental caries
- children with CL/CP had higher risk of dental caries
- higher risk factors: poor oral hygiene and higher levels of salivary lactobacilli
- higher risk children had more caries
Therapeutic Management of CL/CP
- collaboration of specialists: plastic surgery, ENT, speech therapist, and dentist
- closure of clefts, prevention of complications, facilitation of normal growth and development of the child
Surgical Correction: Cleft Lip
- cheiloplasty, surgery
- usually repaired by 3-6 months
- lip sutured together
- protect suture line from tension/trauma
- elbow restraints
Surgical Correction: Cleft Palate
- platoplasty, surgery
- CP repaired by 18 months but usually done earlier (6-12 months)
- protect tooth buds
- allows for development of normal speech (first words)
Nursing Management: Emotional Support
- big deal
- may generate negative responses in both nurses and parent
- have a positive aspect of infant’s physical appearance
- be positive regarding surgical correction
- before positive aspect of infant’s physical appearance
- before and after photographs of possible cosmetic improvements
Nursing Management of CL/CP: Pre-op feeding
- cleft lip/palate reduces ability to suck
- some CL babies may breastfeed
- mother’s breast soft, fill gap caused by cleft
- CP makes it difficult to create suction
- food enters nasal cavity through cleft (OM, fluid accumulation)
- bottle feed with expressed breast milk
- hold head in upright position
Special feeders
long nipples with enlarged holes, gravity nipples with squeezable bottle
Nursing Management: Cleft Lip Post-op Care
- clear liquids - dropper or syringe
- formula/breast feeding resumed when tolerated
- aspirate oral/nasal prn (soft suction tip catheter)
- maintain suture line
- elbows in soft restraints
- no prone position
- minimize crying pain med prn
- incision care, antibiotic cream
Nursing Management: Cleft Palate Post-op Care
- start with clear fluids from syringe or dropper
- advance to formula/breast milk by cup
- protect sutures, no pacifier
- no chewing, pureed diet, no hard foods
- soft tip suction prn
- pain management
Esophageal Artesia and Tracheoesophageal Fistula
- rare congenital malformations, occur by the 4th week of gestation
- cause unknown
- the foregut fails to lengthen, separate and fuse into two parallel tubes
- esophagus may end up in a blind pouch or develop as a pouch connected to the trachea by a fistula
Clinical Manifestations of Esophageal Atresia and Tracheoesophageal Fistula
- excessive salivation and drooling
- the three C’s of TEF: Coughing, Choking, Cyanosis
- feeding: fluid comes out nose and mouth
- apnea, grasping with frothy sputum
- risk of aspiration and penurmonia
Diagnosis of Esophageal Atresia and Tracheoesophageal Fistula
- established clinically: difficulty feeding, excessive drooling, choking, apnea, coughing, cyanosis
- confirmed by attempting to pass a NGT
- x-ray stomach, air pilled pouch
- other tests done R/O associated defects: abdominal ultrasound and echo
Treatment of Esophageal Atresia and Tracheoesophageal Fistula
- tube inserted to suction the upper pouch
- IVF, IV antibiotics
- surgery: accomplished in stages
- stage 1: ligation of fistula, G tube placement
- stage 2: 2 ends of esophagus reconnected if possible
- may need repeated surgeries
Nursing Management: Pre-op Care of Esophageal Atresia and Tracheoesophageal Fistula
- NPO/IVF (offer pacifier)
- maintain patent airway, suction, HOB elevated
- continuous or LIS for blind pouch
- constant monitoring of vital signs and condition: surgical emergency
Nursing Management: Post-op Care of Esophageal Atresia and Tracheoesophageal Fistula
- gastric decompression - GT to drain
- GT care teaching
- administer IVF/antibiotics/watch electrolytes
- TPN until G tube feeds or oral feeding tolerated
- parental support: encourage to hold infant, express emotions
Pyloric Stenosis
- hypertrophic obstruction of the circular muscle of the pyloric canal
- occurs in 1-3 per 1000 live births, may be familial
- male to female ratio 6:1
- seen more frequently in firstborn white males
Pathophysiology for Pyloric stenosis
- pylorus sphincter narrows due to progressive hypertrophy of the circular pylorus muscle
- results in outlet obstruction
Clinical Manifestations of Pyloric Stenosis
- 2-6 weeks after birth
- initially infant appears well or regurgitates after feeding
- vomiting progresses to projectile
- vomiting is non-bilious (no bile in vomit), may be blood tinged
- infant: hungry, irritable, fail to gain weight, fewer and smaller stools
- if goes on too long: dehydration, metabolic alkalosis and increased bilirubin
Clinical therapy: Diagnosis of Pyloric Stenosis
- physical exam: visible peristaltic wave across the abdomen moving from left or right
- olive-size mass in left upper quadrant
- pyloric ultrasound
- upper GI series
Clinical therapy: Treatment of Pyloric Stenosis
- surgery: pyloromyotomy
- release of muscle fibers allows the passage of food and fluid
- high success rate
Nursing Management: Pre-op of Pyloromyotomy
- NPO
- IVF
- Monitor electrolytes
- NGT for decompressing
Nursing Management: Post-op Pyloromyotomy
- pain management
- vital signs monitoring
- establish feeding
- involve parents
- discharge teaching
GASTROESPHAGEAL Reflux (GER)
- return of gastric contents into the esophagus due to relaxation of the lower esophageal or cardiac sphincter
- 50% of FT infants have GER
- higher in premature infants
- males affected 3x more than females
- children with neuro impairment (CP) have increased GER
- peak age is 1-4 months of age, often resolves spontaneously by age 12 months
GERD
- more serious than GER
- spit up any time, even between feedings
- cries and arches back during and after feeds
- eat often but still lose weight
- respiratory problems: cough, wheeze, choking, color changes during feeding (ALTE?)
- may aspirate: pneumonia, apnea
- generalized irritability, poor weight gain, weight loss or delayed growth
Diagnosis of GERD
- hx of feeding, vomiting episodes, pain with feeding
- upper GI series: UGI: check for anatomic abnormalities
- pH probe monitoring: valid and reliable measure of reflux, determines number of reflux episodes
Treatment of GERD
- depends on severity
- mild: “happy spitter”
- modification of feeding habits: small frequent feeds, frequent burping
- thicken formula with rice cereal (1 tsp RC/ 1 oz formula) make nipple hole bigger
- position: hold child upright after feeds for 20-30 min
- supine position while sleeping due to risk of SIDS (AAP)
Pharmacological Tx for GERD
- moderate to severe
- poor weight gain, irritable, no improvement with modification of feeding habits and position
- H2 Receptor Antagonists
- Proton Pump Inhibitors
H2 Receptor Antagonists
Action: decrease gastric acid production
“silent reflux” reflux without vomiting
Ranitidine (Zantac)
Fomatidine (Pepcid)
Proton Pump Inhibitors
Action: blocks acid production by inhibiting proton pumps, increases LES tone, more effective than H2 receptor agonists
- works better than H2
- risks of aspiration patients
- insurance issues (ranitidine first)
Lansoprazole (Prevacid)
Omeprazole (Prilosec)
Severe GERD
- failure to thrive, aspiration
- surgical management: Nissen Fundoplication
- Gastrostomy tube is inserted during surgery and left in place for 6 weeks or longer
Nissen Fundoplcation
involves a 360 degree wrap of the fundus of the stomach around the distal esophagus
-acts like a sphincter
In children with GERD
- observe for respiratory distress, monitor VS
- provide adequate nutrition, small frequent feeds
- position, increase HOB, prone position with caution while awake only
Post-op Fundoplication
- GT: maintain integrity, secure tube, provide pacifier
- educate parent about home care: feeding, position, medication, suctioning
Hirschsprung Disease
- congenital aganglionic megacolon
- decreased motility causes obstruction of the intestines
- incidence: 1:5000, males more than females
- familial tendency
- can occur with Down syndrome, congenital heart disease, other syndromes
Pathophysiology of Hirschsprung
- absence of ganglion cells in one segment of the colon causes lack on innervation in that segment
- usually rectosigmoid colon
- prevents peristalsis: leads to blockage, and stool builds up behind blockage
- results in constipation, abdominal distension, poor weight gain, poor growth
Clinical Manifestations of Hirschsprung Disease in Newborn
- lack of meconium stool
- bilious vomiting
- S/S enterocolitis
Clinical Manifestations of Hirschsprung Disease in Older Child
chronic constipation alternating with diarrhea, ribbon-like stools, abdominal distension, poor weight gain, decreased growth
Diagnosis of Hirschsprung Disease
- barium enema, abdominal xray, dilated bowel
- rectal examination: rectum small, no stool
- anal manometry
- (gold standard) rectal biopsy: absence of ganglionic cells CONFIRMS DIAGNOSIS
Treatment child with milder defect (Hirschsprung)
- dietary modification: high fiber diet
- stool softeners
- enemas to prevent impaction in children not toilet trained
Treatment of infant with Hirschsprung
- surgical removal of the aganglionic bowel and pull through procedure
- temp colostomy: closure 2-6 months later
- normal bowel function depends on the amount of bowel involved
Enterocolitis
inflammation of small intestine and colon
- results in ischemia and ulceration of the bowel wall
- may occur before or after surgery
- greatest cause of morbidity and mortality in Hirschsprungs
Enterocolitis presents with…
-abdominal pain, fever, foul smelling and/or bloody stools
When should enterocolitis be suspected in neonate…
- distended abdomen
- feeding intolerance with bilious vomiting
- delay of meconium
If enterocolitis is not recognized…
- progress to sepsis
- perforation
Tx: IVF, antibiotics, NGT, monitor electrolytes and VS
Nursing Management Pre-op of Enterocolitis
- dependent on condition
- assess: skin turgor, fontanels, urinary output, MMs
- monitor fluid and electrolyte balance
- maintain nutrition, TPN if NPO
- ensure patent NG tube if NPO
- monitor abdominal circumference
- encourage parent to hold and cuddle infant
Nursing Management Post-op of Enterocolities
-PO clear or breast milk in several hours
- Observe for signs of enterocolitis
- Monitor I/O
- Avoid pressure on incision – diapering
- Provide comfort, pain relief
- Encourage parents to partake in infant’s care
- Discharged when tolerating full feeds
Intussusception
- occurs when one portion of the intestine invaginates or telescopes into another
- one of the most frequent causes of intestinal obstruction in children
- more common in males
- peak age: 3-9 months, up to 3 yrs
cause of intussusception
unknown, viral infections, intestinal polyps, medications, Rotashield vaccine
Pathophysiology of Intussusception
- most common site is the ileocecal valve
- telescoping of the intestines obstructs the passage of stools
- intestinal walls rub together causing inflammation, edema, and decreased blood flow
- leads to necrosis, perforation, hemorrhage, peritonitis
Clinical Manifestations of Intussusception
- sudden onset of abdominal pain, draw legs to chest
- may vomit
- periods of calm between episodes of pain
- abdominal pain and distension
- palpable “sausage-shaped mass” in upper right quadrant
- passage of “currant-jelly stools” (blood and mucus stool)
Diagnosis of intussusception
- made on subjective findings, history
- abdominal xray
- abdominal US CONFIRMS DIAGNOSIS
Treatment of Intussusception
- may spontaneously reduce without treatment
- hydrostatic reduction by air, saline, or barium enema
- rare: surgery to reduce or to remove necrotic bowel
- NG tube for gastric decompression
Nursing Management Pre-op: Intussusception
- maintain IVF
- fluid and electrolye balance
- NGT decompression
- antibiotic therapy
Nursing Management Post-op: Intussusception
- monitor for infection
- pain management
- NGT patency
- assess VS
- check for abdominal distension
- bowel sounds
When to discharge from Intussusception surgery
- when tolerating feeds
- D/C teaching: can reoccur after enema or surgery, must return for fever, pain, bloody stools
If infant is NPO…
offer pacifier to continue sucking reflex
-can lead to difficulty eating and develop food aversions
Newborn BMs
1-10 BMs a day
NB NB vomit
non-bilious and non-bloody vomit
bilious vomiting
-if due to obstruction it is a lower obstruction and more serious
Projectile vomiting hallmark sign of…
pyloric stenosis
Priority in the care of an infant with GERD
risk for aspiration
hallmark sign of intussception
currant jelly stools and tension of abdomen
