GI Dysfunction Flashcards
dehydration
A common body disturbance in infants and children, total output of fluid exceeds total intake
mild dehydration percentage loss in infant and children
loss of less than 5% in infants and 3% in children
moderate dehydration percentage loss in infant and children
loss of 5%-10% in infants and 3%-6% in children
severe dehydration percentage loss in infant and children
loss of more than 10% in infants and 6% in older children
predictors of fluid loss
oChange in level of consciousness
oAltered response to stimuli
oDecreased skin elasticity and turgor
oProlonged cap refill
oIncreased heart rate
oSunken eyes and fontanels
what is usually the earliest sign of dehydration
tachycardia
therapeutic management for mild-moderate dehydration
*Oral rehydration over 4 to 6 hours
therapeutic management for sever dehydration
*IV fluids to expand fluid volume and replace deficits
acute diarrhea
sudden increase in frequency and a change in consistency of stools, often caused by an infectious agent in the GI tract
chronic diarrhea
increase in stool frequency and increased water content with a duration of more than 14 days
most pathogens that cause diarrhea are spread by…
the fecal-oral route from person to person
Close contact (day care centers)
What is the most important cause of serious gastroenteritis among children
rotavirus
management for diarrhea
oOral rehydration therapy
oEarly reintroduction to a normal diet is recommended
oEducation regarding s/s of dehydration
oSkin care to prevent excoriation
oEducation regarding prevention measures
constipation
*An alteration in the frequency, consistency, or ease of passing stool
constipation is often associated with
oBlood-streaked or retained stool
oAbdominal pain
oLack of appetite
oStool incontinence
Encopresis
oRepeated and involuntary defecation in a child older than 4, may be the result of constipation
management of constipation and encopresis
high fiber diet, exercise, regular toileting habits after meals, stool softeners, emotional support - helping child to feel in control
Hirschsprung Disease
Lack of innervation often in lower portion of bowel, no peristaltic waves causing chronic constipation above this area, megacolon
*Rectal sphincter fails to relax - Ribbon-like stool from passing through the narrow segment
treatment of Hirschsprung Disease
1) One-stage surgical treatment - transanal pull-through OR
(2)Colostomy (temporary) and then removal of aganglionic section
Hirschsprung Disease is most commonly seen in
neonate, 4x more common in males
clinical manifestations of Hirschsprung Disease in neonates
Failure to pass meconium within 24-48 hours of birth, bilious vomiting
clinical manifestations of Hirschsprung Disease in infancy & children
constipation, recurrent diarrhea, ribbon-like, foul-smelling stool, failure to thrive
diagnosis for Hirschsprung Disease
Rectal biopsy to detect absence of ganglion cells is definitive diagnosis
post of for surgery of Hirschsprung Disease
assess site, NPO until bowel sounds return, IV fluids, may require daily anal dilations
Gastroesophageal Reflux
*The presence of abnormal amounts of gastric contents in the esophagus, upper airways, and tracheobronchial area.
resulting effects of Gastroesophageal Reflux
oAspiration of gastric contents
oRecurrent pneumonia
oPulmonary disease
oEsophagitis
oEsophageal stricture
conservative treatment for GERD
oFeeding thickened formula
oFeeding small, frequent meals
oPositioning - elevating head of the bed
oAcid suppression and neutralization medications (Zantac, Prevacid, Prilosec)
surgical treatment for GERD
Nissan fundoplication (Upper end of stomach (fundus) is wrapped around the lower portion (inferior) of the esophagus creating a lower esophageal sphincter or cardiac sphincter)
how long should an infant be held upright after a feeding for GERD
30 minutes following a feeding
when should a PPI be administered
30 minutes before breakfast and if a second dose is prescribed - 30 minutes before the evening meal.
teaching for PPIs
Remind parents that they may not see results right away as it takes several days for a steady state of acid suppression.
early symptoms of appendicitis
oAnorexia,
oChild doesn’t seem “normal”,
oN&V, fever
oPain is diffuse at first then gradually localizes to RLQ (rebound tenderness)
*MCBURNEYS POINT
oIf pain is suddenly relieved without intervention, suspect perforation
McBurney’s point
a point midway between the anterior superior iliac crest and the umbilicus, pain indicating appendicitis
how long does antibiotics last for peritonitis
7-14 days of abx
pre op for appendicitis
oNPO, IV therapy
oPosition of comfort
oPrepare for surgery
post op for appendicitis
oMonitor VS
oMaintain IV and then advance diet as tolerated
oAssess for pain
oEncourage ambulation
oMonitor incisional site(s)
oDischarge teaching
management for Ruptured Appendix (Peritonitis)
*IV antibiotics
*NPO, NG tube to low continuous suctioning
*May have a drain placed in surgery
*Pain management
*Longer hospital stay
Crohn’s Disease
*An inflammatory and ulcerative disease affecting any part of the alimentary tract from the mouth to the anus.
*Affects the full-thickness of the intestine
*Inflammation “skips” - disease free areas are common
manifestions of chrons
*Diarrhea, occult blood (if colon involved)
*Cramping abdominal pain aggravated by eating
*Growth retardation
*Weight loss and fatigue
*Intestinal blockage
treatment for Crohn’s Disease
oCorticosteroid therapy to induce remission
oAntibiotics to eradicate inflammatory bacterial agents
oInfliximab therapy (tumor necrosis factor blocker)
oImmunosuppressives
oNo known cure
oMay require an ileostomy or colostomy
Infliximab therapy
tumor necrosis factor blocker used to treat crohns
Ulcerative Colitis
*A recurrent inflammatory and ulcerative disease
*Affecting primarily the large intestine
*Continuous distribution; superficial inflammation
manifestations of ulcerative colitis
*Frequent, bloody stools 10-20/day
*Abdominal pain
*Anorexia, pallor, and fatigue
*Electrolyte imbalance
*Ten- to 20-pound weight loss over 2 months
treatment of ulcerative colitis
*Antidiarrheal
*Corticosteroids therapy to induce remission
*Antibiotics may be used
*Immunosuppressives
*Analgesics and narcotics for pain
oNutritional support
oSurgical intervention is eventually needed in 25% of cases and provides a cure
Biliary Atresia
*A progressive inflammatory process that causes bile duct fibrosis
*Results in an obstruction of the bile flow
what does biliary atresias cause
*Causes cholestasis resulting in jaundice
*Eventually progressive fibrosis with end-stage cirrhosis of the liver
clinical manifestations of biliary atresia
oStools will be chalky and white d/t lack of bile pigment
oJaundice of skin and sclera
oEnlarged liver and abdominal distention
-poor weight gain
treatment for biliary atresia
Kasai procedure, liver transplant
Kasai procedure
Procedure done for treatment of biliary atresia in which the bowel lumen is connected to the bile duct
the kasai procedure is most successful if performed …
before 10 weeks of age
if biliary atresia is not identified early enough or Kasai is not successful…
*liver transplant by age of 2
vitamin and calorie support for biliary atresia
Special formula containing medium-chain triglycerides
cleft lip and palate are results from…
*embryonic failure of the soft tissue and/or bony structure to fuse during embryonic development
when does cleft lip/palate defect occur
occurs at approximately 6‐8 weeks gestation
Cleft lip
*a separation of the two sides of the lip
Cleft palate
a midline opening of the palate
Etio Multifactoral
a combination of environmental and genetic factors
clinical manifestations of cleft lip/palate
oVisible unilateral or bilateral cleft lip
oPalpable and/or visible cleft palate
oCleft of the alveolus (gum line)
oNasal distortion
oFeeding difficulties
complications of cleft lip/palate
oSpeech difficulties
oMalocclusion
oExcessive dental decay
oChronic otitis media
oAltered self-esteem and body image
Malocclusion
abnormal tooth eruption pattern; abnormal development of the way the mandible and maxilla meet
cleft lip is repaired at
2 to 3 months of age
(May need modifications at 4 to 5 years of age)
cleft palate is repaired before
12 months of age
goal of cleft lip surgery
to achieve lip competence and to create the most natural-appearing lip
goal of cleft palate surgery
reconstruction of the palatal musculature to allow normal speech development
preoperative care for cleft lip/palate
oFacilitate parents’ positive adjustment to infant
oRefer to cleft palate team
oProvide information and resources to parents
oMaintain adequate nutritional intake
oMonitor respiratory status
adequate nutritional intake for cleft lip/palate
*Use special feeding equipment
*Sit upright
*Learn baby’s feeding cues
postoperative care for cleft lip/palate
oDo not allow the child to use anything that creates suction in the mouth (straws, pacifiers)
oNothing hard in the mouth (candy, crackers or a spoon)
oClean suture line with normal saline
oPosition to allow secretions to drain
oProvide pain medication regularly to prevent crying which can place stress on the suture line
postitioning after cleft lip/ palate surgery
-usually on back to prevent rubbing the face on the bedding
-Back to Sleep
Haberman bottle
a squeeze bottle and a soft nipple with a valve, prevents the baby from ingesting excess air during the feeding, used for infants with cleft lip/palate
feeding for infant with cleft lip/palate
-Place infant in an upright (almost sitting) position
-Place nipple in the mouth - position where there is more palate tissue
-Use chin support with your pinky finger to improve the oral seal
-The nipple should have a X cut in it (soft nipple) - may have to adjust the size of the X
-If using a Haberman - compress bottle in time with the infant’s chewing motions
-Allow for rest periods
what helps keep infants hands away from incision after cleft lip/palate surgery
Elbow immobilizers - keep hands away from mouth for 7-10 days
palate/lip care after feeding
*Rinse mouth after feeding palate repair, clean lip repair site with a wet sterile cotton swab after feeding
Esophageal atresia and tracheoesophageal fistula (TEF)
*failure of the esophagus to develop as a continuous passage and a failure of the trachea and esophagus to separate into distinct structures.
clinical manifestations of esophageal atresia (TEF)
oExcessive salivation and drooling
oThree C’s of tracheoesophageal fistula:
*Coughing
*Choking
*Cyanosis
oApnea
oIncreased respiratory distress during feeding
oAbdominal distension
Three C’s of tracheoesophageal fistula:
*Coughing
*Choking
*Cyanosis
treatment of Esophageal Atresia/TEF
oMaintain patent airway
*Intermittent or continuous suctioning
oPrevention of pneumonia
surgery for Esophageal Atresia/TEF
*Thoracotomy with division
*Ligation of the TEF and an end-to-end or end-to-side anastomosis of the esophagus
*G-tube may be required
Pyloric Stenosis
*Stomach contents unable to empty (usually diagnosed at 4‐6 wks) infant vomits in a projectile way right after eating and then is hungry
an infant with pyloric stenosis is at risk for
metabolic alkalosis
treatment for pyloric stenosis
oSurgical correction (Pyloromyotomy)
oLaparoscopy
oIncision is high risk for infection due to location in diaper area‐fold diaper down to avoid contamination
post op for pyloric stenosis
oBegin small feedings 4 to 24 hours post-op
clinical manifestation of pyloric stenosis
Palpable hard, moveable, “olive” pyloric mass in the right upper quadrant felt many times but not always
Celiac Disease
*A genetic disorder in which gluten causes damage to the small intestine
*Villi of the small intestine absorb nutrients into the bloodstream - now damaged causing malnutrition
treatment for celiac disease
*strict gluten-free diet
clinical manifestations of celiac disease
oSteatorrhea (fatty stools)
oDiarrhea and/or constipation
oVomiting
oFailure to thrive or weight loss
oNutritional deficiencies (low vitamin D)
oAnemia
Celiac crisis
extreme vomiting and diarrhea. Requires IV therapy and electrolyte replacement
*Diagnostic Studies for celiac disease
oCBC
oAnti-tissue transglutamase antibodies
oTotal immunoglobulin A (IgA)
oIgA antiendomysial antibodies
oVitamin B 12 level, ferritin, total iron-binding capacity, folate
oStool for occult blood, fat
oEndoscopy and tissue biopsy for definitive diagnosis
when doing a biopsy for celiac disease…
Do not start gluten free diet before endoscopy
Intussusception
*Proximal segment of bowel telescopes into a more distal segment
intussusception usually occurs before the age of
2 years
clinical manifestations of intussesception
oSudden onset of crampy abdominal pain (Typically flares and then regresses every 15 to 20 minutes)
oSevere pain where child draws up knees and screams
oSausage-shaped abdominal mass
oCURRANT JELLY STOOL
Intussusception needs to be treated immediately or
necrosis of bowel can occur
what is used fro diagnosis of intussesception
Barium enema - use for diagnosis but may be successful in correcting the problem otherwise requires surgery
volvulus
A portion of the intestine twists around itself
clinical manifestations of volvulus
*Intense crying and pain
*Pulling up legs
*Abdominal distension
*Vomiting, usually bilious
*Tachycardia and tachypnea
intervention for volvulus
*Surgical emergency
clinical manifestations Necrotizing Enterocolitis
oTense, distended abdomen
oIncrease in abdominal circumference
oLarge residuals greater than 2 mL
oStool positive for occult blood
oIncreased periods of apnea, decreased BP, temperature instability
treatment of Necrotizing Enterocolitis
oRest the bowel à TPN/Lipids
oAntibiotics
oSurgery
Omphalocele
*A defect of the umbilical ring that allows evisceration of the abdominal contents into an external peritoneal sac.
*Defect varies in size
*Usually detected on prenatal ultrasound
Gastroschisis
*A herniation of the abdominal contents through an abdominal wall defect
*No peritoneal sac protecting the herniated organs
*Exposure to amniotic fluid causes organs to thicken, become edematous, and inflamed
nursing management for Omphalocele and Gastroschisis
oPrevention of hypothermia
oKeep baby in a radiant warmer to maintain temperature
oMaintaining perfusion to the eviscerated abdominal contents by minimizing fluid loss
oCovered with a non-adherent sterile dressing
oMay require 2-3 times maintenance fluids to maintain perfusion
oProtecting the abdominal contents from trauma and infection
oUtilize strict sterile technique to prevent contamination
