Pedi GI Flashcards
Facial defect: frontonasal and maxillary processes did not fuse. First 30-60 days of gestation.
Unknown cause
Contributing factors: Genetics, folic acid deficiency, advanced age, anticonvulsants, ETOH and smoking, family history
25% also have neuro/cardiac anomalies, club foot; 1 in 600-700 births
Cleft Lip/Cleft Palate
Surgical repair. Lip 2-6 months, early repair improves feeding.
Palate 9-18 months, essential for speech development
Cleft Lip/Cleft Palate Treatment
Careful assessment of fluid/caloric intake
Prevent aspiration/respiratory compromise
Unique approach to feeding- positioning, special feeding devices
Assess for respiratory distress, dehydration, weight gain
Control post-op pain; suture removal; prevent infection
Family support, speech therapy
Cleft Lip/Cleft Palate Nursing Considerations
Congential: 3-6 cm outpouching of lower segment of small intestine. Most common birth defect of digestive system. Most children are 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
Xray, U/s, CT
if symptomatic, surgical resection: ex-lap
Meckel Diverticulum
Congenital defect of abdominal wall. Internal organs eviscerate. Sac containing small intestine, colon, spleen, sometimes gonads. Giant sized is over 4.5-5 cm, contains live. Approx 775 babies/year in US. Weeks 6-11 of fetal development. Maternal risk factors: ETOH, smoking, SSRI’s, overweight/obese
High risk of cardiac defects, pulmonary hypoplasia
Treated with Silo surgery
Omphalocele
Protect, minimize fluid/temp loss (wrap with saline-soaked gauze) Pain Prevent infection Hydration/nutritional support NG tube, IV access
Omphalocele and Gastroschisis Nursing Considerations
Congenital defect of abdominal wall, life threatening. Intestines outside body via hole next to umbilicus. May also include stomach, liver. No protective sac/fluid which leads to twisting, shortening, edema.
Cause unknown.
1/3 born to teenage mothers; ETOH, tobacco
Common morbidities, feeding intolerance, NEC, FTT
Treatment is prompt surgical intervention/may be staged; silo
Gastroschisis
Incomplete formation of diaphragm, adominal contents into thoracic cavity, lung compression/hypoplasia. 1 in 2000-5000 births, females 2x more likely. 85% L sided. Severe resp distress. Intermediate intervention after birth: Ventilator, ECMO.
Surgical repair
Congenital Diaphragmatic Hernia (CDH)
ICU-level care; long hospitalizations. Family support (life-altering; 67% survival rate, long term complications). Feeding, pulmonary, re-herniation
Congenital Diaphragmatic Hernia (CDH) Nursing Considerations
esophagus does not connect to stomach (1 in 4000)
Vater (vertebral, anorectal, tracheal, esophageal, renal, radial)/ Vacterl (vertebral, anorectal, cardiac, tracheal, esophageal, renal, radial, or limb); cardiac and vertebral anomalies - 50%
Surgical correction:
Folker- streching
Jejunal interposition
Esophageal Atresia (EA)
connection between esophagus and trachea (90% with EA have TEF)
Vater (vertebral, anorectal, tracheal, esophageal, renal, radial)/ Vacterl (vertebral, anorectal, cardiac, tracheal, esophageal, renal, radial, or limb); cardiac and vertebral anomalies - 50%
Surgical correction:
Folker- streching
Jejunal interposition
Tracheoesophageal Fistula (TEF)
3 mechanisms: Decreased intake and/or increased output, increased insensible loss
Vomiting
Diarrhea
Fever, sweating, wound/tube drainage
Infants and young children especially vulnerable dehydration, (free water), volume depletion (intravascular), hypovolemia
Dehydration
3-5 % volume loss
Mild Dehydration
6-9% volume loss
S/s: tachycardia, decreased urine output, tachypnea, lower BP, delayed cap refill, irritability, thirst, restless, sunken eyes, sunken fontanel, dry mucous membranes, decreased tears
Moderate Dehydration
more than 10% fluid loss
Severe dehydration
Oral: 50mL/kg in first 2-4 hours (1-3 tsp q 15 mins)
Mild to Mod Rehydration
IV: 20 mL/kg in 30-60 mins
Continue until hemodynamically stable (BP and U/O) many will need 40-60 ml/kg
Replacement fluid vs maintenance fluid
Severe rehydration
Nausea, retching, expulsion of stomach contents AKA emesis. More frequent in young children, declines with age. Assess for more serious causes: prolonged and severe- can be life threatening. Assess contents: Bloody? Bilious? Food present? Stool?
Other issues?: GI- diarrhea? Pain? If so, where? Sore throat, ear pain, HA
Highest priority = hydration. Re-hydrate, anti-emetics (over 6 months)
Goals: Resolve within 24-48 hours of onset. Teach: rehydration techniques, positioning; normal u/o, A & O
Vomiting
Acute inflammation of any part of the stomach/intestinal tract, diarrhea vomiting.
Most common in children under 5, under 24 mo. Daycare, sick contacts, travel to foreign country, low socioeconomic status, immunocompromised.
Cause: 75-90% of cases viral. Rotavirus most frequent, norovirus, food sensitivities, stress, fatigue
Mild, moderate, severe: Loose, liquid, watery, mucoid; color? Blood/clots? Abdominal distention; pain/cramping; N&V, headache/muscle aches
Acute Gastroenteritis (AGE)
Affects young infants 3-6 mo. Elongation and thickening of pyloric muscle leading to hypertrophy leading to obstruction of gastric outlet. Projectile vomiting immediately after eating. Increased risk if exposed to erythromycin or azithromycin in 1st 2-6 weeks of life, maternal smoking, bottle feeding, 1st born, C-section, premature. Surgical treament
Pyloric Stenosis
Intestinal necrosis, can be life threatening. Newborn infants (1st few weeks of life). Prematurity = greatest risk factor. Early enteral feeding, bacterial infection, intestinal ischemia. Breastmilk = protective.
S/s: Feeding intolerance, vomiting, abdominal distention, bloody diarrhea
Decompensation- ill appearing, lethargic, apnea/bradycardia
Thorough GI assessment: abd girth q4h, bowel sounds q4h
Treatment: NPO, NG tube, antibiotics, resection if perforation or necrosis
Necrotizing Enterocolitis (NEC)
Bowel obstruction; can be life threatening. One part of intestine prolapses and telescopes into another. 5 mo to 3 y; 80% 2 and under. Abrupt onset of severe, paroxysmal, colicky abdominal pain. N & V, currant jelly/bloody stols. Later: fever & peritonitis, ill, lethargic. Ultrasound
Treat: Reduction with edema, surgery if unsuccessful
Intussusception
Intestine twists upon itself. 1 in 500 births; associated with other abdominal wall defects. Bilious emesis, abdomen firm/distended; bloody stool or no stool.
Treatment: surgery (ladd procedure), possible ostomy
Volvulus/Malrotation
Stomach contents push up into esophagus. Lower esophageal sphincter relaxation. Common; 40% of infants, peaks at 4 mo.
Reflux = “happy spitters” vs miserable, poor weight gain, resp s/s
Thorough history of feeding patterns, vomiting (amount, color, consistency), weight/growth
Gastroesophageal Reflux/ GERD
Feeding techniques (amount, position, burping). PPI (omeprazole) and/or H2 receptor blocker (famotidine). Severe cases: Nissen fundoplication
GERD Treatment
Inflammation of the appendix, obstruction. Most common in 12-18y. Concern: rupture- bacterial peritonitis, shock, sepsis, death
S/s: RLQ pain, cramping, decreased appetite, nausea/vomiting, fever. Rebound tenderness: McBurney’s point, guarding, distention. Sudden relief? rupture likely. Monitor closely for tachycardia, fever, decreased BP (signs of sepsis). Labs, U/S, CT scan.
Surgery (laparoscopy vs. open)
Pain/comfort. Antibiotics/infections. Hydration (NPO; NG tube), emotional support.
Appendicitis
25% of pediatric GI visits. No organic cause - psychological, behavioral. Kids avoid defecation because of: pain, social.
Cycle: stool is retained, water absorbed - becomes harder and larger, more challenging and painful to pass.
Rectum becomes distended- incontinence, loss of rectal sensation/loss of normal urge to go. Distention, pain.
Assess abdomen, stooling patterns, diet/water intake. Exam, xray
Constipation
Disimpact: Enema or PO. Maintenance therapy. Polyethylene glycol, bowel reg, regular toileting, diet/activity (*encopresis)
Constipation Treatment
Birth defect; 1 in 5000 births. Absence of neuronal ganglion cells in a portion of the intestinal tract. No peristalsis and motility leading to cant pass stool. S/s depends on age. Newborns have distention, no meconium passed. Infants/children have chronic constipation, distention, palpable dilated loops. Contrast enema. Tx: surgery, resection? colostomy?
Hirschsprung Disease
Precise assessment and care. Red, moist, painless. Discolored, prolapsed. Skin integrity. Stool appearance/amount. Supplies/teaching.
Ostomy Care
Idiopathic, inflammatory. 15-20% diagnosed in childhood/adolescence. Exacerbations and remissions; chronic, sometimes debilitating.
Treatment is TPN? Colectomy.
Inflammatory Bowel Disease (Crohn’s & Ulcerative Colitis)
Inflammation affecting large and small intestines, can affect entire alimentary canal, mouth to anus. S/s are fever, failure to grow, abdominal pain, perianal lesions
Crohn’s Disease
Inflammation affecting only large intestine and rectal mucosa. S/s are diarrhea, blood/mucus/pus in stool; urgency, cramping
Ulcerative Colitis
Meds: antibiotics, steroids, immunosuppressants (side effects); adherence to regime. Nutrition/supplements. Monitor growth. Coping, teaching (TPN, CVL)
Inflammatory Bowel Disease (Crohn’s and Ulcerative Colitis) Nursing Interventions
Autoimmune reaction to gluten leading to intestinal inflammation, mucosal damage, villous atrophy, malabsorption. Chronic, irreversible. S/s for infants are vomiting, diarrhea, distention, anorexia, FTT. Children: pain, bloating, constipation/diarrhea, weight loss, rash. Impaired fat absorption- steatorrhea; frothy, greasy, malodorous. Blood test, biopsy. Treatment is gluten free diet.
Celiac Disease
Abnormally elevated serum bilirubin. RBCs broken down (heme and globulin). Heme converted to bilirubin in liver, spleen, bone marrow. Bilirubin transported to liver, excreted in bile to gallbladder to intestines to kidneys. Newborns- immature liver and intestinal function. Common, 60%. Benign. Physiological: Serum bili over 3mg/dL. Skin, sclera, mucus membranes YELLOW. Can cause poor feeding/lethargy. Patho: serum bili increase every day, over 15 mg/dL, jaundice after 3 weeks, bilious urine.
Hyperbilirubinemia (Jaundice)
Establish regular feeding/adequate intake.
Phototherapy (prevent rash, overheating, dehydration)
Hyperbilirubinemia (Jaundice) Nursing Interventions
Extrahepatic bile ducts obstructed. Bile flow from liver to gallbladder is blocked (bile trapped in liver). Built up bile causes damage and scarring of liver cells, eventually liver failure. Treatment: Kasai procedure, roux-en-y hepatojejunostomy, liver transplant.
Biliary Atresia
Maintain effective ventilation and oxygenation
Maintain adequate hydration and nutrition
Maintain skin integrity
Prevent infection
Promote pain relief, comfort, and rest
Administer/manage medications
Provide support to child and parents
GI Nursing Interventions
