The Child with a Gastrointestinal Alteration Flashcards
Upper Gastrointestinal (GI) System
* Mouth, esophagus, stomach
- Digestive process begins in mouth
- Propel food through GI system for nutrition absorption
- Upper esophageal sphincter (UES) prevents reflux of esophageal contents into pharynx and lungs and prevents esophageal distention during respirations
- Lower esophageal sphincter (LES or cardiac sphincter) prevents reflux of gastric contents into lower esophagus
Esophagus @ birth = 10 cm length versus Esophagus in adults = 18-25 cm
- Peristalsis moves the bolus through esophagus into stomach
- As LES and pylorus contract - stomach muscles churn contents mixing with digestive juices to form CHYME
- Chyme moves from pylorus into duodenum
Lower Gastrointestinal (GI) System
* Duodenum, liver, gallbladder, pancreas, jejunum, ileum, cecum, appendix, ascending colon, transverse colon, descending colon, sigmoid colon, rectum, and anus
- Functions - digestion and absorption nutrients; detoxify and excrete unwanted waste; aid in fluid and electrolyte balance
- In ___, pancreatic enzymes and bile further breakdown chyme
duodenum
Pancreas secretes:
> Enzymes to aid digestion
> Glucagon and insulin to control motility and absorption
Liver functions:
> phagocytosis; bile production; detoxification; glycogen storage and breakdown; and vitamin storage
___
> Stores bile for secretion into duodenum until stimulated by the presence of fat in duodenum lumen
Gallbladder
* Jejunum and ileum
- Absorption of all nutrients and vitamins occurs through diffusion and active transport
- Absorption of vitamin B12 occurs only in the terminal ileum
* Large intestine
- Starts with the cecum - begins at the ileocecal valve which prevents reverse peristalsis into small intestine
- Major function is water reabsorption - occurs mostly in the cecum and ascending colon
- Intestinal bacteria ferment remaining carbohydrates and aid in synthesis of vitamin B and K
* ___
- Where stool is stored until distention of the rectal walls initiates the defecation reflex
Rectum
Prenatal Development
* Primitive gut develops into 3 sections of the fetal GI tract
___ - duodenum to transverse colon
___ - descending colon, rectum, and anal canal
___ - pharynx to duodenum including liver, pancreas, and biliary tract
Midgut
Hindgut
Foregut
* Problems in the development of any of these sections may lead to malformations and diseases
Laboratory & Diagnostic Tests - Blood (LFT’s [venipuncture])
AST (aspartate transaminase)
Child <9 __-__ U/L
Child >9 __-__ U/L
15-55
5-45
Alanine transaminase (ALT)
__-__ U/L
5-45
Total Bilirubin
__-__ mg/dL
0.2 - 1.0
Ammonia
__-__ mcg/dL children
__-__ mcg/dL newborns
29-70
90-150
Endoscopy
Fiberoptic Upper GI endoscopy
* Views lining of esophagus, stomach, initial portion of duodenum
* Can obtain tissue for biopsy or cultures
* Prep - teaching; NPO at least 6 hours prior; conscious sedation; monitor respiratory function during procedure
Biopsy (gastric, jejunal, rectal, liver)
* Teaching; bowel cleansing; sedation
Colonoscopy
* Colon viewed with fiberoptic scope inserted through rectum
* Detects mucosal changes
* NPO, bowel cleansing, and conscious sedation
Radiologic Examinations
* Abdominal flat plate
- Anterior/posterior views
- Demonstrates presence of gas, stool, patency
* Barium swallow examination
- Radiopaque contrast or air is swallowed
- Identifies esophageal abnormalities or swallowing issues
- Prep teaching; NPO 2-4 hrs pre-procedure
- Adequate fluid intake after to prevent barium impaction
* Upper GI examination
- Radiopaque contrast swallowed
- To determine gastric emptying
- NPO 4 hours prior
- Adequate fluid intake after to prevent barium impaction
* CT scan
- Oral, IV, rectal contrast
- Identifies inflammatory conditions such as appendicitis
* Barium Enema
- Radiopaque contrast inserted via rectum
- To determine bowel patency or abnormalities
- NPO and bowel cleansing required
- Adequate fluid intake after to prevent barium impaction
Other
Ultrasound
* Identifies anatomic abnormalities or inflammatory conditions
* Full bladder needed
Breath hydrogen test
- Carbohydrate solution is given by mouth and exhaled
- Breath samples are collected every 3 hours
- Identifies maldigestion or malabsorption issues
- NPO 4.5 hours prior
- Facemask used to collect expired air
Stool
Culture & Sensitivity (C&S)
> Identifies organisms to determine antibiotic therapy
> Deliver sample to lab immediately
Occult Blood (guaiac, Hematest)
> Used in inflammatory conditions and bowel necrosis
> Blue color is positive
Ova & Parasites (O&P)
> To identify enteric parasites when diarrhea or abdominal pain is present
Urine
Urobilinogen
- Dipstick or lab analysis to determine bile products in urine
- Used to determine hepatic dysfunction or obstruction
Major Digestive Enzymes
Pediatric Differences in the GI System
* Infants have minimal saliva
* Swallowing is not under voluntary control until 6 weeks
* Infants and children have less stomach capacity
> Stomach lies transversely and is horizontal in the infant’s abdomen
> The abdomen is round in infants and toddlers
* Peristaltic waves may reverse in infancy, causing regurgitation and vomiting
> Peristalsis is faster; food remains in the stomach for a shorter period
* Hydrochloric acid concentration is low until school-age
* Fever increases the rate of propulsion
* Immature neonatal liver not efficient in detoxifying ability - results in less vitamin and mineral breakdown than in older children
* The large intestine is relatively short, with less epithelial lining to absorb water from a fecal mass so stools have a soft consistency and peristalsis is more rapid
Stomach Capacity by Age Group
* Prenatal Developmental Disorders
* Motility Issues
* Inflammatory or Infectious Conditions
* Obstructive Disorders
* Malabsorption Conditions
* Hepatic Disorders
Cleft Lip & Palate
Pathophysiology
* Results from an embryonic developmental failure
* An abnormal opening in the lip, palate, and nasal cavities
Manifestations
Cleft lip - notched vermillion border, variable size clefts with dental disorders
Cleft palate - nasal distortion, midline or bilateral cleft from the uvula and soft and hard palates and exposed nasal cavities
?
Results from primary palatal shelves (processes) that fail to fuse at 7-12 weeks gestation
Cleft PALATE
?
Medial nasal and maxillary processes fail to join at 6-8 weeks gestation
Cleft LIP
Cleft Lip & Palate - Therapeutic management
* Based on severity
* First intervention - modification of feeding techniques to allow growth
> Goal is to decrease required energy to take in adequate nutrition
* Multiple surgeries at different stages of growth
> Cleft lip surgery by age 3-6 months
> Cleft palate surgery individualized based on degree of deformity - closure done by 6-24 months
After surgery: Goal is to maintain sutures clean, intact, and avoid tension
* Gentle aspiration of nasopharynx may reduce complications - atelectasis (collapse of lung or section of lung d/t tiny alveoli not filling up with air)
* Ongoing therapy - dental procedures, recurring otitis media (may lead to hearing loss), speech therapy, emotional issues, cosmetic surgery
* Breastfeeding may be possible for infants with cleft lip
* Infants with cleft palate may have difficulty creating the negative pressure to breastfeed
Cleft lip & palate Nursing Diagnosis
* Poor nutritional intake: less than body requirements related to inability to suck and to surgical repair
- Keep feeding to under 30 minutes with frequent rest periods for burping
- Small cleft lip and palate may do well with breastfeeding
- Alternative feeding devices: soft, plastic compression bottle (reduce sucking force), longer nipple able to swallow milk without entering the nose with larger bore
- Burp infant frequently and keep in upright position (minimizes air swallowing and GI flatus and minimizes risk of aspiration); avoid car seat feeding - not able to assist if infant chokes
Post-op keep straws, pacifiers, spoons, or fingers away from mouth for 7-10 days
DO NOT take oral temperature
After repair of cleft palate - should use short nipples to avoid nipple contact with palate sutures or syringe with rubber tip may be used to avoid contact with palate
Deficient knowledge about feeding techniques and surgery related to unfamiliarity with the information
- Be an advocate for your patient
- Provide information and let the healthcare provider know that patient needs more clarification regarding surgical procedures
Risk for skin breakdown related to surgical repair
* Cleanse sutures according to protocol (usually sterile water or saline with cotton swab… especially after feedings)
* Apply antibiotic ointment as ordered to lip
* Use elbow restraints (no-no’s) to keep infant from touching sutures (6-8 days); make sure to remove restraints every 2 hours for 10-15 min - prevent accidental rupture or tear of sutures
* Do not brush teeth for 1-2 weeks
* Keep supine or in infant seat
* Observe for any signs of infection - redness, swelling, excessive bleeding, drainage, respiratory distress, or fever
* Rinse the child’s mouth with water after feedings after a palate repair
Esophageal atresia (EA) with tracheoesophageal fistula (TEF) - Pathophysiology
- Esophageal atresia (EA) with tracheoesophageal fistula (TEF) - failure to differentiate the foregut into the trachea and esophagus and incomplete fusion of these into their corresponding organs (EA) and/or presence of a fistula connecting esophagus and trachea (TEF)
?
Esophagus terminates before reaching the stomach forming a pouch
esophageal atresia (EA)
?
Forming a connection between esophagus and trachea allowing oral intake to enter trachea and into lungs or large amounts of air into stomach
tracheoesophageal fistula (TEF)
Manifestations
- Presence of maternal polyhydramnios (excess amniotic fluid) may lead to suspicion of EA with TEF
- Failure to pass suction catheter, NG tube at birth - atresia suspected if tube cannot be passed 10-11 cm past gum line
- Excessive oral secretions, coughing, choking, and respiratory distress
- Vomiting
- Abdominal distention; airless, scaphoid abdomen (atresia without fistula)
Diagnostic evaluation
- Abdominal x-ray shows dilated esophagus with air (atresia) or abdominal distention with air (fistula)
Any child who exhibits the “three C’s” of
___, ___, and ___
should be suspected of having a tracheoesophageal fistula (TEF)
coughing; choking with feedings; cyanosis
Esophageal atresia and TEF represent a critical neonatal surgical emergency
While the baby is awaiting transfer to a neonatal unit and surgery, management centers on prevention of aspiration
Therapeutic management
* Supine with HOB elevated 30-40° to avoid gastric secretions from entering the lungs
* NG tube is placed and aspirated every 5-10 minutes to clear secretions in pouch
* IV fluids and antibiotics to prevent pneumonia
* Keep infant warm and oxygenated
* Surgical repair essential treatment
> Ligation of the fistula
> End-to-side anastomosis of atresia
> If repair needs to be staged may need to have a gastrostomy tube (G-tube) and cervical esophagostomy
- When the ends are too far apart, surgery is done in stages - in a staged repair the surgeon waits for the esophagus to grow before the final repair
TEF Nursing Care Plan
Risk for aspiration related to TEF
* Pre-op
- To minimize risk of aspiration:
> Use a chalasia or reflux board to keep HOB 30° while supine
> Suction catheter to avoid secretion build-up
> Constant respiratory assessment very important - Prophylactic antibiotics to prevent pneumonia
* Post-op
- Monitor respiratory status
- Maintain fluid balance and nutrition
- Maintain thermoregulation
- Pain relief
- Monitor infection
- Promote bonding between child and parent
- Chest tube care - maintain patency, monitor suction, and document output
- IV fluids, antibiotics, and parenteral nutrition; monitor for dehydration like sunken fontanelle and increased specific gravity
- Daily weighs and head circumference measurements to monitor growth
- Appropriate pain control with pain medication
* Post-op
- If child has a gastrostomy tube -
> Immediately after placement - left open to drainage to allow gastric contents and air to escape (reduce pressure on anastomosis)
> A pacifier is used for sucking, early training in swallowing, which later makes feeding easier and provides comfort through distraction - pacifiers should not be used until child can manage oral secretions
> Site cleaned soap and water
- If crusty drainage - cleanse with half-strengthened hydrogen peroxide
- Rotate tube every day
- Use skin barrier between skin and tube
> Instruct parents to report any redness, exudate, pus, heat, or leakage of formula
> After 1-2 weeks tub baths can be used
Upper GI hernias
Pathophysiology
> Protrusion of portion of stomach through esophageal hiatus of the diaphragm
Manifestations
> Vomiting, abdominal pain, coughing, wheezing, short periods of apnea, failure to thrive
Therapeutic management
> Diet, positional changes, medications, and surgery
Nursing care management
> Monitor respiratory distress, document vomiting, monitor I&O
?
Pathophysiology
> Abdominal contents herniate through diaphragm into thoracic cavity (occurs during the 6-8 week of gestation)
> Can lead to __ __ (incomplete development of lungs) and pulmonary hypotension
Congenital diaphragmatic hernia (CDH)
pulmonary hypoplasia
Manifestations
- Abdominal organs can be seen in chest with fetal ultrasonography
- Diminished or absent breath sounds
- Bowel sounds heard over chest
- Cardiac sounds heard on right side of chest
- Respiratory distress (dyspnea, cyanosis, nasal flaring, tachypnea, retractions)
- Scaphoid abdomen (anterior abdomen has sunken appearance - scaphoid - due to abnormal low number or size of bronchopulmonary segments or alveoli)
Therapeutic management
- NG tube, ventilation, surgery (delayed until 6-18 hr after birth)
Congenital Diaphragmatic Hernia (CDH) - Nursing Care Plan
- Place in semi-Fowler on affected side with HOB elevated
- Maintain NG tube patency
- Monitor IV fluids
- Maintain mechanical ventilation and chest tubes
- Assess oxygenation
- Do not use facemask or bag-valve mask for ventilation due to air entering stomach
- Provide minimal stimulation
- Provide routine postoperative care
- Monitor for signs of infection, respiratory distress, and feeding difficulties
Imperforate Anus
Pathophysiology
- Incomplete development or absence of the anus in its normal position in the perineum
Manifestations
- Failure to pass meconium stool
- Absence of anorectal canal
- Presence of an anal membrane
- External fistula to the perineum
Diagnosis
- During newborn examination with radiography, ultrasound, or CT scan
Therapeutic management
- Anal stenosis treated with repeated dilations
- All other defects require surgical intervention
> May require colostomy and bowel pull through procedure
Nursing care
- Report skin dimples or presence of stool in the urine or vagina
- Determine anal patency - monitor if meconium is not passed within the 1st 24 hours after birth
- Assess for other GI or genitourinary abnormalities
- Facilitate bonding
- Provide appropriate postoperative care including colostomy care
Umbilical Hernia
Pathophysology
* Imperfect closure of umbilical ring which allows intestines to push outward at umbilicus during straining and crying
Manifestations
* Viscera inside the abdominal cavity and under the skin
* Hernia is usually 1-5cm and easily reduced
Therapeutic management
* Most disappear by 1 year of age
* No surgical repair is needed unless it causes symptoms, persists past the age of 5, becomes strangulated, or enlarges
Nursing care
* Monitor for changes in hernia size
* Assess for changing bowel sounds and presence of an irreducible mass - may suggest strangulation
* Teach parents signs of strangulation - vomiting, pain, irreducible mass at umbilicus
* Contact physician immediately if strangulation is suspected
Gastroesophageal Reflux (GER) Disorders
Pathophysiology
> Reflux can be divided into 2 types: physiological GER and pathologic GER
GER - is a normal physiological occurrence - occurs normally throughout the day in healthy infants, children, and adults, especially after meals
> Lower esophageal sphincter (LES) dysfunction allowing gastric contents to reflux back into esophagus
GERD - a more severe and chronic form - causes irritability, frequent back arching, esophagitis, and failure to thrive
Etiology
- GERD may result from cerebral palsy, Down syndrome, head injury, delayed gastric emptying, swallowing dysfunction, medications such as theophylline, and increased intraabdominal pressure (from straining, crying, coughing, or slumping)
? (gastroesophageal reflux [GER])
- Painless emesis after meals
- Parents may be unconcerned or think it’s normal
- Rarely occurs during sleep
- No failure to thrive
- 40% asymptomatic by 3 months
- 70% asymptomatic by 18 months
- Pharmacologic in medical management very effective
Physiological
? (gastroesophageal reflux disease [GERD])
- Failure to thrive
- Aspiration pneumonia and/or asthma
- Apnea, coughing, and choking
- Frequent emesis, abdominal pain, and crying
- May require surgery in pharmacological treatment
Pathologic
Management
* Vomiting or spitting up after meals, hiccuping, and recurrent otitis media (related to pooling of secretions in nasopharynx during sleep)
* Weight loss, failure to thrive, irritability, discomfort, and abdominal pain
* Severe GERD can lead to hematemesis or melena and anemia
* Coughing, choking, asthma, wheezing, pneumonia, apnea, bradycardia
Therapeutic management
Diet
- Small, frequent feedings with frequent burping - 1st line of treatment
> 1-3 oz every 2-3 hrs - may use breastmilk or predigested formulas thickened with rice cereal (1 tsp/oz)
> Frequent burping
> Cross-cut bottle nipples for thickened formulas
> Assess for dehydration (fluid volume deficit): sunken fontanelle; no tears when crying; dry mucous membranes; poor skin turgor; low urine output (few wet diapers)
> Monitor weights carefully
* Feedings thickened with rice cereal may decrease regurgitation and emesis
Positioning
- Prone position while awake only
- HOB elevated
Medications
- Antacids to reduce symptoms
- Proton pump inhibitors (omeprazole or lansoprazole) and H2-receptor antagonists (cimetidine and ranitidine) to decrease acid secretions
- Prokinetic agents (erythromycin and metoclopramide) to accelerate gastric emptying and improve esophageal and intestinal peristalsis
Treatment of acute bleeding
- Complication of chronic GERD and esophagitis
Surgery
- Chronic conditions may need FUNDOPLICATION surgery
> Upper curve of stomach (fundus) is wrapped and sewn around lower esophagus creating a tunnel and strengthening valve muscle between esophagus and stomach
Ulcers
Pathophysiology
- Normally: stomach and duodenum are lined with a thick mucous-bicarbonate barrier layer that slowly releases bicarbonate ions to neutralize the effects of pepsin and acid found in stomach
- An imbalance leads to erosions developing on the surface of the gastric and duodenal mucosa
Etiology
- Excessive acid secretion caused by Zollinger-Ellison syndrome or hyperparathyroidism
- Prostaglandin deficiency impairs barrier formation
- H-pylori bacteria that weakens gastric mucosal barrier
- Physiological stress
- Medications such as ASA, NSAIDs
- Diet high in colas, teas, and chocolate increases acid
Therapeutic management
* Regular diet low in caffeine
* Encourage high fiber diet and polyunsaturated oils
* Medications first line of treatment
> Antibiotics (clarithromycin), proton pump inhibitors (metronidazole), H2-receptor antagonists, and mucosa-protective agents
> For H-pylori - treatment is 4-6 weeks of proton pump inhibitor, antibiotic, and bismuth salts
> Surgery may be used for hemorrhage, perforation, or obstruction
> For active bleeding - NG tube inserted to remove blood, decompress the stomach, and estimate blood loss
Infectious Gastroenteritis
Pathophysiology
* Caused by a group of viruses, bacteria, and parasites that adhere to the intestinal mucosa → inflammatory response and epithelial cell death → causing ulcerations, pseudomembranes, bleeding, and sepsis
* As the pathogen multiplies it produces toxins (enterotoxins, cytotoxins, and neurotoxins) causing communicable diarrhea, massive fluid and electrolyte loss, sepsis, and death
Etiology
* Ingestion of contaminated food or water and person-to-person contamination
McBurney Point
Rovsing sign
Psoas sign (retrocecal appendicitis)
Obturator sign (retrocecal or pelvic appendicitis)
Therapeutic management
* Laparoscopic appendectomy
* Preoperatively - manage fluid therapy, immobilization, pain control, NPO, antibiotics, and antipyretics
Nursing care
Assessment
- Initial symptom “my tummy hurts”
- Pain, anorexia, or N/V, and fever
- If pain occurs before vomiting - suspect appendicitis
- If vomiting occurs before abdominal pain - suspect gastroenteritis
- Refusal to play
- Lie in knee-chest position
?
Chronic inflammatory condition of small and large intestine
Inflammatory Bowel Disease
Hypertrophic Pyloric Stenosis
Pathophysiology
- Muscle surrounding pylorus hypertrophies and obstructs gastric emptying
Manifestations
- Progressive projectile, nonbilious vomiting - starts after 3 weeks of age
- Movable, palpable, firm, olive-shaped mass felt right upper quadrant when stomach empty and infant relaxed
- Deep gastric peristaltic waves from LUQ to RUQ visible before vomiting
- Irritable and hungry after feeding
- If persistent may lead to dehydration and metabolic alkalosis
- Hyperbilirubinemia usually resolves after surgery
?
Pathophysiology
- Invagination of a section of intestine into the distal bowel - bowel obstruction
- In children between ages 5 months and 3 years, most common - section of terminal ileum telescopes into ascending colon through ileocecal valve
Intussusception
Congenital Aganglionic Megacolon (Hirschsprung Disease)
Pathophysiology
- Absence of ganglion cells in rectum and upward in the colon = leads to inadequate peristalsis in the affected colon = a tonic contraction of the lumen occurs causing functional bowel obstruction, chronic constipation, and the passage of ribbon-like stools
- Due to the constriction of the lumen, large amounts of feces and gas collect proximal to the aganglionic portion - results in enlargement of that section = megacolon
Manifestations
* Cardinal sign - delayed passage or absence of meconium stool in neonatal period
Suspicion of disease:
> No passage of meconium within 48 hrs
> Prone to constipation or stool infrequency in first month after birth
Other signs
> Bowel obstruction, abdominal pain and distention, vomiting, and failure to thrive
> Foul-smelling, pellet-like or ribbon-like stools
Therapeutic management
Surgical treatment
* Removing the aganglionic portion of the intestine in a one or two step surgical intervention
> Requires a temporary colostomy
* Botulinum toxin (Botox) injections to the internal anal sphincter
* Rectal irrigations to remove air in stool
Nursing care - Assessments
* Monitor nutritional status
> Assess for malnutrition r/t extreme distention or enterocolitis
- Thin extremities, abdominal distention, history of poor feeding
> Assess bowel sounds, vomiting, diarrhea, changes in abdominal circumference
> Temperatures should be obtained but never through the rectum
?
Pathophysiology
* Known as gluten enteropathy or tropical sprue
* Inability to digest gluten
Etiology
- Unknown but considered autoimmune and occurs in genetically susceptible patients
Celiac Disease
?
Pathophysiology
- Obstruction or absence of extrahepatic bile ducts that eventually leads to inflammation, edema, and hepatic degeneration
Biliary atresia
Therapeutic management
* Surgery
> Hepatic portoenterostomy (Kasai procedure)
- Allows bile to drain from liver into intestine through anastomosis of jejunum and porta hepatis - provides some long-term benefits but does not cure
Main goal is to allow growth and development of child until old enough for liver transplantation
* Treatment includes correcting malnutrition and providing symptom relief
> Administration of TPN
> Vitamin supplements
* Manage portal hypertension - associated with ascites and variceal bleeding
> Control bleeding, restrict salt intake, use diuretics
