The Child with a Gastrointestinal Alteration Flashcards
1
Q
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
A
- 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
2
Q
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
A
duodenum
3
Q
Pancreas secretes:
> Enzymes to aid digestion
> Glucagon and insulin to control motility and absorption
A
Liver functions:
> phagocytosis; bile production; detoxification; glycogen storage and breakdown; and vitamin storage
4
Q
___
> Stores bile for secretion into duodenum until stimulated by the presence of fat in duodenum lumen
A
Gallbladder
5
Q
* 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
A
* 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
6
Q
* ___
- Where stool is stored until distention of the rectal walls initiates the defecation reflex
A
Rectum
7
Q
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
A
Midgut
Hindgut
Foregut
* Problems in the development of any of these sections may lead to malformations and diseases
8
Q
Laboratory & Diagnostic Tests - Blood (LFT’s [venipuncture])
AST (aspartate transaminase)
Child <9 __-__ U/L
Child >9 __-__ U/L
A
15-55
5-45
9
Q
Alanine transaminase (ALT)
__-__ U/L
A
5-45
10
Q
Total Bilirubin
__-__ mg/dL
A
0.2 - 1.0
11
Q
Ammonia
__-__ mcg/dL children
__-__ mcg/dL newborns
A
29-70
90-150
12
Q
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
A
Colonoscopy
* Colon viewed with fiberoptic scope inserted through rectum
* Detects mucosal changes
* NPO, bowel cleansing, and conscious sedation
13
Q
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
A
* 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
14
Q
Other
Ultrasound
* Identifies anatomic abnormalities or inflammatory conditions
* Full bladder needed
A
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
15
Q
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
A
Urine
Urobilinogen
- Dipstick or lab analysis to determine bile products in urine
- Used to determine hepatic dysfunction or obstruction
16
Q
Major Digestive Enzymes
A
17
Q
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
A
* 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
18
Q
Stomach Capacity by Age Group
A
* Prenatal Developmental Disorders
* Motility Issues
* Inflammatory or Infectious Conditions
* Obstructive Disorders
* Malabsorption Conditions
* Hepatic Disorders
19
Q
Cleft Lip & Palate
Pathophysiology
* Results from an embryonic developmental failure
* An abnormal opening in the lip, palate, and nasal cavities
A
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
20
Q
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Results from primary palatal shelves (processes) that fail to fuse at 7-12 weeks gestation
A
Cleft PALATE
21
Q
?
Medial nasal and maxillary processes fail to join at 6-8 weeks gestation
A
Cleft LIP
22
Q
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
A
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
23
Q
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
A
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
24
Q
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
A
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
25
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)
26
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Esophagus terminates before reaching the stomach forming a pouch
esophageal atresia (EA)
27
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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)
28
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)
29
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***
30
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
31
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
32
\* 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
33
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
34
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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
35
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)
36
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
37
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
38
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
39
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
40
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)
41
? (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
42
? (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
43
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**
44
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
45
Nursing care
Risk for aspiration
- **_Critically important to monitor for any signs of respiratory distress_** or periods of apnea by using a cardiac or apnea monitor
- Frequent observation with frequent vital signs check
- Proper positioning in the upright or prone if awake
- Minimal handling after feedings to decrease reflux and aspiration risk
- May use pacifier to reduce crying and encourage swallowing
Deficient fluid volume related to decreased intake and frequent vomiting
- Assess for signs of fluid volume deficit - **_dehydration_**
\> **Signs include sunken fontanelle, no tears when crying, dry mucous membranes of the mouth, poor skin turgor, and low urine output with fewer wet diapers**
\> Weight should be checked daily to assess stability and gains
\> Weight length and head circumference should also be periodically measured and plotted on charts for nutritional status and growth
46
Imbalanced nutrition: less than body requirements related to dysphagia and reflux
- Feeding should be small: 1-3 oz every 2-3 hrs
- Use breast milk or pre-digested formulas and these should be thickened with rice cereal (1 tsp/oz)
- Frequent burping and medications to help with reflux
- Bottle nipples are crosscut to enlarge the opening for thickened formula
Deficient knowledge related to disease process, total care, and medications
- Family education and support are important
- Educate parents on what GERD is and how to manage the disease
- Explain different formulas, feeding routines, and medications
- Parents are taught the purpose dosage schedule and side effects of each medication prescribed
- Teach parents to practice assessments, positioning, formula preparation, feeding techniques, medication administration, and ask for return demonstration
**MOST IMPORTANT - training parents for CPR is mandatory**
47
Constipation & Encopresis
Pathophysiology
\* Defecation reflex - stool in rectum leads to distention of the walls which stimulates peristaltic movement
\* Voluntary retention of stool leads to buildup of stool in the rectum, more water reabsorption from colon - results in HARD DRY STOOL - difficult to pass
Constipation results when there is a delay or difficulty in defecation present for 2 or more weeks
Over time bowel becomes enlarged - leads to failure to control external sphincter - encopresis or bowel incontinence
48
Etiology
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Recurrent fecal impaction and enlarged rectum caused by chronic constipation
Encopresis
49
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Diet, dehydration, lack of exercise, emotional stress, certain drugs, pain from anal fissures, or excessive milk intake
Constipation
50
Manifestations - Constipation
\* absence of stool; abdominal pain and cramping without distention; palpable movable fecal masses with large amounts of stool in an enlarged rectum; diarrheal overflow; normal or decreased bowel sounds; malaise; anorexia; headache; nausea; vomiting; and anal fissures
Manifestations - Encopresis
\* evidence of soiled clothing and fecal odor without awareness;
\* irritation in the anal area leading to scratching or rubbing;
\* social withdrawal and avoidance of extended contact with others
\* urinary incontinence and UTI's may also be present
51
Diagnostic evaluation
- Abdominal radiographs and a rectal examination
52
Therapeutic management
\* First line therapy
\> Polyethylene glycol (PEG) with or without electrolytes orally 1-1.5 g/kg/day for 3-6 days
\> An enema once per day for 3-6 days if PEG is unavailable
\* First line maintenance
\> PEG with or without electrolytes with a starting dose of 0.4 g/kg/day with adjustments based on response
\> Lactulose (10g/15mL) 1-3 mL/kg twice daily if PEG unavailable
Duration of therapy
\> At least 2 months, then decrease gradually
\> Sit on toilet for 5-10 minutes approximately 20-30 minutes after meals
\> Positive rewards and avoid negative reinforcement
\> Increase fiber and fluids
\> Increase physical exercise and relaxation activities
*The goal is for the child to pass 2 or 3 soft stools per day without pain within the first month following treatment*
53
Nursing care
\* Reinforce appropriate diet and exercise
- Ingestion of fructose (prune juice) or lactulose, high fiber fruits and vegetables
- Offer granola bars, dried fruits, whole grain cereals
- Increase water intake
- Decreased sugar and milk intake
\* Regular toileting habits
- Normal frequency is 1.2 stools per day for a child 4 years and older
- Reestablish normal bowel habits - sitting on toilet for 5-10 minutes after breakfast and dinner to allow a normal gastrocolic reflex
- Management of impaction with enemas and PEG treatment
\* Emotional support
- Express feelings of success and failure
- Encourage self care as much as possible
- School-age children should have a complete change of pants and underwear at school
54
Recurrent abdominal pain/Irritable Bowel Syndrome (IBS)
Pathophysiology
- Disorganized contractility causing spasmodic peristaltic rushes and lulls resulting in alternating diarrhea and constipation with intermittent abdominal pain
- Excess mucous production in lumen of bowel which leads to maldigestion and passage of incompletely digested food and nutrients
Manifestations
- Diffuse abdominal pain unrelated to meals or activity, alternating constipation and diarrhea with undigested food and mucous present in the stool, and normal growth
Therapeutic management
- No definitive treatment
- Management: aimed at identifying and reducing triggers and reducing bowel spasms
- Maintenance of a healthy, well-balanced, moderate fiber, low-fat diet
- Eat slowly, avoid caffeine products, and carbonated beverages
- Medications include _antispasmodics_ - dicyclomine and hyoscyamine
55
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
56
Manifestations
\* Burning, cramping, pain with empty stomach
\* Awakening in morning with abdominal discomfort and vomiting (\<6 years of age)
\* Hematemesis and melena common in infants
Diagnostic evaluation
\* Fiberoptic upper endoscopy, ultrasound, fecal occult blood to check for GI bleeding
57
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
58
Nursing care
*Major focus of nursing care is TEACHING*
\* Assess for pain
- Presence of epigastric tenderness
- Abdominal distention
- Changes in appetite
\* Assess for dehydration
- Nausea/vomiting
\* Assess for bleeding
- Vital signs
\> Stools and emesis checked for occult blood
\> Melena (tarry stools)
\> Vomiting (coffee-ground) - hematemesis
\* Bowel sounds auscultated for 5 minutes
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\* Administer medication as ordered
- Do not administer antacids within one hour of antiulcer meds
- Continue meds as ordered
- DO NOT use ASA or NSAIDs - can cause bleeding
- DO NOT use OTC medications unless checked with healthcare provider 1st
\* Educate on dietary modifications
- For poor appetite provide a well-balanced diet with many choices
- Seek assistance from dietary services if needed
- Provide meals and snacks every 2-3 hours
- Avoid caffeine, chocolate, coffee, carbonated beverages and acidic foods
\* Educate on complications
- Instruct patients to call the physician as soon as possible if they encounter any of the following problems:
\> Coffee-ground vomitus
\> Weight loss
\> Tarry stools
\> Increased pain
\> Diarrhea
\> Vomiting
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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
61
?
\* Most common viral cause of gastroenteritis in children
\* Common in winter
\* Oral-fecal contamination
\* Incubation 1-3 days
\* Virus in stool
\* Contact precautions
\* Supportive care: hydration
\* Antiemetics (ondansetron) for children over 2 years of age
\* Vaccination !
Rotavirus
62
?
- Most common in children in daycare centers
- Most common cause of parasitic diarrhea
- Spread through contaminated food/water
- Incubation: 1-2 weeks
- Ova and parasites in stool
- Contact precautions
- Treatment of all drinking water (chlorine/iodine)
- Administer medications: tinidazole, nitzoxanide, or metronidazole
Giardia intestinalis
63
Manifestations
- Diarrhea with varying amount, consistency
- Vomiting
- ___ (feeling the need for a bowel movement even though bowels are empty)
- Fever
- Dehydration
Tenesmus
64
Treatment
\* Priority therapy - replace water and correct acid-base or electrolyte imbalances with IV fluids or oral (PO) electrolyte replacement liquids
Medication is specific for each type of gastroenteritis
\* *Shigella* - azithromycin, ceftriaxone, ciprofloxacin
\* *Giardia* - tinidazole, nitazoxamide, metronidazole
\* *Salmonella and E. coli* - azithromycin
\* *Clostridium difficile* - vancomycin or metronidazole
65
Nursing care
\* Maintaining fluid balance
- Oral (Pedialyte - small amounts every 30 minutes) and parenteral rehydration
- Accurate I&O
- Weight measurements
- Monitor skin turgor, urine output, serum electrolytes
- Breast milk offered as needed and formula full strength
- Oral rehydration if vomiting - start with 5 mL every 2-5 minutes
- Avoid food with high concentrations of sugar and fat; juices, colas, sports drinks, tea, or sugary-type fluids
- Lactobacillus (yogurt or supplement) restores normal flora
\* Decreasing risk
- Preventing the spread of infection - contact precautions and meticulous hand hygiene
- Disinfection of contaminated linens, clothes, and surfaces
- Pain and fever treated with acetaminophen
66
Appendicitis - Pathophysiology
Obstruction of appendix (small lymphoid, tubular, blind sac at end of cecum) leads to accumulation of mucous secretions producing distention
↓
Causes occlusion of capillaries and engorgement of appendix walls
↓
Microabscesses - abscesses - fistulas →
If not treated - perforation with bowel contents spilling into mesenteric bed and peritoneum
↓
Peritonitis and sepsis
Most common cause of emergency surgery in children and adolescents
67
Appendicitis - Manifestations
\* **Classic/cardinal symptom - periumbilical abdominal pain, progressing in intensity and localizing to RLQ (McBurney point)**
\* N/V
\* Anorexia; diarrhea or constipation
\* Fever and chills; with perforation initial relief of pain
Diagnostic evaluation
- Positive Rovsing sign (palpation of left quadrant produces pain in right quadrant)
- Psoas sign (pain with right thigh extension)
- Obturator sign (pain with flexion and internal rotation of hip)
- Guarding, rebound tenderness, N/V, and fever on physical exam
- WBC count of 15,000-20,000/mm3
- Ultrasound or CT scan
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McBurney Point
Rovsing sign
69
Psoas sign (retrocecal appendicitis)
Obturator sign (retrocecal or pelvic appendicitis)
70
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
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Pain
- Topical cold application (do not apply heat)
- Pain meds
- Comfort positioning
- DO NOT administer enemas or laxatives
Infection risk
- Monitor for sepsis or shock
- Assess incision sites for signs of infection, drainage, dehiscence
\* If perforated may need NG tube insertion, incisional drain care, IV antibiotics
\> Monitor vital signs (especially temperature) every 2-4 hours
\> Round the clock opioid analgesics (for incisional pain and dressing changes)
Dehydration
\> IV fluid replacement
\> NPO pre-op
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Chronic inflammatory condition of small and large intestine
Inflammatory Bowel Disease
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\* Can occur anywhere in the GI tract (mouth-anus)
\* Transmural - affecting all layers of the intestine
\* Cobblestone appearance of mucosa
\* Fistulas common
\* Remissions and exacerbations
Manifestations
- Abdominal pain
- Diarrhea (non-bloody); fever
- Palpable abdominal mass; anorexia and severe weight loss
- Significant growth impairment
- Perianal and anal lesions; fistulas and obstructions
- Extraintestinal symptoms - arthralgia and arthritis
Crohn's disease
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\* Affects colon only
\* Involves mucosal and submucosal layers of the intestine
\* Fistulas rare
\* Remissions uncommon
Manifestations
- Abdominal pain unusual
- Diarrhea, occasionally with hemorrhage and anemia
- No masses
- Moderate weight loss
- Mild growth impairment
- Perianal and anal lesions rare
- Fissures and obstructions rare
- Risk of toxic megacolon
Ulcerative colitis
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IBD - Therapeutic management
Medications
- Anti-inflammatory, antibacterial, antibiotic, and immunosuppressive drugs
- Principle medications
\> 5-aminosalicylic acid (5-ASA) - sulphasalazine and mesalazine
\> Corticosteroids - Prednisone
\> Immune-modulating agents: 6-mercaptopurine (6-MP), methotrexate and cyclosporin A
\> TNF alpha antibody - infliximab (Remicade)
\> Antibiotics - metronidazole (Flagyl) and ciprofloxacin (quinolones)
\> First-line immunosuppressants: 5-ASA and 6-MP
Diet
- TPN used for acute flare-ups
- Formula via NG tube or gastrostomy to promote healing
- Crohn's disease malnutrition is common - protein, fat, carbohydrate, and vitamin deficiencies that impede growth
- Ulcerative colitis - avoid milk products and ingestion of hypoallergenic, low fiber, low fat, low residue, high protein, elemental diet
Surgery
- Crohn's disease = partial bowel resections to treat abscesses, fistulas, chronic recurrent obstructions
- Ulcerative colitis = partial or total colectomy with creation of a colostomy or an ileostomy
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Nursing Care
Medications
- Teaching parents about medication administration and adherence
- If on steroids
\> Stress importance of regular administration
\> Risks related to immunosuppression - infections
\> Administer with food or antacids to prevent GI irritation
Nutrition
- Low-fiber, low-residue, low-fat, milk-free, elemental diet
- Vitamin, iron, and folate supplements
Assessments
- Nutritional status, growth patterns, developmental milestones
- Number of stools, weight, pain
77
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
78
Therapeutic management
\* Usually diagnosed early
\* If advance stages of dehydration, malnutrition, and alkalosis are present - must be corrected before surgery to prevent postoperative apnea
\* **Slightly dehydrated infants** with a total serum or plasma CO2 level of 25 mEq/L or less or for infants who are **moderately dehydrated** with a total serum or plasma CO2 of 26-35 mEq/L
\> **treatment includes replacement of IV fluids and electrolytes and insertion of an NG tube for stomach decompression - once the stomach is empty most infants will stop vomiting**
\* **Severely dehydrated and malnourished infants** with CO2 levels above 35 mEq/L
\> **therapy includes a 3-5 day course of IV fluid and electrolyte replacement therapy and infusions of plasma or packed RBC's before surgical repair**
Surgery is delayed 24-48 hours until fluid and electrolyte deficits and acid-base imbalances are corrected
Definitive treatment - **laparoscopic pyloromyotomy** (incision to pyloric muscle to release obstruction)
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Nursing care
- Assess for projectile vomiting after meals
- Determine and document the relation of feedings to vomiting for frequency, amount, color, and consistency as well as projecting
- Assess for signs of dehydration like absence of tears we cry, depressed fontanel, poor skin turgor, dry mucous membranes
- Assess for signs of K+, Na+, and Cl- depletion
- Assess the abdomen for distention, tenderness, bowel sounds, presence of pyloric mass and gastric peristaltic waves
\* Dehydration - loss of fluid volume r/t vomiting
\> Balanced I&O = urine output \> 2-3 mL/kg/hr
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Pre-op
- NPO & stabilize with IV fluids and electrolytes
- Vital signs, weight, labs, I&O are essential nursing interventions
- I&O should include all IV and PO fluids, blood products, emesis, urine output, stools, and NG tube drainage
- HOB elevated to reduce aspiration
Post-op
- NG tube in place and delay feedings for 24 hrs post-op or remove NG and order feedings within 1st 4-6 hrs
- Feedings start with small amount of oral electrolyte (Pedialyte) and slowly increase
- Formula starts at half-strength and progresses slowly to full strength if no vomiting
- Breastmilk does not need to be diluted
- IV fluids are continued until infant is taking and retaining sufficient amounts of formula or breast milk
- Check VS, lab values, hydration, incision site for infection
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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
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Manifestations
\* Paroxysms of pain occur, subside, and reoccur during the first several hours progressing to a more constant severe pain
\* Vomiting
\* ***Classic signs of intussusception***
\> _Abdominal pain_
\> _Passage of bloody mucous ("currant jelly") stool and diarrhea_
\> _A sausage-shaped abdominal mass_
\* If obstruction lasts longer than 12-24 hours - shock and sepsis may occur
Therapeutic management
\* *The goal of treatment is to restore the bowel to its normal position and function - preferably within the first 24 hours of symptoms*
\* Hydrostatic reduction with isotonic saline or enema under fluoroscopic or ultrasonic guidance is first performed
\* In cases where shock and sepsis is present or when reduction fails - immediate surgery is performed
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Assessments
- Assess for bowel obstruction with signs of vomiting, nausea, abdominal distention, and hypo- or hyperactive bowel sounds
- Assess for palpable abdominal mass and passage of "currant jelly" stools
- Assess hydration status
- Assess for fever, increased HR, changes in LOC or BP, and respiratory distress - indicative of sepsis or peritonitis
Initial care
- IV fluids
- Insertion of an NG tube PRN for distention
- During reduction - administer pain medication or sedation to decrease spasms
- After reduction provide clear liquids and advanced diet gradually as tolerated
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Post reduction care
- Observe for passage of stool and note characteristics
- Assess for symptoms of bowel obstruction
- Resume normal diet and activities
- Passage of stool without blood indicates successful outcome
- If hydrostatic reduction fails - prepare child for abdominal or laparoscopic surgery
- Child is kept NPO until bowel function returns
- Intermittent NG suction, IV therapy, pain medication, maintenance of respiratory function
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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
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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
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Pre-op
- Bowel cleansing regimen
\> Isotonic saline enemas
\> PEG electrolyte lavage solution (GoLytely) PO or via NG tube - only for children \>5
\> Sodium phosphate (Fleet Phospho-Soda) PO - only for children \>5
\> After cleansing - child is NPO until surgery
\> IV fluids and strict I&O
Reducing pain
- Administer pain medication as ordered
- Most school-age children can use PCA
- Non-pharmacological therapies - repositioning, backrubs, music, holding, rocking, massage, quiet talking
- If pain control not achieved - assess for complications (bowel obstructions or infection)
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Maintaining nutritional and hydration status
- Child is kept NPO until bowel sounds return or flatus is passed after surgery
- NG tube to intermittent suction until peristalsis returns
- Monitor for signs of dehydration and acid-base imbalances
- IV fluids will continue until tolerating oral fluids well
- If oral fluids are tolerated - diet advanced from clear liquids to regular diet
Preventing infection and maintaining skin integrity
- Neomycin 1.0% solution given by rectum or stoma preoperatively
- IV antibiotics
- Monitor VS and measure abdominal circumference (tympanic, temporal, oral, or axillary temperatures only)
- Check surgical site for signs of infection - redness, swelling, purulent drainage
- If colostomy - check stoma site for bleeding or impaired skin integrity
- Observe anal site for signs of infection and presence of stool
- Dressing changes to keep incision clean and dry
- Ostomy care
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Lactose Intolerance
Absence or deficiency of lactase →
leads to inability to digest lactose (sugar in dairy products) →
lactose accumulates in the lumen of the small intestines →
leads to water being drawn into the colon →
results in watery osmotic diarrhea containing undigested lactose &
GI bacteria break down lactose and release hydrogen - causes excess gas production, bloating, abdominal pain
Manifestations
- Diarrhea, frothy but not fatty
- Abdominal distention
- Cramping, abdominal pain
- Excessive flatus
- Congenital lactose intolerance (rare) symptoms are seen immediately
- Developmental lactose intolerance appears in early to late childhood
Diagnostic evaluation
- Improvement after lactose-free diet
- CLINITEST stool test: 1+ or higher - indicates intestinal malabsorption of sugar
- Lactose tolerance testing (Hydrogen Breath Test)
90
Therapeutic management and nursing care - *Principal nursing intervention is teaching*
\* Removal of lactose from diet
\* Formulas that do not contain lactose - Isomil, Nursoy, Nutramigen, Prosobee, and other soy-based formulas
\* Breastfeeding mothers are encouraged to eliminate lactose products from their diet
\* Children can drink soy, almond, rice, or oat milk as an alternative
\* OTC lactase enzyme supplements
\* Calcium can be obtained from foods (egg yolks, green leafy vegetables, dried beans, cauliflower and molasses) or calcium supplements
91
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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
92
Manifestations
\* Major symptoms
- Diarrhea and growth failure (usually below the 25th percentile on growth charts)
\* Abdominal distention, vomiting, anemia, irritability, anorexia, muscle wasting, edema, folate deficiency
\* Symptoms are usually not seen until 3-6 months after introduction of grains to the diet - around age 9-12 months
\* Celiac crisis - profuse, watery diarrhea and vomiting with electrolyte imbalance (metabolic acidosis) and vascular compromise
Diagnostic evaluation
- Immunoglobulin A testing
- Jejunal biopsy
- Symptoms relieved in 1 week after removal of gluten from diet
93
Therapeutic management
\* Diet
- Dietary restrictions are lifelong
- Eliminate all wheat, rye, barley, oats from diet and replace with corn and rice
- Refer to a nutritionist
\* Vitamin supplements - fat-soluble vitamins and folate
Nursing care
Assessment
- Infant is usually irritable, malnourished, and exhibits failure to thrive by 9-12 months
- Assess bowel patterns
\> Diarrhea
\> Foul-smelling, fatty stools
- Assess for growth delays
- Abdominal assessment - distention and ascites
- Malnutrition signs - thin, edematous extremities, pallor, muscle wasting, anemia
94
Most significant nursing intervention - teaching
\* Diet modifications
\* Learn how to read labels
\* Making appropriate food choices - especially adolescents
\* Referral to a nutritionist
\* Support groups
95
Short Bowel Syndrome
Pathophysiology
- Results from a congenital malformation of the GI tract or surgical resection - decreases the length of the small intestines
- Small bowel is normally 200-250 cm long at birth and 300-800 cm by adulthood
\> Decrease in length of the small bowel \> 50% (either from a malformation or from a bowel resection) - leads to symptoms of generalized malabsorption or nutrient deficiencies
\> Small bowels that are too short have less mucosal surface area - leads to inadequate absorption of fluids, electrolytes, nutrients
Manifestations
- Watery diarrhea (most common)
- Steatorrhea, bloating, excessive gas, foul-smelling stool, poor appetite, vomiting, weight loss or inability to gain weight, fatigue
Complications
- Protein caloric malnutrition, dehydration, electrolyte imbalances, gallstones, kidney stones, high levels of bacteria in the intestines
- Vitamin and mineral deficiencies
\> Loss of vitamin D, magnesium, calcium - leads to paresthesias and tetany
\> Vitamin K depletion - prolongs bleeding time causing increased bruising
96
Therapeutic management
- With surgeries - important to preserve as much small bowel as possible
- After surgery - stabilize fluid and electrolyte balance
- Nutritional support
\> TPN primary source of all nutrients
\> Enteral nutrition
- Continuous small volume feedings
- Enriched formulas
- Proton pump inhibitors - to decrease gastric secretions and improve fluid balance
Nursing care
\* Monitor TPN via CVAD
\> Use aseptic technique for dressing changes and administration of TPN
\* NG tube, G tube, gastrostomy button care
\> Verify proper placement prior to feeds
\> Enteral nutrition - advanced slowly while weaning TPN
\> Note any signs of dehydration, electrolyte imbalances, nutritional deficits
\* Oral stimulation for infants and children
\> Using nonnutritive sucking techniques and providing water and small amounts of solid foods orally - promote learning to suck and swallow and avoid oral hypersensitivity and food aversions
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Hepatic Disorders - Viral Hepatitis: Pathophysiology
Virus causes **necrosis** of the parenchymal cells of liver
Inflammatory response leads to swelling and **blockage of the drainage system** in the liver
**Biliary stasis** leads to further destruction of hepatic cells
Liver cannot excrete bile into intestine, so bile is present in:
BLOOD - ?
URINE - ?
SKIN - ?
hyperbilirubinemia
urobilinogen
hepatocellular jaundice
98
Etiology
\* Most common causes of viral hepatitis are hepatitis A, B, C, D, and E
\* Hepatitis A (HAV) most common in children and highly contagious
\> Transmitted person-to-person, fecal-oral
\> Ingestion of contaminated food or water
\* Hepatitis B
\> Transmitted through contact with infected blood or body fluids, and at birth
Manifestations
\* HAV - anorexia, malaise, fatigue, and nausea
\* HBV
\> Anicteric phase (without jaundice) - anorexia, N/V, RUQ or epigastric pain, fever, malaise, fatigue, depression, irritability - lasts approximately 5-7 days
\> Later icteric phase (with jaundice) - jaundice, urticaria, dark urine, light-colored stools
99
Diagnostic evaluation
\* LFT's can indicate liver damage caused by hepatitis - aspartate transaminase (AST), alanine transaminase (ALT), bilirubin levels, alkaline phosphatase, sedimentation rate
\* Blood tests to diagnose hepatitis - identification of viral antigens and genetic material
\* Liver biopsy
Therapeutic management
\* No specific treatment - mainly supportive
\* Treatment aimed at maintaining comfort and adequate nutritional balance
\* Low-fat balanced diet
\* Discontinue nonessential medications
\* Avoid chemotherapy, corticosteroids, alcohol during infection
100
Hepatitis A or Hepatitis B?
- Standard precautions
- Immunization starting at birth
- Immunoglobulin effective in prevention if given within 2 weeks of exposure
Hepatitis B
101
Hepatitis A or Hepatitis B?
- Hydration, antipruritics, fat-soluble vitamin supplements
- Control spread - good hygiene, thorough disinfection of diaper changing surfaces
- Immunization recommended beginning at age 1
Hepatitis A
102
Nursing care - Assessment
- Assess for flu-like symptoms - fever, malaise, anorexia, fatigue, and nausea
- Assess for RUQ tenderness and hepatomegaly
- Stools pale or clay colored and urine may be dark and frothy
- Jaundice - assess sclera, nail beds, and mucous membranes
- HBV infection arthralgias are often common
103
*Education is crucial*
\* Importance of nutritious low-fat diet and adequate rest
\> Several small meals and snacks through the day
\* Indication of worsening - changes in neurologic status, bleeding, fluid retention
\* Avoid any OTC medications - acetaminophen due to impaired liver function
\* Caution adolescents not to drink alcohol
\* Preventing the spread of infection
- Contact precautions for at least one week after the onset of jaundice
- Hand hygiene - *_most important preventative measure_*
- Cleaning household surfaces with bleach solutions
\* Recommending hepatitis A and hepatitis B vaccinations
104
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Pathophysiology
- Obstruction or absence of extrahepatic bile ducts that eventually leads to inflammation, edema, and hepatic degeneration
Biliary atresia
105
Manifestations
- Healthy at birth
- Later may have jaundice, acholic stools (light d/t absence of bile pigment), bile-stained urine, and hepatomegaly
Diagnostic evaluation
\* Liver function (bilirubin, aminotransferases (ALT, AST), and clotting studies [PT, PTT])
\* Urine and stool samples
\> Urobilinogen levels - determine degree of obstruction
\* Percutaneous liver biopsy - definitive diagnosis
106
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
107
Nursing care
\* Assess for portal hypertension
Psychosocial and family assessment high priority - d/t life-threatening condition - eventually leads to liver transplant
\* Nutritional support
*Goals are to provide adequate calories, aiding in vitamin supply and absorption and preventing hepatic encephalopathy*
- Calorie counts, daily weighs, abdominal girths
- Concentrating calories - administer glucose polymer (polycose) and provide medium-chain triglyceride (MCT) supplements
- NG tube feeding or TPN
- Vitamin supplements - A, D, E, K, and calcium, phosphate, zinc
- Limit protein intake to prevent hepatic encephalopathy
- Plot weight, length, head circumference on growth charts
108
\* Skin care
- Administer bile acid binders (cholestyramine) - aid in excretion of bile salts and decrease pruritis and development of xanthomas
- Colloidal oatmeal baths (Aveeno) - decrease severe itching
- Prevent skin breakdown from severe scratching
\> Wear gloves during sleep
\> Apply soothing lotions and creams to dry skin to prevent infection
\* Developmental stimulation
- Encourage activities that promote developmental stimulation
- Access resources like physical and occupational therapy
- Facilitate achievement of developmental milestones - gross and fine motor skills and social and emotional abilities
109
Cirrhosis
Pathophysiology
- Stasis of bile causes inflammation and hepatomegaly - leads to death of liver cells and malabsorption and malnutrition
Etiology
- Results from chronic liver disease like HBV infection, chronic hepatitis, or biliary atresia
Manifestations
\* Liver cell failure
\> jaundice, pruritis, steatorrhea, abdominal distention, edema, anemia, bleeding, anorexia, frequent infections, poor growth
\* Portal hypertension
\> splenomegaly, esophageal varices, GI bleeding
*Both lead to ascites*
110
Therapeutic management
\* No effective treatment
\* Supportive care: rest, nutritional support, fluid management, relief of symptoms
\* Management of life-threatening complications - bleeding varices, ascites, hepatic encephalopathy
\* Eventually liver transplant
Nursing care
*Goal of nursing care is to sustain optimal conditions until liver transplantation*
Nutritional support
- Diet high in carbohydrates and calories, normal protein and low-fat
- Restrict sodium intake
- Multivitamin supplements - vitamins A, D, E, K
- NG tube feeding and TPN
- Monitor weight daily and record I&O
111
\* Skin care
- Skin assessment - open lesions, scratch marks, bleeding, easy bruising
- Colloidal oatmeal baths and topical antipruritic lotions (calamine)
- Keep nails trimmed or wear cotton gloves to prevent injury
\* Prevent complications
- Edema - diuretics, albumin, low-sodium diet
- Ascites - hospitalization, I&O, daily weights, fluid balance, monitor abdominal girth and distention
- Bleeding - monitor stool (stool guaiac tests), avoid injections, protect from injury, administer vitamin K
- Encephalopathy (results from excess ammonia in blood d/t incomplete breakdown of protein by liver)
\> Assess for changes in behavior and LOC
\> Limit protein
\> Administer lactulose - decreases GI bacteria that produce ammonia
\> Administer antibiotics
\> D/t impaired liver function carefully consider and monitor all drugs (adverse effects; metabolized in liver)
***Sedatives, opioids, acetaminophen, alcohol are strictly avoided***
