UNIT 8 GASTROINTESTINAL CHAPTER 32 and 41 Flashcards
Celiac disorder untreated can lead to…
lactose intolerance
Is gastrointestinal issues related mainly to one race?
A. Yes
B. No
B. No
Can occur in all age groups, cultures,
ethnic groups, and socioeconomic
classes
Can intelligent and wealthy people make non-nutrition food decisions?
Intelligence and wealth do not preclude
development of poor nutritional habits
Does financial stays play apart in nutritional status?
A.Yes
B. No
A.Yes
What is nutritional status influenced by?
nutritional status may be influenced by:
*attitudes and eating habits,
cultural or
*religious preferences,
*financial status
Dehydration- Is there stages to dehydration?
A. No
B. Yes
B. Yes
Are children more susceptible to being sick?
A. No
B. Yes
B. Yes
THE YOUNGER THE CHILD HIGHER DEHYDRATION STATUS
When children are sick that tend to vomit and not what to eat and become anorexic which can cause them to be dehydrated
How do you measure dehydration status
amount of body weight loss related to water
MILD dehydration / 3-5%
MODERATE dehydration/ 6-9%
SEVERE dehydration GREATER THAN 10
INTERVENTIONS FOR DEHYDRATION STAGES
for mild we like to start of with oral rehydration .
moderate -severe= intravenous route (isotonic / good for maintaining rehydration)
S/S od dehydration
S/S dehydration:
*dry skin/mucous membranes,
*lack of tears,
*sunken fontanels,
*irritability,
*LOC change
Is mild vomitting contraindication for oral rehydration?
A. No
B. Yes
A. No
unless the vomitting is severe
- A child is hospitalized because of persistent vomit- ing. The nurse would monitor the child closely for which problem?
- Diarrhea
- Metabolic acidosis
- Metabolic alkalosis
- Hyperactive bowel sounds
- Metabolic alkalosis
What is the best way to evaluate urine output or hydration status for an infant?
wet diapers
Weight is the most important determinant of the percent of total body fluid loss in infants and younger children.
What is the normal urine output
1-3ml/kg/hr
PREFER PEDIALITYE FOR A DEHYDRATED CHILD
A. no
B. yes
B. yes
What can cause diarrhea?
Causes of acute diarrhea include acute infectious disorders of the gastrointestinal tract, antibiotic therapy, rotavirus, and parasitic infestation.
S/s of diarrhea
Character of stools
2. Presence of pain and abdominal cramping
3. Signs of dehydration and fluid and electrolyte
imbalances
4. Signs of metabolic acidosis
is Diarrhea infectious
A. No
B. Yes
B. Yes
Mild dehydration S/S
Increased thirst, slightly dry buccal mucous membranes
Moderate dehydration S/S
Loss of skin turgor, dry buccal mucous membranes, sunken eyes, sunken fontanel
Severe dehydration S/S
Signs of moderate dehydration plus one of following: rapid thready pulse, cyanosis, rapid breathing, lethargy, coma
Dehydration/Diarrhea Managment
Correct fluid imbalance, treat
underlying cause
Oral fluids (ORS) used for
mild to moderate dehydration-
Pedialyte
Vomiting is not a
contraindication for oral
rehydration unless severe
Introduce regular diet as
tolerated
MAIN PRIORITY REHYDRATIONS
What component in the Colon is the disease Hirchsprung missing?
A. Lilli
B. Ganglion
C. Appendix
D. Ostomy
B. Ganglion
Also called congenital
aganglionic megacolon
Mechanical obstruction
from inadequate motility
of intestine
Absence of ganglion
cells in colon
Ganglion is used to create waves in the colon to bring fecal matter into rectum
What is the main issue with Hirchsprung disease?
Mechanical Obstruction of fecal matter
A newborn infant has not passed meconium in 24hrs , what condition would the nurse suspect that the baby is born with?
A. Pyloric stenosis
B. Gastroesophageal reflux disease
C. Lead poisoning
D. Hirschsprung disease
D. Hirschsprung disease
S/S of Hirschsprung for newborn
Newborns
a. Failure to pass meconium stool
b. Refusal to suck
c. Abdominal distention
d. Bile-stained vomitus
S/S of Hirschsprung for infants
- Failure to thrive weight loss
- Constipation
- Abdominal
distention - Diarrhea and
vomiting - Ominous sign-
explosive diarrhea,
MAJOR COMPLICATION
*fever=enterocolitis
S/S of Hirchsprung for Children
- Constipation,
ribbon like, foul-
smelling stools - Abdominal
distention - Visible peristalsis,
*palpable fecal mass - Undernourished, failed weight gain or growth
Can Hirschsprung disease be treated therapeutically or surgically?
A. therapeutically
B. surgically
B. surgically
Therapeutic Management of Hirchsprung
Surgery- removal of aganglionic portion
* Soave pull-through
* Preop bowel cleanout
* Postop- may require daily rectal
dilatation
- Maintain a low-Fiber, high-calorie, high-protein
diet; parenteral nutrition may be necessary in ex-
treme situations. - Administer stool softeners as prescribed.
- Administer daily rectal irrigations with prescribed
fluid/solution to promote adequate elimination
and prevent obstruction as prescribed.
Nursing Considerations Hirchsprung
1.Prepare parents for medical-surgical
procedure
2. Monitor for abdominal distention, VS
3. Assist with ostomy care parents will
perform at home, if needed
4. Teach preschool and older child
about ostomy using concrete terms
and visuals- remind that ostomy is
likely temporar
Post operative teaching Hirchsprung
- Monitor vital signs, AVOID taking the temperature rectally.
- Measure abdominal girth daily and PRN (as needed).
- Assess the surgical site for redness, swelling, and drainage.
- Assess the stoma if present for bleeding or skin breakdown (normal stoma would be red and moist).
- Assess the anal area for the presence of stool, redness, or discharge.
- Maintain NPO status as prescribed and until bowel sounds return or flatus is passed, usually within 48 to 72 hours
After Hirchsprung surgery should you check the pt’s temp rectally?
A. No
B. Yes
A. No
Your pediatric patient has just undergone Hirchsprung surgery. He is saddened to know that he will have an ostomy. What can the nurse say to relieve their concerns.
A. I had this procedure done as a child, it really didn’t affect me at all.
B. No need to cry, this is permanent , so I would hope you get used to it.
C. I understand how you feel this a new way of doing things , but it is only temporary.
D. No worries , whenever you feel uncomfortable we can remove it for you.
C. I understand how you feel this a new way of doing things , but it is only temporary.
- Teach preschool and older child
about ostomy using concrete terms
and visuals- remind that ostomy is
likely temporary
When can the patient be removed off NPO status post op Hirchsprung
- Maintain NPO status as prescribed and until bowel sounds return or flatus is passed, usually within 48 to 72 hours
- The clinic nurse reviews the record of an infant and notes that the primary health care provider (PHCP) has documented a diagnosis of suspected Hirschsprung’s disease. The nurse reviews the as- sessment ndings documented in the record, know- ing that which sign most likely led the parent to seek health care for the infant?
- Diarrhea
- Projectile vomiting
- Regurgitation of feedings
- Foul-smelling ribbon-like stools
- Foul-smelling ribbon-like stools
What occurs during GER Gastroesophageal
Reflux (GER)
Transfer of gastric contents
into the esophagus
Called GERD when
complications/tissue damage
occurs
Transfer of gastric contents
into the esophagus
Called GERD when
complications/tissue damage
occurs
Can occur throughout the
day, but most frequently after
meals and at night
Risk factors of GER, Gastroesophageal
Reflux (GER)
Helicobactor Pylori
Patients who are overweight or have obesity are at highest risk for GERD because increased weight increases intra-abdominal pressure, which contributes to reflux.
*constricting clothing by the abdomen
Other factors that increase intra-abdominal and intragastric pressure (e.g., pregnancy, wearing tight belts or abdominal binders, bending over, ascites
*Pregnancy
*Caffeine (COFFEE),
*chocolate,
*acidic foods,
*fatty foods
*Alcohol,
*smoking
Caffeinated beverages
, tea, and cola (SODA)
* Nitrates
* Citrus fruits
* Tomatoes and tomato products
* Peppermint, spearmint
S/S OF , Gastroesophageal
Reflux (GER)
Symptoms in Infants
*Spitting up, regurgitation, recurrent *vomiting (may be forceful)
*Excessive crying, irritability,
*arching of the back,
*stiffening
*Poor weight gain
*Respiratory problems (e.g., cough, wheeze, stridor, gagging, choking with feedings)
*Feeding refusal
Symptoms in Children
Heartburn
Abdominal pain
Chronic cough, hoarse voice Dysphagia
Asthma
Recurrent vomiting Complications
Esophagitis
Esophageal stricture Laryngitis
Recurrent pneumonia Anemia
Barrett esophagus
Therapeutic management of GER
Therapeutic management
No therapy for normally growing infants without respiratory complications
Lifestyle mods- small, frequent meals; no vigorous play after meals
Meds- ranitidine, famotidine, PPIs(decrease stomach acids (ANATACIDS)
*ADMINISTER 1 HOUR BEFORE MEALS)
Surgical management- Nissen fundoplication
Keeping an infant upright (on a parent’s shoulder or lap) for 20 to 30 minutes after feeding can reduce the likelihood of regurgitation.
The semisupine position (e.g., in an infant seat) is not Recommended as it increases reflux.
- In children older than 1 year, position with the head of the bed elevated.
Burp the infant frequently when feeding, and handle the infant minimally after feedings; monitor for coughing during feeding and other signs of aspiration.
- For toddlers, feed solids first, followed by liquids.
- Instruct the parents to avoid feeding the child fatty foods, chocolate, tomato products, carbon- ated liquids, fruit juices, citrus products, and spicy foods.
What is the proper education for Antacids for children with GER Gastroesophageal
Reflux (GER)
Meds- ranitidine, famotidine, PPIs(decrease stomach acids (ANATACIDS)
*ADMINISTER 1 HOUR BEFORE MEALS)
PPI’S are most effective when administered 30 minutes before breakfast so that the peak plasma concentrations occur with mealtimes
- The nurse provides feeding instructions to the par- ent of an infant diagnosed with gastroesophageal reux disease. Which instruction would the nurse give to the parent to assist in reducing the episodes of emesis?
- Provide less frequent, larger feedings.
- Burp the infant less frequently during feedings.
- Thin the feedings by adding water to the formula.
- Thicken the feedings by adding rice cereal to the formula.
- Thicken the feedings by adding rice cereal to the formula.
Should a patient with a cleft palate undergo tonsillitis surgery ?
A. Yes
B. No
B. No
Contraindications to either tonsillectomy or adenoidectomy are (1) cleft palate, because the tonsils help minimize escape of air during speech;
(2) acute infections at the time of surgery, because locally in-flamed tissues increase the risk of bleeding; and (
3) uncontrolled systemic diseases or blood dyscrasias.
Complications of Nissen surgery that need to be brought to health care provider
Caregivers should be aware of potential postopera- tive problems, such as difficulty vomiting, bloating symptoms, or discomfort with large solid-food meals, and seek guidance from their health care provider as needed.
When does Cleft lip /Cleft palate form inutero?
Facial malformations that
occur during 4th-10th week of
embryonic development
Risk factors of Cleft lip/Palate
Severity of CP has direct
impact on feeding problems
Risk factors: maternal
smoking,
alcohol,
steroids,
anticonvulsants
Is multidisciplinary approach needed for Cleft palate and cleft lip reconstruction surgery?
A. Yes
B. no
A. Yes
Multidisciplinary approach:
pediatrics, plastic surgery,
orthodontics, otolaryngology,
speech/language pathology,
audiology, nursing, and social work
Post operative teaching Cleft lip/Cleft palate
Post-op: protect operative site!
CL: Apply petroleum jelly to suture line
Arms restrained at elbows (~2wks)
Adequate analgesia
Clear liquids initially; progress to full feeding
Discharge on blenderized or soft diet
Avoid suction, pacifiers, oral thermometers, straws, hard food
What should you apply at the suture line post op cleft lip surgery?
A. Hydrogen chloride
B. Silver nitrate
C. Nitroglycerin
D. petroleum jelly
D. petroleum jelly
You notice that the new grad nurse has introduced a star to the pediatric patient who is post operate cleft palate surgery. What is the nurses priority intervention?
A. continue to let the nurse give the pediatric a straw
B. Intervene and take an oral temperature first.
C. Pull the nurse aside and instruct her that nothing but clear liquids should be given to the pediatric patient post op.
D. Use suction tube instead
C. Pull the nurse aside and in strict her that nothing it clear liquids should be given to the pediatric patient post op.
Avoid suction, pacifiers, oral thermometers, straws, hard food
Why is the are elbow restraint important in cleft lip/cleft palate post op patients?
Arms restrained at elbows (~2wks)
to decrease risk of infant destructing suture line
Elbow jacket teaching (skin integrity)
Soft elbow or jacket restraints may be used (check agency policies and procedures) to keep the child from touching the repair site; remove restraints at least every 1 to 2 hours (or per agency procedure) to assess skin integrity and circulation and to allow for exercising the arms.
Nutrition feeding problems with cleft lip/cleft palate
-Growth failure
-feed in upright posistion
-reduced sucking ability
-oral liquids escape through the nose
-breast feeding difficultie- Haberman feeder
-Normal nipples not suitable
- An infant has just returned to the nursing unit after surgical repair of a cleft lip on the right side. The nurse would place the infant in which best position at this time?
- Prone position
- On the stomach
- Left lateral position
- Right lateral position
- Left lateral position
A cleft lip is a congenital anomaly that occurs as a result of failure of soft tissue or bony structure to fuse during embryonic development. After cleft lip repair, the nurse avoids positioning an infant on the side of the repair or in the prone position, because these positions can cause rubbing of the sur- gical site on the mattress. The nurse positions the infant on the side opposite the repair or on the back upright and posi- tions the infant to prevent airway obstruction by secretions, blood, or the tongue. From the options provided, placing the infant on the left side immediately after surgery is best to pre- vent the risk of aspiration if the infant vomits.
Esophageal Atresia (EA) &
Tracheoesophageal Fistula (TEF)
Failure of esophagus to
develop as a continuous
passage; failure of trachea
and esophagus to separate
into distinct structures
Is Esophageal Atresia (EA) &
Tracheoesophageal Fistula (TEF) a clinical emergency
Clinical emergency if not
diagnosed and treated early
S/S OF Esophageal Atresia (EA) &
Tracheoesophageal Fistula (TEF)
Apnea
Increased respiratory distress during feeding
Three C’s
Coughing
Choking
Cyanosis
- Frothy saliva in the mouth and nose and exces-
sive drooling - The “3 Cs”—coughing and choking during feed-
ings and unexplained cyanosis - Regurgitation and vomiting
- Abdominal distention
- Increased respiratory distress during and after
feeding
Nursing Management of Esophageal Atresia (EA) &
Tracheoesophageal Fistula (TEF)
NPO immediately!!
IVF’s
Removal of secretions
Elevation of bed 30 degrees
Broad spectrum antibiotics – to help
prevention of pneumonia
Surgical repair of anomaly
Prognosis r/t birth weight & associated
anomalies – survival rate for healthy
infants near 100%
- The nurse reviews the record of a newborn infant and notes that a diagnosis of esophageal atresia with tracheoesophageal stula is suspected. The nurse expects to note which most likely sign of this condition documented in the record?
- Incessant crying
- Coughing at nighttime
- Choking with feedings
- Severe projectile vomiting
- Choking with feedings
In esophageal atresia and tracheoesophageal fis- tula, the esophagus terminates before it reaches the stomach, ending in a blind pouch, and a fistula is present that forms an unnatural connection with the trachea. Any child who exhib- its the “3 Cs”—coughing and choking with feedings and unex- plained cyanosis— would be suspected to have tracheoesoph- ageal fistula. Options 1, 2, and 4 are not specifically associated with tracheoesophageal fistula.
Hypertrophic Pyloric Stenosis
(HPS)
Constriction of pyloric
sphincter with obstruction
of gastric outlet
S/s of Hypertrophic Pyloric Stenosis
(HPS)
Vomiting 30-60 minutes after a feed (projectile, non-bilious)
No pain or discomfort except chronic hunger
Weight loss, malnourished, FTT
Signs of dehydration, lethargy
Palpable olive-like mass
Should you expect vomitting post op Pyloromyotomy?
A. Yes
B. No
A. Yes
Pyloromyotomy with RUQ incision
Pre-op: Restore hydration &
electrolyte imbalance
Post-op vomiting may occur;
maintain IVF’s
You palpate an olive shaped mass on your patient abdomen. What disease process do you suspect your patient has?
A. Intussusception
B. Pyloric stenosis
C. Anorectal malformations
D. Hirschsprung’s disease
B. Pyloric stenosis
Post operative teaching Pyloric
Pyloromyotomy with RUQ incision
Pre-op: Restore hydration &
electrolyte imbalance
Post-op vomiting may occur;
maintain IVF’s
Begin feedings 4-6 hours
postoperatively
Assess for pain; analgesics as
needed
- The nurse admits a child to the hospital with a diag- nosis of pyloric stenosis. On assessment, which data would the nurse expect to obtain when asking the parent about the child’s symptoms?
- Watery diarrhea
- Projectile vomiting
- Increased urine output
- Vomiting large amounts of bile
- Projectile vomiting
Intussusception
Most common cause of intestinal
obstruction in children between
the ages of 5 months and 3 years;
more common in males
Portion of bowel telescopes into
another portion, causing
inflammation and decreased
blood flow to bowel
Mucus and blood leaks into intestinal
lumen (currant-jelly stools)
Diagnostics: U/S
Intussusception
S/S of Intussusception
Mucus and blood leaks into intestinal
lumen (currant-jelly stools)
Intense abdominal pain
Abdominal swelling or distension
Currant jelly stools
Bilious vomit
Lethargy
Shallow breathing
*Tender distended abdomen, possibly with a palpable sausage-shaped mass in the upper right
quadrant
The HCP has initiates a plan to start Intussusception surgery. What needs to happen in order for the surgery to be stopped?
Passage of a normal brown stool
usually indicates that the
intussusception has reduced
itself
Can Intussusception return back to normal on its own
A. No
B. Yes
B. Yes
Passage of a normal brown stool
usually indicates that the
intussusception has reduced
itself
If unsuccessful, surgery
* Prognosis-nonoperative
reduction successful in 65-75%
of cases
Which of the following disorder , clinical manifestations include bilious vomit?
SELECT ALL THAT APPLY
A. Intussusception
B. Pyloric stenosis
C. Anorectal malformations
D. Hirschsprung’s disease
D. Hirschsprung’s disease
A. Intussusception
Imperforate
Anus
Absence of a normal anal
opening
May be isolated defect or part of
VACTERL association
Diagnosis is usually made shortly
after birth by a routine physical
examination by rectal temp to rule out imperforate anus
S/S OF Imperforate
Anus
Lack of patency and passage of
meconium stool; distended abdomen,
presence of meconium in urine
. Monitor for the presence of stool in the urine
and vagina (indicates a fistula) and report immediately.
Therapeutic management of Imperforate
Anus
Surgical repair- anoplasty
Recommend to delay 24 hrs to evaluate
other anomalies
Surgical site care
May require anal dilation
Encourage breast feeding
Postoperative interventions/TEACHING Imperforate
Anus
ostoperative interventions
1. Monitor the skin for signs of infection.
- The preferred position is a side-lying prone position with the hips elevated or a supine position with the legs suspended at a 90-degree angle to the trunk to reduce edema and pressure on the surgical site.
- Keep the anal surgical incision clean and dry, and monitor for redness, swelling, or drainage.
*NO RECTAL TEMPAERTURES
. Rectal temperatures need to be avoided in the immediate postoperative care due to sutures.
- A new colostomy stoma may be red and edematous, but the edema ought to decrease with time.
- Instruct the parents to perform anal dilation if prescribed to achieve and maintain bowel patency.
- Instruct the parents to use only anal dilators supplied by the PHCP and a water-soluble lu- bricant and to insert the dilator no more than 1 to 2 cm into the anus to prevent damage to the mucosa.
Proper positioning Post op imperfortate anus
- The preferred position is a side-lying prone position with the hips elevated or a supine position with the legs suspended at a 90-degree angle to the trunk to reduce edema and pressure on the surgical site.
- The nurse is caring for a newborn with a suspected diagnosis of imperforate anus. The nurse monitors the infant, knowing that which is a clinical manifes- tation associated with this disorder?
- Bile-stained fecal emesis
- The passage of currant jelly–like stools
- Failure to pass meconium stool in the first 24 hours after birth
- Sausage-shaped mass palpated in the upper right abdominal quadrant
- Failure to pass meconium stool in the first 24 hours after birth
Celiac Disease
Celiac disease is also known as gluten enteropathy or celiac sprue.
2. Intolerance to gluten, the protein component of wheat, barley, rye, and oats, is characteristic.
. The nurse provides home care instructions to the parents of a child with celiac disease. The nurse would teach the parents to include which food item in the child’s diet?
1. Rice
2. Oatmeal
3. Rye toast
4. Wheat bread
- Rice
- The nurse is preparing to care for a child with a di- agnosis of intussusception. The nurse reviews the child’s record and expects to note which sign of this disorder documented?
- Watery diarrhea
- Ribbon-like stools
- Profuse projectile vomiting
- Bright red blood and mucus in the stools
- Bright red blood and mucus in the stools
S/ of celiac disease
- Acute or insidious diarrhea
- Steatorrhea
- Anorexia
- Abdominal pain and distention
- Muscle wasting, particularly in the buttocks and
extremities - Vomiting
- Anemia
- Irritability
celiac crisis
Celiac Crisisa
Acute, severe episodes of profuse watery diarrhea and vomiting May be precipitated by:
* Infections (especially gastrointestinal)
* Prolonged fluid and electrolyte depletion * Emotional disturbance
Therapeutic management of Celiac disease
“GLUTEN FREE” diet Compliance is difficult in
older children and adolescents
Maintain diet high in calories and protein with
simple carbohydrates (fruits & vegetables); low
in fat
Avoid high fiber foods (nuts, raisins, raw
vegetables) until inflammation subsides
Eliminate wheat, rye, barley, and oats
Substitute corn and rice
Untreated children may have lactose
intolerance
Treat nutritional deficiencies with
supplements including vitamins, Fe, &
calories
The nurse knows that a solution to manage high levels of lead in patients is this treatment option that helps to detox the body
Chelation therapy removes lead from the cir-
culating blood and from some organs and
tissues.
b. Therapy does not counteract any effects of the
lead.
When does screening for lead take place
Universal screening
a. Screening is recommended for children 1 to 2 years old; children at high risk need to be
screened earlier.
b. Any child between the ages of 3 and 6 years who has not been screened needs to be tested.
Chelation therapy teaching
Medications include calcium disodium edeate, and succimer, an oral preparation; Brit- ish anti-Lewisite (BAL) is used in conjunction with ethylenediamine tetraacetic acid (EDTA).
d. British anti-Lewisite is administered via the IV route or the deep intramuscular route and is contraindicated in children with an allergy to peanuts because the medication is prepared in a peanut oil solution; it is also contraindicated in children with glucose-6- phosphate dehydrogenase (G6PD) deciency and would not be given with iron.
Provide adequate hydration, and monitor kidney function for nephrotoxicity when the medication is given, because the medication is excreted via the kidneys.
Follow-up of lead levels needs to be done to monitor progress.
i. Provide instructions to parents about safety from lead hazards, medication administration, and the need for follow-up.
j. Confirm that the child will be discharged to a home without lead hazards.
