Week 8 Part 2: PEDS GI Flashcards
What things are more frequent and faster in pediatric GI systems
frequent feedings
frequent bowel movements
faster intestinal motility (peristalsis)
faster rate of dehydration
all due to a higher basal metabolic rate
Since children dehydrate fast, it is important to assess…
assess skin turgor
assess fontanels
lack of tearing
dry mucus membrane assessment
thirst level
skin temp
activity level
What is different regarding breast fed and formula fed infants
the breast milk is easier to digest so more frequent stools and easier stools occur
S/S of a GI disorder in infants/children
vomiting and regurgitation
irritability and fussiness
abdominal pain and distention
FTT
weight loss
stool changes
abdominal pain
fussy with feedings
What are some subjective things to assess regarding Pediatric GI
- Lifestyle and family factors including family hx
- Diet - are they gaining or losing, hx of feeding pattern, allergies, do they spit up
- Elimination patterns - I?Os, encorpresis/constipation, stool patterns
What are some objective things to assess regarding pediatric GI
observe for abdominal distention, symmetry, bumps, bulges, massess, and the umbilicus
Auscultate hyper and hypo active bowel sounds
percussion - tympany v dullness
palpation - light v deep, rebound tenderness, McBurneys point
Always listen ___ before you feel for GI assessments
before
McBurneys Point
area third of the distance laterally of a line drawn from the umbilicus to the anterior superior iliac spine
this corresponds to the base of the appendix
Types of Disorders of the GI System
Structural Defect
Disorders of Motility
Inflammatory Disorders
Disorders of Malabsorption
Hepatic Disorders
Injuries to the GI System
What are some important structural defects to know for peds GI
cleft lip and cleft palate
esophageal atresia and tracheoesophageal fistulas
pyloric stenosis
intussusception
abdominal wall defects
anorectal malformations
umbilical hernia
What is the start of the GI system
the oral cavity
Cleft Lip and Cleft Palate
Structural congenital anamoly that occurs as a result of failure of soft tissue or bony structures to fuse during weeks 6-12 of gestation
multifactorial causes
Do cleft lip and cleft palate always occur together?
they each can appear by themselves or be seen together
Cleft lip can occur ____ or ____
unilaterally or bilaterally
What is the msot common craniofacial deformities overall in the US
cleft lip and cleft palate
Complications caused by cleft lip and cleft palate
Feeding Problems (ability to suck, swallow, breath w/out distress to be checked)
Speech development
Otologic
Dental and orthodontic
Developmental
Why do otologic issues occur with cleft lip and cleft palate
because there is more drainage into the ear leading to more frequent ear infections
What needs to be done in the time between being born but before having surgery to correct a cleft lip or palate
special feeding techniques that will take more time such as the Haberman feeder or ESSR method
Haberman Feeder
special device used for feeding cleft lip and palate babies
It involves holding the infant upright and it stimulates sucking by rupping the nipple to allow the child to get food into the back of the throat withou strong sucking
can even give breast milk instead of formula by first pumping the milk and then putting it inside
ESSR Method
method for feeding cleft lip and palate babies
it stands for: Enlarge nipple (hole) Stimulate sucking Swallow Rest
This allows the baby to not put too much strain and take plenty of time to eat
When feeding the cleft palate or lip baby it is important to allow…
for small and frequent feedings that allow time to swallow and burp frequently
When is cleft lip repair surgery usually done
usually 1-3 months post birth
Cleft Lip Repair
suture line staggered “Z shape” occurs to close the cleft
A logan bar is then put over the child’s mouth along with elbow restraints
Logan Bar
a bar that goes over a post op cleft lip babies mouth to reduce tension on the suture line
What is the purpose of elbow restraints following a cleft lip repair
it prevents the baby from bending the elbow to pick or pull at the incision
Incision care following a cleft lip repair involves…
cleaning sutures with sterile cotton swab and half strength H2O2 followed by saline to prevent crusting
Antibiotic ointment is then applied to suture line
Elbow restraints should be released…
every 2 hours`
What is the feeding technique following a cleft lip repair
Breck Feeder Technique
Breck Feeder
A droplet device that allows for feeding a post-op cleft lip repair infant
Baby must be on their back or side lying to feed
When is a cleft palate usually repaired
it is usually repaired IN STAGES between 6 months to 2 years old
What does a cleft palate repair protect against
altered dentitions and speech dysfunction
What is a common problem for cleft palate babies
frequent otitis media due to an open nasopharynx
For a cleft palate infant to undergo repair, they must be able to…
drink from a cup
Cleft Palate Repair Post Op Considerations
Post Op: Maintain Airway and O2 Sat MOnitor
No bottles, straws, pacifiers, spoons for 7-10 days
Elbow restraints and mittens
Clear to soft diet
all feedings followed by rinsing the mouth with water to clean the suture line
no brushing teeth 1-2x weeks
pain medication
What things should be avoided following a cleft palate repair to prevent injury
bottles
straws
pacifiers
spoons
for at least 7-10 days
What must be done after every post op cleft palate repair feeding
rinse mouth with water to clean suture line
Why is red dye avoided following a cleft palate repair
because you cannot tell it apart from blood
Esophageal Atresia (EA)
structural defect
congenital disruption of the upper and lower portions of the esophagus
basically the esophagus ends in a sac not connected to the stomach
Tracheoesophageal Fistula (TEF)
structural defect
abnormal communication b/t the trachea and the esophagus
a fistula or abnormal connection occurs - so like the esophagus could lead into the trachea which then leads abck to stomach or the two are connected lower down or the esophagus just drains into the trachea
Do EA and TEF occur together?
Usually they occur together but they can occur alone
EA and TEF are associated with
Maternal Polyhydramnios
Too much fluid
S/S of EA and TEF
In the immediate newborn period:
Respiratory Distress
Difficulty Feeding
Excessive Drooling
Choking, Coughing
Cyanosis
How is EA and TEF diagnosed
it is initially notices when the NG tube cannot pass through
Esophageal Atresia (EA) is…
a surgical emergency!
What is the treatment for EA and TEF
surgical correction
Pre Operative Nursing Care for EA and TEF Surgery
Maintain airway
NG Tube to suction - dont want to aspirate
Prevent aspiration by raising HOB and keeping them NPO
IV fluids and TPN
Sometimes a G tube may be placed to drain stomach contents and allow air to escape
May need tracheostomy and care for it
What is the surgical intensity like for EA and TEf surgery
it depends - it can be a single repair or staged surgery depending on age, size, length of gap
Post Operative Nursing Care for EA and TEF Surgery
Initially NPO
TPN
G Tube Feeding
Feeds start with clear diet (pedialyte) then advance over several days
Family teaching
What are some complications that can occur from EA and TEF surgery
tears
strictures
gastric reflux
infection
Pyloric Stenosis
structural defect
narrowing of the pyloric part of the stomach
Etiology of Pyloric Stenosis?
Unknown - but it is present at birth and often affects FIRST BORN MALES 2-5x more than females
How is pyloric stenosis diagnosed
by ultrasound
Where is pyloric stenosis occurring
between the stomach and the duodenum
What is causing the pyloric stenosis in physiologic terms
hypertrophy of the circular muscles of the pylorus that causes narrowing of the pyloric canal between the stomach and the duodenum
S/S of Pyloric Stenosis
Eating/Food leading to irritation, progressive edema, further narrowing, FTT, NV, and poor feeding
What is the hallmark symptom of pyloric stenosis
projectile vomitting (forceful, shortly after meals, 2-4 feet)
Things seen on clinical assessment for pyloric stenosis
vomiting progresses from mild regurgitation to projectile vomiting
The vomiting is forceful, occurs after meals
constant funger, fussiness, and crying
Decreases in size and number of stools
failure to gain weight or loses weight
dehydration results / lyte imbalance
What is sometimes palpable on abdominal exam of an infant of pyloric stenosis
olive shaped mass
What is the treatment for Pyloric Stenosis
Pyloromyotomy - surgery
Preop consideration for pyloromyotomy
NPO
IV fluids for fluids and electrolyte management
NG tube
Post op considerations for pyloromyotomy
maintain IVF, analgesics, d/c NG tube
start feeds - pedialyte, 1.2 strength formula, then full str formula
Gastroschisis and Omphalocele
congenital defect of the ventral abdominal wall
it is characterized by herniation of abdominal viscera outside the abdominal wall
intestines outside the belly
What is the difference between Gastroschisis and Omphalocele
Gastroschisis occurs to the side of the umbilicus and does not have a protective sac covering contents
Omphalocele occurs through the umbilical cord and does have a protective sac covering around its contents
What is the cause of Gastroschisis and Omphalocele
Multifactoral causes
Nursing Management for Gastroschisis and Omphalocele
- Prevent infection - cover the sac with sterile gauze soaked in NS then sterile plas
Monitor VS closely - temperature!!
NPO, Maintain IVF’s, TPN
Parental Support
What is the key to Gastroschisis and Omphalocele nursing treatment
PREVENT INFECTION
Anal Stenosis
Anorectal Malformations
A thickened and constricted anal wall
Anal Atresia
Imperorate Anus
Failure of an infant to pass meconium and examination reveals absent anal opening
What is the key sign of anal stenosis
production of ribbon like stools
What is the key sign of anal atresia
lack of an anal opening and failure to pass meconium
What can help test patency of the infant anus
taking a rectal temperature
Where can stool appear when an infant has anal stenosis or atresia
stool in the urine due to a fistula to the perineum
or
stool in the vagina from a fistula
Treatment for Low Anorectal Defects (Anal Stenosis and Anal Atresia)
Anoplasty and serial digital dilations are effective
Treatment for HIgh Anorectal Defects (Anal Stenosis and Anal Atresia)
2 Step Procedure:
- Temporary Colostomy
- Pull through method
What is the pull through method for high anorectal defects
its pulling the intestines through as the child ages
Umbilical Hernia
Hernia protrusion of an organ or part of an organ through the muscle wall of the cavity that normally contains it
What does an umbilical hernia result from
imperfect closure of the umbilical muscle ring
What is the etiology of umbilical hernias
while it results from imperfect closure of the umbilical muscle ring - the etiology of that is unknown
However, it is often associated with separation of the abdominal muscles
Why is umbilical hernia more seen in premies
because the muscle walls are weakened
Clinical Manifestations of Umbilical Hernia
Herniated umbilicus protrudes with coughing, crying, and or straining - increased pressure occurs with these activities
How may an umbilical hernia reduce?
Hernia can be reduced by pushing contents back into fibrous ring
if it can be pushed back in than its not an emergency
Most umbilical hernias…
spontaneously resolve by 3-4 years old as the muscular ring closes
When is umbilical hernia surgery indicated
in cases of strangulation
increased protrusion after 2 years of age
no improvement in large defect after 4 years
What are some GI Disorders of Motility
Vomiting and Diarrhea
Gastroesophageal Reflux
Constipation and Encopresis
Hirschsprung Disease
Parasitic Disorders
Gastroenteritis
What motility disorders are common causes for hospitalizations in infants
NV and Gastroenteritis
Encopresis
abnormal elimination pattern - recurrent soiling or passage of stool at inappropriate times
How is diagnosis of encopresis made
made on history and physical examination
may need a barium enema to rule out organic causes
Treatment of Encopresis involves…
behavior modification
dietary changes
clearing out impacted stool
bowel program
Nursing Considerations for Encopresis
Education for child and parents
reassurance and emotional support
school nurses keeping spare undergarments around and assisting
investigating potential sexual abuse when other causes ruled out
Hirschspung’s Disease
Absence of ganglion cells in the distal bowel resulting in mechanical obstruction d/t inadequate motility
Causes for Hirschspung’s Disease
Strong genetic predisposition
Increased incidence in downs syndrome and anomalies of urinary tract
What signs in neonates signal potential Hirspung’s Disease
no stool in 24 hours
poor feeding
abdominal distention
chronic constipation
Diagnostics for Hirschspung’s Disease
X Ray
Barium Enema
Rectal Biopsy
Treatment for Hirschspung’s Disease
constipation –> surgical repair
A temp colostomy followed by anastomose - connecting the intestines as they grow
Gastroenteritis
inflammation of the stomach and small and large intestines
it is an infection caused by viruses, bacteria, or parasites
Gastroenteritis commonly manifests as ___
diarrhea
Gastroenteritis usually occurs in children under ___ years old, and they get ___ cases/year on average
5 yo / 2 cases/year
Why do kids get gastroenteritis so commonly
because they are bad at washing hands and not putting them in their mouth -ew
Gastroenteritis caused by viruses lasts how long? What if it is caused by bacterial causes?
viral - 1-2 days
bacteria - a week or more
70-80% of diarrhea of acute diarrahea in NA is caused by what
viral gastroenteritis
Complications of Gastroenteritis
diarrhea
dehydration
lyte and acid base disturbance
bacteremia and sepsis
malnutrition
Diarrhea
watery stool
increased frequency
(Or Both)
caused by dirty hands in kids a lot
What is Acute Diarrhea
lasting less than 2 weeks
usually r/t bacterial or viral infections
Most common childhood reason for Diarrhea
Rotavirus (Causes acute diarrhea)
What is Chronic Diarrhea
lasting longer than 2 weeks
r/t functional disorders like IBS, or diseases like UC or chorhns disease
Meds for Diarrhea
Flagyl (anaerobic bacteria, parasites, H Pylori)
Immodium (anti diarrheal)
It is important to monitor for what with diarrhea
electrolyte imbalances
What is a very common cause of being absent or for reasons for visits to the school nurse
recurrent abdominal pain - challenging
Recurrent abdominal pain is a frequent problem among what groups of children
young children and adolescents, especially school aged girls
Recurrent Abdominal Pain pain is generally where
in the periumbilical area
Causes of Recurrent Abdominal Pain
Examine / check pressures and stressors in life - bullying, trouble with class or teachers
Organic causes - uncommon but must rule out
Abuse or Pregnancy
Nursing Treatment for Recurrent Abdominal Pain
Supportive and non judgmental care
Inflammatory GI Disorders
Appendicitis
Meckel’s Diverticulum
Appendicitis
inflammation of the appendix
Appendicitis is most common in what group
adolescent males 10-19 years of age
What can lead to appendicitis rupture
edema continuing to grow, causing vascular supply to be compromised –> bacteria follow by an immune response –> leads to a rupture
What is indicative of an appendix rupture
decreased pain while still feeling sick - emergency!
S/S of Appendicitis
pain
loss of appetitie
fever
n/v
abdominal rebound tenderness & rectal tenderness
What are positive signs of appendicitis
abdominal rebound tenderness
digital rectal exam elicits tenderness
What confirms a dx of appendicitis
CT or ultrasound
Labs to give and their changes with Appendicitis
elevated WBC - infection
pregnancy test to rule out ectopic pregnancy - would have raised HcG if pregnant
Pre/Post Op Care of Appendicitis
NPO, IV Fluids
Correction of fluid/lyte deficits
Surgical Incision
Antibiotics
Nursing Dx for Appendicitis
Pain
risk for infection
Appendices are removed ___
laproscopically
Meckel’s Diverticulum
inflammatory disorders
occurs when the connetion between the intestine and the umbilical cord doesn’t completely close off during fetal development
this results in a small outpouching of the small intestine - a diverticula sticking out in the intestine that is liek a pouch
What is one of the most common congenital abnormalities
Meckels Diverticulum
What can occur to the diverticula of Meckel’s Divericulum
they can become infected - diverticulitis - causes obstruction of the intestine or causes bleeding from the intestine
Most common symptom of Meckel’s Diverticulitis
Painless bleeding from the rectum!!
Stools may contain fresh blood or may look black and tarry
Meckel’s Diverticulum is an outpouching of the ___ which remains and contains gastric contents leading to what things
ileum; ulceration, bowel obstruction, perforation, peritonitis
What is the Rule of 2’s
It is for Meckel’s Diverticulum
Under 2 yeras old usually, 2% of the population, occurs within 2 feet of the ileocecal valve, 2 inches in length, and affects 2 types of mucosa
What is the most common complication of Meckel’s Diverticulum
Bowel Obstruction
What is the diagnostic needed for Meckel’s Diverticulum
Made on Hx, observed rectal bleeding
Tx for Meckel’s Diverticulum
Surgical incision resetting the diverticulum
Nursing Care for Meckel’s Diverticulum
Pre and Postop care similar to other abdominal surgery
When does malabsorption occur in children
when a child is unable to digest or absorb nutrients in the diet leading to concerns of poor growth and FTT
Disorders of Malabsorption include…
Short Bowel Disease
Celiac Disease
Lactose Intolerance
Cystic Fibrosis *
Pediatric Hepatic Disorders
Hyperbilirubinemia of the newborn
Biliary Atresia
Viral hepatitis
Cirrhosis
Biliary Atresia
Hepatic Disorder
Pathologic closure or absence of hepatic or common bile ducts
Biliary Atresia leads to what things
Cholestasis, Fibrosis, and Cirrhosis
The most common pediatric liver disease is…
biliary atresia
Biliary Atresia often necessitates what
transplantation of the liver
Biliary Atresia is the most common cause of infant ___
jaundice
What gender is more affected by biliary atresia
girls > boys
Cholestasis
gall stones
Etiology of BIliary Atresia
unknown but blockage of bile flow from the liver the duodenum causes inflammation and fibrotic changes
Since there is a lack of bile in biliary atresia what occurs
lack of bile acids interferes with FAT SOLUBLE VITAMIN DIGESTION (ADEK) - leading to steatorrhea and nutritional deficits
Without treatment for biliary atresia ….
it is fatal - FTT will occur, they dont grow well as you cannot get fat soluble vitamins (ADEK)
What is a clinical apperance of a child with biliary atresia
abdominal distention in biliary atresia
distended vessels
thin arms
overall sickly appearance
Clinical Manifestations of Biliary Atresia
newborn is initially asymptomatic
Jaundice around 2-3 weeks
abdominal distention
increase in bilirubin levels
splenomegaly
easy bruising, prolonged bleeding time and intense itching
odd colored urine and stools
FTT/Malnutrition
What color is the urine and stool in biliary atresia
urine - tea colored
stool - clay colored
this is due to impaired bile excretion
Why is there easy bruising, prolonged bleeding time, and intense itching in biliary atresia
clotting factor manufacturing in the liver is impaired
How to dx biliary atresia
History, physical examination, and labs
Treatment for Biliary Atresia
Surgery to correct obstruction
*Liver transplantation
Nursing Care for Biliary Atresia Pre and Post Op
Teach the family
prep for organ transplant
teach about how it is a chronic problem and the need for lifelong organ anti rejection drugs
