Nursing Care of the Child with a Gastrointestinal Disorder

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Nursing Care of the Child with a Gastrointestinal
Disorder
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Normal Gastrointestinal System
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Disorders of Development
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Cleft Lip and Cleft Palate

• Etiology- Failure of maxillary and median nasal
  processes to fuse during embryonic development
• Remember the psycho-social implications for these
  children and families

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Assessment

• Unilateral, bilateral, midline

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Treatment

• Surgical repair between 3 and 6 months
• Multidisciplinary team - involving many
  specialists including plastic surgeons, nurses,
  ear, nose, and throat specialists, orthodontists,
  audiologists, and speech therapists.
• Reconstruction begins in infancy and can continue
  through adulthood.
• Homecare by the family prior to surgery

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Pre-op Nursing Care
Two Main Goals 1. Prevention of Aspiration 2.
Maintain Nutrition
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Pre-op Nursing Care

• May breast feed if has small cleft lip
• If bottle fed, use compressible bottle, longer
  nipple, larger hole in nipple, any other special
  device for feeding this infant.
• Feed slowly in upright position and bubble
  frequently
• Keep bulb syringe and suction equipment at
  bedside
• Position on side after feeding

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Pre-Op Nursing Care

• What are problems that the nurse needs to be
  alert for during feedings?
• Lack of proper seal around nipple to create
  necessary suction
• Excessive air intake
• Use of special feeding techniques
• Feeder with compressible sides
• Syringes with tubing

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Pre-op Nursing Care

• Remind parents that defect is operable- show
  photographs of corrected clefts

Before
After
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Therapeutic Management Surgical Correction

• A number of professionals are involved including
  surgeons, nurses, ear, nose, and throat
  specialists, audiologists, speech therapist,
  orthodontists, and plastic surgeons.

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Post-Op Care

• Prevent trauma to suture line
• Logans bow to protect site
• Do not allow to suck
• Maintain upper arm restraints
• Position supine
• No hard objects in mouth- straws, pacifiers,
  spoons
• Do not take temperature orally
• Reduce Pain
• Mild analgesics and sedatives
• Parents to provide, holding, rocking, and
  parental voices

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Post-op Care

• Prevent Infection
• Cleanse suture lines as ordered
• rinse with water after each feeding
• Use cotton swab, use rolling motion vertically
  down suture line
• Apply anti-infective ointment as ordered
• Call Doctor for any swelling or redness,
  bleeding, drainage, fever
• Make early Referrals to appropriate team members
• Assess for Complications
• Otitis media, hearing loss, speech difficulties,
  growth, altered dentition.

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Esophageal Atresia
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Malformation from failure of esophagus to develop
as a continuous tube
Upper Esophagus
Trachea
Lower Esophagus
An atresia is the absence or closure of a normal
body tubular passage, such as the esophagus and
it ends in a blind pouch. A tracheoesophageal
fistula is when the esophagus connects with the
trachea.
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Signs and Symptoms

• Excessive amounts of salivation / mucus, frothy
  bubbles in the mouth and sometimes nose
• Three Cs - Coughing, choking, and cyanosis
  when fed, overflow may be aspirated
• Food may be expelled through the nose immediately
  
• following the feeding
• Rattling respirations and frequent respiratory
  problems such as aspiration pneumonia
• Gastric distention, if fistula
• History of polyhydramnios during pregnancy can
  suggest a high gastrointestinal obstruction

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Diagnosis and Management

• Early diagnosis
• Ultra sound
• Radiopaque catheter inserted in the esophagus to
  illuminate defect on X-ray
• Surgical repair
• Thoracotomy and anastomosis

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Pre-Op Nursing Care
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Post-Op Nursing Care

• Maintain airway
• Maintain thermoregulation
• Maintain nutrition
• Gastrostomy Tube feedings
• Prevent trauma
• Monitor for potential complications
• Constipation or diarrhea
• Blockage of esophagus
• Infection
• Monitor weight , growth and developmental
  achievements
•  

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Imperforate Anus

• Incomplete development or absence of anus in its
  normal position in perineum.

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Assessment

• Most commonly diagnosed upon Newborn Assessment
• Symptoms
• Absence of anorectal canal
• Failure to pass meconium
• Presence of anal membrane

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Treatment

• Anal stenosis is treated with repeated anal
  dilation
• Surgery

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Omphalocele Gastroschisis
Abdominal Wall Defects
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Omphalocele
Herniation of abdominal contents through the
umbilical cord. Contents are covered by a
translucent sac.
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Gastroschisis

• herniation of abdominal viscera outside the
  abdominal cavity through a defect in the
  abdominal wall to the side of the umbilicus. Not
  covered.

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Diagnosis
Permit a early diagnosis
Alpha-fetaoprotein
Ultrasound
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Pre-op Treatment and Nursing Care

• Focus is on protection of the contents / sac.
  Cover with warm, sterile, saline-soaked dressings
  over the defect.
• Maintain temperature esp. with gastroschisis
  because it is not covered and lose of fluids
• May choose to replace the gut to the abdomen
  gradually over several weeks.
• May place silo or silastic material
• over gut until it returns to the
• abdomen.
• Maintain hydration start IV (NPO)
• NG tube to decompress stomach

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Oomphalocele Repair

• While the baby is deep asleep and pain-free
  (under general anesthesia) an incision is made to
  remove the sac membrane. The bowel is examined
  closely for signs of damage or
• additional birth defects.
• Damaged or defective portions are removed and the
  healthy edges
• stitched together.
• A tube is inserted into the stomach (gastrostomy
  tube) and out through the skin.

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Gastroschisis Repair
Surgical repair of abdominal wall defects
involves replacing the abdomen through the
abdominal wall defect, repairing the defect if
possible, or creating abdominal organs back into
the a sterile pouch to protect the intestines
while they are gradually pushed back into the
abdomen.
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Post-op Nursing Care

• Maintaining fluid and electrolyte balance
• TPN via central venous catheter to provide
  nutrition while bowel rests and heals
• Progress to oral feedings once bowel motility
  occurs
• Prevent Infection
• IV antibiotics
• Assess for Complications
• Ileus
• Educate parents

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Complications
Ileus
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Gastroesophageal Reflux Disease(GERD)

• The cardiac sphincter and lower portion of the
  esophagus are weak, allowing regurgitation of
  gastric contents back into the esophagus.

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Assessment Infant

• Regurgitation almost immediately after each
  feeding when the infant is laid down
• Excessive crying, irritability
• Failure to Thrive
• Life Threatening Risk / Complications
• aspiration pneumonia
• apnea

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Assessment Child

• Heartburn
• Abdominal pain
• Cough, recurrent pneumonia
• Dysphagia

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Signs and Symptoms
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Major Complication is Acute Gastric Bleeding
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Diagnosis

• Assess Ph of secretions in esophagus if lt7.0
  indicates presence of acid
• Also diagnosed using Barium Swallow and
  visualization of esophageal abnormalities

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Management Nursing Care

• Small frequent feedings of predigested formula or
  thicken the formula
• Frequent burping
• Positioning keep upright for 30 minutes after
  feedings. Use reflux board to keep head
  elevated.
• Avoid excessive handling after feedings.

Reflux board
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Medications

• H2 Histamine receptor antagonists reduce
  gastric acidity
• Zantac and Pepcid
• Proton-pump inhibitors
• Prevacid
• Prilosec
• Gastric emptying
• Reglan
• Antacids
• Gaviscon
• be sure to study nursing implications and side
  effects

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Management and Nursing Care

• If history of apnea, bradycardia, r/t GERneeds
  continuous cardiac and apnea monitoring. Arrange
  for CPR teaching for caregivers
• If infant does not responds to non-invasive
  therapy, then a Nissen fundoplication may be done
  to increase the competence of the cardiac
  sphincter.

In a fundoplication, the upper part of the
stomach is wrapped around the lower end of the
esophagus and stitched in place, reinforcing the
closing function of the cardiac sphincter.
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Post-op Nursing Care

• Assess for pain, abdominal distention, and return
  of bowel sounds.
• Teach parents about gastrostomy tube feedings

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Diarrhea
Infectious Gastroenteritis
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Diarrhea/GastroenteritisSevere

• A disturbance of the intestinal tract that alters
  motility and absorption and accelerates the
  excretion of intestinal contents.
• Most infectious diarrheas in this country are
  caused by
• Giardia most commonly seen in daycare centers
• Rotovirus seen in infants in young children

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Clinical Manifestations

• Increase in peristalsis
• Large volume stools
• Increase in frequency of stools
• Nausea, vomiting, cramps
• Increased heart resp. rate, decreased tearing
  and fever
• Complications
• Dehydration
• Metabolic acidosis

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Diagnosis
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Complications
Dehydration
Metabolic Acidosis
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The newborn and infant have a high percentage of
body weight comprised of water, especially
extracellular fluid, which is lost from the body
easily. Note the small stomach size which limits
ability to rehydrate quickly.
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Dehydration

• Infant

• Child

• Depressed fontanels
• Sunken eye orbits
• Fussy, Irritable
• Thirsty
• Fewer wet diapers

• Decreased tear production
• Skin non-elastic
• Decreased urinary output
• Thirsty
• Restless

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Treatment Nursing Care

• Treat cause
• Fluid and electrolyte balance
• Weigh daily
• Monitor IO
• Assess for dehydration
• Isolate
• Skin care

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Oral Rehydration
Avoid fluids that are high in sugar soft
drinks, jello, fruit drinks, tea
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Appendicitis

• Inflammation of the lumen of the appendix which
  becomes quickly obstructed causing edema,
  necrosis and pain.

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Clinical Manifestations

• Abdominal cramps and pain
• Fever
• Guarding
• Abdominal rigidity
• Rebound Tenderness
• Vomiting
• Elevated WBC - gt15,000

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Management and Nursing Care Pre-Op

• NPO
• IV
• Comfort measures semi-fowlers or R side lying
• Antibiotics
• Thermal therapy ice, not heating pads
• Elimination
• Patient education
• Narcotic pain medications are used minimally so
  as not mask the signs of appendicitis.

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Appendicitis

• What is the most common symptom indicating that
  the appendix may have ruptured?

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Management and Nursing Care Post-Op

• NPO
• Antibiotics
• Analgesia
• Patient teaching

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Pyloric Stenosis

• The pylorus muscle which is at the distal end of
  the stomach becomes thickened causing
  constriction of the pyloric canal between the
  stomach and the duodenum and obstruction of the
  gastric outlet of the stomach.

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Pyloric Stenosis

• Narrowing of the pyloric spincter
• Delayed emptying of the stomach

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Assessment
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Treatment and Nursing Care

• Treatment Surgery Pyloromyotomy
• Post Operative Care
• I O
• Feeding
• Feeding begins with clear liquids containing
  glucose and electrolytes. Regime example 8
  hours NPO, 10cc sterile hater feed X 2. Increase
  to 15cc X 2, progressing to ½ strength formula,
  then full strength formula. Observe and record
  the infants response to feeding.
• Position with head elevated
• Assess Surgical site to prevent infection
• Patient teaching

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Critical Thinking

• A 4 week old infant with a history of vomiting
  after feeding has been hospitalized with a
  tentative diagnosis of pyloric stenosis. Which of
  these actions is priority for the nurse?
• Begin an intravenous infusion
• Measure abdominal circumference
• Orient family to unit
• Weigh infant

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Intussuception Volvulus

• Both are forms of bowel obstruction

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Intussuception

• Most commonly seen in infants 3-12 months
• Bowel telescopes
• within itself

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Volvulus

• A twisting of the bowel that leads to a bowel
  obstruction.
•  

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Assessment

• Intussusception

• Volvus

• Pain
• Vomiting
• Stools resemble currant jelly, bloody mucus
• Sausage shape abdominal mass
• Dehydration
• Serious complications
• Shock and sepsis

• Pain
• Bilious vomiting
• Abdominal distention
• Tachycardia

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Therapeutic Intervention

• Intussuception
• Hydrostatic Reduction
• Surgery
• Volvulus
• Surgery

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Nursing Care

• Following Hydrostatic reduction
• Clear liquids and diet is advanced gradually
• Observe for passage of barium and eventually
  passage of stool
• If reduction is not successful
  Surgery
• Post-op Care
• Stabilize the child
• NPO and start IV fluids
• NG tube to decompress the bowel
• Pain medications
• Provide information to the parents

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Hirschsprung's Disease
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Hirschsprungs Disease

• Congenital disorder of nerve cells in lower colon

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Assessment
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Diagnosis

• History Physical
• Barium enema (X-ray)
• Rectal biopsy- absence of ganglionic cells in
  bowel mucosa

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Management

• Surgical intervention
• Colostomy
• Resection

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Nursing Care

• Pre-op
• Cleanse bowel
• Patient/parent teaching
• Post-op
• NPO
• Vital Signs never take a rectal temperature
• Assessment
• Patient/parent teaching
• Colostomy care
• Skin care
• Nutrition

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Lactose intolerance

• the inability to metabolize lactose, because of a
  lack of the required enzyme lactase in the
  digestive system.

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Lactose Intolerance

• Manifestations
• Diarrhea that is frothy, but not fatty
• Abdominal distention
• Cramping
• Abdominal pain
• Excessive flatus

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Lactose Intolerance

• Removal of lactose from the Diet
• Eliminate milk, formulas that contain dairy
  products, ice cream, yogurt, hard cheeses
• Breastfeeding moms eliminate lactose from their
  diet
• Medications
• Lactase preparations Lactaid, Dairy Ease,
  Lac-Dose
• Obtain calcium from other sources

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Celiac Disease

• inability to digest gliadin which is a
• by-product of gluten breakdown.

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Signs and Symptoms
The child with celiac disease commonly
demonstrates failure to grow and wasting of
extremities. The abdomen can appear large due to
intestinal distension and malnutrition
Complications Hypocalcemia, osteomalacia,
osteoporosis, depression.  
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Treatment and Nursing Care
Teach parents DIETARY REGULATIONS
NO !
Gluten Free Diet