Providing Patient Centered Care for the Child with a Gastrointestinal Disorder

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Providing Patient Centered Care for the Child
with a Gastrointestinal Disorder

• Presented by Marlene Meador RN, MSN, CNE

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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
• Rule of 10
• Multidisciplinary team
• Reconstruction begins in infancy and can continue
  through adulthood.
• Homecare by the family prior to surgery

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Pre-operative Nursing Care

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

Before
After
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Pre-operative Nursing Care

• Priority Interventions
• 1. Prevention aspiration
• Maintain nutrition
• Promote bonding

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Post-Operative 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
• Reduce Pain
• Prevent Infection
• Cleanse suture lines as ordered rinse with
  water after each feeding.
• Call Doctor for any swelling or redness
• Referral to appropriate team members

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Nursing Care of the Child with Esophageal Atresia
or Tracheoesophageal Fistula
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Malformation from failure of esophagus to develop
as a continuous tube
Upper Esophagus
Trachea
Lower Esophagus
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Signs and Symptoms

• Excessive amounts of salivation / mucus, frothy
  bubbles
• Three Cs Coughing, choking, and cyanosis when
  fed
• 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
• Ultrasound
• Radiopaque catheter inserted in the esophagus to
  illuminate defect on X-ray
• Surgical repair
• Thoracotomy and anastomosis

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Pre-Op
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Post-Op

• Maintain airway
• Maintain nutrition
• Gastrostomy tube feedings
• Prevent trauma
• Monitor for potential complications
• 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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Abdominal Wall Defects
GastroschisisOmphalocele
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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

• What prenatal testing would detect this defect?
• Alpha-fetoprotein
• Ultrasound

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Treatment and Nursing Care

• Pre-operatively provide protection of the
  contents/sac.
• Cover with warm, sterile, saline-soaked dressings
  
• Maintain temperature esp. with gastroschisis
• May choose to replace the gut to the abdomen
  gradually over several weeks.
• May place silo or silastic
• material over bowel until it
• returns to the abdomen.
• Surgery used to close defect.  

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Post-operative Nursing Care

• Assess for ileus
• Maintain parenteral feedings
• Provide support to the parents.

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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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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 --prone position- flat prone or head
  elevated prone. Use reflux board to keep head
  elevated.
• Avoid excessive handling after feedings.
• Nissen Fundoplication

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

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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 Rotovirus most common non-viral
  pathogen is Giardia

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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

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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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Treatment Nursing Care

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

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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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Management and Nursing Care Pre-Operatively

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

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Clinical Judgment

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

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Post-operative Nursing Care

• 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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Clinical Judgment

• A 4 week old infant with a history of vomiting
  after feeding has been hospitalized with a
  tentative diagnosis of pyloric stenosis. What is
  the nurses priority intervention at this time?
• 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

• Pain
• Vomiting
• Stools resemble currant jelly
• Dehydration
• Serious complications

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Medical Intervention

• Intussuception
• Hydrostatic Reduction
• Surgery
• Volvulus
• Surgery

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Hirschsprungs Disease

• Congenital disorder of nerve cells in lower colon

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Assessment
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Diagnosis Management

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

• Inability to tolerate the sugar found in dairy
  products as a result of an absence or deficiency
  of lactase.

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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
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• For questions or clarification please contact
  Marlene Meador RN, MNS, CNE
• Office 512-223-5769
• Email
• mmeador_at_austincc.edu