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Nursing Care of the Child with a Gastrointestinal Disorder

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Cleanse suture lines as ordered. Call Doctor for any swelling or redness ... disorder of nerve cells in lower colon. Assessment. Diagnosis. History & Physical ... – PowerPoint PPT presentation

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Title: Nursing Care of the Child with a Gastrointestinal Disorder


1
Nursing Care of the Child with a Gastrointestinal
Disorder
2
Normal Gastrointestinal System
3
Disorders of Development
4
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

5
Assessment
  • Unilateral, bilateral, midline

6
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

7
Pre-op Nursing Care
Two Main Goals 1. Prevention of Aspiration 2.
Maintain Nutrition
8
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

9
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

10
Pre-op Nursing Care
  • Remind parents that defect is operable- show
    photographs of corrected clefts

Before
After
11
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.

12
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

13
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.

14
Esophageal Atresia
15
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.
16
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

17
Diagnosis and Management
  • Early diagnosis
  • Ultra sound
  • Radiopaque catheter inserted in the esophagus to
    illuminate defect on X-ray
  • Surgical repair
  • Thoracotomy and anastomosis

18
Pre-Op Nursing Care
19
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
  •  

20
Imperforate Anus
  • Incomplete development or absence of anus in its
    normal position in perineum.

21
Assessment
  • Most commonly diagnosed upon Newborn Assessment
  • Symptoms
  • Absence of anorectal canal
  • Failure to pass meconium
  • Presence of anal membrane

22
Treatment
  • Anal stenosis is treated with repeated anal
    dilation
  • Surgery

23
Omphalocele Gastroschisis
Abdominal Wall Defects
24
Omphalocele
Herniation of abdominal contents through the
umbilical cord. Contents are covered by a
translucent sac.
25
Gastroschisis
  • herniation of abdominal viscera outside the
    abdominal cavity through a defect in the
    abdominal wall to the side of the umbilicus. Not
    covered.

26
Diagnosis
Permit a early diagnosis
Alpha-fetaoprotein
Ultrasound
27
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

28
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.

29
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.
30
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

31
Complications
Ileus
32
Gastroesophageal Reflux Disease(GERD)
  • The cardiac sphincter and lower portion of the
    esophagus are weak, allowing regurgitation of
    gastric contents back into the esophagus.

33
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

34
Assessment Child
  • Heartburn
  • Abdominal pain
  • Cough, recurrent pneumonia
  • Dysphagia

35
Signs and Symptoms
36
Major Complication is Acute Gastric Bleeding
37
Diagnosis
  • Assess Ph of secretions in esophagus if lt7.0
    indicates presence of acid
  • Also diagnosed using Barium Swallow and
    visualization of esophageal abnormalities

38
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
39
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

40
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.
41
Post-op Nursing Care
  • Assess for pain, abdominal distention, and return
    of bowel sounds.
  • Teach parents about gastrostomy tube feedings

42
Diarrhea
Infectious Gastroenteritis
43
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

44
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

45
Diagnosis
46
Complications
Dehydration
Metabolic Acidosis
47
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.
48
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

49
Treatment Nursing Care
  • Treat cause
  • Fluid and electrolyte balance
  • Weigh daily
  • Monitor IO
  • Assess for dehydration
  • Isolate
  • Skin care

50
Oral Rehydration
Avoid fluids that are high in sugar soft
drinks, jello, fruit drinks, tea
51
Appendicitis
  • Inflammation of the lumen of the appendix which
    becomes quickly obstructed causing edema,
    necrosis and pain.

52
Clinical Manifestations
  • Abdominal cramps and pain
  • Fever
  • Guarding
  • Abdominal rigidity
  • Rebound Tenderness
  • Vomiting
  • Elevated WBC - gt15,000

53
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.

54
Appendicitis
  • What is the most common symptom indicating that
    the appendix may have ruptured?

55
Management and Nursing Care Post-Op
  • NPO
  • Antibiotics
  • Analgesia
  • Patient teaching

56
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.

57
Pyloric Stenosis
  • Narrowing of the pyloric spincter
  • Delayed emptying of the stomach

58
Assessment
59
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

60
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

61
Intussuception Volvulus
  • Both are forms of bowel obstruction

62
Intussuception
  • Most commonly seen in infants 3-12 months
  • Bowel telescopes
  • within itself

63
Volvulus
  • A twisting of the bowel that leads to a bowel
    obstruction.
  •  

64
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

65
Therapeutic Intervention
  • Intussuception
  • Hydrostatic Reduction
  • Surgery
  • Volvulus
  • Surgery

66
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

67
Hirschsprung's Disease
68
Hirschsprungs Disease
  • Congenital disorder of nerve cells in lower colon

69
Assessment
70
Diagnosis
  • History Physical
  • Barium enema (X-ray)
  • Rectal biopsy- absence of ganglionic cells in
    bowel mucosa

71
Management
  • Surgical intervention
  • Colostomy
  • Resection

72
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

73
Lactose intolerance
  • the inability to metabolize lactose, because of a
    lack of the required enzyme lactase in the
    digestive system.

74
Lactose Intolerance
  • Manifestations
  • Diarrhea that is frothy, but not fatty
  • Abdominal distention
  • Cramping
  • Abdominal pain
  • Excessive flatus

75
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

76
Celiac Disease
  • inability to digest gliadin which is a
  • by-product of gluten breakdown.

77
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.  
78
Treatment and Nursing Care
Teach parents DIETARY REGULATIONS
NO !
Gluten Free Diet
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