Caring for a Child with Gastrointestinal Disorders

1
Chapter 25

• Caring for a Child with Gastrointestinal Disorders

2
A P Review

• Gastrointestinal system responsible for
• Ingestion
• Digestion
• Absorption
• Metabolism
• Elimination

3
Gastrointestinal System

• Upper portion is responsible for nutrient intake
  (ingestion)
• Includes
• Mouth
• Esophagus
• Stomach

4
Gastrointestinal System

• Lower portion is responsible for remainder of
  digestion, absorption metabolism
• Includes
• Small intestine
• Large intestine
• Rectum
• Anus

5
Gastrointestinal System

• Accessory Structures
• Liver
• Gallbladder
• Pancreas

6
Developmental Aspects(each developmental stage
contributes to the promotion of the health of the
child)

• Infant
• Prevent choking
• Suck-swallow
• Frequent feedings
• Carefully introduce foods about 1 year of age

7
Developmental Aspects

• Toddler
• Weight gain (5-6 lbs/year)
• Deceased caloric needs
• Food jags

8
Developmental Aspects

• Preschooler
• Eats a full range of food
• Appetite fluctuation
• School-age
• GI tract stable (digestive system is adult sized)
• Stools well formed

9
Structural Gastrointestinal Disorders
10
Inguinal Hernia

• Signs symptoms
• Painless swelling extending toward or into the
  scrotum
• Complications
• Incarcerated (strangulated)
• Nursing Care
• Surgery (pre-post operative care)
• Discharge instructions

11
Umbilical Hernia

• Signs Symptoms
• Soft midline swelling in the umbilical area
• Complications
• Incarcerated (strangulated)
• Nursing Care
• Most resolve spontaneously by 3-5 yrs of age
• Surgery (pre-post operative care)
• Discharge instructions

12
Anorectal Malformations

• Signs Symptoms
• Rectal atresia (closure) and stenosis
  (constriction or narrowing of a passage)
• Complications
• Depends on the defect and accompanying
  multisystem involvement
• Nursing Care
• Extensive treatment depending on defect and
  associated organ involvement
• Preoperative care (caregiver education IV
  fluids)
• Postoperative care (pain control, s/s of
  infection, good skin care, NG tube, oral feedings
  resumed)
• Discharge instructions

13
Obstructive Gastrointestinal Disorders
14
Hypertrophic Pyloric Stenosis

• Signs Symptoms
• Typically healthy, male infant new onset
  non-bilious vomiting progressing to projectile
  vomiting
• Diagnosis
• Palpating the pyloric mass (olive-shaped)
• Nursing Care
• Surgery (Ramstedt pyloromyotomy)
• Assess dehydration, changes is VS, weight loss
  discomfort
• Preoperative care (NPO, NG tube,)
• Postoperative care ( maintain fluids
  electrolyte balance, feedings, infection, keeping
  the wound clean pain relief)
• Discharge instructions (care of incision, s/s
  infection, response to feedings)

15
Intussesception

• Signs Symptoms
• Acute abdominal pain, currant jelly stools,
  fever, dehydration, abdominal distention,
  lethargy and grunting due to pain
• Diagnosis
• Based on history presence of sausage-shaped
  mass
• Nursing Care
• A barium or air enema/prompt surgical correction
• Provide information about condition reassurance
  to parents
• Preoperative care (NPO, NG tube, IV fluids,
  monitor for perforation or peritonitis monitor
  record stools)

16
Malrotation and Volvulus

• Signs Symptoms
• Most common during first month of life
  intermittent bilious vomit, abdominal distention,
  recurrent pain, palpable epigastric mass,
  dehydration lethargy
• Complications
• Shock (signs include tachycardia, tachypnea,
  hypotension cool, clammy or cyanotic skin)
• Nursing Care
• Surgery
• Preoperative care (hydration, NG tube, IV
  antibiotics)
• Postoperative care (see nursing care plan)

17
Inflammatory Disorders
18
Irritable Bowel Syndrome (IBS)

• Signs Symptoms
• Abdominal pain, flatus, bloating, constipation or
  diarrhea, nervous stomach, muscle spasms when
  exposed to triggers
• Additional Symptoms
• Headache, nausea, mucus in stools, anorexia
  weight loss
• Nursing Care
• Dietary discover triggers
• Drinking plenty of fluids
• Promote regular bowel elimination
• Children taught to share feelings

19
Inflammatory Bowel Disease (IBD)

• Two types
• Crohns Disese
• Ulcerative Colitis

20
Crohns Disease

• Signs Symptoms
• Abdominal pain, diarrhea, anorexia, weight loss
  
• Additional Symptoms
• Growth sexual delay, arthralgias, arthritis,
  stomatatis, ulcers, inflammation of the eye,
  renal stones rash on shins
• Nursing Care
• Pharmacologic
• Nutritional
• Surgical
• Emotional support

21
Ulcerative Colitis

• Signs Symptoms
• Abdominal pain, bloody diarrhea, urgency, and
  tenesmus (spasmodic contraction of the anal
  sphincter with pain)
• Additional Symptoms
• Arthritis/arthralgias, oral ulcera, liver
  inflammation, skin lesions rash
• Nursing Care
• Disease control, remission, preventing relapse
  achieving normal growth lifestyle
• Pharmacological, nutritional, surgical
  psychosocial management

22
Appendicitis

• Signs Symptoms
• Earliest symptom periumbilical pain, vomiting
• Followed by right lower quadrant pain (classic
  sign)
• Clinical Alert
• Children who respond yes to being hungry most
  likely do not have appendicitis
• Nursing Care
• Surgery
• Postoperative care (monitor intake output,
  wound care, pain control, NPO until peristalsis
  returns, discharged home in 2-3 days)
• If perforate appendix intravenous antibiotics are
  given, NPO with NG tube until bowel function
  returns

23
Omphalitis

• Signs Symptoms
• Redness edema of the soft tissue
• Diagnosis
• Culture obtained to confirm diagnosis
• Nursing Care
• Prevention by good perinatal care caregiver
  education
• Intravenous broad-spectrum antibiotics

24
Meckel Diverticulum

• Signs Symptoms
• Abdominal pain, painless rectal bleeding, stools
  (bright or dark red with mucus)
• Complications
• If undetected severe anemia shock can occur
• Nursing Care
• Surgical removal of the diverticulum or pouch
• Postoperative antibiotics
• Correct fluid electrolyte imbalances
• Monitor for shock blood loss
• Provide rest
• Fluid replacement NG tube

25
Functional Gastrointestinal Conditions
26
Infantile Colic

• Signs Symptoms
• Persistent, unexplained crying younger than 3
  months
• Episodes occur at the same time each day
• Diagnosis
• Based on symptoms occurring for more than 3
  weeks, for 3 days (2-3 hours a day)
• Nursing Care
• Rule out acute conditions
• Management strategies (see Box 25-1)

27
Acute Diarrhea

• Signs Symptoms
• Increased frequency fluid content of the stools
  with or without associated symptoms
• Additional Symptoms
• Caregiver asked about vomiting, fever, pain,
  number of wet diapers in previous 24-hours)
• Nursing Care
• Hydration dietary needs
• Pharmacology treatment not ordered
• IV fluids essential with impaired circulation and
  possible shock

28
Chronic Diarrhea

• Signs Symptoms
• Reflective of underlying pathology
• History of the diarrhea frequency appearance
• Additional Symptoms
• Abdominal distention or tenderness, hyperactive
  bowel sounds, dehydration condition of the
  perineal area
• Nursing Care
• Treat the underlying cause
• Enteral or TPN is provided for the child who is
  unable to maintain adequate oral intake
• Caregiver educated on prevention

29
Vomiting

• Signs Symptoms
• Assessment includes description of onset,
  duration quality, quantity, appearance, presence
  of undigested food and precipitating event
• Additional Symptoms
• Fever, diarrhea, ear pain, headache
• Nursing Care
• Treatment of the cause prevent of complications
  
• Bowel is allowed to rest
• Rehydration
• Bland solids reintroduced
• Antiemetic drugs
• Dehydration, monitor fluid intake output
• Oral hygiene

30
Cyclic Vomiting Syndrome

• Signs Symptoms
• Recurrent episodic vomiting, usually lasts 24-48
  hours. Vomiting occurs at regular intervals,
  usually every two to four weeks
• Diagnosis
• Rule out other conditions
• Nursing Care
• Supportive care fluid replacement, rest,
  pharmacotherapy psychiatric evaluation
• Calm stress-free environment

31
Constipation

• Signs Symptoms
• Poor appetite, straining with stools
• Additional Symptoms
• Blood may occasionally be seen, tenderness in
  colon small intestines, rectal fissures
• Nursing Care
• Focus dietary intake, keeping the bowel
  relatively empty
• Adequate intake of water
• Regular diet (fruits fiber)
• Stool softeners
• Chronic constipation may include bowel cleansing,
  maintenance therapy bowel retraining

32
Encopresis

• Signs Symptoms
• Stained underwear, difficult or painful
  defecation, large and/or hard stools, reports of
  bloating and/or pain, streaks of bright blood,
  anorexia, evidence of attempts to retain stool
• Diagnosis
• Radiography laboratory test to rule out other
  causes
• Nursing Care
• Establish regular bowel habits
• Dietary monitoring (fiber water intake)
• Stool softeners laxatives are avoided
• Child caregiver instructed on the need to
  establish a routine toileting
• Management of children with constipation begins
  with a catharsis phase followed by a maintenance
  phase follow up care
• Anticipatory guidance, caregiver support
  education

33
Gastroesophageal Reflux (GER)

• Signs Symptoms
• Vomiting regurgitation
• Additional Symptoms
• Fussy, refuse to feed because of discomfort,
  choking courting, wheezing apnea, weight loss,
  respiration infections and vomit
• GERD persists beyond 18 months
• Nursing Care
• Caregiver support anticipatory guidance
• Pharmacological therapy for complications
• Surgery (Nissen fundoplication)

34
Hirschsprung Disease

• Signs Symptoms
• Failure to pass meconium within the first 48
  hours of life, failure to thrive, poor feeding,
  chronic constipation, Down syndrome
• Complications
• Entercolitis is the most ominous presentation
  (abrupt onset o foul smelling diarrhea, abdominal
  distention fever. Rapid progress may indicate
  perforation sepsis
• Nursing Care
• Surgical resection (colostomy)
• Preoperative care (fluid electrolyte status,
  NPO, NG tube, IV fluids)
• Postoperative care (maintain NG tube, monitor for
  abdominal distension, assess for bowel sounds)
• Teach caregiver how to car for colostomy, s/s of
  complications)

35
Malabsorption Disorders
36
Lactose Intolerance

• Signs Symptoms
• Bloating, cramping, abdominal pain flatulence
• Diagnosis
• Based on history/physical decrease in symptoms
  with elimination of lactose from the diet
• Nursing Care
• Elimination of dairy products or the use of
  enzyme replacement
• Dietary education (alternative sources of calcium)

37
Celiac Disease

• Signs Symptoms
• Non-specific and include anorexia, irritability,
  weight loss listlessness
• Additional Symptoms
• Classic presentation begins around age 6 months
  to 2 years as gluten products are introduced into
  the diet
• Nursing Care
• Gluten-free diet
• Caregiver introduced to hidden sources of gluten
• Assess symptoms, growth and adherence to dies
• Measurement of transglutaminase (TTG) levels is
  recommended in individuals with recurrent or
  persistent symptoms after initiation of gluten
  free diet

38
Short Bowel Syndrome

• Signs Symptoms
• Malnutrition diarrhea
• Additional Symptoms
• Steatorrhea carbohydrate malabsorption result
  in diarrhea and failure to thrive
• Nursing Care
• Maintain adequate nutrition prevent
  complications
• Total parenteral nutrition (TPN) via central line
  
• Enteral feedings via nasogastric or gastrostomy
  tube
• Feeding tolerance
• Emotional developmental needs
• Assist parents with coping
• Home care services

39
Hepatic Disorders
40
Biliary atresia, or extrahepatic biliary atresia
(EHBA)

• Signs Symptoms
• Jaundice, dark urine, lighter (tan-white) than
  normal stools, poor weight gain, failure to
  thrive, pruritus, hepatomegaly, splenomegaly
• Diagnosis
• Early diagnosis in the key to survival.
• Nursing Care
• Primarily supportive focuses on providing
  nutritional support
• Surgical resection correct obstruction provide
  drainage of bile from the liver into the
  intestines
• Preoperative care (educate family long term
  care)
• Postoperative care (educate family on skin
  stoma care, nutritional therapy, complications,
  psychological support)
• Potential transplant

41
Cirrhosis

• Signs Symptoms
• Vary depending on the cause
• Jaundice, growth failure, muscle weakness,
  anorexia lethargy
• Diagnosis
• Based on history, laboratory values liver
  biopsy
• Nursing Care
• Preventing treating complications
• Nutritional support
• Liver transplant
• Monitor for complications
• Comfort measures emotional support

42
Hepatitis

• Signs Symptoms
• Headache, anorexia, malaise, abdominal pain,
  nausea vomiting
• Diagnosis
• Based on history of exposure, symptoms
  serologic testing
• Nursing Care
• Primarily supportive no specific treatment
• Provide rest to the liver, hydration, maintain
  comfort, adequate nutrition, prevent
  complications
• Immune globulin given to children who have been
  exposed to a person with HAV
• Vaccine available for HAV, HBV HDV
• Educate family regarding prevention measures (see
  Critical Nursing Actions Prevention of Hepatitis
  A and Hepatitis B)

43
Abdominal Trauma Injuries

• Injuries are the leading cause of death in
  children
• Ten percent of serious trauma occurs as a result
  of abdominal genitourinary injury
• See Table 25-5 Injuries Caused by Abdominal
  Trauma