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Ch 24 The Child with Gastrointestinal Dysfunction. Laura Salisbury RN, MSN/Ed. Clinical Manifestations of GI Dysfunction. Failure to thrive Spitting up / Regurgitation Nausea, vomiting, diarrhea, constipation Abdominal Pain, Distention, GI bleeding Jaundice Dysphagia - PowerPoint PPT Presentation
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Ch 24 The Child with
Gastrointestinal Dysfunction
Laura Salisbury RN, MSN/Ed.
Clinical Manifestations of GI Dysfunction Failure to thrive Spitting up / Regurgitation Nausea, vomiting, diarrhea, constipation Abdominal Pain, Distention, GI bleeding Jaundice Dysphagia Hypoactive, hyperactive or absent bowel
sounds
Dehydration Types of dehydration
Isotonic: most common, water and salt both lost, signs of hypovolemic shock are seen
Hypotonic: More electrolytes lost than water; signs are seen with less severe losses
Hypertonic: More water lost than electrolytes: MOST DANGEROUS Seen if infants are given fluids w/too much solute Seen w/high-protein NG tube feedings—too much solute in
kidneys Shock less apparent; neuro signs seen
Diagnostic evaluation: KNOW table 24-1, p. 816
Daily Maintenance Fluid Requirements 1. Calculate weight in kilograms
Wt of child in pounds/ 2.2 kg = wt in kg 2. Allow 100 mL for first 10 kg 3. Allow 50 mL for second 10 kg 4. Allow 20 mL for all remaining kg 5. Divide total amount by 24 hours to obtain
rate of fluid replacement in mL per hour
Pg 815
Diarrhea Often classified by location
Gastroenteritis, Enteritis, Colitis, Enterocolitis Types of Diarrhea
Acute Acute infectious/infectious gastroenteritis
Most typical, Usually subsides on its own Can be from antibiotic administration/c. difficile
Chronic More than 14 days Can be chronic condition OR inadequately treated acute diarrhea
Intractable diarrhea of infancy Usually infectious diarrhea not managed adequately
Chronic nonspecific diarrhea (CNSD)
Diarrhea Diagnostic evaluations Therapeutic management
Assess fluids and electrolytes Rehydrate
Oral Rehydration Solution (ORS)=Pedialyte Give maintenance fluid
Breastfeed, water, ½ strength formula, ORS Reintroduce diet
Regular diet NO BRAT diet
Nursing considerations SEVERE dehydration: IV fluids first
Prevention of Diarrhea Most diarrhea is spread by the fecal-oral route Teach personal hygiene Clean water supply/protect from contamination Careful food preparation Handwashing
Constipation An alteration in frequency/consistency/ease of passage of stool Idiopathic (functional) constipation/Chronic constipation
Majority of cases - Could be environment, psychology, or both Newborn Period
First meconium should be passed within 24-36 hrs of life Meconium ileus=cystic fibrosis
Infancy Constipation in exclusively breastfed infant almost unknown
Infrequent stool may occur from minimal residue in digested breastmilk
Formula fed infants may develop constipation Small amount of corn syrup may solve problem
Constipation Constipation in Childhood
Often due to environmental changes or control over body functions
Encopresis: inappropriate passage of feces, often with soiling May result from stress
Management Nursing Considerations History of bowel patterns, medications, diet Educate parents and child Dietary modifications (age appropriate)
Hirschsprung Disease AKA congenital aganglionic megacolon Mechanical obstruction from inadequate
motility of intestine More common in males and in Down syndrome Clinical Manifestations of Hirschprung
Accumulation of stool with distention Diagnostic Evaluation
X-ray, barium enema, Confirm diagnosis with rectal biopsy
Therapeutic Management Surgery
Hirschsprung Disease Nursing Considerations
Pre-operative care Watch abdominal distention, Education re: colostomy
Postoperative care Be careful about contamination of wound with urine
Discharge care Colostomy care instructions
Small children -involved in care Adolescents may feel more
stressed r/t image of colostomy
Vomiting Therapeutic management
Detect and treat cause Prevent complications from loss of fluids
Nursing considerations Start w/small amounts fluid
Include carbohydrates IV fluid for severe dehydration When vomiting stops: give more fluids and resume
normal diet
Gastroesophageal Reflux Definition: GER and GERD
KNOW box 24-6, p 827; clinical manifestations and complications of GER
Diagnostics Monitor esophageal pH for 24 hours
Therapeutic management Depends on severity Thicken feedings for infants Take foods out of diet that exacerbate reflux Upright/elevated position after feedings Meds as need (H2 antagonists, Proton pump inhibitors) Surgery for most severe: Nissen fundiplication
Functional Abdominal Pain Includes irritable bowel syndrome, abdominal
migraine Episodes of severe abdominal pain Multifactorial etiology Management: alleviate symptoms
May need to use tricyclic antidepressants, SSRI’s, sometimes smooth muscle relaxant, fiber for IBS, anti-migraine for abdominal migraines, manage diet
VALIDATE SYMPTOMS Pain is real!
Acute Appendicitis Etiology and pathophysiology
Obstruction of lumen of appendix—leads to infection Diagnostic evaluation
Difficult to diagnosis KNOW box 24-7, p 830: symptoms Watch for sudden relief from pain (possible perforation)
Therapeutic management Appendectomy; laparoscopic if not ruptured
Nursing considerations If suspected appy: no laxative/enema or heat to area (do
not want to stimulate bowel motility)
Meckel Diverticulum It is the most common congenital malformation
of the GI tract Diagnostic evaluation
Complications=bleeding, obstruction, intussusceptions, diverticulitis, perforation
Most common presentation: painless rectal bleeding, abdominal pain (KNOW box 24-8, p 833)
Therapeutic management=surgery Nursing considerations
Watch for shock from hemorrhage
Inflammatory Bowel Disease IBD Includes ulcerative colitis (UC)
and Crohn’s disease (CD) KNOW the following
Clinical manifestations: TABLE 24-3, p 833 For pediatrics: Growth problems major issue; want
to promote growth and development
Acute Hepatitis ONLY need to know table 24-4 Types of hepatitis How transmitted Clinical features How immunized
Biliary Atresia AKA extrahepatic biliary atresia --Destruction of biliary tree Etiology and pathophysiology
Postnatal: happens early in life Fetal: before birth
Diagnostic evaluation KNOW box 24-10 p. 842- Jaundice, urine, stool, liver, spleen, metabolism,
failure to thrive, pruritus, irritability Therapeutic management
Kasai procedure: “band-aid”; cirrhosis will still occur Most will need liver transplant
Can come from parents Prognosis
Death before age two if not treated Liver failure even post-Kasai Early diagnosis key for survival
Cleft Lip- Cleft Palate Facial malformations that occur during
embryonic development May appear separately or together
Cleft Lip / Cleft Palate Surgical Correction of Cleft Lip
Closure of lip defect precedes correction of the palate Z-plasty to minimize retraction of scar Protect suture line with Logan bow or other methods Arm restraints: take off periodically
Surgical Correction of Cleft Palate Typically 12-18 months of age
Want to minimize effect on speech development Prognosis
Usually good, speech may still be affected May have recurrent OM
MANAGE AIRWAY!!!
Cleft Lip / Cleft Palate Cleft Lip and Palate Feeding
Techniques and interventions: ESSR Enlarge nipple Stimulate suck reflex Swallow fluid Rest when infant signals
Special feeding equipment Breck feeder
Breastfeeding issues Infants with CL/CP CAN BREASTFEED!
Esophagel AtresiaTracheoesophageal Fistula
Failure of esophagus to develop as a continuous passage May occur separately or in combination If suspected: infant NPO, suction setup nearby “3 C’s”: Coughing, Choking, Cyanosis (AIRWAY!!!)
Management of TEF
Surgical interventions Prognosis: depends on extent of defects Associated tracheomalacia (weakness in tracheal wall) Nursing considerations:
Keep infant from losing suck reflex
Hernias Definition: a protrusion of portion of an organ
through an abnormal opening Danger of incarceration/strangulation Pediatric Hernias
Diaphragmatic Hiatal Umbilical/abdominal wall defects
Omphalocele Gastrochisis
KNOW table 24-5, p 850
Pyloric Stenosis Constriction of pyloric sphincter with
obstruction of gastric outlet Clinical Manifestations
Projectile vomiting, Chronic Hunger, weight loss, dehydration, abdominal distention
Surgical intervention is required Preoperative: fix fluid/electrolyte imbalances Postoperative: Vomiting, dehydration,
maintain fluid and electrolyte balance
Intussusception Telescoping/ invagination of one part of intestine into another Occasionally due to intestinal lesions Often cause is unknown Clinical Manifestations
Sudden acute abdominal pain Child screaming and drawing knees to chest Child appears normal and comfortable between episodes of pain Vomiting Lethargy Passage of RED, currant jelly like stool
(mixed with blood and mucus) Sudden passage of normal stool:
intussusception has spontaneously resolved!
Malrotation and Volvulus Malrotation is due to abnormal rotation around the
superior mesenteric artery during embryonic development
Volvulus occurs when intestine is twisted around itself and compromises blood supply to intestines May cause intestinal perforation, peritonitis, necrosis, and death
Anorectal Malformations Imperforate anus Persistent cloaca Cloacal exstrophy
Malabsorption Syndromes Characterized by chronic diarrhea and
malabsorption of nutrients May result in failure to thrive Digestive defects Absorptive defects Anatomic defects
Celiac Disease AKA gluten-induced enteropathy and
celiac sprue Four characteristics
Steatorrhea General malnutrition Abdominal distention Secondary vitamin deficiencies
Gluten-free diet Family support
Short Bowel Syndrome A malabsorptive disorder Decreased surface area in small intestine Need to maintain growth
May need long-term TPN Watch for bacterial overgrowth
Intestinal transplantation may be possible
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