Nursing Care of the Childwith GI anomalies

Clinical Aspect of Maternal and Child NursingNUR 363

Lecture 10

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Gastrointestinal System• Many GI issues require

surgical intervention

• Nursing interventions will often include general pre and post-op care

• Bilious vomiting is a sign of GI obstruction and requires immediate intervention

• Assess stools!

• Assess hydration status

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Gastrointestinal System Pediatric Variances

• Mechanical functions of digestion are immature at birth

• Infants have decreased saliva

• Peristalsis is faster in infants

• Digestive processes are mature as a toddler

• Gastric acidity is low at birth

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The Gastrointestinal System8 Altered Connections

3 Esophageal Atresia/Tracheoesophageal Fistula 3 Cleft Lip and Palate

8 Gastrointestinal Disorders 3 Gastroesophageal Reflux 3 Pyloric Stenosis

8 Acquired Gastrointestinal Disorders 3 Appendicitis

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ESOPHAGEAL ATRESIA & TRACHEOESOPHAGEAL FISTULA

• Congenital defects of esophagus• EA is an incomplete formation of

esophagus• TEF is a fistula between the trachea

and esophagus• Classic 3 “C’s” -

coughing,choking,cyanosis

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ESOPHAGEAL ATRESIA & TRACHEOESOPHAGEAL FISTULA

TREATMENT• Surgery: either a one- or two-stage repair

• Pre-op care focuses on preventing aspiration and hydration

• Post-op care focus is a patent airway, prevent incisional trauma

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Cleft Lip/Palate May present as single defect or

combined

Non-union of tissue and bone of upper lip and hard/soft palate during fetal development

Cleft interferes with normal anatomic structure of lips, nose, palate, muscles – depending on severity and placement

Open communication between mouth and nose with cleft palate

Nutrition is a challenge in infancy Risk for aspiration Respiratory distress

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Cleft Lip/Palate

Operative Care

Monitor for infection Clean Cleft Lip incision

Pain Management

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GASTROESOPHAGEAL REFLUXRegurgitation of

gastric contents back into esophagus

GER may predispose patient to aspiration and pneumonia

Apnea has been associated with GER

chance of GER after 12-18 mo old related to growth due to elongation of esophagus

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GASTROESOPHAGEAL REFLUX

SIGNS/SYMPTOMS• Vomiting• Gagging during

feedings• Irritability• Anemia• Bloody stools

DIAGNOSTIC EVAL• History of

feedings/PE

• Upper GI endoscopy to visualize esophageal mucosa

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GASTROESOPHAGEAL REFLUX: Therapeutic Management

• Positioning• Prone HOB 30°• Right side

• Dietary modifications• Small, frequent

feedings• Possibly thicken

formula• Avoid fatty, spicy

foods caffeine, & citrus

• Teach

• Medications• Prokinetic agents

• Histamine H-2 • Proton Pump

Inhibitors

• Mucosal Protectants

• Surgery: fundoplicationFundoplication (anti-reflux surgery): A surgical technique that strengthens the barrier to

acid reflux when the lower esophageal sphincter does not work normally and there is gastro-esophageal reflux.

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PYLORIC STENOSIS

Hypertrophy of pyloric sphincter, causing a narrowing/ obstruction

Infant presents “always hungry”

Weight loss

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PYLORIC STENOSIS

DIAGNOSTIC EVAL• History/PE• Abdominal

Ultrasound

TREATMENT• Surgical

Intervention: Pyloromyotomy

INTERVENTIONS• Pre-op: NPO, NGT

to hydration, I/O, monitor electrolytes

• Post-op: Start feedings in 4-6 hrs. Progressive feeding schedule

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APPENDICITIS

• Inflammation and infection of vermiform appendix, usually related to an obstruction

• Cause may be bacteria, virus, trauma

• S/S: periumbilical pain, fever, vomiting, diarrhea, irritability, WBC’s

• Surgery is necessary

• Pre-op Care: NPO, pain management, hydration, consent

• Post-op Care: routine post-op care, IVF/antibiotics, NPO ambulation, positioning, pain management, wound care, possible drains.

Nursing Care of the Childwith Respiratory Disorders

Clinical Aspect of Maternal and Child NursingNUR 363

Lecture 11

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Respiratory System Pediatric Variances

The airway is smaller and more flexible. The larynx is more flexible and more

susceptible to spasm.

The tongue is large.

Chest muscles are not well developed

Irregular breathing pattern and brief periods of apnea (10 -

15 secs) are common

Abdominal muscles are used for inhalation until age 5-6 yrs.

Respiratory rate is higher

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The Respiratory System

Upper Airway DisordersTonsillitis CroupEpiglottisForeign Body Aspiration

Lower Airway DisordersBronchiolitisAsthmaCystic Fibrosis

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Tonsillitis

CLINICAL MANIFESTATIONS

Sore throat

Mouth breathing

Sleep Apnea

Difficulty swallowing

Fever

IMPLEMENTATIONS

Provide ComfortWarm saline garglesReduce Fever

Promote Hydration Administer Antibiotics Provide Rest Patient Teaching Tonsillectomy may be necessary

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Tonsillectomy

Pre-operative Nursing CareMonitor Labs (CBC, PT, PTT)Age-appropriate Preparation/TeachingSurgical Consent

Post-operative Nursing CareFrequent site assessmentMonitor for S/S of ComplicationsPain ManagementDietPatient Teaching

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Croup/Epiglottitis• Infection and swelling of

larynx, trachea, epiglottis, bronchi

• Causative agent: Viral

• Characterized by hoarseness, barky cough, inspiratory stridor, and respiratory distress

• Most common ages 6 mo-3 yrs

• LIFE-THREATENING EMERGENCY

• Most common in ages 2-5 years

• Often the child is intubated

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Croup/Epiglottitis

Nursing Interventions Maintain Patent

Airway Assess and

Monitor Promote Hydration Reduce Fever Calm Environment Promote Rest

Nursing Interventions

Administer Meds Corticosteroids

Nebulizer treatment

Antibiotic for epiglottitis

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Foreign Body Aspiration

• Occurs most often in small children

• Choking, coughing, wheezing, respiratory difficulty

• Often it is round food, such as grapes, nuts, popcorn

• Bronchoscopy often needed for removal

• Age-appropriate preparation needed for procedure

• Prevention and parent education is very important

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Bronchiolitis• Acute viral infection of the

bronchioles causing an inflammatory/obstructive process to occur

• CXR shows hyperinflation and consolidation if atelectasis present

• Primarily seen in children under 2 years of age

• Most common in winter and early spring

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Bronchiolitis

CLINICAL MANIFESTATIONS

Nasal Congestion CoughCrackles, Wheezes Increased RR &

SOBRespiratory

Distress Fever Poor Feeding

IMPLEMENTATIONS Suction – priority Bronchodilator CPT Promote fluids Monitor VS , SaO2, lung sounds & respiratory effort Supplemental oxygen Reduce fever Promote rest

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Asthma

Asthma is a common chronic inflammatory disease of the airways

CLINICAL MANIFESTATIONSTachypneaSaO2 below 95%Wheezes, cracklesRetractions, nasal flaringNon-productive coughRestlessness, fatigueAbdominal pain

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AsthmaINTERVENTIONS

Monitor VS (HR, RR) Monitor SaO2 Auscultate lung sounds Monitor respiratory effort Humified oxygen Calm environment Promote hydration Promote rest Monitor labs/x-rays Patient teaching

Administer Medications Bronchodilator Corticosteroid IV or PO Antibiotic if precipitated from a respiratory

infection

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Otitis Media

à Most common childhood illnessà Inflammation of middle earà Acute otitis media (AOM)

à Infectious process by pathogenà S/S: pain, fever, irritability, vomiting,

diarrhea, ear drainage, full/bulging tympanic membrane

à Otitis media with effusion (OME)à Inflammation of middle ear with fluid

behind tympanic membrane-no infectionà Chronic otitis media

à Inflammation of middle earà Can lead to hearing loss/delayed speech

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Otitis MediaTREATMENT

à Antibiotics

INTERVENTIONSà Teaching

àFeeding techniquesàMedication regimen

PAIN MANAGEMENTàFever managementàSurgery prep if needed