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Assessment:
GI disorders among children can lead to dehydration especially if vomiting & diarrhea are the presenting symptoms
Assess for poor skin turgor, dry mucous membranes & lack of tearing
Alert: All children with diarrhea must be seen by a health care provider because of rapid change in fluids & electrolyte levels
Greater percentage of fluid held extracellularly rather than intracellularly
Vomiting
forcible ejection of stomach contents through the mouth
Etiology:
InfectionsObstructionsMotion sickness
Metabolic alterationsPsychological alterations
Allergic reactionsSide effects of medications (chemotherapy)
Toxic effects of medicationsEating disorders
Manifestations:
Sour milk curds without green or brown color
Undigested food (stomach)
Diagnostic Evaluation:
CBCElectrolyte studiesBlood Urea Nitrogen (BUN)
Glucose levelsUrine tests
Radiographic studiesBlood culturesArterial blood gas analysis
Assessment:
Major concern:DehydrationFluid & electrolyte imbalance
Accurate monitoring of intake & output
Assess weightFontanels in infants
Skin turgorEyes/skinHeart/respiratory rates
Determine/describe type & force of vomiting (regurgitation, projectile vomiting)
Assess amount, color, consistency, time (ACCT)
Nursing diagnoses:
Fluid volume deficitImbalanced Nutrition: Less than Body Requirements
Interventions:
Position child upright or side lying
Educate family regarding appropriate feeding techniques (eg. Burping)
Educate family (avoiding certain foods) fatty foods
Minimize stimuli ( stress, anxiety)
Avoid unfavorable smelling food
Therapeutic Management:
Oral Rehydration Treatment (ORT)
IV therapy (prolonged vomiting neonates/infants)
Anti-emetics
Dehydration
Fluid loss in excess of fluid intake
Can cause fluid & electrolyte deficiencies
Classification:
Isonatremic dehydration – most common type of dehydration in children
Water & electrolytes are lost the same proportion they exist in the body
Normal serum Na level (135-145 mEq./L)
Hyponatremic dehydration – electrolyte loss greater than water loss
Serum Na less than 130 mEq./L
Hypernatremic dehydration – water loss is greater than the electrolyte loss
Serum Na concentration above 150 mEq./L
Etiology:
GI tract- vomiting, diarrhea, malabsorption
Endocrine system: - fever, DM,
Skin – burnsLungs – tachypneaKidneys - Renal failureHeart - CHF
Neonates/infants – vulnerable to the effects of dehydration
Mild dehydration – 4-5% loss of body weight; fluid volume loss less than 50ml/kg
Moderate dehydration – 6-10% loss of body weight; fluid volume loss 50-100 ml/kg.
Severe dehydration – 10% or more loss of body weight; fluid volume loss of 100 ml/kg or more
Signs & symptoms of Dehydration:
Fewer wet diapers (6-8 hours)
No tears when crying (if older than 2-4 months)
Sticky/dry mouth
Irritability/high pitched cry
Difficulty in awakeningIncreased RR/DOB
Sunken fontanels/sunken eyes with dark circles
Abnormal skin color, temperature or dryness
Signs of impending shock:Changes in heart rateChanges in sensoriumUrine outputSkin qualitiesFontanels (infants)
Pathophysiology:
Reduced fluid intake Increased fluid lossVomiting, diarrhea,
fever, hyperventilation/burnsTrauma, hemorrhage,
DM
Rapid ECF loss
Electrolyte imbalance
ICF Loss
Cellular dysfunction
Hypovolemic shock
Death
Management:
Directed toward correcting the fluid & electrolyte imbalance & then treating the causative factors
Oral rehydration therapy (Rehydralyte, Pedialyte, Infalyte)
Rehydralyte (WHO’s solution) – best source of oral rehydration
Children (mild to moderate dehydration)
50-100 ml/kg of ORT over 4 hours
Parenteral fluid & electrolyte therapy
Lactated Ringer’s solution/0.9% NaCl
Assessment Parameters:
Intake & outputUrine output & Specific gravity
Output < 2-3 ml./kg./hr –infants & toddlers
1-2 ml/kg/hr – preschoolers & young school- age children
0.5 ml./kg/hr in school-age children or adolescents
Specific gravity above 1.020
Weight crucial indicator of fluid status
Stools/vomitusSweatingSkin, Mucous membranes & presence of tears
Anterior fontanelVital signs/behavior
Nursing diagnosis
Fluid volume deficit
Diarrhea
One of the most common disorders in childhood
Increased in the frequency, fluidity & volume of stools
Gastroenteritis – diarrhea caused by infection
Acute diarrhea can lead to dehydration, electrolyte imbalance & hypovolemic shock
Most common viral pathogens - rotavirus & adenovirus
Bacterial pathogens include – Campylobacter jejuni, Salmonella, Giardia lamblia & Clostridium difficile
Mild DiarrheaFever, anorectic, irritable & appear unwell
2-10 loose, watery stools per day
Dry mucous membranes, rapid pulse, warm skin
Normal skin turgor, normal urine output
Management:Rest the GI tract; 1 hour after offer OHT
Ask parents to wash hands after changing diapers
Continue breastfeedingNotify healthcare provider if condition worsens
Severe diarrheaRectal temperature is high (103-104⁰) F
Pulse/RR weak & rapidSkin pale/cool
Depressed fontanelle, sunken eyes, poor skin turgor
Bowel movement every few minutes
Liquid green stool, mixed with mucus & blood
Urine output is scanty & concentrated
Elevated hemoglobin, hematocrit & serum protein levels
Treatment:Focus is centered in regulating electrolyte & fluid balance
Oral or IV rehydration therapy
Rest the GI tract Identifying the responsible organism
All children with severe diarrhea must have a stool culture taken
IV fluids – NSS or 5% glucose in NS
Nursing diagnosis:Fluid volume deficit
Gastrointestinal Disorders
III. Cleft Lip & Cleft PalateFailure of soft tissue or bony structure to fuse during embryonic development
Abnormal openings in the lip or palate that may occur unilaterally or bilaterally
Causes include genetic, environmental factors; exposure to radiation or rubella virus; chromosome abnormalities; & teratogenic factors
Closure of cleft lip defect precedes that of the palate & is formed usually during the first wks of life
Cleft lip o failure of median & maxillary nasal process to fuse by 5 - 8 weeks of pregnancy
common to boysunilateral
Cleft Palate Failure of the palatine shelves to fuse by 9 – 12 weeks of pregnancy
common to girls unilateral or bilateral
III. Cleft Lip & Cleft Palate
Gastrointestinal Disorders
III. Cleft Lip & Cleft Palate
Cleft palate repair is performed sometime between 12 to 18 months of age ; a cleft palate is closed before the child develops faulty speech habits
Gastrointestinal Disorders
ImplementationAssess fluid & calorie intake daily & monitor weight
Modify feeding techniques; plan to use specialized feeding techniques, obturators, & special nipples & feeders
Hold the child in an upright position & direct the formula to the side & back of the mouth to prevent aspiration; feed small amounts gradually (every 3-5 minutes) & burp frequently (2x in the middle & at the end of feeding)
Gastrointestinal Disorders
ImplementationPosition on side after feedingKeep suction equipment & bulb syringe at bedside
Encourage breastfeeding if appropriate
Teach the parents special feeding or suctioning techniques
Teach the parents the ESSR (enlarge, stimulate sucking, swallow, rest) method of feeding
Gastrointestinal Disorders
ImplementationTeach the parents the ESSR (enlarge, stimulate sucking, swallow, rest) method of feeding
Encourage the parents to describe their feelings related to the deformity
Gastrointestinal Disorders
Implementation Postoperatively Cleft lip repair
A lip protector device may be taped securely to the cheeks
Position the child on the side or on the back; avoid the prone position to prevent rubbing of the surgical site on the mattress
Gastrointestinal DisordersImplementation Postoperatively Cleft lip repair
After feeding, cleanse the suture line of formula or serosanguinous drainage
w/ a cotton-tipped swab dipped in saline; apply antibiotic ointment if prescribed
Gastrointestinal Disorders
Implementation Postoperatively Cleft palate repair
Child is allowed to lie on the abdomen
Feedings are resumed by bottle, breast, or cup
Oral packing may be secured to the palate (removed in 2 to 3 days)
Gastrointestinal Disorders
Implementation Postoperatively Cleft palate repair
Do not allow the child to brush his or her teeth
Avoid offering hard food items to the child, such as toast or cookies
Gastrointestinal Disorders
Implementation Postoperatively Soft elbow or jacket restraints may be used; remove restraints at least every 2 hours to assess skin integrity & allow for exercising the arms
Avoid the use of oral suction or placing objects in the mouth such as tongue depressor thermometer, straws, spoons, forks, or pacifiers
Gastrointestinal Disorders
Implementation Postoperatively Monitor for signs of infection at the surgical site, such as redness, swelling, or drainage
Initiate appropriate referrals for speech impairment or language-based learning difficulties
Gastrointestinal Disorders
IV. Esophageal Atresia & Tracheoesophageal Fistula
The esophagus terminates before it reaches the stomach &/or a fistula is present that forms an unnatural connection w/ the trachea
An obstruction of the esophagusA fistula occurs between the closed esophagus & trachea
Five usual types of esophageal atresia:
Esophagus ends in a blind pouch-TEF between the distal part of the esophagus & trachea
Esophagus ends in a blind pouch-there is no connection in the trachea
Fistula present between a normal esophagus & trachea
Esophagus ends in a blind pouch-fistula connects the blind pouch of the proximal esophagus to the trachea
Blind end portion of the esophagus-fistulas present between both widely spaced segments of the trachea & esophagus
A fistula can allow milk to enter the trachea causing an aspiration
Must be ruled out in any infant born to a woman with hydramnios
Diagnosis:Barium swallowBronchial endoscopy exam
Treatment: Surgery-closing the fistula &
& anastomosing the esophageal segments
Causes oral intake to enter the lungs or a large amount of air to enter the stomach
Gastrointestinal Disorders
IV. Esophageal Atresia & Tracheoesophageal Fistula
Aspiration pneumonia & severe respiratory distress will develop, & death will occur w/out surgical intervention
Gastrointestinal Disorders
AssessmentFrothy saliva in the mouth & nose, & drooling
Coughing & choking during feedings
Unexplained cyanosis
Regurgitation & vomitingAbdominal distentionInability to pass a small-gauge (no. 5 French) orogastric feeding tube via the mouth into the stomach
Gastrointestinal Disorders
ImplementationSuction accumulated secretions
from the mouth & pharynxA double-lumen catheter is placed
into the upper esophageal pouch & attached to intermittent or continuous low suction to keep the pouch empty secretions
Maintain in an upright position to facilitate drainage
Gastrointestinal Disorders
ImplementationA gastrostomy tube may be placed & is left open so that air entering the stomach through the fistula can escape, minimizing the danger of regurgitation
Gastrointestinal Disorders
Implementation postoperatively Monitor respiratory statusInspect surgical siteProvide care to the chest tube if in place
Assess for signs of painMonitor for anastomotic leaks as evidenced by purulent chest drainage, increased temperature, & an increased white blood cell count
Gastrointestinal Disorders
Implementation postoperatively If a gastrostomy tube is present, it is attached to gravity drainage until the infant can tolerate feedings (usually the 5th to 7th day postoperatively)
Before oral feedings & removal of the chest tube, a barium swallow is performed
Gastrointestinal Disorders
Implementation postoperatively Prior to feeding, the gastrostomy tube is elevated to allow gastric secretions to pass to the duodenum & swallowed air to escape through the open gastrostomy tube
The gastrostomy tube may be removed prior to discharge or may be maintained for supplemental feedings at home
Gastrointestinal Disorders
Implementation postoperatively Assess cervical esophagostomy site for redness, breakdown, or exudate; remove drainage frequently & apply a protective ointment
If the infant is awaiting esophageal replacement, nonnutritive sucking is provided by a pacifier; may have difficulty eating by mouth after surgery & develop oral hypersensitivity & food aversion
Gastrointestinal DisordersImplementation postoperatively Instruct parents to identify behaviors that indicate the need of suctioning, signs of respiratory distress, & signs of a constricted esophagus (poor feeding, dysphagia, drooling, or regurgitated undigested food)
Gastrointestinal Disorders
V. Gastroesophageal Reflux Disease (GERD)
Backflow of gastric contents into the esophagus as a result of relaxation or incompetence of the lower esophageal or cardiac sphincter
Complications include esophagitis, esophageal strictures, aspiration of gastric contents, & aspiration pneumonia
V. Gastroesophageal Reflux (GER)
Gastrointestinal Disorders
AssessmentPassive regurgitation or emesisHematemesis & melenaHeartburn (in older children)Anemia from blood loss
Gastrointestinal Disorders
ImplementationAssess amount & characteristics of emesis
Assess the relation of vomiting to the times of feedings & infant activity
Monitor breath sounds before & after feedings
Place suction equipment at the bedside
Gastrointestinal Disorders
PositioningPlace in either the flat prone position or the head-elevated prone position following feedings & at night
Gastrointestinal Disorders
Diet Provide small frequent feedingsFor infants, thicken formula by adding 1 tablespoon of rice cereal per 6 ounces of formula & crosscut the nipple
Breastfeeding may continue, & the mother may provide more frequent feeding times or express milk for thickening w/ rice cereal
Gastrointestinal Disorders
Diet Burp the infant frequently when feeding & handle the infant minimally after feedings
For toddlers, feed solids first, followed by liquids
Avoid feeding the child fatty foods, chocolate, tomato products carbonated liquids, fruit juices, citrus products, & spicy foods
Avoid vigorous play after feeding & avoid feeding just before bedtime
Gastrointestinal Disorders
MedicationsAntacids & histamine receptor antagonists as prescribed
Gastrointestinal Disorders
SurgeryIf surgery is prescribed, it will require a procedure known as fundoplication
A gastrostomy may be performed at the same time as the fundoplication
Fundoplication may be combined w/ pyloroplasty in children w/ GER who also have delayed gastric emptying
Surgery fundoplication
Gastrointestinal Disorders
X. Hirschsprung’s DiseaseA congenital anomaly also known as congenital aganglionosis or megacolon
Congenital Aganglionic MegacolonAbsence of ganglion cells in the rectum & upward in the colon
Results in mechanical obstruction May be associated w/ other anomalies, such as Downs syndrome & genital urinary diarrhea
X. Hirschsprung’s Disease
Gastrointestinal Disorders
X. Hirschsprung’s DiseaseA rectal biopsy demonstrates histologic evidence
The most serious complication is enterocolitis; signs include fever, GI bleeding & explosive watery diarrhea
Gastrointestinal Disorders
X. Hirschsprung’s DiseaseInitially, in the neonatal period, the obstruction is relieved by a temporary colostomy to relieve obstruction & allow the normally innervated, dilated bowel to return to its normal size
A complete surgical repair is performed, when the child weighs approximately 9 kg (20 lbs), via a pull-through procedure
Gastrointestinal Disorders
Assessment 1. Newborn infants
Failure to pass meconium stoolRefusal to suckAbdominal distentionBile-stained vomitus
Gastrointestinal Disorders
Assessment 2. Children
Abdominal distentionVomitingConstipation alternating w/
diarrheaRibbon-like & foul-smelling stools
Gastrointestinal Disorders
Implementation: Medical managementDietary managementDaily rectal irrigations w/ normal saline to promote adequate elimination
Gastrointestinal Disorders
Surgical management: preoperative implementationMaintain NPO statusMeasure abdominal girth
Avoid rectal temperaturesMonitor for respiratory distress associated w/ abdominal distention
Gastrointestinal Disorders
Implementation postoperativelyMonitor vital signs, avoiding rectal temperatures
Assess surgical site for redness, swelling, & drainage
Assess the stoma for bleeding or skin breakdown
Maintain the NG tube to allow intermittent suction until peristalsis returns
Gastrointestinal Disorders
Implementation postoperativelyMaintain the IV until the child tolerates appropriate oral intake; begin the diet w/ clear liquids, advancing to regular as tolerated & as prescribed
Provide the parents w/ instructions regarding colostomy care & skin care
Gastrointestinal Disorders
XI. Intussusception Telescoping of one portion of the bowel into another portion
Results in an obstruction
XI. Intussusception
Gastrointestinal Disorders
AssessmentColicky abdominal pain that causes the child to scream & draw the knees to the abdomen
Currant jelly-like stools containing blood & mucus
Tender distended abdomen, possibly w/ a palpable sausage-shaped mass in the upper right quadrant
Gastrointestinal Disorders
ImplementationMonitor for signs of perforation & shock as evidenced by fever, increased heart rate
Prepare for hydrostatic reduction if prescribed (not performed if signs of perforation of shock occur
Monitor for the passage of normal brown stool, w/c indicates that the intussusception has reduced itself
Gastrointestinal Disorders
ImplementationAfter hydrostatic reductionMonitor for the return of normal bowel sounds, for the passage of barium, & the characteristics of stool
Gastrointestinal Disorders
XIII. Umbilical hernia, Inguinal hernia, or Hydrocele
A hernia is a protrusion of the bowel through an abnormal opening in the abdominal wall
In children, a hernia most commonly occurs at the umbilicus & through the inguinal canal
Omphalocele – protrusion of abdominal contents through the abdominal wall at the point of the junction of the umbilical cord & abdomen
Incidence: 1 in 5000 live birthsDiagnosis:Prenatally through a sonogramInspection after birth
Management:Immediate surgery to replace the bowel backIf large apply silver sulfadiazine to prevent
infection; followed by delay surgical exposure
XIII. Umbilical hernia, Inguinal hernia, or Hydrocele
Gastrointestinal Disorders
XIII. Umbilical hernia, Inguinal hernia, or Hydrocele
A hydrocele is the presence of abdominal fluid in the scrotal sac
Diagnosis: Prenatal sonogramAt birth, scrotum of newborn appears
enlargedIf uncomplicated, fluid will be gradually
reabsorbed in the body; no treatment necessary
Gastrointestinal Disorders
Assessment1.Umbilical herniaSoft swelling or protrusion around the umbilicus that is usually reducible w/ the finger
2.Inguinal herniaPainless inguinal swelling that is reducible
Swelling may disappear during periods of rest
Gastrointestinal Disorders
Assessment3.Incarcerated herniaWhen the descended portion of bowel becomes tightly caught in the hernial sac compromising blood supply
IrritabilityTenderness at siteAbdominal distentionMay lead to complete intestinal obstruction & gangrene
Gastrointestinal Disorders
XVIII. Ingestion of poisonsA. Lead Poisoning
Gastrointestinal Disorders
CausesThe pathway for exposure may be food, air, or water
Dust & soil contaminated w/ lead
Poisoning occurs commonly in 2-3 years old age group; all socioeconomic groups
Poisoning can occur from:OTC drugs (vitamins, aspirin, iron
compounds or prescription drugs; antidepressants)
The most common route is ingestion either from hand to mouth behavior from contaminated objects or from eating loose paint chips
It affects the erythrocytes, bones, & teeth, & organs & tissues, including the brain & nervous system
Gastrointestinal Disorders
Universal screeningRecommended in high-risk areas at the age of 1 to 2 yrs
Any child between the ages 3 & 6 yrs who has not been screened
Common in toddlers. (falls- common to infant)
Gastrointestinal Disorders
Blood lead level (BLL) testBLL less than 10 ug/dl: Reassess or rescreen in 1 year
BLL 10 to 14 ug/dl.: Provide family lead education, follow-up testing, & social service referral
BLL 15 to 19 ug/dL or greater: Provide family lead education, follow-up testing, & social service referral
Gastrointestinal Disorders
Blood lead level (BLL) testBLL 70 ug/dL or greater: medical treatment is immediately provided
BLL 20 to 44 ug/dL: A BLL greater than 20 ug/dL is considered acute; clinical management, including treatment, environmental investigation, & lead-hazard control
Principles:Determine substance taken, assess LOC
Unless poison is corrosive, caustic (strong alkali such as LYE) or a hydrocarbon, vomiting is the most effective way to remove poison.
Give syrup of Ipecac to induce vomiting
Ipecac – oral emetic Dose:* 15 ml – adolescent, school age & pre school
* 10 ml to infant
Vomiting will occur within 20 minutes after giving Ipecac
If vomiting did not occur within 20-30 minutes; another dose maybe given
UNIVERSAL ANTIDOTE- activated charcoal either (orally or via NGT),stools appear black, milk of magnesia & burned toast
Never administer charcoal before ipecac
For caustic poisoning ( muriatic acid ) neutralize acid by giving vinegar . Don’t vomit instead prepare tracheostomy set
Gas - mineral oil will coat intestine
Gastrointestinal Disorders
XVIII. Ingestion of poisons
B. Acetaminophen (Tylenol)
Gastrointestinal Disorders
Description- Seriousness of ingestion is determined by the amount ingested & the length of time before intervention
- Toxic dose is 150 mg/kg or greater in children
Gastrointestinal Disorders
AssessmentGI effects: nausea, vomiting & thirst from dehydration
CNS effects: hyperpnea, confusion, tinnitus, convulsions, coma
Hematopoietic effects: bleeding tendencies
Gastrointestinal Disorders
ImplementationInduce vomiting w/ syrup of ipecac or perform gastric lavage
Administer activated charcoal to decrease absorption of salicylate
Antidote for Acetaminophen poisoning – Acetylcystine ( Mucomyst)
KwashiorkorDiseased caused by CHON insufficiency
Occurs in children 1-3 years oldGrowth failure – major symptomEdemaMuscle wasting
Irritable & disinterested in environment
Lag in motor development compared to other children at same age group
Zebra sign – hair shafts develop a striped appearance
DiarrheaAnemiaHepatomegalyTreatment: Diet high in CHONFatal if not treatedEven if corrected children fail to reach
their full potential (cognitive,psychological)
MarasmusDeficiency of all food groupsChildren affected –younger than 1 year old
Symptoms:Growth failureMuscle wastingIrritabilityIron-deficiency anemiadiarrhea
Starving – will suck on anything offered to them
Treatment:Supply with diet rich in all nutrients