Ch 24 ppt

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The Child with Gastrointestinal Dysfunction

Chapter 24


Clinical Manifestations of GI Dysfunction

• Failure to thrive

• Regurgitation

• Nausea, vomiting, diarrhea, constipation

• Abdominal pain, distention, GI bleeding

• Jaundice

• Dysphagia

• Hypoactive, hyperactive, or absent bowel sounds


Daily Maintenance Fluid Requirements

• Calculate child’s wt in kg

• Allow 100 mL/kg for first 10 kg body wt

• Allow 50 mL/kg for second 10 kg body wt

• Allow 20 mL/kg for remaining body wt


Example #1 of Daily Fluid Calculation

• Child weighs 32 kg

• 100 x 10 for 1st 10 kg of body weight = 1000

• 50 x 10 for 2nd 10 kg of body weight = 500

• 20 x 12 for remaining body weight = 240

• 1000 + 500 + 240 = 1740 mL/24 hrs



• Child weighs 8.5 kg

• 100 x 8.5 for 1st 10 kg of body weight = 850

• No further calculations

• 850 mL/24 hrs



• Child weighs 14 kg

• 100 x 10 for 1st 10 kg of body weight = 1000

• 50 x 4 for 2nd 10 kg of body weight = 200

• No further calculations

• 1000 + 200 = 1200 mL/24 hrs


Diarrhea

• Description: the major concerns when a child is having diarrhea are the risk of dehydration, the loss of fluid & electrolytes, & the development of metabolic acidosis.

• Assessment:

1. Character of stools

2. Pain & abdominal cramping

3. Dehydration

4. Fluid & electrolyte imbalances

5. Metabolic acidosis


Diarrhea (Interventions)

1. Monitor vital signs

2. Monitor the character, amount, & frequency diarrhea

3. Monitor skin integrity

4. Monitor intake & output & signs of dehydration

5. Monitor electrolyte levels


Diarrhea (Interventions)

6. For mild to moderate dehydration, provide oral rehydration therapy.

7. For severe dehydration, maintain NPO status & provide fluid & electrolyte replacement by the IV route

8. Reintroduce a normal diet once rehydration is achieved

9. Provide enteric isolation is required

10. Instruct the parents in good hand-washing technique


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


Vomiting

• Descriptions:

1. The major concerns when a child is vomiting are the risk of dehydration, the loss of fluid & electrolytes, & the development of metabolic alkalosis

2. Additional concerns include aspiration, atelactasis, and the development of pneumonia


Vomiting

• Assessment:

1. Signs of aspiration

2. Character of vomitus

3. Pain & abdominal cramping

4. Dehydration

5. Fluid & electrolyte imbalances

6. Metabolic alkalosis


Vomiting• Interventions:

1. Maintain a patent airway

2. Position the child on side to prevent aspiration

3. Monitor vital signs

4. Monitor the character, amount, & frequency of vomiting

5. Assess the force of vomiting, for projectile vomiting indicates pyloric stenosis or increased intracranial pressure

6. Monitor intake & output & signs of dehydration

7. Monitor electrolyte levels

8. Provide oral rehydration therapy

9. Assess for diarrhea or abdominal pain

10. Advise the parents to inform the physician when signs of dehydration, blood in vomitus, forceful vomiting, or abdominal pain is present


Gastroesophageal Reflux (GER)

• Defined as transfer of gastric contents into the esophagus as a result of relaxation of the lower esophageal or cardiac sphincter.

• Complications include esophageal strictures, aspiration of gastric contents, & aspiration pneumonia.

• Assessment:

1.Passive regurgitation or emesis

2.Poor weight gain

3.Hematemesis

4.Heartburn (in older children)

5.Anemia from blood loss


GER (cont’d)

• Interventions:

1. Assess amount & ch-ch of emesis

2. Monitor breath sounds before &after feeding

3. Place suction equipment at the bedside

4. Monitor intake & output

5. Monitor for signs & symptoms of dehydration


GER (cont’d)

• Treatment:

a) Positioning: prone position after feedings & at night

b) Diet:

1. Provide small, frequent feedings to decrease the amount of regurgitation, nasogastric tube feedings are indicated if severe regurgitation & poor growth are present.

2. For infants, thicken formula by adding rice cereal.

3. Burp the infant frequently when feeding & handle the infant minimally after feedings

4. Instruct the parents to avoid feeding the child fatty foods, chocolate, fruit juices, & spicy foods

5. Avoid feeding just before bedtime

6. Avoid vigorous play after feeding


GER (cont’d)

c) Medications:

1. Administer antacids to reduce the amount of acid present in gastric secretions, & to prevent esophagitis

2. Administer prokinetic agents to accelerate gastric emptying & decrease reflux

3. Administer acetaminophen to relieve reflux pain

d) Surgery:

1. Procedure known as fundoplication to restore the competence of lower esophageal sphincter

2. A gastrostomy may be performed at the same time for decompression of the stomach postoperatively


Cleft Lip and/or Cleft Palate (Description)

• Cleft lip or cleft is a congenital anomaly that occur as a result of failure of soft tissue or bony structure to fuse during embryonic development.

• The defects involve abnormal openings in the lip or palate that may occur unilaterally or bilaterally

• Causes include genetic, hereditary, & environmental factors, exposure to radiation or rubella virus, chromosome abnormalities, & teratogenic factors.

• Closure of cleft lip defect precedes that of the palate? & is performed usually during the 1st weeks of life.

• Cleft palate is repair is performed between 12 & 18 months of age


Cleft Lip and/or Cleft Palate (Assessment)

• Cleft lip can range from a slight notch to a complete separation from the floor of the nose.

• Cleft palate can include nasal distortion, midline or bilateral cleft, & variable extension from the uvula & soft & hard palate.


Cleft Lip and/or Cleft Palate (Interventions)

• Assess the ability to suck, swallow, handle normal secretions, & breathe without distress

• Assess fluid & calorie intake daily & monitor weight

• Modify feeding techniques

• Hold the child in an upright position, and feed small amounts gradually & burp frequently

• Position on side after feeding

• Teach the parents ESSR (enlarge, stimulate, sucking, swallow, rest) method of feeding.


Cleft Lip and/or Cleft Palate (Interventions postoperatively)

1. Cleft lip repair:

a) A lip protector device may be taped securely to the cheeks to prevent trauma to the suture line

b) Position the child on the side lateral to the repair or on the back, avoid the prone position to prevent rubbing of the surgical site on the mattress

c) After feeding, cleanse the suture line of formula or drainage with a cotton tipped swab dipped in saline, apply antibiotic ointment if prescribed



2. Cleft palate repair:

a) Child is allowed to lie on the abdomen

b) Feedings are resumed by bottle, breast, or cup

c) Do not allow the child to brush his or her teeth

d) Instruct the parents to avoid offering hard food items to the child



3. Soft elbow or jacket restraints may be used (check agency policy)

4. Avoid the use of oral suction or placing objects in the mouth as a tongue depressor, thermometer, straws, spoons, forks, or pacifiers

5. Provide analgesics for pain

6. Instruct the parents to monitor for signs of infection at the surgical site

7. Encourage the parents to hold the child

8. Initiate appropriate referrals for speech impairment or language-based learning difficulties


Image 322: Stages in palatine development.


Image 323: Variations in clefts of lip and palate at birth. A, Notch in vermilion border. B, Unilateral cleft lip and cleft palate. C, Bilateral cleft lip and cleft palate. D, Cleft palate.


Image 324: Infant with Logan bow in place to prevent trauma to the suture line. Note elbow restraints.


Image 325: Some devices used to feed an infant with a cleft lip and palate.

Education

Ch 24 ppt