Gastrointestinal Disorders in Pediatric Patients

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Gastrointestinal Disorders in Pediatric Patients Powered By Docstoc
Disorders in Pediatric
Revised, Summer 2009
       Cleft Lip and Cleft Palate
   Etiology- Failure of maxillary and median
    nasal processes to fuse during embryonic

Remember the psycho-social implications for
       these children and families
   Unilateral, bilateral, midline

 Surgical repair done ASAP
 Rule of 10 > 10#, 10 weeks, 10 HGB
 Multidisciplinary team
 Homecare by the family prior to surgery
    –   E-enlarge opening in nipple
    –   S-stimulate suck reflex
    –   S-swallow fluids appropriately
    –   R-rest when infant signals
          Pre-op Teaching
 Remind parents that defect is operable-
  show photographs of corrected clefts
 Introduce cup, spoon feeding devices (see
  your book for feeding tips)
 Explain restraints
   Prevent trauma to suture line – Do not
    allow to suck!
    – Facilitate breathing
    – Maintain nutrition
 Reduce pain to minimize crying
 Prevent infection
    – Cleanse suture lines as ordered
   Referrals to appropriate team members
        Esophageal Atresia/
     Tracheoesophageal fistula

Failure of the esophagus to totally
  differentiate – 4-5th wk gestation
Both are malformations of ESOPHAGUS
Cause is unknown
 3C’s -coughing, choking, cyanosis when
 Respiratory difficulties
 Drooling
 Inability to pass suction catheter, NG @
 Abdominal distention if fistula present

Early diagnosis
  Ultra sound
  Radiopaque catheter inserted in the esophagus
    to illuminate defect on X-ray
Surgical repair- thoracotomy
 Anastomose ends of esophagus if possible (may need 2
 stage repair)
 Ligate fistula
   Maintain airway
    –   Keep NPO- administer IV fluids
    –   Elevate HOB 30 degrees
    –   Suction PRN
    –   Gastrostomy for feedings
   Prevent aspiration pneumonia
    – Suction
    – HOB 30 degrees
    – Prophylactic antibiotics
   Maintain airway

   Maintain nutrition

   Prevent trauma

   Monitor growth and development
     Gastroesophageal Reflux
The cardiac/lower esophageal sphincter
 (AKA LES) and lower portion of the
 esophagus are weak, allowing
 regurgitation of gastric contents back into
 the esophagus.
           Assessment: Infant
 Regurgitation almost immediately after
  each feeding when the infant is laid down
 Excessive crying, irritability
 Risk for:
    – aspiration (pneumonia)
    – Apnea
    – Development of respiratory problems
         Assessment: Child
 Heartburn
 Abdominal pain
 Cough, recurrent pneumonia
 Dysphagia
   Ph of secretions in esophagus <7.0=acid

   Barium Swallow and visualization of any
    esophageal abnormalities
    Management & Nursing Care
 Nutritional needs
 Positioning – PRONE (supine worsens GERD)
 Medications
    – H2 receptor antaqgonists (-tidine)
    – Cholinergics – metoclopramide (Reglan)
    – Proton pump inhibitors – (-prazole)
 CPR instruction for parents/caregivers
 Possible Nissen Fundoplication

 A disturbance of the intestinal tract that
  alters motility and absorption and
  accelerates the excretion of intestinal
  contents. 3-30 stools/day!!!
 Most infectious diarrheas in this country
  are caused by Rotovirus, but can be c.diff
       Clinical Manifestations
 Increase in peristalsis
 Large volume stools (loose, watery, green)
 Increase in frequency of stools with
  cramps, nausea, vomiting
 Urge with small stool present
 Increased heart & resp. rate, decreased
  tearing and fever
   Dehydration
    – Mucus membranes dried, cracked
    – Decreased elasticity of skin
    – Depressed fontanels, eyes sunken
    – Decreased urinary output, dark
   Metabolic Acidosis
    – pH <7.35
    – HCO3 =/<22mEq/L
   Stool culture
    -causative organism

   ABG’s to diagnose Metabolic Acidosis
      Treatment & Nursing Care
 Contact isolation
 Treat cause
 Weigh daily
 Monitor I&O, assess for dehydration
 Skin care
 Fluid and electrolyte balance
    – Oral rehydration
    – IV rehydration (RL or D5NS)

   Inflammation of the lumen of the
    appendix which becomes quickly
    obstructed causing edema, necrosis and
          Clinical Manifestations
 Pain
   – Vague
   – Periumbilical
   – Rebound tenderness
 No bowels sounds “silent abdomen”
 Anorexia with or without vomiting
 Diarrhea
 Increased temperature
 If ruptures/perforates, there is immediate relief of pain
  followed by high fever and dehydration
   WBC <15-20,000

   Rebound tenderness at McBurney’s point

   Abdominal ultrasound or xray - fecalith
Management and Nursing Care:
 Comfort measures, knee chest position
 Antibiotics
 Thermal therapy – Ice pack
 No elimination
 Patient education for post-op
    – +/- NG tube
    – Penrose drain vs open wound bed
Management and Nursing Care:
 NPO, IVs
 Antibiotics
 Analgesia
 Patient teaching
    – Wound care
    – Open vs laproscopic
    – No contact sports, PE, lifting until released by
         Pyloric Stenosis
 Pyloric sphincter
 Incidence
 Possible genetic predisposition
 Vomiting: character??
 Constant hunger and fussiness
 Distended upper abdomen
 Visible peristaltic waves
 Hypertrophied pylorus
 No pain
 Weight loss
 Dehydration and electrolyte imbalance
   History and physical

   Abdominal ultrasound

   Laboratory data
                  Pre-op care
   Restore fluid and electrolyte balance
    – NPO
    – Urine specific gravity
   Parental support
    – Guilt – think they are “bad parents”
    – Emphasize structural problem not parental
      feeding technique
          Management and
           Nursing Care

Pylorotomy via laproscopy
 I&O
 Feeding
 Position – HOB elevated slightly
 Surgical site infection free
 Patient teaching – s/s recurrence
                Critical Thinking
   A 4 week old infant with a history of vomiting
    after feeding has been hospitalized with a
    tentative diagnosis of pyloric stenosis. Which of
    these actions is priority for the nurse?
    –   Begin an intravenous infusion
    –   Measure abdominal circumference
    –   Orient family to unit
    –   Weigh infant

 Most commonly seen in infants 3-12
  months but can
  occur in older child
 Bowel “telescopes”
  within itself usually
  at ileocecal valve

 Pain – colicky, knee chest position
 Vomiting – can contain stool
 Stools – “currant jelly”
 Dehydration
 Serious complications
   Abdominal xray = intraperitoneal AIR

   Abdominal ultrasound
       Therapeutic Intervention

Hydrostatic    reduction

   Surgery
              Post-op care
 NPO with NG tube
 Monitor bowel sounds and passage of
 Gradual introduction of fluids and solids
       Hirschsprung’s Disease

Congenital disorder of nerve cells in lower colon
   Failure to pass meconium

   Vomiting with reluctance to feed

   Bowel assessment

   Breath
             If in older child:
   Constipation

   Offensive ribbon-like stools

   History of REGULAR laxative use

   Palpable fecal mass

   History & Physical

   Barium enema (X-ray)

   Rectal biopsy- absence of ganglionic cells
    in bowel mucosa

Surgical   intervention
 –One stage = resection
 –Two stage
   Temporary diverting colostomy
    with resection
   Re-anastomosis and take-
    down of colostomy
Nursing Care:
   Pre-op
     – Cleanse bowel
     – Neomycin per rectum
     – Patient/parent teaching re: ostomy
   Post-op
     – NPO – N/G tube, IV fluids
     – No rectal thermometers, monitor VS
     – Monitor bowel sounds and abdominal girth
     – Patient/parent teaching
          Incision care, s/s infection
          Pain management
          ?colostomy teaching
         Volvulus & Malrotation
   Assessment- pain, bilious vomiting, S & S
                bowel obstruction

   Treatment- surgery to prevent ischemia

   Nursing Care- same as Intussuception and
      Failure to Thrive (FTH)
 Assessment- low growth for age,
          developmental delays, apathy
 Diagnosis- History to determine organic-
               vs- non-organic
 Nursing Care- Teaching on nutrition
               feeding techniques, feeding
               cues, praise
 Community resources
              Celiac Disease
   Assessment- Growth pattern, GI pattern

 Treatment- Dietary restrictions
 Nursing Care- monitor for dehydration,
          encourage compliance with
          dietary restrictions, provide
          support groups for patient and
   Measure fetal fat

   Duodenal biopsy

   Screen IgA
 Hypocalcemia
 Osteomalacia
 Osteoporosis
 Depression