Gastrointestinal Disorders in Pediatric Patients - PowerPoint

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					Nursing Care of the Child
  with Gastrointestinal
       Disorders
  Ann Hearn RNC, MSN
  Spring 2009
       Cleft Lip and Cleft Palate
   Etiology- Failure of maxillary and median
    nasal processes to fuse during embryonic
    development

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

 Surgical repair done ASAP
 Rule of 10 > 10#, 10 weeks, 10 HGB
 Multidisciplinary team
                Pre-op Goals
   Prevent aspiration / Maintain nutrition

   Provide emotional support to family
      Prevent Aspiration / Maintain
               Nutrition
 Breast feed – small cleft lip
 Bottle feed – special feeding devises
    – Special nipples
    – Enlarge cross cut hole
 Bubble frequently
 Hold upright
 ESSR
    Provide Emotional Support
 Assist with accepting of defect
 Teach proper feeding
 Point out positive attributes
 Encourage participation in care
 Explain surgical procedure
           Pre-op Teaching
 Remind parents that defect is operable-
  show photographs of corrected clefts
 Introduce cup, spoon feeding devices
 Explain elbow restraints
 Explain Logan Bow
                    Post-Op
   Prevent trauma to suture line
    – Reduce pain & infection
 Cleanse suture lines as ordered
 Facilitate breathing
 Maintain nutrition
 Referral to appropriate team members
         Esophageal Atresia
Failure of the esophagus to totally
  differentiate during uterine development.
          Assessment Findings
 Respiratory difficulties
 Drooling
 Coughing, choking, cyanosis
 Gastric distention - if fistula present
 Hx of ??? during pregnancy?
    – Polyhydramnios
       gastrointestinal obstruction
       fetus unable to swallow
             Management

Early diagnosis
  Ultra sound
  Radiopaque catheter inserted in the esophagus
    to illuminate defect on X-ray
Surgical repair- thoracotomy and
  anastomosis
        Pre-Op Nursing Priority
 Maintain airway
 Prevent aspiration pneumonia
 Keep NPO- administer IV fluids
    – Elevate HOB 30 degrees
    – Suction PRN
    – Prophylactic antibiotics
                       Post-Op
   Maintain nutrition
    – TPN
    – Gastrostomy
   Maintain airway
    – Prevent aspiration
 Monitor weigh, growth and development
  achievements
 Complications
    – GERS
    – Stricture formation
 Teaching Plan: Gastrostomy Tube
 Equipment
 Procedure
 Psychosocial needs
 Medication administration
 Stoma care
 Problem solving
Gastroesophagial Reflux Disease
           (GERD)
The cardiac sphincter and lower portion of
 the esophagus are weak, allowing
 regurgitation of gastric contents back into
 the esophagus.
    Assessment findings: Infant
 Regurgitation almost immediately after
  each feeding when the infant is laid down
 Excessive crying, irritability
 Failure to thrive (FTH)
 Complications:
    – aspiration pneumonia
    – apnea
    Assessment findings: Child
 Heartburn
 Abdominal pain
 Cough, recurrent pneumonia
 Dysphagia
               Diagnosis
 Assess Ph of secretions in esophagus if
  <7.0 indicates presence of acid
 Barium Swallow and visualization of
  esophageal abnormalities
    Management & Nursing Care
   Nutritional needs
    – Small frequent feedings
    – Frequent burping
   Positioning
    – Prone flat or head elevated after feedings
     (not for sleep)
 Medications
 CPR instruction for parents/caregivers
 Surgery: Nissen fundoplication
       Post Op Nursing Care
 Feedings
 Bubbling
 Positioning
 Airway
 Medications
                   Medications
 H2 Histamine receptor antagonists – reduce gastric
  acidity
   – Zantac and Pepcid
 Proton-pump inhibitors
   – Prevacid
   – Prilosec
 Gastric emptying
   – Reglan
 Antacids
   – Gaviscon
**be sure to study nursing implications and side effects
            Pyloric Stenosis
   Results when the circular area of the
    muscle surrounding the pylorus
    hypertrophies & obstructs gastric
    emptying.
    – Incidence: 3 in 1000 births
    – Possible genetic predisposition
Pyloric Stenosis
       Narrowing of the pyloric
        spincter
       Delayed emptying of the
        stomach
             Assessment
 Vomiting - projectile
 Constant hunger and fussiness
 Distended upper abdomen
 Hypertrophied pylorus – olive shaped
  mass
 Visible peristaltic waves
               Diagnosis
 History and Physical
 Laboratory values
 X-ray or Ultrasound
       Management and
        Nursing Care

Fred Ramstedt procedure-
 Pyloromyotomy via laproscopy
                 Pre-Op

 Hydration and electrolyte balance
 Weigh daily & I and O
 NG tube
 Support of parents
Management and Nursing Care:
         Post-Op
   NPO until bowel function
    – Progressive feeds: Feeding begins with clear liquids
      containing glucose and electrolytes. Regime
      example: 8 hours NPO, 10cc sterile water feed X 2.
      Increase to 15cc X 2, progressing to ½ strength
      formula, then full strength formula. Observe and
      record the infant’s response to feeding.
 Position with head elevated
 Assess surgical site for infection - Antibiotics
 Analgesia
 Patient teaching
               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?
    a. Begin an intravenous infusion
    b. Measure abdominal circumference
    c. Orient family to unit
    d. Weigh infant
  Gastroschisis

  Omphalocele
Abdominal Wall Defects
               Gastroschisis
   herniation of abdominal viscera outside
    the abdominal cavity through a defect in
    the abdominal wall to the side of the
    umbilicus. Not covered.
     Treatment and Nursing Care
   Pre-operatively – focus is on protection of the
    contents / sac. Cover with warm, sterile,
    saline-soaked dressings over the defect.
   May choose to replace the gut to the abdomen
    gradually over several weeks. May place silo or
    silastic material over gut until it returns to the
    abdomen.
   Surgery used to close defect.
                Gastroschisis
 Assessment- noted on ultrasound and
               obvious at birth
 Treatment- surgical repair in stages
 Nursing care-
    – support parents loss of “Perfect Child”
    – assess for ileus
    – maintain parenteral feeding
           Omphalocele




Herniation of abdominal contents through
the umbilical cord. Contents are covered
          by a translucent sac.
                Omphalocele


   Assessment- ultrasound and at birth

   Treatment- surgical repair in stages

   Nursing care- same as for Gastroschisis
               Intussuception
   Invagination of a section of the intestine,
    into the distal bowel that causes bowel
    obstruction.
    – Usually the terminal ileum telescopes into the
      ascending colon through the ileocecal valve.
   Inflamed bowel & bleeding
    – Leading to necrosis & perforation
                Intussuception
   Most commonly seen in infants 3-12 months
   Bowel “telescopes”
     within itself
       Intussuception: Clinical
           Manifestations
 Intermittent then constant pain
 Vomiting
 Abdominal distention
 Currant jelly-like stools
 Diarrhea
 Dehydration
Serious complications:
Ischemia, perforation & shock
                Volvulus
 Twisting of the bowel that leads to a
  bowel obstruction.
 Vomiting of fecal material
 Abdominal distention
 Pain
Volvulus

    A twisting of the bowel
     that leads to a bowel
     obstruction.
              Assessment

 Pain
 Vomiting
 Stools
 Dehydration
 Serious complications
         Diagnosis

X-ray
Abdominal   ultrasound
       Therapeutic Intervention



Hydrostatic       reduction

   Laparoscopic Surgery
               Nursing Care:

   NPO- NG tube, IV

   Assess – V/S, pain

   Monitor stools

   Re-introduce food
               Appendicitis

   Inflammation of the lumen of the
    appendix at the end of the cecum which
    becomes quickly obstructed causing
    edema, necrosis and pain.
          Clinical Manifestations
   Abdominal pain – McBurney’s point
   Silent Abdomen
   Anorexia & nausea
   Diarrhea
   Elevated temperature
   IF PERFORATED:
    – Sudden pain relief
    – Fever
    – Dehydration
                 Diagnosis
 History and Physical
 Ultrasound
 X-Ray
 Laboratory values
    – increased WBC 15,000 – 20,000
Management and Nursing Care:
         Pre-Op
 NPO
 IV
 Comfort measures
 Antibiotics
 Thermal therapy
 Elimination
 Patient education
       Hirschsprung’s Disease




Congenital disorder of absence of ganglia (nerve
  cells) in lower colon
                  Assessment
   Failure to pass meconium

   Vomiting

   Bowel assessment

   Breath

   Older child
                  Diagnosis

   History & Physical

   Barium enema (X-ray)

   Rectal biopsy- absence of ganglionic cells
    in bowel mucosa
            Management


Surgicalintervention
 –Colostomy
 –Resection
Nursing Care:

   Pre-op
    – Cleanse bowel
    – NPO
    – Patient/parent teaching
   Post-op
    –   NPO
    –   VS (no rectal temperatures)
    –   Assessment
    –   Patient/parent teaching
      Diarrhea/Gastroenteritis
              Severe

 A disturbance of the intestinal tract that
  alters motility and absorption, and
  accelerates the excretion of intestinal
  contents.
 Most infectious diarrheas in this country
  are caused by Rotovirus
                Dehydration
   Infant:
    – Depressed fontanels
    – Sunken eyes


 Little fluid volume reserve
 Hypovolemic Shock
         Clinical Manifestations
 Increase in peristalsis
 Large volume stools
 Increase in frequency of stools
 Nausea, vomiting, cramps
 Metabolic Acidosis:
    – Increased heart & resp. rate, decreased B/P,
      arrhythmias
    – Cold, clammy skin
    – Changes in CNS – stupor, lethergy
                   Diagnosis
   Stool sample
    – culture
    – O&P


   Blood gases
    – Metabolic Acidosis
    Priority Nursing Interventions
 Treat underlying cause
 Restore fluid & electrolyte balance
 Daily weights
 I&O
 Assess for dehydration
 Isolation protocol
 Monitor electrolytes/metabolic acidosis
 Skin care
Oral Rehydration
           Critical Thinking
 Why is there an increase in incidence of
  diarrhea in lower socio-economic groups?
 Why is there and increase in young
  children?
               Celiac Disease
   Celiac disease results from the inability to
    digest gliadin which is a by-product of
    gluten breakdown.

    – This results in the accumulation of the amino
     acid glutamine which is toxic to the mucosal
     cells in the intestines. Damage to the villi
     impairs the ability of the small intestines to
     absorb nutrients
            Celiac Disease
 Assessment- Growth pattern, GI pattern
 Failure to Thrive
 Treatment- Dietary restrictions
 Nursing Care- monitor for dehydration,
          encourage compliance with
          dietary restrictions, provide
          support groups for patient and
          caregiver
          Signs and Symptoms
                                 The child with celiac disease
                                   commonly demonstrates
                                failure to grow and wasting of
                                extremities. The abdomen can
                                appear large due to intestinal
                                  distension and malnutrition




Complications:
Hypocalcemia, osteomalacia, osteoporosis, depression.
        Diagnostic Findings
 Measurement of fat content
 Duodenal or Jejunal biopsy
 Elevated IGA antibodies
Treatment and Nursing Care
Teach parents DIETARY REGULATIONS:
                              NO !

Gluten                      Wheat
  Free
    Diet                     Rye

                            Barley


           Disease specific support groups
The End

				
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