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Pediatric GI. Sheila Gentry,MSN,RN. Development. Begins 3rd week of gestation Mouth to Anus Includes the liver, gallbladder and pancreas Mouth Esophagus Stomach Small intestines Large intestines Rectum. Function.

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pediatric gi

Pediatric GI

Sheila Gentry,MSN,RN

development
Development
  • Begins 3rd week of gestation
  • Mouth to Anus
    • Includes the liver, gallbladder and pancreas
  • Mouth
  • Esophagus
  • Stomach
  • Small intestines
  • Large intestines
  • Rectum
function
Function
  • Digestion and absorption of nutrients and water, secretion of substances and elimination of waste products
    • Digestion: circular muscles churn and mix food. Longitudinal muscles propel the food bolus. And sphincter muscles control passage of food
    • Enzymatic activity: aids in breakdown of foods
general assessment
General Assessment
  • Assess pain(seven variables)
  • Normal bowel habit
  • Assess for changes in appetite
  • Identify thirst level
  • Food intolerance
  • Belching, vomiting, heartburn, flatulence
  • Identify routine eating habits
  • Ask about PMH related to GI
slide5
Height/Weight
  • Hydration status
  • I, A, P, P of abdomen
common diagnostic studies
Common Diagnostic Studies
  • Blood chemistries, liver profile, sed rate, C-reactive protein, thyroid function
  • Stool exams for ova and parasites, blood, WBC’s, pH, cultures, fecal fat collection(72 hr test to r/o fat malabsorption)
  • Bowel studies: UGI, BE, biopsy, rectosigmoidoscopy, Abd. Xrays. US of abdomen and pelvis
congenital gi anomalies
Congenital GI Anomalies
  • Cleft lip/palate
  • Esophageal atresia
  • Tracheoesophageal fistula
  • Omphalocele
  • Gastroschisis
  • Pyloric stenosis
  • Imperforate anus
  • Celiac disease
  • Hirshsprung’s disease
  • Intussusception
  • Hernia’s
cleft lip
Cleft Lip
  • Affects 1 in 800. More common in boys
  • Etiology: hereditary, environmental, teratogenic factors. Occurs around 7 weeks gestation
  • Readily apparent
  • Degree affected may vary. Small notch to complete separation
  • Surgical closure 1-2 months or Rule of 10
cleft palate
Cleft Palate
  • 1-2800 affected. More girls affect
  • Occurs at about 9 weeks gestation
  • May involve soft palate alone to hard palate /more severe maxilla
  • Surgical repair between 6-18mo.
  • Will have long-term care with HCP
  • Plastic surgeon, ENT, Nutritionist, Speech Therapy, Orthodontist, Pediatrician
major nursing diagnoses
Major Nursing Diagnoses
  • Ineffective airway clearance
  • Alt. Nutrition-LBR
  • Potential for Alt. in parenting
  • Risk for infection
  • Pain
management nursing care pre op
Management /Nursing CarePre-op
  • Assess degree of cleft
  • Assess Respiratory status
  • Assess ability to suck(will see difficulty with sucking and swallowing)
  • Assist with feeding: head upright/special nipples/ESSR
  • Continuous monitoring during feeding
  • Remove oral secretions carefully
slide14
Reaction of parents-guilt, disappointment, grief, sense of loss, anger. Encourage verbalization of fears/concerns
  • Encourage bonding/touching
  • Inform parents of successful surgical intervention
nursing care post op
Nursing Care Post-Op
  • Maintain patent airway. Lung assessment before/after feeding
  • Cleft lip proper positioning
    • Upright, or on unaffected side. Never prone
  • Cleft palate-side or abdomen
    • Liquids from side of cup or spoon
  • NO ORAL TEMPS
  • No straws, pacifiers, spoons, or fingers around mouth for 7-10 days
  • Encourage family participation in care
slide16
PROTECT SURGICAL SITE!!!
    • Elbow restraints
    • Minimize crying
    • Maintain Logan Bow if applied
    • No toothbrushes 1-2 weeks
  • Monitor site for infection
  • Assess pain
  • Resume feedings as ordered
  • Care of site after feeding
esophageal atresia with tracheoesophageal fistula
Esophageal Atresia with Tracheoesophageal Fistula
  • Congenital anomalies rare
  • Clinical and Surgical Emergency
  • Assessment
    • Three C’s of TEF
      • Choking, coughing, cyanosis
      • Plain water at birth
  • Management/Nursing Care
    • Surgical correction(thoracotomy)
    • Monitor Resp. status
    • Monitor/Remove excessive secretions
slide18
Elevate infant into anti-reflux position 30 degree incline
  • Provide O2
  • NPO(non-nutritive sucking ok)
  • IVF’s
  • Provide gastrostomy care/feedings
  • Education/Family involved in care
pyloric stenosis
Pyloric Stenosis
  • Assessment
    • Characteristic projectile vomiting(bile free)
    • Hungry, fretful, irritable,dehydration
    • Weight loss/failure to gain weight
    • Metabolic alkalosis
    • Palpable olive-shaped mass in RUQ
  • Diagnosis: US/UGI delayed emptying and elongated pyloric canal
slide22
May require surgical intervention: Pyloromyotomy
  • Nursing Care
    • Monitor respiratory status
    • Hydration status
    • IVF’s, electrolytes, NG tube care, Daily WT, I/O hrly , small frequent meals(clears)NPO prior to surgery.
    • 4-6hrs. After surgery may begin small frequent feeding with lytes solution or glucose
congenital aganglionic megacolon
Congenital/AganglionicMegacolon
  • Also called Hirshsprung’s Disease
  • Congenital 1 in 500
    • Absence of parasympathetic ganglion cells in distal portion of colon and rectum
    • Lack of peristalsis
    • Fecal contents accumulate
    • Mechanical obstruction
management nursing care
Management/Nursing Care
  • Correction- series of surgical intervention(Temporary colostomy with reanastamosis and closure later)
  • Pre-op care
  • Post-op care
      • Same as for any abdominal surgery
      • NPO
      • Routine ABC’s (axillary temps)
      • Monitor colostomy..note stoma color
slide27
Monitor bowel function, abdominal circumference
  • Teach family ostomy care
  • Toilet-training after age 2
intussusception
Intussusception
  • Telescoping of a portion of bowel into another(usually ileum to colon)
  • Partial or complete bowel obstruction. May require Emergency Surgery
  • Assessment
    • Usually infant under 1 yr.
    • Parent may relay acute, intermittent abdominal pain
    • Child may present screaming with legs drawn up
management nursing care1
Management/Nursing Care
  • Vomiting
  • “Currant Jelly” stools
  • Sausage shaped mass in RUQ while RLQ is empty(Dance sign)
  • Management/Nursing Care
    • Medical treatment: Barium enema
    • Monitor VS
    • Monitor for shock or bowel perforation
    • IVF’s, I/O, prepare child for barium enema…monitor stools pre/post BE
anorectal malformations
Anorectal Malformations
  • Congenital
  • Surgical repair based on extent
  • Imperforate Anus
    • Will see unusual anal dimpling
    • No passage of meconium
    • Meconium appearing from perianal fistula or in urine
slide31
Suspicion in newborn for failure to pass meconium in 24 hrs
  • Or if emesis is bile stained
  • Abdominal assessment
  • Chronic constipation in toddlers
  • May alt. With diarrhea
  • “Ribbon-like” stools. Foul-smelling
management nursing care2
Management/Nursing Care
  • Requires surgical correction
  • Discovered with newborn 1st temp rectally
    • Assess passage of meconium
    • Assist family to cope with dx
    • Will usually see other high-level defect
celiac disease
Celiac Disease
  • Genetic: Inability to tolerate foods with gluten(wheat, barley, rye, oats)
  • Life-long dietary modification
  • Diagnosis: Biopsy
  • Celiac crisis
  • Assessment
    • symptoms appear 3-6mo. After introduction of gluten(grains)
    • frequent bulky, greasy, malodorous stools with frothy appearance (Steatorrhea) 72 hr.fecal fat study
management nursing care3
Management/Nursing Care
  • Gluten free diet
  • Read labels
hernias
Hernias
  • Protrusion of an organ through abnormal opening
  • Results in organ constriction and impaired blood flow
    • Diaphragmatic
    • Hiatal
    • Abdominal
diaphragmatic hernia
Diaphragmatic Hernia
  • Congenital
  • Abdominal content protrude into thoracic cavity through an opening in the diaphragm
  • Findings depend on severity
    • diminished/absent breath sounds
    • bowel sound may be heard over chest
    • Cardiac sounds may be heard on right side of chest
    • Dyspnea, cyanosis, nasal flaring, retractions, sunken abdomen and barrel chest
management nursing care4
Management/Nursing Care
  • Surgical correction
  • Medical emergency
    • Chest tubes
    • Maintain airway(ventilator)ECMO
    • HOB^ Position on affected side
    • NG tube
    • IVF
  • Post-op
    • Monitor for infection, respiratory distress
    • Activities to promote lung function
hiatal
Hiatal
  • Sliding
    • Protrusion of abdominal structure(stomach) through the esophageal hiatus
management nursing care5
Management/Nursing Care
  • Depends on severity
  • Diagnosis: Fluoroscopy
  • Assessment
    • See dysphagia, Failure to thrive, vomiting, GER
  • Nursing care:
    • HOB elevated
    • Small frequent feedings
    • Manage GER symptoms
    • Monitor respiratory status pre/post feedings
umbilical hernia
Umbilical Hernia
  • Soft, skin covered protrusion of intestine around umbilicus
  • See in premature infants and African American infants more often
  • Spontaneous closure 3-4 (most by 1yr.)
management nursing care6
Management/Nursing Care
  • Surgical repair if >1.5-2cm or if not spontaneously closed by age 2
  • May be reduced with a finger
  • Nursing Care:
    • Monitor for change in size or for incarceration(hyperactive bowel sounds or inability to reduce)
    • Education
      • Binding not effective
      • Discourage home remedies
omphalocele and gastroschisis
Omphalocele and Gastroschisis
  • Omphalocele:
    • abdominal contents herniate through the umbilical cord
    • Covered with translucent sac
  • Gastroschisis:
    • bowel herniates through defect in abdominal wall. Usually to the right of the umbilicus
    • No covering of on exposed bowel
  • Degree is varied in both
management nursing care7
Management/Nursing Care
  • Surgical Repair necessary
  • Nursing Care:
    • Will be obvious @ delivery
    • Caution not to rupture sac
    • Place in warmer immediately
    • Sterile treatment
    • Immediately cover with sterile gauze saturated with warm saline and wrap with plastic
    • Minimize movement of the infant and handling of sac
slide44
Continuous temperature monitoring
  • ABC’s
  • NG tube
  • Wt, I/O, IVF’s, TPN as ordered
  • Monitor for signs of ileus…
  • Assess parents coping, encourage grieving, and parental participation in care, refer to support group
biliary atresia
Biliary Atresia
  • Unknown cause
  • Intrahepatic and extrahepatic bile duct obstruction
  • Liver becomes fibrotic, cirrhosis and portal HTN develops..Leads to Liver Failure and death without treatment
  • Surgical(Kasai procedure) temporary measure
  • Liver Transplant
slide47
Healthy @ birth
  • Jaundice --2 weeks to 2 month
  • Acholic stools
  • ^Bilirubin
  • Abdominal distention
  • Hepatomegaly
  • ^bruising ^ PT
  • Intense itching
  • Tea-colored urine
infections
Infections
  • Thrush
  • Acute Gastroenteritis
  • Appendicitis
  • Pinworms
thrush
Thrush
  • Monilial (yeast) infection of mouth
  • May or may not have symptoms
    • White coating in oral cavity
    • Fussy and gassy
  • Treatment:
    • If breast fed: treat mother and baby
    • Anti-fungal cream to nipples after feeding
    • Nystatin orally x 7 days
    • Careful hand washing to prevent spread
gastroenteritis vomiting diarrhea
Gastroenteritis Vomiting/Diarrhea
  • Common in childhood, usually self-limiting
  • No specific treatment
management nursing care8
Management/Nursing Care
  • Prevent dehydration
  • Assessment
    • Note onset/ ALWAYS inquire about associated signs/symptoms
    • Color
      • Green-think bile obstruction
      • Curded, stomach contents several hrs. after eating-think delayed gastric emptying
      • Coffee ground- think GI bleeding
nursing care
Nursing Care
  • Monitor hydration status/ IVF’s
  • Vital signs/ no rectal temps
  • Daily wts, I/O, weigh diapers,
  • Diet: NPO, Pedialyte 1-3 tsp q 10-15 minutes, clear to bland, milk free. Progress to BRAT diet
  • No juices, carbonated drinks, or caffeine
  • Standard precautions
appendicitis
Appendicitis
  • Most common reason for surgery in childhood
  • Diagnosis: US show incompressible appendix
  • CBC..^ WBC’s and left shift/symptoms
  • Treatment: Surgical removal
  • Assessment Findings:
    • Abdominal pain/rebound tenderness/ peri-umbilical pain
    • N/V, fever, chills, anorexia, diarrhea or acute constipation
management nursing care9
Management/Nursing Care
  • Pre-op care
    • NPO, IVF’s,Permit
    • Semi-Fowler’s or right side lying
    • Do nothing to stimulate peristalsis
    • No heat application
    • Sudden relief of pain…BAD
  • Post-op care
    • VS
    • Monitor for abdominal distention, wound care, ambulation within 6-8h, T, C, DB
    • Pain assessment
    • D/C education
necrotizing enterocolitis
Necrotizing Enterocolitis
  • Cause: intestinal ischemia, bacterial or viral infection, and premature birth
  • Onset: first 2 weeks of life
  • Diagnosis: Xray- dilated bowel loops/thickening or free air(Medical Emergency)
  • Assessment
    • History prematurity, SGA, maternal hemorrhage, preeclampsia, or umbilical catheter
slide56
Stage I: nonspecific findings that may represent physiologic instability
  • Stage II: nonspecific findings +
    • severe abdominal distention, abd. Tenderness, gross bloody stools, absent bowel sounds and palpable bowel loops
  • Stage III: Acutely ill, Septic shock, DIC, Death
pinworms
Pinworms
  • Enterobiasis
    • Caused by a nematode
    • It is the most common helminthic infection
    • Eggs ingested or inhaled..hatch/mature in upper intestine..then migrate through the intestine to mate and lay eggs at the anal opening
management nursing care10
Management/Nursing Care
  • Symptoms
    • Intense anal pruritis
  • Diagnosis:
    • Tape test early AM
  • DOC:
    • Vermox if >2yrs of age
    • Treat entire family
hepatitis
Hepatitis
  • Same as in adult
  • A,B,C,D,E
  • Anicteric phase 5-7 days
  • Icteric phase last up to 4 weeks
  • Hep A Control spread(standard precaution)
  • Hep B prevent with vaccine
failure to thrive
Failure to Thrive
  • IBW falls below 5th percentile on growth charts
  • Organic:
  • Non-organic
gastroesophageal reflux
Gastroesophageal Reflux
  • Typically self-limiting by 1 yr
  • Severe may require surgery
  • Nissenfundoplication
    • Assessment
      • frequent vomiting, melena, hematemesis, hiccuping, heartburn and abdominal pain
management nursing care11
Management/Nursing Care
  • keep upright, rice cereal added to formula, no fatty foods or citrus juices
  • Asses breath sounds before and after feeding
  • Suction @ bedside
  • Prone head elevated after feeding
  • avoid placing in infant seat
  • administer meds: Antiacids, H2 blockers,
slide63
Assess hydration
  • I/O, Monitor IVF’s, Daily weights
  • Small frequent feedings
  • Solids first then liquids
  • Burp often
  • Monitor for dumping syndrome 30 minutes after feeding (if post-op)
constipation encopresis
Constipation/Encopresis
  • Three or more days without BM
  • Painful BM’s
  • Encopresis is fecal soiling or incontinence
  • Can be secondary to GI disorder, certain medications or psychosocial factors
management nursing care12
Management/Nursing Care
  • Investigate cause
  • Promote regular bowel movement
  • Increase fiber and fluid in diet
  • Stool softeners
  • Provide a non-threatening environment
  • Do not push child during training
fluid and electrolyte imbalance
Fluid and Electrolyte Imbalance
  • Infants and younger children have greater need for water and are more vulnerable to alterations
  • Greater BSA(body surface area)
  • Increased BMR(basal metabolic rate)
  • Decreased kidney function (immaturity)
slide67
Fluid requirements depend of hydration status, size of infant/child,environmental factors and underlying disease
management nursing care13
Management/Nursing Care
  • Daily maintenance based on weight in kilograms
    • 100 ml/kg for 1st 10 kg
    • 50 ml/kg for 2nd 10 kg
    • 20 ml/kg remaining of kg
  • Then divide total amount by 24 hrs
  • This will be the rate in ml/hr
nursing care1
Nursing Care:
  • Be alert to potential problems
  • Accurate I&O’s are vital
  • Daily weights
  • Weigh diapers
  • Assess mucous membranes, fontanels
poisoning foreign bodies
Poisoning/Foreign Bodies
  • Major health concern
  • Most occur in children less than 6
  • 90% occur in the home
  • Most commonly ingested poisons
    • Cosmetic products
    • Cleaning products
    • Plants
    • Foreign body ( toys, batteries)
    • Gasoline
management nursing care14
Management/Nursing Care
  • Emergency treatment may or may not be necessary
  • Assess victim
  • Terminate exposure
  • Identify poison
  • Call poison control
  • Remove poison/Prevent absorption
    • Syrup of Ipecac
slide72
Do not induce vomiting if patient has absent gag reflex
  • Or if poison is corrosive
  • Place child in side-lying, sitting or kneeling position
  • Administer activated charcoal with cathartic usual dose 1gm/kg
  • Education: PREVENTION is key…
colic
Colic
  • Persistent abdominal pain characterized by loud crying, drawing up legs to abdomen lasting greater than 3 hrs.
  • Common in infants less than 3 months
  • Possible causes
    • Too rapid feeding, excessive air
    • Overeating, milk allergy
    • Parental tension, or smoking
management nursing care15
Management/Nursing Care
  • Try to identify causative agent
  • Medications: Atarax and Simethicone
  • Obtain detailed diet history of baby and mother if breast baby
  • Try to identify relationships to crying episodes
  • Parental coping
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