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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

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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


Pediatric gi

  • 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


Pediatric gi

  • 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


Pediatric gi

  • 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


Pediatric gi

  • 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


Pediatric gi

  • 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


Pediatric gi

  • Place on R side/Semi-Fowler’s after feeding

  • Burp frequently


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


Pediatric gi

  • 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


Pediatric gi

  • 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


Pediatric gi

  • 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


Pediatric gi

  • 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


Pediatric gi

  • 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,


Pediatric gi

  • 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)


Pediatric gi

  • 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


Pediatric gi

  • 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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