Gastrointestinal Disorders Jan Bazner-Chandler CPNP, CNS, MSN, RN
Embryonic Development • Failure to fuse = cleft lip and palate • Failure to differentiate = duodenal stenosis • Atresia or abnormal closing of structure: • Esophogeal atresia • Anal-rectal malformation • Biliary atresia
Fetal Development • Fistula is an abnormal connection • Tracheal esophageal fistula • Anal-rectal malformations with fistula • Incomplete or abnormal placement • Mal-rotation • Diaphragmatic hernia
Prenatal History • Birth weight • Prematurity • History of maternal infection • Polyhydramnios • Down Syndrome
Health History • Congenital anomalies • Growth or feeding problems • Travel • Economic status • Food preparation • General hygiene • Family history of allergies
Present Illness • Onset and duration of symptoms • Weight loss or gain • Recent changes in diet
Vomiting • Reflexive = infection or allergy • Central = central nervous system • head trauma • meningitis • CNS tumor
Nursing Assessment • Abdominal distention • Abdominal circumference • Abdominal pain • Acute / diffuse / localized • Abdominal assessment • Inspect / auscultation / palpation / measure
Measuring Abdominal Girth Bowden Text
Diagnostic Tests • Flat plate of abdomen • Fluid • Gas • Structural changes • Barium swallow or UGI • Strictures • Foreign body • Motility disorder
Diagnostic Tests • Ultrasound • Visualize organs • Cysts • Abscess • appendicitis • CT scan = tumors, abscess, obstruction • 24 hour probe = Gastro esophogeal reflux • Biopsy of liver, esophagus, stomach, intestine
Stool and Blood • White blood cells • Ova and Parasite • Bacterial cultures • Blood
Failure to Thrive Inadequate growth resulting from inability to obtain or use calories required for growth.
FTT • Organic • Physical cause identified: heart defect, GER, renal insufficiency, malabsorption, endocrine disease, cystic fibrosis, AIDS. • Non-organic • Inadequate intake of calories • Disturbed mother-infant bonding • Idiopathic: unexplained
Cleft Lip and Palate • Most common craniofacial anomaly • 1 in 700 births • Males 3 to 1 • Higher in Asians • Familial history • Often diagnosed in utero by ultrasound
Cleft Lip Incomplete fusion of the primitive oral cavity • Obvious at birth • Infant may have problems with sucking • Surgery in 2 to 3 months • Goals of surgery • Close the defect • Symmetrical appearance of face
Cleft Lip Plasticsurgery.org
Cleft Lip Plasticsurgery.org
Post Surgery Care • Airway management • Pain control • Position in infant seat – upright position • Elbow restraints • Wound care as ordered by MD • Minimizing crying • Feeding techniques
Cleft Palate Cleft palate occurs when the palatine plates fail to migrate and fuse between the 7th and 12th week of gestation. Diagnosed by looking into infants mouth.
Cleft Palate Pedisurg.com
Cleft Palate Pedisurg.com
Cleft Palate Repair • Babies should be weaned from bottle or breast prior to the surgical procedure. • Done around 1 year of age after teeth have erupted and before the child is talking to promote better speech outcomes • Poor speech outcomes if done after 3 years of age.
Palate Repair • Pre-surgery feeding • Alternate nipple design • Breast feeding consultant • ESSR • Enlarge / stimulate / swallow / rest
ESSR TIP 18-2: Bowden Text
Devices For Feeding • Lamb’s nipple • Flanged nipple • Special nurser • Syringe with rubber tubing Whaley & Wong
Post Surgery Repair • Position on side • NPO for 48 hours • Suction with bulb syringe only • Avoid injury to palate with syringes, straws, cups etc.
Long Term Referrals • Hearing • Speech • Dental • Psychological • Team approach to care
Esophagus ends in a blind pouch. Infant has a lot of mucous at birth. The rationale for giving sterile water for the first feed. Esophageal Atresia Bowden Text
E.A. Tracheo- esophageal Fistula 85 to 90% of defects Failure of the esophagus to recanalize between 4th and 6th week of development. Bowden Text
Clinical Manifestations • Excessive drooling / frothy mucus • Inability to pass NG tube • Choking and cyanosis with feeding • High risk for aspiration of HCL from stomach causing a chemical pneumonia.
Pre-surgery Care • NPO • Up in infant seat or HOB elevated • Continuous suction • G-tube to decompress stomach
Post Surgery Care Ball & Bindler
Post Operative Care • Respiratory support • Gastric decompression • Chest Tube • Gentle suctioning • TPN until taking PO’s • Antibiotics
Long Term Complications • 5 to 15% experience leaking at operative site. • Aspiration • Dysphagia / difficulty swallowing • Stricture of esophagus • Coughing • Regurgitation
Pyloric Stenosis Most common cause of gastric outlet obstruction in infants. • 1 in 500 • More common in males • 3 weeks to 2 months of age • History of regurgitation and non-bilious vomiting shortly after feeding. • Vomiting becomes projectile
Pyloric Stenosis Ball & Bindler
Clinical Manifestations • Projectile vomiting • Visible peristaltic waves • Olive shape mass in the upper abdomen to right of the midline • Electrolyte imbalance
Management Pre-surgery • NPO / document any emesis • IV therapy / Correct electrolyte imbalance • Comfort infant and caretakers
Feeding Post-operatively • Give 10 ml oral electrolyte solution after recovered from anesthesia • Start pyloric re-feeding protocol. • Increase feeding volumes from clear fluids to dilute to full-strength formula. • Keep feeding record • Assess for vomiting • Discharged when taking full-strength formula
Hernias • A hernia is a protrusion of an organ or part of an organ through the wall of the cavity in which it is contained.
Inguinal Hernia Bowden & Greenberg
Inguinal Hernia • Inguinal hernia is the most common congenital anomaly requiring surgical repair in infants: 80% • It is a protrusion of peritoneal sac into the processus vaginalis • Most common in males and pre-term infants.
Hydrocele Bowden & Greenberg
Hydrocele • Caused by peritoneal fluid communication with the scrotal area through a patent processus vaginalis. • Often will resolve on its own unless associated with an inguinal hernia.
Umbilical Hernia More common in African American infants.