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The Child with Gastrointestinal Dysfunction. Chapter 25 Christine Limann Dyer, RN, MSN, CPN. Gastrointestinal System . Upper portion is responsible for nutrient intake (ingestion) Includes: Mouth Esophagus Stomach. Digestion. Required to convert nutrients into usable energy

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the child with gastrointestinal dysfunction

The Child with Gastrointestinal Dysfunction

Chapter 25

Christine Limann Dyer, RN, MSN, CPN

gastrointestinal system
Gastrointestinal System
  • Upper portion is responsible for nutrient intake (ingestion)
  • Includes:
    • Mouth
    • Esophagus
    • Stomach
digestion
Digestion
  • Required to convert nutrients into usable energy
  • Performs excretory function and detoxification
  • Mechanical digestion
  • Chemical digestion
gastrointestinal system1
Gastrointestinal System
  • Lower portion is responsible for remainder of digestion, absorption & metabolism
  • Includes:
    • Small intestine
    • Large intestine
    • Rectum
    • Anus
absorption
Absorption
  • Principally from small intestine
    • Osmosis
    • Carrier-mediated diffusion
    • Active energy-driven transport (“pump”)
  • Large intestine
    • Absorption of water
    • Absorption of sodium
    • Role of colonic bacteria
gastrointestinal system2
Gastrointestinal System
  • Accessory Structures:
    • Liver
    • Gallbladder
    • Pancreas
ingestion of foreign substances
Ingestion of Foreign Substances
  • Pica
    • Food picas
    • Nonfood picas
  • Foreign bodies
  • Nursing considerations
slide8
Developmental Aspects(each developmental stage contributes to the promotion of the health of the child)
  • Infant:
    • Prevent choking
    • Suck-swallow
    • Frequent feedings
    • Carefully introduce foods about 1 year of age
developmental aspects
Developmental Aspects
  • Toddler:
    • Weight gain (5-6 lbs/year)
    • Deceased caloric needs
    • Food “jags”
developmental aspects1
Developmental Aspects
  • Preschooler:
    • Eats a full range of food
    • Appetite fluctuation
  • School-age:
    • GI tract stable (digestive system is adult sized)
    • Stools well formed
umbilical hernia
Umbilical Hernia
  • Signs & Symptoms:
    • Soft midline swelling in the umbilical area
  • Complications:
    • Incarcerated (strangulated)

Nursing Care:

    • Most resolve spontaneously by 3-5 yrs of age
    • Surgery (pre-post operative care)
    • Discharge instructions
anorectal malformations
Anorectal Malformations
  • Signs & Symptoms:
    • Rectal atresia (closure) and stenosis (constriction or narrowing of a passage)
  • Complications:
    • Depends on the defect and accompanying multisystem involvement
  • Nursing Care:
    • Extensive treatment depending on defect and associated organ involvement
    • Preoperative care (caregiver education & IV fluids)
    • Postoperative care (pain control, s/s of infection, good skin care, NG tube, oral feedings resumed)
    • Discharge instructions
slide15
Hypertrophic Pyloric StenosisConstriction of the pyloric sphincter with obstruction of the gastric outlet
hypertrophic pyloric stenosis
Hypertrophic Pyloric Stenosis
  • Signs & Symptoms:
    • Typically: healthy, male infant: new onset non-bilious vomiting progressing to projectile vomiting
  • Diagnosis:
    • Palpating the pyloric mass (olive-shaped)
  • Nursing Care:
    • Surgery (Ramstedt pyloromyotomy)
    • Assess dehydration, changes is VS, weight loss & discomfort
    • Preoperative care (NPO, NG tube,)
    • Postoperative care ( maintain fluids & electrolyte balance, feedings, infection, keeping the wound clean & pain relief)
    • Discharge instructions (care of incision, s/s infection, response to feedings)
intussusception
Intussusception
  • Telescoping or invagination of one portion of intestine into another
  • Signs & Symptoms:
    • Acute abdominal pain, currant jelly stools, fever, dehydration, abdominal distention, lethargy and grunting due to pain
  • Diagnostic evaluation
  • Therapeutic management
  • Prognosis
  • Nursing considerations
malrotation and volvulus
Malrotation and Volvulus
  • Malrotation is due to abnormal rotation around the superior mesenteric artery during embryonic development
  • Volvulus occurs when intestine is twisted around itself and compromises blood supply to intestines
  • May cause intestinal perforation, peritonitis, necrosis, and death
  • Complications:
    • Shock (signs include; tachycardia, tachypnea, hypotension & cool, clammy or cyanotic skin)
irritable bowel syndrome ibs
Irritable Bowel Syndrome (IBS)
  • Identified as cause of recurrent abdominal pain in children
  • Classified as a functional GI disorder
  • Alternating diarrhea and constipation
  • Therapeutic management
  • Nursing considerations
inflammatory bowel disease ibd
Inflammatory Bowel Disease (IBD)
  • Two types
    • Crohn’sDisese
    • Ulcerative Colitis
ulcerative colitis uc
Ulcerative Colitis (UC)
  • Pathophysiology –inflamation in colon and rectum
  • Clinical manifestations – ulceration, bleeding, anorexia, anemia
crohn s disease
Crohn’s Disease
  • Pathophysiology-Crohn's disease is an inflammatory bowel disease (IBD)
  • Clinical manifestations-abdominal pain, severe diarrhea and even malnutrition
  • Extraintestinal manifestations-arthritis, skin problems, fever, anemia
  • Therapeutic management
    • Medical- corticosteriods,
          • Remicade for remission, 6-MP
    • Surgical
  • Nursing considerations – nutritional support, education
appendicitis
Appendicitis
  • Signs & Symptoms:
    • Earliest symptom; periumbilical pain, vomiting
    • Followed by: right lower quadrant pain (classic sign)
  • Clinical Alert:
    • Children who respond yes to being hungry most likely do not have appendicitis
  • Nursing Care:
    • Surgery
    • Postoperative care (monitor intake & output, wound care, pain control, NPO until peristalsis returns, discharged home in 2-3 days)
    • If perforate appendix intravenous antibiotics are given, NPO with NG tube until bowel function returns
omphalitis
Omphalitis
  • Signs & Symptoms:
    • Redness & edema of the soft tissue
  • Diagnosis:
    • Culture obtained to confirm diagnosis
  • Nursing Care:
    • Prevention by good perinatal care & caregiver education
    • Intravenous broad-spectrum antibiotics
meckel diverticulum
Meckel Diverticulum
  • Most common congenital malformation of the GI tract
  • Band connecting small intestine to umbilicus
  • Signs & Symptoms:
    • Abdominal pain, painless rectal bleeding, stools (bright or dark red with mucus)
  • Complications:
    • If undetected severe anemia & shock can occur
  • Nursing Care:
    • Surgical removal of the diverticulum or pouch
    • Postoperative antibiotics
    • Correct fluid & electrolyte imbalances
    • Monitor for shock & blood loss
    • Provide rest
    • Fluid replacement & NG tube
infantile colic
Infantile Colic
  • Signs & Symptoms:
    • Persistent, unexplained crying – younger than 3 months
    • Episodes occur at the same time each day
  • Diagnosis:
    • Based on symptoms occurring for more than 3 weeks, for 3 days (2-3 hours a day)
  • Nursing Care:
    • Rule out acute conditions
    • Management strategies (see Box 25-1)
acute diarrhea
Acute Diarrhea
  • Signs & Symptoms:
    • Increased frequency & fluid content of the stools with or without associated symptoms
  • Additional Symptoms:
    • Caregiver asked about vomiting, fever, pain, number of wet diapers in previous 24-hours)
  • Nursing Care:
    • Hydration & dietary needs
    • Pharmacology treatment not ordered
    • IV fluids essential with impaired circulation and possible shock
chronic diarrhea
Chronic Diarrhea
  • Signs & Symptoms:
    • Reflective of underlying pathology
    • History of the diarrhea; frequency & appearance
  • Additional Symptoms:
    • Abdominal distention or tenderness, hyperactive bowel sounds, dehydration & condition of the perineal area
  • Nursing Care:
    • Treat the underlying cause
    • Enteral or TPN is provided for the child who is unable to maintain adequate oral intake
    • Caregiver educated on prevention
vomiting
Vomiting
  • Signs & Symptoms:
    • Assessment includes description of onset, duration quality, quantity, appearance, presence of undigested food and precipitating event
  • Additional Symptoms:
    • Fever, diarrhea, ear pain, headache
  • Nursing Care:
    • Treatment of the cause & prevent of complications
    • Bowel is allowed to rest
    • Rehydration
    • Bland solids reintroduced
    • Antiemetic drugs
    • Dehydration, monitor fluid intake & output
    • Oral hygiene
cyclic vomiting syndrome
Cyclic Vomiting Syndrome
  • Signs & Symptoms:
    • Recurrent episodic vomiting, usually lasts 24-48 hours. Vomiting occurs at regular intervals, usually every two to four weeks
  • Diagnosis:
    • Rule out other conditions
  • Nursing Care:
    • Supportive care: fluid replacement, rest, pharmacotherapy & psychiatric evaluation
    • Calm stress-free environment
constipation
Constipation
  • An alteration in the frequency, consistency, or ease of passage of stool
  • May be secondary to other disorders
  • Idiopathic (functional) constipation—no known cause
  • Chronic constipation—may be due to environmental or psychosocial factors
newborn period
Newborn Period
  • First meconium should be passed within 24 to 36 hours of life; if not assess for:
    • Hirschsprung disease, hypothyroidism
    • Meconium plug, meconium ileus (CF)
infancy
Infancy
  • Often related to diet
  • Constipation in exclusively breastfed infant almost unknown
    • Infrequent stool may occur because of minimal residue from digested breast milk
  • Formula-fed infants may develop constipation
  • Interventions

- adding cereals, fruits and vegetables may help

(after 4 months)

constipation in childhood
Constipation in Childhood
  • Often due to environmental changes or control over body functions
  • Encopresis: inappropriate passage of feces, often with soiling
  • May result from stress
  • Management
nursing considerations
Nursing Considerations

History of bowel patterns, medications, diet

Educate parents and child

Dietary modifications (age appropriate)

slide39

Case Study

2 week old Joey is brought into the clinic by his mom because he hasn’t had a bowel movement in two days. He is not eating and has abdominal distention. She states that he didn’t pass meconium until the day after his birth.

1. Describe the structural anomaly associated with Hirshbrung’s disease.

2. How is Hirshbrung’s diagnosed?

3. List 2 actual NANDA and 1 risk

4. If Joey is diagnosed with Hirsbrung’s Disease, what is the likely surgical intervention?

5. What are possible complications for an older child?

hirschsprung disease
Hirschsprung Disease
  • Also called congenital aganglionic megacolon
  • Mechanical obstruction from inadequate motility of intestine
  • Incidence: 1 in 5000 live births; more common in males and in Down syndrome
  • Absence of ganglion cells in colon
hirschsprung disease1
Hirschsprung Disease
  • Signs & Symptoms:
    • Failure to pass meconium within the first 48 hours of life, failure to thrive, poor feeding, chronic constipation, & Down syndrome
  • Complications:
    • Entercolitis is the most ominous presentation (abrupt onset o foul smelling diarrhea, abdominal distention & fever. Rapid progress may indicate perforation & sepsis
  • Nursing Care:
    • Surgical resection (colostomy)
    • Preoperative care (fluid & electrolyte status, NPO, NG tube, IV fluids)
    • Postoperative care (maintain NG tube, monitor for abdominal distension, assess for bowel sounds)
    • Teach caregiver how to car for colostomy, s/s of complications)
clinical manifestations of hirschprung disease
Clinical Manifestations of Hirschprung Disease
  • Aganglionic segment usually includes the rectum and proximal colon
  • Accumulation of stool with distention
  • Failure of internal anal sphincter to relax
  • Enterocolitis may occur
diagnostic evaluation
Diagnostic Evaluation
  • X-ray, barium enema
  • Anorectal manometric exam
  • Confirm diagnosis with rectal biopsy
therapeutic management
Therapeutic Management
  • Surgery
  • Two stages
    • Temporary ostomy
    • Second stage “pull-through” procedure

Preoperative care

Postoperative care

Discharge care

gastroesophageal reflux ger
Gastroesophageal Reflux (GER)
  • Defined as transfer of gastric contents into the esophagus
  • Occurs in everyone
  • Frequency and persistency may make it abnormal
  • May occur without GERD
  • GERD may occur without regurgitation
slide46
GER
  • Diagnostics
  • Therapeutic management
  • Nursing considerations
lactose intolerance
Lactose Intolerance
  • Signs & Symptoms:
    • Bloating, cramping, abdominal pain & flatulence
  • Diagnosis:
    • Based on history/physical & decrease in symptoms with elimination of lactose from the diet
  • Nursing Care:
    • Elimination of dairy products or the use of enzyme replacement
    • Dietary education (alternative sources of calcium)
celiac disease
Celiac Disease
  • Also called gluten-induced enteropathy and celiac sprue
  • Four characteristics
    • Steatorrhea-fatty stool
    • General malnutrition
    • Abdominal distention
    • Secondary vitamin deficiencies
celiac disease cont
Celiac Disease (cont.)
  • Pathophysiology
  • Diagnostic evaluation
  • Therapeutic management
  • Nursing considerations
short bowel syndrome sbs
Short Bowel Syndrome (SBS)
  • A malabsorptive disorder
  • Results from decreased mucosal surface area, usually as result of small bowel resection
  • Etiology and pathophysiology
  • Result of decreased mucosal surface area, usually due to extensive resection of small intestine
  • Other causes
    • NEC, volvulus, gastroschisis, Crohn disease in
therapeutic management of sbs
Therapeutic Management of SBS
  • Nutritional support—first phase: TPN
    • Associated risks and complications
  • Second phase: enteral feeding

Long-term maintenance

  • Medical therapies
  • Surgical therapies
  • Nursing Care:
    • Feeding tolerance
    • Emotional & developmental needs
    • Assist parents with coping
    • Home care services
biliary atresia or extrahepatic biliary atresia ehba
Biliary atresia, or extrahepatic biliary atresia (EHBA)
  • Signs & Symptoms:
    • Jaundice, dark urine, lighter (tan-white) than normal stools, poor weight gain, failure to thrive, pruritus, hepatomegaly, splenomegaly
  • Diagnosis:
    • Early diagnosis in the key to survival.
  • Nursing Care:
    • Primarily supportive & focuses on providing nutritional support
    • Surgical resection: correct obstruction & provide drainage of bile from the liver into the intestines
    • Preoperative care (educate family & long term care)
    • Postoperative care (educate family on skin & stoma care, nutritional therapy, complications, psychological support)
    • Potential transplant
cirrhosis
Cirrhosis
  • Signs & Symptoms:
    • Vary depending on the cause
    • Jaundice, growth failure, muscle weakness, anorexia & lethargy
  • Diagnosis:
    • Based on history, laboratory values & liver biopsy
  • Nursing Care:
    • Preventing & treating complications
    • Nutritional support
    • Liver transplant
    • Monitor for complications
    • Comfort measures & emotional support
hepatitis
Hepatitis
  • Signs & Symptoms :
    • Headache, anorexia, malaise, abdominal pain, nausea & vomiting
  • Diagnosis:
    • Based on history of exposure, symptoms & serologic testing
  • Nursing Care:
    • Primarily supportive: no specific treatment
    • Provide rest to the liver, hydration, maintain comfort, adequate nutrition, & prevent complications
    • Immune globulin given to children who have been exposed to a person with HAV
    • Vaccine available for HAV, HBV & HDV
    • Educate family regarding prevention measures (see Critical Nursing Actions Prevention of Hepatitis A and Hepatitis B)
abdominal trauma injuries
Abdominal Trauma: Injuries
  • Injuries are the leading cause of death in children
  • Ten percent of serious trauma occurs as a result of abdominal & genitourinary injury
  • See Table 25-5 Injuries Caused by Abdominal Trauma
dehydration
Dehydration
  • Types of dehydration
  • Diagnostic evaluation
  • Therapeutic management
  • Nursing considerations
  • 1st treatment- Oral hydration Solution-OHS
daily maintenance fluid requirements
Daily Maintenance Fluid Requirements
  • Calculate child’s weight in kg
    • Allow 100 ml/kg for first 10 kg body weight
    • Allow 50 ml/kg for second 10 kg body weight
    • Allow 20 ml/kg for remaining body weight
example 1 daily fluid calculation
Example 1: Daily Fluid Calculation
  • Child weighs 32 kg
    • 100 x 10 for first 10 kg of body weight = 1000
    • 50 x 10 for second 10 kg of body weight = 500
    • 20 x 12 for remaining body weight = 240
    • 1000 + 500 + 240 = 1740 ml/24 hr
example 2 daily fluid calculation
Example 2: Daily Fluid Calculation
  • Child weighs 8.5 kg
    • 100 x 8.5 for first 10 kg of body weight = 850
    • No further calculations
    • 850 ml/24 hr
example 3 daily fluid calculation
Example 3: Daily Fluid Calculation
  • Child weighs 14 kg
    • 100 x 10 for first 10 kg of body weight = 1000
    • 50 x 4 for second 10 kg of body weight = 200
    • No further calculations
    • 1000 + 200 = 1200 ml/24 hr
homemade electrolyte solution
Homemade Electrolyte Solution
  • 2 quarts water
  • 1 teaspoon baking soda
  • 1 teaspoon salt
  • 7 Tablespoons sugar
  • 1/2 teaspoon salt substitute