Ch 24 The Child with Gastrointestinal Dysfunction Laura Salisbury RN, MSN/Ed.
Clinical Manifestations of GI Dysfunction • Failure to thrive • Spitting up / Regurgitation • Nausea, vomiting, diarrhea, constipation • Abdominal Pain, Distention, GI bleeding • Jaundice • Dysphagia • Hypoactive, hyperactive or absent bowel sounds
Dehydration • Types of dehydration • Isotonic: most common, water and salt both lost, signs of hypovolemic shock are seen • Hypotonic: More electrolytes lost than water; signs are seen with less severe losses • Hypertonic: More water lost than electrolytes: MOST DANGEROUS • Seen if infants are given fluids w/too much solute • Seen w/high-protein NG tube feedings—too much solute in kidneys • Shock less apparent; neuro signs seen • Diagnostic evaluation: KNOW table 24-1, p. 816
Daily Maintenance Fluid Requirements • 1. Calculate weight in kilograms • Wt of child in pounds/ 2.2 kg = wt in kg • 2. Allow 100 mL for first 10 kg • 3. Allow 50 mL for second 10 kg • 4. Allow 20 mL for all remaining kg • 5. Divide total amount by 24 hours to obtain rate of fluid replacement in mL per hour • Pg 815
Diarrhea • Often classified by location • Gastroenteritis, Enteritis, Colitis, Enterocolitis • Types of Diarrhea • Acute • Acute infectious/infectious gastroenteritis • Most typical, Usually subsides on its own • Can be from antibiotic administration/c. difficile • Chronic • More than 14 days • Can be chronic condition OR inadequately treated acute diarrhea • Intractable diarrhea of infancy • Usually infectious diarrhea not managed adequately • Chronic nonspecific diarrhea (CNSD)
Diarrhea • Diagnostic evaluations • Therapeutic management • Assess fluids and electrolytes • Rehydrate • Oral Rehydration Solution (ORS)=Pedialyte • Give maintenance fluid • Breastfeed, water, ½ strength formula, ORS • Reintroduce diet • Regular diet • NO BRAT diet • Nursing considerations • SEVERE dehydration: IV fluids first
Prevention of Diarrhea • Most diarrhea is spread by the fecal-oral route • Teach personal hygiene • Clean water supply/protect from contamination • Careful food preparation • Handwashing
Constipation • An alteration in frequency/consistency/ease of passage of stool • Idiopathic (functional) constipation/Chronic constipation • Majority of cases - Could be environment, psychology, or both • Newborn Period • First meconium should be passed within 24-36 hrs of life • Meconium ileus=cystic fibrosis • Infancy • Constipation in exclusively breastfed infant almost unknown • Infrequent stool may occur from minimal residue in digested breastmilk • Formula fed infants may develop constipation • Small amount of corn syrup may solve problem
Constipation • 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 • History of bowel patterns, medications, diet • Educate parents and child • Dietary modifications (age appropriate)
Hirschsprung Disease • AKA congenital aganglionicmegacolon • Mechanical obstruction from inadequate motility of intestine • More common in males and in Down syndrome • Clinical Manifestations of Hirschprung • Accumulation of stool with distention • Diagnostic Evaluation • X-ray, barium enema, Confirm diagnosis with rectal biopsy • Therapeutic Management • Surgery
Hirschsprung Disease • Nursing Considerations • Pre-operative care • Watch abdominal distention, Education re: colostomy • Postoperative care • Be careful about contamination of wound with urine • Discharge care • Colostomy care instructions • Small children -involved in care • Adolescents may feel more stressed r/t image of colostomy
Vomiting • Therapeutic management • Detect and treat cause • Prevent complications from loss of fluids • Nursing considerations • Start w/small amounts fluid • Include carbohydrates • IV fluid for severe dehydration • When vomiting stops: give more fluids and resume normal diet
Gastroesophageal Reflux • Definition: GER and GERD • KNOW box 24-6, p 827; clinical manifestations and complications of GER • Diagnostics • Monitor esophageal pH for 24 hours • Therapeutic management • Depends on severity • Thicken feedings for infants • Take foods out of diet that exacerbate reflux • Upright/elevated position after feedings • Meds as need (H2 antagonists, Proton pump inhibitors) • Surgery for most severe: Nissenfundiplication
Functional Abdominal Pain • Includes irritable bowel syndrome, abdominal migraine • Episodes of severe abdominal pain • Multifactorial etiology • Management: alleviate symptoms • May need to use tricyclic antidepressants, SSRI’s, sometimes smooth muscle relaxant, fiber for IBS, anti-migraine for abdominal migraines, manage diet • VALIDATE SYMPTOMS • Pain is real!
Acute Appendicitis • Etiology and pathophysiology • Obstruction of lumen of appendix—leads to infection • Diagnostic evaluation • Difficult to diagnosis • KNOW box 24-7, p 830: symptoms • Watch for sudden relief from pain (possible perforation) • Therapeutic management • Appendectomy; laparoscopic if not ruptured • Nursing considerations • If suspected appy: no laxative/enema or heat to area (do not want to stimulate bowel motility)
MeckelDiverticulum • It is the most common congenital malformation of the GI tract • Diagnostic evaluation • Complications=bleeding, obstruction, intussusceptions, diverticulitis, perforation • Most common presentation: painless rectal bleeding, abdominal pain (KNOW box 24-8, p 833) • Therapeutic management=surgery • Nursing considerations • Watch for shock from hemorrhage
Inflammatory Bowel Disease IBD • Includes ulcerative colitis (UC) and Crohn’s disease (CD) • KNOW the following • Clinical manifestations: TABLE 24-3, p 833 • For pediatrics: Growth problems major issue; want to promote growth and development
Acute Hepatitis • ONLY need to know table 24-4 • Types of hepatitis • How transmitted • Clinical features • How immunized
BiliaryAtresia • AKA extrahepaticbiliaryatresia --Destruction of biliary tree • Etiology and pathophysiology • Postnatal: happens early in life • Fetal: before birth • Diagnostic evaluation • KNOW box 24-10 p. 842- Jaundice, urine, stool, liver, spleen, metabolism, failure to thrive, pruritus, irritability • Therapeutic management • Kasai procedure: “band-aid”; cirrhosis will still occur • Most will need liver transplant • Can come from parents • Prognosis • Death before age two if not treated • Liver failure even post-Kasai • Early diagnosis key for survival
Cleft Lip- Cleft Palate • Facial malformations that occur during embryonic development • May appear separately or together
Cleft Lip / Cleft Palate • Surgical Correction of Cleft Lip • Closure of lip defect precedes correction of the palate • Z-plasty to minimize retraction of scar • Protect suture line with Logan bow or other methods • Arm restraints: take off periodically • Surgical Correction of Cleft Palate • Typically 12-18 months of age • Want to minimize effect on speech development • Prognosis • Usually good, speech may still be affected • May have recurrent OM • MANAGE AIRWAY!!!
Cleft Lip / Cleft Palate • Cleft Lip and Palate Feeding • Techniques and interventions: ESSR • Enlarge nipple • Stimulate suck reflex • Swallow fluid • Rest when infant signals • Special feeding equipment • Breck feeder • Breastfeeding issues • Infants with CL/CP CAN BREASTFEED!
EsophagelAtresiaTracheoesophageal Fistula • Failure of esophagus to develop as a continuous passage • May occur separately or in combination • If suspected: infant NPO, suction setup nearby • “3 C’s”: Coughing, Choking, Cyanosis • (AIRWAY!!!) • Management of TEF • Surgical interventions • Prognosis: depends on extent of defects • Associated tracheomalacia (weakness in tracheal wall) • Nursing considerations: • Keep infant from losing suck reflex
Hernias • Definition: a protrusion of portion of an organ through an abnormal opening • Danger of incarceration/strangulation • Pediatric Hernias • Diaphragmatic • Hiatal • Umbilical/abdominal wall defects • Omphalocele • Gastrochisis • KNOW table 24-5, p 850
Pyloric Stenosis • Constriction of pyloric sphincter with obstruction of gastric outlet • Clinical Manifestations • Projectile vomiting, Chronic Hunger, weight loss, dehydration, abdominal distention • Surgical intervention is required • Preoperative: fix fluid/electrolyte imbalances • Postoperative: Vomiting, dehydration, maintain fluid and electrolyte balance
Intussusception • Telescoping/ invagination of one part of intestine into another • Occasionally due to intestinal lesions • Often cause is unknown • Clinical Manifestations • Sudden acute abdominal pain • Child screaming and drawing knees to chest • Child appears normal and comfortable between episodes of pain • Vomiting • Lethargy • Passage of RED, currant jelly like stool (mixed with blood and mucus) • Sudden passage of normal stool: intussusception has spontaneously resolved!
Malrotation and Volvulus • Malrotation is due to abnormal rotation around the superior mesenteric artery during embryonic development • Volvulusoccurs when intestine is twisted around itself and compromises blood supply to intestines • May cause intestinal perforation, peritonitis, necrosis, and death • Anorectal Malformations • Imperforate anus • Persistent cloaca • Cloacalexstrophy
Malabsorption Syndromes • Characterized by chronic diarrhea and malabsorption of nutrients • May result in failure to thrive • Digestive defects • Absorptive defects • Anatomic defects
Celiac Disease • AKA gluten-induced enteropathy and celiac sprue • Four characteristics • Steatorrhea • General malnutrition • Abdominal distention • Secondary vitamin deficiencies • Gluten-free diet • Family support
Short Bowel Syndrome • A malabsorptive disorder • Decreased surface area in small intestine • Need to maintain growth • May need long-term TPN • Watch for bacterial overgrowth • Intestinal transplantation may be possible