GI Disorders Final

transcript

Assessment:

GI disorders among children can lead to dehydration especially if vomiting & diarrhea are the presenting symptoms

Assess for poor skin turgor, dry mucous membranes & lack of tearing

Alert: All children with diarrhea must be seen by a health care provider because of rapid change in fluids & electrolyte levels

Greater percentage of fluid held extracellularly rather than intracellularly

Vomiting

forcible ejection of stomach contents through the mouth

Etiology:

InfectionsObstructionsMotion sickness

Metabolic alterationsPsychological alterations

Allergic reactionsSide effects of medications (chemotherapy)

Toxic effects of medicationsEating disorders

Manifestations:

Sour milk curds without green or brown color

Undigested food (stomach)

Diagnostic Evaluation:

CBCElectrolyte studiesBlood Urea Nitrogen (BUN)

Glucose levelsUrine tests

Radiographic studiesBlood culturesArterial blood gas analysis

Assessment:

Major concern:DehydrationFluid & electrolyte imbalance

Accurate monitoring of intake & output

Assess weightFontanels in infants

Skin turgorEyes/skinHeart/respiratory rates

Determine/describe type & force of vomiting (regurgitation, projectile vomiting)

Assess amount, color, consistency, time (ACCT)

Nursing diagnoses:

Fluid volume deficitImbalanced Nutrition: Less than Body Requirements

Interventions:

Position child upright or side lying

Educate family regarding appropriate feeding techniques (eg. Burping)

Educate family (avoiding certain foods) fatty foods

Minimize stimuli ( stress, anxiety)

Avoid unfavorable smelling food

Therapeutic Management:

Oral Rehydration Treatment (ORT)

IV therapy (prolonged vomiting neonates/infants)

Anti-emetics

Dehydration

Fluid loss in excess of fluid intake

Can cause fluid & electrolyte deficiencies

Classification:

Isonatremic dehydration – most common type of dehydration in children

Water & electrolytes are lost the same proportion they exist in the body

Normal serum Na level (135-145 mEq./L)

Hyponatremic dehydration – electrolyte loss greater than water loss

Serum Na less than 130 mEq./L

Hypernatremic dehydration – water loss is greater than the electrolyte loss

Serum Na concentration above 150 mEq./L

Etiology:

GI tract- vomiting, diarrhea, malabsorption

Endocrine system: - fever, DM,

Skin – burnsLungs – tachypneaKidneys - Renal failureHeart - CHF

Neonates/infants – vulnerable to the effects of dehydration

Mild dehydration – 4-5% loss of body weight; fluid volume loss less than 50ml/kg

Moderate dehydration – 6-10% loss of body weight; fluid volume loss 50-100 ml/kg.

Severe dehydration – 10% or more loss of body weight; fluid volume loss of 100 ml/kg or more

Signs & symptoms of Dehydration:

Fewer wet diapers (6-8 hours)

No tears when crying (if older than 2-4 months)

Sticky/dry mouth

Irritability/high pitched cry

Difficulty in awakeningIncreased RR/DOB

Sunken fontanels/sunken eyes with dark circles

Abnormal skin color, temperature or dryness

Signs of impending shock:Changes in heart rateChanges in sensoriumUrine outputSkin qualitiesFontanels (infants)

Pathophysiology:

Reduced fluid intake Increased fluid lossVomiting, diarrhea,

fever, hyperventilation/burnsTrauma, hemorrhage,

Rapid ECF loss

Electrolyte imbalance

ICF Loss

Cellular dysfunction

Hypovolemic shock

Management:

Directed toward correcting the fluid & electrolyte imbalance & then treating the causative factors

Oral rehydration therapy (Rehydralyte, Pedialyte, Infalyte)

Rehydralyte (WHO’s solution) – best source of oral rehydration

Children (mild to moderate dehydration)

50-100 ml/kg of ORT over 4 hours

Parenteral fluid & electrolyte therapy

Lactated Ringer’s solution/0.9% NaCl

Assessment Parameters:

Intake & outputUrine output & Specific gravity

Output < 2-3 ml./kg./hr –infants & toddlers

1-2 ml/kg/hr – preschoolers & young school- age children

0.5 ml./kg/hr in school-age children or adolescents

Specific gravity above 1.020

Weight crucial indicator of fluid status

Stools/vomitusSweatingSkin, Mucous membranes & presence of tears

Anterior fontanelVital signs/behavior

Nursing diagnosis

Fluid volume deficit

Diarrhea

One of the most common disorders in childhood

Increased in the frequency, fluidity & volume of stools

Gastroenteritis – diarrhea caused by infection

Acute diarrhea can lead to dehydration, electrolyte imbalance & hypovolemic shock

Most common viral pathogens - rotavirus & adenovirus

Bacterial pathogens include – Campylobacter jejuni, Salmonella, Giardia lamblia & Clostridium difficile

Mild DiarrheaFever, anorectic, irritable & appear unwell

2-10 loose, watery stools per day

Dry mucous membranes, rapid pulse, warm skin

Normal skin turgor, normal urine output

Management:Rest the GI tract; 1 hour after offer OHT

Ask parents to wash hands after changing diapers

Continue breastfeedingNotify healthcare provider if condition worsens

Severe diarrheaRectal temperature is high (103-104⁰) F

Pulse/RR weak & rapidSkin pale/cool

Depressed fontanelle, sunken eyes, poor skin turgor

Bowel movement every few minutes

Liquid green stool, mixed with mucus & blood

Urine output is scanty & concentrated

Elevated hemoglobin, hematocrit & serum protein levels

Treatment:Focus is centered in regulating electrolyte & fluid balance

Oral or IV rehydration therapy

Rest the GI tract Identifying the responsible organism

All children with severe diarrhea must have a stool culture taken

IV fluids – NSS or 5% glucose in NS

Nursing diagnosis:Fluid volume deficit

Gastrointestinal Disorders

III. Cleft Lip & Cleft PalateFailure of soft tissue or bony structure to fuse during embryonic development

Abnormal openings in the lip or palate that may occur unilaterally or bilaterally

Causes include genetic, environmental factors; exposure to radiation or rubella virus; chromosome abnormalities; & teratogenic factors

Closure of cleft lip defect precedes that of the palate & is formed usually during the first wks of life

Cleft lip o failure of median & maxillary nasal process to fuse by 5 - 8 weeks of pregnancy

common to boysunilateral

Cleft Palate Failure of the palatine shelves to fuse by 9 – 12 weeks of pregnancy

common to girls unilateral or bilateral

III. Cleft Lip & Cleft Palate

Cleft palate repair is performed sometime between 12 to 18 months of age ; a cleft palate is closed before the child develops faulty speech habits

ImplementationAssess fluid & calorie intake daily & monitor weight

Modify feeding techniques; plan to use specialized feeding techniques, obturators, & special nipples & feeders

Hold the child in an upright position & direct the formula to the side & back of the mouth to prevent aspiration; feed small amounts gradually (every 3-5 minutes) & burp frequently (2x in the middle & at the end of feeding)

ImplementationPosition on side after feedingKeep suction equipment & bulb syringe at bedside

Encourage breastfeeding if appropriate

Teach the parents special feeding or suctioning techniques

Teach the parents the ESSR (enlarge, stimulate sucking, swallow, rest) method of feeding

ImplementationTeach the parents the ESSR (enlarge, stimulate sucking, swallow, rest) method of feeding

Encourage the parents to describe their feelings related to the deformity

Implementation Postoperatively Cleft lip repair

A lip protector device may be taped securely to the cheeks

Position the child on the side or on the back; avoid the prone position to prevent rubbing of the surgical site on the mattress

Gastrointestinal DisordersImplementation Postoperatively Cleft lip repair

After feeding, cleanse the suture line of formula or serosanguinous drainage

w/ a cotton-tipped swab dipped in saline; apply antibiotic ointment if prescribed

Implementation Postoperatively Cleft palate repair

Child is allowed to lie on the abdomen

Feedings are resumed by bottle, breast, or cup

Oral packing may be secured to the palate (removed in 2 to 3 days)

Implementation Postoperatively Cleft palate repair

Do not allow the child to brush his or her teeth

Avoid offering hard food items to the child, such as toast or cookies

Implementation Postoperatively Soft elbow or jacket restraints may be used; remove restraints at least every 2 hours to assess skin integrity & allow for exercising the arms

Avoid the use of oral suction or placing objects in the mouth such as tongue depressor thermometer, straws, spoons, forks, or pacifiers

Implementation Postoperatively Monitor for signs of infection at the surgical site, such as redness, swelling, or drainage

Initiate appropriate referrals for speech impairment or language-based learning difficulties

IV. Esophageal Atresia & Tracheoesophageal Fistula

The esophagus terminates before it reaches the stomach &/or a fistula is present that forms an unnatural connection w/ the trachea

An obstruction of the esophagusA fistula occurs between the closed esophagus & trachea

Five usual types of esophageal atresia:

Esophagus ends in a blind pouch-TEF between the distal part of the esophagus & trachea

Esophagus ends in a blind pouch-there is no connection in the trachea

Fistula present between a normal esophagus & trachea

Esophagus ends in a blind pouch-fistula connects the blind pouch of the proximal esophagus to the trachea

Blind end portion of the esophagus-fistulas present between both widely spaced segments of the trachea & esophagus

A fistula can allow milk to enter the trachea causing an aspiration

Must be ruled out in any infant born to a woman with hydramnios

Diagnosis:Barium swallowBronchial endoscopy exam

Treatment: Surgery-closing the fistula &

& anastomosing the esophageal segments

Causes oral intake to enter the lungs or a large amount of air to enter the stomach

IV. Esophageal Atresia & Tracheoesophageal Fistula

Aspiration pneumonia & severe respiratory distress will develop, & death will occur w/out surgical intervention

AssessmentFrothy saliva in the mouth & nose, & drooling

Coughing & choking during feedings

Unexplained cyanosis

Regurgitation & vomitingAbdominal distentionInability to pass a small-gauge (no. 5 French) orogastric feeding tube via the mouth into the stomach

ImplementationSuction accumulated secretions

from the mouth & pharynxA double-lumen catheter is placed

into the upper esophageal pouch & attached to intermittent or continuous low suction to keep the pouch empty secretions

Maintain in an upright position to facilitate drainage

ImplementationA gastrostomy tube may be placed & is left open so that air entering the stomach through the fistula can escape, minimizing the danger of regurgitation

Implementation postoperatively Monitor respiratory statusInspect surgical siteProvide care to the chest tube if in place

Assess for signs of painMonitor for anastomotic leaks as evidenced by purulent chest drainage, increased temperature, & an increased white blood cell count

Implementation postoperatively If a gastrostomy tube is present, it is attached to gravity drainage until the infant can tolerate feedings (usually the 5th to 7th day postoperatively)

Before oral feedings & removal of the chest tube, a barium swallow is performed

Implementation postoperatively Prior to feeding, the gastrostomy tube is elevated to allow gastric secretions to pass to the duodenum & swallowed air to escape through the open gastrostomy tube

The gastrostomy tube may be removed prior to discharge or may be maintained for supplemental feedings at home

Implementation postoperatively Assess cervical esophagostomy site for redness, breakdown, or exudate; remove drainage frequently & apply a protective ointment

If the infant is awaiting esophageal replacement, nonnutritive sucking is provided by a pacifier; may have difficulty eating by mouth after surgery & develop oral hypersensitivity & food aversion

Gastrointestinal DisordersImplementation postoperatively Instruct parents to identify behaviors that indicate the need of suctioning, signs of respiratory distress, & signs of a constricted esophagus (poor feeding, dysphagia, drooling, or regurgitated undigested food)

V. Gastroesophageal Reflux Disease (GERD)

Backflow of gastric contents into the esophagus as a result of relaxation or incompetence of the lower esophageal or cardiac sphincter

Complications include esophagitis, esophageal strictures, aspiration of gastric contents, & aspiration pneumonia

V. Gastroesophageal Reflux (GER)

AssessmentPassive regurgitation or emesisHematemesis & melenaHeartburn (in older children)Anemia from blood loss

ImplementationAssess amount & characteristics of emesis

Assess the relation of vomiting to the times of feedings & infant activity

Monitor breath sounds before & after feedings

Place suction equipment at the bedside

PositioningPlace in either the flat prone position or the head-elevated prone position following feedings & at night

Diet Provide small frequent feedingsFor infants, thicken formula by adding 1 tablespoon of rice cereal per 6 ounces of formula & crosscut the nipple

Breastfeeding may continue, & the mother may provide more frequent feeding times or express milk for thickening w/ rice cereal

Diet Burp the infant frequently when feeding & handle the infant minimally after feedings

For toddlers, feed solids first, followed by liquids

Avoid feeding the child fatty foods, chocolate, tomato products carbonated liquids, fruit juices, citrus products, & spicy foods

Avoid vigorous play after feeding & avoid feeding just before bedtime

MedicationsAntacids & histamine receptor antagonists as prescribed

SurgeryIf surgery is prescribed, it will require a procedure known as fundoplication

A gastrostomy may be performed at the same time as the fundoplication

Fundoplication may be combined w/ pyloroplasty in children w/ GER who also have delayed gastric emptying

Surgery fundoplication

X. Hirschsprung’s DiseaseA congenital anomaly also known as congenital aganglionosis or megacolon

Congenital Aganglionic MegacolonAbsence of ganglion cells in the rectum & upward in the colon

Results in mechanical obstruction May be associated w/ other anomalies, such as Downs syndrome & genital urinary diarrhea

X. Hirschsprung’s Disease

X. Hirschsprung’s DiseaseA rectal biopsy demonstrates histologic evidence

The most serious complication is enterocolitis; signs include fever, GI bleeding & explosive watery diarrhea

X. Hirschsprung’s DiseaseInitially, in the neonatal period, the obstruction is relieved by a temporary colostomy to relieve obstruction & allow the normally innervated, dilated bowel to return to its normal size

A complete surgical repair is performed, when the child weighs approximately 9 kg (20 lbs), via a pull-through procedure

Assessment 1. Newborn infants

Failure to pass meconium stoolRefusal to suckAbdominal distentionBile-stained vomitus

Assessment 2. Children

Abdominal distentionVomitingConstipation alternating w/

diarrheaRibbon-like & foul-smelling stools

Implementation: Medical managementDietary managementDaily rectal irrigations w/ normal saline to promote adequate elimination

Surgical management: preoperative implementationMaintain NPO statusMeasure abdominal girth

Avoid rectal temperaturesMonitor for respiratory distress associated w/ abdominal distention

Implementation postoperativelyMonitor vital signs, avoiding rectal temperatures

Assess surgical site for redness, swelling, & drainage

Assess the stoma for bleeding or skin breakdown

Maintain the NG tube to allow intermittent suction until peristalsis returns

Implementation postoperativelyMaintain the IV until the child tolerates appropriate oral intake; begin the diet w/ clear liquids, advancing to regular as tolerated & as prescribed

Provide the parents w/ instructions regarding colostomy care & skin care

XI. Intussusception Telescoping of one portion of the bowel into another portion

Results in an obstruction

XI. Intussusception

AssessmentColicky abdominal pain that causes the child to scream & draw the knees to the abdomen

Currant jelly-like stools containing blood & mucus

Tender distended abdomen, possibly w/ a palpable sausage-shaped mass in the upper right quadrant

ImplementationMonitor for signs of perforation & shock as evidenced by fever, increased heart rate

Prepare for hydrostatic reduction if prescribed (not performed if signs of perforation of shock occur

Monitor for the passage of normal brown stool, w/c indicates that the intussusception has reduced itself

ImplementationAfter hydrostatic reductionMonitor for the return of normal bowel sounds, for the passage of barium, & the characteristics of stool

XIII. Umbilical hernia, Inguinal hernia, or Hydrocele

A hernia is a protrusion of the bowel through an abnormal opening in the abdominal wall

In children, a hernia most commonly occurs at the umbilicus & through the inguinal canal

Omphalocele – protrusion of abdominal contents through the abdominal wall at the point of the junction of the umbilical cord & abdomen

Incidence: 1 in 5000 live birthsDiagnosis:Prenatally through a sonogramInspection after birth

Management:Immediate surgery to replace the bowel backIf large apply silver sulfadiazine to prevent

infection; followed by delay surgical exposure

A hydrocele is the presence of abdominal fluid in the scrotal sac

Diagnosis: Prenatal sonogramAt birth, scrotum of newborn appears

enlargedIf uncomplicated, fluid will be gradually

reabsorbed in the body; no treatment necessary

Assessment1.Umbilical herniaSoft swelling or protrusion around the umbilicus that is usually reducible w/ the finger

2.Inguinal herniaPainless inguinal swelling that is reducible

Swelling may disappear during periods of rest

Assessment3.Incarcerated herniaWhen the descended portion of bowel becomes tightly caught in the hernial sac compromising blood supply

IrritabilityTenderness at siteAbdominal distentionMay lead to complete intestinal obstruction & gangrene

XVIII. Ingestion of poisonsA. Lead Poisoning

CausesThe pathway for exposure may be food, air, or water

Dust & soil contaminated w/ lead

Poisoning occurs commonly in 2-3 years old age group; all socioeconomic groups

Poisoning can occur from:OTC drugs (vitamins, aspirin, iron

compounds or prescription drugs; antidepressants)

The most common route is ingestion either from hand to mouth behavior from contaminated objects or from eating loose paint chips

It affects the erythrocytes, bones, & teeth, & organs & tissues, including the brain & nervous system

Universal screeningRecommended in high-risk areas at the age of 1 to 2 yrs

Any child between the ages 3 & 6 yrs who has not been screened

Common in toddlers. (falls- common to infant)

Blood lead level (BLL) testBLL less than 10 ug/dl: Reassess or rescreen in 1 year

BLL 10 to 14 ug/dl.: Provide family lead education, follow-up testing, & social service referral

BLL 15 to 19 ug/dL or greater: Provide family lead education, follow-up testing, & social service referral

Blood lead level (BLL) testBLL 70 ug/dL or greater: medical treatment is immediately provided

BLL 20 to 44 ug/dL: A BLL greater than 20 ug/dL is considered acute; clinical management, including treatment, environmental investigation, & lead-hazard control

Principles:Determine substance taken, assess LOC

Unless poison is corrosive, caustic (strong alkali such as LYE) or a hydrocarbon, vomiting is the most effective way to remove poison.

Give syrup of Ipecac to induce vomiting

Ipecac – oral emetic Dose:* 15 ml – adolescent, school age & pre school

* 10 ml to infant

Vomiting will occur within 20 minutes after giving Ipecac

If vomiting did not occur within 20-30 minutes; another dose maybe given

UNIVERSAL ANTIDOTE- activated charcoal either (orally or via NGT),stools appear black, milk of magnesia & burned toast

Never administer charcoal before ipecac

For caustic poisoning ( muriatic acid ) neutralize acid by giving vinegar . Don’t vomit instead prepare tracheostomy set

Gas - mineral oil will coat intestine

XVIII. Ingestion of poisons

B. Acetaminophen (Tylenol)

Description- Seriousness of ingestion is determined by the amount ingested & the length of time before intervention

- Toxic dose is 150 mg/kg or greater in children

AssessmentGI effects: nausea, vomiting & thirst from dehydration

CNS effects: hyperpnea, confusion, tinnitus, convulsions, coma

Hematopoietic effects: bleeding tendencies

ImplementationInduce vomiting w/ syrup of ipecac or perform gastric lavage

Administer activated charcoal to decrease absorption of salicylate

Antidote for Acetaminophen poisoning – Acetylcystine ( Mucomyst)

KwashiorkorDiseased caused by CHON insufficiency

Occurs in children 1-3 years oldGrowth failure – major symptomEdemaMuscle wasting

Irritable & disinterested in environment

Lag in motor development compared to other children at same age group

Zebra sign – hair shafts develop a striped appearance

DiarrheaAnemiaHepatomegalyTreatment: Diet high in CHONFatal if not treatedEven if corrected children fail to reach

their full potential (cognitive,psychological)

MarasmusDeficiency of all food groupsChildren affected –younger than 1 year old

Symptoms:Growth failureMuscle wastingIrritabilityIron-deficiency anemiadiarrhea

Starving – will suck on anything offered to them

Treatment:Supply with diet rich in all nutrients

GI Disorders Final

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