Nursing Care of the Child Nursing Care of the Child with Gastrointestinal with Gastrointestinal

DisordersDisordersAnn Hearn RNC, MSNAnn Hearn RNC, MSN

Spring 2009Spring 2009

Cleft Lip and Cleft PalateCleft Lip and Cleft Palate

Etiology- Failure of maxillary and Etiology- Failure of maxillary and median nasal processes to fuse median nasal processes to fuse during embryonic developmentduring embryonic development

Remember the psycho-social Remember the psycho-social implications for these children and implications for these children and

families families

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AssessmentAssessment

Unilateral, bilateral, midlineUnilateral, bilateral, midline

TreatmentTreatment

Surgical repair done ASAPSurgical repair done ASAP Rule of 10 > 10#, 10 weeks, 10 HGBRule of 10 > 10#, 10 weeks, 10 HGB Multidisciplinary teamMultidisciplinary team

Pre-op GoalsPre-op Goals

Prevent aspiration / Maintain Prevent aspiration / Maintain nutrition nutrition

Provide emotional support to familyProvide emotional support to family

Prevent Aspiration / Maintain Prevent Aspiration / Maintain NutritionNutrition

Breast feed – small cleft lipBreast feed – small cleft lip Bottle feed – special feeding devisesBottle feed – special feeding devises

– Special nipplesSpecial nipples– Enlarge cross cut holeEnlarge cross cut hole

Bubble frequentlyBubble frequently Hold uprightHold upright ESSRESSR

Provide Emotional SupportProvide Emotional Support

Assist with accepting of defectAssist with accepting of defect Teach proper feedingTeach proper feeding Point out positive attributesPoint out positive attributes Encourage participation in careEncourage participation in care Explain surgical procedureExplain surgical procedure

Pre-op TeachingPre-op Teaching

Remind parents that defect is Remind parents that defect is operable- show photographs of operable- show photographs of corrected cleftscorrected clefts

Introduce cup, spoon feeding devices Introduce cup, spoon feeding devices Explain elbow restraints Explain elbow restraints Explain Logan Bow Explain Logan Bow

Post-OpPost-Op

Prevent trauma to suture linePrevent trauma to suture line– Reduce pain & infectionReduce pain & infection

Cleanse suture lines as orderedCleanse suture lines as ordered Facilitate breathingFacilitate breathing Maintain nutritionMaintain nutrition Referral to appropriate team Referral to appropriate team

membersmembers

Esophageal AtresiaEsophageal Atresia

Failure of the esophagus to totally Failure of the esophagus to totally differentiate during uterine differentiate during uterine development.development.

Assessment FindingsAssessment Findings

Respiratory difficultiesRespiratory difficulties Drooling Drooling Coughing, choking, cyanosisCoughing, choking, cyanosis Gastric distention - if fistula presentGastric distention - if fistula present Hx of ??? during pregnancy?Hx of ??? during pregnancy?

– PolyhydramniosPolyhydramnios gastrointestinal obstructiongastrointestinal obstruction fetus unable to swallowfetus unable to swallow

Management Management

Early diagnosisEarly diagnosisUltra soundUltra sound

Radiopaque catheter inserted in the Radiopaque catheter inserted in the esophagus to illuminate defect on X-rayesophagus to illuminate defect on X-ray

Surgical repair- thoracotomy and Surgical repair- thoracotomy and anastomosisanastomosis

Pre-Op Nursing PriorityPre-Op Nursing Priority

Maintain airway Maintain airway Prevent aspiration pneumoniaPrevent aspiration pneumonia Keep NPO- administer IV fluidsKeep NPO- administer IV fluids

– Elevate HOB 30 degreesElevate HOB 30 degrees– Suction PRNSuction PRN– Prophylactic antibioticsProphylactic antibiotics

Post-OpPost-Op

Maintain nutritionMaintain nutrition– TPNTPN– GastrostomyGastrostomy

Maintain airwayMaintain airway– Prevent aspirationPrevent aspiration

Monitor weigh, growth and development Monitor weigh, growth and development achievementsachievements

ComplicationsComplications– GERSGERS– Stricture formationStricture formation

Teaching Plan: Gastrostomy Teaching Plan: Gastrostomy TubeTube

EquipmentEquipment ProcedureProcedure Psychosocial needsPsychosocial needs Medication administrationMedication administration Stoma careStoma care Problem solvingProblem solving

Gastroesophagial Reflux Gastroesophagial Reflux DiseaseDisease(GERD)(GERD)

The cardiac sphincter and lower The cardiac sphincter and lower portion of the esophagus are weak, portion of the esophagus are weak, allowing regurgitation of gastric allowing regurgitation of gastric contents back into the esophagus.contents back into the esophagus.

Assessment findings: InfantAssessment findings: Infant

Regurgitation almost immediately Regurgitation almost immediately after each feeding when the infant is after each feeding when the infant is laid downlaid down

Excessive crying, irritability Excessive crying, irritability Failure to thrive (FTH)Failure to thrive (FTH) Complications:Complications:

– aspiration pneumoniaaspiration pneumonia– apneaapnea

Assessment findings: ChildAssessment findings: Child

HeartburnHeartburn Abdominal painAbdominal pain Cough, recurrent pneumoniaCough, recurrent pneumonia DysphagiaDysphagia

DiagnosisDiagnosis

Assess Ph of secretions in esophagus Assess Ph of secretions in esophagus if <7.0 indicates presence of acidif <7.0 indicates presence of acid

Barium Swallow and visualization of Barium Swallow and visualization of esophageal abnormalities esophageal abnormalities

Management & Nursing Management & Nursing CareCare

Nutritional needsNutritional needs– Small frequent feedingsSmall frequent feedings– Frequent burpingFrequent burping

PositioningPositioning– Prone flat or head elevated after Prone flat or head elevated after

feedings (not for sleep) feedings (not for sleep) Medications Medications CPR instruction for parents/caregiversCPR instruction for parents/caregivers Surgery: Nissen fundoplicationSurgery: Nissen fundoplication

Post Op Nursing CarePost Op Nursing Care

FeedingsFeedings BubblingBubbling PositioningPositioning AirwayAirway MedicationsMedications

Medications H2 Histamine receptor antagonists – reduce gastric acidity H2 Histamine receptor antagonists – reduce gastric acidity

– Zantac and Pepcid Zantac and Pepcid Proton-pump inhibitorsProton-pump inhibitors

– PrevacidPrevacid– PrilosecPrilosec

Gastric emptying Gastric emptying – ReglanReglan

Antacids Antacids – GavisconGaviscon

**be sure to study nursing implications and side effects**be sure to study nursing implications and side effects

Pyloric StenosisPyloric Stenosis

Results when the circular area of the Results when the circular area of the muscle surrounding the pylorus muscle surrounding the pylorus hypertrophies & obstructs gastric hypertrophies & obstructs gastric emptying.emptying.– Incidence: 3 in 1000 birthsIncidence: 3 in 1000 births– Possible genetic predispositionPossible genetic predisposition

Pyloric Stenosis

Narrowing of the Narrowing of the pyloric spincterpyloric spincter

Delayed emptying of Delayed emptying of the stomachthe stomach

AssessmentAssessment

Vomiting - projectileVomiting - projectile Constant hunger and fussinessConstant hunger and fussiness Distended upper abdomenDistended upper abdomen Hypertrophied pylorus – olive shaped Hypertrophied pylorus – olive shaped

massmass Visible peristaltic wavesVisible peristaltic waves

DiagnosisDiagnosis

History and PhysicalHistory and Physical Laboratory valuesLaboratory values X-ray or UltrasoundX-ray or Ultrasound

Management and Management and Nursing CareNursing Care

FredFred Ramstedt procedure- Ramstedt procedure- Pyloromyotomy via Pyloromyotomy via laproscopylaproscopy

Pre-OpPre-Op

Hydration and electrolyte balanceHydration and electrolyte balance Weigh daily & I and OWeigh daily & I and O NG tubeNG tube Support of parentsSupport of parents

Management and Nursing Management and Nursing Care: Post-OpCare: Post-Op

NPO until bowel functionNPO until bowel function– Progressive feeds: Feeding begins with clear Progressive feeds: Feeding begins with clear

liquids containing glucose and electrolytes. liquids containing glucose and electrolytes. Regime example: 8 hours NPO, 10cc sterile water Regime example: 8 hours NPO, 10cc sterile water feed X 2. Increase to 15cc X 2, progressing to ½ feed X 2. Increase to 15cc X 2, progressing to ½ strength formula, then full strength formula. strength formula, then full strength formula. Observe and record the infant’s response to Observe and record the infant’s response to feeding.feeding.

Position with head elevatedPosition with head elevated Assess surgical site for infection - AntibioticsAssess surgical site for infection - Antibiotics AnalgesiaAnalgesia Patient teachingPatient teaching

Critical ThinkingCritical Thinking

A 4 week old infant with a history of A 4 week old infant with a history of vomiting after feeding has been vomiting after feeding has been hospitalized with a tentative diagnosis of hospitalized with a tentative diagnosis of pyloric stenosis. Which of these actions is pyloric stenosis. Which of these actions is priority for the nurse?priority for the nurse?a. Begin an intravenous infusiona. Begin an intravenous infusion

b. Measure abdominal circumferenceb. Measure abdominal circumference

c. Orient family to unit c. Orient family to unit

d. Weigh infantd. Weigh infant

Gastroschisis Gastroschisis

OmphaloceleOmphalocele

Abdominal Wall DefectsAbdominal Wall Defects

Gastroschisis

herniation of abdominal viscera herniation of abdominal viscera outside the abdominal cavity through outside the abdominal cavity through a defect in the abdominal wall to the a defect in the abdominal wall to the side of the umbilicus. Not coveredside of the umbilicus. Not covered. .

Treatment and Nursing Care Pre-operatively – focus is on protection of Pre-operatively – focus is on protection of

the contents / sac. Cover with warm, the contents / sac. Cover with warm, sterile, saline-soaked dressings over the sterile, saline-soaked dressings over the defect. defect.

May choose to replace the gut to the May choose to replace the gut to the abdomen gradually over several weeks. abdomen gradually over several weeks. May place silo or silastic material over gut May place silo or silastic material over gut until it returns to the abdomen. until it returns to the abdomen.

Surgery used to close defect.  Surgery used to close defect.  

GastroschisisGastroschisis

Assessment- noted on ultrasound Assessment- noted on ultrasound and and obvious at birthobvious at birth

Treatment- surgical repair in stagesTreatment- surgical repair in stages Nursing care-Nursing care-

– support parents loss of support parents loss of “Perfect Child”“Perfect Child”– assess for ileusassess for ileus– maintain parenteral feedingmaintain parenteral feeding

Omphalocele

Herniation of abdominal contents through the umbilical cord. Contents are covered

by a translucent sac.

OmphaloceleOmphalocele

Assessment- ultrasound and at birthAssessment- ultrasound and at birth

Treatment- surgical repair in stagesTreatment- surgical repair in stages

Nursing care- same as for Nursing care- same as for GastroschisisGastroschisis

IntussuceptionIntussuception

Invagination of a section of the Invagination of a section of the intestine, into the distal bowel that intestine, into the distal bowel that causes bowel obstruction. causes bowel obstruction. – Usually the terminal ileum telescopes Usually the terminal ileum telescopes

into the ascending colon through the into the ascending colon through the ileocecal valve.ileocecal valve.

Inflamed bowel & bleedingInflamed bowel & bleeding– Leading to necrosis & perforationLeading to necrosis & perforation

Intussuception

Most commonly seen in infants 3-12 monthsMost commonly seen in infants 3-12 months Bowel “telescopes”Bowel “telescopes”

within itselfwithin itself

Intussuception: Clinical Intussuception: Clinical ManifestationsManifestations

Intermittent then constant painIntermittent then constant pain VomitingVomiting Abdominal distentionAbdominal distention Currant jelly-like stoolsCurrant jelly-like stools DiarrheaDiarrhea DehydrationDehydrationSerious complications:Serious complications:Ischemia, perforation & shockIschemia, perforation & shock

VolvulusVolvulus

Twisting of the bowel that leads to a Twisting of the bowel that leads to a bowel obstruction.bowel obstruction.

Vomiting of fecal materialVomiting of fecal material Abdominal distentionAbdominal distention PainPain

Volvulus

A twisting of the A twisting of the bowel that leads to a bowel that leads to a bowel obstruction. bowel obstruction.

  

AssessmentAssessment

PainPain VomitingVomiting StoolsStools DehydrationDehydration Serious complicationsSerious complications

DiagnosisDiagnosis

X-rayX-rayAbdominal ultrasoundAbdominal ultrasound

Therapeutic InterventionTherapeutic Intervention

Hydrostatic reductionHydrostatic reduction

Laparoscopic Surgery Laparoscopic Surgery

Nursing Care:Nursing Care:

NPO- NG tube, IVNPO- NG tube, IV

Assess – V/S, painAssess – V/S, pain

Monitor stoolsMonitor stools

Re-introduce foodRe-introduce food

AppendicitisAppendicitis

Inflammation of the lumen of the Inflammation of the lumen of the appendix at the end of the cecum appendix at the end of the cecum which becomes quickly obstructed which becomes quickly obstructed causing edema, necrosis and pain. causing edema, necrosis and pain.

Clinical ManifestationsClinical Manifestations

Abdominal pain – McBurney’s pointAbdominal pain – McBurney’s point Silent AbdomenSilent Abdomen Anorexia & nauseaAnorexia & nausea DiarrheaDiarrhea Elevated temperatureElevated temperature IF PERFORATED:IF PERFORATED:

– Sudden pain reliefSudden pain relief– FeverFever– DehydrationDehydration

DiagnosisDiagnosis

History and PhysicalHistory and Physical UltrasoundUltrasound X-RayX-Ray Laboratory valuesLaboratory values

– increased WBC 15,000 – 20,000increased WBC 15,000 – 20,000

Management and Nursing Management and Nursing Care: Pre-OpCare: Pre-Op

NPONPO IVIV Comfort measuresComfort measures AntibioticsAntibiotics Thermal therapyThermal therapy EliminationElimination Patient educationPatient education

Hirschsprung’s DiseaseHirschsprung’s Disease

Congenital disorder of absence of ganglia Congenital disorder of absence of ganglia (nerve cells) in lower colon(nerve cells) in lower colon

AssessmentAssessment Failure to pass meconiumFailure to pass meconium VomitingVomiting

Bowel assessmentBowel assessment

BreathBreath

Older childOlder child

DiagnosisDiagnosis

History & PhysicalHistory & Physical

Barium enema (X-ray)Barium enema (X-ray)

Rectal biopsy- absence of ganglionic Rectal biopsy- absence of ganglionic cells in bowel mucosacells in bowel mucosa

Management Management

Surgical intervention Surgical intervention –ColostomyColostomy–ResectionResection

Nursing Care:Nursing Care:

Pre-opPre-op– Cleanse bowel Cleanse bowel – NPONPO– Patient/parent teachingPatient/parent teaching

Post-opPost-op– NPONPO– VS (no rectal temperatures)VS (no rectal temperatures)– AssessmentAssessment– Patient/parent teachingPatient/parent teaching

Diarrhea/GastroenteritisDiarrhea/GastroenteritisSevereSevere

A disturbance of the intestinal tract A disturbance of the intestinal tract that alters motility and absorption, that alters motility and absorption, and accelerates the excretion of and accelerates the excretion of intestinal contents.intestinal contents.

Most infectious diarrheas in this Most infectious diarrheas in this country are caused by Rotoviruscountry are caused by Rotovirus

DehydrationDehydration

Infant:Infant:– Depressed fontanelsDepressed fontanels– Sunken eyesSunken eyes

Little fluid volume reserveLittle fluid volume reserve Hypovolemic ShockHypovolemic Shock

Clinical ManifestationsClinical Manifestations

Increase in peristalsisIncrease in peristalsis Large volume stoolsLarge volume stools Increase in frequency of stoolsIncrease in frequency of stools Nausea, vomiting, crampsNausea, vomiting, cramps Metabolic Acidosis:Metabolic Acidosis:

– Increased heart & resp. rate, decreased Increased heart & resp. rate, decreased B/P, arrhythmiasB/P, arrhythmias

– Cold, clammy skinCold, clammy skin– Changes in CNS – stupor, lethergyChanges in CNS – stupor, lethergy

DiagnosisDiagnosis

Stool sampleStool sample– cultureculture– O&PO&P

Blood gasesBlood gases– Metabolic AcidosisMetabolic Acidosis

Priority Nursing Priority Nursing InterventionsInterventions

Treat underlying causeTreat underlying cause Restore fluid & electrolyte balanceRestore fluid & electrolyte balance Daily weightsDaily weights I&OI&O Assess for dehydrationAssess for dehydration Isolation protocolIsolation protocol Monitor electrolytes/metabolic Monitor electrolytes/metabolic

acidosisacidosis Skin careSkin care

Oral Rehydration

Critical ThinkingCritical Thinking

Why is there an increase in incidence Why is there an increase in incidence of diarrhea in lower socio-economic of diarrhea in lower socio-economic groups?groups?

Why is there and increase in young Why is there and increase in young children?children?

Celiac DiseaseCeliac Disease

Celiac disease results from the Celiac disease results from the inability to digest gliadin which is a inability to digest gliadin which is a by-product of gluten breakdown. by-product of gluten breakdown.

– This results in the accumulation of the This results in the accumulation of the amino acid glutamine which is toxic to amino acid glutamine which is toxic to the mucosal cells in the intestines. the mucosal cells in the intestines. Damage to the villi impairs the ability of Damage to the villi impairs the ability of the small intestines to absorb nutrientsthe small intestines to absorb nutrients

Celiac DiseaseCeliac Disease

Assessment- Growth pattern, GI patternAssessment- Growth pattern, GI pattern Failure to ThriveFailure to Thrive Treatment- Treatment- Dietary restrictions Dietary restrictions Nursing Care- monitor for dehydration, Nursing Care- monitor for dehydration,

encourage compliance with encourage compliance with dietary restrictions, provide dietary restrictions, provide support groups for patient and support groups for patient and

caregivercaregiver

Signs and Symptoms

The child with celiac disease commonly demonstrates

failure to grow and wasting of extremities. The abdomen can appear large due to intestinal distension and malnutrition

Complications: Hypocalcemia, osteomalacia, osteoporosis, depression.  

Diagnostic FindingsDiagnostic Findings

Measurement of fat contentMeasurement of fat content Duodenal or Jejunal biopsyDuodenal or Jejunal biopsy Elevated IGA antibodies Elevated IGA antibodies

Treatment and Nursing Care

Teach parents DIETARY REGULATIONS:

Gluten Free Diet

NO !

Disease specific support groupsDisease specific support groups

The EndThe End