Alterations in
Gastrointestinal
Functioning
Joy A. Shepard, PhD(c), RN-C, CNE
Joyce Buck, MSN, RN-C, CNE
1. Describe anatomic and physiologic characteristics
of developing GI system
2. Discuss pathophysiological processes assoc...
6. Summarize etiology, pathophysiology,
symptoms, and management for the child with a
parasitic or viral infection of the ...
 Function: GI System
◦ Ingestion (food, fluid)
◦ Digestion
◦ Absorption
◦ Metabolism
◦ Elimination (waste)
 Anatomy: GI ...
5
6
7
Pediatric GI
Differences
8
The newborn and infant have a high percentage of body weight comprised of water,
especially extracellular fluid, which is ...
 Newborn
◦ Poor swallowing control
◦ Increased peristalsis
◦ Higher gastric acid pH
◦ Enzyme deficiencies
◦ Limits in bil...
11
 Suck & swallow reflex: 34
wks
 Coordinated oral pharyngeal
movements necessary to
swallow solids: > age 2 mos
 Extrusi...
 Which of the following is NOT a unique
characteristic of the digestive system of infants?
 A. Decreased emptying time (...
14
Pediatric GI History &
Physical
 Birth weight
 Prematurity
 History of
maternal infection
 Polyhydramnios
 General childhood health;
family history
 Congenital anomalies
 Growth & development
 Nutritional status; feeding
pro...
17
 Abdominal assessment
◦Inspection, auscultation, percussion,
palpation
 Abdominal distention
◦Abdominal circumference
 ...
19
 Flat plate of abdomen
 Upper Gastrointestinal
series (UGI)
 Barium swallow / enema
 Gastric emptying study
 Abdomina...
UGI Series with Barium
5-year-old
s/p MVA
Diagnosis: hematoma
of duodenum
Treatment: NG tube,
IV fluids, electrolyte
maint...
Diagnosis of appendicitis, tumors, abscess
Endoscopy
Colonoscopy
 Stool Sample
 White blood cells
 Ova and Parasite
 Bacterial cultures
 Fecal fat
 Stool pH
 Rotazyme
(rotavirus)
...
 Risk for Aspiration
 Imbalanced Nutrition
 Acute/ Chronic Pain
 Nausea
 Constipation
 Diarrhea
 Deficient Fluid Vo...
 Many GI issues require surgical intervention
 Nursing interventions will often include general pre & post-op care
 A b...
30
Developmental
Disorders/ Structural
Defects
 H e a d
◦ Cleft lip and cleft palate
 E s o p h a g u s &
S t o m a c h
◦ Esophageal atresia
◦ Tracheoesophageal
fistul...
 Affects upper lip & roof of mouth
 Most common congenital birth defects
 Etiology – Failure of oral cavity (cleft lip)...
33
 Cleft lip repair: during first 6 months
 Cleft palate repair: by 18 months
 Multidisciplinary team - involving many sp...
 Assessing family reactions
 Providing emotional support
 Facilitating feeding
 Providing parent education
 Assisting...
 Remember the psycho-social implications for these
children and families
 Facial deformities can be devastating to famil...
 Goal: Ensure adequate
intake of food & fluids
without aspiration
 Keep bulb syringe &
suction equipment at
bedside
 Sp...
 What are problems that the nurse needs to be
alert for during feedings?
◦ Lack of proper seal around nipple to create
ne...
 The ESSR feeding technique:
 Enlarge the nipple (cleft palate nipple)
 Stimulate the suck reflex
 Swallow fluid appro...
The nurse is reviewing nursing notes and sees a
notation of “ESSR” in the medical record. “ESSR” refers
to:
A. The feeding...
 Airway management
 Feeding
 Suture care
 Restraints
 Referrals to appropriate
team members
◦ Identify and address
ho...
 Prevent trauma to suture line
◦ Logan’s bow to protect site
◦ Do not allow to suck
◦ Maintain upper arm restraints
◦ Pos...
The best rationale to give parents who are questioning
the use of elbow restraints with their child who has had
cleft pala...
 Congenital defects of esophagus
 Failure of GI tract to separate properly from respiratory tract early
in prenatal life...
46
47
Assessment of every newborn during the first feeding is essential!
 Hx polyhydramnios during pregnancy can suggest a high
gastrointestinal obstruction
 Excessive amounts of salivation / m...
 Early diagnosis
◦ Ultrasound
◦ Radiopaque catheter inserted in
the esophagus to illuminate defect
on X-ray
 Pre-Op Care...
Maintain airway
•jlkjfj
Keep NPO- administer IV fluids
Elevate HOB 45 degrees
Suction PRN
Give Prophylactic antibiotics
 Maintain airway
 Maintain nutrition
◦ Gastrostomy tube feedings
 Prevent trauma
 Monitor for complications
◦ Constipa...
52
Feeding Your Child with the
Gravity Method
 Obstruction of the pyloric canal (stenosis of
passage between stomach and duodenum)
 Narrowing of the pyloric sphincter...
54
Projectile
vomiting
Constant
hunger
Fussiness
Visible peristaltic
waves
Dehydration
Metabolic
alkalosis
Olive-
sized
mass
...
57
58
59
The nurse is caring for an infant vomiting secondary to
pyloric stenosis. The mother questions why the vomitus of
this chi...
 Diagnosis:
◦ Abdominal ultrasound
◦ Upper gastrointestinal (UGI)
series (barium swallow)
◦ Blood tests: hypochloremia,
h...
62
 Assess for dehydration, electrolyte, & acid/base
imbalance
 *Must treat dehydration & electrolyte imbalance
before surg...
Weight Requirement
0-10 kg 100mL/kg/24hr
11-20 kg 1000 +
50mL/kg/24hr
>20 kg 1500 +
20mL/kg/hr
Example: 8 kg child 800mL/2...
 I & O
 Comfort/ pain relief
 Feeding:
◦ Clear liquids
◦ Observe/ record the
infant’s response to
feeding
 Position wi...
 A 4 week old infant with a history of vomiting after
feeding has been hospitalized with a tentative
diagnosis of pyloric...
 GER – Passage of gastric
contents into esophagus
 GERD – Symptoms/
complications that may occur
when gastric contents r...
68
69
 Recurrent regurgitation/ vomiting – most common
sign
 Cranky, excessive crying, irritable, spitting up,
refusing to fee...
 Heartburn or chest pain
 Abdominal pain
 Dysphagia
 Wheezing, stridor, cough,
hoarseness
 Ear infections, sinus
prob...
 H & P
 Esophageal pH probe
(preferred test)
◦ If <7.0 indicates presence of
acid
 Upper GI/ Barium Swallow
 Endoscopy...
 Small frequent feedings of breast milk,
predigested formula or thickened formula
 Frequent burping
 Positioning –
◦ Up...
 Antacids (Neutralize gastric acid)
Calcium carbonate (Tums)
 Histamine-2 Receptor Antagonists (Inhibit gastric acid se...
77
A 3-month-old infant has severe gastroesophageal
reflux (GERD). The mother wants to know if there is
anything she can do d...
 Nissen Fundoplication
◦ Stomach fundus wrapped around distal
end of esophagus (LES)
◦ Reinforces LES, making it less lik...
A 9-year-old with severe esophagitis is 12 hours
status/post-Nissen fundoplication for gastroesophageal
reflux. To impleme...
 Omphalocele – Congenital
malformation in which intra-
abdominal contents herniate
through the umbilical cord,
with trans...
Herniation of abdominal contents through the umbilical cord.
Contents are covered by a translucent sac
 Herniation of abdominal viscera outside the
abdominal cavity through a defect in the
abdominal wall to the side of the u...
84
Alpha-
fetaoprotein
(MSAFP)
Provide an
early diagnosis
Prenatal
Ultrasound
Polyhydramnios
 Pre-operatively – Protect visceral contents/ sac; provide
intravenous fluids
◦ Cover with warm, sterile, saline-soaked d...
 Under general anesthesia, an
incision is made to remove the sac
membrane. The bowel is examined
for signs of damage or a...
88
Thermoregulation
Loss of Fluids
 Pain management
 Prevent infection
 Fluid & electrolyte
balance
 Assess for ileus
 M...
 Intussusception – One portion
of bowel prolapses/ telescopes
into another portion- causes
obstruction; may need surgery
...
 Most common cause of intestinal obstruction in young
children
 Infants 9 – 24 months; males more common
 Bowel “telesc...
 A twisting of the
midgut bowel that
leads to a bowel
obstruction
 Extreme paroxysmal pain (subsides then recurs)
 Vomiting
 Stools – resemble currant jelly
 Sausage-shaped abdominal m...
94
 Diagnosis: H & P;
abdominal x-rays/ US
 CBC – leukocytosis
 Stool – occult/ visible blood
 Hydrostatic reduction
(bar...
 Most common during 1st month of life
 Intermittent bilious vomiting
 Firm abdomen with distention
 Irritability secon...
 Assess for shock
 Vital signs
 I & Os
 Intravenous fluids
 Gradually increase feeding after NG tube removal
 Discha...
 Absence of ganglion cells in
rectum & upward colon
 Prevents peristalsis at that portion
of the colon
 Megacolon: mech...
Congenital disorder of nerve cells in lower colon
No ganglionic nerve innervation or peristalsis in narrowed section
Adjac...
Failure to pass meconium
Severe constipation
Abdominal distension
Reluctance to feed
Bilious vomiting
Failure to thrive
Li...
 Severe diarrhea
 Hypovolemic
shock
 Death
102
Diagnosis
 History & Physical
 Rectal biopsy- absence
of ganglionic cells in
bowel mucosa
(definitive diagnosis)
 Recta...
104
Before pull-through
surgery: The
diseased segment
doesn’t push stool.
Step 1: The
diseased segment
is removed.
Step 2:...
Pre-op
F & E balance
Vital signs
Colonic lavage
(saline)
Patient/parent
teaching
Post-op
NPO
Vital Signs – never
t...
An infant returns from initial surgery for Hirschsprung’s
disease. Because of the type of surgery the child had,
the nurse...
A child with Hirschsprung’s disease is being discharged
after Soave endorectal pull-through procedure for
colostomy closur...
 Opening to anus is missing or blocked
 Usually found with 1st rectal temperature at birth
 Signs & symptoms:
Failure ...
111
See Video Pull-Through (PSARP) Surgery Procedure
 Inguinal hernias – Protrusion of abdominal
cavity contents through the inguinal canal;
elective surgery recommended
 Um...
113
 Painless swelling extending
toward or into the scrotum
 Elective surgery recommended
 Soft midline swelling in umb...
A mother arrives at clinic with her 6-month-old child. While the
nurse is assessing the child, the mother points to the um...
115
 Congenital condition
 Diaphragm fails to close completely
 Abdominal contents enter chest cavity
 Prevents lungs ...
 Scaphoid (concave) abdomen
 Respiratory distress
 Cyanosis
 Asymmetric chest movements (secondary to the
hypoplastic ...
 Diagnosis: chest x-ray (reveals mass with air-filled bowel
on affected side)
 Immediate intubation with mechanical vent...
While performing a newborn assessment, the nurse notices
the infant is having difficulty breathing. Nasal flaring,
cyanosi...
119
120
Inflammatory
Disorders
 Appendicitis
 Meckel’s Diverticulum
121
 Inflammation & obstruction of the
blind sac at the end of the cecum
 Medical emergency:
appendectomy only cure
 Most c...
 Earliest symptom: periumbilical pain, vomiting, rebound
tenderness
 Followed by: pain migrating to rt lower quadrant (c...
12
5
12
6
 Diagnosis: abdominal US/ CT scan
 Appendectomy (open or laparoscopic)
 NPO with NG tube until bowel function returns
...
128
A 10-year-old boy has been admitted with a diagnosis of
“rule out appendicitis.” While the nurse was conducting
a routine ...
The mother of a child undergoing an emergency appendectomy
tells the nurse “If I had brought him in yesterday when he
comp...
 Congenital pouch (diverticulum)
approx 2” in length, located at
the lower (distal) end of small
intestine
 Irritation, ...
 Manifests before 2 yrs of age
 Most common sign: painless rectal bleeding (currant jelly stools or
stools bright or dar...
 Which of the following laboratory findings would
the nurse expect to find in an 18-month old toddler
with Meckel’s diver...
134
Motility Disorders
 Vomiting
 Gastroenteritis/ Acute Diarrhea
 Constipation
 Encopresis
135
 Signs & Symptoms:
◦ Assessment includes
description of onset,
duration quality, quantity,
appearance, presence of
undige...
 Gastroenteritis: inflammation of lining of stomach & intestines
Most common symptoms: diarrhea, anorexia, nausea &
vomi...
 Increase in peristalsis
 Large volume stools (loose, watery, green)
 Increase in frequency of stools
 Nausea, vomitin...
 Dehydration
◦ Mucus membranes dried,
cracked
◦ Decreased elasticity of skin
◦ Depressed fontanels, eyes
sunken & tearles...
Mild Moderate Severe
Fluid Vol loss <50ml/kg 50-90ml/kg >100 ml/kg
Skin Color Pale Gray Mottled
Skin
Elasticity
Decreased ...
142
Stool
Culture
Stoolfor
O&P
Blood
Gases
pH
 Stool Culture
 Causative organism
 Stool for O&P
 ABGs to diagnose Metaboli...
 Prevention of spread of diarrhea:
Contact/ enteric precautions
Meticulous handwashing (soap & water)
Rotavirus vaccin...
145
Skin care
Promotion of rehydration; correction of
electrolyte imbalances
◦ Oral rehydration (Pedialyte, Infalyte, Rehydr...
Avoid fluids that are high in sugar – soft drinks, jello, fruit drinks, tea
50-100 mL/kg within 4 hrs
148
No dehydration Oral rehydration salts
Administer after each stool:
Age Volume of ORS
<2 years
50–100 ml, up to 500 mL/...
 Fewer than normal BMs;
hard or lumpy stool
consistency
 Signs & Symptoms:
◦ Poor appetite, straining
with stools
 Addi...
 Elimination disorder defined as repeated passage
of feces in inappropriate places (involuntary or
intentional), occurrin...
15
1
1. Establish routine bowel habits
through regular toilet sitting with
attempts to defecate
2. Oral lubricants or stool sof...
 Talk to parents about defecation pattern/ ways to
establish regular bowel habits
 Evaluate dietary habits (fiber & wate...
154
Parasitic Disorders
 Protozoa or helminths (worms)
◦ Protozoa – single-celled organisms (often found in contaminated
water sources)
◦ Helmint...
 Giardiasis: diarrhea,
vomiting, anorexia, failure
to thrive
 Pinworm: itching around
anus at night leading to
irritabil...
 Diagnosis:
◦ Stool ova & parasite exam: to identify causative
organism
◦ Nightly anal test (sticky tape): pinworm
◦ Comp...
Always wash hands/ fingernails with soap and water
before eating and handling food and after feeding
Discourage children...
Drink water that is specially treated, especially if
camping
Wash all raw fruits and vegetables or any food that has
fal...
 By which of the following are Ascarisas
(roundworm) infections diagnosed?
 A. Presence of larvae on the skin
 B. Seein...
161
Malabsorption/
Feeding Disorders
 Colic
 Failure to thrive (FTT)
 Celiac disease
 Lactose intolerance
 Short bowel syndrome
162
 Paroxysmal abdominal pain (i.e., sudden recurrent
attacks of abdominal pain)
 Loud persistent continuous cry, ≥ 3 hrs d...
 Rule out acute conditions or causes (e.g., obstruction,
infection, sensitivity to formula)
 Thorough detailed history: ...
 A new mother has some questions about colic.
Which of the following statements made by a
nurse is not correct regarding ...
 Inadequate growth resulting from
inability to obtain or use calories
required for growth
◦ Slow growth/ inadequate weigh...
 Organic
◦ Physical cause identified:
heart defect, GER, renal
insufficiency, malabsorption,
endocrine disease, cystic
fi...
 Multidisciplinary team approach: provide adequate caloric &
nutritional intake; promote normal growth & development;
ass...
 Complete a comprehensive health history
 Perform a physical examination
 Educate regarding nutrition, feeding techniqu...
The nurse is teaching home feeding guidelines to the
mother of a child with non-organic failure to thrive.
Essential infor...
 Gluten sensitivity affecting
small intestine; autoimmune
reaction
 Severe intestinal mucosal
changes
 Leading malabsor...
• Failure to thrive
• Growth failure
• Diarrhea
• Abdominal distention
• Anorexia
• Malnutrition
Stools: large, bulky & fr...
173
The nurse is taking a nursing history from the mother
of a child being admitted with flare-up of celiac
disease. What piec...
 Assessment – Growth pattern, GI pattern
 Diagnosis – serum IGA antitissue transglutaminase
antibodies (tTGA) or IGA ant...
The nurse is teaching the parents of a child with
celiac disease about the dietary restrictions. The
nurse would explain t...
Wheat
Rye
Barley
Oats
Teach parents DIETARY REGULATIONS:
Gluten
Free
Diet
NO !
178
The nurse has taught dietary restrictions to the 7-year-old
child with celiac disease. After teaching, the child is
allowe...
 Food intolerance due to absence
or deficiency of lactase
 Inability to digest lactose in milk
or dairy products
 Diarr...
 Diagnosis: based on H & P, decrease in
symptoms with elimination of lactose from the diet,
family history
 Treatment: a...
 Decreased ability to digest and
absorb a regular diet because of
shortened small intestine
 Diarrhea, dehydration,
maln...
18
3
184
Hepatic Disorders
 Bile ducts fail to develop or are closed;
causes cirrhosis
 End-stage liver disease, death by age 2 (if
untreated)
 Ja...
186
•Damaged ducts removed, replaced
with piece of infant's own intestine
•Small intestine is divided (Roux-en-Y)
•Section is ...
A 10-month-old with biliary atresia is being discharged after
Kasai procedure. Which statement, if made by her parents,
in...
 GI disorders due to many internal and external
causes
 Most involve pain, hydration risks, changes in diet
 Preventive...
Gi lecture nurs 3340 fall 2014
Gi lecture nurs 3340 fall 2014
Gi lecture nurs 3340 fall 2014
Gi lecture nurs 3340 fall 2014
Gi lecture nurs 3340 fall 2014
Gi lecture nurs 3340 fall 2014
Gi lecture nurs 3340 fall 2014
Gi lecture nurs 3340 fall 2014
Gi lecture nurs 3340 fall 2014
Gi lecture nurs 3340 fall 2014
Gi lecture nurs 3340 fall 2014
Gi lecture nurs 3340 fall 2014
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Gi lecture nurs 3340 fall 2014

  1. 1. Alterations in Gastrointestinal Functioning Joy A. Shepard, PhD(c), RN-C, CNE Joyce Buck, MSN, RN-C, CNE
  2. 2. 1. Describe anatomic and physiologic characteristics of developing GI system 2. Discuss pathophysiological processes associated with GI disorders in children 3. Identify signs and symptoms of GI disorders 4. Summarize pre-operative and post-operative care for child born with cleft lip/palate 5. Contrast nursing management for child with GI condition having abdominal surgery vs. nonoperative management 2
  3. 3. 6. Summarize etiology, pathophysiology, symptoms, and management for the child with a parasitic or viral infection of the GI system 7. Analyze developmentally appropriate nursing management of GI disorders 3
  4. 4.  Function: GI System ◦ Ingestion (food, fluid) ◦ Digestion ◦ Absorption ◦ Metabolism ◦ Elimination (waste)  Anatomy: GI Organs ◦ Mouth, esophagus, stomach ◦ Small/ large intestines ◦ Rectum, anus  Accessory Structures ◦ Liver, gallbladder, pancreas 4 Body Basics: Digestive System
  5. 5. 5
  6. 6. 6
  7. 7. 7 Pediatric GI Differences
  8. 8. 8
  9. 9. The newborn and infant have a high percentage of body weight comprised of water, especially extracellular fluid, which is lost from the body easily. Note the small stomach size which limits ability to rehydrate quickly.
  10. 10.  Newborn ◦ Poor swallowing control ◦ Increased peristalsis ◦ Higher gastric acid pH ◦ Enzyme deficiencies ◦ Limits in bilirubin conjugation, gluconeogenesis, deamination, plasma protein, and ketone formation 10
  11. 11. 11
  12. 12.  Suck & swallow reflex: 34 wks  Coordinated oral pharyngeal movements necessary to swallow solids: > age 2 mos  Extrusion reflex – disappears between 4 – 6 mos  Pancreatic amylase secretion – not until age 4 mos  Young infants lack ability to recognize when they've had enough - over feeding, abdominal distention, & spits  Stomach capacity is 10-20 mL in the infant; up to 3 liters by adolescence  Abdominal distension can cause respiratory distress  Stool frequency is highest in infancy  Bowel control (control of anal sphincters) is achieved by 18 months to 4 years  Liver edge palpable 1-2 cm in infants/ young children
  13. 13.  Which of the following is NOT a unique characteristic of the digestive system of infants?  A. Decreased emptying time (stomach empties a lot quicker)  B. Small stomach capacity (10 – 20 mLs)  C. Immature relaxed lower esophageal sphincter (LES)  D. Increased gastric acidity level 13
  14. 14. 14 Pediatric GI History & Physical
  15. 15.  Birth weight  Prematurity  History of maternal infection  Polyhydramnios
  16. 16.  General childhood health; family history  Congenital anomalies  Growth & development  Nutritional status; feeding problems  Screening procedures; immunizations  Medications  Intolerance to certain foods; allergies  Type of stool  Present Illness:  Onset, frequency, & duration of symptoms (e.g., feeding difficulties, vomiting, diarrhea, constipation, abdominal pain, blood in vomit or stool)  Weight loss or gain  Recent changes in diet  Changes in bowel habits
  17. 17. 17
  18. 18.  Abdominal assessment ◦Inspection, auscultation, percussion, palpation  Abdominal distention ◦Abdominal circumference  Abdominal pain ◦Acute; diffuse; localized See video “Physical Exam & Health Assessment: Child” 13:04 – 14:34
  19. 19. 19
  20. 20.  Flat plate of abdomen  Upper Gastrointestinal series (UGI)  Barium swallow / enema  Gastric emptying study  Abdominal ultrasound  CT scan with or without contrast  MRI  Endoscopy Abdominal x-ray
  21. 21. UGI Series with Barium 5-year-old s/p MVA Diagnosis: hematoma of duodenum Treatment: NG tube, IV fluids, electrolyte maintenance
  22. 22. Diagnosis of appendicitis, tumors, abscess
  23. 23. Endoscopy Colonoscopy
  24. 24.  Stool Sample  White blood cells  Ova and Parasite  Bacterial cultures  Fecal fat  Stool pH  Rotazyme (rotavirus)  Blood  Blood Values  Erythrocyte sedimentation rate (ESR)  Complete blood count  Comprehensive metabolic panel  Liver function tests: ALT, AST, GGT, ALP, ammonia levels  Bilirubin direct and indirect  Hepatitis antigens  Total protein, albumin levels
  25. 25.  Risk for Aspiration  Imbalanced Nutrition  Acute/ Chronic Pain  Nausea  Constipation  Diarrhea  Deficient Fluid Volume  Risk for Electrolyte Imbalance  Delayed Growth and Development  Disturbed Body Image  Ineffective Therapeutic Regimen Management 28
  26. 26.  Many GI issues require surgical intervention  Nursing interventions will often include general pre & post-op care  A bulky, frothy stool may indicate malabsorption  Drooling in the newborn is pathological because the salivary glands do not develop for several months  Conditions requiring immediate medical attention: ◦ Bilious vomiting (bright yellow to dark green color in the vomitus, often with fecal appearance and smell) is a sign of GI obstruction ◦ Blood in vomit or stool ◦ Persistent vomiting, watery diarrhea, intractable abdominal pain ◦ Signs of dehydration (e.g., very dry mouth, no tears, <1 mL/kg/hr urinary output) 29
  27. 27. 30 Developmental Disorders/ Structural Defects
  28. 28.  H e a d ◦ Cleft lip and cleft palate  E s o p h a g u s & S t o m a c h ◦ Esophageal atresia ◦ Tracheoesophageal fistula (TEF) ◦ Pyloric stenosis ◦ Gastroesophageal reflux (GER/ GERD)  I n t e s t i n e s ◦ Omphalocele ◦ Gastroschisis ◦ Intussusception ◦ Volvulus ◦ Hirschsprung’s disease  A n u s ◦ Anorectal malformations  H e r n i a s ◦ Diaphragmatic ◦ Umbilical 31
  29. 29.  Affects upper lip & roof of mouth  Most common congenital birth defects  Etiology – Failure of oral cavity (cleft lip) & palatine palates (cleft palate) to fuse during embryonic development  Unilateral, bilateral, midline  Risk factors are multifactorial but could include family hx, maternal smoking, alcohol use, diabetes, folic acid deficiency, & use of antiepileptic medications  Problems: eating, talking, hearing, ear infections, tooth development 32
  30. 30. 33
  31. 31.  Cleft lip repair: during first 6 months  Cleft palate repair: by 18 months  Multidisciplinary team - involving many specialists including plastic surgeons, nurses, ear, nose, and throat specialists, orthodontists, audiologists, and speech therapists.  Reconstruction begins in infancy and can continue through adulthood.  Homecare by the family prior to surgery
  32. 32.  Assessing family reactions  Providing emotional support  Facilitating feeding  Providing parent education  Assisting parents ◦ With coordinating care ◦ With maintaining healthy environment  Making referrals 35
  33. 33.  Remember the psycho-social implications for these children and families  Facial deformities can be devastating to family  Remind parents that defect is operable- show photographs of corrected clefts Before After
  34. 34.  Goal: Ensure adequate intake of food & fluids without aspiration  Keep bulb syringe & suction equipment at bedside  Special feeding devices may be used  May breast feed if has small cleft lip  Feed slowly in upright position & burp frequently  Position on side after feeding  All these measures focus on ways to decrease ASPIRATION
  35. 35.  What are problems that the nurse needs to be alert for during feedings? ◦ Lack of proper seal around nipple to create necessary suction ◦ Excessive air intake  Use of special feeding techniques ◦ Feeder with compressible sides ◦ Syringes with tubing
  36. 36.  The ESSR feeding technique:  Enlarge the nipple (cleft palate nipple)  Stimulate the suck reflex  Swallow fluid appropriately  Rest when infant signals with facial expression 39 How to Use the Haberman Special Needs Bottle Getting Started
  37. 37. The nurse is reviewing nursing notes and sees a notation of “ESSR” in the medical record. “ESSR” refers to: A. The feeding method for children with gastroesophageal reflux. B. The feeding method for children with cleft lip or palate. C. The procedure for repair of pyloric stenosis. D. The procedure for repair of Hirschsprung’s disease. 40
  38. 38.  Airway management  Feeding  Suture care  Restraints  Referrals to appropriate team members ◦ Identify and address home/family needs well in advance of discharge 41
  39. 39.  Prevent trauma to suture line ◦ Logan’s bow to protect site ◦ Do not allow to suck ◦ Maintain upper arm restraints ◦ Position supine or side-lying ◦ No hard objects in mouth  Reduce pain  Prevent infection ◦ Cleanse suture lines as ordered – rinse with water after each feeding. ◦ Call provider for any swelling or redness  Discharge teaching/ home care instructions
  40. 40. The best rationale to give parents who are questioning the use of elbow restraints with their child who has had cleft palate repair is: A. “This device is frequently used postoperatively to protect the IV site in small children.” B. “The restraints will help us maintain proper body alignment.” C. “Elbow restraints are used postoperatively to keep their hands away from the surgical site.” D. “The restraints help us remember that the child is NPO after surgery.” 44
  41. 41.  Congenital defects of esophagus  Failure of GI tract to separate properly from respiratory tract early in prenatal life ◦ Atresia – incomplete formation of esophagus (does not develop as a continuous tube) ◦ TEF – fistula between trachea & esophagus
  42. 42. 46
  43. 43. 47 Assessment of every newborn during the first feeding is essential!
  44. 44.  Hx polyhydramnios during pregnancy can suggest a high gastrointestinal obstruction  Excessive amounts of salivation / mucus, frothy bubbles (drooling)  Three “C’s”: Coughing, choking, and cyanosis when fed  Food may be expelled through the nose immediately following the feeding  Rattling respirations and frequent respiratory problems such as aspiration pneumonia  Gastric distention, if fistula
  45. 45.  Early diagnosis ◦ Ultrasound ◦ Radiopaque catheter inserted in the esophagus to illuminate defect on X-ray  Pre-Op Care: Prevent aspiration, hydration ◦ NG suction upper pouch ◦ IV antibiotics/ fluids  Surgery: one- or two-stage repair ◦ Thoracotomy and anastomosis
  46. 46. Maintain airway •jlkjfj Keep NPO- administer IV fluids Elevate HOB 45 degrees Suction PRN Give Prophylactic antibiotics
  47. 47.  Maintain airway  Maintain nutrition ◦ Gastrostomy tube feedings  Prevent trauma  Monitor for complications ◦ Constipation or diarrhea ◦ Blockage of esophagus ◦ Infection  Monitor weight, growth and developmental achievements 
  48. 48. 52 Feeding Your Child with the Gravity Method
  49. 49.  Obstruction of the pyloric canal (stenosis of passage between stomach and duodenum)  Narrowing of the pyloric sphincter  Delayed emptying of the stomach  2 to 8 weeks after birth  Typically: healthy male infant; new onset non- bilious vomiting 30-60 min after feeding, progressing to projectile vomiting 53
  50. 50. 54
  51. 51. Projectile vomiting Constant hunger Fussiness Visible peristaltic waves Dehydration Metabolic alkalosis Olive- sized mass Peristaltic Wave in Epigastrium pH HCO3 H+ Loss of acid from stomach
  52. 52. 57
  53. 53. 58
  54. 54. 59
  55. 55. The nurse is caring for an infant vomiting secondary to pyloric stenosis. The mother questions why the vomitus of this child appears different from that of her other children when they have the flu. The nurse would explain that the emesis of an infant with pyloric stenosis does not contain bile because: A. The GI system is still immature in newborns and infants. B. The obstruction is above the bile duct. C. The emesis is from passive regurgitation. D. The bile duct is obstructed. 60
  56. 56.  Diagnosis: ◦ Abdominal ultrasound ◦ Upper gastrointestinal (UGI) series (barium swallow) ◦ Blood tests: hypochloremia, hypokalemia, metabolic alkalosis  Treat dehydration & electrolyte imbalances  Treatment: Surgery Pyloromyotomy 61
  57. 57. 62
  58. 58.  Assess for dehydration, electrolyte, & acid/base imbalance  *Must treat dehydration & electrolyte imbalance before surgery*  Examine abdomen and listen for bowel sounds  Accurate I&Os; daily weights ◦ NPO, IV fluids, weigh all diapers; monitor NG tube drainage  Promote rest, comfort  Protect from infection  Supportive care for parents 63 See video Pyloric Stenosis (Nursing Interventions)
  59. 59. Weight Requirement 0-10 kg 100mL/kg/24hr 11-20 kg 1000 + 50mL/kg/24hr >20 kg 1500 + 20mL/kg/hr Example: 8 kg child 800mL/24hr 33 mL/hr
  60. 60.  I & O  Comfort/ pain relief  Feeding: ◦ Clear liquids ◦ Observe/ record the infant’s response to feeding  Position with head elevated  Assess surgical site to prevent infection  Parent teaching (p. 767)
  61. 61.  A 4 week old infant with a history of vomiting after feeding has been hospitalized with a tentative diagnosis of pyloric stenosis. Which of these actions is priority for the nurse? A. Begin an intravenous infusion B. Measure abdominal circumference C. Orient family to unit D. Weigh infant
  62. 62.  GER – Passage of gastric contents into esophagus  GERD – Symptoms/ complications that may occur when gastric contents reflux into the esophagus or oropharynx  Immaturity (relaxation) of lower esophageal sphincter (LES)  Eat often but lose weight 67
  63. 63. 68
  64. 64. 69
  65. 65.  Recurrent regurgitation/ vomiting – most common sign  Cranky, excessive crying, irritable, spitting up, refusing to feed  Poor growth/ weight gain; failure to thrive; anemia  Life Threatening Risk / Complications: ◦ Esophagitis, blood loss ◦ Aspiration pneumonia ◦ Wheezing/ Apnea ◦ Apparent life threatening events (ALTE)
  66. 66.  Heartburn or chest pain  Abdominal pain  Dysphagia  Wheezing, stridor, cough, hoarseness  Ear infections, sinus problems  Recurrent pneumonia/ asthma  Regurgitation
  67. 67.  H & P  Esophageal pH probe (preferred test) ◦ If <7.0 indicates presence of acid  Upper GI/ Barium Swallow  Endoscopy ◦ Visualization of esophageal abnormalities  Gastric Emptying Study pH probe
  68. 68.  Small frequent feedings of breast milk, predigested formula or thickened formula  Frequent burping  Positioning – ◦ Upright position (infant); rt side with head elevated  Prone position (if GERD is severe) ◦ Reflux wedge to keep head elevated (older child)  Avoid soft bedding, pillows, loose sheets  Avoid excessive handling after feedings  Medications  Surgery (Nissen fundoplication) Acid Reflux Wedge Reflux Sling
  69. 69.  Antacids (Neutralize gastric acid) Calcium carbonate (Tums)  Histamine-2 Receptor Antagonists (Inhibit gastric acid secretion) Ranitidine (Zantac) & Famotidine (Pepcid)  Proton-Pump Inhibitors (Block gastric acid secretion) Lansoprazole (Prevacid) Omeprazole (Prilosec) Esomeprazole (Nexium)  Prokinetic Agents (Accelerate gastric emptying/ stimulate GI motility) Metoclopramide (Reglan) & Low-Dose Erythromycin (EES)  Mucosal Surface Agents (Coat stomach lining) Sucralfate (Carafate)
  70. 70. 77
  71. 71. A 3-month-old infant has severe gastroesophageal reflux (GERD). The mother wants to know if there is anything she can do differently to decrease the reflux. Which of the following interventions should the nurse suggest to minimize reflux? A. Discontinue breast-feeding immediately. B. Decrease frequency of feedings as much as possible. C. Place the baby in prone position with the head elevated. D. Place the infant in a car seat after feeding. 78
  72. 72.  Nissen Fundoplication ◦ Stomach fundus wrapped around distal end of esophagus (LES) ◦ Reinforces LES, making it less likely that acid will back up in the esophagus ◦ After surgery: unable to burp/ regurgitate
  73. 73. A 9-year-old with severe esophagitis is 12 hours status/post-Nissen fundoplication for gastroesophageal reflux. To implement appropriate nursing care, the nurse should: A. Encourage him to take small amounts of clear liquids every 4 hours. B. Administer NG or gastrostomy feedings every 4 hours. C. Ask him to choose a face on the FACES pain rating scale. D. Insert a pH probe to monitor esophageal acidity. 80
  74. 74.  Omphalocele – Congenital malformation in which intra- abdominal contents herniate through the umbilical cord, with translucent sac intact  Gastroschisis – Herniation of the abdominal viscera outside the abdominal cavity (usually small intestine and ascending colon) 81
  75. 75. Herniation of abdominal contents through the umbilical cord. Contents are covered by a translucent sac
  76. 76.  Herniation of abdominal viscera outside the abdominal cavity through a defect in the abdominal wall to the side of the umbilicus. Not covered.
  77. 77. 84
  78. 78. Alpha- fetaoprotein (MSAFP) Provide an early diagnosis Prenatal Ultrasound Polyhydramnios
  79. 79.  Pre-operatively – Protect visceral contents/ sac; provide intravenous fluids ◦ Cover with warm, sterile, saline-soaked dressings ◦ Maintain temperature – esp. with gastroschisis (radiant warmer/ isolette) ◦ Sterile wrap or sterile bowel bag  May place silo or Silastic material over gut  Transfer to NICU  Nutrition: NPO & TPN (central venous line)  Strict I & O; VS qhourly  Gastric distention: NG tube  Infection control: broad spectrum abx
  80. 80.  Under general anesthesia, an incision is made to remove the sac membrane. The bowel is examined for signs of damage or additional birth defects  Damaged or defective portions are removed and the healthy edges stitched together  Viscera may be place in Silastic pouch and slowly returned to abdomen using gravity over several weeks
  81. 81. 88
  82. 82. Thermoregulation Loss of Fluids  Pain management  Prevent infection  Fluid & electrolyte balance  Assess for ileus  Maintain parenteral feedings  Provide support to the parents  Facilitate parent- infant bonding
  83. 83.  Intussusception – One portion of bowel prolapses/ telescopes into another portion- causes obstruction; may need surgery  Volvulus – Twisting of intestine- can lead to necrosis of the bowel- surgical emergency  Both are forms of bowel obstruction 90
  84. 84.  Most common cause of intestinal obstruction in young children  Infants 9 – 24 months; males more common  Bowel “telescopes” within itself
  85. 85.  A twisting of the midgut bowel that leads to a bowel obstruction
  86. 86.  Extreme paroxysmal pain (subsides then recurs)  Vomiting  Stools – resemble currant jelly  Sausage-shaped abdominal mass  Dehydration  Primary concern: bowel necrosis, perforation, sepsis 93
  87. 87. 94
  88. 88.  Diagnosis: H & P; abdominal x-rays/ US  CBC – leukocytosis  Stool – occult/ visible blood  Hydrostatic reduction (barium enema): 70 – 90% of cases ◦ Passage of brown stool (if successful)  NPO; IV/ NG tube  Surgery 96 Intraoperative appearance of ileoileal intussusception
  89. 89.  Most common during 1st month of life  Intermittent bilious vomiting  Firm abdomen with distention  Irritability secondary to pain  Passage of blood stools  Signs of obstruction  Dx: GI series/ contrast studies  Tx: Emergency surgery 97
  90. 90.  Assess for shock  Vital signs  I & Os  Intravenous fluids  Gradually increase feeding after NG tube removal  Discharge teaching 98
  91. 91.  Absence of ganglion cells in rectum & upward colon  Prevents peristalsis at that portion of the colon  Megacolon: mechanical obstruction of the colon  Symptoms: failure to gain weight; severe constipation  Newborns: failure to pass meconium; abdominal distension; bilious vomiting 99
  92. 92. Congenital disorder of nerve cells in lower colon No ganglionic nerve innervation or peristalsis in narrowed section Adjacent bowel becomes enlarged, causing abdominal distention
  93. 93. Failure to pass meconium Severe constipation Abdominal distension Reluctance to feed Bilious vomiting Failure to thrive Liquid or ribbon-like stools Recurrent fecal impaction Watery, bloody diarrhea Weight loss, Fatigue, Dehydration
  94. 94.  Severe diarrhea  Hypovolemic shock  Death 102
  95. 95. Diagnosis  History & Physical  Rectal biopsy- absence of ganglionic cells in bowel mucosa (definitive diagnosis)  Rectal manometry  Barium enema (X-ray) Management  Daily colonic lavage (saline)  Preoperative bowel prep  Surgical intervention ◦ Pull-through procedure ◦ Colostomy ◦ Resection
  96. 96. 104 Before pull-through surgery: The diseased segment doesn’t push stool. Step 1: The diseased segment is removed. Step 2: The healthy segment is attached to the remaining rectum.
  97. 97. Pre-op F & E balance Vital signs Colonic lavage (saline) Patient/parent teaching Post-op NPO Vital Signs – never take a rectal temperature Assessment Patient/parent teaching Colostomy care Skin care Nutrition
  98. 98. An infant returns from initial surgery for Hirschsprung’s disease. Because of the type of surgery the child had, the nurse would exclude from the routine postoperative plan-of-care instructions to: A. Maintain the child NPO until bowel sounds return. B. Monitor rectal temperature every 4 hours. C. Reunite the parents with the child as soon as possible. D. Assess the surgical site every 2 hours. 107
  99. 99. A child with Hirschsprung’s disease is being discharged after Soave endorectal pull-through procedure for colostomy closure. Which of these measures should the nurse include in the home care plan? A. Refer the parents to an enterostomal therapist for ostomy care. B. Teach parents how to perform weekly rectal irrigations. C. Teach parents signs and symptoms of infection. D. Teach parents PCA pain-control methods. 108
  100. 100.  Opening to anus is missing or blocked  Usually found with 1st rectal temperature at birth  Signs & symptoms: Failure to pass meconium within 24 - 48 hours after birth Missing or abnormal opening to anus Stool passes out of the vagina, base of penis, scrotum, or urethra (fistula) Swollen belly area (abdominal distention)  Treatment: Colostomy, PSARP procedure, anal dilations, colostomy closure  Nursing care: NPO; IV fluids; NG tube; I & O; emotional support for parents; post-surgical wound care; colostomy care; nothing per rectum! 110
  101. 101. 111 See Video Pull-Through (PSARP) Surgery Procedure
  102. 102.  Inguinal hernias – Protrusion of abdominal cavity contents through the inguinal canal; elective surgery recommended  Umbilical hernias – Weak closed umbilical ring; common in childhood; protrudes with coughing, crying, or straining; if strangulates the bowel- needs surgery  Diaphragmatic - Abdominal contents protrude into the thoracic cavity through an opening in the diaphragm Life-threatening condition Intubation required immediately Continued intensive care – level III NICU 112
  103. 103. 113  Painless swelling extending toward or into the scrotum  Elective surgery recommended  Soft midline swelling in umbilical area  Most resolve spontaneously  If strangulates – needs surgery  No tape, straps, or coins to reduce hernia
  104. 104. A mother arrives at clinic with her 6-month-old child. While the nurse is assessing the child, the mother points to the umbilicus and says: “What am I going to do about this? When he cries, it looks like it’s going to burst.” The nurse's best response would be: A. “It’s best if you don’t let him cry. Just let him do what he wants.” B. “It probably won’t rupture unless he gets real mad. I wouldn’t worry about it.” C. “I know it looks scary, but it really won’t burst.” D. “Put a binder around it, and that will keep it from bursting when he gets mad.” 114
  105. 105. 115  Congenital condition  Diaphragm fails to close completely  Abdominal contents enter chest cavity  Prevents lungs from expanding or developing
  106. 106.  Scaphoid (concave) abdomen  Respiratory distress  Cyanosis  Asymmetric chest movements (secondary to the hypoplastic lung)  Absent breath sounds on the affected side (secondary to the hypoplastic lung)  Shifted heart sounds  Bowel sounds in the chest 116
  107. 107.  Diagnosis: chest x-ray (reveals mass with air-filled bowel on affected side)  Immediate intubation with mechanical ventilation  Oro/ nasogastric tube (gastric decompression)  IV fluids  Position infant with affected side down to aid ventilation of the “good” lung  Cluster care/ minimal handling  Surgical correction  Parental support & education 117
  108. 108. While performing a newborn assessment, the nurse notices the infant is having difficulty breathing. Nasal flaring, cyanosis, and retractions are observed and there are no breath sounds on the left side. The apical pulse is auscultated on the right side of the chest. The nurse would notify the physician immediately because he or she suspects: A. Diaphragmatic hernia. B. Pyloric stenosis. C. Cleft palate. D. Omphalocele. 118
  109. 109. 119
  110. 110. 120 Inflammatory Disorders
  111. 111.  Appendicitis  Meckel’s Diverticulum 121
  112. 112.  Inflammation & obstruction of the blind sac at the end of the cecum  Medical emergency: appendectomy only cure  Most common cause of emergency surgery in children  Children ages 10 – 19 yrs  Ruptured appendix: ◦ Peritonitis, abscess, obstruction, electrolyte imbalances, septicemia, shock, & death 122 See video Appendicitis (Pathology)
  113. 113.  Earliest symptom: periumbilical pain, vomiting, rebound tenderness  Followed by: pain migrating to rt lower quadrant (classic sign), pain most intense at McBurney’s point, increases with movement  Low-grade fever, nausea, vomiting, diarrhea or constipation; anorexia; abdominal swelling  WBC > 10,000; shift to the left  Ruptured appendix: sudden pain relief followed by diffuse pain 123 See video Appendicitis (Nursing Assessment)
  114. 114. 12 5
  115. 115. 12 6
  116. 116.  Diagnosis: abdominal US/ CT scan  Appendectomy (open or laparoscopic)  NPO with NG tube until bowel function returns  IV fluids, VS, I & O  IV abx (e.g., ampicillin, clindamycin [or metronidazole], and gentamicin)  Pain management (morphine)  Monitor wound site, wound care  Discharge planning 127 See video Appendectomy (Pre-Operative vs Post-Operative)
  117. 117. 128
  118. 118. A 10-year-old boy has been admitted with a diagnosis of “rule out appendicitis.” While the nurse was conducting a routine assessment, the boy stated, “It doesn’t hurt anymore.” The nurse suspects that: A. The boy is afraid of going to surgery. B. The boy is having difficulty expressing his pain adequately. C. The appendix has ruptured. D. This is a method the boy uses to receive attention. 129
  119. 119. The mother of a child undergoing an emergency appendectomy tells the nurse “If I had brought him in yesterday when he complained of an upset stomach, this wouldn’t have happened.” The nurse’s best response is: A. “It’s okay; you got him here just in time before it ruptured.” B. “It is often difficult to predict when a simple complaint will become more serious.” C. “Next time he seems sick, you should bring him in immediately.” D. “Sometimes parents can make a mistake without meaning to do so.” 130
  120. 120.  Congenital pouch (diverticulum) approx 2” in length, located at the lower (distal) end of small intestine  Irritation, ulceration, infection  Bleeding (bright red or dark red blood oozing from rectum or in stool)  Volvulus (twisting)/ obstruction  Most common congenital malformation of GI tract (2% of population) 131
  121. 121.  Manifests before 2 yrs of age  Most common sign: painless rectal bleeding (currant jelly stools or stools bright or dark red with mucous) ◦ Iron deficiency anemia/ symptoms (paleness & fatigue) ◦ If undetected, severe anemia & shock can occur  As condition progresses: symptoms similar to intussusception or intestinal obstruction ◦ Mild to severe abdominal pain  Complications: hemorrhage, intussusception, perforation/ peritonitis  Dx: H & P; radionuclide imaging & scanning  Tx: abx, blood transfusion, iron replacement, bowel rest, IV fluids & nutrition; surgical removal of diverticulum or pouch 132
  122. 122.  Which of the following laboratory findings would the nurse expect to find in an 18-month old toddler with Meckel’s diverticulum?  A. Elevated white blood cell count.  B. Elevated blood urea nitrogen concentration.  C. Decreased platelet count.  D. Decreased red blood cell count. 133
  123. 123. 134 Motility Disorders
  124. 124.  Vomiting  Gastroenteritis/ Acute Diarrhea  Constipation  Encopresis 135
  125. 125.  Signs & Symptoms: ◦ Assessment includes description of onset, duration quality, quantity, appearance, presence of undigested food and precipitating event, dehydration  Additional Symptoms: ◦ Fever, diarrhea, ear pain, headache  Nursing Care: ◦ Treatment of the cause & prevent of complications ◦ Bowel is allowed to rest ◦ Oral or parental rehydration ◦ Bland solids reintroduced ◦ Antiemetic drugs ◦ Dehydration, monitor fluid intake & output ◦ Oral hygiene
  126. 126.  Gastroenteritis: inflammation of lining of stomach & intestines Most common symptoms: diarrhea, anorexia, nausea & vomiting, crampy abdominal pain, irritability  Diarrhea: disturbance of intestinal tract that alters motility and absorption, characterized by an increase in frequency, fluid content, and volume of stools Dehydration; hyponatremia, hypokalemia, metabolic acidosis  Most commonly virus (e.g., rotavirus, norovirus, adenovirus)  Bacterial causes 20% (e.g., Salmonella, Shigella, Escherichia coli, Clostridium difficile)  Parasites fewer than 5% (e.g., Giardia lamblia) 137
  127. 127.  Increase in peristalsis  Large volume stools (loose, watery, green)  Increase in frequency of stools  Nausea, vomiting, cramps  Increased heart & resp. rate, decreased tearing and fever  Complications: Dehydration Metabolic Acidosis
  128. 128.  Dehydration ◦ Mucus membranes dried, cracked ◦ Decreased elasticity of skin ◦ Depressed fontanels, eyes sunken & tearless ◦ Decreased urinary output, dark ◦ Listless, irritable  Metabolic Acidosis ◦ pH <7.35 ◦ HCO3 =/<22mEq/L Deficient Fluid Volume Risk for Electrolyte Imbalance Imbalanced Nutrition: Less than body requirements
  129. 129. Mild Moderate Severe Fluid Vol loss <50ml/kg 50-90ml/kg >100 ml/kg Skin Color Pale Gray Mottled Skin Elasticity Decreased Poor Very Poor M.M. Dry Very Dry Parched U.O. Decreased Oliguria <1 mL/kg/hr Marked Oliguria BP Normal Normal or lowered Lowered Pulse Normal or Increased Increased Rapid, thready Cap Refill <2 sec 2-3 sec >3 sec
  130. 130. 142
  131. 131. Stool Culture Stoolfor O&P Blood Gases pH  Stool Culture  Causative organism  Stool for O&P  ABGs to diagnose Metabolic Acidosis Loss of HCO3 from G.I. tract HCO3
  132. 132.  Prevention of spread of diarrhea: Contact/ enteric precautions Meticulous handwashing (soap & water) Rotavirus vaccination  Stools: onset, frequency, color, amount, & consistency  Assess for dehydration: Monitor I&O, vital signs, daily weights Skin color, temperature, turgor, capillary refill, assessment of fontanels Ask caregiver about vomiting, fever, # wet diapers during previous 24 hrs
  133. 133. 145
  134. 134. Skin care Promotion of rehydration; correction of electrolyte imbalances ◦ Oral rehydration (Pedialyte, Infalyte, Rehydralate) ◦ IV rehydration (Lactated Ringers or 0.9%NS)  Provision of age-appropriate nutrition  Prevention of complications  Support of child & family 146
  135. 135. Avoid fluids that are high in sugar – soft drinks, jello, fruit drinks, tea 50-100 mL/kg within 4 hrs
  136. 136. 148 No dehydration Oral rehydration salts Administer after each stool: Age Volume of ORS <2 years 50–100 ml, up to 500 mL/day 2–9 years 100–200 ml, up to 1000 mL/day ≥10 years As much as wanted, up to 2000 mL/day Some dehydration Oral rehydration salts Administer in first 4 hours: Age Weight Volume of ORS <4 months <5 kg 200–400 mL 4–11 months 5–7.9 kg 400–600 mL 1–2 years 8–10.9 kg 600–800 mL 2–4 years 11–15.9 kg 800–1200 mL 5–14 years 16–29.9 kg 1200–2200 mL ≥15 years 30 kg or more 2200–4000 mL Severe dehydration Intravenous Ringer’s Lactate or, if not available, normal saline and oral rehydration salts as outlined above Administer up to 200 ml/kg IV fluids in first 24 hours Age< 12 months Timeframe Total volume 0–30 min 30 ml/kg* 30 min–6 h 70 ml/kg 6 h–24 h 100 ml/kg Age≥ 1 year Timeframe Total volume 0–30 min 30 ml/kg* 30 min–3 h 70 ml/kg 3 h–24 h 100 ml/kg WHO Fluid Replacement or Treatment Recommendations
  137. 137.  Fewer than normal BMs; hard or lumpy stool consistency  Signs & Symptoms: ◦ Poor appetite, straining with stools  Additional Symptoms: ◦ Blood may occasionally be seen, tenderness in colon & small intestines, rectal fissures  Nursing Care: ◦ Focus: dietary intake, keeping the bowel relatively empty ◦ Fluids, fiber, physical activity ◦ Regular diet (fruits & fiber) ◦ Stool softeners; osmotic laxatives (e.g., Miralax) ◦ Chronic constipation may include bowel cleansing, maintenance therapy & bowel retraining
  138. 138.  Elimination disorder defined as repeated passage of feces in inappropriate places (involuntary or intentional), occurring beyond the usual age of toilet training completion (ages 4-5 yrs) and in the absence of an organic pathologic condition  Typically soils during the day; unaware of & unable to control soiling accidents  Chronic constipation with leakage of liquid feces (overflow incontinence)  Developmental crisis: affects peer, school, family relationships; self-esteem and sense of control 150
  139. 139. 15 1
  140. 140. 1. Establish routine bowel habits through regular toilet sitting with attempts to defecate 2. Oral lubricants or stool softeners to ensure passage of soft stools 3. Allow child to experience natural consequences associated with soiling (response cost) 4. Keep a daily chart of stooling activities 5. Retrain anorectal muscles 152 Bowel Incontinence Constipation Toileting Self-Care Deficit
  141. 141.  Talk to parents about defecation pattern/ ways to establish regular bowel habits  Evaluate dietary habits (fiber & water intake)  Child & caregiver instructed on the need to establish a toileting routine (healthy toilet training)  Management of children with constipation begins with a catharsis phase, followed by a maintenance phase & follow up care  Anticipatory guidance, caregiver support & education  Refer family for counseling 153
  142. 142. 154 Parasitic Disorders
  143. 143.  Protozoa or helminths (worms) ◦ Protozoa – single-celled organisms (often found in contaminated water sources) ◦ Helminths (worms) – multicellular organisms with complex body structure & organ systems  On the rise in the U.S.  Common causes ◦ Camping, sandboxes ◦ Ingesting untreated water ◦ Exposure to pets, wildlife  Young children in childcare most at risk  Treated with anthelmintic 155
  144. 144.  Giardiasis: diarrhea, vomiting, anorexia, failure to thrive  Pinworm: itching around anus at night leading to irritability/ restlessness  General symptoms of intestinal worms in children: decreased appetite, weight loss, nutritional deficiencies, nausea & vomiting, abdominal pain 156 See video Pinworms Pediatrics
  145. 145.  Diagnosis: ◦ Stool ova & parasite exam: to identify causative organism ◦ Nightly anal test (sticky tape): pinworm ◦ Complete blood count: eosinophilia  Treatment: anthelmintic medications (e.g., piperazine & mebendazole)  Preventive teaching: ◦ Good hygiene practices, handwashing ◦ Take prescription drugs as directed 157
  146. 146. Always wash hands/ fingernails with soap and water before eating and handling food and after feeding Discourage children from scratching bare anal area Use superabsorbent disposable diapers to prevent leakage Change diapers as soon as soiled and dispose of diapers in closed receptacle out of children’s reach Don’t rinse diapers in toilet Disinfect toilet seats & diaper-changing areas 158
  147. 147. Drink water that is specially treated, especially if camping Wash all raw fruits and vegetables or any food that has fallen on the floor or ground Teach children to defecate only in toilet, not on ground Keep dogs & cats away from play grounds/ sand boxes Avoid swimming in pools frequented by diapered children Wear shoes outside 159
  148. 148.  By which of the following are Ascarisas (roundworm) infections diagnosed?  A. Presence of larvae on the skin  B. Seeing the worm in the stool  C. A “Scotch tape test” in the early morning  D. Laboratory examination of stool specimen 160
  149. 149. 161 Malabsorption/ Feeding Disorders
  150. 150.  Colic  Failure to thrive (FTT)  Celiac disease  Lactose intolerance  Short bowel syndrome 162
  151. 151.  Paroxysmal abdominal pain (i.e., sudden recurrent attacks of abdominal pain)  Loud persistent continuous cry, ≥ 3 hrs duration, ≥ 3 days per week  Episodes occur at same time each day (late afternoon, early evening)  6 weeks – 3 or 4 months; no lasting effects  Flushed face; tense distended abdomen; legs drawn up on abdomen; hands clenched & drawn to body; infant may pass flatus or gas  Both breastfed and bottle fed babies get colic 163
  152. 152.  Rule out acute conditions or causes (e.g., obstruction, infection, sensitivity to formula)  Thorough detailed history: type, frequency, and amount of feeding; diet of breastfeeding mother; time of day when attacks occur; relationship of attacks to feeding time; caregiver activity before, during, and after crying; measures used to relieve the cry/ effectiveness  Five S’s: Swaddling, Shushing, Stomach position, Swinging, Sucking  Support parents  Educate parents on management 164
  153. 153.  A new mother has some questions about colic. Which of the following statements made by a nurse is not correct regarding colic?  A. “Lots of new babies have colic”  B. “Excessive crying tends to start in the late afternoon or early evening”  C. “Most colicky babies stop showing symptoms within 12 months”  D. “If you have a partner, take turns to do the soothing” 165
  154. 154.  Inadequate growth resulting from inability to obtain or use calories required for growth ◦ Slow growth/ inadequate weight gain per standards for children ≤ 6 yrs ◦ Weight < 5th percentile; <10% ideal BMI  Syndrome: not a single disease or medical condition  Multidimensional problem that requires multidisciplinary approach  Early intervention essential Tracking the growth rate
  155. 155.  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 ◦ No associated medical condition  Mixed ◦ Combination of organic & nonorganic causes  Complications: ◦ Poor intellectual, language, & reading skills ◦ Social immaturity ◦ Behavioral disturbances  Assessment ◦ Low growth for age ◦ Developmental delays ◦ Apathy
  156. 156.  Multidisciplinary team approach: provide adequate caloric & nutritional intake; promote normal growth & development; assist parents  Thorough history & physical  Accurate daily weights, I & O  Monitoring of height / weight / HC  Observation of infant / caretaker interaction  Calorie count to determine actual calories consumed  Meals & snacks: pleasant, regularly scheduled (e.g., every 3 hrs), not rushed, established routine, distractions minimized  Grazing in between meals/ snack times should be eliminated  Referral: Community resources
  157. 157.  Complete a comprehensive health history  Perform a physical examination  Educate regarding nutrition, feeding techniques, feeding cues  Offer support for caregivers and families  Report abuse or neglect 169
  158. 158. The nurse is teaching home feeding guidelines to the mother of a child with non-organic failure to thrive. Essential information to include would be the importance of: A. Regularly scheduled meals with limited snacks. B. Allowing the child to eat alone to minimize distraction. C. Not allowing the child to snack on “finger foods,” such as Cheerios, french fries, bananas. D. A relaxed mealtime with firm limits on behavior. 170
  159. 159.  Gluten sensitivity affecting small intestine; autoimmune reaction  Severe intestinal mucosal changes  Leading malabsorption problem in children  Inherited disposition with environmental triggers  Affects fat absorption: stools greasy, foul smelling, frothy (steatorrhea) 171
  160. 160. • Failure to thrive • Growth failure • Diarrhea • Abdominal distention • Anorexia • Malnutrition Stools: large, bulky & frothy Complications: Calorie/ protein deficiency, anemia, fatigue, soft deformed bones, joint pain, dental enamel defects, hemorrhaging, night blindness, peripheral neuropathy, neurological problems, depression
  161. 161. 173
  162. 162. The nurse is taking a nursing history from the mother of a child being admitted with flare-up of celiac disease. What piece of information would the nurse expect the mother to report? A. Steatorrhea. B. Increased appetite. C. Unusually pleasant behavior. D. Soft, formed stools. 174
  163. 163.  Assessment – Growth pattern, GI pattern  Diagnosis – serum IGA antitissue transglutaminase antibodies (tTGA) or IGA antiendomysial antibodies (EMA); Endoscopic biopsy  Treatment - Gluten-free diet  Gluten – bread, crackers, cereals, prepared meats, chocolate, ice cream, soups, sauces/ gravies, condiments, marinades, starch, malt, MSG, etc.  Nursing Care – Monitor for dehydration, encourage compliance with dietary restrictions, vitamin & mineral supplementation, support groups for patient and caregiver
  164. 164. The nurse is teaching the parents of a child with celiac disease about the dietary restrictions. The nurse would explain that the most appropriate diet for their child is: A. Gluten-free. B. Salt-free. C. Fat-free. D. High-calorie, low fat. 176
  165. 165. Wheat Rye Barley Oats Teach parents DIETARY REGULATIONS: Gluten Free Diet NO !
  166. 166. 178
  167. 167. The nurse has taught dietary restrictions to the 7-year-old child with celiac disease. After teaching, the child is allowed to choose a correct menu. The nurse would know that teaching was effective when the child chooses: A. Beef and barley soup, rice cakes, and celery. B. Ham and cheese sandwich with lettuce and tomato on rye toast. C. Beef patty on a hamburger bun and french fries. D. Baked chicken, green beans, and a slice of cornbread. 179
  168. 168.  Food intolerance due to absence or deficiency of lactase  Inability to digest lactose in milk or dairy products  Diarrhea develops rapidly after ingestion of milk  Bloating, cramping, abdominal pain, flatulence  More common: Asians, Native Americans, African Americans 180
  169. 169.  Diagnosis: based on H & P, decrease in symptoms with elimination of lactose from the diet, family history  Treatment: avoidance of milk based products, soy formula, lactase enzyme supplements, Lactaid Milk, calcium & Vit D supplementation  Nursing Care: ◦ Elimination of dairy products or the use of enzyme replacement ◦ Dietary education (alternative sources of calcium) 181
  170. 170.  Decreased ability to digest and absorb a regular diet because of shortened small intestine  Diarrhea, dehydration, malnutrition, FTT  TPN; Neocate (enteral)  Serial transverse enteroplasty (STEP) procedure  Nursing care: monitor F & E, monitor growth/ development; minimize complications; meticulous CVL care; prepare family for home therapy 182 • Center for Advanced Intestinal Rehabilitation (CAIR) (Boston Children’s Hospital) • Premier program for the treatment of SBS
  171. 171. 18 3
  172. 172. 184 Hepatic Disorders
  173. 173.  Bile ducts fail to develop or are closed; causes cirrhosis  End-stage liver disease, death by age 2 (if untreated)  Jaundice, clay-colored stools, dark urine, slow weight gain & growth, irritability, hepatomegaly  Diagnosis: H & P, laboratory evaluation, liver biopsy, diagnostic laparoscopy  Treatment: Kasai procedure (palliation); liver transplant (final option)  Nursing care: monitor vitals, I & O, daily weights, high calorie liquid feedings with MCT oil, vitamin supplementation, parent support & education 185
  174. 174. 186
  175. 175. •Damaged ducts removed, replaced with piece of infant's own intestine •Small intestine is divided (Roux-en-Y) •Section is brought up to the liver •Connection may be inside or outside liver 187
  176. 176. A 10-month-old with biliary atresia is being discharged after Kasai procedure. Which statement, if made by her parents, indicates that teaching with regard to her prognosis has been understood? A. “We are glad this problem was found so early; now everything will be fine.” B. “We will stop her liver medicine now that she is being discharged.” C. “We are happy to be able to stop that special formula and all of those vitamins.” D. “We know that even though surgery is over, she will likely need a liver transplant.” 188
  177. 177.  GI disorders due to many internal and external causes  Most involve pain, hydration risks, changes in diet  Preventive/ post-treatment education a large part of nurse’s role 189

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