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Gi lecture nurs 3340 fall 2014

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  • 1. Alterations in Gastrointestinal Functioning Joy A. Shepard, PhD(c), RN-C, CNE Joyce Buck, MSN, RN-C, CNE
  • 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. 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.  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
  • 6. 6
  • 7. 7 Pediatric GI Differences
  • 8. 8
  • 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.  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
  • 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.  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 Pediatric GI History & Physical
  • 15.  Birth weight  Prematurity  History of maternal infection  Polyhydramnios
  • 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
  • 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
  • 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. UGI Series with Barium 5-year-old s/p MVA Diagnosis: hematoma of duodenum Treatment: NG tube, IV fluids, electrolyte maintenance
  • 22. Diagnosis of appendicitis, tumors, abscess
  • 23. Endoscopy Colonoscopy
  • 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.  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.  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. 30 Developmental Disorders/ Structural Defects
  • 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.  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. 33
  • 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.  Assessing family reactions  Providing emotional support  Facilitating feeding  Providing parent education  Assisting parents ◦ With coordinating care ◦ With maintaining healthy environment  Making referrals 35
  • 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.  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.  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.  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. 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.  Airway management  Feeding  Suture care  Restraints  Referrals to appropriate team members ◦ Identify and address home/family needs well in advance of discharge 41
  • 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. 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.  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. 46
  • 43. 47 Assessment of every newborn during the first feeding is essential!
  • 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.  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. Maintain airway •jlkjfj Keep NPO- administer IV fluids Elevate HOB 45 degrees Suction PRN Give Prophylactic antibiotics
  • 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. 52 Feeding Your Child with the Gravity Method
  • 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. 54
  • 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. 57
  • 53. 58
  • 54. 59
  • 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.  Diagnosis: ◦ Abdominal ultrasound ◦ Upper gastrointestinal (UGI) series (barium swallow) ◦ Blood tests: hypochloremia, hypokalemia, metabolic alkalosis  Treat dehydration & electrolyte imbalances  Treatment: Surgery Pyloromyotomy 61
  • 57. 62
  • 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. 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.  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.  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.  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. 68
  • 64. 69
  • 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.  Heartburn or chest pain  Abdominal pain  Dysphagia  Wheezing, stridor, cough, hoarseness  Ear infections, sinus problems  Recurrent pneumonia/ asthma  Regurgitation
  • 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.  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.  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. 77
  • 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.  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. 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.  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. Herniation of abdominal contents through the umbilical cord. Contents are covered by a translucent sac
  • 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. 84
  • 78. Alpha- fetaoprotein (MSAFP) Provide an early diagnosis Prenatal Ultrasound Polyhydramnios
  • 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.  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. 88
  • 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.  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.  Most common cause of intestinal obstruction in young children  Infants 9 – 24 months; males more common  Bowel “telescopes” within itself
  • 85.  A twisting of the midgut bowel that leads to a bowel obstruction
  • 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. 94
  • 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.  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.  Assess for shock  Vital signs  I & Os  Intravenous fluids  Gradually increase feeding after NG tube removal  Discharge teaching 98
  • 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. 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. 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.  Severe diarrhea  Hypovolemic shock  Death 102
  • 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. 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. 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. 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. 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.  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. 111 See Video Pull-Through (PSARP) Surgery Procedure
  • 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. 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. 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. 115  Congenital condition  Diaphragm fails to close completely  Abdominal contents enter chest cavity  Prevents lungs from expanding or developing
  • 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.  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. 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. 119
  • 110. 120 Inflammatory Disorders
  • 111.  Appendicitis  Meckel’s Diverticulum 121
  • 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.  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. 12 5
  • 115. 12 6
  • 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. 128
  • 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. 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.  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.  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.  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. 134 Motility Disorders
  • 124.  Vomiting  Gastroenteritis/ Acute Diarrhea  Constipation  Encopresis 135
  • 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.  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.  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.  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. 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. 142
  • 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.  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. 145
  • 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. Avoid fluids that are high in sugar – soft drinks, jello, fruit drinks, tea 50-100 mL/kg within 4 hrs
  • 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.  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.  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. 15 1
  • 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.  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. 154 Parasitic Disorders
  • 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.  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.  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. 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. 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.  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. 161 Malabsorption/ Feeding Disorders
  • 150.  Colic  Failure to thrive (FTT)  Celiac disease  Lactose intolerance  Short bowel syndrome 162
  • 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.  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.  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.  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.  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.  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.  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. 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.  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. • 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. 173
  • 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.  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. 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. Wheat Rye Barley Oats Teach parents DIETARY REGULATIONS: Gluten Free Diet NO !
  • 166. 178
  • 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.  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.  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.  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. 18 3
  • 172. 184 Hepatic Disorders
  • 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. 186
  • 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. 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.  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