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T HE C HILD WITH G ASTROINTESTINAL D YSFUNCTION Chapter 25 Christine Limann Dyer, RN, MSN, CPN.

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Presentation on theme: "T HE C HILD WITH G ASTROINTESTINAL D YSFUNCTION Chapter 25 Christine Limann Dyer, RN, MSN, CPN."— Presentation transcript:

1 T HE C HILD WITH G ASTROINTESTINAL D YSFUNCTION Chapter 25 Christine Limann Dyer, RN, MSN, CPN

2 G ASTROINTESTINAL S YSTEM Upper portion is responsible for nutrient intake (ingestion) Includes: Mouth Esophagus Stomach

3 D IGESTION Required to convert nutrients into usable energy Performs excretory function and detoxification Mechanical digestion Chemical digestion

4 G ASTROINTESTINAL S YSTEM Lower portion is responsible for remainder of digestion, absorption & metabolism Includes: Small intestine Large intestine Rectum Anus

5 A BSORPTION Principally from small intestine Osmosis Carrier-mediated diffusion Active energy-driven transport (“pump”) Large intestine Absorption of water Absorption of sodium Role of colonic bacteria

6 G ASTROINTESTINAL S YSTEM Accessory Structures: Liver Gallbladder Pancreas

7 I NGESTION OF F OREIGN S UBSTANCES Pica Food picas Nonfood picas Foreign bodies Nursing considerations

8 D EVELOPMENTAL A SPECTS ( EACH DEVELOPMENTAL STAGE CONTRIBUTES TO THE PROMOTION OF THE HEALTH OF THE CHILD ) Infant: Prevent choking Suck-swallow Frequent feedings Carefully introduce foods about 1 year of age

9 D EVELOPMENTAL A SPECTS Toddler: Weight gain (5-6 lbs/year) Deceased caloric needs Food “jags”

10 D EVELOPMENTAL A SPECTS Preschooler: Eats a full range of food Appetite fluctuation School-age: GI tract stable (digestive system is adult sized) Stools well formed

11 S TRUCTURAL G ASTROINTESTINAL D ISORDERS

12 U MBILICAL H ERNIA Signs & Symptoms: Soft midline swelling in the umbilical area Complications: Incarcerated (strangulated) Nursing Care: Most resolve spontaneously by 3-5 yrs of age Surgery (pre-post operative care) Discharge instructions

13 A NORECTAL M ALFORMATIONS Signs & Symptoms: Rectal atresia (closure) and stenosis (constriction or narrowing of a passage) Complications: Depends on the defect and accompanying multisystem involvement Nursing Care: Extensive treatment depending on defect and associated organ involvement Preoperative care (caregiver education & IV fluids) Postoperative care (pain control, s/s of infection, good skin care, NG tube, oral feedings resumed) Discharge instructions

14 O BSTRUCTIVE G ASTROINTESTINAL D ISORDERS

15 H YPERTROPHIC P YLORIC S TENOSIS C ONSTRICTION OF THE PYLORIC SPHINCTER WITH OBSTRUCTION OF THE GASTRIC OUTLET

16 H YPERTROPHIC P YLORIC S TENOSIS Signs & Symptoms: Typically: healthy, male infant: new onset non-bilious vomiting progressing to projectile vomiting Diagnosis: Palpating the pyloric mass (olive-shaped) Nursing Care: Surgery (Ramstedt pyloromyotomy) Assess dehydration, changes is VS, weight loss & discomfort Preoperative care (NPO, NG tube,) Postoperative care ( maintain fluids & electrolyte balance, feedings, infection, keeping the wound clean & pain relief) Discharge instructions (care of incision, s/s infection, response to feedings)

17 I NTUSSUSCEPTION Telescoping or invagination of one portion of intestine into another Signs & Symptoms: Acute abdominal pain, currant jelly stools, fever, dehydration, abdominal distention, lethargy and grunting due to pain Diagnostic evaluation Therapeutic management Prognosis Nursing considerations

18 I LEOCOLIC I NTUSSUSCEPTION

19 M ALROTATION AND V OLVULUS Malrotation is due to abnormal rotation around the superior mesenteric artery during embryonic development Volvulus occurs when intestine is twisted around itself and compromises blood supply to intestines May cause intestinal perforation, peritonitis, necrosis, and death Complications: Shock (signs include; tachycardia, tachypnea, hypotension & cool, clammy or cyanotic skin)

20 I NFLAMMATORY D ISORDERS

21 I RRITABLE B OWEL S YNDROME (IBS) Identified as cause of recurrent abdominal pain in children Classified as a functional GI disorder Alternating diarrhea and constipation Therapeutic management Nursing considerations

22 I NFLAMMATORY B OWEL D ISEASE (IBD) Two types Crohn’s Disese Ulcerative Colitis

23 U LCERATIVE C OLITIS (UC) Pathophysiology –inflamation in colon and rectum Clinical manifestations – ulceration, bleeding, anorexia, anemia

24 C ROHN ’ S D ISEASE Pathophysiology-Crohn's disease is an inflammatory bowel disease (IBD) Clinical manifestations-abdominal pain, severe diarrhea and even malnutrition Extraintestinal manifestations-arthritis, skin problems, fever, anemia Therapeutic management Medical- corticosteriods, Remicade for remission, 6-MP Surgical Nursing considerations – nutritional support, education

25 A PPENDICITIS Signs & Symptoms: Earliest symptom; periumbilical pain, vomiting Followed by: right lower quadrant pain (classic sign) Clinical Alert: Children who respond yes to being hungry most likely do not have appendicitis Nursing Care: Surgery Postoperative care (monitor intake & output, wound care, pain control, NPO until peristalsis returns, discharged home in 2-3 days) If perforate appendix intravenous antibiotics are given, NPO with NG tube until bowel function returns

26 O MPHALITIS Signs & Symptoms: Redness & edema of the soft tissue Diagnosis: Culture obtained to confirm diagnosis Nursing Care: Prevention by good perinatal care & caregiver education Intravenous broad- spectrum antibiotics

27 M ECKEL D IVERTICULUM Most common congenital malformation of the GI tract Band connecting small intestine to umbilicus Signs & Symptoms: Abdominal pain, painless rectal bleeding, stools (bright or dark red with mucus) Complications: If undetected severe anemia & shock can occur Nursing Care: Surgical removal of the diverticulum or pouch Postoperative antibiotics Correct fluid & electrolyte imbalances Monitor for shock & blood loss Provide rest Fluid replacement & NG tube

28 F UNCTIONAL G ASTROINTESTINAL C ONDITIONS

29 I NFANTILE C OLIC Signs & Symptoms: Persistent, unexplained crying – younger than 3 months Episodes occur at the same time each day Diagnosis: Based on symptoms occurring for more than 3 weeks, for 3 days (2-3 hours a day) Nursing Care: Rule out acute conditions Management strategies (see Box 25-1)

30 A CUTE D IARRHEA Signs & Symptoms: Increased frequency & fluid content of the stools with or without associated symptoms Additional Symptoms: Caregiver asked about vomiting, fever, pain, number of wet diapers in previous 24-hours) Nursing Care: Hydration & dietary needs Pharmacology treatment not ordered IV fluids essential with impaired circulation and possible shock

31 C HRONIC D IARRHEA Signs & Symptoms: Reflective of underlying pathology History of the diarrhea; frequency & appearance Additional Symptoms: Abdominal distention or tenderness, hyperactive bowel sounds, dehydration & condition of the perineal area Nursing Care: Treat the underlying cause Enteral or TPN is provided for the child who is unable to maintain adequate oral intake Caregiver educated on prevention

32 V OMITING Signs & Symptoms: Assessment includes description of onset, duration quality, quantity, appearance, presence of undigested food and precipitating event Additional Symptoms: Fever, diarrhea, ear pain, headache Nursing Care: Treatment of the cause & prevent of complications Bowel is allowed to rest Rehydration Bland solids reintroduced Antiemetic drugs Dehydration, monitor fluid intake & output Oral hygiene

33 C YCLIC V OMITING S YNDROME Signs & Symptoms: Recurrent episodic vomiting, usually lasts hours. Vomiting occurs at regular intervals, usually every two to four weeks Diagnosis: Rule out other conditions Nursing Care: Supportive care: fluid replacement, rest, pharmacotherapy & psychiatric evaluation Calm stress-free environment

34 C ONSTIPATION An alteration in the frequency, consistency, or ease of passage of stool May be secondary to other disorders Idiopathic (functional) constipation—no known cause Chronic constipation—may be due to environmental or psychosocial factors

35 N EWBORN P ERIOD First meconium should be passed within 24 to 36 hours of life; if not assess for: Hirschsprung disease, hypothyroidism Meconium plug, meconium ileus (CF)

36 I NFANCY Often related to diet Constipation in exclusively breastfed infant almost unknown Infrequent stool may occur because of minimal residue from digested breast milk Formula-fed infants may develop constipation Interventions - adding cereals, fruits and vegetables may help (after 4 months)

37 C ONSTIPATION IN C HILDHOOD Often due to environmental changes or control over body functions Encopresis: inappropriate passage of feces, often with soiling May result from stress Management

38 N URSING C ONSIDERATIONS History of bowel patterns, medications, diet Educate parents and child Dietary modifications (age appropriate)

39 2 week old Joey is brought into the clinic by his mom because he hasn’t had a bowel movement in two days. He is not eating and has abdominal distention. She states that he didn’t pass meconium until the day after his birth. 1. Describe the structural anomaly associated with Hirshbrung’s disease. 2. How is Hirshbrung’s diagnosed? 3. List 2 actual NANDA and 1 risk 4. If Joey is diagnosed with Hirsbrung’s Disease, what is the likely surgical intervention? 5. What are possible complications for an older child? Case Study

40 H IRSCHSPRUNG D ISEASE Also called congenital aganglionic megacolon Mechanical obstruction from inadequate motility of intestine Incidence: 1 in 5000 live births; more common in males and in Down syndrome Absence of ganglion cells in colon

41 H IRSCHSPRUNG D ISEASE Signs & Symptoms: Failure to pass meconium within the first 48 hours of life, failure to thrive, poor feeding, chronic constipation, & Down syndrome Complications: Entercolitis is the most ominous presentation (abrupt onset o foul smelling diarrhea, abdominal distention & fever. Rapid progress may indicate perforation & sepsis Nursing Care: Surgical resection (colostomy) Preoperative care (fluid & electrolyte status, NPO, NG tube, IV fluids) Postoperative care (maintain NG tube, monitor for abdominal distension, assess for bowel sounds) Teach caregiver how to car for colostomy, s/s of complications)

42 C LINICAL M ANIFESTATIONS OF H IRSCHPRUNG D ISEASE Aganglionic segment usually includes the rectum and proximal colon Accumulation of stool with distention Failure of internal anal sphincter to relax Enterocolitis may occur

43 D IAGNOSTIC E VALUATION X-ray, barium enema Anorectal manometric exam Confirm diagnosis with rectal biopsy

44 T HERAPEUTIC M ANAGEMENT Surgery Two stages Temporary ostomy Second stage “pull-through” procedure Preoperative care Postoperative care Discharge care

45 G ASTROESOPHAGEAL R EFLUX (GER) Defined as transfer of gastric contents into the esophagus Occurs in everyone Frequency and persistency may make it abnormal May occur without GERD GERD may occur without regurgitation

46 GER Diagnostics Therapeutic management Nursing considerations

47 M ALABSORPTION D ISORDERS

48 L ACTOSE I NTOLERANCE Signs & Symptoms: Bloating, cramping, abdominal pain & flatulence Diagnosis: Based on history/physical & decrease in symptoms with elimination of lactose from the diet Nursing Care: Elimination of dairy products or the use of enzyme replacement Dietary education (alternative sources of calcium)

49 C ELIAC D ISEASE Also called gluten-induced enteropathy and celiac sprue Four characteristics Steatorrhea-fatty stool General malnutrition Abdominal distention Secondary vitamin deficiencies

50 C ELIAC D ISEASE ( CONT.) Pathophysiology Diagnostic evaluation Therapeutic management Nursing considerations

51 S HORT B OWEL S YNDROME (SBS) A malabsorptive disorder Results from decreased mucosal surface area, usually as result of small bowel resection Etiology and pathophysiology Result of decreased mucosal surface area, usually due to extensive resection of small intestine Other causes NEC, volvulus, gastroschisis, Crohn disease in

52 T HERAPEUTIC M ANAGEMENT OF SBS Nutritional support—first phase: TPN Associated risks and complications Second phase: enteral feeding Long-term maintenance Medical therapies Surgical therapies Nursing Care: Feeding tolerance Emotional & developmental needs Assist parents with coping Home care services

53 H EPATIC D ISORDERS

54 B ILIARY ATRESIA, OR EXTRAHEPATIC BILIARY ATRESIA (EHBA) Signs & Symptoms: Jaundice, dark urine, lighter (tan-white) than normal stools, poor weight gain, failure to thrive, pruritus, hepatomegaly, splenomegaly Diagnosis: Early diagnosis in the key to survival. Nursing Care: Primarily supportive & focuses on providing nutritional support Surgical resection: correct obstruction & provide drainage of bile from the liver into the intestines Preoperative care (educate family & long term care) Postoperative care (educate family on skin & stoma care, nutritional therapy, complications, psychological support) Potential transplant

55 C IRRHOSIS Signs & Symptoms: Vary depending on the cause Jaundice, growth failure, muscle weakness, anorexia & lethargy Diagnosis: Based on history, laboratory values & liver biopsy Nursing Care: Preventing & treating complications Nutritional support Liver transplant Monitor for complications Comfort measures & emotional support

56 H EPATITIS Signs & Symptoms : Headache, anorexia, malaise, abdominal pain, nausea & vomiting Diagnosis: Based on history of exposure, symptoms & serologic testing Nursing Care: Primarily supportive: no specific treatment Provide rest to the liver, hydration, maintain comfort, adequate nutrition, & prevent complications Immune globulin given to children who have been exposed to a person with HAV Vaccine available for HAV, HBV & HDV Educate family regarding prevention measures (see Critical Nursing Actions Prevention of Hepatitis A and Hepatitis B)

57 A BDOMINAL T RAUMA : I NJURIES Injuries are the leading cause of death in children Ten percent of serious trauma occurs as a result of abdominal & genitourinary injury See Table 25-5 Injuries Caused by Abdominal Trauma

58 D EHYDRATION Types of dehydration Diagnostic evaluation Therapeutic management Nursing considerations 1 st treatment- Oral hydration Solution-OHS

59 D AILY M AINTENANCE F LUID R EQUIREMENTS Calculate child’s weight in kg Allow 100 ml/kg for first 10 kg body weight Allow 50 ml/kg for second 10 kg body weight Allow 20 ml/kg for remaining body weight

60 E XAMPLE 1: D AILY F LUID C ALCULATION Child weighs 32 kg 100 x 10 for first 10 kg of body weight = x 10 for second 10 kg of body weight = x 12 for remaining body weight = = 1740 ml/24 hr

61 E XAMPLE 2: D AILY F LUID C ALCULATION Child weighs 8.5 kg 100 x 8.5 for first 10 kg of body weight = 850 No further calculations 850 ml/24 hr

62 E XAMPLE 3: D AILY F LUID C ALCULATION Child weighs 14 kg 100 x 10 for first 10 kg of body weight = x 4 for second 10 kg of body weight = 200 No further calculations = 1200 ml/24 hr

63 H OMEMADE E LECTROLYTE S OLUTION 2 quarts water 1 teaspoon baking soda 1 teaspoon salt 7 Tablespoons sugar 1/2 teaspoon salt substitute


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