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Gasrointestinal Disorders In Infants and Children

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1 Gasrointestinal Disorders In Infants and Children
Lori Fox, RN, MSN, APRN, BC References: Society of Pediatric Nursing : Pediatric Nursing Review Saunders Comprehensive Review for the NCLEX Exam 2002 Dorlands's Illustrated Medical Dictonary Twenty Sixth Edition 1981

2 General Energy Requirements: Depend/Based on energy expenditures from:
1. Basal Metabolism 2. Body Activity 3. Growth 4. Dynamic action of food 5. Fecal loss Requirements are the minimum estimated values needed (e.g. calories, vitamins etc.) Dynamic action of food= increased heat production after ingestion of food

3 General Distribution of Calories:
Important so foods chosen contain all essential elements Normal Full -Term Infant: Protein: 6-8 % Fat: % Carbohydrate: approximately 50-60%

4 General Water Requirements vary with energy produced or calories metabolized. Requirements affected by : fluid intake, protein and mineral content of diet, renal solute load, metabolic rate, respiratory rate and body temperature.

5 General Deficiencies or excess amounts of any of these requirements can lead to skin issues, metabolic issues, renal issues etc.

6 General Assessment Assessment should include: Diet history Frequency
Allergies Elimination patterns Diet history: Formula/Br milk: how much, how often Table foods: "typical meal" including snacks Food allergies Frequency of bowel movements, how many wet diapers/day and issues with constipation/diarrhea/blood in stool etc.

7 Disorders in Newborns/Young Infants
Imperforate Anus: "Incomplete development or absence of its normal position in the perineum"-Saunders, Third Edition-2002 Assessment findings: Failure to pass meconium/stool Absence or stenosis of the anal rectal canal Presence of an anal membrane External fistula to the perineum or genitourinary system Usually identified in NB nursery- exam is very important

8 Disorders in Newborns/Young Infants
Necrotizing Enterocolitis: "NEC" Common in neonatal period Increased risk with preemies Causative agent: conditions which cause vascular compromise to the intestine Sx/Sx: lethargy, apnea, bradycardia, hypotension, temperature instability Sepsis and asphyxia can cause this Symptoms in NB very similar, to that of sepsis, so have to put as differential in your diagnosis. ABD X-ray to look for increased gas produced from bacterial growth which invade the necrotic tissue created by asphyxic event

9 Disorders in Newborns/Young Infants
Pyloric Stenosis: A narrowing of the pyloric canal as it exits the stomach Projectile Vomiting=High index of suspicion. (hallmark) Olive sized bulge below the right costal margin (hallmark) Tx: pyloromyotomy=incision through muscle fibers of the pylorus Symptoms seen early 2 wks to 6months-not usually seen right away (until about 2 weeks or older) by it is an increasing hyperplasia and hypertrophy of the circular muscle at the pylorus Hypertrophy= increased thickening of a wall etc. More common in boys Projectile vomiting related to increased narrowing which leads to forceful vomiting Emesis does not contain bile Pyloromyotomy can be done via laparoscopy

10 Disorders in Newborns/Young Infants
Pyloric Stenosis Pyloroplasty Pyloroplasty- widen the narrowed/stenosed pylorus

11 Disorders in Newborns/Young Infants
Biliary Atresia: "obliteration or absence of extrahepatic biliary structures" Cause: Unknown Sx/Sx: Early jaundice; dark urine; pale stools (absence of bile); absorption issues→growth issues DX: Liver biopsy Atresia = congenital absence or closure of a normal body orifice or tubular organ Fat soluable vitamins not well absorbed so need to replace these with water-miscible forms Temporary correction can be done by creating a substitute duct (Kasai procedure) Liver transplant if atresia is uncorrectable

12 Disorders in Newborns/Young Infants
Esophageal Atresia (EA) and Tracheoesophageal Fistula (TEF) Atresia=absence or closure of a orifice or tubular organ Fistula: "tube like connection between two structures" Designated by the organs or parts which with it communicates (e.g. rectovaginal) P. 190 in review book- great explanations (number 4 and 5). Associated with polyhydramnios- excess amniotic fluid as fetus cannot swallow it Often associated with other disorders- especially cardiac, limbs etc.

13 Disorders in Newborns/Young Infants
Sx/Sx: Choking/Coughing during feeds can have intermittent cyanosis EA TEF Staged surgical repair (number 5 page 191 in review book) ligate=tie reanastomose= reconnect two formerly separate structures

14 Disorders in Newborns/Young Infants
Cleft Lip and Palate Congenital Defect -soft tissue or bony structure fails to fuse during embryonic development. Can be unilateral or bilateral Apparent at birth Causes: genetic; hereditary; environmental Closure of lip defect occurs before palate-first few weeks of life with palate around mo. Palate is closed after lip to allow for normal growth of the palate and done before child can develop speech problems.

15 Disorders in Newborns/Young Infants
Gastroesophageal Reflux (GER) Underdeveloped esophageal sphincter Some amount of GER is normal in newborns Often causes apnea

16 Disorders in Newborns/Young Infants
Hirschsprung's Disease (congenital aganglionosis megacolon): Absence of ganglion cells in the retum and colon Mechanical obstruction from inadequate motility DX: Rectal biopsy Serious Complication: Enterocolitis Tx: mild disease: relief of chronic constipation most children require surgery neonates often require temporary colostomy

17 Disorders in Young Infants
Intussusception: Prolapsing of one portion of the intesine into the lumen of the immediately adjoining part Occurs at about 6 months of age Causes: bowel lining abnormality; polyps; hyperactive peristalsis; unknown Inflammation→ swelling →obstruction →necrosis from occlusion of bowel blood supply Can be acute or chronic and can lead to peritonitis. Hallmark: RED Currant jelly like stool (red blood and mucous) TX: Barrium enema or water soluble contrast with air pressure to reduce invagination by hydrostatic pressure Surgery may include temporary colostomy


19 Disorders in Children Inflammatory Bowel Disease:
1. Crohn's disease=regional enteritis- asymmetrical and patchy lesions. Affects all layers of bowel wall; enlarged regional lymph nodes; occurs at any point along the GI tract. 2. Ulcerative colitis=symmetrical and contiguous GI ulcers Affects bowel mucosa; large intestine

20 Disorders in Children Causes: unknown- exacerbated by emotional factors Common to occur in Adolescents DX: made by barium enema; biopsy of GI mucosa; stool studies

21 Disorders in Children Appendicitis: Inflammation and obstruction of blind sac at end of cecum Results in ischemia; gangrene; perforation and peritonitis Causes: include: infections, dietary intake, constipation and parasites Common in school age children Pain that is diffuse- then localizes in right lower quadrant REBOUND tenderness in lower right quadrant Guarding; decreased bowel sounds, N/V Position in semi-fowlers on right side If ruptures often have sudden relief of pain followed by diffuse pain

22 Disorders in Newborns/Young Infants
Celiac Disease: Absence of intestinal mucosal cell enzyme →villi of small intestine atrophy → decreases absorption Gluten intolerance-FATTY STOOLS (Steatorrhea) and chronic diarrhea IgA deficiency and early introduction of protein solids related. Occurs around 2-4 months after solid foods introduced Glutens- rye, oat, wheat and barley Gluten malabsorption leads to fatty stools Gluten free diet: rice; corn, soy and potato flour; Probana formula and fresh fruit

23 Disorders in Children Parasitic Worms: Aquired through skin; ingestion of dirt or raw vegetables not well washed Pinworms are the most common Live in cecum and crawl to anus at night to lay eggs Tape test Anal itching; abdominal distention Medication used may discolor stool red Teach good handwashing technique and sanitary stool disposal Wearing shoes in infested area

24 Disorders in Children Viral Hepatitis: 1. A: Fecal -oral route
2. B: Blood and body secretions 3. C: predominantly parentally spread SX/SX: anorexia; malaise, fatigues easily, fever; jaundice and dark urine; pale stools DX: antigenic markers and body immune response HBIG for Hep B

25 Disorders in Children Acetaminophen Poisoning:
Hepatotoxicity is concern plasma levels greater than 200 µm/ml. Monitor for liver damage hours after overdose Mucomyst is an antidote (acetylcysteine)

26 Disorders in Children Vomiting and Diarrhea:
Issues= frequency, consistency; volume; support electrolytes and hydration Constipation: Frequency, consistency of stools (variation from normal for that child- not necessarily no daily stool) P. 186 of review book- USE CAUTION with recommendation under #3 intervention to add corn syrup to or sugar to infant formula this can lead to botulism.

27 Endocrine Disorders in Children
Inborn Errors of Metabolism: Tested for at birth after first 24 hours of feedings: Early diagnosis leads to better outcome PKU- defect in hydroxylation of phenylalanine to form tryosine →build up of phenylalanine → brain damage/mental retardation. Musty odor to urine

28 Endocrine Disorders in Children
Inborn Errors of Metabolism Con't: Galactosemia: deficiency in galactose enzyme →liver failure; renal tubular problems and cataracts Maple Syrup Urine Disease (MUD): Deficiency of decarboxylase that degrades amino acids →altered tone; seizures Urine has odor of maple syrup

29 Endocrine Disorders in Children
Diabetes Type I and Type II Review Endocrine section in review book-good overview.

30 Endocrine Disorders in Children
Hypothyroid Disease: Thyroid regulates basal metabolic rate CX: decreased secretion from a. Thyroid gland development issues b. Medications that suppress hormone production c. Thyroid relies on early dietary iodine and tyrosine for normal function

31 Endocrine Disorders in Children
Hypothyroid Disease Continued: SX/SX: Easy wt gain Fatigue/tiredness Dry, scaly skin Slow pulse Cool body temp Constipation

32 Endocrine Disorders in Children
Cushing Syndrome: Hyperadrenocorticism Hyper functioning of the adrenal gland. High levels cortisol → decreased ACTH secretion Cause: Tumor in pituitary gland/prolonged or excessive use of corticosteroids Sx/Sx: MOON FACE; muscle weakness; easy bruising; facial hair growth (hirsutism= excessive hair growth); decreased linear growth; HTN; mood disorders; poor wound healing TX: Taper steroids if possible ; remove tumor- Takes weeks/months for hormones to clear body

33 Endocrine Disorders in Children
Deficient Anterior Pituitary Hormone: Pituitary Dwarfism Results in decreased growth hormone Cause: idiopathic; brain tumor; trauma; lesions Normal body proportions, but short stature Bone age studies reveal growth retardation Tx: Administer growth hormone Emotional Support

34 Endocrine Disorders in Children
Hypersecretion of anterior pituitary hormone: Gigantism or acromegaly: Causes: hyperplasia of pituitary cells or pituitary tumor Bone age studies are normal. Signs of gigantism occur if increased release of hormone happens before growth plates close Elongation and enlargement of long bones, facial bones and accompanying body tissue Acromegaly = enlargement of the extremities of the skeleton Idiopathic = self originated or unknown cause Hyperplasia= Increase in the number of cells in normal arrangement in a tissue

35 Endocrine Disorders in Children
Hypersecretion of anterior pituitary hormone: Gigantism or acromegaly Continued: Late closure of fontanels Acromegaly if release of hormone occurs after growth plates close: enlarged hands; feet; nose; tongue; jaw Thickening of skin and facial features TX: Radiation may be used to retard growth Emotional support Acromegaly

36 TEST QUESTIONS 1. A 3 year old is hospitalized because of persistent vomiting. A nurse monitors the child closely for: a. Diarrhea b. Metabolic Acidosis c. Metabolic Alkalosis d. Hyperactive bowel sounds

37 TEST QUESTIONS 2. A nurse is monitoring for signs of dehydration in a 1 year old child who has been hospitalized for diarrhea. The nurse prepares to take the child's temperature and avoids which method of measurement? A. Tympanic B. Axillary C. Rectal D. Electronic

38 TEST QUESTIONS 3. A home care nurse provides instructions to the mother of an infant with cleft palate regarding feeding. Which statement if made by the mother indicates a need for further instructions? A. "I will use a nipple with a small hole to prevent choking" B. "I will stimulate sucking by rubbing the nipple on the lower lip" C. "I will allow the infant time to swallow" D. " I will allow the infant to rest frequently to provide time for swallowing what has been placed in the mouth"

39 TEST QUESTIONS 4. An infant has just returned to the nursing unit following a surgical repair of a cleft lip located on the right side of the lip. The nurse places the infant in which most appropriate position? A. On the right side B. On the left side C. Prone D. Supine

40 TEST QUESTIONS 5. A clinic nurse reviews the recoord of an infant seen in the clinic. The nurse notes that a diagnosis of esophageal atresia with trachesophageal fistula is suspected. The nurse expects to note which most likely sign of this condition documented in the record? A. Severe projectile vomiting B. Coughing at nightime C. Choking with feedings D. Incessant crying

41 TEST QUESTIONS 6. A nurse prepares a teaching plan for the parents of an infant with gastroesophageal reflux regarding proper positioning to manage reflux. The nurse documents that the infant should be maintained in which position following feedings and at night? A. 30-degree angle when supine B. 60-degree angle when supine C. Head-Elevated prone position D. 20-degree angle when supine

42 TEST QUESTIONS 7. A nurse provides feeding instructions to a mother of an infant diagnosed with gastroesophageal reflux.To assist in reducing the episodes of emesis, the nurse tells the mother to : A. Thin the feedings by adding water to the formula B. Thicken the feedings by adding rice cereal to the formula C. Provide less frequent, larger feedings D. Burp the infant less frequently during feedings

43 TEST QUESTIONS 8. A nurse admits a child to the hospital with a diagnosis of pyloric stenosis. ON admission assessment, which data would the nurse expect to obtain when asking the mother about the child's symptoms? A. Vomiting large amounts of bile B. Watery Diarrhea C. Increased urine output D. Projectile vomiting

44 TEST QUESTIONS 9. A nurse provides home care instructions to the parents of a child with celiac disease. The nurse teaches the parents to include which of the following food items in the child's diet? A. Rice B. Rye toast C. Oatmeal D. Wheat Bread

45 TEST QUESTIONS 10. A clinic nurse reviews the record of a 3 week old infant and notes that the physician has documented a diagnosis of suspected Hirshsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which symptom most likely led the mother to seek health care for the infant? A. Diarrhea B. Projectile vomiting C. Regurgitation of feedings D. Foul-smelling ribbon like stools

46 TEST QUESTIONS 11. A nurse is caring for a newborn infant with a suspected diagnosis of imperforate anus. The nurse monitors the infant, knowing that which of the following is a clinical manifestation associated with this disorder? A. Sausage-shaped mass palpated in the upper right abdominal quadrant B. Bile stained fecal emesis C. Failure to pass meconium stool in the first 24 hours after birth D. The passage of currant jelly -like stools

47 TEST QUESTIONS 12. The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child's record and expects to note which symptom of this disorder documented? A. Bright red blood and mucus in the stools B. Profuse projectile vomiting C. Watery Diarrhea D. Ribbon like stools

48 TEST QUESTIONS 13. A pediatric nurse educator provides a teaching session to the nursing staff regarding phenylketonuria. The nurse educator tells the nursing staff that: A. Phenylketonuria is an autosomal dominant disorder B. Treatment includes dietary restriction of tyramine. C. All 50 states require routine screening of all newborn infants for phenylketonuria. D. Phenylketonuria primarily affects the gastrointestinal system.

49 TEST QUESTIONS 14. A school-aged child with type 1 diabetes mellitus has soccer practice three afternoons a week. The school nurse provides instructions regarding how to prevent hypoglycemia during practice. The school nurse tells the child to: A. Take one half of the amount of prescribed insulin on practice days B. Eat twice the amount normally eaten at lunchtime. C. Take the prescribed insulin at noontime rather than in the morning. D. Eat 6 graham crackers or drink a cup of orange juice before soccer practice.

50 TEST QUESTIONS 15. A home care nurse is teaching an adolescent with type 1 diabetes mellitus about insulin administration and rotation sites. Which statement if made by the adolescent, would indicate effective teaching? A. "I need to use a location in one major site for the morning injection and another location for the same major site for the evening injection for 2 to 3 weeks before changing major sites" B. "I need to use a different site for each insulin injection" C. " I need to use the same site for 1 month before rotating to another site" D. " I should use only my stomach and my thighs for injections"

51 TEST QUESTIONS 16. The mother of a 6-year old who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive for ketones. The nurse instructs the mother to A. Come to the clinic immediately B. Hold the next dose of insulin C. Administer an additional dose of regular insulin D. Encourage the child to drink calorie-free liquids.

52 TEST QUESTIONS 17. A child with type 1 diabetes mellitus is brought to an emergency room by the mother, who states that the child has been complaining of abdominal pain and has a fruity odor of the breath. Diabetic ketoacidosis is diagnosed. Anticipating the plan of care, the nurse prepares to administer: A. 5% dextrose IV infusion B. Normal Saline IV infusion C. NPH insulin IV infusion D. Potassium IV infusion

53 TEST QUESTIONS 18. A two month old infant arrives at the pediatric clinic. Upon assessment, the baby exhibits the following characteristics. Which characteristic does the nurse relate to a diagnosis of congenital hypothyroidism? Select all that apply A. Open fontanels B. Protruding tongue C. Tachycardia D. Hypertonia E. Hypotonia Source: Child Health Nursing Second Edition: Reviews and Rationales 2007 Answer is : B and E (often accompanied by bradycardia). Open fontanels are normal for 2 month old

54 TEST QUESTIONS 19. An infant with congenital hypothyroidism shows which sing or symptom? A. Shrill Cry B. Diaphoresis C. Hypothermia D. Diarrhea Reference questions 19-: Straight A's In Pediatric Nursing-A review series Lippincott Williams and Wilkins, 2004

55 TEST QUESTIONS 20. The nurse administers oral thyroid hormone to an infant with hypothyroidism. The nurse should observe the infant for which signs of overdose? A. Tachycardia, fever, irritability, and sweating B. Bradycardia, cool skin temperature and dry scaly skin C. Bradycardia, fever, hypotension, and irritability D. Tachycardia, cool skin temperature and irritability

56 TEST QUESTIONS 21. The nurse draws blood from the heel of an infant for a Guthrie screening test. The Guthrie screening test is used to diagnose which inborn error of metabolism? A. Gludcose-6-phosphate dehydrogenase deficiency B. Phenylketonuria C. Galactosemia D. Hypothyroidism

57 TEST QUESTIONS 22. The nurse is teaching the mother of a child with diabetes how to recognize the sings an symptoms of hypoglycemia. Which signs and symptoms should the nurse discuss? A. Behavioral changes, increased heart rate, sweating and tremors B. Nausea, fruity breath odor, headache and fatigue C. Polydipsia, polyuria, polyphagia, and weight loss D. Enlarged tongue, hypotonia, easy weight gain and cool skin temperature.

58 TEST QUESTIONS 23. The nurse is assessing a child who might have diabetes. Which laboratory values help confirm a diagnosis of diabetes? A. A fasting plasma glucose level of 110mg/dl B. A fasting plasma glucose level of 126 mg/dl C. A random plasma glucose level of 180mg/dl A 2-hour glucose tolerance test of 140 mg/dl

59 TEST QUESTIONS 24. the nurse is teaching the parents of child with diabetes. Which agent should the nurse teach the parents to administer if their child suffers a severe hypoglycemic reaction? A. IV Dextrose B. Subcutaneous insulin C. Subcutaneous glucagon D. Oral fast-acting carbohydrate

60 TEST QUESTIONS 25. Which foods may be eaten by a child with galactosemia? Select all that apply. A. Instant Potatoes B. Chicken C. Lima Beans D. Whole Wheat Bread E. Apples F. 2% Cow's milk

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