1. The Child with a Gastrointestinal Alteration
Pilar C. Smith, RN, BSN
Lake Sumter Community College

2. Cleft Lip and Palate
Cleft lip results when the medial nasal and maxillary processes fail to join at 6 to 8 weeks of gestation.
Cleft palate results from failure of the primary patatal shelves, or processes, to fuse at 7 to 12 weeks of gestation.

3. Manifestations/Diagnostic Assessment
Cleft lip:
A notched vermilion border, cleft that involve the alveolar ridge and dental anomalies.
Cleft palate:
includes nasal distortion, midline or bilateral cleft with variable extension from the uvula, soft and hard palates and exposed nasal cavity. First sign may be formula coming from the nose
Diagnostic is based on observation at birth and complete examination in the neonatal period.

4. Assessment
Assess infant’s ability to suck, swallow and breathe without distress and handle normal secretions.
Assess and record parents’ reactions as well as interaction with the neonate.
Provide information about the causes of the defect
Encourage bonding through touching, holding and examining their newborn.
Point out the newborn’s positive attributes.

5. Intervention Describe the degree of cleft and impairment of sucking.
Modify feeding techniques as needed to allow adequate growth
Provide alternative assistive feeding devices
Hold infant in a more up-right position
Burp infant more frequently
Write down feeding program for parents to use at home
Provide emotional support and positive reinforcement to parents
Keep and accurate record of child’s growth by using a growth chart.
Orthopedic Latham device is use to expand and realign
Explain preoperative and postoperative procedure

6. Surgical Intervention
Cleft lip repair is usually performed by age 3 to 6 months. Cosmetic modification may be needed at age 4 to 5 years.

7. Surgical Intervention
Preoperative care:
Oral feeding withheld for 6 hours
IV line placement
Postoperative care:
Keep straws, pacifiers, spoons, or fingers away from the child’s mouth for 7 to 10 days
Do not take temperature orally
Advance the child’s diet as tolerated from clear liquids to soft diet within 48 hours.

8. Nursing Diagnoses
Alteration in nutrition less then body requirement related to the inability to suck
The child will drink the recommended amount of feeding within 30 minutes
Knowledge deficit about feeding techniques and surgery related to unfamiliarity with the information
The parent will understand expected preoperative and postoperative feeding techniques.

9. Esophageal Atresia with Tracheoesophageal Fistula
Esophageal atresia with TEF are congenital malformations in which the esophagus terminates before it reaches the stomach and/or a fistula is present that forms an unnatural connection with the trachea.

10. Manifestations Failure to pass suction catheter or NGT at birth
Excessive oral secretions
Vomiting
Abnormal distention
Airless, scaphoid abdomen (atresia without fistula)
3 “Cs” coughing and choking with feeding and cyanosis

11. Diagnostic Assessment:
Hx. of maternal polyhydramnios (prenatal clue)
IF NG tube cannot be passed 10 to 11 cm beyond the gum line
Abdominal radiograph (X-ray) with water-soluble contrast medium < 1ml via NGT
Bronchoscopy and endoscopy

12. Management Keep infant warm and oxygenated
Keep infant supine with the HOB elevated to keep gastric secretions from entering the lungs
NGT aspirate every 5 to 10 minutes to keep the keep the proximal pouch clear
Intravenous IV fluids are essential
Surgical repair: Ligation of the fistula and end-to-side anastomosis of the atresia
Nursing diagnosis and planning(read pp )

13. GER in children GER vs GERD.. Page 522
Symptoms range from physiologic to pathologic
Diagnostic exam includes barium swallow, upper GII study, endoscopy
Management: dietary alterations, positional changes, medications and surgery
Diet: predigested formulas.. Nutramigen or progestimal, freq, small feedings, freq. burping, ? Thickened feedings
Positioning : supine

14. GER continued
Medications: antacids for symptom relief, H2 receptor antagonists.. Cimetidine, ranitidine to decrease acid secretion, mucosal protectors, eg. Sucralfate for barrier protection and PPI’s ompeprazole to suppress gastric acid secretion and prokinetic agents metoclopramide to accelerate gastric emptying
Prevent complications
Nursing care plan on page

15. Constipation and Encopresis
Definition: page 529
Etiology: change in diet, lack of exercise, emotional stress certain drugs pain from anal fissure or excessive milk intake
Encopresis generally affects a child from 3 to 7 years old more often in boys than girls.
Constipation affects children at any age.
s/s: constipation versus encopresis page 530
Abdominal x-ray DRE

16. Constipation and Encopresis cont..
Therapeutic Management Page 530
Nursing Care: Assessment
Nursing Diagnosis and Planning..page 531
Interventions: Overcoming withholding, dietary changes, changing the retention habit, emotional support, home care

17. IBS Increased intestinal motility which can lead to spasm and pain
Etiology: stress and emotional factors, lactose deficiency, tends to occur in families with a HX of bowel disturbances can occur as constipation or diarrhea
S/S : abd pain unrelated to meals or activity Normal growth mucous in stool

18. IBS cont
Do definitive treatment Goal is aimed at identifying and reducing triggers and reducing bowel spasms which decreases triggers
Diet is healthy well balanced moderate fiber lower fat diet
Encourage child to eat slow and no carbonated beverages, no juices
Med’s: EC peppermint oil capsules, antispasmodics such as Levsin and Donnatal and antidepressants in severs cases.
Psychosocial support

19. Gastroenteritis Cause: viruses, bacteria and parasites
Etiology: ingestion of contaminated food or water and person to person contamination. High risk groups are children in daycare centers, preschools and long term care facilities and those infected with HIV
Giardia is the most common seen in children in day care and rotovirus is the most common seen in infants and young children
Page 535 characteristics of infectious gastroenteritis

20. Gastro. Cont.
S/S diarrhea, vomiting abdominal pain tenesmus and fever dehydration is a consequence of gastro
Stool culture O&P
Management: replace water and electrolytes
Prevention Rotovirus vaccine at age 2,4, 6 months
What do we assess?
Nursing Diagnosis- page 537
Interventions- page 537

21. Ulcers
Types
Etiology
Diagnostic tests
S/S
therapeutic management

22. Appendicitis
Pain progressing in intensity and localizing to the RLQ at Mc Burney point page 538
Diagnostic evaluation?
Therapeutic management?
Nursing Diagnosis
Interventions

23. Volvulus
Malrotation or twisting of the bowel that results in obstruction.
S/S pain, bilious vomiting
Surgery is the cure

24. Hypertrophic Pyloric Stenosis
Hypertrophic pyloric stenosis results when the circular area of muscle surrounding the pylorus hypertrophies and obstructs gastric emptying.

25. Manifestation
Progressive projectile vomiting , especially after eating
On palpation:
Right upper quadrant movable firm olive-shaped mass can be felt
Visible peristaltic waves
from left upper to right upper quadrant immediately before vomiting.
Dehydration:
absence of tears, a weak cry, depressed fontanel, poor skin turgor and dry mucous membrane.
Metabolic Alkalosis

26. Diagnostic Assessment
history of vomiting, visible peristalsic waves and a palpable pyloric mass
X-ray or US of the abdomen,
Barium swallow
Metabolic alkalosis
Decreased serum potassium and sodium levels
Increased Ph and sodiumbicarbonate, and decreased chloride.
Indirect Bilirubin may be elevated.

27. Management IV fluids and electrolyte replacement
NGT for stomach decompression
Surgery:
Pyloromyotomy, an incision of the pyloric muscle to release the obstruction done by Laparoscopy.
Pre and postoperative care and home care.(read Rowen pp )
Assess family dynamics and support system

28. Nursing Diagnoses Fluid and electrolyte deficit related to vomiting
Alteration in nutrition less then body requirement related to vomiting

29.   Intussusception
Inussusception is an invagination of a section of the intestine into the distal bowel that causes bowel obstruction

30. Manifestation Classic sign Listlessness
Passage of bloody mucus (“currant jelly”) stool and diarrhea
A sausage- shape abdominal mass
Listlessness
Paroxysm pain (pain that comes and go) than becomes more constant
Distention, hypo or hyperactive bowel sounds
Sign and symptoms of dehydration
Symptoms of shock and sepsis if obstruction has been present for longer than 12 to 24 hours
Fever, increased heart rate, changes in LOC

31. Management
The goal is to restore the bowel to its normal position and function.
Hydrostatic reduction if child does not have symptoms of shock or sepsis.
Barium enema or air enema.
Ultrasound-guided isotonic saline enemas
Surgery:
Laparoscopy is use if no bowel necrosis is present.

32. Nursing Diagnoses
Ineffective tissue perfusion related to (GI) bowel compression.
Acute pain related to bowel obstruction and surgery

33. Hirschsprung disease
Hirschsprung disease is caused when parasympathetic ganglion cells in the wall of the large intestine(colon) do not develop before birth. Without these nerves, the affected segment of the colon lacks the ability to relax and move bowel contents along.

34. Manifestation
Delayed or absence of meconium stool in the neonatal period (cardinal sign)
Constipation since neonatal period
Frequent passage of foul-smelling ribbonlike or pelletlike stools
Malnutrition
Abdominal pain and distention
Failure to thrive

35. Diagnostic Assessment
Rectal examination:
tight internal sphincter and absence of stool, follow by an explosive release of gas and stool
Barium enema
Rectal biopsy (definitive)
Absence of ganglia cells confirm the diagnosis

36. Management Treatment for mild to moderate
Stool softener to relieve constipation and rectal irritation
Treatment for moderate to severe:
Surgical intervention: the aganglionic portion of the intestine is removed in two steps.
In the neonatal period, performing a temporary colostomy.
A complete surgical repair when the child weights 8 to 10 kg (18 to 20 Lbs), the colostomy is closed during this time.
Assess family member’s concerns and way of coping with the problem

37. Nursing Diagnoses
Constipation related to aganglionic bowel and inadequate peristalsis
Impaired skin integrity related to colostomy and surgical repair.

38. Celiac disease
Celiac disease, also known as gluten enteropathy results from the inability to digest fully the protein part of wheat, barley, rye, and oats.
This results in the accumulation of glutamine in the intestine, which has a toxic effect in the mucosal cell.
This leads to atrophy of the villi and decrease absorption of fat, carbohydrates and vitamins.
It can cause severe diarrhea and dehydration.

39. Manifestation Profuse diarrhea especially foul-smelling fatty stools
Growth failure: bellow the twenty-fifth percentile
Abdominal distention and ascites
Anemia
irritability
anorexia
muscle wasting
folate deficiency
Edematous extremities

40. Diagnostic Assessment
Serum antigliadin antibody (AGA) assay
allows continued assessment and evaluation of dietary changes
Tissue transglutaminase (tTG)
Breath hydrogen excretion test
identify carbohydrate malabsorption.

41. Management
All wheat, rye, barley, and oat should be eliminated from the diet
Replaced with corn and rice
Fat-soluble vitamins supplement and folate
Fluid replacement if child is dehydrated from severe watery diarrhea
Correct acid-base imbalance
Albumin to treat shock
Corticosteroids to decrease severe mucosal inflammation

42. Nursing Diagnoses
Imbalance nutrition less then body requirement related to malabsorption
Delayed growth and development related to malnutrition

43. Lactose Intolerance Inability to tolerate lactose
Most case of lactose intolerance are the result of inadequate lactase
S/S diarrhea that is frothy, abdominal distention, cramping pain and increase flatus
+1 or greater sugar values on stool clinitest can support the diagnosis
Management: remove the milk
ND: page 553

44. reference
Health topics A-Z University of Virginia Health System Healthline connect to better health Rowen,S. J., Weiler, J. A. (2007). The child with a gastrointestinal alteration. In NursingCare of children principles and practice. (pp ). St. Louis, Missouri: Saunders