Presentation on theme: "The Child with a Gastrointestinal Alteration"— Presentation transcript:
1 The Child with a Gastrointestinal Alteration Pilar C. Smith, RN, BSNLake Sumter Community College
2 Cleft Lip and PalateCleft 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 noseDiagnostic is based on observation at birth and complete examination in the neonatal period.
4 AssessmentAssess 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 defectEncourage 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 growthProvide alternative assistive feeding devicesHold infant in a more up-right positionBurp infant more frequentlyWrite down feeding program for parents to use at homeProvide emotional support and positive reinforcement to parentsKeep and accurate record of child’s growth by using a growth chart.Orthopedic Latham device is use to expand and realignExplain 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 hoursIV line placementPostoperative care:Keep straws, pacifiers, spoons, or fingers away from the child’s mouth for 7 to 10 daysDo not take temperature orallyAdvance the child’s diet as tolerated from clear liquids to soft diet within 48 hours.
8 Nursing DiagnosesAlteration in nutrition less then body requirement related to the inability to suckThe child will drink the recommended amount of feeding within 30 minutesKnowledge deficit about feeding techniques and surgery related to unfamiliarity with the informationThe 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 secretionsVomitingAbnormal distentionAirless, 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 lineAbdominal radiograph (X-ray) with water-soluble contrast medium < 1ml via NGTBronchoscopy and endoscopy
12 Management Keep infant warm and oxygenated Keep infant supine with the HOB elevated to keep gastric secretions from entering the lungsNGT aspirate every 5 to 10 minutes to keep the keep the proximal pouch clearIntravenous IV fluids are essentialSurgical repair: Ligation of the fistula and end-to-side anastomosis of the atresiaNursing diagnosis and planning(read pp )
13 GER in children GER vs GERD.. Page 522 Symptoms range from physiologic to pathologicDiagnostic exam includes barium swallow, upper GII study, endoscopyManagement: dietary alterations, positional changes, medications and surgeryDiet: predigested formulas.. Nutramigen or progestimal, freq, small feedings, freq. burping, ? Thickened feedingsPositioning : supine
14 GER continuedMedications: 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 emptyingPrevent complicationsNursing care plan on page
15 Constipation and Encopresis Definition: page 529Etiology: change in diet, lack of exercise, emotional stress certain drugs pain from anal fissure or excessive milk intakeEncopresis 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 530Abdominal x-ray DRE
16 Constipation and Encopresis cont.. Therapeutic Management Page 530Nursing Care: AssessmentNursing Diagnosis and Planning..page 531Interventions: 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 diarrheaS/S : abd pain unrelated to meals or activity Normal growth mucous in stool
18 IBS contDo definitive treatment Goal is aimed at identifying and reducing triggers and reducing bowel spasms which decreases triggersDiet is healthy well balanced moderate fiber lower fat dietEncourage child to eat slow and no carbonated beverages, no juicesMed’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 HIVGiardia is the most common seen in children in day care and rotovirus is the most common seen in infants and young childrenPage 535 characteristics of infectious gastroenteritis
20 Gastro. Cont.S/S diarrhea, vomiting abdominal pain tenesmus and fever dehydration is a consequence of gastroStool culture O&PManagement: replace water and electrolytesPrevention Rotovirus vaccine at age 2,4, 6 monthsWhat do we assess?Nursing Diagnosis- page 537Interventions- page 537
22 AppendicitisPain progressing in intensity and localizing to the RLQ at Mc Burney point page 538Diagnostic evaluation?Therapeutic management?Nursing DiagnosisInterventions
23 VolvulusMalrotation or twisting of the bowel that results in obstruction.S/S pain, bilious vomitingSurgery 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 ManifestationProgressive projectile vomiting , especially after eatingOn palpation:Right upper quadrant movable firm olive-shaped mass can be feltVisible peristaltic wavesfrom 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 massX-ray or US of the abdomen,Barium swallowMetabolic alkalosisDecreased serum potassium and sodium levelsIncreased Ph and sodiumbicarbonate, and decreased chloride.Indirect Bilirubin may be elevated.
27 Management IV fluids and electrolyte replacement NGT for stomach decompressionSurgery: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 IntussusceptionInussusception 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 diarrheaA sausage- shape abdominal massListlessnessParoxysm pain (pain that comes and go) than becomes more constantDistention, hypo or hyperactive bowel soundsSign and symptoms of dehydrationSymptoms of shock and sepsis if obstruction has been present for longer than 12 to 24 hoursFever, increased heart rate, changes in LOC
31 ManagementThe 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 enemasSurgery:Laparoscopy is use if no bowel necrosis is present.
32 Nursing DiagnosesIneffective tissue perfusion related to (GI) bowel compression.Acute pain related to bowel obstruction and surgery
33 Hirschsprung diseaseHirschsprung 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 ManifestationDelayed or absence of meconium stool in the neonatal period (cardinal sign)Constipation since neonatal periodFrequent passage of foul-smelling ribbonlike or pelletlike stoolsMalnutritionAbdominal pain and distentionFailure to thrive
35 Diagnostic Assessment Rectal examination:tight internal sphincter and absence of stool, follow by an explosive release of gas and stoolBarium enemaRectal biopsy (definitive)Absence of ganglia cells confirm the diagnosis
36 Management Treatment for mild to moderate Stool softener to relieve constipation and rectal irritationTreatment 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 DiagnosesConstipation related to aganglionic bowel and inadequate peristalsisImpaired skin integrity related to colostomy and surgical repair.
38 Celiac diseaseCeliac 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 percentileAbdominal distention and ascitesAnemiairritabilityanorexiamuscle wastingfolate deficiencyEdematous extremities
40 Diagnostic Assessment Serum antigliadin antibody (AGA) assayallows continued assessment and evaluation of dietary changesTissue transglutaminase (tTG)Breath hydrogen excretion testidentify carbohydrate malabsorption.
41 ManagementAll wheat, rye, barley, and oat should be eliminated from the dietReplaced with corn and riceFat-soluble vitamins supplement and folateFluid replacement if child is dehydrated from severe watery diarrheaCorrect acid-base imbalanceAlbumin to treat shockCorticosteroids to decrease severe mucosal inflammation
42 Nursing DiagnosesImbalance nutrition less then body requirement related to malabsorptionDelayed growth and development related to malnutrition
43 Lactose Intolerance Inability to tolerate lactose Most case of lactose intolerance are the result of inadequate lactaseS/S diarrhea that is frothy, abdominal distention, cramping pain and increase flatus+1 or greater sugar values on stool clinitest can support the diagnosisManagement: remove the milkND: page 553
44 referenceHealth 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