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Caring for children with gastrointestinal dysfunction —Chap 17
兒童消化系統的生理特徵 評估 小兒常見腸胃道疾病 Gastroenteritis（Acute diarrhea） Intestinal obstruction--Intussusception Congenital defects Cleft lip and palate Anorectal malformation Esophageal atresia & Tracheoesophageal fistula Hirschsprung’s Disease（Megacolon）
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Anatomy and physiology of pediatric differences
GI system is immature at birth. P586第1段第2行 Absorption and excretion do not begin until after birth Sucking reflex Not have voluntary control over swallowing Stomach Stomach capacity：small Frequently regurgitate Intestinal Peristalsis is greater than older children Deficiency of several enzyme：amylase, lipase, trypsin
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Anatomy and physiology of pediatric differences
Liver function is also immature Second year of life Digestive processes are fairly complete Stomach capacity increase Excretory function can be achieved
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評估（補） 健康史 身體檢查 進食狀況 身體外觀 營養狀況 口腔感染 家庭狀況 腹部評估 主要照顧者的衛生習慣 排便情形
診斷性檢查 血液檢查 糞便檢查 特殊技術
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Caring for children with gastrointestinal dysfunction
Etiology and pathophysiology Clinical manifestations Diagnostic tests Medical management Nursing assessment & management
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Gastroenteritis（Acute diarrhea）P617
Is an inflammation of the stomach and intestines 第1段 Vomiting and diarrhea Infants and small children with gastroenteritis or diarrhea can quickly become dehydrated and are at risk for hypovolemic shock
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Etiology and pathophysiology （P617第2行）
Decrease in the absorptive capacity、decrease in surface area for absorption、alteration of parasympathetic innervation High risk－day-care centers、improper sanitation （第5～6行） Causes（Table 17-2）
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Clinical manifestations P617
Mild －Slightly increased in number and more liquid Moderate －Several loose or watery stools －Irritability、anorexia、nausea、vomiting －Self-limiting Severe －Continuous watery stools －Fluid and electrolyte imbalance －Cramp、extremely irritable、difficult to console
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Diagnosis clinical therapy之第1段
History Physical examination Laboratory finding－S/R、S/C Presence of ova, parasite, infectious organisms, viruses, fat, and undigested sugars.
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Treatment P618第2段 Depends on the severity of the diarrhea and fluid and electrolyte imbalances. Goal：correct the fluid and electrolyte Mild to moderate －oral rehydration therapy ( Contain water, carbohydrate, sodium, potassium, chloride and lactate P315 ) －Carbonated beverages and those containing high amounts of sugar should not be given Severe －IV（N/S with glucose【one half or one quarter normal saline】 or L/R）第3段 －NPO －Antiemetics and antidiarrheals should generally not be used in infants and young children. P618左下 Lactose-free milk, breast milk, half-strength milk P315倒數第4行
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Nursing assessment P618 Skin integrity
Frequency, color, amount and consistency of stools第4行 The amount and type of vomitus Observing dehydration Urine output and specific gravity Weight Vital signs ( Febrile ) Skin integrity
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Nursing diagnosis & management P619
Anxiety Provide Emotional support Sleep pattern disturbance 活動無耐力 Promote rest and comfort Altered nutrition Ensure adequate nutrition CRAM (Complex carbohydrates, Rice and Milk ) P619綠框 Diarrhea related to infectious process P620 Fluid volume deficit P620 Risk for impaired skin integrityP621
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Dehydration Chap 10 --P313 There is not enough fluid in the extracellular compartment. The state of body water deficit is called dehydration. Sodium is generally lost along with water → hyponatremia
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Etiology and pathophysiology
Causes P313 第1段第2行 Loss of fluid containing sodium are vomiting、diarrhea、nasogastric suction、hemorrhage and burns Radiant warmers 第2段第2行 Adrenal insufficiency and overuse of diuretics Bulimic adolescents
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Blood urea nitrogen＞25mg/dL clinical therapy第1段第3行
Serum bicarbonate＞17mEq/L
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Oral rehydration therapy－mild and moderate dehydration
同腸胃炎之治療 Medical management P315 Oral rehydration therapy－mild and moderate dehydration Contain water, carbohydrate, sodium, potassium, chloride and lactate Lactose-free milk, breast milk, half-strength milk 倒數第4行 IV－severely P316第1段 L/R, one half or one quarter normal saline
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Nursing assessment Weight I/O Urine specific gravity Consciousness
Pulse rate and quality Skin turgor and mucous membrane moisture Respiration Blood pressure
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Nursing management Provide oral rehydration therapy guidelines
Teach parents oral rehydration methods Monitor intravenous fluid administration Discharge planning and home care teaching
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Intussusception P602 Etiology and pathophysiology 第1段
One portion of the intestine prolapses and then invaginates(陷入) or telescopes (使嵌入) into another.第1行 One of the most frequent causes of intestinal obstruction during infant Between the age of 3 months and 6 years Site：ileocecal valve 第2段 Telescoping of the Intestine obstructs the passage of stool. The walls of intestine rub together inflammation、edema、decreased blood flow necrosis、perforation、hemorrhage、 peritonitis In infant, intussusception is commonly associated with measles, viral disease, and gastroenteritis syndromes. P603 Fig17-7
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Clinical manifestations P603第2段
Onset is abrupt Acute abdominal pain（periods of comfort between acute episodes of pain） Vomiting Passage of brown stool→become red and resemble currant jelly A palpable mass may be present in the upper right quadrant or mid-upper abdomen 腹部呈柔軟、膨脹 疲倦、虛脫 發燒及腹膜炎之其他徵象 右下腹區排空（Dance徵象）
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Diagnosis P603第2段 History Radiographs and ultrasound of the abdomen
Barium enema
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Treatment P603第3段 Hydrostatic pressure—Barium enema Surgery
Oxygen（air）、saline、aqueous contrast material Surgery Supportive care 液體補充 鼻胃管減壓 抗生素
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Nursing management Maintain fluid and electrolyte balance Post OP
Monitoring for early signs of infection Pain management Maintain NG tube patency Assess vital signs、Abdominal distention、Listen for bowel sounds every 4 hours After normal bowel function Clear liquid feeding half- strength milk and other foods
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Cleft lip and palate P586 More common in Native Americans and Asian P586最後1行 Etiology and pathophysiology P594 A failure of the maxillary processes of fuse with the elevations on the frontal prominence during the sixth weeks of gestation. Hard and soft palates is completed in the first trimester. Congenital defects：tracheoesophageal fistula，omphalocele，trisomy 13，skeletal dysplasias Cause：multifactorial（environmental and genetic influences）
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Clinical manifestation P587
Cleft lip Unilateral or bilateral Alone or in combination with a cleft palate defect Nasal deformity Cleft palate Less obvious A continuous opening between the mouth and nasal cavity Soft palate or both the soft and hard palate
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Clinical manifestation---補
餵食困難 呼吸道感染 口腔感染 聽力受損 語言發展延遲
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Diagnostic tests and medical management P588
Physiologic assessment 第1段 Medical management：multidisciplinary team（plastic surgery、hearing、speech、dentistry） Clef lip 2-3months of age 第2段 Logan bow or other stabilizing device or dressing is put in place. Crying is minimized by use of medication. Clef palate Depends on the size and severity of the cleft. 18 months Longer nipples with enlarged holes（before surgical） Antibiotic therapy：recurrent otitis media Orthodontic care 語言治療
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Physiologic assessment
Nursing assessment Physiologic assessment Observable Palpation Psychosocial assessment—low self-esteem Family’s reaction Low self-esteem Developmental level and social interactions
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Nursing management Preoperative care P590 Postoperative care P592
1.Risk for aspiration 2.Provide emotional support Explaining the cause Interact and speak to the infant Point out positive attributes Self-blame Anxiety 3.Altered nutrition Nursing management Preoperative care P590 1.Risk for infection 2.Ineffective breathing pattern related to anesthesia and increased secretions 3. Impaired tissue integrity 4. Knowledge deficit 5. Altered nutrition Postoperative care P592
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Nursing management Care in the community Feeding techniques
Recognize signs of infection and complications (fever, vomiting, respiratory distress) How to position the infant How to care the suture line Preparation of the sibling Support groups Prevent the infant from touching the suture line
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Anorectal malformation ( Imperforate anus ) P604
Etiology and pathophysiology Malformations of the anus and rectum. Often associated with anomalies：urinary tract, esophagus, and duodenum. VACTER Syndrome
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Clinical manifestations
Diagnosis Failure to pass meconium Stool in the urine Ribbonlike stools 腹脹、嘔吐 Assessment anorectal structure and rectal patency Ultrasound Lower GI PA CXR 倒立3分鐘→x-ray 尿液分析
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Medical management Dilation
低位－Excised surgery，then daily manual dilation 高位－Reconstructive surgery （Posterior Sagittal Anorectoplasy；PSARP ）及temporary colostomy→→關閉結腸造廔。
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Nursing management Assessment
Developed anal dimple or sacral anomalies Rectal thermometer Observation and recording of passage of meconium
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Managemen Preoperation Postoperation Preventing infection IV fluids
Respiratory complication Maintaining hydration Assess vital signs If stable→try feeding Colostomy care 禁量肛溫或使用塞劑 IV fluids NG decompression Monitor I/O Monitor cardiorespiratory function 廔管護理 Emotion support
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Discharge planning and home care teaching
How to take the infant’s temperature Signs and symptoms of infection Feeding Toilet training Assess vital signs If a colonstomy How to care Reassure the colostomy will be closed Follow-up Home care visits
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Esophageal atresia & Tracheoesophageal fistula P595
Etiology and pathophysiology Failure of the esophagus to develop as a continuous tube during the fourth and fifth weeks of gestation. 第1段 The foregut fails to lengthen, separate, and fuse into two parallel tubes during fetal development. 第2段 End in a blind pouch or develop as a pouch connect to the trachea by a fistula.
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Maternal history：polyhydramnios、prematurity、low birth weight
Associated anomalies 第2段第5行 Congenital heart defects Gastrointestinal or urinary tract anomalies Musculoskeletal abnormalities VACTERL：vertebral、anus、cardia、trachea、esophageal、renal、limb
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Clinical manifestation 第3段
Excessive salivation and drooling 3C（coughing, choking, cyanosis）and sneezing Returns fluid through the nose and mouth→pneumonia Abdomen become distended Vomiting soon after feeding
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Diagnosis 第4段 Nasogastric tube meets resistance and can be advanced only minimally. X-ray（air pouch、NG coiling、pneumonia、distended stomach intestine－遠端有fistula） Echocardiogram（2D echo）and abdominal ultrasound（Renal echo） P596
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Treatment P596第2段 OG suction Antibiotics Fluids Surgery：several stages
Ligation of the fistula and insertion of a gastrostomy tube Reconnect the two ends of the esophagus（anastomosis） Potential postoperative complications Gastroesophageal reflux、aspiration、stricture formation、esophageal motor dysfunction
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Nursing management Preoperation Maintain a patent airway NPO
Suction－（continuous or low intermittent） Place the head of the bed slightly lowered Continuous or low intermittent suction is used to remove secretions from the blind pouch. Change position NPO Maintain with intravenous fluids administered through an umbilical vein catheter.
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Postoperation Gastrostomy drainage IV fluids and antibiotics TPN
Maintain a patent airway Emotional support for parent Discharge planning Gastrostomy tube care and feeding、signs of infection、prevent postoperative complications. P598 families want to known
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Megacolon（Hirschsprung Disease） P603
Etiology and pathophysiology Congenital aganglionic megacolon；inadequate motility causes mechanical obstruction Absence of autonomic parasympathetic ganglion cells in the colon→ accumulation of intestinal contents and abdominal distention Combination with congential heart defects、Down syndrome、Imperforate anus More common in boys It can be acute or chronic
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Clinical manifestations P604第2段
Newborn Older child Failure to gain weight and delayed growth 第3段 Abdominal distention Constipation alternating with diarrhea Vomiting Stool may be normal or ribbonlike Failure to pass meconium Refusal to suck Abdominal distention Bile-stained emesis complete obstruction, respiratory distress, and shock
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Diagnosis History Bowel pattern Anorectal manometry Radiographic contrast studies Rectal biopsy Palpation
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Treatment Newborn：surgery
Several cases or ill infants： temporary colostomy → closure of the colostomy and reanastomosis（Soave procedure） Child with milder defect：dietary modification、stool softeners、isotonic irrigations
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Complication P604第7段 Fecal incontinence and constipation Enterocolitis
GI bleeding and diarrhea→ischemia and ulceration TPN Lactose-free diet
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Nursing management Assessment 第1段
Observation for the passage of meconium History of weight gain Nutritional intake Bowel habit
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Management Monitoring fluid and electrolyte balance Maintain nutrition
Teach parents how to ensure regular bowel movements Daily rectal irrigations Prevent skin breakdown Surgery Monitoring for infection Managing pain Maintain hydration Measuring abdominal circumference Emotion support Teach parent about－Ostomy care、signs of complications 、 Be alter for signs of poor growth or malnutrition
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