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

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.

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.

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.

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

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.

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.

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.

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.

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

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

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 520-522)

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

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 527-529

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

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

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

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

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

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

Ulcers Types Etiology Diagnostic tests S/S therapeutic management

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

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

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

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

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.

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.546-547) Assess family dynamics and support system

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

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

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

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.

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

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.

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

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

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

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

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.

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

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.

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

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

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

reference Health topics A-Z http://adam.about.com/encyclopedia/Pyloric-stenosis.htm University of Virginia Health System http://www.healthsystem.virginia.edu/uvahealth/peds_digest/intussus.cfm Healthline connect to better health http://www.healthline.com/channel/hirschsprung-disease_images Rowen,S. J., Weiler, J. A. (2007). The child with a gastrointestinal alteration. In NursingCare of children principles and practice. (pp 507-5596). St. Louis, Missouri: Saunders