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）

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

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

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

Caring for children with gastrointestinal dysfunction Etiology and pathophysiology Clinical manifestations Diagnostic tests Medical management Nursing assessment & management

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

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）

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

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.

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

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

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

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

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

Blood urea nitrogen＞25mg/dL clinical therapy第1段第3行 Serum bicarbonate＞17mEq/L

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

Nursing assessment Weight I/O Urine specific gravity Consciousness Pulse rate and quality Skin turgor and mucous membrane moisture Respiration Blood pressure

Nursing management Provide oral rehydration therapy guidelines Teach parents oral rehydration methods Monitor intravenous fluid administration Discharge planning and home care teaching

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

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）

Diagnosis P603第2段 History Radiographs and ultrasound of the abdomen Barium enema

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

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

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）

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

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

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

Physiologic assessment Nursing assessment Physiologic assessment Observable Palpation Psychosocial assessment—low self-esteem Family’s reaction Low self-esteem Developmental level and social interactions

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

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

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

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

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。

Nursing management Assessment Developed anal dimple or sacral anomalies Rectal thermometer Observation and recording of passage of meconium

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

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

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.

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

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

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

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

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.

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

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

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

Diagnosis History Bowel pattern Anorectal manometry Radiographic contrast studies Rectal biopsy Palpation

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

Complication P604第7段 Fecal incontinence and constipation Enterocolitis GI bleeding and diarrhea→ischemia and ulceration TPN Lactose-free diet

Nursing management Assessment 第1段 Observation for the passage of meconium History of weight gain Nutritional intake Bowel habit

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