Caring for children with gastrointestinal dysfunction —Chap 17 壹、評估評估 貳、小兒常見腸胃道疾病小兒常見腸胃道疾病

壹、評估 （補） 健康史  進食狀況  營養狀況  家庭狀況  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 （ LGI 、 UGI 、 、） 身體檢查  身體外觀  口腔感染  腹部評估

常見腸胃道疾病 Intestinal obstruction Intussusception Intussusception Inflammatory disorders Appendicitis Disorders of motilityDisorders of motility Gastroenteritis （ Acute diarrhea ）Gastroenteritis （ Acute diarrhea ） Dehydration --- Chap 10Dehydration Constipation Feeding disorders Colic Disorders of malabsorptionDisorders of malabsorption Celiac disease Lactose Intolerance Short bowel syndrome

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 togetherThe 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 abdomenRadiographs and ultrasound of the abdomen Barium enema

Treatment P603 第 3 段 Hydrostatic pressure 靜水壓 —Barium enema –Oxygen （ air ）、 saline 、 aqueous contrast material Surgery Supportive care – 液體補充 – 鼻胃管減壓 – 抗生素

Nursing management 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 Maintain fluid and electrolyte balance

Inflammatory disorders Appendicitis P609 Etiology and pathophysiology Result from an obstruction in the appendiceal lumen Caused by a fecalith ， parasitic infestations ， stenosis ， hyperplasia of lymphoid tissue ， or a tumor Obstruction  continued secretion of mucus→pressure↑ →ischemia ， cellular death ， and ulceration Complication ： perforation or rupture → peritonitis → small bowel obstruction ， electrolyte imbalances ， septicemia ， and hypovolemic shock Is an inflammation of the vermiform appendix. Most often in adolescent boys （ y/o ）； rarely seen before 2 years of age

Clinical manifestations Pain Fever, vomiting, diarrhea, constipation P610 第 2 段 Motionless, side-lying position with knees flexed Some children Appendix is in a different location P609 最後 1 行 Differentiation P609 此段第 2 行 Ovulation Ruptured ectopic pregnancy Pelvic inflammatory Caution ：

Pain Periumbilical cramps ， abdominal tenderness 第 1 行 → pain in the right lower abdomen become constant 第 4 行 Most intense halfway between the anterior superior iliac crest and umbilicus → rigidity and rebound tenderness P610 第 2 行 → if sudden relief of pain （ ruptured ）anterior superior iliac crest and umbilicus ruptured

Signs and symptoms of a ruptured appendix include P609 右上 Fever Sudden relief from abdominal pain Guarding Abdominal distention Rapid shallow breathing Pallor Chills Irritability or restlessness

Diagnosis — evaluation over several hours P610 WBC↑ （ teenagers ） 第 2 段 Abdominal pain X-ray Abdominal ultrasound Focused appendiceal computerized tomography （ FACT ）

Treatment 第 3 段 Preoperatively –NPO & NG decompression –IV fluids & electrolytes –Antibiotics Appendectomy Postoperatively –Antibiotics –If ruptured Penrose drain Wound irrigations

Nursing management Promote comfort Maintain hydration Provide emotional support Recognize symptoms of infection Support respiratory function Discharge planning and home care teaching

Disorders of motility Diarrhea  因消化、吸收及分泌不正常所導致的症狀  特徵： （ 1 ）明顯或突然的增加排便次數 （ 2 ）含水量增加、性狀的改變 （ 3 ）糞便傾向綠色並含有黏液或血液。  可能是急性或慢性、發炎或沒發炎，一般和發炎有 關的腹瀉通常被敘述成腸胃炎。

Disorders of motility 急性腹瀉：糞便在次數及性狀上的突然改 變，通常是因為傳染性病源所造成的炎症 反應所致。 慢性腹瀉：持續兩週以上的腹瀉情形，如 吸收不良症候群。

Disorders of motility 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.

Disorders of motility 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 、 urine sp.gr –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 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 care plan Fluid volume deficit P620 Risk for impaired skin integrity P621

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

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 同腸胃炎 之治療

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 guidelinesoral rehydration Teach parents oral rehydration methods Monitor intravenous fluid administrationintravenous fluid Discharge planning and home care teaching

Disorders of malabsorption P627 包括各種不同程度的消化或吸收不良疾病。 消化不良是指消化霉減少或缺乏的狀況，如囊性 纖維、 Lactose Intolerance 。 Lactose Intolerance 吸收不良是指腸道運輸系統缺乏的狀況，可能是 原發性缺損（如 Celiac Disease ）或續發性腸道發 炎；解剖上之缺損，如 short bowel syndrome ，因 物質運輸時間及吸收表面減少，而影響吸收。 short bowel syndrome

Lactose Intolerance P628 Etiology and pathophysiology  Inability to digest lactose （ a disaccharide ） 第 1 行  A congenital or acquired deficiency of the enzyme lactase  Congenital  Rare 第 3 行  Acquired  Highest （約 100 ％） among Asian and Native American 第 5 行

Clinical manifestations 第 4 行 Abdominal pain Flatulence Diarrhea Diagnosis 第 2 段 History Hydrogen breath test Lactose-free diet for confirming the diagnosis

Treatment 第 2 段 第 4 行 Diet –Infant － soy-based formula –Older children － eliminating lactose- containing foods Enzyme tablets

Nursing management Support Explain dietary modifications and discuss alternate sources of calcium P337 右下 Discuss the need for supplementation of calcium and vitamin D Read food labels

Short bowel syndrome （ SBS ） P628 Etiology and pathophysiology 第 1 段 It is a decreased ability to digest and absorb a regular diet because of a shortened intestine. Causes ： necrotizing enterocolitis （ NEC ）、 inflammatory disorders 、 congenital bowel anomaly The extent and location of the involved bowel determine the severityof the disorder. 第 2 段 Adaptation period ： increases its absorptive surface area 第 5 行Adaptation period

Treatment 第 2 段 Nutritional support 第 6 行 –TPN 、 elemental formula 、 MCT Enteral feeding –High-fat, low-carbohydrate diet –Nucleotide, glutamine, polyamine, and fatty acid Surgical （補） Clinical manifestations 第 2 段 Watery diarrhea 第 4 行

Complication （補） 缺少 50% 的腸道（若未缺失遠端迴腸）不 會影響健康 缺少 70% 以上的腸道易導致嚴重吸收不良 通常死於 TPN 相關問題，如 sepsis or TPN- cholestasis

Nursing management Meeting the child’s nutritional and fluid needs Oral and enteral feedings are instituted gradually –Feeding pump –Feeding tube Emotional support Arrange home visits to monitor the child’s growth and development and observed side effects （ fluid and electrolyte imbalance and diarrhea ）