1. Chapter 42: Nursing Care of the Child With an Alteration in Bowel Elimination/Gastrointestinal Disorder

2. Anatomy and Physiology of the Gastrointestinal System of Children
Mouth: highly vascular; entry point of infection
Esophagus: LES not fully developed until age 1, causing regurgitation
Newborn stomach capacity only 10 to 20 mL
Intestines: small intestine not mature at birth
Biliary system: liver relatively large at birth; pancreatic enzymes develop postnatally until around 2 years old
Fluid balance and losses: low fluid volume maintained

3. Medical Treatment
Most common result of GI illness is dehydration, requiring fluid therapy at home or, in more extreme cases, in the hospital

4. Laboratory and Diagnostic Tests
Monitoring the blood count, electrolyte levels, and liver function tests is necessary in many pediatric GI disorders.

5. Laboratory and Diagnostic Tests for Appendicitis
Abdominal computed tomography (CT) scan: performed to visualize the appendix for further evaluation
Laboratory testing: may reveal an elevated white blood cell count
C-reactive protein: may be elevated

6. Medication Therapy Oral Candidiasis
Appropriate administration of oral antifungal agents by administering Mycostatin suspension four times per day following feeding to allow the medication to remain in contact with the lesions.

7. Medications to Manage Short Bowel Syndrome
Antibiotics to control bacterial overgrowth
Vitamin and mineral supplementation to replace lost vitamins
Antidiarrheal agents such as loperamide and gastric acid–suppressive medications to decrease stool output
TPN for extended periods for adequate growth
Progression to enteral feeding may occur extremely slowly

8. Anomalies and Complications Associated With Cleft Lip and Palate
Heart defects
Ear malformations
Skeletal deformities
Genitourinary abnormality
Complications
Feeding difficulties
Altered dentition
Delayed or altered speech development
Otitis media

9. Risk Factors for Dehydration
Diarrhea
Vomiting
Decreased oral intake
Sustained high fever
Diabetic ketoacidosis
Extensive burns

10. Risk Factors for Oral Candidiasis
Young age
Immune suppression
Antibiotic use
Use of corticosteroid inhalers
Fungal infection in the mother

11. Risk Factors for Intussusception
Male gender (higher incidence)
Meckel diverticulum
Duplication cysts
Polyps, hemangiomas, tumors
Appendix
Cystic fibrosis
Celiac disease
Crohn disease

12. Acute GI Disorders Dehydration, vomiting, and diarrhea
Oral candidiasis and oral lesions
Hypertrophic pyloric stenosis
Necrotizing enterocolitis
Intussusception, malrotation, and volvulus
Appendicitis

13. Structural Anomalies of the GI Tract
Cleft lip and palate
Omphalocele and gastroschisis
Hernias (inguinal and umbilical)
Anorectal malformations

14. Question Is the following statement True or False?
The nurse is caring for a child with diarrhea related to infectious enteritis. The nurse accurately informs the parents that most cases of diarrhea are bacterial in nature and therapeutic management is usually supportive in nature.

15. Answer
False.
Most cases of diarrhea are viral in nature and therapeutic management is usually supportive in nature.
Since most cases of diarrhea are acute and viral in nature, therapeutic management of diarrhea is usually supportive (maintaining fluid balance and nutrition). Probiotic supplementation may decrease the length and extent of diarrhea. Bacterial and parasitic causes of diarrhea may be treated with antibiotics or antiparasitic medications, respectively.

16. Chronic GI Disorders Gastroesophageal reflux, peptic ulcer disease
Constipation/encopresis
Hirschsprung disease
Short bowel syndrome
Inflammatory bowel disease
Celiac disease
Recurrent abdominal pain
Failure to thrive and chronic feeding problems

17. Esophageal Atresia
Congenitally interrupted esophagus where the proximal and distal ends do not communicate
Upper esophageal segment ends in a blind pouch
Lower segment ends a variable distance above the diaphragm

18. Common Gastrointestinal Illnesses
Imperforate anus: congenital malformation of the anorectal opening
Pyloric stenosis and point out that hypertrophic pyloric stenosis is one of the most common conditions requiring surgery in the first 2 months of life. Note that a pyloromyotomy is performed to cut the muscle of the pylorus and relieve the gastric outlet obstruction
Intussusception is a process that occurs when a proximal segment of bowel “telescopes” into a more distal segment, causing edema, vascular compromise, and, ultimately, partial or total bowel obstruction

19. Common Gastrointestinal Illnesses (cont.)
Appendicitis is the most common cause of emergent abdominal surgery in children
Hirschsprung disease is the most common cause of neonatal intestinal obstruction and is characterized by constipation in newborns

20. Signs and Symptoms of Crohn Disease and Ulcerative Colitis
Abdominal cramping
Nighttime symptoms, including waking due to abdominal pain or urge to defecate
Fever
Weight loss
Poor growth
Delayed sexual development

21. Recurrent Abdominal Pain
Functional abdominal pain
Nonulcer dyspepsia
Irritable bowel syndrome

22. Hepatobiliary Disorders
Pancreatitis
Gallbladder disease
Jaundice
Biliary atresia
Hepatitis
Cirrhosis and portal hypertension
Liver transplantation

23. Pancreatitis Abdominal trauma Drugs and alcohol Multisystem disease
Infections
Congenital anomalies
Obstruction
Metabolic disorders

24. Cholelithiasis Presence of stones in the gallbladder Associated with
Hyperlipidemia
Obesity
Pregnancy
Birth control pill use
Cystic fibrosis

25. Stool Diversion
Creation of an ostomy
Ileostomy
Colostomy

26. Nursing Interventions
Assess infants and children with an inguinal hernia for the presence of a bulging mass in the lower abdomen or groin area
Therapeutic management of vomiting most often involves slow oral rehydration and at times may require administration of antiemetics
Celiac disease is a strict gluten-free diet, which will cause the villi of the intestines to heal and function normally, with subsequent improvement of symptoms

27. Data Collected in the Physical Assessment
Auscultation
Hyperactive or hypoactive bowel sounds
Percussion
Dullness, flatness, tympany
Palpation
Reserve for last in sequence; palpable kidneys may indicate tumor or hydronephrosis; right lower quadrant pain may warn of appendicitis

28. Question
The nurse is auscultating the bowel sounds of a 4-year-old child and documents hypoactive bowel sounds. What might this finding indicate?
a. obstruction
b. gastroenteritis
c. diarrhea
d. infection

29. Answer a. obstruction Hypoactive bowel sounds indicate obstruction.
Hypoactive or absent bowel sounds may indicate an obstructive process. Hyperactive bowel sounds may be noted in children with diarrhea or gastroenteritis. Fever is an indicator of infection.

30. Nursing Management of a Newborn With Meckel Diverticulum
Signs and symptoms
Bleeding, anemia, severe colicky abdominal pain
Abdominal distention, hypoactive bowel sounds, guarding, abdominal mass, rebound tenderness
Management
Administer ordered blood products and IV fluids
Maintain NPO status
Perform postoperative care and family education

31. Teaching Plan
Child and family education related to the treatment of GI disorders is key to preventing the illness from progressing to an emergency situation
Dehydration need to restore fluid volume and prevent progression to hypovolemia
Vomiting to focus on promotion of fluid and electrolyte balance
Nurses should teach parents that to facilitate daily bowel evacuation, the child should sit on the toilet twice a day (after breakfast and dinner) for 5 to 15 minutes

32. Psychosocial Impact
Constipation can be a very stressful process for both the child and family and behavior modification is necessary for man
Short bowel syndrome considered to be medically fragile for a lengthy period, causing much anxiety related to the initial bowel resection that resulted in short bowel children
Long-term hospitalization is required for GI disorders, causing parents to miss work and cutting down on the time they have to spend with other children