UNIT 1 - GI DISORDER NURSING CARE OF CHILD WITH GASTROINTESTINAL DISORDER Cleft Lip and Palate — incomplete fusion of the oral cavity Most common craniofacial anomaly 1/700 Males 3:1 Higher in asians Familial hx Can be diagnosed in-utero by ultrasound Cleft Lip — can vary from a small notch to a complete cleft extending to the base of nares; may involve dental structures Cleft Palate — can occur alone or with CL and may extend into hard and soft palate in midline or bilaterally and extend through nasal cavity Soft palate deformity — can be sewn back together Hard palate (bone) deformity — don’t want to seal it right away (can change how baby’s face forms) Umcomfortable during feeding (milk going up the nose through the opening) Use obturator for babies with cleft palate — changed every month — creates seal on the opening Don’t use for too long — can cause speech problems Repair within 9-12 months Facial deformities are very disturbing to parents can cause strong negative reaction Feeding is a problem — rinse mouth with water after feeding Long term nursing interventions CL/CP Early intervention for speech Feeding infant with CL/CP — allow a gentle drip to baby’s inside cheek Cleft Palate repair Done between 9-12 mo Babies should be weaned from bottle or breast (to sippy-cups) prior to the surgical procedure Done before 1 year of age to promote better speech outcomes Post-op — Elbow restraints & Logan bow (on the face, to prevent baby from rubbing on the stitches on the bed) * Airway management — priority * Protect operative site * — if baby needs to go back into OR, it becomes state-reportable-offense Keep infant supine — position in infant seat Logan bow Elbow restraints — release restraints one at a time periodically and ROM limbs, cuddle infant Pain control — Tylenol works very well Wound care Minimizing crying — crying can stretch surgical site and create scars Suction any secretions VERY gently — prevent poking the surgical site Esophageal Atresia & Tracheo-Esophageal Fistula EA — interruption in esophagus TEF — abnormal communication between esophagus and trachea; trachea and esophagus connected at some point Incidence — 1:4000 live births Etiology — incomplete elongation and separation Isolated EA (8%)— esophagus from mouth is not connecting to the esophagus portion going into the stomach Esophagus ends in blind pouch Infant has a lot of frothy secretions and mucous at birth The rationale for giving sterile water for the first feed — in case they aspirate; it’s just sterile water Diagnosis — prenatal: polyhydramnios; afterbirth: frothy secretions, choking with feeds Gastric tube will stop in esophageal pouch / coil in esophageal pouch Preoperative care HOB 30-45 degrees Orogastric tube on low suction Don’t use NG tube (obstructs the nose) — babies are obligatory nose breathers (can’t breath with mouth); can suffocate if nose gets clogged Comfort measures-reduce crying — leads to increased swallowed air, abdominal distention, increased risk of reflux Clinical presentation Dependent on type of anomaly Accumulation of oral secretions, drooling Inability to pass gastric tube Coughing, choking, cyanosis with feedings Isolated TEF (4%) — baby seem to be choking on their milk; getting colds and pneumonia; requires scoping to see it or nucleic milk study 85-90% of defects Assessment — if suspected (coughs, gags with first feeding, frothy secretions) — immediate NPO Intervention Place supine with head 30 degrees Minimize reflux of gastric secretions into distal esophagus and possibly into trachea if a fistula is present High risk for aspiration pneumonia EA with TEF — baby will swallow, and it can’t go down; coughing, choking, and excessive frothy secretions (secretions will back up and have excessive frothy secretions [secretions typically go down to the lungs, frothy secretions means they are breathing thru the secretions]) Urgent (within 48 hours) but not an emergency Would want to scan the baby and make sure nothing is amiss before going in to surgery Keep infant seated up — keep stomach acid coming up TPN Use a pacifier when giving TPN so they don’t lose the sucking reflex; baby associate sucking with “getting full” PPI — blocks acid production Surgically reconnect the esophagus POST OP CARE FOR EA/TEF Maintain skin integrity from secretions and irritation IV fluids and strict I/O Intermittent or continuous suctioning via NG tube of blind proximal pouch Surgical repair may be done in steps Gastronomy feedings until anastomosis is healed and oral feedings tolerated approx. 10 -14 days post op Sterile water ,then frequent, small feedings of formula GT is removed when baby is able to tolerate feeds well and is adequately nourished Pacifier used during GT feeding 100% survival in healthy full-term without severe respiratory distress Pyloric Stenosis Etiology — unknown Pathology — muscle of pylorus is hypertrophied (growing thick) severe narrowing of opening between stomach and duodenum —> partial obstruction —> inflammation and edema —> complete closure (Food cannot get out of stomach, cannot get enough hydration, baby pukes, f/e imbalance) F/E imbalance is the true problem Palpable as an olive shaped mass in RU abdomen right of umbilicus Hypereristaltic waves — left to right Projectile vomiting stale milk, non-bilious (before bile tract), beings at 312 weeks, vomiting 30-60 minutes after feeing Infant hungry right after, eats eagerly, no pain, chronic weight loss, dehydration, distended upper abdomen Projectile-nonbilious-vomiting right after eating Not emergency, but a F/E emergency (needs fixed within 24 hours) — do not go into OR until f/e is stable Medical emergency, not surgical emergency (active tissue death) Nursing Care Assessment Restore f/e balance —> NPO, IV fluids, monitor I&O and specific gravity Strict I&O Monitor for dehydration Infant is prone to metabolic alkalosis from loss of H ions, K and Na, Cl from vomiting Interventions NG tube — prevent aspiration Keep flat or head slightly elevated Infant may continue vomiting 24-48 hours post op until swelling goes down. NG tube, IV fluids until baby takes in adequate fluids Teach parents that there may be slight inflammation still, and baby may still vomit a little bit post-op Post op Feed glucose water followed by breast milk or formula, advance diet as tolerated, record response to feeding Progress from thin —> thicker Intussusception (bowel obstruction) — intestine folding inwards, invaginating the bowel Poor blood supply due to the kinking of the intestines Intestines try to squeeze itself back out; almost like a labor contraction S/S — knees up, intense pain q ~20minutes, screaming Can die if the body cannot unkink (turns blue—>perforate—>peritonitis —> die) Active surgical emergency Use air enema to try and un-kink — up to 3x If it doesn’t work, goes to OR Etiology — 90% unknown cause Pathology — telescoping or invagination of intestine into another, (ileum invaginate into cecum and colon) —> intestinal obstruction, necrosis, perforation, sepsis and death follow Previously healthy child with sudden episode of acute abd. Pain; child screams in pain, draws knee to chest, is comfortable between episodes Progress to tender abdomen, distended with palpable, sausage-like mass in RUQ, vomiting, fever, prostration and S/S of peritonitis Currant jelly stools (stool mixed with blood and mucus) is a diagnostic, but late sign (sign of perforation) Nursing Care Parental support IV with I&O, NGT restoration of f/e imbalance Possibly antibiotics Report passage of any brown, normal stool immediately — intestines has fixed on its own; stop and reassess before fluoroscopy (barium) Continually assess of abdomen fro s/s of perforation Medical treatment Initial management involves performing a barium enema in an attempt to reduce intussusception —> 90% success rate Extent of surgery depends if perforation / necrosis has occurred Imperforate Anus / Anorectal Malformations Pathology No opening is found or anal opening is very stenotic Ultrasound confirms if defect continues internally up through rectum of fr anus is be just covered by a membrane Can just anesthetize baby and cut open the membrane Infant does not pass meconium; however, a fistula may exist from vagina/ rectum in girls and meconium may be mixed with urine Boys may piss meconium Girls may have meconium coming out of vagina Any child with imperforate anus requires a comprehensive multi system physical exam a this is rarely an isolated defect Nursing Care One of the reasons why we do rectal temps immediately upon admission to the newborn nursery to check potency of rectum Check for meconium in 24 hours following birth, report if no passage or stool appears in vagina or urine IV, NGT, I&O Doesn’t come out the end (no anus), use NGT on low suction Keep sites clean, use zinc oxide ointment for skin if stool continuously dribbles Colostomy for 1 year until baby has grown more and reassess— easy for surgery Medical management = surgical repair Repair depends on type of defect present Complete repair can take multiple surgeries over many years Appendicitis Etiology / Patho Inflammation / infection of the appendix Obstruction at base blocks outflow of mucus Pressure builds up Blood vessels are compressed Perforation and rupture Higher incidence in children with a low fiber diet Causes ischemia and necrosis of the tissue with rupture and perforation causes fecal and / or bacterial contamination of peritoneal cavity Dx — Ultrasound Sometimes can resolve with complete bowel rest Clinical presentation Abdominal pain — generalized to localized Starts at the belly button Rebound tenderness Pain at McBurney’s point (LRQ) Fever Chills N/ V/ D/ acute Constipation/ anorexia Rupture / Perforation of appendix With perforation, abdominal pain is suddenly relieved As peritonitis develops, pain returns Medical treatment Appendectomy — removal of appendix IV antibiotic therapy If perforated — triple antibiotic therapy x 5-7 days Nursing Interventions Monitor I&O Assess for return of bowel sounds — no feedings until bowel sounds return Dressing change as ordered Ambulate !!! Cough and deep breathing Pain management Hirschprung’s Disease (congenital ganglionic megacolon) — born with it No ganglion at bottom of anus — does not get sensation to poop — gets backed up, belly full of poop Etiology Absence of ganglion cells in one or more segments of colon, usually rectum and proximal portion of large intestine Lack of ganglion cells in colon prevents bowel from transmitting peristaltic waves needed to move fecal material Patho More common in boys More common in Down syndrome Indication — suspected if baby does not poop in 24 hours Clinical manifestations Compacted poop Abdominal distention Complication Enterocolitis — explosive, foul diarrhea; fever; worsening abdominal distention Can lead to sepsis and death Treatment NGT Colostomy distal to enlarged colon Squeeze out the meconium / poop Cut out swollen colon and reconnect colon Nursing Care Pre-Op Improve nutritional status for surgery — high calorie, high protein, or TPN Monitor for S/S bowel perforation — fever, vomiting, increased irritability, tenderness or distention of abdomen F/E replacement, IV, I&O Measure abdomen with paper tape and mark spot Bowel prep with saline enemas until clear, antibiotic enemas, systemic antibiotic prophylactically Explain to child and/or parents and teach colostomy care and skin protection and involve them in care Put babies in onesies Malrotation / Volvulus Definition — assortment of intestinal anomalies of rotation and fixation; intestines are flipped and rotated over; baby cannot grow Etiology exact cause unknown; occurs when intestine do not rotate, occurs ~ week 6-10 gestation Baby vomits — green, yellow, bile-y; does not occur often Emergency — if they get to OR fast enough, they can untwist the small intestine (have 5 minutes before necrosis) If necrosis occurs — no positive outcome — small intestines will die —> baby will die Clinical presentation Acute cases Bilious vomiting, suggestive malrotation with volvulus formation Abdominal distention + pain Rectal bleeding/ currant jelly stools Signs of shock and sepsis Diagnosis Presence of symptoms Xray — evidence of duodenal obstruction and scanty gas distribution in bowel Contraste upper GI tract film Bowel Obstruction Nursing Interventions NPO Strict I&O NGT for GI decompression Monitoring and correction of f/e imbalance Monitoring for S/S of perforation / shock / sepsis Administration of antibiotics * Medical treatment * — reduce obstruction before bowel becomes necrotic Celiac Diseases Etiology — appears to be inherited predisposition influenced by environmental factors Patho Intolerance to the protein gluten, which is found in wheat, barley, rye, and oats Safe grains in USA — rice, corn Child child is unable to digest gluten, resulting in damage to mucosa of small intestine 1:3000 in USA; 1:300 in European countries Genetic predisposition Impaired fat absorption causes steatorrhea Muscle wasting especially in legs and abdomen, anorexia, abdominal distention Celiac crisis — acute, severe episode of diarrhea and vomiting may be precipitated by infection, immunizations, dehydration, and emotional upsets Treatment with gluten-free-diet (for life) — corn and rice are allowed grains If cheat with diet and eat gluten — increase risk for GI cancer Nursing Interventions Strict diet Improvement within a day or two of removing gluten from diet Diarrhea dn steatorrhea improve in several weeks Child and parents need to understand “cheating” —> S/S + increase chance of complications —> high risk of GY lymphoma Diet is high in calories and fat-soluble vitamins Colic Intermittent abdominal pain or cramping manifested by loud crying and drawing legs up to abdomen Usually crying continues 3 or more hours / day and resolves spontaneously around 3 months of age (3 months of due date) Slight chance it may be due to milk intolerance, most commonly no cause can be found, and infant eats well, gains weight, and thrives Crying for no reason, even when kid is eating + thriving However, because of perceived “difficult” temperament, child-parent relationships may be affected Changing formula DOES NOT “cure” colic GERD / Reflux Regurgitation / back flow of gastric content into esophagus Relaxation / incompetence of the lower esophageal neuromuscular function or incompetence of the lower esophageal (cardiac) sphincter Sphincter not mature enough and baby is lying down all the time Etiology — exact cause unknown GERD in children is usually self-limiting Baby starts to sit up ~ 5-6 months Treatment depends on severity Apnea / respiratory problems Excessive vomiting first weeks of life Slow growth / poor weight gain Regurgitation of formula after eating Esophagitis anemia Conservative Management Positioning: upright, semi-prone after feeding to promote gravity resistance to reflux Dietary — thicken feedings Feeding modifications — small feedings with frequent burping to decrease gastric distention Pharmacologic therapy Meds to reduce symptoms Antacids Histamine 2 blocking agents, Histamine 2 blockers Cimitedine, ranitidine, etc Nursing Assessment Frequent vomiting with bloody vomitus — anemia Hiccuping Aspiration, increased respiratory infection, recurrent Otitis Media ALTE (acute life threatening event), cyanotic episodes Nursing Interventions Prevent Aspiration * Treatment and interventions depend on severity of disease Strict I&O, documentation — amount, frequency, characteristics Small frequent feedings Thicken formula with RC or thickener (if ordered) Placed child 30-45 degree angle after feedings Avoid citrus fruits and juice — acidic Family education Hernias Hernia is protrusion of a portion of an organ through an opening in abdominal cavity; Caused by defect in musculature; Usually no medical problem (might get laughed at though) Problem arises when the organ is constricted and impairs circulation 3 Types of hernias in children Inguinal Hernia Most common congenital anomaly requiring surgical repair in infants — 80% Protrusion of peritoneal sac into the processes vaginalis Most common in males and pre-term infants Very simple surgery repair Umbilical Hernia Intestine pouch out at intestine Problem is when kid ages, and the hole starts closing, squeezing the intestines Etiology Incomplete closure of umbilical ring results in protrusion of protons intestines through the opening Defect usually spontaneously by age 5 Surgical correction necessary if closure does not occur at that age or if incarceration of herniated bowel occurs Surgery before school — prevent kids laughed at (social surgery) Swelling or bulge in umbilical area increase with valve maneuver Nursing Considerations Hernia should be easily reducible; painless unless bowel becomes incarcerated; scrotum appears swollen it is easily reducible If bowel is incarcerated, you will not be able to reduce hernia Parental support as families are usually very concerned with the appearance Almost exclusively found in black infants or extreme premies If child does not fit into these groups needs workup for genetic syndrome Diaphragmatic Hernia Mortality rate 40-50% Chest appears barrel-like, abdomen is sunken, bowel sounds in chest, breath sounds are decreased, severe respiratory distress Baby cannot breath (lungs have no space to expand) Need heart-lung bypass immediately Assessment of child with CHD Clinical findings depends on size of defect and degree of pulmonary hypoplasia Postnatal diagnosis is confirmed by CXR diminished or absent breathe sounds on affected side Bowel sounds may be heard over chest, cardiac sounds may be right side of chest Abdominal Pain Periumbilical — IBS, appendicitis, gastroenteritis, Meds, small bowel bacterial overgrowth from antibiotic use, strep pharyngitis Epigastric — GERD, gallbladder disease, pancreatitis RLQ — appendicitis, ovarian torsion, ovarian cysts, PID, ectopic pregnancy, IBS, RLL pneumonia Suprapubic — UTI, constipation, urinary retention
