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CHAPTER 45 Nursing Care of a Family When a Child Has a Gastrointestinal Disorder
The gastrointestinal (GI) system involves a long body
tract and numerous organs. Because it is so long and diverse,
a multitude of possible disorders can occur along it, including both congenital disorders and acquired illnesses. Because
the GI system is responsible for taking in and processing nutrients for all parts of the body, any problem with the system
can quickly affect other body systems and, if not adequately
treated, can affect overall health, growth, and development.
Health education is extremely important for children with
GI disorders and their families because it can be difficult to
appreciate the seriousness of GI illness. Often, parents are surprised to find that what they thought was a simple “stomach
flu” has caused serious electrolyte imbalances and possibly a
life-threatening state for their child. Some GI disorders require both parents and child to learn new nutritional patterns.
When children are young, the parents need education concerning this topic. As children grow older, counseling to help
them maintain self-esteem and learn nutritional requirements
so they can become independent become important.
Food poisoning and hepatitis are examples of GI illnesses
that are so pervasive that national health goals have been set
to limit their incidence (see Box 45.1).
Nursing Process Overview
For a Child With a Gastrointestinal Disorder
Assessment
Children with GI disorders quickly become dehydrated,
especially if vomiting or diarrhea is a symptom. This
means they need to be assessed for signs of fluid loss, such
1319
as poor skin turgor, dry mucous membranes, or lack of
tearing. When talking to parents about a child’s symptoms, ask exactly what they mean when they say “spitting
up” or “a little vomiting.” Also ask how many times a
child has voided or how many diapers have been wet in
the past 24 hours, and whether this is less than usual.
Compare the child’s current weight with past weight measurements, if available. Unless the child is an adolescent
who has been actively dieting, there is never a normal reason for weight loss in children.
Ask parents to describe what they mean by diarrhea as
some parents mistakenly confuse normal newborn or infant stools with diarrhea. As a rule, all children with diarrhea, especially small children, need to be seen by a health
care provider because fluid and electrolyte changes occur
rapidly in children because of the greater percentage of
fluid held extracellularly rather than intracellularly.
For many children, a GI tract disorder is diagnosed
largely by presenting symptoms such as those just described. In other instances, x-ray studies with a contrast
medium (barium) or an endoscopic examination may be
needed to confirm the presence of an anomaly.
Ultrasound or magnetic resonance imaging (MRI) also
may be helpful. Another important assessment area is laboratory testing for electrolyte balance through serum
analysis or fluid concentration through urinalysis.
Nursing Diagnosis
Nursing diagnoses relevant to children with GI disorders
invariably center on imbalanced nutrition, because most
GI diseases alter the kind and amount of nutrients ingested or absorbed into the body in some way. However,
BOX 45.1 ✽ Focus on National Health Goals
Nutrition deficiencies, unsafe food preparation, and hepatitis are three areas that could be reduced in incidence
if people knew more about them and took active interventions to reduce their occurrence or spread. National
Health Goals addressing these include:
• Reduce infections caused by key food-borne
pathogens such as Salmonella infection from 13.6 per
100,000 to 6.8 per 100,000, Listeria infection from
0.47 per 100,000 to 0.24 per 100,000, and E. coli infection from 22 per 100,000 to 11 per 100,000.
• Increase the proportion of persons 2 years of age and
older who meet the daily recommendation of calcium
from 45% to 74%.
• Reduce the incidence of chronic hepatitis B viral infections in infants and young children (perinatal infections) from a baseline of 1682 instances per year to a
target level of 400 instances per year.
• Reduce the rate of hepatitis B infections in adolescents 19 to 24 years of age from 24 per 100,000 population to 2.4 per 100,000 population.
• Reduce the incidence of hepatitis C from a baseline of
2.4 new cases per 100,000 population to 1 new case
per 100,000 population.
• Reduce the rate of hepatitis A infection from a baseline
of 11.3 per 100,000 to 4.5 per 100,000 (http://www
.nih.gov).
Nurses can help the nation achieve these goals by counseling parents about safe food preparation and the need for
children to ingest adequate calcium for sound bone growth,
by serving as consultants to day care providers to reduce
the spread of stool contamination in these settings, and by
actively administering hepatitis A and B vaccines to infants
and adolescents to eradicate these forms of the illness in
another generation. Nursing research in several areas
could be helpful: What is the best media to use to educate
parents about safe food preparation? Does the brand of diapers used by children in day care influence the spread of
infectious stool? How many infants are not being brought for
follow-up care and so do not receive all three immunizations
against hepatitis B? Do most parents appreciate the devastating outcome that can result from hepatitis?
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GI disorders also take an emotional toll on the ill child
and family. Feeding is one of the primary ways mothers
bond with their newborns, so bonding can be seriously
threatened when a newborn develops a GI disorder, especially when hospitalization is required. The process of eating and the types of food eaten are also integral components of family life and culture, so any disruption caused
by illness can place a strain on the entire family. Examples
of nursing diagnoses are:
• Impaired parenting related to interference with establishing parent–infant bond
• Interrupted family processes related to chronic illness
in child
• Risk for deficient fluid volume related to chronic
diarrhea
• Imbalanced nutrition, less than body requirements,
related to malabsorption of necessary nutrients
• Situational low self-esteem related to feelings of being
different resulting from special dietary restrictions
Outcome Identification and Planning
Planning care for a child with a GI disorder often includes
nutritional planning with the child and parents. Be certain when helping to plan a new nutritional pattern that
the person who actually prepares or supervises the child’s
nutrition is included. In many instances, some of the
foods that a child eats may be prepared by a babysitter,
day care center staff, the child’s other parent, or a grandparent. Many children eat breakfast and lunch at school
cafeterias. That means it may be necessary to contact
school staff to ask them to make meal exceptions for a
child or to supervise a choice of foods (or to see that a
child eats only the packaged lunch brought to school, not
extra items the child trades for with friends).
Some parents are unfamiliar with basic food categories
and the importance of providing food from the food pyramid in children’s diets. When a special diet is requested,
they may have little understanding of which foods have high
or low fiber content, or which foods are “bland” or “clear.”
Many parents have difficulty keeping children restricted to
“nothing by mouth” (NPO) for tests or to rest the GI tract
as they have been told that dehydration happens quickly in
infants (which it does). They need support to follow the
necessary restrictions when those restrictions are so opposed
to basic parenting, which involves giving food.
If feedings will be given by nasogastric or gastrostomy
tube, parents need enough practice time to be comfortable
with the equipment and the technique before they are
given the responsibility of doing it alone at home. If a
child is going to gag or become distressed when a new
tube is passed, parents need to have this happen where
there are calm, supportive people nearby, not when they
are by themselves at home.
Anticipate the need for additional support for the family
and child with a chronic GI disorder. Agencies that might
be helpful for referral are the Celiac Disease Foundation
(http://www.celiac.org), Crohn’s and Colitis Foundation of
America (http://www.ccfa.org), International Foundation
for Functional Gastrointestinal Disorders (http://www
.iffgd.org), and North American Society for Pediatric
Gastroenterology, Hepatology and Nutrition (http://www
.naspgn.org).
Implementation
Never underestimate the difficulty family members may
experience adapting to alternative nutrition methods such
as total parenteral nutrition or enteric or gastrostomy
feedings, or caring for a child with a colostomy. Parents
need a great deal of support to adapt their busy life to
these alternative methods of feeding or care.
GI disorders that occur at birth are discussed in
Chapter 27. Insertion of a nasogastric tube, enteral and
parenteral nutrition, and administration of an enema are
discussed in Chapter 37. Be certain to give clear, simple
explanations, and praise both parents and child after they
demonstrate these procedures. Children can easily interpret enemas as punishment because of the extreme intrusiveness. Provide therapeutic play before and after these
procedures to reduce children’s anxiety.
Outcome Evaluation
Recording children’s height and weight is a primary
method to evaluate nutritional outcomes. Even if a diet is
limited in a special way, if it is adequate, children should
gain weight and maintain growth.
Because children will ultimately be responsible for
their own nutrition, expected outcomes should include
making certain that children gradually learn more about
their specific nutritional measures so they can become increasingly responsible for their own intake. Often, only
when they are at this stage can their parents feel secure
enough to let them stay overnight with a friend, visit a relative in a distant city, go to summer camp—activities that
become important to children as they reach school age.
The saying “people are what they eat” has some relevance. Children who require special nutritional plans
need to be evaluated for self-esteem at periodic health visits. Do children think of themselves as inferior to or different from others because of food restrictions? What kind
of positive experiences can be offered to such children, or
what can parents do to provide children with experiences
that would improve self-esteem?
Some examples of expected outcomes are:
• Child lists examples of bland foods to select for lunch
from school cafeteria menu.
• Parent states steps she will take to seek medical care if
child has a second episode of severe diarrhea.
• Family members state they have adjusted to care of a
child with celiac disease.
❧
ANATOMY AND PHYSIOLOGY OF THE
GASTROINTESTINAL SYSTEM
Embryonic development of the GI tract is discussed in
Chapter 9. Digestion begins in the mouth, where food is broken down into small particles and mixed with saliva from the
sublingual, submandibular, and parotid glands. Both gagging
and swallowing reflexes are present even in newborns to prevent aspiration with swallowing. Digestion continues in the
stomach and small intestine, the same as in adults.
The esophagus pierces the diaphragm to serve as a passageway to the stomach (Fig. 45.1). Occasionally, an infant
is born with a portion of the bowel or stomach protruding
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CHAPTER 45 Nursing Care of a Family When a Child Has a Gastrointestinal Disorder
1321
Parotid gland
Tongue
Sublingual gland
Submandibular gland
Pharynx
Larynx
Trachea
Esophagus
Diaphragm
Spleen
Gallbladder
Duodenum
Hepatic flexure
Ascending colon
Ileocecal valve
Cecum
Appendix
Splenic flexure
Pancreas
Duodenojejunal flexure
Transverse colon
Descending colon
Ileum
Sigmoid colon
Rectum
FIGURE 45.1 The gastrointestinal tract.
through the diaphragm’s esophageal opening (hiatal or diaphragmatic hernia). At the junction of the esophagus and
the stomach is the gastroesophageal (cardiac) sphincter. In
some newborns, this sphincter is so lax that fluid regurgitates
into the esophagus (gastroesophageal reflux). At the distal
end of the stomach is the pyloric sphincter. In some infants,
this valve is narrowed (stenosed), preventing food from flowing out of the stomach freely (pyloric stenosis). Originally, it
was believed that the stomach was sterile because the action
of hydrochloric acid could easily kill invading organisms and
limit infections. However, since the discovery that a bacterium, Helicobacter pylori, is the cause of peptic ulcer disease,
it is obvious that organisms can and do survive in the stomach. Vomiting and diarrhea are symptoms that arise because
of stomach or intestinal infections (McQuaid, 2009).
The small intestine is divided into three sections: duodenum, jejunum, and ileum. The large intestine is divided into
the cecum, ascending colon, transverse colon, descending
colon, sigmoid colon, and rectum. The appendix, which frequently becomes diseased in children, is attached to the cecum.
DIAGNOSTIC AND
THERAPEUTIC TECHNIQUES
Several typical procedures are used in the diagnosis and therapy of GI disorders. Common diagnostic procedures include
fiberoptic endoscopy, colonoscopy, and barium enema.
Children need good preparation for these procedures because
they are potentially frightening. If children receive conscious
sedation for a procedure, they need preparation for this as
well as the actual procedure.
Therapy may include alternative methods of feeding such
as enteral (nasogastric or gastrostomy tube feedings) or nutrition sources such as total parenteral nutrition and intravenous (IV) therapy to rest the GI tract. A colostomy or
ileostomy may be created to further rest the GI tract. As these
are used for other disorders as well, these procedures, their
meaning, their impact on children, and nursing responsibilities are discussed in Chapters 37 and 38.
HEALTH PROMOTION AND
RISK MANAGEMENT
Health promotion related to GI disorders focuses on a wide
area because the causes of these disorders cover a wide range.
Some disorders, such as appendicitis, cannot be prevented
because they occur for unpredictable causes. Some, such as
celiac disease (sensitivity or abnormal immunologic response
to protein), involve genetic aspects that cannot be changed.
Some, such as Crohn’s disease and ulcerative colitis, are associated with an autoimmune response. Other conditions, such
as vomiting and diarrhea, are often caused by foods that were
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UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders
refrigerated improperly or spread through improper handwashing and thus can be prevented. A vaccine to prevent rotavirus infections is recommended for infants (Soares-Weiser
et al., 2009). Hepatitis can be prevented through good handwashing (hepatitis A) and immunization (hepatitis A and B).
Vitamin and protein deficiency disorders can be prevented
by educating parents about the food pyramid and how to select foods that fit each of the sections.
The incidence of GI illnesses varies among communities.
Vomiting and diarrhea, for example, tend to occur because of
food poisoning in communities where refrigeration is less
than optimal, and people eat raw meat or unprocessed
cheese. Celiac disease occurs most frequently in children of
Northern European ancestry. Because constipation, vomiting, and diarrhea are so common, every culture has home
remedies for these symptoms: cascara for constipation; psyllium for diarrhea; ginger, peppermint, licorice, or chamomile
tea for nausea or vomiting. To be certain that a child seen in
a health care facility does not receive two forms of the same
drug (one prescribed and one given in an herb form by a parent), always ask what home remedies have been given and
document these on the child’s plan of care.
Because any interference in nutrition pervades many aspects of children’s lives, families often need help with planning care. Help families plan the necessary adaptations to
their lifestyle to prevent the disease from interfering with
family functioning (Will day care center personnel do gastrostomy feedings? Will a nursery school accept a child with
a colostomy? Can a child select a gluten-free diet at the
school cafeteria?). All families should be encouraged to eat at
least one meal a day together so they can have time to share
experiences and “touch base” with each other. For the family
with a child who has a feeding problem such as a gastrostomy
feeding or total parenteral nutrition, this can be difficult.
Urge such families to bring the child to the table for a social
time even if the child cannot eat with the family. If watching
family members eat while the child cannot is too difficult,
urge the family to provide a “together” time in some other
way so they do not miss out on this valuable family activity.
Some GI disorders in children, such as aganglionic megacolon, are diagnosed late because parents think the child’s refusal to eat is just the sign of being a “picky eater” or a manifestation of 2-year-old autonomy. Educating parents about
normal nutrition and how to distinguish things such as vomiting from illness from normal “spitting up” or severe diarrhea
from a simple GI upset helps parents bring their children for
care at the earliest possible time. Early intervention prevents
the child from becoming dehydrated and seriously ill.
greater fraction of the infant’s total weight. In adults, body
water accounts for approximately 60% of total weight. In infants, it accounts for as much as 75% to 80% of total weight;
in children, it averages approximately 65% to 70%.
Fluid is distributed in three body compartments: (a) intracellular (within cells), 35% to 40% of body weight; (b) interstitial (surrounding cells and bloodstream), 20% of body
weight; and (c) intravascular (blood plasma), 5% of body
weight. The interstitial and the intravascular fluid together
are often referred to as the extracellular fluid (ECF), totaling
25% of body weight. In infants, the extracellular portion is
much greater, totaling up to 45% of total body weight (Fig.
45.2). In young children, this amount is 30%; in adolescents,
it is 25%.
Fluid is normally obtained by the body through oral ingestion of fluid and by the water formed in the metabolic
breakdown of food. Primarily, fluid is lost from the body in
urine and feces. Minor losses, insensible losses, occur from
evaporation from skin and lungs and from saliva (of little importance except in children with tracheostomies or those requiring nasopharyngeal suction). Infants do not concentrate
urine as well as adults because their kidneys are immature. As
a result, they have a proportionally greater loss of fluid in
their urine. In infants, the relatively greater surface area to
body mass also causes a greater insensible loss. Fluid intake is
altered when a child is nauseated and unable to ingest fluid
40
35
30
Percent body weight
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20
15
10
5
FLUID, ELECTROLYTE, AND
ACID–BASE IMBALANCES
The GI system plays a major role in maintaining fluid, electrolyte, and acid–base balance. It is the main route by which
substances are taken into the body and can be a major source
of loss if vomiting or diarrhea occurs (Holliday, Ray, &
Friedman, 2007).
Intravascular
fluid
Interstitial
fluid
Intracellular
fluid
Extracellular fluid
= Adult
Fluid Balance
Retaining fluid is of greater importance in the body chemistry of infants than that of adults because fluid constitutes a
= Infant
FIGURE 45.2 Distribution of fluid in body compartments.
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CHAPTER 45 Nursing Care of a Family When a Child Has a Gastrointestinal Disorder
✽
A Method to Calculate Fluid
Body Weight
Fluid Requirement per 24 h
Up to 10 kg
11–20 kg
100 ml/kg
1000 ml ⫹ 50 ml/kg for each
additional kg over 10 kg
1500 ml ⫹ 20 ml/kg for each
additional kg over 20 kg
TABLE 45.1
Requirement
More than 20 kg
or is vomiting and losing fluid ingested. When diarrhea occurs, or when a child becomes diaphoretic because of fever,
the fluid output can be markedly increased. Dehydration
occurs when there is an excessive loss of body water (Scherb,
Stevens, & Busman, 2007).
In an adult’s weighing 70 kg, the extracellular fluid volume is approximately 14,000 mL. Each day, the well adult’s
ingests approximately 2000 mL of fluid and excretes approximately 2000 mL as urine. This means that approximately
14% of the adult’s total ECF (2000 mL of 14,000 mL) is exchanged each day. In contrast to this, 7-kg infants have an
ECF volume of only 1750 mL. They ingest approximately
700 mL daily and excrete approximately 700 mL daily.
Therefore, they exchange approximately 40% of their volume daily. As a result of this increased exchange rate, infants’
fluid balance may be more critically affected when they are
ill. Adults, when they do not eat for a day because of a GI
upset, and whose kidneys continue to excrete at the normal
rate, will have 14% less fluid in the extracellular space by the
end of the day. Infants who do not eat for a day (providing
kidney function remains constant) will be 40% short of ECF
by the end of the day. This is obviously a more important
loss of fluid than the same loss would be in an adult; therefore, dehydration is always a more serious problem in infants
than in older children and adults. Requirements of fluid for
infants and children are shown in Table 45.1.
Fluid Imbalances
Under most circumstances, water and salt are lost in proportion to each other (isotonic dehydration). Occasionally, water
is lost out of proportion to salt or water depletion or hypertonic dehydration occurs. Occasionally, electrolytes are lost
out of proportion to water (hypotonic dehydration). Each of
these abnormal states produces specific symptoms.
TABLE 45.2
✽
Isotonic Dehydration
When a child’s body loses more water than it absorbs (as with
diarrhea) or absorbs less fluid than it excretes (as with nausea
and vomiting), the first result will be a decrease in the volume
of blood plasma. The body compensates for this rapidly by
shifting interstitial fluid into the blood vessels. The composition of fluid in these two spaces is similar, so the replacement
by this fluid does not change plasma composition. However,
this replacement phenomenon can proceed only until the interstitial fluid reserve is depleted—a danger point for a child
because it is difficult for the body to replace interstitial fluid
from the intracellular fluid (the fluids in these two compartments have different electrolyte contents). If an infant continues to lose fluid after this point, the volume of the plasma
will continue to fall rapidly, resulting ultimately in cardiovascular collapse. Typical signs and symptoms of isotonic dehydration are summarized in Table 45.2.
Hypertonic Dehydration
Water is apt to be lost in a greater proportion than electrolytes when fluid intake decreases in conjunction with a
fluid loss increase, as might occur in a child with nausea (preventing fluid intake) and fever (increased fluid loss through
perspiration); profuse diarrhea, where there is a greater loss of
fluid than salt; or renal disease associated with polyuria such
as nephrosis with diuresis. In these instances, fluid loss is out
of proportion to the loss of electrolytes, and, with such an increased loss of fluid, electrolytes concentrate in the blood.
Fluid shifts from the interstitial and intracellular spaces into
the bloodstream (from areas of less osmotic pressure to areas
of greater pressure). Dehydration occurs in the interstitial
and intracellular compartments. The red blood cell count
and hematocrit will be elevated because the blood is more
concentrated than usual. Levels of electrolytes such as
sodium, chloride, and bicarbonate will also likely be increased. Additional signs and symptoms are summarized in
Table 45.2.
Hypotonic Dehydration
With hypotonic dehydration, there is a disproportionately
high loss of electrolytes relative to fluid lost. The plasma concentration of sodium and chloride will be low. This could result from excessive loss of electrolytes by vomiting or from low
intake of salt associated with extreme losses through diuresis.
It also occurs when there is extreme loss of electrolytes in diseases such as adrenocortical insufficiency or diabetic acidosis.
When low levels of electrolytes occur, the osmotic pressure in
Signs and Symptoms of Dehydration
Thirst
Skin turgor
Skin consistency
Skin temperature
Urine output
Activity
Serum sodium level
1323
Isotonic
Hypotonic
Hypertonic
Mild
Poor
Dry
Cool
Decreased
Irritable
Normal
Moderate
Very poor
Clammy
Cool
Decreased
Lethargic
Reduced
Extreme
Moderate
Moderate
Warm
Decreased
Very lethargic
Increased
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UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders
extracellular spaces decreases. The kidneys begin to excrete
more fluid to decrease ECF volume and bring the proportion
of electrolytes and fluid back into line. This may lead to a secondary extracellular dehydration (see Table 45.2).
Overhydration
Overhydration may be as serious as dehydration. It generally
occurs in children who are receiving IV fluid. The excess
fluid in these instances is usually extracellular. The condition
is serious because the ECF overload can lead to cardiovascular overload and cardiac failure.
When large quantities of salt-poor fluid (hypotonic solutions) such as tapwater are ingested or are given by
enema, the body transfers water from the extracellular
space into the intracellular space to restore normal osmotic
relationships. This transfer results in intracellular edema
manifested by headache, nausea, vomiting, dimness and
blurring of vision, cramps, muscle twitching, and seizures.
A situation in which intracellular edema may occur is when
tap water enemas are given to a child with aganglionic disease of the intestine.
Acid–Base Imbalance
The GI system often is involved with two severe acid–base
imbalances: metabolic acidosis and metabolic alkalosis.
These imbalances occur with severe diarrhea or vomiting.
When dealing with acid–base balance, a key component is
pH. The abbreviation “pH” refers to two French words that
mean the “power of hydrogen.” pH denotes whether a solution is acid or alkaline, determined by the proportion of hydrogen (H⫹) ions in relation to hydroxide (OH⫺) ions—the
two substances that disassociate when water is broken down
into its basic components (H2O ⫽ H⫹ and OH⫺). A solution is acid (pH below 7.0) if it contains proportionately
more H⫹ ions than OH⫺ ions. It is alkaline (pH above 7.0)
if the proportion of OH⫺ ions exceeds that of H⫹ ions.
Whether body serum is becoming acidotic is determined
by analyzing a sample of arterial blood for blood gases. The
pH of blood is normally slightly alkaline, ranging from 7.35
to 7.45. PCO2 (the amount of dissolved carbon dioxide in arterial blood) is normally 35 to 45 mm Hg. The level of bicarbonate (HCO3) in arterial blood is normally 22 to 26 mEq/L.
Metabolic Acidosis
Metabolic acidosis may result from diarrhea. When diarrhea
occurs, a great deal of sodium is lost with stool. This excessive loss of Na⫹, in turn, causes the body to conserve H⫹
ions in an attempt to keep the total number of positive and
negative ions in serum balanced. As a result, a child becomes
acidotic as the number of H⫹ ions in the blood increases proportionately over the number of OH⫺ ions present. With
metabolic acidosis, arterial blood gas analysis will reveal a decreased pH (under 7.35) and a low HCO3 value (near or
below 22 mEq/L). The lower the HCO3 value is, presumably
the more Na⫹ ions that have been lost or the more extensive
the diarrhea has been.
To correct this problem (a pH too low is incompatible
with life), the body uses both its kidney and respiratory
buffering systems. The respiratory buffering system attempts
to correct the imbalance quickly. H⫹ ions combine with
HCO3⫺ ions to form carbonic acid. This, in turn, is broken
down into CO2 and water, which is then eliminated by the
lungs during expiration. This process works immediately,
and, as it continues for a time, the bicarbonate level in the
serum falls lower and lower as the body uses up its bicarbonate store.
In the kidneys, H⫹ ions are excreted directly or combine
with other substances, such as phosphate and ammonia, to
form a weak acid, which is excreted. Unfortunately, this
process is slow, taking up to 24 hours.
The child breathes rapidly (hyperpnea) to “blow off” CO2
to prevent it from combining with H2O and reforming
HCO3. Urine becomes more acid as ammonia formation in
the urine is increased.
Metabolic Alkalosis
With vomiting, a great deal of hydrochloric acid is lost.
When Cl⫺ ions are lost this way, the body has to decrease the
number of H⫹ ions present so the number of positive and
negative charges remains balanced. This causes the child to
become alkalotic as the number of H⫹ ions becomes proportionately lower than the number of OH⫺ ions present. To
further reduce the number of H⫹ ions, the lungs conserve
CO2 and water by slowing respirations (hypopnea). The excessive CO2 retained by this maneuver dissolves in the blood
as carbonic acid and then is converted into excessive H⫹ and
HCO3⫺. With metabolic alkalosis, therefore, the serum
HCO3 invariably will be high. The higher the value, presumably the more Cl⫺ ions have been lost or the more extensive the vomiting has been.
The child will breathe slowly and shallowly; pH will be elevated (near or above 7.45), and HCO3 level will be near or
above 28 mEq/L.
When alkalosis occurs from vomiting, a secondary electrolyte problem often occurs. As the kidneys begin to help
conserve H⫹ ions, K⫹ ions are exchanged for H⫹ ions—that
is, K⫹ ions are excreted in order to retain H⫹ ions. As a result of this loss of K⫹ into the urine, low K⫹ levels (hypokalemia) invariably accompany metabolic alkalosis.
✔Checkpoint Question 45.1
Barry has frequent bouts of vomiting. What secondary electrolyte problem often occurs when metabolic alkalosis results
from vomiting?
a. Acidosis.
b. Hyponatremia.
c. Hypokalemia.
d. Hyperchlorosis.
COMMON GASTROINTESTINAL
SYMPTOMS OF ILLNESS IN CHILDREN
Vomiting and diarrhea in children commonly occur as symptoms of disease of the GI tract as well as symptoms of disease
in other body systems (Box 45.2). Pneumonia or otitis
media, for example, may present first with vomiting or diarrhea. The danger is that either can lead to a disturbance in
hydration, electrolyte, or acid–base balance. In many infants,
these secondary disturbances can be more threatening to the
child than the primary disease.
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CHAPTER 45 Nursing Care of a Family When a Child Has a Gastrointestinal Disorder
Vomiting
Box 45.2 Assessment
Assessing a Child With
Altered GI Function
History
Chief concern: Vomiting, diarrhea, constipation, abdominal
pain, abdominal distention, weight below normal standard,
lethargy, paleness.
Past medical history: History of past vomiting or diarrhea or
abdominal pain; hydramnios in pregnancy.
Family history: Relatives have a similar disorder; high stress
level because of home or school environment.
Physical examination
Signs of dehydration
(dry mucous
membranes)
Caries, malocclusion,
inflamed gumline
(periodontal disease)
Hair: Brittle;
loss of pigment
(decreased
protein intake)
Jaundice (liver
involvement)
Lethargy and
paleness
(anemia)
Enlarged liver
(cirrhosis, hepatitis)
Visible peristalsis
(pyloric stenosis)
Increased bowel
sounds (diarrhea)
Displaced heart
sounds
(diaphragmatic
hernia)
Tender abdomen
(appendicitis)
Edema
(kwashiorkor)
Mass at umbilicus
or by inguinal ring
(hernia)
Distended veins
from pressure in
portal circulation
(liver disease)
Distended
abdomen
(Hirschsprung's
disease)
✽
Many children with vomiting are suffering from a mild gastroenteritis (infection) caused by a viral or bacterial organism. The adolescent who is pregnant may also experience
vomiting. Some children develop persistent or cyclic vomiting (Fitzpatrick et al., 2007). In all forms, vomiting is always
potentially serious because a metabolic alkalosis and dehydration may result.
Assessment
In describing symptoms of vomiting, be certain to differentiate between the various terms that are used (Table 45.3). It
is important that vomiting be described correctly this way because different conditions are marked by different forms of
vomiting, and a correct description of the child’s actions can
aid greatly in diagnosis.
Therapeutic Management
The treatment for vomiting is to withhold food from the
stomach for a time as if there is nothing in the stomach, vomiting cannot occur. Most parents treat vomiting in the opposite way. Every time a child vomits, they attempt to feed the
child again. The child vomits again and they feed again, and
so on. This prolongs the vomiting and intensifies the potential for electrolyte imbalance.
Nursing Diagnoses and Related
Interventions
✽
Weight below
10th percentile
TABLE 45.3
1325
Nursing Diagnosis: Risk for deficient fluid volume related to vomiting
Outcome Evaluation: Skin turgor remains good; specific gravity of urine is 1.003 to 1.030; urine output is
more than 1 mL/kg/hr; episodes of vomiting decrease
in frequency and amount.
Differentiation Between Regurgitation and Vomiting
Characteristic
Regurgitation
Vomiting
Timing
Forcefulness
Occurs with feeding
Runs out of mouth with little force
Description
Smells barely sour; only slightly
curdled
Distress
Duration
Nonpainful; child does not appear
to be in distress and may even
smile as if sensation is enjoyable
Occurs once per feeding
Amount
1–2 tsp
Timing unrelated to feeding
Forceful; often projected 1 ft away from the
infant; projectile vomiting—projected as
much as 4 ft (most often related to
increased intracranial pressure in newborns;
in infants age 4–6 wk, possibly because of
pyloric stenosis)
Extremely sour smelling, appearing curdled,
yellow, green, clear or watery, or black;
perhaps fresh blood or old blood staining
from swallowed maternal blood (in newborns)
Possible crying just before vomiting as if
abdominal pain is present, and after vomiting
as if the force of action is frightening
Continuing until stomach is empty; followed by
dry retching
Full stomach contents
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To decrease vomiting, withhold food and fluid for a
time (nothing by mouth [NPO]), depending on the age
of the child. On the average, a period of 3 to 6 hours
is usually sufficient. In the older child, after this period
of fasting, offer a few ice chips, then water in small
amounts—approximately 1 tbsp every 15 minutes,
four times; then 2 tbsp every half-hour, four times.
Popsicles can be substituted for water. If this is retained, children can be given small sips of clear liquids, such as tea, ginger ale, or a rehydration fluid
such as Pedialyte. The World Health Organization provides a home recipe for fluid rehydration of 2 tablespoons of sugar (or honey) with 1⁄4 teaspoon of table
salt and 1⁄4 teaspoon of baking soda dissolved in 1 liter
(1 qt) of water.
Children may become hungry and want whole
glasses of fluid, but keeping the quantity to small sips
prevents vomiting. Once the child is able to retain sips
of clear liquids, the child can be offered portions of
broth, clear soup, and skim milk in addition to clear liquids. Dry crackers or toast will help assuage hunger.
By the second day, children can take a soft diet; by the
third day, they should be back to their regular diet.
For the infant, introduce fluid after a fasting period
of approximately 3 hours in the same slow manner: 1
tbsp every 15 minutes for 2 hours, then 1 oz every 2
hours for the next 12 to 18 hours. Glucose water or a
commercial hydration solution such as Pedialyte may
be given as fluid during this time to help the infant
maintain electrolyte balance. Infants progress, as do
older children, gradually to clear liquids or breast milk,
then a soft diet, then a regular diet. If vomiting is prolonged, infants may need IV therapy or an antiemetic
to restore hydration (Leung et al., 2007).
Teach parents the importance of following these
routines of gradually increasing fluid at intervals.
Assure them that if children receive a small amount of
fluid and do not vomit it, they will ultimately receive
more fluid than if they take a large amount but, because of gastroenteritis, vomit that amount. Parents
are capable of understanding that stomach secretions
are lost along with vomitus each time, and the preservation of these stomach secretions is important to
keep their child well. Antiemetic medicine is rarely
necessary for children because acute gastroenteritis
is a self-limiting condition and vomiting may actually
be helpful if it rids the child’s body of toxic sub-
stances. If vomiting is severe, however, an antiemetic
such as promethazine (Phenergan) or Ondansetron
(Zofran) may be prescribed. Always ask parents if
they have used an herbal remedy, to be certain that
any medication prescribed will be safe with the alternative treatment.
Diarrhea
Diarrhea caused by a virus is the major cause of infant gastroenteritis in developing countries. The most common viral
pathogens that invade the GI tract include rotaviruses and
adenoviruses (Bass, Pappano, & Humiston, 2007). The most
common bacterial pathogens include Campylobacter jejuni,
Salmonella, Giardia lamblia, and Clostridium difficile.
Diarrhea may also be caused by Escherichia coli infection
(Cennimo et al., 2007). It can be easily spread by common
diaper changing areas in day care centers or airport restrooms
(Kotch et al., 2007). Diarrhea that is acute is usually associated with infection; chronic diarrhea is more likely related to
a malabsorption or inflammatory cause.
Diarrhea in infants is always serious because infants have
such a small ECF reserve that sudden losses of water exhaust
the supply quickly. Breastfeeding may actively prevent diarrhea by providing more antibodies and possibly an intestinal
environment less friendly to invading organisms and so
should be advocated.
Mild Diarrhea
Assessment. Normal and diarrheal stool characteristics are
compared in Table 45.4. If diarrhea is mild, fever of 101° to
102° F (38.4° to 39.0° C) may be present. Children usually
are anorectic and irritable and appear unwell. The episodes of
diarrhea consist of 2 to 10 loose, watery bowel movements
per day.
The mucous membrane of the mouth appears dry and the
skin feels warm although skin turgor will not yet be decreased. The pulse will be rapid and out of proportion to the
low-grade fever. Urine output is usually normal.
Therapeutic Management. At this stage, diarrhea is not yet
serious, and children can be cared for at home. As with vomiting, treatment for diarrhea must involve resting the GI
tract, but this is necessary for only a short time. At the end of
approximately 1 hour, parents can begin to offer an oral rehydration solution such as Pedialyte in small amounts on a
TABLE 45.4 ✽ Differentiation Between Infant Normal Stool and
Diarrheal Stool
Characteristic
Infant Normal Stool
Diarrheal Stool
Frequency
Color
Effort of expulsion
pH
Odor
Occult blood
Reducing substances
1–3 daily
Yellow
Some pushing effort
More than 7.0 (alkaline)
Odorless
Negative
Negative
Unlimited number
Green
Effortless; may be explosive
Less than 7.0 (acidic)
Sweet or foul smelling
Positive; blood may be overt
Positive
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CHAPTER 45 Nursing Care of a Family When a Child Has a Gastrointestinal Disorder
regimen similar to that for vomiting (Freedman, 2007). For
breastfed infants, breastfeeding should continue. Again, it
may be difficult for parents to restrict fluid for a short time if
they think they should overfeed children to make up for the
fluid loss. Children also need measures to reduce the elevated
temperature. In developing countries, where children may be
zinc deficient, zinc may be administered. Probiotics (dietary
supplements containing potentially beneficial bacteria or
yeasts) to change the bacterial flora of the intestine may be
administered (Walter & Isolauri, 2007).
Caution parents to contact their health care provider
rather than use over-the-counter drugs such as loperamide
(Imodium) or kaolin and pectin (Kaopectate) to halt diarrhea
because, as a rule, these are too strong for young children
(Karch, 2009). Also caution parents to wash their hands after
changing diapers to prevent the spread of infection to themselves and to notify their health care provider if fever, pain,
or diarrhea worsens.
Infants may develop a lactase deficiency after diarrhea that
leads to lactose intolerance. With lactose intolerance, a child
cannot take formula or breast milk or new diarrhea will
begin. Such an infant will need to be introduced to a lactosefree formula initially before being returned to the usual formula or to breast milk.
Severe Diarrhea
Assessment. Severe diarrhea may result from progressive
mild diarrhea, or it may begin in a severe form. Infants with
severe diarrhea are obviously ill. Rectal temperature is often
as high as 103° to 104° F (39.5° to 40.0° C). Both pulse and
respirations are weak and rapid. The skin is pale and cool.
Infants may appear apprehensive, listless, and lethargic. They
have obvious signs of dehydration such as a depressed
fontanelle, sunken eyes, and poor skin turgor. The episodes
of diarrhea usually consist of a bowel movement every few
minutes. The stool is liquid green, perhaps mixed with
mucus and blood, and it may be passed with explosive force.
Urine output will be scanty and concentrated. Laboratory
findings will show elevated hematocrit, hemoglobin, and
serum protein levels because of the dehydration. Electrolyte
determinations will indicate a metabolic acidosis
(Sondheimer, 2008).
It is difficult to measure the amount of fluid a child has
lost, but an estimate can be derived from the loss in body
weight, if known. For example, if a child weighed 10.4 kg
yesterday at a health maintenance visit and today weighs 8.9
kg, the child has lost more than 10% of body weight. Mild
dehydration occurs with a loss of 2.5% to 5% of body
weight. In contrast, severe diarrhea quickly causes a 5% to
15% loss. Any infant who has lost 10% or more of body
weight requires immediate treatment.
Therapeutic Management. Treatment focuses on regulating
electrolyte and fluid balance by oral or IV rehydration therapy, initiating rest for the GI tract, and discovering the organism responsible for the diarrhea.
All children with severe diarrhea or diarrhea that persists
longer than 24 hours should have a stool culture taken so
definite antibiotic therapy can be prescribed. Stool cultures
may be taken from the rectum or from stool in a diaper or a
bedpan. Blood specimens need to be drawn for a hemoglobin level (an estimation of hydration as well as anemia);
1327
white blood cell and differential counts (to attempt to establish whether infection is present); and determinations of
PCO2, Cl⫺, Na⫹, K⫹, and pH (to establish electrolyte needs).
If a child can drink, the most effective way to replace fluid is
by offering oral rehydration therapy. For a child who will not
drink, an IV solution such as normal saline or 5% glucose in
normal saline is begun. The solution will provide replacement of fluid, sodium, and calories. Although infants usually
have a potassium depletion, potassium cannot be given until
it is established that they are not in renal failure. Giving
potassium IV when the body has no outlet for excessive
potassium can lead to excessively high potassium levels and
heart block. Before this initial IV fluid is changed to a potassium solution, therefore, be certain that the infant or child has
voided—proof that the kidneys are functioning.
Fluid must be given to replace the deficit that has occurred, for maintenance therapy, and to replace the continuing loss until the diarrhea improves. If infants have lost less
than 5% of total body weight, their fluid deficit is approximately 50 mL/kg of body weight. If infants have lost 10% of
body weight, they need approximately 100 mL/kg of body
weight to replace their fluid deficit. If the weight loss suggests
a 12% to 15% loss of body fluid, they require 125 mL/kg of
body weight to replace the fluid lost. This fluid will be given
rapidly in the first 3 to 6 hours, and then it will be slowed to
a maintenance rate. Once infants void, a potassium additive
can be ordered to restore serum potassium.
Nursing Diagnoses and Related
Interventions
✽
Nursing Diagnosis: Deficient fluid volume related to
loss of fluid through diarrhea
Outcome Evaluation: Skin turgor remains good; specific gravity of urine is 1.003 to 1.030; urine output is
more than 1 mL/kg/hr; bowel movements are formed
and fewer than four per day. Stool tests negative for
reducing substances and blood pH is more than 7.
Promote Hydration and Comfort. During the time infants are NPO, wet infants’ lips with a moisturizing
cream or jelly such as Vaseline if they appear to be
dry. Offer them a pacifier to suck if this seems to comfort them. (They want to suck because they are very
thirsty, and, if they have intestinal cramping with the
diarrhea, they interpret this as hunger.)
As the infant’s condition improves, oral intake can
be increased, changing to a soft then a regular diet.
Some children become lactose intolerant after diarrhea and will need a lactose-free formula for rehydration (Misra et al., 2007).
If the child with severe diarrhea also has a fever,
measures to reduce the fever will be necessary (see
Chapter 37). Do not obtain rectal temperatures to assess fever, because stimulating the anal sphincter
could initiate more diarrhea. Assess perianal skin for
irritation from liquid stools, and keep the skin clean
and dry.
Record Fluid Intake and Output. Much of the nursing
care of children with diarrhea focuses on careful
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recording of fluid intake and output. Because children
have dehydration when first seen, oral rehydration or
IV therapy serves as their lifeline. Be sure to maintain
proper functioning of an IV infusion and site if this is
used. An arm board may be necessary to prevent
catheter dislodgment or interference with the infusion.
Soft restraints applied to the affected and unaffected
extremities may be necessary to prevent a child from
pulling, playing with, or poking at the tubing or site. If
soft restraints are used, be sure to release them every
hour and passively exercise the child’s extremities.
Give parents an explanation of why the IV infusion is
important so they will understand the need for the soft
restraints.
In children who are not toilet trained, apply a disposable urine collection bag to help separate urine
from feces. This makes it obvious that the child is
voiding, confirming kidney function. Confirmation of
adequate kidney function is necessary for IV K⫹ replacement therapy, if ordered.
Separating urine from stools also helps to judge the
appearance of stools or their water content. For each
stool passed, record its color, consistency, odor, size,
and the presence of any blood or mucus. Weigh
soiled diapers to reveal the number of grams of stool
in the diaper (1 g ⫽ 1 mL fluid). Testing the stool for
acidity and for reducing substances (sugars) indicates how quickly the stool has passed through the irritated tract. A stool positive for sugar indicates that little absorption occurred, because sugar is normally
absorbed rapidly from ingested food. Acid stool (pH
less than 7.0) shows the presence of unabsorbed
sugar also (a process occurs similar to the process
that causes acid to invade tooth enamel in the presence of glucose on teeth). Diarrheal stools are green
from lack of time for bile to be modified in the intestine.
As diarrhea improves and stool remains in the intestine for a longer period, the stool deepens in color and
the acid and sugar contents fade. Testing stools for
occult blood shows the extent of bowel irritation that is
occurring from the acid stool. As the diarrhea improves and the irritation to the bowel lessens, the finding of occult blood disappears.
Nursing Diagnosis: Anxiety related to traumatic
experience
Outcome Evaluation: Child interacts with parents in
age-appropriate way; can be comforted after painful
procedures.
All children with diarrhea are assumed to have an infectious form of gastroenteritis and therefore need contact and standard infection precautions. Children usually are uncomfortable from the diarrhea, exhausted,
and confused with these new body sensations. They
need the security of someone to stay with them. When
a child with severe diarrhea is admitted to the hospital,
many emergency procedures must be performed, such
as collecting specimens, reducing temperature, and
beginning rehydration. During all of these procedures,
try to remember how all of this must seem to the child
in the bed. Be sure to take time during initial procedures to touch and soothe children and talk to them;
once the initial admission procedures are done, sit by
the bed and hold a child or gently stroke a child’s head.
Teach parents how to adhere to standard infection precautions and follow contact precautions if necessary.
Encourage them to give any care possible. Children
need this support to counteract the strange world into
which they have suddenly been plunged.
What if... Barry’s mother tells you her doctor has told
her to “force fluids” for Barry whenever he has diarrhea? She asks how much she should force the child
to drink. How would you answer her?
Bacterial Infectious Diseases That Cause
Diarrhea and Vomiting
Several common microorganisms are responsible for diarrhea
in children.
Salmonella
Outcome Evaluation: Skin in diaper area is not erythematous or ulcerated.
• Causative agent: One of the Salmonella bacteria
• Incubation period: 6 to 72 hours for intraluminal type; 7
to 14 days for extraluminal type
• Period of communicability: As long as organisms are
being excreted (may be as long as 3 months)
• Mode of transmission: Ingestion of contaminated food,
especially chicken and raw eggs
Because diarrheal stool is extremely irritating to the
skin, change diapers immediately after infants pass
any stool. Wash the skin of the diaper area well after
each stool, and cover it with an ointment such as
Vaseline or A&D to protect it from further irritation. If
the child is older, caution the child to wipe away stool
thoroughly.
If infants already have skin excoriation from the
number of stools they have had at home, an ointment
such as Desitin may help soothe the irritated skin.
Exposing infants’ buttocks to air is generally helpful in
healing irritation. Assure older children that loss of
stool by diarrhea is not “shameful” or “babyish” but to
be expected because they are ill.
Salmonella is the most common type of food poisoning in
the United States and a major cause of diarrhea in children.
The diagnosis of the infection can be made from stool culture.
Children develop diarrhea, abdominal pain, vomiting, high
temperature, and headache. They are listless and drowsy. The
diarrhea is severe and may contain blood and mucus
(Chambers, 2009). Salmonella infection may remain in the
bowel as an intraluminal disease. When it does, it is treated,
like severe diarrhea, with fluid and electrolyte replacement.
Antibiotics are rarely prescribed as they may actually prolong
the length of the infection (Sirinavin & Garner, 2009). If the
infection becomes systemic (extraluminal disease), it is treated
with the addition of an antibiotic such as ampicillin or a
third-generation cephalosporin (Ogle & Anderson, 2008).
Nursing Diagnosis: Risk for impaired skin integrity related to presence of diarrheal stool on skin
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Complications such as meningitis, bronchitis, and osteomyelitis may occur. Because the source of Salmonella generally is infected food (contaminated chicken and eggs are
common sources), caution parents to wash utensils used to
prepare raw chicken such as cutting boards well and to cook
eggs thoroughly. Although rare, Salmonella also may be
transmitted to children by infected turtles (Box 45.3).
Listeriosis
• Causative agent: Listeria monocytogenes
• Incubation period: Variable, ranging from 1 day to more
than 3 weeks
BOX 45.3 ✽ Focus on Family
Teaching
Preventing Salmonella- or Listeria-Caused
Gastroenteritis
Q. Barry’s mother says to you, “Our son had severe diarrhea from food poisoning. How can we make sure
he doesn’t get that again?”
A. Anyone can get food poisoning. However, it can be
prevented by using the following measures:
• Wash your hands well before preparing any foods,
but especially chicken and eggs.
• Remember that chicken may become contaminated
with Salmonella at the factory where it was prepared.
Wash your hands well after handling raw chicken to
prevent the spread of infection to other foods being
prepared.
• Clean cutting boards or food preparation surfaces
with hot, soapy water and dry thoroughly after use to
prevent them from becoming reservoirs of infection.
• Make a habit of preparing chicken last, after other
foods are prepared.
• Cook eggs well (do not use raw eggs in milkshakes;
cook soft-boiled or poached eggs at least 3 min).
• Refrigerate chicken and eggs after preparation.
• Wash hands well after playing with or feeding a pet
turtle or changing the turtle’s water.
• Wash raw vegetables thoroughly before eating.
• Avoid soft cheeses such as feta, Brie, Camembert,
blue-veined, and Mexican queso fresco cheese.
Hard cheeses; processed cheeses, including sliced
cheese, cream cheese, cheese spreads, and cottage cheese; and yogurt need not be avoided.
• Cook leftover foods or ready-to-eat foods such as
hot dogs until steaming hot before eating.
• Avoid foods from delicatessen counters such as prepared salads, meats, and cheeses or heat/reheat
these foods until steaming before eating.
• Avoid refrigerated pates and other meat spreads or
heat/reheat these foods before eating; canned or
shelf-stable pate and meat spreads need not be
avoided.
• Avoid raw or unpasteurized milk, including goat’s
milk, or milk products or foods that contain unpasteurized milk or milk products.
1329
• Mode of transmission: Ingestion of unpasteurized milk or
cheeses or vegetables grown in contaminated soil
Listeriosis is a serious infection caused by eating food
contaminated with the gram-positive bacterium Listeria
monocytogenes. The cause of the infection may be difficult to
locate as the incubation period can last for almost a month.
After this time, however, a child develops fever, muscle
aches, nausea, and diarrhea. If infection spreads to the nervous system, symptoms such as headache, stiff neck, confusion, loss of balance, or convulsions can occur. The infection
is particularly important to avoid during pregnancy as infections during pregnancy can lead to miscarriage or stillbirth,
prematurity, or infection of the newborn. The bacteria is
found in soil and water. Vegetables can become contaminated by being grown in contaminated soil. The most frequent source, however, is unpasteurized (raw) milk or foods
made from unpasteurized milk such as soft cheese. Therapy
is intravenous ampicillin and an aminoglycoside such as
gentamicin. If a child is hospitalized, standard infection precautions should be instituted. Measures to avoid the infection are shown in Box 45.3.
Shigellosis (Dysentery)
•
•
•
•
Causative agent: Organisms of the genus Shigella
Incubation period: 1 to 7 days
Period of communicability: Approximately 1 to 4 weeks
Mode of transmission: Contaminated food, water, or milk
products
Shigella organisms, like the Salmonella group, cause extremely severe diarrhea that contains blood and mucus. As
the organism becomes more resistant, ampicillin or trimethoprim–sulfamethoxazole, typical drugs used for therapy in the
past, are being replaced by cephalosporins. The child needs
intense fluid and electrolyte replacement. Shigella infection
can be prevented by safe food handling and cautioning families to drink only from safe water sources (Ogle & Anderson,
2008).
Staphylococcal Food Poisoning
• Causative agent: Staphylococcal enterotoxin produced by
some strains of Staphylococcus aureus
• Incubation period: 1 to 7 hours
• Period of communicability: Carriers may contaminate
food as long as they harbor the organism
• Mode of transmission: Ingestion of contaminated food
With staphylococcal food poisoning, a child has severe
vomiting and diarrhea, abdominal cramping, excessive salivation, and nausea within 2 to 6 hours of eating (Ogle &
Anderson, 2008). Organisms are most often spread through
creamed foods such as potato salad. It is often difficult to
culture the causative organism from the contaminated food
because although the staphylococci may have been destroyed by cooking, the enterotoxin that actually causes the
disorder will not have been destroyed. The child needs intensive supportive therapy with fluid and electrolyte replacement and perhaps administration of a drug effective
against Staphylococcus, such as cefotaxime. Food poisoning
from this source can be prevented by proper refrigeration of
food.
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✔Checkpoint Question 45.2
Barry’s mother tells you she often makes milkshakes with raw
eggs. What infectious organism is easily spread this way?
a. Pneumococcus.
b. Salmonella.
c. Streptococcus A.
d. H. pylori.
COMMON DISORDERS OF THE
STOMACH AND DUODENUM
Disorders of the upper GI tract in children tend to involve
inadequate valve function or infection.
Gastroesophageal Reflux
Gastrointestinal reflux or the regurgitation of stomach secretions into the esophagus through the gastroesophageal
(cardiac) valve occurs mainly in infants and adolescents.
Gastroesophageal reflux is usually a self-limiting condition. As the esophageal sphincter matures and the child begins to eat solid food and is maintained in a more upright
position, the problem disappears. If not, botulinum toxin
may be injected into the lower esophageal sphincter to temporarily relieve symptoms of obstruction. If medical therapy
this way is ineffective, a laparoscopic or surgical myotomy
procedure (narrowing of the esophageal sphincter) may be
performed. After this procedure, the child will temporarily
have a nasogastric tube in place that is attached to intermittent low suction. It is usually irrigated with normal saline
every 2 hours to ensure patency. Assess nasogastric tube
drainage and any vomitus for coffee-colored drainage (although this is normal for the first 24 hours) that would indicate bleeding from the surgical site. When infants are first
fed after surgery, they may display signs of abdominal discomfort and distention because food can no longer reflux
into the esophagus as readily as it could before surgery. As
their stomach adjusts to this, symptoms fade. Before this
happens, however, the distention may be so extreme that it
leads to bradycardia and dyspnea. Be alert for the development of these important signs and symptoms.
Gastroesophageal Reflux in Infants
Gastroesophageal reflux in infants occurs from a neuromuscular disturbance in which the gastroesophageal (cardiac)
sphincter and the lower portion of the esophagus spasm and
allow easy regurgitation of gastric contents into the esophagus. It usually starts within 1 week after birth and may be associated with a hiatal hernia (see later discussion). Children
with cerebral palsy or other neurologic involvement are at
particular risk. The regurgitation occurs almost immediately
after feeding or when the infant is laid down after a feeding.
If the amount of the reflux is large or constant, an infant does
not retain sufficient calories and will fail to thrive. In addition, aspiration pneumonia or esophageal stricture from the
constant reflux of hydrochloric acid into the esophagus can
occur (Sondheimer & Sundaram, 2008).
Assessment. The diagnosis is suggested by the history.
Vomiting appears effortless and is not projectile; it begins
much earlier in life than the vomiting associated with pyloric
stenosis. The child may be irritable and may experience periods of apnea. Inserting a probe or catheter through the nose
into the distal esophagus and determining the pH from secretions can show whether gastric secretions are entering the
esophagus (if the pH is less than 7.0, then acid is present).
Esophageal manometry is used to measure the strength of the
esophageal sphincter. Fiberoptic endoscopy or esophagography (barium swallow) will further show the involved sphincter and the reflux of stomach contents into the esophagus, especially if the infant’s head is tilted downward.
Therapeutic Management. The traditional treatment of GI
reflux is to feed infants a formula thickened with rice cereal
(1 tbsp of cereal per 1 oz of formula or breast milk) while
holding them in an upright position and then keeping them
upright in an infant chair for 1 hour after feeding so gravity
can help prevent reflux (Craig et al., 2009). An H2 receptor
antagonist such as ranitidine (Zantac) or a proton pump inhibitor such as omeprazole (Prilosec) may be prescribed daily
to reduce the possibility of the stomach acid contents irritating the esophagus.
Nursing Diagnoses and Related
Interventions
✽
Nursing Diagnosis: Risk for imbalanced nutrition, less
than body requirements, related to regurgitation of
food with esophageal reflux
Outcome Evaluation: Skin fold returns to place quickly
when turgor is assessed; specific gravity of urine is
1.003 to 1.030; intake is 50 cal/lb/24 hr.
Teach parents the importance of monitoring intake,
output (urination), and weight. Also reinforce the need
to keep the infant upright, such as in an infant seat,
after a feeding. Be certain parents understand how
much cereal to mix with formula or breast milk.
Encourage parents to feed the infant during the short
time that the infant remains in the hospital after surgery
so that they can regain their confidence as parents.
Gastrointestinal Reflux in Adolescents
Gastroesophageal reflux disease (GERD) affects about 20%
of adults; symptoms frequently begin in adolescence.
Irritation to the esophagus occurs when stomach contents,
including hydrochloric acid, reflux through the lower
esophageal sphincter and irritate the esophageal lining.
Reflux occurs because of an incompetent sphincter especially
when the adolescent lies supine or when intra-abdominal
pressure is increased by a full stomach, lifting or bending, or
tight clothing. It is potentially dangerous because it can lead
to erosion of the esophagus with perforation or stricture of
the esophagus. It may be associated with the development of
esophageal cancer in later life (Zagaria, 2008).
The typical symptom is heartburn that occurs 30–60 minutes after a meal. Diagnosis is based on history (typical symptoms of heartburn) and, if symptoms are severe, endoscopy
to reveal the irritated esophagus (esophagitis). The goal of
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CHAPTER 45 Nursing Care of a Family When a Child Has a Gastrointestinal Disorder
treatment is to provide symptomatic relief and to heal any
esophagitis identified.
Adolescents should avoid lying down until 3 hours after a
meal and should sleep at night with their upper body elevated on a foam wedge. They should avoid acidic foods such
as tomato products, citrus fruits, or spicy foods. Avoiding
foods that delay gastric emptying such as fatty foods, chocolate, or alcohol and eating smaller portions may also be helpful. Weight loss, avoiding bending after meals, and removing
tight belts are also recommended steps.
Antacids relieve pain immediately by decreasing the concentration of the stomach acid and are sold over the counter.
H2-receptor antagonists such as cimetidine (Pepcid) or ranitidine (Zantac) are also available over the counter and can be
taken before meals to prevent heartburn symptoms. Proton
pump inhibitors such as omeprazole (Prilosec) or rabeprazole
(Aciphex), drugs that halt the release of stomach acids, are
prescription drugs that offer the best long-term relief.
Adolescents generally take these for 6 to 8 months until
esophageal healing is complete.
As adults, esophageal reflux may return. Some adults require surgery in later life to relieve esophageal strictures or recurring ulcers from returning irritation.
Pyloric Stenosis
The pyloric sphincter is the opening between the lower portion of the stomach and the beginning portion of the intestine, the duodenum. If hypertrophy or hyperplasia of the
muscle surrounding the sphincter occurs, it is difficult for the
stomach to empty, a condition called pyloric stenosis (Fig.
45.3). With this condition, at 4 to 6 weeks of age, infants
begin to vomit almost immediately after each feeding. The
vomiting grows increasingly forceful until it is projectile, possibly projecting as much as 3 to 4 feet. The incidence is high,
approximately 1:150 in males and 1:750 in females. It tends
to occur most frequently in first-born white male infants.
The exact cause is unknown, but multifactorial inheritance is
the likely cause. It occurs less frequently in breastfed infants
than in formula-fed infants. Formula-fed infants typically
begin having symptoms at approximately 4 weeks of age.
Breastfed infants begin having symptoms at 6 weeks because
the curd of breast milk is smaller than that of cow’s milk, and
it passes through a hypertrophied muscle more easily. For
Stenosed pyloric valve
1331
unknown reasons, an increased incidence is seen in infants
who receive a macrolide antibiotic such as erythromycin
(Maheshwai, 2007).
Vomitus usually smells sour because it has reached the
stomach and has been in contact with stomach enzymes.
There is never bile in the vomiting of pyloric stenosis because
the feeding does not reach the duodenum to become mixed
with bile. Infants are usually hungry immediately after vomiting because they are not nauseated. Although it is difficult
to assess whether nausea is present in infants, signs such as a
disinterest in eating, excessive drooling, or chewing on the
tongue may suggest this.
Assessment
The diagnosis of pyloric stenosis is made primarily from the
history. Whenever parents say that their baby is vomiting or
spitting up, be certain to get a full description:
•
•
•
•
What is the duration? Begins at 6 weeks of age
What is the intensity? Projectile vomiting
What is the frequency? Immediately after eating
What is the description of the vomitus? Sour but contains
no bile
• Is the infant ill in any other way? No.
Many infants have signs of dehydration from the vomiting when they are first seen. Lack of tears (many infants
younger than age 6 weeks do not tear), dry mucous membrane of the mouth, sunken fontanelles, fever, decreased
urine output, poor skin turgor, and weight loss are common
signs seen. Alkalosis also may be present because of the excessive loss of Cl⫺ ions from stomach fluid, along with accompanying hypochloremia, hypokalemia, and starvation.
Hypopnea (slowed respirations) occurs as the body attempts
to compensate for the alkalosis. This will cause the HCO3
content of plasma generally to be above 30 mEq/L (normal
is 22 to 28 mEq/L). Tetany may occur with alkalosis because
the increased HCO3⫺ ions may combine with Ca2⫹ ions,
trying to effect homeostasis and thereby lowering the level of
ionized calcium. Low serum calcium levels lead to tetany.
A definitive diagnosis is made by watching the infant
drink. Before the child drinks, attempt to palpate the right
upper quadrant of the abdomen for a pyloric mass. If one is
present, it feels round and firm, approximately the size of an
olive. As the infant drinks, observe for gastric peristaltic
waves passing from left to right across the abdomen. The
olive-size lump becomes more prominent. The infant vomits
with projectile emesis. If the diagnosis is still in doubt, an ultrasound will show the hypertrophied sphincter (Oldham &
Aiken, 2007). Endoscopy also may be used for diagnosis by
directly visualizing the hypertrophied sphincter.
Therapeutic Management
Stomach
Duodenum
FIGURE 45.3 Pyloric stenosis. Fluid is unable to pass easily
through the stenosed and hypertrophied pyloric valve.
Treatment is surgical or laparoscopic correction (a pyloromyotomy), performed before electrolyte imbalance from
the vomiting or hypoglycemia from the lack of food occurs.
Before surgery, if electrolyte imbalance, dehydration, and
starvation have already occurred, these must be corrected by
administration of IV fluid, usually isotonic saline or 5% glucose in saline. Oral feedings are withheld to prevent further
electrolyte depletion. An infant who is receiving only IV fluid
generally needs a pacifier to meet nonnutritive sucking needs
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and be comfortable. If tetany is present, verified by a low calcium level on blood analysis, IV calcium also must be administered. The infant usually needs additional potassium,
but as a rule this can not be administered until it is determined that the child’s kidneys are functioning (the child is
voiding). Otherwise, the potassium buildup could cause cardiac arrhythmias.
For surgical correction, the muscle of the pylorus is split
down to the mucosa, allowing for a larger lumen. Although
the procedure sounds simple, it is technically difficult to perform, and there is a high risk for infection afterward because
the abdominal incision is near the diaper area.
The prognosis for infants with pyloric stenosis is excellent
if the condition is discovered before an electrolyte imbalance
occurs.
well after a feeding so there is no pressure from air in
the stomach. Lay them on their side after feeding so
that if vomiting does occur, there is little chance of aspiration. Laying them on their right side may aid the
flow of fluid through the pyloric valve by gravity.
Continue to monitor daily weights to confirm that the
child is receiving adequate intake. Usually no vomiting occurs postoperatively, but if it does occur, report
it immediately. The feeding regimen may need to be
adjusted accordingly, and the infant may require a
longer hospital stay. Some infants have a short-term
diarrhea (dumping syndrome) after surgery because
of rapid functioning of the pyloric sphincter, but this
tends to resolve without additional therapy.
Nursing Diagnoses and Related
Interventions
Outcome Evaluation: Infant’s temperature is below
98.6° F (37.0° C) axillary; incision is clean, dry, and intact without erythema or drainage.
Nursing Diagnosis: Risk for deficient fluid volume related to inability to retain food
The surgical incision for pyloric stenosis may be covered with collodion, a solution similar to clear nail polish, or a similar commercial compound to help keep
urine and feces from touching it. Keep diapers folded
low to prevent the incision from being contaminated,
and change diapers frequently. If the incision should
be exposed to feces, wash the collodion well with
soap and water.
✽
Outcome Evaluation: Skin turgor remains good; specific gravity of urine is 1.003 to 1.030; vomiting
episodes have ceased; weight is within acceptable
age-appropriate parameters.
Preoperative Care. Preoperative management consists of fluid and electrolyte replacement based on
laboratory determinations. A baseline weight is essential for establishing the extent of dehydration. Note
carefully the frequency of urination, the specific gravity of the urine, and the number of stools passed to
help assess dehydration and starvation. Parents may
be impatient with preoperative management because
it may take 24 hours or more to restore a severe fluid
imbalance. They need an explanation that infants cannot go to surgery with an electrolyte imbalance; these
hours before surgery are as important to the welfare of
their child as the operation itself.
Postoperative Care. Infants will return from surgery or
laparoscopy with an IV line in place. The postoperative feeding regimen differs from one surgeon to another but usually involves frequent feedings of small
amounts of fluid. Approximately 4 to 6 hours after
surgery, infants are started on a small amount of an
oral rehydrating solution by bottle. If no vomiting occurs, the amount is increased or half-strength formula
or breastfeeding is begun. Finally, by 24 to 48 hours,
infants are taking their full formula diet or being fully
breastfed. They are usually discharged from the hospital at the end of 48 hours.
Postoperatively, it is important that infants be given
no more than the amount of fluid ordered at a time so
the surgical repair site is not overwhelmed. Infants
need to ingest these small amounts because a small
quantity of fluid passing through the sphincter in the
immediate postoperative days helps to keep adhesions of the sphincter from forming. As the amount
taken orally increases, the IV fluid will be decreased
and then discontinued. Infants should be bubbled
Nursing Diagnosis: Risk for infection at site of surgical
incision related to danger of contamination from feces
because of proximity of incision to diaper area
Nursing Diagnosis: Risk for impaired parenting related
to infant’s feeding difficulty and illness
Outcome Evaluation: Parents hold and feed infant; express positive characteristics about infant.
Encourage the parents to “room in” with their child so
they can grow comfortable and confident in caring for
the child again. When the child first began vomiting so
forcefully, parents may have felt they were doing
something wrong and so may have lost confidence in
themselves as parents. Explain to them that the vomiting was caused by a physical problem and not by
anything they did.
Hospitalization often occurs near the infant’s second month, when the child would normally receive
diphtheria-tetanus-pertussis, rotavirus, pneumococcal, oral poliomyelitis, and Haemophilus influenzae
immunizations. Ask if they could be administered before discharge so the child’s immunization status remains current. This also might serve to remind parents
that getting back to normal means regular health care
visits for vaccines and checkups.
Hiatal Hernia
Hiatal hernia is the intermittent protrusion of the stomach
up through the esophageal opening in the diaphragm. When
this occurs, the volume of the stomach is suddenly restricted,
leading to periodic vomiting similar to that of gastroesophageal reflux. With a hiatal hernia, however, pain usually
accompanies the vomiting. Shortness of breath may occur
from compression of the lung space by the stomach
(Skandalakis, 2007).
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Hiatal hernia is diagnosed by history and an ultrasound or
barium swallow. Keeping a baby in an upright position helps
prevent the condition from recurring. Medication to reduce
acid secretions may also be helpful. If the condition has not
corrected itself by the time the infant is 6 months old, even
with maintaining an upright position most of the day, laparoscopic surgery may be performed to reduce the stomach’s ability to protrude through the diaphragm.
Peptic Ulcer Disease
A peptic ulcer is a shallow excavation formed in the mucosal
wall of the stomach, the pylorus, or the duodenum. In infants, ulcers tend to be gastric; in adolescents, they are usually duodenal. Such ulcers occur in a primary form caused
by infection of H. pylori bacteria and a secondary form that
follows severe stress such as burns or chronic ingestion of
medications such as acetylsalicylic acid or prednisone
(Lebwohl, 2007).
Peptic ulcer disease occurs in only 1% to 2% of children.
It occurs more frequently in males than in females. In addition to infection from H. pylori, associated factors in adolescents may include a genetic tendency and use of nonsteroidal
anti-inflammatory drugs (NSAIDs), alcohol, caffeine, and
cigarettes (Barba, Fitzgerald, & Wood, 2007).
The small ulceration of the gastric or duodenal lining
leads to pain, blood in the stool, and vomiting (with
blood). If left uncorrected, peptic ulcer disease can lead to
bowel or stomach perforation with acute hemorrhage or pyloric obstruction (Hua et al., 2007). A chronic ulcer condition may lead to anemia from the constant, gradual blood
loss.
Assessment
An ulcer occurring in a neonate usually presents with hematemesis (blood in vomitus) or melena (blood in the
stool). Such ulcers are usually superficial and heal rapidly, although they can lead to rupture, with symptoms of respiratory distress, abdominal distention, vomiting, and, if extensive, cardiovascular collapse. If an ulcer occurs in a toddler,
the first symptoms are usually anorexia or vomiting.
Bleeding follows in several weeks. If an ulcer begins when
children are of preschool or early school age, pain may be
the presenting symptom. The child may report pain as mild,
severe, colicky, or continuous. It is often poorly localized, although it may be in the epigastric area as in adults. If the
pain occurs in the right lower quadrant, it can be confused
with appendicitis.
In older, school-age children and adolescents, symptoms
are generally those of the adult: a gnawing or aching pain in
the epigastric area before meals that is relieved by eating.
Vomiting (because of spasm and edema of the pylorus) occurs in a small number of children. On abdominal palpation,
epigastric tenderness is noted.
Fiberoptic endoscopy is the most reliable diagnostic test
to confirm the diagnosis of peptic ulcer disease; it allows for
visual inspection and cultures for H. pylori. Because childhood ulcers are shallow, they may not show up well on radiography. In many children, little increase in gastric activity
can be demonstrated by gastric analysis. Children with this
condition must have blood tests done periodically to be
monitored for blood loss anemia.
1333
Therapeutic Management
Children with peptic ulcer disease are treated with a combination of medications to reduce the bacteria count and suppress
gastric acidity. Adolescents are prescribed an antibiotic such as
amoxicillin or clarithromycin (Biaxin) and a proton pump inhibitor such as omeprazole (Prilosec). Bismuth subsalicylate
(Pepto-Bismol) is soothing and mildly antibiotic and so may
be prescribed concurrently. Younger children are prescribed
cimetidine (Tagamet) because safe levels of omeprazole have
yet to be established for this age group. With current therapy,
only a few children experience the potential complications of
perforation, blood loss anemia, and intestinal obstruction, although some school-age children and adolescents will have recurring symptoms as they grow older. Most important to prevent an ulcer reoccurring seems to be evacuation of H. pylori
from the child’s stomach or intestine (Bose et al., 2007).
Nursing Diagnoses and Related
Interventions
✽
Having peptic ulcer disease can be difficult for children because it is painful, and remembering to take
medicine daily may be a problem.
Nursing Diagnosis: Pain related to ulceration in intestinal tract
Outcome Evaluation: Child exhibits verbal and nonverbal signs of decreased pain; the infant appears comfortable without excessive crying.
Children with peptic ulcer disease should be able to
eat a normal diet, avoiding heavily spiced food such
as pizza or sausage if such food causes discomfort.
Work with them to devise a schedule so they can remember to take their medications.
Be certain that the outcomes planned are realistic.
It may not be possible to relieve symptoms of peptic
ulcer immediately. However, children can be helped
immediately to understand why the pain occurs and
what they can do to help relieve it.
✔Checkpoint Question 45.3
Barry’s older sister had pyloric stenosis as an infant. Vomiting
with pyloric stenosis typically occurs:
a. Immediately after feeding.
b. An hour after feeding.
c. On arising in the morning.
d. When the infant cries.
HEPATIC DISORDERS
Hepatic disorders include both acquired disorders, such as
hepatitis or cirrhosis, and congenital disorders, such as obstruction or atresia of the biliary duct.
Liver Function
The liver lies immediately under the diaphragm on the right
side. In infants, 1 or 2 cm of liver is readily and normally
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UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders
palpable. The organ is essential for the normal metabolism of
carbohydrates, proteins, and fats. It plays a role in the maintenance of normal blood sugar level by changing glucose to
glycogen and storing it until needed by body cells. It then reverses the process and changes glycogen back to glucose and
releases it into the blood when cells need it (Jonas & PerezAtayde, 2007).
The liver assists in the catabolism of fatty acids and protein and serves as a temporary storage space for both fat and
protein. The liver, by the means of the enzyme glucuronosyltransferase, converts indirect (or unconjugated) bilirubin
into direct (or conjugated) bilirubin so it can be excreted in
bile and eliminated from the body. This is an important
function in the newborn, and jaundice can result if the level
of glucuronosyltransferase is low because of immaturity.
The liver manufactures bile, a secretion necessary for the
digestion of fat; fibrinogen and prothrombin, substances essential for blood clotting; heparin, a substance necessary to
keep blood from clotting in intact vessels; and blood proteins. It produces large amounts of body heat. It destroys red
blood cells and detoxifies many harmful absorbed substances,
such as drugs. Because the liver, a life-sustaining organ, performs all of these functions, any disorder involving the liver
is always serious. Several common liver function tests are
used to diagnose the nature of liver pathology (Table 45.5).
Hepatitis
Hepatitis (inflammation and infection of the liver) is caused
by invasion by hepatitis A, B, C, D, or E virus (Tan & Lok,
2007).
TABLE 45.5
✽
Hepatitis A
• Causative agent: A picornavirus, hepatitis A virus (HAV)
• Incubation period: 25 days on average
• Period of communicability: Highest during 2 weeks preceding onset of symptoms
• Mode of transmission: In children, ingestion of fecally
contaminated water or shellfish; day care center spread
from contaminated changing tables
• Immunity: Natural; one episode induces immunity for
the specific type of virus
• Active artificial immunity: HAV vaccine (recommended
for all children 12 to 23 months of age and workers in day
care centers) (AAP, 2009)
• Passive artificial immunity: Immune globulin
Hepatitis B
• Causative agent: A hepadnavirus; hepatitis B virus (HBV)
• Incubation period: 120 days on average
• Period of communicability: Later part of incubation period and during the acute stage
• Mode of transmission: Transfusion of contaminated blood
and plasma or semen; inoculation by a contaminated syringe or needle through IV drug use; may be spread to fetus
if mother has infection in third trimester of pregnancy
• Immunity: Natural; one episode induces immunity for
the specific type of virus
• Active artificial immunity: Vaccine for the HBV virus recommended for routine immunization beginning at birth
and also to all health care providers (AAP, 2009)
Liver Function Tests
Test
Description
Serum bilirubin
Indirect bilirubin found in large quantities in bloodstream indicates that the child is not
converting it to direct bilirubin; hence, liver cell function may be impaired; the
normal value of total bilirubin in serum is 1.5 mg per 100 mL; if large amounts of
direct bilirubin are found in serum, it implies obstruction of the bile duct, preventing
the excretion of the converted substance.
If bile pigments can be obtained from stool (excreted as urobilinogen in stool and urine),
it is evidence that bile is being manufactured and excreted from the liver; without
the presence of bile pigment, stool appears light in color (clay colored). Even
trace amounts of bilirubin in urine are abnormal, possibly indicating liver dysfunction.
Alkaline phosphatase is an enzyme produced by the liver and bone and excreted in
the bile; with bile duct obstruction, increased levels of alkaline phosphatase will be
in the blood.
This test is associated with blood coagulation. In chronic liver disease, the level of
prothrombin produced by the liver may fall so severely that the prothrombin time is
increased; there is little change in prothrombin time in mild or short-term liver disease.
AST (SGOT) is an enzyme found in the heart and liver; when there is acute cellular
destruction in either organ, the enzyme is released into the bloodstream from the
damaged cells; the blood levels are increased by 8 hours after injury; the level reaches
a peak in 24 or 36 hours and then falls to normal in 4 to 6 days.
ALT (SGPT) is an enzyme found mostly in the liver; it rises for the same reasons as AST
(SGOT) but is not as sensitive an indicator of liver damage.
Stool and urine bilirubin
Alkaline phosphatase
Prothrombin time
Aspartate transaminase
(AST; serum glutamicoxaloacetic transaminase
[SGOT])
Alanine transaminase (ALT;
serum glutamate pyruvate
transaminase [SGPT])
Lactic dehydrogenase (LDH)
Serum albumin
LDH is another enzyme found in the heart and liver; it is a relatively insensitive indicator
of liver destruction, however; infectious mononucleosis is the one disease in which
increased levels of LDH are seen frequently.
Albumin, a serum protein, is chiefly synthesized in the liver; most acute or chronic liver
disease will cause decreased serum albumin.
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CHAPTER 45 Nursing Care of a Family When a Child Has a Gastrointestinal Disorder
• Passive artificial immunity: Specific hepatitis B immune
serum globulin
Hepatitis C, D, and E
Although hepatitis A and B are the viruses that most frequently cause hepatitis, hepatitis C, D, and E viruses may
also be involved. Hepatitis C (HCV) is a single-strand RNA
virus. Transmission, as with HBV, is primarily by blood or
blood products, IV drug use, or sexual contact. The virus
produces mild symptoms of disease, but there is a high incidence of chronic infection with the virus.
Hepatitis D (HDV) or the delta form is similar to HBV
in transmission, although it apparently requires a coexisting
HBV infection to be activated. Disease symptoms are mild,
but there is a high incidence of fulminant hepatitis after the
initial infection.
The E form of hepatitis is enterically transmitted similarly to hepatitis A (fecally contaminated water). Disease
symptoms from the E virus are usually mild, except in pregnant women, in whom they tend to be severe (Patra et al.,
2007).
Assessment. No matter which virus is involved, hepatitis is a
generalized body infection with specific intense liver effects.
Type A occurs in children of all ages and accounts for approximately 30% of instances. Hepatitis B tends to occur in
newborns from placental-fetal transfer and in adolescents
after intimate contact or the use of contaminated syringes for
drug injection.
Clinically, it is impossible to differentiate the type of hepatitis from the signs that are present. All hepatitis viruses
cause liver cell destruction, leading to increased serum aspartate amino transaminase (AST), alanine aminotransaminase
(ALT), and alkaline phosphatase levels. Albumin synthesis
decreases, and bile formation and excretion are impaired.
The type of virus causing the disease can be determined by
the recognition of a specific antibody against the virus (antiHAV IgM, anti-HBV IgM, and so forth).
Children notice headache, fever, and anorexia.
Symptoms with hepatitis A are generally mild. Jaundice
occurs as liver function slows. This lasts for approximately
a week, and then symptoms fade with full recovery.
Symptoms of hepatitis B are more marked. Children report
generalized aching, right upper quadrant pain, and
headache. They may have a low-grade fever. They feel ill;
they are irritable and fretful from pruritus (itching). After 3
to 7 days of such symptoms, the color of the urine becomes
darker (brown) because of the excretion of bilirubin. In another 2 days, the sclerae of the eyes become jaundiced; soon
a child has generalized jaundice. With the generalized jaundice, there is little excretion of bilirubin into the stool, so
the stools become white or gray. This icteric (jaundiced)
phase lasts for a few days to 2 weeks. Some children have an
anicteric form of infection, in which they develop the
beginning symptoms but then never develop the jaundice.
They are as infectious, however, as children with overt
jaundice.
Laboratory studies will show elevations of the liver enzymes AST (SGOT) and serum alanine transaminase (ALT;
serum glutamate pyruvate transaminase [SGPT]). Levels of
bilirubin are increased in the urine. Bile pigments in the stool
are decreased. Serum bilirubin levels are increased.
1335
Therapeutic Management. All health care providers should
receive prophylaxis against hepatitis with the hepatitis vaccine. Infants should also receive routine immunization against
HBV. All women should be screened during pregnancy for
hepatitis B surface antigen (HBsAg). Infants born to hepatitis-positive mothers receive both HBIG and active immunization at birth to prevent them from contracting the disease
(Lee et al., 2009). Hepatitis A vaccine is available for health
care providers and included in routine immunization programs for infants beginning at one year of age (AAP, 2009).
Strict handwashing and infection control precautions are
mandatory when caring for children with hepatitis. Feces
must be disposed of carefully because the type A virus can be
cultured from feces. Syringes and needles must be disposed of
with caution because the type B virus can be transmitted by
blood. Contacts should receive immune globulin (hepatitis A)
or hepatitis B immune globulin (HBIG) as appropriate.
The treatment for hepatitis A is increased rest and maintenance of a good caloric intake. A low-fat diet, once recommended, is not required and, in any event, is difficult to enforce. Children are generally hungrier at breakfast than later
in the day, so encourage them to eat a healthy breakfast.
Children can be cared for at home. They should not return
to school or a day care center until 2 weeks after the onset of
symptoms.
Lamivudine (Epivir), an antiviral agent, may be effective
in reducing viral replication with hepatitis B. Interferon also
may be prescribed. Of those with type B, 90% will recover
completely, but 10% will develop chronic hepatitis and become hepatitis carriers. Hepatitis B is always potentially serious because newborns who contract the disease at birth have
an increased risk for liver carcinoma later in life (Perrillo &
Jacobson, 2007). As hepatitis B is a sexually transmitted disease, preadolescent children with the infection need to be
screened for the possibility of sexual abuse (Lewin, 2007).
Nursing Diagnoses and Related
Interventions
✽
Nursing Diagnosis: Pain related to pruritus of jaundice
and liver inflammation
Outcome Evaluation: Child states level of itching is tolerable; no scratch marks on skin; reports right upper
quadrant pain is minimal.
Pruritus from jaundice results in extreme discomfort
for some children (Cies & Giamalis, 2007). Being certain that a child is not overheated and not perspiring
reduces the itching. A cool bath is often comforting.
Skin moisturizers such as Eucerin or an antihistamine
may be prescribed. Cholestyramine (Questran) is a
bile acid sequestrant, which binds bile in the GI tract
to prevent its reabsorption so helps prevent pruritus.
Teaching a child distraction techniques such as
putting pressure on a pruritic area or trying imagery to
lessen the urge to scratch can also be helpful.
Chronic Hepatitis
Hepatitis is considered chronic when it persists for longer
than 6 months. This is most often the result of hepatitis B,
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D, or C infection. Abnormal liver enzyme levels and a liver
biopsy establish the diagnosis and can also predict the severity. With chronic hepatitis, fatty infiltration and bile duct
damage can occur. The disease may progress to cirrhosis and
eventually liver failure. Therapy is supportive to compensate
for decreased liver function (Friedman, 2009).
Fulminant Hepatic Failure
Fulminant hepatic failure is present when acute, massive
necrosis or sudden, severe impairment of liver function occurs, leading to hepatic encephalopathy. Hepatic encephalopathy is the result of ammonia intoxication caused by
the inability of the liver to detoxify the ammonia being constantly produced by the intestine in the process of digestion
(Cochran & Losek, 2007).
Children show mental aberrations such as confusion,
drowsiness, or disorientation. Treatment involves reducing
protein intake and administering lactulose to prevent absorption of ammonia in the colon or administering nonabsorbable antibiotics such as neomycin to decrease the production of ammonia by the intestinal bacteria. Liver
transplantation (surgical replacement of a malfunctioning
liver by a donor liver) may be necessary. As adults have excess
liver tissue, a donor liver may be provided by a living donor.
Otherwise, many children cannot survive the long wait for a
cadaver donor organ.
Obstruction of the Bile Ducts
Therapeutic Management
Before treatment is begun, appropriate blood work and a liver
biopsy under local anesthesia may be obtained to rule out
hepatitis. Duodenal secretions may be collected by endoscopy
to assess for bile. Radionuclide imaging may also be performed. For this, the infant is given an IV radioactive isotope
that when taken up by the liver would normally be seen flowing through the bile ducts. If the problem appears to only be
a mucus plug in the duct, children may be given magnesium
sulfate (installed into the duodenum to relax the bile duct) or
dehydrocholic acid (Decholin) IV to stimulate the flow of
bile. If atresia of the bile duct is the problem, surgical correction is the treatment (a Kasai procedure). With this surgery, a
loop of bowel is sutured next to the liver to create a fistula for
bile flow between the liver and intestine. A double-barreled
colostomy is then created (enterostomy). Bile flows out of the
proximal loop into a collecting bag. It is periodically returned
to the distal loop of intestine by injection. After 6 to 12
weeks, the colostomy is closed when a normal bile flow has
been established. However, surgical correction is impossible
in all infants with atresia because the atresia tends to occur too
far back in the liver to be in an operable area. Liver transplantation is needed for children with extensive involvement
or in whom a Kasai procedure is not successful.
Nursing Diagnoses and Related
Interventions
✽
Obstruction of the bile ducts in children generally occurs
from congenital atresia, stenosis, or absence of the duct. It
also can occur from the plugging of biliary secretions, though
this is rare. When the bile duct is obstructed, bile, unable to
enter the intestinal tract, accumulates in the liver. Bile pigments (direct bilirubin) enter the bloodstream and jaundice
occurs, increasing in intensity daily.
Nursing Diagnosis: Risk for imbalanced nutrition, less
than body requirements, related to inability to digest fat
Assessment
Preoperative Care. Infants who are admitted for
Although bile duct obstruction is a congenital disorder, the
chief sign (jaundice) does not develop until approximately 2
weeks of age. This delay differentiates it clinically from physiologic jaundice, which occurs in almost all newborns on the
third day of life, or the jaundice of Rh or ABO isoimmunization, which typically occurs during the first 24 hours of
life. Laboratory findings will also distinguish this type of
jaundice from other types. Physiologic jaundice and isoimmunization jaundice occur from a rise in indirect bilirubin,
whereas the jaundice of bile duct obstruction is a result of a
rise in direct bilirubin. Alkaline phosphatase levels are also elevated. The AST (SGOT) level is normal in the early phase
but later becomes abnormal, when prolonged obstruction
and back-pressure cause liver cell damage. In addition, because bile salts (necessary for fat absorption) are not reaching
the intestine, absorption of fat and fat-soluble vitamins (vitamins A, D, E, and K) is poor. Calcium absorption, which
depends on vitamin D absorption, also is poor. The infant’s
stools appear light in color from lack of bile pigments. The
pressure on the liver from the obstruction becomes so acute
with time that cell destruction or cirrhosis occurs.
Ultimately, without liver transplantation, death from liver
failure will result (Kamath, 2008).
Outcome Evaluation: Infant’s weight remains in same
percentile on standardized growth curve; absence of
signs of vitamin deficiency such as cracked lips or altered bone growth; dietary record reflects intake of
adequate nutrients.
surgery for bile duct obstruction are placed on a lowfat, high-carbohydrate diet preoperatively. They are
given water-soluble forms of vitamins A, D, and K to
improve vitamin levels. If the vitamin K level is too low,
coagulation may be affected, increasing surgical risk.
Vitamin K may be administered parenterally until prothrombin levels rise to normal limits. Infants will also
be well hydrated with parenteral fluids.
Postoperative Care. Following surgery, infants return
with a nasogastric tube in place attached to low intermittent suction. Observe carefully for abdominal distention because paralytic ileus is a frequent complication of this type of surgery. The nasogastric tube will be
left in place until peristalsis has returned. Gradually,
children will be introduced to oral fluids and eventually
to a normal diet. If the repair is successful, the child’s
stools change to a yellow and then brown (normal
stool) color after surgery. Description of stools is,
therefore, an important postoperative observation.
If bile flow is inadequate after surgery, infants will
remain on a medium-fat, high-carbohydrate diet or receive total parenteral nutrition while they await transplantation surgery.
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Cirrhosis
Cirrhosis is fibrotic scarring of the liver. Cirrhosis means “yellow,” or the typical color of hepatic scar tissue. It occurs rarely
in children, although it may be seen as a result of congenital
biliary atresia or as a complication of chronic illnesses such as
protracted hepatitis, sickle-cell anemia, or cystic fibrosis.
When fibrotic infiltrates replace normal liver cells, liver
function is impaired, resulting in a decreased ability to detoxify toxic substances, decreased protein synthesis, inability to
produce prothrombin, decreased ability to produce bile, and,
possibly, hypoglycemia. Children will have large, fatty stools
resulting from the decrease in bile production; avitaminosis
of fat-soluble vitamins; symptoms of hemorrhage from decreased clotting ability; and anemia.
Fibrotic infiltration interferes not only with the function
of liver cells but also with blood flow through the liver. This
leads to portal hypertension from the back-pressure of blood
that cannot flow readily through the scarred organ (Fig.
45.4). This leads to compromised heart action, ascites (an exudate of fluid into the abdomen), possibly esophageal varices
(back-pressure causes them to dilate), and hypersplenism.
Once fibrotic infiltration begins, there is no way to reverse
the changes. Nursing care focuses on promoting comfort,
providing adequate nutrition by a high-carbohydrate,
medium-chain–triglyceride diet, and preventing further involvement until liver transplantation can be scheduled.
1337
Cholestyramine (Questran) may be prescribed to stimulate
bile flow and reduce reabsorption of bile into the circulation
to minimize jaundice.
Esophageal Varices
Esophageal varices (distended veins) is a frequent complication of liver disorders such as cirrhosis (McQuaid, 2009).
They generally form at the distal end of the esophagus near
the stomach because of back-pressure on the veins there because of increased blood pressure in the portal circulation.
Varices may bleed if children cough vigorously or strain to
pass stool. Gastric reflux into the distal esophagus may irritate and erode the fine covering of the distended vessels, causing rupture.
Rupture of esophageal varices is an emergency because
children can lose a large quantity of blood quickly from the
engorged vessels. Vasopressin or nitroglycerin may be given
IV to lessen hypertension and reduce the hemorrhage.
Injection of a sclerosing agent into veins may be attempted to
decrease their size. Iced saline nasogastric lavage may be instituted to promote vasoconstriction. A SengstakenBlakemore tube or Linton-Nachlas catheter may be passed
into the stomach. After insertion, balloons on the sides of the
catheter are inflated to apply pressure against the bleeding
vessels. As with an external tourniquet, the compression must
be reduced for 5 to 10 minutes every 6 to 8 hours, or tissue
necrosis can result.
Children must be monitored for future bleeding episodes.
Frequent vital sign measurements and testing of stool and
any vomitus for the presence of blood will indicate new
esophageal bleeding.
Liver Transplantation
Liver transplantation is the surgical replacement of a malfunctioning liver by a donor liver (Bueno et al., 2007).
Donor livers are not readily available, so the waiting time for
surgery may be months. Finding an acceptable, child-sized
liver may be especially difficult, so adult livers can be reduced
in size for transplantation. A lobe of a liver from a living
donor is frequently used today. Often, the child is extremely
ill with ascites, GI bleeding, extreme pruritus, hepatic encephalopathy, or renal dysfunction before the surgery can be
performed. This makes nursing care after liver transplantation in a child complex because it involves taking care of a
child who has had major surgery, and also one who normally
would be categorized as too ill to undergo surgery.
Despite the severity of illness and the length of surgery,
however, children tend to recover quickly after liver transplantation (Treem, 2007). Both children and parents must
have thorough preoperative preparation so they understand
the seriousness of the surgery and the possibility that the graft
will be rejected. It helps to introduce the parents to others
whose children have successfully undergone the procedure so
they have support people available.
Preoperative Management
FIGURE 45.4 A child with cirrhosis of the liver. Note the abdominal distention and development of prominent, tortuous
veins secondary to portal hypertension. (From Zitelli, B. J., &
Davis, H. W. [1997]. Atlas of pediatric physical diagnosis [3rd
ed.]. St. Louis: Mosby–Year Book, Inc.)
Preoperative management consists of keeping the child in the
best physical condition possible so that, when a liver is available, transplantation can be performed. For many children,
this includes dialysis and severe nutritional restrictions.
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Surgical Procedure
Liver transplantation requires a wide subcostal incision. The
vena cava is temporarily clamped during the removal of the
natural liver to prevent bleeding, which means that all IV
lines must be placed in the upper extremities (if placed in
lower extremities, fluid could not return through the
clamped venous circulation to the upper body). The total operation takes 10 to 14 hours to complete.
Postoperative Management
Rejection of a liver transplant is most often because of the function of T lymphocytes. Careful tissue matching (HLA matching) is necessary to reduce the possibility of stimulating T-cell
rejection. To further reduce the action of T lymphocytes, children are given an immunosuppressive drug such as mycophenolate mofetil (CellCept), cyclosporine (Sandimmune), or
tacrolimus (Prograf ) before the transplantation.
Nursing care after liver transplantation surgery focuses on
preventing complications that may arise from the surgery and
the continued immunosuppression. Children may need assisted ventilation for approximately 24 hours postoperatively
to prevent pulmonary complications such as atelectasis and
pneumonia because the large abdominal incision makes
coughing and deep breathing difficult. In addition, ascites
has placed pressure against the diaphragm, interfering with
lung expansion, and preoperative pulmonary edema may be
present. After discontinuation of mechanical ventilation and
extubation, chest physiotherapy may be started to mobilize
lung secretions.
Advocate for adequate pain control. Assess blood pressure,
capillary refill, peripheral pulses, and skin color frequently to
ensure adequate cardiovascular function, which is important
for good tissue perfusion of the transplanted liver. The child
may have a central venous pressure line or an arterial line
such as a Swan-Ganz catheter inserted to assess hemodynamic status. Assess neurologic status hourly using a modified Glasgow Coma Scale (see Chapter 52).
Usually, a child is positioned flat for the first 24 hours to
prevent cerebral air emboli, which may result from any air remaining in the transplanted liver. Typically, children have a
nasogastric tube inserted during surgery attached to low intermittent suction postoperatively. Irrigate the tube according
to agency policy to maintain patency. Assess the gastric pH by
aspirating stomach contents every 4 hours; based on this assessment, administer antacids or H2 receptor antagonists such
as cimetidine or mucosal protectants as prescribed to help prevent stress ulcer. If preoperative esophageal varices are present,
assess nasogastric drainage carefully for frank or occult blood.
A T-tube inserted into the bile duct for drainage allows
the amount of bile being produced by the new liver to be
evaluated. Once bowel sounds become active, nasogastric
suction and the T-tube are usually discontinued and liquids
and then solid foods are introduced gradually. If vomiting
occurs and is persistent, total parenteral nutrition may be
used for 3 or 4 days to rest the intestinal tract before fluid is
reintroduced.
Hypoglycemia is a danger postoperatively because glucose
levels are regulated by the liver, and the transplanted organ
may not function efficiently at first. Assess serum glucose levels hourly by fingerstick puncture. A 10% solution of dextrose IV may be necessary to prevent hypoglycemia.
Sodium, potassium, chloride, and calcium levels are evaluated approximately every 6 to 8 hours to be certain that an
electrolyte balance is maintained. Even if a low potassium
level is detected, potassium is rarely added to IV solutions because of the risk that renal failure has occurred because of the
stress of surgery. Plus, if the graft begins to necrose, the
breakdown of cells will release potassium, elevating the level
even more. Continuous cardiac monitoring is usually necessary to detect hyperkalemia (hyperkalemia causes elevation of
T waves or ventricular fibrillation), hypokalemia (causes
small T waves and a U wave), or other arrhythmias.
Many children develop hypertension within 72 hours
after surgery. This occurs because of alterations in the
renin–angiotensin system because of the not yet fully functioning transplanted liver or as a side effect of cyclosporine,
tacrolimus, and steroid therapy, which is continued postoperatively to guard against transplant rejection. IV therapy
with hypotensive agents such as hydralazine (Apresoline) and
nitroprusside may be needed to reduce hypertension.
Hypotension will occur if the transplanted liver becomes dysfunctional or if there is bleeding caused by poor blood coagulation. To help detect bleeding, observe and record abdominal girth, the incision line, and drainage from any catheters
or tubes placed in the incision to allow peritoneal secretions
to drain.
A warming blanket may be required postoperatively to
maintain normal body temperature after the long exposure of
surgery. Take axillary or tympanic, not rectal, temperatures,
because many children with liver damage have hemorrhoids
that could rupture from the trauma of a thermometer insertion. Prevent the child from unnecessary exposure during procedures and care to help maintain normal body temperature.
Nursing Diagnoses and Related
Interventions
✽
Nursing Diagnosis: Risk for infection related to administration of immunosuppressive medication
Outcome Evaluation: Temperature remains within normal range; no presence of exudate or inflammation
around abdominal incision.
Liver transplantation is possible because of the preoperative administration of an immunosuppressive
agent that suppresses T lymphocytes, the lymphocytes responsible for rejecting transplanted organs.
Immunosuppressive agents must be continued postoperatively to prevent graft rejection. Because children are prone to infection while receiving immunosuppressive therapy, be sure to use strict aseptic
technique, standard infection precautions, and careful handwashing. Clean the skin around any abdominal drains every 4 hours to avoid skin breakdown and
prevent a portal of entry for microorganisms.
Serum transaminases (AST [SGOT] and ALT
[SGPT]), alkaline phosphatase, serum bilirubin, and
ammonia levels are assessed at least daily to detect
rejection although children usually do not show signs
of liver rejection until 5 to 7 days after surgery. In addition to changes in these laboratory values, with liver
rejection the child also may develop fever and
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increasing abdominal girth. Also, the urine turns orange from increased urobilinogen excretion. If signs
of rejection appear to be occurring, doses of cyclosporine, tacrolimus, and a corticosteroid such as
methylprednisolone are increased to maximum levels.
1339
Cecum
Nursing Diagnosis: Interrupted family processes related to stress of surgery and uncertainty of transplantation outcome
Polyp
Outcome Evaluation: Child and family state that although waiting is difficult, they are able to do so; family identifies ways they have changed family life at
home to accommodate child’s illness and surgery.
Children and parents need continued support during
the postoperative period while they wait to see if the
graft will be rejected. They need continued contact
with health care personnel through telephone calls
and clinic visits.
After successful liver transplantation, a child should
be able to function normally, attending school and enjoying age-appropriate activities. Be certain by hospital
discharge that parents have a return appointment for
evaluation and are aware of the symptoms of graft rejection, such as jaundice, lethargy, and fever. Contact
sports may be limited to prevent injury to the new liver
and adolescents need to be cautioned to avoid alcohol
to prevent liver damage from this source.
✔Checkpoint Question 45.4
Barry’s family likes to eat shellfish. What form of hepatitis is
most apt to be contracted by eating contaminated shellfish?
a. Hepatitis B.
b. Hepatitis A.
c. Hepatitis E.
d. Hepatitis C.
INTESTINAL DISORDERS
Because the intestines form a long body system, several either
congenital or acquired disorders can occur.
Intussusception
Intussusception, the invagination of one portion of the intestine into another (Fig. 45.5), usually occurs in the second
half of the first year of life (Kaiser, Applegate, & Ladd, 2007).
In infants younger than 1 year, intussusception generally
occurs for idiopathic reasons. In infants older than 1 year, a
“lead point” on the intestine likely cues the invagination.
Such a point might be a Meckel’s diverticulum, a polyp, hypertrophy of Peyer’s patches (lymphatic tissue of the bowel
that increases in size with viral diseases), or bowel tumors.
The point of the invagination is generally at the juncture of
the distal ileum and proximal colon.
Assessment
Children with this disorder suddenly draw up their legs and
cry as if they are in severe pain; they may vomit. After the
peristaltic wave that caused the discomfort passes, they are
Ileum
Invaginated bowel
FIGURE 45.5 Intussusception. The distal ileal segment of
bowel has invaginated into the cecum. A polyp serves as a
lead point.
symptom-free and play happily. In approximately 15 minutes, the same phenomenon of intense abdominal pain
strikes again. Vomitus will begin to contain bile because the
obstruction is invariably below the ampulla of Vater, the
point in the intestine where bile empties into the duodenum.
After approximately 12 hours, blood appears in the stool and
possibly in vomitus, described as a “currant jelly” appearance.
The abdomen becomes distended as the bowel above the intussusception distends.
If necrosis occurs, children generally have an elevated temperature, peritoneal irritation (their abdomen feels tender;
they may “guard” it by tightening their abdominal muscles),
an increased white blood cell count, and often a rapid pulse.
Diagnosis is suggested by the history. Any time a parent is
describing a child who is crying, be certain to ask enough
questions to recognize the possibility of intussusception:
• What is the duration of the pain? It lasts a short time, with
intervals of no crying in between.
• What is the intensity? Severe
• What is the frequency? Approximately every 15 to 20 minutes
• What is the description? The child pulls up legs with crying.
• Is the child ill in any other way? Yes. Vomits; refuses food;
states stomach feels “full.”
The presence of the intussusception is confirmed by ultrasound or a CT scan (Applegate, 2008).
Therapeutic Management
The condition is a surgical emergency. Reduction of the intussusception must be done promptly by either instillation of
a water-soluble solution, barium enema, or air (pneumatic
insufflation) into the bowel or surgery to reduce the invagination before necrosis of the effected portion of the bowel
occurs. If there is no lead point, just the pressure of these
nonsurgical techniques may reduce the intussusception. After
this type of reduction, children are observed for 24 hours because some children will have a recurrence of the intussusception within this time. If this occurs, children will be
scheduled for an additional reduction or surgery.
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Nursing Diagnoses and Related
Interventions
✽
Nursing Diagnosis: Pain related to abnormal abdominal peristalsis
Outcome Evaluation: Child can be comforted between
spasms of pain, demonstrates interest in toys or social
interactions.
Infants with intussusception are bewildered by this
type of episodic pain because it is so different from
any pain they have experienced before. Ordinarily, if
they pinch a finger on a toy and it hurts, a parent picks
them up, kisses their fingers, and the pain goes away.
A parent picks them up now and the pain goes away,
but it returns repeatedly. Infants need to be held and
rocked and comforted in an attempt to relieve their
fright at this strange happening.
Nursing Diagnosis: Risk for deficient fluid volume related to bowel obstruction
Outcome Evaluation: Infant’s skin turgor is good; pulse
is 90 to 100 beats/min. Amount of diarrhea and blood
loss in stool is minimal. Episodes of vomiting decrease
in frequency.
Infants are kept on NPO status before surgery or nonsurgical reduction. Because they have abdominal
pain, they may find comfort in sucking a pacifier.
Because they have been vomiting, IV fluid therapy
may be started to re-establish their electrolyte balance and to supply adequate fluid to hydrate them.
Following a nonsurgical reduction, infants are kept
NPO for a few hours and then introduced gradually to
regular feedings. Infants who have surgery will return
with a nasogastric tube attached to low intermittent suction and an IV infusion in place. The nasogastric tube
will remain in place until the suture line is healing and
peristaltic function has returned. Once bowel sounds
are present, oral feedings can be started gradually.
Nursing Diagnosis: Risk for impaired parenting related
to infant’s illness
Outcome Evaluation: Parents hold and talk to infant;
express positive characteristics about infant.
Parents need to hold infants after intussusception reduction or postoperatively to promote bonding and also
to comfort the infant. Provide guidance and support as
needed. When oral feeding is resumed, encourage the
parents to participate with this aspect of care, as it provides them with an opportunity to regain confidence in
themselves as parents. Reassure them that this did not
occur because of anything they did or anything they
fed their child. Urge them to continue to hold and be
with the child as recovery proceeds to reassure themselves that the child is now once again well.
Volvulus
A volvulus is a twisting of the intestine (Fig. 45.6). The
twist leads to obstruction of the passage of feces and compromise of the blood supply to the loop of intestine in-
A
B
FIGURE 45.6 Volvulus of the sigmoid colon. (A) The unattached
loop of bowel twists. (B) The bowel lumen is obstructed, leading
to inability of stool to pass and compression of the blood supply
to the looped bowel segment.
volved. This occurs most often because, in fetal life, a portion of the intestine first protrudes into the base of the umbilical cord at approximately 6 weeks of intrauterine life. At
approximately 10 weeks of intrauterine life, it returns to the
abdominal cavity. As the intestine returns to the abdominal
cavity, it rotates to its permanent position. After the rotation, the mesentery becomes fixed in this position. In
volvulus, this action is incomplete and the mesentery does
not attach in a normal position. The bowel is left free to
move and twist (Ingoe & Lange, 2007).
Usually, the symptoms are those of intestinal obstruction
and occur during the first 6 months of life. Symptoms may
include intense crying and pain, pulling up the legs, abdominal distention, and vomiting. The diagnosis is made
based on the history and an abdominal examination, which
reveals an abdominal mass. An ultrasound or lower barium
x-ray also will show the obstruction. Surgery is used to relieve the volvulus and reattach the bowel so it no longer is so
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free moving. This must be done promptly before necrosis of
the intestine occurs from a lack of blood supply to the involved loop of bowel. Preoperative and postoperative care
will be the same as for infants with intussusception.
Necrotizing Enterocolitis
Necrotizing enterocolitis (NEC) is a condition that develops in approximately 5% of all infants in intensive care nurseries. The bowel develops necrotic patches, interfering with
digestion and possibly leading to a paralytic ileus. Perforation
and peritonitis may follow (Carter, 2007).
The necrosis appears to result from ischemia or poor perfusion of blood vessels in sections of the bowel. The ischemic process may occur when, owing to shock or hypoxia,
there is vasoconstriction of blood vessels to organs such as
the bowel. The entire bowel may be involved, or it may be
a localized phenomenon. The incidence of NEC is highest
in immature infants, those who have suffered anoxia or
shock, and those fed by enteral feedings. Infants with infections may develop it as a further complication of their already stressed state.
Assessment
There is a lower incidence of the condition in infants who
are fed breast milk than in those who are fed formula because intestinal organisms grow more profusely with cow’s
milk than breast milk (cow’s milk lacks antibodies). A response to the foreign protein in cow’s milk may also be a
mechanism that starts the necrotic process. Therefore, encouraging breastfeeding may help prevent this disorder
(Grave et al., 2007).
Signs of NEC usually appear in the first week of life. The
infant’s abdomen becomes distended and tense. The stomach
does not fully empty by the next feeding time because of
poor intestinal action; if the stomach contents are aspirated
before a feeding, a return of undigested milk of more than 2
mL will be obtained. Stool may be positive for occult blood.
Periods of apnea may begin or increase in number. Signs of
blood loss because of intestinal bleeding, such as lowered
blood pressure and inability to stabilize temperature, also
may be present.
Abdominal x-ray films show a characteristic picture of air
invading the intestinal wall; if perforation has occurred, there
will be air in the abdominal cavity. Abdominal girth measurements made just above the umbilicus every 4 to 8 hours
increase.
Therapeutic Management
As soon as the condition is recognized, usual breast or formula feedings are discontinued, and the infant is maintained
on IV or total parenteral nutrition solutions to rest the GI
tract with the additional supplement of enteral probiotics (Al
Faleh & Bassler, 2009). An antibiotic may be given to limit
secondary infection. Handle the abdomen gently to lessen
the possibility of bowel perforation.
If the area of necrosis appears to be localized, surgery to remove that portion of the bowel may be successful. If a large
portion of the bowel is removed, the infant may be prone to
“short-bowel” syndrome or may have a problem with digestion
of nutrients in the future. If the bowel perforates, peritoneal
1341
drainage or a laparotomy will be necessary to help remove fecal
secretions from the abdomen. An infant may need a temporary
colostomy performed to allow for bowel function.
NEC is a grave insult to an infant already stressed by immaturity. The prognosis is guarded until the infant can again
take oral feedings without bowel complications.
Appendicitis
Appendicitis (inflammation of the appendix) is the most
common cause of abdominal surgery in children. It occurs
most frequently in school-age children and adolescents, although it can occur in preschoolers and even in newborns
(Della Rocca, 2007). The appendix, a blind-ended pouch
attached to the cecum, may become inflamed because of an
upper respiratory or other body infection, but the cause of
appendicitis is generally obscure. In most instances, fecal
material apparently enters the appendix, hardens, and obstructs the appendiceal lumen. Inflammation and edema
develop, leading to compression of blood vessels and cellular malnutrition. Necrosis and pain result. If the condition
is not discovered early enough, the necrotic area will rupture and fecal material will spill into the abdomen, causing
peritonitis—a potentially fatal condition.
Assessment
Most parents assume that appendicitis begins with sharp pain,
so they may dismiss a child’s early symptoms for some time as
simple gastroenteritis. Actually, pain is a late symptom.
Diagnosis is made on a cluster of symptoms: anorexia, pain or
tenderness in the right lower quadrant, nausea or vomiting, elevation of temperature, and leukocytosis (Ebell, 2008). The
history typically begins with anorexia for 12 to 24 hours.
Children do not eat and do not act like their usual selves.
Nausea and vomiting may then occur. The abdominal pain,
when it does start, is at first diffuse. Gradually, it becomes localized to the right lower quadrant. The point of sharpest pain
is often one third of the way between the anterior superior iliac
crest and the umbilicus (McBurney’s point). If the child’s appendix is displaced from this usual position, the pain will not
be at this typical point, so pain at any other point does not rule
out appendicitis. Pregnant adolescents are apt to have displaced pain. Fever is a late symptom.
It is important in history taking to document the progress
of the disease, for example:
• How was the child on Monday? Not herself. She was not
eating.
• How was she Monday night? She had generalized abdominal pain.
• Tuesday morning? She had sharp localized pain.
• Now? She has localized pain, vomiting, and fever.
Until the pain becomes localized, appendicitis is difficult
to distinguish from acute gastroenteritis. Often, it is difficult
to palpate children’s abdomens because they guard their abdomen or make abdominal muscles stiff and hard by tensing
them. Although this interferes with abdominal examination,
it is in itself an important sign that children have abdominal
pain. To assist in a diagnosis of a painful abdomen, always
palpate the anticipated tender area last.
Rebound tenderness is a phenomenon in which a child
feels relatively mild pain when the area over the appendix is
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palpated, but, once an examiner’s hand is withdrawn, the
child experiences acute pain caused by the shifting of the abdominal contents. This is diagnostic for appendicitis, but it
should be done with children only when necessary because it
does cause acute pain. Caution children that the maneuver
may cause pain. On auscultation, bowel sounds will be reduced: only one or two are heard in the same length of time
that 30 are normally heard. Absence of bowel sounds on auscultation suggests peritonitis or an appendix that has already
ruptured.
Laboratory findings usually indicate leukocytosis (white
blood cell count between 10,000 and 18,000/mm3), which is
actually low for the extent of the infection that may be present. Ketone levels in the urine are inordinately elevated as a
symptom of starvation from poor intestinal absorption.
An ultrasound reveals the swollen appendix. It can also be
confirmed by a CT scan. Pain in the right lower quadrant
may also occur as a manifestation of right lower lobe pneumonia. Therefore, children may have a chest x-ray taken to
rule this out as the source of pain. Because, in the past, assessment of appendicitis depended on being able to detect
abdominal pain, both parents and health care providers may
be reluctant to administer analgesia to children with abdominal pain. Because ultrasound can successfully reveal appendicitis, however, analgesia to make the child comfortable can
be given (Bromberg & Goldman, 2007).
Therapeutic Management
Therapy for appendicitis is surgical removal of the appendix
by laparoscopy before it ruptures (Sauerland, Lefering, &
Neugebauer, 2009). Achieving surgery before rupture occurs
is easier in older children, who are more capable of relating
the progression of symptoms. It is more difficult in young
children, whose history is not as accurate, who do not have
the words to describe their symptoms, or who will not relax
their abdominal muscles enough to allow for manual examination. Also, the wall of the appendix is thinner and perforates more readily in young children.
appendix rupture by increasing edema in the appendix. Urge the child to find the best position of
comfort, and assure both parents and the child that
surgery is being scheduled as soon as possible.
Nursing Diagnosis: Fear related to emergency nature
of disorder and immediate surgery
Outcome Evaluation: Parents and child state that they
understand what interventions are necessary and cooperate as necessary.
Admission for appendicitis often occurs rapidly. A
parent telephones a primary care provider, who recommends the child be seen in an emergency room.
Surgery is scheduled as soon as it can be arranged.
A mere 30 minutes may pass from the time of the first
phone call until the child is wheeled into surgery.
During this time, the parent and child both need to be
told exactly what is happening (“I’m going to take
some blood; I’m putting your name tag on your arm”)
and who the people are who are caring for them (“This
is Dr. Brown, the anesthesiologist. I’m Ms. Henry, a
registered nurse.”). Parents do not think clearly in this
type of emergency, and their reactions to situations
may not be their usual ones. Explain that the procedures being done for the child such as blood studies
or a short wait while an operating room is prepared
are necessary for safe surgery and that the danger of
the appendix rupturing is not as acute a danger as
they may have believed under these controlled circumstances.
Remember that these children have had no preparation for hospitalization. The axiom “What they don’t
know won’t hurt them” is not true. Lack of knowledge
can make appendicitis a harrowing experience for
parents as well as children. Praise them for the things
they did well, such as recognizing the child was ill and
bringing the child immediately for care, to help offer a
sense of control.
Nursing Diagnosis: Risk for deficient fluid volume related to NPO status
Nursing Diagnoses and Related
Interventions
Outcome Evaluation: Child’s skin fold returns to place
quickly when turgor is assessed; pulse and blood pressure are within normal age limits; weight is maintained.
Priorities for nursing care must be established quickly
because this is an emergency, and the child must
be prepared immediately for surgery (see Focus on
Nursing Care Planning Box 45.4).
Preoperatively, obtain a urine sample for urinalysis
and blood for a complete blood count. IV fluid therapy
may be initiated to hydrate a child who has been vomiting a great deal. Postoperatively, children may have
a nasogastric tube in place; they will be maintained on
IV fluids until they can take adequate oral feedings
(approximately 24 hours). With unruptured appendicitis, the postoperative course is uneventful; children
are up a few hours after surgery and are discharged
within several days. They generally return to school in
another week.
✽
Nursing Diagnosis: Pain related to inflamed appendix
Outcome Evaluation: Child states that level of pain is
tolerable.
Once a diagnosis is made by ultrasound, a child
needs an analgesic for pain. Cathartics and heat to
the abdomen are contraindicated, because these increase the possibility of rupture of the appendix. The
abdomen will be shaved and washed with an antiseptic solution immediately before surgery. If you are
assisting with the procedure, be gentle because the
abdomen is tender, and compression could cause
the appendix to rupture. Use lukewarm, not hot
water, because heat can increase the possibility of
Ruptured Appendix
If a child’s appendix has already ruptured when the child is
seen in the emergency department, the potential for peritonitis increases greatly. Children generally appear severely ill.
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BOX 45.4 ✽ Focus on Nursing Care Planning
A Multidisciplinary Care Map for a Child With Appendicitis
Barry’s parents bring his older sister, 10-year-old Leann,
to the emergency department because of nausea,
vomiting, and abdominal pain since yesterday. Father
states, “We thought it was just an upset stomach, but it
isn’t getting any better, and the pain is much worse
now.”
Family Assessment ✽ Child lives with 2 younger siblings and both parents on a rural horse farm. Father
works as a newspaper printer in town; mother cares for
horses and stable. Mother reports finances as, “Good.
We’re enjoying this time of life.”
vomiting.” Pain now localized in right lower quadrant.
Legs drawn up against abdomen. Bowel sounds sluggish. Rebound tenderness present. White blood cell
count of 17,000/mm3. Ultrasound confirms appendicitis.
Child is scheduled for emergency appendectomy.
Client Assessment ✽ Well-nourished, 10-year-old
female with a history of no major medical problems.
Temperature 101.2° F; pulse 100; respirations 24. Mother
reports that yesterday the child stated she was not feeling well. “She wasn’t eating, and she had pains in her
stomach. Last night, the pain got worse and she started
Nursing Diagnosis ✽ Pain related to presence of
appendicitis
Team Member
Responsible
Assessment
Outcome Criteria ✽ Child states pain is not above a 2
on 1–10 pain scale.
Intervention
Rationale
Expected Outcome
Activities of Daily Living
Nurse
Assess what is child’s
most comfortable
position.
Do not palpate child’s
abdomen.
Palpating could rupture
inflamed appendix.
Child states she knows
not to put pressure
on abdomen.
Emergency surgery
has added risks
because of lack of
preparation.
Anesthesiology service
consults and
readies for surgery.
Consultations
Physician
Assess what anesthetist
is available for
emergency surgery.
Consult with anesthetist
about emergency
surgery.
Procedures/Medications
Nurse
Assess if child has ever
had surgery before.
Nurse
Assess if child’s armband is in place.
Wash abdomen and
shave from nipple
line to groin.
Complete preoperative
checklist.
Removing abdominal
hair helps prevent
infection.
Safety precautions are
important to prevent
misidentification
during surgery.
Abdominal preparation
is completed prior to
surgery.
Child’s armband is in
place; preoperative
checklist completed
and signed.
Nutrition
Nurse
Assess when was the
last time child ate or
drank. Assess skin
turgor.
Keep child NPO while
awaiting surgery.
Eating could evoke
vomiting with aspiration during surgery.
Child cooperates to
remain NPO until
surgery.
Nurse
Assess if child has
had prior experience
with IV fluid administration.
Begin IV fluid as
prescribed.
IV fluid can help
prevent dehydration
from previous
vomiting while NPO.
Child states she understands why IV is
prescribed; protects
infusion site from
trauma.
(continued)
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BOX 45.4 ✽ Focus on Nursing Care Planning
(continued)
Patient/Family Education
Nurse
Assess what
child/parents
understand about
appendicitis.
Teach child and
parents as needed
about cause and
course of
appendicitis.
Better understanding of a
child’s condition can
help child and parents
accept the necessary
procedures.
Child and parents state
they have no
questions about
cause or course of
appendicitis.
Psychosocial/Spiritual/Emotional Needs
Nurse
Assess child’s level
of pain using
a 1-to-10
pain scale.
Nurse
Assess if child has
experience with
nonpharmacologic pain relief
measures.
Assess child and
parents’ level of
apprehension
about emergency
situation.
Nurse
Discuss surgeon’s
preference to not
prescribe analgesic
as child will soon be
anesthetized in O.R.
Teach child a nonpharmacologic pain
relief method such
as imagery.
Discuss positive
aspects of parents’
actions.
Pain relief may be delayed
until appendicitis is
diagnosed.
Nonpharmacologic pain
relief can be very
effective for abdominal
pain in children.
Child states she understands her pain
will be relieved as
soon as anesthesia
is begun.
Child uses imagery as
nonpharmacologic
pain relief
technique.
Reinforcing that parents
acted with good
judgment can increase
self-esteem and ability
to accept new
developments.
Child and parents state
that although their
stress level is high,
they are able to
cope with new
developments.
Discharge Planning
Nurse
Assess if child and
parents have any
questions prior
to leaving for
operating room.
Review what will
happen in O.R. and
immediate postoperative course.
The white blood cell count rises to more than 20,000/mm3.
Position the child in a semi-Fowler’s position, if possible, so
that infected drainage from the cecum drains downward into
the pelvis rather than upward toward the lungs. The child
needs an IV fluid line inserted for hydration. Antibiotics will
be begun preoperatively or as soon as the ruptured appendix
is confirmed (Goldin et al., 2007).
During surgery, the child will have drains placed beside
the surgery incision so any infectious material in the abdomen can continue to drain. Warm soaks to the incision
line may be ordered three or four times a day to encourage
drainage. Examine the wound carefully at each dressing
change. Be certain not to dislodge drains while removing
soiled dressings. Report immediately any drain that is expelled; the surgeon may want to replace it to ensure a patent
drainage route. Often, drains are shortened with each dressing change to encourage initially deep areas, then areas closer
to the skin to drain. IV fluid and antibiotic therapy are continued until full bowel function is restored.
Also assess for signs of peritonitis with dressing changes.
These signs may include a boardlike (rigid) abdomen, generally shallow respirations (because deep breathing puts
pressure on the abdomen and causes pain), and increased
temperature. Although the postoperative course is slower
(approximately 3 weeks) after a ruptured appendix, the
prognosis is still good. A local abscess or intestinal adhesions
The better informed child
and parents are of
happenings, the better
they will be able to
cooperate.
Child and parents state
they feel prepared
for next step in
treatment for child’s
condition.
may result. Adhesion formation, a long-term effect, could
interfere with fertility in girls or cause bowel obstruction in
both sexes later in life.
What if... Barry’s older sister had appendicitis. What if
her parent tells you she “dropped everything” to rush
a child to the emergency department because of appendicitis? What questions would you want to ask to
see if she has thought through the situation?
Meckel’s Diverticulum
In embryonic life, the intestine is attached to the umbilicus
by the omphalomesenteric (vitelline) duct. This duct becomes a vestigial ligament as infants reach term. In 2% or 3%
of all infants, a small pouch of this duct remains, located off
the ileum, approximately 18 inches from the ileum–colon
junction: a Meckel’s diverticulum (Nandish, Weston, &
Wolstenhulme, 2007). In this structure, there may be some
misplaced gastric mucosa, which secretes gastric acids that
flow into the intestine and irritate the bowel wall. This can
lead to ulceration and bleeding. Infants will have painless,
tarry (black) stools or grossly bloody stools. On occasion, the
diverticulum may serve as the lead point causing an intussusception. In some instances, a fibrous band extending from
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1345
the diverticulum pouch to the umbilicus acts as a constricting band, causing bowel obstruction.
The history of the child suggests the diagnosis. Because
the pouch is small, it does not fill, and therefore it may not
be evident on x-ray or ultrasound. Treatment is laparoscopy
exploration and removal of the vestigial structure.
Celiac Disease (Malabsorption Syndrome;
Gluten-Induced Enteropathy)
The basic problem in celiac disease is a sensitivity or abnormal immunologic response to protein, particularly the gluten
factor of protein found in grains—wheat, rye, oats, and barley. When children with the disorder ingest gluten, changes
occur in their intestinal mucosa or villi that prevent the absorption of foods, especially fat, across the intestinal villi into
the bloodstream. As a result, children develop steatorrhea
(bulky, foul-smelling, fatty stools); deficiency of fat-soluble
vitamins A, D, K, and E (the vitamins are not absorbed because the fat is not absorbed); malnutrition; and a distended
abdomen from the fat, bulky stools. Because vitamin D is
one of the fat-soluble vitamins, rickets or loss of calcium
from bones may occur. Hypoprothrombinemia may occur
from loss of vitamin K. In addition, children may have
hypochromic anemia (iron-deficiency anemia) and hypoalbuminemia from poor protein absorption (Tully, 2008).
Although gluten-induced enteropathy is a relatively rare
condition, early recognition is essential so that treatment can
be provided, along with early support and nutritional guidance for the parents. The illness occurs most frequently in
children of a northern European background. It is apparently
a dominantly inherited illness although children have different degrees of involvement. There is also an increased incidence in children of type 1 diabetes mellitus, IgA deficiency,
and Down syndrome, suggesting an associated immune response etiology (Sondheimer & Sundaram, 2008).
Assessment
Children with the syndrome tend to be anorectic and irritable. They gradually fall behind other children their age in
height and weight. They appear skinny, with spindly extremities and wasted buttocks. The face, however, in contrast
to children with true starvation, may be plump and wellrounded (Fig. 45.7).
The diagnosis is based on the history; clinical symptoms
such as bulky stools, malnutrition, distended abdomen, and
anemia which become noticeable between 6 and 18 months
of age; serum analysis of antibodies against gluten (IgA
antigliadin antibodies); and a biopsy of the intestinal mucosa
(done by endoscopy), which establishes the typical changes in
intestinal villi. Children may have an oral glucose tolerance
test, which will reveal poor absorption, and their stool may be
collected to test for fat content, which will be increased.
In addition, the child’s response to gluten is observed by
placing the child on a gluten-free diet. In most instances, the
response to this diet is dramatic: the child begins to gain
weight, steatorrhea improves, and the irritability fades.
Therapeutic Management
Treatment is to continue the gluten-free diet for life, because
there is some suggestion that these children are more prone to
FIGURE 45.7 A child with celiac disease. Typically, the child’s
abdomen will be distended from the fat, bulky stools. Note the
wasted appearance of the buttocks. (From Essentials of
Pediatric Nursing. Philadelphia: Lippincott Williams & Wilkins.)
GI carcinoma later in life if they do not continue the diet into
adulthood. In addition to this, children need to have water-soluble forms of vitamins A and D administered. Both iron and
folate may be necessary as well to correct any anemia present.
Nursing Diagnoses and Related
Interventions
✽
Nursing Diagnosis: Imbalanced nutrition, less than body
requirements, related to malabsorption of food
Outcome Evaluation: Child’s weight is maintained on a
percentile curve on a growth chart; skin turgor is
good; steatorrhea is minimal; parents verbalize appropriate gluten-free food choices.
Parents need to record the consistency, appearance,
size, and number of stools that the child passes. The
disappearance of steatorrhea is a good indicator that
the child’s ability to absorb nutrients is improving.
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Parents need a great deal of nutritional counseling
when their child is first placed on a gluten-free diet so
they can recognize foods that contain gluten (wheat,
rye, oats, and barley products). Gluten is a part of
wheat flour, gravy, soups, and sauces. Packaged and
frozen foods usually contain gluten as fillers. Teach
parents to be careful shoppers and read food labels
carefully. Because children are anorectic when they
are first introduced to the new diet, getting them to eat
it may be a problem. Remember that toddlers often
eat small servings better than larger ones. Help parents create incentives to eat, such as inviting dolls to
“tea” or eating a picnic outside in nice weather.
As children reach school age, preparing a glutenfree diet grows more and more difficult, because favorite school-age foods such as spaghetti, pizza, hot
dogs, cake, and cookies are not allowed. Selecting a
diet in a school cafeteria may be impossible. Holidays
pose additional problems—birthday cake, turkey
stuffing, and holiday cookies are prohibited. Until children can recognize which foods they can or cannot
eat, parents often find it difficult to let them stay at
friends’ houses or go to summer camp—activities important to children’s learning independence.
Assessment
When taking a history, be certain to have parents describe
what they mean by constipation. Some children normally
pass stool only every other day or every 3 days. As long as the
stool is not hard and there is no discomfort associated with
passing stool, this is not constipation. Examine the circumstances that may have led to constipation (diet low in fiber;
little privacy in bathroom; family stress).
Children with constipation should be examined carefully
to see if they have anal fissures. If these are present, sexual
abuse must be ruled out. Constipation must be differentiated
from aganglionic disease of the intestine. In constipation, on
rectal examination, hard stool is found in the rectum; in aganglionic disease of the intestine, no stool is normally present.
Therapeutic Management
Treatment of chronic constipation is aimed at softening stool
so it will pass painlessly. Children also need help to form
good bowel habits so that stools are passed before they become large and hardened (Reading, 2007).
Nursing Diagnoses and Related
Interventions
✽
Celiac Crisis
When children with celiac disease develop any type of infection, a crisis of extreme symptoms may occur. Both vomiting
and diarrhea become acute. Children can quickly experience
electrolyte and fluid imbalances and need intensive therapy to
correct them (see the section on nursing care for children with
vomiting and diarrhea earlier in the chapter). Gradually, after
such an episode, they are placed back on a gluten-free diet.
DISORDERS OF THE LOWER BOWEL
In children, disorders of the lower bowel mainly create problems with evacuation.
Constipation
Constipation, or difficulty passing hardened stools, may occur in
children of any age (Philichi, 2008). Constipation is distressing
to children because passing hardened stool is painful and may
cause anal fissures. A child then represses the next urge to defecate because of pain. The rectum gradually becomes distended
and adjusts to the ever-present bulk of stool. The urge to defecate becomes less frequent. When the child does pass stool, it is
larger and firmer than before and causes even more anal pain.
This vicious cycle continues until the child becomes severely
constipated. Children may have episodes of diarrhea or encopresis (involuntary release of stool) when their rectum can hold
no more (see Chapter 54). They may experience abdominal
pain from forceful intestinal contractions.
Some children begin holding stool for psychological reasons.
Once the process begins, however, the hardened stool, the anal
fissures, and the pain on defecation soon occur, and what began
for an emotional reason becomes a physical ailment. This is
important to understand, because with these children, therapy
involves both counseling to correct the initial problem and
treatment of the physical symptoms (McQuaid, 2009).
Nursing Diagnosis: Constipation related to pain from
anal fissure and hardened stool
Outcome Evaluation: Child has a soft bowel movement
without pain every other day.
For initial therapy, an enema may be administered to
loosen hard stool. After this, a stool softener such as
docusate sodium (Colace) is prescribed. In addition,
children need to ingest a high-fiber, high-fluid diet
and be urged to evacuate their bowels at the same
time every day to form a habit.
Inguinal Hernia
Inguinal hernia is a protrusion of a section of the bowel into
the inguinal ring. It occurs usually in boys (9:1) because, as
the testes descend from the abdominal cavity into the scrotum late in fetal life, a fold of parietal peritoneum also descends, forming a tube from the abdomen to the scrotum
(Brandt, 2008). In most infants, this tube closes completely.
If it fails to close, intestinal descent into it (hernia) may occur
at any time when there is an increase in intra-abdominal
pressure. In girls, the round ligament extends from the uterus
into the inguinal canal to its attachment on the abdominal
wall. In girls, an inguinal hernia may occur because of a
weakness of the muscle surrounding the round ligament.
Assessment
A hernia appears as a lump in the left or right groin. In some
instances, the hernia is apparent only on crying (when abdominal pressure increases) and not when children are less
active. Inguinal hernias are painless. Pain at the site implies
that the bowel has become incarcerated in the sac, an emergency that requires immediate action to prevent bowel obstruction and ischemia.
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Hirschsprung’s Disease
(Aganglionic Megacolon)
The diagnosis is established by history and physical appearance. When taking a history of a well child, be certain
to ask parents whether they have ever noticed any lumps in
the child’s groin area. The hernia may not be noticeable
at the time of a health care visit, so, unless asked specifically, parents may not mention it. If present, the herniated
intestine can be palpated in the inguinal ring on physical
examination.
Hirschsprung’s disease, or aganglionic megacolon, is absence
of ganglionic innervation to the muscle of a section of the
bowel—in most instances, the lower portion of the sigmoid
colon just above the anus (Dasgupta & Langer, 2008). The
absence of nerve cells means there are no peristaltic waves in
this section to move fecal material through the segment of intestine. This results in chronic constipation or ribbonlike
stools (stools passing through such a small, narrow segment
look like ribbons). The portion of the bowel proximal to the
obstruction dilates, distending the abdomen (Fig. 45.8).
The incidence of aganglionic disease is higher in the siblings of a child with the disorder than in other children. It
also occurs more often in males than in females. It is caused
by an abnormal gene on chromosome 10. The incidence is
approximately 1 in 5000 live births (Sondheimer, 2008).
Therapeutic Management
Treatment of inguinal hernia is laparoscopy surgery. The
bowel is returned to the abdominal cavity and retained there
by sealing the inguinal ring. Pneumoperitoneum (instillation
of carbon dioxide into the perineal cavity) during surgery
may be performed to reveal the presence of an enlarged inguinal ring on the opposite side. If this is present, both sides
may be repaired, and the child will return from surgery with
dressings on both groins.
Formerly, surgery for inguinal hernia was delayed until
the child was 3 or 4 years of age. Today, to prevent the complication of bowel strangulation—a surgical emergency—
infants with inguinal hernia may have surgery before 1 year
of age. If surgery is proposed as a prophylactic measure, setting outcomes may be difficult for parents as they weigh the
value of surgical repair against the risk of anesthesia and
surgery.
After surgery, keep the suture line dry and free of urine or
feces to prevent infection. Most incisions in this area are
closed by a tissue adhesive, which is waterproof and seals the
incision from urine and feces. Even so, the infant will need
frequent diaper changes and good diaper-area care. Assess circulation in the leg on the side of the surgical repair to be certain that edema of the groin is not compressing blood vessels
and obstructing blood flow to the leg.
Assessment
Occasionally, infants are born with such an extensive section of
bowel involved that even meconium cannot pass. This is suggested if infants fail to pass meconium by 24 hours of age and
have increasing abdominal distention (Hartman et al., 2007).
Because newborn stools are normally soft, however,
symptoms of aganglionic megacolon generally do not become apparent until 6 to 12 months of age. By the time children are seen by a health care provider, they generally have a
history of constipation or intermittent constipation and diarrhea. A careful history helps to document the illness:
• What is the duration of the constipation? It may have been
a problem from birth.
• What do parents mean by constipation? Children do not
have a bowel movement more than once a week.
Distended
sigmoid
colon
Aganglionic portion
FIGURE 45.8 Aganglionic megacolon
Rectum
(Hirschsprung’s disease). The distal portion of the
bowel lacks nerve innervation. Because there is no
peristalsis in this narrowed segment, the bowel proximal to it distends markedly.
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• What is the consistency of the stool? Ribbonlike or watery
• Is the child ill in any other way? Children with aganglionic
disease of the intestine tend to be thin and undernourished,
sometimes deceptively so because their abdomen is large and
distended.
If a gloved finger is inserted into the rectum of a child
with true constipation, the examining finger will touch hard,
caked stool. With aganglionic colon disease, the rectum is
empty because fecal material cannot pass into the rectum
through the obstructed portion. A barium enema is generally
ordered to substantiate the diagnosis. The barium will outline on x-ray film the narrow, nerveless portion and the proximal distended portion of the bowel. A barium enema must
be used cautiously, however, because children cannot expel
this afterward any more effectively than they can stool. The
definitive diagnosis is by a biopsy of the affected segment to
show the lack of innervation or by anorectal manometry, a
technique to test the strength or innervation of the internal
rectal sphincter by inserting a balloon catheter into the rectum and measuring the pressure exerted against it.
Therapeutic Management
Repair of aganglionic megacolon involves dissection and removal of the affected section, with anastomosis of the intestine
(termed a pull-through operation). Because this is a technically
difficult operation to perform in a small abdomen, the condition is generally treated in the newborn by two-stage surgery:
first a temporary colostomy is established, followed by bowel
BOX 45.5 ✽ Focus on EvidenceBased Practice
What is the quality of life of children who have surgery
for Hirschsprung’s disease?
To answer this question, researchers asked 178 patients who had undergone pull-through operations for
Hirschsprung’s disease at least 5 years earlier to answer a questionnaire about their present state of health.
Results showed that 50% of patients who had surgery 5
to 10 years earlier (67 patients) rated the result of their
surgery as excellent. Sixty-eight percent of patients (75)
who had surgery 10 to 15 years earlier rated their surgical outcome as excellent. Eighty-eight percent of those
patients who had surgery 15 to 20 years earlier rated
their surgical outcome as excellent. Patients who stated
that their outcome was not excellent listed conditions
such as constant soiling and an inability to hold back
defecation. This created marked limitations in their social life because of their dependence on diapers and
frustration because of teasing by their friends.
Based on the above, would you feel confident advising
parents of a child about to have surgery for Hirschsprung’s
disease that their child will have normal fecal continance
and a normal social life in the future?
Source: Niramis, R., et al. (2008). Quality of life of patients with
Hirschsprung’s disease at 5–20 years post pull-through operations. European Journal of Pediatric Surgery, 18(1), 38–43.
repair at 12 to 18 months of age. After the final surgery, children should have a functioning, normal bowel (Box 45.5). In
the few instances in which the anus is deprived of nerve endings, a permanent colostomy will be established.
Nursing Diagnoses and Related
Interventions
✽
Nursing Diagnosis: Constipation related to reduced
bowel function
Outcome Evaluation: Child has a daily bowel movement through either a colostomy or by enema.
Before surgery, the child may be prescribed daily enemas to achieve bowel movements. The fluid used for
enemas must be normal saline (0.9% NaCl) and not tap
water. Tap water is hypotonic. If it is instilled into the
bowel, it moves rapidly across the intestinal wall into interstitial and intravascular fluid compartments to equalize osmotic pressure (by the laws of osmosis, fluid
moves from an area of less to greater concentration).
This has led to death of infants from cardiac congestion
or cerebral edema (water intoxication). Teach parents
how to prepare and administer saline enemas at home.
Parents can buy a ready-made saline preparation at
a pharmacy, or they can prepare their own by mixing
2 tsp of noniodized salt to 1 quart of water. Although
adding salt to water does not seem important, be certain that the parents understand the rationale for doing
so and can demonstrate the proper technique and the
proportion of salt to water for the enema.
Caring for a child with a colostomy is discussed in
Chapter 37. An antibiotic solution or saline may be
prescribed for daily infusion into the distal bowel to reduce the possibility of infection.
Nursing Diagnosis: Imbalanced nutrition, less than
body requirements, related to reduced bowel function
Outcome Evaluation: Child ingests a low-residue diet;
weight follows a percentile curve on a growth chart.
Preoperatively, older children may be in poor health
from poor food intake over a long period. If this is so,
they may be returned home on a minimal-residue diet,
stool softeners, vitamin supplements, and perhaps
daily enemas until their condition improves. Total parenteral nutrition can offer another source of nutrition. If
a child is to be cared for at home, help the parents
learn about a minimal-residue diet or one that is low in
undigestible fiber, connective fiber, and residue. Fried
foods and highly seasoned foods are omitted to eliminate chemical irritants in the intestinal tract.
Help parents to make out a reminder sheet for the
stool softener so it is given daily. When children are
beginning a special diet, it may be advisable to have
parents refrain from introducing new feeding methods, such as a cup or spoon, unless children are at
that developmental point where they will quickly adapt
to the new procedure and are, in fact, so eager to feed
themselves that they will actually eat better this way.
Postoperatively, after removal of the aganglionic
portion and anastomosis of the colon at the second
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step of the repair, infants will return with a nasogastric
tube in place attached to low suction, an IV infusion,
and probably an indwelling urinary (Foley) catheter.
Observe the infant for abdominal distention. Assess
bowel sounds and observe also for passage of flatus
and stools. As soon as peristalsis has returned (approximately 24 hours after surgery), the nasogastric
tube can be removed and the child will be offered
small, frequent feedings of fluids, such as water or
gelatin. The child is then introduced gradually to full
fluids, a soft diet, a minimal-residue diet, and, finally,
a normal diet for age.
Nursing Diagnosis: Risk for compromised family coping related to chronic illness in child
Outcome Evaluation: Parents state they are able to
cope with the level of stress present from their child’s
condition.
Most parents feel tremendous relief after the secondstage surgery is complete. Caution parents that the
child may still remain a “fussy eater” for a few months,
because feeding problems that begin for physical
reasons can continue for emotional or psychological
reasons. Help parents to diminish the importance of
meals gradually; to schedule periods during the day
when they give their full and positive attention to the
child, such as reading a story or putting a puzzle together; and to offer praise for pleasant, not difficult,
behavior. These measures will help mealtime problems gradually diminish.
Inflammatory Bowel Disease: Ulcerative Colitis
and Crohn’s Disease
Two conditions are categorized as inflammatory bowel disease: ulcerative colitis and Crohn’s disease (Merchant, 2007).
Both involve the development of ulcers of the mucosa or submucosa layers of the colon and rectum. They both occur
most frequently in young adults and adolescents, although,
more and more frequently, symptoms first appear during
school age. Both diseases occur more frequently in males
than in females and show familial tendencies.
The cause of these disorders is obscure, but they probably
represent an alteration in immune system response or are autoimmune processes. There is an increased number of immunoglobulins IgA and IgG present on intestinal mucosa.
IgE immunoglobulins and the eosinophil count also may be
elevated. Psychological factors have not been supported as a
primary contributory factor to inflammatory bowel disease,
but psychological problems often occur secondary to the disease, possibly intensifying symptoms. Smoking and frequent
use of antibiotics or aspirin are correlated with the occurrence of Crohn’s disease (Barter & Dunne, 2008).
Crohn’s disease is an inflammation of segments of the intestine; it may affect any part of the GI tract but most commonly involves the terminal ileum. Inflamed segments are
separated by normal bowel tissue. The wall of the colon becomes thickened and the surface is inflamed, leading to a
“cobblestone” appearance of mucosa.
In ulcerative colitis, typically the colon and rectum are involved, with the distal colon and rectum most severely affected, and inflammation involves continuous segments.
1349
As inflammation becomes acute with these disorders, children develop abdominal pain from contractions of the irritated portions. These areas do not absorb nutrients or fluid
well, so diarrhea and malnutrition develop. To reduce abdominal pain (which is most acute after eating, when the
bowel becomes active), children begin to skip meals. They
may be malnourished and have a vitamin or iron deficiency
at the time the condition is diagnosed.
Several complications may occur. Hemorrhage from
bowel perforation during the active disease is possible.
Perforation can lead to peritonitis or the formation of fistulas between bowel loops. Rectal fistula is present in as many
as 20% of children. A relapse is apt to occur 6 to 12 months
after therapy. With ulcerative colitis, there is an association
between the disease and bowel carcinoma if the disease persists over 10 years (McQuaid, 2009).
Assessment
In both conditions, diarrhea and steatorrhea develop from
the irritation and the unabsorbed fluid. If inflamed portions
ulcerate, there will be blood in the stool. Weight loss occurs;
growth failure occurs in prepubertal children. A recurring
fever may be present (Table 45.6).
Diagnosis is established by colonoscopy and barium
enema. On colonoscopy, the shallow ulcerations along the
bowel can be seen; the mucosa is friable (easily irritated) and
bleeds easily from inflammation. A biopsy may be performed
for definite diagnosis. Observe children carefully after a
bowel biopsy to detect rectal bleeding from an internal bleeding point (take blood pressure and pulse, and assess stool for
occult blood).
Therapeutic Management
The child’s bowel heals best if it is allowed to rest for a time.
Enteral or total parenteral nutrition is usually provided for
nutrition during the resting period (Wiskin, Wootton, &
TABLE 45.6 ✽ Comparison of Crohn’s Disease
and Ulcerative Colitis
Comparison
Factor
Crohn’s
Disease
Ulcerative
Colitis
Part of bowel
affected
Nature of
lesions
Diarrhea
Ileum
Colon and
rectum
Continuous
Anorexia
Weight loss
Growth
retardation
Anal and
perianal
lesions
Association with
carcinoma
Intermittent
Moderate
Severe
Severe
Marked
Severe and
bloody
Mild
Mild
Mild
Common
Rare
Rare
Common
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BOX 45.6 ✽ Focus on
Pharmacology
Sulfasalazine (Azulfidine)
Classification: Sulfasalazine is a combination antiinflammatory agent and antibiotic.
Action: Reduces the inflammation of ulcerative colitis
and Crohn’s disease (Karch, 2009).
Pregnancy risk category: C (D at term)
Dosage: Varied, based on severity of illness, 20 to
75 mg/kg/day. Initially, 40 to 60 mg/kg/24 hr orally in
four to six divided doses in children older than age 2
years. Maintenance therapy usually 20 to 30 mg/kg/day
in four equally divided doses.
Possible adverse effects: Sensitivity to sunlight; dizziness; drowsiness, nausea, abdominal pains, crystalluria, and hematuria
Ileum
Line of incision
A
Valve
Interior of
pouch
Nursing Implications
• Caution the parents and child that the drug may turn
urine orange-red and soft contact lenses yellow.
• Advise children to take with or just after meals to
avoid GI irritation.
• Ensure adequate fluid intake to avoid crystallization
of sulfa component in urine.
• Anticipate prescription for folic acid concurrently.
Drug decreases folic acid absorption.
• Instruct the child and parents about the need to use
sunscreens and protective clothing while outside.
B
Ileum
Internal pouch
Stoma
Abdominal wall
C
Beattie, 2007). A child can remain home during this period
as long as parents have thorough education about the child’s
nutritional needs (see Chapter 37).
When food is reintroduced after the resting period, a
high-protein, high-carbohydrate, high-vitamin diet is prescribed to replace nutrients. Children may eat cautiously at
first to avoid reintroducing diarrhea so assess intake and output. A combination of an anti-inflammatory drug such as
prednisone (a corticosteroid), sulfasalazine (Azulfidine; a sulfonamide and salicylic acid), azathioprine (Imuran; an immunosuppressive agent), or monoclonal antibodies (infliximab) generally bring about a great improvement in
symptoms (Box 45.6). For ulcerative colitis, cyclosporine
may be used. If medical therapy is ineffective, bowel resection to remove a portion of the bowel (colectomy) followed
by an ileoanal pull-through may be necessary. In some children, such a large portion of the bowel may be removed that
a colostomy or a continent ileostomy needs to be constructed
(for continent ileostomy, an internal reservoir is created
using a section of bowel and emptied by insertion of a
catheter; Fig. 45.9).
Bowel surgery is a serious step. Because it reduces the possibility of the child’s developing intestinal cancer in association with ulcerative colitis, it may be necessary in children
whose disease is running a long-term, debilitating course that
does not improve (Ba’ath et al., 2007). Children who recover
from inflammatory bowel disease should have a colonoscopy
yearly for the rest of their lives.
FIGURE 45.9 A continent ileostomy. (A) Segment of bowel is
anastomosed. (B) Pouch for stool collection is formed. (C)
Liquid stool is contained in pouch until drained by catheter.
Nursing Diagnoses and Related
Interventions
✽
Nursing Diagnosis: Imbalanced nutrition related to
poor absorption because of disease process
Outcome Evaluation: Child’s weight follows a percentile
growth curve; urine specific gravity is 1.003 to 1.030.
Child states that alternative feeding method is tolerable.
Nutrition is a priority concern for children with both
Crohn’s disease and ulcerative colitis because malnutrition can occur from the combination of poor intestinal absorption and chronic diarrhea. Unless active steps are taken to supplement nutrition, children
with inflammatory bowel disease can be left both short
in stature and light in weight. Anorexia with protein, vitamin, fat, and mineral deficiencies all may occur.
When nutrition is supplied by enteral or total parenteral nutrition solutions, allowing the enteral infusion to
flow during the night and removing the tube during the
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CHAPTER 45 Nursing Care of a Family When a Child Has a Gastrointestinal Disorder
day can make feedings more tolerable. Remember that
food provides social experiences as well as nutrition.
Help parents provide opportunities for usual mealtime
stimulation in other ways.
Nursing Diagnosis: Risk for ineffective coping related
to chronic illness
Outcome Evaluation: Child expresses feelings, states
that she understands the disease and therapy, and
suggests ways to minimize stress.
Caution children about the possible side effects, such
as excessive weight gain, a round facial appearance,
and facial acne, that may occur if corticosteroid therapy,
such as prednisone, is used so they are not surprised
by this. Assess blood pressure, intake and output,
weight, and sleep patterns for any child taking steroids.
Caution children that sulfasalazine (Azulfidine) turns
urine an orange-yellow so they do not mistake this color
change as bleeding.
Provide time to listen so children have someone outside their family to talk to about their symptoms and
family or stress problems (Box 45.7). The disorder follows a chronic course and can involve embarrassing
episodes of diarrhea or acute abdominal pain.
Irritable Bowel Syndrome
(Chronic Nonspecific Diarrhea)
Irritable bowel syndrome involves intermittent episodes of
loose and normal stools or recurrent abdominal pain. It appears slightly more often in girls than in boys. It is most often
seen in infants 6 to 36 months of age. Most children outgrow
the symptoms by 3 years of age. The cause is unknown, but
it is associated with low fat intake (without fat slowing absorption, stool passes rapidly through the bowel). Excessive
fluid intake also may play a role.
The symptoms are usually vague. The episodes of diarrhea
may occur several times a week or as frequently as twice a
day. There seems to be no relationship to meals.
Children are encouraged to eat a regular diet. Psyllium
bulk agents will almost always reduce the frequency of
symptoms. Probiotics or foods supplemented with lactic
acid-producing bacteria may improve symptoms (Walter &
Isolauri, 2007).
Chronic Recurrent Abdominal Pain
Some children develop episodes of recurring abdominal pain.
Although such episodes can occur for reasons such as lactose
intolerance or muscle strain from sports activities, in most instances the cause is unknown (Sondheimer, 2008). Children
who experience this are commonly 6 or 7 years of age or in
prepuberty (11 to 12 years of age). The pain is not accompanied by a change in bowel habits. There is no association
with meals. Episodes of pain can last for only a few minutes
or for hours. The intensity of the pain is mild or “annoying”
rather than severe. It is generally poorly localized, although
children may point to the umbilicus as the primary site. On
physical examination, there is no abdominal tenderness, distention, guarding, or muscle spasm.
Symptoms of stress such as sleep disturbances, fears, or
eating problems may be present. A family history may indi-
1351
BOX 45.7 ✽ Focus on Communication
Barry’s older sister Addie has Crohn’s disease. Her doctor has told her parents she won’t need surgery but will
need long-term therapy. You see Mrs. Abraham filling
out forms by Addie’s bedside.
Less Effective Communication
Nurse: Mrs. Abraham, can I help you with anything?
Mrs. Abraham: No. With Addie well again in a short
time, I’m going to start back to college. I’m filling out
the forms.
Nurse: Do you mean Addie doesn’t need parenteral
nutrition?
Mrs. Abraham: She doesn’t need anything. Not even
surgery.
Nurse: That’s wonderful. She’s very lucky.
More Effective Communication
Nurse: Mrs. Abraham, can I help you with anything?
Mrs. Abraham: No. With Addie well again in a short time,
I’m going to start back to college. I’m filling out the
forms.
Nurse: Do you mean Addie doesn’t need parenteral
nutrition?
Mrs. Abraham: She doesn’t need anything. Not even
surgery.
Nurse: Let’s review exactly what the doctor has told you.
People under stress often do not hear instructions well.
When this happens, they may need them repeated several times before they truly comprehend what was said.
An easy solution when you are aware that a parent has
not heard potentially bad news is to ignore the loss of information, as in the first scenario above. A better solution is to explore with the parents what they did hear and
help them receive more accurate information.
cate problems in the family such as marital discord, financial
problems, or physical illness in parents or siblings.
Although the cause of the pain cannot be identified, the
pain is real. For some children, just having the opportunity
to talk to an understanding person about the problem is all
that is necessary to stop the attacks of pain. Other families
need counseling regarding the underlying problem, such as
allowing children to express their anger, reducing excessive
demands on them, or giving them more attention by
spending more time with them. The family may need to be
referred to a family service agency for counseling (HuertasCeballos et al., 2009).
DISORDERS CAUSED BY FOOD, VITAMIN,
AND MINERAL DEFICIENCIES
There are many underfed and malnourished children in
every part of the world. Although extreme diseases of food
or vitamin deprivation are rare in the United States, they
do exist. Such children need early identification so they
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UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders
can receive better nutrition before permanent damage
occurs.
The average child does not develop a deficient intake of
essential nutrients because, even if the child is occasionally
a fussy eater, over the space of a week, a child does ingest
foods containing the necessary nutrients. Carefully assess
any child who has an interference in nutrition such as a GI
illness or a child is receiving enteric feedings or total parenteral nutrition to make sure that nutrient deficiencies do
not exist. Assess abused or neglected children closely for nutritional deficiencies, because they may not have been given
adequate food.
Kwashiorkor
Kwashiorkor, a disease caused by protein deficiency, occurs
most frequently in children ages 1 to 3 years, because this
age group requires a high protein intake. It is a disease found
almost exclusively in developing countries in Africa, Asia,
and Latin America, although it does occur in the United
States (Baron, 2009). It tends to occur after weaning, when
children change from breast milk to a diet consisting mainly
of carbohydrates. Growth failure is a major symptom.
Because edema is also a symptom, however, children may
not appear light in weight until the edema is relieved. There
is a severe wasting of muscles, but, again, this is masked by
the edema.
Edema results from hypoproteinemia, which causes a
shift of body fluid from the intravascular compartments to
the interstitial space, causing ascites (Fig. 45.10). This is
the same phenomenon that causes extensive edema in children with nephrosis. The edema tends to be dependent, so
it is first noted in the lower extremities. Children are generally irritable and uninterested in their surroundings.
They fall behind other children of the same age in motor
development.
If the child had a period of good protein intake, then poor
protein intake, then good intake again, hair shafts develop a
striped appearance of brown, then white, and so on—a
“zebra sign.” Children also have diarrhea, iron-deficiency
anemia, and enlarged livers.
Without treatment, kwashiorkor is fatal. For therapy, a
diet rich in protein is essential. Even so, there is evidence to
suggest that protein malnutrition early in life, even if corrected later, may result in failure of children to reach their
full potential of intellectual and psychological development.
Nutritional Marasmus
Nutritional marasmus is caused by a deficiency of all food
groups, basically a form of starvation. Although it is seen
most commonly in developing countries where food supplies are short, it can be seen in grossly neglected children
or those with failure to thrive in the United States (see
Chapter 55). These children are most commonly younger
than 1 year of age. They have many of the same symptoms
as children with kwashiorkor, including growth failure,
muscle wasting, irritability, iron-deficiency anemia, and
diarrhea. Whereas children with kwashiorkor are anorectic, children with nutritional marasmus are invariably hungry (starving) and will suck at any object offered them,
such as a finger or their clothing. Treatment is a diet rich
in all nutrients.
Vitamin and Mineral Deficiencies
Both vitamin and mineral deficiencies occur at a low rate in
children of the United States because so many foods are enriched (restoration of ingredients removed by processing) or
fortified (additional vitamins and minerals not normally
present have been added). Milk, for example, is fortified with
vitamins D and A. Orange juice is fortified with calcium.
White bread is enriched with B vitamins. Vitamin deficiency
diseases are summarized in Table 45.7.
Iodine Deficiency
Because iodine is not supplemented in food except as iodized
salt, a diet deficient in iodine may lead to either hypothyroidism or overgrowth (goiter) of the thyroid gland as the
gland struggles to produce thyroxine in the face of deficient
iodine. Goiter tends to occur most commonly in girls at puberty and during pregnancy. It is potentially dangerous as an
enlarged thyroid gland may lead to difficulty breathing. In
the United States, areas where goiter is endemic are mainly
the states bordering Canada, especially the Great Lakes area,
and the states between the Rocky Mountains and the
Appalachians (Rolfes, Pinna, & Whitney, 2009).
Supplemental iodine or synthetic thyroxine (Synthroid) is
needed to correct the deficiency. Children must also be
maintained on a diet adequate in iodine, found most abundantly in seafood (Rolfes, Pinna, & Whitney, 2009).
✔Checkpoint Question 45.5
Kwashiorkor is a disorder common in developing countries.
This disorder occurs because of lack of which nutrient?
FIGURE 45.10 A child with kwashiorkor. Here the extensive
generalized edema masks the severe muscle wasting. Notice
the severe abdominal distention from ascites.
a. Water-soluble vitamins.
b. Fats and triglycerides.
c. Quality protein.
d. Vitamin K.
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CHAPTER 45 Nursing Care of a Family When a Child Has a Gastrointestinal Disorder
TABLE 45.7
✽
Vitamin Deficiency Disorders
Vitamin
Cause of Deficiency
Signs and Symptoms
Vitamin A
Lack of yellow vegetables in diet
Vitamin B1
Most common in children who eat
polished rice as dietary staple,
because B1 is contained in hull
of rice
Niacin
Common in children who eat corn
as dietary staple, because corn
is low in niacin
Lack of fresh fruits in diet
Lack of sunlight
Tender tongue; cracks at corners of mouth
Night blindness
Xerophthalmia (dry and lusterless conjunctivae)
Keratomalacia (necrosis of the cornea with
perforation, loss of ocular fluid, and blindness)
Beriberi (tingling and numbness of extremities; heart
palpitations; exhaustion)
Diarrhea and vomiting
Aphonia (cry without sound)
Anesthesia of feet
Pellagra (dermatitis; resembles a sunburn)
Diarrhea
Mental confusion (dementia)
Scurvy (muscle tenderness; petechiae)
Poor muscle tone; delayed tooth formation
Rickets (poor bone formation)
Craniotabes (softening of the skull)
Swelling at joints, particularly of wrists and cartilage
of ribs
Bowed legs
Tetany (muscle spasms)
Vitamin C
Vitamin D
Key Points for Review
● Peptic ulcer disease may occur in children of all ages. The
● Children with gastrointestinal disorders need to join the
●
●
●
●
●
●
1353
family for mealtime if possible. Even if they cannot eat the
same foods as other family members, they benefit from
the social interaction.
Some gastrointestinal disorders lead to long-term therapies such as colostomy or gastrostomy feedings. Because
these disorders interfere with common body functions
such as eating and elimination, they are difficult for children to accept without the support of concerned health
care providers.
Children lose proportionately more fluid with vomiting
and diarrhea than adults, so they need rapid assessment
and interventions to avoid dehydration.
Fluid, electrolyte, and acid–base imbalances tend to occur
rapidly with vomiting and diarrhea. Vomiting leads to alkalosis. Diarrhea leads to acidosis.
Gastrointestinal disorders almost always interfere with
nutrition to some degree. This is a greater problem in
children than adults because children need to ingest adequate nutrients and fluid daily for growth as well as
body maintenance.
Gastroesophageal reflux is a neuromuscular disturbance in
which the cardiac sphincter is lax, allowing for easy regurgitation of gastric contents into the esophagus. It is treated
by feeding a thickened formula and keeping an infant upright after feedings.
Pyloric stenosis is hypertrophy of the valve between the
stomach and duodenum. It impedes the passage of feedings, leading to vomiting.
●
●
●
●
●
●
●
●
disorder causes a shallow excavation to form in the mucosal wall of the stomach. It is treated, like adult ulcers,
with antibiotics and agents to suppress gastric acidity.
Forms of hepatitis seen in children include hepatitis A and
C (caused usually by eating contaminated shellfish) and
hepatitis B, D, and E (caused by contaminated blood or
placental transfer).
Congenital obstruction of the bile ducts occurs from failure of the bile duct to recanalize in utero. This can lead to
fibrotic scarring of the liver (cirrhosis). Most of these children need a liver transplant to restore liver function.
Intussusception is the invagination of one portion of the
intestine into another. Volvulus is twisting of intestine.
Both may lead to bowel obstruction.
Necrotizing enterocolitis is the development of necrotic
patches on the intestine. It occurs almost exclusively in
immature infants.
Appendicitis is inflammation of the appendix. It is always
an emergency and is the most common reason for abdominal surgery in children. Laparoscopy is done to remove the appendix, ideally before it ruptures.
Celiac disease (gluten-induced enteropathy) is a change in
the ability of the intestinal villi to absorb. It is a dominantly inherited illness.
Both inguinal and hiatal hernia can occur in children.
These are surgically corrected when recognized.
Hirschsprung’s disease (aganglionic megacolon) is absence
of ganglionic innervation in a section of the lower bowel.
Therapy may involve a temporary colostomy followed by
surgery in 6 to 12 months to remove the affected bowel
portion.
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UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders
● Inflammatory bowel disease can occur as either ulcerative
colitis or Crohn’s disease. Therapy is long-term. If medical therapy is unsuccessful, portions of the bowel may be
surgically removed. Ulcerative colitis is associated with the
development of colon cancer later in life.
● Kwashiorkor (protein deficiency), nutritional marasmus
(starvation), vitamins A and D (rickets), B1 (beriberi), and
C (scurvy) deficiencies, or iodine deficiencies occur in
children when they are not provided or cannot absorb adequate nutrients. Although more common in developing
countries, they can occur in a child in any community.
CRITICAL THINKING EXERCISES
1. Barry is the 2-year-old boy you met at the beginning of
the chapter. He was diagnosed with celiac disease.
When you met him, his mother was insisting that he eat
a piece of birthday cake. What health education does his
mother need to help her choose a better diet for her son?
What would have been a better food, probably available
at a birthday party, that he could have eaten?
2. Suppose Barry is seen in a hospital emergency department with severe diarrhea. What emergency interventions does he need to prevent an electrolyte or fluid imbalance? What measures could you take to reduce his
fear of the strange hospital environment?
3. Barry’s older sister, who has Crohn’s disease, is being
cared for at home with total parenteral nutrition. How
can you help her keep pace with her friends at school?
How can you help her maintain a sense of high self-esteem in light of her many hospitalizations and home care?
4. Examine the National Health Goals related to gastrointestinal disorders in children. Most government-sponsored funds for nursing research are allotted based on
these goals. What would be a possible research topic to
explore pertinent to these goals that would be applicable to the Abraham family and also advance evidencebased practice?
CRITICAL THINKING SCENARIO
Open the accompanying CD-ROM or visit http://the
Point.lww.com and read the Patient Scenario included
for this chapter, then answer the questions to further
sharpen your skills and grow more familiar with
NCLEX style questions related to gastrointestinal disorders in children. Confirm your answers are correct by
reading the rationales.
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