THE CHILD WITH GASTROINTESTINAL
DYSFUNCTION
Chapter 25
Christine Limann Dyer, RN, MSN, CPN
GASTROINTESTINAL SYSTEM
Upper portion is responsible for nutrient intake
(ingestion)
 Includes:

Mouth
 Esophagus
 Stomach

DIGESTION
Required to convert nutrients into usable energy
 Performs excretory function and detoxification
 Mechanical digestion
 Chemical digestion

GASTROINTESTINAL SYSTEM
Lower portion is responsible for remainder of
digestion, absorption & metabolism
 Includes:

Small intestine
 Large intestine
 Rectum
 Anus

ABSORPTION

Principally from small intestine
Osmosis
 Carrier-mediated diffusion
 Active energy-driven transport (“pump”)


Large intestine
Absorption of water
 Absorption of sodium
 Role of colonic bacteria

GASTROINTESTINAL SYSTEM

Accessory Structures:
Liver
 Gallbladder
 Pancreas

INGESTION OF FOREIGN SUBSTANCES

Pica
Food picas
 Nonfood picas

Foreign bodies
 Nursing
considerations

DEVELOPMENTAL ASPECTS
(EACH DEVELOPMENTAL STAGE CONTRIBUTES TO THE
PROMOTION OF THE HEALTH OF THE CHILD)

Infant:
Prevent choking
 Suck-swallow
 Frequent feedings
 Carefully introduce foods about 1 year of age

DEVELOPMENTAL ASPECTS

Toddler:
Weight gain (5-6 lbs/year)
 Deceased caloric needs
 Food “jags”

DEVELOPMENTAL ASPECTS

Preschooler:



Eats a full range of food
Appetite fluctuation
School-age:
GI tract stable (digestive system is adult sized)
 Stools well formed

STRUCTURAL
GASTROINTESTINAL DISORDERS
UMBILICAL HERNIA

Signs & Symptoms:


Soft midline swelling
in the umbilical area
Complications:

Incarcerated
(strangulated)
Nursing Care:
Most resolve
spontaneously by 3-5
yrs of age
 Surgery (pre-post
operative care)
 Discharge instructions

ANORECTAL MALFORMATIONS

Signs & Symptoms:


Complications:


Rectal atresia (closure) and
stenosis (constriction or
narrowing of a passage)
Depends on the defect and
accompanying multisystem
involvement
Nursing Care:
Extensive treatment depending
on defect and associated organ
involvement
 Preoperative care (caregiver
education & IV fluids)
 Postoperative care (pain control,
s/s of infection, good skin care,
NG tube, oral feedings resumed)
 Discharge instructions

OBSTRUCTIVE
GASTROINTESTINAL DISORDERS
HYPERTROPHIC PYLORIC STENOSIS
CONSTRICTION OF THE PYLORIC SPHINCTER WITH
OBSTRUCTION OF THE GASTRIC OUTLET
HYPERTROPHIC PYLORIC STENOSIS



Signs & Symptoms:
 Typically: healthy, male infant: new onset non-bilious vomiting
progressing to projectile vomiting
Diagnosis:
 Palpating the pyloric mass (olive-shaped)
Nursing Care:
 Surgery (Ramstedt pyloromyotomy)
 Assess dehydration, changes is VS, weight loss & discomfort
 Preoperative care (NPO, NG tube,)
 Postoperative care ( maintain fluids & electrolyte balance,
feedings, infection, keeping the wound clean & pain relief)
 Discharge instructions (care of incision, s/s infection, response to
feedings)
INTUSSUSCEPTION
Telescoping or invagination of one portion of
intestine into another
 Signs & Symptoms:


Acute abdominal pain, currant jelly stools, fever,
dehydration, abdominal distention, lethargy and
grunting due to pain
Diagnostic evaluation
 Therapeutic management
 Prognosis
 Nursing considerations

ILEOCOLIC INTUSSUSCEPTION
MALROTATION AND VOLVULUS




Malrotation is due to abnormal
rotation around the superior
mesenteric artery during
embryonic development
Volvulus occurs when intestine
is twisted around itself and
compromises blood supply to
intestines
May cause intestinal
perforation, peritonitis,
necrosis, and death
Complications:
 Shock (signs include; tachycardia,
tachypnea, hypotension & cool,
clammy or cyanotic skin)
INFLAMMATORY DISORDERS
IRRITABLE BOWEL SYNDROME (IBS)
Identified as cause of
recurrent abdominal
pain in children
 Classified as a
functional GI disorder
 Alternating diarrhea
and constipation
 Therapeutic
management
 Nursing
considerations

INFLAMMATORY BOWEL DISEASE (IBD)

Two types
Crohn’s Disese
 Ulcerative Colitis

ULCERATIVE COLITIS (UC)
Pathophysiology –inflamation in colon and
rectum
 Clinical manifestations – ulceration, bleeding,
anorexia, anemia

CROHN’S DISEASE
Pathophysiology-Crohn's disease is an
inflammatory bowel disease (IBD)
 Clinical manifestations-abdominal pain, severe
diarrhea and even malnutrition
 Extraintestinal manifestations-arthritis, skin
problems, fever, anemia
 Therapeutic management


Medical- corticosteriods,



Remicade for remission, 6-MP
Surgical
Nursing considerations – nutritional support,
education
APPENDICITIS



Signs & Symptoms:
 Earliest symptom; periumbilical
pain, vomiting
 Followed by: right lower quadrant
pain (classic sign)
Clinical Alert:
 Children who respond yes to being
hungry most likely do not have
appendicitis
Nursing Care:
 Surgery
 Postoperative care (monitor intake
& output, wound care, pain control,
NPO until peristalsis returns,
discharged home in 2-3 days)
 If perforate appendix intravenous
antibiotics are given, NPO with NG
tube until bowel function returns
OMPHALITIS
 Signs

& Symptoms:
Redness & edema of the
soft tissue
 Diagnosis:

Culture obtained to
confirm diagnosis
 Nursing
Care:
Prevention by good
perinatal care & caregiver
education
 Intravenous broadspectrum antibiotics

MECKEL DIVERTICULUM





Most common congenital
malformation of the GI tract
Band connecting small intestine to
umbilicus
Signs & Symptoms:
 Abdominal pain, painless rectal
bleeding, stools (bright or dark
red with mucus)
Complications:
 If undetected severe anemia &
shock can occur
Nursing Care:
 Surgical removal of the
diverticulum or pouch
 Postoperative antibiotics
 Correct fluid & electrolyte
imbalances
 Monitor for shock & blood loss
 Provide rest
 Fluid replacement & NG tube
FUNCTIONAL
GASTROINTESTINAL CONDITIONS
INFANTILE COLIC



Signs & Symptoms:
 Persistent, unexplained crying –
younger than 3 months
 Episodes occur at the same time
each day
Diagnosis:
 Based on symptoms occurring for
more than 3 weeks, for 3 days (2-3
hours a day)
Nursing Care:
 Rule out acute conditions
 Management strategies (see Box
25-1)
ACUTE DIARRHEA



Signs & Symptoms:
 Increased frequency & fluid content of the stools with or without
associated symptoms
Additional Symptoms:
 Caregiver asked about vomiting, fever, pain, number of wet
diapers in previous 24-hours)
Nursing Care:
 Hydration & dietary needs
 Pharmacology treatment not ordered
 IV fluids essential with impaired circulation and possible shock
CHRONIC DIARRHEA
Signs & Symptoms:
 Reflective of underlying pathology
 History of the diarrhea; frequency & appearance
 Additional Symptoms:
 Abdominal distention or tenderness, hyperactive bowel sounds,
dehydration & condition of the perineal area
 Nursing Care:
 Treat the underlying cause
 Enteral or TPN is provided for the child who is unable to
maintain adequate oral intake
 Caregiver educated on prevention

VOMITING



Signs & Symptoms:
 Assessment includes description of onset, duration quality, quantity,
appearance, presence of undigested food and precipitating event
Additional Symptoms:
 Fever, diarrhea, ear pain, headache
Nursing Care:
 Treatment of the cause & prevent of complications
 Bowel is allowed to rest
 Rehydration
 Bland solids reintroduced
 Antiemetic drugs
 Dehydration, monitor fluid intake & output
 Oral hygiene
CYCLIC VOMITING SYNDROME
Signs & Symptoms:
 Recurrent episodic vomiting, usually lasts 24-48 hours.
Vomiting occurs at regular intervals, usually every two to
four weeks
 Diagnosis:
 Rule out other conditions
 Nursing Care:
 Supportive care: fluid replacement, rest, pharmacotherapy
& psychiatric evaluation
 Calm stress-free environment

CONSTIPATION
An alteration in the
frequency, consistency, or
ease of passage of stool
 May be secondary to other
disorders
 Idiopathic (functional)
constipation—no known
cause
 Chronic constipation—may
be due to environmental or
psychosocial factors

NEWBORN PERIOD

First meconium should be passed within 24 to 36
hours of life; if not assess for:
Hirschsprung disease, hypothyroidism
 Meconium plug, meconium ileus (CF)

INFANCY
Often related to diet
 Constipation in exclusively breastfed infant
almost unknown


Infrequent stool may occur because of minimal
residue from digested breast milk
Formula-fed infants may develop constipation
 Interventions
- adding cereals, fruits and vegetables may help
(after 4 months)

CONSTIPATION IN CHILDHOOD
Often due to environmental changes or control
over body functions
 Encopresis: inappropriate passage of feces, often
with soiling
 May result from stress
 Management

NURSING CONSIDERATIONS
History of bowel patterns, medications, diet
Educate parents and child
Dietary modifications (age appropriate)
Case Study
2 week old Joey is brought into the clinic by his mom because he hasn’t had
a bowel movement in two days. He is not eating and has abdominal
distention. She states that he didn’t pass meconium until the day after his
birth.
1. Describe the structural anomaly associated with Hirshbrung’s disease.
2. How is Hirshbrung’s diagnosed?
3. List 2 actual NANDA and 1 risk
4. If Joey is diagnosed with Hirsbrung’s Disease, what is the likely surgical
intervention?
5. What are possible complications for an older child?
HIRSCHSPRUNG DISEASE
Also called congenital
aganglionic megacolon
 Mechanical
obstruction from
inadequate motility of
intestine
 Incidence: 1 in 5000
live births; more
common in males and
in Down syndrome
 Absence of ganglion
cells in colon

HIRSCHSPRUNG DISEASE



Signs & Symptoms:
 Failure to pass meconium within the first 48 hours of life, failure to
thrive, poor feeding, chronic constipation, & Down syndrome
Complications:
 Entercolitis is the most ominous presentation (abrupt onset o foul
smelling diarrhea, abdominal distention & fever. Rapid progress may
indicate perforation & sepsis
Nursing Care:
 Surgical resection (colostomy)
 Preoperative care (fluid & electrolyte status, NPO, NG tube, IV
fluids)
 Postoperative care (maintain NG tube, monitor for abdominal
distension, assess for bowel sounds)
 Teach caregiver how to car for colostomy, s/s of complications)
CLINICAL MANIFESTATIONS
OF HIRSCHPRUNG DISEASE
Aganglionic segment
usually includes the
rectum and proximal
colon
 Accumulation of stool
with distention
 Failure of internal
anal sphincter to relax
 Enterocolitis may
occur

DIAGNOSTIC EVALUATION
X-ray, barium enema
 Anorectal manometric exam
 Confirm diagnosis with rectal biopsy

THERAPEUTIC MANAGEMENT
Surgery
 Two stages

Preoperative care
Postoperative care
Discharge care
Temporary ostomy
 Second stage “pull-through” procedure

GASTROESOPHAGEAL REFLUX (GER)
Defined as transfer of gastric contents into the
esophagus
 Occurs in everyone
 Frequency and persistency may make it
abnormal
 May occur without GERD
 GERD may occur without regurgitation

GER
Diagnostics
 Therapeutic management
 Nursing considerations

MALABSORPTION DISORDERS
LACTOSE INTOLERANCE



Signs & Symptoms:
 Bloating, cramping,
abdominal pain &
flatulence
Diagnosis:
 Based on
history/physical &
decrease in symptoms
with elimination of
lactose from the diet
Nursing Care:
 Elimination of dairy
products or the use of
enzyme replacement
 Dietary education
(alternative sources of
calcium)
CELIAC DISEASE
Also called gluten-induced enteropathy and celiac
sprue
 Four characteristics

Steatorrhea-fatty stool
 General malnutrition
 Abdominal distention
 Secondary vitamin deficiencies

CELIAC DISEASE (CONT.)
Pathophysiology
 Diagnostic evaluation
 Therapeutic management
 Nursing considerations

SHORT BOWEL SYNDROME (SBS)
A malabsorptive disorder
 Results from decreased
mucosal surface area, usually
as result of small bowel
resection
 Etiology and pathophysiology
 Result of decreased mucosal
surface area, usually due to
extensive resection of small
intestine
 Other causes


NEC, volvulus, gastroschisis,
Crohn disease in
THERAPEUTIC MANAGEMENT OF SBS

Nutritional support—first phase: TPN

Associated risks and complications
Second phase: enteral feeding
Long-term maintenance
 Medical therapies
 Surgical therapies


Nursing Care:
 Feeding tolerance
 Emotional & developmental needs
 Assist parents with coping
 Home care services
HEPATIC DISORDERS
BILIARY ATRESIA, OR EXTRAHEPATIC BILIARY
ATRESIA (EHBA)



Signs & Symptoms:
 Jaundice, dark urine, lighter (tan-white) than normal stools, poor weight gain, failure
to thrive, pruritus, hepatomegaly, splenomegaly
Diagnosis:
 Early diagnosis in the key to survival.
Nursing Care:
 Primarily supportive & focuses on providing nutritional support
 Surgical resection: correct obstruction & provide drainage of bile from the liver into
the intestines
 Preoperative care (educate family & long term care)
 Postoperative care (educate family on skin & stoma care, nutritional therapy,
complications, psychological support)
 Potential transplant
CIRRHOSIS



Signs & Symptoms:
 Vary depending on the cause
 Jaundice, growth failure, muscle weakness, anorexia & lethargy
Diagnosis:
 Based on history, laboratory values & liver biopsy
Nursing Care:
 Preventing & treating complications
 Nutritional support
 Liver transplant
 Monitor for complications
 Comfort measures & emotional support
HEPATITIS



Signs & Symptoms :
 Headache, anorexia, malaise, abdominal pain, nausea & vomiting
Diagnosis:
 Based on history of exposure, symptoms & serologic testing
Nursing Care:
 Primarily supportive: no specific treatment
 Provide rest to the liver, hydration, maintain comfort, adequate
nutrition, & prevent complications
 Immune globulin given to children who have been exposed to a person
with HAV
 Vaccine available for HAV, HBV & HDV
 Educate family regarding prevention measures (see Critical Nursing
Actions Prevention of Hepatitis A and Hepatitis B)
ABDOMINAL TRAUMA: INJURIES
 Injuries
are the leading cause of death in
children
 Ten percent of serious trauma occurs as a
result of abdominal & genitourinary injury
 See Table 25-5 Injuries Caused by Abdominal
Trauma
DEHYDRATION
Types of dehydration
 Diagnostic evaluation
 Therapeutic management
 Nursing considerations


1st treatment- Oral hydration Solution-OHS
DAILY MAINTENANCE FLUID
REQUIREMENTS

Calculate child’s weight in kg
Allow 100 ml/kg for first 10 kg body weight
 Allow 50 ml/kg for second 10 kg body weight
 Allow 20 ml/kg for remaining body weight

EXAMPLE 1:
DAILY FLUID CALCULATION

Child weighs 32 kg
100 x 10 for first 10 kg of body weight = 1000
 50 x 10 for second 10 kg of body weight = 500
 20 x 12 for remaining body weight = 240
 1000 + 500 + 240 = 1740 ml/24 hr

EXAMPLE 2:
DAILY FLUID CALCULATION

Child weighs 8.5 kg
100 x 8.5 for first 10 kg of body weight = 850
 No further calculations
 850 ml/24 hr

EXAMPLE 3:
DAILY FLUID CALCULATION

Child weighs 14 kg
100 x 10 for first 10 kg of body weight = 1000
 50 x 4 for second 10 kg of body weight = 200
 No further calculations
 1000 + 200 = 1200 ml/24 hr

HOMEMADE ELECTROLYTE SOLUTION
2 quarts water
 1 teaspoon baking
soda
 1 teaspoon salt
 7 Tablespoons sugar
 1/2 teaspoon salt
substitute
