Nursing Care of the Child with a Gastrointestinal Disorder Normal Gastrointestinal System Disorders of Development Cleft Lip and Cleft Palate Etiology- Failure of maxillary and median nasal processes to fuse during embryonic development Remember the psycho-social implications for these children and families Assessment Unilateral, bilateral, midline Treatment Surgical repair between 3 and 6 months Multidisciplinary team - involving many specialists including plastic surgeons, nurses, ear, nose, and throat specialists, orthodontists, audiologists, and speech therapists. Reconstruction begins in infancy and can continue through adulthood. Homecare by the family prior to surgery Pre-op Nursing Care Pre-op Nursing Care May breast feed if has small cleft lip If bottle fed, use compressible bottle, longer nipple, larger hole in nipple, any other special device for feeding this infant. Feed slowly in upright position and bubble frequently Keep bulb syringe and suction equipment at bedside Position on side after feeding Pre-Op Nursing Care What are problems that the nurse needs to be alert for during feedings? Lack of proper seal around nipple to create necessary suction Excessive air intake Use of special feeding techniques Feeder with compressible sides Syringes with tubing Pre-op Nursing Care Remind parents that defect is operable- show photographs of corrected clefts Before After Therapeutic Management Surgical Correction A number of professionals are involved including surgeons, nurses, ear, nose, and throat specialists, audiologists, speech therapist, orthodontists, and plastic surgeons. Post-Op Care Prevent trauma to suture line Logan’s bow to protect site Do not allow to suck Maintain upper arm restraints Position supine No hard objects in mouth- straws, pacifiers, spoons Do not take temperature orally Reduce Pain Mild analgesics and sedatives Parents to provide, holding, rocking, and parental voices Post-op Care Prevent Infection Cleanse suture lines as ordered rinse with water after each feeding Use cotton swab, use rolling motion vertically down suture line Apply anti-infective ointment as ordered Call Doctor for any swelling or redness, bleeding, drainage, fever Make early Referrals to appropriate team members Assess for Complications Otitis media, hearing loss, speech difficulties, growth, altered dentition. Esophageal Atresia Malformation from failure of esophagus to develop as a continuous tube Upper Esophagus Trachea Lower Esophagus An atresia is the absence or closure of a normal body tubular passage, such as the esophagus and it ends in a blind pouch. A tracheoesophageal fistula is when the esophagus connects with the trachea. Signs and Symptoms Excessive amounts of salivation / mucus, frothy bubbles in the mouth and sometimes nose Three “C’s” - Coughing, choking, and cyanosis when fed, overflow may be aspirated Food may be expelled through the nose immediately following the feeding Rattling respirations and frequent respiratory problems such as aspiration pneumonia Gastric distention, if fistula History of polyhydramnios during pregnancy can suggest a high gastrointestinal obstruction Diagnosis and Management Early diagnosis Ultra sound Radiopaque catheter inserted in the esophagus to illuminate defect on X-ray Surgical repair Thoracotomy and anastomosis Pre-Op Nursing Care Maintain airway • jlkjfj Keep NPO- administer IV fluids Place in warmer, give humidified O2 Elevate HOB 30 degrees, suction PRN Give Prophylactic antibiotics Post-Op Nursing Care Maintain airway Maintain thermoregulation Maintain nutrition Gastrostomy Tube feedings Prevent trauma Monitor for potential complications Constipation or diarrhea Blockage of esophagus Infection Monitor weight , growth and developmental achievements Imperforate Anus Incomplete development or absence of anus in its normal position in perineum. Assessment Most commonly diagnosed upon Newborn Assessment Symptoms Absence of anorectal canal Failure to pass meconium Presence of anal membrane Treatment Anal stenosis is treated with repeated anal dilation Surgery Omphalocele Gastroschisis Omphalocele Herniation of abdominal contents through the umbilical cord. Contents are covered by a translucent sac. Gastroschisis herniation of abdominal viscera outside the abdominal cavity through a defect in the abdominal wall to the side of the umbilicus. Not covered. Diagnosis Alphafetaoprotein Permit a early diagnosis Ultrasound Pre-op Treatment and Nursing Care Focus is on protection of the contents / sac. Cover with warm, sterile, saline-soaked dressings over the defect. Maintain temperature – esp. with gastroschisis because it is not covered and lose of fluids May choose to replace the gut to the abdomen gradually over several weeks. May place silo or silastic material over gut until it returns to the abdomen. Maintain hydration – start IV (NPO) NG tube to decompress stomach Oomphalocele Repair While the baby is deep asleep and painfree (under general anesthesia) an incision is made to remove the sac membrane. The bowel is examined closely for signs of damage or additional birth defects. Damaged or defective portions are removed and the healthy edges stitched together. A tube is inserted into the stomach (gastrostomy tube) and out through the skin. Gastroschisis Repair Surgical repair of abdominal wall defects involves replacing the abdomen through the abdominal wall defect, repairing the defect if possible, or creating abdominal organs back into the a sterile pouch to protect the intestines while they are gradually pushed back into the abdomen. Post-op Nursing Care Maintaining fluid and electrolyte balance TPN via central venous catheter to provide nutrition while bowel rests and heals Progress to oral feedings once bowel motility occurs Prevent Infection IV antibiotics Assess for Complications Ileus Educate parents Complications Thermoregulation Loss of Fluids Ileus Gastroesophageal Reflux Disease (GERD) The cardiac sphincter and lower portion of the esophagus are weak, allowing regurgitation of gastric contents back into the esophagus. Assessment: Infant Regurgitation almost immediately after each feeding when the infant is laid down Excessive crying, irritability Failure to Thrive Life Threatening Risk / Complications: aspiration pneumonia apnea Assessment: Child Heartburn Abdominal pain Cough, recurrent pneumonia Dysphagia Signs and Symptoms Diagnosis Assess Ph of secretions in esophagus if <7.0 indicates presence of acid Also diagnosed using Barium Swallow and visualization of esophageal abnormalities Management & Nursing Care Small frequent feedings of predigested formula or thicken the formula Frequent burping Positioning –keep upright for 30 minutes after feedings. Use reflux board to keep head elevated. Reflux board Avoid excessive handling after feedings. Medications H2 Histamine receptor antagonists – reduce gastric acidity Zantac and Pepcid Proton-pump inhibitors Prevacid Prilosec Gastric emptying Reglan Antacids Gaviscon **be sure to study nursing implications and side effects Management and Nursing Care If history of apnea, bradycardia, r/t GER—needs continuous cardiac and apnea monitoring. Arrange for CPR teaching for caregivers If infant does not responds to non-invasive therapy, then a Nissen fundoplication may be done to increase the competence of the cardiac sphincter. In a fundoplication, the upper part of the stomach is wrapped around the lower end of the esophagus and stitched in place, reinforcing the closing function of the cardiac sphincter. Post-op Nursing Care Assess for pain, abdominal distention, and return of bowel sounds. Teach parents about gastrostomy tube feedings Diarrhea Infectious Gastroenteritis Diarrhea/Gastroenteritis Severe A disturbance of the intestinal tract that alters motility and absorption and accelerates the excretion of intestinal contents. Most infectious diarrheas in this country are caused by: Giardia – most commonly seen in daycare centers Rotovirus – seen in infants in young children Clinical Manifestations Increase in peristalsis Large volume stools Increase in frequency of stools Nausea, vomiting, cramps Increased heart & resp. rate, decreased tearing and fever Complications: Dehydration Metabolic acidosis Diagnosis Blood Gases Stool for O&P Stool Culture Complications Dehydration Metabolic Acidosis The newborn and infant have a high percentage of body weight comprised of water, especially extracellular fluid, which is lost from the body easily. Note the small stomach size which limits ability to rehydrate quickly. Dehydration Infant Depressed fontanels Sunken eye orbits Fussy, Irritable Thirsty Fewer wet diapers Child Decreased tear production Skin non-elastic Decreased urinary output Thirsty Restless Treatment & Nursing Care Treat cause Fluid and electrolyte balance Weigh daily Monitor I&O Assess for dehydration Isolate Skin care Oral Rehydration Avoid fluids that are high in sugar – soft drinks, jello, fruit drinks, tea Appendicitis Inflammation of the lumen of the appendix which becomes quickly obstructed causing edema, necrosis and pain. Clinical Manifestations Abdominal cramps and pain Fever Guarding Abdominal rigidity Rebound Tenderness Vomiting Elevated WBC - >15,000 Management and Nursing Care: Pre-Op NPO IV Comfort measures – semi-fowlers or R side lying Antibiotics Thermal therapy – ice, not heating pads Elimination Patient education **Narcotic pain medications are used minimally so as not mask the signs of appendicitis. Appendicitis What is the most common symptom indicating that the appendix may have ruptured? Management and Nursing Care: Post-Op NPO Antibiotics Analgesia Patient teaching Pyloric Stenosis The pylorus muscle which is at the distal end of the stomach becomes thickened causing constriction of the pyloric canal between the stomach and the duodenum and obstruction of the gastric outlet of the stomach. Pyloric Stenosis Narrowing of the pyloric spincter Delayed emptying of the stomach Assessment Projectile vomiting Distended Abdomen Hypertrophied pylorus Constant hunger fussiness Visible peristaltic waves Treatment and Nursing Care Treatment: Surgery Pyloromyotomy Post Operative Care: I&O Feeding Feeding begins with clear liquids containing glucose and electrolytes. Regime example: 8 hours NPO, 10cc sterile hater feed X 2. Increase to 15cc X 2, progressing to ½ strength formula, then full strength formula. Observe and record the infant’s response to feeding. Position with head elevated Assess Surgical site to prevent infection Patient teaching Critical Thinking A 4 week old infant with a history of vomiting after feeding has been hospitalized with a tentative diagnosis of pyloric stenosis. Which of these actions is priority for the nurse? Begin an intravenous infusion Measure abdominal circumference Orient family to unit Weigh infant Intussuception Volvulus Both are forms of bowel obstruction Intussuception Most commonly seen in infants 3-12 months Bowel “telescopes” within itself Volvulus A twisting of the bowel that leads to a bowel obstruction. Assessment Intussusception Pain Vomiting Stools – resemble currant jelly, bloody mucus Sausage shape abdominal mass Dehydration Serious complications Shock and sepsis Volvus Pain Bilious vomiting Abdominal distention Tachycardia Therapeutic Intervention Intussuception Hydrostatic Reduction Surgery Volvulus Surgery Nursing Care Following Hydrostatic reduction Clear liquids and diet is advanced gradually Observe for passage of barium and eventually passage of stool If reduction is not successful Surgery Post-op Care Stabilize the child NPO and start IV fluids NG tube to decompress the bowel Pain medications Provide information to the parents Hirschsprung's Disease Hirschsprung’s Disease Congenital disorder of nerve cells in lower colon Assessment * • Failure to pass meconium • Ribbon Like stools * • Vomiting • Reluctance to feed * • Abdominal distention • Foul odor of breath Diagnosis History & Physical Barium enema (X-ray) Rectal biopsy- absence of ganglionic cells in bowel mucosa Management Surgical intervention Colostomy Resection Nursing Care Pre-op Cleanse bowel Patient/parent teaching Post-op NPO Vital Signs – never take a rectal temperature Assessment Patient/parent teaching Colostomy care Skin care Nutrition Lactose intolerance the inability to metabolize lactose, because of a lack of the required enzyme lactase in the digestive system. Lactose Intolerance Manifestations Diarrhea that is frothy, but not fatty Abdominal distention Cramping Abdominal pain Excessive flatus Lactose Intolerance Removal of lactose from the Diet Eliminate – milk, formulas that contain dairy products, ice cream, yogurt, hard cheeses Breastfeeding moms – eliminate lactose from their diet Medications Lactase preparations – Lactaid, Dairy Ease, Lac-Dose Obtain calcium from other sources Celiac Disease inability to digest gliadin which is a by-product of gluten breakdown. Signs and Symptoms The child with celiac disease commonly demonstrates failure to grow and wasting of extremities. The abdomen can appear large due to intestinal distension and malnutrition Complications: Hypocalcemia, osteomalacia, osteoporosis, depression. Treatment and Nursing Care Teach parents DIETARY REGULATIONS: NO ! Gluten Free Diet Wheat Rye Barley Oats