Caring for children with gastrointestinal dysfunction

1
Caring for children with gastrointestinal
dysfunction Chap 17

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• Gastroenteritis(Acute diarrhea)
• Intestinal obstruction--Intussusception
• Congenital defects
• Cleft lip and palate
• Anorectal malformation
• Esophageal atresia Tracheoesophageal fistula
• Hirschsprungs Disease(Megacolon)

2
Anatomy and physiology of pediatric differences

• GI system is immature at birth. P586?1??2?
• Absorption and excretion do not begin until after
  birth
• Sucking reflex
• Not have voluntary control over swallowing
• Stomach
• Stomach capacitysmall
• Frequently regurgitate
• Intestinal
• Peristalsis is greater than older children
• Deficiency of several enzymeamylase, lipase,
  trypsin

3
Anatomy and physiology of pediatric differences

• Liver function is also immature
• Second year of life
• Digestive processes are fairly complete
• Stomach capacity increase
• Excretory function can be achieved

4
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5
Caring for children with gastrointestinal
dysfunction

• Etiology and pathophysiology
• Clinical manifestations
• Diagnostic tests
• Medical management
• Nursing assessment management

6
Gastroenteritis(Acute diarrhea)P617

• Is an inflammation of the stomach and intestines
  ?1?
• Vomiting and diarrhea
• Infants and small children with gastroenteritis
  or diarrhea can quickly become dehydrated and are
  at risk for hypovolemic shock

7
Etiology and pathophysiology (P617?2?)

• Decrease in the absorptive capacity?decrease in
  surface area for absorption?alteration of
  parasympathetic innervation
• High risk-day-care centers?improper sanitation
  (?56?)
• Causes(Table 17-2)

8
Clinical manifestations P617

• Mild
• -Slightly increased in number and more liquid
• Moderate
• -Several loose or watery stools
• -Irritability?anorexia?nausea?vomiting
• -Self-limiting
• Severe
• -Continuous watery stools
• -Fluid and electrolyte imbalance
• -Cramp?extremely irritable?difficult to console

9
Diagnosis clinical therapy??1?

• History
• Physical examination
• Laboratory finding-S/R?S/C
• Presence of ova, parasite, infectious organisms,
  viruses, fat, and undigested sugars.

10
Treatment P618?2?

• Depends on the severity of the diarrhea and fluid
  and
• electrolyte imbalances.
• Goalcorrect the fluid and electrolyte

• Mild to moderate
• -oral rehydration therapy ( Contain water,
  carbohydrate, sodium, potassium, chloride and
  lactate P315 )
• -Carbonated beverages and those containing high
  amounts of sugar should not be given
• Severe
• -IV(N/S with glucose?one half or one quarter
  normal
• saline? or L/R)?3?
• -NPO
• -Antiemetics and antidiarrheals should generally
  not be used in
• infants and young children. P618??
• Lactose-free milk, breast milk, half-strength
  milk P315???4?

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Nursing assessment P618

• Frequency, color, amount and consistency of
  stools?4?
• The amount and type of vomitus
• Observing dehydration
• Urine output and specific gravity
• Weight
• Vital signs ( Febrile )
• Skin integrity

12
Nursing diagnosis management P619

• Anxiety
• Provide Emotional support
• Sleep pattern disturbance
• ?????
• Promote rest and comfort
• Altered nutrition
• Ensure adequate nutrition
• CRAM (Complex carbohydrates, Rice and Milk )
  P619??
• Diarrhea related to infectious process P620
• Fluid volume deficit P620
• Risk for impaired skin integrityP621

13
Dehydration Chap 10 --P313

• There is not enough fluid in the extracellular
  compartment.
• The state of body water deficit is called
  dehydration.
• Sodium is generally lost along with water ?
  hyponatremia

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Etiology and pathophysiology

• Causes P313 ?1??2?
• Loss of fluid containing sodium are
  vomiting?diarrhea?nasogastric suction?hemorrhage
  and burns
• Radiant warmers ?2??2?
• Adrenal insufficiency and overuse of diuretics
• Bulimic adolescents

15

• Blood urea nitrogengt25mg/dL
  clinical therapy?1??3?
• Serum bicarbonategt17mEq/L

16
Medical management P315
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• Oral rehydration therapy-mild and moderate
  dehydration
• Contain water, carbohydrate, sodium, potassium,
  chloride and lactate
• Lactose-free milk, breast milk, half-strength
  milk ???4?
• IV-severely P316?1?
• L/R, one half or one quarter normal saline

17
Nursing assessment

• Weight
• I/O
• Urine specific gravity
• Consciousness
• Pulse rate and quality
• Skin turgor and mucous membrane moisture
• Respiration
• Blood pressure

18
Nursing management

• Provide oral rehydration therapy guidelines
• Teach parents oral rehydration methods
• Monitor intravenous fluid administration
• Discharge planning and home care teaching

19
Intussusception P602

• Etiology and pathophysiology ?1?
• One portion of the intestine prolapses and then
  invaginates(??) or telescopes (???) into
  another.?1?
• One of the most frequent causes of intestinal
  obstruction during infant
• Between the age of 3 months and 6 years
• Siteileocecal valve ?2?
• Telescoping of the Intestine obstructs the
  passage of stool.
• The walls of intestine rub together
• ? inflammation?edema?decreased blood flow
• ? necrosis?perforation?hemorrhage? peritonitis
• In infant, intussusception is commonly associated
  with measles, viral disease, and gastroenteritis
  syndromes. P603 Fig17-7

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Clinical manifestations P603?2?

• Onset is abrupt
• Acute abdominal pain(periods of comfort between
  acute episodes of pain)
• Vomiting
• Passage of brown stool?become red and resemble
  currant jelly
• A palpable mass may be present in the upper right
  quadrant or mid-upper abdomen
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• ??????(Dance??)

21
Diagnosis P603?2?

• History
• Radiographs and ultrasound of the abdomen
• Barium enema

22
Treatment P603?3?

• Hydrostatic pressureBarium enema
• Oxygen(air)?saline?aqueous contrast material
• Surgery
• Supportive care
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• ???

23
Nursing management

• Maintain fluid and electrolyte balance
• Post OP
• Monitoring for early signs of infection
• Pain management
• Maintain NG tube patency
• Assess vital signs?Abdominal distention?Listen
  for bowel sounds every 4 hours
• After normal bowel function
• Clear liquid feeding? half- strength milk and
  other foods

24
Cleft lip and palate P586

• More common in Native Americans and Asian
  P586??1?
• Etiology and pathophysiology P594
• A failure of the maxillary processes of fuse with
  the elevations on the frontal prominence during
  the sixth weeks of gestation.
• Hard and soft palates is completed in the first
  trimester.
• Congenital defectstracheoesophageal
  fistula,omphalocele,trisomy 13,skeletal
  dysplasias
• Causemultifactorial(environmental and genetic
  influences)

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Clinical manifestation P587

• Cleft lip
• Unilateral or bilateral
• Alone or in combination with a cleft palate
  defect
• Nasal deformity
• Cleft palate
• Less obvious
• A continuous opening between the mouth and nasal
  cavity
• Soft palate or both the soft and hard palate
• Unilateral or bilateral

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Clinical manifestation---?

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Diagnostic tests and medical management P588

• Physiologic assessment ?1?
• Medical managementmultidisciplinary team(plastic
  surgery?hearing?speech?dentistry)
• Clef lip
• 2-3months of age ?2?
• Logan bow or other stabilizing device or dressing
  is put in place.
• Crying is minimized by use of medication.
• Clef palate
• Depends on the size and severity of the cleft.
• 18 months
• Longer nipples with enlarged holes(before
  surgical)
• Antibiotic therapyrecurrent otitis media
• Orthodontic care
• ????

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Nursing assessment

• Physiologic assessment
• Observable
• Palpation
• Psychosocial assessmentlow self-esteem
• Familys reaction
• Low self-esteem
• Developmental level and social interactions

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Nursing management

• 1.Risk for aspiration
• 2.Provide emotional support
• Explaining the cause
• Interact and speak to the infant
• Point out positive attributes
• Self-blame
• Anxiety
• 3.Altered nutrition

Preoperative care P590
1.Risk for infection 2.Ineffective
breathing pattern related to anesthesia and
increased secretions 3. Impaired tissue
integrity 4. Knowledge deficit 5. Altered
nutrition
Postoperative care P592
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Care in the community
Nursing management

• Feeding techniques
• Recognize signs of infection and complications
  (fever, vomiting, respiratory distress)
• How to position the infant
• How to care the suture line
• Preparation of the sibling
• Support groups
• Prevent the infant from touching the suture line

31
Anorectal malformation ( Imperforate anus ) P604

• Etiology and pathophysiology
• Malformations of the anus and rectum.
• Often associated with anomaliesurinary tract,
  esophagus, and duodenum.
• VACTER Syndrome

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Clinical manifestations
Diagnosis

• Failure to pass meconium
• Stool in the urine
• Ribbonlike stools
• ?????

• Assessment anorectal structure and rectal patency
• Ultrasound
• Lower GI
• PA CXR
• ??3???x-ray
• ????

33
Medical management

• Dilation
• ??-Excised surgery,then daily manual dilation
• ??-Reconstructive surgery (Posterior Sagittal
  AnorectoplasyPSARP )?temporary
  colostomy?????????

34
Nursing management

• Assessment
• Developed anal dimple or sacral anomalies
• Rectal thermometer
• Observation and recording of passage of meconium

35
Managemen
Preoperation
Postoperation

• Preventing infection
• Respiratory complication
• Maintaining hydration
• Assess vital signs
• If stable?try feeding
• Colostomy care
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• IV fluids
• NG decompression
• Monitor I/O
• Monitor cardiorespiratory function
• ????
• Emotion support

36
Discharge planning and home care teaching

• How to take the infants temperature
• Signs and symptoms of infection
• Feeding
• Toilet training
• Assess vital signs
• If a colonstomy
• How to care
• Reassure the colostomy will be closed
• Follow-up
• Home care visits

37
Esophageal atresia Tracheoesophageal fistula
P595

• Etiology and pathophysiology
• Failure of the esophagus to develop as a
  continuous tube during the fourth and fifth weeks
  of gestation. ?1?
• The foregut fails to lengthen, separate, and fuse
  into two parallel tubes during fetal development.
  ?2?
• End in a blind pouch or develop as a pouch
  connect to the trachea by a fistula.

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• Maternal historypolyhydramnios?prematurity?low
  birth weight
• Associated anomalies ?2??5?
• Congenital heart defects
• Gastrointestinal or urinary tract anomalies
• Musculoskeletal abnormalities

• VACTERLvertebral?anus?cardia?trachea?esophageal?r
  enal?limb

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Clinical manifestation ?3?

• Excessive salivation and drooling
• 3C(coughing, choking, cyanosis)and sneezing
• Returns fluid through the nose and
  mouth?pneumonia
• Abdomen become distended
• Vomiting soon after feeding

40
Diagnosis ?4?

• Nasogastric tube meets resistance and can be
  advanced only minimally.
• X-ray(air pouch?NG coiling?pneumonia?distended
  stomach intestine-???fistula)
• Echocardiogram(2D echo)and abdominal
  ultrasound(Renal echo) P596

41
Treatment P596?2?

• OG suction
• Antibiotics
• Fluids
• Surgeryseveral stages
• Ligation of the fistula and insertion of a
  gastrostomy tube
• Reconnect the two ends of the esophagus(anastomosi
  s)
• Potential postoperative complications
• Gastroesophageal reflux?aspiration?stricture
  formation?esophageal motor dysfunction

42
Nursing management
Preoperation

• Maintain a patent airway
• Suction-(continuous or low intermittent)
• Place the head of the bed slightly lowered
• Continuous or low intermittent suction is used to
  remove secretions from the blind pouch.
• Change position
• NPO
• Maintain with intravenous fluids administered
  through an umbilical vein catheter.

43
Postoperation

• Gastrostomy drainage
• IV fluids and antibiotics
• TPN
• Maintain a patent airway
• Emotional support for parent
• Discharge planning
• Gastrostomy tube care and feeding?signs of
  infection?prevent postoperative complications.
  P598 families want to known

44
Megacolon(Hirschsprung Disease) P603
Etiology and pathophysiology

• Congenital aganglionic megacoloninadequate
  motility causes mechanical obstruction
• Absence of autonomic parasympathetic ganglion
  cells in the colon? accumulation of intestinal
  contents and abdominal distention
• Combination with congential heart defects?Down
  syndrome?Imperforate anus
• More common in boys
• It can be acute or chronic

45
Clinical manifestations P604?2?
Newborn
Older child

• Failure to gain weight and delayed growth
  ?3?
• Abdominal distention
• Constipation alternating
• with diarrhea
• Vomiting
• Stool may be normal or
• ribbonlike

• Failure to pass meconium
• Refusal to suck
• Abdominal distention
• Bile-stained emesis
• ? complete obstruction, respiratory distress, and
  shock

46
Diagnosis

• History
• Bowel pattern
• Anorectal manometry
• Radiographic contrast studies
• Rectal biopsy
• Palpation

47
Treatment

• Newbornsurgery
• Several cases or ill infants temporary colostomy
  ? closure of the colostomy and
  reanastomosis(Soave procedure)
• Child with milder defectdietary
  modification?stool softeners?isotonic irrigations

48
Complication P604?7?

• Fecal incontinence and constipation
• Enterocolitis
• GI bleeding and diarrhea?ischemia and ulceration
• TPN
• Lactose-free diet

49
Nursing management Assessment
?1?

• Observation for the passage of meconium
• History of weight gain
• Nutritional intake
• Bowel habit

50
Management

• Monitoring fluid and electrolyte balance
• Maintain nutrition
• Teach parents how to ensure regular bowel
  movements
• Daily rectal irrigations
• Prevent skin breakdown
• Surgery
• Monitoring for infection
• Managing pain
• Maintain hydration
• Measuring abdominal circumference
• Emotion support
• Teach parent about-Ostomy care?signs of
  complications ? Be alter for signs of poor growth
  or malnutrition