Ch 24 The Child with

Gastrointestinal Dysfunction

Laura Salisbury RN, MSN/Ed.

Clinical Manifestations of GI Dysfunction Failure to thrive Spitting up / Regurgitation Nausea, vomiting, diarrhea, constipation Abdominal Pain, Distention, GI bleeding Jaundice Dysphagia Hypoactive, hyperactive or absent bowel

sounds

Dehydration Types of dehydration

Isotonic: most common, water and salt both lost, signs of hypovolemic shock are seen

Hypotonic: More electrolytes lost than water; signs are seen with less severe losses

Hypertonic: More water lost than electrolytes: MOST DANGEROUS Seen if infants are given fluids w/too much solute Seen w/high-protein NG tube feedings—too much solute in

kidneys Shock less apparent; neuro signs seen

Diagnostic evaluation: KNOW table 24-1, p. 816

Daily Maintenance Fluid Requirements 1. Calculate weight in kilograms

Wt of child in pounds/ 2.2 kg = wt in kg 2. Allow 100 mL for first 10 kg 3. Allow 50 mL for second 10 kg 4. Allow 20 mL for all remaining kg 5. Divide total amount by 24 hours to obtain

rate of fluid replacement in mL per hour

Pg 815

Diarrhea Often classified by location

Gastroenteritis, Enteritis, Colitis, Enterocolitis Types of Diarrhea

Acute Acute infectious/infectious gastroenteritis

Most typical, Usually subsides on its own Can be from antibiotic administration/c. difficile

Chronic More than 14 days Can be chronic condition OR inadequately treated acute diarrhea

Intractable diarrhea of infancy Usually infectious diarrhea not managed adequately

Chronic nonspecific diarrhea (CNSD)

Diarrhea Diagnostic evaluations Therapeutic management

Assess fluids and electrolytes Rehydrate

Oral Rehydration Solution (ORS)=Pedialyte Give maintenance fluid

Breastfeed, water, ½ strength formula, ORS Reintroduce diet

Regular diet NO BRAT diet

Nursing considerations SEVERE dehydration: IV fluids first

Prevention of Diarrhea Most diarrhea is spread by the fecal-oral route Teach personal hygiene Clean water supply/protect from contamination Careful food preparation Handwashing

Constipation An alteration in frequency/consistency/ease of passage of stool Idiopathic (functional) constipation/Chronic constipation

Majority of cases - Could be environment, psychology, or both Newborn Period

First meconium should be passed within 24-36 hrs of life Meconium ileus=cystic fibrosis

Infancy Constipation in exclusively breastfed infant almost unknown

Infrequent stool may occur from minimal residue in digested breastmilk

Formula fed infants may develop constipation Small amount of corn syrup may solve problem

Constipation 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)

Hirschsprung Disease AKA congenital aganglionic megacolon Mechanical obstruction from inadequate

motility of intestine More common in males and in Down syndrome Clinical Manifestations of Hirschprung

Accumulation of stool with distention Diagnostic Evaluation

X-ray, barium enema, Confirm diagnosis with rectal biopsy

Therapeutic Management Surgery

Hirschsprung Disease Nursing Considerations

Pre-operative care Watch abdominal distention, Education re: colostomy

Postoperative care Be careful about contamination of wound with urine

Discharge care Colostomy care instructions

Small children -involved in care Adolescents may feel more

stressed r/t image of colostomy

Vomiting Therapeutic management

Detect and treat cause Prevent complications from loss of fluids

Nursing considerations Start w/small amounts fluid

Include carbohydrates IV fluid for severe dehydration When vomiting stops: give more fluids and resume

normal diet

Gastroesophageal Reflux Definition: GER and GERD

KNOW box 24-6, p 827; clinical manifestations and complications of GER

Diagnostics Monitor esophageal pH for 24 hours

Therapeutic management Depends on severity Thicken feedings for infants Take foods out of diet that exacerbate reflux Upright/elevated position after feedings Meds as need (H2 antagonists, Proton pump inhibitors) Surgery for most severe: Nissen fundiplication

Functional Abdominal Pain Includes irritable bowel syndrome, abdominal

migraine Episodes of severe abdominal pain Multifactorial etiology Management: alleviate symptoms

May need to use tricyclic antidepressants, SSRI’s, sometimes smooth muscle relaxant, fiber for IBS, anti-migraine for abdominal migraines, manage diet

VALIDATE SYMPTOMS Pain is real!

Acute Appendicitis Etiology and pathophysiology

Obstruction of lumen of appendix—leads to infection Diagnostic evaluation

Difficult to diagnosis KNOW box 24-7, p 830: symptoms Watch for sudden relief from pain (possible perforation)

Therapeutic management Appendectomy; laparoscopic if not ruptured

Nursing considerations If suspected appy: no laxative/enema or heat to area (do

not want to stimulate bowel motility)

Meckel Diverticulum It is the most common congenital malformation

of the GI tract Diagnostic evaluation

Complications=bleeding, obstruction, intussusceptions, diverticulitis, perforation

Most common presentation: painless rectal bleeding, abdominal pain (KNOW box 24-8, p 833)

Therapeutic management=surgery Nursing considerations

Watch for shock from hemorrhage

Inflammatory Bowel Disease IBD Includes ulcerative colitis (UC)

and Crohn’s disease (CD) KNOW the following

Clinical manifestations: TABLE 24-3, p 833 For pediatrics: Growth problems major issue; want

to promote growth and development

Acute Hepatitis ONLY need to know table 24-4 Types of hepatitis How transmitted Clinical features How immunized

Biliary Atresia AKA extrahepatic biliary atresia --Destruction of biliary tree Etiology and pathophysiology

Postnatal: happens early in life Fetal: before birth

Diagnostic evaluation KNOW box 24-10 p. 842- Jaundice, urine, stool, liver, spleen, metabolism,

failure to thrive, pruritus, irritability Therapeutic management

Kasai procedure: “band-aid”; cirrhosis will still occur Most will need liver transplant

Can come from parents Prognosis

Death before age two if not treated Liver failure even post-Kasai Early diagnosis key for survival

Cleft Lip- Cleft Palate Facial malformations that occur during

embryonic development May appear separately or together

Cleft Lip / Cleft Palate Surgical Correction of Cleft Lip

Closure of lip defect precedes correction of the palate Z-plasty to minimize retraction of scar Protect suture line with Logan bow or other methods Arm restraints: take off periodically

Surgical Correction of Cleft Palate Typically 12-18 months of age

Want to minimize effect on speech development Prognosis

Usually good, speech may still be affected May have recurrent OM

MANAGE AIRWAY!!!

Cleft Lip / Cleft Palate Cleft Lip and Palate Feeding

Techniques and interventions: ESSR Enlarge nipple Stimulate suck reflex Swallow fluid Rest when infant signals

Special feeding equipment Breck feeder

Breastfeeding issues Infants with CL/CP CAN BREASTFEED!

Esophagel AtresiaTracheoesophageal Fistula

Failure of esophagus to develop as a continuous passage May occur separately or in combination If suspected: infant NPO, suction setup nearby “3 C’s”: Coughing, Choking, Cyanosis (AIRWAY!!!)

Management of TEF

Surgical interventions Prognosis: depends on extent of defects Associated tracheomalacia (weakness in tracheal wall) Nursing considerations:

Keep infant from losing suck reflex

Hernias Definition: a protrusion of portion of an organ

through an abnormal opening Danger of incarceration/strangulation Pediatric Hernias

Diaphragmatic Hiatal Umbilical/abdominal wall defects

Omphalocele Gastrochisis

KNOW table 24-5, p 850

Pyloric Stenosis Constriction of pyloric sphincter with

obstruction of gastric outlet Clinical Manifestations

Projectile vomiting, Chronic Hunger, weight loss, dehydration, abdominal distention

Surgical intervention is required Preoperative: fix fluid/electrolyte imbalances Postoperative: Vomiting, dehydration,

maintain fluid and electrolyte balance

Intussusception Telescoping/ invagination of one part of intestine into another Occasionally due to intestinal lesions Often cause is unknown Clinical Manifestations

Sudden acute abdominal pain Child screaming and drawing knees to chest Child appears normal and comfortable between episodes of pain Vomiting Lethargy Passage of RED, currant jelly like stool

(mixed with blood and mucus) Sudden passage of normal stool:

intussusception has spontaneously resolved!

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

Anorectal Malformations Imperforate anus Persistent cloaca Cloacal exstrophy

Malabsorption Syndromes Characterized by chronic diarrhea and

malabsorption of nutrients May result in failure to thrive Digestive defects Absorptive defects Anatomic defects

Celiac Disease AKA gluten-induced enteropathy and

celiac sprue Four characteristics

Steatorrhea General malnutrition Abdominal distention Secondary vitamin deficiencies

Gluten-free diet Family support

Short Bowel Syndrome A malabsorptive disorder Decreased surface area in small intestine Need to maintain growth

May need long-term TPN Watch for bacterial overgrowth

Intestinal transplantation may be possible