Maternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & FamiliesMaternal-Child Nursing CareMaternal-Child Nursing CareOptimizing Outcomes for Mothers, Children, & FamiliesOptimizing Outcomes for Mothers, Children, & Families

Susan WardSusan WardShelton HisleyShelton HisleySusan WardSusan WardShelton HisleyShelton Hisley

Chapter 25

Caring for a Child with Gastrointestinal Disorders

A & P Review

Gastrointestinal system responsible for: Ingestion Digestion Absorption Metabolism Elimination

Gastrointestinal System

Upper portion is responsible for nutrient intake (ingestion)

Includes: Mouth Esophagus Stomach

Gastrointestinal System Lower portion is responsible for remainder

of digestion, absorption & metabolism Includes:

Small intestine Large intestine Rectum Anus

Gastrointestinal System

Accessory Structures: Liver Gallbladder Pancreas

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

Inguinal Hernia Signs & symptoms:

Painless swelling extending toward or into the scrotum

Complications: Incarcerated (strangulated)

Nursing Care: Surgery (pre-post operative care) Discharge instructions

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:

Rectal atresia (closure) and stenosis (constriction or narrowing of a passage)

Complications: 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 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)

Intussesception Signs & Symptoms:

Acute abdominal pain, currant jelly stools, fever, dehydration, abdominal distention, lethargy and grunting due to pain

Diagnosis: Based on history & presence of sausage-shaped mass

Nursing Care: A barium or air enema/prompt surgical correction Provide information about condition & reassurance to parents Preoperative care (NPO, NG tube, IV fluids, monitor for perforation

or peritonitis & monitor & record stools)

Malrotation and Volvulus Signs & Symptoms:

Most common during first month of life: intermittent bilious vomit, abdominal distention, recurrent pain, palpable epigastric mass, dehydration & lethargy

Complications: Shock (signs include; tachycardia, tachypnea, hypotension & cool,

clammy or cyanotic skin) Nursing Care:

Surgery Preoperative care (hydration, NG tube, IV antibiotics) Postoperative care (see nursing care plan)

Inflammatory Disorders

Irritable Bowel Syndrome (IBS) Signs & Symptoms:

Abdominal pain, flatus, bloating, constipation or diarrhea, “nervous stomach”, muscle spasms when exposed to triggers

Additional Symptoms: Headache, nausea, mucus in stools, anorexia & weight loss

Nursing Care: Dietary; discover triggers Drinking plenty of fluids Promote regular bowel elimination Children taught to share feelings

Inflammatory Bowel Disease (IBD)

Two types Crohn’s Disese Ulcerative Colitis

Crohn’s Disease Signs & Symptoms:

Abdominal pain, diarrhea, anorexia, & weight loss Additional Symptoms:

Growth & sexual delay, arthralgias, arthritis, stomatatis, ulcers, inflammation of the eye, renal stones & rash on shins

Nursing Care: Pharmacologic Nutritional Surgical Emotional support

Ulcerative Colitis Signs & Symptoms:

Abdominal pain, bloody diarrhea, urgency, and tenesmus (spasmodic contraction of the anal sphincter with pain)

Additional Symptoms: Arthritis/arthralgias, oral ulcera, liver inflammation, skin lesions &

rash Nursing Care:

Disease control, remission, preventing relapse & achieving normal growth & lifestyle

Pharmacological, nutritional, surgical & psychosocial management

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 broad-spectrum antibiotics

Meckel Diverticulum 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 Signs & Symptoms:

Poor appetite, straining with stools Additional Symptoms:

Blood may occasionally be seen, tenderness in colon & small intestines, rectal fissures

Nursing Care: Focus: dietary intake, keeping the bowel relatively empty Adequate intake of water Regular diet (fruits & fiber) Stool softeners Chronic constipation may include bowel cleansing, maintenance therapy &

bowel retraining

Encopresis Signs & Symptoms:

Stained underwear, difficult or painful defecation, large and/or hard stools, reports of bloating and/or pain, streaks of bright blood, anorexia, evidence of attempts to retain stool

Diagnosis: Radiography & laboratory test to rule out other causes

Nursing Care: Establish regular bowel habits Dietary monitoring (fiber & water intake) Stool softeners & laxatives are avoided Child & caregiver instructed on the need to establish a routine toileting Management of children with constipation begins with a catharsis phase

followed by a maintenance phase & follow up care Anticipatory guidance, caregiver support & education

Gastroesophageal Reflux (GER) Signs & Symptoms:

Vomiting & regurgitation Additional Symptoms:

Fussy, refuse to feed because of discomfort, choking courting, wheezing apnea, weight loss, respiration infections and vomit

GERD; persists beyond 18 months Nursing Care:

Caregiver support & anticipatory guidance Pharmacological therapy for complications Surgery (Nissen fundoplication)

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)

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 Signs & Symptoms:

Non-specific and include anorexia, irritability, weight loss & listlessness Additional Symptoms:

Classic presentation begins around age 6 months to 2 years as gluten products are introduced into the diet

Nursing Care: Gluten-free diet Caregiver introduced to hidden sources of gluten Assess symptoms, growth and adherence to dies Measurement of transglutaminase (TTG) levels is recommended in

individuals with recurrent or persistent symptoms after initiation of gluten free diet

Short Bowel Syndrome Signs & Symptoms:

Malnutrition & diarrhea Additional Symptoms:

Steatorrhea & carbohydrate malabsorption result in diarrhea and failure to thrive

Nursing Care: Maintain adequate nutrition & prevent complications Total parenteral nutrition (TPN) via central line Enteral feedings via nasogastric or gastrostomy tube 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