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DIGESTIVE DISORDERS IN
CHILDREN
PROF. CGBERCILES, RN MANFOR : BSN 3A & 3D NCM-103 FIRST SEM
20111
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Child's GI SYSTEM
1) High rate of peristalsis (increases susceptibility todiarrhea)
2) IMMATURE gastroesophageal sphincter( prone toGER(achalasia)
3) low production of intestinal antibodies till age 6-7mo
4) inc intestinal permeability to whole CHON e.g.cow's milk ( increased susceptibility to allergies)
5) immature liver (poor drug meta & bilirubin conj)
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CLEFT LIP/CHEILOSCHISIS
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BILATERAL COMPLETE
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CLEFT LIP AND PALATE
MAXILLARY & MEDIAN NASAL PROCESSESnormally fuse b/n 5-8 weeks of intrauterine life
Failure to fuse : a small notch in the upper lip to
total separation of the lip & facial structures up intothe nasal floor, the upper teeth and gingiva absent
Unilateral/bilateral; more boys than girls
due to incomplete fusion of the upper lip noseflattens or expands horizontally
Familial tendency /from transmission of multiplegenes
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CLEFT LIP & PALATE
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CLEFT PALATE
PALATIAL PROCESS closes at approx weeks 9 to12 of intrauterine life
Palate opening (midline) , may involve the anterior
hard palate, post soft palate or both
More common in girls than boys
RESULT of polygenic inheritance or environmental
influences (maternal nutrition, drugs)
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CLEFT PALATE/PALATOSCHISIS
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BILATERAL COMPLETE LIP ANDPALATE
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CLEFT LIP AND PALATE
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ASSESSMENT
SONOGRAM while infant is in utero
At birth, apparent on inspection
Depress tongue with tongue blade; adeqlighting
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ASSOCIATED PROBLEMS
feeding difficulties
middle ear fluid buildup and hearing loss
dental abnormalities speech difficulties.
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Management: CLEFT LIP (interfereswith nutrition)
SURGICAL REPAIR : shortly after birth : time ofinitial hosp stay or b/n 2-10 weeks of age
Early repair: sucking pleasure (infant); parental
bonding easier (psychological)
REVISION may be necessary at age 4-6
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CLEFT PALATE REPAIR
POSTPONED until 6-18 months of age : toallow the anatomic change in the palate contour(1st year of life)
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LOGAN'S BAR: toprotect the lip from
injury; add tape ifloosened/removed
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FEEDING MEASURES: poor suckingand risk for aspiration
CLEFT LIP: SUPPORT in an UPRIGHTPOSITION; feed GENTLY using aCOMMERCIAL CLEFT LIP NIPPLE
SYRINGe
Breast-feeding: 7-10 days postop
CLEFT PALATE: COMMERCIAL CLEFTPALATE NIPPLE with extra flange of rubberto close the palate
Delayed repair : beyond 6 mo of age : soft food
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POSTOP CARE
NPO for 4 hr
Plain water/liquid slowly introduced (p/v vomiting)using a specialized feeder to avoid tension to suture
line (NOT BREAST-/BOTTLE) LIQUIDS : 1st 3-4 days-> soft diet til healing is
complete; NO SPOON***BETTER TO BE ONLIQUID DIET UNTIL SUTURES HEAL
NO MILK: curds tend to adhere to suture line
Clear water p/feeding : rinse suture line, cleanmouth
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RISK : INEFFECTIVE AIRWAYP/REPAIR
LOCAL EDEMA
PREOP (mouth- breather); post-op : nose-breathingcan be difficult ****generally, infants are nose -
breathers SUCTIONING : gentle, DO NOT TOUCH THE
SUTURE LINE WITH THE CATHETER
SIDE-LYING with support : to drain mouthsecretions
SHOULD NOT TURN ONTO THEIR SIDES :tension to suture line
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TEA vs TEF
TEA: failure of the esophagus to develop as acontinuous passage. Instead, it ends as a blindpouch.
TEF:an abnormal opening between the tracheaand esophagus.
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TRACHEOESOPHAGEALATRESIA/FISTULA
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MANIFESTATIONS NB:excessive salivation (drooling) ,choking,
coughing, sneezing.
When fed, NB swallows normally but begins tocough and struggle as the fluid returns throughthe nose and mouth
Cyanosis: result of laryngospasm(protectivemech)
apnea as the overflow of fluid from the blindpouch is aspirated resp distress I
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PRESENTATION
BETWEEN weeks 48 of IUL, theLARYNGOTRACHEAL GROOVE developsinto the LARYNX, TRACHEA & LUNG
TISSUE
ESOPHAGEAL LUMEN FORMS
TERATOGEN does not allow the two organs to
separate
defect arises in 4th fetal week
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ASSESSMENT: IMMEDIATELYAFTER BIRTH
WOMAN WITH HYDRAMNIOS
PRETERM/IMMATURITY
SUSPECT in infant with : Excessive mucus
Difficulty with secretions
Unexplained cyanotic episodes
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DIAGNOSTIC
CATHETER INSERTION
BARIUM XRAY
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COMPLICATIONS
DEATH
PNEUMONIA : salivary aspiration, gastricreflux
Concomitant lesions : heart disease, GIanomalies, renal abnormalities etc
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NSG DIAGNOSES: PREOP
Risk for Aspiration
Risk for Deficient Fluid Volume
Anxiety of parents
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SURGERY
PRIMARY REPAIR if infant weighs >2,000 g
Without pneumonia
STAGING
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POSTOP NSG DIAGNOSES
Ineffective Airway Clearance
Ineffective Infant Feeding Pattern
Acute Pain Impaired Tissue Integrity
Risk for Injury
Risk for impaired parental/infant attachment
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POSTOP CARE FOCUS
AIRWAY : endotracheal tube
DO NOT HYPEREXTEND THE NECK....
MAINTAIN CHEST DRAINAGE : IF BREAKOCCURS... stat: CLAMP tubing CLOSE TOTHE INFANT TO P/V PNEUMOTHORAX
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GASTROESOPHAGEALREFLUX(ACHALASIA)
"failure to relax"
the inability of the LES to open and let foodpass into the stomach
Cause: unknown; autoimmune; infection;heredity
degeneration of esophageal muscles and the
nerves that control the muscles.
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MANIFESTATIONS
DYSPHAGIA (solid/liquid) food sticks(consistent
Heavy chest sensation/chest pain
Regurgitation at night, aspiration->pneumonia
Weight loss
esophagitis
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DIAGNOSTIC EVALUATION
HISTORY
XRAY with Barium ***bird's beak
Esophageal manometry endoscopy
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TREATMENT
PO nitrates, calcium blocking agents
DILATION
ESOPHAGEAL MYOTOMY BOTOX INJECTION
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NSG CARE
HEALTH TEACHING
SLEEP POSITION
FOOD INTAKE
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PYLORIC STENOSIS
infantile hypertrophic pyloric stenosis
Males > females / first born
Genetic predisposition; unknown cause Caucasians with blood type B or O
First few months of life
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MANIFESTATIONS
VOMITING, projectile
Palpable olive mass in epigastrium/ RUQpost feeding/after vomiting
Peristaltic waves to the left
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pathophysiology
Non-bilious vomiting-> hypochloremia whichimpairs the kidney's ability to excretebicarbonate** the significant factor that
prevents correction of the alkalosis. secondary hyperaldosteronism (hypovolemia)--
>Na and water retention, K excretion
Compensatory hypoventilation............pCO2? SEVERE ALKALOSIS: irregular resp rate with
apnea
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treatment
CORRECT acid-base imbalance andhypovolemia
Atr SO4
surgery
PYLOROMYOTOMY/RAMSTEDT
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PYLOROMYOTOMY/RAMSTEDTPROCEDURE: definitive treatment
dividing the muscle of the pylorus to open upthe gastric outlet
a relatively straightforward surgery
single incision (usually 34 cm long) orlaparoscopically (through several tinyincisions), depending on the surgeon's
experience and preference.
HORIZONTAL PYLOROMYOTOMY
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HORIZONTAL PYLOROMYOTOMY(1 MO OLD)
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POSTOP POSITION
PROPPED UPRIGHT, slightly ON THERIGHT SIDE to aid gastric emptying
HIRSCHSPRUNG DISEASE:
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HIRSCHSPRUNG DISEASE:congenital aganglionic megacolon
Due to congenital absence of theparasympathetic ganglion nerve cells fromwithin the muscle wall of the intestinal tract
(distal end of the colon) Male/female ratio 4:1 (long segment 1:1)
Genetic; with associated congenital anomalies
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NORMAL MIGRATION
NORMAL: nerve cells migrate to the upper endof the intes tract caudal direction, withmigration to distal colon complete by 12 weeks
MIGRATION occurs Ist in the intermediatelayer ( AUERBACH'S PLEXUS) SUBMUCOSAL PLEXUS GITract in aDESCENDING MANNER
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ETIOLOGY/PATHOPHYSIOLOGY
ARREST in embryonic development affectingthe migration of PS nerve innervation
AGANGLIONOSIS is continuous with the
affected segment
SHORT-SEGMENT (rectosigmoid colon) *
LONG-SEGMENT ( upper descending,
transverse)
Total agangliosis (rare)
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Pathophy.......
(-) peristalsis in affected segment:spastic/contracted/narrowed---> NO FECALMATTER PASSES
DILATED colon(fecal matter, gas)
Muscular coating HYPERTROPHY
Mucosal ulcerations (neonate)
INTERNAL RECTAL SPHINCTER: (-) relax,
Feces/gas : not evacuated---> abddistention/constipation
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CLIN MANIFESTATIONS: depends
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CLIN MANIFESTATIONS: dependson degree of involvement
NEONATESs/s appear at BIRTH/WITHIN1st weeks of life : (-) MECONIUM 1st 48h;vomiting (bile-stained/fecal); abd distention;
CONSTIPATION; overflow type of diarrhea;dehydration; FFT
TEMPORARY RELIEF with ENEMA
C/ O C
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C/M : OLDER CHILD
Obstipation @ birth; progressive abd distention
Peristaltic activity (observed over abdomen)
(-) RETENTIVE POSTURING: ability tocontract the internal & ext sphinchter topurposefully avoid defecation
Constipation -unresponsive to conventional tx
RIBBON-LIKE, FLUIDLIKE, PELLETSTOOLS
Old hild / ( 'd)
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Older child s/s ......(cont'd)
Failure to grow : loss of subc fat, malnourished,stunted growth
Presentation :
insiduous/catastrophic....(ENTEROCOLITIS)
ENTEROCOLITIS
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ENTEROCOLITIS
SEVERE colitis and a PROLIFERATION ofbacteria in the colonic lumen
Abd distention; explosive diarrhea; vimiting,
fever, lethargy, rectal bleeding, SHOCK
NOTIFY DR STAT
Major cause of DEATH
TREATMENT OF ENTEROCOLITIS
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TREATMENT OF ENTEROCOLITIS
IV/PO Antibiotics
INITIAL EMERGENCY TX: Colonicirrigation & decompression with saline solution
Surgal decompression colostomy
At least, one month after-> abdominal perinealpull-through
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MANAGEMENT
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MANAGEMENT
Colostomy/ileostomy: to decompress intestines,divert fecal stream, rest normal bowel
DEFINITIVE : REMOVE the aganglionic,
nonfunctional, dilated bowel segment->anastomosis and improved functioning of theinternal rectal sphincter(RECONSTRUCTION)...
RECONSTRUCTIVE PROCEDURES
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RECONSTRUCTIVE PROCEDURES
SWANSON : abdominoperineal pull-throughleaving the smallest amt of aganglionic bowelremaining
DUHAMEL: retrorectal transanal pull-throughcreating a NEORECTUM with the aganglionicanterior wall & ganglionic posterior wall
SOAVE : laparoscopic endorectal pull-through;infant age 9-12 mo/ wt reaches 15-20 lb
***NSG ALERT***
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***NSG ALERT***
ANY INFANT WHO FAILS TO PASSMECONIUM WITHIN THE FIRST 24 H ANDREQUIRES REPEATED RECTAL
STIMULATION TO INDUCE BM
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NSG DIAGNOSES: PREOP
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NSG DIAGNOSES: PREOP
Ineffective Breathing Pattern r/2..........?
Imbalanced Nutrition MORE OR LESS? Thanbody requirements r/2........?
Acute Pain r/2 int obstruction
Constipation
IMPROVE BREATHING PATTERN
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IMPROVE BREATHING PATTERN
Monitor for resp imbarrassment: sternalretraction; rapid, shallow resp; cyanosis
Elevate infant's head and chest (mattress-tilt)
Adm O2 as ordered
PAIN RELIEF
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PAIN RELIEF
NOTE drawing up of legs; chest breathing
Abdominal color, gastric waves, abd girth meas
Repeated colonic irrigations with wam NSS
Adm antibiotics as ordered
Rectal tube as ordered; NGT decompression
Maintain comfortable position/soothingstimulation e.g. music, touch, play therapy
PROVIDE ADEQUATE NUTRITION
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PROVIDE ADEQUATE NUTRITION
Small, frequent feeding
LOW-RESIDUE DIET
FEED SLOWLY; upright position
Parenteral nutrition may be needed
INFORM PARENTS THAT DEFECT CANBE CORRECTED
NSG DIAGNOSES POSTOP
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NSG DIAGNOSES POSTOP
RISK FOR INJURY r/2 postoperative course
RISK FOR INFECTION OF SURGICALINCISION
RISK for injury r/2 decreased peristalsis
INEFFECTIVE FAMILY COPING r/2 care ofchild with colostomy
PREVENTING COMPLICATIONS
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PREVENTING COMPLICATIONS
Temp: axillary or tympanic
Assess respiratory status
PLACE CHILD in a LATERAL POSITION ona FLAT/SLIGHTLY ELEV BED ***whenhead of the bed is ELEVATED, the residualCO2 in the child's abd cavity CAUSESREFERRED PAIN IN NECK & SHOULDER
NSG CARE POSTOP (CONT'D)
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NSG CARE POSTOP (CONT D)
NOTHING PER RECTUM SIGN : placed athead of bed
PREVENT WOUND INFECTION
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PREVENT WOUND INFECTION
STERILE technique for dressing change
PREVENT CONTAMINATION FROMDIAPER: apply diaper BELOW DRESSING;
FREQUENT diaper change
Proper hand washing
**7-10 stools/ day CAN BE PASSED;
PREVENT PERIANAL EXCORIATION..
Cont-n....
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Cont n....
ENCOURAGE frequent coughing, deepbreathing
Allow infant TO CRY FOR SHORT pd to
prevent ATELECTASIS
FREQUENT change of position
PREVENT ABD DISTENTION
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PREVENT ABD DISTENTION
MAINTAIN NGT PATENCY : NG suct5ionfor 24-48 h/until BS, gas from rectum/ostomy
Watch for distention : abd girth
Measure fluid loss
MAINTAIN NPO status; freq oral hygiene
Adm fluids and electrolytes as ordered
FOLEY CATH 24-48H
BEGIN ORAL FEEDINGS as ordered
ORAL FEEDING
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AVOID overfeeding
BUBBLE frequently during feeding
TURN HEAD TO SIDE/ELEVATE afterfeeding to PREVENT ASPIRATION
OSTOMY CARE
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CELIAC DISEASE
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