THE CHILD WITH GASTROINTESTINAL DYSFUNCTION

Chapter 25

Christine Limann Dyer, RN, MSN, CPN

GASTROINTESTINAL SYSTEM

Upper portion is responsible for nutrient intake (ingestion)

Includes: Mouth Esophagus Stomach

DIGESTION

Required to convert nutrients into usable energy

Performs excretory function and detoxification

Mechanical digestion Chemical digestion

GASTROINTESTINAL SYSTEM Lower portion is responsible for remainder of

digestion, absorption & metabolism Includes:

Small intestine Large intestine Rectum Anus

ABSORPTION

Principally from small intestine Osmosis Carrier-mediated diffusion Active energy-driven transport (“pump”)

Large intestine Absorption of water Absorption of sodium Role of colonic bacteria

GASTROINTESTINAL SYSTEM

Accessory Structures: Liver Gallbladder Pancreas

INGESTION OF FOREIGN SUBSTANCES

Pica Food picas Nonfood picas

Foreign bodies Nursing

considerations

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

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

CONSTRICTION OF THE PYLORIC SPHINCTER WITH OBSTRUCTION OF THE GASTRIC OUTLET

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)

INTUSSUSCEPTION Telescoping or invagination of one portion of

intestine into another Signs & Symptoms:

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

Diagnostic evaluation Therapeutic management Prognosis Nursing considerations

ILEOCOLIC INTUSSUSCEPTION

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

Complications: Shock (signs include; tachycardia,

tachypnea, hypotension & cool, clammy or cyanotic skin)

INFLAMMATORY DISORDERS

IRRITABLE BOWEL SYNDROME (IBS)

Identified as cause of recurrent abdominal pain in children

Classified as a functional GI disorder

Alternating diarrhea and constipation

Therapeutic management

Nursing considerations

INFLAMMATORY BOWEL DISEASE (IBD) Two types

Crohn’s Disese Ulcerative Colitis

ULCERATIVE COLITIS (UC)

Pathophysiology –inflamation in colon and rectum

Clinical manifestations – ulceration, bleeding, anorexia, anemia

CROHN’S DISEASE

Pathophysiology-Crohn's disease is an inflammatory bowel disease (IBD)

Clinical manifestations-abdominal pain, severe diarrhea and even malnutrition

Extraintestinal manifestations-arthritis, skin problems, fever, anemia

Therapeutic management Medical- corticosteriods,

Remicade for remission, 6-MP

Surgical Nursing considerations – nutritional support,

education

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 Most common congenital

malformation of the GI tract Band connecting small intestine to

umbilicus 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 conditionsManagement 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 needsPharmacology treatment not orderedIV 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 intakeCaregiver 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 evaluationCalm stress-free environment

CONSTIPATION

An alteration in the frequency, consistency, or ease of passage of stool

May be secondary to other disorders

Idiopathic (functional) constipation—no known cause

Chronic constipation—may be due to environmental or psychosocial factors

NEWBORN PERIOD

First meconium should be passed within 24 to 36 hours of life; if not assess for: Hirschsprung disease, hypothyroidism Meconium plug, meconium ileus (CF)

INFANCY

Often related to diet Constipation in exclusively breastfed infant

almost unknown Infrequent stool may occur because of minimal

residue from digested breast milk Formula-fed infants may develop

constipation Interventions

- adding cereals, fruits and vegetables may help

(after 4 months)

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 CONSIDERATIONSHistory of bowel patterns, medications, diet

Educate parents and child

Dietary modifications (age appropriate)

2 week old Joey is brought into the clinic by his mom because he hasn’t had a bowel movement in two days. He is not eating and has abdominal distention. She states that he didn’t pass meconium until the day after his birth.

1. Describe the structural anomaly associated with Hirshbrung’s disease.2. How is Hirshbrung’s diagnosed?3. List 2 actual NANDA and 1 risk4. If Joey is diagnosed with Hirsbrung’s Disease, what is the likely surgical intervention?5. What are possible complications for an older child?

Case Study

HIRSCHSPRUNG DISEASE

Also called congenital aganglionic megacolon

Mechanical obstruction from inadequate motility of intestine

Incidence: 1 in 5000 live births; more common in males and in Down syndrome

Absence of ganglion cells in colon

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)

CLINICAL MANIFESTATIONS OF HIRSCHPRUNG DISEASE

Aganglionic segment usually includes the rectum and proximal colon

Accumulation of stool with distention

Failure of internal anal sphincter to relax

Enterocolitis may occur

DIAGNOSTIC EVALUATION

X-ray, barium enema Anorectal manometric exam Confirm diagnosis with rectal biopsy

THERAPEUTIC MANAGEMENT

Surgery Two stages

Temporary ostomy Second stage “pull-through”

procedure

Preoperative carePostoperative careDischarge care

GASTROESOPHAGEAL REFLUX (GER)

Defined as transfer of gastric contents into the esophagus

Occurs in everyone Frequency and persistency may make it

abnormal May occur without GERD GERD may occur without regurgitation

GER

Diagnostics Therapeutic management Nursing considerations

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

Also called gluten-induced enteropathy and celiac sprue

Four characteristics Steatorrhea-fatty stool General malnutrition Abdominal distention Secondary vitamin deficiencies

CELIAC DISEASE (CONT.)

Pathophysiology Diagnostic evaluation Therapeutic management Nursing considerations

SHORT BOWEL SYNDROME (SBS) A malabsorptive disorder Results from decreased

mucosal surface area, usually as result of small bowel resection

Etiology and pathophysiology

Result of decreased mucosal surface area, usually due to extensive resection of small intestine

Other causes NEC, volvulus, gastroschisis,

Crohn disease in

THERAPEUTIC MANAGEMENT OF SBS

Nutritional support—first phase: TPN Associated risks and complications

Second phase: enteral feeding Long-term maintenance Medical therapies Surgical therapies Nursing Care:

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 supportLiver transplantMonitor for complicationsComfort 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

DEHYDRATION

Types of dehydration Diagnostic evaluation Therapeutic management Nursing considerations

1st treatment- Oral hydration Solution-OHS

DAILY MAINTENANCE FLUID REQUIREMENTS

Calculate child’s weight in kg Allow 100 ml/kg for first 10 kg body weight Allow 50 ml/kg for second 10 kg body weight Allow 20 ml/kg for remaining body weight

EXAMPLE 1: DAILY FLUID CALCULATION

Child weighs 32 kg 100 x 10 for first 10 kg of body weight = 1000 50 x 10 for second 10 kg of body weight = 500 20 x 12 for remaining body weight = 240 1000 + 500 + 240 = 1740 ml/24 hr

EXAMPLE 2: DAILY FLUID CALCULATION

Child weighs 8.5 kg 100 x 8.5 for first 10 kg of body weight = 850 No further calculations 850 ml/24 hr

EXAMPLE 3: DAILY FLUID CALCULATION

Child weighs 14 kg 100 x 10 for first 10 kg of body weight = 1000 50 x 4 for second 10 kg of body weight = 200 No further calculations 1000 + 200 = 1200 ml/24 hr

HOMEMADE ELECTROLYTE SOLUTION

2 quarts water 1 teaspoon baking

soda 1 teaspoon salt 7 Tablespoons sugar 1/2 teaspoon salt

substitute