ATI Pedi Book Ch 23 More GI disorders

A nurse is providing preoperative teaching to the parent of a child who is scheduled for initial surgery to treat Hirschsprung's disease. The nurse should recognize that the parent understands the goal of the surgery when the parent says which of the following? 1) "I'm glad that the ostomy is only temporary." 2) "I'm glad my child will have normal bowel movements now." 3) "I want to learn how to use the feeding tube as soon as possible." 4) "I want to learn how to use the urinary catheter as soon as possible."

1) "I'm glad that the ostomy is only temporary." Answer Rationale: Hirschsprung's disease is also known as aganglionic megacolon and is characterized by an area of the large intestine without nerve innervation. The child will probably require two surgeries over a 1 1/2- to 2-year period before normal bowel function is obtained. The initial surgery is creation of an ostomy, which relieves the obstructed area and allows the bowel distal to the ostomy to rest.****

A parent tells a nurse that his 2-month-old infant was well until 2 weeks ago, when the infant began spitting up after eating. "Now the vomit practically shoots across the room. After my baby vomits, she cries and acts very hungry." The appropriate response is: 1) "You should bring your infant in to the clinic today to be seen." 2) "You need to burp your baby more frequently during feedings." 3) "You should give your infant an oral rehydrating solution." 4) "You might want to try switching to a different formula."

1) "You should bring your infant in to the clinic today to be seen." Answer Rationale: The symptoms of worsening projectile vomiting, which began at about 6 weeks of age, and the child acting hungry afterward, are characteristic of pyloric stenosis. The baby needs to be examined in the clinic by the provider as soon as possible.****

Average age for appendicitis

10 years.

Diagnostic procedures for GERD

24-hour esophageal pH study to measure amount of acid reflux into esophagus.**** Upper GI to detect GI structural abnormalities. Endoscopy with biopsy to detect esophagitis and strictures. Scinitgraphy to identify cause of gastric content aspiration.

Manifestations of appendicitis

Abdominal pain. Tachycardia. Decreased or absent bowel sounds.**** Rigid abdomen. Fever. Diarrhea or constipation. Lethargy. Rapid shallow breathing. Anorexia. Possible vomiting.

Diagnostic procedure for intussusception

Abdominal ultrasound.

Preoperative nursing care for appendectomy

Administer IV fluids and antibiotics. For open procedure, place NG.

Ages when intussusception is common

Ages 3 months to 3 years.****

Therapeutic procedure for intussusception

Air enema with or without contrast, performed by radiologist.

Inflammatory GI disorders

Appendicitis, Meckel diverticulum.

Nursing actions for peritonitis

Assess for peritonitis. Assess for pain. Pain management as prescribed. IV fluids. IV antibiotics. NG to suction. Provide preop and postop care. Surgical wound care with irrigation and/or dressing changes if delayed closure is necessary. Psychosocial support. Educate family about preop care such as need for NPO status and pain medication. Educate about postop care: Early ambulation, advancement of diet, wound care, monitoring for infection.

Postoperative nursing care for Hirschsprung disease surgery

Assess respiratory status and maintain airway. O2 as prescribed. Vital signs. Analgesics as prescribed. Assess surgical site for bleeding, other problems. Foley catheter care. Assess bowel sounds and function. Ostomy care as needed. Appropriate referrals. Teach family ostomy care if needed. Teach incision care and signs of infection. Teach manifestations of dehydration.

Postoperative nursing care for Meckel diverticulum

Assess respiratory status and maintain airway. Supplemental O2 as prescribed. Vital signs. Analgesics for pain. Assess surgical site for bleeding or other problems. Assess bowel sounds and function. IV fluids and antibiotics. NPO status. NG to low continuous suction. Teach family manifestations of infection.

Postoperative nursing care for appendectomy

Assess respiratory status and maintain airway. Supplemental O2 as prescribed. Vital signs. Angalgesics for pain. Assess site for bleeding and other problems. Assess bowel sounds and function. Also, for open procedure: NPO. NG to low continuous suction. Wound care to site with antibacterial or saline solution as prescribed. Penrose drain care. Assess for peritonitis. Teach family incision care and manifestations of infection.

Preoperative nursing care for Meckel diverticulum

Blood transfusions to correct hypovolemia. Fluid and electrolyte replacement. O2 as prescribed. IV antibiotics. Bedrest. Monitor blood loss in stools.

Nursing actions for anal stricture related to Hirschsprung disease

Bowel retraining therapy. May require procedure like dilatation.

Lab tests for Hirschsprung disease

CBC and electrolytes.

Lab tests for appendicitis

CBC, urinalysis.

Lab test for Meckel diverticulum

CBC.

Diagnostic procedure for appendicitis

CT: Enlarged diameter of appendix and thickening of appendiceal wall.****

Foods that cause gastroesophageal reflux

Caffeine, citrus, peppermint, spicy food, fried food.****

Postoperative care of infant with cleft palate repair

Change position frequently to facilitate breathing. May be placed on abdomen immediately post-op. IV fluids until able to eat and drink. Monitor packing, which is usually removed in 2-3 days. Avoid placing objects like tongue depressor or pacifier in mouth. May need elbow restraints to avoid injury to site.

Acceptable positions for child who is post-op for cleft palate repair

Change the infant's position frequently to facilitate breathing. The infant may be placed on the abdomen in the immediate postoperative period because, unlike cleft lip, the surgical site is inside the mouth. Lying on face will not cause damage.****

Bronchopulmonary dysplasia

Chronic lung disease that starts in newborns and is caused by damage from mechanical ventilation and high O2 flow.

Structural GI disorders

Cleft lip and palate, GERD, hypertrophic pyloric stenosis, Hirschsprung disease, intussusception.

Meckel diverticulum

Complication resulting from failure of omphalomesenteric duct to fuse during embryonic development. Congenital pouch on part of intestine.

Risk factor for intussusception

Cystic fibrosis.

Complications of cleft palate

Ear infections and hearing loss related to altered structure and recurrent infections. Speech and language impairment, more common with cleft palate. Dental problems: Teeth may not erupt normally and orthodontia is usually necessary later. Also may develop food aversions because of pain after surgery. Could intervene by referring to behaviorist.****

Strategies for feeding infant with isolated cleft lip

Encourage breast feeding. Use wide-based nipple for bottle feeding. Squeeze infant's cheeks together during feeding to decrease gap.

Complications of Hirschsprung disease

Enterocolitis: Inflammation of bowel. Anal stricture and incontinence.

Nursing actions for complications of GERD

Evaluate treatment plan. Monitor for pneumonia and failure to thrive. Reinforce plan of care with family. Teach parents manifestations of pneumonia.

Subjective and objective data for GERD in infants

Excessive spitting up or forceful vomiting, inability to keep food down, failure to thrive.**** Irritability, excessive crying, blood in stool or vomitus, arching of back, stiffening. Respiratory problems, apnea.

Manifestations of Hirschsprung disease in newborn

Failure to pass meconium within 24-48 hours of birth. Vomiting bile. Refusal to eat. Abdominal distention.****

Manifestations of Hirschsprung disease in children

Failure to thrive. Abdominal distention. Severe constipation. Foul-smelling ribbon-like stool from stool oozing around obstruction.**** Visible peristalsis. Palpable fecal mass.

Manifestations of Hirschsprung disease in infant

Failure to thrive. Abdominal distention. Vomiting. Episodes of constipation and watery diarrhea.

True or false: Rapid shallow breathing is manifestation of Meckel diverticulum

False, according to ATI. It is a signs of appendicitis.

Risk factor for Hirschsprung disease

Family history of Hirschsprung disease.

Nursing actions for ear infections related to cleft lip and palate

Feed child in upright position. Monitor temperature. Teach parents manifestations of ear infections. Encourage early intervention.

Signs of peritonitis

Fever, sudden increase in pain, irritability, rigid abdomen, distention, tachycardia, rapid shallow breathing, pallor, chills.

Gastroesophageal reflux and gastroesophageal reflux disease

GER is acidic gastric contents refluxing back up into esophagus. GERD is tissue damage caused by GER.****

Complications of Meckel diverticulum

GI hemorrhage and bowel obstruction (if untreated).

Risk factor for hypertrophic pyloric stenosis

Genetic predisposition.

Subjective and objective data for GERD in children

Heartburn, abdominal pain, difficulty swallowing, chronic cough, chest pain.

Preoperative nursing care for pylorotomy

IV fluids to correct dehydration and electrolyte imbalance. NG decompression. NPO. I&O and daily weight.

Cleft lip

Incomplete fusion of oral cavity during intrauterine life. Can occur with cleft palate or alone. Unilateral or bilateral.****

Cleft palate

Incomplete fusion of palatine plates during intrauterine life. Can occur with cleft lip or alone. Unilateral or bilateral.****

Appendicitis

Inflammation of vermiform appendix caused by obstruction of lumen.****

Preoperative nursing care for cleft lip/palate surgery

Inspect lip and palate using gloved finger. Assess ability to suck. Baseline weight. Observe interaction with family. Determine family coping and support. Support group referrals. Social service consult for financial support. Instruct family on proper feeding technique. Assess ability to feed. Initiate strategies for successful feeding.

Therapeutic procedures for appendicits

Laparoscopic surgery for removal of nonruptured appendix. Laparoscopic or open surgery for removal of ruptured appendix.

Risk factors for cleft lip and palate

Maternal and environmental factors. Folate deficiency during pregnancy. Exposure during pregnancy to alcohol, smoking, anticonvulsants, steroids.**** Family history of cleft lip or palate. Other syndromes.

Manifestations of Meckel diverticulum

May be asymptomatic. Abdominal pain. Bloody, mucous stools.

Postoperative care of infant with cleft lip repair

Monitor integrity and proper positioning of post-op protective device. Position infant upright (car seat position), on back, or on side immediately post-op to maintain integrity of repair. Apply elbow restraints to keep infant from injuring site. Remove restraints periodically for skin integrity, limb movement, and comfort. Clean incision site with saline on a swab. Antibiotic ointment as prescribed. Gently aspirate secretions from mouth and nasopharynx.

Risk factors for GERD

Neurologic impairment, hiatal hernia, esophageal atresia, morbid obesity.

Therapeutic procedure for GERD

Nissen fundoplication: Laparoscopic surgical procedure that wraps fundus of stomach around distal esophagus to decrease reflux. For severe GERD after failure of medication.****

Intussusception

One part of intestine telescopes into another part, causing lympahtic and venous obstruction and edema. Progression to ischemia and increased mucus in intestine.****

Pharmacologic treatment of GERD

PPI like omeprazole (Pepcid) or H2 receptor antagonist like ranitidine (Zantac).****

Complications of appendicitis

Peritonitis: Inflammation in peritoneal cavity.

Teamwork and collaboration for cleft lip and palate

Plastic surgery, orthodontics, ENT, speech and language pathology, OT, dietary, social services.

Strategies for feeding infant with cleft palate or cleft lip and palate

Position infant upright while cradling head during feeding. Use special bottle with one-way valve and specially cut nipple. Burp infant frequently. If other methods unsuccessful, syringe feed infant.

Risk factors for GER

Prematurity, bronchopulmonary dysplasia, neurological impairment, asthma, cystic fibrosis, crebral palsy, scoliosis.****

Nursing care for appendicitis

Prepare for surgery using developmentally appropriate techniques. Avoid applying heat to abdomen. Avoid enemas or laxatives.

Preoperative nursing care for Hirschsprung disease surgery

Prepare for surgery using developmentally appropriate techniques. Electrolyte and fluid replacement as prescribed. Monitor for enterocolitis. Bowel prep with saline enemas and oral antibiotics as prescribed.

Nursing care for Hirschsprung disease

Prepare for surgery. Assist with improving nutritional status until surgery. High protein, high calorie, low fiber diet. TPN in some cases.

Nursing actions for dental problems related to cleft lip and palate

Promote healthy dental hygiene. Encourage early dental care.

Therapeutic procedure for hypertrophic pyloric stenosis

Pylorotomy (laparoscopic).

Diagnostic procedure for Meckel diverticulum

Radionucleotide scan.

Diagnostic procedure for Hirschsprung disease

Rectal biopsy to confirm absence of ganglion cells.****

Complications of GERD

Recurrent pneumonia from aspiration. Weight loss and failure to thrive: Erosion of esophagus and esophageal damage can lead to inability to eat.

Complications of intussusception

Recurring intussusception, which requires surgery.

Nursing actions for speech problems related to cleft lip and palate

Refer to early intervention. Refer to speech therapist.

Surgical intervention for cleft palate

Repair usually done at age 6-12 months. Most require second surgery.****

Postoperative nursing care for pylorotomy

Routine postop vital signs. Antiemetic for vomiting. IV fluids. Daily weight and I&O. Analgesics for pain. Assess for signs of infection. Clear liquids 4-6 hours after surgery. Advance to breast milk or formula as tolerated. Document tolerance to feeding.

Lab tests for hypertrophic pyloric stenosis

Serum electrolytes.

Surgical intervention for cleft lip

Should be at least 10 weeks old, weight 10 pounds, have hemoglobin of 10.**** Repair usually done at age 2-3 months. Revisions required if severe.

Nursing care for GER and GERD

Small frequent meals. Thicken infant formula with 1 tsp to 1 tbsp of rice cereal per 1 oz of formula. Elevate head of bed to 30 degrees for 1 hour after meals.Avoid foods that cause reflux.**** Assist with weight control.

Nursing care for intussusception

Stabilize prior to therapeutic procedure. IV fluids to correct and prevent dehydration. NG decompression. Teach family about nonsurgical procedure.

Postoperative care of infant with cleft lip and palate repair

Standard post-op care including vital signs and pain management. Control pain to decrease crying and strain on repair. Analgesics as prescribed. Assess operative site for crusting and infection. No sucking on nipple or pacifier. Avoid hard toys that infant might put in mouth. Monitor I&O and daily weight. Observe family interaction. Assess coping and support. Client education: Patient may need elbow restraints for 4-6 weeks. Instruct in proper use. Instruct in post-op diet and feeding techniques. Instruct in proper care of site.

Hirschsprung disease

Structural anomaly of GI tract caused by lack of ganglionic cells in segments of the colon resulting in decreased motility and mechanical obstruction.**** Congenital aganglionic megacolon.

Manifestations of intussusception

Sudden episodic abdominal pain. Screaming with drawing knees to chest during pain. Sausage-shaped abdominal mass.**** Red currant jelly stool (stool mixed with blood and mucus). Vomiting. Fever. Dehydration.

Nursing care of cleft lip and palate

Support parents in general care. Promote parent-infant bonding. Promote self-esteem.

Therapeutic procedures for Hirschsprung disease

Surgical removal of aganglionic section of bowel. Temporary colostomy may be required.****

Therapeutic procedure for Meckel diverticulum

Surgical removal of diverticulum.

Hypertrophic pyloric stenosis

Thickening of pyloric sphincter (from stomach to duodenum), which creates obstruction.****

Nursing actions for enterocolitis related to Hirschsprung disease

Treatment aimed at resolving enterocolitis, preventing perforation, maintaining hydration, antibiotic therapy, and colostomy/ileostomy if extensive bowel involvement. Monitor vitals. Assess abdominal girth. Monitor for signs of sepsis, peritonitis, or shock. Fluid, electrolyte, and blood product replacement. Antibiotics as prescribed.

Diagnostic procedure for hypertrophic pyloric stenosis

Ultrasound: Elongated sausage-shaped mass and elongated pyloric area.

Acceptable positions for child who is post-op for cleft lip repair

Upright, on back, on side opposite repair. Surgical site needs to be up to protect it from rubbing against sheet. Place in elbow restraints to prevent injury to surgical site.****

How to measure abdominal girth

Use paper tape measure at level of umbilicus or widest point of abdomen. Mark with pen to assure continuity of future measurements.

Prognosis for GER in infants

Usually self-limiting and resolves by age 1 without medication.****

When hypertrophic pyloric stenosis manifests

Usually within first 5 weeks of life.****

Physical exam findings

Visible separation from upper lip toward nose and/or visible or palpable opening of palate connecting mouth and nasal cavity.

Manifestations of hypertrophic pyloric stenosis

Vomiting after feeding, olive-shaped mass in RUQ, failure to gain weight.**** Vomiting also can occur several hours after feeding and become projectile as obstruction worsens. Blood-tinged vomit. Constant hunger. Possible peristaltic wave that moves from left to right when lying supine. Signs of dehydration: Dry pale skin, cool lips, dry mucosa, decreased skin turgor, decreased urinary output, concentrated urine, thirst, rapid pulse, sunken eyes.