Ch. 38 The Child with a Gastrointestinal/Endocrine Disorder

A 10-year-old child has been diagnosed with type 1 diabetes. The child is curious about the cause of the disease and asks the nurse to explain it. Which explanation will the nurse provide?

- "Special cells in a part of your body called the pancreas cannot make a chemical called insulin, which helps control the sugar level in your blood." Explanation: When providing instruction to a child, the nurse must consider the developmental age. Type 1 diabetes is a disorder that involves an absolute or relative deficiency of insulin, thus the blood glucose level remains high if an appropriate amount of insulin is not administered to the client. With type 2 diabetes, the body produces an adequate amount of insulin; however, the body is resistant to using the insulin properly to keep circulating blood glucose levels at a normal level.

What tiggers a Celiac CRISIS, what are the 5 symptoms?

- Can be triggered by an upper resp infection - Copious amounts of: 1. vomit 2. large 3. watery stools 4. dehydrated 5. irritable

A pediatric client has just been diagnosed with diabetes. What would the nurse do first?

- Check blood glucose levels. Explanation: The nurse must check the insulin level before it can be administered. Once a need is established, then insulin administration becomes the priority intervention. Stress management, glucose checks, and nutritional consultation can all be implemented once therapy with insulin begins.

The nurse is providing care to a child with an intussusception. The child has a bowel movement and the nurse inspects the stool. The nurse would most likely document the stool's appearance as having what quality?

- Currant jelly-like Explanation: The child with intussusception often exhibits currant jelly-like stools that may or may not be positive for blood. Greasy stools are associated with celiac disease. Clay-colored stools are observed with biliary atresia. Bloody stools can be seen with several gastrointestinal disorders, such as inflammatory bowel disease.

When providing diaper care to an infant after pyloric stenosis surgery, which approach is indicated?

- Diapers should be folded so that the incision line does not become contaminated. Explanation: - Folding diapers low so they do not contact the incision line can help prevent infection following surgery.

A child is admitted with a temperature, 101.2°F (38.4°C); pulse rate 100 beats/min; respirations 24 breaths/min. On admission the pain is localized in right lower quadrant. Legs are drawn up against the abdomen. Bowel sounds are sluggish. Rebound tenderness is present. White blood cell count of 17,000/mm3. Ultrasound confirms appendicitis. Which instruction would the nurse give to the child and the parent?

- Do not rub or put pressure on the abdomen. Explanation: The nurse would instruct the child/parent to not rub or put pressure on the abdomen as palpating an inflamed appendix may cause it to rupture. A child with appendicitis will be NPO for surgery and therefore not instructed to drink. Heat to the abdomen may also cause the inflamed appendix to rupture. Ice is not an effective intervention.

A 2-month-old infant experiencing severe diarrhea is prescribed intravenous fluid replacement. Before adding potassium to this solution, which assessment should the nurse make?

- Ensure that the child is voiding. Explanation: Although infants usually have a potassium depletion, potassium is not given until it is established the child is not in renal failure because giving potassium IV when the body has no outlet for excessive potassium can lead to excessively high potassium levels and heart block. Before this initial IV fluid is changed to a potassium solution, the nurse needs to be certain that the infant has voided, which is proof that the kidneys are functioning.

The parents of a boy diagnosed with Hirschsprung disease are anxious and fearful of the upcoming surgery. The mother states, "I'm worried about having to care for our son's ostomy." Which intervention would be most helpful for the parents?

- Having a wound, ostomy, and continence nurse meet with them Explanation: Although explaining about the diagnosis and surgery, reinforcing that the ostomy will be temporary, and teaching them about medications would be appropriate, the parents are voicing concerns about caring for the ostomy. Therefore, having a wound, ostomy, and continence nurse meet with them would address these concerns and help them deal with the anxieties and care of a newly placed stoma.

A neonatal nurse teaches students how to recognize gastrointestinal disorders in infants. The nurse tells the students that failure of the newborn to pass meconium in the first 24 hours after birth may indicate what disease?

- Hirschsprung disease Explanation: The nurse should suspect Hirschsprung disease when the newborn does not pass meconium in the first 24 hours after birth, and has bilious vomiting or abdominal distention and feeding intolerance with bilious aspirates and vomiting. Typical signs and symptoms of gastroenteritis include: - diarrhea - nausea - vomiting - abdominal pain. The characteristic GI manifestation of UC is: - bloody diarrhea accompanied by: - crampy, typically left-sided lower abdominal pain. Clinical manifestations of untreated SBS include: - profuse watery diarrhea - malabsorption - failure to thrive.

A young child has presented to the pediatric unit with a swollen abdomen, edema, thin patchy hair, and irritability with growth retardation and muscle wasting. The nurse suspects a malnutrition disorder. The nurse identifies this child to most likely have which condition?

- Kwashiorkor Explanation: The symptoms presented are classic signs of Kwashiorkor due to the protein deficiency.

The nurse has developed a plan of care for a 12-month-old hospitalized with dehydration as a result of rotavirus. Which intervention would the nurse include in the plan of care?

- Maintaining the intravenous (IV) fluid rate as ordered Explanation: - The nurse should maintain an IV line and administer the IV fluid as ordered to maintain fluid volume High-carbohydrate fluids like fruit juice, Kool-Aid, and popsicles should be avoided as they are low in electrolytes, increase simple carbohydrate consumption, and can decrease stool transit time Milk products should be avoided during the acute phase of illness as they may worsen diarrhea

A group of students are reviewing information about oral diabetic agents. The students demonstrate understanding of these agents when they identify which agent as reducing glucose production from the liver?

- Metformin Explanation: - Metformin, a biguanide, reduces glucose production from the liver - Glipizide, glyburide, and nateglinide all stimulate insulin secretion by increasing the response of β cells to glucose.

Which findings should the nurse expect to assess when completing the health history of a child admitted for possible type 2 diabetes? Select all that apply - Abrupt onset of symptoms - Marked weight loss - Polyuria - Polydipsia - Polyphagia

- Polyuria - Polydipsia - Polyphagia Explanation: Type 2 diabetes mellitus is characterized by a gradual onset and is most often associated with obesity and not marked weight loss. Type 1 diabetes is most often abrupt and associated with marked weight loss. Polyuria, polydipsia, and polyphagia are frequent assessment findings in both types of diabetes mellitus.

A child has been diagnosed with gastroesophageal reflux. The nurse should teach the mother which of the following aspects of care? Select all that apply. - Provide small frequent feedings. - Thicken the formula with rice cereal. - Place the child on his stomach to sleep. - Report signs of respiratory distress immediately. - Burp the baby frequently.

- Provide small frequent feedings. - Thicken the formula with rice cereal. - Report signs of respiratory distress immediately. - Burp the baby frequently Explanation: - The child should be placed on his side or back to sleep The prone position may be used during daytime hours while awake. Small, frequent feedings; thickening formula with rice cereal; burping the child frequently; and immediately reporting signs of respiratory distress are correct instructions.

The nurse is assessing a 13-year-old boy with type 2 diabetes mellitus. What would the nurse correlate with this disorder?

- The parents report that their son "can't drink enough water." Explanation: - Unquenchable thirst (polydipsia) associated with diabetes mellitus, type 1 and 2 TYPE 2: body produces adequate amount of insulin, but body is resistant to using the insulin properly to keep circulating blood glucose levels at a normal level - Gradual onset - Elevated BP - Weight Gain - Delayed wound healing - 3 P's (Polyphagia, polydipsia, polyuria) TYPE 1: absolute or relative deficiency of insulin, thus the blood glucose level remains high if an appropriate amount of insulin is not administered to the client - Sudden onset - flu-like illness - Kussmaul breathing - Normal BP - Weight Loss - Delayed wound healing - 3 P's

A 6-week-old infant is diagnosed with pyloric stenosis. When taking a health history from the parent, which symptom would the nurse expect to hear described?

- Vomiting immediately after feeding Explanation: With pyloric stenosis the circular muscle pylorus is hypertrophied. This thickness causes gastric outlet obstruction. The condition is seen in younger infants starting at 3 to 6 weeks of age The infant has projectile nonbilious vomiting. It occurs directly after eating and is not related to the feeding position. The infant is hungry shortly after eating. There is weight loss and/or dehydration. The treatment is a pyloromyotomy to reduce the increased size and increase the opening. Diarrhea is not associated with the disorder.

A nurse should recognize that which laboratory result would be most consistent with a diagnosis of diabetes mellitus?

- a fasting blood glucose greater than 126 mg/dl Explanation: - A fasting blood glucose greater than 126 mg/dl is diagnostic for diabetes mellitus.

Noah is an 18-month-old boy who is brought to the emergency department with flu-like symptoms. He is diagnosed with pneumonia secondary to aspiration of stomach contents. The nurse explains to the parents that this condition is most likely the result of which of the following?

- gastroesophageal reflux disease Explanation: The child with gastroesophageal reflux disease may present with the physical findings of pneumonia secondary to aspiration of refluxed stomach contents. In this situation, pneumonia is not associated with cystic fibrosis, Hirschsprung disease, or inflammatory bowel disease.

A mother is alarmed because her 6-week-old boy has begun vomiting almost immediately after every feeding. In the past week, the vomiting has grown more forceful, with the vomit projecting several feet from his mouth. He is always hungry again just after vomiting. At the physician's office, the nurse holds the child and offers him a bottle. While he drinks, the nurse notes an olive-size lump in his right abdomen. Which condition should the nurse suspect in this child?

- pyloric stenosis Explanation: With pyloric stenosis, at 4 to 6 weeks of age, infants typically begin to vomit almost immediately after each feeding. The vomiting grows increasingly forceful until it is projectile, possibly projecting as much as 3 to 4 feet. Infants are usually hungry immediately after vomiting because they are not nauseated. A definitive diagnosis can be made by watching the infant drink. If pyloric stenosis is present, the sphincter feels round and firm, approximately the size of an olive in the right abdomen. Peptic ulcer disease in neonates usually presents with hematemesis (blood in vomitus) or melena (blood in the stool). Gastroesophageal reflux involves a small (1-2 tsp) volume and is not forceful. Appendicitis typically begins with anorexia for 12 to 24 hours; children do not eat and do not act like their usual selves. Nausea and vomiting may then occur, followed by diffuse abdominal pain.

The nurse is assessing a 5-year-old child whose parent reports the child has been vomiting lately, has no appetite, and has had an extreme thirst. Laboratory work for diabetes is being completed. Which symptom would differentiate between type 1 diabetes from type 2 diabetes?

- recent weight loss Explanation: - Weight loss is unique to type 1 diabetes, whereas weight gain is associated with type 2 Hypertension is consistent with type 2 diabetes Both type 1 and type 2 diabetes cause delayed wound healing. The increase in blood glucose in diabetes causes damage to the inner lining of the arteries that cause the arteries to develop plaque and harden. These damages to the blood vessels result in a decrease in the ability of oxygen-rich blood to be transported effectively to the tissues to promote wound healing. Loose stools or repeated loose stools (diarrhea) is a common side effect of the oral medication metformin, which is prescribed for clients with type 2 diabetes. Insulin, the treatment for type 1 diabetes, has constipation as one of the side effects

The caregiver of a child diagnosed with celiac disease tells the nurse that the child has large amounts of bulky stools and what looks like fat in the stools. The clinical manifestation this caregiver is describing is:

- steatorrhea. Explanation: Celiac disease is an immunologic response to gluten, which causes damage to the small intestine. Steatorrhea (fatty stools) is a classic symptom of celiac disease. Symptoms also include abdominal distention or bloating, constipation, and nutritional deficiencies Currant jelly stools are a sign of intussusception Projectile vomiting is a sign of pyloric stenosis Severe diarrhea could be caused by a bacteria or virus. Projectile stools represent severe diarrhea.

List and describe the 9 GI Disorders

1. Kwashiorkor- Protein deficiency with adequate calorie intake. Highest incidence 4 mos-5 yrs. Swollen abdomen, edema, alopecia. Mortality rate >30% if untreated. 2. Marasmus- Protein & calorie deficiency. Common in children in 3rd world countries. Severely malnourished. 3. Rickets- Vitamin D deficiency. Affects the growth and calcification of bones (Calcium & Phos not absorbed well). 4. Thiamine deficiency- Vitamin B deficiency. Irritability, loss of appetite, N/V, cardiac or neuro symptoms. 5. Riboflavin deficiency- Thiamine (Vitamine B) & Niacin deficiencies. Skin lesions. Primary source of ribroflavin is milk and whole grains. 6. Niacin insufficiency- Pellagra. Insufficient whole milk or well-balanced diet. GI & neurologic symptoms 7. Vitamin D deficiency - Crabiotabes (softening of the occipital bones) and delayed closure of the fontanelles - Tooth enamel affected and tendency to develop caries. As progresses affects long bones, spinal, and pelvic nerve - Complications: tetany, pneumonia, enteritis. - Infants & children require 400 units of Vitamin D daily to prevent rickets - If not exposed to sun, can be administered fish liver oil or vitamin d supplements. Breast fed infants should receive vitamin D supplements. 8. Vitamin C deficiency: Scurvy - Inadequate vitamin C intake (ascorbic acid). - Early clinical manifestations of: *irritability * loss of appetite * digestive disturbances * general tenderness in the legs severe enough to cause a pseudoparalysis develops * child is apprehensive about being handled and assumes a frog position, with the hips and knees semiflexed and feet rotated outward * gums become red and swollen, and hemorrhage occurs in various tissues (Characteristic hemorrhages in the long bones are subperiosteal, especially at the ends of the femur and tibia. Recovery is rapid with adequate treatment, but death may occur from malnutrition or exhaustion in untreated cases) Treatment consists of therapeutic daily doses of ascorbic acid. 9. Vitamin B- Thiamine is needed to break down and digest foods. If a deficiency can cause cardiac

Define the following terms: 1. angioedema 2. anthelmintic 3. chelating agent 4. colic 5. craniotabes 6. currant jelly stools 7. diabetic ketoacidosis 8. encephalopathy 9. gastroenteritis 10. invagination 11. Kussmaul breathing 12. kwashiorkor 13. lactose 14. lactose intolerance 15. marasmus 16. pica 17. polydipsia 18. polyphagia 19. polyuria 20. pruritus 21. urticaria

1. angioedema - swelling of the face, lips 2. anthelmintic - medication that expels intestinal worms; vermifuge 3. chelating agent - agent that binds with metal 4. colic - episodes of crying in the infant, often associated with recurrent gastrointestinal disturbances that are fairly common among young infants and that usually disappear around the age of 3 months 5. craniotabes - softening of the occipital bones caused by a reduction of mineralization of the skull 6. currant jelly stools - stools that consist of blood and mucus 7. diabetic ketoacidosis - characterized by drowsiness, dry skin, flushed cheeks, cherry-red lips, and acetone breath with a fruity smell as a result of excessive ketones in the blood in uncontrolled diabetes 8. encephalopathy - degenerative disease of the brain 9. gastroenteritis - infectious diarrhea caused by infectious organisms, including Salmonella, Escherichia coli, dysentery bacilli, and various viruses, most notably rotaviruses 10. invagination - telescoping; infolding of one part of a structure into another. 11. Kussmaul breathing - abnormal increase in the depth and rate of the respiratory movements. 12. kwashiorkor - syndrome occurring in infants and young children soon after weaning; results from severe deficiency of protein. Symptoms include a swollen abdomen, retarded growth with muscle wasting, edema, gastrointestinal changes, thin dry hair with patchy alopecia, apathy, and irritability. 13. lactose - a sugar found in milk that, when hydrolyzed, yields glucose and galactose 14. lactose intolerance - inability to digest lactose because of an inborn deficiency of the enzyme lactase. 15. marasmus - deficiency in calories as well as protein. The child suffers growth retardation and wasting of subcutaneous fat and muscle 16. pica - persistent ingestion of nonfood substances such as clay, laundry starch, freezer frost, or dirt. 17. polydipsia - abnormal thirst 18. polyphagia - increased food consumption 19. polyuria - dramatic increase in urinary output, often with enuresis. 20. pruritus - itching 21. urticaria - hives

DIARRHEA & GASTROENTERITIS - Define it - 8 Causes - 5 Clinical manifestations - 7 assessments - 1 Treatment

DEFINITION - Mild diarrhea is loose stools= frequency of defecation 2 to 12 x per day - Infectious diarrhea= gastroenteritis Biggest concern is dehydration CAUSES 1. contaminated food 2. oral-fecal route 3. areas lacking adequate clean water 4. Diseases like - CF - viruses - Salmonella - ecoli - rotavirus 5. Allergies 6. Medications 7. Underfeeding 8. Over feeding CLINICAL MANIFESTATIONS 1. Loose stools 2. irritability 3. poor appetite Severe: 4. vomiting + diarrhea causes large losses of water & electrolytes 5. Dehydration: - sunken fontanel - tachycardia - dry loose skin turgor - Stool is green liquid/ w. blood ASSESSMENT 1. Skin turgor 2. temp 3. fontanel 4. pulse 5. stools 6. LOC 7. mucous membranes TREATMENTS 1. Fluid & Electrolyte balance must be initiated immediately!!! especially for Gastritis 2. Oral feedings discontinued completely if severe with shock 3. IVF given 4. Oral replacement therapy (ORT): - Pedialyte - rehydralyte - infalyte po, unless shock or severe dehydration. Then half strength formula, then food once diarrhea clears - nfants can return to breast feeding 5. Avoid salty broths 6. Avoid foods high in sugar 7. Early return to usual diet has shown to reduce number of stills and decrease weight loss & length of illness 8. Promote skin integrity (change diaper often) 9. Prevent dehydrations 10. Maintain adequate nutrition + oral hygiene Severe: - NPO - IV fluids & boluses - Frequent lab values

PYLORIC STENOSIS

DEFINITION - Pylorus = muscle that controls the flow of food from the stomach to duodenum - Hypertrophy of circular muscle fibers of pylorus with severe narrowing of the lumen - Pylorus is thickened to as much as twice its size, elongated, consistency resembling cartilage. Stomach becomes dilated. CLINICAL MANIFESTATIONS: 1. eats initially but then starts vomiting after meals 2. Vomiting increases in frequency/force, becoming projectile 3. Irritable 4. loses weight rapidly 5. Dehydration TREATMENT 1. pyloromyotomy (also known as a Fredet-Ramstedt operation) is the treatment of choice

CELIAC SYNDROME - Define it - 9 Clinical manifestations - 2 Treatment - 9 Restricted foods - 2 vital supplements

DEFINITION Ingestion of wheat gluten or rye gluten leads to impaired fat absorption, allergic reaction to gluten (protein in wheat) CLINICAL MANIFESTATIONS 1. Steatorrhea 2. chronic diarrhea with foul, bulky, greasy stools (Steatorrhea) 3. FTT (failure to thrive) 4. Resp infections\ 5. malnutrition 6. Onset is insidious 7. distended abdomen 8. retarded growth 9. thin, wasted buttocks and legs TREATMENT 1. Gluten-free, low-fat diet 2. Gradually add lean meets, vegetables, fruits 3. Restricted gluten free diet RESTRICTED FOODS 1. wheat 2. rye 3. oat products 4. malted milk drinks 5. bread 6. cake 7. pastries 8. Some baby food 9. Some candy SUPPLEMENTS - Vitamin A - Vitamin D

COLIC - Define it - Ages affected - 2 Clinical manifestations - 1 Treatment

DEFINITION Recurrent bouts of abdominal pain AGES AFFECTED - common in infants - disappears by 3 mos CLINICAL MANIFESTATIONS 1. Attacks occur suddenly, usually in evening 2. Loud crying, appears to be in pain but is healthy TREATMENT - Antiflatulents, but can be inconsistent - Hold/comfort baby - Give bottle (do not overfeed) - Sit & burp bby after feedings - Rub bbys rigid abdomen - Sleep bby in dark room - stay calm, it is temporary

FOOD ALLERGIES - 8 Common associated allergy-causing foods - 4 Signs & Symptoms - Teachings to parents - Lactose intolerance 4 S&S - 8 Assessments - 2 Interventions

FOODS 1. Milk 2. eggs 3. wheat 4. corn 5. legumes (peanuts & soybeans) 6. oranges 7. strawberries 8. chocolate, milk (most common): gi disturbances SIGNS & SYMPTOMS 1. urticaria (hives) 2. pruritis (itching) 3. abdominal pain 4. resp symptoms (Can be immediate or delayed) TEACHING 1. Introduce one food item at a time with 4-5 day intervals LACTOSE INTOLERANCE 1. Cramping 2. abdominal distention 3. flatus 4. diarrhea after ingesting milk (Provide soy formulas such as Isomil, Nutramigen, ProSobee) Yogurt is tolerated ASSESSMENT 1. Skin turgor 2. Fontanelle 3. Weight 4. Temp 5. Pulse 6. Respirations 7. LOC 8. I/O INTERVENTIONS 1. Increase nutritional intake 2. Hydration: - provide a bottle with a soft nipple with a large enough hole - May need IV fluids, or gavage feedings - feed every 2-3 hrs - frequent small feedings - Feeding <30 min. - remember food allergies can cause malnutrition

GASTROESOPHAGEAL REFLUX DISEASE (GERD)

Most common in preemies or children w/neuro disorders Sphincter in lower esophagus leading into the stomach is relaxed & allows gastric contents back into the esophagus. Typically seen in first week of life and resolved by 18 mos. Can be corrected as esophageal sphincter matures or child eats solid foods and is sitting or standing more. Clinical manifestations: Effortless vomiting after feeding, irritable, hungry, can aspirate & resp s/s Thickened formula w/rice cereal, place in upright position during and after feeding, ngt, gt feeding if necessary. Histamine-2 (H2) blocker receptor antagonist: ranitidine (Zantac), famotidine (Pepcid) to reduce acid secretion. Proton pump inhibitor (PPI): omeprazole (Prilosec) and lansoprazole(Prevacid) to reduce gastric acid. Surgery: Nissen fundoplicaton Nissen part of the upper portion of the stomach wrapped around the lower part of the esophagus to create a valvelike structure to prevent regurg of stomach contents Report any s/s resp destress. Offer smaller, frequent feedings and burp frequently. Studies now show that prone with head elevated may help for several hours, then side lying or supine for sleeping. Monitor and document intake and output, daily weight, emesis.