ch 19 the Child with a Gastrointestinal Alteration

Lactose Intolerance: Therapeutic Management

-removal of lactose from the diet -additional dietary changes -Formulas that do not contain lactose -Isomil, Nursoy, Nutramigen, ProSobee, and other soy-based formulas -breastfeeding mothers urged to eliminate lactose products from diet

Pyloric Stenosis: Therapeutic Management

-replacement IV fluids & electrolyes -NG tube for stomach decompression -infusion of plasma or packed RBCs before surgical repair (severe dehydration) -pyloromyotomy -an incision of the pyloric muscle to release the obstruction

Biliary Atresia: Therapeutic Management

-size of lesion identified to attempt drainage -Kaskai procedure -medical management -treating child's malnutrition -providing symptom relief -MCT old added to formula to increase calories -TPN can be admin to provide essential nutrition -vitamins

Hirschsprung Disease: Therapeutic Management

-treatment involves removing the aganglionic portion of the intestine in a one- or two-step surgical intervention -one-step laparoscopic or transanal pull-through procedure -for neonates a 2-step surgical procedure -relieve the obstruction -medical interventions -Botox injections -Rectal irrigations

Congenital Diaphragmatic Hernia (CDH): Clinical Manifestations

*Clinical findings depend on severity of defect* -abdominal organs in chest (by fetal ultrasonography) -diminished or absent breath sounds on affected side -bowel sounds that may be heard over the chest -cardiac sounds that may be heard on the right side of the chest -respiratory distress developing soon after birth--dyspnea, cyanosis, nasal flaring, tachypnea, retractions -scaphoid abdomen

Constipation and Encopresis

-Constipation: delay or difficulty in defecation that has been present for 2 or more weeks -Encopresis: repeated, involuntary defecation in a child older than 4 years who has normal colon and rectal anatomy Constipation Causes: -changes in diet -dehydration -lack of exercise -emotional stress -certain drugs -pain from anal fissures -excessive milk intake Encopresis caused: -recurrent fecal impaction -enlarged rectum caused by chronic constipation Diagnostic Tests: -abdominal radiographys -rectal examination

Motility Disorders

-Gastroesophagela reflux disease (GERD) -constipation and encopresis -recurrent abdominal pain -irritable bowel syndrome

Inflammatory Bowel Disease

-IBD = chronic inflammatory condition of the small or large intestine -2 conditions: -ulcerative colitis -affects only the colon & involves both the mucosal & submucosal layers of the intestine -Crohn disease -occur anywhere in the GI tract, from mouth to anus, transmural, involving all layers of the intestine -Etiology -viral & other infectious agents -food allergies -vasculitis -increased intestinal permeability -immunologic dysfunction -genetic factors

Intervention of TEF

-Preop -NPO -hydrated with IV fluids -maintain thermoregulation & fluid balance -Vital Signs -Minimize aspiration risk -chalasia board that helps keep child at a 30-degree angle while supine can be useful to decrease reflux -suction catheter -constant assess of respiratory status -Postop -monitor respiratory status -supporting fluid balance & nutrition -maintaining thermoregulation -providing pain relief -monitoring for infection -prompting bonding with parents -Chest tube patency -patency of IV line -monitor I & O's -assess for F&E alterations -Gastrostomy Tube Use -Home Care

Cleft Lip Manifestations

-a notched vermilion border -variably sized clefts that involve the alveolar ridge -dental anomalies

Cleft Lip & Palate

-abnormal openings in the lip or palate -occur from embryonic developmental failures related to multiple genetic and environmental factors -Cleft lip results when the medial nasal and maxillary processes fail to join at 6 to 8 weeks of gestations -Cleft palate results from failure of the primary palatal shelves, or processes, to fuse at 7 to 12 weeks of gestation

Appendicitis: Therapeutic Management

-appendectomy -preop -fluid therapy -immobilization -pain control interventions -NPO status -antibiotics -antipyretics

GERD Diagnostic Tests

-barium swallow examination -upper GI study -fiberoptic endoscopy -esophageal manometry -ambulatory pH studies -gastroesophageal scintigraphy (radionuclide scan) -ultrasound -chest computed tomography (CT)

Volvulus

-caused by malrotation or twisting of the bowel that results in a bowel obstruction -result of a defect in fetal development -the midgut fails to rotate and fixes itself to the abdominal wall -infants usually manifest pain, bilious vomiting, and other signs of bowel obstruction -surgery is essential to prevent bowel ischemia

Gastroesophageal Reflux Disease

-regurgitation of gastric contents back into the esophagus -GERD is a more severe and chronic form -physiologic GER & pathologic -neurological impairment -cerebral palsy -Down syndrome -head injury -delayed gastric emptying of a liquid meal b/c of distention -partial or incomplete swallowing dysfunction -drugs -increased intraabdominal pressure incurred while straining, crying, coughing, or slumping -obesity and hiatal hernias

Cirrhosis

-chronic, degenerative condition of the liver that results in the development of bands of fibrous tissue, firm nodules, and connections between the central and portal areas of the liver -scarring causes irreversible damage to the liver -results from chronic liver disease -HBV infection -chronic hepatitis or biliary atresia -sickle cell disease, inborn errors of metabolism -CF & wilson disease Manifestations -liver cell failure-portal hypertension-jaundice-intense pruritus-steatorrhea -abdominal distention-edema-anemia-bleeding tendencies-anorexia-frequent infections-poor growth

Disorders of Prenatal Development

-cleft lip or palate -esophageal atresia and tracheoesophageal fistula (TEF) -upper GI hernias -imperforate anus -gastroschisis -omphalocele -umbilical hernia

Hirschsprung Disease

-congenital aganglionosis or megacolon -result of an absence of ganglion cells in the rectum and, to varying degrees, upward in the colon -major cause of lower bowel obstruction in newborns Etiology: -result of embryonic failure of migration of the hindgut ganglion cells to the most caudal portion of the GI tract, the rectum -strong hereditary component & higher incidence in children w/ Down syndrome

Esophageal atresia and tracheoesophageal fistula (TEF)

-congenital malformations in which the esophagus terminates before it reaches the stomach and/or a fistual is present that forms an unnatural connection between the esophagus and the trachea -result of an embryonal failure to differentiate the foregut into the trachea and esophagus and the incomplete fusion of them into distinct organs -failure occurs between the 4th or 5th week of preganancy and can be manifested in several ways

GERD Therapeutic Management

-dietary alterations -small, frequent feedings with frequent burping -positional changes -infants younger than 12 months should be placed supine to sleep to reduce risk of SIDS -prone position more effectively reduces reflux (use when infants are awake & monitor)

CD: Therapeutic Management

-dietary management -elimination of wheat, rye, barley, and oats -corn & rice should be the replacements -vitamin supplements Child in celiac crisis -IV fluids -albumin to treat shock -corticosteroids to decrease severe mucosal inflammation -most IMPORTANT intervention is teaching the parents & child about dietary modification

Manifestations/Therapeutic Management of IBS

-diffuse abdominal pain unrelated to meals or activity -alternating constipation & diarrhea -undigested food and mucus present in the stool -normal growth -identifying and reducing triggers -reducing bowel spasms -child instructed to eat slowly, avoid caffeine products/carbonated beverages -medications

Recurrent Abdominal Pain/Irritable Bowel Syndrome (IBS)

-disorganized contractility, which causes spasmodic peristaltic rushes and lulls -causes alternating diarrhea and constipation w/ intermittent abdominal pain -2nd component is excess mucus production in the lumen of the bowel -produces maldigestion and the passage of incompletely digested food and nutrients -believed to be triggered by stress, emotional events, or infection

Etiology/Manifestations/Diagnostic Tests of Ulcers

-excessive acid secretion caused by Zollinger-Ellison syndrome or gastrinoma & hyperparathyroidism -bile salts bread down the mucous structure -prostaglandins augment both the mucous gel lining and bicarbonate secretion -duodenal ulcers show a familial tendency -Helicobacter pylori (H. pylori) -physiologic stress -medications (aspirin, NSAIDS, & indomethacin) -certain foods ingested Manifestations: -burning, cramping pain, awakening during the night or early morning with abdominal discomfort -vomiting in children younger than 6 -hematemesis & melena in infants & young children Diagnostic Tests: -fiberoptic upper endoscopy -ultrasound -fecal occult blood test

TEF Manifestations

-failure to pass suction catheter, NG tube at birth -excessive oral secretions, coughing, choking -vomiting -abdominal distention -airless, scaphoid abdomen (atresia w/o fistula)

Celiac Disease

-gluten enteropathy or tropical sprue -results from the inability to digest gluten -lifelong deficiency requiring dietary modification to prevent chronic maldigestion and malabsorption Etiology: -considered to be an autoimmune disease that occurs in genetically susceptible patients -patients with CD have been found to carry either HLA-DQ2 or HLA-DQ8 genes -multifactorial including both environmental and genetic factors

Intussusception: Therapeutic Management

-goal is to restore the bowel to its normal position & function as quickly as possible (w/i 24 hr) Do not show symptoms of shock or sepsis: -hydrostatic reduction performed w/ barium, isotonic saline, or air enema under fluoroscopic or ultrasonic guidance -surgery -laparoscopy

Infectious Gastroenteritis

-group of viruses and bacteria, and parasites capable of causing serious communicable diarrhea, massive fluid and electrolyte loss, sepsis, and death Etiology: -ingestion of contaminated food or water and person-to-person contamination -Giardia is the most common pathogen in children in daycare settings -Rotavirus is the most common viral cause in all children and accounts for 29% of all deaths due to diarrhea among children younger than age 5

Upper GI Hernias

-hernia is an abnormal protrusion of part of an organ or tissue through the structures that normally contain it -congenital or acquired

Pyloric Stenosis: Diagnostics

-history of vomiting -visible peristaltic waves -palpable pyloric mass -radiography & ultrasonography -barium swallow examination

Congenital Diaphragmatic Hernia (CDH): Nursing Management

-identify clinical findings and report immediately -place child in semi-Fowler position on affected side with head of bed elevated -maintain patency of NG tube -monitor IV fluids -maintain mechanical ventilation, ECMO, chest tubes -assess oxygenation -Do not use facemask or bag-valve-mask for ventilatory support because air can enter stomach and further impair respiratory function -provide minimal stimulation -provide routine postop care -monitor signs of infection, respiratory distress, and feeding difficulties; report to physician -support family mourning loss of perfect child -provide clear, truthful information to parents -encourage parents to see and touch the infant -use prescribed feeding techniques -provide referral to support groups -provide discharge teaching

Congenital Diaphragmatic Hernia (CDH): Therapeutic Management

-if diagnosed prenatally, mother moved to tertiary care center before delivery -in utero surgery may be performed -neonatal emergency NG intubation with suction -ventilate with high-frequency ventilation, manage acidosis with bicarbonate and ventilation ECMO -liquid ventilation -manage pulmonary hypertension; inhaled nitric oxide may be used -surgical reduction of hernia after physiologically stable; may wait 6-18hr after bith -respiratory support and ECMO until lungs functioning after surgery

Lactose Intolerance

-inability to tolerate lactose, the sugar found in dairy products -result of an absence or deficiency of lactase -2 types: congenital & developmental Etiology: -most cases are a result of inadequate levels of lactase

Appendicitis

-inflammation and infection of the vermiform appendix, a small lymphoid, tubular, blind sac at the end of the cecum Etiology -lymphoid swelling related to viral infection -impacted fecal material -foreign bodies -parasites -uncommon in children younger than 4

Intussusception

-invagination of a section of the intestine into the distal bowel that causes bowel obstruction -contributing factors for cause in young children -preexisting upper respiratory tract infection or other viral infection -mass or an anatomic defect w/i colon is most likely cause in children older than 6

Therapeutic Management of TEF

-keeping the infant supine with the head of the bed elevated -NG tube must be in place and aspirated every 5 to 10 mins -IV fluids -Normal newborn care is appropriate with special attention to keeping the infant warm and oxygenated -surgical repair -- initial repair includes ligation of the fistual and end-to0side anastomosis of the atresia to decrease the severity of stricture formation

Therapeutic Management of Ulcers

-medical management -drug safety -symptom relief -child and parent adherence to prescribed regimen -prevention of complications or ulcer recurrence -medications -antibiotics -proton pump inhibitors -H2-receptor antagonists -mucosa protective agents

IBD: Therapeutic Management

-medication -dietary & nutritional support -symptomatic treatment -Pharmacologic treatment -antiinflammatory -antibacterial -antibiotic -immunosuppressive drugs Principal Meds: -5-Aminosalicylic acid (5-ASA) -sulfasalazine -mesalazine -Corticosteroids -prednisone -Immune-modulating agents -azathioprine -6-mercaptopurine (6-MP) -methotrexate -cyclosporin A -Tumor necrosis factor-alpha (TNF-a) antibody -infliximab -antibiotics -metronidazole (Flagyl) -ciprofloxacin (quinolones)

GERD Therapeutic Management

-medications -antacids -symptom relief -proton pump inhibitors (omeprazole & lansoprazole) -decrease acid secretions -H2-receptor antagonists (cimetidine, ranitidine) -decrease acid secretions -prokinetic agents (cisapride, bethanechol, metoclopramide) -accelerate gastric emptying and improve esophageal and intestinal peristalsis -antidopaminergic agents (domperidone and metoclopramide) -facilitate gastric emptying -surgery -fundoplication

Therapeutic Management of Cleft Lip/Palate

-modifying feeding techniques -use of special feeding techniques, obturators, and unique nipples -surgery -removable orthopedic devices (Latham device) -Cleft Lip repair usually performed by age 3 to 6 months -Cleft palate repair individualized and based on the degree of deformity and size of child -closure completed between ages 6 to 24 months -concurrent treatment of altered dentition, recurring otitis media, speech dysfunction, emotional issues, and cosmetic concerns completes the ongoing therapy

GERD Nursing Interventions

-monitor for any signs of respiratory distress or periods of apnea using a cardiac and/or apnea monitor -check vital signs -proper positioning -minimal handling after feedings -pacifier use reduces crying & encourages swallowing -minimize reflux -family education & support

Cleft Palate

-nasal distortion -midline or bilateral cleft with variable extension from the uvula and soft and hard palates, and exposed nasal cavities

Biliary Atresia

-obstruction or absence of the extrahepatic bile ducts -leads to significant cellular damage and eventual liver failure and death Manifestations -acholic stools -bile-stained urine -hepatomegaly Diagnostics -Investigation of liver function (bilirubin, ALT & AST) -clotting studies (PT & PTT) -percutaneous liver biopsy -cholangiography

Short Bowel Syndrome (SBS)

-occurs due to congenital malformations of the GI tract or surgical resection that decreases the length of the small intestines -loss > 50% of the small bowel may result in symptoms of generalized malabsorption or deficiencies of certain nutrients Etiology: -multiple GI tract atresias -grastroschisis -removing portions of the small bowel -preterm infants is NEC

Congenital Diaphragmatic Hernia (CDH)

-opening in the diaphragm through which abdominal contents herniate into the thoracic cavity during prenatal development -results in some degree of pulmonary hypoplasia, determined by the timing and size of the herniation -mortality rate 50% to 80%; 40% if ECMO is used -degree of pulmonary hypoplasia determines outcome -Incidence: 1 in 2200-5000 live births

Appendicitis: Manifestations & Diagnostic Eval

-pain, progressing intensity & localizing to the right lower quadrant at McBurney point -nausea/vomiting -anorexia -diarrhea/constipation -fever/chills Diagnostic Findings: -abdominal pain at McBurney point -guarding -rebound tenderness -nausea/vomiting -fever -WBC count of 15000 to 20000/mm3

Ulcer

-peptic ulcer is an area of sharply circumscribed loss of the mucosa, submucosa, or muscular tissue occuring in areas of the digestive tract exposed to acid and pepsin -primary or secondary/gastric or duodenal

Pyloric Stenosis: Manifestation

-progressive projectile nonbilious vomiting -movable, palpable, firm, olive-shaped mass is felt in the right upper quadrant -irritable/hungry a short time after being fed -dehydration and experience of metabolic alkalosis may occur

Hiatal Hernia

-protrusion of a portion of the stomach through the esophageal hiatus of the diaphragm Clinical Manifestations: -vomiting -coughing, wheezing, short periods of apnea -failure to thrive Therapeutic Management: -medical management similar to the child with reflux -surgical repair of defect Nursing Management: -monitor I&O's -document vomiting -observe for respiratory distress -provide routine postop care for GI surgery -teach parents about surgery and medical treatment of reflux

GERD Manifestations

-vomiting or spitting up after a meal -hiccupping -recurrent otitis media Infant w/ pathological GERD -weight loss -failure to trive -irritability -discomfort -abdominal pain Severe GERD -hematemesis (melena) and anemia Associated w/ respiratory illness or asthma -coughing -choking -asthma -wheezing -pneumonia -apnea -bradycardia

Hypertrophic Pyloric Stenosis

-when the circular area of muscle surrounding the pylorus hypertropies and obstructs gastric emptying -associated w/ other GI anomalies -malrotation -short bowel syndrome -esophageal & duodenal atresia -anorectal anomalies -hiatal hernia -GER -heredity/family predisposition ^

Constipation/Encopresis Therapeutic Management

1. Disimpaction -enemas -stool softeners/laxatives 2. Education/demystification -discussion w/ family & child(ren) 3. Maintenance -mineral oil 2x a day -Lactulose 2x a day -dietary changes 4. Changing the retention habit -sit on commode for 5 to 10 mins (20 to 30 after meals) -Behavioral chart with positive rewards -avoiding negative reinforcement -use biofeedback -increase physical exercise, relaxation activities, & stress reduction approaches

What is an expected outcome for the child with irritable bowel disease? a. Decreasing symptoms b. Adherence to a low-fiber diet c. Increasing milk products in the diet d. Adapting the lifestyle to the lifelong problems

ANS: A Feedback A Management of irritable bowel disease is aimed at identifying and decreasing exposure to triggers and decreasing bowel spasms, which will decrease symptoms. Management includes maintenance of a healthy, well-balanced, moderate-fiber, lower fat diet. B A moderate amount of fiber in the diet is indicated for the child with irritable bowel disease. C No modification in dairy products is necessary unless the child is lactose intolerant. D Irritable bowel syndrome is typically self-limiting and resolves by age 20 years.

What food choice by the parent of a 2-year-old child with celiac disease indicates a need for further teaching? a. Oatmeal b. Rice cake c. Corn muffin d. Meat patty

ANS: A Feedback A The child with celiac disease is unable to fully digest gluten, the protein found in wheat, barley, rye, and oats. Oatmeal contains gluten and is not an appropriate food selection. B Rice is an appropriate choice because it does not contain gluten. C Corn is digestible because it does not contain gluten. D Meats do not contain gluten and can be included in the diet of a child with celiac disease.

The nurse is caring for a neonate with a suspected tracheoesophageal fistula (TEF). Nursing care should include a. Elevating the head but give nothing by mouth b. Elevating the head for feedings c. Feeding glucose water only d. Avoiding suction unless infant is cyanotic

ANS: A Feedback A When a newborn is suspected of having TEF, the most desirable position is supine with the head elevated on an incline plane of at least 30 degrees. It is imperative that any source of aspiration be removed at once; oral feedings are withheld. B Feedings should not be given to infants suspected of having TEF. C Feedings should not be given to infants suspected of having TEF. D The oral pharynx should be kept clear of secretion by oral suctioning. This is to avoid cyanosis that is usually the result of laryngospasm caused by overflow of saliva into the larynx.

A nurse is teaching a group of parents about TEF. Which statement made by the nurse is accurate about TEF? a. This defect results from an embryonal failure of the foregut to differentiate into the trachea and esophagus. b. It is a fistula between the esophagus and stomach that results in the oral intake being refluxed and aspirated. c. An extra connection between the esophagus and trachea develops because of genetic abnormalities. d. The defect occurs in the second trimester of pregnancy.

ANS: A Feedback A When the foregut does not differentiate into the trachea and esophagus during the fourth to fifth week of gestation, a TEF occurs. B TEF is an abnormal connection between the esophagus and trachea. C There is no connection between the trachea and esophagus in normal fetal development. D This defect occurs early in pregnancy during the fourth to fifth week of gestation.

Which assessment finding should the nurse expect in an infant with Hirschsprung disease? a. "Currant jelly" stools b. Constipation with passage of foul-smelling, ribbon-like stools c. Foul-smelling, fatty stools d. Diarrhea

ANS: B Feedback A "Currant jelly" stools are associated with intussusception. B Constipation results from absence of ganglion cells in the rectum and colon, and is present since the neonatal period with passage of frequent foul-smelling, ribbon-like, or pellet-like stools. C Foul-smelling, fatty stools are associated with cystic fibrosis and celiac disease. D Diarrhea is not typically associated with Hirschsprung disease but may result from impaction.

What is an expected outcome for the parents of a child with encopresis? a. The parents will give the child an enema daily for 3 to 4 months. b. The family will develop a plan to achieve control over incontinence. c. The parents will have the child launder soiled clothes. d. The parents will supply the child with a low-fiber diet.

ANS: B Feedback A Stool softeners or laxatives, along with dietary changes, are typically used to treat encopresis. Enemas are indicated when a fecal impaction is present. B Parents of the child with encopresis often feel guilty and believe that encopresis is willful on the part of the child. The family functions effectively by openly discussing problems and developing a plan to achieve control over incontinence. C This action is a punishment and will increase the child's shame and embarrassment. The child should not be punished for an action that is not willful. D Increasing fiber in the diet and fluid intake results in greater bulk in the stool, making it easier to pass.

The nurse is teaching the parents of a child who has been diagnosed with irritable bowel syndrome about the pathophysiology associated with the symptoms their child is experiencing. Which response indicates to the nurse that her teaching has been effective? a. "My child has an absence of ganglion cells in the rectum causing alternating diarrhea and constipation." b. "The cause of my child's diarrhea and constipation is disorganized intestinal contractility." c. "My child has an intestinal obstruction; that's why he has abdominal pain." d. "My child has an intolerance to gluten, and this causes him to have abdominal pain."

ANS: B Feedback A The absence of ganglion cells in the rectum is associated with Hirschsprung disease. B Disorganized contractility and increased mucus production are precipitating factors of irritable bowel disease. C Intestinal obstruction is associated with pyloric stenosis. D Intolerance to gluten is the underlying cause of celiac disease.

What is the best response by the nurse to a mother asking about the cause of her infant's bilateral cleft lip? a. "Did you use alcohol during your pregnancy?" b. "Do you know of anyone in your family or the baby's father's family who was born with cleft lip or palate problems?" c. "This defect is associated with intrauterine infection during the second trimester." d. "The prevalent of cleft lip is higher in Caucasians"

ANS: B Feedback A Tobacco during pregnancy has been associated with bilateral cleft lip. B Cleft lip and palate result from embryonic failure resulting from multiple genetic and environmental factors. A genetic pattern or familial risk seems to exist. C The defect occurred at approximately 6 to 8 weeks of gestation. Second-trimester intrauterine infection is not a known cause of bilateral cleft lip. D The prevalence of cleft lip and palate is higher in Asian and Native American populations.

What maternal assessment is related to an infant's diagnosis of TEF? a. Maternal age more than 40 years b. First term pregnancy for the mother c. Maternal history of polyhydramnios d. Complicated pregnancy

ANS: C Feedback A Advanced maternal age is not a risk factor for TEF. B The first term pregnancy is not a risk factor for an infant with TEF. C A maternal history of polyhydramnios is associated with TEF. D Complicated pregnancy is not a risk factor for TEF.

What is the most important information to be included in the discharge planning for an infant with gastroesophageal reflux? a. Teach parents to position the infant on the left side. b. Reinforce the parents' knowledge of the infant's developmental needs. c. Teach the parents how to do infant cardiopulmonary resuscitation (CPR). d. Have the parents keep an accurate record of intake and output.

ANS: C Feedback A Correct positioning minimizes aspiration. The correct position for the infant is on the right side after feeding and supine for sleeping. B Knowledge of developmental needs should be included in discharge planning for all hospitalized infants, but it is not the most important in this case. C Risk of aspiration is a priority nursing diagnosis for the infant with gastroesophageal reflux. The parents must be taught infant CPR. D Keeping a record of intake and output is not a priority and may not be necessary.

A nurse has admitted a child to the hospital with a diagnosis of "rule out" peptic ulcer disease. Which test will the nurse expect to be ordered to confirm the diagnosis of a peptic ulcer? a. A dietary history b. A positive Hematest result on a stool sample c. A fiberoptic upper endoscopy d. An abdominal ultrasound

ANS: C Feedback A Dietary history may yield information suggestive of a peptic ulcer, but the diagnosis is confirmed through endoscopy. B Blood in the stool indicates a gastrointestinal abnormality, but it does not conclusively confirm a diagnosis of peptic ulcer. C Endoscopy provides direct visualization of the stomach lining and confirms the diagnosis of peptic ulcer. D An abdominal ultrasound is used to rule out other gastrointestinal alterations such as gallstones, tumor, or mechanical obstruction.

What is the major focus of the therapeutic management for a child with lactose intolerance? a. Compliance with the medication regimen. b. Providing emotional support to family members. c. Teaching dietary modifications. d. Administration of daily normal saline enemas.

ANS: C Feedback A Medications are not typically ordered in the management of lactose intolerance. B Providing emotional support to family members is not specific to this medical condition. C Simple dietary modifications are effective in management of lactose intolerance. Symptoms of lactose intolerance are usually relieved after instituting a lactose-free diet. D Diarrhea is a manifestation of lactose intolerance. Enemas are contraindicated for this alteration in bowel elimination.

What clinical manifestation should a nurse be alert for when suspecting a diagnosis of esophageal atresia? a. A radiograph in the prenatal period indicates abnormal development. b. It is visually identified at the time of delivery. c. A nasogastric tube fails to pass at birth. d. The infant has a low birth weight

ANS: C Feedback A Prenatal radiographs do not provide a definitive diagnosis. B The defect is not externally visible. Bronchoscopy and endoscopy can be used to identify this defect. C Atresia is suspected when a nasogastric tube fails to pass 10 to 11 cm beyond the gum line. Abdominal radiographs will confirm the diagnosis. D Infants with esophageal atresia may have been born prematurely and with a low birth weight, but neither is suggestive of the presence of an esophageal atresia.

What information should the nurse include when teaching the parents of a 5-week-old infant about pyloromyotomy? a. The infant will be in the hospital for a week. b. The surgical procedure is routine and "no big deal." c. The prognosis for complete correction with surgery is good. d. They will need to ask the physician about home care nursing.

ANS: C Feedback A The infant will remain in the hospital for a day or two postoperatively. B Although the prognosis for surgical correction is good, telling the parents that surgery is "no big deal" minimizes the infant's condition. C Pyloromyotomy is the definitive treatment for pyloric stenosis. Prognosis is good with few complications. These comments reassure parents. D Home care nursing is not necessary after a pyloromyotomy.

The postoperative care plan for an infant with surgical repair of a cleft lip includes a. A clear liquid diet for 72 hours b. Nasogastric feedings until the sutures are removed c. Elbow restraints to keep the infant's fingers away from the mouth d. Rinsing the mouth after every feeding

ANS: C Feedback A The infant's diet is advanced from clear liquid to soft foods within 48 hours of surgery. B After surgery, the infant can resume preoperative feeding techniques. C Keeping the infant's hands away from the incision reduces potential complications at the surgical site. D Rinsing the mouth after feeding is an inappropriate intervention. Feeding a small amount of water after feedings will help keep the mouth clean. A cleft lip repair site should be cleansed with a wet sterile cotton swab after feedings.

What is an appropriate statement for the nurse to make to parents of a child who has had a barium enema to correct an intussusception? a. "I will call the physician when the baby passes his first stool." b. "I am going to dilate the anal sphincter with a gloved finger to help the baby pass the barium." c. "I would like you to save all the soiled diapers so I can inspect them." d. "Add cereal to the baby's formula to help him pass the barium."

ANS: C Feedback A The physician does not need to be notified when the infant passes the first stool. B Dilating the anal sphincter is not appropriate for the child after a barium enema. C The nurse needs to inspect diapers after a barium enema because it is important to document the passage of barium and note the characteristics of the stool. D After reduction, the infant is given clear liquids and the diet is gradually increased.

What should the nurse teach a school-age child and his parents about the management of ulcer disease? a. Eat a bland, low-fiber diet in small, frequent meals. b. Eat three balanced meals a day with no snacking between meals. c. The child needs to eat alone to avoid stress. d. Do not give antacids 1 hour before or after antiulcer medications.

ANS: D Feedback A A bland diet is not indicated for ulcer disease. The diet should be a regular diet that is low in caffeine, and the child should eat a meal or snack every 2 to 3 hours. B The child should eat every 2 to 3 hours. C Eating alone is not indicated. D Antacids can interfere with antiulcer medication if given less than 1 hour before or after antiulcer medications.

An infant is born and the nurse notices that the child has herniation of abdominal viscera into the base of the umbilical cord. What will the nurse document on her or his assessment of this condition? a. Diaphragmatic hernia b. Umbilical hernia c. Gastroschisis d. Omphalocele

ANS: D Feedback A A diaphragmatic hernia is the protrusion of part of the abdominal organs through an opening in the diaphragm. B An umbilical hernia is a soft skin protrusion of abdominal stricture through the esophageal hiatus. C Gastroschisis is the protrusion of intraabdominal contents through a defect in the abdominal wall lateral to the umbilical ring. There is no peritoneal sac. D Omphalocele is the herniation of the abdominal viscera into the base of the umbilical cord.

The child with lactose intolerance is most at risk for which electrolyte imbalance? a. Hyperkalemia b. Hypoglycemia c. Hyperglycemia d. Hypocalcemia

ANS: D Feedback A The child with lactose intolerance is not at risk for hyperkalemia. B Lactose intolerance does not affect glucose metabolism. C Hyperglycemia does not result from ingestion of a lactose-free diet. D The child between 1 and 10 years requires a minimum of 800 mg of calcium daily. Because high-calcium dairy products containing lactose are restricted from the child's diet, alternative sources such as egg yolk, green leafy vegetables, dried beans, and cauliflower must be provided to prevent hypocalcemia.

Which intervention should be included in the nurse's plan of care for a 7-year-old child with encopresis who has cleared the initial impaction? a. Have the child sit on the toilet for 30 minutes when he gets up in the morning and at bedtime. b. Increase sugar in the child's diet to promote bowel elimination. c. Use a Fleets enema daily. d. Give the child a choice of beverage to mix with a laxative.

ANS: D Feedback A To facilitate bowel elimination, the child should sit on the toilet for 5 to 10 minutes after breakfast and dinner. B Decreasing the amount of sugar in the diet will help keep stools soft. C Daily Fleets enemas can result in hypernatremia and hyperphosphatemia, and are used only during periods of fecal impaction. D Offering realistic choices is helpful in meeting the school-age child's sense of control.

The nurse is discussing home care with a mother whose 6-year-old child has hepatitis A. what should the nurse include in the teaching plan? A. Teach infection control measures to family members B. Bed rest is important until 1 week after the icteric phase C. The child should not return to school until 3 weeks after the icteric phase D. Give reassurance that hepatitis A cannot be transmitted to other family members

Answer: A Rationale: A. Hepatitis A is a contagious disease, transmitted through the fecal-oral route. The nurse should teach infection control measures to family. B. The disease does not usually have an icteric phase and often is subclinical. C. The period of communicability is from the later half of the incubation period, 1 week after the onset of clinical illness. D. Hepatitis A infection is spread through the fecal-oral route.

Which statement best describes Hirschsprung disease? A. The colon has an aganglionic segment B. It results in frequent evacuation of solids, liquid, and gas C. There is a passage of excessive amounts of meconium in the neonate D. It results in excessive peristaltic movements within the gastrointestinal tract

Answer: A Rationale: A. Hirschsprung disease is a mechanical obstruction caused by a lack of motility of a segment of the intestine resulting from the lack of innervation by ganglion cells. B. There is a lack of peristalsis in the affected segment, which interferes with the evacuation of solid waste. C. It is associated with an inability to pass meconium, or feces if the child is older. D. There is a lack of peristalsis in the affected segment, which interferes with the evacuation of solid waste.

The nurse is caring for a child with probable intussusception. The child had diarrhea before admission, but while waiting for administration of air pressure to reduce the intussusception, the child passes a normal brown stool. What is the most appropriate nursing action? A. Notify the physician B. Measure the abdominal girth C. Auscultate for bowel sounds D. Check vital signs, including blood pressure

Answer: A Rationale: A. Passage of a normal stool indicates that the intussusception has resolved. Notification of the physician is essential to determine whether a change in treatment plan is indicated. B. Measuring abdominal girth is indicated, but the physician must be notified of the change in status. C. Auscultating for bowel sounds is indicated, but the physician must be notified of the change in status. D. Vital signs, including blood pressure may be indicated, but the physician must be notified of the change in status.

Management of a peptic ulcer in a child often includes which component? A. Taking proton pump inhibitors B. Drinking milk at frequent intervals C. Coping with stress and adjusting to chronic illness D. Taking antacids 1 and 3 hours before meals and at bedtime

Answer: A Rationale: A. Proton pump inhibitors block the production of acid. They are well tolerated and have infrequent side effects. B. Milk is not beneficial in the management of peptic ulcer disease. C. Coping with stress is beneficial, but peptic ulcer disease is treatable. D. Proton pump inhibitors are more effective than antacids.

The nurse is caring for an infant immediately after returning from having a pyloromyotomy. What actions would the nurse to perform in the immediate post-operative period? (SELECT ALL THAT APPLY.) A. Maintain the infant's head in an elevated position B. Keep the infant on his left side with the head slight elevated C. Irrigate the nasogastric tube with sterile water D. Provide oral care frequently until the infant begins drinking E. Assure bowel sounds are present before feeding the infant F. Weigh diapers after oral feedings have been started

Answer: A, D, E

Which phrase contains a component of the teaching plan for an adolescent with Crohn's disease? A. Adjusting to chronic illness and preventing spread of illness to others B. Preventing spread of illness to others and nutritional guidance C. Coping with stress and adjusting to chronic illness D. Nutritional guidance and preventing constipation

Answer: C Rationale: A. Adjustment to chronic illness is necessary, but Crohn's disease is inflammatory, not infectious. B. Nutritional guidance is necessary, but Crohn's disease is not infectious. C. Crohn's disease is a chronic disease with life-threatening/life-altering complications. The nursing interventions include helping the child cope with stress and learn how to adjust to the illness. D. Nutritional guidance is necessary, but constipation is not an issue.

Which should the nurse consider when providing support to a family whose infant has just been diagnosed with biliary atresia? A. Death usually occurs by 6 months of age B. Prognosis for full recovery is excellent C. Liver transplantation may be needed eventually D. Children with surgical correction live normal lives

Answer: C Rationale: A. If untreated, death will usually occur by 2 years of age. Long-term survival is possible with surgical intervention. B. Liver transplantation is usually required. C. Approximately 80% to 90% of children with biliary atresia will require liver transplantation. D. Even with surgical intervention, most children experience liver failure and require transplantation.

Which food should the nurse serve to a child with celiac disease? A. Macaroni and cheese B. A turkey sandwich C. Cottage cheese and peaches D. Spaghetti and meatballs

Answer: C Rationale: A. The macaroni has gluten, which must not be served. B. The bread for the sandwich has gluten, the protein found in wheat, barley, rye, and oats. C. Cottage cheese with peaches does not have gluten. D. Spaghetti has gluten and should not be served.

A child has a nasogastric tube (NG) after surgery for acute appendicitis. What is the purpose of the tube? A. To maintain electrolyte balance B. To prevent spread of infection C. To prevent abdominal distention D. To maintain an accurate record of output

Answer: C Rationale: A. The nasogastric tube may adversely affect electrolyte balance by removing stomach secretions. B. There is no relationship to the spread of infection. C. The nasogastric tube is used to maintain gastric decompression until the return of intestinal activity. D. Nasogastric drainage is one part of the child's output. The nurse would need to incorporate the drainage with other output.

Therapeutic management of the child with an inflammatory bowel disease (IBD) includes a diet that has which component? A. Low-protein B. Low-calorie C. High-fiber D. Vitamin supplements

Answer: D Rationale: A. A high-protein, high-calorie diet is needed to help correct nutritional deficits. B. A high-protein, high-calorie diet is needed to help correct nutritional deficits. C. A high-fiber diet is not recommended for IBD. Even small amounts of bran have been associated with a worsening of the child's condition. D. Multivitamins, iron, and folic acid supplementation are recommended.

The nurse assesses a neonate immediately after birth and suspects a tracheoesophageal fistula. Which assessment data would cause the nurse to suspect this defect? A. Sneezing B. Flat fontanels C. Absence of sucking and swallowing D. Excessive amount of frothy saliva in the mouth

Answer: D Rationale: A. Sneezing is normally seen in neonates as they clear out their nasal passages. B. Flat fontanels are normally seen in neonates. C. The infant is able to suck, but cannot manage the secretions or oral intake. D. Excessive salivation and drooling is indicative of tracheoesophageal fistulas. With a fistula, the child has difficulty managing the secretions causing choking, coughing, and cyanosis.

The nurse would suspect the presence of a _______ if pain, bilious vomiting, and other signs of bowel obstruction are present.

Answer: Volvulus

Characteristics of Infectious Gastroenteritis (Table 43.-3 pg. 1087)

Clostridium difficile -antibiotic associated -most common nosocomial diarrhea -Clinical Manifestation -Fever 24-48 hr -diarrhea develops after antibiotic treatment -Diagnostic Findings -Blood and PMNs in stool Norwalk -incubation 1-2 days -common in winter in schools & other group settings -fecal-oral route of transmission -Clinical Manifestation -symptoms last 1-2 days -nausea, vomiting, diarrhea -headache, low-grade fever, muscle aches, chills -Diagnostic Findings -Virus in stool

Manifestation of Constipation/Encopresis

Constipation: -absence of stool -abdominal pain -cramping w/o distention -palpable, movable fecal massess with large amts of stool in an enlarged rectum -diarrheal overflow -normal/decreased bowel sounds -malaise -anorexia -headache -nausea/vomiting -anal fissures Encopresis: -soiled clothing and fecal odor w/o apparent awareness -anal irritation leads to scratching/rubbing of anal area -social withdrawal/avoidance of extended contact w/ others -urinary incontinence -UTIs

IBD: Manifestations & Diagnostics

Diagnostics: -Colonoscopy -Rectoscopy -Barium ENema -Biopsy Manifestations: Crohn -abdominal pain -diarrhea, nonbloody -fever -palpable abdominal mass -anorexia and severe weight loss -significant growth impairment -perianal and anal lesions -fistulas and obstructions -extraintestinal symptoms Ulcerative Colitis -abdominal pain unusual -diarrhea, occasionally with hemorrhage and anemia -no masses -moderate weight loss -mild growth impairment -perianal and anal lesions rare -fistulas and obstruction rare -risk of toxic megacolon

Characteristics of Infectious Gastroenteritis (Table 43.-3 pg. 1087)

Escherichia coli -incubation period 1 to 3 days -summer -foodborne -Clinical Manifestations -symptions for 3 to 7 days or longer -green, watery, secretory diarrhea -may cause hemorrhagic colitis -fever -Diagnostic Findings -Blood and PMNs in stool Campylobacter -incubation 2 to 5 days -most common in infants & adolescents -Clinical Manifestations -symptoms for 2 to 10 days -consumption of contaminated foods or water -severe abdominal pain -foul-smelling, watery diarrhea -fever -Diagnostic Findings -Blood and PMNs in stool

Characteristics of Infectious Gastroenteritis (Table 43.-3 pg. 1087)

Giardia lamblia -incubation 1-2 weeks -most common cause of parasitic diarrhea -spread in contaminated food and water -Clinical Manifestation -symptoms for days to weeks -afebrile -abdominal distention, cramps, & flatulence -variable diarrhea -Diagnostic Findings -ova & parasites found in stool -parasites found on duodenal biopsy Rotavirus -incubation 1-3days -common in winter months -fecally contaminated food -Clinical Manifestations -symptoms usually last 3-7days -vomiting, diarrhea, low-grade fever -history of preceding or concurrent respiratory illness -Diagnostic Findings -Virus in stool detected by enzyme immunoassay

Intussusception: Manifestations/Diagnostics

Manifestation: -paroxysms of pain -child may vomit -passage of bloody mucus stol and diarrhea -sausage-shaped abdominal mass -Symptoms of shock and sepsis are present if obstruction has been present for > 12 to 24 hours Diagnostics: Abdominal radiographys -ultrasonography -barium enema/air enema examination

Hirschsprung Disease: Manifestations/Diagnostics

Manifestations: -delayed passage or absence of meconium stool in the neonatal period Neonate, infant, or older child: -bowel obstruction -abdominal pain -distention -vomiting -failure to thrive Diagnostics: -rectal exam -barium enema -suction rectal biopsy -Anal rectal manometry (ARM)

Lactose Intolerance: Manifestations/Diagnostics

Manifestations: -diarrhea -abdominal distention -cramping abdominal pain -excessive flatus Diagnostics: -Finding of 1+ or higher on the Clinitest stool test (0 to 4+) -lactose tolerance testing (breath hydrogen test)

CD: Manifestations/Diagnostics

Manifestations: -diarrhea and growth failure -abdominal distention -vomiting -anemia -irritability -anorexia -muscle wasting -edema -folate deficiency -profuse, watery diarrhea, and vomiting (child in celiac crisis) Diagnostics: -IgA antitissue transglutaminase (tTG) antibody test -IgA antiendomysial antibody test -breath hydrogen test

SBS: Manifestations/Therapeutic Management

Manifestations: -watery diarrhea -steatorrhea -bloating -excessive gas -foul-smelling stool -poor appetite -vomiting -weight loss/inability to gain weight -fatigue Therapeutic Management: -surgery -fluid & electrolytes restored & stabilized -nutritional support -TPN initiated

Gastroesophageal Reflux Disease

Physiologic: -painless emesis after meals -parents may not be concerned or may think it is normal -rarely occurs during sleep -no failure to thrive -40% asymptomatic by 3 months -70% asymptomatic by 18 months -pharmacologic and medical management very effective Pathologic: -failure to thrive -aspiration pneumonia and/or asthma -apnea, coughing, and choking -frequent emesis, abdominal pain, and crying -may require surgery and pharmacologic treatment

HCV

Prevention of spread -Standard precautions -PPE; gloves, mask, eye/face shield -Safe injections Immunization/Postexposure Prophylaxis -NONE

HAV

Prevention of spread -hand hygiene; PPE, gloves -identifying infected food handlers Immunization -given as 2 injections at age 1 yr and at least 6 mo later -recommended for all children at age 1 yr & specific populations in high-risk areas Postexposure Prophylaxis -w/i 2 wk, give hepatitis A immune globulin (HAIG), 0.02 mL/kg IM

HBV

Prevention of spread -standard precautions -PPE, gloves, mask, eye/face shield -safe infections Immunization -3 injections at birth, age 1-2 mo, & age 6-18 mo -recommended for all infants, children, and adolescents Postexposure Prophylaxis -for neonates of infected mothers, give hepatitis B immune globulin (HBIG) w/i 12 hr of birth followed by immunizations -HBIG, 0.06 mL/kg, w/i 24 hr of any percutaneous exposure

Characteristics of Infectious Gastroenteritis (Table 43.-3 pg. 1087)

Shigella (Enteroinvasive with Cytotoxin) -incubation period of 1 to 2 days -most common in the summer -fecal-oral spread -remains communicable for 1-3 weeks -Clinical manifestations -symptoms last 5 to 10 days -diarrhea = watery to bloody with mucus -severe abdominal pain -high fever -neurologic symptoms -risk for sepsis, hemolytic uremic syndrome, rectal prolapsed, and DIC -Diagnostic Findings -blood mucus, WBCS in stool -positive stool culture in some cases Salmonella (Enteroinvasive) -incubation 1 to 3 days -summer & fall -usually foodborne -infectious for duration of illness & variable period afterward -Clinical manifestations -symptoms last 2 to 5 days -rapid onset -secretory diarrhea -abdominal pain, nausea, & vomiting -Diagnostic Findings -blood and PMNs in stool -positive stool culture

Hepatic Disorders

Viral hepatitis -acute or chronic inflammation of the liver caused by several diff viruses, toxins, and disease states Hepatitis A (HAV) -person to person; fecal-oral route -ingestion of contaminated water or food -jaundice, fever, fatigue, anorexia, nausea, vomiting, abdominal pain, dark urine, clay-colored stools, joint pain Hepatitis B (HBV) -percutaneous or mucosal contact w/ infectious blood or body fluids, sexual intercourse, needle sticks, blood transfusions, & birth -same symptoms as HAV -severity from mild illness to sever, acute or chronic illness Hepatitis C (HCV) -primarily by large or repeated percutaneous exposure to infectious blood via injection, blood transfusions, needle sticks, & birth -same symptoms as HAV -most persons w/ chronic HCV infection are asymptomatic Hepatitis D (HDV) -Percutaenous or mucosal contact with infectious blood or body fluids -over 1/2 of children have chronice hepatitis -occurs only as coinfection w/ HBV Hepatitis E (HEV) -fecal-oral -ingestion of contaminated water -same symptoms as HAV -outbreaks in countries w/ poor sanitation & contaminated water supply