Pediatrics Exam 2 - GI

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Esophageal atresia/Tracheoesophageal fistula post-op feedings

Observe first PO feed and monitor, begin with sterile water, follow with small amounts of breastmilk/formula

Nutrition after cleft lip surgery

Often able to eat immediately

Intussusception pathophysiology

One segment of bowel telescopes into another, causing a bowel obstruction

Gastroschisis treatment

Operate within 24 hours, place swollen intestines into silo to shrink, IV fluids and antibiotics, monitor for s/s of infection

Pyloric stenosis diagnosis

Palpation of abdomen for olive shaped mass, ultrasound, upper GI x-ray

Normal surgery age for both cleft lip and palate

9-15 months

Normal surgery age for cleft lip

10 weeks and 10 lbs

GER/GERD medications

Antacids, histamine receptor antagonists, proton pump inhibitors

When does vomiting occur in pyloric stenosis

Around 3 weeks of age, can be 1-5 months of age; usually 30-60 mins after feeding

Hirschsprung Disease manifestations

24-48 hr onset, delayed passing of meconium, distended abdomen, feeding intolerance with bilious vomit

Esophageal atresia/Tracheoesophageal fistula manifestations

3 C's (choking, coughing, cyanosis), frothy saliva, drooling, distended abdomen, coughing with feeds, respiratory distress and chronic issues (pneumonia), may present later in life but *urgent*

When to resume feedings postoperatively for pyloric stenosis

4-6 hour post-op sips of H2O/Pedialyte, 24 hr post-op resume formula in small increments, slowing increase and spread feeds to normal schedule

Normal surgery age for cleft palate

6-12 months

Eight hours ago, an infant with Hirschsprung's disease had surgery to create a colostomy. Which finding should alert the nurse to notify the provider immediately? A. 3 cm increase of abdominal circumference B. Periods of occasional fussiness C. Absence of bowel sounds since surgery D. Appearance of bright red stoma

A. Abdominal circumference is measured post-op to monitor abdominal distention. An increase of 3cm in 8 hours would indicate a substantial degree of abdominal distention, potentially from fluid or gas, so we would want to call the provider.

Surgeries for biliary atresia

Kasai procedure (removing gallbladder and replacing with part of small intestine), liver transplant

How to prevent trauma to sutures postoperatively for cleft lip and palate

Avoid prone positioning, NO forks, spoons, straws, sippy cups with hard straw, try to keep from crying

The nurse admits an infant with pyloric stenosis to the hospital. Which aspect of the plan of care should the nurse implement first? a. Begin an IV infusion b. Weigh the infant c. Switch the infant to an oral electrolyte solution d. Orient the parent to the hospital unit

B Unless in hypovolemic shock, you would want a baseline weight because it will be used to calculate the child's fluid and electrolyte needs

Gastroschisis pathophysiology

Bowel herniates through a defect in abdominal wall to side of umbilical cord and through rectus muscle

The nurses assesses an infant who has had surgery to correct an intussusception and is now at risk for the development of a paralytic ileus postoperatively. Which assessment should be the priority? a. Measurement of urine specific gravity b. Inspection of the first stool passed c. Auscultation of bowel sounds d. Measurement of gastric output

C Development of a paralytic ileus postop is a functional obstruction of the bowel. Bowel sounds may initially be hyperactive, BUT then they will diminish and decrease. USG gives information about fluid and electrolyte status. The first stool and amount and gastric output provides info about return of gastric function

Which statement by the parents would indicate the need for further education regarding caring for their child post cleft lip surgery? A. "I will prop my child up while they are laying down" B. "I will give my child Tylenol for the pain when we are at home" C. "I will feed my child applesauce with a spoon for the first two weeks" D. "I will wash the sutures with soap and water"

C No spoons, straws, forks post-op. These things can disrupt the sutures!

Which of the following is true regarding GER? A. It is a regurgitation of gastric contents into the lung B. Children who are born post-maturely have a higher incidence C. Repeated reflux of gastric contents can damage delicate esophageal mucosa D. Surgery is the usual treatment

C. Surgery is the last resort! Pre-mature children are higher risk.

Ostomy types

Colostomy or ileostomy, based on location

Hirschsprung Disease (Aganglionic Megacolon) pathophysiology

Congenital anomaly that results in mechanical obstruction from inadequate motility; inflamed/narrowed rectum that impedes emptying

Your 4-year-old patient presents to the hospital with the following symptoms: Sudden abdominal pain, abdominal distention, lethargy, and jelly-like stools. What diagnosis do you expect the patient to receive? A. Biliary atresia B. Appendicitis C. GER D. Intussusception

D Jelly-like stools is the main manifestation of intussusception.

Ribbon like stools are associated with which of the following: A. Intussusception B. Crohns Disease C. Biliary Atresia D. Hirschprung's Disease

D. This happens because there is a constriction in the bowel, and so if any stool gets past this, it is not formed, causing the stool to look ribbon like.

Manifestations of chronic intussusception

Diarrhea, weight loss, occasional vomiting, episodic pain

Omphalocele pathophysiology

Failure of in-folding of abdominal wall during gestation, results in intestines in thin sac outside body near umbilical cord

G-button

Form of gastronomy tube that is closer to skin, cosmetically pleasing, and offers more mobility and comfort

Omphalocele complications

GER, feeding issues, failure to thrive

Biliary atresia diagnosis

H&P, elevated AST, ALP, and GGT (liver values), ultrasound, nuclear imaging, exploratory laparotomy with cholangiogram

Acute appendicitis diagnosis

H&P, elevated WBC with elevated % bands, ultrasound/CT

Intussusception diagnosis

H&P, ultrasound showing mass with bullseye

GER/GERD manifestations in older children

Heartburn, abdominal pain, chronic cough, hoarse voice, dysphagia, vomiting

Pyloric stenosis management

IV access, correct alkalosis, NG tube for decompression, pyloromyotomy (cut pyloric muscle, relieve obstruction)

GER/GERD diagnosis

Infant gastroesophageal reflux questionnaire, barium esophogram, radioactive nucleotide studies/scintigraphy, EGD

Enema administration

Isotonic solutions only or 1 tsp salt to tap water, proper volume is age-dependent

Esophageal atresia/Tracheoesophageal fistula post-op care

Maintain airway, nutrition, replace fluids as needed, prevent infection/pneumonia, manage pain, suctioning

Short Bowel Syndrome pathophysiology

Malabsorptive disorder that occurs as a result of decreased mucosal surface area, resulting in need for TPN

Omphalocele presentation

May be small (small bulge in umbilical cord), intestines covered by thin sac

Postoperative pyloric stenosis care

May vomit for 24 hours, manage pain, prevent injury, resume feedings

Postoperative care for cleft lip and palate

Monitor for shock and hemorrhage, prevent aspiration, prevent trauma, prevent pain, promote healing

Intussusception management

NG decompression, antibiotics, IV fluids, gas/water/saline enema, surgery

Hirschsprung Disease pre-op care

NG tube, antibiotics, vit K

Use of ostomies in infants

Necrotizing colitis, imperforate anus, Hirschsprung diease

GER/GERD surgery

Nissen Fundoplication

Cautions/problems with gastronomy tube

No hydrogen peroxide to clean/leaking, clogging, erythema and bleeding around stoma, vomiting, diarrhea, granulation tissue buildup

Fleets enema

No. Fleets enemas are hypertonic, leading to diarrhea and metabolic acidosis

Plain tap water enema

No. Hypotonic solution, leading to rapid fluid shift/overload

Biliary atresia treatment

Nutritional support, tube feeds or TPN, liver transplant

Peritonitis cause and symptoms

Perforated appendicitis; distention, rapid shallow breathing, pallor, chills, restless

Acute appendicitis complications

Perforation: initial relief of pain followed by increase and results in peritonitis.

Acute appendicitis manifestations

Periumbilical pain that moves to RLQ to McBurney's point, N/V/D, lethargy, poor feeding, fever, tachycardia, hypoactive bowels

Biliary atresia manifestations

Persistent jaundice after 2 weeks of age, dark urine, gray stools, hepatomegaly, firm liver on palpation

Short Bowel Syndrome management

Preserve as much bowel as possible, maintain nutrition, intestinal transplant

Cleft lip and palate - preoperative care

Prevent aspiration, prevent infection (improper drainage of middle ear common)

Biliary atresia pathophysiolopgy

Progressing inflammatory process that causes bile duct fibrosis which results in bile duct obstruction, many infants with biliary atresia appear healthy at birth

Manifestations of pyloric stenosis

Projectile vomiting (hallmark symptom), non-bilious vomiting, distended upper abdomen, very hungry, metabolic alkalosis, weight loss, failure to thrive, blood-tinged vomit

Appendectomy considerations

Prophylactic antibiotics, IV fluids/electrolytes, laparoscopic if no perforation

Ostomy care

Protect peristomal area, encourage participation in care, encourage normal life activities

How to prevent aspiration postoperatively for cleft lip and palate

Raise HOB

Hirschsprung Disease diagnosis

Rectal biopsy, anorectal manometry (measures pressure in anus)

GER/GERD manifestations in infants/young children

Regurgitation, vomiting, excessive irritability, poor weight gain, respiratory problems, feeding refusal

Post-appendectomy care w/o perforation

Splint, incision care, early ambulation, pain management

Post-appendectomy care w/ perforation

Splint, incision care, early ambulation, pain management, NG tube to decompress, NPO until GI motility returns, IV antibiotics, may have drain

Esophageal atresia/Tracheoesophageal fistula pre-operative care

Suctioning, parenteral nutrition and fluids, antibiotics, humidified oxygen, NPO

Intussusception manifestations

Sudden abdominal pain, jelly-like mucous stools, vomiting (bile-stained), distention, tenderness, lethargy, crying

Nissen Fundoplication

Surgery for GER/GERD; reinforces lower esophageal sphincter, reserved for those with severe complications (apnea, recurrent aspiration pneumonia, failure to thrive)

Hirschsprung Disease treatment

Surgery to remove aganglionic portion; if diagnosed before distention can operate immediately; if diagnosed later colostomy for 3 mo then surgery

Omphalocele treatment

Surgical closure

Short Bowel Syndrome nutrition

TPN (central line), enteral feeds, oral feeds to stimulate suck reflex, *intestinal transplant for those dependent on TPN*

Tracheoesophageal fistula pathophysiology

The esophagus and trachea are abnormally connected, allowing fluids from the esophagus to enter the airways.

Cleft lip AND palate nutrition

take in a lot of air, need to burp more often, milk leaks from nose, can show signs of stress

Esophageal atresia pathophysiology

The upper and lower parts of the esophagus don't connect, preventing food and saliva from reaching the stomach.

GER/GERD management

Thicken formula, small frequent feeds, slow feeds, frequent burping, upright/side lying position for 1 hr post-feed, elevate HOB, avoid trigger foods

Cleft lip nutrition methods

Trouble getting seal for feeding, squeezing cheeks can help, can typically use regular bottle

Cleft palate nutrition methods

Trouble with suction, bottle with one-way valve

Esophageal atresia/Tracheoesophageal fistula diagnosis

X-ray, bronchoscopy

Pyloric stenosis pathophysiology

circumferential muscle of the pyloric sphincter (stomach to small intestine) becomes thickened resulting in narrowing and elongation of the pyloric canal

Nutrition after cleft palate surgery

clear liquids for 24 hours, full liquid for 2 weeks, soft foods for 6 weeks

Short Bowel Syndrome causes

congenital abnormalities (e.g. Hirschsprungs), ischemia (necrotizing enterocolitis), meconium peritonitis, Crohn's disease

Nasogastric tube measurement

measured NEMU (nose, ear, midway to umbilicus)

Nasoduodenal and nasojejunal tube

nose to duodenum/jejunum for feeding, medications need to be highly diluted

Nasogastric tube

nose to stomach, no enteric or extended release medications, used for feeding, decompression, and lavage

Pain control postoperatively for cleft lip and palate

opiates for 24-48 hours, acetaminophen after

Gastronomy tube location and use

through abdomen wall into stomach, alternative to longterm NG use, can also be a G-button


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