Gastrointestinal Disorders - Peds

Other dx test for acute appendicitis?

CT scan

Assessment and documentation of FTT?

- Accurate height & daily weight - Feeding behavior - Parent-child interactions - Developmental level

What is constipation defined as...

- Decrease in the frequency of stools, - Formation of hard stools - Oozing liquid after passing hard stools ( Encopresis)

Etiology and risk factors for cleft lip and palate?

- Girls > Boys - Multifactoral inheritance - Folic acid deficiency - Maternal smoking & alcohol in first trimester - Maternal exposure: Several drugs ex. Dilantin, Accutane - Pesticide exposure

S/sx of cleft lip?

- Notched vermilion border, sizes vary - Dental anomalies can occur - Feeding difficulties - Potential for problems w/ social acceptance

Nonorganic FTT (NFTT)?

Caused by psychosocial or other factors, such as ... - Poverty - Family stress - Health beliefs (fad diets, etc.) - Lack of emotional & sensory stimulation - Inadequate nutritional information - Difficulty separating from parent - child uses refusing food as attention getting mechanism - Insufficient breast milk

Organic FTT?

Result of a physical cause, such as ... - Congenital heart disease - Malabsorption syndrome, Gastroesophageal reflux - Cystic fibrosis - Chronic renal failure - Endocrine or neurological disorder

GER may occur without what?

actual regurgitation - Spitting up, Cough, CP, nausea, pyrosis, dysphagia, SOB, halitosis, arched back, excessive crying, recurrent pneumonia, failure to thrive - GER may present atypically - Sxs may mimic other conditions (i.e., asthma)

Other concerns with vomiting?

dehydration, electrolyte disturbances, pH changes, malnutrition, aspiration, trauma to esophagus, etc.

Nursing care of FTT?

- Non-judgmental - Provide consistent caregiver - Increase stimulation appropriate to child's dev. level - Provide optimum nutrients - Make feeding priority goal; Keep accurate record I & O; Weigh daily - Introduce positive feeding environment - Establish structured routine & follow consistently; One nurse for feeding; Follow child's rhythms of feeding; Maintain calm, quiet environment; avoid interruptions; Hold young child for feeding; maintain eye contact; Talk to child by giving appropriate directions & praise; Persist in the face of protest by child - Supply parent w/ emotional support w/o fostering dependency - Promote parent's self-respect and confidence by praising achievements of child - Provide for home care..... A lot of teaching necessary - Demonstrate proper care by example, not lecturing

Therapeutic mgmt of GER?

- Nothing if growing well and no respiratory complications, feed upright position, small frequent meal - Positioning: prone if awake with caution, supine prop-up HOB at home - Diet therapy, rice in feedings, hypoallergenic formula, decrease acid/irritating foods, position during and time of meals - Medications: GERD - H2 receptor antagonists, - Proton pump inhibitors, - Nissen fundoplication severe GERD ( lap procedure wraps the fundus of the stomach distal esophagus to decrease reflex). - Monitor for failure to thrive, weight loss

What is a GI obstruction?

- Obstruction in the GI tract = impedes passage of nutrients and secretions - Constriction (narrowing), obstruction (blockage), or decreased motility (ileus) - Congenital or acquired

Pre-op care for acute appendicitis?

- Pain assess - Monitor fever - Abdominal distention - Avoid heat to the abdomen (May use ice for comfort to abdomen) - Pallor, chills, restless, and irritable (Caution sudden relief of pain followed by rigidity) - Potential shock signs - Antibiotics - Avoid laxatives/enemas

Nursing Management cont.

- Prevent spread of infection - Isolation precautions if appropriate - Eliminate and/or correct cause - Usually self-limiting - Antibiotics (?)may be given with E.coli, giadia - NO antidiarrheals if possible - Prevent complications - Meticulous skin care (zinc oxide, etc) - Rinse teeth after vomit (b/c of HCl-) - Position to avoid aspiration - Make child comfortable - Antiemetics if ordered (Ondansetron, Metoclopramide, Promethazine) - Mouth care if NPO - Parent teaching - Prevent recurrence - Rotavirus vaccine, vaccines when traveling, etc

What are hernias?

- Protrusion of a portion of an organ through an abnormal opening - Typically, inguinal or umbilical hernia - Rarely, diaphragmatic hernia - Danger of incarceration or strangulation - Gastroschisis - Omphalocele

Vomiting often has an infectious cause, but other causes may include...

- Psychological stress - Anatomical defect - Abnormal gastric motility - Inflammatory response - Increased ICP - GI obstruction

Post-op nursing care for pyloric stenosis?

- Same as general abd surgery - Pain management - Wound Care - Teach parents: - Feeding method (start w/in 4-6 hrs post op) - Signs of infection or complication (wound dehiscence or GER)

Family teaching and home preparation for cleft lip and palate?

- Support and educate family regarding home care - Teach family to observe for signs of speech or hearing impairment - Refer family to appropriate community resources - Cleft Palate Foundation and Cleft Lip Foundation

Tx for cleft lip and palate?

- Surgical closure of defects at optimum age - Cleft lip repaired first usually (2-3 months) (Cleft palate repair often 6-12 months) - Potential tympanostomy tubes in ears - Extensive orthodontics & surgery often through 18th year of age - Multidisciplinary team approach, lactation, emotional therapist, speech therapist (especially CP) plastic surgeon

What is failure to thrive (FTT)?

- The term used to describe infants & children whose weight & sometimes height fall below the 5th percentile for age - Persistent deviation from established growth curve

Nursing Management for constipation?

- Treat underlying cause - Depends on etiology of constipation - Diet modification = treatment of choice - Increase fiber intake - Increase fluids in older infants and children - Remove constipating foods (Bananas, rice, cheese, apple sauce, etc) - Infants:May add corn syrup (2 tablespoons) to formula or 2oz of pear or apple juice daily - Regular toileting - 30 minutes on toilet after every meal - Role-modeling by parents - Avoid retention - Meds: stool softeners (docusate or lactulose), Miralax, fiber - Caution: risk impaction, risk UTI, vomiting/abdominal distention/pain/growth failure = need evaluation

Dx of GER?

- Usually physical exam and detailed history - Upper GI series, endoscopy, continuous pH monitoring ( amount of acid reflex in the esophagus).

Vomitus Characteristics?

- Visible undigested matter (________ stomach) - Bile colored (small intestine) - Smell like feces (large intestine) - Bright red blood (Upper GI bleed) - Coffee ground (lower GI)

Probable tests ordered for gastroenteritis?

- Weight (degree of dehydration) - Direct evaluation of stools - Hemocult tests and stool pH - Stool culture, O+P, fecal leukocyte testing - Blood Tests: CBC, serum electrolytes, creatinine, BUN, anion gap blood gases

DX for FTT?

- Weight and height plots - Health & dietary history - Possible home inventory - Family assessment - Many other tests based on history: Rule out: anemia, lead toxicity, ova or parasites in stool, zinc levels, etc.

Physical exam for acute appendicitis?

- abdominal pain (periumbilical then RLQ), fever, nausea and vomiting, McBurney positive, guarding, rigid abdomen - + rebound tenderness (sudden relief of pain, followed by increased pain and guarding on the right side of the abdomen)

What is GER?

= transfer of gastric contents into the esophagus from the stomach - GER Caused by incompetent or relaxed sphincter - Occurs naturally in everyone, esp <1 year self- limiting - GERD is a tissue damage from GER

The infant is scheduled for surgery in a few hours to remove the malfunctioning part of the bowel. What teaching from the nurse would best prepare the mother to know what to expect when she first sees her infant after surgery? A. "Your son will have a colostomy with a bag on his abdomen and an IV." B. "Your son will have an IV line, an oxygen source, a dressing, and perhaps a colostomy bag." C. "He will have a colostomy with a bag, a feeding tube, and an oxygen mask." D. "He will be wearing a diaper and will have an abdominal dressing and soft restraints."

B. This choice is the most complete and accurate of the options provided.

What is cleft lip?

Failure of the maxillary & median nasal processes to fuse during embryonic development (1st trimester) - Can be unilateral or bilateral - Defect can range from notch in vermilion border to complete separation to base of the nose

S/sx of FTT?

Growth Failure: - Weight & height below 5th percentile - Developmental delay(s) General Changes: - Hypotonia, decreased muscle mass - Generalized weakness - Abdominal distention - Endocrine changes Depends of type if FTT - OFTT may have associated signs and sxs of physical disease state - NFTT may be associated with unique signs and sxs

Evaluation and nursing care of gastroenteritis?

History: - Recent travel, water sources, animal/bird contact, daycare or school attendance, recent antibiotics, diet changes/food intake

What is hypertrophic pyloric stenosis?

Hypertrophy and hyperplasia of the circular muscle of the pylorus

Tx for intussusception?

Nonsurgical hydrostatic reduction by air or saline enema - Often corrected during the diagnostic procedure - Successful 80% of time - With or without water-soluble contrast - If this doesn't work, have to do surgery (usually laparoscopic) - IV, NG, and antibiotics prior to intervention - Reduction/resolution evidenced by successful passage of normal brown stool > report to practitioner

Post-op care for cleft lip and cleft palate?

Place infant in supine HOB elevated - To reduce edema, respiratory difficulties Liquid diet; progress to soft if appropriate - Progress feedings as tolerated (may use special device) - Caution trauma to suture line Provide pain control - Analgesic medication & nonpharm. Measures, avoid crying Provide emotional support for parents - Recovery is long and prognosis uncertain for scarring and full recovery of function - Protect post-op site

Complications of celiac disease?

growth failure, vitamin deficiency, anemia, osteoporosis, celiac crisis (can lead to shock), later in life: lymphoma if not compliant

Tx for hirshsprungs disease?

Confirm diagnosis: - Rectal biopsy showing absence of nerve fibers Surgical removal of aganglionic portion(s) of bowel - May be multi-stage process: - Performed when physical status appropriate - May need nutrition and enemas prior - Potential colostomy (usually temporary) - Long-term concerns: fecal incontinence and constipation

What is Hirschsprung disease?

Congenital Aganglionic Megacolon - Congenital anomaly (1:5000 live births) - Some familial/genetic tendency - Boys > Girls - Short or long segment; may be single or multiple segment - May not be diagnosed until infancy or childhood (usually first months) - Causes mechanical obstruction due to inadequate motility of part(s) of the intestine.

The nurse is obtaining a history about the infant's early months. What question is most critical for the nurse to ask to aid in the diagnosis of HD? A. "Did your son urinate immediately after delivery?" B. "When did your son have his first bowel movement?" C. "Did you breastfeed or bottle-feed your son?" D. "Did your son experience any colic?"

B. "When did your son have his first bowel movement?"

The absence of parasympathetic ganglion cells in segment causes what?

- Increased sphincter tone and sympathetic activity - Accumulation of intestinal contents and distention of bowel - No evacuation of solid or liquid stool, decreased gas

Post-op care for acute appendicitis?

- Vital signs, T, pain level - Pain assess - NPO status (Side-lying position, IV fluids, Monitor BS and elimination) - Lap vs. Open surgery - Monitor drain - Dressing change - Assess incision for infection - Antibiotics

Idiopathic FTT (IFTT)?

Unexplained (usually NFTT)

Causes of infectious gastroenteritis?

- Fecal-oral spread - Virus, Bacteria, Parasite - Most common: rotavirus

+/- classic triad intussusception?

1. Abd pain 2. Abd mass 3. Bloody stools

What may give clues as to the cause of vomiting in peds patients?

Appearance may give clues - Biliousvs. Non-bilious, undigested food, mucous, heme, etc

Nursing considerations for cleft lip and palate?

Assessment and Documentation: - Feeding behaviors; oral hygiene - Respiratory status - Hearing ability; Speech - Parent/child interaction and adjustment

The infant's mother asks about the testing her little son needs to undergo. She is very worried because she does not understand what testing is involved even after the pediatrician has explained it. What response from the nurse would be most appropriate? A. "What are your concerns?" B. "It's too soon for us to be discussing the tests." C. "Every mother is scared when her baby is ill." D. "There are several tests, including x-rays and a rectal biopsy, but we will keep your son comfortable."

D. This response is brief, correct, and provides concern about the baby's comfort.

What is cleft palate?

Failure of the 2 sides of the palate to fuse during embryonic development (1st trimester) - May occur w/ or w/o cleft lip

Medications if needed (for vomiting)?

- Ondansetron; - Metoclopramide, - Promethazine; - Dimenhydrinate

Tx of celiac disease?

- Lifelong complete elimination of gluten from diet - Eliminate wheat, barley, rye, & oat - Substitute corn, rice, soybeans & millet - Supplementation of vitamins & minerals - Iron, folic acid, fat soluble vitamins - Caution: may develop lactose intolerance from severe damage to mucosa

Dx of pyloric stenosis?

- Physical Exam - Labs: Electrolytes - Decreased K+ & Na, (May be masked by hemoconcentration from dehydration) - Decreased serum Cl- levels - Increased pH & Bicarb levels (metabolic alkalosis) - Elevated BUN (dehydration) - Ultrasound evidence - Laparoscopic Pyloromyotomy Surgery

Pre-op care for pyloric stenosis?

- NPO - Monitor I&O, specific gravity, & signs of dehydration - IV therapy & monitoring (no added K+ if not urinating) - Vital signs, daily weights - Skin care meticulous esp. if dehydrated - NG tube care - Parents: support & education

S/sx of cleft palate?

- Nasal distortion - Midline or bilateral cleft extending uvula & soft/hard palate - Nasal cavity exposure - Feeding problems - Infection, especially aspiration pneumonia - Altered speech - Altered dental development - Hearing problems caused by recurrent otitis media

S/sx of pyloric stenosis?

Vomiting Progressively projectile Shortly after feeding No bile (w/ further obstruction) May be blood tinged (hematemesis) Infant hungry, avid eater Accepts second feeding after vomiting No evidence of pain or discomfort early Mild dehydration (early) Looks increasingly ill: Weight Loss Increasing dehydration Distended upper abdomen Palpable olive-shaped mass in right upper quadrant of abdomen Visible gastric peristalsis Metabolic alkalosis with excess loss of gastric juices

Nursing Management?

Correct fluid, electrolyte, & acid-base imbalance - Usually able at home EDUCATE - Provide oral rehydration (ORT) and ? IV fluid therapy - Replacement per dehydration status (replace then maintain) - If no signs/sxs of dehydration, then just maintenance fluid amounts - Still encourage oral with vomiting (unless sign of blockage or risk aspiration) - Replace extra for each vomit/diarrheal stool - ORT then advance to regular diet - SLOW BUT CONSTANT: 5-10 mL every 2-5 minutes - Medicine cup, syringe, NG tube, G-tube, etc. - Age-appropriate unrestricted diet ASAP - Continue low-sodium fluids, such as breastfeed/formula - Educate on correct replacement fluids - Monitor for signs/sxs of electrolyte imbalance - Accurate I & O - Daily weights, weigh diapers, abdominal girth, etc. - IVF only if severe or if unable ORT - usually NS or LR

What else to note with vomiting?

volume, frequency, appearance, and associated signs/sxs

When should the first meconium be passed?

within 24 to 36 hours of life; if not... - assess forHirschsprung disease - Hypothyroidism - Meconium plug or meconium ileus (cystic fibrosis)

Tx of FTT?

- OFTT: Determine and treat cause - NFTT: - Hospitalize for feeding trial and observation - Teaching! - Home treatment - Implement feeding program - Implement infant stimulation program - Provide stress relieving services for family - Provide mental health counseling as needed - Terminate parental rights if necessary

The mother asks about giving Brian 4 years old food after he is rehydrated. Which is the most appropriate recommendation?

- Offer a regular diet. - Offer a regular diet except high-protein foods. - Give clear liquids for the next 24 hours. - Start the BRAT diet (bananas, rice, apples, and tea).

Pediatric differences in the digestive and gastrointestinal system?

- Infant ability to swallow limited to fluids until about 4 months of age. Extrusion reflex. - Smaller stomach capacity - Lacking in digestive enzymes to about 4 months of age - Immature liver - Immature and young immune system - Proportionally longer GI tract in neonate/infant

Etiology and pathology of acute appendicitis?

- Inflammation of vermiform appendix - Avg age =10 years, boys = girls - Obstruction of the lumen of the appendix (usually fecalith = stool) or sometimes from a viral infection or parasite inflammation and infection - Mucous secretions blocked by obstruction pressure increases - Pressure compresses the blood vessels decreased blood flow to area ulceration occurs in the epithelial lining allows invasion of bacteria, eventual necrosis of tissue - Appendix perforates and ruptures contaminates the peritoneal cavity with stool and bacteria

Feeding considerations for cleft lip and palate?

- May use special nipple or appliance - Feed in upright position - Burp frequently during feeding - Teach breast feeding moms: - Positioning of infant - Molding breast to fill gap or using mother's thumb to fill gap - Soft diet post-op for older child (until healed)

Common causes of constipation?

- Most: environmental changes and/or development - DIET: Improper diet is frequent cause of constipation in infants and children - Control of bodily functions emerging - Psychological Factors( Fear) - Underlying disease or anatomical deformity - Medications (antacids, diuretics, antihistamines, opioids, iron, etc.)

Risks for gastroenteritis?

Fluid and electrolyte loss - Dehydration - Acid-Base Imbalance - Shock

Post-op care for hirshsprungs disease?

- NG suction until peristasis - No rectal temps - Abdominal girths, stool patterns - IV therapy - Colostomy care - Refer stoma therapist (Age appropriate) - Diet as prescribed - Teaching for family re: colostomy care, etc.

Pre-op care for hirshsprungs disease?

- NPO status - Maintain NG suction - IV therapy - Enemas, saline - Antibiotics - Measure abdominal girths with VS - Monitor stool pattern - Psychological preparation express grief - Loss of a perfect child

How does hypertrophic pyloric stenosis present?

- 2-5 weeks of age (usually) - Males > Females - Not congenital, although can be familial - Classic sign: projectile nonbilious vomiting after eating 4-5 ft

S/sx of intussusception?

- Abdominal pain:Intermittent, sudden, cramping - Inconsolable crying, drawing up knees (Child normal between episodes) - Palpable sausage-shaped abdominal mass - Bilious vomiting as progresses - Currant-jelly stools

S/sx of hirschsprung disease?

- Absence of meconium stool in newborn - Reluctance to ingest fluids - Abdominal distention - Palpable fecal mass, impactions - Chronic constipation and/or overflow diarrhea (older infants) - Ribbon like stool (foul smelling) - Failure to thrive (FTT)

NFTT may be associated with....

- Apathy and withdrawal behavior - Feeding or eating dysfunction - No fear of strangers at age when appropriate - Avoidance of eye contact - Wide-eyed gaze and continual scan of environment - Minimal smiling - Lack of attachment to parents - Stiff & unyielding or flaccid and unresponsive

Cleft palate post-op care?

- Avoid placing objects in child's mouth, i.e. standard spoon, tongue depressor, thermometer, straw, toothbrush - USE ONLY wide-bowled spoon - Restrain arms - Rinse mouth w/ water after feedings

Cleft lip post-op care?

- Avoid positioning on stomach - Apply elbow restraints - Cleanse operative site after feeding and as indicated. - Prevent sucking: use medicine dropper or syringe; - DO NOT use pacifier until site healed - Try to avoid crying as much as possible

What is gastroenteritis?

- By definition, involvement of the upper and lower GI tracts (stomach and intestines) - Most common cause of acute diarrhea, may also be associated with vomiting

Lab for acute appendicitis?

- CBC with differential (elevated WBC with left shift), - U/A (rule out test) - Serum human chorionic gonadotropin (rule out test: pregnancy)

Dx of intussusception?

- Clinical picture (assessment) - Ultrasound - Radiologist-guided enema (diagnosis and often resolution)

What is intussusception?

- Common cause of intestinal obstruction - Infants & toddlers (3 months - 3 years) - Peak 3-9 months - Cause not usually known, Rota virus vaccine - Most common site = ileocecal valve - Proximal segment of bowel telescopes into a distal segment pulling the mesentery with it

Dx of celiac disease?

- Definitive: Tissue biopsy of small intestine atrophy of intestinal villi - Blood tests for antibodies may be helpful Positive IgA antibody test - Remission when eliminate gluten from diet

S/sx of celiac diease?

- Diarrhea (Bulky, foul smelling stools (steatorrhea)) - Abdominal pain & distention change in behaiovr - Dermatitis - Highly pruritic rash knees , elbows buttocks bilaterally. - Muscle wasting, especially buttocks & extremities - Irritability, apathy

Major Pediatric Disorders of the Gastrointestinal Tract?

- Diarrhea/vomiting - Gastroenteritis - Constipation - Gastroesophageal Reflux - Pyloric Stenosis - Hirschsprungs Disease - Intussusception - Celiac Disease - Acute Appendicitis - Cleft Lip and Cleft Palate - Hepatitis - Irritable Bowel Syndrome - Inflammatory Bowel Disease

Diarrhea is often infectious, but may be r/t...

- Dietary indiscretions (hyperosmolar formulas, overfeeding, - Infection outside GI tract, esp. respiratory or UTI - Emotional tension - Medications - Inflammation or anatomical abnormalities

Nursing care for celiac disease?

- Extensive time, support, and education needed - Diet - Many hidden sources (i.e., in processed food as fillers, "hydrolyzed vegetable protein", hotdogs, hamburgers, lunch meats, gravies, etc.) - Complications if don't adhere to diet - Signs and symptoms of disease - Growth retardation - Anemia - Osteoporosis - Malignant lymphoma of small intestine

What is Celiac Disease?

- Gluten-Sensitive Enteropathy; "Celiac Sprue" - Malabsorption Syndrome - Biggest concern = risk of growth failure - Hypersensitivity/intolerance to gluten protein - Celiac disease affects one out of every 130 individuals in US. - Genetic mutation chromosome 6 may or may not develop celiac - Female > male - Onset often 6 months - 2 years - Appears in genetically sensitive kids - Inability to digest peptides contained in the gluten protein(gliadin) of wheat, barley, rye and (oat) grains Toxic substance and peptides accumulate in gut stimulation of immune and inflammatory response Inflammation & ulceration of intestinal mucosa atrophy of villi Malabsorption

What is diarrhea?

- Increase in # of stools (frequency) - Less consistency, more fluid, color can vary - Usually acute (sudden and duration less than 14 days) - Toxic reaction to pathogen + body ridding of pathogen - Most often viral - Chronic is greater than 14 days - More often chronic condition, food indiscretion, food sensitivity