GI dysfunction - Peds
A nurse in the pediatric clinic is caring for a child with lead poisoning (plumbism). For which associated complications should the nurse assess the child? Select all that apply. A. Malnutrition B. Liver damage C. Marked anemia D. Kidney damage E. Encephalopathy
C, d, e Not a - malnutrition increases absorption of lead, but lead poisoning does not increase malnutrition.
A newborn with a cleft lip is fed with a special nipple. What instructions should the nurse give the parents to reduce the incidence of regurgitation of the feedings? A. Offer thickened formula as prescribed. B. Place the baby in an infant seat during feedings. C. Position the infant on one side with the bottle propped. D. Burp frequently during feedings.
D Thickened formula - would be used for kids with reflux never prop a bottle Care seat - better off holding them.
A 3-week-old infant who has been vomiting for 3 days is admitted to the pediatric unit with a diagnosis of hypertrophic pyloric stenosis. What essential information should the nurse identify during the admission procedure? A. Character and amount of vomitus B. Size and shape of the abdominal mass C. Time of the last feeding, type of formula, and amount taken D. Respiratory status, amount and appearance of last voiding
D - aspiration? Voiding - hydration NOT: A - because of problem, going to already have non-bilius, projectile vomiting. We know this. C - going to continue to eat and eat despite vomiting
Causes of metabolic acidosis
DKA Hypermetabolism Renal failure dehydration liver failure diarrhea fistulas
stomach capacity
Day 1 = marble Day 3 = ping pong ball Day 10 = egg School-age = baseball Adult = softball.
Short Bowel Sydrome
Decreased ability to absorb nutrients d/t shortened intestine. - bowel resection or inflammation disorder (NEC, gastroschisis, atresia, etc.) - extent of bowel loss & location = severity. Treatment: - decreased bowel activity after resection = water stools X 3m - TPN until bowel begins recovery - Add small oral or enteral feeds (to promote motility) - Pectin, Loepramide - Monitor G&D - Teaching
Appendicitis
Inflammation of vermiform appendix - obstruction from stool, parasite, stenosis, hypeplasia, tumor. Often males 10-19 yrs. Ruptures highest in children under 4 yrs. S/sx: -periumbilical cramping, abd. tenderness, fever. - increased pain in RLQ (McBurney's point) - rupture = fever, pain relief, & distention, irritability, tachypnea = peritonitis. Dx: - less specific s/sx in younger kids - Increased WBC - US or CT Treatment: - Pre-op: NPO, IVF, electrolytes, ATB - OR - Postop: ATBs, possible wound packing, NG for decompression, NPO until bowel activity returns, correct F/E imbalances - Psychosocial report & teaching.
Necrotizing Enterocolitis (NEC)
Most common emergency condition of GI tract in neonates. - affects 4-13% of VLBW infants - mortality rate of 25-30% Lack of O2 to gut causes rapid multiplication of anerobic bacteria - produce air as byproduct. Air can be trapped in bowel wall (pneumatosis) or escape bowel wall (perforation). Hypoxia and bacteria cause infection and ischemia = bowel death. Clinical Manifestations: - feeding intolerance - bloody stools - S&S of sepsis (fever, increased temp, VS changes) - free peritoneal gas, dilate bowel loops, or pneumatosis on abd. xray Nursing Management: - early detection & management of feeding intolerance - insert/maintain Salem Sumpo or Anderson drain to LIWS - NPO: IV fluid/TPN/IL - ATBs - support of family - surgical site - care of penrose drain or ostomy + mucus fistula
A 4-yr-old child is returning from the PACU after an ruptured appendectomy. What physician orders do you anticipate? What would be your top 5 nursing priorities?
Possible wound packing NG for decompression NPO until bowel activity returns Combination of ATB's - IV Correct fluid & electrolyte imbalances - IV fluids Monitor for infection over time Wound care - drainage, bleeding, dressing... Pain management Respiratory assessment - distress possible. GI - return of bowel sounds/activity
1. A specimen for arterial blood gases is obtained from a severely dehydrated 3-month-old infant with a history of diarrhea. The pH is 7.30, Pco2 is 35 mm Hg, and HCO3- is 17 mEq/L. What complication does the nurse conclude has developed?
pH = low pCO2 = okay Bicarb = low Metabolic acidosis
Development of the GI tract
- placenta provides nutrients & waste removal in utero - GI tract is complete but immature at birth - sucking reflex voluntary after 6wks. - excretory control by 2-3 yrs.
Hernia
- Inguinal, Umbilical Diaphragmatic: abdominal contents into thoracic cavity - leading to respiratory distress shortly after birth w/50% mortality rate - S/Sx: barrel chest & sunken abdomen - Dx: S/Sx, x-ray - Treatment: Support cardiac and respiratory complications (ECMO, high frequency ventilation, increase HOB) Decrease stimulation. OR. Post OP (lay on unaffected side, resp. support, F/E support, monitor for infection). Psychosocial Support & teaching.
Most frequently ingested injurious agents
- Pharmaceuticals - Cosmetic & personal care products - cleaning products - plants - toys - miscellaneous substances Initially: Airway Breathing Circulating Disability - what has been affected/what is not working? Exposure
Gastroesophageal Reflux (GER) or GERD
- Return of gastric contents into the esophagus - common GI disorder of childhood - 99% resolve by 12m Lower esophageal sphincter relaxes & allows passive regurgitation of stomach contents into esophagus. May also enter airway (aspiration) Pathologic condition: - poor weight gain, esophagitis, neurobehavioral changes, respiratory symptoms (Sandifer's Syndrome) Diagnosis: Hx, upper GI, pH probe... test for food allergy. Treatment: - depends on severity - Feeding: small/thickened & position upright after - Meds: Proton pump inhibitors (Prevacid), Antacids, histamine antagonists (Zantac), Prokinetic agents (reglan). - Severe SX = OR
Heavy Metal Poisoning
- mercury thermometers - lead poisoning (most common). Paints in older homes, contaminated bare soil, cultural or ethnic traditions. Screening for lead poisoning - 1 to 2 yrs, happens to everyone. Screens for anemia, H&H, and tack on lead too. - Chelation therapy if positive.
Food Allergy VS Intolerance
Allergy: A specific immune response upon exposure to a given food. Intolerance: Situation in which a food elicits an adverse rxn w/out an immunologic mechanism. Ex. lactose intolerance. Clinical Manifestations: - systemic: anaphylaxis - GI: abdominal pain, diarrhea - Respiratory: cough, wheeze - Cutaneous: atopic dermatitis
Omphalacele
Associated w/other anomalies (cardiac, GU, trisomy, craniofacial, diaphragm). Happens more often than gastroschisis. Treatment: - Prevent heat loss - Protect from injury (sterile plastic, saline soaked gauze) - NPO - OR to correct defect (pain control, infection control, maintain I/Os, incision care) - Psychosocial support & teaching.
Gastroschisis
Associated w/other anomalies (cardiac, GU, trisomy, craniofacial, diaphragm). Omphalacele happens more often. Treatment: - Prevent heat loss - Protect from injury (sterile plastic, saline soaked gauze) - NPO - OR to correct defect (pain control, infection control, maintain I/Os, incision care) - Psychosocial support & teaching.
Lab tests for GI function
Bilirubin - to monitor for jaundice/liver disease Stool for ova/parasites or occult blood Electrolytes - sodium/potassium Acid/Base balance
Types of Dehydration
Change over time w/compensation. Isotonic - H2O loss = Na+ loss - V & diarrhea primary form Hypotonic - Na+ los > H2O loss - compensatory shift from ECF to ICF = increased dehydration - prolonged V & D, burns, renal disease, diluted formula, increased H2O intake, IVF admin. w/out electrolytes. Hypertonic dehydration - H2O loss > Na+ loss - shift from ICF to ECF = delayed onset of symptoms - neuro symptoms w/onset of dehydration symptoms - DI, IVF or feeds w/high electrolyte levels, concentrated formula.
Constipation
Common complaint of childhood. Hard, pebble-like stools for 2 wks. May present w/decreased stool, hard/dry stool, oozing/liquid stool. Defective filling or emptying of rectum. - hypothyroid, meds (narcs), diet, obstruction, immobility, structural anomaly (stricture/stenosis), aganglionic segment (Hirshprung) No rectal fill = excessve drying of stool. No rectal emptying = decreased defecation reflex (spinal cord lesion, weak abd. muscles, lesion blocks sphincter release). Psychological influences: - shame (hx of bullying, no privacy). - encopresis - recurrent soiling at inappropriate times. - Fear of pain from passage of hard stools (common w/toilet training, self-fulfilling prophecy). - Too busy to go to restroom.
Hirschprung Disease
Congenital aganglionic megacolon. Inadequate motility = obstruction. Genetic tendency, affecting males more than females. Usually affects rectum & sigmoid colon. S/Sx: vary w/age of onset. Infant: - failure to pass meconium w/in 48 hrs of birth - abdomnial distention - emesis - no tx = fever, blood diarrhea, enterocolitis - GI bleed Older infant: - FTT, severe constipation, abdominal distention - Pencil thin stools Dx: Hx, bowel pattern, rectal biopsy Treatment: - remove aganglionic bowel - possible colostomy - monitor I&O's, growth - bowel irrigation - Post-Op: monitor for infection, pain control, hydration, abd. assessment. - Psychosocial support & teaching
Esophageal Atresia (EA) & Tracheoesophageal Fistula (TEF)
EA: Failure of esophagus to develop as a continuous tube (90% w/TEF) TEF: Fistula connects esophagus and trachea. Associated w/other anomalies (cardiac, GI, GU, musculoskeletal) What would you see? Would become apparent pretty quickly. Choking, distended stomach, copious drooling and return of oral secretions, potential respiratory issues S&S: - Excessive drooling, salivation, cyanosis, choking, coughing, & sneezing. - Feeding - fluids return though nose & mouth. - abdominal distention from trapped air. Diagnosis: - inability to pass NG w/EA - X-ray, US Treatment/Management: - Suction at bedside - NPO - Raise HOB - NG to LIWS - OR: ASAP (ligate fistula, G-tube, anastomisis) - OR complications (reflux, aspiration, stricture formation, infection) - Psychosocial support & teaching
Cleft lip/Cleft palate
Etiology - 10% associated with syndrome - cause: multifactoral (genetics, environment, folate) S/Sx - defects may occure separately or in combination Treatment: - multidisciplinary - screen for otitis media - intervention for compromised family coping - prepare for OR - lip approximation Imbalanced nutrition/Risk for Aspiration - Feeding: Hold upright or semi sitting Place nipple in check facing back of tongue Special Bottles/nipples Feed slowly & burp regularly NG feeds with inadequate PO feeds Hold upright for 30 min after feeding Elevate HOB Keep suction equipment at bedside. OR - Lip closure: 2-3 m to enhance feeds - Palate closure: 18 m, w/increased severity = more surgeries Post-Op Care: Maintain suture line - IV fluids then advance from clears - formula - solids - Use dropper, asepto syringe, or special feeder (avoid sutures, no metal utensils or straws) - no pacifier - position supine - ATB ointment - medicate to avoid crying - elbow immobilizers Monitor for respiratory complications.
A nurse is caring for an infant with known GER. The child was re-admitted to the hospital for failure to thrive (FTT). What questions does the nurse need to ask the family/care givers?
How often? For feeding and amount Overall weight gain, pre and post feeds Diapers Explain how to go about feedings... positioning, what are they eating, F or BF, how often are they burping during the feed? How much/often with vomiting Sleep/wake cycle, irritability...
Pyloric Stenosis
Hypertrophy of pyloric muscle = stenosis of passage from stomach to duodenum. Edema = increased stenosis leading to obstruction. Major symptom = vomiting. - usually present 2-8 wks. - Non-bilious vomiting that becomes projective w/greater stenosis. - irritable, no weight gain or loss, FFT, decreased stool. - later s/sx = dehydration & metabolic alkalosis - visible peristaltic waves, hyperactive BS - olive size mass in RUQ - hungry despite vomiting. Treatment: - correct dehydration, alkalosis, & electrolyte imbalances (decreased Cl, Na, K/ increased pH) - NG to decompress stomach (NPO) - OR - release circular fibers of hypertrophic muscle - After: advance PO feeds as tolerated - avoid incision pressure (no lifting of legs w/diaper change (roll side to side) - Analgesics - Keep incision clean & dry - teaching (vomiting common 24-48 hrs post repair)
Fluid & Electrolyte Changes
Infants are so small and they have a so much body surface area that they can lose a lot of fluid. Younger the child - greater risk of dehydration with illness. NB - 75% total body water ECF 45% ICF 30% Brain and skin occupy a greater portion of body weight & are high in interstitial fluid. Infant - 65% total body water ECF 25% ICF 30-40% High BSA promotes fluid loss. 5-6X greater fluid exchange daily. Little fluid reserve in intracellular fluid. High metabolic demand rate requires generous fluid intake. Child/Adolescent - 50% total body water. ECF 10-15% ICF 40% Kidneys are immature until 2 yrs and unable to conserve water and electrolytes or fully assist in acid-base balance.
Gastroenteritis
Inflammation of stomach & intestines. Diarrhea often accompanied by N/V. Inflammation < SA available for absorption. Accounts for 13% of hospitalizations in children < 5yrs. Acute - bacteria, virus, parasite... Rotavirus = #1 cause. Chronic. S/Sx range from mild, moderate, to severe diagnosis. Diagnosis: - Hx: illness exposure, meds, travel, food prep., allergies, childcare. - Physical exam: severity of dehydration (output exceeds input). Labs: - stool: occult blood, parasites, bacteria, viruses, fats, sugars. - serum & urine - F/E imbalances - chemistry = Na, K, HCO3, BUN, UA. Management: - limit simple carb intake - antimicrobial therapy w/bacteria or parasitic process - anti-emetics/antidiarrheals = not used in small children d/t high degree of SE's - Strictly monitor I&O's/wt - skin care - teaching. Mild to moderate treatment. Oral rehydration therapy. - rapid absorption - less expensive & invasive that IVF - small frequent amounts: 10-15 ml q 10-15 min. mild = 50 mL/kg for first 4 hrs. replace fluids lost (vomiting/stool). - may continue lactose-free milk, breast milk, or 1/2 strength milk/juice. Moderate to severe: - IV fluid replacement: Calculate 24 hr maintenance fluid. Calculate % wt. loss. Add 24 hr maintenance + (% wt. loss X10) = mL of fluid intake for next 24 hrs. Administer 50% over 6 hrs - 10 to 20 mL/kg bolus - IVF at 1.5 X maintenance - Maintain safety - IV line - Change in LOC
Celiac Disease
Malabsorption from immunologic intolerance of gluten: increased glutamine in GI tract leads to mucosal cell damage = impaired absorption. S/Sx: - stetatorhhea, chronic diarrhea, vomiting, irritability, FTT, abd. pain. Diagnosis: - fecal fat, jejuna bx - serum studies increased antigliadin (AGA) antibodies and IgA components Tx: lifelong removal of gluten from diet. Continued exposure = G&D delay & increased risk of GI CA
All GI illnesses affect what?
Nutrient absorption. If short or long term.
Intussusception
Telescoping of the bowel. Frequent cause of bowel obstruction in infancy. Etiology: - Multifactoral & often unidentified - Viral infection, meds, inflammation - Telescoping - stool blockage - intestinal walls rub together - leading to edema & decreased blood flow = necrosis, perforation, and hemorrhage S/Sx: abrupt onset, acute abd. pain & vomiting, stool brown - red/currant jelly, palpable RUQ mass Dx - Hx, US, x-ray (contrast enema diagnostic & therapeutic - pressure of giving the enema may actually produce enough pressure to reverse the telescope & fix the problem) Tx: - enema or OR - monitor I&O - correct F/E - reduce infection - pain control - assess for distention (BS q4 hrs) - Clears - advance as tolerated after normal bowel activity returns
Atresia
absence or closure of a normal body orifice
Causes of metabolic alkalosis
antacid use/NaHCO3 use NG suctioning prolonged emesis hypercortisolism