OB Chap 28 The child with a Gastrointestinal Condition
Failure to Thrive: Can be caused by - ◦ Non-organic
(NFTT) is from the lack of parent-infant interaction resulting from environmental factors or neglect
Hernias (cont.): May be present at birth
(congenital) or acquired Is reducible if it can be put back into place by gentle pressure
Overhydration: Manifests as edema
(excess fluid in interstitial spaces) ◦ Interstitial fluid is similar to plasma, but contains little protein ◦ Any factor causing sodium retention can cause edema
Failure to Thrive: Can be caused by - ◦ Physical
(organic) pathology (OFTT), such as congenital heart or malabsorption syndrome
Treatment of Pyloric Stenosis Surgery is called pyloromyotomy Preoperative nursing care: ◦ Place on right side
(preferably Fowler's position) after feeding to facilitate stomach drainage into the intestines
Failure to Thrive (cont.): In some cases
, child is removed from home environment and placed elsewhere
Hirschsprung's Disease (Aganglionic Megacolon) (cont.) • Treatment: • Nursing Care
-Dependent upon age of child -In newborns, detection is high-priority -As child grows, careful attention to a history of constipation and diarrhea is important -Signs of undernutrition, abdominal distention, and poor feedings are suspect
Overhydration (cont.) • Treatment:
-IV therapy is ordered and child is monitored -Is dependent upon type of electrolyte imbalance child has -If child has a hypertonic type of dehydration, tomato juice should not be offered -If child has a hypotonic type of dehydration, plain water should not be offered
Overhydration (cont.) • Treatment:
-IV therapy is ordered and child is monitored -Is dependent upon type of electrolyte imbalance child has -If child has a hypertonic type of dehydration, tomato juice should not be offered -If child has a hypotonic type of dehydration, plain water should not be offered Nursing care ◦ Early detection and management of edema are essential ◦ Accurate daily weight, vital signs, observing physical appearance, and noting changes in urine output ◦ Important for nurse to monitor clinical laboratory results and adjust fluids and foods offered to the child
Hirschsprung's Disease (Aganglionic Megacolon) (cont.) • Treatment:
-Surgery to remove impaired part of colon and an anastomosis of intestine is performed -In newborns, a colostomy may be needed until 12 to 18 months of age, when more extensive repair may be performed
Hirschsprung's Disease (Aganglionic Megacolon) (cont.) • Treatment:
-Surgery to remove impaired part of colon and an anastomosis of intestine is performed -In newborns, a colostomy may be needed until 12 to 18 months of age, when more extensive repair may be performed • Nursing Care -Dependent upon age of child -In newborns, detection is high-priority -As child grows, careful attention to a history of constipation and diarrhea is important -Signs of undernutrition, abdominal distention, and poor feedings are suspect
Kwashiorkor (cont.): Occurs in children
1 to 4 years of age who have been weaned from the breast ◦ Oral intake is deficient in protein ◦ Child fails to grow normally
How much weight loss is indicative of this? Moderate dehydration
5% to 10% weight loss
Foreign Bodies:
80% of all ingestions occur in children between 6 months and 3 years of age ◦ About 80% of items ingested pass through the GI tract without difficulty ◦ May take up to 6 days to occur Caution parents not to use laxatives and to maintain a normal diet to avoid intestinal spasms
Intussusception:
A slipping of one part of the intestine into another part just below it ◦ Often seen at the ileocecal valve ◦ The mesentery, a double fan-shaped fold of peritoneum that covers most of intestine and is filled with blood vessels and nerves, is also pulled along Edema occurs At first, intestinal obstruction occurs, but then strangulation of the bowel occurs as peristalsis occurs Affected portion may burst, leading to peritonitis
Clostridium difficile infection
Abdominal pain, fever, bloody diarrhea
Identify symptoms associated with this. Clostridium difficile infection
Abdominal pain, fever, bloody diarrhea
Hirschsprung's disease (aganglionic megacolon)
Absence of ganglion nerve cells in the colon
Hirschsprung's Disease (Aganglionic Megacolon):
Absence of ganglionic innervation to the muscle of a segment of bowel ◦ Usually in lower portion of sigmoid colon Lack of normal peristalsis, results in constipation Stools are ribbonlike due to feces passing through the narrow segment of colon ◦ Portion of bowel nearest obstruction dilates, causing abdominal distention ◦ Seen more often in boys and in children with Down syndrome May be acute or chronic
The most commonly ingested drug is ______.
Acetaminophen
Poisons Commonly Encountered in Pediatrics
Acids Alkalines Medications Cyanide Ethanol Petroleum distillates Carbon monoxide Lead Arthropods, insect stings Snakes Poisonous plant
Celiac Disease:
Also known as gluten enteropathy and sprue Leading malabsorption problem in children ◦ Thought to be caused by inherited disposition with environmental triggers Symptoms not evident until 6 months to 2 years of age when foods containing gluten are introduced ◦ Wheat, barley, oats, and rye
Worms Pinworms (Enterobiasis) and Roundworms (Ascariasis)
Antihelminth medications are given for both types of worm infestations
Identify a blood test used to determine this. Liver function
Aspartate aminotransferase (AST)
Identify symptoms associated with this. Hernia
Asymptomatic or may see constipation and irritability
Describe treatment of this. Intussusception
Barium enema
Intussusception
Barium enema
Lead Poisoning (Plumbism) (cont.) Symptoms occur gradually:
Beginning stages, signs may be weakness, weight loss, anorexia, pallor, irritability, vomiting, abdominal pain, and constipation Later stages, signs may be anemia and nervous system involvemen
Treatment of Diarrhea
Bowel Rest ORS ◦ 1 tsp every 5 min. to start & gradually increase Lactobacillus helpful ◦ Probiotics reduce antibiotic induced diarrhea by 60%
Lead Poisoning (Plumbism):
Can have a lasting effect on the CNS, especially the brain Mental retardation occurs in severe cases of lead poisoning
Rickets:
Caused by deficient amounts of vitamin D ◦ Exposure to sunshine is necessary for proper absorption and metabolism of calcium and phosphorus Classic symptoms are bow-legs; knock-knees; beading of the ribs, called rachitic rosary; and, improper formation of teeth ◦ Vitamin supplements along with exercise and exposure to outdoor sunlight is primary form of treatment
Scurvy:
Caused by insufficient fruits and vegetables that contain vitamin C Symptoms include joint pain, bleeding gums, loose teeth, lack of energy Vitamin C ◦ Easily destroyed by heat and exposure to air ◦ Not stored in the body and daily intake of the vitamin is necessary Vitamin supplements and dietary intake such as citrus fruits and raw leafy vegetables
Dehydration:
Causes fluid and electrolyte disturbances Evaluation of type and severity, including clinical observation and chemical analysis of the blood Types of dehydration are classified according to level of serum sodium, which depends on the relative losses of water and electrolytes ◦ Isotonic ◦ Hypotonic ◦ Hypertonic
Appendicitis (cont.):
Characteristic symptoms ◦ Tenderness in RLQ, known as McBurney's point ◦ Guarding ◦ Rebound tenderness ◦ Pain on lifting thigh while in supine position ◦ Pain in RLQ Diagnostics can include ◦ Blood tests ◦ Abdominal X-ray ◦ CT scan ◦ Ultrasound Treatment ◦ Surgical intervention typically required Nursing care is the same as with most other abdominal surgery patients
Clarifying Food Labels
Children may have food allergies, so teach parents the following Ingredient What it may contain Binder Egg Bulking agent Soy Casein Cow's milk Coagulant Egg Emulsifier Egg Protein extender Soy
Lead Poisoning (Plumbism):
Children who chew on window sills and stair rails ingest flakes of paint, putty, or crumbled plaster Eating nonfood items is called pica Can have a lasting effect on the CNS, especially the brain Mental retardation occurs in severe cases of lead poisoning
Describe treatment of this. Imperforate anus
Colostomy
Failure to thrive (FTT)
Condition characterized by the inability to grow and develop appropriately
Congenital Disorders
Congenital Disorders
Identify symptoms associated with this. Hirschsprung's disease
Constipation, ribbonlike stools, abdominal distention
Identify symptoms associated with this. Intussusception
Currant jelly stools, sudden episode of severe colic, fever
Dehydration (cont.):
Deficit therapy restores preexisting body fluid and electrolyte deficiencies ◦ Shock is greatest threat to life in isotonic dehydration ◦ Children with hypotonic dehydration are at risk for water intoxication
Schilling test
Determines absorption capacity of the lower ilium
Hirschsprung's Disease (Aganglionic Megacolon) (cont.): Diagnostics
Diagnostics ◦ Barium enema ◦ Rectal biopsy ◦ Anorectal manometry Measures pressure in anal sphincter
Diarrhea:
Diarrhea in infant is a sudden increase in stools from the infant's normal pattern, with a fluid consistency and a color that is green or contains mucus or blood ◦ Acute sudden diarrhea most often caused by inflammation, infection, or a response to medications, food, or poisoning ◦ Chronic diarrhea lasts more than 2 weeks and may indicate malabsorption problem, longterm inflammatory disease, or allergic responses ◦ Infectious diarrhea caused by viral, bacterial, or parasitic infection, usually involves gastroenteritis
STUDY
Disorders of Motility Acid-Base Balance ◦ Norms pH: 7.35-7.45 PaCO2: 35-45 HCO3: 22-26 ◦ ROME PaCO2 is the respiratory component HCO3 is the metabolic component pH tells the acidity
Manifestations of TEF (Tracheoesophageal Fistula):
Earliest sign is when mother develops polyhydramnios ◦ If it ends in blind pouch, fetus cannot swallow amniotic fluid and it will accumulate ◦ At birth, the infant will vomit and choke when the first feeding is introduced ◦ Drooling may also be present at birth and is related to atresia If upper esophagus enters trachea, the first feeding will enter the trachea and result in coughing, choking, cyanosis, and apnea If lower end of esophagus enters trachea, air will enter stomach each time infant breathes, causing abdominal distention
Isotonic dehydration
Equal amounts of fluid and electrolytes are lost
Failure to Thrive (cont.): Prevention of environmental
FTT consists chiefly of social measures
Esophageal atresia (tracheoesophageal fistula [TEF])
Failure of the esophagus to connect with the stomach
Failure to Thrive:
Failure to gain weight and often lose weight
Failure to Thrive:
Failure to gain weight and often lose weight Can be caused by ◦ Physical (organic) pathology (OFTT), such as congenital heart or malabsorption syndrome ◦ Non-organic (NFTT) is from the lack of parent-infant interaction resulting from environmental factors or neglect
Identify symptoms associated with this. Imperforate anus
Failure to pass meconium in the first 24 hours
Identify symptoms associated with this. Celiac disease
Failure to thrive, large frothy stools, abdominal distention, buttock atrophy
Constipation (cont.):
Fewer than 7 bowel movements in a 2-week period Ask caregiver to define constipation Evaluate dietary and bowel habits ◦ Some infants develop constipation due to high iron content in formula Note frequency, color, and consistency of stool Document any medications child is taking Dietary modifications include increasing roughage in diet ◦ Foods high in fiber include whole-grain breads and cereals, raw vegetables and fruits, bran, and popcorn for older children Stool softener may be prescribed
Dehydration
Fluid output exceeds fluid intake
Fluid and Electrolyte Imbalance (cont.):
Fluid turnover is rapid, and dehydration occurs more quickly in infants than in adults A sick infant does not adapt as readily to shift in intake and output
Fluid and Electrolyte Imbalance (cont.):
Fluid turnover is rapid, and dehydration occurs more quickly in infants than in adults A sick infant does not adapt as readily to shift in intake and output Less able to concentrate urine and require more water than an adult's kidneys to excrete a given amount of solute
A diarrheal stool in an infant is manifested by a waatery consistency and a greenish color with the possible presence of mucus or blood.
Frequency of bowel movement, by itself is not an indication of diarrhea in infants
GI System Differences Between Children and Adults
GI System Differences Between Children and Adults
Intussusception (cont.)
Generally occurs in boys between 3 months and 6 years ◦ Frequency decreases after age 36 months Can have spontaneous reduction Onset is usually sudden ◦ May have a fever as high as 106° F (41.1° C) ◦ As it progresses, child may show signs of shock, sweating, weak pulse, shallow, grunting respirations; abdomen is rigid In infants, severe pain in abdomen, loud cries, straining efforts, and kicking and drawing of legs toward abdomen Child vomits green or greenish-yellow fluid (bilious) Bowel movements diminish, little flatus is passed Blood and mucus with no feces are common about 12 hours after onset of obstruction, called currant jelly stools
What is proper nursing care of a child after this? Pyloromyotomy
Gentle handling, daily weights, position on right side after feeding
Celiac disease
Gluten intolerance
How much weight loss is indicative of this? Severe dehydration
Greater than 10% weight loss
How much weight loss is indicative of this? Severe dehydration
Greater than 10% weight loss
Inguinal hernia
Hernia in which part of the abdominal contents protrudes through the inguinal canal in the groin
Umbilical hernia
Hernia in which there is a protrusion of a portion of intestine through the umbilical ring
Reducible hernia
Hernia that can be put back into place by gentle pressure
Incarcerated hernia
Hernia that cannot be put back into place by gentle pressure
Strangulated hernia
Hernia that occurs when the intestine is caught in the passage and the blood supply is diminished
Describe treatment of this. Hernia
Herniorrhaphy
Isotonic dehydration is the loss of equal amounts of water and electrolytes.
Hypertonic dehydration is the loss of more water than electrolytes. hypotonic dehydration is the loss of more electrolytes than water.
Hirschsprung's Disease (Aganglionic Megacolon) (cont.):
If untreated, other signs of intestinal obstruction and shock may be seen Enterocolitis (inflammation of the small bowel and colon) is a serious condition ◦ Fever, explosive stools, and depletion of strength Diagnostics ◦ Barium enema ◦ Rectal biopsy ◦ Anorectal manometry Measures pressure in anal sphincter
Fluid and Electrolyte Imbalance (cont.):
In children under 2 years of age, surface area is important because more water is lost through the skin than through the kidneys
Fluid and Electrolyte Imbalance (cont.):
In children under 2 years of age, surface area is important because more water is lost through the skin than through the kidneys Metabolic rate and heat production are also 2 to 3 times greater in infants per kg of body weight ◦ Produces more waste products, which must be diluted to be excreted ◦ Stimulates respirations, which increase evaporation through the lungs ◦ Greater percentage of body water in children under 2 years is contained in extracellular compartment
Celiac Disease (cont.):
Infant presents with failure to thrive Infant is irritable Stools are large, bulky, and frothy Diagnosis confirmed by serum immunoglobin A (IgA) and small bowel biopsy Treatment ◦ Lifelong diet restricted in wheat, barley, oats, and rye ◦ Detailed parent teaching is essential A professional nutritionist or dietitian can aid in identifying foods that are gluten-free
Constipation - Treatment
Infants <1 year ◦ Prune, Pear, or Apple Juice: 2-4 oz/day Maintenance Management ◦ Fluids ◦ Fiber ◦ Behavioral Modification 10 min. on toilet qAM or qHS ◦ Laxatives Mineral Oil, Magnesium Hydroxide, Lactulose, Miralax, Sorbitol
Infections
Infections
Colitis
Inflammation of the colon
Enterocolitis
Inflammation of the colon and small intestine
Gastroesophageal reflux disease (GERD)
Inflammation of the esophagus caused by an incompetent lower esophageal sphincter
Gastroenteritis
Inflammation of the stomach and the intestines
Gastroenteritis
Involves inflammation of the stomach and intestines Colitis involves an inflammation of the colon Enterocolitis involves an inflammation of the colon and small intestines Most common noninfectious causes of diarrhea ◦ Food intolerance ◦ Overfeeding ◦ Improper formula preparation ◦ Ingestion of high amounts of sorbitol Priority problem in diarrhea is fluid and electrolyte imbalance and failure to thrive
Lead Poisoning (Plumbism) (cont.):
Lead is toxic to the synthesis of heme in the blood, which is necessary for hemoglobin formation and renal tubule functioning Blood lead levels are primary screening test X-ray films of bones may show further lead deposits History may reveal pica Treatment is aimed at reducing concentration of lead in blood ◦ Chelating agents may be taken for several months Prognosis depends on extent of poisoning
Fluid and Electrolyte Imbalance (cont.):
Less able to concentrate urine and require more water than an adult's kidneys to excrete a given amount of solute
Gastroesophageal Reflux:
Lower esophageal sphincter is relaxed or not competent, allowing stomach contents to regurgitate into esophagus ◦ Associated with neuromuscular delay, such as Down syndrome or cerebral palsy Often seen in preterm infants Symptoms often decrease once child is able to stand upright and eats more solid foods Symptoms ◦ Vomiting ◦ Weight loss ◦ Failure to thrive ◦ Infant is fussy and hungry ◦ Respiratory problems can occur when vomiting stimulates closure of epiglottis and infant presents with apnea
Patient Teaching - worms
Main nursing responsibility is educating parents and child about the prevention of worm infestation through general hygiene, food handling and preparation, as well as through environmental controls
Dehydration (cont.):
Maintenance fluid therapy replaces normal water and electrolyte losses
Dehydration (cont.):
Maintenance fluid therapy replaces normal water and electrolyte losses Deficit therapy restores preexisting body fluid and electrolyte deficiencies ◦ Shock is greatest threat to life in isotonic dehydration ◦ Children with hypotonic dehydration are at risk for water intoxication Potassium is lost in almost all degrees of dehydration and is replaced only after normal urinary excretion is confirmed
Safety Alert - OTC drugs
Many over-the-counter medications are considered harmless by parents but can be deadly to the toddler or small child Keep all medications (prescription or otherwise), including herbal supplements, out of reach of small children
Hernias (cont.):
May be present at birth (congenital) or acquired Is reducible if it can be put back into place by gentle pressure If it cannot be put back, it is irreducible or incarcerated Strangulated hernia is when intestine becomes caught in the passage and the blood supply is diminished Child may vomit and have severe abdominal pain Emergent surgery is indicated in this type of situation In most cases, same-day surgery is performed
Hypotonic dehydration
More electrolytes than water are lost
Hypertonic dehydration
More fluids than electrolytes are lost
Clostridium difficile
Most common diarrhea associated with antimicrobial therapy; health care-associated condition
Gastroenteritis: Most common
Most common noninfectious causes of diarrhea ◦ Food intolerance ◦ Overfeeding ◦ Improper formula preparation ◦ Ingestion of high amounts of sorbitol
Appendicitis:
Most common reason for emergency abdominal surgery ◦ Small appendage arising from the cecum ◦ Lumen may become obstructed with fecal matter or with lymphoid tissue after a viral illness or with parasites ◦ Stasis, increased swelling, edema, and growth of organisms Initial pain usually in periumbilical and increases within a 4-hour period When inflammation spreads to peritoneum, pain localizes in RLQ of abdomen Appendix may become gangrenous or rupture Can lead to peritonitis and septicemia
Failure to Thrive (cont.):
Multidisciplinary approach in accordance with circumstances In some cases, child is removed from home environment and placed elsewhere Assigning the same nursing staff to care for the child may increase nurturing and interaction with the infant and parent
Hirschsprung's Disease (Aganglionic Megacolon) (cont.):
Newborns: failure to pass meconium stools within 24 to 48 hours may be a symptom Infants: constipation, ribbonlike stools, abdominal distention, anorexia, vomiting, and failure to thrive Young children: usually seen in clinic after parents have tried over-the-counter laxatives to treat the constipation
Gastroenteritis: vaccine
Norovirus - Top cause in children <5-years (20-22%) 1 in 278 children hospitalized Development phase for Norovirus vaccines
Failure to Thrive (cont.):
Nurse is vital in supporting rather than in rejecting the mother ◦ Encourages mother to assist with daily care of child ◦ Points out developmental patterns and provides anticipatory guidance in this area Prognosis is uncertain ◦ Emotional starvation, particularly in the early years, can be psychologically traumatic ◦ Inadequacies in intelligence, language, and social behavior have been documented in children who fail to thrive
Nutritional Deficiencies
Nutritional Deficiencies
Pyloric stenosis
Obstruction at the lower end of the stomach
Pyloric Stenosis:
Obstruction of the lower end of the stomach caused by overgrowth of the circular muscles of the pylorus or spasms of the sphincter Commonly classified as a congenital anomaly Symptoms usually do not appear until the infant is 2 or 3 weeks old ◦ Most common surgical condition of GI tract in infancy Incidence is higher in boys
Kwashiorkor (cont.):
Occurs in children 1 to 4 years of age who have been weaned from the breast ◦ Oral intake is deficient in protein ◦ Child fails to grow normally ◦ Muscles become weak and wasted ◦ Edema of abdomen ◦ Diarrhea, skin infections, irritability, anorexia, and vomiting may be present ◦ Hair thins and is dry and may contain a white streak ◦ Child looks apathetic and weak
Detecting the Poison by Specific Odor of Vomitus
Odor of Vomitus Probable Content Sweet Chloroform, acetone Bitter almond Cyanide Pear Chloral hydrate Garlic Phosphorus, arsenic Shoe polish Nitrobenzene Violet Turpentine
Failure to Thrive (cont.):
Often admitted to hospital Presents with weight loss, irritability, disturbances of food intake, vomiting, diarrhea, and general neuromuscular spasticity sometimes accompany the condition Children fall below the third percentile in weight and height on standard growth charts Development is delayed Due to multiple factors, there may be a disturbance in the mother-child relationship Prevention of environmental FTT consists chiefly of social measures Pregnancy history sometimes reveals circumstances that may contribute to a lack of mother-infant bonding
Describe treatment of this. Thrush
Oral antifungal drugs
Symptoms of GI Disorders Systemic signs: Local signs
Pain ◦ Vomiting ◦ Diarrhea ◦ Constipation ◦ Rectal bleeding ◦ Hematemesis
Identify symptoms associated with this. Appendicitis
Pain at McBurney's point, guarding, rebound tenderness
Cyanide poisoning can be caused by eating _______.
Peach or apricot pits
Colonoscopy
Permits visualization and biopsy of entire colon
Sigmoidoscopy
Permits visualization and biopsy of the lower colon
Endoscopy
Permits visualization and biopsy of upper gastrointestinal (GI) tract
Poisonous Plants
Poisonous Plants
Esophageal atresia
Polyhydramnios, drooling, choking, cyanosis
Identify symptoms associated with this. Esophageal atresia
Polyhydramnios, drooling, choking, cyanosis
Dehydration (cont.):
Potassium is lost in almost all degrees of dehydration and is replaced only after normal urinary excretion is confirmed
Nursing Care of TEF (Tracheoesophageal Fistula):
Prevent pneumonia, choking, and apnea in the newborn
Nursing Care of TEF (Tracheoesophageal Fistula):
Prevent pneumonia, choking, and apnea in the newborn ◦ Assessment of the newborn during the first feeding for signs/symptoms of TEF is essential ◦ Feeding usually is with clear water or colostrum to minimize seriousness of aspiration Surgical repair is essential for survival
Pinworm is diagnosed by a scotch tape test.
Preventing the child from scratching the anal area is an essential part of breaking the cycle of worm infestation
Describe treatment of this. Gastroenteritis
Probiotics, oral rehydration
Failure to Thrive (cont.): Prognosis is uncertain
Prognosis is uncertain ◦ Emotional starvation, particularly in the early years, can be psychologically traumatic ◦ Inadequacies in intelligence, language, and social behavior have been documented in children who fail to thrive
Manifestations of Pyloric Stenosis:
Projectile vomiting is outstanding symptom from force or pressure being exerted on the pylorus ◦ Vomitus contains mucus and ingested milk ◦ Infant is constantly hungry and will eat again immediately after vomiting Dehydration and olive-shaped mass may be felt in upper right quadrant of abdomen
Identify symptoms associated with this. Pyloric stenosis
Projectile vomiting, dehydration, olive-shaped mass in right upper quadrant of the abdomen
Pyloric stenosis
Projectile vomiting, dehydration, olive-shaped mass in right upper quadrant of the abdomen
Kwashiorkor
Protein deficiency
Describe treatment of this. Pyloric stenosis
Pyloromyotomy
Maintenance fluid therapy
Replaces normal water and electrolyte losses
Deficit fluid therapy
Restores preexisting body fluid and electrolyte deficiencies
Imperforate anus
Result of the lower end of the GI tract and the anus ending in blind pouches
Vomiting:
Results from sudden contractions of diaphragm and muscles of the stomach Persistent vomiting requires investigation because it results in dehydration and electrolyte imbalance ◦ Continuous loss of hydrochloric acid and sodium chloride from the stomach can cause alkalosis ◦ Can result in death if left untreated Multiple causes of vomiting ◦ Improper feeding technique ◦ Systemic illness such as increased intracranial pressure or infection ◦ Child at risk for aspiration pneumonia
Lead Poisoning (Plumbism):
Results when a child repeatedly ingests or absorbs substances containing lead Incidence higher in inner-city tenements
Lead Poisoning (Plumbism):
Results when a child repeatedly ingests or absorbs substances containing lead Incidence higher in inner-city tenements Children who chew on window sills and stair rails ingest flakes of paint, putty, or crumbled plaster Eating nonfood items is called pica Can have a lasting effect on the CNS, especially the brain Mental retardation occurs in severe cases of lead poisoning
The incidence of _______ poisoning is decreasing.
Salicylate
Selected OTC Drugs that Are Deadly to Toddlers
Selected OTC Drugs that Are Deadly to Toddlers
Kwashiorkor:
Severe deficiency of protein in the diet despite the fact that the number of calories consumed may be nearly adequate • Belongs to a class of disorders termed protein-energy malnutrition • Seen most often in third-world countries
Ascariasis (roundworms)
Spread by the unsanitary disposal of human feces
Enterobiasis (pinworms)
Spread via hand-to-mouth contamination
Symptoms of Diarrhea:
Stools watery and explosive; may be yellowish-green Listlessness, refusal to eat, weight loss, temperature may be elevated, possible vomiting Dehydration evidenced by sunken eyes and fontanel; dry skin, tongue, and mucous membranes; less frequent urination In severe cases, excessive loss of bicarbonate from GI tract results in acidosis
Describe treatment of this. Esophageal atresia
Surgical repair
Describe treatment of this. Hirschsprung's disease
Surgical resection and temporary colostomy
Meckel's Diverticulum (cont.):
Symptoms can occur at any age, but typically appear by 2 years of age ◦ Painless bleeding from rectum ◦ Bright-red or dark-red blood is more usual than tarry stools ◦ Abdominal pain may or may not be present Diagnostics ◦ Barium enema or radionuclide scintigraphy are used in diagnosing ◦ X-ray films are not helpful Treatment ◦ Surgical removal of the diverticulum Nursing care is same for any patient having undergone abdominal surgery
Esophageal Atresia (Tracheoesophageal Fistula [TEF])
TEF is caused by a failure of the tissues of the GI tract to separate properly in prenatal life
Esophageal Atresia (Tracheoesophageal Fistula [TEF])
TEF is caused by a failure of the tissues of the GI tract to separate properly in prenatal life Four types ◦ Upper and lower esophagus (from the stomach) end in a blind pouch ◦ Upper esophagus ends in a blind pouch; lower esophagus (from stomach) connects to the trachea ◦ Upper esophagus is attached to trachea; lower esophagus (from stomach) also attached to trachea ◦ Upper esophagus connects to trachea; lower esophagus (from stomach) ends in a blind pouch
Describe treatment of this. Gastroesophageal reflux disease (GERD)
Teaching regarding burping, overfeeding; thickened formula; medication/surgery for complicated cases
Intussusception
Telescoping of the proximal end of the bowel into the distal end
Overhydration:
The body receives more fluid than it can excrete Manifests as edema (excess fluid in interstitial spaces) ◦ Interstitial fluid is similar to plasma, but contains little protein ◦ Any factor causing sodium retention can cause edema Flow of blood out of the interstitial compartments depends on adequate circulation of blood and lymph Low protein levels disturb osmotic cellular pressure Anasarca is severe generalized edema
Treatment of Intussusception:
This condition is an emergency Diagnosis is determined by history and physical findings May feel a sausage-shaped mass in right upper abdomen Barium enema is treatment of choice, with surgery if reduction does not occur
Three Most Common Forms of TEF
Three Most Common Forms of TEF
Infection of the mucous membranes of the mouth caused by fungus
Thrush (oral candidiasis)
Overview of the Gastrointestinal (GI) Tract
Transports and metabolizes nutrients necessary for the life of the cell Extends from mouth to anus Nutrients are broken down into absorbable products by enzymes from various digestive organs
Gastroenteritis (cont.):
Treatment is focused on identifying and eradicating cause Priority goal of care is restoring fluid and electrolyte balance Accurate intake and output, weighing of diapers, observing for dehydration or overhydration, and keeping infant/child warm Review with parents proper hand hygiene techniques, safe food handling and storage, principles of cleanliness, and infection prevention
How much weight loss is indicative of this? Mild dehydration
Up to 5% weight loss
Thrush (Oral Candidiasis):
Usually caused by a fungus, Candida Anorexia may be present Systemic symptoms are generally mild if infection remains in the mouth; can pass into GI tract causing inflammation of the esophagus and stomach Responds well to local application of antifungal suspension, such as nystatin ◦ Medication should remain in contact with "patches" as long as possible With proper care, the condition disappears within a few days after onse
Meckel's Diverticulum:
Usually occurs near ileocecal valve and may be connected to umbilicus by a cord ◦ A fistula may also form ◦ This sac is subject to inflammation Most common congenital malformation of the GI tract ◦ Seen more often in boys
Scurvy
Vitamin C deficiency
Rickets
Vitamin D deficiency
Gastroesophageal reflux disease (GERD)
Vomiting, weight loss, failure to thrive
Identify symptoms associated with this. Gastroesophageal reflux disease (GERD)
Vomiting, weight loss, failure to thrive
Describe treatment of this. Celiac disease
Wheat, barley, and rye diet restrictions
Identify symptoms associated with this. Thrush
White painless patches that appear on the tongue and oral mucosa and cannot be wiped away
Kwashiorkor is a protein deficiency characterized by
a depigmented white streak of hair
Intussusception: ◦ The mesentery,
a double fan-shaped fold of peritoneum that covers most of intestine and is filled with blood vessels and nerves, is also pulled along Edema occurs
Celiac disease is caused by
a genetic sensitivity to gluten in the diet
Diarrhea: Diarrhea in infant is
a sudden increase in stools from the infant's normal pattern, with a fluid consistency and a color that is green or contains mucus or blood
Failure to Thrive (cont.): Often
admitted to hospital Presents with weight loss, irritability, disturbances of food intake, vomiting, diarrhea, and general neuromuscular spasticity sometimes accompany the condition
Manifestations of TEF (Tracheoesophageal Fistula): If lower end of esophagus enters trachea,
air will enter stomach each time infant breathes, causing abdominal distention
Rickets: ◦ Vitamin supplements
along with exercise and exposure to outdoor sunlight is primary form of treatment
Meckel's Diverticulum: ◦ A fistula may
also form ◦ This sac is subject to inflammation
Manifestations of TEF (Tracheoesophageal Fistula): ◦ At birth, the infant will vomit
and choke when the first feeding is introduced
Dehydration: Causes fluid
and electrolyte disturbances Evaluation of type and severity, including clinical observation and chemical analysis of the blood
Symptoms of Diarrhea: Stools watery
and explosive; may be yellowish-green Listlessness, refusal to eat, weight loss, temperature may be elevated, possible vomiting
Fluid and Electrolyte Imbalance (cont.): Metabolic rate
and heat production are also 2 to 3 times greater in infants per kg of body weight ◦ Stimulates respirations, which increase evaporation through the lungs
Hirschsprung's Disease (Aganglionic Megacolon): ◦ Seen more often in boys
and in children with Down syndrome May be acute or chronic
Manifestations of Pyloric Stenosis: ◦ Vomitus contains mucus
and ingested milk ◦ Infant is constantly hungry and will eat again immediately after vomiting
An intake and output recoerd includes accurate documentation of information concerning oral
and parenteral intake and suction, wound drainage, sweating, vomiting, urine and stool output
Nursing Interventions o GI Disorders: • Focuses on providing adequate nutrition
and preventing infection -Can result from malnutrition or depressed immune function
Teaching parents basic hygienic practices, handwashing,
and proper animal handling can prevent outbreaks of diarrhea
Lab studies: ◦ CBC with differential:
anemia, infections, chronic illness
Failure to Thrive (cont.): Multidisciplinary
approach in accordance with circumstances
Fluid and Electrolyte Imbalance (cont.): Metabolic rate and heat production
are also 2 to 3 times greater in infants per kg of body weight ◦ Greater percentage of body water in children under 2 years is contained in extracellular compartment
Dehydration: Types of dehydration
are classified according to level of serum sodium, which depends on the relative losses of water and electrolytes ◦ Isotonic ◦ Hypotonic ◦ Hypertonic
Thrush (Oral Candidiasis): Systemic symptoms
are generally mild if infection remains in the mouth; can pass into GI tract causing inflammation of the esophagus and stomach
Appendicitis: ◦ Small appendage
arising from the cecum ◦ Lumen may become obstructed with fecal matter or with lymphoid tissue after a viral illness or with parasites ◦ Stasis, increased swelling, edema, and growth of organisms
Manifestations of TEF (Tracheoesophageal Fistula): ◦ Drooling may also be present
at birth and is related to atresia
Appendicitis: Appendix may
become gangrenous or rupture Can lead to peritonitis and septicemia
Intussusception (cont.): Generally occurs in boys
between 3 months and 6 years ◦ Frequency decreases after age 36 months
Meckel's Diverticulum (cont.): Bright-red or dark-red
blood is more usual than tarry stools ◦ Abdominal pain may or may not be present
Rickets: Classic symptoms are
bow-legs; knock-knees; beading of the ribs, called rachitic rosary; and, improper formation of teeth
The treatment of gastroesophageal reflux includes thickened feedings,
burping and maintaining fowler's position
Intussusception: At first, intestinal obstruction occurs,
but then strangulation of the bowel occurs as peristalsis occurs Affected portion may burst, leading to peritonitis
Treatment of Intussusception: Diagnosis is determined
by history and physical findings May feel a sausage-shaped mass in right upper abdomen
Symptoms of Diarrhea: Dehydration evidenced
by sunken eyes and fontanel; dry skin, tongue, and mucous membranes; less frequent urination In severe cases, excessive loss of bicarbonate from GI tract results in acidosis
Lead poisoning (plumbism)
can cause neurological damage.
Gastroesophageal Reflux: Symptoms: ◦ Respiratory problems
can occur when vomiting stimulates closure of epiglottis and infant presents with apnea
Diarrhea: ◦ Infectious diarrhea
caused by viral, bacterial, or parasitic infection, usually involves gastroenteritis
Currant jelly stools
characterize intussusception
Constipation (cont.): Document any medications
child is taking Dietary modifications include increasing roughage in diet
Oral rehydrating solutions are
commercially prepared electrolyte solutions.
Constipation (cont.): ◦ Some infants develop
constipation due to high iron content in formula
Hirschsprung's Disease (Aganglionic Megacolon) (cont.): Infants:
constipation, ribbonlike stools, abdominal distention, anorexia, vomiting, and failure to thrive
Vomiting: Results from sudden
contractions of diaphragm and muscles of the stomach
Constipation: • Difficult or infrequent
defecation with the passage of hard, dry fecal material -May be periods of diarrhea or encopresis (constipation with fecal soiling)
Gastroesophageal Reflux: ◦ Associated with neuromuscular
delay, such as Down syndrome or cerebral palsy Often seen in preterm infants Symptoms often decrease once child is able to stand upright and eats more solid foods
Overhydration: Low protein levels
disturb osmotic cellular pressure Anasarca is severe generalized edema
Celiac Disease: Also known as gluten
enteropathy and sprue Leading malabsorption problem in children
Hirschsprung's Disease (Aganglionic Megacolon) (cont.): Newborns:
failure to pass meconium stools within 24 to 48 hours may be a symptom
Manifestations of TEF (Tracheoesophageal Fistula): ◦ If it ends in blind pouch,
fetus cannot swallow amniotic fluid and it will accumulate
Intussusception (cont.): Child vomits green or greenish-yellow
fluid (bilious) Bowel movements diminish, little flatus is passed
Imperforate Anus: • Lower GI and anus arise
from two different types of tissue during fetal development
Scurvy: Caused by insufficient
fruits and vegetables that contain vitamin C
Hirschsprung's disease occurs when there is an absence of
ganglionic innervation of the muscle of a bowel segment
Infants who are fed by the IV route should be picked up and
held and allowed to suck on a pacifier
Imperforate Anus (cont.) Manifestations: ◦ Infant should not be discharged
home until a meconium stool has passed
Vomiting: ◦ Continuous loss of
hydrochloric acid and sodium chloride from the stomach can cause alkalosis. ◦ Can result in death if left untreated
Meckel's Diverticulum: Usually occurs near
ileocecal valve and may be connected to umbilicus by a cord
Gastroesophageal Reflux (cont.): Nursing care: ◦ Sitting upright
in an infant seat is not recommended as it increases intra-abdominal pressure Administer medications to relax pyloric sphincter before meals
Gastroenteritis: Priority problem
in diarrhea is fluid and electrolyte imbalance and failure to thrive
Imperforate Anus (cont.) Manifestations: ◦ Failure to pass meconium
in the first 24 hours must be reported
Kwashiorkor: • Seen most often
in third-world countries
Constipation (cont.): ◦ Foods high in fiber
include whole-grain breads and cereals, raw vegetables and fruits, bran, and popcorn for older children Stool softener may be prescribed
the functions of the gastrointestinal tract have a great
influence on the fluid and electrolyte balance in infants and children
Celiac Disease: ◦ Thought to be caused by
inherited disposition with environmental triggers
Gastroenteritis: Enterocolitis
involves an inflammation of the colon and small intestines
Nursing Interventions o GI Disorders: • Skin problems may be related to pruritus,
irritation from frequent bowel movements, or other disorders
Celiac Disease (cont.): • Characteristic profile
is abdominal distention with atrophy of the buttocks
Treatment of Intussusception: This condition
is an emergency
Pica, the eating of nonfood items,
is characteristic of children with lead poisoning
◦ Erythrocyte sedimentation rate (ESR)
is indicative of inflammation
Kwashiorkor (cont.) Treatment
is mainly preventive Simple protein powder sprinkled on the culturally prepared meal will alleviate the problem
Manifestations of Pyloric Stenosis: Projectile vomiting
is outstanding symptom from force or pressure being exerted on the pylorus
Gastroesophageal Reflux: Lower esophageal sphincter
is relaxed or not competent, allowing stomach contents to regurgitate into esophagus
Hernias (cont.): Strangulated hernia
is when intestine becomes caught in the passage and the blood supply is diminished
Scurvy: Symptoms include
joint pain, bleeding gums, loose teeth, lack of energy Vitamin C
Failure to Thrive (cont.): ◦ Inadequacies in intelligence,
language, and social behavior have been documented in children who fail to thrive
Intussusception (cont.): In infants, severe pain in abdomen,
loud cries, straining efforts, and kicking and drawing of legs toward abdomen
Meckel's Diverticulum: Most common congenital
malformation of the GI tract ◦ Seen more often in boys
Manifestations of Pyloric Stenosis: Dehydration and olive-shaped
mass may be felt in upper right quadrant of abdomen
Treatment of Pyloric Stenosis Surgery is called pyloromyotomy Preoperative nursing care: ◦ Thickened feedings
may be given by a teaspoon or through a nipple with a large hole
Intussusception: Affected portion
may burst, leading to peritonitis
Overhydration: The body receives
more fluid than it can excrete Manifests as edema (excess fluid in interstitial spaces)
Diarrhea: ◦ Acute sudden diarrhea
most often caused by inflammation, infection, or a response to medications, food, or poisoning
Constipation (cont.): Fewer than 7 bowel
movements in a 2-week period Ask caregiver to define constipation Evaluate dietary and bowel habits
Nursing Interventions o GI Disorders: • Pain and discomfort
need to be addressed
Foreign Bodies: Caution parents
not to use laxatives and to maintain a normal diet to avoid intestinal spasms
Failure to Thrive (cont.): Assigning the same
nursing staff to care for the child may increase nurturing and interaction with the infant and parent
Gastrointestinal (GI) Tract: Transports and metabolizes
nutrients necessary for the life of the cell
Drooling in the newborn may be a sign of an
obstructed oesophagus or TEF
Hirschsprung's Disease (Aganglionic Megacolon): ◦ Portion of bowel nearest
obstruction dilates, causing abdominal distention
Meckel's Diverticulum (cont.): Symptoms can
occur at any age, but typically appear by 2 years of age ◦ Painless bleeding from rectum
Foreign Bodies: 80% of all ingestions
occur in children between 6 months and 3 years of age ◦ About 80% of items ingested pass through the GI tract without difficulty ◦ May take up to 6 days to occur
Pyloric Stenosis: ◦ Most common surgical condition
of GI tract in infancy. Incidence is higher in boys
Celiac Disease: Symptoms not evident until 6 months to 2 years
of age when foods containing gluten are introduced
Symptoms of Diarrhea: In severe cases, excessive loss
of bicarbonate from GI tract results in acidosis
Lead Poisoning (Plumbism) (cont.): X-ray films
of bones may show further lead deposits History may reveal pica Treatment is aimed at reducing concentration of lead in blood ◦ Chelating agents may be taken for several months Prognosis depends on extent of poisoning
Treatment of Intussusception: Barium enema is treatment
of choice, with surgery if reduction does not occur
Kwashiorkor: • Belongs to a class
of disorders termed protein-energy malnutrition
Prevention of accidental poisoning should be part
of every plan for teaching parents.
Large, bulky, frothy stools are characteristic
of malabsorption syndromes
Hirschsprung's Disease (Aganglionic Megacolon) (cont.) Enemas: ◦ Due to increased size
of mucous membranes' surface area, an increased absorption of the fluid can be anticipated Therefore, normal saline solution should be used to prevent water intoxication and death
Constipation: • May be a symptom
of other disorders • Diet, culture, and social, psychological, and familial patterns may also influence occurrence
Kwashiorkor: Severe deficiency
of protein in the diet despite the fact that the number of calories consumed may be nearly adequate
Hirschsprung's Disease (Aganglionic Megacolon): ◦ Usually in lower portion
of sigmoid colon Lack of normal peristalsis, results in constipation Stools are ribbonlike due to feces passing through the narrow segment of colon
Intussusception: A slipping of one part
of the intestine into another part just below it ◦ Often seen at the ileocecal valve
Gastroenteritis: Involves inflammation
of the stomach and intestines Colitis involves an inflammation of the colon
Pyloric Stenosis: Obstruction of the lower end
of the stomach caused by overgrowth of the circular muscles of the pylorus or spasms of the sphincter
Gastroenteritis (cont.): Treatment is focused
on identifying and eradicating cause Priority goal of care is restoring fluid and electrolyte balance
Constipation: • Daily use of laxatives
or enemas should be discouraged
Hirschsprung's Disease (Aganglionic Megacolon) (cont.): If untreated,
other signs of intestinal obstruction and shock may be seen Enterocolitis (inflammation of the small bowel and colon) is a serious condition ◦ Fever, explosive stools, and depletion of strength
Overhydration: Flow of blood
out of the interstitial compartments depends on adequate circulation of blood and lymph
A chronic productive cough without fever is
part of the roundworm life cycle in children
Failure to Thrive (cont.): Prognosis is uncertain -◦ Emotional starvation,
particularly in the early years, can be psychologically traumatic
Imperforate Anus: • Once the two meet,
perforation occurs allowing for a passageway
Nursing care for the child with pyloric stenosis involves frequent assessment careful feeding,
positioning on the right side after feedings, and education and support of the parents
Fluid and Electrolyte Imbalance (cont.): Metabolic rate and heat
production are also 2 to 3 times greater in infants per kg of body weight ◦ Produces more waste products, which must be diluted to be excreted
Gastroenteritis (cont.): Review with parents
proper hand hygiene techniques, safe food handling and storage, principles of cleanliness, and infection prevention
Treatment of Pyloric Stenosis Surgery is called pyloromyotomy Postoperative nursing care: ◦ Monitor intravenous fluids,
provide feedings as prescribed by surgeon, document intake and output, monitor surgical site
Pyloric stenosis is caused by hypertrophy of the
pyloric muscles and is manifested by projectile vomiting
Failure to Thrive (cont.): Nurse is vital in supporting
rather than in rejecting the mother ◦ Encourages mother to assist with daily care of child ◦ Points out developmental patterns and provides anticipatory guidance in this area
Hand hygiene with soap and water rather than alcohol based hand sanitizer is
recommended when caring for paatients with C. Diff diarrhea. Contact precautions are recommended, and the environment should be cleaned with a bleach disinfectant by housekeeping staff.
Intussusception (cont.): Can have spontaneous
reduction Onset is usually sudden ◦ May have a fever as high as 106° F (41.1° C)
Thrush (Oral Candidiasis): ◦ Medication should
remain in contact with "patches" as long as possible With proper care, the condition disappears within a few days after onse
Vomiting: Persistent vomiting
requires investigation because it results in dehydration and electrolyte imbalance
Celiac Disease (cont.): Diagnosis confirmed by
serum immunoglobin A (IgA) and small bowel biopsy
Hernias (cont.): Child may vomit and have
severe abdominal pain Emergent surgery is indicated in this type of situation In most cases, same-day surgery is performed
Nursing Interventions o GI Disorders: • Developmental delays
should be investigated
Disposable nipples, pacifiers, and bottles
should be used for infants with thrush
Intussusception (cont.): ◦ As it progresses, child may show
signs of shock, sweating, weak pulse, shallow, grunting respirations; abdomen is rigid
Failure to Thrive (cont.): Pregnancy history
sometimes reveals circumstances that may contribute to a lack of mother-infant bonding
Appendicitis: When inflammation
spreads to peritoneum, pain localizes in RLQ of abdomen
Rickets: ◦ Exposure to
sunshine is necessary for proper absorption and metabolism of calcium and phosphorus
Lead Poisoning (Plumbism) (cont.): Lead is toxic to the
synthesis of heme in the blood, which is necessary for hemoglobin formation and renal tubule functioning Blood lead levels are primary screening test
To prevent the development of water intoxication,
tap water should not be used for enemas in children with megacolon
Diarrhea: ◦ Chronic diarrhea lasts more
than 2 weeks and may indicate malabsorption problem, longterm inflammatory disease, or allergic responses
C. diff is a health care assocciated diarrhea
that may occur with antimicrobial therapy
Manifestations of TEF (Tracheoesophageal Fistula): If upper esophagus enters trachea,
the first feeding will enter the trachea and result in coughing, choking, cyanosis, and apnea
Imperforate Anus: • When perforation does not take place,
the lower end of the GI tract and anus end in a blind pouch
Failure to Thrive (cont.): Children fall below
the third percentile in weight and height on standard growth charts Development is delayed
the higher daily exchange of water that occurs in infants leaves
them less volume reserve when they are dehydrated
Failure to Thrive (cont.): Due to multiple factors,
there may be a disturbance in the mother-child relationship
Imperforate Anus: • Four types ranging from stenosis
to complete separation or failure of the anus to form
Celiac Disease (cont.): • Repeated exposure
to gluten damage the villi of intestines resulting in malabsorption
Thrush (Oral Candidiasis): Responds well
to local application of antifungal suspension, such as nystatin
Overhydration (cont.) • Treatment: ◦ Important for nurse
to monitor clinical laboratory results and adjust fluids and foods offered to the child
The first stool of the newborn should be documented
to record the patency of the anus
Treatment of Pyloric Stenosis Surgery is called pyloromyotomy Preoperative nursing care: ◦ Burped before and during feedings
to remove any gas accumulated in the stomach
The nurse should teach parents not
to store poisonous substances in food containers
Celiac Disease (cont.): Infant presents with failure
to thrive. Infant is irritable. Stools are large, bulky, and frothy
Pyloric Stenosis: Symptoms usually do not appear
until the infant is 2 or 3 weeks old
Appendicitis: Initial pain
usually in periumbilical and increases within a 4-hour period
Hirschsprung's Disease (Aganglionic Megacolon) (cont.): Young children:
usually seen in clinic after parents have tried over-the-counter laxatives to treat the constipation
Overhydration (cont.) • Treatment: ◦ Accurate daily weight,
vital signs, observing physical appearance, and noting changes in urine output
Gastroenteritis (cont.): Accurate intake and output,
weighing of diapers, observing for dehydration or overhydration, and keeping infant/child warm
The newborn shold be closely observed for signs of tracheoesphageal fistula (TEF)
which include coughing choking, cyanosis, and apnea during feedings.
Lab studies:◦ Comprehensive chemistry panel
will reveal electrolyte and chemical imbalances
Intussusception (cont.): Blood and mucus
with no feces are common about 12 hours after onset of obstruction, called currant jelly stools
Hirschsprung's Disease (Aganglionic Megacolon) (cont.) Enemas: ◦ Parents should check
with the pediatrician to see how much saline should be administered with each enema
Constipation:
• Difficult or infrequent defecation with the passage of hard, dry fecal material -May be periods of diarrhea or encopresis (constipation with fecal soiling) • May be a symptom of other disorders • Diet, culture, and social, psychological, and familial patterns may also influence occurrence • Daily use of laxatives or enemas should be discouraged
Fluid and Electrolyte Imbalance (cont.):
• Electrolyte balance depends on fluid balance and cardiovascular, renal, adrenal, pituitary, parathyroid, and pulmonary regulatory mechanisms
Fluid and Electrolyte Imbalance (cont.):
• Electrolyte balance depends on fluid balance and cardiovascular, renal, adrenal, pituitary, parathyroid, and pulmonary regulatory mechanisms • Signs of dehydration may not be evident until the fluid loss reaches 4%, and severe dehydration may not be evident until the fluid loss reaches 10% • Can treat with oral fluids or parenteral fluids
Nursing Interventions o GI Disorders
• Focuses on providing adequate nutrition and preventing infection -Can result from malnutrition or depressed immune function • Developmental delays should be investigated • Skin problems may be related to pruritus, irritation from frequent bowel movements, or other disorders • Pain and discomfort need to be addressed
Imperforate Anus:
• Lower GI and anus arise from two different types of tissue during fetal development • Once the two meet, perforation occurs allowing for a passageway • When perforation does not take place, the lower end of the GI tract and anus end in a blind pouch • Four types ranging from stenosis to complete separation or failure of the anus to form
Celiac Disease (cont.):
• Repeated exposure to gluten damage the villi of intestines resulting in malabsorption • Characteristic profile is abdominal distention with atrophy of the buttocks
Fluid and Electrolyte Imbalance (cont.):
• Signs of dehydration may not be evident until the fluid loss reaches 4%, and severe dehydration may not be evident until the fluid loss reaches 10% • Can treat with oral fluids or parenteral fluids
Nursing Care of TEF (Tracheoesophageal Fistula):
◦ Assessment of the newborn during the first feeding for signs/symptoms of TEF is essential
Meckel's Diverticulum (cont.): Diagnostics
◦ Barium enema or radionuclide scintigraphy are used in diagnosing ◦ X-ray films are not helpful
Gastroesophageal Reflux (cont.): Tests include
◦ Barium swallow ◦ Esophageal sphincter pressure ◦ pH monitoring—most diagnostic
Appendicitis (cont.): Diagnostics can include
◦ Blood tests ◦ Abdominal X-ray ◦ CT scan ◦ Ultrasound
Laboratory and Diagnostic Studies Clinical laboratory
◦ CBC with differential: anemia, infections, chronic illness ◦ Erythrocyte sedimentation rate (ESR) is indicative of inflammation ◦ Comprehensive chemistry panel will reveal electrolyte and chemical imbalances ◦ Liver function test (LFT) ◦ Stool cultures X-ray studies ◦ GI series, barium enema, flat plates of the abdomen Endoscopy allows direct visualization and biopsy of the GI tract Upper—esophagus, stomach, duodenum, bile and pancreatic ducts Can remove foreign objects and cauterize bleeding vessels Lower colon—sigmoidoscopy Entire colon—colonoscopy
Gastroesophageal Reflux (cont.): Nursing care
◦ Careful burping ◦ Prevent overfeeding ◦ Proper positioning ◦ Feedings are thickened with cereal After being fed, infant is place in an upright position or propped ◦ Sitting upright in an infant seat is not recommended as it increases intra-abdominal pressure Administer medications to relax pyloric sphincter before meals
Vomiting (cont.) Nursing care:
◦ Carefully feed and burp infant ◦ Place infant on side after feeding to prevent aspiration if vomiting occurs
Vomiting (cont.) Nursing care:
◦ Carefully feed and burp infant ◦ Place infant on side after feeding to prevent aspiration if vomiting occurs ◦ When an older child vomits, turn head to one side and offer emesis basin ◦ IV fluids may be ordered ◦ Slowly introduce foods to allow stomach to rest Documentation ◦ Time, amount, color, consistency, force, frequency, and whether vomiting was preceded by nausea or feedings ◦ Administration of antiemetic agents should also be documented, including time given and if/when vomiting subsided
Hirschsprung's Disease (Aganglionic Megacolon) (cont.) Enemas:
◦ Due to increased size of mucous membranes' surface area, an increased absorption of the fluid can be anticipated Therefore, normal saline solution should be used to prevent water intoxication and death ◦ Parents should check with the pediatrician to see how much saline should be administered with each enema
Overhydration (cont.) • Treatment: Nursing care
◦ Early detection and management of edema are essential
Scurvy: Vitamin C
◦ Easily destroyed by heat and exposure to air ◦ Not stored in the body and daily intake of the vitamin is necessary Vitamin supplements and dietary intake such as citrus fruits and raw leafy vegetables
Imperforate Anus (cont.) Manifestations:
◦ Failure to pass meconium in the first 24 hours must be reported ◦ Infant should not be discharged home until a meconium stool has passed Treatment ◦ Once established, infant is NPO and prepared for surgery ◦ Initial surgical procedure may be a colostomy ◦ Subsequent surgeries will reestablish patency of anal canal
Symptoms of GI Disorders Systemic signs
◦ Failure to thrive (FTT)—failure to develop according to established growth parameters
Symptoms of GI Disorders Systemic signs
◦ Failure to thrive (FTT)—failure to develop according to established growth parameters ◦ Pruritus (itching) in the absence of allergy may indicate liver dysfunction Local signs ◦ Pain ◦ Vomiting ◦ Diarrhea ◦ Constipation ◦ Rectal bleeding ◦ Hematemesis
Nursing Care of TEF (Tracheoesophageal Fistula):
◦ Feeding usually is with clear water or colostrum to minimize seriousness of aspiration Surgical repair is essential for survival
Kwashiorkor (cont.): More Symptoms
◦ Hair thins and is dry and may contain a white streak ◦ Child looks apathetic and weak
Worms Roundworms (Ascariasis)
◦ If child eats soil, eggs develop into larvae in intestine, penetrate intestinal wall and enter liver; from there, the worms circulate to the lungs and heart ◦ Chronic cough without fever is characteristic of this form of infestation
Vomiting: Multiple causes of vomiting
◦ Improper feeding technique ◦ Systemic illness such as increased intracranial pressure or infection ◦ Child at risk for aspiration pneumonia
Treatment of Pyloric Stenosis Surgery is called pyloromyotomy Preoperative nursing care:
◦ Intravenous fluids to treat or prevent dehydration ◦ Thickened feedings may be given by a teaspoon or through a nipple with a large hole ◦ Burped before and during feedings to remove any gas accumulated in the stomach ◦ Place on right side (preferably Fowler's position) after feeding to facilitate stomach drainage into the intestines ◦ If infant vomits, nurse is instructed to refeed the infant Postoperative nursing care ◦ Monitor intravenous fluids, provide feedings as prescribed by surgeon, document intake and output, monitor surgical site
Lead Poisoning (Plumbism) (cont.) Symptoms occur gradually:
◦ Lead settles in soft tissues and bones ◦ Is excreted in urine Beginning stages, signs may be weakness, weight loss, anorexia, pallor, irritability, vomiting, abdominal pain, and constipation Later stages, signs may be anemia and nervous system involvement
Celiac Disease (cont.): Treatment
◦ Lifelong diet restricted in wheat, barley, oats, and rye ◦ Detailed parent teaching is essential A professional nutritionist or dietitian can aid in identifying foods that are gluten-free
Worms Pinworms (Enterobiasis)& Roundworms (Ascariasis)
◦ Looks like a white thread; lives in lower intestine but lays eggs outside anus ◦ Eggs become infective within hours of being deposited ◦ Route of entry into the body is through the mouth ◦ "Scotch tape" test Antihelminth medications are given for both types of worm infestations Roundworms (Ascariasis) ◦ Seen more in U.S. southern states and among immigrants and migratory workers ◦ Caused by unsanitary disposal of human feces and poor hygiene ◦ Eggs can survive for weeks in soil ◦ If child eats soil, eggs develop into larvae in intestine, penetrate intestinal wall and enter liver; from there, the worms circulate to the lungs and heart ◦ Chronic cough without fever is characteristic of this form of infestation
Kwashiorkor (cont.): Symptoms
◦ Muscles become weak and wasted ◦ Edema of abdomen ◦ Diarrhea, skin infections, irritability, anorexia, and vomiting may be present
Imperforate Anus (cont.) Manifestations: Treatment
◦ Once established, infant is NPO and prepared for surgery ◦ Initial surgical procedure may be a colostomy ◦ Subsequent surgeries will reestablish patency of anal canal
Hernias Umbilical:
◦ Protrusion of a portion of the intestine through the umbilical ring ◦ Appears as a soft swelling covered by skin, which protrudes when infant cries or strains
Hernias Inguinal:
◦ Protrusion of part of the abdominal contents through the inguinal canal in the groin
Hernias Inguinal and Umbilical
◦ Protrusion of part of the abdominal contents through the inguinal canal in the groin Umbilical ◦ Protrusion of a portion of the intestine through the umbilical ring ◦ Appears as a soft swelling covered by skin, which protrudes when infant cries or strains
Symptoms of GI Disorders Systemic signs
◦ Pruritus (itching) in the absence of allergy may indicate liver dysfunction
Poisoning: Goals of treatment
◦ Remove the poison ◦ Prevent further absorption ◦ Call the poison control center ◦ Provide supportive care—seek medical help
Worms Roundworms (Ascariasis)
◦ Seen more in U.S. southern states and among immigrants and migratory workers ◦ Caused by unsanitary disposal of human feces and poor hygiene ◦ Eggs can survive for weeks in soil
Appendicitis (cont.): Treatment
◦ Surgical intervention typically required Nursing care is the same as with most other abdominal surgery patients
Meckel's Diverticulum (cont.): .Treatment
◦ Surgical removal of the diverticulum Nursing care is same for any patient having undergone abdominal surgery
Appendicitis (cont.): Characteristic symptoms
◦ Tenderness in RLQ, known as McBurney's point ◦ Guarding ◦ Rebound tenderness ◦ Pain on lifting thigh while in supine position ◦ Pain in RLQ
Vomiting (cont.) Nursing care: Documentation
◦ Time, amount, color, consistency, force, frequency, and whether vomiting was preceded by nausea or feedings ◦ Administration of antiemetic agents should also be documented, including time given and if/when vomiting subsided
Esophageal Atresia (Tracheoesophageal Fistula [TEF]) : 1 of 4 types
◦ Upper and lower esophagus (from the stomach) end in a blind pouch
Esophageal Atresia (Tracheoesophageal Fistula [TEF]): Four types
◦ Upper and lower esophagus (from the stomach) end in a blind pouch ◦ Upper esophagus ends in a blind pouch; lower esophagus (from stomach) connects to the trachea ◦ Upper esophagus is attached to trachea; lower esophagus (from stomach) also attached to trachea ◦ Upper esophagus connects to trachea; lower esophagus (from stomach) ends in a blind pouch
Esophageal Atresia (Tracheoesophageal Fistula [TEF])1 of 4 types
◦ Upper esophagus connects to trachea; lower esophagus (from stomach) ends in a blind pouch
Esophageal Atresia (Tracheoesophageal Fistula [TEF])1 of 4 types
◦ Upper esophagus ends in a blind pouch; lower esophagus (from stomach) connects to the trachea
Esophageal Atresia (Tracheoesophageal Fistula [TEF]) one of 4 types
◦ Upper esophagus is attached to trachea; lower esophagus (from stomach) also attached to trachea
Poisoning (cont.) General concepts
◦ Volume of swallow ◦ Principles of care—education ◦ Poison control centers—nationwide phone number is 1-800-222-1222 ◦ Ipecac syrup—no longer recommended ◦ Activated charcoal—given for some substances ◦ Charcoal or any gastric lavage is not effective if administered after 1 hour post-ingestion
Gastroesophageal Reflux: Symptoms
◦ Vomiting ◦ Weight loss ◦ Failure to thrive ◦ Infant is fussy and hungry ◦ Respiratory problems can occur when vomiting stimulates closure of epiglottis and infant presents with apnea
Vomiting (cont.) Nursing care:
◦ When an older child vomits, turn head to one side and offer emesis basin ◦ IV fluids may be ordered ◦ Slowly introduce foods to allow stomach to rest
Gastroesophageal Reflux (cont.) History includes
◦ When vomiting started ◦ Type of formula ◦ Type of vomiting ◦ Feeding techniques ◦ Infant's eating in general Tests include ◦ Barium swallow ◦ Esophageal sphincter pressure ◦ pH monitoring—most diagnostic Nursing care ◦ Careful burping ◦ Prevent overfeeding ◦ Proper positioning ◦ Feedings are thickened with cereal After being fed, infant is place in an upright position or propped ◦ Sitting upright in an infant seat is not recommended as it increases intra-abdominal pressure Administer medications to relax pyloric sphincter before meals
