Peds exam 2 GI

Post op care for cleft lip/palate

- Place infant in supine HOB elevated to reduce edema, respiratory difficulties - Liquid diet initially and progress to soft (if appropriate for age) --- Progress feedings as tolerated (may use special device). --- Caution not to traumatize the suture line - Provide pain control --- Analgesic medication & nonpharmacologic measures --- Avoid crying - Provide emotional support for parents --- Recovery is long and prognosis uncertain for scarring and full recovery of functions - Restraints needed on arms so they can not pull out any tubes - The scar doesn't grow, the child does!

GER nursing considerations

- SIDS risk - educate parents

nursing care for Hypertrophic pyloric stenosis POSTOP

- Same as general abdominal surgery - Pain management - Wound Care - Teach parents: --- Feeding method (restart within 4-6 hrs. post op and advance as tolerated ) --- Signs of infection or complication (wound dehiscence or GER)

family teaching and home prep for cleft lip/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

probable tests ordered

- WEIGHT (must evaluate the degree of dehydration)* - direct evaluation of stools - hemoccult tests and stool pH - blood tests: CBC, serum electrolytes, creatinine, BUN, anion gap blood gasses

Dx FTT

- Weight and height plots - Health and 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...

appendicitis physical exam/ S/S

- abdominal pain (periumbilical then RLQ)** - fever - nausea and vomiting - McBurneys point positive** - guarding - rigid abdomen - rebound tenderness**

vomitus characteristics:

- bilious vs non bilious - visible undigested matter --> stomach - bile colored --> small intestine - smells like feces --> large intestine - bright red blood --> upper GI bleed - coffee ground --> lower GI bleed

other causes of diarrhea

- dietary indiscretions (hyperosmolar formula. overfeeding, infection outside GI tract, especially respiratory or UTI) - emotional tension (people who have alot of GI issues also usually have psych issues) - medications - inflammation of anatomical abnormalities (UC, Crohns) ALOT of diarrhea = feeding issue infection (ex. UTI, resp) = diarrhea

Cleft palate

- failure of the 2 sides of the palate to fuse during embryonic development (1st trimester) -- may occur with or without cleft lip - may have dental, speech, or hearing issues

cleft lip

- failure of the maxillary and median nasal processes to fuse during embryonic development (1st trimester) - nose did not completely form/fuse - can be unilateral or bilateral - defect can range from notch in vermillion border to complete separations to base of nose - CAN breastfeed

nursing considerations cleft lip/palate

- feeding behaviors - oral hygiene - respiratory status - hearing ability - speech - parent/child interaction

Gastroenteritis risks

- fluid and electrolyte loss - dehydration - acid-base imbalance - shock

pediatric differences for the digestive and GI system

- infant ability to swallow limited to fluids UNTIL 4 MONTH OF AGE -- they have an extrusion (tongue-thrust) reflex (why you give fluids instead of solids at this age - smaller stomach capacity - lacking in digestive enzymes to about 4 months of age - immature liver (mg/kg for a reason -- so sensitive to meds) - proportionally longer GI tract in neonate/infant - varying food/fluid needs and intake patterns (needs more fluid) - increased risk of dehydration and fluid overload in younger

acute appendicitis

- inflammation of vermiform appendix - average age: 10 years (both boys and 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 - - the key is to diagnose and treat prior to perforation

risk factors of cleft lip/palate

- more in girls multi-factoral inheritance: - folic acid deficiency - maternal smoking and alcohol in first trimester - maternal exposure to several medications ---- dilantin, accutane - pesticide exposure

Cleft palate S/S

- nasal distortion - midline or bilateral cleft extending uvula and soft/hard palate - nasal cavity exposure - feeding problems - infection, especially aspiration pneumonia** - altered speech - altered dental development - hearing problems caused by recurrent otitis media

Cleft Lip S/S

- notch vermillion border, size vary - dental anomalies can occur - feeding difficulties - potential for problems with social acceptance

GER therapeutic management

- nothing if growing well and no respiratory complications - feed upright position - small frequent meals - frequent burping - positioning: prone if awake with caution, supine prop-up HOB at home - diet therapy: rice feedings, hypoallergenic formula, decrease acid/irritating foods, position during and time of meals

Hypertrophic pyloric stenosis DX

- physical exam -- palpate empty stomach for olive - electrolyte labs --- decreased K+ and Na********* --- decreased serum Cl- levels --- increased pH and bicarb levels (MET ALK) --- elevated BUN (dehydration) - U/S -- DIAGNOSTIC EVIDENCE

GER dx

- physical exam and detailed history -- usually the history alone is enough - upper GI series: endoscopy, continuous pH monitoring (amount of acid reflux in the esophagus)

S/S intussusception CLASSIC TRIAD

1. Abdominal pain 2. Abdominal mass 3. Bloody stools **********

4 main S/S of celiac disease**

1. Steatorrhea 2. Malnutrition 3. Abdominal distention 4. Vitamin deficiencies

organic FTT (OFTT)

A biological underlying health problem accounts for infant's failure to obtain or make use of adequate nutrition. Does not make normal gains in weight physical cause: - Congenital heart disease - Malabsorption syndrome, GER - Cystic fibrosis - Chronic renal failure - Endocrine or neurological disorder

intussusception

A common intestinal obstruction occurring in infants and toddlers (3 months-3 years) peak incidence 3-9 months of age Proximal segment of bowel telescopes (invagination) into a distal segment pulling the mesentery with it Lymphatic and venous congestion/obstruction - edema of bowel wall pressure increases - occlusion of arterial blood flow - ischemia Potential infarction and perforation Venous engorgement - blood and mucus leakage into intestinal lumen - classic currant-jelly stools*******

appendicitis scans

CT

FTT nursing care

Non-judgmental Provide consistent care 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

intussusception TX

Non-surgical hydrostatic (saline enema) reduction OR air enema - Often corrected during the diagnostic procedure - Successful 80% of time - With or without water-soluble contrast If the enema does not work, then surgery for a surgical reduction (usually laparoscopic) or excision of nonviable segment of colon - IV, NG, and abx prior to intervention -- reduction/resolution: is evidenced by successful passage of normal brown stool - report to practitioner****

FTT

The term is used to describe infants and children whose weight and sometimes height fall below the 5th percentile Persistent deviation from established growth curve Falling off growth curve is bad

constipation nursing mgmt

Treat underlying cause Diet modifications: Increase fiber intake, increase fluids in older infants and children, remove constipating foods, (ex. Bananas, rice, cheese, apple sauce, etc...), For infants: may add corn syrup (2 tbsp) to formula OR 2oz of pear or apple juice daily Regular toileting 30 min on toilet after every meal Role-modeling by parents Avoid retention Medications: Stool softeners: Docusate, lactulose, miralax, fiber evaluate/assess for: impaction, UTI, vomiting, abdominal distention, pain, growth failure - All need further evaluation

protect post-op site for cleft palate

- 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

protect post-op site for cleft lip

- 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* - Will be grumpy because they cannot suck - Try to avoid crying as much as possible

appendicitis labs

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

assessment of GI function labs and dx too

- History -Clinical examination and observation -I & O ****** what goes in must come out!!!!! -Weight and height -Abdominal assessment -GI issues effect RR*** Labs: - Stool exam - O&P (ova and parasites) Diagnostic procedures: - Barium swallow, EGD, etc...

other S/S intussusception

- Inconsolable crying - Drawing up knees --- Child normal between cramping episodes - Palpable sausage-shaped abdominal mass - Bilious vomiting as progresses

constipation of newborns

- MECONIUM -- should be passed in 24-36 hours of life* -- if NOT PASSED assess for: hirschsprung disease, hypothyroidism, meconium plug/meconium ileus*

Preop feedings with cleft lip/palate

- May use special nipple or appliance - Feed in upright position - Burp frequently during feeding - Teach breastfeeding 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)

QUESTION 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?

Your son will have an IV line, an oxygen source, a dressing, and perhaps a colostomy bag

QUESTION 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?

"There are several tests, including x-rays and a rectal biopsy, but we will keep your son comfortable"

QUESTION 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 Hirschprung's disease (HD)?

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

intussusception DX

- Assessment (clinical picture) - Abdominal U/S - Radiologist-guided enema* --- This can be diagnostic and is often curative --- Radiology first to try to decrease pressure, if radiology did not work then surgery

GER

- transfer of gastric contents into the esophagus from the stomach - GER caused by incompetent or relaxed sphincter (LES) - occurs naturally in everyone, especially <! year self-limiting - GERD may occur without actual regurgitation: spitting up, cough, CP, nausea, pyrosis, dysphagia, SOB, halitosis, arched back, excessive crying, recurrent pneumonia, failure to thrive - GER may present atypically: s/s mimic other conditions like asthma, non cardiac chest pain, or a chronic cough

fluid correction with gastroenteritis

- usually able ot manage at home -- educate parents - provide oral rehydration and/or IV fluid therapy - if no signs of dehydration then just maintenance fluid amounts - still encourage oral rehydration with vomiting (unless sign of blockage or risk of aspiration - replace extra for each diarrhea/stool ORT THEN ADVANCE to REGULAR diet - slow but constant - 5-10 mL every 2-5 minutes - age appropriate unrestricted diet ASAP** - continue low sodium fluids, such as breasfteed/formula - educate on correct replacement fluids rehydration: - 0-3% = oral rehydration - middle = IV or oral - 10% = IV (usually NS or LR)

Appendicitis Nursing Considerations POSTOP

- vitals, pain level - NPO status - side-lying position -- helps with drainage - IV fluids - monitor BS and elimination - lap vs open surgery - monitor drain - dressing change - assess incision for infection - abx

Celiac Nursing care

-Diet *** -- What diet can we give them**** EXAM QUESTION: --- 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 - May need lactose free diet due to mucosal damage

cleft lip/palate TX

-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 (to drain) - Extensive orthodontic and surgery - often through 18th year of age - Multidisciplinary team approach: --Hearing evaluation --Lactation consult

Hirschsprung's Disease S/S

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

FTT assessment and documentation

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

Hx questions

recent travel water sources animal/bird contact daycare or school attendance recent abx diet changes/food intake

cause of intussusception

rotavirus VACCINE

Nonorganic FTT

stressor/environment/ psychosocial - Poverty, family stress, health beliefs, lack of emotional information, inadequate nutritional information, difficulty separating from parent - child uses refusing food as attention getting mechanism, insufficient breast milk

acute diarrhea

sudden duration less than 14 days toxic reaction to pathogen + body ridding of pathogen most often viral

when child goes to surgery for Hirschsprung's Disease tell parents...

tell parents they may have ostomy or may just be a bandaid when they come out**

Celiac Dx

Definitive: tissue biopsy of small intestine atrophy of intestinal villi Blood tests for antibodies may be helpful - Positive IgA antibody test

TX OFTT

Determine and treat cause

other S/S of celiac disease

Diarrhea (bulky, foul smelling, steatorrhea) Abdominal pain and distention Dermatitis: high pruritic rash knees, elbows buttock bilaterally Muscle wasting: especially buttocks and extremities - Not absorbing Change in behavior: irritability, apathy Anemia and failure to thrive - Bruises and bleeds easily

S/S Hypertrophic pyloric stenosis

EARLY Vomiting - Progressively projectile - Shortly after feeding - No bile (with further obstruction) - May be blood tinged (hematemesis) - Infant hungry, avid eater -- Accepts second feeding after vomiting, no nausea - No evidence of pain or discomfort early - Mild dehydration (early) AS MUSCLE ENLARGES: looks increasingly ill: - weight loss - increasing dehydration - distended upper abdomen - palpable olive-shaped mass in RUQ** - visible gastric peristalsis - electrolyte imbalances: METABOLIC ALKALOSIS**

S/S FTT

Growth failure: - Weight and height below the 5th percentile - Developmental delays - Usually developmentally behind when growth is behind → because all nutrients are going to try to grow Other general changes: - Hypotonia - Decreased muscle mass - Generalized weakness - Abdominal distention - Endocrine changes

Medications for GER

H2 receptors (-dine) PPIs (-zole)

QUESTION To prepare the infant for surgery, the nurse has a number of activties to perform, including repeated saline enemas and intravenous antibiotics. What can the nurse instruct the mother to encourage while her infant is receiving nothing by mouth (NPO) preoperatively?

Have the infant use a pacifier to maintain his sucking ability

TX 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

Hypertrophic pyloric stenosis

Hypertrophy and hyperplasia of the circular muscle of the pylorus Partial to total obstruction of the pyloric sphincter -- Causing obstruction of the gastric outlet Usually takes 2-4 weeks until it is found Clinical presentation: - 2-5 weeks of age (usually) - Not congenital, although can be familial* - Classic sign: projectile vomiting after eating 4-5 ft***** Could be a touch of blood b/c vomiting so much - makes U-turn

Celiac TX

Lifelong complete elimination of gluten from diet**** - Eliminate wheat, barley, rye, and oat - substitute corn, rice, soybeans, and millet Remission occurs when they eliminate gluten from the diet Supplementation of vitamins and minerals: Iron, folic acid, fat soluble vitamins Caution: - May develop lactose intolerance from severe damage to mucosa - A lot of education → reading labels

Celiac disease

Malabsorption syndrome: more in females appears in genetically sensitive kids Cannot process gluten Inability to digest peptides contained in the gluten protein (gliadin) of wheat, barley, rye, and oat grains Swelling of the gut

constipation causes

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) "I do not want to go at school" Underlying disease or anatomical deformity Medications: Antacids, diuretics, ANTIHISTAMINES********, opioids, iron, etc

Hirschsprung's Disease POSTOP

NG suction until peristalsis No rectal temps*************** Abdominal girths Stool patterns IV therapy Colostomy care Referral: stoma therapist Diet as prescribed Teaching for family re: colostomy care, etc...

nursing care for Hypertrophic pyloric stenosis PREOP

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

Hirschsprung's Disease PREOP

NPO status Maintain NG suction IV therapy Enemas, saline (clean out)*** ABX (no spillage in abd cavity) Measure abdominal girth with VS Monitor stool pattern Psychological preparation express grief Loss of perfect child

medications for vomiting (if needed)

Ondansetron (Zofran) Metoclopramide (Reglan) Promethazine (Phenergan) Dimenhydrinate (Dramamine)

Appendicitis Nursing Considerations PREOP

PREOP - pain assessment with VS - monitor fever - abdominal distention - avoid heat to abdomen* use ice - pallor, chills, restless, irritable - potential shock signs - avoid laxative/enemas - abx - if pain suddenly stops = RUPTURE**

Gastroenteritis most common cause

ROTAVIRUS (only oral vax can only be given in short window of time) fecal-oral spread virus, bacteria, parasite

Hirschsprung's Disease

congenital aganglionic megacolon stuff CANNOT move alone BIG colon MECHANICAL OBSTRUCTION

chronic diarrhea

duration greater than 14 days more often chronic condition, food indiscretion, food sensitivity

treatment for Hirschsprung's Disease

first confirm diagnosis with rectal biopsy surgical removal of aganglionic portions of bowel type of surgery depends on extent/location of aganglionic bowel may be a single surgery or multi-stage process - performed when physical status appropriate, may need IV nutrition and enemas prior, potential colostomy (usually temporary)**

complications of celiac disease

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

most common site of intussusception

ileocecal valve

vomiting often caused by:

infection psych stress anatomical defect abnormal gastric motility inflammatory response increased ICP GI obstruction

treatment for Hypertrophic pyloric stenosis

laparoscopic pyloromyotomy surgery

S/S NFTT

may be associated with unique signs and symptoms - Apathy and withdrawal behavior - Feeding or eating dysfunction (Ex. dont suck/swallow properly) - No fear of stranger at age when appropriate - Avoidance of eye contact - Wide-eyed gaze and continual scan of environment - Minimal smiling - Lack of attachment to parents - Stiff and unyielding or flaccid and unresponsive

S/S OFTT

may have associated signs and symptoms of physical disease state

nursing care gastroenteritis

monitor fo ss of electrolyte imbalance accurate I&O -- daily weights, weigh diapers, abdominal girth, etc... prevent spread of infection - isolation - eliminate and/or correct cause -- usually self limiting -- abx may be given with ECOLI or GIADIA - NO ANTIDIARRHEALS if possible - meticulous skin care - rinse teeth after vomit - position to avoid aspiration - make child comfy - antiemetics teach: - prevent recurrence - rotavirus vaccine

GER surgery

nissen fundoplication for severe cases (procedure wraps the fundus of the stomach distal esophagus to decrease reflux) - monitor for FTT and weight loss

infants constipation

often diet related - formula fed = constipation*

Idiopathic (IFTT)

unexplained (usually NFTT)

gastroenteritis

upper and lower GI tract diarrhea and vomiting caused by ROTAVIRUS