Pediatrics Exam 2 - GI
Esophageal atresia/Tracheoesophageal fistula post-op feedings
Observe first PO feed and monitor, begin with sterile water, follow with small amounts of breastmilk/formula
Nutrition after cleft lip surgery
Often able to eat immediately
Intussusception pathophysiology
One segment of bowel telescopes into another, causing a bowel obstruction
Gastroschisis treatment
Operate within 24 hours, place swollen intestines into silo to shrink, IV fluids and antibiotics, monitor for s/s of infection
Pyloric stenosis diagnosis
Palpation of abdomen for olive shaped mass, ultrasound, upper GI x-ray
Normal surgery age for both cleft lip and palate
9-15 months
Normal surgery age for cleft lip
10 weeks and 10 lbs
GER/GERD medications
Antacids, histamine receptor antagonists, proton pump inhibitors
When does vomiting occur in pyloric stenosis
Around 3 weeks of age, can be 1-5 months of age; usually 30-60 mins after feeding
Hirschsprung Disease manifestations
24-48 hr onset, delayed passing of meconium, distended abdomen, feeding intolerance with bilious vomit
Esophageal atresia/Tracheoesophageal fistula manifestations
3 C's (choking, coughing, cyanosis), frothy saliva, drooling, distended abdomen, coughing with feeds, respiratory distress and chronic issues (pneumonia), may present later in life but *urgent*
When to resume feedings postoperatively for pyloric stenosis
4-6 hour post-op sips of H2O/Pedialyte, 24 hr post-op resume formula in small increments, slowing increase and spread feeds to normal schedule
Normal surgery age for cleft palate
6-12 months
Eight hours ago, an infant with Hirschsprung's disease had surgery to create a colostomy. Which finding should alert the nurse to notify the provider immediately? A. 3 cm increase of abdominal circumference B. Periods of occasional fussiness C. Absence of bowel sounds since surgery D. Appearance of bright red stoma
A. Abdominal circumference is measured post-op to monitor abdominal distention. An increase of 3cm in 8 hours would indicate a substantial degree of abdominal distention, potentially from fluid or gas, so we would want to call the provider.
Surgeries for biliary atresia
Kasai procedure (removing gallbladder and replacing with part of small intestine), liver transplant
How to prevent trauma to sutures postoperatively for cleft lip and palate
Avoid prone positioning, NO forks, spoons, straws, sippy cups with hard straw, try to keep from crying
The nurse admits an infant with pyloric stenosis to the hospital. Which aspect of the plan of care should the nurse implement first? a. Begin an IV infusion b. Weigh the infant c. Switch the infant to an oral electrolyte solution d. Orient the parent to the hospital unit
B Unless in hypovolemic shock, you would want a baseline weight because it will be used to calculate the child's fluid and electrolyte needs
Gastroschisis pathophysiology
Bowel herniates through a defect in abdominal wall to side of umbilical cord and through rectus muscle
The nurses assesses an infant who has had surgery to correct an intussusception and is now at risk for the development of a paralytic ileus postoperatively. Which assessment should be the priority? a. Measurement of urine specific gravity b. Inspection of the first stool passed c. Auscultation of bowel sounds d. Measurement of gastric output
C Development of a paralytic ileus postop is a functional obstruction of the bowel. Bowel sounds may initially be hyperactive, BUT then they will diminish and decrease. USG gives information about fluid and electrolyte status. The first stool and amount and gastric output provides info about return of gastric function
Which statement by the parents would indicate the need for further education regarding caring for their child post cleft lip surgery? A. "I will prop my child up while they are laying down" B. "I will give my child Tylenol for the pain when we are at home" C. "I will feed my child applesauce with a spoon for the first two weeks" D. "I will wash the sutures with soap and water"
C No spoons, straws, forks post-op. These things can disrupt the sutures!
Which of the following is true regarding GER? A. It is a regurgitation of gastric contents into the lung B. Children who are born post-maturely have a higher incidence C. Repeated reflux of gastric contents can damage delicate esophageal mucosa D. Surgery is the usual treatment
C. Surgery is the last resort! Pre-mature children are higher risk.
Ostomy types
Colostomy or ileostomy, based on location
Hirschsprung Disease (Aganglionic Megacolon) pathophysiology
Congenital anomaly that results in mechanical obstruction from inadequate motility; inflamed/narrowed rectum that impedes emptying
Your 4-year-old patient presents to the hospital with the following symptoms: Sudden abdominal pain, abdominal distention, lethargy, and jelly-like stools. What diagnosis do you expect the patient to receive? A. Biliary atresia B. Appendicitis C. GER D. Intussusception
D Jelly-like stools is the main manifestation of intussusception.
Ribbon like stools are associated with which of the following: A. Intussusception B. Crohns Disease C. Biliary Atresia D. Hirschprung's Disease
D. This happens because there is a constriction in the bowel, and so if any stool gets past this, it is not formed, causing the stool to look ribbon like.
Manifestations of chronic intussusception
Diarrhea, weight loss, occasional vomiting, episodic pain
Omphalocele pathophysiology
Failure of in-folding of abdominal wall during gestation, results in intestines in thin sac outside body near umbilical cord
G-button
Form of gastronomy tube that is closer to skin, cosmetically pleasing, and offers more mobility and comfort
Omphalocele complications
GER, feeding issues, failure to thrive
Biliary atresia diagnosis
H&P, elevated AST, ALP, and GGT (liver values), ultrasound, nuclear imaging, exploratory laparotomy with cholangiogram
Acute appendicitis diagnosis
H&P, elevated WBC with elevated % bands, ultrasound/CT
Intussusception diagnosis
H&P, ultrasound showing mass with bullseye
GER/GERD manifestations in older children
Heartburn, abdominal pain, chronic cough, hoarse voice, dysphagia, vomiting
Pyloric stenosis management
IV access, correct alkalosis, NG tube for decompression, pyloromyotomy (cut pyloric muscle, relieve obstruction)
GER/GERD diagnosis
Infant gastroesophageal reflux questionnaire, barium esophogram, radioactive nucleotide studies/scintigraphy, EGD
Enema administration
Isotonic solutions only or 1 tsp salt to tap water, proper volume is age-dependent
Esophageal atresia/Tracheoesophageal fistula post-op care
Maintain airway, nutrition, replace fluids as needed, prevent infection/pneumonia, manage pain, suctioning
Short Bowel Syndrome pathophysiology
Malabsorptive disorder that occurs as a result of decreased mucosal surface area, resulting in need for TPN
Omphalocele presentation
May be small (small bulge in umbilical cord), intestines covered by thin sac
Postoperative pyloric stenosis care
May vomit for 24 hours, manage pain, prevent injury, resume feedings
Postoperative care for cleft lip and palate
Monitor for shock and hemorrhage, prevent aspiration, prevent trauma, prevent pain, promote healing
Intussusception management
NG decompression, antibiotics, IV fluids, gas/water/saline enema, surgery
Hirschsprung Disease pre-op care
NG tube, antibiotics, vit K
Use of ostomies in infants
Necrotizing colitis, imperforate anus, Hirschsprung diease
GER/GERD surgery
Nissen Fundoplication
Cautions/problems with gastronomy tube
No hydrogen peroxide to clean/leaking, clogging, erythema and bleeding around stoma, vomiting, diarrhea, granulation tissue buildup
Fleets enema
No. Fleets enemas are hypertonic, leading to diarrhea and metabolic acidosis
Plain tap water enema
No. Hypotonic solution, leading to rapid fluid shift/overload
Biliary atresia treatment
Nutritional support, tube feeds or TPN, liver transplant
Peritonitis cause and symptoms
Perforated appendicitis; distention, rapid shallow breathing, pallor, chills, restless
Acute appendicitis complications
Perforation: initial relief of pain followed by increase and results in peritonitis.
Acute appendicitis manifestations
Periumbilical pain that moves to RLQ to McBurney's point, N/V/D, lethargy, poor feeding, fever, tachycardia, hypoactive bowels
Biliary atresia manifestations
Persistent jaundice after 2 weeks of age, dark urine, gray stools, hepatomegaly, firm liver on palpation
Short Bowel Syndrome management
Preserve as much bowel as possible, maintain nutrition, intestinal transplant
Cleft lip and palate - preoperative care
Prevent aspiration, prevent infection (improper drainage of middle ear common)
Biliary atresia pathophysiolopgy
Progressing inflammatory process that causes bile duct fibrosis which results in bile duct obstruction, many infants with biliary atresia appear healthy at birth
Manifestations of pyloric stenosis
Projectile vomiting (hallmark symptom), non-bilious vomiting, distended upper abdomen, very hungry, metabolic alkalosis, weight loss, failure to thrive, blood-tinged vomit
Appendectomy considerations
Prophylactic antibiotics, IV fluids/electrolytes, laparoscopic if no perforation
Ostomy care
Protect peristomal area, encourage participation in care, encourage normal life activities
How to prevent aspiration postoperatively for cleft lip and palate
Raise HOB
Hirschsprung Disease diagnosis
Rectal biopsy, anorectal manometry (measures pressure in anus)
GER/GERD manifestations in infants/young children
Regurgitation, vomiting, excessive irritability, poor weight gain, respiratory problems, feeding refusal
Post-appendectomy care w/o perforation
Splint, incision care, early ambulation, pain management
Post-appendectomy care w/ perforation
Splint, incision care, early ambulation, pain management, NG tube to decompress, NPO until GI motility returns, IV antibiotics, may have drain
Esophageal atresia/Tracheoesophageal fistula pre-operative care
Suctioning, parenteral nutrition and fluids, antibiotics, humidified oxygen, NPO
Intussusception manifestations
Sudden abdominal pain, jelly-like mucous stools, vomiting (bile-stained), distention, tenderness, lethargy, crying
Nissen Fundoplication
Surgery for GER/GERD; reinforces lower esophageal sphincter, reserved for those with severe complications (apnea, recurrent aspiration pneumonia, failure to thrive)
Hirschsprung Disease treatment
Surgery to remove aganglionic portion; if diagnosed before distention can operate immediately; if diagnosed later colostomy for 3 mo then surgery
Omphalocele treatment
Surgical closure
Short Bowel Syndrome nutrition
TPN (central line), enteral feeds, oral feeds to stimulate suck reflex, *intestinal transplant for those dependent on TPN*
Tracheoesophageal fistula pathophysiology
The esophagus and trachea are abnormally connected, allowing fluids from the esophagus to enter the airways.
Cleft lip AND palate nutrition
take in a lot of air, need to burp more often, milk leaks from nose, can show signs of stress
Esophageal atresia pathophysiology
The upper and lower parts of the esophagus don't connect, preventing food and saliva from reaching the stomach.
GER/GERD management
Thicken formula, small frequent feeds, slow feeds, frequent burping, upright/side lying position for 1 hr post-feed, elevate HOB, avoid trigger foods
Cleft lip nutrition methods
Trouble getting seal for feeding, squeezing cheeks can help, can typically use regular bottle
Cleft palate nutrition methods
Trouble with suction, bottle with one-way valve
Esophageal atresia/Tracheoesophageal fistula diagnosis
X-ray, bronchoscopy
Pyloric stenosis pathophysiology
circumferential muscle of the pyloric sphincter (stomach to small intestine) becomes thickened resulting in narrowing and elongation of the pyloric canal
Nutrition after cleft palate surgery
clear liquids for 24 hours, full liquid for 2 weeks, soft foods for 6 weeks
Short Bowel Syndrome causes
congenital abnormalities (e.g. Hirschsprungs), ischemia (necrotizing enterocolitis), meconium peritonitis, Crohn's disease
Nasogastric tube measurement
measured NEMU (nose, ear, midway to umbilicus)
Nasoduodenal and nasojejunal tube
nose to duodenum/jejunum for feeding, medications need to be highly diluted
Nasogastric tube
nose to stomach, no enteric or extended release medications, used for feeding, decompression, and lavage
Pain control postoperatively for cleft lip and palate
opiates for 24-48 hours, acetaminophen after
Gastronomy tube location and use
through abdomen wall into stomach, alternative to longterm NG use, can also be a G-button
