Chapter 20: Nursing Care of the Child With an Alteration in Bowel Elimination/Gastrointestinal Disorder

A child is scheduled for a urea breath test. The nurse understands that this test is being performed for which reason?

Detect Helicobacter pylori Urea breath test is used to detect the presence of H. pylori in the exhaled breath. This test does not evaluate gastric pH. Serum amylase and lipase levels are used to confirm pancreatitis. Esophageal manometry is used to evaluate esophageal contractile activity and effectiveness

The nurse is caring for a child admitted with gastroesophageal reflux (GER). Which clinical manifestation would likely be seen in this child?

Effortless vomiting just after the child has eaten : Almost immediately after feeding, the child with gastroesophageal reflux vomits the contents of the stomach. The vomiting is effortless, not projectile in nature.

A nurse taking a health history of a newborn notes that there is a maternal history of polyhydramnios. What GI condition might this history precipitate?

Esophageal atresia (EA) A maternal history of polyhydramnios is usually present in one-third of cases of EA and in some cases of tracheoesophageal fistula (TEF).

An adolescent boy is diagnosed with hepatitis A. Which problem should be considered when planning care?

He will become fatigued easily. Most children with hepatitis are exhausted. Urine is not infectious.

The nurse is caring for a child with a diagnosis of pyloric stenosis during the preoperative phase of the child's treatment. What is the highest priority at this time?

Improving hydration Preoperatively the highest priority for the child with pyloric stenosis is to improve nutrition and hydration. Maintaining mouth and skin integrity, and relieving family anxiety are important, but these are not the priority. The child will not likely have intense pain. Preparing the family for home care would be a postoperative goal.

The nurse is reviewing the medical record of a child with a cleft lip and palate. When reviewing the child's history, what would the nurse identify as a risk factor for this condition?

Mother age 42 with pregnancy Advanced maternal age is a risk factor for cleft lip and palate. Drugs such as anticonvulsants, steroids, and other medications during early pregnancy are considered risk factors. Acetaminophen is not associated with an increased risk for cleft lip and palate. Preterm birth is not a risk factor for the development of cleft lip and palate. Hypoxia or anoxia is a risk factor for the development of necrotizing enterocolitis.

The nurse caring for an 18-month-old infant with Meckel diverticulum knows that the most common clinical manifestation of this condition is:

Painless rectal bleeding With Meckel diverticulum, most symptomatic children present younger than age 2 years. Intermittent, painless rectal bleeding is the most common clinical manifestation of Meckel diverticulum. The blood is most often bright red or maroon and may be passed independent of stool due to ulceration at the junction of the ectopic tissue and the normal ileal mucosa.

In caring for an infant diagnosed with pyloric stenosis, the nurse would anticipate that she would:

Prepare the infant for surgery. A surgical procedure called a pyloromyotomy (also known as a Fredet-Ramstedt operation) is the treatment of choice for pyloric stenosis.

If an adolescent has hepatitis B, what would be an important nursing action?

Strict enforcement of standard precautions Hepatitis B is spread through contaminated blood. Standard precautions help prevent contact with this.

The nurse is caring for a 2-year-old boy with an umbilical hernia and is teaching the mother about this condition. Which response from the mother indicates a need for further teaching?

"I can tape a quarter over the hernia to reduce it." The use of home remedies to reduce an umbilical hernia should be discouraged because of the risk of bowel strangulation. The mother needs to be aware that strangulation can occur, but it is rare with an umbilical hernia. Pain, tenderness, or redness indicates incarceration, which although rare with umbilical hernias, can occur. She needs to understand the signs of strangulation and understand that some children have self-esteem issues related to the large protrusion of the unrepaired umbilical hernia. Physical needs of the child have priority over any types of potential psychosocial issues. Self-esteem issues may arise due to a large protrusion of an unrepaired umbilical hernia.

The nurse has performed client teaching to a 15-year-old boy with Crohn disease, and his parents regarding the cobblestone lesions in his small intestine. Which comment by the family indicates learning occurred?

"I have to be careful because I am prone to not absorbing nutrients." Crohn disease typically effects the small intestine more than the large intestine and it's onset is between the ages of 10 to 20 years. The cobblestone lesions in the small intestine prevents absorption of nutrients that normally occurs. The diarrhea is not directly related to the cobblestone lesions, and ulcerative colitis is characterized by the disease effecting the intestine(s) in a continuous pattern.

The nurse is caring for an infant recently diagnoses with thrush and was prescribed nystatin. Which statement by the infant's mother would suggest a need for further education?

"I will add the nystatin to her bottle four times per day." Administer nystatin suspension four times per day following feeding, not mixed in the bottle, to allow the medication to remain in contact with the lesions. In the younger infant, apply nystatin to the lesions with a cotton-tipped applicator. Infants and young children often mouth their toys, so it is important to clean them appropriately. Explain to parents of infants with thrush the importance of reporting diaper rash because fungal infections in the diaper area often occur concomitantly with thrush and also need to be treated.

The mother of a young child, who has been treated for a bacterial urinary tract infection, tells the nurse her daughter has a white thick covering over her tongue. The mother states that she "has tried everything to get it off my child's tongue." How should the nurse respond?

"It's not unusual for a fungal infection to occur while taking an antibiotic for an infection. I will let your primary care provider know so we can get it treated." Thrush is a fungal infection that can occur on the tongue while on an antibiotic for an unrelated bacterial infection. The antibiotic destroys normal flora, which allows the fungal infection to occur. Thrush requires an antifungal agent, such as nystatin liquid, to destroy the infection. Additional antibiotics will not help since it is a fungal infection

The nurse is reinforcing dietary teaching with the caregiver of a child diagnosed with celiac syndrome. The caregivers make the following statements. Which statement indicates a need for further teaching regarding the dietary restrictions for the child with celiac syndrome?

"She loves hotdogs, and we always cut hers up into small pieces." Commercially canned creamed soups, cold cuts, frankfurters, and pudding mixes generally contain wheat products and should not be included in the diet of the child with celiac syndrome. This caregiver needs further teaching regarding giving her child hotdogs, even if they are cut into small pieces. The other choices show an understanding of the dietary restrictions.

The nurse is collecting data on a 2 ½-year-old child admitted with a diagnosis of gastroenteritis. When interviewing the caregivers, which question is most important for the nurse to ask?

"Tell me about the types of stools you child has been having." For the child with gastroenteritis, the interview with the family caregiver must include specific information about the history of bowel patterns and the onset of diarrheal stools, with details on number and type of stools per day. Recent eating patterns, if the child is toilet trained, and how many times a day the child urinates are important questions, but the highest priority is gathering data regarding the stools and stool pattern

A physician recommends a gastrostomy for a 4-year-old client with an obstruction. The parents ask the certified wound, ostomy, and continence nurse (CWOCN) what the surgery entails. What is the nurse's best response?

"The surgery creates an opening between the stomach and abdominal wall." Ostomies can be created at various sites in the GI tract, depending on the child's clinical condition. A gastrostomy provides an opening between the stomach and the abdominal wall, and an esophagostomy communicates between the esophagus and an external site on the neck. Ostomies may be created at various sites in the small intestine (e.g., jejunostomy, ileostomy) or in the large intestine (e.g., colostomy).

The nurse is discussing the treatment of congenital aganglionic megacolon with the caregivers of a child diagnosed with this disorder. Which statement is the best explanation of the treatment for this diagnosis?

"The treatment for the disorder will be a surgical procedure." Treatment of congenital aganglionic megacolon involves surgery with the ultimate resection of the aganglionic portion of the bowel. Chronic anemia may be present, but iron will not correct the disorder. Enemas may be given to initially achieve bowel elimination, but they will not treat the disorder. Differentiation must be made between this condition and psychogenic megacolon because of coercive toileting or other emotional problems. The child with aganglionic megacolon does not withhold stools or defecate in inappropriate places, and no soiling occurs.

The child has been diagnosed with severe dehydration. The physician has ordered the nurse to administer a bolus of 20 mL/kg of normal saline over a 2-hour period. The child weighs 63.5 lb (28.8 kg). At which mL/hour should the nurse set the child's intravenous administration pump? Record your answer using a whole number.

289 The child weighs 63.5 pounds. 63.5 pounds x 1 kg/2.2 pounds = 577.2727 mL 577.2727 mL of normal saline/2 hours = 288.6364 mL Rounded to the nearest whole number = 289 mL/hour

The nurse is to obtain a stool specimen from a 4-year-old child who has very liquid stool. The child is ambulatory but weak. Which collection method would be most effective for the nurse to use?

Apply a urine bag to the anal area. With very liquid stool, applying a urine bag to the anal area is most effective in collecting the specimen. Using a tongue blade to scrape a specimen from a diaper would be appropriate if the stool is formed. However, putting a diaper on a 4-year-old would be demeaning. Defecating into a collection container that sits at the back of the toilet would be more appropriate for an older child who is ambulatory. A bedpan would be appropriate if the child was bedridden.

The nurse is doing dietary teaching with the caregivers of a child diagnosed with idiopathic celiac disease. Of the following foods, which would most likely be appropriate in the child's diet?

Bananas The young child should be started on a starch-free, low-fat diet. Bananas contain invert sugar and are usually well tolerated. Products that contain wheat, rye, or oats should be excluded.

The labor and delivery nurse is caring for a mother who has demonstrated polyhydramnios upon delivery. The newborn displays copious, frothy bubbles of mucus in the mouth and nose, as well as drooling. The nurse is concerned that the infant has what disorder?

Esophageal atresia Esophageal atresia refers to a congenitally interrupted esophagus where the proximal and distal ends do not communicate; the upper esophageal segment ends in a blind pouch and the lower segment ends a variable distance above the diaphragm. Polyhydramnios is often the first sign of esophageal atresia because the fetus cannot swallow and absorb amniotic fluid in utero, leading to accumulation. Omphalocele and gastroschisis are congenital anomalies of the anterior abdominal wall. Hiatal hernia involves a weakened diaphragm.

The nurse is conducting a physical examination of an infant with suspected pyloric stenosis. Which finding indicates pyloric stenosis?

Hard, moveable "olive-like mass" in the upper right quadrant A hard, moveable "olive-like mass" in the right upper quadrant is the hypertrophied pylorus. A sausage-shaped mass in the upper mid abdomen is the hallmark of intussusception. Perianal fissures and skin tags are typical with Crohn disease. Abdominal pain and irritability is common with pyloric stenosis but are seen with many other conditions

A nurse reads the medical history of a client who is scheduled for a hernia repair that is termed "reducible." What best describes this type of hernia?

Its contents can be easily manipulated back into the peritoneal cavity. A hernia in the abdominal region is considered reducible when its contents are easily manipulated back into the peritoneal cavity. An incarcerated hernia occurs when the abdominal contents become trapped and difficult to reduce. A strangulated hernia occurs when the herniated intestines become twisted and edematous compromising blood flow. Intestinal obstruction and ischemia may occur

A mother calls the doctor's office and tells the nurse that she is concerned because her 4-month-old keeps "spitting up" with every feeding. What would indicate that the child is regurgitating as opposed to vomiting?

Only occurs with feeding Regurgitation typically occurs only with feeding, runs out of the mouth with little force, smells barely sour and is only slightly curdled, appears to cause no pain or distress, occurs only once per feeding, and amounts to only about 1 to 2 tsp. Vomiting may occur at times other than feeding, is forceful and is typically projected 1 ft or more away from infant, is extremely sour smelling and curdled, is typically accompanied by crying, continues until the stomach is empty, and amounts to the full stomach contents.

A mother brings her 10-year-old son to the ER with complaints of abdominal pain. The nurse performing a physical assessment notes the following symptoms: upper right quadrant pain that radiates to the back; fever; nausea; and abdominal distention. Which disease would the nurse consider as a diagnosis?

Pancreatitis The child admitted with the suspicion of pancreatitis typically has a complaint of abdominal pain, either epigastric, upper left, or upper right quadrant pain that may radiate to the back. Nausea and vomiting, fever, tachycardia, hypotension, and jaundice may be present. Abdominal signs such as abdominal distention, decreased bowel sounds, rebound tenderness, and guarding also may be noted.

The caregiver of a child diagnosed with celiac disease tells the nurse that the child has large amounts of bulky stools and what looks like fat in his stools. The clinical manifestation this caregiver is describing is:

Steatorrhea. Steatorrhea (fatty stools) is a classic symptom of celiac disease. Currant jelly stools are a sign of intussusception. Projectile vomiting is a sign of pyloric stenosis.

The nurse is assessing a 10-day-old infant for dehydration. Which finding indicates severe dehydration?

Tenting of skin Tenting of skin is an indicator of severe dehydration. Soft and flat fontanels indicate mild dehydration. Pale and slightly dry mucosa indicates mild or moderate dehydration. Blood pressure of 80/42 mm Hg is a normal finding for an infant.

In understanding the gastrointestinal system, the nurse recognizes that this system includes the stomach and intestines as well as:

The pharynx and esophagus The main organs of the gastrointestinal (GI) or digestive system are the mouth, pharynx (throat), esophagus, stomach, small intestine, large intestine, rectum, and anal canal. The brain, spinal column, and nerves are part of the nervous system, and there is a protective coating surrounding the nerves.

Constipation may be initially caused by psychological problems.

True Some children begin holding stool for psychological reasons. Once the process begins, however, the hardened stool, the anal fissures, and the pain on defecation soon occur, and what began for an emotional reason becomes a physical ailment. This is important to understand, because with these children, therapy involves both counseling to correct the initial problem and treatment of the physical symptoms

A nurse caring for Paulo, an infant born with a cleft palate, notices that the parents rarely interact with their child. The nurse overhears the mother telling her husband that she "feels like crying" every time she looks at their son. What would be the best response from the nurse?

"I sense you could use more information on caring for a cleft palate. Would you be interested in meeting with other parents who have dealt with this?" The nurse should support the family's adjustment to a child's condition by demonstrating an accepting, caring attitude toward the child and family and providing the parents with opportunities and support for normal infant-parent interactions.

Noah is an 18-month-old who is brought to the ER with flu-like symptoms. He is diagnosed with pneumonia secondary to aspiration of stomach contents. The nurse explains to the parents that pneumonia is a condition that often occurs secondary to:

Gastroesophageal reflux disease. The child with gastroesophageal reflux disease may present with the physical findings of pneumonia secondary to aspiration of refluxed stomach contents.

A father brings his 10-year-old daughter in to the physician's office with jaundice, headache, fever, and anorexia, symptoms she has had for the past few days. The nurse should suspect infection of which organ in this client?

Liver No matter which virus is involved, hepatitis is a generalized body infection with specific intense liver effects. Type A occurs in children of all ages and accounts for approximately 30% of instances. With hepatitis A, children notice headache, fever, and anorexia. Jaundice occurs as liver function slows

A 12-year-old boy has just undergone a liver transplantation and is recovering. After performing a finger stick puncture and assessing the results, the nurse administers a 10% solution of dextrose IV. What is the correct rationale for this intervention?

Prevention of hypoglycemia Hypoglycemia is a major danger following liver transplantation because glucose levels are regulated by the liver, and the transplanted organ may not function efficiently at first. Assess serum glucose levels hourly by finger stick puncture. A 10% solution of dextrose IV may be necessary to prevent hypoglycemia. Careful tissue matching before the transplantation is needed to reduce the possibility of stimulating T-cell rejection. Sodium, potassium, chloride, and calcium levels are evaluated approximately every 6 to 8 hours to be certain electrolyte balance is maintained, but potassium is rarely added to IV solutions because of the risk that renal failure has occurred. IV therapy with hypotensive agents such as hydralazine (Apresoline) and nitroprusside may be needed to reduce hypertension

The nurse is caring for a child who was involved in an automobile accident in which extensive damage to the small intestine occurred. A surgical resection of the small intestine resulted in massive small intestine loss, causing short bowel syndrome. The parents voice concern to the nurse that their child will "never be the same." What is the best response by the nurse?

"I can't imagine what you're going through. We will be here to support and educate you on your child's condition and treatments throughout their care." Being empathetic and reassuring the parents that the staff will be there to support them and educate them will provide some relief of anxiety since this is a chronic condition. Telling them their is nothing they could have done to prevent this from happening does not help the current situation. Giving hope is good, but giving possible false hope sets the family up for disappointment. Telling the family to be strong does not provide support.

The nurse is conducting a physical examination of an 18-month-old with suspected intussusception. Which finding would the nurse identify as the hallmark of this condition?

A sausage-shaped mass in the upper midabdomen A sausage-shaped mass in the upper midabdomen is the hallmark of intussusception. Perianal skin tags are highly suspicious of Crohn disease. Abdominal pain and guarding are also common with intussusception but are seen with many other conditions. Tenting would indicate dehydration

A child is diagnosed with intussusception. The nurse anticipates that what action would be attempted first to reduce this condition?

Barium enema A barium enema is successful in reducing a large percentage of intussusception cases. Other cases are reduced surgically. Upper endoscopy is used to visualize the upper gastrointestinal tract from the mouth to the upper jejunum. Endoscopic retrograde cholangiopancreatography is used to view the hepatobiliary system.

A neonatal nurse teaches students how to recognize gastrointestinal disorders in infants. The nurse tells the students that failure of the newborn to pass meconium in the first 24 hours after birth may indicate what disease?

Hirschsprung disease The nurse should suspect Hirschsprung disease when the newborn does not pass meconium in the first 24 hours after birth, and has bilious vomiting or abdominal distention and feeding intolerance with bilious aspirates and vomiting. Typical signs and symptoms of gastroenteritis include diarrhea, nausea, vomiting, and abdominal pain. The characteristic GI manifestation of UC is bloody diarrhea accompanied by crampy, typically left-sided lower abdominal pain. Clinical manifestations of untreated SBS include profuse watery diarrhea, malabsorption, and failure to thrive

The nurse is teaching an in-service program to a group of nurses on the topic of gastrointestinal disorders. The nurses in the group make the following statements. Which statement is most accurate related to the diagnosis of gastroesophageal reflux?

In this disorder the sphincter that leads into the stomach is relaxed. Gastroesophageal reflux (GER) occurs when the sphincter in the lower portion of the esophagus, which leads into the stomach, is relaxed and allows gastric contents to be regurgitated back into the esophagus. Congenital aganglionic megacolon is characterized by persistent constipation resulting from partial or complete intestinal obstruction of mechanical origin. Colic consists of recurrent paroxysmal bouts of abdominal pain. Pyloric stenosis is characterized by hypertrophy of the circular muscle fibers of the pylorus which leads to an obstruction at the distal end of the stomach.

The parents of a 6-month-old have brought their child to the emergency department with vomiting and diarrhea for the past 3 days. The report the child as being very lethargic today. During the assessment the nurse notes decreased skin turgor, delayed capillary refill, and pale, slightly dry skin. Based on the objective and subjective data, what does the nurse determine the child to be?

Moderately dehydrated In addition to these signs and symptoms, signs and symptoms of moderate dehydration also include sunken fontanels, mildly sunken orbits, and urine output

The nurse is working with the mother of a toddler experiencing constipation. What information regarding childhood constipation should the nurse share with the mother?

• "Have your son sit on the toilet twice a day, after breakfast and dinner, for 5 to 15 minutes." • "If your child has a fecal impaction, you can give him an enema." • "Reward your child for sitting on the toilet as asked, not just when they have a bowel movement." Proper education for constipation in children includes educating the families about the importance of compliance with medication use. Many children present to their physician or nurse practitioner with fecal impaction or partial impaction. Teach parents how to disimpact their children at home; this often requires an enema or stimulation therapy. To facilitate daily bowel evacuation, the child should sit on the toilet twice a day (after breakfast and dinner) for 5 to 15 minutes. Instruct the family to keep a "star" or reward chart to encourage compliance. Parents should award the star for compliance with time sitting on the toilet and should not reserve rewards for successful bowel movements only.