Gastrointestinal Structural & Inflammatory Disorders (Ch. 23 ATI)

Hirschsprung's Disease

- (Congenital Aganlionic Megacolon) - Structural anomaly of GI tract caused by lack of ganglionic cells in segments of colon resulting in decreased motility & mechanical obstruction

Diagnostic Findings (Appendicitis)

- Abdominal pain in right lower quadrant - Rigid abdomen - Decreased or absent bowel sounds - Fever - Diarrhea or constipation - Lethargy - Tachycardia - Rapid, shallow breathing - Anorexia - Possible vomiting

Complications (Hirschsprung's Disease) - Anal Stricture & Incontinence

- Bowel-retaining therapy - Can require further procedures, such as dilation

Laboratory Tests (Meckel's Diverticulum)

- CBC - Metabolic Panel

Laboratory Tests (Appendicitis)

- CBC - Urinalysis

Diagnostic Findings (Cleft Lip & Palate)

- Cleft lip is visible separation from upper lip toward nose - Cleft palate is visible or palpable opening of palate connecting mouth & nasal cavity

Risk Factors (Hirschsprung's Disease)

- Family history of disease

Complications (Meckel's Diverticulum)

- GI hemorrhage & bowel obstruction (for untreated Meckel's diverticulum)

Complications (Appendicitis) - Peritonitis

- Inflammation in peritoneal cavity Nursing Actions: - Assess for peritonitis - Provide pain management: -- Assess for pain using a developmentally appropriate tool -- Administer analgesics as prescribed - Manage IV fluid therapy - Administer IV antibiotics for infection - Manage NG tube suction - Provide preoperative & postoperative nursing care - Provide surgical wound care with wound irrigation and/or dressings if delayed wound closure necessary - Provide psychosocial support for child & family Client Education: - Educate child & parents about preoperative care, such as need to maintain NPO status & need for pain medication - Educate child & parent about postoperative care, such as early ambulation, advancement of diet, wound care, & monitoring for infection

Complications (Hischsprung's Disease) - Enterocolitis

- Inflammation of bowel - Treatment focuses on resolving inflammation, preventing bowel perforation, maintaining hydration, initiating antibiotic therapy, & perform surgery for colostomy or ileostomy if there is extensive bowel movement Nursing Actions: - Monitor vital signs - Assess abdominal girth: -- Measure girth with a paper tape at level of umbilicus or at widest point of abdomen -- Mark area with pen to ensure continuity of future measurement - Monitor for signs of sepsis, peritonitis, or shock caused by enterocolitis - Monitor & manage fluid, electrolyte, & blood product replacement - Administer antibiotics as prescribed

Appendicitis

- Inflammation of vermiform appendix caused from obstruction of lumen of appendix - Average client age is 10 years

Therapeutic Procedures (Cleft Lip & Palate) - Preoperative Nursing Actions

- Inspect lip & palate, using gloved finger to palpate palate - Assess ability to suck - Obtain baseline weight - Observe interaction between family & infant - Determine family coping & support - Refer parents to appropriate support groups - Consult with social services to provide needed services (e.g., financial, insurance) for the family & infant) - Instruct parents about proper feeding & care - Assess ability to feed - Initiate strategies for successful feeding - For isolated cleft lip, -- Encourage breast feeding -- Use wide-based nipple for bottle feeding -- Squeeze infant's cheeks together during feeding to decrease gap - For cleft palate or cleft lip & palate, -- Position infant upright while cradling head during feeding -- Use specialized bottle with one-way valve & specially cut nipple -- Burp infant frequently -- Syringe feeding can be necessary for infant who is unsuccessful with other methods

Therapeutic Procedures (Appendicitis) - Removal of Ruptured Appendix

- Laparoscopic or open surgery Preoperative Nursing Actions: - Administer electrolyte & fluid replacement as prescribed - Place NG tube for decompression - Administer IV antibiotics Postoperative Nursing Actions: - Assess respiratory status & maintain airway - Provide supplemental oxygen as prescribed - Obtain vital signs - Administer analgesics for pan as prescribed - Assess surgical site for bleeding or other abnormalities - Assess bowel sounds & function - Administer IV fluids & antibiotics as prescribed - Maintain NPO status - Maintain NG tube to low continuous suction - Provide wound care for open surgical sites with wound irrigations with antibacterial solution or saline-soaked gauze as prescribed - Provide drain care - Assess for peritonitis (e.g., fever, sudden increase in pain, irritability, rigid abdomen, abdominal distention, tachycardia, rapid & shallow breathing, pallor, & chills

Therapeutic Procedures (Appendicitis) - Removal of Nonruptured Appendix

- Laparoscopic surgery Preoperative Nursing Actions: - Administer IV fluid replacement as prescribed - Administer IV antibiotic Postoperative Nursing Actions: - Assess respiratory status & maintain airway - Provide supplemental oxygen as prescribed - Obtain vital signs - Administer analgesics for pain as prescribed - Assess surgical site for bleeding or any other abnormalities - Assess bowel sounds & function

Gastrointestinal Reflux Disease (GER)

- Occurs when gastric contents reflux back up into esophagus, making esophageal mucosa vulnerable to injury from gastric acid - GERD is tissue damage from GER - Self-limiting & usually resolves by 1 year of age

Risk Factors (Cleft Lip & Palate)

- Other syndromes - Combo of maternal & environmental factors - Family history of CL or CP - Exposure to ETOCH, cigarette smoke, anticonvulsants, retinoids, or steroids during pregnancy - Folate deficiency during pregnancy

Therapeutic Procedures (Cleft Lip & Palate) - Postoperative Nursing Actions

- Perform standard postoperative care, including assessment of vital signs, oxygen saturation, & pain management using age-appropriate tool - Keep infant pain-free to decrease crying & stress on repair - Administer analgesics as prescribed - Assess operative sites for signs of crusting, bleeding, & infection - Avoid having infant suck on nipple or pacifier - Avoid spoons, forks, & other objects infant might bring to mouth that could damage incision site - Monitor I & O & weigh daily - Observe family's interaction with infant - Assess family coping & support For cleft lip, - Monitor integrity of postoperative protective device to ensure proper positioning - Position infant on her back & upright, or on her side during immediate postoperative period to maintain integrity of repair - Apply elbow restraints to keep infants from injuring repair site - Restraints should be removed periodically to assess skin, allow limb movement, & for comfort - Use normal saline, water, or diluted hydrogen peroxide to clean incision site. Apply antibiotic ointment if prescribed - Gently aspirate secretions of mouth & nasopharynx to prevent respiratory complications For cleft palate, - Change infant's position frequently to facilitate drainage & breathing. Infant may be placed on abdomen in immediate postoperative period - Maintain IV fluids until infant is able to eat & drink - Clear liquid diet for first 24 hr - Avoid placing a straw, tongue depressor, hard pacifier, rigid utensils, hard-tipped sippy cups, or suction catheters in infant's mouth after cleft palate repair - Elbow restraints needed to prevent infant from injuring repair - Close observation for signs of airway obstruction, hemorrhage, & laryngeal spasm - Face mask to deliver oxygen

Nursing Care (Appendicitis)

- Prepare child & family for surgery using developmentally appropriate techniques - Avoid applying heat to abdomen - Avoid enemas or laxatives

Nursing Care (Hirschsprung's Disease)

- Prepare family & client for surgery - Assist family with improving nutritional status until surgery: -- High-protein, high-calorie, low-fiber diet -- Total parenteral nutrition in some cases

Intussusception

- Proximal segment of bowel telescopes into more distal segment, resulting in lymphatic & venous obstruction, causing edema in area. With progression, ischemia & increased mucus into intestine will occur - Common in infants & children ages 3 months to 6 years

Diagnostic Findings (Meckel's Diverticulum)

- Rectal bleeding, usually painless - Abdominal pain - Bloody, mucus stools

Laboratory Tests (Hirschsprung's Disease)

- Serum electrolytes - CBC

Nursing Care (Intussusception)

- Stabilize child prior to procedure -- IV fluids to correct & prevent dehydration -- Nasogastric (NG) tube for decompression - Teach family & child about nonsurgical procedure

Diagnostic Findings (Intussusception)

- Sudden episodic abdominal pain - Screaming with drawing knees to chest during episodes of pain - Abdominal mass (sausage-shaped) - Stools mixed with blood & mucus that resemble consistency of red currant jelly - Vomiting - Fever - Tender, distended abdomen

Nursing Care (Cleft Lip & Palate)

- Support & encourage parents in general care of their child - Promote parent-infant bonding - Promote healthy self-esteem throughout child's development

Therapeutic Procedures (Hirschsprung's Disease)

- Surgical removal of aganglionic secretion of bowel - Temporary colostomy can be required Preoperative Nursing Actions: - Prepare child & family for surgery using developmentally appropriate techniques - Administer electrolyte & fluid replacement as prescribed - Monitor for enterocolitis - Bowel prep with saline enemas & oral antibodies as prescribed Postoperative Nursing Actions: - Assess respiratory status & maintain airway - Provide supplemental oxygen as prescribed - Obtain vital signs - Administer analgesics for pain as prescribed - Assess surgical site for bleeding or other abnormalities - Provide Foley catheter care - Assess bowel sounds & function - Provide ostomy care if appropriate - Make appropriate referrals Client Education: - Teach family ostomy care, if indicated - Teach family incisional care & to monitor for infection - Teach family manifestations of dehydration

Therapeutic Procedures (Meckel's Diverticulum)

- Surgical removal of diverticulum Preoperative Nursing Actions: - Provide blood transfusions to correct hypovolemia - Administer IV fluid & electrolyte replacement as prescribed - Provide oxygen as prescribed - Administer IV antibiotics - Maintain bed rest - Closely monitor blood loss in stools Postoperative Nursing Actions: - Assess respiratory status & maintain airway - Provide supplemental oxygen as prescribed - Obtain vital signs - Administer analgesics for pain as prescribed - Assess surgical site for bleeding or any other abnormalities - Assess bowel sounds & function - Administer IV fluids & antibiotics as prescribed - Maintain NPO status - Maintain NG tube to low continuous suction Client Education: - Teach family manifestations of infection

Therapeutic Procedures (Appendicitis) - Client Education

- Teach family incision care - Teach family manifestations of infection

Therapeutic Procedures (Cleft Lip & Palate) - Client Education

- Teach parents that infant can require elbow restraints under lip/palate healed. Instruct parents in proper use of restraints - Instruct parents on postoperative diet & feeding techniques - Instruct parents in proper care of operative site

Hypertrophic Pyloric Stenosis

- Thickening of pyloric sphincter, which creates obstruction - Usually occurs first few weeks of life

Diagnostic Procedures (GER & GERD)

- Upper GI endoscopy to detect GI structural abnormalities - 24-hr intresophageal pH study to measure amount of gastric acid reflux into esophagus - Endoscopy with bipsy to detect esophagitis & strictures - Scintigraphy to identify cause of gastric content aspiration

Diagnostic Findings (Hypertrophic Pyloric Stenosis)

- Vomiting that often occurs following a feeding, but can occur up to several hours following a feeding & becomes projectile as obstruction worsens - Nonbilious vomitus can be blood-tinged - Constant hunger - Olive-shaped mass in right upper quadrant of abdomen & possible peristaltic wave that moves from left to right when lying supine - Failure to gain weight & signs of dehydration (e.g., dry &/or pale skin, cool lips, dry mucous membranes, decreased skin turgor, diminished urinary output, concentrated urine, thirst, rapid pulse, sunken eyes)

Therapeutic Procedures (Intussusception) - Air Enema

- With or without contrast - Performed by radiologist

Q4. A nurse is caring for a child who has Meckel's diverticulum. Which of the following manifestations should the nurse expect? (Select all that apply.) A. Abdominal pain B. Fever C. Mucus, bloody stools D. Vomiting E. Rapid, shallow breathing

A. Abdominal pain C. Mucus, bloody stools

Q5. A nurse is teaching a parent of infant about gastrointestinal reflux disease. Which of the following should the nurse include in the teaching? (Select all that apply.) A. Offer frequent feedings B. Thicken formula with rice cereal C. Use a bottle with a one-way valve D. Position baby upright after feedings E. Us a wide-based nipple for feedings

A. Offer frequent feedings B. Thicken formula with rice cereal D. Position baby upright after feedings

Q1. A nurse is assessing an infant who has hypertrophic pyloric stenosis. Which of the following findings should the nurse expect? A. Projectile vomiting B. Dry mucus membrane C. Currant jelly stools D. Sausage-shaped abdominal mass E. Constant hunger

A. Projectile vomiting B. Dry mucus membrane E. Constant hunger

Q3. A nurse is caring for an infant who is postoperative following cleft lip & palate repair. Which of the following actions should the nurse take? A. Remove the packing in the mouth B. Place infant in upright position C. Offer pacifier with sucrose D. Assess mouth with tongue blade

B. Place infant in upright position

Q2. A nurse is caring for a child who has Hirschsprung's disease. Which of the following actions should the nurse take? A. Encourage a high-fiber, low-protein, low-calorie diet B. Prepare family for surgery C. Place NG tube for decompression D. Initiate bed rest

B. Prepare family for surgery

Cleft Lip (CL) & Palate (CP)

CL: results from incomplete fusion of oral cavity during intrauterine life CP: results from incomplete fusion of palates during intrauterine life Although CL & CP can occur together, either defect can appear alone; defects can be unilateral (one-sided) or bilateral (two-sided)

Interprofessional Care (Cleft Lip & Palate)

Care of child who has CL & CP requires care from members of various disciplines (e.g., plastic surgeon, orthodontist, otolaryngologist, speech-language, pathologist, pediatrician, nursing, audiologist, social worker, & psychologist)

Therapeutic Procedures (Cleft Lip & Palate)

Cleft Lip: - Repair typically done between 2 - 3 months of age - Revisions usually required in severe defects Cleft Palate: - Repair typically done between 6 & 12 months of age - Most require secondary surgery

Diagnostic Procedures (Appendicitis)

Computed tomography scan (CT scan) shows enlarged diameter of appendix, as well as thickening of appendiceal wall

Nursing Care (GER & GERD)

GER: - Depends on severity of symptoms - Offer small, frequent meals - Thicken infants formula with 1 tsp - 1 tbsp rice cereal per 1 oz formula - Avoid foods that cause reflux (e.g., caffeine, citrus, peppermint, spicy or fried foods) - Assist with weight control - Position child with head elevated after meals - Position prone with extreme caution; supine is still recommended position GERD: - Initiate interventions for GER - Adminster proton pump inhibitor (e.g., omeprazole, esomeprazole, pantoprazole, & rabeprazole) or H2-receptor antagonist (e.g., ranitidine, cimetidine, or famotidine)

Risk Factors (GER & GERD)

GER: - Prematurity - Bronchopulmonary dysplasia - Neurological Impairments - Asthma - Cystic Fibrosis - Cerbral Palsy - Scoliosis GERD: - Nerological impairments - Hiatal hernia - Morbid obesity

Risk Factors (Hypertrophic Pyloric Stenosis)

Genetic predisposition

Diagnostic Findings (GER & GERD)

Infants: - Spitting up or forceful vomiting - Irritability - Excessive crying - Blood in vomitus - Arching of back - Stiffening - Respiratory problems - Failure to thrive - Apnea Children: - Heartburn - Abdominal pain - Difficulty following - Chronic cough - Noncardiac chest pain

Diagnostic Findings (Hirschsprung's Disease)

Newborn: - Failure to pass meconium within 24 to 48 hr after birth - Episodes of vomiting bile - Refusal to eat - Abdominal distention Infant: - Failure to thrive - Constipation - Vomiting - Episodes of diarrhea & vomiting Child: - Undernourished, anemic appearance - Abdominal distention - Visible peristalsis - Palpable fecal mass - Constipation - Foul-smelling, ribbon-like stool

Therapeutic Procedures (GER & GERD)

Nissen fundoplication: - Laparoscopic surgical procedure that wraps fundus of stomach around distal esophagus to decrease reflux - Used for clients who have severe cases of GERD

Nursing Care (Meckel's Diverticulum)

Prepare child & family for surgery using developmentally appropriate techniques

Nursing Care (Hypertrophic Pyloric Stenosis)

Prepare child for surgery

Diagnostic Evaluation (Meckel's Diverticulum)

Radionucleotide Scan: Meckel's scan is most effective diagnostic test

Diagnostic Procedures (Hirschsprung's Disease)

Rectal biopsy to confirm absence of ganglion cells

Laboratory Tests (Hypertrophic Pyloric Stenosis)

Serum electrolytes

Complications (Intussusception) - Reoccurring Intussusception

Surgery is required for reoccurring cases

Diagnostic Procedures (Intussusception)

Ultrasound

Diagnostic Procedures (Hypertrophic Pyloric Stenosis)

Ultrasound reveals elongated mass, surrounding elongated pyloric canal

Meckel's Diverticulum

complication resulting from failure of omphalomesenteric duct to fuse during embryonic development

Complications (Cleft Lip & Palate) - Speech & Language Impairment

more common with cleft palate Client Education: - Refer for early intervention - Refer parents to speech therapist for care

Therapeutic Procedures (Hypertrophic Pyloric Stenosis) - Pylorotomy

performed by laparoscope Preoperative Nursing Actions: - IV fluids for correction of dehydration & electrolyte imbalances - Nasogastric (NG) tube for decompression - NPO - I & O - Daily weights Postoperative Nursing Actions: - Obtain routine postoperative vital signs - Provide IV fluids - Monitor daily weights & I & O - Administer analgesics for pain - Assess for signs of infection - Start clear liquids 4 - 6 hr after surgery - Document tolerance to feedings

Complications (Cleft Lip & Palate) - Ear Infections & Hearing Loss

related to altered structure & recurrent otits media Nursing Actions: - Feed infant in upright position - Monitor temperature - Insertion of pressure-equalizing tubes to facilitate fluid drainage from ears & prevent middle ear effusion & otitis media Client Education: - Teach parents manifestations of ear infections - Encourage early intervention

Complications (GER & GERD) - Recurrent Pneumonia, Weight Loss, & Failure to Thrive

repeated reflux of stomach contents can lead to erosion of esophagus or pneumonia if stomach contents are aspirated Nursing Actions: - Evaluate prescribed treatment of plan - Monitor for manifestations of pneumonia & failure to thrive Client Education: - Reinforce plan of care with family - Teach parents about manifestations for pneumonia

Complications (Cleft Lip & Palate) - Dental Problems

teeth might not erupt normally, & orthodontis usually necessary later in life Client Education: - Instruct parents & child to promote healthy dental hygiene - Encourage parents to seek early dental care