gastrointestinal disorders

malabsorption syndromes

- characterized by chronic diarrhea and malabsorption of nutrients - may result in failure to thrive - digestive defects --> celiac - absorptive defects - anatomic defects

pediatric differences for the digestive and gastrointestinal system

- infant ability to swallow limited to fluids until about 4 months of age. they have an extrusion (tongue-thrust) reflex. that's why we give liquids first b/c of tongue thrusting - smaller stomach capacity - lacking in digestive enzymes to about 4 months of age - immature liver --> smaller meds, so sensitive to meds - immature and young immune system - proportionally longer GI tract in neonate/infant - varying food/fluid needs and intake patterns. drink little at a time but through out the day - increased risk of dehydration and fluid overload in younger

most common consequences of GI dysfunction in children

- malabsorption - fluid and electrolyte disturbances - malnutrition - poor growth/development

ingestion of foreign bodies

*leading cause of accidental death less than 4 years* peanuts, nuts, and seeds are most common; hotdogs, vegetables, metal or plastic objects, and bones other frequently aspirated items *risk of airway obstruction, perforation, acid burns, esophageal erosion* signs and symptoms diagnostic evaluation

failure to thrive (FTT)

- the term used to describe infants and children whose weight and sometimes height fall below the 5th percentile for age - persistent deviation from established growth curve signs and symptoms: - growth failure - weight and height below 5th percentile - developmental delays - hypotonia - decreased muscle mass - generalized weakness - abdominal distention - endocrine changes diagnosis: - weight and height plots - health and dietary history - possible home inventory - family assessment assessment and documentation: - accurate height and daily weights - feeding behavior - parent-child interactions - developmental level nursing care: - provide optimum nutrients; make feeding priority goal; keep accurate record I&O; weigh daily - introduce positive feeding environment: establish structured routine and 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 and praise; persist in the face of protest by child - provide for home care ... a lot of teaching - demonstrate proper care by example, not lecturing

to prepare the infant for surgery, the nurse has a number of activities 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 preoperatively? a. have the infant use a pacifier to maintain his sucking ability b. lubricate his lips with water to maintain their hydration c. continually hold the infant so he feels loved and secure d. maintain the infant in a 45-degree position for easier breathing

a

organic (OFTT)

result of physical cause, such as: - congenital heart disease - malabsorption syndrome, gastroesophageal reflux - cystic fibrosis - chronic renal failure - endocrine or neurological disorder may have associated signs and symptoms of physical disease state

intussusception

a common intestinal obstruction occurring in infants and toddlers (3 months - 1 year) peak incidence 3-9 months of age cause: - not usually known. Rotavirus vaccine most common site: - ileocecal valve 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, other signs of intestinal blockage signs and symptoms: - abdominal pain: **intermittent**, sudden, cramping - inconsolable crying - drawing up knees, child normal between cramping episodes - **palpable sausage=shaped abdominal mass** - bilious vomiting as progresses - **currant jelly-like stools/bloody** - classic triad: 1. abd. pain, 2. abd mass, 3. bloody stools diagnosis: - assessment (clinical picture) - abdominal ultrasound - **radiologist-guided enema**: this can be diagnostic and is often curative (push/reduce pressure) treatment: - **nonsurgical hydrostatic (saline enema) reduction OR air enema** - often corrected during the diagnostic procedure - if the enema doesn't work, then surgery for a surgical reduction or excision of nonviable segment of colon - **reduction/resolution: is evidenced by successful passage of normal brown stool --> report to practitioner**

celiac disease

also called: Gluten-Sensitive Enteropathy; and "Celiac Sprue" malabsorption syndrome: - **biggest concern = risk of growth failure** hypersensitivity/intolerance to gluten protein: - celiac disease affects one out of every 130 individuals - genetic mutation chromosome 6 may or may not develop celiac - female > male - onset after 6 months - 2 years - appears in genetically sensitive kids pathology: - inability to digest peptides contained in the gluten protein (gliadin) of wheat, barley, rye, and grains - toxic substance and peptides accumulate in gut --> stimulation of immune and inflammatory response --> **inflammation and ulceration of intestinal mucosa --> atrophy of villi causes malabsorption** complications: - growth failure (FTT), vitamin deficiency, anemia, osteoporosis, celiac crisis (can lead to shock), later in life: **lymphoma if not complaint with diet** **4 characteristics** 1. steatorrhea, 2. malnutrition, 3. abdominal distention, 4. vitamin deficiencies signs and symptoms: - **diarrhea**: bulky, foul smelling stools (steatorrhea) - **abdominal pain and distention** - **dermatitis**: highly pruritic rash knees, elbows buttocks bilaterally - **muscle wasting**: especially buttocks and extremities - change in behavior: **irritability**, apathy - anemia and failure to thrive: bruises and bleeds easily diagnosis: - definitive: tissue biopsy of small intestine atrophy of intestinal vili - blood tests for antibodies may be helpful. positive IgA antibody test treatment: - 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 their diet - supplementation of vitamins and minerals: iron, folic acid, fat soluble vitamins - caution: **may develop lactose intolerance** from severe damage to mucosa

constipation

an alteration in frequency, consistency, or ease of passage of stool - decrease in frequency of stools - formation of hard stools - oozing liquid after passing hard stools (Encopresis) or around impacted stool common cause of constipation: can be idiopathic or chronic - most: environmental changes and/or development - diet: **improper diet is frequent cause of constipation in infants and children** - control of bodily function emerging - **psychological factors (fear) (dont want to go to the bathroom at school)** - underlying disease or anatomical deformity - medications: antacids, diuretics, **antihistamines**, opioids, **iron** treat underlying cause: - depends on etiology of constipation diet modification: - increase fiber intake - increase fluids in older infants and children - remove constipating foods (ex: bananas, rice, cheese, apple sauce) - for infants: may add corn syrup 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

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? a. your son will have a colostomy with a bag on his abdomen and an IV b. your son will have an IV line, an oxygen source, a dressing, and perhaps a colostomy bag c. he will have a colostomy with a bag, a feeding tube, and an oxygen mask d. he will be wearing a diaper and will have an abdominal dressing and soft restraints

b

the nurse is obtaining a history about the infants early months. what question is most critical for the nurse to ask to aid in the diagnosis of Hirschsprung's disease (HD) a. did your son urinate immediately after delivery b. when did your son have his first bowel movement c. did you breastfeed or bottle-feed your son d. did your son experience any colic

b`

nonorganic (NFTT)

caused by psychosocial or other factors: - poverty - family stress - health beliefs - lack of emotional and sensory stimulation - inadequate nutritional information - difficulty separating from parent - child uses refusing food as attention getting mechanism - insufficient breast milk signs and symptoms: - apathy and withdrawal behavior - feeding or eating dysfunction - no fear of strangers at age when appropriate - avoidance of eye contact - wide-eyed gaze and continual scan of environment - minimal smilling - lack of attachment to parents - stiff and unyielding or flaccid and unresponsive treatment: - 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

Hirschsprung disease

congenital aganglionic megacolon - no ganglionic cells --> not moving stool along tract - boys > girls - short or long segment; may be single or multiple segment may not be diagnosed until infancy or childhood (usually first few months). the more involvement the earlier it is diagnosed **cause mechanical obstruction** due to inadequate motility of parts of the intestine due to the absence of parasympathetic ganglion cells in the segment: - increased sphincter tone and sympathetic activity - accumulation of intestinal contents and distention of bowel - no evacuation of solid or liquid stool, decreased gas signs and symptoms: - **absence of meconium stool in newborn** - reluctance to ingest fluids - abdominal distention - palpable fecal mass, impactions - chronic constipation and/or overflow diarrhea (older infants) - ribbon like stool (foul smelling) - failure to thrive (FTT) not absorbing nutrients treatment: first confirm diagnosis - rectal biopsy showing absence of nerve fibers surgical removal of aganglionic portions of bowel type of surgery depends on extent/location of aganglionic bowel - may be single surgery or a multi-stage process - performed when physical status appropriate - may need IV nutrition and enemas prior - **potential colostomy (usually temporary)** long term concerns: **fecal incontinence and constipation** nursing care before surgery: - NPO status - maintain NG suction - IV therapy - enemas, saline - antibiotics - measure abdominal girths with VS - monitor stool pattern - psychological preparation express grief - loss of a perfect child nursing care after surgery: - NG suction until peristalsis - no rectal temps - abdominal girths - stool patterns - IV therapy - colostomy care - referral: stoma therapist - diet as prescribed - teaching for family `

the infants 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? a. what are your concerns b. its too soon for us to be discussing the tests c. every mother is scared when her baby is ill d. there are several tests, including x-ray and a rectal biopsy, but we will keep your son comfortable

d

cleft palate

failure of the 2 sides of the palate to fuse during embryonic development ( 1st trimester ) - may occur with or without cleft lip risk factors: - girls > boys - multi-factoral inheritance: - folic acid deficiency - maternal smoking and alcohol in first trimester - maternal exposure to several medications (Dilantin, Accutane) - pesticide exposure signs and symptoms: - nasal distortion - midline or bilateral cleft expanding uvula and soft/hard palate - nasal cavity exposure (sinus infection) - feeding problems - infection, especially aspiration pneumonia - altered speech - altered dental development - hearing problems caused by recurrent otitis media assessment and documentation: - feeding behaviors; oral hygiene - respiratory status - hearing ability; speech - parent/child interaction and adjustment surgical closure: - repair often 6-12 months nursing considerations post op - 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 with water after feedings

cleft lip

failure of the maxillary and median nasal processes to fuse during embryonic development ( 1st trimester ) - can be unilateral or bilateral - defect can range from notch in vermilion border to complete separation to base of the nose risk factors: - girls > boys - multi-factoral inheritance: - folic acid deficiency - maternal smoking and alcohol in first trimester - maternal exposure to several medications (Dilantin, Accutane) - pesticide exposure signs and symptoms: - notched vermilion border, sizes vary - dental anomalies can occur - feeding difficulties - potential for problems with social acceptance assessment and documentation: - feeding behaviors; oral hygiene - respiratory status - hearing ability; speech - parent/child interaction and adjustment surgical closure: - repaired first usually 2-3 months nursing considerations post op - 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 - try to avoid crying as much as possible

assessment of GI function

history clinical examination and observation - inspection - auscultation - palpation I&O weight and height abdominal assessment - can they breathe? can effect respiratory tract b/c abdominal breathers lab tests - stool exam - O and P (bugs) diagnostic procedures

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 clinical presentation: - 2-5 weeks of age (usually) - males > females - not congenital, although can be familial - classic sign: projectile nonbilious vomiting after eating signs and symptoms: - **vomiting** - **progressively projectile, shortly after feeding, no bile (with further obstruction) may be blood tinged** - **infant hungry**, avid eater, accepts second feedings after vomiting, no nausea - no evidence of pain or discomfort early - mild dehydration (early) as the muscle enlarges: - looks increasingly ill - weight loss - increasing dehydration - distended upper abdomen - palpable olive-shaped mass in right upper quadrant of abdomen - visible gastric peristalsis - **electrolyte imbalances-metabolic alkalosis with excess loss of gastric juices** physical exam: - palpate empty stomach for olive labs: - **electrolytes** - decreased K+ and Na --> make be masked by hemoconcentration from dehydration - decreased serum Cl- levels - increased pH and bicarb levels **(metabolic alkalosis)** - elevated BUN (dehydration) treatment: - laparoscopic pyloromyotomy surgery pre-op nursing care: - NPO - monitor I&O, specific gravity and signs of dehydration - IV therapy and monitoring (no added K+ if not urinating) - vital signs, daily weights - skin care meticulous esp if dehydrated - NG tube care - parents: support and education post op nursing care: - same as general abdominal surgery - pain management - wound care - teach parents: feeding methods (restart within 4-6 hrs post op and advance as tolerated) **signs of infection or complication (wound dehiscence or GER)**

diarrhea

increase in number of stools (frequency), less consistency, more fluid, color can vary acute (sudden): - duration less than 14 days - toxic reaction to pathogen and body riding of pathogens - most often viral chronic: - duration greater than 14 days - more often chronic condition, food indiscretion, food sensitivity often infectious, but may be r/t: - dietary indiscretions (hyperosmolar formulas, overfeeding) - infection outside GI tract, respiratory or UTI - emotional tension - medications - inflammation or anatomical abnormalities

constipation in newborn and infancy

newborn - **the first stool is meconium. it should be passed within 24-36 hours of life** - **if meconium is not passed, assess for:** - Hirschsprung disease - hypothyroidism - meconium plug or meconium ileus (cystic fibrosis) infancy - often diet related: for those exclusively breastfed it is rare, **formula fed may develop constipation**

GI obstruction

obstruction in the GI tract = impedes passage of nutrients and secretions due to: - constriction (narrowing) - obstruction (blockage) - decreased motility (ileus) the obstruction can be congenital or acquired

vomiting

often infectious cause as with diarrhea, but other causes possible: - psychological stress - anatomical defect - abnormal gastric motility - inflammatory response - increased ICP - GI obstruction appearance may give clues: - bilious vs. non-bilious - undigested food - mucous - heme nursing note should include: - volume, frequency, appearance, and associated s/s nursing concerns: - dehydration - electrolyte disturbances - pH changes - malnutrition - aspiration - trauma to esophagus medications (if needed): - Ondansetron (Zofran) - Metoclopramide (Reglan) - Promethazine (Phenergan) - Dimenhydramine (Dramamine) characteristics: - visible undigested matter --> stomach - bile colored --> small intestine - smell like feces --> large intestines - bright red blood --> upper GI bleed - coffee ground --> lower GI `

acute appendicitis

patho: - inflammation of vermiform appendix - average age = 10 years, boys = 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 physical exam: - abdominal pain (periumbilical then RLQ), fever, nausea and vomiting, McBurney positive, guarding, rigid abdomen + rebound tenderness (sudden relief of pain, followed by increased pain and guarding on the right side of the abdomen) labs: - CBC with differential (elevated WBC with left shift), U/A (rule out test) - serum human chorionic gonadotropin (rule out test: pregnancy) radiological studies: - CT scan nursing considerations pre op: - pain assess with VS - monitor fever - abdominal distention - avoid heat to the abdomen (may use ice for comfort to abdomen) - pallor, chills, restless, and irritable - **caution sudden relief of pain followed by rigidity (rupture)** - potential shock signs - avoid laxatives/enemas nursing considerations post op: - vital signs, T, pain level - pain assess - NPO status - side lying position - IV fluids - monitor BS and elimination - monitor drain - dressing change - assess incision for infection - antibiotics

gastroenteritis

the involvement of the upper and lower GI tracts (stomach and intestines) most common cause of acute diarrhea may also be associated with vomiting infectious gastroenteritis: - fecal-oral spread - virus, bacteria, parasite - **most common: rotavirus** --> vaccine can only be given in first year of life; 2, 4, 6 months; ONLY oral vaccine risk: - fluid and electrolyte loss - dehydration - acid-base imbalance - shock history questions: - recent travel, *water source*, animal/bird contact, *daycare or school attendance*, *recent antibiotics*, diet changes/food intake probably test ordered: - *weight (must be evaluated the degree of dehydration)* - direct evaluation of stools - blood tests: CBC, serum electrolytes, creatinine, BUN, anion gap blood gases nursing care management: - *correct fluid, electrolyte, and acid-base imbalance* - usually able to manage at home --> EDUCATE the parents - *provide oral rehydration (ORT) and/or IV fluid therapy* - still encourage oral with vomiting (unless sign of blockage or risk of aspiration) - ORT then advance to regular diet - SLOW BUT CONSTANT : 5-10 mL every 2-5 min - monitor for s/s of electrolyte imbalances - accurate I&O (daily weights, weight diapers, abdominal girth) - IVF only if severe or if unable ORT -- usually NS or LR prevent spread of infection - isolation precautions if appropriate eliminate and/or correct cause: - usually self limiting - antibiotics may be given with E.coli, giadia - NO antidiarrheals if possible prevent complications: - meticulous skin care (barrier creams like zinc oxide to avoid skin breakdown from the acid) - rinse teeth after vomit (b/c of HCL-) - position to avoid aspiration make child comfortable - antiemetics if ordered (Ondansetron, Metoclopramide, Promethazine) - mouth care if NPO parent teaching: - prevent recurrence - Rotavirus vaccine, vaccines when traveling

gastroesophageal reflux

transfer of gastric contents into the esophagus from the stomach - caused by incompetent or relaxed sphincter "spitters" - occurs naturally in everyone, esp <1 year self-limiting - GERD is a tissue damage from GER GERD may occur without actual regurgitation: - spitting up, cough, CP, nausea, pyrosis, dysphagia, SOB, halitosis, arched back, excessive crying, recurrent pneumonia, failure to thrive GERD may present atypically: - symptoms may mimic other conditions like asthma, non cardiac chest pain, or a chronic cough diagnostics: - physical exam and detailed history -- usually the history alone is enough - upper GI series, endoscopy, continuous pH monitoring (amount of acid reflex in the esophagus) therapeutic management: - nothing if growing well and no respiratory complications, feed upright position, small frequent meal/frequent burping - positioning: prone if awake with caution, supine prop-up HOB at home - diet therapy, rice in feedings, hypoallergenic formula, decrease acid/irritating foods, position during and time of meals medications: - H2 receptor antagonists - proton pump inhibitors surgery: - Nissen fundoplication for severe GERD -- procedure wraps the fundus of the stomach distal - monitor for failure to thrive, weight loss nursing considerations: - monitor for failure to thrive and weight loss - education for the parents - **SIDS**