OB Chap 28 The child with a Gastrointestinal Condition

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Failure to Thrive: Can be caused by - ◦ Non-organic

(NFTT) is from the lack of parent-infant interaction resulting from environmental factors or neglect

Hernias (cont.): May be present at birth

(congenital) or acquired Is reducible if it can be put back into place by gentle pressure

Overhydration: Manifests as edema

(excess fluid in interstitial spaces) ◦ Interstitial fluid is similar to plasma, but contains little protein ◦ Any factor causing sodium retention can cause edema

Failure to Thrive: Can be caused by - ◦ Physical

(organic) pathology (OFTT), such as congenital heart or malabsorption syndrome

Treatment of Pyloric Stenosis Surgery is called pyloromyotomy Preoperative nursing care: ◦ Place on right side

(preferably Fowler's position) after feeding to facilitate stomach drainage into the intestines

Failure to Thrive (cont.): In some cases

, child is removed from home environment and placed elsewhere

Hirschsprung's Disease (Aganglionic Megacolon) (cont.) • Treatment: • Nursing Care

-Dependent upon age of child -In newborns, detection is high-priority -As child grows, careful attention to a history of constipation and diarrhea is important -Signs of undernutrition, abdominal distention, and poor feedings are suspect

Overhydration (cont.) • Treatment:

-IV therapy is ordered and child is monitored -Is dependent upon type of electrolyte imbalance child has -If child has a hypertonic type of dehydration, tomato juice should not be offered -If child has a hypotonic type of dehydration, plain water should not be offered

Overhydration (cont.) • Treatment:

-IV therapy is ordered and child is monitored -Is dependent upon type of electrolyte imbalance child has -If child has a hypertonic type of dehydration, tomato juice should not be offered -If child has a hypotonic type of dehydration, plain water should not be offered Nursing care ◦ Early detection and management of edema are essential ◦ Accurate daily weight, vital signs, observing physical appearance, and noting changes in urine output ◦ Important for nurse to monitor clinical laboratory results and adjust fluids and foods offered to the child

Hirschsprung's Disease (Aganglionic Megacolon) (cont.) • Treatment:

-Surgery to remove impaired part of colon and an anastomosis of intestine is performed -In newborns, a colostomy may be needed until 12 to 18 months of age, when more extensive repair may be performed

Hirschsprung's Disease (Aganglionic Megacolon) (cont.) • Treatment:

-Surgery to remove impaired part of colon and an anastomosis of intestine is performed -In newborns, a colostomy may be needed until 12 to 18 months of age, when more extensive repair may be performed • Nursing Care -Dependent upon age of child -In newborns, detection is high-priority -As child grows, careful attention to a history of constipation and diarrhea is important -Signs of undernutrition, abdominal distention, and poor feedings are suspect

Kwashiorkor (cont.): Occurs in children

1 to 4 years of age who have been weaned from the breast ◦ Oral intake is deficient in protein ◦ Child fails to grow normally

How much weight loss is indicative of this? Moderate dehydration

5% to 10% weight loss

Foreign Bodies:

80% of all ingestions occur in children between 6 months and 3 years of age ◦ About 80% of items ingested pass through the GI tract without difficulty ◦ May take up to 6 days to occur Caution parents not to use laxatives and to maintain a normal diet to avoid intestinal spasms

Intussusception:

A slipping of one part of the intestine into another part just below it ◦ Often seen at the ileocecal valve ◦ The mesentery, a double fan-shaped fold of peritoneum that covers most of intestine and is filled with blood vessels and nerves, is also pulled along Edema occurs At first, intestinal obstruction occurs, but then strangulation of the bowel occurs as peristalsis occurs Affected portion may burst, leading to peritonitis

Clostridium difficile infection

Abdominal pain, fever, bloody diarrhea

Identify symptoms associated with this. Clostridium difficile infection

Abdominal pain, fever, bloody diarrhea

Hirschsprung's disease (aganglionic megacolon)

Absence of ganglion nerve cells in the colon

Hirschsprung's Disease (Aganglionic Megacolon):

Absence of ganglionic innervation to the muscle of a segment of bowel ◦ Usually in lower portion of sigmoid colon Lack of normal peristalsis, results in constipation Stools are ribbonlike due to feces passing through the narrow segment of colon ◦ Portion of bowel nearest obstruction dilates, causing abdominal distention ◦ Seen more often in boys and in children with Down syndrome May be acute or chronic

The most commonly ingested drug is ______.

Acetaminophen

Poisons Commonly Encountered in Pediatrics

Acids Alkalines Medications Cyanide Ethanol Petroleum distillates Carbon monoxide Lead Arthropods, insect stings Snakes Poisonous plant

Celiac Disease:

Also known as gluten enteropathy and sprue Leading malabsorption problem in children ◦ Thought to be caused by inherited disposition with environmental triggers Symptoms not evident until 6 months to 2 years of age when foods containing gluten are introduced ◦ Wheat, barley, oats, and rye

Worms Pinworms (Enterobiasis) and Roundworms (Ascariasis)

Antihelminth medications are given for both types of worm infestations

Identify a blood test used to determine this. Liver function

Aspartate aminotransferase (AST)

Identify symptoms associated with this. Hernia

Asymptomatic or may see constipation and irritability

Describe treatment of this. Intussusception

Barium enema

Intussusception

Barium enema

Lead Poisoning (Plumbism) (cont.) Symptoms occur gradually:

Beginning stages, signs may be weakness, weight loss, anorexia, pallor, irritability, vomiting, abdominal pain, and constipation Later stages, signs may be anemia and nervous system involvemen

Treatment of Diarrhea

Bowel Rest ORS ◦ 1 tsp every 5 min. to start & gradually increase Lactobacillus helpful ◦ Probiotics reduce antibiotic induced diarrhea by 60%

Lead Poisoning (Plumbism):

Can have a lasting effect on the CNS, especially the brain Mental retardation occurs in severe cases of lead poisoning

Rickets:

Caused by deficient amounts of vitamin D ◦ Exposure to sunshine is necessary for proper absorption and metabolism of calcium and phosphorus Classic symptoms are bow-legs; knock-knees; beading of the ribs, called rachitic rosary; and, improper formation of teeth ◦ Vitamin supplements along with exercise and exposure to outdoor sunlight is primary form of treatment

Scurvy:

Caused by insufficient fruits and vegetables that contain vitamin C Symptoms include joint pain, bleeding gums, loose teeth, lack of energy Vitamin C ◦ Easily destroyed by heat and exposure to air ◦ Not stored in the body and daily intake of the vitamin is necessary Vitamin supplements and dietary intake such as citrus fruits and raw leafy vegetables

Dehydration:

Causes fluid and electrolyte disturbances Evaluation of type and severity, including clinical observation and chemical analysis of the blood Types of dehydration are classified according to level of serum sodium, which depends on the relative losses of water and electrolytes ◦ Isotonic ◦ Hypotonic ◦ Hypertonic

Appendicitis (cont.):

Characteristic symptoms ◦ Tenderness in RLQ, known as McBurney's point ◦ Guarding ◦ Rebound tenderness ◦ Pain on lifting thigh while in supine position ◦ Pain in RLQ Diagnostics can include ◦ Blood tests ◦ Abdominal X-ray ◦ CT scan ◦ Ultrasound Treatment ◦ Surgical intervention typically required Nursing care is the same as with most other abdominal surgery patients

Clarifying Food Labels

Children may have food allergies, so teach parents the following Ingredient What it may contain Binder Egg Bulking agent Soy Casein Cow's milk Coagulant Egg Emulsifier Egg Protein extender Soy

Lead Poisoning (Plumbism):

Children who chew on window sills and stair rails ingest flakes of paint, putty, or crumbled plaster Eating nonfood items is called pica Can have a lasting effect on the CNS, especially the brain Mental retardation occurs in severe cases of lead poisoning

Describe treatment of this. Imperforate anus

Colostomy

Failure to thrive (FTT)

Condition characterized by the inability to grow and develop appropriately

Congenital Disorders

Congenital Disorders

Identify symptoms associated with this. Hirschsprung's disease

Constipation, ribbonlike stools, abdominal distention

Identify symptoms associated with this. Intussusception

Currant jelly stools, sudden episode of severe colic, fever

Dehydration (cont.):

Deficit therapy restores preexisting body fluid and electrolyte deficiencies ◦ Shock is greatest threat to life in isotonic dehydration ◦ Children with hypotonic dehydration are at risk for water intoxication

Schilling test

Determines absorption capacity of the lower ilium

Hirschsprung's Disease (Aganglionic Megacolon) (cont.): Diagnostics

Diagnostics ◦ Barium enema ◦ Rectal biopsy ◦ Anorectal manometry Measures pressure in anal sphincter

Diarrhea:

Diarrhea in infant is a sudden increase in stools from the infant's normal pattern, with a fluid consistency and a color that is green or contains mucus or blood ◦ Acute sudden diarrhea most often caused by inflammation, infection, or a response to medications, food, or poisoning ◦ Chronic diarrhea lasts more than 2 weeks and may indicate malabsorption problem, longterm inflammatory disease, or allergic responses ◦ Infectious diarrhea caused by viral, bacterial, or parasitic infection, usually involves gastroenteritis

STUDY

Disorders of Motility Acid-Base Balance ◦ Norms pH: 7.35-7.45 PaCO2: 35-45 HCO3: 22-26 ◦ ROME PaCO2 is the respiratory component HCO3 is the metabolic component pH tells the acidity

Manifestations of TEF (Tracheoesophageal Fistula):

Earliest sign is when mother develops polyhydramnios ◦ If it ends in blind pouch, fetus cannot swallow amniotic fluid and it will accumulate ◦ At birth, the infant will vomit and choke when the first feeding is introduced ◦ Drooling may also be present at birth and is related to atresia If upper esophagus enters trachea, the first feeding will enter the trachea and result in coughing, choking, cyanosis, and apnea If lower end of esophagus enters trachea, air will enter stomach each time infant breathes, causing abdominal distention

Isotonic dehydration

Equal amounts of fluid and electrolytes are lost

Failure to Thrive (cont.): Prevention of environmental

FTT consists chiefly of social measures

Esophageal atresia (tracheoesophageal fistula [TEF])

Failure of the esophagus to connect with the stomach

Failure to Thrive:

Failure to gain weight and often lose weight

Failure to Thrive:

Failure to gain weight and often lose weight Can be caused by ◦ Physical (organic) pathology (OFTT), such as congenital heart or malabsorption syndrome ◦ Non-organic (NFTT) is from the lack of parent-infant interaction resulting from environmental factors or neglect

Identify symptoms associated with this. Imperforate anus

Failure to pass meconium in the first 24 hours

Identify symptoms associated with this. Celiac disease

Failure to thrive, large frothy stools, abdominal distention, buttock atrophy

Constipation (cont.):

Fewer than 7 bowel movements in a 2-week period Ask caregiver to define constipation Evaluate dietary and bowel habits ◦ Some infants develop constipation due to high iron content in formula Note frequency, color, and consistency of stool Document any medications child is taking Dietary modifications include increasing roughage in diet ◦ Foods high in fiber include whole-grain breads and cereals, raw vegetables and fruits, bran, and popcorn for older children Stool softener may be prescribed

Dehydration

Fluid output exceeds fluid intake

Fluid and Electrolyte Imbalance (cont.):

Fluid turnover is rapid, and dehydration occurs more quickly in infants than in adults A sick infant does not adapt as readily to shift in intake and output

Fluid and Electrolyte Imbalance (cont.):

Fluid turnover is rapid, and dehydration occurs more quickly in infants than in adults A sick infant does not adapt as readily to shift in intake and output Less able to concentrate urine and require more water than an adult's kidneys to excrete a given amount of solute

A diarrheal stool in an infant is manifested by a waatery consistency and a greenish color with the possible presence of mucus or blood.

Frequency of bowel movement, by itself is not an indication of diarrhea in infants

GI System Differences Between Children and Adults

GI System Differences Between Children and Adults

Intussusception (cont.)

Generally occurs in boys between 3 months and 6 years ◦ Frequency decreases after age 36 months Can have spontaneous reduction Onset is usually sudden ◦ May have a fever as high as 106° F (41.1° C) ◦ As it progresses, child may show signs of shock, sweating, weak pulse, shallow, grunting respirations; abdomen is rigid In infants, severe pain in abdomen, loud cries, straining efforts, and kicking and drawing of legs toward abdomen Child vomits green or greenish-yellow fluid (bilious) Bowel movements diminish, little flatus is passed Blood and mucus with no feces are common about 12 hours after onset of obstruction, called currant jelly stools

What is proper nursing care of a child after this? Pyloromyotomy

Gentle handling, daily weights, position on right side after feeding

Celiac disease

Gluten intolerance

How much weight loss is indicative of this? Severe dehydration

Greater than 10% weight loss

How much weight loss is indicative of this? Severe dehydration

Greater than 10% weight loss

Inguinal hernia

Hernia in which part of the abdominal contents protrudes through the inguinal canal in the groin

Umbilical hernia

Hernia in which there is a protrusion of a portion of intestine through the umbilical ring

Reducible hernia

Hernia that can be put back into place by gentle pressure

Incarcerated hernia

Hernia that cannot be put back into place by gentle pressure

Strangulated hernia

Hernia that occurs when the intestine is caught in the passage and the blood supply is diminished

Describe treatment of this. Hernia

Herniorrhaphy

Isotonic dehydration is the loss of equal amounts of water and electrolytes.

Hypertonic dehydration is the loss of more water than electrolytes. hypotonic dehydration is the loss of more electrolytes than water.

Hirschsprung's Disease (Aganglionic Megacolon) (cont.):

If untreated, other signs of intestinal obstruction and shock may be seen Enterocolitis (inflammation of the small bowel and colon) is a serious condition ◦ Fever, explosive stools, and depletion of strength Diagnostics ◦ Barium enema ◦ Rectal biopsy ◦ Anorectal manometry Measures pressure in anal sphincter

Fluid and Electrolyte Imbalance (cont.):

In children under 2 years of age, surface area is important because more water is lost through the skin than through the kidneys

Fluid and Electrolyte Imbalance (cont.):

In children under 2 years of age, surface area is important because more water is lost through the skin than through the kidneys Metabolic rate and heat production are also 2 to 3 times greater in infants per kg of body weight ◦ Produces more waste products, which must be diluted to be excreted ◦ Stimulates respirations, which increase evaporation through the lungs ◦ Greater percentage of body water in children under 2 years is contained in extracellular compartment

Celiac Disease (cont.):

Infant presents with failure to thrive Infant is irritable Stools are large, bulky, and frothy Diagnosis confirmed by serum immunoglobin A (IgA) and small bowel biopsy Treatment ◦ Lifelong diet restricted in wheat, barley, oats, and rye ◦ Detailed parent teaching is essential A professional nutritionist or dietitian can aid in identifying foods that are gluten-free

Constipation - Treatment

Infants <1 year ◦ Prune, Pear, or Apple Juice: 2-4 oz/day Maintenance Management ◦ Fluids ◦ Fiber ◦ Behavioral Modification 10 min. on toilet qAM or qHS ◦ Laxatives Mineral Oil, Magnesium Hydroxide, Lactulose, Miralax, Sorbitol

Infections

Infections

Colitis

Inflammation of the colon

Enterocolitis

Inflammation of the colon and small intestine

Gastroesophageal reflux disease (GERD)

Inflammation of the esophagus caused by an incompetent lower esophageal sphincter

Gastroenteritis

Inflammation of the stomach and the intestines

Gastroenteritis

Involves inflammation of the stomach and intestines Colitis involves an inflammation of the colon Enterocolitis involves an inflammation of the colon and small intestines Most common noninfectious causes of diarrhea ◦ Food intolerance ◦ Overfeeding ◦ Improper formula preparation ◦ Ingestion of high amounts of sorbitol Priority problem in diarrhea is fluid and electrolyte imbalance and failure to thrive

Lead Poisoning (Plumbism) (cont.):

Lead is toxic to the synthesis of heme in the blood, which is necessary for hemoglobin formation and renal tubule functioning Blood lead levels are primary screening test X-ray films of bones may show further lead deposits History may reveal pica Treatment is aimed at reducing concentration of lead in blood ◦ Chelating agents may be taken for several months Prognosis depends on extent of poisoning

Fluid and Electrolyte Imbalance (cont.):

Less able to concentrate urine and require more water than an adult's kidneys to excrete a given amount of solute

Gastroesophageal Reflux:

Lower esophageal sphincter is relaxed or not competent, allowing stomach contents to regurgitate into esophagus ◦ Associated with neuromuscular delay, such as Down syndrome or cerebral palsy Often seen in preterm infants Symptoms often decrease once child is able to stand upright and eats more solid foods Symptoms ◦ Vomiting ◦ Weight loss ◦ Failure to thrive ◦ Infant is fussy and hungry ◦ Respiratory problems can occur when vomiting stimulates closure of epiglottis and infant presents with apnea

Patient Teaching - worms

Main nursing responsibility is educating parents and child about the prevention of worm infestation through general hygiene, food handling and preparation, as well as through environmental controls

Dehydration (cont.):

Maintenance fluid therapy replaces normal water and electrolyte losses

Dehydration (cont.):

Maintenance fluid therapy replaces normal water and electrolyte losses Deficit therapy restores preexisting body fluid and electrolyte deficiencies ◦ Shock is greatest threat to life in isotonic dehydration ◦ Children with hypotonic dehydration are at risk for water intoxication Potassium is lost in almost all degrees of dehydration and is replaced only after normal urinary excretion is confirmed

Safety Alert - OTC drugs

Many over-the-counter medications are considered harmless by parents but can be deadly to the toddler or small child Keep all medications (prescription or otherwise), including herbal supplements, out of reach of small children

Hernias (cont.):

May be present at birth (congenital) or acquired Is reducible if it can be put back into place by gentle pressure If it cannot be put back, it is irreducible or incarcerated Strangulated hernia is when intestine becomes caught in the passage and the blood supply is diminished Child may vomit and have severe abdominal pain Emergent surgery is indicated in this type of situation In most cases, same-day surgery is performed

Hypotonic dehydration

More electrolytes than water are lost

Hypertonic dehydration

More fluids than electrolytes are lost

Clostridium difficile

Most common diarrhea associated with antimicrobial therapy; health care-associated condition

Gastroenteritis: Most common

Most common noninfectious causes of diarrhea ◦ Food intolerance ◦ Overfeeding ◦ Improper formula preparation ◦ Ingestion of high amounts of sorbitol

Appendicitis:

Most common reason for emergency abdominal surgery ◦ Small appendage arising from the cecum ◦ Lumen may become obstructed with fecal matter or with lymphoid tissue after a viral illness or with parasites ◦ Stasis, increased swelling, edema, and growth of organisms Initial pain usually in periumbilical and increases within a 4-hour period When inflammation spreads to peritoneum, pain localizes in RLQ of abdomen Appendix may become gangrenous or rupture Can lead to peritonitis and septicemia

Failure to Thrive (cont.):

Multidisciplinary approach in accordance with circumstances In some cases, child is removed from home environment and placed elsewhere Assigning the same nursing staff to care for the child may increase nurturing and interaction with the infant and parent

Hirschsprung's Disease (Aganglionic Megacolon) (cont.):

Newborns: failure to pass meconium stools within 24 to 48 hours may be a symptom Infants: constipation, ribbonlike stools, abdominal distention, anorexia, vomiting, and failure to thrive Young children: usually seen in clinic after parents have tried over-the-counter laxatives to treat the constipation

Gastroenteritis: vaccine

Norovirus - Top cause in children <5-years (20-22%) 1 in 278 children hospitalized Development phase for Norovirus vaccines

Failure to Thrive (cont.):

Nurse is vital in supporting rather than in rejecting the mother ◦ Encourages mother to assist with daily care of child ◦ Points out developmental patterns and provides anticipatory guidance in this area Prognosis is uncertain ◦ Emotional starvation, particularly in the early years, can be psychologically traumatic ◦ Inadequacies in intelligence, language, and social behavior have been documented in children who fail to thrive

Nutritional Deficiencies

Nutritional Deficiencies

Pyloric stenosis

Obstruction at the lower end of the stomach

Pyloric Stenosis:

Obstruction of the lower end of the stomach caused by overgrowth of the circular muscles of the pylorus or spasms of the sphincter Commonly classified as a congenital anomaly Symptoms usually do not appear until the infant is 2 or 3 weeks old ◦ Most common surgical condition of GI tract in infancy Incidence is higher in boys

Kwashiorkor (cont.):

Occurs in children 1 to 4 years of age who have been weaned from the breast ◦ Oral intake is deficient in protein ◦ Child fails to grow normally ◦ Muscles become weak and wasted ◦ Edema of abdomen ◦ Diarrhea, skin infections, irritability, anorexia, and vomiting may be present ◦ Hair thins and is dry and may contain a white streak ◦ Child looks apathetic and weak

Detecting the Poison by Specific Odor of Vomitus

Odor of Vomitus Probable Content Sweet Chloroform, acetone Bitter almond Cyanide Pear Chloral hydrate Garlic Phosphorus, arsenic Shoe polish Nitrobenzene Violet Turpentine

Failure to Thrive (cont.):

Often admitted to hospital Presents with weight loss, irritability, disturbances of food intake, vomiting, diarrhea, and general neuromuscular spasticity sometimes accompany the condition Children fall below the third percentile in weight and height on standard growth charts Development is delayed Due to multiple factors, there may be a disturbance in the mother-child relationship Prevention of environmental FTT consists chiefly of social measures Pregnancy history sometimes reveals circumstances that may contribute to a lack of mother-infant bonding

Describe treatment of this. Thrush

Oral antifungal drugs

Symptoms of GI Disorders Systemic signs: Local signs

Pain ◦ Vomiting ◦ Diarrhea ◦ Constipation ◦ Rectal bleeding ◦ Hematemesis

Identify symptoms associated with this. Appendicitis

Pain at McBurney's point, guarding, rebound tenderness

Cyanide poisoning can be caused by eating _______.

Peach or apricot pits

Colonoscopy

Permits visualization and biopsy of entire colon

Sigmoidoscopy

Permits visualization and biopsy of the lower colon

Endoscopy

Permits visualization and biopsy of upper gastrointestinal (GI) tract

Poisonous Plants

Poisonous Plants

Esophageal atresia

Polyhydramnios, drooling, choking, cyanosis

Identify symptoms associated with this. Esophageal atresia

Polyhydramnios, drooling, choking, cyanosis

Dehydration (cont.):

Potassium is lost in almost all degrees of dehydration and is replaced only after normal urinary excretion is confirmed

Nursing Care of TEF (Tracheoesophageal Fistula):

Prevent pneumonia, choking, and apnea in the newborn

Nursing Care of TEF (Tracheoesophageal Fistula):

Prevent pneumonia, choking, and apnea in the newborn ◦ Assessment of the newborn during the first feeding for signs/symptoms of TEF is essential ◦ Feeding usually is with clear water or colostrum to minimize seriousness of aspiration Surgical repair is essential for survival

Pinworm is diagnosed by a scotch tape test.

Preventing the child from scratching the anal area is an essential part of breaking the cycle of worm infestation

Describe treatment of this. Gastroenteritis

Probiotics, oral rehydration

Failure to Thrive (cont.): Prognosis is uncertain

Prognosis is uncertain ◦ Emotional starvation, particularly in the early years, can be psychologically traumatic ◦ Inadequacies in intelligence, language, and social behavior have been documented in children who fail to thrive

Manifestations of Pyloric Stenosis:

Projectile vomiting is outstanding symptom from force or pressure being exerted on the pylorus ◦ Vomitus contains mucus and ingested milk ◦ Infant is constantly hungry and will eat again immediately after vomiting Dehydration and olive-shaped mass may be felt in upper right quadrant of abdomen

Identify symptoms associated with this. Pyloric stenosis

Projectile vomiting, dehydration, olive-shaped mass in right upper quadrant of the abdomen

Pyloric stenosis

Projectile vomiting, dehydration, olive-shaped mass in right upper quadrant of the abdomen

Kwashiorkor

Protein deficiency

Describe treatment of this. Pyloric stenosis

Pyloromyotomy

Maintenance fluid therapy

Replaces normal water and electrolyte losses

Deficit fluid therapy

Restores preexisting body fluid and electrolyte deficiencies

Imperforate anus

Result of the lower end of the GI tract and the anus ending in blind pouches

Vomiting:

Results from sudden contractions of diaphragm and muscles of the stomach Persistent vomiting requires investigation because it results in dehydration and electrolyte imbalance ◦ Continuous loss of hydrochloric acid and sodium chloride from the stomach can cause alkalosis ◦ Can result in death if left untreated Multiple causes of vomiting ◦ Improper feeding technique ◦ Systemic illness such as increased intracranial pressure or infection ◦ Child at risk for aspiration pneumonia

Lead Poisoning (Plumbism):

Results when a child repeatedly ingests or absorbs substances containing lead Incidence higher in inner-city tenements

Lead Poisoning (Plumbism):

Results when a child repeatedly ingests or absorbs substances containing lead Incidence higher in inner-city tenements Children who chew on window sills and stair rails ingest flakes of paint, putty, or crumbled plaster Eating nonfood items is called pica Can have a lasting effect on the CNS, especially the brain Mental retardation occurs in severe cases of lead poisoning

The incidence of _______ poisoning is decreasing.

Salicylate

Selected OTC Drugs that Are Deadly to Toddlers

Selected OTC Drugs that Are Deadly to Toddlers

Kwashiorkor:

Severe deficiency of protein in the diet despite the fact that the number of calories consumed may be nearly adequate • Belongs to a class of disorders termed protein-energy malnutrition • Seen most often in third-world countries

Ascariasis (roundworms)

Spread by the unsanitary disposal of human feces

Enterobiasis (pinworms)

Spread via hand-to-mouth contamination

Symptoms of Diarrhea:

Stools watery and explosive; may be yellowish-green Listlessness, refusal to eat, weight loss, temperature may be elevated, possible vomiting Dehydration evidenced by sunken eyes and fontanel; dry skin, tongue, and mucous membranes; less frequent urination In severe cases, excessive loss of bicarbonate from GI tract results in acidosis

Describe treatment of this. Esophageal atresia

Surgical repair

Describe treatment of this. Hirschsprung's disease

Surgical resection and temporary colostomy

Meckel's Diverticulum (cont.):

Symptoms can occur at any age, but typically appear by 2 years of age ◦ Painless bleeding from rectum ◦ Bright-red or dark-red blood is more usual than tarry stools ◦ Abdominal pain may or may not be present Diagnostics ◦ Barium enema or radionuclide scintigraphy are used in diagnosing ◦ X-ray films are not helpful Treatment ◦ Surgical removal of the diverticulum Nursing care is same for any patient having undergone abdominal surgery

Esophageal Atresia (Tracheoesophageal Fistula [TEF])

TEF is caused by a failure of the tissues of the GI tract to separate properly in prenatal life

Esophageal Atresia (Tracheoesophageal Fistula [TEF])

TEF is caused by a failure of the tissues of the GI tract to separate properly in prenatal life Four types ◦ Upper and lower esophagus (from the stomach) end in a blind pouch ◦ Upper esophagus ends in a blind pouch; lower esophagus (from stomach) connects to the trachea ◦ Upper esophagus is attached to trachea; lower esophagus (from stomach) also attached to trachea ◦ Upper esophagus connects to trachea; lower esophagus (from stomach) ends in a blind pouch

Describe treatment of this. Gastroesophageal reflux disease (GERD)

Teaching regarding burping, overfeeding; thickened formula; medication/surgery for complicated cases

Intussusception

Telescoping of the proximal end of the bowel into the distal end

Overhydration:

The body receives more fluid than it can excrete Manifests as edema (excess fluid in interstitial spaces) ◦ Interstitial fluid is similar to plasma, but contains little protein ◦ Any factor causing sodium retention can cause edema Flow of blood out of the interstitial compartments depends on adequate circulation of blood and lymph Low protein levels disturb osmotic cellular pressure Anasarca is severe generalized edema

Treatment of Intussusception:

This condition is an emergency Diagnosis is determined by history and physical findings May feel a sausage-shaped mass in right upper abdomen Barium enema is treatment of choice, with surgery if reduction does not occur

Three Most Common Forms of TEF

Three Most Common Forms of TEF

Infection of the mucous membranes of the mouth caused by fungus

Thrush (oral candidiasis)

Overview of the Gastrointestinal (GI) Tract

Transports and metabolizes nutrients necessary for the life of the cell Extends from mouth to anus Nutrients are broken down into absorbable products by enzymes from various digestive organs

Gastroenteritis (cont.):

Treatment is focused on identifying and eradicating cause Priority goal of care is restoring fluid and electrolyte balance Accurate intake and output, weighing of diapers, observing for dehydration or overhydration, and keeping infant/child warm Review with parents proper hand hygiene techniques, safe food handling and storage, principles of cleanliness, and infection prevention

How much weight loss is indicative of this? Mild dehydration

Up to 5% weight loss

Thrush (Oral Candidiasis):

Usually caused by a fungus, Candida Anorexia may be present Systemic symptoms are generally mild if infection remains in the mouth; can pass into GI tract causing inflammation of the esophagus and stomach Responds well to local application of antifungal suspension, such as nystatin ◦ Medication should remain in contact with "patches" as long as possible With proper care, the condition disappears within a few days after onse

Meckel's Diverticulum:

Usually occurs near ileocecal valve and may be connected to umbilicus by a cord ◦ A fistula may also form ◦ This sac is subject to inflammation Most common congenital malformation of the GI tract ◦ Seen more often in boys

Scurvy

Vitamin C deficiency

Rickets

Vitamin D deficiency

Gastroesophageal reflux disease (GERD)

Vomiting, weight loss, failure to thrive

Identify symptoms associated with this. Gastroesophageal reflux disease (GERD)

Vomiting, weight loss, failure to thrive

Describe treatment of this. Celiac disease

Wheat, barley, and rye diet restrictions

Identify symptoms associated with this. Thrush

White painless patches that appear on the tongue and oral mucosa and cannot be wiped away

Kwashiorkor is a protein deficiency characterized by

a depigmented white streak of hair

Intussusception: ◦ The mesentery,

a double fan-shaped fold of peritoneum that covers most of intestine and is filled with blood vessels and nerves, is also pulled along Edema occurs

Celiac disease is caused by

a genetic sensitivity to gluten in the diet

Diarrhea: Diarrhea in infant is

a sudden increase in stools from the infant's normal pattern, with a fluid consistency and a color that is green or contains mucus or blood

Failure to Thrive (cont.): Often

admitted to hospital Presents with weight loss, irritability, disturbances of food intake, vomiting, diarrhea, and general neuromuscular spasticity sometimes accompany the condition

Manifestations of TEF (Tracheoesophageal Fistula): If lower end of esophagus enters trachea,

air will enter stomach each time infant breathes, causing abdominal distention

Rickets: ◦ Vitamin supplements

along with exercise and exposure to outdoor sunlight is primary form of treatment

Meckel's Diverticulum: ◦ A fistula may

also form ◦ This sac is subject to inflammation

Manifestations of TEF (Tracheoesophageal Fistula): ◦ At birth, the infant will vomit

and choke when the first feeding is introduced

Dehydration: Causes fluid

and electrolyte disturbances Evaluation of type and severity, including clinical observation and chemical analysis of the blood

Symptoms of Diarrhea: Stools watery

and explosive; may be yellowish-green Listlessness, refusal to eat, weight loss, temperature may be elevated, possible vomiting

Fluid and Electrolyte Imbalance (cont.): Metabolic rate

and heat production are also 2 to 3 times greater in infants per kg of body weight ◦ Stimulates respirations, which increase evaporation through the lungs

Hirschsprung's Disease (Aganglionic Megacolon): ◦ Seen more often in boys

and in children with Down syndrome May be acute or chronic

Manifestations of Pyloric Stenosis: ◦ Vomitus contains mucus

and ingested milk ◦ Infant is constantly hungry and will eat again immediately after vomiting

An intake and output recoerd includes accurate documentation of information concerning oral

and parenteral intake and suction, wound drainage, sweating, vomiting, urine and stool output

Nursing Interventions o GI Disorders: • Focuses on providing adequate nutrition

and preventing infection -Can result from malnutrition or depressed immune function

Teaching parents basic hygienic practices, handwashing,

and proper animal handling can prevent outbreaks of diarrhea

Lab studies: ◦ CBC with differential:

anemia, infections, chronic illness

Failure to Thrive (cont.): Multidisciplinary

approach in accordance with circumstances

Fluid and Electrolyte Imbalance (cont.): Metabolic rate and heat production

are also 2 to 3 times greater in infants per kg of body weight ◦ Greater percentage of body water in children under 2 years is contained in extracellular compartment

Dehydration: Types of dehydration

are classified according to level of serum sodium, which depends on the relative losses of water and electrolytes ◦ Isotonic ◦ Hypotonic ◦ Hypertonic

Thrush (Oral Candidiasis): Systemic symptoms

are generally mild if infection remains in the mouth; can pass into GI tract causing inflammation of the esophagus and stomach

Appendicitis: ◦ Small appendage

arising from the cecum ◦ Lumen may become obstructed with fecal matter or with lymphoid tissue after a viral illness or with parasites ◦ Stasis, increased swelling, edema, and growth of organisms

Manifestations of TEF (Tracheoesophageal Fistula): ◦ Drooling may also be present

at birth and is related to atresia

Appendicitis: Appendix may

become gangrenous or rupture Can lead to peritonitis and septicemia

Intussusception (cont.): Generally occurs in boys

between 3 months and 6 years ◦ Frequency decreases after age 36 months

Meckel's Diverticulum (cont.): Bright-red or dark-red

blood is more usual than tarry stools ◦ Abdominal pain may or may not be present

Rickets: Classic symptoms are

bow-legs; knock-knees; beading of the ribs, called rachitic rosary; and, improper formation of teeth

The treatment of gastroesophageal reflux includes thickened feedings,

burping and maintaining fowler's position

Intussusception: At first, intestinal obstruction occurs,

but then strangulation of the bowel occurs as peristalsis occurs Affected portion may burst, leading to peritonitis

Treatment of Intussusception: Diagnosis is determined

by history and physical findings May feel a sausage-shaped mass in right upper abdomen

Symptoms of Diarrhea: Dehydration evidenced

by sunken eyes and fontanel; dry skin, tongue, and mucous membranes; less frequent urination In severe cases, excessive loss of bicarbonate from GI tract results in acidosis

Lead poisoning (plumbism)

can cause neurological damage.

Gastroesophageal Reflux: Symptoms: ◦ Respiratory problems

can occur when vomiting stimulates closure of epiglottis and infant presents with apnea

Diarrhea: ◦ Infectious diarrhea

caused by viral, bacterial, or parasitic infection, usually involves gastroenteritis

Currant jelly stools

characterize intussusception

Constipation (cont.): Document any medications

child is taking Dietary modifications include increasing roughage in diet

Oral rehydrating solutions are

commercially prepared electrolyte solutions.

Constipation (cont.): ◦ Some infants develop

constipation due to high iron content in formula

Hirschsprung's Disease (Aganglionic Megacolon) (cont.): Infants:

constipation, ribbonlike stools, abdominal distention, anorexia, vomiting, and failure to thrive

Vomiting: Results from sudden

contractions of diaphragm and muscles of the stomach

Constipation: • Difficult or infrequent

defecation with the passage of hard, dry fecal material -May be periods of diarrhea or encopresis (constipation with fecal soiling)

Gastroesophageal Reflux: ◦ Associated with neuromuscular

delay, such as Down syndrome or cerebral palsy Often seen in preterm infants Symptoms often decrease once child is able to stand upright and eats more solid foods

Overhydration: Low protein levels

disturb osmotic cellular pressure Anasarca is severe generalized edema

Celiac Disease: Also known as gluten

enteropathy and sprue Leading malabsorption problem in children

Hirschsprung's Disease (Aganglionic Megacolon) (cont.): Newborns:

failure to pass meconium stools within 24 to 48 hours may be a symptom

Manifestations of TEF (Tracheoesophageal Fistula): ◦ If it ends in blind pouch,

fetus cannot swallow amniotic fluid and it will accumulate

Intussusception (cont.): Child vomits green or greenish-yellow

fluid (bilious) Bowel movements diminish, little flatus is passed

Imperforate Anus: • Lower GI and anus arise

from two different types of tissue during fetal development

Scurvy: Caused by insufficient

fruits and vegetables that contain vitamin C

Hirschsprung's disease occurs when there is an absence of

ganglionic innervation of the muscle of a bowel segment

Infants who are fed by the IV route should be picked up and

held and allowed to suck on a pacifier

Imperforate Anus (cont.) Manifestations: ◦ Infant should not be discharged

home until a meconium stool has passed

Vomiting: ◦ Continuous loss of

hydrochloric acid and sodium chloride from the stomach can cause alkalosis. ◦ Can result in death if left untreated

Meckel's Diverticulum: Usually occurs near

ileocecal valve and may be connected to umbilicus by a cord

Gastroesophageal Reflux (cont.): Nursing care: ◦ Sitting upright

in an infant seat is not recommended as it increases intra-abdominal pressure Administer medications to relax pyloric sphincter before meals

Gastroenteritis: Priority problem

in diarrhea is fluid and electrolyte imbalance and failure to thrive

Imperforate Anus (cont.) Manifestations: ◦ Failure to pass meconium

in the first 24 hours must be reported

Kwashiorkor: • Seen most often

in third-world countries

Constipation (cont.): ◦ Foods high in fiber

include whole-grain breads and cereals, raw vegetables and fruits, bran, and popcorn for older children Stool softener may be prescribed

the functions of the gastrointestinal tract have a great

influence on the fluid and electrolyte balance in infants and children

Celiac Disease: ◦ Thought to be caused by

inherited disposition with environmental triggers

Gastroenteritis: Enterocolitis

involves an inflammation of the colon and small intestines

Nursing Interventions o GI Disorders: • Skin problems may be related to pruritus,

irritation from frequent bowel movements, or other disorders

Celiac Disease (cont.): • Characteristic profile

is abdominal distention with atrophy of the buttocks

Treatment of Intussusception: This condition

is an emergency

Pica, the eating of nonfood items,

is characteristic of children with lead poisoning

◦ Erythrocyte sedimentation rate (ESR)

is indicative of inflammation

Kwashiorkor (cont.) Treatment

is mainly preventive Simple protein powder sprinkled on the culturally prepared meal will alleviate the problem

Manifestations of Pyloric Stenosis: Projectile vomiting

is outstanding symptom from force or pressure being exerted on the pylorus

Gastroesophageal Reflux: Lower esophageal sphincter

is relaxed or not competent, allowing stomach contents to regurgitate into esophagus

Hernias (cont.): Strangulated hernia

is when intestine becomes caught in the passage and the blood supply is diminished

Scurvy: Symptoms include

joint pain, bleeding gums, loose teeth, lack of energy Vitamin C

Failure to Thrive (cont.): ◦ Inadequacies in intelligence,

language, and social behavior have been documented in children who fail to thrive

Intussusception (cont.): In infants, severe pain in abdomen,

loud cries, straining efforts, and kicking and drawing of legs toward abdomen

Meckel's Diverticulum: Most common congenital

malformation of the GI tract ◦ Seen more often in boys

Manifestations of Pyloric Stenosis: Dehydration and olive-shaped

mass may be felt in upper right quadrant of abdomen

Treatment of Pyloric Stenosis Surgery is called pyloromyotomy Preoperative nursing care: ◦ Thickened feedings

may be given by a teaspoon or through a nipple with a large hole

Intussusception: Affected portion

may burst, leading to peritonitis

Overhydration: The body receives

more fluid than it can excrete Manifests as edema (excess fluid in interstitial spaces)

Diarrhea: ◦ Acute sudden diarrhea

most often caused by inflammation, infection, or a response to medications, food, or poisoning

Constipation (cont.): Fewer than 7 bowel

movements in a 2-week period Ask caregiver to define constipation Evaluate dietary and bowel habits

Nursing Interventions o GI Disorders: • Pain and discomfort

need to be addressed

Foreign Bodies: Caution parents

not to use laxatives and to maintain a normal diet to avoid intestinal spasms

Failure to Thrive (cont.): Assigning the same

nursing staff to care for the child may increase nurturing and interaction with the infant and parent

Gastrointestinal (GI) Tract: Transports and metabolizes

nutrients necessary for the life of the cell

Drooling in the newborn may be a sign of an

obstructed oesophagus or TEF

Hirschsprung's Disease (Aganglionic Megacolon): ◦ Portion of bowel nearest

obstruction dilates, causing abdominal distention

Meckel's Diverticulum (cont.): Symptoms can

occur at any age, but typically appear by 2 years of age ◦ Painless bleeding from rectum

Foreign Bodies: 80% of all ingestions

occur in children between 6 months and 3 years of age ◦ About 80% of items ingested pass through the GI tract without difficulty ◦ May take up to 6 days to occur

Pyloric Stenosis: ◦ Most common surgical condition

of GI tract in infancy. Incidence is higher in boys

Celiac Disease: Symptoms not evident until 6 months to 2 years

of age when foods containing gluten are introduced

Symptoms of Diarrhea: In severe cases, excessive loss

of bicarbonate from GI tract results in acidosis

Lead Poisoning (Plumbism) (cont.): X-ray films

of bones may show further lead deposits History may reveal pica Treatment is aimed at reducing concentration of lead in blood ◦ Chelating agents may be taken for several months Prognosis depends on extent of poisoning

Treatment of Intussusception: Barium enema is treatment

of choice, with surgery if reduction does not occur

Kwashiorkor: • Belongs to a class

of disorders termed protein-energy malnutrition

Prevention of accidental poisoning should be part

of every plan for teaching parents.

Large, bulky, frothy stools are characteristic

of malabsorption syndromes

Hirschsprung's Disease (Aganglionic Megacolon) (cont.) Enemas: ◦ Due to increased size

of mucous membranes' surface area, an increased absorption of the fluid can be anticipated Therefore, normal saline solution should be used to prevent water intoxication and death

Constipation: • May be a symptom

of other disorders • Diet, culture, and social, psychological, and familial patterns may also influence occurrence

Kwashiorkor: Severe deficiency

of protein in the diet despite the fact that the number of calories consumed may be nearly adequate

Hirschsprung's Disease (Aganglionic Megacolon): ◦ Usually in lower portion

of sigmoid colon Lack of normal peristalsis, results in constipation Stools are ribbonlike due to feces passing through the narrow segment of colon

Intussusception: A slipping of one part

of the intestine into another part just below it ◦ Often seen at the ileocecal valve

Gastroenteritis: Involves inflammation

of the stomach and intestines Colitis involves an inflammation of the colon

Pyloric Stenosis: Obstruction of the lower end

of the stomach caused by overgrowth of the circular muscles of the pylorus or spasms of the sphincter

Gastroenteritis (cont.): Treatment is focused

on identifying and eradicating cause Priority goal of care is restoring fluid and electrolyte balance

Constipation: • Daily use of laxatives

or enemas should be discouraged

Hirschsprung's Disease (Aganglionic Megacolon) (cont.): If untreated,

other signs of intestinal obstruction and shock may be seen Enterocolitis (inflammation of the small bowel and colon) is a serious condition ◦ Fever, explosive stools, and depletion of strength

Overhydration: Flow of blood

out of the interstitial compartments depends on adequate circulation of blood and lymph

A chronic productive cough without fever is

part of the roundworm life cycle in children

Failure to Thrive (cont.): Prognosis is uncertain -◦ Emotional starvation,

particularly in the early years, can be psychologically traumatic

Imperforate Anus: • Once the two meet,

perforation occurs allowing for a passageway

Nursing care for the child with pyloric stenosis involves frequent assessment careful feeding,

positioning on the right side after feedings, and education and support of the parents

Fluid and Electrolyte Imbalance (cont.): Metabolic rate and heat

production are also 2 to 3 times greater in infants per kg of body weight ◦ Produces more waste products, which must be diluted to be excreted

Gastroenteritis (cont.): Review with parents

proper hand hygiene techniques, safe food handling and storage, principles of cleanliness, and infection prevention

Treatment of Pyloric Stenosis Surgery is called pyloromyotomy Postoperative nursing care: ◦ Monitor intravenous fluids,

provide feedings as prescribed by surgeon, document intake and output, monitor surgical site

Pyloric stenosis is caused by hypertrophy of the

pyloric muscles and is manifested by projectile vomiting

Failure to Thrive (cont.): Nurse is vital in supporting

rather than in rejecting the mother ◦ Encourages mother to assist with daily care of child ◦ Points out developmental patterns and provides anticipatory guidance in this area

Hand hygiene with soap and water rather than alcohol based hand sanitizer is

recommended when caring for paatients with C. Diff diarrhea. Contact precautions are recommended, and the environment should be cleaned with a bleach disinfectant by housekeeping staff.

Intussusception (cont.): Can have spontaneous

reduction Onset is usually sudden ◦ May have a fever as high as 106° F (41.1° C)

Thrush (Oral Candidiasis): ◦ Medication should

remain in contact with "patches" as long as possible With proper care, the condition disappears within a few days after onse

Vomiting: Persistent vomiting

requires investigation because it results in dehydration and electrolyte imbalance

Celiac Disease (cont.): Diagnosis confirmed by

serum immunoglobin A (IgA) and small bowel biopsy

Hernias (cont.): Child may vomit and have

severe abdominal pain Emergent surgery is indicated in this type of situation In most cases, same-day surgery is performed

Nursing Interventions o GI Disorders: • Developmental delays

should be investigated

Disposable nipples, pacifiers, and bottles

should be used for infants with thrush

Intussusception (cont.): ◦ As it progresses, child may show

signs of shock, sweating, weak pulse, shallow, grunting respirations; abdomen is rigid

Failure to Thrive (cont.): Pregnancy history

sometimes reveals circumstances that may contribute to a lack of mother-infant bonding

Appendicitis: When inflammation

spreads to peritoneum, pain localizes in RLQ of abdomen

Rickets: ◦ Exposure to

sunshine is necessary for proper absorption and metabolism of calcium and phosphorus

Lead Poisoning (Plumbism) (cont.): Lead is toxic to the

synthesis of heme in the blood, which is necessary for hemoglobin formation and renal tubule functioning Blood lead levels are primary screening test

To prevent the development of water intoxication,

tap water should not be used for enemas in children with megacolon

Diarrhea: ◦ Chronic diarrhea lasts more

than 2 weeks and may indicate malabsorption problem, longterm inflammatory disease, or allergic responses

C. diff is a health care assocciated diarrhea

that may occur with antimicrobial therapy

Manifestations of TEF (Tracheoesophageal Fistula): If upper esophagus enters trachea,

the first feeding will enter the trachea and result in coughing, choking, cyanosis, and apnea

Imperforate Anus: • When perforation does not take place,

the lower end of the GI tract and anus end in a blind pouch

Failure to Thrive (cont.): Children fall below

the third percentile in weight and height on standard growth charts Development is delayed

the higher daily exchange of water that occurs in infants leaves

them less volume reserve when they are dehydrated

Failure to Thrive (cont.): Due to multiple factors,

there may be a disturbance in the mother-child relationship

Imperforate Anus: • Four types ranging from stenosis

to complete separation or failure of the anus to form

Celiac Disease (cont.): • Repeated exposure

to gluten damage the villi of intestines resulting in malabsorption

Thrush (Oral Candidiasis): Responds well

to local application of antifungal suspension, such as nystatin

Overhydration (cont.) • Treatment: ◦ Important for nurse

to monitor clinical laboratory results and adjust fluids and foods offered to the child

The first stool of the newborn should be documented

to record the patency of the anus

Treatment of Pyloric Stenosis Surgery is called pyloromyotomy Preoperative nursing care: ◦ Burped before and during feedings

to remove any gas accumulated in the stomach

The nurse should teach parents not

to store poisonous substances in food containers

Celiac Disease (cont.): Infant presents with failure

to thrive. Infant is irritable. Stools are large, bulky, and frothy

Pyloric Stenosis: Symptoms usually do not appear

until the infant is 2 or 3 weeks old

Appendicitis: Initial pain

usually in periumbilical and increases within a 4-hour period

Hirschsprung's Disease (Aganglionic Megacolon) (cont.): Young children:

usually seen in clinic after parents have tried over-the-counter laxatives to treat the constipation

Overhydration (cont.) • Treatment: ◦ Accurate daily weight,

vital signs, observing physical appearance, and noting changes in urine output

Gastroenteritis (cont.): Accurate intake and output,

weighing of diapers, observing for dehydration or overhydration, and keeping infant/child warm

The newborn shold be closely observed for signs of tracheoesphageal fistula (TEF)

which include coughing choking, cyanosis, and apnea during feedings.

Lab studies:◦ Comprehensive chemistry panel

will reveal electrolyte and chemical imbalances

Intussusception (cont.): Blood and mucus

with no feces are common about 12 hours after onset of obstruction, called currant jelly stools

Hirschsprung's Disease (Aganglionic Megacolon) (cont.) Enemas: ◦ Parents should check

with the pediatrician to see how much saline should be administered with each enema

Constipation:

• Difficult or infrequent defecation with the passage of hard, dry fecal material -May be periods of diarrhea or encopresis (constipation with fecal soiling) • May be a symptom of other disorders • Diet, culture, and social, psychological, and familial patterns may also influence occurrence • Daily use of laxatives or enemas should be discouraged

Fluid and Electrolyte Imbalance (cont.):

• Electrolyte balance depends on fluid balance and cardiovascular, renal, adrenal, pituitary, parathyroid, and pulmonary regulatory mechanisms

Fluid and Electrolyte Imbalance (cont.):

• Electrolyte balance depends on fluid balance and cardiovascular, renal, adrenal, pituitary, parathyroid, and pulmonary regulatory mechanisms • Signs of dehydration may not be evident until the fluid loss reaches 4%, and severe dehydration may not be evident until the fluid loss reaches 10% • Can treat with oral fluids or parenteral fluids

Nursing Interventions o GI Disorders

• Focuses on providing adequate nutrition and preventing infection -Can result from malnutrition or depressed immune function • Developmental delays should be investigated • Skin problems may be related to pruritus, irritation from frequent bowel movements, or other disorders • Pain and discomfort need to be addressed

Imperforate Anus:

• Lower GI and anus arise from two different types of tissue during fetal development • Once the two meet, perforation occurs allowing for a passageway • When perforation does not take place, the lower end of the GI tract and anus end in a blind pouch • Four types ranging from stenosis to complete separation or failure of the anus to form

Celiac Disease (cont.):

• Repeated exposure to gluten damage the villi of intestines resulting in malabsorption • Characteristic profile is abdominal distention with atrophy of the buttocks

Fluid and Electrolyte Imbalance (cont.):

• Signs of dehydration may not be evident until the fluid loss reaches 4%, and severe dehydration may not be evident until the fluid loss reaches 10% • Can treat with oral fluids or parenteral fluids

Nursing Care of TEF (Tracheoesophageal Fistula):

◦ Assessment of the newborn during the first feeding for signs/symptoms of TEF is essential

Meckel's Diverticulum (cont.): Diagnostics

◦ Barium enema or radionuclide scintigraphy are used in diagnosing ◦ X-ray films are not helpful

Gastroesophageal Reflux (cont.): Tests include

◦ Barium swallow ◦ Esophageal sphincter pressure ◦ pH monitoring—most diagnostic

Appendicitis (cont.): Diagnostics can include

◦ Blood tests ◦ Abdominal X-ray ◦ CT scan ◦ Ultrasound

Laboratory and Diagnostic Studies Clinical laboratory

◦ CBC with differential: anemia, infections, chronic illness ◦ Erythrocyte sedimentation rate (ESR) is indicative of inflammation ◦ Comprehensive chemistry panel will reveal electrolyte and chemical imbalances ◦ Liver function test (LFT) ◦ Stool cultures X-ray studies ◦ GI series, barium enema, flat plates of the abdomen Endoscopy allows direct visualization and biopsy of the GI tract Upper—esophagus, stomach, duodenum, bile and pancreatic ducts Can remove foreign objects and cauterize bleeding vessels Lower colon—sigmoidoscopy Entire colon—colonoscopy

Gastroesophageal Reflux (cont.): Nursing care

◦ Careful burping ◦ Prevent overfeeding ◦ Proper positioning ◦ Feedings are thickened with cereal After being fed, infant is place in an upright position or propped ◦ Sitting upright in an infant seat is not recommended as it increases intra-abdominal pressure Administer medications to relax pyloric sphincter before meals

Vomiting (cont.) Nursing care:

◦ Carefully feed and burp infant ◦ Place infant on side after feeding to prevent aspiration if vomiting occurs

Vomiting (cont.) Nursing care:

◦ Carefully feed and burp infant ◦ Place infant on side after feeding to prevent aspiration if vomiting occurs ◦ When an older child vomits, turn head to one side and offer emesis basin ◦ IV fluids may be ordered ◦ Slowly introduce foods to allow stomach to rest Documentation ◦ Time, amount, color, consistency, force, frequency, and whether vomiting was preceded by nausea or feedings ◦ Administration of antiemetic agents should also be documented, including time given and if/when vomiting subsided

Hirschsprung's Disease (Aganglionic Megacolon) (cont.) Enemas:

◦ Due to increased size of mucous membranes' surface area, an increased absorption of the fluid can be anticipated Therefore, normal saline solution should be used to prevent water intoxication and death ◦ Parents should check with the pediatrician to see how much saline should be administered with each enema

Overhydration (cont.) • Treatment: Nursing care

◦ Early detection and management of edema are essential

Scurvy: Vitamin C

◦ Easily destroyed by heat and exposure to air ◦ Not stored in the body and daily intake of the vitamin is necessary Vitamin supplements and dietary intake such as citrus fruits and raw leafy vegetables

Imperforate Anus (cont.) Manifestations:

◦ Failure to pass meconium in the first 24 hours must be reported ◦ Infant should not be discharged home until a meconium stool has passed Treatment ◦ Once established, infant is NPO and prepared for surgery ◦ Initial surgical procedure may be a colostomy ◦ Subsequent surgeries will reestablish patency of anal canal

Symptoms of GI Disorders Systemic signs

◦ Failure to thrive (FTT)—failure to develop according to established growth parameters

Symptoms of GI Disorders Systemic signs

◦ Failure to thrive (FTT)—failure to develop according to established growth parameters ◦ Pruritus (itching) in the absence of allergy may indicate liver dysfunction Local signs ◦ Pain ◦ Vomiting ◦ Diarrhea ◦ Constipation ◦ Rectal bleeding ◦ Hematemesis

Nursing Care of TEF (Tracheoesophageal Fistula):

◦ Feeding usually is with clear water or colostrum to minimize seriousness of aspiration Surgical repair is essential for survival

Kwashiorkor (cont.): More Symptoms

◦ Hair thins and is dry and may contain a white streak ◦ Child looks apathetic and weak

Worms Roundworms (Ascariasis)

◦ If child eats soil, eggs develop into larvae in intestine, penetrate intestinal wall and enter liver; from there, the worms circulate to the lungs and heart ◦ Chronic cough without fever is characteristic of this form of infestation

Vomiting: Multiple causes of vomiting

◦ Improper feeding technique ◦ Systemic illness such as increased intracranial pressure or infection ◦ Child at risk for aspiration pneumonia

Treatment of Pyloric Stenosis Surgery is called pyloromyotomy Preoperative nursing care:

◦ Intravenous fluids to treat or prevent dehydration ◦ Thickened feedings may be given by a teaspoon or through a nipple with a large hole ◦ Burped before and during feedings to remove any gas accumulated in the stomach ◦ Place on right side (preferably Fowler's position) after feeding to facilitate stomach drainage into the intestines ◦ If infant vomits, nurse is instructed to refeed the infant Postoperative nursing care ◦ Monitor intravenous fluids, provide feedings as prescribed by surgeon, document intake and output, monitor surgical site

Lead Poisoning (Plumbism) (cont.) Symptoms occur gradually:

◦ Lead settles in soft tissues and bones ◦ Is excreted in urine Beginning stages, signs may be weakness, weight loss, anorexia, pallor, irritability, vomiting, abdominal pain, and constipation Later stages, signs may be anemia and nervous system involvement

Celiac Disease (cont.): Treatment

◦ Lifelong diet restricted in wheat, barley, oats, and rye ◦ Detailed parent teaching is essential A professional nutritionist or dietitian can aid in identifying foods that are gluten-free

Worms Pinworms (Enterobiasis)& Roundworms (Ascariasis)

◦ Looks like a white thread; lives in lower intestine but lays eggs outside anus ◦ Eggs become infective within hours of being deposited ◦ Route of entry into the body is through the mouth ◦ "Scotch tape" test Antihelminth medications are given for both types of worm infestations Roundworms (Ascariasis) ◦ Seen more in U.S. southern states and among immigrants and migratory workers ◦ Caused by unsanitary disposal of human feces and poor hygiene ◦ Eggs can survive for weeks in soil ◦ If child eats soil, eggs develop into larvae in intestine, penetrate intestinal wall and enter liver; from there, the worms circulate to the lungs and heart ◦ Chronic cough without fever is characteristic of this form of infestation

Kwashiorkor (cont.): Symptoms

◦ Muscles become weak and wasted ◦ Edema of abdomen ◦ Diarrhea, skin infections, irritability, anorexia, and vomiting may be present

Imperforate Anus (cont.) Manifestations: Treatment

◦ Once established, infant is NPO and prepared for surgery ◦ Initial surgical procedure may be a colostomy ◦ Subsequent surgeries will reestablish patency of anal canal

Hernias Umbilical:

◦ Protrusion of a portion of the intestine through the umbilical ring ◦ Appears as a soft swelling covered by skin, which protrudes when infant cries or strains

Hernias Inguinal:

◦ Protrusion of part of the abdominal contents through the inguinal canal in the groin

Hernias Inguinal and Umbilical

◦ Protrusion of part of the abdominal contents through the inguinal canal in the groin Umbilical ◦ Protrusion of a portion of the intestine through the umbilical ring ◦ Appears as a soft swelling covered by skin, which protrudes when infant cries or strains

Symptoms of GI Disorders Systemic signs

◦ Pruritus (itching) in the absence of allergy may indicate liver dysfunction

Poisoning: Goals of treatment

◦ Remove the poison ◦ Prevent further absorption ◦ Call the poison control center ◦ Provide supportive care—seek medical help

Worms Roundworms (Ascariasis)

◦ Seen more in U.S. southern states and among immigrants and migratory workers ◦ Caused by unsanitary disposal of human feces and poor hygiene ◦ Eggs can survive for weeks in soil

Appendicitis (cont.): Treatment

◦ Surgical intervention typically required Nursing care is the same as with most other abdominal surgery patients

Meckel's Diverticulum (cont.): .Treatment

◦ Surgical removal of the diverticulum Nursing care is same for any patient having undergone abdominal surgery

Appendicitis (cont.): Characteristic symptoms

◦ Tenderness in RLQ, known as McBurney's point ◦ Guarding ◦ Rebound tenderness ◦ Pain on lifting thigh while in supine position ◦ Pain in RLQ

Vomiting (cont.) Nursing care: Documentation

◦ Time, amount, color, consistency, force, frequency, and whether vomiting was preceded by nausea or feedings ◦ Administration of antiemetic agents should also be documented, including time given and if/when vomiting subsided

Esophageal Atresia (Tracheoesophageal Fistula [TEF]) : 1 of 4 types

◦ Upper and lower esophagus (from the stomach) end in a blind pouch

Esophageal Atresia (Tracheoesophageal Fistula [TEF]): Four types

◦ Upper and lower esophagus (from the stomach) end in a blind pouch ◦ Upper esophagus ends in a blind pouch; lower esophagus (from stomach) connects to the trachea ◦ Upper esophagus is attached to trachea; lower esophagus (from stomach) also attached to trachea ◦ Upper esophagus connects to trachea; lower esophagus (from stomach) ends in a blind pouch

Esophageal Atresia (Tracheoesophageal Fistula [TEF])1 of 4 types

◦ Upper esophagus connects to trachea; lower esophagus (from stomach) ends in a blind pouch

Esophageal Atresia (Tracheoesophageal Fistula [TEF])1 of 4 types

◦ Upper esophagus ends in a blind pouch; lower esophagus (from stomach) connects to the trachea

Esophageal Atresia (Tracheoesophageal Fistula [TEF]) one of 4 types

◦ Upper esophagus is attached to trachea; lower esophagus (from stomach) also attached to trachea

Poisoning (cont.) General concepts

◦ Volume of swallow ◦ Principles of care—education ◦ Poison control centers—nationwide phone number is 1-800-222-1222 ◦ Ipecac syrup—no longer recommended ◦ Activated charcoal—given for some substances ◦ Charcoal or any gastric lavage is not effective if administered after 1 hour post-ingestion

Gastroesophageal Reflux: Symptoms

◦ Vomiting ◦ Weight loss ◦ Failure to thrive ◦ Infant is fussy and hungry ◦ Respiratory problems can occur when vomiting stimulates closure of epiglottis and infant presents with apnea

Vomiting (cont.) Nursing care:

◦ When an older child vomits, turn head to one side and offer emesis basin ◦ IV fluids may be ordered ◦ Slowly introduce foods to allow stomach to rest

Gastroesophageal Reflux (cont.) History includes

◦ When vomiting started ◦ Type of formula ◦ Type of vomiting ◦ Feeding techniques ◦ Infant's eating in general Tests include ◦ Barium swallow ◦ Esophageal sphincter pressure ◦ pH monitoring—most diagnostic Nursing care ◦ Careful burping ◦ Prevent overfeeding ◦ Proper positioning ◦ Feedings are thickened with cereal After being fed, infant is place in an upright position or propped ◦ Sitting upright in an infant seat is not recommended as it increases intra-abdominal pressure Administer medications to relax pyloric sphincter before meals


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