[PREPU] Chapter 42 - Nursing Care of the Child With an Alteration in Bowel Elimination/Gastrointestinal Disorder
The mother of an infant tells the nurse during a routine visit to the clinic that she often notices a bulging mass in the lower abdominal and groin area when her baby cries. She asks the nurse if this is normal. How should the nurse respond? - "The muscle wall of infants are not yet strong so it isn't unusual to see this happening when the baby is crying or straining." - "I didn't notice any masses while I was assessing your infant. It may just appear they have a mass due to pressure in the abdomen when crying." - "I will be sure to note this in your child's chart so it is something we will continue to monitor in future visits." - "I understand your concern. I will be sure to document this in your child's medical record and report this information to your child's physician immediately."
"I understand your concern. I will be sure to document this in your child's medical record and report this information to your child's physician immediately." The mother is describing common symptoms of an inguinal hernia. It may be possible to visualize the mass, but often the mass is seen only during crying or straining, making it difficult to actually identify in the clinic setting. It is important to notify the physician so treatment can be initiated.
A physician recommends a gastrostomy for a 4-year-old client with an obstruction. The parents ask the certified wound, ostomy, and continence nurse (CWOCN) what the surgery entails. What is the nurse's best response? - "The surgery is performed to create an opening between the esophagus and the neck." - "The surgery creates an opening between the stomach and abdominal wall." - "The surgery will create an opening to the small intestine." - "The surgery will create an opening to the large intestine."
"The surgery creates an opening between the stomach and abdominal wall." Ostomies can be created at various sites in the GI tract, depending on the child's clinical condition. A gastrostomy provides an opening between the stomach and the abdominal wall, and an esophagostomy communicates between the esophagus and an external site on the neck. Ostomies may be created at various sites in the small intestine (e.g., jejunostomy, ileostomy) or in the large intestine (e.g., colostomy).
A neonatal nurse teaches students how to recognize gastrointestinal disorders in infants. The nurse tells the students that failure of the newborn to pass meconium in the first 24 hours after birth may indicate what disease? - Gastroenteritis - Ulcerative colitis (UC) - Hirschsprung disease - Short bowel syndrome (SBS)
Hirschsprung disease. The nurse should suspect Hirschsprung disease when the newborn does not pass meconium in the first 24 hours after birth, and has bilious vomiting or abdominal distention and feeding intolerance with bilious aspirates and vomiting. Typical signs and symptoms of gastroenteritis include diarrhea, nausea, vomiting, and abdominal pain. The characteristic GI manifestation of UC is bloody diarrhea accompanied by crampy, typically left-sided lower abdominal pain. Clinical manifestations of untreated SBS include profuse watery diarrhea, malabsorption, and failure to thrive.
A 9-month-old girl is brought to the emergency room with what appears to be bouts of intense abdominal pain 15 minutes apart in which she draws up her legs and cries, often accompanied by vomiting. In between the bouts, the child recovers and appears to be without symptoms. Blood is found in the stool. What condition should the nurse suspect in this case? - Intussusception - Volvulus with malrotation - Necrotizing enterocolitis - Short-bowel/short-gut syndrome
Intussusception. Intussusception, the invagination of one portion of the intestine into another, usually occurs in the second half of the first year of life. Children with this disorder suddenly draw up their legs and cry as if they are in severe pain; they may vomit. After the peristaltic wave that caused the discomfort passes, they are symptom-free and play happily. In approximately 15 minutes, however, the same phenomenon of intense abdominal pain strikes again. After approximately 12 hours, blood appears in the stool and possibly in vomitus, described as a "currant jelly" appearance. Volvulus with malrotation and necrotizing enterocolitis typically occur in the first 6 months of life and do not match the symptoms described above. Short-bowel/short-gut syndrome typically occurs when a large portion of the intestine has been removed due to a previous disease or trauma.
A 10-year-old male presents with low-grade fever, nausea, and abdominal pain. The nurse examining him suspects appendicitis and checks for rebound tenderness in what quadrant? - Upper left - Upper right - Lower left - Lower right
Lower right. With appendicitis, percussion reveals irritation and pain in the right lower quadrant. Rebound tenderness present with palpation in the right lower quadrant is referred to as the McBurney point, an area of tenderness 1.5 to 2 inches (3.8 to 5 cm) in from the right anterior superior iliac spine along a line extending to the umbilicus.
A mother calls the doctor's office and tells the nurse that she is concerned because her 4-month-old keeps "spitting up" with every feeding. What would indicate that the child is regurgitating as opposed to vomiting? - Only occurs with feeding - Is projected 1 ft away from infant - Is curdled and extremely sour smelling - Continues until stomach is empty
Only occurs with feeding. Regurgitation typically occurs only with feeding, runs out of the mouth with little force, smells barely sour and is only slightly curdled, appears to cause no pain or distress, occurs only once per feeding, and amounts to only about 1 to 2 tsp. Vomiting may occur at times other than feeding, is forceful and is typically projected 1 ft or more away from infant, is extremely sour smelling and curdled, is typically accompanied by crying, continues until the stomach is empty, and amounts to the full stomach contents.
A 6-week-old infant is diagnosed with pyloric stenosis. When taking a health history from the parent, which symptom would the nurse expect to hear described? - Refusal to eat - Vomiting about 2 hours after feeding - Chronic diarrhea - Vomiting immediately after feeding
Vomiting immediately after feeding. With pyloric stenosis the circular muscle pylorus is hypertrophied. This thickness causes gastric outlet obstruction. The condition is seen in younger infants starting at 3 to 6 weeks of age. The infant has projectile nonbilious vomiting. It occurs directly after eating and is not related to the feeding position. The infant is hungry shortly after eating. There is weight loss and/or dehydration. The treatment is a pyloromyotomy to reduce the increased size and increase the opening. Diarrhea is not associated with the disorder.
An 18-month-old infant is brought to the emergency department with flu-like symptoms. The infant is diagnosed with pneumonia secondary to aspiration of stomach contents. The nurse explains to the parents that pneumonia is a condition that often occurs secondary to: - gastroesophageal reflux disease. - cystic fibrosis. - Hirschsprung disease. - inflammatory bowel disease.
gastroesophageal reflux disease. Gastroesophageal reflux (GER) is the passage of gastric contents into the esophagus. These refluxed contents may be aspirated into the lungs. The child with gastroesophageal reflux disease may present with the physical findings of pneumonia or GER-induced asthma. GER may cause apnea or an apparent life-threatening event in the younger infant. Pneumonia can occur in children with cystic fibrosis, but the child would need to have the cystic fibrosis diagnosis first. Hirschsprung and inflammatory bowel diseases are diseases of the gastrointestinal tract that do not present with respiratory symptoms.
The nurse is preparing a client for surgery and the client asks, "What does it mean when they say they are going to reduce my abdominal hernia?" Which response by the nurse is most appropriate? - "This means the hernia contents will be manipulated back into your peritoneal cavity during surgery." - "If you do not understand this, I need to cancel your surgery and have the health care provider come back." - "All this means is that the herniated intestines are twisted and edematous, which is why you need surgery." - "The health care provider will remove about half of the herniated contents during the procedure."
"This means the hernia contents will be manipulated back into your peritoneal cavity during surgery." A hernia in the abdominal region is considered reducible when its contents are easily manipulated back through the inguinal ring into the peritoneal cavity. The nurse would reinforce this education, already provided by the primary health care provider when the surgery was explained, to the client. It is not necessary to cancel surgery when the nurse can provide education to the client. Reducing does not mean the intestines are twisted and edematous. Nor does it mean half of the contents will be removed.
A child is diagnosed with intussusception. The nurse anticipates that what action would be attempted first to reduce this condition? - Barium enema - Surgery - Upper endoscopy - Endoscopic retrograde cholangiopancreatography
Barium enema. A barium enema is successful in reducing a large percentage of intussusception cases. Other cases are reduced surgically. Upper endoscopy is used to visualize the upper gastrointestinal tract from the mouth to the upper jejunum. Endoscopic retrograde cholangiopancreatography is used to view the hepatobiliary system.
A parent brings a 2-year-old child to the health clinic with reports of diarrhea, vomiting, and abdominal pain. The father tells the nurse that he is a single parent and his child is enrolled in a local day care center. Based on this information, what gastrointestinal condition might the nurse suspect? - Appendicitis - Pancreatitis - Gastroenteritis - Hirschsprung disease
Gastroenteritis. Outbreaks of gastroenteritis routinely occur in day care centers, schools, institutions for the handicapped, and other places where overcrowding is prevalent and hygiene is inadequate. Typical signs and symptoms include diarrhea, nausea, vomiting, and abdominal pain.
In caring for an infant diagnosed with pyloric stenosis the nurse would anticipate which intervention? - Prepare the infant for surgery. - Medicate the infant with analgesics. - Change the infant's diet to one that is lactose-free. - Assist in doing a barium enema procedure on the infant.
Prepare the infant for surgery. In pyloric stenosis, the thickened muscle of the pylorus causes gastric outlet obstruction. The treatment is a surgical correction called a pyloromyotomy. The condition is not painful, so no analgesics would be needed until after surgical repair. The condition is not related to lactose in the diet, so changing to lactose-free formula would not correct the condition. A barium enema would be used to diagnose intussusception.
The nurse is caring for a 12-year-old child with Crohn disease. What assessment finding will the nurse report to the health care provider when caring for the child? - clear lung sounds - fever - no joint swelling - report of a headache
fever. Crohn disease may affect any area of the digestive tract. It causes acute and chronic inflammation. It may also cause abscesses and fistulas. Inflammation and abscesses can cause fever. An increasing temperature could be the manifestation of the inflammation worsening or the development of an abscess and subsequent infection. The progression of the disease will be reported to the health care provider. A headache may accompany the fever and is a sign of generally not feeling well. It does not indicate progression of the disease, thus does not need to be reported. Clear lung sounds and no swollen joints are good signs, but they are not associated with Crohn disease.
The nurse caring for an 18-month-old infant with Meckel diverticulum knows that the most common clinical manifestation of this condition is: - respiratory distress. - painless rectal bleeding. - dehydration. - ischemia.
painless rectal bleeding. With Meckel diverticulum, most symptomatic children present younger than age 2 years. Intermittent, painless rectal bleeding is the most common clinical manifestation of Meckel diverticulum. The blood is most often bright red or maroon and may be passed independent of stool due to ulceration at the junction of the ectopic tissue and the normal ileal mucosa.
The student nurse is preparing a presentation on celiac disease. What information should be included? Select all apply. - "Symptoms of celiac disease include diarrhea, steatorrhea, anemia, and dental disorders." - "Most children with celiac disease are diagnosed within the first year of life." - "The only treatment for celiac disease is a strict gluten-free diet." - "Gluten is found in most wheat products, rye, barley and possibly oats." - "The entire family will need to eat a gluten-free diet."
- "Symptoms of celiac disease include diarrhea, steatorrhea, anemia, and dental disorders." - "The only treatment for celiac disease is a strict gluten-free diet." - "Gluten is found in most wheat products, rye, barley and possibly oats." Celiac disease is an immunologic disorder in which gluten causes damage to the small intestine. The only treatment currently is consuming a gluten-free diet. While the child needs to have a gluten-free diet, the rest of the family does not. Most children present by the age of 2 for evaluation. Symptoms of celiac disease include diarrhea, constipation, steatorrhea, weight loss, poor muscle tone, anemia and dental disorders. Gluten is found in most grains, like wheat, rye, barley and possibly oats.
An adolescent has hepatitis B. What would be the most important nursing action? - Conscientious collection of stool for ova and parasites - Strict calculation of caloric and vitamin B intake - Strict enforcement of standard precautions - Close observation to detect cerebral hallucinations
Strict enforcement of standard precautions Hepatitis B is spread through IV drug use, sex, contaminated blood and perinatally. The treatment is rest, hydration, and nutrition. Hospitalization is required if there is vomiting, dehydration, elevated bleeding times and mental status changes. The adolescent should be taught about good hygiene, safe sex practices, careful handwashing and blood/bodily fluid contact precautions. Using standard precautions of gloves and good handwashing will help prevent spread of the disease. Ova and parasites are not present with hepatitis B. A good diet with adequate protein and vitamins will help the body heal, so these should not be restricted. The nurse observes for mental status changes. These can occur as a complication, but preventing spread of the disease is the nursing priority.
An adolescent is diagnosed with hepatitis A. Which problem should be considered when planning care? - The adolescent will become fatigued easily. - The adolescent will be very irritable and perhaps require sedation. - Hypothermia is common. - The adolescent's urine will be dark and infectious.
The adolescent will become fatigued easily. Hepatitis A is transmitted via the oral-fecal route; it is water borne and often occurs in areas of poor sanitation. The adolescent with hepatitis A will exhibit flu-like symptoms, a headache, anorexia and fatigue. The urine is not infectious and fever may be present as opposed to hypothermia. Irritability is not one of the symptoms of hepatitis A. The client is usually lethargic or listless.
A 4-month-old has had a fever, vomiting, and loose watery stools every few hours for 2 days. The mother calls the physician's office and asks the nurse what she should do. Which response by the nurse is most appropriate? - "Do not give the child anything to drink for 4 hours. If the fever goes down and the loose stools stop, you can resume breastfeeding." - "Continue breastfeeding as you have been doing. The fluid from the breast milk is important to maintain fluid balance." - "Give a clear pediatric electrolyte replacement for the next few hours, then call back to report on how your child is doing." - "Bring the child to the office today so we can evaluate her fluid balance and determine the best treatment."
"Bring the child to the office today so we can evaluate her fluid balance and determine the best treatment." Infants are comprised of a high percentage of fluid that can be lost very quickly when vomiting, fever, and diarrhea are all present. This infant needs to be seen by the physician based on her age and symptoms; hospitalization may be necessary for intravenous rehydration depending upon her status when assessed.
The nurse is administering an enteral feeding to a child with a gastrostomy tube (G-tube). Which action will the nurse take when administering a prescribed feeding through the client's G-tube? - Check for gastric residual before starting feeding. - Position the client with the head of the bed at a 20° angle. - Use a syringe plunger to administer the feeding. - After feeding, flush the tube with a small amount of saline and leave the G-tube open for 2 minutes.
Check for gastric residual before starting feeding. The nurse should check for gastric residual before starting feeding by gently aspirating from the tube with a syringe or positioning the tube below the level of the stomach with only the barrel of the syringe attached. The client should be positioned with his or her head elevated 30° to 45° and the formula should be allowed to flow with gravity, not plunged unless the tube is clogged. After feeding, the nurse should flush the tube with a small amount of water, unless contraindicated, and leave the G-tube open for 5 to 10 minutes after feeding to allow for escape of air.
