Caring for children with gastrointestinal dysfunction —Chap 17

1. Caring for children with gastrointestinal dysfunction —Chap 17 兒童消化系統的生理特徵 評估 小兒常見腸胃道疾病 Gastroenteritis（Acute diarrhea） Intestinal obstruction--Intussusception Congenital defects Cleft lip and palate Anorectal malformation Esophageal atresia & Tracheoesophageal fistula Hirschsprung’s Disease（Megacolon）

2. Anatomy and physiology of pediatric differences • GI system is immature at birth.P586第1段第2行 • Absorption and excretion do not begin until after birth • Sucking reflex • Not have voluntary control over swallowing • Stomach • Stomach capacity：small • Frequently regurgitate • Intestinal • Peristalsis is greater than older children • Deficiency of several enzyme：amylase, lipase, trypsin

3. Anatomy and physiology of pediatric differences • Liver function is also immature • Second year of life • Digestive processes are fairly complete • Stomach capacity increase • Excretory function can be achieved

4. 評估（補） 身體檢查 身體外觀 口腔感染 腹部評估 • 健康史 進食狀況 營養狀況 家庭狀況 主要照顧者的衛生習慣 排便情形 • 診斷性檢查 • 血液檢查 • 糞便檢查 • 特殊技術

5. Caring for children with gastrointestinal dysfunction • Etiology and pathophysiology • Clinical manifestations • Diagnostic tests • Medical management • Nursing assessment & management

6. Gastroenteritis（Acute diarrhea）P617 • Is an inflammation of the stomach and intestines 第1段 • Vomiting and diarrhea • Infants and small children with gastroenteritis or diarrhea can quickly become dehydrated and are at risk for hypovolemic shock

7. Etiology and pathophysiology （P617第2行） • Decrease in the absorptive capacity、decrease in surface area for absorption、alteration of parasympathetic innervation • High risk－day-care centers、improper sanitation （第5～6行） • Causes（Table 17-2）

8. Mild －Slightly increased in number and more liquid Moderate －Several loose or watery stools －Irritability、anorexia、nausea、vomiting －Self-limiting Severe －Continuous watery stools －Fluid and electrolyte imbalance －Cramp、extremely irritable、difficult to console Clinical manifestationsP617

9. Diagnosisclinical therapy之第1段 • History • Physical examination • Laboratory finding－S/R、S/C • Presence of ova, parasite, infectious organisms, viruses, fat, and undigested sugars.

10. Treatment P618第2段 Depends on the severity of the diarrhea and fluid and electrolyte imbalances. Goal：correct the fluid and electrolyte • Mild to moderate • －oral rehydration therapy ( Contain water, carbohydrate, sodium, potassium, chloride and lactate P315) • －Carbonated beverages and those containing high amounts of sugar should not be given • Severe • －IV（N/S with glucose【one half or one quarter normal • saline】 or L/R）第3段 • －NPO • －Antiemetics and antidiarrheals should generally not be used in • infants and young children. P618左下 • Lactose-free milk, breast milk, half-strength milk P315倒數第4行

11. Nursing assessmentP618 • Frequency, color, amount and consistency of stools第4行 • The amount and type of vomitus • Observing dehydration • Urine output and specific gravity • Weight • Vital signs ( Febrile ) • Skin integrity

12. Nursing diagnosis & management P619 • Anxiety • Provide Emotional support • Sleep pattern disturbance • 活動無耐力 • Promote rest and comfort • Altered nutrition • Ensure adequate nutrition • CRAM (Complex carbohydrates, Rice and Milk ) P619綠框 • Diarrhea related to infectious process P620 • Fluid volume deficit P620 • Risk for impaired skin integrityP621

13. DehydrationChap 10 --P313 • There is not enough fluid in the extracellular compartment. • The state of body water deficit is called dehydration. • Sodium is generally lost along with water → hyponatremia

14. Etiology and pathophysiology Causes P313 第1段第2行 • Loss of fluid containing sodium are vomiting、diarrhea、nasogastric suction、hemorrhage and burns • Radiant warmers 第2段第2行 • Adrenal insufficiency and overuse of diuretics • Bulimic adolescents

15. Blood urea nitrogen＞25mg/dLclinical therapy第1段第3行 • Serum bicarbonate＞17mEq/L

16. Medical managementP315 同腸胃炎之治療 • Oral rehydration therapy－mild and moderate dehydration • Contain water, carbohydrate, sodium, potassium, chloride and lactate • Lactose-free milk, breast milk, half-strength milk倒數第4行 • IV－severelyP316第1段 • L/R, one half or one quarter normal saline

17. Nursing assessment • Weight • I/O • Urine specific gravity • Consciousness • Pulse rate and quality • Skin turgor and mucous membrane moisture • Respiration • Blood pressure

18. Nursing management • Provide oral rehydration therapy guidelines • Teach parents oral rehydration methods • Monitor intravenous fluid administration • Discharge planning and home care teaching

19. Intussusception P602 • Etiology and pathophysiology 第1段 • One portion of the intestine prolapses and then invaginates(陷入) or telescopes (使嵌入) into another.第1行 • One of the most frequent causes of intestinal obstruction during infant • Between the age of 3 months and 6 years • Site：ileocecal valve 第2段 • Telescoping of the Intestine obstructs the passage of stool. • The walls of intestine rub together •  inflammation、edema、decreased blood flow •  necrosis、perforation、hemorrhage、 peritonitis • In infant, intussusception is commonly associated with measles, viral disease, and gastroenteritis syndromes. P603 Fig17-7

20. Clinical manifestations P603第2段 Onset is abrupt • Acute abdominal pain（periods of comfort between acute episodes of pain） • Vomiting • Passage of brown stool→become red and resemble currant jelly • A palpable mass may be present in the upper right quadrant or mid-upper abdomen • 腹部呈柔軟、膨脹 • 疲倦、虛脫 • 發燒及腹膜炎之其他徵象 • 右下腹區排空（Dance徵象）

21. Diagnosis P603第2段 • History • Radiographs and ultrasound of the abdomen • Barium enema

22. Treatment P603第3段 • Hydrostatic pressure—Barium enema • Oxygen（air）、saline、aqueous contrast material • Surgery • Supportive care • 液體補充 • 鼻胃管減壓 • 抗生素

23. Nursing management • Maintain fluid and electrolyte balance Post OP • Monitoring for early signs of infection • Pain management • Maintain NG tube patency • Assess vital signs、Abdominal distention、Listen for bowel sounds every 4 hours • After normal bowel function • Clear liquid feeding half- strength milk and other foods

24. Cleft lip and palateP586 • More common in Native Americans and Asian P586最後1行 • Etiology and pathophysiology P594 • A failure of the maxillary processes of fuse with the elevations on the frontal prominence during the sixth weeks of gestation. • Hard and soft palates is completed in the first trimester. • Congenital defects：tracheoesophageal fistula，omphalocele，trisomy 13，skeletal dysplasias • Cause：multifactorial（environmental and genetic influences）

25. Clinical manifestation P587 • Cleft lip • Unilateral or bilateral • Alone or in combination with a cleft palate defect • Nasal deformity • Cleft palate • Less obvious • A continuous opening between the mouth and nasal cavity • Soft palate or both the soft and hard palate • Unilateral or bilateral

26. Clinical manifestation---補 • 餵食困難 • 呼吸道感染 • 口腔感染 • 聽力受損 • 語言發展延遲

27. Diagnostic tests and medical managementP588 • Physiologic assessment 第1段 • Medical management：multidisciplinary team（plastic surgery、hearing、speech、dentistry） • Clef lip • 2-3months of age 第2段 • Logan bow or other stabilizing device or dressing is put in place. • Crying is minimized by use of medication. • Clef palate • Depends on the size and severity of the cleft. • 18 months • Longer nipples with enlarged holes（before surgical） • Antibiotic therapy：recurrent otitis media • Orthodontic care • 語言治療

28. Nursing assessment • Physiologic assessment • Observable • Palpation • Psychosocial assessment—low self-esteem • Family’s reaction • Low self-esteem • Developmental level and social interactions

29. Nursing management Preoperative care P590 1.Risk for aspiration 2.Provide emotional support • Explaining the cause • Interact and speak to the infant • Point out positive attributes • Self-blame • Anxiety 3.Altered nutrition 1.Risk for infection 2.Ineffective breathing pattern related to anesthesia and increased secretions 3.Impaired tissue integrity 4.Knowledge deficit 5. Altered nutrition Postoperative careP592

30. Care in the community Nursing management • Feeding techniques • Recognize signs of infection and complications (fever, vomiting, respiratory distress) • How to position the infant • How to care the suture line • Preparation of the sibling • Support groups • Prevent the infant from touching the suture line

31. Anorectal malformation ( Imperforate anus )P604 • Etiology and pathophysiology • Malformations of the anus and rectum. • Often associated with anomalies：urinary tract, esophagus, and duodenum. • VACTER Syndrome

32. Clinical manifestations Diagnosis • Failure to pass meconium • Stool in the urine • Ribbonlike stools • 腹脹、嘔吐 • Assessment anorectal structure and rectal patency • Ultrasound • Lower GI • PA CXR • 倒立3分鐘→x-ray • 尿液分析

33. Medical management • Dilation • 低位－Excised surgery，then daily manual dilation • 高位－Reconstructive surgery （Posterior Sagittal Anorectoplasy；PSARP ）及temporary colostomy→→關閉結腸造廔。

34. Nursing management Assessment • Developed anal dimple or sacral anomalies • Rectal thermometer • Observation and recording of passage of meconium

35. Managemen Preoperation Postoperation • IV fluids • NG decompression • Monitor I/O • Monitor cardiorespiratory function • 廔管護理 • Emotion support • Preventing infection • Respiratory complication • Maintaining hydration • Assess vital signs • If stable→try feeding • Colostomy care • 禁量肛溫或使用塞劑

36. Discharge planning and home care teaching • How to take the infant’s temperature • Signs and symptoms of infection • Feeding • Toilet training • Assess vital signs • If a colonstomy • How to care • Reassure the colostomy will be closed • Follow-up • Home care visits

37. Esophageal atresia & Tracheoesophageal fistulaP595 • Etiology and pathophysiology • Failure of the esophagus to develop as a continuous tube during the fourth and fifth weeks of gestation. 第1段 • The foregut fails to lengthen, separate, and fuse into two parallel tubes during fetal development. 第2段 • End in a blind pouch or develop as a pouch connect to the trachea by a fistula.

38. Maternal history：polyhydramnios、prematurity、low birth weight • Associated anomalies 第2段第5行 • Congenital heart defects • Gastrointestinal or urinary tract anomalies • Musculoskeletal abnormalities • VACTERL：vertebral、anus、cardia、trachea、esophageal、renal、limb

39. Clinical manifestation 第3段 • Excessive salivation and drooling • 3C（coughing, choking, cyanosis）and sneezing • Returns fluid through the nose and mouth→pneumonia • Abdomen become distended • Vomiting soon after feeding

40. Diagnosis第4段 • Nasogastric tube meets resistance and can be advanced only minimally. • X-ray（air pouch、NG coiling、pneumonia、distended stomach intestine－遠端有fistula） • Echocardiogram（2D echo）and abdominal ultrasound（Renal echo） P596

41. Treatment P596第2段 • OG suction • Antibiotics • Fluids • Surgery：several stages • Ligation of the fistula and insertion of a gastrostomy tube • Reconnect the two ends of the esophagus（anastomosis） • Potential postoperative complications • Gastroesophageal reflux、aspiration、stricture formation、esophageal motor dysfunction

42. Nursing management Preoperation • Maintain a patent airway • Suction－（continuous or low intermittent） • Place the head of the bed slightly lowered • Continuous or low intermittent suction is used to remove secretions from the blind pouch. • Change position • NPO • Maintain with intravenous fluids administered through an umbilical vein catheter.

43. Postoperation • Gastrostomy drainage • IV fluids and antibiotics • TPN • Maintain a patent airway • Emotional support for parent • Discharge planning • Gastrostomy tube care and feeding、signs of infection、prevent postoperative complications. P598 families want to known

44. Megacolon（Hirschsprung Disease）P603 Etiology and pathophysiology • Congenital aganglionic megacolon；inadequate motility causes mechanical obstruction • Absence of autonomic parasympathetic ganglion cells in the colon→ accumulation of intestinal contents and abdominal distention • Combination with congential heart defects、Down syndrome、Imperforate anus • More common in boys • It can be acute or chronic

45. Clinical manifestations P604第2段 Newborn Older child • Failure to pass meconium • Refusal to suck • Abdominal distention • Bile-stained emesis  complete obstruction, respiratory distress, and shock • Failure to gain weight and delayed growth 第3段 • Abdominal distention • Constipation alternating with diarrhea • Vomiting • Stool may be normal or ribbonlike

46. Diagnosis • History • Bowel pattern • Anorectal manometry • Radiographic contrast studies • Rectal biopsy • Palpation

47. Treatment • Newborn：surgery • Several cases or ill infants：temporary colostomy → closure of the colostomy and reanastomosis（Soave procedure） • Child with milder defect：dietary modification、stool softeners、isotonic irrigations

48. ComplicationP604第7段 • Fecal incontinence and constipation • Enterocolitis • GI bleeding and diarrhea→ischemia and ulceration • TPN • Lactose-free diet

49. Nursing managementAssessment 第1段 • Observation for the passage of meconium • History of weight gain • Nutritional intake • Bowel habit

50. Management • Monitoring fluid and electrolyte balance • Maintain nutrition • Teach parents how to ensure regular bowel movements • Daily rectal irrigations • Prevent skin breakdown • Surgery • Monitoring for infection • Managing pain • Maintain hydration • Measuring abdominal circumference • Emotion support • Teach parent about－Ostomy care、signs of complications、Be alter for signs of poor growth or malnutrition