Nursing Care of the Child with a Gastrointestinal Disorder

1. Nursing Care of the Child with a Gastrointestinal Disorder

2. Normal Gastrointestinal System

3. Disorders of Development

4. Cleft Lip and Cleft Palate • Etiology- Failure of maxillary and median nasal processes to fuse during embryonic development Remember the psycho-social implications for these children and families

5. Assessment • Unilateral, bilateral, midline

6. Treatment • Surgical repair between 3 and 6 months • Multidisciplinary team - involving many specialists including plastic surgeons, nurses, ear, nose, and throat specialists, orthodontists, audiologists, and speech therapists. • Reconstruction begins in infancy and can continue through adulthood. • Homecare by the family prior to surgery

7. Pre-op Nursing Care • Remind parents that defect is operable- show photographs of corrected clefts Before After

8. Pre-op Nursing Care Two Main Goals: 1. Prevention of Aspiration 2. Maintain Nutrition

9. Pre-op Nursing Care May breast feed if has small cleft lip Feed slowly in upright position and bubble frequently Keep bulb syringe and suction equipment at bedside Position on side after feeding All these measures focus on ways to decrease ASPIRATION.

10. Pre-Op Nursing Care • What are problems that the nurse needs to be alert for during feedings? • Lack of proper seal around nipple to create necessary suction • Excessive air intake • Use of special feeding techniques • Feeder with compressible sides • Syringes with tubing

11. Post-Op • Prevent trauma to suture line • Logan’s bow to protect site • Do not allow to suck • Maintain upper arm restraints • Position supine • No hard objects in mouth • Reduce Pain • Prevent Infection • Cleanse suture lines as ordered – rinse with water after each feeding. • Call Doctor for any swelling or redness • Referral to appropriate team members

12. Esophageal Atresia

13. Malformation from failure of esophagus to develop as a continuous tube Upper Esophagus Trachea Lower Esophagus An atresia is the absence or closure of a normal body tubular passage, such as the esophagus that ends in a blind pouch. A tracheo-esophageal fistula is when the esophagus connects with the trachea.

14. Signs and Symptoms Excessive amounts of salivation / mucus, frothy bubbles Three “C’s”: Coughing, choking, and cyanosis when fed Food may be expelled through the nose immediately following the feeding Rattling respirations and frequent respiratory problems such as aspiration pneumonia Gastric distention, if fistula History of polyhydramnios during pregnancy can suggest a high gastrointestinal obstruction

15. Diagnosis and Management • Early diagnosis • Ultrasound • Radiopaque catheter inserted in the esophagus to illuminate defect on X-ray • Surgical repair • Thoracotomy and anastomosis

16. Pre-Op

17. Post-Op • Maintain airway • Maintain nutrition • Gastrostomy tube feedings • Prevent trauma • Monitor for potential complications • Constipation or diarrhea • Blockage of esophagus • Infection • Monitor weight, growth and developmental achievements

18. Imperforate Anus Incomplete development or absence of anus in its normal position in perineum.

19. Assessment • Most commonly diagnosed upon Newborn Assessment • Symptoms • Absence of anorectal canal • Failure to pass meconium • Presence of anal membrane

20. Treatment Anal stenosis is treated with repeated anal dilation Surgery

21. Abdominal Wall Defects Omphalocele Gastroschisis

22. Omphalocele Herniation of abdominal contents through the umbilical cord. Contents are covered by a translucent sac.

23. Gastroschisis herniation of abdominal viscera outside the abdominal cavity through a defect in the abdominal wall to the side of the umbilicus. Not covered.

24. Diagnosis Provide an early diagnosis Alpha-fetaoprotein Ultrasound

25. Treatment and Nursing Care • Pre-operatively – provide protection of the contents/sac. • Cover with warm, sterile, saline-soaked dressings • Maintain temperature – esp. with gastroschisis • May choose to replace the gut to the abdomen gradually over several weeks. May place silo or silastic material over gut until it returns to the abdomen. • Surgery used to close defect.  

26. Oomphalocele/Gastroschisis Repair Under general anesthesia, an incision is made to remove the sac membrane. The bowel is examined for signs of damage or additional birth defects. Damaged or defective portions are removed and the healthy edges stitched together. Viscera may be place in Silastic pouch and slowly returned to abdomen using gravity. A gastrostomy tube is inserted into the stomach and out through the skin for feeding.

27. Complications

28. Post-op Care • Assess for ileus • Maintain parenteral feedings • Provide support to the parents.

29. Gastroesophageal Reflux Disease(GERD) The cardiac sphincter and lower portion of the esophagus are weak, allowing regurgitation of gastric contents back into the esophagus.

30. Assessment: Infant • Regurgitation almost immediately after each feeding when the infant is laid down • Excessive crying, irritability • Failure to Thrive • Life Threatening Risk / Complications: • aspiration pneumonia • apnea

31. Assessment: Child • Heartburn • Abdominal pain • Cough, recurrent pneumonia • Dysphagia

32. Signs and Symptoms

33. Diagnosis • Assess Ph of secretions in esophagus if <7.0 indicates presence of acid • Also diagnosed using Barium Swallow and visualization of esophageal abnormalities

34. Management & Nursing Care • Small frequent feedings of predigested formula or thicken the formula • Frequent burping • Positioning --prone position- flat prone or head elevated prone. Use reflux board to keep head elevated. • Avoid excessive handling after feedings. Reflux board

35. Medications • H2 Histamine receptor antagonists – reduce gastric acidity • Zantac and Pepcid • Proton-pump inhibitors • Prevacid • Prilosec • Gastric emptying • Reglan • Antacids • Gaviscon **be sure to study nursing implications and side effects

36. Major Complication is Acute Gastric Bleeding

37. Operative Procedure • Neissan Fundiplocation • The stomach fundus is wrapped around the distal end of the esophagus.

38. Diarrhea Infectious Gastroenteritis

39. Diarrhea/GastroenteritisSevere • A disturbance of the intestinal tract that alters motility and absorption and accelerates the excretion of intestinal contents. • Most infectious diarrheas in this country are caused by: • Giardia – most commonly seen in daycare centers • Rotovirus – seen in infants in young children

40. Clinical Manifestations • Increase in peristalsis • Large volume stools • Increase in frequency of stools • Nausea, vomiting, cramps • Increased heart & resp. rate, decreased tearing and fever • Complications: • Dehydration • Metabolic acidosis

41. Diagnosis

42. Complications Dehydration Metabolic Acidosis

43. The newborn and infant have a high percentage of body weight comprised of water, especially extracellular fluid, which is lost from the body easily. Note the small stomach size which limits ability to rehydrate quickly.

44. Treatment & Nursing Care • Treat cause • Fluid and electrolyte balance • Weigh daily • Monitor I&O • Assess for dehydration • Isolate • Skin care

45. Oral Rehydration Avoid fluids that are high in sugar – soft drinks, jello, fruit drinks, tea

46. Appendicitis Inflammation of the lumen of the appendix which becomes quickly obstructed causing edema, necrosis and pain.

47. Clinical Manifestations Abdominal cramps and pain Fever Guarding Abdominal rigidity Rebound Tenderness Vomiting Elevated WBC - >15,000

48. Management and Nursing Care: Pre-Op • NPO • IV • Comfort measures – semi-fowlers or R side lying • Antibiotics • Thermal therapy – ice, not heating pads • Elimination • Patient education • **Narcotic pain medications are used minimally so as not mask the signs of appendicitis.

49. Appendicitis What is the most common symptom indicating that the appendix may have ruptured?

50. Management and Nursing Care: Post-Op • NPO • Antibiotics • Analgesia • Patient teaching