Home

Monday, 29 August 2011

GASTROINTESTINAL SYSTEM PEDIATRICS


Physiology of DIGESTIVE SYSTEM
         Mechanical functions of digestion immature at birth
                          No voluntary control over swallowing until 6 weeks
                  Stomach capacity decreased
                  Relaxed sphincter contributes to tendency to regurgitate
       Liver functions immature throughout infancy
       Gastric acidity low in infants à rises until age 10
       Digestive processes are mature by toddlerhood

Assessment:
       Presenting problem
            a.  Vomiting
            b.  Abnormal bowel habits:  diarrhea, constipation, bleeding
            c.  Weight loss, failure to thrive
            d.  Pain

       Nutritional history

Physical Examination:
         General appearance:
            a.  Height and weight
            b.  Measure mid arm circumference
            c.  Observe color: jaundice
         Mouth: dentition
         Abdomen
            a.  Skin integrity
            b.  Abdominal distension; visible peristaltic waves
            c.  Inspect for hernias
            d.  Auscultate bowel sounds ( every 10-30 seconds)
            e.  Palpate for tenderness
            f.  Liver span (inferior edge palpated 1-2 cm below RCM)
            g.  Spleen (felt on inspiration 1-2 cm below left costal margin)

DISORDERS OF THE TEETH

DENTAL CARIES
         erosion of the enamel and dentine of teeth
         results from combination of fermenting sugars and starched
            and acid forming organisms

Prevention:
         dental hygiene
         regular dental hygiene
         good nutrition
         fluoridation

CLEFT LIP AND CLEFT PALATE

       1 in 1000 births
       multifactorial
       common among children with chromosomal abnormalities
       results from failure of the embryonic structures of the face to unite
       may occur separately or may combine to produce a single unilateral
            or bilateral cleft from the lip through the soft palate
       interfere with the child’s capacity to meet oxygenation and
            nutritional needs
       may seriously hamper normal bonding process of children with parents

Assessment:
       facial abnormality visible at birth- cleft lip or palate or both, unilateral or bilateral
       difficulty sucking
       inability to form airtight seal around nipple
       formula/milk escapes through nose in infants with cleft palate
       predispose to infection – communication between mouth and nose
       difficulty swallowing
       abdominal distension – air swallowing

Management:
         team approach
         otolaryngologist, audiologist, pediatrician, dentist, orthodontist, speech therapist
         Surgical correction:
       early correction – prevent speech defects

  Cheiloplasty
         correction of cleft lip
         unite edges to allow lips to be both functional; aesthetic reasons
         performed usually at age 2 months

Cleft palate repair
         not done until age 18 months – anticipation for speech development
         child should be weaned and able to take liquids from a cup before
            palate repair

NURSING INTERVENTION:

Cleft Lip (PreOP)
         feed in upright position
         burp frequently
         press cleft lip together with fingers – to encourage sucking and to strengthen muscles
       if unable to suck, use a rubber tipped syringe; drip onto side
            of mouth
         finish feeding with water to wash away formula in palate area
         provide small, frequent feedings
         provide emotional support for parents

Post OP: Cleft Lip repair
         maintain patent airway
         monitor amount of swallowing to detect hemorrhage
         do not place in prone position or with pressure on cheeks
         avoid any tension on suture line
         avoiding straining on suture line
         prevent crying
         keep child comfortable and contented
         use elbow restraint
         keep suture line clean – clean after each feeding with saline, peroxide or water to remove crusts
         pain relief

Nursing Intervention:  Preop cleft palate repair
         prepare parents to care fro child after surgery
         instruct concerning feeding methods and positioning

Post Op cleft palate repair
         position on side for drainage of blood
         have suction available
         prevent injury or trauma on suture line
  1. Use cups only for liquids; no bottles
  2.  avoid straws, utensils, popsicle sticks, chewing gum
  3.  provide soft toys
  4. Use elbow and wrist restraints
  5. Provide liquid diet initially à soft à normal diet
  6. Give water after each feeding to clean suture line
  7. Hold and cuddle 

ESOPHAGEAL ATRESIA and TRAACHEOESOPHAGEAL FISTULA

Esophageal atresia
         congenital defect; upper segment of the esophagus ends in a blind
            pouch

TEF
         defect in which embryonic structures fail to divide into a separate esophagus and trachea
         opening between the two structures
         usually occur together

Assessment:
       copious oral and nasal secretions –first sign of a defect
       choke or cough
       when suctioning or gavage is attempted – catheter cannot pass into stomach

Medical and Surgical intervention
         prevention of aspiration
         drainage tube may be placed in the blind pouch – to suction secretions
         esophageal atresia – medical emergency
            - end to end anastomoses
         feeding tube maybe inserted into the stomach through gastrostomy until repair heals

Nursing intervention:
         provide nutrition
  1. Provide gastrostomy tube feeding until anastomosis site has healed
  2.  start oral feedings when infant can swallow well
        promote respiratory function
            1.  position properly
                                               
PYLORIC STENOSIS
       narrowing of the outlet of the stomach
       caused by excessive growth of circular muscles that surrounds the pylorus
       hypertrophy develops over 4-6 weeks of life when symptoms begin to appear
       more common in Caucasian; first born, full term boys

Assessment:
         olive size bulge under right rib cage
         vomiting – projectile; non bilous
         peristaltic waves during and after feeding
         failure to thrive
         dehydration
         diagnostic tests:
            a.  UGIS – narrowing of diameter of pylorus
            b.  Decreased serum Na, K, Cl
            c.  Increased Hct
            d.  Metabolic alkalosis
Nursing intervention:  Preop
         replace fluids and electrolytes
         prevent vomiting
  1. Give thickened feedings
  2. High Fowler’s
  3. Place on right side after feeding
  4. Minimize handling
  5. Strict I and O, daily weights, urine sp gravity

Nursing Intervention: post Op
       Advance diet as tolerated
       Place on right side after feeding
       Observe incision for signs of infection
       Provide client teaching and discharge planning

INTUSSUSCEPTION
         telescoping of bowel into itself
         ileocecal region
         edema, necrosis of bowel,  obstruction
         most common at age 6 months
         more in boys than in girls
         associated with cystic fibrosis

Assessment:
         piercing cry
         severe abdominal pain (pulls leg up)
         vomiting of bile stained fluid
         bloody mucus in stool
         “currant jelly” stool

Management:
                        1.  barium enema
                        2.  surgery

Nursing Intervention:
                        1.  provide routine pre and post op care
                        2.  monitor for peritonitis

HIRSCHSPRUNG’S DISEASE
       absence of autonomic parasympathetic ganglion cells  in large intestines
       results in decreased motility in that portion of the colon and signs of functional obstruction

Assessment:
         failure or delay in passing meconium
         abdominal distension
         failure to pass stool
         temporary relief following rectal exam
         loose stools – only liquid can pass thru
         ribbon like stools
         nausea, anorexia, fecal vomiting
         weight loss, failure to grow
         volvulus – bowel twists upon itself
         diagnostic tests:   rectal biopsy – confirms presence of aganglionic cells
        
Nursing intervention:
         enema as ordered
A.  Mineral oil or isotonic saline
  1. Do not use water or soap suds – water intoxication
  2. Use volume appropriate to weight of child
            infants – 150-200ml
            children – 250-500 ml
         administer TPN as ordered
       Provide low residue diet
        provide client teaching and discharge teaching
       Colostomy care
       Low residue diet

IMPERFORATE ANUS
       during embryonic life – membrane that separates the rectum and anus is absorbed
       absorption fails to occur -> imperforate anus
       anus appear as a dimple
       fistula may be present – rectovaginal, rectourethral

Assessment:
         inspection of anus, check rectum for patency
         insert rectal thermometer
         absence of stool during 1st 24 hours
         development of a distended abdomen

Intervention:
         surgery
            anoplasty – if possible
            temporary colostomy
         if with distension – nasogastric suction

Nursing intervention:
         keep operative site clean
         observe infant for signs of hypovolemic shock and infection
         if anoplasty heals – regular dilatation of anus to prevent stricture
         colostomy care
            a.  Kept clean
            b. zinc oxide
         after surgery – side lying or prone with hips elevated

CELIAC DISEASE
         malabsorption syndrome characterized by intolerance of gluten,
            found in rye, oats, wheat and barley
         familial disease
         more common in Caucasians
         cause unknown
         flat mucosal surface and atrophy of villi of the intestine
         reduced absorptive surface -> marked malabsorption of fats

Assessment:
         steatorrhea
         chronic diarrhea
         failure to thrive
         distended abdomen
         abdominal pain, irritability, listlessness, vomiting
         symptoms of ADEK deficiency
         diagnostic tests:
       1.  pancreatic enzymes
       2.  jejunal or duodenal biopsies
Management:
         diet therapy
         gluten free diet
         TPN in children

Nursing Intervention:
         gluten free diet (BROW – Barley, Rye, Oatmeal, Wheat)
         supplemental fat soluble vitamins
         client teaching
       1.  gluten free diet
       2.  importance of reading the label
       3.  avoidance of infection
       4.  adhering to diet even if symptoms are controlled
       5.  importance of long term follow up

APPENDICITIS
         inflammation of the appendix
         ischemia, gangrene, rupture, peritonitis – if untreated
         school age children – most common
         due to mechanical obstruction or anatomic defects

Assessment:
         diffuse pain à  RLQ
         nausea, vomiting
         guarding of abdomen
         rebound tenderness
         decreased bowel sounds
         fever
         diagnostic tests:
            1.  CBC
            2.  elevated acetone in urine

Nursing Intervention:
         antibiotics/ antipyretics as ordered
         no enemas
         no heating pads
         routine preop care
         post op care:
  1. semi-Fowler’s position
  2. Monitor NGT
  3. Monitor penrose drains

PARASITISM
         roundworms, pinworms

Assessment:
         pinworms – anal itching, disturbed sleep
         roundworms – colic , abdominal pain, lack of appetite, weight loss

Nursing intervention:
         obtain stool culture
         observe all excreta for worms
         Scoth tape swab
         instruct parents  to change clothing, bed linens, towels and launder in hot water
         instruct all family members to scrub hands and fingernails prior to eating and after using toilet

DIABETES MELLITUS
         most common endocrine disease of children
         onset maybe any age
         type 1 IDDM
         risk of complication is high – retinopathy, neuropathy, nephropathy,
            skin changes, predisposition to infection

Assessment:
         rapid onset
         polyuria, polydipsia, polyphagia, fatigue
         weight loss
         ketoacidosis
      -Dry flushed skin

Management:
         insulin
         diet therapy
         exercise
         prevention of complications

Nursing intervention:
         administer insulin as ordered
         force fluids without sugar
         monitor blood glucose levels daily
         observe for hypoglycemia: behavior changes, sweating
         provide client teaching
            a.  Daily regimen for home care
            b.  Urine and blood glucose monitoring
            c.  Nutrition management
            d.  Effects of infection and exercise on CHO metabolism
            e.  Prevention of acute and chronic complications

No comments:

Post a Comment