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
- Use cups only for liquids; no bottles
- avoid straws, utensils, popsicle sticks, chewing gum
- provide soft toys
- Use elbow and wrist restraints
- Provide liquid diet initially à soft à normal diet
- Give water after each feeding to clean suture line
- 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
- Provide gastrostomy tube feeding until anastomosis site has healed
- 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
- Give thickened feedings
- High Fowler’s
- Place on right side after feeding
- Minimize handling
- 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
- Do not use water or soap suds – water intoxication
- 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:
- semi-Fowler’s position
- Monitor NGT
- 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
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