GI System

Babies are born with immature GI tracts that do not fully mature until

age 2. Newborns have a very small stomach capacity. Hydrochloric acid reaches adult levels at 6 months of age. Amylase is limited until 4-6 months of life. (intro of food) Liver is large at birth.

Babies Mouth-

Highly vascular. Infants and toddlers explore the world through their mouth.

The lower esophageal sphincter (LES) prevents

regurgitation of stomach contents up the esophagus. The muscle tone of the LES is immature.

Dehydration & Fluid Loss Physiological Risk Factors

Higher Body Surface Area, Basal Metabolic Rate (BMR), Developing Kidneys, Different Cooling Mechanisms

Higher Body Surface Area

Children have a larger body surface area to body mass ratio. This means they lose more fluid through evaporation and skin exposure.

Basal Metabolic Rate (BMR)

Children have a higher rate, which causes them to process and lose fluids at a quicker rate.

Developing Kidneys

A child's are less mature and cannot conserve or concentrate water as effectively as adults.

Different Cooling Mechanisms

Children generate more heat per body size yet often sweat less efficiently than adults, making them more prone to heat-related fluid loss.

An increased BMR means increased insensible fluid losses. What are these and what vital signs would alert the nurse to the child being at increased risk?

Behavioral and Illness Factors FEVER

fluid loss increases 7ml/kg every 24-hour period for every sustained 1 degree Celcius rise in temperature.

Behavioral and Illness Factors Poor Communication

Young children often do not recognize thirst or cannot communicate when they need fluids.

Behavioral and Illness Factors Illness Vulnerability

Children are highly susceptible to vomiting and diarrhea, which are leading causes of rapid fluid loss.

Behavioral and Illness Factors Dependency

Infants and young children rely entirely on caregivers to provide them with food and liquids.

The most common result of a GI illness is

dehydration. Family education related to the treatment of GI disorders and rehydration is often the key to preventing illnesses from progressing to an emergency.

S/S of dehydration

Weight loss, Decreased Skin turgor, Fontanels- sunken, Capillary refill changes, Sunken eyes- Infants, Irritability, Decreased tears, Increased HR, Decreased BP, Decreased urine output

If weight changes in infants and children most accurately reflect their fluid status, what must the nurse include in the plan of care?

Levels of Dehydration

Nurses can determine the severity of dehydration by monitoring for weight loss.

Mild Dehydration

3% - 5% weight loss , Possible slight thirst, Behavior, mucous membranes, anterior fontanel within expected findings. Pulse & BP within expected findings

Moderate Dehydration

6% - 9% weight loss, cap refill 2 – 4 sec, Possible thirst & irritability, Dry mucous membranes, low Tears & skin turgor, Normal to sunken anterior fontanel on infants

Severe Dehydration

10% + weight loss , > 4 sec, Extreme thirst, Irritability progresses to lethargy, Very dry mucous membranes, Tented skin, No tears, Sunken eyes, Sunken anterior fontanel, Oliguria or anuria

Moderate Dehydration VS

Pulse-slight increase, BP – normal to orthostatic, Resp – slight tachypnea

Severe Dehydration VS

Tachycardic, Orthostatic BP progressing to SHOCK!, Hyperpnea

Dehydration will ultimately result in hypernatremia What would alert the nurse to this complication?

neuro changes - high pitched cry, irritability, lethargy

Oral rehydration is

always attempted first for mild and moderate cases of dehydration.

Mild dehydration treatment

50ml/Kg rehydration fluid within 4 hours, Consider giving ½ oz of Pedialyte Q10-15min, Consider NGT placement

Moderate dehydration treatment

100ml/kg rehydration fluid within 4 hours

IV/Parenteral rehydration fluid

initiated when a child is unable to drink enough oral fluids to correct fluid losses, severe dehydration &/OR continued vomiting. Bolus IV (20ml/kg) , Isotonic fluids, Given in addition to maintenance fluids

Isotonic IVF

Don’t forget to calculate fluid losses from diarrhea >>> Diarrhea losses are

10ml/kg each stool.

Once the nurse initiates rehydration interventions it is imperative that he/she

Monitors for signs of increased intracranial pressure (ICP), Assess vital signs, Monitor weight, Maintain accurate I & O

Signs of increased ICP are

Bulging fontanelle, Nausea and vomiting

Gastroenteritis

Infection & inflammation of the GI tract, Most common cause for children <5 years is ROTAVIRUS, Most common antimicrobial-associated cause of diarrhea is C-Diff., DX is by stool culture

Gastroenteritis S/S

watery stool (Copious Diarrhea), Fever, vomiting

Pediatric Diarrhea Severe Risks

Fluid & electrolyte depletion, especially in pediatric patients!

Pediatric Diarrhea Assessment

Dehydration Signs, Sunken fontanels (infants)m Decreased tearing Sunken eyes, Decreased tearing, Dry mucous membranes (dry lips, tongue), Decreased skin turgor, Weight loss = water loss, Fatigue, lethargy

Pediatric Diarrhea Critical Finding

Urine specific gravity > 1.035

Pediatric Diarrhea Causes Viruses

Rotavirus (most common under 5)

Pediatric Diarrhea Causes Bacteria & Parasites

salmonella (undercooked food), Poor sanitation, Lack of clean water

Pediatric Diarrhea Causes Medications

Antibiotics and Laxatives

Pediatric Diarrhea Causes Dietary

Lactose intolerance

Pediatric Diarrhea Interventions Rehydration

Oral Rehydration Solutions, IV Fluids

Oral Rehydration Solutions (ORS)

First line for able patients (offer small amounts frequently)

Pediatric Diarrhea Education Diet

Continue normal diet (solid foods) NOT "BRAT" diet

Pediatric Diarrhea Avoid

Antidiarrheal medications (e.g., Loperamide/Imodium)

pediatric client with diarrhea at risk for metabolic acidosis What s/s would the nurse notice

loss of base, compensation with slow RR

Vomiting Can be caused by

anatomical issues, food allergies, gastroenteritis, or overfeeding (#1 cause)., Can also have a non-GI cause (Ex. increased intracranial pressure)

Vomiting assessment

projectile OR non-projectile? Bileous non bilious? Are there accompanying symptoms like fever, headache, constipation, or diarrhea?

Vomiting Risk for ABG

Metabolic Alkalosis

Vomiting TX

Gut rest or slow introduction of bland foods, Anti-emetics

Lab values to monitor for vomiting &/or diarrhea

High Na, Low K, Low chloride

Gastroesophageal Reflux (GER) S/S

Vomiting & regurgitation, Fussiness, Refusal to feed, Choking, Apnea, Weight Loss

Gastroesophageal Reflux (GER Risk factors

Prematurity, Bronchopulmonary Dysplasia, Cerebral Palsy, OVERFEEDING, greasy foods

Gastroesophageal Reflux (GER Complications

Aspiration pneumonia, failure to thrive

Gastroesophageal Reflux (GER Treatment

Small, frequent feedings upright position, Thickened with rice formula., Upright position for 30 minutes after feeding (not in car seat) Medications - Antacids, Proton Pump Inhibitors

Hypertrophic Pyloric Stenosis

Thickening of the abdominal muscle around the circular pylorus muscle causes obstruction of the gastric outlet. More common in males than females. Typically presents between 1 and 3 months of life.

Hypertrophic Pyloric Stenosis S/S

Non-bilious vomiting (yellow) progressing to projectile vomiting especially after feeding, olive-shaped pyloric mass to RUQ, , Failure to thrive, dehydration

Genetic predisposition

Hypertrophic Pyloric Stenosis Risk Factor

Hypertrophic Pyloric Stenosis Treatment

Surgery (pyloromyotomy) involves splitting and spreading open the overdeveloped muscle; enlarging the pylorus to relieve the obstruction

pyloromyotomy pre-operative Care

IVF to correct dehydration/electrolyte imbalances, NGT to decompress stomach , NPO status , daily weights, strict I&O

Children NPO status

No forlmua/food 6-8 hr, no Breast milk 4 hr before, no Clear liquids 2 hrs (dehydration and hypoglycemia if too long

pyloromyotomy Postoperative care

maintaining fluids & electrolyte balance, document tolerance to feedings, Monitor for signs of infection, keeping the incision clean, Manage pain and promote comfort (analgesics, positioning) Start clear liquids 4-6 hrs after surgery. Advance to breast milk or formula as tolerated 24 hrs after surgery.

Intussusception

This is considered a critical medical emergency!, A proximal segment of the bowel telescopes into a more distal segment, causing a bowel, lymphatic and venous obstruction.

Intussusception S/S

Sudden episodic acute abdominal pain, Screaming and drawing knees to chest., Currant jelly stools (blood & mucous in stools), Fever, Abdominal distention, tender on palpation, Sausage-shaped mass to RUQ, vomiting

Intussusception Risk Factors

male infants <18 months

Intussusception DX

Barium Enema or Ultrasound

Intussusception Treatment

Barium/hydrostatic Enema or Air Enema. If this does not work, they will do surgery.

Intussusception Complications

Ischemia, Peritonitis

Cleft Lip and Cleft Palate

A congenital defect where there is incomplete fusion of the bones and tissues of the upper jaw and palate. Can be lip only, palate only, or both lip and palate.

Cleft Lip and Cleft Palate Complications

Ear infections and hearing loss.

Cleft Lip surgical repair

1-4 months

If a cleft palate is involved

surgical repair at 6-12 months

Cleft Lip and Cleft Palate Issues

Feeding, Speech/Dental issues, parental shock/grief, Risk for frequent otitis media infections, Aspiration risk.

Cleft Lip and Cleft Palate Pre-operative

Visualize and inspect the palate. Evaluate the suck and swallow. Evaluate for any aspiration during feeding and the ability to feed. Ability to form a tight sear around a nipple. Assess for abdominal discomfort from swallowed air.

Cleft Lip and Cleft Palate Educate/Demonstrate proper feeding techniques

special bottles (with elongated nipple), positioning up right, proper hold while breastfeeding, frequent burping. Small frequent feedings Provide psychological/emotional support for parents

Cleft Lip and Cleft Palate Post-Operative

The priority is to assess for respiratory distress! Pain management Keep hands away from face/mouth, Elbow restraints or swaddle, Maintain/protect intact suture line, Avoid prone positioning, Support for parents, Follow up with ENT

Cleft Lip and Cleft Palate Maintain/protect intact suture line

No pacifier, syringe feed or NGT, rinse mouth with each feeding, keep comfortable reduce crying

Hirschsprung disease

A congenital anomaly of decreased intestinal motility resulting in mechanical obstruction of the intestine. Congenital Aganglionic Megacolon (Absence of ganglionic cells in the distal bowel). Presents as a bowel obstruction!

Family History

Hirschsprung disease Risk factors

Hirschsprung disease S/S

Abdominal distention, Constipation, ribbon-like, liquid stools, or fails to pass meconium within the first 24-48 hours after birth. Vomiting bile, Refusal to eat, Progresses to Failure to Thrive (FTT), diarrhea and vomiting

Hirschsprung disease Diagnosis

with rectal biopsy

Hirschsprung disease Intervention

Surgical correction with or without an ostomy. Consider pre and post operative care for a bowel resection. Think about ostomy care just like with an adult! (no recta ltemps, only breast milk after)

Omphalocele & Gastroschisis – Life Threatening Abdominal Wall Defect

First covered, other uncovered

Omphalocele & Gastroschisis Nursing care

The goal is to protect the abdominal contents Reduce heat and moisture loss. Oral Gastric tube to decompress stomach. Place protective, non-adherent dressing. May place the infant’s lower body in a sterile clear plastic bowel bag

Hernias

More common in boys and premature infants

Inguinal Hernia

Painless swelling extending toward or into the scrotum Abdominal or pelvic viscera travels through the internal inguinal ring into the inguinal canal.

Inguinal Hernia Signs & symptoms

Painless swelling extending toward or into the scrotum

Umbilical Hernia

Soft midline swelling in the umbilical area, Most resolve spontaneously by 3-5 yrs of age

Hernias Complications

Incarcerated (strangulated)

Hernias Nursing Care

Urgent Surgery

Appendicitis Acute inflammation and infection of the appendix S/S

Pain progresses from diffuse to localized in the RLQ at McBurney’s Point, Rebound tenderness, Decreased bowel sounds, N/V, Abdominal distention, Rigidity, Guarding, Fever, Anorexia

Appendicitis DX

Abdominal imaging- CT or Ultrasound

Appendicitis TX

IV Antibiotics, Pain management. Open or laparoscopic appendectomy, Risk of Rupture increases with worsening of symptoms. , Sudden relief of pain is the classic sign of rupture.

Appendicitis Postoperative management

NG to low-intermittent suction, Monitor bowel sounds, Antibiotics, Pain meds, JP drain care if post operative rupture

Why does the pediatric client need an NGT post operatively? When should it be removed?

Short Bowel Syndrome

Loss of a part of the small bowel (small intestine). Nutrient malabsorption and excessive fluid loss follow.

Short Bowel Syndrome Common causes

necrotizing enterocolitis, small intestinal atresia, gastroschisis, and malrotation with volvulus

Short Bowel Syndrome S/S

diarrhea, greasy, foul-smelling stools, fatigue, weight loss, malnutrition, edema.

Failure to thrive

Refers to malnourished infants <1 year of age, The neurodevelopment of the infant is greatly affected if prolonged.

Failure to thrive 3 categories

Not Enough In, Too Much Out, Burning up too Much

Organic FFT

refers to growth failure due to an acute or chronic medical condition that interferes with normal food intake, absorption or digestion of food, or is due to increased calorie need to keep up or help growth.