Week 2: GI and GU

Components of the GI System

-Mouth

-Esophagus

-Pancreas

-Stomach

-Gallbladder

-Small and large intestine

-Appendix

-Rectum

-Anus

What are the 3 differences in the pediatric GI system?

-Small capacity of stomach

-Immaturity of digestive systems

-Stool frequency

Why is enteral nutrition utilized in pediatrics?

To provide nutrition for child unable to safely eat by mouth

Types of Enteral Nutrition Tubes

-NG

-NJ

-G-tube

-GJ-tube

When is parenteral nutrition utilized in pediatrics?

Provide nutrition for patients unable to eat or receive tube feeds

What is the only way parenteral nutrition can be provided?

Central Line Only

-TPN

-Lipids

What are the two types of GI concerns?

-Structural

-Non-structural (infectious)

GI Pediatric Structural Differences

-Cleft lip/palate

-Abdominal Wall Defect

-Hirschsprung’s Disease

-Intussusception

-GERD

-Nissen Fundoplication

-Pyloric Stenosis

-Celiac Disease

-Anorectal Malformation

-Necrotizing Enterocolitis

What is cleft lip/palate in general?

Incomplete fusion of facial structures

Cleft Lip Defintion

Failure of fusion of maxillary processes with nasal evaluations

Cleft Palate Defintion

Failure of fusion of secondary palate

Cleft Lip Surgical Management

-Unilateral/bilateral

-First weeks of life (by 3 months of age)

Cleft Palate Surgical Management

-6 to 12 months of age

-Enhance speech development

-Timing individualized secondary to extent of cleft

Cleft Palate Effects on Speech

Defective Speech

Cleft Palate Improper Tooth Alignment

Malposition or missing tooth

Cleft Palate Improper Drainage of Middle Ear

Recurrent otitis media

Cleft Palate Parental Concerns

-Obvious defect

-Compassion and knowledgable

-Be in control of informing conversation

-Make pointed effort to comfort parents

-Allow parents to talk and show feelings

What should be completed in cleft palate care?

-Oral feedings in 20 to 30 minutes

-May need supplemental tube feedings

-Prolonged feedings burn calories

What head position should a patient with a cleft palate be in?

Head in an upright position

What should be monitored for patients with cleft palate?

Signs of aspiration

-Choking

-Coughing

-Sputtering

-Color change

What position would be the best for breastfeeding mother whose infant has a cleft palate?

Football hold

What technique should a mother be taught to assist in a breastfeeding infant with a cleft palate?

Push great tissue into cleft lip, allowing for more closure

Cleft Palate Bottle Feeds

Squeezable bottle

-Frequency of squeezing determined by infant’s response to flow rate

Haberman Feeder

What physical device could be used to protect surgical site for cleft lip?

Elbow immobilizer “welcome sleeves”

-Remove every 2 hours

-Skin breakdown assessment

What position should be avoided in the protection of surgical site for cleft lip?

Prone

How should a newborn be fed after cleft palate surgery?

With nipple or cup

-Pureed/soft diet

-Avoid hard foods

Embryonic Abdominal Development Week 4

Intestine present

Embryonic Abdominal Development Week 5&6

Intestine elongates and rotates

Embryonic Abdominal Development Week 7

Intestinal loops herniate into umbilical cord

Embryonic Abdominal Development Week 9&10

Intestine re-enters abdominal cavity and continues rotation

Omphalocele

Herniation of abdominal viscera and contents into the umbilical cord

-Covered by the sac peritoneal sac

Gastroschisis

Failure of the closure of the lateral fold of the abdominal wall

-No covering

Respiratory Support for Omphalocele and Gastroschisis

Hypoventilation

Pain Management for Omphalocele and Gastroschisis

-Hypoventilation

-Slows GI motility

Should the NG/OG be replaced for patients with Omphalocele and Gastroschisis?

Yes

How should introductions of feeds be to pediatrics with Omphalocele and Gastroschisis?

Slowly

What should the nurse monitor for in Omphalocele and Gastroschisis?

Signs of bowel obstruction

Hirschsprung Disease is a lack of what?

Ganglion cells and gut peristalsis

Hirschsprung Disease Location

Gut proximal to affected area hypertrophies

What is not present in the first 48 hours after birth in a patient with Hirschsprung Disease?

No meconium

Hirschsprung Disease Newborn Clinical Manifestations

-Failure to meconium

-Bile emesis

-Abdominal distention

Hirschsprung Disease Infancy Clinical Manifestations

-Constipation with diarrhea

-Poor growth

Hirschsprung Disease Childhood

-Chronic constipation

-Abdominal distention

How is Hirschsprung Disease identified?

-Barium enema

-Anorectal manometry (not normal anal sphincter relaxation)

-Rectal biopsy

What is the definitive diagnostic of Hirschsprung Disease?

Rectal biopsy

What is the initial treatment for Hirschsprung Disease?

Colostomy

What is the definitive surgical correction for Hirschsprung Disease?

Pull-through

What factor influences the nursing care pre-op?

Child’s age at diagnosis

Hirschsprung Disease Nursing Care Pre-op

-Assess GI function

-Bowel preparation

-Parent child teaching related to colostomy

-Monitor for signs of enterocolitis

-I&O (NG tube losses and still from ostomy)

-Assess GI function, stoma, and infection

-Pain management

Stoma Assessment of Hirschsprung Disease

Pink and moist

Hirschsprung Disease Colostomy Care

-Skin care

-Emptying and changing ostomy bag

-Monitor bowel function

Following Pull-through in Hirschsprung Disease

-Good skin care in peripheral area (Breakdown)

-Toilet training

-Monitoring bowel function

Intussusception Definition

One segment of intestine “telescopes” inside of another, causing an intestinal obstruction

Where does Intussusception usually occur?

At the junction of the small and large intestines

Intussusception Symptoms

-Intermittent loud crying every 15 to 20 minutes

-Vomiting

-”Currant jelly” stool, mixed with blood and mucus

Intussusception Diagnosis

-Ultrasound

-Barium Enema X-ray

-CT scan

Intussusception Treatment

-Urgent intervention to prevent necrosis

-Air or saline enema

-Laparoscopic surgery

Gastroesophageal Reflux Defintion

-Passive transfer of gastric contents into esophagus

-Due to inappropriate or transient relaxation of the lower esophageal sphincter

-Regurgitation

GER Regurgitation

-Greater than 60% of infants regurgitate at least once a day

-Happy spitters

GER Infant Clinical Manifestations

-Spitting up/vomiting

-Fussiness

-Arching position

-Failure to gain weight

-Hematemesis

-Respiratory problems

-Apnea

GER Child Clinical Manifestations

-Heartburn

-Abdominal pain

-Chest pain

-Chronic cough

-Dysphagia

-Nocturnal asthma

-Recurrent pneumonia

GER Diagnosis

-H&P

-Barium swallow study with upper GI

-Esophageal pH monitoring

-Endoscopy

-Empiric trial of acid suppression

Esophageal pH Monitoring

-Frequency of acid reflux

-Relate to feeding, positioning, and sleep

GER Conservative Therapy

Positioning

-During and after feeds

Thickening

-Infant formula (add cereal)

What medications can be given to treat GER?

-Histamine-2 Receptor Antagonists

-Proton Pump Inhibitor

Histamine-2 Receptor Antagonists

-Decrease amount of acid in gastric contents

-Pepcid

Proton Pump Inhibitor

-Block acid production and heal the esophagus

-Prilosec, Prevacid

GER Infant Nutrition Education

-Thicken

GER Older Child Nutrition Education

-Eliminate certain foods which lower esophageal sphincter pressure

-Eliminate foods causing gastric acid secretion

GER Positioning Education

-Elevate HOB

-Upright after feeds

GER Medication Education

Begin after conservative treatment attempted

Nissen Fundoplication

Fundus of the stomach is used to reinforce the esophageal sphincter

Nissen Fundoplication Indication

For patients with reflux causing severe complications

Pyloric Stenosis Defintion

Gastric outlet obstruction

What is the most common GI abnormality of infancy?

Pyloric Stenosis

Is pyloric stenosis more common in males or females?

Males

When does pyloric stenosis occur?

2 to 6 weeks after birth

When is pyloric stenosis rarely seen?

After 3 months

Pyloric Stenosis Clinical Manifestations

-Non-bilious vomiting

-Progressing from simple to projectile

-Palpable pyloric mass in RUQ (olive shape)

-Dehydration

-Hypochloremia → Metabolic acidosis

Pyloric Stenosis Pre-op Nursing Care

-Parenteral nutrition

-Assessment of fluid and electrolyte balance

Pyloric Stenosis Post-op Nursing Care

-Infection protection

-Begin feeds 8 to 12 hours after OR
-Will have some vomiting

Celiac Disease

Triggered by the ingestion of products that contain wheat, barley or rye, collectively known as gluten

-Results in damage to the lining of the small intestines

Celiac Disease GI Initial Symptoms

-Chronic diarrhea

-Ab pain/discomfort

-Bloating and gas

-Poor weight gain or loss

-Constipation

Celiac Disease Non-specific Initial Symptoms

-Unexplained growth failure

-Anemia

-Chronic fatigue

-Delated onset of puberty

-Dermatitis herpetiforms

-Chronic joint pains

-Abnormal liver tests

Celiac Diagnosis and Treatment

-Bloodwork to look for antigens

-Definitive diagnosis with bowel biopsy

-Cured by altering diet to remove all gluten

-Not altered: increased risk for GI complications

Anorectal Malformation (ARM)

Improper development of anus and rectum

Severity Variation of Anorectal Malformation

-Narrow anal passage

-Present membrane over the anal opening

-Rectum may not connect to the anus

-Rectum connects to a part of urinary tract or reproductive system through fistula

What intervention is needed to correct Anorectal Malformation?

Surgical

Necrotizing Enterocolitis Definition

Poor perfusion that causes inflammation of intestinal tissue, causing it to die

-Can result in perforation → Sepsis

When is Necrotizing Enterocolitis common?

Premature infants and infants with congenital heart issues

Necrotizing Enterocolitis Initial Symptoms

-Abdominal distention

-Blood in stools

-Pneumoatosis on X-ray

Necrotizing Enterocolitis Treatment

-Bowel rest for 7 to 10 days (NPO/TPN/Lipids)

-Broad spectrum ATB

Necrotizing Enterocolitis Severe

Child will need ostomy to allow for bowel to heal

Necrotizing Enterocolitis “Short Gut”

Child who’s had portions of bowel removed for necrosis

Appendicitis

Painful swelling and infection of the appendix

-Rupture concern

What causes appendicitis?

Blockage

Appendicitis Symptoms

-Develop slowly over approximately 12 hour period

-Pain

-Anorexia

-Nausea

-Vomiting

-Fever

If pain is preceding what, appendicitis is more likely?

Vomiting

Where is the greatest pain usually felt in appendicitis?

Right Lower Quadrant

Appendicitis Testing

-McBurney’s Point

-Rebound tenderness in RLQ

-Diagnosis with US