Peds GI DO

• Take in food and fluids

• Begin digestive process

• Propel feed into intestines

What are the primary functions of the UPPER GI tract?

• Mouth

• Esophagous

• Stomach

What are the parts of the UPPER GI tract?

Food broken up and mixed wtih saliva, to start the digestion of carbs

What is the function of the mouth?

Mouth

Which part of the body is the most common for portal infections in young infants?

Ends in lower esophageal sphincter

Where does the esophagous end?

Risk for spit ups due to relaxed sphincter

What are infants at risk for if they have an immature esophagus?

• Size and acid levels increase

• Hydrochloric acid (protection) not adult levels until 6 months

What happens to the stomach as children age?

• Digest and absorb nutrients

• Detoxify and excrete waste

What is the primary function of the LOWER GI tract?

• Small intestines

• Large intestines

• Liver

• Pancreas

What are the parts of the LOWER GI tract?

Absorb nutrients and vitamins

What is the function of the small intestine?

Water reabsorption, synthesis of vitamin B and K

What is the function of the large intestine?

• Bile production

• Detoxification

• Glycogen storage and breakdown

• Vitamin storage

What is the function of the liver?

• Digestive enzymes

• Secretes insulin

What is the function of the pancreas?

• Growth patterns (weight gain, growth chart)

• Dietary concerns (what did they eat?)

• Toilet training and bowel patterns (diarrhea, older kids: constipation)

• Pt. hx (baseline)

• Fam hx

What is the health hx assessment of a GI patient?

• Ab Xray, US, CT

• Endoscopy; UGI, colonscopy w/biopsy

• Barium studies; swallow, UGI, enema

• Esophageal pH probe

• Stool studies; culture and sensitivity, occult blood

What is the dx testing of a GI patient?

Tube that goes into the nose to the bottom of the esophagous, right above the sphinchter

• Meaures acidity (should be basic) and left for 24 hours

• Determines GE REFLUX

What is the esophageal pH probe?

• Inspection and observation

  • Ab size and shape (distended or tender)

• Ascultation (before palpation)

• Percussion

• Palpation

What is the physical exam of a GI patient?

1. Cleft lip and palate

2. GERD

3. Appendicitis

4. Hypertrophic pyloric stenosis

5. Intssusception

6. Volvulus

7. Hirschsprung disease/ congenital aganglionic megacolon

8. Celiac

9. Short bowel syndrome

10. Dehydration

What are the GI issues of children?

• Genetic or enivronmental

• Mom smoking

• Mom drinking

• Medications

What is the CAUSE of cleft lip and palate?

Early developement; tissues do not fuse properly during development

• Unilateral or bilateral

What is the PATHO for cleft lip and palate?

• ASPIRATION, airway problems

• Feeding difficulty (can’t attach to breast)

• Altered dentation (teeth)

• Ear infection (airway open with fluid)

• Speech and language development difficulty

• Issues with parent-infant bond

What are the COMPLICATIONS of cleft lip and palate?

• Surgery at young age

• 2 separate surgeries

  • First lip, second palate (6-9 months)

• Speech therapist (feeding)

What is the TX for cleft lip and palate?

• Feeding management (growth, speech therapist)

  • Use of a special feeding device for cleft palate

• CPR training (risk of aspiration)

• Parent support and bonding

• Pre and post op education

• Long term plan and follow-up

What is the fam edu for cleft lip and palate?

C: calming techniques

L: lip suture line care (AB ointment, keep clean)

E: evaluate plan

F: feeding techniques

T: teaching

L: lip protection (Logan bow)

I: infection (suture line)

P: Protective devices (no-nos on arm and face 24/7)

CLEFT LIP

What is the post op nuring care for CLEFT LIP?

P: pain management

A: airway management (assess swelling, HOB up)

L: liquid diet (3 weeks for sutures to heal)

A: avoid hard foods and objects in mouth (no straws, sippy cups, pacifiers)

T: too hot, spicy, citrusy fluids and foods should be avoided

E: educate parents on signs of infection (foul odor, oozing, bleeding), use of arm restraints (no-nos), and advancing diet

What is the post op nursing care for CLEFT PALATE?

• Failure to thrive/ weight loss

• Respiratory problems/infection (silent aspiration)

• Hungry/ irritability (can’t keep food down)

• “Wet burps” or vomiting after feeds

• Infant: pain with feeding/posturing (arching is abnormal)

• Older: dental erosion

What is the health hx and S/S for GERD?

pH probe (mild, mod, severe)

What is the DX for GERD?

1. Alter feeding techniques (initially, may outgrow)

2. Meds

3. Nissen fundoplication

What is the nursing management for GERD?

• Small, frequent feedings with frequent burping

• Upright positioning for 30-45 mins after feeds

• Thickened formula with rice cereal (1tsp/oz) (heavier)

What does alter feeding techniques mean for management of GERD?

• H2 blockers (Block acidity, -dine)

• PPIs (-zole)

• Prokinetics (increase stomach motility to empty faster)

What are the MEDS used for GERD?

Surgical procedure for severe GERD by wrapping the upper part of the stomach around the lower end of the esophagus

• Risk for vomiting

• Still need medications, not a tx

What is nissen fundoplication?

1. Obstruction of the appendix (stool)

2. Increased pressure (trapped mucus)

3. Edema

4. Bacterial overgrowth (gets caught inside)

5. Perforation (overtime can rupture)

What is the PATHO of appendicitis?

• Perotinitis

• Sepsis

What are the COMPLICATIONS of appendicitis?

• Periumbilical pain

  • Progressing in intensity and localizing to the RLQ

• N/V

• Fever

Assessment

• McBurney’s point (where appendix is, RLQ)

• Rebound tenderness (release after pressing creates pain)

• Increased WBC

What is the health hx and S/S for appendicitis?

Labs

• Increased WBCs

DX

• CT or US

What are the LABS/DX for appendicitis?

1. Non-perforated (uncomplicated)

2. Perforated (complicated)

What are the TWO TYPES of appendicitis?

Appendectomy

• Preop AB

• F/E

• Pain meds

• Possible post op AB

What is the TX for non-perforated appendicitis?

• Appendectomy

  • Drainage and irrigation of peritoneal cavity

  • IV AB 7-14 days

What is the TX for perforated appenditcitis?

1. Pylorus becomes hypertrophied

2. Stenosis of the pyloric sphincter

3. Leads to obstruction

What is the PATHO for hypertrophic pyloric stenosis?

What are the RISK FACTORS for hypertrophic pyloric stenosis?

• NON-BILIOUS emesis 30-60 mins after feeding (deydrated → shock, iv fluids)

• Hungry and crying despite having been fed

• Progressive weight loss

Physical exam

• “Olive shaped” mass in upper ab

• Progressive dehydration

What are the health hx and S/S for hypertrophic pyloric stenosis?

• SURGICAL: pyloromyotomy (cut through thick pyloric muscle, letting food get through)

• F/E management

• Parental education

• Pre and post op care

• Resume feedings

  • Resume 1-2 days after surgery

What is the management for hypertrophic pyloric stenosis?

1. Bowel telescopes into a distal segment (slide inside another)

2. Edema and impaired blood circulation (ischemic)

3. Partial or total bowel obstruction (food and stool can’t move)

What is the PATHO for intussusception?

• Sudden onset intermittent pain

• Bilious emesis

• “Currant jelly” stools (damaged bowel lining begins to bleed and produces mucus)

• Lethargy

Physical exam

• “Sausage” shaped mass (palpate)

What is the health hx and S/S of intussusception?

• Barium or air enema (push the telescope section back into normal position)

  • effective in 95% of cases

• Surgical repair (if enema doesn’t work or ischemia)

• Pre/post op care

• Emotional support

What is the management of intussusception?

Malrotation or twisting of the bowel that results in bowel obstruction

What is volvulus?

Children with neurological impairment

Who may have an increased risk for volvulus?

• Pain

• Bilious vomiting

• Other signs bowel obstruction

(similar to intussusception)

What are the S/S volvulus?

X ray (differentiate from intussusception)

What is the DX for volvulus?

• Surgery to prevent bowel ischemia

• Nursing care is similar to intussusception who requires surgical tx

What is the TX and management for volvulus?

Lack of ganglionic cells in the bowel which cause inadequate motility (can’t move stool)

What is the PATHO for hirschsprung disease/ congenital aganglionic megacolon?

• Not passing meconium for first 24 HOURS

• Male

What are the RISK FACTORS for hirschsprung disease/ congenital aganglionic megacolon?

• Ab distension and pain

• Constipation (palpate)

• Vomiting

• Poor weight gain

• Slow growth (don’t feel like eating)

What are the S/S hirschsprung disease/ congenital aganglionic megacolon?

1. First give golytely

2. Rectal suction biopsy

What is the DX of hirschsprung disease/ congenital aganglionic megacolon?

• Surgical resection of the bowel with reanastomosis; “pull through” procedure

• Depending on age and severity of disease, surgery may be done in “parts” and the child may have a temporary or permanent colostomy

• Edu parent/child pre and post op

What is the TX for hirschsprung disease/ congenital aganglionic megacolon?

1. Autoimmune DO in genetically susceptible people

2. Inability to digest gluten

   1. Found in wheat, barley, rye, some oats

3. Damages villi in small intestine (whole area not absorbing)

4. Malabsorbtion leading to malnutrition

What is the PATHO for celic disease?

• Ab distension

• Thin extremities

• Poor muscle tone

• Anemia

• Steatorrhea

• Poor weight gain, failure to thrive

What is the health hx and S/S for celiac disease?

• Screening

  • Blood test

• DEFINITIVE DX

  • Small bowel biopsy (shows villi atrophy)

• GENETIC TESTING

What is the DX for celiac disease?

IgA antitissue transglutaminase antibodies (tTG2)

• Will be positive in about 98% of patients for who are on a gluten containing diet

What is the blood test screening for celiac disease?

For human leukocyte antigens (HLA-DQ2 and HLA-DQ8)

• Those with celiac disease usually carry 1 or both genes

What is the genetic testing for celiac disease?

• Dietary alterations

  • Strict gluten-free diet for life (rice is ok)

  • Vitamins if malnourished

  • Referral to dietician

• Close monitoring of growth

What is the management for celiac disease?

Typically caused by congenital malformations of the GI tract or surgical resection of the small intestine at a young age (eg. premature infants with NEC); too little functional small intestine

What is short bowel syndrome?

Severe malabsorption

• Inability to gain weight

• Vitamin and mineral deficiencies

What are the S/S of short bowel syndrome?

• NO CURE

• IV total parenteral nutrition via central line and enteral feedings as tolerated

What is the TX for short bowel syndrome?

• Infection

• Liver disease (due to long term TPN administration)

What are the complications for short bowel syndrome?

Occurs more readily in infants and young children due to:

• Greater proportion of body water in extracellular fluids, with increased sodium and chloride

• Have a higher metabolic rate and experience greater insensible fluid losses through the skin and GI tract

• Higher body surface area (BSA) in ratio to body mass

  • 2-3x higher in infants

  • 5x higher in premies

• Immature renal system in infants, is less capable to concentrate urine like adults

What are the RISK FACTORS for dehydration in children?

1. Reduced fluid intake or fluid loss

2. Sudden, rapid ECF loss

3. Imbalace in electrolytes

4. Loss of ICF

5. Cellular dysfunction

6. Hypovolemic shock

7. Death

How does dehydration in children quickly lead to shock and death?

• Vomiting

• Diarrhea

• Fever

• Hyperventillation

• Burns

• Trauma/shock

• Hemorrhage

• Diabetes

What are the types of decreased fluid intake or increased fluid loss?

Restore fluid volume and prevent hypovolemia

What is the GOAL of dehydration in children?

• Tachypnea and tachycardia, thready pulse

• Hypotension

• Peripheral vasoconstriction

• Sunken fontanelle

• Reduced LOC, lethargy

• Parched

• Dry mucous membranes

• Reduced tissue turgor, tenting

• Oliguria (low UOP)

• Eyes sunken and tearless

• Sudden weight loss

• Reduced cap refill

• Cold, cyanotic extremities

What are the S/S dehydration in children?

• Mild to moderate: Oral replacement therapy (ORT)

  • Pedialyte, Rehydralyte, Enfalyte recommended

• Severe: IV fluids management; 20 mL/kg with LR or NS

What is the TX for dehydration in children?

For mild to moderate dehyration if NO vomiting or lethargy

When do you give ORT?

Oral: 50-100 mL/kg or an oral rehydration solution + relacing continued losses

• Given over 3-4 HOUR period

How do you give ORT?

Can give up to 3 boluses of fluids to stablize patient

• Then can move to IV fluids and ORT when able

How to give LR or NS for severe dehydration?