Lec. 11 - Nursing care of the child with an alteration in bowel elimination/GI disorders

cleft lip and palate - what is it

monst common cogenital craniofacial anomaly

• development starts early in pregnancy

• lip d/t improper fuse during embryonic stage at week 5

• palate d/t absence of midline fusion by week 7

• can occur together or on there own

• can be unilateral or bilateral

• 30% have genetic syndrome

claft lip/palate - risk factors

• maternal smoking

• prenatal infection

• advanced maternal age

• medication use - anticonvulsants, steroids

cleft lip/palate - complications

• feedings difficulties: improper suction, excessive feeding times, inadequate intake, nasal regurgitation

• altered dentition: missing, malformed, malposition

• delayed or altered speech development

• otits media: fluid buildup in mid ear, temporary/permanent loss of hearing

Cleft lip/palate - therepeutic management

• repair of lip: 2-3months of age

• surgical repair of palate: 6-9 months of age

• revisions necessary as time grows

cleft lip/palate - nursing management

• prevent injury to suture line

• promote adequate nutrition

• encourage infant parent bonding

• provide emotional support

esophageal artesia - what is it

• congenitally interrupted esophagus

• the poximal and distal ends dont communicate

transeophageal fistula

• abnormal communication between trachea and esophagus

esophageal artesia/ transesophageal fistula - clinical manifestations

• polyhydraminos is first indication - ususally w/ artesia

• excessive salivaiton (frothy)

• drooling

• abd distention

• unable to pass feeding tube

• rattling resp.

• the 3 Cs - coughing, choking, cyanosis

esophageal artesia/ transesophageal fistula - nursing management

• preop: NPO, baseline Vitals, Assessments, labs, IV insertion

• Postop: incision care/monitoring, NG tube proteciton, IV fluids, O2, nutrition, pain management

omphalocele - what is it

• defect of the umbilical ring allows evisceration of abd content into external periotneal sac

Gastroschisis - what is it

herniation of abd wall contents d/t abd wall defect

• usually to left or right of umbilicus

• no membrane

• requires pediatric surgeon available at delivery

omphalocele/Gastroschisis - nursing assessment

review maternal hx

• illness and infxn

• drug use, smoking

• genetic abnormalities

associated cogenital anomalies

• cardiovascular

• genitourinary

• CNS

omphalocele/Gastroschisis - Nursing management

• preventing hypothermia

• maintain perfusion to eviscerated abd contents

• protect exposed abd contents

• minimize fluid loss

• prevent trauma and infxn

• postop care

• promote parent newborn interaction

dehydration

occurs more readily in infants and children

• inc. extracellular fluid percent

• inc. in body water

• inc. metabolic rate

• inc. ratio BSA to body mass

• immature renal fxn

• inc. insensible loss through temp eval.

these can also cause overhydration

dehydration - s/sx

• sunken fontanelle

• sunken eyes

• lack of tears when crying

• excessive thirst but vomits after drinking lots of water

• dec. UO

  • infants/babies - no wet diapers in 6-8hrs, little dark yellow urine

  • toddlers - very little dark yellow urine

dehydration - history

• diarrhea

• vomitting

• dec. oral intake

• sustained high fever

• DKA

• extensive burns

dehydration - nursing assessment

hydration status

• heart rate

• BP

• skin tugor

• fontanels

• oral mucosa

• eyes

• temp and color of extremeties

• mental status

• UO

dehydration - nursing management

• promote F/E balance

• oral rehydration (pedialyte) - should have 75mmol/L NaCl and 13.5 g/L glucose

  • tap water, milk, undiluted fruit juice, soup, broth = not good for this

  • children w/ mild to moderate require 50-100ml/kg ORS over 4 hrs

• mild to moderate - withhold oral feedings 1-2hrs after last emesis, give 0.5-2oz Q15mins

• IV fluids if oral replacement not successful

• restore fluid vol.

• prevent progression to hypovolemia -

• IV fluids for severe dehydration - 20ml/kg NS or LR

• maintenance fluids

Vomiting

• ginger capsules, ginger tea, candied ginger reduces nausea and is safe in children <2yo

Vomitting - Nursing Assessment

onset and progression - hours after meal, middle of night

Effortless or projectile

contents and character - bilious is never normal, suggest obstruction

past medical history

risk factors

Diarrhea - what is it

most commonly caused by infxn

• acute or chronic

• inc. in frequency or dec. in consitency

diarrhea - nurisng assessment/diagnostics

• details about stool

• other symptoms ?

• gained through travel or household illness

• hydration status

• abd assessment

• electrolytes

• stool cultures/stool OandP

• stool for occult blood

• abd radiograph

Diarrhea - nursing managment

• restore F&E balance

• provide family education

  • med. instruciton PRN

  • prevention if pertinent

  • proper handwashing

  • avoid excessive formula, water, fruit juice

hypertrophic pyloric stenosis

circular muscle of pyloris becomes atrophied, causing thickness in luminal side of pyloric canal, causing gastric outlet obstruction, causing nobilious vomitting

• presents at 3-6 wks of life

• more in males than fems

• requires surgical interventions

hypertrophic pyloric stenosis - nursing assessment

common symptoms

• forecful nonbilious vomitting unrelated to feeding positiomn

• hunger after vomitting

• weight loss

• progressive dehydration w/ lethargy

• possible fam. history

• palpate for moveable “olive” in right upper quadrant

hypertrophic pyloric stenosis - nursing management

preop

• fluid management

• correcting electrolyte values

• emotional support

• education

postop

• NPO

• IV

• dextrose

• family talks w/ surgeon

intussusception

occurs when proximal segment of bowel telescopes into distal segment

• causes edema, vascular compromise, partial/total bowel obstruction

• occurs at 1-2 yrs of age

intussusception - common symptoms

• sudden intermittent, crampy abd pain

• severe pain

• vomitting

• diarrhea

• currant - jelly stools, gross blood, hemoccult positive stool

• lethargy

intussusception - nursing assessment

assess risk factors

• cystic fibrosis

• celiacs disease

• sausage shaped mass in upper mid abd

• diagnosed with air or barium enema

intussusception - nursing management

• IV fluids, ABX prior to diagnostic testing

• emotional support

• spontaneous reduction

• barium enema reduciton

• surgical reduction

appendicits - what is it

acute inflammation of the appendix

• ruptures if untreated

• abd pain suddenly relieved w/o intervention, suspect perforation

• diffuse abd tenderness/distention = peritonitis

appendicitis - physical assessment

• ill appearing child

• maximal tenderness over mcburneys point in RLQ

• rebound tenderness

• daignos w/ CT, CBC, CRP

appendicitis - nursing management

• preop care

• postop care

• abx if ruptured or gangrenous

• education

Hirschsprung disease (Cogenital Aganglionic Megacolon) - what is it

disorder of the motility of intestinal tract resulting in obstruction

• lack of ganglion cells in intestine

• 4x more common in boys

• rectal biopsy is definitve exam

Hirschsprung disease (Cogenital Aganglionic Megacolon) - Nursing assessment

• stool pattern is key - did newborn pass meconium in 24-48hrs or life? rectal stim required? meconium plug present ?

• family history - down syn. hirschprung dz

• palpate - presence of stool, rectal tone, forceful expulsion of fecal matter while finger withdrawn from rectum

Hirschsprung disease (Cogenital Aganglionic Megacolon) - therapeutic management

• surgical resection - usually w/ ostomy

• reanstomosis of intestine

• ostomy closure at later date

Hirschsprung disease (Cogenital Aganglionic Megacolon) - nursing management

• postop ostomy care

• child and fam education

• prompt treatment if show signs of entercolitis

Celiac Dz

immunologic disorder where gluten cause damage in villi in small intestine causing malnutrition

• strict gluten free diet is only treatment

• autotissue stranglutemase IgA is first line test

• atiendomysium IgA test specific to celiac dz

celiac dz - Nursing assessment

• diarrhea

• steatorrhea

• constipation

• failure to thrive/weight loss

• abd distention/bloating

• poor muscle tone

• irritability/listlessness

• dental disorders

• anemia

• delayed onset of puberty or amenorrhea

• nutritional deficiencies