Peds GGG

GI assessment

•History

•Medical hx

•Family hx

•Abdominal Exam

•Inspection

•Interaction with family

•Child movements

•Abdomen changes: size and shape changes as they grow

•Newborn round belly

•Older children flat belly

•Distraction during exam—pacifier, toys, answer questions

•Ascultation

•Infant—easier when sucking and quiet

•Preschool/school-age—allow children to listen with stethoscope

•Palpation

•Position—supine, arms at side, light palpation

Assessment for cleft lip and palette

•Cleft lip—visually apparent 

•Cleft palate—must inspect top of mouth

Nursing interventions for cleft lip and palette

•Feeding problems

•Adaptive methods-- special nipple or syringe for feedings

•Ear infections—short horizontal eustachian tubes

Treatment for cleft lip and palette

•Repair 2-18 months. Better outcome before 12 months

•Postoperative care—NPO after surgery, elbow restraints, no suction, feed in upright position, burp frequently, rinse with sterile water after each feeding

Nursing goals for cleft lip and palette

•Suture line—maintain integrity

•Respiratory status

•Bonding between parent and caregiver

•Optimal nutritional intake—eating and getting necessary nutrition

•Pain management

Assessment for celiac disease

•Abdominal bloating, diarrhea, vomiting, weight loss, flatulence, foul stools

•Dermatitis hepetiformis: blistering, itchy rash on elbows, knees, buttocks

•Severe forms: iron deficiency anemia, B12 deficiency, osteoporosis

Diagnosing celiac disease

• CBC, anti-tissue transglutaminase antibodies

•Endoscopy and tissue biopsy

Nursing interventions for celiac disease

•IV fluids

•Gluten-free diet after endoscopy to prevent tissue healing

Caregiver education for celiac

•Gluten-free diet

•Referral to dietician

•Follow-up with GI doctor

Assessment for appendicitis

•Pain

•Fever

•N/V

•Rebound tenderness

•McBurney’s Point—right lower quadrant near belly button

Diagnostic tests for appendicitis

•Lab Tests—CBC and UA

•Ultrasound, CT to confirm diagnosis

Nursing interventions for appendicitis

•Emergency: NPO, VS, IV fluids, preop teaching, get informed consent signed

•Acute Hospital: VS, IV fluids, pain assessment, pain management, incentive spirometer, ambulate, incision care

•Chronic Hospital: Ruptured, possible peritonitis, IV fluids, antibiotics, NG tube, JP drain, dressing change

Caregiver education for appendicitis

•Medications: Pain medicine, antibiotics (if ruptured)

•S/s Infection: Redness, fever, unrelieved pain

•Discharge instructions: no heavy lifting, no physical activities, follow up appts.

Assessment for inguinal hernia

•Lump in groin—typically on right side

•pain and swelling—intermittent

•Burning at buldge

•Incarceration: pain, fever, tachycardia, bilious vomiting, no stools

•Strangulation: erythema and edema over tender groin mass

Diagnostic tests for inguinal hernia

palpation

Nursing interventions for inguinal hernia

•IV fluids, surgery prep, informed consent, post-op care—pain medicine, non-nutrative sucking, frequent diaper changes, circulation at surgical site

Caregiver education for inguinal hernia

•Pain medicine

•Incision care

•Observe opposite side for hernia

Crohns

•Chronic IBD characterized by immune response to injured tissue that causes: ulcers in the digestive tract, may mimic appendicitis

•Diarrhea, fever, pain, wt loss, fatigue, oral aphthous ulcers

•Surgery if medication doesn’t control symptoms & correct complications

Ulcerative colitis

•Symptoms may be mild or with frequent bouts of bloody diarrhea, fever & abd cramping

•Drug therapy is necessary

•If severe: colon resection with ileostomy

Peptic ulcer disease

•Sores that develop on the inside lining of stomach or upper small intestine

•Most common causes: NSAIDS (ibuprofen), H-pylori

Assessment for peptic ulcer disease

•Abdominal pain, n/v, anorexia - proceeds to anemia, GI bleed, perforation, shock

Diagnostic tests for peptic ulcer disease

•Lab: CBC, Sed rate, H.Pylori Blood, H.Pylori Stool, SFOB, WBC

•Upper GI series, Endoscopy

Nursing interventions for peptic ulcer disease

•NPO, IV fluids, Triple Therapy (2 antibiotics, and 1 proton pump inhibitor)

Caregiver education for peptic ulcer disease

•Med compliance

•Stress reduction techniques

Assessment for IBS

•Cramping, bloating, diarrhea, constipation

•More common in: females than males

•Pain Syndromes: chronic fatigue syndrome, fibromyalgia

Diagnostic tests for IBS

•History

•Medical

•Family

•Labs: CBC, stool study, ova and parasite, occult blood

•Endoscopy: if bleeding occurs to rule out ulcerative colitis 

Nursing interventions for IBS

•Avoid trigger foods: dairy, carbonated beverages

•Diary of symptoms, bowel habits, diet 

•Increase fiber, eat small meals, increase fluids

Caregiver education for IBS

•Use of diet: school age and adolescents allow to plan meals

•Complementary and alternative therapies: fish oil and probiotics

Assessment for GERD

•Pain: after eating

•Slow or no weight gain: not eating due to pain, Failure to thrive

•Irritability or crying

•Arching: after meals

•Infants: apnea

•Children: chronic cough, midsternal pain, interrupts sleep, sore throat

Diagnostic tests for GERD

•Weight, length, head circumference

•pH probe—see stomach pH

•Esophagram

Nursing interventions for GERD

•Medications: rinidadine, Reglan (infants), older children get proton pump inhibitors

•Nissen fundoplication: esophagus wrapped around sphincter (cannot vomit after)

Caregiver education for GERD

•Feedings: small and frequent

•Burping often

•Upright position during and after feedings

•Older children: educate no eating 2 hours before bed, no caffeine, chocolate, spicy, or fatty foods

Pyloric stenosis

•Pylorus muscle thickens and becomes abnormally large

Assessment for pyloric stenosis

•Projectile vomiting

•Poor weight gain: failure to thrive

•Dehydration and metabolic alkalosis 

Diagnostic tests for pyloric stenosis

•Olive sign: olive shaped mass in epigastrium

•Ultrasound: pyloric thickening

Nursing interventions for pyloric stenosis

•Pre-op: NPO, pacifier, IV fluids

•post-op care: I&O, daily weight, watch incision, advance diet as tolerated

Caregiver education for pyloric stenosis

•Report: continuation of vomiting. Vomiting will not go away instantly. Vomiting is bad if it continues a few days post op

Volvulus

•Abnormal twisting of portion of GI tract, usually intestine, that can impair blood flow

Assessment for Volvulus

•Occurs in first 6 months

•Intense crying and pain

•Abdominal distention and vomiting

Diagnostic tests for volvulus

•Upper GI Series

•CBC and electrolytes

Nursing interventions for volvulus

•Surgery for correction

•I&O

•NG tube

•Pain management 

•Bowel sounds: introduce feedings after bowel sounds return

Caregiver education for volvulus

•Feedings: know S/S when to stop feeding

•Educate on infection, complications

Intussusception

•Part of intestine telescopes into adjacent part

• Most common cause of intestinal obstruction in children younger than 3

Assessment for Intussusception

•Sudden drawing up of legs, crying, possible vomiting, then symptom free

•Pain in intervals: q15-20 min

•Currant jelly stools: blood and mucus mixed together

•As problem progresses:fever, peritoneal irritation, guarding, elevated WBC

Diagnostic tests for intussusception

•Ultrasound, CBC

•Barium enema: enema with barium– barium straightens colon at as it passes

Nursing interventions for intussusception

•IV therapy, barium enema reduction, surgery

Caregiver education for intussusception

•procedures

•s/s of infection, follow up appts.

Necrotizing enterocolitis

•premature of chronically ill infants

Assessment for necrotizing enterocolitis

•Abdomen tense and distended

•Large gastric residual

•SFOB—positive

•Periods of apnea, poor temp stability

Diagnostic tests for necrotizing enterocolitis

•CBC, CRP, SFOB

•xray

•abdominal girth measurement—will be increased

Nursing interventions for necrotizing enterocolitis

•NPO – IV therapy – TPN – Antibiotics- surgical correction

Short bowel syndrome (SBS)—alteration in intestinal digestionà bowel obstruction

Caregiver education for necrotizing enterocolitis

•breast milk

•SBS—entero feedings, no Kool-Aid or juice, can start solids at a normal age

Gastroenteritis

•Major source of morbidity and hospitalization in children younger than 5

Assessment for gastroenteritis

•Watery diarrhea, cramping, vomiting

•Fever and chills—102.5 or <

•Symptoms last 1-10 days

•Stools with blood and pus

Diagnostic tests for gastroenteritis

•Symptoms and examination

•Stool sample

Nursing interventions for gastroenteritis

•Severe vomiting or diarrhea: IV fluids

•Withhold fluids for 2-3 hrs; 1 tbsp (15 ml) wait 1 hour, give 1 oz (30 mls): give pedialite or popsicles

Caregiver education for gastroenteritis

•Fluids: push fluids

•anti-diarrheals: DON’T GIVE

•Regular diet: after 48 hours

Assessment for functional constipation

•Infrequent hard stools: <2/week

•Pain with stooling

•Holding behaviors with stooling: do not want to use the bathroom

Diagnostic tests for functional constipation

•Occult blood: rule out other conditions

•Flat plate abdominal xray

•Barium enema: rule out Hirschsprung's disease

Nursing interventions for functional constipation

•Disimpaction: enema or oral electrolyte solutions

•Medications: MiraLAX, mineral oil, lactulose

•Behavior modification: toileting schedule, reward BM

•Diet: No cows milk, record diet

Caregiver education for functional constipation

•Medications

•Behavior modification: toileting schedule, and rewards 

•Diet: increased veggies and fluids

Hirschsprung’s disease

Congenital condition

Assessment for Hirschprungs’s

•Meconium: doesn’t pass in first 24 hours

•Constipation

•Stools: ribbon-like or watery stools

•Thin child with protuberant abdomen

Diagnostic tests for Hirschprungs

•Digital exam: empty rectum

•Abdominal xray, Barium enema

•Rectal biopsy: provides definitive dx 

Nursing interventions for Hirschprungs

•IV fluids

•Prepare for surgery: NG tube, preop antibiotics

•Post-op: advance feedings, I&O, observe for pain 

Caregiver education for Hirschprungs

•infection or complications

•Follow-up appointments

•Educate child may be fussy eater after surgery

Omphalocele

•stomach and intestines are contain within a sac of amnio, peritoneum and Wharton’s jelly outside of the abdomen

Gastroschisis

•opening on right side of umbilical cord that stomach, small and large intestine and in rare cases, the liver.

Omphalocele & gastroschisis clinical presentation

•Malrotation of intestines

•Omphalocele: large defect 4-12 cm: sac contains liver, spleen, gonads, bladder, sac may rupture in utero, neural tube defects

•Gastroschisis: intestine at risk for vascular compromise, no neural tube defects

Omphalocele & gastroschisis diagnostic tests

•maternal triple screen alpha-fetoprotein: elevated

•prenatal ultrasound

•Amniocentesis: recommended to see if baby has other defects,

•Nursing Interventions

•C-section delivery

•Wrap defect in sterile gauze soaked in sterile saline

•Prepare for surgery: done in stages

Caregiver education for Omphalocele & gastroschisis

•Procedures

•Post-op care

Biliary atresia

•Congenital absence or closure of the major bile ducts that drain bile from the liver

•progressive inflammatory process that causes cirrhosis

Assessment for biliary atresia

•Significant jaundice by 2 weeks

•Direct bilirubin increased

•Dark urine

•Enlarged liver

•Light-colored stools after 2 months (pale white or grey colored)

Diagnostic tests for biliary atresia

•LFT’s – AST, bilirubin, alk phos

•Ultrasound of liver – liver scan – liver biopsy

Nursing interventions for biliary atresia

•IVF – low-fat, high protein diet, give vitamins A,K,&D

•Surgery

•NG to compress stomach

•Abdominal girth daily

•Advance diet as tolerated

Caregiver education for biliary atresia

•Liver transplant

•emotional support

Obesity

•Overweight: BMI >85 percentile

•Obese: BMI >95 percentile

Assessment for obesity

•Knee pain, abdominal pain, daytime somnolence, menstrual irregularities, infertility

•Associated problems: diabetes, fatty liver disease, heart disease, HTN, sleep apnea, gall bladder disease, slipped capital femoral epiphysis

Nursing interventions for obesity

•Wt loss program

•Nutrition assessment

•daily activity increased

Caregiver education for obesity

•effects of obesity: short and long term

•overfeeding

•diet and exercise

FTT

5th percentile or less

Assessment for FTT

•Vomiting

•Food refusal

•Fixation with food

•Anticipatory gagging

Nursing interventions for FTT

•Nutrition assessment

•Refer to feeding clinic

•positive parenting techniques

•Evaluate for normal weight gain every 1-3 weeks

Caregiver education for FTT

•short and long-term complications for FTT

•healthy diet and activity

Assessment for renal disorders

•Renal function not completely mature until 2 years

•General history: problems, hospitalizations, hx of catheter use, drugs leading to renal issues

•Family history: of thyroid issues, kidney stones, dialysis

•Dietary history: protein and fluid intake, hx of FTT

•Physical exam: head to toe

UTI

•E.coli most common cause of UTI

•Seen in ages 2-6

•Chronic UTI’s cause permanent renal damage

Assessment for UTI

•Fever greater than 100.9

•Vomiting

•Pain abdominal, flank, or back

•Dysuria, urgency, and hematuria

Diagnostic tests for UTI

•Urinalysis—Nitrates always treat for UTI

Nursing intervention for UTI

•Antibiotics—broad spectrum

Caregiver education for UTI

•No tight clothing

•No bubble baths

Vesicoureteral reflux

•Most common congenital anomaly that allows retrograde flow of urine from bladder into the ureters and renal collecting system.

Assessment for Vesicoureteral reflux

•Frequent UTI’s

•Suprapubic pain

•Urinary incontinence

•Enlarged bladder

•Family history of VUR

Diagnostic tests for Vesicoureteral reflux

•Urinalysis and urine culture

•Postvoiding catheterization

•Renal ultrasound: show hydronephrosis

•VCUG: grade VUR 

•DMSA scan: shows renal scarring

Nursing interventions for Vesicoureteral reflux

•Dialysis

•Antibiotics

Caregiver education for Vesicoureteral reflux

•Medications: give all meds finish antibiotics

•Siblings: high risk for VUR and should be screened

Renal calculi

•Various causes of disorder: decreased water consumption, decreased calcium consumption, female more prone, increased Na

Assessments for renal calculi

•Colic type abdominal, flank or back pain

•Hematuria, UTI

•Poor feeding, n/v

•Acute renal failure

Diagnostic tests for renal calculi

•UA: hematuria

•Abdominal xray: calcium calculi

•Ultrasound: calculi obstruction or hydronephrosis

Nursing interventions for renal calculi

•Fluid intake: push fluids (1.5-2X normal fluids)

•Pain control

•Strain urine: make sure stone passes

•Surgery or lithotripsy

Caregiver education for renal calculi

•Medications

•Pain meds

•How to strain urine

•Diet modification