gastrointestinal disorders

muscle tone variation

-lower esophageal sphincter is not fully developed until 1 month old

-may not have proper sphincter tone until almost 1 year

stomach capacity newborn

10-20 mL

stomach capacity 2 month old

can hold up to 200 mL

stomach capacity age 16

1500 mL

stomach capacity of adults

2000-3000 mL

small intestines

not functionally mature at birth

-develops over the first few years of life

-matures a lot during infancy

body water

-greater amount

-ECF makes up about half of the total until age 2

fluid loss

higher risk for insensible loss and dehydration

-fever

-can't concentrate urine

-high basal metabolic rate

fever

-increases the fluid loss rate of 7 mL/kg/day for every 1.8 degree rise in temp

stool diversions

surgical procedures to create an ostomy (ileostomy or colostomy)

*a portion of the small or large intestine to the surface of the abdomen

ostomy pouch

-worn over the ostomy site to collect stool

-ensure appropriate size and fit

-avoid tight/restrictive clothing

ostomy care

-challenging with a child especially if they are very active

-empty several times per day

-stool is different depending on location (higher = liquid; lower = solid)

-change every 1-4 days

-remove with adhesive remover or wet washcloth

-clean the stoma and surrounding skin and allow to dry thoroughly

*assess the skin when doing this

cleft lip

*30% have some sort of genetic disorder

-tissue that forms the lip ordinarily fuses by 5 weeks

-may occur in isolation

-50% may also have cleft palate

cleft palate

*30% have some sort of genetic disorder

-tissue that forms the palate closes by 7 weeks

-may occur in isolation

cleft lip and palate complications

-feeding difficulties (latching issues, through the nasal passage, frequent burping, spitting up)

-altered tooth growth

-delayed/altered speech

-otitis media

cleft lip and palate tx

-managed by a specialized team

-lots of people to figure out best treatment options

-surgery

*may require revisions as the child grows (not a one-and-done)

cleft lip repair

2-3 months

-allows for more of a "normal" appearance

cleft palate repair

6-12 months

-depends on the degree of opening

cleft lip and palate nursing

-Breastfeeding is best

-may have respiratory difficulties with feeding

-speech development and AOM (montior)

*may need special feeding devices

-encourage bonding

after lip repair

-arm restraint to stop hands from touching suture line

after palate repair

*nothing in mouth to disrupt sutures

-side lying immediately after surgery

-NPO x 4 hours

-liquids only x3-4 days then soft diet

esophageal atresia

*congentally interrupted esophagus

-proximal and distal ends do not connect/communicate

-maternal hx often positive for polyhydramnios (baby not swallowing the fluid like they should)

tracheoesophageal fistula

-abnormal communication between the trachea and esophagus

*trachea/esophagus connect >> food into the trachea

-maternal hx often positive for polyhydramnios (baby not swallowing the fluid like they should)

esophageal atresia and tracheoesophageal fistula s/sx

NEWBORN: copious, frothy bubles of mucus in mouth and nose accompanied by drooling and abdominal distention

FISTULAS: feeding may cause coughing, choking, cyanosis, aspiration pneumonmia, and atelectasis

esophageal atresia and tracheoesophageal fistula pre-op

-surgery ASAP

-NPO

-elevate HOB 30-45 degrees

-monitor hydration and fluid/electrolyte balance

*I&Os, weight, labs

-administer fluids

-maintain patency of OG tube, continuous low suction

-O2 and suctioning equipment available for possible cyanotic episodes

esophageal atresia and tracheoesophageal fistula post-op

-TPM and antibiotics until we can confirm reconnections are working and doing its job

-oral feedings 5-7 days after surgery

-closely assess feedings and swallowing (observe parent feeding or you do the feeding)

imperforate anus

-congenital malformaiton of the anorectal opening

-malformaiton can be high or low

-usually require stages repair with ostomy unitl full repair can be done

*why the first temp taken is rectal

high imperforate anus

no opening at all

-going to need multiple surgeries to fix

*ostomu until repair is done

low imperforate anus

opening but is irregular

-fistula, blind pouch, connected to vagina or urethra

imperforate anus s/sx

-no meconium in the first 24 hours of life

-abdomnial distension

-no passing gas

-bilious vomiting (green/dark yellow)

imperforate anus pre-op

-NPO

-IV fluids

-gastric decompression (NG/OG tube)

imperforate anus post-op

-pain relief

-NPO

-gastric decompression until bowel function resumes

*check bowel sounds and ensure they are passing gas

-barrier cream at anal sphincter to avoid irritation

imperforate anus surgery challenge

maintaining the nerves and muscles so they can maintian normal evacuation of stool

omphalocele and gastroschisis

congenital abnormalities of the anterior abdominal wall

-both should be seen on the 20 week ultrasound

*need more specialized delivery/care (pediatric surgeon)

*c-section delivery

omphalocele

-defect of umbilical ring

-allows for abdominal content into an external peritoneal sac

-sac offers slight protection to the protrusions

gastroschisis

-herniation of abdominal contents through abdominal wall defect

-no peritoneal sac to protect protruding organs (very swollen and red due to exposure to amniotic fluid)

-quicker surgery intervention

*high rate of mortality and morbidity despite surgical correction

omphalocele and gastroschisis maternal risk factors

-maternal illness/infection

-drug use

-smoking

-genetic abnormalities

omphalocele and gastroschisis nursing

-prevent hypothermia (warmer/isolet)

-never place prone

-maintain profusion by minimizing fluid loss and protecting exposed organs from trauma and infection

*non-adherent sterile dressing

*plastic wrap (good visualization and decreased heat/moisture loss)

-low suction to OG tube to prevent distension

-IV fluids and electrolyte balance

-monitor fluid status (I&O and daily weights)

-promote parent/newborn interaction

omphalocele and gastroschisis post-op care

-OG to suction

-pain management

-STRICT I&O

-daily weights

-cardiac and respiratory function

meckel diverticulum

-fibrous band connects small intestine to the umbilicus

-MOST common congenital abnormality of the GI tract

-can cause bowel obstruction

-packed RBCs before surgery if they present with significant anemia

meckel diverticulum s/sx

-bleeding/anemia (increased ulcer risk)

-severe colicky abdominal pain

-abdominal distention

-hypoactive bowel sounds

-guarding

-rebound tenderness

-stool positive for occult blood

meckel diverticulum surgery

-if child is symptomatic

*NPO and IV fluids

-to remove fibrous band and push small intestine back

inguinal herniia

-can be seen at birth or present later in life

-abdominal or pelvic viscera travels though inguinal ring into the inguinal canal

-more common in premature infants

-surgical correction @ several weeks old

*should be manually reduced

*contact surgeon if it becomes irreducible

umbilical hernia

-incomplete closure of umbilical ring, allowing intestinal contents to herniate through

-most have spontaneous closure by 4-5

*surgery needed if it's still there and large

-seek care if it does not reduce

-discourage home remedies, can cause bowel strangulation

dehydration

-occurs more readily in infants and children

-can lead to hypovolemic shock if left unchecked without intervneiton

dehydration risk factors

-diarrhea

-vomiting

-decreased oral intake

-sustained high fever

-DKA

-extensive burns

mild dehydration sx

-alert

-soft flat fontanels

-normal eyes

-pink/moist oral mucosa

-elastic turgor

-normal HR

-normal BP

-warm, prink brisk cap refill of extremities

-slightly decreased urine output

-3%-5% weight loss

moderate dehydration sx

-alert to listless

-sucken fontanels

-midly sunken orbits of eyes

-pale and slightly dry oral mucosa

-decreased skin turgor

-may have increased HR

-normal BP

-delayed cap refill

-<1 mL/kg/hr urine output

-6%-9% weight loss

severe dehydration sx

-alert to comatose

-sunken fontanels

-deeply sunken orbits

-no tears

-dry mucosa

-tenting

-increased then bradycardia HR

-normal then hypotension BP

-cool, mottled, telayed cap refill

-significantly <1 mL/kg/hr urine output

- more than 10% weight loss

isotonic dehydration

water and sodium loss equal

-most common

-replace with NS or LR

hypotonic dehydration

electrolyte loss greater than water loss

*see with cystic firbosis)

-more severe manifestations (seizures/coma)

-replace with NS + dextrose

hypertonic dehydration

water loss is greater than electrolyte loss

*see with laxitive use

-neuro changes can occur (confusion)

-replace with 1/2 NS

dehydration nursing: oral rehydration

-for mild to moderate dehydration

-oral rehydration solution 50-100 mL/kg over 4 hours

dehydration nursing: IV fluids

for severe dehydration

-administer 20 mL/kg then reassess hydration status

*balanced restored; recieve fluids at maintenance rate or as much as 1.5x maintenance

vomiting

-forceful expulsion of gastric content through the mouth

-many causes (infectious, GI , GU, endocrine/metabolic, neurologic)

vomiting hx

-what did the emesis look like

-was it effortless or projectile

-was it before or after feeding

-does it have other associated sx (GI upset, fever, abdominal pain)

vomiting labs and tests

-abdominal US

-upper GI series

-plain abdominal radiographs

-barium swallow

vomiting nursing

-offer 1-2 oz every 15 minutes

-IVF's if not tolerated

-antiemetics if appropariate

-ginger capsules (not used in kids <2 years old)

diarrhea

increased in frequency or a decrease in consistency of stool

acute diarrhea

-caused by virus/bacteria/parasites

-bloody or non-bloody

-antibiotic use (maybe)

*probiotic use may be helpful

acute diarrhea risk factors

-recent ingestion of undercooked meats

-foreign travel

-day care attendance

-well water use

diarrhea hx

-number and frequency of stools within the last 24 hours

-duration of sx

-presence of blood and mucus in stool

-any associated sx (N/V, fever, abdominal pain)

rotavirus diarrhea

loose watery stools (5-7 days)

-fever and vomiting for around 2 days

-TX: rehydration, electrolyte replacement, refeeding

*common in young children

norovirus diarrhea

loose watery stools (5-7 days)

-fever and vomiting for around 2 days

-TX: rehydration, electrolyte replacement, refeeding

*common in older children

salmonella/E. coli diarrhea

-blood or mucus in stools

-may shed for a year, diarrhea for 2-3 weeks

-may cause hemolytic anemia

-TX: rehydration, electrolyte replacement, refeeding, may need antibiotic

giardia lamblia diarrhea

-fatty/greasy stools

-oral fecal transmission

-TX: rehydration, electrolyte replacement, refeeding, and may need antiparasitic therapy

chronic diarrhea infants

-hirschsrung diease

chronic diarrhea toddlers

celiac disease

chronic diarrhea school age children

constipation with encopresis (run around)

chronic diarrhea nursing

stool studies for diagnosis or KUB (radiographs)

-fluid and electrolyte balance

-regular diet encouraged

-avoid fruit juice

-encourage probiotics when taking antibiotics

constipation

-bowel habits vary among children

-many etiologies

-can be functional

functional constipation

*no underlying cause; two out of these in one month period

-less than 3 BM per week

-1 fecal incontinence per week after toilet trained

-hard or painful BM

-volume of stool large enough to clog toilet

-stool withholding behavior

encopresis

-soiling of fecal content into underwear after 5 years old

-usually from chronic constipation or withholding stool

constipation dx

-abdominal x-rays

-barium enema

-rectal manometry to evaluate musculature

constipation nursing

-educate on high fiber foods

-increase water

-educate one how to use suppositories

-enema

-bowel training (try to get them on a schedule)

oral candidiasis

-fungal infection of the oral mucosa

-common in newborns and infants

oral candidiasis risk factors

-immune disorders

-use of corticosteroid inhalers

-immunosuppressive drugs

-antibiotic use

-breastfeeding

oral candidiasis signs

-thick white patches on the tongue, mucosa, and palate

-patches are not wiped off with a swab or washcloth

-may also have a candida diaper rash

-satellite lesions (bumps around the area) HURT

oral candidiasis nursing

FIRST LINE: nystatin suspension 4x per day following feeding

-infant (apply with swab)

SECOND LINE: fluconazole once daily with food

-monitor for hepatotoxicity

-breastfeeding mom may need tx

-continue to breastfeed

-handwashing is important to prevent

-keep pacifiers and bottle nipples clean

hypertrophic pyloric stenosis

thickening of the sphincter, which creates an obstruction

hypertrophic pyloric stenosis s/sx

-nonbilious vomiting presents at 3-6 weeks of life

-projectile vomiting occurs as it worsens

-weight loss

-progressive dehydration

***olive-shaped mass in RUQ

***catapillar sign

catapillar sign

GI peristaltic wave from left to right of the abdomen when supine

hypertrophic pyloric stenosis dx

ultrasound

-shows mass at elongated pyloric canal

hypertrophic pyloric stenosis tx

-surgical intervention (pyloromyotomy by laparoscope)

*cut the thickened muscle to relieve obstruction

hypertrophic pyloric stenosis pre-op and post-opm

-IVF's for dehydration and electrolyte imbalance

-one to two days after start oral feedings

intussusception

-when a proximal segment of bowel telescopes into a more distal segment (collapses in on itself and crashes down)

-causes: edema, vascular compromise, and a partial/total bowel obstruction

intussusception s/sx

-sudden onset of intermittent crampy abdominal pain

-severe pain

-vomiting

-diarrhea

*currant-jelly stools

-gross blood or hemocult positive stools

*sausage-shaped mass in mid-upper abdomen

intussusception dx

-air or barium enema (may also reduce it)

intussusception tx

-surgical intervention if not resolved with an enema

*may have to resect portions of the bowel if necrosis occurs

appendicitis

-acute inflammation of the appendix due to a closed loop obstruction

-causes subsequent mucosal edema, bacterial overgrowth, and eventual perforation

*results in peritonitis

appendicitis s/sx

*abdominal pain localized to the RLQ

-McBurney point tenderness

-n/v

-frequent soft stools

-fever

-ill-appearing

appendicitis diagnosis

-iliopsoas test

-CT scans

-increased WBCs

ilipsoas test

-raising the right leg causes severe pain

-due to muscle connection

appendicitis tx

-surgical emergency

-GOAL = prevent rupture

-appendectomy is usually done by laparoscopy

-if perforation = open surgical procedure and lavage of the abdominal cavity

*IV antibiotics (7-14 days post-op)

*JP drain

gastroesophageal reflex

-gastric contents into the esophagus

-normal physiologic process in infants and children

-usually resolves by 12-18 months old

gastroesophageal reflux disease (GERD)

-pathologic process with:

-recurrent vomiting or regurgitation

-weight loss or poor weight gain

-irritability in infants

-respiratory symptoms

-hoarseness/sore throat

-heartburn

gastroesophageal reflux disease (GERD) tx

-appropriate positioning

-keep upright after feeding

-smaller feedins

-may need meds that decrease acid production (flamotidine)

-may need prokinetic agents (metoclopramide) that minimize amount of gastric contents in stomach

-nissen fundoplication if necessary

nissen fundiplication

-take fundus of the stomach and wrap around lower esophagus to increase pressure and decrease reflux

Hirschsprung disease

-absence of ganglion cells in a portion of the intestines, resulting in obstruction

-characterized by failure to pass meconium within the first 24 hours of life

Hirschsprung disease risk factors

-family hx

-down syndrome

-intestinal atresia (disconnect)