Week 10 Peds GI

Pediatric differences

• frequent feedings

• frequent bowel movements

• faster peristalsis

• breast fed stools and frequency

• formula fed stools and frequency

How to assess for dehydration in children?

• assess skin turgor

• fontanels

• lack of tearing

• dry mucus membranes

• thirst

• skin temperature

• activity level

S/S GI disorders in infants/children

• vomting/regurgitation

• irritability/fussiness

• abdominal pain/distention

• Failure to thrive

• weight lost

• stool changes

Subjective assessment Peds GI

• family hx

• diet

• gaining/losing weight

• through hx feeding pattern

• allergies (lactose intolerant, celiac dx)

• spitting up

• elimination pattern

• I/Os

• encorpresis/constipation

Objective assessment Peds GI

• inspect distention, symmetry, bulges or masses, umbilicus

• auscultate hyper/hypo bowel sounds

• percuss tympany vs dullness

• palpate light vs deep, rebound tenderness, McBurney’s point

Disorders of the GI system include

• structural defects

• disorders of motility

• inflammatory disorders

• disorders of malabsorption

• hepatic disorders

• injuries to the GI system

Structural defects

• cleft lip and cleft palate

• esophageal atresia and tracheoesophageal fistula

• pyloric stenosis

• intussusception

• abdominal wall defects

• anorectal malformations

• umbilical hernia

Cleft lip and cleft palate is a

congenital anomaly that occurs as a result of failure of soft tissue or bony structure to fuse during weeks 6-12 gestation

Characteristics Cleft lip and Cleft palate

• may appear by itself or together

• cleft lip can be unilateral or bilateral

• most common craniofacial deformities in the US

• multifactorial causes

Complications with CL/CP

• feeding problems (ability to suck, swallow, and breath without distress)

• speech development

• otologic

• dental and orthodontic

• developmental delays

Cleft lip management

• special feeding techniques until surgery

• Haberman feeder

• ESSR method

What is the Haberman feeder technique used for infant with cleft lip?

• hold infant in upright position

• stimulate sucking by rubbing nipple to allow child to get food into back of throat without strong sucking

• allow time to swallow and burp frequently

What is the ESSR method for cleft lip?

• enlarge nipple

• stimulate sucking

• swallow rest

Cleft lip repair

• surgery usually done at 1-3 months

• z shape suture line

Post op cleft lip repair

• logan bar over child’s mouth to reduce tension on suture line

• clean sutures, use saline to prevent crusting, antibiotic ointment on suture line

• elbow restraints (release every 2 hours)

• breck feeder technique

• position on back or side lying

Cleft palate is repaired in stages between

6 months and 2 years of age

Repairing cleft palate protects against

• altered dentition and speech dysfunction

• frequent ear infection (otitis media) d/t open nasopharynx

• need to be able to use cup to drink

Cleft palate repair post op

• maintain airway, O2 sat monitor

• no bottles, straws, pacifiers, spoons for at least 7-10 days

• elbow restraints and mittens

• clears to soft diet

• all feedings followed by rinsing mouth with water to clean suture line

• pain med

• no brushing teeth 1-2 weeks

Esophageal Atresia (EA) & Tracheoesophageal Fistula (TEF)

• associated with maternal polyhydramnios

• may occur alone or together (usually tgt)

Esophageal Atresia (EA) is a

congenital disruption of upper and lower portions of esophagus

surgical emergency

Tracheoesophageal Fistula (TEF) is a

abnormal communication b/t trachea and esophagus

S/S Esophageal Atresia (EA) and Tracheoesophageal Fistula (TEF)

immediate newborn period

• respiratory distress

• difficulty feeding

• excessive drooling

• choking, coughing

• cyanosis

Pre-op EA and TEF

• maintain airway

• NG tube to suction

• prevent aspiration (HOB increase, NPO)

• IV fluids, IV abx

• G tube may be placed to drain stomach content/allow air to escape

• surgical repair single or staged surgery depending on age, size, length of gap

Post-op EA and TEF

• initally NPO

• TPN

• g tube feeds

• feeds start with clears then advance over several days

• complications: tears, stricture, reflux, infection

• family teaching

Pyloric stenosis characteristics

• etiology unknown but often affects first born males

• present at birth

• food causes irritation, progressive edema and further narrowing

Pylroic stenosis is diagnosed by

ultrasound

Pyloric stenosis occurs

between stomach and duodenum

Pyloric stenosis is

hypertrophy of the circular muscles of the pylorus hat causes narrowing of the pyloric canal between the stomach and duodenum

Physical assessment of pyloric stenosis

• vomiting progresses from mild regurgitation to projectile vomiting

• vomiting occurs shortly after meals

• vomiting is forceful (2-4feet)

• constant hunger, fussiness, crying

• decrease in size and number of stools

• failure to gain or lose weight

• dehydration & electrolyte imbalance

• olive shaped mass sometimes palpable on abdominal exam

How is pyloric stenosis treated?

surgery= pyloromyotomy

Pre-op Pyloric stenosis surgery

• NPO

• IVFs for fluids/electrolyte management

• NG tube

Post-op Pyloric stenosis surgery

• maintain IVF, analgesics, NG tube

• start feeds

Gastroschisis & Omphalocele are

Abdominal wall defects

Gastroschisis & Omphalocele

• a congenital defect of the ventral abdominal wall, characterized by herniation of abdominal visceral outside the abdominal wall

gastroschisis occurs

to the side of umbilicus

omphalocele occurs

through the umbilical cord

Nursing management for Gastroschisis & Omphalocele

• prevent infection by covering sac with sterile gauze soaked in NS, then sterile plastic

• monitor VS closely; assess temperature

• NPO, maintain IVFs, TPN

• parental support

Anal stenosis & Anal atresia are

Anorectal malformations

Anal stenosis is

thickened & constricted anal wall (produce ribbon-like stools

Anal atresia (imperforated anus)

• failure to pass meconium

• exam reveals absent anal opening

What would you see in anal stenosis & anal atresia?

stool in urine or vagina due to fistulas

Treatment for Anorectal malformations depends on

where it is located and if it is low/high defect

Treatment for low defect Anorectal malformations

anoplasty and serial digital dilations are effective

Treatment for high defect anorectal malformations

2 step procedure that may involve a temporary colostomy

Umbilical hernia is

hernia protrusion of an organ or part of an organ through the muscle wall of the cavity that normally contains it

Umbilical hernia results from

imperfect closure of the umbilical muscle ring and often associated with separation of the abdominal muscles

Clinical manifestations Umbilical Hernia

• herniated umbilicus protrudes with coughing, crying, or straining

• hernia can be reduced by pushing contents back into fibrous ring

• most defects spontaneously resolve by 3-4 years old, as muscular ring closes

• surgery indicated in cases of strangulation, increased protrusion after 2 years of age or no improvement in large defect after 4 years