GI

The Child with Gastrointestinal Dysfunction

Introduction

  • Presenter: Megan Anibas, DNP, MS, RN, Winona State University

Objectives

  • Identify Signs and Symptoms of Dehydration in Pediatric Patients
      - Early and late signs

  • Differentiate Levels of Dehydration
      - Mild, moderate, and severe dehydration

  • Describe Common Treatment Methods for Dehydration
      - Oral Rehydration Solutions (ORS)
      - Medications
      - IV fluid replacement, including indications for each treatment

  • Identify Assessment Findings Indicating Improvement in Dehydrated Children

  • Compare and Contrast Inflammatory Diseases of the Gastrointestinal Tract

  • Explain the Pathophysiology of Cleft Lip and Palate
      - List nursing interventions to implement pre- and post-operatively

  • Identify Obstructive Disorders and Disorders of Motility
      - Nursing care related to these disorders

Body Fluids

  • Water Balance in Infants and Young Children
      - Greater need for water
      - More vulnerable to alterations in fluid and electrolyte balance
      - Water and electrolyte imbalances occur more frequently and rapidly
      - Require greater fluid intake and output relative to body size
      - Expanded extracellular fluid (ECF) compartment

Total Body Water by Age Group

  • Term Newborn: 75% water, ECF = 50%

  • Toddlers and Young Children: 65% water, ECF = 30%

  • Teen to Adult: 50% water, ECF = 10-15%

Maintenance Water Requirement

  • Increased Requirements for infants and young children

  • Decreased Requirements for older children and adults

Gastrointestinal Topics Covered

  • Alterations in Fluid and Electrolyte Balance

  • Disorders of Motility

  • Gastrointestinal Structural Disorders

  • Obstructive Disorders

  • Malabsorption Disorders

  • Inflammatory Disorders

Alterations in Fluid and Electrolyte Balance

  • Water Intoxication

  • Dehydration

Water Intoxication

  • Definition: Condition of fluid excess where intake exceeds output

  • Potential Causes:
      - Acute IV fluid replacement
      - Too rapid dialysis
      - Tap water enemas
      - Incorrectly mixed formula feedings
      - Participation in swimming lessons

Dehydration

  • Definition: Condition where output exceeds intake.

  • Types of Dehydration:
      - Isotonic Dehydration
      - Hypotonic Dehydration
      - Hypertonic Dehydration

Isotonic Dehydration

  • Characteristics:
      - Water and sodium loss equal
      - Common primary form of dehydration in children
      - Major concern: reduced circulating fluid leading to hypovolemic shock
      - Serum sodium normal (130-150 mEq/L)

  • Treatment: Isotonic solutions (NS or LR) as bolus

  • Examples: Large blood loss (e.g., surgery, trauma), sweating

Hypotonic Dehydration

  • Characteristics:
      - Electrolyte loss greater than water loss
      - Shifts water from ECF to ICF leading to shock
      - Requires close monitoring with smaller fluid loss
      - Serum sodium less than 130 mEq/L

  • Treatment: Isotonic solutions (NS or LR) as bolus

  • Examples: GI losses such as diarrhea and vomiting

Hypertonic Dehydration

  • Characteristics:
      - Water loss greater than electrolyte loss
      - Most dangerous, requires specific fluid therapy
      - Water shifts from ICF to ECF
      - Serum sodium high (>150 mEq/L)

  • Examples: Large water loss or hypertonic fluid intake (e.g., high protein NG tube feedings)

Degree of Dehydration

  • Mild:
      - Weight loss: <5% infants, <3% children   - Capillary refill: >2 sec
      - Thirst: Slight
      - Skin color: Pale
      - Skin elasticity: Decreased
      - Mucous membrane: Dry
      - Urine output: Decreased
      - Blood pressure: Normal
      - Heart rate: Normal or increased

  • Moderate:
      - Weight loss: 5-10% infants, 3-6% children
      - Capillary refill: 2-4 sec
      - Thirst: Moderate
      - Skin color: Gray
      - Skin elasticity: Poor
      - Mucous membrane: Very dry
      - Urine output: Oliguria
      - Blood pressure: Normal or lowered
      - Heart rate: Increased

  • Severe:
      - Weight loss: >10% infants, >6% children
      - Capillary refill: >4 sec
      - Thirst: Extreme
      - Skin color: Mottled
      - Skin elasticity: Very poor
      - Mucous membrane: Parched
      - Urine output: Marked oliguria
      - Blood pressure: Lowered
      - Heart rate: Rapid, thready

Earliest Detectable Signs of Dehydration

  • Tachycardia (earliest clinical sign, indicating decreased circulating ECF)

  • Dry mouth and mucous membranes (check eyes for tearing)

  • Sunken fontanels (in children <18 months)

  • Coolness and mottling indicative of circulatory failure

  • Loss of skin elasticity

  • Delayed capillary refill

Assessment Parameters for Dehydration

  • Vital signs (VS)

  • Weight measurement

  • Input/Output (I/O) monitoring

  • Behavior changes (response to stimuli)

  • Skin changes

  • General body assessment

Oliguria in Infants or Children

  • Definition: Urine output <1 mL/kg/hr

  • Example Calculation: For an 8 kg child, maximum urine output should be ____ mL per hour

Measuring Urine Output for Non-Toilet Trained Children

  • Method: Use of diaper weights
      - Note: 1 gram equals 1 mL of urine

Management of Dehydration

  • Focus on correcting the fluid loss deficit and treating underlying causes

Management of Mild to Moderate Dehydration

  • Oral Rehydration:
      - Attempted if child is alert and awake
      - Approved fluids include:
        - Pedialyte
        - Infalyte
        - Breastmilk/formula
      - Mild Dehydration: 50 mL/kg rehydration fluid every 4-6 hours
      - Moderate Dehydration: 100 mL/kg rehydration fluid every 4-6 hours
      - Replace diarrhea losses with 10 mL/kg for each stool

Management of Severe Dehydration

  • Parenteral Fluid Therapy:
      - Isotonic solution at 20 mL/kg IV bolus, repeat as necessary
      - Maintenance IV fluids

Conditions Causing Fluid Imbalances

  • Phototherapy

  • Tachypnea

  • Fever

  • Vomiting

  • Diarrhea (Gastroenteritis)

  • Drainage tubes, blood loss

  • Burns

Assessment Findings Indicating Improvement in a Dehydrated Child

  • Moist mucous membranes

  • Serum sodium (Na) and potassium (K) within normal limits (WNL)

  • Voiding greater than 1 cc/kg/hr

  • Capillary refill less than 3 seconds

  • Skin turgor is brisk

  • I/O balance achieved

Disorders of Motility

  • Diarrhea

  • Constipation

  • Hirschsprung Disease

Diarrhea

  • Definition: Abnormal intestinal water and electrolyte transport

  • Transmission: Spread by the fecal-oral route

  • Acute Diarrhea: Duration <14 days; common causes:
      - Infectious agents in GI tract
      - Often self-limiting without specific treatment

  • Chronic Diarrhea: Duration >14 days; caused by:
      - Chronic conditions such as malabsorption syndromes, inflammatory bowel disease, food allergies, lactose intolerance

Gastroenteritis

  • Description: Most common cause of acute diarrhea

  • Causes:
      - Viral
      - Bacterial
      - Medications
      - Food intolerances
      - Parasites
      - Intestinal disease or bowel disorders

Rotavirus

  • Characteristics:
      - Viral infection causing 70-80% of serious gastroenteritis
      - Most severe in children aged 3 to 24 months
      - Symptoms include fever and diarrhea lasting approximately 2 days, with diarrhea continuing for 5-7 days; vomiting lasts about 2 days

Therapeutic Management for Diarrhea

  • Major Goals:
      - Assess fluid and electrolyte imbalance
      - Ensure rehydration
      - Provide maintenance fluid therapy
      - Reintroduce an adequate diet
      - Use oral rehydration solutions at a rate of 10 mL/kg for each diarrheal stool

Constipation

  • Definition: Decrease in bowel movement frequency or difficulty defecating for >2 weeks
      - Signifies passing fewer than 3 stools per week
      - Symptoms may include painful bowel movements and blood streaking (anal fissure), alongside stool retention
      - Frequency of stools varies widely among children; hence, not a diagnostic criterion

Hirschsprung’s Disease

  • Characteristics:
      - Structural anomaly caused by absence of ganglionic cells in segments of the colon

  • Symptoms:
      - Failure to pass meconium
      - Bile-stained vomit
      - Abdominal distention
      - Watery diarrhea
      - Constipation
      - Fever indicating inflammation and possible sepsis

  • Diagnosis:
      - Physical exam and history
      - Barium enema
      - Rectal biopsy to confirm the absence of ganglion cells
      - X-rays as necessary

  • Treatment:
      - Surgical removal of the aganglionic bowel section to relieve obstruction
      - May involve a temporary colostomy
      - Usually undergoes reanastomosis ("pull through") after 8 months to a year
      - Closure of colostomy involved

Structural Disorders

  • Gastroesophageal Reflux (GER) vs. Gastroesophageal Reflux Disease (GERD)

Gastroesophageal Reflux (GER)

  • Description: Gastric contents refluxing into the esophagus, can lead to mucosal trauma; typically resolves by 1 year.

Gastroesophageal Reflux Disease (GERD)

  • Description: Tissue damage due to GER.

Symptoms of GER and GERD

  • Excessive spitting up or forceful vomiting

  • Irritability and excessive crying

  • Blood in stool or vomitus

  • Arching of back

  • Stiffening during feeding

  • Heartburn and abdominal pain

  • Respiratory problems

Diagnosis of GER and GERD

  • Methods:
      - Detailed history and physical examination of the child.
      - Upper GI series to detect abnormalities.
      - 24-hour pH probe study.
      - Endoscopy with biopsy to assess for esophagitis and strictures.

Treatment of GER and GERD

  • For GER:
      - Offer small, frequent meals.
      - Thicken infant formula.
      - Avoid risk foods (caffeine, citrus, spicy foods).
      - Elevate the head of the bed (HOB).

  • For GERD:
      - Use GER interventions
      - Proton pump inhibitors (e.g., Prilosec) or H2 receptor antagonists (e.g., Zantac).
      - Surgical options like Nissen fundoplication (wraps fundus of stomach around distal esophagus).

Complications of Nissen Fundoplication

  • Breakdown of the wrap

  • Small bowel obstruction

  • Gas-bloat syndrome

  • Infection risk

  • Retching issues

  • Gastrostomy tubes

Cleft Lip and/or Palate

  • Cleft Lip: Incomplete fusion of the oral cavity during intrauterine development.

  • Cleft Palate: Incomplete fusion of the palatine plates.

Treatment Options for Cleft Disorders

  • Surgical Repair:
      - Requires coordination with a plastic surgeon, orthodontist, and ENT specialist.
      - Cleft lip repair occurs between 2-3 months of age.
      - Cleft palate repair is done between 6-12 months of age.

  • Additional Support Needs:
      - Speech and language therapy
      - Occupational therapy,
      - Dietitian support,
      - Social work involvement.

Nursing Interventions for Cleft Disorders

  • Preoperative Care:
      - Attention to feeding practices.

  • Postoperative Care:
      - Protecting the surgical site using elbow immobilizers.
      - Managing feeds considering surgical recovery.

  • Long-term Care Goals:
      - Enhancing healthy personality and self-esteem.

Obstructive Disorders

  • Definition and types include Intussusception and Pyloric Stenosis.

Intussusception

  • Overview:
      - One of the most frequent causes of intestinal obstruction in children aged 3 months to 5 years.
      - Most common site: ileocecal valve.

  • Symptoms:
      - Sudden abdominal pain and vomiting.
      - Presence of a sausage-shaped mass in the right upper quadrant.
      - Jelly-like stools.

  • Diagnosis:
      - Ultrasound imaging.

  • Treatment:
      - IV fluids to correct dehydration if present.
      - NG decompression.
      - Air enema as a potential treatment option.
      - Surgical intervention may be necessary in about 20% of cases.

Hypertrophic Pyloric Stenosis

  • Overview:
      - Thickening of the pyloric sphincter causing obstruction
      - Typically occurs within the first 2-5 weeks of life.

  • Symptoms:
      - Projectile vomiting following feedings.
      - Blood-tinged vomit.
      - Constant hunger complaints.
      - Olive-shaped mass in the right upper quadrant.
      - Signs of dehydration and failure to gain weight.

  • Diagnosis Method:
      - Comprehensive history and physical examination.
      - Ultrasound confirmation.

  • Treatment:
      - Pyloromyotomy: surgical intervention opening the pyloric valve.
      - Incision typically made around the belly button or on the right side of the abdomen (approx 1 inch).
      - Gradual reintroduction of feeding (starting 4-6 hours post-surgery).

Malabsorption Problems

  • Short Bowel Syndrome (SBS):
      - A malabsorption disorder resulting from reduced mucosal surface area due to extensive small intestine resection.
      - Definitions combine two findings:
        1. Decreased intestinal absorption surface for fluids, electrolytes, and nutrients.
        2. Requirement for parenteral nutrition (PN).

  • Goals of Treatment for SBS:
      - Preserve as much intestinal length as feasible.
      - Maintain optimal nutritional status, growth, and overall development.
      - Encourage intestinal adaptation through enteral feedings.
      - Minimize complications derived from the disease and its therapies.

Malrotation with Volvulus

  • Definition: Abnormal intestinal rotation around itself.

  • Incidence: 80% of cases present within the first month of life.

  • Symptoms:
      - Bilious vomiting
      - Abdominal pain
      - Abdominal distention
      - Lower GI bleeding

  • Treatment: Surgery required; classified as a medical emergency.

Gastroschisis

  • Description: A malformation characterized by the intestines being outside the abdominal wall.

Nursing Interventions for Short Bowel Syndrome

  • Key Focus Areas:
      - Administration and careful monitoring of nutritional therapy.
      - Central line care for parenteral nutrition.
      - Enteral feeding tube care.
      - Preparation for home care management.

Inflammatory Disorders

Appendicitis

  • Definition: Inflammation of the vermiform appendix.

  • Symptoms:
      - Abdominal pain localized in the right lower quadrant.
      - Rigid abdomen.
      - Decreased or absent bowel sounds.
      - Presence of fever.
      - Changes in bowel habits (diarrhea or constipation).
      - Lethargy.
      - Tachycardia.

  • Diagnosis Methods:
      - CT scan.
      - Ultrasound.

  • Treatment:
      - Appendectomy (surgical removal).
      - Administration of IV antibiotics.

  • Potential Complications:
      - Perforation of the appendix.
      - Development of peritonitis.

References

  • Hockenberry, M.J., Wilson, D., & Rodgers, C.C. (2022). Wong’s Essentials of Pediatric Nursing (11th ed.). St. Louis, MO: Elsevier Mosby.