Chapter 20 Nursing Care of Child With GI DISTURBANCES – Flashcards

common Nursing diagnosis I n o daily weight Measures

1.Mouth: highly vascular and entry point of infection 2.Esophagus: LES not fully developed until age 1, causing regurgitation 3.Newborn stomach: Capacity of only 1o to 20 cc. less than 1 ounce -Possible new parents feeding the babies a couple of ounce this is over feeding really why we get regurgitation 4.Instentines: small and not small at birth. -It is harder for them to absorb nutrients and same for Large intestine means water is going to be absorbed slower -Infants who have small bowel loss during early infacy have more problems withabsortpion and diarrhea than adults who have the same small bowel loss 5. Biliary system: relatively large at birth, pancreatic enzymes continue to develop post naturally, reaching adult levels around 2 years of age. - Do not absorb 6. Fluid Balance and Losses: low fluid volume maintained -Infants and children have a greater amount of body water than do adults. -require a larger relative fluid intake than adults and excrete a relatively greater amount -INCREASED RISK FOR FLUID LOSS

Caused by underdeveloped LES and allow gastric contents to come up Tx parents to decrease the food amount and increase the head after eating , no tummy time after eating

-If the child is in diapers, use a tongue bade to scare a specimen into the collection container -If the child has a runny stool, place a piece of plastic wrap in the diaper may catch the stool specimen. Very liquid stool may require application of urine bag to the anal area to collect the stool. - Th older ambulatory child may first urinate in the toilet and then the stool specimen may be retrieved from the new or clean collection container that fits under the seat at the back of the toilet -For the bedridden child, collect the stool specimen from a clean bedpan (do not allow urine to contaminate -Send the specimen down to lab

If the childs pain is suddenly relived without intervention, suspect perforation and notify the Physcian immediatelu

how: acute inflammation of the appendix Nursing assessment: S/Sx: -Vauge abdmoinal pain, RLQ -Nausea dn vomiting -Small frequent soft stood -Fveer Assessment test: -Palpate: tenderness is not a normal physical finding -RUQ pain could indicate liver enlargement -RLQ pain including rebound tenderness : Pain upon release of pressure during palpation) can be a warning sign of appendicitis. report to physician PAIN may be localized t MCBURNEYS point. a point midway between the anterior superior iliac crest and the umbilicus. Laboratory and Diagnostic Tests for Appendicitis p.730 Abdominal Computed tomograohy (CT) Scan : performed to visualize the appendix for further evaluation -Lab testing: May reveal and elevate WBC -C-Reactive Protein: may be elevated -Ultra sound: - know how to find mcburneys point Nursing management: Preand postperative care -Administer 48 to 72 hours of ordered antibiotics to child to decrease risk of post op infection -child with perforated appendix will require 7 to 14 days of IV antibiotic therapy -Provide family teaching

1.Intestines are not as long was they should be -Complications: Malabsorption,alteration in body requirements LESS THAN... -Child may be taking in the right amount of food but they are not growing Nurse: -We need to increase caloric intake and get them nutrient dense foods 2. Because of the shortness of the bowel and the bowel still continues to produce that bacteria 3. Not the same in all children... depends on where the bowel is short 4. Nurtrition is main goal... So that they GROW . -What nutritional variances can we implement so the child can grow -HIGH CALORIC FOODS, HIGH NUTRITION 5. Complications of The bile flow is reduced either because the liver cannot make bile properly or because it cannot get it out of the liver cells into the bile ducts, or both. The bile ducts themselves may also be abnormal reducing the flow of bile through them.

Antibiotics to contorl bacterial growth -Vitamin and mineral supplementation to replace lost vitamins -Antidiarrheal agents such as loperamide and gastric acid suppressive medications to decrease stool output -TPN for extened periods for adeqate growth -Progression to enternal feeding may occur extremely slowly

-Gentically related -Leads to problems with ear infections (otis media) and nutrients (Eating), altered dentition, delayed or altered speech development -Can be r/t cardio problems, ear malformations, skeletal malformations and speech problems - The infant have difficulty forming an adequate seal around a nipple in order to create necessary suction: SO WE HAVE TO USE A HABERMAN FEEDER: big nipple and squeeze formula or milk into babe -Mother cannot breast feed, or use a regular bottle -Surgical repair (multiple_ 1. infection 2. dental issues 3. messing up the incision: have to keep the childs arm retained so they cannot get the sutures (nono) 4. Must place them on their back !

Anomalies: -Heart defects -Ear malformattions -Skeletal deformities -Genitourinary abnormality Complications: -Feeding difficulties -Altered dentition -Delayed or altered speech development -ottis media : ear infection due to build up of fluid in the middle ear.

Diarrhea Vomiting Decreased oral intake Sustained high fever Diabetic ketoacidosis Extensive burns Nursing management: -Restoring fluid volume and preventing prognosis to hypovolemia -Provide oral rehydration -children who are severly dehydrated admin 20ml/kg of normal saline or LR and then re assess hydration status Formula for maintenace volume:

Labs are going to concentrated May see high potassium, sodium When you have a child that is dehydrated. We never ever add potassium to their IIV until they have voided. - Poassium induced in the IV, ca cause URINARY retention - Unitl child voids then we can give the potassium

Formula for Fluid maintenance: 100 ml/kg for the first 10 kg 50 ml/kg for the next 10 kg 2o ml/kg for remaining kg Add together for total ml needed per 24 hour period Divide by 24 for ml/hr fluid requirement Example: for a 23 kg child -100X10 =1000 -50 x 10=500 -20 x 3 = 60 - 1000 + 500 + 60 = 1560 1560/24=65 ml/hr -

Tx the Primary caregiver: oral rehydration In a Child with mild to moderate dehydration resulting from vomiting -WITHHOLD oral feeding for 1 to 2 hours after Emesis -After this time oral rehydration may begin -Give the infant of child 0.5 to 2 oz of oral rehydration solution every 15 mins note: most infants and children can retain this small amount of fluid if fed the restricted amount very 15 mins. -As child improves larger amounts will be tolerated Take note: homemade oral rehydration solution can by combining 1 quarts of water , 8 teaspoons sugar and 1 teaspoon of salt Take note: Ginger capsules, ginger tea and candied ginger are usfull in reducing nausea and are safe in children over the age of 2 years an no side effect.

-Restoring fluid and electrolyte balance -Continue childs regular diet if the child is not dehydrated Take note: AVOID prolonged use of clear liquids in the child with diarrhea because "starvation stools" may result - also Avoid fluids high in glucose , such as fruit juice gelatin, and soda, wich may worsen diarrhea -Tx parents importance of oral rehydration therapy -Finishing all antibiotics

telescoping of bowel Nursing Assessment: -Can lead to bowel changes s/sx: currant jelly stools, sausage shaped mass -MAY PALPATE SAUSAGE MASS - Sudden onset of pain locate the time and feel, commit , diarrhea; lethargy -Assess the severity of pain etc.... Lab test: -Diagnosed with air or barium enema. Nurse management: Give IV fluids and antibiotics before labs or radiograph studies -Give laxatives and give barium enemas -Offer emotional support

Children younger than 2 years Males Meckel diverticulum Duplication cysts Polyps, hemangiomas, tumors Appendix Cystic fibrosis Celiac disease Crowns disease r/t other GI issues :

Dehydration, vomiting and diarrhea -Oral candidasis and oral lesions: -Hypertophic pyloric stenosis (Covered) -Necrotizing entercolitis (brief) -Intussesception, malrotation and volvulus -Appendicitis

What is it: LES isn't fully developed so allows back flow -Nonbilious vomit unrelated to food and position: The child is not throwing old formula its the formula they just ate. -Nonbilious vomiting: undigested non curddled formula -They wanna eat again Nursing Assessment: -When palpating the abdomen it is hard, moveable, OLIVE shaped mass... in RUQ. (Cardinal symptom) -IF no mass is not felt then a Ultra sound is ordered Complications: - Can cause dehydration -Abnormal Electroltye Values -Can have family predisposition Nursing Management: -fluid management -correcting ELectrolyte vaules -Providing emotional support tx: Surgical repair no long term effects

We see this in premature babies -The bowel stops moving and the bowel gets narcotic Tx: in surgery Many premature babies dies from this

A.Intestines Malrotates-Intestine is abnormally attached and it narrows -Results from a disruption in embryonic development Volvulus: when the bowel twists on its self. Nursing Assessmnet: Cardinal S/Sx is Bilious vomiting. Also, abdominal pain, shock symptoms, abdominal distention, tachycardia and bloody stools Test: KUB can show Volvules note: Whenever you have an infant that has vomit that looks like bile this is bad CALL DOC RIGHT AWAY! -yellow or green gastric content Nurse managemnt: -Give IV fluids and IV antibioticcs -NASO GASTRIC TUBE is placed to decompress the stomach -Post op care for Surgery to fix

1.Cleft lip and palate 2.Omphalocele and Gastroschisis (big one) 3.Hernias (Inguinal and Umbilical 4.Anorectal Malformations Big one: 1.Cleft lip and palate 2.Omphalocele and Gastroschisis (big one)

False. Mostly viral but management is supportive, replace what the child is putting out Gastro enteritis do not want to give an Anti Diarehhal- will cause the flushing to stop , you support them with rehydration making them npo -tylenol and

-Gasteoesophageal felux, Peptic ULCER disease -Constipation/Encopresis -Hirschsprung disease -Short bowel syndrome -Inflammatory bowel disease -Celiac disease -Recurrent abdominal pain - Failure to thrive and chronic feeding problems

A.How? Genetic disorder, lower portion does not move resulting in obstruction, due to lack of ganglion cells S/SX: -Failure to pass stool (Meconium) with the first 24 hours of life -Not feeding well general malaise B.Nursing Assessment: -Assess wether or not the the infant has passed a Meconium stool: most with disease do not -Newborns that require stimulation to pass their first meconium stool should be evaluated for hirschsprung disease Lab test: Barium Enema, Renal suction biopsy Tx: SURGERY on the portion of colon that is effected ....depedning on how large they may have a colestomy - Short gut syndrome: shorteer larger intestine: Water is aborbed : they have for frequent watery stools C.Nursing management: -Provide routine post care -May either have colostomy or ileostomy: perform proper osmotic care to avoid skin breakdown -Acurately measure stool output to assess the childs fluid volume statu -Watch fro possible Enterocolitis: fever, abdominal distention, chronic diarrhea, explosive stools, rectal bleeding, straining IF ANY ARE PRESENT CALL HCP -Make child NPO -Give IV fluids -Give Antibiotics

A.How? -Is an immunologic disorder in which gluten causes damage to the small intestine (Were nutrients are absorbed) - villi damage due to inflammation -Malnutrition occurs B.S/SX - Diarrhea,constipation -STEATORRHEA (fatty stools) -Faliure to thrive -Wt loss -Anemia -Nutritional defeicenses C.Nursing Assessment: gather a health hx of s/sx - Assess for distended abdomen, wasted buttocks and think extremities -Lab test: Antibody screen(IGa) is the first line test , Intestinal Biopsy and genetic testing D.Nursing management: educate to family that child must adhere to a strict gluten free diet for his entire life

Food Allowed: Potato, soy, rice, bean flour, rice bran, cornmeal , arrow root corn potato starch Plan, fresh , frozen or canned vegetables made with allowed ingredient all fruits and fruit juices All milk and milk products all meat, poultry fish and shell fish died peas and beans, nuts, peanut butter, soybean, cold cuts, frank furthers Butter margine , salard dressing sauces aoups desert with allowable ingredients: sugar, honey, jelly, jam, hard candy, plain chocolate, coconut, molasses, marshmallows , meringues , purse Foods to avoid: All wheat products All creamed or breaded vegetables Some commercial fruit pie Malted milk flavored or forzen yogurt Any meats or poultry prepared with wheat,thy, its barely glueten Commercial salad dressings , condiments sauces and seasonings

A.How? -Failure to achieve complete evacuation of the lower colon. -Term newborn should pass a meconium stool within the first 24 hours of live. If this this does not occur, new born is at risk for developing an underlying GI Disorder -Bottle fed may not go for 2-3 days with out stool. Functional Constipation : Mostly in school age ...s/x -Less than three bowel movements weekly -at least one episode of fecal incontinence weekly -stool withholding behavior (retentive posturing) -Hard or painful bowel movements -Large fecal rectal mass -Stool passage of a volume to clog the toilet Encopresis : soiling of fecal contents into underwear... is a result of chronic constipation and withholding of stool. B.S/SX -Altered stool pattersn, pain with defecation, withholding behaviors, crossing less, squatting or hiding in a corner or dancing -Compaints of abdominal pain and cramping and poor appetite -Diarhea leakage -Soiling of undergarments NOTE the duration of symptoms to determine onset C.Nursing Assessment: Assess for signs and symptoms order for abdomen: Inspect auscultation, Percussion, Palpate last D.Nursing management: - Tx parents how to assess for signs of constipation and withholding behavior -scheduling and supervisiing bowel habits reconditioning the child to use the toilet regularly -Tx to use positive reinforcement techniques (reward with stickers extra play time or -Dietary changes: HIGH fiber diets -Increasing fluid intake

A.How? Chrons-A segment of bowel affected (UPPER BOWEL), good and bad ares; Full thickness Ulcerative Colitis: Affects WHOLE COLON, affects continuous;superficial inflammation B.S/SX: Cramping, fever, wt loss , poor growth, delayed sexual development, nighttime symptoms C.Nursing Assessment: Assess: Abdominal cramping, Night time symptoms, including waking due to abdominal pain to urge to defecate -Fever -Weight loss -Poor growth (Small childs) -Delayed sexual development -Assess stool pater history -Inspect preening area look for skin tags of fissures which would be highly supiscous of crones D.Nursing management: - Provide teaching - Tx about nutritional management : high protein and high carbohydrate diet. When a diet is active, lactose may be poorly tolerated and vitamin and iron supplements are needs -MAKE THEM NPO when the flare up occurs gives it times to heals. TPN may be need -Tx about medication therapy 1.5 Aminosalicylates (5-ASA) : used to prevent relapse (Usually used in ulcerative colitis 2. Antibiotics: (Metronidazole (flagel) and Ciprofloxacin) used in children who have perianal Crohn disease 3. Immunodulators (Usually 6 mercaptopurine or azathioprine): used to help maintain remission. -Monitor children for neutropenia and hepatotoxicity 4. Cyclosporine or tacroliums: used in junction with 6-mp or azathioprine to maintain remission in fulminant ulcerative colitis 5. Methotrexate: used to manage severe crohn disease 6. anti-tumore necrosis Antibody therapy: widely used for children with crohn disease, accessional used with ulcerative colitis -Promoting family coping and child coping: arrange for counseling ... may need to write letters to the school explaining the frequent absences

A.How? -Abdominal pain is relieved by defecation B.S/SX: What is the criteria for DX? -Onset of pain or discomfort with Change in: - Frequency of Stool -Form of Stool note their is no structural or metabolic explanation for this abdominal pain C.Nursing Assessment: Rule out other issues before dingo D.Nursing management: -Increasing dietary fiber -Counseling

A.Pancreatitis: don't see it much unless immunocompromised - very painful, Inflammation of pancreas Nurse: -Rest GI, NPO -Naso gastric tube to decompress -Seial monitoring of serum amylase levels note: oral feedings are restarted when levels have reached to normal -Admin IV fluids Pain management B.Gallbladder disease Cholelithiasis-Presence of stones in the gallbladder, that causes obstruction, which causes inflammation -S/x: RUQ pain Not a lot of digestion Nurse: -Admin IV fluids -Make them NPO -Gastric Decompression -Pain management -Post op care if Cholecystectomy C.Jaundice -Seen in newborns, tx with Biliy light , related to immature of liver If we see it anywhere else it is secondary D.Billiary atresia -Absence of some or major biliary ducts resulting in obstruction of bile flow wich causes cholestaisis and jaundice Nursing management -Vitamin and caloric support -Admin fat soluble vitamin A, D, E, K -Give feedings through NG Tube -make NPO E.Hepatitis Inflammation of liver s/sx: Jaundice , Fever, Abdominal pain Nurse Management: -Bowel Rest , Hydration and nutriton - Provide tx about transmission and prevention, including proper hygiene, safe sexual activity careful hand washing -NPO status and nasogastric tube admin of lactulose to decrease ammonia levels -TPN nutrition Labs: AST and ALT elevated Cautious of blood and body fluid precautions for the hepatitis that is not transmitted through food : BCDF F.Cirrhosis and portal hypertension Cirrhosis : blood flow to nd from the liver meet resistance causing portal blood flow pressure to ruse Most important complication is GI BLEEDING Nurse: GI bleeding must be controlled -Replacing bloos loss and providing vasopressive therapy to constrict the shunted blood flow G.liver transplantation Looking with clotting disorders Nurse: assist with trans plant work up -tx child and family what to expect -Monitor child for s/sx of rejection and infection : fever, increasing liver function test, increasing pain, redness and swelling at the incision site

A.Colostomy in the LARGE intestine -Depending on where they are depends on the type os stool being formed Ascending : liquid Middle: mix B.Ileostomy: in the SMALL intestine -Issues with absorption -It is common to see undigested food in bag after eating712 -Much harder to manage Think little children: accidents that occur after absorbing large amounts of foods. Nurse: -Educate parents to inform school staff that the child should be allowed to use the water fountain and the bathroom with out restriction and School nurse should have extra supplies -Empty the ostoomy pouch and measure for stool several times a day -Liquid stool output can be acidic causing irritation and severe burn like areas on the surrounding skin -Tx special attention to skin care around osmotic site -tx that stoma should be moist and pink or red (demonstrating circulation) -Tx to notify HCP immediately if stoma is not moist or pink -Tx to perfrom ostomy care as needed. Pouches need to be changed every 1 to 4 days.

1. set up equipment -warm wet washcloths or paper towels -Clean ouch and clamp -skin barrier powder, paste -pencil or pen -scissors -pattern to measure stoma sixe 2. Take off much (may need adhesive removal or wet wash cloth 3. Observe the stoma and surrounding skin. clean the stoma and skin as needed , allowing it to dry thoroughly 4. Measure the stoma, mark the new push backing and cut the new backing to seize 5. Apply the new pouch.

Omphalocele A.How? -Defect in umbilical ring-Evisceration of Abdominal contents into external peritoneal sac: A membranous sac covers exposed organs B.S/SX C.Nursing Assessment: -Readily availabbe to see, not appearance and evidence of sac or not -Perform complete physcial examination, congenital conditions are associated with other congenital anomalies D.Nursing management: Gastroschisis: same thing but the organs are NOT COVERED by a membrane Nursing Manangent: Goals: Preventing hypothermia, maintaining perfusion of evicertaed abdominal contents by -Minimizing fluid loss -protecting the exposed abdominal contestants from trauma and infection, -The abdominal contents are covered with a non-adherent sterile dressing in such a fasssion to avoid causing trauma Invervention: -Strict sterile technique : Place infant in a sterile drawstring bowel bag (feet first) that maintains a sterile environment for exposed contents, allows visualization, reduced heat and moisture loss and allows heat from radiant warmers to reach the newborns -Place child on back -A radiant warmer -Covering the dressing with plastic wrap may help to decrease heat and fluid loss - Maintain low suction to and orogastric tube to prevent intestinal distention -Establish IV line for fluid and electrolyte balance -Closely observe for bowel compromise: color, decrease in temp and report these immediately

painmangenment monitoring respiratory and cardiac status monitor I n O -Assessing for vascular compromse maintaining orogastric tube to suction -documenting amount or color of drainage

C. ACITIS FLUID RETENTION, GASEOUS DISTENTION OR EVEN TUMORE -MANY CHILDREN HAV POT BELLY A DEPRESED CONCAVE ABDOMEN MIGHT INDICATED HIGH ABDOMINAL OBSTRUCTION OR DEHYDRATION

1.INSPECT FIRST 2.AUSCULTATION HYPERACTIVE INDICTAED DIARRHEEA OR GASTRO ENTERUTUS OR HYPOACTIVE BOWEL: EITHER OBSTRUCTION OR CONSTIPATION 3. PERCUSSION: DULLNESS, FLATNESS, TYMPANY 4. PALPATION -PALPATE LIGHLT FIRST AMD THEN DEEP PALPATION -RESRVE FOR LAST IN SEQUENCE, PALPABLE KIDNEYS MAY INDICATE TUMORE OR HYDROPHROSIS; RLQ PAIN MAY WARN OF APPENDICITIS

A. Obstruction

A.How? Incomplete fusion of omphalomesenteric duct causes a fibrous ban that connect to the small intestine to the umbilicus dx with Meckel Scan B.S/SX -bleeding, anemia, sever colicky abdominal pain -Abdominal distention, hypoactive bowel sounds, guarding, adbodimal mass, rebound tenderness C.Nursing Assessment: D.Nursing management: -Administer blood products and IV Fluids -Maintain NPO status -Perform Post op care and Family education

Children are considered medically fragile for a lengthy period A lot of anxiety -Long term hospitalization is usually required , parents may miss work and time with other children -Encourage famalies to become experts on their childs needs and condition via education and participation in care -Provide teaching so that t the family is better able to care for the child in and outpatient setting