View
217
Download
2
Category
Preview:
Citation preview
Child with Altered Gastrointestinal Status
Jan Bazner-Chandler
CPNP, CNS, MSN, RN
Developmental and Biologic Variances Suck and swallow reflex develops at 34 weeks Stomach capacity is 10-20 mL in the infant up to
3 liters by adolescence Coordinated oral pharyngeal movements
necessary to swallow solids develops after age 2 months
Stool frequency is highest in infancy Control of stool is achieved by 18 months to 4
years
Developmental and Biologic Variances Liver edge is palpable 1-2 cm in infants and
young children Abdominal distension can cause respiratory
distress Pancreatic amylase secretion does not begin
until age 4 months
Prenatal History
Birth weight Prematurity History of maternal infection Polyhydramnion
Focused Health History
Congenital anomalies Growth or feeding problems Travel Economic status Food preparation General hygiene Family history of allergies
Present Illness
Onset and duration of symptoms
Weight loss or gain
Recent changes in diet
Vomiting
Reflexive = infection or allergy
Central = central nervous system head trauma meningitis CNS tumor
Nursing Assessment
Abdominal distention Abdominal circumference
Abdominal pain Acute / diffuse / localized
Abdominal assessment Inspect / auscultation / palpation / measure
Measuring Abdominal Girth
Bowden Text
Diagnostic Tests
Flat plate of abdomen Upper Gastrointestinal series (UGI) Barium swallow / enema Gastric emptying study Abdominal ultrasound CT scan with or without contrast MRI Endoscopy
Abdominal x-ray
UGI Series with Barium
5-year-olds/p MVADiagnosis: hematomaof duodenumTreatment: NG tube, IVfluids, electrolytemaintenance
Diagnosis of appendicitis, tumors, abscess
CT of liver with metastasis
Endoscopy Colonoscopy
Stool Sample
White blood cells Ova and Parasite Bacterial cultures Fecal fat Stool pH Rotazyme (rotovirus) Blood
Blood Values
Liver function tests: ALT, AST, GGT, ALP, ammonia levels
Bilirubin direct and indirect Hepatitis antigens Total protein, albumin levels
Treatments
Endoscopy Surgical interventions Ostomy Nutritional therapy Modified diet Enteral nutrition
Failure to Thrive
Inadequate growth resulting from inability to obtain or use calories required for growth.
FTT is failure to grow at a rate consistent with standards for infants and toddlers younger than 3 years of age.
Symptom – not a diagnosis
FTT
Organic Physical cause identified: heart defect, GER, renal
insufficiency, malabsorption, endocrine disease, cystic fibrosis, AIDS.
Non-organic Inadequate intake of calories Disturbed mother-infant bonding No associated medical condition
Interdisciplinary Interventions If no medical cause is found focus of care is on
environmental / developmental / behavioral cause
Occupational therapy to determine infant ability to suck / swallow
Observation of infant / caretaker interaction Calorie count to determine actual calories
consumed Monitoring of height / weight / HC
Cleft Lip and Palate
Most common craniofacial anomaly Males 3 to 1 Higher in Asians Familial history Often diagnosed in utero by ultrasound
Cleft Lip
Incomplete fusion of the primitive oral cavity• Obvious at birth• Infant may have problems with sucking• Surgery in 2 to 3 months• Goals of surgery
• Close the defect• Symmetrical appearance of face
Feeding
Cleft Lip
Plasticsurgery.org
Cleft Lip Repair
Plasticsurgery.org
Post Surgery Care
Airway management Pain control / minimize crying Position with HOB elevated 30 degrees Elbow immobilizers Suture line care as ordered by MD
Cleanse with saline or dilute hydrogen peroxide to remove crusts and minimize scarring
Arm Immobilizer
Cleft Lip Repair
Cleft Palate
Cleft palate occurs when the palatine plates fail to migrate and fuse between the 7th and 12th week of gestation.
Diagnosed by looking into infants mouth.
Note disruption of tooth development in D.
A. Cleft LipB. Complex Cleft Lip
C. Cleft Lipand palate
Cleft Palate Repair
Babies should be weaned from bottle or breast prior to the surgical procedure.
Done around 1 year of age after teeth have erupted and before the child is talking to promote better speech outcomes
Poor speech outcomes if done after 3 years of age.
Post Surgery Repair
Position on side NPO for 48 hours Suction with bulb syringe only Avoid injury to palate with syringes, straws,
cups etc.
Long Term Referrals
Hearing Speech Dental Psychological Team approach to care
Esophageal Atresia EA
Congenital anomaly that results from failure of the esophagus to develop normally.
The proximal esophagus ends in a blind pouch instead of communicating with the stomach.
EA is often associated with a tracheal esophageal fistula (TEF)
Esophageal Atresia
Tracheal Esophageal Fistula
TEF TEF results from failure of
the trachea and esophagus to separate.
Fistula
Assessment- Prenatal
Clinical manifestations may be noted prenatally History of polyhydramnios Stomach cannot be easily identified on ultrasound
Assessment at Birth
CaREminder: Excessive drooling of saliva may be first symptom of TEF. When fed, the infant sucks well but then chokes and coughs as the feeding enters the lungs.
Diagnostic Tests
Feeding tube is passed into the esophagus but resistance will be felt.
Diagnosis confirmed by radiographs
Interdisciplinary Interventions Pre-surgery Care Sump catheter in upper esophageal pouch to
provide continuous suction of pooled secretions
Gastrostomy may be performed to provide gastric decompression
Respiratory support Antibiotics for aspiration pneumonia
Interdisciplinary Interventions Repair done within 24 to 72 if infants
condition is stable Done through a thoracotomy or
thoracoscopic repair Antibiotics Acid suppression therapy Chest tube, gastric decompression and
continued respiratory support TPN
Esophageal Repair
Long Term Complications
5 to 15% experience leaking at operative site. Aspiration Dysphagia / difficulty swallowing Stricture of esophagus
Coughing Regurgitation
Pyloric Stenosis
Most common cause of gastric outlet obstruction in infants.
1 in 500 More common in males 3 weeks to 2 months of age History of regurgitation and non-bilious
vomiting shortly after feeding. Vomiting becomes projectile
Hypertrophic Pyloric Stenosis Most common cause of gastric outlet
obstruction in infants. More common in males 2 to 4 per 1,000 births
Pathophysiology
Hypertrophy and hyperplasia of the circular smooth muscle of the pylorus of the stomach.
The lumen of the pylorus narrows and lengthens and the gastric outlet is progressively obstructed.
Pyloric Stenosis
Assessment
History of regurgitation and nonbilious vomiting during or shortly after feeding.
Within a week vomiting becomes projectile Olive shape mass in the upper abdomen to
right of the midline Weight loss and FTT Because of persistent vomiting will often
present with dehydration
Interdisciplinary Interventions Initial goal of therapy is to correct any fluid
and electrolyte imbalance NPO / NG tube insertion to empty and
decompress stomach Comfort infant and caretakers
Interdisciplinary Interventions After fluid and electrolyte balance is re-
established surgery is the definitive treament. Postoperative care:
IV fluids Oral feeding
Starting with small amounts of pedialyte Advance to full formula feedings as tolerated
Feeding Post-operatively
Give 10 ml oral electrolyte solution after recovered from anesthesia
Start pyloric re-feeding protocol. Increase feeding volumes from clear fluids to
dilute to full-strength formula. Keep feeding record Assess for vomiting Discharged when taking full-strength formula
Recommended