Notesale: Turn your study into money

Document Preview

Extracts from the notes are below, to see the PDF you'll receive please use the links above

---

Chapter 24

The Child with
Gastrointestinal
Dysfunction

Chapter Outline
Disturbance of Fluid and electrolyte
Dehydration
Gastrointestinal dysfunction
-diarrhea
-Colic (Paroxysmal Abdominal Pain)
-Constipation
-Vomiting
-Hirschsprung disease
- Gastroesophageal Reflux
Inflammatory disorders
Acute appendicitis
Necrotizing enterocolitis

Chapter Outline
Structural defects
Cleft lip and cleft palate
Esophageal atresia and tracheoesophageal
fistula
Hernias

Obstructive disorders
Hypertrophic pyloric stenosis
Intussusception
Anorectal malformations

Learning Objectives
On completion of this chapter the student
will be able to
1-Describe the disturbance of fluid and electrolyte
...

3-Formulate the plan of teaching for parents
preoperative and postoperative care for the child
with cleft palate
...


Introduction
The GI tract extends from the mouth to the anus
...

The functions of the GI tract are ingestion of food,
movement of food from the mouth to the rectum,

mechanical and chemical changes to the food, absorption
of the nutrients, and elimination of waste products
...
Digestion is continued
in the stomach, whereas food is turned into liquid and is

propelled to the small intestine
...


Fat absorption occurs mainly in the jejunum, accomplished
with the aid of the pancreatic enzymes
...


Hematemesis:
Vomiting of bright red blood or denatured blood that results from
bleeding in the upper GI tract or from swallowed blood from the nose
or oropharynx
...


Disturbance of Fluid and electrolyte DEHYDRATION

Dehydration is common body fluid disturbance in infants
and children and occurs whenever the total output of
fluid exceeds the total intake regardless of the cause

Types of dehydration
Dehydration is classified into three categories
(1)Isotonic

(isosmotic or isonatremic)

The primary form dehydration in children occurs in
conditions in which electrolyte and water deficits are
present in approximately balanced proportions
...

(3) Hypertonic (hyperosmotic or hypernatremic)
Results from water loss in excess of electrolyte loss

Degree of Dehydration
Diagnosis of the type and degree of dehydration is necessary
to develop an effective plan of therapy
...

• Any associated electrolyte (especially serum
potassium) and acid base imbalance as indicated

Iagnostic

DEHYDRATION

Therapeutic Management
Medical management is directed at
1-Correcting the fluid loss or deficit
2-Treating the underlying cause
1-Correction dehydration may be attempted with oral
fluid administration
...
Rehydration may be administering 2 to 5 ml

of ORS by a syringe or small medication cup every 2 to 3
minutes: if the child has emesis administering small
amounts (5-10 ml) of fluid every 5 minutes
...
g
...


Gastrointestinal dysfunction Disorders of motility diarrhea

Diarrhea is a symptom that results disorders involving
digestive,
...
diarrhea

Iagnostic

is caused by abnormal intestinal water and electrolyte

transport
...
Diarrhea
Is classified as acute or chronic

Diarrhea
ACUTA DIARRHEA
...
It may
be associated with upper respiratory or urinary tract
infections
...
Or laxative use
...
Is defined as an increase in stool frequency and
increased water content with a duration is more than 14 days
...


Diarrhea
ROTAVIRUS
...
salmonella, shigella,

Iagnostic

and campylbacterter organisms are the most
frequently isolated bacterial pathogens
...


Diarrhea
The major goals in the management of acute diarrhea
include
(1)assessment of fluid and electrolyte imbalance

Iagnostic

(2)rehydration

(3)maintenance fluid therapy
(4) reintroduction of an adequate diet

Infants and children with acute diarrhea and dehydration
should the treated first with oral rehydration therapy (ORT)

...


Diarrhea
A child who is vomiting should be given an ORS at frequent
intervals and in small amounts
...
An ORS may
– to 10 – ml increments every 1
also be given via NG or gastrostomy tube infusion
...
Formula-fed infants should resume their formula
In case of severe dehydration and shock, IV are initiated

Diarrhea
After severe effects of dehydration are under control, specific
diagnostic and therapeutic measures are begun to detect and treat

Iagnostic the course of some diarrheal
controversial
...
The use of antibiotic therapy in children is

illness (e
...
, those caused by Shigella organisms)
...

Antimotility drugs such as Lopramide are not recommended in
children and antiemetic drugs such as the phenothiazines are not
recommended because their side effects
...

It is more common under the age of 3 months than
older infants
...

Over eating, swallowing excessive air
...

Excessive fermentation and gas production in the
intestines
...

Constipation may arise secondary to a variety of organic
disorders or in association with a wide range of systemic
disorders
...

2- Systemic disorders associated with constipation include
hypothyroidism , hyperparathyroidism
...


-More amount of range juice or high fiber diet
...

-Dietary modifications are essential in
preventing constipation
...

-During childhood, the diet should contain
increased amounts of fiber and fluid
...

Reflexive = infection or allergy
...

-Meningitis
...

1-In nonbilious vomiting, the majority of the bile
drains into the more distal portion of the intestine
...

2-In bilious vomiting is implies a disorder in motility
Cause include intestinal atresia and stenosis
intussusception

Vomiting
Vomiting may also associated with other processes,
including acute infectious diseases, increased

intracranial pressure, allergies and toxic ingestion

Complications of vomiting
1-Acute fluid volume loss(dehydration)

2-Electrolyte disturbance
3-Malnutrition
4-Aspiration

Hirschsprung Disease
Hirschsprung disease is a congenital anomaly
that results in mechanical obstruction from

inadequate motility of part of the intestine
...
It is four times
more common in males than in females
...


The absence of ganglion cells in the affected bowel
results in a lack of enteric nervous system stimulation,

which decreases the internal sphincter’s ability to relax
...


Normally, when a stool bolus enters the rectum, the
internal sphincter relaxes and the stool is evacuated
...


Clinical manifestations
Neonatal period
1-Failure to pass meconium within 24 hours after
birth
...

-A neonate usually is seen with distended abdomen
...

-An unprepped barium enema
...


Therapeutic management
The majority of children with HD require surgery
rather than medical therapy with frequent
enemas
...
If the disorder is diagnosed during
the neonatal period, the main objectives are to
(1) Help the parents adjust to a congenital defect in their child,
(2) Foster infant-parent bonding
...

(4) Assist them in colostomy care after discharge
...

This phenomena is
physiologic, occurring
throughout the day;
most frequently after
meals and at night
therefore it is important to
differentiate GER from
Gastroesophageal reflux
disease(GERD)

Gastroesophageal Reflux
Certain conditions predispose children to a high
prevalence of GERD, including
-Neurologic impairment, hiatal hernia and repaired
esophageal atresia (EA)
Pathophysiology

Although the pathogenesis of GER is multifactorial, its
primary causative mechanism likely involves inappropriate
transient relaxation of the lower esophageal sphincter

Gastroesophageal Reflux

Clinical manifestations
Symptoms in infants
-Spitting up, regurgitation, vomiting (may be
forceful)
-Excessive crying, irritability, arching of the
back with -neck extension stiffening
-May be “silent” (no clinical signs observed)
...

-Modified barium swallow with video fluoroscopy

Therapeutic Management
Therapeutic management of GER depends on its severity
...

-Avoidance of certain foods that exacerbate acid reflux
...

-Elevation the head of the bed 30 degree for 1 hour after feedings

Gastroesophageal Reflux

Pharmacologic Therapy
-Both H2-receptor antagonists (cimetidine {Tagamet}
ranitidine {Zantac})
...

-Use available prokinetic drugs (Urecholine )
...


Appendicitis

Etiology
1- The cause of appendicitis is obstruction of the

lumen of the appendix

2-Swollen of the lymphoid tissue frequently
occurring after a viral infection can also
obstruct the appendix

3-Another rare cause of obstruction is a parasite such as
Entrobius vermicularis or pinwoems which can obstruct
the appendical lumen

Appendicitis
Clinical Manifestations:
1-Right lower abdominal pain

2-Fever
3-Rigid abdomen
4-Decreased or absent bowel sounds

5-Vomiting (typically follows onset of pain)
...


Laboratory studies usually include:
1-CBC, urine analysis
...

3- Ultrasonography

Therapeutic management
Treatment of appendicitis before perforation include

1-Rehydration
2-Antibiotic

3-Surgical removal of the appendix(appendectomy)
...


Appendicitis

Ruptured appendix
Management of the child diagnosed with peritonitis

caused by a rupture appendix often begin preoperatively
-with IV administration of fluid and electrolytes
-systemic antibiotics

-NGS suction
...
Such measures
stimulate bowel motility and increase the risk of perforation
...

Care of the child with rupture appendix and
peritonitis, the child is maintained on
-IV fluids,
-NPO
-NG tube is kept on low continuous gastric
decompression until there is evidence of
intestinal activity

Necrotizing Enterocolitis
Necrotizing Entercolitis is an acute inflammatory disease of
the bowel with increased incidence of in preterm infants
...

Clinical manifestations
Specific signs
-Destined (often shiny) abdomen
-Blood in the stool or gastric contents
-Gastric retention (undigested formulae)
-Localized abdominal wall erythema
- Bilious vomiting

Necrotizing Enterocolitis
Interventions
NPO
...

IV fluid replacement
...

Extra oxygen
...

Measure abdominal girth every four hours
...

-Hypoglycaemia
...
They may appear separately or, more often,
together
...
CL can be unilateral or bilateral
...

The palate can be divided
Into the primary and

secondary palates
...

-The secondary palate consists of the remaining portion
of hard palate and all of the Soft palate

 Isolated CP occurs in the midline of the secondary
palate
...
CL/P tends to be more common in boys

and isolated CP occurs more frequently in girls
...


Is generally caused by a combination of genetic and
environmental factors
...
Steroids, and

retinoids are associated with higher rates of oral clefting
...
CP is identified
through visual examination of the oral cavity or when the

examiner places a gloved finger directly on the palate

Therapeutic Management:
Treatment of the child with CL and CP involves the
‫ب‬

cooperative efforts of a multidisciplinary health care team
...
Most physicians
adhere to the ‘’rule of tens’’: the
infant must be 10 weeks old,
weigh 10 pounds, and have a
hemoglobin of 10
...


Surgical Correction of Cleft
Palate:
Cleft palate repair typically occurs
between 6 and 12 months
...


Feeding
Infant with CP and CL/P are often unable to feed which

reduce the infant’s ability to suck if bottle feed infant with an
isolated CL, using bottle with a wide base of the nipple, such
as playtex nurseror a NUK (orthodontic) nipple

Infant with CP can feed efficiently by

modification positioning,
bottle selection

and feeder supportive technique
Begin by positioning an infant in an upright position with
the head supported by the caregiver’s hand or cradled in
the arm; this position allows gravity to assist with the
flow of the liquid

Preoperative Care
In preparation for surgical repair, parents may be taught to
use alternative feeding systems (e
...
,) several days before
surgery
...


-For CL, CP, or CL/P, elbow immobilizers may be used to
prevent the infant from rubbing or disturbing the
suture line, they are applied immediately after surgery
and may be used for 7 to 10 days
...

-Avoid the use of suction or other objects in the mouth,
such as tongue depressors, thermometers, pacifiers,
spoons, and straws
...
g
...


Esophageal Atresia and Tracheoesophgeal Fistula

Etiology
,There

appears to be an equal sex incidence

and the incidence of preterm birth is high
...

The bifurcation (see Fig
...
The second most common variety (5%8%) consists of a blind pouch at each end, widely separated and with no
communication to the trachea (see Fig
...
An H-type EA refers to an
otherwise normal trachea and esophagus connected by a fistula (4%-5%)
(see Fig
...
Extremely rare anomalies involve a fistula from the

trachea to the upper esophageal segments (0
...
24-4, B) or to
both the upper and lower segments (0
...
24-4 D)
...

-A radiopaque catheter is inserted into the hypopharynx
and advanced until it encounters an obstruction
...

The presence of gas in the stomach or small bowel is

indicative of a coexisting TEF
...

Nursing Care Management
Nursing responsibility for detection of this serious malformation
beings immediately after birth
...


Esophageal Atresia and Tracheoesophgeal Fistula
NURSING ALERT
Any infant who has an excessive amount of frothy saliva in the mouth
or difficulty with secretions and unexplained episodes of apnea,
cyanosis, or oxygen desaturation should be suspected of having an EA

or TEF and referred immediately for medical evaluation
...

It is imperative to immediately remove any secretions that can be aspirated
...
Feedings through the
gastrostomy tube and irrigations with fluid are contraindicated before
surgery in an infant with a distal TEF
...


Hernias

A hernia is a protrusion of a portion of an organ or organs through the
abnormal opening
...

Often diagnosed prenatally as early as 25th week of gestation
...

2-Provide supportive treatment of respiratory distress
3-Additional treatment of pulmonary hypertension
4-Perform surgical reduction of repair of defect after respiratory status
is stable

Hernias

Nursing
Preoperative
1-Monitor respiratory status and mechanical ventilation
2-Monitor cardiovascular status
3-Reduce stimulation
4-Maintain NG suction, oxygen and IV fluid
...


Nursing care management
Therapeutic

-Surgical treatment is necessary when complications are related
to GER despite medical management
Nursing
Be alert to significant signs and carry out routine postoperative

Hernias

Abdominal
-Umbilical
Weakness in abdominal wall around umbilicus; incomplete closure
of abdominal wall, allowing intestinal contents to protrude through
opening
...


Nursing management
Therapeutic
No treatment is necessary for small defect
Operative repair if persists to 4-6 years or if defect is more than 1
...


Obstructive Disorders

Obstruction in the GI tract when the passage of nutrition and
secretion is impeded by constricted occluded lumen or when there
is impaired motility (Paralytic ileus)
Obstructions may be 1-congenital or 2-acquired
...

2- Acquired obstructions such as intussusception and tumors

Hypertrophic Pyloric Stenosis

Hypertrophic pyloric stenosis (HPS) occurs when the circumferential
muscle of the pyloric sphincter becomes thickened, resulting in elongation
and narrowing of the pyloric channel between the stomach and duodenum
...
This condition usually
develops in the

first few weeks of life, causing projectile vomiting,

dehydration, metabolic alkalosis , and failure to thrive
...
There is a genetic predisposition , and siblings and offspring of
affected persons are at increased risk of developing HPS
...


Hypertrophic Pyloric Stenosis

1-The diagnosis of HPS is often made after the history and
physical examination
...
Vomiting usually
occurs 30 to 60 minutes after feeding and become
projectile as the obstruction progresses
...
dehydration
2-Ultrasonography
...

4-Laboratory Findings reflect metabolic alterations

Clinical manifestations of hypertrophic pyloric stenosis

Projectile vomiting
-May be ejected 3 to 4 feet from the child
- Occurs shortly after a feeding
-May follow each feeding
-May be blood-tinged

Infant hungry, avid feeder, eagerly accepts a second feeding after
vomiting episode
No evidence of pain or discomfort except that of chronic hunger
weight loss
Signs of dehydration
Distended upper abdomen
Readily palpable olive-shaped tumor in the epigastrium just to
the right of the umbilicus
Visible gastric peristaltic waves that move from left to right
across the epigastrium
...

-Start pyloric re-feeding protocol
...


-Assess for vomiting
...


Intussusception
Intussusception is the most common cause of intestinal
obstruction in children between
age 3 months and 3 years
...


Intussusception

Pathophysiology
Intussusception occurs when one segment of the bowel telescoping
into another segment pulling the mesentery with it
...


Diagnostic Evaluation
Clinical manifestations of Intussusception
Sudden acute abdominal pain
Child screaming and drawing the knee onto the chest
Child appearing normal and comfortable between episodes of pain
Vomiting lethargy
passage of red, current jelly –like stools (stool mixed with blood and
mucus)
...

Palpable sausage –shaped mass in upper right quadrant
Empty lower eight quadrant
Eventual fever prostration and other signs of peritonitis

Intussusception
Therapeutic Management
-Conservative treatment consists of application of
Pneumoenema (air enema) with or without water
soluble contrast or ultrasound hydrostatic (saline)
enema
...


Intestinal Parasitic Diseases Enterobiasis (Pinworms)

Enterobiasis , or pinworms ,caused by the nematode enterobius
vermicularis , is the most common helminthic infection in the
united states
...

repeated testes to collect eggs may be necessary , and if
there is a possibility that other family members may be
infected, a tape test should be performed on them

Enterobiasis (Pinworms)
Clinical manifestations of pinworms

Intense perianal itching evidence itching in
young children includes the following :
-General irritability
-Restlessness
-Poor sleep
-Bed- wetting
-Distractibility
-Short attention span
Perianal dermatitis and excoriation secondary
to itching if worms migrate, possible vaginal
and urethra infection

Therapeutic management
 The drugs available for treatment of pinworms
include mebendazole (vermox)
 It is not recommended for children younger than
2years of age
...
the dose should be
repeated in 2 weeks to completely eradicate the
parasite and prevent reinfection
...

Helpful suggestions include

hand washing after toileting and before eating ,

keeping the child's fingernails short to minimize the
chance of ova collecting under the nails

...

Repeated infections should be treated in the same
manner as first one



---