Nursing Care of the Child with Gastrointestinal Disorders Ann Hearn RNC, MSN Spring 2009.
Nursing Care of the Child with Gastrointestinal Disorders
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Transcript of Nursing Care of the Child with Gastrointestinal Disorders
Nursing Care of the Child Nursing Care of the Child with Gastrointestinal with Gastrointestinal
DisordersDisordersAnn Hearn RNC, MSNAnn Hearn RNC, MSN
Fall 2009Fall 2009
Cleft Lip and Cleft PalateCleft Lip and Cleft Palate
Unilateral, bilateral, midlineUnilateral, bilateral, midline
pphhoottooss
TreatmentTreatment
Surgical repair done ASAPSurgical repair done ASAP Rule of 10 > 10#, 10 weeks, 10 HGBRule of 10 > 10#, 10 weeks, 10 HGB Multidisciplinary teamMultidisciplinary team
Pre-op GoalsPre-op Goals
Prevent Aspiration / Maintain Prevent Aspiration / Maintain NutritionNutrition
Breast feed – small cleft lipBreast feed – small cleft lip Bottle feed – special feeding devisesBottle feed – special feeding devises
– Special nipplesSpecial nipples– Enlarge cross cut holeEnlarge cross cut hole
Bubble frequentlyBubble frequently Hold uprightHold upright ESSRESSR
Provide Emotional SupportProvide Emotional Support
Assist with accepting of defectAssist with accepting of defect Teach proper feedingTeach proper feeding Point out positive attributesPoint out positive attributes Encourage participation in careEncourage participation in care Explain surgical procedureExplain surgical procedure
Pre-op TeachingPre-op Teaching
Remind parents that defect is Remind parents that defect is operable- show photographs of operable- show photographs of corrected cleftscorrected clefts
Introduce cup, spoon feeding devices Introduce cup, spoon feeding devices Explain elbow restraints Explain elbow restraints Explain Logan Bow Explain Logan Bow
Post-OpPost-Op
Prevent trauma to suture linePrevent trauma to suture line– Reduce pain & infectionReduce pain & infection
Cleanse suture lines as orderedCleanse suture lines as ordered Facilitate breathingFacilitate breathing Maintain nutritionMaintain nutrition Referral to appropriate team Referral to appropriate team
membersmembers
Esophageal AtresiaEsophageal Atresia
Assessment FindingsAssessment Findings
Respiratory difficultiesRespiratory difficulties Drooling Drooling Coughing, choking, cyanosisCoughing, choking, cyanosis Gastric distention - if fistula presentGastric distention - if fistula present Hx of ??? during pregnancy?Hx of ??? during pregnancy?
– PolyhydramniosPolyhydramnios gastrointestinal obstructiongastrointestinal obstruction fetus unable to swallowfetus unable to swallow
Management Management
Early diagnosisEarly diagnosis– UltrasoundUltrasound– Radiopaque catheter inserted in the Radiopaque catheter inserted in the
esophagus to illuminate defect on X-rayesophagus to illuminate defect on X-ray Surgical repairSurgical repair
– Thoracotomy and anastomosisThoracotomy and anastomosis
Pre-Op Nursing PriorityPre-Op Nursing Priority
Maintain airway Maintain airway Prevent aspiration pneumoniaPrevent aspiration pneumonia Keep NPO- administer IV fluidsKeep NPO- administer IV fluids
– Elevate HOB 30 degreesElevate HOB 30 degrees– Suction PRNSuction PRN– Prophylactic antibioticsProphylactic antibiotics
Post-OpPost-Op
Maintain nutritionMaintain nutrition– TPNTPN– GastrostomyGastrostomy
Maintain airwayMaintain airway– Prevent aspirationPrevent aspiration
Monitor weigh, growth and development Monitor weigh, growth and development achievementsachievements
ComplicationsComplications– GERSGERS– Stricture formationStricture formation
Teaching Plan: Gastrostomy Teaching Plan: Gastrostomy TubeTube
EquipmentEquipment ProcedureProcedure Psychosocial needsPsychosocial needs Medication administrationMedication administration Stoma careStoma care Problem solvingProblem solving
Gastroesophagial Reflux Gastroesophagial Reflux DiseaseDisease(GERD)(GERD)
Assessment findings: InfantAssessment findings: Infant
Regurgitation almost immediately Regurgitation almost immediately after each feeding when the infant is after each feeding when the infant is laid downlaid down
Excessive crying, irritability Excessive crying, irritability Failure to thrive (FTH)Failure to thrive (FTH) Complications:Complications:
– aspiration pneumoniaaspiration pneumonia– apneaapnea
Assessment findings: ChildAssessment findings: Child
HeartburnHeartburn Abdominal painAbdominal pain Cough, recurrent pneumoniaCough, recurrent pneumonia DysphagiaDysphagia
DiagnosisDiagnosis
Management & Nursing Management & Nursing CareCare
Nutritional needsNutritional needs– Small frequent feedingsSmall frequent feedings– Frequent burpingFrequent burping
PositioningPositioning– Prone flat or head elevated after Prone flat or head elevated after
feedings (not for sleep) feedings (not for sleep) Medications Medications CPR instruction for CPR instruction for
parents/caregiversparents/caregivers
SurgerySurgery
Nissen fundoplicationNissen fundoplication
Post Op Nursing CarePost Op Nursing Care
FeedingsFeedings Burping (bubbling)Burping (bubbling) PositioningPositioning AirwayAirway MedicationsMedications
Medications H2 Histamine receptor antagonists – suppress gastric H2 Histamine receptor antagonists – suppress gastric
acid secretionsacid secretions– Zantac and Pepcid Zantac and Pepcid
Proton-pump inhibitors – reduce gastric acid productionProton-pump inhibitors – reduce gastric acid production– Prevacid and PrilosecPrevacid and Prilosec
Gastric emptying - increasesGastric emptying - increases– ReglanReglan
Antacids – neutralize gastric acidityAntacids – neutralize gastric acidity– GavisconGaviscon
**be sure to study nursing implications and side effects**be sure to study nursing implications and side effects
Pyloric StenosisPyloric Stenosis
– Incidence: 3 in 1000 birthsIncidence: 3 in 1000 births– Possible genetic predispositionPossible genetic predisposition
Pyloric Stenosis
Narrowing of the Narrowing of the pyloric spincterpyloric spincter
Delayed emptying of Delayed emptying of the stomachthe stomach
AssessmentAssessment
Vomiting - projectileVomiting - projectile Constant hunger and fussinessConstant hunger and fussiness Distended upper abdomenDistended upper abdomen Hypertrophied pylorus – olive shaped Hypertrophied pylorus – olive shaped
massmass Visible peristaltic wavesVisible peristaltic waves
DiagnosisDiagnosis
History and PhysicalHistory and Physical Laboratory valuesLaboratory values X-ray or UltrasoundX-ray or Ultrasound
SurgerySurgery
FredFred Ramstedt procedure- Ramstedt procedure-
Pyloromyotomy via laparoscopyPyloromyotomy via laparoscopyPre-opPre-op
Hydration and electrolyte balanceHydration and electrolyte balanceWeigh daily & I and OWeigh daily & I and ONG tubeNG tubeSupport of parentsSupport of parents
Management and Nursing Management and Nursing Care: Post-OpCare: Post-Op
NPO until bowel functionNPO until bowel function– Progressive feeds: Feeding begins with clear Progressive feeds: Feeding begins with clear
liquids containing glucose and electrolytes. liquids containing glucose and electrolytes. Regime example: 8 hours NPO, 10cc sterile water Regime example: 8 hours NPO, 10cc sterile water feed X 2. Increase to 15cc X 2, progressing to ½ feed X 2. Increase to 15cc X 2, progressing to ½ strength formula, then full strength formula. strength formula, then full strength formula. Observe and record the infant’s response to Observe and record the infant’s response to feeding.feeding.
Position with head elevatedPosition with head elevated Assess surgical site for infection - AntibioticsAssess surgical site for infection - Antibiotics AnalgesiaAnalgesia Patient teachingPatient teaching
Critical ThinkingCritical Thinking
A 4 week old infant with a history of A 4 week old infant with a history of vomiting after feeding has been vomiting after feeding has been hospitalized with a tentative diagnosis of hospitalized with a tentative diagnosis of pyloric stenosis. Which of these actions is pyloric stenosis. Which of these actions is priority for the nurse?priority for the nurse?
a. Begin an intravenous infusiona. Begin an intravenous infusion
b. Measure abdominal circumferenceb. Measure abdominal circumference
c. Orient family to unit c. Orient family to unit
d. Weigh infantd. Weigh infant
Gastroschisis Gastroschisis &&
OmphaloceleOmphalocele
Gastroschisis
Treatment and Nursing Care Pre-operatively – focus is on protection of Pre-operatively – focus is on protection of
the contents / sac. Cover with warm, the contents / sac. Cover with warm, sterile, saline-soaked dressings over the sterile, saline-soaked dressings over the defect. defect.
May choose to replace the gut to the May choose to replace the gut to the abdomen gradually over several weeks. abdomen gradually over several weeks. May place silo or silastic material over gut May place silo or silastic material over gut until it returns to the abdomen. until it returns to the abdomen.
Surgery used to close defect. Surgery used to close defect.
GastroschisisGastroschisis
Assessment- noted on ultrasound and Assessment- noted on ultrasound and obvious at birthobvious at birth
Treatment - surgical repair in stagesTreatment - surgical repair in stages Nursing care:Nursing care:
– monitor thermoregulation and loss of monitor thermoregulation and loss of fluidsfluids
– assess for ileusassess for ileus– maintain parenteral feedingmaintain parenteral feeding– provide support to the parentsprovide support to the parents
Omphalocele
OmphaloceleOmphalocele
Assessment- ultrasound and at birthAssessment- ultrasound and at birth
Treatment - surgical repair in stagesTreatment - surgical repair in stages
Nursing care- same as for Nursing care- same as for GastroschisisGastroschisis
IntussuceptionIntussuception
Results in inflamed bowel & bleedingResults in inflamed bowel & bleeding– Leading to necrosis & perforationLeading to necrosis & perforation
Intussuception
Most commonly seen in infants 3-12 monthsMost commonly seen in infants 3-12 months Bowel “telescopes” within itselfBowel “telescopes” within itself
Intussuception: Clinical Intussuception: Clinical ManifestationsManifestations
Intermittent then constant painIntermittent then constant pain VomitingVomiting Abdominal distentionAbdominal distention Currant jelly-like stoolsCurrant jelly-like stools DiarrheaDiarrhea DehydrationDehydrationSerious complications:Serious complications:
Ischemia, perforation & shockIschemia, perforation & shock
Volvulus
Clinical ManifestationsClinical Manifestations and Assessment and Assessment
PainPain Vomiting (fecal material)Vomiting (fecal material) Abdominal distentionAbdominal distention StoolsStools DehydrationDehydration Serious complication: shockSerious complication: shock
DiagnosisDiagnosis
X-rayX-ray Abdominal ultrasoundAbdominal ultrasound
Therapeutic InterventionTherapeutic Intervention
Hydrostatic reductionHydrostatic reduction
Laparoscopic Surgery Laparoscopic Surgery
Post-op Nursing Care:Post-op Nursing Care:
NPO- NG tube, IVNPO- NG tube, IV
Assess – V/S, painAssess – V/S, pain
Monitor stoolsMonitor stools
Re-introduce foodRe-introduce food
AppendicitisAppendicitis
Clinical ManifestationsClinical Manifestations
Abdominal pain – McBurney’s pointAbdominal pain – McBurney’s point Silent AbdomenSilent Abdomen Anorexia & nauseaAnorexia & nausea DiarrheaDiarrhea Elevated temperatureElevated temperature IF PERFORATED:IF PERFORATED:
– Sudden pain reliefSudden pain relief– FeverFever– DehydrationDehydration
DiagnosisDiagnosis
History and PhysicalHistory and Physical UltrasoundUltrasound X-RayX-Ray Laboratory valuesLaboratory values
– increased WBC 15,000 – 20,000increased WBC 15,000 – 20,000
Management and Nursing Management and Nursing Care: Pre-OpCare: Pre-Op
NPONPO IVIV Comfort measuresComfort measures AntibioticsAntibiotics Thermal therapyThermal therapy EliminationElimination Patient educationPatient education
What is the most common symptom What is the most common symptom indicating that the appendix may indicating that the appendix may have ruptured? have ruptured?
Hirschsprung’s DiseaseHirschsprung’s Disease
AssessmentAssessment Failure to pass meconiumFailure to pass meconium VomitingVomiting
Bowel assessmentBowel assessment
BreathBreath
Older childOlder child
DiagnosisDiagnosis
History & PhysicalHistory & Physical
Barium enema (X-ray)Barium enema (X-ray)
Rectal biopsy- absence of ganglionic Rectal biopsy- absence of ganglionic cells in bowel mucosacells in bowel mucosa
Management Management
Surgical intervention Surgical intervention – ColostomyColostomy– ResectionResection
Nursing Care:Nursing Care:
Pre-opPre-op– Cleanse bowel Cleanse bowel – NPONPO– Patient/parent teachingPatient/parent teaching
Post-opPost-op– NPONPO– VS (no rectal temperatures)VS (no rectal temperatures)– AssessmentAssessment– Patient/parent teachingPatient/parent teaching
Diarrhea/GastroenteritisDiarrhea/GastroenteritisSevereSevere
Most infectious diarrheas in this country Most infectious diarrheas in this country are caused by Rotovirus but could be C. are caused by Rotovirus but could be C. difficeledifficele
Clinical ManifestationsClinical Manifestations
Increase in peristalsisIncrease in peristalsis Large volume stoolsLarge volume stools Increase in frequency of stoolsIncrease in frequency of stools Nausea, vomiting, crampsNausea, vomiting, cramps Metabolic Acidosis:Metabolic Acidosis:
– Increased heart & resp. rate, decreased Increased heart & resp. rate, decreased B/P, arrhythmiasB/P, arrhythmias
– Cold, clammy skinCold, clammy skin– Changes in CNS – stupor, lethergyChanges in CNS – stupor, lethergy
DiagnosisDiagnosis
Stool culture
Stool O & P
Blood gases
ComplicationsComplications
Priority Nursing Priority Nursing InterventionsInterventions
Treat underlying causeTreat underlying cause Restore fluid & electrolyte balanceRestore fluid & electrolyte balance Daily weightsDaily weights I&OI&O Assess for dehydrationAssess for dehydration Isolation protocolIsolation protocol Monitor electrolytes/metabolic Monitor electrolytes/metabolic
acidosisacidosis Skin careSkin care
Oral Rehydration
Critical ThinkingCritical Thinking
Why is there an increase in Why is there an increase in incidence of incidence of
diarrhea in lower socio-economic diarrhea in lower socio-economic
groups?groups?
Why is there and increase in youngWhy is there and increase in young
children?children?
Celiac DiseaseCeliac Disease
This results in the accumulation of the This results in the accumulation of the amino acid glutamine which is toxic to the amino acid glutamine which is toxic to the mucosal cells in the intestines. Damage to mucosal cells in the intestines. Damage to the villi impairs the ability of the small the villi impairs the ability of the small intestines to absorb nutrientsintestines to absorb nutrients
Signs and Symptoms
The child with celiac disease commonly demonstrates
failure to grow and wasting of extremities. The abdomen can appear large due to intestinal distension and malnutrition
Complications: Hypocalcemia, osteomalacia, osteoporosis, depression.
Celiac DiseaseCeliac Disease
Assessment - Growth pattern, GI patternAssessment - Growth pattern, GI pattern Failure to ThriveFailure to Thrive Treatment - Treatment - Dietary restrictions Dietary restrictions Nursing Care - monitor for dehydration, Nursing Care - monitor for dehydration,
encourage compliance with encourage compliance with dietary restrictions, provide dietary restrictions, provide support groups for patient and support groups for patient and
caregivercaregiver
Diagnostic FindingsDiagnostic Findings
Measurement of fat contentMeasurement of fat content Duodenal or Jejunal biopsyDuodenal or Jejunal biopsy Elevated IGA antibodies Elevated IGA antibodies
Treatment and Nursing Care
Teach parents DIETARY REGULATIONS:
Gluten Free Diet
NO !
Disease specific support groupsDisease specific support groups
The EndThe End