Pediatric Nursing: Gastrointestinal Problems Flashcards
(40 cards)
1
Q
Vomiting
A
- major concern is the risk of dehydration, electrolyte imbalances, and development of metabolic alkalosis (due to loss of hydrochloric acid).
- additional concern include aspiration and the development of atelectasis or pneumonia.
- causes: acute infections diseases, increased IPC, toxic ingestions, food intolerance, mechanical obstruction of the GI tract, metabolic disorders, and psychogenic disorders.
- assessment: emesis, abd pain, cramping, signs of aspiration, dehydration, fluid or electrolyte imbalances, metabolic alkalosis.
- interventions: maintain patent airway, position child on the side, monitor character, amount, and frequency. Assess force, projectile vomiting (may indicate pyloric stenosis or increased IPC). Monitor strict intake and output, sings of dehydration, electrolyte levels. Provide oral rehydration (if possible) or IV fluids, adm antiemetics, assess pain.
2
Q
Diarrhea
A
- a concern for acute diarrhea is dehydration (particularly < 5 years).
- causes (acute): acute infectious disorders of the GI tract, ATB therapy, rotavirus, and parasitic infestation.
- causes (chronic): malabsorption syndromes, inflammatory bowel disease, immunodeficiencies, food intolerances, and nonspecific factors.
- rotavirus is a serious gastroenteritis and is nosocomial, most severe in children 3-24m.
- assessment: character of stools, abd pain and cramping, signs of dehydration and electrolyte imbalances, and metabolic acidosis.
- interventions: monitor character, amount, and frequency, provide enteric isolation. Monitor skin, strict intake and output, electrolyte levels, signs of dehydration. Provide rehydration therapy as prescribed.
3
Q
Cleft Lip and Cleft Palate: description and assessment
A
- are congenital anomalies that occur as a result of failure of soft tissue or bony structure to fuse during embryonic development.
- involves abnormal openings in the lip and palate.
- causes include hereditary (chromosome abnormalities, family history) and environmental (exposure to radiation, rubella, maternal smoking, medications taken during pregnancy).
- prenatal supplementation of folic acid is important decrease the risk.
- closure of cleft lip is first by age 3-6m. Closure of palate around 1y. A cleft palate is closed as early as possible to facilitate speech development.
- child with cleft palate is at risk for frequent otitis media (that can result in hearing loss).
- assessment: cleft lip can range from a slight notch to a complete separation from the floor of the nose. Cleft palate can include nasal distortion, midline or bilateral cleft, and variable extension from the uvula and soft and hard palate.
4
Q
Cleft Lip and Cleft Palate: Interventions
A
- assess the ability to suck, swallow, handle normal secretions, and breath without distress.
- monitor daily weight, fluid and calorie intake.
- plan to use specialized feeding techniques, obturators, and special nipples and feeders. hold in upright position and direct the formula to the side and back of the mouth to prevent aspiration.
- feed small amounts and burp frequently.
- keep suction equipment and bulb syringe at the bedside.
- instruct the parents on care and the ESSR method (Enlarge the nipple, Stimulate the sucking reflex, Swallow, Rest).
5
Q
Cleft Lip and Cleft Palate: Postoperative interventions
A
- provide lip protection and prevent trauma to the suture line.
- avoid positioning on the side of the repair or prone.
- keep the surgical site clean and dry, after feeding, gently cleanse the suture line with a solution such as normal saline.
- apply ATB ointment to the site as prescribed.
- elbow restraints should be used.
- after cleft palate repair, feedings are resumed by bottle, breast, or cup (surgeon preference).
- oral packing may be secured to the palate (usually removed in 2-3 days.
- avoid placing anything in the child’s mouth (includes pacifiers), and the use of oral suction.
- soft elbow or jacket restraints may be used, but should be removed at least every 1-2h.
- initiate appropriate referrals (dental, speech therapy).
6
Q
Esophageal Atresia and Tracheoesophageal Fistula: description and assessment
A
- esophagus terminates before it reaches the stomach or a fistula is present that forms an unnatural connection with the trachea.
- condition causes oral intake to enter the lungs or large amount of air to enter the stomach.
- aspiration pneumonia and severe respiratory distress may develop, and death is likely to occur without surgical intervention.
- treatment includes maintenance of a patent airway, gastric or blind pouch decompression, supportive therapy, and surgical repair.
- assessment: frothy saliva in the mouth and nose, and excessive drooling. The “3Cs” - coughing, chocking, and unexplained cyanosis. Regurgitation and vomiting, abd distension, increased respiratory distress during and after feeding.
7
Q
Esophageal Atresia and Tracheoesophageal Fistula: Interventions
A
PREOP
- infant may be placed in a radiant warmer in which humidified oxygen is adm (intubation and MV may be necessary).
- maintain NPO status, IV fluids, supine position (at least 30 degrees).
- monitor respiratory status, suction secretions.
- if GTT is inserted, may be left open.
POSTOP
- monitor VS, respiratory status, strict intake and output, daily weight, anastomotic leaks.
- maintain IV fluids, ATB, parenteral nutrition, and chest tube if present.
- assess for pain, dehydration, fluid overload.
- if GTT present, it is usually attached to gravity drainage until the infant can tolerate feedings and the anastomosis is healed (5-7 days postop).
- prepare for esophagogram.
- before feeding elevate the GTT and secure it above stomach to allow gastric secretions to pass to the duodenum.
- adm oral feedings with sterile water, followed by frequent small feedings.
- provide nonnutritive sucking (pacifier) for infants who remain NPO.
8
Q
Gastroesophageal Reflux Disease
A
- is backflow of gastric contents into the esophagus as a result of relaxation or incompetence of the lower esophageal or cardiac sphincter.
- usually improves in about 1 year and requires medical therapy only.
- assessment: passive regurgitation or emesis, poor weight gain, irritability, hematemesis, heartburn (older children), anemia from blood loss.
- interventions: assess amount and characteristics, relationship to the times of feeding or activity. Monitor breath sounds before and after feeding, assess for signs of aspiration, place suction equipment close. Monitor intake and output, signs of dehydration, maintain IV fluids as prescribed.
- keep supine position while sleeping and head of bed elevated (prone only acceptable when awake and monitored).
9
Q
Gastroesophageal Reflux Disease: diet and medications
A
- provide small, frequent feedings with predigested formula.
- nutrition via GTT may be prescribed if severe and poor growth.
- formula may be thickened by adding rice cereal to the formula.
- breast feeding may continue, and the mother may provide more frequent feeding times or express milk for thickening with rice cereal.
- burp the infant frequently.
- for toddlers, feed solids first, followed by liquids. Also, avoid fatty food, chocolate, tomato products, carbonated liquids, fruit juices, citrus products, and spicy food.
- child should avoid vigorous play after feeding, and feeding just before bedtime.
- antiacids for symptoms relief.
- proton pump inhibitors and histamine H2 receptor antagonist to decrease gastric acid secretion.
10
Q
Hypertrophic Pyloric Stenosis
A
- hypertrophy of the circular muscles of the pylorus causes narrowing of the pyloric canal between the stomach and the duodenum.
- stenosis usually develops in the first few weeks of life, causing projectile vomiting, dehydration, metabolic alkalosis, and failure to thrive.
- assessment: vomiting, hunger, irritability, peristaltic waves are visible from left to right across the epigastrium during or right after feeding. An olive shaped mass is in the epigastrium just right of the umbilicus. Signs of dehydration, malnutrition, electrolyte imbalances, metebolic alkalosis.
- interventions: monitor strict intake and output, vomiting episodes and stools, daily weight, signs of dehydration. Prepare child for pyloromyotomy.
11
Q
Pyloromyotomy
A
- an incision through the muscle fibers of the pylorus.
- preop: monitor hydration status by daily weight, intake and output, urine for specific gravity. Maintain NPO stauts, correct fluid and electrolyte imbalances, adm fluids. Monitor the number and character of stools, maintain patency of nasogastric tube placed of decompression.
- postop: monitor intake and output. Begin small, frequent feedings and gradually increase in amount and interval. Feed slowly, burping frequently and handle the infant minimally after feedings. Monitor for abd distension, surgical wound for signs of infections, and instruct parents about wound care and feeding.
12
Q
Lactose Intolerance
A
- inability to tolerate lactose as a result of an absence or deficiency of lactase.
- assessment: symptoms occur after ingestion. Abd distension, pain, cramping, colic, diarrhea, and excessive flatus.
- intervention: eliminate dairy products or adm an enzyme tablet replacement. instruct that child should drink milk with other foods and encourage consumption of hard cheese, cottage cheese, and yogurt, which contain the inactive lactase enzyme. Encourage consumption of small amounts of dairy foods daily to help colonic bacteria adapt to ingested lactose. Instruct parents about the foods that contain lactose, including hidden sources.
13
Q
Celiac Disease: description
A
- also known as gluten enteropathy or celiac sprue.
- intolerance to gluten (protein content of wheat, barley, rye, and oats).
- results in the accumulation of the amino acid glutamine, which is toxic to intestinal mucosal cells.
- intestinal villous atrophy occurs, which affects absorption of ingested nutrients.
- symptoms occur most often between the ages 1-5y.
- there is usually an interval of 3-6m between the introduction of gluten and the onset of symptoms.
- strict dietary avoidance of gluten minimizes the risk of developing malignant lymphoma of the small intestine and other GI malignancies.
14
Q
Celiac Disease: assessment and crisis
A
- acute or insidious diarrhea, steatorrhea, anorexia, abd pain and distension, muscle wasting (particularly in the buttocks and extremities), vomiting, anemia, irritability.
- celiac crisis: precipitated by fasting, infection, or ingestion of gluten. Causes profuse watery diarrhea and vomiting. Can lead to rapid dehydration, electrolyte imbalance, and severe acidosis.
15
Q
Celiac Disease: interventions
A
- maintain a gluten-free diet, substituting corn, rice, and millet as grain sources.
- instruct the parents of the child about lifelong elimination of gluten sources such as wheat, rye, oats, and barley.
- adm mineral and vitamins supplements, including iron, folic acid, and fat-soluble vitamins A, D, E, and K.
- teach the child and parents about gluten-free diet and about reading food labels carefully for hidden sources of gluten.
- inform the parents in measures to prevent celiac crisis and about the Celiac Sprue Association.
16
Q
Appendicitis
A
- inflammation of the appendix.
- when the appendix becomes inflamed or infected, perforation may occur within a matter of hours, leading to peritonitis, sepsis, septic shock, and potentially death.
- treatment is surgical removal of the appendix before perforation occurs.
- assessment: pain in periumbilical area that descends to the right lower quadrant, most intense at Mcburney’s point. Referred pain indicating the presence of peritoneal irritation, rebound tenderness and abd rigidity. Elevated WBC count, difficulty walking with pain in the right hip, low-grade fever, anorexia, nausea, vomiting, and diarrhea.
17
Q
Peritonitis
A
- results from a perforated appendix.
- causes increased fever, progressive abd distension, tachycardia, tachypnea, pallor, chills, restlessness, and irritability.
- an indication of a perforated appendix is the sudden relief of pain and then a subsequent increase in pain accompanied by right guarding of the abdomen.
18
Q
Appendectomy
A
- surgical removal of the appendix.
PREOP: - maintain NPO status, adm IV fluids and electrolytes as prescribed. Monitor changes in the level of pain and avoid the use of pain meds so as to mask pain changes associated with perforation. Monitor signs of ruptured appendix and bowel sounds. Adm ATB as prescribed. Position in a right side-lying or low or semi-fowler’s position to promote comfort. Apply ice packs to the abdomen for 20-30 min every hour if prescribed. Avoid application of heat, laxatives or enemas.
POSTOP: - monitor VS, maintain NPO status until bowel function has returned, advancing the diet gradually. Asses the incision and monitor drainage from the drain. Position the child in a a right side-lying or low or semi-fowler’s position with the legs slightly flexed to facilitate drainage. Change the dressing and perform wound irrigations as prescribed. Maintain nasogastric tube suction and patency if present. Adm ATB and analgesics as prescribed.
19
Q
Hirschsprung’s Disease: description
A
- a congenital anomaly also known as congenital aganglionosis or aganglionic megacolon.
- occurs as a result of an absence of ganglion cells in the rectum and other areas of the affected intestine.
- mechanical obstruction results because of inadequate motility in an intestinal segment.
- disease may be familial congenital defect or may be associated with other anomalies such as down’s syndrome and genitourinary abnormalities.
- a rectal biopsy shows histological evidence of the absence of ganglionic cells.
- most serious complication is enterocolitis; signs include fever, severe prostration, GI bleeding, and explosive watery diarrhea.
- treatment for mild or moderate disease is based on relieving the chronic constipation with stool softeners and rectal irrigations; however, many children require surgery.
- treatment for moderate to severe disease involve a 2-step surgical procedure. Initially in neonatal period, a temporary colostomy is created to relieve obstruction and allow the normally innervated, dilated bowel to return to its normal size. When that happens, a complete surgical repair is performed via a pull-through procedure to excise portions of the bowel; at this time, the colostomy is closed.
20
Q
Hirschsprung’s Disease: Assessment and interventions
A
- Newborns: failure to pass meconium stool, refusal to suck, abd distension, bile-stained vomitus.
- Children: failure to gain weight, delayed growth, abd distension, vomiting, constipation alternating with diarrhea, ribbon-like and foul-smelling stools.
- Inteventions: maintain a low-fiber, high-calorie, high-protein diet; parental nutrition may be necessary in extreme situations. Adm stool softeners and daily rectal irrigations as prescribed.
21
Q
Hirschsprung’s Disease: Surgical management
A
PREOP
- assess bowel function, adm bowel preparation, maintain NPO status, monitor hydration and electrolytes. Adm ATB or colonic irrigations as prescribed. Monitor strict intake and output, daily weight, measure abd girth daily, and monitor for respiratory distress. Avoid taking rectal temp.
POSTOP
- monitor VS, measure abd girth daily, assess surgical site, stoma, and anal area. Maintain NPO status until bowel sounds return or flatus is passed (usually 48-72h), and nasogastric tube to allow intermittent suction until peristalsis returns. Main IV fluids until child tolerates oral intake, assess for dehydration and pain. Monitor strict intake and output and obtain daily weight. Provide parents with instructions on care and diet.
22
Q
Intussusception: description and assessment
A
- telescoping of one portion of the bowel into another portion.
- condition results in obstruction to the passage of intestinal contents.
Assessment: - colicky abd pain that causes the child to scream and draw the knees to the abd (fetal position).
- vomiting of gastric contents and bile-stained fecal vomiting.
- currant jelly-like stools containing blood and mucus.
- hypoactive or hyperactive bowel sounds.
- tender distended abd, possibly with a palpable sausage-shaped mass in the upper right quadrant.
23
Q
Intussusception: Interventions
A
- monitor for signs of perforation and shock as evidenced by fever, increased HR, changes in level of consciousness or BP, and respiratory distress.
- ATB, IV fluids, and decompression via nasogastric tube may be prescribed.
- monitor for the passage of normal, brown stool, which indicates that the intussusception has reduced itself.
- prepare for hydrostatic reduction as prescribed to resolve the prolapse.
- post-hydrostatic reduction monitor for the return of normal bowel sounds, for the passage of barium, and the characteristics of stool. Adm clear fluids, and advance the diet gradually.
- if surgery is required, postop care is similar to care after any abd surgery.
24
Q
Abdominal Wall Defects: Omphalocele
A
- refers to herniation of the abdominal contents through the umbilical ring, usually with an intact peritoneal sac.
- protrusion is covered by a translucent sac that may contain bowel or other abd organs.
- rupture of the sac results in evisceration.
- immediately after birth, the sac is covered with sterile gauze soaked in normal saline to prevent drying of abd contents; a layer of plastic wrap is placed over the gauze to provide additional protection against moisture loss.
- monitor VS every 2-4h.
- preop: maintain NPO status, adm IV fluids, and handle infant carefully.
- postop: control pain, prevent infection, maintain fluid and electrolyte balance, and ensure adequate nutrition.
25
Abdominal Wall Defects: Gastroschisis
- occurs when the herniation of the intestine is lateral to the umbilical ring.
- no membrane covers the exposed bowel and should be covered loosely in saline-soaked pads and wrapped in a plastic drape.
- preop: care is similar to that for omphalocele, surgery is performed within several hours after birth.
- postop: most infants develop prolonged ileus, require MV, and need parenteral nutrition; otherwise, care is similar to that for omphalocele.
26
Umbilical and Inguinal Hernia
- umbilical hernia is a protrusion of the bowel through an abnormal opening in the abd wall.
- in children, hernias most commonly occur at the umbilicus and also through the inguinal canal.
Assessment:
- umbilical hernia refers to a soft swelling or protrusion around the umbilicus that is usually reducible with a finger.
- inguinal hernia refers to a painless inguinal swelling that is reducible. Swelling may disappear during periods of rest and is most noticeable when the infant cries or coughs.
27
Incarcerated hernia and postop interventions
- occurs when the descended portion of the bowel becomes tightly caught in the hernial sac, compromising blood supply.
- represents a medical emergency requires a surgical repair.
- assessment: irritability, tenderness at site, anorexia, abd distension, and difficulty walking.
PostOp
- assess wound for infection, redness or drainage, monitor VS, input and output (hydration status).
- advance the diet as tolerated.
- adm analgesics as prescribed.
28
Hydrocele
- the presence of abd fluid in the scrotal sac.
- noncommunicating: occurs when residual peritoneal fluid is trapped in the scrotum with no communication to the peritoneal cavity. Usually disappears by age 1 year as the fluid is absorbed.
- communicating: associated with a hernia that remains open from the scrotum to the abd cavity. A bulge in the inguinal area or the scrotum that increases with crying or straining and decreases when the infant is at rest.
PostOp
- provide icebags and a scrotal support to relieve pain and swelling.
- instruct the parents that tub bathing needs to be avoided until the incision heals, strenuous physical activities need to be avoided, and advise that the scrotum may not immediately return to normal size.
29
Constipation: description and assessment
- is the infrequent and difficult passage of dry, hard stool.
- abd pain and cramping without distension, palpable movable fecal masses, normal or decreased bowel sounds, malaise, headache, anorexia, nausea, and vomiting.
30
Encopresis: description and assessment
- constipation with fecal incontinence; children oftem complain that soiling is involuntary and occurs without warning.
- child does not have a neurological or anatomical disorder, usually the result of fecal impaction and an enlarged rectum caused by chronic constipation.
- evidence of soiling of clothing, scratching or rubbing of the anal area, fecal odor, social withdrawal.
31
Constipation and Encopresis Interventions
- maintain a diet high in fiber and fluids.
- monitor treatment regimen for severe encopresis for 3-6 months.
- decrease sugar and milk intake.
- adm enemas as prescribed.
- monitor for hypernatremia or hyperphosphatemia when adm repeated enemas.
- adm stool softeners or laxatives as prescribed.
- encourage the child to sit on the toilet for 5 to 10 min approx 20-30 min after breakfast and dinner to assist defecation.
32
Irritable Bowel Syndrome
- results from increased motility, which can lead to spasm and pain.
- diagnosis is based on the elimination of pathological conditions.
- is a self-limiting, intermittent problem with no definitive treatment.
- stress and emotional factors may contribute to its occurrence.
- Assessment: diffuse abd pain unrelated to meals or activity. Alternating constipation and diarrhea with the presence of undigested food and mucus in the stool.
- Intervention: anticholinergics may be prescribed. Encourage the maintenance of a healthy diet and activities.
33
Imperforate Anus: description, types, and assessment
- incomplete development or absence of the anus in its normal position.
Types:
- a membrane is noted over the anal opening, with a normal anus just above.
- there is complete absence of the anus with a rectal pouch ending some distance above.
- rectum ends blindly or has a fistula connection to the perineum, urethra, bladder, or vagina.
Assessment:
- failure to pass meconium stool.
- absence or stenosis of the anal rectal canal.
- presence of an anal membrane.
- external fistula to the perineum.
34
Imperforate Anus: interventions
PreOp
- determine presence of an anal opening.
- monitor for the presence of stool in the urine and vagina.
- prepare child and family for surgery and potencial colostomy.
PostOp
- preferred position is a side-lying prone position with the hips elevated or a supine with the legs suspended at a 90 degree angle to the trunk to reduce edema and pressure on the surgical site.
- keep incision clean and dry and monitor for infection.
- maintain NPO status, NGT, IV fluids until GI motility returns.
- provide care for colostomy if present.
- instruct parents on care and anal dilation if prescribed.
35
Lead poisoning (chumbo)
- excessive accumulation of lead in the blood and the pathway for exposure may food, air, or water.
- screening is recommended for children 1-2 years old (high risk before). Children 3-6 years who has not been screened should be tested.
- when lead enters the body, it affects the erythrocytes, bones and teeth, and organs and tissues, including the brain and nervous system; the most serious consequences are the effects on the CNS.
- chelation therapy removes lead from the circulating blood and from some organs and tissues.
- medications include calcium disodium edetate, and succimer (an oral preparation); British anti-Lewsite (IV or IM and contraind. in children alergic to peanut or with G6PD deficiency) is used in conjunction with EDTA.
- ensure adequate hydration, urine output, monitor for nephrotoxicity.
- erythrocyte protoporphyrin test: normal value 35mcg/100ml.
- blood lead level test: >70 emergency! <5 reassess in 1y.
36
Acetaminophen
- seriousness depends on amount and length of time before intervention.
- toxic dose is 150 mg/kg or higher in children.
Assessment:
- first 2-4h: malaise, nausea, vomiting, sweating, pallor, weakness.
- latent period (24-36h): child improves.
- hepatic involvement: may last 7 days and may be permanent, right upper quadrant pain, jaundice, confusion, stupor, elevated liver enzyme and bilirubin levels, prothrombin time.
Interventions:
- adm antidote: N-acetylcysteine (dilute on juice or soda).
- unconscious child, prepare for gastric lavage with activated charcoal.
37
Acetylsalicylic Acid (aspirin)
- overdose may be caused by acute ingestion or chronic ingestion.
- acute: severe toxicity with 300 to 500 mg/kg.
- chronic: ingestion of more than 100 mg/kg per day for 2 or more, which can be more serious than the acute ingestion.
Assessment:
- GI: nausea, vomiting, and thirst from dehydration.
- CNS: hyperpnea, confusion, tinnitus, seizures, coma, respiratory failure, circulatory collapse.
- Renal: oliguria.
- Hematopoietic: bleeding tendencies.
- Metabolic: diaphoresis, fever, hypoglycemia, hyponatremia, hypokalemia, dehydration, metabolic acidosis.
Interventions:
- prepare to adm activated charcoal, emesis or cathartic measures may be prescribed.
- adm IV fluids, sodium bicarbonate may be prescribed to correct metabolic acidosis.
- external cooling, anticonvulsants, vit K (if bleeding), and oxygen.
- prepare for dialysis as prescribed.
38
Corrosives
- items that can cause poisoning include household cleaners, detergents, bleach, paint or paint thinners, and batteries.
- liquid corrosives can cause more damage.
Assessment:
- severe burning in the mouth, throat, or stomach.
- edema of the mucous membranes, lips, tongue, and pharynx.
- vomiting, drooling, and inability to clear secretions.
Interventions:
- dilute corrosive with water or milk as prescribed.
- neutralization is not done because it can cause a reaction. Inducing vomiting is contraindicated.
- instruct parents to call Poison Control Center if event occurs.
39
Intestinal Parasites: Giardiasis
- caused by protozoa and is prevalent among children in crowded environments, such as classrooms or day care centers.
Assessment:
- diarrhea, vomiting, anorexia, failure to thrive, abd cramps with intermittent loose stools and constipation, steatorrhea. Stool specimens from 3 or more collections are used for diagnosis.
Interventions:
- medications that kill the parasites may be prescribed (usually not prescribed for younger than 2y.
- provide education to family and caregivers about sanitary practices and hand washing.
40
Intestinal Parasites: Pinwarms (enterobiasis)
- are universally present in temperate climate zones and are easily transmitted in crowded environment.
Assessment:
- intense perianal itching, irritability, restlessness, poor sleeping, bed wetting.
Interventions:
- perform visual inspection of the anus with a flashlight 2-3h after sleep.
- tape test is the most common diagnostic test. A loop of transparent tape is placed firmly against the child's perianal area; it is removed in the morning and placed in a glass jar or plastic bag and transported to the lab for analysis.
- meds that kill the parasits may be prescribed (usually not prescribed for children <2y).
- med regimen may be repeated in 2 weeks to prevent reinfection.
- all family members should be treated for the infection.
