NURSING CARE OF THE CHILD WITH ALTERATIONS IN GASTROINTESTINAL FUNCTION

Anatomy and Physiology of the Gastrointestinal Tract Pediatric Differences

1. CLEFT LIP (HARELIP)/CLEFT PALATE

 Distinct facial defect that occurs singly or in combination

 Both occur during embryonic development
 Merging of the upper lip is completed between 7-8th wk AOG
 Fusion of the palate is completed between 9-12th wk AOG
 Significant concerns:
 Negative sucking reflex
 Prone to Otitis media w/c can lead to hearing loss

Causes: Multi-factorial
1. Genetics
2. Environmental
3. Maternal Diseases

Diagnosis:

Ultrasound

Physical Assessment
 CL is apparent at birth
 CP may not be detected without thorough assessment of the mouth

Management: Surgery

For Cleft lip:

CHEILOPLASTY - before 2 months/6-12th wks after birth
- Rule of 10
- done earlier because: * center of pleasure is oral
* Psychological
* Nutrition
For Cleft palate:
URANOPLASTY - done 12-18 months after birth
- done in anticipation of speech development
- done before the child develops faulty speech habits

Nursing Care:

1. Help parents cope with the impact of the defect

2. Provide adequate nutrition
A. ESSR (Richard, 1991)
Enlarge the nipple (long and soft)
Stimulate the suck reflex
Swallow fluid appropriately
Rest
B. Upright position when feeding to facilitate swallowing and prevent aspiration.
C. Burp frequently because more air is swallowed which can cause regurgitation.
D. NGT feeding as ordered.
3. Prepare for surgery
4. Post -operative Care
A. Airway
- if necessary gentle aspiration - NO SUCTIONING
- Positioning
B. Bleeding
C. Avoid trauma to the operative site
- Logan’s bow/butterfly adhesive
- Restraints
- Minimize crying
- No to sucking
- No hard items on the mouth
5. Optimum Nutrition
6. Prevent infection
A. Assess vs.
 B. Cleanse suture line with normal saline/ sterile water if ordered.
C. Cleanse cleft areas by giving 5-15 cc of H2O after feeding
D. If crust has formed, use cotton swab to apply a half strength peroxide solution
E. antibiotic cream as prescribed
F. careful hand washing and sterile technique.

2. HYPERTROPHIC PYLORIC STENOSIS

- A hypertrophy obstruction of the circular muscle of the pyloric canal

Incidence:

 One of the most common conditions requiring surgery in infants

 First few weeks of life (1-10 weeks)
 First born male infants
 Full term, premature infants
 Caucasians, less frequently in Asians and Black

Cause: unknown, genetic predisposition (children of parents who had PS as infants)

Clinical Manifestations:
1. Projectile vomiting
* Nonbilous
* Blood Tinged
2. No evidence of pain or discomfort except that of chronic hunger
3. S/s of dehydration -decreased number of stools, weight loss.
4. Distended upper abdomen
5. Readily palpable olive mass in the upper abdomen.
6. Visible peristaltic waves
7. Hyperactive Bowel sounds

Diagnosis:

1. History and physical exam.

2. Ultrasonography
3. Upper G.I. series
4. Blood test for metabolic alterations from extensive vomiting

Management: Surgery

PYLOROMYTOMY (FREDET RAMSTEDT PROICEDURE)

- Longitudinal incision through the circular muscle fibers of the pylorus down to, but not
including the sub mucosa
- Complication: persistent pyloric obstruction, wound dehiscence and GER
Nursing Care:
1. Maintain fluid and electrolyte balance and minimize weight loss
2. Provide supportive care to parents.
3. Prepare infant for surgery
4. Post OP
A. maintain fluid and electrolyte balance
B. Minimize weight loss
C. Promote rest and comfort
D. Prevent infection
* Discharge planning and patient’s family home care teachings.

3. ESOPHAGEAL ATRESIA with TRACHEOESOPHAGEAL FISTULA

* Esophageal Atresia
- failure of the esophagus to develop a continuous passage
- esophagus ends in a blind pouch with no entry to the stomach

* Tracheoesophageal Fistula
- abnormal opening between the esophagus and the trachea

Incidence:
- rare
- equal sex incidence
- low birth weight
 - prematurely
Cause: unknown

Types:

Name Description
A Simple Esophageal atresia with no fistula Upper and lower ends of the esophagus are blind,
(Isolated EA) no connection to the trachea
B EA with proximal TEF Upper end of the esophagus ends into the trachea
C EA with Distal TEF Upper end of esophagus is blind, lower end
connects into the trachea - most common
D EA with double TEF Both upper and lower ends of the esophagus open
into the trachea by a fistula
E Isolated TEF Esophageal atresia but with fistula between
normal esophagus and trachea

Clinical Manifestation:

1. 3 C’s of TEF - CHOKING, COUGHING & CYANOSIS

2. Copious, fine white frothy bubbles of mucus in the mouth and nose - EA
3. Increased respiratory distress after feeding
4. Distended abdomen
5. Aspiration Pneumonia

Diagnosis:

1. History and clinical manifestations

2. Inability to insert an NGT
3. Radiogrphy
4. Fluoroscopy

Management:
1. Prevention of aspiration pneumonia
2. Surgery to repair anomaly
- Several stages- indicated for premature, multiple anomalies, in poor condition

LIGATION OF TEF
Gastrostomy - for gastric decompression and jejunostomy feeding
 Provision of constant drainage of the esophageal pouch - tube in the mouth to
upper pouch

Complications of Surgery:
 Anastomostic leak
 Stricture due to tension
 Esophageal motility disorders

Nursing Care:

* Pre-operative
1. Maintain open airway
2. NPO
3. Administer IVF as ordered
4. Oxygen to relieve respiratory distress
5. Positioning
* Post-operative
1. Promote respiratory function
2. Provide optimum nutrition
A. Gastrostomy tube feedings
* elevated and secured t a point above level of the stomach (4‘’)
B. Oral feeding when anastomosis site is healed
C. Maintain IVF
D. Use of Pacifier
E. Diet - Liquid - small frequent feedings
4. GASTROESOPHAGEAL REFLUX
- return of gastric contents into the esophagus

Risk Factors:
1. Prematurity
2. Neurologic disorders
3. Asthma
4. TEF/EA repair
5. Gastrostomy placement
6. Neurologic disorders

Causes:
1. Related to the dysfunction of the lower esophageal sphincter (LES)
2. Delayed gastric emptying
3. Increased abdominal pressure

Clinical Manifestations:
1. Passive regurgitation, spitting up/vomiting
2. Poor weight gain
3. Hematemesis and melena
4. Irritability or excessive crying
5. Heartburn in older clients
6. Anemia
7. Respiratory problems - pneumonia, chronic cough, wheezes, stridor, gagging, choking at end of
feeding
8. Dysphagia

Diagnosis:
1. History and clinical manifestations
2. Barium swallow (esophagography)
3. 24 hour pH probe study

Complications of GERD
1. Persistent esophagi is with scarring
2. Recurrent aspiration pneumonia

* Barret’s syndrome disorder of the lower esophagus marked by benign ulcer like lesions resulting
most often from chronic irritation of the esophagus by gastric reflux of acidic digestive juices

Management:

1. Diet
2. Pharmacologic
A. H2 antagonist
- Cimetidine (Tagamet), Famotidine (Pepcid), Ranidine (Zantac)
B. Proton Pump Inhibitor
- Omeprazol (Prilosec), Lansoprazole (Prevacid)
C. Prokinetic Agents
- Metochlopromide Hcl (Placil)

3. Surgery for severe complications

* NISSEN FUNDOPLICATION
- Valve mechanism by 360 degrees wrap of the fundus around the esophagus
- A gastrostomy tube is usually inserted during the procedure
Complications:
- small bowel obstruction, retching, gas-bloat syndrome, Dumping Syndrome

4. NON- SURGICAL PERCUTANEOUS GASTROJEJUNOSTOMY and placement of

jejunostomy tube
- alternative for children with neurologic impairment who are continuously tube fed
Nursing Care:
1. Identifying children with symptoms that suggest GER
2. Preparing for surgery and post-OP care
3, Maintaining adequate nutrition
 4. Educating parents regarding home care
A. Feeding
B. Positioning
C. Medications and their side effects
D. How to suction mouth and nose when vomiting occurs
E. Gastrostomy feeding and site care

5. INTUSSUSCEPTION
- An invagination or telescoping of one portion of intestines into another

Incidence:
- onset: abrupt
- one of the most frequent cause of intestinal obstruction between 3 months to five years of age; 50
% below 1 year (3-12 mos.) of age
- 2X greater in males than in females

Cause: unknown , likely a result of hypertrophy of intestinal lymphoid tissue secondary to viral infection

Clinical Manifestations:
1. Pain (acute), severe, colicky abdominal pain
2. Vomiting
3. Passage of red currant jelly like stools
4. Palpable sausage-shaped in RUQ
5. Empty RLQ (Dance sign)
6. Tender, distended abdomen
7. Lethargy

Complications:
1. Perforation
2. Peritonitis
3. Sepsis

Diagnosis:
1. History and physical exam
2. Abdominal radiograph to detect intraperitoneal air from a bowel perforation
3. Barium enema.
4. Ultrasound
5. Rectal Exam

Management:
1. Non-surgical
A. HYDROSTATIC REDUCTION
B. PNEUMATIC INSUUFFLATION
2. Surgical-manual reduction of invagination and resection of nonviable intestines when
necessary

Nursing Care:
1. Monitoring for S/s of complications
2. Maintain or establishing fluid and electrolyte balance
3. Preparing for hydrostatic reduction and/or surgery

6. HIRSCHPRUNG’S DISEASE/CONGENITAL AGANGLIONIC MEGACOLON

- Mechanical obstruction due to inadequate motility of the intestines

Incidence:
- 1:5000
- Accounts for ¼ of all cases of neonatal obstruction although diagnosed in later infancy/childhood
- 4X greater in males than in females
- More common in children with Down’s syndrome
- can present as an acute or chronic disorder

Complications:

1. Obstruction
2. Bowel perforation
A. Peritonitis - s/s: relief of pain, increased RR and PR, fever, vomiting, absence of
bowel sounds and increased abdominal distention
 B. Bleeding
3. Enterocolitis - s/s: fever, explosive watery diarrhea, dehydration, severe prostration
4. Dehydration

Diagnosis:
1. History and clinical manifestations
2. Barium enema
3. Rectal Biopsy

Management: (most require surgery rather than medical therapy)

Mild Cases (#s 1-3)

1. Low residue diet
2. Stool softeners
3. Isotonic irrgations
4. Surgery
A. Staged Repair
1. Removal of aganglionic segment and temporary colostomy made with the
part of the bowel with normal nerve transmission.
2. Corrective - closure of the colostomy and reanastomosis of working part of
colon to point near rectum.

Nursing Care:
1. Monitoring vs. including abdominal circumference and ominous sign (enterocolitis)
2. Maintain fluid and electrolyte balance
3. Maintain adequate nutrition
4. Help parent adjust to the congenital defect in the child
5. Prepare client for surgery
6. Post-OP care
7. Discharge - assisting parents in proper colostomy care