Chapter 38

The Child with a

Gastrointestinal/Endocrine
Disorder

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The Child with Gastrointestinal/Endocrine
Disorders
• Gastrointestinal (GI) system: Responsible for ingesting
and processing nutrients
– Mouth; throat; esophagus; stomach; intestines;
rectum; anal canal; accessory organs
– Infant GI system
• Endocrine system: Number of ductless glands throughout
the body that secrete hormones
– Hormones regulate: Metabolism, growth,
development, reproduction
– All body systems interface with endocrine gland
function
– Infant endocrine system
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Gastrointestinal Disorders

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 Malnutrition and Nutritional Problems

• Protein malnutrition
– Kwashiorkor: Severe protein deficiency with
adequate caloric intake
– Marasmus: Severe protein and caloric deficiency
• Vitamin deficiency diseases
– Vitamin D: Rickets Vitamin C: Scurvy
– Thiamine: Beriberi Riboflavin: Skin lesions
– Niacin insufficiency: Pellagra

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 Malnutrition and Nutritional Problems
(cont.)
• Mineral insufficiencies
– Iron: Anemia
– Calcium: Hypocalcemia
• Food allergies
– Milk allergy
– Lactose intolerance

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 Malnutrition and Nutritional Problems
(cont.)
• Nursing process for the child with malnutrition and
nutritional problems
– Assessment
– Selected nursing diagnoses
– Outcome identification and planning: Preoperative
care

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 Malnutrition and Nutritional Problems
(cont.)
• Nursing process (cont.)
– Implementation
• Promoting adequate nutrition
• Improving fluid intake
• Monitoring elimination patterns
• Promoting skin integrity
• Providing family teaching
– Evaluation: Goals and expected outcomes
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 Question
A child comes into the clinic presenting with the following
symptoms: A swollen abdomen, edema, and GI changes;
the hair is thin and dry with patchy alopecia. The child is
apathetic and irritable. When weighed and measured, the
nurse finds the child has retarded growth. What does the
nurse suspect is the diagnosis?
a. Marasmus
b. Kwashiorkor
c. Mineral insufficiencies
d. Niacin insufficiency

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 Answer
b. Kwashiorkor

Rationale: The affected child develops a swollen abdomen,

edema, and GI changes; the hair is thin and dry with
patchy alopecia; and the child becomes apathetic and
irritable and has retarded growth with muscle wasting.

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 Celiac Syndrome

• Basic metabolic defect precipitated by gluten (wheat or

rye) ingestion, leading to impaired fat absorption
• Clinical manifestations
– Chronic diarrhea with foul, bulky, greasy stools;
progressive malnutrition
• Diagnosis: Serum antibody screening; gluten-free diet
trial
• Treatment: Gluten-free, low-fat diet
• Nursing care

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 Gastroesophageal Reflux
• Lower esophogeal sphincter relaxes, allowing gastric
contents to regurgitate back into esophagus
• Clinical manifestations
– Effortless vomiting; irritability; hunger; failure to
thrive; lack of normal weight gain
• Diagnosis: Endoscopy
• Treatment: Nutritional correction; medications; sphincter
maturation can resolve (within 18 months)
• Nursing care: Feedings; positioning

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 Colic
• Fairly common, recurrent paroxysmal bouts of abdominal
pain
• Clinical manifestations
– Late afternoon/evening, sudden attacks of pain
– Otherwise healthy (feeds well, gains weight)
• Diagnosis: Rule out food allergies
• Treatment: Medications (inconsistent efficacy); comfort
measures
• Nursing care: Family support

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 Diarrhea and Gastroenteritis
• Clinical manifestations
– Mild: Frequent (two to 12 times/day), loose stools;
minimal to slight dehydration
– Moderate or severe: Frequent, loose stools; vomiting;
significant dehydration; dangerous condition
• Diagnosis
• Treatment
– Stop diarrhea immediately
– Restore fluid/electrolyte balance

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 Diarrhea and Gastroenteritis (cont.)
• Nursing process for pediatric diarrhea, gastroenteritis
– Assessment
– Selected nursing diagnoses
– Outcome identification and planning
– Implementation
• Controlling diarrhea, reducing risk of infection
transmission
• Promoting skin integrity
• Preventing dehydration
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Diarrhea and Gastroenteritis (cont.)
– Implementation (cont.)
• Maintaining adequate nutrition
• Maintaining body temperature
• Supporting family coping
• Promoting family teaching
– Evaluation: Goals and expected outcomes

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 Pyloric Stenosis

• Hypertrophic circular muscle fibers of the pylorus narrow

its lumen resulting in increasing, forceful vomiting
• Clinical manifestations: Increasing frequency of vomiting
undigested food; constipation; scant urine
– Progression: Ravenous hunger; irritability; weight
loss; dehydration
• Diagnosis: Based on clinical evidence; radiographic
studies
• Treatment: Surgical repair

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 Pyloric Stenosis (cont.)

• Nursing process for the child with pyloric stenosis

– Assessment
– Selected nursing diagnoses: Preoperative phase
– Outcome identification and planning: Preoperative
phase

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 Pyloric Stenosis (cont.)

• Nursing process for the child with pyloric stenosis (cont.)

– Implementation: Preoperative phase
• Maintaining adequate nutrition, fluid intake
• Providing mouth care
• Promoting skin integrity
• Promoting family coping
– Evaluation: Goals and expected outcomes—
preoperative phase

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 Pyloric Stenosis (cont.)

• Nursing process for the child with pyloric stenosis (cont.)

– Selected nursing diagnoses: Postoperative phase
– Outcome identification and planning: Postoperative
phase

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 Pyloric Stenosis (cont.)
• Nursing process for the child with pyloric stenosis (cont.)
– Implementation: Postoperative phase
• Maintaining a patent airway
• Promoting comfort
• Providing nutrition
• Promoting skin integrity
• Promoting family coping
– Evaluation: Goals and expected outcomes—
postoperative phase
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 Question
You are caring for a 2-year-old with gastroenteritis with
severe diarrhea. What nursing action would be important
in dealing with this child’s diarrhea?

a. Reducing the risk of infection

b. Increasing adequate nutrition
c. Decreasing skin integrity
d. Preventing dehydration

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 Answer
d. Preventing dehydration

Rationale: A child can dehydrate quickly and can get into

serious trouble after less than three days of diarrhea.
Carefully count diapers and weigh them to determine the
infant’s output accurately. Measure each voiding in the
older child. Closely observe all stools. Document the
number and character of the stools, as well as the
amount and character of any vomitus.

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 Congenital Aganglionic Megacolon
• Persistent constipation resulting from partial or complete
mechanical obstruction of the colon
• Clinical manifestations
– Newborn: Absence of meconium stool; bile-stained
emesis; generalized abdominal distention;
gastroenteritis
– Older infant/child: Severe constipation from early
infancy; ribbon-like or hard pellet stools; progressive
abdominal enlargement and hardening
• Diagnosis: Radiographs; biopsy
• Treatment: Surgical resection of the bowel
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Congenital Aganglionic Megacolon (cont.)
• Nursing process for the child undergoing surgery for
congenital aganglionic megacolon
– Assessment
– Selected nursing diagnoses: Preoperative phase
– Outcome identification and planning: Preoperative
phase

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Congenital Aganglionic Megacolon (cont.)
• Nursing process for the child undergoing surgery for
congenital aganglionic megacolon (cont.)
– Implementation: Preoperative phase
• Preventing constipation
• Maintaining adequate nutrition
• Reducing fear
• Promoting family coping
– Evaluation: Goals and expected outcomes—preoperative
phase

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Congenital Aganglionic Megacolon (cont.)

• Nursing process for the child undergoing surgery for

congenital aganglionic megacolon (cont.)
– Selected nursing diagnoses: Postoperative phase
– Outcome identification and planning: Postoperative
phase

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Congenital Aganglionic Megacolon (cont.)
• Nursing process for the child undergoing surgery for
congenital aganglionic megacolon (cont.)
– Implementation: Postoperative phase
• Promoting skin integrity
• Promoting comfort
• Maintaining fluid balance
• Providing oral and nasal care
• Providing family teaching
– Evaluation: Goals and expected outcomes—
postoperative phase
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 Intussusception
• Telescoping of one portion of bowel into distal portion
• Clinical manifestations
– Happy, healthy infant: Suddenly becomes pale, cries
sharply, draws legs in severe pain spasm; occurs
episodically
– Cardinal symptoms: Shock; vomiting (progressive,
bile-stained); currant jelly stools
• Diagnosis: Clinical symptoms; palpation; radiographs
• Treatment: Barium enema; surgery (if barium enema
unsuccessful
• Nursing care
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 Appendicitis
• Clinical manifestations
– Infant/small child: Pain symptoms; frequently present
with ruptured appendix
– Older child: Right lower quadrant pain, tenderness;
nausea/vomiting; fever; constipation
• Treatment: Surgical removal
• Nursing process for the child with appendicitis
– Assessment
– Selected nursing diagnoses
– Outcome identification and planning
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 Appendicitis (cont.)
• Nursing process for the child with appendicitis (cont.)
– Implementation
• Reducing fear
• Promoting comfort
• Monitoring fluid balance
• Providing family teaching
– Evaluation: Goals and expected outcomes

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 Question
What is the major preoperative goal for the child undergoing
surgery for congenital aganglionic megacolon?

a. Reducing anxiety
b. Maintaining skin integrity
c. Preventing constipation
d. Maintaining moist, clean nasal and oral mucous
membranes

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 Answer
c. Preventing constipation

Rationale: The preoperative goals for the child undergoing

surgery for congenital aganglionic megacolon include
preventing constipation, improving nutritional status, and
relieving fear (in the older child).

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 Intestinal Parasites
• Enterobiasis (pinworm infection)
– Treatment and nursing care
• Roundworms
• Hookworms
– Clinical manifestations and diagnosis
– Treatment and nursing care
• Giardiasis
– Clinical manifestations and treatment
– Nursing care
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 Ingestion of Toxic Substances

• Emergency treatment
1. Remove remnants of poison
2. Call 911
3. If child is alert: Call Poison Help Line (800) 222-1222
4. Follow PHL instructions
5. Administer antidote (if recommended)
6. Administer general supportive, symptomatic care

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 Ingestion of Toxic Substances (cont.)
• Lead poisoning (plumbism)
– Sources of chronic lead poisoning
• Paint: Furniture/toys; hobby materials; mini blinds
• Contaminated: Water, dust, food/juices
• Inhalation: Engine fumes, industrial areas
– Clinical manifestations: Insidious; progressive to
encephalopathy
– Diagnosis: Blood-level screening
– Treatment: Chelating agent
– Prognosis: Uncertain
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 Ingestion of Foreign Objects
• “Offenders”: Small objects; food
• Treatment
– Asymptomatic: Watch/wait for passing in stool
– Symptomatic: Sharp back blows; extraction; surgical
removal
– Respiratory distress: Heimlich maneuver; extraction;
surgical removal
• Nursing care

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Endocrine Disorders

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 Type 1 Diabetes Mellitus

• Pathogenesis: Beta-cell dysfunction (islets of Langerhans

in the pancreas)
• Clinical manifestations: Polyuria; polydipsia; polyphagia
– Diabetic ketoacidosis
• Diagnosis: Glucose tolerance tests

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 Type 1 Diabetes Mellitus (cont.)

• Treatment: Ongoing blood glucose monitoring; insulin

therapy; meal and exercise plan
– Insulin therapy: Insulin types, administration
– Insulin reaction: Requires immediate treatment
– Insulin regimen
– Insulin administration methods
• Unique needs of the adolescent
• Treatment of diabetic ketoacidosis

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 Type 1 Diabetes Mellitus (cont.)
• Nursing process for the child with type 1 diabetes mellitus
– Assessment
– Selected nursing diagnoses
– Outcome identification and planning
– Implementation
• Ensuring adequate and appropriate nutrition
• Preventing skin breakdown

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 Type 1 Diabetes Mellitus (cont.)

• Nursing process for the child with type 1 diabetes

mellitus (cont.)
– Implementation (cont.)
• Preventing infection
• Regulating glucose levels
• Providing child and family teaching in the
management of hypoglycemia and hyperglycemia
• Providing child and family teaching on insulin
administration

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 Type 1 Diabetes Mellitus (cont.)

• Nursing process for the child with type 1 diabetes

mellitus (cont.)
– Implementation (cont.)
• Providing child and family teaching about exercise
and activity
• Promoting family coping
• Promoting self-care and positive self-esteem
– Evaluation: Goals and expected outcomes

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 Question
Tell whether the following statement is true or false.

The most significant endocrine disorder affecting children is

noninsulin-dependent diabetes mellitius.

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 Answer
False

Rationale: Type 1 diabetes mellitus is the most significant

endocrine disorder that affects children.

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 Type 2 Diabetes Mellitus

• Clinical manifestations: Body uses insulin improperly

– Physical characteristics: Overweight/obese; high
blood glucose level; glucosuria
• Diagnosis: Similar to type 1
• Treatment: Oral medications; lifestyle changes
• Nursing care

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