Caring for children with gastrointestinal dysfunction —Chap 17
兒童消化系統的生理特徵 評估 小兒常見腸胃道疾病
Gastroenteritis(Acute diarrhea) Intestinal obstruction--Intussusception
Congenital defects Cleft lip and palate
Anorectal malformation
Esophageal atresia & Tracheoesophageal fistula
Hirschsprung’s Disease ( Megacolon )
Anatomy and physiology of pediatric differences
• GI system is immature at birth. P586 第 1 段第 2 行 – Absorption and excretion do not begin until after birt
h– Sucking reflex– Not have voluntary control over swallowing
• Stomach– Stomach capacity : small– Frequently regurgitate
• Intestinal – Peristalsis is greater than older children– Deficiency of several enzyme : amylase, lipase, try
psin
Anatomy and physiology of pediatric differences
• Liver function is also immature• Second year of life
– Digestive processes are fairly complete
– Stomach capacity increase
– Excretory function can be achieved
評估(補)
• 健康史 進食狀況 營養狀況 家庭狀況 主要照顧者的衛生習慣 排便情形 診斷性檢查
血液檢查 糞便檢查 特殊技術
身體檢查 身體外觀 口腔感染 腹部評估
Caring for children with gastrointestinal dysfunction
– Etiology and pathophysiology – Clinical manifestations – Diagnostic tests – Medical management – Nursing assessment & management
Gastroenteritis ( Acute diarrhea ) P617
• Is an inflammation of the stomach and intestines 第 1 段
• Vomiting and diarrhea• Infants and small children with gastroenteritis
or diarrhea can quickly become dehydrated and are at risk for hypovolemic shock
Etiology and pathophysiology ( P617 第 2 行) • Decrease in the absorptive capacity 、 d
ecrease in surface area for absorption 、alteration of parasympathetic innervation
• High risk - day-care centers 、 improper sanitation (第 5 ~ 6 行)
• Causes ( Table 17-2 )
Clinical manifestations P617 • Mild - Slightly increased in number and more liquid
• Moderate- Several loose or watery stools
- Irritability、 anorexia、 nausea、 vomiting
- Self-limiting
• Severe- Continuous watery stools
- Fluid and electrolyte imbalance
- Cramp、 extremely irritable、 difficult to console
Diagnosis clinical therapy 之第 1 段
• History
• Physical examination
• Laboratory finding- S/R、 S/C – Presence of ova, parasite, infectious
organisms, viruses, fat, and undigested sugars.
Treatment P618 第 2 段
Depends on the severity of the diarrhea and fluid and electrolyte imbalances.
Goal: correct the fluid and electrolyte
Mild to moderate- oral rehydration therapy ( Contain water, carbohydrate, sodium, potassium, chloride and lactate P315 )
- Carbonated beverages and those containing high amounts of sugar should not be given
Severe- IV ( N/S with glucose 【 one half or one quarter normal saline 】 or L/R )第 3 段 - NPO- Antiemetics and antidiarrheals should generally not be used in infants and young children. P618 左下
Lactose-free milk, breast milk, half-strength milk P315 倒數第 4行
Nursing assessment P618
• Frequency, color, amount and consistency of stools 第 4行
• The amount and type of vomitus
• Observing dehydration
• Urine output and specific gravity
• Weight
• Vital signs ( Febrile )
• Skin integrity
Nursing diagnosis & management P619
• Anxiety– Provide Emotional support
• Sleep pattern disturbance• 活動無耐力
– Promote rest and comfort
• Altered nutrition– Ensure adequate nutrition – CRAM (Complex carbohydrates, Rice and Milk ) P619 綠框
• Diarrhea related to infectious process P620
• Fluid volume deficit P620
• Risk for impaired skin integrityP621
Dehydration Chap 10 --P313
• There is not enough fluid in the extracellular compartment.
• The state of body water deficit is called dehydration.
• Sodium is generally lost along with water → hyponatremia
Etiology and pathophysiology
Causes P313 第 1 段第 2 行 • Loss of fluid containing sodium are vomiting、 diarrhea、 nasogastric suction 、 hemorrhage and burns
• Radiant warmers 第 2 段第 2 行
• Adrenal insufficiency and overuse of diuretics
• Bulimic adolescents
• Blood urea nitrogen > 25mg/dL clinical therapy 第 1 段第 3 行
• Serum bicarbonate > 17mEq/L
Medical management P315
• Oral rehydration therapy - mild and moderate dehydration– Contain water, carbohydrate, sodium, potassiu
m, chloride and lactate
• Lactose-free milk, breast milk, half-strength milk 倒數第 4 行
• IV - severely P316 第 1 段
– L/R, one half or one quarter normal saline
同腸胃炎之治療
Nursing assessment
• Weight• I/O• Urine specific gravity• Consciousness• Pulse rate and quality• Skin turgor and mucous membrane moisture• Respiration • Blood pressure
Nursing management
• Provide oral rehydration therapy guidelines • Teach parents oral rehydration methods • Monitor intravenous fluid administration • Discharge planning and home care teaching
Intussusception P602
• Etiology and pathophysiology 第 1 段 – One portion of the intestine prolapses and then invaginates
( 陷入 ) or telescopes ( 使嵌入 ) into another. 第 1 行 – One of the most frequent causes of intestinal obstruction du
ring infant – Between the age of 3 months and 6 years– Site : ileocecal valve 第 2 段– Telescoping of the Intestine obstructs the passage of stool.– The walls of intestine rub together
inflammation 、 edema 、 decreased blood flow necrosis 、 perforation 、 hemorrhage 、 peritonitis
– In infant, intussusception is commonly associated with measles, viral disease, and gastroenteritis syndromes. P603 Fig17-7
Clinical manifestations P603 第 2 段
Onset is abrupt• Acute abdominal pain ( periods of comfort between acu
te episodes of pain ) • Vomiting • Passage of brown stool→become red and resemble curran
t jelly• A palpable mass may be present in the upper right quadr
ant or mid-upper abdomen• 腹部呈柔軟、膨脹• 疲倦、虛脫• 發燒及腹膜炎之其他徵象 • 右下腹區排空( Dance 徵象)
Diagnosis P603 第 2 段
• History
• Radiographs and ultrasound of the abdomen
• Barium enema
Treatment P603 第 3 段
• Hydrostatic pressure—Barium enema – Oxygen ( air )、 saline 、 aqueous c
ontrast material
• Surgery • Supportive care
– 液體補充– 鼻胃管減壓– 抗生素
Nursing management • Maintain fluid and electrolyte balance
Post OP • Monitoring for early signs of infection• Pain management • Maintain NG tube patency • Assess vital signs 、 Abdominal distention 、
Listen for bowel sounds every 4 hours • After normal bowel function
– Clear liquid feeding half- strength milk and other foods
Cleft lip and palate P586 • More common in Native Americans and Asian P586
最後 1 行 • Etiology and pathophysiology P594
– A failure of the maxillary processes of fuse with the elevations on the frontal prominence during the sixth weeks of gestation.
– Hard and soft palates is completed in the first trimester.
– Congenital defects : tracheoesophageal fistula , omphalocele , trisomy 13 , skeletal dysplasias
– Cause : multifactorial ( environmental and genetic influences )
Clinical manifestation P587
• Cleft lip– Unilateral or bilateral– Alone or in combination with a cleft palate defect– Nasal deformity
• Cleft palate– Less obvious– A continuous opening between the mouth and nasal
cavity– Soft palate or both the soft and hard palate– Unilateral or bilateral
Clinical manifestation---補
• 餵食困難• 呼吸道感染• 口腔感染• 聽力受損• 語言發展延遲
Diagnostic tests and medical management P588
• Physiologic assessment 第 1 段
• Medical management : multidisciplinary team ( plastic surgery 、 hearing 、 speech 、 dentistry )– Clef lip
• 2-3months of age 第 2 段• Logan bow or other stabilizing device or dressing is put in place.• Crying is minimized by use of medication.
– Clef palate• Depends on the size and severity of the cleft.• 18 months
– Longer nipples with enlarged holes ( before surgical )– Antibiotic therapy : recurrent otitis media– Orthodontic care– 語言治療
Nursing assessment
• Physiologic assessment– Observable– Palpation
• Psychosocial assessment—low self-esteem– Family’s reaction– Low self-esteem – Developmental level and social interactions
Nursing management
1.Risk for aspiration 2.Provide emotional support
– Explaining the cause– Interact and speak to the
infant– Point out positive
attributes– Self-blame– Anxiety
3.Altered nutrition
Preoperative care P590
Postoperative care P592
1.Risk for infection
2.Ineffective breathing pattern related to anesthesia and increased secretions
3. Impaired tissue integrity
4. Knowledge deficit
5. Altered nutrition
Care in the community• Feeding techniques• Recognize signs of infection and complications
(fever, vomiting, respiratory distress)• How to position the infant• How to care the suture line• Preparation of the sibling• Support groups• Prevent the infant from touching the suture line
Nursing management
Anorectal malformation ( Imperforate anus ) P604
• Etiology and pathophysiology– Malformations of the anus and rectum.– Often associated with anomalies : uri
nary tract, esophagus, and duodenum.– VACTER Syndrome
Clinical manifestations
• Failure to pass meconium
• Stool in the urine• Ribbonlike stools• 腹脹、嘔吐
Diagnosis
Assessment anorectal structure and rectal patencyUltrasoundLower GIPA CXR
倒立 3 分鐘→ x-ray尿液分析
Medical management
• Dilation• 低位- Excised surgery , then daily manual
dilation• 高位- Reconstructive surgery ( Posterior
Sagittal Anorectoplasy ; PSARP )及 temporary colostomy→→ 關閉結腸造廔。
Nursing management
Assessment • Developed anal dimple or sacral anomalies
• Rectal thermometer
• Observation and recording of passage of meconium
Managemen
• IV fluids• NG decompression• Monitor I/O• Monitor cardiorespi
ratory function• 廔管護理• Emotion support
Preoperation Postoperation Preventing infection Respiratory complication Maintaining hydration Assess vital signs If stable→try feeding Colostomy care 禁量肛溫或使用塞劑
Discharge planning and home care teaching
• How to take the infant’s temperature• Signs and symptoms of infection• Feeding• Toilet training• Assess vital signs• If a colonstomy
– How to care– Reassure the colostomy will be closed– Follow-up– Home care visits
Esophageal atresia & Tracheoesophageal fistula P595
• Etiology and pathophysiology– Failure of the esophagus to develop as a conti
nuous tube during the fourth and fifth weeks of gestation. 第 1 段
– The foregut fails to lengthen, separate, and fuse into two parallel tubes during fetal development. 第 2 段
– End in a blind pouch or develop as a pouch connect to the trachea by a fistula.
• Maternal history : polyhydramnios 、 prematurity 、 low birth weight
• Associated anomalies 第 2 段第 5 行– Congenital heart defects– Gastrointestinal or urinary tract anomalies– Musculoskeletal abnormalities
VACTERL : vertebral 、 anus 、 cardia 、 trachea 、 esophageal 、 renal 、 limb
Clinical manifestation 第 3 段
• Excessive salivation and drooling
• 3C( coughing, choking, cyanosis) and sneezing
• Returns fluid through the nose and mouth→pneumonia
• Abdomen become distended
• Vomiting soon after feeding
Diagnosis 第 4 段
• Nasogastric tube meets resistance and can be advanced only minimally.
• X-ray ( air pouch 、 NG coiling 、 pneumonia 、 distended stomach intestine -遠端有 fistula )
• Echocardiogram ( 2D echo ) and abdominal ultrasound ( Renal echo ) P596
Treatment P596 第 2 段
• OG suction• Antibiotics• Fluids• Surgery : several stages
– Ligation of the fistula and insertion of a gastrostomy tube
– Reconnect the two ends of the esophagus ( anastomosis )
• Potential postoperative complications– Gastroesophageal reflux 、 aspiration 、 strict
ure formation 、 esophageal motor dysfunction
Nursing management
• Maintain a patent airway– Suction-( continuous or low intermittent)– Place the head of the bed slightly lowered– Continuous or low intermittent suction is used to
remove secretions from the blind pouch. – Change position
• NPO• Maintain with intravenous fluids administered
through an umbilical vein catheter.
Preoperation
Postoperation
• Gastrostomy drainage• IV fluids and antibiotics • TPN• Maintain a patent airway• Emotional support for parent• Discharge planning
– Gastrostomy tube care and feeding 、 signs of infection 、 prevent postoperative complications. P598 families want to known
Megacolon ( Hirschsprung Disease ) P6
03
• Congenital aganglionic megacolon ; inadequate motility causes mechanical obstruction
• Absence of autonomic parasympathetic ganglion cells in the colon→ accumulation of intestinal contents and abdominal distention
• Combination with congential heart defects 、 Down syndrome 、 Imperforate anus
• More common in boys • It can be acute or chronic
Etiology and pathophysiology
Clinical manifestations P604 第 2 段
• Failure to pass meconium
• Refusal to suck• Abdominal distenti
on• Bile-stained emesis complete obstructio
n, respiratory distress, and shock
Failure to gain weight and delayed growth 第 3段Abdominal distentionConstipation alternating with diarrheaVomitingStool may be normal or ribbonlike
Newborn Older child
Diagnosis
• History
• Bowel pattern
• Anorectal manometry
• Radiographic contrast studies
• Rectal biopsy
• Palpation
Treatment
• Newborn : surgery• Several cases or ill infants : temporary col
ostomy → closure of the colostomy and reanastomosis ( Soave procedure )
• Child with milder defect : dietary modification 、 stool softeners 、 isotonic irrigations
Complication P604 第 7 段
• Fecal incontinence and constipation• Enterocolitis
– GI bleeding and diarrhea→ischemia and ulceration
– TPN– Lactose-free diet
Nursing management Assessment 第 1 段
• Observation for the passage of meconium
• History of weight gain
• Nutritional intake
• Bowel habit
Management• Monitoring fluid and electrolyte balance• Maintain nutrition• Teach parents how to ensure regular bowel movements• Daily rectal irrigations• Prevent skin breakdown • Surgery
– Monitoring for infection– Managing pain– Maintain hydration– Measuring abdominal circumference– Emotion support
• Teach parent about - Ostomy care 、 signs of complications 、 Be alter for signs of poor growth or malnutrition