GI Round 1

The gastrointestinal system encompasses the esophagus, stomach, small and large intestine, or the accessory organs of the liver, gallbladder, and pancreas.

Primary function:
Ingestion
Digestion
Absorption of nutrients
Maintenance of fluid and electrolyte balance
Elimination

Newborn GI system immature at birth
Sucking and swallowing automatic reflexes at birth, controlled by 6 weeks
Newborn stomach capacity 60 ml.
Peristalsis stronger in the infant
Emptying time 2-3 hours, 3-6 hours at 2 months
Infants require 100 calories per kilogram of body weight (Adults 30-40)
Infants small intestine longer, infant secretes more fluid and electrolytes into the intestine.
If diarrhea more electrolytes lost.
Large intestine shorter so less absorption.
Liver functions are immature, toxins and meds inefficiently processed

Infant deficient in digestive enzymes
Amylase responsible for digestion of carbohydrates
(no cereal before 4-6 months)
Lactase breaks down lactose in infant formula and breast milk
Lipase is responsible for the breakdown of fats
*Fat in breast milk absorbed more readily because breast milk contains lipase*
Receive protective immunoglobulin proteins

Gastroenteritis:




Rotavirus


Dehydration:



Upper Gastrointestinal problems include:
GERD
Hypertropic Pyloric Stenosis (HPS)
Cleft lip and cleft palate
Esophageal atresia, tracheoesophageal atresia

GERD


Hypertropic pyloric stenosis (HPS)
Most common intra –abdominal condition requiring surgery
First born Caucasian males, more males than females
Cause? Genetic predisposition & environmental allergies, pylorospasm
New theory duodenal hyperacidity

Pathology:
Pylorus- opening between stomach and the intestines
Opening surrounded by muscular ring, pyloric sphincter
Increases to 4xs normal width, narrowed opening, prevents emptying into the duodenum

Clinical Manifestations:
Symptoms 3-4 week of life
Nonbilious vomiting starting between the 2 and 4 week, progressive, projectile
Small bms due to food not passing through
Hungry will eat again
Poor weight gain or weight loss
Irritable, lethargic


Diagnosis:
History
Physical assessment
Olive shaped mass above & to the right of the umbilicus
Abdominal ultrasound (procedure of choice)
Barium upper GI series

Treatment:
Pyloromyotomy muscle fiber released
Open or laparoscopic
Preop- NG tube, fluid imbalance corrected
Medical management- antispasmodic meds to relax sphincter
Thickened feeds

Post-op
ng removed
Blood glucose, electrolytes, CBC monitored
IV until can feed
Gastric motility slowed for up to 24 hours
Small frequent feedings resume at 4-6 hours

Nursing management:
Assessment- history, signs of dehydration

Nursing Diagnosis:
Deficient fluid volume
Imbalanced nutrition
Acute pain
Risk for infection
Deficit knowledge

Outcome identification:
Improved fluid and electrolyte balance
Tolerate feedings and demonstrate improved nutrition, weight gain
Minimal postoperative pain
Surgical site free from infection
Caregivers verbalize and demonstrate care, S&S of infections or complications

Planning and implementation:
Preop-
IV , rehydrate
Daily weights
NPO
I&O
NG suctioning
Review labs

Postop-
Monitor IV
Monitor oral feeds
Analgesics
Observation of S&S of infection

Family teaching
Nothing they did caused this
Reassure may have some postop vomiting (> 48 hrs call)



Case Study 2: Pyloric Stenosis

David is a 2-month-old infant who has failed to gain weight in spite of his alert nature and vigorous appetite. He has a history of projectile vomiting 30-60 minutes after a feeding that has steadily gotten worse. His mother is very upset. “I don’t understand; I feed him all the time! Look at him!” The examining doctor thinks he feels a small olive shaped mass in the epigastrum. The doctors have scheduled to admit David to the hospital for some tests.


What might be noted on a physical exam?

What tests are likely to be ordered for this infant and why?

What might be the likely diagnosis?

What treatment or surgical intervention might be instituted?

What are the immediate nursing needs in this situation?

Is gastroesophageal reflux a possible diagnosis, why or why not?





Cleft lip and cleft palate:

Classification of Cleft Lip and Palate:


1/700 births more common Asian, Caucasians, males; palates alone females

Etiology:
Environmental- alcohol, drug exposure (Dilantin, Valium), dietary (low folic acid, vitamins), smoking

Genetic

Pathophysiology:
Failure to fuse nasal and maxillary processes 5-8th week
Failure of palatine plates to fuse between 7-12th week
Unilateral or bilateral

Diagnosis:
Obvious at birth
Mouth checked at birth for sucking reflex
Later milk coming through the nose
Can be seen on ultrasound

Treatment:
Complex
Specialists – plastic surgeon, orthodontist, speech pathologist, pediatrician, nurse, audiologist
Closure of lip at 3 months of age/ 12 pounds
Clefts of hard and soft palate at 12 months so not to interfere with speech

Long-term- problems with ear infections, speech, tooth eruption, body image

Nursing Management:
Newborn Assessment examines visually and palpation with a gloved finger
Ability to suck, swallow and feed
Caregivers reactions

Nursing diagnosis:

Preop
Imbalanced nutrition
Altered parenting

Postop
Risk of injury or infection
Acute pain
Deficient knowledge

Outcome identification:
Adequate nutrients
Caregivers adjust, bond
Infant comfort
Caregivers verbalize understanding
Infant normal growth and development

Planning:
Preop:
Support for caregivers- shock, grief, (anger, guilt, frustration, depression) isolation, inadequacy, failure; these are normal reactions. Fears relieved by seeing before and after photos.
Prevent aspiration and infection
Ensure adequate nutrition- poor inadequate suctioning, prolonged feeding time, nasal regurgitation, and inadequate weight gain.
Breast feeding possible, CL infants have no more trouble than other infants as the breast molds and tends to fill in the empty space or breast pump
Bottle feeding - Enlarge, Stimulate, Swallow and Rest (ESSR)
Feed in upright position
Burp frequently

Postop
Protect the operative area with Logan Bow
Decrease tension on the suture line
Elbow restraints
Back or side position
Decrease crying, adequate pain med.
Clean suture line with Q-tip dipped in Hydrogen peroxide, sterile water
Small amounts of water to rinse away milk residue
Take restraints off several times a day for 10 min., *one at a time*
NO oral thermometers, tongue depressors, straws, forks

Case Study 2: Cleft lip and Cleft Palate






What is often the first reaction to the birth of a child with cleft lip and/or cleft palate?

Can these children breast feed?

Do they require special equipment or accommodations for feeding?

At what age is the repair of cleft lip performed? Cleft palate?

The mother wants to know what she did wrong. How would you respond?

Post surgery what are some appropriate nursing diagnoses, interventions, and outcomes?


Esophageal atresia
Tracheoesophageal fistula

Congenital defects of the esophagus
Incomplete formation of the esophagus, terminates before reaching the stomach
Often associated with fistula between the trachea and esophagus, many variations
Associated other defects present in approx. ½ of all infants with EA with TEF

VACTERL
V - Vertebral defect
A - Anorectal defect
C - Cardiac defects
T – Tracheoesophageal fistula
E – Esophageal atresia
R – Renal anomalies
L – Limb defects

Pathophysiology:
Occurs during the 6-8th week
Defective separation of the foregut into the esophagus and the trachea

Clinical Manifestations:
Fine, frothy bubbles of mucous, clear with suctioning only to return
3 C’s- Episodes of coughing, choking and cyanosis, esp. with feeding
Abdominal distention, air builds up in the stomach

Diagnosis:
History of polyhydramnious
Unable to view stomach bubble on ultrasound
Feeding tube passed stops at 10-12 cm instead of 17 cm.
Follow-up with radiographic studies, absence of air in stomach – EA w/o TEF

Treatment :
Before 1939 fatal
Now surgery in the first few days
Goal is to prevent aspiration until then
One stage repair preferred
Premie or fragile infants close fistula, gastrostomy tube
Anastomosis of esophagus later

Nursing Management:
Preop –
Goal prevent aspiration and regurgitation
NPO
Continuous suction
Supine with elevated head

Postop –
Goals patent airway, prevent trauma
Gentle suctioning
Observation for airway obstruction – anxious look, tachypnea, abnormal breath sounds
NPO until bowel sounds return
IV
Glucose water if tolerated then formula or breast milk
Pacifier for sucking needs
Family teaching:
Observe for esophageal stricture- dysphagia, increased drooling, coughing, choking
If gastrostomy, care and feeding


Case Study 3: Esophageal Atresia with Tracheoesophageal Fistula


The young mother is crying and upset. Her husband stands by her mutely unsure of what to do or say. Shortly before their newborn boy, Dillon, had been rushed to the NICU. He was cyanotic, coughing and choking after his first feeding. The mother says the doctor came in and said Dillon's "eso..esopha..jus wasn't formed right...what does this mean? Is my baby going to die?" As the primary care nurse, you know the child has been diagnosed with esophageal atresia with tracheoesphageal fistula.


What might be some nursing diagnoses at this moment and what other nursing interventions, nursing outcomes would be appropriate?

Explain the anomaly to the mother and father. Draw pictures.

Explain the probable surgical intervention and what to expect.

What pregnancy condition might have been noted prior to delivery.

What other conditions might be associated with this condition? What is the acronym?

What is the prognosis? Prior to 1939 what was the prognosis?










References:

Daigneau, C. V. (2005). The child with gastrointestinal dysfunction. In M. Hockenberry, D. Wilson & M. Winkelstein (Eds.), Wong's essentials of pediatric nursing (7th ed., pp. 839-889). St. Louis, Missouri: Elsevier Mosby.

Ellett, M. L. (2009). Chapter 24: The child with gastrointestinal dysfunction. In M. J. Hockenberry & D. Wilson (Eds.), Wong's essentials of pediatric nursing (8th ed., pp. 813-860). St. Louis, MO: Mosby Elsevier.


Videos:
Gastroenteritis:
https://youtu.be/pIDmePznLBo?list=PLziHOo2bzkwDAHharVuFsVw3RYnflultD

Dehydration:
https://youtu.be/IAnL-Viyd5M

GERD
https://youtu.be/FXEpnVwLXcA

Healthy kid tips Pyloric Stenosis
http://youtu.be/6vhbA1vyBfU

Classification of Cleft lip and Palate
http://youtu.be/ghL4idjlBnA

Nationwide Children's Hospital cleft lip and palate
http://youtu.be/QpLJFr4Yel4

Tracheoesophageal fistula by Children's miracle network
http://youtu.be/qbdVzd1A2rU