Digestive System & Gastrointestinal

Disorder

OBJECTIVES
1. Explain important concepts of the
Gastrointestinal system
2. Describe the pathophysiology, clinical
manifestation, collaborative care, and
medical/surgical therapy of GI disorders
3. Plan nursing care for a child with a
gastrointestinal disorder
4. Implement nursing care for a child with a
gastrointestinal disorder
5. Analyze ways that nursing care of a child THE DIGESTIVE SYSTEM
with a gastrointestinal disorder can be more
family-centered Laboratory Studies And Diagnostic Tests
6. Integrate knowledge of gastrointestinal
 Stool examination
disorders with nursing process to achieve
 Complete blood count
quality child nursing care
 Hematocrit – 37% - 47%
 Hemoglobin – 12mg% - 16mg%
 RBC – 4.0 – 5.5/cu. mm
 WBC – 5 – 10 /cu. mm

Differential count
Neutrophils – 50 – 80%
Eosinophils – 0 – 5%
Monocytes – 2 – 10%
Lymphocytes – 25 – 50%
Platelet count – 140 – 400 10^3/cu

Laboratory Studies
 Abdominal ultrasound
 Computed tomography
 Upper GI Imaging
 Upper GI Series
 Small-bowel series
 Barium or Meglumine Diatrizoate
OVERVIEW OF ANATOMY AND (Gastrografin) swallow
PHYSIOLOGY OF THE GI SYSTEM  Barium Enema (Lower GI series)
 Upper GI endoscopic procedure
(Esophagogastroduodenoscopy)
 Fiber-optic Testing
 Lower GI endoscopic procedure
(Proctosigmoidoscopy, Colonoscopy)
 Gastric Analysis
 Gastroesophageal reflux disease (GERD  Anticholinergic
[chalasia])  Beta-adrenergic blockers
 Calcium channel blockers
 Nitrates
 Theophylline
 Diazepam
 Tight, restrictive clothing
 Bending, straining
 Hiatal Hernia

 Is a neuromuscular disturbance

Cause: unknown Nursing Assessment

 Heartburn or substernal burning pain,
Causes exacerbated by bending, straining and
 relaxation of lower esophageal sphincter recumbent position
(LES)  Forceful vomiting, possibly with
 decreased LES tone hematemesis
 increased  Weight loss
 intra-abdominal pressure  Aspiration and recurrent respiratory tract
 increased gastric volume, or a infections
combination  Cyanotic and apneic episodes
 Esophagitis and bleeding from repeated
Possible Complications: irritation
1. Aspiration Pneumonia  Melena
2. Esophageal stricture  Abdominal pain and a bitter taste

Factors Decreasing LES tone Diagnostic Assessment

 Nicotine  24 hours pH monitoring
 Caffeine  Esophagography
 Chocolate  Esophagoscopy
 Fatty Foods
 Alcohol Nursing Management
 Peppermint, spearmint  Promote adequate hydration
 Levels of estrogen and progesterone
  assess the amount, frequency, and
characteristics of vomitus Nursing care
 Assess the relationship between feeding and • Risk for altered nutrition, less than body
vomiting and the infant’s activity level. requirements related to regurgitation of
 Improve nutritional status through food with esophageal reflux
feeding techniques
 small frequent feedings 1. Monitor intake and output (urination)
 Formula thickened and weight.
 burp the infant frequently 2. After the feeding, the infant should lie on
 Prevent reflux and respiratory the side or prone on a slanted surface
complications 3. Use a sheepskin-like covering
 upright position in an infant seat
 Assess breath sounds before and after  Risk for altered nutrition, less than body
feedings requirements related to regurgitation of
food with esophageal reflux
Pharmacological Intervention
 Administer prescribed medications, 4. Be certain parents understand how
including: Antacid and histamine much cereal to mix with formula
receptor antagonist (cimetidine, 5. Mothers who are breastfeeding may
 ranitidine) manually express breast milk and mix it
 Omeprazole with rice cereal for feedings.
 Optokinetic medication 6. Encourage them to feed the infant in the
(metoclopramide) hospital after surgery and give care

Nursing Management Cleft Lip / Cleft Palate

 Provide child and family teaching
regarding feeding and positioning Cleft Lip /Cheiloschisis
 Provide postoperative care
 May require hospitalization and possibly
surgery
 Placement of a nonsurgical percutaneous
gastrojejunostomy tube
 Postoperative nursing responsibilities
include:
 preventing gastric distention
 Assess for flatulence, inability to vomit,
poor feeding habits, and choking on solid
foods

Nissin Fundoplication

Cleft Palate / Palatoschisis

  nasal distortion
 may include unilateral or bilateral
involvement.

Cleft lip

 is a visible or palpable gap in uvula, soft

palate, hard palate
 incisive foramen with exposed nasal
cavities and associated nasal distortion
 partial or complete

Cleft Palate

Complications
Cause  Speech defects
 Hereditary  Dental and orthodental problems
 Environmental  Nasal defects
 Teratogenic effect  Alteration in hearing
 Shock, guilt and grief for the parents
Assessment  Increased risk of aspiration
 abdominal distention  URTI
 difficulty swallowing  Otitis media
 involves a notched upper lip border
Diagnostic Findings
Ultrasonography

Palatoplasty (cleft palate repair surgery)

Medical Management
Cheiloplasty (cleft lip repair surgery)
 Breck – feeder

Haberman feeder
Preoperative Nursing Care
1. Assess degree of cleft and ability to
suck
2. Provide postoperative feeding
instructions
3. Encourage parents to verbalize fears,
concerns, negative emotions
4. Facilitate grief responses of shock,
denial, anger, and mourning
5. Encourage touching, holding, cuddling,
and bonding
6. Provide parents with pictures of other
children before and after surgical repair
7. Parents of children with a cleft palate must
be alert to the signs of infection; they need
to report pharyngeal infection

 Infant is kept on NPO status for at least 4

hours. Introduced to liquids after.
Preoperative Nursing Care  Monitor for respiratory distress
1. Assess respiratory status continuously  No oral temperatures
during feedings  Advance feedings as tolerated
2. Feed infant in upright position  No straws, pacifiers, spoons, or fingers in
3. Feed slowly and burp the infant or around mouth for 7 to 10 days
frequently (ESSR)  For cleft lip, a metal appliance or
4. Use alternate feeding devices such as adhesive strips may be used (Logan
elongated nipple (Lamb’s nipple) Bar).
  For cleft palate, liquids can be taken from 1. body pigment fades and the child
a cup; no straws are allowed; soft food can become:
be taken from side of spoon  very fair skinned
 Clean lip from suture line out after  blonde
feedings and pm  blue eyed
 Apply antibacterial ointments as ordered 2. The child fails to meet average growth
 Use elbow restraints standards
 No tooth brushing for I to 2 weeks 3. Many children develop an
 Place infant in side-lying position on accompanying seizure disorder.
unaffected side 4. The skin is prone to eczema (atopic
 Monitor site for signs of infections dermatitis).
 Assess pain using appropriate tools 5. Untreated, the child with PKU will have
 Provide comfort measures such as an IQ that is generally below 20 – motor-
crying. mental retardation
 Provide analgesics and sedatives on a 6. Recurrent convulsions
scheduled basis 7. muscular hypertonicity and spasticity.
 Provide age-appropriate activities for 8. Mouse-like odor in urine and sweat
diversion
Diagnostic Test
Client and Family Teaching  Recombinant DNA techniques
1. Stress importance of follow-up care and  Guthrie Test
referral appointments
2. Make appropriate and early referrals for
speech and language disabilities
3. Encourage early speech attempts and Normal Findings
arrange for speech therapy Phenylalanine level
4. Encourage good dental hygiene and  A serum level of > 4 mg/dl is strongly
orthodontic follow-up suggestive of phenylketonuria
 Phenylalanine level of the blood stays
Phenylketonuria below 8 mg/dl
Because a child with PKU lacks the normally
Phenylketonuria: Therapy
functioning enzyme necessary to break down
 Phenylalanine resitricted diet,
phenylalanine (PHE), it accumulates in the blood
and body tissues. supplementation of tyrosine, essential
amino acids and trace elements.
This excess PHE can prevent normal brain
development and result in mental retardation. Goals of the therapy:
 0-10 years: phenylalanine values: 0.7-4
Overview: mg/dL
 a disease of metabolism inherited as an  11-16 years: phenylalanine values: <15
autosomal recessive, trait. mg/dL
 Absence of the liver enzyme  16+ years: phenylalanine values: <20
phenylalanine hydroxylase prevents mg/dL
conversion of phenylalanine to tyrosine (a  Pregnant mothers with PKU:
precursor of epinephrine, thyroxin and phenylalanine values < 7mg/dL
melanin)
 excessive phenylalanine can lead to Prognosis: with immediate and efficient
severe cognitive impairment treatment, normal development and
 phenylpyruvic acid spills into the urine intelligence

Nursing Assessment Diagnostic Tests

Guthrie Test for PKU
Bacterial plate with newborn blood samples Therapeutic Management
1. Parents of children with PKU need a
realistic prognosis of their child's
potential.
2. Parents need an opportunity to express
their feelings about the difficulty of
maintaining a young child on such a
restricted diet.

Hirschsprung's disease
(aganglionic megacolon)
 Congenital anomaly resulting from an
absence of ganglion cells in colon

Therapeutic Management
1. Placed on an extremely low
phenylalanine formula (Lofenalac)
2. A dietitian may recommend a small Cause
amount of milk in the infant's diet every  Familial
day  Incidence is higher in children with
Down syndrome and genitourinary
abnormalities
 Rectosigmoid region is most commonly
affected
 Absence of autonomic parasympathetic
ganglion cells – myenteric and
submucosal plexus are absent
 Caused by an abnormal gene on
chromosome 10

Defecation Reflex
a Local reflexes
b Parasympathetic reflexes

Nursing Management
Clinical manifestations in newborns:
 Failure to pass meconium stools within 24
hours
 Liquid or ribbonlike stools
 Reluctant to ingest fluids
  Abdominal distention and easily
palpable stool masses Monitor urine specific gravity
 Bile-stained emesis or fecal vomiting  monitor electrolytes
 assess hydration status
Clinical manifestations in infants:
 Failure to thrive Postoperative Nursing Care
 Constipation  Prepare child for surgery and temporary
 Abdominal distention placement of colostomy
 Vomiting  Administer antibiotics as ordered
 Episodic diarrhea  Monitor VS
 measure abdominal girth
Clinical manifestations in toddlers:  assess surgical site for redness,
 Chronic constipation swelling, drainage after surgery
 Foul-smelling stools
 Abdominal distention
 Visible peristalsis
 Palpable fecal mass
 Malnourishment
 Signs of anemia and hypoproteinemia

Diagnostic Tests  Assess stoma for color, bleeding,

 Rectal examination breakdown of surrounding skin
 Rectal Biopsy  Assess anal area after pull-through for
 Absence of ganglion cells patency of any appliance that may be in
Nursing diagnoses: place, presence of stool, redness, drainage
1. Constipation r/t reduced bowel function  Provide meticulous skin care, use
2. Altered nutrition, less than body appropriately sized stoma supplies
requirements r/t reduced bowel function  Notify physician of any fever, unusual
3. Risk for ineffective family coping, drainage, redness, or odor
compromised, r/t chronic illness in child  Keep child NPO until bowel sounds
Therapeutic Management return or flatus is passed
 Temporary colostomy  maintain NG tube,
 administer IV fluids as ordered
 monitor daily weights
 begin diet with clear liquids and
progress as tolerated
 Assess pain using age-appropriate
scales
 provide comfort measures and involve
parents
 provide pain medications on regular
basis as ordered
 notify physician if pain is not managed
 Involve child in quiet, age-appropriate
Preoperative Nursing Care
activities for diversion
Assess bowel function and characteristics of
 Encourage parents to share feelings,
stool;
anxieties, and concerns about disorder and
 measure abdominal girth
post-surgical care
 monitor child for vomiting and  Refer to support groups and make
respiratory appropriate referrals
 distress
  Atrophy of the villi
Client and Family Teaching  Reduce absorption
1. Explain surgical repair and recovery  Chronic diarrhea
process
2. Encourage preschool and early school-
aged children to draw pictures, use dolls,
and play
3. Provide parents with instructions about
how to complete rectal irrigations and
allow time for return demonstration
4. Teach colostomy care in immediate
postoperative period and encourage
parents
5. Teach parents how to assess for distention
and obstruction and importance of reporting
these findings to Nursing Assessment
6. physician • symptoms typically appear within 3 to 6
7. Help the parents learn about a minimal months
residue diet • Frequent bulky, greasy, malodorous
stools with frothy appearance
2ns step repair malnutrition; Abdominal distention,
1. Infants will return with a nasogastric vomiting, and anorexia
tube in place attached to low suction. • Growth retardation
2. Intravenous infusion • deficiency of fat sol vitamins (ADEK)
3. Indwelling urinary catheter • Anemia, irritability, edema
• In a celiac crisis, severe diarrhea and
1. Observe for abdominal distention dehydration; electrolyte imbalances and
2. Assess bowel sounds and observe also for metabolic acidosis
passage of flatus and stools
3. As soon as peristalsis has returned, the
NGT may be removed, hen offered small,
frequent feedings of fluids

Celiac Disease
Overview
• a genetic GI malabsorption condition
• known as gluten-induced enteropathy
• inability to tolerate foods containing
gluten
• inability to fully digest gliadin and
glutenin or protein component

Cause:
• “unknown”
• Genetic predisposition
• possibly influenced by environmental
factors
• an immunologic abnormality

 Exposed to gluten
 Damage in Intestinal mucosa
Laboratory Studies and Diagnostic Tests • Importance of lifelong compliance with
• Flat mucosal surface, absence or atrophy dietary modifications and follow-up
of villi, and deep crypts visible on biopsy medical care
of small intestine
• Steatorrhea on analysis of 72-hour Intussusception
quantitative fecal fat study  Is the invagination of one portion of the
• Presence of serum antigliadin antibody intestine into another
(AGA) and reticulin antibody levels are  occurs mostly in the ILEOCECAL
elevated VALVE
Nursing Diagnosis
• Altered nutrition; less than body
requirements, related to malabsorption of
food

Therapeutic Management

Younger than 1 year old – idiopathic reasons

Older than age 1 year – lead cause

• Assess child's growth at each routine

visit using a standard growth chart
• Administer fluids for hydration; serum
electrolytes and serum osmolality
• Monitor I & 0, assess skin turgor, mucous
membranes, and urine specific gravity
• Encourage participation in age-
appropriate activities
• Inform parents of organizations

Client and Family Teaching

• Parents need a great deal of nutritional
counseling when children are first placed
on a gluten-free diet
• Written and verbal instructions on
gluten-free diet
• Read labels of processed foods, because
most contain gluten as a filler
• Urgency of seeking medical care in the
event of celiac crisis
 Intussusceptions
Overview:
• occurs in the second half of the first year
• The point of the invagination is generally
the juncture of the distal ileum and proximal
colon.
• Classifications:
1. Ileocecal
2. Ileoileal
3. Colocolic

Causes:
 Meckel’s diverticulum

 Intraoperative appearance of ileocolic

intussusception due to Meckel
diverticulum.

 Polyps
 Intussusception
Obstruction
Edema
Venous and
arterial
obstruction
GI bleeding and
fluid loss
Ischemia
Necrosis
 Hypertrophy of Peyer’s patches Perforation
Sepsis

Nursing Assessment
 Distended and tender abdomen with a
palpable, sausage-shaped abdominal mass
 If necrosis has occurred, children
generally have
 an elevated temperature,
 peritoneal irritation
 Bowel tumors  Increased WBC,
 and often a rapid pulse.
Nursing Assessment
 Intermittent attacks (15 min.) of colicky Laboratory Studies and Diagnostic Tests
pain…
 History - (duration, intensity, frequency,
 Emesis containing bile or fecal material
description, associated manifestations)
 After approximately 12 hours, children  Sonogram (ULZ)
develop blood in stool, containing mucus
 Increased WBC
described as a "currant jelly" appearance.
 Abdominal X ray, Ultrasound,
Computerized Tomography

This is an abdominal plain radiograph of a 14-

week-old patient with intussusception. Note the
nonspecific appearance of bowel obstruction
Transverse ultrasonographic view This ileocolic intussusception is observed using
barium contrast enema. Intussusception has been
reduced to the level of the proximal transverse colon.

Therapeutic Management

Appearance of intussusception on CT scan.

A. Reduction by a water-soluble solution

B. Pneumatic insufflation

Surgery
 Manual Reduction
 Resection

This ileocolic intussusception is observed using air-

contrast enema. Intussusception has been
reduced to the level of the cecum.
 Bowel Resection

Manual Reduction
Nursing care
 Pain related to abnormal abdominal
peristalsis
1. Infants need to be held and rocked and
comforted

 Risk for fluid volume deficit related to

bowel obstruction
1. NPO status before surgery or  Diagnosis: palpable olive shaped, firm,
nonsurgical reduction movable mass, located above to the right
2. Intravenous fluid therapy - Vomiting of umbilicus (mid epigastrium), after
3. If a nonsurgical reduction was vomiting.
accomplished, infants are kept NPO for a  Visible gastric peristaltic wave across
few hours… abdomen.
4. Infants who have surgery will return with  Confirmed by USG (>> length, >>
NGT thickness of wall, << luminal diameter)
5. Once bowel sounds are present, oral
feedings will be started gradually. Pyloric Stenosis
 Visible peristalsis
 Risk for altered parenting related to  “Olive” shaped mass at right upper
infant's illness quadrant
1. Parents need to hold infants after
reduction or Complications:
2. postoperatively  Dehydration
3. Provide guidance and support as they
 Alkalosis
hold the infant.
 Hypopnea
4. When oral feeding is resumed,
encourage the parents to participate  Tetany
with this aspect of care
Diagnostic Procedure:
 Risk for altered parenting related to  Ultrasound
infant's illness  Endoscopy
1. Reassure them that this did not occur
because of anything they did. Medical Management
2. They need to hold and be with the child as Surgical Management
recovery occurs.  Laparoscopic correction
(pyloromyotomy)
Pyloric Stenosis  Performed before electrolyte imbalance
Hypertrophic Pyloric Stenosis  Oral feeding is withheld - NPO
Hypertonic pyloric stenosis results when the  IV fluids
circular area of muscle surrounding the pylorus  IV calcium and potassium
hypertrophies and obstructs gastric emptying.

Clinical Manifestations
 Begins at 4-6 weeks of age
 Projectile vomiting
 Sour but contains no bile
 No presenting illnesses
 Gastric peristaltic movement passing from
Left to Right across the abdomen
 Round and firm olive size lump
 Biliary Atresia

Causes:
Prenatal period
 Unknown
 Viruses
 Toxins
 Chemicals

Overview:
A progressive inflammatory process that causes
both intrahepatic and extrahepatic bile duct fibrosis.

Nursing Assessment
1. Healthy - appearing infant at birth
 2. Jaundice occurs within 2 weeks to 2
months
3. Acholic stools: puttylike, clay-colored
stools
4. Abdominal distention and hepatomegaly
5. Increased bruising of the skin,
prolonged bleeding time
6. Intense itching
7. Tea-colored urine
8. Malnutrition and growth failure

Diagnostic tests
 Liver biopsy
 Ultrasound

Medical Management
 Kasai Procedure Therapeutic Management
1. Weigh daily
Surgery – for temporarily correct
2. Administer TPN with or without
obstruction and supportive care
intralipids as ordered
3. Administer fat-soluble vitamins A, D, E,
and K as ordered
4. Monitor stool pattern
5. Establish an open, caring relationship
with family
6. Refer parents to support groups

Client and Family Teaching

1. Instruct the parents in meticulous skin
care
2. Provide verbal and written information
regarding nutritional needs
3. Provide instructions on home medication
regimen and allow time for return
demonstration
 Liver tranplatation 4. Inform parents of the signs and symptoms
for which to call the physician
Post OP Patient 5. If a transplant is performed, include
detailed instruction on post-transplant
medication.