Git Disorders in Children

8/3/2019 Git Disorders in Children

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DIGESTIVE DISORDERS IN

CHILDREN

PROF. CGBERCILES, RN MANFOR : BSN 3A & 3D NCM-103 FIRST SEM

20111


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Child's GI SYSTEM

1) High rate of peristalsis (increases susceptibility todiarrhea)

2) IMMATURE gastroesophageal sphincter( prone toGER(achalasia)

3) low production of intestinal antibodies till age 6-7mo

4) inc intestinal permeability to whole CHON e.g.cow's milk ( increased susceptibility to allergies)

5) immature liver (poor drug meta & bilirubin conj)


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CLEFT LIP/CHEILOSCHISIS


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BILATERAL COMPLETE


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CLEFT LIP AND PALATE

MAXILLARY & MEDIAN NASAL PROCESSESnormally fuse b/n 5-8 weeks of intrauterine life

Failure to fuse : a small notch in the upper lip to

total separation of the lip & facial structures up intothe nasal floor, the upper teeth and gingiva absent

Unilateral/bilateral; more boys than girls

due to incomplete fusion of the upper lip noseflattens or expands horizontally

Familial tendency /from transmission of multiplegenes


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CLEFT LIP & PALATE


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CLEFT PALATE

PALATIAL PROCESS closes at approx weeks 9 to12 of intrauterine life

Palate opening (midline) , may involve the anterior

hard palate, post soft palate or both

More common in girls than boys

RESULT of polygenic inheritance or environmental

influences (maternal nutrition, drugs)


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CLEFT PALATE/PALATOSCHISIS


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BILATERAL COMPLETE LIP ANDPALATE


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CLEFT LIP AND PALATE


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ASSESSMENT

SONOGRAM while infant is in utero

At birth, apparent on inspection

Depress tongue with tongue blade; adeqlighting


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ASSOCIATED PROBLEMS

feeding difficulties

middle ear fluid buildup and hearing loss

dental abnormalities speech difficulties.


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Management: CLEFT LIP (interfereswith nutrition)

SURGICAL REPAIR : shortly after birth : time ofinitial hosp stay or b/n 2-10 weeks of age

Early repair: sucking pleasure (infant); parental

bonding easier (psychological)

REVISION may be necessary at age 4-6


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CLEFT PALATE REPAIR

POSTPONED until 6-18 months of age : toallow the anatomic change in the palate contour(1st year of life)


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LOGAN'S BAR: toprotect the lip from

injury; add tape ifloosened/removed


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FEEDING MEASURES: poor suckingand risk for aspiration

CLEFT LIP: SUPPORT in an UPRIGHTPOSITION; feed GENTLY using aCOMMERCIAL CLEFT LIP NIPPLE

SYRINGe

Breast-feeding: 7-10 days postop

CLEFT PALATE: COMMERCIAL CLEFTPALATE NIPPLE with extra flange of rubberto close the palate

Delayed repair : beyond 6 mo of age : soft food


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POSTOP CARE

NPO for 4 hr

Plain water/liquid slowly introduced (p/v vomiting)using a specialized feeder to avoid tension to suture

line (NOT BREAST-/BOTTLE) LIQUIDS : 1st 3-4 days-> soft diet til healing is

complete; NO SPOON***BETTER TO BE ONLIQUID DIET UNTIL SUTURES HEAL

NO MILK: curds tend to adhere to suture line

Clear water p/feeding : rinse suture line, cleanmouth


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RISK : INEFFECTIVE AIRWAYP/REPAIR

LOCAL EDEMA

PREOP (mouth- breather); post-op : nose-breathingcan be difficult ****generally, infants are nose -

breathers SUCTIONING : gentle, DO NOT TOUCH THE

SUTURE LINE WITH THE CATHETER

SIDE-LYING with support : to drain mouthsecretions

SHOULD NOT TURN ONTO THEIR SIDES :tension to suture line


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TEA vs TEF

TEA: failure of the esophagus to develop as acontinuous passage. Instead, it ends as a blindpouch.

TEF:an abnormal opening between the tracheaand esophagus.


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TRACHEOESOPHAGEALATRESIA/FISTULA


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MANIFESTATIONS NB:excessive salivation (drooling) ,choking,

coughing, sneezing.

When fed, NB swallows normally but begins tocough and struggle as the fluid returns throughthe nose and mouth

Cyanosis: result of laryngospasm(protectivemech)

apnea as the overflow of fluid from the blindpouch is aspirated resp distress I


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PRESENTATION

BETWEEN weeks 48 of IUL, theLARYNGOTRACHEAL GROOVE developsinto the LARYNX, TRACHEA & LUNG

TISSUE

ESOPHAGEAL LUMEN FORMS

TERATOGEN does not allow the two organs to

separate

defect arises in 4th fetal week


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ASSESSMENT: IMMEDIATELYAFTER BIRTH

WOMAN WITH HYDRAMNIOS

PRETERM/IMMATURITY

SUSPECT in infant with : Excessive mucus

Difficulty with secretions

Unexplained cyanotic episodes


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DIAGNOSTIC

CATHETER INSERTION

BARIUM XRAY


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COMPLICATIONS

DEATH

PNEUMONIA : salivary aspiration, gastricreflux

Concomitant lesions : heart disease, GIanomalies, renal abnormalities etc


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NSG DIAGNOSES: PREOP

Risk for Aspiration

Risk for Deficient Fluid Volume

Anxiety of parents


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SURGERY

PRIMARY REPAIR if infant weighs >2,000 g

Without pneumonia

STAGING


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POSTOP NSG DIAGNOSES

Ineffective Airway Clearance

Ineffective Infant Feeding Pattern

Acute Pain Impaired Tissue Integrity

Risk for Injury

Risk for impaired parental/infant attachment


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POSTOP CARE FOCUS

AIRWAY : endotracheal tube

DO NOT HYPEREXTEND THE NECK....

MAINTAIN CHEST DRAINAGE : IF BREAKOCCURS... stat: CLAMP tubing CLOSE TOTHE INFANT TO P/V PNEUMOTHORAX


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GASTROESOPHAGEALREFLUX(ACHALASIA)

"failure to relax"

the inability of the LES to open and let foodpass into the stomach

Cause: unknown; autoimmune; infection;heredity

degeneration of esophageal muscles and the

nerves that control the muscles.


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MANIFESTATIONS

DYSPHAGIA (solid/liquid) food sticks(consistent

Heavy chest sensation/chest pain

Regurgitation at night, aspiration->pneumonia

Weight loss

esophagitis


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DIAGNOSTIC EVALUATION

HISTORY

XRAY with Barium ***bird's beak

Esophageal manometry endoscopy


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TREATMENT

PO nitrates, calcium blocking agents

DILATION

ESOPHAGEAL MYOTOMY BOTOX INJECTION


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NSG CARE

HEALTH TEACHING

SLEEP POSITION

FOOD INTAKE


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PYLORIC STENOSIS

infantile hypertrophic pyloric stenosis

Males > females / first born

Genetic predisposition; unknown cause Caucasians with blood type B or O

First few months of life


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MANIFESTATIONS

VOMITING, projectile

Palpable olive mass in epigastrium/ RUQpost feeding/after vomiting

Peristaltic waves to the left


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pathophysiology

Non-bilious vomiting-> hypochloremia whichimpairs the kidney's ability to excretebicarbonate** the significant factor that

prevents correction of the alkalosis. secondary hyperaldosteronism (hypovolemia)--

>Na and water retention, K excretion

Compensatory hypoventilation............pCO2? SEVERE ALKALOSIS: irregular resp rate with

apnea


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treatment

CORRECT acid-base imbalance andhypovolemia

Atr SO4

surgery

PYLOROMYOTOMY/RAMSTEDT


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PYLOROMYOTOMY/RAMSTEDTPROCEDURE: definitive treatment

dividing the muscle of the pylorus to open upthe gastric outlet

a relatively straightforward surgery

single incision (usually 34 cm long) orlaparoscopically (through several tinyincisions), depending on the surgeon's

experience and preference.

HORIZONTAL PYLOROMYOTOMY


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HORIZONTAL PYLOROMYOTOMY(1 MO OLD)


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POSTOP POSITION

PROPPED UPRIGHT, slightly ON THERIGHT SIDE to aid gastric emptying

HIRSCHSPRUNG DISEASE:


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HIRSCHSPRUNG DISEASE:congenital aganglionic megacolon

Due to congenital absence of theparasympathetic ganglion nerve cells fromwithin the muscle wall of the intestinal tract

(distal end of the colon) Male/female ratio 4:1 (long segment 1:1)

Genetic; with associated congenital anomalies


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NORMAL MIGRATION

NORMAL: nerve cells migrate to the upper endof the intes tract caudal direction, withmigration to distal colon complete by 12 weeks

MIGRATION occurs Ist in the intermediatelayer ( AUERBACH'S PLEXUS) SUBMUCOSAL PLEXUS GITract in aDESCENDING MANNER


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ETIOLOGY/PATHOPHYSIOLOGY

ARREST in embryonic development affectingthe migration of PS nerve innervation

AGANGLIONOSIS is continuous with the

affected segment

SHORT-SEGMENT (rectosigmoid colon) *

LONG-SEGMENT ( upper descending,

transverse)

Total agangliosis (rare)


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Pathophy.......

(-) peristalsis in affected segment:spastic/contracted/narrowed---> NO FECALMATTER PASSES

DILATED colon(fecal matter, gas)

Muscular coating HYPERTROPHY

Mucosal ulcerations (neonate)

INTERNAL RECTAL SPHINCTER: (-) relax,

Feces/gas : not evacuated---> abddistention/constipation


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CLIN MANIFESTATIONS: depends


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CLIN MANIFESTATIONS: dependson degree of involvement

NEONATESs/s appear at BIRTH/WITHIN1st weeks of life : (-) MECONIUM 1st 48h;vomiting (bile-stained/fecal); abd distention;

CONSTIPATION; overflow type of diarrhea;dehydration; FFT

TEMPORARY RELIEF with ENEMA

C/ O C


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C/M : OLDER CHILD

Obstipation @ birth; progressive abd distention

Peristaltic activity (observed over abdomen)

(-) RETENTIVE POSTURING: ability tocontract the internal & ext sphinchter topurposefully avoid defecation

Constipation -unresponsive to conventional tx

RIBBON-LIKE, FLUIDLIKE, PELLETSTOOLS

Old hild / ( 'd)


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Older child s/s ......(cont'd)

Failure to grow : loss of subc fat, malnourished,stunted growth

Presentation :

insiduous/catastrophic....(ENTEROCOLITIS)

ENTEROCOLITIS


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ENTEROCOLITIS

SEVERE colitis and a PROLIFERATION ofbacteria in the colonic lumen

Abd distention; explosive diarrhea; vimiting,

fever, lethargy, rectal bleeding, SHOCK

NOTIFY DR STAT

Major cause of DEATH

TREATMENT OF ENTEROCOLITIS


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TREATMENT OF ENTEROCOLITIS

IV/PO Antibiotics

INITIAL EMERGENCY TX: Colonicirrigation & decompression with saline solution

Surgal decompression colostomy

At least, one month after-> abdominal perinealpull-through


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MANAGEMENT


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MANAGEMENT

Colostomy/ileostomy: to decompress intestines,divert fecal stream, rest normal bowel

DEFINITIVE : REMOVE the aganglionic,

nonfunctional, dilated bowel segment->anastomosis and improved functioning of theinternal rectal sphincter(RECONSTRUCTION)...

RECONSTRUCTIVE PROCEDURES


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RECONSTRUCTIVE PROCEDURES

SWANSON : abdominoperineal pull-throughleaving the smallest amt of aganglionic bowelremaining

DUHAMEL: retrorectal transanal pull-throughcreating a NEORECTUM with the aganglionicanterior wall & ganglionic posterior wall

SOAVE : laparoscopic endorectal pull-through;infant age 9-12 mo/ wt reaches 15-20 lb

***NSG ALERT***


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***NSG ALERT***

ANY INFANT WHO FAILS TO PASSMECONIUM WITHIN THE FIRST 24 H ANDREQUIRES REPEATED RECTAL

STIMULATION TO INDUCE BM


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Ineffective Breathing Pattern r/2..........?

Imbalanced Nutrition MORE OR LESS? Thanbody requirements r/2........?

Acute Pain r/2 int obstruction

Constipation

IMPROVE BREATHING PATTERN


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IMPROVE BREATHING PATTERN

Monitor for resp imbarrassment: sternalretraction; rapid, shallow resp; cyanosis

Elevate infant's head and chest (mattress-tilt)

Adm O2 as ordered

PAIN RELIEF


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PAIN RELIEF

NOTE drawing up of legs; chest breathing

Abdominal color, gastric waves, abd girth meas

Repeated colonic irrigations with wam NSS

Adm antibiotics as ordered

Rectal tube as ordered; NGT decompression

Maintain comfortable position/soothingstimulation e.g. music, touch, play therapy

PROVIDE ADEQUATE NUTRITION


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PROVIDE ADEQUATE NUTRITION

Small, frequent feeding

LOW-RESIDUE DIET

FEED SLOWLY; upright position

Parenteral nutrition may be needed

INFORM PARENTS THAT DEFECT CANBE CORRECTED

NSG DIAGNOSES POSTOP


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NSG DIAGNOSES POSTOP

RISK FOR INJURY r/2 postoperative course

RISK FOR INFECTION OF SURGICALINCISION

RISK for injury r/2 decreased peristalsis

INEFFECTIVE FAMILY COPING r/2 care ofchild with colostomy

PREVENTING COMPLICATIONS


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PREVENTING COMPLICATIONS

Temp: axillary or tympanic

Assess respiratory status

PLACE CHILD in a LATERAL POSITION ona FLAT/SLIGHTLY ELEV BED ***whenhead of the bed is ELEVATED, the residualCO2 in the child's abd cavity CAUSESREFERRED PAIN IN NECK & SHOULDER

NSG CARE POSTOP (CONT'D)


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NSG CARE POSTOP (CONT D)

NOTHING PER RECTUM SIGN : placed athead of bed

PREVENT WOUND INFECTION


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PREVENT WOUND INFECTION

STERILE technique for dressing change

PREVENT CONTAMINATION FROMDIAPER: apply diaper BELOW DRESSING;

FREQUENT diaper change

Proper hand washing

**7-10 stools/ day CAN BE PASSED;

PREVENT PERIANAL EXCORIATION..

Cont-n....


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Cont n....

ENCOURAGE frequent coughing, deepbreathing

Allow infant TO CRY FOR SHORT pd to

prevent ATELECTASIS

FREQUENT change of position

PREVENT ABD DISTENTION


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PREVENT ABD DISTENTION

MAINTAIN NGT PATENCY : NG suct5ionfor 24-48 h/until BS, gas from rectum/ostomy

Watch for distention : abd girth

Measure fluid loss

MAINTAIN NPO status; freq oral hygiene

Adm fluids and electrolytes as ordered

FOLEY CATH 24-48H

BEGIN ORAL FEEDINGS as ordered

ORAL FEEDING


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AVOID overfeeding

BUBBLE frequently during feeding

TURN HEAD TO SIDE/ELEVATE afterfeeding to PREVENT ASPIRATION

OSTOMY CARE


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CELIAC DISEASE


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Git Disorders in Children

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