INTERFERENCES WITH ELIMINATION
CONGENITAL OBSTRUCTIVE INTERFERENCESAnorectal MalformationsDefinition: malformation of anus and/or rectum minor to severe forms-rectal atresia -imperforate anus
Assessment May Include:
- failure to pass meconium stool ( imperforate anus)
- stools in urine ( fistula)
- ribbonlike stools (anal stenosis)
Inspection of perineal area for abnormalities
Insert lubricated rectal thermometer short distance(check protocol of agency)
Interventions- corrective surgery (anoplasty)- perform manual dilation as ordered- instruct parents in proper technique- prevent infection keeping anal area as clean as possible
HIRSCHSPRUNGS DISEASE:AGANGLIONIC MEGACOLON
Definition/Pathophysiology autonomic parasympathetic ganglion cells absent in part of the large colon resulting in decreased motility, causing mechanical obstruction
-familial disease, more common in boys and associated with Down’s syndrome
Diagnosis: - history of bowel patterns
- radiographic contrast studies
- rectal biopsy to check for ganglion cells
AssessmentNewborns: failure to pass meconium, refusal to suck, abdominal distention and bile stained emesisOlder Child: failure to gain weight and delayed growth, abdominal distention, constipation alternating with diarrhea and vomiting
Treatment/InterventionsSurgical removal of aganglionic bowel with a temporary colostomy (in severe cases)
Milder case: dietary modification ( low residue), stool softeners-isotonic irrigations to prevent impactions
Nursing ManagementIdentify early through history
Monitor fluid & lyte balance; nutrition
Patient education- teach ostomy care if needed- teach how to perform irrigations- teach how to prevent skin breakdown- teach proper nutrition
Post op care/measures: monitor for infection,pain control, measure abdominal circumference,maintain hydration
VOLVULUS
Definition/Pathophysiology: bowel twists upon itself causing obstruction and necrosis
Assessment: nausea, vomiting, no bowel sounds,severe gripping pain and a tense distended abdomenConfirmed by x-ray
Treatment/Interventionssurgical intervention with a bowel resection follow with post op care
INTUSSUSCEPTIONDefinition/Pathophysiology:
- telescoping of the bowel into itself
- usually at the ileocecal valve
- causes inflammation and edema
-blood flow becomes decreased
- commonly in boys (2 months to 5 yrs old) -associated with cystic fibrosis and celiac disease
Assessment: abrupt onset with acute abdominal pain, vomiting and the passage of brown stool
- as condition worsens stools become red andresemble currant jelly
- possibly a palpable mass in R upper quadrantor mid upper abdomen
Diagnosis: history of child and radiography, ultra-sound of abdomen and/or barium enema
Treatments
-Barium Enema can reduce telescoping by hydro-static pressure
-Surgery to reduce invaginated bowel and removenecrotic tissue
Nursing Management for Intussusception
IV’s started immediatelyPost Op -monitor VS, bowel sounds -monitor abdominal distention -check for S&S of infection-manage pain- maintain NGT patencyPATIENT EDUCATION
Omphalocele Definition/Pathophysiology: -congenital malformation where intra- abdominal contents
herniate through the umbilical cord -covered by translucent sac-peritoneum
-may have other congenital anomalies
Nursing Management-cover with NS soaked gauze & cover with plastic-monitor VS especially temp-NPO with IV’s to maintain fluid & lyte balance
Post Op Care
prevent infection
maintain fluid & lytes
control pain
ensure adequate nutritional intake
support parents in dealing with crisis
Hernias Definition: -protrusion of viscus from its normal
cavity through an abnormal openingTypes: Reducible: can be manually placed back into
abdominal cavity
Irreducible: cannot be placed back into cavity
Inguinal: weakness of abdominal wall- spermatic cord emerges in males- round ligament in females
Strangulated: irreducible with blood flow cut off
Treatment/Interventionsmanual reductionuse of supports (TRUSS)surgery for strangulated hernia repair
Nursing Interventions -Post op prevent bladder distention splint incision site deep breathe Q 2 HR (avoid coughing) ice to scrotal area & support avoid heavy lifting 4-6 weeks report pain or difficulty urinating
INFLAMMATORY INTERFERENCES
Necrotizing Enterocolitis -inflammatory disease of the intestinal tract r/t intestinal ischemia, infection, gut immaturity - primarily in premature infants
Assessment -feeding intolerance ( vomiting, abdominal distention, irritability)
-bloody diarrhea - possible sepsis
Diagnostics-X-rays showing free peritoneal gas-bowel wall thickening
Interventions: - NPO and maintain IV’s - NGT to suction - antibiotics
- bowel resection- possible ileostomy, colostomy
NURSING MANAGEMENT
• ID early (monitor feedings)• Maintain fluid & lyte balance• Comfort infant (holding, pacifier to meet
sucking needs)• Patient Education post op
APPENDICITISDefinition
- inflammation of the vermiform appendix preventing mucus from passing into the cecum
-untreated can cause ischemia, gangrene, rupture and peritonitis (may be caused by mechanical obstruction or anatomical defect)
Assessment - low grade fever - Rt. Lower quadrant pain (McBurney’s point) - vomiting, diarrhea, constipation
- rebound tenderness - Rovsing’s sign: palpate Lt. abdomen, pain felt on Rt.
Diagnostics - increased WBC count - CAT scan
Figure 24–16 Common location of pain in children and adolescents with appendicitis.
TREATMENTS/INTERVENTIONS
Pre Op Post OpNPO check VS, monitor incisionIV’s IV’sAntibiotics antibioticsNGT (if peritonitis) coughing & deep breathingNo laxatives drain (penrose) if ruptured
Ruptured Appendix - fever - sudden relief of pain
-chills, pallor
NURSING MANAGEMENT-Promote comfort: Rt. Side lying, semi- fowler’s with knees bent, analgesics-Maintain hydration: I&O, skin turgor-Support respiratory function: cough, deep breathe / splint-Check for S&S of infection:
check incision, check drainage, change dressing, antibiotics
Discharge teaching: -how to check for infection-no strenuous activities
INFLAMMATORY BOWEL DISEASECROHN’S DISEASE
Definition - chronic, inflammatory process along the GI tract - involves all layers of the bowel
(deep fissures & ulcerations may develop between loops of bowel or nearby organs) - possible genetic association
Assessment - crampy abdominal pain (RLQ) - fever - diarrhea (weight loss )
- ileum involvement ( steatorrhea)
(prevalent in individuals of Jewish descent between the ages of 15- 25 yrs. old )
Diagnostics
- CBC: increased WBC, decreased H&H - increased ESR
- hypoalbumineria- abdominal tenderness- thrombocytosis- radiologic & biopsy examination- lower endoscopy (proctosigmoidoscopy)- barium study of UGI tract- CAT scan
ULCERATIVE COLITIS
Definition -chronic disease of colon/rectal mucosa
- can involve entire length of bowel -only involves mucosa/submucosa with ulcerations & inflammation
- emotional/psychosocial factors may have an effect-peak incidence 15 – 25 yrs & 55- 65 yrs. Old F>M
Assessment- bloody/mucus diarrheal stools- lower abdominal pain (cramping) -tenesmus- wt. loss (possible delayed growth & arthralgias)- ID nutritional deficiencies
Diagnostics -ID the extent of involved bowel - r/o any infectious process
(i.e. Shigella) - radiologic studies & endoscopy
with biopsy - decreased H&H, albumin -increased WBC
Treatment/ManagementMedications Salicylate Compounds: Sulfasalazine Corticosteroids: prednisone Immunosuppressants: cyclosporine Antidiarrheals: immodium Antibiotics : ciprofloxacilNutrition Therapy - low fiber diet - if poor appetite (high protein) -supplemental vitamins, iron, zinc & folic acid -TPN
Ulcerative Colitis Crohn’s
Temporary colostomy/ileostomy bowel resection
DIFFERENTIAL FEATURES OF U. C. AND CROHN’S
FeatureFeature Ulcerative Ulcerative ColitisColitis
Crohn’s DiseaseCrohn’s Disease
LocationLocation Begins in rectumBegins in rectum
Proceeds to cecumProceeds to cecumUsually terminal Usually terminal ileumileum
w/ patchy w/ patchy involvement involvement through all bowel through all bowel layerslayers
EtiologyEtiology UnknownUnknown UnknownUnknown
Peak Peak IncidenceIncidence
15-25 & 55-6515-25 & 55-65 15 - 4015 - 40
StoolsStools 10-20 liquid, bloody10-20 liquid, bloody
stoolsstools5-6 soft, loose 5-6 soft, loose stoolsstools
Per day, rarely Per day, rarely bloodybloody
Common Common
ComplicationsComplicationsHemorrhageHemorrhage
PerforationPerforation
FistulasFistulas
Nutritional Nutritional DeficienciesDeficiencies
FistulasFistulas
Nutritional Nutritional DeficienciesDeficiencies
wt. losswt. loss moderatemoderate severesevere
GASTROENTERITIS (ACUTE DIARRHEA)Definition
- inflammation of the stomach and intestines
-may be accompanied by vomiting and diarrhea (bacterial or parasitic infections)Assessment
-mild, moderate or severe diarrhea (loose, watery stools) - irritabilty, cramping - nausea and vomiting - fluid & lyte balance - hx & physical exam of patient - stool examination (ova and parasite)
Treatments/Interventions-ID the causative factor-moderate: maintain fluid & lytes balance-oral replacement therapy
(pedialyte, gatorade) -no carbonated or sugar drinks
-severe: keep NPO; give IV fluids (NS/ RL) - start with clear liquids - monitor lytes especially potassium for
cardiac patients - antidiarrheals for adults
Nursing Interventions -Provide emotional support : allow pt. to talk
-Provide rest and comfort: quiet environment-Ensure adequate nutrition: BRAT diet
(bananas, rice, applesauce & toast)CRAM (complex carbohydrates
rice and milk)milk free for 48 hrs.; caffeine free
Discharge planning: teach parents S&S of dehydration
DIVERTICULITISDefinition/Pathophysiology: -a saclike outpouching of the lining of the bowel
(If bowel contents are retained in the sac, it becomes inflamed or infected)
Assessment: -chronic constipation-abdominal pain (especially LLQ)-fever-abdominal distention/tenderness
Diagnostics:- Ultrasonography-barium enema( not during acute phase)-increased ESR & WBC-decreased H&H-colonoscopy (after acute phase)
Complications:-possible peritonitis- abscess formation & bleeding
Treatment/ManagementDietary: -Severe stage: NPO, NGT, IV’s -During inflammation: low fiber clear liquids initially -After inflammation: high fiber -Avoid foods with seeds, nuts, alcohol -Rest
Medications-Broad spectrum antibiotics (Flagyl, Cipro)- Mild analgesics
- Anticholinergics (pro banthine)- Bulk forming laxatives (metamucil)
Surgical Managementperitonitis or abscess formations may require surgery - one stage: bowel resection - multistaged: bowel resected and temporary colostomy performed
Nursing Managementteach pt. about dietary modificationsteach pt. about the various medsteach pt. about ostomy care if needed
PARALYTIC ILEUSDefinition/Pathophysiology: paralysis of peristaltic movement due to effect of trauma or toxins on the nerves that regulate intestinal movement
Assessment-abdominal pain/distention: accumulation of gas/fluid above the obstruction-rigid abdomen: increased distention makes it rigid-vomiting: earliest sign of high obstruction; bile if lower obstruction- constipation-absent bowel sounds: no peristalsis with obstruction-shock: loss of fluid/lytes from the bloodstream into intestines
IRRITABLE BOWEL SYNDROMEDefinition: functional disorder of intestinal mobility with no irritation (spasms)
Assessment: symptoms range from mild to severe in intensity with constipation, diarrhea or both - pain, cramps (LLQ) - bloating, abdominal distention -more females than males
Treatment/ManagementDietary modifications: ID food intolerances
limiting caffeine and avoiding alcohol -dietary fiber and bulk help stools
Medications -bulk forming laxatives (metamucil) -antidiarrheal agents (Lomotil) -anticholinergic agents (Bentyl) -tricyclic antidepressants (Elavil)-5-HT4 (Zelnorm)
Stress Management
Diagnostics: CT scan, possible endoscopy
Treatment/InterventionsNPONGTNasointestinal tube (Cantor/Harris tube
with mercury)IV’sPain managementTreat shock
Nursing InterventionsID earlyMonitor pt. and all tubesMaintain accurate I&O with monitoring of lytes
Table 24–2 Causes of diarrhea in children.
HEMORRHOIDSDefinition/Pathophysiology
- hyperplastic areas of vascular tissue in the anal canal - Internal hemorrhoids above the internal sphincter - External hemorrhoids outside the external sphincter.
AssessmentInternal: prolapse causing discomfortExternal
-itching - pain - bright red bleeding with defecation
Treatment/InterventionsConservative measures: increase fiber diet
(fruit, bran, whole grains)-encourage plenty of water-analgesic ointments, suppositories-stool softeners-Sitz baths
Teach to avoid irritating laxatives, spicy foods, caffeine, alcohol, nutsSurgery
Pre op: enemas & laxativesPost op: monitor rectal bleeding report significant bloody drainage side lying position
Nursing Interventions
-flotation pad-pain med before BM-stool softener-increased fiber in diet-sitz bath-perianal care
Table 24–3 Influential factors in childhood constipation.
CONSTIPATIONDefinition
- decrease in the number of stools - stools become hard and dry - may even have oozing of liquid stool around impaction.
Causes Medications: opoids, iron Obstruction: tumors Neuromuscular condition: Multiple Sclerosis Dietary habits: decreased fiber and fluid intake
AssessmentAbdominal distention with painPressure strainingHeadacheFatigue
ComplicationsHypertensionFecal impactionHemorrhoids and fissuresStraining causing Valsalva Manuever
TreatmentTreat underlying causeIncrease fiber & fluid in dietBowel habit trainingMedication: stool softeners ( colace)
bulk forming agent (metamucil)stimulants (dulcolax)
Nursing InterventionsTeach change in life style habits
PARASITIC INFECTIONS (see Ball & Bindler )Definition/Pathophysiology A parasite is an organism that lives in, on or at the expense of a host. Common GI parasites disorders include giardia, enterobiasis and ascariasis.Assessment
Giardiasis(Giardia)S&S: diarrhea Treatment: vomiting furazolidine
anorexia quinicrine
Enterobiasis (Pinworm)S&S: perianal itching Treatment:
irritability antihelminthic meds- restlessness mebendazole
pyrantel pamoate
Ascariasis ( Roundworm)S&S TreatmentSevere can cause intestinal same as above obstructionPeritonitisLung involvement
InterventionsPatient Teaching
Preventative measures Proper hygiene Careful handwashingMedication Education
Practice Question
The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child’s record and expects to note which symptom of this disorder documented?
A. watery diarrhea B. ribbon-like stools C. profuse projectile vomiting D. bright red blood and mucus in the stools
Practice Question
A nurse is reviewing the record of a client with Crohn’s disease. Which of the following stool characteristics would the nurse expect to be documented in the client’s record?
A. chronic constipation B. diarrhea C. constipation alternating with diarrhea D. stool constantly oozing from the rectum
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