EXAM 3: Pediatric Gastrointestinal

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ETSU Accelerated BSN Program

Fever and diarrhea accompanying vomiting will indicate....

an infection

Constipation with vomiting will indicate...

an obstruction

Localized abdominal pain and vomiting may indicate...

appendicitis, pancreatitis, or peptic ulcer disease

GI problems with a change in LOC or headache may indicate...

CNS or metabolic disorder

Projectile vomiting may indicate...

pyloric stenosis

Green bilious vomiting may indicate...

obstruction

Curdled stomach contents, mucous, or fatty foods vomited several hours after eating may indicate....

poor gastric emptying

Coffee ground looking vomit may indicate...

GI bleed

What will an imbalance of K+ electrolytes manifest as?

-flaccid skeleton muscles
-GI cramping
-cardiac dysrhythmias

When beginning hydration how much pedialyte should be offered?

1 tsp every 15 minutes

How do infants progress from NPO?

clear liquids to bland, milk free diets

*BRAT (bananas, rice, applesauce, toast) is NO longer recommend

How much weight loss is considered mild? What are the clinical manifestations?

-<5%
-behavior, mucous membranes, anterior fontanel, pulse, and bp are all WNL
-cap refill is > 2 sec
-slight thirst maybe experienced

How much weight loss is considered moderate? What are the clinical manifestations?

-6%-9%
-cap refill bt 2-4 sec
-thirst/irritability may be experienced
-pulse slightly increased with normal orthostatic bp
-mucous membranes are dry and tears/skin turgor are decreased
-slight tachypnea
-normal to sunken anterior fontanel on infants

How much weight loss is considered severe? What are the clinical manifestations?

->10%
-cap refill >4 sec
-tachycardia and orthostatic bp may progress to shock
-extreme thirst
-mucous membranes are very dry and skin is tented
-hyperpnea
-no tearing with sunken eyeballs
-anterior fontanel is sunken
-oliguria or anuria is present

How should diarrhea be treated?

-rehydrate with ORS
-avoid caffeine, sugar, salt
-Give gelatin, soups (not creamed), bananas, strained carrots, crackers, rice, and toast with jelly
-once hydrated...give regular diet

What is the most common cause of diarrhea in children <5 years of age?

-rotavirus

*onset of foul-smelling, watery stools, diarrhea for 5-7 days and vomiting for 2 days
*transmission is fecal-oral route

What are clinical manifestations of E.coli infection?

-watery diarrhea for 1-2 days, followed by abd cramping and bloody diarrhea
-could lead to HUS

What are clinical manifestations of Salmonella infection?

-mild to severe nausea, vomiting, abd cramping, bloody diarrhea and fever
-diarrhea may last 2-3 weeks
-possible HA, confusion, drowsiness, and seizures
-may lead to meningitis and septicemia

*transmission (person to person, undercooked meats/poultry)

What are clinical manifestations of C. Diff infection?

-mild, watery diarrhea for few days
-possible leukocytosis, hypoalbumemia and high fever in certain children
-possible pseudomembranous colitis

*transmission (contact with spores, common in health care settings)

What are clinical manifestations of Shigella infection?

-sick appearance
-fever, fatigue and anorexia
-cramping abdomen followed by watery or bloody diarrhea lasting 5-10 days

*transmission (contaminated food or water)

At what age does GERD typically resolve itself?

1 year old

What is Nissen fundoplication?

surgery to correct GERD in severe cases

How soon does pathologic GERD show up?

by 6 weeks of age

What are some s/s that may come up in assessment of GERD?

-Frequent vomiting
-Weight loss, FTT
-Aspiration and recurrent respiratory infection, recurrent otitis media
-Near miss SIDS and cyanotic episodes
-Esophagitis and bleeding
-Heartburn, abdominal pain

What are some ways to treat mild GERD?

-change feeding habits
-keep child upright
-add rice cereal to formula
-decrease amount of feeding

What are some ways to treat severe GERD?

-surgical treatment
-Assess breath sounds and respiratory status before feedings
-Place infant in upright position
-teach parents to avoid placing in a car seat after feeding as this increases abdominal pressure
-Give medications as directed

How much should you feed an infant that has GERD?

10cc and then burp them

How long should you keep a GERD infant upright after feeding?

at least 20 minutes

What results when circular areas of muscle surrounding pylorus hypertrophy and block gastric emptying?

pyloric stenosis

At what age will pyloric stenosis be seen?

8-12 weeks of age

What will you see upon assessment of a child with pyloric stenosis?

-visibile peristaltic wave in abdomen (moving from left to right)
-Progressive, projectile, non-bilious vomiting
-constant hunger
-olive-shaped mass in RUQ and an elongated pyloric area
-signs of dehydration

Preoperative care for a Pylorotomy

-IV fluids (correct dehydration and lytes)
-NG for decompression (low, intermittent suction)
-NPO
-I&Os
-daily weights

What is the most common cause for an intestinal obstruction between 3 months and 3 years of age?

Intussusception (an invagination or telescoping of non portion of the intestine into another)

Who is at a higher risk for Intussusception?

patients with CF

What is the classic triad of symptoms with intussusception?

-pain
-sausage-shaped abdominal mass RLQ
-currant jelly-like stools

What is the management of intussusception?

-Reduce the obstruction by performing a barium enema (the force exerted by the flow of barium will push the invaginated portion of bowel back into its original position)
-Water-soluble contrast and air pressure to reduce invaginated bowel.
-IV fluids
-NG decompression
-Antibiotic therapy- if perforation occurs
-Surgical intervention

If a patient with intussusception has a normal brown stool...what should you do as the nurse?

report to the MD (this means the invaginated bowel has reduced and no further treatment is needed.)

When is cleft lip repaired?

1-2 months of age

*infant must be at least 10 wks old, 10 lbs and Hgb 10 g/dL

When is cleft palate repaired?

6-18 months of age

What are some considerations when feeding a child with cleft lip/palate?

-assess respiratory status during feedings
-feed infant in upright position
-feed slowly and burp often
-use ESSR (enlarged nipple, stimulate suck by rubbing nipple on lower lip, swallow, rest after each shallow to allow for complete swallowing)
-use alternate feeding devices (elongated nipple or breast shield)
-assess degree of cleft and ability to suck
-syringe feeding as last resort

What can cause cleft lip/palate?

-family hx
-exposure to alcohol, cigarette smoke, anticonvulsants, or steroids during pregnancy
-folate deficiency during pregnancy

If infant has cleft lip on left side, how should the infant be positioned during feeding?

on the right side

If infant has only cleft lip, what considerations are used during feeding?

-encourage breast feeding
-use wide based nipple for bottle
-squeeze infant's cheeks together during feeding to decrease the gap

What is Hirschsprung Disease?

structural abnormality of the GI tract that is caused by lack of ganglionic cells in segments of the colon resulting in decreased motility and mechanical obstruction

Characteristics of Hirschsprung Disease

-failure to pass meconium within 24-48 hrs after birth
-episodes of vomiting bile
-refuse to eat
-abdominal distention
-ribbon like stool (older child)

What are some environmental/psychosocial issues that cause children to have constipation?

-If a child experiences pain when passing stool, they will hold it to prevent experiencing pain.
-Don't want to interrupt play
-Overzealous toilet training

What causes appendicitis?

Results form obstruction by hardened fecal material, foreign bodies, microorganisms, or parasites

What are ways to assess the abdomen without palpating (do not palpate if you suspect appendicitis)?

-see if child can raise right knee up to chest
-try to abduct leg (will have pain)

What are clinical manifestation of appendicitis?

-general abdominal pain that progressively worsens in RLQ at McBurney's point
-low grade fever and chills
-n/v

*late signs (fever and sharp stabbing pain)

What is a complication of appendicitis surgery?

peritonitis (inflammation of peritoneal cavity)

What is esophageal atresia?

There are several types. In most cases, the upper esophagus ends and does not connect with the lower esophagus and stomach. The top end of the lower esophagus connects to the windpipe (AKA Tracheoesophageal Fistula)

What s/s would make you suspect esophageal atresia?

-Frothy saliva in mouth and nose
-Drooling
-Coughing
-Swallow normally during feeding then suddenly gags/coughs
-May become cyanotic/apneic because of aspiration of formula or saliva

IF an infant or child falls below the 5th percentile for weight or has persistent weight loss, what is this called?

Failure to Thrive

S/S of Failure to Thrive

-malnourished appearance
-no fear of strangers
-minimal smiling
-decreased activity level
-withdrawal behavior
-developmental delays
-feeding disorder
-wide-eyed gaze
-stiff or flaccid body

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