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Nursing Care of a Family When a Child Has a Gastrointestinal Disorder

الكلية كلية التمريض     القسم قسم التخصصات التمريضية     المرحلة 3
أستاذ المادة عبد المهدي عبد الرضا حسن الشحماني       23/12/2018 18:18:23

Nursing Care of a Family When a Child Has a Gastrointestinal Disorder

O B J E C T I V E S:
1. Describe common gastrointestinal disorders seen in children.
2. Assess a child with a gastrointestinal disorder.
3. Formulate nursing diagnoses for a child with a gastrointestinal disorder.
4. Implement nursing care for a child with a gastrointestinal disorder,

The gastrointestinal (GI) system involves a long body tract and numerous organs. Because it is so long and diverse, a multitude of possible disorders can occur along it, including both congenital disorders and acquired illnesses. Because the GI system is responsible for taking in and processing nutrients for all parts of the body, any problem with the system can quickly affect other body systems and, if not adequately treated, can affect overall health, growth, and development.

Common Disorders of The Stomach and Duodenum
Gastroesophageal Reflux in Infants:
in infants occurs from a neuromuscular disturbance in which the gastroesophageal (cardiac) sphincter and the lower portion of the esophagus spasm and allow easy regurgitation of gastric contents into the esophagus. It usually starts within 1 week after birth and may be associated with a hiatal hernia. Children with cerebral palsy or other neurologic involvement are at particular risk. The regurgitation occurs almost immediately after feeding or when the infant is laid down after a feeding. If the amount of the reflux is large or constant, an infant does not retain sufficient calories and will fail to thrive. In addition, aspiration pneumonia or esophageal stricture from the constant reflux of hydrochloric acid into the esophagus can occur
Assessment:
1- History, vomiting appears effortless and is not projectile; it begins much earlier in life than the vomiting associated with pyloric stenosis.
2- The child may be irritable and may experience periods of apnea.
3- Inserting a probe or catheter through the nose into the distal esophagus and determining the pH from secretions can show whether gastric secretions are entering the esophagus (if the pH is less than 7.0, then acid is present).

Therapeutic Management.
1- The traditional treatment of GI reflux is to feed infants a formula thickened with rice cereal (1 tbsp of cereal per 1 oz of formula or breast milk) while holding them in an upright position and then keeping them upright in an infant chair for 1 hour after feeding so gravity can help prevent reflux.
2- An H2 receptor antagonist such as ranitidine (Zantac) or a proton pump inhibitor such as omeprazole may be prescribed daily to reduce the possibility of the stomach acid contents irritating the esophagus.
Nursing Diagnoses and Related Interventions:
Nursing Diagnosis: Risk for imbalanced nutrition, less than body requirements, related to regurgitation of food with esophageal reflux




Nursing Interventions:
1- Teach parents the importance of monitoring intake, output (urination), and weight. Also reinforce the need to keep the infant upright, such as in an infant seat, after a feeding. Be certain parents understand how much cereal to mix with formula or breast milk.
2- Encourage parents to feed the infant during the short time that the infant remains in the hospital after surgery so that they can regain their confidence as parents.

Pyloric Stenosis:
The pyloric sphincter is the opening between the lower portion of the stomach and the beginning portion of the intestine, the duodenum. If hypertrophy or hyperplasia of the muscle surrounding the sphincter occurs, it is difficult for the stomach to empty, a condition called pyloric stenosis. With this condition, at 4 to 6 weeks of age, infants begin to vomit almost immediately after each feeding. The vomiting grows increasingly forceful until it is projectile. cause is unknown, but multifactorial inheritance is the likely cause.
Assessment
The diagnosis of pyloric stenosis is made primarily from the history.
• What is the duration? Begins at 6 weeks of age
• What is the intensity? Projectile vomiting
• What is the frequency? Immediately after eating
• What is the description of the vomitus? Sour but contains no bile
• Is the infant ill in any other way? No.
1- Many infants have signs of dehydration from the vomiting when they are first seen.
2- Lack of tears (many infants younger than age 6 weeks do not tear.
3- dry mucous membrane of the mouth
4- sunken fontanels, fever, decreased urine output
5- poor skin turgor, and weight loss are common signs seen.

? A definitive diagnosis is made by watching the infant drink. Before the child drinks, attempt to palpate the right upper quadrant of the abdomen for a pyloric mass. If one is present, it feels round and firm, approximately the size of an olive. As the infant drinks, observe for gastric peristaltic waves passing from left to right across the abdomen. The olive-size lump becomes more prominent. The infant vomits with projectile emesis.
? If the diagnosis is still in doubt, an ultrasound will show the hypertrophied sphincter.
Therapeutic Management:
Treatment is surgical or laparoscopic correction (a pyloromyotomy), performed before electrolyte imbalance from the vomiting or hypoglycemia from the lack of food occurs.
Nursing Diagnoses and Related Interventions:
Nursing Diagnosis: Risk for deficient fluid volume related to inability to retain food.
Nursing Interventions:
Preoperative Care.
1- Preoperative management consists of fluid and electrolyte replacement based on laboratory determinations. A baseline weight is essential for establishing the extent of dehydration.
2- Parents may be impatient with preoperative management because it may take 24 hours or more to restore a severe fluid imbalance. They need an explanation that infants cannot go to surgery with an electrolyte imbalance; these hours before surgery are as important to the welfare of their child as the operation itself.


Postoperative Care.
1- The postoperative feeding regimen differs from one surgeon to another but usually involves frequent feedings of small amounts of fluid. Approximately 4 to 6 hours after surgery, If no vomiting occurs, the amount is increased or half-strength formula or breastfeeding is begun.
2- Continue to monitor daily weights to confirm that the child is receiving adequate intake. Usually no vomiting occurs postoperatively, but if it does occur, report it immediately.
3- Some infants have a short-term diarrhea (dumping syndrome) after surgery because of rapid functioning of the pyloric sphincter, but this tends to resolve without additional therapy.
Nursing Diagnosis: Risk for infection at site of surgical incision related to danger of contamination from feces because of proximity of incision to diaper area
Nursing Interventions:
1- The surgical incision for pyloric stenosis may be covered with collodion, a solution similar to clear nail polish to help keep urine and feces from touching it.
2- Keep diapers folded low to prevent the incision from being contaminated, and change diapers frequently. If the incision should be exposed to feces, wash the collodion well with soap and water.








Obstruction of the Bile Ducts:
Obstruction of the bile ducts in children generally occurs from congenital atresia, stenosis, or absence of the duct. It also can occur from the plugging of biliary secretions, though this is rare. When the bile duct is obstructed, bile, unable to enter the intestinal tract, accumulates in the liver. Bile pigments (direct bilirubin) enter the bloodstream and jaundice occurs, increasing in intensity daily.
Assessment:
Although bile duct obstruction is a congenital disorder, the chief sign (jaundice) does not develop until approximately 2 weeks of age. the jaundice of bile duct obstruction is a result of a rise in direct bilirubin. when prolonged obstruction and back-pressure cause liver cell damage. In addition, because bile salts (necessary for fat absorption) are not reaching the intestine, absorption of fat and fat-soluble vitamins (vitamins A, D, E, and K) is poor. Calcium absorption, which depends on vitamin D absorption, also is poor.

Therapeutic Management:
1- If the problem appears to only be a mucus plug in the duct, children may be given magnesium sulfate (installed into the duodenum to relax the bile duct) or dehydrocholic acid (Decholin) IV to stimulate the flow of bile.
2- If atresia of the bile duct is the problem, surgical correction is the treatment (a Kasai procedure).

Nursing Diagnoses and Related Interventions
Nursing Diagnosis: Risk for imbalanced nutrition, less than body requirements, related to inability to digest fat

Nursing Interventions:
Preoperative Care:
1- Infants who are admitted for surgery for bile duct obstruction are placed on a lowfat, high-carbohydrate diet preoperatively.
2- They are given water-soluble forms of vitamins A, D, and K to improve vitamin levels.
3- If the vitamin K level is too low, coagulation may be affected, increasing surgical risk.
4- Vitamin K may be administered parenterally until prothrombin levels rise to normal limits. Infants will also be well hydrated with parenteral fluids.
Postoperative Care:
1- infants return with a nasogastric tube in place attached to low intermittent suction.
2- Observe carefully for abdominal distention because paralytic ileus is a frequent complication of this type of surgery.
3- If the repair is successful, the child’s stools change to a yellow and then brown (normal stool) color after surgery. Description of stools is, therefore, an important postoperative observation.

Intestinal Disorders
Celiac Disease (Malabsorption Syndrome; Gluten-Induced Enteropathy)
The basic problem in celiac disease is a sensitivity or abnormal immunologic response to protein, particularly the gluten factor of protein found in grains—wheat, rye, oats, and barley. When children with the disorder ingest gluten, changes occur in their intestinal mucosa or villi that prevent the absorption of foods, especially fat, across the intestinal villi into the bloodstream. As a result, children develop steatorrhea (bulky, foul-smelling, fatty stools). There is also an increased incidence in children of type 1 diabetes mellitus, IgA deficiency, and Down syndrome.
Assessment:
1- The diagnosis is based on the history; clinical symptoms such as bulky stools, malnutrition, distended abdomen, and anemia which become noticeable between 6 and 18 months of age.
2- serum analysis of antibodies against gluten (IgA antigliadin antibodies); and a biopsy of the intestinal mucosa (done by endoscopy), which establishes the typical changes in intestinal villi.

Nursing Diagnoses and Related Interventions
Nursing Diagnosis: Imbalanced nutrition, less than body requirements, related to malabsorption of food.
Nursing Interventions:
1- Parents need to record the consistency, appearance, size, and number of stools that the child passes. The disappearance of steatorrhea is a good indicator that the child’s ability to absorb nutrients is improving.
2- Parents need a great deal of nutritional counseling when their child is first placed on a gluten-free diet so they can recognize foods that contain gluten (wheat, rye, oats, and barley products).
3- Until children can recognize which foods they can or cannot eat, parents often find it difficult to let them stay at friends’ houses or go to summer camp—activities important to children’s learning independence.




Disorders of The Lower Bowel
Hirschsprung’s Disease (Aganglionic Megacolon):
Hirschsprung’s disease, or aganglionic megacolon, is absence of ganglionic innervation to the muscle of a section of the bowel in most instances, the lower portion of the sigmoid colon just above the anus. The absence of nerve cells means there are no peristaltic waves in this section to move fecal material through the segment of intestine. This results in chronic constipation or ribbon like stools (stools passing through such a small, narrow segment look like ribbons). The portion of the bowel proximal to the obstruction dilates, distending the abdomen.
Assessment:
1- Occasionally, infants are born with such an extensive section of bowel involved that even meconium cannot pass. This is suggested if infants fail to pass meconium by 24 hours of age and have increasing abdominal distention. Because newborn stools are normally soft, however, symptoms of aganglionic megacolon generally do not become apparent until 6 to 12 months of age.
2- A barium enema is generally ordered to substantiate the diagnosis.
Therapeutic Management:
the condition is generally treated in the newborn by two-stage surgery: first a temporary colostomy is established, followed by bowel repair at 12 to 18 months of age. After the final surgery, children should have a functioning, normal bowel.







Nursing Diagnoses and Related Interventions:
Nursing Diagnosis: Constipation related to reduced bowel function.
Nursing Interventions:
Before surgery, the child may be prescribed daily enemas to achieve bowel movements. The fluid used for enemas must be normal saline (0.9% NaCl) and not tap water. Tap water is hypotonic. If it is instilled into the bowel, it moves rapidly across the intestinal wall into interstitial and intravascular fluid compartments to equalize osmotic pressure (by the laws of osmosis, fluid moves from an area of less to greater concentration). This has led to death of infants from cardiac congestion or cerebral edema (water intoxication).
Nursing Diagnosis: Risk for compromised family coping related to chronic illness in child.
Nursing Interventions:
Help parents to diminish the importance of meals gradually; to schedule periods during the day when they give their full and positive attention to the child, such as reading a story or putting a puzzle together; and to offer praise for pleasant, not difficult, behavior. These measures will help mealtime problems gradually diminish.


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