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GASTROINTESTINAL SYSTEM DISORDERS

CLEFT LIP & PALATE

Definition: facial malformations that occur during embryonic development (6-12 weeks gestation) causing a failure(6 12 weeks gestation) causing a failure of the maxillary and median nasal structure to fuse.

CLEFT LIP & PALATE

Nonunion of the tissue and bone of the upper lip and hard/soft palate during embryologic developmentembryologic developmentFamilial disorder, often associated with other congenital abnormalities.

Cleft lip/palate 1 in 1000 birthsCleft lip with or without cleft palate affects more boys; cleft palate affects more girls.

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CLEFT LIP & PALATEEtiology: unknown; may occur as part of a genetic disorder or environmental factors such as:

a) Exposure to teratogens b) Familial tendencyc) Increased incidence in Asians, Native

Americans, lowest in African Americans.

CLEFT LIP

Signs and symptomsa) May be unilateral or bilateral

Varies from simple notching ofb) Varies from simple notching of vermillion border of the lip to a deep cleft, extending through the lip or into the nose.

CLEFT PALATESigns and symptoms

a) Midline fissure or opening in the hard and/or soft palate areas

b) ff l f l f kb) Difficulty forming a seal for sucking c) Coughing and choking d) Nasal distortion e) Congestionf) Failure to thrive (un-repaired defect with

persistent feeding difficulties)

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Figure 46-1A Cleft lips

Unilateral cleft lipLondon / Ladewig / Ball / BindlerMaternal-Newborn and Child Nursing: Family-Centered Care

Figure 46-1B Cleft lips

Bilateral cleft lip

London / Ladewig / Ball / BindlerMaternal-Newborn and Child Nursing: Family-Centered Care

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CLEFT LIP & PALATE

Diagnostic tests and labs:a) History and physical

Prenatal ultrasoundb) Prenatal ultrasoundc) Pre-op laboratory data (CBC,

electrolytes)d) Wound and sputum culture if infection

is suspected

Medical Management

A team approach for therapySpeech TherapistDentist and OrthodontistDentist and OrthodontistAudiologistOtolaryngologistThese children are prone to otitis media and possible hearing lossPediatrician

Surgical ManagementTiming varies with severity of the defect; early correction helps to avoid speech defectsCleft Lip Repair

Usually performed at age 2 monthsCleft Palate Repair

Usually performed at 18 months in anticipation of speech development

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Figure 46-2A Repaired cleft lips

Repaired unilateral cleft lip.

London / Ladewig / Ball / BindlerMaternal-Newborn and Child Nursing: Family-Centered Care

Figure 46-2B Repaired cleft lips

Repaired bilateral cleft lip.

London / Ladewig / Ball / BindlerMaternal-Newborn and Child Nursing: Family-Centered Care

Nursing Care Pre-opFeed in upright position to decrease possible aspiration and swallowing of air

Tube feeding as necessaryEmotional Support to parents:

Burp frequentlySpecial feeding devices as needed:

a) Cleft palate nippleb) Syringe with soft rubber

tubingc) Soft nipple with enlarged

hole

pDemonstrate benefits of surgeryReinforce that disorder is not their fault and will not affect child’s life span or mental abilityPrepare for surgery

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Nursing Care Pre-op

Position on side with head of the bed elevatedProvide oral care and suction as neededProvide oral care and suction as neededTeach family to use bulb suction to clear airway

Post-op Nursing CareCleft Lip Repair

Maintain patent airway

Use elbow restraints to keep child’s hands away from the suture line

Position on back or sideAVOID ANY STRAIN ON SUTURE LINE

suture lineKeep suture line cleanTeach parents to keep suture line clean at home

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Post-op Nursing CareCleft Palate Repair

Position on side or abdomen for d i f

Prevent injury or trauma to suture lineGive water after feedings to cleandrainage of

blood/mucusHave suction at the bedside for emergency use

feedings to clean suture lineRinse mouth with water after feedingHold and cuddle these babies

Post-op Nursing Care

Address pain management needsAvoid placing hard items in mouth (suction catheters spoons ice chips)(suction catheters, spoons, ice chips)Use a cup for drinking to avoid placing anything in mouthMonitor for bleeding, infection or breakdown at the surgical site

Complications

Otitis media and hearing lossSpeech difficultiesPulmonary complications fromPulmonary complications from aspirationMalocclusion due to abnormal teeth eruption

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Altered Connections between Trachea, Esophagus and Stomach

Congenital rare malformation that represents a failure of the esophagus to develop as a continuous passage. Often found in:

Low birth weight infantsHX of maternal polyhydramnios

TYPESEsophageal atresia

Esophagus ends in a blind pouch; no entry route to the stomach

Tracheoesophageal fistula (TEF)Open connection between trachea and esophagus

Esophageal atresia with TEFEsophagus ends in blind pouch, stomach end of esophagus connects with trachea

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Management

Drug therapyantibiotics for respiratory infections

SurgerySurgeryPalliative

Gastrostomy for placement of a feeding tube

CorrectiveEnd-to-end anastomosis to correct the defect and restore normal anatomy

Assessment Findings

Esophageal atresiaInability to pass an NG tubeIncreased drooling and salivationIncreased drooling and salivationImmediate regurgitation of undigested formula/milk when fedIntermittent cyanosis from choking on aspirated secretionsC-C-C (choking, coughing, cyanosis)

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Assessment Findings

TEFNormal swallowing but some food/mucus crosses fistula, causing choking and , g gintermittent cyanosisDistended abdomen from inhaled air crossing fistula into stomachAspiration pneumonia from reflux of gastric secretions into the trachea

Nursing InterventionsPre-operative

Head of bed slightly lowered-minimize aspiration of secretions into tracheaKeep NPOProvide suctioningIV fluidsMaintain patent airway and lung expansionRecognize defect early (excess salivation)Prevent aspiration pneumonia

Nursing InterventionsPost-operative

Provide nutritionSupport parentsProvide client teaching and discharge teaching

Alternative feeding methods (GT and then advance to oral feeding as child progresses) Signs of respiratory distressSuctioningCPR

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Nursing InterventionsPromote respiratory function

a) Suction secretions as neededb) Maintain care of chest tube and drainage

apparatusapparatus c) Administer oxygen as indicatedd) Prevent aspiration of feedings

Prevent infections at the operative sitesMaintain fluid and electrolyte balanceComfort measures (pacifier, tactile stimulation)

GASTROESOPHAGEAL REFLUX

GER

Relaxation or incompetence of the lower esophagus sphincter which results in frequent return of stomachresults in frequent return of stomach contents into the esophagus

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GERReversal of flow of stomach contents into lower portion of the esophagusCommon in premature infants due to hypotoniahypotoniaCaused by relaxed cardiac sphincter or overdistension of stomach by gas or overfeedingResults in local irritation of lining of esophagus from gastric secretions

Manifestations of GERInfants

“Spitting up”/vomitingIrritabilityWeight loss

Older childrenHeartburnAbdominal painChest pain (noncardiac)Weight loss

Frequent URIsRespiratory problemsLife-threatening apneaBloody stools/emesisAnemia

Chest pain (noncardiac)Nocturnal asthmaRecurrent pneumoniaChronic cough

DiagnosticsHistoryFluoroscopic observation of reflux following a barium swallow

l dUpper gastrointestinal endoscopyDirect measurement of pH (probe monitoring) of the distal esophagusScintigraphy which detects radioactive substances in the esophagus after a feeding of the compound

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Nursing InterventionsPosition with head elevated 30-45 ºSmall, frequent feedings with adequate burpingp gProvide client teaching and discharge planning

Teach parents how to position and feed infantAdministration of medications

Treatment

MildModification of feeding habits

Thicken feedingsThicken feedingsAvoid fatty foods and citrus

MedicationAntacids, histamine blockers, metoclopramide

PositioningProne after feedings

Treatment

SevereFundoplication

Wrapping of the fundus of the stomach aroundWrapping of the fundus of the stomach around the distal esophagusGT usually inserted during surgery and left in place for six weeks

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PYLORIC STENOSIS

Hypertrophy (thickening) of the pyloric sphincter causing stenosis and obstructionobstruction5 in 1000 births, more common in Caucasian, firstborn, full-term boysCause unknown; possibly familial

PYLORIC STENOSIS

Pathophysiologya) Hypertrophy of the pylorus muscle

(stenosis of stomach lumen)(stenosis of stomach lumen)b) Lumen (inflamed and

edematous/complete obstruction) c) Projectile vomiting (dehydration and

electrolyte depletion)

Assessment FindingsOlive-size mass in RUQPeristaltic waves during & after feedings (move left to right towards pylorus)Hyperactive BSVomiting

As obstruction increases, vomiting becomes more forceful and projectileHungry after vomiting

Dehydration

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DiagnosticsUpper GIPyloric ultrasoundElectrolyte imbalance

a) Severe depletion of water and electrolytes from extensive vomiting

b) Decreased serum levels of sodium and potassium

c) Increased pH and bicarbonate levels (metabolic alkalosis)

Interventions

Replacement of fluid and electrolytesNPO promote gastric decompressiona) promote gastric decompression

b) Carry out lavage c) Maintain patency of NGTd) Measure and record amount and type

of drainage

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Interventions

Surgery: Pylorotomy (the circular muscle fibers of the pylorus are released to allow the passage of foodreleased to allow the passage of food and fluids-incision through muscle fiber)

Clear liquids post-operatively; then advanceHOB elevated

InterventionsAssess adequacy of intake

a) Weigh dailyb) Measure carefully: intake (PO and parental),b) Measure carefully: intake (PO and parental),

output ( vomitus, NGT drainage, stools, urine)

c) Urine specific gravity

HIRSCHSPRUNG’S DISEASE(Aganglionic Megacolon)

Absence of autonomic parasympathetic ganglion cells in a portion of the large colon resulting in decreased motility incolon resulting in decreased motility in that portion of the colon and signs of functional obstructionUsually diagnosed in infancy

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Hirschsprung’s Disease

When stool enters the affected part of the colon, lack of peristalsis causes it to remain there until additional stoolremain there until additional stool pushes it through; colon dilates as stool is impactedFamilial disease; more common in boys; associated with Down’s syndrome

Assessment

Failure or delay in passing meconiumAbdominal distensionChronic constipationChronic constipationFoul, ribbon-like stoolsBile-stained emesis Nausea, anorexia, lethargyWeight loss

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Assessment: Newborn

Failure to pass meconium within 24-48 hours after birthReluctance to ingest fluidsReluctance to ingest fluidsBile stained vomitusAbdominal distension

Assessment: Infancy

Failure to thrive (FTT)ConstipationAbdominal distentionAbdominal distention Episodes of diarrhea and vomiting

Assessment: ChildhoodConstipationPassage of ribbon-like-stoolFoul smelling stoolAbdominal distentionAbdominal distentionVisible peristalsisFecal masses easily palpablePoorly nourishedAnemicHypoproteinemic from malabsorption of nutrients

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DiagnosticsBarium enema In neonate, Dx is usually made based on clinical signs of intestinal obstruction gand failure to pass meconiumRectal exam

Rectum empty of stoolRectal biopsy confirms the diagnosis (absence of ganglia)

TreatmentDrug Therapy: stool softenersIsotonic or Mineral Oil enemasDiet Therapy: low residue, diet modificationDiet Therapy: low residue, diet modification (milder defect) Surgery:

Palliative: loop or double-barrel colostomyCorrective: abdominal-perineal pull through; bowel containing ganglia is pulled down and anastomosed to the rectum

Nursing Interventions

Administer enemas as orderedAdminister TPN as orderedProvide low residue dietProvide low residue dietProvide client teaching and discharge planning concerning colostomy care and low residue diet

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IMPERFORATE ANUS

Congenital malformation caused by abnormal fetal developmentMany variationsMany variationsOften associated with fistula formation to rectum or vagina and other congenital anomalies

Imperforate Anus

Surgical correction performed in stages with completion at about age 1 yearMay need temporary colostomyMay need temporary colostomy

AssessmentNo stool passage within 24 hours of birthMeconium stool from inappropriate orifice (appears in urine)

b l l hInability to insert rectal thermometerAbsence of an anal openingChecking for patency of the anus and rectum is a routine part of the newborn assessment including observation or inquiries regarding the passage of meconium

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Management

Manual dilation for anal stenosis Surgery

Anoplasty (reconstruction of the anus)Anoplasty (reconstruction of the anus)Colostomy for higher anomalies in infants

Prophylactic Antibiotics

Nursing InterventionsIf suspected, do NOT take rectal temperature because of risk of penetrating wall and causing peritonitisPerform manual dilation as ordered, instructPerform manual dilation as ordered, instruct parents in proper techniqueAfter surgery keep incision clean as possibleUse side-lying/prone position post-surgeryFor colostomy teach parents colostomy care (dressing change, skin care, correct application of collection devices)

CONSTIPATION

Decrease in number of bowel movements with large, hard stoolsMay be caused by high fat and proteinMay be caused by high fat and protein and low fluid dietMay cause bowel obstruction if severe

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Assessment

Less frequent stoolsDifficulty eliminating stoolHard consistency compared to normalHard consistency compared to normal patternBleeding with stoolingAbdominal pain

Management

Drug therapyStool softenerssuppositoriessuppositoriesenemas

DietIncreased fiber and fluids

Nursing Interventions

Assess for other pathologic causesDietary modificationApply lubricant around anusApply lubricant around anusRemove stool digitally if possibleProvide prune juice (1 oz), add fruits to diet

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DIARRHEAInflammatory process of GI lining

Acute caused by:Infections (bacterial, viruses)Antibiotic therapyDiet conditions

Chronic caused by:Malabsorption disordersStructural defectsAllergic disorders

Assessment

Frequent watery stoolsAnorexiaDehydrationDehydrationWeight loss

Nursing Interventions

Mild diarrhea – home treatmentORT (oral rehydration therapy)Dietary advancement (clear liquidsDietary advancement (clear liquids, electrolyte solutions)Bland/BRATT dietInfants may need soy formulaTeach parents signs & symptoms of dehydration

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Nursing InterventionsSevere diarrhea – hospitalize esp. infants

Isolation (enteric) until organism isolatedNPO to rest bowelFluid & electrolyte replacementStrict I & ODaily weightSkin care

Gastroenteritis

Definition: an inflammation of the mucous membranes of the GI tract characterized by vomiting and diarrhea resulting in F&E losses that lead to dehydration and electrolyte imbalances.

Gastroenteritis

Predisposing factors:Age (NBs and infants)Impaired healthImpaired healthClimateEnvironment

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Gastroenteritis

Pathophysiology:Pathogens infect the cellsProduce enterotoxins that damage the cellsProduce enterotoxins that damage the cellsOr, enterotoxins adhere to the walls of the intestines

Gastroenteritis

Enteropathogenic organisms:ShigellaSalmonellaSalmonellaEschericha Coli

Gastroenteritis

Transmission:Fecal-oral route, person to personContaminated water and food suppliesContaminated water and food suppliesExposure to day care facilities increased riskTravel to other countries

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GastroenteritisOther causative factors:VirusesStressFeverParasitesFood intoleranceOverfeedingMedicationsColon disease

Gastroenteritis

Major physiological disturbances:DehydrationElectrolyte imbalanceElectrolyte imbalanceMetabolic acidosis

Gastroenteritis

Diagnostic evaluation:Stool specimenSerum electrolytesSerum electrolytesHematocritBUN

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GastroenteritisSigns of dehydration:Sunken fontanelSunken eyesPoor skin turgorDryness of mouthLoss of weightIncreased heart rateConcentrated urineirritability

Gastroenteritis

Treatment:Home careOral hydration therapy (Pedialyte>1/2 stOral hydration therapy (Pedialyte>1/2 st formula>FS formula)BRATT diet contraindicated

Gastroenteritis

Contraindicated foods:Carbonated beverages and those containing sugargCaffeinated sodaChicken or beef broth

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GastroenteritisNursing interventions:Assessment and historyWeight and vital signsg gMonitor IV fluidsI & ODescription of stools, vomitus, and urineSkin careGood hand washing