Caring for children with gastrointestinal dysfunction —Chap 17

兒童消化系統的生理特徵 評估 小兒常見腸胃道疾病

Gastroenteritis（Acute diarrhea） Intestinal obstruction--Intussusception

Congenital defects Cleft lip and palate

Anorectal malformation

Esophageal atresia & Tracheoesophageal fistula

Hirschsprung’s Disease （ Megacolon ）

Anatomy and physiology of pediatric differences

• GI system is immature at birth. P586 第 1 段第 2 行 – Absorption and excretion do not begin until after birt

h– Sucking reflex– Not have voluntary control over swallowing

• Stomach– Stomach capacity ： small– Frequently regurgitate

• Intestinal – Peristalsis is greater than older children– Deficiency of several enzyme ： amylase, lipase, try

psin

Anatomy and physiology of pediatric differences

• Liver function is also immature• Second year of life

– Digestive processes are fairly complete

– Stomach capacity increase

– Excretory function can be achieved

評估（補）

• 健康史 進食狀況 營養狀況 家庭狀況 主要照顧者的衛生習慣 排便情形 診斷性檢查

血液檢查 糞便檢查 特殊技術

身體檢查 身體外觀 口腔感染 腹部評估

Caring for children with gastrointestinal dysfunction

– Etiology and pathophysiology – Clinical manifestations – Diagnostic tests – Medical management – Nursing assessment & management

Gastroenteritis （ Acute diarrhea ） P617

• Is an inflammation of the stomach and intestines 第 1 段

• Vomiting and diarrhea• Infants and small children with gastroenteritis

or diarrhea can quickly become dehydrated and are at risk for hypovolemic shock

Etiology and pathophysiology （ P617 第 2 行） • Decrease in the absorptive capacity 、 d

ecrease in surface area for absorption 、alteration of parasympathetic innervation

• High risk － day-care centers 、 improper sanitation （第 5 ～ 6 行）

• Causes （ Table 17-2 ）

Clinical manifestations P617 • Mild － Slightly increased in number and more liquid

• Moderate－ Several loose or watery stools

－ Irritability、 anorexia、 nausea、 vomiting

－ Self-limiting

• Severe－ Continuous watery stools

－ Fluid and electrolyte imbalance

－ Cramp、 extremely irritable、 difficult to console

Diagnosis clinical therapy 之第 1 段

• History

• Physical examination

• Laboratory finding－ S/R、 S/C – Presence of ova, parasite, infectious

organisms, viruses, fat, and undigested sugars.

Treatment P618 第 2 段

Depends on the severity of the diarrhea and fluid and electrolyte imbalances.

Goal： correct the fluid and electrolyte

Mild to moderate－ oral rehydration therapy ( Contain water, carbohydrate, sodium, potassium, chloride and lactate P315 )

－ Carbonated beverages and those containing high amounts of sugar should not be given

Severe－ IV （ N/S with glucose 【 one half or one quarter normal saline 】 or L/R ）第 3 段 － NPO－ Antiemetics and antidiarrheals should generally not be used in infants and young children. P618 左下

Lactose-free milk, breast milk, half-strength milk P315 倒數第 4行

Nursing assessment P618

• Frequency, color, amount and consistency of stools 第 4行

• The amount and type of vomitus

• Observing dehydration

• Urine output and specific gravity

• Weight

• Vital signs ( Febrile )

• Skin integrity

Nursing diagnosis & management P619

• Anxiety– Provide Emotional support

• Sleep pattern disturbance• 活動無耐力

– Promote rest and comfort

• Altered nutrition– Ensure adequate nutrition – CRAM (Complex carbohydrates, Rice and Milk ) P619 綠框

• Diarrhea related to infectious process P620

• Fluid volume deficit P620

• Risk for impaired skin integrityP621

Dehydration Chap 10 --P313

• There is not enough fluid in the extracellular compartment.

• The state of body water deficit is called dehydration.

• Sodium is generally lost along with water → hyponatremia

Etiology and pathophysiology

Causes P313 第 1 段第 2 行 • Loss of fluid containing sodium are vomiting、 diarrhea、 nasogastric suction 、 hemorrhage and burns

• Radiant warmers 第 2 段第 2 行

• Adrenal insufficiency and overuse of diuretics

• Bulimic adolescents

• Blood urea nitrogen ＞ 25mg/dL clinical therapy 第 1 段第 3 行

• Serum bicarbonate ＞ 17mEq/L

Medical management P315

• Oral rehydration therapy － mild and moderate dehydration– Contain water, carbohydrate, sodium, potassiu

m, chloride and lactate

• Lactose-free milk, breast milk, half-strength milk 倒數第 4 行

• IV － severely P316 第 1 段

– L/R, one half or one quarter normal saline

同腸胃炎之治療

Nursing assessment

• Weight• I/O• Urine specific gravity• Consciousness• Pulse rate and quality• Skin turgor and mucous membrane moisture• Respiration • Blood pressure

Nursing management

• Provide oral rehydration therapy guidelines • Teach parents oral rehydration methods • Monitor intravenous fluid administration • Discharge planning and home care teaching

Intussusception P602

• Etiology and pathophysiology 第 1 段 – One portion of the intestine prolapses and then invaginates

( 陷入 ) or telescopes ( 使嵌入 ) into another. 第 1 行 – One of the most frequent causes of intestinal obstruction du

ring infant – Between the age of 3 months and 6 years– Site ： ileocecal valve 第 2 段– Telescoping of the Intestine obstructs the passage of stool.– The walls of intestine rub together

inflammation 、 edema 、 decreased blood flow necrosis 、 perforation 、 hemorrhage 、 peritonitis

– In infant, intussusception is commonly associated with measles, viral disease, and gastroenteritis syndromes. P603 Fig17-7

Clinical manifestations P603 第 2 段

Onset is abrupt• Acute abdominal pain （ periods of comfort between acu

te episodes of pain ） • Vomiting • Passage of brown stool→become red and resemble curran

t jelly• A palpable mass may be present in the upper right quadr

ant or mid-upper abdomen• 腹部呈柔軟、膨脹• 疲倦、虛脫• 發燒及腹膜炎之其他徵象 • 右下腹區排空（ Dance 徵象）

Diagnosis P603 第 2 段

• History

• Radiographs and ultrasound of the abdomen

• Barium enema

Treatment P603 第 3 段

• Hydrostatic pressure—Barium enema – Oxygen （ air ）、 saline 、 aqueous c

ontrast material

• Surgery • Supportive care

– 液體補充– 鼻胃管減壓– 抗生素

Nursing management • Maintain fluid and electrolyte balance

Post OP • Monitoring for early signs of infection• Pain management • Maintain NG tube patency • Assess vital signs 、 Abdominal distention 、

Listen for bowel sounds every 4 hours • After normal bowel function

– Clear liquid feeding half- strength milk and other foods

Cleft lip and palate P586 • More common in Native Americans and Asian P586

最後 1 行 • Etiology and pathophysiology P594

– A failure of the maxillary processes of fuse with the elevations on the frontal prominence during the sixth weeks of gestation.

– Hard and soft palates is completed in the first trimester.

– Congenital defects ： tracheoesophageal fistula ， omphalocele ， trisomy 13 ， skeletal dysplasias

– Cause ： multifactorial （ environmental and genetic influences ）

Clinical manifestation P587

• Cleft lip– Unilateral or bilateral– Alone or in combination with a cleft palate defect– Nasal deformity

• Cleft palate– Less obvious– A continuous opening between the mouth and nasal

cavity– Soft palate or both the soft and hard palate– Unilateral or bilateral

Clinical manifestation---補

• 餵食困難• 呼吸道感染• 口腔感染• 聽力受損• 語言發展延遲

Diagnostic tests and medical management P588

• Physiologic assessment 第 1 段

• Medical management ： multidisciplinary team （ plastic surgery 、 hearing 、 speech 、 dentistry ）– Clef lip

• 2-3months of age 第 2 段• Logan bow or other stabilizing device or dressing is put in place.• Crying is minimized by use of medication.

– Clef palate• Depends on the size and severity of the cleft.• 18 months

– Longer nipples with enlarged holes （ before surgical ）– Antibiotic therapy ： recurrent otitis media– Orthodontic care– 語言治療

Nursing assessment

• Physiologic assessment– Observable– Palpation

• Psychosocial assessment—low self-esteem– Family’s reaction– Low self-esteem – Developmental level and social interactions

Nursing management

1.Risk for aspiration 2.Provide emotional support

– Explaining the cause– Interact and speak to the

infant– Point out positive

attributes– Self-blame– Anxiety

3.Altered nutrition

Preoperative care P590

Postoperative care P592

1.Risk for infection

2.Ineffective breathing pattern related to anesthesia and increased secretions

3. Impaired tissue integrity

4. Knowledge deficit

5. Altered nutrition

Care in the community• Feeding techniques• Recognize signs of infection and complications

(fever, vomiting, respiratory distress)• How to position the infant• How to care the suture line• Preparation of the sibling• Support groups• Prevent the infant from touching the suture line

Nursing management

Anorectal malformation ( Imperforate anus ) P604

• Etiology and pathophysiology– Malformations of the anus and rectum.– Often associated with anomalies ： uri

nary tract, esophagus, and duodenum.– VACTER Syndrome

Clinical manifestations

• Failure to pass meconium

• Stool in the urine• Ribbonlike stools• 腹脹、嘔吐

Diagnosis

Assessment anorectal structure and rectal patencyUltrasoundLower GIPA CXR

倒立 3 分鐘→ x-ray尿液分析

Medical management

• Dilation• 低位－ Excised surgery ， then daily manual

dilation• 高位－ Reconstructive surgery （ Posterior

Sagittal Anorectoplasy ； PSARP ）及 temporary colostomy→→ 關閉結腸造廔。

Nursing management

Assessment 　　　　　　• Developed anal dimple or sacral anomalies

• Rectal thermometer

• Observation and recording of passage of meconium

Managemen

• IV fluids• NG decompression• Monitor I/O• Monitor cardiorespi

ratory function• 廔管護理• Emotion support

Preoperation Postoperation Preventing infection Respiratory complication Maintaining hydration Assess vital signs If stable→try feeding Colostomy care 禁量肛溫或使用塞劑

Discharge planning and home care teaching

• How to take the infant’s temperature• Signs and symptoms of infection• Feeding• Toilet training• Assess vital signs• If a colonstomy

– How to care– Reassure the colostomy will be closed– Follow-up– Home care visits

Esophageal atresia & Tracheoesophageal fistula P595

• Etiology and pathophysiology– Failure of the esophagus to develop as a conti

nuous tube during the fourth and fifth weeks of gestation. 第 1 段

– The foregut fails to lengthen, separate, and fuse into two parallel tubes during fetal development. 第 2 段

– End in a blind pouch or develop as a pouch connect to the trachea by a fistula.

• Maternal history ： polyhydramnios 、 prematurity 、 low birth weight

• Associated anomalies 第 2 段第 5 行– Congenital heart defects– Gastrointestinal or urinary tract anomalies– Musculoskeletal abnormalities

VACTERL ： vertebral 、 anus 、 cardia 、 trachea 、 esophageal 、 renal 、 limb

Clinical manifestation 第 3 段

• Excessive salivation and drooling

• 3C（ coughing, choking, cyanosis） and sneezing

• Returns fluid through the nose and mouth→pneumonia

• Abdomen become distended

• Vomiting soon after feeding

Diagnosis 第 4 段

• Nasogastric tube meets resistance and can be advanced only minimally.

• X-ray （ air pouch 、 NG coiling 、 pneumonia 、 distended stomach intestine －遠端有 fistula ）

• Echocardiogram （ 2D echo ） and abdominal ultrasound （ Renal echo ） P596

Treatment P596 第 2 段

• OG suction• Antibiotics• Fluids• Surgery ： several stages

– Ligation of the fistula and insertion of a gastrostomy tube

– Reconnect the two ends of the esophagus （ anastomosis ）

• Potential postoperative complications– Gastroesophageal reflux 、 aspiration 、 strict

ure formation 、 esophageal motor dysfunction

Nursing management

• Maintain a patent airway– Suction－（ continuous or low intermittent）– Place the head of the bed slightly lowered– Continuous or low intermittent suction is used to

remove secretions from the blind pouch. – Change position

• NPO• Maintain with intravenous fluids administered

through an umbilical vein catheter.

Preoperation

Postoperation

• Gastrostomy drainage• IV fluids and antibiotics • TPN• Maintain a patent airway• Emotional support for parent• Discharge planning

– Gastrostomy tube care and feeding 、 signs of infection 、 prevent postoperative complications. P598 families want to known

Megacolon （ Hirschsprung Disease ） P6

03

• Congenital aganglionic megacolon ； inadequate motility causes mechanical obstruction

• Absence of autonomic parasympathetic ganglion cells in the colon→ accumulation of intestinal contents and abdominal distention

• Combination with congential heart defects 、 Down syndrome 、 Imperforate anus

• More common in boys • It can be acute or chronic

Etiology and pathophysiology

Clinical manifestations P604 第 2 段

• Failure to pass meconium

• Refusal to suck• Abdominal distenti

on• Bile-stained emesis complete obstructio

n, respiratory distress, and shock

Failure to gain weight and delayed growth 第 3段Abdominal distentionConstipation alternating with diarrheaVomitingStool may be normal or ribbonlike

Newborn Older child

Diagnosis

• History

• Bowel pattern

• Anorectal manometry

• Radiographic contrast studies

• Rectal biopsy

• Palpation

Treatment

• Newborn ： surgery• Several cases or ill infants ： temporary col

ostomy → closure of the colostomy and reanastomosis （ Soave procedure ）

• Child with milder defect ： dietary modification 、 stool softeners 、 isotonic irrigations

Complication P604 第 7 段

• Fecal incontinence and constipation• Enterocolitis

– GI bleeding and diarrhea→ischemia and ulceration

– TPN– Lactose-free diet

Nursing management Assessment 第 1 段

• Observation for the passage of meconium

• History of weight gain

• Nutritional intake

• Bowel habit

Management• Monitoring fluid and electrolyte balance• Maintain nutrition• Teach parents how to ensure regular bowel movements• Daily rectal irrigations• Prevent skin breakdown • Surgery

– Monitoring for infection– Managing pain– Maintain hydration– Measuring abdominal circumference– Emotion support

• Teach parent about － Ostomy care 、 signs of complications 、 Be alter for signs of poor growth or malnutrition