Ch 24 ppt

The Child with
Gastrointestinal
Dysfunction
Chapter 24

Mosby items and derived items © 2005, 2001 by Mosby, Inc.

Clinical Manifestations
of GI Dysfunction
• Failure to thrive
• Regurgitation
• Nausea, vomiting, diarrhea, constipation
• Abdominal pain, distention, GI bleeding
• Jaundice
• Dysphagia
• Hypoactive, hyperactive, or absent bowel
sounds

Daily Maintenance Fluid
Requirements
• Calculate child’s wt in kg
• Allow 100 mL/kg for first 10 kg body wt
• Allow 50 mL/kg for second 10 kg body wt
• Allow 20 mL/kg for remaining body wt


Example #1 of Daily Fluid
Calculation
• Child weighs 32 kg
• 100 x 10 for 1st 10 kg of body weight =
1000
• 50 x 10 for 2nd 10 kg of body weight =
500
• 20 x 12 for remaining body weight = 240
• 1000 + 500 + 240 = 1740 mL/24 hrs


Calculation
• Child weighs 8.5 kg
• 100 x 8.5 for 1st 10 kg of body weight =
850
• No further calculations
• 850 mL/24 hrs


Calculation
• Child weighs 14 kg
• 100 x 10 for 1st 10 kg of body weight =
1000
• 50 x 4 for 2nd 10 kg of body weight = 200
• No further calculations
• 1000 + 200 = 1200 mL/24 hrs


Diarrhea
• Description: the major concerns when a child is
having diarrhea are the risk of dehydration, the loss
of fluid & electrolytes, & the development of
metabolic acidosis.
• Assessment:
1. Character of stools
2. Pain & abdominal cramping
3. Dehydration
4. Fluid & electrolyte imbalances
5. Metabolic acidosis

Diarrhea (Interventions)
1. Monitor vital signs
2. Monitor the character, amount, &
frequency diarrhea
3. Monitor skin integrity
4. Monitor intake & output & signs of
dehydration
5. Monitor electrolyte levels


Diarrhea (Interventions)
6. For mild to moderate dehydration,
provide oral rehydration therapy.
7. For severe dehydration, maintain NPO
status & provide fluid & electrolyte
replacement by the IV route
8. Reintroduce a normal diet once
rehydration is achieved
9. Provide enteric isolation is required
10. Instruct the parents in good hand-
washing technique

Prevention of Diarrhea
• (Most diarrhea is spread by the fecal-oral
route)
• Teach personal hygiene
• Clean water supply/protect from
contamination
• Careful food preparation
• Handwashing


Vomiting
• Descriptions:
1. The major concerns when a child is
vomiting are the risk of dehydration, the
loss of fluid & electrolytes, & the
development of metabolic alkalosis
2. Additional concerns include aspiration,
atelactasis, and the development of
pneumonia


Vomiting
• Assessment:
1. Signs of aspiration
2. Character of vomitus
3. Pain & abdominal cramping
4. Dehydration
5. Fluid & electrolyte imbalances
6. Metabolic alkalosis


Vomiting
• Interventions:
1. Maintain a patent airway
2. Position the child on side to prevent aspiration
3. Monitor vital signs
4. Monitor the character, amount, & frequency of vomiting
5. Assess the force of vomiting, for projectile vomiting
indicates pyloric stenosis or increased intracranial pressure
6. Monitor intake & output & signs of dehydration
7. Monitor electrolyte levels
8. Provide oral rehydration therapy
9. Assess for diarrhea or abdominal pain
10. Advise the parents to inform the physician when signs of
dehydration, blood in vomitus, forceful vomiting, or
abdominal pain is present

Gastroesophageal Reflux
(GER)
• Defined as transfer of gastric contents into the esophagus
as a result of relaxation of the lower esophageal or cardiac
sphincter.
• Complications include esophageal strictures, aspiration of
gastric contents, & aspiration pneumonia.
• Assessment:
1.Passive regurgitation or emesis
2.Poor weight gain
3.Hematemesis
4.Heartburn (in older children)
5.Anemia from blood loss


GER (cont’d)
• Interventions:
1. Assess amount & ch-ch of emesis
2. Monitor breath sounds before &after
feeding
3. Place suction equipment at the bedside
4. Monitor intake & output
5. Monitor for signs & symptoms of
dehydration


GER (cont’d)
• Treatment:
a) Positioning: prone position after feedings & at night
b) Diet:
1. Provide small, frequent feedings to decrease the
amount of regurgitation, nasogastric tube feedings are
indicated if severe regurgitation & poor growth are
present.
2. For infants, thicken formula by adding rice cereal.
3. Burp the infant frequently when feeding & handle the
infant minimally after feedings
4. Instruct the parents to avoid feeding the child fatty
foods, chocolate, fruit juices, & spicy foods
5. Avoid feeding just before bedtime
6. Avoid vigorous play after feedingitems and derived items © 2005, 2001 by Mosby, Inc.
Mosby

GER (cont’d)
c) Medications:

1. Administer antacids to reduce the amount of
acid present in gastric secretions, & to prevent
esophagitis
2. Administer prokinetic agents to accelerate
gastric emptying & decrease reflux
3. Administer acetaminophen to relieve reflux
pain
d) Surgery:
1. Procedure known as fundoplication to restore
the competence of lower esophageal sphincter
2. A gastrostomy may be performed at the same
time for decompression of the stomach

Cleft Lip and/or Cleft Palate
(Description)

• Cleft lip or cleft is a congenital anomaly that occur
as a result of failure of soft tissue or bony
structure to fuse during embryonic development.
• The defects involve abnormal openings in the lip
or palate that may occur unilaterally or bilaterally
• Causes include genetic, hereditary, &
environmental factors, exposure to radiation or
rubella virus, chromosome abnormalities, &
teratogenic factors.
• Closure of cleft lip defect precedes that of the
palate? & is performed usually during the 1st
weeks of life.
• Cleft palate is repair is performed between 12 &
18 months of age

(Assessment)

• Cleft lip can range from a slight notch to a
complete separation from the floor of the
nose.
• Cleft palate can include nasal distortion,
midline or bilateral cleft, & variable
extension from the uvula & soft & hard
palate.


(Interventions)
• Assess the ability to suck, swallow, handle
normal secretions, & breathe without distress
• Assess fluid & calorie intake daily & monitor
weight
• Modify feeding techniques
• Hold the child in an upright position, and feed
small amounts gradually & burp frequently
• Position on side after feeding
• Teach the parents ESSR (enlarge, stimulate,
sucking, swallow, rest) method of feeding.


(Interventions postoperatively)
1. Cleft lip repair:
a) A lip protector device may be taped securely
to the cheeks to prevent trauma to the suture
line
b) Position the child on the side lateral to the
repair or on the back, avoid the prone position
to prevent rubbing of the surgical site on the
mattress
c) After feeding, cleanse the suture line of
formula or drainage with a cotton tipped swab
dipped in saline, apply antibiotic ointment if
prescribed



2. Cleft palate repair:
a) Child is allowed to lie on the abdomen
b) Feedings are resumed by bottle, breast,
or cup
c) Do not allow the child to brush his or
her teeth
d) Instruct the parents to avoid offering
hard food items to the child


3. Soft elbow or jacket restraints may be used
(check agency policy)
4. Avoid the use of oral suction or placing objects
in the mouth as a tongue depressor,
thermometer, straws, spoons, forks, or
pacifiers
5. Provide analgesics for pain
6. Instruct the parents to monitor for signs of
infection at the surgical site
7. Encourage the parents to hold the child
8. Initiate appropriate referrals for speech
impairment or language-based learning
difficulties

Image 322: Stages in palatine development.


Image 323: Variations in clefts of lip and palate at birth. A, Notch in vermilion
border. B, Unilateral cleft lip and cleft palate. C, Bilateral cleft lip and cleft
palate. D, Cleft palate.

Image 324: Infant with Logan bow in place to prevent trauma to the suture line.
Note elbow restraints.

Image 325: Some devices used to feed an infant with a cleft lip and palate.


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