disorders of gastrointestinal system- child health nursing

1. By-
Ramya Deepthi P
Asst Professor
Vijay Marie college of Nursing

2. cleft lip and cleft palate
tracheo- esophageal fistula
pyloric stenosis
intestinal obstruction
Hernia
Intussusception
Hirschprung’s disease
Anorectal malformations

5.  A cleft lip result from failure of fusion of
maxillary process with nose elevation on
frontal prominence.
 The extent of defect varies from notch in the
lip to a large cleft reaching the floor of the
nose

6.  Cleft lip can be on one side called unilateral
cleft lip or may be on both sides called as
bilateral cleft lip.

7.  Cleft palate results from
failure of the hard palate
with each other and with
the soft palate.
 Cleft lip also usually
occurs with cleft palate.
 Cleft palate can be
complete or incomplete.

10.  The incidence of cleft lip is 1 in 750 births
 Cleft lip is predominantly seen in males and
cleft palate in females.
 For cleft palate 1 in 2500 births.
 Approximately 15% of affected infants will
have associated defects.

11.  Cleft lip and cleft palate are facial malformations
that occurs during early weeks of fetal growth
and development.
 The exact cause is not known but it is believed
that it occurs as a result of genitical and
environmental factors.

12.  Medications taken during pregnancy –
anticonvulsants, acne
 Exposure to virus or chemicals during fetal G & d
 Exposure to X-ray
 Maternal alcohol intake
 Maternal smoking

13.  Failure or incomplete fusion of embryonic
structures
 Fusion of maxillary and premaxillary process
normally occurs during 5th and 8th week of
gestation
 The palatal process fuse about a month later
 Failure of fusion results in cleft lip and cleft palate

15.  Prenatal diagnosis of cleft is at times possible by
maternal ultrasonography.
 After birth, a physical examination of the mouth,
palate and nose confirms the presence of cleft lip
or palate
 A gloved finger placed in the mouth to feel defect
or visual examination with flash light will confirm
the diagnosis.

16.  A team of surgeon are required to treat cleft
lip and cleft palate. Team must include-
 A plastic surgeon
 An otolaryngologist
 Oral surgeon
 Orthodontist
 Dentist
 Prosthodontist
 Speech pathologist
 Nurse coordinator

17.  Cleft lip may require one or two surgeries
depending on severity of defect.
 The initial surgery is usually performed at the age
of 3months.
 Tennison Randall Triangular Flap ( Z-plasty) is the
surgical correction most usually performed. Or
Millard’s Rotational Advancement technique.

18.  It requires many surgeries over the course of
18 years.
 First surgical repair is done between 6-12
months of age which helps in promoting
functional palate and reduces the chance of
fluid entering the middle ears and helps in
proper development of teeth
 When child is 8 years old they may need a
bone graft to fill in the upper gum line
 Once the permanent teeth grows they may
need braces to straighten teeth.

19.  Care of baby at birth
 Care of baby before surgery
 Care of baby after surgery

20.  It is detected soon after delivery
 Check for associated congenital anomalies
 Explain about possibility of complete
correction to parents
 Feeding is a very problem as the defect
reduces baby’s ability to suck milk.
 Palatal prosthesis, rubber tube with syringe
can be used for feeding.
 Burp the baby between feeds

23.  Consent
 Investigative report checking
 NPO for 6 hours before surgery.

24.  Close observation and monitoring
 Observe for bleeding
 Turn baby’s face to one side for draining
secretions
 Protect surgical site from injury
 Arched devise called a s logan bow is used to
prevent tension on suture site
 Administer prescribed medications
 Do not allow baby to put any object in mouth

26.  Tracheo-esophageal fistula and esophageal
Atresia are the malformations of digestive
system, in which esophagus does not develop
properly.
 Esophagus is a tube that normally carries
food from the mouth to the stomach

27. : it is the failure of
esophagus to form a continuous passage
from the pharynx to the stomach

28. It is an abnormal connection between the
trachea and the esophagus.

29.  Occurs in 1 in 3500 births
 Male predominance
 Esophageal Atresia with or without fistula is
common among premature births.
 50% of these cases will have associated
anomalies like-

30.  The upper part of esophagus develops from the
retropharyngeal segment and lower half from
gastric segment.
 At about 4 weeks of gestation, a laryngo-tracheal
groove is formed which divides the foregut into
two longitudinal tubes, which further develops into
trachea and esophagus
 Defective separation and ineffective fusion will
leads to the development of TEF

32.  Type I: in this type, there
is esophageal atresia and
proximal and distal
segments of esophagus
are blind. There is no
communication between
trachea and esophagus.
This type is seen in 3-7%
of cases.

33.  In this type, esophageal
Atresia is present and the
blind proximal segment
of esophagus connects
with trachea by fistula.
 The distal end of
esophagus is blind.
 This types is seen in 0.8%
of cases.

34.  In this type,
esophageal Atresia is
present. The proximal
end of esophagus is a
blind pouch and distal
segment of esophagus
is connected by fistula
to trachea
 Observed in 87% of
cases.

35.  It is the rarest type that
occurs in 0.7% of cases.
In this type, both upper
and lower segments of
esophagus
communicate with
trachea.

36.  In this type,
esophagus and
trachea are normal
and completely
formed but are
connected by a fistula.
 This type is also
known as ‘H’ type and
is present in 4.2% of
cases.

37.  The presence of maternal polyhydromnias and
single umbilical artery should alert pediatricians
about the presence of Atresia of upper digestive
tract.
 Disorder is usually detected soon after birth
when feeding is attempted on the basis of
following manifestations-
Violent response on feeding-
 Infant coughs and chokes
 Fluid returns through nose and mouth
 Cyanosis occur
 Infant struggles

38.  Excessive secretions coming out of nose and
constant drooling of saliva
 Frothy saliva
 Abdominal distension
 Intermittent unexplained cyanosis and
laryngospasm caused due to aspiration of
accumulated saliva in blind esophageal pouch
 Pneumonia may occur due to overflow of milk
and saliva

39.  Diagnosis can be made antenatally also
 It can be suspected if the ultrasound of the pregnant
women shows polyhydromnias.
 Soon after birth vigorous coughing, choking in response
to feeding is an important manifestation
 As soon as the diagnosis is suspected, an attempt is made
to pass feeding tube through nose or mouth into stomach.
 The feeding tube does not pass into the stomach it is an
indication of atresia
 X-ray of chest shows air filled esophageal pouch and air in
stomach. If the feeding tube has been inserted, it appears
coiled up in the upper esophageal pouch.
 An ultrasound enables identification of the type of
tracheo-esophageal pouch
 Ultrasound helps in identification of type of tracheo-
esophageal fistula.

42.  The management of tracheo esophageal
fistula is mainly surgical.
 Surgical intervention depends upon the
distance between the proximal and distal
pouch of esophagus, type of defect, condition
of neonate and his weight.
 If the distance between proximal and distal
tube is less than 2.5 cms, and the infant
condition is good, primary repair is done by
division and ligation of the fistula along with
end to end anastamosis.

43.  When the distance is more than 2.5 cms and
condition of infant is poor, a two stage
procedure is done.
Stage I: tracheo esophageal fistula is ligated
and gastrostomy is done to reduce the risk of
reflux and to provide feeding
Stage II: proximal and distal pouches are
anastamosed. If the gap is too large, a
segment of colon is used for reconstruction
of the esophagus.
 This is done at 18-24 months of age.

45.  Pre-operative nursing management
 Post operative nursing management

46.  Soon after diagnosis attempt to feed should be
stopped
 NG tube aspiration should be done frequently to
aspirate pooled secretions in upper blind pouch
 Maintain patency of NG tube by irrigating it with
NS
 Observe for respiratory distress like pallor,
cyanosis, choking, nasal flaring etc
 Administer prescribed medications

47.  Iv fluid are administered as prescribed by
physicians
 Maintain IO chart
 Maintain hydration status of child by
monitoring signs of dehydration
 Monitor vitals of child
 Administer oxygen in case of cyanosis
 Keep child in semi-upright position

48.  Ineffective airway clearance related to disease
process
 Impaired nutrition related to surgery
 Altered comfort related to chest tube
drainage and surgery
 Anxiety of parents related to disease process
and care of baby after discharge

49. PYLORIC
STENOSIS

51.  It occurs typically in infants between 2-8 weeks
of age.
 1 in 500 – 1000 live births
 5times more in boys than girls
 No particular cause
 Genetic predisposition and environmental
factors are risk

53.  Symptoms appears between 2-4 weeks of age
 Initial presentation is regurgitation and non-
bilious vomiting which may occur both during
and after feeding
 Vomiting becomes progressively forceful, until
it is projectile in nature.
 In projective vomiting, the vomitus is propelled
several feet from the infant
 It is the characteristic feature of pyloric
stenosis.
 Vomitus contains gastric contents, mucous and
streaks of blood but does not contain bile.

55.  Infant seems to be hungry
Other symptoms include-
 Weight loss
 Poor weight gain
 Dehydration
 Less bowel movement
 Reduced frequency and
amount of stool

56.  Careful physical examination reveals a firm,
olive sized mass in epigastrium
 In severely malnourished infants, epigastric
distension may be seen and peristalysis
waves may be seen passing from left to right
during and after feeding
 Barium meal X-ray study reveals the
narrowed pylorus

58.  Surgical management
 Nursing management

59.  It is treated in 2 stages.
 Initially fluids are given intravenously to treat
dehydration and restore body’s normal
chemistry
 Pyloromuotomy is followed or Fredet- Ramstedt
surgery is performed.
 This surgery helps in opening tight muscles of
pylorus that caused narrowing.

61.  Pre operative nursing management
 Observe and record vitals
 Note and record vomitus and stools
 Stop oral feeds and administer IV fluids
 Give small frequent feeds
 Weigh the infant daily to find degree of
dehydration
 Maintain strict intake and output chart

62.  Observe for signs of complications
 Manage pain
 Provision of adequate fluid and nutrition
 Parental education and follow up after
surgery

63. DISORDERS OF
INTESTINE

64.  Hernia is the protrusion of intestine through
a weakness in the abdominal muscles.
 Hernias occurring in newborns are
Omphalocele, Gastroschisis and
Diaphragmatic Hernia.
 Commonly diagnosed hernias during infancy
and childhood are inguinal and umbilical
hernia.

65.  For a hernia to occur, two factors must be
present-
a. A defect in the integrity of muscular
abdominal wall
b. Increased intra-abdominal pressure

66. Abdominal protrusion of abdominal organs
through the structure that contain it
Reducible ( when the contents
of hernia sac can be replaced in
the abdominal cavity by
manipulation )
Irreducable/ incarcerated ( when
contents can not be replaced in
abdominal cavity due to
strangulation of hernial
segment of intestine )

67. Definition-
 Gastroschisis is a congenital anomaly
characterized by a defect in the anterior
abdominal wall through which the abdominal
contents freely protrude.

68.  There will not be any overlying sac and the
size of the defect is less than 4cms.
 The abdominal wall defect is located at the
junction of the umbilicus and normal skin,
and is almost always to the right of the
umbilicus.

69.  Omphalocele is another congenital anomaly
that involves the umbilical cord itself, and the
organs remain enclosed in the visceral
peritoneum. With Omphalocele the defect is
usually much larger than that of
Gastroschisis.

71.  Younger mothers less than 20 years
 Folic acid deficiency
 Hypoxia
 Salicylates, acetaminophen, ibuprofen
consumption during pregnancy
 Cocaine and alcohol consumption during
pregnancy
 High risk pregnancies complicated by low
birth weight babies.

72. OMPHALOCELE GASTROSCHISIS
1 in 5,000 new born babies 1 in 11,000 babies
Malformation are slightly more frequent in males than females. The
male- female ratio is 5:1.

74. Omphalocele-
 Diameter of abdominal wall defect is 4-12
cm, it may be centrally located or in the
epigastrium or the hypogastrium
 Results to injury to baby’s liver
 Sac may rupture in 10-20% of case; rupture
may occur in utero or during delivery.

75. Gastroschisis:
 The abdominal wall defect is fairly uniform in
size (less than 5cms ) and location to the
right of the umbilical cord.
 Edema, inflammation and turgor of intestine
depends on the size of the abdominal cavity
and opening of the abdominal wall.

76.  Observe for any associated problems such as
chromosomal abnormalities, congenital heart
diseases or any other malformations.
 Maintain IV fluids
 Cover omphalocele with non-adherent dressing
to preserve body heat and moisture
 Prophylactic antibiotic may be given pre
operatively
 Closure of small or medium sized omphalocele is
accomplished without difficulty.
 A baby with ruptured omphalocele should be
treated as the child with Gastroschisis

77.  Omphalocele may be treated by mobilizing
skin flaps to cover the sac.
 A circumferential incision is made along the
skin- omphalocele junction, keeping
membrane intact.
 Teflon sheets are sutures along the edge and
approximated over the omphalocele sac.

81.  Gastroschisis should be carefully wrapped in
saline so that the intestine does not dry out.
 NG tube is put to remove air from the intestines
 Respiratory distress in neonate with Gastroschisis
may respond to gastric decompression, although
intubation may still be needed.
 Administer iv fluid bolus ( 20ml/kg, RL or NS
followed by 10% dextrose and normal saline 2-3
times the baby’s maintenance fluid requirement).
 Monitor urinary output
 Do rectal examination to dilate anal opening
 Broad-spectrum antibiotics to prevent
contamination of peritoneal cavity.

82.  Silastic sheets are sutured to full thickness of
extended abdominal wall defect and closed over
the intestines.
 This should be helpful in stretching abdominal
musculature, emptying stomach and bladder, and
manually evacuating the colon.
 With new advancement like silo helps in replacing
intestines into abdominal cavity.
 This new procedure allows the bowel to return to
its intended shape and location without further
traumatizing viscera.

84.  Current advances in surgical techniques and
intensive care management of neonates have
increased the survival rate to 90%.
 Pre-natal diagnosis either through
ultrasonography or any other method
available are helpful.
 Morbidity is closely related to the presence of
other malformations and complications of
wound or intestines.

85. II-INGUINAL HERNIA

86.  It is the most common hernia seen in infants
and children. It occurs in the groin region. It
may be unilateral or bilateral, more frequently
in boys (90%) then girls (10%). It is more
common in premature than term infants.

87.  As the male fetus grows and matures during
pregnancy, the testicles develop in the abdomen
and then move down into the scrotum, through
an area called the inguinal canal.
 Shortly after the baby is born, the inguinal canal
close, preventing the testicles from moving back
into the abdomen.
 If the closure does not occur completely, a loop
of intestine can move into the inguinal canal,
through the weakened area of the lower
abdominal wall, causing hernia.

88.  Hernia can be reducible or irreducible.
 If the hernia is reducible, the contents of the
hernia sac can be placed into the abdominal
cavity by manipulation.
 In an irreducible hernia, the contents of the
hernia sac cannot be reduced or replaced.

90.  Vomiting that contains bile
 Cramping pain
 Abdominal distension
 Fever
 Irritable and restless infant
 Strangulation and gangrene

91.  It can be diagnosed by physical
examination.
 Determine for reducible or
irreducible type of hernia
 Abdominal X-ray or
ultrasonography also helps in
confirming diagnosis.

92.  Specific treatment for hernia depends on the
child’s age, overall health and type of hernia
 Two types of surgeries are done. for the
repair-
1. Open inguinal hernia repair ( Herniorrhaphy,
Hernioplasty )
2. Laproscopic repair.

100.  Umbilical hernia occurs in about 10% of all
children, more often in girls than in boys. It
frequently occurs in premature infants.

101.  When the fetus is growing and developing during
pregnancy, there is small opening in the
abdominal muscles so that the umbilical cord can
pass through, connecting the mother to the
baby.
 After birth, the opening in the abdominal muscle
closes as the baby matures.
 Sometimes, these muscle do not meet together
completely, and a small opening remains.
 A loop of intestine can move into the opening
between abdominal muscle and cause hernia.

103.  Appears as bulge or swelling in the belly-button
area.
 The swelling may be more noticeable, when the
baby cries and may get smaller or disappear
when baby relaxes.
 If the physician gently pushes on the bulge
when the child is calm and quiet laying down, it
will usually get smaller and go back into the
abdomen.

104.  Physical examination reveals the presence of
bulge in umbilical region
 Abdominal X-ray & ultrasound may be done
to examine intestine closely

105.  By 1 year of age many hernias will close with out any
surgeries.
 All hernias are expected to close by 5years of age
 Hernia becomes bigger with age, is not reducible, or
still is present after 3 years of age- it needs surgical
repair.
 During surgery the child is placed under anesthesia.
 A small incision is made in the umbilicus and the
loop of intestine is placed back into the abdominal
cavity.
 Muscles are then sutured together.
 Sometimes a piece of meshed material is used
strengthen the area where the muscle are repaired.

106.  Pre operatively the infant is fed until few
hours before surgery, in order to prevent
dehydration.
 All the preoperative routine care is given-like
bath to the child in the morning, putting
operation theatre clothes, placing
identification band on wrist, collecting all
reports of laboratory investigations and
preparing patients file.

107.  Later the child comes form operation theatre,
receive him in a comfortable operation bed.
 Monitor vitals
 IV fluids still bowel movements return
 Observe site for bleeding
 Discharge once baby starts oral feeds
 No tub baths until 1 week of surgery. Sponge
is advised.
 No restriction on movements and play.

108. INTESTINAL
OBSTRUCTION

109.  Bowel obstruction is a mechanical or
functional obstruction of the intestines,
preventing the normal transit of the products
of digestion.
 It can occur at any level distal to the
duodenum of the small intestine and is
medical emergency.

110.  1 in 15oo births
 Intrinsic causes- atresia, stenosis, meconium
ileus
 Extrinsic causes- malrotation, constructing
bands, intra abdominal hernia.

111.  Adhesions from previous surgery
 Hernias contain bowel
 Neoplasm's
 Intussusception
 Strictures
 Foreign bodies
 Intestinal atresia

112.  Neoplasm's
 Inflammatory bowel disease
 Adhesions
 Constipation
 Fecal impaction
 Colon atresia
 Pseudo obstruction

113.  Normal bowel contains gas and Chyme
(mixture of food, saliva, gastric , biliary,
pancreatic and intestinal secretions)
 Chyme continues to accumulate even without
intake of oral fluids.
 Intrinsic or extrinsic obstruction of bowel
leads to accumulation of secretions that
dilate the intestine proximal to the
obstruction.

114.  Increased peristaltic contractions and
intraluminal pressure may cause frequent
loose stools, flatulus and vomiting
 Bowel becomes ischemic when capillary blood
flow stops, allowing bacteria to pass into the
peritoneum and then into the blood stream,
leading to septicemia.

115.  Abdominal pain
 Abdominal distention
 Vomiting
 Constipation
 Dehydration
 Electrolyte imbalance
 Respiratory compromise
 Bowel ischemia
 Colicky pain

116. 1. Blood investigations- serum electrolyte,
BUN , creatinine , glucose , CBP, ABG
2. Urinalysis
3. Stool for occult blood
4. Imaging studies
5. ultrasound

117.  Stabilize the patient and monitor vital signs
 Replace fluids with isotonic sodium chloride
or RL
 Opioid analgesics
 Antiemetics
 Broad-spectrum antibiotics

118.  Adhesions often settles with out surgery
 In infants most of these obstruction are due
to adhesions which needs complete surgical
correction.

119. INTUSSUSCEPTION

120.  Intussusception is the invagination or
telescoping of one segment of intestine into
another adjacent distal segment of the
intestine.
 The term intussusception is derived from
Latin words “Intus” meaning within and
“suscipere” means to receive within

121.  It is most common cause in children between
3 months and 6months of age or in older
children and adults.
 The incidence is 1-4 in 1000 live births.
 More common in boys than girls.
 Cause is not known.
 Since intestinal tract in children is freely
movable, hyperperistalisis due to
gastroenteritis or lesion may lead to this
condition.

122. A. ILEOCOLIC: This is the commonest type
where ileum invaginates into the caecum
and then into the ascending colon.
B. CAECOCOLIC: in this type, the caecum
invaginates into colon.
C. ILEOILEAL: in this type, one portion of ileum
invaginates into the other portion of ileum.

123.  A segment of bowel telescopes into a more
distal segment, and drags all the associated
blood supply, nerves, lymph of that part.
 This results in compression of veins followed
by swelling of that region, leading to
obstruction and decreased blood floe to that
part
 Leads to gangrene and bleeding
 Rupture may follow leading to abdominal
infection and shock.

124.  Onset of symptom is sudden
 Triad of symptoms- colicky pain, bilious vomiting and
jelly like stool
 Colicky pain is identified by infant’s sudden loud crying
and drawing of knees up to the chest while crying
 As the pain increases, infant becomes progressively
weaker and lethargic and shock like state develops.
 Body temperature rises to 41 degrees (106 F)
 Shallow respirations
 Episodes of vomiting
 Abdominal tenderness, distention
 On palpation sausage shaped mass is felt in right
upper quadrant.

125.  Barium enema
 Abdominal ultrasound

126.  The treatment for Intussusception is non
surgical, hydrostatic reduction using barium
and air enema
 Air insufflation is believed to be safer than
barium enema.
 Successful reduction is reported in about 65-
85% of cases of barium enema an 90% cases
in air insufflation.
 If the hydrostatic reduction is unsuccessful
then a surgery is required.

127.  Pre-operative nursing management:
 Prepare for admission and surgery
 Help parents understand modalities of treatment
 Withhold oral fluid 6-8 hours prior to surgery
 Parenteral fluid is administered incase of shock
 Nasogastric suctioning for decompression of
bowel
 Enema
◦ I/O chart
◦ ANTIBIOTICS AS PRESCRIBED

128.  Assess general condition
 Assess and observe for barium in stool
If surgery is performed-
 Monitor vitals
 Observe the incision site for drainage
 Dressing
 Monitoring abdominal girth daily
 Parenteral fluid until peristalsis is returned
 GI suctioning to keep stomach empty
 Monitor urinary output
 Ambulate child as early as possible
last