Transcript 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）

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
birth
– 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,
trypsin
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
身體檢查
身體外觀
口腔感染
腹部評估
診斷性檢查
血液檢查
糞便檢查
特殊技術
Caring for children with gastrointestinal
dysfunction
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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、
decrease 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
• Fluid volume deficit P620
• Risk for impaired skin integrityP621
P620
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
同腸胃炎
之治療
• Oral rehydration therapy－mild and
moderate dehydration
– Contain water, carbohydrate, sodium,
potassium, 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
Nursing assessment
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Weight
I/O
Urine specific gravity
Consciousness
Pulse rate and quality
Skin turgor and mucous membrane moisture
Respiration
Blood pressure
Nursing management
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Provide oral rehydration therapy guidelines
Teach parents oral rehydration methods
Monitor intravenous fluid administration
Discharge planning and home care teaching
Intussusception
• Etiology and pathophysiology
P602
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
during 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 acute
episodes of pain）
• Vomiting
• Passage of brown stool→become red and resemble
currant jelly
• A palpable mass may be present in the upper right
quadrant 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
contrast 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
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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）
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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
1.Risk for aspiration
2.Provide emotional support
Nursing management
Preoperative
care P590
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Explaining the cause
Interact and speak to the
infant
Point out positive
attributes
Self-blame
Anxiety
3.Altered nutrition
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
Nursing management
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
Anorectal malformation ( Imperforate anus ) P604
• Etiology and pathophysiology
– Malformations of the anus and rectum.
– Often associated with anomalies：
urinary 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
patency
Ultrasound
Lower GI
PA 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
Preoperation
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IV fluids
NG decompression
Monitor I/O
Monitor
cardiorespiratory
function
• 廔管護理
• Emotion support
Postoperation

Preventing infection
Respiratory complication
Maintaining hydration
Assess vital signs
If stable→try feeding
Colostomy care
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禁量肛溫或使用塞劑
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Discharge planning and home care teaching
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How to take the infant’s temperature
Signs and symptoms of infection
Feeding
Toilet training
Assess vital signs
If a colonstomy
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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
continuous 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
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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、stricture
formation、esophageal motor dysfunction
Nursing management
Preoperation
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Maintain a patent airway
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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.
Postoperation
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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）
P603
Etiology and pathophysiology
• 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
Clinical manifestations
Newborn
• Failure to pass
meconium
• Refusal to suck
• Abdominal
distention
• Bile-stained emesis
 complete
obstruction,
respiratory distress,
and shock
P604第2段
Older child
Failure
to gain weight
and delayed growth 第3段
Abdominal distention
Constipation alternating
with diarrhea
Vomiting
Stool may be normal or
ribbonlike
Diagnosis
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History
Bowel pattern
Anorectal manometry
Radiographic contrast studies
Rectal biopsy
Palpation
Treatment
• Newborn：surgery
• Several cases or ill infants： temporary
colostomy → 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
• Observation for the passage of
meconium
• History of weight gain
• Nutritional intake
• Bowel habit
第1段
Management
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Monitoring fluid and electrolyte balance
Maintain nutrition
Teach parents how to ensure regular bowel movements
Daily rectal irrigations
Prevent skin breakdown
Surgery
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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