Transcript Caring for children with gastrointestinal dysfunction 壹、 貳、

Caring for children with
gastrointestinal dysfunction
—Chap 17
壹、評估
貳、小兒常見腸胃道疾病
壹、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
（LGI、UGI、 、）
常見腸胃道疾病
Intestinal obstruction
Intussusception
Inflammatory disorders
Appendicitis
Disorders of motility
Gastroenteritis（Acute diarrhea）
Dehydration ---Chap 10
Constipation
Feeding disorders
Colic
Disorders of malabsorption
Celiac disease
Lactose Intolerance
Short bowel syndrome
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靜水壓—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
Appendicitis
P609
Is an inflammation of the vermiform appendix.
Most often in adolescent boys（10-19 y/o）；rarely seen
before 2 years of age
Etiology and pathophysiology
• Result from an obstruction in the appendiceal lumen
• Caused by a fecalith，parasitic infestations，stenosis，
hyperplasia of lymphoid tissue，or a tumor
• Obstructioncontinued secretion of mucus→pressure↑
→ischemia，cellular death，and ulceration
• Complication：perforation or rupture → peritonitis → small
bowel obstruction，electrolyte imbalances，septicemia，and
hypovolemic shock
Inflammatory disorders
Clinical manifestations
• Pain
• Fever, vomiting, diarrhea, constipation P610第2段
• Motionless, side-lying position with knees flexed
Caution：
Some children
Appendix is in a different location
Differentiation
P609此段第2行
Ovulation
Ruptured ectopic pregnancy
Pelvic inflammatory
P609最後1行
Pain
• Periumbilical cramps，abdominal tenderness第1行
→ pain in the right lower abdomen become
constant第4行
• Most intense halfway between the anterior
superior iliac crest and umbilicus → rigidity and
rebound tenderness P610第2行 → if sudden relief of
pain（ruptured）
Signs and symptoms of a ruptured appendix include
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Fever
Sudden relief from abdominal pain
Guarding
Abdominal distention
Rapid shallow breathing
Pallor
Chills
Irritability or restlessness
P609右上
Diagnosis
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— evaluation over several hours
P610
WBC↑（teenagers）第2段
Abdominal pain
X-ray
Abdominal ultrasound
Focused appendiceal computerized tomography
（FACT）
Treatment
第3段
• Preoperatively
– NPO & NG decompression
– IV fluids & electrolytes
– Antibiotics
• Appendectomy
• Postoperatively
– Antibiotics
– If ruptured
• Penrose drain
• Wound irrigations
Nursing management
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Promote comfort
Maintain hydration
Provide emotional support
Recognize symptoms of infection
Support respiratory function
Discharge planning and home care teaching
Disorders of motility
Diarrhea
因消化、吸收及分泌不正常所導致的症狀
特徵：
（1）明顯或突然的增加排便次數
（2）含水量增加、性狀的改變
（3）糞便傾向綠色並含有黏液或血液。
可能是急性或慢性、發炎或沒發炎，一般和發炎有
關的腹瀉通常被敘述成腸胃炎。
Disorders of motility
•急性腹瀉：糞便在次數及性狀上的突然改
變，通常是因為傳染性病源所造成的炎症
反應所致。
慢性腹瀉：持續兩週以上的腹瀉情形，如
吸收不良症候群。
Disorders of motility
Gastroenteritis（Acute diarrhea）P617
Is an inflammation of the stomach and intestines
Vomiting and diarrhea
Infants and small children with gastroenteritis or
diarrhea can quickly become dehydrated and are
at risk for hypovolemic shock .
Disorders of motility
第1段
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）
Disorders of motility
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 、urine sp.gr
– 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 care plan
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
Disorders of malabsorption
P627
包括各種不同程度的消化或吸收不良疾病。
• 消化不良是指消化霉減少或缺乏的狀況，如囊性
纖維、Lactose Intolerance 。
• 吸收不良是指腸道運輸系統缺乏的狀況，可能是
原發性缺損（如Celiac Disease）或續發性腸道發
炎；解剖上之缺損，如short bowel syndrome，因
物質運輸時間及吸收表面減少，而影響吸收。
Lactose Intolerance
P628
Etiology and pathophysiology
 Inability to digest lactose（a disaccharide）第1行
 A congenital or acquired deficiency of the enzyme
lactase
 Congenital
 Rare
第3行
 Acquired
 Highest（約100％）among Asian and Native American
第5行
Clinical manifestations
第4行
• Abdominal pain
• Flatulence
• Diarrhea
Diagnosis
第2段
History
Hydrogen breath test
Lactose-free diet for confirming the diagnosis
Treatment
第2段 第4行
• Diet
– Infant－soy-based formula
– Older children－eliminating lactosecontaining foods
• Enzyme tablets
Nursing management
• Support
• Explain dietary modifications and
discuss alternate sources of calcium
P337右下
• Discuss the need for supplementation
of calcium and vitamin D
• Read food labels
Short bowel syndrome（SBS）
P628
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Etiology and pathophysiology 第1段
It is a decreased ability to digest and absorb a
regular diet because of a shortened intestine.
Causes：necrotizing enterocolitis（NEC）、
inflammatory disorders、congenital bowel
anomaly
The extent and location of the involved bowel
determine the severityof the disorder. 第2段
Adaptation period：increases its absorptive
surface area 第5行
Clinical manifestations第2段
Watery diarrhea
第4行
Treatment 第2段
• Nutritional support 第6行
– TPN、elemental formula、MCT
• Enteral feeding
– High-fat, low-carbohydrate diet
– Nucleotide, glutamine, polyamine, and
fatty acid
• Surgical（補）
Complication（補）
•缺少50%的腸道（若未缺失遠端迴腸）不
會影響健康
•缺少70%以上的腸道易導致嚴重吸收不良
•通常死於TPN相關問題，如sepsis or TPNcholestasis
Nursing management
• Meeting the child’s nutritional and fluid needs
• Oral and enteral feedings are instituted gradually
– Feeding pump
– Feeding tube
• Emotional support
• Arrange home visits to monitor the child’s growth
and development and observed side effects （fluid
and electrolyte imbalance and diarrhea）