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




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


                        Mosby items and derived items © 2005, 2001 by Mosby, Inc.
Example #2 of Daily Fluid
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




                            Mosby items and derived items © 2005, 2001 by Mosby, Inc.
Example #3 of Daily Fluid
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



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


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


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


                        Mosby items and derived items © 2005, 2001 by Mosby, Inc.
Vomiting
• Assessment:
 1. Signs of aspiration
 2. Character of vomitus
 3. Pain & abdominal cramping
 4. Dehydration
 5. Fluid & electrolyte imbalances
 6. Metabolic alkalosis

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


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

                       Mosby items and derived items © 2005, 2001 by Mosby, Inc.
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
                            Mosby items and derived items © 2005, 2001 by Mosby, Inc.
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
                               Mosby items and derived items © 2005, 2001 by Mosby, Inc.
Cleft Lip and/or Cleft Palate
             (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.




                         Mosby items and derived items © 2005, 2001 by Mosby, Inc.
Cleft Lip and/or Cleft 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.

                              Mosby items and derived items © 2005, 2001 by Mosby, Inc.
Cleft Lip and/or Cleft Palate
    (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


                            Mosby items and derived items © 2005, 2001 by Mosby, Inc.
Cleft Lip and/or Cleft Palate
    (Interventions postoperatively)

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

                          Mosby items and derived items © 2005, 2001 by Mosby, Inc.
Cleft Lip and/or Cleft Palate
    (Interventions postoperatively)
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
                             Mosby items and derived items © 2005, 2001 by Mosby, Inc.
Image 322: Stages in palatine development.

                                             Mosby items and derived items © 2005, 2001 by Mosby, Inc.
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.
                                                 Mosby items and derived items © 2005, 2001 by Mosby, Inc.
Image 324: Infant with Logan bow in place to prevent trauma to the suture line.
Note elbow restraints.
                                              Mosby items and derived items © 2005, 2001 by Mosby, Inc.
Image 325: Some devices used to feed an infant with a cleft lip and palate.

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

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Ch 24 ppt

  • 1. The Child with Gastrointestinal Dysfunction Chapter 24 Mosby items and derived items © 2005, 2001 by Mosby, Inc.
  • 2. 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 Mosby items and derived items © 2005, 2001 by Mosby, Inc.
  • 3. 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 Mosby items and derived items © 2005, 2001 by Mosby, Inc.
  • 4. 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 Mosby items and derived items © 2005, 2001 by Mosby, Inc.
  • 5. Example #2 of Daily Fluid 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 Mosby items and derived items © 2005, 2001 by Mosby, Inc.
  • 6. Example #3 of Daily Fluid 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 Mosby items and derived items © 2005, 2001 by Mosby, Inc.
  • 7. 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 Mosby items and derived items © 2005, 2001 by Mosby, Inc.
  • 8. 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 Mosby items and derived items © 2005, 2001 by Mosby, Inc.
  • 9. 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 Mosby items and derived items © 2005, 2001 by Mosby, Inc.
  • 10. 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 Mosby items and derived items © 2005, 2001 by Mosby, Inc.
  • 11. 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 Mosby items and derived items © 2005, 2001 by Mosby, Inc.
  • 12. Vomiting • Assessment: 1. Signs of aspiration 2. Character of vomitus 3. Pain & abdominal cramping 4. Dehydration 5. Fluid & electrolyte imbalances 6. Metabolic alkalosis Mosby items and derived items © 2005, 2001 by Mosby, Inc.
  • 13. 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 Mosby items and derived items © 2005, 2001 by Mosby, Inc.
  • 14. 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 Mosby items and derived items © 2005, 2001 by Mosby, Inc.
  • 15. 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 Mosby items and derived items © 2005, 2001 by Mosby, Inc.
  • 16. 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
  • 17. 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 Mosby items and derived items © 2005, 2001 by Mosby, Inc.
  • 18. 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 Mosby items and derived items © 2005, 2001 by Mosby, Inc.
  • 19. Cleft Lip and/or Cleft Palate (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. Mosby items and derived items © 2005, 2001 by Mosby, Inc.
  • 20. Cleft Lip and/or Cleft 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. Mosby items and derived items © 2005, 2001 by Mosby, Inc.
  • 21. Cleft Lip and/or Cleft Palate (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 Mosby items and derived items © 2005, 2001 by Mosby, Inc.
  • 22. Cleft Lip and/or Cleft Palate (Interventions postoperatively) 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 Mosby items and derived items © 2005, 2001 by Mosby, Inc.
  • 23. Cleft Lip and/or Cleft Palate (Interventions postoperatively) 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 Mosby items and derived items © 2005, 2001 by Mosby, Inc.
  • 24. Image 322: Stages in palatine development. Mosby items and derived items © 2005, 2001 by Mosby, Inc.
  • 25. 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. Mosby items and derived items © 2005, 2001 by Mosby, Inc.
  • 26. Image 324: Infant with Logan bow in place to prevent trauma to the suture line. Note elbow restraints. Mosby items and derived items © 2005, 2001 by Mosby, Inc.
  • 27. Image 325: Some devices used to feed an infant with a cleft lip and palate. Mosby items and derived items © 2005, 2001 by Mosby, Inc.