Saunders Gastrointestinal Problems Nclex

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C H A P T E R 33Gastrointestinal Problemshttp://evolve.elsevier.com/SilvestrVcomprehensiveRhJ/P r i o r i t y C o n c e p t sElimination; NutritionI. VomitingA. Description1..The major concerns when a child is vomitingare the risk of dehydration, the loss of fluid andelectrolytes, and the development of metabolicalkalosis.2. Additional concerns include aspiration and thedevelopment of atelectasis or pneumonia.3. Causes of vomiting include acute infectious diseases,increased intracranial pressure, toxic ingestions, foodintolerance, mechanical obstruction of thegastrointestinal tract, metabolic disorders, andpsychogenic disorders.B. Assessment1. Character of vomitusA2.Signs of aspiration3. Presence of pain and abdominal cramping4. Signs of dehydration and fluid and electrolyteimbalances5. Signs of metabolic alkalosisC.Interventions1. Maintain a patent airway.2. Position the child on the side to prevent aspiration.3. Monitor the character, amount, and frequency ofvomiting.4. Assess the force of the vomiting; projectile vomitingmay indicate pyloric stenosis or increased intracranialpressure.5. Monitor strict intake and output.6. Monitor for signs and svmptoms of dehydration, such

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as a sunken fontanel (age-appropriate), nonelasticskin turgor, dry mucous membranes, decreased tearproduction, vital sign changes, and oliguria.7. Monitor electrolyte levels.8. Provide oral rehydration therapv as tolerated and asprescribed; begin feeding slowly, with small amountsof fluid at frequent intervals.9. Administer antiemetics as prescribed.10. Assess for abdominal pain or diarrhea.11. Advise the parents to inform the primary health careprovider (PHCP) if signs of dehydration, blood in thevomitus, forceful vomiting, or abdominal pain arepresent.II. DiarrheaA. DescriptionA1.Acute diarrhea is a cause of dehydration,particularly in children younger than 5 years.2. Causes of acute diarrhea include acute infectiousdisorders of the gastrointestinal tract, antibiotictherapv, rotavirus, and parasitic infestation.3. Causes of chronic diarrhea include malabsorptionsyndromes, inflammatory7bowel disease,immunodeficiencies, food intolerances, andnonspecificfactors.4. Rotavirus is a cause of serious gastroenteritis and is anosocomial (hospital-acquired) pathogenthat is mostin children 3 to 24 months old; childrenyounger than 3 monthssome protection becauseof maternally acquired antibodies.B. Assessment1. Character of stools2. Presence of pain and abdominal cramping3. Signs of dehydration and fluid and electrolyteimbalances4. Signs of metabolic acidosisC. Interventions1. Monitor character, amount, and frequency of diarrhea.2.Provide enteric isolation as required; instructthe parents in effective handwashing technique(children should be taught this technique also).

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3. Monitor skin integrity.4. Monitor strict intake and output.5. Monitor electrolyte levels.6. Monitor for signs and symptoms of dehydration.7.Formild to moderate dehydration, provide oralrehydration therapy with Pedialyte or a similarrehydration solution as prescribed; avoid carbonatedbeverages because they are gas-producing, and fluidsthat contain high amounts of sugar, such as applejuice.8. For severe dehydration, maintain NPO (nothing bymouth) status to place the bowel at rest and providefluid and electrolyte replacement by the intravenous(IV) route as prescribed;ifpotassium is prescribed forIV administration, ensure that the child lias voidedbefore administering and has adequate renal function.9. Reintroduce a normal diet when rehydration isachieved.Fhe major concerns when a child is having diarrhea are therisk of dehydration, the loss of fluid and electrolytes, and thedevelopment of metabolic acidosis. Orthostatic vital signs are helpful inassessing hydration status.III. Cleft Lip and Cleft PalateA. Description1. Cleft lip and deft palate are congenital anomalies thatoccur as a result of failure of soft tissue or bonystructure to fuse during embryonic development.2. The defects involve abnormal openings in the lip andpalate that may occur unilaterally or bilaterally andare readily apparent at birth.3. Causes include hereditary and environmental factors—exposure to radiation or rubella virus, chromosomeabnormalities, family history, maternal smoking, andteratogenic factors such as medications taken duringpregnancy.4. Prenatal dietary supplementation of folic add isimportant to decrease the risk of cleft lip and palate.5. Closure of a cleft lip defect precedes closure of the deftpalate and is usually performed by age 3 to 6 months.6. Cleft palate repair is usually performed around1yearof age, following the successful repair of deft lip ifpresent, and to allow for the palatal changes thatoccur with normalgrowth;a cleft palate is closed asearly as possible to facilitate speech development.7. A child with cleft palate is at risk for developingfrequent otitis media; this can result in hearing loss.

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8. An interprofessional team approach, includingaudiologists, orthodontists, plastic surgeons, andoccupational and speech therapists, is taken toaddress the many needs of the child.B.Assessment (Fig. 33-1)1. Cleft lip can range from a slight notch to a completeseparation from the floor of the nose.2. Cleft palate can include nasal distortion, midline orbilateral deft, and variable extension from the uvulaand soft and hard palate.C. Interventions1.Assess the ability to suck, swallow, handlenormal secretions, and breathe without distress.2. Assess fluid and calorie intake daily.3. Monitor daily weight.4. Modify feeding techniques; plan to use specializedfeeding tedmiques, obturators, and spedal nipplesand feeders.5.Hold the infant in an upright position anddirect the formula to the side and back of the mouthto prevent aspiration.6.Feed small amounts gradually and burp frequently.7.Keep suction equipment and a bulb syringe atthe bedside.8. Teach the parents spedal feeding or suctioningtechniques.9. Teach the parents the £SSA method of feeding—enlarge the nipple, stimulate the sucking reflex,swallow, rest to allow the infant to finish swallowingwhat has been placed in the mouth.10.Encourage parents to express their feelings about thedisorder.11.Encourage parental bonding with the infant, includingholding the infant and calling the infant by name.D. Postoperative interventions1. Cleft lip repaira. Provide lip protection; a metalappliance or adhesive strips may betaped securely to the cheeks to preventtrauma to the suture line.Ab.Avoid positioning the infant onthe side of the repair or in the proneposition because these positions can

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cause rubbing of the surgical site onthe mattress (position on the backupright and position to prevent airwavobstruction bv secretions, blood, or thetongue).c. Keep the surgical site dean and div;after feeding, gently cleanse the sutureline of formula or serosanguineousdrainage with a solution such asnormal saline oi as designated bvagencv procedure.d. Apply antibiotic ointment to the site asprescribed.e. Elbow restraints should be used toprevent the infant from injuring oitraumatizing the surgical site.f. Monitor for signs and symptoms ofinfection at the surgical site.2. Cleft palate repaira. Feedings are resumed bv bottle, breast,or cup per surgeon preference; somesurgeons prescribe the use of anAsepto syringe for feeding or a softcup such as a sippy cup.b. Oral packing may be secured to thepalate (usually removed in 2 to 3days).c. Instruct the parents to avoid placinganything in the child's mouth that isharsh and could cause disruption ofthe surgical site.3.Soft elbow or jacket restraints may be used(check agency policies and procedures) to keep thechild from touching the repair site; remove restraintsat least every 1 to 2 hours (or per agencv procedure)to assess skin integrity and circulation and to allowfor exercising the arms.4.Avoid the use of oral suction or placing objectsin the mouth such as a tongue depressor,thermometer, straws, spoons, forks, or pacifiers.5. Provide analgesics for pain as prescribed.6. Instruct the parents in feeding techniques and in thecare of the surgical site.7. Instruct the parents to monitor for signs of infection atthe surgical site, such as redness, swelling, or

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drainage.8. Encourage the parents to hold the child.9.Initiate appropriate referrals such as a dental referraland speech therapv referral.IV. Esophageal Atresiaand Tracheoesophageal Fistula (Fig. 33-2)A. Description1. The esophagus terminates before it reaches thestomach, ending in a blind pouch, or a fistula ispresent that forms an unnatural connection with thetrachea.2. The condition causes oral intake to enter the lungs or alarge amount of air to enter the stomach, presenting arisk of coughing and choking; severe abdominaldistention can occur.3. Aspiration pneumonia and severe respiratory distressmay develop, and death is likely to occur withoutsurgical intervention.4. Treatment includes maintenance of a patent airway,prevention of aspiration pneumonia, gastric or blindpouch decompression, supportive therapy, andsurgical repair.B. Assessment1. Frothv saliva in the mouth and nose and excessivedrooling2.The "3 Cs"— coughing and choking duringfeedings and unexplainedcyanosis3.Regurgitationand vomiting4. Abdominal distention5. Increased respiratory distress during and after feedingC. Preoperative interventions1. The infant mav be placed in a radiant warmer inwhich humidified oxvgen is administered (intubationand mechanical ventilation mav be necessary ifrespiratory distress occurs).2. Maintain NPO status.3. Maintain IV fluids as prescribed.4. Monitor respirator,7status closely.5. Suction accumulated secretions from the mouth andpharynx.A6.Maintain in a supine upright position (at least30 degrees upright) to facilitate drainage and preventaspiration of gastric secretions.7. Keep the blind pouch empty of secretions byintermittent or continuous suction as prescribed;monitor its patencv closely, because clogging from

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mucus can occur easily.8. If a gastrostomy tube is inserted, it may be left open sothat air entering the stomach through the fistula canescape, minimizing the risk of regurgitation of gastriccontents into the trachea.9.Broad-spectrum antibiotics maybe prescribed becauseof the high risk for aspiration pneumonia.D.Postoperative interventions1. Monitor vital signs and respiratory status.2. Maintain IX7fluids, antibiotics, and parenteralnutrition as prescribed.3. Monitor strict intake and output.4. Monitor daily weight; assess for dehydration andpossible fluid overload.5. Assess for signs of pain.6. Maintain chest tube if present.7. Inspect the surgical site for signs and symptoms ofinfection.8. Monitor for anastomotic leaks as evidenced bypurulent drainage from tire chest tube, increasedtemperature, and increased white blood cell count.9. If a gastrostomy tube is present, it is usually attachedto gravity drainage until the infant can toleratefeedings and the anastomosis is healed (usuallypostoperative day 5 to 7); then feedings areprescribed.10.Before oral feedings and removal of the chest tube,prepare for an esophagogram as prescribed to checkthe integrity of the esophageal anastomosis.11. Before feeding, elevate the gastrostomy tube andsecure it above the level of the stomach to allowgastric secretions to pass to the duodenum andswallowed air to escape through the opengastrostomy tube.12. Administer oral feedings with sterile water, followedby frequent small feedings of formula as prescribed.13. Assess the centical esophagostomv site, if present, forredness, breakdown, or exudate; remove accumulateddrainage frequently, and apply protective ointment,barrier dressing, or a collection device as prescribed.14. Provide nonnutritive sucking, using a pacifier forinfants who remain NPO for extended periods (apacifier should not be used if the infant is unable tohandle secretions).15. Instruct the parents in the techniques of suctioning,gastrostomy tube care and feedings, and skin site careas appropriate.

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16.Instruct the parents to identify behaviors thatindicate the need for suctioning, signs of respiratorydistress, and signs of a constricted esophagus (e.g,,poor feeding, dysphagia, drooling, coughing duringfeedings, regurgitated undigested food).V. Gastroesophageal Reflux DiseaseA. Description1.Gastroesophageal reflux is backflow of gastriccontents into the esophagus as a result of relaxation orincompetence of the lower esophageal or cardiacsphincter.2. Most infants with gastroesophageal reflux have a mildproblem that improves in about 1 year and requiresmedical therapy only.3. Gastroesophageal reflux disease occurs when gastriccontents reflux into the esophagus or oropharynx andproduce symptoms.B.Assessment1. Passive regurgitation or emesis2. Poor weight gain3. Irritability4. Hematemesis5. Heartbum (in older children)6. Anemia from blood lossC.Interventions1. Assess amount and characteristics of emesis.2. Assess the relationship of vomiting to the times offeedings and infant activity.3. Monitor breath sounds before and after feedings.4. Assess for signs of aspiration, such as drooling,coughing, or dyspnea, after feeding.5. Place suction equipment at the bedside.6. Monitor intake and output.7. Monitor for signs and symptoms of dehydration.8. Maintain IV fluids as prescribed.Comptications of gastroesophageal reflux disease includeesophagitis, esophageal strictures, aspiration of gastnc contents, andaspiration pneumonia.Positioning

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1. The infant is placed in the supine position duringsleep (to reduce the incidence of sudden infant deathsyndrome) unless the risk of death from aspiration orother serious complications of gastroesophagealreflux disease greatly outweighs the risks associatedwith the prone position (check the FHCP'sprescription); otherwise, the prone position isacceptable only while the infant is awake and can bemonitored.2. In children older than 1 year, position with the head ofthe bed elevated.E. Diet1. Provide small, frequent feedings with predigestedformula to decrease the amount of regurgitation.2. Nutrition via nasogastric tube feedings may beprescribed if severe regurgitation and poor growthare present.3. For infants, formula may be thickened by adding ricecereal to the formula (follow agency procedure);cross-cut the nipple.4. Breast-feeding may continue, and the mother mayprovide more frequent feeding times or express milkfor thickening with rice cereal.A5.Burp the infant frequently when feeding andhandle the infant minimally after feedings; monitorfor coughing during feeding and other signs ofaspiration.6. For toddlers, feed solids first, followed by liquids.7. Instruct the parents to avoid feeding the child fattyfoods, chocolate, tomato products, carbonated liquids,fruit juices, citrus products, and spicy foods.8. Instruct the parents that the child should avoidvigorous play after feeding and avoid feeding justbefore bedtime.F. Medications1. Antacids for svmptom relief2. Proton pump inhibitors and histamine Hj-receptorantagonists to decrease gastric add secretionVI. Hypertrophic Pyloric Stenosis (Fig. 33-3)A. Description1. Hypertrophy of the circular muscles of the pyloruscauses narrowing of the pyloric canal between thestomach and the duodenum.2. The stenosis usually develops in the first few weeks oflife, causing projectile vomiting, dehydration,metabolic alkalosis, and failure to thrive.

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B. Assessment1.Vomiting that progresses from mildregurgitation to forceful and projectile vomiting; itusually occurs after a feeding.2. Vomitus contains gastric contents such as milk orformula, may contain mucus, may be blood-tinged,and does not usually contain bile.3. The child exhibits hunger and irritability.4.j *Peristaltic waves are visible from left to rightacross the epigastrium during or immediately after afeeding.5.An olive-shaped mass is in the epigastrium justright of the umbilicus.6. Signs of dehydration and malnutrition7. Signs of electrolyte imbalances8. Metabolic alkalosisC. Interventions1. Monitor strict intake and output.2. Monitor vomiting episodes and stools.3. Obtain daily weights.4. Monitor for signs of dehydration and electrolyteimbalances.5. Prepare the child and parents for pyloromvotomv ifprescribed.▲D.Pyloromvotomv1. Description: An incision through the muscle fibers ofthe pylorus; mav be performed by laparoscopy2. Freoperative interventionsa. Monitor hydration status bv dailyweights, intake and output, and urinefor specific gravity.b. Correct fluid and electrolyteimbalances; administer fluidsintravenously as prescribed forrehydration.c. Maintain NPO status as prescribed.d. Monitor the number and character ofstools.e. Maintain patency of the nasogastrictube placed for stomachdecompression.3. Postoperative interventionsa. Monitor intake and output.

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b. Begin small, frequent feedingspostoperatively as prescribed.c. Gradually increase amount and intervalbetween feedings until a full feedingschedule has been reinstated.▲d.Feed the infant slowly, burpingfrequently, and handle the infantminimally after feedings.e. Monitor for abdominal distention,f.Monitor the surgical wound and forsigns of infection.g. Instruct the parents about wound careand feeding.VII. Lactose IntoleranceA, Description: Inability to tolerate lactose as a result of an absenceor deficiency of lactase, an enzvme found in the secretions of thesmall intestine that is required for the digestion of lactoseB. Assessment1. Symptoms occur after the ingestion of milk or otherdairy products.2. Abdominal distention3. Crampv, abdominal pain; colic4. Diarrhea and excessive flatusC. Inter.-entions1.Eliminate the offending dairy product, oradminister an enzyme tablet replacement.2. Provide information to the parents about enzvmetablets that predigest the lactose in dairy products orsupplement the body's own lactase.3. Substitute soy-based formulas for cows milk formulaor human milk.4. Allow milk consumption as tolerated.5. Instruct the child and family that the child shoulddrink milk with other foods rather than bv itself.6. Encourage consumption of hard cheese, cottagecheese, and yogurt, which contain the inactive lactaseenzvme.7. Encourage consumption of small amounts of dairyfoods daily to help colonic bacteria adapt to ingestedlactose.8. Instruct the parents about the foods that containlactose, including hidden sources.

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vitamin D deficiency, instruct the parents about the importance ofproviding these supplements.VIII. Celiac DiseaseA. Description1. Celiac disease is also known as gluten enteropathy orceliac sprue.A2.Intolerance to gluten, the protein component ofwheat, barlev, rve, and oats, is characteristic.3. Celiac disease results in the accumulation of the aminoacid glutamine, which is toxic to intestinal mucosalcells.4. Intestinal villous atrophy occurs, which affectsabsorption of ingested nutrients.5. Symptoms of the disorder occur most often betweenthe ages of 1 and 5 years.6. There is usually an interval of 3 to 6 months betweenthe introduction of gluten in the diet and the onset ofsymptoms.7. Strict dietarv avoidance of gluten minimizes the risk ofdeveloping malignant Ivmphoma of the smallintestine and other gastrointestinal malignancies.B. Assessment1. Acute or insidious diarrhea2. Steatorrhea3. Anorexia4. Abdominal pain and distention5. Muscle wasting, particularly in the buttocks andextremities6. Vomiting7. Anemia8. IrritabilityC.Celiac crisis1. Precipitated by fasting, infection, or ingestion ofgluten2. Causes profuse watery diarrhea and vomiting3. Can lead to rapid dehydration, electrolyte imbalance,and severe acidosisD. InterventionsA1.Maintain a gluten-free diet, substituting com,rice, and millet as grain sources.A2.Instruct the parents and child about lifelongelimination of gluten sources such as wheat, rye, oats,and barlev.

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3. Administer mineral and vitamin supplements,including iron, folic acid, and fat-soluble vitamins A,D, E, and K.4. Teach the child and parents about a gluten-free dietand about reading food labels carefully for hiddensources of gluten (Box 33-1).5. Instruct the parents in measures to prevent celiaccrisis.6. Inform the parents about the Celiac Sprue Association.IX. AppendicitisA. Description1. Inflammation of the appendix2. When the appendix becomes inflamed or infected,perforation may occur within a matter of hours,leading to peritonitis, sepsis, septic shock, andpotentially death.3. Treatment is surgical removal of the appendix beforeperforation occurs.B.Assessment1. Pain in periumbilical area that descends to the rightlower quadrantA2.Abdominal pain that is most intense atMcBurnev's point3. Referred pain indicating the presence of peritonealirritation4. Rebound tenderness and abdominal rigidity5. Elevated white blood cell count6. Side-lving position with abdominal guarding (legsflexed) to relieve pain7. Difficulty walking and pain in the right hip8. Low-grade fever9. Anorexia, nausea, and vomiting after pain develops10. DiarrheaAC.Peritonitis1. Description: Results from a perforated appendix2. Assessmenta. Increased feverb. Progressive abdominal distentionc. Tachycardia and tachypnead. Pallore. Chillsf. Restlessness and irritability

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tfiesudcfen refief of pain and thena subsequentjncrease Jnpafn accompanredby rjgjtt guardingofthe abdomen.D. Appendectomy1. Description: Surgical removal of the appendix2. Interventions preoperativelva. Maintain NFO status.b. Administer IV fluids and electrolytes asprescribed to prevent dehydration andcorrect electrolyte imbalances.c. Monitor for changes in the level of pain.d. Monitor for signs of a rupturedappendix and peritonitis.e. Avoid the use of pain medications so asnot to mask pain changes associatedwith perforation.f. Administer antibiotics as prescribed.g. Monitor bowel sounds.Ah.r.yPosition in a right side-lying orlow to semi-Fowler's position topromote comfort.i. Apply ice packs to the abdomen for 20to 30 minutes every hour if prescribed.j.Avoid the application of heat tothe abdomen.k.Avoid laxatives or enemas.3. Postoperative interventionsa. Monitor vital signs, particularlytemperature.b. Maintain NFO status until bowelfunction has returned, advancing thediet gradually as tolerated and asprescribed when bowel sounds return.c. Assess the incision for signs of infectionsuch as redness, swelling, drainage,and pain.d. Monitor drainage from the drain, whichmay be inserted if perforationoccurred.e.Position the child in a right side-lying or low to semi-Fowler’s positionwith the legs slightly flexed to facilitatedrainage.

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