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Saunders Gastrointestinal Problems Nclex

Pediatric GI guide on vomiting: covers causes, assessment, risks (dehydration, aspiration, alkalosis), and key nursing interventions. Prioritizes nutrition & elimination for NCLEX prep or review.

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    C H A P T E R 33 Gastrointestinal Problems http://evolve.elsevier.com/SilvestrVcomprehensiveRhJ/ P r i o r i t y C o n c e p t s Elimination; Nutrition I. Vomiting A. Description 1. . The major concerns when a child is vomiting are the risk of dehydration, the loss of fluid and electrolytes, and the development of metabolic alkalosis. 2. Additional concerns include aspiration and the development of atelectasis or pneumonia. 3. Causes of vomiting include acute infectious diseases, increased intracranial pressure, toxic ingestions, food intolerance, mechanical obstruction of the gastrointestinal tract, metabolic disorders, and psychogenic disorders. B. Assessment 1. Character of vomitus A 2. Signs of aspiration 3. Presence of pain and abdominal cramping 4. Signs of dehydration and fluid and electrolyte imbalances 5. Signs of metabolic alkalosis C. Interventions 1. Maintain a patent airway. 2. Position the child on the side to prevent aspiration. 3. Monitor the character, amount, and frequency of vomiting. 4. Assess the force of the vomiting; projectile vomiting may indicate pyloric stenosis or increased intracranial pressure. 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), nonelastic skin turgor, dry mucous membranes, decreased tear production, vital sign changes, and oliguria. 7. Monitor electrolyte levels. 8. Provide oral rehydration therapv as tolerated and as prescribed; begin feeding slowly, with small amounts of 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 care provider (PHCP) if signs of dehydration, blood in the vomitus, forceful vomiting, or abdominal pain are present. II. Diarrhea A. Description A 1. Acute diarrhea is a cause of dehydration, particularly in children younger than 5 years. 2. Causes of acute diarrhea include acute infectious disorders of the gastrointestinal tract, antibiotic therapv, rotavirus, and parasitic infestation. 3. Causes of chronic diarrhea include malabsorption syndromes, inflammatory 7 bowel disease, immunodeficiencies, food intolerances, and nonspecific factors. 4. Rotavirus is a cause of serious gastroenteritis and is a nosocomial (hospital-acquired) pathogenthat is most in children 3 to 24 months old; children younger than 3 months some protection because of maternally acquired antibodies. B. Assessment 1. Character of stools 2. Presence of pain and abdominal cramping 3. Signs of dehydration and fluid and electrolyte imbalances 4. Signs of metabolic acidosis C. Interventions 1. Monitor character, amount, and frequency of diarrhea. 2. Provide enteric isolation as required; instruct the 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. For mild to moderate dehydration, provide oral rehydration therapy with Pedialyte or a similar rehydration solution as prescribed; avoid carbonated beverages because they are gas-producing, and fluids that contain high amounts of sugar, such as apple juice. 8. For severe dehydration, maintain NPO (nothing by mouth) status to place the bowel at rest and provide fluid and electrolyte replacement by the intravenous (IV) route as prescribed; if potassium is prescribed for IV administration, ensure that the child lias voided before administering and has adequate renal function. 9. Reintroduce a normal diet when rehydration is achieved. Fhe major concerns when a child is having diarrhea are the risk of dehydration, the loss of fluid and electrolytes, and the development of metabolic acidosis. Orthostatic vital signs are helpful in assessing hydration status. III. Cleft Lip and Cleft Palate A. Description 1. Cleft lip and deft palate are congenital anomalies that occur as a result of failure of soft tissue or bony structure to fuse during embryonic development. 2. The defects involve abnormal openings in the lip and palate that may occur unilaterally or bilaterally and are readily apparent at birth. 3. Causes include hereditary and environmental factors —exposure to radiation or rubella virus, chromosome abnormalities, family history, maternal smoking, and teratogenic factors such as medications taken during pregnancy. 4. Prenatal dietary supplementation of folic add is important to decrease the risk of cleft lip and palate. 5. Closure of a cleft lip defect precedes closure of the deft palate and is usually performed by age 3 to 6 months. 6. Cleft palate repair is usually performed around 1 year of age, following the successful repair of deft lip if present, and to allow for the palatal changes that occur with normal growth; a cleft palate is closed as early as possible to facilitate speech development. 7. A child with cleft palate is at risk for developing frequent otitis media; this can result in hearing loss.

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    8. An interprofessional team approach, including audiologists, orthodontists, plastic surgeons, and occupational and speech therapists, is taken to address the many needs of the child. B. Assessment (Fig. 33-1) 1. Cleft lip can range from a slight notch to a complete separation from the floor of the nose. 2. Cleft palate can include nasal distortion, midline or bilateral deft, and variable extension from the uvula and soft and hard palate. C. Interventions 1. Assess the ability to suck, swallow, handle normal secretions, and breathe without distress. 2. Assess fluid and calorie intake daily. 3. Monitor daily weight. 4. Modify feeding techniques; plan to use specialized feeding tedmiques, obturators, and spedal nipples and feeders. 5. Hold the infant in an upright position and direct the formula to the side and back of the mouth to prevent aspiration. 6. Feed small amounts gradually and burp frequently. 7. Keep suction equipment and a bulb syringe at the bedside. 8. Teach the parents spedal feeding or suctioning techniques. 9. Teach the parents the £SSA method of feeding — enlarge the nipple, stimulate the sucking reflex, swallow, rest to allow the infant to finish swallowing what has been placed in the mouth. 10. Encourage parents to express their feelings about the disorder. 11. Encourage parental bonding with the infant, including holding the infant and calling the infant by name. D. Postoperative interventions 1. Cleft lip repair a. Provide lip protection; a metal appliance or adhesive strips may be taped securely to the cheeks to prevent trauma to the suture line. A b. Avoid positioning the infant on the side of the repair or in the prone position because these positions can

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    cause rubbing of the surgical site on the mattress (position on the back upright and position to prevent airwav obstruction bv secretions, blood, or the tongue). c. Keep the surgical site dean and div; after feeding, gently cleanse the suture line of formula or serosanguineous drainage with a solution such as normal saline oi as designated bv agencv procedure. d. Apply antibiotic ointment to the site as prescribed. e. Elbow restraints should be used to prevent the infant from injuring oi traumatizing the surgical site. f. Monitor for signs and symptoms of infection at the surgical site. 2. Cleft palate repair a. Feedings are resumed bv bottle, breast, or cup per surgeon preference; some surgeons prescribe the use of an Asepto syringe for feeding or a soft cup such as a sippy cup. b. Oral packing may be secured to the palate (usually removed in 2 to 3 days). c. Instruct the parents to avoid placing anything in the child's mouth that is harsh and could cause disruption of the surgical site. 3. Soft elbow or jacket restraints may be used (check agency policies and procedures) to keep the child from touching the repair site; remove restraints at least every 1 to 2 hours (or per agencv procedure) to assess skin integrity and circulation and to allow for exercising the arms. 4. Avoid the use of oral suction or placing objects in 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 the care of the surgical site. 7. Instruct the parents to monitor for signs of infection at the 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 referral and speech therapv referral. IV. Esophageal Atresiaand Tracheoesophageal Fistula (Fig. 33-2) A. Description 1. The esophagus terminates before it reaches the stomach, ending in a blind pouch, or a fistula is present that forms an unnatural connection with the trachea. 2. The condition causes oral intake to enter the lungs or a large amount of air to enter the stomach, presenting a risk of coughing and choking; severe abdominal distention can occur. 3. Aspiration pneumonia and severe respiratory distress may develop, and death is likely to occur without surgical intervention. 4. Treatment includes maintenance of a patent airway, prevention of aspiration pneumonia, gastric or blind pouch decompression, supportive therapy, and surgical repair. B. Assessment 1. Frothv saliva in the mouth and nose and excessive drooling 2. The "3 Cs"— coughing and choking during feedings and unexplained cyanosis 3. Regurgitation and vomiting 4. Abdominal distention 5. Increased respiratory distress during and after feeding C. Preoperative interventions 1. The infant mav be placed in a radiant warmer in which humidified oxvgen is administered (intubation and mechanical ventilation mav be necessary if respiratory distress occurs). 2. Maintain NPO status. 3. Maintain IV fluids as prescribed. 4. Monitor respirator, 7 status closely. 5. Suction accumulated secretions from the mouth and pharynx. A 6. Maintain in a supine upright position (at least 30 degrees upright) to facilitate drainage and prevent aspiration of gastric secretions. 7. Keep the blind pouch empty of secretions by intermittent 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 so that air entering the stomach through the fistula can escape, minimizing the risk of regurgitation of gastric contents into the trachea. 9. Broad-spectrum antibiotics maybe prescribed because of the high risk for aspiration pneumonia. D. Postoperative interventions 1. Monitor vital signs and respiratory status. 2. Maintain IX 7 fluids, antibiotics, and parenteral nutrition as prescribed. 3. Monitor strict intake and output. 4. Monitor daily weight; assess for dehydration and possible fluid overload. 5. Assess for signs of pain. 6. Maintain chest tube if present. 7. Inspect the surgical site for signs and symptoms of infection. 8. Monitor for anastomotic leaks as evidenced by purulent drainage from tire chest tube, increased temperature, and increased white blood cell count. 9. If a gastrostomy tube is present, it is usually attached to gravity drainage until the infant can tolerate feedings and the anastomosis is healed (usually postoperative day 5 to 7); then feedings are prescribed. 10. Before oral feedings and removal of the chest tube, prepare for an esophagogram as prescribed to check the integrity of the esophageal anastomosis. 11. Before feeding, elevate the gastrostomy tube and secure it above the level of the stomach to allow gastric secretions to pass to the duodenum and swallowed air to escape through the open gastrostomy tube. 12. Administer oral feedings with sterile water, followed by frequent small feedings of formula as prescribed. 13. Assess the centical esophagostomv site, if present, for redness, breakdown, or exudate; remove accumulated drainage frequently, and apply protective ointment, barrier dressing, or a collection device as prescribed. 14. Provide nonnutritive sucking, using a pacifier for infants who remain NPO for extended periods (a pacifier should not be used if the infant is unable to handle secretions). 15. Instruct the parents in the techniques of suctioning, gastrostomy tube care and feedings, and skin site care as appropriate.

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    16. Instruct the parents to identify behaviors that indicate the need for suctioning, signs of respiratory distress, and signs of a constricted esophagus (e.g,, poor feeding, dysphagia, drooling, coughing during feedings, regurgitated undigested food). V. Gastroesophageal Reflux Disease A. Description 1. Gastroesophageal reflux is backflow of gastric contents into the esophagus as a result of relaxation or incompetence of the lower esophageal or cardiac sphincter. 2. Most infants with gastroesophageal reflux have a mild problem that improves in about 1 year and requires medical therapy only. 3. Gastroesophageal reflux disease occurs when gastric contents reflux into the esophagus or oropharynx and produce symptoms. B. Assessment 1. Passive regurgitation or emesis 2. Poor weight gain 3. Irritability 4. Hematemesis 5. Heartbum (in older children) 6. Anemia from blood loss C. Interventions 1. Assess amount and characteristics of emesis. 2. Assess the relationship of vomiting to the times of feedings 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 include esophagitis, esophageal strictures, aspiration of gastnc contents, and aspiration pneumonia. Positioning

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    1. The infant is placed in the supine position during sleep (to reduce the incidence of sudden infant death syndrome) unless the risk of death from aspiration or other serious complications of gastroesophageal reflux disease greatly outweighs the risks associated with the prone position (check the FHCP's prescription); otherwise, the prone position is acceptable only while the infant is awake and can be monitored. 2. In children older than 1 year, position with the head of the bed elevated. E. Diet 1. Provide small, frequent feedings with predigested formula to decrease the amount of regurgitation. 2. Nutrition via nasogastric tube feedings may be prescribed if severe regurgitation and poor growth are present. 3. For infants, formula may be thickened by adding rice cereal to the formula (follow agency procedure); cross-cut the nipple. 4. Breast-feeding may continue, and the mother may provide more frequent feeding times or express milk for thickening with rice cereal. A 5. Burp the infant frequently when feeding and handle the infant minimally after feedings; monitor for coughing during feeding and other signs of aspiration. 6. For toddlers, feed solids first, followed by liquids. 7. Instruct the parents to avoid feeding the child fatty foods, chocolate, tomato products, carbonated liquids, fruit juices, citrus products, and spicy foods. 8. Instruct the parents that the child should avoid vigorous play after feeding and avoid feeding just before bedtime. F. Medications 1. Antacids for svmptom relief 2. Proton pump inhibitors and histamine Hj-receptor antagonists to decrease gastric add secretion VI. Hypertrophic Pyloric Stenosis (Fig. 33-3) A. Description 1. Hypertrophy of the circular muscles of the pylorus causes narrowing of the pyloric canal between the stomach and the duodenum. 2. The stenosis usually develops in the first few weeks of life, causing projectile vomiting, dehydration, metabolic alkalosis, and failure to thrive.

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    B. Assessment 1. Vomiting that progresses from mild regurgitation to forceful and projectile vomiting; it usually occurs after a feeding. 2. Vomitus contains gastric contents such as milk or formula, 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 right across the epigastrium during or immediately after a feeding. 5. An olive-shaped mass is in the epigastrium just right of the umbilicus. 6. Signs of dehydration and malnutrition 7. Signs of electrolyte imbalances 8. Metabolic alkalosis C. Interventions 1. Monitor strict intake and output. 2. Monitor vomiting episodes and stools. 3. Obtain daily weights. 4. Monitor for signs of dehydration and electrolyte imbalances. 5. Prepare the child and parents for pyloromvotomv if prescribed. ▲ D. Pyloromvotomv 1. Description: An incision through the muscle fibers of the pylorus; mav be performed by laparoscopy 2. Freoperative interventions a. Monitor hydration status bv daily weights, intake and output, and urine for specific gravity. b. Correct fluid and electrolyte imbalances; administer fluids intravenously as prescribed for rehydration. c. Maintain NPO status as prescribed. d. Monitor the number and character of stools. e. Maintain patency of the nasogastric tube placed for stomach decompression. 3. Postoperative interventions a. Monitor intake and output.

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    b. Begin small, frequent feedings postoperatively as prescribed. c. Gradually increase amount and interval between feedings until a full feeding schedule has been reinstated. ▲ d. Feed the infant slowly, burping frequently, and handle the infant minimally after feedings. e. Monitor for abdominal distention, f. Monitor the surgical wound and for signs of infection. g. Instruct the parents about wound care and feeding. VII. Lactose Intolerance A, Description: Inability to tolerate lactose as a result of an absence or deficiency of lactase, an enzvme found in the secretions of the small intestine that is required for the digestion of lactose B. Assessment 1. Symptoms occur after the ingestion of milk or other dairy products. 2. Abdominal distention 3. Crampv, abdominal pain; colic 4. Diarrhea and excessive flatus C. Inter.- entions 1. Eliminate the offending dairy product, or administer an enzyme tablet replacement. 2. Provide information to the parents about enzvme tablets that predigest the lactose in dairy products or supplement the body's own lactase. 3. Substitute soy-based formulas for cows milk formula or human milk. 4. Allow milk consumption as tolerated. 5. Instruct the child and family that the child should drink milk with other foods rather than bv itself. 6. Encourage consumption of hard cheese, cottage cheese, and yogurt, which contain the inactive lactase enzvme. 7. Encourage consumption of small amounts of dairy foods daily to help colonic bacteria adapt to ingested lactose. 8. Instruct the parents about the foods that contain lactose, including hidden sources.

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    vitamin D deficiency, instruct the parents about the importance of providing these supplements. VIII. Celiac Disease A. Description 1. Celiac disease is also known as gluten enteropathy or celiac sprue. A 2. Intolerance to gluten, the protein component of wheat, barlev, rve, and oats, is characteristic. 3. Celiac disease results in the accumulation of the amino acid glutamine, which is toxic to intestinal mucosal cells. 4. Intestinal villous atrophy occurs, which affects absorption of ingested nutrients. 5. Symptoms of the disorder occur most often between the ages of 1 and 5 years. 6. There is usually an interval of 3 to 6 months between the introduction of gluten in the diet and the onset of symptoms. 7. Strict dietarv avoidance of gluten minimizes the risk of developing malignant Ivmphoma of the small intestine and other gastrointestinal malignancies. B. Assessment 1. Acute or insidious diarrhea 2. Steatorrhea 3. Anorexia 4. Abdominal pain and distention 5. Muscle wasting, particularly in the buttocks and extremities 6. Vomiting 7. Anemia 8. Irritability C. Celiac crisis 1. Precipitated by fasting, infection, or ingestion of gluten 2. Causes profuse watery diarrhea and vomiting 3. Can lead to rapid dehydration, electrolyte imbalance, and severe acidosis D. Interventions A 1. Maintain a gluten-free diet, substituting com, rice, and millet as grain sources. A 2. Instruct the parents and child about lifelong elimination 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 diet and about reading food labels carefully for hidden sources of gluten (Box 33-1). 5. Instruct the parents in measures to prevent celiac crisis. 6. Inform the parents about the Celiac Sprue Association. IX. Appendicitis A. Description 1. Inflammation of the appendix 2. When the appendix becomes inflamed or infected, perforation may occur within a matter of hours, leading to peritonitis, sepsis, septic shock, and potentially death. 3. Treatment is surgical removal of the appendix before perforation occurs. B. Assessment 1. Pain in periumbilical area that descends to the right lower quadrant A 2. Abdominal pain that is most intense at McBurnev's point 3. Referred pain indicating the presence of peritoneal irritation 4. Rebound tenderness and abdominal rigidity 5. Elevated white blood cell count 6. Side-lving position with abdominal guarding (legs flexed) to relieve pain 7. Difficulty walking and pain in the right hip 8. Low-grade fever 9. Anorexia, nausea, and vomiting after pain develops 10. Diarrhea A C. Peritonitis 1. Description: Results from a perforated appendix 2. Assessment a. Increased fever b. Progressive abdominal distention c. Tachycardia and tachypnea d. Pallor e. Chills f. Restlessness and irritability

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    tfie sudcfen refief of pain and then a subsequent jncrease Jnpafn accompanred by rjgjtt guarding of the abdomen. D. Appendectomy 1. Description: Surgical removal of the appendix 2. Interventions preoperativelv a. Maintain NFO status. b. Administer IV fluids and electrolytes as prescribed to prevent dehydration and correct electrolyte imbalances. c. Monitor for changes in the level of pain. d. Monitor for signs of a ruptured appendix and peritonitis. e. Avoid the use of pain medications so as not to mask pain changes associated with perforation. f. Administer antibiotics as prescribed. g. Monitor bowel sounds. A h. r . y Position in a right side-lying or low to semi-Fowler's position to promote comfort. i. Apply ice packs to the abdomen for 20 to 30 minutes every hour if prescribed. j. Avoid the application of heat to the abdomen. k. Avoid laxatives or enemas. 3. Postoperative interventions a. Monitor vital signs, particularly temperature. b. Maintain NFO status until bowel function has returned, advancing the diet gradually as tolerated and as prescribed when bowel sounds return. c. Assess the incision for signs of infection such as redness, swelling, drainage, and pain. d. Monitor drainage from the drain, which may be inserted if perforation occurred. e. Position the child in a right side- lying or low to semi-Fowler’s position with the legs slightly flexed to facilitate drainage.

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