Pedi: Gi Lecture

Front 1

Nurse tells parents about post-op feeding following pyloromyotomy. Parents understand when state they will:
1. Avoid bubbling baby after feeding to prevent vomiting.
2. Rock baby to sleep after feeding to keep baby calm
3. Slowly increase the volume offered accoridnt to the MD orders
4. Maintain the baby on antiemetics to prevent vomiting

Back 1

3. Slowly increase the volume offered accoridnt to the MD orders

Front 2

GERD compared to GER

Back 2

GERD is more serious and consists of:
1. poor wt. gain --> failure to thrive
2. Esophagitis
3. Respiratory sx (secondary to aspiration)
4. Consequences: Damage to esophageal mucosa & Pneumonia or asthma r/t aspiration

Front 3

Parents want to know why child who just had cleft palate sx needs restraints. Nurse says:
1. This device is frequently used post-op to pretect the IV site in small children
2. The restraints will help us maintain proper body alignment
3. Elbow restraints are used post-op to keep kid's hands away from sx site
4. Restraints help maintain the child's NPO status

Back 3

3. Elbow restraints are used post-op to keep kid's hands away from sx site

Front 4

When do most reflux issues occur?

Back 4

After eating when stomach is dilated.

Front 5

Name symptoms of GER

Back 5

1. Vary from occasional emesis to frequent vomiting & failure to thrive
2. Frequent hungry & irritable
3. Frequent upper respiratory tract infections. Or: stridor (inspiratory); Wheezing (expiratory), recurrent cough

Front 6

How is GER diagnosed?

Back 6

1. History (?)
2. Upper GI (barium swallow or contrast medium)
3. pH probe is BEST --> Let baby eat and if pH is down (acid) = GER; Eat and no change = not GER

Front 7

Which s/s does nurse recognize as indication of moderate dehydration in prechooler?
1. sunken fontanel
2. Diaphoresis
3. Dry mucous membranes
4. Decreased urine specific gravity

Back 7

3. Dry mucous membranes

Front 8

What meds treat GER and how do they work?

Back 8

1. Antacids --> Neutralize refluxed material and decrease resultant discomfort, but not often used in infants and children due to aluminum content
2. H2 (histamine) blockers --> Pepcid, Rantac --> Decrease gastric acid production
3. Proton pump inhibitor --> Prilosec --> Inhibit gastric acid secretion to reveal symptoms and heal irritated tissue
4. Reglan (only in book, not notes) --> Increase esophageal motility and tone

Front 9

Nursing assessment of infant suspected of having necrotizing enterocolitis would be:
1. pH of the stomach contents
2. Neurological status q 2 hr
3. Rectal temp q 2 hr
4. Abdominal girth q 4 hr

Back 9

4. Abdominal girth q 4 hr

Front 10

S/S of pyloric stenosis

Back 10

* Occur between 2-8 wks after birth (peak is 3-5 wks)
* Symptoms manifest as hypertrophy (organ enlargement) worsen
* projectile vomit
* Hungry
* Fails to gain wt
* Decreased # stools
* Eventually, dehydration and electrolyte imbalances

Front 11

What type of acid-base imbalance would an infant with pyloric stenosis be at risk for?

Back 11

MIX!!

* Metabolic alkalosis from vomiting

* Metabolic acidosis from lack of fluid --> producing lactic acid

Front 12

You are caring for 4 m.o. infant with GERD admitted for cough, cyanosis and upper resp infection. Which statement by the dad would indicate need for further teaching?

A. I should feed baby 6 oz q 2 hrs
B. I need to burp baby q 2 oz that he eats
C. I will give baby Zantac to decrease stomach acidity
D. Baby will likely outgrow this disease by 1 y.o.

Back 12

A!!

At 4 months old, the baby's stomach can hold 150-200 mL, which is about 5-6 oz. Don't want to totally fill up.

Front 13

Would the chloride levels in an infant with pyloric stenosis be low or high?

Back 13

LOW cos HCl in vomit. (Cl = chloride)

Front 14

What is sx called to treat pyloric stenosis? Describe it. What are pre-op & post-op nursing duties?

Back 14

PRE-OP:
* IV, give fluids
* correct electrolyte imbalances
* keep NPO

SX = pyloromyotomy
* ligating pyloric sphincter
* usually fast & laparoscopically
* performed as soon as rehdration and electrolyte balance is restored

POST-OP
* Pain control
* feeding protocols vary by MD: start small and increase; may start pedialyte
* sponge baths

Front 15

Mom asks: Why does vomit of child with pyloric stenosis look different than other children's vomit? Nurse explains b/c no bile in vomit b/c:
1. The GI system is still immature in newborns and infants
2. Obstruction is above the bile duct
3. Emesis is from passive regurgitation
4. Bile duct is obstructed

Back 15

2. Obstruction is above the bile duct

Front 16

Nursing management for cleft lip, palate

Back 16

* Most infants able to breast feed or bottle feed with modifications
* Fed upright with frequent burping
* Watch for attachment problems with parents
** Assess for weight gain --> will take them longer to eat**

Front 17

Infant returns from initial surgery for Hirschsprung's disease. Which routine post-op intervention will nurse NOT do:
1. Maintain child NPO until bowel sounds return
2. Monitor rectal temp q 4 hrs
3. Reunite parents asap
4. Assess sx site q 2 hrs

Back 17

2. Monitor rectal temp q 4 hrs

Front 18

Complications of cleft palate

Back 18

* speech development
* high risk for ear infection b/c Eustachian tubes don't ventilate well (pressure not normal)
* dental and orthodontic problems (if palate pulled together, might be crowded)

Front 19

What symptoms apply to dx of moderate dehydration in a 4 month old?
1. Elevated HR
2. Urine specific gravity of 1.038
3. Wt gain
4. Polyuria
5. Slow cap refill

Back 19

1. Elevated HR
2. Urine specific gravity of 1.038
5. Slow cap refill

Norm USG= 1.005 - 1.035

Front 20

Recurrence rates of intussusception

Back 20

Air enema treatment = 15%

Surgery treatment = 7.5%

Front 21

6 week old with hx of frequent vomiting after feedings and failure to gain wt. DX of gastroesophageal reflux is made. While planning discharge teaching to parents, nurse should include instructions to:
1. Dilute the formula
2. Delay burping to prevent vomiting
3. Change from milk-based formula to soy-based formula
4. Position the infant at a 30- o 45-degree angle after feedings

Back 21

4. Position the infant at a 30- o 45-degree angle after feedings

Front 22

How do you know when intussusception treatment has been successful?

Back 22

Passage of normal brown stool (vs. the hallmark "currant jelly stool" of intussusception)

Front 23

How is Hirschsprung's disease diagnosed?

Back 23

X-ray with contrast
-- or --
rectal biopsy to look for ganglion cells (most reliable)

Front 24

Treatment of Hirschsprung's disease

Back 24

* Sx removal of the affected bowel soon after diagnosis -- reattach the healthy areas
* Colostomy vs. end-to-end anastomosis
* Most have return of bowel function and can become continent

Front 25

Nursing management of Hirschsprung's patient before and after surgery

Back 25

PRE-OP:
* Normal saline enemas
* NPO

POST-OP:
*Typically stay for one night unless colostomy is done (then might stay for 2 to allow for teaching)
* Pain control
*** Monitor abdominal circumference ***
* If colostomy present, what color should it be? Beefy red

Front 26

True or False:
Pain relief from appendicitis is a good sign.

Back 26

False. Likely perforation.

Front 27

If perforation occurs, what are the complications?

Back 27

* Infections
* Adhesions -- scar tissue in peritoneum
* Abscesses

Front 28

Describe appendicitis pain

Back 28

* Most intense at McBurney's point: halfway between the anterior superior iliac crest & umbilicus

* Rebound tenderness -- press in at McBurney's OK, but when let go it hurts

Front 29

14 y.o. boy brought to ED with dx of rule out appendicitis. Complaining of RLQ pain. Nurse's most appropriate action to assist in managing his pain would be:
1. insert a rectal tube
2. Apply an ice bag
3. Apply a heating pad
4. Administer an intravenous antispasmodic agent

Back 29

2. Apply an ice bag

Front 30

Dx and Tx for appendicitis

Back 30

DX: CT with contrast (best)

TX: Appendectomy (open or laparoscopic)
-- pt on abx for 24 hours and then go to OR (if not perfed)

Front 31

Who is most likely to get appendicitis?

Back 31

* Adolescent males
* Rare before 2 y.o.
* Most common emergency abdominal sx for kids

Front 32

A 3 month old has gastroesophageal reflux but doing well otherwise. What can mom do to decrease reflux?
1. D/C breast feeding asap
2. Increase frequency of feeding and keep them small
3. Place baby in prone position with head flat
4. Place infant in car seat after feeding

Back 32

2. Increase frequency of feeding and keep them small

Front 33

What can happen if Celiac Disease is untreated?
(In order of events)

Back 33

1. Body can't digest gluten
2. Results in buildup of glutamine (metabolite)
3. Glutamine is toxic to mucosal cells of intestine
4. Affects absorption of nutrients b/c cells damaged
5. If untreated, CA can develop (r/t toxic metabolite)

Front 34

S/S of Celiac disease?

Back 34

EARLY SIGNS:
* Steatorrhea (r/t fat malabsorption)
* Abdominal pain
* These will often begin at age 6 months - 2 y.o., when foods with gluten are first fed to kid

LATER SIGNS:
* Failure to thrive
* Malnutrition
* Osteoporosis

Front 35

While gathering data on 16 month old, nurse gathers data. Which is related to dx of hirschsprung's disease?
1. Bile-stained vomit
2. Decreased urine output
3. Poor wt gain since birth
4. Intermittent sharp pain
5. Alternating constipation and diarrhea

Back 35

1. Bile-stained vomit

3. Poor wt gain since birth

5. Alternating constipation and diarrhea

Front 36

DX Celiac disease?

Back 36

*** Duodenal biopsy looking for mucosal damage --> no villi ***
* analysis of fecal fat content

Front 37

TX if Celiac disease -- when does body start returning to "normal"

Back 37

* SX improve within days-weeks
* Intestinal villi return to normal in abut 6 months
* Catch-up growth occurs over the next 1-2 yrs

Front 38

S/S of TEF?

Back 38

* Maternal hx of polyhydramnios b/c baby can't swallow amniotic fluid.
* Increased salivation & drooling b/c no place for saliva to go
* With first feeding, formula comes up thru nose. --> Cyanosis, Choking, Coughing are classic signs

Front 39

After delivery of baby with omphalocele, the nurse would do what?
1. Weigh baby
2. Insert orogastric tube
3. Call the blood band for 2 units of blood
4. Cover the sac with moistened sterile gauze

Back 39

4. Cover the sac with moistened sterile gauze

Front 40

DX of TEF?

Back 40

* Try to pass an NG tube and get X-ray --> then hook up to suction and collect secretions.
* NG tube will be coiled in blind pouch

Front 41

TX of TEF?

Back 41

* IV fluids cos NPO
* abx b/c risk of aspiration
* sx correction immediately (not compatible with life)

Front 42

Post-op care for TEF baby?

Back 42

* Will have an NG tube to suction --> do not manipulate b/c there is a suture line that could be disrupted

* ABX
* IV fluids --> small feedings
* Might have a G-tube

Front 43

What are two abdominal wall defects & what (generally) causes them?

Back 43

1. Gastroschisis
2. Omphalocele

Caused by problem at 11 wks gestation. Before 11 weeks, the intestines are located outside of the abdomen. But at 11 wks, they move inside.

Front 44

Nurse has completed discharge teaching for celiac disease. Teaching successful when mom says child must comply with gluten-free diet:
1. Throughout life
2. Until the child has achieved all major developmental milestones
3. Only until all sx are resolved
4. Until the child has reached adolescence

Back 44

1. Throughout life

Front 45

What is gastroschisis?

Back 45

* Intestines herniated thru abdominal wall (usually to the right)
* Small intestine only (usually)
* NOT usually associated with other congenital issues
* No membrane covers bowel
* Umbilical cord intact
* More common in infants of moms who smoke
* 1 : 10,000 births

Front 46

What is omphalocele?

Back 46

* Intra-abdominal contents herniated thru umbilical opening
* Covered by a translucent sac (peritoneal tissue)
* Sac may also contain bowel, gall bladder, internal genitalia, bladder, spleen and pancreas
* Often associated with other congenital defects
* 1 : 5,000 births

Front 47

DX omphalocele?

Back 47

prenatal US

Front 48

TX omphalocele?

Back 48

* Sac protected after birth by keeping it moist
* Temp regulation (hypothermia likely)
* IV fluid replacement
* SX repair with "silo" (like a ziploc baggie to stay hydrated).
* Repair usually staged 7-10 days to prevent intra-abdominal pressure
* Could take wks for bowel function to return. TPN for nutrition
* NPO

Front 49

Nurse teaches child about celiac disease. Child understands when he chooses which meal?
1. Beef and barley soup, rice cakes & celery
2. Ham and cheese sandwich with lettuce and tomato on rye toast
3. Beef patty on a hamburger bun and home fries
4. Baked chicken, green beans & slice cornbread

Back 49

4. Baked chicken, green beans & slice cornbread

Front 50

Which defect -- gastroschisis or omphalocele -- would have more problems with fluid management?

Back 50

Gastroschisis b/c not covered by peritoneal tissue

Front 51

Child with celiac should not eat: (select all that apply)
1. Rice
2. Wheat
3. Oats
4. Barley
5. Corn

Back 51

2. Wheat
3. Oats
4. Barley

Front 52

What is necrotizing enterocolitis? (NEC)

Back 52

* Inflammatory disease of he intestinal tract where the bowel mucosa die

Front 53

What groups most often get NEC?

Back 53

* premature infants
* 4-13% of preemies, with a 40% mortality

Front 54

Pathology of necrotizing enterocolitis?

Back 54

1. Bacterial infection (immune system is not developed in preemies)
2. Edema and inflammation cause vascular compromise
3. Bowel mucosa (not just lumen) dies
4. Bacteria invade necrotic tissue --> gas causes abdominal distention
5. Bowel may perforate --> SEPSIS

Front 55

10 yr old dx with "rule out appendicitis." Boy states, "It doesn't hurt anymore." Nurse suspects that:
1. Boy is afraid of going to sx
2. Boy is having prob expressing pain
3. Appendix has ruptured
4. Boy trying to get attention

Back 55

3. Appendix has ruptured

Front 56

S/S of NEC

Back 56

* feeding intolerance
* vomiting
* bloody diarrhea (due to breakdown of bowel mucosa)
* abdominal distention

Front 57

DX necrotizing enterocolitis?

Back 57

**** X-ray = gold standard ***

Front 58

Medical prevention & treatment of NEC?

Back 58

PREVENT:
* give breast milk (antibodies)

TREATMENT:
* NPO
* NG tube to decompress bowel
* IV fluids / TPN, lipids
* abx to prevent, treat sepsis
* serial abdominal circumference checks
* serial x-rays to detect perforation (until can get to OR)
* Immediate sx if perforation

Front 59

After necrotizing enterocolitis

Back 59

* short bowel syndrome -- may need bowel transplant (!)

* Cholestasis (disruption of bile flow) --> complication of being on TPN; can be prevented with ursodiol (med that prevent gallstone formation)

Front 60

An 18 month old infant w/ hx of cleft lip and palate admitted for palate sx. Why should toothbrush not be used after sx?
1. Toothbrush frightening to kid
2. Kid no longer has deciduous teeth
3. Suture line could be interrupted
4. Child will be NPO

Back 60

3. Suture line could be interrupted

Front 61

What is Esophageal Atresia and Tracheoesopageal Fistula? (TEF)

Back 61

Esophagus is not a continuous tube.
-- Ends in a blind pouch = EA
-- And is connected to the trachea = TEF