Chapter 20 Nursing care - Alteration in bowel elimination/GI disorder
Anatomy and Physiology of the Gastrointestinal System in Children
● The primary functions of the GI system are
○ the digestion and absorption of nutrients and water,
○ elimination of waste products,
○ secretion of various substances required for digestion.
● Babies are born with immature GI tracts that are not fully mature until age 2.
● Mouth
○ common entry point for infectious invaders.
○ Young children tend to bring objects to the mouth thus increasing the incidence of infection via
the mouth.
● Esophagus
○ The lower esophageal sphincter muscles are not fully developed until the age of 1 month,
○ regurgitation of stomach contents happens.
○ Dysphagia can occur with frequent regurgitation due to edema or narrowing of the esophagus.
● Stomach
○ Stomach capacity of a newborn is only 10-20 ml,
○ at 2 months the stomach can hold up to 200ml.
○ By the age of 16 the stomach capacity increases to 1,500ml,
○ in adulthood it increases to 2,000-3,000 ml.
○ Hydrochloric acid reaches the adult level by the age of 6 months.
● Intestines
○ AT birth the small intestine is not functionally mature as a result they have problems with
absorption and diarrhea.
● Biliary System
○ The liver is large at birth and the pancreatic enzymes continue to develop reaching adult level
at age 2 years of age.
● Fluid Balance and Losses
○ greater amount of body water than do adults.
○ require a larger relative fluid intake than adults and excrete a relatively greater amount of fluid.
○ at increased risk for fluid loss with illness compared to adults.
○ Until age 2 years, the extracellular fluid, makes up about half of the child’s total body water.
● Insensible Fluid Loss
○ Fever increases fluid loss at a rate of about 7 mL/kg/24-hour period for every sustained 1°C
rise in temperature.
○ fevers are higher than those of adults,
○ more apt than adults to experience insensible fluid loss with fever when ill.
○ Fluid loss via the skin accounts for about two thirds of insensible fluid loss.
● Infants have a relatively larger body surface area (BSA) relative to their body mass as compared to
older children and adults.
● The basal metabolic rate in infants and children is higher than that of adults to support growth.
Risk factors for GI disorder
● Prematurity
● Family history
● Genetic syndromes
● Chronic illness
● Prenatal factors
● Exposure to infectious agents
● Foreign travel
● Immune deficiency, chronic steroid use
, Common labs and diagnostics
Stool Collection Techniques
● Diapers
○ Use a tongue blade to scrape a specimen into the collection container.
● Runny stool
○ A piece of plastic wrap in the diaper may catch the specimen
○ Very liquid stool may require application of a urine bag to the anal area
● Older ambulatory child
○ First urinate in the toilet
○ Then retrieve specimen from a clean collection container fitting under the seat at the back of
the toilet
● Bedridden child
○ Collect the specimen from a clean bedpan
○ Do not allow urine to contaminate the stool specimen
Common medical treatments
Drug guide
Structural anomalies of the GI tract
Cleft lip and palate
● Most common congenital craniofacial anomaly
● Causes
○ hereditary and environemntal factors
● Risk factors
○ Maternal smoking
○ Prenatal infection
, ○ Advanced maternal age
○ Use of anticonvulsants, steroids, and other medications during early pregnancy
● Assessment
○ Gagging, choking, and nasal regurgitation of milk may occur in babies with cleft palate.
○ may have difficulty forming an adequate seal around a nipple, excessive air intake
○ Primary or permanent teeth may be missing, malformed or unusually positioned
● Anomalies
○ Heart defects
○ Ear malformations
○ Skeletal deformities
○ Genitourinary abnormality
● Management
○ Cleft lip → Surgery around the age of 2 to 3 months
○ Cleft palate → surgery at 6 to 9 months.
○ Post-op
■ Lip repeair → Avoid positioning the infant on the side of the repair or in the prone
position
■ Palate repair → avoid the use of oral suction or placing objects in the mouth such as
tongue depressors, thermometer, straws, spoons, froks, pacifiers
■ prevent injury to the facial suture line or to the palatal operative sites
■ Do not allow the infant to rub the facial suture line
● infant in a supine or side-lying position
■ may be necessary to use arm restraints to stop the hands from touching the face or
entering the mouth
■ Clean the suture line as ordered
■ Avoid putting items in the mouth that might disrupt the suture
○ Adequate nutrition
■ Some infants will be fed with a special cleft lip nipple.
■ a prosthodontic device may be created to form a false palate covering
● may prevent breast milk or formula from being aspirated.
■ burp the infant well
○ Encourage infant-parent bonding
○ Emotional support
● Interventions
○ assess ability to suck, swallow, handle nassal secritions and breath dithout distress
○ Hold the infant in upright position and direct the formula to the side and back of the mouth to
prevent aspiration
○ keeo suction equipment and bulb syrange at bedside
● Complications
○ feeding difficulties,
○ altered dentition,
○ delayed or altered speech development,
○ otitis media.
Esophageal atresia and tracheoesophageal fistula
● GI anomalies in which the esophagus and trachea do not separate normally during embryionic
development
● Esophageal atresia → congenitally interrupted esophagus where proximal and distal ends do not
communicate
● Tracheoesphageal fistula → abnormal communication between the trachea and esophagus
, ● Both are thought to be a result of incomplete separation of the lung bed from the foregut during early
fetal development
● Assessment
○ Maternal history of polyhydramnios → first sign of esophageal atresia
○ Copious, frothy bubbles of mucus in the mouth and nose, accompanied by drooling
○ abdominal distention
○ rattling respirations
○ excessive salivation and drooling
○ coughing, choking, and cyanosis “the 3 Cs”
○ regurgitation and vomiting
● Diagnostics
○ Radiograph
● Management
○ Surgery
○ Preop
■ NPO
■ HOB 30-45º
■ monitory hydration and fluid and electrolyte balance
■ Assess amd maintain the patency of the orogastric tube
■ Oxygen and suction equipment readly available
■ Comfort measures
○ Postop
■ identity any complications
■ TPN
■ antibiotics
■ oral feedings within a week
■ assess child during feeding and report difficulty swallowing
■ Instruct the parents to identify behaviors that indicate need for suctioning
● Complications
○ pnaumonitis
○ atelectasis
Omphalocele and Gastroschisis
● Congenital anomalies of the anterior abdominal wall.
● Omphalocele → is a defect of the umbilical ring that allows evisceration of the abdominal contents
into an external peritoneal sac.
● Gastroschisis → is a herniation of the abdominal contents through an abdominal wall defect,
usually to the left or right of the umbilicus.
● Gastroschisis differs from omphalocele in that there is no peritoneal sac protecting the herniated
organs, and thus exposure to amniotic fluid makes them thickened, edematous, and inflamed.
● Assessment
○ Note the appearance of the protrusion on the abdomen and evidence of a sac.
○ Inspect the sac closely for the presence of organs, most commonly the intestines but
sometimes the liver.
○ Also inspect the contents for any twisting of the intestines.
○ Note the color of the organs within the sac and measure the size of the omphalocele.
