Gasrointestinal Disorders In Infants and Children

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Gasrointestinal Disorders In Infants and Children

• Lori Fox, RN, MSN, APRN, BC
• References Society of Pediatric Nursing
  Pediatric Nursing Review
• Saunders Comprehensive Review for the NCLEX Exam
  2002
• Dorlands's Illustrated Medical Dictonary Twenty
  Sixth Edition 1981

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General

• Energy Requirements
• Depend/Based on energy expenditures from
• 1. Basal Metabolism
• 2. Body Activity
• 3. Growth
• 4. Dynamic action of food
• 5. Fecal loss

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General

• Distribution of Calories
• Important so foods chosen contain all essential
  elements
• Normal Full -Term Infant
• Protein 6-8
• Fat 30-55
• Carbohydrate approximately 50-60

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General

• Water Requirements vary with energy produced or
  calories metabolized.
• Requirements affected by fluid intake, protein
  and mineral content of diet, renal solute load,
  metabolic rate, respiratory rate and body
  temperature.

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General

• Deficiencies or excess amounts of any of these
  requirements can lead to skin issues, metabolic
  issues, renal issues etc.

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General Assessment

• Assessment should include
• Diet history
• Frequency
• Allergies
• Elimination patterns

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Disorders in Newborns/Young Infants

• Imperforate Anus "Incomplete development or
  absence of its normal position in the
  perineum"-Saunders, Third Edition-2002
• Assessment findings
• Failure to pass meconium/stool
• Absence or stenosis of the anal rectal canal
• Presence of an anal membrane
• External fistula to the perineum or genitourinary
  system

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Disorders in Newborns/Young Infants

• Necrotizing Enterocolitis "NEC"
• Common in neonatal period
• Increased risk with preemies
• Causative agent conditions which cause vascular
  compromise to the intestine
• Sx/Sx lethargy, apnea, bradycardia,
  hypotension, temperature instability

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Disorders in Newborns/Young Infants

• Pyloric Stenosis A narrowing of the pyloric
  canal as it exits the stomach
• Projectile VomitingHigh index of suspicion.
  (hallmark)
• Olive sized bulge below the right costal margin
  (hallmark)
• Tx pyloromyotomyincision through muscle fibers
  of the pylorus

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Disorders in Newborns/Young Infants

• Pyloric Stenosis Pyloroplasty

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Disorders in Newborns/Young Infants

• Biliary Atresia "obliteration or absence of
  extrahepatic biliary structures"
• Cause Unknown
• Sx/Sx Early jaundice dark urine pale stools
  (absence of bile) absorption issues?growth
  issues
• DX Liver biopsy

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Disorders in Newborns/Young Infants

• Esophageal Atresia (EA) and Tracheoesophageal
  Fistula (TEF)
• Atresiaabsence or closure of a orifice or
  tubular organ
• Fistula "tube like connection between two
  structures" Designated by the organs or parts
  which with it communicates (e.g. rectovaginal)

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Disorders in Newborns/Young Infants

• Sx/Sx Choking/Coughing during feeds can have
  intermittent cyanosis
• EA TEF

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Disorders in Newborns/Young Infants

• Cleft Lip and Palate
• Congenital Defect -soft tissue or bony
  structure fails to fuse during embryonic
  development.
• Can be unilateral or bilateral
• Apparent at birth
• Causes genetic hereditary environmental
• Closure of lip defect occurs before palate-first
  few weeks of life with palate around 12-18 mo.

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Disorders in Newborns/Young Infants

• Gastroesophageal Reflux (GER)
• Underdeveloped esophageal sphincter
• Some amount of GER is normal in newborns
• Often causes apnea

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Disorders in Newborns/Young Infants

• Hirschsprung's Disease (congenital aganglionosis
  megacolon)
• Absence of ganglion cells in the retum and colon
• Mechanical obstruction from inadequate motility
• DX Rectal biopsy
• Serious Complication Enterocolitis
• Tx mild disease relief of chronic constipation
• most children require surgery
• neonates often require temporary colostomy

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Disorders in Young Infants

• Intussusception Prolapsing of one portion of the
  intesine into the lumen of the immediately
  adjoining part
• Occurs at about 6 months of age
• Causes bowel lining abnormality polyps
  hyperactive peristalsis unknown
• Inflammation? swelling ?obstruction ?necrosis
  from occlusion of bowel blood supply

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Disorders in Children

• Inflammatory Bowel Disease
• 1. Crohn's diseaseregional enteritis-
• asymmetrical and patchy lesions.
• Affects all layers of bowel wall
  enlarged
• regional lymph nodes occurs at any
  point
• along the GI tract.
• 2. Ulcerative colitissymmetrical and
• contiguous GI ulcers
• Affects bowel mucosa large intestine

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Disorders in Children

• Causes unknown- exacerbated by emotional
  factors
• Common to occur in Adolescents
• DX made by barium enema biopsy of GI mucosa
  stool studies

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Disorders in Children

• Appendicitis Inflammation and obstruction of
  blind sac at end of cecum
• Results in ischemia gangrene perforation and
  peritonitis
• Causes include infections, dietary intake,
  constipation and parasites
• Common in school age children

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Disorders in Newborns/Young Infants

• Celiac Disease Absence of intestinal mucosal
  cell enzyme ?villi of small intestine atrophy ?
  decreases absorption
• Gluten intolerance-FATTY STOOLS (Steatorrhea) and
  chronic diarrhea
• IgA deficiency and early introduction of protein
  solids related.
• Occurs around 2-4 months after solid foods
  introduced

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Disorders in Children

• Parasitic Worms Aquired through skin ingestion
  of dirt or raw vegetables not well washed
• Pinworms are the most common
• Live in cecum and crawl to anus at night to lay
  eggs
• Tape test
• Anal itching abdominal distention

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Disorders in Children

• Viral Hepatitis
• 1. A Fecal -oral route
• 2. B Blood and body secretions
• 3. C predominantly parentally spread
• SX/SX anorexia malaise, fatigues easily, fever
  jaundice and dark urine pale stools
• DX antigenic markers and body immune response
• HBIG for Hep B

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Disorders in Children

• Acetaminophen Poisoning
• Hepatotoxicity is concern plasma levels greater
  than 200 µm/ml.
• Monitor for liver damage 24-36 hours after
  overdose
• Mucomyst is an antidote (acetylcysteine)

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Disorders in Children

• Vomiting and Diarrhea
• Issues frequency, consistency volume support
  electrolytes and hydration
• Constipation Frequency, consistency of stools
  (variation from normal for that child- not
  necessarily no daily stool)

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Endocrine Disorders in Children

• Inborn Errors of Metabolism
• Tested for at birth after first 24 hours of
  feedings Early diagnosis leads to better outcome
• PKU- defect in hydroxylation of phenylalanine to
  form tryosine ?build up of phenylalanine ? brain
  damage/mental retardation.
• Musty odor to urine

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Endocrine Disorders in Children

• Inborn Errors of Metabolism Con't
• Galactosemia deficiency in galactose enzyme
  ?liver failure renal tubular problems and
  cataracts
• Maple Syrup Urine Disease (MUD)
• Deficiency of decarboxylase that degrades amino
  acids ?altered tone seizures
• Urine has odor of maple syrup

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Endocrine Disorders in Children

• Diabetes Type I and Type II
• Review Endocrine section in review book-good
  overview.

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Endocrine Disorders in Children

• Hypothyroid Disease
• Thyroid regulates basal metabolic rate
• CX decreased secretion from
• a. Thyroid gland development issues
• b. Medications that suppress hormone
• production
• c. Thyroid relies on early dietary
  iodine
• and tyrosine for normal function

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Endocrine Disorders in Children

• Hypothyroid Disease Continued
• SX/SX Easy wt gain
• Fatigue/tiredness
• Dry, scaly skin
• Slow pulse
• Cool body temp
• Constipation

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Endocrine Disorders in Children

• Cushing Syndrome Hyperadrenocorticism
• Hyper functioning of the adrenal gland. High
  levels cortisol ? decreased ACTH secretion
• Cause Tumor in pituitary gland/prolonged or
  excessive use of corticosteroids
• Sx/Sx MOON FACE muscle weakness easy
  bruising facial hair growth (hirsutism
  excessive hair growth) decreased linear growth
  HTN mood disorders poor wound healing
• TX Taper steroids if possible remove tumor-
  Takes weeks/months for hormones to clear body

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Endocrine Disorders in Children

• Deficient Anterior Pituitary Hormone Pituitary
  Dwarfism
• Results in decreased growth hormone
• Cause idiopathic brain tumor trauma lesions
• Normal body proportions, but short stature
• Bone age studies reveal growth retardation
• Tx Administer growth hormone
• Emotional Support

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Endocrine Disorders in Children

• Hypersecretion of anterior pituitary hormone
  Gigantism or acromegaly
• Causes hyperplasia of pituitary cells or
  pituitary tumor
• Bone age studies are normal. Signs of gigantism
  occur if increased release of hormone happens
  before growth plates close
• Elongation and enlargement of long bones, facial
  bones and accompanying body tissue

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Endocrine Disorders in Children

• Hypersecretion of anterior pituitary hormone
  Gigantism or acromegaly Continued
• Late closure of fontanels
• Acromegaly if release of hormone occurs after
  growth plates close enlarged hands feet nose
  tongue jaw
• Thickening of skin and facial features
• TX Radiation may be used to retard growth
• Emotional support

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TEST QUESTIONS

• 1. A 3 year old is hospitalized because of
  persistent vomiting. A nurse monitors the child
  closely for
• a. Diarrhea
• b. Metabolic Acidosis
• c. Metabolic Alkalosis
• d. Hyperactive bowel sounds

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TEST QUESTIONS

• 2. A nurse is monitoring for signs of
  dehydration in a 1 year old child who has been
  hospitalized for diarrhea. The nurse prepares to
  take the child's temperature and avoids which
  method of measurement?
• A. Tympanic
• B. Axillary
• C. Rectal
• D. Electronic

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TEST QUESTIONS

• 3. A home care nurse provides instructions to
  the mother of an infant with cleft palate
  regarding feeding. Which statement if made by
  the mother indicates a need for further
  instructions?
• A. "I will use a nipple with a small hole to
  prevent choking"
• B. "I will stimulate sucking by rubbing the
  nipple on the lower lip"
• C. "I will allow the infant time to swallow"
• D. " I will allow the infant to rest frequently
  to provide time for swallowing what has been
  placed in the mouth"

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TEST QUESTIONS

• 4. An infant has just returned to the nursing
  unit following a surgical repair of a cleft lip
  located on the right side of the lip. The nurse
  places the infant in which most appropriate
  position?
• A. On the right side
• B. On the left side
• C. Prone
• D. Supine

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TEST QUESTIONS

• 5. A clinic nurse reviews the recoord of an
  infant seen in the clinic. The nurse notes that
  a diagnosis of esophageal atresia with
  trachesophageal fistula is suspected. The nurse
  expects to note which most likely sign of this
  condition documented in the record?
• A. Severe projectile vomiting
• B. Coughing at nightime
• C. Choking with feedings
• D. Incessant crying

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TEST QUESTIONS

• 6. A nurse prepares a teaching plan for the
  parents of an infant with gastroesophageal reflux
  regarding proper positioning to manage reflux.
  The nurse documents that the infant should be
  maintained in which position following feedings
  and at night?
• A. 30-degree angle when supine
• B. 60-degree angle when supine
• C. Head-Elevated prone position
• D. 20-degree angle when supine

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TEST QUESTIONS

• 7. A nurse provides feeding instructions to a
  mother of an infant diagnosed with
  gastroesophageal reflux.To assist in reducing the
  episodes of emesis, the nurse tells the mother to
  
• A. Thin the feedings by adding water to the
  formula
• B. Thicken the feedings by adding rice cereal to
  the formula
• C. Provide less frequent, larger feedings
• D. Burp the infant less frequently during
  feedings

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TEST QUESTIONS

• 8. A nurse admits a child to the hospital with a
  diagnosis of pyloric stenosis. ON admission
  assessment, which data would the nurse expect to
  obtain when asking the mother about the child's
  symptoms?
• A. Vomiting large amounts of bile
• B. Watery Diarrhea
• C. Increased urine output
• D. Projectile vomiting

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TEST QUESTIONS

• 9. A nurse provides home care instructions to
  the parents of a child with celiac disease. The
  nurse teaches the parents to include which of the
  following food items in the child's diet?
• A. Rice
• B. Rye toast
• C. Oatmeal
• D. Wheat Bread

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TEST QUESTIONS

• 10. A clinic nurse reviews the record of a 3
  week old infant and notes that the physician has
  documented a diagnosis of suspected Hirshsprung's
  disease. The nurse reviews the assessment
  findings documented in the record, knowing that
  which symptom most likely led the mother to seek
  health care for the infant?
• A. Diarrhea
• B. Projectile vomiting
• C. Regurgitation of feedings
• D. Foul-smelling ribbon like stools

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TEST QUESTIONS

• 11. A nurse is caring for a newborn infant with
  a suspected diagnosis of imperforate anus. The
  nurse monitors the infant, knowing that which of
  the following is a clinical manifestation
  associated with this disorder?
• A. Sausage-shaped mass palpated in the upper
  right abdominal quadrant
• B. Bile stained fecal emesis
• C. Failure to pass meconium stool in the first
  24 hours after birth
• D. The passage of currant jelly -like stools

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TEST QUESTIONS

• 12. The nurse is preparing to care for a child
  with a diagnosis of intussusception. The nurse
  reviews the child's record and expects to note
  which symptom of this disorder documented?
• A. Bright red blood and mucus in the stools
• B. Profuse projectile vomiting
• C. Watery Diarrhea
• D. Ribbon like stools

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TEST QUESTIONS

• 13. A pediatric nurse educator provides a
  teaching session to the nursing staff regarding
  phenylketonuria. The nurse educator tells the
  nursing staff that
• A. Phenylketonuria is an autosomal dominant
  disorder
• B. Treatment includes dietary restriction of
  tyramine.
• C. All 50 states require routine screening of all
  newborn infants for phenylketonuria.
• D. Phenylketonuria primarily affects the
  gastrointestinal system.

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TEST QUESTIONS

• 14. A school-aged child with type 1 diabetes
  mellitus has soccer practice three afternoons a
  week. The school nurse provides instructions
  regarding how to prevent hypoglycemia during
  practice. The school nurse tells the child to
• A. Take one half of the amount of prescribed
  insulin on practice days
• B. Eat twice the amount normally eaten at
  lunchtime.
• C. Take the prescribed insulin at noontime
  rather than in the morning.
• D. Eat 6 graham crackers or drink a cup of orange
  juice before soccer practice.

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TEST QUESTIONS

• 15. A home care nurse is teaching an adolescent
  with type 1 diabetes mellitus about insulin
  administration and rotation sites. Which
  statement if made by the adolescent, would
  indicate effective teaching?
• A. "I need to use a location in one major site
  for the morning injection and another location
  for the same major site for the evening injection
  for 2 to 3 weeks before changing major sites"
• B. "I need to use a different site for each
  insulin injection"
• C. " I need to use the same site for 1 month
  before rotating to another site"
• D. " I should use only my stomach and my thighs
  for injections"

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TEST QUESTIONS

• 16. The mother of a 6-year old who has type 1
  diabetes mellitus calls a clinic nurse and tells
  the nurse that the child has been sick. The
  mother reports that she checked the child's urine
  and it was positive for ketones. The nurse
  instructs the mother to
• A. Come to the clinic immediately
• B. Hold the next dose of insulin
• C. Administer an additional dose of regular
  insulin
• D. Encourage the child to drink calorie-free
  liquids.

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TEST QUESTIONS

• 17. A child with type 1 diabetes mellitus is
  brought to an emergency room by the mother, who
  states that the child has been complaining of
  abdominal pain and has a fruity odor of the
  breath. Diabetic ketoacidosis is diagnosed.
  Anticipating the plan of care, the nurse prepares
  to administer
• A. 5 dextrose IV infusion
• B. Normal Saline IV infusion
• C. NPH insulin IV infusion
• D. Potassium IV infusion

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TEST QUESTIONS

• 18. A two month old infant arrives at the
  pediatric clinic. Upon assessment, the baby
  exhibits the following characteristics. Which
  characteristic does the nurse relate to a
  diagnosis of congenital hypothyroidism? Select
  all that apply
• A. Open fontanels
• B. Protruding tongue
• C. Tachycardia
• D. Hypertonia
• E. Hypotonia
• Source Child Health Nursing Second Edition
  Reviews and Rationales 2007

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TEST QUESTIONS

• 19. An infant with congenital hypothyroidism
  shows which sing or symptom?
• A. Shrill Cry
• B. Diaphoresis
• C. Hypothermia
• D. Diarrhea
• Reference questions 19- Straight A's In
  Pediatric Nursing-A review series Lippincott
  Williams and Wilkins, 2004

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TEST QUESTIONS

• 20. The nurse administers oral thyroid hormone to
  an infant with hypothyroidism. The nurse should
  observe the infant for which signs of overdose?
• A. Tachycardia, fever, irritability, and
  sweating
• B. Bradycardia, cool skin temperature and dry
  scaly skin
• C. Bradycardia, fever, hypotension, and
  irritability
• D. Tachycardia, cool skin temperature and
  irritability

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TEST QUESTIONS

• 21. The nurse draws blood from the heel of an
  infant for a Guthrie screening test. The Guthrie
  screening test is used to diagnose which inborn
  error of metabolism?
• A. Gludcose-6-phosphate dehydrogenase
  deficiency
• B. Phenylketonuria
• C. Galactosemia
• D. Hypothyroidism

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TEST QUESTIONS

• 22. The nurse is teaching the mother of a child
  with diabetes how to recognize the sings an
  symptoms of hypoglycemia. Which signs and
  symptoms should the nurse discuss?
• A. Behavioral changes, increased heart rate,
  sweating and tremors
• B. Nausea, fruity breath odor, headache and
  fatigue
• C. Polydipsia, polyuria, polyphagia, and weight
  loss
• D. Enlarged tongue, hypotonia, easy weight gain
  and cool skin temperature.

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TEST QUESTIONS

• 23. The nurse is assessing a child who might
  have diabetes. Which laboratory values help
  confirm a diagnosis of diabetes?
• A. A fasting plasma glucose level of 110mg/dl
• B. A fasting plasma glucose level of 126 mg/dl
• C. A random plasma glucose level of 180mg/dl
• A 2-hour glucose tolerance test of 140 mg/dl

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TEST QUESTIONS

• 24. the nurse is teaching the parents of child
  with diabetes. Which agent should the nurse teach
  the parents to administer if their child suffers
  a severe hypoglycemic reaction?
• A. IV Dextrose
• B. Subcutaneous insulin
• C. Subcutaneous glucagon
• D. Oral fast-acting carbohydrate

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TEST QUESTIONS

• 25. Which foods may be eaten by a child with
  galactosemia? Select all that apply.
• A. Instant Potatoes
• B. Chicken
• C. Lima Beans
• D. Whole Wheat Bread
• E. Apples
• F. 2 Cow's milk