 NURSING PROCESS OVERVIEW

 Assessment
Children with GI disorders need to be assessed urgently for signs of fluid loss, such as poor skin
turgor, dry mucous membranes, or lack of tears. When assessing the child's symptoms:
- Ask for details regarding "spitting up" or "a little vomiting" to be certain you are talking about the
same amount.
- Ask how many times the child has voided or how many diapers have been wet in the past 24
hours and whether this is less than usual.
- Compare the child's current weight with past weight measurements, if available.

 Nursing Diagnosis
Examples of nursing diagnoses include:
- Fluid volume deficiency risk related to chronic diarrhea.
- Malnutrition risks related to malabsorption of essential nutrients.
- Altered parenting related to interference with establishing the parent-infant bond.

 Outcome Identification and Planning

- Ensure that when providing nutritional instructions for a child that you include the person who
prepares or supervises the child's meals.
- Parents need support to follow the necessary dietary guidelines, whether short-term or long-term,
as providing nutrition to a child is integral to parenting.
- If feedings will be provided by nasogastric or gastrostomy tube, parents need sufficient practice to
be proficient with the equipment and the technique before they are given the responsibility of
doing it independently at home.

 Implementation
- Use clear, simple explanations to parents and children regarding performing procedures, and
provide encouragement to parents and children after they correctly demonstrate these
procedures.
- Provide therapeutic play before and after procedures to reduce children's anxiety.

 Evaluation
Some examples of expected outcomes include:
- Child lists examples of gluten-free foods to select for lunch from the school menu.
- Parents identify the indications for seeking medical care if their child has severe diarrhea.
- Family members state they have adjusted to care of the child with liver disease.

 ANATOMY & PHYSIOLOGY

Nursing Care of a Family When a Child Has a Gastrointestinal Disorder | GROUP 5

 DIGESTION PROCESS
- Digestion begins with the mouth, where food is broken down into small particles and mixed with
saliva. Digestion continues in the stomach and small intestine. The esophagus pierces the
diaphragm to serve as a passageway to the stomach. At the junction of the esophagus and the
stomach is the gastroesophageal (cardiac) sphincter. A sphincter is a section of circular muscle.
In newborns, this sphincter is immature and allows fluid to regurgitate into the esophagus
(gastroesophageal reflux). At the distal end of the stomach is the pyloric sphincter. In some
infants, this muscular channel becomes narrowed (stenosed), preventing food from flowing out of
the stomach freely (pyloric stenosis). Originally, it was believed that the stomach was sterile
because the action of hydrochloric acid could easily kill invading organisms and limit infections.
However, since the discovery that a bacterium, Helicobacter pylori, is the cause of peptic ulcer
disease, it is now obvious that organisms can and do survive in the stomach. The small intestine
is divided into three sections: the duodenum, the jejunum, and the ileum. The large intestine is
divided into the cecum, the ascending colon, the transverse colon, the descending colon, the
sigmoid colon, and the rectum. The appendix, which frequently becomes diseased in children, is
attached to the cecum.

 DIAGNOSTIC AND THERAPEUTIC TECHNIQUES

- Endoscopy
- Small intestine wireless enteroscopy (capsule endoscopy)
- Colonoscopy
- Radiology studies

 HEALTH PROMOTION AND RISK MANAGEMENT

- A vaccine to prevent rotavirus, an infectious diarrhea, is recommended for infants.
- Providing anticipatory guidance to parents about normal nutritional variances and how to
distinguish vomiting from illness from normal “spitting up” or how to identify the severity of
diarrhea helps parents seek prompt care for their children.
- Early assessment and prompt interventions for GI symptoms may prevent complications.

 FLUID, ELECTROLYTE, AND ACID-BASE IMBALANCES

- Because the GI system is the expected route (as opposed to IV) by which nutrition and fluids are
taken into the body, it can be a major source of fluid and electrolyte loss if vomiting or diarrhea
occurs. Retaining fluid is of greater importance in the body chemistry of infants than that of an
older child or adolescent because fluid constitutes a greater fraction of the infant’s total weight. In
adolescents, body water accounts for approximately 60% of total weight. In infants, it accounts for
as much as 70% of total weight; in children, it averages approximately 65%.
- Fluid is normally obtained by the body through oral ingestion of fluid and by the water formed in
the metabolic breakdown of food. Primarily, fluid is lost from the body in urine and feces. Minor
losses (insensible losses) occur from evaporation from skin and lungs and from saliva, which is
of little importance except in children with tracheostomies or those requiring nasopharyngeal
suction. Infants do not concentrate urine as well as adults because their kidneys are mmature. As
result, they have a proportionally greater loss of fluid in their urine. In infants, the relatively greater
ratio of surface area to body mass also causes a greater insensible loss. When diarrhea occurs,
or when a child becomes diaphoretic because of fever, the fluid output can be markedly
increased, quickly leading to dehydration (excessive loss of fluid).

o FLUID IMBALANCES
- Under most circumstances, water and salt are lost in proportion to each other, termed isotonic
dehydration. Occasionally, water is lost out of proportion to salt and water depletion, or
hypertonic dehydration occurs. If electrolytes are lost out of proportion to water, this is termed
hypotonic dehydration.

Nursing Care of a Family When a Child Has a Gastrointestinal Disorder | GROUP 5

  Isotonic Dehydration
- Occurs when a child’s body loses more water than it absorbs (as with diarrhea) or absorbs less
fluid than it excretes (as with nausea and vomiting). The main result of isotonic dehydration is a
decrease in the volume of blood serum.

 Hypertonic Dehydration
- When water is lost in a greater proportion than electrolytes, hypertonic dehydration occurs. This
might occur in a child with nausea (thus preventing fluid intake) and fever (which increases fluid
loss through perspiration); profuse diarrhea, where there is a greater loss of fluid than salt; or
renal disease associated with polyuria such as nephrosis with diuresis.

 Hypotonic Dehydration
- With hypotonic dehydration, there is a disproportionately high loss of electrolytes in proportion to
fluid loss. The plasma concentration of sodium and chloride are low. This could result from
excessive loss of electrolytes by vomiting, from an increased loss of salt from diuresis, or from
diseases such as adrenocortical insufficiency or diabetic acidosis.

 Overhydration
- Overhydration, or excessive body fluid intake, can be as serious as dehydration. It generally
occurs in children who are receiving IV fluid and can lead cardiovascular and cardiac failure.

 ACID-BASE IMBALANCE
- When vomiting or diarrhea occurs, the GI system often is involved with two severe acid-base
imbalances: metabolic acidosis and metabolic alkalosis. Whether body serum is becoming
acidotic is determined by analyzing a sample of atrial blood for blood gases.

 Metabolic Acidosis
- Results from diarrhea because a great deal of sodium is lost with stool. This excessive loss of
Na+ causes the body to conserve H+ ions in an attempt to keep the total number of positive and
negative ions in serum balanced.

 Metabolic Alkalosis
- With vomiting, a great deal of hydrochloric acid is lost. When Chloride ions are lost this way, the
body has to decrease the number of Hydrogen ions present so that the number of positive and
negative charges remains balanced. This causes the child to become alkalotic because the
number of Hydrogen ions becomes proportionately lower than the number of Hydroxide ions
present.

 COMMON GI SYMPTOMS OF ILLNESS IN CHILDREN

 Vomiting
- Most children with vomiting are suffering from an acute episode of gastroenteritis (infection) due
to a viral or bacterial organism, but other causes of vomiting should be considered, including
emergent reasons such as obstruction, increased intracranial pressure, and inborn errors of
metabolism (IEM).

 Treatment:
- Give small amounts of fluid frequently as soon as tolerated to prevent dehydration and electrolyte
imbalance.
- Clear liquids can be used to maintain hydration, but they are not suitable for rehydration.
- Oral rehydration solutions (ORS) such as Pedialyte should be used for infants and younger
children as well as older children with dehydration.

Nursing Care of a Family When a Child Has a Gastrointestinal Disorder | GROUP 5

 - Children with intractable vomiting or severe dehydration will require IV fluids and should be
treated emergently.

 DIARRHEA
- Diarrhea that is acute is usually associated with infection. Chronic diarrhea is more likely related
to malabsorptive and inflammatory cause.
- GIARDIA LAMBLIA: a frequent protozoan infection that causes diarrhea.
- Diarrhea in infants is always serious because infants have such small ECF (extracellular fluid).
Breast and chest feeding may actively prevent by providing antibodies and possibly an intestinal
environment less friendly to invading organisms.

 MILD DIARRHEA
 Assessment
- Anorectic
- Irritable and appear unwell
- A fever of 101°F to 102°F (38.4°C to 39.0°C)
- 2-10 episodes of diarrhea
- Watery bowel movement per day

 Therapeutic Management
- Feeding recommendations are similar to those for children and infants with vomiting
- Administration of probiotics

 SEVERE DIARRHEA
- May result in dehydration and the need for hospitalization.

 Assessment
- Appears obviously ill
- Rectal temperature is often as high as 103°F to 104°F (39.5°C to 40.0°C).
- Both pulse and respirations are weak and rapid.
- Skin is pale and cool.
- Infants may be apprehensive, listless, and lethargic.
- Obvious signs of dehydration such as a depressed fontanelle, sunken eyes, and poor skin turgor
are usually present.
- The episodes of diarrhea usually consist of a movement of liquid green stool perhaps mixed with
mucus and blood, passed with explosive force every few minutes.
- Urine output will be scanty and concentrated.

 Laboratory Findings
- Elevated Hematocrit
- Elevated Hemoglobin and serum protein levels because of dehydration.

 Therapeutic Management
- Regulating electrolytes and fluids balance by oral or IV rehydration therapy
- Discovering the organism responsible for diarrhea

 BACTERIAL INFECTIOUS DISEASES THAT CAUSE DIARRHEA AND VOMITTING

 Salmonellosis
• Causative agent: Salmonella
• Incubation period: 6 to 72 hours for intraluminal type; 7 to14 days for extraluminal type
• Period of communicability: While the organisms are being excreted (may be as long as 3
months)

Nursing Care of a Family When a Child Has a Gastrointestinal Disorder | GROUP 5

 • Mode of transmission: Ingestion of contaminated food, especially chicken and uncooked eggs

 Listeriosis
• Causative agent: Listeria monocytogenes
• Incubation period: variable, ranging from 1 day to more than 3 days.
• Mode of transmission: Ingestion of unpasteurized milk or cheese or vegetables grown in
contaminated soil.

 Shigellosis (Dysentery)
• Causative agent: Shigella
• Incubation period: 1 to 7 days
• Period of communicability: Approximately 1 to 4 weeks
• Mode of transmission: Contaminated food, water, or milk products

 Staphylococcal Food Poisoning

• Causative agent: Staphylococcal enterotoxin produced by some strains of staphylococcus
aureus
• Incubation period: 1 to 7 hours
• Period of communicability: Carriers may contaminate food as long as they harbor the organism.
• Mode of transmission: Ingestion of contaminated food such as poultry, creamed foods, and
inadequate cooking.

 PROTOZOAN OR VIRAL DIARRHEA

• Results in loose, watery stools.
• Chief therapy —ORS
• Children who are cultured with G. lamblia may be prescribed metronidazole

 COMMON DISORDERS OF THE STOMACH AND DUODENUM

 GASTROESOPHAGEAL REFLUX
- The regurgitation of stomach secretions into the esophagus through the lower esophageal
(cardiac) sphincter.

 GASTROESOPHAGEAL REFLUX IN INFANTS

- It occurs in infants due to the immaturity to the lower esophageal sphincter, which allows easy
regurgitation of gastric contents into the esophagus.
- Usually requires no treatment

 GASTROESOPHAGEAL REFLUX DISEASE (GERD)

Infants develop complications from reflux such as:
- Irritability
- Failure to thrive
- Esophagitis

Severe cases;
- Aspiration pneumonia
- Wheezing
- Apnea

 Assessment
In patient with GERD, diagnostic workup may include:
• Upper GI series
• pH probe
• Esophageal manometry
• Endoscopy

 Therapeutic Management
• Feed infants small frequent feedings of formula thickened with rice cereal (1tbsp of cereal per 1 oz
of human milk or formula)
• Infant should be held in an upright position for 30 minutes after feedings if possible
• Tight clothing and diapers should be avoided.
• If medical therapy is ineffective, laparoscopy or surgical fundoplication may be performed.

Nursing Care of a Family When a Child Has a Gastrointestinal Disorder | GROUP 5

  GASTROESOPHAGEAL REFLUX IN CHILDREN AND ADOLESCENT
GERD occurs when the reflux causes symptoms that affect quality of life or cause pathologic
complications such as:
- Inadequate weight gain
- Irritability
- Persistent emesis
- Gagging
- Choking

 Typical symptoms:
- Heartburn that occurs 30 to 60 minutes after a meal
- Regurgitation

 Diagnosis:
- History
- Endoscopy

 Therapeutic Management
- Avoid lying down until 3 hours after a meal and should sleep at night with their upper body
elevated.
- Avoid acidic foods.
- Avoiding foods that delay gastric emptying.
- OTC antacids
- H2-receptors antagonists (famotidine or ranitidine)
- PPI (omeprazole or rabeprazole)

 PYLORIC STENOSIS
- The pyloric sphincter is the opening between the lower portion of the stomach and the beginning
portion of the intestine (the duodenum). If hypertrophy or hyperplasia of the muscle surrounding
the sphincter occurs, it is difficult for the stomach to empty, a condition called pyloric stenosis.

 Incidence
- The incidence is high, approximately 1:150 in males and 1:750 in females. It tends to occur most
frequently in first-born white male infants. The exact cause is unknown, but multifactorial
inheritance is a presumed etiology.

 Assessment:
- The hallmark symptom of pyloric stenosis is projectile vomiting, which occurs shortly after feeding
- Weight loss or poor weight gain.
- Dehydration and electrolyte imbalances due to excessive vomiting.
- Palpable “olive-shaped” mass in the epigastric region.
- Infants appear hungry, irritable, and unsatisfied after feeds.

 Diagnostic Evaluations:
- Physical Examination
- Abdominal Ultrasound

● Medical Management:
- Fluid and Electrolyte Management
- Atropine Therapy
- In some cases, medical management with intravenous atropine may be attempted as temporary
measure to relieve pyloric spasm and improve the passage of food. However, surgical

Nursing Care of a Family When a Child Has a Gastrointestinal Disorder | GROUP 5

 intervention remains the definitive treatment for pyloric stenosis, and atropine therapy is
considered a temporary measure or a nonsurgical alternative in certain cases.

 Surgical Management:
- Surgical management of pyloric stenosis involves performing a pyloromyotomy. This procedure
is typically done under general anesthesia and can be performed as an open surgery or
laparoscopically.

 PEPTIC ULCER
- Shallow excavation formed in the mucosal wall of the stomach, the pylorus, or the duodenum.
- Peptic ulcer disease includes gastritis (irritation of the lining of the stomach or duodenum) and is
more commonly seen in childhood.
- In infants, ulcers tend to occur in the stomach; in adolescents, they are usually duodenal.

 Assessment
- An ulcer occurring in a neonate usually presents with hematemesis or hematochezia. Such ulcers
are usually superficial and heal rapidly, although they can lead to rupture, with symptoms of
respiratory distress, abdominal distention, vomiting, and, if extensive, cardiovascular collapse.
- If an ulcer occurs in a toddler, the first symptoms are usually anorexia or vomiting. Bleeding
follows in several weeks.
- If an ulcer begins when the child is of preschool or early school age, pain may be the presenting
symptom. It is often poorly localized, although it may be in the epigastric area as in adults. If the
pain occurs in the right lower quadrant, it may be confused with appendicitis.
- In school-aged children and adolescents, symptoms are generally similar to those of adults- a
gnawing or aching pain in the epigastric area before meals that is relieved by eating. Vomiting
(because of spasm and edema of the pylorus) occurs in a small number of children. On
abdominal palpation, epigastric tenderness is present.

 Diagnostic Test
- Endoscopy is the most reliable diagnostic test to confirm the diagnosis of peptic ulcer disease.

 Therapeutic Management
 Triple therapy, a combination of medications that is given to attempt to eradicate the bacteria
from the stomach.
 This treatment consists of two antibiotics, usually amoxicillin and clarithromycin, and a PPI such
as omeprazole.
 Bismuth subsalicylate is soothing and mildly antibiotic and so may be prescribed concurrently.

 HEPATIC DISORDERS

 LIVER FUNCTION
- In healthy infants, 1 or 2 cm of liver is palpable under the diaphragm on the right upper quadrant
of the abdomen. The liver is essential for the normal metabolism of carbohydrates, proteins, and
fats, and it plays a major role in the maintenance of glucose metabolism by converting glucose to
glycogen for cell storage. The process is reversed, glycogen to glucose, when required by the
cells for energy. The liver assists in the catabolism of fatty acids and protein and serves as a
temporary storage space for both fat and protein.

Nursing Care of a Family When a Child Has a Gastrointestinal Disorder | GROUP 5

  HEPATITIS
 CHRONIC HEPATITIS
- Chronic hepatitis causes the liver to become inflamed for at least six months. Hepatitis is an
inflammatory condition affecting the liver. When liver inflammation persists for at least six months,
it’s referred to as chronic hepatitis.
- Causes
Chronic hepatitis is most commonly caused by:
- The hepatitis C virus (HCV)
- The hepatitis B virus (HBV)
- Alcohol-related liver disease
- Nonalcoholic fatty liver disease (nonalcoholic steatohepatitis)
 Notably, the hepatitis A virus (HAV) does not cause chronic hepatitis.

 Symptoms
These symptoms may include:
- Fatigue
- Low-grade fever
- Loss of appetite
- Mild discomfort in the upper abdomen
- An overall feeling of being ill (malaise)

 Diagnostic Test
- Blood tests
- A liver biopsy
- Elastography

 Treatment
- Chronic hepatitis treatment will vary depending on what is causing the inflammation.
- Treatment also involves managing any complications arising from chronic hepatitis. And if this
condition has caused someone to experience severe liver failure, liver transplantation may be
necessary.

 FULMINANT HEPATIC FAILURE

- Present when acute, massive necrosis or sudden, severe impairment of liver function occurs,
leading to liver failure and hepatic encephalopathy. It can be due to infection or toxicity.

- Treatment:
- Reducing protein intake and administering lactulose
- Liver transplantation (surgical replacement of a malfunctioning liver by a donor liver) may be
necessary.

 OBSTRUCTION OF THE BILE DUCTS

- Commonly caused by congenital biliary atresia, stenosis, or absence of duct.
- Rarely occurs from the plugging of biliary secretions.
- When the bile duct is obstructed, bile, unable to enter the intestinal tract, accumulates in the liver.

- Assessment
- Bile duct obstruction is a congenital disorder with jaundice developing between 2 and 6 weeks of
age. This delay distinguishes it from physiologic jaundice, which occurs on the third day of life,
and the jaundice of Rh or ABO isoimmunization, which occurs during the first 24 hours of life.
- Alkaline phosphatase levels will also be elevated.
- The AST (SGOT) level is normal in the early phase but later becomes abnormal, when prolonged
obstruction and back pressure cause liver cell damage.

- Therapeutic Management
- Before treatment is begun, appropriate blood work and a liver biopsy under local anesthesia may
be obtained.

Nursing Care of a Family When a Child Has a Gastrointestinal Disorder | GROUP 5

 - If atresia of the bile duct is the problem, surgical correction is the treatment (a Kasai procedure).
With this surgery, a Roux-en-Y loop of bowel is sutured directly onto the hilum of the liver.
- Surgical correction may not be possible in all infants.

 NONALCOHOLIC FATTY LIVER DISEASE

- Accumulation of fatty deposits in liver, often linked to obesity.
- Increased obesity in school-aged children and adolescents.
- Rarely progresses to cirrhosis.

 CIRRHOSIS
- Fibrotic scarring of the liver. It rarely occurs in children, although it may be seen as a result of
congenital biliary atresia or as a complication of chronic illnesses such as protracted hepatitis,
sickle cell anemia, or cystic fibrosis.

- MANAGEMENT:
- Cholestyramine may be prescribed.
- Nursing care focuses on promoting comfort, providing adequate nutrition by a high-carbohydrate,
medium chain-triglyceride diet, and preventing further involvement until liver transplantation.

 ESOPHAGEAL VARICES
- Common complication of liver disorders like cirrhosis. They generally form at distal end of
esophagus near the stomach because of back pressure on the veins resulting from increased
portal circulation blood pressure. Varices may bleed if the child coughs vigorously or strains to
pass stool.
Gastric reflux into the distal esophagus may irritate and erode the fine covering of the distended
vessels, causing rupture.

 Treatment:
- Octreotide or vasopressin may be given
- Endoscopic variceal band ligation is the preferred method of treatment.
- A balloon tamponade may be utilized to prevent bleeding.
- A Sengstacke-Blakemore tube or Linton-Nachlas catheter may be passed into the stomach.
- Frequent vital sign measurements and testing of stool and any vomitus for the presence of blood.

 LIVER TRANSPLANTATION
- Liver transplantation is the surgical replacement of a malfunctioning liver by a donor liver. Child-
size donor livers are not readily available, so the waiting time for surgery may be months. Adult
livers can be reduced in size for transplantation or a lobe of a liver from a living donor can be
used.

 Preoperative Management
- Preoperative management consists of keeping the child in the best physiologic condition possible
so that transplantation can be performed when a liver is available.

 Surgical Procedure
- Liver transplantation is a time-consuming procedure and requires a wide subcostal incision. The
vena cava is temporarily clamped during the removal of the natural liver to prevent bleeding,
which means that all IV lines are placed in the upper extremities.

 Postoperative Management
- Careful tissue matching (human leukocyte antigen [• HLA] matching) is necessary.
- Children are given an immunosuppressive drug such as mycophenolate mofetil, cyclosporine, or
tacrolimus before the transplantation.
- Advocate for adequate pain control.
- IV therapy with hypotensive agents such as hydralazine and nitroprusside may be needed to
reduce hypertension.
- To help detect bleeding, observe and record abdominal girth, the incision line, and drainage from
any catheters or tubes placed in the incision to allow peritoneal secretions to drain.

 INTESTINAL DISORDERS

 INTUSSUSCEPTION
- The invagination of one portion of the intestine into another, most frequently occurs in the second
half of the first year of life, with 90% of cases occurring by 2 years of age.
- About 75% of intussusception occurs for idiopathic reasons where there is no clear cause.
- In other cases, a "lead point" on the intestine likely initiates the invagination.

 Assessment\
- Children with this disorder may present with vomiting and abdominal pain. They may suddenly
draw up their legs and ay as if they are in severe pain. After the peristaltic wave that caused the
discomfort passes, they are symptom free and play happily.\

Nursing Care of a Family When a Child Has a Gastrointestinal Disorder | GROUP 5

  Therapeutic Management
- The condition is a surgical emergency. Reduction of the intussusception must be done promptly
by either instillation of a water-soluble solution, barium enema, or air (pneumatic
insuflacion) into the bowel to reduce the invaginacion before necrosis of the affected portion of
the bowel occurs.

 VOLVULUS WITH MALROTATION\

- A volvulus is a twisting of the intestine. The twist leads to obstruction of the passage of feces and
to compromise of the blood supply to the loop of intestine involved.
- Volvulus occurs due to intestinal malrotation and may be associated with other congenital
anomalies.

 Symptoms
- Usually, the symptoms occur during the first 6 months of life and are those of intestinal
obstruction such as intense crying and pain, pulling up the legs, abdominal distention, and
vomiting.

 Diagnosis
- History and an abdominal examination, which reveals an abdominal mass.
- The diagnosis is confirmed by an ultrasound or lower barium X-ray.

 Management
- Emergency surgery should be performed before necrosis of the intestine occurs from a lack of
blood supply to the involved loop of bowel. Preoperative and postoperative care will be the same
as for infants with intussusception.

 NECROTIZING ENTEROCOLITIS
- A condition that develops in approximately 5% of all infants in neonatal intensive care nurseries,
with premature and low-birth-weight infants at highest risk.
- Cause is unknown and thought to be due to a variety of factors.
- The necrosis appears to result from ischemia or poor perfusion of blood vessels in the entire
bowel or in isolated sections of the bowel. The ischemic process tends to occur from hypovolemic
shock or hypoxia in which there is vasoconstriction of blood vessels to organs such as the bowel.

 Assessment
- Signs of NEC usually appear in the first week of life. The infant's abdomen becomes distended
and tense.
- Abdominal girth measurements made just above the umbilicus every 4 to 8 hours will show a
gradual increase.
- Abdominal radiology films show a characteristic picture of air invading the intestinal wall; if
perforation has occurred, there will be air in the abdominal cavity.

 Therapeutic Management
- As soon as the condition is recognized, oral feedings are discontinued, and the infant is
maintained on IV or total parenteral nutrition solutions to rest the GI tract except for additional
supplements of enteral probiotics.
- An antibiotic may be given to limit secondary infection. Handle the infant's abdomen gently to
lessen the possibility of a bowel perforation.

 SHORT-BOWEL / SHORT GUT SYNDROME

Short-bowel or short-gut syndrome is an absorptive disorder in which there is not sufficient bowel
surface area in the small intestine for proper nutrient absorption. The condition has several
causes:
- Surgery for NEC
- Volvulus
- GI tract trauma (resulting in a large portion of the intestine being removed)

 Treatment:
- Ensuring adequate hydration
- Proper intake of vitamins and minerals
- Bowel resection surgery
- Total parenteral nutrition (including lipids)
- Oral or enteral feedings are progressed as tolerated

 APPENDICITIS
- Appendicitis (inflammation of the appendix) is the most common cause of abdominal surgery in
children. It occurs most frequently in school-aged children and adolescents, although it can occur
in preschoolers and even in newborns.
- The appendix, a blind-ended pouch attached to the cecum, may become inflamed because of an
upper respiratory or other body infection, but the cause of appendicitis is generally obscure. In

Nursing Care of a Family When a Child Has a Gastrointestinal Disorder | GROUP 5

 most instances, fecal material apparently enters the appendix, hardens, and obstructs the
appendiceal lumen.

 Assessment
- Diagnosis is made on a cluster of symptoms: anorexia, pain or tenderness in the right lower
quadrant, nausea or vomiting, elevation of temperature, and leukocytosis.
- If the child's appendix is displaced from this usual position, the pain will not be at this typical point,
so pain at any other point does not rule out appendicitis. Pregnant adolescents are apt to have
displaced pain. Fever is a late symptom.
- Rebound tenderness is a phenomenon in which a child feels relatively mild pain when the area
over the appendix is palpated, but, once an examiner's hand is lifted, the child experiences acute
pain caused by abdominal contents shifting. This is diagnostic of appendicitis, but it should be
done with children only when necessary because it does cause acute pain. If, on auscultation,
bowel sounds are reduced (hypoactive), this suggests peritonitis or that the appendix has already
ruptured.

 Laboratory Findings
- Usually indicate leukocytosis (white blood cell count between 10,000 and 18 , 000/mm3 )
- Ketone levels in the urine are inordinately elevated as a symptom of starvation from poor
intestinal absorption.
- An ultrasound or computed tomography (CT) scan will reveal the swollen appendix.
- Pain in the right lower quadrant may also occur as a manifestation of right lower lobe pneumonia.
Therefore, the child may have a chest radiograph taken to rule this out as the source of pain.

 Treatment
- Treatment for acute appendicitis is surgical removal of the appendix before it ruptures, usually an
elective laparoscopic appendectomy.

 RUPTURED APPENDIX
- If a child's appendix has already ruptured when the child is seen in the emergency department,
the potential for peritonitis increases greatly. Children generally appear severely ill. Their white
blood cell count may be elevated to more than 20,000/mm. Position the child in a semi-Fowler
position, if possible, so that infected drainage from the cecum drains downward into the pelvis
rather than upward toward the lungs. The child needs an IV fluid line inserted for hydration.
Antibiotics will be given preoperatively or as soon as the ruptured appendix is confirmed. During
surgery, the child will have drains placed beside the surgery incision so that any infectious
material in the abdomen can continue to drain. Warm soaks to the incision line may be prescribed
three or four times a day to encourage drainage. Examine the wound carefully at each dressing
change. Be certain not to dislodge drains while removing soiled dressings. Report immediately
any drain that is expelled because the surgeon may want to replace it to ensure a patent drainage
route. Often, drains are shortened with each dressing as wound healing progresses from the
deep tissue to the surface incision. IV Fluid and antibiotic therapy are continued until full bowel
function is restored. When changing dressings, assess for signs of peritonitis such as a board like
(rigid) abdomen, generally shallow respirations (because deep breathing puts pressure on the
abdomen and causes pain), and increased temperature. Although the postoperative course is
slower (approximately 3 weeks) after a ruptured appendix, the prognosis is still good. A local
abscess or intestinal adhesions may result. Adhesion formation, a long-term complication, could
cause bowel obstruction in the future and/or interfere with fertility in biologic females.

 MECKEL'S DIVERTICULUM
- In embryonic life, the intestine is attached to the umbilicus by the omphalomesenteric (vitelline)
duct. This duct becomes a vestigial ligament as infants reach term. In 2% or 3% of all infants,
however, a small pouch of this duct remains, located off the ileum, approximately 18 inches from
the ileum-colon junction: a Meckel diverticulum). The structure often contains some misplaced
gastric mucosa, which secretes gastric acids that flow into the intestine and irritate the bowel wall,
leading to ulceration and bleeding. Children will have painless, tarry (black) stools or grossly
bloody stools. On occasion, the diverticulum may serve as the lead point, causing an
intussusception. In some instances, a fibrous band extending from the diverticulum pouch to the
umbilicus acts as a constricting band, causing bowel obstruction. The child's history suggests the
diagnosis. Because the pouch is small, it does not fill; therefore, it may not be evident on
radiologic or ultrasound examination. A nuclear medicine test called a Meckel scan is used to
identify the area of gastric mucosa in the intestine. Treatment is laparoscopy exploration and
removal of the vestigial structure.

 CELIAC DISEASE
- Celiac disease is an immune-mediated abnormal response to gluten, the protein in wheat, and
related proteins in rye, barley, and possibly oats, in a genetically susceptible individual. When
children with the disorder ingest gluten, flattening of projections (villi) of the small intestine occurs,
preventing the absorption of foods, especially fat, into the body.

 Assessment

Nursing Care of a Family When a Child Has a Gastrointestinal Disorder | GROUP 5

 - Poor growth
- Bulky stools
- Malnutrition
- Distended abdomen
- Anemia

 Therapeutic Management
- Gluten free diet for life
- Correction of any vitamin and mineral deficiencies may be necessary

 DISORDERS OF THE LOWER BOWEL

 CONSTIPATION

- Functional constipation, or constipation without an underlying medical disease, is a very common

problem in childhood, often starting in the first year of life. Some children begin holding stool for
psychological reasons. Once the process begins, however, the hardened stool, the anal fissures,
and the pain on defecation can soon occur, and what began for an emotional reason becomes a
physical abnormality.

 Assessment

- When obtaining a history, have parents describe what they mean by constipation.
- Examine the circumstances that may have led to constipation.
- It is also important to know the age of onset of the constipation, whether or not the child is toilet-
trained, and if they exhibit stool withholding behaviors.

 Treatment

- Treatment of functional constipation is focused on softening the stool so that it passes painlessly.
- Bowel cleansing to remove retained stool with weight-appropriate doses of polyethylene glycol is
recommended before beginning daily treatment.
- Enemas are avoided if possible.
- After this, a stool softener such as polyethylene glycol is prescribed daily.

 INGUINAL HERNIA

- Protrusion of a section of the bowel into the inguinal ring. It usually occurs in biologic males
because, as the testes descend from the abdominal cavity into the scrotum late in fetal life, a fold
of parietal peritoneum also descends, forming a tube from the abdomen to the scrotum.

 Assessment
- Appears as a lump in the left or right groin.
- Apparent only on crying and not when children are less active.
- Pain at the site implies that the bowel has become incarcerated in the sac.
- Ask parents whether they noticed any lumps in the child’s groin area .

 Therapeutic Management
- Laparoscopic surgery
- Pneumoperitoneum (instillation of carbon dioxide into the peritoneal cavity
- Infants with inguinal hernia may have surgery before 1 year of ages.
- After surgery keep the suture line dry and free of urine or feces.
- The infant will need frequent diaper changes and appropriate diaper area care.
- Assess circulation in the leg on the side of the surgical repair.

 HIRSCHSPRUNG DISEASE

Nursing Care of a Family When a Child Has a Gastrointestinal Disorder | GROUP 5

 - Hirschsprung disease, or aganglionic megacolon, is an absence of ganglionic innervation to the
muscle of a section of the bowel-in most instances, the lower portion of the sigmoid colon just
above the anus.

 Assessment:
- Failure to pass meconium
- Ribbon like stool
- Vomiting
- Reluctance to feed
- Abdominal distention
- Foul odor of breath

 Diagnosis
- Rectal Exam
- Barium Enema
- Rectal biopsy or Anorectal manometry

 Therapeutic Management
- Anastomosis of the intestine
- Colostomy
- Resection\

 INFLAMMATORY BOWEL DISEASE: ULCERATIVE COLITIS AND CROHN DISEASE

- UC affects only the mucosal lining of the colon, whereas CD can affect any part of the GI tract
from the mouth to the anus.

 ULCERATIVE COLITIS

 Assessment:
- Crampy abdominal pain
- Urgency tenesmus
- Frequent bloody stools
- Anemia and hypoalbuminemia

 CROHN DISEASE
 Assessment:
- Abdominal pain
- Diarrhea with or without blood
- Weight loss
- Inflamed area may become narrowed

 Diagnosis
- Endoscopy
- Colonoscopy
- MRI

 Therapeutic Management

- Oral medications
- Bowel rest
- Enteral or total parenteral nutrition
- Maintenance therapy
- Infliximab or mercaptopurine (immunomodulator) or mesalamine alone or combination of
medication

Nursing Care of a Family When a Child Has a Gastrointestinal Disorder | GROUP 5

 - Total Colectomy
- Ileostomy

 IRRITABLE BOWEL SYNDROME (IBS)

- Irritable bowel syndrome (IBS) is a common pediatric functional gastrointestinal disorder (FGID).
that typically causes symptoms of abdominal pain and altered bowel habits with no underlying
organic cause. It differs from IBD. It may be either constipation or diarrhea predominant, or there
may be a mixed picture. Diagnosis is based on the Rome III criteria. It is a common disorder in
adolescents and adults and thought to affect 15% of the population with a 2:1 female to male
predominance. The symptoms can adversely affect quality of life and cause children to miss
school. Etiology is unknown. The onset of loose stools can follow an infection and may be due to
an alteration in the intestinal flora. Other studies have looked at intestinal bacterial over-growth,
food sensitivities, visceral hyperalgesia (heightened sensitivity to bowel distention), and
psychosocial factors. Antidepressants, anticholinergics, and antibiotics that work to reduce
bacteria in che gut such as rifaximin may be prescribed to treat the symptoms of IBS. There is a
lack of research showing improvement with pharmacologic agents

 RECURRENT ABDOMINAL PAIN (RAP)

- Functional GI disorder and is defined as a minimum of three episodes of pain over 3 months that
affect normal activities.
- Pain that has non other identifiable cause.
- Children who experience this are commonly 6 or 7 years of age or in prepuberty (11 to 12 years
of age)

 Signs and Symptoms

- Pain is usually located in the periumbilical area.
- Pain may be associated with pallor, nausea, vomiting and slight temperature alleviation.

 Treatment
- Cognitive Behavioral Therapy
- Hypnotherapy
- Probiotics

 DISORDERS CAUSED BY FOOD, VITAMIN, AND MINERAL DEFICIENCES

 KWASHIORKOR
- Kwashiorkor, a disease caused by protein deficiency, occurs most frequently in children aged 1 to
3 years because this age group requires a high-protein intake. It is a disease found almost
exclusively in low-income nations, although it does occur in the United States (Brumbaugh et al.,
2020). It tends to occur after weaning, when children change from human milk to a diet consisting
mainly of carbohydrates. Growth failure is a major symptom. Because edema is also a symptom,
how-ever, the child may not appear underweight until the edema is relieved. There is a severe
wasting of muscles, which the edema may mask. Edema results from hypoproteinemia, which.
causes a shift of body fluid from the intravascular compartments to the interstitial space, causing
ascites. The edema tends to be depen-dent, so it is first noted in the lower extremities. The child
is generally irritable and uninterested in their surroundings. They lag in motor development. If the
child had intermittent periods of adequate and inadequate protein intake, the hair shafts develop
a striped appearance of brown, then white a "zebra sign." Children also have diarrhea, iron-
deficiency anemia, and enlarged livers. Without treatment, kwashiorkor is fatal. For therapy, a diet
rich in protein is essential. There is evidence to suggest that protein malnutrition early in life, even
with intervention, may result in failure of the child to reach their full potential of intellectual and
psychological development.

 NUTRITIONAL MARASMUS

Nursing Care of a Family When a Child Has a Gastrointestinal Disorder | GROUP 5

 - Nutritional marasmus results from a deficiency in all nutrients-basically, a form of starvation.
Although it occurs most commonly in nations where food supplies are limited, it can occur in the
United States in grossly neglected children or those with failure to thrive (see Chapter 55).
Children with marasmus are commonly younger than 1 year of age. They have symptoms similar
to that of children with kwashiorkor, including growth failure, muscle wasting, irritability, iron-
deficiency anemia, and diarrhea. Children with kwashiorkor are anorectic, whereas children with
nutritional marasmus are invariably hungry (starving) and will suck at any object of fered to them,
such as a finger or their clothing. Treatment focuses on providing an adequate quantity of food,
containing all essential nutrients. Like children with kwashiorkor, children with marasmus may
suffer cognitive challenges that persist throughout life.

 VITAMIN AND MINERAL DEFICIENCIES

- Both vitamin and mineral deficiencies occur at a low fate in children of the United States because
so many foods are enriched (restoration of ingredients removed by procesting en fortified
(additional vitamins and minerals not normal, present have been added). Milk, for example, is
fortified wit Vitamins D and A. Orange juice is fortified with calcium. White bread is enriched with
B vitamins.

Nursing Care of a Family When a Child Has a Gastrointestinal Disorder | GROUP 5