Nursing care of The Child

With gastrointestinal disorders

1
 Out line
1. Cleft lip and palate
Congenital hypertrophic pyloric stenosis( CHPS).2
.Hirschsprung’s Disease .3
intussusception .4
Esophageal atresia and tracheoesophageal .5
.fistula
Hernia .6
Celiac disease .7
 Objectives
At the end of this lecture the student will be able
:to
.Define all congenital anomalies in GIT -1
Mention sign and symptom of each disorder-2
Enumerate at least three preoperative -3
.nursing care for children
Apply special post operative care for each -4
.disorder
 Cleft lip and palate
Incidence: Cleft lip are more common in
males. Cleft palate alone is more common in
females.
Etiology: Genetic factors. Non genetic
influences (maternal corticosteroids therapy).
-They may appear separately or, more often,
together.
 Cleft Lip (CL)

Cleft lip results from failure of the maxillary and median nasal
process to fuse. Deformed dental structures are associated with
CL.
Clefts can be unilateral or bilateral.

Unilateral Bilateral
 Cleft Palate

Cleft palate is a midline fissure of the palate that results from

failure of the two sides to fuse.
 Common preoperative problems

• Feeding difficulties

• Respiratory infections

• Otitis media

• Speech problems

• Hearing defects
 Treatment
1. Feeding
a. Patients with isolated cleft lip may be breast-fed.
b. Patients with cleft palate usually need feeding by
spoon or dropper, or specific nipple.
2. Surgical closure of a cleft lip: Cheiloplasty at
2 months
3. Surgical closure of a cleft palate:
Palatoplasty, time depends on the size and severity of
the defect. Usually done between 6-14 months
(before 18 months).
Cleft lip
Cleft palate
 Preoperative Nursing Diagnosis Management
• Ineffective infant feeding R/T anatomical
abnormality.
• Interventions
–Support the baby in upright position and feed gently using a
cleft lip nipple.
–Do not hurry, be careful to prevent aspiration.
–Encourage breast feeding, bulk of breast will seal the defect
and create the vacuum.
–If the policy is not to breast feed before surgery, teach the
mother how to express the milk and feed the infant using Breck
feeder.
–In the infant with cleft palate use the special plate to cover the
defect.
–Do frequent bubbling to expel the swallowed air.
 Postoperative Nursing Management
• Ineffective infant feeding R/T surgery to the
organs of oral cavity.
• Interventions
–Keep the baby NPO immediately after the surgery.
–Provide IV fluids.
–No tension of the suture lines- no bottle or breast.
–After feeding the infant give clear water to clean the suture
lines.
–Support the baby in upright position and feed gently using a
cleft lip nipple.
–Do not hurry, be careful to prevent aspiration.
–Teach the mother how to express the milk and feed the infant
using Breck feeder.
Risk for infection R/T surgical incision.
•Interventions
– To avoid tension on suture lines a Logan bar is
kept post operatively after cleft lip surgery.
– Give pain medications round the clock to prevent
baby crying
– Elbow restraint to prevent the infant from
touching suture lines.
– Do not put anything in mouth.
– Aseptic precautions while caring.
 Congenital Hypertrophic Pyloric Stenosis
(CHPS)
•Obstruction of the pyloric lumen due to pyloric
muscular hypertrophy.

•Hypertrophy is rare at birth but develops over

the initial 4 to 6 weeks of life.
Clinical manifestations of CHPS
•No abnormal signs in the first week or two after
birth.
•Forceful projectile vomiting of feedings
without bile usually begins late in the first month
of life.
• Gastric peristaltic waves may be visible,
crossing the epigastrium from left to right.
•Weight loss and dehydration
Clinical manifestations of CHPS

•Distended upper abdomen

•Decreased frequency and quantity of stool

•Delayed diagnosis may lead to repeated

vomiting, dehydration, failure to gain weight,
and hypochloremic metabolic alkalosis (from
losses of hydrochloric acid).
Diagnostic evaluation
• Diagnosis can be made by palpation of a
discrete, 2- to 3-cm, firm, movable pyloric olive-
like mass deep in the right side of the epigastrium.
• abdominal Ultrasonography.
• If the diagnosis is uncertain, a barium swallow
will show delayed gastric emptying and the typical
"string sign" of a markedly narrowed, elongated
pyloric lumen.
• Therapeutic management

•The treatment of choice is a

longitudinal pyloromyotomy, which
leaves the mucosa intact and
separates the incised muscle fibers.
Postoperatively, the infant usually
tolerates feedings within a few days.
Preoperative care
Restore hydration status by I.V. fluids
•Assess the amount, characteristics, and
frequency of vomiting.
•Monitoring intake and output
•Careful observation and recording of vomiting
and bowel elimination.
•NG tube insertion
•General hygienic care
•Support family
•Monitor G&D parameters
 Postoperative care
• Ensure adequate hydration
• Care for operative side
• NG tube should be maintained, oral hygiene should
offered
• Give clear oral fluids from 4-6 hours postoperatively as
ordered.
• Feed the baby slowly; burp frequently, and in high
Fowler's position on the right side after feeding.
• Family teaching and follow-up (feeding, positioning,
surgical wound care, medications…ect).
 Hirschsprung’s Disease
( Congenital aganglionic megacolon)
• It is a mechanical obstruction due to inadequate
motility of the part of intestine related to absence of
ganglion cells in the colon.
• Most common area affected is rectosigmoid colon.
Associated with other congenital anomalies as Down
syndrome.
 Clinical manifestation:
• Newborns :
–Failure to pass meconium within the first 48 hours of life
–Abdominal distension
–Bilious vomiting
• infant:
–As new born +
– enter colitis ( diarrhea and fever)
–constipation
–Failure to thrive
• old child :
–As infant + ribbon like stool, visible peristalsis, palpable fecal
mass
 Hirschsprung’s Disease
• Diagnosis:
– Abdominal x- rays
– Barium enema
– Rectal biopsy makes
definitive diagnosis –
absence of ganglion cells
Management
1. Surgery to remove a ganglionic bowel
– First stage : temporary colostomy (until infant
weighs 8-10kg or 10mos-1yr)—to decompress the
colon
– Second stage : Abdominal pull-through with
excision of a ganglionic segment and
reanastomosis
• NG tube is generally inserted preoperative
• Milder cases
– Dietary modification, stool softeners, and isotonic
irrigation,….
Pre operative care
1. NPO
2. V.S especially Bp
3. assess S&S of intestinal perforation ( fever, increase
abdominal distention, vomiting, increase tenderness,
dyspnea and cyanosis).
4. prepare the child for colostomy ( picture with another
child with colostomy, use doll,…….)
5. if the child is malnourished and not tolerate, treat by
symptomatic treatment with enema, low fiber diet,
high calorie and protein, and total parental nutrition
for needed child.
6. measure abdominal girth
Post operative care
1- colostomy care: clean skin, non allergic tape, large
pouch to collect a moderate amount of stool to prevent
leakage, use zinc oxide to prevent peristomal
breakdown, a gauze over wafer to absorb any drainage,
reassure child related disturbance in body image,
……...etc.

2- avoid infection( diaper pinned below the dressing,

insert urinary catheter,….).
 Intussusception
• Invagination (telescoping) of one portion of intestine
into another or ileum invaginates colon that leads to
intestinal obstruction. (like a sock, pushing the end of
finger on a rubber gloves). Peak age 3-6 months,
common in girls than boys.
Pathophysiology of Mechanical Bowel
Obstruction:
The condition can progress from intestinal
obstruction to necrosis (tissue death) of a segment
of the intestine, decrease blood flow causing
swelling and inflammation. The swelling can lead to
perforation (tearing) and generalized abdominal
infection, shock and dehydration
Causes
-idiopathic (unknown)
- following a viral infection
• Clinical Manifestations:
–Sudden sever colicky abdominal pain + vomiting
–child is relaxed between pain intervals.
–Child screams and draws knees up to abdomen
–Red currant jelly like stool ( blood and mucus).
– tender and distended abdomen
–Palpable sausage shaped mass in upper right
quadrant and empty lower right quadrant ( dance
sign).
– sign of peritonitis
Diagnosis:
– history, physical examination, Laboratory tests
–X-ray of abdomen may show absence of gas or
mass in right upper quadrant.
–Barium enema shows a concave filling defect (will
help reduce the invagination).
–Digital rectal exam reveals mucous, blood and
sometimes the intussusceptions
Treatment:
1- reduction of bowel by pressure( fill the gloves with
water which pushes the finger into a fully extended
position).
– hydrostatic ( saline) enema, Barium enema
– pneumoenema ( air) enema.
– antibiotic therapy before reduction
– normal stool after reduction indicates that the
intussusceptions reduced itself
2- NG decompression
3-Surgical intervention is a last resort and must be
done if there are signs of perforation and
peritonitis
Preoperative care
1- NPO
2- laboratory testing
3- signed parental consent
4- NG suction

Post operative care

1- observe vital sign, return bowel sound, intact suture
and dressing
2-obseve passing of stool
3- follow up child (recurrence intussusception )
 Esophageal atresia and
tracheoesophageal fistula
it is a failure of esophagus to develop as a
continuous single passage (atresia) and
failure of a trachea and esophagus to
separate into distinct structures (have
fistula)
 Types

.A to E, Five most common types of esophageal atresia and tracheoesophageal fistula

A.
•It consists of a blind pouch at each end, widely separated and with no
communication to the trachea (7% to 8% of cases).
B and D.
•Extremely rare anomalies involve a fistula from the trachea to the upper
esophageal segment (0.8%) (Type B) or to both the upper and lower segments
(0.7% to 6%).
C.
•The proximal esophageal segment terminates in a blind pouch, and the distal
segment is connected to the trachea or primary bronchus by a short fistula at or
near the bifurcation (80% to 90%).
E.
•An H-type EA refers to an otherwise normal trachea and esophagus connected by
a fistula (4% to 5%).
 Clinical manifestation:
*EA is suspected in anew born with
- Frothy saliva in the mouth and nose, drooling,
Chocking and respiratory distress.
Three Cs of tracheoesophageal fistula (TEF):
• Coughing
• Choking
• Cyanosis
• Apnea
- If fed, the infant may swallow normally but suddenly
cough and gag with return of fluid through the nose and
mouth with cyanosis from aspiration.
 Clinical manifestation:
*In type C

the stomach become distended with air with thoracic

and abdominal compression cause regurgitation of
gastric content through fistula into trachea and
produce chemical pneumonitis
 Diagnosis:
- Inability to pass NG-orogastric catheter into the
esophagus
- Radiographic studies and chest film
- Carful bronchoscopy examination
- Polyhydrominios (accumulation of 200 ml of amniotic
fluid) prenatally is a clue for EA in the unborn infant.

Therapeutic management:
- Surgical repair
- Maintain patent airway
- Prevent pneumonia and aspiration
 Preoperative care
1. Maintain patent airway ( positioning, keep head
upright,…)
2. Prevent pneumonia and aspiration ( NPO, IV
fluid, suction,, upper esophageal pouch ..)
• The most desirable position for a newborn who is
suspected of having the typical EA with a TEF (e.g.,
type C) is supine (or sometimes prone) with the
head elevated on an inclined plane of at least 30
degrees. This positioning minimizes the reflux of
gastric secretions at the distal esophagus into the
trachea and bronchi, especially when
intraabdominal pressure is elevated.
 Preoperative care
-In some cases, a percutaneous gastrostomy tube is
inserted and left open so that any air entering the
stomach through the fistula can escape, thus
minimizing the danger of gastric contents being
regurgitated into the trachea.

-The gastrostomy tube is emptied by gravity drainage.

Feedings through the gastrostomy tube and
irrigations with fluid are contraindicated before
surgery in the infant with a distal TEF.
 Post operative
- Thermoregulation
- Maintain patent airway
- Gastrostomy feeding then gradual oral feeding
after healing
- Pain management
- thoracotomy and chest tube care
 Hernia
A hernia is a protrusion of a portion of an organ or
.organs through an abnormal opening
-The danger of herniation arises when the organ
protruding through the opening is constricted to the
extent that circulation is impaired or when the
protruding organs encroach on and impair the function
of other structures.
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Umbilical Hernia
An umbilical hernia usually
is an isolated defect, but it
may be associated with
other congenital anomalies,
such as Down syndrome

(trisomy 21) and trisomies

13 and 18.
Inguinal hernia
Inguinal hernias account for
approximately 80% of all
childhood hernias and occur more
frequently in boys than in girls.
-An inguinal hernia that cannot be
reduced easily is called an
incarcerated hernia. A strangulated
inguinal hernia is one in which the
blood supply to the herniated organ is
impaired. If left untreated, both
incarcerated and
strangulated hernias will progress to
necrotic bowel.
Celiac disease (Gluten sensitive
enteropathy)
it is an immunologically mediated small intestine
enteropathy, is permanent intestinal intolerance to
dietary gluten that cause damage of intestinal mucosa.
Symptoms can be vary widely person to person but
often include poor growth, abdominal pain, chronic
diarrhea, and abdominal distension, anaemia.

Celiac crisis
*acute profuse watery diarrhea and vomiting
* may be precipitated by: infections, prolonged and
electrolyte depletion and emotional disturbance.
- It is diagnosed by serologic blood test
(antiendomyseal antibodies) and endoscopy
- it is most common among children with
autoimmune disorder such as ( diabetes type 1).

-The only proven treatment is 100% Gluten free

diet.