Digestive Disorders

Pediatric Nursing
VONR 2012

Thrush
 Oral Moniliasis---Candida albicans
 Slightly raised patches that resemble milk-curds.
 Adhere to the surface of the mucus membranes.
 Feeding difficulties.
Thrush
Causes:
 Newborn infected @ birth.
 Improper feeding techniques.
 Long-term antibiotic therapy.
Treatment:
 Nystatin (Mycostatin) QID X 10 days

Pyloric Stenosis
 Obstruction @ the pyloric sphincter.
 One of most common surgical disorders in infancy.
Caused by:
 Spasms of the pyloric sphincter
 Hypertrophy of circular muscle fibers of the pylorus
Pyloric Stenosis
Incidence:
 Five times more common in males
 Familial or inherited tendency
 Often first-born males
 More in whites than non-whites.
 More likely to affect full-term infants
Pyloric Stenosis
Pathophysiology:
 Circular muscles of pylorus enlarge
 Narrows the pyloric lumen
 Inflammation & edema
 Partial or complete obstruction
Pyloric Stenosis
 Symptoms:
 At about 2-3 weeks of age
 Initially regurgitation/occasional vomiting
 Projectile vomiting before & after feedings>>weight loss/dehydration
 Constantly hungry
Pyloric Stenosis
Diagnosis:
 History of symptoms
 Physical exam—Olive shaped mass
 X-ray with barium
 Visible gastric peristalsis from left>right over epigastrium.
Pyloric Stenosis
Treatment:
 Surgery—Pyloromyotomy
 Medical management
Pre-operative care:
 Improve nutrition / state of health
 NPO with IV s to restore fluid balance

Pyloric Stenosis
Pre-operative cont’d.
 Feedings with thickened formulas.
 Burp carefully.
 Feed slowly.
 Place on right side or elevated as with infant seat.
 Minimal handling after feedings/re-feed if vomiting occurs.
Pyloric Stenosis
Pre-operative care contd.
 Antispasmodic medications before feedings (atropine/phenobarbital)
.
 Sometimes this medical management works and surgery is unnecessary.
Pyloric Stenosis
Nursing Care:
 Careful assessment with v/s daily weights.
 Careful I & O.
Post-operative care:
 Maintain IV fluids 24 hours.
 Not uncommon for some vomiting to occur.

Pyloric Stenosis
Post-Operative care contd.
 Monitor v/s, IV fluids, incision site.
 Careful I & O.
 Start feeding with clear liquids, in small amounts at frequent intervals.
 Gradually increase amounts and strength of feedings.
 Position after feedings—right side or elevated.

Intussusception

 Telescoping of one part of intestine into another part below it.

 Often @ ileocecal valve.
 A common cause of intestinal obstruction in infancy.
Intussusception
Incidence:
 3-12 months
 Three times more often in males
 Specific cause is unknown.
Intussusception
Pathophysiology:
 Telescoping cause obstruction of the lumen of the bowel>>
 Inflammation and edema>>
 Reduce blood flow>>
 Gangrene/necrosis>>
 Perforation>>peritonitis
Intussusception
Symptoms:
 Sudden onset of sever abdominal pain
 Vomiting—more frequent>>fecal
 Stools—less frequent with blood and mucus with fecal matter.—(Currant jelly)
 Fever (106), rigid abdomen, signs of shock
Intussusception
Diagnosis:

 History of symptoms
 PE—rectal exam reveal blood/mucous
 Barium enema shows obstruction.
Intussusception
Treatment:
 Emergency situation
 Non-surgical reduction by Ba enema
 Force of Ba flowing will push bowel into place
 Successful in many uncomplicated cases.
 Contraindicated with signs of perforation or shock.
Intussusception
Surgical treatment:

 Manually reduce by ‘milking’ bowel back into place.

 If necessary resect any nonviable bowel tissue.
Intussusception
Pre-operative care:
 Alert to parents’ description of illness
 Measures to prevent shock/correct fluid & electrolyte balance
 Gastric suction—restraints/observe drainage.
 Antibiotics started before surgery.
 Parental support.
Intussusception
Post-operative care:
 IV until feeding can resume.
 Clear liquids after vomiting/distension clear & bowel sounds present.
 Observe stool pattern noting passage of barium and stool.
 Recurrences likely within 36 hours of reduction.
Intussusception
Post-operative care contd:
 If resection is necessary
 Naso-gastric tube/suctioning
 Watch for signs of shock / peritonitis
 Prognosis:
 Good if treated early
 If treatment delayed 24 hours >>mortality
 Untreated—death in 3-5 days.

Diarrhea
 More frequent or loose stools
 Especially serious in infants and small children
 Can become severely dehydrated very quickly.
Diarrhea
Causes:

 Overfeeding
 Formula improperly prepared
 Infectious—dangerous /highly contagious
Diarrhea
Treatment:
 Adjust feedings (formula/amounts)
 Stool specimen for C & S
 Antibiotics
 IV therapy—replacement fluids/electrolytes

Vomiting
 Occasionally healthy infant—not significant.
 Frequently—can lead to dehydration

Causes:
 Feeding difficulties
 Illnesses
Vomiting
 Treat underlying cause
 Handle gently
 Note & record vomitus
 Never leave infant alone
 Never leave infant supine
 Wipe vomitus from mouth quickly and turn to side

Dehydration
 Normally homeostasis with intake and output.
 If output exceeds intake==dehydration.
 Infant’s weight is 77 % fluid
 Can become critically dehydrated very quickly.
Dehydration
Symptoms:
 Fever
 Sunken fontanels, eyes
 Skin—dry with poor turgor
 Concentrated urine
 Oligiuria
Dehydration
Treatment:

 IV therapy to replace fluid/electrolytes.

 NPO—may need pacifier for comfort
 Avoid circulatory overload.

Hernias
Inguinal hernia:
 Protrusion of abdominal contents through inguinal canal in the groin.
 Hernial sac present @ birth.
 Not apparent until 2-3 months of age.
Hernias
Incidence:
 More often in boys (90%).
 Can be seen in girls
Symptoms:
 Asymptomatic until abdominal contents push through sac.
 Initially painless swelling when cries, strains.
 May be fretful, prone to constipation.
Hernias
Complications
 Strangulation or incarceration
Symptoms:
 Increasing irritability
 Tenderness, anorexia
 Abdominal distention
 Difficulty with defecating.
Hernias
Treatment:
 Surgery—to reduce the hernia.
Pre-operative care includes:
 If incarceration—ice bag to area, elevate foot of bed
Post-operative care
 Keep wound clean & dry
 Note 1st voiding, v/s, and I & O.
Hernias
 Umbilical hernia—Incomplete closure of umbilical ring can allow protrusion of
intestines through.
Symptoms:
 May be 1-5 cm in size
 More visible as soft swelling when strains.
 Most close spontaneously by 1-2 years
 Strangulation very rare.
Hernias
Treatment
 Observation only unless persists.
 Tapping or strapping does not help.
If surgery is necessary, post-operative care includes:
 Deep dressing clean/dry
 Normal diet for age

Parasitic Infestation
 Pinworms—most common variety of parasites affecting humans
 Looks like a thin, white thread.
Cycle:
 Infested as an egg>>
 Hatches in duodenum>>
 Migrates & matures in cecum>>
 Female emerges & lays eggs in perianal region
Infestation
Symptoms:

 Itching/scratching around perianal area.

 Irritability and restlessness @ night.
 Secondary infection –vaginitis occur.
Infestation
Transmission:
 Person-to-person.
 Particularly in close contact.
 Sharing toys, food with contaminated hands.
 May need to treat all in family.
Infestation
Diagnosis:
 Confirmed by presence of ova or worms.
 Transparent tape test.
Treatment:
 Povan @ 5 mg / kg.
 Causes secretions to turn red.
Infestation
Treatment cont’d:
 Enema may be ordered.
 Under 1 year of age ---60-100 mls.
 Older children—over up to 300 mls.
 Insert catheter only 1 ½ -3 “ into rectum.
Infestation
Parental teaching:
 Aim is to avoid reinfestation
 Keep fingernail short, clean/mittens
 Careful hand washing upon arising, before meals, after toileting.
 Scrub toilet seat daily.
 Wash underwear, bed linens, pajamas in very hot water & strong detergent.

Appendicitis
 Inflammation of the appendix or blind sac @ end of cecum.
 Most common reason for abdominal surgery in childhood years.
Incidence:
 Rare in children under 2 years old.
 Progresses rapidly to perforation.
 Treatment often delayed.
Appendicitis
Causes:

 Specific not clear

Predisposing factors may be:
 Diets low in fiber
 Parasitic infestations
Appendicitis
Symptoms:
 Abdominal pain
 Initially generalized or periumbilical pain
 Localizes to RLQ
 McBurney’s point—rebound tenderness
 Rigid abdomen with decrease bowel sounds.
Appendicitis
Symptoms cont’d.
 Fever—low-grade initially.
 A sudden sharp rise may indicate perforation.
 Vomiting—a common early sign.
 Constipation or diarrhea.
Appendicitis
Signs of peritonitis:
 Sudden relief of pain.
 Followed by greater intensity of pain.
 Rigid abdomen with tenderness.
 Tachycardia, rapid shallow breathing.
 Sharp rise in fever/chills.
 Increasing irritability, restlessness.
Appendicitis
Symptoms cont’d

 Change in behavior—significant.
 Non-verbal clues—side-lying position with knees flexed to abdomen.
 Don’t want to be handled or moved.
Appendicitis
Diagnosis:
 History and physical examination.
 Increase in WBC s up to 15-20,000.

Treatment:
 Surgery—appendectomy
Appendicitis
Pre-operative care:
 Bedrest in fowler’s position.
 Ice bag to abdomen.
 Vital signs frequently
 NPO
 Antibiotic started before surgery.
Appendicitis
To avoid increases risks of perforation:
 Teach parents, that for a child with abdominal pain---.
 Never give:
 Laxatives.
 Enemas.
 Apply heat to abdomen.
 Until appendicitis has been ruled out.
 These will increase bowel motility.

Appendicitis
Post-operative care”
 Keep wound clean & dry.
 Observations—v/s incision site, IV s
 Position with semi-fowlers
 TCDB
 Monitor I & O
 Early ambulation
Anorexia Nervosa
 Psychosocial in origin
 Characterized by
 Starvation
 Excessive weight loss
 Weight loss of more than 25% of total body weight.
Anorexia Nervosa

 Incidence is more in girls

 During adolescence and early twenties.
 More is also being seen in males.
Anorexia Nervosa
Predisposing factors:
 High expectations of family
 Low-self esteem
 Unrealistic idea of perfection:
 Sees weight loss as desirable
 Sees themselves as ‘fat’
 Refuses to see seriousness
Anorexia Nervosa
Predisposing factors cont’d
 Society’s emphasis on slimness
 Feel they have lack of control over their lives, and diet is one way to control.
 Anxieties caused by adolescence
 Rapidly changing body
 New feelings/fears
 Peer group pressures
Anorexia Nervosa
Symptoms:
 Distorted attitude regarding eating, food, weight
 Overrides hunger and reason
 Weight in absence of illness
 Amenorrhea, overactivity
 Bradycardia, decrease in temperature & B/P.

Anorexia Nervosa
Typical meal plan:

 Breakfast—nothing
 Lunch—plain lettuce
 Dinner—piece of fruit or several spoonfuls of vegetable.

Bulemia

 Binge-purge pattern of eating

 Overindulge
 Self-induced vomiting
 Laxatives, enemas
Eating disorders
Treatment:
 Psychotherapy for patient and family.
 Therapeutic environment
 Aim is to improve eating habits
 Acceptable weight gain
 Improved emotional status & interpersonal relationships

Obesity in children
 Frequently a problem in prepubescent and adolescent children.
 Often these children may feel:
 Inadequate, ridiculed
 Rejected, unloved
 Unable to participate in many activities
Obesity
Causes:
 Rarely abnormal functions of glands
 Overfeeding in infancy or young childhood.
 Unhappiness—increase food intake
 Obese parents—set role model
 Poor dietary pattern with >>CHO/fats
Obesity
Treatment:
 Improve self-image
 Improve dietary pattern
 Weigh @ regular intervals (1-2 months)
 Give praise and rewards for weight loss