PEDIATRIC NURSING: GASTROINTESTINAL SYSTEM AND ITS DISORDERS

The gastrointestinal (GI) system involves a long body tract with numerous organs. This system is
responsible for taking in and processing nutrients for all parts of the body. Any problem can quickly affect
other systems, and if not adequately treated can affect overall health, growth and development.

NURSING PROCESS for a Child with GI Problem

ASSESSMENT
Nausea and Vomiting
Signs of dehydration
- dry mucous membranes
- poor skin turgor
- lack of tearing
Weight comparison – compare the child’s current weight with past weight measurements
Stool characteristics – color, consistency; presence of diarrhea

NURSING DIAGNOSIS
Imbalance nutrition, less than body requirements r/t malabsorption of necessary nutrients.
Impaired parenting r/t interference with establishing parent-infant bond.
Interrupted family processes r/t chronic illness in child.
Low self-esteem r/t feelings of different resulting from special dietary restrictions.
Risk for deficient fluid volume r/t chronic diarrhea.

PLANNING
After effective nursing interventions the parents will be able to:
Learn appropriate nutritional pattern for their child;
Learn information about the basic food group categories;
Learn the importance of providing food from the food pyramid;
Learn how to do nasogastric feedings.
Develop skills in caring for their child with GI disorder.

IMPLEMENTATION
Discuss appropriate nutritional pattern specific for the child’s disorder and needs.
Provide information about the basic food groups as well as the food pyramid.
Provide parental support in caring for their child with chronic disorder.
Encourage parents to follow religiously the necessary guidelines in the care of their child.
Demonstrate how to do NG feeding and have the parent or caregiver do the demonstration
themselves after.

EVALUATION
Expected outcome will be the child should gain weight and maintain growth and development
appropriate for his/her age.

GASTROINTESTINAL DISORDERS

CLEFT LIP AND CLEFT PALATE

CLEFT LIP – incomplete fusion of facial processes. It occurs between 5 & 8th weeks of fetal life.
Common in Males. It occurs in 1 in every 1, 000 births.

CLEFT PALATE – fissures in soft & hard palate & dental ridge. Failure of union of embryonic structure of
face (palatal structures) which occurs at 9-12 weeks of fetal life.
Common in Females. Occurs in 1 in every 2,500 births.

Classifications of Cleft Lip Classifications of Cleft Palate

Unilateral – more common on the left side Midline
Bilateral Unilateral
Bilateral
Types of Cleft Lip
Incomplete – maybe a small notch in the upper lip.
Complete – extended to the nasal system and dental ridge; continuous with cleft palate.
Etiology: Unknown
Genetic
Hereditary
Maternal alcohol/drug ingestion
Prenatal infection
Clinical Manifestations:
Cleft Lip
Difficulty in sucking- inability to form airtight seal around nipple
Difficulty swallowing
Abdominal distention – mouth breathing which increases swallowed air
Predisposition to infection – free communication, mucous membranes of the
oropharynx become dried & cracked
Cleft Palate
Infection – aspiration pneumonia
Altered speech – palate is needed to tap air in the mouth
Dental caries development.
Hearing problems – caused by recurrent otitis media
Management:
Surgical correction- early correction to avoid speech defects
Cheiloplasty – correction of cleft lip; to unite edges to allow lips to be both functional & usually
performed at age of 2 months after birth
Cleft palate repair is usually after the child has grown but before speech is well-developed
(between 6 – 18 months).
Nursing management: (Pre-op)
1. Feed in upright position to decrease chance of aspiration & decrease amount of air swallowed.
2. Burp frequently – increased swallowed air causes abdominal distention & discomfort
3. Use a soft with large hole nipple. Press cleft lip together with fingers to encourage sucking &
strengthening muscles needed for speech.
4. If infant is unable to suck, use a rubber tipped syringe & drip formula side of mouth.
5. Finish feeding with water to wash away formula in palate area.
6. Provide small frequent feedings.
7. Provide emotional support by demonstrating benefits of surgery by showing before & after pictures.
(Post-op)
1. Maintain patent airway. Keep laryngoscope, ET tube and suction nearby.
2. Avoid pressure or tension on suture lines. Supine position for cleft lip and prone position for cleft palate.
3. Cleft palate: avoid the use of straw, spoon, toothbrush.
4. Resume feedings as ordered.
5. Keep suture line clean. Give water after each feeding to clean suture line.

TRACHEOESOPHAGEAL FISTULA
Presence of abnormal opening between trachea & esophagus. Occurs in about 1 in 4,000 live
births.
Esophageal Atresia – failure of esophagus to form a continuous passage between pharynx &
stomach
Etiology: Unknown
Types: (American Academy of Pediatrics)
Type A – esophageal atresia without fistula (7.7%)
Type B – esophageal atresia with tracheoesophageal fistula to the proximal segment (0.8%)
Type C – esophageal atresia with fistula to the distal segment (86.5%)
Type D – esophageal atresia with fistula to both segments (0.7%)
Type E or H type – tracheoesophageal fistula without atresia (4.2%)
Clinical Manifestations:
Maternal hydramnios – 3rd trimester & at delivery of infant
After birth : excessive salivation
- dysphagia : stenosis type
- 3 C’s : choke, cough, cyanosis (after initial feeding)
Abdominal distention
Respiratory distress
Severe pneumonia & atelectasis
Diagnostic tests:
Bronchoscopy – visualize the fistula between the trachea & esophagus
Chest X-ray – detect pneumonia & a dilated, air-filled upper esophageal pouch
Management: (Pre-op)
1. Monitor respiratory status – observe signs & symptoms of distress
2. Proper positioning – upright position
3. Regular/intermittent suctioning.
4. Oxygen administration – cyanosis
5. Hydration & nutrition – maintain IV (TPN)
6. Antibiotics – to prevent or treat pneumonia
7. Assist in Bougie test
Surgical intervention:
Primary repair – division of fistula & esophageal anastomosis
If gap is large, repair is done which includes creation of gastrostomy & esophagostomy as the
initial intervention.
(Post-op)
1. Keep on NPO – gastrostomy feeding is started 3-4 days post-op
2. Proper positioning – avoid hyperextension of neck to prevent stricture in the anastomosed site to develop
3. Monitor for signs of respiratory distress.
4. Change position to prevent pneumonia.
5. Check dressing as frequent as possible.
Early signs of STRICTURE: dysphagia, refuses feeding, pronounced cough

PYLORIC STENOSIS
Hypertrophy or hyperplasia of the muscle surrounding the pyloric sphincter. It usually occurs 1-10
weeks after birth. With this condition children begin to vomit almost immediately after each feeding.
Etiology: unknown
first born white males
more frequent in formula-fed infants
increase incidence in infants who receive macrolide antibiotic (erythromycin)
Clinical manifestations:
Vomiting – progressively projectile, non-bile stained and sour vomitus
Constipation
Distention of epigastrium
Visible peristalsis – palpable olive-shaped mass in the Upper Right Quadrant
Dehydration & weight loss
Classic sign – “string sign” on bowel elimination
Diagnostic tests:
Sonogram & Endoscopy – visualize hypertrophied sphincter
Definitive diagnosis: Watch the child drink – before he drinks, attempt to palpate the RUQ of the
abdomen for pyloric mass, as the child drinks the lump becomes prominent.
Management:
Surgical or laparoscopic correction – pyloromyotomy
(Pre-op)
1. Fluid & electrolyte replacement based on laboratory determinations.
2. Watch for signs of dehydration.
(Post-op)
1. Infants are started on a small amount of an oral rehydrating solution by bottle as ordered.
2. Lay them on their right side after each feeding to prevent aspiration.
3. Prevent infection on the incision site – change diapers frequently and keep it low.
4. Provide parental support.

INTUSSUSCEPTION
Invagination of one portion of the intestine into another. This disorder usually occurs in the second
half of the first year of life.
Etiology: Unknown for infants younger than 1 year.
For older than 1 year : Meckel’s diverticulum; polyp; hypertrophy of Peyer’s patches; bowel
tumors
Clinical manifestations:
Sudden onset of abdominal pain
With pain – child scream & draws his knees towards his chest
Vomiting with bile
Irritable; lethargic; apathetic
Abdomen becomes rigid, tender & distended
Sausage-shaped mass felt in the upper abdomen
Classic sign: “currant jelly” stool (bloody, loose & mucoid)
Diagnostic tests:
Barium enema
Sonogram
Complications: Perforation; Peritonitis; Shock
Management:
Surgery – to straighten the invaginated portion
Barium enema, water-soluble solution or air is used to reduce intussusception.
Pre-op and post-op management are the same with any abdominal surgery.

DIVERTICULUM
Pouch like herniations of intestinal mucosa as a result of weakness and intra-abdominal pressure;
maybe asymptomatic.
Most commonly occurs in the sigmoid colon, but could occur anywhere along the GI tract.
 Diverticulitis – inflammation caused by food & feces trapped in a diverticulum; may lead to
bleeding perforation, peritonitis & bowel obstruction.
Clinical manifestations:
Altered bowel elimination
Diarrhea/constipation
Abdominal distention
Fever; leukocytosis
Painless, tarry black stool/ grossly bloody stool
Diagnostic tests:
CT scan; colonoscopy - provide direct evidence of the disease
Management:
1. Teach the importance of high fiber diet & high fluid intake to prevent diverticulitis & to prevent
constipation.
2. Maintain NPO & gastric decompression if ordered during acute episode.
3. Monitor for signs of peritonitis: pain, hypotension, abdominal rigidity, abdominal distention,
leukocytosis.
4. Administer fluid & electrolyte replacement.
Surgery: hemicolectomy – excision of the half of the colon
Temporary loop colostomy
Removal of the involved bowel

CELIAC DISEASE
Sensitivity or abnormal immunologic response to protein, particularly the gluten factor of protein
found in grains-wheat, rye, oats and barley. The disease becomes usually becomes apparent between ages 6
& 18 months, after gluten containing foods are introduced into the diet. There are theories that suggest that
the disease involves an abnormal immune response. Another theory proposes that an intra-mucosal enzyme
defect produces an inability to digest gluten.
Etiology: unknown
Genetic predisposition
Environmental factors
Clinical manifestations:
Recurrent attacks of diarrhea
Abdominal pain & distention
Anorexia & malnutrition
Steatorrhea – bulky, foul-smelling, fatty stools
Hypoprothrombinemia
Hypochromic anemia
Hypoalbuminemia
Diagnostic tests:
Serum analysis of antibodies against gluten (IgA antigliadin antibodies)
Endoscopy – obtain biopsy of the intestinal mucosa
Stool analysis for fat content
Management:
1. Nutritional counseling for parents.
2. High caloric but gluten-free diet for life.
3. Small frequent feedings, adequate fluids.
4. Vitamin supplements.
 The disappearance of steatorrhea is a good indicator that the child’s ability to absorb nutrients is
improving.
 Celiac crisis – extreme symptoms may occur, both vomiting & diarrhea become acute

HIRSCHSPRUNG’S DISEASE (Aganglionic Megacolon)

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. The absence of nerve cells means no peristaltic
waves in this section to move fecal material through that segment of intestine. The portion of the bowel
proximal to the obstruction dilates, distending the abdomen.
Etiology: unknown
Familial predisposition
Common in males
Genetics - abnormal gene on chromosome 10
Incidence – 1 in 5,000 live births
Clinical manifestations:
Neonate:
Delay passage of meconium by 24 hours of life
Increasing abdominal distention
Develops disinterest in feeding
Vomiting
Older infants:
Persistent constipation
Poor feeding, failure to thrive
Irritable & fretful
Fever
Passage of Ribbon-like stools
Complication: Diarrheal enterocolitis (below 3 mos.)
Diagnostic tests:
Barium enema – outline on x-ray the narrow, nerveless portion & the proximal
distended portion of the bowel.
Rectal biopsy – definitive diagnosis
Anorectal manometry – to test the innervation of the internal sphincter
Management:
1. Prevent constipation. Administer saline enemas and teach parents how to do so.
2. Provide good nutrition. Help parents learn about low-residue diet.
3. Provide parental support.
Treatment of choice: 3 stage approach
Temporary colostomy
Definitive repair – 12-18 months
Closure of colostomy

ULCERATIVE COLITIS and CROHN’S DISEASE

Categorized as inflammatory bowel disease. They both involve the development of ulcers of the
mucosa or submucosa layers of the colon & rectum.
Crohn’s disease is an inflammation of segments of the intestine; it may affect any part of the GI
tract but most commonly involves the terminal ileum. Inflamed segments are separated by normal bowel
tissue and there is a “cobblestone” appearance of the mucosa.
Ulcerative colitis typically involves the colon and rectum, with the distal part most severely
affected and the inflammation involves continuous segments.
Etiology: unknown
Alteration in immune system response - increase number of IgA & IgG on intestinal mucosa
Familial tendencies
Common in males
Incidence: most frequent in young adults though first symptoms appear during school age
Frequent use of antibiotics/aspirin
Smoking
Clinical manifestations:
Abdominal pain
Diarrhea, malnutrition, growth retardation
Anorexia, weight loss
Complications: Bowel perforation; hemorrhage; peritonitis; fistula
Diagnostic tests:
Colonoscopy
Barium enema
Bowel biopsy
Occult blood
Management:
1. Provide enteral or total parenteral nutrition to allow the bowel to rest.
2. After the resting period, high protein, high carbohydrate, high vitamin diet is prescribed.
3. Drug therapy: Prednisone, sulfasalazine, azathioprine – generally brings improvement in symptoms.
Cyclosporine may be use for ulcerative colitis.
4. Surgery: Colectomy
Colostomy or continent ileostomy

ANORECTAL MALFORMATION/IMPERFORATE ANUS

A congenital absence or obstruction of the anal opening. The disorder can be relatively minor,
requiring incision of the persistent, or much more severe, involving sections of the bowel that are many
inches apart with no anus. There may be accompanying fistula to the bladder in boys and to the vagina in
girls.
Types:
Anal stenosis – (10%); characterized by small opening
o Treatment : serial dilations of the anus
Imperforate anal membrane – noted after birth
Initial manifestations: failure to pass meconium; inability to insert thermometer; presence of greenish
bulging membrane
Anal or rectal agenesis – (75-85%); maybe associated with vaginal/urethral fistulas
Rectal atresia – blind rectal pouch with a normal anus
Etiology:
May occur as an additional complication of spinal cord disorders
Common in males
Incidence: 1 in 5,000 live births
Clinical manifestations:
Failure to pass meconium in 24 hours of life
Abdominal distention
Presence of protruding membrane-filled with black meconium on the anus
Inability to insert rectal thermometer
Management:
Surgical: Anoplasty – surgical reconstruction
(Pre-op)
1. Keep on NPO.
2. Assist in gastric intubation.
3. Psychosocial support to parents.
(Post-op)
1. Proper positioning.
2. Proper post-op wound care.
3. Monitor bowel sounds.
 11 KEY AREAS OF NURSING RESPONSIBILITIES

Safe & Quality Nursing Care

Asses the health status of the patient.
Identifies the health needs of the patient and the appropriate nursing care to be provided.
Reinforces physicians’ explanation if patient/significant other doesn’t understand the
condition/procedure/regimen.
Performs age-specific safety & comfort measures in all aspects of patient care.
Conforms to the 10 golden rules in medication administration.
Management of Resources and Environment
Plans the performance of activities based on priority.
Determines the resources and equipments needed to deliver patient care.
Adheres to policies, procedures, and protocols on prevention and control of infection.
Health Education
Assess and identifies priority needs.
Utilizes appropriate strategies & considers client & family’s preparedness.
Formulates a comprehensive health education plan involving the patient, family and
significant others.
Monitors client & family’s responses to the health education.
Legal Responsibility
Confirms information given by the physician for informed consent.
Secures waiver of responsibility for refusal to undergo treatment or procedure.
Checks the completeness of informed consent & other legal forms.
Accomplishes accurate documentation in all matters concerning patient care.
Fulfill legal requirements in nursing practice.
Ethico-Moral Responsibility
Renders nursing care consistent with the patient’s bill of rights.
Reports unethical & immoral incidents to proper authorities.
Personal and Professional Development
Maintains membership to professional organization.
Participates in formal & non-formal education and applies learned information for the
improvement of care.
Tries new strategies or approaches & adapts to changes willingly.
Quality Improvement
Solicits feedback from patient & significant others regarding care rendered.
Contributes relevant information about patient condition.
Gives appropriate suggestions on corrective & preventive measures.
Research
Identifies researchable problems regarding patient care and the appropriate methods of
research.
Communicates results of findings to colleagues, patients and family.
Makes use of evidence-based nursing to ameliorate nursing practice.
Record Management
Completes updated documentation of patient care and uses record system like Kardex.
Observes confidentiality & privacy of the patient’s records.
Maintains an organized system of filing & keeping patient’s records in a designated area.
Refrains from releasing records & other information without proper authority.

Communication
Spends time with the client & family to facilitate conversation that allows expression of
concerns.
Creates trust & confidence.
Communicates through therapeutic touch, warmth & comforting words of
encouragement.
Collaboration and Teamwork
Maintains good interpersonal relationships with patients, colleagues, and other members
of the health team.
Contributes to decision making regarding patient’s needs and concerns.
Recommends appropriate intervention to improve patient care.
Refers patient to appropriate health agencies.
 Pillcam May Be Valuable Children's Diagnostic Tool
10/22/2008
VIENNA, Austria — Given Imaging Ltd. announced today that results from two new studies confirm
the value of PillCam SB capsule endoscopy among young children with a range of small intestinal
disorders, and in adults with overt obscure gastrointestinal bleeding (OGIB). The abstracts were
presented during the 16th United European Gastroenterology Week (UEGW) 2008 conference taking
place in Vienna, Austria from October 18 to 22.

Following evaluation with PillCam capsule endoscopy, investigators changed the treatment and
management of the disease in 60 percent of children with small intestinal disorders. The capsule was
most effective in those children with severe recurrent abdominal pain, Crohn's disease and GI
hemorrhage. Even in those cases when a negative diagnosis was made for severe recurrent abdominal
pain, the PillCam video capsule provided sufficient information to alter management in 85 percent of
children.

"These data suggest that the PillCam SB capsule may be particularly helpful in the management of
young children with recurrent abdominal pain," said Annette Fritscher-Ravens, MD, Homerton
University Hospital, London and lead investigator. "The capsule is particularly suited to children, where
previously diagnostic tools required anesthesia, were uncomfortable, or had a significant radiation
burden. In contrast, the capsule is child- and parent-friendly."

The 83 patients who were included in the study underwent upper and lower GI endoscopy, and
physicians recommended a course of treatment prior to capsule evaluation. Suggested changes to disease
management were documented following the capsule evaluation.

The PillCam SB video capsule, when used with the PillCam Platform, is intended for visualization of the
small bowel mucosa. It may be used as a tool in the detection of abnormalities of the small bowel in
adults and children from 10 years of age and up. The PillCam SB video capsule and the PillCam
Platform are not cleared for use in children less than 10 years of age and should not be used outside of
the context of approved clinical trials with such patients.

Use of Complementary and Alternative Medicine by Pediatric Patients with Functional and
Organic Gastrointestinal Diseases: Results from a Multicenter Survey

Published online July 28, 2008

PEDIATRICS Vol. 122 No. 2 August 2008, pp. e446-e451 (doi:10.1542/peds.2008-0266)

Arine M. Vlieger, MD, Marjolein Blink, MD, Ellen Tromp, PhD and Marc A. Benninga, MD, PhD
Departments of Pediatrics
   ABSTRACT
 
OBJECTIVES. Many pediatric patients use complementary and alternative medicine, especially when
facing a chronic illness for which treatment options are limited. So far, research on the use of
complementary and alternative medicine in patients with functional gastrointestinal disease has been
scarce. This study was designed to assess complementary and alternative medicine use in children with
different gastrointestinal diseases, including functional disorders, to determine which factors predicted
complementary and alternative medicine use and to assess the willingness of parents to participate in
future studies on complementary and alternative medicine efficacy and safety.
RESULTS. In this study population, the frequency of complementary and alternative medicine use was
37.6%. A total of 60.3% of this group had used complementary and alternative medicine specifically for
their gastrointestinal disease. This specific complementary and alternative medicine use was higher in
patients with functional disorders than organic disorders (25.3% vs. 17.2%). Adverse effects of
allopathic medication, school absenteeism, age 11 years, and a low effect of conventional treatment
were predictors of specific complementary and alternative medicine use. Almost all (93%) of the parents
considered it important that pediatricians initiate complementary and alternative medicine research, and
51% of parents were willing to participate in future complementary and alternative medicine trials.
CONCLUSIONS. Almost 40% of parents of pediatric gastroenterology patients are turning to
complementary and alternative medicine for their child. Lack of effectiveness of conventional therapy,
school absenteeism, and adverse effects of allopathic medication are more important predictors of
complementary and alternative medicine use than the type of gastrointestinal disease. Because evidence
on most complementary and alternative medicine modalities in children with gastrointestinal disorders is
lacking, there is an urgent need for research in this field.

CENTRAL PHILIPPINE UNIVERSITY

School of Graduate Studies
Jaro, Iloilo City
GASTROINTESTINAL DISORDERS OF PEDIATRIC CLIENTS

In partial Fulfillment in the

Requirements in the Subject
Cognate (Pedia)

Submitted to:

Atty. Salex Alibogha

Instructor

Submitted by:

Mary R. Repedro, RN
MN Student