HESI REVIEW

GI
Collaborative Care
Objectives of collaborative care for acute pancreatitis include (a) relief of pain; (b)
prevention or alleviation of shock; (c) reduction of pancreatic secretions; (d) control of
fluid and electrolyte imbalance; (e) prevention or treatment of infections; and (f) removal
of the precipitating cause, if possible (Table 46-19). 

Table 46-19   -- COLLABORATIVE CARE Acute Pancreatitis

Diagnostic Collaborat
   •   History and physical examination    •  

   •   Serum amylase measurement    •  

   •   Serum lipase measurement    •  

   •   Blood glucose measurement    •  

   •   Serum calcium measurement    •  

   •   Triglyceride measurement    •  

   •   Flat-plate radiography of the abdomen    •  

   •   Abdominal ultrasonography

   •   Endoscopic ultrasonography

   •   Contrast medium–enhanced CT

    •   MRCP

   •   ERCP

   •   Chest radiography

CT, computed tomography; ERCP, endoscopic retrograde

cholangiopancreatography; IV, intravenous; MRCP, magnetic resonance
cholangiopancreatography; NG, nasogastric; NPO,nothing by mouth.

Conservative Therapy.
Treatment is focused principally on supportive care, including aggressive hydration,
pain management, management of metabolic complications, and minimization of
pancreatic stimulation. A primary consideration in the treatment of acute pancreatitis is
the relief and control of pain. IV morphine may be administered. Pain medications may
be combined with an antispasmodic. However, atropine-like drugs should be avoided
when paralytic ileus is present because they may contribute to the problem. Other
medications that relax smooth muscles (spasmolytics), such as nitroglycerin or
papaverine, may be administered.
If shock is present, plasma or plasma volume expanders such as dextran or albumin
may be given. Fluid and electrolyte imbalances are corrected with lactated Ringer's
solution. Central venous pressure readings may be used to assist in determining
requirements for fluid replacement. Vasoactive drugs such as dopamine may be
administered to increase systemic vascular resistance in patients with ongoing
hypotension.
Pancreatic enzyme secretion must be reduced or suppressed in order to decrease
stimulation of the pancreas and allow it to rest. Suppression of pancreatic secretion is
accomplished by keeping the patient on nothing-by-mouth (NPO) status and by using
NG suction to reduce vomiting and gastric distension and to prevent gastric acidic
contents from entering the duodenum. Certain drugs may also be administered for this
purpose (Table 46-20). The inflamed and necrotic pancreatic tissue is a good medium
for bacterial growth; therefore, it is important to prevent infections. The prophylactic use
of antibiotics is somewhat controversial. The patient should be monitored closely so that
antibiotic therapy can be instituted early if infection occurs. 

Table 46-20   -- DRUG THERAPY Acute and Chronic Pancreatitis

 DRUG MECHANIS

Acute Pancreatitis

Morphine, meperidine (Demerol) Relief of p

Nitroglycerin or papaverine Relaxation

Antispasmodics (e.g., dicyclomine [Bentylol]* Decrease o

concentrat

Carbonic anhydrase inhibitor (acetazolamide [Diamox]) Reduction

Antacids Neutraliza
production

Histamine H2-receptor antagonists (cimetidine [Tagamet], ranitidine [Zantac]); Decrease i

proton pump inhibitors (omeprazole [Prevacid])

Chronic Pancreatitis

Pancreatin (Viokase), pancrelipase (Cotazym) Replacem

Insulin Treatment

HCl, hydrochloric acid.

Contraindicated in patients with paralytic ileus.

*

Surgical Therapy.
When the acute pancreatitis is related to the presence of gallstones, urgent ERCP and
endoscopic sphincterotomy may be performed and followed by laparoscopic
cholecystectomy to reduce the potential for recurrence. Surgical intervention may also
be indicated when the diagnosis is uncertain and in patients who do not respond to
conservative therapy. Patients with severe acute pancreatitis may require drainage of
necrotic fluid collections. This can be accomplished either surgically, under guidance by
CT, or endoscopically. A pseudocyst can be drained percutaneously, and a drainage
tube is left in place.
Drug Therapy.
Several different drugs may be used in the treatment of both acute and chronic
pancreatitis (see Table 46-20). A number of drugs are administered in an effort to
suppress pancreatic secretion, but these drugs have not proved effective in the
management of pancreatitis.
Nutritional Therapy.
Initially, patients with acute pancreatitis are kept on NPO status to reduce pancreatic
secretion. When food is allowed, small, frequent feedings are given. The diet is usually
high in carbohydrate content because that is the least stimulating to the exocrine portion
of the pancreas. Intolerance to oral foods should be suspected if a patient reports pain,
has increasing abdominal girth, or has elevated amylase and lipase levels. The patient
needs to abstain from alcohol. Supplemental fat-soluble vitamins may be administered.
Depending on the severity of the pancreatitis, the patient may require enteral feeding
via nasojejunal tube. Because of infection risk, parenteral nutrition is reserved for
patients who cannot tolerate enteral nutrition (see  Chapter 42).

Respiratory
Opioids.
Opioids are used before surgery for sedation and analgesia, intraoperatively for
induction and maintenance of anaesthesia, and after surgery for pain management.
Opioids alter the perception of pain and the response to painful stimuli. When
administered before the end of a surgical procedure, the residual analgesia often carries
over into the PACU, allowing the patient to awaken relatively pain free.
All opioids produce dose-related respiratory depression. Respiratory depression may be
difficult to detect in the OR and, therefore, necessitates close observation and pulse
oximetry monitoring. Respiratory depression can be reversed with naloxone. However,
its use is often associated with a reversal of the analgesic effects of the narcotics as
well.

Respiratory
Respiratory Depression
Long-term opioid use is generally associated with tolerance to respiratory depression
but can occur because opioids can inhibit brainstem respiratory pathways.
Preventive measures: For severe respiratory depression, narcotic antagonists may be
used to improve respiratory status and, if titrated in small amounts, the respiratory
depression may be reversed without analgesia reversal.

Clinical Unit
Deep breathing is encouraged to facilitate gas exchange and promote the return to
consciousness. The patient should be taught to take in slow, deep breaths, ideally
through the nose, to hold the breath, and to then slowly exhale. This type of breathing is
also useful as a relaxation strategy when the patient is anxious or in pain.

Deep breathing and coughing techniques in the postoperative phase help the patient
prevent alveolar collapse and move respiratory secretions to larger airway passages for
expectoration. The patient should be assisted to breathe deeply 10 times every hour
while awake. The use of an incentive spirometer is helpful in providing visual feedback
of respiratory effort (Harton, Grap, Savage, & Elswick, 2007). The nurse should teach
the patient to use an incentive spirometer, which involves the following: inhale into the
mechanism, hold the ball for about 3 seconds, and then exhale. This procedure should
be done 10 to 15 times, and then the nurse should encourage the patient to cough. It is
recommended that an incentive spirometer should be used every 2 hours while awake
(University of Pittsburgh Medical Center, 2011). Diaphragmatic or abdominal breathing
is accomplished by inhaling slowly and deeply through the nose, holding the breath for a
few seconds, and then exhaling slowly and completely through the mouth. The patient's
hands should be placed lightly over the lower ribs and upper abdomen. This allows the
patient to feel the abdomen rise during inspiration and fall during expiration.
Effective coughing is essential in mobilizing secretions (see  Chapter 30). If secretions
are present in the respiratory passages, deep breathing often will move them up to
stimulate the cough reflex without any voluntary effort by the patient, and then they can
be expectorated. Splinting an abdominal incision with a pillow or a rolled blanket
provides support to the incision and aids in coughing and expectoration of secretions

Techniques for splinting wound when coughing.

The patient's position should be changed every 1 to 2 hours to allow full chest
expansion and increase perfusion of both lungs. Ambulation, not just sitting in a chair,
should be aggressively carried out unless contraindicated by the surgical procedure
performed or other concurrent diagnoses. Adequate and regular analgesic medication
should be provided because incisional pain often is the greatest deterrent to patient
participation in effective ventilation and ambulation. The patient should also be
reassured that these activities will not cause the incision to separate. Adequate
hydration, either parenteral or oral, is essential to maintain the integrity of mucous
membranes and to keep secretions thin and loose for easy expectoration.

Neuro
Dysphagia
Dysphagia is a symptom of disease or dysfunction and can be the result of a number of
medical conditions. Among adults, the prevalence of dysphagia ranges from 10 to 50%
in acute-care facilities and up to 66% in long-term care facilities (Dietitians of Canada,
2005). Defined as any impairment in eating, drinking, or swallowing, the consequences
of unrecognized and untreated dysphagia can be life-threatening: protein–calorie
malnutrition, dehydration, acute choking episodes that may lead to airway occlusion,
chronic aspiration leading to frequent chest infections, and unnecessary long-term EN
support (Dietitians of Canada, 2005).
Nurses must carefully assess all patients for the presence of signs of dysphagia (Table
42-7). A swallowing assessment, performed by a speech language pathologist can help
identify patients at risk of aspiration, including the location of the swallowing problem
and which food consistencies are safest. The speech language pathologist may also
determine swallowing exercises, appropriate head positioning, and swallowing
techniques. 

Table 42-7   -- Indicators of Dysphagia

Obvious Indicators of Dysphagia

   •   Difficult, painful chewing or swallowing

   •   Regurgitation of undigested food

   •   Difficulty controlling food or liquid in the mouth

   •   Drooling

   •   Hoarse voice

   •   Coughing or choking before, during, or after swallowing

   •   Globus sensation (lump in the throat)

   •   Nasal regurgitation

   •   Feeling of obstruction

   •   Unintentional weight loss—for example, in people with dementia

Less Obvious Indicators of Dysphagia

   •   Change in respiration pattern

   •   Unexplained temperature spikes

    •   Wet voice quality

   •   Tongue fasciculation (may be indicative of motor neuron disease)

   •   Xerostomia

   •   Heartburn

   •   Change in eating—for example, eating slowly or avoiding social

occasions

   •   Frequent throat clearing

   •   Recurrent chest infections

   •   Atypical chest pain

GI
Hernias
A hernia is a protrusion of a portion of an organ or organs through an abnormal
opening. The danger of herniation arises when the protrusion is constricted,
impairing circulation, or when the protrusion interferes with the function or
development of other structures. The herniations discussed in this section are those
that protrude through the diaphragm, the abdominal wall, or the inguinal canal.
Congenital Diaphragmatic Hernia
Congenital diaphragmatic hernia (CDH) results when the diaphragm does not
form completely, resulting in an opening between the thorax and the abdominal
cavity. The most common type of CDH (90%) is a left posterolateral defect, also
known as a Bochdalek hernia because the herniation occurs through the foramen of
Bochdalek (Fig. 11-25). If the diaphragm does not form completely, the intestines
and other abdominal structures, such as the liver, can enter the thoracic cavity,
compressing the lung. Lung growth may be arrested on the affected side and to a
lesser degree on the contralateral side. Ventilation is further compromised by
hypoplasia and compression of the lung, including the airways and blood vessels. In
addition to the anatomic defect, pulmonary hypoplasia and pulmonary hypertension
have also been recently recognized as components in the pathology of CDH. 

Fig. 11-25 A, Normal diaphragm separating the abdominal and thoracic

cavities. B, Diaphragmatic hernia with a small lung and abdominal contents in the
thoracic cavity.
This serious defect requires prompt recognition and aggressive treatment to reduce
its high mortality. The incidence of CDH is approximately 1 in 2000 to 5000 live
births (Ehrlich and Coran, 2007). When stillbirths, intrauterine deaths, and elective
abortions are included, the total incidence of CDH is higher than data observed in
practice (Brownlee, Howatson, Davis, et al, 2009). Associated anomalies have
occurred in as many as 30% of CDH, and CDH is observed in several chromosomal
syndromes (Ehrlich and Coran, 2007).
Clinical Manifestations
The most common manifestation of CDH is acute respiratory distress in the
newborn. Entrance of air into the intestines after birth further compromises
respiration. Infants with a CDH may be dyspneic and cyanotic and have a scaphoid
abdomen (because of abdominal contents in the chest). Cardiac output is impaired,
and the infant exhibits signs and symptoms of shock. Some infants with small
defects may not exhibit respiratory symptoms until later in infancy.
Diagnostic Evaluation
Prenatal diagnosis of CDH as early as the twenty-fifth week of gestation is possible.
The three main features detected by ultrasonography that confirm the diagnosis are
polyhydramnios, mediastinal shift, and loops of bowel in the chest cavity. In severe
cases fetal hydrops is evident. Low MS-AFP levels are seen in cases of CDH;
however, the finding is not specific for this anomaly.
Antenatal diagnosis of CDH is reported to have the following advantages: (1)
counseling the family regarding pregnancy alternatives and potential problems of the
neonatal period; (2) continuation of the pregnancy and further management,
including possible antenatal treatment; and (3) transport of the fetus with a CDH in
utero to a tertiary center for management. A multidisciplinary team of neonatologists,
neonatal nurses, and pediatric surgeons can intervene early in the acute phase to
improve the infant's chances for survival and a positive outcome.
After birth, the diagnosis of CDH may depend on the type of hernia present. In the
majority of cases the diagnosis is suspected on the basis of the clinical
manifestations and is confirmed by a chest radiograph. The chest radiograph shows
fluid- and air-filled loops of intestine in the affected side of the chest. The
mediastinum may be shifted to the unaffected side, and auscultation may reveal
decreased breath sounds on the affected side.
Therapeutic Management
Fetal Surgery
Advances in fetal diagnostic and surgical techniques led to intrauterine repair of
CDH in the 1990s, but the outcomes were poor and prenatal surgery was
discontinued for a period in the United States (Kays, 2006). Tracheal occlusion (TO)
has been shown to expand the lungs and push the abdominal contents back into the
abdomen, thus producing larger, functional lungs. Several surgical techniques, such
as PLUG (plug the lung until it grows) and EXIT (ex utero intrapartum treatment),
have been used in human fetuses to increase fetal lung growth and establish an
effective airway for ventilation. Minimally invasive fetal surgical endoscopic tracheal
occlusion techniques (FETENDO) in the United States have had moderate success
(Jelin and Lee, 2009). Recently two outcome-prediction factors—intrathoracic liver
position and lung (contralateral) area–to–head circumference ratio—have been used
in combination with fetal endoscopic TO surgery in Europe with varying results
(Deprest, Gratacos, Nicolaides, et al, 2009).
After Birth
Many infants with a CDH require immediate respiratory assistance, which includes
endotracheal intubation and GI decompression with a double-lumen catheter to
prevent further respiratory compromise. At birth, bag and mask ventilation is
contraindicated to prevent air from entering the stomach and especially the
intestines, further compromising pulmonary function. In infants with mild respiratory
distress, oxygen may be given by hood. However, close attention to the infant's acid-
base status is imperative in the management and prevention of pulmonary
hypertension. Low ventilatory positive pressure and the lowest mean airway
pressure possible, combined with rapid ventilatory rates (80 to 120 breaths/min),
may reduce the incidence of pulmonary leaks from overinflation of the unaffected
lung.
IV fluids are initiated during the stabilization period. A transcutaneous oxygen
pressure monitor or pulse oximeter may be placed preductally (right hand) and
postductally (left hand, arm, or either foot) to monitor the amount of ductal shunting
through the patent ductus arteriosus. An umbilical arterial catheter will help monitor
postductal arterial oxygen tension (Pao2) and allow infusion of fluids, glucose, and
electrolytes. Ductal shunting of deoxygenated blood occurs when pressure in the
pulmonary artery is equal to or less than peripheral blood pressure. If pulmonary
hypertension is severe with decreased pulmonary venous return, right atrial pressure
will be greater than left atrial pressure, resulting in shunting of blood through the
foramen ovale. The net results of these events cause further hypoxia, hypercarbia,
and acidosis. (See Persistent Pulmonary Hypertension of the Newborn,  Chapter
10.)
Because acidosis increases pulmonary hypertension and consequently shunting of
unoxygenated blood away from the lungs, it is imperative to monitor acid-base status
closely. Close attention to the infant's thermoregulatory status (maintaining a neutral
thermal environment) and glucose requirements during the acute phase is another
priority of care. Individualize ventilatory management on the basis of the infant's
response and requirements. Surfactant replacement therapy may also be used to
stabilize neonates with CDH, but outcomes have not demonstrated an overall
advantage in relation to extracorporeal membrane oxygenation requirement and
mortality (Kays, 2006). The use of inhaled nitric oxide to relieve pulmonary
hypertension of CDH has also been used in some cases with mixed results (Kays,
2006). (See Nitric Oxide, Surfactant, and Persistent Pulmonary Hypertension of the
Newborn,  Chapter 10.)
Another strategy that has demonstrated considerable success in the management of
CDH is the use of permissive hypercapnia wherein hyperventilation is not employed
in order to reduce iatrogenic lung injury and barotrauma. Preductal Spo2 is
maintained at 90, Pco2 is ignored, and metabolic acidosis is corrected with buffers
instead of hyperventilation. Using lung protective ventilation (gentle ventilation)
strategies aimed at decreasing mean inflation pressures (<25cm H 2O) and avoiding
hyperventilation have demonstrated better overall outcomes and have significantly
decreased pulmonary complications such as pneumothorax (Kays, 2006).
Operative treatment involves returning the abdominal organs to the abdomen and
repairing the diaphragmatic defect. The timing of surgical repair may vary.
Postoperative management involves continuation of ventilatory therapy, monitoring
of acid-base balance, and allowing slight hypercapnea. In addition, gastric
decompression, thermoregulation, sedation, and maintenance of adequate cardiac
output and peripheral perfusion are continued. When muscle paralysis is required,
pay careful attention to suctioning oropharyngeal secretions and maintaining intact
skin is vital. If paralysis is continued in the postoperative period, appropriate pain
management should not be overlooked.
Prognosis
CDH is a complex problem of pulmonary hypoplasia, immature lungs, and other
associated problems. The overall mortality rates for CDH are decreasing as the
pathophysiology is better understood in relation to current treatment modalities.
Current data suggest overall survival rates of 80% to 90% in isolated CDH (Abdullah,
Zhang, Sciortino, et al, 2009; Kays, 2006). Surgical repair of the defect alone does
not resolve the infant's problems related to organ immaturity. Long-term
complications of CDH include chronic lung disease, gastroesophageal reflux, feeding
problems, recurrent diaphragmatic herniation, pneumonia, growth failure,
sensorineural hearing loss, scoliosis, and impaired motor and cognitive function.
Nursing Care Management
Assessment of the infant at birth is an integral component of nursing care. This is
accentuated in life-threatening cases such as CDH, where prompt recognition of
neonatal respiratory distress, cyanosis, a scaphoid abdomen, and a possible
mediastinal shift would alert the nurse to investigate further. Any one or a
combination of these signs may signal the presence of CDH. A newborn in
respiratory distress at birth who does not initially respond to resuscitation is further
evaluated for CDH; endotracheal intubation is an option for providing adequate
oxygenation until CDH is ruled out. If CDH is diagnosed prenatally and the infant is
in distress, endotracheal intubation is required to prevent further accumulation of air
in the stomach and intestines and subsequent respiratory compromise. 

 NURSING ALERT

Any newborn infant with a scaphoid abdomen, moderate to severe

 respiratory distress, decreased breath sounds unilaterally, and a history of
polyhydramnios should be suspected of having a CDH. Ventilation should
not be given with bag and mask to prevent further intestinal air and
subsequent respiratory compromise.
Preoperative care involves prompt recognition, resuscitation, and stabilization of the
infant, including ventilatory support, blood gas monitoring, fluid volume maintenance,
and administration of IV fluids and electrolytes. Gastric decompression is achieved
with a double-lumen tube, and the infant is observed for signs of impaired cardiac
output, acidosis, and hypoxemia.
Postoperative care includes the routine observations discussed in the care of the
high-risk infant. Close observation to detect signs of respiratory distress or fluid and
electrolyte imbalances is an important nursing function. Closely monitor the infant for
signs of mediastinal shift, pulmonary air leak, and infection. Hypovolemia as a result
of third spacing of intravascular fluids may occur. Also pay attention to skin care,
since these infants often experience prolonged sedation, an increase in skin
moisture, tubes and drains coming in contact with the skin, altered nutrition, and
altered hemodynamics, all of which place the infant at risk for skin breakdown. Pain
management and developmental needs must be met in addition to lifesaving therapy
to ensure the infant has optimal development.
Nursing care of the infant with a CDH is also aimed at reducing stimulation either
from care activities such as routine suctioning or from environmental factors such as
noise and light. Measures that further reduce infant stress, such as management of
pain, should be a routine aspect of care for the infant with a CDH.
Because of the serious nature of the condition and the urgency of treatment, the
parents are in great need of ongoing support and education regarding postoperative
care. The infant with a CDH may require long-term hospitalization and care. As soon
as medically possible, the parents should be involved in the daily care of their child.
Umbilical Hernia
The umbilical hernia is a common hernia observed in infants. It occurs when fusion
of the umbilical ring is incomplete at the point where the umbilical vessels exit the
abdominal wall. It affects African-Americans more often than Caucasians and low-
birth-weight and preterm infants more often than full-term infants. 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. The size
of the defect is variable, and the protrusion is more prominent when the infant is
crying (Fig. 11-26). Incarceration, in which the hernia is constricted and cannot be
reduced manually, is rare; usually the defect resolves spontaneously by 3 to 5 years
of age. If the hernia persists beyond this age, it is usually surgically corrected on an
elective basis. 

Fig. 11-26 Newborn with umbilical hernia.

Nursing Care Management
The appearance of an umbilical hernia may be disconcerting to parents. Therefore
they need reassurance that the defect usually is not harmful. Taping or strapping the
abdomen to flatten the protrusion does not aid in resolution and can produce skin
irritation.
Nursing care of the child with an umbilical hernia repair is essentially the same as
that for other minor GI surgery. The procedure may be performed on an outpatient
basis. Observe the child for complications related to a hematoma or infection. The
child may resume a normal diet and activity postoperatively; however, strenuous
activity or play is restricted for 2 to 3 weeks.
Inguinal Hernia
Inguinal hernias account for approximately 80% of all childhood hernias and occur
more frequently in boys than in girls (roughly 6:1). An incidence of 3.5% to 5% is
reported in term newborns; 9% to 11% in low-birth-weight and preterm infants, and
30% in very low–birth-weight infants (Aiken and Oldham, 2007).
Pathophysiology
Inguinal hernia comes from persistence of all or part of the processus vaginalis, the
tube of peritoneum that precedes the testicle through the inguinal canal into the
scrotum (in boys), or the round ligament into the labia (in girls), during the eighth
month of gestation. After descent of the testicle, the proximal portion of the
processus vaginalis normally atrophies and closes, whereas the distal portion forms
the tunica vaginalis, which envelops the testicle in the scrotum. When the upper
portion fails to atrophy, the abdominal fluid or an abdominal structure (bowel, ovary,
Fallopian tubes) can be forced into it, creating a palpable bulge or mass. The
persistent sac may end at any point along the inguinal canal; it may stop at the
inguinal ring or extend all the way into the scrotum or labia (Fig. 11-27). 

Fig. 11-27 Development of inguinal hernias. A and B, Prenatal migration of

processus vaginalis. C, Normal. D, Partially obliterated processus
vaginalis. E, Hernia. F, Hydrocele.
Clinical Manifestations
This common defect is asymptomatic unless the abdominal contents are forced into
the patent sac. Most often it appears as a painless inguinal swelling that varies in
size. It disappears during periods of rest or is reducible by gentle compression. It
appears when the infant cries or strains or when the older child strains, coughs, or
stands for a long time. The defect can be palpated as a thickening of the cord in the
groin, and the silk glove sign can be elicited by rubbing together the sides of the
empty hernial sac.
Sometimes the herniated loop of intestine becomes partially obstructed, producing
variable symptoms that may include irritability, tenderness, anorexia, abdominal
distention, and difficulty defecating. Occasionally the loop of bowel becomes
incarcerated (irreducible), with symptoms of complete intestinal obstruction that, left
untreated, will progress to strangulation and necrotic bowel. Incarceration occurs
more often in infants under 10 months of age.
Therapeutic Management
The treatment for hernias is prompt, elective surgical repair in the healthy child as
soon as the defect is diagnosed. However, an incarcerated hernia requires emergent
surgical care. Because there was believed to be a significant incidence of bilateral
 involvement, many surgeons advocated exploration of both sides; however, this
practice has gained disfavor due to complications occurring with open exploration
and is seldom used (Brandt, 2008). Laparoscopic exploration of the contralateral
side may be performed without risk of injury to the vas deferens (Brandt, 2008).
Nursing Care Management
Prompt recognition of an inguinal hernia is imperative. The hernia may first be
noticed when the infant is crying or straining to stool (Valsalva maneuver). Nursing
care of the infant or child with an inguinal hernia involves preoperative preparation of
the infant and appropriate explanation to the parents of the child's expected
postoperative status. Most hernia repairs can be managed on an outpatient basis.
The preterm infant usually has hernia repair several days before discharge. The
former preterm infant diagnosed after discharge is admitted the day of surgery and,
after repair, is observed for 12 to 24 hours for apnea and bradycardia.
Postoperatively the incision is kept clean and dry, and the infant's pain is managed
appropriately. In infants and small children who are not yet toilet trained, the wound
may be covered with an occlusive dressing or left without a dressing. Changing
diapers as soon as they become damp helps reduce the chance of irritation or
infection of the incision.
No restrictions are placed on the infant's or toddler's activity, but older children are
cautioned against lifting, pushing, wrestling or fighting, bicycle riding, and athletics
for about 3 weeks.
If surgery is postponed, parents need to learn the signs of incarcerated hernia,
simple measures to reduce it (a warm bath, avoidance of upright positioning, and
comfort measures to reduce crying), and where to call for assistance if relief is not
obtained in a reasonably short time.
Femoral Hernia
Femoral hernias are rare in children, with a reported incidence of less than 1%
(Brandt, 2008). The incidence is higher in girls than in boys. The hernia may
manifest as a recurrent hernia following inguinal hernia repair (Brandt, 2008). Initial
symptoms are swelling in the groin area associated with severe abdominal pain and
cramping. Treatment and management are the same as for inguinal hernia.
Incarceration and strangulation are frequent complications.

GI
The Infant
Inspection.
The contour of the abdomen is protuberant because of the immature abdominal
musculature. The skin contains a fine, superficial venous pattern. This may be visible in
lightly pigmented children up to the age of puberty.
Abnormal Findings

Scaphoid shape occurs with dehydration.

Dilated veins.
Inspect the umbilical cord throughout the neonatal period. At birth, it is white and
contains two umbilical arteries and one vein surrounded by mucoid connective tissue,
called Wharton's jelly. The umbilical stump dries within a week, hardens, and falls off by
10 to 14 days. Skin covers the area by 3 to 4 weeks.
Abnormal Findings

The presence of only one artery signals the risk of congenital defects.
Inflammation.
Drainage after cord falls off.
The abdomen should be symmetrical, although two bulges are common. You may note
an umbilical hernia. It appears at 2 to 3 weeks and is especially prominent when the
infant cries. The hernia reaches maximum size at 1 month (up to 2.5 cm) and usually
disappears by 1 year. Another common variation is diastasis recti, a separation of the
rectus muscles with a visible bulge along the midline. The condition is more common
with infants of African descent, and it usually disappears by early childhood.
Abnormal Findings

Refer any umbilical hernia larger than 2.5 cm (see Table 21-3, p. 589);
continuing to grow after 1 month; or lasting for more than 2 years in a child of
European descent or for more than 7 years in a child of African descent.
Refer diastasis recti lasting more than 6 years.
The abdomen shows respiratory movement. The only other abdominal movement you
should note is occasional peristalsis, which may be visible because of the thin
musculature.
Abnormal Findings

Marked peristalsis with pyloric stenosis (see Table 21-4, p. 590).

Auscultation.
Auscultation yields only bowel sounds, the metallic tinkling of peristalsis. No vascular
sounds should be heard.
Abnormal Findings

Bruit.
Venous hum.
Percussion.
Percussion finds tympany over the stomach (the infant swallows some air with feeding)
and dullness over the liver. Percussing the spleen is not done. The abdomen sounds
tympanitic, although it is normal to percuss dullness over the bladder. This dullness may
extend up to the umbilicus.
Palpation.
Aid palpation by flexing the baby's knees with one hand while palpating with the other
(Fig. 21-34). Alternatively, you may hold the upper back and flex the neck slightly with
one hand. Offer a pacifier to a crying baby. 

Fig. 21-34
The liver fills the RUQ. It is normal to feel the liver edge at the right costal margin or 1 to
2 cm below. Normally, you may palpate the spleen tip and both kidneys and the
bladder. Also easily palpated are the cecum in the RLQ, and the sigmoid colon, which
feels like a sausage in the left inguinal area.
Make note of the newborn's first stool, a sticky, greenish black meconium stool within 24
hours of birth. By the fourth day, stools of breastfed babies are golden yellow, pasty,
and smell like sour milk, whereas those of formula-fed babies are brown-yellow, firmer,
and more fecal smelling.