Disorders of the Gastrointestinal System

A. Cleft Lip and Cleft Palate

B. Esophageal Atresia and Tracheoesophageal Fistula
C. Gastroesophageal Reflux Disease
D. Hypertrophic Pyloric Stenosis
E. Appendicitis
F. Hirschsprung’s Disease
G. Intussusception
H. Umbilical Hernia
I. Imperforate Anus
J. Celiac Disease

A. Cleft Lip and Cleft Palate

 Congenital anomalies that occur as a result of failure of soft tissue or bony structure to
fuse during embryonic development.
 The defects involve abnormal openings in the lip and palate that may occur unilaterally or
bilaterally and are readily apparent at birth.
 The causes include hereditary and environmental factors –
 Exposure to radiation or rubella virus,
 Chromosome abnormalities
 Teratogenic factors

Types of Cleft Lip and Cleft Palate

 Unilateral cleft lip
 Bilateral cleft lip
 Unilateral cleft lip and palate

 Closure of a cleft lip defect precedes closure of the cleft palate and is usually performed by
age 3 to 6 months
 Cleft palate repair is usually performed between 6 and 24 months of age to allow for the
palatal changes that occur with normal growth.
 A cleft palate is closed as early as possible to facilitate speech development
 A child with cleft palate is at risk for developing frequency otitis media which can result in
hearing loss

Assessment:
 Cleft lip can range from a slight notch to a complete separation from the floor of the nose
 Cleft palate can include nasal distortion midline or bilateral cleft, and variable extension
from the uvula and soft and hard palate
 Cleft lip may be detected by a sonogram while an infant is in utero, if not detected then, it
is readily apparent on inspection at birth
  Cleft palate can be determined by depressing the newborns tongue with a tongue blade.
This reveals the total palate and the extent of any cleft present.

What are the possible Nursing Diagnosis??? Risk of aspiration r/t

Intervention:
 Assess the ability to suck, swallow, handle normal secretions and breathe without
distress.
 Assess fluid and calorie intake daily
 Monitor daily weight (IBM)
 Modify feeding techniques; plan to use specialized feeding techniques, obturators, and
special nipples and feeders.
 Hold the infant in an upright position and direct the formula to the side and back of the
mouth to prevent aspiration.
 Feed small amounts gradually and burp frequently.
 Keep suction equipment and a bulb syringe at the bedside.
 Teach the parents special feeding or suctioning techniques.

Teach the parents the ESSR method of feeding –

 Enlarge the nipple,
 Stimulate the sucking reflex,
 Swallow,
 Rest to allow the infant to finish swallowing what has been placed in the mouth.

Postoperative interventions:
Cleft lip repair
 Provide lip protection; a metal appliance or adhesive strips may be taped securely to the
cheeks to prevent trauma to the suture line.
 #1 Priority-Protect operative site!
 Logan Bar: thin arched metal device taped or butterflied to cheeks protects suture line
from tension & trauma
 Arms restrained at elbows x 2 weeks.
 Avoid positioning the infant on the side of the repair or in the prone position
 Keep the surgical site clean and dry; saline or as designated by agency procedure
 Apply antibiotic ointment to the site as prescribed
 Elbow restraints should be used to prevent the infant from injuring or traumatizing the
surgical site
 Monitor for signs and symptoms of infection at the surgical site.

Cleft palate repair

 Feedings are resumed by bottle, breast, or cup per surgeon preference;
 Oral packing may be secured to the plate (usually removed in 2 to 3 days).
 Do not allow the child to brush his or her teeth.
 Instruct the parents to avoid offering hard food items to the child, such as toast or cookies
 Soft elbow or jacket restraints may be used to keep the child from touching the repair
site; remove restraints at least every 2 hours.
 Avoid the use of oral suction or placing objects in the g. Provide analgesics for pain as
prescribed.
 Instruct the parents in feeding techniques and in the care of the surgical site
 Instruct the parents to monitor for signs of infection at the surgical site, such as redness,
swelling, or drainage.
 Initiate appropriate referrals such as a dental referral and speech therapy referral.

B. Esophageal Atresia and Tracheoesophageal Fistula

 The esophagus terminates before it reaches the stomach, ending in a blind pouch, or a
fistula is present that forms an unnatural connection with the trachea.
  The condition causes oral intake to enter the lungs or a large amount of air to enter the
stomach, presenting a risk of coughing and choking
 Aspiration pneumonia and severe respiratory distress may develop, and death is likely to
occur without surgical intervention.

Assessment
 Frothy saliva in the mouth and nose and excessive drooling
 The “3Cs” – coughing and choking during feedings and unexplained cyanosis
 Regurgitation and vomiting
 Abdominal distention
 Increased respiratory distress during and after feeding

What are the possible Nursing Diagnosis?

Esophageal Atresia and Tracheoesophageal

Preoperative interventions
 The infant may be placed in a radiant warmer in which humidified oxygen is
administered
 Maintain NPO status
 Maintain IV fluids as prescribed
 Monitor respiratory status closely
 Suction accumulated secretions from the mouth and pharynx
 Maintain in a supine upright position
 Keep the blind pouch empty of secretions by intermittent or continuous suction as
prescribed.
 If a gastrostomy tube is inserted, it may be left open so that air entering the stomach
through the fistula can escape, minimizing the risk of regurgitation of gastric contents
into the trachea
 Broad-spectrum antibiotics may be prescribed because of the high risk of aspiration
pneumonia

Postoperative interventions
 Inspect the surgical site for signs and symptoms of infection.
 Monitor for anastomotic leaks as evidence by purulent drainage from the chest tube.
 If a gastrostomy tube is present, it is usually attached to gravity drainage until the infant
can tolerate feedings and the anastomosis is healed (usually postoperative day 5 to 7);
then feedings are prescribed.
 Before feeding, elevate the gastrostomy tube and secure it above the level of the stomach
to allow gastric secretions to pass to the duodenum and swallowed air to escape through
the open gastrostomy tube.
 Administer oral feedings with sterile water, followed by frequent small feedings of
formula as prescribed.
 Instruct the parents in the techniques of suctioning, gastrostomy tube care and feedings,
and skin site care as appropriate.

C. Gastroesophageal Reflux Disease (GERD)

 Gastroesophageal reflux is backflow of gastric contents into the esophagus as a result of

relaxation or incompetence of the lower esophageal or cardiac sphincter.
 Most infants with gastroesophageal reflux have a mild problem that improves in about 1
year and requires medical therapy only.
 Gastroesophageal reflux disease occurs when gastric contents reflux into the esophagus
or oropharynx and produce symptoms.

Assessment
 Passive regurgitation or emesis
  Poor weight gain
 Irritability
 Hematemesis
 Heartburn (in older children)
 Anemia from blood loss

Intervention
 Assess amount and characteristics of emesis.
 Assess the relationship of vomiting to the times of feedings and infant activity
 Monitor breath sounds before and after feedings
 Assess for signs of aspiration, such as drooling, coughing or dyspnea, after feeding
 Place suction equipment at the bedside.
 Monitor intake and output
 Monitor for signs and symptoms of dehydration
 Maintain IV fluids as prescribed
 Assess for complications of gastroesophageal reflux disease which include:
 Esophagitis, esophageal strictures, aspiration of gastric contents, and
aspiration pneumonia.

Positioning
 The infant is placed in the supine position during sleep (to reduce the incidence of
sudden infant death syndrome) unless the risk of death from aspiration or other serious
complications of gastroesophageal reflux disease greatly outweighs the risks associated
with the prone position.
 In children older than 1 year, position with the head of the bed elevated.

Diet
 Provide small, frequent feedings with predigested formula to decrease the amount of
regurgitation
 Nutrition via nasogastric tube feedings may be prescribed if severe regurgitation.
 For infants, formula may be thickened by adding rice cereal to the formula, cross-cut the
nipple.
 Breast-feeding may continue.
 Burp the infant frequently when feeding and handle the infant minimally after feedings,
 Monitor for coughing during feeding and other signs of aspiration.
 For toddlers, feeds solids first, followed by liquids.
 Instruct the parents to avoid feeding the child fatty foods, chocolate, tomato products,
carbonated liquids, fruit juices, citrus products, and spicy foods
 Instruct the parents that the child should avoid vigorous play after feeding and avoid
feeding just before bedtime.

Medications
 Antacids for symptom relief
 Proton pump inhibitors and histamine H2-receptor antagonists to decrease gastric acid
secretion.

D. Hypertrophic Pyloric Stenosis

 Hypertrophy of the circular muscles of the pylorus causes narrowing of the pyloric canal
between the stomach and the duodenum.

 The stenosis usually develops in the first few weeks of life, causing projectile vomiting
dehydration, metabolic alkalosis, and failure to thrive.

Assessment
 Vomiting that progresses from mild regurgitation to forceful and projectile vomiting; it
usually occurs after a feeding.
 Vomitus contains gastric contents such as milk or formula, does not usually contain bile.
  The child exhibits hunger and irritability.
 An olive shaped mass is in the epigastrium just right of the umbilicus.
 Signs of dehydration and malnutrition
 Signs of electrolyte imbalances
 Metabolic alkalosis
 Digestive issues disrupt the blood’s acid-base balance

Interventions
 Monitor strict intake and output
 Monitor vomiting episodes and stools.
 Obtain daily weights.
 Monitor for sings of dehydration and electrolyte imbalances
 Prepare the child and parents for pyloromyotomy if prescribed.

Pyloromyotomy
 An incision through the muscle fibers of the pylorus; may be performed by laparoscopy

Postoperative interventions
 Monitor intake and output
 Begin small, frequent feedings postoperatively as prescribed.
 Gradually increase amount and interval between feedings until a full feeding schedule has
been reinstated
 Feed the infant slowly, burping frequently, and handle the infant minimally after
feedings.
 Monitor for abdominal distention.
 Monitor the surgical wound and for signs of infection
 Instruct the parents about wound care and feeding.

E. Hirschsprung’s Disease
 Hirschsprung’s disease congenital anomaly also known as congenital aganglionosis of
aganglionic megacolon.
 The disease occurs as the result of an absence of ganglion cells in the rectum and other
areas of the affected intestine.
 To allow the bowel to relax without being able to relax, the bowel remains
constricted and narrow.
 No stool can pass this point in the bowel and accumulates back up the bowel.

Treatment for moderate to severe disease involves as 2 step surgical procedure.

1. Initially, in the neonatal period a temporary colostomy is created to relieve obstruction
and allow the normally innervated, dilated bowel to return to its normal size.
2. When the bowel returns to its normal size, a complete surgical repair is performed via a
pull-through procedure to excise portions of the bowel; at this time, the colostomy is
closed.

ASSESSMENT
Newborns:
 Failure to pass meconium stool
 Refusal to suck
 Abdominal distention
 Bile-stained vomitus

Children
 Failure to gain weight and delayed growth
 Abdominal distention
 Vomiting
 Constipation alternating with diarrhea
 Ribbon-like and foul-smelling stools
Interventions: Medical management
 Maintain a low-fiber, high-calorie, high protein diet; parenteral nutrition may be
necessary in extreme situations
 Administer stool softeners as prescribed.
 Administer daily rectal irrigations with normal saline to promote adequate elimination
and prevent obstruction as prescribed.

Surgical management: Preoperative Interventions:

 Assess bowel function
 Maintain NPO status
 Monitor hydration and fluid and electrolyte status; provide fluids intravenously as
prescribed for hydration
 Administer antibiotics or colonic irrigations with an antibiotics or colonic irrigations with
an antibiotic solution as prescribed to clear the bowel of bacteria
 Monitor strict intake and output
 Obtain daily weight
 Avoid taking the temperature rectally.

Surgical management: Postoperative interventions:

 Assess the surgical site for redness, swelling, and drainage.
 Assess the stoma if present for bleeding
 Assess the anal area for the presence of stool redness, or discharge.
 Maintain NPO status until flatus is passed, usually within 48 to 72 hours.
 Maintain IV fluids until the child tolerates appropriate oral intake
 Assess for pain and provide comfort
 Provide the parents with instructions regarding colostomy care and skin care
 Teach the parents about the appropriate diet and the need for adequate fluid intake.

F. Intussusception
 Telescoping of one portion of the bowel into another portion
 The condition results in obstruction to the passage of intestinal contents

Assessment
 Colicky abdominal pain
 Vomiting of gastric contents
 Bile-stained fecal emesis
 Currant jelly-like stools containing blood and mucus
 Hypoactive or hyperactive bowel sounds
 Tender distended abdomen, possibly with a palpable sausage-shaped mass in the upper
right quadrant

Interventions
 Monitor for signs of perforation as evidenced by fever, increased heart rate, changes in
level of consciousness or blood pressure, and respiratory distress
 Antibiotics, IV fluids, and decompression via nasogastric tube may be prescribed.
 Monitor for the passage of normal, brown stool, which indicates that the intussusception
has reduced itself.
 Prepare for hydrostatic reduction as prescribed, if no signs of perforation or shock occur
 In hydrostatic reduction, air or fluid is used to exert pressure on area involved to lessen,
diminish, or rid the intestine of prolapse.

Post hydrostatic reduction

 Monitor for the return of normal bowel sounds, for the passage or barium, and the
characteristics of stool.
 Administer clear fluids and advance the diet gradually as prescribed.
 If surgery is required, postoperative care is similar to care after any abdominal surgery.
Celiac Disease
 Celiac disease is also known as gluten enteropathy or celiac sprue intolerance to glute,
the protein component of wheat, barley, rye, and oats, is characteristic.

 Celiac disease results in the accumulation of the amino acid glutamine, which is toxic to
intestinal mucosal cells
 Intestinal villous atrophy occurs, which affects absorption of ingested nutrients.
 Symptoms of the disorder occur most often between the ages of 1 and 5 years.

Assessment
 Acute or insidious diarrhea
 Steatorrhea
 Anorexia
 Abdominal pain and distention
 Muscle wasting particularly in the buttocks and extremities
 Vomiting
 Anemia
 Irritability.

Interventions
 Maintain a gluten-free diet, substituting corn, rice, and millet as grain sources.
 Instruct the parents and child about lifelong elimination of gluten sources such as wheat,
rye, oats, and barley.
 Administer mineral and vitamin supplements, including iron, folic acid, and fat-soluble
vitamins A, D, D, and K.
 Teach the child and parents about a gluten-free diet and about reading food labels
carefully for hidden sources of gluten.

Foods Allowed
 Meat such as beef, pork, poultry, and fish; eggs; milk and some dairy products
vegetables, fruits, rice, corn, gluten-free flour, puffed rice, cornflakes, cornmeal, and
precooked gluten-free cereals are allowed.
Foods Prohibited
 Commercially prepared ice cream; malted milk, prepared puddings, and grains, including
anything made from wheat, rye, oats, or barley, such as breads, rolls, cookies, cakes,
crackers, cereal, spaghetti, macaroni noodles, beer, and ale, are prohibited.
 Instruct the parents in measures to prevent celiac crisis.

G. Crohn’s Disease

 Pediatric Crohn’s disease is a rare, inflammatory bowel disease characterized by severe,

chronic inflammation of the intestinal wall or any portion of the gastrointestinal tract.

 Crohn’s disease is more commonly diagnosed in adults, but approximately 25% are
diagnosed as children and teenagers (pediatrics population).
 The exact cause of pediatric Crohn’s disease is not fully understood, but this is believed
to develop because of multiple different factors occurring together including genetic,
immunologic, and environmental triggers.

ASSESSMENT
 Common symptoms:
 Cramping
 Abdominal pain
 Chronic episodes of watery diarrhea; blood may at times be seen in the diarrhea
  Some affected individuals may
 Feel tired a lot and experience fever
 Nausea, or loss of appetite. Loss of appetite may cause some children to tail to gain
weight and grow as would be expected for their age and gender.

 In rare instances, children with pediatric Crohn’s disease develop lesions of the mouth
and the perianal region, but with limited or mild intestinal disease.

 The treatment of pediatric Crohn’s disease is directed toward the specific symptoms that
are apparent in each individual.

NURSING PROCESS
Assessment
 Children with GI disorders quickly need to be assessed for signs of fluid loss, such as
poor skin turgor, dry mucous membranes or lack of tearing
 When talking to parents about a child’s symptoms, as exactly what they mean when they
say “spitting up” or “a little vomiting” to be certain you’re talking about the same amount
 Children with severe diarrhea, especially small children, need to be seen by a healthcare
provider.
 For many children, a GI tract disorder is largely diagnosed by presenting symptoms such
as those just described
 In other instances, X-ray studies with a contrast medium (barium) or an endoscopic
examination may be needed to confirm the presence of an anomaly.
 Ultrasound or magnetic resonance imaging (MRI) also may be helpful.

NURSING DIAGNOSIS

 Impaired parenting related to interference with establishing the parent infant bond
 Interrupted family processes related to a chronic illness in child Risk for deficient fluid
volume related to chronic diarrhea
 Imbalanced nutrition, less than body requirements, related to malabsorption of necessary
nutrients
 Situational low self-esteem related to feelings of being different resulting from special
dietary restrictions.

INTERVENTION
 Parents need a great deal of support to adapt their busy life to these alternative methods
of feeding or care
 Be certain to give clear, simple explanations and praise both parents and child after they
demonstrate these procedures.

EVALUATION
 Recording children’s height and weight is a primary method to evaluate nutritional
outcomes.
 Even if a diet is limited in a special way, if it is adequate, children should gain weight and
maintain growth.
 Because children will ultimately be responsible for their own nutrition expected
outcomes should include making certain children gradually learn more about their
specific nutritional measures so they can become increasingly responsible for their own
intake.
CARDIOVASCULAR DISORDER IN CHILDREN

Palliative care – only support (50/50), specialized care.

2 Types of Cardiovascular Disorder

1. Congenital Heart Defect - are conditions that are present at birth, most common type of
birth defect
- Common in premature baby, normally 1 week before term nag closed na ang mga
shunts.
2. Congestive Heart Failure – in ability of the heart to supply adequate oxygenated blood
(insufficient cardiac output or blood).

 Congenital - ex. Cardiomegaly – enlargement of the heart)

3 Shunts of Fetal Circulation:

1. Ductus Venosus
2. Foramen Ovale
3. Ductus Arteriosus

3 major category of congenital Heart Defect divide into:

1. Right Sided Failure – general, systematic
2. Left Sided Failure – related to respiratory

Left Sided Failure

 Crackles
  Wheezing sounds
 Dyspnea
 Nasal flaring
 Orthopnea (difficulty breathing except in an upright position because of increased
pulmonary congestion).

Right Sided Failure

 Ascites
 +4 edema
 Hepatosplenomegaly (Enlarged liver)
 Weight gain
 Periorbital edema

2 Types of Congenital Heart Disorder blood flow:

1. Acyanotic heart disease – When the venous blood from the right side of the heart mixes
with blood on the left side, this is a right to left shunt that delivers deoxygenated blood to
the body
2. Cyanotic heart disease – If the blood shunts left to right, then oxygenated blood from
the left side mixes with blood in the right side of the heart and goes back to the lungs
again.

TYPES OF CONGENITAL HEART DEFECTS:

1. Atrial Septal Defect (in fetal: Foramen Ovale)
- an abnormal communication between the two atria
- common located in the center atrium septum
- acyanotic defect

Assessment:
 Decrease pulse
 Activity intolerance
Nursing Diagnosis:
 Ineffective tissue peripheral tissue perfusion
 Impaired gas exchange
 Decreased cardiac output
Management:
 Surgery start 6 months to school age (before start the school)
2 Types of treatment:
 Insertion of cardiac catheter (only temporary)
 Open surgery

2. Ventricular Septal Defect

- Occurs when a portion of the ventricular septum does not completely close, may be
single or multiple septum.
- Acyanotic

Assessment:
 Murmur is always associated
 Decreased cardiac output

Management:
 Surgery start 6 months to school age (before start the school)
2 Types of treatment:
 Insertion of cardiac catheter (only temporary)
 Open surgery

3. Atrioventricular Septal Defect (affected pulmonary artery)

 - This defect comprises several congenital heart defects; a primum ASD, a high VSD,
and failure of the tricuspid and mitral valves to develop and attach correctly.
- Common with Down syndrome
- Signs of acyanotic

Management:
PAB (Pulmonary Artery Band) - palliative surgical technique used for the correction of
congenital cardiac defects, characterized by pulmonary over-circulation caused by left-to-right
shunting of blood.

4. Patent Ductus Arteriosus (in fetal Ductus Arteriosus) mag closed in the 1st week of life
- More frequently in children born prematurely,
- If ductus arteriosus does not close after birth it allow the blood to fow from the aorta
 If Premature baby administer Indomethacin ( prostaglandin in), is used to treat patent
ductus arteriosus (PDA) in premature infants to closed the patent ductus arteriosus.
Management:
 If not Indomethacin
 Cardiac Catheter
 Open surgery (should 6 months to before school age)

This cavity is divided into two separate cavities by the septum.

3 OBSTRUCTED DEFECT OF THE HEART

1. Pulmonary Stenosis (Stenotic Pulmonary Valve)

- Narrowing of passage of pulmonary valve.
- RV (Right Ventricle) nag hypertrophy
- Decreased blood flow to the lungs

Assessment:
 Murmur associated
 Infant is asymptomatic
 Newborn severe narrowing (common narrowing and cyanosis)
 Lead to congestive

Management:
 Insertion of cardiac catheter sa valve
 Open surgery
 For Infant – valvotomy
 For children – valvotomy + cardio pulmonary bypass

2. Aortic Stenosis (Stenotic Aortic Valve)

- LV resistance to the aorta
o Hypertrophy in Left Ventricle
o Decreased blood flow in aorta
o Pulmonary vascular congestion
Assessment:
 Murmur – common heart failure
 Activity intolerance

Management:
 Insertion of cardiac catheter to dilate the stenosis
 Valvotomy
 Artificial valve
 Heart transplant for permanent

3. Coarctation of the Aorta

 - Narrowing of the Aorta
- Narrowing of ductus arteriosus

Assessment:
 Increased / higher blood pressure in upper part of the body
 Heart failure
 Visible decreased cardiac output
 Headache
 Fainting
 Epistaxis

Management:
 Cardiac catheterization
 Balloon angioplasty
 Anastomosis of the aorta is the best management