Chapter-45-CHILD-WITH-GI-DISORDERS

Chapter 45
Nursing Care of a Family When a

Child Has a Gastrointestinal
Disorder
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomy and Physiology of the
Gastrointestinal System

2020 National Health Goals Related to
Gastrointestinal Disorders in Children
• Increase the contribution of fruits and

vegetables to the diets of the population aged 2
years from 0.5 cup of fruits per 1,000 calories to
0.9 cup per 1,000 calories.
• Achieve and maintain effective vaccination
coverage levels for universally recommended
vaccines among young children and older (three
doses of hepatitis B vaccine and two doses of
hepatitis A vaccine by 19 to 35 months of age).

2020 National Health Goals Related to
Gastrointestinal Disorders in Children—
(cont.)
• Reduce infections caused by key pathogens
transmitted commonly through food including
Escherichia coli (from 200 to 180 cases per
year), Listeria (from 0.3 to 0.2 cases per
100,000 population per year) and Salmonella
(from 15.2 to 11.4 cases per 100,000 population
per year).
• Increase the proportion of consumers who follow
key food safety practices of “Chill: refrigerate
promptly” from 88.1% to 91.1%.
Nursing Process: Gastrointestinal
Disorder
• Assessment
– signs of fluid loss: poor skin turgor, dry mucos
membranes, lack of tears
– # of times voided; wet diapers
– compare past and present weight

Disorder
• Nursing diagnosis
– altered parenting r/t interference with
establishing parent-infant bond
– altered family process r/t chronic illness of child
– fluid volume deficiency r/t chronic diarrhea
– malnutrition risks r/t malabsorption of essential
nutrients

Disorder
• Outcome identification and planning

• Implementation
• Outcome evaluation

Fluid, Electrolyte, and Acid–Base
Imbalance
• Fluid balance
– Distribution of fluids and nutrition
– Insensible losses - evaporation from skin, lungs,
saliva
– Dehydration - excessive loss of fluid

Assessing Disorders of Fluid, Electrolyte,
and Acid–Base Imbalance
• Fluid imbalances
– Isotonic dehydration - child loses more water
than it absorbs (diarrhea) or absorbs less fluid
than it excretes (nausea and vomiting)
• decrease in the volume of blood serum

– Hypertonic dehydration - more water is lost than
electrolytes
– occurs in child with nausea (no fluid intake),
fever (fluid loss thru perspiration)
– occurs in profuse diarrhea -> greater loss of
fluid than salt
– renal disease: polyuria, nephrosis with diuresis

– Hypotonic dehydration - more electrolytes are
lost than water
– vomiting, increased loss of salt from diuresis,
diabetic acidosis

– Overhydration - excessive body fluid intake
– can be as serious as dehydration
– in children with IV fluid
– can lead to CV and cardiac failure

and Acid–Base Imbalance—(cont.)
• Acid‒base imbalance - when vomiting or

diarrhea occurs
– Metabolic acidosis - diarrhea (more Na+ lost)
• Blood gas analysis (low pH, low HCO3); increased acid
in urine; rapid breathing
– Metabolic alkalosis - vomiting

• Slow, shallow breathing; blood gas analysis (high
HCO3); hypokalemia

Vomiting
• Many children with vomiting are suffering

from a mild gastroenteritis (infection) caused
by a viral or bacterial organism.
• The adolescent who is pregnant may mistake
the normal nausea and vomiting of
pregnancy for an illness.
• Some children develop persistent or cyclic
vomiting.

Vomiting
• Management:
– give small amounts of fluid frequently as
tolerated
– clear liquids for hydration
– ORS such as Pedialyte
– IV fluids

Diarrhea
• Acute diarrhea is associated with infection;

chronic diarrhea is likely related to a
malabsorption or inflammatory cause.
• Giardia lamblia, Campylobacter jejuni,
Salmonella, Clostridium difficile, and
Escherichia coli are the common pathogens.
• Diarrhea in infants is always serious; infants
have such a small extracellular fluid reserve
that sudden losses of water quickly exhaust
the supply.
Diarrhea
• Mild diarrhea
– Anorectic, irritable, appears unwell
– Fever, warm skin
– 2-10 loose, watery stools per day
– Rapid pulse
– Urine output may be normal

Diarrhea
• Mild diarrhea
– Management:
– Probiotics
– Proper handwashing after diaper change
– Notify if fever, pain or diarrhea worsens

Diarrhea
• Severe diarrhea
– Appear very ill; high fever
– Weak and rapid pulse and respirations
– Skin is pale and cool
– Apprehensive, listless, lethargic
– Depressed fontanels, sunken eyes, poor skin
tugor
– Urine output scanty and concentrated

Diarrhea
• Severe diarrhea
– Management:
– Oral or IV rehydration therapy
– Stool culture
– Check electrolyte levels

Bacterial Diseases That May
Cause Diarrhea and Vomiting
• Salmonellosis
• Causative agent: One of the Salmonella bacteria
• Incubation period: 6 to 72 hours for intraluminal type; 7
to 14 days for extraluminal type
• Period of communicability: As long as organisms are
being excreted (may be as long as 3 months)
• Mode of transmission: Ingestion of contaminated food,
especially chicken and raw eggs

• Listeriosis
– Causative agent: Listeria monocytogenes
– Incubation period: 1 day to 3 weeks
– Mode of transmission: unpasteurized
cheese or milk or vegetables grown in
contaminated soil
– Infections during pregnancy may lead to
stillbirth, prematurity or infection

• Shigellosis (Dysentery)
– Causative agent: Shigella
– Incubation period: 1 to 7 days
– Period of communicability: 1 to 4 weeks
– Mode of transmission: contaminated food
or water or milk products

• Staphylococcal Food Poisoning

– Causative agent: staphylococcus aureus
– Incubation period: 1 to 7 hours
– Period of communicability: carriers may
contaminate food as long they harbor the
organism
– Mode of transmission: contaminated food
such as poultry, creamed foods and
inadequate cooking

Assessing Common Disorders of the
Stomach and Duodenum
• Gastroesophageal Reflux – immature LES
– In infants, history of effortless vomiting;
endoscopy or esophagography; esophageal
manometry
– In adolescents, history of heartburn; if severe,
endoscopy

• Gastroesophageal Reflux – immature LES
– Management:
– Avoid lying down until 3 hours after meal
– Sleep with upper body elevated
– Avoid acidic foods, citrus fruits or spicy foods
– Avoid foods that delay gastric emptying
– Meds: Antacids; H2 receptor antagonists; Proton
pump inhibitors

• Pyloric stenosis
– Vomit immediately after feedings dehydration;
alkalosis; hypopnea;
– Less in breastfed infants
– sour-smelling vomitus without bile
– Hungry after vomiting
– Signs of dehydration

• Pyloric stenosis
– Management:
– Pyloromyotomy
– Hold oral feedings
– IV fluids

• Peptic ulcer disease – shallow excavation in
the mucosal wall of the stomach, pylorus or
duodenum
– In infants: hematemesis or melena
– In toddlers: anorexia, vomiting, bleeding
– In early school-agers: report of epigastric pain
– In school-agers and adolescents: report of
epigastric area pain relieved by eating;
vomiting; epigastric tenderness

• Peptic ulcer disease – shallow excavation in
the mucosal wall of the stomach, pylorus or
duodenum
– Management:
– H pylori infection – amoxicillin + clarithromycin;
PPI
– Stress ulcers – PPI alone

Therapeutic Techniques for Common
Disorders of the Stomach and
Duodenum—(cont.)
• Peptic ulcer disease
– In children, combination of medications to
reduce the bacteria count and suppress gastric
acidity; younger children are prescribed
cimetidine (safe levels of omeprazole have yet
to be established for this age group)
– In adolescents, combination of antibiotic and a
proton pump inhibitor; bismuth subsalicylate
may be prescribed concurrently

Hepatic Disorders
• Hepatitis – inflammation and infection of the

liver
– Hepatitis A
– Causative agent: HAV
– Incubation period: 25 days
– Mode of transmission: ingestion of fecal-
contaminated water or shellfish
– Immunity: natural – one episode
active artificial – HAV vaccine
passive artificial - immunogobulin
Hepatic Disorders

liver
– Hepatitis B
– Causative agent: HBV
– Incubation period: 120 days
– Mode of transmission: blood and plasma or
semen; contaminated syringe
– Immunity: natural – one episode
active artificial – HBV vaccine
passive artificial - immunoglobulin
Hepatic Disorders

liver
– Hepatitis C, D, E
– Causative agent: HCV, HDV, HEV
– Mode of transmission: C & D like B; E like A

Hepatic Disorders

liver
– Laboratory studies show elevations of AST
(SGOT) and ALT (SGPT), and serum bilirubin;
increased bilirubin in urine; decreased bile
pigments in the stool
– All hepatitis viruses cause liver cell destruction
– Chronic hepatitis – more than 6 months; fatty
infiltration and bile duct damage; may progress
to cirrhosis and liver failure
– Fulminant hepatic failure – due to infection
Therapeutic Techniques for Hepatic
Disorders
• Hepatitis
– Hepatitis A: increased rest; good caloric intake
– Hepatitis B: lamivudine (antiviral agent); possibly
interferon
• Chronic hepatitis
– Supportive compensation for decreased liver function
• Fulminant hepatic failure

– Liver transplant

• Obstruction of the bile ducts
– Congenital biliary atresia, stenosis or absence of
the duct
– When CBD is obstructed, bile can’t enter
intestinal tract, accumulates in the liver
– Bile pigments (direct bilirubin) enter
bloodstream and jaundice occurs
– Jaundice at 2 weeks of age, laboratory findings
of increased direct bilirubin and APT levels,
normal AST (SGOT) in the early phase that later
becomes abnormal, poor absorption of fat and
fat-soluble vitamins (vitamins A, D, E, and K)
and calcium absorption, light-colored stool
• Obstruction of the bile ducts
– Management:
– Surgical correction for atresia - KASAI procedure
or hepatoportoenterostomy
– Liver transplant

• Nonalcoholic fatty liver disease (NAFLD) and
cirrhosis
– NAFLD – accumulation of fatty deposits in the
liver; associated with obesity
– Cirrhosis – fibrotic scarring of the liver
– Large, fatty stools; avitaminosis of fat-soluble
vitamins; symptoms of hemorrhage; anemia;
portal hypertension; ascites; possibly
esophageal varices

Assessing Intestinal Disorders
• Intussusception – invagination of one portion

of the intestine into another
• Idiopathic cause
• Location: juncture of the distal ileum and
proximal colon
• Vomiting and abdominal pain
• Draw up legs and cry as if in severe pain
• Distended abdomen

• Intussusception
• Management:
• Surgical emergency: reduction by instillation
of a water-soluble solution, barium enema,
or air into the bowel or surgery correction

• Volvulus with malrotation

• Volvulus – twisting of the intestine;
obstruction of passage of feces
• Intense crying and pain, pulling up legs,
abdominal distention and vomiting
• Emergency surgery before necrosis of the
intestine occurs

• Necrotizing enterocolitis
– In the first week of life, distended, tense
abdomen; stool positive for occult blood; apnea;
signs of blood loss; increasing abdominal girth;
air in intestinal wall or abdomen
– TPN, antibiotics
– Surgery to remove that portion that is
necrotized

• Short-bowel/short-gut syndrome
– Insufficient bowel surface area in the SI for
proper nutrient absorption
– Causes: surgery for NEC, volvulus, GIT trauma
– Adequate hydration, proper intake of essential
vitamins and minerals
– TPN after bowel surgery
– liver transplantation may be necessary

• Appendicitis
– Anorexia, pain or tenderness in the right lower
quadrant, nausea or vomiting, elevated
temperature, leukocytosis, ultrasound or CT
– Appendectomy (lap)
• Meckel’s Diverticulum
– History; painless, tarry or grossly bloody stools;
X-ray or ultrasound

Therapeutic Techniques for Intestinal
Disorders—(cont.)
• Appendicitis
– Surgical removal
• Meckel’s diverticulum
– Laparoscopy exploration and removal

Assessing Intestinal Disorders—(cont.)
• Celiac disease (malabsorption syndrome,
gluten-induced enteropathy, celiac sprue)
– An immune-mediated abnormal response to
gluten, the protein in wheat, and possibly oats
– Flattening of the fingerlike projections of the SI
occurs, preventing absorption of foods, esp. fat
– Steatorrhea: bulky, foul-smelling, fatty stools
– Failure to thrive and malnutrition
– Thin child with distended abdomen
Assessing Intestinal Disorders—(cont.)
• Celiac disease (malabsorption syndrome,
gluten-induced enteropathy, celiac sprue)
– Mgt: gluten-freed diet strictly
– Celiac crisis occurs when children with celiac
disease develop any type of infection
• Acute vomiting and diarrhea; electrolyte and fluid
imbalances; gradual return to gluten-free diet

Assessing Disorders of the Lower Bowel
• Constipation
– History of difficulty passing hardened stools
– Child represses urge to defecate to avoid pain (stool
holding)
– Rectum becomes distended; anal pain
– Bowel cleansing; stool softener
– Polyethylene glycol
– Increase fiber and fluid intake

Assessing Disorders of the Lower Bowel
• Inguinal hernia
– Protrusion of a section of the bowel into the inguinal
ring
– Painless lump in the left or right groin; apparent only
when crying
– Laparoscopic surgery
– Keep suture line dry and free of urine or feces to prevent
infection
– Assess circulation in the leg on the side of the surgical
repair to check for edema

• Hirschsprung disease (aganglionic megacolon)
– Absence of ganglionic innervations to the muscle of a
section of the bowel (sigmoid colon)
– Absence: no peristaltic waves to move fecal material
– Chronic constipation or ribbonlike stools
– Thin, undernourished appearance; bowel history;
rectal exam (no stool)

• Hirschsprung disease (aganglionic megacolon)
– Management:
– Dissection and removal of affected section with
anastomosis of the intestine
– Two-stage surgery:
– 1: temporary colostomy
– 2: bowel repair at 12 or 18 months of age

• Ulcerative colitis
– Crampy, abdominal pain, urgency, frequent
bloody stools
– Oral and IV medications such as infliximab
– If no response to therapy – surgery to remove
colon (colectomy)
– Association between UC and colon carcinoma if
disease persists for 10 years
– Yearly colonoscopy at age 8 years

• Crohn’s disease
– Abdominal pain, diarrhea with or without blood,
and weight loss
– Inflamed area becomes narrowed causing bowel
stricture and bowel obstruction
– Fistulae, small tunnels that run either from the
bowel to the skin or to another organ, can
develop
– Surgery to remove strictures or repair fistulae
– Endoscopy and colonoscopy

• Irritable bowel syndrome (IBS)
– History of intermittent episodes of loose and
normal stools or recurrent abdominal pain
– Either constipation or diarrhea predominant, or
mixed
– etiology is unknown
– Antidepressants, anticholinergics and antibiotics
to reduce bacteria

• Chronic recurrent abdominal pain
– Age (6 or 7 years; 11 to 12 years); no
abdominal tenderness, distention, guarding, or
muscle spasm; symptoms of stress such as
sleep disturbances, fears, or eating problems
– Family history with anxiety, depression or
somatization

Assessing Disorders Caused by Food,
Vitamin, and Mineral Deficiencies
• Kwashiorkor
– Age (1 to 3 years), growth failure, dependent
edema in LE, severe muscle wasting
– Protein deficiency
– Occurs after weaning –Inc. CHO
– Ascites – shift of fluid from intravascular to
interstitial
– Lag in motor development
– Diet richCopyright
in CHON © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
• Nutritional marasmus
– Age (younger than 1 year), growth failure,
muscle wasting, irritability, iron-deficiency
anemia, diarrhea
– Deficiency in all nutrients – form of starvation
– Suffer from cognitive challenges

Nursing Diagnoses
• Impaired parenting
• Interrupted family processes
• Risk for deficient fluid volume
• Imbalanced nutrition
• Situational low self-esteem

Quality & Safety Education for Nurses
(QSEN)
• Patient-Centered Care
• Teamwork & Collaboration
• Evidence-Based Practice
• Quality Improvement
• Safety
• Informatics

Therapeutic Techniques for Disorders of
the Lower Bowel—(cont.)
• Irritable bowel syndrome

– Regular diet with supplemental psyllium bulk
agents; probiotics or foods supplemented with
lactic acid–producing bacteria may improve
symptoms
• Chronic recurrent abdominal pain

– For some children, opportunity to talk about the
problem; for others, family counseling regarding
the underlying problem

Question
A 3-year-old male is diagnosed with
intussusception. Which symptom reported by
the parents would have led the nurse to
suspect this diagnosis?
A. Projectile vomiting
B. Right lower quadrant pain
C. Bloody mucus stool
D. Rebound tenderness
Answer
C. Bloody mucus stool

Rationale: The “currant jelly” stool is a classic sign
of intussusception. It is the presence of blood with
mucus in the bowel movements as the digested
food is blocked from advancing past the point
where the bowel is telescoped.

Question
A school-aged boy has an emergency

appendectomy. Which assessment should the
nurse report to his physician if noticed in the
immediate postoperative period?
A. Abdominal pain
B. A feeling of “tugging” at the incision line
C. Thirst
D. A rigid abdomen
Answer
D. A rigid abdomen
Rationale: One of the first symptoms of peritonitis
(infection of the peritoneal cavity) is a tense, rigid
abdomen.

Question
The nurse discovers that an infant is
developing necrotizing enterocolitis. Which is
the best action?
A. Institute NPO status.
B. Insert a glycerin suppository.
C. Count respirations.
D. Dilute next formula feeding to 13 calories
per ounce.
Answer
A. Institute NPO status.

Rationale: The damaged bowel is not able to
process food, so keeping it free of food to rest is
important.

1. Vomiting 11. Short gut syndrome
2. Diarrhea 12. Appendicitis
3. GERD 13. Meckel’s diverticulum
4. PUD 14. Inguinal hernia
5. Pyloric stenosis 15. Hirschsprung disease
6. Hepatitis 16. Ulcerative colitis
7. Obstruction of bile duct 17. Crohn disease
8. Intussusception 18. IBS
9. Volvulus 19. Kwashiorkor
10. NEC 20. Marasmus
21. Celiac disease

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Chapter 45

Nursing Care of a Family When a

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Increase the contribution of fruits and

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Outcome identification and planning

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

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Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

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Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Acid‒base imbalance - when vomiting or

– Metabolic alkalosis - vomiting

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• Many children with vomiting are suffering

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

• Acute diarrhea is associated with infection;

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• Staphylococcal Food Poisoning

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• Hepatitis – inflammation and infection of the

• Hepatitis – inflammation and infection of the

• Hepatitis – inflammation and infection of the

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• Hepatitis – inflammation and infection of the

• Fulminant hepatic failure

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• Intussusception – invagination of one portion

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• Volvulus with malrotation

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