3/26/20

ARPON, MARY DOIND LLYRA B.

Health Problems Common In

INFANCY Gastrointestinal
Prepared by: Dysfunctions: Infancy
April G. Marqueses-Obon, RN, MSN

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Gastrointestinal System
Nursing Overview

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Health History Physical Examination

•Vital signs
•Signs and symptoms •Inspection
•Prenatal, personal, and •Inspect the skin, mouth, abdomen, anus
family history for risk factors •Auscultation
for GI disorders •Palpation
•Nutritional history •Percussion

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Laboratory Studies and Diagnostic Tests

• Stool analysis
• Erythrocyte sedimentation rate
• CBC
• Abdominal ultrasound Common GI Symptoms
• Barium swallow
• Barium enema
• Computed Tomography
Vomiting
• Esophagogastroduodenoscopy, endoscopy, and gastroscopy Diarrhea
• Colonoscopy, proctoscopy, anoscopy,
sigmoidoscopy, and proctosigmoidoscopy
• Endoscopic retrograde cholangiopancreatography

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Vo m i t i n g Assessment
• Children
•infection (viral or bacterial)
• Adolescent
•pregnant •Describe
vomiting
• Some children develop persistent of cyclic correctly
vomiting.

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Therapeutic Management Diarrhea

•Withhold food from the stomach for
a time as if there is nothing in the
stomach
• After fasting hours, give glucose
water hydration solution
(Pedialyte) to maintain electrolyte
balance then clear liquids of breast
milk
• Soft diet, then regular diet.
•Diarrhea in infants is always serious because
they have little extracellular fluid reserve.
Sudden losses of water may lead to
dehydration.
• May be bacterial or viral origin
• E. coli

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Mild Diarrhea Management

• 2-10 loose watery stools/day

•Rest gastrointestinal tract for 1 hour then
•Fever, anorexia, irritability, dry mucous start rehydration
membrane, increase PR, warm skin, • Probiotics may be given (erceflora)
good skin turgor, normal urine. • Continue breastfeeding

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Severe Diarrhea Management

• Fever, weak and rapid PR, cool skin, pale,
apprehension, listlessness or lethargy
• With obvious signs of dehydration: increase
PR, depressed fontanelle, sunken eyes, poor
skin turgor, weight loss
• Bowel movement every few min, scanty
and concentrated urine output
• Stool is liquid green with mucus and blood
•
•Maintain fluid and electrolyte balance by
replacing lost fluids and electrolytes by
starting IV infusion
•Provide skin care because diarrheal stool is irritating
• Wet lips with moisturizing jelly to
prevent cracking.

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Incidence
Cleft Lip/Palate
• Definition: Failure of fusion in
the “Cupid’s bow” or in the roof •Cleft LIP
the mouth (Palate).
• Cleft lip • Cleft lip is more prevalent among
• failure of union of embryonic structure
Males. 1 in every 700 live births
of the face (maxillary and premaxillary • 46% of children have combined cleft lip and
processes).
•occurs between 5-8 weeks of fetal life palate, 21% cleft lip, and 33% cleft palate.
• Cleft palate •Cleft PALATE
• Failure of union of palatal structures • frequent among females. 1 in every 2000 birhts
between 9-12 weeks of fetal life

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Etiology C h a ra c t e r i s t i c s
• The defect can be just a
small notch in the upper lip
•Cleft LIP or a total separation of the
lip and facial structure up
• Chromosomal abnormality into the floor of the nose.
• Prenatal exposure to teratogens (during 5-8 weeks • nose is generally flattened
of intrauterine life or possibly deficient in folic acid • Gingiva and upper teeth
•multifactorial inheritance may be absent
• may be unilateral or bilateral
•Cleft PALATE
•Prenatal exposure to teratogens 9-12 weeks
of intrauterine life

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Associated Problems:
Clinical Manifestations
• Feeding
•Abdominal distention •Can’t maintain close suction on the nipple
• Difficulty in swallowing or latching on to a bottle • URTI
or breast • They are mouth breathers
• Cleft lip can range from a simple notch on the • Ear infection
upper lip to a complete cleft from the lip edge to • Because pharyngeal opening of the eustachian
the floor of the nostril tube is in an abnormal position
• Cleft palate may be partial or complete • Speech defects
• Dental malformation
• Body image

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Preoperative Nursing Care

Medical/Surgical Management

•Cheiloplasty, primary cleft lip repair: •Provide emotional support to

done as early as possible parents
• Is done as early as possible using the Rule of 10
•Feeding (Altered Nurtrition)
• Palatoplasty
•Haberman Feeder
• Is not done earlier than 10-12 months but not
too late • Gravity flow nipple allows fluid
• Velopharyngeal flap operation to be deposited into infant’s
• Is done to revise previous repair, correct
mouth.
nose deformities, reconstruct the nasopharynx
for speech improvement. Done age 8-9

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Feeding cont… Feeding Considerations

•Burp more frequently • Attention to infant’s
facial signal to
•Do not feed lying down, done in a upright
determine when infant
position. needs to stop feeding.
• BREASTFEEDING is
• Be patient. possible… a breast
• Do not confine to lying on back for long pump maybe used to
periods to prevent URTI or ear infections stimulate the letdown
reflex when infant
• Rinse with water after feeding cannot generate
• Prevent dry cracked lips since the baby is enough suction.
a mouth breather

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Nursing Diagnosis Postoperative Nursing Care

• Ineffective airway clearance • Keep on NPO for at least 4 hours

• Impaired tissue integrity at incision
• Infection
• Altered communication pattern
• Avoid placing tension on the suture line
• Breast feeding or bottle feeding is contraindicated during
the immediate post operative period. Use a breck feeder.
• Do not use straw to drink
• After repair of the cleft palate, liquid is continued for the first 3-
4 days followed by a soft diet until healing is complete
• never use spoon or fork when feeding
• Offer water after feeding to rinse suture line

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Postoperative CHEILOPLASTY

• Complication: respiratory distress during the

48 hours because of:
• Swelling of tongue, mouth, and nostrils (put
downward pressure on the chin to increase air passage
•increased respiratory secretions
• Difficulty adjusting to a smaller airway
• Nursing Care
• Avoid reasons for crying because it adds to an
already irritable, fussy crying
• Put inside mist tent to liquefy secretions
• Elbow restraints should be used at all times to
prevent him from putting his hands or objects on his
mouth

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Nursing care cont… Logan’s Bow

•Logan’s bow is taped after surgery
• Maintain OS with sterile NSS
• OS is removed before feeding and cleaning
• After feeding, suture line is cleansed with cotton
tip applicator dipped in ½ strength hydrogen
peroxide in order to prevent crusts which cause
uneven healing and infection, leaving ugly scars.
• Feedings – formula resumed after 3-4 weeks post-op

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Postoperative PALATOPLASTY Colic

• Complication: Hemorrhage
• Nursing Care
• Position on abdomen to facilitate drainage of blood
and mucus (SUCTION is never done in this case) Paroxysmal abdominal
• Use of mist tent is recommended pain that generally occur
•Elbow restraints applied in infants under 3
• Sucking, blowing, talking, laughing or months of age, marked
putting object to mouth is not allowed. by loud, intense crying.

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Assessment

• Loud, intense crying

•Cause is unclear
•Susceptible infants: overfeeding or from
swallowing too much air while drinking.
•Formula-fed infants are more likely to
have colic than breastfed babies
• An infant cry loudly and pulls the legs up
against the abdomen
• Infant’s face: red and flushed
•clenched fists and the abdomen become tense
• If offered a bottle. The infant will suck
vigorously for a few minutes, then stop as
another wave of abdominal pain occurs.

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Nursing Responsibilities

• Assess for signs of colic.

• Determine the babies feeding pattern (breastfed
or bottle fed).
•Recommend small, frequent feedings.
• Avoid placing hot water bottle on the
infant’s stomach.
• Change formula bottles to the type with
disposable bags that collapse as the baby sucks

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Gastroesophageal Reflux
• Taking infants for car rides may often
reported as being helpful in soothing colicky The regurgitation of
babies. stomach secretions
• Some music boxes stimulate the sound of into the esophagus
through
a heartbeat which also may be helpful.
gastroesophageal
• Help parents plan relief time from infant are (cardiac) valve occurs
to relieve stress level. mainly in infants and
adolescents.

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PATHOPHYSIOLOGY

Immaturity of the cardiac sphincter relaxation of the

→ • Infants
sphincter stomach contents return to the
→ • Occurs from a neuromascular disturbance in which
esophagus reflux to pharynx and irritation of the cardiac sphincter and the lower portion of the
→ → esophagus spasm and allow easy regurgitation of
esophagus esophagitis Bleeding and heartburn gastric contents into the esophagus.
• Reflux occur immediately after feeding or when
the infant is laid down after feeding

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Assessment Therapeutic Management

• Vomiting appears effortless and is not projectile •Feed infants

• Begins earlier in life
• Irritable and may experience periods of apnea
• Check the ph of the secretions from the esophagus
• Esophageal manometry – measures the strength
of the esophageal sphincter
•Medications
• Fiberoptic endoscopy or Barium swallow
• Formula thickened with rice cereal (1 tbsp
of cereal per 1 oz of formula or breast milk)
• Hold the infant in upright position and then
keeping them upright in an infant chair for 1
hour after feeding
• Ranitidine (H2 receptor antagonist)
• Omeprazole (proton pump inhibitor)

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Postoperative Nursing Care

• Botulinum toxin injected to the lower
esophageal sphincter to temporarily
relieve symptoms of obstruction.
• Surgery (laparoscopic or surgical myotomy
procedure)
• NGT will be inserted attached to
intermittent low suction
• Irrigated with normal saline every 2 hours
to ensure patency
• Assess the drainage and any vomitus for coffee-colored
drainage (although this is normal for the first 24hours)
st
• 1 feeding after surgery, abdominal
discomfort and distention may be present.

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Hypertrophic Pyloric Stenosis Incidence

• Occurs approximately at 1:150 males and

• Difficulty of the stomach to 1:170 females
empty its content due to • Tends to occur most frequently in first-born
hypertrophy or hyperplasia white male infants
of the muscle surrounding
the pylorus (valve between • Occurs less frequent in breastfed infants
the stomach and beginning than in formula-fed infants
portion of the intestine).

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PATHOPHYSIOLOGY
→ Assessment
Hypertrophy or hyperplasia
→ →
obstruction prevent stomach emptying
→ • What is the duration?
distention increase pressure in the
→ •Begins 6 week of age
stomach projectile vomiting(without bile) • What is the intensity?
•Projectile vomiting
• What is the frequency?
•Immediately after eating
• What is the description of the vomitus?
•Sour but contains no bile
• Is the infant ill in any way?
•no

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Laboratory and Diagnostic Findings

• Signs of Dehydration (dry mucous •Ultrasonography and an upper GI study

membrane of mouth, depressed
fontanels, fever, decreased urine output, •Arterial blood gas analysis
poor skin turgor, weight loss) •Electrolyte studies
• Alkalosis •CBC
•Olive shaped mass •Endoscopy
• Gastric peristaltic waves passing from left
to right across the abdomen
•projectile vomiting shortly after feeding

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Fredet-Ramstedt procedure
Medical/Surgical Management
(pyloric myotomy)
• NPO status before surgery
• IV therapy
• NGT insertion – lavage
• Surgical intervention –
• Pyloromyotomy
• Fredet Ramstedt surgery

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Nursing Management

• Provide the child with an age-appropriate •provide adequate hydration

explanation of all tests, procedures, and surgery. • Prevent aspiration.
Make sure the parents’ questions are answered. • Provide postoperative care.
• Monitor feeding pattern and the • Promoting comfort.
association between feeding and vomiting. • Providing nutrition as prescribed
• Assess the amount, character and • Provide family teaching.
frequency of vomitus
• Explain all procedure.
• Weigh the patient daily, intake • Demonstrate feeding and positioning
and output monitoring. techniques and surgical wound care.

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Intussusception Incidence

Invagination or
telescoping of the • More likely to
portion of the occur in males, and
intestine into another children with cystic
which causes fibrosis
obstruction.

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PATHOPHYSIOLOGY
→ hyperistasis→pulling of the
Etiology unknown(idiopathic) Assessment
→ → →
bowel invagination obstruction inflamation and
→ → →
ischema distention non projectile vomiting with bile decreased
→ • Severe abdominal pain which causes them to dram up
fluid dehydration their legs and cry
• They may be symptom free after pain
• In approximately 15 minutes, the abdominal pain
may strike again
•Vomiting
•Blood in stool after 12 hours(currant jelly appearance)
• Tender, distended abdomen, possibly a
palpable sausage-shaped abdominal mass
• Increased pulse, shallow respiration, decreased
blood pressure

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Laboratory and Diagnostic Findings

• Abdominal x-rays show a soft tissue mass

and signs of complete or partial obstruction
• Barium enema show the characteristic coiled
spring signs that confirms the disease
• Increase WBC

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Medical/Surgical Management Nursing Management

• IV Therapy – to correct hydration • Provide simple explanations to all procedures to

• NGT insertion – minimize vomiting be performed
• Monitor vital signs
• Hydrostatic reduction
• Monitor intake and output to prevent
• Air pressure, solution through barium enema
dehydration and administer IV fluids as ordered
• Help the intestine to go back (air • Administer pain medication as ordered
or water pressure)
•Provide age appropriate diversional activities
• Surgery
• Manual reduction
• Resection of the affected bowel segment

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• For the child who has undergone hydrostatic

reduction, monitor for the passage of stool Hirschsprung Disease
to determine the need for surgery (congenital aganglionic megacolon)
• Postoperative care:
• Encourage the parents to stay with the child
as much as possible Absence of ganglionic
• Administer antibiotics as ordered
to prevent infection innervation to the muscle
• Monitor the incision site for signs of infection, such as of a section of the bowel –
inflammation, drainage, and suture separation. there are no peristaltic
• Monitor for the rectum of bowel sounds waves to further the
to allow advancement of the diet. passage of fecal material.
• Continue to offer emotional support
and encouragement to the parents.

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PATHOPHYSIOLOGY
Etiology Accumulation of intestinal contents
→
→
→
→ →
constipation distention perforation and
ischema peritonitis and necrosis gangrene
Accumulation of intestinal
• Believe to be a familial, congenital defect → → → → →
contents constipation enterocolitis sepsis septicemia septic shock then
death.

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Assessment Laboratory and Diagnostic Findings

• Neonates • Barium enema

• Failure to pass meconium, reluctance of ingest fluids, • Rectal biopsy
abdominal distention, and bile stained vomitus
• Infants • Anorectal manometry
•Failure to thrive constipation, abdominal
distention, vvomiting, and episodic diarrhea
• Older children
• Anorexia, chronic constipation, ribbon-like stools,
abdominal distention, visible peristalsis, poor
growth, signs of anemia, and hypoproteinemia

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Medical/Surgical Management Nursing Management

• Medications • Assess for and promptly report signs of enterocolitis

• Manual dilation of the anus • Assess bowel functioning. (assess
• Dietary management meconium, measure abdominal girth)
• Surgery • Provide adequate nutrition according to child’s
• Temporary colostomy before definitive surgery to
age and nutritional requirements.
allow the bowel to rest and the child to gain weight. • Administer enemas, as prescribed. To relieve constipation
•Swenson pull through
• Closure of the colostomy about 3 months after
the pull-through procedure

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• Nursing responsibilities for preoperative care:

•Avoid taking temperatures rectally
• Administer prescribed medications,
• Decrease discomfort caused by
abdominal distention.
•Support the child and parents
• Prepare the child and the parents for the
procedure and treatments.
• Maintain on NPO status and insert an NGT
• Assisting with symptomatic treatment.
•preparing the bowel for surgery
• Nursing responsibilities postoperative care:
• Keeping the child on NPO
•Monitor I/O, including NGT drainage
• Keep the infant’s diaper away from the dressing
• Initiate oral fluids once bowel functioning is established
• Provide ostomy care
• Instruct the family regarding home care.

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Imperforate Anus
• Educate the child and family Failure of the 2
• Explain the procedures and treatments, such as sections of the bowel
enemas, stool softeners, and a low-residue or to meet or if the
low-fiber diet. membrane between
• Discuss and answer questions about diagnosis, the 2 surfaces doesn’t
surgery, preoperative and postoperative care, dissolve during the
and colostomy care, if applicable. th
8 week of uterine
life

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Assessment Management

•No anal formation •Postoperative

•Inability to insert rectal thermometer • Check bowel sounds
• Small oral feedings are resumed when
•A membrane filled with black meconium bowel sounds are present
is seen protruding from the anus • Maintain the suture line clean by irrigating it
with normal saline
•No stool is passed leading to
•Take temperature through axilla
abdominal distention

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Failure to Thrive
• A unique syndrome in which an infant falls below
th
the 5 percentile for weight and height on the
standard growth monitoring chart.
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Assessment
• Weigh all children at routine health
assessments, and plot and compare their
weight with standard growth curves.
• Assess for motor and social
developmental delays.
• Take a detailed pregnancy history.
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• Possibly a greater reluctance to reach for
toys or initiate human contact
• Staring hungrily at people who
approach them as if they are starved for
human contact.
• Little cuddling or conforming to being held
by the second month of life.
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2 Categories
•Organic causes
• Cardiac disease
•Disturbance in the parent-child relationship
• Maternal role insufficiency
• Considered a form of child neglect
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Characteristics
•Lethargy with poor muscle tone, a loss of
subcutaneous fat, or skin breakdown
•Lack of resistance to the examiner’s
manipulation
•Rocking on all fours excessively, as if seeking
stimulation, if emotionally deprived.
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•Achievement of developmental milestones in
the prone position such as lifting head and
rd
chest and following an object by eyes by 3
th
and 4 month, but delays behaviors that
should appear in later months such as sitting
erect, pulling to a standing position, crawling,
and walking.
•Markedly delayed or absent speech
•Diminished or nonexistent crying
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Management

• Remove from parents’ care for evaluation

and therapy.
• Severe failure to thrive child in the early
months must be treated rigorously, or it may
lead to permanent neurologic damage or leave
a child cognitively challenged.
• If admitted to the hospital, studies other
than routine admission blood work and Respiratory Dysfunction: Infancy
urinalysis are usually delayed.
•place infants on diet appropriate for their ideal
weight.

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Functions of Eustachian Tube

Otitis Media
- Protection of the middle ear from
nasopharyngeal secretions
-Drainage of secretions produced in the middle ear
• Inflammation of the into the nasopharynx
middle ear with a - Ventilation of the middle ear to equalize air
rapid onset of pressure within the middle ear and
symptoms and atmospheric pressure in the external ear
clinical signs. canal and replenishment of oxygen that has
been absorbed.

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Predisposing Factors
• Infants and young
children are more •Etiology:
predisposed to acute
• Frequently caused by Streptococcus pneumonia, H.
Otitis media because
influenzae, and Moraxella catarrhalis
they have:
• Short, horizontally
positioned •Classifications:
• Immature humoral
• < 3 wks
defense mechanisms,
which increased the • 3wks – 3 mos.
risk for infection • >3 mos.

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Clinical Manifestations Complications

MAAM IT SKIPPED TO LAB AND DIAGNOSTIC FINDINGS

• Hearing impairment or hearing loss

• Pain
• Fever, irritability, loss of appetite •
• Nasal congestion, cough • Chronic suppurative otitis media
• • Mastoiditis
• Older children – •
• Otoscopy
• Air-fluid level
• Full and Bulging of tympanic membrane
• Diminished mobility of the tympanic membrane

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Medical Management

• Analgesics
Laboratory and Diagnostic Findings • Acetaminophen,.ibuprofen(pain)
• Antibiotics
• Culture and sensitivity • Amoxicillin, Amoxicillin-clavulanate (Augmentin),
• Tympanometry if allergic reaction occurs cephalosporins,
azithromycin, clarithromycin, co-trimoxazle
• Audiometric testing

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Surigical Management
• Myringotomy tube – to drain the fluid
from the ear (position on affected side)
• (+) secretion is expected →
• (-) sectretion →
• Surgery
• Tympanoplasty – surgical reconstruction of
the eardrum or small bones of the middle ear.
Nursing Management
• Assess child for pain.
• Assess hearing loss
• Offer liquid or soft foods and apply local heat
over affected ear
• Provide cooling measures and provide
extra clothing or provide blanket.
• Administer analgesic as ordered.
• Adminsiter antipyretics as ordered.

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Cont…
• Facilitate drainage by having the child lie with
the affected ear.
•Help prevent the skin breakdown by keeping
the external ear clean and dry
• Administer prescribed medication as ordered.
• Provide pre-op and post-op care if
surgical intervention is required.
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Cont…
• Provide child and family teaching:
• Explain dosage and administration techniques
and possible adverse effects of medications.
• Emphasize the importance of completing
the entire course of antibiotics.
• Identify signs of hearing loss
• Point out the need for follow-up care after
completing the antibiotic
• Educate parents about the indication for and use
of ear plugs post-op for bathing and swimming.