Gastrointestinal Disorders

1. Lower gastrointestinal anomalies/obstruction
1. Hirschsprung’s disease(congenital aganglionic megacolon)
1. Introduction: Hirschsprung’s disease is a congenital anomaly of the lower GI tract, but the diagnosis is often not established until the infant is 6-12 months old. The major problem is a functional obstruction of the colon caused by the congenital anatomical defect of lack of nerve cells in the walls of the colon, resulting in the absence of peristalsis. Hirschsprung’s disease is four times more common in boys than girls and is frequently noted in children with Down syndrome.
2. Assessment:
1. In the newborn, failure to pass meconium (in addition to other signs and symptoms of intestinal obstruction).
2. Obstinate constipation-history of inability to pass stool without stool softeners, laxatives, or enemas; persists despite all attempts to treat medically.
3. Stools are infrequent and tend to be thin and ribbonlike.
4. Vomiting: bile stained, flecked with bits of stool (breath has fecal odor), due to Gl obstruction and eventual backing up of stools.
5. Abdominal distention can be severe enough to impinge on respirations, due to GI obstruction and retention of stools.
6. Anorexia, nausea, irritability due to severe constipation.
7. Malabsorption results in anemia, hypoproteinemia, and loss of subcutaneous fat.
8. Visible peristalsis and palpable fecal masses may also be detected.
3. Analysis/nursing diagnosis:
1. Constipation related to impaired bowel functioning.
2. Altered nutrition, less than body requirements, related to poor absorption of nutrients.
3. Risk for injury/infection related to malnutrition.
4. Pain related to surgery and treatments.
5. Knowledge deficit regarding care of the child with a colostomy and follow-up care.
4. Nursing care plan/implementation:
1. Goal (preoperative): promote optimum nutritional status, fluid and electrolyte balance.
1. Monitor for signs and symptoms of progressive intestinal obstruction: measure abdominal girth daily.
2. Administer IV fluids, as ordered-may include hyperalimentation or intralipids.
3. Daily weights, I&O, urine specific gravity.
4. Monitor for possible dehydration.
5. Diet: low residue.
2. Goal (preoperative): assist in preparing bowel for surgery.
1. Teach parents what will be done and why-enlist their cooperation as much as possible.
2. Insert NG tube, connect to low suction to achieve and maintain gastric decompression.
3. Position: semi-Fowler’s.
4. Bowel is cleansed with a series of isotonic saline (0.9%) enemas.
5. Administer oral antibiotics and colonic irrigations to decrease bacteria.
6. Take axillary temperatures only.
7. If child can understand, prepare for probable colostomy using pictures, dolls (usual age at surgery is 10-16 months).
3. Postoperative goals: same as for adult having major abdominal surgery or a colostomy.
4. Goal (postoperative): discharge teaching to prepare parents to care at home for infant with a colostomy.
1. Home care of colostomy of infant is essentially same as for adult.
2. Teach parents to keep written records of stools: number, frequency, consistency.
3. Teach parents to tape diaper below colostomy to prevent irritation.
4. Because colostomy is usually temporary, discuss:
1. Second-stage repair (closure and pull-through) done when the child weighs approximately 20 lb.
2. Possible difficulties in toilet training.
5. Stress need for long-term follow-up care.
6. Make referral to home care if indicated
5. Evaluation/outcome criteria:
1. Infant is prepared for surgery and tolerates procedure well.
2. Postoperative recovery is uneventful.
3. Parents verbalize confidence in ability to care at home for infant with a colostomy and verbalize their understanding that second surgery will be needed to close the colostomy.
2. Intussusception
1. Introduction: Intussusception is the apparently spontaneous telescoping of one portion of the intestine into another, resulting in a mechanical obstruction of the lower GI tract. There is no known cause, and intussusception is three times more common in boys than girls; the child with intussusception is usually between 3 and 24 months of age.
2. Assessment:
1. Typically presents with sudden onset in healthy, thriving child.
2. Pain: paroxysmal, colicky, abdominal, with intervals when the child appears normal and comfortable.
3. Stools: “currant-jelly,” bloody, mixed with mucus.
4. Vomiting due to intestinal obstruction.
5. Abdomen: distended, tender, with palpable, sausage-shaped mass in RUQ.
6. Late signs: fever, shock, signs of peritonitis as the compressed bowel wall becomes necrotic and perforates.
3. Analysis/nursing diagnosis:
1. Fluid volume deficit related to diarrhea and vomiting.
2. Pain related to bowel-wall ischemia, necrosis, and death.
3. Risk for injury/infection related to bowelwall perforation and peritonitis.
4. Knowledge deficit regarding the disease, medical or surgical treatment, and prognosis.
4. Nursing care plan/implementation:
1. Goal: assist with attempts at medical treatment.
1. Explain to parents that a barium enema will be given to the child in an attempt to reduce the telescoping through hydrostatic pressure (succeeds in 75% of cases).
2. Stress that, if this treatment is not successful, or if perforation of the bowel wall has already occurred, surgery will be necessary.
3. If medical treatment is apparently successful, monitor child for 24-36 hr for recurrence before discharge.
2. Preoperative and postoperative goals: same as for adult with major abdominal surgery.
3. Goal: discharge teaching to prepare parents for care of the child at home.
1. Stress that recurrence is rare (10%) and most often occurs within the first 24-36 hr after reduction.
2. Other teaching: same as for adult going home after bowel surgery.
5. Evaluation/outcome criteria:
1. Infant tolerates medical-surgical treatment and completely recovers.
2. Parents verbalize confidence in ability to care for infant after discharge.
2. Acute gastroenteritis (AGE)
1. Introduction: In infants and young children, gastroenteritis is a common acute illness that can rapidly progress to dehydration, hypovolemic shock, and severe electrolyte disturbances.
2. Assessment:
1. Diarrhea: often watery, green, explosive, contains mucus and blood.
2. Abdominal cramping and pain, often accompanied by bouts of diarrhea.
3. Dehydration.
4. Irritability, restlessness, alterations in level of consciousness.
5. 19 Electrolyte disturbances.
3. Analysis/nursing diagnosis:
1. Fluid volume deficit related to vomiting and diarrhea.
2. Altered nutrition, less than body requirements, related to AGE and its treatment, i.e., dietary restrictions.
3. Pain related to abdominal cramping, diarrhea.
4. Impaired skin integrity related to diarrhea.
5. Altered tissue perfusion related to dehydration and hypovolemia.
6. Knowledge deficit regarding diagnosis, dietary restrictions, treatment.
4. Nursing care plan/implementation:
1. Goal: prevent spread of infection.
1. Standard precautions to prevent infection.
2. Enforce strict hand washing.
3. Institute and maintain enteric precautions-follow policies regarding linens, excretions, specimens (“double bag, special tag”).
4. Tape diapers snugly; keep hands out of mouth.
5. Obtain stool culture to identify causative organism; then administer antibiotics as ordered.
6. Identify family members and others at high risk, obtain cultures.
2. Goal: restore fluid and electrolyte balance.
1. Administer IV fluids and electrolytes as
2. Monitor for appropriate response to therapy: decreased specific gravity, good skin turgor, normal vital signs.
3. Monitor weight, I&O, specific gravity.
4. Oral feedings-oral rehydration therapy (ORT) with Pedialyte or comparable solution; resume normal diet as quickly as possible.
5. Ongoing assessment of stools: note Amount, Color, Consistency, Timing 9 (ACCT).
3. Goal: maintain or restore skin integrity.
1. Frequent diaper changes (use cloth diapers).
2. Keep perineal area clean and dry.
3. Apply protective ointments, (petroleum jelly, A and D emollient ointment).
4. If feasible, expose reddened buttocks to air (but not with explosive diarrhea).
4. Goal: provide discharge teaching to parents.
1. Careful review of diet to be followed at home.
2. Review principles of food preparation and storage to prevent infection.
3. Instruct in disposal of stools at home.
4. Emphasize importance of good hygiene.
5. Evaluation/outcome criteria:
1. No spread of infection noted.
2. Fluid and electrolyte balance normal.
3. No skin breakdown noted.
4. Parents verbalize understanding of home care.