Johnson J., Keogh J. Pediatric Nursing Demystified: A Self-Teaching Guide
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䊋 Monitor intake and output.
䊋 Assist patient to plan palatable meals; remember that breakfast is
generally the best tolerated meal.
䊋 Avoid smoking areas—intolerance to smoking.
䊋 Assess mental status for changes due to encephalopathy.
䊋 Explain the disorder and treatment to the family.
HIRSCHSPRUNG DISEASE
What Went Wrong?
Hirschsprung disease is a congenital condition where there is the lack of nerve
cells in the colon causing a lack of peristalsis, resulting in stool being unable
to be pushed through the colon.
Nursing alert Hirschsprung disease is common in Down syndrome.
Signs and Symptoms
䊋 Failure to pass meconium within the first 48 hours following birth
䊋 Failure to pass stool within the first 48 hours following birth
䊋 Abdominal distention
䊋 Abdominal mass
䊋 Ribbon-like or liquid stool
䊋 Sunken eyes
䊋 Pallor
䊋 Dehydration
䊋 Irritable
䊋 Weight loss
䊋 Lethargic
Nursing alert Monitor for fecal vomiting.
Test Results
䊋 Abdominal radiograph: Shows distended colon
䊋 Rectal biopsy: Absence of ganglion cells in the colon
䊋 Full-thickness surgical biopsy: Absence of ganglion cells in the colon
䊋 Suction aspiration of rectum: Absence of ganglion cells in the colon
Treatment
䊋 Surgery: After 9 months of age, the affected portion of the colon is
removed.
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Nursing alert If the colon is obstructed, a temporary colostomy or ileostomy
is performed to decompress the colon. Once decompressed, a second surgery is
performed to remove the affected portion of the colon and remove the
colostomy or ileostomy.
Nursing Intervention
䊋 Preoperative care:
• Nothing by mouth.
• Administer IV fluids as ordered to prevent maintain fluid and elec-
trolyte balance.
• Insert an nasogastric (NG) tube to decompress the upper GI tract.
• Administer normal saline or mineral oil enemas to clean the bowel.
• Administer antibiotics as ordered.
䊋 Postoperative care:
• Strict input and output.
• Provide care for the colostomy or ileostomy, if necessary.
• Monitor bowel sounds.
• Begin feeding by mouth when bowel sounds are present.
• Nothing should be placed in the rectum.
• Monitor for constipation.
䊋 Explain the disorder and treatment to the family and instruct them on
proper care for the wound and how to care for the colostomy or ileostomy,
if necessary. Tell the family to call the health-care provider at the first
signs of constipation, dehydration, fever, vomiting, and diarrhea.
Nursing alert Don’t use tap water in the enema because this can induce water
intoxication. Return of anal sphincter control and complete continence can take
months to develop.
INTUSSUSCEPTION
What Went Wrong?
Intussusception is a disorder where the intestine telescopes and causes inflam-
mation and edema resulting in blood vessel occlusion leading to necrosis.
Intussusception occurs between 6 months and 3 years of age and is common
in children who have cystic fibrosis (See Figure 11-2).
Signs and Symptoms
䊋 Colicky
䊋 Knees drawn to chest
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䊋 Grunting
䊋 Fecal material in vomit
䊋 Sweating
䊋 Red currant jelly-like stool
䊋 Dehydration
䊋 Distended abdomen
䊋 Fever
䊋 Shallow respiration
䊋 Sausage-shaped abdominal mass
Test Results
䊋 Abdominal radiograph: Shows mass.
䊋 Barium enema: Shows intussusception.
䊋 Complete blood count—elevated WBC (leukocytosis):
• 10,000 to 15,000 μL is a sign of bowel obstruction.
• 15,000 to 20,000 μL is a sign of bowel strangulation.
• >20,000 μL is a sign of bowel infarction.
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Colon
Intussuscipens
Intussusceptum
Ileum
Cecum
FIGURE 11-2
Treatment
䊋 Insert an NG tube to reduce vomiting and decompress the GI tract.
䊋 Hydrostatic reduction of bowel: The bowel is moved back into position
using a barium solution, water-soluble contrast solution, or air pressure.
䊋 Surgery: Pulling the intussusceptions back into position or resectioning
the bowel if other treatments fail to resolve the intussusceptions.
Nursing alert Treatment must begin within 24 hours.
Nursing Intervention
䊋 Monitor vital signs.
䊋 Insert the NG tube as ordered and measure output.
䊋 Administer the enema as ordered.
䊋 Strict intake and output.
䊋 Postoperative care:
• Administer antibiotics
• Monitor signs of infection
• Monitor bowel sounds
䊋 Explain the disorder and treatment to the family.
Nursing alert Intussusception is an emergency condition.
PYLORIC STENOSIS
What Went Wrong?
Pyloric stenosis is spasms of the pylorus muscle in the pyloric sphincter that
connects the stomach to the duodenum, causing the pyloric sphincter to
become inflamed and swell, thus preventing the stomach from emptying into
the duodenum. The cause is unknown and is seen in children between 1 and
6 months of age.
Signs and Symptoms
䊋 Projectile vomiting caused by reverse peristaltic and gastritis
䊋 No nausea
䊋 Blood-stained vomit caused by gastritis
䊋 Olive-shaped bulge below the right costal margin
䊋 Malnutrition
䊋 Poor weight gain
䊋 Normal appetite
䊋 Eats after vomiting
CHAPTER 11 / Gastrointestinal Conditions
245
Test Results
䊋 Abdominal ultrasound: Increased size of pyloric sphincter
䊋 Endoscopy: Increased size of pyloric sphincter
䊋 Upper GI series: Delayed gastric emptying
䊋 Blood chemistry: Decreased calcium, sodium, potassium
䊋 Blood gases: Metabolic alkalosis
Treatment
䊋 Insert NG tube to decompress the GI tract.
䊋 Administer IV fluids and electrolytes to maintain fluid and electrolytes
balance.
䊋 Surgery: Pyloromyotomy to repair the pyloric sphincter.
Nursing Intervention
䊋 Nothing by mouth.
䊋 Strict intake and output to assess for dehydration.
䊋 Daily weight.
䊋 Assess vomitus for character and frequency.
䊋 Monitor vital signs.
䊋 Postoperative care:
• Monitor intake and output.
• Elevate the child’s head when feeding.
• Burp frequently.
• Small frequent feedings until the pyloric sphincter function returns
to normal.
䊋 Explain the disorder and treatment to the family.
Nursing alert Position the child on her right side to prevent aspiration and to
use gravity to help emptying of the stomach.
TRACHEOESOPHAGEAL FISTULA/ESOPHAGEAL ATRESIA
What Went Wrong?
A tracheoesophageal fistula is a congenital anomaly in which the trachea and
the esophagus are connected. A child with a tracheoesophageal fistula is likely to
have an esophageal atresia where the esophagus ends in a blind pouch preventing
food from entering the stomach. These disorders occur approximately at 5 weeks
of gestation when the foregut normally develops into the trachea and esophagus.
Nursing alert Tracheoesophageal fistula and esophageal atresia are an emergency
condition.
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Signs and Symptoms
䊋 Frothy saliva
䊋 Coughing due to excessive secretions
䊋 Gagging when feeding
䊋 Feedings exiting the mouth and nose
䊋 Aspiration
䊋 Difficulty breathing
䊋 Distended stomach
Nursing alert Monitor for aspiration when first feeding a newborn.
Test Results
䊋 Radiopaque catheter radiograph: A radiograph is taken after the radiopaque
catheter is inserted into the esophagus to identify the fistula or blind pouch.
䊋 Bronchoscopy: Shows the fistula.
䊋 Chest radiograph: Shows pneumonia and air in the esophageal pouch.
Treatment
䊋 Suction the contents of the blind pouch.
䊋 Insert NG tube to decompress the stomach.
䊋 Surgery: Repair the fistula and/or blind pouch.
Nursing Intervention
䊋 Nothing by mouth:
• Insert the NG tube as ordered.
• Suction the contents of the blind pouch as ordered.
• No pacifier because this increases saliva production.
• Elevate the child’s head.
䊋 Postoperative care:
• Monitor vital signs.
• Place NG tube to low suction per order.
• Monitor output of NG tube every 4 hours.
• Provide gastrostomy feeding until esophagus returns to normal.
• Monitor chest tube drain, if necessary.
• Use pacifier.
• Start feeding by mouth with sterile water and then advance diet as
tolerated.
䊋 Explain the disorder and treatment to the family.
Nursing alert No pacifier prior to surgery because sucking increases saliva
production. Saliva can enter the lungs through the fistula and/or accumulate in
the blind pouch.
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ULCERATIVE COLITIS
What Went Wrong?
Ulcerative colitis is an inflammation of the large intestine affecting the
mucosal layer beginning in the rectum and colon and spreading into the adja-
cent tissue. Ulcerations in the mucosal layer of the intestinal wall lead to
inflammation and abscesses, resulting in bloody diarrhea with mucus, which
is the primary symptom.
There are periods of exacerbations and remissions. Symptom severity may
vary from mild to severe. The exact cause is unknown, but there is increased
incidence in people with northern European, North American, or Ashkenazi
Jewish origins. The peak incidences are from mid-teen to mid-20s and again
from mid-50s to mid-60s.
Patients may have an increase in symptoms with each flare-up of the disease.
Malabsorption of nutrients can cause weight loss and health problems. Some
patients need surgery to resect the affected area of the large intestine, resulting
in a colostomy, ileal reservoir, ileoanal anastomosis, or ileoanal reservoir.
There is an increased risk of colon cancer in patients with ulcerative colitis.
The patient is also at risk for developing toxic megacolon or perforating the
area of ulceration.
Nursing alert The patient is at risk for toxic megacolon, perforation of the
intestine, and colon cancer.
Signs and Symptoms
䊋 Weight loss
䊋 Abdominal pain
䊋 Chronic bloody diarrhea with pus due to ulceration
䊋 Electrolyte imbalance due to diarrhea
䊋 Tenesmus, which is a persistent desire to empty bowel
Test Results
䊋 Blood count: Decreased hemoglobin (anemia), hematocrit due to blood
loss and chronic disease
䊋 Erythrocyte sedimentation rate: Elevated due to inflammation
䊋 Electrolytes: Abnormal due to diarrhea and poor absorbance of
nutrients
䊋 Double-contrast barium enema: Shows ulceration and inflammation.
䊋 Sigmoidoscopy: Shows ulcerations and bleeding
䊋 Colonoscopy: Shows ulcerations and bleeding
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Treatment
䊋 Keep stool diary to identify irritating foods.
䊋 Low-fiber, high-protein, high-calorie diet.
䊋 Administer antidiarrheal medications:
• Loperamide
• Diphenoxylate hydrochloride and atropine
䊋 Administer salicylate medications to reduce inflammation within the
intestinal mucosa:
• Sulfasalazine
• Mesalamine
• Olsalazine
• Balsalazide
䊋 Administer corticosteroids during exacerbations to reduce inflam-
mation:
• Prednisone
• Hydrocortisone
䊋 Nothing by mouth to rest the bowel during exacerbations.
䊋 Administer anticholinergics to reduce abdominal cramping and
discomfort:
• Dicyclomine
䊋 Surgical resection of affected area of large intestine.
Nursing Intervention
䊋 Monitor intake and output.
䊋 Monitor stool output, frequency.
䊋 Weigh patient regularly.
䊋 Provide a sitz bath to soothe the skin.
䊋 Administer A and D ointment or barrier cream to skin.
䊋 Administer witch hazel to soothe sensitive skin.
䊋 Teach:
• Dietary modification, foods to avoid
• Medication use, schedule, and side effects
• Importance of follow-up care
• Proper wound care for postoperative patients
• Proper skin care of perianal area to avoid skin breakdown
• Avoidance of fragrant products that can be irritating
• Home care for new ostomy patients
Nursing alert Monitor for toxic megacolon (distended and tender abdomen,
fever, elevated WBC, elevated pulse, distended colon).
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VOLVULUS
What Went Wrong?
Volvulus is a disorder where the intestine twists around itself as a result
of ingesting a foreign substance and adhesion or from unknown causes that
result in blood vessels to compress and an ischemia to that can lead to
necrosis.
Signs and Symptoms
䊋 Abdominal pain
䊋 Vomiting after feeding
䊋 No bowel sounds
䊋 Bloody stool
䊋 Distended abdomen
Test Results
䊋 Abdominal radiograph: Shows distended intestine loops and no gas in
large intestine
䊋 Upper GI series: Shows distended intestine loops and no gas in large
intestine
䊋 Barium enema: Shows distended intestine loops and no gas in large
intestine
䊋 Blood chemistry: Increased potassium and decreased calcium
Treatment
䊋 Surgery: Untwisting the intestine and removal of any necrotic tissue.
䊋 Administer total parenteral nutrition (TPN) to maintain nutrition until
the intestine heals.
䊋 Administer antibiotics to prevent infection.
䊋 Administer IV fluids to maintain fluid and electrolyte balance.
Nursing Intervention
䊋 Nothing by mouth.
䊋 Insert NG tube to decompress the GI tract.
䊋 Monitor bowel sounds.
䊋 Monitor bowel movements.
䊋 Postoperative care:
• Increase dietary fiber and fluid and increase the child’s activity to
encourage normal bowel movements.
䊋 Explain the disorder and treatment to the family.
Nursing alert Administer stool softeners following surgery because opioid anal-
gesics decrease GI motility.
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CASE STUDY
Vivian Hoffman, age 5, presented in the ED with his parents at 12:30 PM.
His mother reported that he vomited a few minutes after eating and the
vomit flew nearly across the table. She was fine afterward but the vomit
had reddish tint so she thought to bring her into the ED.
Assessment data: There was no nausea. The child has a normal appetite
and wants to eat after vomiting. The child’s weight seems below the nor-
mal percentile for her age. She appears to have a bulge below the costal
margin. Blood gases show an elevated pH and bicarbonate. Blood chem-
istry shows a decreased calcium, sodium, and potassium.
Interpretation: Blood-stained projectile vomiting without nausea is
characteristic of pyloric stenosis. Further confirming this suspicion is the
child’s normal appetite and wanting to eat after vomiting. The low weight
gain is probably caused by malnutrition because little food is passing
through to the intestines. The bulge below the costal margin is also an
indication of an obstruction in the area of the pyloric sphincter. Blood
gases indicate metabolic alkalosis, which is consisted with severe vom-
iting, as is the results of the blood chemistry.
Nursing intervention: Give the child nothing by mouth because pyloric
sphincter is either partially or fully obstructed. Prepare to insert an NG
tube to decompress the GI tract and prepare to administer IV fluids to
maintain fluid and electrolyte balance. Prepare the child for pyloromy-
otomy surgery to repair the pyloric sphincter. Strict intake and output.
Monitor vital signs. Daily weight. After surgery, elevate the child’s head
when feeding. Burp frequently and provide small frequent feedings until
the pyloric sphincter function returns to normal. Position the child on her
right side to prevent aspiration and to use gravity to help emptying of the
stomach.
Evaluation: Assess the surgical site for infection. Listen to determine if
the child’s bowel sounds return following surgery. Monitor the child’s
intake and output and weigh daily to determine if the child is receiving
nutrition.