Gasrointestinal Disorders In Infants and Children Lori Fox, RN, MSN, APRN, BC References: Society of...

Gasrointestinal Disorders In Gasrointestinal Disorders In Infants and ChildrenInfants and Children

Lori Fox, RN, MSN, APRN, BC References: Society of Pediatric Nursing : Pediatric Nursing Review

Saunders Comprehensive Review for the NCLEX Exam 2002

Dorlands's Illustrated Medical Dictonary Twenty Sixth Edition 1981

General General

Energy Requirements:

• Depend/Based on energy expenditures from:

1. Basal Metabolism

2. Body Activity

3. Growth

4. Dynamic action of food

5. Fecal loss

GeneralGeneral

• Distribution of Calories:

Important so foods chosen contain all essential elements

Normal Full -Term Infant:

Protein: 6-8 %

Fat: 30-55%

Carbohydrate: approximately 50-60%

GeneralGeneral

• Water Requirements vary with energy produced or calories metabolized.

• Requirements affected by : fluid intake, protein and mineral content of diet, renal solute load, metabolic rate, respiratory rate and body temperature.

GeneralGeneral

• Deficiencies or excess amounts of any of these requirements can lead to skin issues, metabolic issues, renal issues etc.

General AssessmentGeneral Assessment

• Assessment should include:

• Diet history

• Frequency

• Allergies

• Elimination patterns

Disorders in Newborns/Young Disorders in Newborns/Young InfantsInfants

• Imperforate Anus: "Incomplete development or absence of its normal position in the perineum"-Saunders, Third Edition-2002

Assessment findings:

Failure to pass meconium/stool

Absence or stenosis of the anal rectal canal

Presence of an anal membrane

External fistula to the perineum or genitourinary system


• Necrotizing Enterocolitis: "NEC"

• Common in neonatal period

• Increased risk with preemies

• Causative agent: conditions which cause vascular compromise to the intestine

• Sx/Sx: lethargy, apnea, bradycardia, hypotension, temperature instability


• Pyloric Stenosis: A narrowing of the pyloric canal as it exits the stomach

• Projectile Vomiting=High index of suspicion. (hallmark)

• Olive sized bulge below the right costal margin (hallmark)

• Tx: pyloromyotomy=incision through muscle fibers of the pylorus


• Pyloric Stenosis Pyloroplasty


• Biliary Atresia: "obliteration or absence of extrahepatic biliary structures"

• Cause: Unknown

• Sx/Sx: Early jaundice; dark urine; pale stools (absence of bile); absorption issues→growth issues

• DX: Liver biopsy


• Esophageal Atresia (EA) and Tracheoesophageal Fistula (TEF)

• Atresia=absence or closure of a orifice or tubular organ

• Fistula: "tube like connection between two structures" Designated by the organs or parts which with it communicates (e.g. rectovaginal)


• Sx/Sx: Choking/Coughing during feeds can have intermittent cyanosis

• EA TEF


• Cleft Lip and Palate

Congenital Defect -soft tissue or bony structure fails to fuse during embryonic development.

• Can be unilateral or bilateral

• Apparent at birth

• Causes: genetic; hereditary; environmental

• Closure of lip defect occurs before palate-first few weeks of life with palate around 12-18 mo.


• Gastroesophageal Reflux (GER)

• Underdeveloped esophageal sphincter

• Some amount of GER is normal in newborns

• Often causes apnea


• Hirschsprung's Disease (congenital aganglionosis megacolon):

• Absence of ganglion cells in the retum and colon

• Mechanical obstruction from inadequate motility

• DX: Rectal biopsy

• Serious Complication: Enterocolitis

• Tx: mild disease: relief of chronic constipation

• most children require surgery

• neonates often require temporary colostomy

Disorders in Young InfantsDisorders in Young Infants• Intussusception: Prolapsing of one portion of

the intesine into the lumen of the immediately adjoining part

• Occurs at about 6 months of age• Causes: bowel lining abnormality; polyps;

hyperactive peristalsis; unknown• Inflammation→ swelling →obstruction

→necrosis from occlusion of bowel blood supply

Disorders in ChildrenDisorders in Children• Inflammatory Bowel Disease:

1. Crohn's disease=regional enteritis-

asymmetrical and patchy lesions.

Affects all layers of bowel wall; enlarged

regional lymph nodes; occurs at any point

along the GI tract.

2. Ulcerative colitis=symmetrical and

contiguous GI ulcers

Affects bowel mucosa; large intestine

Disorders in ChildrenDisorders in Children

• Causes: unknown- exacerbated by emotional factors

• Common to occur in Adolescents

• DX: made by barium enema; biopsy of GI mucosa; stool studies


• Appendicitis: Inflammation and obstruction of blind sac at end of cecum

• Results in ischemia; gangrene; perforation and peritonitis

• Causes: include: infections, dietary intake, constipation and parasites

• Common in school age children


• Celiac Disease: Absence of intestinal mucosal cell enzyme →villi of small intestine atrophy → decreases absorption

• Gluten intolerance-FATTY STOOLS (Steatorrhea) and chronic diarrhea

• IgA deficiency and early introduction of protein solids related.

• Occurs around 2-4 months after solid foods introduced

Disorders in ChildrenDisorders in Children• Parasitic Worms: Aquired through skin;

ingestion of dirt or raw vegetables not well washed

• Pinworms are the most common• Live in cecum and crawl to anus at night to lay

eggs• Tape test• Anal itching; abdominal distention

Disorders in ChildrenDisorders in Children• Viral Hepatitis:

1. A: Fecal -oral route

2. B: Blood and body secretions

3. C: predominantly parentally spread

SX/SX: anorexia; malaise, fatigues easily, fever; jaundice and dark urine; pale stools

DX: antigenic markers and body immune response

HBIG for Hep B


• Acetaminophen Poisoning:

• Hepatotoxicity is concern plasma levels greater than 200 µm/ml.

• Monitor for liver damage 24-36 hours after overdose

• Mucomyst is an antidote (acetylcysteine)


• Vomiting and Diarrhea:

• Issues= frequency, consistency; volume; support electrolytes and hydration

• Constipation: Frequency, consistency of stools (variation from normal for that child- not necessarily no daily stool)

Endocrine Disorders in ChildrenEndocrine Disorders in Children

• Inborn Errors of Metabolism:• Tested for at birth after first 24 hours of feedings:

Early diagnosis leads to better outcome• PKU- defect in hydroxylation of phenylalanine

to form tryosine →build up of phenylalanine → brain damage/mental retardation.

• Musty odor to urine


• Inborn Errors of Metabolism Con't:• Galactosemia: deficiency in galactose enzyme

→liver failure; renal tubular problems and cataracts

• Maple Syrup Urine Disease (MUD):• Deficiency of decarboxylase that degrades amino

acids →altered tone; seizures• Urine has odor of maple syrup


• Diabetes Type I and Type II

• Review Endocrine section in review book-good overview.


• Hypothyroid Disease:• Thyroid regulates basal metabolic rate• CX: decreased secretion from

a. Thyroid gland development issues

b. Medications that suppress hormone

production

c. Thyroid relies on early dietary iodine

and tyrosine for normal function


• Hypothyroid Disease Continued:

SX/SX: Easy wt gain

Fatigue/tiredness

Dry, scaly skin

Slow pulse

Cool body temp

Constipation

Endocrine Disorders in ChildrenEndocrine Disorders in Children• Cushing Syndrome: Hyperadrenocorticism• Hyper functioning of the adrenal gland. High levels cortisol

→ decreased ACTH secretion

• Cause: Tumor in pituitary gland/prolonged or excessive use of corticosteroids

• Sx/Sx: MOON FACE; muscle weakness; easy bruising; facial hair growth (hirsutism= excessive hair growth); decreased linear growth; HTN; mood disorders; poor wound healing

• TX: Taper steroids if possible ; remove tumor- Takes weeks/months for hormones to clear body

Endocrine Disorders in ChildrenEndocrine Disorders in Children• Deficient Anterior Pituitary Hormone:

Pituitary Dwarfism• Results in decreased growth hormone• Cause: idiopathic; brain tumor; trauma; lesions• Normal body proportions, but short stature• Bone age studies reveal growth retardation• Tx: Administer growth hormone • Emotional Support

Endocrine Disorders in ChildrenEndocrine Disorders in Children• Hypersecretion of anterior pituitary

hormone: Gigantism or acromegaly:• Causes: hyperplasia of pituitary cells or pituitary

tumor• Bone age studies are normal. Signs of gigantism

occur if increased release of hormone happens before growth plates close

• Elongation and enlargement of long bones, facial bones and accompanying body tissue

Endocrine Disorders in ChildrenEndocrine Disorders in Children• Hypersecretion of anterior pituitary

hormone: Gigantism or acromegaly Continued:

• Late closure of fontanels

• Acromegaly if release of hormone occurs after growth plates close: enlarged hands; feet; nose; tongue; jaw

• Thickening of skin and facial features

• TX: Radiation may be used to retard growth

• Emotional support

TEST QUESTIONSTEST QUESTIONS

• 1. A 3 year old is hospitalized because of persistent vomiting. A nurse monitors the child closely for:

a. Diarrhea

b. Metabolic Acidosis

c. Metabolic Alkalosis

d. Hyperactive bowel sounds

TEST QUESTIONSTEST QUESTIONS 2. A nurse is monitoring for signs of dehydration in a 1 year

old child who has been hospitalized for diarrhea. The nurse prepares to take the child's temperature and avoids which method of measurement?

A. Tympanic

B. Axillary

C. Rectal

D. Electronic


3. A home care nurse provides instructions to the mother of an infant with cleft palate regarding feeding. Which statement if made by the mother indicates a need for further instructions?

A. "I will use a nipple with a small hole to prevent choking"

B. "I will stimulate sucking by rubbing the nipple on the lower lip"

C. "I will allow the infant time to swallow"

D. " I will allow the infant to rest frequently to provide time for swallowing what has been placed in the mouth"


• 4. An infant has just returned to the nursing unit following a surgical repair of a cleft lip located on the right side of the lip. The nurse places the infant in which most appropriate position?

• A. On the right side• B. On the left side• C. Prone• D. Supine


• 5. A clinic nurse reviews the recoord of an infant seen in the clinic. The nurse notes that a diagnosis of esophageal atresia with trachesophageal fistula is suspected. The nurse expects to note which most likely sign of this condition documented in the record?

• A. Severe projectile vomiting

• B. Coughing at nightime

• C. Choking with feedings

• D. Incessant crying


• 6. A nurse prepares a teaching plan for the parents of an infant with gastroesophageal reflux regarding proper positioning to manage reflux. The nurse documents that the infant should be maintained in which position following feedings and at night?

• A. 30-degree angle when supine

• B. 60-degree angle when supine

• C. Head-Elevated prone position

• D. 20-degree angle when supine


• 7. A nurse provides feeding instructions to a mother of an infant diagnosed with gastroesophageal reflux.To assist in reducing the episodes of emesis, the nurse tells the mother to :

• A. Thin the feedings by adding water to the formula

• B. Thicken the feedings by adding rice cereal to the formula

• C. Provide less frequent, larger feedings

• D. Burp the infant less frequently during feedings


• 8. A nurse admits a child to the hospital with a diagnosis of pyloric stenosis. ON admission assessment, which data would the nurse expect to obtain when asking the mother about the child's symptoms?

• A. Vomiting large amounts of bile

• B. Watery Diarrhea

• C. Increased urine output

• D. Projectile vomiting


• 9. A nurse provides home care instructions to the parents of a child with celiac disease. The nurse teaches the parents to include which of the following food items in the child's diet?

• A. Rice• B. Rye toast• C. Oatmeal• D. Wheat Bread


• 10. A clinic nurse reviews the record of a 3 week old infant and notes that the physician has documented a diagnosis of suspected Hirshsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which symptom most likely led the mother to seek health care for the infant?

• A. Diarrhea

• B. Projectile vomiting

• C. Regurgitation of feedings

• D. Foul-smelling ribbon like stools


• 11. A nurse is caring for a newborn infant with a suspected diagnosis of imperforate anus. The nurse monitors the infant, knowing that which of the following is a clinical manifestation associated with this disorder?

• A. Sausage-shaped mass palpated in the upper right abdominal quadrant

• B. Bile stained fecal emesis

• C. Failure to pass meconium stool in the first 24 hours after birth

• D. The passage of currant jelly -like stools


• 12. The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child's record and expects to note which symptom of this disorder documented?

• A. Bright red blood and mucus in the stools

• B. Profuse projectile vomiting

• C. Watery Diarrhea

• D. Ribbon like stools


• 13. A pediatric nurse educator provides a teaching session to the nursing staff regarding phenylketonuria. The nurse educator tells the nursing staff that:

• A. Phenylketonuria is an autosomal dominant disorder

• B. Treatment includes dietary restriction of tyramine.

• C. All 50 states require routine screening of all newborn infants for phenylketonuria.

• D. Phenylketonuria primarily affects the gastrointestinal system.


• 14. A school-aged child with type 1 diabetes mellitus has soccer practice three afternoons a week. The school nurse provides instructions regarding how to prevent hypoglycemia during practice. The school nurse tells the child to:

• A. Take one half of the amount of prescribed insulin on practice days

• B. Eat twice the amount normally eaten at lunchtime.

• C. Take the prescribed insulin at noontime rather than in the morning.

• D. Eat 6 graham crackers or drink a cup of orange juice before soccer practice.


• 15. A home care nurse is teaching an adolescent with type 1 diabetes mellitus about insulin administration and rotation sites. Which statement if made by the adolescent, would indicate effective teaching?

• A. "I need to use a location in one major site for the morning injection and another location for the same major site for the evening injection for 2 to 3 weeks before changing major sites"

• B. "I need to use a different site for each insulin injection"

• C. " I need to use the same site for 1 month before rotating to another site"

• D. " I should use only my stomach and my thighs for injections"


• 16. The mother of a 6-year old who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive for ketones. The nurse instructs the mother to

• A. Come to the clinic immediately

• B. Hold the next dose of insulin

• C. Administer an additional dose of regular insulin

• D. Encourage the child to drink calorie-free liquids.


• 17. A child with type 1 diabetes mellitus is brought to an emergency room by the mother, who states that the child has been complaining of abdominal pain and has a fruity odor of the breath. Diabetic ketoacidosis is diagnosed. Anticipating the plan of care, the nurse prepares to administer:

• A. 5% dextrose IV infusion

• B. Normal Saline IV infusion

• C. NPH insulin IV infusion

• D. Potassium IV infusion

TEST QUESTIONSTEST QUESTIONS• 18. A two month old infant arrives at the pediatric clinic. Upon

assessment, the baby exhibits the following characteristics. Which characteristic does the nurse relate to a diagnosis of congenital hypothyroidism? Select all that apply

• A. Open fontanels

• B. Protruding tongue

• C. Tachycardia

• D. Hypertonia

• E. Hypotonia

• Source: Child Health Nursing Second Edition: Reviews and Rationales 2007

TEST QUESTIONSTEST QUESTIONS• 19. An infant with congenital hypothyroidism

shows which sing or symptom?• A. Shrill Cry• B. Diaphoresis• C. Hypothermia• D. Diarrhea• Reference questions 19-: Straight A's In Pediatric

Nursing-A review series Lippincott Williams and Wilkins, 2004


• 20. The nurse administers oral thyroid hormone to an infant with hypothyroidism. The nurse should observe the infant for which signs of overdose?

• A. Tachycardia, fever, irritability, and sweating

• B. Bradycardia, cool skin temperature and dry scaly skin

• C. Bradycardia, fever, hypotension, and irritability

• D. Tachycardia, cool skin temperature and irritability


• 21. The nurse draws blood from the heel of an infant for a Guthrie screening test. The Guthrie screening test is used to diagnose which inborn error of metabolism?

• A. Gludcose-6-phosphate dehydrogenase deficiency

• B. Phenylketonuria• C. Galactosemia• D. Hypothyroidism


• 22. The nurse is teaching the mother of a child with diabetes how to recognize the sings an symptoms of hypoglycemia. Which signs and symptoms should the nurse discuss?

• A. Behavioral changes, increased heart rate, sweating and tremors

• B. Nausea, fruity breath odor, headache and fatigue

• C. Polydipsia, polyuria, polyphagia, and weight loss

• D. Enlarged tongue, hypotonia, easy weight gain and cool skin temperature.


• 23. The nurse is assessing a child who might have diabetes. Which laboratory values help confirm a diagnosis of diabetes?

• A. A fasting plasma glucose level of 110mg/dl• B. A fasting plasma glucose level of 126 mg/dl• C. A random plasma glucose level of 180mg/dl• A 2-hour glucose tolerance test of 140 mg/dl


• 24. the nurse is teaching the parents of child with diabetes. Which agent should the nurse teach the parents to administer if their child suffers a severe hypoglycemic reaction?

• A. IV Dextrose• B. Subcutaneous insulin• C. Subcutaneous glucagon• D. Oral fast-acting carbohydrate


• 25. Which foods may be eaten by a child with galactosemia? Select all that apply.

• A. Instant Potatoes• B. Chicken• C. Lima Beans• D. Whole Wheat Bread• E. Apples• F. 2% Cow's milk

Gasrointestinal Disorders In Infants and Children Lori Fox, RN, MSN, APRN, BC References: Society of...

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