INTERFERENCES WITH ELIMINATION CONGENITAL OBSTRUCTIVE INTERFERENCES Anorectal Malformations

INTERFERENCES WITH ELIMINATION CONGENITAL OBSTRUCTIVE INTERFERENCES Anorectal Malformations Definition: malformation of anus and/or rectum minor to severe forms -rectal atresia -imperforate anus

Assessment May Include: - failure to pass meconium stool ( imperforate - stools in urine ( fistula) - ribbonlike stools (anal stenosis) Inspection of perineal area for abnormalities Insert lubricated rectal thermometer short distance (check protocol of agency) anus)

Interventions - corrective surgery (anoplasty) - perform manual dilation as ordered - instruct parents in proper technique - prevent infection keeping anal area as clean as possible

HIRSCHSPRUNGS DISEASE: AGANGLIONIC MEGACOLON Definition/Pathophysiology autonomic parasympathetic ganglion cells absent in part of the large colon resulting in decreased motility, causing mechanical obstruction -familial disease, more common in boys and associated with Down’s syndrome Diagnosis: - history of bowel patterns - radiographic contrast studies - rectal biopsy to check for ganglion cells

Assessment Newborns: failure to pass meconium, refusal to suck, abdominal distention and bile stained emesis Older Child: failure to gain weight and delayed growth, abdominal distention, constipation alternating with diarrhea and vomiting Treatment/Interventions Surgical removal of aganglionic bowel with a temporary colostomy (in severe cases) Milder case: dietary modification ( low residue), stool softeners -isotonic irrigations to prevent impactions

Nursing Management Identify early through history Monitor fluid & lyte balance; nutrition Patient education - teach ostomy care if needed - teach how to perform irrigations - teach how to prevent skin breakdown - teach proper nutrition Post op care/measures: monitor for infection, pain control, measure abdominal circumference, maintain hydration

VOLVULUS Definition/Pathophysiology: bowel twists upon itself causing obstruction and necrosis Assessment: nausea, vomiting, no bowel sounds, severe gripping pain and a tense distended abdomen Confirmed by x-ray Treatment/Interventions surgical intervention with a bowel resection follow with post op care

INTUSSUSCEPTION Definition/Pathophysiology: - telescoping of the bowel into itself - usually at the ileocecal valve - causes inflammation and edema -blood flow becomes decreased - commonly in boys (2 months to 5 yrs old) -associated with cystic fibrosis and celiac disease

Assessment: abrupt onset with acute abdominal pain, vomiting and the passage of brown stool - as condition worsens stools become red and resemble currant jelly - possibly a palpable mass in R upper quadrant or mid upper abdomen Diagnosis: history of child and radiography, ultrasound of abdomen and/or barium enema

Treatments -Barium Enema can reduce telescoping by hydrostatic pressure -Surgery to reduce invaginated bowel and remove necrotic tissue

Nursing Management for Intussusception n IV’s started immediately n Post Op n -monitor VS, bowel sounds n -monitor abdominal distention n -check for S&S of infection n -manage pain n - maintain NGT patency n PATIENT EDUCATION

Omphalocele Definition/Pathophysiology: -congenital malformation where intraabdominal contents herniate through the umbilical cord -covered by translucent sac-peritoneum -may have other congenital anomalies Nursing Management -cover with NS soaked gauze & cover with plastic -monitor VS especially temp -NPO with IV’s to maintain fluid & lyte balance

Post Op Care prevent infection maintain fluid & lytes control pain ensure adequate nutritional intake support parents in dealing with crisis

Hernias Definition: -protrusion of viscus from its normal cavity through an abnormal opening Types: Reducible: can be manually placed back into abdominal cavity Irreducible: cannot be placed back into cavity Inguinal: weakness of abdominal wall - spermatic cord emerges in males - round ligament in females Strangulated: irreducible with blood flow cut off

Treatment/Interventions manual reduction use of supports (TRUSS) surgery for strangulated hernia repair Nursing Interventions -Post op prevent bladder distention splint incision site deep breathe Q 2 HR (avoid coughing) ice to scrotal area & support avoid heavy lifting 4 -6 weeks report pain or difficulty urinating

INFLAMMATORY INTERFERENCES Necrotizing Enterocolitis -inflammatory disease of the intestinal tract r/t intestinal ischemia, infection, gut immaturity - primarily in premature infants Assessment -feeding intolerance ( vomiting, abdominal distention, irritability) -bloody diarrhea - possible sepsis

Diagnostics -X-rays showing free peritoneal gas -bowel wall thickening Interventions: - NPO and maintain IV’s - NGT to suction - antibiotics - bowel resection - possible ileostomy, colostomy

NURSING MANAGEMENT • ID early (monitor feedings) • Maintain fluid & lyte balance • Comfort infant (holding, pacifier to meet sucking needs) • Patient Education post op

APPENDICITIS Definition - inflammation of the vermiform appendix preventing mucus from passing into the cecum -untreated can cause ischemia, gangrene, rupture and peritonitis (may be caused by mechanical obstruction or anatomical defect) Assessment - low grade fever - Rt. Lower quadrant pain (Mc. Burney’s point) - vomiting, diarrhea, constipation - rebound tenderness - Rovsing’s sign: palpate Lt. abdomen, pain felt on Rt. Diagnostics - increased WBC count - CAT scan

pain in children and adolescents with appendicitis.

TREATMENTS/INTERVENTIONS Pre Op Post Op NPO check VS, monitor incision IV’s Antibiotics antibiotics NGT (if peritonitis) coughing & deep breathing No laxatives drain (penrose) if ruptured Ruptured Appendix - fever - sudden relief of pain -chills, pallor

NURSING MANAGEMENT -Promote comfort: Rt. Side lying, semi- fowler’s with knees bent, analgesics -Maintain hydration: I&O, skin turgor -Support respiratory function: cough, deep breathe / splint -Check for S&S of infection: check incision, check drainage, change dressing, antibiotics Discharge teaching: -how to check for infection -no strenuous activities

INFLAMMATORY BOWEL DISEASE CROHN’S DISEASE Definition - chronic, inflammatory process along the GI tract - involves all layers of the bowel (deep fissures & ulcerations may develop between loops of bowel or nearby organs) - possible genetic association Assessment - crampy abdominal pain (RLQ) - fever - diarrhea (weight loss ) - ileum involvement ( steatorrhea) (prevalent in individuals of Jewish descent between the ages of 15 - 25 yrs. old )

Diagnostics - CBC: increased WBC, decreased H&H - increased ESR - hypoalbumineria - abdominal tenderness - thrombocytosis - radiologic & biopsy examination - lower endoscopy (proctosigmoidoscopy) - barium study of UGI tract - CAT scan

ULCERATIVE COLITIS Definition -chronic disease of colon/rectal mucosa - can involve entire length of bowel -only involves mucosa/submucosa with ulcerations & inflammation - emotional/psychosocial factors may have an -peak incidence 15 – 25 yrs & 55 - 65 yrs. Old F>M Assessment - bloody/mucus diarrheal stools - lower abdominal pain (cramping) -tenesmus - wt. loss (possible delayed growth & arthralgias) - ID nutritional deficiencies effect

Diagnostics -ID the extent of involved bowel n - r/o any infectious process (i. e. Shigella) n - radiologic studies & endoscopy with biopsy n - decreased H&H, albumin n -increased WBC

Treatment/Management Medications Salicylate Compounds: Sulfasalazine Corticosteroids: prednisone Immunosuppressants: cyclosporine Antidiarrheals: immodium Antibiotics : ciprofloxacil Nutrition Therapy - low fiber diet - if poor appetite (high protein) -supplemental vitamins, iron, zinc & folic acid -TPN Ulcerative Colitis Temporary colostomy/ileostomy Crohn’s bowel resection

DIFFERENTIAL FEATURES OF U. C. AND CROHN’S Feature Ulcerative Colitis Crohn’s Disease Location Begins in rectum Proceeds to cecum Usually terminal ileum w/ patchy involvement through all bowel layers Etiology Unknown Peak Incidence Stools 15 -25 & 55 -65 15 - 40 10 -20 liquid, bloody stools 5 -6 soft, loose stools Per day, rarely bloody Common Complications Hemorrhage Fistulas Perforation Nutritional Deficiencies Fistulas Nutritional Deficiencies

GASTROENTERITIS (ACUTE DIARRHEA) Definition - inflammation of the stomach and intestines -may be accompanied by vomiting and diarrhea (bacterial or parasitic infections) Assessment -mild, moderate or severe diarrhea (loose, watery stools) - irritabilty, cramping - nausea and vomiting - fluid & lyte balance - hx & physical exam of patient - stool examination (ova and parasite)

Treatments/Interventions -ID the causative factor -moderate: maintain fluid & lytes balance -oral replacement therapy (pedialyte, gatorade) -no carbonated or sugar drinks -severe: keep NPO; give IV fluids (NS/ RL) - start with clear liquids - monitor lytes especially potassium for cardiac patients - antidiarrheals for adults

Nursing Interventions -Provide emotional support : allow pt. to talk -Provide rest and comfort: quiet environment -Ensure adequate nutrition: BRAT diet (bananas, rice, applesauce & toast) CRAM (complex carbohydrates rice and milk) milk free for 48 hrs. ; caffeine free Discharge planning: teach parents S&S of dehydration

DIVERTICULITIS Definition/Pathophysiology: -a saclike outpouching of the lining of bowel (If bowel contents are retained in the sac, it becomes inflamed or infected) Assessment: -chronic constipation -abdominal pain (especially LLQ) -fever -abdominal distention/tenderness the

Diagnostics: - Ultrasonography -barium enema( not during acute phase) -increased ESR & WBC -decreased H&H -colonoscopy (after acute phase) Complications: -possible peritonitis - abscess formation & bleeding

Treatment/Management Dietary: -Severe stage: NPO, NGT, IV’s -During inflammation: low fiber clear liquids initially -After inflammation: high fiber -Avoid foods with seeds, nuts, alcohol -Rest Medications -Broad spectrum antibiotics (Flagyl, Cipro) - Mild analgesics - Anticholinergics (pro banthine) - Bulk forming laxatives (metamucil)

Surgical Management peritonitis or abscess formations may require surgery - one stage: bowel resection - multistaged: bowel resected and temporary colostomy performed Nursing Management teach pt. about dietary modifications teach pt. about the various meds teach pt. about ostomy care if needed

PARALYTIC ILEUS Definition/Pathophysiology: paralysis of peristaltic movement due to effect of trauma or toxins on the nerves that regulate intestinal movement Assessment -abdominal pain/distention: accumulation of gas/fluid above the obstruction -rigid abdomen: increased distention makes it rigid -vomiting: earliest sign of high obstruction; bile if lower obstruction - constipation -absent bowel sounds: no peristalsis with obstruction -shock: loss of fluid/lytes from the bloodstream into intestines

IRRITABLE BOWEL SYNDROME Definition: functional disorder of intestinal mobility with no irritation (spasms) Assessment: symptoms range from mild to severe in intensity with constipation, diarrhea or both - pain, cramps (LLQ) - bloating, abdominal distention -more females than males

Treatment/Management Dietary modifications: ID food intolerances limiting caffeine and avoiding alcohol -dietary fiber and bulk help stools Medications -bulk forming laxatives (metamucil) -antidiarrheal agents (Lomotil) -anticholinergic agents (Bentyl) -tricyclic antidepressants (Elavil) -5 -HT 4 (Zelnorm) Stress Management

Diagnostics: CT scan, possible endoscopy Treatment/Interventions NPO NGT Nasointestinal tube (Cantor/Harris tube with mercury) IV’s Pain management Treat shock Nursing Interventions ID early Monitor pt. and all tubes Maintain accurate I&O with monitoring of lytes

Table 24– 2 Causes of diarrhea in children.

HEMORRHOIDS Definition/Pathophysiology - hyperplastic areas of vascular tissue in the anal canal - Internal hemorrhoids above the internal sphincter - External hemorrhoids outside the external sphincter. Assessment Internal: prolapse causing discomfort External -itching - pain - bright red bleeding with defecation

Treatment/Interventions Conservative measures: increase fiber diet (fruit, bran, whole grains) -encourage plenty of water -analgesic ointments, suppositories -stool softeners -Sitz baths Teach to avoid irritating laxatives, spicy foods, caffeine, alcohol, nuts Surgery Pre op: enemas & laxatives Post op: monitor rectal bleeding report significant bloody drainage side lying position

Nursing Interventions -flotation pad -pain med before BM -stool softener -increased fiber in diet -sitz bath -perianal care

Table 24– 3 Influential factors in childhood constipation.

CONSTIPATION Definition - decrease in the number of stools - stools become hard and dry - may even have oozing of liquid stool around impaction. Causes Medications: opoids, iron Obstruction: tumors Neuromuscular condition: Multiple Sclerosis Dietary habits: decreased fiber and fluid intake

Assessment Abdominal distention with pain Pressure straining Headache Fatigue Complications Hypertension Fecal impaction Hemorrhoids and fissures Straining causing Valsalva Manuever

Treatment Treat underlying cause Increase fiber & fluid in diet Bowel habit training Medication: stool softeners ( colace) bulk forming agent (metamucil) stimulants (dulcolax) Nursing Interventions Teach change in life style habits

PARASITIC INFECTIONS (see Ball & Bindler ) Definition/Pathophysiology A parasite is an organism that lives in, on or at the expense of a host. Common GI parasites disorders include giardia, enterobiasis and ascariasis. Assessment Giardiasis(Giardia) S&S: diarrhea Treatment: vomiting furazolidine anorexia quinicrine

Enterobiasis (Pinworm) S&S: perianal itching Treatment: irritability antihelminthic medsrestlessness mebendazole pyrantel pamoate Ascariasis ( Roundworm) S&S Treatment Severe can cause intestinal same as above obstruction Peritonitis Lung involvement

Interventions Patient Teaching Preventative measures Proper hygiene Careful handwashing Medication Education

Practice Question n 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? n A. watery diarrhea n B. ribbon-like stools n C. profuse projectile vomiting n D. bright red blood and mucus in the stools

Practice Question n A nurse is reviewing the record of a client with Crohn’s disease. Which of the following stool characteristics would the nurse expect to be documented in the client’s record? n A. chronic constipation n B. diarrhea n C. constipation alternating with diarrhea n D. stool constantly oozing from the rectum