GI Outline With Notes

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Louisiana State University, Health Sciences Center *

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4352

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Health Science

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Dec 6, 2023

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docx

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The Child with Gastrointestinal Dysfunction DIGESTION Mechanical Circular muscles- churn & mix food particles Longitudinal muscles -propel food mass Sphincter muscles- control passage of food to next segment Chemical Enzymes- degrades nutrients Hormones - stimulate or inhibits GI secretions Hydrochloric acid- produces the pH necessary Mucus -lubricates and protects Water & Electrolytes- transports nutrients ABSORPTION Occurs in the small intestine Passive diffusion- goes from higher concentration to lower concentration Carrier-mediated diffusion - molecules are carried across epithelial membrane Active energy-driven transport- nutrients require energy to be absorbed, so pump transports Engulfment- pinocytosis or large macromolecules absorbed by the villi ABSORPTION (con’t) Fat-soluble vitamins absorbed with fats in the process of bile Water-soluble vitamins absorbed in small intestine Vitamin B12 absorbed in the ileum Water and electrolyte absorption in small intestine Large intestine completes process with Na+ and additional water Feces excreted consist of undigested residue, water, bacteria, and mucus NUTRITION Healthy Newborn- 108 kcal/kg/day Toddlers- 102 kcal/kg/day Preschoolers- 90 kcal/kg/day School Age- 1200-1800 kcal/day Adolescents- 1800-2200 kcal/day Won’t need to these numbers, but understand the concept than newborns needs more calories than a preschooler, but adolescent needs more Infant Organ Systems’ Maturation GI Infant Nutritional Care Solid Foods 6 months Cow’s milk 1 year Primary sources of food. Introduce one at time, over 4-7 days to make sure they don’t have allergies(solid food) Increased risk of anemia Infants primary nutrition is either going to be breast milk or iron fortified formula until 6 months of age. When introducing solid food you should introduce one at a time over a 4-7 days intervals so we can make sure the child doesn't have an allergy at 1 yr we can start to introduce cow's milk but not before because is deficient in vit C, zinc and iron. Infants don't have a consistent source of this until table food is established which is at 1 yr of age At 6 months gI mature enough to digest solid (introduce 1 at time over 4 –7 days ) Increase milk consumption may decrease iron vit c and zinc consumption causing anemia
Toddler and Pre Schooler Nutritional Concerns Physiologic Anorexia At 12- 18 months the toddler’s speed of growth slows down (need less calories) Become finicky eaters; appetite diminishes Non-Nutritive Function Food gives pleasure/comfort in some cases Food/ becomes a social activity Food becomes a means of asserting control Parental Guidance they are at a high risk for physiologic anorexia and the parents start to freaking out because the child is not eating what they supposed to be eating to get the nutrients that they need. Stress the importance of providing nutritional snacks and choices at meals time. focus on quality not quantity, evidence shows that toddlers will eat what they need to survive and when they are hungry and its up to the parents to provide these healthy choices and not freak out over them not eating everything on plate. Encourage to eat, talk to them, but not disciplining them when they don’t Toddler and Pre Schooler Parental Guidance for Good Nutrition How do we guide parents? On how to deal with toddler teach them to create a calm eating environment, if they are outside call them 15 mins before so they can get ready for dinner. make meal a time that is stress free. offer a variety of choices from all the food groups suggested by healthy plate. Quality over quantity, cut up in small chunks for them to grab and go. Finger foods are fun avoid like casseroles School Age Child Nutrition Need less calories/kg of body weight- 2000-2200kcal/day Family diet/eating habits remain a large influence Peer influences at lunch begin- be sensitive to this issue Increased independence in food choice- should be reminded to stop eating when full. Learn to differentiate hunger, thirst, tired, etc Mid afternoon snacks common and healthy choices are important- no mid-morning snack Many have insufficient dairy intake More children with Vitamin D deficiency 17% of children 6-11 years old are obese: BMI> 95 th %ile (CDC) Peer influences may become more important Half of the plate is designed to be fruit and vegetables. No longer use food pyramid Understand what plate should look like Parents need to be educated to provide children with well rounded meals, and so kids can learn what their plates should look like Adolescent Nutrition/Exercise Most females need about 2200 calories daily to support growth spurt, males need 2500- 2900 kcal/day Preparing much of their own food and eating with friends- still need adult guidance Need four servings of dairy during growth spurt Calcium recommendations are 1300mg/day to allow for bone mineralization and skeletal growth- prime physiologic function in adolescence Many teens are being found to be Vitamin D deficient 17% of 12-19 yo are obese: BMI > 95 th %ile (CDC) Nutrition/Exercise
All well visits should include a nutritional and exercise screen Desirable BMI is between 5 th and 84 th %ile Exercise – discuss the emotional, social, and physical benefits Heart healthy activity levels 1 hour/day of moderate-to-vigorous activity Vigorous activity 3 days/week Limit total media time to no more than 1-2 hours/day of quality programming How do we know if our kids are getting enough nutrients Limit does not include what is needed for school PICA Eating disorder of compulsive and excessive ingestion Consumption of food and nonfood substances at least 1 month Includes coffee grounds, clay, soil, stones, paint, ice, hair, paper, rubber, and feces Very serious when substance toxic How do we know if our kids are getting enough nutrients Limit does not include what is needed for school STARVATION Severe Acute Malnutrition (Protein-Energy Malnutrition )- caused from poor feeding and poor sanitary conditions; 3 rd World countries Kwashiorkor deficient protein w/ adequate calorie diet consists of starch and potatoes thin, wasted extremities w/ protuberant abdomen general edema masks atrophy Marasmus - general malnutrition of both calories and protein; decreased subcutaneous tissue Starvation Treatment Provide a diet with high-quality proteins, carbs, vitamins and minerals. 3 goals: Rehydration w/oral solution to replace electrolytes Antibiotics to prevent infection Adequate nutrition by either breastfeeding or proper weaning diet 3 phases: 1- acute/initial phase (first 2-10 days)- oral rehydration and tx of diarrhea/intestinal parasites 2- recovery/rehabilitation (next 2-6 weeks)- increasing dietary intake and weight gain 3- follow-up phase (after discharge)-promote weight gain, developmental stimulation and evaluate cognitive/motor development. Goals occur during overall 3 phases Vitamin and mineral supplements given to replenish them. Vitamin a zinc and copper. Do not give iron until patient is able to tolerate a steady food source Nursing Care Focus on nutrition of pregnant mother which will effect nutrition of the infant Education: Childhood vaccines Nutrition and well-being for lactating mothers Attending well-child visits, weight, height, and head circumference and make sure they are growing correctly Appropriate food sources when weaning from breastfeeding Sanitation practices to avoid GI illness Maintain appropriate skin care to prevent alteration in skin integrity (higher risk of infection, due to lower nutritional status.
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Mainly focus on parent education on what to expect and proper nutrition of child. Offer counseling if necessary. This is KEY. Weight gain/Obesity Concerns Hypertension BP screening should begin at 3 years of age Prevalence of pediatric HTN Currently 5% but is increasing 30% of obese children are hypertensive Hyperlipidemia (Dyslipidemia) 20% of US children and teens have abnormally high lipid levels Type II Diabetes Acanthosis nigricans (screening tool) Overweight/obesity And these are all linked together!! Acanthosis nigricans Darkening or thickening of the skin. this doesn't mean that the child has type 2 diabetes, but they are at high risk to develop it. the body is not able to use all the glucose and it starts storing it at the back of the neck (mainly at creases) Increased insulin Overweight/Obesity One definition/measure BMI > 85 th %ile - < 95 th %ile = overweight BMI > 95 th %ile = obesity Risk factors- parental BMI, disease, possible hormones/neurotransmitters, socioeconomic 18.5% of children ages 2-19 according to the CDC 2019 CDC Prevalence of Obesity Map Contributing factors= Multifactorial Nutrition and physical activity are key Environment (what is available to eat, in stores, neighborhood safety, proximity of fast- food outlets, walking neighborhood etc) Portion size (education is needed here) Race (minorities more likely to be overweight or obese) In some individuals, medical conditions and genetics can play a role Obesity complications Physical Type 2 diabetes- epidemic proportions Syndrome X- obesity, hyperinsulinemia, HTN, dyslipidemia Fatty liver- leading cause of chronic liver disease and cirrhosis Pulmonary- sleep apnea, exercise intolerance, asthma Growth acceleration- Blount disease and slipped capital epiphyses Psychological Depression Low self- esteem Social Bullying Blount's disease is a condition found in children that affects the growth plates around the knee. a disorder of adolescents in which the growth plate is damaged and the femoral head moves (“slips”) with respect to the rest of the femur. Might need to involve psychology as well for depression, bullying, and low self esteem Diagnostic/treatment Diagnostic labs: lipid panel, A1C, liver enzymes, possible sleep study PREVENTION is KEY. Treatment MUST include the family!
Diet- https://www.choosemyplate.gov/MyPlate Exercise: 60 min adult led physical activity per day Behavior modification Family interventions- change entire family’s eating habits Pharmacologic agents- treat complications Surgical Interventions- usually over age 18 Nursing care management- readiness to change ** Tx must include the whole family, the child will not succeed if only 1 person in the family is making the changes and the rest of the family is drinking sodas and eating trash food Sleep study if falling in sleep or snoring Refer to my plate for portion education Obesity Videos https://www.youtube.com/watch?v=h2ku2Ws_Zzo TEDx: https://www.youtube.com/watch?v=KWBOIj3GK-M&t=92s Constipation Definition: Alteration in the frequency, consistency or ease of passing stool. Obstipation: long intervals between defecation Encopresis: constipation with fecal soiling (add more from book) Causes???? Newborn-meconium in 24-36hrs Infancy-organic causes (HD, hypothyroidism, strictures), dietary practices Early childhood- due to environmental changes, school, or normal development School Age- due to environmental changes, stress, and changes in toileting habits, What is going on at school Toddler hood- the need to be in control, would have to use stool softener Know the definition Constipation Treatment Treatment depends on cause Hypertonic solution or water-soluble enema Infant= parent education on normal bowel habits Simple constipation- promote regular bowel habits- more fiber/fluids and bowel routine Stool softeners= docusate or lactulose or polyethylene glycol 3350 (Miralax)- not effective for severe constipation. Chronic constipation= goals include regular evacuation of stool, shrinking distended rectum, promoting regular toileting routine See Box 25.8 page 839 for detailed treatment phases High fiber diet, hydration (water not sodas), reassuring them about normal bowel habits. Rice cereal is constipating Discourage use of rectum stimulation can cause anal fissures With infants we usually let it resolve on its own Constipation- Nursing Implications What do you do as the nurse?? How do you handle? Get detailed history of what is going on, bowel patterns, routine like bowel habits Diet habits, changes in home or school life, Then thorough assessment Then patient and parent education- high fiber diet, healthy food choices, hydration (healthy choices), reassuring them Motility Disorders • HIRSCHSPRUNG DISEASE (Congenital Aganglionic Megacolon) • Congenital abnormality from inadequate motility causing mechanical obstruction • Absence of ganglion cells in rectum, colon, small intestine • ¼ cases of neonatal obstruction • Occurs in 1:5,000 births
• Family hx. • This is a congenital abnormality from the inadequate motility and it causes a mechanical obstruction to the actual obstruction of soul within the bowel contraction of the Admiral bowl and there's a lack of terror of solstice and loss of rectal scientific enteric reflex so that reflex that helps you to evacuate so there is no would they lose that reflex so there's no relaxation with the sphincter of the sphincter which is my school is normally excreted so they can't escape the stools because there is no relaxation there's an absence of ganglion cells in the ****** of: and the smaller happens in ¼ 5000 • like a normal ganglion itself you know this little yellow spots over by • (insert pic) • SYMPTOMS Newborn Infant Child -failure to pass meconium -FTT -undernourished, anemic -vomits bile -constipation -abdominal distention -refuse to eat -vomiting -visible peristalsis -abdominal distention -diarrhea -palpable fecal mass -constipation -foul-smelling ribbon like stool Very important that you're monitoring the newborn may vomit bile and refused to eat and have some abdominal distinction in infants they can have failure to thrive Constipation vomiting and diarrhea child they may be undernourished or anemic have some abdominal distension visible peristalsis they can oftentimes have a palpable fecal mass that's why they tell you palpation is so important and your abdominal assessment Constipation and then about smelling ribbon like stool so diagnosis is gonna be done through a rectal biopsy that's the only way that you do if they suspect it they'll do X-rays just to make sure nothing else is going on but then the diagnosis is going to be done by rectal biopsy and it will show no ganglion cells down the ****** majority of children will achieve fecal continence after they do what's called a pull through procedure and that's the procedure for surgical procedure that's done for her strong disease • CARE • Diagnosis- rectal biopsy shows no ganglion cells • Diet: High calorie, high protein, low-fiber diet • Treatment: surgical removal of a ganglionic portion and possible colostomy Complications: enterocolitis; ABX. sometimes if it's bad enough they'll have to go diet should be high calorie high protein low fiber Constipation high fiber low fiber yes it's usually in that lower section because you can't and so think it's part it's close to that sphincter you can't get that relaxation of the sphincter supreme procedurally we need to concentrate on nutrition emptying of the bowel except in the newborn and part of that is because the newborn has normal doesn't have all the different flora that we have so then I was concerned about making sure that bowl is empty prior to surgery OK measuring abdominal circumference and we're watching for abdominal distention with us and then monitoring vitals for any signs of shock postoperatively it's going to be education and things like enterocolitis which are some of the complications of this procedure and instruction and in care of ostomies not all kids are first a lot of them will so you need to teach the parents how to use and care for that OK reflux who knows about reflux • GASTROESOPHAGIAL REFLUX GER • Transfer of gastric contents into the esophagus • Physiologic- peak incidence at 4 mos. old • Occurs throughout day, but more after meals and nighttime • Usually resolves by 1 year old
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• got some head shaking reflux last couple of weeks you are others of you may have as well so this is a transfer of gastric contents into this painful right yeah peak incidence is at four months of age and usually by a year of age if it's just good old-fashioned reflux it's going away occurs throughout the day but more often after meals and at night time and it usually resolves by one year of age several risk factors prematurity DPD and BPD • Risk Factors Prematurity Cystic Fibrosis BPD Cerebral Palsy Neurological impairments Scoliosis Asthma • neurological impairment asthma cystic fibrosis cerebral palsy and scoliosis you don't have to have any of these 50% of babies will have reflux that's a big number I heard that right 50% of it's kind of normal normal but not reassured when you tell a parent that's normal because they're usually very fussy and this may be spitting up forceful vomiting irritability why are they irritable it hurts OK excessive crying they may have blood in their bonnet arching of the back reflex why it hurts and they're trying to they're trying to stretch all this think about if you've ever had any felt like anything was ever stuck there when you're eating the same thing they may even have hold their breath children can have heartburn abdominal pain difficulty swallowing chronic coughs and noncardiac chest pain and a lot of kids who have a chronic cough but they go into the pulmonologist that’s one of the things that a lot of kids with reflux will be super irritable but not all some can be what we call happy spitters they're perfectly fine to take the rattle • SYMPTOMS Infants Children • Spitting up or forceful vomiting Heartburn • Irritability Abdominal pain • Excessive crying Difficulty swallowing • Blood in vomitus Chronic cough • Arching of back Noncardiac chest pain • FTT • Apnea • as long as they're gaining weight they're happy issues not gonna do anything again it's gonna go away by you OK having had a child with reflux watch invisible me you can see them as soon as you back if that's the situation then oftentimes at that point you're gonna start a patient on medication • DIAGNOSIS • 24 hour pH probe study- intraesophageal • Upper GI Endoscopy • we can do what's called a 24 hour pH probe I'm actually not seeing this done as much anymore this used to be done all the time but you still working on the floor we used to have babies admitted overnight for study all the time as much as they can do an upper or upper GI endoscopy or even what's called a swallow so carol • CARE • Small, frequent meals • Thicken infant formula with 1 tsp. or 1 tbsp. of rice cereal/oz. • Avoid caffeine, citrus, peppermint, spicy, or fried foods • Assist with weight control • ^HOB after meals • thinking of infant formula with one anywhere from one teaspoon to one tablespoon of rice cereal and that's just gonna be dependent on what the meeting needs got rice cereal for older children or for a mom that's breastfeeding avoid caffeine citrus peppermint and any spicy or fried foods magine what living in New Orleans is like if you're breastfeeding a baby with reflux you have to avoid spicy foods and fried foods
but that all and even as a as a child that's going to increase the reflux assist with weight control and then keeping the head of bed up after meals if it's an infant we usually say hold them up for 30 minutes after no matter what they do not sleep on their bellies see so no matter what they need to sleep on their back OK • GERD GE Reflux Disease • Symptoms or tissue damage from GER • Becomes disease with FTT, respiratory issues, or dysphagia • All nursing interventions for GER plus: Proton pump inhibitor- Omeprazole or Pantoprazole H2 receptor- Ranitidine, Cimetidine, Famotidine diaper before they eat because if you feed them and then you lay them down and change their diaper after change your diaper before so GE reflux disease it becomes an actual disease when you have a comorbidity with it or another problem with it something like failure to thrive issues like the coughing not wanting to eat OK that's when it actually becomes GE reflux disease so you're gonna get the same intervention that you would do for regular reflux but then you're gonna start adding medication and that was all our pantoprazole or your proton pump inhibitors and H2 receptors like reading some medicine or Famotidine OK these are not going to necessarily make them quit vomiting it's just gonna help with the pain it will reduce it but it's not gonna completely get rid of the spitting up it's just going to help with the pain • Nissen Fundoplication • so this is what we call a Nissan fundoplication and this is worst case scenario on the child sending this in front application usually they're getting they're also getting and so what's happening is you're taking a portion of the stomach and wrapping it around the esophagus in order to keep the content from coming up they're gonna need gastric decompression with either an NGO or YouTube a lot of them get YouTube and if the child has an Ng tube for gastric decompression and they have a freshness in front application as the nurse you cannot replace that OK and the reason is that you could potentially hurt the surgical site • regardless of another breast fed or formula what can become an issue either way as well is like a milk protein allergy really dive into that in this you don't need to know all this also in which case you have different formulas and if you're breastfeeding mom you have to cut out all dairy or it doesn't it doesn’t to be a little bit more complicated if they're breastfed because the mom has to avoid everything and then you can't stick in FedEx so that makes it a little bit more complicated sometimes if it's bad enough beatings any other questions • ACUTE APPENDICITIS • Inflammation of the vermiform appendix (end of cecum) causing obstruction of the lumen -Most common surgical emergency in kids -Peak incidence 12-18 years old -Boys more often acute appendicitis how many of you guys have taken care of appendicitis kid in clinical already only one really those of you that are on 3rd floor y'all haven't had any appendicitis tapes wow lot of birds well I will tell you all that summer time I don't know why I don't know the science between this the summer time seems to be the the season of appendicitis third floor it was like everybody multiple times because there were so many of them on the floor so this is an inflammation of the vermiform appendix which is the end of the cecum and it causes them instruction of the lumen it is the most surgical emergency that's common surgical emergency for kids and the peak incidence is usually in boys and 12 to 18 years of age new jersey • Clinical Manifestations • Periumbilical pain shifting to right lower quadrant • Nausea -- vomiting
• Fever • Decreased/absent bowel sounds • Diarrhea or constipation • Tachycardia • Lethargy • so generally there is a periumbilical pain which means essential pain it starts to shift to the right lower quadrant mcburney's point oftentimes kids will just be saying for couple of days my stomach hurts my stomach hurts my stomach hurts don't think anything of it running fever because it's such a nondescript pain initially it's not usually picked up until it starts to migrate or the pain gets real severe nausea and vomiting but again fever they had some diarrhea or Constipation going into shock they'll have what's called a referred pain which is that they feel pain and that's because of the deep all that area is on the T10T10I can't say it T10 dermatome which is what's causing the referred pain to all of the stomach versus just that right lower which is where the appendix is what's one of the tests for somebody said it who is it tenderness no tell me tell me what it is like how would you detect rebound tenderness putting pressure where actually if you push on the left side when you let it go when you let go it is not you can have with other things but it is a pretty big sign with appendicitis as well so I can • Diagnostics • CT scan • Ultrasound • CBC, UA, CRP- ^WBC > 10,000/mm3 • Management • Removal before perforation- Appendectomy • Laparoscopic surgery or open incision • Ruptured: antibiotics, IV fluids, NG- suction • Close or open wound • Drain spontaneously and elective appendectomy in 2-3 months • thank you oftentimes the laparoscopic surgery sometimes I'll do an open incision but usually laparoscopic nursing care focuses on pain management both before and after surgery and hydration OK once we know that this is appendicitis she just wanted to light palpation very light palpation before surgery postoperatively monitoring for what when you're doing your assessment we're gonna do think about your focus assessments listen to bowel sounds OK why check for like rigid abdomen yes so that's also that is going to be your focus because if they don't bowel sounds don't return they're not gonna start feeding them think about all sounds how long do you listen for bowel sounds 5 minutes to determine what if you hear them you hear them but if they're not if you don't hear them you have to listen for that full 5 minutes OK if the child is on an Ng deception you have to turn that section off while you're listening OK you have to listen for that full 5 minutes and then yes you're palpation of your admin your visual inspection of your abdomen as well usually be on low intermittent wall suction not continuous Pogo and then pain management as well if it ruptures antibiotics I need fluids they and definitely an Ng destruction if they don't rupture they may not put them on an Ng tube if it's rupture they're gonna put them on an Ng tube to suction it out they might even put in a drain so if it's ruptured sometimes they will do a drain like a JP drain and leave that in there for a while and then do an elective appendectomy 2 to three months later • Complications • 82% of children < 5 y.o perforate- unable to verbalize symptoms so delayed dx. • Peritonitis • Abscess • Phlegmon- acute inflammation of subcutaneous connective tissue that spreads • Fistula
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• Partial bowel obstruction • I found this a little bit longer but 82% of children under the age of five will ruptured or perforated because they're unable to verbalize those symptoms again it's just because my stomach hurts I'm nauseous and vomiting I have a fever until it's too late they may have some parrots nitis could have an Abscess phlegmon is an acute inflammation of the subcutaneous connective tissue that can actually spread or partial bowel obstruction • MECKEL’S DIVERTICULUM • Failure of the omphalomesenteric duct to fuse during embryonic development • Usually obliterated when placenta replaces yolk sac • Causes fistula, umbilical cyst • True diverticulum because includes all layers of intestinal wall • diverticula any questions about appendicitis Nichols advertising is a failure of the during embryonic development I'm gonna show you guys a little picture of this in a minute usually what causes a fistula it is a true diverticulum because it includes all the layers of the intestinal wall it's actually a 2 to one male to female ratio with this one and there's more common before the age of two • Symptoms • Rectal bleeding- usually painless • Abdominal pain, distention, nausea, vomiting • Bloody, mucus stools • diverticula any questions about appendicitis Nichols advertising is a failure of the during embryonic development I'm gonna show you guys a little picture of this in a minute usually what causes a fistula it is a true diverticulum because it includes all the layers of the intestinal wall it's actually a 2 to one male to female ratio with this one and there's more common before the age of two • Rule of 2’s • Occurs in 2% of population • 2:1 male-to-female ratio • Located within 2 feet of ileocecal valve • 2 cm . in diameter; 2 inches in length • 2 types of ectopic tissue- pancreatic and gastric • More common before age 2 • centimeters in diameter and two inches in length and there's two types of it it can be your pancreatic or gastric and it is more common before the age of two the rules of things • Diagnosis • Radionucleotide scan- Meckel’s scan-wouldn't think this would cause that much issues but that's this little diverticulum • Obstructive Disorders • HYPERTROPHIC PYLORIC STENOSIS • Circular muscle of pylorus thickens so pyloric canal narrows • Lumen becomes partially obstructed and hypertrophy worsens • Not congenital- males 4-6 times more frequently • Develops in the first weeks of life • so this is what we call hypertrophic pyloric stenosis anybody heard of this one we're taking care of the baby with this yet so if you can see right here here's your esophagus stomach and your normal anatomy and right here is this enlarged pylorus what do you see what what do you think this right • right there's no there's restriction there's nowhere for the food to go right so the circular muscle of the pylorus gets enlarged and thickens and I pyloric canal narrow so there's nowhere for this thing to go it can't empty it is not congenital but it usually happens in the first few weeks of life and males are four to six more times four to six times more likely to have lower synopsis but this is my first couple of weeks • Clinical Manifestations
• Vomiting occurs 30-60 min. after feeding • Irritable and hungry • Dehydration, weight loss, and FTT • Olive-shaped mass in upper abdomen • Gastric peristalsis visible • Entire bottle across the world Cortana how come no airport to go it goes in the stomach and it gets stuck so they will spit up the entire bottle it's usually non bilious and early stages and it normally begins around three weeks of age but can happen as late as actually five months of age usually in the first couple of weeks they'll be irritable and hungry because I just threw up their entire bottle OK dehydration weight loss they generally have this olive shaped mass on palpation in that upper and you can actually see visible peristalsis do you know what that means to see the stomach moving and you can feel that olive shaped mass in the upper part of the stomach the treatment is surgery • Management • Pyloromyotomy- surgery usually done laparoscopically; incision through muscle fibers • Pre-0p tx.- correct metabolic alkalosis w/ IV fluids w/ electrolytes • Post-op may need NG tube if vomiting continues • Feeds started 4-6 hours- clear electrolyte solution • Formula feeds started after 24 hrs. • Small, frequent feeds - full feeds • Prognosis excellent! • I'll go in and out do an incision through the muscle fibers and open up that heroin of the Taylors oftentimes these kids are gonna come in with a metabolic alkalosis because they're dehydrated so you have to put them on IV fluids you're gonna keep them in PO and correct that metabolic alkalosis vomiting continues sometimes I don't come back fantastic absolutely fantastic beasts were usually started four to six hours with like clear electrolyte solution Pedialyte and then slowly formula feed after 24 hours they will do breast milk a little bit earlier because it is more water based formula small frequent feeds to start with and then advancing to full feeds but like I said these kids do fantastic once you correct it they're usually home within 48 hours and they never have another issue • INTUSSUSCEPTION • Proximal segment of bowel telescopes into distal segment pulling mesentery • Mesentery becomes angled and compressed causing lymphatic and venous obstruction • Ischemia occurs and mucus pours into intestine • Forms currant-jelly stools • Most common site is ileocecal valve • Occurs 3 months- 6 y.o. • Interception looks like you see the small intestine right here this is your appendix down here but you can see the small intestine how it's going into the large intestine so intersection is a telescoping into the distal second and then the mesentery all becomes angled and compressed and it causes a lymphatic and venous obstruction within the bowel and you can start pouring into the intestine as a result as well so you're gonna have this current Jelly seeds within this section and you can see this little X-ray right here that is a picture of the small intestine telescope tell sign • the most common site is the ileocecal valve and it usually occurs between three months and six years of age now that telescoping can go in come back up go in and come back out OK so they don’t have • Donut sign • Clinical Manifestations • Sudden acute abdominal pain • Screaming and drawing knees to chest
• Comfortable between episodes • Vomiting • Red, currant jelly-like stools (blood and mucus mixed) • Palpable sausage-shaped mass in upper right quadrant • Eventual fever and signs of peritonitis • doubled over in pain screaming and pain episodes and that's because it's telescoping in and then coming back out vomiting they do have these red currant Jelly like stools and then we have a palpable sausage shaped mask mask mask in the upper right quadrant OK that's think that's the actual small intestine actually going into that large intestine so you're going to have a palpable sausage mass up in that upper right quadrant may have eventual fever and signs of peritonitis classic triad of intussusception abdominal pain that abdominal mass sausage like mass and bloody stools current Jelly stools • Treatment • Hydrostatic enema- gas enema • Recurrence is rare • IV fluids, NG decompression, ABX therapy • Surgery if needed w/ possible bowel resection • the treatment of inception is done with a hydrostatic animal or gas anima usually done in radiology recurrence is rare once this happens once they treat it done they may be put on Ivy fluids they may need decompression but that's not all the time and then antibiotic therapy nonoperative reduction is successful in the majority of cases so this is usually done in radiology and radiology surgery is needed with a bowel resection if they cannot correct but again the majority of cases are gonna be able to do the hydrostatic • Malabsorption Syndromes • CELIAC DISEASE (Gluten-Sensitive Enteropathy) • Autoimmune disorder triggered by ingestion of glutens • Damages villi in small intestine-villous atrophy- malabsorption • Genetically susceptible with permananent intolerance to glutens • 1% of population, mostly in Europe and U.S. • Rare in Asians and African Americans • so which one of the rules thanks antisocial which one is right lower quadrant pain I'm showing you some of the biggest differences between them and abdominal pain so think about what is the biggest difference is the difference between the diagnosis OK so celiac disease celiac disease right celiac disease so it's an autoimmune disorder that's triggered by injection of glutens autoimmune disorders tend to run in families OK they can be different each family can have a different autoimmunity somebody may have type one diabetes somebody they have lupus somebody may have arthritis somebody may have celiac disease but it's the autoimmunity that runs in the family so this is common also very common with type one diabetes already have that small intestine which leads to villas atrophy and malabsorption genetically susceptible with a permanent intolerance occurs in 1% of the population usually in Europe and the US it is actually rare in Asians and African Americans • Food Intolerances • Protein present in wheat, barley, and rye • Appears at 1-5 y.o. when solids are introduced such as beans/pasta • Bread pasta pasta pizza right everything although there's a lot of food there's a lot of recipes now to do these things out of Donuts king cake I mean you name it everything has gluten in it so it's very difficult for kids compliant with this diet OK think about grammar school you went to a birthday party you're in class and somebody had a birthday my kids school she can't bring birthday treats but a lot of schools you can't you got 30 kids in the class you got a lot of birthdays throughout the year and everybody's bringing king cake or cupcakes or cookies or whatever
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maybe you think about how difficult that is on the child who has a right think about that stage of development especially at school age where really wanna be with our peers right adolescents we're even more into our peers in the peer pressure and if you can't eat the same things what you feel like you feel like you're not included so it's very difficult dying for kids thankfully a lot of there's lots of different bakeries that are gluten-free there's lots of different recipes that are gluten free now so that you know we've come a long way with treatment of this they may also need a lactose free diet temporarily because that can lactose intolerance can go along with celiac disease beer bear has • Clinical Manifestations • Takes a couple of months to appear • Intestinal symptoms -Abdominal distention & pain • FTT -Fatigue • Chronic diarrhea -Muscle Wasting • Aphthous ulcers- canker -Untreated may have lactose sores intolerance appropriately they don't grow that's not growing appropriately this is one of the things we're gonna look at so chronic diarrhea actors ulcers or canker canker sores fatigue muscle wasting and I also may have an untreated lactose intolerance as well remember how we talked about the road sparks so This is why those are so important we are tracking we're looking we're looking at those trends we're looking at single plots and we're tracking those trends so because kids can have celiac disease and lots of other diseases as well they may quit growing so you may suddenly see a height growing something's going on there's lots of diseases and there's a screening whole screening process that we do but this is one of the things that get screened let's see what time is it gonna go a few more minutes and I'll take a break • SHORT-BOWEL SYNDROME Decreased mucosal surface area due to small intestine resection 1) Decreased intestinal surface area for absorption of fluid, electrolytes, and nutrients 2) Need for Parenteral Nutrition-TPN Mortality rate 27%-37% within 5 years so short bowel syndrome it's a decrease in coastal surface area due to small intestine resection decrease intestinal surface because you have a decrease intestinal surface you have a a lack of absorption of fluid electrolytes and important nutrients most of these kids will need TPN and the mortality rate 37% within five years lots of different of • CAUSES OF SBS • Multiple Atresias • Gastroschisis • Necrotizing volvulus • Meconium peritonitis • Crohn Disease • Trauma • not for trees baconian peritonitis disease or any kind of anything that's gonna lead to a possible surgical resection of the bowel anything that requires a bowel resection can lead to short bowel syndrome • Management • 1) Preserving as much length of bowel as possible • 2) Maintain optimum nutritional status, growth, and development while intestinal adaptation occurs • 3) Stimulating intestinal adaptation with enteral feeding • 4) Minimizing complications • 5) Most deaths related to sepsis from poor care of Central line
• you need to absorb those nutrients for growth and development right so gotta make sure the nutrition is adequate which is why most of them are we're gonna stimulate the intestinal adaptation with some enteral feeding so they won't have feelings but we're just going to supplement with TPN and minimizing the complications most deaths are related to sepsis because of poor care from the central line because in order to do TPN which we'll get into this a little bit later have to have a central line so a lot of them get septic from the central • NECROTIZING ENTEROCOLITIS NEC • Acute inflammatory disease of the bowel • Most common in preterm infants • Potential cause is decreased blood flow to intestines • Mucosal wall damaged and gas-forming bacteria invade damaged area • Pneumatosis - air in the submucosal & subserosal surfaces of bowel • let's take a break and we'll come back at 5/2 and catch up.Blood flow where most of the blood brain blood away from the increase blood flow can lead to there is a coastal wall damage and gas forming bacteria that doesn't damage the damaged area and then pneumatosis is where there's actually air in the submucosal and subserosal surfaces of the bowel • and so it's inflamed and there's lots of gas bubbles in there there's usually like to the X-ray babies with this is a preterm baby this is a teeny tiny baby but you can see look at this that way babies with neck can go from looking perfectly fine one minute to the next meeting you turned them over it's very scary it's very critical that you're monitoring babies that are at risk for neck and so we'll talk a little bit about the clinical manifestations of it • Insert pic • CLINICAL MANIFESTATIONS of NEC • Distended abdomen • Gastric residuals • Blood in stools Also: poor feeding, lethargy, hypotension, apnea, vomiting-bile stained, decreased urine output, hypothermia Onset is 4-10 days, after initial feeds; 10 days for full term infant first and foremost gastric residual gastric residuals how do we know what's in the stomach when you pull it back most often these babies are on or have either OG or Ng tube so before every single feed and you were checking out gastric residual residual is OK contents of their last meeting 3 hours ago still in their stomach that needs to be a bigger or they've only been having like one or two CC's and now suddenly we have 20 out of a 60CC something might be happening that might not be a big deal but but that might be included and they have blood in their stools as well poor feeding lethargy hypotension apnea is a big sign neonate often have periods of apnea because their brain they forget to breathe they don't know they don't have that coordinated response yet depending especially depending on the age of gestation some apnea involved vomiting bile stain decreased during output hypothermia remember kids kids and especially until the system is mature enough correct number of newborns are swaddling we're putting on hats those kind of things to keep them warm so they baby with neck they may start dropping their temperature onset is usually 4 to 10 days after the initial feeds and 10 days for a full term infant • Diagnosis • Sausage-shaped dilation of the intestine • “Soapsuds” bubbly appearance • Free air in abdomen indicating perforation • LABS: anemia, leukopenia, leukocytosis metabolic acidosis, electrolyte imbalance
the diagnosis is usually done and they'll be with an X-ray they'll be a sausage shaped dilation of the intestine and see how bubbly this is this is all free air that shouldn't be there free air does indicate perforation and is an absolute emergency those kids will be 666 labs they have leukopenia Leukocytosis that will usually have a metabolic acidosis and electrolyte imbalance as well • Management of NEC • Hold feeds 24-48 hours if asphyxia suffered at birth • BREAST MILK preferred for enteral feeds • Minimal feeds- trophic feeding • Probiotics in first 7 days • NGT- abdominal decompression • IV Antibiotics • TPN for nutrition • 48 hours and if there's a 60 advert they're not gonna start feeding right away again because there's decreased blood flow breast milk is preferred because it has that normal gut flora it's better for the baby so the best milk is preferred I will do what's called minimal feeding or trophic feeding you'll need to understand that word trophic feeding is where you're doing drops of a feed so in neonates 824 to I don't have my exact dates anymore because I don't do that anymore but it's been a while 242628 meters we're not gonna just jump to four feet little bits of food at a time one CC an hour the next day we were very very slow in building up those fees to give them what's called trophic feeds and it's basically to wake up the gut tell the guy it's time for you to start doing start digesting indeed two for abdominal decompression like probiotics for the first seven days they'll get IV antibiotics as well and then TPN for nutrition again these kids are sick those of you that have been working when you see a baby with neck you will never ever forget it I promise you and I have a baby see in my brain who was perfectly beautiful and healthy and doing fantastic in the morning and we were taking pictures and looked fantastic and by the end of the day so they get sick very very fast it's a very very scary thing OK that's not always the case this baby went down real quick I've never really nothing we could do we all kind of watched and it just wasn't we couldn't get enough so it is just one of the things that sticks in your mind they are they get sick fast maybe there hasn't been having any apnea spells have apnea cells that needs to be approved but something might be going on close monitoring very very important they're gonna be antibiotics and again this trophic feeds we start those but then when they go to restart them as well after so that's one of our biggest monitoring things for what are we checking gotta check our residuals OK obviously the term baby this is a little bit different because you have a term baby that's healthy and doesn't have but and this is more than a preterm baby that's gonna be mostly preterm babies they don't have their swallow coordination so they're gonna be making sure you're checking before every single feeding and if they're bigger than they have been or they're more than half the provider • BILIARY ATRESIA • Inflammatory process that causes intrahepatic and extrahepatic bile duct fibrosis --- ductal obstruction • Unknown cause, immune or infection response • 1:10,000-15,000 births • Not seen in fetus, stillborn, or newborn infant • May occur late in gestation or perinatal period • Manifests after a few weeks after birth • and then just persist and so then we start thinking about what might be going on • Clinical Manifestations • Complete obliteration of extrahepatic biliary tree and ducts - Jaundice persists beyond 2 weeks of birth - Dark urine
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- Gray stools- no bile pigment - Hepatomegaly- firm - great schools and I know I already have it on here actually but there's no bile pigment so the bile is what makes your soul is the color that they are with filaria trees are there is no bile coming through so there is no pigment they're like literally the color of these chairs is what they look like grayish whitish early chairs on the hepatomegaly which means that the liver is very firm again they just they look normal at first these kids go home they might have a little bit of jaundice when they go back to the pediatrician two weeks of life • Management of BA • Aggressive nutritional support- enteral or TPN • Enteral feeds should be low in sodium • Supplements of fat-soluble vitamins (A,D,E,K) • Phenobarbital used to stimulate bile flow • Ursodeoxycholic acid (Ursiodol) to decrease cholestasis, itching, and jaundice • Surgery • Management is gonna be aggressive nutritional support either intro or TPN or combination of the two medical care is gonna be supportive at this point internal fees need to be low in sodium and they do need supplements of fat soluble vitamins vitamins because they're not absorbing those within the intestines vinegar is sometimes used to stimulate bile flow which talk about they're not getting that bile flowing through the intestines and you're a social have this actually spelled backwards but you're a social to decrease Cholestasis itching and so that will kind of help with some of that surgery is gonna be there how do you treat it OK the initial management is all supportive but then surgery is gonna be you’ractual treatment they have what's called the kasai procedure where a segment of the intestine is anastomosed to the resected now a • Hepatic Portoenterostomy KASAI Procedure so this is the resection it's connected to the liver • Prognosis • Death by 3 y.o. if untreated • 20% survival by 20 years with Kasai procedure • Liver transplant • death is usually by three years old if it's left untreated 20% survival after 20 years with a kasai procedure and they ultimately end up needing a liver transplant look up kids • ESOPHAGEAL ATRESIA & TRACHEOESOPHAGEAL FISTULA • Esophagus fails to develop as continuous passage • Trachea and esophagus fail to separate • 1:3000 births • 50% from VACTERL association (vertebral, anal, cardiac, tracheal, esophageal, renal, and limb • questions about yes they do this procedure to help but they end up ultimately needing a liver transplant alright so esophageal atresia or tracheal esophageal fistula this is where the esophagus fails to develop as a continuous passage whenever you have your trachea and you have your esophagus right next to each other and then does not actually continue fully developed and they failed to separate 50% of these are from what's called a bacterial association which these kids have multiple anomalies vertebral annual cardiac tracheal esophageal renal and limb it is common for them to have cardiac anomalies along with this is this was • so you can see the most common is the sea type there's a complete blind out right here it's not going anywhere passage like it's posted this type right here this is only 45% you can see it develops and the trachea but there's this passage still right there there’s a fully separate there there's a normal trachea and esophagus but there's official form and this one can actually pick this up until later in life oftentimes these
are picked up because the child has having lots of saliva in the mouth brought this alive of the drawing insert pic • Clinical Manifestations • Frothy saliva in nose & mouth -Stomach distended w/ air • Drooling -Gastric contents regurgitated • Choking -Apneic • Coughing -Resp. distress • Cyanotic Polyhydramnios possible clue to unborn infant- amniotic fluid cannot reach GI tract to be absorbed and excreted by kidneys • through just going into that blind pouch won't go anywhere they had stomach distended with air because the trait the trachea is connected to their stomach so air is going in and gastric contents and respiratory distress that they can manage polyhydramnios is a possible clue and an unborn infant so there's if there's still an ultrasound like polyhydramnios that is a possible clue and that's because the amniotic fluid can't actually reach the GI tract and be excluded like it needs to be people say what's going on then they swallow normally and then cough and gag and milk starts coming up through their nose and mouth it's just going into the blind pouch • Treatment of EF/TEF • Maintain patent airway • Prevent pneumonia • Gastric or blind pouch decompression • Supportive therapy • Surgical repair • so the president is going to maintain maintain a patent airway frequent suctioning of secretions in the mouth fluids are gonna be NPO until they get repaired to prevent pneumonia in some of these cases they're not fully split so some of that food may be going down into the trachea gastric or blind pouch decompression where they'll put a little to help decompress that blind pouch supportive therapy until surgery repair and they have a surgical repair some of the complications drinking Malaysia is one of them where there's a weakening of the tracheal wall dilated proximal pouch and you can see right here this is so this is normal inspiration expiration with the trachea looks like and then you see here • Complication of TEF • Tracheomalacia- caused from weakening of tracheal wall from dilated prox. pouch • Symptoms : barking cough, stridor, wheezing, recurrent resp. infections, cyanosis, apnea • OK signs of tracheal Malaysia barking cough strider sounds like lots of striders like a loud high pitch sound that's coming out when they're inhaling and they have some wheezing recurrent respiratory infections there’s different levels • Abdominal Wall Defects • GASTROSCHISIS • Bowel herniates through defect in abdominal wall on right side of umbilicus • Intestines outside body in utero • 3-4/10,000 live births • so this is gastroschisis and this is where the bowel herniates through the defect in the abdominal wall on the right side of the umbilicus things are on the outside of the body in utero you can see this is all vowels right here it's not in any kind of a sack it's just loose on the outside of the body give me simple • Complications • Can be simple or complicated • Bowel atresia • Perforation • Ischemia
• Necrosis • and actually what's happening and you can't see it is there's actually a string hanging from the top of the warmer warmer from the top of the warmer to keep this all upright because you don't wanna • Management • Cover exposed bowel with transparent bag or moist sterile gauze- Silo • Silo reduced over days to weeks • IV fluids and IV antibiotics • Double-lumen NG tube inserted for decompression • Need 2-3X maintenance fluids for replacement • THERMOREGULATION !!!!! • Simple treated with surgery right away • while it's in that silo the provider is pushing a little bit of bowel back into the stomach OK over several days they'll do an early surgical closure if the baby is having lots of temperature instability in other we talked about they can't hold their temperatures so if they're unable to hold their temperatures dropping their temperatures a lot and they will go ahead and do it early surgical closure to reduce the risk of fluid loss and infection and they're gonna be united fluids and antibiotics because again you have part of your the stomach is open you have part of the bowel now that you're gonna have fluid loss double lumen Ng decompression they're doing two or three times maintenance fluids because of all that fluid loss and thermoregulation is gonna be super important they're gonna be in a warmer and again if they're having a lot of temperature instability that closure sooner rather than later some of the simple ones will be just treated right away that some more complicated • Post-Op • Mechanical ventilation from abdominal pressure • Pain meds- Morphine and Fentanyl • Prolonged TPN • May take days to weeks for normal bowel function • postoperatively they're going to have mechanical ventilation because of that abdominal pressure think about it all the intestines were on the outside of the body now we're going to put that on the inside of the body we are drastically increasing the pressure within the abdomen which also puts pressure on your lungs mechanical ventilation and then prolonged TPN for these kiddos they are talk about risk of short bowel syndrome for short bowel syndrome because of potential necrosis it can take days or weeks for normal bowel function to resume • Omphalocele • True failure of embryonic development • Failure of lateral folding of abdominal wall at 3 rd week gestation • Covered by translucent peritoneal sac • Includes bowel and maybe liver • Associated with other anomalies- 50%-70% • Cortana we're not doing anything initially OK there It includes bowel and it can include the liver this is just about on the outside and there's no sack around the bottle and it is often associated with them • Management • Place nonadherent dressing over defect • IV fluids and IV antibiotics • Double-lumen NG/OG tube for decompression • Sac resected and reduced • May need mechanical ventilation and TPN • Feedings resumed once bowel function established • and over because we want to protect that sack the stack is gonna eventually be resected and reduced as well and then you're gonna need mechanical ventilation so a lot of the same treatment as gastroschisis there's not gonna have that silo bag like
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gastroschisis does long term complications of reflex to thrive they could have a ventral hernia and then feeding issues as well because again that bowls on the outside we gotta put it back on the inside we could have some issues with blood flow prior to so we could have some feeding issues going on too • UMBILICAL HERNIAS - Common; rarely incarcerated - Affects premies and low-birth weight newborns - Usually resolves by 3-5 years - Surgery elective if not resolved these are very common in babies and they're rarely what we call incarcerated affects preemies and both were low birth weight newborns usually resolved by three to five years of age if they're not incarcerated we don't do anything about it they will resolve overtime surgery is just elective • INGUINAL HERNIA • 80% of childhood hernias • Boys more common 6:1 • Peritoneum precedes testicle into scrotum in boys • Round ligament into labia in girls • Emergency surgery for incarcerated; elective in healthy infants • so it's constricted and so you can actually risk lack of blood flow to that area so the way that we test to see if it's incarcerated is we have to try to reduce it you have to try to push it back incarcerated he does push back in that usually hernia is the same thing more common the testicle into the scrotum and girls around ligament into the labia and there's an emergency surgery if it's incarcerated same thing this one they will surgically repair incarcerated it’s an emergency • CLEFT LIP & CLEFT PALATE • Incomplete fusion of the oral cavity or palates in utero • Can be bilateral or unilateral • 1:600 births • Genetic and environmental factors- alcohol use, cigarette smoking, drugs- anticonvulsants, steroids, and retinoids • Occurs in other syndromes • Folic acid helps prevent • alright click weapon palette this is an incomplete fusion of the oral cavity or pallets in utero to show you guys some different pictures of them can be bilateral or you know I wanted 600 birds with other syndromes they are treated by a full craniofacial team which includes plastics and T orthodontics speech Pediatrics nursing audiology social work and psychology whole team get together most clinics have what they call a craniofacial clinic for the kids go to and all of these different people are there folic acid does help prevent we'll talk about this in our regulatory lecture but folic acid should be given to all women of childbearing age and that's to prevent cleft lip and palate but also to prevent yeah thank you I was trying to get the actual word out that you got it thank you • CLEFT LIP • Surgical correction at 2-3 months • Must be free on infection • is this thing right here is a list think these are all just lips this actually might be a pallet right here but you can see this is Cliff lip right here there may be a pallet I can't tell whether right here but then after repair you can't really see there's often a little bitty scar right here but it's not huge surgical resection correction is usually at two to three months of age and it must be free of infection • CLEFT PALATE • Surgery by 6-12 months • Early repair restricts skeletal growth and delayed repair results in speech disorders
• so this is what the cleft palate itself looks like this is the hard part it's just going up there into that pallet early repair does restrict skeletal growth but delayed repair results in speech disorder so there's a fine line of when they actually do this repair but usually between 6 and 12 months of age • Post-Op Care • Monitor integrity • Elbow restraints so unable to bend arms • Position upright or on back • Clean incision with NS, water or diluted hydrogen peroxide • IV fluids and clear liquids first 24 hours • NO straw, tongue depressor, sippy cups, hard utensils • Observe for airway obstruction or hemorrhage • fingers in their mouth so they have to do a little bit position upright or on their back we're just gonna clean that incision with some normal saline or water or diluted hydrogen peroxide a lot of times I just use a little water and just clean that off gently Ivy fluids and clear liquids the first 24 hours no straws tongue depressors sippy cups or hard utensils OK especially with that palette repair it's not really gonna pertain as much with two to three month old but if they're 12 month old and then observing from the airway obstruction or hemorrhage postoperative like • Management • May need additional surgeries • Orthodontics • Speech Therapy • Orofacial Maxillary team • Pediatrics • Audiology • Social work • Psychology • Feeding Problems • Encourage breast feeding for cleft lip • Position upright • Burp frequently • Specialized bottle w/ one-way valve and special nipple • Syringe feed if necessary • we have a lot of feeding problems makes it hard for that milk to go down lips and have them positioning them upright breastfeeding football hold to get them upright if they need to burping frequently they are swallowing tons of air because they don't necessarily get the closure on the ****** so they swallow a lot of air maybe what's called a wider base you can see this right here this is one of them or like a milk ****** that is a water base and that's because that kind of helps get that stuck around you may need to squeeze their cheeks for support nobody ever seen on earth speed is left with babies so oftentimes it they'll do is they'll kind of put their finger one finger underneath the chin and then the other two fingers on the cheek to kind of help them get that suction because if they've got that especially with the power this is a specialized bottle right here with a one way valve So what happens is when you turn the bottle upside down for them if necessary if they're really not feeding them we'll do syringe feedings OK waiting waiting for years because of that excess • ENTERAL FEEDINGS • Nasogastric- NG • Orogastric- OG • Nasojejunal- NJ • Gastrostomy tube- GT • NG/OG Feeding Tubes • Tube passed through nose or mouth • Left in place or removed after each feed
• Replace long term w/ hospital policy • May be used for gavage, continuous, or medication administration • Check placement on hospital policy- usually x-ray initially, then pH test- <5.5 • how do we measure for feedings air nose round down to process sometimes they're weighted sometimes they’re not replace them long term with the hospital policy they can be used for gabage continuous or just medication administration depends on the baby placement based on hospital policy all hospitals require chest X-ray initially so once that team is place you have to confirm it with with their chest X-ray before you can use it and then depending on the place some use the pH strips and other children's they use the pH strips others measure they'll measure either the market the nose or they'll measure from the tip of the nose to the end of the tube and that's what they do every single time no longer put air into the belly and listen for that bubble because of the risk of perforation • Naso-jejunal Tubes NJT • Used for high risk aspiration or regurgitation • Has radiopaque guidewire to help with placement • Placed in jejunum/duodenum • Must get x-ray before use • Only continuous feeds given • so these are your nasal tubes these are those these are your kids that are high risk for aspiration has a radio type guidewire you can kind of see it right here there's a guide wire that's in here these are only used for continuous seats • so here's the difference you can see the nasogastric feeding tube goes right here into the stomach but the digital tube goes further down into the intestines • Gastrostomy Tubes • If tube unable to pass through mouth, pharynx, esophagus, or cardiac sphincter • Long term tube feeding • Placed under general or local anesthesia • Tube through abdominal wall into stomach • Clean w/ soap and water • No need to check for placement • Different types • at this point yeah there's so many different kinds this little Mickey one Nikki you can disconnect the tubing from here and you can see it on their belly disconnect the tubing from here and you can just close it up parents don't have to have that connected to them all the time they can disconnect the tubing it is placed under general or local anesthesia and goes through the abdominal wall into the stomach you have to clean around that how often once a shift with what they can get very irritated especially some of them have some leaking they can irritate the skin have some skin breakdown so make sure you're monitoring the site lots of different types but it has a little unfortunately disconnecting and reconnecting versus the Mickey button where they have you can disconnect the actual feeding tube and then from i did not • PARENTERAL Nutrition • TPN- Total Parenteral Nutrition • Provides total nutritional needs • IV infusion of highly concentrated protein, glucose, and nutrients • Filtered to remove particulate matter • Central line- >Dextrose 13% • Peripheral <Dextrose 12.5% • and those can actually be gastric tubes so they can be GJ tubes so with the GJ tube there's actually kind of two lumens so one goes into the stomach and the other one extends further into the vaginal so parents are this is your TPM when are we gonna use absorption it's in disorder or something like we have to give them nutrition and this provides their total nutrition needs they're high in protein glucose and all
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nutrients patients cannot have anything greater than 13 percent 12 1/2% or less would be in your peripheral lines and then once you get the 13% you have to be on a central line it's important that you're double checking percentage • Management of TPN • New bag/tubing hung every 24 hours • 2 Nurses sign off • High risk for infection in IV • against the bag of TPN just like pressing blood two nurses must check it and then you have to check your details so if you all of a sudden get a bag of TPN for a patient who's been on had a PID for an extended period of time that you've been doing it through and suddenly that dextrose is now 14% 14% and they are the high risk of infection because like I said earlier in this but a lot of these kids are on higher concentrations of dextrose have a central line so they're at higher risk of infection question
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