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Introduction to pediatric nursing Dr.khamees B.Obaid Gastrointestinal System of Children Learning objectives To know the anatomy and physiology of the gastrointestinal (GI) system To Describe the etiology, pathophysiology, clinical manifestations, diagnosis, and treatment of common GI alterations To Discuss the nursing management and interventions appropriate for children with GI disorders Introduction And Overview Of Digestive System Disorders that affect the digestive (gastrointestinal) system are called digestive disorders. Some disorders simultaneously affect several parts of the digestive system. The digestive system is responsible for breaking down food we eat into smaller components so that nutrients can be easily absorbed by the body and the waste discarded. Several body parts, including the mouth, esophagus, stomach, small intestine, large intestine, and anus, make up the digestive (gastrointestinal) tract. The digestive process begins when food enters a Introduction to pediatric nursing Dr.khamees B.Obaid Classification of digestive diseases A-Congenital and structure disorders Cleft lip and Palate -Esophageal Atresia & Tracheoesophageal Fistula -Pyloric Stenosis -Intussusceptions -Hirschsprung’s Disease -Hernias Imperforated anus B-Infection and inflammatory Disorders Appendicitis Peptic Ulcer Diarrhea Gastritis Stomatitis Introduction to pediatric nursing Dr.khamees B.Obaid C-Disorders of Motility -Constipation D- Allergic and Malabsorption disorders -Celiac Disease Common terminology Enteritis: inflammation of the intestines and especially of the human ileum Gastroenteritis: means inflammation or irritation of the stomach and intestines. is a very common and infectious illness involving vomiting and diarrhea. Oral rehydration therapy (ORT): The administration of special fluids by mouth or by adding fluid and electrolytes directly into the blood stream Oral rehydration solution (ORS): a liquid specially formulated to be given as a drink to correct the water, mineral, and nutritional deficiencies in an individual, especially an infant, who is affected by dehydration Diarrhea: frequent and excessive bowel movements: frequent and excessive discharging of the bowels producing thin watery feces, usually as a symptom of gastrointestinal upset or infection Dehydration: a dangerous lack of water in the body resulting from inadequate intake of fluids or excessive loss through sweating, vomiting, or diarrhea. Vomiting: Throw up stomach contents: to expel the contents of the stomach through the mouth as a result of a series of involuntary spasms of the stomach muscles Stomatitis :is inflammation of the mouth and lips Introduction to pediatric nursing Dr.khamees B.Obaid GI Facts Suck and swallow reflex develops at 34 weeks Stomach capacity is 10-20 mL in the infant up to 3 liters by adolescence Coordinated oral pharyngeal movements necessary to swallow solids develops after age 2 months Stool frequency is highest in infancy Control of stool is achieved by 18 months to 4 years Assessment of GI Disorders includes Child History Birth weight Prematurity History of maternal infection Feeding The nurse Ask about: Duration of illness Frequency of stools and associated vomiting Color of vomit (if green bilious vomit, consider obstruction) Introduction to pediatric nursing Dr.khamees B.Obaid Nature of stools, including presence of blood in stool Feeds (fluid and food intake Urine output (number of wet nappies Exposure to infect Recent antibiotic use Weight loss Underlying problems e.g. Low birth-weight, malnutrition, neurodisability Nurse Assessment Weight, including any previous recent weight Temperature, pulse, respiratory rate Degree of dehydration Complete systemic examination Abdominal distention Abdominal circumference Abdominal pain Note :Children aged <1 yr are at increased risk of dehydration Common GI Diagnostic Test Barium swallow / enema Gastric emptying study Introduction to pediatric nursing Dr.khamees B.Obaid Abdominal ultrasound CT scan with or without contrast MRI Endoscopy Diarrhea Diarrhea is defined either as watery stool or increased frequency (or both) when compared to a normal amount. It is a common problem that may last a few days and disappear on its own. Types of Diarrhea Acute (short-term, usually lasting less several days), which is usually related to bacterial or viral infections. Chronic (long-term, lasting longer than four weeks), which is usually related to functional disorders, such as irritable bowel syndrome, or may be due to diseases such as ulcerative colitis, Crohn's disease, celiac sprue, or Giardia. Bloody diarrhea (dysentery ) Common Causes of Diarrhea Causes Examples Intestinal Viral (Rotavirus), bacterial ( E. coli, Vibrio infection cholera),fungal overgrowth ,parasites( Giardia ) Food Gluten ,cow's milk Introduction to pediatric nursing Dr.khamees B.Obaid sensitivity Food Overfeeding ,introduction of new foods intolerance medications Iron ,antibiotics Colon disease Ulcerative colitis ,cancer Surgical Short bowel syndrome , alteration Emotional Anxiety ,fatigue stress Causes Of Vomiting Improper feeding technique Infections (respiratory tract ,meningitis ) Food allergy and dietary protein intolerance Intestinal obstruction (pyloric stenosis intussusceptions ICP Types Of Vomiting Reflexive = infection or allergy Central = central nervous system (projectile): head trauma ,meningitis and brain tumor Introduction to pediatric nursing Dr.khamees B.Obaid Regurgitations Means to express "spill out" of "spill over" a small amount of formula. a during or small amount of swallowed food Also spitting up from stomach shortly after eating Differences between regurgitation and vomiting: Regurgitation is not accompanied by nausea. No forceful contraction of abdominal muscle. Occurs in early weeks of life. A short time after feed babies regurgitate small amounts (1-2 mouthfuls) of milk. Weight gain is normal. Doesn't need any treatment. When To Admit Children With Diarrhea And Vomiting Children should be admitted to hospital if they are: moderately dehydrated — observe for 4–6 hours to ensure adequate rehydration; Severely dehydrated or in shock — intravenous fluids are required; At high risk of dehydration — < 6 months old, high frequency of watery stools or vomits, minimal oral intake, worsening symptoms; At high risk of complications — children with significant underlying disease (e.g., diabetes, renal failure), high fever, poor nutrition; or Suspected of having another diagnosis (eg, appendicitis, intussusceptions). Introduction to pediatric nursing Dr.khamees B.Obaid Note :Children should also be admitted if the parent or carer is unable to manage the child at home Symptoms of diarrhea? Cramping Abdominal pain Bloating Nausea Urgent need to use the restroom Fever Bloody stools Dehydration Warning Signs Of Severe Diarrhea Abdominal pain Blood in the stool Frequent vomiting Loss of appetite for liquids High fever Dry, sticky mouth Weight loss Urinates less frequently (wets fewer than 6 diapers per day) Frequent diarrhea Extreme thirst No tears when crying Depressed fontanel (soft spot) on infant's head Treatment For Diarrhea Introduction to pediatric nursing Dr.khamees B.Obaid treatment of diarrhea depend on the cause. Treatment usually involves replacing lost fluids. Antibiotics may be prescribed when bacterial infections are the cause fluids. Antibiotics may be prescribed when bacterial infections are the cause Dangerous of Diarrhea Diarrhea can be dangerous if not treated properly because it drains water and salts from the child. If these are not put back quickly, dehydration can occur and hospitalization may be necessary. It is most important that the child with diarrhea continues to drink an appropriate quantity of fluids to avoid dehydration. Dehydration is a loss of body fluids, which are made up of water and salts. When sick children vomit or have diarrhea, they can lose large amounts of salts and water from their bodies, and can become dehydrated very quickly dehydration can be very dangerous, especially for babies and toddlers. Children can even die if they are not treated Types of Dehydration Isotonic : Water and salt are lost in equal amounts Hypotonic (hyponatremic): Electrolyte deficit exceeds water deficit Hypertonic (hypernatremic): Water loss exceeds electrolyte loss Severity of Dehydration Mild Moderate (some) Severe Signs of dehydration Decreased urination (less than four wet diapers in 24 h) Introduction to pediatric nursing Dr.khamees B.Obaid decreased urination (less than four wet diapers in 24 h) no tears dry skin, mouth and tongue sunken eyes grayish skin sunken soft spot (fontanel) on infant’s head Oral Rehydration Solutions They are exact mixtures of water, salts, and sugar. These solutions can be absorbed by the body, even when infection is causing the child to vomit. Introduction to pediatric nursing Dr.khamees B.Obaid COMPOSTION OF ORS (MMOI/L) STANDARD SOLUTION WHO /UNICEF SODIUM 60 90 POTASSIUM 20 20 CHLORIDE 50 80 CITRATE 10 10 GLUGOSE 75-110 110 Assessment of dehydration Moderate Severe General appearance Lethargic or thirsty cold, cyanotic extremities, drowsy Radial pulse rapid Feeble , impalpable, weak Respiration Deep Deep and rapid Skin elasticity Pinch retracts slowly Pinch retracts very slowly (>2 sec) Anterior fontanel Sunken Very sunken Eyes Sunken Very sunken Tears Reduced, Absent Absent Mucous membranes Dry Very dry Introduction to pediatric nursing Dr.khamees B.Obaid Urine output Reduced None passed ,oliguria body weight 5%–10% Loss of body weight: > 10% Treatment Of Mild Dehydration: 1-give extra fluid more than usually to prevent dehydration such as ORT 2-increase breast feeding 3-IF THE not breast feeding give ORT (50 ml/kg) in 4 hr. or food based fluid (such as soup, rice water) 4-the mother should know how prepare and how much ORS give for her child 5- Take child to hospital when: the signs and symptoms of sever dehydration appear Treatment Of Moderate Dehydration: 1-Extra fluid 2-Contiuous feeding 3-ORS (100 ml/kg) in 4 hr. 4- Take child to hospital when: the signs and symptoms of sever dehydration appear Treatment Of Severe Dehydration: 1- Intravenous fluid will be given 2- The child need to stay in hospital until the dehydration is controlled 3- Reassess the child every 1-2 hr. Introduction to pediatric nursing Dr.khamees B.Obaid SUMMARY OF TREATMENT PLANE FOR DEHYDRATION General Nursing responsibility toward child with Gastroenteroritis A-Nurse and child • frequent monitor intake and output • Monitor vital signs every 2-4 hr. • Observe and record the stool or vomiting contain (amount ,color ,consistency ,odor and frequency ) • Wash hand before and after contact with the child • Daily measure body weight • Give special care hygiene for child skin ,mouth) Introduction to pediatric nursing Dr.khamees B.Obaid • Determine the causes of G.E. • Isolate child until the cause determined • Asses the level of consciousness • Provide and maintain fluid and electrolyte (ORT or I.V. fluid) • Promote child at rest and comfort • When child become better a normal diet for the child's age is slowly reintroduced B-Nurse and family: • Teach family to seek care when child's vomiting or diarrhea worsens • Teach family the signs and symptoms of severe dehydration • Encourage family to keep appropriate fluid at home to deal with mild dehydration • Teach family how prepare ors • Encourage mother to continuous breast feeding in mild or moderate dehydration • Teach family this condition may lead to severe dehydration and life threating • Teach family to when child become better a normal diet for the child's age is slowly reintroduced Introduction to pediatric nursing Dr.khamees B.Obaid Child Constipation? Constipation is an abnormal pattern of bowel movements that causes a person to pass stools less often than usual. The stools may be difficult to pass or harder than usual. Causes of constipation? In most children, constipation is caused by issues with bowel routines or diet. Some common causes of constipation are: Not drinking enough fluids Not having enough fiber from whole grains or cereals, fruits and vegetables Eating too much junk food or other foods that promote constipation Withholding stools to avoid painful bowel movements if there are small tears (fissures) at the bowel opening (anus) Genetics - some children inherit a tendency toward constipation from their parents Poor bowel routines, problems with toilet training and sometimes refusing to spend time on the toilet. Illnesses that cause vomiting, diarrhea or fever and lead to a loss of body fluids and dehydration Some medicines such as morphine Underactive thyroid gland (hypothyroidism) Introduction to pediatric nursing Dr.khamees B.Obaid Hirschsprung's disease, a disease of the bowel that is usually diagnosed in the first few weeks of life Nursing intervention: Increase fluid intake. Laxative fluids e.g. orange juice relives mild constipation. Small soapy enema may be given. Milk of magnesia may be used as a temporary measure. Establish or maintain regular bowel action by nature means rather than using purgatives. Psychological support to express his fear and his own emotional reactions. Key points for Constipation Constipation means bowel movements that are less frequent than usual, painful or hard to pass. Constipation can be caused by inadequate fibre in the diet, poor bowel routines, fissures in the anus, medicines, genetics or not drinking enough fluids. Family bowel patterns may play an important role. Changes in your child's diet may stop constipation. Your child's doctor may also suggest giving medicine such as stool softeners to clear the bowel. See your doctor if your child has blood in their stool, loses control over bowel movements or has a fever Introduction to pediatric nursing Dr.khamees B.Obaid Key points for Diarrhea Diarrhea is frequent bowel movements and loose or watery stool. Diarrhea can cause dehydration which can be dangerous. Signs of dehydration include dry mouth, sunken eyes, not peeing often and low energy. When your child has diarrhea, continue with their regular diet. Give plenty of fluids. If your child is a baby check with the doctor about giving certain fluids. Talk to your doctor before giving your child an oral rehydration solution to prevent dehydration. Talk to your doctor if your child is not able to drink fluids, has blood in their stool, or has pain that does not go away. Talk to your doctor if your child seems to be getting sicker.
