3Disorders of Digestive System Prepared byDr / Magda Abd-El-Aziz
4INTRODUCTIONFocuses on most common gastrointestinal disorders such as foreign bodies in G .I .T system,thrush stomatitis ,vomiting, colic, constipation,diarrhea and dehydration,major nursing diagnostic and nursing intervention related to recognition and management of the child.
5Objectives General : General : By the end of this lecture the student will be able to discuss Disorders of Digestive System
6Specific objectives:By the end of this lecture the student nurse will be able to::Define the common gastrointestinal disorders (ingestion of foreign bodies, stomatitis, vomiting, colic, constipation, diarrhea and dehydration).Mention the etiology and causative organisms of these disorders.Apply the nursing process to different gastrointestinal disorders.Provide health education to parents regarding the management and prevention of common gastrointestinal disorders.
7Out line:- Introduction. Foreign body in G.I.T. Stomatitis. Vomiting. Colic.Constipation.Diarrhea.Dehydration.Nursing intervention.Prevention of diarrhea.
8Disorders of Digestive System A- Foreign bodies in G.I.TEtiologyThe infant during the oral phase of development enjoys putting objects into his mouth, as he sucks upon a small object lie may swallow it. Objects may lodge at any part in the stomach or pass through the intestinal tract or it may perforate the intestine.Assessment:Observation for sign of perforation, which are: nausea vomiting, blood in stools, tenderness of the abdomen, evidence of pain.
9Nursing diagnosis:High risk for intestinal perforation related to swallowing of foreign bodies.Goal:The infant/child will experience no signs of perforation.
10Intervention and treatment: No specific nursing care other than close observation of the child's stools and signs of perforation. Stool must be placed in a fine mashed sieve and water run with force upon it until the fecal matter disintegrates and object if present is clearly seen.Outcome criteria:The infant/child will experience normal bowel movement.
11B- Stomatitis Definition: Inflammation of the mucous membrane of the mouth. It may be due to local lesion in the mouth or a feature of a systemic disease e.g. measles.
12Causes of stomatitis: Infection: Viruses: measles, primary herpes simplex, coxsackie A.Bacteria: streptococcus, diphtheria.Fungus: monilia coral thrush.Eruption stomatitis: associated with eruption of teeth.Traumatic: cheek biters.Local reactions: due to sensitivity to contact substances from toys and foods.Immunological impairment: in leukemias.Drugs and poisons: phenytoin, salicylates, corrosives.
13Types of Stomatitis:Catarrhal stomatitis.Herpetic stomatitis.Thrush stomatitis.
14Thrush stomatitis: Definition Etiology It is a "fungus infection" of the skin and mucous membrane of the mouth characterized by white patches, resembling milk curds.EtiologyCandida albicans infection is due to inadequate sterilization of teats and bottles or from mother's breast of the attendant's hand. Newborns are infected during passage in birth canal.
15Assessment:Mouth contains white patches, which resembles milk curds (it is difficult to remove and if removed bleeding occurs). Also there discomfort during feeding.Nursing diagnosisAltered oral mucous membrane related to mouth infection.GoalPrevent and reduce the effects of oral ulceration.
17Absolute cleanliness of all articles which enter infants mouth-such as mothers nipple, rubber nipple, pacifiers, teats, or his toys.Applicators used must be sterile.Infants must have their own feeding equipment to prevent spread of infection.Medicine dropper may be used, if nipple irritates the child.Give infant some sterile water after each feeding to wash the mouth.
18Expected outcome:Mouth membrane remains intact.Ulcers show evidence of healing.Nursing diagnosisAltered nutrition less than body requirements related to loss of appetite. Also discomfort and interference with feeding.Goal:Appetite stimulation.
19Nursing management:Encourage parents to relax pressure placed on eating.Allow infant any tolerated food; plan to improve quality of food selection when appetite increases.Take advantage of any hungry period, serve small snacks.Allow child to be involved in food preparation selection.Outcome criteriaThe nutritional intake is adequate.
20Medical treatment: Prognosis: Treatment should be continued for one week after recovery prevent recurrence.Cleanliness and sterilization of the feeding bottles and teats.The infant's mouth is gently painted three times daily with 1% aqueous solution of gentian violet.This may be combined with nystatine, units by month, 3 – 4 times daily.Mother's nipple and areola painted with nystatine ointment between meals.Prognosis:Generally very good, recovery occurs after (3 – 5) days.
21في الحالة الطبيعية يمر الطعام بعد خروجه من المعدة إلى الأمعاء الدقيقة التي يتم فيها الاستفادة من محتويات الطعام من خلال امتصاص مكوناته ثم ينتقل الجزء المتبقي إلي الأمعاء الغليظة حيث يتم امتصاص الماء والأملاح وما بقي يتماسك على شكل براز متماسك ورطب يتم طرده إلى خارج الجسم مره إلى ثلاث مرات في اليوم عبر الشرج.
22في حاله الإسهال فأن النظام يختل إما في الأمعاء الدقيقة حيث يقل امتصاص الغذاء أو في الأمعاء الغليظة حيث يقل بشكل بارز امتصاص الماء أو يكون الخلل في آلية مرور البراز حيث تزداد تقلصات وحركه عضلات الجهاز الهضمي فيؤدي كل ذلك إما إلى زيادة المحتوى المائي للبراز أو إلى زيادة عدد مرات التبرز أو الاثنين معاً.
23Diarrhea Disorders Definition: It is defined as "An increase in the fluidity, volume and number of stools relative to the usual habits of each individual".
24Morbidity and Mortality in Egypt: Diarrhea is a leading cause of illness among children in developing countries. In Egypt a child under five years suffers an average three bouts of acute diarrhea yearly; that is to say 10 millions children suffer 30 millions episodes of diarrhea every year.Mortality:Diarrhea accounts for % of deaths among children under five years. It is estimated that Egyptian infants and preschool children die yearly from diarrhea (about 42 deaths every day), 80% of them being in the first two years of life.
25Factors promoting the transmission of enteric pathogens: Failure to breast – feed exclusively for the 1st 4 – 6 months.Using infant feeding bottles (easily contaminated).Inappropriate storing of cooked food.Using drinking water contaminated with fecal bacteria.Failing to dispose of feces hygienically
26Failing to wash hands after defection. Host factors: young age (highest incidence in the age group 6 – 12 months).Malnutrition.Measles in the previous 4 weeks.Immunodeficiency.Season:Bacterial diarrheas are more frequent in summer.Rotavirus is more frequent in winter but occur throughout year.
27Types of diarrhea : Acute Watery Diarrhea: (80% of cases) This refers to diarrhea that begins suddenly; it persists for days then gradually improves over another days. It is usually self-limited (lasts less than 14 days) and involves the passage of frequent loose or watery stool without visible blood.Dysentery: (5 – 10% of cases)This is diarrhea with visible fresh blood in the stools. Its sequelae include anorexia and damage to the intestinal mucosa.Persistent Diarrhea: (10% of cases)Post infectious diarrhea that begins actually and lasts at least 14) days. Persistent diarrhea is not chronic diarrhea which is recurrent or long- lasting due to non-infectious causes. (e.g. metabolic disorders).
28Dangers of diarrhea :Dehydration, which might lead to death if not properly, treated.Malnutrition: diarrhea is worse in persons with malnutrition and can make it worst because:Nutrition is lost from the body in diarrhea.The patient may not be hungry (due to diminished absorption).Mothers may not feed their children during the episode or even for some days after the diarrhea improves.N.B. The life span of intestinal mucosal cells is 3-5 days. New normal cells will replace the destroyed cells damaged by toxins, within this period. This is why diarrhea is usually a self-limited disease of 3-5 days duration.
29Incidence of diarrhea : The peak incidence of diarrhea is between months to 2 years. This is due to:Declining level of maternal antibodies.Exposure to enteric pathogens through contaminated weaning food.The pleasure of picking -up contaminated objects and putting them in the mouth while crawling.Seriousness of diarrheal disorders during infancy :Their higher needs for water exchange to meet their high metabolism.Greater susceptibility of infants to infection .Lower power of their kidneys to concentrate urine, which results in relative polyuria.Their smaller metabolic reserves of water and electrolytes.Therefore, with limited intake and /or extra loss of fluid during diarrhea, acute dehydration usually occurs
30Causes of diarrhea: 1- Enteropahtogenic: (infectious diarrhea) Viruses (rotavirus) (15 – 25% of cases).Bacteria (E.Coli 10 – 20% of cases), (shigell 5 – 15% of cases).Protozoa (cryptosporidium 5-15% of cases).Other less common pathogens include (Giardia - doudenaris, Entamoeba histoloticày andsalomnella).
312- Dietary : A-Formula feeding problems: Contaminated feeding bottles. Overfeeding.Over concentrated formula.Excess sugar or fat in formula.
33B-Weaning food problems: Introduction of food, which is not suitable for the age.Unripe fruits.Introduction of new food.Improperly cooked diet.Malnutrition .3- Some parenteral infections:Pneumonia and otitis media may be accompanied by diarrhea. It may actually be due to an associated intestinal infection.Communicable diseases (e.g. measles) diarrhea occurs due to immunological impairment.
35N.B.Teething is not a cause of diarrhea. Diarrhea that occurs during teething is usually caused by an intestinal infection and should be treated properly.
36درجات الإسهال : إسهال بسيط: 4 – 6 مرات في اليوم. إسهال متوسط: 6 – 10 مرات في اليوم.إسهال شديد: أكثر من 10 مرات في اليوم.
37الأعراض المصاحبة للإسهال: القيء و يعد هو العرض الرئيسي و الأولى.الاحمرار الشديد حول فتحة الشرج.ارتفاع درجة الحرارة.آلام البطن.الجفاف: يعد الجفاف من أخطر مضاعفات الإسهال، و لذا حين يصاب الطفل بالإسهال يجب متابعة حالته لملاحظة أي بوادر للجفاف قد تظهر عليه.
40Dehydration Definition It is one of the consequences of watery diarrhea. It is caused by the loss of water and electrolytes in liquid or loose stools and vomitus. Fever can make it worse as it causes additional loss of water. Dehydration can lead to hypovolemia, cardiovascular collapse, and death if not treated promptly.The signs of dehydration are the result of 2 important factors:Type of dehydration: Isotonic, hyperonic, hypotonic.Degree: Mild, moderate or sever.
41Types of dehydration:1- Isotonic (isonatremic) dehydration: This is the most common result of acute watery cliarrhea (more than 75% of cases). Deficits of water and sodium are balanced .2- Hypertonic (hypernatremic) dehydration the net loss of water is greater than that of sodium . The condition is more common in young infants who can't verbally ask for water . It results from the intake of large amounts of hpertonic fluids ( high content of sodium or sugar ) during diarrhea.3- Hypotonic (hypontremic) dehydration: it is less common and the net loss of sodim is greater than that of water. This result from the intake of large amounts of water or hypnotic fluids during diarrhea.
42Therapy of dehydration : Oral rehudration:The rehydrauon therapy in the form of ORS is considered an effective treatment of dehydration, It is a mixture of water, glucose, and electrolytes and is used to correct or prevent dehydration. Glucose is added (2%) to promote sodium absorption. Increasing the concentration of glucose by 2% increase the osmolarity of the solution and may cause osmotic diarrhea.
45N.B. The use of citrate increases the shelf life of ORS and therefore lowers its cost. Tape water(200 ml) is used to dissolve the mixture and needs no boiling. It is given by cup and spoon, but :It can be given by nasogastric tube in the following conditions :When the patient is unable to drink but not in shock, or has severe dehydration or paralytic ileus.When the patient has severe repeated vomiting, or if dehydration is not improving when ORS is given slowly by cup and spoon.
46Nursing management of diarrhea Nursing Assessment:It includes taking the patient's history, measuring weight and temperature and Assessing the degree of dehydration.1- History:Personal characteristics (age and sex) and socioeconomic background (home environment, income, education, occupation, beliefs .... etc).Duration of the episode.Frequency and consistency of stool.
47Presence or absence of mucus, pus or blood in stool. Patient's ability to drink and or presence of thirst.Presence of vomiting, fever or other problems (cough, otitis media).Last time urine passed.Feeding practices before and during illness.Treatment during this episode (ORS, drugs).Vaccination taken especially measles vaccine.2- Assessment of the degree of dehydration:Assessment of the degree of dehydration is based on 4 signs which are the most important to be detected:
49Assessment of the degree of dehydration. CSevere dehydration loss > 10% of body weightBSome dehydration loss 5 – 10% of body weightANo signs of dehydration loss < 5% of body weightSingsLethargic, floppy unconsciousRestlessness and irritableWell and alertG-General conditionVery sunken and drySunkenNormalE- EyesDrinks poorly or unable to drink.Thirsty, drinks eagerlyDrinks normallyM- ThirstGoes back very slowly (>2 seconds).Goes back slowlyGoes back quicklyS-Skin pinchIf 2 or more signs are present there is severe dehydration.If 2 or more signs are present, there is moderate dehydration.Patient has no sings of dehydration (mild)DecidePlan CPlan BPlan ASelect treatment plan
50Other signs that are used in the assessment of dehydration are: Anterior fontanel: normal, depressed or severely depressed.Mucous membrane of the mouth and tongue: moist, dry or very dry.Tears: present in mild dehydration, absent in severe dehydration.Pulse (radial) as dehydration increase, pulse becomes more rapid. In severe dehydration pulse becomes weak.Extremities: in severe dehydration, skin becomes cool and moist and the nail bed may be cyanosed.Breathing : rapid deep breathing is a sign of acidosis.Weighing is essential as it helps to estimate the amount of fluid required, for an initial rehydration . Patient should be weighted to the nearest 50 – 100 grams at the beginning of the assessment and recorded. Towards the end of rehydration , the child should have gained weight.
51Nursing diagnosis:Bowel elimination is altered related to diarrhea.Fluid and electrolyte balanced is altered related to diarrhea.Altered nutrition less than body requirement related to loss of appetite.High risk for infection related to body resistance.Altered parenthood related to knowledge deficit about child care.
52Nursing intervention: The aim of nursing intervention is:To hydrate the infant.To feed the infant.To deal with associated problems.
54In OP rehydration center At home Give IV fluids Gives ORS Plan CPlan BPlan ATreatmentIn hospitalIn OP rehydration centerAt homeWhereGive IV fluidsGives ORSGive more fluid than usual1- Fluid therapyPansol .Ringer's lactate. Normal saline.Home made fluids (rice, water, tea without sugar, soup, yogurt).What type100 ml/kg of body wt. given in 3 – 6 hrs.1st 30 ml/kg given in 1/2 to 1 hr.Next 70 ml/kg given in 2.5 – 5hrs, longer time is used for infant < 1 year. (NB*)Goes back slowlyGive after each loose stool for child <2 years : 50 – 100mlFor child > 2 years: 100 – 200 ml.How muchI.V.Slowly (1 spoon 1-2 min) by cup and spoon, cup alone, dropper/syringe. Nasogastric tube.Slowly (1 spoon 1-2 min)By cup and spoon, cup alone, dropper/syringe.How given
55متى يجب الاتصال بالطبيب في حالات الإسهال؟ Further assessment إذا كان الطفل اقل من 6 شهور.إذا كان الإسهال مصاحبا بارتفاع شديد في درجة الحرارة ≥ 39 درجة مئوية.ظهور أعراض الجفاف.إذا كان الإسهال مصاحبا بترجيع لمدة أكثر من 8 ساعات أو احتواء الترجيع على مخاط اخضر أو دم.احتواء البراز على مخاط أو دم.إذا لم يتبول الطفل لمدة 8 ساعات.حدوث تصلب في رقبة الطفل.ألم شديد بالبطن لمدة أكثر من ساعتان.الميل الشديد للنوم الزائد أو النعاس الشديد الزائد
56B) Reassess the patient's condition. If no signs of dehydration shift to plan A.Some dehydration shift to plan BSevere dehydration shift to plan C.Further assessmentA) Advice the mother to bring the child to a health facility if :Frequent large stools.Repeated vomitingIncreased thirstNo improvement after daysBloody stools .Fever.
57Guidance during intervention : Mothers should be taught how to give ORS (one teaspoonful every 1-2 minutes and the child should be in a semi-sitting position).Give ORS as much as the desires.If vomiting occurs, wait 10 minutes. then continue giving ORS solution but more slowly (one teaspoonful every 2-3 minutes).Watch for puffy eyes as a sign of over hydration. If this occurs, stop ORS solution and give breast feeding and plain water. When puffiness is gone, the child is considered fully dehydrated . Further treatment should follow treatment plan A.
58Feeding during and after the episode: During diarrhea give the child as much food as he wants.Offer food every 3-4 hours.Small frequent feeding are better tolerated than less frequent and large feedings.Children will anorexia have to be gently encouraged to eat.After stoppage diarrhea, give one extra meal per day for 2 weeks in normal child and longer period in malnourished one .
59Advantage of continued feeding during diarrhea.(important point) Preserves body weight and sustains growth, thus maintaining strength and health avoiding lowered resistance.The contact of foodstuffs with the gut mucosa protects its absorptive capacity and stimulates the production of digestive enzymes.Easily digestible foods may enhance intestinal salt and water absorption by providing organic molecules, which facilities their absorption.Studies have shown that continued feeding actually hastens recovery from a diarrheal episode.
60Assessment of the progress of rehydration The patient's progress should be assessed at least every hour .The signs of a satisfactory response are:Return of a strong radial pulse.Improved consciousness level.Ability to drink.Much improved skin turgor.Passage of urine
61Drugs therapy in diarrhea : 1- Antibiotic are ineffective and may lead to( prolonged diarhea –cause malabsorption-have side effect – prolong the duration of infection – their abuse will increase the resistance of organism).2 - Anti - diarrheal drugs.3 - Anti -motility drugs.4 - Anti – emetics.
62Therapy of diarrheaإعطاء المضادات الحيوية المناسبة للالتهاب البكتيري أو أدوية الأميبا الحادة
63Prevention of diarrhea: 1- Promotion of breast-feeding2- Improved weaning practices3- Proper use of water for hygiene and drinking:4- Personal hygiene5- Use of latrines6- Safe disposal of stools of young children7- Measles vaccination