1. Disorders of Digestive System
Prepared by
Dr / Magda Abd-El-Aziz

2. INTRODUCTION
Focuses 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.

3. Objectives General : General :
By the end of this lecture the student will be able to discuss Disorders of Digestive System

4. Specific 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.

5. Out line:- Introduction. Foreign body in G.I.T. Stomatitis. Vomiting.
Colic.
Constipation.
Diarrhea.
Dehydration.
Nursing intervention.
Prevention of diarrhea.

6. Disorders of Digestive System
A- Foreign bodies in G.I.T
Etiology
The 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.

7. Nursing diagnosis:
High risk for intestinal perforation related to swallowing of foreign bodies.
Goal:
The infant/child will experience no signs of perforation.

8. Intervention 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.

9. B- 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.

10. Causes 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.

11. Types of Stomatitis:
Catarrhal stomatitis.
Herpetic stomatitis.
Thrush stomatitis.

12. Thrush stomatitis: Definition Etiology
It is a "fungus infection" of the skin and mucous membrane of the mouth characterized by white patches, resembling milk curds.
Etiology
Candida 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.

13. Assessment:
Mouth contains white patches, which resembles milk curds (it is difficult to remove and if removed bleeding occurs). Also there discomfort during feeding.
Nursing diagnosis
Altered oral mucous membrane related to mouth infection.
Goal
Prevent and reduce the effects of oral ulceration.

14. Nursing management

15. Absolute 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.

16. Expected outcome:
Mouth membrane remains intact.
Ulcers show evidence of healing.
Nursing diagnosis
Altered nutrition less than body requirements related to loss of appetite. Also discomfort and interference with feeding.
Goal:
Appetite stimulation.

17. Nursing 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 criteria
The nutritional intake is adequate.

18. Medical 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.

19. C– Vomiting:
Complete or partial emptying of the stomach especially when it occurs sometimes after feeding i.e. bringing up an appreciable amount of the swallowed food.
Vomiting results from a coordinated sequence of abdominal muscle contractions and reverse esophageal peristalsis. It is usually associated with nausea except when projectile.

20. Vomiting is classified as follows:
Mechanical: secondary at an obstructive lesion.
Reflexive: due to gastrointestinal tract stimuli (e.g. infection, allergy).
Central:
Central nervous system involvement (e.g. neoplasms, meningitis).
Caused by other than primary central nervous system involvement (e.g., abnormal metabolites, sepsis, psychogenic vomiting).

21. 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. Or non forceful expulsion of food and secretions from esophagus or stomach through the mouth.

22. 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.

23. Rumination:
Means voluntary or habitual regurgitation of formula into the mouth after it has been swallowed i.e. returning of food from stomach and chewing it again . Vomiting is one of the most common symptoms in infancy and may be associated with a wide variety of disturbances.

24. Causes of vomiting:
Causes of vomiting are classified according to different periods:
1- In newborn:
Physiological vomiting at or soon after birth as a normal process by which swallowed blood and amniotic fluid are removed. It may occur once or twice.
Congenital esophegeal obstruction, which is manifested by regurgitation, chocking and perhaps cyanosis with first feed.
Intestinal obstruction gives symptom usually in the first 24 hours after birth.
Imperforated anus gives symptoms that begin on the first hours of life with abdominal distention,, vomiting and meconium is passed.
Cerebral birth injuries due to stimulation of vomiting center in the brain.

25. 2. In infancy:
Improper feeding habit
Over feeding or underfeeding.
Error in feeding technique.
Failure to eructate.
Too small teat.
Excessive handling after feeding.

26. Placing baby on left side after feeding.
Too tight clothing especially around the abdomen.
Infections such as otitis media, tonsillitis, pyelitis and pneumonia Acute diarrheal diseases due to bacterial or viral infection in the intestinal tract.
Intestinal obstruction e.g. pyloric stenosis or intussusception.
Cerebral causes as hydro-cephalus

27. 3- In older children :
Dietary causes e.g. ingestion of unripe fruits or contaminated food.
Acute infections such as streptococcal pharyngitis, diphtheria, reflex vomiting in pertussis or intestinal infection as food poisoning.
Drugs as digitalis, sulphonamides, broad-spectrum antibiotics.
lntracranial hemorrhage and brain tumors.
Organic nervous diseases e.g. meningitis, encephalitis.
.Metabolic disturbances as in diabetic acidosis.
Psychogenic vomiting as by forcing a child with poor appetite to eat more than he wants.
Acute peritonitis due to development of paralytic ileus.

28. Assessment:
Failure to gain weight.
Feible, weak child with free perspiration.
Sometimes feeling of nausea.
Stomach pain.
Dehydration.
Alkalosis due to failure to retain food inside the body.
Nursing diagnosis:
Fluid volume deficit related to nausea and vomiting.
Goal:
To promote hydration.

29. Nursing intervention:
Correct the cause of vomiting.
Discontinue fluids and foods for older children by mouth for hours permitting only crushed ice to alleviate dryness of the mouth and resort to parental fluid.
In milder cases sips of cold drinks or glucose water.
Correct dehydration by parental fluid.
Mummy restraints to protect the IV and child as needed.
Mouth care after vomiting to prevent aspiration of vomitus.
Close observation if infant tends to vomit, whether he tolerates food or not, or if he vomits immediately after feeding (congenital abnormalities).

30. Nursing care should be planned to eliminate unnecessary movement after feeding.
Bubbling is very important.
Place child on right side and elevate head of the bed after feeding.
Change soiled clothes and linen to prevent skin irritation.
weight infants daily.
Charting amount, color, nature, odor, consistency, and time in relation to feeding.

31. Expected outcome:
Child shows signs of adequate hydration.
Nursing diagnosis:
Altered comfort related to acute pain in the stomach.
Goal:
Relieve pain.
Intervention:
Refer to lecture of congenital anomalies.
Child rest quietly, shows no evidence of discomfort, verbalizes no complaints of discomfort.

32. D- Colic :
Definition:
Paroxysmal intestinal cramps occurring due to accumulation of excessive gases and cause discomfort and pain. It is most common during the first 3 or 4 months of life.

33. Etiology: The causative factors are not known, but it might be due to:
Excessive swallowing of air.
Too much excitement.
Excessive intake of carbohydrate leads to gas formation.
Over rapid feeding.
Diseases of GIT e.g. gastroenteritis, constipation .

34. Hernias: diaphragmatic, inguinal, or umbilical.
Parasites.
Allergy to certain foods.
Hunger .
Intestinal obstruction e.g. pyloric stenosis .
Emotional stress or tension between parent and child.

35. Assessment : Sudden attack of abdominal pain.
Cry in loud voice more or less continuous.
Distended and tense abdomen.
Congestion of face may be cyanotic in severe cases.
Legs are drawn up on the abdomen.

36. Feet are often cold.
Arms are flexed and drawn to the body.
Neck may be flexed.
Infant may pass flatus or feces.

37. Nursing diagnosis :
Altered comfort related to colic.
Goal :
To relive pain.
Nursing intervention :
Bubble infant frequently and gently; use upright position to help eructation.
Give infant hot watery fluids (as caraway) to help expulsion of gases or use hot water bottle.
Turn the infant on abdomen to help expulsion of gases.

38. Loving care to relief his tension (hug him).
Teach mother the details of good feeding techniques.
Doctor may order small warm enema or change formula.
Doctor may order drugs as atropine to reduce intestinal movement.
Expected outcome :
Infant/child is resting and shows no evidence of discomfort.

40. Constipation : Definition :
Difficulty or insufficient passage of hard stools at infrequent intervals.
Causes :
Underfeeding with insufficient intake of milk or fluid.
Intestinal obstruction .
Pyloric stenosis .
Congenital Megacolon.
Infant receiving cow's milk.
Starvation.

41. Assessment:
Colic and passage of gases.
Passage of infrequent hard dry stools, which occasionally fissures the rectum while being expelled.
Distension of the rectum and colon.
Anxiety.
Nursing diagnosis:
Altered comfort related to acute colic.
Goal :
Infant/child will feel comfort.

42. 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.
Expected outcome:
Infant/child will show no evidence of discomfort and passes stool according to his habit.

43. Diarrhea Disorders Definition:
It is defined as "An increase in the fluidity, volume and number of stools relative to the usual habits of each individual".

44. Morbidity 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.

45. Factors 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

46. Failing 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.

47. Types 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).

48. Dangers 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.

49. Incidence 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

50. Causes 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).

51. 2- Dietary : A-Formula feeding problems: Contaminated feeding bottles.
Overfeeding.
Over concentrated formula.
Excess sugar or fat in formula.

52. B-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.

53. 4- Miscellaneous:
Emotional tension & Irritable colon.
Heavy metal poison (arsenic, lead, mercury).
Antibiotic
5- Malabsorption:
Cystic fibrosis, ciliac disease.

54. N.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.

56. Dehydration 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.

57. Types 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.

58. Therapy 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.

60. Composition of ORS : Amount G/L Components g/1 3.5 G/L
Sodium chloride.
2.9 G/L
Trisodium citrate.
1.5 G/L
potassium chloride
20.0 G/L
Glucose

61. N.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.

62. Nursing 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.

63. Presence 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:

65. Assessment of the degree of dehydration.C
Severe dehydration loss > 10% of body weight B
Some dehydration loss 5 – 10% of body weight A
No signs of dehydration loss < 5% of body weight
Sings
Lethargic, floppy unconscious
Restlessness and irritable
Well and alert
G-General condition
Very sunken and dry
Sunken
Normal
E- Eyes
Drinks poorly or unable to drink.
Thirsty, drinks eagerly
Drinks normally
M- Thirst
Goes back very slowly (>2 seconds).
Goes back slowly
Goes back quickly
S-Skin pinch
If 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)
Decide
Plan C
Plan B
Plan A
Select treatment plan

66. Other 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.

67. Nursing 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.

68. Nursing intervention:
The aim of nursing intervention is:
To hydrate the infant.
To feed the infant.
To deal with associated problems.

69. In OP rehydration center At home Give IV fluids Gives ORS
Plan C
Plan B
Plan A
Treatment
In hospital
In OP rehydration center
At home
Where
Give IV fluids
Gives ORS
Give more fluid than usual
1- Fluid therapy
Pansol .Ringer's lactate. Normal saline.
Home made fluids (rice, water, tea without sugar, soup, yogurt).
What type
100 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 slowly
Give after each loose stool for child <2 years : 50 – 100ml
For child > 2 years: 100 – 200 ml.
How much
I.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

70. B) Reassess the patient's condition.
If no signs of dehydration shift to plan A.
Some dehydration shift to plan B
Severe dehydration shift to plan C.
Further assessment
A) Advice the mother to bring the child to a health facility if :
Frequent large stools.
Repeated vomiting
Increased thirst
No improvement after days
Bloody stools .
Fever.

71. Guidance 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.

72. Feeding 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 .

73. Advantage 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.

74. Assessment 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

75. Drugs 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.

76. Prevention of diarrhea:
1- Promotion of breast-feeding
2- Improved weaning practices
3- Proper use of water for hygiene and drinking:
4- Personal hygiene
5- Use of latrines
6- Safe disposal of stools of young children
7- Measles vaccination

78. An ounce of prevention better than cure درهم وقايه خيرا من قنطار علاج

79. Thank you