Disorders of Digestive System

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

4. 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.

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

6. Specificobjectives: 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.

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

8. 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.

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

10. 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.

11. 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.

12. 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.

13. Types of Stomatitis: • Catarrhal stomatitis. • Herpetic stomatitis. • Thrush stomatitis.

14. Thrush stomatitis: Definition • 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.

15. 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.

16. Nursing management

17. 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.

18. 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.

19. 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.

20. Medical treatment: • 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, 100.000 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.

21. في 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.

22. في 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.

23. 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".

24. Morbidity and Mortality in Egypt: Morbidity: • 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 25 - 30% of deaths among children under five years. It is estimated that 15000 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.

25. 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

26. 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.

27. Types of diarrhea : Acute Watery Diarrhea: (80% of cases) • This refers to diarrhea that begins suddenly; it persists for 3 - 4 days then gradually improves over another 4 - 5 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).

28. 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.

29. Incidence of diarrhea : The peak incidence of diarrhea is between 6 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

30. 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, Entamoebahistoloticày andsalomnella).

31. 2- Dietary : A-Formula feeding problems: • Contaminated feeding bottles. • Overfeeding. • Over concentrated formula. • Excess sugar or fat in formula.

33. 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.

34. 4- Miscellaneous: • Emotional tension & Irritable colon. • Heavy metal poison (arsenic, lead, mercury). • Antibiotic 5- Malabsorption: Cystic fibrosis, ciliac disease.

35. 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.

36. درجات الإسهال : • إسهال بسيط: 4 – 6 مرات في اليوم. • إسهال متوسط: 6 – 10 مرات في اليوم. • إسهال شديد: أكثر من 10 مرات في اليوم.

37. الأعراض 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.

40. 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 dehydrationare the result of 2 important factors: • Type of dehydration: Isotonic, hyperonic, hypotonic. • Degree: Mild, moderate or sever.

41. 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.

42. 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.

44. Composition of ORS :

45. 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.

46. 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.

47. 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:

49. Assessment of the degree of dehydration.

50. 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.