Gastrointestinal Stressors and Adaptation

1. Gastrointestinal Stressors and Adaptation

2. Obesity Anorexia Nervosa Bulimia Cleft lip/Cleft palate GER Pyloric Stenosis Intussusception Hernias Hirschprung’s Disease Celiac disease Giardiasis Pin worm Diarrhea Common GI disorders in Children

3. Obesity • Caused by an increased number of fat cells due to excessive caloric intake. • Increased weight w/o proportion to height and bone structure • Cultural, environmental, socioeconomic factors are the cause

4. Childhood Obesity • National epidemic • Healthy People 2010 goal • Both immediate and long term side effects • Low Self-esteem • Can be a precursor of hyperlipidemia, sleep apnea, gall stones, orthopedic problems, HTN, DM

5. Management Infants and Toddlers • No more than 32 oz. of formula per day • If concerned with intake > 32 oz. do not give skim milk or low fat diets • Add a source of fiber to oprolong emptying time

6. Management School-age child and adolescent • Participation in a formal weight loss program. (support of other members) • Teach methods to manage stress • Set short term, reachable goals (5lbs. over 1 month, not 50 for the year)

7. Management • Teach children how to prepare food. • Teach children the food pyramid • Parental education plays a very important part in success.

8. Anorexia Nervosa • 95% of cases are girls age 12-18 • A voluntary refusal to eat b/c of an intense fear of gaining weight leads to: • Preoccupation with food and body weight • Excessive weight loss

9. Causes of Anorexia Nervosa • May have existing “Perfectionist” personality • Conflict in the family • the child is not encouraged to be independent, and never develops autonomy…feelings of loss of control, poor self esteem • Poor self-esteem leads to a pronounced disturbed body image • Excessive dieting leads to a feeling of control over body

10. Anorexia Nervosa Assessment: • Intense and irrational fear of becoming obese (although underweight) • Perceive food as revolting • Refuse to eat or vomit immediately after eating • Use of laxatives, diuretics, Ipecac

11. Excessive weight loss (25% less than normal body weight) Acidosis or alkalosis Dependent edema Hypotension, Hypothermia, Bradycardia Lanugo formation Amenorrhea (< 95lbs.) Starvation => death Signs & Symptoms

12. Management Hospitalization is limited to acute weight restoration • Establish realistic goals • Build rapport, trusting relationship • 2-3 days IV fluid, TPN for fat & protein Through counseling-body image is improved and goals include: • Need to gain weight to reach 90-95 lbs. • 3lbs per week, only weigh once a week. • Need continued follow-up, 2-3 years of counseling to be sure that self-image is being maintained

13. Bulimia Binge eating followed by depression and activities to control weight gain • Also occurs primarily in adolescent females • Food is eaten secretly, high in calories • Abdominal pain from overfull stomach • Vomit to relieve the pain • Laxatives and diuretics • Electrolyte imbalances, tooth erosion

14. Cause of Bulimia • Adolescent may be unable to express feelings • Has an existing low self esteem or depression • Lacks impulse control • Poor body image • Purging leads to increased sense of control and decreased anxiety

15. Cleft lip/Cleft palate • CL: failure of maxillary and median nasal processes to fuse • CP: midline fissure of palate • Apparent at birth => severe emotional reaction by parents • Swallow normal, suck is not • Collaborative effort: RN, pediatrician, plastic surgeon, orthodontist, speech therapist

16. Cleft Lip: Immediate nursing challengesbirth until surgery • Keep upright during feeding • Cannot use a normal nipple (can’t generate suction) • Use large soft nipple with large hole or a “gravity flow” nipple (deposits formula in mouth) • Needs breaks during feedings

17. Cleft Palate: Immediate nursing challengesbirth until surgery • Nipple must be positioned so that it is compressed by infant’s tongue and existing palate • Swallow excessive air, burp frequently

18. Both CL and CP • If breast feeding, use pump to stimulate “let down” reflex • Mother should feed as soon as possible when infant indicates hunger

19. Immediate nursing challenges Parents • Emphasize positive aspects of child • Hold infant close (modeling behavior), infant is special • Explanation of immediate and long-range problems assoc. with CL/CP

20. Post-operatively: Cleft Lip Repair(age 6-12 wks) • Protect operative site • Clear liquids first => formula • Breck feeder (syringe with rubber tubing), prevents infant from sucking on tubing until lip heals • Meticulous care to suture line, carefully cleanse after feeding • Position on side or back

21. Post-operatively: Cleft Lip Repair(age 6-12 wks) • Z-plasty: staggered suture line minimizes scar tissue formation • Logan Bar: thin arched metal device taped or butterflied to cheeks, protects suture line from tension & trauma • Arms restrained at elbows

22. Post-operatively: Cleft Palate Repairat 12-18 months • Can lie on abdomen • Fluids from a cup • Still needs restraint at elbow • No: pacifiers, tongue depressors, thermometers, straws, spoons • Blended diet => soft (no food harder than mashed potatoes)

23. Prognosis: good, BUT • Speech impairment • Improper tooth alignment • Varying degree of hearing loss • Improper drainage of middle ear => recurrent otitis media • Therefore upper respiratory infections need prompt treatment

24. Gastroesophageal Reflux (GER) • LE sphincter & lower portion of esophagus are lax • Regurgitation of gastric contents into esophagus • Usually begins 1 week after birth • Regurgitation immediately after feeding

25. Gastroesophageal Reflux Diagnosis: • History, check pH of esophageal secretions ( if < 7.0, positive dx) Management: • Upright position for feeding & 1h after feeding • Formula thickened with rice cereal or special formula • Zantac or Prilosec (decrease irritation)

26. Pyloric Stenosis hypertrophied muscle of the pylorus is grossly enlarged; leads to delayed stomach emptying

27. Symptoms • Begins a few weeks after birth • regurgitation, occasional non-projectile vomiting 4-6 weeks after birth • progresses to projectile vomiting (3-4 feet) shortly after feeding

28. Signs & Symptoms(continued) • Emesis contains stale milk, sour smell, no bile • Chronic hunger • Visible gastric peristalsis moves from left to right across the epigastrium • Dehydration, lethargic, weight loss

29. Treatment • Pylorotomy: longitudinal incision through muscle fibers of the pyloris Preop: • Check for electrolyte imbalance, dehydration • NG tube to wall suction

30. Pyloric Stenosis Post-op: • High risk for infection • Small, frequent feedings • “Down’s Regimen • NPO x 4 hrs, then Glucose and H2O q 2-3 hrs, then ½ strength formula/breast milk q 2-3 hrs, then full strength • Burp well to prevent air in stomach • Position right side

31. Intussusception • telescoping of one portion of the intestine into another • most common site is the ileocecal valve • inflammation, edema, ischemia => peritonitis & shock

32. Signs & Symptoms • Affects children (3mos to 5 years, usually occurs in first year of life) • Sudden acute abdominal pain q 15minutes • Vomiting (bile) • Lethargy • Tender, distended abdomen • Stools contain blood and mucus (“currant jelly”) Diagnosis: • Signs & symptoms plus sonogram

33. Management Initial treatment: • nonsurgical hydrostatic reduction (barium enema) • force is exerted by flowing barium via enema to push bowel back into place • surgery if unsuccessful • if positive bowel sounds (oral feedings) • watch for passage of normal brown stool

34. Hirschprung’s Disease • absence of nerve cells to the muscle portion of part of the bowel

35. Hirschprung’s Disease S/S: Newborn period: • Failure to pass meconium • Spitting up, poor feeding • Bile-stained vomit • Abdominal distention

36. Hirschprung’s Disease S/S (Infancy): • Failure to thrive • Constipation • Abdominal distention • Episodes of vomiting an diarrhea • Explosive, watery diarrhea with fever

37. Hirschprung’s Disease S/S Childhood: • Chronic constipation • Ribbon-like stools • Abdominal distention • Poorly nourished, anemic

38. Diagnosis • Barium enema, x-ray • Biopsy of intestine (will show lack of nerve enervation) • Surgery to remove the agaglionic portion of the bowel, 2 parts • Temporary colostomy • Bowel repair at 12-18 months

39. Surgery Preop: • Depends on age and clinical condition • Daily NS enemas • Assess nutritional & electrolyte status Postop: • NG tube, IV, Foley • Abdominal distention • Assess bowel status • Small, frequent feedings

40. Malabsorption syndrome Diagnosis: jejunal biopsy (atrophic changes in mucosa) Inability to digest gluten leads to toxic levels that damage mucosal cells of small intestine Celiac disease

41. Signs and Symptoms • Usually noticed at 9-18 months of age • Impaired fat absorption (Steatorrhea) • Behavioral changes (irritability, apathy) • Impaired absorption of nutrients (malnutrition, abdominal distention, anemia, anorexia, muscle wasting)

42. Celiac Crisis • Acute, severe, profuse watery diarrhea and vomiting • May be precipitated by: infections, prolonged fluid and electrolyte depletion, emotional distress • Corn and rice are the dietary substitutes

43. Intestinal parasites • Nurse’s most important function is preventative education of children and parents regarding good hygiene and health habits. (appropriate sanitation practices i.e.: wash hands after diaper changes, toilet use, deposit soiled diaper in closed receptacle)

44. Giardiasis Infants & young children: • Diarrhea, vomiting, anorexia, poor weight gain Children >5yo: • Abdominal cramps, intermittent loose stools (malodorous, watery, pale, greasy), constipation Treatment: • Drug of choice: Flagyl x 7 days)

45. Pin Worms • Eggs float in air (easily inhaled) • Worms move on skin and mucous membranes cause intense itching • As child scratches eggs are deposited under fingernails • Hand to mouth activity leads to continual reinfection • Can live on toilet seats, doorknobs, bed linen, underwear, food

46. Signs & Symptoms • Intense rectal itching • Nonspecific s/s: irritability, poor sleep, bed-wetting, distractibility • Tape test: loop of transparent tape pressed to perianal area for microscopic exam • Drug of choice: (Vermox) mebendazole

47. Diarrhea Mild: • A few loose stools each day without evidence of illness Moderate: • Several loose or watery stools daily • Normal or elevated temp • Vomiting • Irritability • No signs of dehydration

48. Diarrhea Severe: • Numerous to continuous stools • Flat affect, lethargic • Irritability • Weak cry • Increased temperature (103-104) • Pulse & respirations weak & rapid

49. Severe: • Depressed fontanels • Sunken eyes, no tears • Poor skin turgor • Pale, cold skin • Urine output decreased • Increased specific gravity • 5-15% body weight loss • Metabolic acidosis

50. Mild to mod: managed at home Major goals: • Assess fluid & electrolyte balance • Rehydration • Maintenance of fluid therapy • Reintroduction of adequate diet (BRAT) Oral rehydration therapy: (Pedialyte)