مصر بلدي ربنا حافظها

1. Prepared by:
Asmaa Gamal Elsied
Ghalia Gouda Mohamed
UNDER SUPERVISOR
Prof. Dr/ Iman Ibrahim Abd El Moneim
Assit. Prof. Dr. Madiha Amin Morsy 1Nov 8, 2015

2. Objectives
Introduction
Anatomy and physiology of gastrointestinal tract.
Classification of gastrointestinal disorder.
Congenital gastrointestinal disorder.
* Cleft Lip and Cleft Palate
* Esophageal Artesia and trachea- esophageal fistula
* infantile hypertrophic Pyloric stenosis (IHPS)
* Duodenal atresia
* Gastroesophageal Reflux Disease(GERD).
* Hirschsprung's disease
* Intussusceptions
* Imperforate anus
2Nov 8, 2015

3. • Acquired gastrointestinal disorder:-
* Stomatitis
* Vomiting
*colic
* Dysphagia
*Constipation
* Diarrhea
*Food allergy
* Gastro-enteritis
• Pediatric emergency :-
*Gastrointestinal Bleeding
* Dehydration.
• Level of prevention.
• Nursing care plan.
3Nov 8, 2015

4. At the end of this seminar the participants
should be able to:
• Discuss the anatomy and physiology of the
digestive system in children.
• Distinguish different digestive disorder
- Problems need surgical intervention.
- Problems need medical intervention
- Emergency cases
• Discuss nursing care of digestive disorder.
4Nov 8, 2015

5. effects on the health of children from birth to
adolescence range from simple to complex
problems , such as illness need short term
plan orneed long term plan.
Digestive disorders cause digestive system
does not properly function. It causes a set of
signs and symptoms which represented those
disorders.
It is the responsibilities of pediatric nurses to
perform direct care forthose children.
5Nov 8, 2015

6. 6Nov 8, 2015

7. consisting of the following:
 Mouth.
 Esophagus.
 small intestine.
 large intestine.
 Anus.
Organs that help with digestion include:
 Tongue.
 Glands in the mouth that make saliva.
 Pancreas.
 Liver.
 Gallbladder.
7Nov 8, 2015

8. Function of the Digestive System
• 1-Food passing through the
internal cavity, or lumen, of the
GI tract does not technically enter
the body until it is absorbed
through the walls of the GI tract
and passes into blood or
lymphatic vessels.
8Nov 8, 2015

9. Function of the Digestive System
2) Accessory organs include the
teeth and tongue, salivary
glands, liver, gallbladder, and
pancreas.
3) Ingestion is the process of
eating.
4) Propulsion is the movement of
food along the digestive tract.
9Nov 8, 2015

10. 5- Secretion of digestive
enzymes and other substances
liquefies, adjusts the pH of,
and chemically breaks down
the food.
6- Mechanical digestion is the
process of physically breaking
down food into smallerpieces.
10Nov 8, 2015

11. 7- Chemical digestion is the
process of chemically breaking
down food into simpler
molecules.
8- Absorption is the movement
of molecules (by passive
diffusion or active transport)
from the digestive tract to
adjacent blood and lymphatic
vessels. 11Nov 8, 2015

12. Congenital gastrointestinal disorder.
* Cleft Lip and Cleft Palate
* Esophageal Artesia and
trachea- esophageal fistula
* infantitle hypertrophic Pyloric
stenosis (IHPS)
* Duodenal atresia
* Intestinal atresias
* Gastroesophageal Reflux
Disease(GERD).
* Hirschsprung's disease 12Nov 8, 2015

13. • Acquired gastrointestinal disorder:-
* Stomatitis
* Vomiting
*Constipation
* Diarrhea
* Gastro-enteritis
13Nov 8, 2015

14. 14Nov 8, 2015

15. • Definition cleft lip
Is a physical split orseparation of
the one ortwo sides of the upperlip
and appears as a narrow opening or
gap in the skin of the upperlip. This
separation often extends beyond
the base of the nose and includes
the bones of the upperjaw and/or
15Nov 8, 2015

16. Definition cleft palate
Is a split oropening in the roof of the
mouth. May not be detected without
inspection of the mouth. Identified by
placing the examiner’s fingers directly on
the palate
16Nov 8, 2015

17. Incidance
Cleft lip: one in 1000 babies
annually, and is the fourth most
common birth defect in the U.S.
Cleft palate : one in 2500, males
more females.
17Nov 8, 2015

18. Problems Are Associated With Cleft
Lip and/or Palate
*Eating problems
*Earinfections hearing
loss
*Speech problems
*Dental Problems
18Nov 8, 2015

19. Treatment
Due to the numberof oral health and medical
problems
associated with a cleft lip orcleft palate, a team of
doctors and
otherspecialists is usually involved in the care of
these children.
Members of a cleft lip and palate team typically
include:
• Plastic surgeon to evaluate and perform
necessary surgeries on the lip and/orpalate
• An otolaryngologist (an ear, nose, and throat
doctor) to evaluate hearing problems and
considertreatment options forhearing problems
19Nov 8, 2015

20. An orthodontist to straighten and reposition teeth
A dentist to perform routine dental care
A speech pathologist to assess speech and feeding
problems
A speech therapist to work with the child to improve
speech
An audiologist (a specialist in communication disorders
stemming from a hearing impairment); to assess and
monitor hearing
A nurse coordinator to provide ongoing supervision of
the child's health
A social worker/psychologist to support the family and
assess any adjustment problem
20Nov 8, 2015

21. Tracheoesophageal Fistula:
• Tracheoesophageal fistula is an
abnormal connection in one ormore
places between the esophagus and the
trachea.
Incidence:
• Esophageal artesia occurs in
approximately 2 or3 infants per
10.000 births
21Nov 8, 2015

22. Esophageal atresia:
TEfistula often occurs with anotherbirth
defect known as “Esophageal Atresia”.
The esophagus is a tube that leads from
the throat to the stomach.
With esophageal atresia, the esophagus
does not form properly while the fetus is
developing before birth, resulting in two
segments; one part that connects to the
throat, and the otherpart that connects to
the stomach. However, the two segments
do not connect to each other.
22Nov 8, 2015

23. Types :-
1. Blind upperpouch &a fistula between the lower
pouch &the trachea (85% )
2- Fistula between the upperpouch and the
trachea, the lower: pouch is blind .
3- Upperpouch and lowerpouch end with a fistula
4- Both pouches end without a fistula.
S- fistula without atresia
23Nov 8, 2015

24. Nov 8, 2015 24

25. 25Nov 8, 2015

26. Symptoms may include the following:
• Frothy white bubbles in the mouth.
• Coughing orchoking when feeding.
• Vomiting.
• Blue colorof the skin, especially when
the baby is feeding.
• Difficulty breathing.
• full abdomen.
26Nov 8, 2015

27. Associated conditions:
*Vertebral anomaliesi.e. hemi
vertebrae, spinal bifida.
* Anal malformationsi.e. imperforate
anus.
* Cardiac. Malformationsi.e. VSD,
ASD, Tetralogy Fallot.
*Renal deformitiesi.e. absent kidney.
“VECTRA”
27Nov 8, 2015

28. pathophysiology:-
• The effect of esophageal
atresia on the infant is that
Saliva or milk accumulates in
the upper esophageal pouch
and spills over into the
trachea, causing choking and
cyanosis
28Nov 8, 2015

29. pathophysiology:-
• Gastric: contents may be
aspirated through the distal
tracheo-esophageal fistula to
the bronchial tree
complications as atelectasis
and pneumonia.
29Nov 8, 2015

30. pathophysiology:-
• Abdominal distension from
air passing down the fistula
into the stomach may
elevate and the diaphragm
adversely the affecting the
infant ability to ventilate
adequately
30Nov 8, 2015

31. Diagnosis
Before birth:-
Polyhydramnios: Excessive amniotic
fluid will arouse suspicion of
esophageal atresia of other
obstruction of the gastro intestinal
tract.
31Nov 8, 2015

32. Diagnosis
After birth :-
1-A small tube may also be placed into the
mouth or nose and then guided into the
esophagus. With esophageal atresia, the tube
usually cannot be inserted very far into the
esophagus. The tube's position in the
esophaguscan also beseen with thex-ray.
32Nov 8, 2015

33. Diagnosis
After birth :-
2- about 40% of infants are born
prematurity.
3- Excessive salivation.
4- When "feeding is attempted, infant
coughs, chokes and turn blue
(cyanosis).
33Nov 8, 2015

34. Complications:-
Aspiration of secretions into the
lungs, causing pneumonia.
choking and the possibility of
death.
34Nov 8, 2015

35. Treatment:-
• Early surgical repair for those babies
with adequate arterial blood gases.
Adequate weight (> 1200 gm) and no
significant associated anomalies.
• Sometimes esophageal atresia requires
more than one surgery. The baby’s
surgeon and otherphysicians will decide
when it is best to do the operations,
based on the baby's condition and the
type of problem
• Gastrostomy and repaired followed.
35Nov 8, 2015

36. Complications after surgery:-
• Anastomotic leak.
• Strictur.
• Gastroesophageal reflux.
• Recurrent TEF.
36Nov 8, 2015

37. Definition:
GERD is a digestive disorder that is the return of acidic
stomach juices, or food and fluids, back up into the
esophagus.
GER is very common in infants, though it can occur at any
age. It is the most common cause of vomiting during
infancy.
37Nov 8, 2015

38. Causes of GERD
• GERD is often the result of conditions that affect
the lower esophageal sphincter (LES). The LES,
a muscle located at the bottom of the esophagus,
opens to let food in and closes to keep food in
the stomach. When this muscle relaxes too long,
acid refluxes back into the esophagus, causing
vomiting or heartburn.
38Nov 8, 2015

39. Clinical picture:
• Heartburn is the most common symptom of GERD.
• Wheezing. - Choking.
• Refusal to eat. - Stomachache.
• Frequent vomiting. - Sour taste in the mouth.
• Hiccups. - Gagging.
• Frequent cough. - Frequent sore throats in the
morning
• Coughing fits at night.
• Frequent upper respiratory infections (colds).
39Nov 8, 2015

40. Why is GERD a concern?
• Some infants and children who have GERD may not
vomit, but may still have stomach contents move up the
esophagus & spill over into the wind pipe.This can cause:
- asthma
- pneumonia
- SIDS (sudden infant death syndrome).
• Infants & children with GERD who vomit frequently may:
- Not gain weight and grow normally.
- Esophagitis or ulcers.
- Bleeding, leading to anemia.
- Esophageal narrowing (stricture).
40Nov 8, 2015

41. Tests:
*Barium meal study .
*Endoscopy.
* PH probe monitoring of esophagus.
Treatment:-
1- Put the infant in an upright position for 1 to 2 hours
after feeding.
2- Thickened foods are preferable to thin foods.
3- Medications, including antacids and prokinetic as
Motilium.
41Nov 8, 2015

42. • Complications:-
* Esophageal irritation and inflammation
* Esophageal stricture ( scarring & narrowing )
* Pneumonia caused by aspirating stomach
contents into the lungs
42Nov 8, 2015

43. Management and instruction
1. Treatment of the cause.
2. Ask the child's if medications he/she is taking - some may
irritate the lining of the stomach or esophagus.
3. Watch the child's food intake - limit fatty foods, chocolate,
drinks with caffeine (such as colas and tea), citrus fruit and
juices, and tomato products.
4. Offer the child smaller portions at mealtimes, and include
small snacks in-between meals if the child is hungry. Avoid
letting the child overeat.
5. Do not allow the child to lie down or go to bed right after a
meal. Serve the evening meal early - at least two hours
before bedtime.
6. After feedings, place the infant on his/her stomach with the
upper body elevated at least 30 degree.
43Nov 8, 2015

44. • If bottle-feeding, keep the nipple filled with milk
so the infant will not swallow too much airwhile
eating.
• Burp the baby several times during bottle or
breast feeding. The child may reflux more often
when burping with a full stomach.
• Tube feedings forsome babies with reflux have
otherconditions that make them tired, such as
congenital heart disease orprematurity.
 Stomach.
44Nov 8, 2015

45. Definition:
• Obstruction at the pyloric sphincter
by hypertrophy of the circular
muscle of the pylorus is one of the
most common surgical disorders of
early infancy. Incidence:-
• 3 per1000 live births.
45Nov 8, 2015

46. Pathophysiology:
• The circular muscle of the Pylorus as a result of the
hypertrophy. This produces severe narrowing of the
pyloric canal between the stomach and the
duodenum.
• Circular muscle of the pylorus enlarges due to
hypertrophy “ increased size” & hyperplasia
“increased mass”  severe narrowing of the
pyloric canal between the stomach & duodenum
obstruction of the lumen inflammation & edema
that reduce the size of the opening complete
obstruction, palpable as an olive-like mass in the
upper abdomen
46Nov 8, 2015

47. Clinical Manifestations
• regurgitation or occasional non projectile vomiting 2-4 weeks after
birth, and then suddenly develop projectile vomiting that rapidly
leads to dehydration.
• The vomitus is non bilious, containing only gastric contents.
• The infants fails to gain weight or may lose weight
• the stools diminish in number and size from the reduced intake.
• The upper abdomen is distended.
• A readily palpable olive shaped tumor (hypertrophied pylorus) in
epigastrium just to the right of the umbilicus.
47Nov 8, 2015

48. Diagnosis:-
* Non – bilious projectile vomiting classically 3-6 weeks
of' age.
*Palpable pylorus.
*Marked dehydration and underweight.
*Plain x-ray abdomen show dilated stomach.
*Ba meal :,shows string sign.
* US show enlarged width & length of pylorus
48Nov 8, 2015

49. Treatment:-
1. Correction of hypochloremic alkalosis.
2. Correction of dehydration.
3. Pyloromyotomy, either open or by laparoscopy.
4. Post- operative management consist of: initial feeds start:
8- 12 hours after surgery and go home in 24-36 hours.
5. Weight the child daily to assess growth
6. Reestablish of normal feeding pattern
7. Keep NGT, NPO, IV fluids based on serum electrolyte,
usually sodium chloride with potassium
8. Strict intake & output, urine specific gravity
49Nov 8, 2015

50. Definition:-
A condition in which the duodenum is not 'patent and
cannot allow the passage of stomach contents
Causes:-
The causes is loss of blood supply during gestation
causing the duodenum to narrow or become obstructed.
50Nov 8, 2015

51. Incidence:-
• 1 out 6,000 newborns.
Associated Conditions:-
• Approximately 25% of duodenal atresia is
found in infants with Down syndrome .
51Nov 8, 2015

52. Presentatation :-
1-large amounts of bilious vomiting shortly
afterbirth.
2-One ortwo initial meconium stools may be
passed but no others .
3- If untreated, these infants dehydrate and
become
critically. ill very rapidly.
Treatment:-
• dudenostomy, to bypass the obstructing
segment
52Nov 8, 2015

53. Tests:-
1- Prenatal ultrasound may show
poly-hydramnios.
2- Abdominal x- ray.
3- Blood chemistries (to check blood
electrolytes).
4- Echocardiography to exclude
cardiac anomalies
53Nov 8, 2015

54. Definition:-
• Hirschsprung's is the congenital absence or
parasympathetic innervations of the distal intestine.
It arises when certain nerve cells (called ganglion
cells) fail to develop and mature correctly. The result
is a section of bowel that is essentially paralyzed.
Incidence:-
• 1 in 1000-1500 live births with a 4%
premature.
54Nov 8, 2015

55. Etiology:-
Failure of cranio- caudal migration of parasympathetic
ganglion cells to the distal bowel.
The aganglionic segment almost includes the rectum and
some portion of the distal colon, but the entire colon or part
of the small intestine may be involved.
Intestinal distention and ischemia may occur as a result of
distention of the bowel wall, which contributes to the
development of enterocolitis "inflammation of small bowel
and colon", the leading cause of death in children with
Hirschsprung disease. 55Nov 8, 2015

56. Presentation:-
* The main symptoms of HD are constipation or intestinal
obstruction, usually appearing shortly after birth.
In the newborn:
• Failure to pass meconium.
• Resistance to ingest fluid.
• Bile stained vomitus.
• Abdominal distention
56Nov 8, 2015

57. Symptoms in older children :
• Constipation.
• Passage of foul smelling stools, passage of ribbon-like.
• Abdominal distention.
• Visible peristalsis.
• Fecal masses are easily palpable.
• Failure to thrive.
• Signs of dehydrationSigns of dehydration pallor, dry mucous membranes,
sunken eyes"
57Nov 8, 2015

58. • Treatment:-
• The urgency of treatment depends on the child’s age
and clinical presentation.
• The infant or child will require a temporary
colostomy.
• Surgical removal of the abnormal section of bowel
with an anastomosis of the remaining normal colon
to the anal canal (pull-through procedure).
* Once the child has reached an adequate size and
age (6-12 months), a formal pull; through procedure
is done.
58Nov 8, 2015

59. Preoperative care:
• Children beyond the newborn period need bowel emptying with
repeated saline enema & reduction of bacterial flora with systemic
antibiotics & colonic irrigations.
• NG may be inserted to prevent abdominal distension.
• All intake and output of irrigation are noted.
• Rectal tube may be inserted to allow for escape of accumulated
fluid and gas.
• Only axillary temperature are taken.
• Abdominal circumference is measure.
• Prepare child and parents for colostomy. Stress that colostomy is
temporary.
• Maintain F&E balance to prevent dehydration & shock
• Monitor VS to prevent sepsis & enterocolitis
• Enemas, a lower-fiber, high-calorie-protein diet, and in severe
situations, the use of TPN 59Nov 8, 2015

60. Post operative care
1. Physical postoperative care is usually includes: NPO, IV, NG
suctioning, frequent abdominal dressing changes.
2. The diaper should be placed below the dressing
3. Drainage from the NG tube and the colostomy is measured.
4. Monitor fluid intake & output
5. Don’t use a rectal thermometer or suppositories
6. Monitor IV fluids to maintain adequate hydration & electrolyte
balance
7. Abdominal assessment, including monitoring of bowel sounds
8. Ostomy care
60Nov 8, 2015

61. • Definition:-
• A telescoping of one a portion-of the intestine into
another, which results in decreased blood supply of the
involved segment.
• Symptom:-
1- Abdominal pain manifested in an infant by drawing
Knees to chest with crying.
2- Sool mixed with blood and mucus (currant jelly stool)
3- Lethargy and dehydration.
4- Fever. 5- Vomiting.
61Nov 8, 2015

62. Signs:
• A physically examination may reveal a mass in the
abdomen.
• Signs of dehydration or shock may be present [sunken
eyes, dry mouth, loss of skin turgor].
• Episode of acute, colicky abdominal pain
• Vomiting, abdomen is soft, may pass a normal stool. A
sausage-shaped mass in the upper Rt quadrant
62Nov 8, 2015

63. pathophysiology
• The pressure created by the two walls of the intestine
pressing together causes inflammation, swelling, and
decreased blood flow.
• Death of bowel tissue can occur with significant bleed,
perforation, and infection.
• Shock and dehydration can occur very rapidly.
• Invagination obstruction to the passage of intestinal
contents beyond the defect. The two walls of the intestine
press against each other causing inflammation edema &
decreased blood flow ischemia perforation
peritonitis shock are serous complications of
intussusceptions. 63Nov 8, 2015

64. Treatment:-
*In some cases the bowel obstruction can be reduced
with a barium enema or pneumatic reduction there is
risk of bowel perforation with this procedure, and the
procedure is not used if al bowel perforation is already
present.
*If non-operative reduction is unsuccessful, a surgical
reduction is indicated. Or resection may be needed if
bowel is not viable.
64Nov 8, 2015

65. Nursing ConsiderationsNursing Considerations
1) Prepare for enema "barium or water soluble contrast"
2) Monitor VS ; a change in temperature may indicate sepsis
3) Monitor intake & output to prevent dehydration
4) Monitor NGT output & replace volume lost as ordered
5) Post operative interventions:
 Check electrolyte imbalance, hemorrhage, peritonitis
 Replacement fluids
 Antibiotics
 Monitor incision site for any signs of infection
 Monitor bowel movement
 NGT suctioning
 Examined stool before hydrostatic reduction
Nov 8, 2015 65

66. Definition:-
Imperforated anus is the absence
of an opening to the anus.
66Nov 8, 2015

67. Imperforate Anus Symptoms & Signs
• No anal opening observed during newborn
examination.
• A finger or thermometer cannot beinserted
into therectum.
• Abdominal distension after 2 to 3 daysof life.
• no passageof first stool within 24 to 48 hours
after birth
• stool passed by way of vagina, baseof penis
or scrotum, or urethra
• Abdominal distension
67Nov 8, 2015

68. • Etiology: unknown
• Incidence: 1 in 4,500
• SEX: 60% male
68Nov 8, 2015

69. forms
Low abnormalities:
Termination of bowel below thepelvic floor,
A- Covert anus
B- Ectopic anus
C-Stenoised anus
D-Membranousstenosis
69Nov 8, 2015

70. Low abnormalities:
Termination of bowel abovethepelvic
floor,
A- rectal atresia
B- Anorectal agenesis
70Nov 8, 2015

71. Common Children's
Digestive Problems
That Need Medical
Interventions
71Nov 8, 2015

72. Definition:
Inflammation of the oral mucous membrane
Causes:
• It is due to infection of the oral mucous
membrane by the fungus (Candida albicans) .
• Commonly it affects;
1- Newborn infants natal acquired.→
2- Malnutrition babies.
3- afterprolonged use of broad-spectrum
antibiotics, orsteroids.
72Nov 8, 2015

73. Clinical pictures:
• Numerouswhiteof mousemembraneof oral cavity.
They arenot washed away after feeding water. Pain
and sorenessof oral mucosaaremarked, which may
lead to refusal of feeding.
Treatment:
- mycostatin drops1 ml (100.000iu)/6hours,for 1 week.
- Gentian violet paint 1%
- Careof feeding.
- Correction of theunderlying disturbances.
73Nov 8, 2015

74. ColicColic Infant colic is not a disease but rather a condition
characterized by a collection of symptoms. There is no specific
test for colic but rather it is the symptoms themselves that
indicate a colic diagnosis:
Is a problem that affects some babies during the first three to four
months of life.
Colic usually begins suddenly, with loud and mostly continuous
crying.
Colic
74Nov 8, 2015

75. colic
75Nov 8, 2015

76. Causes of colic:
 Oversensitivity to gas.
 Milk allergy.
 Infants who are either under or over feed.
 Infants in the 0 to 3 months age range who are started high
carbohydrate food.
 An emotionally unstable environment may contribute to colic
symptoms in an infant.
76Nov 8, 2015

77. Symptoms of colic:
• A child who cries or fussy several hours a day, especially from 6
pm to 10 pm, with no apparent reason.
• Babies with colic frequently pass a significant amount of gas.
• The face may be flushed.
• The abdomen may be tense with legs drawn toward it.
77Nov 8, 2015

78. Management of colic:
78Nov 8, 2015

79. Management of colic:
 Treatment of the cause.
 Make sure that the baby is not hungry.
 Change the baby's position. Sit him/her up if lying down.
 Give the baby interesting things to look at, e.g. different shapes,
colors, textures, and sizes.
 Talk to the baby.
 Sing softly to the baby.
 Walk the baby.
 Place the baby in an infant swing on a slow setting.
79Nov 8, 2015

80. Management of colic “cont.”
• Try using something in the child's room that makes a repetitive
sound.
• Hold and cuddle the baby.
• Let an adult family member or friend (or a responsible
babysitter) care for the baby from time to time so that you can
take a break.
80Nov 8, 2015

81. 81Nov 8, 2015

82. * Vomiting :-
Is simply the forceful ejection of stomach & sometimes
intestinal contents from the mouth. In medical terms,
vomiting is known as emesis. Vomiting is not itself a
disease; but it is the manifestation of some inner
ailment.
Vomiting can be harmful because the child may lose
too much fluid and salt from his body. This is called
dehydration.
VomitingVomiting
82Nov 8, 2015

83. Causes of vomiting:
 Acute gastroenteritis is a very common problem in infants and
children.
 Food Poisoning.
 Pyloric Stenosis.
 Appendicitis.
 Intestinal obstruction, A common cause of obstruction in young
children is intussusceptions.
 Hepatitis.
 Other causes of vomiting can include infections, such as the flu or
strep throat, and more serious disorders, such as meningitis, brain
tumors or head injury.
83Nov 8, 2015

84. Complications of Vomiting:
In general cases, there are no complications of
vomiting.
If a lot of water is lost it may lead to dehydration.
Prolonged vomiting can cause drastic changes in the
acid-base balance of the child, which could also be
fatal.
In severe cases, vomiting can cause aspiration
pneumonia. This can happen when the contents of the
stomach repeatedly enter into the bronchial tract.
84Nov 8, 2015

85. Management of Vomiting:
• Treatment of the cause.
• After a child has vomited, rinse their mouth with water.
• A child is often cold, sweaty and tired after they have
vomited. Wipe his face with a damp cloth and let them
rest.
• Put the baby or young child on his stomach or side
whenever he is lying down.
• Breastfeeding can be continued. But if vomiting
continues, call the doctor.
85Nov 8, 2015

86. Management of Vomiting “cont.”
• If it's an older child who vomits, it mayn’t help to give
them milk, milk products or fatty foods for a couple of
days.
• Make sure that the child doesn't become dehydrated by
giving them plenty of fluids to drink. An oral
rehydration solution, breast milk or water are
recommended.
• In the meantime: if the child is thirsty, give him small
amounts of water using a teaspoon.
• Water is easier for the stomach to handle, if it'sn’t ice
cold. If the child wants to drink too much, too fast, give
him a clean facecloth soaked in cold water to suck, or an
ice-cube.
86Nov 8, 2015

87. Diarrhea
Is defined either as watery stool or increased frequency
(or both) when compared to a normal amount.
Diarrhea may be:
1. Acute (short-term, lasting less than two weeks).
2. Chronic (long-term, lasting longer than two weeks).
Diarrhea
87Nov 8, 2015

88. Causes of diarrhea
Diarrhea in children may be caused by a number of conditions,
including the following:
• Bacterial infection.
• Viral infection.
• Food intolerances or allergies.
• Parasites.
• Reaction to medications.
88Nov 8, 2015

89. 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.
● Extremely thirst.
● No tears when crying.
● Depressed fontanel.
The mother should call the pediatrician if her child is less than
6 months of age or presents any of the following symptoms:
89Nov 8, 2015

90. Management of diarrhea:
90Nov 8, 2015

91. Management of diarrhea:
●Treatment of the cause.
● Obtain baseline vital signs and monitor every 2- 4 hours.
● Observe stools for amount, color, consistency, odor & frequency.
● Test stool for occult blood.
● Monitor results of stool culture and sample for ova and parasites.
● Wash hands well before and after contact with the child.
● Isolate the child until the cause of the diarrhea is determined.
● Assist the child with toileting and hygiene.
● Administer prescribed oral rehydration and intravenous
solutions.
● Notify the physician if diarrhea persists, stool characteristics
change, or other symptoms of dehydration/electrolyte
imbalance occur.
91Nov 8, 2015

92. Constipation
92Nov 8, 2015

93. Constipation
Decrease in frequency of bowel movements, compared to a child's
usual pattern.
• The passage of hard, often times large caliber, dry bowel
movements.
• Bowel movements that are difficult or painful to push out.
Constipation
93Nov 8, 2015

94. Causes of constipation:
Sometimes, there is no identifiable reason for
constipation in children. However, some of the causes
may include:
 Diet.
 Lack of exercise.
 Emotional issues.
94Nov 8, 2015

95. Causes of constipation cont…
Physical problems that can cause constipation include
the following:
 Abnormalities of the intestinal tract, rectum, or anus.
 Problems of the nervous system, such as cerebral palsy.
 Endocrine problems, such as hypothyroidism.
 Certain medications (i.e., iron preparations and narcotics such
as codeine).
95Nov 8, 2015

96. Symptoms of constipation:
Symptoms of constipation in children
include:
 Fewer bowel movements than usual.
 Postures that indicate the child is withholding stool, such as
standing on tiptoes and then rocking back on the heels of the feet.
 Abdominal pain and cramping.
 Painful or difficult bowel movements.
 Hard, dry, or large stools.
 Stool in the child’s underwear.
96Nov 8, 2015

97. The mother should seek medical interference when:
 Fever.
 Vomiting.
 Blood in the stool.
 A swollen abdomen.
 Weight loss.
 Painful cracks in the skin around the anus, called anal fissures.
 Intestine coming out of the anus, called rectal prolapse.
97Nov 8, 2015

98. Management of constipation:
 Treatment of the cause.
 Diet changes:
 Increase the amount of fiber in the child's diet by adding more
fruits, vegetables, grain cereals and breads.
 Encourage your child to drink more fluids, especially water.
 Limit fast foods and junk foods that are usually high in fats
and offer more well-balanced meals and snacks.
 Limit drinks with caffeine, such as cola drinks and tea.
98Nov 8, 2015

99. Management of constipation cont…
 Increase exercise: Exercise aids digestion by helping the
normal movements the intestines.
 Proper bowel habits: Encourage the child to sit on the toilet at
least twice a day for at least 10 minutes, preferably shortly after
a meal.
 Give recommend laxatives, stool softeners, or an enema.
99Nov 8, 2015

100. Food Allergies
100Nov 8, 2015

101.  Definition
A food allergy is an abnormal response of the body to a certain
food.
 The difference between:
Food allergy causes an immune system response, causing symptoms
in the child that range from uncomfortable to life threatening.
Food intolerance does not affect the immune system, although some
symptoms may be the same as in food allergy.
Food Allergies
101Nov 8, 2015

102. Causes of food allergy:
 Before having a food allergy reaction, a sensitive child must have
been exposed to the food at least once before, or could also be
sensitized through breast milk.
 It is the second time the child eats the food that the allergic
symptoms happen. At that time, when antibodies react with the
food, histamines are released, which can cause the child to
experience asthma, itching in the mouth, trouble breathing,
stomach pains, vomiting, and/or diarrhea.
102Nov 8, 2015

103. foods cause food allergy:
Approximately 90% of all food allergies in
children are caused by the following :
• Milk.
• Eggs.
• Wheat.
• Soy.
• Tree nuts.
103Nov 8, 2015

104. The symptoms of food allergy:
The most common symptoms of food allergy include:
• Vomiting.
• Diarrhea.
• Cramps.
• Swelling.
• Eczema.
• Itching or swelling of the lips, tongue, or mouth
• Itching or tightness in the throat.
• Difficulty breathing.
• Wheezing.
• Lowered blood pressure.
104Nov 8, 2015

105. Management for food allergy:
There is no medication to prevent food allergy.
The goal of treatment is to avoid the foods and
other similar foods that cause the symptoms.
• If the mother is breastfeeding her child, it is
important to avoid foods in her diet that her
child is allergic to.
• It is also important to give vitamins and
minerals to the child if he/she is unable to eat
certain foods.
105Nov 8, 2015

106. Management for food allergy:
• Children who have had a severe food reaction,
the child's physician may prescribe an
emergency kit that contains epinephrine, which
helps stop the symptoms of severe reactions.
• Some children may be given certain foods again
after 3 to 6 months to see if he/she has outgrown
the allergy. Many allergies may be short-term in
children and the food may be tolerated after the
age of 3 or 4.
106Nov 8, 2015

107. Dysphagia
Dysphagia is a term that means "difficulty of
swallowing." It is the inability of food or liquids to
pass easily from the mouth into the throat, and down
into the esophagus to the stomach during the process
of swallowing.
107Nov 8, 2015

108. Causes of dysphagia:
●Children's health problems that can affect swallowing include:
• Cleft lip or cleft palate.
• Dental problems.
• Large tongue.
• Paralysis or poor function of the tongue or the muscles in
the throat and esophagus due to diseases such as a stroke,
tumor, nerve injury, brain injury, or muscular dystrophy.
• Large tonsils.
• Tumors or masses in the throat.
• Prenatal malformations of the digestive tract, such as
esophageal atresia or tracheoesophageal fistula
108Nov 8, 2015

109. Causes of dysphagia” Cont.“
• Oral sensitivity in very ill children who have been on a ventilator
for a prolonged period of time.
• Irritation of the vocal cords after being on a ventilator for long
periods of time.
• Paralysis of the vocal cords.
• Having a tracheostomy.
• Foreign bodies in the esophagus, such as a swallowed coin.
• Prematurity.
109Nov 8, 2015

110. Why is dysphagia a concern?
• Dysphagia can result in aspiration which may cause pneumonia
and/or other serious lung conditions.
• Children with dysphagia usually have eating trouble enough,
leading to inadequate nutrition and failure to gain weight or
grow properly.
110Nov 8, 2015

111. Management for dysphagia
• Treatment of the cause.
The following should be considered when caring for a child with
dysphagia:
• Adding a small amount of rice cereal to infant formula or pumped
breast milk. the mixture easier to suck through a nipple, as well as
easier to swallow.
• Do not cut holes in nipples, since this can increase the risk for
choking and aspiration.
• Baby foods should not be offered to infants from a spoon until
they are at least 4 months old, since they do not have the proper
coordination to swallow foods from a spoon until this age. 111Nov 8, 2015

112. Management for dysphagia “cont…”
• Provide safe toys and other objects for babies to chew on and
mouth.
• Vary the taste, texture, and temperature of soft foods for children
over the age of 4 months.
• Allow the child to play with foods and get messy at mealtime.
• Remaining upright for at least an hour after eating.
• Medications to decrease stomach acid production.
• Medications to help food move through the digestive tract faster.
112Nov 8, 2015

113. Definition
• mean local inflammation of the GIT
manifesting by diarrhea with or
without vomiting and /orfever.
• It is the most important killerof
infants in Egypt.
113Nov 8, 2015

114. Causes:
A) - enteral infections:
- Bacterial: salmonella, shigella, E.coli, staphylococcus,
cholera.
- Viral: rota viurs - Fungal: monilia albicans.
- Parasitic: entameba, coli,B.
B) parentral infections :( infections outside the GIT )
-- otitis media
- Tonsillitis, pharyngitis, sore throat.
- Bronchopneumonia, bronchitis.
- Common cold, influenza.
- Urinary tract infection
114Nov 8, 2015

115. Predisposing factors:
-- Season→ more in summer (↑flies)
- Types of feeding→ less common in breast
feeding.
- Nutritional state plus general condition.
115Nov 8, 2015

116. Clinical pictures
1. Simple dyspepsia;
* diarrhea is mild. * vomiting may be absent.
* fever is mild or absent.
2- Toxic dyspepsia:
• Diarrhea and vomiting are severe.
* Fever:
* Dehydration; * Acidosis.
* Electrolyte imbalance.
116Nov 8, 2015

117. Complication of gastro –enteritis:
1- Dehydration, electrolyte imbalance, acidosis. This are the
most frequent complications and may lead to shock and
death.
2- Malnutrition as a result of starvation and recurrent attacks.
3- Undercurrents infections e.g. bronchopneumonia.
4- Lactose intolerance.
5- Pre-renal failure, and acute tubular necrosis may result from
collapse.
6- Cerebral damage as a result of thrombosis, hypernatremia ,
IC hemorrhage.
7- Tetany: due to hypocalcemia, or during correction of
acidosis.
117Nov 8, 2015

118. Treatment:
• The main lines of treat are:
- Prevention and treat of dehydration by oral
rehydration solution (ORS).
- Feeding.
- Other:
- * Antibiotics
- * Symptomatic treatment .
* Intravenous rehydration when indicated
118Nov 8, 2015

119. 1-Administer Oral Rehydration
• *The baby is given as long as he
wishes until he refuses
• * in mild cases 50 ml/kg are given in
first 4 hours
• * in moderate cases 100ml/kg are
given in first 6hours
119Nov 8, 2015

120. 2-Feeding
• If should be noted that (starvation therapy) which was used
before has no place in the treatment of GE.
• An initial period of 4-6 hours is used for initial rehydration after
which feeding should restart.
• If the baby breast feeding ----continue on breast feeding.
• If he was artificial feeding -----the same type of milk is regained
to, but in half strength, and in smaller amount until tolerated, then
increased gradually in amount and concentration till normal
intake is regained.
• If lactose intolerance-----lactose free milk is given.
120Nov 8, 2015

121. 3- Antibiotic
• Shigella, entameba are regularly sensitive to antibiotic.
• Viruses are not sensitive , while salmonella and E.Coli are not
regularly sensitive to antibiotic.
4- Symptomatic treatment:
• ( vomiting, diarrhea, colic, fever, distention).
121Nov 8, 2015

122. Definitions:-
• A. Hematemesis:- refers to the emesis of fresh
(bright red) or old ("coffee grounds")
blood. Fresh blood becomes chemically
altered to a coffee-ground appearance
within 5 minutes in the stomach.
122Nov 8, 2015

123. • B. Hematochezia is the passage of fresh (bright
red) or dark maroon blood from the rectum.
The source is usually the colon, although
upper gastrointestinal bleeding that has a rapid
transit can also result in hematochezia.
• C. Melena is the passage of shiny, jet black
stools of tarry consistency
123Nov 8, 2015

124. newborn Infant to 2
years
2 years to
preschool
Preschool
-adolsccence
*Vitamin k
deficiency
* Ingested
maternal
blood cow
/soy milk
enterocolitis
*Anal fissure
*milk colitis
*Infectious
diarrhea
*Intussupception
*Esophagitis
*Infectious
diarrhea
*Anal fissure
*Intussupception
*Esophagitis
*Infectious
diarrhea
*esophageal
varices
*Peptic ulcer
124Nov 8, 2015

125. Causes of rectal bleeding by age of patientCauses of rectal bleeding by age of patient
• A-True upper gastrointestinal bleeding:-
Occurs at a site proximal to the ligament of Treitz.
Common disorders causing upper gastrointestinal
bleeding include esoph-agitis, gastric erosions, peptic
ulcer disease, or esophageal varices.
125Nov 8, 2015

126. B.True lower gastrointestinal bleeding :-
• Is due to a source distal to the ligament of Treitz.
Minor bleeding presents as stool streaked with blood
or the passage of a few drops of blood after stool is
passed.
• It is commonly due to an anal fissure or poly.
Inflammatory disease such infectious colitis results in
diarrhea stool mixed with blood.
126Nov 8, 2015

127. Management
A. The unstable child
Order a stat (CBC), platelet count, cross-match,
(PT), (PIT), liver function tests, & measurements
electrolytes, BUN, and creatinine. A normal
hemoglobin or hematocrit does not rule out
severe acute bleeding.
Insert a well-lubricated nasogastric (NGT) of the
largest bore possible after cutting side holes in
the distal 5 cm of tubing a gastroenterologist
before commencing treatment.
Consult a gastroenterologist when possible.
127Nov 8, 2015

128. Management
A. The unstable child
In the child with heavy bleeding or
hypovolemia, assess and control problems
in the airway, breathing, and circulation.
Give oxygen by mask,
Start two large-bore IV lines,
128Nov 8, 2015

129. B. The stable child:
• The stable child without heavy bleeding or signs of
hypovolemia must be treated according to age and the
suspected diagnosis.
• Obtain a CBC to determine the significance of bleed-
ing.
• A thorough history and examination and consider-
ation of age-related causes will usually lead to the
diagnosis.
129Nov 8, 2015

130. Specific disorders
Upper gastrointestinal bleeding
1- Esophageal varices
• Esophageal varices occur in children with portal
hypertension secondary to an extrahepatic cause such
as portal vein thrombosis, or an intrahepatic cause
such as cirrhosis due to any of a number of disorders
(e.g., biliary atresia, chronic hepatitis
2- Peptic ulcer.
• Occur in the stomach and are associated with sepsis,
head injury, multiple trauma, burn, hypoxemia, or
acidosis. Chronic peptic ulcer disease can occur in
children of all ages but is unusual under 5 years. 130Nov 8, 2015

131. 3- Esophagitis.
• Peptic esophagitis due to gastroesoph-ageal reflux is
the most common form of esophagitis in children.
Other causes include esophageal dysmotility with poor
acid clearance (usually secondary to CNS disorders)
4- Gastritis.
• Acute "stress" gastritis is associated with sepsis, head
injury, burns, hypoxemia, and acidosis. Initial manage-
ment includes therapy with antacids and H, blockers
until a specific diagnosis is made at endoscopy
131Nov 8, 2015

132. 5- Mechanical causes
• Gastric erosions due to forceful vomiting are
common causes of upper gastrointestinal
bleeding in chil-dren. Endoscopy is required
to make the diagnosis.
132Nov 8, 2015

133. Lower gastrointestinal bleeding.
• 1- Intussusception.
• 2- Inflammatory bowel disease.
Inflammatory bowel disease, although common in
children aged 8-18 years, may also occur in younger
children. It is rare in those under 2 years of age.
133Nov 8, 2015

134. 134Nov 8, 2015

135. Signs and symptoms:
1- Acute and marked loss weight
2- Depressed anterior fontanelle
3- Sunken eyes + soft intra-ocular pressure
4- Dry tongue
5- Marked thirst.
6-Diminished urine flow: oliguria and may be anuria.
7-Loss of skin elasticity (turgor)
8- Heart rate is rapid. The pulse may be thready.
9- In sever cases, the patient may be shocked & collapsed.
10- Convulsions.
135Nov 8, 2015

136. Minimal or sub-clinical Dehydration
A. Deficit: 1-2% (10-20 ml/kg)
B. Symptoms and signs
1. Increased Thirst
2. Mild Oliguria
136Nov 8, 2015

137. Mild Dehydration
• A.A. DeficitDeficit
1. Child: 3% deficit (30 ml/kg)
2. Infant: 5% deficit (50 ml/kg)
• B. Signs and Symptoms
1. Dry lips 4. Anterior Fontanelle flat
2. Thick Saliva 3. Decreased Tears
5. Decreased Urine output
137Nov 8, 2015

138. Moderate Dehydration
A. Deficit
1. Child: 6% deficit (60
ml/kg)
2. Infant: 9% deficit (90
ml/kg)
B. Signs and symptoms
1. Eyes sunken
2. Tears absent
3. Pulse weak and rapid
4. Skin turgur decreased
5. Sunken Fontanelle
6. Dry mucus membranes
7. Delayed capillary refill (>2 seconds)
8. Skin slowly retracts
9. Listless and Irritable
10. Urine characteristics
a. Dark color
b. Oliguria (Urine output <1-2 cc/kg/hour)
c. Urine Specific Gravity = 1.030
11. Blood Urea Nitrogen (BUN) increased
12. Arterial pH <7.30Nov 8, 2015 138

139. Severe Dehydration
A. Deficit
1. Child: 10% deficit (100 ml/kg)
2. Infant: 15% deficit (150 ml/kg)
B. Signs and symptoms
1. Limp and cold.
2. Lethargy or coma
3. Grunting.
4. (BUN) markedly increased
5. Arterial pH <7.10
139Nov 8, 2015
6. Oliguria or Anuria
7. Specific Gravity >1.035
8. Capillary refill >4 seconds
9. Deep and rapid RR
10. Decreased Bp
11. Skin retracts >2 sec

140. Management
140Nov 8, 2015

141. • In case of mild and moderate dehydration, and in
absence of shock or circulatory collapse characteristic
of sever dehydration, O.R.S is used .
• Management depends on;
1- Amount of fluid needed
2- Composition of fluids to be given
3- Route of administration
4- Rate of administration.
141Nov 8, 2015

142. • History disease
• Physical examination
• High risk child forG.I.T. disorders
related to factoraffected the child
142Nov 8, 2015

143. The main goals related to the child with G.I.T.
disorders and Family are:-
• Child will be protected from further disorders
• Child and family will receive adequate support.
• Hospitalized child and family prepared for discharge
• Family home care to prevent and dealing with
disorders
143Nov 8, 2015

144. Based on
• Observation of child for physical and behavior evidence
of GIT. disorders.
• Interview with parent's child by counseling
• Training & supervising all categories of health worker.
• Investigate community programs for prevent GIT
disorders
144Nov 8, 2015

145. Prevention of child GIT disorders
1-Primary level
2-Secondary level 3-
Tertiary level
145Nov 8, 2015

146. Primary prevention
Primary assessment :-
• Identify necessary and sufficient components for GIT. Disorders.
• Gather information about population at risk.
Primary nursing diagnosis:-
• High risk for GIT. Disorders.
• High risk for dehydration (vomiting, diarrhea )
• Preoperative anxiety
• High risk for injury during anesthesia
Primary planning :-
• Successful prevention at the primary level will result in the
absence of GIT. Disorders.
• Identification of the child at risk and intervening to alleviation the
risk factors before the disorders occurs.
146Nov 8, 2015

147. Primary intervention:-
1) Identification of special child liable to GIT disorders .
2) Dysfunctional Families can be guided toward improving
3) environment sanitation.
4) Improvising self concept and self esteem of parents.
5) Provide social support to the families.
6) Education 'of parents toward follow up cases at risk
Primary Evaluation:-
• The absence of child with GIT. disorders
• Risk factors will be modified as ' evidenced by improving
environment sanitation through (save water, proper nutrition,
good ventilation )
147Nov 8, 2015

148. Secondary prevention
Secondary assessment :-
• The nurse should be recognize the normal anatomy & physiology
of the GIT & be consistently alert to the age ,developmental level,
history of the family ,social and environmental issues relative to
each child.
• The nurse must be a awareness of the different types and extents
of disorder, provide a cluster of data from which a conclusion of
cases.
148Nov 8, 2015

149. Secondary nursing diagnosis:-
• Altered growth & development due to alterations in body weight
• Fear ,anxiety.
• Alterations in body temperature .
• High risk to infection.
• Impaired social interaction.
Secondary planning
• Early detection & treatment of incidents of child & adolescent
pts.
• Prevention from infection .
• Identify and alleviate dysfunctional patterns
149Nov 8, 2015

150. Secondary interventions :-
• Nursing interventions with the patient:-Nursing interventions with the patient:-
• It is important to provide reassurance to the child.
• The nurse must communicate to the child to relieve
fear and anxiety.
• Apply the nursing process during provide a care to
the child.
• Protect the child against the infection through kept
the child away from the source of infection.
• Maintaining confidentiality and recognizing the
child's right to privacy.
150Nov 8, 2015

151. Nursing interventions with parents:-
• The nurse must be a ware that not every disorder is the result
of maltreatment. .
• The nurse needs to anticipate the parent's responses, anger,
denial, and over protectiveness.
• The nurse must honestly communicate to the parent his or
her professional responsibilities to report suspected or actual
disorder
Secondary evaluation
• Evaluation of nursing process.
151Nov 8, 2015

152. Tertiary Prevention:-
Tertiary assessment:-
• It must project the long term needs.
• It is entered after the stressor has impacted the child, and the
reaction occurred.
Tertiary Nursing diagnosis:-
• Post trauma response. .
• Altered thought processes.
• Powerlessness
• Impaired social interaction.
• Self -esteem disturbance.
• Body image disturbance.
152Nov 8, 2015

153. Tertiary planning
• It involves the recognition, intervention, and
1. Rehabilitees of the cases
2. Help the patient to move forward in as normal a progression as
possible.
3. Education not only for child but also for parent.
4. Ability to establish personal boundaries.
153Nov 8, 2015

154. Tertiary intervention:-
Nursing intervention with the patient:-Nursing intervention with the patient:-
1) The Nurse must intervenes on the basis of the age of the child,
hisher assessment of the child's developmental dysfunction,
quality and quality of relationships ,and behavior
manifestations.
2) The child must be in an emotionally and physically safe
environment.
3) The nurse must conducive a trusting relationship with the child.
4) The nurse assists the child in the identification of feelings.
5) The children need assistance in ventilating feelings in a socially
acceptance manner.
6) The nurse can provide verbal and physical redirection.
7) Teaching appropriate prevention skills.
154Nov 8, 2015

155. Nursing intervention with the parent :-
•Exploring various problem solving strategies with the parent.
•It assists in promoting parental self esteem.
•Parents can provide information regarding the
•Child like and dislikes and can be approached as an equal in the
planning process.
Nursing intervention with the family:-
•Provide services in three phases: intensive crisis intervention,
stabilization, and follow up.
Tertiary evaluation:- .
•one goal of tertiary prevention is to halt dysfunctional patterns.
1.Promote developmental adaptation.
2.Development of age appropriate behaviors,
3.Adequate social and peer relationships,
155Nov 8, 2015

156. 156Nov 8, 2015