Gastrointestinal Dysfunction

1. Gastrointestinal Dysfunction Vomiting, Diarrhea, Constipation Fluid & Electrolyte Balance, Dehydration

2. Anatomy

3. Overview/ Review of Anatomy of the GI system: The primary function of the GI tract is digestion and absorption of nutrients, water, secretion to aid in these processes and elimination of waste products. The GI tract extends from the mouth to the anus and consists of the following: mouth, teeth, tongue, esophagus, stomach, small intestine, large intestine, liver, gallbladder, pancreas, large intestine, rectum, and anus. The basic activities of the GI tract are: • Muscular activity • Enzymatic Activity • Absorption of nutrients occurs primarily in the small intestine • Absorption of Na and H20 occurs in the large intestine.

4. Dehydration The excessive loss of water from body tissues. It is a common occurrence in the pediatric population whenever total fluid intake is less than total fluid intake. Dehydration is classified by degree: Mild, Moderate and Severe and the type Isotonic/hypertonic/hypotonic The main causes of dehydration in the pediatric population are: • Vomiting • Diarrhea • Increased BMR • Decreased intake • Diabetic ketoacidosis • Severe burns • Prolonged high fever • Hyperventilation

5. DEHYDRATION Physical assessment findings and lab values make the diagnosis of dehydration. Serum Na+ level can increase or stay within normal limits, serum K+ stays normal or decrease, CL- level decreases. Serum Na+ levelvary, CL- decreases and K+ level vary.

6. Degrees of Dehydration Mild/Early Dehydration, loss of up to 5% of pre illness weight • Dry mucous membranes • Decreased urine output • Increased specific gravity • Decreased tear production • Irritability

7. Degrees of Dehydration Moderate dehydration, loss of up to 10% of pre illness weight All the criteria of mild dehydration plus: • Tachycardia • Pallor • Listlessness/ lethargy

8. Degrees of Dehydration Severe dehydration, loss up to 10% of pre illness weight All of the criteria of mild & Moderate dehydration plus: • Poor skin turgor • Sunken fontanel • Sunken eyes • Fluid & electrolyte imbalances • Hypotension • Lethargy

11. Potassium (K+) 3.5 – 5.5 Sodium (Na+) 135 - 145 Chloride (CL-) 20 – 35 Normal Pediatric Electrolyte Values

12. . Types of Dehydration

13. Isotonic Dehydration The major fluid loss involves extracellular components and circulating blood volume, this puts the child at risk for Hypovolemic shock Serum Na+ level can stay WNL, serum K+ stays WNL or decrease, CL- level decreases

14. Hypertonic Dehydration The excessive loss of water compared to electrolytes, which results in fluid shifts from the intracellular to the extracellular compartment, which can lead to neurological disturbances such as seizures. Serum Na+ increases (>150), serum K+ varies, and CL- level increases.

15. Hypotonic Dehydration Water shifts from the extracellular to the intracellular compartments in an attempt to establish osmotic equilibrium, which further increase the loss of extracellular fluid and commonly results in Hypovolemic shock. Serum Na+ decreases (<130), K+ level varies, CL- decreases

16. Nursing Process - child with dehydration Nursing Diagnosis • Fluid volume deficit • Fluid volume excess • Fluid volume imbalance • Altered tissue perfusion • Altered urinary elimination

17. Nursing Process - child with dehydration Nursing assessment (s & s will depend on the degree of dehydration) • Excessive Thirst • Fatigue • Weight loss • Dry Mucous membranes • Decreased or absent tear production • Poor skin turgor • Increased capillary refill time • Depressed/sunken fontanel • Decrease urinary output • Tachycardia • Tachypnea

18. Nursing Process - child with dehydration Lab studies • U/A will concentrate with high SG (>1.030) • CBC with elevated Hgb • BUN will be elevated • Electrolytes will indicate altered serum Na+, K+, CL-

19. . NORMAL DAILY FLUID REQUIREMENTS FOR CHILDREN IS: 100ml/kg/qd MINIMAL URINARY OUTPUT IS 1ml/kg/hr

20. Nursing Interventions - child with dehydration Restoration and maintenance of adequate hydration and electrolyte balance is the priority goal of the RN • Initial fluid replacement consists of fluid boluses of an isotonic fluid the rate of 20-30ml/kg (contraindicated in hypertonic dehydration due to the risk of water intoxication) • Subsequent therapy is used to replace fluid & electrolyte losses. The fluid of choice is usually a saline solution with 5% dextrose (D5 ½ NS, D5 1/3 NS with or without K+). The selection of fluid is based on the probable cause of dehydration.

21. Nursing Interventions cont….. • Oral dehydration with Pedialyte (or its equivalent) in small quantities (1-2 oz/hr) Pedialyte promotes reabsorption of Na, H20 and reduces vomiting and diarrhea. • If child has diarrhea without dehydration, give pedialye + normal diet for age • If child is vomiting give very small amounts of Pedialyte (1-2 teaspoons) q5-10min as tolerated for 1 hour, increase as child's vomiting subsides. • DO NOT give fruit juice, soda , sports drinks, chicken or beef broth. They are all very high in Na+ and glucose and will make the diarrhea & vomiting worse.

22. Nursing Interventions cont….. • IV therapy, monitor IV site • If child has diarrhea, meticulous care of perineum • Strict I & O • Maintenance of Foley catheter • Daily weights • Assist with treatment of causes

23. Nursing Interventions cont….. • Parent teaching: • Anti-diarrheal agents (lopermide) are not for use in children, their use can be fatal • Reassurance and support • Teach parents that acute diarrhea may produce a temporary lactose intolerance, avoid lactose for about 1 week after resolution.

24. BRAT Diet BRAT diet: • bananas (fresh or baby food) • rice (white, plain no salt or butter) • apples (not apple juice or sauce) • Tea or toast (no butter or jelly) Advance to BRAT diet when acute diarrhea has subsided and rehydration is achieved.

25. Disorders of Motility Vomiting Diarrhea Constipation

26. VOMITING The forceful ejection of gastric contents through the mouth, it is a well defined complex and coordinated process that is under the control of the CNS. Etiology/Pathphysiology : • VERY common in children and is usually self-limiting. • Can be associated with infectious process, ICP, toxin ingestion, food intolerance or allergy, obstruction in the GI tract, metabolic disorders or psychogenic problem. • Requires NO treatment unless there are complications (dehydration/electrolyte imbalance/malnutrition/aspiration).

27. Vomiting The child’s age, pattern of vomiting and duration of symptoms help determine the cause/etiology 1) Green bilious vomiting - think bowel obstruction 2) Curdled stomach contents, mucous or fatty foods that are vomited several hours after eating suggest poor gastric emptying time. 3) Vomitus that looks like coffee grounds is associated with bleeding

28. Symptoms associated with Vomiting Fever and diarrhea infection Constipation obstruction Localized abdominal pain appendicitis pancreatitis peptic ulcer

29. Symptoms associated with Vomiting Headache/change in LOC CNS disorder Vomiting without nausea Brain tumor Forceful or projectile pyloric stenosis

30. Nursing Process - child who is vomiting Assessment: • child’s hydration and electrolyte balance is the highest priority • Note /document color, consistency, time • Daily weights • Strict I & O • Activity level • Abdominal cramping • Fever • Lab and dx tests (x-ray’s, sono, endoscopy, electrolytes, bun)

31. Nursing Process - child who is vomiting Nursing Diagnosis: • Fluid volume deficit • Fluid volume imbalance • Alteration in nutrition: less than body requirements • Aspiration: risk for • Electrolyte imbalance

32. Nursing Process - child who is vomiting Nursing Intervention: • Based on the cause of the vomiting • Prevention of electrolyte imbalance , dehydration and aspiration are the priority of all interventions

33. Diarrhea/Acute Gastroenteritis • Diarrhea is the passage of frequent, watery, loose stools and is actually a symptom and not a disease. It can affect any part of the GI tract. Diarrhea accompanies many childhood diseases including respiratory infections and GI disorders. Etiology/Pathphysiology: • It can have many different causes the specific etiology is not always identified. • Stress, anxiety, fatigue • Bacterial infection (e.coli/salmonella/shigella) • Viral infection(rotovirus/adenovirisu)

34. Diarrhea/Acute Gastroenteritis • Fungal over growth • Food sensitivity • Food intolerance • Parasitic infection • Lactose intolerance • Introduction of new foods • Over eating • Medications • Colon diseases • Surgical intervention (SBS)

35. Diarrhea/Acute Gastroenteritis There is a increase in intestinal motility and rapid bowel emptying results in impaired absorption, this decrease in absorption causes inflammation of the bowel and a decrease in surface area for absorption. Can be acute, chronic, inflammatory, viral or bacterial in nature. Electrolytes effected: Na+, K+, CL- The younger the child the more severe the faster the diarrhea will cause electrolyte imbalance, in young children untreated diarrhea can lead to Hypovolemic shock and death. Diarrhea is the leading cause of death in children in the world.

36. Nursing Process - child with diarrhea Assessment • Amount, color, consistency and time of stools • Strict I & O • Daily weights • Child's activity level • Abdominal cramping, fever • Skin integrity • Lab: electrolytes with special attention to Na+, K+, CL- • Diagnostic test: ova & parasites, roto virus, bacteria, salmonella, shigella, giardia

37. Nursing Process - child with diarrhea Nursing Diagnosis • Same as with vomiting Nursing Interventions • Based on the cause of the diahhrea PREVENT dehydration, maintain electrolyte balance

38. CAUTIONS • Pepto-Bismol – contains salycilates (Reye’s) • Lomotil – can slow peristalsis and trap causitive organism in gut – making child EXTREMELY ill. • NEVER give these medication for vomiting/diarrhea unless specific reasons are explained.