→ A benign neoplasm is an abnormal but noncancerous growth that may occur in different
parts of the body.
→ “Neoplasm” came from the Greek word
“neo”, which means new, and “plasma”,
which means formation or creation
(abnormal growth of new tissue)
NCM 109 – FINALS
Care of Mother and Child at Risk or with
Problems
Learning Outcome:
 Describe usual cellular growth & theories.
 Assess a child with a common malignant
process.
 Formulate nursing diagnosis related to a
child with a malignancy.
 Establish expected outcomes for a child
with a malignancy.
 Implement nursing care for a child with a
malignancy.
 Evaluate expected outcomes for
achievement and effectiveness of care.
a)
b)
c)
d)
e)
f)
BENIGN
slow growing
capsulated
noninvasive
do not metastasize
well-differentiated
suffix “oma” (ex.
fibroma)
a)
b)
c)
d)
e)
f)
MALIGNANT
fast growing
non capsulated
invasive & infiltrate
metastasize
poorly
differentiated
suffix “carcinoma”
or “sarcoma”
HYPERTROPHY
CELLULAR ABERRATIONS
→ The cell is the body’s basic building block
and the smallest living component of an
organism
→ The cell faces many challenges through its
life span.
→ If the cell’s reserves are insufficient, the cell
dies.
•
•
increase in cell size
normal organization
•
•
increase in cell
number
normal organization
•
disorganized growth
•
•
disorganized growth
net increase in
number of dividing
cells
HYPERPLASIA
CANCER
→ “Cancri” “Crab”
→ A disease of the cell in which the normal
mechanisms of the control of growth &
proliferation have been altered or there is an
uncontrolled proliferation of cells.
DYSPLASIA
TERMINOLOGIES RELATED TO CANCER
1. Benign Neoplasm
2. Neoplasia
3. Hyperplasia
4. Hypertrophy
5. Metaplasia
6. Dysplasia
7. Anaplasia
8. Metastases
9. Oncology
10. Adenocarcinoma
11. Carcinoma
12. Sarcoma
13. Carcinogens
NEOPLASIA
Metaplasia
• initial changes of normal cells to a different
cell type
• replacement of one adult cell type by a
different adult cell type
• noncancerous while dysplasia can be
cancerous
1
Carcinoma
• a cancer arising in the epithelial tissue of
the skin or of the lining of the internal
organs
Adenocarcinoma
• a malignant tumor formed from glandular
structures in epithelial tissue
ADENOMA
develop in
glands which
secrete fluids
• benign
• can affect
people at any
age
•
CARCINOMA
develops in
tissues that line
the inner or
outer surfaces
of the body
• malignant
• rarely affect
children
•
Soft Tissue Sarcomas: Definition
•
•
Sarcomas are malignant tumors that arise
from skeletal and extraskeletal connective
tissues (mecells) .
Including:
o Adipose tissue
o Bone
o Cartilage
o Smooth muscle
o Skeletal muscle
PATHOGENESIS OF CANCER
a) Cellular Transformation & Derangement
Theory
− normal cells may be transformed into
cancer cells due to exposure to some
etiologic agents.
b) Failure of the Immune Response Theory
− Cancer cells are recognized by the immune
response system. So, the cancer cells
undergo destruction.
− Failure of the immune response system
leads to inability to destroy the cancer cells.
Etiologic Factors:
1. Viruses
− Prolonged or frequent viral infections may
cause breakdown of the immune system or
overwhelm the immune system.
2. Chemical Carcinogens
− Causes cell mutation or alteration in cell
enzymes and proteins causing altered cell
replication.
− eg. Industrial compounds; drugs , food
preservatives
3. Physical Agents
− Radiation. from x rays; from
sunlight/ultraviolet rays.
−
Physical irritation/trauma from pipe
smoking, multiple deliveries, jagged tooth,
irritation of the tongue, “overuse” of any
organ/body part.
4. Hormones
− Hormone Therapy
5. Genetics
− A family history of certain cancers can be a
sign of a possible inherited cancer
syndrome.
− When oncogene(hidden or repressed
genetic code of cancer that exists in all
Individuals) is exposed to carcinogens,
changes in cell structure occurs, malignant
tumor develops.
Predisposing Factors:
1. Sex
2. Urban Residence
3. Geographic Distribution
4. Occupation
5. Heredity
6. Stress
7. Precancerous Lesions
8. Obesity
Causes of Neoplastic Growth
−
−
Exact origin is unknown.
cancerous tumor growth is triggered by DNA
mutations within the cells.
Pathophysiology of Cancer
1. Genetic mutation. The disease process of
cancer starts when the genetic mutation in
the cellular DNA transforms an abnormal
cell.
2. Neoplasia or proliferation. The abnormal
cells grow uncontrollably without following
any physiologic demand. Cancer cells also
do not appear the same as normal cells and
are termed "undifferentiated". They tend to
increase in number and size at the
periphery while attempting to infiltrate the
body tissues nearby in order to destroy
them.
3. Metastasis. Malignant cells invade other
parts of the body by means of using blood
and lymphatic channels. They can also
"metastasize" or spread to a distant body
part or region.
a)
−
−
Cell Injury
Injury to components of cells can
lead to disease as the cells lose their
ability to adapt.
Cell injury may result from any of
several intrinsic or extrinsic causes
and may be classified as:
2
•
•
•
•
Toxic injury (endogenous &
exogenous factors)
Infectious injury
physical injury (2 major
types: thermal & mechanical)
deficit injury
WARNING SIGNS
 Change in bowel/ bladder habits
 A Sore that does not heal
 Unusual bleeding / discharges.
 Unexplained sudden weight loss.
 Unexplained anemia
 Thickening/lump in the breast/elsewhere
 Indigestion or difficulty in swallowing
 Obvious change in wart or mole.
 Nagging cough/ hoarseness of voice.
Signs & symptoms of childhood cancer are
nonspecific and include many findings observed in
a variety of childhood disorders.
These include:
a. Fever
b. Musculoskeletal symptoms
c. Pain, fatigue
d. Pallor
e. Bruising
f. Bleeding
g. Headache
h. Lymphadenopathy & loss of appetite
i. Vomiting & weight loss.
Cancer Detection Examination
1.
−
2.
−
3.
−
4.
−
Cancer screening
screening exams are useful in
diagnosing cancer early to give the
patient the opportunity to be treated
as soon as possible.
Physical exam
the doctor will find lumps, skin
changes, and other signs and
symptoms related to cancer
Imaging tests
X-rays, CT scans, PET scans,
ultrasounds, and other imaging
exams can be used to examine the
body in a non-invasive method;
imaging tests are useful in knowing
the extent of cancer, also known as
cancer staging
Biopsy
the collection of cell samples and the
subsequent examination of these
cells under a microscope; this can
be a definitive diagnostic tool to
determine if cancer cells exist
Staging of Cancer
Three factors:
− size and growth of the tumor
whether cancer has spread to the
lymph nodes whether it has spread
to other parts of the body.
The TNM Staging System
− The TNM system is the most widely
used cancer staging system. Most
hospitals and medical centers use
the TNM system as their main
method for cancer reporting. You are
likely to see your cancer described
by this staging system in your
pathology report unless there is a
different staging system for your type
of cancer. Examples of cancers with
different staging systems include
brain and spinal cord tumors and
blood cancers.
In the TNM system
− The T refers to the size and extent of
the main tumor. The main tumor is
usually called the primary tumor.
− The N refers to the number of
nearby lymph nodes that have
cancer.
− The M refers to whether the cancer
has metastasized. This means that
the cancer has spread from the
primary tumor to other parts of the
body.
3
Cancer Treatment Measures Used
Treatment Modalities for Cancer
1) Immunotherapy
− a type of cancer treatment that helps
your immune system fight cancer.
− The immune system helps your body
fight infections and other diseases. It
is made up of white blood cells and
organs and tissues of the lymph
system.
− a type of biological therapy
2) stem cell transplant
− A procedure in which a patient
receives healthy stem cells (bloodforming cells) to replace their own
stem cells that have been destroyed
by treatment with radiation or high
doses of chemo
How is childhood Cancer different from Adult
cancer?
−
−
Therapy for a child w/ cancer focuses on
devising ways to kill the growth of abnormal
cells while protecting the normal
surrounding cells.
Treatment may include any one or a
combination of cancer treatment
4
−
−
Children are different from adults in
terms of body structure and function,
social, emotional and cognitive
aspects.
−
Tumors may grow because normal
cell growth has been altered by
environmental exposure such as
chronic exposure to chemical
irritants or cigarette smoke.
ADULTS:
CHILDREN:
−
Tumors most frequently occurs in
organs unexposed to the
environment such as
• leukemia of the bone marrow
• nephroblastoma of the
kidney (Wilm tumor)
• tumors of the brain; or
• neuroblastoma in the
abdomen.
CHILDHOOD CANCER
The Problem
CHILDHOOD CANCER Key Facts:
− Each year, approximately 400 000
children & adolescents of 0-19 years
old are diagnosed with cancer.
− The most common types of
childhood cancers include
leukemias, brain cancers,
lymphomas and solid tumors , such
as neuroblastoma and Wilms
tumors.
− Cancer is a leading cause of death
for children and adolescents,
particularly in high income countries.
− The likelihood of surviving a
diagnosis of childhood cancer
depends on the country in which the
child lives: in high-income countries,
more than 80% of children with
cancer are cured, but in many
LMICs only 15-45% are cured.
Key Facts:
 high-income countries >
more than 80% of children
with cancer are cured.
 In low- and middle-income
countries (LMICs), an
estimated 15-45% are cured.
 Childhood cancer cannot
generally be prevented or
identified through screening.
 cancers can be cured with
generic medicines and other
forms of treatment, including
surgery and radiotherapy.
 Treatment: can be costeffective in all 9income
settings.
The problem …
The reasons for lower survival rates in
LMICs include:
a. delay in diagnosis and advanced
disease
b. inability to obtain an accurate
diagnosis
c. inaccessible therapy
d. abandonment of treatment
e. death from toxicity (side effects)
f. avoidable relapse.
 Childhood cancer data systems are
needed to drive continuous
improvements in the quality of care,
and to inform policy decisions.
The Problem
− Improving access to childhood
cancer care, including to essential
medicines and technologies, is
highly cost effective, feasible and
can improve survival in all settings
What Causes CANCER in children?
1. HIV
2. Epstein-Barr virus
3. Malaria
− approximately 10% of all children with
cancer have a predisposition because of
genetic factors.
5
Improving outcomes of childhood cancer
− Prompt, correct diagnosis
− Effective, evidence-based therapy with
tailored supportive care.
Treatment
− Chemotherapy, surgery and/or radiotherapy.
− Physical, cognitive growth and nutritional
status.
− Effective diagnosis, essential medicines,
pathology, blood products, radiation therapy,
technology.
− Psychosocial and supportive care.
Most Common Cancer in Children
1. Leukemia
2. Brain and spinal cord tumors
3. Neuroblastoma
4. Wilms tumor
5. Lymphoma (including both
6. Hodgkin and non-Hodgkin)
7. Rhabdomyosarcoma
8. Retinoblastoma
9. Bone cancer (including osteosarcoma and
Ewing sarcoma)
−
−
−
−
−
1.
LEUKEMIA
is a type of cancer of the blood or bone
marrow characterized by an abnormal
increase of immature white blood cells
called "blasts”.
Is the distorted and uncontrolled
proliferation of WBCs(leukocytes)
Classifications:
a. Acute Lymphocytic
(Lymphoblastic) Leukemia
(ALL)
→ is a type of cancer of the
blood and bone marrow —
the spongy tissue inside
bones where blood cells are
made.
−
→ the disease progresses
rapidly and creates immature
blood cells, rather than
mature ones.
→ Account 75% of leukemias
and involve lymphoblasts
(immature lymphocytes).
→ Rapid proliferation of so
many immature lymphocytes
causes decrease production
of RBC and Platelets.
Symptoms:
• nose bleeds
• weight loss
• swollen lymph nodes
• fever
• night sweats
• bleeding easily
• bone pain
• red spots on skin
Assessment:
1) Pallor
2) Low-grade fever
3) Lethargy
4) A low thrombocyte count
5) Spleen and liver begin to enlarge,
abdominal pain, vomiting & anorexia
occur.
6) Bone & joint pain
7) Headache or unsteady gait
8) RBCs are of normal size and color
but few in number
9) X-rays of long bones may reveal
lesions
10) Lumbar puncture – shows evidence
of blast cells in the CSF
Therapeutic Management:
 Up to 95 % of children with ALL will
achieve a first remission.
 If a child experiences relapse, the
chances of long term survival are
reduced & bone marrow
transplantation may be required to
achieve long term survival.
 Chemotherapy
6
 Radiation Therapy
 Biological Therapy
 Stem Cell Transplant
−
−
2. LYMPHOMA
b. Acute Myeloid Leukemia (AML)
→ characterized by the rapid
growth (fast-growing) of
abnormal cells that build up
in the bone marrow & blood
& interfere with normal blood
cells.
Symptoms:
• shortness of breath
• easy bruising
• fever
• weakness
• pale skin
• infections
Therapeutic Management:
 bone marrow aspiration and biopsy
−
−
−
−
−
−
−
Nursing Diagnosis:
o Risk for infection r/t non -functioning
WBCs and immunosuppressive
effects of therapy
o RISK for deficient fluid volume r/t
increased chance of hemorrhage
from poor platelet production
o PAIN r/t invasion of leukocytes
o Ineffective health maintenance r/t
long-term therapy for leukemia
−
The disease can spread to nearby lymph
nodes.
Later it may spread to the lungs, liver, or
bone marrow.
Etiology is unknown but both genetic and
environmental factors both play a part.
Many researchers have suspected an
infectious component (viral).
The first sign is often an enlarged lymph
node.
Symptoms:
• Fever
• Swelling of the face and neck
• Lump in your neck, armpits, or groin
• Excessive sweating at night
• Unexpected weight loss
• Loss of appetite
• Feeling of weakness
• Breathlessness
• Itchiness
Classifications:
a. Hodgkin Lymphoma
→ More often localized to a
single axial group of nodes
(cervical, mediastinal, paraaortic)
→ Spreads by contiguity
→ Mesenteric nodes and
Waldeyer’s ring rarely
involved
→ Extranodal involvement
uncommon
7
−
−
−
b. Non-Hodgkin Lymphoma
→ More frequent involvement of
multiple peripheral nodes
→ Noncontagious spread
→ Waldeyer’s ring and
mesenteric nodes commonly
involved
→ Extranodal involvement
common
c. Burkitt’s Lymphoma
→ 30-50 day incubation
→ Most cases asymptomatic
→ Associated with chronic
coinfections with malaria
→ Nasopharyngeal carcinoma
in Chinese & African men
Causes:
o Unknown
o It occurs when the body makes too
many abnormal lymphocytes,
continue to grow and divide.
o Enlarges the lymph nodes.
Who Is at Risk?
o older age
o the use of immunosuppressant
drugs
o an infection (HIV, Epstein-Barr virus,
or Helicobacter pylori )
o exposure to certain chemicals
Can be detected using Kidney Function
Test
−
Primary Nursing Diagnosis:
o Risk for infection related to impaired
primary and secondary defenses
3. Neoplasm of the Brain
TYPES
1. CEREBELLAR ASTROCYTOMAS
→ Slow-growing, cystic tumors
that arise from glial or
supporting tissue
surrounding neural cells
2. MEDULLOBLASTOMAS
→ Fast-growing tumor found
most commonly in the
cerebellum
→ Causes 4th ventricle
compression and
disturbances in the flow of
CSF
−
−
−
Confirmation Test
1) Bone marrow analysis
2) Liver function test
3) Chest and Abd’l CT SCAN/MRI
4) Lymphangiography (detects size and
location of deep nodes involved)
5) 5. Abd’l biopsy
Diagnostic Tests:
Therapeutic Management:
 Chemotherapy
 Radiation
 A stem cell transplant
 Medications
3. BRAINSTEM GLIOMAS
→ A cancerous glioma tumor in
the brainstem
→ Start in the brain or spinal
cord tissue and typically
spread throughout the
nervous system.
8
•
•
•
Form a preventive strategy for pain
management around the clock
Educate parents and child about
analgesics
Assist parents to formulate activities
that will not trigger or heighten
headache pain.
4. OTHER CHILDHOOD NEOPLASM
a. Neuroblastoma
→ Tumors that arise
from the cells of the
sympathetic nervous
system
−
−
−
−
Diagnostic Tests
• Neurologic exam
• CT
• MRI
• Angiogram
• Spinal tap
• Biopsy
Management
• Surgery
• Radiation therapy
• Chemotherapy
Nursing Diagnosis
• Acute pain
• Anxiety
• Risk for injury
• Fear r/t diagnosis of brain tumor
Assessment/Nsg. Mgt.
• PAIN, Assess the severity and
duration of a headache
• Use a pain assessment tool
appropriate for age and
developmental level to determine the
pain intensity
• Administer analgesic as prescribed
• Instruct the child to refrain from
sneezing, coughing, or straining,
during defection
• Apply a cool compress on the head
for low to moderate pain
• Provide toys, games for quiet play
−
Symptoms
−
b. Rhabdomyosarcoma
→ A tumor of straited
muscle
→ arises from the
embryonic
mesenchyme tissue
the form muscle,
connective, and
vascular tissue
Symptoms
c. Nephroblastoma (Wilms
Tumor)
→ A malignant tumor
that arises from the
metanephric
mesoderm cells of the
upper pole of the
kidney
9
→ Commonly seen in
kids from ages 3-4
and tends to occur
less frequently after
the age of 5
→ Most common kidney
cancer in children
−
−
−
−
Symptoms
• swelling in the abdomen
• pain in the abdomen
• mass in the abdomen which can be
felt
• fever
• hematuria or blood in the urine
Birth Defects & Risk Factors of Wilms
Tumor
• Aniridia
• Cryptorchidism
• Hypospadias
Assessment
• Tumor is felt as firm, nontender
abdominal mass
• Child’s abdomen should not be
palpated –may ais to metastasis.
Place a sign reading “No Abdominal
Palpation” over the child’s crib.
Therapeutic Management
 Tumor will be removed by
nephrectomy
 Followed by radiation therapy
 Chemotherapy –given for as long as
15 months
 Second surgical procedure may be
scheduled after 2 or 3 months to
remove any remaining tumor
−
Complications
 nephritis, small bowel obstruction,
hepatic damage caused by fibrotic
scarring from radiation can occur
 sterility in girls –radiation related
damage to the ovaries
 radiation to the lungs –interstitial
pneumonia
 spine radiation-scoliosis
d. Retinoblastoma
→ An eye cancer that begins in the retina –the
sensitive lining on the inside of your eye
− Symptoms
• A pupil that looks white or red,
instead of the normal black
• A crossed eye, which is an eye
looking either toward the ear or
toward the nose.
• Poor vision.
• A red, painful-looking eve
• An enlarged pupil.
• Different-colored irises
−
−
−
Diagnostic Tests
1. MRI
2. CT scan
3. Ultrasound (sonogram)
4. PET scan
5. X-ray
6. Biopsy
Management
a. Surgery
b. Radiation
c. Chemotherapy
Nursing Interventions
 Protect the skin receiving radiation
 Protect oral and gastro-intestinal
tract mucous membranes
 For diarrhea, switch to low-residue
diet and administer anti-diarrheas as
ordered
 Teach patient about risk infection
10
TOPIC 2
ALTERATION IN NUTRITION
I.
Objectives:
 Identify factors influencing nutrition.
 Discuss essential components and
purposes of nutritional assessment and
nutritional screening.
 Present nursing interventions to promote
optimal nutrition and to treat clients with
nutritional problems.
 Plan, implement ,and evaluate nursing care
associated with nursing diagnoses related
to nutritional problems.
Nutrition
→ the sum of all the interactions between an
organism and the food it consume.
Nutrients
→ are organic and inorganic substance s
found in foods that are required for body
functioning.
Factors Affecting Nutrition
1. Development
2. Gender
3. Ethnicity and Culture
4. Beliefs about Food
5. Personal Preferences
6. Religious Practices
7. Lifestyle
8. Economics
9. Medications and therapy
10. Health
11. Alcohol Consumption
12. Advertising
13. Psychological factors
Daily Food Guide
→ Both inadequate and excessive intakes of
nutrients result in malnutrition.
→ Malnutrition is commonly defined as the lack
of necessary or appropriate food
substances, but in practice includes both
undernutrition and overnutrition.
Overnutrition
→ a caloric intake in excess of daily
energy requirements, resulting in
storage of energy in the form of
adipose tissue.
National Heart, Lung, and Blood Institute
→ overweight = BMI is between 25 &
29.9 kg/m2 and obese when the
BMI is >30 kg/m2.
II.
Undernutrition
→ intake of nutrients insufficient to
meet daily energy requirements
because of inadequate food intake
or improper digestion and absorption
of food.
Inadequate food intake may be caused by:
 inability to acquire and prepare food
 inadequate knowledge about essential
nutrients and a balanced diet
 discomfort during or after eating
 dysphagia
 anorexia
 nausea
 vomiting
Improper digestion and absorption of nutrients
may be caused by:
 an inadequate production of hormones or
enzymes
 medical conditions
Inadequate nutrition can be associated with:
 marked weight loss
 generalized weakness
 altered functional abilities
 delayed wound healing
 increased susceptibility to
 infection
 decreased
 immunocompetence
 impaired pulmonary function
 prolonged length of
 hospitalization.
III.
Protein-calorie malnutrition (PCM)
 significant problem of clients with long-term
deficiencies in caloric intake
− Characteristics
1) depressed visceral proteins (e.g.,
albumin)
2) weight loss
3) visible muscle and fat wasting.
11
−
−
−
−
−
Nursing Management
→ A comprehensive nutritional
assessment.
• Components:
Anthropometric, Biochemical,
Clinical, Dietary
Nutritional Screening
→ an assessment performed to identify
clients at risk for malnutrition or
those who are malnourished.
Nursing History
1) Age, sex, and activity level
2) Difficulty eating
3) Condition of the mouth, teeth, and
presence of dentures
4) Changes in appetite
5) Changes in weight
6) Physical disabilities that affect
purchasing , preparing, and eating
7) Cultural and religious beliefs that
affect food choices
8) Living arrangements (e.g., living
alone) and economic status
9) General health status and medical
condition
10) Medication history.
Diagnosis
a) Imbalanced Nutrition: Less Than
Body Requirements
b) Obesity
c) Overweight
d) Readiness for Enhanced Nutrition
e) Activity Intolerance related to
inadequate intake of iron-rich foods
resulting in iron deficiency anemia
f) Constipation related to inadequate
fluid intake and fiber intake
g) Chronic Low Self-Esteem related to
obesity
h) Risk for Infection related to
immunosuppression secondary to
insufficient protein intake.
Planning
→ Maintain or restore optimal
nutritional status.
→ Promote healthy nutritional
practices.
→ Prevent complications associated
with malnutrition.
→ Decrease weight.
→ Regain specified weight.
ALTERATION IN GASTROINTESTINAL SYSTEM
Learning Objectives
At the end of the lecture discussion, students will
be able to:
 Reviewed the anatomy and physiology of Gl
system.
 Assess child with altered gastrointestinal
function.
 Describe common gastrointestinal disorders
seen in children.
 Utilize nursing process in the care of
children with gastrointestinal disorder.
12
−
−
−
−
−
Disorders Caused by Food, Vitamin,&
Mineral Deficiencies
1) Kwashiorkor
2) Nutritional Marasmus
3) Vitamins & Mineral Deficiencies
Gastro Intestinal Tract Disorder
(Nursing Process)
→ Assessment
 assessed for signs of fluid
loss
 compare the child's current
weight with past weight
measurements
 Refer
→ Nursing Diagnosis
1) Impaired parenting related to
interference with establishing
the parent-infant bond.
2) Interrupted family processes
related to a chronic illness in
child.
3) Risk for deficient fluid volume
related to chronic diarrhea.
4) Imbalanced nutrition, less
than body requirements,
related to malabsorption of
necessary nutrients
5) Situational low self-esteem
related to feelings of being
different resulting from
special dietary restrictions
Outcome Identification and Planning
→ Include the person who prepares or
supervises the child's nutrition when
helping plan a new nutritional pattern
for a child.
→ If feedings will be given by
nasogastric or gastrostomy tube,
parents need enough practice to be
proficient with the equipment and the
technique before they are given the
responsibility of doing it alone at
home.
Implementation
→ Parents need a great deal of support
to adapt their busy life to these
alternative methods of feeding or
care.
→ Be certain to give clear, simple
explanations and praise both
parents and child after they
demonstrate these procedures
Outcome Evaluation
→ Recording children's height and
weight.
→ making certain children gradually
learn more about their specific
nutritional measures.
Common Gastrointestinal Symptoms of Illness
in Children
1) Vomiting
2) Diarrhea (Mild, Severe)
3) Bacterial Infectious Diseases that Cause
Diarrhea & Vomiting
4) Protozoan or Viral Diarrhea
I.
VOMITING
→ Or throwing up is a forceful
discharge of stomach content
→ Recurrent vomiting may be caused
by underlying medical conditions
→ Is Vomiting Harmful?
Some examples of serious
conditions that may result in
nausea or vomiting include:
 Concussions
 Meningitis
 Intestinal blockage
 Appendicitis
 Brain tumors
 Dehydration
→ A concussion is a traumatic brain injury that
affects your brain function.
→ Effects are usually temporary but can
include headaches and problems with
concentration, memory, balance and
coordination.
→ Concussions are usually caused by a blow
to the head
→ Assessment: Differentiation Between
Regurgitation & Vomiting
• Vomiting is the ejection of contents
of the stomach and upper intestine
• Regurgitation is the ejection of
small amounts of chyme or gastric
juice from the mouth and antecedent
nausea.
13
→ Differentiation between normal
stool and diarrheal stool in an
infant
→ When to seek immediate medical
care?
• blood in the vomit (bright red or
"coffee grounds" in appearance)
• Severe headache or stiff neck
• Lethargy, confusion, or a decreased
alertness
• Severe abdominal pain
• Diarrhea
• Rapid breathing or pulse
→ Therapeutic Management
II. DIARRHEA
→ When stools (bowel movements) are
loose and watery.
→ Mild
→ Severe
→ Causes
• Bacterial infection.
• Viral infection.
• Trouble digesting certain
things (food intolerance)
• An immune system response
to certain foods (food
allergy).
• Parasites that enter the body
through food or water
• Reaction to medicines.
• An intestinal disease, such
as inflammatory bowel
disease.
→ Diarrhea may be either:
a. Short-term (acute)
• Diarrhea that lasts 1
or 2 days and goes
away.
• may be caused by
food or water that was
contaminated by
bacteria (bacterial
infection). Or it may
happen if your child
gets sick from a virus.
b. Long-term (chronic)
• Diarrhea that lasts for
a few weeks.
• May be caused by
another health
problem such as
irritable bowel
syndrome. Can also
be caused by an
Intestinal disease.
(ulcerative colitis,
Crohn's disease, or
celiac disease)
→ Symptoms:
 Cramping
 Belly (abdominal) pain
 Swelling (bloating)
 Upset stomach
 Urgent need to use the
bathroom
 Fever
 Bloody stools
 Loss of body fluid
 Incontinence
→ Diagnostic Test
 Stool evaluation
 Blood tests
 Imaging tests
 Stool culture
 Sigmoidoscopy
14
→ Sample Nursing Sample Nursing
Diagnoses and Related
Interventions
a. Nursing Diagnosis:
• Deficient fluid volume
related to loss of fluid
through diarrhea.
b. Related Interventions:
• Promote Hydration
and Comfort.
• Record Fluid Intake
and Output.
I.
GASTROESOPHAGEAL REFLUX
DISEASE (GERD)
→ A digestive disorder that affects the
ring of muscle between the
esophagus and stomach.
→ This ring is called the lower
esophageal sphincter (LES).
→ GERD occurs when stomach acid
frequently flows back into the tube
connecting the mouth and stomach
(esophagus).
→ This backwash (acid reflux) can
irritate the lining of the esophagus.
III. BACTERIAL INFECTIOUS DISEASES
THAT CAUSE DIARRHEA & VOMITING
a. Salmonellosis
b. Listeriosis
c. Shigellosis (Dysentery)
d. Staphylococcal Food
Poisoning
IV. PROTOZOAN OR VIRAL DIARRHEA
Common Disorder of the Stomach and
Duodenum
1) Gastroesophageal Reflux Disease
2) Pyloric Stenosis
3) Peptic Ulcer Disease
4) Hepatic Disorders:
→ Hepatitis
a. Нера А, B, C, D, E
b. Acute Hepatis
c. Chronic Hepatitis
d. Fulminant Hepatic Failure
5) Obstruction Of The Bile Ducts
6) Nonalcoholic Fatty Liver Disease &
Cirrhosis
a. Esophageal Varices
7) Liver Transplantation
→ (stomach acid) Hydrochloric acid in
the gastric juice breaks down the
food and the digestive enzymes
split up the proteins.
→ Diagnostic workup may include the
following:
a) Upper Gl series
b) pH probe
c) Esophageal manometry
d) Endoscopy
15
−
−
−
−
−
Therapeutic Management
 conservative treatment
 medication
 surgery
 In infants, it is treated by feeding a
thickened formula and keeping the
infant upright after feedings. •
Adolescents are prescribed a proton
pump inhibitor and advised to sleep
with two pillows.
→ avoid lying down until 3 hours after a
meal
→ sleep at night with their upper body
elevated on a foam wedge or extra
pillow. avoid acidic foods
→ Avoiding foods that delay gastric
emptying such as fatty foods,
chocolate, or alcohol losing some
weight if overweight
→ avoid bending over after meals
→ Remove tight belts
Risk factors
• cerebral palsy
• Down syndrome cystic fibrosis
• Obesity
• Typical symptoms
 heartburn that occurs 30 to
60 minutes after a meal and
regurgitation.
Common symptoms of GERD include
1. Burping or belching
2. Not eating
3. Having stomach pain
4. Being fussy around mealtimes
5. Vomiting often
6. Having hiccups
7. Gagging
8. Choking
9. Coughing often
10. Having coughing fits at night
Therapy:
→ In many cases, GERD can be eased
by diet and lifestyle changes.
→ Sometimes medicines, tube
feedings, or surgery may be needed.
For babies:
→ After feedings, hold the baby in an
upright position for 30 minutes.
→ If bottle-feeding, keep the nipple
filled with milk. This way the baby
won't swallow too much air while
eating. Try different nipples. Find
one that lets the baby's mouth make
a good seal with the nipple during
feeding.
II. PYLORIC STENOSIS
→ an uncommon condition in infants
that blocks food from entering the
small intestine.
→ Thickening and abnormal
enlargement of the pylorus
muscles, blocking food from
reaching the small intestine.
−
−
−
→ Pyloric stenosis can lead to forceful
vomiting, dehydration and weight
loss.
→ Babies with pyloric stenosis may
seem to be hungry all the time.
Surgery cures pyloric stenosis.
→ Cause:
• Unknown, but genetic and
environmental factors might
play a role
Risk factors
• Sex
• Race
• Premature birth
• Family history
• Smoking during pregnancy
• Early antibiotic use
• Bottle-feeding
→ Infantile hypertrophic pyloric
stenosis is 5 times more common in
male infants
Complications:
1. Failure to grow and
2. develop
3. Dehydration
4. Stomach irritation
5. Jaundice
When to see a doctor
 Projectile vomits after feeding
 Seems less active or unusually
irritable
 Urinates much less frequently or has
noticeably fewer bowel movements •
 Isn't gaining weight or is losing
weight
16
−
−
−
III. PEPTIC ULCER DISEASE
→ a shallow excavation formed in the
mucosal wall of the stomach, the
pylorus, or the duodenum.
→ Includes gastritis (irritation of the
lining of the stomach or duodenum)
−
Cause:
 Helicobacter Pylori infection
 NSAIDs (Diclofenac, Indomethacin,
Ibuprofen)
 Alcohol, Caffeine
Common Signs of a Stomach Ulcer:
 A dull burning or gnawing ache in
the stomach
 Gas and bloating
 Nausea or vomiting
 Loss of appetite
 Fatigue
Symptoms:
 Burning
 Fatigue
 Heartburn
 Loss of appetite
 Vomiting
 Nausea
 Bloating
 Burping
 Weight loss
 Dull pain
Diagnostic
→ History
• Epigastric abdominal pain,
postprandial
• For patients <60 without
alarm features, in regions
with I.
• Pylori prevalence > 20%
• Other patients, patients 260,
patients with alarm features
→ Test and treat for H. Pylori
→ Endoscopy with ulcer biopsy
17
−
−
−
Drug Therapy
→ Antacids
• Used as adjunct therapy for
peptic ulcer disease
• ↑ gastric pH by neutralizing
acid
→ Anticholinergic drugs
• Occasionally ordered for
treatment
• ↓ cholinergic stimulation of
HCI acid
Management
The objectives of management are to:
 relieve pain and discomfort
 accelerate healing
 prevent recurrence and
complications
Treatment
 If the ulcer is related to H. pylori, the
doctor will prescribe a combination
of drugs to eradicate the infection
and normalize gastric acid levels so
that the stomach can heal.
 Diet > foods that are easily digested
and place little stress on the
stomach
→ Vaccines to hepatitis A and B are
available and are routinely given to
children.
IV. HEPATITIS
→ "Hepatitis" means inflammation of
the liver
→ Can be caused by:
a) Genetic diseases
b) Medications (including overthe-counter)
c) Alcohol
→ Hepatitis viruses (A,B,C, D, E)
−
Signs and Symptoms of HCV
• When patients develop
symptomatic acute HCV infection,
they most often present with dark
urine and light colored stools,
followed by jaundice in which the
skin and whites of the eyes appear
yellow
• Itching of the skin may be present.
• On average, symptoms appear 6 to
7 weeks after infection
18
−
−
Chronic Hepatitis
→ Chronic hepatitis is defined as
continuing or relapsing hepatic
disease for more than 6 months,
with presence of symptoms and
other diagnostic parametersserology, biochemical and
histopathology
→ Fulminant hepatic failure is a
clinical syndrome resulting from
massive necrosis of hepatocytes or
from severe functional impairment of
hepatocytes
→ Synthetic, excretory, and detoxifying
functions of the liver are all severely
impaired.
Patterns of Hepatitis:
1) Acute hepatitis: if its manifestation
persist for period less than six
months
2) Chronic hepatitis: if there is clinical
or serological evidence of liver
pathology persistent for more than
six consequent months.
3) Fulminant hepatitis: if massive
hepatic cell necrosis happened
within few weeks leading to acute
hepatic failure and hepatic
encephalopathy
4) Carrier state: is an individual who
harbor and can transmit the virus but
has no manifest symptoms.
→ the blockage of any duct that carries
bile from the liver to the gallbladder
or from the gallbladder to the small
intestine
→ this can occur at various levels
within the biliary system.
→ the major signs and symptoms of
biliary obstruction result directly from
the failure of bile to reach its proper
destination.
−
Possible causes of a blocked bile duct include:
• Cysts of the common bile duct.
• Enlarged lymph nodes in the portal
hepatis
V. OBSTRUCTION OF THE BILE DUCTS
→ A biliary obstruction is a blockage
of the bile ducts
19
VII. LIVER TRANSPLANTATION
VI. Non Alcoholic Fatty Liver Disorder
(Esophageal Varices)
→ abnormally enlarged veins in the
lower part of esophageal tube
−
−
−
The main causes of portal hypertension in
children:
a. portal vein thrombosis or cirrhosis
Treatment options:
• Endoscopic
• Radiographic
• surgical strategies
−
−
−
Cirrhosis
→ General Signs associated with liver
disease:
1. Jaundice
2. Clubbing
3. Palmar erythema
4. Spider nevi
5. Hepatomegaly
6. Gynaecomastia
7. Testicular atrophy
8. Caput medusae
Preoperative Care
• nursing history and physical
examination.
• Provide routine preoperative care.
• Discuss preoperative and
postoperative expectations with the
client and family
• Once a donor liver is located, check
for evidence of infection; if no
infection is present. begin
preoperative antibiotics as ordered.
Postoperative Care
• Routine postoperative care
• Maintain airway and ventilatory
support until awake and alert.
• Frequently monitor hemodynamic
pressures, including arterial BP,
central venous pressure, and
pulmonary artery pressures. Monitor
for signs of active bleeding.
Provide discharge teaching:
a. Teach how to reduce risk of
infection, and signs of infection to
report.
b. Instruct to recognize and report
signs of organ rejection.
c. Discuss all medications.
d. Discuss possible changes in body
image and psychologic responses to
receiving a transplanted organ.
Refer to a counselor or support
group as indicated.
e. Refer for home health services for
continued assessment and teaching.
f. Stress importance of continued
follow-up with transplant team and
primary care provider.
20
Intestinal Disorders
1) Intussusception
2) Volvulus with malrotation
3) Necrotizing enterocolitis
4) Short Bowel/Short -Gut Syndrome
5) Appendicitis
a. Ruptured Appendicitis
6) Meckel's Diverticulum
7) Celiac Disease (Malabsorption
syndrome, Gluten-Induced
Enteropathy, Celiac Sprue)
I.
INTUSSUSCEPTION
→ Intussusception of the bowel is
defined as the telescoping of a
proximal segment of the
gastrointestinal tract within the
lumen of the adjacent segment
II. VOLVULUS WITH MALROTATION
→ Malrotation occurs when the
intestine does not make the turns as
it should.
→ Volvulus is a problem that can occur
after birth as a result of intestinal
malrotation.
−
Etiology:
21
−
−
Ladd Procedure
Types:
1. Midgut Volvulus
2. Cecal Volvulus
3. Sigmoid Volvuluis
−
Midgut volvulus Malrotation
−
Symptoms:
• Vomiting bile †greenish-yellow
digestive fluid)
• Drawing up the legs
• Pain in the abdomen (belly)
• Abdominal distention (swelling)
• Rapid heart rate
• Rapid breathing
• Bloody stools
• Malnutrition
• Slowed growth
Diagnostic Test (Adbml UTZ)
−
III. NECROTIZING ENTERO COLITIS (NEC)
→ is a devastating disease that affects
mostly the intestine of premature
infants.
−
−
Symptoms: STAGE 1
 suspected NEC
 bloody stools
 diminished activity (lethargy)
 slow heart rate
 an unstable temperature mild
abdominal bloating vomiting.
Symptoms: STAGE 2
 definite NEC
 symptoms of stage 1
 slightly reduced blood platelet levels
 slight excess of lactic acid
 no bowel sounds
 pain when the abdomen is touched
 reduced or no intestinal movement
 growth of gas-filled spaces in the
walls of the intestine.
22
−
−
Treatment:
a) Primarily supportive care.
 Enteral feeds, gastric
decompression with
intermittent suction fluid
repletion to correct electrolyte
abnormalities, parenteral
nutrition and prompt
antibiotic therapy.
b) Monitoring is clinical.
 Abdominal roentgenograms
should be performed every 6
hours.
c) Bowel perforation.
 Emergency surgery to resect
the dead bowel.
 Colostomy - which may be
able to be reserved at a later
time
 Short bowel syndrome malabsorption caused by the
surgical removal of small
intestines.
Management, Surgical
→ Early Surgical Consultation
→ Indications for surgery:
 Perforation:
20-30 % of cases
12-48 hrs after onset
 Full-thickness necrosis
 Deterioration despite
aggressive medical treatment
V. APPENDICITIS
→ where the appendix becomes
swollen, inflamed, and filled with
pus.
1) McBurney’s Point: The junction of the
lateral and middle third of the line joining the
right anterior superior iliac spine and the
umbilicus. typically, this area is of greatest
discomfort in acute appendicitis.
IV. SHORT BOWEL -GUT SYNDROME
−
Treatment:
 Mild Short Bowel Syndrome:
1. eating small, frequent meals
2. drinking fluid
3. taking nutritional
supplements
4. using medications to treat
diarrhea
 Moderate Short Bowel Syndrome:
1. similar to that for mild short
bowel syndrome, with the
addition of parenteral
nutrition as needed.
2) Psoas Sign: Irritation of the psoas muscle
caused by active right thigh flexion or
passive right hip extension in patients with
appendicitis. The psoas sign. Pain on
passive extension of the right thigh. Patient
lies on left side. Examiner extends patient's
right thigh while applying counter resistance
to the right hip (asterisk).
23
3) Obturator Sign: Irritation of the obturation
muscle caused by passive internal rotation
of the right thigh in patients with
appendicitis. Inflamed appx is in pelvis, in
contact with obturator muscle.
4) Rovsing's Sign: Palpation of the left lower
quadrant causes pain at the right lower
quadrant in patients with appendicitis.
−
−
Symptoms:
 Sudden pain on the right side of
abdomen
 Vomiting
 Fever
 Abdominal bloating
 Constipation or diarrhea
 Loss of appetite
Management:
 Surgery is indicated if appendicitis is
diagnosed.
 To correct or prevent fluid and
electrolyte imbalance and
dehydration, antibiotics and
intravenous fluids are administered
until surgery is performed.
 Analgesics can be administered
after the diagnosis is made.
(Morphine sulphate 10 mg/ml)
 Antibiotics
o Cefotaxime 250mg, 500mg
o Levofloxacin 500 mg
24
o
Metronidazole 500mg/100ml,
400 mg tablet
−
−
−
−
−
Ruptured Appendicitis
→ A rupture spreads infection
throughout the abdomen
(peritonitis).
→ requires immediate surgery to
remove the appendix.
→ Symptoms:
 Nausea
 Vomiting
 Diarrhea
 Constipation
 Appetite loss
 Swelling in the abdomen
 Fever
 Pain in the lower right
abdomen
Acute Appendicitis Signs
1. RIF Tenderness in McBurney’s point
2. RIF Rebound Tenderness, Release
tenderness or Blumberg's sign
3. Guarding/Rigidity
4. Cope's Psoas Test
5. Cope's Obturator Test
6. Rovsing's Sien
7. Hyperesthesia in Sherren's Triangle
−
Clinical Presentation
→ Majority of Meckel's diverticuli are
clinically silent (Asymptomatic)
Symptoms
a) Severe hemorrhage
b) Intussusception
c) Meckel's diverticulitis
d) Chronic peptic ulceration
e) Intestinal obstruction
Nursing Management: (newborn)
 Symptoms:
 Bleeding, anemia, severe colicky
abdominal pain
 Abdominal distention, hypoactive
bowel sounds, guarding,
abdominal mass, rebound
tenderness
 Administer ordered blood products and
IV fluids
 Maintain NPO status
 Perform postoperative care and family
education
Surgery:
VII. CELIAC DISEASE
→ a digestive disorder that damages
the small intestine, triggered by
eating foods containing gluten
VI. MECKEL'S DIVERTICULUM
→ most common congenital defect of
the GIT
→ an abnormal pouch of tissue on the
small intestine.
25
→ Skin
Brittle nails
Ache or eczema
→ Stomach
Pain and nausea
→ Intestinal
Diarrhea
Bloating
Constipation
→ In female
Infertility
Miscarriage
Early menopause
→ Mouth
Ulcer and tooth enamel erosion
→ Joint and muscle
Pain and swelling
 Lactose intolerance
 Anemia
 Dizziness
 Migraines
 Depression
 Low vitamin D
 Chronic fatigue
−
−
→ inherited condition that prevents the
small intestine from absorbing
nutrients, causing malnutrition.
→ Gluten, a protein found in some
grains. stimulates immune system
antibodies. Antibodies attack.
damage lining of small intestine.
Celiac disease, Endothelial cells,
Villi, microvilli are damaged by
body's reaction to gluten.
Symptoms:
 Diarrhea
 Malnutrition
 weight loss
 skin rash
 some people have no symptoms
−
Management
 Dietary
 Complete elimination of glutencontaining grain products (including
wheat, rye, and barley)
 Children must follow a gluten-free diet
for life.
Benefits of a Gluten-Free Diet
 Lowers the risk of intestinal distress
 Controls the itching connected to
dermatitis herpetiformis
 Can possibly lower death risk when
followed from under the age of two
26
BRISTOL STOOL CHART
−
Gluten Free Substitutes
1) Grains (avoid wheat barley and rye)
2) Dairy (plain milk, cheese, yogurt)
3) Beans
4) Fish
5) Meat
6) Fruits
7) Vegetables
−
CONSTIPATION
→ refers to bowel movements that are
infrequent or hard pass. The stool is often
hard and dry.
Etiology
→ Congenital:
a) Anorectal defects
b) Neurogenic
c) Colonic neuropathies
d) Colonic defects
→ Acquired:
a) Functional
b) Anal lesions
c) Neurologic conditions
d) Metabolic
e) Endocrine
f) Drug induced
g) Low fiber diet
h) Psychiatric problems
SEVERE
CONSTIPATION
TYPE 2
Lumpy and
sausage like
MILD
CONSTIPATION
A sausage
shape with
cracks in the
surface
NORMAL
like a smooth,
soft sausage
or snake
NORMAL
Soft blobs
with clear-out
edges
LACKING
FIBRE
TYPE 3
Disorders of the Lower Bowel
1) Constipation
2) Inguinal Hernia
3) Hirschsprung Disease (Aganglionic
Megacolon)
4) Inflammatory Bowel Disease
a. Ulcerative Colitis
b. Crohn Disease
5) Irritable Bowel Syndrome
6) Chronic Recurrent Abdominal Pain
I.
TYPE 1
Separate
hard lumps
TYPE 4
TYPE 5
−
TYPE 6
Mushy
consistency
with ragged
edges
MILD
DIARRHEA
TYPE 7
Liquid
consistency
with no solid
pieces
SEVERE
DIARRHEA
Management
 foods high in fiber
 non-stimulant laxatives
 stimulant laxatives
 enemas
 suppositories
 biofeedback training
 prescription medications
 surgery
27
−
−
Nursing Intervention
1. Increase fluid intake.
2. Laxative fluids (e.g., orange juice relives
mild constipation)
3. Small soapy enema may be given.
4. Milk of magnesia may be used as a
temporary measure.
5. Establish or maintain regular bowel action
by nature means rather than using
purgatives.
6. 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.
II. INGUINAL HERNIA
→ a protrusion of abdominal-cavity contents
through the inguinal canal.
→ symptoms are present in about 66% of
affected people.
−
−
Signs and Symptoms
→ Many hernias present no problem,
showing a painless swelling that gives
no symptoms, which may be worse
when standing, straining, or lifting heavy
items.
→ Immediate medical attention should be
sought if an inguinal hernia produces
acute abdominal complaints such as:
a) Pain
b) Nausea
c) Vomiting.
d) The swelling in these cases is
typically firm and tender and cannot
usually be reduced
e) Hiatal hernia can produce
symptoms of acid reflux - producing
heartburn when stomach acid gets
into the esophagus.
Management
→ Inguinal hernias should always be
repaired (herniotomy, herniorrhaphy)
unless there are specific
contraindications.
→ Types of operations:
a) a permanent suture, as in Shouldice
repair (layered suture).
b) a permanent mesh -greater
frequency to decrease tension.
→ Inguinal hernia can occur in
children. It is surgically
corrected when recognized.
III. HIRSCHSPRUNG DISEASE
→ Also known as congenital aganglionic
megacolon.
→ Is an absence of ganglionic innervation to
the muscle of a section of the bowel—in
most instances, the lower portion of the
sigmoid colon just above the anus.
→ This results in chronic constipation or
ribbonlike stools.
−
→ Congenital agenesis of ganglion cells of
distal colon
Clinical
• Failure to pass meconium
• Constipation/Intermittent loose stool
• Bilious vomiting, poor PO intake,
abdominal distension
• Enterocolitis (toxic megacolon)
complication
28
−
−
−
−
−
Diagnosis
• Rectal biopsy (gold standard)
• Contrast enema (presence of transition
zone)
Management
• Surgical excision of aganglionic
segment
• Colostomy with subsequent end-to-end
anastomosis
Clinical Manifestations
1. Failure to pass meconium within 24
hours
2. Constipation during first month of life
3. Bile-stained emesis
4. Abdominal distension
5. Distended abdomen
6. Reluctance to eat
7. Failure to thrive
8. V/D; stool w/ ribbon-like appearance
Diagnostic evaluation
1. Rectal exam
2. Barium enema or ultrasound
3. Biopsy of the affected segment or
4. Anorectal manometry
Therapy
→ may involve a temporary colostomy followed
by surgery in 6 to 12 months to remove the
affected bowel portion
−
−
−
−
−
IV. INFLAMMATORY BOWEL DISEASE (IBD)
→ is an umbrella term used to describe
disorders that involve chronic inflammation
of the digestive tract.
−
Crohn's Disease
→ may affect any part of the digestive system
from mouth to anus. All layers of the lining
of the bowel may be inflamed.
Ulcerative Colitis
→ affects the large intestine, which is made up
of the rectum and colon. Only the inner
lining of the bowel is inflamed.
Signs & Symptoms
→ Ulcerative colitis
• Attack of diarrhea
• Rectal bleeding
• Abdominal cramps
→ Crohn's disease
• Recurrent diarrhea
• Abdominal pain
• Anorexia
• Unexplained fever
• Malaise
• Arthritis
• Weight loss
Management
 Mild to moderate symptoms
 oral medication, vitamins and
mineral deficiencies should
be corrected.
 Severe cases
 bowel rest, enteral or total
parenteral nutrition
Non-pharmacological therapy:
 Avoid anti-diarrheal meds,
anticholinergics, opiates and
NSAIDs.
 Address diet case-by-case.
 Vit D and Ca supplementations in all
pts on steroids.
 Surgery case by case
Therapy
• Long term
• If medical therapy is unsuccessful,
portions of the bowel may be surgically
removed.
29
V. IRRITABLE BOWEL SYNDROME (IBS)
→ a common disorder that affects the large
intestine.
→ a chronic condition that need to manage
long term.
− Signs & Symptoms
• Cramping
• abdominal pain
• bloating
• gas
• diarrhea or constipation, or both
− Causes
1. Diet
2. Intolerance to Food Items
3. Mental Ailments
4. Infections
5. Emotional Stress
6. GI Motor Problems
−
−
Inflammatory Bowel Disease
• Classified as a disease
• Inflammatory condition
• Can cause hospitalization and/or need
for surgery
• Can cause permanent damage to
intestines
• Doctors can diagnose with exam and
imaging
• Risk factor for colon cancer
• Treated with anti-inflammatory drugs or
surgery
Irritable Bowel Syndrome
• Classified as a syndrome set of
symptoms)
• Non-inflammatory condition
• Rarely requires hospitalization or
surgery
• Doesn't cause permanent damage to
intestines
• Exam and imaging don't show clinical
signs of disease
• Not a risk factor for colon cancer
• Diet is the primary treatment
VI. CHRONIC RECURRENT ABDOMINAL PAIN
→ Chronic abdominal pain
- pain of at least three months
duration, although some
clinicians consider pain of more
than one to two months' duration
to be chronic.
→ Recurrent abdominal pain
- one of the most common
recurrent pain syndromes in
childhood. The classic definition
is based upon four criteria:
1. History of at least three
episodes of pain
2. Pain sufficiently severe to
affect activities
3. Episodes occur over a period
of three months
4. No known organic cause
→ Recurrent (Chronic) Abdominal Pain
- Recurrent abdominal pain is
defined as the occurrence of
multiple episodes of abdominal
pain over at least 3 months that
are severe enough to cause
some limitation of activity.
- Recurrent abdominal pain is a
common problem in children,
affecting more than 10% of
children at some time during
childhood.
- The peak incidence occurs
between ages 7 and 12 years.
- Although the differential
diagnosis of recurrent abdominal
pain is fairly extensive, most
children with this condition are
not found to have a serious (or
even identifiable) underlying
illness causing the pain.
Disorder Caused by Food, Vitamin and Mineral
Deficiencies
1) Kwashiorkor
2) Nutritional Marasmus
3) Vitamins & Mineral Deficiencies
I.
PROTEIN ENERGY MALNUTRITION
(PEM)
→ Marasmus was thought to result
primarily from inadequate energy
intake, whereas kwashiorkor was
thought to result primarily from
inadequate protein intake.
→ Marasmic kwashiorkor, has features of
both disorders (wasting and edema).
30
−
Types of Malnutrition
−
Kwashiorkor
→ a form of severe protein malnutrition
characterized by edema and an
enlarged liver with fatty infiltrates.
→ It is caused by sufficient calorie intake.
Symptoms
 failure to grow or gain weight.
 edema (swelling) of the ankles, feet, and
belly.
 damaged immune system, which can
lead to more frequent and severe
infections.
 irritability.
−
−
II. NURITIONAL MARASMUS
→ a severe form of protein-energy
malnutrition that results when a
person does not consume enough
protein and calories.
Signs & Symptoms
31
TOPIC 3
ALTERATION IN ENDOCRINE
OR METABOLIC FUNCTION
III. VITAMIN E MINERAL DEFICIENCES
Vitamin A
Lack of yellow
vegetables in diet
Tender tongue, cracks at
corners of mouth, night
blindness
Xerophthalmia (dry and
lusterless conjunctivae)
Keratomalacia (necrosis of
the cornea with perforation,
loss of ocular fluid, and
blindness)
Vitamin B1
Most common in
children who cat
polished rice as
dietary staple
because B, is
contained in hull of
rice
Beriberi (tingling and
numbness of extremities,
heart palpitations,
exhaustion)
Diarrhea and vomiting
Aphonia (crying without
sound)
Anesthesia of feet
Niacin
Common in children
who cat corn as
dietary staple
because corn is low
in niacin
Pellagra (dermatitis,
resembles a sunburn),
diarrhea, mental confusion
(dementia)
Vitamin C
Lack of fresh fruits
in diet
Scurvy (muscle tenderness,
petechiae)
Vitamin D
Lack of sunlight
Poor muscle tone, delayed
tooth formation
Rickets (poor bone
formation)
Craniotabes (softening of the
skull)
Swelling at joints, particularly
of wrists and cartilage of ribs
Bowed legs, tetany (muscle
spasms)
Learning Outcomes :
 Review the structure and function of the
endocrine glands and why metabolic
illnesses occur.
 Identify metabolic & endocrine disorders
 Assess a child with a disorder of endocrine
or metabolic dysfunction.
 Formulate nursing diagnoses for a child with
altered endocrine or metabolic dysfunction.
 Establish expected outcomes for a child
with endocrine or metabolic dysfunction.
 Implement nursing care for a child with
endocrine or metabolic dysfunction.
 Evaluate expected outcomes for
achievement and effectiveness of care.
The word hormone is from the Greek
hormaein ,which means “to set in motion.”
32
Endocrine & Metabolic Disorder
I.
PITUITARY GLAND DISORDERS
1. Growth hormone deficiency
2. Growth hormone excess
3. Diabetes insipidus
Function of the pituitary gland:
• Anterior Pituitary Gland
a) GH
b) TSH
c) ACTH
d) FSH
e) LH
f) PROLACTIN
• Posterior Pituitary Gland
a) Oxytocin
b) ADH
−
−
GH Deficiency
→ The cause of the defect is unknown; it may
have a genetic origin.
→ A pituitary tumor must be ruled out as the
cause of decreased GH production
→ Results in extremely short stature if left
untreated
• Therapeutic Management
 Administration of intramuscular
recombinant human growth hormone
(rhGH)
 Usually given daily at bedtime, the time
of day at which GH normally peaks
GH Excess
→ There is an overgrowth of body tissues
→ Usually is caused by a benign tumor of the
anterior pituitary (an adenoma)
•
Diagnostic Test:
 CBC
→ erythrocyte sedimentation rate
(ESR);
→ electrolytes and general health
chemistry panel
→ urinalysis
→ serum for thyroid function
studies,
 ESR
→ is a type of blood test that
→ measures how quickly
erythrocytes (red blood cells)
settle at the bottom of a test tube
that contains a blood sample.
− Diabetes Inspidus
→ Extreme thirst or appetite may occur
→ Therapy is the administration of
desmopressin, an arginine vasopressin.
(Pituitary gland produces insufficient ADH, hence
the kidneys make a lot of urine)
• Assessment
 Frequent voiding in children most often
reflects a urinary tract infection, but it
may be evidence of excessive urine
excretion (polyuria), possibly from
pituitary dysfunction or diabetes mellitus.
 A child’s general appearance may reveal
early or late puberty changes, scaling or
dry or darkening skin, drooping eyelids,
protrusion of the eyeballs.
II.
THYROID GLAND DISORDERS
1. Congenital Hypothyroidism
2. Acquired Hypothyroidism (Hashimoto
Thyroiditis)
3. Hyperthyroidism (Graves Disease)
Function of the thyroid gland:
a) It plays a major role in the metabolism,
growth and development of the human
body.
b) Thyroxine - controls metabolic rate
c) Calcitonin - lowers blood calcium levels
Functions of Thyroid Hormone:
1) Metabolic: increases cellular oxygen
consumption and heat production in part by
stimulating Na+/K+ ATPase
2) Cardiovascular: marked positive inotropic
and chronotropic effects on heart
3) Sympathetic: increases number of alpha
and beta-adrenergic receptors in heart
muscle and beta receptors in skeletal
muscle, adipose tissue, and lymphocytes
4) Respiratory: maintains normal hypoxic and
hypercapneic drive in medullary respiratory
center
5) Hematopoietic effects: stimulates
secretion of Epo to increase BC synthesis
33
−
•
Congenital Hypothyroidism
• (Cretinism) occurs as a result of an absent
or nonfunctioning thyroid gland.
• The condition is discovered by a blood spot
test at birth
• Therapy: oral administration of synthetic
thyroid hormone
• The symptoms of the disorder become
apparent during the first 3 months of life in a
formula-fed infant and at about 6 months in
a breastfed infant.
−
•
−
Almost all cases identified through
Neonatal Screening
 Clinical
- Constipation
- Hypotonia
- Hoarse cry
- Macroglossia
 Delayed treatment can lead to:
- Learning disabilities
- Cognitive deficits
- Clumsiness
- Diminished fine motor skills
• Therapeutic Management
 Oral administration of synthetic
thyroid hormone (sodium
levothyroxine) a small dose is given
at first, and then the dose is
gradually increased to therapeutic
levels.
Acquired Hypothyroidism
• (Hashimoto disease) is an autoimmune
phenomenon that interferes with thyroid
gland function.
• Therapy: administration of synthetic thyroid
hormone.
Symptoms of hypothyroidism in children
 Short stature or slow growth
 Rough, dry skin
 Cold intolerance
 Fatigue
 Bruising easily
 Delayed puberty
→ The excretion of thyroid-stimulating
hormone (TSH) from the pituitary increases
when thyroid hormone
→ production decreases in an attempt by the
pituitary gland to increase thyroid function.
→ in response to the increased level of TSH,
hypertrophy of the thyroid gland (goiter) can
occur,
→ and body growth is impaired by a lack of T4,
with prominent symptoms of obesity,
lethargy,
→ and delayed sexual development
• Therapeutic Management
 Administration of synthetic thyroid
hormone (sodium levothyroxine)
Hyperthyroidism
• (Graves Disease) caused by
overproduction of thyroid hormones. It leads
to jitteriness and tachycardia. Treated by
medication to suppress thyroxine release.
• in children is caused by an autoimmune
reaction that results in overproduction of
immunoglobin G (IgG)
III.
ADRENAL GLAND DISORDER
1. Acute Adrenocortical insufficiency
2. Congenital Adrenal Hyperplasia
3. Cushing Syndrome
→ also known as suprarenal glands
→ Adrenal glands secrete hormones which
help regulate stress and metabolism and
supplement other glands
→ Fight or Flight Response
- A reflex response which is designed
to help individual manage physically
when under stress.
- Activated in times of stress as the
body perceive stress as a threat.
34
secreted by the pituitary increases in an
attempt to stimulate the gland to increase
function.
→ Although the adrenals enlarge (hyperplasia)
under the effect of ACTH, they still cannot
produce cortisol; instead, they overproduce
androgen.
-
−
Physical Indications of Fight or Flight
Response
 dilated pupils
 trembling
 pale or flushed skin
 rapid heart beat and breathing
Acute Adrenocortical Insufficiency
→ an emergency situation in which there is
abrupt nonfunction of the adrenal glands.
→ Usually, this occurs following a severe
overwhelming body infection such as
meningococcemia.
→ can occur in either an acute or chronic form.
•
−
Assessment
 BP drops to extremely low levels
 May appears ashen gray, and the
pulse will be weak.
 Temp. gradually becomes elevated
 dehydration and hypoglycemia
 seizures may occur.
• Therapeutic Management
 Immediate replacement of cortisol
 Administration of
deoxycorticosterone acetate (DOCA)
 IV 5% glucose in normal saline
solution
Congenital Adrenogenital Hyperplasia
→ Abnormalities in specific enzyme of the
adrenal gland that causes severe salt lose,
dehydration and abnormally high levels of
male hormones in both boys and girls.
→ Therapy: administration of hydrocortisone
and also aldosterone if sodium loss is
present.
→ a syndrome that is inherited as an
autosomal recessive trait and which causes
the adrenal glands is not able to
synthesize/produce cortisol.
→ Because the adrenal gland is unable to
produce cortisol , the level of
adrenocorticotropic hormone (ACTH)
−
→ Salt-wasting Congenital adrenogenital
hyperplasia
- adrenal glands make too little
aldosterone, causing the body to be
unable to retain enough sodium
(salt).
- Too much sodium is lost in urine
(thus the name, "salt-wasting").
• Assessment
 genital organs in a male fetus to
"overgrow," or increase in size
 masculinizes a female fetus if the
labia are fused, she appears to be a
boy with undescended testes and
hypospadias
• Therapeutic Management
 Replace the cortisol that is missing
 corticosteroid agent
Cushing Syndrome
→ caused by the overproduction of cortisol by
the adrenal gland, which is usually caused
by a tumor in the gland.
→ Children appear abnormally obese.
→ Therapy is the surgical removal of the tumor
35
−
•
IV.
Type 1 Diabetes Mellitus
→ an autoimmune process that destroys
insulin production islet cells.
→ An acute loss in weight is often the first
symptom
→ Therapy is a combination of insulin, diet,
and exercise.
Therapeutic Management
a) Treatment: surgical removal of the
causative tumor
b) Prognosis depends on whether the
tumor is benign or malignant
because a carcinoma of this type
trends to metastasize rapidly.
c) If a major part of the adrenal glands
are surgically removed, the child will
need replacement cortisol therapy
indefinitely.
PANCREATIC DYSFUNCTION
1. Type 1 diabetes mellitus
2. Type 2 diabetes mellitus
3. Cystic fibrosis
36
•
−
Therapeutic Management
 Insulin administration
 Regulation of nutrition and exercises
 Stress management
 Blood glucose and urine ketone
monitoring.
Type 2 Diabetes
→ Sometimes called a “lifestyle” disease.
→ May be revealed by being overweight
→ Therapy: diet, exercises, and an oral
anti glycemic agent.
•
Two diagnostic tests used to confirm
diabetes:
 Fasting blood glucose test
 Random blood glucose test
→ Role of insulin in the body
1. Insulin helps your body turn blood
sugar (glucose) into energy.
2. It also helps your body store it in
your muscles, fat cells, and liver to
use later, when your body needs it.
•
Laboratory Studies
 Laboratory studies usually show a
random plasma glucose level
greater than 200 mg/dl
 Normal range, 70 to 110mg/dl
fasting; 90 to 180mg/dl not fasting
and significant glycosuria.
37
−
Gestational Diabetes
→ condition in which blood sugar (glucose)
levels become high during pregnancy and
usually disappears after giving birth
•
•
−
Complications
- Fetal risks
 Excessive birth weight
 Jaundice: baby with yellow
skin
 Hypoglycemia (Their own
insulin production is high as
mother gave them lots of
glucose)
 Higher risk of type I diabetes
later in life (Breastfeeding
may lower the risk)
Cystic fibrosis
→ is a hereditary disease that affects the lungs
and digestive system.
→ The body produces thick and sticky mucus
that can clog the lungs and obstruct the
pancreas.
→ Cystic fibrosis (CF) can be life-threatening,
and people with the condition tend to have a
shorter-than-normal life span.
Cystic fibrosis and your child's body
a) Children with CF have a high ratr of
sinus infection.
b) In 90% of children with CF, the
pancreatic duct is blocked.
c) The lack of sufficient pancreatic
enzymes leads to the malabsorption
of nutrients.
d) Cross section thru bronchus (Normal
airway); thin layer of mucus
e) (Airway with CF) bacterial infection,
thick layer of mucus, blocks airway
→ causes thick mucus that clogs certain
organs, such as the lungs, pancreas, and
intestines.
→ This may cause malnutrition, poor growth,
frequent respiratory infections, breathing
problems, and chronic lung disease.
V.
PARATHYROID GLAND DISORDER
1. Hypocalcemia
2. Hypercalcemia
38
−
Hypocalcemia
→ LOWERED blood calcium level, causing
tetany to develop.
→ Therapy: administration of calcium.
•
Signs
•
Causes
1. Supplements
2. Overactive parathyroid glands
(hyperparathyroidism)
3. Cancer
4. Other diseases
5. Hereditary factors
6. Immobility
7. Severe dehydration
8. Medications
Treatment
- If hypercalcemia is mild:
 monitoring of bones and
kidneys over time to be sure
they remain healthy.
- severe hypercalcemia:
 medications or treatment of
the underlying disease
 Surgery
Medications:
Calcitonin - controls calcium levels in the
blood
Calcimimetics - help control overactive
parathyroid glands.
Bisphoshonates - Intravenous
osteoporosis drugs, which can levels, are
often used to treat hypercalcemia due to
cancer
Denosumab - used to treat people with
cancer-caused hypercalcemia who don't
respond well to bisphosphonates.
Prednisone - If hypercalcemia is caused by
high levels of vit. D, short term use of
steroid pills such as prednisone are usually
helpful.
IV fluids and diuretics - to promptly lower
the calcium level to prevent heart rhythm
problems or damage to the nervous system.
•
•
1)
2)
•
−
Signs and Symptoms
C – onvulsions
A – arrhythimus
T – etany
S – tridor and spasms
• Causes
 Vitamin D inadequacy or vitamin D
resistance
 Hypoparathyroidism following
surgery
 Hypoparathyroidism owing to
autoimmune disease or genetic
causes
 Renal disease or end-stage liver
disease causing vit. D inadequacy
 Pseudohypoparathyroidism
Hypercalcemia
→ Calcium level in the blood is above
normal
3)
4)
5)
6)
VI.
DISORDERS OF METABOLISM
1. PKU
2. Galactosemia
3. Tay – Sachs disease
→ a term that is used to describe all
chemical reactions involved in
maintaining the living state of the cells
and the organism.
39
→ Metabolism two categories:
a) Catabolism
b) Anabolism
•
•
1) PKU
→ A disorder of amino acid metabolism
wherein the body is not able to use
phenylalanine leading to its
accumulation.
→ Phenylalanine is an amino acid
found in many foods and used by
your body to produce proteins and
other important molecules.
2) Galactosemia
→ A disorder of carbohydrate
metabolism wherein the body is not
able to use galactose leading to its
accumulation.
3) Tay-Sachs disease
→ a rare disorder passed from parents
to child
→ caused by the absence of an
enzyme (gangliosides) that helps
break down fatty substances.
→ Leading to build up to toxic levels in
the child's brain and affect the
function of the nerve cells
−
Classical Phenylketonuria
(Phenylalanine hydroxylase deficiency)
- Most common outcome is severe
mental retardation (IQ <50)
- Cerebral palsy (33 %), behavioral
problems
- Often associated with a mousy odor
- Vomiting - prominent early
symptoms
- Eczema (20-40%) – mild
- Reduced hair, skin and iris
pigmentation
- Reduced growth and microcephaly
- Neurologic impairments (25%
epilepsy, 30% tremors, 5%
spasticity, 80% EEG abnormalities)
Management
 Dietary Restriction of PHE
- Special formulas
- Limited protein diets/food
- Vitamin supplement
 Periodic assessment of plasma PHE
levels
- Weekly for 2-4 months
- Every 2 weeks until 6-12 months
- Monthly thereafter
 Neurodevelopmental assessment
 Early intervention
(speech therapy, PT, OT)
 Genetic counseling
Phenylketonuria
→ (PKU) A disorder of amino acid
metabolism wherein the body is not able
to use phenylalanine leading to its
accumulation
40
•
−
•
TREATMENT:
 Dietary restriction of phenylalanine
 Goal: limit dietary intake of
phenylalanine in amount required for
normal growth and development but
below toxic level.
 For babies: special milk formula +
controlled amount of breast milk
and/or regular milk formula
 Typical diet consist of low protein
foods, meaning limited intake of
meat, fish, poultry, milk, eggs,
cheese, legumes, and regular flour.
 Monitoring of blood phenylalanine
level at least quarterly.
•
Galactosemia
→ A disorder of carbohydrate metabolism
wherein the body is not able to use
galactose leading to its accumulation.
→ Galactosemia, which means "galactose
in the blood," refers to a group of
inherited disorders that impair the body's
ability to process and produce energy
from a sugar called galactose.
•
−
•
Clinical Manifestations:
1. It appear within days of birth or initiation
of milk feedings
2. Signs and symptoms depend on the
level of enzymes deficiency.
3. Vomiting & jaundice - early signs
4. Sepsis - neonatal period
5. Failure to thrive
6. Hepatomegaly
7. Cataract - after 3-4 weeks of milk
feedings
8. Mental Retardation
9. Fatal - if milk feedings are continued
Diagnosis
 Newborn Screening can detect
virtually 100% of affected infants
Requirements:
1. Lactose-containing
milk/foods
2. No blood transfusions
 Confirmatory Test FREE
Repeat DBS (filtercard) — Beutler
test
Long term treatment and follow-up
a. Diet - remove galactose from the
diet
b. Monitor Gal/Gal-1-P level
c. Early intervention for problems of
motor, speech and cognitive
development
d. All girls should be evaluated for
premature ovarian failure at 10-12
years of age
e. Regular ophthalmologic evaluation
for those with cataracts
f. Regular evaluation of liver profile
Prognosis:
 With strict adherence to a galactosefree diet, the prognosis is good.
 Cataracts are reversible if therapy is
started before 3 months.
 There is recovery of the liver
abnormalities with dietary
restrictions.
Tay-Sachs Disease
→ is a rare, inherited disorder. It causes
too much of a fatty substance to build
up in tissues and nerve cells of the
brain.
→ A rare disorder passed from parents to
child.
→ Caused by the absence of an enzyme
(gangliosides) that helps break down
fatty substances. Leading to build up
toxic levels in the child’s brain and affect
the function of the nerve cells.
• Signs and Symptoms
Is classified in variant forms, based on the
time of onset of neurological symptoms.
1. Infantile (3 to 10 months)
2. Juvenile (Two and 10 years)
(extremely rare)
3. Adult/Late Onset (20 and 30 years)
(usually non-fatal)
41
2. Effective treatment plans and medication
administration techniques can facilitate
successful interventions in long-term care.
3. Increase compliance
Nursing Process
Assessment
1. Measure the child’s height and weight to
find out if above or below a typical
measurement for that age.
2. To obtain information on activity in the child,
take a day history by asking a parent or
child to describe all the child’s actions on a
typical day.
3. Assess dietary and elimination habits.
Nursing Diagnosis
1. Deficient fluid volume related to constant
excessive loss of fluid through urination.
2. Risk for imbalanced nutrition, less than body
requirements, related to an inability to use
glucose because of diabetes mellitus
3. Disturbed body image related to abnormal
height (Health-seeking behaviors related to
the self-administration of insulin).
4. Deficient knowledge related to long-term
treatment needs.
5. Fear related to the potential and unknown
illness outcome.
6. Anticipatory grieving related to presumed
losses associated with diagnosis of longterm illness.
7. Interrupted family processes related to the
child's chronic illness.
8. Anxiety related to financial resources
required to maintain optimum family health
Outcome Evaluation
1. Periodic evaluations throughout childhood
because growth and changing activities
necessitate changes in medication dosages
or schedules.
2. Adherence to a medication program may
become erratic. Only by periodic
reevaluation can these problems be
identified so that healthcare plans can be
modified and adapted to the child's s needs,
enabling the child and family to continue
coping with a long-term illness.
The following examples suggest desired
outcomes have been achieved:
1. The child brings to clinic a written record
showing that she took her medication as
recommended. Parents list developmentally
appropriate, not size-appropriate, activities
for their child with a short stature.
2. Parents demonstrate correct insulin
injection technique and state they are
comfortable administering an injection to
their child.
3. Education and genetic counseling
4. School nurses can be instrumental not only
in counseling and helping students manage
this disorder during school hours but also in
helping prevent T2D by serving as an
advisor to what foods and snacks ought to
be available in school settings.
Outcome Identification and Planning
1. Helping parents create reminder charts or
set alerts on their smartphones are effective
measures to increase compliance.
2. Evaluate both the school and home
situation for any child with a chronic illness.
Implementation
1. Referrals to age-appropriate support groups
within their communities that will serve to
build lifelong bonding and relationships.
42