gisystem111-20120505560876900000005.pptx

Gastrointestinal disorder

1. Gastrointestinal Disorder INTRODUCTION Gastrointestinal problems are very common in childhood . Number of medical & surgical problems are found among children. GI disturbances are influenced by problems of liver & pancreas. Digestion , absorption and metabolism are the combined actions of gastrointestinal and hepato- pancreative system.

2. List Of Disease Condition:- Diarrhea Gastroesophagial reflux Hepatitis Childhood cirrhosis Liver transplantation Malabsorption syndrome Malnutrition

3. Review Of Anatomy & Physi o log y

4. Overall Digestive System Function Breaks up food physically and chemically. Stores food for a short period of time. A b sorbs the d i gest e d foods an d passes t h em i n to the circulatory system. S tor es an d eli m in a tes un d igested food f r om the body.

5. D I A R R H E A DEFINATION:- Diarrhea is defined as the passage of loose , liquid or watery stool ,more than three times per day

6. Acute diarrhea is an attack of loose motion with sudden onset which usually lasts 3-7 days but may last upto 10-14 days. It is associated with gastric mucosa & small intestines. Chronic diarrhea is termed when the loose motion is occurring for 3 weeks or more .It is usually related to underlying organic diseases with or without mal-absorptions t yp e s

7. AGENT FACTORS- The infectious agent causing diarrheas with enteric infection include the following: VIRUSES : rotavirus, adenovirus, enterovirus, measles virus etc. BACTERIA : E.coli, shigella, salmonella, vibrio etc. PARASITES : E.histolytica, malaria. FUNG I: candida albicans . Etiology of diarrhea

8. ENVIRONMENTAL FACTORS - Bacterial diarrhea is a more frequently occur in summer and rainy season, whereas viral diarrhea (especially rotavirus) found in winter. Diarrheal diseases are commonly seen in unhygienic environment. MODE OF TRANSMISSION- is mainly feco-oral route . it is water-born disease or may transmit via fingers, fomites , flies or dirt. C o n t i . .

9. SECRETORY DIARRHEA- It has tendency to be watery, voluminous and persistent, even if no oral feeding is allowed. This is decrease absorption and increased secretion. OSMOTIC DIARRHEA- It is due to ingestion of poorly absorbed solute or maldigestion or a small bowel defect. It tends to be watery and acidic with reducing substances. MOTILITY DIARRHEA - It is associated with the increased or delayed motility of the bowel. There is decreased transmit time of bacteria leading to overgrowth Other types of DIARRHEA

10. PATHOPHYSIOLOGY Bacterial toxins stimulating active transport of electrolytes into the small intestine: cells in the mucosal lining of the intestine are irritated and secrete increased amounts of water and electrolytes. Organisms invading and destroying intestinal mucosal cells, decreasing intestinal surface areas, and impairing the intestine’s capacity to absorb fluids and electrolytes Inflammation, which decreases the intestine’s ability to absorb fluid, electrolyte and nutrients. Increased intestinal motility, resulting in impaired intestinal absorption.

11. CLINICAL MANIFESTATION on s et Sympt o ms va r y with s e verity, s p e c if i c c a use, and ty p e of (insidious versus acute). Low-grade fever to 100° F (37.8° C) Anorexia Vomiting (can precede diarrhea by several days); mild and intermittent to severe Stools appearance of diarrhea from a few hours to 3 days Loose and fluid consistency Greenish or yellow-green May contain mucus, pus, or blood Frequency varies from 2 to 20 per day Expelled with force; may be preceded by pain

12. Conti… Behavioral changes Irritability and restlessness Weakness Extreme prostration Stupor and convulsions Flaccidity Physical changes Little to extreme loss of subcutaneous fat Up to 50% total body weight loss Poor skin turgor; capillary refill longer than 2 seconds Dry mucous membranes and dry, cracked lips Normal capillary refill time is usually less than 2 seconds.

13. Contii… Pallor Sunken fontanelles and eyes Petechiae seen with bacterial infections Excoriated buttocks and perineum. Urine with blood Vital sign and urine output changes (signal imminent cardiovascular collapse) Low BP High pulse Respirations rapid and hyperapneic Decreased or absent urine output

14. ASSESSMENT OF DEHYDRATION Diarrhea 10 liquids V o m it i ng Less than 4 liquid 4 to 10 liquid stools per day More than stools per day stools per day None or s m all a m ount So m e V ery f r equ e nt Normal Greater than normal Unable to drink Normal A small amount and dark No urine for 6 hours Well, alert or Nor m al P r esent Moist Nor m al Goes back quickly Thirst Urine 2. LOOK AT Condition Eyes Tears Mouth and tongue Breathing 3. FEEL Skin pinch Pulse nor m al Restless, irritable or sleepy, Lethargic unwell unconscious, floppy Sunken Very sunken and dry Absent Absent Dry Very dry Faster than normal Very fast and deep Goes back slowly Goes back very slowly Faster than nor m al V ery fas t , w eak or cannot feel OF DEHYDRATION 4. DECIDE D E G REE The pat i ent SIGNS D EH YDR A TION least one si g n t h e r e SOME DEHYDRATION has NO If the patient has two or If the patient has two or OF more signs including at more signs including at is least one sign there is SEVERE DEHYDRATION

15. DIAGNOSTIC EVALUATION STOOL : Cultures (for bacteria, ova, parasites, rotavirus), ph, red blood cells, leukocytes, glucose, blood . BREATH HYDROGEN TEST : Check for carbohydrate malabsorption. BLOOD TEST: Especially blood cells counts, electrolytes, blood urea nitrogen, glucose, and blood cultures. X-RAYS: Check for possible bowel abnormalities.

16. MANAGEMENT Treatment is based on the degree of dehydration; mild (less than 5%), moderate (5% to 10%), and severe (greater than 10% weight loss) Goal is to prevent spread of disease; communicable disease is suspected until proved otherwise; enteric precautions are followed. Bowel rest may be required based on degree of diarrhea and vomiting, if blood present, or electrolyte abnormalities.

17. Conti… For mild to moderate dehydration (5%), oral rehydration solution is given to maintain fluid and electrolyte balance (WHO solution, Pedialyte, Infalyte) and BRATS (Bananas, Rice cereal, Apple & sauce, dry Toast, and Saltine crackers) diet is followed to provide rest for the inflamed intestines. For oral rehydration, 100 mL/kg over 4 hours, with additional fluids after each liquid bowel movement. Candidates for oral rehydration include mild to moderate (greater than 10%) dehydration, older than age 4 months, no persistent vomiting, and probable gastroenteritis.

18. For moderate to severe dehydration (10% or greater): I.V. fluid and electrolyte replacement is given slowly as ordered (usually 20 mL/kg); usually over 2 days to prevent hypotonic hypervolemia (water intoxication). Supportive care is given : monitoring oral and I.V. fluid intake, output from all sources, and patient's response to treatment.

19. Conti . . Specific antimicrobial therapy may be given in some cases such as immunosuppression, bacteremia, documented C. difficile. Metronidazole 20 mg/kg/day in divided doses orally or I.V. may be used. Vancomycin I.V. for resistant C. difficile

20. Conti… REHYDRATION THERAPY- INGREDIENTS OF ORAL REHYDRATION SALTS: COMPONENT CONTENT PER LITER WATER Sodium chloride 3.5gm Potassium chloride 1.5 gm Sodium citrate 2.9gm Glucose anhydrous 20.0gm

21. ASSESSMENT FOR DEHYDRATION IN CHILDREN DEGREE OF DEHYDRATION C L INICAL SIGNS MILD MODE R A TE SEVERE General Infant's behavior Thirsty, alert, restless Restless or lethargic; irritable to touch Limp, drowsy; cyanotic extremities Child's behavior Thirsty, alert, restless Thirsty, alert; postural hypotension Usually conscious; cyanotic ex t remi t ies Res p irations Slightly increased Inc r ea s ed Deep and rapid

22. CONTI.. DEGREE OF DEHYDRATION C L INICAL SIGNS M I LD M O D E R A TE SEVERE Pulse Slightly increased Inc r ea s ed Rapid Blood pressure No r mal Decreased May be un r e c or d able Capillary refill <2 seconds 2 TO 3 seconds >3 seconds

23. C L INICAL SIGNS DEGREE OF DEHYDRATION M I LD M O D E R A TE SEVERE Skin turgor Normal Slightly reduced Redu c ed Skin color Pale Gr a y Mot t led Weight loss Up to 5% Up to 10% Up to 15%

24. CONTI… CLINICAL SIGNS DEGREE OF DEHYDRATION MILD MODERATE SEVERE Mucous membrane Tacky Tacky/dry Parched Specific gravity <1.020 >1.030 >1.035 Anterior fontanelle Flat Slightly depressed Sunken Urine volume Small Oliguria Oliguria/anuria

25. Com p li c at i ons Severe dehydration derangements with acidosis and a c i d - base Sh o c k

26. NURSING MANAGEMENT Fluid volume deficit related to diarrhea. Risk for cross infection related to infective loose motions. Po t ential t o alter e d skin integrity r el a t ed t o f requ e nt p a ssage of stools. Al t ered nu t ritional st a t u s, less t h an body re q uirement r elated to malabsorption and poor oral intake. Fear and anxiety related to illness and hospital procedures. Knowledge deficit related to causes of diarrhea and its prevention.

27. Nursing Interventions GOAL- Restoring Fluid Balance Monitor amount and rate of I.V. fluid therapy, which have been calculated by the health care provider. Fluid needs are based on fluid deficit, ongoing losses, and body weight. Prevent overload of circulatory system. Check flow rate and amount absorbed hourly and totally

28. CONTI.. Adhere to prescribed volume carefully when oral feedings are given in conjunction with I.V. fluid. Never administer I.V. fluids to pediatric patient without safeguard of a volume-control infusion device or pump. Observe for signs of fluid overload: edema, increased BP, bounding pulse, labored respirations, and crackles in lung field s.

29. CONTII . . Check I . V . site for i n filtrat i o n o r improper flow so site can be changed as necessary. Use a ppr o priate protect ive devices to prevent the c hild f r om injuring involved extremity or causing I.V. to malfunction. Weigh the patient daily as a guide for fluid needs and patient status. Monitor urine output an d keep accurate i n take an d output record, including vomitus and liquid stools.

30. Preventing Spread of Infection Ensure adherence to good hand-washing and gown technique protocols for all people having contact with infant or child. Follow your facility's policy on care of diapers. Han d le s p ecimens collect e d using un i v er s al prec a ut i ons, and transport to laboratories in appropriate containers per policy. Co l l e ct stool sam p le for culture before instituting antib i otic therapy. Teach good hygiene measures to older children

31. The important preventive measures are improvement of food hygiene, personal hygiene and environmental hygiene. These include safe water , adequate sewage disposal, hand washing practices, clean utensil, avoidance of exposure of food to dust and dirt, fly control, washing of fruits and vegetables Avoidance of bottle feeding is most significant practice needed for prevention of diarrhea. Boiling or filtering to be practiced for safe drinking water. of LBW and prematurity, exclusive breastfeeding, Prevention app r opri a te significant aspects of child c are weaning practices, balanced which diet, preve n ts im m uniz a tion are m alnut r i t ion a n d diarrheal episodes PREVENTIVE MEASURES-

32. PROGNOSIS- Mortality is higher in neonates and infants than the older children Maln o u ri s hed c h i l d ren are having poor pro g no s is and greater mortality. Ant i biot i c re s i s tant type E . c o li a n d Shige l la c a u s e ve r y severe illness and poor prognosis. Presence of severe dehydration, electrolyte imbalance Early diagnosis with prompt and appropriate management helps in good prognosis.

33. RESEARCH- Case-control study of risk of dehydrating diarrhoea in infants in vulnerable period after full weaning BMJ 1996; 313 doi: http://dx.doi.org/10.1136/bmj.313.7054.391 (Published 17 August 1996) Cite this as: BMJ 1996;313:391 Objectives: To investigate risk factors for dehydrating diarrhoea in infants, with special interest in the weaning period.

34. Results: In infants aged <12 months the risk of dehydrating diarrhoea was significantly higher in the first 9 months of life (P<0.001), and in those aged 12-23 months the risk was again greater in younger children (12-17 months) (P = 0.03). The type of milk consumed before start of diarrhoea episode was strongly associated with dehydration independent of socioeconomic, environmental, maternal reproductive, demographic, and health services factors. Compared with infants exclusively breast fed, bottle fed infants were at higher risk (odds ratio (95% confidence interval) for cow's milk 6.0 (1.8 to 19.8), for formula milk 6.9 (1.4 to 33.3)). Compared with those still breast feeding, children who stopped in the previous two months were more likely to develop dehydrating diarrhoea (odds ratio 8.4 (2.4 to 29.6)). This risk decreased with time since breast feeding stopped.

35. C o nc l us i on: These results confirm the protective effect of breast feeding and suggest there is a vulnerable period soon after breast feeding is stopped, which may be of relevance for developing preventive strategies.

36. Gastroesophageal Reflux Disease (GERD)

37. Introduction:- Gast roesophag ea l R e f l ux D i sease (GERD) is a digestive d i sorder that occurs w h e n acidic stomach juices, or food and fluids back up from the stomach into the esophagus. GERD affects pe o p le of all a ge s — f r om infants to older adults.

38. Delayed neuromuscular development Physiological immaturity Cerebral defects Increased abdominal pressure Obesity Coughing &wheezing in case of cystic fibrosis Bronchopulmonary dysplasia Asthma Indwelling orogastric or nasogastric tube C a us e s -

39. Primary barrier to gastro esophageal reflux i s t he low e r es o pha g eal sphincter LES normally wo r ks i n c o nju n ction with the diaphragm I f b ar rier d i srupte d , a cid go e s f rom stomach to esophagus PATHOPHYSIOLOGY.

40. Sy m ptoms In Infants- The feature are unexplained vomiting immediate after feeding Regurgitation Refusal to eat & features of dehydration Irritability Excessive crying Sleep disturbances Arching and stiffening Respiratory symptoms like cough, strider, and pneumonia may found. Loss of weight or failure to gain weight

41. c o n t . In Older Children- Non cardiac chest discomfort Upper abdominal discomfort Chronic cough StridOr Nocturnal asthma Dysphasia Anemia

42. Other symptoms Difficulty or pain when swallowing Sudden excess of saliva Chronic sore throat Laryngitis or hoarseness Inflammation of the gums Cavities Bad breath Chest pain

43. Diagnosis X-ray of the upper digestive system Endoscopy (examines the inside of the esophagus) Ambul a tory acid (pH) test ( m on i tors the a mount of acid in the esophagus) Es o p hage a l im p ed a nce test ( m eas u res the movement of substances in the esophagus)

44. Treatment & Management Medical Management:- Positioning- It helps to reduce the amount of reflux. Infants younger than 6 months should be placed on right lateral position during sleep, head of the crib should be raised at least 6 inches. The infant may also be held upright. Older children should be placed in head raised to 30-45 degree angle position. Avoid recumbent position after meal for at least 3 hours .Upright of semi upright position during awaking is helpful.

45. Cont i - 2. Feeding- Special precautions to be taken during feeding of infants and older children. Infants to be given thickened feed in small amount frequently followed by appropriate positioning, to prevent the reflux. Older children should be allowed nothing per mouth 2hours before bed time. Low fat diet , spicy and acidic foods (onion, citrus products , apple juice , tomato) , esophageal irritants ( chocolate , peppermint , passive smoke) and carbonated beverages should be avoided .Chewing gum can be allowed to stimulate parotid secretions which increases esophageal clearance.

46. Co n t i - 3. Medications - A n taci d s H 2 – rece p tor a n tagonists (cimetidin e ) , prokinetic drugs ( m etaclo p ro m ide) and proton pump can be g i ven a l o ne o r in inhi b itors(o m epraz o le) combination

47. Surgical Management- Fudoplication ( Nissen’s operation) is most popular method. A gastric wrap procedure is done. Wrapping of t h e f un d us a rou n d t he low e r oesophageal sphinc t er ( a 3 60 completely pre v ent degree wrap) reflux episodes. Fundoplication is a surgical procedure that helps treat some gastroesophageal conditions. During a fundoplication for gastroesophageal reflux disease (GERD), for example, a surgeon will attach part of the stomach to the lower esophageal sphincter, which helps reduce acid reflux

48. A n troplasty or pyloroplasty may be performed in some cases. Gastrotomy may be needed for feeding purposes or temporarily to decompress the stomach . Pyloroplasty is surgery to widen the opening in the lower part of the stomach (pylorus) so that stomach contents can empty into the small intestine (duodenum). The pylorus is a thick, muscular area. When it thickens, food cannot pass through

49. Nursing Management : Preventing aspiration by positioning and appropriate feeding technique. Maintaining fluid & electrolyte balance by I/V fluid therapy , (whenever needed) ,intake and output recording and estimation of electrolyte level. Providing adequate nutritional intake Continuous monitoring of vital signs , Assessment of features of complication and necessary investigations.

50. C o nti- Reducing fear of eating and modifying feeding schedule Prov i ding preoperati v e an d p o s tope r ative care a s for abdominal surgery of children. Providing emotional support Giving health education regarding , positioning , feeding, home based care and follow up.

51. Complication- Aspiration pneumonia Chronic esophagitis Failure to thrive Anemia Asthma Sudden infant death syndrome ESophageal stricture An esophageal stricture is an abnormal tightening or narrowing of the esophagus .

52. HEAPATITIS

53. Function Of Liver- Bile production that is essential to digestion Filtering of toxins from the body Excretion of bilirubin, cholesterol, hormones, and drugs Metabolism of carbohydrates, fats, and proteins Activation of enzymes (specialized proteins essential to metabolic functions) Storage of glycogen, vitamins (a, d and k), and minerals Synthesis of plasma proteins, such as albumin Synthesis of clotting factors HEPATITIS means inflammation of liver

54. Causes of Hepatitis ACUTE: Viral hepatitis Non-viral infection Alcohol Toxins Drugs Ischemic hepatits Autoimmune Metabolic diseases CHRONIC: Viral hepatitis Alcohol Drugs Non-alcoholic steatohepatitis Autoimmune Heredity

55. Classification of Hepatitis Hepatitis A Hepatitis B Hepatitis C H e p a titis D Hepatitis E

56. Pathophysiology Targets of the Hep viruses are hepatocytes: Hepatocyte uptake involves a receptor on the plasma membrane of the cell After entry into the cell, viral RNA is uncoated, and host ribosomes bind to form polysomes. Viral proteins are synthesized, and the viral genome is copied by a viral RNA polymerase Minimal cellular morphologic changes result from hepatocyte infection Lymphocytic infiltrate; varying degree of necrosis.

57. Diagnosis Of Hepatitis Physical Exam Liver Biopsy Liver Function Tests Ultrasound Blood Tests Viral Antibody Testing

58. Diagnosis: HAV S e rum S e rolo g y : presence o f serum antigens and immunoglobins HAV: IgM anti-HAV: positive at the time of onset of symptoms; results remain positive for 3-6 months after the primary infection Anti-HAV IgG appears soon after IgM and generally persists for many years. Treatment : supportive

59. Hepatitis B Epidemiology HBV is a DNA virus that belongs to the hepatovirus family. 2 billion people worldwide have past or present infections 400 million people are chronic HBV carriers. Eight genotypes of HBV identified and re-labeled A through H. HBV i s the ca u se o f 60% t o 80% of worldwide Carcinoma(HCC). Hepatocellular 500,000 to 1 million deaths worldwide are attributed to it. 5% to 10% of all liver transplants are attributed to HBV.

60. AT Risk Groups IV drug users People receiving multiple blood transfusions Sexual promiscuity People in contact with HBV carriers Traveler s to en d em ic areas o f S o uth America, Southern Asia, and Africa Resident and employees of residential care facilities Promiscuity is the practice of engaging in sexual activity frequently with different partners or being indiscriminate in the choice of sexual partners. The term can carry a moral judgment if the social ideal for sexual activity is monogamous relationships.

61. Transmission 3 main ways: Parenterally/percutaneous route----IV Drug Users, needle sticks, Hemodialysis patients Sexually Vertical/ Perinatal route

62. Clinical Manifestation- Acute Hepatitis B – Less than 6 mont h s; bas e d o n signifi c ant aminotransferase activity due to necro inflammatory injury Symptoms are often non-specific symptoms such as myalgia, malaise , nausea, fatigue , pruritus, abdominal pain, jaundice Fulminant hepatitis--acute HBV results in liver failure

63. Chronic Hepatitis B – Greater than 6 months; based on grade, stage, and etiology. Fibrosis and necroinflammatory processes; can last for decades Immune tolerant--high viral replication, low inflammation and fibrosis. Seen in children or those affected early in life. I m m u ne ac t i v e - -high li v er e n zym e s a n d high hbv dna and h be ag, a c ti v e replication Carrier state with low replication Seroconversion from hbeag to hbeab Low HBV levels, reduced liver inflammation

64. Diagnosis- Serology- Liver Chemistry tests Histology--Immunoperoxidase staining HBV Viral DNA--Most accurate marker of viral DNA and detected by PCR Liver Biopsy--to determine grade(Inflammation) and stage(Fibrosis) in chronic Hepatitis

65. Progress- Incubation Period : 30-180 days Acute HBV Infection : 90% resolve by themselves; less than 1% develop fulminant hepatitic failure Chronic HBV Infection : 2-10% progress to chronic state 90% in children less than five progress to chronic state Risk of Liver Cirrhosis: 5 year accumulation risk of 8% to 20%

66. Treatment- 1) Interferon therapy – First Line Method of action is the inhibition of viral replication of cells thus assisting the immune system Side effects : "Flulike Symptoms", alopecia, rash, diarrhea

67. Nucleoside Analogues -- Lamivudine, Entecavir, Telbivudine Method of action is the inhibition of viral reverse transcriptase Lamivudine Dose : 100 mg PO q daily Problem : High rates of resistant mutations Side effect : lactic acidosis Entecavir – 1 st line 0.5 to 1mg PO very effective; more effective than lamivudine Side effect : lactic acidosis Telbivudine Dose : 600mg daily Side effect : lactic acidosis

68. 3) Nucleotide analogues Method of action is the inhibition of viral reverse transcriptase Tenovir Dose: 300mg od Highly effective with low resistance Well tolerated Adefovi r – 1 st line Dose : 10mg daily Resistance less than Tenovir Side effect : nephrotoxicity

69. Hepatitis C Spherical, enveloped, single-stranded RNA virus Incubation period : 7-8 wks 170 million infected worldwide Parenteral Transmission : IV drug users Most common indication for liver transplantation

70. Diagnosis: HCV HCV: Anti-HCV ; cannot distinguish acute from chronic infection EIA: antibodies against core protein and nonstructural proteins; may appear 3 – 5 months after infection 80% of cases: patients are asymptomatic and do not develop icterus. Treatment: Interferon alpha, Ribavirin; (better sustained absorption, a slower rate of clearance, )

71. Hepatitis D This is also called “delta hepatitis.” Hepatitis D is a serious liver disease caused by the Hepatitis D virus (HDV), which is contracted through puncture wounds or contact with infected blood. This is a rare form of hepatitis that occurs in conjunction with hepatitis B infection.

72. Hepatitis E Hepatitis E virus (HEV) RNA virus of the genus Hepevirus E n ter ic a lly t r ansmitt e d i n fect i on; feca l - o r al route, typically self-limited Most outbreaks occur in developing countries. Symptoms of acute hepatitis Incubation period of hepatitis E virus is 2-9 weeks Case fatality rate is 4%

73. Diagnosis- Serum, liver, and stool samples can be tested for HEV RNA Anti-HEV antibodies: IgM (acute) IgG (chronic) Treatment: supportive

74. Hepatitis F It is well documented that even after a detailed serological study, 10 percent of children will not have marked to the known viruses A to E. These could be HBV variants with mutation, or a budding RNA virus French workers have identified an enteric virus in this non A-E group and call it the hepatitis French virus(HFV).

75. HEPATITIS G Hepatitis G (HGV) virus is a single stranded RNA flavi virus which shares limited identity with HCV. It is distributed widely among the population and spreads by parenteral route.

76. Surgical Management: Liver Transplantatiion

77. Preventive Management Of Hepatitis Hygiene Practicing good hygiene i s the m ain w a y to avoid catching hepatitis. I f y ou are trav e l ling standards, avoid: Drinking local water Ice Sea food Raw fruit and vegetables to a count r y w ith l o w sa n i t ary

78. C o nti- H e p atitis co n tr o l led through co n tam i nated b lo o d can be prevented by: Not sharing drug needles Not sharing razors Not using someone else’s toothbrush Not touching spilled blood

79. Nursing Management:- Imbalanced Nutrition Less Than Body Requirements Acute pain related to swelling of the liver is inflamed liver and portal vein dam. Hyperthermia related to invasion agents in the blood circulation secondary to liver inflammation. F a tigue r elated t o ch r onic inflam m at o ry pr o ce s s secondary to hepatitis. Risk for impaired tissue integrity related to pruritus secondary t o a ccu m ulation o f biliru b in pigme n ts i n bile s a l t s .

80. Complications of Hepatitis Chronic liver disease Cirrhosis (scarring of the liver) Cancer of the liver (in rare cases)

81. H A V HBV HCV HDV HEV HGV [*] V i r ology RNA DN A RNA RNA RNA RNA I n cubation (days) 15–19 60–180 14–160 21–42 21–63 ? Transmission Pa r enteral Ra r e Y es Y es Y es No Y es F e ca l -oral Y es No No No Y es Possible Sexual No Y es Y es Y es No Y es P e r i natal No Y es Ra r e Y es No Y es Chronic infe c tion No Y es Y es Y es No Y es Fulm i na n t disease Ra r e Y es Ra r e Y es Y es No

82. INDIAN CHILDHOOD CIRRHOSIS

83. Childhood Cirrhosis Indian childhood cirrhosis is a disease peculiar to the Indian infants and children, usually occurs between 6 months & 4 years of age. It may also found in Indian subcontinent and west Indies

84. Etiolo g y - Hepatotoxic agents- Hepatotoxic harmful agents like guttis or aspergillus flavus that grow on ground nuts, maize and rice may cause ICC . Metabolic Defects- They may cause ICC specially disturbed lactose ,zinc, copper and magnesium metabolism. Immunologic Disturbances- These are found in high levels of circulating immune complexes which can cause immune mediated injury of the liver.

85. Conti- Genetic factors- Familiar occurrence of ICC points the possibility of underlying genetic factor along with environmental factors. Nutritional Factors- previously it was believed that malnutrition was an important cause of cirrhosis. Viral Infection- ICC has been thought to be a consequence of neonatal hepatitis or infective hepatitis.

86. Pathophysiology- Due to the disease process. The basic pathologic change is the diffuse liver damage by way of degeneration going on to necrosis and replacement fibrosis . The capsule shows patchy thickening and the surface is finely nodular . THE microscopic study shows marked hepatocyte damage as degenerative changes in the cytoplasm. Kupffers cell shows mild degree of proliferation. Gross pericellular fibrosis in the hepatic lobules are found.

87. Clinical Manifestation- Onset is acute Irritability Disturbed appetite Chalky & pasty stools with constipation or diarrhe Mild fever Progressive growth failure usually present in spite of adequate diet.

88. Cont i - Within few months to a years, there is hepatomegaly , jaundice and features of portal hypertension including splenomegaly , ascities, hematemasis , anemia, prominent superficial abdominal veins and thrombocytopenia There may be high incidence of intravascular hemolysis. Liver is usually gross enlarged with proturbent abdomen Th e child g e n e r a lly h a ve h e p a tic failure infections which may be fatal Duration of illness may be 6 month to 3 years and intercurrent

89. Diagnosis- Liver Biopsy Cupriuresis a d mi n i s tr a ti o n test –it may be pe r fo r med by oral o f D - p e n i c i ll a mi n e, u s i n g u r i n a r y copper / creatinine ratio as the index parameters, sensitivity and specificity with positive and negative values are obtained.

90. Managemen t - Medical Management:- Fe w cases o f ICC improve spon t an e ously an d survi v e w i th out specific treatment. Penicilline therapy is used as copper- chelating agent from the liver, which improves the survivals. Immunomodulating agents like levamisole , corticosteroids, gammaglobulins may also be used. Symptomatic treatment should be done especially for infections and vitamins and minerals deficiency

91. Co n t i - Supportive care should be provided as rest , diet with good quality proteins , I/V glucose drip , oxygen therapy, antibiotic s therapy and good nursing care Nursing intervention – improving nutritional status, promoting of activity tolerance , protecting skin integrity , preventing injury & bleeding. Exchange transfusion may be effective to remove circulating toxins In case of portal hypertension causing hematemesis, sengastaken tube may be of help to control esophageal bleeding

92. sengastaken tube

93. Nursing Mangement- Nur s i n g i nt e r v e n ti o n s h o u ld p r o v i d e s p e c i a l at t e n ti o n on improving nutritional status promoting of activity tolerance protecting skin integrity p r e v e n ti n g i n j u ry an d b l e e d i ng an d exper t c a re for unconscious patients if needed.

94. Preventive Management- Continue breastfeeding upto six months and avoiding boiling of milk in copper or copper alloy pots Increasing public awareness about the preventive measures is important regarding lowering of copper intake through copper- rich food , water and utensils.

95. Liver Transplantation

96. Indications for Pediatric Liver Transplantation INDICATIONS P ER C E N T OF T RAN S P L AN TS ( % ) Biliary atresia 39 Metabolic liver disease 13 α 1 -Antitrypsin deficiency 5 Tyrosinemia 1 Wilson disease 1 Other 6 Acute hepatic necrosis 12 Biliary hypoplasia including Alagille syndrome 5 TPN-associated liver disease 5 Idiopathic cirrhosis 4 Autoimmune hepatitis 3 Tumors including hepatoblastoma 3 Neonatal hepatitis 2 Cystic fibrosis 2 Primary sclerosing cholangitis 2 Congenital hepatic fibrosis 1 Other 9

97. Ben e fits Transplant can be done on an elective basis because the donor is readily available There are fewer possibilities for complications and death while waiting for a cadaveric organ donor .

98. Screening for donors All donors are assessed medically to ensure that they can undergo the surgery Confidentiality The transplant team provides both the donor and family thorough counseling and support which continues until full recovery is made.

99. Malabsorption is a state arising from abnormality in absorption of food nutrients across the gastrointestinal (GI) tract. MALABSORPTION SYNDROME

100. Classification Selective , as seen in lactose malabsorption. Partial , as observed in a-beta-lipoproteinaemia. Total as in coeliac disease.

101. Pathophysiology The main purpose of the gastrointestinal tract is to digest and absorb nutrients, micronutrients , water, and electrolytes. Malabsorption constitutes the pathological interference with the normal physiological sequence of digestion (intraluminal process), absorption (mucosal process) and transport (postmucosal events) of nutrients.

102. Caus e s HIV related malabsorption Intestinal tuberculosis Due to infective agents Blind loops Inflammatory bowel diseases, as in Crohn's Disease Fistulae, diverticulae and strictures Due to structural defects Coeliac disease Cows' milk intolerance Soya milk intolerance Fructose malabsorption Due to mucosal abnormality Lactase deficiency inducing lactose intolerance Sucrose intolerance Intestinal disaccharidase deficiency Due to enzyme deficiencie Cystic fibrosis Chronic pancreatitis Carcinoma of pancreas Pancreatic insufficiencies

103. Clinical features- Diarrhoea, often steatorrhoea, is the most common feature. Watery, d i urnal an d n o cturnal, bulky, fre q u e nt stools are the clinical hallmark of overt malabsorption. Weight loss can be significant despite increased oral intake of nutrients. Growth retardation, failure to thrive, delayed puberty in children

104. Co n t i - Swelling or oedema from loss of protein Anaemias, commonly from vitamin B 12 , folic acid and iron deficiency presenting as fatigue and weakness. Muscle cramp from decreased vitamin D, calcium absorption. Also lead to osteomalacia and osteoporosis Bleeding tendencies from vitamin K and other coagulation factor deficiencies.

105. Diagnosis Blood tests Stool studies Radiological studies - Barium enema may be undertaken to see colonic or ileal lesions -CT abdomen is useful in ruling out structural abnormality, -Magnetic resonance cholangiopancreatography complement or as an alternative to ERCP. Interventional studies ( M R CP) to -Colonoscopy -Biopsy of small bowel showing coel iac disease

106. Other investigations Glucose hydrogen breath test for bacterial overgrowth Lactose hydrogen breath test for lactose intolerance Sugar probes or 51 Cr-EDTA to determine intestinal permeability.

107. Management Medical Management- Rep l ace ment o f nu t rients, necessary. e l ect r o l ytes an d fl u id may be In severe deficiency, hospital admission may be required for nutritional support Use of enteral nutrition by naso-gastric or other feeding tubes may be able to provide sufficient nutritional supplementation. Tube placement may also be done by percutaneous endoscopic gastrostomy, or surgical jejunostomy. Pancreatic enzymes are supplemented orally in pancreatic insufficiency.

108. Cont i - Dietary modification is important in some conditions: Gluten-free diet in coeliac disease. Lactose avoidance in lactose intolerance. Antibiotic therapy to treat Small Bowel Bacterial overgrowth. Cholestyramine o r other bile acid sequestrants will he l p reducing diarrhoea in bile acid malabsorption.

109. Nursing Management- Improvement of nutritional status by appropriate diet planning and supplemention of deficient nutrients or substituting them. Restoration of fluid and electrolyte balance by oral and parentral therapy. Continuous monitoring and recording of patient’s condition. Relief of pain by medications , Fower’s position and comfort. Analgesics ,antiflatulents and antidiarrheal agents are administered as prescribed.

110. Conti- Maintenance of skin integrity specially of perineal area . Health education to the parent about general cleanliness , nutrition , hydration, danger signs, home care and follow up for necessary medical help Relief of fear and anxiety about long –term illness and hospitalization by appropriate explanation , reassurance and necessary support.

111. MALNUTRITION

112. Definitions MALNUTRITION WHO defines Malnutrition as "the cellular imbalance between the supply of nutrients and energy and the body's demand for them to ensure growth, maintenance, and specific functions. “ Malnutrition is the condition that develops when the body does not get the right amount of the vitamins, minerals, and other nutrients it needs to maintain healthy tissues and organ function.

113. Causes Of PEM- Inadequate intake of food both in quality and quantity Infection especially ARI ,diarrhea, measles & worm infestations lead to the condition which increases in requirement for calories, proteins and other nutrients, while decreasing important cause of PEM.

114. Classification Of PEM- Syndromal Classification- Kwashiorkor Nutritional Marasmus Prekwashiorkor Nutritional dwarfing

115. Classification by Indian Academy Of Pediatrics- When the child is having weight more than 80% of expected weight for age , considered as normal. The grade of malnutrition is described as follows; Grade I - between 71-80% of expected weight for the age Grade II- between 61-70% of expected weight for the age Grade III - between 51-60% of expected weight for the age Grade IV- between 50% or less of expected weight for the age

116. Pathophysiology- Inadequate dietary intake protein/ calories Malabsorption and altered metabolism Nutrient less so appetite loss Weight loss, growth flattering Immunity lowered Incidence of infection, increased Prolonged duration of condition Malnutrition

117. Kwa s hior k or- K w ashi o r kor w a s Dr.Cicely particular i n t r od u c ed Williams term i n 193 5 , first described by in 1933 , but the “kw a sh i orkor ” w a s according to local “red b o y ” pigmentary name for the disease in Ghana. Th e term w a s said to mean due to characteristics changes.

118. Essential features of Kwashiorkor- Marked growth retardation with low weight and low height gain. Muscle wasting with retention of some subcutaneous fat Psychomotor changes characterized by mental apathy with listless , inertness , lack of interest about the surrounding , Lethargy , Dullness loss of appetite.

119. Pitting edema ,especially over the pretibial region , due to hypoalbunenia, and increased capillary permeability with damage cell membrane. To determine the extent of the pitting edema , your doctor will push on your skin, measure the depth of the indention, and record how long it takes for your skin to rebound back to its original position. They will then grade it on a scale from 1-4.

120. Non –Essential features of Kwashiorkor- Skin changes- It is found initially with erythema and hyperpigmented skin patches but later found as desquamated and hypopigmented patch with the appearance like old paint flaking off the surface of the wood (flaky –paint dermatosis).

121. Hair changes-hair Light colored hair or reddish brown color hair which becomes thin , dry, coarse, silky with easy pluckability. The affected child may have alopecia with alternate band of light and dark color hair as ‘flag sign’ which indicates period of inadequate , adequate and inadequate nutrition over a prolonged period.

122. C o nti- Su p eradded In f ecti o ns - Th e se chi l dren usua l ly suff er f r om repeated infections of GI tract with diarrhea ,vomiting, anorexia, and dehydration. Respiratory infections (ARI, tuberculosis) , skin infection, & septicemia , are common & difficult to manage in these patients.

123. Marasmu s - . Essential features of nutritional marasmus- Mar ked growth reta r dation with l e ss than 60 % o f expected weight for age & subnormal height/ length. Gross wasting of muscle & subcutaneous tissue Marked stunting & absence of edema.

124. Non Essential features of nutritional marasmus- Hair changes usually not present or may be hypopigmented. S k in l o oks dry , sc a ly with pr o mine nt l o o se folds a nd h avi n g reduced mid-upperarm circumference. Su p eradded i n fection are c omm on . S kin infections and diarrhea with vomiting & abdominal distention usually occur.

125. Cont i - Liver usually shrunk and the child is having craving for food & hunger. Psychomotor changes usually present with irritability , apathy & miserable appearance Features of mineral deficiencies (anemia) & vitamin deficiencies are usually found.

126. Preventive Management Health Promotion - Improvement of health of pre-pregnant state , pregnant mother and lactating women towards healthy mother for healthy child. Promotion of exclusive breastfeeding upto 4-6 months of age to prepare firm base of child health and promotes nutritional status. Appropriate weaning practices and nutritional supplementations. Improvement of family dietary habit with locally available , low cast food items for balanced diets.

127. Co n t i - Nutrition education and nutrition counseling to promote correct feeding practices , food habits ,food hygiene , safe water , environmental sanitation and to eliminate misconceptions regarding food & feedings. Improvement of home economics , earnings income generating activities , adequate dietary budget & diet planning for family members. Birth spacing & regulating family size

128. Cont i - Promotion o f ed u cational stat us espe c ially w o m e n lit e racy to improve the family health Provision of nutritional supplementations from ICDS centers & schools Mai n te n ance o f h e althy fami l y environ m ent , con g e n ital for physical , social and psychological development of children.

129. Specific Protection- Provision of balance diet with adequate proteins & energy for all children according to the age. Immunization against vaccine preventable diseases Promotion & maintenance of hygienic measures Food fortification to enrich the food items.

130. Early Diagnosis & Treatment Periodic health check –up of all children for health supervision & maintenance of growth chart. Detection of growth lag or growth failure as early as possible Early diagnosis and management of infections , worm infections & common childhood illnesses.

131. Promotion o f early rehy d ration therapy i n the child having diarrhea, without restriction of feeding. I m plementation o f s upp l ementary feedi n g programs & services.

132. Rehabilitation- Nutritional rehabilitation services Hospital management of advanced PEM cases Follow up care

133. Nursing Responsibilities- Assessment of nutritional status of the children with collection of ap p ropri a te dietary h i s tory ,h i story of breastfeeding, weaning, food habits, status, ba l an c ed diet , s o c i o e c on o mic presence of illness etc. physical examination and anthropometric assessment also important to detect the nutritional deficiency states.

134. Cont i - Implementing nutritional rehabilitation activities Encouraging the parents for home care & follow up at regular interval. Nutr i ti o n ed u c a ti o n , dem o n s tr a ti o n & c o un s eling a c cordi n g to identified problems of particular child informing about breast feeding, ap p ropri a te feeding p ra c ti c es and food h a bits, weaning , balanced diet , food hygiene , personal hygiene, cultural taboos , irr a ti o nal be l iefs , qu a li ty of c o m m on foods , food values , food preservations.etc. Promoting preventive measures for individuals , family & community to overcome the problem of PEM

135. Conti- Assisting in diagnostic investigations whenever necessary Maintenance of growth chart by regular health check-up at home , clinic or health centre for early detection of growth failure Participating in the hospital management in complications & life threatening situations related to PEM & other related illnesses.

136. NURSING ASSESSMENT I m ba l ance nutrition l e ss than body rq u irement related to unhealthy dietary practices Altered growth and development related to deficit of protein Risk for infection related to lowered resistence to disease Activity intolerance related to weakness Fear and anxiety related to hospitalization

137. BIBLIOGRAPHY:- As s u m a B e e v i . T .M , T e x t b o o k o f p e di a tr i c n u r s i n g , , 1 S T ed i tio n , p ubl i s h ed b y Elsei v er p v t , ltd. Noida, Parul dutta, pediatric nursing,3 RD edition, jaypee publication, page no.288-315. Marlow R.D. “Textbook of pediatric Nursing” 6 TH edition ,W.B. Saunders company, Wong L.D. Hockenberry J.M. “Nursing care of infants & children” 7 TH edition.,Philadelphia, Piyush gupta , “Essential Pediatrics Nursing”, 3 rd edition, CBS Publcation & distributers pvt.ltd. Swarna Rekha Bhat, Achars, Textbook of pediatrics , 4 th edition, published by universities press ( india) pvt. Ltd. Rimple Sharma, Essentials of pediatric Nursing, 1 st edition, jaypee publication , page no- 456-458. WWW.GOOLE search