Maternal & Child Nursing II PDF

ALTERATIONS WITH NUTRITION AND GASTROINTESTINAL, b. Baby's face may flush and extremely difficult to METABOLISM AND ENDOCRINE comfort TOPIC OUTLINE...

ALTERATIONS WITH NUTRITION AND GASTROINTESTINAL, b. Baby's face may flush and extremely difficult to METABOLISM AND ENDOCRINE comfort TOPIC OUTLINE 4. Crying that occurs for no apparent reason 5. Posture changes a. Curled up legs, clenched fists and tensed I. Colic abdominal muscles during colic episodes II. Cleft Lip and Palate RELIEVING COLIC III. Imperforated anus IV. Intussusception 1. Change infant’s position frequently, with child’s face down V. Hirschprung’s Disease and with body across parent’s arm, with parents’ hand under VI. Failure to Thrive infant’s abdomen, applying gentle pressure VII. Poisoning 2. Gently massage infant’s abdomen VIII. Diabetes mellitus 3. Swaddle infant tightly with a soft stretchy blanket IX. Obesity 4. Provide smaller, frequent feedings X. Anorexia Nervosa 5. Burp infant during and after feeding 6. Place infant in an upright seat after feeding COLIC 7. Respond immediately to the crying 8. Change from one cow's milk formula to another “Infant colic or baby colic” 9. Change from a cow's milk formula to a soy formula ▪ Described as paroxysmal abdominal pain or cramping that is 10. Change from a regular formula to a "predigested," manifested by loud crying and drawing the legs up to the hypoallergenic formula abdomen 11. If you're breastfeeding, avoid eating certain foods and taking ▪ The term applies to any healthy, well-fed infant who cries herbal supplements. more than 3 hours a day, more than 3 days a week, for more 12. Change the type of nipples on your baby's bottle, use bottles than 3 weeks. with plastic liners. a. Regurgitation – return of undigested food from the 13. Try giving him more time in a front baby carrier stomach, usually accompanied by burping. 14. Take your baby for a ride in the car for a change in b. Spitting up – dribbling of unswallowed formula from environment the infant’s mouth immediately after a feeding. 15. Use "white noise" (such as static on the radio or the vacuum cleaner), classical music, or a "heartbeat tape" next to the POSSIBLE TRIGGERING FACTORS crib 16. Try infant massage. 1. More common in young infants less than 3 months old 17. Put a warm water bottle on your baby's belly. 2. Infants of mothers who smoke during pregnancy or after 18. Have him or her suck on a pacifier. delivery. 19. Soak baby in a warm bath 3. Allergy to formula milk or problem with the cow's milk 20. Try an infant swing. protein or lactose in some baby formulas a. Reflux -- 21. Increase or decrease the amount of stimulation in the heartburn due to stomach acid and milk flowing back into the environment. windpipe. 22. Watch out for over-stimulation or increased fatigue. 4. A growing digestive system with muscles that often spasm. 23. Use of homeopathic drops for colic, some parents say they 5. Air intake from feeding or crying have helped their colicky baby 6. Hormones that cause stomachaches or a fussy mood. 7. Oversensitivity or over-stimulated by light, noise, etc. CLEFT LIP AND PALATE 8. A moody baby 9. A still-developing nervous system 1. Defects that occur when a baby's lip or mouth do not form 10. Improper feeding technique properly. 11. Over feeding the infant 2. Happen early during pregnancy. 12. Too rapid feeding 3. A baby can have a cleft lip, a cleft palate, or both. 13. Emotional stress or tension between parent and child During the first six to eight weeks of pregnancy, the shape of the embryo's head is formed. Five CLINICAL MANIFESTATION primitive tissue lobes grow: 1. Abdominal bloating a) One from the top of the head down towards the 2. Predictable crying episodes a. Cries about the same time future upper lip; (Frontonasal Prominence) every day, usually in the late afternoon or evening. b. Colic episodes may last from a few minutes to three hours or more b-c) two from the cheeks, which meet the first lobe on any given day. c. Baby may have a bowel movement or to form the upper lip; (Maxillar Prominence) pass gas near the end of the colic episode. 3. Intense or inconsolable crying d-e) and just below, two additional lobes grow from a. Intense, sounds distressed and is often high pitched each side, which form the chin and lower lip; (Mandibular Prominence) NUR 1210 – MODULE 3B: ALTERATIONS IN NUTRITION AND GASTROINTESTINAL, METABOLISM AND ENDOCRINE ALMEÑANA, JOHN RENDEW | BSNR 2026  NUR 1210 | MATERNAL & CHILD NURSING II | NCM 1209 If these tissues fail to meet, a gap appears where NURSING CARE MANAGEMENT the tissues should have joined (fused). 1. Address the infant’s physical needs as well as the parents’ The upper lip is formed earlier than the palate, emotional needs from the first three lobes named a to c above. 2. Encourage expression of parental grief and fears Formation of the palate is the last step. 3. Teach the parent how to successfully feed the child Back portions are called palatal shelves Pre operative Care CAUSES 1. Elbow restraints 1. Genetic 2. Feeding the infant in the manner to be used postoperatively 2. Maternal hypoxia (due to maternal smoking, maternal 3. Medication (determined by the surgeon and anesthesiologist) alcohol or drug abuse or some forms of maternal 4. Feed a child with cleft lip using the ESSR method. a. Enlarge hypertension treatment) the nipple with head Elevated b. Stimulate the sucking reflex 3. Seasonal causes (such as pesticide or Lead exposure) c. Swallow thoroughly d. Rest after each swallow 4. Maternal diet and vitamin intake; retinoids — which are members of the vitamin A family. Post operative Care: Cleft Lip 5. Anticonvulsant drugs 6. Lack of Folic acid 1. Avoid prone position (To prevent suture damage). 2. Breast-feeding may be initiated once the child is awake and VARIATION IN CLEFTS LIP AND PALATE AT BIRTH alert. 3. Elbow restraints may be applied immediately after surgery. 1. Unilateral incomplete Cleft Lip a. Prevents infant from rubbing the suture line 2. Unilateral complete Cleft Lip b. Advisable to pin the cuffs of the restraints to the 3. Bilateral complete Cleft Lip infant’s clothing 4. Unilateral complete lip and palate c. Jacket restraints for older infant who is able to roll 5. Bilateral complete Lip and Cleft Palate over 6. Complete Cleft Palate (soft and hard palate, possibly 4. Offer clear liquids when the infant has fully recovered from including a gap in the jaw) anesthesia (via syringe or dropper). 7. Incomplete Cleft Palate (a 'hole' in the roof of the mouth, 5. Cleanse the suture line as needed. usually as a cleft soft palate) 6. Thin layer of prescribed antibiotic may be applied. DIAGNOSTIC AND LABORATORY PROCEDURES 7. osition the infant side lying on the opposite side of the operative site to prevent airway obstruction by secretions, 1. Ultrasonography - As early as 14 to 16 weeks of gestation. 2 blood or the tongue 2. Determine whether the defect is isolated or one feature of a 8. Monitor operative sites for bleeding (frequent swallowing). broader syndrome. 9. Pain management should continue in the home setting THERAPEUTIC MANAGEMENT Post Operative Care: Cleft Palate 1. Cheiloplasty 1. Allow to lie on the abdomen. a. Surgical Correction of Cleft Lip 2. May resume feedings by special feeding device (soup spoon) b. Within the first 2–3 months after birth shortly after the surgery c. "Rule of 10s": the child is at least 10 weeks of age; 3. Parents can assist palatal function weighs at least 10 pounds and has at least 10g a. Stimulate the child to use simple words that require hemoglobin). the coordination of the speech apparatus d. If the cleft is bilateral and extensive, two surgeries may b. Encourage chewing be required to close the cleft, one side first, and the c. Frequent swallowing (To exercise throat and second side a few weeks later. The most common palatine muscles) procedure to repair a cleft lip is the Millard procedure e. Repair involves one of the staggered suture lines (Z Care of Children with CL and CP – plasty) 4. Involves a group of specialists who meet periodically 2. Palatoplasty 5. Regular examination of the ears a. Surgical Correction of Cleft Palate 6. Speech therapy is required. b. Often a cleft palate is temporarily covered by a palatal 7. Extensive orthodontics and prosthodontics obturator (a prosthetic device made to fit the roof of the mouth covering the gap). COMPLICATIONS c. Usually performed between 6 and 12 months. d. Bone tissue can be acquired from the patients own 1. Feeding problems chin, rib or hip 2. Ear disease 3. Insertion of Tympanostomy tube into the eardrum to aerate 3. Speech problem the middle ear. 4. Socialization problems a. Beneficial for the hearing ability of the child. b. Hearing impairment is particularly prevalent in children with cleft palate c. Speech therapy (/p/, /b/, /t/, /d/, /s/, /z/, etc) d. Prosthetics NUR 1208 – MODULE 3B: ALTERATIONS IN NUTRITION AND GASTROINTESTINAL, METABOLISM AND ENDOCRINE Page | 2 ALMEÑANA, JOHN RENDEW | BSNR 2026  NUR 1210 | MATERNAL & CHILD NURSING II | NCM 1209 IMPERFORATED ANUS SURGICAL TREATMENT ▪ Birth defect where the anus has no normal opening or is 1. Colostomy blocked. 2. Anoplasty with pull-through operation – Pulling the rectum ▪ The condition develops in utero during the 5TH to 7TH weeks down to the anus where a new anal opening is created. of pregnancy. 3. Anal dilatation – Repeatedly done periodically for a few months to stretch the anus to prevent it from narrowing. CAUSES NURSING CARE MANAGEMENT 1. More common in boys than girls 2. Imperforate anus is an occasional complication of Pre-operative Care sacrococcygeal teratoma 3. Associated Anomalies (VACTERL) ▪ Assist in diagnostic evaluation a. Vertebral defects - malformation of the vertebrae ▪ Gastro intestinal decompression b. Anal atresia - a congenital anorectal malformation ▪ Monitor IV fluids (ARM) where a normal anal opening is absent at birth ▪ Give medications c. Cardiac anomalies - problems with the structure of ▪ Inform the family of the surgical procedure to be done. the heart. Post-operative Care d. Tracheal fistula - an abnormal connection between your esophagus and trachea ▪ Monitor vital signs e. Esophageal atresia - a rare birth defect in which a ▪ Administer IV fluids, antibiotics and pain medication baby is born without part of the esophagus ▪ Maintain appropriate skin care at the stoma site f. Renal anomalies – congenital (present at birth) ▪ Teach parents how to provide optimum care of the skin and abnormalities or malformations in the structure or the appliance, while maintaining an appropriate bond with function of the kidneys the child. g. Limb a. Normal skin should be intact and clear b. Ensure that the skin is dried well before applying a FORMS OF IMPERFORATED ANUS new pouching system 1. Low lesion c. Examine skin and stoma before applying a new a. The colon remains close to the skin pouch b. There may be a stenosis or narrowing of the anus, d. If there is any itching or leakage, change pouch or the anus may be missing altogether, with the immediately rectum ending at a blind pouch. e. Ensure that stoma size is re measured periodically 2. High lesion PROGNOSIS a. The colon is higher up in the pelvis b. There is a fistula connecting the rectum and the 1. Children who have more complex surgeries still have control bladder, urethra or the vagina. over their bowel movements most of the time. 3. Persistent cloaca 2. Some children may need more surgery. a. The rectum, vagina and urinary tract are joined into 3. Toilet training may take a bit longer. a single large opening called a “Cloaca” INTUSSUSCEPTION CLINICAL MANIFESTATION Invagination of one portion of the intestine - either the small ▪ Anal opening very near the vaginal opening in girls intestine or colon slides into another part of the intestine. ▪ Missing or misplaced opening to the anus ▪ No passage of first stool within 24-48 hours after birth CAUSING AND RISK FACTORS ▪ Stool passes out of the vagina, base of penis, scrotum or 1. Children between 3 months and 3 years; peak occurrence is urethra between ages of 5-9 months ▪ Swollen belly area 2. Affects mostly boys than girls, ratio of 3:2 DIAGNOSTIC AND LABORATORY PROCEDURES 3. Infection’s rotavirus 4. Anatomical factors 5. Socioeconomic status 6. Improper 1. Physical examination vaccination a. Absence of anal opening b. Flat perineum PATHOPHYSIOLOGY c. Absence of a midline intergluteal groove Intussusception is believed to be secondary to an imbalance in the d. Presence of a prominent anal dimple and a band of longitudinal forces along the intestinal wall. This imbalance can be skin tissue (“bucket handle”) caused by a mass acting as a lead point or by a disorganized 2. Abdominal, spine and Pelvic ultrasonography pattern of peristalsis. 3. Radiography of the abdomen and the spine 4. CT Scan ▪ The invaginating portion of the intestine completely 5. Pelvic and esophageal MR “telescopes” into the receiving portion of the intestine. 6. Fluoroscopic examination pelvic anatomic contents and ▪ Ischemic mucosa sloughs off, leading to the heme- lower spinal anatomy positive stools and subsequently to the classic "currant 7. IV pyelogram and cystourethrogram jelly stool" 8. Echocardiogram NUR 1208 – MODULE 3B: ALTERATIONS IN NUTRITION AND GASTROINTESTINAL, METABOLISM AND ENDOCRINE Page | 3 ALMEÑANA, JOHN RENDEW | BSNR 2026  NUR 1210 | MATERNAL & CHILD NURSING II | NCM 1209 CLINICAL MANIFESTATIONS ▪ Most intussusceptions recur within 72 hours of the initial event; however, recurrences have been reported as long as 1. Colicky, severe, and intermittent abdominal pain 36 months later. 2. Nausea and bilous vomiting 3. Drawing of the knee to the chest and kicking the legs in the HIRSCHRPRUNG’S DISEASE air 4. Currant jelly stool mixed with sloughed mucosa, blood and “Congenital Aganglionic Megacolon; Congenital megacolon” mucus. ▪ "A developmental disorder of the enteric nervous system 5. Palpable right hypochondrium sausageshaped mass and (ENS) and is characterized by an absence of ganglion cells in emptiness in the right lower a. quadrant (Dance sign) the distal colon thus, poor muscle movement in the bowel 6. Inconsolable crying resulting in blockage of the large intestine, a congenital 7. Swollen (distended) abdomen condition. 8. Fever 9. Dehydration RISK FACTORS 10. Periods of lethargy alternating with crying spells (cycle repeats every 15-30 minutes) ▪ Japanese and American children. ▪ 4x more common in males than females DIAGNOSTIC AND LABORATORY PROCEDURES ▪ Sometimes associated with other inherited or congenital conditions such as Down syndrome 1. Barium enema demonstrates the obstruction 2. Abdominal radiograph to detect intraperitoneal air from a PATHOPHYSIOLOGY bowel perforation 3. Rectal examination reveals mucus, blood and occasionally a Hirschsprung's disease (HD) is a disorder of the abdomen that low intussusception. occurs when part or all of the large intestine or antecedent parts 4. Ultrasound of the gastrointestinal tract have no ganglion cells and therefore cannot function. During normal fetal development, cells from the THERAPEUTIC MANAGEMENT neural crest migrate into the large intestine (colon) to form the networks of nerves called Auerbach's plexus and Meissner's 1. Hydrostatic reduction (With barium or watersoluble contrast) plexus. 2. Non-surgical treatment Barium enema ▪ In most affected people, the disorder affects the part of the 3. Intussusception reduction colon that is nearest the anus. Laparoscopy (segments of intestine are pulled ▪ In rare cases, the lack of nerve bodies involves more of the apart by forceps) colon. In five percent of cases, the entire colon is affected. Manual reduction (Milking the intussusceptum out ▪ Muscle contractions in the gut help digested foods and of the intussuscipiens) liquids move through the intestine. This is called peristalsis. Segmental resection with an end-to-end CLINICAL MANIFESTATION anastomosis Medications are limited to pain control after 1. Abdominal distention (relieved by rectal stimulation or surgery enema) 2. Green or brown Vomitus NURSING CARE MANAGEMENT 3. Failure to pass meconium within the last 48 hours of life ▪ Explain the nonsurgical techniques and possibility of surgery 4. Fecal impaction to the parents. 5. Poor feeding and Failure to thrive ▪ Explain the basic defect of intussusceptions and how 6. Jaundice intussusceptions are corrected with contrast enemas. 7. Chronic constipation with passage of ribbon like, foul ▪ Preserve the parent- child relationship by encouraging smelling stools rooming-in or extended visiting. 8. Poor weight gain ▪ Frequent v/s and BP monitoring 9. Evidence of previous GI dysfunction 10. Watery diarrhea (in the newborn) COMPLICATIONS DIAGNOSTIC AND LABORATORY PROCEDURES ▪ Perforation during nonoperative reduction ▪ Wound infection 1. Abdominal x-ray ▪ Internal hernias and adhesions causing intestinal obstruction 2. Anal manometry – a balloon is inflated in the rectum to ▪ Sepsis from undetected peritonitis (major complication from measure pressure in the area a missed diagnosis) 3. Barium enema ▪ Intestinal hemorrhage 4. Rectal biopsy – for histological evidence of the absence of ▪ Necrosis and bowel perforation ganglion cells (Gold 1. standard) ▪ Recurrence 5. Palpate loops of bowel in the swollen belly 6. A rectal exam reveal tight muscle tone in the rectal muscles. PROGNOSIS THERAPEUTIC MANAGEMENT ▪ Outlook for intussusception is excellent when treated quickly, but when untreated it can lead to death w/in 2–5 days. ▪ Serial rectal irrigation helps relieve pressure in (decompress) the bowel. ▪ Colostomy is performed first NUR 1208 – MODULE 3B: ALTERATIONS IN NUTRITION AND GASTROINTESTINAL, METABOLISM AND ENDOCRINE Page | 4 ALMEÑANA, JOHN RENDEW | BSNR 2026  NUR 1210 | MATERNAL & CHILD NURSING II | NCM 1209 ▪ Surgical removal (resection) of the abnormal section of the 3. Psychosocial factors colon, followed by reanastomosis a. Loss of emotional bond between parent and child b. Child-caregiver relationship NURSING CARE MANAGEMENT a. Physical inability to produce enough 1. Help the parents adjust to the congenital disorder breastmilk. a. Foster an infant – parent bonding b. Using only babies' cues to regulate b. Prepare the parents for medical surgical breastfeeding so as to not offer a sufficient intervention. numbers of feeds (sleepy baby syndrome) c. Assist them in caring for the colostomy after c. Inability to procure formula when needed. discharge. d. Purposely limiting total caloric intake 2. Post-operative Care e. Not offering sufficient age-appropriate solid a. Monitor bowel sounds and passage of stools will foods for babies and toddlers over the age of indicate when can oral feeding. six months c. 3. Home Care c. Parents do not understand the appropriate diet a. Provide instructions about colostomy care; skin needs for the child. care, emptying and changing the ostomy appliance, d. Exposure to infections, parasites, or toxins and monitoring for problems. e. Poor eating habits, such as eating in front of the television and not having formal mealtimes. POSSIBLE COMPLICATIONS 4. Idiopathic failure to thrive 1. Inflammation and infection of the intestines (enterocolitis) CLINICAL MANIFESTATION may occur before surgery, and sometimes during the first 1 - 2 years afterwards. 1. Lack of appropriate weight gain (Weight is lower than 3rd 2. Perforation or rupture of the intestine percentile of standard growth charts or 20% below the ideal 3. Short bowel syndrome, a condition that can lead to weight for their height) malnourishment and dehydration 2. Growth may have slowed or stopped 3. Delayed motor development PROGNOSIS 4. Irritability and excessive crying 5. Easy fatigue ability 1. A small number of children may have constipation or 6. Avoids eye contact problems controlling stools (fecal incontinence). 7. Excessive sleepless (lethargy) 2. Children who get treated early or who have a shorter 8. Skin and hair - Poor hair texture and amount, nails, alopecia, segment of bowel involved have a better outcome. hygiene, rashes, birth marks, trauma (eg, bruises, burns, or scars as signs of physical abuse) FAILURE TO THRIVE 9. Protruding abdomen ▪ Growth failure; FTT; Feeding disorder; Poor feeding; faltering 10. Constipation weight or weight faltering ▪ Refers to children whose current weight or rate of weight DIAGNOSTIC AND LABORATORY PROCEDURES gain is below the third or fifth percentiles than that of other 1. Anthropometric measurement children of similar age and gender 2. Physical examination for evidence of organic causes ▪ Failure to maintain an established pattern of growth and 3. Denver Developmental Screening Test to show any delays in development that responds to the provision of adequate development nutritional and emotional needs of the patient. 4. Dietary intake CATEGORIES OF FAILURE TO THRIVE 5. Blood count, urine test and other blood chemical and electrolyte test to search for 1. underlying medical problem 1. Endogenous or Organic failure to thrive (OFTT) 6. Create a growth chart outlining all types of growth since birth a. Inborn error of metabolism is created. b. Cystic fibrosis, diarrhea, liver disease, and celiac 7. Electrolyte balance disease 8. Hemoglobin electrophoresis to check for conditions such as c. Gas and acid reflux sickle cell disease d. Physical deformities such as cleft palate and tongue 9. Hormone studies, including thyroid function tests tie 10. X-rays to determine bone age knee studies, wrist studies, or e. Milk allergies both f. Parasites, asthma, urinary tract infections, heart 11. Skeletal survey for occult trauma if physical abuse is disease suspected 2. Exogenous or Nonorganic failure to thrive (NFTT) 12. Head CT scanning or MRI studies to reveal microcephaly, a. Caregiver's actions Factors that lead to inadequate macrocephaly, or congenital malformation or if abusive head infant caloric intake: trauma is a concern a. Poverty 13. Urinalysis - Hydration status with specific gravity, evidence of b. Health or childrearing beliefs infection, renal tubular acidosis c. Inadequate nutritional knowledge 14. Renal function - Serum electrolytes, BUN, and creatinine d. Family stress levels e. Feeding resistance 15. Liver function – to determine protein wasting or f. Insufficient breast milk organomegaly 16. Sweat test for cystic fibrosis NUR 1208 – MODULE 3B: ALTERATIONS IN NUTRITION AND GASTROINTESTINAL, METABOLISM AND ENDOCRINE Page | 5 ALMEÑANA, JOHN RENDEW | BSNR 2026  NUR 1210 | MATERNAL & CHILD NURSING II | NCM 1209 17. Zinc level reported to be low in malnourished infants and 4. Cosmetic items (nail polish, nail glue remover and nail children primer) 18. Metabolic and endocrinology screening (only as needed) 5. Carbon Monoxide. 19. Tuberculosis testing 6. Poorly prepared or cooked food, and food that has gone 20. Stool studies mouldy or been contaminated with bacteria from raw meat. 7. Insect stings GOAL OF MANAGEMENT 8. Snake bites Goal: provide sufficient calories to support “catch up” growth, a 9. Alcohol, if an excessive amount is consumed in a short period rate of growth greater than the expected rate for age (alcohol poisoning) NURSING CARE MANAGEMENT CLINICAL MANIFESTATION ▪ Accurate assessment of initial weight and height and daily ▪ Vomiting weight ▪ Burns or redness around the mouth and lips, from drinking ▪ Record all food intake certain poisons ▪ Provide a positive feeding environment ▪ Stomach pains ▪ Teach the parent successful feeding strategies ▪ Breath that smells like chemicals, such as gasoline or paint ▪ Support the child and family thinner ▪ High temperature NUTRITIONAL MANAGEMENT ▪ Empty medication bottles or scattered pills ▪ Sleepiness 1. Correct nutritional deficiencies and achieve appropriate ▪ Difficulty breathing weight for height ▪ Confusion 2. Allow for “catch–up” growth ▪ Drowsiness and fainting fits 3. Restore optimum body composition 4. Educate the parents, primary caregivers regarding child’s PREVENTION OF POISONING nutritional requirements and appropriate feeding methods 5. Increase the number of calories and amount of fluid the 1. Store medicine, cleaning and laundry products, infant receives paints/varnishes and pesticides in their original packaging in 6. Correct any vitamin or mineral deficiencies locked cabinets or containers, out of sight and reach of 7. Identify and treat any other medical conditions children. 8. The child may need to stay in the hospital for a little while. 2. Purchase and keep all medicines in containers with safety 9. Help improve family relationships and living conditions. caps. Discard unused medication 10. Avoid distractions, such as television, at meal time. 3. Never refer to medicine as “candy” or another appealing name. PREVENTION 4. Check the label each time you give a child medicine; Use correct dosage ▪ Regular checkups can help detect failure to thrive in children 5. Never place poisonous products in food or drink containers POSSIBLE COMPLICATION 6. Keep coal, wood or kerosene stoves in safe working order 7. Maintain working smoke and carbon monoxide detectors. ▪ Permanent mental, emotional, or physical delays can occur. THERAPEUTIC MANAGEMENT PROGNOSIS 1. Swallowed poison: 1. Normal growth and development may be affected if a child a. Take the item away from the child, and have the fails to thrive for a long time. child spit out any remaining substance. 2. Normal growth and development may continue if the child b. Do not make your child vomit. Do not use syrup of has failed to thrive for a short time, and the cause is ipecac. determined and treated. 2. Skin poison: a. Remove the child’s clothes and rinse the skin with POISONING lukewarm water for at least 20 minutes. 3. Eye poison: ▪ When a person is exposed to a substance that can damage a. Flush the child’s eye by holding the eyelid open and their health or put their life in danger. pouring a steady stream of room temperature ▪ Poisons can be: water into the inner corner for 15 minutes. Swallowed 4. Poisonous fumes: Splashed into the eyes a. Take the child outside or into fresh air immediately. Inhaled b. If the child has stopped breathing, start Injected cardiopulmonary resuscitation (CPR) and do not Absorbed through the skin stop until the child breathes on his or her own, or TYPES OF POISON until someone can take over 5. Injected poisons (e.g. from the sting of poisonous animals): 1. Household products (bleach, drain openers, toilet bowl a. Bind the affected body part with a pressure 2. Some types of plants and fungi cleaners, rust removers, and bandage to make sure the poison is not pumped oven cleaners) through the body and by placing the affected body 3. Certain types of chemicals and pesticides NUR 1208 – MODULE 3B: ALTERATIONS IN NUTRITION AND GASTROINTESTINAL, METABOLISM AND ENDOCRINE Page | 6 ALMEÑANA, JOHN RENDEW | BSNR 2026  NUR 1210 | MATERNAL & CHILD NURSING II | NCM 1209 part in hot water (with a temperature of 50 °C) to PATHOPHYSIOLOGY break down the poison 6. Take the poison container (or any pill bottles) with you to the Insulin is needed to support the metabolism of carbohydrates, hospital. fats, and proteins primarily by facilitating the entry of these 7. Don't give ipecac syrup or do anything to induce vomiting. substances into the cell, with the exception of nerve cells and vascular tissue. GASTRIC DECONTAMINATION ▪ Glucose “spills” into the urine (glycosuria), along with an 1. Activated charcoal osmotic diversion of water (polyuria) a. To prevent poison absorption ▪ Excessive thirst (polydipsia) observed in diabetes b. Ineffective against metals such as sodium, potassium and lithium and alcohol and glycols CLASSIFICATION c. Not recommended for ingestion of corrosive 1. Insulin – dependent diabetes mellitus (IDDM) /Type I chemicals such as acids and alkalis ▪ Can develop at any time during childhood, even during 2. Whole bowel irrigation infancy, but usually begins between ages 6 & 13 years a. Cleanses the bowel 2. Non – insulin – dependent diabetes mellitus (NIDDM)/Type II b. Patient is given large amounts of a polyethylene ▪ Occurs mainly in adolescents but is becoming glycol solution which is not absorbed into the body, increasingly common among overweight or obese having the effect of flushing out the entire GIT children. c. Used following ingestion of sustained release drugs, toxins that are not absorbed by activated TYPE 1 TYPE 2 charcoal and for the removal of ingested packets of Definition ▪ Beta cells in Diet related insulin drugs (body packing/smuggling) pancreas are release is so large and 3. Gastric lavage (Stomach pump) being attacked by frequent that receptor a. Insertion of a tube into the stomach, followed by body's own cells cells have become less administration of water or saline down the tube. thus can't produce sensitive to the insulin to take insulin. Thus, less The liquid is then removed along with the contents sugar out of the sugar is being of the stomach Blood stream removed from the b. Performed within 1 hour of ingestion and the ▪ Insulin is not Blood. exposure is potentially lifethreatening. produced 4. Nasogastric aspiration Diagnosis Genetic, Genetic, obesity a. Involves placement of tube via the nose down into environmental, and (central adipose), the stomach, stomach contents are then removed auto- immune factors, physical inactivity, by suction idiopathic high/low birth weight, GDM, poor placental Enhanced excretion growth, metabolic syndrome ▪ Diuresis Warning Increased thirst & Feeling tired or ill, ▪ Hemoperfusion Signs urination, constant frequent urination ▪ Peritoneal dialysis hunger, weight loss, (esp. at night), unusual ▪ Hemodialysis blurred vision and thirst, weight loss, ▪ Hyperbaric medicine extreme tiredness, blurred vision, ▪ Exchange transfusion glycosuria frequent infections ▪ Chelation (use of chelating agents to detoxify poisonous and slow wound metal agents) healing, Commonly Triggered autoimmune Appears to be related DIABETES MELLITUS Afflicted destruction of the beta to aging, sedentary Groups cells; autoimmune lifestyle, genetic ▪ A chronic disorder of metabolism characterized by a partial attack may occur after influence, but mostly or complete deficiency of the hormone insulin because the a viral infection obesity body does not produce enough insulin. Common Mostly Normal or Thin Mostly Overweight or ▪ DM in children can occur at any age but has a peak incidence physical Obese between age 10 and 15 years with 75% diagnosed before 18 attributes years of age. found ▪ Diabetes fasting blood sugar level is 126 milligrams per You have Your body makes too Body can still produce deciliter (mg/dL) or higher. this when little or no insulin insulin but does not use it properly (insulin RISK FACTORS FOR TYPE 2 DM resistance) Affected Between 5 - 25 Most children who 1. Overweight age group (Maximum numbers in have Type 2 Diabetes 2. Having a close relative with type 2 diabetes this age group; Type 1 has a family history of 3. Being Native American, black, Hispanic, or Asian/Pacific can affect at any age) diabetes, are Islander overweight, and are 4. Having high blood pressure, high blood levels of lipids (fats), not very physically or polycystic ovary syndrome. active. Usually develops around puberty NUR 1208 – MODULE 3B: ALTERATIONS IN NUTRITION AND GASTROINTESTINAL, METABOLISM AND ENDOCRINE Page | 7 ALMEÑANA, JOHN RENDEW | BSNR 2026  NUR 1210 | MATERNAL & CHILD NURSING II | NCM 1209 TYPE 1 TYPE 2 THERAPEUTIC MANAGEMENT Glucose Open and absorb Are unable to open Channels / glucose into cell to be and absorb glucose, The definitive treatment is replacement of insulin that the child is Receptors utilized by processes therefore, glucose unable to produce. Insulin - is a hormone that is released by the after the induction of cannot be utilized by pancreas. insulin processes as a result the glucose stays in 1. Insulin Therapy- The goal is maintaining near normal blood the blood stream glucose values while avoiding too frequent episodes of Cure None There is no cure hypoglycemia. There are four main types of insulin: for type 2 a. Rapid acting insulin – used as a bolus dosage diabetes, although − Action onset is 15 minutes with peak actions sometimes gastric in 30 to 90 minutes; lasts as long as 5 hours o surgery and/or Lispro lifestyle/medication b. Short acting insulin treatment − Onset is within 30 minutes with peak action can result in around 2 to 4 hours; lasts for about 4 to 8 remission hours o Regular insulin Treatment Insulin Injections, Diet, exercise, weight c. Intermediate acting insulin dietary plan, regular loss, and in many − Onset is within 1 to 2 hours with peak action check-up of blood cases medication. sugar levels, daily of 4 to 10 hours; lasts for about 14 to 20 exercise hours o PH and Lente insulin Onset Rapid (weeks) often Slow (years) d. Long acting insulin present acutely with − Usually given around bedtime; onset is 6 to ketoacidosis 14 hours; has no peak or avery small peak; stays in the blood between 20 to 24 hours o Ultralente insulin CLINICAL MANIFESTATION Method of Administration 1. Polyphagia 2. Weight loss i. Daily insulin is administered subcutaneously by twice – 3. Enuresis or nocturia daily injections, by multiple – dose injections, or by 4. Polydipsia means of an insulin infusion pump. 5. Irritability ii. Insulin Pump- an electromechanical device designed to 6. Flushed skin deliver fixed amounts of regular or lispro insulin 7. Polyuria continuously, thereby more closely imitating the release 8. Fatigue of the hormone by the islet cells. 9. Shortened attention span Monitoring 10. Pruritus 11. Blurred vision i. Daily monitoring of blood glucose levels 12. Poor wound healing (euglycemic/normal range of 80 to 120 mg/dL) 13. Paresthesia ii. Urine testing for glucose is no longer used for 14. Headache diabetic management; However, urine testing can 15. Frequent infections be carried out to detect evidence of ketonuria. 2. Diet DIAGNOSTIC AND LABORATORY PROCEDURES a. Plenty of complex carbohydrates, such as whole- ▪ 8- hour fasting blood glucose level Fasting (DM if higher than grain breads, pastas, potatoes, beans, and peas 126 mg/dL) b. Unprocessed foods, such as bran cereals, oatmeal, ▪ Random blood glucose (level of 200 mg/dL or higher often and fresh fruits and vegetables. means you have diabetes) c. Snacks are important since children require ▪ Oral glucose tolerance test (OGTT) frequent feedings to supply necessary calories for Between 140 and 200 mg/dL is called impaired growth. glucose tolerance d. Good snack choices include fresh fruit, dried fruit, Before the test begins, a sample of blood will be cheese crackers, peanut butter crackers, yogurt, taken. You will then be asked to drink a liquid trail mix, vanilla wafers, grain crackers, or granola containing a certain amount of glucose (usually 75 bars, if strenuous exercise is planned. grams). e. Desserts good for all members of the family include ▪ Postprandial blood glucose fresh fruit, low-fat yogurt, pudding, and Jell- O. Several Meal Planning Approaches a. Exchange NURSING DIAGNOSIS system b. Carbohydrate counting c. Dietary fiber 3. Exercise 1. Risk for infection r/t reduced body defences a. Exercise is encouraged and never restricted unless 2. Altered Nutrition: Less than Body Requirements indicated by other health conditions. 3. Altered Family Process r/t a child with a lifethreatening illness b. Exercise lowers blood glucose levels and aids in 4. Activity intolerance r/t fatigue utilization of food & often results in reduction of 5. Body image Disturbance insulin requirements. 6. Individual Coping: Ineffective NUR 1208 – MODULE 3B: ALTERATIONS IN NUTRITION AND GASTROINTESTINAL, METABOLISM AND ENDOCRINE Page | 8 ALMEÑANA, JOHN RENDEW | BSNR 2026  NUR 1210 | MATERNAL & CHILD NURSING II | NCM 1209 c. Physical training tends to increase tissue sensitivity 4. Psychiatric illness. to insulin even in the resting state. a. Psychological factors. For some people, emotions 4. Health Team for DM: influence eating habits. Many people eat a. Diabetes educators excessively response to emotions such as boredom, b. Physician - how many insulins injections child need sadness, stress, or anger. to control his blood sugars and manage his diabetes 5. Insufficient sleep c. Nurse - how to test blood glucose levels from a 6. Endocrine disruptors (environmental pollutants that drop of blood from a finger stick and how to give interfere with lipid metabolism insulin injections 7. Increased use of medications that can cause weight gain d. Dietitian - food, planning meals and snacks, and (antidepressants, anticonvulsants about activity and exercise 8. Genetics 9. Childhood weight COMPLICATIONS THE PATTERN OF BODY FAT DISTRIBUTION 1. Hypoglycemia a. Hypoglycemic episodes most commonly occur ▪ In general, women collect fat in their hips and buttocks, before meals, or when the insulin effect is peaking. giving their figures a "pear" shape. b. Common cause: Burst of physical activity without ▪ Men, on the other hand, usually collect fat around the belly, additional food, or delayed, omitted or giving them more of an "apple" shape. incompletely consumed meals. Treatment DIAGNOSTIC AND LABORATORY PROCEDURES c. 50% Glucose administered intravenously 1. Waist-hip ratio d. Glucagon administered IM or SC a. To find out a person's waist-to-hip ratio o Measure 2. Hyperglycemia the waist at its narrowest point, and then measure a. Insulin the hips at the widest point. b. Diet- simple carbohydrates b. Divide the waist measurement by the hip c. Fluid measurement. OBESITY 2. Waist circumference to estimate the amount of a person's abdominal fat Men with a waist circumference of 40 inches ▪ Obesity is a medical condition in which excess body fat has or greater are considered to have Increased health risks accumulated to the extent that it may have a negative effect related to obesity on health, leading to reduced life expectancy and/o increased a. Women with a waist circumference of 35 inches or health problems. greater are considered to have increased health ▪ Person is traditionally considered obese if they are more than risks related to obesity 20% over their ideal weight 3. Body Mass Index ▪ Obesity has been more precisely defined by the National a. Defined as the subject's weight divided by the Institute of Health (the NIH) as a BMI of 30 and above. (A BMI square of their height of 30 is about 30 pounds overweight.) b. BMI is usually expressed in kilograms per square ▪ In the Philippines, 1% of young children (0-10 years) and 3% metre, resulting when weight is measured in of adolescents (11-17 years) were overweight. kilograms and height in metres. c. To convert from pounds per square inch multiply by RISK FACTORS 703 (kg/m2)/(lb/sq in) 1. Genetics / Hereditary 4. Underwater weighing (hydrostatic weighing) 2. Behavioral Factor a. Weighs a person underwater and then calculates 3. Environment lean body mass (muscle) and body fat. One of the most accurate ones CAUSES 5. DEXA: Dual-energy X-ray absorptiometry (DEXA) a. Used to measure bone density 1. Sedentary lifestyle - Sedentary people burn fewer calories b. Uses X-rays to determine not only the percentage than people who are active. a. Large shift towards less of body fat but also where and how much fat is physically Demanding work b. increasing use of mechanized located in the body. transportation c. Greater prevalence of labor-saving 6. Skin calipers technology in the home. a. Measures the skinfold thickness of the layer of fat 2. The balance between calorie intake and energy expenditure just under the skin in several parts of the body with determines calipers (a metal tool similar to forceps) a. Overeating b. The results are then used to calculate the b. Foods high in fat or sugar percentage of body fat. c. Diet high in simple carbohydrates 7. Bioelectric impedance analysis (BIA) There are two methods d. Frequency of eating of the BIA: e. Easily accessible and palatable die a. One type involves standing on a special scale with 3. Slow metabolism footpads. A harmless amount of electrical then a. Women have less muscle than men. Muscle burns percentage of body fat is calculated. (metabolizes) more calories than other tissue b. The other type involves electrodes that are typically (which includes fat). placed on a wrist and an ankle and on the back of the right hand and on the top of the foot. NUR 1208 – MODULE 3B: ALTERATIONS IN NUTRITION AND GASTROINTESTINAL, METABOLISM AND ENDOCRINE Page | 9 ALMEÑANA, JOHN RENDEW | BSNR 2026  NUR 1210 | MATERNAL & CHILD NURSING II | NCM 1209 THERAPEUTIC MANAGEMENT RISK FACTORS FOR ANOREXIA The goal of treatment is to achieve and maintain a "healthier 1. Being more worried about, or paying more attention to, weight," not necessarily an ideal weight. weight and shape 2. Having an anxiety disorder as a child 1. Diet 3. Having a negative self-image a. Reduce the consumption of energy-Middle man for 4. Having eating problems during infancy or early childhood foods, such as those high in fat and sugars 5. Having certain social or cultural ideas about health and b. Increase the intake of dietary fiber beauty c. At least 1800 calories per day is recommended for 6. Trying to be perfect or overly focused on rules adolescents d. Eat fewer calories. One pound is equal to 3,500 CAUSES OF ANOREXIA NERVOSA calories e. Read food labels and estimating calories and 1. Cultural Pressures serving size. a. In many societies, being extremely thin is the f. Balance the food you eat with physical activity standard of beauty for women and represents g. Choose a diet with plenty of grain products, success, happiness, and self-control vegetables, and fruits. 2. Psychological issues/Characteristics h. Choose a diet low in fat, saturated fat, and a. Low self-esteem cholesterol, moderate in sugars, salt and sodium b. Feeling of ineffectiveness 2. Physical activity and exercise help burn calories c. Poor body image 3. Medication d. Difficulty expressing feelings a. Anti-obesity drugs to reduce appetite or decrease e. Rigid thinking pattern fat absorption f. Need for control j. Perfectionism i. Orlistat (Xenical) g. Physical or sexual abuse ii. Lorcaserin (Belviq) h. Avoidance of conflict with others iii. a combination of Phentermine and i. Depression Topiramate (Qsymia) 3. Family Environment - Families of people with the disorder iv. Surgery are more likely to be: a. Overprotective COMPLICATIONS b. Rigid - Suffocating in their closeness c. Develops as a struggle for independence and 1. Type 2 diabetes individuality. 2. High blood pressure and elevated cholesterol, especially d. Over valuing appearance and thinness elevated "bad" LDL, and triglycerides e. Criticizing a child’s weight or shape 3. Sleep apnea (obstruction of the airway in sleep resulting in a f. Being physical or sexually abusive serious drop in blood oxygen levels) g. Life transition can often trigger anorexia nervosa in 4. Several bone and joint disorders in childhood someone who is already vulnerable because of 5. Stroke (cerebrovascular accident or CVA) several Factors: 6. Heart attack i. Beginning of adolescence 7. Congestive heart failure ii. Beginning of falling in school or at work 8. Cancer iii. Breakup of a relationship 9. Gallstones iv. Death of a loved one 10. Gout and gouty arthritis v. Genetic factors 11. Osteoarthritis (degenerative arthritis) of the knees, hips, and the lower back SUBTYPES ANOREXIA NERVOSA 1. Restricting type – Individual does not utilize binge eating nor displays purging behavior as their main strategy for weight ▪ Intense fear of becoming obese loss. ▪ An eating disorder characterized by immoderate food 2. Binge-eating/purging type – Individual utilizes binge eating restriction, inappropriate eating habits or rituals, obsession or displays purging behavior as a means for losing weight with having a thin figure, and an irrational fear of weight (eating a lot of food and then trying to get rid of the calories gain, as well as a distorted body selfperception by forcing themselves to vomit, using laxative or exercising ▪ Occurs most often in girls (90%), usually at puberty or during excessively, or some adolescence between 13 and 20 yrs. of age. ▪ It includes three separate features: a. A self-induced starvation to a significant degree. b. A relentless drive for thinness, a morbid fear of fatness, or both c. And medical signs and symptoms resulting from starvation NUR 1208 – MODULE 3B: ALTERATIONS IN NUTRITION AND GASTROINTESTINAL, METABOLISM AND ENDOCRINE Page | 10 ALMEÑANA, JOHN RENDEW | BSNR 2026