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INTERFERENCES WITH NUTRITION UPP

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					        INTERFERENCES WITH NUTRITION: UPPER GI

Normal GI Tract

Organs of Digestion
  Mouth: salivary glands; CHO (starch) digestion

  Esophagus: hollow tube from pharynx to
      stomach

  Stomach: stores and mixes food with gastric
      juices and mucus forming chyme

              -pepsin: protein digestion

              -intrinsic factor: helps with vitamin B12
              absorption
GI SYSTEM
• Small Intestine
    – Duodenum: first part of intestine connecting
               to stomach with intestinal juices
               that are alkaline
    – Jejunum: middle portion
    – Ileum: lower portion
    Large Intestine
    –   Cecum ( with appendix)
    –   Colon
    –   Rectum
    –   Anus
• Accessory Digestive Organs


   – Liver: largest internal organ which
       metabolizes fat, glucose, protein
          - produces bile
          - stores vitamins A,B,D and some B
       complex
          - coagulation factors

   – Gall Bladder: under liver; concentrates and stores bile
     (emulsifies ingested fats)
• Pancreas
      Exocrine: trypsin and chymotrypsin for
                    protein
                - amylase for starch
                - lipase for fat

       Endocrine: insulin

• GENERAL GI FUNCTION: Digestion
               Absorption
               Elimination
• DIAGNOSTIC TESTS
      Lab tests (blood)
       - amylase & lipase: increase with
         pancreatic problems

        - albumin: produced by liver cells
              (decreased in cirrhosis)

        - LDH: shows liver damage
• Stool Examination
      -check for presence of:
             blood
             bacteria
             parasites

• Gastric Analysis
      - shows presence/absence of acid
      - check for carcinoma cells
• PROCEDURES

  Abdominal Ultrasonography: non-invasive using high
     frequency sound waves

  Upper/Lower GI series: visualizes structures and
     motility of the stomach

  Barium Swallow: shows esophageal lesions,
       hernia
• Upper/Lower Endoscopy: direct visualization of the
      GI tract
       - Colonoscopy
       - Sigmoidoscopy

• CAT Scan: (non-invasive) checks for structures,
       tumors

• MRI: checks for structures, abnormalities
       (pt. cannot have any metal implants)
                   THINK - PAIR - SHARE


• Discuss the follow-up care following
• The diagnostic studies of the GI tract
  – -upper endoscopy
  – -barium enema
  – -colonoscopy
• General Nursing Interventions
   Preparation
      - informed consent
      - pt. usually fasts 8 – 12 hours or more
      - diet may be low fat, low residue, clear liquids
      - check for allergies if contrast is being used
      - enemas may be given for lower GI studies

  Post Procedure
       - monitor vital signs
       - follow up care if barium used for study
• Impairments to Intake
       Obesity: 2x the ideal body weight or 100 lbs.
                or more over the ideal body weight

          Etiology/Pathophysiology: physiological, social,
                 or psychological interrelationships
                 Other factors: possible genetic
                          CNS disturbance
                          hormonal (thyroid, BMR)

Body Mass Index= 703 x wt. in lbs.
                  (height in inches)2
• Nursing Interventions

  Diet: most important method of weight reduction
       with well planned meals ( 4 basic groups/ caloric
       intake

  Exercise: second part of weight reduction (burns
      calories and affects plasma & lipid levels
      - increases muscle tone
• Medication
     Appetite suppressants
       Sibutramine Hcl (Meridia): decreases appetite
       by inhibiting reuptake of serotonin and
       norepinephrine (SE: increases BP)

       Alters Digestion
        Orlistar (Xenical): decreases caloric intake by
        preventing digestion of fats (SE: increased BM)
• Behavior Modification
   Promote change in eating habits and lifestyle

• Bariatric Surgery
   Jejunoileal bypass: pouch with a small capacity
       created
   Gastric bypass and vertical gastroplasty (most
       frequently used): pouch with a smaller capacity
       created
• Nursing Interventions (post op)
      Help reduce anxiety
      Pain control
      Observe for potential complications
        - peritonitis
        - stomal problems
        - respiratory problems (atelectasis/pneumonia)
        - vomiting/ diarrhea ( metabolic imbalances)
        - 6 small feedings; encourage po intake
    Studies regarding p/o bariatric surgery

• Changes in metabolism
• Malnutrition
   Etiology/ Pathophysiology
     related to decrease in nutrient intake
                 increase in nutrient losses
                 increase in nutrient requirement
  (body depends on proteins for 8 amino acids it can’t produce)

Negative Nitrogen Balance
  Using more than taking in: decrease in albumin will decrease
        osmotic pressure leading to interstitial fluid
• Malnutrition
    interferes with wound healing
    increases susceptibility to infections
    increases incidence of complications ie. GI,
       mechanical or metabolic
Assessment: Subjective- dietary likes/dislikes, ability
       and desire to eat, financial
    Objective- height, weight, lab data such as H&H
       and albumin, S&S of infection or skin breakdown
• Nursing Interventions
   Encourage po intake: fluids, supplements (ensure)
   Tube Feedings (nasogastric)
      Levin (single lumen): can be used for suctioning,
        meds, feedings
      Gastric sump (Salem): double lumen used to
        decompress the stomach
       Dobhoff: tungsten weighted that takes about
        24 hrs to pass; pt. lies on right side to
        facilitate passage
Gastrostomy: surgical procedure creating an
         opening in the stomach to provide nutrition

    -benefits are gastroesophageal sphincter remains
       intact so less of a chance for regurgitation

Cantor tube: weighted tip with mercury, water, saline
       used for decompression of the intestines
• Nursing Care
   Instruct regarding insertion
   Cetacaine to numb area
   Instruct to swallow
   Confirm placement/positioning by x-ray, NG
      aspirate (gastric pH 3, intestine pH 6.5),
      measurement of tube length
   Comfort measures: HOB up 30 for 1-2hrs after feed
• Nursing Care (continued)
      Check tube patency & residual ( no more than
      10-20% >hourly rate)
      Monitor for nausea & vomiting
      Provide oral/nasal hygiene
      Monitor electrolytes, I & O
      Check for metabolic acidosis
      Flush tube with water
                   Think- Pair- Share

• Compare and Contrast the advantages
• and disadvantages of the following tubes for
  enteral nutrition:
  – nasogastric (NG) tube
  – Nasointestinal (NI) tube
  – Gastrostomy tube
  used to feed the child with a
gastrointestinal disorder such as
      esophageal atresia.
• Tube Feeding Formulas
   High molecular weight: protein, CHO, fats -2cal HN

    Chemically defined formulas containing predigested
      and easy to absorb nutrients-Osmolite HN

    Modular products that contain 1 major nutrient
      such as protein- Promote

    Fiber added to try to decrease diarrhea- Jevity
• Dumping Syndrome
   Increased concentration of tube feeding causes
      water to move to stomach and intestines
      thereby making the pt. feel full with nausea
      diarrhea

    Pt. develops dehydration, hypotension and
       tachycardia
Total Parenteral Nutrition (TPN):
     - hypertonic solution[10%/20%/50%]
        providing calories and nutrition

     - contains amino acids, lytes, vits, minerals, and
  trace elements

       - prepared aseptically

       - keep refrigerated ( use with 24-36 hrs)
• Method of Administration
     (Since it’s concentrated, give into larger vessel)
     Nontunneled central catheters (subclavian)
       Percutaneous Subclavian

       PICC lines

       Tunneled central caths Hickman

       Implanted ports
Nursing Care
       Check insertion site to prevent infection/sepsis

       Prevent mechanical problems

       Check I&O, daily wts., fluid & lyte balance

       Monitor glucose

       If new TPN not available, hang up high
         concentration (D 10%)
       D/C TPN gradually
•   Fluid and Electrolyte Balance/Problems
    (GI tract has increased lyte content)
    Etiology: loss of secretions from vomiting, diarrhea
           and suctioning r/t intestinal parasites, virus
    Assessment: N&V, wt. loss, bowel patterns, abdomen
           bowel sounds and pain

    Deficits:
     Metabolic alkalosis- loss of gastric acid ( suctioning
          or vomiting)
     Metabolic acidosis-loss of bicarbonate secretion from
          diarrhea or intestinal fistulas
• Problems
   Nausea & vomiting (2 centers in medulla can
      trigger vomiting leading to altered nutrition,
      lyte imbalance, metabolic alkalosis, dehydration

    Dehydration (poor intake)
      assessment- poor skin turgor
                    sunken eyes
                    dry membranes
         Nursing Interventions


-Treat nausea/vomiting with meds

- diet

-Treat dehydration
          increase fluids
          IV fluids
• Gastroesophageal Reflux Disease (GERD)

    Lower esophageal sphincter (LES) allows reflux of the
  stomach contents back into the esophagus

  Assessment: heartburn & regurgitation occurs shortly after
  eating when bending over or lying down;
  dyspepsia; dysphagia; esophagitis (can mimic
  heart attack symptoms)
• Nursing Interventions
   Antacids: magnesium hydroxide/aluminum
      hydroxide (MOM)
   Histamine blockers: ranitidine (Zantac)
   Proton Pump Inhibitors: lansoprazole (Prevacid)
   Prokinetic agents: accelerate gastric emptying
      metoclopramide (Reglan) S.E.= CNS problems

    Drugs to promote gastric emptying; avoid spicy,
      acidic, caffeinated & fatty foods

    Remain sitting up after eating
• Structural Defects
    Cleft Lip/ Cleft Palate

      Cleft Lip         Cleft Palate
 opening in upper       openings in hard and/or
 lip or to nasal septum     soft palate
Assessment:
 easily recognizable     seen on thorough exam of
                             mouth
Figure 24–3 (continued) A, Unilateral
 cleft lip. B, Bilateral cleft lip. Courtesy
of Dr. Elizabeth Peterson, Spokane, WA.




                                     B
  Feeder (B) both have longer, softer
nipples and make it easier for the child
         to feed from a bottle.
A, photo courtesy of Mead Johnson &
 Company; B, courtesy of Medela AG,
              Switzerland.


                 A               B
• Psychological Assessment of Parents

   Nursing Responsibilities
      Emphasize positive aspects of infant
      Surgical intervention
      Advise of long range problems (speech)

• Therapeutic Management (surgical repair)
        Cleft Lip                 Cleft Palate
  by 2- 3 months              by 18 months
 staggered suture line wait for palatal changes
• Nursing Interventions

   Cleft Lip                                 Cleft Palate
Monitor VS; I&O             Monitor VS; I&O
Protect surgical site                Position on abdomen
Keep suture line clean             Protect suture line
 (NS/ sterile water)                 Oral packing 2-3 days
Sedation/analgesia                   Nutrition( blenderized from cup)
Lie on back/side                     Cleanse after feeding
Gently aspirate if needed
Logan Bar: protect site
           Developmental appropriate activites
• Feeding problems

  - can’t make tight seal
  - need special devices:
               - Bulb
               - asepto
               - Brecht syringes
   - positioning:
               -upright position
               - frequent burping
               -nipple must make seal
• Esophageal Atresia (tracheolesophageal fistula) TEF
  Pathophysiology: failure of esophagus to develop as
    continuous passage in a variety of ways

Assessment
   excessive salivation/drooling, sneezing
   the 3 C’s: coughing, choking, cyanosis

Therapeutic Management
   Prevent pneumonia by preventing aspiration of fluids
    antibiotics if needed
   Surgery: NPO, IV’s, positioning, ligation of fistula with
        end to end anastomosis
• Nursing Interventions
      Early identificaton
      NPO & IV’s
      Keep blind pouch empty ( suctioning)
      HOB down
      Infant in incubator with O2
      Meet nutritional needs with gastrostomy tube
• Hernias
Pathophysiology (various types)
  protrusion/ projection of an organ through the
      muscle wall
Assessment
  Diaphragmatic: abdominal contents protrude through
          muscle into cavity
  Respiratory distress with absent breath sounds
          possibly hear bowel sounds
    Davis, H. (Eds.). (2002). Atlas of
pediatric physical diagnosis (4th ed., p.
 43). Philadelphia: Mosby. Note: From
  Zitelli, B., & Davis, H. (Eds.). (2002).
  Atlas of pediatric physical diagnosis
 (4th ed., p. 43). Philadelphia: Mosby.
Management/ Nursing Care

Prep op                           Post op
HOB elevated        Monitor VS; I&O
NGT                       Check for S&S of infection
Respiratory support   Monitor fluid & lytes
IV’s                      Position on affected side
• Umbilical Hernia
     Weakness of umbilical ring & will protrude with
       crying, coughing, straining

       Most defects resolve spontaneously by 3-4 yrs
       Surgery if other measures don’t work
• Pyloric Stenosis

    Pathophysiology: narrowing of pyloric canal
       between stomach and duodenum r/t hypertrophy
       of circular pylorus muscle
       - S&S usually start 2-4 weeks after birth

    Diagnostic Assessment
       Sonogram
        UGI series
        Blood studies to check for dehydration, lyte
       imbalance, anemia
• Clinical Manifestations

    Projectile vomiting
    Chronic hunger/irritability
    Weight loss
    Dehydration
    Distended upper abdomen
    Olive shaped tumor in right upper quadrant
    Gastric peristaltic waves from left to right
    Decreased number of stools
    Possible alkalosis
• Therapeutic Management
   Surgery: pyloromyotomy where the circular muscle
       fibers are released

Nursing Care
Pre-op                                          Post-op
Check I&O                             Check VS; I&O
Restore hydration/lytes          Maintain IV’s
Check urine specific gravity     Monitor incision site
Monitor daily wt., N&V           HOB elevated
NGT                                   Initial feeds- clear liquids
Prevent infection            Tylenol for pain
Parental involvement                   Parental support/reassurance
• Inflammatory Interferences
  (Thrush, Peridontal disease, Gastritis)

    Thrush (Candida Albicans): fungus infection of mucus membranes with
      cheesy, white plaque
      that looks like milk curds
      -possible side effect of antibiotic use

    Nursing Management
      Mycostantin: swish and swallow
     Good mouth care
• Peridontal Disease

   Gingivitis: painful inflamed swollen gums r/t
      inadequate dental care
      -bleeding/ infection of gums

Nursing Care:
  Promote proper oral hygiene
  Routine flossing and dental visits
• Gastritis

       Inflammation of gastric or stomach mucosa r/t
         - inappropriate dietary intake (foods, alcohol)
         - overuse of meds (ASA, NSAIDS)
         - H. pylori bacteria

      Assessment
        -Nausea and vomiting                           -
  Abdominal discomfort                                 -
  Anorexia
  -Heartburn
Nursing Management

  NPO with IV’s to maintain hydration/lyte balance
  Non-irritating diet
  Try to reduce anxiety

  Meds
   Antibiotics for H. pylori (Tetracycline)
   H2 Receptor Antagonists (Zantac)
   Proton Pump Inhibitor (Prevacid)
   Cytoprotective: Sucrafate (Carafate) forms a
      protective layer
• Traumatic Interferences with Nutrition
    Facial Fractures: fractures of jaw/face requiring
       wiring; trauma to facial bones

   Nursing Interventions
        Teeth are wired (upper/lower connected with
   rubber bands to immobilize
        Monitor N&V; dressings
        Keep HOB elevated
        Have suctioning available/scissors & wire cutters
        High calorie liquid diet
        Good mouthcare
• Poison Ingestion
     Poison: any ingested substance that can cause
       tissue destruction after coming in contact with
       mucous membranes
       Assessment
         ABC’s
         Check for: N&V;
               abdominal pain
               convulsions
               change in LOC
               decrease in pulse and respirations
  Try to ID what was ingested and how much
• Management
   Stabilize condition
   ID toxic substance
   Reverse its affects
   Eliminate substance from the body
   Support individual physically and psychologically

American Association of Poison Control Centers
         1-800-222-1222
• Therapeutic Management
   Elimination of poison: syrup of ipecac to induce
    vomiting EXCEPT if it was a caustic (alkaline, acid,
    petroleum distillate) product (mainly adults)
       Doses: 6-12 months, 10 ml; DO NOT REPEAT
         1-12 yrs, 15 ml; if no vomiting may repeat X1
        >12 yrs. 30 ml; if no vomiting may repeat X1
  Administer clear fluids (10-20ml/kg) after giving
       ipecac
    Therapeutic Management

• Gastric lavage: aspirate stomach contents and
  wash out stomach in order to remove
  substance or decrease absorption

•    Inactivate poison
•      Activated charcoal (30 – 50 grams):
  binds with metabolite to prevent absorption
•      Antidotes: call poison control center
                        Practice Question
•   A client is being weaned TPN and is expected to take solid food today. The ongoing solution
    rate has been 100 ml/ hr. A nurse anticipates that which of the following orders regarding
    the TPN solution will accompany the diet orders?

•   A. discontinue the TPN
•   B. continue the current infusion rate orders for TPN
•   C. decrease TPN rate to 50 ml/ hr.
•   D. hang 1000 ml 0.9 % normal saline
                                  Practice Question



•   A home health nurse provides instructions to the mother of an infant with cleft
    palate regarding feeding. Which statement if made by the mother indicates a
    need for further instructions?


     –   A. “I will use a nipple with a small hole to prevent choking>”
     –   B. “I will stimulate sucking by rubbing the nipple on the lower lip.”
     –   C. “I will allow the infant time to swallow.”
     –   D. “I will allow the infant to rest frequently to provide time to swallow
         what has been placed in the mouth.”
                                Practice Question

• A five-month old girl is admitted with gastroesophageal
• reflux. Her signs and symptoms include emesis, poor weight gain,
  irritability and gagging with feeds. The nurse would include which
  intervention?
    –   A. bi-weekly weights
    –   B. urine dipstick each void
    –   C. appropriate feeding position
    –   D. monitor white blood count as indicator for infection

				
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