Diarrhea is a condition in which there is :- Unusual frequency of bowel movements (more than 3 times a day).- Changes in the amount ( more than 200g a day).- Change in consistency( liquid stool).It is a common cause of death in developing countries and the second most common cause of infant deaths worldwide.WHO defines :Having 3 or more loose or liquid stools per day, or as having 3 or more loose stool.
TYPES OF DIARRHEA Acute diarrhea is an attack of loose motion with sudden onset which usually lasts 3 to 7days but may last up to 10 – 14 days. It is caused by an infection of the large intestine, but may be associated with infection of gastric mucosa and small intestine. The term “acute gastroenteritis” is most frequently used to describe acute diarrhea.
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 malabsorption. Diarrhea with watery stools and visible blood in the stools is called dysentery. Persistent diarrhea refers to the episodes of acute diarrhea that last for 2 weeks or more and may be due to infective origin.
CAUSES OF DIARRHEA The main causes of this disease are lack of knowledge of hygiene and sanitation, home environment, feeding practices of the parents and under five years of children. It can be caused by chronic ethanol ingestion. Chronic mild diarrhea in infants and toddlers may occur with no obvious cause and with no other ill effects ,this condition is called toddler’s diarrhea.
EPIDEMIOLOGY About 1/3 of total hospitalized children are due to diarrheal diseases and 17%of all deaths in indoor pediatric patients are related to this condition. The morbidity rate in terms of diarrhea episodes per year per child under the age of 5 years is about 1.7.
AGENT FACTORS Diarrhea is mostly infectious. A large numbers of organism are responsible for acute diarrhea.The infectious agent causing diarrhea with enteric infection include the followings:- Viruses: Rota virus, adenovirus,enterovirus,norwalk group viruses,measles virus etc.
RESERVOIR OF INFECTION Man is the main reservoir of enteric pathogens ,so most transmission originates from human factors. For some enteric pathogens and viral agents animals are important reservoir.
HOST FACTORS: The disease is most common specially between 6months to 2years.The incidence is higher during weaning period,i.e 6 to 11 months of age. It occurs due to combined effects of reduced maternal antibodies, lack of active immunity and introduction of contaminated food or direct spread through child’s hands.
CONTINUE: Diarrhoea is more common in artificial feeding,specially with contaminated cow’s milk or unhygienic preparation of tin milk. Malnutrition leads to infection leads to infection and infection leads to diarrhoea.
CONTINUE: The predisposing factors of diarrhoea include prematurity,immunodeficiency conditions,lack of personal hygiene,inadequate food hygiene,infant feeding practices,illiteracy,poor socio-economic status etc.
ENVIRONMENTAL FACTORS: Bacterial diarrhea is more frequently occur in summer and rainy season,whereas viral diarrhea ( specially rotavirus ) found in winter.
MODE OF TRANSMISSION: It is mainly feco-oral route.It is water- borne,food- borne disease or may transmit via fingers,fomites,flies or dirt.
CLINICAL MANIFESTATIONS: Stools are usually loose watery in consistency.It may be greenish or yellowish-green in color with offensive smell. It may contain mucus, pus or blood and may expelled with force,preceded by abdominal pain. Frequency of stools varies from 2 to 20 per day or more.
The child may have low grade fever,thirst, anorexia. Behavioral changes like irritability,restlessness,weakness, lethargy, sleepyn ess, delirium,stupor and flaccidity are usually presengort. Physical changes like loss of weight, poor skin turgor, dry mucus membranes,dry lips, pallor, sunken eyes,depressed fontanelles are also found.
Vital signs are changed as low blood pressure,tachycardia,rapid respiration,cold limbs and collapse. Decreased or absent urinary output. Convulsions and loss of consiousness may also present in some children with diarrheal diseases.
DIAGNOSIS: History taking and physical assessment. Stool examination can be done for routine and microscopic study and identification of causative organisms. Blood examination can be performed to detect electrolyte imbalance,acid- base disturbances,hematocrit value,TC,DC,ESR etc.The suspected associated cause should be ruled out for adequate management.
ASSESSMENT OF DEHYDRATION: A B C1. Ask about• Diarrhea -Less than 4 liquid -4 to 10 liquid -More than 10 stools per day. stools per day. liquid stools per -None or a small day.• Vomitting amount . -Some -Very frequent. -Normal• Thirst -Greater than -Unable to drink. -Normal normal.• Urine -A small amount -No urine for 6 and dark. hours2. Look at• Condition -Well, alert -Restless,Irritable -Lethargic or or sleepy ,unwell. unconsious,
CONTINUE: A B C•Mouth and -Moist -Dry -Very drytongue•Breathing -Normal -Faster than - Very fast and normal deep3. Feel• Skin pinch -Goes back -Goes back -Goes back very quickly. slowly. slowly.•Pulse -Normal -Faster than -Very fast,weak normal. or cannot feel.4. Decide -The patient has -If patient has -If the patientDegree of NO SIGNS OF two or more has two or moreDehydration DEHYDRATION signs including signs including at least one sign at least one sign there is SOME there is DEHYDRATION SEVERE
MANAGEMENT: Rehydration Therapy:The management of diarrhea is a vast majority of children is best done with ORS solution and continued feeding.ORT means drinking of solution of clean water, sugar and mineral salt to replace the water and salt lost from the body during diarrhoea,especially when accompanied by vomitting,i.e gastroenteritis.
MGMT CONT: The child with loose motion having no dehydration can be treated at home. There are three rules for treating diarrhea at home,which should be explained to the mother.The rules are:1. Give the child more fluids than usual to prevent dehydration, with home available food and ORS, until the diarrhea stops.
CONTINUE:2. Give the child plenty of food to prevent undernutrition.Continue breast feeding frequently. Offer food at least 6 times a day with cereals, pulses,vegetables,meat or fish, vegetable oil, fresh fruit juices or mashed banana etc.3.Take the child to the health worker/health center,if the child does not get better in 3 days or develops any of the followings watery stools,repeated vomitting,marked thirst,eating or drinking poorly,fever or blood in the stool.
When the child is having diarrhea with some dehydration,management should be done under supervision of health worker with ORS. The appropriate amount of ORS solution to be given in the first 4 hours are as follows: Age less than 4 months or weight less than 5 kg- 200 to 400ml. Age 4 to 11months or weight 5 to 7.9 kg – 400 to 600 ml. Age 12 to 23 months or weight 8 to 10.9 kg – 600 to 800ml. Age 2 to 4 years or weight 11 to 15.9 kg – 800 to 1200ml. Age 5 to 14 years or weight 16 to 29.9 kg – 1200 to 2200 ml. Age 15years or older or weight 30kg or more to 2200 to 4000ml.
MGMT CONT: After 4 hours of rehydration therapy the child should be reassess for degree of dehydration. If there is no sign of dehydration the child should be managed at home with necessary instructions to the mother. If the signs of severe dehydration have appeared the child should be admitted in the hospital for I/V fluid therapy. During ORS therapy ,if child is having puffy eyelids,then ORS should be stopped and plain water and breastfeeding to be given.
MGMT CONT: The child with severe diarrheal dehydration should be treated quickly. Intravenous fluid to be started immediately with Ringerlactate solution 100ml/kg. If the patient can drink,ORS to be given by mouth about 5ml/kg/hour. Ringer-lactate to be infused at first 30ml/kg/hour and then 70 ml/kg in 5 hours for infants. In older children, it should be given first 30 ml/kg in 30 minutes and then 70ml/kg in 2.5 hours. The patient should be reassess every one to two hours.
MGMT CONT: Bacterial or protozoal diarrhea can be treated with specific drugs. Ampicillin,nalidoxic acid,norfloxacin,ciprofloxacin,furazolidine,metronida zole can be used.
DIETARY MANAGEMENT: Diet to be planned to prevent malnutrition and allow normal nutritional requirement. Food items may include energy rich food with rice,potatoes,wheat,pulses,vegetables oil,curd,fish,high fiber content foods and soft drinks should be avoided. Breast feeding to be continued during diarrheal episodes even along with ORS. Cereal mixture like rice- milk, dalia- sagu, or khichri can be given to the infants more than 6 months of age. If the infant is non breast fed,cow’s or buffalo’s milk should not be diluted with water. Feeding to be given in small quantity frequently every 2 to 3 hours.
THE IMPORTANT NURSING DIAGNOSIS Fluid volume deficit related to diarrhea. Risk for cross-infection related to infective loose motion. Potential to altered skin integrity related to frequent passage of stools. Altered nutritional status, less than body requirement related 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.
NURSING INTERVENTION: Restoring fluid and electrolyte balance by ORS,IV fluid therapy, intake and output recording and checking of vital signs. Prevention of spread of infection by good hand washing practice, hygienic disposal of stools, care of diapers,general cleanliness and universal precautions. Preventing skin breakdown by frequent change of diaper,keeping the perineal area dry and clean,avoiding scratching and rubbing of irritated skin and use of protective barrier cream.
NSG MGMT CONT: Providing adequate nutritional intake by appropriate dietary management. Reducing fear and anxiety by explanation,reassurance,answering questions and providing information. Giving health education for prevention of diarrhea, home management of diarrheal diseases, importance of ORS,dietary management, hygienic practices,medical help etc.
PREVENTIVE MEASURES: Improvement of food hygiene and environmental hygiene.These includes: Safe water,adequate sewage disposal, hand washing practices,clean utensils,avoidance of exposures of food to dust and dirt,fly control, washing of fruits and vegetables etc. Avoidance of bottle feeding is most significant practice needed for prevention of diarrhea. Boiling or filtering to be practiced for safe drinking water. Prevention of LBW and prematurity,exclusive breast feeding,appropriate weaning practices,balanced diet,immunization are significant aspects of child care.
PROGNOSIS Mortality is higher in neonate and infants than the older children. Malnourished children are having poor prognosis and greater mortality. Antibiotic resistant type E.Coli and shigella cause very severe illness and poor prognosis. Presence of severe dehydration ,electrolyte imbalance and pneumonia have poor prognosis.