Care of child with diarrhoea

1. DIARRHOEA
VIJI V S
LECTURER
KIMS COLLEGE OF NURSING

2. INTRODUCTION
• According to WHO & UNICEF, diarrhea is the second leading cause of
death after pneumonia among under five globally accounting about 1.5
million deaths each year mostly in developing countries.
• Each child under 5 years of age experiences an average of three episodes of
acute diarrhea each year.
DEFINITION
Diarrhea is the passage of loose or watery stools at least 3 times in a 24hrs
period.

3. ACUTE DIARRHOEA
• Attack of loose motion with sudden onset which usually last 3-7 days, but
may last upto 10-14 days.
• It can be caused by an infection of the large intestine, but may be associated
with infection of gastric mucosa or small intestine.
• The term gastro enteritis is most frequently used to describe acute diarrhoea.
CHRONIC DIARRHOEA
• It is termed when loose motion occurring more than 3 weeks or more.

4. • It is usually caused by underlying disease
• Diarrhoea with watery stools and visible blood in the stools is called
dysentery
• The disease is most common in age between 6 months to 2 years.
• The incidence higher during weaning period.

5. ETIOLOGY
• Intestinal infection with various organisms
• Bacteria: Escherichia coli, Vibrio cholera, Shigella species, Chlostridium
difficile, Nontyphoidal Salmonellae…
• Virus: Rotavirus, Norovirus, Adeno virus, Astrovirus , Cytomegalovirus
• Protozoa : Cryptosporidium parvum, Giardia intestinalis, Entamoeba
histolytrica.
• Helminths: Strongyloidiasis stercoralis, Angiostrongyliasis costaricensis

6. • Systemic infections like urinary tract infection or otitis media
• Certain drugs and food allergy
• Malabsorption
• Malnutrition
• Immunocompromised state like HIV infection
• It occurs due to combined effect of maternal antibodies, lack of active
immunity and introduction of contaminated food or direct spread through
child’s hand

7. • Diarrhoea is more common in artificial feeding, specially with contaminated
cow milk or unhygienic preparation of tin milk
PREDISPOSING FACTORS OF DIARRHOEA
• Prematurity
• Immunodeficiency conditions
• Lack of personal hygiene
• Poor socio economic status
• Poor infant feeding practices

8. HIGH RISK GROUPS
• Lack of breast feeding
• Children
• Immunodeficient children
• Malnutrition
• Poor maternal education
• Exposure to unsanitary conditions

9. PATHOPHYSIOLOGY
• Etiological factors attach to the intestinal mucosa
• Bowel mucosa secretes excessive amounts of fluid into the gut lumen
• Large amount of water, nutrients and vitamins are lost from the body
• Excessive sodium loss results in hyponatremia
• Movement of water from extracellular to intracellular compartment
• Reduces extracellular volume

10. • Decreased blood volume results in weak thready pulse, low blood pressure,
cold extremities, shrinkage of skin
• Filtration of urine is reduced due to low hydrostatic pressure in renal
glomeruli
• Potassium and bicarbonate are lost in diarrhoeal stool
• Acidosis may result with dehydration

11. CLINIAL FEATURES
• Frequent loose watery stool, may be greenish or yellowish in colour with
offensive smell, may contain mucous, pus or blood, may expelled with force,
precede by abdominal pain
• Frequency of stools may be 2 to 20 per day or more
• Irritability, lethargy, delirium, stuper, flaccidity
• Signs of dehydration

12. • Abdominal distension
• Weak & thread pulse, hypotension, tachycardia, rapid respiration
• ECG changes with ST depression and flat T waves
• Kussamaul breathing in acidosis
• Cold extremities, collapse
• Decreased or absent urine output
• Convulsions or loss of consciousness in some children

13. Assessment of dehydration
• Dehydration is excess loss of fluid more than fluid intake
Clinical features of dehydration
• Sunken fontanelle
• Sunken eyes
• Non tears from eyes
• Reduced level of consciousness

14. • Reduced capillary refill time
• Dry mucous membrane
• Reduced skin turger
• Tachypnea
• Tachycardia
• Hypotension
• Sudden weight loss
• oliguria

15. Assessment No dehydration Some dehydration Severe dehydration
Look at
General condition
Eyes
Tears
Mouth and tongue
Thirst
Well alert
Normal
Present
Moist
Drinks normally, no
thirst
Restless, irritable
Sunken
Absent
Dry
Drinks eagerly, thirsty
Lethargic/unconsciou
s
Sunken
Absent
Very dry
Unable to drink or
drinking poorly
Feel
Skin pinch Goes back quickly Goes back slowly Goes back very
slowly

18. DIAGNOSTIC FINDINGS
• History collection
• Physical examination
• Stool examination can be done for routine and microscopic study to find
causative agent
• Blood investigations to detect electrolyte imbalances, acid base disturbances

19. MANAGEMENT
Rehydration therapy
• It is done with ORS solution and continued feeding
• Oral rehydration therapy is the drinking of clean water, sugar and mineral
salt to replace water and salt loss from the body during diarrhoea, especially
when accompanied by vomiting, eg in gastro enteritis
• The management of child with diarrhoea and dehydration can be given under
3 catagory

20. Plan A for child with no dehydration
• A child with no signs of dehydration needs home treatment to treat current
episodes of diarrhoea and prevent dehydration
Give child more fluids than usual to prevent dehydration
• Breastfeed frequently and for longer at each feed
• If child is exclusively breastfeed give ORS or clean water along with breast
milk
• If child is not exclusively breastfeed, give one or more of the following:

21. • ORS solution, food based fluids such as soup, rice water and yoghurt drinks
or clean water.
• Teach mother how to prepare the ORS
• Fluid intake upto 2 years of age 50-100ml after each loose stool and in
between them and for 2 years or more, give 100-200 ml after each loose
stool or in between them
• Give frequent small sips from a cup
• If the child vomits, wait 10 minutes, then continue, but more slowly

22. • Continue giving extra fluids until the diarrhoea stops
Give zinc supplements
• Amount: upto 6 months- half tablet per day for 14 days and 6 month or
more- 1 tablet per day for 14 days
• For infants dissolve the tablet in a small amount of expressed breast milk,
ORS or clean water, in a small cup or spoon
Continue feeding
• Up to 6 months of age: breast feed atleast 8 times in 24 hrs

23. • 6 months to 1 year: Breastfeed and 3 meals per day , if not breast feed 5
meals per day
• 1-2 years: Breastfeed and 5 meals per day
• Above 2 years: family foods 3 meals per day 2 times nutritious foods
between meals.
• Offer cereal, pasta, or potato mixed with legumes, vegetables, fish or
chicken and freshly prepared ground or mashed foods
• Provide fresh fruit juice, coconut milk or banana to provide potassium

24. • After diarrhoea stops, give an extra meal each day for 2 weeks, until child’s
weight before illness is attained.
Return to health worker
• Advise to take the child to a healthcare worker if he or she does not get
better in 3 days or develops any of the following:
• Many watery stools, fever, poor eating or drinking, marked thirst, repeated
vomiting and blood in the stools

25. PLAN B FOR CHILD WITH SOME DEHYDRATION
Give ORS in the health centre until the skin pinch is normal, the thirst is
over , the child is calm
• Four hours of rehydration are usually necessary for this
• If the patient wants more than recommended amount, give more
• For infants below 6 months who are not breastfeed , give 100-200ml clean
water in addition during this period

26. Observe the child closely and help to give the ORS
• Show how much solution to give and how to give to the child
• Give frequent small sips from a cup
• If the child vomits, wait 10 mts , then continue, but more slowly
• Continue breastfeeding whenever the child wants
After 4 hours
• Reassess the child and select plan A, B, or C to continue the treatment

27. • If there are no signs of dehydration, then shift to plan A
• If signs indicate that some dehydration is still present, repeat plan B and
reassess 2 hrs later or signs indicate that severe dehydration has occurred,
shift to plan C
If the mother must leave before completing treatment:
• Show her how to prepare ORS solution at home
• Show her how to continue with the rest of the 4hr treatment at home
• Supply enough ORS packets to complete rehydration and to continue

28. • For 2 more days as recommended in plan A
Explain the 4 rules in plan A for treating her child at home
• Give ORS or other fluids continuously until diarrhoea stops
• Give the zinc supplements for 10-14 days
• Continue feeding
• Come back to the healthcare worker if necessary

29. PLAN C FOR CHILD WITH SEVERE DEHYDRATION
• Children with severe dehydration should be treated by IV drip as soon as
possible and admitted to the hospital or health centre
If IV fluid can be given immediately:
• Start IV immediately, if the child is able to drink, give ORS by mouth until
the drip is set up.
• Give 100ml/kg Ringer lactate solution ( or if not available normal saline) as
following

30. • Infants (under 12 months): first give 30ml/kg in 1 hour and give rest
70ml/kg in next 5 hours
• Children ( 12 months upto 5 years): first give 30ml/kg in 30 min and give
rest 70ml/kg in next 2 ½ hrs
• Repeat once if radial pulse is still very weak or not detectable
• Reassess the child every 1-2 hrs
• If hydration status is not improving give IV drip more rapidly
• Also give ORS (about 5ml/kg/hr) as soon as the child can drink, usually
after 3-4hrs (infants) or 1-2hrs (children)

31. • Reassess an infant after 6 hrs and a child after 3 hrs and choose the
appropriate plan (A,B, or C) to continue treatment
If IV treatment available nearby (within 30 min):
• Refer urgently to hospital for IV treatment
• If the child can drink, provide the mother with ORS solution and advise to
give frequent sips during the trip.
• If IV therapy is not possible immediately insert nasogastric tube and start
rehydration by nasogastric tube or by mouth with ORS : give 20ml/kg/hr for
6 hrs(total of 120ml/kg)

32. • Reassess the child every 1-2hrs
• If not improving after 3 hrs refer to the hospital urgently for IV therapy
• After 6hrs, reassess the child and select the appropriate plan A, B or C to
continue the treatment.
Treatment of child with blood in the stools
• These children should be treated for dehydration and Shigella infection
• Treat severe dehydration and severe malnutrition in hospital
• Administer prescribed antibiotics effective against Shigella

33. • Provide zinc supplement
DRUG THERAPY
Symptomatic treatment-
• If vomiting Antiemetics-ondansetron(0 .1-0.2 mg/kg/dose)
• Hypokalemia with paralytic ileus –KCL(30-40 mEq/l)iv infusion
• Antibiotics,
• Antimotility agents –lomotil or loperamide should not used

34. • Antisecretory agents-in acute diarrhea –Racecadotril
• Probiotics –microorganisms that exert beneficial effects on human health
when they colonize the bowel eg.enterogermina.
ZINC IN DIARRHOEA
• During diarrhoea zinc is lost from body
• Treatment with zinc reduces the duration and severity of acute diarrhoea and
reduces the frequency of further episodes during subsequent 2-3 months
• WHO recommends that children suffering from diarrhoea should be given
zinc for 10-14 days

35. • 10mg daily for children less than 6 months
• 20 mg daily for children more than 6 months
Home available fluids
• Rice water
• Home made ORS
• Dhal water
• Lemon juice
• Soups

36. • Lassi
• Coconut water
• Plain water
DIETARY MANAGEMENT
• Diet should be planned to prevent malnutrition and to provide adequate nutritional
requirement
• Continue breastfeeding as the child wants
• Provide energy dense soft diet like cereals, legumes, vegetables, freshly prepared
mashed foods

37. • Provide fresh fruit juices and bananas which are helpful as they contain
potassium
• Avoid high fibre or bulky foods or foods with a lot of sugar
• Advice to prepare foods by cooking well, fermenting, mashing or grinding
which is easier to digest
• Provide small and frequent feeding
• After diarrhoea has stopped, give the child one extra meal each for a week to
regain weight

38. NURSING MANGEMENT
Nursing Assessment
• Assess for frequency and consistency and signs of dehydration
• Monitor urine output
• Check vital signs
Nursing Diagnosis
• Fluid volume deficit r/t diarrhoea

39. • Risk for infection r/t contamination during episodes of diarrhoea
• Impaired skin integrity r/t skin irritation caused by frequent stool
• Imbalanced nutrition less than body requirement r/t inadequate intake and
malabsorption
Nursing Interventions
• Maintain fluid volume
• Prevention of infection
• Maintain skin integrity

40. • Maintain nutrition
• Care of oral mucosa
• Health education
COMPLICATIONS
• Dehydration
• Hypovolemic shock
• Renal failure
• Paralytic ileus

41. • Hypoglycemia
• Convulsions
• Malnutrition
• Mental subnormalities
PREVENTION
• Safe water, adequate sewage disposal
• Hand washing practices
• Clean utensils

42. • Avoidance of exposure of food to dust and dirt
• Fly control. Washing of fruits and vegetables before eating
• Avoidance of bottle feeding
• Safe drinking water
• Balanced diet
• Immunization

43. ORAL REHYDRATION THERAPY
Definition
• It is the administration of solution of rehydration salts orally to prevent or
correct diarrhoeal dehydration
Aim
• To correct water electrolyte imbalance
• To prevent dehydration
• To reduce mortality

44. WHO recommended ORS
• Sodium chloride- 3.5gm.
• Potassium chloride-1.5 gm
• Trisodium citrate - 2.9 gm
• Glucose - 20 gm
• in 1 liter of clean drinking water
• ORS day is celebrated every year on 29th July

45. • If the child is less than 2 years give 1-2 teaspoon every 2-3 minutes
• In older children offer frequents sips out of a cup
• Adults can drink as much as they can
• Give the estimated amount within 4 hours
• If the child vomits, then wait for 10 minutes and then give a teaspoon full
every 2-3 minutes
• In breastfed child give ORS along with breastfeed and in non breastfeed
children give extra clean water 100-200 ml for first 4 hours along with ORS

46. Home preparation of ORS with ORS packet
• Put the content of ORS packet in to a clean container, check the packet for
directions and add the amount clean water as indicated
• Add water only, do not add ORS to milk, soup, fruit juice or any soft drinks
• Stir it well and feed it to child from a clean cup
How do ORS is prepared in home
• Clean water- 1 litre-5 cupful ( each cup about 200ml)
• Sugar- 6 lever teaspoons (1 tsp=5grams)

47. • Salt- half level spoons
• Stirr mix till the sugar dissolves
• Too much sugar can make the diarrhoea worse, and too much salt can be
harmful to child
• ORS solution should be covered and should not store more than 24 hrs.