gastroenteritis. most common childhood disorder...gastroenteritis. most common childhood disorder................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................;kouirydjh;lk;/////mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuuudddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxgggggggg

2. GASTROENTERITIS/
DIARRHEA
ATHIRA V S.
LECTURER.
KIMS COLLEGE OF NURSING.

3. •The second leading cause of death after
pneumonia among children under five.
•Globally accounting about 1.5 million deaths
each year mostly in developing countries.
•Globally, there are nearly 1.7 billion cases of
childhood diarrheal disease every year.

4. DIARRHEA.
The passage of loose or watery stools at least 3
times in a 24-hr period. (The consistency of the
stools rather than the number is most important.)

5. THREE MAIN FORMS.
Acute watery diarrhea: Change in frequency and consistency of
stool.
Dysentery or Bloody diarrhea: Visible blood in the stools.
Persistent diarrhea: Episode of diarrhea, with or without blood,
which lasts at least 14 days associated with malnutrition or HIV
infection

6. ETIOLOGY.
a) INTESTINAL INFECTION WITH VARIOUS ORGANISMS ;
Bacteria: Diarrheagenic Escherichia coli, Campy Tobacter jejuni, Vibrio
cholera, Shigella species, V. Parahaemolyticus, Nontyphoidal Salmonellae,
Clostridium difficile, Yersinia enterocolitica and Bacteroides fragilis.
Virus: Rotavirus, Norovirus (calicivirus), Adenovirus, Astrovirus, and
Cytomegalovirus.
Protozoa: Cryptosporidium parvum, Giardia intestinalis, Entamoeba
histolytica, Isospora belli and Cyclospora cayetanen.
 Helminths: Strongyloides stercoralis and Angiostrongylus costaricensis.

7. B) SYSTEMIC INFECTIONS LIKE URINARY TRACT
INFECTION OR OTITIS MEDIA.
C) CERTAIN DRUGS AND FOOD ALLERGY.
D) MALABSORPTION.
E) MALNUTRITION.
F) IMMUNOCOMPROMISED STATE LIKE HIV INFECTION.

8. TYPES.
ACUTE DIARRHEA.
leading cause of illness in children younger than 5 years of
age, is defined as a sudden increase in frequency and a
change in consistency of stools, often caused by an
infectious agent in the GI tract.
 It may be associated with upper respiratory or urinary tract
infections, antibiotic therapy, or laxative use.

9. Acute diarrhea is usually self-limited (less than 14 days’
duration) and subsides without specific treatment if
dehydration does not occur.
Acute infectious diarrhea (infectious gastroenteritis) is
caused by a variety of viral, bacterial, and parasitic
pathogens.

10. CHRONIC DIARRHEA.
Defined as an increase in stool frequency and increased
water content with a duration of more than 14 days.
It is often caused by chronic conditions such as
malabsorption syndromes, inflammatory bowel disease
(IBD), immunodeficiency, food allergy, lactose intolerance,
or chronic nonspecific diarrhea, or as a result of inadequate
management of acute diarrhea.

11. INTRACTABLE DIARRHEA
Intractable diarrhea of infancy is a syndrome that occurs
in the first few months of life, persists for longer than 2
weeks with no recognized pathogens, and is refractory to
treatment.
The most common cause is acute infectious diarrhea that
was not managed adequately.

12. CHRONIC NONSPECIFIC DIARRHEA (CNSD).
Also known as irritable colon of childhood and toddlers’
diarrhea, is a common cause of chronic diarrhea in children
6 to 54 months of age.
These children have loose stools, often with undigested
food particles, and diarrhea greater than 2 weeks’ duration.
Children with CNSD grow normally and have no evidence
of malnutrition, no blood in their stool, and no enteric
infection.

13. Dietary indiscretions and food sensitivities have been
linked to chronic diarrhea.
The excessive intake of juices and artificial sweeteners
such as sorbitol, a substance found in many
commercially prepared beverages and foods, may be a
factor.

14. PATHOPHYSIOLOGY.
Diarrhea may occur due to following mechanisms:
Osmotic diarrhea.
Secretary diarrhea.
Alteration of motility

15. • Osmotic diarrhea occurs when excessive osmotically active
particles are present in the lumen, resulting in more fluid
passively moving into the bowel lumen down the osmotic
gradient.
• Secretory diarrhea occurs when the bowel mucosa secretes
excessive amounts of fluid into the gut lumen, either due to
activation of a pathway by a toxin, or due to inherent
abnormalities in the enterocytes.

16. Loss of fluid from the body leads to reduced extracellular volume
and sodium loss.
This causes movement of water from extracellular to intracellular
compartment.
Decreased blood volume results in weak thread pulse, low blood
pressure and cold extremities.

17. Filtration of urine is reduced due to low hydrostatic pressure in renal
glomeruli.
Potassium and bicarbonate are lost in diarrheal stool and acidosis
may result with dehydration.

18. CLINICAL FEATURES.
Frequent loose watery stool, oliguria, absence of tears.
Signs of dehydration, sunken fontanelle, decreased LOC, Weak
and thread pulse, hypotension, decreased capillary refill.
ECG changes with ST depression and flat T Waves.

19. Muscle hypotonia.
Kussamaul breathing in acidosis.
Abdominal distension.
Irritability.

20. ASSESSMENT OF DEHYDRATION.
Excessive fluid loss: Vomiting, diarrhea, excessive Sweating in
fever or hot climate, abdominal surgery, haemorrhage, nasogastric
drainage, excessive use of laxatives and aggressive diuretic
therapy.
Inadequate fluid intake: Dysphagia, coma, and environmental
conditions.
Others: Polyuria, diabetes mellitus or insipidus, fistula, cystic
fibrosis, burn injury.

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

22. MANAGEMENT OF DIARRHEA AND
DEHYDRATION.
PLAN A - For Child with no Dehydration.
A child with no signs of dehydration needs home
treatment to treat current episodes of diarrhea and
prevent dehydration.
Mother should be counselled to follow 4 rules of
home treatment.

23. RULE 1: GIVE THE CHILD MORE FLUIDS THAN USUAL
TO PREVENT DEHYDRATION.
Breastfeed frequently and for longer at each feed.
If the child is exclusively breastfed, give ORS or clean water
along with breast milk.
 If the child is not exclusively breastfed, give one or more of
the following: ORS solution, food based fluids (such as soup,
rice water, and yoghurt drinks), or clean water.

24.  Teach the mother how to prepare the ORS. ORS is
essential to give if diarrhea worsens.
 Fluid intake: Up to 2 years of age give 50-100 mL
after each loose stool and in between them and for 2
years or more, give 100-200 mL after each loose
stool and in between them.

25. Give frequent small sips from a cup.
If the child vomits, wait 10 min. Then continue, but
more slowly.
Continue giving extra fluid until the diarrhea stops.

26. RULE 2: GIVE ZINC SUPPLEMENTS.
Amount: Up to 6 months -1/2 tablet per day for 14 days and 6
months 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.
Advise to visit health centre if the child has any of the following
problems: Persistent diarrhea, Acute or chronic ear infection, and
any other illness like pneumonia, measles.

27. RULE 3: CONTINUE FEEDING.
Up to 6 month of age: breastfeed at least 8 times in 24 hours.
6 months to 1 year: breastfed and 3 meals per day, if not
breastfed give 5 meals per day.
1 to 2 years: breastfeed plus 5 meals per day.
Above 2 years: family foods 3 meals per day with 2 times
nutritious foods between meals.

28. RULE 4: RETURN TO HEALTH WORKER
Advise to take the child to a health care worker if the
child does not get better in 3 days or develops any of
the following:
Frequent watery stool.
fever, poor eating or drinking, marked thirst,
repeated vomiting and blood in the stools.

29. PLAN B FOR CHILD WITH SOME DEHYDRATION.
1. Give ORS in the health center 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 the recommended amount,
give more.
For infants below 6 months who are not breastfed, give
100-200 mL clean water in addition during this period.

30. 2. Observe the child closely and help 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 min. Then continue, but more
slowly.
Continue breastfeeding whenever the child wants.

31. 3. After 4 hours; Reassess the child and select plan A, B or C to
continue treatment.
If there are no signs of dehydration, shift to Plan A.
If signs indicate that some dehydration is still
present, repeat Plan B and reassess 2 hrs later or if
signs indicate that severe dehydration has occurred,
shift to Plan C.

32. 4. 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 for 2 more days as recommended in plan A.

33. 5. Explain the 4 rules in Plan A for treating her child at home:
Give ORS or other fluids continuously until diarrhea stops.
Give the zinc supplement for 10-14 days.
Continue feeding.
Come back to the healthcare worker, if necessary.

34. 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 center.
• If a health facility with an IV is not within 30 minutes, the
use of an NG tube is recommended.

35. • Start IV fluids immediately. If the child is able to drink, give
ORS by mouth until the drip is set up.
• Give 100 mL/kg Ringer’s lactate solution (or, if not
available, normal saline) as following:
 Infants (under 12 months): First give 30 mL/ kg in 1 hour
and give rest 70 mL/kg in next 5 hours.

36. Children (12 months up to 5 years):
First give 30 ml/kg in 30 min and give rest 70 mL/kg in next 2
¹/2hrs.
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 the IV drip more rapidly.

37. Also give ORS (about 5 mL/kg/hr) as soon as the child
can drink, usually after 3-4 hrs. (infants) or 1-2 hrs
(children).
Reassess an infant after 6 hrs and a child after 3 hrs and
choose the appropriate plan (A, B, or C) to continue
treatment.

38. 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.

39. If IV therapy is not possible, immediately insert nasogastric tube
and start rehydration by nasogastric tube or by mouth with ORS:
Give 20 mL/kg/hr for 6 hrs (total of 120 mL/kg). Reassess the
child every 1 - 2 hours.
If not improving after 3 hrs refer to the hospital urgently for IV
therapy.
After 6 hrs, reassess the child and select the appropriate plan (A,
B, or C) to continue treatment.

40. TREATMENT OF CHILD WITH BLOOD IN THE STOOL.
These children should be treated for dehydration and Shigella
infection.
Treat severe dehydration and/or severe malnutrition in hospital.
Administer prescribed antibiotics against Shigella.
Provide zinc supplementation.

41. DRUG THERAPY.
Antimotility agents like Imodium reduce peristalsis and be
avoided in children.
Antisecretary agents like raececadotril have antidiarrheal effect
but not recommended for routine use in children.
 Probiotics like lactobacillus has efficacy as adjunctive therapy
in early phases of illness.

42. ORS COMPOSITION..
Composition. g/dl
Sodium chloride. 2.6
Glucose 13.5
Potassium chloride 1.5
Trisodium citrate 2.

43. Components of rehydration salts - Content per liter
water
 Sodium chloride - 35 g
 Potassium chloride - 15 g
 Sodium citrate - 29 g
 Glucose anhydrous - 200 g

44.  Oral rehydration therapy (ORT) is the administration of solution
of rehydration salts orally to prevent or correct diarrheal
dehydration. ORS is a simple, inexpensive and lifesaving
remedy that prevents dehydration among children with diarrhea.
 Infants and children with acute diarrhea and dehydration should
be treated first with oral rehydration therapy (ORT).

45. • In older children ORS can be given and a regular diet
continued. Ongoing stool losses should be replaced on
a 1:1 basis with ORS. If the stool volume is not
known, approximately 10 ml/kg (4 to 8 ounces) of
ORS should be given for each diarrheal stool.

46. • A child who is vomiting should be given an ORS at
frequent intervals and in small amounts. For young
children the caregiver may give the fluid with a
spoon or small syringe in 5- to 10-ml increments
every 1 to 15 minutes.

47. ORAL REHYDRATION THERAPY.
Instructions.
 To be diluted in one liter of potable water.
 Mix entire content of the packet in one liter of water.
 ORS solution to be used within 24 hours of preparation

48. Oral rehydration therapy means drinking of
solution of clean water, sugar and mineral salts
to replace the water and salt lost from the body
during diarrhea, especially when accompanied
by vomiting, i.e. gastroenteritis.

49. ORT is beneficial in three stages of diarrheal disease, i.e.
i. prevention of dehydration.
ii.Rehydration of the dehydrated child.
iii.Maintenance of hydration after severely dehydrated
patient has been rehydrated with IV fluid therapy.

50. ORT is provided with ORS solution and home
available fluid (HAF), i.e. fruit juices, tender
coconut water, dal-soup, sarbat (with sugar, salt and
lemon), weak tea, etc.
The child with loose motion having no dehydration
can be treated at home

51. The approximate amounts of ORS solution must be given in
the first 4 hours are as follows:
 Age less than 4 months or weight less than 5 kg-200 to 400
mL
 Age 4 to 11 months 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 800 mL

52.  Age 2 to 4 years or weight 11 to 15.9 kg-800 to 1200 mL.
 Age 5 to 14 years or weight 16 to 29.9 kg-1200 to 2200 mL.
 Age 15 years or older or weight 30 kg or more to 2200 to 4000
mL.

53. If the patient can drink, ORS to be given by mouth about 5
mL/kg/hour.
 Ringer lactate should be infused at first 30 mL/kg in one
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 70 mL/kg in 2.5 hours. The patient must
be reassessed every one to two hours.

54. MECHANISM OF ORS.
In a normal child, the small intestine absorbs water and
electrolytes from the digestive tract so that these nutrient rich
fluids may be transported in the body through the circulation.
In diarrhea, pathogens damage the intestine leading to
secretion of an excessive amount of water and electrolytes
rather than absorption.
But glucose absorption remains largely intact.

55. Therefore, when the ORS solution reaches the small intestines,
the sodium and glucose in the mixture are transported together
across the lining of the intestines, and the sodium, with increased
concentrations in the intestines, promotes water absorption back
into the body from the gut to compensate for fluid losses.
The osmotic gradient in the intercellular space maintains the
absorption of potassium and bicarbonate thus correcting
metabolic acidosis.

56. NURSING MANAGEMENT.
NURSING ASSESSMENT;
Assess for frequency and consistency.
signs of dehydration.
Monitor urine output.
Check vital signs

57. NURSING DIAGNOSIS.
Deficient fluid volume related to Excessive GI losses in stool or vomiting.
Risk for infection related to contamination during episodes of diarrhea.
Impaired Skin integrity and related skin irritation caused by frequent stool.
Imbalanced nutrition less than requirement related to inadequate intake and diarrheal
losses.
Impaired oral mucous membrane related to effect of dehydration.
Anxiety related to unfamiliar environment and parental separation
Deficient knowledge related to home care and prevention of diarrhea.