DIARRHOEA

1. DIARRHOEA
Ms. Khushboo singh
Nursing Tutor

2. DEFINITION
• ACC TO WHO- having three or
more loose or liquid stools per day,
or as having more stools than is
normal for that person.

3. INCIDENCE
• Worldwide in 2004 approximately 2.5 billion
cases of diarrhea occurred which results in
1.5 million deaths among children under the
age of five.
• This is down from a death rate of 5 million
per year two decades ago.
• Now approximately 500 million children
suffer diarrhea each year .
• Diarrhea remains the second leading cause
of death (16%) after pneumonia (17%) in
under fives

4. An electron micrograph of rotavirus, the cause of nearly
40% of hospitalizations from diarrhoea in children under
five

5. TYPES
1.On the basis of duration
Diarrhea lasts
for less than
14 days
1.Acute
diarrhea
Diarrhea lasts
for more than
14 days
2.Chronic
diarrhea

6. TYPES
2.On the basis of clinical
presentation
Diarrhea lasts for
several hours or
days and occurs
in condition like
cholera
1.Acute
watery
diarrhea
diarrhea
Diarrhea with
blood in stool ,
with or without
mucus is known
as dysentery
2.Acute
bloody
diarrhea

7. TYPES
On the basis of clinical
presentation3.On the basis of
physiology
1.Secretery
diarrhea :
means
there is an
increase in
the active
secretions
or an
inhibition of
absorption
in intestine
2.Osmotic
diarrhea :
occurs
when too
much water
is drawn in
to bowel
when child
drinks
excessive
sugar or
salt solution
3.Exudate
diarrhea :
presence of
blood and
pus in stool .
It occurs due
to
inflammatory
bowel
disease such
as ulcerative
colitis , food
poisoning ,
etc.
4.Motility-
related
diarrhea: by
the rapid
movement
of food
through the
intestine ,
This occurs
in diabetics ,
hyperthyroid
ism , etc
5.Inflammat
ory diarrhea
: occurs due
to damage to
mucosal
lining which
leads to
passive loss
of protein
rich fluid and
decrease
ability to
absorb the
lost fluid . It
can be seen
in
inflammatory
bowel

8. ETIOLOGY
• Bacteria : shigella , E.coli , salmonella
, staphylococcus
• Virus:influenza,adenovirus,enterovirus
,rotavirus,measles virus
• Parasites:giardia lamblia,entamoeba
histolytic and amoeba
• Fungi:candida albicans
1.Infection
• Intake of antibiotics and iron supplements2.Drugs
• Food poisoning , food allergies , over eating
and eating of stale foods
3.Dietery
cause
• Intussusception,polyps,diverticulitis,and
appendicular abscess
4.Surgical
condition

9. PREDISPOSING FACTOR
• More frequent in children under the age
of 2 years , with peak incidence during
6-9 months of age
1.Age
• More common in summer and rainy
season2.season
• More common in children from poor
families , living in poor sanitary
environment
3.socio-
economic status
• Higher in artificially fed children as
compared to those who breastfed4.Dietery factor
• During tooth eruption , infants put dirty
objects and fingers in mouth , thus
causing infection and diarrhea
5.Teething

10. PATHOPHYSIOLOGY
Diarrhea
Loss of normal
alkaline
secretions
&fluid
Metabolic
acidosis
Inflammation and
edema of mucosal
membrane
Chronic
diarrhea
Released
organic
acids
Poor nutritional status secondary to
loss of essential nutrients
Increased bacterial
growth fermentation
Increased
carbohydrate
level in gut &
increases fluid
loss
Dehydratio
n

11. CLINICAL FEATURES AND ASSESSMENT
1.Mild diarrhea
• May be 2-5
loose stools
which may be
green ,
offensive ,
containing
mucus and
have milk curd
like consistency
• Volume may be
small or large
• May subside in
a day or two
2.Moderate
diarrhea
• Number of
loose stools is
10 or more
• May have fever ,
irritability ,
anorexia and
vomiting
• Mild
dehydration
3.Severe
diarrhea
• May pass too
many or even
100 loose
stools within 24
hrs.
• Severe vomiting
, marked fever ,
anorexia and
irritability
• Oral intake
becomes
impracticable

12. Signs of various degrees of dehydrationAsk :
Diarrhea Less than 4 loose
stools/day
4-10 loose
stools/day
More than 10 loose
stools /day
vomiting None or small
amount
same Very frequent
Thirst More than normal More than normal Unable to drink
urine Normal Small amount and
dark
No urine for 6 hrs
Look :
Condition Baby is well alert Unwell , sleepy or
irritable
Very sleepy ,
unconscious , floppy
or having fits
Tears Present Present Absent
Eyes Normal Sunken Very sunken
Mouth and tongue Wet Dry Very dry
Breathing Normal Faster than normal Very fast and deep
Feel :
Skin When pinched ,
goes back quickly
When pinched ,
goes back slowly
When pinched ,
goes back very
slowly

14. Diagnostic evaluation
• Number and description of stools
per day , body weight , fluid intake
, frequency of urination , etc.
1.History
• To asses degree of dehydration2.Physical
examination
• For volume, consistency, color ,
pH and presence of blood ,
mucus , leucocytes , glucose ,
ova and cysts of parasites
3.Stool examination
• Helps to identify micro-organisms
4.Stool culture
• Hematocrit , BUN , WBC , serum
sodium , serum bicarbonate ,
serum chloride
5.Blood test

15. MANAGEMENT
1.Replacement of fluids
2.Administration of
prescribed drugs
3.Maintenance of nutritional
status
4Prevention of diarrhea
5.Educating parents

16. 1 . Fluid replacement
Administration of ORS:
ORS can be used to
prevent development of
dehydration . At home ORS
can be made by mixing in 1
litre water , three finger
pinch salt(3gms) and 2 table
spoons
sugar(18gms).should be
given to child after every
loose stool

17. Composition standard ORS recommended by WHO
Content Amount in g/L Ingredient Osmolality in
mmol/L
Sodium
chloride
3.5 Sodium 90
Potassium 20
Sodium
bicarbonate
2.5 Chloride 80
Potassium
chloride
1.5 Glucose 111
Glucose 20 Bicarbonate 30
Total osmolality
= 311

18. New reduced osmolality ORS recommended by
WHO
Content Amount in g/L Ingredient Osmolarity in
mmol/L
Sodium
chloride
2.6 Sodium 75
Potassium 20
Trisodium
citrate
dihydrate
2.9 Chloride 65
Potassium
chloride
1.5 Glucose 75
Glucose 13.5 Citrate 10
Total

19. Management of patient with diarrhea depends on the severity
of dehydration- 3 plans are followed
A . Treatment plan A:This plan for child with mild dehydration .
Mothers are educated to provide home based fluids to child
like rice water , salted lassi , lemon water , coconut water ,
soups , fruit juice , dal water ,etc. The mother should be told
to give ORS after each loose stool

20. Oral rehydration therapy(plan A)
Age Amount of ORS to
be given after each
stool
Amount of ORS to
be made for use at
home
Less than 24 months 50-100ml 500ml/day
2-10 years 100-200ml 1000ml/day
More than 10 years As much as child
can drink
2000ml/day

21. B . Treatment plan B:This plan for child with moderate
dehydration . These patients need to be treated in a
hospital . It has three components
a)rehydration therapy
b)maintenance therapy

22. a)Oral rehydration therapy(plan B)-during first 4 hrs
Age <4
months
4-12
months
1-2
years
2-4
years
5-14
years
15
years
Approxi
m . Wt.
in kg
<5 kg 5-8 kg 8-11 kg 11-16
kg
16-30
kg
>30 kg
ORS
(in ml)
200-400 400-600 600-800 800-
1200
1200-
2200
>2200
Measur
e
(in
glass)
1-2 2-3 3-4 4-6 6-11 12-20
If the child’s age is not known , then give ORS in dose of 75ml/kg body
weight during first 4 hrs

23. b)maintenance therapy : ORS should be administered in
volume equal to diarrheal losses.ORS in dose of
approximately10-20 ml/kg body weight is given after each
liquid stool

24. C. Treatment plan C:This plan for child with severe
dehydration .Start IV fluids immediately . The best IV fluid
solution that should be given is RL solution(5%).If RL
solution not available normal saline (0.9%) can be used

25. IV fluid therapy(plan C)
Age First give Then give
<12 month 30ml/kg in 1
hour(repeat if radial
pulse is still weak)
70ml/kg in 5 hours
12 months-5 years 30ml/kg in 30
minutes
70ml/kg in 2 and half
hours
ORS should be given to patient in dose of 5ml/kg body weight , if
patient can drink. Reassess the patient every 15-30 mints till a
strong radial pulse is present. If the patient does not pass urine
within this period then 10ml/kg body weight of RL or blood plasma

26. 2.Administration of prescribed
drugs:
-Antibiotics
-Binding agents like bismuth compounds
(pectin and kaolin)
-Anti motility agents ( loperamide ,
codeine)
-Anti-secretory agents( aspirin,
chlorpromazine , etc)

27. 3.maintain nutritional status:
-fed during acute diarrhea
- breast feeding should continue along with ORS
-in non-breast fed infants diluted cow’s or
buffalo’s milk along with semi solid foods after
correction of dehydration
-soft cooked rice with milk or curd and sugar ,
mashed banana , mashed potato should be
given to child
-avoid spicy foods
-zinc supplementation

28. 4.Educate mothers on
prevention:
-avoid bottle feeding
- good food hygiene
-balanced diet
-clean water for drinking , cooking , etc
-proper excreta disposal
-eat freshly cooked food
-proper hand washing by children before eating
food
-never use open spaces for passing stool
-isolation

29. T
H
A
N
K
Y
O
U