Diarrhea is characterized by loose or watery stool more than 3 times per day. It is a major cause of death in developing countries and infants worldwide. Diarrhea can be acute lasting 1-2 weeks, chronic lasting more than 3 weeks, or persistent lasting 2 weeks or more. Causes include viruses, bacteria, parasites, and fungi transmitted through the fecal-oral route. Management involves oral rehydration therapy with continued feeding. For severe dehydration intravenous fluids are given along with monitoring until rehydration is complete. Diet emphasizes continued breastfeeding and eating small, frequent meals high in nutrients.

1. DIARRHEA

2.  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.

3. 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.

4.  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.

5. 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.

6. 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.

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.

8. CONTINUE:
- Bacteria: Campylobacter
jejuni,E.coli,Shigella,Salmonella,cholera
vibrio,vibrio parahemolyticus etc.
- Parasites:
E.histolytica, G.lambia, Cryptosporidium,H.nana
, malaria etc.
- Fungi: Candida albicans

9. 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.

10. 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.

11. 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.

12. 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.

13. ENVIRONMENTAL FACTORS:
 Bacterial diarrhea is more frequently occur in
summer and rainy season,whereas viral diarrhea (
specially rotavirus ) found in winter.

14. 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.

15. 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.

16.  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.

17.  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.

18. 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.

19. ASSESSMENT OF DEHYDRATION:
A B C
1. 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. hours
2. Look at
• Condition -Well, alert -Restless,Irritable -Lethargic or
or sleepy ,unwell. unconsious,

20. CONTINUE:
A B C
•Mouth and -Moist -Dry -Very dry
tongue
•Breathing -Normal -Faster than - Very fast and
normal deep
3. 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 patient
Degree of NO SIGNS OF two or more has two or more
Dehydration DEHYDRATION signs including signs including
at least one sign at least one sign
there is SOME there is
DEHYDRATION SEVERE

21. 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.

22. 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.

23. 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.

24.  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.

25. 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.

26. 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.

27. MGMT CONT:
 Bacterial or protozoal diarrhea can be treated with
specific drugs. Ampicillin,nalidoxic
acid,norfloxacin,ciprofloxacin,furazolidine,metronida
zole can be used.

28. 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.

29. 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.

30. 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.

31. 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.

32. 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.

33. COMPLICATIONS:
 Dehydration
 Hypovolemic shock
 Renal failure
 Paralytic ileus
 Thromboembolism
 CCF
 Convulsions
 Overdehydration
 Hypoglycemia
 Consumptive coagulapathy
 Toxic megacolon
 Malnutrition
 Growth retardation
 Mental subnormalities

34. 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.