2. Learning objectives
General objectives
At the end of class students will be able to gain
knowledge about diarrhea and vomiting in
paediatric population and it’s management
&apply the knowledge in clinical practice
3. Specific objectives
The students will be able to
To define diarrhea and vomiting
To enlist the etiology,riskfactors, clinical manifestations of
diarrhea and vomiting
To enlist possible complications
To enumerate medical management of diarrhea and
vomiting
To enumerate Nursing management of diarrhea and
vomiting
To explain oral rehydration therapy
4. Introduction
Diarrhoeal disease remains a leading cause of morbidity
and mortality amongst children in low and middle income
countries.
Most deaths result from the associated shock, dehydration
and electrolyte imbalance.
In malnutrition, the risk of AD, its complications and
mortality are increased.
5. What is DIARRHEA?
Diarrhea is defined as a change in consistency and
frequency of stools, i.e. Liquid or watery stools, that
occur >3 times a day.
If there is associated blood in stools, it is termed
dysentery
Acute episodes subside within 7 days.
persist for >2 weeks in 5-15% cases, which is labeled as
persistent diarrhea
6. RISK FACTORS
Poor sanitation and personal hygiene
nonavailability of safe drinking water, unsafe food
low rates of breastfeeding and immunization.
Young children ( <2 yr) and those with
malnutrition
presence of hypo- or achlorhydria
Alteration of normal intestinal microflora by
antibiotics
30. Medical management
Principles of Management
Management of acute diarrhea has four major
components:
Rehydration and maintaining hydration
Ensuring adequate feeding
Oral supplementation of zinc
Early recognition of danger signs and treatment of
complications.
31.
32. Treatment plan A - No dehydration
Treat Diarrhea at Home
Give Extra fluids (as much as the child will take)
Tell the mother: Breastfeed frequently and for longer at each
feed.
If the child is exclusively breastfed, give ORS or clean water in
addition to breast milk
If the child is not exclusively breastfed, give one or more of the
following: Food-based fluids: Soup, Rice water and yoghurt or
clean water. “ KYB DIET”
33. Plan B – Some dehydration
1. Daily fluid requirement: – Up to 10 kg = 100 ml/ kg
10 – 20 kg = 50 ml/ kg > 20 kg = 20 ml/ kg
2. Deficit replacement: 75 ml/ kg ORS to be given over 4
hours
3. Replace losses: ORS should be administered in volumes
equal to diarrheal losses. Maximum of 10 ml/ kg per stool.
4. Give Supplemental Zinc (20 mg) to the child, everyday for
10 to 14 days
34. Plan C – Severe dehydration
Treated with 20 mL/ kg IV of isotonic crystalloid over 10 to 15
minutes. Repeat as necessary.
Monitor pulse strength, capillary refill time, mental status, urine
output and electrolytes.
After resuscitation: A total of 100 ml/ kg of fluid given over 3
hours in children > 12 months and over 6 hours in children < 12
months.
Assess the patient every 3 hours accordingly repeat Plan C or shift
to Plan B .
35. ORS Mechanism
ORS Constituent
STANDARD WHO ORS LOW OSMOLARITY ORS
ADVANTAGES OF LOW OSMOLARITY ORS
Cereal based ORS/ Rice based ORS • Super ORS
Other types of ORS
Contraindications to ORT
38. NURSING DIAGNOSIS
1. Fluid volume deficit related to diarrhea.
2. Altered nutritional status, less than body requirement
related to malabsorption and poor oral intake.
3. Risk for cross-infection related to infective loose
motion.
4. Potential to altered skin integrity related to frequent
passage of stools.
5. Fear and anxiety related to illness and hospital
procedure.
39. Nursing Interventions
Record the intake and output&
frequency and characteristics of
stools & assess vital signs.
Weigh child daily on same scale at
same time
Assess and record • IV fluids and
condition of IV site every hour •
bowel sounds .
Provides information on child’s
hydration status.
Decrease
in weight may be due to
increased fluid loss
Provides information about flui
status of patient.
Rationale
Deficient Fluid Volme r/t Volume loss due to diarrhea
Goal:Child will have an adequate fluid volume
40. Nursing Interventions. Rationale
Assess and record any
signs/symptoms of imbalanced
nutrition,I V fluids
Feed slowly with small, frequent
feedings,Place in a semierect
posi-tion. Burp infant at frequent
intervals
It is necessary to record the
amount of IV fluids every
hour to make sure the child
is not being over or under
hydrated
These interventions help the
infant to retain feedings
Imbalanced Nutrition: Less than Body Requirements r/t
Malabsorption and poor oral intake
Goal:Child will be adequately nourished
41. Nursing Interventions. Rationale
Maintain good hand-washing
technique.
Check and record results of
WBC. Notify physician.
Administer antibiotics on
schedule. Assess and record
any side effects
Decreasing infection
Abnormal WBC results may
indicate an Infection
Antibiotics are given to
combat infection or
prophylactically
Risk for infection related to presence of invading microorganisms
Goal:Child will be free of infection
42. NURSING INTERVENTIONS
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.
43. 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
44. 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.
45. 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.
47. VOMITING in children
Definition
Vomiting refers to acute expulsion of gastric contents
through the mouth.
Vomiting is a symptom, presenting complaint in multitude
of disorders
Range from gastrointestinal pathology to disease in distant
organ (otitis media or intracranial lesion) .
In children, especially infants, must distinguish from
regurgitation – effortless expulsion of gastric contents
48. Vomiting is an active process , composed of 3 linked
activities : Nausea , retching, active propulsion of
stomach contents.
Control of vomiting by 2 anatomic centers
1. medulla
2. Chemoreceptor trigger zone CTZ
50. Classification of vomiting
According to nature
1. Projectile - Increased ICP or Pyloric stenosis
2. Non Projectile – GER or other causes
According to quality
1. Bilious
2. Bloody
3. Non bloody or non bilious
51. Causes of vomiting
Nonorganic causes
Neonates
Swallowed AF or blood
Faulty feeding techniques
Swallowed air due to erratic feeding
Possetting
Side effects of drugs
59. Cyclic vomiting syndrome
Cyclic Vomiting :This is defined as occurrence of
stereotypic episodes of intense nausea and vomiting as
defined previously, with complete normalcy between
episodes.
The absence of a metabolic, neurologic or
gastrointestinal disorder.
The patient should have had at least 5 episodes in all or
3 episodes during a 6-month period.
76. Medical management
Promethazine and ondansetron are useful in postoperative
vomiting and to abort episodes of cyclical vomiting.
Ondansetron, given alone or with dexamethasone, is preferred
for chemotherapy related vomiting.
Domperidone and metoclopramide are useful in patients with
gastroparesis.
Antihistaminics like diphenhydramine help in motion sickness.
Management of the underlying condition is essential.
77. Management
Known precipitants of the episodes should be avoided.
Management of an attack includes providing a quiet
environment, admistration of I V fluids, use of serotonin 5
HT3 antagonists such as ondansetran and sedation with
lorazepam
Agents recommended for prophylaxis against future attacks
are cyproheptadine in children below 5 yr and, in older
children, amitriptyline or propranolol
78. Nursing management
Nursing diagnosis
1. Deficient Fluid Volume r/t volume loss due to vomiting
2. Imbalanced Nutrition: Less Than Body Requirements r/t
inability to absorb nutrients secondary to inability to ingest
food
3. Risk for Electrolyte Imbalance: Risk factor: loss of stomach
content containing electrolytes secondary to vomiting
4. Risk for aspiration r/t vomiting
79. Nursing Interventions. Rationale
Assess and record RR, breath
sounds, and any
signs/symptoms of aspiration
Ensure that infant receives small,
frequent feedings (every 2 to 3
hours).
If aspiration has occurred
the RR will increase, and
abnormal breath sounds
may be present.
promote retention of
feedings and decrease the
chance of aspiration
Risk for aspiration related to excessive vomiting, reflux of gastric
contents into the esophagus
Goal: Child will be free of signs/symptoms of aspiration
81. Evaluation Questions
The nurse provides feeding instructions to a parent of an infant
diagnosed with gastroesophageal reflux disease. Which
instruction should the nurse give to the parent to assist in
reducing the episodes of emesis?
1. Provide less frequent, larger feedings.
2. Burp the infant less frequently during feedings.
3. Thin the feedings by adding water to the formula.
4. Thicken the feedings by adding rice cereal to the formula.
82. A child is hospitalized because of persistent
vomiting. The nurse should monitor the child
closely for which problem?
1. Diarrhea
2. Metabolic acidosis
3. Metabolic alkalosis
4. Hyperactive bowel sounds
83. The nurse admits a child to the hospital with a
diagnosis of pyloric stenosis. On assessment,
which data would the nurse expect to obtain
when asking the parent about the child’s
symptoms?
1. Watery diarrhea
2. Projectile vomiting
3. Increased urine output
. 4. Vomiting large amounts of bile
