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- 1. DIARRHEA VOMITING IN PAEDIATRICS YAKE MICHAEL UGANDA CHRISTAIN UNIVERSITY
- 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
- 7. ETIOLOGY Infectious Viral: Rotavirus, adenovirus, astrovirus, CMV Bacterial: Salmonellae, shigellae, staphylococci, E. Coli Parasitic: Giardia, cryptosporidia, cyclospora Hemolytic uremic syndrome Congenital :Chloride and sodium diarrhea ,Enterocyte abnormalities Disaccharidase malabsorption
- 9. Functional: Toddler’s diarrhea ,Irritable bowel syndrome Causes of acute diarrhea : acute infectious disorders of the GI tract, antibiotic therapy, rotavirus, parasitic infestation. chronic diarrhea :malabsorption syndromes, inflammatory bowel disease, immunodeficiencies, food intolerances, and nonspecific factors.
- 12. PATHOPHYSIOLOGY
- 15. TYPE OF DIARRHEA 1. Secretory diarrhea 2. Osmotic diarrhea 3. Inflammatory diarrhea 4. Malabsorption
- 18. Diagnostic Evaluation History Examination Degree of dehydration Assessment of fluid loss No dehydration. <50 ml/kg Some dehydration. 50-100 ml/kg Severe dehydration > 100 ml/kg
- 27. Thromboembolism Congestive heart failure
- 29. DIC
- 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.
- 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
- 36. Physiological basis of efficacy of ORS
- 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.
- 46. Let’s summarise pediatric diarrhea
- 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
- 52. Early Infancy Excessive cry Faulty feeding Overfeeding Rumination Introduction of solids Loneliness Forced feeding Emotional disorders Motion sickness Repetitive Swinging Sudden excitement Fear, Anxiety, Unpleasant sight,odour Late Infancy& Childhood
- 53. Differncial diagnosis of vomiting Organic causes Age- 0 to 3 months
- 54. • Infections , Toxic, Emotional ,Neurological, Metabolic causes,Child abuse GERD
- 55. 3 to 12 months
- 56. UTI
- 57. Duodenal Atresia. Jejunoileal Atresia
- 58. Superior Mesenteric Artery syndrome
- 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.
- 60. Clinical manifestations Vomiting in early morning Vertigo
- 65. Diagnostic Evaluation:AcuteVomiting 1. Assessment of hydration, electrolytes, creatine 2. plain X-ray abdomen (in suspected surgical causes).
- 67. Barium studies:
- 68. Gastric Emptying Scan CT or MRI of Brain
- 69. Urine analysis
- 70. Complications : Nutritional Metabolic Alkalosis
- 71. Cutaneous
- 72. Oropharyngeal
- 74. GE Functional
- 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
- 84. Bibliography 1. Datta P, Pediatric nursing, 3rd edition , Jaypee brothers medical publication (P) ltd. New Delhi, P-164, 274-278. 2. T.R Harrison, Principles of Internal Medicine, 18th edition, The McGraw-Hill Companies, Inc. 2012, P- 308-319 3. Gupta P, Essential pediatric Nursing,4th edition,CBS publication (p)Ltd.Newdelhi,P-362,363,121,191. 4. Links: • http://www.worldgastroenterology.org/assets/export/ userfiles/Acute%20Diarrhea_long_FINAL_120604.pdf • http://www.clevelandclinicmeded.com/medicalpubs/ diseasemanagement/gastroenterology/acute- diarrhea/Default.htm •
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