DIARRHOEAL DISEASES. DIARRHOEAL DISEASES. INTRODUCTION. INTRODUCTION. Gastro intestinal complaints are a significant part of Gastro intestinal complaints are a significant part of paediatrics. Abdominal pains, diarrhoea, constipation, paediatrics. Abdominal pains, diarrhoea, constipation, emesis and gastro intestinal bleeding are seen frequently. emesis and gastro intestinal bleeding are seen frequently. Diarrhoeal diseases are Diarrhoeal diseases are a major cause of morbidity and a major cause of morbidity and mortality in children around the world, accounting for 1.8 mortality in children around the world, accounting for 1.8 million deaths annually in children younger than 5 years, or million deaths annually in children younger than 5 years, or roughly 17% of all child deaths (Levine, 2006). roughly 17% of all child deaths (Levine, 2006). Diarrhoeal Diarrhoeal diseases are indicators of poor water supply and inadequate diseases are indicators of poor water supply and inadequate sanitation, systemic infection and poor weaning methods as sanitation, systemic infection and poor weaning methods as well as abnormality of the GIT. well as abnormality of the GIT. In our discussion we are going to look at Diarrhoeal In our discussion we are going to look at Diarrhoeal diseases under the following classifications Bloody diarrhea diseases under the following classifications Bloody diarrhea such as Dysentery and Non-bloody diarrhea such as Cholera such as Dysentery and Non-bloody diarrhea such as Cholera and Typhoid fever. and Typhoid fever. Definitions of diarrhoea. 1. Diarrhoea is abnormally frequent evacuation of watery stools (Novak, 2001). 2. Diarrhoea is an increase in the number of stools or an increase in the fluid content of the fecal material (Bernstein et al, 2003). 3. Diarrhoea is defined as three or more loose watery stools in a 24 hour period(CBOH,2002) Classifications. 1
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DIARRHOEAL DISEASES.DIARRHOEAL DISEASES.
INTRODUCTION.INTRODUCTION.Gastro intestinal complaints are a significant part of paediatrics. Abdominal pains,Gastro intestinal complaints are a significant part of paediatrics. Abdominal pains,
diarrhoea, constipation, emesis and gastro intestinal bleeding are seen frequently.diarrhoea, constipation, emesis and gastro intestinal bleeding are seen frequently.
Diarrhoeal diseases areDiarrhoeal diseases are a major cause of morbidity and mortality in children around thea major cause of morbidity and mortality in children around the
world, accounting for 1.8 million deaths annually in children younger than 5 years, orworld, accounting for 1.8 million deaths annually in children younger than 5 years, or
roughly 17% of all child deaths (Levine, 2006).roughly 17% of all child deaths (Levine, 2006). Diarrhoeal diseases are indicators of poorDiarrhoeal diseases are indicators of poor
water supply and inadequate sanitation, systemic infection and poor weaning methods aswater supply and inadequate sanitation, systemic infection and poor weaning methods as
well as abnormality of the GIT.well as abnormality of the GIT.
In our discussion we are going to look at Diarrhoeal diseases under the followingIn our discussion we are going to look at Diarrhoeal diseases under the following
classifications Bloody diarrhea such as Dysentery and Non-bloody diarrhea such asclassifications Bloody diarrhea such as Dysentery and Non-bloody diarrhea such as
Cholera and Typhoid fever.Cholera and Typhoid fever.
Definitions of diarrhoea.
1. Diarrhoea is abnormally frequent evacuation of watery stools (Novak, 2001).
2. Diarrhoea is an increase in the number of stools or an increase in the fluid content
of the fecal material (Bernstein et al, 2003).
3. Diarrhoea is defined as three or more loose watery stools in a 24 hour
period(CBOH,2002)
Classifications.
Diarrhoea can be classified as inflammatory, non inflammatory, bloody and non bloody;
however in our discussion the focus will be on bloody as well as non bloody diarrhoea.
Blood diarrhoea.
Dysentery is an acute or chronic disease of the large intestine of human beings,
characterized by frequent passage of small, watery stools, often containing blood and
mucus, accompanied by severe abdominal cramps. Ulceration of the walls of the intestine
may occur. Although many severe cases of diarrhoea have been called dysentery, the
word properly refers to a disease caused by a specific amoeba, Entamoeba hystolytica,
virus, or a bacillus that infects the colon (Encarta ® Encyclopedia, 2005).
Bacillary dysentery is an acute inflammation of large intestines characterized byBacillary dysentery is an acute inflammation of large intestines characterized by
diarrhoea, blood and mucous in stool.diarrhoea, blood and mucous in stool.
Bacillary dysentery is caused by certain nonmotile bacteria of the genus Shigella (Encarta
® Encyclopedia 2005).
Causes.Causes.
The cause is shigella. Shigella is in 4 strains:The cause is shigella. Shigella is in 4 strains:
1.1. Shigella flexneriShigella flexneri
2.2. Shigella boydiiShigella boydii
3.3. Shigella dysenteriaeShigella dysenteriae
4.4. Shigella sonneiShigella sonnei
Epidemiology.Epidemiology.
This form of dysentery is also most prevalent in unhygienic areas of the tropics, but,
because it is easily spread, sporadic outbreaks are common in all parts of the world. This
dysentery is usually self-limiting and rarely manifests the more severe organ
involvements characteristic of amoebic dysentery (Encarta ® Encyclopedia, 2005).
Shigellosis commonly occurs among confined populations, such as those in nursingShigellosis commonly occurs among confined populations, such as those in nursing
homes (Diseases, 1993). Crowded living conditions.homes (Diseases, 1993). Crowded living conditions.
Pathophysiology.Pathophysiology.
When the bacillus enters the GIT, it invades the large intestines causing inflammation ofWhen the bacillus enters the GIT, it invades the large intestines causing inflammation of
the mucosa.the mucosa.
Ulceration and bleeding of the mucosa result to blood stained and mucoid stool.Ulceration and bleeding of the mucosa result to blood stained and mucoid stool.
In the later stage, pus forms due to infection.In the later stage, pus forms due to infection.
Adjacent lymph nodes may be affected resulting into fever.Adjacent lymph nodes may be affected resulting into fever.
Mode of spread.
Feacal oral.
Bacillary dysentery is spread by contaminated water, milk, and food. Faeces from active
cases as well as those from healthy carriers contain immense numbers of the disease-
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producing bacteria. Flies carry the bacteria on their feet or in their saliva and faeces, and
deposit them on food; ants are also believed to spread the disease (Encarta ®
Encyclopedia, 2005).
Incubation period.Incubation period.
The incubation period is within a week i.e. one (1) to seven (7) days.The incubation period is within a week i.e. one (1) to seven (7) days.
Signs and symptoms.Signs and symptoms.
The clinical spectrum varies from mild, chronic diarrhoea to an abrupt massive toxic
process with a high mortality. The most common presentation involves;
Sudden onset of sign s and symptoms.Sudden onset of sign s and symptoms.
Abdominal cramps. Abdominal cramps.
Fever.Fever.
Diarrhoea follows, often frequent with small volumes but mixed with blood andDiarrhoea follows, often frequent with small volumes but mixed with blood and
pus.pus.
Urgency(sudden desire to defecate).
Tenesmus (painful straining at stool).Tenesmus (painful straining at stool).
Dehydration is not unusual.Dehydration is not unusual.
Vomiting.Vomiting.
Meningismus and seizures often develop due to presence neuro toxins (Bernstein
and shelov, 2003).
Medical management.
Diagnosis.
It is diagnosed in the lab by examination of stool collected from an infected person and
below are some of the investigations done.
Investigations.Investigations.
History and clinical presentation.
Stool for culture and sensitivity. Stool for culture and sensitivity.
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Microscopic examination of a fresh stool specimen may reveal mucus, RBCs andMicroscopic examination of a fresh stool specimen may reveal mucus, RBCs and
Sigmoidoscopy may reveal typical superficial ulcerations.Sigmoidoscopy may reveal typical superficial ulcerations.
Treatment.Treatment.
In the treatment of bacillary dysentery, proper replacement of fluid is important.
Sulphonamides, tetracycline, and streptomycin were effective in curing acute cases until
drug-resistant strains emerged. Chloramphenical is sometimes used to treat these strains.
Quinolones such as norfloxacin and ciprofloxacin are also effective against Shigella
infection (Encarta ® Encyclopedia 2005).
Recommended antibiotics for shigella: nalidixic acids first line antibiotic.Age or weight. Nalidixic acid tablet ( 250mg)
Give 4 times daily for 5 days.2 to 4 months ( 4 to 6 kg). Quarter tab.4 to 12 months ( 6 to 10 kg). Half tab.12 months to five years ( 10 to 19 kg). One tab.
Second line antibiotic: cotrimoxazole. Trimethoprim + sulphamethoxazole 2 times daily for five days.Age or weight. Adult tab. Paediatric. Syrup.
480mg. 120mg. 240mg/ 5mls.2 to 12 months ( 4 to 10 kg). Half tab. Two tabs. 5mls. 12 months to 5 years (10 to 19 kg). 1 tab. 3 tabs. 7.5mls
Complications.
1. Anaemia due to bleeding.
2. Perforation due to ulceration created by bacteria.
3. Peritonitis as a result of perforation.
4. Renal failure due to dehydration.
5. Meningitis due to the neurotoxins irritation to the brain.
This is a chronic enteric infection caused by protozoa known as Entamoeba hystolyticaThis is a chronic enteric infection caused by protozoa known as Entamoeba hystolytica
(Billings and stokes, 1982).(Billings and stokes, 1982).
Amoebiosis is an infection of the large intestines caused by Entamoeba hystolytica a
single celled parasite (Berkow et al, 1997).
Forms.Forms.
Amoeba hystolytica (protozoa) is in 2 forms:Amoeba hystolytica (protozoa) is in 2 forms:
1. Resting or cystic form; (inactive form) the cyst will grow into a vegetative form that is
an adult.
2. Vegetative form ;( active form or trophozoite) these are motile which enter the
intestinal wall and cause ulcers of the small intestines, causes diarrhoea and expels
Trophozoites. Trophozoites.
Mode of transmission.Mode of transmission.
Faecal oral.Faecal oral.
Amoebic dysentery is most commonly spread by water or contaminated, uncooked foodAmoebic dysentery is most commonly spread by water or contaminated, uncooked food
or from carriers. Flies may carry the cysts to spread the amoeba from the faeces ofor from carriers. Flies may carry the cysts to spread the amoeba from the faeces of
infected people to food (Encarta ® Encyclopedia 2005).infected people to food (Encarta ® Encyclopedia 2005).
Epidemiology.Epidemiology.
It’s endemic in many tropical countries, but is attributed to unsanitary conditions than toIt’s endemic in many tropical countries, but is attributed to unsanitary conditions than to
heat. It is the most common type of dysentery in the Philippine Islands, the Malayheat. It is the most common type of dysentery in the Philippine Islands, the Malay
Archipelago, and the Caribbean, but it also occurs in almost all temperate countriesArchipelago, and the Caribbean, but it also occurs in almost all temperate countries
Just like in bacillary dysentery, but the ulcers they form are flux like. Once ingested, theJust like in bacillary dysentery, but the ulcers they form are flux like. Once ingested, the
trophozoite the intestinal wall and intestinal mucosal through the mesenteric artery. Thetrophozoite the intestinal wall and intestinal mucosal through the mesenteric artery. The
trophozoite will reach the liver causing total destruction of the liver thus causingtrophozoite will reach the liver causing total destruction of the liver thus causing
destruction and hepatocellular necrosis and then liver abscess. It also affects the spleendestruction and hepatocellular necrosis and then liver abscess. It also affects the spleen
and lungs as well as brain and other organs as the trophozoite spread through circulation.and lungs as well as brain and other organs as the trophozoite spread through circulation.
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Signs and symptoms.Signs and symptoms.
Some clients’ remains asymptomatic but are carriers of the protozoan and can transmit
the infection to others if careful hand washing and food handling procedure are not held.
Some of the presentations are as follows;
Onset is gradual; may take 2 weeks or years.Onset is gradual; may take 2 weeks or years.
Abdominal pains that may be on and off on the right lower quadrant of theAbdominal pains that may be on and off on the right lower quadrant of the
abdomen.abdomen.
Nausea and vomiting.
Fowl smelling stools containing pus, blood.
Diarrhoea may alternate with constipationDiarrhoea may alternate with constipation
Tenderness in the affected colon area.Tenderness in the affected colon area.
If there is hepatic Amoebiosis there would be: general body malaise, swingingIf there is hepatic Amoebiosis there would be: general body malaise, swinging
temperature, sweating, and enlarged tender liver.temperature, sweating, and enlarged tender liver.
Inceased flatulence.
Medical management.
Diagnosis.
Amoebiosis is diagnosed in the lab by examination of stool collected from an infected
person and below are some of the investigations done.
Investigations.Investigations.
History taking.History taking.
Clinical picture.
Microscopic examination of stool.Microscopic examination of stool.
Sigmoidoscopy with biopsy/ proctoscpy.Sigmoidoscopy with biopsy/ proctoscpy.
Liver aspiration at sometimes. Aspirate can be pink and chocolate or yellowish.Liver aspiration at sometimes. Aspirate can be pink and chocolate or yellowish.
Urine output: Increase or decrease in frequency of urination measured by
number of wet diapers, time since last urination, color and concentration of urine,
and presence of dysuria.
Abdominal pain: Location, quality, radiation, severity, and timing of pain, per
report of parents and/or child. In general, pain that precedes vomiting and diarrhea
is more likely to be due to abdominal pathology other than gastroenteritis.
Signs of infection: Presence of fever, chills, myalgia, rash, rhinorrhea, sore
throat, coughs. These symptoms may indicate evidence of systemic infection or
sepsis.
Appearance and behavior: Weight loss, quality of feeding, amount and
frequency of feeding, level of thirst, level of alertness, increased malaise,
lethargy, or irritability, quality of crying, and presence or absence of tears with
crying.
Antibiotics: History of recent antibiotic use increases the likelihood of
Clostridium difficile colitis.
Travel: History of travel to endemic areas may make prompt consideration of
relatively rare organisms, such as parasitic diseases or cholera.
Physical examinations.
The physical examination should confirm and clarify the assessment of dehydration and
should narrow diagnostic possibilities generated by the history.
General survey: Weight, appearance, level of alertness, lethargy, irritability
HEENT: Presence or absence of tears, dry or moist mucous membranes, sore
throat, sunken eyes, or sunken fontanelle
Cardiovascular: Heart rate, blood pressure, quality of pulses, perfusion,
temperature of skin and distal extremities.
Respiratory: Rate and quality of respirations; the presence of deep, acidotic
breathing increases the likelihood of dehydration.
Abdomen: Abdominal tenderness, guarding, and rebound, bowel sounds.
Abdominal tenderness on examination, with or without guarding, should prompt
consideration of diseases other than viral gastroenteritis.
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Back: Flank/costovertebral angle (CVA) tenderness increases the likelihood of
pyelonephritis.
Rectal: Quality and color of stool, presence of gross blood or mucous in stool.
Extremities: Capillary refill time, warm or cool extremities.
Skin: Abdominal rash may indicate typhoid fever (infection with Salmonella
typhi) while jaundice might make viral or toxic hepatitis more likely.
Treatment.
Minimal or no dehydration: No immediate treatment is required. Instruction to
caretakers about ORS to be taken at home. Giving instructions regarding signs of
dehydration are recommended.
Plan A. for treating minimal or no dehydration.
Age Amount of ORS to give
after each loose stool.
Amount of ORS to
provide for use at home.
Less than 24 months. 50 – 100 ml. 500ml/ day.
Two up to ten years. 100 – 200 ml. 1000ml / day
Ten years or more. As much as wanted. 2000ml / day.
Source:CBoH,2002.
Mild-to-moderate dehydration: Children should be given 50-100 mL/kg of ORS
over a 2- to 4-hour period to replace their estimated fluid deficit, with additional
ORS given to replace ongoing losses (10 mL/kg body weight for each stool and 2
mL/kg body weight for each episode of emesis). After the initial rehydration
phase, patients may be transitioned to maintenance fluids as described above.
o ORS should be given slowly by the parent using a teaspoon, syringe, or
medicine dropper at the rate of 5 mL every 1-2 minutes. If tolerated by the
patient, the rate of ORS delivery can be increased slowly over time.
o For patients who do not tolerate ORS by mouth due to persistent vomiting
or oral ulcers, nasogastric (NG) feeding is a safe and effective alternative.
Multiple large clinical trials have found NG rehydration to be as
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efficacious as intravenous rehydration but more cost-effective and with
fewer adverse events.
o Patients with moderate dehydration should be reassessed frequently by the
clinician to ensure adequacy of oral intake and resolution of the various
signs and symptoms of dehydration.
Severe dehydration: This constitutes a medical emergency requiring immediate
resuscitation with intravenous fluids.
o Intravenous access should be obtained, and patients should be
administered repeat boluses of 20 mL/kg lactated Ringer (LR) or normal
saline (NS) until pulse, perfusion, and mental status return to normal. If no
peripheral veins are available, an intraosseous line should be placed.
Serum electrolytes, bicarbonate, urea/Creatinine, and glucose levels
should be sent.
o Once resuscitation is complete and mental status returns to normal,
rehydration should continue with ORS as described above, as it has been
shown to decrease the rate of hyponatremia and hypernatremia when
compared to intravenous rehydration.
Plan B: Treat mild to moderate dehydration.
Approximate amount of ORS solution to give in the first four [4] hours.
age Less than
four
months.
Four to
eleven
months.
Twelve to
twenty
three
months.
Two to
four years.
Five to
Firthteen
years.
Firthteen
years or
older.
Weight: Less than
four
months.
5 – 7.9 kg. 8 – 10.9
kg
11 – 15.9
kg.
16 kg –
29.9 kg.
30 kg or
more.
In ml 200 – 400. 400 – 600. 600 – 800. 800 –
1200.
1200 –
2200.
2200 –
4000.
Source:CBoH,2002.
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Plan C.Treament for severe dehydration with ringers lactate solution.AGE First give 30mls/kg in: Then give 70mls/kg in:Infants less than one year. One hour Five hours.
Older 30minutes. Two and half hours.
Source : CBoH, 2002.
N.B.In developing countries, clinicians can use WHO ORS or a homemade
solution of 3 g (1 tsp) salt and 18 g (6 tsp) sugar added to 1 L of clean water
(WHO, 2002).
Feeding and nutrition: In general, children with gastroenteritis should be
returned to a normal diet as rapidly as possible. Early feeding reduces illness
duration and improves nutritional outcome.
o Breastfed infants should continue to breastfeed throughout the rehydration
and maintenance phases of acute gastroenteritis.
o Formula fed infants should restart feeding at full strength as soon as the
rehydration phase is complete (ideally in 2-4 h).
o Weaned children should restart their normal fluids and solids as soon as
the rehydration phase is complete. Fatty foods and foods high in simple
sugars should be avoided.
o For most infants, clinical trials have found no benefit of lactose-free
formulas over lactose-containing formulas. Similarly, highly specific diets,
such as the BRAT (bananas, rice, applesauce, and toast) diet, have not
been shown to improve outcomes and may provide suboptimal nutrition
for the patient.
Patient is nursed on a commode bed
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PROBLEM ANALYSIS USING THE ROPPER LOGAN AND TIERNEY MODELPROBLEM ANALYSIS USING THE ROPPER LOGAN AND TIERNEY MODEL
OF NURSING.OF NURSING.
Maintenance of Safe EnvironmentMaintenance of Safe Environment
•• Potential for aspiration, and injury because of restlessness, child may fall because ofPotential for aspiration, and injury because of restlessness, child may fall because of
abdominal pain.abdominal pain.
• Potential for dehydration because of diarrhoea and vomiting.
• The child may develop hypothermia because of dehydration.
• Potential for circulatory over load during rehydration therapy.
• Potential for spreading infection because of inadequate isolation and preventive
measures.
• Potential for renal failure because of dehydration.
Communication. Communication.
•• Voice changes and difficulties in communicating because of severe pain andVoice changes and difficulties in communicating because of severe pain and
lethargy.lethargy.
•• The may be crying excessively because of pain and restlessness.The may be crying excessively because of pain and restlessness.
• Knowledge deficit to both care taker and patient about the disease process and its
management.
Breathing.Breathing.
•• The patient may be tachypnoeic because of respiratory acidosis.The patient may be tachypnoeic because of respiratory acidosis.
Eating and Drinking. Eating and Drinking.
•• The child may be anorexic because of due severe abdominal pain or the diseaseThe child may be anorexic because of due severe abdominal pain or the disease
process. process.
•• Nausea and vomiting may be present because of gastro intestinal irritation byNausea and vomiting may be present because of gastro intestinal irritation by
organisms or inflammation. organisms or inflammation.
•• There will be altered nutrition deficit because of anorexia, nausea and vomiting.There will be altered nutrition deficit because of anorexia, nausea and vomiting.
• Potential for electrolyte imbalance because of vomiting, limited intake and
diarrhoea.
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• There will be fluid volume deficit because inadequate fluid intake, nausea, vomiting
and excessive diarrhoea.
Personal Cleansing And Dressing.Personal Cleansing And Dressing.
•• Poor personal hygiene because of excessive diarrhoea and general body weakness.Poor personal hygiene because of excessive diarrhoea and general body weakness.
Elimination. Elimination.
•• Rectal irritation and ulceration because excessive and frequent diarrhoea. Rectal irritation and ulceration because excessive and frequent diarrhoea.
• Potential for oliguria because of dehydration.
Work and Play.Work and Play.
•• Limited activity due to severe pain, diarrhoea and weakness.Limited activity due to severe pain, diarrhoea and weakness.
• There will be activity intolerance because of prostration and muscle cramps.
Expressing Sexuality.Expressing Sexuality.
•• Altered body image because of loss of weight.Altered body image because of loss of weight.
•• Inability to carry out Gender/sex roles because of hospitalizationInability to carry out Gender/sex roles because of hospitalization
Rest and Sleep.Rest and Sleep.
•• Disturbed sleep pattern because of severe abdominal pain, vomiting andDisturbed sleep pattern because of severe abdominal pain, vomiting and
diarrhoea.diarrhoea.
Mobilization.Mobilization.
•• There will be reduced mobility because of fatigue and general body malaiseThere will be reduced mobility because of fatigue and general body malaise
which may predispose the patient to having complications of prolonged bed rest such aswhich may predispose the patient to having complications of prolonged bed rest such as
loss of skin integrity and hypostatic pneumonia. loss of skin integrity and hypostatic pneumonia.
DYING.DYING.
•• The mother / caretaker will emotionally / psychologically affect because of fear ofThe mother / caretaker will emotionally / psychologically affect because of fear of
losing the child. losing the child.
• The parents or care taker may be anxious, apprehensive or worried because of
inadequate knowledge about the prognosis of the child.
NURSING PROBLEMS.NURSING PROBLEMS.
1.1. Fluid volume deficit.Fluid volume deficit.
2. Altered nutrition less than body requirements.
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3. Abdominal pain.
4.4. Knowledge deficit about the disease.Knowledge deficit about the disease.