Encoporesis/Enuresis Diarrhea and Vomiting. Encoporesis Involuntary Passage of Feces Primary Child NEVER achieved bowel control by 4 y/o Secondary.

Alteration in Elimination

Encoporesis/EnuresisDiarrhea and Vomiting

EncoporesisInvoluntary Passage of Feces

Primary Child NEVER

achieved bowel control by 4 y/o

Secondary Fecal Incontinence

occurring after 4 y/o More in Boys than

Girls

Causes Constipation Stress Myelomeningocele CP Hypothyroidism

Encoporesis

Assessment History Doing a Dance Self-Esteem

Diagnosis X-ray to r/o

Hirschsprung’s Disease

Congenital GI anomaly

Treatment Hi-Fiber Diet Lubricants Behavior Therapy

Anticipatory Guidance Normal Patterns Trx Regime Counseling Behavior Modification

EnuresisBedwetting 2x/week; for 3 mos.; at least 5 y/o

Primary Never been dry

Secondary Incontinent after have

established continence Causes

Sleep Theory Functional Bladder

Capacity Nocturnal Polyuria

Theory

Assessment Urgency

Diagnosis History and Physical Functional Bladder

Capacity History of Toilet

Training

Conditioning Therapy Retention Control Training Waking Schedule Behavior Modification Therapy Drug Therapy

Tricyclic antidepressants Anticholenergics

Ditropan Desmopressin (DDAVP)

Enuresis--Treatment

Greater need for water More vulnerable to alterations in balance Don’t adjust quickly ECF > ICF at birth w/ greater relative content

of extracellular Na & Cl Thus, more susceptible to dehydration and

fluid overload Metabolic rate 2-3x > adults BSA > adults; neonate 5x greater Immature kidney function;↓ability to conc. or

dilute urine

Fluid Imbalance Specific to Peds

Isotonic – most common in peds H2O Loss = Electrolyte Loss

Major loss from ECF→ ↓plasma volume → ↓circulating blood volume → ↓to skin, muscles, kidneys → hypovolemic SHOCK

Plasma Na stays bet 137-147 mEq/L (nl)

Types of dehydration

Hypotonic = Na+ BELOW normal H2O Loss < Electrolyte Loss

Hypertonic = Na+ ABOVE normal H2O Loss > Electrolyte Loss

SEE HANDOUTS “A” & “B”

See Tables 28-2 & 28-4 on p. 1056-60(9th ed.)

Level/Degrees of Dehydration p. 1059 (9th ed.) Mild = Up to 5% of body weight lost Moderate = Between 5-9% of body weight lost Severe = 10-15% of body weight lost

Level & Types of Dehydration

Observation & history of recent symptoms

Diarrhea, vomiting, fever, renal disease, medications, trauma, extensive surgery, extensive burns, ketoacidosis

Take a good history: drugs, allergy, diet, travel, pet contact, contact w/others who have been sick, etc.

Most Important → General Appearance & Behavior! Urinary output Mucus membranes Skin Turgor Infant fontanels Weight change Pale, cool dry skin ↑Pulse, ↑resp, ↓BP, cap refill >2sec → shock

Fluid Imbalance Assessment

Degree, type of dehydration Identify causative agent Initial & ongoing evaluations of the following:

Na and other electrolytes (K+), pH Weight

Same scale, same clothes, same time of day For each 1% wt loss, 10 ml/kg fluids lost

Changing sensorium; Response to stimuli Integumentary changes (elasticity & turgor) Heart rate (pulse - weak & rapid) Sunken eyes Sunken fontanels

Any 2 of the 4: cap refill of >2 sec, absent tears, dry mucous membranes, ill appearance.

Nursing Assessment

Accurate I & O

Measure ALL Output Emesis, void (weigh diapers), stool, NG suction

drainage Specific Gravity

Increase = Concentrated Urine Know Norms for frequency of voiding

1 y/o = every 1-2 hours Toddlers = every 3 hours Older children = 4 – 5 times/day during day

Include parents in prescribed plan of care

Nursing Assessment (cont)

Oral Rehydrating Solutions (ORS)

Rehydralyte, Pedialyte, Infalyte, WHO Mild Dehydration

50 ml/kg in 4 hours Moderate Dehydration

100 ml/kg in 4 hours Severe Dehydration

IV’s (Ringer’s Lactate/NS) 40 ml/kg/hr until pulse and LOC are normal Then 50-100 ml/kg of ORS

Diarrhea – Medical Management

Recommended for mild to moderate dehydration Oral Rehydration Solution (ORS): 75-90 mMol Na+, 111-

139mMol glucose – Pedialyte RS, Rehydralyte for the 1st 4-6 hours.

Then – 30-60 mMol Na+, 111-139mMol glucose – Pedialyte,Resol, Lytren, Infalyte – for the next 18-24hrs. @ 1-2 oz/# divided into freq. feedings;

Older child: 1-2 oz q hr.

It is no longer recommended to withhold food/fluids for 24º after onset of diarrhea or use the BRAT diet!!!

Oral Rehydration Therapy

Ingest excessive amts of fluids develop concurrent ↓

serum Na+ accompanied by CNS symptoms. CNS irritability, somnolence, HA, vomiting, diarrhea,

gen. seizures, may have edema or be dehydrated but looks well hydrated.

Causes: acute IV water overload, too rapid dialysis, tap water enemas, feeding incorrectly mixed formulas (diluted to make it last longer), excess water ingestion, too rapid reduction of glucose levels in diabetic ketoacidosis; those with CNS infections may retain excessive amts of H2O if administered hypotonic sol. rapid reduction in Na+H2O overload.

Problem: ↓GFR is incapable of compensation to excrete the excesses fast enough, ADH levels are not able to compensate

Water Intoxication (water overload)

Diarrhea: ↑ in stool frequency and ↑ in

water content. Varies by severity, duration, presence of blood or mucous, age of child, & nutritional status.

Acute Diarrheal Disease: Leading cause of illness in children < 5yrs; 400 die ea yr; caused by infectious agents including viral, bacterial and parasitic pathogens.

Results in dehydration, electrolyte imbalance, hypovolemic shock, & even death

Gastrointestinal Disorders

2nd only to URI as cause of childhood illness Self-limiting and benign Bacterial seen in summer and fall Viral (rotovirus)

seen in winter After a URI Daycare setting

Spread by person-to-person contact and oral-fecal route

Acute Infectious Gastroenteritis

Diarrhea---Causes

Acute Table 29-1, p. 1091 Viral = Rotovirus Bacterial

Shigella E-coli Salmonella C. difficile Vibrio cholerae

Toxins (bad food) Overfeeding Systemic Infection

Irritable Bowel Syndrome Lasts 3 weeks

Chronic Box 29-4 p.1093 Malabsorption Allergic Reactions Immunodeficiencies Endocrine Parasites (Giardia) Motility disorders

Hirschsprung’s Ds.

Inflammatory Bowel Crohn’s disease Ulcerative Colitis

Sugar intolerance: watery, explosive stools Fat malabsorption: foul-smelling, greasy, bulky stools;

stearrhea Enzyme deficiency/protein intolerance: develops after

intro of cow’s milk, fruits, cereal Bacterial gastroenteritis/IBS: presence of

neutrophils/RBC’s Protein intolerance/parasitic infection: presence of

eosinophils Cultures: performed if blood or mucus is present, or Sx’s

are severe, travel to developing country and polymorphonuclear leukocytes are found in stool.

ELISA: used to confirm presence of rotavirus,

Differential Diagnosis

Other

Fever and abdominal cramps = Shigella Abrupt onset = Toxins, seen in Food Poisoning

> 4 stools/day No vomiting prior to diarrhea onset

Hx of antibiotic use: test stool for C. Difficle toxin. Persistent diarrhea: test for ova & parasites when

bacterial, viral cultures are negative. Labs

Stool Culture, Stool Exam (WBC’s, RBC’s, Fat content) Blood- ↑Hct, ↑BUN + Creatinine if ↓renal circulation,

Acid/Base Balance; Electrolytes (NA+ and K+)

Diarrhea—Differential Diagnosis

Labs: ↑Hct, ↑BUN + Creatinine if ↓renal

circulation, Acid/Base Balance; Electrolytes Metabolic Acidosis

Loss of Na+ and HCO3 in stool Impaired Renal Function ↑ Lactic Acid formation Ketosis from Catabolism

Shock---in severe Cases Altered K+ levels, K+ lost is stool

Body conserving Na+ and H+I in cells move K out

Clinical Manifestations

Chronic Diarrheal Disease: caused by

malabsorption syndromes, inflammatory bowel disease, immune deficiency, food allergy, lactose intolerance, etc.

Chronic Nonspecific Diarrhea: irritable colon of childhood/toddler’s diarrhea; ages 6-54 mos; loose stools w/undigested food particles. Grows normally w/ no evidence of malnutrition

Intractable Diarrhea of Infancy: occurs first few months of life, refractory to treatments. May need cont. tube feedings or parenteral nutrition. Can result in death.

Other Diarrheal Diseases

Forceful ejection of gastric contents thru the mouth. CNS

control. Accompanied by nausea and retching.

Malrotation: chronic and intermittent episodes Bowel obstruction: green bilious Poor gastric emptying/high obstruction: curdled,

mucus, fatty foods several hrs after ingestion GI bleeding: coffee ground appearance Associated symptoms: fever and diarrheainfection;

constipationanatomic or functional obstruction; forcefulpyloric stenosis

Localized abd. pain→ appendicitis, PUD, pancreatitis Headache and change in LOC→ CNS related Well recognized response to psychological stress;

can be a learned behavioral response

Vomiting

Vomiting

Assessments Color, consistency, odor Amount Frequency Forcefulness Relationship to feeding History

Allergy, Illness w/ or w/o diarrhea

Child’s behavior in association with vomiting

Diagnosis Routine labs

Hct/Hgb CBC Electrolytes

Na+, K+

BUN Creatinine TCO2

U/A Physical Assessment

Assess abdomen and hydration status, presence of pain, constipation, diarrhea, or jaundice.

Assess relationship of vomiting to meals, specific foods or behavior

When cause of vomiting determined then interventions are decided

Sm, freq feeding of fluid or food preferable, position to prevent aspiration.

Brush or rinse the mouth to remove HCl from the teeth, monitor fluids & electrolyte status

Vomiting

Complications: dehydration, electrolyte

disturbances, malnutrition, aspiration, Mallory-Weiss sydrome

Antiemetics: can be given if cause is known and vomiting is anticipated; Motion sickness - dimenhydrinate (Dramamine) before a trip

Generally vomiting is self limiting requiring no specific tx

Vomiting (cont’d)

That’s It