PEDIATRIC NURSING

1. DIARRHEAL
DISEASE
Presented by
Ms Arifa T N, Second year M.Sc Nursing, MIMS CON

2. Introduction
 Diarrheal diseases rank among the “top
three” causes of death in pediatric
Population of the developing world
 Globally, approximately 4-5 million deaths
occur as a result of diarrheal diseases every
year
 Eight out of these 10 deaths are in the first 2
years of life.
 Diarrheas account for about 20% of the
hospitalized pediatric cases in India.

3. Definition
Diarrhea means passage of 3 or more
loose or watery motions per 24 hours, resulting
in excessive loss of fluid and electrolytes in
stools.

4. Epidemiology
 Worldwide, there are an estimated 1.7 billion
episodes of diarrhea each year
 The incidence and morbidity of diarrhea are
more prominent in low-income countries
 Among children younger than 5 years old

5.  Diarrheal disturbances involve the stomach
and intestines (gastroenteritis),
 The small intestine (enteritis),
 The colon (colitis), or
 The colon and intestines (enterocolitis).

6. Types
Secretory
diarrhea
Osmotic
diarrhea
Motility
diarrhea
Acute
diarrhea
Chronic
diarrhea
Persistent
diarrhea
Intractable
diarrhea

7. Types
 Secretory diarrhea has a tendency to be
watery, voluminous and persistent even when
no feeding is given orally.
 It is usually caused by an external or internal
secretagogue (cholera toxin, lactase
deficiency)
Secretagogue : a substance which promotes secretion.

8.  Osmotic diarrhea
 Ingestion of a poorly absorbed solute because
of an inherent character of the solute
(magnesium phosphate, alcohol, sorbitol) or a
small bowel defect (lactose in lactase
deficiency in brush border)
 It tends to be watery and acidic with reducing
substances.

9.  Motility diarrhea is associated with increased
(irritable bowel syndrome) or delayed motility
(intestinal pseudo-obstruction)
 Acute diarrhea refers to diarrhea that begins
acutely and terminates within a week or so,
only a small proportion of cases passing to the
second week or even beyond

10.  Chronic diarrhea refers to diarrhea beyond 2
weeks. The term is best reserved for cases
with an obvious malabsorption or an
underlying organic disease without obvious
malabsorption.
 Persistent diarrhea denotes an episode of
acute diarrhea, presumably of infective origin,
that lasts for 2 weeks or more

11.  Intractable diarrhea of infacy, should be
reserved for cases who have onset of
protracted diarrhea before the age of 3
months.
 These infants start as an infective diarrhea,
become dehydrated and wasted and have
high mortality. They need emergency
treatment.

12. Etiology
 Emotional stress (anxiety, fatigue)
 Intestinal infection
 Bacteria [escherichia coli, salmonella,shigella],
 Viral [human rotavirus, enteric adenovirus],
 Fungal
 Food sensitivity (gluten, cow’s milk)
 Food intolerance (lactose, introduction of new
foods, overfeeding)
 Medications (iron, antibiotics)
 Colon disease (colitis, necrotizing enterocolitis,
enterocolitis)
 Surgical alterations (short bowel syndrome)

13. Etiology…who is in risk ?
 Sanitary and personal hygiene standards of
the community.
 Infants and children are more frequently and
more severely affected
The specific etiology is not always
identified

14. Pathogenesis
3 mechanism……………
Adhesio
n
Elaboration
of an
exotoxin
Mucosal
invasion

15. Pathogenesis
Adhesion to the intestinal mucosal wall
e.g. Enteropathogenic E. coli (EPEC) which are further
categorized as class I EPEC (showing localized adherence)
and class II EPEC (showing diffuse adherence).
Elaboration of an exotoxin , (secretory diarrhea)
e.g. rotavirus, enterotoxigenic E. coli (ETEC), Vibrio
cholera, Aeromonas hydrophilia, Plesiomonas shigelloides,
causes excessive secretions.
fasting has no effect
Mucosal invasion (exudative diarrhea),
e.g. enteroinvasivem E. coli (EIEC), Shigella, Salmonella
(nontyphi), Cl. Defficile, Campylobacter jejuni, Yersinia
enterocolitica, enteropathogenic E. coli (EPEC), rotavirus,
damage and exudative blood. No effect of fasting.

16. Pathophysiology
 Invasion of the GI tract by pathogens
results in increased intestinal secretion as
a result of enterotoxins, cytotoxic mediators, or
decreased intestinal absorption secondary to
intestinal damage or inflammation
 Enteric pathogens attach to the mucosal
cells and form a cuplike pedestal on which
the bacteria rest

17.  The pathogenesis of the diarrhea depends on
whether the organism remains attached to the
cell surface, resulting in a secretory toxin
(noninvasive, toxin-producing, non
inflammatory type diarrhea), or penetrates the
mucosa (systemic diarrhea).
 Non-inflammatory diarrhea is the most
common diarrheal illness, resulting from the
action of enterotoxin that is released after
attachment to the mucosa.

18.  The most serious and immediate physiologic
disturbances associated with severe diarrheal
disease are dehydration, acid-base
imbalance with acidosis, and shock that
occurs when dehydration progresses to the
point that circulatory status is seriously
imp.aired

19. Clinical features
Mild
 In mild cases, onset is usually insidious with 2
to 5 motions which may be,
 Loose, green, offensive and contain mucus and
milk curds.
 The volume may be small or large.
 The attack usually subside in a day or two without
any remarkable constitutional manifestations or
dehydrations

20. Moderate
 The number of motions is 10 or more and
constitutional symptoms like
 Fever,
 Irritability
 Anorexia and vomiting.
 Mild dehydration (3 to 5%)

21. Severe
 Child passes “too many”
loose motions
 Severe vomiting to the
extent that nothing is
retained and
 The oral intake becomes
virtually impracticable
 Sudden rather than
gradual onset
 Moderate (5 to 10%) to
severe (>10%)
dehydration.

26. Diagnosis
 History
Careful history that seeks to discover the
possible cause of diarrhea,
 To assess the severity of symptoms
 The risk of complications, and
 To elicit information about current symptoms
indicating other treatable illnesses

27.  The history should include
questions about
 Recent travel,
 Exposure to untreated
drinking or washing water
sources,
 Contact with animals or birds,
 Daycare center attendance,
 Recent treatment with
antibiotics, or recent diet
changes.

28.  History questions should
also explore the presence
of other symptoms, such
as
 Fever and vomiting,
 Frequency and character of
stools (e.G., Watery,
bloody),
 Urinary output,
 Dietary habits, and
 Recent food intake

29. Assessment of dehydration

32. Diagnosis
 Lab diagnosis
 The stool can be examined for the presence of
ova, parasites, infectious organisms, viruses, fat,
and undigested sugars.
 Laboratory evaluation of serum and urine helps
identify electrolyte imbalances and other
deficiencies.

33. Diagnosis
 Watery, explosive stools suggest glucose
intolerance
 Foul-smelling, greasy, bulky stools suggest fat
malabsorption
 Develops after the introduction of cow's milk,
fruits, or cereal may be related to enzyme
deficiency or protein intolerance
 Neutrophils or red blood cells in the stool
indicate bacterial gastroenteritis or IBD.
 The presence of eosinophils suggests protein
intolerance or parasitic infection

34.  Stool cultures
 Gross blood or occult blood
Gross blood or occult blood may indicate
pathogens, such as Shigella, Campylobacter, or
hemorrhagic Escherichia coli strains.
 Enzyme-linked immunosorbent assay (ELISA)
 used to confirm the presence of rotavirus or
Giardia organisms
 Complete blood count (CBC), Serum
electrolytes, Creatinine, and BUN

35.  If there is a history of recent antibiotic use, test the
stool for C. difficile toxin
 When bacterial and viral culture results are
negative and when diarrhea persists for more than
a few days, examine stools for ova and parasites
 A stool specimen with a pH of less than 6 and the
presence of reducing substances may indicate
carbohydrate malabsorption or secondary lactase
deficiency
 Stool electrolyte measurements may help identify
children with secretory diarrhea

36. Management
Medical management
 Goal
 To correct the fluid and electrolyte imbalances
 Mild and moderate dehydration
 Oral rehydration therapy (Home & Hospital)
 Severe
 Intravenous infusion with a solution chosen to
correct the specific electrolyte imbalances

37. Medical management……….
 Introduce clear liquids or breast milk
 Encourage the child to progress to a regular diet.
 Foods generally are not withheld for more than 1
to 2 days.
 Bacteria or parasites: antimicrobial therapy
 Antiemetics and antidiarrheals (Antimotility drugs
such as loperamide are not recommended in
children, the use of antiemetic agents have
historically not been recommended)

40.  Ongoingstool losses should be replaced on a
1 : 1 basis with ORS
 Probiotics when used in conjunction with ORS
reduces the duration of antibiotic-associated
diarrhea in children by 1 day
 Severe dehydration and shock, IV fluids are
initiated

46. Nursing management

47. Assessment
 History
 Physical examination
 Assess onset, frequency, color, amount, and
consistency of stools.
 Monitor the amount and type of vomitus
 Observing for signs and symptoms of dehydration
 Evaluate urinary output and specific gravity
 Accurate weight must be obtained on admission and
daily thereafter
 Monitor vital signs every 2 to 4 hours (fever causes
waterloss)
 Assess skin integrity, especially in the perineal and
rectal areas, and note any breakdown or rashes

48. Nursing diagnosis
 Diarrhea related to infectious process
 Fluid electrolyte imbalance
 Risk for Impaired skin integrity
 Imbalanced nutritional status
 Parental anxiety
 Fatigue/Discomfort
 Knowledge deficit
 Acute pain ( abdominal cramps)

49. Planning and implementation
Diarrhea related to infectious process
 Obtain baseline vital signs and monitor ever 2–4
hr
 Observe stools for amount, color, consistency,
odor, and frequency
 Test stools for occult blood
 Monitor results of stool culture and sample for ova
and parasites
 Wash hands well before and after contact with the
child

50. Planning and implementation
Diarrhea related to infectious process
 Isolate the child until the cause of the diarrhea is
determined
 Assist the child with toileting and hygiene.
 Administer prescribed oral rehydration and
intravenous solutions.
 Notify the healthcare provider if diarrhea persists,
stool characteristics change, or other symptoms
of dehydration electrolyte imbalance occur.

51. Planning and implementation
Fluid electrolyte imbalance
 Monitor intake and output. Document time of each
voiding. Weigh all diapers.
 Compare admission weight to preadmission weight.
Assess weight daily.
 Assess level of consciousness, skin turgor, mucous
membranes, skin color and temperature, capillary refill,
eyes, and fontanelles every 4 hours.
 Assess for vomiting.
 Provide oral fluid and electrolyte replacement solution
if able to tolerate.
 Provide and maintain IV replacement therapy, as
ordered

52. Planning and implementation
Risk for Impaired skin integrity
 Assess skin of perineum and rectum for signs of
skin breakdown or irritation.
 Provide prevention or restorative care for infants
as follows:
Preventive Care:
 Change diapers every 2 hr or as needed.
 Wash diaper area after each soiling.
 Apply A&D ointment, Aquaphor, or another barrier
ointment with each diaper change.

53. Planning and implementation
Risk for Impaired skin integrity
Restorative Care:
 Leave the buttocks open to air for a few minutes
several times daily, placing absorbent pads under
the infant.
 Notify the healthcare provider if the skin is
severely broken or peeling or if a rash is present.
 For toddlers and older children: Tub bathe at least
daily (if condition allows) in tepid water.
 Pat the area dry.
 Discourage the wearing of underwear if possible.
 Apply barrier ointment

54. Planning and implementation
Imbalanced nutritional status
 Oral and IV rehydration
 Dietary history
 Diet plan
 Infants are breastfed or given formula feed.
 Small amounts of normal diet for age are
provided

55. Planning and implementation
Parental / child anxiety
 Allow them to talk and ask questions
 encourage parents to room-in
 Reassurance
 Place the child’s favorite toys and comfort objects
 Using therapeutic play techniques, such as
allowing the child to manipulate equipment, can
reduce anxiety

56. Planning and implementation
Fatigue / Discomfort
 Provide a quiet, restful environment
 Cluster nursing care to allow for periods of
uninterrupted rest
 Keep the child’s mouth moistened with a wet
washcloth, or an occasional ice chip
 Provide skin care after each diarrheal episode to
maintain skin integrity.
 Avoid using commercial baby wipes that contain
alcohol as these irritate the skin and cause
discomfort for the child.

57. Planning and implementation
Knowledge deficit
 Reassurance
 Involve parents in care
 Educate,
 To monitor for signs of dehydration
 The amount of fluids taken by mouth
 To assess the frequency and amount of stool losses
 Careful monitor intake and output
 ORT at home
 Introduction of a normal diet
 Hygiene

58. Prevention
 Personal hygiene,
 Protection of the water supply from
contamination,
 Careful food preparation.
 Disposal of soiled diapers,
 Proper hand washing,
 Isolation of infected persons
 Meticulous attention to perineal hygiene,

59. Evaluation
 Stable Vitals
 Hydration and nutritional level
 Food intake
 Activity level
 Confidence of parents
 Adequate knowledge