DIARRHOEA-PPT.pptx

Care of child with diarrhoea

1. DIARRHOEA VIJI V S LECTURER KIMS COLLEGE OF NURSING

2. INTRODUCTION According to WHO & UNICEF, diarrhea is the second leading cause of death after pneumonia among under five globally accounting about 1.5 million deaths each year mostly in developing countries. Each child under 5 years of age experiences an average of three episodes of acute diarrhea each year. DEFINITION Diarrhea is the passage of loose or watery stools at least 3 times in a 24hrs period.

3. ACUTE DIARRHOEA Attack of loose motion with sudden onset which usually last 3-7 days, but may last upto 10-14 days. It can be caused by an infection of the large intestine, but may be associated with infection of gastric mucosa or small intestine. The term gastro enteritis is most frequently used to describe acute diarrhoea. CHRONIC DIARRHOEA It is termed when loose motion occurring more than 3 weeks or more.

4. It is usually caused by underlying disease Diarrhoea with watery stools and visible blood in the stools is called dysentery The disease is most common in age between 6 months to 2 years. The incidence higher during weaning period.

5. ETIOLOGY Intestinal infection with various organisms Bacteria: Escherichia coli, Vibrio cholera, Shigella species, Chlostridium difficile, Nontyphoidal Salmonellae… Virus: Rotavirus, Norovirus, Adeno virus, Astrovirus , Cytomegalovirus Protozoa : Cryptosporidium parvum, Giardia intestinalis, Entamoeba histolytrica . Helminths: Strongyloidiasis stercoralis , Angiostrongyliasis costaricensis

6. Systemic infections like urinary tract infection or otitis media Certain drugs and food allergy Malabsorption Malnutrition Immunocompromised state like HIV infection It occurs due to combined effect of maternal antibodies, lack of active immunity and introduction of contaminated food or direct spread through child’s hand

7. Diarrhoea is more common in artificial feeding, specially with contaminated cow milk or unhygienic preparation of tin milk PREDISPOSING FACTORS OF DIARRHOEA Prematurity Immunodeficiency conditions Lack of personal hygiene Poor socio economic status Poor infant feeding practices

8. HIGH RISK GROUPS Lack of breast feeding Children Immunodeficient children Malnutrition Poor maternal education Exposure to unsanitary conditions

9. PATHOPHYSIOLOGY Etiological factors attach to the intestinal mucosa Bowel mucosa secretes excessive amounts of fluid into the gut lumen Large amount of water, nutrients and vitamins are lost from the body Excessive sodium loss results in hyponatremia Movement of water from extracellular to intracellular compartment Reduces extracellular volume

10. Decreased blood volume results in weak thready pulse, low blood pressure, cold extremities, shrinkage of skin Filtration of urine is reduced due to low hydrostatic pressure in renal glomeruli Potassium and bicarbonate are lost in diarrhoeal stool Acidosis may result with dehydration

11. CLINIAL FEATURES Frequent loose watery stool, may be greenish or yellowish in colour with offensive smell, may contain mucous, pus or blood, may expelled with force, precede by abdominal pain Frequency of stools may be 2 to 20 per day or more Irritability, lethargy, delirium, stuper , flaccidity Signs of dehydration

12. Abdominal distension Weak & thread pulse, hypotension, tachycardia, rapid respiration ECG changes with ST depression and flat T waves Kussamaul breathing in acidosis Cold extremities, collapse Decreased or absent urine output Convulsions or loss of consciousness in some children

13. Assessment of dehydration Dehydration is excess loss of fluid more than fluid intake Clinical features of dehydration Sunken fontanelle Sunken eyes Non tears from eyes Reduced level of consciousness

14. Reduced capillary refill time Dry mucous membrane Reduced skin turger Tachypnea Tachycardia Hypotension Sudden weight loss oliguria

15. Assessment No dehydration Some dehydration Severe dehydration Look at General condition Eyes Tears Mouth and tongue Thirst Well alert Normal Present Moist Drinks normally, no thirst Restless, irritable Sunken Absent Dry Drinks eagerly, thirsty Lethargic/unconscious Sunken Absent Very dry Unable to drink or drinking poorly Feel Skin pinch Goes back quickly Goes back slowly Goes back very slowly

16. DIAGNOSTIC FINDINGS History collection Physical examination Stool examination can be done for routine and microscopic study to find causative agent Blood investigations to detect electrolyte imbalances, acid base disturbances

17. MANAGEMENT Rehydration therapy It is done with ORS solution and continued feeding Oral rehydration therapy is the drinking of clean water, sugar and mineral salt to replace water and salt loss from the body during diarrhoea, especially when accompanied by vomiting, eg in gastro enteritis The management of child with diarrhoea and dehydration can be given under 3 catagory

18. Plan A for child with no dehydration A child with no signs of dehydration needs home treatment to treat current episodes of diarrhoea and prevent dehydration Give child more fluids than usual to prevent dehydration Breastfeed frequently and for longer at each feed If child is exclusively breastfeed give ORS or clean water along with breast milk If child is not exclusively breastfeed, give one or more of the following:

19. ORS solution, food based fluids such as soup, rice water and yoghurt drinks or clean water. Teach mother how to prepare the ORS Fluid intake upto 2 years of age 50-100ml after each loose stool and in between them and for 2 years or more, give 100-200 ml after each loose stool or in between them Give frequent small sips from a cup If the child vomits, wait 10 minutes, then continue, but more slowly

20. Continue giving extra fluids until the diarrhoea stops Give zinc supplements Amount: upto 6 months- half tablet per day for 14 days and 6 month or more- 1 tablet per day for 14 days For infants dissolve the tablet in a small amount of expressed breast milk, ORS or clean water, in a small cup or spoon Continue feeding Up to 6 months of age: breast feed atleast 8 times in 24 hrs

21. 6 months to 1 year: Breastfeed and 3 meals per day , if not breast feed 5 meals per day 1-2 years: Breastfeed and 5 meals per day Above 2 years: family foods 3 meals per day 2 times nutritious foods between meals. Offer cereal, pasta, or potato mixed with legumes, vegetables, fish or chicken and freshly prepared ground or mashed foods Provide fresh fruit juice, coconut milk or banana to provide potassium

22. After diarrhoea stops, give an extra meal each day for 2 weeks, until child’s weight before illness is attained. Return to health worker Advise to take the child to a healthcare worker if he or she does not get better in 3 days or develops any of the following: Many watery stools, fever, poor eating or drinking, marked thirst, repeated vomiting and blood in the stools

23. PLAN B FOR CHILD WITH SOME DEHYDRATION Give ORS in the health centre until the skin pinch is normal, the thirst is over , the child is calm Four hours of rehydration are usually necessary for this If the patient wants more than recommended amount, give more For infants below 6 months who are not breastfeed , give 100-200ml clean water in addition during this period

24. Observe the child closely and help to give the ORS Show how much solution to give and how to give to the child Give frequent small sips from a cup If the child vomits, wait 10 mts , then continue, but more slowly Continue breastfeeding whenever the child wants After 4 hours Reassess the child and select plan A, B, or C to continue the treatment

25. If there are no signs of dehydration, then shift to plan A If signs indicate that some dehydration is still present, repeat plan B and reassess 2 hrs later or signs indicate that severe dehydration has occurred, shift to plan C If the mother must leave before completing treatment: Show her how to prepare ORS solution at home Show her how to continue with the rest of the 4hr treatment at home Supply enough ORS packets to complete rehydration and to continue

26. For 2 more days as recommended in plan A Explain the 4 rules in plan A for treating her child at home Give ORS or other fluids continuously until diarrhoea stops Give the zinc supplements for 10-14 days Continue feeding Come back to the healthcare worker if necessary

27. PLAN C FOR CHILD WITH SEVERE DEHYDRATION Children with severe dehydration should be treated by IV drip as soon as possible and admitted to the hospital or health centre If IV fluid can be given immediately: Start IV immediately, if the child is able to drink, give ORS by mouth until the drip is set up. Give 100ml/kg Ringer lactate solution ( or if not available normal saline) as following

28. Infants (under 12 months): first give 30ml/kg in 1 hour and give rest 70ml/kg in next 5 hours Children ( 12 months upto 5 years): first give 30ml/kg in 30 min and give rest 70ml/kg in next 2 ½ hrs Repeat once if radial pulse is still very weak or not detectable Reassess the child every 1-2 hrs If hydration status is not improving give IV drip more rapidly Also give ORS (about 5ml/kg/hr) as soon as the child can drink, usually after 3-4hrs (infants) or 1-2hrs (children)

29. Reassess an infant after 6 hrs and a child after 3 hrs and choose the appropriate plan (A,B, or C) to continue treatment If IV treatment available nearby (within 30 min): Refer urgently to hospital for IV treatment If the child can drink, provide the mother with ORS solution and advise to give frequent sips during the trip. If IV therapy is not possible immediately insert nasogastric tube and start rehydration by nasogastric tube or by mouth with ORS : give 20ml/kg/hr for 6 hrs(total of 120ml/kg)

30. Reassess the child every 1-2hrs If not improving after 3 hrs refer to the hospital urgently for IV therapy After 6hrs, reassess the child and select the appropriate plan A, B or C to continue the treatment. Treatment of child with blood in the stools These children should be treated for dehydration and Shigella infection Treat severe dehydration and severe malnutrition in hospital Administer prescribed antibiotics effective against Shigella

31. Provide zinc supplement DRUG THERAPY Symptomatic treatment- If vomiting Antiemetics -ondansetron(0 .1-0.2 mg/kg/dose) Hypokalemia with paralytic ileus –KCL(30-40 mEq /l)iv infusion Antibiotics, Antimotility agents – lomotil or loperamide should not used

32. Antisecretory agents-in acute diarrhea – Racecadotril Probiotics –microorganisms that exert beneficial effects on human health when they colonize the bowel eg.enterogermina . ZINC IN DIARRHOEA During diarrhoea zinc is lost from body Treatment with zinc reduces the duration and severity of acute diarrhoea and reduces the frequency of further episodes during subsequent 2-3 months WHO recommends that children suffering from diarrhoea should be given zinc for 10-14 days

33. 10mg daily for children less than 6 months 20 mg daily for children more than 6 months Home available fluids Rice water Home made ORS Dhal water Lemon juice Soups

34. Lassi Coconut water Plain water DIETARY MANAGEMENT Diet should be planned to prevent malnutrition and to provide adequate nutritional requirement Continue breastfeeding as the child wants Provide energy dense soft diet like cereals, legumes, vegetables, freshly prepared mashed foods

35. Provide fresh fruit juices and bananas which are helpful as they contain potassium Avoid high fibre or bulky foods or foods with a lot of sugar Advice to prepare foods by cooking well, fermenting, mashing or grinding which is easier to digest Provide small and frequent feeding After diarrhoea has stopped, give the child one extra meal each for a week to regain weight

36. NURSING MANGEMENT Nursing Assessment Assess for frequency and consistency and signs of dehydration Monitor urine output Check vital signs Nursing Diagnosis Fluid volume deficit r/t diarrhoea

37. Risk for infection r/t contamination during episodes of diarrhoea Impaired skin integrity r/t skin irritation caused by frequent stool Imbalanced nutrition less than body requirement r/t inadequate intake and malabsorption Nursing Interventions Maintain fluid volume Prevention of infection Maintain skin integrity

38. Maintain nutrition Care of oral mucosa Health education COMPLICATIONS Dehydration Hypovolemic shock Renal failure Paralytic ileus

39. Hypoglycemia Convulsions Malnutrition Mental subnormalities PREVENTION Safe water, adequate sewage disposal Hand washing practices Clean utensils

40. Avoidance of exposure of food to dust and dirt Fly control. Washing of fruits and vegetables before eating Avoidance of bottle feeding Safe drinking water Balanced diet Immunization

41. ORAL REHYDRATION THERAPY Definition It is the administration of solution of rehydration salts orally to prevent or correct diarrhoeal dehydration Aim To correct water electrolyte imbalance To prevent dehydration To reduce mortality

42. WHO recommended ORS Sodium chloride- 3.5gm. Potassium chloride-1.5 gm Trisodium citrate - 2.9 gm Glucose - 20 gm in 1 liter of clean drinking water ORS day is celebrated every year on 29 th July

43. If the child is less than 2 years give 1-2 teaspoon every 2-3 minutes In older children offer frequents sips out of a cup Adults can drink as much as they can Give the estimated amount within 4 hours If the child vomits, then wait for 10 minutes and then give a teaspoon full every 2-3 minutes In breastfed child give ORS along with breastfeed and in non breastfeed children give extra clean water 100-200 ml for first 4 hours along with ORS

44. Home preparation of ORS with ORS packet Put the content of ORS packet in to a clean container, check the packet for directions and add the amount clean water as indicated Add water only, do not add ORS to milk, soup, fruit juice or any soft drinks Stir it well and feed it to child from a clean cup How do ORS is prepared in home Clean water- 1 litre-5 cupful ( each cup about 200ml) Sugar- 6 lever teaspoons (1 tsp=5grams)

45. Salt- half level spoons Stirr mix till the sugar dissolves Too much sugar can make the diarrhoea worse, and too much salt can be harmful to child ORS solution should be covered and should not store more than 24 hrs.