INTRODUCTIONINTRODUCTION

Focuses on most common gastrointestinal Focuses on most common gastrointestinal disorders such as foreign bodies in G .I .T disorders such as foreign bodies in G .I .T system,thrush stomatitis ,vomiting, colic, system,thrush stomatitis ,vomiting, colic, constipation,diarrhea and constipation,diarrhea and dehydration,major nursing diagnostic and dehydration,major nursing diagnostic and nursing intervention related to nursing intervention related to recognition and management of the childrecognition and management of the child..

By the end of this lecture the By the end of this lecture the student will be able to discuss student will be able to discuss Disorders of Digestive SystemDisorders of Digestive System

SpecificSpecific objectivesobjectives::

By the end of this lecture the student nurse will By the end of this lecture the student nurse will be able to::be able to::

Define the common gastrointestinal disorders Define the common gastrointestinal disorders (ingestion of foreign bodies, stomatitis, (ingestion of foreign bodies, stomatitis, vomiting, colic, constipation, diarrhea and vomiting, colic, constipation, diarrhea and dehydration).dehydration).

Mention the etiology and causative Mention the etiology and causative organisms of these disorders.organisms of these disorders.

Apply the nursing process to different Apply the nursing process to different gastrointestinal disorders.gastrointestinal disorders.

Provide health education to parents Provide health education to parents regarding the management and prevention regarding the management and prevention of common gastrointestinal disorders.of common gastrointestinal disorders.

Introduction.Introduction. Foreign body in G.I.T.Foreign body in G.I.T. Stomatitis.Stomatitis. Vomiting.Vomiting. Colic. Colic. Constipation. Constipation. Diarrhea.Diarrhea. Dehydration.Dehydration. Nursing intervention.Nursing intervention. Prevention of diarrhea.Prevention of diarrhea.

A- Foreign bodies in G.I.TA- Foreign bodies in G.I.T

Etiology Etiology

The infant during the oral phase of development The infant during the oral phase of development enjoys putting objects into his mouth, as he sucks enjoys putting objects into his mouth, as he sucks upon a small object lie may swallow it. Objects may upon a small object lie may swallow it. Objects may lodge at any part in the stomach or pass through lodge at any part in the stomach or pass through the intestinal tract or it may perforate the intestine.the intestinal tract or it may perforate the intestine.

Assessment:Assessment:

Observation for sign of perforation, which are: Observation for sign of perforation, which are: nausea vomiting, blood in stools, tenderness of the nausea vomiting, blood in stools, tenderness of the abdomen, evidence of pain.abdomen, evidence of pain.

Nursing diagnosis:Nursing diagnosis:

High risk for intestinal perforation High risk for intestinal perforation related to swallowing of foreign bodies.related to swallowing of foreign bodies.

Goal:Goal:

The infant/child will experience no signs The infant/child will experience no signs of perforation.of perforation.

Intervention and treatment:Intervention and treatment:

No specific nursing care other than close No specific nursing care other than close observation of the child's stools and signs of observation of the child's stools and signs of perforation. Stool must be placed in a fine perforation. Stool must be placed in a fine mashed sieve and water run with force upon mashed sieve and water run with force upon it until the fecal matter disintegrates and it until the fecal matter disintegrates and object if present is clearly seen.object if present is clearly seen.

Outcome criteria:Outcome criteria:

The infant/child will experience normal The infant/child will experience normal bowel movement.bowel movement.

B- B- StomatitisStomatitis

Definition:Definition: Inflammation of the mucous Inflammation of the mucous

membrane of the mouth. It may be membrane of the mouth. It may be due to local lesion in the mouth or a due to local lesion in the mouth or a feature of a systemic disease e.g. feature of a systemic disease e.g. measles.measles.

Causes of Causes of stomatitis:stomatitis:

Infection:Infection: Viruses: measles, primary herpes simplex, coxsackie Viruses: measles, primary herpes simplex, coxsackie

A.A. Bacteria: streptococcus, diphtheria.Bacteria: streptococcus, diphtheria. Fungus: monilia coral thrush.Fungus: monilia coral thrush. Eruption stomatitis: associated with eruption of teeth.Eruption stomatitis: associated with eruption of teeth. Traumatic: cheek biters.Traumatic: cheek biters. Local reactions: due to sensitivity to contact Local reactions: due to sensitivity to contact

substances from toys and foods.substances from toys and foods. Immunological impairment: in leukemias.Immunological impairment: in leukemias. Drugs and poisons: phenytoin, salicylates, Drugs and poisons: phenytoin, salicylates,

corrosives. corrosives.

Types of Stomatitis:Types of Stomatitis:

Catarrhal stomatitis.Catarrhal stomatitis. Herpetic stomatitis.Herpetic stomatitis. Thrush stomatitis.Thrush stomatitis.

Thrush stomatitis:Thrush stomatitis:

DefinitionDefinition It is a "It is a "fungus infectionfungus infection" of the skin and " of the skin and

mucous membrane of the mouth characterized mucous membrane of the mouth characterized by white patches, resembling milk curds.by white patches, resembling milk curds.

EtiologyEtiology Candida albicans infection is due to inadequate Candida albicans infection is due to inadequate

sterilization of teats and bottles or from sterilization of teats and bottles or from mother's breast of the attendant's hand. mother's breast of the attendant's hand. Newborns are infected during passage in birth Newborns are infected during passage in birth canal.canal.

Assessment:Assessment: Mouth contains white patches, which Mouth contains white patches, which

resembles milk curds (it is difficult to resembles milk curds (it is difficult to remove and if removed bleeding remove and if removed bleeding occurs). Also there discomfort during occurs). Also there discomfort during feeding.feeding.

Nursing diagnosisNursing diagnosis Altered oral mucous membrane related Altered oral mucous membrane related

to mouth infection.to mouth infection.

GoalGoal Prevent and reduce the effects of oral Prevent and reduce the effects of oral

ulceration.ulceration.

Nursing managementNursing management

– Absolute cleanliness of all articles which Absolute cleanliness of all articles which enter infants mouth-such as mothers enter infants mouth-such as mothers nipple, rubber nipple, pacifiers, teats, or his nipple, rubber nipple, pacifiers, teats, or his toys.toys.

– Applicators used must be sterile.Applicators used must be sterile.– Infants must have their own feeding Infants must have their own feeding

equipment to prevent spread of infection.equipment to prevent spread of infection.– Medicine dropper may be used, if nipple Medicine dropper may be used, if nipple

irritates the child.irritates the child.– Give infant some sterile water after each Give infant some sterile water after each

feeding to wash the mouth.feeding to wash the mouth.

Expected outcome:Expected outcome:

– Mouth membrane remains intact.Mouth membrane remains intact.– Ulcers show evidence of healing.Ulcers show evidence of healing.

Nursing diagnosisNursing diagnosis Altered nutrition less than body Altered nutrition less than body

requirements related to loss of appetite. requirements related to loss of appetite. Also discomfort and interference with Also discomfort and interference with feeding.feeding.

Goal:Goal: Appetite stimulation.Appetite stimulation.

Nursing Nursing managementmanagement:: Encourage parents to Encourage parents to relax pressurerelax pressure

placed on eating.placed on eating. Allow infant any tolerated food; Allow infant any tolerated food; plan to plan to

improve quality of food selection improve quality of food selection when appetitewhen appetite increases. increases.

Take advantage of any hungry periodTake advantage of any hungry period, , serve small snacks.serve small snacks.

Allow child to be Allow child to be involved in food involved in food preparation selection.preparation selection.

Outcome criteriaOutcome criteria The nutritional intake is adequate.The nutritional intake is adequate.

Medical treatment:Medical treatment: Treatment should be continued for one week after Treatment should be continued for one week after

recovery prevent recurrence.recovery prevent recurrence. Cleanliness and sterilization of the feeding bottles and Cleanliness and sterilization of the feeding bottles and

teats.teats. The infant's mouth is gently painted three times daily The infant's mouth is gently painted three times daily

with 1% aqueous solution of gentian violet.with 1% aqueous solution of gentian violet. This may be combined with nystatine, 100.000 units by This may be combined with nystatine, 100.000 units by

month, 3 – 4 times daily.month, 3 – 4 times daily. Mother's nipple and areola painted with nystatine Mother's nipple and areola painted with nystatine

ointment between meals.ointment between meals.

Prognosis:Prognosis: Generally very good, recovery occurs after (3 – 5) days.Generally very good, recovery occurs after (3 – 5) days.

C– Vomiting:C– Vomiting: Complete or partial emptying of the Complete or partial emptying of the

stomachstomach especially when it occurs especially when it occurs sometimes after feeding i.e. bringing up sometimes after feeding i.e. bringing up an appreciable amount of the swallowed an appreciable amount of the swallowed food.food.

Vomiting results from a coordinated Vomiting results from a coordinated sequence of abdominal muscle sequence of abdominal muscle contractions and reverse esophageal contractions and reverse esophageal peristalsis. It is usually associated with peristalsis. It is usually associated with nausea except when projectile.nausea except when projectile.

Vomiting is classified as followsVomiting is classified as follows::

MechanicalMechanical:: secondary at an obstructive secondary at an obstructive lesion.lesion.

ReflexiveReflexive: due to gastrointestinal tract : due to gastrointestinal tract stimuli (e.g. infection, allergy).stimuli (e.g. infection, allergy).

CentralCentral:: Central nervous system involvement (e.g. Central nervous system involvement (e.g.

neoplasms, meningitis).neoplasms, meningitis).

Caused by otherCaused by other than primary central than primary central nervous system involvement (e.g., nervous system involvement (e.g., abnormal metabolites, sepsis, psychogenic abnormal metabolites, sepsis, psychogenic vomiting).vomiting).

Regurgitations:Regurgitations: Means to express "Means to express "spill out"spill out" of " of "spill spill

overover" a small amount of formula. " a small amount of formula. a during or small amount of swallowed a during or small amount of swallowed food Also spitting up from stomach shortly food Also spitting up from stomach shortly after eating. Or non forceful expulsion of after eating. Or non forceful expulsion of food and secretions from esophagus or food and secretions from esophagus or stomach through the mouth.stomach through the mouth.

Differences between regurgitation and Differences between regurgitation and vomiting:vomiting:

Regurgitation is not accompanied Regurgitation is not accompanied by nausea.by nausea.

No forceful contraction of No forceful contraction of abdominal muscle.abdominal muscle.

Occurs in early weeks of life.Occurs in early weeks of life.A short time after feed babies A short time after feed babies

regurgitate small amounts (1-2 regurgitate small amounts (1-2 mouthfuls) of milk.mouthfuls) of milk.

Weight gain is normal.Weight gain is normal. Doesn't need any treatment.Doesn't need any treatment.

Rumination:Rumination:

Means voluntary or habitual Means voluntary or habitual regurgitation of formula into the regurgitation of formula into the mouth after it has been swallowed mouth after it has been swallowed i.e. returning of food from stomach i.e. returning of food from stomach and chewing it again .and chewing it again . Vomiting is Vomiting is one of the most common symptoms one of the most common symptoms in infancy and may be associated in infancy and may be associated with a wide variety of disturbances.with a wide variety of disturbances.

Causes of vomitingCauses of vomiting::

Causes of vomiting are classified according to different periods:Causes of vomiting are classified according to different periods:

1- In newborn:1- In newborn:

Physiological vomiting at or soon after birth as a normal process by Physiological vomiting at or soon after birth as a normal process by which swallowed blood and amniotic fluid are removed. It may occur which swallowed blood and amniotic fluid are removed. It may occur once or twice.once or twice.

Congenital esophegeal obstruction, which is manifested by Congenital esophegeal obstruction, which is manifested by regurgitation, chocking and perhaps cyanosis with first feed.regurgitation, chocking and perhaps cyanosis with first feed.

Intestinal obstruction gives symptom usually in the first 24 hours Intestinal obstruction gives symptom usually in the first 24 hours after birth.after birth.

Imperforated anus gives symptoms that begin on the first 24-36 Imperforated anus gives symptoms that begin on the first 24-36 hours of life with abdominal distention,, vomiting and meconium is hours of life with abdominal distention,, vomiting and meconium is passed.passed.

Cerebral birth injuries due to stimulation of vomiting center in the Cerebral birth injuries due to stimulation of vomiting center in the

brainbrain..

2. In infancy:2. In infancy:

Improper feeding habitImproper feeding habit Over feeding or underfeeding.Over feeding or underfeeding. Error in feeding technique.Error in feeding technique. Failure to eructate.Failure to eructate. Too small teat.Too small teat. Excessive handling after feeding.Excessive handling after feeding.

Placing baby on left side after feeding.Placing baby on left side after feeding. Too tight clothing especially around the Too tight clothing especially around the

abdomen.abdomen. InfectionsInfections such as otitis media, such as otitis media,

tonsillitis, pyelitis and pneumonia. tonsillitis, pyelitis and pneumonia. Acute diarrheal diseasesAcute diarrheal diseases due due to bacterial or viral infection in the to bacterial or viral infection in the intestinal tract.intestinal tract.

Intestinal obstructionIntestinal obstruction e.g. pyloric e.g. pyloric stenosis or stenosis or intussusception.intussusception.

Cerebral causesCerebral causes as hydro-cephalus as hydro-cephalus

3- In older children :3- In older children :

Dietary causesDietary causes e.g. ingestion of unripe fruits or e.g. ingestion of unripe fruits or contaminated food.contaminated food.

Acute infectionsAcute infections such as streptococcal pharyngitis, such as streptococcal pharyngitis, diphtheria, reflex vomiting in pertussis or intestinal diphtheria, reflex vomiting in pertussis or intestinal infection as food poisoning.infection as food poisoning.

DrugsDrugs as digitalis, sulphonamides, broad-spectrum as digitalis, sulphonamides, broad-spectrum antibiotics.antibiotics.

lntracranial hemorrhage and brain tumors. lntracranial hemorrhage and brain tumors. Organic nervous diseasesOrganic nervous diseases e.g. meningitis, e.g. meningitis,

encephalitis.encephalitis. ..Metabolic disturbancesMetabolic disturbances as in diabetic acidosis. as in diabetic acidosis. Psychogenic vomitingPsychogenic vomiting as by forcing a child with poor as by forcing a child with poor

appetite to eat more than he wants.appetite to eat more than he wants. Acute peritonitis due to development of paralytic ileus.Acute peritonitis due to development of paralytic ileus.

Assessment:Assessment: Failure to gain weight.Failure to gain weight. Feible, weak child with free perspiration.Feible, weak child with free perspiration. Sometimes feeling of nausea.Sometimes feeling of nausea. Stomach pain.Stomach pain. Dehydration.Dehydration. Alkalosis due to failure to retain food inside Alkalosis due to failure to retain food inside

the body.the body.Nursing diagnosis:Nursing diagnosis: Fluid volume deficit related to nausea and Fluid volume deficit related to nausea and

vomiting.vomiting.Goal:Goal: To promote hydration.To promote hydration.

Nursing interventionNursing intervention::

Correct the cause of vomiting.Correct the cause of vomiting. Discontinue fluids and foods for older children by mouth Discontinue fluids and foods for older children by mouth

for 12-24 hours permitting only crushed ice to alleviate for 12-24 hours permitting only crushed ice to alleviate dryness of the mouth and resort to parental fluid.dryness of the mouth and resort to parental fluid.

In milder cases sips of cold drinks or glucose water.In milder cases sips of cold drinks or glucose water. Correct dehydration by parental fluid.Correct dehydration by parental fluid. Mummy restraints to protect the IV and child as needed.Mummy restraints to protect the IV and child as needed. Mouth care after vomiting to prevent aspiration of Mouth care after vomiting to prevent aspiration of

vomitus.vomitus. Close observation if infant tends to vomit, whether he Close observation if infant tends to vomit, whether he

tolerates food or not, or if he vomits immediately after tolerates food or not, or if he vomits immediately after feeding (congenital abnormalities).feeding (congenital abnormalities).

Nursing care should be planned to Nursing care should be planned to eliminate unnecessary movement after eliminate unnecessary movement after feeding.feeding.

Bubbling is very important.Bubbling is very important. Place child on right side and elevate Place child on right side and elevate

head of the bed after feeding.head of the bed after feeding. Change soiled clothes and linen to Change soiled clothes and linen to

prevent skin irritation.prevent skin irritation. weight infants daily.weight infants daily. Charting amount, color, nature, odor, Charting amount, color, nature, odor,

consistency, and time in relation to consistency, and time in relation to feeding.feeding.

Expected outcome:Expected outcome: Child shows signs of adequate hydration.Child shows signs of adequate hydration. Nursing diagnosis:Nursing diagnosis: Altered comfort related to acute pain in the Altered comfort related to acute pain in the

stomach.stomach.

Goal:Goal: Relieve pain.Relieve pain.

Intervention:Intervention: Refer to lecture of congenital anomalies.Refer to lecture of congenital anomalies.

Expected outcome:Expected outcome: Child rest quietly, shows no evidence of Child rest quietly, shows no evidence of

discomfort, verbalizes no complaints of discomfort, verbalizes no complaints of discomfort.discomfort.

D- Colic :D- Colic :

Definition:Definition:

Paroxysmal intestinal cramps Paroxysmal intestinal cramps occurring due to accumulation of occurring due to accumulation of excessive gases and cause excessive gases and cause discomfort and pain. It is most discomfort and pain. It is most common during the first 3 or 4 common during the first 3 or 4 months of life.months of life.

EtiologyEtiology::

The causative factors are not known, The causative factors are not known, but it might be due to:but it might be due to:

Excessive swallowing of air.Excessive swallowing of air. Too much excitement.Too much excitement. Excessive intake of carbohydrate Excessive intake of carbohydrate

leads to gas formation.leads to gas formation. Over rapid feeding.Over rapid feeding. Diseases of GIT e.g. gastroenteritis, Diseases of GIT e.g. gastroenteritis,

constipationconstipation . .

Hernias: diaphragmatic, inguinal, or Hernias: diaphragmatic, inguinal, or umbilical.umbilical.

Parasites.Parasites. Allergy to certain foods. Allergy to certain foods. Hunger .Hunger . Intestinal obstruction e.g. pyloric Intestinal obstruction e.g. pyloric

stenosis . stenosis . Emotional stress or tension Emotional stress or tension

between parent and child.between parent and child.

AssessmentAssessment ::

Sudden attack of abdominal pain.Sudden attack of abdominal pain. Cry in loud voice more or less Cry in loud voice more or less

continuous.continuous. Distended and tense abdomen.Distended and tense abdomen. Congestion of face may be cyanotic Congestion of face may be cyanotic

in severe cases.in severe cases. Legs are drawn up on the abdomen.Legs are drawn up on the abdomen.

Feet are often cold.Feet are often cold. Arms are flexed and drawn to the Arms are flexed and drawn to the

body. body. Neck may be flexed. Neck may be flexed. Infant may pass flatus or feces.Infant may pass flatus or feces.

Nursing diagnosis :Nursing diagnosis : Altered comfort related to colic.Altered comfort related to colic.Goal :Goal : To relive pain.To relive pain.Nursing intervention :Nursing intervention : Bubble infant frequently and gently; Bubble infant frequently and gently;

use upright position to help eructation.use upright position to help eructation. Give infant hot watery fluids (as Give infant hot watery fluids (as

caraway) to help expulsion of gases or caraway) to help expulsion of gases or use hot water bottle.use hot water bottle.

Turn the infant on abdomen to help Turn the infant on abdomen to help expulsion of gases.expulsion of gases.

Loving care to relief his tension Loving care to relief his tension (hug him).(hug him).

Teach mother the details of good Teach mother the details of good feeding techniques.feeding techniques.

Doctor may order small warm Doctor may order small warm enema or change formula.enema or change formula.

Doctor may order drugs as atropine Doctor may order drugs as atropine to reduce intestinal movement.to reduce intestinal movement.

Expected outcome :Expected outcome : Infant/child is resting and shows no Infant/child is resting and shows no

evidence of discomfort.evidence of discomfort.

ConstipationConstipation: : Definition :Definition : Difficulty or Difficulty or insufficient passage of insufficient passage of

hard stoolshard stools at infrequent intervals. at infrequent intervals. Causes :Causes : Underfeeding with insufficient intake of Underfeeding with insufficient intake of

milk or fluid. milk or fluid. Intestinal obstruction .Intestinal obstruction . Pyloric stenosis .Pyloric stenosis . Congenital Megacolon.Congenital Megacolon. Infant receiving cow's milk.Infant receiving cow's milk. Starvation.Starvation.

Assessment:Assessment: Colic and passage of gases.Colic and passage of gases. Passage of infrequent hard dry stools, Passage of infrequent hard dry stools,

which occasionally fissures the rectum which occasionally fissures the rectum while being expelled.while being expelled.

Distension of the rectum and colon.Distension of the rectum and colon. Anxiety.Anxiety.Nursing diagnosis:Nursing diagnosis: Altered comfort related to acute colic.Altered comfort related to acute colic.Goal :Goal : Infant/child will feel comfort.Infant/child will feel comfort.

Nursing interventionNursing intervention::

Increase fluid intake.Increase fluid intake. Laxative fluids e.g. orange juice relives mild Laxative fluids e.g. orange juice relives mild

constipation.constipation. Small soapy enema may be given.Small soapy enema may be given. Milk of magnesia may be used as a Milk of magnesia may be used as a

temporary measure.temporary measure. Establish or maintain regular bowel action by Establish or maintain regular bowel action by

nature means rather than using purgatives.nature means rather than using purgatives. Psychological support to express his fear and Psychological support to express his fear and

his own emotional reactions.his own emotional reactions.Expected outcome:Expected outcome: Infant/child will show no evidence of Infant/child will show no evidence of

discomfort and passes stool according to his discomfort and passes stool according to his habit.habit.

Diarrhea Diarrhea DisordersDisorders

Definition:Definition: It is defined as "It is defined as "An increase in An increase in

the fluidity, volume and the fluidity, volume and number of stools relative to number of stools relative to the usual habits of each the usual habits of each individualindividual". ".

Morbidity and Mortality in Morbidity and Mortality in Egypt:Egypt:

Morbidity:Morbidity: Diarrhea is a leading cause of illness among Diarrhea is a leading cause of illness among

children in developing countries. In Egypt a child children in developing countries. In Egypt a child under five years suffers an average three bouts of under five years suffers an average three bouts of acute diarrhea yearly; that is to say 10 millions acute diarrhea yearly; that is to say 10 millions children suffer 30 millions episodes of diarrhea children suffer 30 millions episodes of diarrhea every year.every year.

Mortality:Mortality: Diarrhea accounts for 25 - 30% of deaths among Diarrhea accounts for 25 - 30% of deaths among

children under five years. It is estimated that 15000 children under five years. It is estimated that 15000 Egyptian infants and preschool children die yearly Egyptian infants and preschool children die yearly from diarrhea (about 42 deaths every day), 80% of from diarrhea (about 42 deaths every day), 80% of them being in the first two years of life.them being in the first two years of life.

Factors promoting the Factors promoting the transmission of enteric transmission of enteric pathogenspathogens::

Failure to breast – feed exclusively for Failure to breast – feed exclusively for the 1st 4 – 6 months.the 1st 4 – 6 months.

Using infant feeding bottles (easily Using infant feeding bottles (easily contaminated).contaminated).

Inappropriate storing of cooked food.Inappropriate storing of cooked food. Using drinking water contaminated Using drinking water contaminated

with fecal bacteria.with fecal bacteria. Failing to dispose of feces hygienicallyFailing to dispose of feces hygienically

Failing to wash hands after defection.Failing to wash hands after defection. Host factors: young age (highest incidence Host factors: young age (highest incidence

in the age group 6 – 12 months).in the age group 6 – 12 months). Malnutrition.Malnutrition. Measles in the previous 4 weeks.Measles in the previous 4 weeks. Immunodeficiency.Immunodeficiency. Season: Season:

Bacterial diarrheas are more frequent in Bacterial diarrheas are more frequent in summer.summer.

Rotavirus is more frequent in winter but occur Rotavirus is more frequent in winter but occur throughout year.throughout year.

Types of Types of diarrhea :diarrhea :

Acute Watery Diarrhea: (80% of cases)Acute Watery Diarrhea: (80% of cases) This refers to diarrhea that begins suddenly; it persists for This refers to diarrhea that begins suddenly; it persists for

3 - 4 days then gradually improves over another 4 - 5 3 - 4 days then gradually improves over another 4 - 5 days. It is usually self-limited (lasts less than 14 days) days. It is usually self-limited (lasts less than 14 days) and involves and involves the passage of frequent loose or the passage of frequent loose or watery stool without visible blood.watery stool without visible blood.

Dysentery: (5 – 10% of cases)Dysentery: (5 – 10% of cases) This is diarrhea This is diarrhea with visible fresh blood in the stoolswith visible fresh blood in the stools. .

Its sequelae include anorexia and damage to the Its sequelae include anorexia and damage to the intestinal mucosa.intestinal mucosa.

Persistent Diarrhea: (10% of cases)Persistent Diarrhea: (10% of cases) Post infectious diarrhea that begins actually and lasts at Post infectious diarrhea that begins actually and lasts at

least 14) days. Persistent diarrhea is least 14) days. Persistent diarrhea is not chronic not chronic diarrhea whichdiarrhea which is recurrent or long- lasting due to non- is recurrent or long- lasting due to non-infectious causes. (e.g. metabolic disorders). infectious causes. (e.g. metabolic disorders).

Dangers of diarrhea :Dangers of diarrhea : Dehydration, which might lead to death if not Dehydration, which might lead to death if not

properly, treated.properly, treated. Malnutrition: diarrhea is worse in persons with Malnutrition: diarrhea is worse in persons with

malnutrition and can make it worst because:malnutrition and can make it worst because: Nutrition is lost from the body in diarrhea.Nutrition is lost from the body in diarrhea. The patient may not be hungry (due to diminished The patient may not be hungry (due to diminished

absorption).absorption). Mothers may not feed their children during the Mothers may not feed their children during the

episode or even for some days after the diarrhea episode or even for some days after the diarrhea improves.improves.

N.B.N.B. The life span of intestinal mucosal cells is 3-5 The life span of intestinal mucosal cells is 3-5 days. New normal cells will replace the destroyed cells days. New normal cells will replace the destroyed cells damaged by toxins, within this period. This is why damaged by toxins, within this period. This is why diarrhea is usually a self-limited disease of 3-5 days diarrhea is usually a self-limited disease of 3-5 days duration.duration.

Incidence of diarrhea :Incidence of diarrhea :The peak incidence of diarrhea is between The peak incidence of diarrhea is between

6 months to 2 years. This is due 6 months to 2 years. This is due to:to:

Declining level of maternal antibodies.Declining level of maternal antibodies. Exposure to enteric pathogens through contaminated Exposure to enteric pathogens through contaminated

weaning food.weaning food. The pleasure of picking -up contaminated objects and The pleasure of picking -up contaminated objects and

putting them in the mouth while crawling.putting them in the mouth while crawling.Seriousness of diarrheal disorders during infancy :Seriousness of diarrheal disorders during infancy : Their higher needs for water exchange to meet their Their higher needs for water exchange to meet their

high metabolism.high metabolism. Greater susceptibility of infants to infection .Greater susceptibility of infants to infection . Lower power of their kidneys to concentrate urine, Lower power of their kidneys to concentrate urine,

which results in relative polyuria.which results in relative polyuria. Their smaller metabolic reserves of water and Their smaller metabolic reserves of water and

electrolytes.electrolytes. Therefore, with limited intake and /or extra loss of Therefore, with limited intake and /or extra loss of

fluid during diarrhea, acute dehydration usually occursfluid during diarrhea, acute dehydration usually occurs

Causes of diarrhea:Causes of diarrhea:

1- Enteropahtogenic: (infectious 1- Enteropahtogenic: (infectious diarrhea)diarrhea)

Viruses (rotavirus) (15 – 25% of cases).Viruses (rotavirus) (15 – 25% of cases). Bacteria (E.Coli 10 – 20% of cases), (shigell 5 Bacteria (E.Coli 10 – 20% of cases), (shigell 5

– 15% of cases).– 15% of cases). Protozoa (cryptosporidium 5-15% of cases).Protozoa (cryptosporidium 5-15% of cases). Other less common pathogens include Other less common pathogens include

(Giardia - (Giardia - doudenarisdoudenaris,, Entamoeba Entamoeba histoloticày histoloticày andsalomnellaandsalomnella).).

22 - -DietaryDietary: :

A-Formula feeding problems:A-Formula feeding problems: Contaminated feeding bottles.Contaminated feeding bottles. Overfeeding. Overfeeding. Over concentrated formula.Over concentrated formula. Excess sugar or fat in formula.Excess sugar or fat in formula.

B-Weaning food problemsB-Weaning food problems:: Introduction of food, which is not suitable Introduction of food, which is not suitable

for the age.for the age. Unripe fruits.Unripe fruits. Introduction of new food.Introduction of new food. Improperly cooked diet.Improperly cooked diet. Malnutrition .Malnutrition .3- Some parenteral infections:3- Some parenteral infections: Pneumonia and otitis media may be Pneumonia and otitis media may be

accompanied by diarrhea. It may actually accompanied by diarrhea. It may actually be due to an associated intestinal be due to an associated intestinal infection.infection.

Communicable diseases (e.g. measles) Communicable diseases (e.g. measles) diarrhea occurs due to immunological diarrhea occurs due to immunological impairment.impairment.

4- Miscellaneous: 4- Miscellaneous: Emotional tension & Irritable colon.Emotional tension & Irritable colon. Heavy metal poison (arsenic, lead, Heavy metal poison (arsenic, lead,

mercury).mercury). AntibioticAntibiotic5- Malabsorption:5- Malabsorption:Cystic fibrosis, ciliac diseaseCystic fibrosis, ciliac disease..

N.BN.B..

Teething is not a cause Teething is not a cause of diarrhea. Diarrhea of diarrhea. Diarrhea that occurs during that occurs during teething is usually teething is usually caused by an intestinal caused by an intestinal infection and should be infection and should be treated properly.treated properly.

DehydratioDehydrationn

Definition Definition It is one of the consequences of watery It is one of the consequences of watery

diarrhea. It is caused by the loss of water and diarrhea. It is caused by the loss of water and electrolytes in liquid or loose stools and electrolytes in liquid or loose stools and vomitus. Fever can make it worse as it causes vomitus. Fever can make it worse as it causes additional loss of water. Dehydration can lead additional loss of water. Dehydration can lead to hypovolemia, cardiovascular collapse, and to hypovolemia, cardiovascular collapse, and death if not treated promptly.death if not treated promptly.

The signs of dehydrationThe signs of dehydration are the result of 2 are the result of 2 important factors:important factors:

Type of dehydrationType of dehydration:: Isotonic, hyperonic, Isotonic, hyperonic, hypotonic.hypotonic.

DegreeDegree:: Mild, moderate or sever. Mild, moderate or sever.

Types of Types of dehydration:dehydration:

1- Isotonic 1- Isotonic (isonatremic) dehydration: This is the most (isonatremic) dehydration: This is the most common result of acute watery cliarrhea common result of acute watery cliarrhea (more than 75% of cases). (more than 75% of cases). Deficits of water and Deficits of water and sodium are balanced .sodium are balanced .

2- 2- Hypertonic Hypertonic (hypernatremic) dehydration (hypernatremic) dehydration the net the net loss of water is greater than that of sodium loss of water is greater than that of sodium . . The condition is more common in young infants who The condition is more common in young infants who can't verbally ask for water . It results from the intake can't verbally ask for water . It results from the intake of large amounts of hpertonic fluids ( high content of of large amounts of hpertonic fluids ( high content of sodium or sugar ) during diarrhea.sodium or sugar ) during diarrhea.

3- 3- Hypotonic Hypotonic (hypontremic) dehydration: it is less (hypontremic) dehydration: it is less common and the net common and the net loss of sodim is greater than loss of sodim is greater than that of waterthat of water. This result from the intake of large . This result from the intake of large amounts of water or hypnotic fluids during diarrhea.amounts of water or hypnotic fluids during diarrhea.

Therapy of dehydration :Therapy of dehydration :

Oral rehudration:Oral rehudration: The rehydrauon therapy in the form of The rehydrauon therapy in the form of

ORS is considered an effective treatment ORS is considered an effective treatment of dehydration, It is a mixture of water, of dehydration, It is a mixture of water, glucose, and electrolytes and is used to glucose, and electrolytes and is used to correct or prevent dehydration. Glucose is correct or prevent dehydration. Glucose is added (2%) to promote sodium absorption. added (2%) to promote sodium absorption. Increasing the concentration of glucose by Increasing the concentration of glucose by 2% increase the osmolarity of the solution 2% increase the osmolarity of the solution and may cause osmotic diarrhea.and may cause osmotic diarrhea.

Composition of Composition of ORSORS: :

Components g/1Components g/1Amount G/LAmount G/L

Sodium chloride.Sodium chloride.3.5 3.5 G/LG/L

Trisodium citrate.Trisodium citrate.2.9 2.9 G/LG/L

potassium chloridepotassium chloride1.5 1.5 G/LG/L

GlucoseGlucose20.0 20.0 G/LG/L

N.B.N.B. The use of citrate increases the shelf life of The use of citrate increases the shelf life of ORS and therefore lowers its cost. Tape ORS and therefore lowers its cost. Tape water(200 ml) is used to dissolve the mixture water(200 ml) is used to dissolve the mixture and needs no boiling. It is given by cup and and needs no boiling. It is given by cup and spoon, but :spoon, but :

It can be given by nasogastric tube in the It can be given by nasogastric tube in the following conditions :following conditions :

When the patient is unable to drink but not in When the patient is unable to drink but not in shock, or has severe dehydration or paralytic shock, or has severe dehydration or paralytic ileus.ileus.

When the patient has severe repeated vomiting, When the patient has severe repeated vomiting, or if dehydration is not improving when ORS is or if dehydration is not improving when ORS is given slowly by cup and spoon.given slowly by cup and spoon.

Nursing management of Nursing management of diarrhea diarrhea

Nursing Assessment:Nursing Assessment: It includes taking the patient's history, It includes taking the patient's history,

measuring weight and temperature and measuring weight and temperature and Assessing the degree of dehydration.Assessing the degree of dehydration.

1- History:1- History: Personal characteristics (age and sex) and Personal characteristics (age and sex) and

socioeconomic background (home socioeconomic background (home environment, income, education, environment, income, education, occupation, beliefs .... etc).occupation, beliefs .... etc).

Duration of the episode.Duration of the episode. Frequency and consistency of stool.Frequency and consistency of stool.

Presence or absence of mucus, pus or blood in Presence or absence of mucus, pus or blood in stool.stool.

Patient's ability to drink and or presence of Patient's ability to drink and or presence of thirst.thirst.

Presence of vomiting, fever or other problems Presence of vomiting, fever or other problems (cough, otitis media).(cough, otitis media).

Last time urine passed.Last time urine passed. Feeding practices before and during illness.Feeding practices before and during illness. Treatment during this episode (ORS, drugs).Treatment during this episode (ORS, drugs). Vaccination taken especially measles vaccine.Vaccination taken especially measles vaccine.2- Assessment of the degree of dehydration:2- Assessment of the degree of dehydration: Assessment of the degree of dehydration Assessment of the degree of dehydration is is

based on 4 signsbased on 4 signs which are the most which are the most important to be detected:important to be detected:

AssessmeAssessment nt of the degree of dehydration.of the degree of dehydration.

SingsSings

AANo signs of No signs of dehydration dehydration loss < 5% of loss < 5% of body weightbody weight

BBSome Some

dehydration dehydration loss 5 – 10% loss 5 – 10%

of body of body weight weight

CCSevere Severe

dehydration dehydration loss > 10% of loss > 10% of body weightbody weight

G-General G-General conditioncondition

Well and alertWell and alertRestlessness and Restlessness and irritableirritable

Lethargic, floppy Lethargic, floppy unconscious unconscious

E- Eyes E- Eyes Normal Normal Sunken Sunken Very sunken and Very sunken and dry dry

M- Thirst M- Thirst Drinks normally Drinks normally Thirsty, drinks Thirsty, drinks eagerly eagerly

Drinks poorly or Drinks poorly or unable to drink.unable to drink.

S-Skin pinch S-Skin pinch Goes back quickly Goes back quickly Goes back slowly Goes back slowly Goes back very Goes back very

slowly (>2 slowly (>2 seconds).seconds).

Decide Decide

Patient has no Patient has no sings of sings of dehydration dehydration (mild)(mild)

If 2 or more signs If 2 or more signs are present, are present, there is there is moderate moderate dehydration.dehydration.

If 2 or more signs If 2 or more signs are present are present there is severe there is severe dehydration.dehydration.

Select Select treatment treatment plan plan

Plan APlan APlan BPlan BPlan CPlan C

Other signs that are used in the assessment of Other signs that are used in the assessment of dehydration are:dehydration are:

Anterior fontanel: normal, depressed or severely Anterior fontanel: normal, depressed or severely depressed.depressed.

Mucous membrane of the mouth and tongue: moist, dry Mucous membrane of the mouth and tongue: moist, dry or very dry.or very dry.

Tears: present in mild dehydration, absent in severe Tears: present in mild dehydration, absent in severe dehydration.dehydration.

Pulse (radial) as dehydration increase, pulse becomes Pulse (radial) as dehydration increase, pulse becomes more rapid. In severe dehydration pulse becomes weak.more rapid. In severe dehydration pulse becomes weak.

Extremities: in severe dehydration, skin becomes cool Extremities: in severe dehydration, skin becomes cool and moist and the nail bed may be cyanosed.and moist and the nail bed may be cyanosed.

Breathing : rapid deep breathing is a sign of acidosis.Breathing : rapid deep breathing is a sign of acidosis.Weighing Weighing is essential as it helps to estimate the amount of is essential as it helps to estimate the amount of

fluid required, for an initial rehydration . fluid required, for an initial rehydration . Patient should Patient should be weighted to the nearest 50 – 100 grams at the be weighted to the nearest 50 – 100 grams at the beginning of the assessment and recorded.beginning of the assessment and recorded. Towards Towards the end of rehydration , the child should have gained the end of rehydration , the child should have gained weight.weight.

Nursing Nursing diagnosis:diagnosis:

Bowel elimination is altered related to Bowel elimination is altered related to diarrhea.diarrhea.

Fluid and electrolyte balanced is Fluid and electrolyte balanced is altered related to diarrhea.altered related to diarrhea.

Altered nutrition less than body Altered nutrition less than body requirement related to loss of appetite. requirement related to loss of appetite.

High risk for infection related to body High risk for infection related to body resistance.resistance.

Altered parenthood related to Altered parenthood related to knowledge deficit about child care.knowledge deficit about child care.

Nursing intervention:Nursing intervention:

The aim of nursing intervention is:The aim of nursing intervention is: ToTo hydrate the infant. hydrate the infant. ToTo feed the infant. feed the infant. ToTo deal with associated problems. deal with associated problems.

Treatment Treatment Plan APlan APlan BPlan BPlan CPlan C

Where Where At home At home In OP In OP

rehydration rehydration center center

In hospital In hospital

1- Fluid therapy 1- Fluid therapy Give more Give more fluid than fluid than usual usual

Gives ORSGives ORSGive IV fluids Give IV fluids

What type What type

Home made Home made fluids (rice, fluids (rice, water, tea water, tea without without sugar, soup, sugar, soup, yogurt).yogurt).

Pansol .Ringer's Pansol .Ringer's lactate. Normal lactate. Normal saline.saline.

How much How much

-Give after Give after each loose each loose stool for child stool for child <2 years : 50 <2 years : 50 – 100ml– 100ml-For child > 2 For child > 2 years: 100 – years: 100 – 200 ml.200 ml.

Goes back Goes back slowly slowly

-100 ml/kg of body 100 ml/kg of body wt. given in 3 – 6 wt. given in 3 – 6 hrs.hrs.-11stst 30 ml/kg given 30 ml/kg given in in 11//22 to 1 hr. to 1 hr.-Next 70 ml/kg Next 70 ml/kg given in 2.5 – 5hrs, given in 2.5 – 5hrs, longer time is used longer time is used for infant < 1 year. for infant < 1 year. (NB*)(NB*)

How given How given

-Slowly (1 Slowly (1 spoon 1-2 spoon 1-2 min)min)-By cup and By cup and spoon, cup spoon, cup alone, alone, dropper/syrindropper/syringe.ge.

Slowly (1 spoon Slowly (1 spoon 1-2 min) by cup 1-2 min) by cup and spoon, cup and spoon, cup alone, alone, dropper/syringedropper/syringe. Nasogastric . Nasogastric tube.tube.

I.V.I.V.

Further Further assessmentassessment

A) Advice the mother A) Advice the mother toto bring the child to a bring the child to a

health facility if :health facility if :-Frequent large stools.Frequent large stools.

-Repeated vomitingRepeated vomiting-Increased thirstIncreased thirst

-No improvement after No improvement after daysdays

-Bloody stools .Bloody stools .-Fever.Fever.

B) Reassess the B) Reassess the patient's condition.patient's condition.

-If no signs of dehydration If no signs of dehydration shift to plan A.shift to plan A.

-Some dehydration shift to Some dehydration shift to plan Bplan B

-Severe dehydration shift Severe dehydration shift to plan C.to plan C.

Guidance during intervention Guidance during intervention :: Mothers should be taught how to give ORS Mothers should be taught how to give ORS

(one teaspoonful every 1-2 minutes and the (one teaspoonful every 1-2 minutes and the child should be in a semi-sitting position).child should be in a semi-sitting position).

Give ORS as much as the desires.Give ORS as much as the desires. If vomiting occurs, wait 10 minutes. then If vomiting occurs, wait 10 minutes. then

continue giving ORS solution but more slowly continue giving ORS solution but more slowly (one teaspoonful every 2-3 minutes).(one teaspoonful every 2-3 minutes).

Watch for puffy eyes as a sign of over Watch for puffy eyes as a sign of over hydration. If this occurs, stop ORS solution hydration. If this occurs, stop ORS solution and give breast feeding and plain water. and give breast feeding and plain water. When puffiness is gone, the child is When puffiness is gone, the child is considered fully dehydrated . Further considered fully dehydrated . Further treatment should follow treatment plan A.treatment should follow treatment plan A.

Feeding during and after the Feeding during and after the episode:episode:

– During diarrhea give the child as much During diarrhea give the child as much food as he wants.food as he wants.

– Offer food every 3-4 hours.Offer food every 3-4 hours.– Small frequent feeding are better tolerated Small frequent feeding are better tolerated

than less frequent and large feedings.than less frequent and large feedings.– Children will anorexia have to be gently Children will anorexia have to be gently

encouraged to eat.encouraged to eat.– After stoppage diarrhea, give one extra After stoppage diarrhea, give one extra

meal per day for 2 weeks in normal child meal per day for 2 weeks in normal child and longer period in malnourished one .and longer period in malnourished one .

Advantage of continued feeding Advantage of continued feeding during diarrhea.(during diarrhea.(important pointimportant point))

Preserves body weight and sustains growth, Preserves body weight and sustains growth, thus maintaining strength and health avoiding thus maintaining strength and health avoiding lowered resistance.lowered resistance.

The contact of foodstuffs with the gut mucosa The contact of foodstuffs with the gut mucosa protects its absorptive capacity and stimulates protects its absorptive capacity and stimulates the production of digestive enzymesthe production of digestive enzymes..

Easily digestible foods may enhance intestinal Easily digestible foods may enhance intestinal salt and water absorption by providing organic salt and water absorption by providing organic molecules, which facilities their absorptionmolecules, which facilities their absorption..

Studies have shown that continued feeding Studies have shown that continued feeding actually hastens recovery from a diarrheal actually hastens recovery from a diarrheal episodeepisode..

Assessment of the progress of Assessment of the progress of rehydrationrehydration

The patient's The patient's progressprogress should be should be assessed assessed at leastat least every hour . every hour .

The signsThe signs of a satisfactory response of a satisfactory response areare::

Return of a strong radial pulse.Return of a strong radial pulse. Improved consciousness level.Improved consciousness level. Ability to drink.Ability to drink. Much improved skin turgor.Much improved skin turgor. Passage of urinePassage of urine

Drugs therapy in diarrhea :Drugs therapy in diarrhea :

1- Antibiotic are ineffective and may 1- Antibiotic are ineffective and may lead to( prolonged diarhea –cause lead to( prolonged diarhea –cause malabsorption-have side effect – malabsorption-have side effect – prolong the duration of infection – prolong the duration of infection – their abuse will increase the their abuse will increase the resistance of organism).resistance of organism).

2 - Anti - diarrheal drugs.2 - Anti - diarrheal drugs.

3 - Anti -motility drugs.3 - Anti -motility drugs.

4 - Anti – emetics.4 - Anti – emetics.

Prevention of Prevention of diarrhea:diarrhea:

1- Promotion of breast-feeding1- Promotion of breast-feeding

2- Improved weaning practices2- Improved weaning practices

3- Proper use of water for hygiene and 3- Proper use of water for hygiene and drinking:drinking:

4- Personal hygiene 4- Personal hygiene

5- Use of latrines 5- Use of latrines

6- Safe disposal of stools of young 6- Safe disposal of stools of young children children

7- Measles vaccination 7- Measles vaccination

Thanks….

But it’s not the end !!!