Health Alterations class 10: Gastro, dehydration, diarrhea and constipation

First class after midterm 1

Constipation

Alteration in frequency, consistency or ease of passage of stool

Idiopathic (functional) constipation

Constipation with no known cause

Chronic constipation

Constipation that may be due to environmental or psychosocial factors

When should the first meconium be passed

First 24-36 hours of life

What should we assess for if a newborn doesn’t pass meconium in the first. 24-36 hours of life

1. Hirschsprung disease (lacking certain nerves in the colon)

2. Hypothyroidism

3. Meconium plug

4. Meconium ileus (early sign of (cystic fibrosis)

What is infant constipation normally related to

Diet

Breast fed babies elimination

Infrequent stool may occur because if minimal residue from digested breast milk

Why are formula fed babies more prone to constipation than breast fed babies?

1. Iron is added in

2. If switched to different brand or higher calorie formula

What is child hood constipation normally related to

Environmental changes or wanting control over body functions (may be from stress, embarrassment, pain…)

Management of constipation in children

least to most invasive (diet/formula changes, fluid, eliminate binding foods then suppository (glycerin or mineral oil) then laxatives (don’t want to use, PEG if needed)

Binding foods

Foods such as rice, banana, dairy, apple sauce and toast. Cause stool to form, want to avoid with constipation

Establishing regular times for defecatiom

Can help with constipation, put child on toilet same time every day

Why is glycerin suppositories used for constipation in children

Stimulates motility, used more than mineral oil

Why do we avoid laxatives in constipated children

Can become addictive

What laxative is used in children

Try to avoid but PEG is used if needed (draws in water, no cramping, flavourless so can be put in any drink)

Examples of foods with fibre

Popcorn, grains, fruits, bran, prunes, raisins

Nursing considerations for constipation

1. Assess bowel patterns

2. Assess medications and diet

3. Educate parents and child on age appropriate foods, bowel training

4. Discourage laxatives

5. Offer reassurance

Leading of cause of illness in children under 5

Acute diarrhea

Acute diarrhea

Happens suddenly and doesn’t last long, has a variety of causative organisms

Acute infectious diarrhea/infectious gastroenteritis

Caused by viral, bacterial and parasitic pathogens

Chronic diarrhea

Increase in stool frequency and increased water content for more than 14 days

Intractable diarrhea of infancy

No pathogens, lasts longer than 2 weeks

Chronic non specific diarrhea is also known as

1. Irritable colon of childhood

2. Toddlers diarrhea

Clinical manifestations of CNSD

1. Diarrhea that lasts longer than 2 weeks

2. Poor dietary habits and food sensitivities

3. No blood in stool

4. No infection

5. Normal growth/no evidence of malnutrition

What age group does CNSD occur in

6-54 months

Diarrheal disturbances

1. Gastroenteritis

2. Enteritis

3. Colitis

4. Enterocolitis

Gastroenteritis

Involves the stomach and intestines

Enteritis

Involves just the small intestine

Colitis

Involves just the colon

Enterocolitis

Involves the colon and intestines

How are most pathogens causing diarrhea spread

Fecal oral route

Risk factors for diarrhea

1. Lack of clean water

2. Poor hygiene

3. Poor sanitation

Most common cause of acute gastroenteritis

Rotavirus (effects kids, prevent through hand hygiene and vaccine, vaccines comes in oral form)

Antibiotic therapy

Diarrhea can be a side effect

Diagnostic evaluation of diarrhea

1. Observe general appearance and behaviour

2. Assess severity of symptoms

3. Risk of complications (dehydration)

4. Other symptoms (fever, stool character, vomiting, urine output, dietary habits etc)

5. Ask questions on recent travel, animal contact, antibiotic use, diet changes, exposure to untreated drinking water, day care attendance etc

6. Lab data is used for severe dehydration and clients with Iv therapy

When is lab data used in pediatrics

In kids with severe dehydration or kids who already have an IV present

Watery, explosive stools indicate

Glucose intolerance

Foul smelling, greasy, bulky stools indicate

Fat malabsorption, indicator of food intolerance

Diarrhea after the introduction of cows milk, fruits or cereal may be related to

Enzyme deficiency or protein intolerance (milk intolerance)

Neutrophils or blood cells in stool indicate

Bacterial gastroenteritis or IBD

Eosinophils in stool indicate

Protein intolerance or parasitic infection

When are stool cultures taken

When blood, mucous or leukocytes are present

When is a CBC, creatinine and BUN taken

In children with moderate-severe dehydration

Whats usually elevated with acute diarrhea

Hemoglobin, creatinine and BUN

Major goals in managements of acute diarrhea

1. Assessment of fluid and electrolyte imbalance

2. Rehydration

3. Maintenance fluid therapy

4. Reintroduction of an adequate diet

Oral rehydration therapy

1. More effective, safer and less painful and costly than IV rehydration

2. Treatment of choice

3. Promotes and enhances reabsorption of sodium and water

4. Gatorade diluted with 50% water

How much fluid should be given for ORT

1. Young children: 5-10 ml every 1-5 minutes

2. Older children: 30-40 ml every 1-5 minutes

Why do you continue feeding/reintroduce a normal diet when doing ORT/when a child is sixk

Has no adverse effects and can lessen severity and duration of illness and improves weight gain compared to gradual reintroduction

What is indicated if dehydration is severe or shock is present or if uncontrollable vomiting is happening and the child can’t keep ORT down

IV fluids

Antibiotics and acute gastroenteritis

Controversial, if needed use probiotic to build up flora

Breastfeeding and dehydration/diarrhea

Continue breast feeding (if child tolerates it)

Contraindications with diarrhea

1. Caffeine ( pop, tea- too much carbs and not enough electrolytes)

2. BRAT diet (high carb with not enough protein, calories or electrolytes)

3. Clear fluids alone (not enough electrolytes or energy)

4. Fluids with high carbs, low electrolytes and high osmolality such as sodas, fruit juice, gelatin and broth)

Prevention of diarrhea

1. Hand and personal hygiene

2. Disposed soiled diapers, clean change tables etc

3. Careful food preparation

4. Isolation (until certain if pt is contagious or not)

Nonbilious vomiting

Clear vomit

Bilious vomiting

Yellow/green vomit

Vomiting treatment

1. Usually self limiting and doesn’t require treatment

2. Treat cause

3. Prevent complications from fluid loss

4. May need antiemetics

Antiemetics used in pediatrics

1. Gravol- drowsy

2. Zofran- non drowsy, used more

3. Maxeran

Isotonic dehydration

1. Primary form of dehydration in kids

2. Electrolytes/sodium and water are lost in equal amounts

3. No osmotic force between ICF and ECF, major loss is from ECF

4. Plasma sodium in normal limits (130-150)

Hypotonic dehydration

1. Electrolyte deficit is greater than the water deficit

2. Water moves from ECF to ICF to establish osmotic equilibrium, causing ECF volume loss

3. Serum sodium less than 130

4. Can get low BP, muscles cramps or weakness, headache

Hypertonic dehydration

1. Most dangerous!

2. More water is lost than electrolytes

3. Fluid shifts from ICF to ECF

4. Serum sodium over 150

5. Can get increased BP, cardiac issues and stroke

6. Thirst and edema may occur

Mild dehydration in older children

Less than 3% lost

Mild dehydration in infants

Less than 5%

Moderate dehydration in older children

3-6% lost

Moderate dehydration in infants

5-10% lost

Severe dehydration in older children

More than 6 %, IV fluids used

Severe dehydration in infants

More than 10% lost, IV fluids used

Earliest clinical sign of dehydration

Tachycardia

Other clinical signs of dehydration

1. Dry skin and mucous membranes

2. Sunken fontanelles

3. Signs of circulatory failure (coolness and mottling of extremities)

4. Prolonged capillary refill (over 2 seconds)

5. Body weight

6. Urine and stool (amount and look)

7. Vital signs

Diagnostic Evaluation for dehydration

1. Physical exam (look sick? Irritable? Toddler may be quieter than normal)

2. Weight

3. Lab data (Blood work if severe, check lytes for dehydration, BUN, creatinine)

4. Urine output

5. Urine specific gravity (concentration of urine)

Normal urine output for kids

1ml/kilo/hour

Normal urine specific gravity for kids

1.005-1.030

Therapeutic management of dehydration

1. Correct fluid imbalance

2. Treat underlying cause

3. Mild dehydration:ORT

4. Severe dehydration (unable to ingest sufficient fluids) IV fluids

5. Solution based on type and cause of dehydration

Nursing care of dehydration

1. Accurate measurement and assessment

2. Urine and stools

3. Vomit

4. Sweating

5. Vital signs

6. Skin and mucous membranes

7. Body weight

8. Fontanel (infants)

9. Lab data

10. Fluid intake