DISEASES GASTROENTERITIS PRESENTED BY NYIRONGO RNROTNBSc NSG 7222013 NYIRONGO2013 1 At the end of the lecture student should be able to demonstrate an understanding of managing patients with diarrheal diseases ID: 933227
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MANAGEMENT OF PATIENTS WITH DIARRHEAL DISEASES(GASTROENTERITIS).
PRESENTED BY NYIRONGORN,ROTN,BSc NSG.
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Slide2At the end of the lecture, student should be able to demonstrate an understanding of managing patients with diarrheal diseasesGENERAL OBJECTIVE7/22/2013
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Slide3Define diarrheaExplain causes of diarrheaMention signs and symptoms of diarrheaAssess and classify dehydrationDescribe management of a patient with different forms of dehydrationList complications of diarrhea
SPECIFIC OBJECTIVES7/22/2013
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Slide4Gastro enteritis is the general term for a group of conditions that are usually caused by infections and produce symptoms such as loss of appetite, vomiting, mild to severe diarrhoea, cramps and discomfort in the abdomen (Berkow, 1999). This is an inflammation of the mucosa of the stomach and intestines and it is more likely to occur in developing countries; also called “traveler's diarrhoea” (Saunders, 1997). It is more frequent in the very young and in older adults.INTRODUCTION
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Slide5Despite many advances by medical personnel to overcome diarrhea, it still remains a global problem. It is one of the major causes of morbidity and mortality most especially among children under the age of (5) five years. Diarrhoeal diseases and resulting dehydration account for 1.3 million deaths annually in developing countries in under- fives.
INTRODUCTION
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Slide6It is the frequent passage of 3 or more loose or liquid stools in 24 hours. Hence diarrhea means increased stool water/ volume and frequency of passing stool in 24hrs.It is common in children, especially those between 6months and two years of age.
DEFINITION OF DIARRHEA7/22/2013
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Slide7Common Causes1.Gastroenteritis-Gastroenteritis is a condition that causes irritation and inflammation of the stomach and intestines (the gastrointestinal tract).
Pathogenic Organisms that Can Cause GE BACTERIA VIRUS
PARASITES
CAUSES OF DIARRHEA
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Slide8BACTERIACampylobacterVibro choleraSalmonellaShigella E coliGiardia
CAUSES OF DIARRHEA7/22/2013
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Slide9VIRUSESRotavirus
NorwalkEnteric adenovirusPARASITESCryptosporidiosis
Entameoba
histolyticWorms
Isospora
belli
Radiation
injury as in radiotherapy or nuclear accidents.
.
CAUSES OF DIARRHEA
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Slide10Drugs –Antibiotics, ironColorectal cancerUlcerative colitisCrohn’s Disease Chronic cicatrizing enteritis, granulomatous enteritis, distal ileitis
CAUSES OF DIARRHEA
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Slide11Un common causes 1.Food allergy2.Laxative abuse3.
Lactose intolerance, attracting fluids into the intestinal lumen leading to excessive lose of fluids4. Coeliac Disease
5.Ileal/gastric resection 6.Thyrotoxicosis
7.Chronic pancreatitis
CAUSES OF DIARRHEA
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Slide12Faecal-oral routeIncludes ingestion of faecal contaminated water or foodDirect contact with infected faeces
ROUTES OF TRANSMISSION
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Slide13Unsafe drinking water, erratic water supply and poor sanitation.Poor personal and domestic hygiene due to inadequate or lack of water supply.Non availability and adequacy of isolation facilities.Un vaccinated children, especially against measles are prone to developing measles associated diarrhoea.
PREDISPOSING FACTORS7/22/2013NYIRONGO,2013
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Slide14Failing to breastfeed exclusively for first 6 monthsFailing to continue breastfeeding until at least one year of ageUsing of infant feeding bottlesStoring cooked food at room temperature
PREDISPOSING FACTORS7/22/2013
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Slide15Over crowding places.Failing to wash hands before handling food, after defecation, or after handling faecesFailing to dispose of faeces hygienically
PREDISPOSING FACTORS7/22/2013
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Slide16Under nutritionFrequency, severity are increasedCurrent or recent measlesMore severe probably due to immunological impairment
Immunodeficiency or immunosuppressionHOST FACTORS THAT INCREASE SUSCEPTIBILITY TO DIARRHOEA
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Slide17AgeAge group of 6 -11 monthsSeasonBacterial diarrhoeas occur during warm season
Rotavirus tend to occur during winterEpidemicsV.Cholera and
shigella dysentery cause major epidemics
HOST FACTORS THAT INCREASE SUSCEPTIBILITY TO DIARRHOEA
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Slide18Diarrhea can be classified as: Inflammatory Non inflammatory Bloody and Non BloodyCLASSIFICATION OF DIARRHEA
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Slide19ACUTE WATERY DIARRHOEAThis is diarrhea of sudden onset, often short-lived- lasts for less than 14 days and it self limiting.It is a major cause of dehydration leading to deaths among under –fives.
CLINICAL TYPES OF DIARRHOEA7/22/2013
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Slide20It is often due to dietary indiscretion but may also be due to infections caused by:V.Cholera, rotavirus, shigellaContributes to Under nutrition when food intake is reduced
CLINICAL TYPES OF DIARRHOEA7/22/2013
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Slide21ACUTE BLOODY DIARRHOEAShigella, E. histolytica, E.Coli, SamonellaDiarrhoea with visible blood in faeces
It causes anorexia, rapid weight loss, damage to intestinal mucosal CLINICAL TYPES OF DIARRHOEA
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Slide22PERSISTENT/CHRONIC DIARRHOEAThis is diarrhea lasting more than 14 days. Persistent diarrhea is more common in people with HIV infection and is associated with malnutrition and contributes to a significant proportion of diarrhea deaths. May be caused by E.Coli, Cryptospordia
CLINICAL TYPES OF DIARRHOEA7/22/2013
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Slide23May either be watery or bloodyIt causes dehydration, weight loss, serious non intestinal infectionsCLINICAL TYPES OF DIARRHOEA
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Slide24DIARRHOEA WITH SEVERE MALNUTRITION Main dangers are:Severe systemic infectionDehydrationHeart failureVitamin and mineral deficiency
CLINICAL TYPES OF DIARRHOEA7/22/2013
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Slide25SECRETORY DIARRHOEAIn infectious diarrhoea the absorption of sodium by the villi is impaired and this leads to increased loss of water and salts from the body tissues.These changes may result from the action of bacterial toxins on the bowel mucosa.
MECHANISMS OF WATERY DIARRHOEA
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Slide26OSMOTIC DIARRHOEADiarrhoea occurs when a poorly absorbed osmotically active or hypertonic solution is ingested
This solution will cause water and electrolyte to move from the ECF into the Gut lumen until the osmolality of the intestinal content equals that of ECF and bloodIncreases volume of stool and causes dehydration
MECHANISMS OF WATERY DIARRHOEA
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Slide27EXUDATES DIARRHOEA: There is mucosal destruction that leads to output of purulent and bloody stool, it persist even on fasting. This occurs mainly with bacterial infections e.g. shigella dysentery.MALABSORPTION DIARRHOEA: There is improper absorption of gut nutrients producing voluminous, bulky stool with increased Osmolality combined with excess fat in stool (steatorrhoea).this type usually abates on fasting.
MECHANISMS OF WATERY DIARRHOEA7/22/2013
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Slide28DERANGED MOTILITY DIARRHOEA: This mechanism occurs because of the improper gut neuromuscular function leading to increased motility of intestinal contents, poor digestion and poor absorption of nutrients. This produces high variable patterns of increased stool volume.MECHANISMS OF WATERY DIARRHOEA
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Slide29Low grade fever (37.7℃ )Frequent Passage of loose/waterly stoolVomitingLoss of appetiteBlood in stoolAbdominal pain
LassitudeDehydration
CLINICAL MANIFESTATIONS
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Slide30History TakingHistory of recent travelWhether patient is being treated with antibioticsHistory of contact with any person who has diarrheaHistory of last meal/s taken in the previous 3-4 daysOnset of disease
Duration
ASSESSMENT
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Slide31Find out if any other person at home or in the community is affectedWorsening and relieving symptomsAny accompanying symptomsHistory of recurrence of disease. Assess the patient for signs of dehydration and classify dehydration to determine level of dehydration and route of adminstering fluids:
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Slide32weakness, dry skin, dry mouth and lack of sweat and tears, sunken eyes, drinking habits, loss of skin elasticity and restlessness.Check for vital signs to obtain baseline dataDo a system review to detect any abnormality and manage them accordingly
ASSESSMENT7/22/2013
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Slide33Ask Diarrhoea, vomiting, thirstyUrine when last passedLook
General appearance, eyes, mouth and tongue, breathing rateFeelSkin, pulse, fontanelle
DIAGNOSIS of DEHYDRATION
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Slide34SIGNS OF DEHYDRATIONExcessive thirstMuscle cramps
Loss of skin turgorSunken eyesSunken anterior fontanel Dry mouth and mucous membrane
DIAGNOSIS of DEHYDRATION
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Slide35Low urine outputDeep respirationsWeak pulse or weak or absent blood pressureAltered state of consciousnessWeight loss
DIAGNOSIS of DEHYDRATION7/22/2013NYIRONGO,2013
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Slide36NO DEHYDRATIONpatient presents with no enough signs to classify as some dehydration or severe dehydration.-Loss of less than 5% of total body fluids-Not enough signs to classify as some or severe dehydration.
CLASSIFICATION
OF DEHYDRATION
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Slide37patient presents with two or more of the following signs -Loss of between 5%-10% body weight-Any two of the following signsa) Restless or irritabilityb) Sunken eyes and fontanelsc) Drinks eagerly and is very thirstyd) Skin pinch on the abdomen goes back slowly
SOME DEHYDRATION
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Slide38The patient [child] presents with two or more of the following signs:-Loss of more than 10% total body fluidsa) Lethargic or unconsciousnessB)Not able to drink or drinks poorlyc) Skin pinch goes back very slowly (longer than two seconds).d
) Sunken eyes and fontanels.SEVERE DEHYDRATION
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Slide39No specific diagnostic tests are required in most patients with simple gastroenteritisHowever, if symptoms including fever, bloody stool and persistent diarrhea for more than two weeks, then examination of stool for cultures for bacteria including Salmonella, Shigella, Campylobacter and Enterotoxic Escherichia coli may be necessary.
Microscopy for parasites, ova and cysts may also be helpful.
DIAGNOSIS
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Slide40The objective of treatment is to replace lost fluids and electrolytes. Oral rehydration is the preferred treatment of fluid and electrolyte losses caused by diarrhea in patients with mild to moderate dehydration.MANAGEMENT
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Slide41The aim is to rehydrate the patient with fluids and electrolyte replacementFeeding should continue during all types of dehydrationTREATMENT OF DEHYDRATION
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Slide42Plan A is treatment of a patient who has diarrhea with no dehydration. The rehydration goal is deliver about 50mL/kg ORS over a 4 hour period Counsel the patient on the following1. Take extra fluids as much as possible
2. Take ZINC supplements as possible3. Continue feedingTREATMENT OF NO DEHYDRATION
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Slide43AGEAMOUNT OF ORS TO GIVE AFTER EACH LOOSE STOOL.AMOUNT OF ORS TO PROVIDE FOR USE AT HOME.
Less than 24 months.50 – 100 ml.500ml/ day.Two up to ten years.
100 – 200 ml.1000ml / day
Ten years or more.As much as wanted.
2000ml / day.
TREATMENT OF NO DEHYDRATION
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Slide44Treat some dehydration with ORS. Give the recommended amount of ORS over 4 hour period. (At the Health Facility).Determine the amount of ORS to give during first 4 hours to patients with some dehydration. TREATMENT OF SOME DEHYDRATION
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Slide45PLAN B75 TO 100MLS PER KG BODY WEIGHT OF ORS OVER 4 HOUR PERIODREASSESS AND CLASSIFY DEHYDRATION STATUSSELECT APPROPRIATE PLAN TO CONTINUE TREATMENTENCOURAGE BREASTFEEDING IF IT IS A CHILD OR OTHER FEEDS FOR ADULTS
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Slide46age
Less than four months.Four to eleven months.
Twelve to twenty three months.
Two to four years.
Five to Firthteen years.
Firthteen years or older.
Weight:
Less than four months.
5–7.9
kg.
8–10.9
kg
11–15.9kg
.
16kg-29.9kg
.
>30kg
In ml
200-400
400–600
.
600–800
800–1200
1200-2200
2200–4000
.
Approximate amount of ORS solution to give in the first four [4] hours.
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Slide47Show mother how to give ORS solutionMonitor treatment and reassess the child periodically until rehydration is completedIdentify patients who cannot be treated satisfactorily with ORS by mouth and adopt a more appropriate methodGive instructions for continuing treatment with Plan A after rehydration is completed
TREATMENT OF SOME DEHYDRATION7/22/2013NYIRONGO,2013
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Slide48PLAN C IS USEDINDICATIONS-Severe Dehydration-Unconsciousness-Prolonged oliguria or anuria
TREATMENT OF SEVERE DEHYDRATION7/22/2013
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Slide49AGEFirst give 30mls/kg in:Then give 70mls/kg in:Infants less than one year.
One hourFive hoursOlder30minutes.Two and half hours
PLAN C.
TREAMENT FOR SEVERE DEHYDRATION WITH RINGERS LACTATE SOLUTION
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Slide50Repeat once if radial pulse is still very weak or not detectable. Reassess the patient every 1-2 hours. If hydration is not improving, give the IV drip more rapidly. Also give ORS solution (about 5 ml/kg per hour) as soon as the patient can drink. TREATMENT OF SEVERE DEHYDRATION
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Slide51After 6 hours (infants) or 3 hours (older patients), perform a full reassessment. Switch to ORS solution if hydration is improved and the patient can drink. TREATMENT OF SEVERE DEHYDRATION
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Slide52Alternative method of rehydration-Nasogastrict rehydration-120 mls of ORS/kg body weight over 6 hours-Reassess patient after 3 hours
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Slide53Gastroenteritis is usually an acute and self-limited disease that does not require pharmacological therapy. Antibiotics are usually not useful for gastroenteritis, although they are sometimes used if symptoms are severe or a susceptible bacterial cause is isolated or suspected. If antibiotics are decided, drugs such as fluoroquinolone can be prescribed.
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Slide54Antiemetic drugs Antiemetic drugs may be helpful for patients with diarrhea associated with vomitingTREATMENT
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Slide551. Fluid volume deficit related to inadequate fluid intake, vomiting and diarrhoea manifested by loss of skin tugor,
oliguria and sunken orbits. Goal of interventions To replace lost fluids and electrolytes during the critical phase
COMMON NURSING PROBLEMS
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Slide56INTERVENTIONS Provide oral fluidsAdminister IV fluidMonitor intake/outputMonitor vital signs of TPR/BP
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Slide572. Risk of spread of infectionGoal of interventions To prevent spread of infection to other patients and members of the health care team
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Slide58INTERVENTIONSIsolate patient with infectious diarrheaUse infection prevention measures such as meticulous hand washing, wearing of protective clothing, careful disposal of eliminants, Restrict visitations
COMMON NURSING PROBLEMS
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Slide593. Need to observe the patientGoal of interventions To observe the patient’s condition and detect any change in the patient’s condition
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Slide60INTERVENTIONSVital signs observations will be done at least 4 hourly to assess response to treatmentObserve frequency of diarrhea and vomiting taking note of the amount, smell consistency and colorCOMMON NURSING PROBLEMS
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Slide61Observe patient for presence or absence of signs of dehydration 2-4 hourlyObserve for intake of fluid and foods COMMON NURSING PROBLEMS7/22/2013
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Slide624. Altered nutrition less than body requirements related to inability to digest nutrients, nausea and vomiting manifested by weakness and loss of weightGoal of interventions To improve the patient’s nutritional status
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Slide63InterventionsAssess presence of anorexia, nausea and vomiting as well as precipitating factors in order to plan for appropriate feeds (NGT, IV or Oral). Serve small frequent meals to prevent nausea, vomiting and promote absorption of nutrients.
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Slide64Do oral toilet to promote salivation and appetite.Monitor the client’s weight daily to assess progress.Administer anti emetics as prescribed one hour before meals to prevent vomiting during and after meals.
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Slide65Elevate head of bed at least 35 to 40 degrees during tube feeding and for one hour after completion of intermittent tube feeding to prevent aspiration of feeds and to promote feeds retention.COMMON NURSING PROBLEMS
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Slide665. Potential for Impaired skin integrity related to contact with diarrhoeal stool and inadequate perineal hygiene manifested by redness on the anal region, irritation, swelling and ulceration.Goal of interventions To prevent skin breakdown
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Slide67INTERVENTIONSAssess the skin of the perineal area to plan for appropriate intervention.Cleanse area with warm water after each bowel movement, rinse well and dry with soft towel to prevent further skin breakdown and promote comfort.
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Slide68Apply ointments such as Zinc oxide, Vaseline and barrier cream to protect skin and promote healing.Use an anaesthetic spray or ointment to reduce discomfort locally.COMMON NURSING PROBLEMS
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Slide696. Abdominal Pain related to irritated mucosa, ulceration and muscle spasms evidenced by restlessness, crying/ and verbalization.Goal of interventions
To promote patient’s comfort
COMMON NURSING PROBLEMS
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Slide70INTERVENTIONS Assess the nature, duration, location and severity of pain in order to come up with pain relief strategies.
Promote bed rest in a quite environment, minimizing on visitors.
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Slide71Allow the patient to maintain his own preferred comfortable position to relieve abdominal pain.Provide
diversional therapy (toys, T.V.) so as to divert the patient’s mind from the pain.
COMMON NURSING PROBLEMS
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Slide72Instruct patient to eat slowly and chew small pieces of food to prevent abdominal discomfort.Administer the prescribed analgesia for relief of pain.
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Slide73Consider the followingEnvironment where to nurse the patientRehydrate the patient as soon as possible and meet his nutritional needs
Prevent spread of infectionEnsure that the hygiene needs of the patient are met
SUMMARY OF NURSING CARE
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Slide745. Do vital signs and general observations6.Promote patient’s comfort by relieving abdominal pain and other discomfortsSUMMARY OF NURSING CARE
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Slide75Hypovolemic ShockBacteremiaRenal failure due to dehydration.Anaemia due to bleeding.Rectal prolapse due to Tenesmus.
COMPLICATIONS7/22/2013
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Slide76Improving acess to clean drinking water and safe sannitationPromoting domestic hygiene educationExclusive breastfeeding for the first 6 months of lifeImproved weaning practicesImmunizing all children especially against measlesPromoting use of latrines
PREVENTION
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Slide77Keeping food and water cleanWashing hands with soap and running water before touching food (baby’s as well) Sanitary disposal of stool of babiesPREVENTION
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Slide78Smeltze Kozier.B. (2000) Medical –Surgical Nursing Prentice-Hall of Japan,Inc., Tokyo.Lewis et al (1996): Medical-Surgical Nursing. Assessment and Management of Clinical Problems. 4th Edition. Mosby Year Book Inc.
REFERENCES7/22/2013
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