DIARRHEA

Definition:
Diarrhea is defined as a change in consistency and frequency of stools, i.e. liquid or watery stools,
that occur >3 times a day.
Incidences:
The global annual burden of diarrhea is huge, affecting 3-5 billion cases and causing approximately 2
million deaths a year. Diarrhea accounts for over 20% of all deaths in under-five children.
Risk factors:
Factors determining susceptibility to diarrhea include-
 Poor sanitation and personal hygiene
 Non-availability of safe drinking water
 Unsafe food preparation practices
 Low rates of breastfeeding and immunization
 Young children (<2yr) and those with malnutrition are more susceptible to acute diarrhea.
Pathophysiology:

Ingestion of organisms

Intestinal colonization

Mucosal invasion Cytotoxin

elaboration

Intramucosal multiplication

Acute inflammation

Diarrhea

Etiology:
 Bacterial
- Escherichia coli: Enterotoxigenic, enteropathogenic, enteroinvasive, enterohemorrhagic and
enteroaggregative types
- Shigella
 - Vibrio choleraeserogroups 01 and 0139
- Salmonella: Chiefly S typhi and S. paratyphi A, B or C.
- Others: Aeromonasspp., Bacillus cereus, Clostridium difficile, Clostridium perfringens,
Staphylococcus aureus, Vibrio parahemolyticus, Yersinia enterocolitica, Plesiomonasshigelloides
 Viral
- Rotavirus
- Human caliciviruses: Norovirus spp.; Sapovirusspp.
- Enteric adenoviruses serotypes 40 and 41
- Others Astroviruses, coronaviruses, cytomegalovirus, picornavirus
 Parasitic
- Giardia lamblia
- Cryptosporidium parvum
- Entamoebahistolytica
- Cyclosporacayetanensis
- Isospora belli
- Others: Balantidium coli, Blastocystishominis, Encephalitozoonintestinalis, Trichuristrichiura
Clinical manifestation:
- Liquid or watery stools, that occur >3 times a day
- Dehydration
- Depressed fontanelle
- Eyes appear sunken
- Tongue and inner side of cheeks appear dry
- Abdomen may become distended in hypokalemia
- The child passes urine at longer intervals
- Deep and rapid breathing
- In extreme cases, the child appears moribund, with weak and thread pulses, low blood pressure and
reduced urine output.
- Children with severe dehydration may succumb rapidly if not treated promptly
Diagnostic evaluation:
- Stool culture is of little value in routine management of acute diarrhea. It is useful to decide on
antibiotic therapy in patients with Shigella dysentery who do not respond to the initial empiric
antibiotics.
- Stool microscopy is not helpful in management except in selected situations, such as cholera.
- Hemogram, blood gas estimation, serum electrolytes, renal function tests are not indicated
routinely and are performed only if the child had associated findings like pallor, labored breathing,
altered sensorium, seizures, paralytic ileus or oliguria which suggests acide-base imbalance,
dyselectrolytemia or renal failure.

MEDICAL MANAGEMENT: (From book)

Management of acute diarrhea has four major components: (i) rehydration and maintaining
hydration; (ii) ensuring adequate feeding; (iii) oral supplementation of zinc; and (iv) early recognition of
danger signs and treatment of complications.
The cornerstone of acute diarrhea management is rehydration by using oral rehydration solutions.
After the history and examination, the child’s dehydration status is classified as no dehydration, some
dehydration or severe dehydration and appropriate treatment started.
 The Government of India has adopted the low osmolarity ORS as the single universal ORS to be
used for all ages and all types of diarrhea.
The composition of WHO recommended ORS---
Constituents gm/lit Osmole or ion mmol/lit

Sodium chloride 2.6 Sodium 75

Glucose anhydrous 13.5 Chloride 65

Potassium chloride 1.5 Glucose, anhydrous 75

Trisodium citrate, dihydrate 2.9 Potassium 20

Citrate 10

Total Osmolarity 245

Home available fluids for acute diarrhea_

Acceptable home available fluids

Fluids that contain salt Oral rehydration solution, salted drinks (e.g. salted rice water or
salted yoghurt drink), vegetable or chicken soup with salt
(preferable)
Fluids that do not contain salt Plain water, water in which a cereal has been cooked (e.g. unsalted
rice water), unsalted soup, yoghurt drinks without salt, green coconut
(acceptable)
water, weak unsweetened tea, unsweetened fresh fruit juice
Unsuitable home available fluids Commercial carbonated beverages, commercial fruit juices,
sweetened tea.
Treatment plan A: Treatment of “No Dehydration”
Such children may be treated at home after explanation of feeding and the danger signs to the mother
/ caregiver. Danger signs requiring medical attention are those of continuing diarrhea beyond 3 days,
increased volume / frequency of stools, repeated vomiting, increasing thirst, refusal to feed, fever or blood in
stools. The mother may be give WHO ORS for use at home as per---
Treatment of “no dehydration” Plan A
Age Amount of ORS or other culturally appropriate Amount of ORS to provide for use
ORT fluids to give after each loose stool at home
<24 months 50-100ml 500 ml/day

2-10 yr 100-200ml 1000ml/day

>10 yr Ad lib 2000ml/day

Treatment plan B: Treatment of “Some Dehydration”

All cases with obvious signs of dehydration need to be treated in a health center or hospital. Fluid
requirement is calculated under the following three headings: (i) provision of normal daily fluid
requirements; (ii) rehydration to correct the existing water or electrolyte deficits and (iii) maintenance to
replace ongoing losses to prevent recurrence of dehydration.
1. The daily fluid requirements in children are calculated as follows:
Up to 10 kg = 100ml/kg
10-20 kg = 50ml/kg
>20kg = 20ml/kg
2. Deficit replacement or rehydration therapy is calculated as 75ml/kg of ORS, to be given over 4 hr. if
ORS cannot be taken orally then nasogastric tube can be used. If child’s weight cannot be taken, then
only age may be used to calculate fluid requirement.
If after 4 hr, the child still has some dehydration then another treatment with ORS is to be
given.
3. Maintenance fluid therapy to replace losses. This phase should begin when signs of dehydration
disappear, usually within 4 hr. ORS should be administered in volumes equal to diarrheal losses,
usually to a maximum of 10ml/kg per stool. Breastfeeding and semi solid food are continued after
replacement of deficit. Plain water can be offered in between.

Treatment plan B “some dehydration”

Age <4 4-11 12-23 2-4 yr 5-14 yr >15 yr
months months months

weight <5kg 5-8 kg 8-11 kg 11-16kg 16-20 kg >30 kg

ORS, ml 200-400 400-600 600-800 800-1200 1200-2200 >2200

Number of 1-2 2-3 3-4 4-6 6-11 12-20

glasses

Treatment plan C: Children with “Severe Dehydration”

Intravenous fluids should be started immediately using Ringer lactate with 5% dextrose. Normal
saline or plain Ringer solution may be used as an alternative, but 5% dextrose alone is not effective. A total
of 100ml/kg of fluid is given, over 6 hr in children<12 months and over 3 hr in children>12 months.
ORS solution should be started simultaneously if the child can take orally. If IV fluids cannot be
given nasogastric feeding is given at 20ml/kg/hr for 6 hr. The child should be reassessed every 1-2 hr; if
there is repeated vomiting or abdominal distension, the oral or nasogastric fluids are given more slowly. If
there is no improvement in hydration after 3 hr, IV fluids should be started as early as possible.
Ths child should be reassessed every 15-30min for pulses and hydration status after the first bolus of
100ml/kg of IV fluid. Management following intravenous hydration end is to be done as follows:
Age 30ml/kg 70mkl/kg
<12mo 1hr 5hr
>12mo 30min 21/2hr

i) Persistence of severe dehydration. Intravenous infusion is repeated.

ii) Hydration is improved but some dehydration is present. IV fluids are discontinued; ORS is
administered over 4 hr according to plan B.
iii) There is no dehydration. IV fluids are discontinued; treatment plan A is followed.
The child should be observed for at least 6 hr before discharge, to confirm that the mother is able to
maintain the child’s hydration by giving ORS solution. Breastfeeding must continue during the rehydration
process, whenever the infant is able to suck.
Nutritional management of diarrhea
Children with severe malnutrition are at an increased risk of developing both acute diarrhea and its
complications, such as severe systemic infection, dehydration, heart failure, vitamin and mineral
deficiencies. Feeding should not be restricted in such patients as this aggravates complications and increases
morbidity and mortality. Early feeding during diarrhea not only decreases the stool volume by facilitating
sodium and water absorption along with the nutrients, but also facilitates early gut epithelial recovery and
prevents malnutrition.
Following are the recommendations on dietary management of acute diarrhea:
i. In exclusively breast feed infants, breastfeeding should continue as it helps in better weight gain and
decreases the risk of persistent diarrhea.
ii. Optimally energy dense foods with the least bulk, recommended for routine feeding in the
household, should be offered in small quantities but frequently (every 2-3 hr).
iii. Staple foods do not provide optimal calories per unit weight and these should be enriched with fat or
oil and sugar, e.g. khichri with oil, rice with milk or curd and sugar, mashed banana with milk or
curd, mashed potatoes with oil and lentil.
iv. Foods with high fiber content, e.g. coarse fruits and vegetables should be avoided.
v. In nonbreastfed infants, cow or buffalo milk can be given undiluted after correction of dehydration
together with semisolid foods. Milk should not be diluted with water during any phase of acute
diarrhea.
vi. Routine lactose-free feeding, e.g. soy formula is not required during acute diarrhea even when
reducing substances are detected in the stools.
vii. During recovery, an intake of at least 125 % of recommended dietary allowances should be
attempted with nutrient dense foods; this should continue until the child reaches pre-illness weight
and ideally until the child achieves a normal nutritional status.
Zinc supplementation
Zinc deficiency has been found to be widespread among children in developing countries. It is
helpful in decreasing severity and duration of diarrhea and also risk of persistent diarrhea. Zinc is
recommended to be supplemented as sulphate, acetate or gluconate formulation, at a dose of 20mg of
elemental zinc per day for children >6 months for a period of 14 days.
Symptomatic treatment
 An occasional vomit in a child with acute diarrhea does not need antiemetics. If vomiting is severe or
recurrent and interferes with ORS intake, then a single dose of ondansetron (0.1-0.2 mg/kg/dose) should be
given. Children with refractory vomiting despite administration of ondansetron may require intravenous
fluid.
Drug therapy
Most episodes of diarrhea are self-limiting and do not require any drug therapy except in a few
situations. Antibiotics are not recommended for routine treatment of acute diarrhea in children.
Anti-secretory agents have been used in acute diarrhea. Racecadotril is an anti-secretory drug that
exerts its antidiarrheal effects by inhibiting intestinal enkephalinase.
Probiotics, defined as microorganisms that exert beneficial effects on human health when they
colonize the bowel, have been proposed as adjunctive therapy in the treatment of acute bacteria.

Prevention of diarrhea and malnutrition

Prevention of diarrhea and its nutritional consequences should receive major emphasis in health
education. The three main measures to achieve this are:
i. Proper nutrition. Since breast milk offers distinct advantages in promoting growth and development
of the infant and protection from diarrheal illness, its continuation should be encouraged. Exclusive
breast feeding may not be adequate to sustain growth beyond the first 6 months of life. Therefore,
supplementary feeding with energy-rich food mixtures containing adequate amounts of nutrients
should be introduced by 6 months of age without stopping breastfeeding.
ii. Adequate sanitation. Improvement of environment sanitation, clean water supply, adequate sewage
disposal system and protection of food from exposure to bacterial contamination are effective long-
term strategies for control of all infectious illnesses including diarrhea. Three ‘Cs; clean hands, clean
container and clean environment are the key messages. Mother should be properly educated about
this. Complementary food should be protected from contamination during preparation, storage, or at
the time of administration.
iii. Vaccination. Evidence suggests that with improvement in sanitation and hygiene in developing
countries, the burden of bacterial and parasitic has decreased and viral agents have assumed an
increasingly important etiologic role. Effective vaccines are now available against the commonest
agent, i.e. rotavirus and their use might be an effective strategy for preventing acute diarrhea.

NURSING MANAGEMENT

Assessment
 Goals of assessment:

- These are to (i) determine the type of diarrhea, i.e. acute watery diarrhea, dysentery or persistent
diarrhea; (ii) look for dehydration and other complications; (iii) assess for malnutrition; (iv) rule out
non-diarrheal illness especially systemic infection; and (v) assess feeding, both pre-illness and during
illness.
 Health history:

- This should include information on: (i) onset of diarrhea; duration and number of stools per day; (ii)
blood in stools; (iii) number of episodes of vomiting; (iv) presence of fever, cough, or other
significant symptoms (e.g. convulsions, recent measles); (v) type and amount of fluids, including
breastmilk and food during the illness and pre-illness feeding practices; (vi) drugs or other local
remedies taken (including opioids or antimotility drugs like loperamide that may cause abdominal
distention); and (vii) immunization history.
  Physical examinations:

- The most important assessment is for dehydration. One should look at the child’s general condition,
whether he/she is alert, restless or irritable or lethargic or unconscious.
- Other important assessments are for the appearance of eyes (normal or sunken) and the ability to
drink water or ORS solution, whether taken normally or refused, taken eagerly, or an inability to
drink due to lethargy or coma. Dehydration is also assessed by feeling for skin turgor; following
pinching, the abdominal skin may flatten immediately, go back slowly or return very slowly (more
than 2 seconds). Based on the degree of dehydration after history and examination, the estimated
fluid loss is calculated as follows-

Degree of dehydration Assessment of fluid loss

No dehydration <50ml/kg

Some dehydration 50-100ml/kg

Severe dehydration >100ml/kg

- In addition, one should examine for features of malnutrition (anthropometry for weight and height;
examine for wasting, edema and signs of vitamin deficiency), systemic infection (presence of cough,
high grade fever, fast breathing and chest in drawing suggests pneumonia; high grade fever with
splenomegaly suggests malaria) and fungal infections (oral thrush or perianal satellite lesions).
Assessment of dehydration in patients with diarrhea

Look at
Condition Well alert Restless, irritable Lethargic or unconscious; floppy
Eyes Normal Sunken Very sunken and dry
Tears Present Absent Absent
Mouth and tongue Moist Dry Very dry
Thirst Drinks normally; not Thirsty, drinks eagerly Drinks poorly or is not able to drink
thirsty

Feel
Skin pinch Goes back quickly Goes back slowly Goes back very slowly

Decide The patient has no If the patient has two or If the patient has two or more signs,
signs of dehydration more signs, there is there is severe dehydration
some dehydration

Treat Use treatment Plan Weigh the patient, if Weigh the patient and use treatment
A possible, and use Plan C urgently
treatment Plan B

 Family knowledge:
- The family members don’t have knowledge about diarrhea.
- Family coping.
- Level of anxiety.
NURSING DIAGNOSIS
1. Deficient fluid volume related to diarrhea (gastrointestinal losses, inadequate intake as evidence by
dry skin.
2. Risk for infection related to microorganisms invading GI tract as evidence by increased body
temperature.
3. Impaired skin integrity related to irritation caused by frequent, loose stools as evidence by redness,
itching.
NURSING INTERVENTIONS
1. Deficient fluid volume-
- Assess for signs of dehydration and the amount of fluids taken by mouth, and to assess the frequency
and amount of stool losses.
- Treat the patient according to treatment Plan A, B, C.
- Administer ORS in small quantities at frequent intervals.
- For hospitalized child accurate weight must be obtained, as well as careful monitoring of intake and
output.
- The child may be placed on parental fluid therapy with nothing by mouth for 12 to 48 hrs.
2. Prevention of infection-
- Check the temperature at a regular interval.
- Keep informing parents regarding child’s progress.
- Teach caregiver how to dispose soiled diapers, cloths and bed linen and about proper hand washing
technique.
3. Impaired skin integrity
- Protect the skin of the diaper region from excoriation.
- Rectal temperatures are avoided because they stimulate the bowel, increasing passage of stool.
- Apply antiseptic powder after cleaning the area.
HEALTH EDUCATION:
During hospitalization During discharge
1. Advice the mother to continue 1. Advice the mother and family members
breastfeeding during diarrheal period. regarding improvement of sanitation, clean water
2. Educate the mother regarding disposal of supply, adequate sewage disposal system and
soiled diapers. protection of food from exposure to bacterial
3. Informed the parents about treatment plan. contamination.
4. Teach the mother how to check dehydration. 2. Advice the mother and family members to
complete immunization.
3. Advice for follow-up care.

PROGNOSIS: Diarrhea can be dangerous in newborns and infants. In small children, severe diarrhea
lasting just a day or two can lead to dehydration. Because a child can die from dehydration within a few
days, the main treatment for diarrhea in children is rehydration.