CONTROL OF DIARRHEAL DISEASES BRIEF HISTORY A 2 years old client was admitted at RHU bambang with chief complaint

t of loose bowel movement for more than ten times a day prior to consultation and was attended by the physician with the following physical assessment of hyperactive bowel sound, soft abdomen and diagnosed with acute gastroenteritis.

DIARRHEA

Diarrhea is defined by the World Health Organization as having three or more loose or liquid stools per day, or as having more stools than is normal for that person
Is an increased frequency of bowel movements ( more than three per day), an increased amount of stool ( more than 200 g/day) , and altered consistency ( increased liquidity) of stool Usually associated with urgency, peri anal discomfort, incontinence or a combination of these factors Any condition that causes increased intestinal secretions, decreased mucosal absorption or alatered motility can produce diarrhea o Irritable bowel syndrome , inflammatory bowel disease and lactose intolerance are frequently the underlying disease that causes diarrhea

Oral rehydration solutions (ORS) with modest amounts of salts and zinc tablets are the treatment of choice and have been estimated to have saved 50 million children in the past 25 years. In cases where ORS is not available, homemade solutions are often used
o

Acute Diarrhea Most often associated with infection and is usually self limitiIng lasting up to 7 to 14 days Chronic Diarrhea Persists for more than 2 to 3 weeks and may return sporadically Causes of Diarrhea Medications o Thyroid hormone replacement, stool softeners and laxatives , antibiotics, chemotheraphy , antiarrythmics, anti hypertensive, magnesium-based anatacids Viral or Bacterial infectious processes o Dysentery, shigellosis , food poisoning , Norwalk virus Nutritional and Malabsorptive disorders ( celiac disease) , anal sphincter defect, Zollinger Ellison syndrome, paralytic ileus, intestinal obstruction and AIDS

Classification or Types of Diarrhea

Secretory o Usually high volume diarrhea , often associated with bacterial toxins and neoplasm, it is caused by increased production and secretion of waterand electrolytes by the intestinal mucosa into the intestinal lumen. Osmotic o Occurs when water is pulled into the intestines by the osmotic pressure of unabsorbed particles, slowing the reabsorption of water . It is caused by lactase deficiency, pancreatic dysfunction or intestinal hemorrhage. Malabsorptive o Combines mechanical and biochemical actions, inhibiting effective absorption of nutrients manifested by markers of malnutrition that include hypoalbuminemia . Low serum albumins lead to intestinal mucosa swelling and liquid stool. Infectious o Exudative o Is caused by changes in mucosal integrity , epithelial loss or tissue destruction caused by radiotheraphy or chemotheraphy.

Clinical Manifestations Increased frequency and fluid contest of stools, abdominal cramps, distention, intestinal rumbling ( borborygmus) anorexia and thirst. Painful spasmodic contraction of the anus and ineffective straining ( tenesmus) may occur with defecation. Other symptoms depend on the cause and severity of diarrhea but are related to dehydration and to fluid and electrolyte imbalances o

Watery stools are the characteristics of disorders of the small bowel , where as loose, semisolid stools are associated more often with the disorders of the large bowel

COMPLICATIONS OF DIARRHEA Potential for cardiac dysrhythmias because of significant fluid and electrolyte loss ( especially loss of potassium ) Urinary output of less than 30 ml per hour for 2 o 3 consecutive hours, muscle weakness, paresthesia, hypotension, anorexia and drowsiness with a potassium level of less 3.5 mEq/L GERONTOLOGIC CONSIDERATIONS Can become dehydrated quickly and develop low potassium levels ( hypokalemia ) as a result of diarrhea

Observe for clinical manifestations of muscle weakness, dysrhtmias or decreased peristaltic motility that may lead to paralytic ileus. Older patient taking digitalis ( digoxin ) must be aware of how quickly dehydration and hypokalemia can occur with diarrhea . o Teach the patient to recognize the symptoms of hypokalemia because low levels of potassium potentiate the action of digitalis , leading to digitalis toxicity NURSING MANAGEMENT Assessment includes abdominal auscultation and palpation for tenderness. Inspection of the abdomen, Mucuos membranes and skin is important to determine hydration status. Stool samples are obtained for testing. It is also necessary to assess the perianal area. During an episode of acute diarrhea o Encourage bed rest and intake of liquids and foods low in bulk until the acute attack subsides o When patient is able to tolerate food intake , recommend a bland diet of semi solid and solid foods o Intrsuct to avoid caffeine, carbonated beverages, and very hot and very cold foods because they stimulate intestinal motility MANAGEMENT

Probiotics
Recently, some strains of probiotics (defined as live microorganisms that when ingested in adequate doses, provide a benefit to the host) have been found to be effective as an adjunct when treating children with acute diarrhea. Data from well-conducted randomized controlled trials on efficacy of probiotics in children with diarrhea are definitely positive. They consistently show a statistically significant benefit and moderate clinical benefit of a few, now well-identified probiotic strains (mostly Lactobacillus GG and Saccharomyces boulardii but also Lactobacillus reuteri) in the treatment of acute watery diarrhea (primarily rotaviral) in infants and young children in developed countries. Such a beneficial effect seems to result in a reduction of the duration of diarrhea of about one day and seems to be exerted mostly on rotaviral diarrhea, with much less evidence of efficacy in invasive bacterial diarrhea. The effect is not only strain-dependent but also dose-dependent, with doses of at least 5 billion/d being required for effect.[10] Shortening the duration of diarrhea by one day may not appear to be hugely beneficial. However, in consideration of the high morbidity of the infection, even a reduction of this order is indeed desirable because it affords considerable savings in terms of loss of working days and direct health costs. Furthermore, probiotics may reduce the risk of spreading rotavirus infection by shortening diarrhea duration and volume of watery stool output and by reducing the fecal shedding of rotavirus, and they have been found useful in preventing the dissemination of hospital-acquired diarrheas.

Diet

Breastfed infants with acute diarrhea should be continued on breast milk without any need for interruption. In fact, breastfeeding not only has a well-known protective effect against the development of enteritis, it also promotes faster recovery and provides improved nutrition. This is even more important in developing countries, where withdrawal of breastfeeding during diarrhea has been shown to have a deleterious effect on the development of dehydration in infants with acute watery diarrhea.

Bananas, rice, applesauce, and toast diet o A banana, rice, applesauce, and toast (BRAT) diet was introduced in the United States in 1926 and has enjoyed vast popularity. However, no evidence shows that this diet is useful, and its poor protein content may be a contraindication; therefore, it is not recommended. o A strong body of evidence now suggests that resuming the prediarrhea diet is perfectly safe and must be encouraged, obviously respecting any (usually temporary) lack of appetite. Lactose ingestion o Although rotavirus can cause secondary transient lactose intolerance, this finding is believed to be generally not clinically relevant; use lactose-containing formulas in all individuals with diarrhea.

In an incident of worsening of diarrhea proven to be secondary to a clinically important lactose malabsorption in infants positive for rotavirus, a very transient use of lactose-free formulas (5-6 d) can be considered