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Diarrhea

Created by :

Emmi Valentina Pardede Po.71.20.1.11.020 IIB.1

KEMENTERIAN KESEHATAN REPUBLIK INDONESIA POLITEKNIK KESEHATAN PALEMBANG JURUSAN KEPERAWATAN 2012-2013

Diarrhea Food nutrients are absorbed in the small intestine. The waste is pushed into the large intestine (bowel) where water is removed. The resulting faeces is stored temporarily within the rectum then passed out of the body through the anus. Faeces are usually firm, moist and easy to pass. Diarrhoea is the frequent passing of loose, watery and unformed faeces. The most common cause of diarrhoea is an infection of the intestines, such as gastroenteritis or food poisoning. Viruses are responsible for most cases. The intestinal lining becomes irritated and inflamed, which hinders the absorption of water from food waste. In severe cases, the intestinal lining may even leak water. Generally, acute diarrhoea resolves after a day or two. Chronic diarrhoea, which lasts four weeks or more, can be caused by a range of conditions that affect the intestines including inflammatory bowel disease (IBD). Causes of chronic diarrhoea Some of the causes of chronic diarrhoea include: Coeliac disease which reduces the intestines ability to absorb food Chronic constipation the bowel is blocked by hard, impacted faeces, but some liquids manage to seep past the blockage. This condition, called spurious or overflow diarrhoea, is more common in the elderly Hormone disorders such as diabetes or hyperthyroidism (overactive thyroid gland) Cancer such as bowel cancer Inflammatory bowel disease including ulcerative colitis and Crohns disease Irritable bowel syndrome symptoms include abdominal pain, bloating, and alternating constipation and diarrhoea Lactose intolerance the inability to digest the milk sugar lactose Medications including antibiotics, antacids that contain magnesium, laxatives, and drugs for treating hypertension (high blood pressure) and arthritis. Diagnosis of diarrhoea : Successful treatment depends on diagnosing the cause. Investigations may include: Medical history Physical examination Blood tests Laboratory analysis of stool sample Colonoscopy (the insertion of a slender instrument into the anus so that the doctor can look at the bowel lining).

Treating diarrhoea Diarrhoea will usually clear up without treatment after a few days because the immune system fights off the infection. In children, the symptoms of diarrhoea will usually pass within five to seven days. In most cases, diarrhoea does not last more than two weeks. In adults, diarrhoea usually improves within two to four days. However, it can last longer depending on the particular type of infection involved. For example: rotavirus three to eight days norovirus about two days campylobacter and salmonella infections two to seven days giardiasis several weeks

While waiting for your diarrhoea to pass, you can ease your symptoms by following the advice outlined below. This advice also applies if you are pregnant or breastfeeding and have diarrhoea. Diarrhea What is the best way to treat diarrhea? Most children with mild diarrhea can continue to eat a normal diet including formula or milk. Breastfeeding can continue. If your baby seems bloated or gassy after drinking cow's milk or formula, call your pediatrician to discuss a temporary change in diet. Special fluids for mild illness are not usually necessary. Special fluids for moderate illness Children with moderate diarrhea may need special fluids. These fluids, called electrolyte solutions, have been designed to replace water and salts lost during diarrhea. They are extremely helpful for the home management of mild to moderately severe illness. Do not try to prepare these special fluids yourself. Use only commercially available fluidsbrand-name and generic brands are equally effective. Your pediatrician or pharmacist can tell you what products are available. If your child is not vomiting, these fluids can be used in very generous amounts until the child starts making normal amounts of urine again. ReminderDo's and Don'ts Do

Watch for signs of dehydration which occur when a child loses too much fluid and becomes dried out. Symptoms of dehydration include a decrease in urination, no tears when baby cries, high fever, dry mouth, weight loss, extreme thirst, listlessness, and sunken eyes. Keep your pediatrician informed if there is any significant change in how your child is behaving. Report if your child has blood in his stool. Report if your child develops a high fever (more than 102F or 39C). Continue to feed your child if she is not vomiting. You may have to give your child smaller amounts of food than normal or give your child foods that do not further upset his or her stomach. Use diarrhea replacement fluids that are specifically made for diarrhea if your child is thirsty.

Don't

Try to make special salt and fluid combinations at home unless your pediatrician instructs you and you have the proper instruments. Prevent the child from eating if she is hungry. Use boiled milk or other salty broth and soups. Use "anti-diarrhea" medicines unless prescribed by your pediatrician.

. Drink fluids It is important to drink plenty of fluids to avoid dehydration. Take small, frequent sips of water. You are more likely to become dehydrated if you are also vomiting. It is very important for babies and small children not to become dehydrated. Give your child frequent sips of water, even if they are vomiting. A small amount is better than none. Fruit juice or fizzy drinks should be avoided because they can make diarrhoea worse in children. Contact your GP immediately if your child shows signs of dehydration, such as:

irritability or drowsiness passing urine infrequently pale or mottled skin cold hands and feet becoming increasingly unwell

Children at increased risk of dehydration Your child's risk of becoming dehydrated is increased if they: are younger than one year old (particularly if they are less than six months) are younger than two years old and had a low birth weight have had more than six episodes of diarrhoea in the last 24 hours have vomited more than twice in the last 24 hours have been unable to hold down fluids have suddenly stopped breastfeeding If you are breastfeeding or bottlefeeding your baby and they have diarrhoea, you should continue to feed them as normal. While breastfeeding, you should increase your fluid intake to help maintain your milk supply. You may be able to give your baby oral rehydration solution (ORS) if they become dehydrated. However, check with your pharmacist or health visitor before giving rehydration fluids to young babies and infants. Read more about diarrhoea and vomiting in children. Oral rehydration solutions (ORS) Your GP or pharmacist may suggest using an oral rehydration solution (ORS) if you or your child are at risk from the effects of dehydration. For example, if you: are 60 years of age or over are frail have a pre-existing health condition, such ascardiovascular disease Rehydration drinks usually come in sachets available from your local pharmacist without a prescription. They are dissolved in water and replace salt, glucose and other important minerals that are lost through dehydration. Rehydration drinks do not cure diarrhoea but they can help treat or prevent dehydration. Avoid using homemade salty or sugary drinks. Children Your GP or pharmacist may recommend giving your child an ORS if they are dehydrated or at risk of becoming dehydrated. The usual recommendation is for your child to drink an ORS each time they have an episode of diarrhoea. The amount they should drink will depend on their size and weight. Your pharmacist will be able to advise you about this. The manufacturer's instructions should also give information about the recommended dose. Eating Opinion is divided over when and what you should eat if you have diarrhoea. However, most experts agree that you should eat solid food as soon as you feel able to. Eat small, light meals, avoiding fatty, spicy or heavy foods. If you feel you cannot eat, it should not do you any harm. Make sure you continue to drink fluids and eat as soon as you feel able to.

Children If your child is dehydrated, do not give them any solid food until they have drunk enough fluids. Once they have stopped showing signs of dehydration, they can start eating their normal diet. If your child is not dehydrated, offer them their normal diet. If they refuse to eat, continue to give them fluids and wait until their appetite returns. Medicines Antidiarrhoeal medicines Antidiarrhoeal medicines may help reduce your diarrhoea and shorten how long it lasts by around 24 hours. However, they are not usually necessary unless shortening the duration of your diarrhoea helps you get back to essential activities sooner. Loperamide is the preferred antidiarrhoeal medicine because it has been shown to be effective and causes few side effects. Loperamide slows down the muscle movements in your gut so that more water is absorbed from your stools. This makes your stools firmer and they are passed less frequently. Some antidiarrhoeal medicines can be bought from a pharmacy without a prescription. Check the patient information leaflet that comes with the medicine to find out whether it is suitable for you and what dose you should take. Ask your pharmacist for advice if you are unsure. Do not take antidiarrhoeal medicines if there is blood or mucus in your stools and/or you have a fever (high temperature). Contact your GP. Children should not be given antidiarrhoeal medicines. Painkillers Painkillers will not cure your diarrhoea, but you can take the recommended dose of paracetamol or ibuprofen if you have a fever or a headache. Do not take ibuprofen if you have asthma or stomach, liver or kidney problems. If necessary, you can give your child liquid paracetamol or ibuprofen. Check the patient information leaflet to find out whether it is suitable for your child. Children under 16 years of age should not be given aspirin. Antibiotics Treatment with antibiotics is not recommended for diarrhoea if the cause is unknown. This is because antibiotics: will not work if the diarrhoea is caused by a virus can cause unpleasant side effects can become less effective at treating more serious conditions if they are repeatedly used to treat mild conditions Antibiotics may be recommended if you have very severe diarrhoea and a specific type of bacteria has been identified as the cause. They may also be recommended if you have a pre-existing risk factor that makes you more vulnerable to infection, such as a weakened immune system. Hospital treatment Occasionally, hospital treatment may be needed if you or your child is seriously dehydrated due to diarrhoea. Treatment will involve administering fluids and nutrients directly into a vein (intravenously).

Management: General A. Goal Prevent dehydration Stay ahead of Diarrhea B. Maintain oral hydration See Pediatric Diarrhea Fluid Replacement Rapidly initiate rehydration protocol at the onset of illness (within first 4-5 hours) Gastrointestinal rest is a dangerous myth Delaying drinking risks further dehydration C. Probiotics Preparations: Lactobacillus, Saccharomyces bouladii Efficacy: Reduces Diarrhea by 1 day Effect requires continued use (eliminated within 2 hours of ingestion)Antiinflammatory effect and degrades dietary antigens D. Antidiarrheals Loperamide (Imodium) Has been used in older children and adults, but with only limited supporting evidence Contraindicated under age 2 years and not routinely recommended overall in children 2. Lomotil Do not use at any age due to potential risks E. Antibiotics 1. Not indicated in most cases 2. Trend toward use of antibiotics in adult Diarrhea is not mirrored in children Age restrictions on many antimicrobial agents used for Diarrhea Avoid Fluoroquinolones under age 18 years Avoid Septra under age 2 months Avoid Tetracycycline under age 9 years Avoid Bismuth Subsalicylate (Pepto Bismol) under age 12 years Contains Aspirin and increases risk of Reye's Syndrome

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Management: Diarrhea in infants A. See Pediatric Diarrhea Fluid Replacement B. Avoid supplementing with water (risk of Hyponatremia) C. Formula fed infants Continue full strength, standard milk-based formula Half-strength formula is unlikely to offer an advantage over full strength formula Soy Formula (e.g. Isomil) is unlikely to offer an advantage over standard milk-based formula

D. Breast fed infants Consider supplementing with Oral Rehydration Solution between Breast feeds Continue Breast Feeding through the Diarrhea Avoid stopping Breast Feeding for mild or moderate Diarrhea Consult physician if considering discontinuing Breast Feeding Management: Diarrhea in Children over age 6 months A. Increase clear fluid intake : See Pediatric Diarrhea Fluid Replacement B. Unrestricted diets are generally tolerated 1. BRAT diet is based on the use of tolerated, constipating foods However it is considered too limiting and not recommended by AAP Applesauce Rice Bananas or carrots (strained for infants)

2. Some foods may potentially worsen Diarrhea and observe for adverse effects 3. Milk products (see lactase below) Raw fruits and vegetables Bran and beans Spices Juices with high sugar content

If Watery stools recur after Diarrhea had been improving

Recovering child normally has 2-3 mushy stools per day Consider using constipating solids on BRAT diet Consider avoiding milk products for a few additional days C. Risk of transient Lactase Deficiency with Diarrhea Usually no need to avoid lactose Observe for signs of Lactose Intolerance Large, foamy, explosive stools Stools with acid pH and reducing substances D. Sample menu of well tolerated foods after Diarrhea (however restrictions typically not needed) 1. Day 1 Saltines White toast with jelly Rice Applesauce Bland soups 2. Day 2 Lean meats Soft boiled eggs Noodles 3. Day 3 Soft fruits and vegetables Pears Carrots Potatoes

Cheese Cottage cheese Yogurt 4. Day 4 Regular diet Consider delaying milk and ice cream introduction for several days

Prevention A. Pediatric Diarrhea is very contagious B. Wash hands after each diaper change C. Avoid mess Close diapers tightly Cover diapers with plastic pants Complications: Other A. See Pediatric Dehydration B. See Diaper Rash

Bibliography DuPont HL, Ericsson CD. Prevention and treatment of travelers diarrhea. N Engl J Med. 1993 Jun 24;328(25):18217. Bhutta ZZ. Acute gastroenteritis in children. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds.Nelson Textbook of Pediatrics. 19th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 332. Schiller LR, Sellin JH. Diarrhea. Diarrhea. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger & Fordtrans Gastrointestinal and Liver Disease. 9th ed. Philadelphia, Pa: Saunders Elsevier; 2010:chap 15.