Download Alteration in Elimination

Encoporesis/Enuresis
Diarrhea and Vomiting
Encoporesis
Involuntary Passage of Feces

 Primary
 Child NEVER
achieved bowel
control by 4 y/o
 Secondary
 Fecal Incontinence
occurring after 4 y/o
 More in Boys than
Girls
 Causes
 Constipation
 Stress
 Myelomeningocele
 CP
 Hypothyroidism
Encoporesis
 Treatment
 Assessment
 History
 Doing a Dance
 Self-Esteem
 Diagnosis
 X-ray to r/o
 Hirschsprung’s
Disease
 Congenital GI anomaly
 Hi-Fiber Diet
 Lubricants
 Behavior Therapy
 Anticipatory Guidance

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Normal Patterns
Trx Regime
Counseling
Behavior Modification
Enuresis
Bedwetting 2x/week; for 3 mos.; at least 5 y/o
 Primary
 Never been dry
 Secondary
 Incontinent after have
established continence
 Causes
 Sleep Theory
 Functional Bladder
Capacity
 Nocturnal Polyuria
Theory

 Assessment
 Urgency
 Diagnosis
 History and Physical
 Functional Bladder
Capacity
 History of Toilet Training
Enuresis--Treatment

 Conditioning Therapy
 Retention Control Training
 Waking Schedule
 Behavior Modification Therapy
 Drug Therapy
 Tricyclic antidepressants
 Anticholenergics
 Ditropan
 Desmopressin (DDAVP)
Fluid Imbalance Specific to Peds

Greater need for water
More vulnerable to alterations in balance
Don’t adjust quickly
ECF > ICF at birth w/ greater relative content
of extracellular Na & Cl
Thus, more susceptible to dehydration and
fluid overload
Metabolic rate 2-3x > adults
BSA > adults; neonate 5x greater
Immature kidney function;↓ability to conc. or
dilute urine
Types of dehydration

Isotonic – most common in peds
H2O Loss = Electrolyte Loss
Major loss from ECF→ ↓plasma volume →
↓circulating blood volume → ↓to skin,
muscles, kidneys → hypovolemic SHOCK
Plasma Na stays bet 137-147 mEq/L (nl)
Level & Types of Dehydration

 Hypotonic = Na+ BELOW normal
 H2O Loss < Electrolyte Loss
 Hypertonic = Na+ ABOVE normal
 H2O Loss > Electrolyte Loss
 SEE HANDOUTS “A” & “B”
 See Tables 28-2 & 28-4 on p. 1056-60(9th ed.)
 Level/Degrees of Dehydration p. 1059 (9th ed.)
 Mild = Up to 5% of body weight lost
 Moderate = Between 5-9% of body weight lost
 Severe = 10-15% of body weight lost
Fluid Imbalance Assessment
 Observation & history of recent symptoms

 Diarrhea, vomiting, fever, renal disease, medications, trauma,
extensive surgery, extensive burns, ketoacidosis
 Take a good history: drugs, allergy, diet, travel, pet contact,
contact w/others who have been sick, etc.
 Most Important → General Appearance & Behavior!
 Urinary output
 Mucus membranes
 Skin Turgor
 Infant fontanels
 Weight change
 Pale, cool dry skin
 ↑Pulse, ↑resp, ↓BP, cap refill >2sec → shock
Nursing Assessment

 Degree, type of dehydration
 Identify causative agent
 Initial & ongoing evaluations of the following:
 Na and other electrolytes (K+), pH
 Weight
 Same scale, same clothes, same time of day
 For each 1% wt loss, 10 ml/kg fluids lost
 Changing sensorium; Response to stimuli
 Integumentary changes (elasticity & turgor)
 Heart rate (pulse - weak & rapid)
 Sunken eyes
 Sunken fontanels
 Any 2 of the 4: cap refill of >2 sec, absent tears, dry
mucous membranes, ill appearance.
Nursing Assessment
(cont)

 Accurate I & O
 Measure ALL Output
 Emesis, void (weigh diapers), stool, NG suction drainage
 Specific Gravity
 Increase = Concentrated Urine
 Know Norms for frequency of voiding
 1 y/o = every 1-2 hours
 Toddlers = every 3 hours
 Older children = 4 – 5 times/day during day
 Include parents in prescribed plan of care
Diarrhea – Medical
Management

 Oral Rehydrating Solutions (ORS)
 Rehydralyte, Pedialyte, Infalyte, WHO
 Mild Dehydration
 50 ml/kg in 4 hours
 Moderate Dehydration
 100 ml/kg in 4 hours
 Severe Dehydration
 IV’s (Ringer’s Lactate/NS)
 40 ml/kg/hr until pulse and LOC are normal
 Then 50-100 ml/kg of ORS
Oral Rehydration Therapy

 Recommended for mild to moderate dehydration
 Oral Rehydration Solution (ORS): 75-90 mMol Na+, 111139mMol glucose – Pedialyte RS, Rehydralyte for the
1st 4-6 hours.
 Then – 30-60 mMol Na+, 111-139mMol glucose –
Pedialyte,Resol, Lytren, Infalyte – for the next 18-24hrs.
@ 1-2 oz/# divided into freq. feedings;
 Older child: 1-2 oz q hr.
 It is no longer recommended to withhold food/fluids
for 24º after onset of diarrhea or use the BRAT diet!!!
Water Intoxication
(water overload)

 Ingest excessive amts of fluids develop concurrent ↓
serum Na+ accompanied by CNS symptoms.
 CNS irritability, somnolence, HA, vomiting, diarrhea,
gen. seizures, may have edema or be dehydrated but
looks well hydrated.
 Causes: acute IV water overload, too rapid dialysis, tap
water enemas, feeding incorrectly mixed formulas
(diluted to make it last longer), excess water ingestion, too
rapid reduction of glucose levels in diabetic ketoacidosis;
those with CNS infections may retain excessive amts of
H2O if administered hypotonic sol. rapid reduction in
Na+H2O overload.
 Problem: ↓GFR is incapable of compensation to excrete
the excesses fast enough, ADH levels are not able to
compensate
Gastrointestinal Disorders

Diarrhea: ↑ in stool frequency and ↑ in water
content. Varies by severity, duration,
presence of blood or mucous, age of child, &
nutritional status.
Acute Diarrheal Disease: Leading cause of
illness in children < 5yrs; 400 die ea yr;
caused by infectious agents including viral,
bacterial and parasitic pathogens.
Results in dehydration, electrolyte imbalance,
hypovolemic shock, & even death
Acute Infectious Gastroenteritis

2nd only to URI as cause of childhood illness
Self-limiting and benign
Bacterial seen in summer and fall
Viral (rotovirus)
 seen in winter
 After a URI
 Daycare setting
Spread by person-to-person contact and oralfecal route
Diarrhea---Causes
 Acute Table 29-1, p. 1091  Chronic Box 29-4 p.1093

 Viral = Rotovirus
 Malabsorption
 Bacterial
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Shigella
E-coli
Salmonella
C. difficile
Vibrio cholerae
 Toxins (bad food)
 Overfeeding
 Systemic Infection
 Irritable Bowel Syndrome
 Lasts 3 weeks
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Allergic Reactions
Immunodeficiencies
Endocrine
Parasites (Giardia)
Motility disorders
 Hirschsprung’s Ds.
 Inflammatory Bowel
 Crohn’s disease
 Ulcerative Colitis
Differential Diagnosis

 Sugar intolerance: watery, explosive stools
 Fat malabsorption: foul-smelling, greasy, bulky stools;
stearrhea
 Enzyme deficiency/protein intolerance: develops after
intro of cow’s milk, fruits, cereal
 Bacterial gastroenteritis/IBS: presence of
neutrophils/RBC’s
 Protein intolerance/parasitic infection: presence of
eosinophils
 Cultures: performed if blood or mucus is present, or Sx’s
are severe, travel to developing country and
polymorphonuclear leukocytes are found in stool.
 ELISA: used to confirm presence of rotavirus,
Diarrhea—Differential Diagnosis
 Other

 Fever and abdominal cramps = Shigella
 Abrupt onset = Toxins, seen in Food Poisoning
 > 4 stools/day
 No vomiting prior to diarrhea onset
 Hx of antibiotic use: test stool for C. Difficle toxin.
 Persistent diarrhea: test for ova & parasites when
bacterial, viral cultures are negative.
 Labs
 Stool Culture, Stool Exam (WBC’s, RBC’s, Fat content)
 Blood- ↑Hct, ↑BUN + Creatinine if ↓renal circulation,
Acid/Base Balance; Electrolytes (NA+ and K+)
Clinical Manifestations

Labs: ↑Hct, ↑BUN + Creatinine if ↓renal
circulation, Acid/Base Balance; Electrolytes
Metabolic Acidosis
 Loss of Na+ and HCO3 in stool
 Impaired Renal Function
 ↑ Lactic Acid formation
 Ketosis from Catabolism
Shock---in severe Cases
Altered K+ levels, K+ lost is stool
 Body conserving Na+ and H+I in cells  move K
out
Other Diarrheal Diseases

Chronic Diarrheal Disease: caused by
malabsorption syndromes, inflammatory
bowel disease, immune deficiency, food
allergy, lactose intolerance, etc.
Chronic Nonspecific Diarrhea: irritable
colon of childhood/toddler’s diarrhea; ages 654 mos; loose stools w/undigested food
particles. Grows normally w/ no evidence of
malnutrition
Intractable Diarrhea of Infancy: occurs first
few months of life, refractory to treatments.
May need cont. tube feedings or parenteral
nutrition. Can result in death.
Vomiting
 Forceful ejection of gastric contents thru the mouth. CNS
control. Accompanied by nausea and retching.

 Malrotation: chronic and intermittent episodes
 Bowel obstruction: green bilious
 Poor gastric emptying/high obstruction: curdled,
mucus, fatty foods several hrs after ingestion
 GI bleeding: coffee ground appearance
 Associated symptoms: fever and diarrheainfection;
constipationanatomic or functional obstruction;
forcefulpyloric stenosis
 Localized abd. pain→ appendicitis, PUD, pancreatitis
 Headache and change in LOC→ CNS related
 Well recognized response to psychological stress;
can be a learned behavioral response
 Assessments
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Vomiting
 Diagnosis

Color, consistency, odor
Amount
Frequency
Forcefulness
Relationship to feeding
History
 Allergy, Illness
 w/ or w/o diarrhea
 Child’s behavior in
association with vomiting
 Routine labs
 Hct/Hgb
 CBC
 Electrolytes

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Na+, K+
BUN
Creatinine
TCO2
 U/A
 Physical Assessment
Vomiting

 Assess abdomen and hydration status, presence of
pain, constipation, diarrhea, or jaundice.
 Assess relationship of vomiting to meals, specific foods
or behavior
 When cause of vomiting determined then interventions
are decided
 Sm, freq feeding of fluid or food preferable, position
to prevent aspiration.
 Brush or rinse the mouth to remove HCl from the teeth,
monitor fluids & electrolyte status
Vomiting (cont’d)

 Complications: dehydration, electrolyte
disturbances, malnutrition, aspiration, Mallory-Weiss
sydrome
 Antiemetics: can be given if cause is known and
vomiting is anticipated; Motion sickness dimenhydrinate (Dramamine) before a trip
 Generally vomiting is self limiting requiring no
specific tx
That’s It
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