DIARRHEA

JANHVI SHUKLA
NURSING TUTOR
DIVINE INSTITUTE OF NURSING AND
PARAMEDICAL SCIENCES
Definition
Diarrhea is defined as increase in frequency and change in consistency of stools,
passage of liquids(or)watery stools more than 3 times a day per 24 hours, resulting
in excessive loss of fluid and electrolytes in stool .
Diarrhea is the body's way of ridding itself of germs, and most episodes last a few
days to a week. Diarrhea often occurs with fever, nausea, vomiting, cramps, and
dehydration.
Diarrhea: Loose, watery stools occurring more than three times in one day is a
common problem that usually lasts a day or two and goes away on its own without
any special treatment.
Diarrhea can be of sudden onset and lasting for less than two weeks (acute) or
persistent (chronic).
 Types
Acute diarrhea:
It is defined as a sudden increase in frequency a change inconsistency stool often causal by
infectious agent in the tract. It terminates within a14 days.

Chronic diarrhea:
It is defined as an increase in stool frequency, increased water contents with duration of
more than 14 days, caused by chronic condition such as malabsorption syndrome,
inflammatory bowel disease (IBD).
Subtypes
Protracted diarrhea: It is defined as persistence of diarrhea beyond 2weeks with attract
liquid stool per day with no weight gain weight loss and which the conventional time of
treatment has failed.
Intractable diarrhea of infancy: It is a syndrome that occurs on the first few months of life
Persist for longer than 2 weeks with no recognized pathogenesis secretary to treatment.
Persistent diarrhea: It persists for more than 2 weeks, it carries a much higher use for
mortality to main nutritional malabsorption.
Osmotic diarrhea: It follows ingestion of absurdly absorbed solute because an inherent
character of the solute (magnesium phosphate, alcohol) (or) a small bowel defect (lactose in
lactase deficiency). It tends to be waters acidic with reducing substances.
Motility diarrhea: It is associated with increased (writable bowel syndrome) or delayed
motility (dentinal pseudo-obstruction).
Mode of transmisson
■ Dirty hands
■ Contaminated food and water
■ Some pets
■ Direct contact with fecal matter (i.e. from dirty diapers or the toilet)
■ Feco-oral route either by contaminated food and water
Etiologies
■ Intestinal infection with various organisms
• Bacteria: Diarrheagenic Escherichia coli, Campylobacter jejuni, Vibrio cholera, Shigella
species, V. Parahaemolyticus, Nontyphoidal Salmonellae, Clostridium difficile, Yersinia
enterocolitica and Bacteroides fragilis.
• Virus: Rotavirus, Norovirus (calicivirus), Adenovirus, Astrovirus, and Cytomegalovirus.
• Protozoa: Cryptosporidium parvum, Giardia intestinalis, Entamoeba histolytica,
Isosporabelli and Cyclospora cayetanen.
• Helminths: Strongyloides stercoralis and Angiostrongylus costaricensis.
■ Systemic infections like urinary tract infection or otitis media
■ Certain drugs and food allergy
■ Malabsorption
■ Malnutrition
■ Immunocompromised state like HIV infection
Warning signs
Certain symptoms are cause for concern. They include:
■ Signs of dehydration, such as decreased urination, lethargy, crying without tears,
extreme thirst, and a dry mouth.
■ Blood in stool
■ Pain in the abdomen and when touched, extreme tenderness
■ Bleeding in the skin (seen as tiny reddish purple dots [petechiae])
Pathophysiology
Loss of fluid from body

Shift of fluid from extracellular to

intracellular

Decrease blood volume

Weak pulse, low BP and cold extremities

Clinical features
Degree of dehydration
Diagnostic evaluation
■ History collection
■ Physical examination
■ Stool culture
■ Blood tests: Blood tests can be helpful in ruling out certain diseases.
■ Fasting tests: To find out if a food intolerance or allergy is causing the diarrhea, the
doctor may ask you to avoid lactose (found in milk products), carbohydrates, wheat, or
other foods to see whether the diarrhea responds to a change in diet.
■ Sigmoidoscopy
■ Colonoscopy.
■ Rotavirus antigen tests: False negative rate is approximately 50% and false positive
results occur, particularly in the presence of blood in the stools. Adenovirus (serotype 40
and 41) antigen can be detected by enzyme immunoassay.
Cont.
■ White cell count is usually normal but may be raised in some bacterial infections.
■ Renal function and electrolytes: Occasionally, a protein-losing enteropathy may lead to
a low serum albumin.
■ Other investigations: It will depend on the individual situation. Further investigations
may include endomysial antibodies (celiac disease), intestinal biopsy (celiac disease or
inflammatory bowel disease) and sweat test (cystic fibrosis) if indicated, especially if Jon
diarrhea persists.
Assessment of dehydration
Dehydration is excess loss of fluid more than fluid intake. Causes of dehydration are as
following:
■ Excessive fluid loss: Vomiting, diarrhea, excessive sweating in fever or hot climate,
abdominal surgery, hemorrhage, nasogastric drainage, excessive use of laxatives and
aggressive diuretic therapy
■ Inadequate fluid intake: Dysphagia, coma, and environmental conditions
■ Others: Polyuria, diabetes mellitus or insipidus, fistula, cystic fibrosis, burn injury
Composition of ORS
Management of diarrhea and
dehydration
■ Plan A for child with no dehydration
Need home treatment only. Mother should be counselled to follow 4 rules of home
treatment.
RULE 1- give more fluids than usual to prevent dehydration
• Breastfeed frequently and for longer at each fed
• If the child is exclusively breastfed, give ORS or clean along with the breast milk
• If the child is not exclusively breastfed, give one or more of the following ORS food
based fluid or clean water
• Teach the mother how to prepare ORS. ORS is essential to give if diarrhea worsens
• Fluid intake- up to 2 years of age give 20-100ml after each loose stool and in between
them and for 2 years or more, give 100-200 ml after each loose stool and in between
them.
Cont.
• Give frequent small sips from a cup
• If the child vomits, wait 10 min. then continue, but more slowly.
• Continue giving extra fluid until the diarrhea stops
RULE 2 – give zinc supplements
• Amount- up to 6 months – ½ tablet per day for 14 days and 6 moths or more- 1 tablet per
day for 14 days.
• For infants dissolves the tablets in a small amount of expressed breast milk, ORS or
clean water, in a small cup or spoon.
RULE 3- continue feeding
• Up to 6 months of age: Breastfeed at least 8 times in 24 hrs.
• 6 months to 1 year: Breastfeed and 3 meals per day; if not breast fed 5 meals per day.
• 1-2 years: Breastfeed + 5 meals per day.
Cont.
• Above 2years: Family foods 3 meals per day with 2 times nutritious foods between
meals.
• Offer cereal, potato mixed with legumes, vegetables, fish or chicken and freshly
prepared ground or mashed foods.
• Provide fresh fruit juice, coconut milk, or mashed banana to provide potassium.
• After diarrhea stops, give an extra meal each day for 2 weeks, until the child's weight
before illness is attained.
RULE 4: Return to health worker
• Advise to take the child to a healthcare worker if he or she does not get better in 3 days
or develops any of the following: Many watery stools, fever, poor eating or drinking,
marked thirst, repeated vomiting and blood in the stools.
Cont.
• Advise to visit health centre if the child has any of the following problems: persistent
diarrhea, acute or chronic ear infection, and any other illness like pneumonia, measles.
■ Plan B for child with some dehydration
 Give ORS in the health centre until the skin pinch is normal, the thirst is over, the child
is calm.
o Four hours of rehydration are usually necessary for this.
o If the patient wants more than the recommended amount, give more. For infants below 6
months who are not breastfed, give 100-200 mL clean water in addition during this
period.
 Observe the child closely and help give the ORS.
o Show how much solution to give and how to give to the child.
o Give frequent small sips from a cup. If the child vomits, wait 10 min. Then continue, but
more slowly.
o Continue breastfeeding whenever the child wants.
Cont.
 After 4 hours
o Reassess the child and select plan A, B or C to continue treatment.
o If there are no signs of dehydration, shift to Plan A.
o If signs indicate that some dehydration is still present, repeat Plan B and reassess 2 hrs later or if signs
indicate that severe dehydration has occurred, shift to Plan C.
 If the mother must leave before completing treatment:
o Show her how to prepare ORS solution at home.
o Show her how to continue with the rest of the 4hr treatment at home.
o Supply enough ORS packets to complete rehydration and to continue for 2 more days as recommended in
plan A.
 Explain the 4 rules in Plan A for treating her child at home:
• Give ORS or other fluids continuously until diarrhea stops.
• Give the zinc supplement for 10-14 days.
• Continue feeding.
•
Cont.
■ Plan C for child with severe dehydration
Children with severe dehydration should be treated by IV dirp as soon as possible and admitted
to the hospital or health centre. If a health facility with an IV is not within 30 min, the use of an
NG tube is recommended.
1. If IV fluid can be given immediately:
• Start IV fluids immediately. If the child is able to drink, give ORS by mouth until the drip is
set up.
• Give 100 ml/kg Ringer's lactate solution (or, if not available, normal saline) as following:
 Infants (under 12 months): First give 30 mL/ kg in 1 hour and give rest 70 mL/kg in next 5
hours
 Children (12 months up to 5 years): First give 30 mL/kg in 30 min and give rest 70 mL/kg
in next 2 1/2hrs.
• Repeat once if radial pulse is still very weak or not detectable.
• Reassess the child every 1-2 hrs. If hydration status is not improving, give the IV drip more
rapidly.
Cont.
• Also give ORS (about 5 mL/kg/hr) as soon as the child can drink, usually after 3-4 hrs
(infants) or 1-2 hrs (children).
• Reassess an infant after 6 hrs and a child after 3 hrs and choose the appropriate plan (A,
B, or C) to continue treatment.
 If IV treatment available nearby (within 30 min):
• Refer urgently to hospital for IV treatment.If the child can drink, provide the mother
with ORS solution and advise to give frequent sips during the trip.
• If IV therapy is not possible immediately insert nasogastric tube and start rehydration by
nasogastric tube or by mouth with ORS: give 20 mL/kg/hr for 6 hrs (total of 120 mL/kg).
Reassess the child every 12 hours
• If not improving after 3 hrs refer to the hospital urgently for IV therapy.
• After 6 hrs, reassess the child and select the appropriate plan (A, B, or C) to
continue treatment.