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Encoporesis/Enuresis Diarrhea and Vomiting.  Encoporesis Involuntary Passage of Feces  Primary  Child NEVER achieved bowel control by 4 y/o  Secondary.

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Presentation on theme: "Encoporesis/Enuresis Diarrhea and Vomiting.  Encoporesis Involuntary Passage of Feces  Primary  Child NEVER achieved bowel control by 4 y/o  Secondary."— Presentation transcript:

1 Encoporesis/Enuresis Diarrhea and Vomiting

2  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

3  Encoporesis  Assessment  History  Doing a Dance  Self-Esteem  Diagnosis  X-ray to r/o  Hirschsprung’s Disease  Congenital GI anomaly  Treatment  Hi-Fiber Diet  Lubricants  Behavior Therapy  Anticipatory Guidance  Normal Patterns  Trx Regime  Counseling  Behavior Modification

4  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

5   Conditioning Therapy  Retention Control Training  Waking Schedule  Behavior Modification Therapy  Drug Therapy  Tricyclic antidepressants  Anticholenergics  Ditropan  Desmopressin (DDAVP) Enuresis--Treatment

6   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 Fluid Imbalance Specific to Peds

7   Isotonic – most common in peds  H 2 O Loss = Electrolyte Loss  Major loss from ECF→ ↓plasma volume → ↓circulating blood volume → ↓to skin, muscles, kidneys → hypovolemic SHOCK  Plasma Na stays bet mEq/L (nl) Types of dehydration

8   Hypotonic = Na + BELOW normal  H 2 O Loss < Electrolyte Loss  Hypertonic = Na + ABOVE normal  H 2 O Loss > Electrolyte Loss  SEE HANDOUTS “A” & “B”  See Tables 28-2 & 28-4 on p (9 th ed.)  Level/Degrees of Dehydration p (9 th ed.)  Mild = Up to 5% of body weight lost  Moderate = Between 5-9% of body weight lost  Severe = 10-15% of body weight lost Level & Types of Dehydration

9   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 Fluid Imbalance Assessment

10   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

11   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 Nursing Assessment (cont)

12   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 ml/kg of ORS Diarrhea – Medical Management

13   Recommended for mild to moderate dehydration  Oral Rehydration Solution (ORS): mMol Na+, mMol glucose – Pedialyte RS, Rehydralyte for the 1st 4-6 hours.  Then – mMol Na+, mMol glucose – Pedialyte,Resol, Lytren, Infalyte – for the next 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!!! Oral Rehydration Therapy

14   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 Water Intoxication (water overload)

15   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 Gastrointestinal Disorders

16   2 nd 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 oral- fecal route Acute Infectious Gastroenteritis

17  Diarrhea---Causes  Acute  Acute Table 29-1, p  Viral = Rotovirus  Bacterial  Shigella  E-coli  Salmonella  C. difficile  Vibrio cholerae  Toxins (bad food)  Overfeeding  Systemic Infection  Irritable Bowel Syndrome  Lasts 3 weeks  Chronic  Chronic Box 29-4 p.1093  Malabsorption  Allergic Reactions  Immunodeficiencies  Endocrine  Parasites (Giardia)  Motility disorders  Hirschsprung’s Ds.  Inflammatory Bowel  Crohn’s disease  Ulcerative Colitis

18   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, Differential Diagnosis

19   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 + ) Diarrhea—Differential Diagnosis

20   Labs: ↑Hct, ↑BUN + Creatinine if ↓renal circulation, Acid/Base Balance; Electrolytes  Metabolic Acidosis  Loss of Na + and HCO 3 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 Clinical Manifestations

21   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 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. Other Diarrheal Diseases

22   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 Vomiting

23   Assessments  Color, consistency, odor  Amount  Frequency  Forcefulness  Relationship to feeding  History  Allergy, Illness  w/ or w/o diarrhea  Child’s behavior in association with vomiting  Diagnosis  Routine labs  Hct/Hgb  CBC  Electrolytes  Na +, K +  BUN  Creatinine  TCO 2  U/A  Physical Assessment

24   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

25   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 Vomiting (cont’d)

26  That’s It


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