1. Alteration in Elimination
Encopresis/Enuresis
Diarrhea and Vomiting

2. Encopresis 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. Encopresis Assessment Treatment Diagnosis Anticipatory Guidance
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. Enuresis--Treatment Conditioning Therapy Retention Control Training
Waking Schedule
Behavior Modification Therapy
Drug Therapy
Tricyclic antidepressants
Anticholenergics
Ditropan
Desmopressin (DDAVP)

6. 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

7. 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 between mEq/L (nl)
Rapid Rate Replacement is OK for Isotonic & Hypotonic NOT for HYPERTONIC

8. Level & Types of Dehydration
Hypotonic = Na+ BELOW normal
H2O Loss < Electrolyte Loss
Hypertonic = Na+ ABOVE normal
H2O Loss > Electrolyte Loss (common with burns)
SEE HANDOUTS “A” & “B”
See Tables 28-2 & 28-4 on p (9th ed.)
See Tables 24-3 & 24-4 on p. 953 (10th ed.)
Level/Degrees of Dehydration p (9th ed.), p. 953 (10th ed.)
Mild = Up to 5% of body weight lost
Moderate = Between 5-9% of body weight lost
Severe = 10-15% of body weight lost

9. 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

10. Nursing Assessment Degree, type of dehydration
Identify causative agent
Initial & ongoing evaluations of the following:
Na and other electrolytes (K+), pH
Weight—measures insensible fluid loss
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 as appropriate to age.
Any 2 of the 4: cap refill of >2 sec, absent tears, dry mucous membranes, ill appearance.

11. Nursing Assessment (cont)
Accurate I & O
Measure ALL Output
Emesis, void (weigh diapers), stool, NG suction drainage
Urine 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

12. 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 ml/kg of ORS

13. Oral Rehydration Therapy
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!!!

14. 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

15. 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

16. 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 oral-fecal route

17. Diarrhea---Causes
Acute Table 29-1, p (9th ed.); Box 26-4, p (10th ed.)
Viral = Rotovirus
Bacterial
Shigella
E-coli
Salmonella
C. difficile
Vibrio cholerae
Toxins (bad food)
Overfeeding
Systemic Infection
Irritable Bowel Syndrome
Lasts 3 weeks
Chronic Box 29-4 p.1093 (9th ed.); Box 26-6, p (10th ed.)
Malabsorption
Allergic Reactions
Immunodeficiencies
Endocrine
Parasites (Giardia)
Motility disorders
Hirschsprung’s Ds.
Inflammatory Bowel
Crohn’s disease
Ulcerative Colitis

18. 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,

19. 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+)

20. 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

21. 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 6-54 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.

22. 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

23. Vomiting Assessments 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
Diagnosis
Routine labs
Hct/Hgb
CBC
Electrolytes
Na+, K+
BUN
Creatinine
TCO2
U/A
Physical Assessment

24. 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

25. 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

26. That’s It