A. Definition1. Diarrhea is a bowel movement (defecation), with feces as a liquid or semi-liquid, thus the water content in the stools more than normal defecation once ie 100-200 ml (Hendarwanto, 1999).
2. According to WHO (1980) defecate diarrhea is watery or liquid for more than three times a day.
3. Diarrhea is the state of the frequency of bowel movements more than 4 times in infants and more than 3 times in children with watery stool consistency, can be green or can be mixed with mucus and blood (Ngastiyah, 1997).
4. Infectious diarrhea is a condition where children frequent bowel movements with watery stools as a result of an infection. (Www.medicastore, 2007)
B. Etiology
1. Factors infection
a) enteral infections, gastrointestinal infections are a major cause of diarrhea, including infectious bacteria (Vibrio, E. coli, Salmonella, Shigella, Campylobacter, Yersinia, Aeromonas, etc.), viral infections (enterovirus, adenovirus, Rotavirus, Astrovirus, etc.) , parasitic infections (E. hystolytica, G.lamblia, T. hominis) and fungi (C. albicans).
b) Parenteral Infection; an infection outside the digestive system that can cause diarrhea, such as: acute otitis media, tonsillitis, bronchopneumonia, encephalitis and so forth.
2. Factors malabsorption
Carbohydrate malabsorption: disaccharides (lactose intolerance, maltose and sucrose), monosaccharides (glucose intolerance, fructose and galactose). Lactose intolerance is the most important cause of diarrhea in infants and children. In addition it is also possible malabsorption of fat and protein.
3. Food factor:
Diarrhea may occur due to eating spoiled food, toxic and allergic to certain foods.
4. Psychological Factors
Diarrhea may occur due to psychological factors (fear and anxiety)
C. Pathophysiology
The basic mechanism that causes diarrhea are:
1. Impaired osmotic
The presence of food or substance that can not be absorbed to cause osmotic pressure in the intestinal lumen increased resulting in a shift of water and elektroloit into the intestinal lumen. Fill cavity of excessive bowel will stimulate the intestines to release it causing diarrhea.
2. Impaired secretion
Due to certain stimuli (eg toxins) in the intestinal wall will increase secretion, water and electrolytes into the intestinal lumen and diarrhea because arises subsequent increase in intestinal luminal contents.
3. Gut motility disorders
Hiperperistaltik will cause a reduction in the gut a chance to absorb food, causing diarrhea. In contrast when intestinal peristalsis decreases will result in excessive growth of bacteria, subsequent diarrhea can occur as well.
D. Clinical manifestations
a. Throw up
b. Fever
c. Abdomen Pain
d. Mucous membranes of the mouth and dry lips
e. Sunken Fontanel
f. Weight loss
g. No appetite
h. Weak
In children with diarrhea without dehydration (dehydration).
The signs:
· Berak liquid 1-2 times a day
· Vomiting does not exist
· Haus no
· Still want to eat
· Still want to play
In children with diarrhea with dehydration mild / moderate.The signs:
· Berak liquid 4-9 times daily
· Sometimes vomiting 1-2 times a day
· Sometimes heat
· Haus
· Not want to eat
· Agency limp lethargic
In children with diarrhea with severe dehydration.
The signs:
· Berak continuous liquid
· Vomiting continuously
· Once Haus
· Sunken eyes
· Dry lips and blue
· Cold hands and feet
· Very weak
· Not want to eat
· Not willing to play
· Not urinating 6 hours or more
· Sometimes with convulsions and high fever.
Acute diarrhea due to infection can be accompanied by vomiting, fever, tenesmus, hematoschezia, and abdominal pain or stomach cramps. The most fatal result of diarrhea that lasted long without adequate rehydration is the cause of death from dehydration or hypovolemic shock biochemical disturbances in the form of ongoing metabolic acidosis. Seseoran a lack of fluids will feel thirst, weight loss, sunken eyes, dry tongue, cheek bones appear more prominent, decreased skin turgor and the voice becomes hoarse. Complaints and symptoms caused by the depletion of isotonic water.
Because the loss of bicarbonate (HCO3), the comparison with carbonic acid is reduced resulting in decreased blood pH, which stimulates the respiratory center so that the frequency of respiration increased and deeper (Kussmaul breathing).
Cardiovascular disorders at this stage can be a severe hypovolemic shock with signs of rapid pulse (> 120 x / min), blood pressure drops to be measured. The patient became restless, pale face, cold akral and sometimes cyanosis. Because of potassium deficiency on acute diarrhea can also arise cardiac arrhythmias.
Decrease in blood pressure will cause renal perfusion decreased to arise oliguria / anuria. If this situation does not immediately diatsi will arise complications of acute renal tubular necrosis, which means a state of acute renal failure.
E. COMPLICATIONS
a. Dehydration
b. Hypovolemic shock
c. Convulsions
d. Bacteremia
e. Mal nutrition
f. Hypoglycemia
g. Intolerance secondary to intestinal mucosal damage.
From complications of gastroenteritis, dehydration level can be classified as follows:
a) mild dehydration
Loss of fluid 2-5% of body weight with the clinical picture is less elastic skin turgor, hoarseness, the patient has not fallen on the state of shock.
b) Moderate Dehydration
Loss of fluid 5-8% of body weight with poor skin turgor clinical picture, hoarseness, people with pre-shock pulse falling fast and deep.
c) Dehydration Weight
Loss of fluid 80-10% of bedrat body with such clinical signs of dehydration is coupled with decreased consciousness, apathy to coma, stiff muscles until cyanosis.
F. EXAMINATION SUPPORT
Diagnosis based on symptoms and physical examination.
Blood tests conducted to determine electrolyte levels and white blood cell count. To determine the causative organism, carried breeding of stool samples. Laboratory examination. Stool examination. Examination of acid-base balance disorders in the blood Astrup, if possible by determining the pH balance of blood gas analysis or Astrup, if possible. Examination urea and creatinine levels to determine kidney puncture.
duodenal intubation electrolyte examination to determine the micro-organism or parasite, quantitatively, mainly performed in patients with chronic diarrhea.
G. MANAGEMENT
1. In children with diarrhea without dehydration (dehydration).
Action:
• To prevent dehydration, give children drink more than usual
· ASI (Air Susu Ibu) forwarded
· Food is given as usual
· When state child gain weight, immediately take it to the nearest health center
2. In children with diarrhea with dehydration mild / moderate
Action:
· Give ORS
· ASI (Air Susu Ibu) forwarded
· Forward feeding
· We recommend a soft, easily digested and does not stimulate
· When there are no immediate changes to get it back to the nearest health center
3. In children with diarrhea with severe dehydration
Action:
· Immediately taken to the hospital / health center with treatment facilities
· ORS and breast milk can still be continued for a drink
Giving dose ORS.
- Under 1 year
The first 3 hours then 0.5 cups 1.5 cups every time diarrhea
- Under 5 years (young children)
3 hours 3 cups first, then 1 cup every time diarrhea
- Children above 5 yrs
The first 3 hours 6 cups, 1.5 cups each time subsequent diarrhea
- Children above 12 yrs & Adult
3 hours 12 cups first, then 2 cups each time diarrhea (1 cup: 200 cc)
MANAGEMENT PRINCIPLES
The management of acute diarrhea due to infection in adults consists of:
a. Rehydration therapy as a top priority.
b. Good work directed to identify the cause of the infection.
c. Provide symptomatic treatment
d. Provide definitive therapy.
1. Rehydration therapy as a top priority.
There are 4 important things to provide quick and accurate rehydration, namely:
1) Type of liquid you want to use.
At this time Ringer Lactate fluid is a liquid because it provides more choice in the market even though the amount of potassium low potassium levels when compared with faeces. If RL is not available to diberiakn isotonic NaCl (0.9%) which should be added with 1 ampoule Nabik 50 ml of 7.5% on every one liter of isotonic NaCl. In the initial state of mild acute diarrhea can be given fluids to prevent dehydration with ORS consequences.
2) The amount of fluid that would be given.
In principle, the amount of fluid replacement is about to be given shall be in accordance with the amount of fluid that comes out from the body. Total loss of body fluid can be calculated in a way / formula: Measure Plasma BJ.
Fluid requirements are calculated using the formula:
BJ Plasma - 1.025
------- X BB x 4 ml
0,001
a) Method Pierce
Based on the clinical situation, namely:
· Mild diarrhea, fluid requirements = 5% x kg BW
· Moderately severe illness, the need for fluid = 8% x kg BW
· Mild diarrhea, fluid requirements = 10% x kg BW
b) Method Daldiyono
Based on the scoring of clinical conditions as follows:
· Thirst / vomiting = 1
· Systolic BP 60-90 mm Hg = 1
· Systolic BP <60 mm Hg = 2 · Frequency pulse> 120 x / min = 1
· Awareness apathetic = 1
· Awareness somnolen, sopor or coma = 2
· Frequency of breathing> 30 x / min = 1
· Facies cholerica = 2
· Vox cholerica = 2
· Decreased skin turgor = 1
· Washer women's hand = 1
· Cold extremities = 1
· Cyanosis = 2
· Age 50-60 years = 1
· Age> 60 years = 2
Needs fluid =
Score --- x 10% x kg x 1 ltr
3) The entrance or way of giving fluids
Routes of fluid in adults include oral and intravenous. ORS solution with a composition ranging from 29 g glucose, 3.5 g NaCl, 2.5 g and 1.5 g KCl NaBik stiap liter given orally in mild diarrhea as the first attempt and also after initial rehydration to maintain hydration.
4) Schedule for fluid administration
Rehydration schedule is calculated based on the initials BJ plasma or scoring system given within 2 hours in order to achieve optimal rehydration as soon as possible. Schedule for the second phase of a liquid that is for the clock to-3 based on the loss of fluid during the initial phase 2 hours earlier. Thus, rehydration is expected to complete by the end of the 3rd hour.
2. Good work directed to identify the cause of the infection.
To find out the cause of infection is usually associated with the clinical state of diarrhea but the exact cause can be identified through examination of stool culture is accompanied by a complete urine and stool examination complete. Disorders of fluid balance, electrolyte and acid base clarified through a complete blood count, blood gas analysis, electrolytes, urea, creatinine and plasma BJ. If there is a high fever and systemic infection are suspected bile culture examination, Widal, malaria blood smear and serological Helicobacter jejuni is highly recommended. Special inspections such as serology amoeba, fungi and Rotavirus usually catch up after seeing the results of a filter.
Clinically diarrhea due to acute infection were classified as follows:
1) Koleriform, diarrhea with feces mainly consists of liquids only.
2) Disentriform, diarrhea with feces mixed with thick mucus and sometimes blood.
Investigations that have been alluded to above can be directed in accordance manifestation klnis diarrhea.
3. Provide symptomatic treatment
Symptomatic therapy should really be considered losses and profits. Antimotilitas Loperamid will aggravate the gut such as diarrhea caused by entero-invasive bacteria because it extended the contact time of bacteria with the intestinal epithelium should be quickly eliminated.
4. Provide definitive therapy.
Causal therapy can be given to the infection:
1) Cholera-eltor: Tetracyclines or co-trimoxazole or chloramphenicol.
2) V. parahaemolyticus,
3) E. coli, no specific therapy memerluka
4) C. perfringens, specific
5) A. aureus: chloramphenicol
6) Salmonellosis: Ampicillin or co-trimoxazole or quinolones such as Ciprofloxacin group
7) Shigellosis: Ampicillin or chloramphenicol
8) Helicobacter: Erythromycin
9) Amebiasis: metronidazole or Trinidazol or Secnidazol
10) Giardiasis: quinacrine or metronidazole or Chloroquineitiform
11) Balantidiasis: Tetracyclines
12) Candidiasis: Mycostatin
13) Virus: Symptomatic and supportive
Diarrhea diseases can be transmitted through:
- The use of unclean milk bottles
- Use of contaminated water sources
- Dispose of water disembarang place
- Contamination of food by insects (flies, cockroaches, etc.) or by dirty hands.
NURSING CONCEPTS IN CHILDREN WITH DIARRHEA
A. ASSESSMENT.
Systematic assessment includes data collection, data analysis and problem determination. The collection of data obtained by means of intervention, observation, psikal assessment. Assess the data by Cyndi Smith Greenberg, 1992 are:
a. The identity of the client.
b. History of nursing.
c. Prefix attack: Originally whiny child, anxiety, increased body temperature, anorexia and diarrhea occur.
d. The main complaint: the more liquid Faeces, vomit, if losing a lot of water and electrolytes occur symptoms of dehydration, body weight decreased. In infants sunken fontanel large, tone and reduced skin turgor, mucous membranes of the mouth and lips dry, CHAPTER frequency more than 4 times with watery consistency.
e. Past medical history.
f. History of the illness, history of immunization.
g. Family psychosocial history.
Treated will be a stressor for the child itself and for the family, the anxiety increases if the parents do not know the procedure and treatment of children, after realizing her illness, they will react with anger and guilt.
h. Basic needs.
i. The pattern of elimination: will change the BAB more than 4 times a day, BAK few or rare.
j. Nutritional pattern: beginning with nausea, vomiting, anopreksia, causing weight loss patients.
k. The pattern of sleep and rest will be disturbed because of abdominal distension that would cause discomfort.
l. Pattern hygiene: bathing habits every day.
m. Activities: will be disturbed because the body is very lamah and the pain due to abdominal distension.
n. Physical examination.
o. Psychological examination: general condition seemed weak, kesadran composmentis to coma, high body temperature, rapid and weak pulse, breathing rather quickly.
p. Systematic examination:
· Inspection: sunken eyes, large fontanel, mucous membranes, mouth and dry lips, weight loss, anal redness.
· Percussion: presence of abdominal distension.
· Palpation: less elastic skin turgor
· Auscultation: bowel sounds hearing.
q. Examination tinglkat growth and development.
Diarrhea in children will experience disruption due to child dehydration so that body weight decreased.
r. Investigations.
Stool examination, complete blood and doodenum intubation is to find the cause of the quantitative and qualitative.
B. Nursing Diagnosis
1. Lack of fluid volume bd excessive loss through feces and vomiting and restricted intake (nausea).
2. Changes in nutrition less than body requirements bd disturbance nutrient absorption and increase intestinal peristalsis.
3. Pain (acute) bd hiperperistaltik, irritation perirektal fissure.
4. Anxiety bd family child health status change
5. Lack of family knowledge about the condition, prognosis and therapy needs bd limited exposure information, misinterpretation of information and / or cognitive limitations.
6. Bd child separation anxiety with parents, new environments.
C. NURSING PLAN
1. Lack of fluid volume b / d of excessive loss through feces and vomiting and restricted intake (nausea)
Objective: The need will be met with the criteria liquid no signs of dehydration
Intervention & Rational
- Give fluid according to the oral and parenteral rehydration program Monitor intake and output. R /: In an effort rehydration to replace fluids that come out with feces
- Provide information to determine the status of fluid balance fluid needs replacement.
- Assess vital signs. R /: signs / symptoms of dehydration and laboratory test results
- Assessing hydration status. R /: electrolyte and acid base balance
- Collaboration execution of definitive therapy. R /: Delivery of drugs causally important after the cause of diarrhea in mind
2. Changes in nutrition less than body requirements b / d disturbance nutrient absorption and increase intestinal peristalsis.
Objective: The nutritional requirements are met by the criteria of an increase in fallow body
Intervention & Rational
- Maintain bed rest and limitation of activity during the acute phase. R /: Lowering the metabolic needs
- Maintain the status of fasting during the acute phase (based therapy programs.) R /: restricted diet by mouth may be determined during the acute phase to reduce peristalsis resulting in nutritional deficiencies
- Immediately begin oral feeding after the client's condition allows. R /: Delivery of food as soon as may be necessary after the client's clinical condition allows.
- Assist the implementation of appropriate feeding with diets R /: Meeting the nutritional needs of clients
- Collaboration parenteral nutrition as indicated. R /: resting the gastrointestinal work and overcome / prevent further nutritional deficiencies
3. Pain (acute) b / d hiperperistaltik, irritation perirektal fissure.
Objectives: Pain is reduced to the criteria there are no blisters on perirektal
Intervention & Rational
- Set a comfortable position for the client, for example with knee flexion. R /: Lowering the surface tension and reduce abdominal pain
- Do activities transfer to give a sense of comfort such as back massage and warm compresses abdomen. R /: Improve relaxation, shifting the focus of attention kliendan improve coping skills
- Clean the area with mild soap and anorectal airsetelah defecation and provide skin care. R /: Protecting skin from feces acidity, preventing irritation
- Collaboration of analgesics and / or anticholinergic drugs as indicated. R /: Analgesic as an anti-pain and anticholinergic agents to reduce the spasm of the GI tract can be given according to clinical indication
- Assess complaints of pain by Visual Analog Scale (scale 1-5), changes in the characteristics of pain, verbal and non verbal clues. R /: Evaluating the development of pain to determine the next intervention
4. Family anxiety b / d of changes in health status of children.
Objective: The family expressed anxiety is reduced.
Intervention & Rational
- Encourage clients to discuss family concerns and provide feedback on appropriate coping mechanisms. R /: Help identify the cause of anxiety and alternative solutions to problems
- Emphasize that anxiety is a common problem that occurs in the elderly clients whose children have the same problem. R /: Helps to reduce stress by knowing that the client is not the only people who experience such problems
- Create a calm environment, show warm-hearted and sincere attitude in helping klien.R /: Reduce external stimuli that can trigger an increase in anxiety
5. Lack of family knowledge about the condition, prognosis and therapy needs b / d of exposure information is limited, incorrect interpretation of information and / or cognitive limitations.
Goal: Families will understand about the disease and treatment of children, and able to demonstrate the care of children at home.
Intervention & Rational
- Assess client's readiness to follow the family learning, including knowledge about the disease and child care. R /: Effectiveness of learning is influenced by physical and mental readiness as well as prior background knowledge.
- Explain about his disease process, causes and consequences of disruption of daily needs of everyday activities. R /: An understanding of this issue is important to increase the participation of the client families and families in the process of client care
- Explain the purpose of drug administration, dosage, frequency and route of administration and possible side effects. R /: Increase understanding of the client and family participation in treatment.
- Explain and demonstrate how to perineal care after defecation. R /: Improve client independence and family control of self-care needs of children.
6. Bd child separation anxiety with parents, of environmental newly
Objective: Anxiety is reduced by the criteria of children showing signs of comfort
Intervention & Rational
- Encourage the family to always visit clients and participate in perawatn performed. R /: Preventing stress associated with separation
- Give a touch and talk to children as often as possible. R /: Providing a sense of comfort and reduce stress
- Perform sensory stimulation or play therapy in accordance with ingkat client development. R /: Improving the optimum growth and development.
D. EVALUATION
Evaluation is measuring the success of the extent to which that goal is reached. If there is not reached then conducted the review, then prepared a plan, then implemented in the implementation of nursing evaluated plainly, if the evaluation is not resolved then made the first step again and so on until the destination is reached.
· Volume of fluid and electrolytes returned to normal as needed.
· Nutritional needs are met in accordance kebutuhantubuh.
· Skin integrity returns to normal.
· Comfort are met.
· Knowledge ancestry increases.
· Anxious in client is resolved.
Reference : dharmahusadakediri.blogspot.com
