Kamis, 05 Mei 2011
A. DEFINITIONS.
According Haroen N, S. Suraatmaja and Asdil PO (1998), defecation watery diarrhea is more than 3 times a day with or without blood or mucus in the stool.
Meanwhile, according to Betz CL & LA Sowden (1996) diarrhea is a condition of gastric mucosa or intestinal inflammation.
According Suradi & Rita (2001), diarrhea is defined as a situation where the loss of excess fluid and electrolytes that occur because the frequency of bowel movements with one or more watery or liquid form.
So diarrhea can mean a condition, bowel movements are not normal ie more than 3 times a day with the consistency of watery stools may be accompanied or without blood or mucus as a result of inflammation of the stomach or intestine.
B. CAUSE
According Haroen NS, Suraatmaja and PO Asnil (1998), from the point of the pathophysiology, causes of acute diarrhea can be divided into two groups, namely:
1. Secretory diarrhea (secretory diarrhoe), caused by:
a) Viral infection, pathogenic germs and apatogen as shigella, salmonella, E. Coli, vibrio group, B. Cereus, clostridium perfarings, stapylococus aureus, comperastaltik small intestine caused by food chemicals (eg food poisoning, food is spicy, sour terlalau), psychological disorders (fear, nervousness), neurological disorders, cold, allergy, and so forth.
b) Deficiency Imum especially SIGA (secretory imonol bulin A) which resulted in a doubling of bacteria / fungi flata intestine and especially canalida.
2. Osmotic diarrhea (osmotic diarrhea) caused by:
a) malabsorption of food: carbohydrates, fats (LCT), protein, vitamins and minerals.
b) Less calories of protein.
c) Infants with low birth weight and newborn.
Meanwhile, according Ngastiyah (1997), the cause of diarrhea can be divided into several factors:
1. Factors infection
a) Infection enteral
Is a major cause of diarrhea in children, which include: bacterial infections, viral infections (enteovirus, polimyelitis, echo coxsackie virus). Adeno virus, Rota virus, astrovirus, etc.) and parasitic infections: worms (Ascaris, Trichuris, oxyuris, strongxloides), protozoa (Entamoeba histolytica, giardia lamblia, trichomonas homunis) mushrooms (canida albicous).
b) parenteral infection is an infection beyond the means of digestion of food such as acute otitis media (OMA), tonsillitis / tonsilofaringits, bronkopeneumonia, encephalitis, and so forth. This situation is mainly found in infants and children under two (2) years.
2. Factors malaborsi
Malaborsi carbohydrates, fats and proteins.
3. Food factor
4. Psychological factors
C. Pathophysiology
The basic mechanism that causes diarrhea is the first osmotic disruption, due to the presence of food or substance that can not be absorbed to cause osmotic pressure rises in the intestinal cavity, resulting in a shift of water and electrolytes into the intestinal cavity, the contents of this excessive intestinal cavity will stimulate the intestines to release causing diarrhea.
Both due to certain stimuli (eg toxins) in the intestinal wall will increase once the water and electrolytes into the intestinal cavity and subsequent diarrhea arises because there is an increasing content of the gut cavity.
Third motalitas intestinal disorders, the occurrence will result in reduced opportunities hiperperistaltik intestine to absorb food, causing diarrhea, decreased intestinal peristalsis vice versa if the bacteria will cause excessive arise which can cause diarrhea as well.
In addition, diarrhea can also occur, due to the entry of microorganisms living in the intestine after successfully passing the stomach acid barrier, these microorganisms multiply, then remove toxins and these toxins occur due to hypersecretion which in turn will cause diarrhea.
While the consequences of diarrhea will occur a few things as follows:
1. Water loss (dehydration)
Dehydration occurs because the loss of water (output) more than revenue (input), is the cause of death in diarrhea.
2. Acid-base balance disturbances (metabik acidosis)
This occurs because the loss of Na-bicarbonate with feces.Fat metabolism is not perfect so dirty objects buried in the body, the accumulation of lactic acid due to anorexia network. Acidic metabolic products increased because it can not removed by the kidneys (oliguria occurs / anuria) and the transfer of Na ions from extracellular fluid into the intracellular fluid.
3. Hypoglycemia
Hypoglycemia occurs in 2-3% of children suffering from diarrhea, more frequently in children who previously had suffered from the CTF. This occurs because of the interference storage / supply of glycogen in the liver and absorption interference glukosa.Gejala hypoglycaemia will occur if the blood glucose level decreased to 40 mg% in infants and 50% in children.
4. Nutritional disorder
The occurrence of weight loss in a short time, this is caused by:
- Food is often stopped by their parents for fear of diarrhea or vomiting that grow great.
- Although milk forwarded, often given with spending and dilute the milk was given for too long.
- Food provided often can not be digested and absorbed properly because of hiperperistaltik.
5. Impaired circulation
As a result of diarrhea can occur shock (shock), hypovolemic, resulting in decreased tissue perfusion and occurs hypoxia, acidosis gain weight, can lead to brain hemorrhage, decreased consciousness, and if not addressed client will die.
D. Clinical manifestations DIARRHEA
1. At first the child / baby whiny anxiety, body temperature may be increased, decreased appetite.
2. Frequent bowel movements with the consistency of liquid or watery stools, often accompanied wial and wiata.
3. Stool color changed to greenish because of mixed bile.
4. The anus and surrounding areas because of frequent difekasi blisters and feces become more acidic due to the number of lactic acid.
5. There are signs and symptoms of dehydration, clear skin turgor (skin elistitas decreased), the crown and sunken eyes and dry mucous membranes accompanied by weight loss.
6. Changes in vital signs, pulse and respiration, blood pressure fell rapidly, rapid heart rate, the patient is very weak, decreased consciousness (apathetic, samnolen, sopora komatus) as a result hipovokanik.
7. Diuresis decrease (oliguria to anuria).
8. In case of metabolic acidosis client will look pale and breathing fast and deep. (Kusmaul).
D. DIAGNOSTIC EXAMINATION
1. Stool examination
a) macroscopic and microscopic
b) pH and sugar content in feces
c) If necessary to hold the test bacteria
2. Examination of acid-base balance disorders in the blood, to determine the pH and alkaline reserve and blood gas analysis.
3. Examination urea and creatinine levels to determine kidney function.
4. Checking electrolyte levels, especially Na, K, Calcium and Phosphate.
E. COMPLICATIONS
1. Dehydration (mild, moderate, severe, hypotonic, isotonic or hypertonic).
2. Hypovolemic shock.
3. Hypokalemia (with symptoms mekorismus, hiptoni muscle, weakness, bradycardia, changes in the electro kardiagram).
4. Hypoglycemia.
5. Introleransi secondary lactose, as a result of lactase deficiency due to damage to the mucosal villi, the small intestine.
6. Seizures, especially in hypertonic dehydration.
7. Energy malnutrition, protein, because in addition to diarrhea and vomiting, the patient also suffered from hunger.
F. DEGREE OF DEHYDRATION
According to the amount of fluid lost, the degree of dehydration can be divided based on:
a. Weight loss
1) No dehydration, if there is a weight loss of 2.5%.
2) Dehydration occurs when light from 2.5 to 5% weight loss.
3) Severe dehydration in case of weight loss 5-10%
b. Score Mavrice King
Body parts
Value examined for symptoms found
0 1 2
General condition
Skin elasticity
Eye
Large fontanel
Mouth
Pulse rate / eye Healthy
Normal
Strong <120 Restless, Apathy whiny, sleepy hollow Slightly Slightly Slightly less concave Dry Medium (120-140) Delirious, coma, or shock is less concave Very Very Dry & cyanosis concave Weak> 40
Information
- If the score 0-2 mild dehydration
- If dehydration was scored 3-6
- If given the value 7-12 severe dehydration
c. Clinical symptoms
Clinical symptoms of clinical symptoms
Light Medium Heavy
General condition
Awareness
Thirst
Circulation
Pulse
Respiration
Respiratory
Skin
Uub
Good (CM)
+
N (120)
Ordinary
Slightly concave
Slightly concave
Ordinary
Normal
Normal
Nervous
+ +
Fast
Smartish
Concave
Concave
Somewhat less
Oliguric
Slightly dry
Apathy-coma
+ + +
Very fast
Kusz maull
Very concave
Very concave
Less so
Anuri
Dry / acidosis
G. FLUID NEEDS CHILDREN
The body normally consists of 60% water and 40% solids such as proteins, fats and minerals. In children the income and expenditure should be balanced, if terganmggu correction must be made possible with parenteral fluids, fluid balance mathematically in children can be described as follows:
Age Requirement Weight Total/24 hours Fluids / Kg BB/24 hour
3 days
10 days
3 months
6bulan
9 months
1 year
2 years
4 years
6 years
10 years
14 years
18 years 3.0
3.2
5.4
7.3
8.6
9.5
11.8
16.2
20.0
28.7
45.0
54.0 250-300
400-500
750-850
950-1100
1100-1250
1150-1300
1350-1500
1600-1800
1800-2000
2000-2500
2000-2700
2200-2700 80-100
125-150
140-160
130-155
125-165
120-135
115-125
100-1100
90-100
70-85
50-60
40-50
Whaley and Wong (1997), Haroen NS, PO Asnil Suraatmaja and 1998), Suharyono, Aswitha, Mist (1998) and the Department of Health child UI FK (1988), states that the amount of fluid lost by the degree of dehydration in children under 2 year are as follows:
Degree of Dehydration PWL CWL NWL Number
Light
Medium
Weight 50
75
125 100
100
100 25
25
25 175
200
250
Description:
PWL: Previous Water loss (ml / kg)
NWL: Normal Water losses (ml / kg)
CWL: Concomitant Water losses (ml / kg)
H. Pathways
Factor Factor infection malabsorption peristaltic Disorders
The osmotic pressure ↑ Endotoxin Hiperperistaltik Hipoperistaltik
mucosal damage
The shift intestinal bacterial growth in liquid food was not
and electrolytes to be absorbed was
Endotoxin excessive intestinal lumen
Hypersecretion of fluid
and electrolyte
The contents of the bowel lumen ↑
Stimulus spending
Hiperperistaltik
Diarrhea
Hearing Impaired balance electrolyte fluid balance
Less volume of fluid (dehydration), Hyponatremia
Hypokalemia
Dizziness, weakness, fatigue, syncope, anorexia, decrease in serum chloride
nausea, vomiting, thirst, oliguric, skin turgor
less, dry oral mucosa, eyes and postural hypotension, cold skin, sunken fontanel, the increase in temperature tremor
body, weight loss seizure, stimuli sensitive, rapid and weak heartbeat
(Horne & Swearingen, 2001; Smeltzer & Bare, 2002
I. MANAGEMENT
1. Medical
Basic treatment of diarrhea are:
a. Fluid, fluid type, how to give fluids, the amount of administration.
1) Liquid orally
In clients with mild dehydration and was given orally in the form of liquids which are NaCl and NaHCO3 and glucose.For acute diarrhea and cholera in children above 6 months 90 meg Sodium content / l. In children under 6 months with mild to moderate dehydration sodium levels 50-60 meg / l.Complete formula called ORS, while salt and starch sugar solution is called an incomplete formula because many contain sodium chloride and sucrose.
2) The liquid parenteral
Given to clients who experience severe dehydration, with details as follows:
- For children age 1 bl-2 years 3-10 kg body weight
• 1 first hour: 40 ml / kg / min = 3 tts / kg / min (infusion set size 1 ml = 15 or 13 tts tts / kg / min (set infusion of 1 ml = 20 drops).
• 7 next hour: 12 ml / kg / min = 3 tts / kg / min (infusset measuring 1 ml = 15 tts or 4 tts / kg / min (set infusion of 1 ml = 20 drops).
• The next 16 hours: 125 ml / kg / ORS
- For children over 2-5 years with 10-15 kg weight
• 1 first hour: 30 ml / kg / hour or 8 tts / kg / min (1 ml = 15 or 10 tts tts / kg / min (1 ml = 20 drops).
- For children 5-10 years with more than 15-25 kg body weight
• 1 first hour: 20 ml / kg / hour or 5 tts / kg / min (1 ml = 15 or 7 tts tts / kg / min (1 ml = 20 drops).
• 7 hours of the following: 10 ml / kg / hour or 2.5 tts / kg / min (1 ml = 15 or 3 tts tts / kg / min (1 ml = 20 drops).
• 16 hours of the following: 105 ml / kg ORS orally.
- For new-born babies weighing 2-3 kg
• The need for fluids: 125 ml + 100 ml + 25 ml = 250 ml/kg/BB/24 hours, type of fluid 4:1 (4 parts 5% glucose + 1 part of 1 ½% NaHCO3.
Speed: 4 first hour: 25 ml / kg / hour or 6 tts / kg / min (1 ml = 15 tts) 8 tts / kg / BW / mt (1MT = 20 tts).
• For low birth weight babies
Fluid requirements: 250 ml/kg/BB/24 hours, type of fluid 4:1 (4 parts 10% glucose + 1 part NaHCO3 1 ½%).
b. Dietetic treatment
For children under 1 year and children over 1 year weighing less than 7 kg, the type of food:
- Milk (breast milk, infant formula and low lactose-containing unsaturated fats
- Semi-solid foods (mashed or solid food (rice team)
- Milk specifically tailored to the abnormalities found in such milk that contains no lactose and medium-chain fatty acids or unsaturated.
c. Drugs
The principle of treatment to replace fluids lost with the fluids that contain electrolytes and glucose or other carbohydrates.
2. Nursing
Diarrhea client problems that need attention is the risk of blood circulation disorders, nutritional needs, the risk of complications, impaired sense of safe and comfortable, the lack of parental knowledge about the disease process.
Given most infectious diarrhea, it is necessary to setup the environment so there is no transmission to other clients.
a. Data focus
1) Hydration
- Skin turgor
- Mucous membrane
- Intake and output
2) Abdomen
- Pain
- Kekauan
- Noisy gut
- Vomiting-number, frequency and characteristics
- Faeces-number, frequency, and characteristics
- Cramps
- Tenesmus
b. Nursing Diagnosis
- High risk associated with lack of fluid volume imbalance between intake and output.
- High risk of infection related to intestinal contamination by microorganisms.
- Damage to skin integrity related to the irritation caused by the increased frequency of bowel movements.
- Anxiety related to separation from parents, not about the environment, procedures performed.
- Anxiety-related family crisis situations or lack of knowledge.
c. Intervention
1) Improve and monitor fluid and electrolyte balance
- Monitor IV fluids
- Assess intake and output
- Assess hydration status
- Monitor daily weight
- Monitor the child's ability to rehydration
- Through the mouth
2) Prevent irritability further gastro intestinal tract
- Assess children's ability to consume by mouth (for example: the first were given oral rehydration solution, and then increased to the normal food that is easily digested, such as: bananas, rice, bread or ation.
- Avoid giving milk products.
- Consult with a dietitian about food selection.
3) Prevent irritation and skin damage
- Change diapers frequently, examine skin conditions at any time.
- Wash the perineum with mild soap and water and lay out to air.
- Give a lubricating ointment at the rectum and perineum (the acidic feces will irritate the skin).
4) Follow the general precautions to prevent transmission of enteric infections (refer to institutional policies and procedures).
5) Meet the developmental needs of children during hospitalization.
- Provide age-appropriate toys.
- Input routines at home during the hospitalization.
- Encourage the disclosure of feelings in ways that fit the age.
6) Provide emotional support for families.
- Encourage to express his worries.
- Refer to social services if necessary.
- Give the physical and psychological comfort.
7) Plan for repatriation.
- Teach parents and children about personal and environmental hygiene.
- Strengthen information about diet.
- Give information about the signs of dehydration in the elderly.
- Teach parents about the agreement re-examination.
REFERENCES
1. Cecily L. Betz, Linda A. Sowden 2002. Nursing Handbook Pediatik, Jakarta, EGC
2. Sachasin Rosa M. 1996. Nursing Principles Pediatik.Translation languages: Manulang R.F. Jakarta, EGC
3. Arjatmo T. 2001. Emergency life-threatening situation, a new style of Jakarta
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