What is Gastroenteritis?
Infectious diarrhea is commonly referred to as gastroenteritis.
- Although often considered a benign disease, acute gastroenteritis remains a major cause of morbidity and mortality in children around the world, accounting for 1.34 million deaths annually in children younger than 5 years, or roughly 15% of all child deaths.
- Diarrhea may be mild, accompanied by slight dehydration, or it may be extremely severe, requiring prompt and effective treatment.
The 2 primary mechanisms responsible for acute gastroenteritis are:
- There is damage to the villous brush border of the intestine, causing malabsorption of intestinal contents and leading to an osmotic diarrhea.
- There is a release of toxins that bind to specific enterocyte receptors and cause the release of chloride ions into the intestinal lumen, leading to secretory diarrhea.
- Even in severe diarrhea, however, various sodium-coupled solute co-transport mechanisms remain intact, allowing for the efficient reabsorption of salt and water.
- By providing a 1:1 proportion of sodium to glucose, classic oral rehydration solution (ORS) takes advantage of a specific sodium-glucose transporter (SGLT-1) to increase the reabsorption of sodium, which leads to the passive reabsorption of water.
Statistics and Incidences
Gastroenteritis is prevalent in areas lacking adequate clean water and sanitation facilities.
- Children in the United States experience, on average, 1.3-2.3 episodes of diarrhea each year.
- Overall, acute gastroenteritis accounts for than 1.5 million outpatient visits, 220,000 hospitalizations, and direct costs of more than $2 billion each year in the United States alone.
- Worldwide, children younger than 5 years have an estimated 1.7 billion episodes of diarrhea each year, leading to 124 million clinic visits, 9 million hospitalizations, and 1.34 million deaths, with more than 98% of these deaths occurring in the developing world.
- Although the prevalence of acute gastroenteritis in children has changed little over the past 4 decades, mortality has declined sharply, from 4.6 million in the 1970s to 3 million in the 1980s and 2.5 million in the 1990s.
Gastroenteritis may be caused by the following, yet it may be difficult to determine the causative factor in many instances:
- Infectious agents. The infectious organisms may be salmonella, Escherichia coli, dysentery bacilli, and various viruses, most notably rotaviruses.
- Contaminated food. Many diarrheal disturbances in children are caused by contaminated food or human or animal fecal waste through the oral-fecal route.
- Unsanitary water and environment. This condition is prevalent in areas lacking adequate clean water and sanitary facilities.
- Antibiotic therapy. Diarrhea may also be caused by antibiotic therapy.
Gastroenteritis may present the following:
- Diarrhea. Frequent, watery stools are more consistent with viral gastroenteritis, while stools with blood or mucous are indicative of a bacterial pathogen.
- Vomiting. When symptoms of vomiting predominate, one should consider other diseases such as gastroesophageal reflux disease (GERD), diabetic ketoacidosis, pyloric stenosis, acute abdomen, or urinary tract infection.
- Dysuria. Determine if there is an increase or decrease in the frequency of urination as measured by the number of wet diapers, time since last urination, color and concentration of urine, and presence of dysuria.
- Abdominal pain. In general, pain that precedes vomiting and diarrhea is more likely to be due to abdominal pathology other than gastroenteritis.
- Infection. Determine the presence of fever, chills, myalgias, rash, rhinorrhea, sore throat, cough, known immunocompromised status.
Assessment and Diagnostic Findings
The vast majority of children presenting with acute gastroenteritis do not require serum or urine tests, as they are unlikely to be helpful in determining the degree of dehydration.
- Stool exam. Stool specimens may be collected for culture and sensitivity testing to determine the causative infectious organism, if there is one.
Medical treatment for gastroenteritis include:
- Oral rehydration solution. The American Academy of Pediatrics (AAP), the European Society of Pediatric Gastroenterology and Nutrition (ESPGAN), and the World Health Organization (WHO) all recommend oral rehydration solution (ORS) as the treatment of choice for children with mild-to-moderate gastroenteritis in both developed and developing countries.
- NG feeding. For patients who do not tolerate ORS by mouth, nasogastric (NG) feeding is a safe and effective alternative.
- IV rehydration. IV access should be obtained in severe dehydration and patients should be administered a bolus of 20-30 mL/kg lactated Ringer (LR) or normal saline (NS) solution over 60 minutes.
- Diet. In general, children with gastroenteritis should be returned to a normal diet as rapidly as possible; early feeding reduces illness duration and improves nutritional outcome.
The goals of pharmacotherapy are to reduce morbidity, prevent complications, and provide prophylaxis.
- Vaccines. In February 2006, the US Food and Drug Administration (FDA) approved the RotaTeq vaccine for the prevention of rotavirus gastroenteritis.
- Metronidazole. Metronidazole is recommended as the treatment of choice for mild-to-moderate cases of C difficile colitis.
- Antiemetics. A review of 7 randomized, controlled trials in children found that oral ondansetron reduced vomiting and the need for intravenous (IV) rehydration and hospital admission, IV ondansetron and metoclopramide reduced the number of episodes of vomiting and hospital admission, and dimenhydrinate suppository reduced the duration of vomiting.
Nursing management in a child with gastroenteritis includes:
Assessment of a child with gastroenteritis include:
- Assess stool characteristics. In addition to basic information about the child, the interview with the family must include specific information about the history of bowel patterns and the onset of diarrheal stools, with details on number and type of stools per day; suggest terms to describe the color and odor of stools to assist the caregiver with descriptions.
- Assess for vomiting. Inquire about recent feeding patterns, nausea, and vomiting.
- Assess for presence of illness. Ask the caregiver about fever and other signs of illness in the child and signs of illness in any other family members.
- Physical examination. The physical exam of the child includes observation of skin turgor and condition, including excoriated diaper area, temperature, anterior fontanelle, apical pulse rate, stools, irritability, lethargy, vomiting, urine, lips and mucous membranes of the mouth, eyes, and any notable physical signs.
- Risk for infection related to inadequate secondary defenses or insufficient knowledge to avoid exposure to pathogens.
- Impaired skin integrity related to constant presence of diarrheal stools.
- Deficient fluid volume related to diarrheal stools.
- Imbalanced nutrition: less than body requirements related to malabsorption of nutrients.
- Hyperthermia related to dehydration.
- Risk for delayed development related to decreased sucking when infant is NPO.
Nursing Care Planning and Goals
Main Article: 4 Gastroenteritis Nursing Care Plans
The major goals for a child with acute gastroenteritis are:
- Control of diarrhea.
- Minimize the risk for infection.
- Maintain good skin condition.
- Improve hydration and nutritional intake.
- Satisfy sucking needs in the infant.
- Eliminate the risk of infection transmission.
Nursing interventions for the child with gastroenteritis are:
- Reduce infection transmission. All caregivers must wear gowns; gloves are used when handling articles contaminated with feces; place contaminated linens and clothing in specially marked containers to be processed according to facility policy; visitors are limited to family only; teach the family caregivers the principles of aseptic technique and observe them; and good handwashing must be carried out.
- Promote skin integrity. To reduce irritation and excoriation of the buttocks and genital area, cleanse those areas frequently and apply a soothing protective preparation such as lanolin A or D ointment; change diapers as quickly as possible, and placing disposable pads under the infant can facilitate easy and frequent changing.
- Prevent dehydration. Carefully count diapers and weigh them to determine the infant’s output accurately; measure each voiding in the older child; document the number and character of the stools, as well as the amount and character of any vomitus.
- Maintain adequate nutrition. Weigh the child daily on the same scale; take measurements in the early morning before the morning feeding; monitor the intake and output strictly; good mouth care is essential when the child is NPO; when oral fluids are started, the child is given oral replacement solutions; after the child tolerates these solutions, half-strength formula may be introduced.
- Maintain body temperature. Monitor vital signs at least every 2 hours if there is fever; follow appropriate procedures for fever reduction, and administer antipyretics and antibiotics as prescribed.
Goals are met as evidenced by:
- Control of diarrhea.
- Minimized risk for infection.
- Maintained good skin condition.
- Improved hydration and nutritional intake.
- Satisfied sucking needs in the infant.
- Eliminated risk of infection transmission.
Documentation in a child with gastroenteritis includes:
- Individual findings, including factors affecting, interactions, nature of social exchanges, specifics of individual behavior.
- Intake and output.
- Characteristics of stool and vomitus.
- Cultural and religious beliefs, and expectations.
- Plan of care.
- Teaching plan.
- Responses to interventions, teaching, and actions performed.
- Attainment or progress toward desired outcome.
Practice Quiz: Gastroenteritis
1. Amikacin (Amikin) is given to a client with E-coli infection. The nurse advises the client to report which of the following symptoms immediately?
1. Answer: D. Hearing loss
- Option D: Amikacin is an aminoglycoside. Side effects of this medication include ototoxicity (Hearing loss), confusion, disorientation, gastrointestinal irritation, palpitations, blood pressure changes and nephrotoxicity.
- Options A, B, C: Options A, B, and C are not related to the medication.
2. Ricky is suffering from persistent vomiting for two days now. He appears to be lethargic and weak and has myalgia. He is noted to have dry mucus membranes and his capillary refill takes >4 seconds. He is diagnosed as having gastroenteritis and dehydration. Measurement of arterial blood gas shows pH 7.5, PaO2 85 mm Hg, PaCO2 40 mm Hg, and HCO3 34 mmol/L. What acid-base disorder is shown?
A. Respiratory Alkalosis, Uncompensated
B. Respiratory Acidosis, Partially Compensated
C. Metabolic Alkalosis, Uncompensated
D. Metabolic Alkalosis, Partially Compensated
2. Answer: C. Metabolic Alkalosis, Uncompensated
- Option C: The primary disorder is uncompensated metabolic alkalosis (high HCO3 -). As CO2 is the strongest driver of respiration, it generally will not allow hypoventilation as compensation for metabolic alkalosis.
- Options A, B, D: Options A, B, and D are incorrect.
3. Baby Angela was rushed to the Emergency Room following her mother’s complaint that the infant has been irritable, difficult to breastfeed and has had diarrhea for the past 3 days. The infant’s respiratory rate is elevated and the fontanels are sunken. The Emergency Room physician orders ABGs after assessing the ABCs. The results from the ABG results show pH 7.39, PaCO2 27 mmHg and HCO3 19 mEq/L. What does this mean?
A. Respiratory Alkalosis, Fully Compensated
B. Metabolic Acidosis, Uncompensated
C. Metabolic Acidosis, Fully Compensated
D. Respiratory Acidosis, Uncompensated
3. Answer: C. Metabolic Acidosis, Fully Compensated
- Option C: Baby Angela has metabolic acidosis due to decreased HCO3 and slightly acidic pH. Her pH value is within the normal range which made the result fully compensated.
- Options A, B, D: Options A, B, and D are incorrect.
4. While preparing to discharge an 8-month-old infant who is recovering from gastroenteritis and dehydration, the nurse teaches the parents about their infant’s dietary and fluid requirements. The nurse should include which other topic in the teaching session?
A. Nursery schools
B. Toilet Training
C. Safety guidelines
D. Preparation for surgery
4. Answer C. Safety guidelines
- Option C: The nurse always should reinforce safety guidelines when teaching parents how to care for their child.
- Options A and B: For parents of a 9-month-old infant, it is too early to discuss nursery schools or toilet training.
- Option D: Because surgery is not used gastroenteritis, this topic is inappropriate.
5. When caring for an 11-month-old infant with dehydration and metabolic acidosis, the nurse expects to see which of the following?
A. A reduced white blood cell count
B. A decreased platelet count
C. Shallow respirations
5. Answer D. Tachypnea
- Option D: The body compensates for metabolic acidosis via the respiratory system, which tries to eliminate the buffered acids by increasing alveolar ventilation through deep, rapid respirations.
- Options A and B: Altered white blood cell or platelet counts are not specific signs of metabolic imbalance.
- Option C: Shallow respirations is not a symptom of metabolic acidosis.