A. Definition
Some understanding of diarrhea:
1. Diarrhea is a bowel movement (defecation) with fecal liquid or semi-liquid, thus the water content in the stools more than normal bowel movements once the 100-200 ml (Hendarwanto, 1999).
2. According to WHO (1980) are diarrhea or loose stools liquid more than three times a day.
3. Diarrhea is a state frequency of bowel movements more than 4 times in infants and more than 3 times in a child with watery stool consistency, or green can be mixed with mucus and blood (Ngastiyah, 1997).
B. Cause
1. Factors infection
a. Enteral infection; 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.), infection parasites (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 on.
2. Factors malabsorption
Carbohydrate malabsorption: disaccharides (lactose intolerance, maltose, and sucrose), monosaccharides (glucose intolerance, fructose and galactose). Lactose intolerance is an important cause of diarrhea in infants and children. In addition it is also possible malabsorption of fat and protein.
3. Food factor:
Diarrhea can occur by ingestion of spoiled food, toxic and allergic to certain foods.
4. Psychological Factors
Diarrhea can occur due to psychological factors (fear and anxiety).
C. Pathophysiology
The basic mechanisms that cause diarrhea are:
1. Impaired osmotic
The presence of food or substances that are not absorbed will cause the osmotic pressure in the intestinal lumen increases resulting in a shift in the water and elektroloit into the intestinal lumen. Fill cavity excessive bowel will stimulate the intestines to remove it causing diarrhea.
2. Impaired secretion
Due to certain stimuli (such as toxins) in the gut wall will increase the secretion of water and electrolytes into the lumen of the intestine and subsequent diarrhea arise because they increase the contents of the intestinal lumen.
3. Intestinal motility disorders
Hiperperistaltik will cause a reduction in the opportunity intestine to absorb food causing diarrhea. Conversely when intestinal peristalsis decreases will result in excessive growth of bacteria, subsequent diarrhea also can occur.
D. Clinical Manifestations
Acute diarrhea due to infection may be accompanied by vomiting, fever, tenesmus, hematoschezia, and abdominal pain or cramps. The most fatal consequence of diarrhea that lasts long without adequate rehydration is the cause of death due to dehydration or hypovolemic shock in the form of biochemical disorder continued 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 are caused by the depletion of water isotonic.
Since the loss of bicarbonate (HCO3), the comparison with carbonic acid is reduced resulting in decreased blood pH stimulates the respiratory center so that the frequency increases and deeper breathing (Kussmaul breathing)
Cardiovascular problems at a later stage can be severe hypovolemic shock with signs of rapid pulse (> 120 x / min), blood pressure decreased to immeasurable. The patient became restless, pale face, cold akral and sometimes cyanosis. Due to a lack of potassium in acute diarrhea also can occur cardiac arrhythmias.
Drop in blood pressure will cause decreased renal perfusion to arise oliguria / anuria. If the condition is not immediately diatsi complications will arise acute renal tubular necrosis, which means a state of acute renal failure.
E. Management
Principles of Management
Management of acute diarrhea due to infection in adults consists of:
1. Rehydration therapy as a top priority.
2. Tata directed the work to identify the cause of the infection.
3. Provide symptomatic treatment
4. Provide definitive therapy.
ad.1. Rehydration therapy as a top priority.
There are 4 things to look for in order to deliver fast and accurate rehydration, namely:
1) Type of fluid to be used.
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 feces. If RL is not available to diberiakn isotonic saline (0.9%), which should be supplemented with 1 ampoule Nabik 50 ml of 7.5% on every single liter of isotonic NaCl. In the initial state of mild acute diarrhea may be given fluids to prevent dehydration oralit with all its consequences.
2) The amount of fluid that was about to be given.
In principle, the amount of replacement fluids wish shall be proportionate to the amount of fluid out of the body. The amount of fluid loss from the body can be calculated in a way / formula:
- Measure BJ Plasma
Fluid requirements calculated by the formula:
BJ Plasma - 1.025
-------- X BB x 4 ml
0.001
- Methods Pierce
Based on the clinical situation, namely:
* Mild diarrhea, fluid needs = 5% x kg BW
* Moderate diarrhea, fluid requirement = 8% x kg BW
* Mild diarrhea, fluid requirement = 10% x kg BW
- Methods Daldiyono
Based on the clinical scoring as follows:
* Thirst / vomiting = 1
* 60-90 mmHg systolic BP = 1
* Systolic BP <60 mmHg = 2 * Frequency pulse> 120 x / min = 1
* Awareness of apathy = 1
* Awareness somnolence, sopor or coma = 2
* Frequency of breathing> 30 times / min = 1
* Facies Cholerica = 2
* Vox Cholerica = 2
* Decreased skin turgor = 1
* Washer women's hand = 1
* Extremities cold = 1
* Cyanosis = 2
* Age 50-60 years = 1
* Age> 60 years = 2
Fluid needs =
Score
--- X 10% x kg x 1 ltr
15th
3) The entrance or means of fluid
Route of administration of fluid in adults include oral and intravenous administration. Orali solution with a composition ranging from 29 g of glucose, 3.5 g NaCl, 2.5 g and 1.5 g KCl NaBik stiap liter is given orally in mild diarrhea as well as the first attempt after initial rehydration to maintain hydration.
4) Schedule of fluid
Initial rehydration schedule is calculated by BJ plasma or scoring system administered within 2 hours in order to achieve optimal rehydration as soon as possible. Fluid schedule for the second phase of the clock to-3 based on the loss of fluid 2 hours before the initial phase. Thus, rehydration is expected to complete by the end of the third hour.
2. Tata directed the work to identify the cause of the infection.
To determine the cause of the infection is usually associated with the clinical condition of diarrhea but the exact cause can be determined through examination of stool culture examination of urine accompanied by a full and complete stool.
Disorders of fluid balance, electrolyte and acid-base clarified through a complete blood count, blood gas analysis, electrolytes, urea, creatinine and plasma BJ.
When there is high fever and suspected systemic infection bile culture examination, Widal, malarial preparations and serological Helicobacter jejuni is highly recommended. Special examinations such as serology amoeba, fungi and Rotavirus usually follows after seeing the results of the filter.
Clinically acute diarrhea due to infection classified as follows:
1) Koleriform, diarrhea with fecal matter consists primarily of liquids only.
2) Disentriform, diarrhea with mucus mixed with feces and sometimes blood.
Investigations that have been mentioned above can be directed to appropriate manifestation klnis diarrhea.
3. Provide symptomatic treatment
Symptomatic therapy should really be considered losses and profits. Antimotilitas intestine as loperamide would worsen diarrhea caused by entero-invasive bacteria because the bacteria prolong the contact time with the intestinal epithelium should be rapidly eliminated.
4. Provide definitive therapy.
Causal therapy can be given to infection:
1) Cholera-eltor: tetracyclines or cotrimoxazole or chloramphenicol.
2) V. parahaemolyticus,
3) E. coli, do not need a specific therapy
4) C. perfringens, specific
5) A. aureus: Chloramphenicol
6) Salmonellosis: ampicillin or cotrimoxazole 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 Chloroquineitiform or Metronidazole
11) Balantidiasis: Tetracycline
12) Candidiasis: Mycostatin
13) Virus: symptomatic and supportive
G. The concept of Nursing
1. Assessment (Children Age 3 Years)
a. Main complaints: Discard the water several times with dilute consistency
b. Health History Now
In general, children entered hospital with complaints of waste liquid water many times either with or without vomiting, dpat feces and mucus or blood, other complaints that may be obtained are decreased appetite, increased body temperature, decreased volume diuresis and symptoms of impairment of consciousness
c. Past Medical History
Includes history assessment:
1) Prenatal
Keberapa pregnancy, date of birth, gestational (fulterm, premature, post-mature), abortion or the birth of life, health, long before / pregnancy, and medications were eaten and immunization.
2) Christmas
The duration of labor, place of birth, drugs, people who help labor, childbirth complications.
3) Post natal
Nomal weight 2.5 kg - 4 kg, normal body length of 49 -52 cm, good health, Apgar scores, or no congenital abnormalities.
4) Feeding
Breast milk or formula, weaning age (2 years), eating schedule / amount, the introduction of soft foods at 4-6 months, peubahan weight-gain, feeding problems (vomiting, colic, diarrhea), and the use of vitamins and minerals or other supplements.
5) previous Diseases
The causes, symptoms, disease, healing, kompliksi, the incidence of the disease in the family or community, emotional response to the previous hospitalization.
6) Allergies
Did you ever suffer from hay fever, asthma, eczema. Drugs, animals, plants, house dust
7) Medications obtained last
Name, dose, schedule, duration, reason for giving.
8) Immunization
Polio, hepatitis, BCG, DPT, measles, are complete at the age of 3 years, the reaction is usually fever, serum-serum granting another, gamma globulin / transfusion, giving tubrkulin test and reaction.
9) Growth
Weight at birth 2, 5 Kg - 4 Kg. Weight gain 150-200 g / week, increasing TB 2.5 cm / month, this increase occurred up to 6 months. Teeth begin to grow at the age of 6-7 months, start to sit alone at the age of 8-9 months, and can be up and running at the age of 10-12 months.
d. Psychosocial History
Children love toys, children are dependent on their parents and so hysterical when her parents separated. Minimum 3 years (toddlers) have learned to play with peers.
e. Spiritual History
Children already know a few things that are rituals such as praying.
f. Reaction Hospitalization
1. Separation anxiety: loss of family and community interaction are known, insecurity, anxiety and sadness
2. Changes in patterns of routine activities
3. Limited ability to communicate
4. Loss of autonomy
5. Fear of body integrity
6. Decreased mobility as an opportunity to learn about their world and the lack of opportunity to carry out his pleasure
g. Day-to-Day Activities
1. Fluid requirements at age 3 years was 110-120 ml / kg / day
2. Output fluid:
(A) IWL (Insensible Water Loss)
(1) Children: 30 cc / kg BW / 24 hours
(2) increased body temperature: 10 cc / Kg BB + 200 cc (body temperature - 36.8 ° C)
(B) SWL (Sensible Water Loss) is the loss of fluid that can be observed, for example in the form of urine and faeces. That is:
(1) Urine: 1-2 cc / kg BW / 24 hours
(2) Faeces: 100-200 cc / 24 hours
3. At the age of 3 years has taught toilet training.
h. Physical examination
a) Vital signs
Body temperature: an increase
Nadi: fast and weak
Respiratory: respiratory frequency increased
Blood pressure: decreased
b) Anthropometry
Anthropometric examination includes weight, height, circle head, arm circumference, and abdominal circumference. In children with diarrhea, weight loss.
c) Respiratory
Usually breathing rather fast, normal chest shape, and found no additional breath sounds.
d) cardiovascular
Usually there were no abnormalities, rapid and weak pulse.
e) Digestion
Found symptoms of nausea and vomiting, dry lips and mouth mucosa, increased intestinal peristalsis, anorexia, SECTION 3 x more watery consistency
f) urinal
Volume decreased diuresis.
g) Musculoskeletal
Physical weakness due to excessive output.
h) Integumentary
abrasions around the anus, the skin felt warm, ugly skin turgor
i) Endocrine
Not find any kelaianan.
A) Sensing
Sunken eyes, nose, ears no abnormalities
k) Reproduction
No abnormalities.
l) Neorologis
Impairment of consciousness can occur.
2. Level Examination Development
1) gross motor
It can go up / down stairs without assistance, mamakai clothes with help, can start cycling tricycle.
2) fine motor
Menggambat circle, washing hands and brushing teeth alone
3) Personal Social
've Learned to play with his peers.
4. Nursing Diagnosis
a. Lack of fluid volume excess bd loss through feces and vomiting, and limited intake (nausea).
b. Changes in nutrition less than body requirements bd impaired nutrient absorption and increased intestinal peristalsis.
c. Pain (acute) hiperperistaltik bd, irritation perirektal fissure.
d. Anxiety bd families change their child's health status
e. Lack of family knowledge about the condition, prognosis and therapy needs exposure bd limited information, false or interpretation of information and cognitive limitations.
f. Bd separation anxiety children with parents, new environmental
5. Nursing Plan
Lack of fluid volume Dx.1 b / d lost in faeces and vomit excessively and limited intake (nausea)
Objective: fluid requirements will be met with the criteria no signs of dehydration
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