No More Tears for Henry

Page 1

No More Tears for Henry Learning Aims:

1. Understand the complexities of fluid and electrolyte imbalances in children - Dawn

2. Explore health care values from a transcultural perspective - Michelle

3. Identify the impact of a child's illness on individual family members and the family. Apply family theory in caring for children and caregivers - Mary

Required Reading:

Managing acute gastroenteritis among children: Oral rehydration, maintenance, and nutritional therapy. MMWR: Morbidity & Mortality Weekly Report, 52(RR-16), 1-16. Retrieved from http://www.cdc.gov/mmwr/index.html

Canadian fundamentals of nursing (5th ed.). Toronto, ON: Elsevier (pg. 339-345)

Learning Activities for Students

Utilize the a family assessment tool to guide interviewing Henry’s mother

in a role playing situation - CALGARY Assessment tool - Kate

Have students contact a resource agency to learn more about the Mennonite culture and share findings with group - Gabriella

No More Tears for Henry…Chart Data

History of present problem:

2 day history of vomiting and diarrhea; not eating or drinking well

Mother states Henry felt “warm” to touch

Decreased appetite, refusing solids, Henry is drinking small amounts of chamomile tea

Sleeping poorly

Helen reports that Henry has been lethargic, irritable and clingy the last 2 days

Health History:

Mother states her pregnancy with Henry was normal

He was born at 40 weeks gestation; uneventful labour and delivery

His immunizations are up to date.

Family History:

Helen is 23 years old. Husband, Peter, is 28 years old.

At age 2, Henry is the youngest of three children. He has a brother who is 3 and a sister who is 4 ½ years.

Gordon’s Functional Health Patterns

1. Health Perception - Health Management:

Folk remedies are frequently used in this culture. Helen believes the chamomile tea is helping with Henry’s symptoms. When Henry has had an ear infection in the past, he has taken Tylenol to help his symptoms.

The family has a pattern of seeking medical care late in an illness

2. Nutrition/Metabolic:

Henry was breastfed until 1 year of age. He now drinks milk, water or juice from a Sippy cup. He is able to hold his own spoon and feed himself finger foods

Under usual circumstances, Henry is a “good eater”. His diet consists mainly of homemade soups, fruits, vegetables and stews.

For the last 2 days, he has been vomiting and refusing to eat

3. Elimination

Henry is not toilet trained; he wears cloth diapers

He usually has 1 formed bowel movement per day and 5 heavy, wet diapers

For the last 2 days, he has been having 5 liquid, loose stools per day

4. Activity & Exercise

Henry is meeting all developmental milestones appropriately. He started walking at 13 months and is very active.

5. Values & Beliefs

Helen and Peter are Old Order Mennonite and believe in God. Their lives are very tied to their Mennonite culture.

6. Coping and Stress

Helen states that having 3 children under the age of 5 can be very busy and stressful. Henry’s current illness has impacted her ability to spend time with the other children.

7. Sleep & Rest

Henry usually sleeps 10 hours a night and takes a 1-hour afternoon nap. His usual bedtime is 8 pm. He sleeps in a room with his older siblings.

8. Roles & Relationships

Peter works on the family farm. Helen is a stay at home mom with the 3 children.

Helen does not drive, and needs to wait for Peter to drive her or the children to any appointments.

9. Cognitive/Perceptual

Helen states that Henry recognizes and repeats a few words and can obey simple commands. His vision, hearing and speech are normal.

Physical Assessment1. General Appearance:

Sitting on mother's lap resting against her chest

Skin pale in colour

Feels warm to touch.

Weight – 11 kg. (24 lbs); Height – 83 cm (33”)

2. Vital Signs:

Temperature 37.5°C (axilla)

Heart rate: 120 beats per minute

Respiratory rate: 24 breaths per minute

Blood pressure 92/56

Skin

Warm to touch, pale in colour, pink nail beds, mucous membranes dry and pink, skin turgor poor, no bruises, red rash around anus

4. Respiratory:

Lungs clear to auscultation, no crackles, no wheezes

5. Cardiac

Heart – normal, no murmurs heard

Capillary refill 3 seconds, skin pale

6. Abdomen:

No masses

Not tender to touch

Hyperactive bowel sounds

7. Musculoskeletal:

Full range of movement in neck without complaints of pain

No joint pain

8. Neurological:

Irritable and lethargic

9. Genital/Urinary:

Normally has 5 wet diapers per day.

Has been having loose stools for the last 2 days. Helen is not sure if he has been voiding along with the loose stools.

Patient’s Lab Data for Nurse to Review

Test

NORMAL

Henry’s RESULTS

136-145 mmol/ L

133 mmol/L

3.4-4 .7 mmol/ L

4.3 mmol/ L

90-110mmol/L

112 mmol/ L

C02

20-28 mmol/L

24 mmol/L

Blood Urea Nitrogen

1.8-6.4 mmol/L

6.8 mmol/L

CREATININE

18-62 mcmol/L

65 mmol/ L

Stool for Culture and Sensitivity (C&S)

Normal Intestinal Flora

Stool for Ova and Parasites (O&P)

Normal Intestinal Flora

1. Understand the complexities of fluid and electrolyte imbalances in children

http://ovidsp.tx.ovid.com.libaccess.lib.mcmaster.ca/sp-3.18.0b/ovidweb.cgi?WebLinkFrameset=1&S=BLCKF...

Changes in fluid and electrolyte balance may

happen quickly in infants and children (I & Y C, increasing the nurses

responsibility to anticipate often discreet signs of an imbalance

Children and infants present unique problems in

managing fluids and electrolytes.

Differences in the rate of metabolism and body surface area are two

unique aspects

a Childs body composition and homeostatic

controls differ from those of an adults the younger the child the greater the

differences

Fluid and electrolyte imbalances occur more

quickly in children

a newborn’s body is 70-80% water and an adults

body is approx. 60%

By the time a child is almost 3 yrs old, the

total body water is approx. 60%

Although infants have more fluid in their

bodies, they are more susceptible to fluid loss problems because they intake

and output more water volume daily than do adults

Insensible water loss (fluids lost through the

skin and lungs) are higher for infants and children than for adults.

Any situation that causes an increase in loss of

water and electrolytes through he skin threatens the body fluid balance of the

infant and small child to a greater degree than it would an older adult

Basal metabolic rate (BMR) for children than it

is for adults. An infants high BMR means

the fluid intake per Kg body weight per day actually must exceed the per

kilogram fluid requirements of an adult.

Infant kidneys are not mature enough to

concentrate urine efficiently. The infant needs more water to excrete a given

amount of solute.

Assessment

As fluid volume decreases extremities become

cool, even if the child is febrile

Assess fluid deficit in the mouth

If the pulse rate is greater than 160 beats per

min for infants and 120 for children, hypervolemia should be suspected.

Children often hyperventilate to compensate for

acidosis

BP is the last vital sign to show changes and

not be relied on as an assessment indicator of dehydration

Fontanels of infants will be depressed with a

moderate fluid deficit.

Dehydration

In children, dehydration is usually attributable

to vomiting or an acute viral or bacterial diarrhea

2. Explore health care values from a transcultural perspective

Sunrise Model:

See the diagram at the bottom of the page. I wasn't able to paste it here.

CNO

Culturally Sensitive Care Practice guideline

Culture- Refers to the learned values,

beliefs, norms, and way of life that influence an individuals thinking,

decisions and actions in certain ways.

· Client centered care requires that

nurses recognize the clients culture, the nurses culture and how both affect

the nurse client relationship.

· There is no single “RIGHT” way to

do this for everyone, each client and situation is unique and therefore needs

to be assessed and planned for individually

· The focus must always be on the

clients needs

Assumptions

· Everyone has a culture

· Culture is individual

· Individual culture is influenced

by many factors (See Figure Sunrise Model)

· Culture is always changing

· Reactions to other cultures can be

automatic, subconscious and have an impact on the nurse client relationship

· A nurses own culture is influenced

by personal beliefs in addition to our nursing values

· We are responsible for assessing and

responding appropriately to the clients cultural expectations and needs

Acquiring cultural knowledge

· It is impossible for nurses to

know the details of every culture

· It is however, possible for nurses

to have a broad understanding of how culture can affect beliefs and behaviours

· In health care culture may affect

beliefs and values regarding

Perception

of health illness and death

Meaning

and role of suffering

View

of hospitals, nurses, doctors and other healers

Rituals

and customs (religious and other)

Boundaries

related to privacy, age, gender, and relationships

Effectiveness

and values of different types of therapies

Individual

time keeping beliefs and practices that may direct activities

Family

and social relationships

Decision

making on consent to treatment

Independence/self

care versus interdependence/being cared for

Communication

norms (eye contact)

Facilitating client choice

· Nurse role is to help client meet

their specific health goals.

· We need to investigate into the

clients view and try to understand the meaning behind a particular request, in

addition to their overall treatment goals

· If it becomes apparent that a

clients cultural preference will negatively affect the client, the nurse works

with the client to explain the harm/risks associated with that choice

· Likewise, if the preference will

affect the wellbeing of other clients, the nurse must look for some ways of

achieving some parts of the clients preference, while safeguarding the other

clients.

Assessment

Ask

open-ended questions to find out relevant cultural information, nurse needs to

listen with respect and remain nonjudgmental

1. What do you think has caused your

problems?

2. Why do you think the problem

started when it did?

3. What do you think the sickness

does to you?

4. What are the major problems the

sickness has caused?

5. What have you done for the illness

until now?

6. What kind of treatment do you

think you should receive?

7. Is there anything else that could

be done either by you or by others (family priest)

8. What are the most important

results you hope to achieve form these treatments?

9. What do you fear most about your

sickness?

10. What do you fear most about the

treatment?

11. Who should be consulted or

involved in your care?

http://www.cno.org/globalassets/docs/prac/41040_culturallysens.pdf

Leininger,

M. M. (1988). Leininger’s theory of nursing: cultural care diversity and

universality. Nursing Science Quarterly,

1 (4), pp. 154-160.

No More Tears for Henry

Mennonite Culture

· In Ontario often difficult to

distinguish Mennonites from others

· Old Order – easier to recognize

- Typically live without

electricity, card and dress in simple, plain clothing

- Men wear plain trousers and

jackets with a plain straw hat

- Women wear their hair long,

covered by a prayer cap and have plain dresses

- Sometimes use horse drawn buggies

to get around

- Often choose to educate the

children in schools run by themselves ensuring their beliefs continue to get

passed down each generation

· Many don’t accept heath care and

education by the government

· Founding beliefs – Anabaptists

· New order – live like

non-Mennonites but religion is a major aspect

- Also called Third Way

- Try to connect faith to daily

actions

- Some believe that baptism and

church involvement are voluntary

- Use some forms of technology –

depends on the community

· Woolwich Community Health Centre

- Non-profit organization

- Provides health care, illness

prevention and health promotion services

- Funded by Ontario Ministry of

Health but not through OHIP

- Works with groups of people who

face barriers to health and accessing health care

http://www.thecanadianencyclopedia.ca/en/article/mennonites/

http://www.wchc.on.ca/about_chc.php

3. Identify the impact of a child's illness on individual family members and the family. Apply family theory in caring for children and caregivers

Impact of Pediatric Critical Illness and Injury on Families: A Systematic Literature Review

Marysia Shudy, Mary Lihinie de Almeida, Susan Ly, Christopher Landon, Stephen Groft, Tammara L. Jenkins, Carol E. Nicholson

http://pediatrics.aappublications.org/content/118/Supplement_3/S203#T2

As shown in Table 1, studies using the PSS:PICU indicate that the most severe parental stress is role alteration.

This is understood as the sense of helplessness in parents who are accustomed to control in providing safety and advocacy.

Those we reviewed concluded that the main sources of stress in siblings were changes in parental behavior and care by a substitute caregiver

Needs: Contact with child; nearby resting place, Know what is wrong with child; informed of changes, Feeling of hope; assurance of best care; maintaining caregiver role

Parents felt guilty, excited, discouraged, and exhausted during hospitalization; siblings felt isolated, unimportant, and resentful

Parents of children with LT illnesses were given more emotional support than those with NLT illnesses

Family dynamics were negatively affected; siblings exhibited increased fears and withdrawal from injured child

Family unit experienced increased stress, social distress, and adverse psychological effects

In some instances, a major illness brings a family closer together; in others, even a minor illness causes significant strain.

4. Utilize the a family assessment tool to guide interviewing Henry’s mother in a role playing situation - CALGARY Assessment tool

Calgary

Assessment model (diagram pasted at the bottom of the page showing the flow chart)

Wright, L. M., & Leahey, M. (2009). Nurses and

families: A guide to family assessment and intervention (5th ed., p. 5).

Philadelphia, PA: F. A. Davis Company.

and

Potter, Patricia, Anne Perry, Janet Ross-Kerr, Marilynn

Wood, Barbara Astle, Wendy Duggleby. Canadian Fundamentals of Nursing, 5th

Edition. Mosby Canada, 2014. VitalBook file.

Be selective

in which subcategories to use as it could be overwhelming to the family

Structural

Assessment

•

Internal structure is who is included in

the family /how they are related to one another

ie. gender roles, sexual

orientation, family composition, ranking (number of children, their ages, their

expectations based on age)

Questions to ask:

o Who is in your

family?

o Does anyone else

live with you: for example, grandparents, boarders?

o Has anyone recently

moved out of your household, married, or died?

o Can you think of

anyone else who is like a family member but is not biologically related?

o How have your

parents' ideas about masculinity and femininity affected your own? Have your

ideas about gender been challenged in any way since you became parents?

o Do you have

expectations of your children on the basis of their gender?

o Is the division of

labour at home based on gender roles?

o How many children

are in your family?

o What are the

children's ages?

o Do you have

distinct expectations for the oldest and younger children?

•

External structure is relationships the

family shares with people and institutions outside of the family unit

ie. extended family

Context is the whole

situation/background relevant to the family

ie. religion, socioeconomic

class, ethinicity

Questions to ask:

o Where do your parents

live? How often do you have contact with them and your siblings?

o Which family

members do you see or speak with regularly? Who in your extended family are you

the closest to?

o Have members of

your extended family been helpful to you during this time of illness? In what

way?

o What is your job?

How many hours a week do you work? How does this affect family life?

o Does anyone in the

family work shifts? How does that influence your family functioning?

o What level of

education have you completed?

o Does your family

have economic challenges at this time?

Developmental

Assessment

•

Stages that families go through

that requires adjustment or change

•

Interaction between

individual’s development and the phase of the family developmental life cycle

that are important to family functioning

•

Cycles: Leave home, become

young adults, families join together through marriage, families have young

children, then families have adolescents, move on to mid life, families in late

middle age, and families at end of life

Functional

Assessment

•

Divided into instrumental and

expressive

•

It's how family members

interact with each other

•

Instrumental Functioning

Normal ADL's

ie. meals, sleep schedules,

attending health needs

How these roles change when coping

with relative’s illness or disability

o Who is usually

responsible for housekeeping and child care?

o Do other family

members help with these tasks?

o Does anyone in the

family require help with activities of daily living?

o Who will be

primarily responsible for flushing Mary's broviac line (an intravenous access

device for the administration of medications and blood tests) when she is

discharged home?

•

Expressive Functioning

How people communicate

Emotional: feelings expressed by the family

Verbal: focusing on using words

Nonverbal: body language,

gestures, crying

Circular: how each family

member influences the behaviour of others

o How can you tell

when each member of your family is happy, sad, or under stress?

o How do you express

happiness, sadness, or stress?

o Johnny, when you

are sad or worried, who in the family do you most like to spend time with or

talk to about that?

I've embeded the youtube video at the bottom of this document.

5. Mennonite Culture

· In Ontario often difficult to

distinguish Mennonites from others

· Old Order – easier to recognize

- Typically live without

electricity, card and dress in simple, plain clothing

- Men wear plain trousers and

jackets with a plain straw hat

- Women wear their hair long,

covered by a prayer cap and have plain dresses

- Sometimes use horse drawn buggies

to get around

- Often choose to educate the

children in schools run by themselves ensuring their beliefs continue to get

passed down each generation

· Many don’t accept heath care and

education by the government

· Founding beliefs – Anabaptists

· New order – live like

non-Mennonites but religion is a major aspect

- Also called Third Way

- Try to connect faith to daily

actions

- Some believe that baptism and

church involvement are voluntary

- Use some forms of technology –

depends on the community

· Woolwich Community Health Centre

- Non-profit organization

- Provides health care, illness

prevention and health promotion services

- Funded by Ontario Ministry of

Health but not through OHIP

- Works with groups of people who

face barriers to health and accessing health care

http://www.thecanadianencyclopedia.ca/en/article/mennonites/

http://www.wchc.on.ca/about_chc.php

https://www.youtube.com/watch?v=ZHw7CvKonMw (Embed)

No More Tears for Henry

Readings for scenario

“No more tears for Henry”

King, C.K., Glass,

R., Bresee, J.S., & Duggan, C. (2003). Managing acute gastroenteritis among

children: Oral rehydration, maintenance, and nutritional therapy. MMWR: Morbidity & Mortality Weekly Report, 52(RR-16), 1-16. Retrieved from

http://www.cdc.gov/mmwr/index.html

Summary

Acute Gastroenteritis:

Common illness among infants and children in the

world

accounting for >1.5 million outpatient

visits, 200,000 hospitalizations, and approximately 300 deaths/year

Diarrhea is one of the common causes of

mortality for children < 5 y o

Oral Rehydration Therapy (ORT)

Improved health outcomes among children in

developing countries – decreased mortality

Use has lagged in US

Physicians recognize:

Supplementation of zinc can reduce incidence and

severity of diarrheal disease

ORS of reduced osmolality (proportional reduced

sodium nad glucose): recommended for global use

This article updates recommendations of managing

gastroenteritis

Introduction &

Background

ORT

encompasses two phases of treatment: 1) a rehydration phase, in which water and

electrolytes are administered as oral rehydration solution (ORS) to replace

existing losses, and 2) a maintenance phase, which includes both replacement of

ongoing fluid and electrolyte losses and adequate dietary intake

The

lag of ORT use in US is thought to be due to the ingrained use of IV therapy

and reduced appeal of a technologically simple solution

Many

children with mild dehydration and vomiting have ORT withheld

ORT

use began in developing countries where IV availability is reduced

NOW,

ORT accepted as standard of care for the clinically efficacious and

cost-effective management of acute gastroenteritis

Physiologic Basis for

using ORS

The

adult intestinal epithelium must handle 6,500 mL of fluids/day, consisting of a

combination of oral intake, salivary, gastric, pancreatic, biliary, and upper

intestinal secretions. This volume is typically reduced to 1,500 mL by the

distal ileum and is further reduced in the colon to a stool output of <250

mL/day in adults --- during diarrhea the volume of intestinal fluid output is

substantially increased overwhelming the reabsorptive capacity of the GI tract

Solutions

with a high concentration of co-transporters increase the risk from hypertonic

solutions that decrease rather than improve sodium and water transport into the

bloodstream. However, solutions of lower osmolarity, but that maintain the 1:1

glucose to sodium ratio, perform optimally as oral solutions for diarrhea

management (see Choice of ORS).

Home Management of

Acute Diarrhea

Initiation of Therapy:

All

families should be encouraged to have a supply of ORS in the home at all times

and to start therapy with a commercially available ORS product as soon as

diarrhea begin

Need to recognize severity:

Infants are more at risk for becoming dehydrated

because of higher body-surface-to-volume ratio, higher metabolic rate, smaller

fluid reserves and depend on others for fluid

When fever is present: infants and children

should be evaluated to rule out other serious illnesses (sepsis and meningitis)

Box 1 provides a guide for when to seek medical

evaluation:

Referral for Evaluation:

This is the responsibility of the physician

Focus on factors putting a child at risk of

dehydration

Number of days the child has been ill

# of episodes of diarrhea or vomiting

Volume of fluid output

Mental status

Past medical history

Clinical Assessment

Diarrhea is 3 or more loose/ watery stools/day

Volume of fluid lost through stools can vary

from 5mL/kg body weight/day (normal) à

>200 mL/ kg body weight/ day

Dehydration

and electrolyte losses associated with untreated diarrhea cause the primary

morbidity of acute gastroenteritis.

Diarrhea can be among the initial signs of

non-gastrointestinal tract illnesses, including meningitis, bacterial sepsis,

pneumonia, otitis media, and urinary tract infection.

Vomiting

alone can be the first symptom of metabolic disorders, congestive heart

failure, toxic agent ingestion, or trauma.

rule out other serious illnesses, a detailed history and physical examination

should be performed as part of the evaluation of all children with acute

gastroenteritis.

History:

onset,

frequency, quantity, and character (i.e., the presence of bile, blood, or

mucus) of vomiting and diarrhea

Recent

oral intake, including breast milk and other fluids and food; urine output;

weight before illness; and associated symptoms, including fever or changes in

mental status, should be noted.

The

past medical history should identify underlying medical problems, history of

other recent infections, medications, and human immunodeficiency virus (HIV)

status. A relevant social history can include the number and nature of

caregivers, which can affect instructions regarding follow-up care.

Physical Examination

Things to gather:

Body weight

Vitals: T, HR, RR, BP

special

concern given to infants and children who appear listless, apathetic, or less

reactive

sunken

eyes? Tearing?

lips, mouth, and tongue will yield

critical clues regarding the degree of dehydration

Deep

respiration can be indicative of metabolic acidosis

Faint

or absent bowel sounds can indicate hypokalemia

general

perfusion and capillary refill

check

skin turgor

Dehydration

Assessment

This table provides a guideline for a starting point for

treatment and who can be sent home for therapy

Lab Evaluation

stool

cultures should be gathered in there is dysentery but not for acute, watery

diarrhes for immunocompetent pt

CBC

and urine and blood cultures might be indicated when sepsis or UTIs are a

concern

Acute

Gastroenteritis Therapy based on degree of dehydration

principles guide optimal treatment in Box 2

Treatment

should include two phases: rehydration and maintenance.

Rehydration phase: the fluid deficit is replaced quickly

(i.e., during 3--4 hours) and clinical hydration is attained.

Maintenance phase: maintenance calories and fluids are

administered. Rapid realimentation should follow rapid rehydration, with a goal

of quickly returning the patient to an age-appropriate unrestricted diet,

including solids

Breastfeeding should be continued at all

times

Diet:

increased as soon as tolerated to compensate for lost caloric intake during the

acute illness.

Lactose

restriction is usually not necessary (although it might be helpful in cases of

diarrhea among malnourished children or among children with a severe

enteropathy), and changes in formula usually are unnecessary

During

both phases, fluid losses from vomiting and diarrhea are replaced in an ongoing

manner

Antidiarrheal

medications are not recommended for infants and children

Minimal

Dehydration

treatment

is aimed at providing adequate fluids and continuing an age-appropriate diet

use of ORS should be encouraged: 1 mL of

fluid should be administered for each gram of output

hospital: weigh soiled diapers (without urine)

unable to measure: children

weighing <10 kg should be administered 60--120 mL (2--4 ounces) ORS for each

episode of vomiting or diarrheal stool, and those weighing >10 kg should be

administered 120--240 mL (4--8 ounces)

Mild – Moderate

Dehydration

should have their estimated fluid deficit

rapidly replaced - administering

50--100 mL of ORS/kg body weight during 2--4 hours using additional ORS to

replace continued losses

Using

a teaspoon, syringe, or medicine dropper, limited volumes of fluid (e.g., 5 mL

or 1 teaspoon) should be offered at first, with the amount gradually increased

as tolerated

Nasogastric (NG) feeding allows continuous

administration of ORS at a slow, steady rate for patients with persistent

vomiting or oral ulcers

cost-effective and well-tolerated than IV rehydration

ORT doesn’t improve child’s dehydration keep them until signs of dehydration

subside

After

dehydration is corrected, further management can be implemented at home,

provided that the child's caregivers demonstrate comprehension of home

rehydration techniques (including continued feeding)

Severe Dehydration

constitutes

a medical emergency requiring immediate IV rehydration

LR,

NS/ similar solution administered until pulse, perfusion and mental status

return to normal

Serum

electrolytes, bicarbonate, blood urea nitrogen, creatinine, and serum glucose

levels should be obtained

Hypotonic

solutions should not be used for acute parenteral rehydration

Watch

for overhydration

Hydration

status should be reassessed frequently to determine the adequacy of replacement

therapy

soon as the severely dehydrated patient's level of consciousness returns to

normal, therapy usually can be changed to the oral route, with the patient

taking by mouth the remaining estimated deficit. An NG tube can be helpful for

patients with normal mental status but who are too weak to drink adequately.

Clinical

management in the hospital

Inpatient

care is indicated for children if

caregivers

cannot provide adequate care at home;

substantial

difficulties exist in administrating ORT, including intractable vomiting,

ORS refusal, or inadequate ORS intake;

concern

exists for other possible illnesses complicating the clinical course;

ORS

treatment fails, including worsening diarrhea or dehydration despite

adequate volumes;

severe

dehydration (>9% of body weight) exists;

social

or logistical concerns exist that might prevent return evaluation, if

necessary, or

such

factors as young age, unusual irritability or drowsiness, progressive

course of symptoms, or uncertainty of diagnosis exist that might indicate

a need for close observation.

Limitations of

ORT:

children in hemodynamic shock – their

airway protective reflexes might be impaired

ileus: don’t give fluids until BS are audible

Bowel

obstruction

limited percentage of infants (<1%) with acute diarrhea experience

carbohydrate malabsorption. This is characterized by a dramatic increase in

stool output after intake of fluids containing simple sugars (e.g., glucose),

including ORS

Hypernatremic

Dehydration

serum sodium concentration >145 mEq/L

Respond

well to ORT

Dietary Therapy

Breastfed

infants: feed on demand

Formula-fed

infants should continue their usual formula immediately upon rehydration in

amounts sufficient to satisfy energy and nutrient requirements

Not

necessary to use lactose free formulas (unless lactose intolerant)

Children

receiving semisolid or solid foods should continue to receive their usual diet

during episodes of diarrhea. Foods high in simple sugars should be avoided

because the osmotic load might worsen diarrhea; therefore, substantial amounts

of carbonated soft drinks, juice, gelatin desserts, and other highly sugared

liquids should be avoided.

Early feeding decreases changes in

intestinal permeability caused by infection, reduces illness duration, and

improves nutritional outcomes

Recommended foods include age-appropriate

unrestricted diets, including complex carbohydrates, meats, yogurt, fruits, and

vegetables.

Pharmacological

Therapy

Antimicrobial

antimicrobial

therapy is not usually indicated among children because the majority of cases

of acute diarrhea are self-limited and not shortened by antimicrobial agents.

Exceptions to these rules involve special needs of individual children

Nonantimicrobial Drug Therapies

Nonspecific

antidiarrheal agents (e.g., adsorbents such as kaolin-pectin), antimotility

agents (e.g., loperamide), antisecretory drugs, and toxin binders (e.g.,

cholestyramine), are commonly used among older children and adults, but data

are limited regarding their efficacy.

Supplemental Zinc

Therapy

severe

zinc deficiency (e.g., acrodermatitis enteropathica) is associated with

diarrhea, milder deficiencies of zinc might play a role in childhood diarrhea,

and zinc supplementation might be of benefit either for improved outcomes in

acute or chronic diarrhea or as prophylaxis against diarrheal disease

# of

trials have been shown that zinc supplements help in treating diarrheal disease

but this needs further evaluation

Probiotics

Further

human trials are needed before making specific recommendations

Acute Bloody Diarrhea (Dysentery)

Oral

rehydration therapy is critical in managing specific types of diarrheal

diseases.

Dysentery: acute bloody diarrhea caused by

invasive microbial infection.

o Doesn’t include occult blood (detected by guaiac card only) or streaks of

blood on the surface of formed stool

of dehydration in dysentery follows the same principles as treatment of acute watery

diarrhea.

Child

with bloody diarrhea is at higher risk for complications, including sepsis and

other systemic diseases - threshold for admission of such children to the

hospital for close observation is lower.

Stool

cultures are needed for guiding therapy. Food should not be withheld for

children with dysentery any more than in other cases of diarrhea. More

frequent, smaller meals might be better tolerated, and higher protein intakes

the majority of cases, empiric antimicrobial agents should not be administered

while awaiting culture results, because antimicrobial therapy might not be

indicated even when culture results are positive. Amoebiasis is an unusual

cause of bloody diarrhea in young children, even in less-developed countries.

Treatment for amoebiasis should be reserved for those cases in which

trophozoites are detected on microscopic examination of the stools

Choice of ORS:

1975, WHO and the United Nations Children's Fund (UNICEF) agreed to promote a

single ORS (WHO-ORS) containing (in mmol/L) sodium 90, potassium 20, chloride

80, base 30, and glucose 111 (2%) for use among diverse populations – single

solution to be used for diarrhea treatment with a variety of electrolytes

losses

Further

studies have shown ORS of lower osmolality is better than ORT

Barriers

Cultural

practices

Lack

of parental knowledge

Lack

of training for HCP

Cost

Among

physicians, preference for IV hydration, even where evidence indicates improved

results from oral rehydration = major barrier

Conclusion:

Treatment

of acute diarrhea has relied upon simple and effective therapy of oral

rehydration. The critical co-principle in case management of early resumption

of feeding of children immediately upon rehydration has also gained wide

acceptance. More recent advances in the science of diarrhea treatment include

recognition for the role of zinc supplementation in reducing disease severity

and occurrence, and development of an oral rehydration solution of lower

osmolarity for global use. The combination of oral rehydration and early

nutritional support promises to safely and effectively assist a patient through

an episode of diarrhea. If the principles of therapy outlined in this report

are accepted by all levels of the medical community and if education of parents

includes teaching them to begin ORT at home, numerous deaths and unnecessary

clinic visits and hospitalizations can be avoided. ORT is suitable for use

among children throughout the world

Toddlers

(18months – 3 yrs old)

Important stages of growth, development and maturation:

Physical

Growth is slower

Growth in spurts

Wide gait and walk hesitantly

Fine and gross motor skills progress

quickly

Fine Motor skills: reaching, grasping,

manipulating small objects

Gross Motor skills: balance and

coordination continuously improve, most are walking alone by 18months, tend to

experiment with skills

Cognitive

Relationships between objects and

actions

Imitate adults

Develop a number sense, match colours

and shapes

Engage in symbolic play (object-use and

make-believe)

Social/ Emotional

Egocentric

Autonomous and independent

No conscience

Demonstrate negativism

Enjoy ritualism

Experience separation anxieties

Tantrums as coping mechanism

Early toddlers: solitary play

Early preschoolers: associative play

Common Concerns/Hazards

Illnesses: chickenpox, viruses

Hazards: most deaths are a result of

accidents (from their curiosity): falls, chemicals, burns, drowning, choking,

and MVA

Communication Techniques:

Demonstrate and use play to teach a

procedure

Provide visuals

Simplify vocabulary: clear and firm

instructions

Offer limited options: don’t offer a

choice when there is none

Praise a child for a job well done

No More Tears for Henry

Content of the notes (1)

Page 1

Information

Feedback

What do you think of the new look?