Nausea Vomiting &Diarrhea Flashcards
How is diarrhea defined?
inc freq of bowel movements (>3 a day), inc amount of stool (>200g/day), and altered consistency (such s inc liquidity) of stool
•often assoc w urgency, perianal discomfort, incontinence, or combo of these factors
What causes diarrhea (general categories)?
- conditions that cause inc intestinal secretions, dec mucosal absorption, or altered motility can prod diarrhea
- often caused by IBS, lactose intolerance
meds, some tube feeding formulas, metabolic and endocrine disorders (DM, addisons, thyrotoxicosis), bacterial and viral infections, nutritional and malabsorptive disorders (celiac)…..
Is diarrhea an acute or chronic problem?
- can be acute (often assoc w infection, self limiting usually, lasts up to 7-14days
- or chronic (>2-3wks and may return sporadically)
5 types of diarrhea?
secretory, osmotic, malabsorptive and exudative, infectious
Secretory diarrhea?
is usually high volume. Often assoc w bacterial toxins and neoplasms. Caused by inc prod and secretion of water and lytes by the intestinal mucosa into intestinal lumen
Osmotic diarrhea?
when water is pulled into intestines by the osmotic pressure of unabsorbed particles which slows water reabsorption may be caused by lactase deficiency, pancreatic dysfx, intestinal hemmorhage
Malabsorptive diarrhea?
combined mechanical and biochemical actions which inhibits absorption of nutrients.
See markers of malnutrition such as hypoalbuminuria, which leads to intestinal mucosa swelling and liquid stool
What is the most commonly identified cause of antibiotic-associated diarrhea in the hospital?
C. Diff
Cause of exudative diarrhea?
caused by changes in mucosal integrity, epithelial loss, or tissue destr by radiation or chemo
Term for intestinal rumbling?
borborygmus
Term for ineffective straining?
Tenesmus
Manifestations of diarrhea?
- inc freq
- fluid stools
- abdominal cramps
- distension
- intestinal rumbling (borborygmus)
- anorexia
- thirst
- on defecation painful spasmodic contractions of the anus and ineffective straining (tenesmus) may occur
- other symp may relate to lytes, fluid balance, dehydration
Voluminous greasy stools suggest?
intestinal malabsorption
Presence of blood, pus, mucus suggests?
inflm enteritis or colitis
How does size of the bowel relate to characteristics of diarrhea?
• watery stools are char of sm bowel disorders.
• Semisolid stool are assoc w disorders of lg bowel.
(this is talking about small vs large intestine?)
Oil droplets on the toilet water are almost aways diagnostic of?
pancreatic insufficiency
Nocturnal diarrhea may be a mnft of?
diabetic neuropathy
What is it important to investigate in all unexplained diarrhea in pts recently taking Abx?
C. Diff
Dx when cause of diarrhea not obvious
o CBC
o Serum chemistries
o Urinalysis
o Routine stool exam and exam for infection/paratistes, bacterial toxins, blood, fat, lytes, WBCs
o Endoscopy or barium enema may help id the cause
Complications of diarrhea?
- Potential dysrhythmias d/t fluid and lyte loss
* Chronic diarrhea can result in irritant dermatitis (prevent w wet wipe, dry, barrier cream)
What conditions regarding symptoms and potassium level must be reported in individuals with diarrhea (as indicates risk for potential cardiac complications)?
• Urinary output of
Gerantological considerations r/t digoxin use and diarrhea?
Elderly dehydrate quickly, more susceptible to hypokalemia
Teach if on digoxin abt hypokalemia and dehydration (they occur v fast) and signs & symp of hypokalemia
–> need to know symptoms of hypokalemia because low K levels potentiate digoxin action and thus inc risk of digitalis toxicity
Geriatric considerations regarding what to look for as a nurse?
- Observe pt for mnfts of muscle weakness, dysrhythmas, dec peristaltic motility that may lead to paralytic ileus
- Esp sensitive to excoriation of perianal area
Medical management of diarrhea?
WHat is often the med of choice?
• Control symp, prevent complic, elim cause
- Abx, anti-inflm, antidiarrheals used
• Often loperamide (imodium) is the med of choice as it has less side effects than diphenoxylate (Lomotil)
How to assess perianal area?
pt either standing and bent forward ont he exam table or ling on left side w left leg extened and right leg flexed (sims).
Spread buttocks and ask pt to bear down. Look for lesions, hemmorhoids, warts, rectal fissures
Nursing assessments r/t diarrhea?
- Assess and monitor the characteristics and pattern of diarrhea
- Pmhx should include med therapy, med and surg hx, dietary pattern and intake, recent exposure, travel
If acute diarrhea episode, what should nurse do?
encourage bed rest, intake of liquids and foods w low bulk (restriction may be nec eg no dairy, veggies, grains etc for several days)
When eating start w bland, semisolid and solids.
what kind of food to encourage in pt with diarrhea?
What not to eat?
- When eating start w bland, semisolid and solids.
* No: caffeine, carbonation, v hot or v cold (they stimulate intestinal motility)
What is Hyperemesis gravidarum?
aka pernicious or presistent vomiting)
= n+v that lasts past wk 16 of regnancy or thats so severe it results in dehydration, ketonuria and significant wt loss (>5%) occur within the first 12wks of pregnancy
•Often stops abruptly at ~13 weeks (end of first trimester) d/t change in hormones from placenta
How common is HG?
Cause?
- 2% incidence
* Unknown cause, may relate to inc thyroid stim from high hCG levels or maybe r/t H. Pylori
What sort of changes are seen in blood of woman with HG?
- May have elevated hct due to inability to retain fluid leading to hemoconcentration-can lead to thromboemboism
- d/t low intake may have dec sodium, potassium and chloride.
- hypokalemic alkalosis may result from loss of HCL from stomach
Metabolic disorders (ketosis)
Physical manifestations of HG for mother and baby?
- Wt loss can be severe
- ataxia (loss of control of body movements) and confusion can occur as result of vitamin B1 deficiency
- if not treated she may get so dehydrated she cant give fetus nutrients for growth resulting in preterm birth or intrauterine growth restriction
Assessment of woman with HG?
- how much N and V is the women having should always be determined
- ask her to describe the previous day
- how much food could she eat
- how late did the N last? How often did she V and how much?
Management/interventions of HG?
How will a woman presenting with this be treated in hospital?
- women w this must be hospitalized 24hrs to monitor and document their I/O (measure vomitus etc), blood chemistries and to restore hydration
- oral food and fluids are withheld for first 24hrs. If no V after 24hrs they can start clear fluids and progress on to crackers etc then reg diet but if V resumes then she may be put on TPN to ensure adequate nutrition
- Give ringers lactate w vitamin B1 for hydration
- may give metoclopramide (preg class B) for V
What are the initial goals of nursing care of woman with HG?
• main challenge initially is dehydration then lack of nutrition
Some need counselling for psychological distress r/t this condition
Important consideration for monitoring if woman is on TPN?
check blood glucose twice daily
- -> if high, shows can’t process as much sugar as is being admin’d
- -> if ketones present, may need more
Does HG have long term ramifications?
if caught early, doesn’t lead to problems
- IF not treated, can cause death!
How to manage n and V for woman with HG (r/t food characteristics)
- enc small portions and limit exposure to aromatic foods if hypersensitive to smells
- Serve hot foods hot, and cold foods cold
Common cause of vomiting in children?
•many kids who V are suffering from mild gastroenteritis (infection). Some develop persistent or cyclic vomiting
Vomiting assessment components?
o timing
o is it forceful projected 1ft from infant or up to 4ft (often assoc w pyloric stenosis)
o duration
o amount
o description eg colour, smell, blood tinged etc
o distress
•use accurate descriptors such as on table on 1315 (comparing regurgitation and vomiting) as diff conditions have diff types of V
Should a child be fed after vomiting?
How should introduction of food progress?
• often parents feed kids after vomiting but it is best to give the stomach a rest as if it is empty the child wont vomit.
3-6hrs is often enough of a rest for the stomach.
Initially offer ice chips, water by tbsp, or use popsicles. Then give clear liquids, then broths and milk then crackers or toast
• By day 2 the kid can be on soft diet
Resuming intake in infant that is vomiting?
W infant have them fast 3hrs then give 1 tbsp q15mins for 2hrs then 1oz water q2hrs for 12-18hrs, then clear fluid then breast milk. Can use rehydration soln
Are children typically given anti-emetics?
Which are appropriate?
• Acute gastroenteritis is self limiting so its rare to give kids antiemetics
if nec use Ondansetron or promethazine (ask abt herbal remedies theyve given the kid first)
Why is diarrhea so dangerous in infants + children?
d/t their small ECF reserves
Common Causes of diarrhea in children?
- Giardia lamblia often causes protozoan infction.
- Viruses=adenovirus and rotaviruses are common
- Campylobacter jejuni, salmonella, c diff, e coli are common bacterial
- These can be easily spread from public change areas etc
What is the relationship between breast milk and diarrhea?
actively prevents diarrhea by providing more Abs
How does mild diarrhea manifest in children and infants?
What does it look like?
What physiological changes will you see?
- Kids w diarrhea appear unwell and often have a fever 38.4-39
- Diarrhea contains 2-10 loose watery BMs/day
- Unlike normal infant stool which is yellow diarrheal stool is green and is effortless to pass, more acidic, sweet or foul smelling
- Skin is warm and mucous memb are dry but skin turgor wont be dec yet. Urine output normal
- Pulse may be rapid
Therapeutic mgmt of diarrhea in children
-
- Rest the gi tract for a short time
- After 1hr can give rehydrating soln
- If infant is breastfed have them continue
- Can give probiotics
- May need to treat fever
Can parents give OTC drugs to children for diarrhea?
What deficiency occurs in infants following diarrhea?
- Have parents contact dr before beginning OTC drugs eg loperamide (immodium) etc as toxic levels can occur quick
- Infants can get temporary lactase deficiency after diiarrhea
How do kids present with severe diarrhea?
Temp?
- Kid appears v unwell
* Rectal temp can be 39.5-40. Pulse and resps weak and rapid, skin cool and pale
How do infants with severe diarrhea present?
What does the diarrhea look like?
- Infants can be listless, apprehensive and lethargic
- Will have obvious signs of dehydration eg depressed fontanelles, sunken eyes,poor skin turgor
- Diarrhea is often green, every few minutes and mixed with mucus and blood
- Urine output will be concentrated and small
How will labs appear for child with severe diarrhea?
- will show hemoconcentration –> inc Hct, Hb, + protein levels d/t dehydration
- Electrolytes will show metabolic acidosis
How would fetal growth restriction be assessed in pt with HG?
fundal height and U/S
How can fluid loss be determined in children?
What parameters indicate mild dehydration?
When is immediate tx necessary for infants?
Is difficult…
Can be best assessed by weighing kid. Loss of 2.5%-5% of body weight suggests mild dehydration
•Infants that have lost >10% of body weight require immed Tx
How do you intervene with child with severe diarrhea?
Focus on regulation of electrolyte and fluid balance by giving GI tract rest, oral or IV rehydration and figuring out the organism responsible for the diarrhea
- -> oral rehydration therapy is ideal, but may give IV NS or 5% glucose in NS
- Measure intake/output
What is typically done if child’s diarrhea persists for more than 24 hours?
Are antibiotics typically used right away?
take a stool culture (from diaper, bed pan or rectum)
As abx can cause diarrhea the pt shouldn’t be put straight on them without figuring out which organism it is
What labs are taken for child with diarrhea?
- Hct + Hb (to show dehydration and anemia)
- WBC (infection?)
- ## PCo2, Cl-, Na+, K+ and pH (to establish electrolyte needs)
Children tend to have potassium depletion with diarrhea. What must first be established prior to giving IV fluid with K+?
MUST FIRST establish that child is not in renal failure
- Child must void first (indicating proper kidney fx)
What to do with infants while on NPO status?
Wet lips with moisturizing cream or jelly
offer pacifier for comfort (will want to suck if thirsty and also want to feed because interpret intestinal cramping as hunger)
Should you take a rectal temp on an infant when they are having diarrhea?
No, use other method as this stimulating anal sphincter may cause more diarrhea
Weight equivalent of 1mL of fluid in diaper?
1g
Why is diarrhea green
lack of time for bile to be modified by intestine
What measurement of stool indicates acute diarrhea?
Presence of sugars and ph below 7.0
(sugar normally should be rapidly absorbed in intestine but not having time to do so)
- as diarrhea improves, sugar and acidity will decrease
Why is diarrhea acidic?
??
When to change diapers for infant with diarrhea?
What to do if irritation already exists in area?
Immediately!
Is very irritating to skin
Clean area thoroughly and if agency protocol allows, put on Vaseline or A&D ointment
- If already excoriated, exposing to air + using ointment can help
Causes of chronic diarrhea
tumours, AIDS, diabetes, hyperthyroidism, Addisons disease and IBS
Why are children at increased risk of dehydration
- Immature kidneys, less concentrated urine
- Greater body surface area= greater insensible losses
- Infants and children become dehydrated FAST (infants can lose 40% ECF in 24 hours)
- Dehydration becomes a medical emergency can lead to kidney failure, cardiac collapse, death
Key nursing concerns for woman with HG? (class slides)
- FVD/Dehydration
- Malnutrition
- Vitamin deficiencies (especially B), weight
- Metabolic disorders (ketosis)
- Stress and extreme fatigue (impaired coping)
- Fetal Growth Restriction (fundal height and U/S)
- DVT (r/t increased HCT and immobility/fatigue)
- Inability to perform ADL’s, loss of role in home
- Anxiety r/t fear for fetus
Medical interventions for woman with HG? (class slides)
—Antiemetics: ondansetron, metoclopramide
—medical cannabis
— folic acid, thiamine (B6), B1
— LMWH
Key nursing interventions for woman with HG?
Consult w SW, neonate, pharmacy
Therapeutic Communication and active listening
Reduce odours, noises, provide fresh air, “breezes”, encourage woman to move slowly, provide socialization and contact as directed by patient to avoid isolation/depression
Monitor weight and electrolytes, nutritional profile and contact physician if worsening
IV rehydration (B1 + B6 added)
Possible TPN in severe cases
Early signs of dehydration in peds (class slides)
Dry mouth
Late signs of dehydration in peds (class slides)
Sunken fontanelles in babies Loss of tears Sunken eyes Rapid, deep respirations (acidosis) Cold extremeties Rapid weak pulse Cyanosis Loss of skin turgor Coma
Why are the elderly at increased risk as result of vomitting + diarrhea?
- Less body water overall–> more rapid dehydration
- Kidneys function declines –> less able to concentrate urine + regulate Na excretion, etc
- ## Less functional reserve of all organs –> water + electrolyte imbalance means organs cannot compensate as quickly, more prone to fail
What is the most pertinent sign of dehydration in children?
Weight loss
