Gastroenteritis pathophysiology nursing

Gastroenteritis pathophysiology nursing DEFAULT

Acute Gastroenteritis (Stomach flu)

by Daisy Jane Antipuesto RN MN · November 9, 2010

Acute Gastroenteritis (also called Stomach Flu)

  • Acute gastroenteritis is a sudden condition that causes irritation and inflammation of the stomach and intestines or the gastrointestinal tract.
  • Viral infection is the most common cause of gastroenteritis but bacteria, parasites, and food-borne illness (such as shellfish) can also cause acute gastroenteritis.
  • Fifty to seventy percent of cases of gastroenteritis in adults are caused by the noroviruses while rotavirus is the leading cause of infection in children. Staphylococcus aureus can form a toxin that cause food poisoning while the resident Escherichia coli can also cause significant problems.
  • Many people who experience symptoms of vomiting and diarrhea, which develop from these types of infections or irritations believe they have food poisoning, and they indeed have a food-borne illness.
  • The severity of gastroenteritis depends on the immune system’s ability to resist and fight the infection. Electrolytes, especially sodium and potassium may be lost if the client continue to vomit and experience diarrhea.
  • Most people recover easily from a short course of vomiting and diarrhea by drinking lots of fluids and resuming a typical diet. But for some, especially the young and the old, loss of body fluids with gastroenteritis can cause dehydration, which is a life-threatening condition unless it is treated and fluids are replaced.

Pathophysiology:

The mechanisms potentially responsible for viral diarrhea include lysis of enterocytes, interference with the brush border function that leads to malabsorption of electrolytes, stimulation of cyclic adenosine monophosphate (cAMP), and carbohydrate malabsorption. For bacterial gastroenteritis, the pathophysiology involves the elaboration of toxin by enterotoxigenic pathogens and the invasion and inflammation of mucosa by invasive pathogens. Parasitic organisms invade epithelial cells and cause villus atrophy and eventual malabsorption.

Clinical Manifestations:

  • Low grade fever to 100°F (37.8°C)
  • Nausea with or without vomiting
  • Mild to moderate diarrhea
  • Crampy and painful abdominal bloating

More serious symptoms include:

  • Blood in vomit or stool
  • Vomiting more than 48 hours
  • Fever higher than 101°F (40°C)
  • Swollen abdomen or abdominal pain
  • Dehydration that is manifested by weakness, lightheadedness, decreased and concentrated urination, dry skin and poor turgor, and dry lips and mouth

Diagnostic Tests:

  • Blood test
  • Analysis of stool samples
  • Electrolyte tests
  • Physical examination to rule other existing conditions such as appendicitis

Medical Management:

Home care:

  • Clear fluids are appropriate for the first 24 hours to maintain adequate hydration.
  • They should be given oral rehydration solutions such as Pedialyte for pediatric patients or commercially prepared oral rehydration solution.  For homemade ORS, mix 2 tablespoons of sugar (or honey) with ¼ teaspoon of table salt in 1 liter (1 qt) of clean or previously boiled water.
  • After 24 hours without vomiting , begin to offer soft bland foods such as the BRAT diet, which includes bananas, rice, applesauce without sugar, toast, pasta, and potatoes.

Hospitalization:

  • Hydration through intravenous line.
  • Replacement of fluid losses volume per volume.
  • Encourage small, frequent feedings.

Prevention:

  • Always wash your hands before eating and after using the comfort room.
  • Eat only properly cooked and stored food.
  • Bleach soiled linens used.
  • Have vaccinations for salmonella typhi, vibrio cholerae, and rotavirus.

Photo credits:  www.nlv.ch

Daisy Jane Antipuesto RN MN

Currently a Nursing Local Board Examination Reviewer. Subjects handled are Pediatric, Obstetric and Psychiatric Nursing. Previous work experiences include: Clinical instructor/lecturer, clinical coordinator (Level II), caregiver instructor/lecturer, NC2 examination reviewer and staff/clinic nurse. Areas of specialization: Emergency room, Orthopedic Ward and Delivery Room. Also an IELTS passer.

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Tags:acute gastroentiritisGastrointestinal diseasesstomach flu

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Gastroenteritis Nursing Care Plans

Definition

Gastroenteritis is an inflammation of the stomach and intestinal tract that primarily affects the small bowel. The major clinical manifestations are diarrhea of varying degrees and abdominal pain and cramping. Associated clinical manifestations are nausea, vomiting, fever anorexia, distention, tenesmus (straining on defecation), and borborygmi (hyperactive bowel sounds).

Nursing Care Plans

The nursing goals for patients with Acute Gastroenteritis are toward avoiding dehydration and management of diarrhea. This post contains 4 nursing care plans and 3 possible nursing diagnoses for AGE.

Diarrhea

Diarrhea is defined as an increase in the frequency, volume and fluid content of stool. Rapid propulsion of intestinal contents through the small bowel results in diarrhea. Diarrhea is a hallmark sign of gastroenteritis.

Assessment

Patient may manifest

  • Hyperactive bowel sounds
  • Audible borborygmi
  • Passage of loose liquid watery stools for more than 3 times
  • Poor skin turgor
  • Dehydration
  • Dry lips and oral mucosa
  • Altered LOC
  • Pain
  • Stomach cramping

Nursing Diagnosis

Outcomes

  • Patient will verbalize understanding of causative factors and rationale for treatment regimen.
  • Patient will reestablish and maintain normal pattern of bowel functioning AEB passage of semi-solid stools
Nursing InterventionsRationale
Establish rapportTo gain patient’s trust
Assess general condition and vital signsFor baseline data
Auscultate abdomenFor presence, location, and characteristics of bowel sounds
Discuss the different causative factors and rationale for treatment regimenFor patient education
Restrict solid food intakeTo allow for bowel rest and reduce intestinal workload
Provide for changes in dietary intakeTo prevent foods/substances that precipitate diarrhea
Limit caffeine and high-fiber foods and so as fatty foodsTo prevent gastric irritation
Promote use of relaxation techniqueTo decrease stress and anxiety that can aggravate diarrhea
Encourage oral fluid intake of fluids containing electrolyteFor fluid replacement
Recommend products like yogurt and cultured milkTo restore normal flora
Emphasize importance of handwashingTo prevent spread of infectious diseases
Acute Pain

One of the manifestations of gastroenteritis is abdominal pain. During the course of inflammation, the body’s immune response, causing the release of cytokine and prostaglandin causing an increase in vascular permeability and causes pain, which felt by the patient in the abdomen.

Assessment

Patient may manifest

  • Abdominal Pain
  • Appears weak
  • Limited range of motion
  • Restlessness
  • Verbalization of pain with a pain
  • Facial grimaces
  • Irritability
  • Impaired thought process
  • Reduced interaction with people
  • sleep disturbances
  • Diaphoresis

Nursing Diagnosis

Outcomes

  • Patient will report a decrease of pain.
  • Patient will be free from pain and demonstrate relaxational skills.
Nursing InterventionsRationale
 Review factor that aggravate or alleviate pain To lessen/alleviate pain caused by various factors (administer meds via IV push)
 Instruct the SO to massage the area where pain is elicited if not contraindicated To reduce pain and promote relief/comfort
 Encourage pain reduction techniques To promote healing and provide non-pharmacological pain reduction techniques
 Provide adequate rest To reduce pain and promote relief/comfort
 Provide diversional activities like socialization For client’s comfort and relief from pain
 Administer analgesics to maintain acceptable level of pain if not contraindicated For client’s comfort and relief from pain
 Instruct client to perform deep breathing exercises (DBE)  Deep breathing exercises may reduce pain sensation/ used in pain management
 Monitor effectiveness of pain medications To promote timely intervention/ revision of plan of care
Deficient Fluid Volume

Rapid propulsion of intestinal contents through the small bowels may lead to a serious fluid volume deficit. The body would want to expel the foreign objective as much as possible thus it doesn’t undergo its “normal” speed, with that, the digestive system organs are not able to absorb the excess fluids that are usually absorbed by the body.

Assessment

Patient may manifest

  • passage of loose watery stool
  • vomiting
  • abdominal cramping
  • dehydration
  • nausea
  • fatigue
  • weakness
  • nervousness
  • confusion
  • weight loss
  • decreased skin turgor
  • decreased urine output
  • dry mucous membrane
  • fever

Nursing Diagnosis

  • Deficient fluid volume RT excessive losses through normal routes AEB frequent passage of loose watery stool

Outcomes

  • Patient will report understanding of causative factors for fluid volume deficit
  • Patient will maintain fluid volume at functional level AEB well hydrated, intake is equal as output, and normal skin turgor.
Nursing InterventionsRationale
 Maintain adequate hydration, increase fluid intake. To prevent dehydration & maintain hydration status.
 Provide frequent oral care To prevent from dryness
 Administer Intravenous fluids as prescribed To deliver fluids accurately and at desired rates.
 Determine effects of age. Very young and extremely elderly individuals are quickly affected by fluid volume deficit
 Restrict solid food intake, as indicated To allow for bowel rest and to reduced intestinal workload.
 Discuss individual risk factors/ potential problems and specific interventions To prevent or limit occurrence of fluid deficit.
Activity Intolerance

Activity intolerance is insufficient physiological or psychological energy poor endure or complete required or desired daily activities. Because of low hgb and hct level there will be decrease oxygen being delivered to the tissues of the body since the hgb is responsible for the oxygenation of tissue. As a compensatory mechanism, the body will increase its demand of oxygen by increasing respiratory rate of the patient which results then to fatigue. Because of this there will be fast consumption of ATP leading to weaker contractions thus causing muscle weakness. And if the patient has muscle weakness there will be activity intolerance.

Assessment

Patient may manifest

  • Weakness
  • Restlessness
  • Physical inactivity
  • Increase respiratory rate
  • Fatigue
  • Low hgb count
  • Low hct count

Nursing Diagnosis

  • Activity intolerance related to generalized weakness AEB limited physical activity.

Outcomes

  • Patient will identify negative factors affecting activity intolerance and eliminate or reduce their effects.
  • Patient will participate willingly in necessary or desired activities.
Nursing InterventionsRationale
 Provide health teaching on the client regarding the organization and time management technique to prevent while on activity To enhance patient ability to participate in activity
 Provide enough air coming from the electric fan or from the window  To monitor patients response to activities
 Develop and adjust simple activity like brushing his teeth To prevent overexertion
 Assist client with activity To protect patient from injury
 Promote comfort measures on the activity To prevent over-exhaustion
 Cluster nursing care To prevent over-exhaustion
 Ascertain ability to stand and move about degree of assistance To determine current status and needs
 Encourage complete bed rest For patient recuperation and recovery
Other Possible Nursing Care Plans
  • Imbalanced Nutrition: Less than Body Requirements due to insufficient intake and excessive output;
  • Risk for Deficient Fluid Volume (if diarrhea does not occur or intake of fluids is insufficient but does not have any signs of dehydration);
  • Hyperthermia RT inflammatory process.

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Gastroenteritis is inflammation of the lining of the stomach and small and large intestines. Most cases are infectious, although gastroenteritis may occur after ingestion of drugs and chemical toxins (eg, metals, plant substances). Acquisition may be foodborne, waterborne, or via person-to-person spread. In the US, an estimated 1 in 6 people contracts foodborne illness each year. Symptoms include anorexia, nausea, vomiting, diarrhea, and abdominal discomfort. Diagnosis is clinical or by stool culture, although polymerase chain reaction testing and immunoassays are increasingly used. Treatment is symptomatic, although some parasitic and some bacterial infections require specific anti-infective therapy.

Gastroenteritis is usually uncomfortable but self-limited. Electrolyte and fluid loss is usually little more than an inconvenience to an otherwise healthy adult but can be grave for people who are very young (see Dehydration in Children Dehydration in Children Dehydration is significant depletion of body water and, to varying degrees, electrolytes. Symptoms and signs include thirst, lethargy, dry mucosa, decreased urine output, and, as the degree... read more ), elderly, or immunocompromised or who have serious concomitant illnesses. Worldwide, an estimated 1.5 to 2.5 million children die each year from infectious gastroenteritis (1 General reference Gastroenteritis is inflammation of the lining of the stomach and small and large intestines. Most cases are infectious, although gastroenteritis may occur after ingestion of drugs and chemical... read more ); although high, this number represents one half to one quarter of previous mortality. Improvements in water sanitation in many parts of the world and the appropriate use of oral rehydration therapy for infants with diarrhea are likely responsible for this decrease.

  • 1. Sattar SBA, Singh S: Bacterial gastroenteritis [Updated 2019 Mar 8]. In StatPearls (Internet). Treasure Island, StatPearls Publishing, 2020.

Infectious gastroenteritis may be caused by viruses, bacteria, or parasites. Many specific organisms are discussed further in the Infectious Diseases section.

The viruses most commonly implicated are

Viruses are the most common cause of gastroenteritis in the US. They infect enterocytes in the villous epithelium of the small bowel. The result is transudation of fluid and electrolytes into the intestinal lumen; sometimes, malabsorption of carbohydrates worsens symptoms by causing osmotic diarrhea. Diarrhea is watery. Inflammatory diarrhea (dysentery), with fecal white blood cells (WBCs) and red blood cells (RBCs) or gross blood, is uncommon. Four categories of viruses cause most gastroenteritis: norovirus and rotavirus cause the majority of viral gastroenteritis, followed by astrovirus and enteric adenovirus.

Norovirus infects people of all ages. Since the introduction of rotavirus vaccines, norovirus has become the most common cause of acute gastroenteritis in the US, including in children. Infections occur year-round, but 80% occur from November to April. Norovirus is now the principal cause of sporadic and epidemic viral gastroenteritis in all age groups; however, the peak age is between 6 months and 18 months. Large waterborne and foodborne outbreaks occur. Person-to-person transmission also occurs because the virus is highly contagious. This virus causes most cases of gastroenteritis epidemics on cruise ships and in nursing homes. Incubation is 24 to 48 hours.

Astrovirus can infect people of all ages but usually infects infants and young children. Infection is most common in winter. Transmission is by the fecal-oral route. Incubation is 3 to 4 days.

The bacteria most commonly implicated are

Bacterial gastroenteritis is less common than viral. Bacteria cause gastroenteritis by several mechanisms.

Mucosal invasion occurs with other bacteria (eg, Shigella Shigellosis Shigellosis is an acute infection of the intestine caused by the gram-negative Shigella species. Symptoms include fever, nausea, vomiting, tenesmus, and diarrhea that is usually bloody. Diagnosis... read more , Salmonella Overview of Salmonella Infections The genus Salmonella is divided into 2 species, S. enterica and S. bongori, which include > 2400 known serotypes. Some of these serotypes are named. In such cases, common usage sometimes shortens... read more , CampylobacterCampylobacter and Related Infections Campylobacter infections typically cause self-limited diarrhea but occasionally cause bacteremia, with consequent endocarditis, osteomyelitis, or septic arthritis. Diagnosis is by culture, usually... read more , C. difficile Overview of Clostridial Infections Clostridia are spore-forming, gram-positive, anaerobic bacilli present widely in dust, soil, and vegetation and as normal flora in mammalian gastrointestinal tracts. Pathogenic species produce... read more , some Escherichia coliEscherichia coli Infections The gram-negative bacterium Escherichia coli is the most numerous aerobic commensal inhabitant of the large intestine. Certain strains cause diarrhea, and all can cause infection when they invade... read more subtypes) that invade the mucosa of the small bowel or colon and cause microscopic ulceration, bleeding, exudation of protein-rich fluid, and secretion of electrolytes and water. The invasive process and its results can occur whether or not the organism produces an enterotoxin. The resulting diarrhea contains WBCs and RBCs and sometimes gross blood.

Several different subtypes of E. coli cause diarrhea. The epidemiology and clinical manifestations vary greatly depending on the subtype:

  • Enterohemorrhagic E. coli is the most clinically significant subtype in the US. It produces Shiga toxin, which causes bloody diarrhea (hemorrhagic colitis). Thus, these subtypes are sometimes termed Shiga toxin–producing E. coli (STEC). E. coli O157:H7 Infection by Escherichia coli O157:H7 and Other Enterohemorrhagic E. coli (EHEC) The gram-negative bacteria Escherichia coli O157:H7 and other enterohemorrhagic E. coli (EHEC) typically cause acute bloody diarrhea, which may lead to hemolytic-uremic syndrome. Symptoms are... read more is the most common strain of this subtype in the US. Undercooked ground beef, unpasteurized milk and juice, and contaminated water are possible sources. Person-to-person transmission is common in the day care setting. Outbreaks associated with exposure to water in recreational settings (eg, pools, lakes, water parks) have also been reported. Hemolytic-uremic syndrome is a serious complication that develops in 5 to 10% of STEC cases (and 10 to 15% of O157:H7), most commonly among the young and old.

  • Enteropathogenic E. coli causes watery diarrhea. Once a common cause of diarrhea outbreaks in nurseries, this subtype is now rare.

  • Enteroinvasive E. coli causes bloody or nonbloody diarrhea, primarily in the developing world. It is rare in the US.

  • Enteroaggregative E. coli causes diarrhea of lesser severity but longer duration than the other subtypes. As with some of the other subtypes, it is more common in the developing world and can be a cause of traveler's diarrhea.

Each of these E. coli subtypes can be detected in stool by polymerase chain reaction testing, typically using a multiplex panel. Sometimes more than one organism is detected simultaneously, the clinical significance of which is unclear.

Pearls & Pitfalls

  • C. difficile is now probably the most common bacterial cause of diarrhea in the US.

Several other bacteria cause gastroenteritis, but most are uncommon in the US. Yersinia enterocolitica Plague and Other Yersinia Infections Plague is caused by the gram-negative bacterium Yersinia pestis. Symptoms are either severe pneumonia or massive lymphadenopathy with high fever, often progressing to septicemia. Diagnosis is... read more Plague and Other <i>Yersinia</i> Infections can cause gastroenteritis or a syndrome that mimics appendicitis. It is transmitted by undercooked pork, unpasteurized milk, or contaminated water. Several Vibrio Noncholera Vibrio Infections Noncholera vibrios include the gram-negative bacteria Vibrio parahaemolyticus, V. mimicus, V. alginolyticus, V. hollisae, and V. vulnificus; they may cause diarrhea, wound infection, or septicemia... read more species (eg, V. parahaemolyticus) cause diarrhea after ingestion of undercooked seafood. V. cholerae Cholera Cholera is an acute infection of the small bowel by the gram-negative bacterium Vibrio cholerae, which secretes a toxin that causes copious watery diarrhea, leading to dehydration, oliguria... read more sometimes causes severe dehydrating diarrhea in the developing world and is a particular concern after natural disasters or in refugee camps. Listeria Listeriosis Listeriosis is bacteremia, meningitis, cerebritis, dermatitis, an oculoglandular syndrome, intrauterine and neonatal infections, or rarely endocarditis caused by Listeria species. Symptoms vary... read more can rarely cause food-borne gastroenteritis but more often causes bloodstream infection or meningitis in pregnant women, neonates (see Neonatal Listeriosis Neonatal Listeriosis Neonatal listeriosis is acquired transplacentally or during or after delivery. Symptoms are those of sepsis. Diagnosis is by culture or polymerase chain reaction testing of mother and infant... read more ), or the elderly. Aeromonas is acquired from swimming in or drinking contaminated fresh or brackish water. Plesiomonas shigelloides can cause diarrhea in patients who have eaten raw shellfish or traveled to tropical regions of the developing world.

The parasites most commonly implicated are

Certain intestinal parasites, notably Giardia intestinalis (G. lamblia), adhere to or invade the intestinal mucosa, causing nausea, vomiting, diarrhea, and general malaise. Giardiasis occurs in every region of the US and throughout the world. The infection can become chronic and cause a malabsorption syndrome. It is usually acquired via person-to-person transmission (often in day care centers) or from contaminated water.

Cryptosporidium parvum causes watery diarrhea sometimes accompanied by abdominal cramps, nausea, and vomiting. In healthy people, the illness is self-limited, lasting about 2 weeks. In immunocompromised patients, illness may be severe and prolonged, causing substantial electrolyte and fluid loss. Cryptosporidium is usually acquired through contaminated water. It is not easily killed by chlorine and is the most common cause of recreational waterborne illness in the US, accounting for about three fourths of outbreaks.

Symptoms and Signs of Gastroenteritis

The character and severity of symptoms of gastroenteritis vary. Generally, onset is sudden, with anorexia, nausea, vomiting, abdominal cramps, and diarrhea (with or without blood and mucus). Malaise, myalgias, and prostration may occur. The abdomen may be distended and mildly tender; in severe cases, muscle guarding may be present. Gas-distended intestinal loops may be palpable. Hyperactive bowel sounds are present on auscultation even without diarrhea (an important differential feature from paralytic ileus, in which bowel sounds are absent or decreased). Persistent vomiting and diarrhea can result in intravascular fluid depletion with hypotension and tachycardia. In severe cases, shock, with vascular collapse and oliguric renal failure, occurs.

Viral gastroenteritis

In viral infections, watery diarrhea is the most common symptom; stools rarely contain mucus or blood.

Rotavirus gastroenteritis in infants and young children may last 5 to 7 days. Vomiting occurs in 90% of patients, and fever > 39° C (>102.2° F) occurs in about 30%.

Norovirus typically causes acute onset of vomiting, abdominal cramps, and diarrhea, with symptoms lasting only 1 to 2 days. In children, vomiting is more prominent than diarrhea, whereas in adults, diarrhea usually predominates. Patients may also have fever, headache, and myalgias.

The hallmark of adenovirus gastroenteritis is diarrhea lasting 1 to 2 weeks. Affected infants and children may have mild vomiting that typically starts 1 to 2 days after the onset of diarrhea. Low-grade fever occurs in about 50% of patients. Respiratory symptoms may be present. Symptoms are generally mild but can last longer than with other viral causes of gastroenteritis.

Astrovirus causes a syndrome similar to mild rotavirus infection.

Bacterial gastroenteritis

Bacteria that cause invasive disease (eg, Shigella Shigellosis Shigellosis is an acute infection of the intestine caused by the gram-negative Shigella species. Symptoms include fever, nausea, vomiting, tenesmus, and diarrhea that is usually bloody. Diagnosis... read more , Salmonella Overview of Salmonella Infections The genus Salmonella is divided into 2 species, S. enterica and S. bongori, which include > 2400 known serotypes. Some of these serotypes are named. In such cases, common usage sometimes shortens... read more ) are more likely to result in fever, prostration, and bloody diarrhea.

Parasitic gastroenteritis

  • Stool testing in select cases

Other gastrointestinal disorders that cause similar symptoms (eg, appendicitis Appendicitis Appendicitis is acute inflammation of the vermiform appendix, typically resulting in abdominal pain, anorexia, and abdominal tenderness. Diagnosis is clinical, often supplemented by CT or ultrasonography... read more Appendicitis, cholecystitis Acute Cholecystitis Acute cholecystitis is inflammation of the gallbladder that develops over hours, usually because a gallstone obstructs the cystic duct. Symptoms include right upper quadrant pain and tenderness... read more , ulcerative colitis Ulcerative Colitis Ulcerative colitis is a chronic inflammatory and ulcerative disease arising in the colonic mucosa, characterized most often by bloody diarrhea. Extraintestinal symptoms, particularly arthritis... read more Ulcerative Colitis) must be excluded (see also evaluation of diarrhea Evaluation Stool is 60 to 90% water. In Western society, stool amount is 100 to 200 g/day in healthy adults and 10 g/kg/day in infants, depending on the amount of unabsorbable dietary material (mainly... read more ).

Findings suggestive of gastroenteritis include copious, watery diarrhea; ingestion of potentially contaminated food (particularly during a known outbreak), untreated surface water, or a known gastrointestinal irritant; recent travel; or contact with certain animals or similarly ill people.

Stool testing is guided by clinical findings and the organisms that are suspected based on patient history and epidemiologic factors (eg, immunosuppression, exposure to a known outbreak, recent travel, recent antibiotic use). Cases are typically stratified into

  • Subacute or chronic watery diarrhea

  • Acute inflammatory diarrhea

Multiplex polymerase chain reaction platforms that can identify causative organisms in each of these categories are being used more often. However, this testing is expensive, and because the categories are distinguishable clinically, it is usually more cost-effective to test for specific microorganisms depending on the type and duration of diarrhea. In addition, polymerase chain reaction testing does not allow for antibiotic susceptibility testing.

Acute watery diarrhea is probably viral and testing is not indicated unless the diarrhea persists. Although rotavirus and enteric adenovirus infections can be diagnosed using commercially available rapid assays that detect viral antigen in the stool, these assays are rarely indicated.

Acute inflammatory diarrhea without gross blood can be recognized by the presence of WBCs on stool examination. Patients should have stool culture for typical enteric pathogens (eg, Salmonella Overview of Salmonella Infections The genus Salmonella is divided into 2 species, S. enterica and S. bongori, which include > 2400 known serotypes. Some of these serotypes are named. In such cases, common usage sometimes shortens... read more , Shigella Shigellosis Shigellosis is an acute infection of the intestine caused by the gram-negative Shigella species. Symptoms include fever, nausea, vomiting, tenesmus, and diarrhea that is usually bloody. Diagnosis... read more , CampylobacterCampylobacter and Related Infections Campylobacter infections typically cause self-limited diarrhea but occasionally cause bacteremia, with consequent endocarditis, osteomyelitis, or septic arthritis. Diagnosis is by culture, usually... read more , E. coliEscherichia coli Infections The gram-negative bacterium Escherichia coli is the most numerous aerobic commensal inhabitant of the large intestine. Certain strains cause diarrhea, and all can cause infection when they invade... read more ).

Acute inflammatory diarrhea with gross blood should also prompt testing specifically for E. coli O157:H7, as should nonbloody diarrhea during a known outbreak. Specific cultures must be requested because this organism is not detected on standard stool culture media. Alternatively, a rapid enzyme assay for the detection of Shiga toxin in stool can be done; a positive test indicates infection with E. coli O157:H7 or one of the other serotypes of enterohemorrhagic E. coli. (NOTE: Shigella species in the US do not produce Shiga toxin.) However, a rapid enzyme assay is not as sensitive as culture. Polymerase chain reaction testing is used to detect Shiga toxin in some centers.

  • Consideration of antidiarrheal agents if C. difficile or E. coli O157:H7 infection is not suspected

  • Antibiotics only in select cases

Supportive treatment is all that is needed for most patients. Bed rest with convenient access to a toilet or bedpan is desirable. Oral glucose-electrolyte solutions, broth, or bouillon may prevent dehydration or treat mild dehydration. Even if vomiting, the patient should take frequent small sips of such fluids; vomiting may abate with volume replacement. For patients with E. coli O157:H7 infection, rehydration with isotonic IV fluids may attenuate the severity of any renal injury should hemolytic-uremic syndrome develop. Children may become dehydrated more quickly and should be given an appropriate rehydration solution (several are available commercially—see Oral Rehydration Oral Rehydration Oral fluid therapy is effective, safe, convenient, and inexpensive compared with IV therapy. Oral fluid therapy is recommended by the American Academy of Pediatrics and the WHO and should be... read more ). Carbonated beverages and sports drinks lack the correct ratio of glucose to sodium and thus are not appropriate, particularly for children < 5 years. If the child is breastfed, breastfeeding should continue. If vomiting is protracted or if severe dehydration is prominent, IV replacement of volume and electrolytes is necessary (see Intravenous Fluid Resuscitation Intravenous Fluid Resuscitation Almost all circulatory shock states require large-volume IV fluid replacement, as does severe intravascular volume depletion (eg, due to diarrhea or heatstroke). Intravascular volume deficiency... read more ).

When the patient can tolerate fluids without vomiting and the appetite has begun to return, food may be gradually restarted. There is no demonstrated benefit from restriction to bland food (eg, cereal, gelatin, bananas, toast). Some patients have temporary lactose intolerance.

Antidiarrheal agents are safe for patients > 2 years with watery diarrhea (as shown by heme-negative stool). However, antidiarrheals may cause deterioration of patients with C. difficile or E. coli O157:H7 infection and thus should not be given to any patient with recent antibiotic use or heme-positive stool, pending specific diagnosis. Effective antidiarrheals include loperamide 4 mg orally initially, followed by 2 mg orally for each subsequent episode of diarrhea (maximum of 6 doses/day or 16 mg/day), or diphenoxylate 2.5 to 5 mg 3 times a day or 4 times a day in tablet or liquid form. For children, loperamide is used. The dose for children 13 to 21 kg is 1 mg after the first loose stool then 1 mg after each subsequent loose stool (maximum dose is 3 mg/day); for children 21 to 28 kg, 2 mg after the first loose stool then 1 mg after each subsequent loose stool (maximum dose is 4 mg/day); and for children 27 to 43 kg, up to age 12, 2 mg after the first loose stool followed by 1 mg after each subsequent loose stool (maximum dose is 6 mg/day).

If vomiting is severe and a surgical condition has been excluded, an antiemetic may be beneficial. Drugs useful in adults include prochlorperazine 5 to 10 mg IV 3 times a day or 4 times a day, or 25 mg rectally 2 times a day and promethazine 12.5 to 25 mg IM 3 times a day or 4 times a day, or 25 to 50 mg rectally 4 times a day. These drugs are usually avoided in children because of lack of demonstrated efficacy and the high incidence of dystonic reactions. Ondansetron is safe and effective in decreasing nausea and vomiting in children and in adults, including those with gastroenteritis, and is available as a standard tablet, oral disintegrating pill, or IV formulation. The dose for adults is 4 or 8 mg orally or IV 3 times a day. For children, the IV dose is 0.15 or 0.3 mg/kg (maximum 16 mg) and the oral dose for children 8 to 15 kg is 2 mg, for children > 15 to 30 kg, 4 mg, and for children > 30 kg, 8 mg. A single dose of ondansetron is usually adequate for children, but if needed the dose may be repeated every 8 hours for 2 more doses; children still vomiting after 24 hours require reevaluation.

Although probiotics appear to briefly shorten the duration of diarrhea, there is insufficient evidence that they affect major clinical outcomes (eg, decrease the need for IV hydration and/or hospitalization) to support their routine use in the treatment or prevention of infectious diarrhea.

For cryptosporidiosis, a 3-day course of nitazoxanide may be helpful in immunocompetent patients. The dose is 100 mg orally 2 times a day for children 1 to 3 years, 200 mg orally 2 times a day for children 4 to 11 years, and 500 mg orally 2 times a day for children ≥ 12 years and adults. Giardiasis is treated with metronidazole or nitazoxanide.

icon

To prevent recreational waterborne infections, people should not swim if they have diarrhea. Infants and toddlers should have frequent diaper checks and should be changed in a bathroom and not near the water. Swimmers should avoid swallowing water when they swim.

Infants and other immunocompromised people are particularly predisposed to developing severe cases of salmonellosis and should not be exposed to reptiles, birds, or amphibians, which commonly carry Salmonella.

Breastfeeding affords some protection to neonates and infants. Caregivers should wash their hands thoroughly with soap and water after changing diapers, and diaper-changing areas should be disinfected with a freshly prepared solution of 1:64 household bleach (¼ cup diluted in 1 gallon of water). Children with diarrhea should be excluded from child care facilities for the duration of symptoms. Children infected with enterohemorrhagic E. coli or Shigella should also have two negative stool tests before readmission to the facility.

Drug NameSelect Trade

prochlorperazine

COMPRO

Ciprofloxacin

CILOXAN, CIPRO

metronidazole

FLAGYL

trimethoprim

No US brand name

promethazine

PROMETHEGAN

nitazoxanide

ALINIA

Azithromycin

ZITHROMAX

fidaxomicin

DIFICID

Ondansetron

ZOFRAN

Doxycycline

PERIOSTAT, VIBRAMYCIN

iodoquinol

YODOXIN

Tinidazole

TINDAMAX

loperamide

IMODIUM

vancomycin

VANCOCIN

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NOTE: This is the Professional Version. CONSUMERS: Click here for the Consumer Version Sours: https://www.merckmanuals.com/professional/gastrointestinal-disorders/gastroenteritis/gastroenteritis
  • Gastroenteritis is a short-term illness triggered by the infection and inflammation of the digestive system. Symptoms can include abdominal cramps, diarrhoea and vomiting. 
  • Some of the causes of gastroenteritis include viruses, bacteria, bacterial toxins, parasites, particular chemicals and some drugs.
  • Good old-fashioned handwashing with soap and water is still the best defence against spreading the bug.
  • Clean kitchen tops, toys, toilet seats, nappy change tables and taps to ensure you don’t spread the infection to others at home.
  • If you or anyone in your household is ill, stay home for 48 hours after symptoms have stopped to ensure you are clear of infection.

Gastroenteritis is an illness triggered by the infection and inflammation of the digestive system. Typical symptoms include abdominal cramps, diarrhoea and vomiting. In many cases, the condition heals itself within a few days. 

The main complication of gastroenteritis is dehydration, but this can be prevented if the fluid lost in vomit and diarrhoea is replaced. A person suffering from severe gastroenteritis may need fluids administered intravenously (directly into the bloodstream via a vein – the setup is often referred to as a ‘drip’). Some of the causes of gastroenteritis include viruses, bacteria, bacterial toxins, parasites, particular chemicals and some drugs.

Symptoms of gastroenteritis

The symptoms of gastroenteritis can include: 

  • Loss of appetite.
  • Bloating.
  • Nausea.
  • Vomiting.
  • Abdominal cramps.
  • Abdominal pain.
  • Diarrhoea.
  • Bloody stools (poo) – in some cases.
  • Pus in the stools – in some cases.
  • Generally feeling unwell – including lethargy and body aches.

Causes of gastroenteritis

There are many things that can cause gastroenteritis, including: 

  • Viruses – such as norovirus, calicivirus, rotavirus, astrovirus and adenovirus.
  • Bacteria – such as the Campylobacter bacterium.
  • Parasites – such as Entamoeba histolytica, Giardia lamblia and Cryptosporidium.
  • Bacterial toxins – the bacteria themselves don’t cause illness, but their poisonous by-products can contaminate food. Some strains of staphylococcal bacteria produce toxins that can cause gastroenteritis.
  • Chemicals – lead poisoning, for example, can trigger gastroenteritis.
  • Medication – certain medication (such as antibiotics), can cause gastroenteritis in susceptible people.

Infectious gastroenteritis

Infectious gastroenteritis is caused by viruses, bacteria or parasites. In each case, infection occurs when the agent is ingested, usually by eating or drinking. Some of the common types of infectious gastroenteritis include: 

  • Escherichia coli infection – this is a common problem for travellers to countries with poor sanitation. Infection is caused by drinking contaminated water or eating contaminated raw fruits and vegetables
  • Campylobacter infection – the bacteria are found in animal faeces (poo) and uncooked meat, particularly poultry. Infection is caused by, for example, consuming contaminated food or water, eating undercooked meat (especially chicken), and not washing your hands after handling infected animals
  • Cryptosporidium infection – parasites are found in the bowels of humans and animals. Infection is caused by, for example, swimming in a contaminated pool and accidentally swallowing water, or through contact with infected animals. An infected person may spread the parasites to food or surfaces if they don’t wash their hands after going to the toilet
  • Giardiasis – parasite infection of the bowel. Infection is caused by, for example, drinking contaminated water, handling infected animals or changing the nappy of an infected baby and not washing your hands afterwards.
  • Salmonellosis – bacteria are found in animal faeces. Infection is caused by eating contaminated food or handling infected animals. An infected person may also spread the bacteria to other people or surfaces by not washing their hands properly
  • Shigellosis – bacteria are found in human faeces. An infected person may spread the bacteria to food or surfaces if they don’t wash their hands after going to the toilet
  • Viral gastroenteritis – infection is caused by person-to-person contact such as touching contaminated hands, faeces or vomit, or by drinking contaminated water or food.

Diagnosis of gastroenteritis

It is important to establish the cause, as different types of gastroenteritis respond to different treatments. Diagnostic methods may include: 

  • medical history
  • physical examination
  • blood tests
  • stool tests.

Treatment for gastroenteritis

Treatment depends on the cause, but may include: 

  • Plenty of fluids.
  • Oral rehydration drinks, available from your pharmacist.
  • Admission to hospital and intravenous fluid replacement, in severe cases.
  • Antibiotics, if bacteria are the cause.
  • Drugs to kill the parasites, if parasites are the cause.
  • Avoiding anti-vomiting or anti-diarrhoea drugs unless prescribed or recommended by your doctor, because these medications will keep the infection inside your body.

Prevention of gastroenteritis

Gastroenteritis is highly contagious, general suggestions on how to reduce the risk of infection include: 

  • Stay home while sick, until 48 hours after symptoms have stopped. If symptoms persist, visit your GP.
  • Wash hands thoroughly with soap and water after going to the toilet or changing nappies, after smoking, after using a handkerchief or tissue, or after handling animals.
  • Wash your hands thoroughly with soap and water before preparing food or eating.
  • Use disposable paper towels to dry your hands rather than cloth towels, since the bacteria can survive for some time on objects.
  • Do not handle raw and cooked foods with the same implements (tongs, knives, cutting boards), unless they have been thoroughly washed between uses. 
  • Keep all kitchen surfaces and equipment clean.
  • Keep cold food cold (below 5 °C) and hot food hot (above 60 °C) to discourage the growth of bacteria.
  • Make sure foods are thoroughly cooked.
  • Clean kitchen tops, toys, toilet seats, nappy change tables and taps to ensure you don’t spread the infection to others at home.
  • Clean the toilet and bathroom regularly (especially the toilet seat, door handles and taps).
  • Clean baby change tables regularly.
  • When travelling overseas to countries where sanitation is suspect, only drink bottled water. Don’t forget to brush your teeth in bottled water too. Avoid food buffets, uncooked foods or peeled fruits and vegetables, and ice in drinks.

Note: Wash hands with soap and water as this is the best way to prevent infection. Alcohol-based hand sanitisers while effective against some viruses (such as coronavirus), are not effective against gastroenteritis.

Learn more about gastroenteritis in children and how to be a Soapy Hero!

Where to get help

  • Gastroenteritis – viral pamphlet, 2008, Department of Health and Human Services, Victorian Government.
  • Shigellosis, Communicable Disease Epidemiology and Surveillance, Department of Health, Victorian Government. 
  • Rotavirus, Communicable Disease Epidemiology and Surveillance, Department of Health, Victorian Government. 
  • Viral gastroenteritis (not rotavirus), Communicable Disease Epidemiology and Surveillance, Department of Health, Victorian Government.

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Sours: https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/gastroenteritis

Nursing gastroenteritis pathophysiology

Viral Gastroenteritis (Nursing)

Learning Outcome

  1. List the types of viruses that cause gastroenteritis

  2. Describe the presentation of viral gastroenteritis

  3. Summarize the treatment of viral gastroenteritis

  4. Recall the role of the nurse in the care of a patient with viral gastroenteritis

Introduction

Acute infectious gastroenteritis is a common illness seen around the world. Viral pathogens cause most of these cases. Acute diarrheal disease is generally self-limiting in industrialized nations but can have significant morbidity for young and elderly patients. In underdeveloped countries, viral diarrheal diseases are a significant cause of death, especially in infants [1][2]. According to the Centers for Disease Control, viral gastroenteritis infections can account for over 200,000 deaths of children per year worldwide. Viral gastroenteritis is a known cause of nausea, vomiting, diarrhea, anorexia, weight loss, and dehydration. Isolated cases can occur, but viral gastroenteritis more commonly occurs in outbreaks within close communities such as daycare centers, nursing facilities, and cruise ships. Many different viruses can lead to symptomatology, though in routine clinical practice the true causative virus is generally not identified. Regardless of the viral cause, treatment is generally uniform and directed toward symptomatic improvement with a focus on hydration status [1][2]. In the United States and other industrialized countries, the disease is most often self-limited and resolves in 1 to 3 days. However, in susceptible patients including young children, elderly patients, and the immunocompromised, hospitalization can occur without proper supportive care leading to increased morbidity and mortality [3][4].

Nursing Diagnosis

  • Diarrhea

  • Fluid imbalance

  • Risk for malnutrition

  • Risk for dehydration

  • Irritability

Causes

Several different viruses including rotavirus, norovirus, adenovirus, and astroviruses account for most cases of acute viral gastroenteritis. Most are transmitted via the fecal-oral route, including contaminated food and water. Transmission has also been shown to occur via fomites, vomitus, and possibly airborne methods. Norovirus is more resistant to chlorine and ethanol inactivation than other viruses.

Rotavirus

Rotavirus is a double-stranded RNA virus named for the wheel-like appearance of its viral capsid on an electron micrograph. Rotavirus infection is universal among humans, and almost all children acquire antibodies by age 3 [5]. Rotavirus infection usually presents with acute vomiting followed by several days of diarrhea, crampy abdominal pain, anorexia, and low-grade fevers. Infants and young children who develop severe dehydration are more likely to have an infection from rotavirus than other viral gastroenteritis pathogens. Viral shedding of infectious particles can occur in the stool for up to 10 days [6]. Adults are more likely to develop an asymptomatic infection with a rise in antibody titer. Immunosuppressed individuals can experience more prolonged and severe disease, with longer viral shedding [7]. Rotavirus pathogenesis is complicated with several possible mechanisms including malabsorption from mucosal damage, viral enterotoxin secretion, and enteric secretions in response to the virus. Rotavirus increases electrolyte secretion from the small intestine and decreases glucose cotransport of these electrolytes [8].

Throughout recorded history, rotavirus has been the leading cause of episodic infantile illness worldwide. However, in 2006 an oral vaccine was introduced. Since the introduction and utilization of this vaccine, the United States and many other industrialized countries have seen a sharp decline in the number and severity of gastroenteritis cases caused by rotavirus. Before 2006, it was estimated that over 3.5 million infants were affected annually in the United States and that rotavirus led to 440,000 deaths annually worldwide in children less than five years old [9]. Since the routine vaccination of children, each year has seen a 58% to 90% reduction in cases [10]. Before vaccination, the United States saw an estimated 55,000-70,000 hospitalizations of children under five due to rotavirus. This number has decreased by 40,000-50,000 since the vaccine became available, according to the Centers for Disease Control. Although the incidence of rotavirus in the United States has been historically seasonal, with peak seasonality being from December to April, this pattern has become very inconsistent since vaccination became common [11]. Now, the virus tends to infect sporadically throughout the year in the United States. Despite the widespread use of the vaccine in developed countries, rotavirus is still the leading cause of infantile diarrheal illness worldwide. The Centers for Disease Control estimated that there were still 215,000 rotavirus-related deaths in 2013. More than 40% of World Health Organization member countries have initiated large-scale vaccination of children. This number is anticipated to rise in the next few years. In turn, infection and mortality caused by rotavirus are expected to continue declining.

Norovirus

Norovirus is a single-stranded RNA member of the calicivirus family [12]. It is the most common cause of epidemic diarrheal illness, accounting for over 90% of viral gastroenteritis outbreaks and approximately 50% of cases worldwide [13]. Norovirus can withstand freezing, heating, and common disinfectant products containing alcohol or chlorine [14]. It is a frequent cause of outbreaks within somewhat closed communities such as nursing homes, schools, military populations, athletic teams, and cruise ships.

Norovirus presents most commonly with abdominal cramps and nausea followed by vomiting and/or diarrhea. Onset can be abrupt. Symptoms also include myalgias, malaise, and low-grade fevers up to 39 C. Diarrhea is non-bloody and can consist of multiple bowel movements per day. The illness is self-limiting, and most patients have recovered in 72 hours without sequelae [1]. Elderly individuals and immunocompromised patients may have a more severe and prolonged illness. 

Norovirus infection causes histopathologic changes in the jejunum of blunted villi with intact mucosa [15]. These changes occur quickly and usually resolve by two weeks after the onset of illness. Fat and d-xylose absorption decrease as does brush border enzyme activity leading to diarrhea [15]. Unlike rotavirus, there does not seem to be enterotoxin production.

Since the advent of the rotavirus vaccine, norovirus has become the most common cause of viral gastroenteritis in the United States, responsible for 19 to 21 million total illnesses per year. It is estimated to cause 56,000-71,000 hospitalizations and 570-800 deaths annually in the United States [13]. Because of its relative stability in the environment, norovirus is implicated in nearly 50% of all foodborne outbreaks [13]. Norovirus is present throughout the year, despite initially being thought of as a disease that peaked in the winter months.

Other viral causes of acute viral gastroenteritis include adenovirus, Sapovirus, and Astrovirus [16]. Each of these viruses can cause anywhere between 2 to 9% of viral gastroenteritis cases, with developing countries seeing a slightly higher burden of disease from the astrovirus group. These viruses tend to affect children more than adults.

Risk Factors

The most frequent cause of diarrheal disease worldwide is acute viral gastroenteritis. Men and women are affected equally. Norovirus is the most common viral cause. It is responsible for 90% of epidemic diarrheal cases worldwide and approximately 50% of all viral gastroenteritis cases. It accounts for 19 to 21 million cases of diarrheal illness annually in the United States alone. Norovirus causes 50% of all foodborne diarrheal outbreaks [13]. Prior to routine vaccination, rotavirus was the most common cause of diarrheal illness in the pediatric population with roughly 3.5 million cases per year in the United States. Nearly all children possessed rotavirus antibodies by age three. Worldwide, rotavirus accounted for 440,000 deaths per year [9]. However, since the implementation of vaccination in 2006, the number of cases seen annually in the United States has declined 50% to 90% per year [11]. As more countries adopt the standard practice of rotavirus vaccination, the overall number of cases is expected to continue to decrease. Other viral causes such as adenovirus, Sapovirus, and astrovirus account for 2 to 9% of cases worldwide, with a higher bias for children than adults [16].

Assessment

Acute gastroenteritis is defined by loose or watery diarrhea that consists of 3 or more bowel movements in a day. Other symptoms may include nausea, vomiting, fever, or abdominal pain [3]. Symptoms usually last for less than a week, most often improving after 1 to 3 days. Any signs of illness that persist past two weeks are classified as chronic and therefore do not meet the requirements for acute gastroenteritis. Patients often present with complaints of a relatively sudden onset of symptoms, usually over the course of 1 to 2 hours. Other people in the family or close contacts may have similar complaints. Mild fever and mild abdominal pain are common. Vomiting is present in most but not all cases. Concerning symptoms include high fever, bloody diarrhea, protracted vomiting, or severe abdominal pain. These may indicate to the clinician that another disease process may be the cause. It is important to elicit information relevant to causes other than viral gastroenteritis, such as bacterial agents or other acute abdominal pathology including acute appendicitis, bowel obstruction, and diverticulitis. Travel history, recent antibiotic use, disease exposure, occupational exposures, and immune status should all be considered. Particular attention should be paid to infants, elderly patients, and individuals who are immunosuppressed due to disease or medication usage. 

Upon physical exam, it is important to address any abnormal vital signs. Mild fever is common in viral gastroenteritis, but high fever (greater than 39 C) should trigger concern for causes that are not viral in origin. Additionally, tachycardia and tachypnea may be present due to fever and dehydration. An assessment for dehydration is of the utmost importance, especially in patients who demonstrate extremes of age, chronic illness, or immunosuppression. These patient groups are at a much higher risk for severe complications due to dehydration. Another physical exam finding may include mild, diffuse abdominal tenderness. Significant tenderness to palpation, guarding, rebound, or point-specific tenderness should lead the clinician to consider other causes of symptomatology.

Evaluation

Due to the lack of readily available viral testing capabilities in most clinics and emergency departments, acute viral gastroenteritis is a clinical diagnosis. Therefore, patients who appear clinically well-hydrated and who lack risk factors for severe disease do not necessarily warrant further testing. Diagnostics are used to help rule out other causes of the patient’s symptoms. Complete blood counts may reveal a mild leukocytosis in a patient with viral gastroenteritis. Other serum inflammatory markers may also show mild elevation. Patients who are suffering from significant dehydration may demonstrate hemoconcentration on complete blood count testing as well as electrolyte disturbances on chemistry panels. Dehydration may also present as acute kidney injury, evidenced by changes in the BUN and creatinine on a chemistry panel.

Imaging studies of the abdomen most often appear normal. CT scans may reveal mild, diffuse colonic wall thickening or other inflammatory changes of the bowel. However, there are no specific findings, and CT scanning should be performed to rule out other, more severe etiologies. Stool studies may be obtained, but readily available laboratory testing assays assess only for bacterial causes and do not diagnose specific viral causes. Patients with bloody stool, high fever, severe abdominal pain, or severe dehydration warrant stool studies as these symptoms are not consistent with simple viral gastroenteritis.

Medical Management

The treatment of viral gastroenteritis is based on symptomatic support [3][4]. The most important goal of treatment is to maintain hydration status and effectively counter fluid and electrolyte losses. Fluid therapy is a fundamental part of treatment. Intravenous fluids may be administered to those individuals who appear dehydrated or to those unable to tolerate oral fluids. Antiemetic medications such as ondansetron or metoclopramide may be used to assist with controlling nausea and vomiting symptoms. Patients demonstrating severe dehydration or intractable vomiting may require hospital admission for continued intravenous fluids and careful monitoring of electrolyte status. Electrolyte abnormalities may be addressed on an individual level, although often these are caused by an overall fluid volume depletion which, when corrected, will also cause electrolytes to normalize. Both saline and lactated Ringer’s solutions appear to be effective for the treatment of dehydration due to viral gastroenteritis. 

Debate exists over antidiarrheal medication usage. Medications such as diphenoxylate/atropine or loperamide are not recommended in patients who are 65 or older. Younger patients may benefit from antimotility medications [4]. However, some feel that if a patient can maintain a well-hydrated status, antidiarrheal treatment should not be initiated. For oral rehydration, some studies have shown that commercially available oral rehydration solutions containing electrolytes are superior to sports drinks and other forms of oral rehydration [2]. However, a recent study using children with mild dehydration demonstrated no differences between children receiving oral rehydration solutions versus ad lib oral intake [17]. No specific nutritional recommendations are universal for patients with viral gastroenteritis. A diet of banana, rice, apples, tea, and toast is often advised, but several studies have failed to show any significant outcome difference when compared to regular diets [18].

Most patients who present to outpatient clinics or the emergency department with acute viral gastroenteritis can be discharged home safely. Adults often benefit from antiemetic medications at home although home antiemetic medication is not recommended in young children. Patients who may benefit from hospital observation or admission are those that demonstrate signs or symptoms of dehydration, intractable vomiting, severe electrolyte disturbances, significant renal failure, severe abdominal pain, or pregnancy.

Nursing Management

  • Assess vital signs

  • Encourage intake of fluids

  • Educate caregiver about viral gastroenteritis

  • Assess infant/child for abdominal pain, nausea

  • Assess ins and outs

  • Assess for signs of dehydration

  • Educate about handwashing and proper hygiene measures

  • Educate about the importance of clean water for cooking

  • Encourage the parent to follow up with medical care

  • Educate caregiver about the rotavirus vaccine

Outcome Identification

  • Able to eat

  • No diarrhea

  • No abdominal symptoms

  • Normal mentation

Coordination of Care

Many patients with gastroenteritis present to the emergency room. However, because there are so many causes of gastroenteritis, the emergency department physician, nurse practitioner, and internist need to rule out other serious disorders first become making a diagnosis of viral gastroenteritis, which is a clinical diagnosis aided with laboratory data.

Food poisoning due to bacterial toxins frequently causes symptoms very similar to viral gastroenteritis, though the treatment for food poisoning often parallels that of viral gastroenteritis. Bacterial and protozoal causes of gastroenteritis can potentially mimic symptoms of viral gastroenteritis but often require a different treatment approach and may carry higher morbidity potential.

If there is any doubt about the diagnosis, the infectious disease expert should be consulted before discharging the patient. Most patients with viral gastroenteritis improve with supportive measures including hydration and bowel rest.

References

1.

Shane AL, Mody RK, Crump JA, Tarr PI, Steiner TS, Kotloff K, Langley JM, Wanke C, Warren CA, Cheng AC, Cantey J, Pickering LK. 2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea. Clin Infect Dis. 2017 Nov 29;65(12):1963-1973. [PMC free article: PMC5848254] [PubMed: 29194529]

2.

King CK, Glass R, Bresee JS, Duggan C., Centers for Disease Control and Prevention. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21;52(RR-16):1-16. [PubMed: 14627948]

3.

Thielman NM, Guerrant RL. Clinical practice. Acute infectious diarrhea. N Engl J Med. 2004 Jan 01;350(1):38-47. [PubMed: 14702426]

4.

Guerrant RL, Van Gilder T, Steiner TS, Thielman NM, Slutsker L, Tauxe RV, Hennessy T, Griffin PM, DuPont H, Sack RB, Tarr P, Neill M, Nachamkin I, Reller LB, Osterholm MT, Bennish ML, Pickering LK., Infectious Diseases Society of America. Practice guidelines for the management of infectious diarrhea. Clin Infect Dis. 2001 Feb 01;32(3):331-51. [PubMed: 11170940]

5.

Parashar UD, Nelson EA, Kang G. Diagnosis, management, and prevention of rotavirus gastroenteritis in children. BMJ. 2013 Dec 30;347:f7204. [PMC free article: PMC5776699] [PubMed: 24379214]

6.

Bishop RF, Davidson GP, Holmes IH, Ruck BJ. Letter: Evidence for viral gastroenteritis. N Engl J Med. 1973 Nov 15;289(20):1096-7. [PubMed: 4742237]

7.

Rayani A, Bode U, Habas E, Fleischhack G, Engelhart S, Exner M, Schildgen O, Bierbaum G, Maria Eis-Hübinger A, Simon A. Rotavirus infections in paediatric oncology patients: a matched-pairs analysis. Scand J Gastroenterol. 2007 Jan;42(1):81-7. [PubMed: 17190767]

8.

Mavromichalis J, Evans N, McNeish AS, Bryden AS, Davies HA, Flewett TH. Intestinal damage in rotavirus and adenovirus gastroenteritis assessed by d-xylose malabsorption. Arch Dis Child. 1977 Jul;52(7):589-91. [PMC free article: PMC1544758] [PubMed: 195541]

9.

Parashar UD, Hummelman EG, Bresee JS, Miller MA, Glass RI. Global illness and deaths caused by rotavirus disease in children. Emerg Infect Dis. 2003 May;9(5):565-72. [PMC free article: PMC2972763] [PubMed: 12737740]

10.

Aliabadi N, Tate JE, Haynes AK, Parashar UD., Centers for Disease Control and Prevention (CDC). Sustained decrease in laboratory detection of rotavirus after implementation of routine vaccination—United States, 2000-2014. MMWR Morb Mortal Wkly Rep. 2015 Apr 10;64(13):337-42. [PMC free article: PMC4584623] [PubMed: 25856253]

11.

Tate JE, Panozzo CA, Payne DC, Patel MM, Cortese MM, Fowlkes AL, Parashar UD. Decline and change in seasonality of US rotavirus activity after the introduction of rotavirus vaccine. Pediatrics. 2009 Aug;124(2):465-71. [PubMed: 19581260]

12.

Glass RI, Parashar UD, Estes MK. Norovirus gastroenteritis. N Engl J Med. 2009 Oct 29;361(18):1776-85. [PMC free article: PMC3880795] [PubMed: 19864676]

13.

Hall AJ, Lopman BA, Payne DC, Patel MM, Gastañaduy PA, Vinjé J, Parashar UD. Norovirus disease in the United States. Emerg Infect Dis. 2013 Aug;19(8):1198-205. [PMC free article: PMC3739528] [PubMed: 23876403]

14.

Keswick BH, Satterwhite TK, Johnson PC, DuPont HL, Secor SL, Bitsura JA, Gary GW, Hoff JC. Inactivation of Norwalk virus in drinking water by chlorine. Appl Environ Microbiol. 1985 Aug;50(2):261-4. [PMC free article: PMC238613] [PubMed: 2996421]

15.

Robilotti E, Deresinski S, Pinsky BA. Norovirus. Clin Microbiol Rev. 2015 Jan;28(1):134-64. [PMC free article: PMC4284304] [PubMed: 25567225]

16.

Olortegui MP, Rouhani S, Yori PP, Salas MS, Trigoso DR, Mondal D, Bodhidatta L, Platts-Mills J, Samie A, Kabir F, Lima A, Babji S, Shrestha SK, Mason CJ, Kalam A, Bessong P, Ahmed T, Mduma E, Bhutta ZA, Lima I, Ramdass R, Moulton LH, Lang D, George A, Zaidi AKM, Kang G, Houpt ER, Kosek MN., MAL-ED Network. Astrovirus Infection and Diarrhea in 8 Countries. Pediatrics. 2018 Jan;141(1) [PubMed: 29259078]

17.

Freedman SB, Willan AR, Boutis K, Schuh S. Effect of Dilute Apple Juice and Preferred Fluids vs Electrolyte Maintenance Solution on Treatment Failure Among Children With Mild Gastroenteritis: A Randomized Clinical Trial. JAMA. 2016 May 10;315(18):1966-74. [PubMed: 27131100]

18.

DuPont HL. Guidelines on acute infectious diarrhea in adults. The Practice Parameters Committee of the American College of Gastroenterology. Am J Gastroenterol. 1997 Nov;92(11):1962-75. [PubMed: 9362174]

Sours: https://www.ncbi.nlm.nih.gov/books/NBK568704/
Acute Gastroenteritis (Paediatrics) Overview

Infectious diarrhea is commonly referred to as gastroenteritis.

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.

Pathophysiology

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.

Causes

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.

Clinical Manifestations

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 Management

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.

Pharmacologic Management

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

Nursing management in a child with gastroenteritis includes:

Nursing Assessment

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.

Nursing Diagnoses

Based on the assessment data, the major nursing diagnoses are:

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

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.

Evaluation

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 Guidelines

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

Please visit our nursing test bank page for more NCLEX practice questions.

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?

A. Muscle pain
B. Constipation
C. Fatigue
D. Hearing loss

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
D. Tachypnea

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.

See Also


Related topics to this study guide:

Further Reading


Recommended resources and books for pediatric nursing:
  1. PedsNotes: Nurse's Clinical Pocket Guide (Nurse's Clinical Pocket Guides)
  2. Pediatric Nursing Made Incredibly Easy
  3. Wong's Essentials of Pediatric Nursing
  4. Pediatric Nursing: The Critical Components of Nursing Care
Categories Pediatric NursingTags American Academy of Pediatrics (AAP), Antiemetics, Chills, cough, deficient knowledge, Diabetic Ketoacidosis, Diarrhea, European Society of Pediatric Gastroenterology and Nutrition (ESPGAN), fatigue, fever, Fluid Volume Deficit, gastroenteritis, Gastroesophageal Reflux Disease (GERD), Imbalanced Nutrition Less Than Body Requirements, Metabolic Acidosis, Metabolic Alkalosis, metronidazole, Myalgias, Oral Rehydration Solution (ORS), rash, Rhinorrhea, Risk for Fluid Volume Deficit, Sodium, Sore Throat, World Health Organization (WHO)Sours: https://nurseslabs.com/gastroenteritis/

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