Gastroenteritis Nursing Care Planning and Management

Gastroenteritis (stomach flu) is inflammation of the stomach and intestines that drives nausea, vomiting, diarrhea, and abdominal cramps. Most cases are viral and self-limiting, but the thing that hurts kids is dehydration, so that is where your attention goes. Track wet diapers, weigh stools and diapers, protect the perianal skin, and start oral rehydration early. Viral, bacterial, and parasitic pathogens all cause it, with viruses most common.

What is Gastroenteritis?

Acute gastroenteritis is often called benign, but it remains a major cause of morbidity and mortality in children worldwide, accounting for 1.34 million deaths a year in children younger than 5 years, roughly 15% of all child deaths. Diarrhea ranges from mild with slight dehydration to severe needing prompt, effective treatment.

Pathophysiology

Two mechanisms drive acute gastroenteritis. Damage to the villous brush border causes malabsorption and osmotic diarrhea. Toxins binding specific enterocyte receptors trigger chloride release into the lumen, causing secretory diarrhea. Even in severe diarrhea, sodium-coupled solute co-transport stays intact, allowing efficient reabsorption of salt and water. Classic oral rehydration solution (ORS) exploits this: a 1:1 proportion of sodium to glucose uses the sodium-glucose transporter (SGLT-1) to drive sodium reabsorption, which pulls water along passively.

Statistics and Incidences

Gastroenteritis is most common where clean water and sanitation are lacking. US children average 1.3-2.3 episodes of diarrhea per year. Acute gastroenteritis accounts for more than 1.5 million outpatient visits, 220,000 hospitalizations, and direct costs over $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 those deaths in the developing world. Prevalence has changed little over the past four decades, but mortality has fallen sharply, from 4.6 million in the 1970s to 3 million in the 1980s and 2.5 million in the 1990s.

Causes

The cause is often hard to pin down, but the usual sources are:

• Infectious agents. Salmonella, Escherichia coli, dysentery bacilli, and various viruses, most notably rotaviruses.
• Contaminated food. Many cases come from food or human or animal fecal waste via the oral-fecal route.
• Unsanitary water and environment, especially where clean water and sanitation are lacking.
• Antibiotic therapy, which can itself cause diarrhea.

Clinical Manifestations

• Diarrhea. Frequent watery stools point to viral disease; blood or mucus points to a bacterial pathogen.
• Vomiting. When vomiting predominates, consider GERD, diabetic ketoacidosis, pyloric stenosis, acute abdomen, or urinary tract infection.
• Dysuria. Track urination frequency by wet diapers, time since last void, urine color and concentration, and any dysuria.
• Abdominal pain. Pain that precedes vomiting and diarrhea is more likely from abdominal pathology other than gastroenteritis.
• Infection. Note fever, chills, myalgias, rash, rhinorrhea, sore throat, cough, and known immunocompromised status.

Assessment and Diagnostic Findings

Most children with acute gastroenteritis do not need serum or urine tests, which rarely help gauge dehydration. Stool specimens may be collected for culture and sensitivity to identify the causative organism if there is one.

Medical Management

• Oral rehydration solution. The AAP, ESPGAN, and WHO all recommend ORS as the treatment of choice for mild-to-moderate gastroenteritis in developed and developing countries.
• NG feeding. For patients who cannot tolerate ORS by mouth, nasogastric feeding is a safe, effective alternative.
• IV rehydration. Obtain IV access in severe dehydration and give a bolus of 20-30 mL/kg lactated Ringer or normal saline over 60 minutes.
• Diet. Return children to a normal diet as fast as possible; early feeding shortens illness and improves nutritional outcome.

Pharmacologic Management

• Vaccines. In February 2006, the FDA approved the RotaTeq vaccine to prevent rotavirus gastroenteritis.
• Metronidazole, the treatment of choice for mild-to-moderate C difficile colitis.
• Antiemetics. A review of seven randomized controlled trials in children found oral ondansetron reduced vomiting and the need for IV rehydration and admission, IV ondansetron and metoclopramide reduced vomiting episodes and admission, and dimenhydrinate suppository reduced the duration of vomiting.

Nursing Management

Nursing Assessment

• Stool characteristics. Get a history of bowel patterns and onset of diarrhea, with the number and type of stools per day; offer the caregiver terms for color and odor to help them describe stools.
• Vomiting. Ask about recent feeding patterns, nausea, and vomiting.
• Illness. Ask about fever and other signs of illness in the child and in other family members.
• Physical examination. Observe skin turgor and condition (including an excoriated diaper area), temperature, anterior fontanelle, apical pulse, stools, irritability, lethargy, vomiting, urine, lips and oral mucous membranes, eyes, and any notable signs.

Nursing Diagnoses

• Risk for infection related to inadequate secondary defenses or insufficient knowledge to avoid pathogen exposure.
• Impaired skin integrity related to constant diarrheal stools.
• Deficient fluid volume related to diarrheal stools.
• Imbalanced nutrition: less than body requirements related to malabsorption.
• Hyperthermia related to dehydration.
• Risk for delayed development related to decreased sucking while NPO.

Nursing Care Planning and Goals

• Control diarrhea.
• Minimize the risk for infection.
• Maintain good skin condition.
• Improve hydration and nutritional intake.
• Satisfy the infant's sucking needs.
• Eliminate the risk of infection transmission.

Nursing Interventions

• Reduce transmission. Caregivers wear gowns; use gloves when handling articles contaminated with feces; place contaminated linens and clothing in marked containers per facility policy; limit visitors to family; teach and observe aseptic technique; and enforce good handwashing.
• Protect skin. Cleanse the buttocks and genital area frequently and apply a soothing protectant such as lanolin or A and D ointment; change diapers promptly, and place disposable pads under the infant for easy, frequent changes.
• Prevent dehydration. Count and weigh diapers to measure output accurately; measure each void in older children; document the number and character of stools and any vomitus.
• Maintain nutrition. Weigh the child daily on the same scale, in the early morning before the first feeding; monitor intake and output strictly; give good mouth care while NPO; start oral replacement solutions, then introduce half-strength formula once those are tolerated.
• Maintain temperature. Monitor vital signs at least every 2 hours with fever; follow fever-reduction procedures and give antipyretics and antibiotics as prescribed.

Evaluation

Goals are met when diarrhea is controlled, infection risk is minimized, skin stays intact, hydration and nutrition improve, the infant's sucking needs are met, and transmission risk is eliminated.

Documentation Guidelines

• Individual findings, contributing factors, interactions, the nature of social exchanges, and specifics of behavior.
• Intake and output.
• Characteristics of stool and vomitus.
• Cultural and religious beliefs and expectations.
• Plan of care and teaching plan.
• Responses to interventions, teaching, and actions performed.
• Attainment of or progress toward the desired outcome.