Interference with Need for Elimination

1. Interference with Need for Elimination By Prof. Unn Hidle Updated Spring 2010

2. Overview • Bowel Elimination • Diarrhea • Acute Diarrhea • Chronic Diarrhea • Urinary Elimination • Hypospadius • Epispadius • Glomerulonephritis • Nephrotic Syndrome

3. DIARRHEA

5. Diarrhea - Overall • Accurate definition difficult! • Usually defined as abnormal increase in frequency or decreased consistency of stools for < 2-3 weeks duration (more than that duration is considered chronic diarrhea).

6. Stool patterns

7. Diarrhea - Cause • Most common cause in children is gastroenteritis • Gastritis = inflammation of the stomach • Enteritis = inflammation of the small intestine • Colitis = inflammation of the large intestine • Combinations are • Gastroenteritis (stomach + small intestine) • Enterocolitis (small and large intestine) • Caused by invasion of bacteria, viruses or certain parasites into the GI tract

8. Diarrhea – Cause/Types • Often the result of osmosis caused by poor absorption • Generalized malabsorption of nutrients • Poorly absorbed certain carbohydrates: • Mannitol, sorbitol, lactulose • Malabsorption of magnesium-containing antiacids • Secretory diarrhea • Results from increased secretion from the small intestine or reduced absorption • Results in a large volume of watery stools without RBC or WBC • Causes: • invasion of bacterial enterotoxins • response to hormones • hypersecretion of the GI tract • excessive laxative use • pancreatic insufficiency • small intestinal mucosal disease

9. Diarrhea – Cause/Types • Exudative diarrhea • Results from an inflammatory process such as: • Inflammatory bowel disease • Infection from invasion of organisms • Exposure to toxins • Ischemia • Vasculitis • Inflammation of the bowel causes mucus, blood and pus to leak and disturb motility • Other types: • AIDS • Post-gastrectomy dumping syndrome • Hyperthyroidism • Cancer (chemotherapy, radiation)

10. Diarrhea - Diagnosis • Determined by: • History • Physical Exam

11. ACUTE vs.CHRONIC diarrhea

12. ACUTE DIARRHEA • Abnormal increased frequency or decreased consistency of stools for < 2-3 weeks duration • Usually self-limiting • CAUSES: • Infectious sources: Contaminated food and water • Bacteria: Escheriachia coli (E. Coli), Shigella, Clostridium, Aeromonas • Viruses: Rotavirus (a word on Rotavirus vaccine and intussusception!), HIV, enterovirus, hepatitis A and C

13. ACUTE DIARRHEA cont. • CAUSES cont.: • Infectious sources cont.: • Fungi: Candida, Histoplasma • Parasites: Giardia lamblia (found in the mountains of Russia and North America); Entamoeba histolytica, Cryptosporidium • Toxins: • Bacterial toxins: Staphylococcus (food poisoning); Clostridium perfringens, C. botulinum, C. difficile, Cryptosporidium, E. coli • Chemical toxins: heavy metals, poison mushrooms

14. ACUTE DIARRHEA cont. • CAUSES cont.: • Drugs: • Laxatives, antacids w/magnesium, antibiotics, lactulose, AIDS drugs, etc. • Visceral disturbances: • Appendicitis, diverticulites, GI hemorrhage, fecal impaction, ischemic colitis, pseudomembranous colitis • Food intolerance: • Sugar substitutes (non-absorbable), i.e. sorbitol; food allergies; irritating foods; excessive caffeine • Emotional stress: • Increases peristalsis and causes bowel irritation

15. ACUTE DIARRHEA cont. • Signs and symptoms: • Bacterial infection: More severe s/s, diarrhea, fever, chills, sometimes blood or mucus in the stools • Viral gastroenteritis (stomach flu): Usually 1-3 days of nausea, vomiting, watery diarrhea, fever and aches • Food intolerance / lactose intolerance: bloating, gas, cramps, loose stools hours after eating diary products or other offending foods. No other s/s.

16. ACUTE DIARRHEA cont. • Possible diagnostic tools: Usually done only if severe diarrhea X 24 hours; signs of toxicity; severe pain, dehydration, or blood in stool • CBC w/differential • Urinalysis and serum electrolytes (if dehydration) • Stool culture • Stool for ova and parasites • Stool for occult blood and leukocytes • Levels of C. difficile toxins if use of antibiotics

17. ACUTE DIARRHEA cont. • Possible diagnostic tools: cont. • Sigmoidoscopy if bloody diarrhea to check for inflammatory bowel disease, Shigellosis and amebic dysentery • Abdominal X-ray or CAT scan if obstruction or perforation is suspected (i.e. signs of bloating, severe pain, “very sick”)

18. ACUTE DIARRHEA cont. • TREATMENT: To be discussed in detail • Re-hydration: • Oral re-hydration (ORS) • IV • Antidiarrheal medications: • Adsorbents • Antisecretory • Antiperistaltics • Antibiotics • Treatment for “traveler’s diarrhea”

19. ACUTE DIARRHEA cont. • Oral re-hydration: • Preferred if tolerated (i.e. no vomiting) • Use solutions with sodium and small amounts of glucose, i.e. Pedialyte, Kaolectrolyte, Lytren, Infalyte. WHO and AAP have very similar recommendation of ORS to these products. • Avoid high glucose drinks (i.e. fruit juices) and high caffeine drinks as they are “natural laxatives”

20. ACUTE DIARRHEA cont. • Oral re-hydration: • Although they contain valuable electrolytes, avoid “sport enhancement drinks” as they are very concentrated and high in glucose and may limit intestinal water absorption and aggravate vomiting and diarrhea) • Formula for re-hydration: • Mild diarrhea: ORS with 50ml/kg over 4 hours • Moderate diarrhea: ORS with 100ml/kg over 6 hours • Maintenance: ORS with 100ml/kg/24 hours

21. ACUTE DIARRHEA cont. • Oral re-hydration: • ORS should equal volume of loss in stools (+ the maintenance fluids needed) • With mild or moderate diarrhea, home management is usually acceptable. However, children with moderate diarrhea should first be consult with an MD or NP. • Remember to also watch for signs of over-hydration (i.e. periorbital edema)

22. ACUTE DIARRHEA cont. • IV re-hydration • Given with SEVERE diarrhea or if vomiting • A “quick fix”, but not necessarily long term solution • Solution utilized is ISOTONIC: • 0.9% Normal Saline • Lactated Ringer’s solution

23. ACUTE DIARRHEA cont. • Anti-diarrheals: • Adsorbents: • Increases time between stools.Do not correct dehydration or prevent fluid loss, but increases control over times of defecation. I.e. Kaopectate and aluminum hydroxide (Maalox, Mylanta) • Antisecrtory: • Given to stop diarrhea. The medication usually used is bismuth subsalicylate (Pepto-Bismol). 30ml Q30min until diarrhea stops for a max of 8 doses • Antiperistalties: • Derivates of opium. Fosters absorption of electrolytes and H2O while slowing motility in the intestine with goal of decreasing # of stools and duration of diarrhea. Do not use if fever, bloody diarrhea or s/s of toxicity. D/C if condition worsens. Examples: Diphenoxylate with atropine (Lomotil) or loperamide (Imodium). Use for max 24 hours.

24. ACUTE DIARRHEA cont. • Antibiotics: • Administered when pathogens are identified or strongly suspected as the cause for diarrhea • Drugs: • Fluoroquinolone (ciprofloxacin or norfoxacin) • TMP/SMX (Bactrim) • For Vibrio cholerae or Vibrio parahaemolyticus (diarrhea caused by seafood), treatment is usually with doxycycline or the fluoroquinolone group

25. ACUTE DIARRHEA cont. • Traveler’s diarrhea: • Caused by traveling to other countries that do not have good refrigeration or poor water • Prophylactic medications (i.e. antibiotics) are not usually recommended due to the risk of side effects, some meds are still utilized including: • Bismuth subsalicylate (Pepto-Bismol) • Ciprofloxacin • Doxycycline • TMP/SMX (Bactrim) • Norflaxin • All medications administered for prophylaxis or actual treatment should be take for 1-2 days after returning home to prevent rebound

26. ACUTE DIARRHEA cont. • NURSING CARE: • Assess for consistency, amount and frequency • Note s/s of dehydration (may include diaphoresis!) • MILD = thirst, dry lips and slightly dry oral mucous membranes • MODERATE = very dry oral mucous membranes, sunken eyeballs, sunken anterior fontanel in infants <18 months; poor skin turgor • SEVERE = s/s of moderate + tachycardia, weak peripheral pulses, tachypnea, circumoral cyanosis, cold hands and feet, decreased LOC with confusion, lethargy and difficult to arouse as the condition progresses • Assist with mode of treatment, especially oral re-hydration!

27. CHRONIC DIARRHEA • Diarrhea for > 4 weeks! • Etiology: • Diet: may be as simple as ingestion of apple juice • Infections: giardiasis, amebiasis, C.difficile, Cryptosporidium • Inflammatory disorders: ulcerative colitis, Crohn’s disease (inflammatory bowl disease;), ischemic colitis and some other types of colitis, diverticulitis, AIDS-related chronic diarrhea • Drug side effects: laxatives, antibiotics, NSAIDs, Mg-containing antacids, alcohol, exogenous prostaglandins

28. CHRONIC DIARRHEA cont. • Etiology cont.: • Malabsorptive disorder: short bowel syndrome, celiac sprue (= celiac disease NO GLUTEN : genetic disorder), carbohydrate malabsorption, pancreatic insufficiency, bacterial overgrowth • Endocrine disorders: hyperthyroidism, diabetes, adrenal insufficiency and hypoparathyroidism • Motility disorders: diffuse intestinal lymphoma, scleroderma (progressive systemic sclerosis w/thickening of the skin) • Hormone-producing tumors: carcinoid tumor, pheochromocytoma (sympathetic nervous systm tumor: HTN, etc), ganglioneuroma

29. CHRONIC DIARRHEA cont. • Diagnosis/Nursing Assessment • History taking: Inquire about diurnal variation (day/night), effect of meals, weight loss, and amount and characteristics of stool (i.e. frothy, greasy and foul-smelling may suggest malabsorption) • Physical exam: Begin with auscultation since palpation may cause changes in bowel sounds. Finally, palpate for abdominal tenderness, distension, organomegaly, rectal masses and anal fistulas.

30. CHRONIC DIARRHEA cont. • Lab findings for differential diagnosis: • CBC w/differential: Anemia; infection; malabsorption; eosinophilia = parasitic disease or allergic reaction. • ESR: If elevated, may indicate chronic inflammation or allergic reaction • Serum electrolytes: Ca, PO4, alk. Phosphate levels to look for parathyroid disease. Fasting glucose to look for diabetes. Also evaluate Mg, iron, albumin, cholesterol and renal function (BUN/Creat) • Carotene: Levels are low in fat malabsorption (i.e. Cystic Fibrosis) • PT/PTT: May be abnormal with poor Vit. K absorption • Thyroid function test

31. CHRONIC DIARRHEA cont. • Lab findings for differential diagnosis: • Stool: Occult blood, leukocytes, steatorrhea, culture and ova/parasites should be sent for evaluation. Stool antigen can be done for Giardia (more sensitive than O&P) • pH test (<6) is seen in carbohydrate intolerance • Small intestinal biopsy: for colitis, enteritis and some parasitic infections • Urine tests: can detect aloes, senna alkaloids, and bisacodyl • Sigmoidoscopy: detects inflammation of the colon or rectum, neoplasms and parasites • Radiographic studies: Plain abdominal X-ray and barium studies of the upper GI tract, small intestine, and colon abnormalities

32. CHRONIC DIARRHEA cont. • TREATMENT: • Treat underlying cause (i.e. according to lab findings) • Re-hydration • If unable to find cause, treatment is attempted with restriction of lactose, gluten or long-chain fatty acids in the diet. Restrict one item at a time to find out the source. • If pancreatic deficiency is suspected (i.e. cystic fibrosis), supplement with pancreatic enzyme • Antimicrobials as needed • Anti-diarrhea medications for symptomatic relief

33. DIARRHEA OVERALL • The diet dilemma…………… • When should foods be introduced? • Should the body go through a “starvation period” (i.e. 24 hours with only liquids)? • What factors contradict introduction of foods? • What types of food should be introduced? • BRAT DIET or NOT??????

34. Recent recommendations …… • In recent years, the medical community has made contrary treatment recommendations. The American Academy of Pediatrics suggests children with mild diarrhea "continue to eat a normal diet including formula or milk". • A CDC study made similar recommendation by stating that "older children accustomed to eating a variety of table foods should continue receiving a regular diet" including "starches (e.g., rice, potatoes, noodles, crackers, and bananas), cereals (e.g., rice, wheat, and oat cereals), soup, yogurt, vegetables, and fresh fruits". • It also cautioned against foods high in fat and foods high in simple sugars, such as "soft drinks, undiluted apple juice, Jell-O, and presweetened cereals". • The study called the BRAT diet a "reasonable dietary recommendation", but warned against prolonged use to prevent "inadequate energy and protein content in the recovering child's diet".

35. HYPOSPADIUS

36. HYPOSPADIUS • A common abnormality of the penis • 3 out of 1,000 newborns, mostly boys but may be in females (urethra is found inside the upper portion of the vaginal wall) • Abnormal opening of the penis where the meatus is beneath or on the ventral side of the penis instead of at the tip • Often accompanied by a chordee or ventral curvature (“curvature downwards”) which results from replacement of normal skin with a fibrous band that pulls the penis down (especially visible with erection)

37. HYPOSPADIUS cont. • Foreskin may be absent • Often smaller appearance of penis, especially if testes are undescended • Sometimes there is doubt of the sex of the infant as the penis appears as a clitoris

39. HYPOSPADIUS cont. • Signs & Symptoms: • Opening of the penis is NOT at the tip, but displaced to the ventral surface • Penis usually has a marked curvature downward (Chordee) • Child has to SIT to void

40. HYPOSPADIUS cont. • Signs & Symptoms: • Opening of the penis is NOT at the tip, but displaced to the ventral surface • Penis usually has a marked curvature downward (Chordee) • Child has to SIT to void • Diagnosis: • Radiologic Intravenous Pyelogram (IVP) and possibly cystoscopy, cystogram and ultrasound evaluation of the urogenital system (kidneys, ureters, bladder, urethra, and genitalia) will be necessary to evaluate the extent of the defect

41. HYPOSPADIUS cont. • Treatment Goals: • Enable child to void standing and directing stream • Improve physical appearance • Produce sexually adequate organ

42. HYPOSPADIUS cont. • Infants with hypospadius should NOT be circumcised because the foreskin is usually needed for later surgical repair (grafting for the urethral meatus) • Surgery begins early (6-18 months) • Goal is to complete surgery before child starts school to avoid emotional problems • Surgery may be once or staging, depending on the extent of the defect

43. HYPOSPADIUS cont. • NURSING: • Restraints are frequently needed • “Castration fear” for children (older) and needs emotional support • Older children need clear explanations and expectations for post-surgical condition (refer to growth and development. • Prognosis is usually good, cosmetically and functionally

44. EPISPADIUS

45. EPISPADIUS • A defect much less common than hypospadius • Affects male when the urethra opens on the top of the penis (dorsal) • SIGNS / SYMPTOMS: • Either: • urethra opening just on top of the head of the penis • entire urethra may be open the full length of the penis, • entire urethra open with the bladder opening on the abdominal wall (Extrophy of the bladder) • Very rare in females, but may occur

47. EPISPADIUS cont. • DIAGNOSIS: • Similar to hypospadius • TREATMENT: • Surgical repair with goal: • Continence • Good cosmetic functioning organ • Incontinence may require a second-stage repair • Urinary incontinence may continue to occur in some people even after surgery

48. EXTROPY OF THE BLADDER

49. BLADDER EXTROPHY • Uncommon congenital defect, males > females • The bladder is inside-out and protrudes through the wall of the abdomen • Includes separation (widening) of the pelvis bones • Kidneys are normal • Surgery done within 48 hours after birth to prevent infection that can damage kidneys

50. BLADDER EXTROPHY cont. • Males: • Almost always associated with epispadius • Other associated problems: undescended testes, short penis and inguinal hernia • Sexual handicap: penis is not an adequate length (too short) • Females: • May be a cleft clitoris • Separated labia and/or absent vagina