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Max: Gastroenteritis (Circulation)

Assessment

This assessment is on a three-year-old boy, whose name is Max. He is normally healthy child, and updated with his immunizations. But one day he has been camping with his family over the weekend, and suddenly he starts vomiting at approximately 0500 hours. His family immediately packed up and come back to their home by doing four hours of journey. Max still continue his vomiting, even when he is thirsty and drink water, he does vomit. His mother brings him to the emergency department at 1600 hours for diagnosis and treatment. Initially, doctors record the circulation assessment for these symptoms, so they check his pulse rate, temperature, respiratory rate, blood pressure, and SpO2. The effect of circulatory inadequacy on other organs has been accessed. The results concluded that his heart rate is 140 beats per minute, respiratory rate is 35 breaths per minute, blood pressure is 100/65mmHg, auxiliary temperature is 37⁰C, and SpO2 is 99% on room air. Max has currently been diagnosed with moderate dehydration, which is caused by viral gastroenteritis. This is due the ongoing situation of Max that indicates the dehydration and vomiting issues, which clearly find out as gastroenteritis. This finding differs form other normal findings because he has been continuously vomiting and get thirsty soon, his skin is showing a clear decreased skin turgor condition which is not normal in all children of his age group (Forster & Scaini, 2017).

When a person is affected by infectious diarrhoea, then it is commonly referred as gastroenteritis. Gastroenteritis is a condition when then there is sudden change in consistency of stool to lose or watery level, or sudden beginning of vomiting. Children that have gastroenteritis either remains with diarrhoea for 5-7 days, which lasts up to 2 weeks, or they face vomiting that ends usually within three days (Hartman et al., 2019). Physical examination and previous symptoms should be recorded to determine if the child is dehydrated, and if needed then diagnose the aetiology of gastroenteritis. Variety of factors can influence the accurate assessment of gastroenteritis, such as, duration of illness, urine excretion, mental state of child, number of episodes of vomiting and diarrhoea each day, type of emesis, child’s ability to intake solid or fluids, medical conditions, symptoms like fever, urinary complaints, or abdominal pain, current contact with any person with vomiting or diarrhoea, recent travel to abroad, exposure to contaminated food or water, and success rate of oral rehydration therapy (Clinical assessment of child with gastroenteritis, 2018).

Physical examinations are important to identify the symptoms of dehydration, along with other factors such as, sunken eyes, skin turgor, dry mucous membrane, and alertness level. Children who are less than 1 year, infants with low birth weight or stopped breastfeeding because of illness, children who vomit more than twice in 24 hours, or those who are not even able to tolerate fluid intake, and children who has symptoms of malnutrition, are at high risk of dehydration. The images shown in the clinical scenario signifies the decreased skin turgor in Max, and sunken fontanelle, eyes and cheeks are observed. These are the signs of child that has gastroenteritis. Middle image shows the urine colour and concentration, which determines another clinical symptom of gastroenteritis, that is dysuria (NSW health government, 2014). It is also reported that Max wears pullups and he has not been wet since morning. This kind of increased or decreased urination frequency shows the presence of dysuria.

The suggested management required to treat the children with gastroenteritis includes:

  • Nurses and medical practitioners’ duty of 24 hours for management of children.
  • 24 hours access of standard biochemistry for inpatient care and management.
  • Standard resuscitation fluids like 0.9% sodium chloride without glucose must be available.
  • Recommended rehydration fluids availability, such as 0.9% sodium chloride, 20mmols/L potassium chloride, and 5% glucose.
  • Presence of infusion pumps, and oral rehydration solutions like hydrolyte®, gastrolyte®, and repalyte®.
  • Treatment of severely dehydrated child should be previously consulted with a paediatrician, and then the child will be transferred to intensive care unit.
  • Appropriate fluids should be provided to the children, such as ORS, juice, or lemonade. Avoid giving diet drink or low-calorie drinks to the child (Belleza, 2018).
  • Child should be rehydrated in every 5minutes duration at 0.5mL/kg concentration.
  • Anti-diarrhoeal agents, antiemetic medications, or antibiotics are not required in gastroenteritis, and it may cause other side-effects. However, zinc and probiotics may be helpful to manage the conditions of gastroenteritis.
  • Other nursing interventions includes the use of protective clothing to reduce the risk of infection transmission, promoting skin integrity by help of soothing ointment or cleaning the infected area, maintaining appropriate nutrition and body temperature to prevent dehydration (Brown, 2017).

Underlying Pathophysiology

The assessment findings suggest that Max conditions demonstrate the medical illness of gastroenteritis. The underlying pathophysiology of common paediatric gastrointestinal condition that is causing the dehydration and vomiting in Max is discussed in this section. These conditions refer to the symptoms of gastroenteritis which is caused due to inflammation of large or small bowel. This inflammation is usually occurring due to the infections, which can be bacterial or viral. Large bowel changes are inflammatory, whereas infections in small bowel are considered as non-inflammatory. Effect of virus of bacteria is depending on the number of pathogens that can be one for Cryptosporidium, and can be more in case of Vibrio cholerae, that is 108 (Panjwani, 2018).

Pathophysiology of gastroenteritis can be defined as the leading cause of dehydration and reduction of nutrients and electrolytes in the body of child, because of which he vomits. It can cause vomiting by mucosal invasion, cytotoxin production, and enterotoxin production, and ultimately results in enhanced secretion of fluids or reduced absorption. Appropriate balance of fluids among children are equally important as in adults, and it depends on the electrolytes and fluid secretion and absorption in intestinal tract of the body (Tomasik et al., 2016). Vomiting or diarrhoea conditions happens when output fluids of intestine overcome the absorption capability of gastrointestinal tract. Mechanism involved in acute gastroenteritis involved two major steps:

  • Villous brush border of the intestine is damaged that cause intestine content malabsorption and ultimately leads to cause osmotic diarrhoea.
  • Another primary mechanism involves the release of toxins which further binds to their receptors of specific enterocyte, and release chloride ions into the lumen of intestine. This will eventually lead to cause secretory diarrhoea (Tomasik et al., 2016).

Gastroenteritis is majorly caused by viruses, but parasites, fungi, and bacteria are also sometimes responsible to cause this disease. Children are mostly affected by retrovirus and it can be prevented by hand-washing, safe drinking and eating habits, and safe disposal of waste products. Rotavirus vaccine is also recommended for children to prevent gastroenteritis. Oral rehydration solutions for mild cases, and intravenous fluids for severe cases are the most common treatment procedures for this disease (Canziani et al., 2017). Further, pathophysiology of bacteria, virus and parasite is been discussed that tends to cause gastroenteritis conditions among children.

Bacterial pathophysiology is by three different ways, that is mucosal adherence, mucosal invasion, and production of toxins. Mucosal adherence means the adherence of bacteria on the gut mucosa receptors, which cause further illness. Mucosal invasion in the initial entry of bacteria into the mucosal cells which is facilitated by invasion production that disrupt the cytoskeleton of host cell. Invasive pathogens can be Shigella species, such as enteroinvasive E. coli, and Campylobacter species that could penetrate into the mucosa of intestinal cells. Therefore, epithelial cells were disrupted which further allows the entry of bacteria, and cause dysentery (Belleza, 2018). Moreover, gastroenteritis is caused due to variety of bacterial toxins, such as enterotoxins, cytotoxins, and Bacillus cereus toxins. Enterotoxins are produced by the adherence of bacteria on the epithelial cells of the intestine and induce more secretion of fluids into lumen without causing any damage to mucosa. Some of the enterotoxins cause vomiting, such as Bacillus cereus, and Staphylococcus aureus. For example, if cooked rice were left overnight at room temperature, then it may cause food poisoning due to the developed toxin ‘Bacillus cereus’ (Panjwani, 2018).

Viral pathophysiology of gastroenteritis includes the spread of virus from one person to other through fecal-oral transmission of contaminated water and food material. Virus can be of different types, such as norovirus which is transferred by air and affects adults, and rotavirus that affects the children. Rotavirus binds and enter into mature enterocytes at tips of small intestinal villi. Rotavirus secrets enterotoxin named NSP4 that leads to calcium dependent secretory mechanism of chloride ions. Moreover, pathophysiology of parasite includes the intestinal parasites and adhere into the intestinal mucosa, that cause vomit, nausea, and diarrhoea (Panjwani, 2018).

References for Gastroenteritis Nursing Care Management

Belleza, M. (2018). Gastroenteritis Nursing Care Management. Retrieved October 08, 2020, from https://nurseslabs.com/gastroenteritis/

Brown, N. (2017). Evidence-based nursing: The acutely ill child. In Fraser, J., Waters, D., Forster, E., & Brown, N. (eds), Paediatric Nursing in Australia: Principles for Practice, 2nd ed, Cambridge University Press, Melbourne, pp. 155-160.

Canziani, B. C., Uestuener, P., Fossali, E. F., Lava, S. A., Bianchetti, M. G., Agostoni, C., & Milani, G. P. (2017). Clinical Practice: Nausea and vomiting in acute gastroenteritis: Physiopathology and management. European Journal of Pediatrics,177(1), 1-5. doi:10.1007/s00431-017-3006-9

Clinical assessment of child with gastroenteritis. (2018). Retrieved October 08, 2020, from https://gpnotebook.com/simplepage.cfm?ID=x20090429181117749131

Forster, L., & Scaini, L. (2017). Recognising and responding to the sick child. In: Fraser, J., Waters, D., Forster, E., & Brown, N. (eds), Paediatric Nursing in Australia: Principles for Practice, 2nd ed, Cambridge University Press, Melbourne, pp. 105-108.

Hartman, S., Brown, E., Loomis, E., Russell, H. A. (2019). Gastroenteritis in Children. Am Fam Physician, 99(3), 159-165.

NSW health government. (2014). Infants and Children: Management of Acute Gastroenteritis, Fourth Edition. Retrieved October 08, 2020, from http://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2014_024.com

Panjwani, K. (2018). Gastroenteritis- Pharmacotherapy. Retrieved October 08, 2020, from https://www.slideshare.net/KainatPanjwani/gastroenteritis-pharmacotherapy

Tomasik, E., Ziółkowska, E., Kołodziej, M., & Szajewska, H. (2016). Systematic review with meta-analysis: Ondansetron for vomiting in children with acute gastroenteritis. Alimentary Pharmacology & Therapeutics,44(5), 438-446. doi:10.1111/apt.13728

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