Rotavirus Vaccine Offers Earlier Protection

New Vaccine Could Prevent Thousands of Childhood Diarrhea-Related Hospitalizations Each Year

By Kelli Miller StacyWebMD Health News

Reviewed by Louise Chang, MD

April 8, 2008 -- A new vaccine approved by the FDA promises to provide earlier protection against a leading cause of potentially deadly diarrhea in children. GlaxoSmithKline's Rotarix vaccine helps prevent rotavirus gastroenteritis, a common childhood condition responsible for as many as 70,000 hospitalizations each year in the United States.

The two-dose vaccine is a liquid taken by mouth and fully vaccinates infants by 4 months of age, 2 months earlier than the existing Rotateq vaccine, which is manufactured by Merck. The CDC recommends that rotavirus vaccination be completed by the time a child is 6 months old. However, one out of every five children admitted to the hospital with such infections is younger than 6 months.

Becoming protected against the disease at an earlier age could reduce the number of emergency room visits made by families. About 2.7 million children in the U.S. develop rotavirus disease every year. Rotavirus-related gastrointestinal illness typically strikes the southwestern U.S. during the late fall and early winter and the Northeast by spring.

"This vaccine provides another option to combat and reduce a potentially severe illness that affects so many children," Jesse L. Goodman, MD, MPH, director of the FDA's Center for Biologics Evaluation and Research, says in a news release.

The CDC, The American Academy of Pediatrics, and the American Academy of Family Physicians all recommend rotavirus immunization for infants. According to an FDA news release, "without vaccination, nearly every child in the U.S. would likely be infected at least once with rotavirus by age 5."

Studies involving 24, 000 infants showed that the Rotarix vaccine helped protect against both mild and severe rotavirus-associated gastroenteritis in children under age 2. The vaccine protects against the most commonly circulating strains of rotavirus.

Some children who receive the vaccine may experience side effects including fussiness, irritability, cough, runny nose, fever, lose of appetite, and vomiting.

An earlier rotavirus vaccine manufactured by Wyeth was pulled from the U.S. market after several children developed a potentially life-threatening intestinal condition called intussusception after being immunized. Researchers with GlaxoSmithKline evaluated more than 63,000 infants who received their vaccine and found no increased risk. However, the FDA has requested post-market testing to provide additional safety information.

I. INTRODUCTION

Acute Gastroenteritis

Acute Gastroenteritis is inflammation of the gastrointestinal tract, involving both the

stomach and the small intestine and resulting in acute diarrhea. The inflammation is caused

most often by infection with certain viruses, less often by bacteria or their toxins, parasites,

or adverse reaction to something in the diet or medication. At least 50% of cases of

gastroenteritis as foodborne illness are due to norovirus. Another 20% of cases, and the

majority of severe cases in children, are due to rotavirus. Other significant viral agents

include adenovirus and astrovirus.

Different species of bacteria can cause gastroenteritis, including Salmonella,

Shigella, Staphylococcus, Campylobacter jejuni, Clostridium, Escherichia coli, Yersinia, and

others. Each organism causes slightly different symptoms but all result in diarrhea. Colitis,

inflammation of the large intestine, may also be present. Some types of acute

gastroenteritis will not resolve without antibiotic treatment, especially when bacteria or

exposure to parasites are the cause. Physicians may want to diagnose the cause by

analyzing a stool sample, when stomach symptoms remain problematic.

Worldwide, inadequate treatment of gastroenteritis kills 5 to 8 million people per year

and is a leading cause of death among infants and children under 5. The most common

symptoms are diarrhea, vomiting and stomach pain, because whatever causes the

condition inflames the gastrointestinal tract. Another reason to seek medical treatment is

that some forms of acute gastroenteritis mimic appendicitis, which may require emergency

treatment. As well, young children run an especially high risk of becoming dehydrated

during a long course of the stomach flu. One should receive directions regarding how to

help affected kids or adults get more fluids. Sometimes children, those with compromised

immune systems, and the elderly may require hospitalization and intravenous fluids.

Dehydration can actually cause greater nausea, and can begin to cause organ shut down if

not properly addressed.

Acute gastroenteritis is quite common among children, though it is certainly possible

for adults to suffer from it as well. While most cases of gastroenteritis last a few days, acute

gastroenteritis can last for weeks and months.

Acute gastroenteritis remains a serious health issue, and is responsible for over

50,000 hospitalizations of children. In developing countries, acute gastroenteritis is the

leading cause of death for infants. Acute gastroenteritis should thus be taken seriously, and

people should not hesitate to seek medical treatment for especially seniors and children

who have been ill for more than a day.

In the Philippine Health Statistic, gastroenteritis range as number 10 in the ten

leading causes of infant mortality, with the rate of 0.5 and percentage of 4.1 cases in the

Philippines by the year 2004 this was updated last February 12, 2008.

Significance of the study:

his study will enable the students to understand better about acute gastroenteritis

and will explain the different risk factors for developing the disease, including consumption

of improperly prepared foods or contaminated water and travel or residence in areas of

poor sanitation Since we are client-centered, we really should consider our patient’s

comfort and this study will give the students sufficient knowledge that will help them to plan

and implement nursing care plans that will satisfy patient’s needs.

II. OBJECTIVES:

A. General Objectives

This study aims to convey familiarity and to provide an effective nursing care to a

patient diagnosed with Acute Gastroenteritis through understanding the patient history, disease

process and management.

B. Specific Objectives

1. To present a thorough assessment, through Nursing Health History, Gordon’s Typology

11 Functional Pattern, Physical Assessment, and the interpretation of the laboratory

examination done on the patient.

2. To discuss the anatomy and physiology, pathophysiology of the patient’s condition,

usual clinical manifestations and possible complications of this condition.

3. To have knowledge to the client medication and be familiar to that medication.

4. To formulate a workable nursing care plan on the subjective and objective cues

gathered through nurse-patient interaction to be able to help the patient recover.

V. ANATOMY AND PHYSIOLOGY

Anatomy of the Digestive System

If a human adult’s digestive tract were stretched out, it would be 6 to 9 m (20 to 30 ft) long.

In humans, digestion begins in the mouth, where both mechanical and chemical digestion occur.

The mouth quickly converts food into a soft, moist mass. The muscular tongue pushes the food

against the teeth, which cut, chop, and grind the food. Glands in the cheek linings secrete mucus,

which lubricates the food, making it easier to chew and swallow. Three pairs of glands empty

saliva into the mouth through ducts to moisten the food. Saliva contains the enzyme ptyalin, which

begins to hydrolyze (break down) starch—a carbohydrate manufactured by green plants.

Once food has been reduced to a soft mass, it is ready to be swallowed. The tongue

pushes this mass—called a bolus—to the back of the mouth and into the pharynx. This cavity

between the mouth and windpipe serves as a passageway both for food on its way down the

alimentary canal and for air passing into the windpipe. The epiglottis, a flap of cartilage, covers the

trachea (windpipe) when a person swallows. This action of the epiglottis prevents choking by

directing food from the windpipe and toward the stomach.

Mouth

The mouth plays a role in digestion, speech, and breathing. Digestion begins when food

enters the mouth. Teeth break down food and the muscular tongue pushes food back toward the

pharynx, or throat. Three salivary glands—the sublingual gland, the submandibular gland, and the

parotid gland—secrete enzymes that partially digest food into a soft, moist, round lump. Muscles

in the pharynx swallow the food, pushing it into the esophagus, a muscular tube that passes food

into the stomach. The epiglottis prevents food from entering the trachea, or windpipe, during

swallowing.

Esophagus

The presence of food in the pharynx stimulates swallowing, which squeezes the food into

the esophagus. The esophagus, a muscular tube about 25 cm (10 in) long, passes behind the

trachea and heart and penetrates the diaphragm (muscular wall between the chest and abdomen)

before reaching the stomach. Food advances through the alimentary canal by means of rhythmic

muscle contractions (tightenings) known as peristalsis. The process begins when circular muscles

in the esophagus wall contract and relax (widen) one after the other, squeezing food downward

toward the stomach. Food travels the length of the esophagus in two to three seconds.

A circular muscle called the esophageal sphincter separates the esophagus and the

stomach. As food is swallowed, this muscle relaxes, forming an opening through which the food

can pass into the stomach. Then the muscle contracts, closing the opening to prevent food from

moving back into the esophagus. The esophageal sphincter is the first of several such muscles

along the alimentary canal. These muscles act as valves to regulate the passage of food and keep

it from moving backward.

Stomach

The stomach, located in the upper abdomen just below the diaphragm, is a saclike

structure with strong, muscular walls. The stomach can expand significantly to store all the food

from a meal for both mechanical and chemical processing. The stomach contracts about three

times per minute, churning the food and mixing it with gastric juice. This fluid, secreted by

thousands of gastric glands in the lining of the stomach, consists of water, hydrochloric acid, an

enzyme called pepsin, and mucin (the main component of mucus). Hydrochloric acid creates the

acidic environment that pepsin needs to begin breaking down proteins. It also kills microorganisms

that may have been ingested in the food. Mucin coats the stomach, protecting it from the effects of

the acid and pepsin. About four hours or less after a meal, food processed by the stomach, called

chyme, begins passing a little at a time through the pyloric sphincter into the duodenum, the first

portion of the small intestine.

Liver

The liver is the largest internal organ in the human body, located at the top of the abdomen

on the right side of the body. A dark red organ with a spongy texture, the liver is divided into right

and left lobes by the falciform ligament. The liver performs more than 500 functions, including the

production of a digestive liquid called bile that plays a role in the breakdown of fats in food. Bile

from the liver passes through the hepatic duct into the gallbladder, where it is stored. During

digestion bile passes from the gallbladder through bile ducts to the small intestine, where it breaks

down fatty food so that it can be absorbed into the body. Nutrient-rich blood passes from the small

intestine to the liver, where nutrients are further processed and stored. Deoxygenated blood

leaves the liver via the hepatic vein to return to the heart.

Small Intestine

Most digestion, as well as absorption of digested food, occurs in the small intestine. This

narrow, twisting tube, about 2.5 cm (1 in) in diameter, fills most of the lower abdomen, extending

about 6 m (20 ft) in length. Over a period of three to six hours, peristalsis moves chyme through

the duodenum into the next portion of the small intestine, the jejunum, and finally into the ileum,

the last section of the small intestine. During this time, the liver secretes bile into the small

intestine through the bile duct. Bile breaks large fat globules into small droplets, which enzymes in

the small intestine can act upon. Pancreatic juice, secreted by the pancreas, enters the small

intestine through the pancreatic duct. Pancreatic juice contains enzymes that break down sugars

and starches into simple sugars, fats into fatty acids and glycerol, and proteins into amino acids.

Glands in the intestinal walls secrete additional enzymes that break down starches and complex

sugars into nutrients that the intestine absorbs. Structures called Brunner’s glands secrete mucus

to protect the intestinal walls from the acid effects of digestive juices.

The small intestine’s capacity for absorption is increased by millions of fingerlike projections

called villi, which line the inner walls of the small intestine. Each villus is about 0.5 to 1.5 mm (0.02

to 0.06 in) long and covered with a single layer of cells. Even tinier fingerlike projections called

microvilli cover the cell surfaces. This combination of villi and microvilli increases the surface area

of the small intestine’s lining by about 150 times, multiplying its capacity for absorption. Beneath

the villi’s single layer of cells are capillaries (tiny vessels) of the bloodstream and the lymphatic

system. These capillaries allow nutrients produced by digestion to travel to the cells of the body.

Simple sugars and amino acids pass through the capillaries to enter the bloodstream. Fatty acids

and glycerol pass through to the lymphatic system.

Large Intestine

A watery residue of indigestible food and digestive juices remains unabsorbed. This residue

leaves the ileum of the small intestine and moves by peristalsis into the large intestine, where it

spends 12 to 24 hours. The large intestine forms an inverted U over the coils of the small

intestine. It starts on the lower right-hand side of the body and ends on the lower left-hand side.

The large intestine is 1.5 to 1.8 m (5 to 6 ft) long and about 6 cm (2.5 in) in diameter.

The large intestine serves several important functions. It absorbs water—about 6 liters (1.6

gallons) daily—as well as dissolved salts from the residue passed on by the small intestine. In

addition, bacteria in the large intestine promote the breakdown of undigested materials and make

several vitamins, notably vitamin K, which the body needs for blood clotting. The large intestine

moves its remaining contents toward the rectum, which makes up the final 15 to 20 cm (6 to 8 in)

of the alimentary canal. The rectum stores the feces—waste material that consists largely of

undigested food, digestive juices, bacteria, and mucus—until elimination. Then, muscle

contractions in the walls of the rectum push the feces toward the anus. When sphincters between

the rectum and anus relax, the feces pass out of the body.

PHYSICAL EXAMINATION (IPPA – PSA cephalocaudal approach)

Initial Assessment upon Admission: August 16, 2009

**Taken from the chart

Skin: No jaundice, No rashes

Head EENT: anicteric sclerae, pale palbepral conjunctivitis

Lymph Nodes: no mass

Chest:

Lungs: (-) crackles on both lungs

Cardiovascular: No murmur

Breast: no mass

Abdomen:

The abdomen was distended, soft and there was no palpable mass felt upon palpation. Hypoactive bowel sound heard upon auscultation. The patient vomited 3-5 times a day and defecated more than 6 times a day with watery stool.

Genito-Urinary System:

Patient voided 60 – 350 cc per shift as weighed and yellow in color.

PHYSICAL ASSESSMENT

Date: August 17, 2009 Clinical Area : Pedia ward

BODY

PARTS

ASSESSED

TECHNIQUES NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION

1.Skin

a. Moisture Palpation Moisture in skin folds and axillae Dry skin Deviated due to slight

dehydration

b Texture Palpation Smooth Rough Deviated due to slight

dehydration

c. Turgor Inspection and

Palpation

Springs back immediately to

previous state

Moves back slowly Deviated due to slight

dehydration

2. Mouth

a. LipsInspection Pink in color, soft moist, smooth

texture, symmetrical no

tenderness, no lesions

Dry lipsDeviated due to slight

dehydration

b.Mucosa Inspection and

Palpation

Uniform pink color Dry and slightly pink in color Deviated from normal due

to slight dehydration

c. Gums Inspection and

Palpation

Pink gums, moist, firm texture Pink gums, dry, firm texture Deviated from normal due

to slight dehydration

3.

Abdomen

Bowel

sounds

Auscultation Audible bowel sounds Hyperactive bowel sound Deviated due to diarrhea

III. REVIEW OF SYSTEM

Digestive System

The primary function of the digestive system is to break down the food we

eat into smaller parts so the body can use them to build and nourish cells and provide

energy. There occurs propulsion which is the movement of food along the digestive

tract. The major means of propulsion is peristalsis, a series of alternating contractions

and relaxations of smooth muscle that lines the walls of the digestive organs and that

forces food to move forward. It secretes digestive enzymes and other substances

liquefies, adjusts the pH of, and chemically breaks down the food. Mechanical

digestion is the process of physically breaking down food into smaller pieces. This

process begins with the chewing of food and continues with the muscular churning

of the stomach. Additional churning occurs in the small intestine through muscular

constriction of the intestinal wall. This process, called segmentation, is similar to

peristalsis, except that the rhythmic timing of the muscle constrictions forces the

food backward and forward rather than forward only. Chemical digestion which is the

process of chemically breaking down food into simpler molecules. The process is

carried out by enzymes in the stomach and small intestines. Then absorption or the

movement of molecules (by passive diffusion or active transport) from the digestive

tract to adjacent blood and lymphatic vessels. Absorption is the entrance of the

digested food into the body. And lastly, defecation which is the process of

eliminating undigested material through the anus.

But because of acute gastroenteritis the normal functions were altered.

The infectious agents that cause acute gastroenteritis causes diarrhea by

adherence, mucosal invasion, enterotoxin production, and/or cytotoxin production.

These mechanisms result in increased fluid secretion and/or decreased

absorption leading to diarrhea. This produces an increased luminal fluid content that

cannot be adequately reabsorbed, leading to dehydration and the loss of electrolytes

and nutrients.

FATHER

HPN

MOTHER

SISTER 1 SISTER 2

Asthma

ALVIN MONEZA

Acute Gastroenteritis

With SevereDHN, Intestinal Parasitism

and 1st Degree of Malnutrion

IV. DEVELOPMENTAL TASK

Erik Erikson-Psychosocial development

The patient is currently in the early childhood stage (3-6 y/o) wherein the

central task is Initiative vs. Guilt. During this stage, initiative adds to autonomy

the quality of undertaking, planning, and attacking a task for the sake of being active

and on the move. The child is learning to master the world around him or her, learning

basic skills and principles of physics; things fall to the ground, not up; round things roll,

how to zip and tie, count and speak with ease. Guilt is a new emotion and is

confusing to the child; he or she may feel guilty over things which are not logically guilt

producing, and he or she will feel guilt when his or her initiative does not produce the

desired results. At this stage the client wants to begin and complete her own actions

for a purpose.

Interpretation: Positive Resolution

Jean Piaget’s Cognitive Development

The patient is under the Pre-operational stage. In this period intelligence is

demonstrated through the use of symbols, language use matures, and memory and

imagination are developed, but thinking is done in a nonlogical, nonreversible manner.

Egocentric thinking predominates. The patient was able to do make believe play and

able to imitate others, like her mother doing some household chores as verbalized by

the "SO".

Interpretation: Positive Resolution

ELECTROLYTES NURSING RESPONSIBILITIES

SERUM SODIUM

SERUM POTASSIUM

Before getting sample:

Explain to the patient that this test is used to determine the sodium, potassium, calcium content of blood.

Tell the SO of the patient that the test requires blood sample.

Explain who will perform the diagnostic tests and when.

Explain that the patient may experience slight discomfort from the needle.

During getting sample:

Assess the physical appearance of the patient

Try to get a sample once

After getting sample:

Encourage the patient to relax

Send the specimen to the laboratory immediately.

Diagnostic/ Laboratory Procedures

Date ordered

Date result(s)

In;

Indication(s) or Purpose(s)

Result

(1st, 2nd , 3rd )

Normal value

(units used in the hospital)

Analysis and Interpretation of results

SODIUM Date Ordered

8 - 16 - 09

Date Results in

8 - 16 - 09

To measure serum levels of sodium in relation of the amount of water in the body.

Used to evaluate fluid electrolyte acid base balance and related renal and adrenal functions.

124.7 mEq/L 135-150 mEq/L Decreased sodium level or altered state of hydration may be found

Diagnostic/ Laboratory Procedures

Date ordered

Date result(s)

In;

Indication(s) or Purpose(s)

Result

(1st, 2nd , 3rd )

Normal value

(units used in the hospital)

Analysis and Interpretation of results

POTASSIUM Date Ordered

8 – 16 - 09

Date results in

8 – 16 - 09

To evaluate clinical signs of potassium excess (hyperkalemia) or potassium depletion (hypokalemia)

To measure serum levels of potassium in relation in the amount of water in the body.

2.5 mEq/L 3.5 – 5.2 mEq/L Decreased potassium level due to diarrhea and vomiting in relation to decrease amount of water in the body

SYNTHESIS OF THE DISEASE

Definition of the disease

Acute Gastroenteritis is a catchall term for infection or irritation of the digestive tract, particularly the stomach and intestine. It is frequently referred to as the stomach or intestinal flu, although the influenza virus is not associated with this illness. Major symptoms include nausea and vomiting, diarrhea, and abdominal cramps. These symptoms are sometimes also accompanied by fever and overall weakness. Gastroenteritis typically lasts about three days. Adults usually recover without problem, but children, the elderly, and anyone with an underlying disease are more vulnerable to complications such as dehydration

Description of the disease

Gastroenteritis is an uncomfortable and inconvenient ailment, but it is rarely life-threatening in the United States and other developed nations. However, an estimated 220,000 children younger than age five are hospitalized with gastroenteritis symptoms in the United States annually. Of these children, 300 die as a result of severe diarrhea and dehydration. In developing nations, diarrheal illnesses are a major source of mortality. In 1990, approximately three million deaths occurred worldwide as a result of diarrheal illness.

The most common cause of gastroenteritis is viral infection. Viruses such as rotavirus, adenovirus, astrovirus, and calicivirus and small round-structured viruses (SRSVs) are found all over the world. Exposure typically occurs through the fecal-oral route, such as by consuming foods contaminated by fecal material related to poor sanitation. However, the infective dose can be very low (approximately 100 virus particles), so other routes of transmission are quite probable.

Typically, children are more vulnerable to rotaviruses, the most significant cause of acute watery diarrhea. Annually, worldwide, rotaviruses are estimated to cause 800,000 deaths in children below age five. For this reason, much research has gone into developing a vaccine to protect children from this virus. Adults can be infected with rotaviruses, but these infections typically have minimal or no symptoms.

Children are also susceptible to adenoviruses and astroviruses, which are minor causes of childhood gastroenteritis. Adults experience illness from astroviruses as well, but the major causes of adult viral gastroenteritis are the caliciviruses and SRSVs. These viruses also cause illness in children. The SRSVs are a type of calicivirus and include the Norwalk, Southhampton, and Lonsdale viruses. These viruses are the most likely to produce vomiting as a major symptom.

Bacterial gastroenteritis is frequently a result of poor sanitation, the lack of safe drinking water, or contaminated food—conditions common in developing nations. Natural or man-made disasters can make underlying problems in sanitation and food safety worse.

In developed nations, the modern food production system potentially exposes millions of people to disease-causing bacteria through its intensive production and distribution methods. Common types of bacterial gastroenteritis can be linked to Salmonella and Campylobacter bacteria; however, Escherichia coli 0157 and Listeria monocytogenes are creating increased concern in developed nations. Cholera and Shigella remain two diseases of great concern in developing countries, and research to develop long-term vaccines against them is underway

Pathophysiology: Infectious agents usually cause acute gastroenteritis. These agents cause diarrhea by adherence, mucosal invasion, enterotoxin production, and/or cytotoxin production. These mechanisms result in increased fluid secretion and/or decreased absorption. This produces an increased luminal fluid content that cannot be adequately reabsorbed, leading to dehydration and the loss of electrolytes and nutrients.

Pathogenesis

Diarrhea results when secretory process for water and electrolytes predominates over absorption.There is much overlap in the following mechanisms which cause diarrhea."        Osmotic"        Secretory"        Increased motility"        Inflammatory

Osmotic Diarrhea

When there is an absorbable solute in the lumen e.g. lactose, there is water retention instead of the normal absorption, resulting in diarrhea. Some enteric infections can cause damage to epithelial cells leading to brush border villi destruction and malabsorption, hence osmotic diarrhea.

Secretory Diarrhea

When there is active secretion of water into the gut lumen e.g. in infections such as cholera. Noninfectious causes can be VIP and gastrin mediated diarrhea; Bile acids & fatty acids in the lumen; Laxatives; Congenital chloride diarrhea.

Combined Osmotic and Secretory Diarrhea

Can occur due to: Clostridium difficile endotoxin; Shigella (Shiga toxin); E. coli; Rotavirus gastroenteritis, wherein the virus causes disruption of the brush border resulting in osmotic diarrhea and also Non-Structural Protein (NSP4) causes Ca++  dependant transepithelial Cl- secretions from crypt cell with resultant secretory diarrhea.

Diarrhea due to Increased Motility

As in IBS, can cause stasis, inflammation, bacterial overgrowth and secondary bile acid deconjugation and malabsorption.

Inflammatory Diarrhea

Exudation of mucus, proteins and blood in the gut lumen cause water and electrolyte loss resulting in diarrhea. Most common cause is infections which can cause mucosal damage directly and via enterotoxins. Intestinal inflammation due to Inflammatory Bowel Disease and Celiac disease can also cause diarrhea. The etiology is multifactorial, but mostly secondary to malabsorption.

It is most ikely that Mary Ann is showing the effects of a Combined Osmotic and Secretory Diarrhea.  The most common form of infdectious diarrhea, likely in a day-care child - is rota virus.   This is associated with a stool sodium concentration of 70 milliEquivilents/liter (mEq/L).   Note that the mother is giving her a sugar beverage without sodium.  This will be discussed below.

Predisposing Factors

Environment Hygiene Stress

Precipitating Factors

Age Sex