ORAL REHYDRATION THERAPY:

Oral rehydration therapy introduced by WHO to establish Oral rehydration treatment can be
safely and successfully used in treating acute diarrhea s due to all etiologies in all age group.
The main aim of oral rehydration therapy:
--To prevent dehydration and reduce mortality.
Oral rehydration therapy is based on the observation that glucose given orally enhances the
intestinal absorption of salt and water and is capable of correcting that electrolyte and water
deficit.
COMPOSITION OF ORAL REHYDRATION:
Composition of oral rehydration salt (O!" recommended by WHO was sodium
bicarbonate based.
#nclusion of trisodium citrate in place of bicarbonate made the product more stable and it
resulted in less stool output especially in high output diarrhea as in cholera.
$ropabably because of direct effect of trisodium citrate in increasing intestinal absorption
of sodium and water.
%ore recently an improved O! formulation has been developed which is as safe and
effective as the original in preventing and treating diarrheal dehydration but also reduce
stool output or offers additional clinical benefit or both.
#t is focused on reducing the osmolarity of O! solution to avoid possible adverse effects
of hyper tonicity on net fluid absorption by reducing the concentration of glucose and
sodium chloride in the solution.
The need for unscheduled supplemental intravenous therapy in children given the new
O! fell by &&'( the stool output is decreased by )*' and vomiting was reduced by
&*'.
RECOMMENED FORMULATION:
+ecause of the effectiveness of reduced osmolarity O! solution( WHO and ,-#C./ are
recommending that formulation recommended O! solution.
CO%$O!T#O- O/ .0,C.0 O!%O12#T3 O!:
.0,C.0 O!%O12#T3 O! 42%!51#T.
!odium chloride ).6gms
4lucose( anhydrous 7&.8gms
$otassium chloride 7.8gms
Trisodium citrate( dehydrate ).9gms
Total weight )*.8gms
.0,C.0 O!%O12#T3 O! %%O151#T.
!odium :8
Chloride 68
4lucose( anhydrous :8
$otassium )*
Citrate 7*
Total O!%O12#T3 );8
DEHYDRATION:
0ehydration occurs when the amount of water leaving the body is greater than the amount being
ta<en in.
ASSESSMENT OF DEHYDRATION:
0.H302T#O-
%#10 !.=..
7.$atient>s
appearance
). radial pulse
&. blood pressure
;. s<in elasticity
8. tongue
Thirsty: alert restless
-ormal rate and volume
-ormal
$inch retracts immediately
%oist
0rowsy: limp( cold( sweaty: may be
comatose.
apid( feeble( sometimes impalpable.
1ess than ?*mmhg may be
unrecordable.
$inch retracts very slowly (more than
) seconds".
=ery dry
6. ant.fontanelle
:.urine flow
--'body weight
loss
--.stimated fluid
deficit
-ormal
-ormal
;-8'
;*-8*ml5<g
=ery sun<en
1ittle or none
7*' or more
7**-77*ml5<g
When obvious signs of dehydration e@ist( the water deficit is somewhere between 8*A
7**ml5<g of body weight.
#f the child weight is <nown( the amount of O! solution reBuired for rehydration during
first ; hours may be calculated by the setting the deficit at appro@imately :8ml5<g.
#f the child weight is not <nown( the appro@imate deficit may be determined on the basis
of age.
GUIDELINES FOR ORAL REHYDRATION THEARAPY (for all ages) DURING THE
FIRST FOUR HOURS:
24. ,-0. ;
%O-TH!
;-77
%O-TH!
7-)
3.2!
)-;
3.2!
8-7;
3.2!
78 3!
O
%O.
W.#4HT (C4"
O!
!O1,T#O-(ml"
,nder 8
)**-;**
8-:.9
;**-6**
?-7*.9
6**-?**
77-78.9
?**-7)**
76-)9.9
7)**-))**
&* or over
))**-;***
ORS SOLUTION PREPARATION:
The ingredients reBuired for the preparation of oral fluid are ine@pensive and readily
available and the solution can be prepared with ordinary drin<ing water
$ac<ets of oral rehydration mi@ture are now freely available at all primary health centers(
sub-centers( and hospital and chemist shops.
The contents of the pac<et are to be dissolved in one liter of drin<ing water. The solution
should be made fresh daily and used within ); hours.
Other methods by WHO:
2 simple mi@ture consisting table salt(8g" and sugar ()*g" dissolved in one liter of
drin<ing water may be safety used until the proper mi@ture is obtained.
FLUID REPLACEMENT THERAPY:
/luid replacement therapy is the medical practice of replenishing body fluids through pathologic
process. /luids can be replaced via oral administration( intravenous administration( rectally and
the direct inDection of fluid into the subcutaneous tissue.
0ehydration is significant depletion of body water and to varying degrees( electrolytes.
CLINICAL CORRELATES OF DEHYDRATION:
!.=.#T3
%#10
%O0.2T.
!.=..
/1,#0 0./#C#T in ml5<g (percent of body weight"
#-/2-T!
8* (8'"
7** (7*'"
78* (78'"
20O1.!C.-T!
&* (&'"
8*-6* (8-6'"
:*-9* (:-9'"
!#4-!
!lightly dry buccal mucus membranes(
increased thirst( slightly decreased urine
output.
0ry buccal mucus membranes(
tachycardia( little or no urine output(
lethargy( sun<en eyes( and loss of s<in.
!ame as moderate pulse a rapid( thread
pulseE no tears( cyanosis( rapid breathingE
delayed capillary refill( hypotension(
mottled s<in( and coma.
Treate!t for "e#$"rat%o!:
Fl&%" res&s'%tat%o! re(&%ree!ts:
$atients with signs of hypotension should receive fluid resuscitation with isotonic
fluid.
..g. *.9' saline or ringer>s lactate
The 4O21 is to restore adeBuate circulating volume to restore +$ and perfusion.
#f dehydration is severe dehydration to a deficit of about ?' body wt. #f dehydration is moderate
)*ml ()' body wt" is given #= over )*-&*min.
Def%'%t re)la'ee!t:
Total deficit volume is essential -a deficits are usually about ?*meB5l and C deficits
are usually about &*meB5l of fluid deficit.
O!go%!g losses:
=olume of ongoing losses should be measured or estimated.
Ongoing electrolytes losses can be estimated by source or course.
.!T#%2T.0 .1.CTO13T.! 0./#C#T! +3 C2,!.
C2,!. !O0#,% (%.F51" $OT2!!#,%
(%.F51"
0#H.2:
#sotonic dehydration
Hypotonic dehydration
Hypertonic dehydration
$yloric stenosis
0iabetic <etoacidosis
?*
7**
)*
?*
?*
?*
?*
7*
7**
8*

Ma%!te!a!'e re(&%ree!ts:
/luid and electrolyte needs from basal metabolism must also be accounted for
maintenance reBuirements are related to metabolic rate and affected by body temperature.
HYDERA*AD MI+:
Hyderabad mi@ is not a commercial dietary product. This is invented by -#- -national institute
of nutrition Hyderabad for %alnutrition cases and this li<e GG !attuH - a homemade multimi@ture
of - +engal gram(grount nuts Daggery and s<immed mil< fortified by vit 2 (and this is served in
2aganbadis for socioeconomically poor classes.
Co)o!e!ts of H$"era,a" %-:.
The community health nurse has to ta<e certain measures ta<e:-
7. $rovision of sufficient whole or s<immed mil< to e@pectant and nursing mothers( eggs and
fish( etc with the help of team members
). !upply of animals proteins to be increased by development co-ordination with related sectors
&. $rovision and inta<e of mi@tures of adeBuate vegetable protein especially such as pulses( nuts(
beans( and green vegetables( through nutrition education and counseling.
;. supplementary feeding of infants and young children with good Buality of proteins as 0hal
2har and ground nut flour( a cheap food proteinE +lac< gram flour should be mi@ed with wheat
flour.
8. $rovision to treat malnutrition with Hyderabad mi@ture that is formulated by -ational #nstitute
of -utrition.
Hyderabad mi@ture contains:
Whole wheat (roasted" ---------- ;* grams
+engal gram ---------- 76 grams
4round nut ---------- 7* grams
Iaggery ----------- )* grams
Total ---------- ?6grams.
This yields energy of &&* <cal and 77.&grams of protein. %any children with $.%
treated with this mi@ture( recovered from $.% within & months.
ROAD TO HEALTH CARD
The growth or Jroad to healthK chart first designed by 0avid %orley and later modified by WHO
is a visible display of the child>s physical growth and development.
#t is important to note that in the weight-for-age chart( the height of the child is not ta<en into
consideration. This is because weight is most sensitive measure of growth( and any deviation
from JnormalK can be detected easily by comparison with refere!'e '&r/es0 2 child can lose
weight( but not height. #n short( the growth chart offers a simple and ine@pensive way of
monitoring weight gain( and in fact child health over time.
There are many types of growth charts use in different countries. !ome have only ) reference
curves and others as many as five (8". The WHO in recent years has made an effort to unify the
countless growth charts and curves used throughout the World.
10 T#e 2HO Gro3t# C#art:
The WHO prototype (home based" chart. #t has ) reference curves.
The upper reference curve represents the median (8*
th
percentile" for boys.
The lower reference curve represents the &
rd
percentile for girls. Thus the chart
can be used for both se@es.
The space between the two growth curves has been called Jroad-to-healthK. This will include the
Lone of normality for most populations. #.e. the weight of 98' of normal healthy children used
as a reference fall within this area.
#f the child is growing normally( its growth line will be above the &
rd
percentile and will
run parallel to the Jroad to health curves.
#t is direction of growth that is more important than of dots on the line.
#f the growth curves falling of the child>s weight curve is a signals growth failure( which
is the earliest sign of $.% and clinical signs by wee<s or even months. !uch a child
needs special care.
O,4e't%/e: child care is to <eep the child above the &
rd
percentile.
The WHO chart can be to local needs and circumstances. !ome guidelines intended to be
adapted locally are given in the WHO publication entitled and needed training for community
health wor<ers in nutrition.
!pace is also provided on the growth chart for recording information and registrationE
birth date and weightE
chronological age
history of sibling health
immuniLation procedures
supplementary foods
episodes of sic<ness
child spacing and reasons for special care
The home chart is easily understood by the mother as well as health wor<ers.
50 Gro3t# '#art &se" %! I!"%a:
There are ;9 different types of growth charts in use in #ndia. The growth chart
recommended by the 4overnment of #ndia( has four reference curves.
The top most curve corresponds to ?*' of the median (8*
th
percentile" of the
WHO reference standard.
The lower lines represent :*'( 6*' and 8*' of that standard.
?*' median weight is appro@imately eBualent to ) !0 below the median which is
the conventional lower limit of Jnormal rangeK.
The purpose of lines is to indicate the degree of malnutrition( as recommended by
the #ndian 2cademy of $ediatrics.
The growth chart recommended by the 4overnment of #ndia shows three degrees
of malnutritionE
/irst degree (4rade-#" malnutrition: the child weight between ?*' and
:*' lines( it indicates first-degree or mild degree malnutrition.
!econd degree (4rade-###" malnutrition: if the child weight between:*
and 6*'( it indicates second-degree or moderate degree malnutrition
Third degree (4rade-#=" malnutrition: if the weight is below the 6*'
line( it is third degree or severe malnutrition.
#n addition( 4rade #=( below 8*' has also been added.
,!.! O/ 4OWTH CH2T:
The growth chart has many potential usesE
7. /or growth monitoring which is of great value in child health care
). 0iagnostic tool: for identifying high ris< children. /or e@ample (malnutrition can be
detected long before signs and symptoms of it become apparent
&. $lanning and policy ma<ing :by grading malnutrition( it provides an obDective basis
for planning and policy ma<ing in relation to child health care at the local and central
levels
;. .ducational tool :because of its visual character( the mother can be education in the
care of her own child and encourage her to participate more actively in growth
monitoring
8. Tool for action: #t helps the health wor<er on the type of intervention that is neededE it
will help to ma<e referrals easier.
6. .valuationE it provides a good method to evaluate impact of a programme or of
special interventions for improving child growth and development( and
:. Tool for teachingE it can also be used and for teaching( for e@ample( the importance of
adeBuate feedingE the deleterious effects of diarrhea.
The growth chart has been described as a passport to child health care.
./..-C.:
7. C.$ar< J$reventive and social medicineK +hanot publications( )*
th
edition( )**9( page
noE 796-9?.
). C.$ar< J$reventive and social medicineK +hanot publications( )*
th
edition( )**9( page
noE ;6?-;:7.
&. Camala.4 JCommunity health nursimg-7K( /lorence publishers( 7
st
edition( )*7*( page
noE &*?-&7*.
;. +.T.+asavanthappaKCommunity health nursingK Iaypee publishers( &
rd
edition( )**&(
page noE 7&:.
8. www.biomedsearch.com/nih/Road-to-Health-card.