Diarrhea is an increase in the frequency of bowel movements, as well as the water content and volume of the waste. It may arise from a variety of factors, including malabsorption disorders, increased secretion of fluid by the intestinal mucosa, and hypermotility of the intestine. It may also due to infection, inflammatory bowel diseases, side effects of drugs, increased osmotic loads, radiation, or increased intestinal motility.
Diarrhea can be an acute or a severe problem. Mild cases can be recovered in a few days. However, severe diarrhea can lead to dehydration or severe nutritional problems. Problems associated with diarrhea include fluid and electrolyte imbalances, impaired nutrition, and altered skin integrity. Additionally, nurses and the members of the healthcare team must take precautions to prevent transmission of infection associated with some causes of diarrhea.
The following are the common causes of diarrhea:
- Alcohol abuse
- Disagreeable dietary intake
- Enteric infections: viral, bacterial, or parasitic
- Gastrointestinal disorders
- Increased secretion
- Laxative abuse
- Malabsorption (e.g., lactase deficiency)
- Motor disorders: irritable bowel
- Mucosal inflammation: Crohn’s disease or ulcerative colitis
- Short bowel syndrome
- Side effects of medication use
- Surgical procedures: bowel resection, gastrectomy
- Tube feedings
Signs and Symptoms
A patient with diarrhea may report the following signs and symptoms:
- Abdominal pain
- Frequency of stools (more than 3/day)
- Hyperactive bowel sounds or sensations
- Loose or liquid stools
Goals and Outcomes
The following are the common goals and expected outcomes for Diarrhea:
- Patient explains cause of diarrhea and rationale for treatment.
- Patient consumes at least 1500-2000 mL of clear liquids within 24 hours period.
- Patient maintains good skin turgor and weight at usual level.
- Patient reports less diarrhea within 36 hours.
- Patient defecates formed, soft stool every day to every third day.
- Patient maintains a rectal area free of irritation.
- Patient states relief from cramping and less or no diarrhea
- Patient has negative stool cultures.
Thorough assessment is important to ascertain potential problems that may have lead to diarrhea as well as handle any conflict that may appear during nursing care.
|Assess for abdominal discomfort, pain, cramping, frequency, urgency, loose or liquid stools, and hyperactive bowel sensations.||These assessment findings are usually linked with diarrhea.|
|Evaluate pattern of defecation.||Assessment of defecation pattern will help direct treatment.|
|Culture stool.||Testing will distinguish potential etiological organisms for the diarrhea.|
|Inquire about the following:|
||Diarrhea is a typical indication of lactose intolerance. Patients with lactose intolerance have insufficient lactase, the enzyme that digests lactose. The presence of lactose in the intestines increases osmotic pressure and draws water into the intestinal lumen.|
||Foods may trigger intestinal nerve fibers and cause increased peristalsis. Some foods will increase intestinal osmotic pressure and draw fluid into the intestinal lumen. Spicy, fatty, or high-carbohydrate foods; caffeine; sugar-free foods with sorbitol; or contaminated tube feedings may cause diarrhea.|
||Diarrhea may also be due to inadequately cooked food, food contaminated with bacteria during preparation, foods that are not maintained at appropriate temperatures, or contaminated tube feedings.|
||Drugs such as laxatives and antibiotics usually cause diarrhea. magnesium and calcium supplements can also cause diarrhea.|
||Alterations in eating schedule can cause changes in intestinal function and can lead to diarrhea.|
||Hyperosmolar food or fluid draws excess fluid into the gut, stimulates peristalsis, and causes diarrhea.|
||Certain individuals respond to stress with hyperactivity of the gastrointestinal tract.|
|Assess for fecal impaction.||Liquid stool (apparent diarrhea) may seep past fecal impaction.|
|Assess hydration status, including:|
||Diarrhea can lead to profound dehydration|
||Dehydration causes dry mucous membranes.|
||Decreased skin turgor and tenting of the skin occur in dehydration.|
|Check for a history of the following:|
||Diseases such as gastroenteritis and Crohn’s disease can result in malabsorption and lead to chronic diarrhea.|
||Radiation causes sloughing of the intestinal mucosa, decreases usual absorption capacity, and may result in diarrhea.|
||Diarrhea is normal 1 to 3 weeks after bowel resection. Patients who have gastric partitioning surgery for weight loss may experience diarrhea as they begin refeeding. Diarrhea is a manifestation of dumping syndrome in which an increased osmotic bolus entering the small intestine draws fluid into the small intestine.|
||Patients may acquire intestinal infections from eating contaminated foods or drinking contaminated water.|
|Assess the condition of perianal skin.||Diarrheal stools may be highly corrosive as a result of increased enzyme content.|
|Examine the emotional impact of illness, hospitalization, and/or soiling accidents.||Loss of control of bowel elimination that occurs with diarrhea can lead to feelings of embarrassment and decreased self-esteem.|
The following are the therapeutic nursing interventions for diarrhea:
|Weigh patient daily and note decreased weight.||An accurate daily weight is an important indicator of fluid balance in the body.|
|Have patient keep a diary that includes the following: time of day defecation occurs; usual stimulus for defecation; consistency, amount, and frequency of stool; type of, amount of, and time food consumed; fluid intake; history of bowel habits and laxative use; diet; exercise patterns; obstetrical/gynecological, medical, and surgical histories; medications; alterations in perianal sensations; and present bowel regimen.||Evaluation of defecation pattern will help direct treatment.|
|Avoid using medications that slow peristalsis. If an infectious process is occurring, such as Clostridium difficile infection or food poisoning, medication to slow down peristalsis should generally not be given.||The increase in gut motility helps eliminate the causative factor, and use of antidiarrheal medication could result in a toxic megacolon.|
|Give antidiarrheal drugs as ordered.||Most antidiarrheal drugs suppress gastrointestinal motility, thus allowing for more fluid absorption. Supplements of beneficial bacteria (“probiotics”) or yogurt may reduce symptoms by reestablishing normal flora in the intestine.|
|Provide the following dietary alterations:|
||Bulking agents and dietary fibers absorb fluid from the stool and help thicken the stool.|
||Stimulants may increase gastrointestinal motility and worsen diarrhea.|
|Record number and consistency of stools per day; if desired, use a fecal incontinence collector for accurate measurement of output.||Documentation of output provides a baseline and helps direct replacement fluid therapy.|
|Evaluate dehydration by observing skin turgor over sternum and inspecting for longitudinal furrows of the tongue. Watch for excessive thirst, fever, dizziness, lightheadedness, palpitations, excessive cramping, bloody stools, hypotension, and symptoms of shock.||Severe diarrhea can cause deficient fluid volume with extreme weakness and cause death in the very young, the chronically ill, and the elderly.|
|Encourage fluids 1.5 to 2 L/24 hr plus 200 mL for each loose stool in adults unless contraindicated; consider nutritional support.||Increased fluid intake replaces fluid lost in the liquid stool.|
|Monitor and record intake and output; note oliguria and dark, concentrated urine. Measure specific gravity of urine if possible.||Dark, concentrated urine, along with a high specific gravity of urine, is an indication of deficient fluid volume.|
|Evaluate the appropriateness of protocols for bowel preparation on basis of age, weight, condition, disease, and other therapies.||Older, frail patients or those patients already depleted may require less bowel preparation or additional intravenous fluid therapy during preparation.|
|Provide perianal care after each bowel movement.
|Mild cleansing of the perianal skin after each bowel movement will prevent excoriation. Barrier creams can be used to protect the skin.|
|Avoid the use of rectal Foley catheters.||Rectal Foley catheters can cause rectal necrosis, sphincter damage, or rupture, and the nursing staff may not have the time to properly follow the necessary and very time-consuming steps of their care.|
|If diarrhea is associated with cancer or cancer treatment, once infectious cause of diarrhea is ruled out, provide medications as ordered to stop diarrhea.||The loss of proteins, electrolytes, and water from diarrhea in a cancer patient can lead to rapid deterioration and possibly fatal dehydration.|
|For patients with enteral tube feeding, employ the following:|
||Contaminated equipment can result to diarrhea.|
||Extremes of temperature can stimulate peristalsis.|
||Starting a tube feeding at a slow infusion rate allows the gastrointestinal system to accommodate intake.|
||Decreasing the rate of infusion or osmolarity of the feeding prevents hyperosmolar diarrhea.|
|If diarrhea is chronic and there is an indication of malnutrition, discuss with primary care practitioner for a dietary consult and possible use of a hydrolyzed formula to maintain nutrition while the gastrointestinal system heals.||A hydrolyzed formula has protein that is partially broken down to small peptides or amino acids for people who cannot digest nutrients.|
|Encourage patient to eat small, frequent meals and to consume foods that normally cause constipation and are easy to digest.||Bland, starchy foods are initially recommended when starting to eat solid food again.|
|Educate the patient or caregiver about the following dietary measures to control diarrhea:
|These dietary changes can slow the passage of stool through the colon and reduce or eliminate diarrhea.|
|Allow the patient to communicate with caregiver if diarrhea occurs with prescription drugs.||This should be reported immediately to prevent worsening of diarrhea.|
|Educate patient or caregiver the proper use of antidiarrheal medications as ordered.||Appropriate use of antidiarrheal medications can promote effective bowel elimination.|
|Discuss the importance of fluid replacement during diarrheal episodes.||Fluid intake is necessary to prevent dehydration.|
|Impart to patient the importance of good perianal hygiene.||Hygiene reduces the risk of perianal excoriation and promotes comfort.|
|Educate patient and SO on how to prepare food properly and the importance of good food sanitation practices and handwashing.||These could prevent outbreaks and spread of infectious diseases transmitted through fecal-oral route.|
|Provide emotional support for patients who are having trouble controlling unpredictable episodes of diarrhea.||Diarrhea can be a great source of embarrassment to the elderly and can lead to social isolation and a feeling of powerlessness.|