Diarrhea: Nursing

Diarrhea is a condition where loose or watery stools are discharged from the intestines more frequently than normal, so more than three times in 24 hours.

Now, based on its duration, diarrhea can be classified as acute, if it lasts for 2 weeks or less; persistent, if it lasts for more than 2 weeks but less than 30 days; and chronic if it lasts for more than 30 days.Okay, let’s focus on the physiology of the intestines, which include the small intestine, as well as the large intestine or colon, and the rectum.

The small intestine is the longest portion of the gastrointestinal tract, and it’s the main site for food digestion and absorption of most nutrients, such as amino acids, fatty acids, monosaccharides, vitamins, and minerals, as well as water.

The food that is not digested and absorbed travels to the large intestine, where the remaining nutrients and water are absorbed, and the stools are formed.

From the large intestine, stools travel down to the rectum, and are eliminated from the body through the anus. Moreover, the intestines contain a variety of non-pathogenic bacteria, which form the healthy intestinal flora, and aid with food digestion, as well as with the prevention of intestinal invasion by pathogenic bacteria and other microorganisms.Now, based on the cause, diarrhea can be defined as infectious or non-infectious diarrhea.

As its name implies, infectious diarrhea is caused by pathogenic microorganisms, which include: bacteria, most commonly Salmonella spp, and Shigella spp, as well as Escherichia coli, Vibrio cholerae, and Clostridioides difficile; as well as viruses, such as adenoviruses, norovirus, and rotavirus; and protozoa, such as Giardia lamblia and Entamoeba spp.

On the flip side, non-infectious diarrhea can be subdivided into three main groups. The first group is when diarrhea occurs as a side effect of medications that can disrupt the intestinal flora, such as antibiotics.

The second group is food intolerance, like lactose intolerance; and finally, the third group includes underlying conditions, such as irritable bowel syndrome, Crohn disease, ulcerative colitis, and celiac disease.

However, not everyone who gets exposed to a causative agent will get diarrhea. Important risk factors for diarrhea include older age, living in or traveling to places with poor hygiene and sanitation, improper keeping and heating of food, poor water storage and handling practices, and living in overcrowded spaces.Regardless of the cause, diarrhea occurs when there’s impairment of the normal intestinal absorption of water and nutrients, so diarrhea can also be classified into three major types, including inflammatory, fatty, and watery.

Inflammatory diarrhea occurs when there's damage to the intestinal mucosa due to inflammation, which can be caused by conditions like Crohn disease, or by food poisoning due to contamination by infectious microorganisms.

Next, fatty diarrhea is specifically associated with impaired digestion and absorption of fats. Finally, watery diarrhea occurs when water is abnormally secreted into the stools instead of being absorbed; watery diarrhea can be either osmotic or secretory.

Osmotic diarrhea occurs due to an osmotic imbalance in the gastrointestinal tract, and it’s commonly seen in clients with lactose intolerance, who cannot digest lactose.

As a result, lactose remains as an osmotically active compound, which attracts water molecules in the intestinal lumen and decreases their absorption, eventually causing diarrhea.

On the flip side, secretory diarrhea is typically caused by infectious microorganisms that secrete toxins, such as Escherichia coli or Vibrio cholerae, or medications, such as laxatives, which stimulate the secretion of water into the intestinal lumen; as well as conditions like diabetic neuropathy, which may alter gastrointestinal motility.Now, the typical clinical manifestations of diarrhea include frequent, loose stools, often accompanied by abdominal pain and cramps, as well as urgency.

Some clients may also experience bloating, nausea, vomiting, and weight loss; as well as fever, especially with infectious diarrhea.

In some cases, the stools may have visible blood, mucus, or fat. The main complication of diarrhea is dehydration, which can present with poor skin turgor and dry mucous membranes; and in severe cases, sunken-appearing eyes and delayed capillary refill.

If not recognized in time, dehydration can eventually lead to electrolyte imbalance and metabolic acidosis, and can be life-threatening.

Other severe complications of diarrhea include malnutrition, gastrointestinal perforation, sepsis, and even death.The diagnosis of diarrhea is typically based on the client's history and physical assessment.

Additionally, stool tests, such as a stool culture can be ordered to see if there’s an infectious microorganism; while the fecal osmotic gap can be measured in clients with watery diarrhea to determine if it’s osmotic or secretory.The treatment of diarrhea is mostly supportive and includes oral rehydration and eating a low-fiber diet that’s easy to digest, including bananas, white rice,yogurt, applesauce, noodles, crackers, potatoes, boiled vegetables and soups.

Some clients might require administration of glucose-electrolyte solutions, or even antidiarrheal medications, such as loperamide, which reduces the motility of the gastrointestinal tract, eventually reducing the frequency of stools.

It’s important to note that medications that reduce motility should not be used in infectious diarrhea, since their effect might delay the elimination of pathogens and toxins out of the gastrointestinal tract.

Instead, these clients might require the administration of antimicrobials to fight the causative microorganism. Finally, clients can also take probiotics to help restore the intestinal flora, and for recurrent episodes of Clostriodiodes difficile diarrhea, fecal microbiota transplant can be helpful.All right, when caring for a client who is experiencing severe diarrhea, priority nursing goals are focused on restoring normal bowel elimination; maintaining fluid, electrolyte, and acid-base balance; and preventing perineal skin breakdown.

Begin by assessing your client’s symptoms, including onset, frequency, and amount of diarrhea. Use the Bristol Stool Chart by asking your client to point to the picture that looks most like their stool.

Next, assess your client’s vital signs, noting fever and signs of dehydration, such as tachycardia, weak pulse, or decreased blood pressure.

Also assess for other signs of dehydration by checking their oral mucosa for dryness, as well as their skin for decreased turgor; keep in mind that in older adults, skin turgor is less predictive of fluid loss due to reduced elasticity.

Then administer IV fluids, and if an infection is diagnosed, administer antimicrobials as prescribed. Encourage oral fluid intake as tolerated, weigh your client daily, and keep a close eye on your client’s fluid intake, output, and electrolyte levels, as well as their CBC, BUN, and creatinine.

Report to the healthcare provider if you notice indications that your client’s condition is worsening, such as increased production of watery stool, blood or mucus in the stool, or continued signs of dehydration despite treatment.

Be prepared to send a stool sample to the lab for analysis. Also be sure to assess your client’s perineal area for irritation and impaired skin integrity; and provide regular, gentle, perineal care, pat dry, and apply barrier cream to help prevent breakdown.

Lastly, ensure a bedside commode is positioned close to your client’s bed, and that the call light is within reach so they can call for assistance when needed.Now, if you are caring for a client diagnosed with a Clostridioides difficile infection, initiate contact precautions.

Be sure to isolate them from other clients if possible, or cohort them with other clients with a C. difficile infection.

Always wear a gown and gloves each time you enter the room, and remember that alcohol-based solutions do not kill the bacteria spores, so always wash your hands thoroughly with soap and water before and after providing care.

Also be sure equipment used to assess your client’s vital signs stays in the room, and is cleaned thoroughly with a 10% bleach solution after your client is discharged.

Finally, remind housekeeping staff to clean surfaces and door handles frequently, and remind visitors to adhere to infection control guidelines.

All right, let’s move on to client and family teaching. For a client with mild to moderate diarrhea, teach them how to care for themselves at home.

Emphasize the importance of increasing fluids, and advise them to drink diluted fruit juices and broths to provide a balance of water, sugar, and salt.

Also stress the importance of maintaining good nutrition during their illness, and suggest foods like boiled vegetables, potatoes, bananas, soups, and crackers.

Tell your client that they may take the prescribed antidiarrheal medication to help decrease the frequency of stools, but if they have a temperature greater than 100.4°F or 38°C, or if their stools contain mucus or blood, they should not take the medication, and they should contact their healthcare provider immediately.

Also, instruct them to contact their healthcare provider right away if their diarrhea does not improve within two days; if they experience severe abdominal pain; if they notice signs of dehydration like decreased urine output or dark concentrated urine; increased thirst and dry mouth and tongue; or dizziness when standing or sitting up from a supine position.

Next, teach your client to avoid spreading their infection to household members by emphasizing the importance of washing their hands frequently, especially after having a bowel movement, and before and after preparing foods.

Instruct them to clean underneath their fingernails, to thoroughly rinse and dry their hands, and to not share their towel with others.Finally, teach your client to prevent diarrhea by practicing frequent hand hygiene.

Also review food safety principles, such as avoiding unpasteurized milk; washing raw fruits and vegetables before eating them; and cooking eggs until the yolk is firm.

Emphasize the importance of keeping raw meat, fish, and poultry separate from other food; washing hands, knives, and cutting boards after handling any uncooked food; and cooking meat to a safe internal temperature, such as 160°F or 71°C for ground beef; 170°F or 77°C for chicken.

Lastly, let them know that they can maintain a healthy gut microbiome by eating a healthy diet which includes fruits, vegetables, whole grains, and yogurt with live bacteria cultures.

All right, as a quick recap… Diarrhea is a condition in which a person has loose or watery stools more than 3 times per day.

Diarrhea can be acute, persistent, or chronic, and it can be caused by infectious or non-infectious processes. It can be further classified as inflammatory when there's damage to the intestinal mucosa due to inflammation; fatty when associated with impaired digestion and absorption of fats; or watery, which can be either osmotic due to an imbalance that attracts water into the gastrointestinal tract, or secretory when water is secreted into the intestinal lumen.

Diarrhea may be accompanied by abdominal discomfort, nausea, vomiting, and can cause complications like dehydration, malnutrition, gastrointestinal perforation, sepsis, and even death.

Priority nursing goals are focused on restoring normal bowel elimination; maintaining fluid, electrolyte, and acid-base balance; and maintaining nutrition during their illness.

Client education centers on reducing risk, staying hydrated, preventing spread, and what signs and symptoms should be reported to their healthcare provider.