Diarrhea, characterized by an increase in the frequency of bowel movements with loose stools and urgency, is a common health issue. It can manifest as acute diarrhea, lasting a few days, or chronic diarrhea, persisting for weeks. While mild cases often resolve spontaneously, severe diarrhea can indicate underlying conditions like ulcerative colitis, cancer, or infections. Persistent diarrhea necessitates thorough investigation and prompt intervention, especially if it leads to dehydration or electrolyte imbalances.
Nurses play a crucial role in monitoring patients with diarrhea, observing for worsening symptoms and their impact on nutrition, vital signs, lab values, and skin integrity. Patient education on dietary adjustments, medication management, and hydration strategies is also vital in diarrhea prevention and management.
Note on Terminology: While the nursing diagnosis “Diarrhea” has been updated to “Impaired Fecal Continence” by NANDA International, this article will continue to use the widely recognized term “Diarrhea” for clarity and familiarity among students and practicing nurses.
Diarrhea: Common Causes
Diarrhea can be triggered by a variety of factors, including:
- Infections/Parasites: Viral, bacterial, or parasitic infections of the gastrointestinal tract are frequent culprits.
- Laxative Use: Overuse or misuse of laxatives can lead to diarrhea.
- Medication Side Effects: Many medications list diarrhea as a potential side effect.
- Chemotherapy/Radiation: Cancer treatments can disrupt the digestive system, causing diarrhea.
- Travel: Traveler’s diarrhea is often caused by consuming contaminated food or water in new environments.
- Contaminated Food or Water: Food poisoning from bacteria or toxins can result in acute diarrhea.
- Tube Feedings: The composition or administration of enteral feedings can sometimes induce diarrhea.
- Gastrointestinal Inflammation: Conditions like inflammatory bowel disease (IBD) cause chronic diarrhea.
- Anxiety/Stress: Psychological stress can impact bowel function and contribute to diarrhea.
- Alcohol Abuse: Alcohol can irritate the gastrointestinal tract and alter bowel habits.
- Food Allergies: Allergic reactions to certain foods can manifest as diarrhea.
- Antibiotic Use: Antibiotics can disrupt the natural gut flora, leading to antibiotic-associated diarrhea.
- Malabsorption: Conditions that impair nutrient absorption can result in diarrhea.
- Autoimmune Disorders: Autoimmune diseases like Crohn’s disease and ulcerative colitis are major causes of chronic diarrhea.
- Gastrointestinal Surgery: Procedures like colectomy or bowel resection can alter bowel function and cause diarrhea.
Recognizing Diarrhea: Signs and Symptoms
Identifying diarrhea involves both subjective reports from the patient and objective assessments by the nurse.
Subjective Symptoms (Patient-Reported)
- Abdominal Pain: Cramping or general discomfort in the abdomen is common.
- Gas and Bloating: Increased intestinal gas can cause bloating and discomfort.
- Urgency and Frequency: A sudden and frequent need to defecate is a hallmark symptom.
Objective Signs (Nurse-Assessed)
- Hyperactive Bowel Sounds: Auscultation of the abdomen reveals increased bowel sounds due to rapid intestinal movement.
- Three or More Loose Stools per Day: An increase in stool frequency and liquidity beyond the patient’s normal pattern.
- Blood or Mucus in Stool: These are alarming signs that may indicate infection or inflammation.
Expected Outcomes for Diarrhea Care
Effective nursing care aims to achieve the following outcomes for patients experiencing diarrhea:
- Patient Education on Dietary Triggers: The patient will be able to identify foods that exacerbate their diarrhea and understand dietary modifications.
- Maintain Adequate Hydration: Patient will maintain a fluid intake of at least 1500 mL/day to prevent dehydration.
- Reduced Stool Frequency: Patient will report experiencing fewer than three loose stools daily.
- Improved Stool Consistency: Patient will report stools that are formed and soft, without blood or mucus.
- Symptom Relief: Patient will report relief from abdominal pain, gas, and cramping.
Nursing Assessment for Diarrhea
A comprehensive nursing assessment is crucial for understanding the patient’s diarrhea and guiding appropriate interventions.
1. Onset and Pattern of Diarrhea: Determine when the diarrhea started, any potential triggers like recent food intake, travel, or medication changes. The duration helps differentiate between acute and chronic diarrhea, influencing treatment strategies.
2. Stool Characteristics and Frequency: Assess the number of loose stools per day, their color, consistency, and presence of blood or mucus. This can be done through direct observation and patient reports.
3. Stool Culture: If infection is suspected, obtain a stool culture to identify specific pathogens and guide targeted treatment.
4. Abdominal Pain and Associated Symptoms: Evaluate the type, location, and severity of abdominal pain. Inquire about related symptoms such as nausea, vomiting, loss of appetite, fever, and dizziness, which can indicate dehydration.
5. Bowel Sounds Assessment: Auscultate bowel sounds; hyperactive bowel sounds are typically present in diarrhea due to increased intestinal motility.
6. Electrolyte Imbalance Monitoring: Prolonged or severe diarrhea can lead to dehydration and electrolyte imbalances. Monitor electrolyte levels through blood tests, particularly potassium, sodium, and bicarbonate.
7. Gastrointestinal History: Gather information about pre-existing GI conditions like colitis, Clostridium difficile infection, autoimmune disorders, or recent GI surgeries, as these can be contributing factors to diarrhea.
Nursing Interventions for Diarrhea Management
Nursing interventions are essential for alleviating symptoms, addressing the underlying cause, and preventing complications of diarrhea.
1. Liquid Diet Encouragement: Bowel rest might be necessary. The healthcare provider may prescribe NPO (nothing by mouth) initially, progressing to clear or full liquid diets to ease digestive workload.
2. Dietary Education for Diarrhea Prevention: Advise patients on bland, low-fiber diets to help bulk up stools. Recommended foods include white rice, white toast, crackers, and cooked eggs. Discourage raw fruits and vegetables, sugary foods, and caffeine, which can exacerbate diarrhea.
3. Medication Review: Evaluate the patient’s current medications. If diarrhea is a significant side effect, discuss potential medication adjustments with the healthcare provider. Review patient’s use of laxatives or stool softeners and educate on appropriate use and discontinuation if diarrhea develops.
4. Antidiarrheal Medication Administration: Once the cause of diarrhea is identified and contraindications are ruled out (like parasitic infections where eliminating the pathogen is crucial), administer antidiarrheal medications as prescribed to reduce bowel motility and stool frequency.
5. Electrolyte Imbalance Correction: Dehydration is a major concern. Administer intravenous (IV) fluids for severe dehydration. Replace electrolytes, particularly potassium, based on lab results and physician orders.
6. Oral Rehydration for Children: Children are particularly vulnerable to dehydration from diarrhea. Utilize oral rehydration solutions (ORS) like Pedialyte. In resource-limited settings, a homemade ORS can be prepared with a precise mixture of water, sugar, and salt to replenish lost fluids and electrolytes.
7. Stress and Anxiety Reduction Techniques: Stress can worsen inflammatory responses in the gut and disrupt the gut microbiome, potentially exacerbating conditions like IBD. Promote relaxation techniques such as deep breathing exercises, meditation, or gentle activity to manage stress and anxiety.
8. Skin Integrity Promotion: Frequent diarrhea can irritate the perianal skin, leading to breakdown. Educate patients on proper hygiene, including front-to-back wiping and using gentle, non-irritating cleansers. For incontinent patients, implement frequent diaper changes, meticulous perineal care, and application of skin barrier ointments to protect the skin.
9. Food Safety Education: Food poisoning is a common cause of diarrhea. Educate patients on safe food handling and preparation practices. Emphasize preventing cross-contamination when handling raw meats, washing produce thoroughly, proper refrigeration and cooking of food, and the importance of handwashing before meals.
10. Referral to Specialists for Chronic Diarrhea: Diarrhea lasting longer than four weeks warrants further investigation. Refer patients with chronic diarrhea to a gastroenterologist to investigate for underlying conditions like IBD or malabsorption issues. Procedures such as colonoscopy may be necessary. If food allergies are suspected, referral to an allergist may be beneficial. A dietitian can provide specialized dietary guidance for managing chronic diarrhea.
11. Lifestyle Modifications Counseling: Alcohol and smoking can significantly impact gut health. Alcohol irritates the intestines and accelerates digestion, while chronic alcohol use is linked to small intestinal bacterial overgrowth. Smoking is a known risk factor for developing and worsening Crohn’s disease. Counsel patients on the adverse effects of these lifestyle factors and provide resources for cessation.
12. Post-Surgical Expectations Education: Patients undergoing gastrointestinal surgeries should be informed that loose stools are common in the days and weeks following surgery. Explain dumping syndrome, which can occur after stomach or esophageal surgery, causing rapid gastric emptying and diarrhea. For patients with ostomies, especially ileostomies (where the colon is removed), educate them that looser stools with frequent output are typical.
Diarrhea Nursing Care Plans: Examples
Nursing care plans provide a structured approach to prioritize assessments and interventions for both short-term and long-term patient care goals. Here are three example care plans addressing different causes of diarrhea.
Care Plan #1: Diarrhea related to Malabsorption secondary to Irritable Bowel Syndrome (IBS)
Diagnostic Statement:
Diarrhea related to malabsorption secondary to irritable bowel syndrome, as evidenced by more than three loose stools per day.
Expected Outcomes:
- Patient will achieve Bristol stool chart Type 3 (sausage-shaped with cracked surfaces) or 4 (sausage-shaped, smooth, and soft) consistency, with bowel movements no more than twice daily.
- Patient will have a negative stool culture, if performed to rule out infectious causes.
- Patient will demonstrate understanding and implementation of dietary modifications to manage irritable bowel syndrome.
Assessment:
1. Bowel Elimination History: Assess bowel habits using Rome IV Criteria for IBS-D, noting abdominal pain improved by defecation and changes in stool frequency and form for at least 3 months with symptoms onset at least 6 months prior to diagnosis. In IBS-D, more than 25% of stools are Bristol Type 6 or 7.
2. Rule Out Other Causes: Exclude high-risk causes of diarrhea, especially if new onset, such as colon cancer, celiac disease, or inflammatory bowel disease. Assess for red flag symptoms like unexplained weight loss, rectal bleeding, iron deficiency anemia, and family history of bowel diseases.
3. Hydration Status Monitoring: Closely monitor fluid balance by tracking input and output to assess and manage dehydration risk.
4. Review Laboratory Data: Evaluate stool culture results to rule out infection. Review results of other diagnostic tests like CT scans or colonoscopy, if performed, to assess for structural or inflammatory bowel disease.
Interventions:
1. Medication Administration: Administer antidiarrheal medications as prescribed. These medications primarily work by slowing down gastrointestinal motility, allowing for increased fluid absorption in the intestines.
2. Dietary Modifications Education:
- Increase Bulk Fiber/Bulking Agents: Recommend incorporating bulk fiber (e.g., cereal, grains) and natural bulking agents (e.g., rice, apples, cheese) to absorb excess fluid in the stool and promote stool thickening.
- Avoid Stimulants: Advise patients to avoid stimulants like caffeine and certain spices, as they can increase gastrointestinal motility and worsen diarrhea.
3. Fluid Intake Encouragement: Encourage daily fluid intake of 1.5 to 2 liters to replace fluids lost through diarrhea and prevent dehydration.
4. Perianal Care: Provide thorough perianal care after each bowel movement to maintain hygiene, reduce the risk of skin excoriation, and promote patient comfort.
5. Contact Precautions (if infectious cause suspected): If IBS is suspected to be triggered by intestinal infection, implement contact precautions to prevent the spread of microorganisms.
6. Education on Preventing Infectious Diarrhea Spread: Educate the patient and family on proper hand hygiene, safe food handling and storage, and thorough cleaning of bathroom and kitchen surfaces to prevent the spread of infectious diarrhea.
Care Plan #2: Diarrhea related to Lactose Deficiency
Diagnostic Statement:
Diarrhea related to lactose deficiency as evidenced by cramping and abdominal pain.
Expected Outcomes:
- Patient will achieve formed, soft stools every 1 to 3 days.
- Patient will report relief from abdominal pain and cramping associated with lactose intolerance.
- Patient will verbalize understanding of dietary modifications necessary to prevent diarrhea related to lactose intolerance.
Assessment:
1. Lactose Tolerance Assessment: Evaluate the patient’s tolerance to milk and other dairy products. Lactose intolerance results from insufficient lactase enzyme, leading to undigested lactose in the intestines, increasing osmotic pressure, and drawing water into the intestinal lumen, causing diarrhea.
2. Bowel Elimination Pattern Assessment: Assess the patient’s usual bowel elimination pattern and identify factors that trigger diarrhea episodes to guide targeted interventions and treatment.
Interventions:
1. Dietary Changes Instruction: Educate the patient on dietary modifications to manage lactose intolerance. Advise avoidance of high-lactose foods such as soft and processed cheeses, buttermilk, ice cream, sour cream, whey, mashed potatoes prepared with milk, and butter. Ensure the patient understands the various food groups where lactose is commonly found, including hidden sources in processed foods.
2. Medication Administration (Antidiarrheals): Administer antidiarrheal medications as prescribed to decrease GI motility, alleviate abdominal pain and cramping, and prevent further fluid loss.
3. Lactase Supplement Instruction/Administration: Instruct on or administer lactase supplements as indicated. Lactase supplements provide the enzyme needed to digest lactose in milk and milk-containing products. They are available in tablet or liquid drop form and should be taken before consuming dairy.
4. Lactose Intolerance Education: Educate the patient about lactose intolerance and its management, emphasizing reading food labels for hidden lactose. Differentiate lactose intolerance from milk allergy, clarifying that lactose intolerance is a GI disorder, while milk allergy is a potentially life-threatening autoimmune reaction. Advise on ensuring sufficient calcium and vitamin D intake from non-dairy sources to compensate for dairy restriction.
Care Plan #3: Diarrhea related to Medication Adverse Effects
Diagnostic Statement:
Diarrhea related to adverse effects of medication as evidenced by urgency and hyperactive bowel sounds.
Expected Outcomes:
- Patient will achieve formed, soft stools every 1 to 3 days.
- Patient will report relief from cramping and a reduction or absence of diarrhea.
Assessment:
1. Defecation Pattern Assessment: Thoroughly assess the patient’s defecation pattern and associated factors, including timing, usual stimuli, stool characteristics, dietary intake, fluid intake, laxative use history, exercise patterns, comorbidities, current and past medications, and perianal sensations.
2. Abdominal Assessment (Inspection, Auscultation, Palpation, Percussion): Perform a comprehensive abdominal assessment in the order of inspection, auscultation, palpation, and percussion. Expect to find hyperactive bowel sounds in patients experiencing diarrhea.
3. Medication Review: Conduct a thorough review of the patient’s current medications to identify potential culprits causing diarrhea as a side effect and determine if medication adjustments are necessary in consultation with the prescriber.
Interventions:
1. Dietary Management: Encourage small, frequent meals of easy-to-digest foods initially, gradually transitioning to a regular diet as tolerated. Recommend easily digestible foods such as bananas, crackers, pretzels, rice, potatoes, clear soups, and applesauce. Advise avoiding milk products, high insoluble fiber foods (like leafy green vegetables), and caffeine (dark sodas, tea, coffee, and chocolate) as these can worsen diarrhea.
2. Perianal Skin Care: Thoroughly cleanse and dry the perianal and perineal skin daily and after each bowel movement. Use a gentle cleanser to remove stool and apply a skin moisture barrier cream as needed to protect the skin from irritation and breakdown caused by frequent stools.
3. Medication Education: Provide comprehensive education about the patient’s current medications, including potential side effects, drug interactions, proper dosing, and frequency to facilitate long-term management of drug-induced diarrhea.
4. Antidiarrheal Medication Administration and Education: Administer and educate the patient on the appropriate use of prescribed antidiarrheal medications (e.g., loperamide, bismuth subsalicylate). Emphasize the importance of medication compliance and potential side effects if not taken as directed.
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