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Friday, November 26, 2010

Diarrhea

Diarrhea

NANDA Definition
It is a passage of loose, unformed stools.


Discussion of the Problem
Diarrhea refers to the passage of liquid feces and an increased frequency of defecation. It is one of the four most common problems related to fecal elimination namely; constipation, diarrhea, bowel incontinence, and flatulence. In diarrhea, rapid passage of chime reduces the time available for the large intestine to reabsorb water and electrolytes. It may result from a variety of factors and they are as follows: intestinal absorption disorders, increased secretion of fluid by the intestinal mucosa, hypermotility of the intestine, infectious (i.e., viral, bacterial, or parasitic) processes, primary bowel diseases, drug therapies, increased osmotic loads, radiation, or increased intestinal motility. Medical conditions associated with diarrhea are the following: subtotal gastrectomy, Chron’s disease, ulcerative colitis, inflammatory bowel disease (IBD), and cancer. Management is based on the following: addressing the cause of the diarrhea, replacing fluids and electrolytes, providing nutrition, and maintaining skin integrity. Precautions should be taken by the health care workers to as not to spread diarrhea from one person to another, including self. Further, health care personnel and other caregivers must take precautions to avoid spreading diarrhea from person to person, including self.

Nursing Interventions Classification (NIC)
  • Diarrhea Management
  • Enteral Tube Feeding
  • Teaching: Prescribed Medications

Nursing Outcomes Classification (NOC)
  • Bowel Elimination
  • Fluid Balance
  • Medication Response

Goal and Objectives
  • Patient will express understanding of factors and suitable interventions or solutions related to individual condition.
  • Patient will institute an elimination pattern appropriate to physical needs and lifestyle with effluent of suitable quantity and consistency.
  • Patient will pass soft, formed stool no more than three times per day.
  • Patient will recognize or avoid contributing factors.
  • Patient will verbalize decrease in frequency of stools, return to more normal stool consistency

Subjective and Objective Data
·         Changes in frequency, characteristics, and amount of stool
  • Frequency of stools
  • Hyperactive bowel sounds or sensations
  • Loose or liquid stools
·         Nausea/vomiting, decreased appetite
·         Reports of abdominal pain, urgency, cramping
  • Urgency

Related Factors
  • Anxiety
  • Bowel disorders: inflammation
  • Bowel resection
  • Chemotherapy
·         Decreased dietary intake; changes in digestive processes
  • Disagreeable dietary intake
·         Drug therapy side effects
  • Enteric infections
  • Increased secretion
  • Lactose intolerance
  • Malabsorption
  • Medication use
  • Radiation
  • Short bowel syndrome
  • Stress
  • Tube feedings

Assessment (Dx)
  • Assess and establish patient’s previous bowel habits and lifestyle. Help in formulation of an individualized care plan.

GORDON’S FUNCTIONAL HEALTH PATTERN ASSESSMENT TOOL
ELIMINATION PATTERN ASSESSMENT
SUBJECTIVE
1.         What is your usual frequency of bowel movements? _________________
            a.         Have to strain to have a bowel movement? No__ Yes__
            b.         Same time each day? No__ Yes__
2.         Has the number of bowel movements changed in the past week?
            No__ Yes__ Increased?__ Decreased?__
3.         Character of stool
            a.         Consistency: Hard__ Soft__ Liquid__
            b.         Color: Brown__ Black__ Yellow__ Clay-colored__
            c.         Bleeding with bowel movements: No__ Yes__
4.         History of constipation: No__ Yes__  How often? ____________________          
5.         History of diarrhea: No__ Yes__ When?___________________________
6.         History of incontinence: No__ Yes__ Related to increased abdominal pressure             (coughing,        aughing, sneezing)? No__ Yes__
7.         History of travel? No__ Yes__ Where?____________________________
8.         Usual voiding pattern:
            a.         Frequency (times per day) ____ Decreased?__ Increased?__
            b.         Change in awareness of need to void: No__ Yes__ Increased?__ Decreased?__
            c.         Change in urge to void: No__ Yes__ Increased?__ Decreased?__
            d.         Any change in amount? No__ Yes__ Increased?__ Decreased?__
            e.         Color: Yellow__ Smokey__ Dark__
            f.          Incontinence: No__ Yes__ When? _____________________________

Difficulty holding voiding when urge to void develops? No__ Yes__
Have time to get to bathroom: Yes__ No__ How often does problem reaching bathroom occur?
            g.         Retention: No__ Yes__ Describe: _____________________________
            h.         Pain/burning: No__ Yes__ Describe: ___________________________
            i.          Sensation of bladder spasms: No__ Yes__ When? ________________

OBJECTIVE
1.         Auscultate abdomen:
            a.         Bowel sounds: Normal__ Increased__ Decreased__ Absent__
2.         Palpate abdomen:
            a.         Tender: No__ Yes__ Where?_________________________________
            b.         Soft: No__ Yes__; Firm: No__ Yes__
            c.         Masses: No__ Yes__ Describe: _______________________________
            d.         Distention (include distended bladder): No__ Yes__ Describe: _______
            e.         Overflow urine when bladder palpated? Yes__ No__
3.         Rectal Exam:
            a.         Sphincter tone: Describe: ____________________________________
            b.         Hemorrhoids: No__ Yes__ Describe: ___________________________
            c.         Stool in rectum: No__ Yes__ Describe: _________________________
            d.         Impaction: No_- Yes__ Describe:______________________________
            e.         Occult blood: No__ Yes__ Location: ___________________________
4.         Ostomy present: No__ Yes__ Location: ___________________________


  • Assess and document for presence of abdominal pain, cramping, frequency, urgency, loose or liquid stools, and hyperactive bowel sensations.

  • Auscultate for bowel sounds. Inspect for abdominal distension and presence of nausea/vomiting. Generally, bowel sounds are increased in diarrhea.

  • Monitor and document I&O and especially the weight. Complications of diarrhea are dehydration, weight loss, and electrolyte imbalance.

  • Subject patient for stool culture as necessary. Subjecting the stool will identify causative organisms.

  • Watch out for fever, tachycardia, lethargy, leukocytosis, reduced serum protein, restlessness, and prostration. This may indicate a toxic megacolon or perforation and peritonitis are imminent or have occurred, needing immediate medical intervention.

  • Assess for:
    1. Alteration in eating schedule. Change in schedule or time in eating may cause diarrhea.
    2. Current and past stressors. Each individual has a specific respond to stress with hyperactivity of the GI tract.
    3. Level of activity. Peristalsis depends on one’s activity.
    4. Means of food preparation. Any food contaminated with bacteria during preparation may cause diarrhea.
    5. Medications/Drugs that patient is or has been taking like Laxatives and antibiotics that may cause diarrhea. Clostridium difficile can colonize the intestine following antibiotic use and lead to pseudomembranous enterocolitis.
    6. Sufficiency of privacy for elimination. , Provide privacy
    7. Tolerance to drink milk and other dairy products. Those patients with lactose intolerance have inadequate lactase, the enzyme that process lactose. The presence of lactose in the intestines enhances osmotic pressure and draws water into the intestinal lumen.
    8. Unknown food intolerances. Intolerance to spicy, fatty, or high-carbohydrate foods may cause diarrhea.

  • Assess for history of the following:
    1. Previous and current GI diseases. History of GI diseases such as amoebiasis and the like may cause the current condition.
    2. Previous surgery regarding gastrointestinal (GI). Diarrhea is expected following a bowel resection, a period (1 to 3 weeks) is said to be normal.
    3. Radiation of the abdomen. Intestinal mucosa sloughs off due to effects of radiation, it decreases usual absorption capacity, and may cause diarrhea.

  • Evaluate impact of therapeutic or diagnostic interventions on diarrhea. Diarrhea is caused by altering mucosal surface and transit time through bowel thru some preparation like for radiography or surgery, and radiation or chemotherapy predisposes to d.

  • Evaluate hydration status, watch out for the following:
    1. Input and output. Diarrhea can lead to intense dehydration and electrolyte imbalance.
    2. Moisture of mucous membrane. Dry mucous membranes is expected in dehydration.
    3. Skin turgor. Poor skin turgor suggests dehydration.

  • Assess and inspect condition of perianal skin. In diarrhea, stools may be highly acidic, as a result of increased enzyme content.

  • Assess correctness of physician’s radiograph protocols for bowel preparation on basis of age, weight, condition, disease, and other therapies. Elderly patient may require additional intravenous (IV) fluid therapy during preparation.

  • Assess for fecal impaction by digital examination. To verify if seepage of stool is caused by diarrhea or fecal impaction.

  • Explore emotional impact of illness, hospitalization, and/or soiling accidents by providing privacy and opportunity for verbalization.

  • Monitor and document laboratory studies as indicated, e.g., electrolytes. Electrolyte imbalances can contribute to altered GI function.

Therapeutic Interventions (Tx)
  • Offer antidiarrheal drugs as ordered by the physician. To allow more fluid absorption, most antidiarrheal drugs suppress GI motility.

  • Offer sitz bath. It minimizes discomfort by promoting muscle relaxation.

  • Promote adequate rest periods, offer bedside commode. Rest reduces intestinal motility and decreases the metabolic rate when infection or hemorrhage is a complication.

  • Provide room deodorizers. Promote enough ventilation in the room. Remove stool as soon as possible. To prevent undue patient embarrassment by reducing noxious odors.

  • Reinforce oral fluid intake gradually. Offer clear liquids hourly. This promotes rest for the colon by omitting or reducing the stimulus of foods or fluids. Gradual continuation of liquids may avoid cramping and recurrence of diarrhea.

  • Discuss the following dietary alterations as recommended:
    1. "Natural" antidiarrheals (e.g., pretzels, matzos, cheese)
    2. Avoidance of stimulants (e.g., caffeine, Softdrinks and other carbonated beverages). Stimulants may increase GI motility and worsen diarrhea.
    3. Bulk former from fiber (e.g., cereal, grains, Metamucil)

  • Administer medications as ordered like Antidiarrheals, e.g., diphynoxylate (Lomotil), loperamide (Imodium), anodyne suppositories. This reduces GI motility/peristalsis and decreases digestive secretions to alleviate abdominal cramping and diarrhea.

  • Assist with perianal care after each bowel movement (BM). This prevents perianal skin irritation.

Educative (Edx)
  • Discuss to patient or significant others the following dietary factors that can be modified:
    1. Avoid spicy, fatty foods and salty foods.
    2. Avoid foods that are disagreeable.
    3. Broil, bake, or boil foods; avoid frying.

  • Encourage reporting of diarrhea that occurs with prescription drugs. There are usually several antibiotics with which the patient can be treated; if the one prescribed causes diarrhea, this should be reported promptly.

  • Encourage liberal fluid intake; consider nutritional support. Fluids compensate for dehydration and loss of nutrients.

  • Teach patient or significant others the following measures that can manage diarrhea:
1.     Obtain antidiarrheal medications as ordered.
2.     Encourage utilization of "natural" antidiarrheals (effects and dosage may differ person to person).

  • Stress to patient or significant others the importance of good perianal hygiene after each bowel movement. Hygiene controls perianal skin irritation and reduces risk of spread of infectious diarrhea.

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