DIARRHEA

(DIARE)
Diarrhea: Passage of loose, unformed stools.

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.

Nurses and the members of the healthcare team must take precautions to prevent transmission
of infection associated with some causes of diarrhea.

Related Factors

Here are some factors that may be related to Diarrhea:

Anxiety
Alcohol abuse
Chemotherapy
Disagreeable dietary intake
Enteric infections: viral, bacterial, or parasitic
Gastrointestinal disorders
Increased secretion
Laxative abuse
Malabsorption (e.g., lactase deficiency)
Motor disorders: irritable bowel

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 Mucosal inflammation: Crohns disease or ulcerative colitis
Radiation
Short bowel syndrome
Side effects of medication use
Stress
Surgical procedures: bowel resection, gastrectomy
Tube feedings

Defining Characteristics

Diarrhea is characterized by the following signs and symptoms:

Abdominal pain
Cramping
Frequency of stools (more than 3/day)
Hyperactive bowel sounds or sensations
Loose or liquid stools
Urgency

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.

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Nursing Assessment

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.

Assessment Rationales

Assess for abdominal

discomfort, pain, cramping,
These assessment findings are usually linked with
frequency, urgency, loose or liquid
diarrhea.
stools, and hyperactive bowel
sensations.

Assessment of defecation pattern will help direct

Evaluate pattern of defecation.
treatment.

Testing will distinguish potential etiological organisms

Culture stool.
for the diarrhea.

Inquire about the following:

Diarrhea is a typical indication of lactose intolerance.

Tolerance to milk and Patients with lactose intolerance have insufficient lactase,
other dairy products 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
Food intolerances 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 preparation food contaminated with bacteria during preparation,
foods that are not maintained at appropriate temperatures,
or contaminated tube feedings.
Medications the patient Drugs such as laxatives and antibiotics usually cause
is or has been taking diarrhea. magnesium and calcium supplements can also
cause diarrhea.

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 Change in eating pattern Alterations in eating schedule can cause changes in
intestinal function and can lead to diarrhea.

Osmolality of tube
Hyperosmolar food or fluid draws excess fluid into the
feedings gut, stimulates peristalsis, and causes diarrhea.

Current stressors Certain individuals respond to stress with hyperactivity

Assess for fecal impaction.
Assess hydration status, including:
Input and output
of the gastrointestinal tract.
Liquid stool (apparent diarrhea) may seep past fecal
impaction.
Diarrhea can lead to profound dehydration

Moisture of mucous
membranes Dehydration causes dry mucous membranes.

Skin turgor
Check for a history of the following:
Gastrointestinal diseases
Abdominal radiation
Previous
gastrointestinal surgery
Foreign travel, ingestion
of unpasteurized dairy
products, or drinking
untreated water.
Decreased skin turgor and tenting of the skin occur
in dehydration.
Diseases such as gastroenteritis and Crohns 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 Diarrheal stools may be highly corrosive as a result of
skin. increased enzyme content.

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 Examine the emotional impact of Loss of control of bowel elimination that occurs with
illness, hospitalization, and/or diarrhea can lead to feelings of embarrassment and
soiling accidents. decreased self-esteem.

Nursing Interventions

The following are the therapeutic nursing interventions for Diarrhea:

Interventions Rationales

An accurate daily weight is an important

Weigh patient daily and note decreased weight.
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
Evaluation of defecation pattern will help
food consumed; fluid intake; history of bowel
direct treatment.
habits and laxative use; diet; exercise patterns;
obstetrical/gynecological, medical, and surgical
histories; medications; alterations in perianal
sensations; and present bowel regimen.

Avoid using medications that slow peristalsis. If an

The increase in gut motility helps
infectious process is occurring, such as Clostridium
eliminate the causative factor, and use of
difficile infection or food poisoning, medication to
antidiarrheal medication could result in a
slow down peristalsis should generally not be
toxic megacolon.
given.

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 Most antidiarrheal drugs suppress
gastrointestinal motility, thus allowing
for more fluid absorption. Supplements of
Give antidiarrheal drugs as ordered. beneficial bacteria (probiotics) or
yogurt may reduce symptoms by
reestablishing normal flora in
the intestine.

Provide the following dietary alterations:

Bulk fiber (e.g., cereal, grains, Bulking agents and dietary fibers absorb
Metamucil) fluid from the stool and help thicken the
stool.

Natural bulking agents (e.g., rice,

apples, matzos, cheese)

Avoidance of stimulants (e.g., caffeine,

Stimulants may increase gastrointestinal
carbonated beverages) motility and worsen diarrhea.

Record number and consistency of stools per day; Documentation of output provides a
if desired, use a fecal incontinence collector for baseline and helps direct replacement
accurate measurement of output. fluid therapy.

Evaluate dehydration by observing skin turgor

over sternum and inspecting for longitudinal Severe diarrhea can cause deficient fluid
furrows of the tongue. Watch for excessive volume with extreme weakness and cause
thirst, fever, dizziness, lightheadedness, death in the very young, the chronically
palpitations, excessive cramping, bloody ill, and the elderly.
stools, hypotension, and symptoms of shock.

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Encourage fluids 1.5 to 2 L/24 hr plus 200 mL for
Increased fluid intake replaces fluid lost
each loose stool in adults unless contraindicated;
in the liquid stool.
consider nutritional support.

Monitor and record intake and output; note oliguria Dark, concentrated urine, along with a
and dark, concentrated urine. Measure specific high specific gravity of urine, is an
gravity of urine if possible. indication of deficient fluid volume.

Older, frail patients or those patients

Evaluate the appropriateness of protocols for bowel
already depleted may require less bowel
preparation on basis of age, weight, condition,
preparation or additional intravenous
disease, and other therapies.
fluid therapy during preparation.

Provide perianal care after each bowel movement.

Cleanse with a mild cleansing agent

Mild cleansing of the perianal skin after
(perineal skin cleanser). each bowel movement will prevent
Apply protective ointment prn. excoriation. Barrier creams can be used to
protect the skin.
If skin is still excoriated and
desquamated, apply a wound hydrogel.

Rectal Foley catheters can cause rectal

necrosis, sphincter damage, or rupture,
Avoid the use of rectal Foley catheters. 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 The loss of proteins, electrolytes, and

with cancer or cancer treatment, once infectious water from diarrhea in a cancer patient
cause of diarrhea is ruled out, provide medications can lead to rapid deterioration and
as ordered to stop diarrhea. possibly fatal dehydration.

For patients with enteral tube feeding, employ the following:

Change feeding tube equipment

according to institutional policy, but no Contaminated equipment can result to
diarrhea.
less than every 24 hours.

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 Administer tube feeding at room
Extremes of temperature can
temperature. stimulate peristalsis.

Starting a tube feeding at a slow infusion

Initiate tube feeding slowly.
Decrease the rate or dilute feeding if
diarrhea persists or worsens.
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.
Encourage patient to eat small, frequent meals and
to consume foods that normally
cause constipation and are easy to digest.
Educate the patient or caregiver about the
following dietary measures to control diarrhea:
rate allows the gastrointestinal system to
accommodate intake.
Decreasing the rate of infusion or
osmolarity of the feeding prevents
hyperosmolar diarrhea.
A hydrolyzed formula has protein that is
partially broken down to small peptides or
amino acids for people who cannot digest
nutrients.
Bland, starchy foods are initially
recommended when starting to eat solid
food again.

Avoid spicy, fatty foods, alcohol, and These dietary changes can slow the
passage of stool through the colon and
caffeine.
reduce or eliminate diarrhea.
Broil, bake, or boil foods; avoid frying.
Avoid foods that are disagreeable.

Allow the patient to communicate with caregiver if This should be reported immediately to
diarrhea occurs with prescription drugs. prevent worsening of diarrhea.
Appropriate use of antidiarrheal
Educate patient or caregiver the proper use of
medications can promote effective bowel
antidiarrheal medications as ordered.
elimination.
Discuss the importance of fluid replacement during Fluid intake is necessary to
diarrheal episodes. prevent dehydration.
Impart to patient the importance of good perianal Hygiene reduces the risk of perianal
hygiene. excoriation and promotes comfort.
Educate patient and SO on how to prepare food These could prevent outbreaks and spread
properly and the importance of good food of infectious diseases transmitted through
sanitation practices and handwashing. fecal-oral route.
Provide emotional support for patients who are
Diarrhea can be a great source of
having trouble controlling unpredictable episodes
embarrassment to the elderly and can lead
of diarrhea.

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 to social isolation and a feeling of
powerlessness.