Diarrhea
Diarrhea: Excerpt from Nursing: Interpreting Signs and Symptoms
Usually a chief sign of an intestinal disorder, diarrhea is an increase in the volume of stools compared with the patient's normal bowel habits. It varies in severity and may be acute or chronic. Acute diarrhea may result from acute infection, stress, fecal impaction, or the effect of a drug. Chronic diarrhea may result from chronic infection, obstructive and inflammatory bowel disease, malabsorption syndrome, an endocrine disorder, or GI surgery. Periodic diarrhea may result from food intolerance or from ingestion of spicy or high-fiber foods or caffeine.
One or more pathophysiologic mechanisms may contribute to diarrhea. (See What causes diarrhea? page 194.) The fluid and electrolyte imbalances it produces may precipitate life-threatening arrhythmias or hypovolemic shock.
Action stat!
If the patient's diarrhea is profuse, check for signs of shock—tachycardia, hypotension, and cool, pale, clammy skin. If you detect these signs, place the patient in the supine position and elevate his legs 20 degrees. Insert an I.V. catheter for fluid replacement. Monitor him for electrolyte imbalances, and look for an irregular pulse, muscle weakness, anorexia, and nausea and vomiting. Keep emergency resuscitation equipment handy.
History and physical examination
If the patient isn't in shock, proceed with a physical examination. Evaluate hydration, check skin turgor and mucous membranes, and take blood pressure with the patient lying, sitting, and standing. Inspect the abdomen for distention, and palpate for tenderness. Auscultate bowel sounds. Check for tympany over the abdomen. Take the patient's temperature, and note any chills. Also, look for a rash. Conduct a rectal examination and a pelvic examination if indicated.
Explore signs and symptoms associated with diarrhea. Does the patient have abdominal pain and cramps? Difficulty breathing? Is he weak or fatigued? Find out his drug history. Has he had GI surgery or radiation therapy recently? Ask the patient to briefly describe his diet. Does he have any known food allergies? Last, find out if he's under unusual stress.
Medical causes
Anthrax (GI).Anthrax manifests after the patient has eaten contaminated meat from an animal infected with Bacillus anthracis. Early signs and symptoms include decreased appetite, nausea, vomiting, and a fever. Later signs and symptoms include severe bloody diarrhea, abdominal pain, and hematemesis.
Carcinoid syndrome.With carcinoid syndrome, severe diarrhea occurs with flushing—usually of the head and neck—that's commonly caused by emotional stimuli or the ingestion of food, hot water, or alcohol. Associated signs and symptoms include abdominal cramps, dyspnea, weight loss, anorexia, weakness, palpitations, valvular heart disease, and depression.
Cholera.After ingesting water or food contaminated by the bacterium Vibrio cholerae, the patient experiences abrupt watery diarrhea and vomiting. Other signs and symptoms include thirst (due to severe water and electrolyte loss), weakness, muscle cramps, decreased skin turgor, oliguria, tachycardia, and hypotension. Without treatment, death can occur within hours.
Clostridium difficile infection. The patient may be asymptomatic or may have soft, unformed stools or watery diarrhea that may be foul smelling or grossly bloody; abdominal pain, cramping, and tenderness; a fever; and a white blood cell count as high as 20,000/ml. In severe cases, the patient may develop toxic megacolon, colon perforation, or peritonitis.
Crohn's disease.Crohn's disease is a recurring inflammatory disorder that produces diarrhea accompanied by abdominal pain with guarding and tenderness and nausea. The patient may also display a fever, chills, weakness, anorexia, and weight loss.
Escherichia coli O157:H7. Watery or bloody diarrhea, nausea, vomiting, fever, and abdominal cramps occur after the patient eats undercooked beef or other foods contaminated with this particular strain of bacteria. Hemolytic uremic syndrome, which causes red blood cell destruction and eventually acute renal failure, is a complication of E. coli O157:H7 in children age 5 and younger and elderly people.
Infections.Acute viral, bacterial, and protozoal infections (such as cryptosporidiosis) cause the sudden onset of watery diarrhea as well as abdominal pain, cramps, nausea, vomiting, and a fever. Significant fluid and electrolyte loss may cause signs of dehydration and shock. Chronic tuberculosis and fungal and parasitic infections may produce a less severe but more persistent diarrhea, accompanied by epigastric distress, vomiting, weight loss and, possibly, passage of blood and mucus.
Intestinal obstruction.Partial intestinal obstruction increases intestinal motility, resulting in diarrhea, abdominal pain with tenderness and guarding, nausea and, possibly, distention.
Irritable bowel syndrome (IBS).With IBS, diarrhea alternates with constipation or normal bowel function. Related findings include abdominal pain, tenderness, and distention; dyspepsia; and nausea.
Ischemic bowel disease.Ischemic bowel disease is a life-threatening disorder that causes bloody diarrhea with abdominal pain. If severe, shock may occur, requiring surgery.
Lactose intolerance.With lactose intolerance, diarrhea occurs within several hours of ingesting milk or milk products. It's accompanied by cramps, abdominal pain, borborygmi, bloating, nausea, and flatus.
Listeriosis.With listeriosis, diarrhea occurs in conjunction with a fever, myalgia, abdominal pain, nausea, and vomiting. A fever, a headache, nuchal rigidity, and an altered level of consciousness may occur if the infection spreads to the nervous system and causes meningitis.
Pseudomembranous enterocolitis.Pseudomembranous enterocolitis is a potentially life-threatening disorder that commonly follows antibiotic administration. It produces copious watery, green, foul-smelling, bloody diarrhea that rapidly precipitates signs of shock. Other signs and symptoms include colicky abdominal pain, distention, a fever, and dehydration.
Q fever.Q fever is caused by the bacterium Coxiella burnetii and causes diarrhea along with a fever, chills, a severe headache, malaise, chest pain, and vomiting. In severe cases, hepatitis or pneumonia may follow.
Rotavirus gastroenteritis.Rotavirus gastroenteritis commonly starts with a fever, nausea, and vomiting, followed by diarrhea. The illness can range from mild to severe and can last from 3 to 9 days. Diarrhea and vomiting may result in dehydration.
Thyrotoxicosis.With thyrotoxicosis, nervousness, tremors, diaphoresis, weight loss despite increased appetite, dyspnea, palpitations, tachycardia, an enlarged thyroid, heat intolerance and, possibly, exophthalmos accompany diarrhea.
Ulcerative colitis.The hallmark of ulcerative colitis is recurrent bloody diarrhea with pus or mucus. Other signs and symptoms include tenesmus, hyperactive bowel sounds, cramping lower abdominal pain, a low-grade fever, anorexia and, at times, nausea and vomiting. Weight loss, anemia, and weakness are late findings.
Other causes
Drugs.Many antibiotics—such as ampicillin, cephalosporins, tetracyclines, and clindamycin—cause diarrhea. Other drugs that may cause diarrhea include magnesium-containing antacids, colchicine, guanethidine, lactulose, dantrolene, ethacrynic acid, mefenamic acid, methotrexate, metyrosine and, in high doses, cardiac glycosides and quinidine. Laxative abuse can cause acute or chronic diarrhea.
Treatments.Gastrectomy, gastroenterostomy, and pyloroplasty may produce diarrhea. High-dose radiation therapy may produce enteritis associated with diarrhea.
Nursing considerations
▪ Administer an analgesic for pain and an opiate to decrease intestinal motility, unless the patient has a possible or confirmed stool infection.
▪ Ensure the patient's privacy during defecation, and empty bedpans promptly.
▪ Clean the perineum thoroughly, and apply ointment to prevent skin breakdown.
▪ Note the amount and characteristics of the patient's stool.
▪ Monitor intake and output.
▪ Obtain serum samples for electrolytes and treat imbalances.
▪ Provide fluid replacement orally or I.V., as appropriate.
Patient teaching
▪ Stress the need for medical follow-up to patients with inflammatory bowel disease (particularly ulcerative colitis) who have an increased risk of developing colon cancer.
▪ Emphasize the importance of maintaining adequate hydration.
▪ Explain food or fluids that should be avoided.
▪ Discuss stress reduction techniques.
▪ Explain the diagnosis and treatment plan.
Pictures
Book Source Details
- Book Title: Nursing: Interpreting Signs and Symptoms
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Nursing: Interpreting Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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