Diarrhea
Diarrhea: Excerpt from Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series
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.) The fluid and electrolyte imbalances it produces may precipitate life-threatening arrhythmias or hypovolemic shock.
Act Now: 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. line 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.
Assessment
History
Obtain the patient’s history. Does he have abdominal pain and cramps? Difficulty breathing? Is he weak or fatigued? Ask about 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? Lastly, find out if he’s under unusual stress.
Physical examination
If the patient isn’t in shock, proceed with a brief 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.
Pediatric pointers
Diarrhea in children commonly results from infection, although chronic diarrhea may result from malabsorption syndrome, an anatomic defect, or allergies. Because dehydration and electrolyte imbalance occur rapidly in children, diarrhea can be life-threatening. Diligently monitor all episodes of diarrhea, and immediately replace lost fluids.
Geriatric pointers
In elderly patients with new-onset segmental colitis, rule out ischemia before considering a diagnosis of Crohn’s disease.
Medical causes
Anthrax, GI.
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 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; fever; and a white blood cell count as high as 20,000/µl. In severe cases, the patient may develop toxic megacolon, colonic 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 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
E. coli O157:H7. 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 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
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
Diarrhea occurs within several hours of ingesting milk or milk products. It’s accompanied by cramps, abdominal pain, borborygmi, bloating, nausea, and flatus.
Large-bowel cancer
With large-bowel cancer, bloody diarrhea is seen with a partial obstruction. Other signs and symptoms include abdominal pain, anorexia, weight loss, weakness, fatigue, exertional dyspnea, and depression.
Lead poisoning
. Alternating diarrhea and constipation occur with lead poisoning. Other GI effects include abdominal pain, anorexia, nausea, and vomiting. The patient complains of a metallic taste, headache, and dizziness and displays a bluish gingival lead line.
Listeriosis
With listeriosis — an infectious disease — diarrhea occurs in conjunction with fever, myalgias, abdominal pain, nausea, and vomiting. Fever, headache, nuchal rigidity, and altered level of consciousness may occur if the infection spreads to the nervous system and causes meningitis. This infection, caused by the ingestion of food contaminated with the bacterium
Listeria monocytogenes primarily affects pregnant females, neonates, and those with weakened immune systems.
Malabsorption syndrome
Occurring after meals, diarrhea is accompanied by steatorrhea, abdominal distention, and muscle cramps. The patient also displays anorexia, weight loss, bone pain, anemia, weakness, and fatigue. He may bruise easily and have night blindness.
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, fever, and dehydration.
Q fever.
Q fever is caused by the bacterium
Coxiella burnetii and causes diarrhea along with fever, chills, severe headache, malaise, chest pain, and vomiting. In severe cases, hepatitis or pneumonia may occur.
Rotavirus gastroenteritis.
Rotavirus gastroenteritis commonly starts with a fever, nausea, and vomiting, followed by diarrhea. The illness can range from mild to severe and last from 3 to 9 days. Diarrhea and vomiting may result in dehydration.
Thyrotoxicosis.
With thyrotoxicosis, diarrhea is accompanied by nervousness, tremors, diaphoresis, weight loss despite increased appetite, dyspnea, palpitations, tachycardia, enlarged thyroid, heat intolerance and, possibly, exophthalmos.
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, 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.
Foods
Foods that contain certain oils may inhibit absorption of food causing acute uncontrollable diarrhea and rectal leakage.
Herbal remedies
Certain herbal remedies, such as ginkgo biloba, ginseng, and licorice, may cause diarrhea.
Medical 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 opioid 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.
ALERT: Excessive diarrhea may cause skin breakdown and excoriation. To decrease excoriation and facilitate drainage measurement, insert a rectal tube or large indwelling catheter.
Help the patient maintain adequate hydration, administering I.V. fluid replacements. Measure liquid stools, and weigh the patient daily. Monitor electrolyte levels and hematocrit.
Quantify the amount of liquid stool and carefully observe intake and output.
Patient teaching
Explain the purpose of diagnostic tests to the patient. These tests may include blood studies, stool cultures, X-rays, and endoscopy.
Advise the patient to avoid spicy or high-fiber foods (such as fruits), caffeine, high-fat foods, and milk. Suggest smaller, more frequent meals if he has had GI surgery or disease. If appropriate, teach the patient stress-reducing exercises, such as guided imagery and deep-breathing techniques, or recommend counseling.
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.
Pictures
Book Source Details
- Book Title: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 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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