Diarrhea
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.
Emergency Actions
If the patient’s diarrhea is profuse, check for signs of shock, including 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 patient for electrolyte imbalances, and look for an irregular pulse, muscle weakness, anorexia, and nausea and vomiting. Keep emergency resuscitation equipment handy.
History
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? Lastly, find out if he’s under unusual stress.
Physical assessment
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.
Medical causes
Anthrax, GI
Early signs and symptoms of GI anthrax, an infectious disease caused by eating meat contaminated with the bacterium Bacillus anthracis, include decreased appetite, nausea, vomiting, and fever. Later signs and symptoms include severe bloody diarrhea, abdominal pain, and hematemesis.
Clostridium difficile infection
With a 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, a recurring inflammatory disorder, 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 0157:H7
Watery or bloody diarrhea, nausea, vomiting, fever, and abdominal cramps occur after the patient eats undercooked beef or other foods contaminated with the Escherichia coli 0157:H7 strain of bacteria. Hemolytic uremic syndrome, which causes red blood cell destruction and eventually acute renal failure, is a complication of E. coli 0157: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. Other signs and symptoms may include borborygmi and rushes on auscultation and vomiting of fecal material.
Irritable bowel syndrome
Diarrhea alternates with constipation or normal bowel function. Related findings include abdominal pain, tenderness, and distention; dyspepsia; and nausea. The patient may also report passage of mucus and pasty pencil-like stools.
Ischemic bowel disease
A life-threatening disorder, ischemic bowel disease causes bloody diarrhea with abdominal pain. The patient may also experience abdominal distention, nausea, and vomiting. 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 in a patient 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.
Malabsorption syndrome
In a patient with malabsorption syndrome, diarrhea occurs after meals, 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, a potentially life-threatening disorder, 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 an infection that’s 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 follow. Chronic Q fever may cause prolonged fever, night sweats, chills, fatigue, and dyspnea.
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. Herbal remedies — such as ginkgo biloba, ginseng, and licorice — may also cause diarrhea.
Foods
Foods that contain certain oils may inhibit absorption causing acute uncontrollable diarrhea and rectal leakage.
Treatments
Gastrectomy, gastroenterostomy, and pyloroplasty may produce diarrhea. High-dose radiation therapy may produce enteritis, which is associated with diarrhea.
Special 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. Quantify the amount of liquid stools and carefully observe intake and output. Measure liquid stools, and weigh the patient daily. Monitor electrolyte levels and hematocrit. Accurately administer I.V. fluid replacements.
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.
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 the elderly patient with new-onset segmental colitis, always consider ischemia before asssuming that the patient has Crohn’s disease.
Patient counseling
Explain the purpose of diagnostic tests to the patient. These tests may include blood studies, stool cultures, X-rays, and endoscopy.
Help the patient maintain adequate hydration. Remember that dehydration occurs rapidly in elderly people. Encourage the patient to drink plenty of fluids.
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.
Pictures
Book Source Details
- Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2008 Williams & Wilkins.
More About Causes of Loose stool
» Next page: Rectal pain (Signs & Symptoms: A 2-in-1 Reference for Nurses)
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