DIARRHEA

Group 4 :
Surya Patricya
Serikat Niscaya
Theresia Yuni
Venggy Reylandhie
Yustina Nay

Diarrhea is the rapid movement of fecal matter

through the intestine, resulting in an excessive loss of water
and electrolytes and producing more frequent loose,
unformed, or watery stools.

Definition

Pathogenic Etiology
Bacteria : Escherichia coli, Salmonella, Shigella, Yersinia
enterocolitica, Campylobacter jejuni, Clostridium difficile,
dysentery, cholera
Viral : rotavirus, enteroviruses (echovirus), adenoviruses,
human reovirus-like agent, Norwalk virus
Normal intestinal tract inhabitants that act as pathogens in
certain circumstances (eg, after ingestion of antibiotics)
Fungal Candida enteritis
Parasitic Giardia lamblia, Cryptosporidium parvum
Protozoal

Etiology

Noninfectious Etiologic Factors

Malabsorption lactase deficiency, cows milk protein allergy, wheat
protein allergy, celiac disease, cystic fibrosis, microvillus inclusion
disease.
Inflammatory bowel disease ulcerative colitis, Crohns disease
Immune deficiency severe combined immunodeficiency, IgA
deficiency
Infant exposed to overeating
Child exposed to excessive stress, emotional excitement, and fatigue
Direct irritation of GI tract by foods, medications, chemicals,
radiation
Inappropriate use of laxatives and purgatives
Mechanical disorders malrotation, incomplete small-bowel
obstruction, intermittent volvulus
Congenital anomalies (eg, Hirschsprungs disease)

Cont

Symptoms very with severity, specific cause, and type of onset

(insidious versus acute):
Low-grade fever to 100 F (37.8 C)
Anorexia
Vomiting (can precede diarrhea by several days) mild and
intermittent to severe
Stools appearance of diarrhea from a few hours to 3 days
Loose and fluid consistency
Greenish or yellow-green
May contain mucus, pus, or blood
Frequency varies from 2 to 20 per day
Expelled with force; may be preceded by pain

Clinical Manifestations
of Diarrhea

Behavioral changes

Irritability and restlessness

Weakness
Extreme prostration
Stupor and convulsions
Flaccidity

Phisycal changes
Little to extreme loss of subcutaneous fat
Up to 50% total body weight loss
Poor skin turgor; capillary refill longer
than 2 seconds
Dry mucous membranes and dry, cracked
lips
Pallor
Sunken fontanelles and eyes
Petechiae seen with bacterial infections
Excoriated buttocks and perineum.
Urine with blood
Vital sign and urine output changes
(signal imminent cardiovascular
collapse)
Low BP
High pulse
Respirations rapid and hyperpneic
Decreased or absent urine output

Acute Diarrhea
1. Sudden change in frequency of stools
2. Usually self-limited, but can result in dehydration
Chronic or Persistent Diarrhea
1. Passage of more than three liquid stools in a day for
more than 2 weeks duration.
2. Associated with disorders of malabsorption, anatomic
defects, abnormal bowel
motility, hypersensitivity reaction, or a long-term
inflammatory response.

Classification

 Physical exam of the abdomen and questions about eating habits

Thorough history and physical examination to determine hydration status
Electrolyte and kidney function tests serum sodium, chloride, potassium, and
blood urea nitrogen variable
Acid-base balance serum carbon dioxide; arterial pH and carbon dioxide possibly
abnormal
CBC to determine plasma volume by hematocrit; infection by WBC count and
differential
Medication review, including over-the-counter drugs and supplements
Blood tests to rule out certain diseases
Stool culture to determine whether bacteria or parasites are present
Fasting tests, avoiding various foods to determine whether diarrhea responds to
dietary changes
Sigmoidoscopy or colonoscopy, which allow doctors to view the colon and
rectum internally
Imaging tests to rule out intestinal blockages or other abnormalities

Diagosis and Test

 Severe dehydration and acid-base derangements with

acidosis
Hypovolemic shock
Hypokalemia
Hypocalcemia
Cardiac dysrhythmias due to hypokalemia and
hypocalcemia
Hyponatremias

Diarrhea Complications

Goal is to prevent spread of disease; communicable disease is suspected until proved otherwise; enteric
precautions are followed.
Bowel rest may be required based on degree of diarrhea and vomiting, if blood present, or electrolyte
abnormalities.
For mild to moderate dehydration (5%), oral rehydration solution is given to maintain fluid and electrolyte
balance (WHO solution, Pedialyte, Infalyte) and BRATS (Bananas, Rice cereal, Applesauce, dry Toast, and
Saltine crackers) diet is followed to provide rest for the inflamed intestines.
For oral rehydration, 100 mL/kg over 4 hours, with additional fluids after each liquid bowel movement.
Candidates for oral rehydration include mild to moderate (greater than 10%) dehydration, older than age 4
months, no persistent vomiting, and probable gastroenteritis.
For moderate to severe dehydration (10% or greater): I.V. fluid and electrolyte replacement is given slowly
as ordered (usually 20 mL/kg); usually over 2 days to prevent hypotonic hypervolemia (water
intoxication).
Supportive care is given: monitoring oral and I.V. fluid intake, output from all sources, and patients
response to treatment.
Specific antimicrobial therapy may be given in some cases such as immunosuppression, bacteremia,
documented C. difficile.
Metronidazole 20 mg/kg/day in divided doses orally or I.V. may be used.
Vancomycin I.V. for resistant C. difficile

Diarrhea Management

 Obtain accurate history of signs and symptoms: nature

and frequency of stools, type of onset, length of illness,
associated symptoms.
Assess degree of dehydration .
Monitor intake and output including oral and I.V. fluids,
fluid loss from diarrhea, urine output, and vomitus;
monitor weight
Note color and consistency of stool and vomitus.

Nursing Assessment of
Diarrhea

 Deficient Fluid Volume related to diarrhea and ECF loss

Risk for Infection and transmission to others related to
infectious diarrhea
Risk for Impaired Skin Integrity related to irritation by
frequent stools
Imbalanced Nutrition: Less Than Body Requirements
related to malabsorption
Anxiety and Fear related to hospitalization and illness

Nursing Diagnose

Assess pattern of defecation, time of day defecation occurs, usual stimulus for defecation,
consistency, amount, frequency of stool, fluid intake
Identify cause of diarrhea if possible (e.g., viral, rotavirus, HIV, food, medication effect,
radiation therapy, protein malnutrisi, laxative abuse, stress)
If client has watery diarrhea, a low-grade fever, abdominal cramps, and a history of
antibiotic therapy, consider possibility of Clostridium difficile infection.
Use Standard Precautions when caring for clients with diarrhea to prevent spread of
infectious diarrhea; use gloves and handwashing
Obtain stool specimens as ordered to either rule out or diagnose an infectious process (e.g.,
ova and parasites, C. difficile infection, bacterial cultures).
If client has infectious diarrhea, avoid using medications that slow peristalsis.
Assess for dehydration by observing skin turgor over sternum and inspecting for
longitudinal furrows of the tongue. Watch for excessive thirst, fever, dizziness,
lightheadedness, palpitations, excessive cramping, bloody stools, hypotension, and
symptoms of shock.
Monitor and record intake and output; note oliguria and dark, concentrated urine. Measure
specific gravity of urine if possible.

Nursing Intervention

 Assess the home for general sanitation and methods of food

preparation. Reinforce principles of sanitation for food handling.
Assess for methods of handling soiled laundry if client is bedbound
or has been incontinent. Instruct or reinforce Standard Precautions
with family and bloodborne pathogen precautions with agency
caregivers. The Bloodborne Pathogen Regulations of the
Occupational Safety and Health Administration (OSHA) identify
legal guidelines for caregivers.
When assessing medication history, include over-the-counter drugs,
both general and those currently being used to treat the diarrhea.
Instruct clients not to mix over-the-counter medications when selftreating. Mixing over-the-counter medications can further irritate the
gastrointestinal system, intensifying the diarrhea or causing nausea
and vomiting.

Home Care Intervention

 Encourage avoidance of coffee, spices, milk products, and

foods that irritate or stimulate the gastrointestinal tract.
Teach appropriate method of taking ordered antidiarrheal
medications; explain side effects.
Explain how to prevent the spread of infectious diarrhea (e.g.,
careful handwashing, appropriate handling and storage of
food).
Help client to determine stressors and set up an appropriate
stress reduction plan.
Teach signs and symptoms of dehydration and electrolyte
imbalance.

Client/Family Teaching