DIARRHEA (English Version)

• Meaning
  Diarrhea is one of the cardinal symptoms of small-bowel disease, although it may also be due to emotional stress; to infections; or to gastric, pancreatic, and large intestine disorders. It is a condition in which there is unusual frequency of bowel movements, as well as changes in the amount, the character, and the consistency of the stools. It is best defined, quantitatively as more than 200 g of stool per day.
  
• Clinical Manifestations.
  In acute cases the stools are grayish brown, foul smelling, and filled with undigested particles of food and mucus. The patient complains of abdominal cramps, distention, intestinal rumbling (borborygmus), anorexia, and thirst. Painful spasms (tenesmus) of the anus may attend each defecation.
  
• Nursing Assessment.
  Diarrhea and its associated symptoms occur in a variety of disorders. The nurse will facilitate the diagnosis in each case by recording discerning observations, including the patient's symptoms, behavior, and remarks. Watery stools are characteristic of small-bowel disease, whereas loose, semisolid stools are associated more often with disorders of the colon. Voluminous, greasy stools suggest intestinal malabsorption, and the presence of mucus and pus in the stools denotes inflammatory enteritis or colitis. Oil droplets in the toilet water are almost always diagnostic of pancreatic insufficiency Nocturnal diarrhea may be a manifestation of diabetic neuropathy. Questions to ask the patient include:
  
  • Do you have loose stools or more frequent stools? How frequent?
    
  • What do they look like?
    
  • How long have you had this problem? Is this the first time?
    
  • Does this occur during the day only? Just _in the morning? Nightly too?
    
  • Is there an urgency about your movements? Signs of incontinency?
    
  • Have you noticed mucus mixed with your stool? Blood, pus, or undigested food?
    
  • Have you traveled recently? Out of the country?
    
    
• Acute Diarrhea
  
  • Pathophysiology.
    
    Most acute diarrheas are due to increased secretion of water and electrolytes by the intestinal mucosa. The irritant stimulating the diarrhea may arise from a localized infection or ulceration in the intestinal wall, owing, for example, to carcinoma or diverticulitis. The irritant may be chemical. Castor oil, after it has been acted upon by the digestive juice, is an example of a mild intestinal irritant, as are most of the vegetable cathartics. Certain unripe fruits, which cause crampy diarrhea, likewise belong in this category. The inflammatory response to these mild irritants is slight; little or no mucous membrane lining is destroyed on exposure to them unless their concentration in the intestinal fluid is excessive. Their chief effect is to produce hyperemia (vascular dilatation, with local increase in blood flow) of the intestinal mucosa and increase in mucous secretion. There also occurs a motor response of hyperperistalsis, which persists until the irritant is excreted. This explains the symptoms of crampy diarrhea.
    
  • Infectious Diarrhea.
    
    By far the most common intestinal irritants are the products of certain ' bacteria, whether their growth occurred in the intestine or in the food before it was eaten. In the case of the enteric pathogens, the organisms causing bacillary dysentery, bacterial growth with release of the irritating toxins takes place in the intestine. On the other hand, practically all cases of food poisoning, or ptomaine poisoning, are due to the ingestion of food heavily contaminated and already containing the toxin. Staphylococcus aureus, for example, if given an opportunity to grow in food, produces an exotoxin that is extremely irritating to the intestinal tract.
    
    Clinically, except for the presence of diarrhea, there is little similarity between a case of food poisoning owing to the ingestion of food containing bacterial toxins and a case of bacillary dysentery. The diarrhea in food poisoning is explosive in onset, develops within a very few hours following the toxic meal and, except in severe cases, subsides within 1 or 2 days—as soon as the toxin is excreted and the inflammatory response subsides. There is little or no fever, and usually the only associated symptoms are those directly attributable to the diarrhea, namely, dehydration and weakness.
    Dysentery owing to the growth of gastrointestinal pathogens within the gastrointestinal tract, on the other hand, develops with a more gradual onset and persists for several days or weeks, with striking constitutional symptoms in addition to the diarrhea.
    
    These clinical differences are quite understandable when it is realized that in the infectious diarrheas, a bacterial invasion of the intestinal mucosa is involved. Then, not only must the bacterial toxins be excreted or destroyed, but also the bacteria themselves must be eradicated, and this takes considerably longer.
    

  
   

• Assessment
  The diagnosis of an acute diarrhea is based on the course of the disease: the type of onset and progression, the presence or absence of fever, and a study of the stools, which are examined for bacteria as well as for blood and pus. In cases of possible infection, the suspected food is tested by bacteriologic cultures. It is very important to remember that diarrhea often is present in various systemic infections. It may be the initial misleading complaint in certain of the exanthemata before the appearance of the rash, or it may appear as an early symptom of hepatitis. It- may complicate or mask such conditions as pneumonia and pyelitis.
  
  
• Planning and Implementation
  
  • Goals
    Goals of nursing care for the patient with diarrhea are:
    
    • Provision of physical support during the acute episode
      
    • Maintainance of adequate hydration
      
    • Correction of alterations in fluid and electrolyte balance related to hyperperistalsis
      
      
  • Nursing Intervention.
    Patients with acute diarrhea are placed on bed rest until the episode has terminated. Fluid and electrolyte replacement, orally or parenterally, is an extremely important measure, symptomatically as well as
    
    supportively. During the acute stages the gastrointestinal tract is kept at rest by administering only liquids and foods low in bulk or by withholding oral feeding entirely. Glucose can be absorbed normally in many diarrheas and will reduce water loss. Antidiarrheal agents are often given to delay the passage of food through the intestine, including diphenoxylate hydrochloride (Lomotil), paregoric (Camphorated Tincture of Opium) and codeine. This, however, is controversial in that in some bacterial diseases it may be better not to give an agent that slows intestinal motility. Ready access to a bathroom, privacy, and adequate personal and environmental cleaning after each episode of diarrhea are measures that the patient will appreciate.
    
    
• Preventive Health Measures.
  All cases of acute diarrhea should be treated as potentially infectious until they are proved otherwise. If the diarrhea is of infectious origin, those caring for the patient should determine whether there is any diarrhea among the family and neighbors. Ask the patient about recent sources of food and water. By reporting a larger than usual number of cases of diarrhea, the nurse .assists in determining whether an epidemic is starting in the community.
  
  Proper precautions to avoid the spread of the disease through contamination of the hands, the clothing, the bed linen, etc., with feces or vomitus, must be taken.
  
  Diarrhea always should be regarded as a potential risk under conditions of crowding; outbreaks occur with particular frequency in institutions such as prisons, boarding schools, army camps, and even hospitals, unless sanitary precautions are observed rigidly and constantly.
  
  Precautions include ensuring that proper storage and refrigeration facilities are available and are used for the handling of all fresh fruits and meats. Meat products should be cooked thoroughly, and all cooked meats should be refrigerated immediately unless they are consumed promptly. Milk and milk products should be refrigerated constantly and protected against exposure. Food items that are particularly prone to infection and provide the best environment for bacterial growth include custards and cream fillings, such as are prepared in eclairs, cream pies, layer cakes, cream puffs, etc. Such materials should be cooked thoroughly and then brought to refrigerator temperature immediately.
  
  Proper housekeeping, especially in kitchen maintenance, is obviously very important in the prevention of ep idemic diarrhea. All materials used in the preparation and the serving of food must be cleansed rigorously and kept in immaculate condition. All food handlers should receive detailed instructions in hygienic principles and practices and, upon the development of any illness that is potentially infectious, should be relieved of their duties immediately.
  
  
• Evaluation.
  
  Evaluation activities can be carried out through an assessment of:
  
  • The return of normal peristalsis, as evidenced b^y normal bowel sounds and the absence of diarrhea without antidiarrheal agents
    
  • Adequate fluid and electrolyte balance, as evidenced by normal tissue turgor; moist mucous membranes; adequate urinary output; absence of fatigue and muscle weakness; normal body temperature; ability to resume adequate food and fluid intake orally; and an alert, oriented patient