DIARRHEA P 1007 1009 Passage of at least three loose or liquid stools per day Can be acute usually from infection or chronic lasting longer than 4 weeks Organism enter the body through eating drinking and person to person contact ETIOLOGY AND PATHOPHYSIOLOGY Ingestion of an infectious organism is the primary cause of acute diarrhea o Viral Rotavirus and Norovirus aka Norwalk like virus Alteration in secretion or absorption of the electrolytes in the small intestine with NO inflammation Most common in the US and usually last 48 hours o Bacterial some damage intestines directly and others produce damaging toxins Enterotoxigenic E coli Enter hemorrhagic E coli Shigella Salmonella Staphylococcus Campylobaccter jejuni Clostridium perfringens Clostridium difficile E coli is the most common cause of bloody diarrhea in US from eating C Diff Impair absorption by destroying cells in the colon WITH inflammation o Parasitic Giardia lamblia Entamoeba histolytica Cryptosporidium G Lamblia most common in US from drinking o Rotaviris Noroviris E coli Susceptibility influence by genetics gastric acidity first line of defense intestinal microflora and immunocompetence o Medications can cause a person to be more susceptible lowering the stomach acid proton pump inhibitors and H2 receptor blockers killing normal flora broad spectrum antibiotics C Diff is the most common and serious Non infectious causes o Large amounts of undigested carbohydrate in the bowel can produce osmotic diarrhea Rapid transit and decreased absorption of fluid and electrolytes Laxatives o o Bile salts and undigested fats o Lactose intolerance celiac disease short bowel syndrome and Crohn s disease CLINICAL MANIFESTATIONS Lethargy sunken eyeballs fever malnutrition Pallor dry mucous membranes poor skin turgor perianal irritation Frequent soft liquid stool altered stool color abdominal distention hyperactive bowel sounds presence of pus blood mucus fat leukocytes in stool fecal impaction Decreased output concentrated urine Bacteria that attacks the colon causing inflammation and systemic symptoms o Fever headache malaise nausea vomiting abdominal cramping and diarrhea Can be contagious for up to two weeks Usually self limiting in adults Can cause life threatening dehydration electrolyte disturbances hypokalemia and acid base imbalance metabolic acidosis C Diff o Mild to severe diarrhea abdominal cramping and fever and in some cases fulminant colitis intestinal perforation paralytic ileus and toxic megacolon Chronic can lead to malabsorption leading to malnutrition DIAGNOSTIC STUDIES History physical examination and laboratory testing o Recent travel Medication use Diet Surgical hx Interpersonal contacts Family hx o Anemia increase in H H BUN creatinine WBC decrease in albumin Acute stool is examined for blood mucus WBCs parasites and toxins Chronic stool examined for electrolytes pH and osmolality r t decreased fluid absorption or increased fluid secretion Double balloon enteroscopy and colonoscopy to exam mucosa and obtain biopsies Capsule endoscopy for visualization of intestinal mucosa COLLABORATIVE CARE Dependent on cause o Infectious diarrhea is usually self limiting Avoid medications and food that can cause loose stool Mild oral solutions containing glucose and electrolytes Gatorade or Pedialyte Severe parenteral administration of fluids electrolytes vitamins and nutrition Antidiarrheal agents coat and protect membranes absorb irritating substances inhibit GI motility decrease secretions and decrease CNS GI tract stimulation o Bismuth subsalicylate Pepto Bismol calcium polycarbophil Mitrolan loperamide Imodium diphenoxylate with atropine Lomotil paregoric camphorated tincture Donnagel PG combination of kaolin pectin and pareforic and octreotide acetate Sandostatin o Contraindicated in the treatment of infectious due to prolonging exposure o Use cautiously in inflammatory bowel disease o Only use for short term therapy C Difficile o Spores can survive up to 70 days on objects o Usually resolves after antibiotic therapy ends If not Flagyl first line of therapy or Vancmycin for serious infection o Probiotics and stool transplantation are under investigation NURSING MANAGEMENT Assessment Nursing Diagnosis o Thorough history and physical examination vital signs height weight o Describe stool pattern and symptoms duration frequency character and consistency o Eating habits appetite changes in diet and food intolerances o Assess for dehydration poor turgor dryness and breakdown o Abdomen distension bowel sounds and tenderness o Diarrhea related to acute infectious process aeb frequent loose liquid stool and cramping o Deficient fluid volume r t excessive fluid loss and decreased fluid intake secondary to diarrhea aeb dry skin mucous membranes poor skin turgor orthostatic hypotension tachycardia decreased urine output and electrolyte imbalance o Risk for impaired skin integrity r t perianal exposure to chemical irritants and excretions Planning o No transmission of the infection o Cessation of diarrhea and resumption of normal bowel patterns o Normal fluid electrolyte and acid base balance o Normal nutritional status o No perianal skin breakdown Nursing Implementation o Consider all cases infections until the cause is known o Strict infection control and hand washing o Teach patient and family about hygiene infection control and proper food handling cooking and storage o C Difficile is not killed by alcohol based hand cleaners or ammonia based disinfectants Isolation necessary Must be disinfected with 10 solution of bleach FECAL INCONTINENCE P 1009 1012 Involuntary passage of stool and occurs when the normal structures that maintain continence are disrupted ETIOLOGY CAUSES Result of a problem with motor function sphincter contraction and rectal floor muscles and or sensory function ability to experience the urge to defecate o Weakness of the internal or external anal sphincters damage to the nerves that innervate the anorectum damage to the anal tissue and weakness or trauma to the puborectalis muscle Obstetric trauma is the most common female cause o Childbirth especially with episiotomy aging and menopause Risk factors urinary stress incontinence constipation and diarrhea Chronic constipation fecal impaction leakage of liquid stool o Straining during defecation weakens pelvic floor muscles Anorectal surgery for hemorrhoids fistula and fissures Neurologic brain tumor cauda equine nerve injury congenital abnormalities dementia