16.9 Diarrhea

Diarrhea is caused by increased water content of stools, leading to three or more unformed or watery bowel movements per day. Acute diarrhea refers to symptoms lasting fewer than two weeks. Diarrhea is considered chronic when it lasts longer than two weeks. Acute diarrhea is usually caused by an infectious source or contaminated food or water. Chronic diarrhea is often a symptom of another medical disorder, such as inflammatory bowel disease. Risk factors for acute diarrhea are daycare attendance, antibiotic use, consuming contaminated food or water, traveling to developing countries, water exposure in pools or marine environments, and exposure to animals infected with Salmonella. Acute diarrhea will be the focus of this section.^[1]

Pathophysiology

Diarrhea often has a viral cause with norovirus being the leading culprit. Other commonly encountered pathogens in daycare centers are rotavirus, astrovirus, calicivirus or Shigella, Campylobacter, Giardia, and Cryptosporidium bacteria. Although the pathophysiology of diarrhea can vary based on its causative factor, it ultimately results from the bowels either reducing the amount of water they absorb or increasing the amount of water they secrete. In the case of diarrhea caused by bacterial or viral infection, the pathogen damages the epithelial cells that line the intestines, causing poor water absorption and, therefore, watery stool.^[2]

Assessment (Recognizing Cues)

Physical Exam

Clients with acute diarrhea may have other gastrointestinal symptoms that may include the following^[3]:

• Nausea and vomiting
• Fever
• Abdominal pain
• Blood in stool
• Hyperactive bowel sounds

The prognosis for pediatric clients with diarrhea in developing countries is good, but potential complications of severe diarrhea are dehydration and malnutrition that can lead to death, especially in infants with low birthweight or those living in developing countries. Other complications of diarrhea are possible depending on the specific pathogen causing the diarrhea.^[4],[5]

Common Laboratory and Diagnostic Tests

In most cases, acute diarrhea does not require laboratory or diagnostic testing. However, labs or imaging may be ordered by a health care provider in severe cases, when blood is present in the stool, or if the diarrhea is chronic. Stool cultures can be used to detect the causative organism in some cases. In the case of rotavirus, stool can be tested for the presence of antigens to this virus. Stool can also be examined for the presence of white blood cells or ova and parasites if a parasitic infection is suspected.^[6]

Nursing Diagnosis (Analyzing Cues)

Nursing priorities for clients with diarrhea include symptom and fluid management, electrolyte monitoring, and promoting skin integrity.

Nursing diagnoses for clients with diarrhea are created based on the specific needs of the client, their signs and symptoms, and the etiology of the disorder. These nursing diagnoses guide the creation of client-specific care plans that encompass client outcomes and nursing interventions, as well the evaluation of those outcomes. These individualized care plans then serve as a guide for client treatment. Possible nursing diagnoses for clients with diarrhea include the following^[7]:

• Diarrhea r/t disease process
• Fluid volume deficit r/t increased bowel movements
• Impaired skin integrity r/t increase bowel movements
• Imbalanced nutrition: less than body requirements r/t disease process
• Risk for electrolyte imbalance r/t increased bowel movements

Outcome Identification (Generate Solutions)

Outcome identification encompasses the creation of short- and long-term goals for the client. These goals are used to create expected outcome statements that are based on the specific needs of the client. Expected outcomes should be specific, measurable, achievable, relevant, and timebound (SMART) within a set time frame based on the application of appropriate nursing interventions.

Sample expected outcomes for clients with diarrhea include the following:

• The client will exhibit formed stools that occur at the client’s normal frequency within one week.
• The client will exhibit a blood pressure, heart rate, and urine output within normal limits for age, as well as moist mucous membranes during the course of their illness.
• The client will exhibit skin in the peri-area that is an appropriate color for race and free from skin breakdown during the course of the illness.
• The client will maintain their weight within a healthy range that is appropriate for their height until the next follow-up appointment.
• The client will exhibit electrolyte levels that are within normal limits during the course of their illness.

Interventions (Generate Solutions & Take Action)

Medical Interventions

Medical treatment for diarrhea mostly consists of supportive care, particularly managing fluids and electrolytes. Liquids by mouth should be encouraged, but intravenous fluids may be required in serious cases. Diet modification is also essential, and clients should consume foods that are easily tolerated such bananas, oatmeal, toast, rice, applesauce, and soup or broth.^[8],[9]

Depending on the etiology of diarrhea, antibiotics and/or anti-diarrheals may be prescribed. In some cases, antispasmodics may be prescribed to reduce abdominal pain or cramping. Probiotics can also help reduce symptom severity and duration.^[10],[11]

Diarrhea can usually be managed at home, but further evaluation is recommended for children who are younger than three months or weigh less than 8 kg, have a fever, chronic medical conditions, blood in the stool, persistent symptoms, signs of dehydration, changes in mental status, or those who cannot take fluids by mouth.^[12],[13]

Nursing Interventions

Registered nurses develop interventions based on the expected outcomes of the client. Prior to implementation, the nurse must determine if all previously planned interventions are still suitable based on the current situation of the client. When caring for a pediatric client with diarrhea, nursing interventions can be divided into nursing assessments, nursing actions, and client teaching as described in the following subsections.^[14],[15]

Nursing Assessments

• Frequently assess the fluid and electrolyte status of the client to allow for timely intervention.
• Monitor intake and output, including the frequency, consistency, and color of stools.
• Assess the perineum for signs of impaired skin integrity.
• Assess the client for the presence of abdominal cramping or pain using an age-appropriate pain scale.
• Frequently assess the vital signs of the client, as changes in vital signs can occur with dehydration.
• Monitor the client’s weight daily to help assess nutritional status.
• Assess the client’s gastrointestinal system for the presence of hyperactive bowel sounds as this may occur with diarrhea.

Nursing Actions

• Encourage oral rehydration if possible or administer intravenous fluids per provider order. Oral fluid intake should occur frequently and in small amounts.
• Administer antidiarrheals, antibiotics, and electrolyte replacements per provider order.
• Encourage cleaning with soap and water after each bowel movement, as well as the application of a barrier cream.
• Encourage the use of heat, relaxation, and comfortable positioning to relieve pain if present.
• Obtain a stool specimen for further testing if ordered by the provider.

Client Teaching

• Educate the client and their family about the signs and symptoms of dehydration.
• Educate the client and their family about foods that are easily tolerated, as well as foods that can exacerbate symptoms.
• Teach about the need for proper hand hygiene and food preparation techniques to prevent the spread of infectious diarrhea.

Evaluation (Evaluate Outcomes)

Evaluation of client outcomes refers to the process of determining whether or not client outcomes were met by the indicated time frame. This is done by reevaluating the client as a whole and determining if their outcomes have been met, partially met, or not met. If the client outcomes were not met in their entirety, the care plan should be revised and reimplemented. Evaluation of outcomes should occur each time the nurse assesses the client, examines new laboratory or diagnostic data, or interacts with another member of the client’s interdisciplinary team.