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. It is a symptom of many conditions and may be caused by many diseases . Commonly, the cause is difficult to determine; occasionally, it is unknown.
Pathophysiology and Etiology of Diarrhea
Mechanisms of Diarrhea
- Secretory decreased absorption, increased secretion
- Osmotic maldigestion, transport defects, ingestion of unabsorbable solute
- Increased motility decreased transit time or stasis (bacterial overgrowth)
- Decreased surface area decreased functional capacity
- Mucosal invasion (motile or secretory) inflammation, decreased colonic reabsorption, increased motility
Physiologic Effects of Diarrhea
– Dehydration (extracellular fluid [ECF] loss)
- Large loss of fluid and electrolytes in watery stools
- Losses with repeated vomiting; decreased fluid intake
- Increased insensible fluid losses from skin and lungs resulting from fever and rapid respirations
- Continued urine excretion
– Electrolyte imbalance
- Potassium may be hyper or hypokalemic
– Sodium and chloride are directly related and may be increased or decreased
- Hypernatremic hyperchloremic (hypertonic) dehydration occurs with acute diarrhea
- Hyponatremic hypochloremic (hypotonic) hypervolemia occurs with too rapid fluid replacement
– Acid-base imbalance metabolic acidosis
- From large losses of potassium, sodium, and bicarbonate in stools
- From impaired renal function
– Monosaccharide intolerance and protein hypersensitivity
- Bacteria Escherichia coli O157:H7, Salmonella, Shigella, Yersinia enterocolitica, Campylobacter jejuni, Clostridium difficile, dysentery, cholera
- Viral rotavirus (most common; peaks during winter months), 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
Noninfectious Etiologic Factors
- Malabsorption lactase deficiency, cow’s milk protein allergy, wheat protein allergy, celiac disease, cystic fibrosis, microvillus inclusion disease.
- Inflammatory bowel disease ulcerative colitis, Crohn’s 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, Hirschsprung’s disease)
- Sudden change in frequency of stools
- Usually self-limited, but can result in dehydration
Chronic or Persistent Diarrhea
– Passage of more than three liquid stools in a day for more than 2 weeks’ duration.
– Associated with disorders of malabsorption, anatomic defects, abnormal bowel motility, hypersensitivity reaction, or a long-term inflammatory response.
Infants and young children in daycare centers may be at increased risk for diarrhea due to Shigella, Salmonella, rotavirus, endopathogenic E. coli, and giardiasis. Hand washing is the major preventive measure. These infections are usually reportable to the health department. Bloody diarrhea should be immediately referred for medical evaluation.
Risk Factors for Diarrhea
– Age the younger the child, the greater the susceptibility and severity.
- ECF volume is proportionately larger in the infant and young child.
- Nutritional reserves are relatively smaller in the young child.
– Impaired health susceptibility is increased in the malnourished or debilitated child.
– Climate susceptibility is increased in warm weather.
– Environment frequency is increased where there is overcrowding, poor sanitation, inadequate refrigeration of food, and inadequate health care and education.
– Virulence of a potential pathogen affects severity.
– Internationally adopted child.
Clinical Manifestations of Diarrhea
– Symptoms vary with severity, specific cause, and type of onset (insidious versus acute).
- Low-grade fever to 100آ° F (37.8آ° C)
- 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
- Irritability and restlessness
- Extreme prostration
- Stupor and convulsions
- 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
- Sunken fontanelles and eyes
- Petechiae seen with bacterial infections
- Excoriated buttocks and perineum.
- Urine with blood
- Low BP
- High pulse
- Respirations rapid and hyperpneic
- Decreased or absent urine output
Studies to Evaluate Condition
- 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
- Sedimentation rate elevated in infection and inflammation
A postural change in heart rate is a useful clue in assessing the fluid state of a toddler. An increase greater than 20 beats/minute when moving from lying to standing is an indicator of hypovolemia.
Studies to Determine Cause
- Thorough history to determine recent contact or exposure, contact with potentially contaminated water (swimming in lakes and ponds, well water), travel to at-risk countries, antibiotic therapy, and possible immunosuppression.
- Rotazyme (rapid test for rotavirus).
- Multiple stool and rectal swab for bacterial cultures, ova and parasites, and Clostridium difficile. Some labs require the sample specify for Giardia profile, Cryptosporidium, and E. coli O157:H7 serotyping. If immunosuppressed, add Microsporidian, Cryptosporidium, and Giardia lamblia antigen 65.
- Stool for WBC count to screen for colitis that may of a bacterial or inflammatory nature.
- Stool pH, reducing substances decreased pH may indicate various noninfectious causes; acid stool containing sugar is characteristic of disaccharide intolerance, abnormality of bile salt reabsorption.
- Blood cultures can rule out septicemia.
- Serologic studies can detect viral pathogens.
- Breath hydrogen test can determine carbohydrate malabsorption and bacterial overgrowth.
- Urinalysis can exclude UTI as cause of nonspecific diarrhea and screen for blood, which may be part of hemolytic uremic syndrome associated with E. coli O157:H7 infection.
Treatment is based on the degree of dehydration; mild (less than 5%), moderate (5% to 10%), and severe (greater than 10% weight loss) .
- 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 patient’s 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
- Severe dehydration and acid-base derangements with acidosis
Nursing Assessment of Diarrhea
- 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.
Assess child’s behavior to determine comfort level. Crying or legs drawn up to abdomen usually indicates pain.
- 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 Interventions in Diarrhea
Restoring Fluid Balance
- Monitor amount and rate of I.V. fluid therapy, which have been calculated by the health care provider. Fluid needs are based on fluid deficit, ongoing losses, and body weight.
- Prevent overload of circulatory system.
- Check flow rate and amount absorbed hourly and totally.
- Adhere to prescribed volume carefully when oral feedings are given in conjunction with I.V. fluid.
- Never administer I.V. fluids to pediatric patient without safeguard of a volume-control infusion device or pump.
- Observe for signs of fluid overload: edema, increased BP, bounding pulse, labored respirations, and crackles in lung fields.
Unless vomiting is severe, do not deprive the patient of nutrition for longer than 1 or 2 days. If adequate nutrition cannot be provided, parental nutrition should be instituted.
- Diluted fruit juices and soft drinks are not recommended. High disaccharide content aggravates diarrhea by osmotic effect.
- Preventing Spread of Infection
- Ensure adherence to good hand-washing and gown technique protocols for all people having contact with infant or child.
- Follow your facility’s policy on care of diapers.
- Handle specimens collected using universal precautions, and transport to laboratories in appropriate containers per policy. Collect stool sample for culture before instituting antibiotic therapy.
- Teach good hygiene measures to older children.
Preventing Skin Impairment
- Protect infant’s diaper area from becoming excoriated by making frequent diaper changes.
- Expose to air and light as much as possible.
- Avoid commercial baby wipes, which contain alcohol and may sting inflamed or excoriated diaper area. Use mild soap and water, place infant in tub of water or baking soda bath (soothing and neutralizing) for cleaning.
- Prevent scratching or rubbing of irritated area. Holding infant on parent’s protected lap may provide comfort and stimulation for parent and infant.
- Use protective barrier creams, such as zinc oxide (Desitin) or karaya powder; if excoriated, soak off cream and pat dry do not rub. Not all cream barrier has to be removed because this can denude skin.
- Leave diaper area open to air until thoroughly dried.
Resuming Adequate Nutritional Intake
- After rehydration, advance slowly from clear liquids, such as Pedialyte, to half-strength formula, to regular diet.
- If chronic diarrhea, bloody diarrhea, or secretory diarrhea, limit milk products containing lactose.
- In older infants and children, offer rice cereal, bananas, potatoes, or other nonlactose, carbohydrate-rich foods shortly after successful rehydration.
Reducing Fear and Anxiety
- Acknowledge that hospitalization is frightening, especially when it is sudden, as with diarrhea.
- Many treatments and procedures may be painful. Give reassurance to the child before, during, and after treatment.
- Talk to the child.
- Hold and comfort child after the procedure.
- Explain in age-appropriate language.
- Include family in care and treatments when possible.
Community and Home Care Considerations
- Infants and young children in day care centers may be at increased risk for diarrhea due to Shigella, Salmonella, rotavirus, E. coli, Cryptosporidium, Campylobacter, C. difficile, and Giardia. Good hand washing is the major preventive measure. This is especially important with rotavirus because it can be excreted for as long as 57 days in some cases.
- If infectious agent is identified, it should be reported because other children may be at risk.
- Encourage parents to contact the child care center and report.
- A child with diarrhea containing blood or mucus should be excluded from day care and medically evaluated. Exclusion from day care should occur until the diarrhea resolves.
- Stool cultures positive for E. coli O157:H7 or Shigella are reportable to the county health department, and the child should be excluded until the diarrhea resolves and two cultures, from two different stools, are negative for these organisms.
Family Education and Health Maintenance
- After the cause of the diarrhea is determined, it may be necessary to teach proper hygiene, formula or food preparation, handling, and storage.
- Use hand washing before bottle and food preparation.
- Use disposable bottles, or sterilize or use dishwasher for reusable bottles.
- Refrigerate reconstituted formula and all other fluids between uses. Milk may become contaminated within 1 hour if left out at room temperature; juice becomes contaminated within several hours.
- Discard small amounts of food or fluid from containers already used.
Bismuth subsalicylate, an over-the-counter drug that is readily available, has shown only modest beneficial effects in children and may increase the risk of Reye’s syndrome due to salicylate absorption.
Evaluation: Expected Outcomes
- Vital signs stable; urine output adequate
- Family, staff members hand washing properly and frequently
- No redness or excoriation of diaper area
- Tolerates small feedings of clear liquids without diarrhea or vomiting
- Plays quietly