Chapter 42: Lower GI Problems DIARRHEA - Passage of at least three loose or liquid stool per day - Acute: lasting 14 days or less - Persistent: lasting longer than 14 days - Chronic: lasts 30 days or longer Etiology and
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Chapter 42: Lower GI Problems DIARRHEA - Passage of at least three loose or liquid stool per day - Acute: lasting 14 days or less - Persistent: lasting longer than 14 days - Chronic: lasts 30 days or longer Etiology and Patho - Primary cause of acute diarrhea is ingesting an infectious organism - Viruses are also a common cause in the US - E. coli is most common (can be bloody) - Undercooked chicken or beef and fruits and vegetables contaminated manure - Travelers diarrhea: Giardia lamblia, intestinal parasite - C. diff: impairs absorption by destroying cells, causing inflammation of the colon, and produces toxins that cause damage - Secretory diarrhea: common result of bacterial or viral infections - A person's age, gastric acidity, intestinal microflora, and immune status influence susceptibility to pathogenic organisms - Older adults are most at risk - if on proton pump inhibitors or H2 blockers decrease the stomach acid that would kill the organism - Antibiotics kill of the normal flora making a person more susceptible - Patients that are immunosuppressed are also very susceptible to organisms - Diarrhea is not always due to infection- large amounts of undigested carbs, lactose intolerance, and certain laxatives produce osmotic diarrhea - Osmotic diarrhea: results from rapid GI transit that prevents absorption of electrolytes - Diarrhea from celiac and short bowel syndrome results from malabsorption in the small intestine Clinical Manifestations - Large volume, watery stool, cramping and periumbilical pain - Low grade fever or none - Often experience nausea and vomiting before the diarrhea begins - Infections of the colon and distal small bowel produce fever and frequent bloody diarrhea - Severe diarrhea - life threatening dehydration , electrolyte disturbances (hypokalemia), acid base imbalance (metabolic acidosis) Diagnostic Studies - Stool cultures are only done on patients who are very ill, have a high fever, pr have had diarrhea longer than 3 days - Stools are examined for blood, mucus, WBCs, and parasites - Cultures are reliable - Testing for ova and parasites is reserved for people who have diarrhea more than 2 weeks - WBC may be elevated - Long standing diarrhea results in anemia from iron and folate deficiencies - Increased hematocrit , BUN, and creatinine levels are signs of fluid deficit - Chronic- measuring stool electrolytes , pH, and osmolality helps determine helps determine whether it is due to decreased fluid absorption or increased fluid secretion - Measuring for fat and digestible muscle fibers may indicate fat and protein malabsorption which would indicate pancreatic insufficiency Interprofessional Care - Treatment depends on the cause - Acute infections are usually self limiting - Major concerns are preventing transmission, replacing fluid and electrolytes, and protecting the skin - Pedialyte or parenteral can be used to replace - Antidiarrheals are used for short term and coat and protect mucous membranes, absorb irritating substances, inhibit intestinal transit ,decrease intestinal secretions, or decrease CNS stimulation of the GI tract. - They can be contraindicated in treatment of some infectious diarrheas because they potentially prolong exposure to the organism- used cautiously in inflammatory bowel disease (IBS) - Antibiotics are rarely used to treat - Clostridium difficile Infection - Is a hazardous health care associated infection (HIA) - Spores can last up to 70 days on objects - MUST WASH WITH SOAP AND WATER - Treated with either metronidazole (Flagyl)- first line treatment or Vancomycin (Vancocin)- for severe - Fecal microbiota transplant (FMT) is the most effective treatment by establishing healthy intestinal flora by infusing fecal bacteria obtained from a healthy donor and is put into patients colon - Most likely to have diarrhea right after the procedure NURSING MANAGEMENT : ACUTE INFECTIOUS DIARRHEA Assessment - Ask to describe stool pattern and symptoms - On any meds ( antibiotics) ? - Been to any foreign countries, day care facilities? or if other family members are ill? - Diet, any changes? - Milk tolerance - Assess for fever and signs of dehydration - Assess abdomen for distension and patient guarding - Inspect the perineal skin for signs of redness and breakdown from the diarrhea Diagnosis - Diarrhea r/t acute infectious process - Deficient fluid volume r/t excessive fluid loss and decreased fluid intake Planning - No transmission of the microorganism - Stopping the diarrhea and back to normal stool habits - Normal fluid , electrolyte , and acid base balance - Normal nutrition status - No perianal/ perineal skin breakdown Implementation - Considered infectious until the actual cause is known - Strict infection control precautions - Wash hands - Teach proper hygiene, infection control precautions, and potential dangers - Discuss proper food handling and storage - Viruses and C. diff are alcohol and ammonia resistant, MUST WASH WITH SOAP AND WATER - Need to be put on contact precautions (gloves and gown) and have their own equipment FECAL INCONTINENCE Etiology and Pathophysiology - Involuntary passage of stool - Happens when the normal structures that keep it in are damaged or disrupted - Defections is a voluntary action when the neuromuscular system is intact - Problems with motor function such as contraction of sphincters and rectal floor muscles or sensory function such as the ability to perceive the urge to defecate or perceive rectal filling can result in incontinence - Most common for women because if obstetric trauma (sphincter disruption)- childbirth, aging, menopause - Common with diarrhea as accidental discharge - Can occur with fecal impaction ( harden stool in the rectum or sigmoid colon that cannot be expelled) incontinence will occur as liquid stool seeps around the feces that cannot be expelled - Constipation can also cause straining that weakens pelvic floor muscles - Anorectal surgeries can damage sphincter and pudendal nerves - Radiation for prostate cancer decreases rectal compliance - Stroke, spinal cord injury, MS all can interfere with defecation - Even normal people can experience if they cannot reach a toilet in time Diagnostic Studies and Interprofessional Care - Ask about number of episodes, consistency and volume, and degree that it interferes with work and social activities - REctal exam can reveal reduced muscle tone - Anorectal manometry, anorectal ultrasonography, and defecography are some tests - Sigmoidoscopy or colonoscopy can identify inflammation, tumors, fissures and other pathologic conditions - Dietary fiber supplements or bulk forming laxatives promote sensation of rectal filling and can be used as a treatment - May need to avoid certain things such as coffee, dried fruits, onions, mushrooms, green veggies, fruits with peels, spicy foods, and foods with monosodium glutamate - Kegel exercises can be used to strengthen and coordinate to improve incontinence - Biofeedback therapy can improve awareness of the rectal sensation, coordinate internal and external sphincters , and increase strength and contraction of the sphinctersrequires intact sensory and motor nerves and motivation to learn , it is safe, painless, and effective treatment - Mild electric stimulation of the sacral nerves targets communication problems between the brain and the nerves that control the pelvic floor and sphincters, it can improve quality of life and some may achieve complete continence - Treatment with dextranomer/ hyaluronic gel - less conservative - gel is injected to the deep submucosa of the anal canal,this builds up tissue in the anal area making it more narrow allowing it to adequately close - no anesthesia required and postinetin site pain and bleeding may occur - Surgery of the sphincter is an option when all else fails, a colostomy is sometimes necessary NURSING MANAGEMENT : FECAL INCONTINENCE Assessment - Ask about daily activities - Ask about bowel patterns before incontinence developed - Check for irritation and skin breakdown- Bristol Stool scale is helpful - Are at risk for incontinence-associated dermatitis (IAD)- results from chemical irritants in the feces causing skin damage appears red and loss of skin - Fungal infections have dark red centers surrounded by satellite lesions Implementation - Regardless of the cause bowel training is an effective strategy for many patients (good time schedule is within 30 mins after breakfast) - If that is ineffective administer bisacodyl (Dulcolax) a glycerin suppository or a small phosphate enema 15 to 30 mins before evacuation time (this stimulates the rectal reflex) - Neurogenic bowels (spinal cord injuries) either get digital stimulation of the anorectal reflex or irrigating the rectum with tap water at regular intervals - Maintaining perineal skin integrity is of utmost importance especially in bedridden patients -
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