CASE STUDY ON DIARRHEA

I. DEFINITION OF DIARRHEA
Diarrhea — loose, watery and possibly more-frequent bowel movements — is a common problem. It
may be present alone or be associated with other symptoms, such as nausea, vomiting, abdominal pain or
weight loss. Luckily, diarrhea is usually short-lived, lasting no more than a few days. But when diarrhea lasts
beyond a few days into weeks, it usually indicates that there's another problem — such as irritable bowel
syndrome (IBS) or a more serious disorder, including persistent infection, celiac disease or inflammatory
bowel disease (IBD).
Diarrhea can be an acute or severe problem. Mild diarrhea cases can recover in a few days. However,
severe diarrhea can lead to dehydration or severe nutritional problems. Problems associated with diarrhea
include fluid and electrolyte imbalances, impaired nutrition, and altered skin integrity. Additionally, nurses
and the healthcare team members must take precautions to prevent transmission of infection associated with
some causes of diarrhea.

II. SIGNS AND SYMPTOMS

Diarrhea can be described as an abnormal increase in the frequency, volume or liquidity of your stools.
The condition usually lasts a few hours to a couple of days. Diarrhea is typically associated with abdominal
cramps.
The most common causes of diarrhea include:
1. Viruses
2. Bacteria
3. Parasites

Other causes include medications, such as antibiotics that disturb the natural balance of the bacteria in
your intestines, artificial sweeteners and lactose, which is a sugar found in milk.
Diarrhea that persists for more than a couple of days is considered chronic and may be a sign of an underlying
condition, such as inflammatory bowel disease or an infection. In these cases, diarrhea may lead to
dehydration and requires the care of your doctor. Dehydration occurs when the body has lost too much fluid
and electrolytes -- the salts potassium and sodium. The fluid and electrolytes lost during diarrhea need to be
replaced promptly because the body cannot function properly without them.
Signs and symptoms associated with diarrhea may include:
1. Frequent loose, watery stools
2. Abdominal cramps
3. Abdominal pain
4. Fever
5. Bleeding
6. Lightheadedness or dizziness from dehydration

Diarrhea caused by a viral infection, such as a stomach virus, or bacterial infection also may cause vomiting.
In addition, blood and mucus in the stools may appear with diarrhea caused by bacterial infections.
III. PATHOPHYSIOLOGY

In the gastrointestinal tract, ionic balance, fluid absorption, and secretion are vital to maintain
homeostasis allowing for the maintenance of a membrane potential, adequate nutrient intake, normal gut
motility, protection against microbes, and epithelial cell viability. This homeostatic state relies on the normal
physiological function of the small and large intestinal cells and a complex array of hormonal mechanisms
that control gut motility as well as entry and exit of fluid into the gastrointestinal lumen. Approximately, 8–10
L of fluid pass through the
small intestinal lumen daily. It is remarkable that in health, the small intestine absorbs all but 1.5 L and the
colon absorbs the rest leaving approximately 100 mL of fluid to be lost in stool. Intestinal ion transport
mechanisms play a significant role in determining overall fluid balance in the gut, namely chloride secretion,
electroneutral sodium chloride absorption and electrogenic sodium absorption. Moreover, a variety of
hormones and neurotransmitters are synthesized locally in the intestinal mucosa and modify intestinal ion
transport either directly by binding to receptors on the basolateral membrane of enterocytes or indirectly via
the release of other effectors. In certain pathophysiologic states, the finely tuned ionic-fluid exchange
becomes dysfunctional as a result of the failure of compensatory pro-absorptive/antisecretory mechanisms.
Different pathophysiological mechanisms causing diarrhea, mainly secretory, osmotic, inflammatory, altered
intestinal transit and loss of functional absorptive area, have been elucidated.

IV. MEDICAL MANAGEMENT

1. Assess for abdominal discomfort, pain, cramping, frequency, urgency, loose or liquid stools, and
hyperactive bowel sensations. These assessment findings are usually linked with diarrhea. Patients differ
in their definition of diarrhea, noting loose stool consistency, increased frequency, the urgency of bowel
movements, or incontinence as key symptoms. Normal stool frequency ranges from three times a week to
three times a day.
2. Evaluate the pattern of defecation. Everyone’s bowels are unique to them. What’s normal for one
person may not be normal for another. A person can have a bowel movement anywhere from one to three
times a day at the most, or three times a week at the least, and still be considered regular, as long as it’s
their usual pattern. Assessment of defecation pattern will help direct treatment.
3. Culture stool. Testing or stool examinations will distinguish infectious or parasitic organisms, bacterial
toxins, blood, fat, electrolytes, white blood cells, and potential etiological organisms for diarrhea
4. Determine intolerances to food. If a person has a food intolerance, eating that food can cause diarrhea or
loose stool. Foods may trigger intestinal nerve fibers and cause increased peristalsis. Some foods can
increase intestinal osmotic pressure and draw fluid into the intestinal lumen. Spicy, fatty, or high-
carbohydrate foods; caffeine; sugar-free foods with sorbitol; or contaminated tube feedings may cause
diarrhea. Keeping a food and symptom diary can help determine a pattern.
5. Determine hydration status by assessing input and output. Diarrhea can lead to profound dehydration.
A prolonged episode of diarrhea or vomiting can push the body to lose more fluid than it can take in. The
result is dehydration, which happens when the body doesn’t have the fluid it requires to function
correctly.
6. Assess skin turgor. A decrease in skin turgor is exhibited when the skin (on the back of the hand for an
adult or the abdomen for a child) is pinched and released but does not flatten back to normal right away.
V. NURSING MANAGEMENT

The following are the therapeutic nursing interventions for diarrhea:

1. Weigh daily and note decreased weight. Diarrhea causes severe water loss from the body. As a result,
the body loses weight. An accurate daily weight is an important indicator of fluid balance in the body. It
has consistently been associated with decreased weight over the short term, but the longer-term impact of
diarrhea on weight has been less consistently documented and is more controversial
2. Avoid using medications that slow peristalsis. If an infectious process occurs, such as Clostridium
difficile infection or food poisoning, medication to slow down peristalsis should generally not be given.
3. Give antidiarrheal drugs as ordered. Most antidiarrheal drugs suppress gastrointestinal motility, thus
allowing for more fluid absorption. Supplements of beneficial bacteria (“probiotics”) or yogurt may
reduce symptoms by reestablishing normal flora in the intestine. Antidiarrheal agents are of two types:
those used for mild to moderate diarrheas and those used for severe secretory diarrheas.
4. Provide bulk fiber (e.g., cereal, grains, psyllium) in the diet. Bulking agents and dietary fibers absorb
fluid from the stool and help thicken the stool. Psyllium is found in some cereal products, dietary
supplements, and commercial bulk fiber laxatives (e.g., Metamucil, Konsyl, generic).
5. Explain the need to avoid stimulants (e.g., caffeine, carbonated beverages, artificial sweeteners).
Caffeine may stimulate the intestines and increase motility. Aside from caffeine, some sugary sodas also
contain high-fructose corn syrup, a combination of fructose and dextrose that may lead to fructose
malabsorption. Symptoms include bloating and stomach pain, heartburn, diarrhea, and gas. Artificial
sweeteners can have a laxative effect. They pull water into the colon and aid to mobilize the stool, which
can cause the runs.

VI. DIAGNOSTIC TOOLS

Your doctor will ask about your medical history, review the medications you take, conduct a physical exam
and may order tests to determine what's causing your diarrhea. Possible tests include:

1. Blood test. A complete blood count test, measurement of electrolytes and kidney function tests can help
indicate the severity of your diarrhea.
2. Stool test. Your doctor might recommend a stool test to see if a bacterium or parasite is causing your
diarrhea.
3. Hydrogen breath test. This type of test can help your doctor determine if you have a lactose intolerance.
After you drink a liquid that contains high levels of lactose, your doctor measures the amount of
hydrogen in your breath at regular intervals. Breathing out too much hydrogen indicates that you aren't
fully digesting and absorbing lactose.
4. Flexible sigmoidoscopy or colonoscopy. Using a thin, lighted tube that's inserted in your rectum, your
doctor can see inside your colon. The device is also equipped with a tool that allows your doctor to take a
small sample of tissue (biopsy) from your colon. Flexible sigmoidoscopy provides a view of the lower
colon, while colonoscopy allows the doctor to see the entire colon.
5. Upper endoscopy. Doctors use a long, thin tube with a camera on the end to examine your stomach and
upper small intestine. They may remove a tissue sample (biopsy) for analysis in the laboratory.