Clostridium difficile infection, also known as C. diff, is a gram-positive rod-shaped bacteria that forms spores enabling pathogens to survive in unfavorable conditions and enable human-to-human transmission. C. diff infection causes colitis and diarrhea.
Some people who have C. diff bacteria but do not have symptoms are referred to as carriers who can spread the infection to others. Signs and symptoms of mild to moderate C. diff include watery diarrhea more than three times a day for more than a day and mild abdominal tenderness and cramping. Severe C. diff symptoms include:
- Severe abdominal pain and cramping
- Watery diarrhea occurring more than 10 times a day
- Swollen abdomen
- Weight loss
- Loss of appetite
- Kidney failure
- Presence of blood or pus in the stool
Antibiotic use is the most common cause of C. diff infection. Recent admission to a healthcare facility, underlying medical conditions, and older age increases the risk. Antibiotics like clindamycin, penicillins, and cephalosporins tend to destroy healthy bacteria in the body along with the bacteria they are formulated to destroy. Without these helpful bacteria, C. difficile can grow out of control and cause infection.
C. diff is also highly contagious and can easily be transmitted through person-to-person contact and contaminated fomites. C. diff spores are only killed through hand washing with warm water and soap, not hand sanitizers.
C. diff is confirmed through a stool sample and a colon examination. Imaging tests such as an abdominal x-ray or a CT scan can detect complications like bowel enlargement, colon wall thickening, and perforation of the colon.
The Nursing Process
Since C. difficile infection is often related to a current antibiotic regimen that the patient is taking, it is critical to stop the current antibiotic causing C. difficile infection and replace it with another medication that will be less likely to cause this bacteria. Metronidazole may be given in combination with vancomycin to help treat severe C. difficile infection. Surgery may be required in severe cases if the colon is damaged.
Supportive treatment through proper nutrition and adequate fluid intake is necessary to prevent dehydration. Nurses play a vital role in managing symptoms of C. diff like diarrhea and abdominal pain. Nurses also instruct patients and staff on precautions to prevent the transmission of C. diff bacteria.
Nursing Care Plans Related to C. Difficile Infection
Deficient Fluid Volume Care Plan
Patients with C. difficile infection experience watery diarrhea. In severe cases, diarrhea can occur as often as 15 times per day, causing severe dehydration.
Nursing Diagnosis: Deficient Fluid Volume
- Disease process
- Insufficient fluid intake
- Loose watery stools more than 3 times per day
As evidenced by:
- Altered skin turgor
- Decreased blood pressure
- Dry skin
- Increased body temperature
- Increased heart rate
- Increased urine concentration
- Sudden weight loss
- Sunken eyes
- The patient will remain free of any signs of dehydration and exhibit normal vital signs
- The patient will experience no more than two loose stools per day
- The patient will consume at least 500 mL of water per day if not contraindicated
Deficient Fluid Volume Assessment
1. Assess for any signs of hypovolemia and dehydration.
Thirst, headaches, restlessness, and an inability to concentrate are the first signs of dehydration. Closely monitor for poor skin turgor, dry mucous membranes, dizziness, and weakness.
2. Assess and monitor vital signs.
A decrease in blood pressure occurs when the patient is dehydrated due to a decrease in blood volume. The heart rate and respiratory rate may increase in an attempt to compensate.
Deficient Fluid Volume Interventions
1. Monitor fluid intake and output.
Urine output is an accurate indicator of fluid balance and poor urine output along with a dark urine color can indicate dehydration.
2. Monitor the patient’s bowel movements.
Since patients with C. diff infection often exhibit loose watery stools, it is essential to monitor the number of bowel movements and observe for complications such as blood or pus in the stool.
3. Provide oral or intravenous fluid replacement therapy.
Fluid replacement is essential to restore circulatory volume and correct electrolyte imbalances in patients with C. diff infection. Continuous IV fluids will likely be ordered and the patient should be encouraged to consume water and other fluids.
4. Administer antibiotics as indicated.
Antibiotic use causes C. diff, but it is also the required treatment. The offending antibiotic should be discontinued. Metronidazole is the recommended antibiotic to treat C. diff and prevent diarrhea.
Acute Pain Care Plan
C. difficile infection causes abdominal pain, cramping, and inflammation of the colon. Frequent diarrhea also causes burning and discomfort to the perianal area.
Nursing Diagnosis: Acute Pain
- C. difficile infection
- Inflammatory process
- Skin breakdown
As evidenced by:
- Distraction behavior
- Expression of pain
- Guarding behavior
- Positioning to ease the pain
- Protective behavior
- The patient will report pain 2/10 or less using a pain scale
- The patient will report an absence of cramping or abdominal tenderness
- The patient will report relief from perianal discomfort
Acute Pain Assessment
1. Evaluate the patient’s pain and note its characteristics.
Abdominal pain and tenderness are expected with C. diff. Closely monitor for abdominal swelling and distention which can signal a worsening in condition and complications such as toxic megacolon.
2. Assess the patient’s pain relief efforts.
This can help determine and evaluate effective pain relief methods as well as other interventions to try.
Acute Pain Interventions
1. Administer specified medications as indicated.
Metronidazole and vancomycin are considered the mainstay antibiotic treatment options for C. diff infection. NSAIDs like naproxen, ibuprofen, and indomethacin are contraindicated as they can increase the risk of C. diff infection. Opioids are also found to increase the risk of severe disease, complications, longer hospital stays, and readmission.
2. Encourage the patient to use non-pharmacologic pain relief methods.
Instruct on the use of positioning, rest, distraction, breathing techniques, and heating pads to promote comfort.
3. Offer pain relief to irritated skin.
Frequent diarrhea from C. diff can cause skin irritation to the perianal area. Offer comfort measures such as a Sitz bath and cooling ointments.
4. Involve the patient’s family in patient care.
Since C. diff is highly contagious it can be an isolating illness. Instruct family members on proper precautions to prevent transmission but encourage contact to reduce feelings of pain and discomfort.
Deficient Knowledge Care Plan
C. difficile infection is highly transmissible and inaccurate knowledge about the disease process, treatment, and prevention increases the incidence of transmitting the infection.
Nursing Diagnosis: Deficient Knowledge
- Inadequate access to resources
- Inadequate awareness of resources
- Inadequate information
- Inadequate interest in learning
- Inadequate knowledge of resources
- Inadequate participation in care planning
As evidenced by:
- Inaccurate follow-through of instructions
- Inaccurate statements about a topic
- Poor adherence to the care plan
- Worsening of symptoms
- Development of preventable complications
- The patient will adhere to infection control interventions to prevent the spread of C.diff
- The patient will not experience a recurrence of C. diff infection
Deficient Knowledge Assessment
1. Assess the patient’s health literacy and readiness to learn.
Assessment of the patient’s learning needs, learning styles, and attitude toward learning is an essential part of the process of patient education.
2. Evaluate the patient and family’s understanding of C.difficile infection.
The patient and family members must be assessed to ensure an appropriate understanding of how C. diff is spread.
Deficient Knowledge Interventions
1. Educate the patient about symptoms requiring immediate medical attention.
Educate on symptoms (loose watery stools, blood or pus in the stool, fever, and vertigo) that need to be reported right away to prevent progression and complications.
2. Educate the patient & family about infection control interventions.
Frequent handwashing before and after patient contact is essential in preventing the spread of C. diff infection. Remind family members that alcohol-based hand sanitizers do not kill C. diff spores.
3. Educate staff and visitors.
Patients with C. diff are placed on contact precautions. A gown and gloves must be worn when entering their room and providing care and disposed of after.
4. Educate on possible surgical treatments.
Fecal transplants are an experimental treatment used to restore healthy bacteria into the patient’s colon from a donor. This treatment may be effective for patients with recurrent C. diff infections.
5. Instruct on medications to prevent reinfection.
The patient may be instructed to continue taking probiotics that maintain the “good” bacteria in the gut.
References and Sources
- C. difficile infection. Mayo Clinic. Updated: Aug. 27, 2021. From: https://www.mayoclinic.org/diseases-conditions/c-difficile/symptoms-causes/syc-20351691
- Clostridium difficile (C. diff) infection. NHS. Reviewed: 08 February 2022. From: https://www.nhs.uk/conditions/c-difficile/
- Lewis’s Medical-Surgical Nursing. 11th Edition, Mariann M. Harding, RN, PhD, FAADN, CNE. 2020. Elsevier, Inc.
- Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. 9th Edition. Donna D. Ignatavicius, MS, RN, CNE, ANEF. 2018. Elsevier, Inc.
- What is C. diff? Centers for Disease Control and Prevention. Reviewed: September 7, 2022. From: https://www.cdc.gov/cdiff/what-is.html