Diarrhea is an increase in the frequency of bowel movements often characterized by loose stools and urgency. Diarrhea can be acute (lasting only a few days) or chronic (lasting for weeks). Mild cases will resolve on their own while more severe cases may be a sign of a more serious illness such as ulcerative colitis, cancer or an infectious process. Persistent diarrhea warrants further investigation and may also require acute intervention if severe enough to lead to dehydration or electrolyte imbalance.
Nurses should monitor a patient’s diarrhea for worsening symptoms and subsequent alterations to nutrition, vital signs, lab values, and skin integrity. Nurses should also educate patients on diet recommendations, medication use, and hydration guidelines to prevent diarrhea.
Attention: This nursing diagnosis has been renamed.
Nursing diagnoses are revised, added, or retired by the NANDA International Diagnosis Development Committee (DDC) to coincide with shifts in language standardization. “Diarrhea” has been renamed to “Impaired Fecal Continence”. Students and seasoned nurses alike may be unfamiliar with this change, and thus NurseTogether has chosen to continue to use the diagnostic label “Diarrhea” in this article until the recent relabeling receives wider adoption.
In this article:
- Causes (Related to)
- Signs and Symptoms (As evidenced by)
- Expected Outcomes
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- References
Causes (Related to)
The following are the common causes of diarrhea:
- Infection/Parasites
- Laxative use
- Medication side effects
- Chemotherapy/Radiation
- Travel
- Consuming contaminated food or water
- Tube feedings
- Gastrointestinal inflammation
- Anxiety/Stress
- Alcohol abuse
- Food allergy
- Antibiotic use
- Malabsorption
- Autoimmune disorders (Crohn’s disease or ulcerative colitis)
- Gastrointestinal surgery (colectomy, bowel resection)
Signs and Symptoms (As evidenced by)
The following are the common signs and symptoms of diarrhea. They are categorized into subjective and objective data based on patient reports and assessment by the nurse.
Subjective: (Patient reports)
- Abdominal pain
- Gas, bloating
- Urgency and frequency
Objective: (Nurse assesses)
- Hyperactive bowel sounds
- Three or more loose stools per day
- Blood or mucus in the stool
Expected Outcomes
The following are the common nursing care planning goals and expected outcomes for diarrhea:
- Patient will verbalize understanding of foods that contribute to diarrhea.
- Patient will maintain adequate fluid intake to prevent dehydration of at least 1500 mL/day.
- Patient will report experiencing less than three loose stools per day.
- Patient will report stools are formed and soft without blood or mucus.
- Patient will report relief from abdominal pain, gas, or cramping.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In the following section, we will cover subjective and objective data related to diarrhea.
1. Assess onset and pattern of diarrhea.
Note when symptoms started, recent foods eaten, any recent travel, or change in medications. Length of time of diarrhea can dictate between acute or chronic diarrhea and determine treatment.
2. Assess characteristics and number of stools.
Either through observation or patient verbalization, gather an understanding of the number of loose stools per day, the color, and any blood or mucus in the stool.
3. Obtain a stool culture.
A stool culture will help determine treatment if a specific organism can be identified.
4. Assess for abdominal pain and related symptoms.
Assess the type and location of abdominal pain as well as related symptoms of nausea, vomiting, loss of appetite, fever, and faintness or dizziness from dehydration.
5. Assess bowel sounds.
Diarrhea normally results in hyperactive bowel sounds.
6. Monitor electrolyte imbalances.
Severe or prolonged diarrhea can result in dehydration and electrolyte imbalances. Obtain these results through blood work.
7. Assess gastrointestinal history.
Assess for a history of colitis, Clostridium Difficile, autoimmune diseases, or recent GI surgery that may be causing diarrhea.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you’ll learn more about possible nursing interventions for a patient with diarrhea.
1. Encourage a liquid diet.
Diarrhea may require bowel rest and the healthcare provider may order an NPO diet, but more likely a clear or full liquid diet.
2. Educate on diet changes to prevent diarrhea.
A bland diet with low fiber is needed to bulk the stools. This includes soft foods without added sugar or spices such as white rice, white toast, crackers, and eggs. Raw, fresh foods and caffeine are not recommended.
3. Review medications.
Medications may need to be changed if diarrhea is an intolerable side effect. Review how a patient is taking their medications. If they are taking laxatives or stool softeners, educate on the appropriate use and to discontinue if diarrhea develops.
4. Administer antidiarrheals as appropriate.
Once the cause of diarrhea has been determined and it is not contraindicated, administer antidiarrheals to stop diarrhea. These should not be given if the patient has a parasitic infection as the infectious process needs to be eliminated.
5. Correct electrolyte imbalances.
Dehydration is common with diarrhea. Administer IV fluids if dehydration is severe. Replace electrolytes such as potassium if required.
6. Children may need oral rehydration.
Children experiencing diarrhea may need oral rehydration solutions such as Pedialyte. These can also be concocted through a mixture of water, sugar, and salt to replace lost fluids.
7. Promote relaxation for stress or anxiety.
Stress can exacerbate an inflammatory reaction by disrupting the immune system and intestinal microbiome which can exacerbate inflammatory bowel disease including Crohn’s disease or ulcerative colitis.
8. Promote skin integrity.
Frequent diarrhea can cause skin breakdown to the perianal area. Educate on proper wiping from front to back and the use of non-irritating cleansers. If the patient is incontinent, provide frequent diaper changes and keep the perineum dry and apply skin barrier ointments.
9. Educate on proper food handling.
Food poisoning is a common cause of diarrhea. Ensure the patient understands how to properly handle and cook food. Prevent cross-contamination when handling raw meats and clean produce before ingesting. Do not eat food that has not been properly refrigerated or cooked. Always wash hands before eating.
10. Refer to specialists for chronic diarrhea.
Chronic diarrhea that lasts longer than four weeks requires further assessment. The patient may need a referral to a gastroenterologist to investigate for a possible inflammatory bowel disease or a cause of malabsorption. Procedures such as a colonoscopy may be needed. Allergists can assist if diarrhea seems to be related to certain foods such as gluten. Dieticians can recommend diet adjustments.
11. Lifestyle modifications.
Alcohol can be irritating to the intestines and speeds digestion. Chronic alcohol use has been shown to increase bacterial overgrowth in the small intestine. Smoking is a common cause of developing and exacerbating Crohn’s disease. Educate patients on the consequences of their lifestyle behaviors and provide resources to quit.
12. Educate on post-surgical expectations.
Patients undergoing GI surgeries will likely have loose stools for days to weeks. Dumping syndrome occurs when part of the stomach or esophagus is removed causing food to move too quickly into the small intestine. Patients who have ostomies, particularly ileostomies, in which the colon is completely or partially removed, tend to have looser stools with frequent output.
Nursing Care Plans
Nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for diarrhea.
Care Plan #1
Diagnostic statement:
Diarrhea related to malabsorption secondary to irritable bowel syndrome, as evidenced by more than three loose stools per day.
Expected outcomes:
- Patient will defecate Bristol stools Type 3 (sausage-shaped with cracked surfaces) or 4 (sausage-shaped, smooth, and soft) no more than twice per day.
- Patient will have a negative stool culture.
- Patient will demonstrate diet changes to prevent irritable bowel syndrome.
Assessment:
1. Obtain bowel elimination history.
Based on Rome IV Criteria, a patient with Irritable Bowel Syndrome Diarrhea predominant (IBS-D) experiences abdominal pain/discomfort improved by defecation and changes in frequency and appearance of stools for at least three days a month in the last three months. More than 25% of their bowel movements are Bristol stools Type 6 (mushy stools, fluffy pieces with ragged edges) or 7 (watery, no solid pieces, entirely liquid).
2. Rule out other concerning causes of diarrhea
If the diarrhea is new in onset, it is important to rule out high risk causes such as colon cancer, celiac disease, inflammatory bowel disease. Assess for history of unexplained weight loss, blood in stools, iron deficiency and family history of bowel diseases.
3. Monitor hydration status.
Diarrhea can lead to severe dehydration. Monitoring input and output will provide an estimation of fluid needs.
4. Review available laboratory data.
Stool culture identifies etiologic agent for IBS. CT scan and colonoscopy findings may also be checked.
Interventions:
1. Administer medications as ordered.
Most antidiarrheal drugs suppress gastrointestinal motility, thus allowing for more fluid absorption.
2. Instruct the following dietary modifications:
- Bulk fiber (e.g., cereal, grains) / Natural bulking agents (e.g., rice, apples, cheese): Bulking agents and dietary fibers absorb fluid from the stool and help thicken the stool.
- Avoidance of stimulants: Stimulants may increase gastrointestinal motility and worsen diarrhea.
3. Encourage fluids 1.5 to 2 L per day.
Increased fluid intake replaces fluid lost in the liquid stool.
4. Provide perianal care after each bowel movement.
Hygiene reduces the risk of perianal skin excoriation and promotes comfort.
5. If the cause of the IBS is due to intestinal infections, observe contact precautions.
Contact precautions are necessary to prevent the transmission of microorganisms to others.
6. Explain how to prevent the spread of infectious diarrhea.
Good hand hygiene prevents the spread of infectious diarrhea (e.g., careful handwashing, appropriate handling and storage of food, and thoroughly cleaning the bathroom and kitchen).
Care Plan #2
Diagnostic statement:
Diarrhea related to lactose deficiency as evidenced by cramping and abdominal pain.
Expected outcomes:
- Patient will defecate formed soft stool every 1 to 3 days.
- Patient will verbalize relief from abdominal pain and cramping.
- Patient will verbalize understanding of dietary modifications to prevent diarrhea.
Assessment:
1. Assess tolerance to milk and other dairy products.
Patients with lactose intolerance have insufficient lactase, the enzyme that digests lactose. The presence of lactose in the intestines increases osmotic pressure and draws water into the intestinal lumen.
2. Assess the patient’s usual pattern of bowel elimination.
Assessment of defecation patterns and factors associated with diarrhea episodes will help direct interventions and treatment.
Interventions:
1. Instruct on dietary changes.
The core management of lactose intolerance is to modify the diet. Instruct to avoid the following: soft and processed cheese, buttermilk, ice cream, sour cream, whey, mashed potatoes, and butter. Ensure the patient understands the food groups that lactose is present in.
2. Administer medications as ordered.
Antidiarrheal drugs decrease GI motility, relieve abdominal pain/cramping, and prevent further fluid losses.
3. Instruct or administer lactase supplement as indicated.
Lactase supplements contain lactase—the enzyme needed to digest lactose in milk and milk-containing products. They are available as tablets or drops.
4. Educate about lactose intolerance and its management. Instruct about reading food labels.
Lactose intolerance is often confused with milk allergy. Lactose intolerance is a GI disorder, while milk allergy is a life-threatening autoimmune disease. Some people with lactose intolerance may tolerate milk and other milk-containing products. It is also important to instruct the patient about sufficient intake of calcium and vitamin-D rich foods to to replace dairy.
Care Plan #3
Diagnostic statement:
Diarrhea related to adverse effects of medication as evidenced by urgency and hyperactive bowel sounds.
Expected outcomes:
- Patient will defecate formed, soft stool every 1 to 3 days.
- Patient will state relief from cramping and a reduction or no diarrhea.
Assessment:
1. Assess pattern of defecation.
Assessment of defecation patterns and factors surrounding diarrhea episodes, including changes in diet, medications, exercise, and health history, will help direct interventions and treatment. Asses for the following:
- Time of day defecation
- Usual stimulus for defecation
- Stool consistency, amount, and frequency
- Type and amount of food consumed
- Fluid intake
- History of bowel habits and laxative use
- Exercise patterns
- History of comorbidities
- Current and past medications
- Alterations in perianal sensations
2. Inspect, auscultate, palpate, and percuss the abdomen in that order.
Expect an increased frequency of bowel sounds with diarrhea.
3. Review current medications.
A medication review will help identify which medication causes the diarrheal side effects and whether there are needed adjustments to be made.
Interventions:
1. Encourage the patient to eat small, frequent meals, or easy-to-digest foods first, but switch to a regular diet as soon as tolerated.
Easy-to-digest foods include but are not limited to bananas, crackers, pretzels, rice, potatoes, clear soups, and applesauce. The nurse can recommend that the patient avoids milk products, foods high in insoluble fiber, and caffeine (dark sodas, tea, coffee, and chocolate). Patients experiencing diarrhea may only be able tolerate small amounts of food at a time. Despite eating in small amounts, the body can compensate for the needed nutrients by eating frequently. Milk, foods with insoluble fiber, such as green leafy vegetables, and caffeine can worsen diarrhea because they speed up digestion.
2. Thoroughly cleanse and dry the perianal and perineal skin daily and as needed.
Use a cleanser capable of stool removal and apply skin moisture barrier cream as needed. Frequent defecation can cause abrasion to the perianal skin. Skincare prevents infection.
3. Educate about current medications.
Since diarrhea is drug-induced, education about the current medications, including side effects, interactions, proper dosing, and frequency, is crucial to manage diarrhea long-term.
4. Administer and teach appropriate methods of taking ordered antidiarrheal medications.
Some patients may be required to take antidiarrheal medications (i.e., loperamide, bismuth subsalicylate) as indicated. Compliance with the prescription is important as these medications have their side effects when not taken properly.
References
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