Passage of three or more loose or liquid stools per day

Abdominal cramping

Abdominal pain

Bowel urgency

Dehydration

Hyperactive bowel sounds

Anxiety

Early formula feeding

Inadequate access to safe drinking water

Inadequate access to safe food

Inadequate knowledge about rotavirus vaccine

Inadequate knowledge about sanitary food preparation

Inadequate knowledge about sanitary food storage

Inadequate personal hygiene practices

Increased stress level

Laxative misuse

Malnutrition

Substance abuse

Pathophysiologic* *

Related to malabsorption or inflammation secondary to:

Colon cancer

Diverticulitis

Irritable bowel

Crohn's disease

Peptic ulcer

Ulcerative colitis

Celiac disease (sprue)

Gastritis

Spastic colon

Related to lactose deficiency, dumping syndrome

Related to increased peristalsis secondary to increased metabolic rate (hyperthyroidism)

Related to infectious processes secondary to:

Food poisoning

Shigellosis

Infectious hepatitis

Trichinosis

Cholera

Cryptosporidium

Typhoid fever

Microsporidia

Malaria

Dysentery

Related to excessive secretion of fats in stool secondary to liver dysfunction

Related to inflammation and ulceration of gastrointestinal mucosa secondary to high levels of nitrogenous wastes (renal failure)

Treatment Related* *

Related to malabsorption or inflammation secondary to surgical intervention of the bowel

Related to adverse effects of pharmaceutical agents of (specify):

Thyroid agents

Laxatives

Analgesics

Iron sulfate

Stool softeners

Antacids

Chemotherapy

Cimetidine

Antibiotics

Related to tube feedings

Situational (Personal, Environmental)

Related to irritating foods (fruits, bran cereals) or increase in caffeine consumption

Related to changes in water and food secondary to travel

Related to change in bacteria in water

Related to bacteria, virus, or parasite to which no immunity is present

* *Indicates that these additions have been added by L. Carpenito for clarity and usefulness.

Frequent travelers

Individual exposed to toxins

Individuals at extremes of age

Critical illness

Endocrine system diseases

Enteral nutrition

Gastrointestinal diseases

Immunosuppression

Infections

Pharmaceutical preparations

Treatment regimen

Level 1 Fundamental Focused Assessment

Assess Bowel Function

Subjective

Elimination pattern (Usual, present)

What frequency is considered normal?

Laxative/enema use (Type? How often?)

Can the individual recognize bowel cues?

Associated symptoms/complaints of:

Headache

Thirst

Weakness

Pain

Lethargy

Cramping

Anorexia

Weight loss/gain

Awareness of bowel cues

Objective Exam

Stool (Color, consistency [hard, dry, formed, watery], blood present, undigested food)

Bowel Sounds (High-pitched, gurgling, frequent, loud, pushing [5/min], weak and infrequent, absent)

Perianal Area/Rectal Examination (RN observed)

Hemorrhoids

Fissures

Irritation

Impaction

Control of rectal sphincter (presence of anal wink, bulbocavernosus reflex)

Stool in rectum

Assess for Related Factors

Decreased peristalsis secondary to immobility

Inadequate diet (lack of roughage, fiber, thiamine)

Diet high in sodium, fat, sugar

Insufficient fluid intake or excessive intake of fluids that are diuretics (coffee, black tea, green tea)

Recent foreign travel

Ill household member

R:Fiber requires hydration to be effective. About 2 to 3 cups of caffeine drinks (coffee, tea, cola) are known to have a diuretic effect (Mazur & Litch, 2019).

The individual/parent will report less diarrhea as evidenced by the following indicators:

• Describes contributing factors when known
• Explains rationale for interventions
• Explains what foods and fluids to avoid
• Relates when medical care is needed

Level 1 Fundamental Focused Interventions (all settings)

Assess Causative Contributing Factors

• Tube feedings
• Dietetic foods
• Foreign travel
• Contaminated foods
• Food allergies
• Medications (e.g., antibiotics, laxative abuse)

Level 1 Fundamental Focused Interventions

For Diarrhea Initially:

Explain antidiarrheal medications. Over-the-counter (OTC) antidiarrheal medications, such as loperamide and bismuth subsalicylate, might help reduce the number of watery bowel movements and control severe symptoms if there is no fever (temperature greater than 100.4°F or 38°C) and the stools are not bloody (LaRocque & Harris, 2018).

R:These medications are not indicated if bacteria or parasites have caused the diarrhea because they prevent the diarrhea that can rid the body of the toxin.

Instruct to (Mazur & Litch, 2019):

• Drink plenty of clear liquids, including water, broths, coconut drinks, and diluted juices.
• Increase oral intake to maintain a normal urine, light yellow in color.
• Avoid soda, sport drinks, caffeine, and alcohol.

R:Soft drinks (nondietetic or dietetic) and sport drinks are unsatisfactory for fluid replacement for moderate or severe fluid loss because of their high sugar and salt content.

• Add semisolid and low-fiber foods gradually as bowel movements return to normal. Initially try soda crackers, toast, yogurt, bananas, applesauce, then boiled eggs, rice, or chicken.
• Avoid certain foods, such as dairy products, fatty foods, high-fiber foods, such as vegetables, or highly seasoned foods for a few days.

R:Foods with complex carbohydrates (e.g., rice, toast, cereal) facilitate fluid absorption into the intestinal mucosa (Mazur & Litch, 2019).

• Instruct the individual to seek medical care if blood and mucous are in stool and fever greater than 101°F.

R:Acute bloody diarrhea (dysentery) has certain causative pathogens (e.g., Campylobacter jejuni, shigella, salmonella) that require antibiotic therapy (Norris, 2019).

• Teach the individual to gently clean the anal area after bowel movements; apply lubricants (e.g., petroleum jelly), which can protect skin from irritation.

R:The acidity of diarrheal stools can irritate the anal membranes.

• See Deficient Fluid Volume for additional interventions.

Conduct Health Teaching as Indicated

Explain the interventions required to prevent future episodes and effects of diarrhea on hydration.

Explain safe food handling in home (e.g., required temperature storage, washing of food preparation objects after use with raw food, frequent hand washing) (Mazur & Litch, 2019).

• Refrigerate all perishable foods.
• Cook all food at high temperature or boil (212°F) for at least 15 minutes before serving.
• Avoid allowing food to stand at warm temperatures for several hours.
• Caution about foods at picnics in hot summer.

R:Improper storage can cause microorganisms to multiply.

• Thoroughly clean kitchen equipment after contact with perishable foods (e.g., meats, dairy, fish).

R:Failure to clean equipment used with raw foods can transfer microorganisms to cooked foods.

• Explain that a diet primarily made up of dietetic foods containing sugar substitutes (hexitol, sorbitol, and mannitol) can cause diarrhea.

R:Sugar substitutes cause rapid small-bowel motility.

• Consult with primary healthcare provider for prophylactic use of bismuth subsalicylate (BSS; e.g., Pepto Bismol) 30 to 60 mL or 2 tablets q.i.d. during travel and 2 days after return; or antimicrobials for the prevention of traveler's diarrhea.
• Advise that BSS is the active ingredient in adult formulations of Pepto Bismol and Kaopectate. BSS commonly causes blackening of the tongue and stool and may cause nausea, constipation, and rarely tinnitus (ringing in ears) (Connor, 2019).
• Alert travelers with aspirin allergies, renal insufficiency, and gout, and those taking anticoagulants, probenecid, or methotrexate that they should not take BSS. In travelers taking aspirin or salicylates for other reasons, the use of BSS may result in salicylate toxicity (Connor, 2019).
• Advise not to treat traveler's diarrhea with antimotility agents (e.g., Lomotil, Imodium).

R:Antimotility agents can delay the clearance of organisms and thus can increase the severity of traveler's diarrhea with complications (e.g., sepsis, toxic megacolon).

R:Bismuth subsalicylate (Pepto Bismol), in a dosage of two 262-mg tablets 4 times a day (taken with meals and in the evening), can prevent traveler's diarrhea. It has been shown to provide a 60% protection rate (Connor, 2019).

Teach basic precautions to take when traveling to foreign lands:

• Avoid salads, milk, fresh cheese, cold cuts, and salsa.
• Drink carbonated or bottled beverages; avoid ice.
• Peel fresh fruits and vegetables.
• Avoid foods not stored at proper temperature.
• Cleanse hands with hand sanitizers before eating and throughout the day.

R:Microorganisms can multiply in foods not stored properly and/or washed with contaminated water. Ice can be contaminated.

Refer individuals to//wwwnc.cdc.gov/travel/yellowbook/2020/preparing-international-travelers/travelers-diarrhea for guidelines to prevent traveler's diarrhea and other health problems.

Level 2 Extended Focused Interventions (pediatrics)

Monitor Fluid and Electrolyte Losses

• Fluid volume lost
• Urine color and output
• Skin color
• Mucous membranes
• Capillary refill time

Instruct to Consult with Primary Care Provider if:

• Diarrhea persists.
• Blood or mucus is in stools.
• Child is lethargic.
• Urine output is scanty.
• Stools suddenly increase.
• Child is vomiting.

R:Children with signs of moderate or severe dehydration should be referred to an urgent care facility for possible parenteral therapy (Hockenberry, Rodgers, & Wilson, 2018).

Reduce Diarrhea

• Avoid milk (lactose) products, fat, whole grains, fresh fruits, and vegetables.
• Avoid high-carbohydrate fluids (e.g., soft drinks), gelatin, fruit juices, caffeinated drinks, and chicken or beef broths.

R:Fluids high in carbohydrates can worsen diarrhea because of their high osmolarity, which pulls more fluid into the bowel.

Provide Oral Rehydration

• Use oral rehydration solutions (e.g., Pedialyte, Lytren, Ricelyte, Resol).
• Determine fluid loss by body weight loss. If less than 5% of total weight is lost, 50 mL per kg of fluids will be needed during the next 3 to 6 hours (Silbert-Flagg & Pillitteri, 2018).
• For more than a 5% weight loss, consult with the primary care provider for fluid replacement.
• Fluids must be given to replace losses and continuing losses until diarrhea improves (Silbert-Flagg & Pillitteri, 2018).

R:Fluid replacement should be aggressive in infants and very young children.

Reintroduce Food

• Begin with bananas, rice, cereal, and crackers in small quantities.
• Gradually return to regular diet (except milk products) after 36 to 48 hours; after 3 to 5 days, gradually add milk products (half-strength skim milk to skim milk to half-strength milk [whole or 1%]).
• Gradually introduce formula (half-strength formula to full-strength formula).

R:Small quantities of nonirritating foods will decrease stimulation of the bowel.

R:Lactose-containing fluids or foods can worsen diarrhea in some children.

Protect Skin from Irritation with Nonwater-Soluble Cream (e.g., petroleum jelly).

R:Diarrheal stools are acidic and irritating.

Initiate Health Teaching as Needed

Teach Parents Signs to Report:

• Sunken eyes
• Dry mucous membranes in mouth
• Rapid pulse
• Rapid breathing
• Lethargy
• If diarrhea increases

R:Diarrhea in infants and small children can be serious because of their small extracellular fluid reserve. Early signs of hypovolemia need to be reported to prevent circulatory collapse, renal failure, and irreversible acidosis and death (Silbert-Flagg & Pillitteri, 2018).