BOWEL
ELIMINATION:
Diarrhea
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GROUP 5:
● Redil, Krystelle Mae
● Rose, Alliah Rae
Antonette
● Salmorin, Bashracel
Marie
● Sanmiguel, Angellie
BSN 4F (A.Y. 2021-2022)
TABLE OF CONTENTS
01 02
Case Scenario Pathophysiology
03 04
14 Program Critical Appraisal Skill
Outcomes Programme
01
CASE SCENARIO
Diarrhea: SCENARIO
Mr. Greaves is a direct admission from his assisted care facility to the
intermediate care unit with dehydration secondary to profuse diarrhea. He is
awake, alert, and oriented (×3, has a low-grade fever, abdominal cramps, and
diarrhea (5 to 10 watery stools a day). He tells you, “I don’t think I have gone
this much in my entire life! I can’t even describe how bad my bottom feels! I
was just getting over my chest infection with all those antibiotic pills.” You
receive the following orders from the primary care provider:
● Vital signs q4h while awake
● IV of lactated Ringer’s solution (LR) @ 150 mL/hr
● BRAT diet
● Stool for occult blood, O&P, and Clostridium difficile
● BR/BRP with assistance
● Skin/wound care consult
Diarrhea: SCENARIO
1. Which order will you implement first? Why?
As a nurse, I will first implement the order to start infusing the client with
an IV of lactated Ringer’s solution to run for 150 mL/hr. Due to the diarrhea, the
patient is dehydrated and needs to be initiated with fluid replacement therapy
as soon as possible to prevent further complications such as hypokalemia. This
decision is also in accordance with Maslow’s Hierarchy of Needs wherein the
administration of IV fluids in this scenario fulfils the patient’s immediate
physiological needs, which makes this action the priority among other orders.
Diarrhea: SCENARIO
2. You need to obtain a stool specimen for the ordered tests. Describe the
process to complete this procedure considering Mr. Greaves’s situation.
In order to obtain a stool specimen for the ordered tests, the patient
needs to prepare a clean specimen container first. It is best to avoid mixing the
specimen with urine and water from the toilet, which It why it is important to
place something in the toilet to catch the specimen. Some people
recommend defecating in a sheet of paper, but in this case the patient where
the patient has watery stools he could defecate in a clean plastic bag or large
container. Scoop up a pea-sized portion of your specimen using the spatula
from the specimen container, and make sure to properly seal and label the
container. It is best to submit the specimen as soon as possible to the
laboratory for testing.
Diarrhea: SCENARIO
3. The fecal occult blood test (FOBT) is done on the nursing unit. Describe the critical
steps of this procedure that are necessary to ensure valid results.
In order to ensure that the validity of the results of the FOBT, the patient should
strictly follow proper collection of stool specimen. First, the patient should collect stool
samples from 3 separate bowel movements. The specimens should be stored in
separate clean containers and labelled accurately. The patient should make sure that the
specimens do not mix in urine or water from the toilet. Some people recommend
defecating in a sheet of paper, but in this case where the patient has watery stools he
could defecate in a clean plastic bag or large container. Use the applicator from the test
kit to smear some of the stool on the test slide included in the kit. It is also important to
recheck if the specimens are labelled and sealed correctly, and submit the specimens to
the lab as soon as possible. The patient should also avoid eating certain fruits and
vegetables such as beetroot and turnip, red meat, vitamin supplements, and pain
relievers prior to the test.
Diarrhea: SCENARIO
4. Mr. Greaves says to you, “I think I need some medication to stop this
diarrhea. Could you ask the doctor for something?” How should you respond
to this question?
Doctors often prescribe medication to reduce the severity of the diarrhea,
especially with cases just like that of the patient who has persistent diarrhea. I
would inform the patient that I would talk to his doctor about his request for
medication to stop the disease.
Diarrhea: SCENARIO
5. Mr. Greaves tells you, “I know this sounds crazy but I am hungry in spite of
all this mess. What can you get me to eat?” Discuss the dietary order as you
would for this patient?
First, I would inform the patient that his doctor prescribed him with the
BRAT diet and then I would provide him with an explanation of some of the
basic information about this diet, as well as the food he is and isn’t allowed to
eat while on this diet.
Diarrhea: SCENARIO
Mr. Greaves: “I know this sounds crazy but I am hungry in spite of all this mess.
What can you get me to eat?”
Nurse: “You’re doctor prescribed you with the BRAT diet, which basically entails
consuming bland food until your stomach would be able to handle other types
of food. So, this diet will help make your stools firmer and replace nutrients
your body needs, and is also non-irritating for your stomach.”
Nurse: “You can eat bland foods like bananas, rice, applesauce, toast, saltine
crackers, plain potatoes, or clear soup broths. Please refrain from eating
anything fatty or sugary or any dairy products, as these foods can upset your
stomach again.”
02
Pathophysiology
Diarrhea: PATHOPHYSIOLOGY
Diarrhea: PATHOPHYSIOLOGY
Diarrhea: PATHOPHYSIOLOGY
Diarrhea: PATHOPHYSIOLOGY
03
14 PROGRAM OUTCOMES
Diarrhea: 14 PROGRAM OUTCOMES
● 1. Apply knowledge of physical, social, natural and health sciences, and humanities in
the practice of nursing.
Discontinuity theory of Immunity - Grossman and Paul
● According to the discontinuity theory of immunity, the immune system responds to sudden
changes in antigenic stimulation and is rendered tolerant by slow or continuous stimulation.
Consequently, the immune system can detect sudden changes, leading to the triggering of
effector immune responses.
General Adaptation Syndrome- Hans Selye
● GAS is the three-stage process that describes the physiological changes the body goes
through when under stress. When you are stressed over a long period, your intestines keep
messing up their filtration duties. Your nervous system reacts with more inflammatory
responses, which can lead to a mild diarrhea case.
Diarrhea: 14 PROGRAM OUTCOMES
● 2.Provide safe, appropriate band holistic care to individuals, families, population
group and community utilizing nursing process.
Assessment: Elicit a complete health history to identify the cause, character and
pattern of diarrhea. Mr. Greaves will have an assessment for bowel patterns
(frequency and consistency of stool, pain or cramping with bowel movements).
Determine also the hydration status by assessing the fluid volume intake and loss.
Diagnoses: Deficit fluid volume related to diarrhea as evidenced by 5 to 10 watery
stools a day.
Planning: Goals for the patient include resumption of usual bowel patterns, adequate
hydration and balanced fluid volume and verbalizes understanding of diarrhea’s
causes and the rationale for treatment.
Diarrhea: 14 PROGRAM OUTCOMES
● 2.Provide safe, appropriate band holistic care to individuals, families, population
group and community utilizing nursing process.
Implementation: Nursing interventions for Mr. Greaves includes documenting and
monitoring of vital signs, fluid volume loss, and serum electrolyte levels closely.
Encourage increased fluid intake and small, frequent meals. Educate patient about
ways to decrease diarrhea ( avoid foods that act as bowel irritants, including raw
fruits and vegetables). Administer prescribed medications and provide IV fluids and
electrolytes as prescribed.Evaluation: The patient resumes usual bowel habits,
maintains skin integrity and reports increased understanding of diarrhea and
participates in self-care activities as possible.
Evaluation: The patient resumes usual bowel habits, achieve adequate hydration and
balanced fluid volume and reports increased understanding of diarrhea.
Diarrhea: 14 PROGRAM OUTCOMES
● 3.Apply guidelines and principles of evidence-based practice in the delivery of care.
● In the case of Mr. Greaves, the diarrhea could be a side effects of taking
antibiotics for his chest infection. This put stress on his body and results to
physiologic changes. Proper diet and lifestyle can help mitigate the cause of
diarrhea and at the same time provide adequate nutrition to the patient.
Antidiarrheal medications such as loperamide may also be advised to treat
diarrhea. Provide explanation to the patient and make sure the he understands
and agrees to the treatment plan provided.
Diarrhea: 14 PROGRAM OUTCOMES
● 4.Practice nursing in accordance with existing laws, legal, ethical and moral
principles.
● The nurse must practice within RA 9173 or Philippine Nursing Act of 2002.
Comprehensive legislation regulating various aspects of nursing profession. Main objective
is to provide for protection and improvement of nursing profession by instituting measures
that shall result in relevant nursing education, humane working conditions, better career
prospects and dignified existence for nurses.
● Implements interventions guided by Patient’s Bill of Rights and Obligations.
It is a declared policy of the State to ensure and protect the rights of patients to decent, humane
and quality health care
● Acts in accordance with the terms of contract of employment and other rules and
regulations.
● Decides on cases based on ethical and moral reasoning.
Diarrhea: 14 PROGRAM OUTCOMES
● 5.Communicate effectively in speaking, writing and presenting using culturally-
appropriate language.
● The nurse can ask open ended questions using clear and complete sentences.
Using medical jargons should also be avoided. Make sure that the patient
understand your instructions by asking them to repeat the information back. The
nurse should be polite all the time. The nurse should observe for patients’ non
verbal cues such as expression, gait, or body language. Lastly, the nurse must
always be aware and sensitive to the patients’ cultural, social and educational
background.
Diarrhea: 14 PROGRAM OUTCOMES
● 6. Document to include reporting up-to-date client care accurately and
comprehensively.
● Prepare accurate documentation which includes findings of the assessment and the
updated monitoring of patient’s status such as the vital signs, character and pattern of
diarrhea,weight gain or loss, and serum electrolyte levels.
● Document the independent nursing interventions performed and the orders of the
physician being done to manage the patient with diarrhea.
● 7.Work effectively in collaboration with inter-, intra-and multi- disciplinary and multi-
cultural teams
● Refer patient to gastroenterologist or the diagnosis and treatment of digestive
disorders.
● Refer patient a nutritionist to provide proper diet
Diarrhea: 14 PROGRAM OUTCOMES
● 8.Practice beginning management and leadership skills in the delivery of client care
using a systems approach.
● Organizes workload to ensure efficiency in performing nursing responsibilities.
● Ensure that the prescribed medications, IV fluids and medical supplies are
available.
● Identify the need to develop in policies and participate in policy making.
● Adheres to policies, procedures, and protocols on prevention and control of
infection.
● 9.Conduct research with an experienced researcher.
● Collaborate with the different healthcare teams especially in gastroenterology
department and nutritionist to search and provide proper and holistic care for
the patient. Identify evidence based solutions to the problem at hand and apply
to practice the solution that is deemed appropriate for the patient.
Diarrhea: 14 PROGRAM OUTCOMES
● 10.Engage in lifelong learning with a passion to keep current with national and global
developments in general, and nursing and health developments in particular.
● Identifies learning needs about gastrointestinal diseases (diarrhea) and update
learning plans to enhance competence such as reading peer reviewed articles
and attending symposium and/or seminars.
● Participate in post-graduate conferences and comply with regulatory
requirement for practice such as Continuing Professional Development by
participating in formal, informal and non formal learning.
● Evaluate own performance against standards of nursing practice and listen to
suggestions and recommendations for corrective actions to improve
performance.
Diarrhea: 14 PROGRAM OUTCOMES
● 11.Demonstrate responsible citizenship and pride of being a Filipino.
● The nurse should also empathetic to the patient while providing compassionate
care.Always show respect to the elderly and do not discriminate. Do not disclose
information to anyone unless with permission. Partner with a nutritionist or
dietician to provide proper diets and promote healthy lifestyle especially for
elderly. Provide assistance to the local government unit in enhancing the quality
of life of the elderly.
Diarrhea: 14 PROGRAM OUTCOMES
● 12.Apply techno-intelligent care systems and processes in healthcare delivery.
● Utilizes basic information technology systems in the delivery of healthcare.
● Demonstrate competence in utilizing basic computer systems in documenting
and updating client care.
● The Diarrhea Innovations Group (DIG) seeks to defeat diarrhea and address these
long-term effects through global collaboration. It is a global network of innovators
committed to reducing deaths from diarrhea through the development of new
diagnostic and therapeutic technologies and approaches. Regular conference calls
feature experts speaking on topics such as a potential intervention for environmental
enteric dysfunction (EED); diarrheal disease burden measured in disability-adjusted
life years; and liposome salt as the next generation of oral rehydration solution.
Diarrhea: 14 PROGRAM OUTCOMES
● 13.Adopt the nursing core values in the practice of the Profession
● The nurse should be sensitive to the needs of their patient and the patients’ family.
● The nurse must deliver care fairly, justly and equitably among a group of patients.
● The nurse must do good and the right for the patient.
● The nurse must be accountable for their nursing care and actions.
● The nurse must be true to their professional promise and responsibility of providing
high quality care.
● The nurse must uphold patient self determination who has innate rights to have their
own opinion, perspective, values and beliefs.
● The nurse must not withhold the whole truth from their clients.
● 14.Apply entrepreneurial skills in the delivery of nursing care
● Nurse entrepreneurs may build their businesses to develop and distribute medical
products or medicines for diarrhea and offer direct patient care.
● Provide a leaflet with improved instructions that include treatments.
04
Critical Appraisals Skills
Programme
Diarrhea: Critical Appraisals Skills Programme
Prevalence and management of antibiotic associated diarrhea in
general hospitals
Background
Antibiotic-associated diarrhea (AAD) is a common adverse effect of
antibiotic (AB) treatment. This study aimed to measure the overall
prevalence of AAD (including mild to moderate diarrhea) in
hospitalized AB treated patients, to investigate associated risk
factors and to document AAD associated diagnostic investigations,
contamination control and treatment.
Diarrhea: Critical Appraisals Skills Programme
Prevalence and management of antibiotic associated diarrhea in
general hospitals
Methods
During 8 observation days (with time delay of 10–14 days between each
observation day), all adult patients hospitalized at an internal medicine
ward of 4 Belgian participating hospitals were screened for AB use.
Patients receiving AB on the observation day were included in the study
and screened for signs and symptoms of AAD using a period prevalence
methodology. Clinical data were collected for all AB users and AAD
related investigations and treatment were collected for the entire
duration of AAD. Additionally, nurses noted daily the frequency of all
extra care associated to the treatment of the diarrhea
Diarrhea: Critical Appraisals Skills Programme
Prevalence and management of antibiotic associated diarrhea in
general hospitals
Results
A total of 2543 hospitalized patients were screened of which 743 were treated
with AB (29.2%). Included AB users had a mean age of 68 yr (range 16–99) and
52% were male. Penicillins were mostly used (63%) and 19% received more than
one AB. AAD was observed in 9.6% of AB users including 4 with confirmed
Clostridium difficile infection. AAD started between 1 and 16 days after AB start
(median 5) and had a duration of 2 to 41 days (median 4). AAD was significantly
associated with higher age and the use of double AB and proton pump inhibitors.
AAD patients had extra laboratory investigations (79%), received extra
pharmacological treatment (42%) and 10 of them were isolated (14%). AAD
related extra nursing time amounted to 51 minutes per day for the treatment of
diarrhea.
Diarrhea: Critical Appraisals Skills Programme
Prevalence and management of antibiotic associated diarrhea in
general hospitals
Conclusions
In this observational study, with one third of hospitalized patients
receiving AB, an AAD period prevalence of 9.6% in AB users was
found. AAD caused extra investigations and treatment and an
estimated extra nursing care of almost one hour per day. Preventive
action are highly recommended to reduce the prevalence of AAD and
associated health care costs.
Diarrhea: Critical Appraisal Skills Programme
1. Was there a clear statement of the Yes No Can’t tell
aims of the research?
COMMENTS:
This study aimed to measure the overall prevalence of AAD (including mild to
moderate diarrhea) in hospitalized AB treated patients, to investigate
associated risk factors and to document AAD associated diagnostic
investigations, contamination control and treatment.
Diarrhea: Critical Appraisals Skills Programme
2. Is a qualitative methodology appropriate? Yes No Can’t tell
COMMENTS:
During 8 observation days (with time delay of 10–14 days between each observation
day), all adult patients hospitalized at an internal medicine ward of 4 Belgian participating
hospitals were screened for AB use. Patients receiving AB on the observation day were
included in the study and screened for signs and symptoms of AAD using a period
prevalence methodology. Clinical data were collected for all AB users and AAD related
investigations and treatment were collected for the entire duration of AAD. Additionally,
nurses noted daily the frequency of all extra care associated to the treatment of the
diarrhea.
Diarrhea: Critical Appraisals Skills Programme
3. Was the research design appropriate to address Yes No Can’t tell
the aims of the research?
In all adult patients, hospitalized in one of the internal medicine wards of four participating hospitals, a
point prevalence methodology was used to screen for AB use. Charts from all patients treated with AB on
the observation day were investigated for signs and symptoms of AAD on that day as well as in the week
before and the week after (period prevalence). In patients with AAD, related diagnostic procedures,
contamination control, AAD treatment and extra nursing care were registered.
4. Was the recruitment strategy appropriate to the Yes No Can’t tell
aims of the research?
During the study period (January-April 2013), a research nurse visited all participating wards at time
intervals of 10 to 14 day between observations. At each observation day, all hospitalized patients were
screened for AB use. Patients were included in the study if over 16 years, hospitalized at the
participating ward and treated with AB at the observation day
Diarrhea: Critical Appraisals Skills Programme
5. Was the data collected in a way that Yes No Can’t tell
addressed the research issue?
COMMENTS: A patient checklist was used by the nurse researcher to collect data on personal
characteristics (age, gender, ADL, dementia), hospitalization admission and discharge dates, AB
treatment (start and stop date, type of AB prescribed) and clinical conditions known to increase the risk
for the development of diarrhea (inflammatory bowel disease, diabetes, COPD, HIV, transplantation,
chemotherapy, radiotherapy, endoscopy, abdominal surgery, use of proton pump inhibitors and
nasogastric tubes) [2,3,9]. In case of diarrhea, start and stop dates were noted together with associated
diagnostic procedures (laboratory tests, endoscopy, etc.), contamination control and diarrhea treatment
(IV hydration, medication). AAD related investigations and treatments were collected for the entire
duration of AAD.
Additionally, a checklist of nursing care for patients with diarrhea was completed by the treating nurses
from the day of inclusion up to a maximum of seven consecutive days or until the end of the diarrhea
period. Nurses noted per day of treatment the frequency of all extra care associated to diarrhea.
Diarrhea: Critical Appraisals Skills Programme
6. Has the relationship between researcher Yes No Can’t tell
and participants been adequately
considered?
Since inclusion of the total eligible population is a basic requirement for a trustful
prevalence measurement, the researcher had a long discussion with both ethical
commissions to obtain a special permission to perform this study without informed
consent. Permission was obtained under the condition that (1) the researchers had no
any direct patient contact, (2) data were provided by the treating nurse based on the
medical chart, and (3) data were completely anonymized before handed over to the
researcher.
Diarrhea: Critical Appraisal Skills Programme
7. Have ethical issues been taken into Yes No Can’t tell
consideration?
COMMENTS: This study received an approval by the local ethical commission and was
given in January 2013.
Diarrhea: Critical Appraisal Skills Programme
8. Was the data analysis sufficiently Yes No Can’t tell
rigorous?
COMMENTS: Data analysis was performed using the statistical package IBM SPSS statistics, version
20.0. Mainly descriptive statistical methods were used to calculate the prevalence of AAD and to
describe patient characteristics, associated risk factors, clinical course of diarrhea, diagnostic
procedures and treatment of AAD patients. Differences in characteristics between AAD and non-AAD
patients were analyzed using independent sample t-test (or Mann–Whitney-U test for skewed
distributions) and chi-square test for means and proportions respectively. Logistic multiple regression
analysis was performed to investigate risk factors associated with the development of AAD.
Diarrhea: Critical Appraisal Skills Programme
9. Is there a clear statement of findings? Yes No Can’t tell
COMMENTS: A total of 2543 hospitalized patients were screened of which 743
were treated with AB (29.2%). Included AB users had a mean age of 68 yr (range
16–99) and 52% were male. Penicillins were mostly used (63%) and 19% received
more than one AB. AAD was observed in 9.6% of AB users including 4 with
confirmed Clostridium difficile infection. AAD started between 1 and 16 days after
AB start (median 5) and had a duration of 2 to 41 days (median 4). AAD was
significantly associated with higher age and the use of double AB and proton pump
inhibitors. AAD patients had extra laboratory investigations (79%), received extra
pharmacological treatment (42%) and 10 of them were isolated (14%). AAD related
extra nursing time amounted to 51 minutes per day for the treatment of diarrhea.
Diarrhea: Critical Appraisal Skills Programme
10. How valuable is the research? Yes No Can’t tell
COMMENTS: In this study, with one third of hospitalized patients receiving AB
treatment, an AAD period prevalence of 9.6% in AB users was found. AAD
was associated with extra investigations, extra treatment and extra time of
nursing care of almost one hour per day. Preventive actions are highly
recommended to reduce the prevalence of AAD and associated health care
costs.
THANK YOU!
