Gonorrhea Sexually Transmitted Disease (STD)

 Diarrhoea 

Definition of  Diarrhoea 

The term diarrhoea originates from the Greek for ‘to flow through and can be characterized according to its onset and duration (acute or chronic) or by type (e.g. secretory, osmotic or malabsorptive). Diarrhoea can also be defined in terms of stool frequency, consistency, volume or weight. The World Health Organization (2014) defines diarrhoea as the passage of three or more loose stools per day, or more frequently than is normal for the individual.

Related theory 

Diarrhoea is a serious global public health problem, in particularly in low-income and middle-income countries due to poor sanitation. There are almost 1.7 billion cases of diarrhoeal disease each year, with many people dying (WHO 2014 ). The disease pathogens are most commonly transmitted via the faecal-oral route. Diarrhoea should be classified according to time (acute or chronic) and the characteristics of the stools.

Acute diarrhoea 

Acute diarrhoea is very common, usually self-limiting, generally lasting less than 2 weeks and often requires no investigation or treatment. Causes of acute diarrhoea include.

• dietary indiscretion (eating too much fruit, alcohol misuse) 

• allergy to food constituents 

• infective: 

– travel associated 

– viral 

– bacterial (usually associated with food) 

– antibiotic related. 

One of the most common causes of acute diarrhoea in the adult population worldwide is viral gastroenteritis resulting from norovirus. Its low infectious dose, resistance to extreme temperatures as well as many household cleaning products, along with viral shedding, before and after symptoms are apparent, have resulted in this virus being prolific during colder months and becoming widely known as the winter vomiting bug.

Gonorrhea Sexually Transmitted Disease (STD)

Chronic diarrhoea 

Chronic diarrhoea generally lasts longer than 2–4 weeks and may have more complex origins. Chronic causes can be divided as follows. 

• Colonic: colonic neoplasia, ulcerative colitis and Crohn’s disease, microscopic colitis. 

• Small bowel: small bowel bacterial overgrowth, coeliac disease, Crohn’s disease, Whipple’s disease, bile acid malabsorption, disaccharidase deficiency, mesenteric ischaemia, radiation enteritis, lymphoma, giardiasis. 

• Pancreatic: chronic pancreatitis, pancreatic carcinoma, cystic fibrosis. 

• Endocrine: hyperthyroidism, diabetes, hypoparathyroidism, Addison’s disease, hormone-secreting tumours. 

• Other causes: laxative misuse, drugs, alcohol, autonomic neuropathy, small bowel resection or intestinal fistulas, radiation enteritis. 

Pre-procedural considerations 

 Assessment 

The cause of diarrhoea needs to be identified before effective treatment can be instigated. This may include clinical investigations such as stool cultures for bacterial, fungal and viral pathogens or a more formal medical evaluation of the gastrointestinal tract. 

Ongoing nursing assessment is essential for ensuring individualized management and care. The lack of a systematic approach to assessment and poor documentation cause problems in effective management of diarrhoea. 

Nurses need to be aware of contributing factors and be sensitive to patients’ beliefs and values in order to provide holistic care. A comprehensive assessment is therefore essential and should include the following. 

• History of onset, frequency and duration of diarrhoea: patient’s perception of diarrhoea is often related to stool consistency. 

• Consistency, colour and form of stool, including the presence of blood, fat and mucus. Stools can be graded using a scale such as the Bristol Stool Chart, where diarrhoea would be classified as types 6 or 7.

• Associated symptoms: pain, nausea, vomiting, fatigue, weight loss or fever. 

• Physical examination: check for gaping anus, rectal prolapse and prolapsed haemorrhoids. 

• Recent lifestyle changes, emotional disturbances or travel abroad. 

• Fluid intake and dietary history, including any cause-and-effect relationships between food consumption and bowel action. 

• Regular medication, including antibiotics, laxatives, oral hypoglycaemics, appetite suppressants, antidepressants, statins, digoxin or chemotherapy. 

• Effectiveness of antidiarrhoeal medication (dose and frequency). 

• Significant past medical history: bowel resection, pancreatitis, pelvic radiotherapy. 

• Hydration status: evaluation of mucous membranes and skin turgor. 

• Perianal or peristomal skin integrity: enzymes present in faecal fluid can cause rapid breakdown of the skin. 

• Stool cultures for bacterial, fungal and viral pathogens: to check for infective diarrhoea. Treatment may not be commenced until results are available except if the patient has been infected by Clostridium difficile in the past. 

• Blood tests: full blood count, urea and electrolytes, liver function tests, vitamin B 12, folate, calcium, ferritin, erythrocyte sedimentation rate (ESR) and C-reactive protein. 

• Patient’s preferences and own coping strategies including nonpharmacological interventions and their effectiveness. 

All episodes of acute diarrhoea must be considered potentially infectious until proven otherwise. The risk of spreading the infection to others can be reduced by adopting universal precautions such as wearing of gloves, aprons and gowns, disposing of all excreta immediately and, ideally, nursing the patient in a side room with access to their own toilet. Advice should always be sought from the infection control team. At this stage nursing care should also include educating patients about careful hand washing. 

    Diarrhoea can have profound physiological and psychosocial consequences for a patient. Severe or extended episodes of diarrhoea may result in dehydration, electrolyte imbalance and malnutrition. Patients not only have to cope with increased frequency of bowel movement but may have abdominal pain, cramping, proctitis and anal or perianal skin breakdown. Food aversions may develop or patients may stop eating altogether as they anticipate subsequent diarrhoea following intake. Consequently, this may lead to weight loss and malnutrition. Fatigue, sleep disturbances, feelings of isolation and depression are all common consequences for those experiencing diarrhoea. The impact of severe diarrhoea should not be underestimated; it is highly debilitating and may cause patients on long-term therapy to be non-compliant, resulting in a potentially life-threatening problem. 

Once the cause of diarrhoea has been established, management should be focused on resolving the cause and providing physical and psychological support for the patient. Most cases of chronic diarrhoea will resolve once the underlying condition is treated, for example, drug therapy for Crohn’s disease or dietary management for coeliac disease. Episodes of acute diarrhoea, usually caused by bacteria or viruses, generally resolve spontaneously and are managed by symptom control and the prevention of complications. 

DIFFERENTIAL DIAGNOSIS MANUAL: Nursing pdf download 

Treatment of  Diarrhoea 

 The treatment for diarrhoea depends on the cause 

Antimotility drugs 

Antimotility drugs such as loperamide or codeine phosphate may be useful in some cases, for example in blind loop syndrome and radiation enteritis. These drugs reduce gastrointestinal motility to relieve the symptoms of abdominal cramps and reduce the frequency of diarrhoea. It is important to rule out any infective agent as the cause of diarrhoea before using any of these drugs, as they may make the situation worse by slowing the clearance of the infective agent. 

Antibiotics 

In the case of bacterial diarrhoea, treatment with antibiotics is recommended only in patients who are very symptomatic and show signs of systemic involvement. Not uncommonly, Salmonella can become resistant to commonly used antimicrobial agents such as amoxicilline. When dealing with antibiotic-associated diarrhoea, most patients will notice a cessation of their symptoms with discontinuation of the antibiotic therapy. If diarrhoea persists, it is important to exclude pseudomembranous colitis by performing a sigmoidoscopy and sending a stool for cytotoxin analysis. However, over recent years there has been increasing evidence supporting the use of probiotics in cases of diarrhoea associated with antibiotics. Researchers believe that probiotics restore the microbial balance in the intestinal tract previously destroyed by inciting antibiotics. There are a variety of probiotic products available and their effectiveness appears to be related to the strain of bacteria causing the diarrhoea.

Fluid replacement 

The prevention and/or correction of dehydration is the first step in managing an episode of diarrhoea. Adults normally require 1.5–2 L of fluid in 24 hours. The person who has diarrhoea will require an additional 200 mL for each loose stool. Dehydration can be corrected by using intravenous fluids and electrolytes or by oral rehydration solutions. The extent of dehydration dictates whether a patient can be managed at home or will need to be admitted to hospital. Nursing care should also include monitoring signs or symptoms of electrolyte imbalance, such as muscle weakness and cramps, hypokalaemia, tachycardia and hypernatraemia.

 Non-pharmacological support of  Diarrhoea 

Maintaining dignity 

Preserving the patient’s privacy and dignity is essential during episodes of diarrhoea. The nurse has an important role in minimizing the patient’s distress by adjusting language and using terms that are appropriate to the individual to reduce embarrassment  ) and by listening to the patient’s preferences for care. Additionally, the use of deodorizers and air fresheners to remove the smell caused by offensive diarrhoea contributes to the person’s dignity. Stoma deodorants are thought to be more effective and samples can be obtained from company representatives. 

Skincare 

It is important that the patient has easy access to clean toilets and washing facilities and that requests for assistance are answered promptly. Skincare is also essential to prevent bacteria present in faecal matter from destroying the skin’s cellular defences and causing skin damage. This is particularly important with diarrhoea since it has high levels of faecal enzymes that come into contact with the perianal skin. The anal area should be gently cleaned with warm water immediately after every episode of diarrhoea. Frequent washing of the skin can alter the pH and remove protective oils from the skin. Products aimed at maintaining healthy peristomal skin should be used to protect perianal skin in patients with diarrhoea. Soap should be avoided unless it is an emollient, to avoid excessive drying of the skin and gentle patting of the skin is preferred for drying to avoid friction damage. Talcum powder should not be used and barrier creams should be applied sparingly, gently layered on in the direction of the hair growth rather than rubbed into the skin. The use of incontinence pads should be carefully considered in a person with severe episodes of diarrhoea. This particular material does not absorb fluid stools, protect the skin from damage or contain smells. 

Dilated Cardiomyopathy Causes Diagnosis Treatment

Faecal collection devices may leak with movement, so are most useful for patients who are cared for in bed. This type of device is fitted over the anus and fluid stools drain into a drainage bag similar to a drainable stoma bag. It is imperative that such devices are fitted by appropriately trained, competent healthcare professionals and that both local policies and manufacturer’s instructions are followed to ensure this equipment is used in an appropriate and safe manner.

Diet 

A diet rich in fibre, or ‘roughage’, can cause diarrhoea. In such cases, individuals should be advised to reduce their intake of foods including cereals, fruit and vegetables and space it out over the day. Chilli and other spices can irritate the bowel and should be avoided. Sorbitol (artificial sweetener), beer, stout and high doses of vitamins and minerals should also be avoided. 

 Faecal incontinence 

Faecal incontinence is a clinical symptom associated with diarrhoea.which has been defined as the uncontrolled passage of solid or liquid faeces at socially inappropriate times and places. When it is not possible to treat the cause of the diarrhoea, a care plan should be created to manage incontinence and prevent complications. 

Factors that can contribute to the development of faecal incontinence include: 

• damage or weakness of the anal sphincter: obstetric damage, haemorrhoidectomy, sphincterotomy or degeneration of the internal anal sphincter muscle 

• severe diarrhoea 

• faecal loading (impaction): immobility, lack of fluids 

• neurological conditions: spinal cord injury, Parkinson’s disease 

• cognitive deficits. 

Diarrhoea can potentially disrupt a person’s well-being. Community nurses and hospital-based specialist nurses have an essential role in supporting those affected by this condition. Diagnosis, treatment and management of diarrhoea and potential faecal incontinence can take place at home where individuals are more familiar with the environment.