The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [192]
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 (Cadd et al. 2000, Smith 2001). 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 (Metcalf 2007).
Consistency, colour and form of stool, including the presence of blood, fat, mucus. Stools can be graded using a scale such as the Bristol Stool Form Chart (see Figure 6.2), where diarrhoea would be classified as types 6 or 7 (Longstreth et al. 2006).
Associated symptoms: pain, nausea, vomiting, fatigue, weight loss or fever.
Physical examination: check for gaping anus, rectal prolapse and prolapsed haemorrhoids (Nazarko 2007).
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 (Nazarko 2007).
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 (Nazarko 2007).
Stool cultures for bacterial, fungal and viral pathogens: to check for infective diarrhoea (Pellatt 2007). 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 B12, folate, calcium, ferritin, ESR (erythrocyte sedimentation rate) and C-reactive protein.
Patient’s preferences and own coping strategies including non-pharmacological interventions and their effectiveness (Cadd et al. 2000, Chelvanayagam and Norton 2004, King 2002, Kornblau et al. 2000).
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 (King 2002). Advice should always be sought from infection control teams. At this stage nursing care should also include educating patients about careful handwashing.
Diarrhoea can have profound physiological and psychosocial consequences on 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 (Kornblau et al. 2000).
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