The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [193]
Pharmacological support
The treatment for diarrhoea depends on the cause.
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 (Shepherd 2000). 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.
In the case of bacterial diarrhoea, treatment with antibiotics is recommended only in patients who are very symptomatic and show signs of systemic involvement (Metcalf 2007). Not uncommonly, Salmonella can become resistant to commonly used antimicrobial agents such as amoxicillin (Metcalf 2007). 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 the last few years there has been increasing evidence supporting the use of probiotics in cases of diarrhoea associated with antibiotics (McFarland 2007). Researchers believe that probiotics restore the microbial balance in the intestinal tract previously destroyed by inciting antibiotics (Hickson et al. 2007). There are a variety of probiotic products available and their effectiveness appears to be related to the strain of bacteria causing the diarrhoea (Hickson et al. 2007, McFarland 2007).
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 litres 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 (Nazarko 2007). Nursing care should also include monitoring signs or symptoms of electrolyte imbalance, such as muscle weakness and cramps, hypokalaemia, tachycardia and hypernatraemia (Metcalf 2007).
Non-pharmacological support
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 (Smith 2001) and by listening to the patient’s preference for care (Cadd et al. 2000). 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 (Nazarko 2007).
Skin care
It is important that the patient has easy access to clean toilet and washing facilities and that requests for assistance are answered promptly. Skin care 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 (Le Lievre 2002). 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 have been used to protect perianal skin in patients with diarrhoea (Nazarko 2007). Soap should be avoided, unless it is an emollient,