NURSING PROCESS: THE PATIENT WITH INFECTIOUS DIARRHEA
The most important element of assessment in the patient with diarrhea is to determine hydration status. The goal of rehydration is to correct the dehydration. Assessment includes evaluation for thirst, oral mucous membrane dryness, sunken eyes, a weakened pulse, and loss of skin turgor. Careful observation for these signs is especially important in cases of rapidly dehydrating diseases (most notably cholera) and in younger children.
Intake and output measurements are crucial in determining fluid balance. Liquid stool should be measured and recorded along with a record of the frequency of stools. It is important to note the consistency and appearance of stool as key indicators of the type and severity of the diarrheal disease. The presence of mucus or blood should also be documented.
When conducting a health history, the nurse must determine whether the patient has recently traveled, whether the patient is being treated with antibiotics, whether the patient has been in contact with anyone who has recently had diarrheal disease, and what the patient has recently eaten. Frequently, patients attribute the most recent meals eaten as the cause of symptoms. However, the incubation period for most diarrheal conditions is longer than the time interval between meals, and the nurse needs to get de-tailed information about the meal preceding the illness and about all food intake in the previous 3 to 4 days. When eliciting this kind of history, it is helpful to ask the patient to list every food tasted. The nurse also asks patients if they are employed in a food preparation service, because the local public health departments should be notified about any patient with infectious diarrhea who works in the food industry.
Based on the assessment data, the patient’s major nursing diag-noses may include the following:
· Deficient fluid volume related to fluid lost through diarrhea
· Deficient knowledge about the infection and the risk of transmission to others
Based on the assessment data, potential complications that may develop include the following:
· Hypovolemic shock
The most important goals are maintenance of fluid and elec-trolyte balance, increased knowledge about the disease and risk of transmission, and absence of complications.
The patient is assessed to determine the degree of dehydration. This assessment helps determine the amount and route of re-hydration needed. Oral therapy can rehydrate most patients. Oral rehydration therapy is a strategy used to reduce the severe com-plications of diarrheal disease regardless of causative agent. It is inexpensive and effective, but it is often underused because of sus-tained cultural beliefs discouraging oral intake during episodes of diarrhea. After much refinement of the formula, the World Health Organization (WHO) and the United Nation’s International Children’s Emergency Fund (UNICEF) agreed on the makeup of a single solution for treatment of dehydration and electrolyte imbalance associated with cholera and other forms of diarrheal disease. The solution contains (in millimoles per liter) sodium, 90; potassium, 20; chloride, 80; citrate, 10; and glucose, 111.
The patient exhibits dry mucous membranes of the mouth and increased thirst. The rehydration goal at this level is to deliver about 50 mL of oral rehydration solution (ORS) per 1 kg of weight over a 4-hour interval.
Sunken eyes, loss of skin turgor, and dry oral mucous mem-branes are common manifestations. An infant may have a sunken fontanel. The rehydration goal is about 100 mL/kg over 4 hours for the patient with moderate dehydration.
The patient with severe dehydration shows signs of shock (ie, rapid thready pulse, cyanosis, cold extremities, rapid breathing, lethargy, or coma) and should receive intravenous replacement until hemodynamic and mental status return to normal. When improvement is evident, the patient can be treated with ORS.
In the United States, commercially available preparations, such as Pedialyte and Rice-Lyte, have been effective fluid and electrolyte replacements for children with viral diarrheal disorders commonin this country. When diarrheal losses are very high (>10 mL/kg per hour), however, the lower sodium concentrations of these for-mulas make them less appropriate than the WHO formula.
For the hospitalized child, diarrheal fluid loss should be weighed, and ORS should be administered at a rate of 1 mL for each gram of diarrheal stool. Stool losses can be estimated so that the patient receives about 10 mL/kg ORS for each diarrheal stool.
It is important for children and adults suffering from acute di-arrheal symptoms to maintain caloric intake. Infants who are breastfed should continue to feed on demand; those who are re-ceiving formula should receive full-strength, lactose-free or lactose-reduced formulas immediately after rehydration. Children who normally eat semisolid or solid food should have that food of-fered. Recommended foods include starches, cereals, yogurt, fruits, and vegetables. Foods that are high in simple sugars, such as undiluted apple juice or gelatin, should be avoided.
Because diarrheal episodes are often accompanied by vomit-ing, rehydration and refeeding can be difficult. Oral rehydration therapy should be delivered frequently in small amounts. When vomiting is persistent, small children often require frequent ad-ministration of fluids by spoonfuls rather than by drinking from a bottle or a cup. Intravenous therapy is necessary for the patient who is severely dehydrated or in shock.
Public health nurses, school nurses, and others who are involved in patient teaching should emphasize principles of safe food preparation, with special attention to meat preparation and cook-ing. Ground beef should be cooked until no longer pink, and all meat should be maintained at temperatures below 40°F or above 140°F. In planning events for groups of people, adequate provi-sion for storage and reheating to meet temperature thresholds is important. When preparing food, it is important to use different surfaces, knives, and other equipment for meat and nonmeat items.
Diarrheal diseases discussed in this section must be reported to local or state health departments. The goal of reporting is to pro-vide information that will be used to assess disease incidence trends and to identify at the earliest point if there is a restaurant or other food preparation establishment that has served contaminated food.
The need for rehydration and refeeding should be taught to parents of children with diarrheal disease. Beliefs about illness and food patterns may have a traditional or cultural basis, and any teaching of health facts requires cultural sensitivity.
Good hygiene in the health care delivery and home settings must be a focus when caring for patients with infectious diarrheal diseases. The principles of hand washing and glove use that are emphasized with Standard Precautions are important aspects of disease control.
E. coli and Salmonella and Shigella species are all organisms thatcan be introduced into the bloodstream and disseminate to other organs. Blood cultures should be done for the acutely febrile pa-tient with diarrhea. If initial smear results reveal gram-negative organisms, antibiotic therapy is instituted.
Shock associated with diarrheal diseases demands accurate intake and output assessment and vigorous fluid replacement. In rare in-stances, patients with severe fluid imbalance require intensive care nursing support with aggressive hemodynamic monitoring.
Expected patient outcomes may include the following:
1) Attains fluid balance
a) Output approximates intake
b) Mucous membranes appear moist
c) Normal skin turgor
d) Adequate amounts of fluids and calories ingested
e) Absence of vomiting
f) Stools of normal color and consistency
2) Acquires knowledge and understanding about infectious diarrhea and transmission potential
a) Takes proper precautions to prevent spread of infection to others
b) Describes principles and techniques of safe food storage, preparation, and cooking
3) Absence of complications
a) Temperature within normal range
b) Negative blood culture reports
c) Achieves fluid balance
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