Diarrhea
Also Consider: Abdominal Discomfort, Constipation, Dehydration, Nausea/Vomiting, Rectal Bleeding, Vomiting Blood
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Diarrhea Definition & Causes
Definition: Three (3) or more loose or watery stools in twenty-four (24) hours.
Common causes: diet, tube feeding, viral gastroenteritis, medications, irritable bowel syndrome, lactose intolerance
Less common causes: bacterial or parasitic infections, fecal impaction, ischemic colitis, drug overdose or withdrawal
The main concerns for patients with acute diarrhea are dehydration and electrolyte (sodium, potassium, bicarbonate) imbalances.
1. Take Vital Signs
Temperature:
Blood Pressure lying:
Blood Pressure standing:
Heart Rate lying:
Heart Rate standing:
Respiratory Rate:
Oxygen Saturation:
2. Evaluate Symptoms and Signs
Acute mental status change
Not eating or drinking as much as usual
Acute decline in ADL abilities
Signs of dehydration
Measurement of blood pressure and pulse when lying, sitting, and standing (if patient is able)
GI: Nausea, vomiting, abdominal distention or tenderness, rebound tenderness, bowel sounds
Appearance of any vomited material, presence of occult blood
Rectal check for impaction (if slowly oozing stool), appearance of stool (consistency, presence of blood or mucus)
Fingerstick glucose (patients with diabetes)
3. Take Action using SBAR Report:
Immediately notify the medical staff & resident representative
Sudden onset >3 loose stools with change in mental status, Temp>101 F., blood in stool, altered vital signs, or recent C diff colitis
Notify medical staff & resident representative within the next 16 hours.
New onset of multiple loose stools with stable vital signs, or with fever, or with evidence of impaction or dehydration
Notify medical staff on the next business day
Persistent loose stools.
Notify medical staff at the next regular rounds
Recurrent fecal impaction; periodic loose stools
SBAR Report
Situation: "Diarrhea with ___ stools in the last 24 hours, associated with (fever of ___ ) (altered mental status) (altered vital signs) (dehydration) (fecal impaction) (in a patient with a recent history of C diff colitis)
Background:
Reason the patient is in the nursing home (rehab for___, long term care for __).
When the problems started, how severe they are, getting worse or staying the same, alleviating or aggravating factors, what treatments have been used.
Abnormal Vital Signs based on patient’s previous values
MOLST / Advance Directives
Recent illness, antibiotics, medication changes
History of C diff (pseudomembranous) colitis
General observation of patient condition
Very low urinary output (<30cc/hr)
Diet restrictions, Fluid restriction, thickened liquids
Similar symptoms in other patient(s) on unit or in facility
Tube feeding rate, water flush orders, residual measurements, recent changes
Availability of IV or clysis hydration (i.e., PICC line)
Assessment: I am concerned about: __________
Recommendations/Requests:
Labs: CBC with manual diff, Lactic Acid, CMP/Chem14, Magnesium, Drug levels
Start or stop a medication
IV or SC (clysis) fluids
Antibiotic if C diff colitis is suspected
Stool for occult blood testing
Probiotic supplement
Antidiarrheal medication, only if there is no fever or other symptoms
Stool culture and C diff testing.
Increase tube feed water flushes
Change fluid restriction orders
Other:
Clarify expectations for care, interventions, and illness course/prognosis. Repeat any telephone orders back to the provider to ensure that they are correct and complete
4. Implement Management Plan
Monitor vital signs, fluid intake/urine output every 4-8 hrs for 2-3 days
Offer fluids frequently if nausea/vomiting allow
Place on Intake & Output monitoring
Place on 24-hour report for 2-3 days
Record all episodes of vomiting or diarrhea
Do not administer laxatives until diarrhea is resolved for 2 days
BRAT diet; avoid milk, alcohol, caffeine, fatty foods
Obtain lab results (if ordered), and notify medical as needed of:
Significantly abnormal values in blood count or metabolic panel (refer to appropriate Situation)
WBC > 12,000 or neutrophils > 90%
Positive C. Diff
Positive stool culture
Monitor meal acceptance
Resume normal diet when symptoms are resolved
Implement infection control measures if indicated
Update care plan regarding fall risk, pressure ulcer prevention, assistance needed with ADLs, supervision for safety, restorative needs
Review status and plan of care with designated representative daily
2025-04-26
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