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Chronic diarrhoea:investigation, treatment and nursing care

NS377 Metcalf C (2007) Chronic diarrhoea: investigation, treatment and nursing care. Nursing Standard. 21, 21, 48-56. Date of acceptance: August 17 2006.

Summary
Chronic diarrhoea is a distressing symptom of a number of conditions. This article explains the assessment of patients at the initial outpatient visit through the various investigations and finally medical and surgical treatment. Emphasis is placed on the nursing management of chronic diarrhoea, particularly the treatment of physical effects such as dehydration and perianal skin soreness, and the psychological aspects of care.

Describe the investigations a patient may undergo. Outline medical and surgical treatment. Discuss the nursing care of a patient with chronic diarrhoea. Understand the psychological impact of coping with chronic diarrhoea.

Author
Chris Metcalf is nurse specialist/senior nurse endoscopy, West Hertfordshire Hospitals NHS Trust, Hertfordshire. Email: Chris.Metcalf@whht.nhs.uk

Introduction
Disorders of bowel function resulting in either diarrhoea or constipation are not unusual and chronic diarrhoea is one of the most common reasons why patients are referred to a hospital gastroenterology clinic (Thomas et al 2003). Several studies have indicated that approximately 95 per cent of the population open their bowels between three times per day and three times per week, with women being twice as likely as men to have fewer than three bowel actions per week (Spiller 1994). Contrary to popular belief, the passage of a single motion once a day, at the same time each day, is found in only one third of the population. Most people experience much day-to-day variability in both stool frequency and consistency. This should be regarded as part of normal physiology and not a sign of disease, as some patients believe (Spiller 1994). A persons personality is also intimately linked to his or her bowel habits. For example, it has been shown that extroverts produce bulkier, more frequent stools, illustrating the complex interaction between the mind and the gut. Mental illness in later life is often associated with changes in bowel function. Anxiety and fear may cause diarrhoea, while depressed patients are four to five times more likely to report constipation (Spiller 1994). NURSING STANDARD

Keywords
Body image; Chronic diarrhoea; Gastrointestinal system and disorders; Patients: psychology These keywords are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review. For author and research article guidelines visit the Nursing Standard home page at www.nursing-standard.co.uk. For related articles visit our online archive and search using the keywords.

Aim and intended learning outcomes

The aim of this article is to provide ward-based nurses with an overview of the investigation, treatment and nursing care of a patient with chronic diarrhoea. After reading this article you should be able to: Provide a definition of diarrhoea. Identify the main causes of chronic diarrhoea. Explain initial patient assessment. 48 january 31 :: vol 21 no 21 :: 2007

Diarrhoea
Diarrhoea may be defined in terms of stool frequency, consistency, volume or weight. Patients perceptions of diarrhoea often focus on stool consistency. However, quantification of stool consistency in clinical practice can prove difficult and so other criteria, such as the passage of more than three stools per day or stool weight provide an alternative meaningful definition. However, although a stool weight of 200g/day is often regarded as the upper limit of normal, this can be misleading because stool weights vary greatly and normal stool volumes can exceed this value, particularly when a non-Western diet is consumed (Thomas et al 2003). There is further potential for confusion arising from the discrepancy between medical and lay concepts of diarrhoea and these concepts need to be clarified at a patients initial assessment. For example, faecal incontinence in particular is commonly misinterpreted as diarrhoea while symptoms relating to functional bowel disease can be difficult to distinguish from organic pathology on the basis of history alone (Thomas et al 2003). There is no consensus on the duration of symptoms that define chronic rather than acute diarrhoea. Most clinicians, however, would accept that symptoms persisting for longer than four weeks suggest a non-infectious aetiology and merit further investigation (Thomas et al 2003).

History and causes

A detailed history is essential when assessing patients with chronic diarrhoea. It is useful to distinguish between the acute, usually selflimiting diarrhoeas, which are largely infective and chronic diarrhoea. It is also important to distinguish progressive persistent diarrhoea, which is usually a result of more serious medical conditions, from the fluctuating, erratic diarrhoea more characteristic of diverticular disease and irritable bowel syndrome (Travis et al 1991). A patients previous medical history will identify whether the diarrhoea is more likely to be of organic origin and also help direct the physician as to what investigations should be undertaken. Significant previous medical history includes (Thomas et al 2003): Family history of neoplastic, inflammatory bowel disease or coeliac disease in particular. Previous surgery Extensive resections of the ileum and right colon cause diarrhoea because of lack of absorptive surfaces and hence fat and carbohydrate malabsorption, decreased transit time, or malabsorption of bile acids. Shorter resections of the terminal ileum can lead to bile acid diarrhoea that typically occurs after NURSING STANDARD

meals and usually responds to fasting and cholestyramine. Chronic diarrhoea may also occur in up to 10 per cent of patients after colycystectomy through mechanisms that include increased gut transit and bile acid malabsorption. Previous pancreatic disease Diseases such as chronic pancreatitis and cystic fibrosis. Systemic disease Thyrotoxicosis and parathyroid disease, diabetes mellitus or systemic sclerosis may predispose patients to diarrhoea through various mechanisms, including endocrine effects, autonomic dysfunction and small bowel bacterial overgrowth or the use of concomitant drug therapy. Alcohol Diarrhoea is common in alcohol misuse. Mechanisms include rapid gut transit, decreased activity of intestinal disaccharides and decreased pancreatic function. Drugs Up to 4 per cent of people have diarrhoea because of the side effects of medications they are prescribed particularly magnesium containing products, antihypertensives, non-steroidal anti-inflammatories, theophyllines, antibiotics, antiarrhythmics and antineoplastic agents and food additives such as sorbitol and fructose. Diarrhoea is a relatively frequent adverse event accounting for about 7 per cent of all drug adverse effects. Certain new drugs are likely to induce diarrhoea because of their pharmacodynamic properties, for example, lipase inhibitors and cholinesterase inhibitors. Antimicrobials are responsible for 25 per cent of drug-induced diarrhoea ranging from benign to potentially life-threatening pseudomembranous colitis (Chassany et al 2000). Recent overseas travel or other potential sources of infectious gastrointestinal pathogens Entertoxigenic Escherichia coli is the most common cause of travellers diarrhoea. Other organisms that would be suspected are Shigella, Salmonella and Campylobacter. Giardiasis, amoebiasis and cryptosporidiosis are common particularly where water quality is not predictably high (Spiller 1994). Recent antibiotic therapy and Clostridium difficile infection Antibiotic-associated diarrhoeas are much more common than pseudomembranous colitis, occurring in about 20 per cent of patients taking broad-spectrum antibiotics such as ampicillin. The incidence is lower with amoxicillin, which is better absorbed, suggesting that it is the unabsorbed antibiotics that most disturb colonic flora (Spiller 1994). Although a small proportion of individuals carry C. difficile without illness, broad-spectrum antibiotic therapy is thought to allow the organism to multiply by suppressing other enteric organisms. The onset may be early in the treatment course or it may occur up to a month after cessation of antibiotics. Asymptomatic january 31 :: vol 21 no 21 :: 2007 49

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infection is common but about one third of patients develop high fever, severe abdominal pain, leucocytosis and profuse watery diarrhoea. Occasionally blood is found in the stool and toxic megacolon and perforation may occur. Diagnosis is made by detecting the C. difficile cytotoxin in the stool or by sigmoidoscopy, which shows the characteristic white patches due to focal disruption of the endothelium with an inflammatory exudate (Spiller 1994). Lactase deficiency Lactase, the enzyme responsible for hydrolysis of dietary lactase, is located in the microvilli of small intestinal enterocytes. Lactase deficiency may lead to lactose malabsorption and hence a mild osmotic diarrhoea (Thomas et al 2003). The common causes of chronic diarrhoea are summarised in Box 1. Classification into osmotic, secretory, motility and combined types (Table 1) helps when planning later investigation but diagnosis initially depends on excluding colonic causes and identifying common conditions. More than one mechanism may contribute to a patient having diarrhoea. Enteropathogens that cause diarrhoeas affect the physiology of the gut in different ways. By modifying the equilibrium of water and electrolytes, they induce different types of diarrhoea. Thus, osmotic diarrhoeas result from an excess of non-absorbable and osmotically active solutes in the lumen and secretory diarrhoea results when the secretory activity of the mucosa exceeds its absorption capacity. Diarrhoea of a predominantly osmotic basis is usually investigated by measurement of faecal carbohydrates; cessation of diarrhoea within 72 hours of fasting is a confirmatory feature of this pathological mechanism (Castro-Rodriguez et al 1997).

inflammatory bowel disease where persistent bleeding typically accompanies frequent bouts of diarrhoea with or without crampy abdominal pain (Sands and Daniel 1999). Abdominal pain may be related to a variety of different conditions. Crohns disease or ulcerative colitis may cause a diffuse, crampy and spasmodic pain associated with bloody diarrhoea. Understanding and eliciting the symptoms of abdominal pain will enable the clinician to conduct an examination to locate the site of discomfort as well as its severity and arrive at the correct diagnosis (Sands and Daniel 1999). The history, no matter how accurate, is never complete without an adequate physical examination. A smooth tongue may reflect vitamin B12 or iron deficiency, while spontaneous bruising may be a feature of malabsorption arising from a lack of vitamin K. The abdomen will be BOX 1 Causes of chronic diarrhoea
Colonic Colonic neoplasia Ulcerative colitis and Crohns disease Microscopic colitis Small bowel Coeliac disease Crohns disease Other small bowel enteropathies, for example, Whipples disease Bile acid malabsorption Disaccharidase deficiency Small bowel bacterial overgrowth Mesenteric ischaemia Radiation enteritis Lymphoma Giardiasis Pancreatic Chronic pancreatitis Pancreatic carcinoma Cystic fibrosis Endocrine Hyperthyroidism Diabetes Hypoparathyroidism Addisons disease Hormone-secreting tumours Other causes Factitious diarrhoea, for example, caused by laxative misuse Surgical causes, for example, small bowel resection or intestinal fistulae Drugs Alcohol Autonomic neuropathy
(Thomas et al 2003)

Initial assessment
At the initial assessment the patient will be asked questions about the history of the illness and these will focus on several key symptoms. These include a change in bowel habit that is, onset of diarrhoea, frequency of stool and consistency whether the patient has noticed any rectal bleeding, experienced abdominal pain or noticed any abdominal swellings. In obtaining the history of passing blood per rectum it is important to establish both the quantity and quality of bleeding. While the patient may fear that rectal bleeding is associated with colorectal neoplasm, bleeding may occur for a variety of benign reasons, for example, 50 january 31 :: vol 21 no 21 :: 2007

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palpated for abdominal masses. These can be felt in association with Crohns disease when a painful mass of matted ileum may be palpable in the right iliac fossa. However, most masses that are palpable in the abdomen are faecal. The sigmoid colon can often be felt in the left iliac fossa and may be tender in both diverticular disease and irritable bowel syndrome. Evidence of hepatic enlargement will also be looked for but this is a very late feature of most neoplasms (Spiller 1994). Blood tests are a routine part of initial assessment. An abnormal erythrocyte sedimentation rate (ESR), anaemia or low albumin have a high specificity for the presence of organic disease. The presence of iron deficiency anaemia is a sensitive indicator of small bowel enteropathy, particularly of coeliac disease. A basic screen for evidence of malabsorption should include full blood count, urea and electrolytes, liver function tests, vitamin B12, folate, calcium, ferritin, ESR and C-reactive protein together with thyroid function test (Thomas et al 2003). The patient should also be weighed because malabsorption and inflammatory bowel disease often cause weight loss (Spiller 1994). Given the difficulty in assessing diarrhoea based on history alone, inspection of stool may be helpful, especially while the patient is in hospital. Hospital trusts will have their own documentation, which may include an assessment tool such as the Kings Stool Chart (Whelan et al 2004) (Figure 1). Stool cultures should be obtained for persistent diarrhoea, which allow for the ready detection of Salmonella, Campylobacter and Shigella (Spiller 1994). Investigations for other infectious organisms are considered, particularly if there is a history of travel to highrisk areas such as Egypt or India (Thomas et al 2003). Tests may be divided into specific and non-specific. There are a few specific stool tests that are of value, for example, pancreatic enzymes for faecal elastase (Thomas et al 2003).

However, where it is suspected that patients may have small bowel malabsorption, despite negative blood tests, endoscopic duodenal biopsies (via an oesophogastroduodenoscopy) should be to exclude other rarer forms of small bowel disease (Thomas et al 2003). Non-invasive tests for pancreatic insufficiency currently depend on the presence of at least moderate exocrine function before they achieve adequate sensitivity (Thomas et al 2003). The optimal investigation for small bowel bacterial overgrowth remains unclear, because the sensitivity of hydrogen breath tests is only 75 per cent (Thomas et al 2003). In most patients with chronic diarrhoea some form of endoscopic investigation will be necessary. Unprepared rigid sigmoidoscopy has long been used in the outpatient setting to assess the rectum and stool quickly. This remains an appropriate examination in younger patients who, on clinical grounds, are believed to have a functional bowel disorder. However, for patients with chronic diarrhoea, flexible sigmoidoscopy is the preferred examination, allowing assessment of the sigmoid and descending colon and sampling of the colonic mucosa for histological examination (Thomas et al 2003). Although colonoscopy can also be indicated, inpatients are more likely to be referred for a flexible sigmoidoscopy because this test is quicker to organise and is safer to perform on a sick patient.

Time out 2
Try to organise a visit to your endoscopy department to observe an inpatient undergoing a flexible sigmoidoscopy. Pay particular attention to the pre, peri and post-examination nursing care that patients receive.

Time out 1
Find out the normal values for the blood tests described. Check your answers with those listed in Box 2.

TABLE 1 Mechanisms of diarrhoea

Osmotic Hypolactasia Secretory Toxins, for example, Escherichia coli, Staphylococcus aureus Peptides Motility Irritable bowel syndrome Combined Ulcerative colitis

Investigations
Most chronic diarrhoea is caused by colonic disease and in the absence of clinical evidence for malabsorption, initial investigations should focus on the lower gastrointestinal tract. Patients with malabsorption represent a small proportion of those who present with chronic diarrhoea. Serological blood testing for coeliac disease will determine those patients who have the disease without invasive investigation. NURSING STANDARD
Drugs, for example, lactulose and magnesium salts Malabsorption
(Travis et al 1991)

Drugs, for example, senna

Coeliac disease

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Nursing care
For a patient with chronic diarrhoea the examination and investigations undertaken can cause extreme anxiety. Because illness disrupts normal equilibrium and activities of daily living, a patients ability to think critically and make decisions may be decreased. Nurses should therefore focus on the emotional wellbeing of the patient as well as his or her physical health. An understanding of basic human needs should equip nurses to provide educational information, for example, about inpatient flexible sigmoidoscopy (Box 3) and emotional support for patients undergoing investigation (Sands and Daniel 1999). It may not be possible to establish a definitive diagnosis for some patients despite extensive and exhaustive investigations. Some patients may be FIGURE 1 Kings Stool Chart
Less than 100g Hard and formed Hard or firm texture Retains a definite shape Like a banana a cigar or marbles Soft and formed Retains general shape Like peanut butter a) b)

found to have self-limiting idiopathic diarrhoea (infective) or undiagnosed factitious diarrhoea, for example, laxative misuse. Since, in the majority of these patients the overall prognosis is good, further investigation is not warranted and symptomatic treatment should be instigated (Thomas et al 2003).

Treatment of diarrhoea
Bacterial diarrhoea Treatment with antibiotics is recommended only in patients who are severely affected and show signs of systemic involvement, including high fever and prostration. It is not uncommon for Salmonella to become resistant to commonly used antimicrobial agents such as amoxicillin. Campylobacter is sensitive to erythromycin and tetracycline, while ciprofloxacin is effective against both organisms (Spiller 1994). Antibiotic-associated diarrhoea For most patients symptoms will cease rapidly on discontinuation of the antibiotic. However, if

Between 100-200g c)

More than 200g

d)

e)

f)

Loose and unformed Lacks any shape of its own May spread easily Like porridge or thick milkshake

g)

h)

i)

Liquid Runny Like water

j)

k)

l)

0cm Scale
The chart and instructions for use can be downloaded free from www.kcl.ac.uk/stoolchart 2001 Kings College London

10cm

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diarrhoea persists, it is important to exclude pseudomembranous colitis by performing a sigmoidoscopy and sending a stool for cytotoxin assay. Otherwise, the prognosis is excellent and apart from ensuring adequate hydration, no specific treatment is indicated. Using antidiarrhoeal agents may delay the return of bacterial flora to normal and they are to be discouraged where possible (Spiller 1994). Inflammatory bowel disease Both ulcerative colitis and Crohns disease are characterised by frequent remission and relapses. Treatment of an attack depends on the severity of symptoms and amount of bowel involved (Spiller 1994). Oral corticosteroids such as prednisolone or intravenous hydrocortisone for severe disease and 5-aminosalicylates are the mainstay of treatment. Immunosuppressant drugs have become established second-line agents for resistant disease while nutritional therapy also has a role in treatment for some patients (Metcalf 2002). Bowel cancer Colon cancer usually requires segmental surgical resection of the colon. Adequate margins, with the removal of all gross disease as well as adequate lymph node removal, are primary in the treatment of colon cancer. Segmental colectomy, typically in the form of right hemicolectomy, left hemicolectomy or sigmoid resection, is the primary procedure performed for the majority of cancers. Rectal cancer is much more complex. Currently, tumours at least 2cm from the dentate line an area just inside the anal canal which represents an important landmark between two distinct origins of venous and lymphatic drainage, nerve supply and epithelial lining can be managed by sphincter sparing techniques, but contraindications include poor sphincter function, patient preference, co-morbidity and technical ability (Weiss and Johnson 1999). These patients will therefore have formation of a permanent colostomy. Coeliac disease Once a diagnosis has been made the patient should be referred to a dietician for advice about a gluten-free diet. Iron and folate stores should be replenished with ferrous sulphate and folic acid (Spiller 1994). Pancreatic insufficiency Pancreatic enzyme supplements and, when necessary, insulin therapy can control many of the symptoms of pancreatic insufficiency. Abstinence from alcohol is essential for patients with alcoholic pancreatitis (Spiller 1994).

Nursing care
Fluid replacement In the normal human gut, 99 per cent of water and electrolytes in the form of food or gastrointestinal secretions are absorbed by gut mucosa. An individuals water requirement is 25-40ml/kg a day and this is achieved through the ingestion of drinks (approximately 1,200ml), solid food (approximately 1,000ml) and from water oxidation (approximately 300ml). The reabsorption of water from the gastrointestinal tract is usually so effective that, of the six litres of gastrointestinal secretions and two litres of oral intake per day, only 150ml are excreted in the faeces. This flux is closely linked to nutrition, as salt and water absorption in the jejunum is linked to carbohydrate absorption and in the large bowel to the absorption of short chain fatty acids derived from the bacterial fermentation of soluble fibre (Macafee et al 2005). In gastrointestinal disease large amounts of fluid and electrolytes may be pooled (ileus) or lost from the gastrointestinal tract. Diarrhoea, fistulae or short bowel syndrome may cause rapid and life-threatening losses, or the chronic depletion of water, salt, potassium, magnesium and trace elements. A knowledge of the electrolyte content of various parts of the gastrointestinal tract is an important guide to appropriate replacement (Macafee et al 2005). Most patients with gastrointestinal fluid losses are satisfactorily managed by conservative means using drugs, for example, loperamide hydrochloride, small frequent meals and oral BOX 2 Normal values for blood tests
White cell count Women: 3.90-10.10g/l Men: 3.49-9.21g/l Red blood cell count Women: 3.86-4.94 x 1012 Men: 4.28-5.49 x 1012 Haemoglobin Female: 12.0-14.7g/dl Male: 13.1-16.5g/dl Albumin 39-50g/l C-reactive protein 0-10mg/l Platelet count 150-400 x 109/l Erythrocyte sedimentation rate Normal value is calculated at about half the patients age

Time out 3
Before reading on, spend some time considering the physical and emotional nursing care that an inpatient with chronic diarrhoea may require. NURSING STANDARD

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rehydration solution, and mineral supplements (Macafee et al 2005). The extent of dehydration will dictate whether a patient can be managed at home or will need to be admitted to hospital. For example, unrelenting diarrhoea experienced during an acute exacerbation of ulcerative colitis, causing a loss of more than 10 per cent of body weight, with decreased skin tone or sunken eyes and a moribund state is indicative of severe dehydration and requires intravenous rehydration and monitoring of fluid balance (Table 2). It is also BOX 3 Flexible sigmoidoscopy: inpatient information sheet
What is a flexible sigmoidoscopy? Flexible sigmoidoscopy is an investigation that allows us to look directly at part of the colon. A flexible tube is passed into your bottom and around the lower part of your colon. Through this tube we will be able to look for any abnormalities that may be present. If necessary, small tissue samples (biopsies) can be taken during the examination for laboratory analysis. Preparation You may eat and drink up to having the test done but we suggest that you limit this to a snack. If you are taking blood thinning tablets (warfarin) do not stop taking these but please inform the doctor at the time of the investigation. To allow a clear view you will be given a small enema to clear the lower part of the bowel of waste material. What will happen? When you arrive the nurse will explain the procedure and answer any questions you may have. You will be asked to sign a consent form, giving us your permission to have the procedure performed. In the examination room you will be made comfortable on your left hand side with your knees tucked up. Throughout the procedure you may experience some abdominal cramping and pressure from air that is introduced into your bowel. This is normal. You may also get the sensation of wanting to open your bowels, but because the bowel is empty there is no risk of this happening. Afterwards After the procedure you are encouraged to rest for a short while. For some time afterwards your tummy may feel bloated. This is caused by the air that was introduced into the bowel during the procedure. The discomfort should settle in a few hours but you may find walking around, massaging your tummy and passing wind helps. You may also find that you experience a small amount of bleeding from your bottom when you first have your bowels open following the investigation. This should soon settle. When will I get the results of the test? The doctor will talk to you at the end of the procedure explaining what has been found. Are there any risks? Very rarely, a small hole in the colon wall can develop (perforation). If this occurs, observation in hospital is necessary and surgery may be required to seal the perforation. If you have any further questions please do not hesitate to contact the department. Further copies of this information sheet are available from the endoscopy unit.
(Reproduced with permission of West Hertfordshire Hospitals NHS Trust)

important to monitor the patient for signs or symptoms of electrolyte imbalance, such as muscle weakness and cramps (hypokalaemia) and tachycardia and pyrexia (hypernatraemia). Temperature, pulse and blood pressure should be monitored closely for signs of colonic dilation or perforation together with daily abdominal X-ray (Joels 1999). Nutrition During an exacerbation of ulcerative colitis or Crohns disease, patients can experience rapid and marked weight loss and malnutrition. Nutritional assessment by the nurse or dietician is essential to the patients management, taking account of body mass, weight loss, muscle strength, stamina and serum albumin levels. Dietary improvements should first be achieved within patients usual everyday foods, trying to ensure that they have three meals per day, supplemented with nutritious snacks in between where possible (Joels 1999). Patients should be advised to reduce or avoid fresh fruit and vegetables because although they can satiate quickly they contain relatively little nutritional content. Because patients often have a poor appetite or feel that eating will exacerbate their symptoms, they need to be encouraged to eat little and often with tempting and appetising food. When inflammatory bowel disease is active, patients need to ensure that they have a diet containing adequate or increased protein and calories (Cox 1995). If patients are unable to eat, supplements can be prescribed. Only where there is severe malabsorption, or where the bowel needs rest, should intravenous nutrition be considered. The roles of elemental or polymeric diet orally or nasogastrically are still being evaluated but they have been found to produce a similar effect to steroids when given to patients with Crohns disease. They can be unpleasant, expensive and result in early relapse (Joels 1999). Skin care With repeated bouts of diarrhoea good hygiene and skin care are important. Nurses can assist patients by providing sound practical advice. Wiping around the anus with dry paper does not always completely remove faecal residue from the perianal area and any stool remaining can soon make the skin sore. Some patients who are not aware of soiling may be offended by the suggestion that they may need to improve their personal hygiene (Norton 2006) and so it is important to approach the topic in a sensitive and tactful way. After diarrhoea, wet wiping or cleansing is usually more effective. Some patients may be unaware of skin tags, common with Crohns disease, and these will require extra care. A bidet is ideal to cleanse the area thoroughly but moist toilet tissue wipes can also be effective provided that they do not contain alcohol or perfumes, because these may burn or irritate skin (Norton 2006). NURSING STANDARD

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Perineal faecal collection pouches are only suitable for bed-bound and critically ill patients, but can be useful to protect the perianal skin in highly selected patients, for example, those in intensive care or with profuse uncontrolled diarrhoea. The pouches can be difficult to apply, usually taking at least two people and a great deal of care. If good adhesion is achieved, each drainable pouch may stay in place for two to three days, thus providing skin protection and avoiding repeated bed changes (Norton and Kamm 1999). There is a small but growing body of evidence that skin cleaning regimens and the products used can make a difference to perianal skin integrity. Using soap and water is generally thought to raise the pH of skin, making it more likely to become dry and flaky. Most modern products, particularly those that make complete removal of faeces easier following an episode of faecal incontinence, may improve skin health and save time and money. It is recognised, however, that more research is needed on the subject (Norton 2006). Following effective cleansing and drying of the perianal area patients should be encouraged to use a barrier cream to protect the skin from further excoriation. Some products perform better than others in treating soreness, for example, Sudocrem has been found to be more effective than zinc and castor oil (Norton and Kamm 1999). Many patients have misconceptions about how to manage sore skin, for example, bathing in disinfectant or salt baths and should be given detailed guidance about the correct way to manage it. Advice to prevent soreness or manage mild problems is provided in Box 4.

face people afterwards (Joels 1999). This is compounded in hospital where many of the facilities are public and patients sometimes have BOX 4 Advice on anal skin care for patients
After a bowel action always wipe gently with soft toilet paper, or ideally moist toilet paper. Whenever possible, wash around the anus after a bowel action. A bidet is ideal. If this is not possible you may be able to use a shower attachment with your bottom over the edge of the bath or use a soft disposable cloth with warm water. Some people find that a small plant spray or watering jug filled with warm water makes washing easier on the toilet or over the edge of the bath. Do not be tempted to use disinfectants or antiseptics in the washing water as these can sting, and many people are sensitive to the chemicals in them. Just plain water is best. Avoid using products with a strong perfume such as scented soap, talcum powder or deodorants on your bottom. Choose a non-scented soap. Many baby wipes contain alcohol and are best avoided. When drying the area be gentle. Pat gently with soft toilet paper or a soft towel. Do not rub. Treat the whole area as you would a newborn babys skin. If you are very sore, a hairdryer on a low setting may be most comfortable. Wear cotton underwear to allow the skin to breath. Avoid tight jeans, G-strings and other clothes that might rub in the area. Women should usually avoid tights and use stockings or crotchless tights instead. Use non-biological washing powder for underwear and towels. Avoid using any creams or lotions in the area, unless advised to do so. A few people who are prone to sore skin find that regular use of cream helps to prevent this. Your doctor or nurse may suggest using a barrier wipe which forms a protective film over the skin, especially if you have diarrhoea and are opening your bowels very frequently (available on prescription). If you need to wear a pad because of faecal incontinence, try to make sure that no plastic comes into contact with your skin and that you use a pad with a soft surface. Whenever possible, unless you have been advised not to for other reasons, eat a healthy, balanced diet, drink plenty and take as much exercise as you can. Some people find that certain food or drink makes them more prone to soreness, especially citrus fruit such as oranges. It may be worth cutting these out on a trial basis and more permanently if this helps.
(Norton and Kamm 1999)

Psychological effects
As a culture we tend not to discuss our bowels, regarding them as fulfilling a function conducted in the privacy of the bathroom. For patients with chronic diarrhoea this changes and bowel function becomes more public. They have to endure unpleasant and undignified investigations and use toilets in public or at work, often with explosive and noisy diarrhoea and then have to TABLE 2 Assessment of dehydration
Severity Mild Moderate Severe
(Spiller 1994)

Pulse (beats/min) <100 >100 >100

Systolic blood pressure (mmHg) >100 >100 <100

Urine output Plentiful, dilute Reduced, concentrated Minimal and very concentrated

Behaviour Active, up and about Lethargic Apathetic and lies down

Skin turgor Normal Normal Decreased, sunken eyes

Weight loss <5 per cent 5-10 per cent >10 per cent

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Time out 4
Imagine that a patient complaining of chronic diarrhoea has been admitted to your ward. Write a nursing care plan taking into account what has been discussed regarding a patients physical and psychological needs.

to rely on commodes with only flimsy curtains to provide privacy. It is therefore essential for nurses to be sensitive to patients needs by making them aware of the location of the nearest toilets or if possible providing a bed close to the bathroom or a side room with ensuite facilities. Casati et al (2000) identified eight categories of concerns patients have about living and coping with inflammatory bowel disease. Patients struggle to cope with the sense of loss of control and feeling dirty. Symptoms such as diarrhoea, urgency and faecal incontinence can dominate a persons life, making accessibility to a toilet a priority. Faecal incontinence in particular is a problem that can have a major effect on the quality of life of those affected. Deutekom et al (2005) demonstrated that the more severe the faecal incontinence, the greater the effect it had on everyday activities and the more pain, discomfort, anxiety and depression it caused. Social stigma caused by the unpredictability and embarrassing nature of the symptoms can affect people psychologically. Patients can feel that they are the only one to have the problem, which can make them feel isolated and alone. Nurses can help by encouraging patients to share their feelings and concerns with those closest to them (Metcalf 2002).

Conclusion
Chronic diarrhoea can be a distressing symptom. This article provides an overview of the care of a patient with this condition. You should now understand the importance of patients being accurately assessed and asked questions to identify any significant medical history, both of which can guide the clinician as to the diagnostic tests required. The most common causes of diarrhoea have been explained together with the appropriate treatments. The management of a patient has been outlined, focusing on the nursing care with relation to fluid replacement, nutrition and skin care. Finally, the psychological impact of having diarrhoea has been discussed outlining nurses contribution in helping patients to cope with what can be a distressing symptom NS

Time out 5
Now that you have completed this article you might like to write a practice profile. Guidelines to help you are on page 60.

References
Casati J, Toner BB, de Rooy EC, Drossman DA, Maunder RG (2000) Concerns of patients with inflammatory bowel disease: a review of emerging themes. Digestive Diseases and Sciences. 45, 1, 26-31. Castro-Rodriguez JA, Salazar-Lindo E, Leon-Barua R (1997) Differentiation of osmotic and secretory diarrhoea by stool carbohydrate and osmolar gap measurements. Archives of Disease in Childhood. 77, 3, 201-205. Chassany O, Michaux A, Bergmann JF (2000) Drug induced diarrhoea. Drug Safety. 22, 1, 53-72. Cox J (1995) Inflammatory bowel disease: implications for the medical-surgical nurse. Medsurg Nursing. 4, 6, 427-437. Deutekom M, Terra MP, Dobben AC et al (2005) Impact of faecal incontinence severity on health domains. Colorectal Disease. 7, 3, 263-269. Joels J (1999) Inflammatory bowel disease: the nursing implications. In Porrett T, Daniel N (Eds) Essential Coloproctology for Nurses. Whurr, London, 119-145. Macafee DA, Allison SP, Lobo DN (2005) Some interactions between gastrointestinal function and fluid and electrolyte homeostasis. Current Opinion in Clinical Nutrition and Metabolic Care. 8, 2, 197-203. Metcalf C (2002) Crohns disease: an overview. Nursing Standard. 16, 31, 45-52. Norton C (2006) Perianal skin care. Gastrointestinal Nursing. 4, 1, 18-25. Norton C, Kamm M (1999) Bowel Control: Information and Practical Advice. Beaconsfield Publishers, Beaconsfield. Sands LR, Daniel N (1999) Investigation and examination of a patient with colorectal problems. In Porrett T, Daniel N (Eds) Essential Coloproctology for Nurses. Whurr, London, 52-75. Spiller R (1994) Diarrhoea and Constipation. Science Press, London. Thomas PD, Forbes A, Green J et al (2003) Guidelines for the investigation of chronic diarrhoea. Second edition. Gut. 52, Suppl 5, v1-15. Travis SPL, Taylor RH, Musiewicz J (1991) Gastroenterology. Blackwell Science, Oxford. Weiss EG, Johnson TE (1999) Colorectal cancer. In Porrett T, Daniel N (Eds) Essential Coloproctology for Nurses. Whurr, London, 97-118. Whelan K, Judd PA, Taylor MA (2004) Assessment of fecal output in patients receiving enteral tube feeding: validation of a novel chart. European Journal of Clinical Nutrition. 58, 7, 1030-1037.

56 january 31 :: vol 21 no 21 :: 2007

NURSING STANDARD