DIARRHEA2.1. DefinitionDiarrhea is a bowel movement (defecation) with fecal liquid or semi-liquid, thus the watercontent in the stools more than normal which is 100-200 ml / once defecation (Hendarwanto,1999).According to WHO (1980) are diarrhea or loose stools liquid more than three times a day.Acute diarrhea is diarrhea that initially abrupt and short-lived in a few hours or a few days.CauseAcute diarrhea due to infection (gastroenteritis) can be caused by:1. Bacteria: Escherichia coli, Salmonella typhi, Salmonella typhi the A / B / C, dysentriaeShigella, Shigella flexneri, Vivrio cholera, Vibrio eltor, parahemolyticus Vibrio, Clostridiumperfrigens, Campilobacter (Helicobacter) jejuni, Staphylococcus sp, Streptococcus sp,Yersinia intestinalis, Coccidiosis.2. Parasites: Protozoa (hystolitica Entamoeba, Giardia lamblia, Trichomonas hominis,Isospora sp) and worms (A. lumbricodes, A. duodenale, N. americanus, T. trichiura, O.velmicularis, S. stercoralis, T. saginata and T. solium )3. Virus: Rotavirus, Adenovirus and Norwalk.Research at Friendship Hospital, East Jakarta (1993-1994) in 123 adult patients who weretreated in the wards of acute diarrhea RESULTS isolation causes of acute diarrhea are mostE. coli (38%), V. cholerae Ogawa (18%) and Aeromonas sp. 14%).PathophysiologyA total of approximately 9-10 liters of fluid enters the digestive tract every day from outside(dietary intake) and from within the body itself (the secretion of gastric juices, bile and soon). Most of the amount tersebt diresorbsi in the remaining small intestine and colon into1500 ml. Some 90% of the fluid so that the colon will diresorbsi left some 150-250 ml offluid makes up the stool.Physiological factors that cause diarrhea are closely related to each other. For example, thefluid in the lumen of the intestine will cause terangsangnya mengkat mechanical bowel due tothe increased volume that increased intestinal motility. Conversely, if the time constant offood in the intestines too quickly will cause interference when touching food with intestinalmucosa so that the absorption of electrolytes, water and other substances impaired. Chart
pathophysiology of diarrhea and compensation mechanism with a simple salt sugar solutioncan be seen in the following figure:Mechanism of Cyclic AMP enterotoxinCompensation and Ways with Sugar Salt SolutionPathogenesisTwo things to note on the general state of acute diarrhea due to infection is a causal factor(agent) and host factors (host). Factor host is the bodys ability to defend itself against anorganism that can cause acute diarrhea consisting faktordaya immune factors or internalenvironment such as the acidity of gastric intestinal tract, intestinal motility and also includesthe normal intestinal flora.
Decrease gastric acidity shigella infection has been shown to cause more severe invasiveinfections and causes higher sensitivity to infection V.cholera. Hipomotilitas intestine inintestinal infections increase the time of diarrhea and symptoms of the disease and reduce thespeed of elimination of sources of disease agent. The role of acquired immunity as evidencedby the higher frequency of giardiasis in those who lack Ig-A. Another experiment proved thatwhen the intestinal lumen stimulated a toxoid antibody secretion will occur repeatedly.Experiments on animals showed reduced progression S. typhi murium in normal intestinalmicroflora.Causal factors that affect pathogenicity include penetration power that can damage cellmembranes, the ability to produce a toxin that affects the secretion of intestinal fluids andbacteria adhesion to the intestinal lumen. Germs can form colonies that can induce diarrhea.Based on the ability of the invasion of the bacteria penetrate the intestinal mucosa, bacteriadistinguished by:1. Non-invasive bacteria (enterotoxigenic)For example, V. cholera / eltor, enterotoxigenic E. coli (ETEC) and C. perfringens nomucosal damage, remove toxins bound to the intestinal mucosa after 15-30 minutes producedthat activates chloride anion secretion from the cell into the intestinal lumen followed bywater, bokarbonat ions, sodium and potassium so that the body will lack of fluids andelectrolytes are out with feces.2. Bacteria enterovasifFor example enteroinvasive E. Coli (EIEC), Salmonella, Shigella, Yersinia, and C.perfringens type CV. cholera / eltor, enterotoxigenic E. coli and C. perfringens. In this case,diarrhea caused by necrosis and ulceration of the intestinal wall. The nature of secretorydiarrhea exudative., Can mixed mucus and blood. However, infection by germs can alsomanifest as a koleriformis diarrhea.Clinical ManifestationsAcute diarrhea due to infection may be accompanied by vomiting, fever, tenesmus,hematoschezia, and abdominal pain or cramps. The most fatal consequence of diarrhea thatlasts long without adequate rehydration is the cause of death due to dehydration orhypovolemic shock in the form of biochemical disorder continued metabolic acidosis.Seseoran a lack of fluids will feel thirst, weight loss, sunken eyes, dry tongue, cheek bonesappear more prominent, decreased skin turgor, and the voice becomes hoarse. Complaintsand symptoms are caused by the depletion of water isotonic.
Since the loss of bicarbonate (HCO3), the comparison with carbonic acid is reduced resultingin decreased blood pH stimulates the respiratory center so that the frequency increases anddeeper breathing (Kussmaul breathing)Cardiovascular problems at a later stage can be severe hypovolemic shock with signs of rapidpulse (> 120 x / min), blood pressure decreased to immeasurable. The patient becamerestless, pale face, cold akral and sometimes cyanosis. Due to a lack of potassium in acutediarrhea also can occur cardiac arrhythmias.Drop in blood pressure will cause decreased renal perfusion to arise oliguria / anuria. If thecondition is not immediately diatsi complications will arise acute renal tubular necrosis,which means a state of acute renal failure.Principles of ManagementManagement of acute diarrhea due to infection in adults consists of:1. Rehydration therapy as a top priority.2. Tata directed the work to identify the cause of the infection.3. Provide symptomatic treatment4. Provide definitive therapy.1. Rehydration therapy as a top priority.There are 4 things to look for in order to deliver fast and accurate rehydration, namely:1) Type of fluid to be used.At this time Ringer lactate fluid is a liquid because it provides more choice in the marketeven though the amount of potassium low potassium levels when compared with feces. If RLis not available to diberiakn isotonic saline (0.9%), which should be supplemented with 1ampoule Nabik 50 ml of 7.5% on every single liter of isotonic NaCl. In the initial state ofmild acute diarrhea may be given fluids to prevent dehydration oralit with all itsconsequences.2) The amount of fluid that was about to be given.In principle, the amount of replacement fluids wish shall be proportionate to the amount offluid out of the body. The amount of fluid loss from the body can be calculated in a way /formula:- Measure BJ PlasmaFluid requirements calculated by the formula:BJ Plasma - 1.025
---------------------- X BB x 4 ml 0.001- Methods PierceBased on the clinical situation, namely:* Mild diarrhea, fluid needs = 5% x kg BW* Moderate diarrhea, fluid requirement = 8% x kg BW* Mild diarrhea, fluid requirement = 10% x kg BW- Methods DaldiyonoBased on the clinical scoring as follows:* Thirst / vomiting = 1* 60-90 mmHg systolic BP = 1* Systolic BP <60 mmHg = 2* Frequency pulse> 120 x / min = 1* Awareness of apathy = 1* Awareness somnolence, sopor or coma = 2* Frequency of breathing> 30 times / min = 1* Facies Cholerica = 2* Vox Cholerica = 2* Decreased skin turgor = 1* Washer womens hand = 1* Extremities cold = 1* Cyanosis = 2* Age 50-60 years = 1* Age> 60 years = 2Fluid needs = Score-------- X 10% x kg x 1 ltr 15th3) The entrance or means of fluidRoute of administration of fluid in adults include oral and intravenous administration. Oralisolution with a composition ranging from 29 g of glucose, 3.5 g NaCl, 2.5 g and 1.5 g KClNaBik stiap liter is given orally in mild diarrhea as well as the first attempt after initial
rehydration to maintain hydration.4) Schedule of fluidInitial rehydration schedule is calculated by BJ plasma or scoring system administered within2 hours in order to achieve optimal rehydration as soon as possible. Fluid schedule for thesecond phase of the clock to-3 based on the loss of fluid 2 hours before the initial phase.Thus, rehydration is expected to complete by the end of the third hour.2. Tata directed the work to identify the cause of the infection.To determine the cause of the infection is usually associated with the clinical condition ofdiarrhea but the exact cause can be determined through examination of stool cultureexamination of urine accompanied by a full and complete stool.Disorders of fluid balance, electrolyte and acid-base clarified through a complete bloodcount, blood gas analysis, electrolytes, urea, creatinine and plasma BJ.When there is high fever and suspected systemic infection bile culture examination, Widal,malarial preparations and serological Helicobacter jejuni is highly recommended. Specialexaminations such as serology amoeba, fungi and Rotavirus usually follows after seeing theresults of the filter.Clinically acute diarrhea due to infection classified as follows:1) Koleriform, diarrhea with fecal matter consists primarily of liquids only.2) Disentriform, diarrhea with mucus mixed with feces and sometimes blood.Investigations that have been mentioned above can be directed to appropriate manifestationklnis diarrhea.3. Provide symptomatic treatmentSymptomatic therapy should really be considered losses and profits. Antimotilitas intestine asloperamide would worsen diarrhea caused by entero-invasive bacteria because the bacteriaprolong the contact time with the intestinal epithelium should be rapidly eliminated.4. Provide definitive therapy.Causal therapy can be given to infection:1) Cholera-eltor: tetracyclines or cotrimoxazole or chloramphenicol.2) V. parahaemolyticus,3) E. coli, do not need a specific therapy
4) C. perfringens, specific5) A. aureus: Chloramphenicol6) Salmonellosis: ampicillin or cotrimoxazole or quinolones such as Ciprofloxacin group7) Shigellosis: Ampicillin or Chloramphenicol8) Helicobacter: Erythromycin9) Amebiasis: Metronidazole or Trinidazol or Secnidazol10) giardiasis: quinacrine or Chloroquineitiform or Metronidazole11) Balantidiasis: Tetracycline12) Candidiasis: Mycostatin13) Virus: symptomatic and supportiveNURSING CONCEPTSHistory of Nursing and Physical Assessment:Based on the classification Doenges et al. (2000) have studied the history of nursing is:2. Activity / rest:Symptoms:- Kelelelahan, weakness or general malaise- Insomnia, did not sleep all night because of diarrhea- Restlessness and anxiety3. Circulation:Signs:- Tachycardia (reapon to dehydration, fever, inflammation and pain)- Hypotension- Skin / mucous membranes: ugly turgor, dry, fissured tongue4. Ego integrity:Symptoms:- Anxiety, fear, emotional upset, feeling helplessSigns:- Response rejected, narrowed attention, depression5. Elimination:
Symptoms:- Texture liquid feces, mucus, accompanied by blood, rancid odor / smell.- Tenesmus, pain / abdominal crampsSigns:- Bowel decreased or increased- Oliguria / anuria6. Food and fluids:Symptoms:- Haus- Anorexia- Nausea / vomiting- Weight loss- Intolerance diet / sensitive to fresh fruit, vegetables, dairy products, fatty foodsSigns:- Decrease in sub cutaneous fat / muscle mass- Weakness muscle tone, poor skin turgor- Pale mucous membranes, wounds, inflammation of the oral cavity7. Hygiene:Signs:- The inability to maintain self-care- The smell8. Pain and Comfort:Symptoms:- Pain / tenderness in the right lower quadrant, may disappear with defecationSigns:- Abdominal tenderness, distention.9. Safety:Signs:- Increased temperature in acute infection,- Decrease in level of consciousness, anxiety
- Skin lesions around the anus10. SexualitySymptoms:- Ability to decline, decreased libido11. Social InteractionSymptoms:- Decreased social activities12. Guidance / learning:Symptoms:- History of family members with diarrhea- The process of transmission of faecal-oral infections- Personal higyene- RehydrationDiagnostic TestsView medical concepts.Nursing Diagnosis13. Fluid volume deficiency b / d lost in faeces and vomit excessively and limited intake(nausea).14. Changes in nutrition less than body requirements b / d impaired nutrient absorption andincreased intestinal peristalsis.15. Pain (acute) b / d hiperperistaltik, irritation perirektal fissure.16. Anxiety b / d change in health status, socio-economic status changes, changes in the roleand function of the interaction patterns.17. Lack of knowledge about the condition, prognosis and therapy needs b / d exposurelimited information, false or interpretation of information and cognitive limitations.INTERVENTION
Lack of fluid volume Dx.1 b / d lost in faeces and vomit excessively and limited intake(nausea)Intervention and Rational:18. Give parenteral fluid rehydration program in accordance with- In an effort rehydration to replace fluids out with feces.19. Monitor intake and output.- Provide status information to establish fluid balance fluid needs replacement.20. Assess vital signs, signs / symptoms of dehydration and laboratory- Assess hydration status, electrolyte and acid-base balance.21. Collaborative implementation of definitive therapy.- Provision of drugs is causally important as causes of diarrhea known.Dx.2 Changes in nutrition less than body requirements b / d impaired nutrient absorption andincreased intestinal peristalsis.Intervention and Rational:1. Maintain bed rest and activity restriction during the acute phase.- Lowering metabolic needs.2. Maintain NPO status (fasting) during the acute phase / medical provision and immediatelybegin feeding by mouth once conditions allow clients- Restricted diet by mouth may be determined during the acute phase to reduce peristalsisresulting in nutritional deficiencies. Important feeding as soon as possible after the clientsclinical condition allows.3. Collaboration of roborantia such as vitamin B 12 and folic acid.- Diarrhea causes ileus dysfunction that results in malabsorption of vitamin B 12;reimbursement sum required for bone marrow depression, increase RBC production.- Folic acid deficiency can occur if diarrhea persists due to malabsorption.4. Collaboration parenteral nutrition as indicated.- Resting gastrointestinal work and solve / prevent further malnutrition.Dx.3 pain (acute) b / d hiperperistaltik, irritation perirektal fissure.Intervention and Rational:1. Set a comfortable position for the client, for example, with the knee flexed.- Lowering the voltage abdomen.2. Perform transfer activity to provide a sense of comfort such as back massage and warm
compresses abdomen- Increase relaxation, shifting the focus of attention kliendan improve coping abilities.3. Clean the area with mild soap and anorectal airsetelah defecation and give skin care- Protects skin from stool acidity, preventing irritation.4. Collaboration or anticholinergic drugs and analgesics as indicated- Analgesic and anti-pain as an anticholinergic agent to lower the GI tract spasm can besupplied according to clinical indication.5. Assess pain (scale 1-10), changes in the characteristics of pain, verbal and non-verbal clues- Evaluating the development of pain to determine interventions.Anxiety Dx.4 b / d change in health status, socio-economic status changes, changes in therole and function of the interaction patterns.Intervention and Rational:1. Encourage clients to discuss concerns and provide feedback on appropriate copingmechanisms.- Help identify the cause of anxiety and alternative solutions.2. Emphasize that anxiety is a common problem that happens to other people experiencingthe same problem with a client.- Helps reduce stress by knowing that the clients are not the only people experiencing suchproblems.3. Create an environment that is quiet, suave demeanor and show genuine interest in helpingclients.- Reducing the external stimuli that can trigger an increase in kecamasan.4. Collaboration of sedative drugs when needed.- Can be used as an anti ansitas and increase relaxation.5. Assess changes in the level of anxiety (eg, Hars index)- Evaluating the development of anxiety to establish interventions.Dx.5 Lack of knowledge about the condition, prognosis and therapy needs b / d exposurelimited information, false or interpretation of information and cognitive limitations.Intervention and Rational:1. Assess the clients readiness to follow lessons, including the clients knowledge about thedisease and its treatment.- The effectiveness of learning is influenced by the physical and mental readiness as well as
background prior knowledge.2. Explain about the disease, its causes and consequences of the disruption of daily activities.- An understanding of this issue is important to increase the participation of the client and theclients family in the care process.3. Explain the purpose of the medication, dosage, frequency and route of administration aswell as possible side effects.- Improve the understanding and participation of clients in treatment.4. Explain and show how to perineal care after defecation.- Increase the independence and control of the clients self-care needs.REFERENCESCarpenito (2000), Nursing-Application to Clinical Practice, Ed.6, EGC, JakartaDoenges et al (2000), Nursing care plan, Ed.3, EGC, JakartaPrice & Wilson (1995), Patofisologi-Concept Clinical Disease Processes, Book 1, Ed.4, EGC,JakartaSoeparman & Waspadji (1990), Internal Medicine, Volume I, Ed. To-3, BP FKUI, Jakarta