Fundamentals of Nursing Q 546
A nurse is caring for a client who has diarrhea for the past four days. When assessing a client, the nurse should expect which of the following findings? Select all that apply.
A. Bradycardia
B. Hypotension
C. Fever
D. Poor skin turgor
E. Peripheral edema
Correct Answer: B, C, and D
Diarrhea is described as three or more loose or watery stools a day. Infection commonly causes acute diarrhea. Noninfectious etiologies are more common as the duration of diarrhea becomes chronic. Treatment and management are based on the duration and specific etiology. Rehydration therapy is an important aspect of the management of any patient with diarrhea. Prevention of infectious diarrhea includes proper handwashing to prevent the spread of infection.
Option A: Prolonged diarrhea is more likely to cause tachycardia than bradycardia. Diarrhea is the result of reduced water absorption by the bowel or increased water secretion. A majority of acute diarrheal cases are due to infectious etiology. Chronic diarrhea is commonly categorized into three groups; watery, fatty (malabsorption), or infectious.
Option B: Prolonged diarrhea leads to dehydration, which causes a decrease in blood pressure. In bacterial and viral diarrhea, the watery stool is the result of injury to the gut epithelium. Epithelial cells line the intestinal tract and facilitate the absorption of water, electrolytes, and other solutes. Infectious etiologies cause damage to the epithelial cells which leads to increased intestinal permeability. The damaged epithelial cells are unable to absorb water from the intestinal lumen leading to loose stool.
Option C: Prolonged diarrhea leads to dehydration, which causes fever. History should include the duration of symptoms, accompanying symptoms, travel history, and exposures to medications and food. It is important to ask about the stool frequency, type, volume, and presence of blood or mucus. Patients with diarrhea may also complain of abdominal pain or cramping, vomit, bloating, flatulence, fever, and bloody or mucoid stools.
Option D: Prolonged diarrhea is more likely to cause a fluid deficit. An important aspect of diarrhea management is replenishing fluid and electrolyte loss. Patients should be encouraged to drink diluted fruit juice, Pedialyte or Gatorade. In more severe cases of diarrhea, IV fluid rehydration may become necessary.
Option E: Peripheral edema results from a fluid overload. Important aspects of the physical exam include the patient’s vital signs, volume status, and abdominal exam. Dry mucous membranes, poor skin turgor, and delayed capillary refill are signs of dehydration. A thorough history and physical exam are important to determine the proper diagnostic workup.