CHAPTER I

INTRODUCTION

1.1 The Background

Diarrhea is a disease in which feces or faeces turn into soft or liquid that usually occurs at
least three times in 24 hours. In developing countries, diarrhea is the most common cause of
death of under-five mortality, and also kills more than 2.6 million people annually. Diarrhea is a
common complaint in adults. It is estimated in adults each year to experience acute diarrhea or
acute gastroentritis as many as 99 million cases. In the United States, an estimated 8 million
patients go to a doctor and more than 250,000 patients are admitted to hospital each year (1.5%
are adult patients) caused by gastroenteritis. Most deaths are related to the incidence of diarrhea
in children or elderly, where the health of the patient's age is susceptible to moderate-to-severe
dehydration. The frequency of incidence of diarrhea in developing countries including Indonesia
is more 2-3 times than developed countries.

Diarrhea is a contagious disease of one part of our body which becomes a bridge in this
transmission is the hand, because the hand is one of the body parts that most often make direct
contact with other objects, then before eating is recommended to wash hands with soap. A
Cochrane study results found that in social movements by agencies and communities to get used
to wash hands causes a significant decrease in the incidence rate of diarrhea. Therefore, get used
to wash your hands before eating with soap. Do the same after a bowel movement. Try to drink
water that has been boiled to boil so that all bacterial diseases do not enter the body. Immediately
clean up the residue from waste remnants in case of natural disaster. Immediately remove the
pile of garbage so as not to mount and become a den of disease.

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1.2 The formulation of the problem

1. Explain the definition of diarrhea !

2. Specify the etiology of diarrhea !

3. Mention the clinical manifestations of diarrhea !

4. Explain the pathophysiology of diarrhea !

5. How is management in patients with diarrhea ?

6. What are the investigations supporting for diarrhea sufferers ?

7. What are the complications that can arise from diarrhea ?

8. How nursing care in patients with diarrhea ?

1.3 Objective

1. To know the definition of diarrhea

2. To know the etiology of diarrhea

3. To know the clinical manifestations of diarrhea

4. To know the pathophysiology of diarrhea

5. To know the management of diarrhea

6. To know the investigation supporting of diarrhea

7. To know the complications of diarrhea

8. To know nursing care in patients with diarrhea

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 CHAPTER II

DISCUSSION

PRELIMINARY REPORT OF DIARRHEA

A. Definition
Diarrhea by definition hippocrates is a bowel movement with an abnormal
frequency (increased) the consistency of the stool becomes more soft or liquid
(Child health science section, FK UI 1998)
Diarrhea is a condition of abnormal stool expenditure or not as is usually
characterized by increased volume, dilution and frequency more than 3 times a
day in neonates more than 4 times a day with or without blood lenders (Aziz
2016)
Diarrhea can also bedefined as a condition in which there is a change in density
and stool character, or liquid stool is releases 3ties daily or more per day (2002)
Diarrhea is one symptom of disesase in the gastrointestinal system or other
diseases outside the digestive tract (Ngastiyah 2003)
So diarrhea is a bowelfrequency of more than 3 times a day with the consistency
of a water stool.

B. Classification
Diarrhea classification based on the duration of diarrhea consists of:
1. Acute diarrhea
Acute diarrhea is a bowel movement with increasing frequency and consistency of
soft and sudden stools that lasts less than 2 weeks.
According to Depkws (2002) acut5e diarrhea that is diarrgea lasting less than 14 days
withoutintermittent stop more than 2 say. Based on the amount of fluid lost from the
patients body, the gradation of acute diarrhea disese can be distinguished in 3
categories:
1) Diarrhea without dehydration
2) Diarrhea with mild dehydration, if fluid loss 2-5% of body weight
3) Diarrhea with moderate dehydration if fluid loss is 5-8% of body weight

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 4) Diarrhea with severe dehydration, if fluid loss is more than 8-10%
2. Persistent diarrhea
Persistent diarrhea is diarrhea lasting for 15-30 days, aa continuation of acute diarrhea
or a skill between acute and chronic diarrhea.
3. Chronic diarrhea
Chronic diarrhea is diarrhea, or laste long with non-infectious causes, such as gluten-
sensitive disease or decreased metabolic disorders (Suryono 2008), chronic diarrhea
is diarrheathyat is chronic or persistent and laste 2 weeks more.

C. Etiology
1. Infection factor
Bacteria: salmonella, shigella, compylobacteri, E. Coli, yasina acromonas,
clostridium deficite, stophilococcus aureus.
Virus: virus rota, norwalk virus, astro virus/corona virus, adeno virus, virs
pesti, carieci virus, porvo virus.
Parasites: entamuba histolotica, clardia loambia, nocros palidium, tricuris
tricuria.
2. Malabsorption factor
Malabsorption of carbohydrates:
Disaccharide, (lactose intoolerance, maltose and sucrose),monosaccharides: (glucose
intolerance, fructose and galactose). Lactose intolerance is the most important cause
of diarrhea in in infants anf children. Besides it can also accur malabsorption of fat
and protein.
3. Dietary factor
Diarrhea can accur due to eating iron food, toxic and allergi to certain types of food.
Milkig is too early after diarrhea, new foods, excessive sugar delivery, excessive
ingestion of fructose.
4. Psychological factor
Diarrhea can occur due to psyhcological factor (fear and anxiety)

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D. Clinical Manifestations

Acute diarrhea due to infection can be accomanied by

vomiting,fever,tenesmus,hematoschezia,abdominal pain and or stomach cramps.the most fatal
consequences of long-lasting diarrhea without adequate rehydration resulting in hypovolemic
shock or biocemical disorderss of continued metabolic acidosis. Person who lack fluid will feel
thirsty reduced weight,sunken eyes,dry tongue, cheekbones appear, more prominet,skin turgor
decreased and the voice became husky. these complaints and simptoms are caused by isotonic
water depletion

Due to the loss of bicarbonate (HCO3),the coomparetion with carbonic acid decreases
resulting in a decrease in blood pH that stimulates the respiratory center so increases and deepens
(kussmaul respiration) cardiovascular disoredes in severe hypovolemic stage may be shoked by
signs of rapid pulse (<120 x /min),blood presure decreased to immeasurable. The patient stars
anxious,pale face,cold acral and occasionaly cyanosis .because of potassum deficiency in acute
diarrhea may also arise cardiac arrhytmias. A decrease in blood presure will cause renal
perfusion to decrease until oluguria /anuria develops.if this condition is not immediately
addressed ,acute renal tubular necrosis complication willaccur,which means a state of acute renal
failure.

E. Pathophysiology

Based on hasan (2005), the basic mechanisms that cause diarrhea are :

1) Disorder of secretion
Due to certain disorders (eg by toxins) on the intestinal wall there will be increasead
secretion, water and electrolytes into the intestinal cavity andd subseqent diarrhea is not
due to increased intestinal cavity content.
2) Osmotic disorders
due to the presence of food or substances that can not be absorbed will cause osmotic
pressure in the inrensital cavity rises,resulting in a shift of water and electrolytes into the
intestinal cavity.the contens of this excessive intestinal cavity will stimulate the intestine
to remove it resluting in diarrhea
3) Impaired bowel Motility;

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 Hyperperistaltik will lead to reduced intestinal opportunities to absorb food so that
diarrhea occurs,on the contrary if decresed intestinal peristaltic will cause bacteria to
grow excessively wich cause diarrhea as well.

F. Management
According to Supartini (2004), medical management in diarrheal patients includes: fluid
administration, dietetic treatment (feeding) and drug delivery

1. Giving of fluids
Giving fluids to diarrhea patients and paying attention to the degree of dehydrationand
general circumstances
a. Giving of fluids
Patients with mild and moderate dehydration fluids are administered orally in the form
of a fluid containing NaCl and Na HCO3, KCl and glucose for acute diarrhea and
because in children over 6 months of age a sodium level of 90 ml g / L. In children
under 6 months of mild / moderate dehydration 50-60 mfa / L sodium, the complete
formula is often called: ORS.
b. Parenteral fluid
Actually there are several types of fluids required according to the needs of the patient,
but all of them depend on the availability of local fluids. In general, Ringer lactate (RL)
fluid is given depending on the weight / lightness of dehydration, which is calculated
by fluid loss according to age and weight.
1) No dehydration yet
Orally as many children want to drink / 1 cup each defecation.
2) mild dehydration
1 hour first: 25 - 50 ml / kgBW orally further: 125 ml / kg body weight / day
3) Moderate dehydration
1 hour first: 50 - 100 ml / kg BW per oral (sonde) next 125 ml / kg BW / day
4) Severe dehydration
Depends on age and patient BB

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2. Dietary treatment
For children under 1 year and children over 1 year with BB less than 7 kg food type:
I. Milk (breast milk is low-lactose lactose milk and unsaturated fatty acids, eg LLM, al
miron)
II. Content. Half dense food (porridge) or solid foods (team rice), if the child does not want
to drink milk because at home is not normal.
III. Special milk adapted to abnormalities found in milk containing no lactose / fatty acid

3. Drugs
The principle of treatment of diarrhea is to replace the fluid lost through the stool with / without
vomiting with fluids containing electrolytes and glucose / other carbohydrates (sugar, water tajin,
rice flour as follows.
i. Anti-secreting drugs
Acetosal, dose 25 mg / c with a minimum dose of 30 mg. Chlorrpomozine, dose of
0.5 - 1 mg / kg BW / day
ii. Spasmolytic drugs, etc. Commonly spasmolytic drugs, such as papaverine, beladonal
extract, opium loperamia are not used to treat acute diarrhea anymore, stool-like
drugs such as kaolin, pectin, charcoal, tabonal, are of no use to cope with diarrhea so
no longer given.
iii. Antibiotics
Generally, antibiotics are not given if there is no obvious cause when the cause of
cholera, tetracycline is given 25-50 mg / kg BW / hari.Antibiotik also given bile there
are diseases such as: OMA, pharyngitis, bronchitis / bronkopneumonia.

G. Supporting Investigation
1) Fecal examination
a. Macroscopic and microscopic
b. Ph and sugar levels in the stool
2) Blood gas analysis if there are signs of acid base balance disturbance (Kusmaul
respiration)
3) Examination of levels of urea and creatinine to determine the renal physiology

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 4) Electrolyte examination especially Na, K, Calcium and Phosphate.

H. Complications

Based on Supartini (2004), the consequences of diarrhea or sudden loss of fluid and
electrolytes can occur various complications such as:
1) Water loss (dehydration)
Dehydration occurs because the loss of water (output) more than the input (input), is the
cause of death in diarrhea. Disturbance of acid-base balance (metabolic acidosis). This
occurs due to loss of Na-bicarbonate with feces. Fat metabolism is not perfect so that
dirty objects buried in the body, the accumulation of lactic acid due to anorexia tissue.
Acid metabolic products increase because they can not be excreted by the kidneys
(oliguria / anuria occur) and the transfer of Na ions from the extracellular fluid into the
intracellular fluid.
2) Hypoglycemia
Hypoglycemia occurs in 2-3% of children with diarrhea, more often in children who have
previously suffered from CTF. This occurs because of impaired storage / provision of
glycogen in the liver and the presence of glucose absorption disorder. Symptoms of
hypoglycemia will appear if blood glucose levels decrease to 40 mg% in infants and 50%
in children.
3) The occurrence of weight loss in a short time
This is caused by food is often stopped by parents for fear of diarrhea or vomiting is
getting great. Although milk is continued, it is often given with expenditure and this
dilute milk is given too long. The food given is often indigestible and absorbed well
because of hyperperistaltic.
4) Circulatory disorders
As a result of diarrhea may occur hypovolemic shock, resulting in reduced tissue
perfusion and hypoxia, acidosis increases, can result in cerebral hemorrhage, decreased
consciousness and if not immediately addressed the client will die

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 NURSING CARE IN DIARE PATIENTS

1. Assessment
a. Main complaint: defecate many times with dilute consistency
b. Current medical history: in general, the client is admitted to the hospital with
complaintsof frequent bowel movements accompanied or without vomiting, the stool
may be mixed with the bleeder and/or blood, other complaints that may be obtained are
decreased appetite, increased body temperature, volume decreased diuresis and
symptoms of decreased consciousness blood, other complaints that may be obtained are
decreased appetite, increased body temperature, volume decreased diuresis and
symptoms of decreased consciousness
c. Previous medical history
- Previous illness
The cause, its symptoms, the course of the healing diseases, complications, incidents
of the desease in the family or community, the emotional response to the previous
hospitalization
- Allergies: have ever suffered from hay fever, asthma, eczema and medicines

Physical examination

1) Vital Sign
body temperature : increased

Pulse : fast and weak

Breathing : The frequency of breath increased

Blood Pressure : Decreased

2) Anthropometry
Anthropometric examination includes weight, height, head circumference, arm
circumference, and abdominal circumference. In children with diarrhea weight loss.

3) Breathing
Usually breathing is rather fast, normal chest shape, and no additional breath is found.

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4) Cardiovasculer
Usually there is no abnormality, fast and weak pulse.

5) Digestion
Found symptoms of nausea and vomiting, lips mucosa and dry mouth, increased
bowel peristaltic, anorexia, bowel movements more than three times with dilute
consistency

6) Urination
The volume of diuresis decreases.

7) Muskuloskeletal
Physical weakness due to excessive output

8) Integument
Abrasions around the anus, skin feeling warm, skin turgor ugly

9) Endocrine
Not found any Abnormalities
10) Sensing
Sunken eyes, nose, ears no abnormalities

11) Reproduction
Not abnormal

12) Neuorological
Consciousness may decrease.

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 PATHWAY OF DIARRHEA

Infection Food Malabsorption Psychology

Develop in Toxic cant be Osmotic pressure Adrenal hormone

intestines reserve increases increases

Mutation water &

Hypersecretion
Tek. Hyperperistaltic Affecting the
electrolyte to
water & electrolyte parasympathetic nerves
intestines
Food
Contents of intestines absorption Acute Hyperperistaltic
decreased pain

Diarrhea

Fq of defecation
Damage to skin integrity Abdominal
inincreases
distension

Lost fluids &

electrolyte Nauseous
Metabolic acidosis
vomit
Fluid balance disorder &
Crowded
electrolyte Anorexia

Dehydration Disturbance of gas

exchange Nutrition
Lack of fluid volume imbalance is less
Risk of shock than body needs
(hypovolemic)

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 2. Nursing Diagnosis
a. lack of fluid volume associated with excessive loss through feces and vomiting
and limited intake (nausea)
b. Gas exchange disorders associated with alveolar-capillary membrane change
c. nutrition imbalances less than body demand associated with impaired nutrient
absorbtion and intestinal peristalsis improvement
d. Pain (acute) associated with hyperperistaltik, perirektal fissure irritation
e. Damage to skin integrity is associated with frequent excretion / bowel movements
f. Risk Hypovolemic shock is associated with fluid and electrolyte loss

3. Nursing Plan

Diagnosis 1: lack of fluid volume associated with excessive loss through feces and
vomiting and limited intake (nausea)
Objective: fluid and electrolyte volume in balanced body (lack of fluids and electrolyte
fulfilled) with criteria:
- Quick skin turgor back
- Balanced intake and expenditure
- BJ urine between 1,010-1,025

Intervenstion:

a. Observe vital sign every 4 hours until the state is stable and determine the cause of
fluid and electrolyte deficiency
R: continuous loss of fluid will affect vital sign in maintaining activity
b. Observe the state of the skin through color, moisture and skin turgor.
Maintain IV therapy to replace fluids by colloidal fluid, crystalloid and give PO flu as
needed
R: colloid avoids intravascular space and collects fluid from interstitium into the
blood vessels, replaces intra extra cell and distributes intravascular and interstitial
outflows

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c. Monitor your intake and expenditures hourly and report whwn there are great
expenses.
R: decreased and hypovolemic fluid volume caused by decreased plasma resulted in
decreased flows towards the kidneys
d. Weight the patient every day at the same time
R: weight is an indicator for body fluid balanced through intake and discharge
process
e. Observasion of urine BJ every 8 hours
R: urine concentration is a response to a lack of water as ADH release in response to
osmolitas body fluids
f. Monitor electrolyte serum of excess fluid during fluid replacement and report if any
signs of disturbance of fluid and electrolyte balance and worsening condition
R: worsening conditions of electrolyte disturbance or decreased urinary output sign,
urinary concentration, hypotention, increased pulse and tention, weakness and altered
mental status
g. Collaborative implementation of definitive therapy
R: drug administration is causally important after the cause of diarrhea is known

Diagnosis 2: Gas exchange disorders associated with alveolar-capillary membrane

change
Objective: Show adequate ventilation and oxygenation improvement, with yield criteria:
- Free respiratory distress symptoms
- CRT (2 seconds, RR=16x24 x/min)
- Skin is not pale, akral warm

Intervention
a. Asses respiratory status as well as changes in respiratory pattern
R: increased respiratory effort may indicate hypoxemia level
b. Note the presence of additional breath sounds

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 R: krekles> evidence of decreasded fluid in the tissue area
c. Give additional oxygen as indicated
R: maximize oxygen preparation for gas exchange
d. Give periods of rest and quiet environment
R: saves patient energy, decreases oxygen demand

Diagnosis 3: nutrition imbalances less than body demand associated with impaired
nutrient absorbtion and intestinal peristalsis improvement
Obj :
- Age-appropriate weight
- Dietary clients as needed

Intervenstion
a. Together with the patient and family determine the childs ideal weight according to
the stage of growth and the diet program done for the child
R: active family participation in determining nutritional intake causes the family to
play an active role in subsequent actions
b. Do a program of cooperation with nutritionists in determining the diet, give small
portions but often
R: determining the diet/calories consumed by children is very important role in
weight gain, give small portion with frequency often minimize body metabolism
c. Teach the client/family to monitor the income and food expenditure of children
R: note the oral intake and the patients desire ti facilitate early detection of inadequate
intake
d. Assist client and families in identifying high protein and carbohydrate refence foods
R: the addition of some small meals adds an increase in caloric intake
e. Teach clean oral hygiene and clean room before meals
R: the oral and clean conditions of the room improve the taste and appetite
f. Weight the childs weight every day, monitor the intake and output
R: weight is an indicator of the balance of intake and output

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Diagnosis 4 : Pain (acute) associated with hyperperistaltik, perirektal fissure irritation
Obj : comfort is fulfilled, Children are free from abdominal distension by criteria :

- Abdomen supel no distension

- Can sleep comfortably
- Can play without interruption
Intervention :

a. Assess pain complaints with Visual Analog Scale (scale 1-5), Changes in pain
characteristics, verbal and non verbal clues
R : Evaluate the development of pain to establish subsequent interventions
b. Set a comfortable position for the client, for example with flex knees
R : Lower abdominal surface tension and reduce pain

c. Change or change the sleeping position every 3 hours

R : Positional changes can stimulate intestinal peristalsis thus reducing abdominal
distension

d. Apply warm compresses to the abdominal area

R : With warm compresses, abdominal distension will relax, in case of acute
inflammation / peritonitis will cause the spread of infection

e. Minimizing child crying (in children)

R : Crying allows air to enter inside the stomach to aggravate abdominal distension

f. Collaborate with the medical team in drug administration and monitor the side
effects of the drug.
R : The pharmacological effects in children are determined by individual
sensitivity

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Diagnosis 5 : Damage to skin integrity is associated with frequent excretion / bowel
movements
Obj : keeping the perianal skin intact with the criteria:

- Intac skin / skin with lesions healed

- Steady skin moisture
- Circulation integument smoothly
Intervention :

a. Perform assessment of skin damage and regular recording

R : pH stool is getting acidic, skin damage is increasing

b. Keep skin clean

R : Moist skin is an effective medium for the proliferation of germs.

c. Perform debridement and clean the wound, use a cream / ointment for wound and do
massage around the wound.
R : Wound removal allows the dirt of germs to rise so that the cream / ointment
can be absorbed well.

Diagnosis 6 : Risk Hypovolemic shock is associated with fluid and electrolyte loss

Obj : After the treatment performed during the hospital the risk of hypovolemic shock did not
occur, the criteria :

Vital signs within normal limits (P: 120-60 x/mnt, T; 36-37,50 c, RR : < 40 x/mnt )
Elastic tumor, mucous membrane of wet lips, eyes are not deep, The large crown is not
concave
The patient's body fluid is adequate
Consistency of soft stool
Intervention :

a. Monitor signs and symptoms of fluid and electrolyte shortages

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R: Decreased circulation of volume causes mucosal dryness and urinary concentration. Early
detection allows immediate fluid replacement therapy to correct deficits.

b. Monitor intake and output

R: Dehydration can increase the glomerular filtration rate making the output inadequate to clean
up the rest of the metabolism.

c. Weigh the patient's weight every day

R: Detecting fluid loss, a decrease of 1 kg of body weight means 1 liter of fluid loss

d. Encourage clients / family to give a large drink to the patient (2-3 liters / day)

R: Replace fluids and electrolytes lost orally

e. Collaboration in administration of parenteral fluids (IV Line) according to age

R: Replace fluids and electrolytes adequately and quickly

f. Collaboration in administration of anti-crescin, anti-spasmolytic, and antibiotic drugs

R: Anti secretion to decrease the secretion of fluid and electrolyte to balance, anti spasmolitik for
normal absorption process, antibiotic as anti-bacterium wide-spectrum to inhibit endotoxin.

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 CHAPTER III

COVER

3.1 CONCLUSIONS

Diarrhea is a dilute defekasi more than 3 times a day with or without blood or mucus in the
stool. Diarrhea can also be defined as a situation where the occurrence of loss of fluids and
electrolytes is excessive that occurs because of the frequency of defecation one or more times
with a dilute form or liquid. So the diarrhea can be interpreted as a condition, bowel movements
are not normal i.e. over 3 times a day with a diluted fecal consistency may be accompanied or
without accompanied phlegm or blood as a result of the onset of inflammatory processes in the
stomach or intestines.

3.2 ADVICE

On nursing care he made With the client that is experiencing Diarrhoea it is expected
students to better understand, know and understand about the ways of making nursing care on the
client that is experiencing diarrhoea.

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