Frequent bouts of diarrhea make it difficult to care for wounds on the sacrum or coccyx, and healing often is impeded because of fecal contamination.
Many patients, particularly those with mobility issues, have pressure injuries on the sacrum or coccyx. Frequent bouts of diarrhea make it difficult to care for these wounds, which affects healing. If frequent, loose, and watery stools contaminate the wound, it can make the healing process more challenging. The first step is to identify the cause of the diarrhea in order to begin the appropriate nutritional, medical, and pharmaceutical treatment plan.
Causes of Diarrhea
Diarrhea is a symptom of many diseases and disorders. Here are just a few to consider.
Food intolerance/allergies: These include lactose and gluten intolerance or excessive intake of sorbitol, mannitol, or xylitol.
Protein energy malnutrition: Hypoproteinemia (albumin levels < 2.6 g/dL) is associated with intestinal edema, which negatively affects luminal absorption and may result in diarrhea.
Bacterial contamination: Contaminated food or water may lead to Campylobacter, Salmonella, Shigella, Clostridium difficile, or Escherichia coli.
Viral infections: Rotavirus, Norwalk virus, cytomegalovirus, herpes simplex virus, or viral hepatitis may all cause diarrhea.
Enteral tube feedings: Hypertonic formulas, refeeding syndrome, contamination, bolus feedings into the small intestine, and lack of fiber in the formula are all reasons that some patients may experience diarrhea.
Parasites: Giardia lamblia, Entamoeba histolytica, or Cryptosporidium can enter the body through food or water and settle in the digestive tract.
Drug reactions: Laxatives, diuretics, cholinergic drugs, antibiotics, prostaglandins, liquid medications containing sugar alcohols, warfarin, thyroid preparations, anti-epileptics, and many other drugs can cause diarrhea.
Gastrointestinal disease: Inflammatory bowel disease, short gut syndrome, HIV/AIDS, Crohn’s disease, chronic ulcerative colitis, bowel resection, and malabsorption syndrome all have diarrhea as a symptom of the disease.
Fecal impaction: Impacted feces prevent the passage of normal stool. Only watery stool is able to pass the point of impaction.
Types of Diarrhea
The list of possible causes of diarrhea is lengthy, and it sometimes is difficult to pinpoint the cause. It may help to classify the diarrhea in one of the three common categories—watery, fatty, or small volume.
Watery diarrhea occurs when the amount of water and electrolytes moving into the intestinal mucosa exceeds the amount absorbed into the bloodstream. Watery diarrhea is further classified into two subtypes—osmotic or secretory. Osmotic diarrhea abates with fasting, while secretory does not. Watery osmotic diarrhea usually accompanies lactose intolerance, dumping syndromes, and enteral feeding intolerances. Watery secretory diarrhea is often a sign of bacterial enterotoxins and viruses.
Fatty diarrhea, or steatorrhea, usually accompanies conditions associated with malabsorption, such as chronic pancreatitis or short bowel syndrome.
Small volume diarrhea may accompany diverticulitis of the colon.
Bloody or black tarry stools may indicate a more serious condition—this is not common diarrhea. Black tarry stools, or melena, usually indicates that blood is coming from the upper part of the gastrointestinal tract. Maroon or red, bloody stools, called hematochezia, usually suggests that blood is coming from the large intestine or rectum. These conditions warrant prompt medical attention and testing.
Occasionally, the ingestion of black licorice, lead, iron supplements, or even blueberries can cause black stools or false melena. A fecal occult blood test can rule our false melena.
Medical Record Documentation
Always document diarrhea, including the frequency, odor, color, presence of blood, abdominal pain, bloating, and fever. Also document what you suspect are the possible causes and type of diarrhea because this information will form the basis for the treatment plan.
Detailed records describing what is occurring with the patient provide essential information to the entire care team. These types of wounds may take longer to heal or present challenges. Therefore, thorough documentation also is needed in case any future legal or care questions arise.
Medical Treatment
The first step is to obtain a detailed medical and nutritional history. A nutritional history should include questions about the use of dietetic food products. Many patients with diabetes replace sugary foods with dietetic foods containing the sugar alcohols sorbitol, mannitol, and xylitol. These products frequently cause diarrhea, making it necessary to eliminate them from the diet if they are not well tolerated. Many medications also contain sugar alcohols, so the pharmacist should review the medication list and recommend appropriate substitutes. Magnesium-containing medications and supplements also may cause diarrhea, so the pharmacist should monitor this as well.
A stool culture sometimes is ordered to identify parasites, bacteria, or other signs of infections. In addition, sometimes stools are examined for fecal white blood cells and Clostridium difficile toxin. Blood tests can rule out or confirm the presence of certain diseases such as human immunodeficiency virus. A fasting or elimination test can confirm if diarrhea is caused by a food allergy or intolerance. Finally, a sigmoidoscopy or colonoscopy sometimes is performed.
Preventing Dehydration
The main goal of treatment for diarrhea is to prevent dehydration and electrolyte imbalance. It is necessary to correct losses of potassium and sodium as soon as possible by oral rehydration therapy (ORT). ORT is simply the provision of a proper oral rehydration solution. Water does not contain the necessary electrolytes for ORT, and sugary juices such as apple juice may worsen diarrhea. Limiting of caffeinated and alcoholic beverages is recommended.
Proper homemade and commercially produced oral rehydration solutions are both used. Commercially available products include Pedialyte® (Abbott Nutrition, Columbus, OH) and CeraLyte® (Cera Products Inc, Hilton Head Island, SC). Sports drinks such as Gatorade® (Pepsi-Co, Harrison, NY) also help. While many patients can rehydrate orally, individuals with symptoms of severe dehydration should stay in a healthcare facility so they can receive intravenous fluids.
Careful laboratory monitoring of sodium, potassium, chloride, BUN/creatinine ratio, and albumin also is necessary. Monitoring of patients with a history of hypertension or heart failure is recommended when giving high-sodium solutions.
Medical Nutrition Therapy
Medical nutrition therapy (MNT) is determined by the specific cause of the diarrhea. However, some general recommendations apply in most situations. In acute cases, it sometimes is necessary to begin treatment by having the patient NPO for 12 hours. Intravenous fluids sometimes are ordered if dehydration is present. Oral fluids are started as soon as tolerated.
The initial oral diet should consist of broth, tea, and toast with additional foods added as tolerated. High sugar foods are not recommended.
Also:
- Consider using foods containing probiotics, such as yogurt with live cultures, especially for patients taking antibiotics
- Serve small, frequent meals throughout the day because they are best tolerated
- Reintroduce dairy products and wheat products slowly
- Avoid foods high in roughage, such as raw fruits and vegetables
- Add soluble fiber, which dissolves in water, to the diet as tolerated (soluble fiber, including pectin is found in oatmeal, apples, bananas, beans, and psyllium)
- Prescribe a lactose-free diet if lactose intolerance is present
- Replace fat-soluble vitamins with a vitamin supplement if steatorrhea is present
- Order pharmaceuticals such as Imodium®, Pepto-Bismol®, Kaopectate®, or Lomotil® as needed
- Provide total parenteral nutrition if complete bowel rest is needed
Wound Healing
Most cases of diarrhea will resolve with time and a multifaceted treatment plan involving a history and physical exam, medical work-up, MNT, and pharmaceuticals. Unfortunately, some patients may fail to improve despite all of these approaches. When treating the wound, use techniques to minimize contamination from stools. For some patients, a fecal incontinence pouch or operative diversion is necessary until the wound heals. It is important to document all interventions, and if one approach does not work, keep trying another idea or product.
Wound Care Education Institute® provides online and onsite courses in Skin & Wound, Diabetic and Ostomy Management. Eligible clinicians may sit for the prestigious WCC®, DWC®, OMS and NWCC™ national board certification exams through the National Alliance of Wound Care and Ostomy®(NAWCO®). For details, see wcei.net.
DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.
