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Impact of C.Diff Infection on Nutrition

Question:

Discuss about the Clostridium Difficile Case of James.

In the recent years, Clostridium difficile (C-Diff) has emerged as major source of morbidity among the older adults in long-term care (Lessa, Gould and McDonald 2012). The clinical manifestations range from diarrhoeal illness to toxic megacolon and pseudomembranous colitis. It is the most common infectious disease that is transmitted through spores in the stool and can persist for weeks in the environment after infection (Blakney et al. 2015). Therefore, environmental modification is required to decontaminate and reduce the severe infection. Similarly, the given case study involves the in-depth analysis and nursing care plan for Mr. James, an 82-year-old male admitted with C-Diff infection. He is currently showing symptoms of abdominal pain, watery diarrhoea, loss of appetite, sudden weight loss and has an elevated temperature of 38 degrees as the colon has inflamed forming raw tissues producing pseudo membranous colitis. He is also complaining of lethargy affected by C-Diff that indicates severe dehydration. There is lack of ability to perform the daily activities due to the severe infection and so he requires assistance with activities of living (AoLs) (Rao et al. 2013). Personal dressing, cleaning, safe environment, eating, drinking, elimination are some of the AoLs that require modification for Mr. James. Apart from AOL’s modifications, proper nursing care plan is also required for the proper management of the infection by identifying the risk factors, signs, symptoms, nursing and medical management of the patient. However, there are issues related to these AoLs and so,  plan is necessary for Mr. James. Therefore, following discussion involves the modifications in AoLs, the issues observed and proper nursing care plan for Mr. James in the proper management of infection and patient care.

Eating and drinking is affected in Mr. James as due to diarrhoea, there is frequent active fluid volume loss resulting in deficit in fluid volume. There are complications of diarrhoea that compromises the health of the infected patient. Severe diarrhoea results in metabolic, haemodynamic instability, and that result in lethargic condition and poor drinking and eating patterns. The rapid propulsion of the intestinal contents through small bowels from the body results in serious fluid deficit in the body. Moreover, the body wants to expel the foreign material so that the body regains its normal digestion, however, the organs are unable to absorb excess fluids that can absorbed by normal body. There is dehydration, impaired skin integrity due to loss of moisture because of loose liquid stools (Surawicz et al. 2013). Similarly, the infection has made him lose the ability to absorb the nutrients properly and that resulted in loss of appetite and sudden weight loss. He is unable to digest the hard foods that irritate stomach like spicy foods or raw vegetables. This depicts that nutrition plays an important role that has an impact on James health as the infection resulted in dehydration being a common side effect of severe diarrhoea. Another side effect of C.Diff infection that results in poor appetite and loss of weights is malabsorption of nutrients. There is lack of nutrients like vitamin, sodium, potassium, calcium and magnesium that result in weakness. This shows that dietary changes are required for Mr James to regain weight and appetite (Leffler and Lamont 2015).

Nutritional Screening for Patients with C.Diff Infection


Nutritional screening can be used for the assessment of nutrition and fluid intake of James. Nutritional screening tools like Mini Nutritional Assessment (MNA) can be used for him, as it is a very reliable way for screening nutritional status and adding nutritional component to the geriatric assessment. It identifies the nutritional status in him that identifies malnutrition with a sensitivity of 98%, specificity 100% and 99% diagnostic accuracy among the individuals above 65 years of age (Cereda 2012). Another screening tool Malnutrition Universal Screening Tool (MUST) also assess nutritional level on three criteria; unintentional weight loss, BMI and acute effect of disease that causes poor appetite and sudden weight loss (Poulia et al. 2012).nursing care

The  nursing assessment comprises of the abdominal discomfort, cramping, frequency, liquid stools and pattern of defecation. This assessment is important for knowing the eating patterns as these symptoms are linked to diarrhoea. Moreover, food intolerances, medications, changes in eating pattern, tolerance to dairy products are also important for the assessment of alterations in eating patterns that can cause intestinal function changes leading to diarrhoea. Assessment is also required for hydration status as diarrhoea results in profound dehydration like input and output, mucous membrane moisture and skin turgid (Shimizu et al. 2012). Due to dehydration, there is dryness in the mucous membrane and decrease in skin turgidity along with skin tenting. The nursing care plan for AoL issue in eating and drinking comprises of maintaining the normal fluid volume at the patient’s functional level so that he remain hydrated, maintain normal skin turgid and diet intake is equal to the output. The modifications are required in diet that comprises of easily digestible foods and proper fluid intake so that electrolyte balance is maintained in the body. Nurse also needs to look for lactose intolerance that is common side effect of C. Diff along with gluten intolerance (Hooper et al. 2014).

Personal cleansing and dressing activities require modifications as they require attention to reduce the transmission of infection and disease progression. As the infection spores are persistent and viable in the environment, it is important to look for the personal hygiene like hand hygiene, cleaning, dressing and personal protective equipments (PPEs). Due to diarrhoea, James uses toilet frequently that may infect hands and it can spread through hand contamination. This bacterium resides in the bowel and its multiplication produces toxins that cause diarrhoea. It is highly infectious and spread rapidly through hand contamination, therefore, the strict hand hygiene is required to reduce the spreading of germs and spore transmission through hands. Personal dressing should also be clean and hygienic so that there is reduction in infection transmission and spread of spores (Jetha 2014).

Nursing Assessment of Personal Hygiene


Personal hygiene assessment can be done through assessing the unwillingness or inability of James to perform personal hygiene measures that would reflect self-care deficit. Good hygiene like flossing, brushing, bathing should be assessed in James so that there should be reduction in contamination of body fluids and transmission of pores. It can also be assessed that PPE are being used James; hand washing is being performed by him after using toilet and before eating (Farthing et al. 2013). All these assessments help to evaluate the personal hygiene compliance in James. Functional Independence Measures (FIM) can be used for assessing self-care items like dressing, bathing, brushing, grooming, bowel movement and toileting (Turolla et al. 2013).

The nurse should help James to maintain good personal hygiene by washing hands thoroughly using soap and water that removes the spores from the hand. Alcohol hands gels can also be used to reduce the germ spreading before and after eating food. It prevents the spread of infection as the spore transmission is prevented and as a result, the risk of getting C.Diff infection would be reduced. The nurse should ensure that he uses gloves and decontaminate hands after gloves removal with soap and water and should be encouraged to wash hands regularly, nails kept clean, and short. Therefore, the nurse should evaluate his adherence to good hand hygiene practices by performing hand washing that can reduce the incidence of spore transmission and contamination (Dubberke et al. 2014).

The defecation or elimination is important in clostridium-infected patients as the stool contains the spores. The safe disposal of the excrement is important as it helps in the prevention of contamination of the patient’s clothing, hands and environment. The transport of the waste and urine of the patients may contaminate the surrounding people and environment. This depicts that elimination and disposal of waste should be safe through bedpans and urinals for proper disinfection and cleaning. The stool contains spores in large amount that can infect healthy people. Effective elimination of spores is important, as it can be helpful in the transmission of spores and infection spread. There can also be abdominal tenderness that causes cramps and pain due to continuous liquid bowel movements and so promotion of comfort is important for James as it can result in emotional distress (McCune, Struthers and Hawkey 2014).

The assessment of elimination excrements and nursing care can be done through safe disposal of waste and proper faecal transplantation. This is of critical importance by the nurse for the prevention of contamination and soiling of hands, personal clothing and environment by spores. Nurse should look that the excrements should be disposed safely to the soiled service room and proper disinfection and cleaning of the patient after defecation. The nurses and midwives should use washers and disinfectors after the elimination of waste and hand washing. The nurse should teach James about hand washing after using toilet by using soap and water. In this way, the nurse can provide care to James in the prevention and control of the spread of infection. Bristol stool chart is important for the stool consistency pattern and in tracking daily bowel movements as these are linked to diarrhoea (Burke and Lamont 2013).

Nursing Care for Personal Hygiene


From the above AoLs in the given case study, there are issues that require nursing goals and interventions for the reduction of the infection spread and ensure patient care.

There is issue of diarrhoea in regards to eating and drinking of the patient in the case study. Nursing goals, proper nursing interventions are required to restore the fluid and electrolyte loss and gain normal appetite (Mitchell, Russo and Race 2014).

Diagnosis

Nursing Goals

Nursing interventions

Rationale

Evaluation

Eating and drinking

The diagnosis is required for abdominal pain, cramping, bowel movements, frequency and urgency of liquid or loose stools as these are linked with diarrhoea.

The pattern of defecation needs to be evaluated, as it is important to direct treatment.

Food intolerances, tolerance to dairy products, changes in eating pattern as it can cause intestinal function changes leading to diarrhoea.

The expected nursing goals comprises of more consumption of liquids ~1500-2000 mL within 24 hours.

The reporting of less diarrhoea within 36 hours and the patient defecates soft and formed stool that reliefs cramping, abdominal pain with less or no diarrhoea.

The nurse should weigh James weight daily and should note the decrease in weight.

Dietary alterations are important for the patient:

Easily digestible foods are important that contain-

Bulk fibre like grains, cereals and Metamucil

Natural bulking agents can be used like rice, apples

There should be avoidance of stimulants like caffeine.

The nurse should encourage the patient to intake fluids 1.5 to 2 L/24 hr and 200 mL that provide nutritional support.

The nurse should encourage the patient to eat frequent, but small meals that can be easily digestible by him and causes constipation.

For controlling diarrhoea, the nurse should make dietary changes like avoidance of spicy foods, fried and encourage boiled or braked foods.

This is important, as accurate weight measurement is an indicator of water and fluid balance in the body (Hall et al. 2012).

These dietary fibres and bulking agents are important as it absorb fluids from stool and thicken it (Dhingra et al. 2012).

These stimulants are harmful as it increase the mobility of gastrointestinal tract and worsen the diarrhoea condition.

This increased fluid intake replenishes the fluid loss due to continuous liquid stools.

Starchy and blanchy foods are recommended before starting to eat normal food again (Slavin 2013).

These dietary modifications aid in slowing down the passage of stool through colon and help to eliminate or reduce diarrhoea (Mudgil and Barak 2013).

The nurse would evaluate that James consume clear liquids and look for improvement in skin turgidity, moisture and weight.

The stool becomes soft and formed and ensures that rectal area is free from irritation and cramping with no negative stools.

Personal cleansing and dressing

The diagnosis is required for the self-care activities like disorderly appearance, ambulation, grooming and bathing self-independently, dressing and feeding independently and autonomously, finishing of toilet tasks and maintaining personal hygiene.

The ability to perform tasks like taking off and wearing clothes, grooming also needs to be assessed for the patient.  

The nursing goals comprises of the optimization of independence in performing activities of personal dressing and cleansing.

The patient can execute activities of personal care within his ability and be able to meet his self-care needs.

 The nurse should promote privacy during dressing.

Frequent encouragement needs to be given so that it can aid him in dressing.

The clothing size should be one size longer.

The use of assistive devices for dressing by nurse can help the patient in self-care tasks.

The assessment of toileting pattern is important for the patient.

The assessment of James ability to verbalize necessitates voiding the use for bedpan or urinal.  

The patient needs to be aid in the changing or elimination of soiled clothing.

The nurse should observe patient for fall or balance loss during toileting.

Encourage patient to use soap and water for washing hands before and after eating and toileting.

 This privacy need is important for James, as it is fundamental for him, as he may fear of privacy breaching.

This assistance can be helpful so that his tasks are smooth and do not negate the attempts of the patient.

This imparts comfort and easier dressing. 

This intervention can help James to continue independence and autonomy in self-care activity.

This would help to improve the efficacy of bladder movement and bowel movement patters are taken into consideration (Keller and Surawicz 2014).

This helps in the recovery state and help to recover the patient and gain independence.

Independence in personal dressing is important as inability to dress compromises capability to be continent.

The patient may hurry to toileting due to fear of soiling and as a result, may face a risk for fall or loss of balance (Podhorecka et al. 2016).

The evaluation can be done by looking into optimization of independence and autonomy. There are lifestyle changes so that James is able to meet the self-care needs and able to recognize individual needs or weakness.  The tasks include ability to feed, dress, bathe, groom, independently and maintain personal hygiene like finishing of toilet tasks and cleaning.

The patient is able to execute self-care tasks with utmost capacity.

Elimination

The nurse needs to diagnose for the frequency, urgency and faecal volume of the patient for the control of diarrhoea. Observation of lethargy, fever is important for the evaluation of bowel elimination alterations for the patient.

The minor evaluation of symptoms like abdominal pain, stool volume, cramping and urgency is also important for the patient.

The nursing outcome comprises of proper bowel elimination for the bowel sounds, distension and abdominal pain assessment as these are contributing factors in diarrhoea.

The nurse would be able to encourage patient to verbalize the void feelings and gain self-control for proper bowel elimination and fluid intake.

Recording of input  and output urine and bowel movement

Stool softeners should be given.

The nurse should keep a check on the time, stimulus, amount, consistency, urgency and frequency of stool.

The elimination of stool should be safe, proper disinfection and cleaning of the patient after defecation.

After bowel movement, clean with mild cleansing agent and use of wound hydrogel for perineal care.

This can help to assess the extent of diarrhoea severity and its contributing factors.

This helps to institutionalize normal bowel functioning without any irritation (Martínez et al. 2012).  

This helps to evaluate the elimination pattern that can direct the course of treatment (Smits et al. 2016).

This would help to reduce the transmission of spores and spread of infection through faeces (Kassam et al. 2013).

Perineal care is important as continuous bowel movement can cause excoriation and tearing of skin (Hussein and Anaya 2013).

The nurse should evaluate the decrease in incidence of diarrhoea, safe disposal of waste, rectal area free from irritation and softening of stool for easy defecation.


From the above discussion case study of James, it is evident that Clostridium difficile is highly infected disease that affects elderly population in long-term care facilities. It is transmitted through defecation that contains spores, being highly infectious. Diarrhoea condition is highly severe where the patient manifests signs and symptoms like abdominal pain, cramping, fever, lethargic condition. The patient also manifests issues in AoLs like personal hygiene, elimination and eating and drinking. Proper nursing diagnosis, nursing care plan, interventions and evaluation is important to direct proper treatment and management of the disease. This case study provided an in-depth knowledge about spread of Clostridium infection and nursing care plan for the infection control and management.

References

Blakney, R., Gudnadottir, U., Warrack, S., O’Horo, J.C., Anderson, M., Sethi, A., Schmitz, M., Wang, J., Duster, M., Ide, E. and Safdar, N., 2015. The relationship between patient functional status and environmental contamination by Clostridium difficile: a pilot study. Infection, 43(4), pp.483-487.

Burke, K.E. and Lamont, J.T., 2013. Fecal transplantation for recurrent Clostridium difficile infection in older adults: a review. Journal of the American Geriatrics Society, 61(8), pp.1394-1398.

Cereda, E., 2012. Mini nutritional assessment. Current Opinion in Clinical Nutrition & Metabolic Care, 15(1), pp.29-41.

Dhingra, D., Michael, M., Rajput, H. and Patil, R.T., 2012. Dietary fibre in foods: a review. Journal of food science and technology, 49(3), pp.255-266.

Dubberke, E.R., Carling, P., Carrico, R., Donskey, C.J., Loo, V.G., McDonald, L.C., Maragakis, L.L., Sandora, T.J., Weber, D.J., Yokoe, D.S. and Gerding, D.N., 2014. Strategies to prevent Clostridium difficile infections in acute care hospitals: 2014 update. Infection Control & Hospital Epidemiology, 35(S2), pp.S48-S65.

Farthing, M., Salam, M.A., Lindberg, G., Dite, P., Khalif, I., Salazar-Lindo, E., Ramakrishna, B.S., Goh, K.L., Thomson, A., Khan, A.G. and Krabshuis, J., 2013. Acute diarrhea in adults and children: a global perspective. Journal of clinical gastroenterology, 47(1), pp.12-20.

Hall, K.D., Heymsfield, S.B., Kemnitz, J.W., Klein, S., Schoeller, D.A. and Speakman, J.R., 2012. Energy balance and its components: implications for body weight regulation. The American journal of clinical nutrition, 95(4), pp.989-994.

Hooper, L., Bunn, D., Jimoh, F.O. and Fairweather-Tait, S.J., 2014. Water-loss dehydration and aging. Mechanisms of ageing and development, 136, pp.50-58.

Safe Disposal of Waste in C.Diff-Infected Patients

Hussein, Q.A. and Anaya, D.A., 2013. Necrotizing soft tissue infections. Critical care clinics, 29(4), pp.795-806.

Jetha, Z.A., 2014. Nursing Care in the Lance of Florence Nightingale. i-Manager's Journal on Nursing, 4(4), p.32.

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Keller, J.M. and Surawicz, C.M., 2014. Clostridium difficile infection in the elderly. Clinics in geriatric medicine, 30(1), pp.79-93.

Leffler, D.A. and Lamont, J.T., 2015. Clostridium difficile infection. New England Journal of Medicine, 372(16), pp.1539-1548.

Lessa, F.C., Gould, C.V. and McDonald, L.C., 2012. Current status of Clostridium difficile infection epidemiology. Clinical Infectious Diseases, 55(suppl_2), pp.S65-S70.

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McCune, V.L., Struthers, J.K. and Hawkey, P.M., 2014. Faecal transplantation for the treatment of Clostridium difficile infection: a review. International journal of antimicrobial agents, 43(3), pp.201-206.

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Rao, K., Micic, D., Chenoweth, E., Deng, L., Galecki, A.T., Ring, C., Young, V.B., Aronoff, D.M. and Malani, P.N., 2013. Poor functional status as a risk factor for severe Clostridium difficile infection in hospitalized older adults. Journal of the American Geriatrics Society, 61(10), pp.1738-1742.

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