When To Get Professional Help

Call the doctor or nurse if any of the following are true:

• Severe Diarrhea. Ask the doctor or nurse when to call about diarrhea. Severe diarrhea means that a lot of fluid is being lost. With severe diarrhea, stools are very runny and frequent, and the person often complains of stomach cramps as well. The severity of the problem depends on many factors, such as the person's weight or previous state of fluid balance. Losing small, frequent amounts of fluid in the stool in diarrhea can be dangerous for a small child or for anyone who has been recently struggling with diarrhea or vomiting. In this situation, dehydration happens or worsens quickly. Reporting severe diarrhea early is important so that fluids are given to reverse or prevent the dehydration.
• Diarrhea for more than one day.
• Blood in the diarrhea stool.
• Fever above 101 degree F with diarrhea.

Know the following facts before you call:

1. How many bowel movements are usual each day?
2. How many bowel movements were there in the past 24 hours?
3. How runny were they?
4. Any other symptoms with the diarrhea? Information about other symptoms tells the doctor or nurse how serious the problem is. There can be a danger of other side effects, such as a rectal infection or dehydration. Rectal infections are caused by bacteria that invade the body when the skin is broken down from the acids and irritants in the diarrhea stool. This is uncomfortable and painful. Examples of other symptoms are:
   • stomach pain
   • stomach cramps
   • bloating (feeling very full in the stomach or abdomen)
   • nausea (sick to the stomach)
   • vomiting
   • decreased urine output
5. How much liquid was taken and how much as eaten in the past two days? Liquids and foods that were taken inform the health professionals if the amount of liquid coming out of the body is being replaced by fluid intake. Dehydration is important to treat because it could lead to dangerously low blood pressure and chemical imbalance. Sometimes intravenous (IV) fluids are ordered to balance out the fluid loss. These IV fluids can contain other nutrients that are being lost in the diarrhea, such as glucose, potassium, and sodium.
6. What medicines were taken in the past two to three days?
   • chemotherapy (when)
   • stool softeners
   • antibiotics
7. Has weight been lost? How much?
8. Is there any history of other bowel problems?

Here is an example of what someone might say when calling for help:

"I am Joan Smith, Harry Smith's mother. My son is a patient of Dr. Ungar's with leukemia. The homecare plan on diarrhea says to call if he's had diarrhea for more than one day."

What You Can Do To Help

If you decide that this is not an emergency, then there are three things you can do to solve this problem. Consider them in this order:

1. Replace lost fluids and nutrients promptly
2. Avoid certain foods
3. Increase comfort

Replace lost fluids and nutrients

Important fluids and salts are lost with diarrheal stool. Replacing them is crucial. Here are several ways to do this.

• Offer clear liquids, for example, Pedialyte, Ricelyte, and Gatorade. Chicken broth, tea, flat ginger ale, and Popsicles; may be used in small quantities in addition to electrolyte supplements. If an infant is breast-fed, continue breast-feeding. Drinking clear liquids like chicken broth or juice provides nourishment but also lets the bowel rest. Clear liquids are easier for the intestines to absorb into the bloodstream, and they quickly replace the fluids being lost with diarrhea. Ricelyte, Pedialyte, and Gatorade have a balance of liquid and electrolytes (salts) which are easily absorbed and will maintain the proper balance in the body.
  
• Serve fluids between meals. Taking fluids between meals keeps a steady amount of water and other nutrients going into the body. Drinking between meals is also less likely to cramp a sore stomach or lower intestines.
  
• After 24 hours of clear liquids, add low-fiber foods, for example, bananas, rice, applesauce, mashed potatoes, dry toast, crackers, eggs, fish, and poultry. Low-fiber foods do not attract or pull water out of the body into the bowel. They are easier to digest than high-fiber vegetables.
  
• Eat small meals throughout the day instead of three larger meals. Smaller meals are easier to digest. The person will take in more fluid and food this way if served more frequently than three times a day.
  
• Increase high-potassium foods in the diet, such as apricot or peach nectar, bananas, and mashed or baked potatoes. People tend to lose potassium when they have diarrhea. This chemical is vital to the body and needs to be replaced.

Avoid certain foods

Some foods increase the action of the bowel and how quickly it pulls fluid out of body tissues into stool. Avoiding these foods will help reduce a problem with diarrhea.

• Avoid serving foods that produce gas, for example beans, raw vegetables, raw fruits, broccoli, corn, cabbage, cauliflower, carbonated drinks, and chewing gum. These foods make a person stop eating or drinking early. Gas also adds to discomfort. Chewing gum also should be avoided because it makes some people swallow air, which also adds to abdominal discomfort.
  
• Avoid serving foods that contain acids, such as highly spiced food or citrus juices like orange or grapefruit. These make the stomach and intestines churn and can create more discomfort as well as more diarrhea.
  
• Avoid serving fat, such as fatty meats and greasy fried foods. Fats are difficult to digest. If the person has diarrhea, then fats are pushed through without being digested, and their undigested presence adds to the diarrhea.
  
• Cool down extremely hot food or hot drinks. Hot foods and liquids stimulate the bowels. Avoid these until the diarrhea is solved.
  
• Limit the person's caffeine, for example, coffee, strong teas, sodas with caffeine, and fruit juices. Caffeine and fruit juices make the bowel work faster. If a person has diarrhea, you want to slow down their bowels because they are already overactive.
  
• Avoid giving milk and milk products if they seem to make diarrhea worse. Milk can also make diarrhea worse. Milk and dairy products should be resumed last-after diarrhea is resolved and the child is tolerating other foods and fluids.

Increase comfort

The lower abdomen can become quite sore from intestinal cramps that may accompany diarrhea. The person with cancer can also feel very worn out from bouts with diarrhea. Rectal skin or skin around a stoma can become very sore. Here are several ways to ease abdominal or skin soreness:

• Put a warm hot water bottle wrapped in a towel on the abdomen. Warmth on the stomach can relieve pain and discomfort caused by stomach tightness or cramps. However, do not use a heating pad. The skin may be very sensitive to heat, especially if the person is receiving chemotherapy or radiation therapy, and a heating pad could cause additional problems with the skin.
  
• Cleanse anal area gently, but thoroughly, after each bowel movement. After diarrhea, cleanse the outside of the anus very gently with warm water and then dry the skin to reduce redness and prevent infection. (You may need to pat the skin dry or dry with a hair dryer set on "cool"-no heat.
  
• Soak in warm water. Use a tub or Sitz bath. Sitz baths can be bought at most pharmacies or medical equipment stores. Sitz baths are plastic bowls that are placed over the toilet and the person can sit in the bowl of warm water while it flows into the bowl from above and spills into the toilet below. Sitting in a tub of warm water is also practical.
  
• Apply soothing creams, ointments, or astringent pads to the rectal area, such as Tucks. Creams prevent anal skin from chapping in the same way they prevent diaper rash or chapping on infant skin. Try Nupercainal, A&D, or Vaseline. Astringent pads also help to dry the area and soothe irritated skin.
  
• Protect the rectal skin with a barrier ointment such as Desitin, Balmex, or Criticaid. If the diarrhea continues and the anal area becomes very sore and red (or to prevent redness and breakdown), apply an ointment, such as Desitin, Balmex, or Criticaid to cover the skin. Fluids will be less likely to burn the skin since this type of ointment covers the skin with a protective layer. These ointments must be thoroughly cleaned away and then reapplied after each bowel movement.

Possible Obstacles

Think about what ideas or attitudes could prevent you from carrying out your plan and reaching the goal of controlling or preventing diarrhea.

Here are some obstacles that other people have faced.

"He's had nothing to eat or drink for days so this diarrhea can't last much longer."

Response: The body can keep removing fluid for much longer than you think. The fluid is drawn from body tissues and diarrhea can continue even if the person stops eating or drinking. It's very important to replace the fluids that are lost even if the person thinks that these will be washed out instantly.

Carrying Out and Adjusting Your Plan

Be aware of the frequency and severity of diarrhea. Are you able to stop the diarrhea on your own whenever it starts? Is the anal skin or skin around a stoma as well cared for and protected as it can be? Are other precautions with fluids and diet being followed to prevent diarrhea?

If your plan doesn't work

If problems with diarrhea are getting worse or the person with cancer is becoming very worn out, review When to get professional help When calling, tell the doctor or nurse what was done to deal with diarrhea and discuss what else should be done. If you don't think that you need to talk with a doctor or nurse about this problem, then ask yourself if you are doing every-thing you can to protect the skin against soreness and to encourage plenty of fluid intake to prevent dehydration. If diarrhea problems continue, ask the doctor or nurse for help. Tell them what you have done and what the results have been.

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