- 3 sections: BOWEL ELIMINATION > Scientific Knowledge - mouth - esophagus - stomach a. duodenum Bowel elimination Function: 1. excrete/eliminate waste products of digestion 2. Maintaining normal bowel elimination is essential to health and efficient body functions GI System > Small Intestine - absorption of nutrients & electrolytes - 20 ft length, 1 in. in diameter - pressure on abd. Organs - iron supplements c. Ileum > Large Intestine Elderly prone to constipation - slowing of peristalsis - Absorbs H2O & electrolytes - Temporarily stores waste products - anus - defecation Pregnant women prone to constipation b. jejunum - small intestine - large intestine - Main function: ELIMINATION - 5 – 6 ft. length, 6 – 7 cm. diameter a. cecum b. ascending colon (right side) c. transverse colon d. descending colon Patterns through Life Cycle Babies- 3-6 BM’s/day Children - neuromuscular structures not developed until 15-18mos - voluntary control: 2-3 years Nursing Knowledge Base: Factors Affecting Bowel Elimination 1. Age 2. Diet 3. Fluid intake 4. Physical activity 5. Psychological factors 6. Personal habits 7. Position during defecation 8. pain 9. Pregnancy 10. Surgery and anesthesia 11. medication 12. Diagnostic tests Factors affecting Elimination 1. Fiber (undigestible residue) provides bulk – Absorbs fluid – Increases stool mass – Bowel wall stretches – Peristalsis stimulated – Defecation results 2. Personal habits – Busy schedule, postpone BM, constipation 3. Activity & Exercise – Immobile ↓ activity in colon 4. Medications – Laxatives – Narcotics w/ codeine 5. Emotions - Anxiety ↑ peristalsis & diarrhea - depression 6. Pain 7. Surgery – Anaesthetic causes temporary cessation of peristalsis 2. Impaction- results from unrelieved constipation – Direct manipulation of the bowel stops peristalsis - a collection of hardened feces wedged in the rectum that a person cannot expel Promoting Healthy Bowel Elimination Privacy Squatting position Bedpan position Cathartics & laxatives Anti-diarrheal agents Enemas Disimpaction Bowl routine 3. Diarrhea- an increase in the number of stools and the passage of liquid, unformed feces 4. Incontinence- Inability to control passage of feces and gas to the anus 5. Flatulence- accumulation of gas in the intestines causing the walls to stretch 6. Hemorrhoids- dilated, engorged in veins in the lining of the rectum a. daily time clock b. hot drinks c. stool softeners d. privacy e. position and abdominal pressure f. bearing down Common Bowel Elimination Problems 1. Constipation- a symptom, not a disease; infrequent stool and/or hard, dry, small stools that are difficult to eliminate Assisting with Elimination 1. Embarrassing & stressful 2. Bedpans a. metal or plastic b. regular or fracture pan c. cleanliness 3. Commode Procedure 1. Privacy-close door 2. Side rail as needed > Ostomies 3. Recumbent with HOB ↑ – Sigmoid colostomy 4. Tissue 5. Call bell 6. Leave alone if possible 7. Gloves 8. Clean genitals – Transverse colostomy – Ileostomy – Loop colostomy – End colostomy – Identifying normal and abnormal patterns, habits, and the patient’s perception of normal and abnormal regarding bowel elimination allows you to accurately determine a patient’s problems Elimination Factors a. Elimination pattern b. Surgery or illness c. Stool characteristics 9. Remove pan and cover Other approaches d. Medications 10. In & Out 1. Ileoanal pouch anastomosis e. Routines 11. Specimens 2. Continent ileostomy f. Emotional state 12. Clean pan 3. Antegrade continence enema g. Bowel diversions 13. Wash hands – yours and client’s h. Exercise 14. Lower bed i. Appetite changes 15. Client comfort j. Pain or discomfort Bowel Diversions > Temporary or permanent artificial opening in the abdominal wall - stoma > Surgical opening in ileum or colon - ileostomy or colostomy Nursing Process: Assessment k. Diet history 1. Through the patient’s eyes l. Social history 2. Nursing History m. Daily fluid intake – What a patient describes as normal or abnormal is often different from factors and conditions that tend to promote normal elimination n. Mobility and dexterity 3. Physical assessment - mouth, abdomen, and rectum 4. Laboratory tests- fecal specimens 5. Diagnostic examinations – Incorporate elimination habits or routines – Reinforce routines that promote health – Direct visualization – Indirect visualization – Bowel preparation Nursing Diagnosis Some diagnoses that apply to patients with elimination problems include: – Disturbed body image – Bowel incontinence – Consider preexisting concerns – Constipation – Perceived constipation – Risk for constipation – Diarrhea – Nausea – Deficit knowledge (nutrition) Planning Teamwork and collaboration Implementation: Health Promotion – When patients are immobile or it is unsafe to allow them to raise their hips, they remain flat and roll onto the bedpan Setting priorities – Patients often have multiple diagnoses – Wear gloves when handling bedpans Routine Colorectal cancer Promotion of normal defecation ACUTE CARE – Cathartics have a stronger and more rapid effect on the intestines than laxatives – Suppositories may act more quickly than oral medications c. positioning on bedpan – Prevent muscle strain and discomfort Goals and outcomes – Elevate head of the bed 30 to 45 degrees Antidiarrheal agents - opiates used w/ caution a. sitting position b. privacy Enema Cathartics and laxatives Enemas - cleansing enemas a. tap water b. normal saline c. hypertonic solutions d. soapsuds - oil retention - other types of enemas b. Large-bore (12-French and above) for gastric decompression or removal of gastric secretions - Carminative and - Clean technique Kayexalate – Sterile technique is unnecessary – Wear gloves – Explain the procedure, positioning, precautions to avoid discomfort, & length of time necessary to retain the solution before defecation Digital Removal of Stool – Use if enemas fail to remove an impaction – Last resort in managing severe constipation - Maintaining patency Enema Administration Inserting and Maintaining a Nasogastric Tube - Purpose: Decompression, enteral feeding, compression, and lavage - Categories of NG Tubes a. Fine- or small-bore for medication administration and enteral feedings Continuing and Restorative Care Care of ostomies Pouching ostomies Nutritional considerations Psychological considerations Bowel training Maintenance of proper fluid & food intake Promotion of regular exercise Management of patient w/ fecal incontinence or diarrhea Maintenance of skin integrity Evaluation 1. Through the patient’s eyes – Develop a therapeutic relationship – Evaluate a patient’s level of knowledge – Determine the extent to which the patient accomplishes normal defecation – Ask the patient to describe changes in diet, fluid intake, and activity to promote bowel health Safety Guidelines for Nursing Skills 1. Instruct patients who self-administer enemas to use the side-lying position 2. If a patient has cardiac disease or is taking cardiac or hypertensive medication, obtain a pulse rate, because manipulation of rectal tissue stimulates the vagus nerve and sometimes causes a sudden decline in pulse rate Suppository Administration • Check physician’s order, protocol – The patient or caregiver determines which therapies were the most effective • Left Lateral position 2. Patient outcomes • Lubrication • Gloves • Hold with thumb and index finger - used only once - electrolyte imbalance • Insert with index finger (3 – 4”) never force • Deep breath = relaxes anal sphincter CAUTION! – Vagus nerve stimulation can cause heart rate to slow – avoid excess manipulation a. water toxicity 5. Oil retention – Oil based solution b. circulatory overload (concentrating gradient) – Lubricates the rectum and colon 2. Normal Saline – Softens stool, easier to pass - used when more than one enema is needed – Retain 1 –2 hrs if possible Enema Administration - safest • Main purpose - isotonic a. Promotion of defecation, stimulate peristalsis - large volume to distend bowel b. The fluid breaks up fecal mass, stretches the rectal wall & initiates the defecation reflex – 5 – 15 mls. Castile soap in 1000mls warm water 3. Hypertonic solution – Smaller volume of fluid – Draws from surrounding tissue into bowel to soften stool and stimulate peristalsis – Follow with cleansing enema 6. Medicated – Instill meds. – Rectal mucosa absorption – Ex. – Kayexalate to ↓ K (potassium)Absorbs K from the intestinal tract Volumes for Enemas 1. Large volume – 500 – 1000mls – Fleets – sodium phosphate Types of Enemas > CLEANSING ENEMAS 1. Tap water - hypotonic – Container 12 – 18 in. above the • Low volume, concentrated solution bowel 4. Soap suds – Lg. Volume stimulates & causes evacuation of stool – Less common – Soap irritates the bowel 2. Small volume – 500 mls. – Container 12 in.above bowel 3. Pre-packaged – Fleet 150mls – Microlax 5mls – Hypertonic solution Procedure for Enema Administration 1. Confirm Dr’s order, prepare client, verbal consent, equipment, privacy • Prepackaged used more than large volume because: a. works • C/O discomfort, lower bag, slow infusion, stop, then start again – Left lateral position (fld. Flows by – Remain side lying to retain 5 – 10 min. or as long as possible – Drape, pad under buttocks 7. Assist to bathroom or give bedpan gravity – User friendly – Hold for 5min. – Higher the bag – greater the pressure – Warm solution- stimulates peristalsis • Hot sol’n burns mucosa • Cold sol’n causes cramping 8. Evaluate results 9. Document – Type & volume of enema – Color, amount, consistency of fecal return b. less risk for electrolyte imbalance 2. Prime tubing c. rapid administration 3. Lubricate tip d. less discomfort 4. Glove 10. Wash hands e. convenient and quick 5. Insert 7-10 cm (3-4 in) adult Ostomy Care • Physician’s order reads “enemas to clear” – Return solution will be highly colored but no solid stool – Isotonic solution (normal saline) Excess enema use seriously depletes fluid and electrolytes – Hygienic measures for client – Do not force – Deep breath – Guide toward umbilicus 6. Container at appropriate height – Lg. = 12 – 18in – Sm. = 12in – 1000mls takes ~ 10 min to instill • Certain diseases require surgical interventions to create an opening into the abdominal wall for fecal and urinary elimination • Enterostomy – the surgical procedure performed to produce the artificial stoma • Ostomy = opening made to allow passage of urine or stool • Ostomies may be permanent – More common 2. Skin Breakdown – Continuous drainage – Moisture on skin – Piece of intestine is brought out onto the client’s abd. • temporary – Rest the bowel – Crohn’s 3. Replace urinary pouch q 2-3 days – Lacks nerve endings Urinary Ostomies – Doesn’t hurt to touch but has other implications • Provide drainage of urine that bypasses the bladder = Urinary Diversion • Stoma = mouth like opening in the abdominal wall to drain urine or stool • Ureterostomy • Effluent – drainage from stoma – Ureter to abd. Wall – Lt., Rt., Bilateral • Bowel ostomies – Cancer ( Ca) – Drain fecal material – Consistency depends on location - Higher up = more liquid -greater risk skin irritation b/c concentration of digestive enzymes • Ileostomy – End of small intestine – By passes lg. Intestine = freq. Liquid stools • Colostomy – Large intestine – More solid stool Ileal conduit • 6 – 8 in. ileum • 1 end for external opening • Other end closed off • Ureters implanted into this piece of bowel • Pouch Pouching an Enterostomy 1. Effluent (drainage) may begin immediately 2. Collects all effluent 3. Protects the skin 4. Stoma should be moist and reddish pink (same as other mucus membranes) 5. Flush to skin or bud-like protrusion 6. Black, purple, dry = inadequate circulation Pouch w/ Skin Barrier • Comfortable fit • Cover skin surrounding stoma • Good seal • Urine will have shred of mucus b/c bowel still produces same • Post-op pouch should allow for visibility of stoma Concerns Types of Pouches and Skin Barriers 1. Infection – Sterile ureters provide opening into system 1. One Piece Pouching System – Skin barriers preattached, precut, custom fit 2. Two Piece System – Skin barrier with flange (plastic ring) – Corresponding size pouch 3. Assess stoma – Measure correct size 7. Remove backing – Fear of rejection 8. Ileostomy- apply thin circle barrier paste around opening of pouch and allow to dry (if creases or bumps use barrier paste to even surface for pouch application) – Sexual function 9. Pouch should point to client’s knees 10. Maintain gentle finger pressure around barrier for 1-2 min. – Change q 3-7 days 11. Picture frame flange with non-allergic paper tape – Empty 1/3 to ½ full, expel flatus 12. Ostomy deodorant for pouch prn 13. Tub bath or shower Steps to Care for Ostomies 14. Normal stoma oozes blood if rubbed 1. Supine position 15. Actual bleeding into pouch is abnormal 2. Wash hands, glove 16. Pouch covers are available 3. Remove pouch & skin barrier, push skin away from barrier 17. The client will be watching the nurse during ostomy care to gage reaction 4. Cleanse peristomal skin gently with warm tap water and clean cloth 18. Be conscious of facial expression & nonverbal cues – Do not scrub, Avoid soap (residue- pouch won’t adher) 19. Education 5. Correct sizing 6. Cut opening 1/16 – 1/8 larger than stoma 20. Counseling – Body image – Self-care – Powerlessness over bowel regulation
