bowel

You are caring for a patient with a colostomy. In order to provide safe care you understand that when irrigating a colostomy a proper fitting cone is needed to prevent A. Introducing air into the colon B. Leaking the solution around the stoma C. Administering the solution too rapidly D. Introduction of bacteria from the stoma

B A proper fitting cone prevents leakage of the solution around the stoma that may cause irritation and damage to the skin surrounding the stoma.

different ostomy pouches single vs double pouch

single - bag and wafer do not come apart, comes off as one piece double - 2 piece system - wafer and pouch not together differences -2 piece pouch --> instead of emptying it you can take it off and throw it away and get a new one

factors that affect bowel elimination pain

•Hemorrhoids •Rectal surgeries •Fissures •Abdominal surgery

factors that affect bowel elimination physical activity

•Promotes peristalsis

type 5

Soft blobs with clear-cut edges (passed easily)

cleansing enemaas

- help promote the complete evacuation of feces from the colon. - Works by stimulating peristalsis through the infusion of a large volume of fluid that could include normal tap water, normal saline soapsuds, and then a low volume hypertonic solution

assessment mouth

- inspect teeth, tongue, and gums- looking for poor dentation or poor fitting dentures that could influence the patient's ability to chew and would impact the whole elimination patter as well as nutrition

psychological considerations

-Assess patient emotionally - anxiety, self-esteem, concerns, monitoring body image There going to have changes with sexuality and need emotional support ****Patient needs to feel confident in it and they are comfortable with managing it and changing it

care of ostomies

-Empty the bag when 1/3-1/2 full -Change every 3-7 days - make sure to assess stoma while doing so, and assess that skin around the stoma (make sure it is not too tight to affect blood flow but if too loose decal mater could break down the skin if it leaks and cause pressure or skin ulcers --Can use skin protectant --If one doesn't fit appropriately -we have different types of pastes and powders ****•Teaching needs to begin immediately -especially if we know it is going to be a lifelong thing

nutritional considerations

-New ostomies take a few days for their appetite to return -Start with servings of small soft foods - new norm -Have no diet restrictions -->Just adjusting to the new norm -Ileostomy - their food will be digested differently because it is not going into the large intestine , so they are lacking a lot of absorption and has a lot of water and sodium in it (watch for fluid and sodium levels)

loop ostomy

-Reversible stomas and instructed in ileum or colon -Pulls a loop of intestine into the abdomen and they place a plastic rod or bridge temporarily under the bowel loop to keep it from slipping back into the abdomen •Surgeon opens the bowel in two spots within the intestine and suitors it to the skin of the abdomen, so we still have 2 openings

stomach 3 tasks

-Storage of swallowed food and liquid -Mixing of food with digestive juices called chyme -Regulating the contents by moving it forward to small intestine

oil retention

-help to lubricate the feces and rectum and colon (feces absorb the oil and it softens and makes it easier to pass) -->Helps if the patient tries to retain the enema for several hours

assessment

-through the patients eyes nursing history - •What a patient describes as normal or abnormal is often different from factors and conditions that tend to promote normal elimination. •Identifying normal and abnormal patterns, habits, and the patient's perception of normal and abnormal with regard to bowel elimination allows you to accurately determine a patient's problems.

double barrel stoma

-two stomas right next to each other or distance between them (2 separate stomas) -Bowel was brought up at both ends -Proximal end is draining the fecal material (higher end) -Distal end is the natural mucus that occurs in the GI system •Share the same pouching system if possible •When they are not next together it can be more challenging

constipation

A symptom, not a disease; infrequent stool and/or hard, dry, small stools that are difficult to eliminate causes -improper diet, reduced fluid intake, lack of exercise, medications - narcotics (need to look at if we can fix these causes or if it is a disease process) -when intestinal motility slows, the fecal mass is exposed to the intestinal walls over time and most of the free water is absorbed and the stool becomes hard leading to constipation interventions - laxatives, stool softeners, increase fiber, increase water, increase mobility, postion changes

flatulence

Accumulation of gas in the intestines causing the walls to stretch

•The nurse is preparing to administer medication to the patient with gastric decompression with suction. What does the nurse need to remember after administration? •A. Assess the patient for bladder distention. •B. Turn the suction on after 30 mins of administration. •C. Turn the suction on immediately after administration. •D. Make sure the head of the bed is at 20 degrees.

B •The nurse needs to ensure that the suction is turned on 30 min following PO meds. The suction needs to be off during this time to allow for breakdown and metabolism of the medication. The HOB of the should be 30 degrees or higher and bladder distension is not related to the question asked

•Which statement by a patient with an ileostomy alert the nurse to the need for further education? •A. "I don't expect to have much of a problem with fecal odor." B. "I will have to take special precaution to protect my skin around the stoma." C. "I'm going to have to irrigate my stoma, so I have a bowel movement every morning." D. "I should avoid gas forming foods like beans to limit funny noises from the stoma."

C •This statement is inaccurate in relation to an ileostomy and indicates that the patient needs more teaching. And ileostomy produces liquid fecal drainage that is constant and cannot be regulated. The odor from drainage is minimal because fewer bacteria are present in the ileum compared with the colon. And ileostomy is an opening into the ileum (distal small intestine from the jejunum to the cecum). Cleansing the skin, skin barriers, and a well fitted appliance are precautions to protect the skin around the ileostomy stoma. The drainage from ileostomy contains enzymes that can damage the skin. An ileostomy stoma does not have a sphincter that can control the flow of flatus or drainage, resulting in noise.

•While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following is the appropriate intervention? •A. Have a client hold his breath. B. Discontinue the fluid installation. C. Remind the client that cramping is common. D. Lower the enema fluid container.

D •To relieve the client's discomfort, the nurse should slow the rate of installation by reducing the height of the enema solution container. Taking slow, deep breaths is more therapeutic for easing discomfort than holding the breath. The nurse should stop the installation if the client's abdomen becomes a rigid and distended or if the nurse notes bleeding from the rectum.Option C is not therapeutic as it implies that the client must tolerate the discomfort and that the nurse cannot or will not do anything to ease it.

type 3

Like a sausage but with cracks on surface

factors that affect bowel elimination

age fluid intake psychological factors position during defecations pregnancy medications diet physical activity personal habits pain surgery and anesthesia diagnostic tests

diarrhea

an increase in the number of stools and the passage of liquid, unformed feces •Passing too quickly and preventing the usual absorption of the nutrients •Causes: irritation within the colon that could result in increased secretion and as a result the feces can become watery and the patient may have difficulty controlling that urge to defecate causes: •Cdiff can cause it •Food borne pathogens •Surgery •Food intolerance •Excess loss of colonic fluid can result in dehydration, poor electrolyte balance and may have an acid base imbalance •Need good skin care to prevent breakdown •Are they dizzy, orthostatic hypertension, skin changes,

how stoma is formed

bring a piece of the intestine out through a surgical opening created in the abdominal wall -turn it down like a turtleneck •and suturing it to abdominal wall and that holds in place and where the stool will eliminate •Can be temporary or permanent

hypertonic solutions

colon fills with the fluid and can result in distension to promote defection. If patients are unable to tolerate large volumes of fluid they may benefit from this type of enema (contraindicated for patients who are dehydrated or young)

ostomy based on location and what will the stool look like

colostomy (large intestine) -sigmoid colostomy - more formed stool-lower in the colon --normally left lower quadrant of the abdomen -transverse location - going to be more liquid (thick liquid to soft consistency) ileostomy (small intestine) -ileostomy - fecal material has not gone to the large intestine --> so the nutrition has not been absorbed (going to be more liquid and more often)

•Clients should be taught that repeatedly ignoring the sensation of needing to defecate could result in which of the following?

constipation •Ignoring the urge to defecate can lead to constipation through loss of the urge and the accumulation of feces. Diarrhea will not result anything, there is increased opportunity for water reabsorption because the stool remains in the colon, leading to firmer stool. Ignoring the urge shows a strong voluntary sphincter, not a weak one. Hemorrhoids would only occur only if severe drying out of the stool occurs, and thus repeated need to strain to pass stool.

hemorrhoids

dilated, engorged veins in the lining of the rectum •Assess if the hemorrhoid break open and start bleeding •Often times it is very minimal and stop quickly but sometimes if their large we may need to intervene

type 6

fluffy pieces with ragged edges, a mushy stool

Bristle scale

help classify feces used as an objective tool type 1 constipation type 7 watery

tap water

hypertonic solution, and tap water escapes from the bowel movement into the intestinal spaces and that movement of water is low and helps stimulate defecation before large amounts of water can actually leave the bowel (if we do this multiple times we worry about water toxicity or fluid volume overload)

incontience

inability to control passage of feces and gas from the anus •Many conditions can cause it •Does the patient know they need to go to the bathroom? •**need to assess and understand why they had it

type 4

like a sausage or snake, smooth and soft

mouth

mechanically and chemically breaks down nutrients into sizeable forms

esophagus

passes through the upper esophagus sphincter and the bolus of food travels down the esophagus with the aid of peristalsis (contraction that propels the food through the length of the GI tract)à passes through cardiac sphincter (what helps prevent acid reflex) which leads into stomach

impaction

results from unrelieved constipation; a collection of hardened feces wedged in the rectum that a person cannot expel •Can be up until the sigmoid colon •Severe impaction can result in intestinal obstruction (nothing can get around it) •Debilitated, confused, or unconscious are at most risk •If you start to notice oozing or liquid stools is when you should suspect an impaction -->need KUB or abdominal x-ray to assess if you have an obstruction

normal saline

safest solution, same osmotic pressure of fluid--natural

type 2

sausage shaped but lumpy

Type 1

separate hard lumps like nuts (difficult to pass)

ostomies

something is preventing the colon from doing its job

type 7

watery, no solid pieces (entirely liquid)

factors that affect bowel elimination fluid intake

•3L men 2.2 L for women (help soften stool)

factors that affect bowel elimination diagnostic tests

•Bowel prep •Enema -to clear the bowel -cause loose stools

health promotion/ restorative care

•Bowel training (habit training) setting up a daily routine, want patient to defecate at same time each day, helps them have normal patterns •Maintenance of proper fluid and food intake (consider the frequency and characteristics of stool) (want whole grains, fiber, fruits and vegetables) •Promotion of regular exercise •Management of the patient with fecal incontinence or diarrhea •Maintenance of skin integrity ***we want to teach the patient less invasive ways to have good bowel movements

factors that affect bowel elimination personal habits

•Busy work schedule may prevent a person from having the time to go •Disruption of regular habits can cause changes such as constipation

other types carminative

•Carminative (provide relief for gastric distension, improve ability to pass flatus) and Kayexalate (these are medications)

cathartics and laxatives

•Cathartics have a stronger and more rapid effect on the intestines than laxatives used for bowel surgery or constipated •Suppositories may act more quickly than oral medications (shortly after patient usual time to defecate- try to follow patients regular bowel pattern)

factors that affect bowel elimination surgery and anesthesia

•Cause temporary sensation of peristalsis - stops it, •should return, if not could have an illias and usually lasts about 24 - 48 hours and its because their no moving, so if patient remains inactive or cannot eat, could potentially lead to a bowel obstruction

diagnostic exams

•Diagnostic exams - just be aware what they are and how to help the patient •Direct visualization - directly visualizing the GI system endoscopy, need bowel preparation •Indirect visualization- xrays, ultrasound, CT, MRI •Bowel preparation/colonoscopy-- NPO and clear small and large intestine -going to have loose stool want them to call us so we can help them to the bathroom and they don't get lightheaded

enemas

•Enemas (insulation of solution into rectum and sigmoid colon- volume of fluid instilled that breaks up fecal mass and stimulates peristalsis) -Can put meds in it (most commonly used for relief of constipation or empty the bowel before a procedure) •Typically in hospital it is a bag system (similar to tube feeding) and end of it will be a tube system inserted into the rectum •Normally use tap water and hypertonic at times

Pouching ostomies

•Fairly odor proof, also protects the stoma Tan-yellow piece (wafer) - this piece you will cut around-has lines of measurement- trace around the stoma to know how large an opening you need-then you use that transparent piece to cut the stoma- it should fit snugly- not tight but snug to prevent fecal material from leaking onto the skin you can get different solutions to clean the bottom of the bag to prevent odor -not completely odor proof can get covers for ostomy

laboratory tests

•Fecal occult blood test, measures the amount of blood in feces. -->Used to screen colon cancer as well as if we think the patient is bleeding in their rectum •Fecal immunochemical test, tests similar things, all positive tests are followed up with endoscopy (colonoscopy) •Monitor by lab to look for pus, blood, mucus •Assess for pin warms in children - take piece of tape over their rectum and take it off right away and see little egg sacs, sometimes you can see the warms •CBC (complete blood count) - tell us hemoglobin or hematocrit to tell us if there is a GI bleed, if WBC up can tell us an infection •look at fluid and electrolytes (if diarrhea and vomiting à lost some electrolytes)

factors that affect bowel elimination age

•Infants have smaller stomach capacity --Less secretion of digestive enzymes and more rapid peristalsis --Stools little softer and loose --Ability to control defecations doesn't happen until about age 2-3 --Need to be able to communicate needs and have some sort of muscular control •Adolescents experience rapid growth and increased metabolic rate and increase secretion of gastric acid and can act as a bacteria against organisms •Older adults - worry about chewing, decreased ability to do that --Cognitive issue, stroke, --peristalsis declines, and esophageal emptying begins to slow --Impair absorption, and intestinal mucosa begins to relax and make it more difficult for the older adult to be able to control defecation

decompresion

•Inserting and Maintaining a Nasogastric Tube -Purposes •Decompression, enteral feeding, compression -Categories of nasogastric (NG) tubes •Large-bore (12-French and above) for gastric decompression or removal of gastric secretions -Clean technique -Maintaining patency •Remember the blue port is for air to escape, do NOT use this to flush the NG. •Used for bowel obstruction •GI system not functioning •Decompression takes over some of the work of the GI system •Larger NG tube, want to suck things out •Clean procedure and want good patency and flushing the tube regularly to prevent blockage •Patient is continuously hooked to suction ******If patient is ordered PO meds, we shut suction off for 30 mins but has to go back on -->If we don't have the suction on the abdomen will become firm and distended (Most patients changed into IV meds) •NPO, pry on TPN •Measure the gastric output daily, note color consistency (normally green brown) •Do not flush the air line (the blue port) do not put anything down this line, it is to remove the gas from the abdomen •When patient is coming off it (we lower the suction rate before coming off of it)

assessment abdomen

•Inspect all 4 quadrants of the abdomen and looking for any changes in abdominal status (curve? bulge?) •Auscultate for bowel sounds- listen for full minute if we need it •Percuss to look for abdominal structures and detect lesions of gas, fluid, anything really within the abdomen •Palpate for any mases or tenderness

rectum

•Inspect areas around the anus - look for lesions, discoloration, inflammation and looking for hemorrhoids or any sign or symptoms of really skin breakdown or pain that the patient may be discussing

safety guidelines for nursing skills

•Instruct patients who self-administer enemas to use the side-lying position ideally to left. -->If on a toilet can result in rectal tearing, can injure their rectal wall •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. -

antidiarrheal agents

•Opiates used with caution (can be habit forming) •Decrease the intestinal muscle tone to slow passage --> body reabsorbs the water in the intestinal walls •Educate patient to follow instructions because if they take too much, they will become constipated

factors that affect bowel elimination medications

•Pain meds- cause constipation •Stool softeners •Locatives

health promotions

•Primary prevention - hydration, adequate dietary intake, regular tolieting practices (not holding it), regular exercise, take time to defecate •Routine- establish routine (good time an hour after a meal) •Colorectal cancer- can be treated and eliminated, if patient is noticing changes or blood in the stool - report any abnormal findings to be screened further •Promotion of normal defecation -->Sitting position (if using a bed pan elevate head of bed to 35-40 degrees) -->Privacy -->Positioning on bedpan

factors that affect bowel elimination psychological factors

•Prolonged emotional stress impairs the function of really all body systems --Slows peristalsis - digestive process can be accelerated, and peristalsis could be potentially increased, over time it can be decreased •**big thing is that long term stress can have an affect

factors that affect bowel elimination diet

•Regular food intake helps maintain a regular pattern of peristalsis •Fiber helps us provide the bulk of our fecal material (help remove fats and waste products from the body) •Some food produce gas and will distend intestinal walls and increase the motility in peristalsis

factors that affect bowel elimination pregnancy

•Size of baby increases --> puts pressure on rectum --> causes temporary obstruction --> slows peristalsis and can lead to constipation

enema administration

•Sterile technique is unnecessary. (clean technique) •Wear gloves. •Explain the procedure, positioning (left side lying), precautions to avoid discomfort, and 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.

soapsuds

•add soapsuds to tap water to create the effect of intestinal irritation and that irritation helps stimulate the bowel (caution in pregnant women and older adults because it can cause electrolyte imbalances or potential damage to the intestinal mucosa)

small intestine

•chyme comes into intestines as a liquid and moves with the digestive enzymes and reabsorption in the small intestine is very effective -Duodenum, jejunum and ileum

assess the stoma

•several times throughout the shift •Looking for it to be beefy red, pink, appear moist and glisten, slightly protruded from skin but very stubble •If lack of blood flow to stoma it will be pale, gray, appears dry -->That piece of intestine is beginning to die and we need to act quickly

factors that affect bowel elimination position during defecations

•squatting is normal position, •if patient is immobilized in bed it can be difficult to have a bowel movement

large intestine

•time the fluid reaches the colon it is starting to be solid (semi-solid) - primary organ for bowel elimination -lot of absorption, secretion, and elimination of nutrition -Cecum, ascending colon, ascending colon, transverse colon, descending colon, sigmoid colon, and rectum -These mass movements occur about 3-4 times daily, strongest an hour after mealtime -Rectum - contains vertical and transverse folds of tissue that help control expulsion of our fecal contents, •These folds contain veins that can become distended from pressure during straining (result in hemorrhoid formation)