Bowel Elimination (Ch.47)

steps for administering a prepackaged enema with the correct order in which they occur

1. Explain procedure to the patient 2. Perform hand hygiene and apply clean gloves. 3. Position patient on side 4. Insert enema tip gently in the rectum. 5. Squeeze contents of container into rectum. 6. Help patient to bathroom when he or she feels urge to defecate. These steps are used to administer a prepackaged enema.

correct order for an ostomy pouch change

1. Remove the old pouch 2.Cleanse and dry the peristomal skin. 3. Assess the stoma and the skin around it. 4. Trace the correct measurement onto the back of the wafer. 5.Measure the stoma. 6. Cut the hole in the wafer. 7. Press the pouch in place over the stoma. 8. Close the end of the pouch.

How many times do you have a bowel movement per week with constipation?

<3 per week w/hard, dry stools

Opiates

A category of psychoactive drugs that are chemically similar to morphine and have strong pain-relieving properties. * Opiates can cause flatulence (gas accumulation in the lumen of intestines' and bowel walls)

constipation

A symptom, not a disease; infrequent stool and/or hard, dry, small stools that are difficult to eliminate

flatulence

Accumulation of gas in the intestines causing the walls to stretch

The nurse should do which of the following when placing a bedpan under an immobilized patient? Lift the patient's hips off the bed and slide the bedpan under the patient After positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle Adjust the head of the bed so it is lower than the feet and use gentle but firm pressure to push the bedpan under the patient Have the patient stand beside the bed and then have him or her sit on the bedpan on the edge of the bed

After positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle Elevating the head of the bed allows the patient the most normal and comfortable position for defecation on a bedpan.

A patient has not had a bowel movement for 4 days. Now she has nausea and severe cramping throughout her abdomen. On the basis of these findings, what should the nurse suspect? An intestinal obstruction Irritation of the intestinal mucosa Gastroenteritis A fecal impaction

An intestinal obstruction Absence of bowel movement, nausea, cramping, and possibly vomiting are characteristic of an intestinal obstruction.

A newly admitted patient states that he has recently had a change in medications and reports that stools are now dry and hard to pass. This type of bowel pattern is consistent with: A. abnormal defecation B. constipation C. fecal impaction D. fecal incontinence

B. constipation •Rationale: Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. When intestinal motility slows, the fecal mass becomes exposed over time to the intestinal walls and most of the fecal water content is absorbed. Little water is left to soften and lubricate the stool. Constipation is a significant source of discomfort and the nurse should assess the need for intervention before the defecation becomes painful or the stool is impacted.

To maintain normal elimination patterns in the hospitalized patient, you should instruct the patient to defecate 1 hour after meals because: A. the presence of food stimulates peristalsis. B. mass colonic peristalsis occurs at this time. C. irregularity helps to develop a habitual pattern. D. neglecting the urge to defecate can cause diarrhea.

B. mass colonic peristalsis occurs at this time. Rationale: Mass peristalsis pushes undigested food toward the rectum. These mass movements occur only three or four times daily, with the strongest during the hour after mealtime.

digital removal of fecal impaction

Break up fecal mass with fingers and remove it in portions •Use if enemas fail to remove an impaction. •Last resort in managing severe constipation. •Loosening of fecal mass by massaging around it. •May follow with enema or cathartics

How often should you change colostomy pouch?

Change every 3 to 7 days

Which of the following symptoms are warning signs of possible colorectal cancer according to the American Cancer Society guidelines? Select all that apply. Change in bowel habits Blood in the stool A larger-than-normal bowel movement Fecal impaction Muscle aches Incomplete emptying of the colon Food particles in the stool Unexplained abdominal or back pain

Change in bowel habits Blood in the stool Incomplete emptying of the colon Unexplained abdominal or back pain According to the American Cancer Society current guidelines, anyone with these symptoms should seek medical evaluation because they may have colon cancer. Other conditions may also cause these symptoms; but, if colon cancer is present, early diagnosis is important.

Which of the following may cause Clostridium difficile infection? Select all that apply. Chronic laxative use Contact with C. difficile bacteria Overuse of antibiotics Frequent episodes of diarrhea caused by food intolerance Inflammation of the bowel

Contact with C. difficile bacteria Overuse of antibiotics These are the two main causes of C. difficile infection.

purpose of nasogastric tube

Decompression, enteral feeding, compression, and lavage [Review Table 47-3, Purposes of Nasogastric Intubation]

An elderly patient comes to the hospital with a complaint of severe weakness and diarrhea for several days. Of the following problems, which is the most important to assess initially? Malnutrition Dehydration Skin breakdown Incontinence

Dehydration Dehydration caused by fluid loss from the intestinal tract is an immediate and possibly dangerous consequence of diarrhea.

Enemas

Drug is suspended in a solution and infused into the rectum. ◦Cleansing enemas ◦Tap water (hypotonic) ◦Normal saline (safest) ◦Hypertonic solutions ◦Soapsuds ◦Oil retention ◦Other types of enemas ◦Carminative and Kayexalate

Categories of nasogastric (NG) tubes

Fine- or small-bore for medication administration and enteral feedings Large-bore (12-French and above) for gastric decompression or removal of gastric secretions

end colostomy

Formed stool

The nurse is taking a health history of a newly admitted patient with a diagnosis of possible fecal impaction. Which of the following is the priority question to ask the patient or caregiver? Have you eaten more high-fiber foods lately? Are your bowel movements soft and formed? Have you experienced frequent, small liquid stools recently? Have you taken antibiotics recently?

Have you experienced frequent, small liquid stools recently? Frequent or continuous oozing of liquid stools occurs when liquid fecal matter above the impacted stool seeps around the fecal impaction.

Which skills must a patient with a new colostomy be taught before discharge from the hospital? Select all that apply. How to change the pouch How to empty the pouch How to open and close the pouch How to irrigate the colostomy How to determine if the ostomy is healing appropriately

How to change the pouch How to empty the pouch How to open and close the pouch How to determine if the ostomy is healing appropriately The patient must be able to do these tasks to successfully manage his or her colostomy when going home.

bowel incontinence

Inability to control passage of feces and gas to the anus Causes: •Impaction •Bowel (Crohn's disease) or neurological disease (spinal cord injuries) or malignancy (rectal cancer) •Pathogens (C. diff, parasites) •Laxative abuse Harms body image and social isolation.

Which are key points that the nurse should include in patient education for a person with complaints of chronic constipation? Select all that apply. Increase fiber and fluids in the diet Use a low-volume enema daily Avoid gluten in the diet Take laxatives twice a day Exercise for 30 minutes every day Schedule time to use the toilet at the same time every day Take probiotics 5 times a week

Increase fiber and fluids in the diet Exercise for 30 minutes every day Schedule time to use the toilet at the same time every day These steps are the initial ones to take to resolve chronic problems with constipation before considering regular laxative or enema use.

When a patient has fecal incontinence as a result of cognitive impairment, it may be helpful to teach caregivers to do which of the following interventions? Cleanse the skin with antibacterial soap and apply talcum powder to the buttocks Use diapers and heavy padding on the bed Initiate bowel or habit training program to promote continence Help the patient to toilet once every hour

Initiate bowel or habit training program to promote continence A cognitively impaired patient may have forgotten how to respond to the urge to defecate and benefit from a structured program of bowel retraining.

During the nursing assessment a patient reveals that he has diarrhea and cramping every time he has ice cream. He attributes this to the cold nature of the food. However, the nurse begins to suspect that these symptoms are associated with what problem? Food allergy Irritable bowel Increased peristalsis Lactose intolerance

Lactose intolerance These symptoms are consistent with lactose intolerance, and they occur with ingestion of dairy products.

The nurse is teaching the patient to obtain a specimen for fecal occult blood testing using fecal immunochemical (FIT) testing at home. How does the nurse instruct the patient to collect the specimen? Three fecal smears from one bowel movement One fecal smear from an early-morning bowel movement One fecal smear from three separate bowel movements Three fecal smears when blood can be seen in the bowel movement

One fecal smear from three separate bowel movements Samples from three separate bowel movements decrease the risk of a false-negative or a false-positive result.

Nutritional considerations with ostomies

Post operative: •Will take a few days for appetite to return •Small servings of soft foods Colostomies: •Regular diet with adequate fiber to keep stool soft Ileostomies: •Risk for Dehydration: will lose fluid and salt through stoma •Encourage drinking of 8 oz. of water after emptying pouch •Food blockage with indigestible fiber •Rare with ileostomies •Corn, popcorn, raw mushrooms, fresh pineapples, Chinese cabbage •Advise to eat small amounts (chew thoroughly) and increase fluids

The nurse is caring for a patient with an ileostomy. Which intervention is most important? Cleansing the stoma with hot water Inserting a deodorant tablet in the stoma bag Selecting or cutting a pouch with an appropriate-size stoma opening Wearing sterile gloves while caring for the stoma

Selecting or cutting a pouch with an appropriate-size stoma opening A properly fitting pouch that does not leave skin exposed prevents peristomal skin breakdown.

During the administration of a warm tap-water enema, the patient complains of cramping abdominal pain that he rates 6 out of 10. What is the first thing the nurse should do? Stop the instillation Ask the patient to take deep breaths to decrease the pain Add soapsuds to the enema Tell the patient to bear down as he would when having a bowel movement

Stop the instillation When a patient complains of pain during an enema, the instillation should be stopped, and an assessment done before discontinuing or resuming the procedure.

loop colostomy

This is temporary in the transverse colon 2 openings: fecal (proximal) and mucus (distal)

Fecal immunochemical test (FIT)

Use antibodies to detect blood in the stool detects human-globin protein-- specific for colonic blood loss (Doesn't work for blood loss proximal to colon)

guaiac test

a diagnostic test looking for occult blood in the stool. It is done after taking a small stool sample during a rectal examination

flatulence

gas accumulates in the lumen of the intestines, the bowel wall stretches and distends Symptoms: •Abdominal fullness •Pain •Cramping Causes: ◦Opiates ◦Immobilization ◦Surgery

factors affecting bowel elimination

age, diet/fluid intake, physical activity, psychological factors, personal habits, position during defecation, pregnancy, surgery/ anesthesia, meds/laxatives/ cathartics

diarrhea

an increase in the number of stools and the passage of liquid, unformed feces

Crohn's disease

chronic inflammation of the intestinal tract

bowel training

defecation at the same time each day

hemorroids

dilated, engorged veins in the lining of the rectum

laxative abuse

electrolyte imbalance severe dehydration dependency stretched or "lazy" colon

when should you empty colostomy pouch?

empty pouch when 1/3 to 1/2 full

ileostomy

liquid stools

sigmoid colostomy

more formed stool -left lower quadrant

Cathartics and laxatives

promote bowel movements •Cathartics have a stronger and more rapid effect on the intestines than laxatives •Suppositories may act more quickly than oral medications refer to table 47-2 on pg. 1215

Impaction

results from unrelieved constipation; a collection of hardened feces wedged in the rectum that a person cannot expel

Antidarrheal Agents

some agents contain opiates

Bowel Diversions

temporary or permanent artificial opening in the abdominal wall *stoma Surgical opening in the ileum or colon ◦Ileostomy or colostomy

colonoscopy

the direct visual examination of the inner surface of the entire colon from the rectum to the cecum

Transverse Colostomy

thick liquid to soft consistency

Impaction

•A collection of hardened feces wedged in the rectum that a person cannot expel for several days Signs & Symptoms: liquid stools (similar to diarrhea) inability to pass stool urge to defecate abdominal pain nausea or vomiting loss of appetite rectal pain Dehydration Intervention: ◦Digital rectal exam ◦Removal of impaction Risk factors: •Confused •Unconscious •Debilitated

causes of diarrhea (increase # of stools & the passage of liquid or unformed stools) :

•Antibiotic use •Food intolerances or allergies •Hospital acquired pathogens (C. diff, VRE) •Food borne pathogens •Surgeries

care of ostomies

•Assess stoma and skin breakdown •Stoma should be PINK or RED •Look for skin irritation and breakdown from GI content •Fungal rashes, folliculitis or ulcerations •Pouch care •Change every 3 to 7 days •Empty pouch when 1/3 to ½ full •Patient teaching and participation •Psychosocial: Body image disturbances •Wound Ostomy Nurse Referral

concerns with diarrhea

•Dehydration •Fluid and electrolyte imbalance •Skin breakdown (perineum and buttocks)

Causes of constipation include:

•Irregular bowel habits •Chronic illnesses (arthritis, depression) or neurological conditions or chronic bowel dysfunction •Low fiber diet high in animal fats, low fluid intake •Stress •Physical inactivity •Medications (opiates) •Changes in life or routines (pregnancy, travel

environment while promoting defecation

•Maintain privacy and sensitivity •Bedpan or commode for non-ambulatory patients

position while promoting defecation

•Position •Sitting position •Bedpan •Types: Regular and Fracture •Prevent muscle strain and discomfort. •Never lift a patient onto a bed pan •HOB elevated 30-45 degrees pg.1164, Box 47-9

Enema administration

•Position patient in side lying position (Sims) •Caution with patients with cardiac disease - vagus nerve stimulation •Explain the procedure, positioning, precautions to avoid discomfort, and length of time necessary to retain the solution before defecation.

Interventions to prevent constipation

•Stool softeners •Diet modification and fiber •Increase activity •Increase fluids