Bowel Elimination NUR212B

BOX 37-1 Warning Signs of Colon Cancer (Taylor 1355)

1. Change in the bowel elimination pattern 2. Blood in the stools 3. Rectal or abdominal pain 4. Change in the character of the stool 5. Sensation of incomplete emptying after bowel movement

At the age of 1 year, all infants commonly pass ____ or ____ stools a day. Parents may mistakenly interpret the infant's liquid stool as DIARRHEA or passage of more than three loose stools a day. Loose stools may be related to OVERFEEDING.

At the age of 1 year, all infants commonly pass ONE or TWO stools a day. Parents may mistakenly interpret the infant's liquid stool as diarrhea passage of more than three loose stools a day. Loose stools may be related to overfeeding.

Breastfed babies have more FREQUENT stools; the stools are YELLOW to ____ and loose, and usually have little odor. The stools of formula-fed infants vary from YELLOW to _____, are paste-like in consistency, and have a stronger odor because of the decomposition of protein.

Breastfed babies have more FREQUENT stools; the stools are YELLOW to GOLDEN and loose, and usually have little odor. The stools of formula-fed infants vary from YELLOW to BROWN, are paste-like in consistency, and have a stronger odor because of the decomposition of protein.

Provide easy access to the bathroom. Use assistive devices when necessary (raised toilet seat, grab bars, walker). Ensure safety when ambulating (e.g., skid-proof slippers). Encourage participation in a bowel-retraining program. (Taylor 1349)

Decreased muscle tone/incontinence (Taylor 1349)

Encourage small, frequent meals. Discourage heavy activity after eating. Encourage a HIGH-FIBER, low-fat diet. Encourage adequate fluid intake. Discourage regular use of laxatives. Evaluate medication regimen for possible adverse effects. (Taylor 1349)

Slowing of gastrointestinal motility with increased stomach-emptying time (Taylor 1349)

The number of stools infants pass varies greatly. For example, breastfed infants can pass from ___ to ___ stools daily, whereas bottle-fed infants typically pass ___ or ___ stools daily. (Taylor 1348)

The number of stools infants pass varies greatly. For example, breastfed infants can pass from 2 to 10 stools daily, whereas bottle-fed infants typically pass 1 or 2 stools daily.

Encourage a high-fiber diet and adequate fluid intake. Teach patients not to ignore the urge to have a bowel movement. Encourage regular exercise. (Taylor 1349)

Weakening of intestinal walls with greater incidence of diverticulitis

A nasogastric tube is a pliable single- or double-lumen (inner open space) tube that is hollow, allowing for the removal of gastric secretions and instillation of solutions into the stomach. The tube is passed through the nasopharynx into the stomach (Fig. 37-8). Refer to Chapter 35, Skill 35-1, for the procedure for nasogastric tube insertion and Skill 35-3 for the procedure for removal of a nasogastric tube. Tubes for decompression typically are attached to suction. Suction can be applied intermittently or continuously. (Taylor 1370)

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A surgical intervention that does not involve an external stoma is the creation of an ileoanal reservoir. Ileoanal reservoir surgery is an option when the large intestine is removed but the anus remains intact and disease-free. The terminal ileum is sutured directly to the anus, a colon-like pouch is created from the last several inches of the ileum, and the patient is able to control expulsion of feces through the intact anal sphincter (Fig. 37-10). Two or more surgeries are usually required, including a temporary ileostomy, and an adjustment period lasting several months is needed for the newly formed ileoanal reservoir to stretch and adjust to its new function (National Institute of Diabetes and Digestive and Kidney Diseases [NIDDK] & NIH, 2012). This procedure also has complications; candidates are carefully selected for this surgery. (Taylor 1371-1372)

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Because patients are often reluctant to discuss their bowel habits and stool characteristics, nurses need to be familiar with bowel concerns pertinent to each developmental group.

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Developmental Considerations Age affects what a person eats and the body's ability to digest nutrients and eliminate wastes. The stools of an infant are markedly different from those of an older person. (Taylor 1348)

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Health teaching about medication use is frequently overlooked for patients with ostomies. Some medications may discolor the stool and cause unusual odors, some may cause constipation, and some may not dissolve or be absorbed completely because the small bowel is where most absorption occurs. The use of liquid, chewable, or injectable forms rather than long-acting, enteric-coated, or sustained-release medications is recommended. Laxatives and enemas are dangerous because they may cause severe fluid and electrolyte imbalance. Many times, patients are embarrassed when they have to use public restrooms to empty their bag. Teach patients with ostomies about the various methods of odor control. Remind them that if the bag is clean and sealed well, odor usually is not a problem during normal activity. Encourage the intake of dark green vegetables. These vegetables contain chlorophyll, which helps to deodorize the feces. Buttermilk, cranberry juice, parsley, and yogurt can also prevent odor. Crackers, toast, and yogurt can help to reduce gas, which in turn aids in odor control. Commercial odor-control products also are available for purchase. The WOCN can help with the selection of odor-control strategies. The patient with an ostomy can resume normal activity, including work and sexual relations. However, the patient should avoid direct physical contact sports and heavy lifting. The patient can go swimming. When traveling, the patient should carry a 1- to 2-day supply of equipment in a carry-on bag in case checked luggage is lost. Nurses play a significant role in helping patients, their families, and significant others adjust to this major life change. These surgeries result in physical discomfort, changes in body image, loss of body function, and changes in personal hygiene. Patients need significant physical and psychological support to adjust to these changes. See the accompanying display, Research in Nursing: Living With a Colostomy. (Taylor 1375)

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View and process the image on p1356: FIGURE 37-5. Testing a stool specimen for occult blood. (A) Applying a stool specimen to the test paper. (B) Adding developing solution to the back side of the paper according to directions. (C) Blue coloration indicating positive results. (Taylor 1356)

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Administration Using a Hypotonic or Isotonic (Large-Volume) Solution. The procedure for administering a cleansing enema using a large volume of solution is described in Skill 37-1. Administration Using a Hypertonic (Small-Volume) Solution. Administering a cleansing enema using a hypertonic solution differs from the procedure described in Skill 37-1 in the following ways: The equipment is included in the commercially prepared set. The only additional equipment needed is a bedpan for a bedridden patient and a disposable waterproof pad to protect bed linens. Do not warm the hypertonic solution. Administer it at room temperature, and warm it only if it is very cold. Place the patient in the left side-lying position or the knee-chest position, which helps to distribute the solution throughout the lower intestinal tract and is recommended if the patient can assume it. Additional lubrication of the rectal tip is recommended, even though it is prelubricated. Instill the solution into the rectum by applying gentle pressure on the collapsible solution container (Fig. 37-6). It should take 1 to 2 minutes to administer the enema. Administer the hypertonic enema solution cautiously to a patient with hemorrhoids. The rigid tip may tear fragile rectal mucosa that is enlarged and inflamed, causing pain, torn rectal tissue, and necrosis. Generous lubrication is recommended before inserting the enema tip. (Taylor 1366)

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Administration of an Oil-Retention Enema. The procedure for giving an oil-retention enema differs from that for giving a cleansing enema in the following respects: A small rectal tube is used. The small size helps to reduce intestinal contractions so that the patient can retain the oil more easily. Oil enemas are available in commercial kits similar to those for hypertonic-solution enemas. The kits contain a small rectal tube. Administer the oil-retention enema at body temperature to minimize muscle contractions caused by a warmer or cooler solution. Instruct the patient to retain the oil for at least 30 minutes for best cleansing results. A cleansing enema is often ordered after an oil-retention enema to facilitate emptying of the bowel. (Taylor 1366)

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BOX 37-3 Dietary Considerations for Patients with an Ileostomy or Colostomy (Taylor 1374)***

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Bowel Elimination as the Problem When the analysis of assessment data points to a bowel elimination problem that can be prevented or resolved by independent nursing intervention, a nursing diagnosis is developed. If alterations in bowel elimination require new self-care behaviors—for example, colostomy management—Deficient Knowledge may be an appropriate nursing diagnosis. See the accompanying box, Examples of NANDA-I Nursing Diagnoses: Bowel Elimination . Bowel Elimination as the Etiology Problems of bowel elimination may also affect other areas of human functioning. In the nursing diagnoses that follow, problems of bowel elimination are the etiology for other problems: Delayed Growth and Development related to child's inability to attain bowel control secondary to inconsistency and lack of adequate parental knowledge Deficient Fluid Volume related to prolonged diarrhea Impaired Skin Integrity related to prolonged diarrhea, fecal incontinence Ineffective Coping related to inability to accept permanent ostomy Outcome Identification and Planning Interventions for patients without specific bowel elimination problems are directed toward the patient's achievement of the following outcomes. The patient will: Have a soft, formed bowel movement every 1 to 3 days without discomfort Explain the relationship between bowel elimination and dietary fiber, fluid intake, and exercise Relate the importance of seeking medical evaluation if changes in stool color or consistency persist Interventions for patients with specific bowel elimination problems are directed to appropriate outcomes based on the specific problem. Examples of problem-based outcomes include the following: The patient will: Describe the functioning and purpose of the ostomy Ingest an adequate amount of fiber Monitor the amount and consistency of stools Express acceptance of the ostomy Demonstrate skin care for the ostomy Respond to the urge to defecate in a timely manner Maintain the integrity of perineal skin (Taylor 1359)

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Bowel Elimination: Changing an Ostomy Appliance (Taylor 1373)

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Changing the Ostomy Appliance. The ostomy appliance should protect the skin, collect the fecal discharge, and control odor. Typically, a colostomy does not produce drainage until normal peristalsis returns, usually within 2 to 5 days. An ileostomy drains within 24 to 48 hours because of the liquid contents in the small intestine. For the first few days after surgery, most patients wear an open-ended appliance that allows for drainage of fecal material without removing the appliance. The skin barrier has an adhesive barrier that protects the surrounding skin from the stoma output. Appliances are either one-piece (barrier backing already attached to the pouch) or two-piece (separate pouch that fastens to the barrier backing). A transparent one-piece appliance is used in the initial postoperative period to allow for visualization of the stoma. Appliances can be either drainable or closed. Empty a pouch that can be drained when it is one-third full and replace it every 3 to 7 days, or whenever the seal comes away from the skin. Remove and change nondrainable pouches when they are half full. Types of ostomy equipment are illustrated in Figure 37-12 and include various types of one-piece and two-piece pouches. (Taylor 1373)

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Cleansing Enemas. Cleansing enemas are given to remove feces from the colon, commonly to: Relieve constipation or fecal impaction Prevent involuntary escape of fecal material during surgical procedures Promote visualization of the intestinal tract by radiographic or instrument examination Help establish regular bowel function during a bowel-training program The most common types of solutions used for cleansing enemas are tap water, normal saline solution, soap solution, and hypertonic solution. Commonly used enema solutions are described in Table 37-4. (Taylor 1365)

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Common Diagnostic Studies for the Gastrointestinal Tract Esophagogastroduodenoscopy (EGD) It allows visual examination of the esophagus, stomach, and upper duodenum by means of a long, flexible, fiber-optic-lighted scope. Preparation A signed consent form is required for this procedure. Fasting is required 6 to 12 hours before the test (check agency policy). Dentures need to be removed before the test. Remind patients that they will be awake but sedated and that a local anesthetic will be sprayed into the mouth and throat to depress the gag reflex. Aftercare Withhold food and fluids until the gag reflex returns. Check vital signs according to the protocol. Observe for signs of perforation: pain, persistent difficulty swallowing, vomiting blood, or black, tarry stools. Explain to the patient that it is normal to sense throat soreness and hoarseness for several days; saline gargles and lozenges may be helpful. Colonoscopy It allows visual examination of the rectum, colon, and distal small bowel using a long, flexible, fiber-optic-lighted scope. Preparation Ensure that an informed consent is signed. Preparation prior to test may involve: Clear liquid diet (24-48 h before test) 2-day bowel preparation—strong cathartic and Dulcolax on day 1 and enema the day of the test, or 1-day bowel preparation—ingestion of a gallon of bowel cleanser, such as GoLytely, in a short period of time Sedation will be given before the test. Aftercare Patient may experience flatulence or gas pains because air was used to distend the intestines for better visibility. Usual diet may be resumed once patient recovers from the sedation. Check vital signs according to agency protocol. Observe for signs of bowel perforation: rectal bleeding, abdominal pain and distention, fever, malaise. Sigmoidoscopy It allows visual examination of the distal sigmoid colon, the rectum, and the anal canal through a flexible or rigid sigmoidoscope. Preparation Ensure that an informed consent is signed. Preparation usually consists of a light meal before the test and two Fleet enemas. Sedation is not usually required. Aftercare Patient may experience flatulence or gas pains because air was used to distend the intestines for better visibility. Observe for signs of bowel perforation. If biopsy was performed, patient should be informed that slight rectal bleeding may occur. Upper Gastrointestinal (UGI) and Small-Bowel Series This involves fluoroscopic examination of the esophagus, stomach, and small intestine after ingestion of barium sulfate. Preparation Ensure that an informed consent is signed. Keep patient NPO after midnight the day of the test. Inform patient that a chalky-tasting barium contrast mixture will be given to drink before the test. Aftercare A post-test cathartic (e.g., Milk of Magnesia) is usually prescribed to prevent fecal impaction from barium sulfate that has hardened. Notify the physician or primary care provider if barium is not passed, usually within 2 days. Explain that the barium may lighten the color of stools for the next several days. After the barium is expelled, the stool color will return to normal. Barium Enema This involves a series of radiographs that examine the large intestine after rectal instillation of barium sulfate. Preparation An informed consent must be signed. Preparation may consist of dietary modifications, increased fluid intake, a cathartic, NPO after midnight, and enemas until clear before the test. Review the patient's history for any history of ulcerative colitis or active GI bleeding that would prohibit the use of the standard bowel preparation. Aftercare Encourage fluids to prevent dehydration. Inform the patient that the barium may lighten the color of the stools. A cathartic may be prescribed. Notify the physician or primary care provider if barium is not passed, usually within 2 days. Encourage rest because the bowel preparation and the test exhaust many patients. Abdominal Ultrasound Uses ultrasound waves to visualize organs via a small transducer placed against the skin. Preparation Assure the patient that no radiation is employed and that the test is painless. Patient must be NPO for a minimum of 8 hours before the examination. Explain that gel will be applied to the skin and that a sensation of warmth or wetness may be felt. The gel does not stain, but avoid wearing nonwashable clothing. Abdominal ultrasound must be performed before studies involving barium, as retained barium may compromise the study. Aftercare Ensure that any residual gel is removed from the skin. Normal diet and fluids may be resumed, unless contraindicated by the test results. Magnetic Resonance Imaging (MRI) This test provides physiologic information and detailed anatomic views of tissues using a superconducting magnet and radiofrequency signals. Preparation Evaluate the patient for need for sedation. Patients who are claustrophobic or unable to lie still during study may benefit from sedation. Patient may need to fast or consume only clear liquids prior to study. Patient should avoid alcohol, nicotine, caffeine, and iron supplements prior to the study. Patients with implanted surgical clips or other metallic structures and those with implanted electromechanical devices, such as cardiac pacemakers, drug infusion pumps, and cochlear implants, should not be exposed to MRI procedures. An informed consent is required. Pregnant patients are not routinely scanned because an increase in amniotic fluid/fetal temperature may be harmful. Aftercare If intravenous contrast is used during study, monitor for sensitivity and adverse reactions. Monitor contrast injection site for signs of irritation, infection, and bruising. If prestudy sedation was given, monitor patient closely until sedation wears off to prevent injury. Abdominal CT Scan Thin beams of x-rays are directed at and move around the abdomen, resulting in computer-manipulated pictures that are not obscured by overlying anatomy. Preparation An oral contrast is consumed before the study if the upper gastrointestinal tract is to be examined. Intravenous iodine contrast is usually administered. Assess for patient allergies to iodine, IV contrast, and/or shellfish. Prestudy preparation may be required if allergies are present. Assess for renal impairment; check laboratory values for elevated BUN and creatinine levels. Patient should be NPO for at least 4 hours before study. CT scan is contraindicated for pregnant patients. An informed consent is required. Metformin (Glucophage) must be discontinued prior to study and held after study to prevent renal failure. Consult with physician for patient medication modifications. Aftercare If intravenous contrast is used during study, monitor for sensitivity and adverse reactions. Monitor contrast injection site for signs of irritation, infection, and bruising. If prestudy sedation was given, monitor patient closely until sedation wears off to prevent injury. (Taylor 1358-1359)

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DIGITAL REMOVAL OF STOOL Fecal impaction often prevents the passage of normal stools. Small amounts of fluid may pass around the impacted mass; liquid fecal seepage with no passage of normal feces is a sign of an impaction. Include dietary interventions, adequate fluids, and adjustment of medication in the patient's plan of care before considering digital removal of feces (Kyle, Prynn, & Oliver, 2004). Increasing dietary fiber content to 30 g/day, increased water intake, and discontinuation of medications that can contribute to colonic hypomotility can help manage and prevent fecal impaction (Obokhare, 2012). If a patient with a fecal impaction cannot expel the fecal mass voluntarily and oil and cleansing enemas fail to break up the mass, the impaction must be broken up manually. An order from the primary health care provider is required. This procedure is very uncomfortable and may cause great discomfort to the patient as well as irritation of the rectal mucosa and bleeding. Digital removal of a fecal mass can stimulate the vagus nerve, resulting in a slowed heart rate. If this occurs, stop the procedure immediately, monitor the patient's heart rate and blood pressure, and notify the physician. Many patients find that a sitz bath or tub bath after this procedure soothes the irritated perineal area. The primary health care provider may order an oil-retention enema to be given before the procedure to soften stool. The procedure for digital (manual) removal of a fecal impaction is outlined in the Guidelines for Nursing Care 37-2; Digital Removal of Fecal Impaction . (Taylor 1367)

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Decreasing Flatulence Excessive formation of gases in the stomach or intestines is known as flatulence. When the gas is not expelled but accumulates in the intestinal tract, the condition is referred to as intestinal distention or tympanites. Gas-producing foods, such as beans, cabbage, onions, cauliflower, and beer, often predispose a person to flatulence and distention. In addition to teaching about the avoidance of irritating foods, explain to the patient that reclining should be avoided after meals and one should move around in bed and ambulate in order to promote peristalsis and the escape of flatus. (Taylor 1364-5)

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Designing and Implementing Bowel-Training Programs Patients with a history of chronic constipation and impaction and those who are incontinent of stool may benefit from a bowel-training program. The purpose of this program is to manipulate factors within the person's control (food and fluid intake, exercise, time for defecation) to produce the elimination of a soft, formed stool at regular intervals without a laxative. This effort to regain bowel control may be initiated in the health care setting or the patient's home. The accompanying Nursing Intervention and Nursing Outcome Classifications (NIC/NOC) box lists standardized nursing interventions and corresponding outcomes related to bowel management and training. When the patient has established a regular pattern of defecation, continue to offer assistance with toileting at the successful time. (Taylor 1368)

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Diagnosing 💀 Nursing Diagnoses for bowel elimination can be divided into two categories: Bowel elimination as the problem and bowel elimination as the etiology. (Taylor 1359)

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EXAMPLES OF NURSING INTERVENTIONS AND NURSING OUTCOMES CLASSIFICATIONS (NIC/NOC) Bowel Management (Taylor 1369) Reread this multiple times*** or make flashcards (advanced studying would be to make flashcards on these)

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Emptying the Colon of Feces Several methods are used to help promote elimination of feces: enemas, suppositories, oral intestinal lavage, and digital removal of stool. Discussion of each of these methods follows. ENEMAS An enema is the introduction of a solution into the large intestine, usually to remove feces. The instilled solution distends the intestine and irritates the intestinal mucosa, thus increasing peristalsis. Enemas are classified as cleansing or retention enemas. Rectal agents and manipulation, including enemas, are discouraged for use with myelosuppressed patients and/or patients at risk for myelosuppression and mucositis, because they can lead to development of bleeding, anal fissures, or abscesses, which are portals for infection (Taylor 1365)

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Evaluating The nurse evaluates the effectiveness of the plan of care to promote regular bowel elimination by checking to see if the patient has met the individualized patient outcomes specified in the plan. Nursing care is considered effective if the patient expresses satisfaction with regular pattern of defecation and the ability to pass a soft, formed stool comfortably without the use of medications or laxatives. The plan of care is most successful when the patient is able to accomplish the following: Verbalize the relationships among bowel elimination and nutrition, fluid intake, exercise, and stress management. Develop a plan to modify any factors that contribute to current bowel problems or that might adversely affect bowel functioning in the future. (Taylor 1375)

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FIGURE 37-10. Ileoanal reservoir. (Taylor 1372)

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FIGURE 37-8. Levine tube and Salem sump nasogastric tubes. Insert on right shows close up of a one-way antireflux valve for Salem sump tube. (Taylor 1370) ——> View and process the photo, make flashcards if needed

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GUIDELINES FOR NURSING CARE 37-1 TESTING FOR FECAL OCCULT BLOOD Instruct the patient about food and drug restrictions for at least 4 days before the test, if applicable. Review manufacturer's directions for collecting the specimen. Equipment may include a specimen card, collection tissues, or test paper. Avoid mixing the specimen with urine or water. Inform the patient that multiple or serial specimens are usually collected from different bowel movements to verify results. Collect the amount recommended for the particular test (usually only a small amount is required). Wear gloves and perform hand hygiene if collecting a specimen from a bedpan, commode, or plastic receptacle. Use tongue blades to transfer the stool to the test tape or folder. Follow instructions based on type of test. Hemoccult slide test requires placing 2 drops of developer solution on the back side of the specimen paper. Document the test results according to facility policy. A blue color is a positive result and needs to be reported. Inform the patient of the test results. (Taylor 1356)

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Go over the Skills separately and in detail***

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Hypotonic (tap water) and isotonic (normal saline solution) enemas are large-volume enemas that result in rapid colonic emptying. However, using such large volumes of solution (adults, 500-1,000 mL; infants, 150-250 mL) may be dangerous for patients with weakened intestinal walls, such as those with bowel inflammation or bowel infection. These solutions often require special preparation and equipment. Hypertonic solution preparations are available commercially and are administered in smaller volumes (adult, 70-130 mL). These solutions draw water into the colon, which stimulates the defecation reflex. They may be contraindicated in patients for whom sodium retention is a problem. They are also contraindicated for patients with renal impairment or reduced renal clearance because such patients have compromised ability to excrete phosphate adequately, with resulting hyperphosphatemia (Taylor 1365)

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INDIRECT VISUALIZATION STUDIES Indirect visualization of the gastrointestinal tract is commonly performed through radiography. The passage of x-rays through the patient creates a radiograph or film depicting body structures. This technique is useful for detecting obstructions, strictures, inflammatory disease, tumors, ulcers, and other lesions, and for diagnosing a hiatal hernia and other structural changes in the gastrointestinal tract. Use of a radiopaque contrast medium, such as barium sulfate, accentuates the body structures being visualized. In the upper gastrointestinal examination and small-bowel series, the patient drinks the barium sulfate like a milkshake. The barium coats the esophagus, stomach, and small intestine to enhance visualization. In the barium enema or lower gastrointestinal examination, barium sulfate is instilled into the large intestine through a rectal tube inserted through the anus. Fluoroscopy projects consecutive x-ray images onto a screen for continuous observation of the flow of the barium. During a computerized tomography (CT) scan, thin beams of x-rays are directed at and move around the abdomen, resulting in computer-manipulated pictures that are not obscured by overlying anatomy. Contrast may be given orally or intravenously to enhance the images. Magnetic resonance imaging (MRI) provides physiologic information and detailed anatomic views of tissues using a superconducting magnet and radiofrequency signals. Computers use the signals to construct detailed sectional images of the abdomen. Intravenous contrast can be given to enhance the images. Abdominal ultrasound visualizes all solid upper abdominal organs, including the liver, bile ducts, gallbladder, appendix, pancreas, kidneys, adrenals, spleen, and the abdominal aorta and vena cava. (Taylor 1357)

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Implementing Nursing care related to bowel elimination includes interventions to promote regular bowel habits, prevent and treat constipation, prevent and treat diarrhea, decrease flatulence, promote elimination of feces, manage bowel incontinence, and implement bowel-training programs. Nursing care related to caring for a patient with a nasogastric tube for gastric decompression is also discussed in the following sections. Promoting Regular Bowel Habits Promote regular bowel habits in well and ill patients by attention to timing, positioning, privacy, nutrition, and exercise. TIMING Encourage toileting at the patient's usual time during the day. Offer whatever assistance is needed to help the patient to the bathroom, commode, or bedpan at the time that a patient usually experiences the urge to defecate. This is often about an hour after meals, when mass colonic peristalsis occurs. Because many patients feel uncomfortable about requesting time for elimination, inform all patients about the importance of heeding this natural urge, explaining that postponing it could result in constipation and other problems. POSITIONING Sitting upright on a toilet or commode promotes defecation. Most patients who are able to use the bedside commode or bathroom toilet have little difficulty assuming this position, although they may need support. An elevated toilet seat may be ordered for patients with orthopedic problems who cannot lower themselves to a toilet seat. Sitting upright promotes a sense of normalcy and the effects of gravity help to promote regular bowel movements. Patients who need to use a bedpan in bed often benefit from having the head of the bed elevated to as close to a sitting position as possible, at least 30 degrees, unless this is contraindicated. An overhead trapeze may be helpful for patients with weak lower extremities. Refer to Skill 37-2 on pp. 1382-1385 for more information about positioning a patient on a bedpan. Offer the patient moistened hand wipes at the bedside to substitute for handwashing after toileting. Always empty, clean, and return bedpans to the patient's bedside stand or store according to facility policy. PRIVACY Because most people consider elimination a private act, always respect the patient's need to be alone while defecating, unless the patient's condition makes this impossible. Pull the bedside drapes around a patient who is using a bedside commode or bedpan. If any visitors are present, ask them to step outside for a few minutes. For well patients who cannot defecate in a public restroom (with multiple toilets) or strange environment, suggest that they use a private restroom with only one toilet. NUTRITION Patients with bowel elimination problems may need a dietary analysis to determine which foods and fluids are contributing to their problem and which may help in its treatment. General dietary recommendations to promote regular defecation include a fluid intake of 2,000 to 3,000 mL and high fiber intake. Water is recommended as the fluid of choice because fluids containing large amounts of caffeine and sugar may have a diuretic effect. Increasing fiber intake without sufficient fluid intake can result in severe gastrointestinal problems, including fecal impaction. Specific recommendations for treating constipation, diarrhea, and excessive flatulence follow. EXERCISE Regular exercise improves gastrointestinal motility and aids in defecation. Encourage well patients to exercise regularly for two and a half hours or more a week (U.S. Department of Health and Human Services, 2008). Ambulate patients who are ill as soon as possible, instructing them about how inactivity can lead to constipation, distention, and impaction. Bedside exercises may be helpful for patients who are immobile. Teach the following exercises to help patients with weak abdominal and perineal muscles who are using a bedpan: Abdominal setting: The patient, lying in a supine position, tightens and holds the abdominal muscles for 6 seconds and then relaxes them. Repeat several times each waking hour. Thigh strengthening: The thigh muscles are flexed and contracted by slowly bringing the knees up to the chest one at a time and then lowering them to the bed. Perform this exercise several times for each knee each waking hour. Providing Comfort Measures Comfort measures related to defecation include working with the patient to develop a bowel elimination routine that results in the easy passage of a soft, formed stool; being attentive to perineal hygiene and the maintenance of skin integrity; and using warm, moist heat (sitz bath or tub bath) to soothe the perineal area. Additional nonsurgical treatment options include the following (Hinkle & Cheever, 2014): Encouraging recommended diet (if pertinent) and exercise Using medications, such as laxatives and antidiarrheals, only as needed Applying ointments or astringents (witch hazel) Using suppositories that contain anesthetics Preventing and Treating Constipation Constipation is dry, hard stool; persistently difficult passage of stool; and/or the incomplete passage of stool. Decreased gastric motility slows the passage of feces through the large intestine, resulting in increased fluid absorption from the fecal mass and causing dry, hard stool. Straining often accompanies defecation. Some people may be constipated and yet have a daily bowel movement, whereas others who regularly defecate no more than three times a week are not constipated. People at high risk for constipation include patients on bedrest or with decreased mobility who take medications that cause constipation (e.g., opioids, anticholinergics), patients with reduced fluids, bulk, or fiber in their diet, people who are depressed, and patients with central nervous system disease or local lesions that cause pain while defecating. TEACHING ABOUT NUTRITION Promoting healthy behaviors can assist the patient and family to achieve mutually desirable outcomes for preventing constipation. A combination of high-fiber foods (20-35 g of fiber), 60 to 80 oz (1.8-2.4 L) of fluid daily, and exercise has been shown to be effective in controlling constipation in patients with deficiencies in dietary intake of fiber and/or fluid and reduced amounts of exercise (Toner & Claros, 2012). Caution the patient to avoid increasing fiber intake without drinking enough fluids; this can lead to a bowel obstruction. Foods that contain high amounts of fiber include bran, fruits, vegetables, and whole grains. (Taylor 1360-1361) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.

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Ingestion of certain foods and medications before the specimen collection can result in false-positive results. Foods that may cause a false-positive result include red meat, animal liver and kidneys, salmon, tuna, mackerel and sardines, tomatoes, cauliflower, horseradish, turnips, melon, bananas, and soybeans. Certain medications, such as a salicylate intake of more than 325 mg daily, steroids, and iron preparations, also may lead to false-positive readings (Leeuwen, Poelhuis-Leth, & Bladh, 2011). The ingestion of vitamin C can produce false-negative results even if bleeding is present. The following are recommendations for the patient preparing for a fecal occult blood test: Before stool testing, avoid the foods (for 4 days) and drugs (for 7 days) that may alter test results. Do not use laxatives, enemas, or suppositories for 3 days before testing. Postpone the test until 3 days after her period has ended if a woman is menstruating. Postpone the test if hematuria or bleeding hemorrhoids are present. Postpone the test if the patient has had a recent nose or throat bleed. Caution a person who is color-blind to the color blue not to attempt to interpret the test results. In clinical settings, these restrictions are usually not practical. It is important to note the presence of any of the aforementioned conditions in the clinical setting. Guidelines for Nursing Care 37-1 gives additional nursing considerations for fecal occult blood testing. Figure 37-5 demonstrates the procedure for a Hemoccult test. (Taylor 1356)

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Measure the patient's fluid intake and output. Check the ostomy appliance for the quality and quantity of discharge. Initially after surgery, peristalsis may be inhibited. As peristalsis returns, stool will be eliminated from the stoma. Record intake and output every 4 hours for the first 3 days after surgery. If the patient's output decreases while intake remains stable, report the condition promptly. Explain each aspect of care to the patient and explain what the patient's role will be when beginning self-care. Patient teaching is one of the most important aspects of colostomy care and should include family members and/or people identified by the patient to include in care, when appropriate. Teaching can begin before surgery so that the patient has adequate time to absorb information. Encourage the patient to participate in care and to look at the ostomy. Patients normally experience emotional depression during the early postoperative period. Help the patient cope by listening, explaining, and being available and supportive. A visit from a representative of the local ostomy support group may be helpful. Patients usually begin to accept their altered body image when they are willing to look at the stoma, make neutral or positive statements concerning the ostomy, and express interest in learning self-care. (Taylor 1373)

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Palpation. Next, perform light palpation in each quadrant. Watch the patient's face for nonverbal signs of pain during palpation. Palpate each quadrant in a systematic manner, noting muscular resistance, tenderness, enlargement of the organs, or masses. If the patient complains of abdominal pain, palpate the area of pain last. If the patient's abdomen is distended, note the presence of firmness or tautness. (Taylor 1353)

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Patient Preparation. Because enemas are a common procedure, some patients already know why they are used and how they are administered. Reinforce this information and correct any misconceptions that they may have. For patients who have not previously had an enema, explain the purpose, what they can expect, and how they can participate. In all cases, provide for patient privacy. The procedure offers an excellent opportunity for health teaching because many people are unfamiliar with or uncomfortable talking about the functioning of the intestinal tract. Failure to provide explanations and protect privacy may result in an uncomfortable and disagreeable situation for the patient. A reclining position for enema administration—specifically left side-lying or the knee-chest position—is recommended, but if the patient has a respiratory disorder or is having difficulty breathing, elevate the head of the bed slightly. Avoid the Fowler's position because the solution will remain in the rectum and expulsion will occur rapidly, resulting in minimal cleansing. Some patients think the solution should be expelled as soon as possible. Reinforce the need to retain the solution to achieve the desired results. (Taylor 1366)

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RECTAL SUPPOSITORIES A suppository is a conical or oval solid substance shaped for easy insertion into a body cavity and designed to melt at body temperature. Various rectal suppositories are available. Some are fecal softeners, others have a direct action on the nerve endings in the rectal mucosa, and some liberate carbon dioxide when moistened. Fecal softeners are useful when the stool is very hard. Substances that stimulate the rectal nerves are helpful for people with weak muscle tone or poor innervation. The carbon dioxide suppositories liberate about 200 mL of gas, which causes distention, causing stimulation and elimination impulses. Refer to Chapter 28 for Guidelines for Nursing Care 28-7: Inserting a Rectal Suppository. (Taylor 1366)

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Reread FOCUSED ASSESSMENT GUIDE 37-1 BOWEL ELIMINATION (Taylor 1353) ******Factors to Assess vs Questions/Approaches

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Reread and process GUIDELINES FOR NURSING CARE 37-2 DIGITAL REMOVAL OF FECAL IMPACTION (Taylor 1368) Make flashcards if needed

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Retention Enemas. Retention enemas are retained in the bowel for a prolonged period for different reasons: Oil-retention enemas: lubricate the stool and intestinal mucosa, making defecation easier. About 150 to 200 mL of solution is administered to adults. Carminative enemas: help to expel flatus from the rectum and provide relief from gaseous distention. Common solutions include the milk and molasses enema (equal parts) and the magnesium sulfate-glycerin-water (MGW) enema (30 mL of magnesium sulfate, 60 mL of glycerin, and 90 mL of warm water). Medicated enemas: provide medications that are absorbed through the rectal mucosa. Anthelmintic enemas: destroy intestinal parasites. Equipment. Commercially prepared enema kits include a flexible bottle containing hypertonic solution with an attached prelubricated firm tip about 5 to 7.5 cm (2-3 inches) long. Its ease of use makes it particularly convenient in the home. Patients can readily administer their own enema in many instances. For tap water, saline solution, or soap solution enema, a container, rubber or plastic tubing with side openings near its distal end, a tubing clamp, lubricant, and the solution are necessary. Regardless of the type of enema to be given, clean or medically aseptic technique is used. Always wear or have the caregiver wear disposable gloves to protect from exposure to blood, body fluids, and microorganisms. (Taylor 1365)

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Stool Characteristics Nurses are responsible for observing and recording information about the patient's stool. Table 37-1 describes the characteristics of a normal stool, along with special considerations used when observing a stool. Report and record anything unusual, including the passage of little or no gas or unusual amounts of gas. Note and record, usually on the patient's bedside flow sheet, the frequency, amount, and characteristics of the patient's bowel movements. Describe any additional unusual observations, such as lightheadedness or straining, on the patient's medical record. When assistive personnel or the patient assumes this responsibility, check with the patient at regular intervals to see that the recording is accurate. Ideally, populations at high risk for bowel elimination problems are identified before problems occur, and such problems are prevented or minimized through vigilant nursing care. Be aware of the clinical manifestations of colon cancer because early detection significantly improves survival. Refer to Box 37-1, Warning Signs of Colon Cancer. (Taylor 1355)

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TABLE 37-3 Classification of Antidiarrheal Medications (Taylor 1364)——> ***Reread, process, and make flashcards on what needs flashcards

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TABLE 37-4 Commonly Used Enema Solutions (Taylor 1365) —> make flashcards out of this table or process whatever info can be processed

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TEACHING ABOUT LAXATIVES Cathartics and laxatives are drugs that induce emptying of the intestinal tract. Although these terms are sometimes used interchangeably, cathartics exert a stronger effect on the intestines than do laxatives. Some of these drugs, such as castor oil, cascara, senna, and phenolphthalein, and bisacodyl (Dulcolax), act chemically by stimulating peristalsis. Others, such as psyllium hydrophilic mucilloid (Metamucil), act by increasing the intestinal bulk, which promotes additional mechanical stimulation on the intestine. Still others, such as mineral oil and docusate sodium (Colace), soften the fecal material. Other frequently used laxatives are the saline-osmotics, such as magnesium hydroxide (Milk of Magnesia [MOM]) and sodium phosphate (Phospho-Soda). These act by drawing water into the intestines, stimulating peristalsis. Magnesium hydroxide has antacid properties in small dosages and laxative properties in larger doses. Table 37-2 summarizes the types of laxatives. (Taylor 1361)

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THE NURSING PROCESS FOR BOWEL ELIMINATION (Taylor 1352)***************

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The Levine tube is a common single-lumen tube. It lacks a venting system, and mucosal damage can occur when suction is applied continuously. Therefore, suction usually is applied intermittently. Salem sump nasogastric tubes are double-lumen tubes. One lumen empties the stomach, and the other provides for a continuous flow of air. The airflow lumen controls suction by preventing the drainage lumen from pulling stomach mucosa into the tube's openings and irritating the stomach lining. A one-way antireflux valve may be used in the airflow lumen to prevent reflux of gastric contents through the airflow lumen (see Fig. 37-8). When pressure from gastric contents enters the airflow tubing, the valve closes to prevent secretions from exiting the tube. Nasogastric tubes used for decompression require irrigation with 30 to 60 mL of normal saline solution to maintain patency. Skill 37-2 describes the procedure for irrigating a nasogastric tube connected to suction. To promote patient safety when instilling solutions into a nasogastric tube, tube placement must be verified before administration of any fluids or medications. Radiographic examination, measurement of aspirate pH, visual assessment of aspirate, measurement of tube length and measurement of tube marking, and monitoring of carbon dioxide are used to confirm nasogastric tube placement. With the exception of radiographic examination, the use of several of these techniques in conjunction with each other increases the likelihood of correct tube placement. An old technique of auscultation of air injected into a nasogastric tube has proved unreliable and may result in tragic consequences if used as an indicator of tube placement (American Association of Critical-Care Nurses [AACN], 2010; Best, 2005; Khair, 2005). Therefore, do not use it to confirm nasogastric tube placement. Radiographic examination to confirm placement is the most accurate method for checking if the NG tube is in the stomach, but is often only ordered on initial placement, and many times is not prescribed for nasogastric tubes inserted for decompression. Two methods recommended for checking placement, other than radiograph, are visual assessment of aspirated gastric contents and measuring the pH of the aspirate (AACN, 2010; Best, 2005; Hinkle & Cheever, 2014). Refer to Chapter 35, Guidelines for Nursing Care 35-1; Visual Assessment and pH Measurement of Gastric Contents. In addition, the length of the exposed tube is measured and marked after insertion and documented. Check and compare tube length with this initial measurement, in conjunction with the previous two methods for checking tube placement. An increase in the length of the exposed tube may indicate dislodgement (AACN, 2010; Hinkle & Cheever, 2014). Marking the tube with an indelible marker at the nostril and then assessing this marking each time the tube is used ensures that the tube has not become displaced. Monitoring for carbon dioxide to determine nasogastric tube position and/or dislodgement has been evaluated (Gilbert & Burns, 2012; Chau, Lo, Thompson, Fernandez, & Griffiths, 2011; Munera-Seeley et al., 2008). This involves the use of a capnograph or a colorimetric end-tidal CO2 detector to detect the presence of carbon dioxide, which would indicate tube positioning in the patient's airway. However, a carbon dioxide sensor cannot determine where a nasogastric tube's tip ends in the gastrointestinal tract (esophagus, stomach, or small bowel; AACN, 2010). Patients with nasogastric tubes often experience discomfort related to irritation to nasal and throat mucosa, and drying of the oral mucous membranes. Administer oral hygiene frequently, as often as every 2 to 4 hours, to prevent drying of tissues and to relieve thirst. Frequently offer the patient the opportunity to rinse the mouth with warm water and mouthwash solution. Lubricate the lips generously. Keep the nares clean, especially around the tube, where secretions tend to accumulate. Use a lubricant after cleaning the nares. Help control local irritation from the tube in the throat by offering analgesic throat lozenges or anesthetic sprays, as prescribed. Ensure that the tube is secured to the patient's nose and gown to prevent tension and tugging on the tube, causing trauma to the nares and potential displacement (Taylor 1370-1371) Taylor, Carol. Fundamentals of Nursing. Wolters Kluwer Health, 10/2014. VitalBook file.

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The act of defecation is usually painless. If the bowels move at regular intervals and the stools are formed and soft, functional problems involving frequency of elimination seldom occur. Many people become concerned if they do not have a daily bowel movement. However, normal elimination patterns can vary widely among people. Although many adults pass one stool each day, other healthy people have more frequent or less frequent bowel movements. Some people have a bowel movement two or three times a week; others, two or three times a day. (Taylor 1348)

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The focus of nursing care is on eliminating the cause of the diarrhea and replacing lost fluids as well as treating the symptoms. Some commercial fluid and electrolyte replacement products, such as Gatorade, may be helpful. Oral rehydration therapy using fluid and electrolyte replacement and water for adults is cost-effective and replaces fluid loss without the challenges associated with intravenous fluid therapy. Replace lost fluids and electrolytes with weak tea, water, bouillon, clear soup, and gelatin. It is particularly important to maintain fluid balance in older patients because of their increased risk for dehydration, fluid overload, and electrolyte imbalances. Additional measures for preventing or treating diarrhea include avoiding highly spiced foods and foods with laxative effects, such as raw fruits and vegetables. Encourage the patient to eat foods with low fiber content. Foods low in fiber include eggs; well-cooked meat, fish, and poultry; juices without pulp; refined bread and cereal products; and well-cooked fruits and vegetables. The use of probiotics (live microorganisms that are similar to beneficial microorganisms found in the human gastrointestinal tract) to prevent, limit, and control diarrhea has been suggested as an effective dietary intervention for diarrhea, particularly antibiotic-associated diarrhea and C. difficile-associated disease. Examples of foods containing probiotics include cheese, yogurt, tempeh, miso, soymilk, and some commercial dairy drinks (Salfi & Holt, 2012; Avadhani & Miley, 2011). Probiotics can also be ingested through the use of commercially prepared supplements. Alterations in fluid and electrolyte balance occur faster and more often in infants and children compared to adults. Therefore, infants and children experiencing diarrhea require more fluid and electrolyte replacement compared to adults. Encourage fluids, especially oral rehydration solutions containing sodium chloride, potassium, and glucose (Pedialyte®, Infalyte®, and Ricelyte®), and make them accessible for the child. Special diets for dehydration such as the BRAT diet (bananas, rice cereal, applesauce, and toast) are no longer recommended because they lack sufficient calories. (Taylor 1364)

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View FIGURE 37-7. Applying a fecal incontinence device. (Taylor 1369)

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View Figure 37-4 Interior view of the rectum and anal canal. (Taylor 1348)

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View and process FIGURE 37-10. Ileoanal reservoir. (Taylor 1372)

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View and process FIGURE 37-11 and 12. Comparison of stomal appearance. (A) Normal-appearing stoma is bright red, moist, and rounded. (B) A pale stoma indicates severe anemia. (C) Eroded skin around the area may lead to a flush stoma. (Taylor 1372) FIGURE 37-12. Examples of ostomy pouches and closures. This equipment comes in various models and sizes. Convex pouches, belts, and other devices to prevent leaks and irritation are also available. (Taylor 1373)

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View and process FIGURE 37-9. (A-D) Location of various colostomies, and (E) location of an ileostomy. The shaded portions represent the sections of the bowel that have been removed or are currently inactive. (Taylor 1371)

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View and process Figure 37-6

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Watch the video on administering a cleansing enema

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View Figure 37-1 and -2 and -3 if not viewed already

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Make flashcards out of TABLE 37-1 The Stool: Normal Characteristics and Special Considerations for Observation (Taylor 1354)

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Make flashcards out of —-> EXAMPLES OF NANDA-I NURSING DIAGNOSES BOWEL ELIMINATION (Taylor 1360)

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