Ch. 29

o Double Barrel-

* When creating a double-barrel colostomy, the surgeon divides the bowel completely. Each opening is brought to the surface as a separate stoma so has 2 stomas the proximal one drains feces and the distal one drains mucus, which may be called a mucus fistula * has two separate stomas that externalize the bowel on both sides of the portion that has been removed.

Flat:

0 degrees

Common food allergies-

dairy, egg whites, shellfish, gluten, nuts, citrus fruits and soy.

potassium (K):

o 3.5-5 mEq/L * usually buy 3-5 bananas and you want them half (0.5) ripe

pH:

o 7.35-7.45

Calcium (Ca):

o 8.5-10.5 mg/dL) * People ages 85-105 are more likely to produce osteoporosis (remember decimals!)

Chloride (Cl):

o 95-105 mEq/L * Think chlorine—Best temperature to go swimming is in 95-105 degrees

dietary supplements (factor that influences bowel elimination)

o Calcium may cause constipation. o Magnesium loosens stools. (almonds, cashews, tofu) o Vitamin C softens stools and in high doses may cause diarrhea in sensitive clients.

Temporary-

to allow bowel to heal and rest after a surgical intervention. When healed reversed with reanastomosis (reconnection) to the bowel occurs with regular BM's. (when healed, MD comes back in and does a reversal)

· LUQ

§ Esophagus § Stomach § Pancreas

· Retention enemas

§ introduce a solution into the colon that is meant to be retained for a prolonged period. Consequently, the volume is small, usually 90 to 120 mL (3 to 4 oz). The following are the most common forms of retention enemas.

1. Where is most of the fluids absorbed in GI tract?

· Colon (large intestine)

1. Assessment of a stoma

· Initially may have some edema for 2-3 weeks but should shrink and be permanent size in 6-8 weeks post-op. · A healthy stoma ranges in color from deep pink to brick red (should be beefy red and shiny—if it appears any other way, you need to report it), regardless of the patient's skin color, and is shiny and moist. Pallor or a dusky blue color indicates ischemia, and a brown-black color indicates necrosis. · Skin around it should be free of irritation tenderness, skin breakdown (leads to infection, pain, and leakage), drainage, excoriation (Loss of superficial layers of the skin caused, for example, by scratching and by the digestive enzymes and feces—skin picking), and erythema (Redness of the skin. It is related to vasodilation and inflammation. It is difficult to see in dark-skinned people, so you may discover it by palpating this skin for areas of increased warmth.) · Stoma slightly protrudes above the abd about 0.5-1 in · An ileostomy stoma is generally smaller than a colostomy stoma · Help the patient adapt- they will not want to look at or touch many times, gradually get them to assist with care by demonstrating. Adapt your attitude and be willing to listen to concerns. § May take while; Tell them how well it's healing and how you wanted to see it look like that. They will eventually begin to look at it; They will eventually be more open about learning how to take care of it · Be kind! Can cause body image disturbance and low self-esteem. Encourage to look at the stoma and take care of it. (show empathy) · No diet restrictions but start with small meals § Some diet restrictions; start with small meals to see if GI tract can handle it/see how GI system reacts · ILEOSTOMY PT'S ARE MORE AT RISK FOR SKIN BREAKDOWN DUE TO LIQUID STOOL W/ MORE ENZYMES IN IT · Pt's are evaluated before having an ostomy created to see how they wear their clothes and where would be the best place to put it, so it isn't rubbing on their clothes · If stoma is pallor, cyanotic, dusty-colored, black = it is not getting enough circulation and the blood flow is compromised—CALL MD IMMEDIATELY

· PERSONAL AND SOCIOCULTURAL FACTORS -- stress (factor that influences bowel elimination)

o Have you ever heard the following phrase: "He puts his stress in his gut"? Stress has a major influence on motility of the GI tract. o It may cause diarrhea or constipation, and it is a primary risk factor in the development of irritable bowel syndrome, a disorder associated with bloating, pain, and altered bowel function

hypertonic: enemas

o Hypertonic Sodium phosphate (Fleets) usually smaller in volume (90- 120ml)- pulls fluids out of interstitial space. * adults only. Contraindicated if dehydrated or infant.

Anaphylactic reaction

o airway will start to shut down in the circulatory system (made up of blood vessels that carry blood away from and towards the heart) starts to collapse. THIS IS A MEDICAL EMERGENCY

Common GI symptoms suggesting food allergy

o include constipation, diarrhea, a red, blistering rash around the anus, abdominal discomfort, bloating, excessive gas, and intestinal bleeding

· AGE: (affects color of BM) infant (factor that influences bowel elimination)

o stomach has a small capacity, less GI enzyme secretions, ^ peristalsis. o breast fed=loose bright golden, yellow, pasty, seedy looking o bottle fed=firm and formed darker yellowish/brownish or tan colored o Initially, babies defecate frequently, usually after each feeding. The stools tend to be watery, while the large intestine is still immature. o Gradually, normal flora develop in the colon, and stools become firmer and less frequent. o Usually urinate more due to them ingesting liquids

bowel training

o used for chronic constipation or fecal incontinence- involve pt. and caregiver in plan, need a dedicated, private, uninterrupted time for defecation. If constipation develops- add fiber to diet, then stool softener, followed by Dulcolax (Bisacodyl). Increase fluids, and modify plan as needed.

RLQ

§ Colon § appendix

timing (measure to ensure regular BM)

§ Don't want to use public restroom (only want to go at home). Not responding to the urge. (this will affect bowels and eventually, will cause a person to lose the urge to defecate) § Recall that food entering the duodenum triggers mass peristalsis. As a result, the urge to defecate often occurs after meals. Ignoring this urge may lead to constipation

· RUQ

§ Liver § gallbladder

LLQ

§ Small intestine § Rectum § Anus

Antibiotics

§ disrupt the normal flora in the GI tract causing diarrhea; antibiotics are given to combat infection and decrease the normal flora in the colon. The result is often diarrhea. Bacterial populations can be maintained with supplements of probiotics (e.g., acidophilus) or daily consumption of yogurt (need yogurt/probiotics to prevent C. diff); usually tell pt to eat something after taking meds (read medication label to see if it causes diarrhea)

a colostomy created in the transverse colon

§ usually temporary and may be either a double barrel or loop

Fecal immunochemical test (FIT)

· (done every year) more sensitive, more expensive, most effective

1. What is a fecal impaction (nursing dx)

· Constipation can lead to fecal impaction · hardened mass of stool that is impossible for client to pass voluntarily. Can occur anywhere in GI tract causing an impaction. (could be hard as stone—could be given oil enema, which lubricates the GI tract in stool, so it can be removed) · Usually occurs in elderly, bedridden, confused, and those severely dehydrated. Complains of N/V, abd, distention/cramping, and rectal pain. · S/S = small amounts of diarrhea will seep around obstruction causing smears in attends or underwear- nurse needs to make sure it is not treated as diarrhea because can lead to obstruction or perforation (stool is there and any liquid stool is draining around it) · Digital Rectal Exam (DRE) can be performed. This involves insertion of lubricated gloved index finger into anus to manually break up fecal mass, helps if retention enema given first. May need mild pain meds; may stimulate vagal response (stimulation of the vagus nerves that also stimulates the heart (heart rate drops 30-40 BPM, C/O chest pain/pressure (b/c it increases pressure in the thoracic cavity), dizziness, and nausea, clammy skin, pallor [pale]) and bronchioles (causes constriction and can't breathe). § DRE Cannot be delegated! (have to have Medical order b/c of high risk of perforating rectum/colon/GI mucosa) § first check WBC to make sure not immunocompromised, trim nails, baseline VS (b/c if changed, could mean you perforated GI mucosa; assess VS before and very closely afterwards), determine if has cardiac problems or other contraindications, monitor for vagal nerve response. § Monitor very closely after DRE for any other type of issue · Fecal impaction is a complication of constipation. When severe complications occur, they develop tachypnea, dehydration, fever, agitation, which means could have tear in colon or anus or bleeding. After removing impaction implement measures to prevent.

Guaiac Testing/Fecal Occult Blood Test (FOBT):

· Microscopic blood—used to see if pt needs colonoscopy § MAKE SURE PT VOIDS BEFORE GETTING STARTED (using a sample of stool that comes in contact with either urine or water may produce an inaccurate test result) § Collect supplies: tongue blade, specimen pan/BSC/bedpan, gloves, biohazard bag, stool specimen cup, and label. § If incontinent collect from attends/ and child collect from diaper. § Some stool samples require special preservatives (special container) or placed in refrigerator/or on ice and some need to be warm. o Should collect specimen and bring it down to the lab immediately; But in LTC, you need to know what the process is for collecting, so you don't have to repeat test for that patient § *Collect accurately, tell to not mix urine and stool or put toilet paper on specimen. § need test card, collect areas that are red, maroon, black, or tarry. § Collect a sample of stool and spread it thinly onto one "window" of the FOBT slide o with opposite side of the tongue blade, collect second sample of stool from a different location. Spread the second sample thinly on to the second "window" of the slide § Requires dietary restrictions of NOTHING red, alcohol (increases bleeding and thins blood out), NSAIDS (cause GI irritation), iron supplements, foods 6 peroxidase, red meats, citrus fruits, and vitamin C x 3 days. § Anticoagulants (ASA, Ibuprofen, NSAIDS) stop x 7 days. § Need to test on 3 separate occasions (50 years of age and older) if positive schedule for colonoscopy to R/O cancer. § If in hospital, it is tested in the lab (cannot be done at bedside for quality control purposes). If in an office, apply thin strip of feces to sample areas on test card, apply 2 developer drops to areas— if areas turns blue/bluish purple then it is positive for blood. (you can perform the test for occult blood at the bedside, although some institutions require that it be done in the laboratory) § requires a special reagent that detects the presence of peroxidase, an enzyme present in hemoglobin § only a small smear of stool is required § for home testing, remind patients to wash their hands before and after collecting stool § Put in plastic bag and send to the lab. § Prior to collecting sample, have pt void and then defecate into a clean, dry container i.e. bedpan, BSC, half Hat. § Total care and incontinent will need to obtain from attends. § Testing for FOBT- start at age 50, unless at high risk and will start earlier (age 40). § Screened every 1-2 years to see if you need any type of procedure § If done at bedside check dates of developer and card. § If blood is in the stool, report it (unless patient has a history of hemorrhoids) § one side of the test card is for feces, the other side is the developer; Put samples of stool on feces side and close it off. place drops of developer on the other side. If it's clear, that means it's negative; If it turns blueish/purple, then it is positive for blood

Fecal collection and drainage devices are used to

(1) prevent Skin Integrity Impairment by keeping feces away from the skin and (2) collect large fecal samples

Loop

* Stoma where both the upstream (proximal) and downstream (distal) openings of the bowel are brought out through the same hole in the abdominal wall. The proximal opening of the stoma drains feces from the intestine, while the other opening of the stoma drains mucus from the lower part of the bowel that leads to the anus. (both are coming out of the same stoma) * consists of a segment of bowel brought out to the abdominal wall. à The posterior wall of the bowel remains intact, but a plastic rod is wedged under the bowel to keep it from slipping back into the abdomen. à The anterior wall is incised, and the mucosal surface is left visible and open to air. à the loop colostomy has a functioning proximal end and limited drainage from the distal end.

o May use an external incontinence pouch-

* a plastic bag with peel-off backing, then apply ring around anus. * Empty when ½ full; change every 2-3 days—(fits around anus and stool falls into bag) * Pouch used to prevent excoriation of skin or collect specimens. * Also help to minimize odors (b/c it's liquid, make sure you measure), track output, and of course for patient comfort that includes preventing UTI's. * Do not use if skin is not intact. * Place side lying position, spread buttocks, clean and dry perineal area, clip hair if needed, apply device avoiding gaps and creases, hang drainage bag lower than the pt. * They are not typically used for patients who are ambulatory, agitated, or active in bed because the device may be dislodged, causing skin breakdown.

o Kock pouch/continent ileostomy

* creates an internal pouch, or reservoir, to collect ileal drainage. * To drain the pouch, the patient inserts a tube through the external stoma into the pouch several times per day. * This alternative avoids continuous drainage, so the patient does not need to wear an ostomy appliance. * continent diversion that uses the terminal portion of ileum (part of the small intestine that intersects with the colon) to form an internal pouch to collect and store the effluent, it has a flap to prevent leakage. à The client must drain the reservoir with a tube (catheter) several times a day. * Connects the end of the ileum to the outside surface of the skin by making a permanent opening (stoma) à to protect stoma from infection, need to keep it covered with sterile gauze or padding. à It is a continent ileostomy, meaning stool stays within your body until you decide to remove it (tube/catheter)

o Internal drainage devices-

* same as above, but for total care patients. * Soft latex free catheter attached to a collection bag. * Attach syringe to inflation port, lubricate then insert balloon into rectum and blow it up and fill with saline or water (usually balloons have pre-set amt of H2O/saline you're supposed to put in them) * lubricate syringe, insert into rectum, blow up balloon, feces go out from syringe into the balloon * This protects caregivers from potentially infectious stool * Disadvantage- can only use for 29 days, not used on pediatrics, and contraindications include: severe hemorrhoids, recent bowel/rectal surgery, rectal/anal tumors, or stricture (abnormal narrowing of a body passage) /stenosis.

o total colectomy with ileoanal reservoir

* surgical procedure in which the colon is removed, a pouch is created from the ileum, and the ileum is connected to the rectum. * The patient evacuates the bowel on the commode in the usual manner. * Although this procedure should result in continence of bowel elimination, the feces will still be liquid * diversion of the ileum due to removal of large colon (colectomy). A pouch is created from the end of the small intestine and attaches it to the anus. A pouch collects the stool to simulate (replicate) normal emptying. à May have to use catheter/may have normal defecation—depends; most of the time, person can control it * The person does not have a permanent stoma; the small intestine connects to the anus after the colon and rectum are removed (internal pouch made out of the ileum)—connects the small intestine to anus

Low Fowler's (semi-fowler's):

30 degrees

Pco2 (partial CO2):

35-45 mmHg

Mid Fowler's:

45 degrees

High Fowler's:

90 degrees

Melena

GI bleed from high up in the tract

Hypotonic: enemas

Tap water- cleansing- contains a large volume of fluid that is instilled into the rectum (500-1000ml)- Do not use in infants, children, and CHF pt's— causes hypervolemia—use normal saline. Moves water out of interstitial space- stimulates BM; watch for water toxicity.

Normal/active:

bowel sounds; high pitched gurgling noise; Approximately 5-35 sounds per minute, or at least one every 5-15 seconds

Hyperactive-

bowel sounds; loud, gurgling, frequent sounds. Greater than 35 BS a min o inflammation of the bowel, anxiety, diarrhea, bleeding, excessive ingestion of laxatives, reaction of intestines to certain food o borborygmi- loud stomach growling, rumbling sound produced by movement of gas in the stomach and intestines. Heard with or without stethoscope

absent

bowel sounds; no Bell sounds heard. Must listen for five minutes before concluding that Bell sounds are absent; Late stage bowel obstruction, paralytic ileus, peritonitis

Hypoactive-

bowel sounds; often soft and widespread. Less than five BS per minute (postop following general anesthesia)

LOW: enema

cleans the rectum and sigmoid colon; given by standard procedure

HIGH: enema

cleanse the entire colon; § try to make solution go all through GI; attempts to clear as much of the colon as possible

Antimotility drugs-

diphenoxylate (Lomotil) are used to treat diarrhea; they work by slowing peristalsis

Colostomy in the transverse colon

formless feces

Antacids-

heartburn medicine; neutralize stomach acid, but may slow peristalsis (food stays in GI tract longer—can casue complications)

Carminative enema (retention enema)

help expel flatus from the rectum; used to remove flatus or gas; relieves bloating and. Distention; used after abdominal or pelvic surgery when peristalsis is slow

Red (blood), occult (abnormal stools)

hidden blood (guaiac test), and frank bleeding- visible, old blood coming from high in GI tract appears black/tarry (melena—if not on iron; don't mix these up b/c iron causes stool to be black/tarry as well)

If passage through the colon is slowed,

more water is reabsorbed from the feces. The stool becomes dry and hard, requiring more effort to pass.

1. Physiology

mouth upper esophageal sphincter esophagus lower esophageal sphincter stomach pyloric sphincter small intestine ileocecal valve large intestine rectum anus

Antacids/no bile/x-ray barium- abnormal stools

o § Antacids/no bile/x-ray barium- white/clay colored

Magnesium (Mg):

o 1.6-2.6 mEq/L * Peoples ages 16-26 are most likely to read MAGazines (remember decimals!)

sodium (Na):

o 135-145 mEq/L * remember 35 and 45 from pH, but think people like a lot of salt

Phosphate (PO4):

o 2.5-4.5 mg/dL * Even though it says phosphate, think phosphorus (phosphor [pronounced phosphor—think the number 4; us= you and me—2 people); (remember the 0.5!)

Bicarbonate (HCO3-):

o 22-26 mEq/L * Most females 22-26 are trying to say bye to carbs

§ R/O (rule out) causes of Diarrhea:

o Antibiotics- can kill good bacteria (normal flora) causing opportunistic infection—can leads to diarrhea. C-Diff occurs, and the person needs to be on contact precautions. o Hard to prevent spreading. Must wash hands with soap and water! (no hand sanitizer) o diagnosed with ELISA test. o (wash hands—change gloves, gown [sometimes mask] before going into someone else's room) o Want to rule out the causes of diarrhea b/c if a person is having diarrhea, it could be a good thing; you need to know the cause because if you ate something with a foodborne pathogen, it needs to get out of your system, so you would want diarrhea (don't want anything to stop it); There are other causes of diarrhea you would want to stop

· AGE: (affects color of BM) children (factor that influences bowel elimination)

o Can't control BM until 2-3 YOA due to that fact that toilet training requires having neural and muscular control, as well as knowing what it means to have the urge. * Prior to this, children haven't developed neural and muscular control * bringing kids to the bathroom helps them understand what the urge is o The child must be aware of the urge to defecate, be able to maintain closure of the external anal sphincter while getting to the toilet, and be able to remove clothing. o When toddlers become engrossed in play, they sometimes ignore the need to move their bowels, and soiling is common. o As children mature, they gradually learn to gain more control over defecation.

· SIGMOIDOSCOPY/COLONOSCOPY

o Detects ulcerations, punctures, lacerations, tumors, hemorrhoids, polyps, fissures, fistulas, & abscesses. o Air is put into colon to distend them so view is better. o Tell them they may feel pressure, cramping, or urge to defecate- take slow deep breathes. o Placed left lateral knee-chest position. Afterwards will have flatus, abd cramps, and see blood in first BM. * When procedure is over, patients need to get up and move around; only getting up and moving around will help get gas out (normal part of having procedure done) * After procedure, keep them on their side, and monitor them (you do not have to check for gag reflex) o S/S of perforation to report (cyanosis, substernal or abd. Pain, vomiting blood, difficulty swallowing, or black, tarry, stools.)

isotonic: enemas

o NS (normal saline)- cleansing- 500-1000ml for adult and less for school-age to infants- Isotonic- safe for CHF pt. Osmotic pressure same in intestines and interstitial spaces. (same fluids as the body; same consistency as body fluids) o INFANTS, CHILDREN, AND CHF PT'S CAN ONLY GET NS (NO TAP WATER)

· PERSONAL AND SOCIOCULTURAL FACTORS-- privacy and time (factor that influences bowel elimination)

o Privacy is important to most people, as is sufficient time to have a bowel movement without feeling the need to hurry. o Clients working in fast-paced jobs may have difficulty even consciously recognizing the need to defecate, and some habitually ignore the need, promoting bowel dysfunction. o Parents and caregivers of infants and toddlers may postpone their own toileting needs because of fear of leaving the children alone. o Some clients are embarrassed by the thought that anyone might realize they are having a bowel movement and will wait until they are entirely alone before even entering the bathroom.

contraindications for enemas

o Rectal surgery o Bleeding hemorrhoids o Ulcerative colitis and Crohns disease o Rectal fissure or cancer o Bleeding potentials (meds that increase risk for bleeding, disease process that increases risk of bleeding) o Certain heart conditions- MI or unstable angina. o do not give if has IICP (increased intracranial pressure) or glaucoma.

§ Medicating Enemas- (retention enema)

o Steroid to decrease inflammation o Neomycin to reduce bacteria in colon before surgery (given before abdominal surgery in case GI mucosa gets puncture, which can cause peritonitis (neomycin can reduce bacteria) o other medications to cause an exchange of substances (Kayexalate - to decrease K+ levels—draws K out of body through stool, so it can be excreted—used in pt's w/ hyperkalemia) o may be used to instill antibiotics to treat infections in the rectum or anus or to introduce anthelmintic agents for treatment of intestinal worms and parasites

§ Use the following interventions to help clients manage flatulence:

o Teach clients to be aware of and avoid foods that trigger flatulence. o Teach clients to follow self-care strategies (identified earlier) for maintaining regular bowel movements. o Encourage patients who have had surgery with gaseous anesthesia to ambulate and perform bed exercises to stimulate peristalsis and the passage of gas. (abd surgery/colonoscopy) o In severe cases, if one has a lot of gas and it is casuing them a lot of discomfort, you may need to insert a rectal tube to aid in the elimination of flatus. * Lubricate 4-5 inches, attach collecting bag to rectal tube, position on left side, insert, leave in place 15-20 minutes, assist into knee chest position of possible (can help get rid of more gas).

§ Anesthesia- (factor that influences bowel elimination)

o When one is under anesthesia, their bowels go to sleep as well o general anesthesia in which the patient becomes unconscious, which decreases or stops peristalsis, causing an ileus (inability of the intestine (bowel) to contract normally and move waste out of the body) o Spinal anesthesia and epidural anesthesia are less likely to cause this effect o must make sure bowel sounds return prior to giving anything orally (usually takes 24-48 hours.) (nothing to eat or drink; bs pt has no control over anything)

§ bowel manipulation (factor that influences bowel elimination)

o abd. or pelvic surgery, in which the bowel is manipulated (intestines are taken out and put on your chest; MD lets them fall back into abdominal cavity), may result in paralytic ileus (cessation of bowel peristalsis) o although peristalsis stops, the bowel continues to produce secretions. The secretions remain stagnant (still), causing distention (enlargement, increase in size, bloating) and discomfort o Nasogastric tube is inserted to constant or low intermittent suction. This tube removes secretions until peristalsis return/until bowel sounds return. (the tube is pulling out secretions in your intestines, so they can rest, open up, and peristalsis can return) o Bowel gets distended because secretions can't move through (may have blockage that occurred because intestines didn't fall right)

§ sigmoidoscopy-

o anal canal, rectum, and sigmoid colon NOT sedated, light meal allowed before or clear liquids last 24 hrs. prior to procedure, prep- two small volume enemas. o Post-test care: * Observe for Potential Complication: bowel perforation (cyanosis, substernal or abd. Pain, vomiting blood, difficulty swallowing, or black, tarry, stools.) * The patient may resume normal activity. * Explain that air was introduced into the intestines to distend them for better visibility and that this may cause gas pains or flatulence for a few hours. à When procedure is over, patients need to get up and move around; only getting up and moving around will help get gas out (normal part of having procedure done) * A small amount of blood in the first bowel movement is normal. Notify the physician of significant bleeding.

Diverticulosis

o constipation causes muscles to enlarge and develop pouches where fecal material becomes trapped; the pouches then become infected o Person has a weakend area in the GI tract that becomes a pouch that sticks out. As food goes through the GI tract, fecal material becomes deposited into diverticulosis o If it ruptures, patient may have to go in and have bowel diversion which can either be temporary or permanent (colostomy) o Antibiotic therapy or surgery is required. o People whose diets are low in fiber or consist mainly of refined foods are especially at risk for diverticulosis. o Obesity and red meat intake are also risk factors

· AGE: (affects color of BM) elderly (factor that influences bowel elimination)

o decreased ability to chew (losing teeth, cavities)/esophageal emptying (harder for esophagus to push food), decreased peristalsis, loss of muscle tone, and decreased control of rectal sphincters can lead to fecal incontinence (if peristalsis is sped up) or constipation, especially if they decrease their activity and fiber intake (not eating well, food staying in the GI tract longer)

· AGE: (affects color of BM) newborn (factor that influences bowel elimination)

o during the first few days of life, newborns pass a green-black, shiny, sticky, and odorless substance that lines the baby's intestines during pregnancy; this is called meconium o meconium is formed by swallowed mucus, hair, and amniotic fluid. Stools transition to a yellow-green color over the next few days o Make sure newborns have meconium within 24 hours of being born; this ensures that their GI tract is working well in their anus is patent (open, unobstructed)—taking a rectal T also makes sure that their anus is patent

§ Perineal surgery (factor that influences bowel elimination)

o holds stool because of fear of pain or rupturing sutures. o Patients who have had surgical interventions involving the perineal region (e.g., an episiotomy (surgical cut made at the opening of the vagina during childbirth, to aid a difficult delivery) after childbirth) may fear pain or that their sutures will "tear" or "break" during bowel elimination, and therefore they resist the urge to evacuate their bowel. o Esp. on rectum—pt is scared of rupturing sutures—can end up constipated

§ Anal surgery (factor that influences bowel elimination)

o may have stool leakage. o Patients who have had surgery that disrupts the anal sphincter may experience uncontrolled rectal drainage after surgery. o Scared it will hurt

· AGE: (affects color of BM) adults (factor that influences bowel elimination)

o pattern set in childhood and normally continues into late adulthood if the client consumes adequate fiber, fluid, and engages in regular physical activity o can be affected by diet exercise, and rectal GI muscle tones.

§ Colonoscopy-

o rectum colon, entire large intestine, and distal small bowel. NPO with bowel prep, versed/propofol (given during procedure so you aren't awake) o Detects early-stage malignancies (colorectal cancer) so, after age 50, it is recommended to do every 5 years. * Colonoscopy may need to be performed even earlier if there is a history of it o 24-48 hours before test— clear liquid diet with thing red or purple (MD may mistake it for blood). NPO after Midnight. o Takes Go-Lytly or a strong cathartic and Dulcolax tablets day before (depending on MD determines bowel prop—but def have to be NPO and take some type of bowel prep), then enemas until clear the morning of. o Will need a ride home and no major decisions for 24 hours o Post-test care: * Monitor vital signs (per agency protocol). * Observe for Potential Complication: Bowel perforation (cyanosis, substernal or abd. Pain, vomiting blood, difficulty swallowing, or black, tarry, stools) * Explain that air was introduced into the intestines to distend them for better visibility and that, as a result, the patient may experience gas pains or flatulence for a few hours. à When procedure is over, patients need to get up and move around; only getting up and moving around will help get gas out (normal part of having procedure done) * Instruct the patient to resume a normal diet when she has recovered from sedation

Permanent-

performed when bowel is dead or can't be salvaged due to disease process. (always will have colostomy)

Colostomy in ascending colon

semi-solid feces

Colostomy in the descending colon:

solid feces

Laxatives and cathartics

stronger/work faster); they are used to treat constipation and promote defecation by stimulating peristalsis (They are frequently abused by people who self-medicate with OTC drugs and may become dependent on them, requiring ever-increasing dosages until the intestine fails to work properly—if overused, pt can become dependent). Can be taken orally, suppositories (work in 30 minutes), enemas

Direct studies-

used for diagnostic and treatment. Invasive with the use of instruments. (contrast dye, catheter, etc.)

Parasites- abnormal stools

worms/eggs

Indirect studies-

x-rays of GI tract. (not inserting anything in pt)

Colon tumor- abnormal stools

§ - ribbon like (may be malignancy)—flat; could be cancerous

risk factors for colorectal cancer

§ 50 + § Family history, personal hx of polyps, IBD (inflammatory bowel disease), UC (ulcerative colitis) § AA § Diet—lots of red meat/fats, veggie/fruits § Obesity/inactive/DM § Smoking/ETOH abuse

· ABD. Flatplate

§ AP (anterior/posterior) x-ray of abd. To view for gallstones, fecal impaction, and distended bowels. No prep and nothing post- op.

· Antidiarrheals

§ Antidiarrheals usually used for chronic issues (not in acute diarrhea) § only use when cause known- decreases motility to increase water absorption. (might need to get bacteria out of GI tract) § Common meds are opiates such as paregoric (some antidiarrheals have opiods in it and can be very addictive; Find out patients history w/ drug abuse) and loperamide. Can be addictive- side effect is drowsiness (tell pt not to operate heavy machinery while taking these meds) § Bismuth Subsalicylate (Pepto-Bismol) - OTC drug has antimicrobial and antisecretory (helps decrease release of enzymes) properties. Contact MD prior to use (b/c based on some meds pt's are taking, MD may not want them to be taking that antidiarrheal) § Antidiarrheals decreased motility or peristalsis, so that liquids do stay inside system for better nutrients and water absorption

· MEDICATIONS (make sure MD tells you how medication affects GI tract) (factor that influences bowel elimination)

§ Antimotility drugs- diphenoxylate (Lomotil) are used to treat diarrhea; they work by slowing peristalsis § Laxatives and cathartics (stronger/work faster); they are used to treat constipation and promote defecation by stimulating peristalsis (They are frequently abused by people who self-medicate with OTC drugs and may become dependent on them, requiring ever-increasing dosages until the intestine fails to work properly—if overused, pt can become dependent). Can be taken orally, suppositories (work in 30 minutes), enemas o Types of stool softeners: * Stool softeners- à allows fat and moisture to enter stool making it soft and easier to pass. à (Ex. Docusate Sodium,Colace, Surfak) à Short term to decrease straining/ when on opioids also during pregnancy/immobility etc. à effectiveness of stool softeners in relieving chronic constipation is being questioned, but they are still in use à take 1-2 times a day à take when you notice bowel pattern has changed and gotten harder * Bulking agents (bulk Forming medications)- à NOT FOOD- nonfoods high in fiber. à They must be combined with sufficient fluid intake to be effective—mix 240 mL of water (have to drink all of it) and you will have BM in 12 to 24 hours. à Bulking agents increase fluids to prevent constipation; the fiber attracts fluid into the colon, and the increased bulk of the stool stimulates the urge to defecate. à (Fibercon, Metamucil, Citrucel- Drugs of choice for constipation may interfere with nutrient absorption—too much fiber can cause constipation) à These are considered the safest form of laxative, but may interfere with absorption of some medicines. They are the drug of choice for chronic constipation. * Osmotic laxatives à Draws water into the bowel from surrounding tissue that cause bowel distention—gives urge to have BM à Magnesium citrate, Milk of Mag, Fleet Phospo soda, MiraLAX, lactulose. à You can't buy Lactulose OTC (need rx) b/c it has given people problems w/ their liver; lactulose helps pull ammonia out of the system that has built up in blood (also given for constipation) à Used for acute emptying/may be used to treat chronic constipation. * Stimulants Cathartics- à causes local irritation to intestines (bowel irritants)—they irritate the intestinal wall. Stimulating intense peristalsis à works in 6-8 hrs. à used during periods when one is getting GI tract evacuated of stool for dx test/surgery/procedures à chronic use causes fluid and electrolyte imbalances. à Senna, biscadoyl, and castor oil. * Lubricant laxatives- à coats stool and GI tract with thin waterproof layer, which may interfere with proper absorption of nutrients needed. à e.g., Mineral oil- CAREFUL- not used in debilitated people and inhaled droplets can lead to pneumonia. (don't encourage pt's to use this) * Chloride channel activators à increase intestinal fluid and motility to help stool pass. * Combination laxatives à laxatives that contain more than one type of laxative ingredient. à The most common type is a combination stimulant laxative and stool softener.

Perforation of the Colon when administering an enema:

§ Be gentle when inserting tubing, aim toward umbilicus, and never force it or insert further than 4-6 inches. § If inserted incorrectly, it can push tubing through intestinal wall, leading to bacteria entering peritoneal cavity and leading to hemorrhage. (if you perforate colon, GI tract has bacteria and enzymes in it that can cause peritonitis in the pt (deadly)

fluids (factor that influences bowel elimination)

§ Can be obtained through liquids/foods § decreased fluid intake/excessive fluid loss leads to decreased peristalsis, which makes stool dry, hard, and difficult to pass. § Increase fluids— 3 liters/day for men and 2.2 liters/day for women to keep intestinal content liquid. However, too much can lead to a rapid passage causing loose stools. § any changes can cause fluid/electrolyte imbalances that affects peristalsis o sodium (Na): 135-145 mEq/L * remember 35 and 45 from pH, but think people like a lot of salt o potassium (K): 3.5-5 mEq/L * usually buy 3-5 bananas and you want them half (0.5) ripe o Calcium (Ca): 8.5-10.5 mg/dL) * People ages 85-105 are more likely to produce osteoporosis (remember decimals!) o Magnesium (Mg): 1.6-2.6 mEq/L * Peoples ages 16-26 are most likely to read MAGazines (remember decimals!) o Chloride (Cl): 95-105 mEq/L * Think chlorine—Best temperature to go swimming is in 95-105 degrees o Phosphate (PO4): 2.5-4.5 mg/dL * Even though it says phosphate, think phosphorus (phosphor [pronounced phosphor—think the number 4; us= you and me—2 people); (remember the 0.5!) o Bicarbonate (HCO3-): 22-26 mEq/L * Most females 22-26 are trying to say bye to carbs o pH: 7.35-7.45 o Pco2 (partial CO2): 35-45 mmHg § Inadequate fluid intake or excessive fluid loss, as in diarrhea or vomiting, slows peristalsis and leads to dry, hard stools that are difficult to pass § Excessive fluid intake (especially beverages with high sugar content) may lead to rapid passage through the colon and soft or watery stools. § Different types of fluids have varying effects on sensitive individuals. For instance, consuming large amounts of milk may cause constipation in some people. Coffee promotes peristalsis in many clients and may even cause loose stools in sensitive clients.

· MRI

§ Cross-sectional images of body. (very sensitive and may be used to detect edema, hemorrhage, blood flow, infarcts, tumors, infections in organ structures) § Noninvasive- uses magnet and radio waves. § May be NPO x 4-6 hrs. § May be given contrast dye, assess to see if pt is allergic to iodine or shellfish- if given monitor for adverse reactions (Hives, headaches, N/V if contrast medium was used) § May be given sedative if claustrophobic. (going through little tunnel, will hear clicking noise—may need Ativan) § NO metal objects jewelry/clothes, pacemaker, metal implants—can rip out metal (this is the difference between an MRI and CT) § Post procedure- return to normal activity, meds, and diet.; observe for delayed allergic reactions

exercise (measure to ensure regular BM)

§ Daily walking/light activity or exercise 3-5 days/week. § If in hospital, get them up ASAP, even if only 10 ft. If on bedrest, perform AROM/ PROM (if they can't) exercises (can promote peristalsis) § Physical activity increases peristalsis and promotes defecation. § Assist hospitalized or institutionalized patients to ambulate as soon as their condition permits. Even limited activity, such as getting out of bed or walking 10 feet, decreases the risk for constipation. § For clients who can assist with exercise, the following exercises promote abdominal and perineal strength: o Thigh strengthening. Have the client slowly bring one knee up to his chest, briefly hold it, then lower the leg to the bed. Repeat this pattern alternating legs. Encourage the client to perform this exercise several times per hour while he is awake. o Abdominal tightening. Have the client tighten and hold the abdominal muscles for a count of five and then relax. This core exercise works the abdominal muscles used during defecation

· Upper GI- Barium Swallow

§ Drink thick, chalky barium while standing in front of a fluoroscopic tube. X-ray films are taken in various positions and at specific intervals to visualize the outline of the organs and to note the passage of the barium through the GI tract. o barium helps outline organs and see how well barium is floating through GI tract § The passage of the barium through the esophagus, stomach, and small intestine is monitored § Oral liquid contrast § NPO 8 hours prior and no smoking (b/c smoking stimulates peristalsis/GI tract) § Will pass barium in stool (white) § increase fluids and take a laxative (after procedure) § always check to see if consent is needed or contrast dye being used

1. Know about colorectal cancer

§ Dx: Hx and PE, early screening: § Third leading cause of death esp. AA, early dx and treatment is key § Warning signs: change in bowel habits (change in vital patterns), rectal bleeding, incomplete emptying, abd/back pain. § Early screening starting at age 50 (may need to be performed even earlier if there is a hx of it or AA—45) § Higher risk in African Americans—early screening should start at 45 § FBOT (fecal occult blood test—microscopic blood; used to see if pt needs colonoscopy)/FIT (fecal immunochemical test—Annually; more sensitive, more expensive, most effective) § ColonCare (home screening)—do it yourself and bring fecal matter to the MD § Flexible sigmoidoscopy (done every 5 years) § Colonoscopy (done every 10 years/age 50, AA-45) (Gold standard—best screening) § Colonoscopies detect early-stage malignancies (colorectal cancer) so, after age 50, it is recommended to do every 5 years. o Colonoscopy may need to be performed even earlier if there is a history of it

· Food and fluid intake (measure to ensure regular BM)

§ Eat a balanced diet with 25-30 grams of fiber that comes from fruits, vegetables, popcorn, dried beans, etc. § Increase fluids (water preferred—Gatorade if you don't like water [electrolytes]) to a minimum of 1500 mL/day [minimum], recommended 8-10 eight oz. glasses per day. § Teach pt's the importance of a balanced diet in promoting soft, formed, regular bowel movements. § Ample Fiber. Encourage a daily intake of 25 to 30 grams of fiber to provide bulk, attract water into the stool, and promote peristalsis. The diet should be rich in fresh fruits, dried fruits, vegetables (esp. raw), whole-grain foods, flaxseed, popcorn, dried beans, peas, and legumes. o Adding fiber does not help to relieve opioid-induced constipation unless the patient's current intake is deficient. o In fact, excessive fiber might put the patient at risk for bowel obstruction due to * opioid-induced decreased peristalsis * delayed gastric emptying * prolonged intestinal transit time of the feces § Without adequate fluid intake, a high-fiber diet can actually cause constipation. Recommend a minimum intake of 1,500 mL of fluid per day to: o keep stool soft o aid in production of mucus to lubricate the colon. o Ideally, a person should drink eight to ten 8-ounce glasses of fluid daily (2,000 to 2,400 mL recommended to have a normal functioning GI tract). § Water Is Preferred. Water is the preferred fluid because soda, coffee, and tea often contain caffeine or additives that promote diuresis (increased of excessive production of urine); However, because the diuretic effect of these fluids is minimal, they are acceptable for clients who simply will not drink enough plain water.

· CT Scan

§ Examines body sections from different 3-D angles using an x-ray beam; useful in diagnosis of many abdominal disorders § Contrast (allows for improved visualization of circulatory systems) may or may not be used (based on exam and what they're using). § Must ask about allergies to iodine, shell fish, etc. o If using contrast, have to ask about allergies to iodine or shellfish!!! o contrast is given either by IV or liquid form o Since contrast eyes at high risk for an allergic reaction, monitor patients very closely (they could have a mild reaction [rash], or a severe reaction [anaphylactic—deadly]) § Will drink 450ml 1 hour before procedure. (so that it gets to GI tract before doing procedure) § During procedure, if injected with contrast dye, may cause pt to have nausea or a warm feeling, or metallic taste in mouth (may cause pt to feel like they will urinate themselves) § Get baseline renal function test (RFT)- BUN and Creatine levels. § Ask if taking Metformin (Glucophage)- if yes- do not take day of test or for 48 hours afterwards to prevent lactic acidosis (lactic acid buildup in bloodstream) o Some MD may want you to come back and get repeat lab values to prevent lactic acidosis (key thing you're looking for in people who have sepsis) o Renal function should be assessed before metformin (Glucophage) is restarted § Must lie VERY still and if claustrophobic needs sedative. § Post-procedure- resume normal diet, activity, and medication. ^ fluids to flush out dye if given IV and get repeat RFT lab values (BUN—can vary for various reasons and Creatine levels—can really tell you if there is some type of kidney damage going on). If drank, may have diarrhea. o MD wants to know if there is any type of kidney damage going on because contrast is excreted through kidneys and if kidneys aren't functioning properly, it can cause a lot of problems (always want to check our RFT before giving contrast dye) § Assess patient for adverse reactions (delayed allergic reactions) to dye can happen during or after test completed. Hives, headaches, N/V if contrast medium was used

1. Care of a stoma

§ Faceplate changed every 3-5 days and PRN. § Empty when 1/3 to ½ full. (don't pull on abd/stoma) o Bags have opening on end to drain and sealed with clamp or velcro. If drained, rinse out with cool water, dry, and reapply it. (the bag snaps on around the wafer—it doesn't interfere with the wafer); have to change bags frequently * Empty pouch before removing. Remove wafer pulling toward top. Assess skin and peristomal area for discolorations, swelling, redness, irritation/excoriation, and bleeding. · Assess stoma and skin with each change. · Clean around it with warm water, soap, rinse, and pat dry. (where faceplate was) · Use protective barrier cream around peristomal area that will be exposed after faceplate/wafer applied (moisture barrier to protect skin as much as possible from excessive moisture due to incontinence, perspiration, or wound drg) · Sometimes wafers do not fit/stick very well—there's a sticky ostomy paste that you can put underneath wafer that helps it to stick better

· FOOD ALLERGIES/INTOLERANCE (factor that influences bowel elimination)

§ Food allergy is a recurrent response to a food each time consumed; an adverse health effect arising from an immune response that occurs reproducibly on exposure to a given food. (could potentially kill you) o Common food allergies- dairy, egg whites, shellfish, gluten, nuts, citrus fruits and soy. o Immune response- mild rash to severe called anaphylactic reaction (shock)- deadly! o Anaphylactic reaction—airway will start to shut down in the circulatory system (made up of blood vessels that carry blood away from and towards the heart) starts to collapse. THIS IS A MEDICAL EMERGENCY o Common GI symptoms suggesting food allergy include constipation, diarrhea, a red, blistering rash around the anus, abdominal discomfort, bloating, excessive gas, and intestinal bleeding § Food Intolerance linked directly to GI system- causes pain, gas, bloating, constipation/diarrhea after eating the food (ex. Lactose intolerant= diarrhea with dairy products.); Such symptoms can mimic those of a food allergy, but food intolerances are not caused by immune responses § (you can take something to offset this—OTC products can help w/ symptoms if they are taken before eating dairy)

· Provide privacy (measure to ensure regular BM)

§ Imagine that your class assignment for today is to stand in front of the classroom and describe to the class your normal pattern of defecation, including frequency, appearance, and other characteristics of the stool. How would you feel about that? Would you do it? § Although defecation is a normal physiological function, most patients consider it a very private matter. The following help to minimize embarrassment: o Take a matter-of-fact approach. This confirms to patients that you are comfortable with this aspect of care. o Provide privacy for your patient when discussing or providing care related to bowel elimination. When assisting a patient with bowel elimination, excuse visitors from the room, draw the dividing curtains in shared rooms, and close the door. o Control odors because many patients are embarrassed by the odor of bowel movements and therefore may ignore the urge to defecate. Using an aromatic spray or other odor-reducing product may help to reduce embarrassment.

· PREGNANCY (factor that influences bowel elimination)

§ In early pregnancy, many women experience fluid loss due to "morning sickness"—periods of nausea and vomiting (causes constipation). § slower peristalsis during pregnancy causing constipation § decreased appetite, and irregular food intake (changes woman's appetite) § increases the risk of hemorrhoids. (the increasing pressure of the uterus from the baby and the increased blood volume to support the growing baby increases the woman's risk for hemorrhoids) § Growing fetus puts pressure on rectum obstructing it—decreased peristalsis 3rd semester.

· Ileostomy

§ In the small intestine, where most nutrients are absorbed § Presence of digestive enzymes (which make it more likely for skin breakdown to occur) § brings a portion of the ileum through a surgical opening in the abdomen, bypassing the large intestine entirely. Because most of the water is absorbed from the feces in the large intestine, drainage at this level is liquid and continuous. The patient must wear an ostomy appliance at all times to collect the drainage. Some variations of an ileostomy are designed to control drainage more effectively and to cause less body image disturbance. However, many clients are not candidates for these procedures because of their underlying disease.

· MEDICATIONS (make sure MD tells you how medication affects GI tract) (factor that influences bowel elimination)

§ Many medications may affect peristalsis. All oral medicines have the potential to affect the function of the GI tract. § Dietary supplements- o Calcium- constipation o Magnesium- loosen stools (almonds, cashews, tofu) o Vitamin C softens stool and in high doses, causes diarrhea § Antacids- heartburn medicine; neutralize stomach acid, but may slow peristalsis (food stays in GI tract longer—can casue complications) § ASA (Aspirin) and NSAID's (Nonsteroidal Anti-Inflammatory Agents)- such as naproxen and ibuprofen, irritate the stomach (can damage mucus that covers stomach lining), causing ulcerations to stomach and duodenum. ; if patients have a history of ulcers/high risk for ulcers/ GI problems tell them to avoid these drugs (MD will give them something else to take) § Iron is a common mineral supplement that treats anemia—it is an OTC medication. it has a harsh effect on the bowel and is notorious for causing constipation and changing stool color to black (can be tarry). It also causes nausea if taken when there is no food in the stomach. (make sur ept is aware black stools will occur, so they don't think it's blood) § Pain meds- opioids (narcotics) slow peristalsis and are associated w/ a high incidence of constipation. (need to take a stool softener 1-2 times a day; MD will recommend pt takes Dulcolax 1-2 times/day—helps keep stools soft and moving through the GI tract) § Antibiotics - disrupt the normal flora in the GI tract causing diarrhea; antibiotics are given to combat infection and decrease the normal flora in the colon. The result is often diarrhea. Bacterial populations can be maintained with supplements of probiotics (e.g., acidophilus) or daily consumption of yogurt (need yogurt/probiotics to prevent C. diff); usually tell pt to eat something after taking meds (read medication label to see if it causes diarrhea)

· PATHOLOGICAL CONDITIONS (factor that influences bowel elimination)

§ Neurological disorders that affect innervation (nerve supply) of the lower GI tract § Cognitive conditions that limit the ability to sense the urge to defecate § Pain § Immobility that leads to sluggish peristalsis § Pathological conditions of the GI tract.

· SURGERY and PROCEDURES (factor that influences bowel elimination)

§ Patients undergoing anesthesia and surgery often experience sluggish bowel elimination; § Stress - o Regardless of the type of anesthesia, most patients find surgery a stressful event o Decreases or slows peristalsis § decreased mobility o get them up and moving after surgery!! o After surgery, pt's often experience discomfort that affects mobility—this hinders GI motility (refers to the movement of food from the mouth to out of the body) and increases the risk for constipation o ROM- make sure pt can move joints o Mobility prevents blood clots in legs, it airs out lungs, and help the GI tract

1. How do you put a patient on a bedpan?

§ Position the patient. § Variation: Supine Position o a. Lower the head of the bed, placing the patient in a supine position. o b. Ask the patient to lift her hips. The patient may need to raise her knees to a flexed position, place her feet flat on the bed, and push up. You can also assist the patient to raise her hips by sliding a hand under the small of her back. § Variation: Semi-Fowler's Position o c. Place the bed in a semi-Fowler's position. o d. Ask the patient to raise the hips by pushing up on raised siderails or by using an overhead trapeze. § Place the bedpan. § Variation: Regular Bedpan o Place the bedpan under the patient's buttocks so that the wide, rounded end is toward the back. o Sliding the pan against the patient's skin may cause damage to skin. § Variation: Fracture Pan o Place the wide, rounded end of the pan toward the front. § Instruct or assist the patient to lower her hips onto the bedpan. § Procedure Variation: For the Patient Unable to Move/Turn Independently § Ask for help from another healthcare worker if the patient's condition warrants. § With the patient in a supine position, lower the head of the bed. § Assist the patient to a side-lying position. Use a turn sheet, if necessary. § Place the bedpan. § Variation: Regular Bedpan o Place the bedpan under the patient's buttocks so that the wide, rounded end is toward the back. Do not push the pan under the patient's buttocks § Variation: Fracture Pan o Place the wide, rounded end toward the front. § Holding the bedpan in place, slowly roll the patient back and onto the bedpan. § Replace the covers; raise the head of the bed to a position of comfort for the patient. Place a rolled towel, blanket, or small pillow under the sacrum (lumbar curve of the back). § Place the call light and toilet tissue within the patient's reach. Return the bed to its lowest position if not already done, and raise the upper siderails o Provides privacy, comfort, and safety. § Remove your gloves, and perform hand hygiene. o Prevents the transmission of intestinal bacteria.

diet (factor that influences bowel elimination)

§ Regular diet helps to maintain a normally functioning system § 5 servings of fiber per day increases peristalsis and defecation (25-30 g/day). Bulky foods absorb fluids and increase stool (muscle?) mass— The increased mass stretches bowel walls, initiating peristalsis and the defecation reflex (Fruits, raw veggies—leaving peeling on is better, whole grains) § Foods and Fiber: Regular intake of food promotes peristalsis. § A regular schedule for eating. o People who eat on a regular schedule are likely to develop a regular pattern of defecation, whereas irregular eating creates irregular bowel elimination. § Some foods have specific effects in the bowel. For example: o The active bacteria in yogurt stimulate peristalsis, while at the same time promoting healing of intestinal infections. (normal flora in GI tract) o Low-fiber foods, such as pasta and other simple carbohydrates and lean meats, slow peristalsis. o Foods such as broccoli, onions, and beans, cauliflower, cabbage lead to excess gas in many people. Spicy foods may also cause gas, as well as more frequent bowel movements.

positioning (measure to ensure regular BM)

§ Squatting/upright sitting position slightly leaning forward (decreases the need for strain) § bedpan- raise the head of the bed with side rails up or trapeze bar in reach (so they can reposition themselves—broken leg/hip) o A patient who must remain in bed should assume a semi-Fowler's position (30 degrees) to use the bedpan. o Patients who are unable to assume this position because of surgery, trauma, or other medical conditions must use supine or side-lying positions. (These positions are unnatural for bowel elimination and place the patient at risk for constipation) o Raise the siderails or provide an overhead trapeze so that the patient can grip them to maneuver on and off the bedpan § When possible, assist the patient to the bathroom to use the toilet. § Place a bedside commode next to the bed for patients who are unable to ambulate to the bathroom.

· Measures for preventing constipation are also used for treating fecal impaction

§ Toileting o For ambulatory patients, allow uninterrupted time for defecation, especially after meals, when mass peristalsis occurs. o Provide privacy for using the toilet. * Assist to/with bathroom/bedpan/BSC then shut door or pull curtain, give toilet paper, give call light, and IF they can be alone step out. o Advise patients not to ignore urge to defecate, because doing so may lead to constipation. o Assist those who cannot toilet independently to ambulate to the bathroom or use the bedpan. o Assist the patient to a seated or squatting position whenever possible. A semi-Fowler's position is preferred for a client on bedrest. Upright, if possible. If in bed- high or semi-fowlers. o Discuss with unlicensed assistive personnel (UAP) the need to offer help without waiting to be asked so that patients experience minimal delays. § Diet and Fluids o Encourage fluid intake: eight to ten 8-oz glasses/day (2,000-2,400 mL); minimum should be 1,500 mL or 50 oz per day) to prevent dehydration and complications. o Encourage fluid intake by offering a variety of flavors and teach why it is important. o If debilitated (RA) then assist with straws, holding cups, positioning, and offer a drink every 20-30 minutes. o Fiber: A person needs 25-35g/day of fiber. Increase whole grains, fruits, and vegetables in the diet o Older people lose their thirst mechanism and don't feel thirsty as often § Activity o Increase physical activity. o For those unable to walk or who are restricted to bed, exercises such as trunk rotation, pelvic tilt, and leg lifts may be helpful o activity stimulates peristalsis. Encourage to ambulate in room or hallways 3-4 times per day unless contraindicated. If bedridden turn at least every two hours and ROM twice a day.

1. When is contrast used, what allergies do you ask about, and what medications, what labs will you review?

§ Used in MRIs (maybe), CTs (maybe), Barium swallow, Barium enema—used to improve pictures inside of the body; allows the ability to distinguish normal from abnormal conditions § Determine that the patient is not allergic to contrast medium, iodine, or shellfish. § Check blood urea nitrogen and creatinine levels to ensure adequate kidney function. § BUN—can vary for various reasons and Creatine levels—can really tell you if there is some type of kidney damage going on). § MD wants to know if there is any type of kidney damage going on because contrast is excreted through kidneys and if kidneys aren't functioning properly, it can cause a lot of problems (always want to check our RFT before giving contrast dye) § Patients taking metformin (Glucophage) should discontinue it on the day of the test and withhold it for 48 hours after to prevent lactic acidosis (lactic acid buildup in bloodstream) § Some MD may want you to come back and get repeat lab values to prevent lactic acidosis (key thing you're looking for in people who have sepsis) § Renal function should be assessed before metformin (Glucophage) is restarted § Restrict food and fluids for 6 to 8 hours if contrast medium is to be given.

· Cleansing enemas-

§ Used to relieve constipation and as a bowel prep prior to surgery/procedures/test (till clear but no more than 3,000 mls consecutively b/c patient will be re absorbing some water when doing that and can cause them to go into fluid volume overload). Large volumes of 500-1000 mls (hypotonic) used or small ones 250 mls or less (hypertonic) § Used to relieve constipation or empty bowels prior to surgery/procedures. § Include hypotonic solutions and hypertonic solutions: o Hypotonic: Tap water- cleansing- contains a large volume of fluid that is instilled into the rectum (500-1000ml)- Do not use in infants, children, and CHF pt's— causes hypervolemia—use normal saline. Moves water out of interstitial space- stimulates BM; watch for water toxicity. o Isotonic- NS (normal saline)- cleansing- 500-1000ml for adult and less for school-age to infants- Isotonic- safe for CHF pt. Osmotic pressure same in intestines and interstitial spaces. (same fluids as the body; same consistency as body fluids) o Hypertonic Sodium phosphate (Fleets) usually smaller in volume (90- 120ml)- pulls fluids out of interstitial space. * adults only. Contraindicated if dehydrated or infant. o INFANTS, CHILDREN, AND CHF PT'S CAN ONLY GET NS (NO TAP WATER)

· Endoscopy

§ Uses a tube & a fiberoptic scope system for observing inside a hollow organ or cavity. § Can also remove polyps, take biopsy specimens, or coagulate bleeding sites. Need a consent form (before giving sedatives)

· Ultrasound

§ Using soundwaves § Looks for masses, cysts, edema, and stones. § Lubricant put on area with transducer (what carries soundwaves, so it can make images show up on screen) displaying sound waves, moved over skin abdomen to visualize visible images. § Might have to go in w/ full bladder

· ESOPHAGOGASTRODUODENOSCOPY(EGD)

§ Visualizes the esophagus, stomach, & duodenum. § NPO for 6-12 hours. Sedatives for relaxation and atropine to dry secretions. o Need consent form before giving anyone sedatives, before performing procedure o Cannot use abbreviations on consent form—must know how to spell esophagogastroduodenoscopy § Spray Local anesthetic to mouth/throat to inhibit gag reflex. (Pt. must be NPO after procedure until gag reflex returns to prevent aspiration.) § placed on left side and tube is passed down GI tract. Photos or videotapes can be made. Biopsy & cytology (examination of cells) specimens can be obtained. § Post-procedure: keep side lying until awake and monitor for perforation (puncture) § can resume normal activity, diet, and medications within 24 hours. § Explain will have sore throat for a few days- gargle with saltwater or use throat lozenges. § Complication Perforation of esophagus or bowel - cyanosis, substernal or abd. Pain, vomiting blood, difficulty swallowing, or black, tarry, stools. § Call MD if runs fever, has difficulty breathing, or severe pain. § Will need a ride home after procedure and no major decisions for 24 hours

· Dehydration- can occur with loss of fluids.

§ Water loss of 5% requires treatment; Loss of 8-10% is critical; A loss of 13-15% can lead to death o 75-80% of an infant's weight is water- highest risk of dehydration that can occur quickly. o 65-70% of an adult body is water o 55-60% of elderly is water- less amount and has decreased thirst mechanism so high risk of dehydration also. o Entering quickly if you see infants or elderly having diarrhea and becoming dehydrated; need IVF o Elderly and infants are at the highest risk for dehydration o Infants, young children, and frail elderly are most vulnerable and may require hospitalization and IV fluid replacement therapy.

· Colostomy

§ a surgical procedure in which an opening is formed by drawing the healthy end of the colon through an incision, into the anterior abdominal wall and turning it down like a turtleneck then suturing it into place. o The distal end is removed or sewn shut (called a Hartman's Pouch) and left in the cavity. o The rectum is left intact or removed. § In colostomies, either the: o Distal end of the colon is removed, and rectum is removed (never will have a BM again) o distal end of the colon is sewn shut (Hartman's pouch) and left in the cavity; the rectum is left intact (left b/c MD can do a reversal) § Most colostomies are usually temporary § depending on what type of stoma it is in what is draining out of it, it may be continent (person can control it) or incontinent (have to use a pouch or bag) § The location of the colostomy determines the consistency of the feces eliminated, as well as the need to wear an ostomy appliance o The closer the colostomy is to the ascending colon and the ileocecal valve (between the small and large intestine), the more liquid and continuous the drainage will be. o A colostomy close to the sigmoid colon (near the rectum), in contrast, will produce solid feces. o Colostomies near the rectum, such as sigmoid colostomies, can often be controlled by diet and irrigation. As a result, the client may not need to wear an ostomy appliance to collect drainage.

· factors affecting bowel elimination:

§ abd. Pain o NPO: nothing to eat or drink in case they have to have surgery § anal itching § medications o Ca, Mg, Fe, ASA, NSAIDs o Some medications may stimulate peristalsis, soften the stool, or add bulk to the stool. Stool softeners and those that add bulk are better to use than laxatives o elderly osmotic laxatives such as polyethylene glycol and Lactulose (doesn't cause much electrolyte changes in body and doesn't cause as many complications in the elderly) § changes in bowel habits (having BM more frequently? Less frequently? Hard/dry BM?, loose?) /appetite/diet (what kind of diet? Have they changed their diet?)/fluid intake § N/V § any hemorrhoids § condition of teeth/oral cavity o can they chew well? enough to be able to breakdown food, swallow, and digest? What does the oral cavity look like? § activity level § stressors § family history o Family history of colon disease? Ulcers? § surgeries o Ever had surgery on GI tract before? § pain § living arrangements

Liver/gallbladder problems/GI issues- abnormal stools

§ clay colored/pale stools (urine becomes darker d/t bilirubin); 2 systems affect each other-- a lot of times when you have liver problems, it can cause changes in urine and stool and vice versa o Bilirubin is what gives stool its color; Anytime you have problems in the GI tract, whether it's the Gallbladder, liver, etc , and with the bilirubin level, you will start seeing this (pale stools, darker urine)

· Lower GI- Barium Enema

§ colon filled with barium (contrast medium) § low residue/clear liquid diet for two days, then NPO for 8 hours prior (avoid dairy products that day) § Golytely, laxative, enema's until clear the night before § after ^ fluids, take a laxative, and stool will be white § Always check to see if consent is needed or if contrast dye is being used (consent is needed for this, since it is invasive) § The test is especially useful for visualizing polyps, diverticula, and tumors § The patient is not sedated § The patient should understand that the procedure may take several hours § GoLYTELY is chilled and drunk full strength with no ice (cannot be diluted), 8 ounces every 10 minutes for a total of 4 L. § Drinking this solution can be unpleasant for the patient. § Inform the patient that a watery diarrhea will begin in about 1 hour and continue for up to 5 hours as the bowel is cleared. § Other bowel preparations are available such as polyethylene glycol (Miralax). § Bowel preparation is necessary for adequate visualization during the procedure. § If the patient has active inflammatory disease of the colon or suspected perforation or obstruction, a barium enema is contraindicated. § Active GI bleeding may also prohibit the use of laxatives and enemas. § Takes about 15 minutes may have cramping tell to take slow deep breaths. § one 8-ounce glass of liquid per hour for the next 24 waking hours to help remove the barium. § The patient may have bloating and cramping after the tests and will probably feel the need to empty her bowels as soon as the test is done § After the procedure, instruct the patient to resume food, fluids, and medications § Instruct the patient to take a mild laxative and increase fluid intake (four glasses) to aid in elimination of barium. Barium can cause Constipation for a few days § The patient is told to report any abdominal pain, bloating, or absence of stool.

1. How do you put a patient on a bedpan?

§ do they need a fracture pan (hip problems/back problems) or a regular one? § Have pt. roll over, place firmly against buttocks, and assist to roll back toward you while holding bedpan in place with handle. § Raise hob 30 degrees (BM sitting up) with side rails up/trapeze bar in reach (so they can reposition themselves) § Remove by lowering HOB, holding onto handle, have patient roll away from you, clean, remove bedpan and dispose of waste. § If pt can clean themselves, give toilet paper, clean wash cloths and towels for hygiene.

managing flatulence (measure to ensure regular BM)

§ gas accumulates in intestine, caused by foods/food intolerances, celiac disease (ingestion of gluten leads to damage in the small intestine); C/O abd. fullness, cramping, and pain—Can pass by belching or flatus. § Recall that flatus is a natural by-product of digestion. When gas is excessive or leads to complaints of abdominal distention, cramping, or discomfort, it is known as flatulence. § Teach to avoid gas forming foods- beans, cabbage, cauliflower, onions, and spicy food; increased fiber intake can also promote flatulence § If had surgery (abd.) or procedure (Colonoscopy) that uses gas, get them up to increase peristalsis. (these surgeries/procedures cause gas) § Flatulence is one of the cluster of symptoms of irritable bowel syndrome. § Constipation is often accompanied by flatulence because digestive by-products undergo prolonged fermentation (chemical breakdown of a substance) in the colon.

· PHYSICAL ACTIVITY (factor that influences bowel elimination)

§ increases peristalsis and stimulates bowel elimination and if immobile, peristalsis decreases— get pt. up and moving ASAP after surgery, etc. (Kegel exercise if weak abd./pelvic muscles—also prevents you from getting blood clots) § Sedentary people are likely to have weaker abd muscles § Pt's w/ health concerns that limit activity (SOB, pain, or required bedrest) often experience constipation)

Iron

§ is a common mineral supplement that treats anemia—it is an OTC medication. it has a harsh effect on the bowel and is notorious for causing constipation and changing stool color to black (can be tarry). It also causes nausea if taken when there is no food in the stomach. (make sur ept is aware black stools will occur, so they don't think it's blood)

oil retention (retention enemas)

§ mineral oil, cottonseed oil, olive oil- softens stool and lubricates rectum; feces absorbs oil and it becomes softer. (used 1 hour prior to removing fecal impaction, pt. must retain)- 90- 120ml-adults only; may be used to assist a patient to pass hard stool or before digital removal of stool (can be useful w/ fecal impaction)

Inflammation/infection- abnormal stools

§ mucus, pus, blood (Crohn's disease, GI bleed—anytime you see blood, it needs to be investigated—probably something serious) (ulcerative colitis)

Pain meds-

§ opioids (narcotics) slow peristalsis and are associated w/ a high incidence of constipation. (need to take a stool softener 1-2 times a day; MD will recommend pt takes Dulcolax 1-2 times/day—helps keep stools soft and moving through the GI tract)

· Inserting an enema

§ place sign on door when performing. § Always prime tubing first. § Put patient in left lateral (Sim's Position) § Insert 4-6 in § Hang on IV pole 12-18 inches and raise pt's hip. § Regulate flow by raising or lowering bag- if goes in too fast, it causes cramping. If cramping occurs, clamp tube and encourage pt to take slow deep breaths through pursed lips. o If cramping continues, might want to stop and contact MD o The higher the fluids are on IV pole, faster they'll go (can cause cramping) and; The lower the fluids are an IV pole, the slower they'll go in § Lubricate tube 2.5-3 inches with KY. Insert pointing tip toward umbilicus based on if adult, child, or infant. § Perforation of the Colon: Be gentle when inserting tubing, aim toward umbilicus, and never force it or insert further than 4-6 inches. § If inserted incorrectly, it can push tubing through intestinal wall, leading to bacteria entering peritoneal cavity and leading to hemorrhage. (if you perforate colon, GI tract has bacteria and enzymes in it that can cause peritonitis in the pt (deadly) § Instruct pt to hold for 5-15 minutes and to notify you when they have gone so you can assess the output. (make sure there is a BSC nearby or put attends on them—in case they can't make it in time)

ASA (Aspirin) and NSAID's (Nonsteroidal Anti-Inflammatory Agents)-

§ such as naproxen and ibuprofen, irritate the stomach (can damage mucus that covers stomach lining), causing ulcerations to stomach and duodenum. ; if patients have a history of ulcers/high risk for ulcers/ GI problems tell them to avoid these drugs (MD will give them something else to take)

1. Physiology

· 1. Mouth is where food is broken down into small pieces and mixes with salvia (moistens food) to dilute and soften it. § Glands excrete ptyalin and amylase- begins digestion of carbs. (enzyme; Breaks down carbohydrates—food becomes a bolus) § When you swallow the bolus, it goes through the pharynx (throat) where the epiglottis closes over the trachea to prevent choking and aspiration. · 2. Upper esophageal sphincter prevents us from swallowing air and prevents food/acidic juices from refluxing into the throat (pharynx—above esophagus) (laughing and swallowing something and it goes down the wrong tube) · 3. Lower esophageal sphincter (right above stomach) prevents reflux of food back into the esophagus (could go back into the throat). (usually burns because of enzymes from the stomach) · 4. Stomach enzymes- Hydrochloric acid and pepsin breaks down proteins, mucus- protects (coats) the stomach lining from the acid/enzymes (so it doesn't damage it), and intrinsic factor - important in Vitamin b12 absorption. (something happens to the mucus that is covering the stomach lining, one can get ulcers); a lot of stomach issues occurs people get older

1. Physiology

· 5. Small intestine is broken down into duodenum (processes chyme from stomach through the release of enzymes from bile duct—bile, pancreatic duct—pancreatic juices, and liver—release of liver enzymes), jejunum (absorbs carbohydrates and proteins), and ileum (absorbs water, fats, bile salts) chyme is liquid when enters duodenum but is a liquidity semi solid when leaves ileum. Duodenum and jejunum absorbs most nutrients and electrolytes. The ileum absorbs vitamins, iron, and bile salts. Pancreatic enzymes and bile from liver are important to this process. Based on this if there is a problem the person ends up malnourished and with electrolyte imbalances that we would have to monitor them for. (if the small intestine is not working properly, a person can become malnourished); the small intestine consists of: duodenum, jejunum, ileum · 6. Ileocecal valve- prevents content from going back into the small intestine · 7. Large Intestine aka Colon- primary function is bowel elimination; absorbs most of the water. Made of cecum, ascending, transverse, descending, sigmoid, and rectum. Functions are absorption, secretion, and elimination. Reabsorbs majority of water, sodium, and chloride. Faster peristaltic less water can be absorbed so this means the stool is loose compared to being slow the stool will be harder leading to constipation. BM's usually occur after meals and 3-4 times per day. (also has normal flora to prevent you from getting bacterial infections in the GI tract) · 8. Rectum until defecation occurs. Veins in rectum distend when a person strains that can lead to hemorrhoids. (rectum is at the end of the colon) (food (turned into chyme) stays in the rectum for a long period of time, starts absorbing water and the longer it stays in there, the more water that is being absorbed, which leads to Constipation) · 9. Anus - has internal and external sphincters. That contract and relax when stimulated by the sympathetic and parasympathetic nerves the sensation of rectum being full.

soap suds enema

· 5ml of SS (Castile Soap) per 1000ml of Tap water or NS. For infants and those with CHF use only NS. Irritates rectal mucosa. Avoid if elderly or pregnant- electrolyte imbalances (increases their risk for electrolyte imbalances)

1. Ileostomy vs. colostomy

· A colostomy close to segment effluent is solid and the closer a colostomy is to the ileocecal valve, the more liquid (pouch needed) with continuous drainage occurs. If occurs near the rectum, pt can be continent and treated with diet and irrigation. · As you go through the colon, you are absorbing more and more water= harder stool · The small intestine is where chyme is present and going through the small intestine; as it continues to go through into the large intestine, more water is absorbed—stool will become more solid § Colostomy in ascending colon: semi-solid feces § Colostomy in the transverse colon: formless feces § Colostomy in the descending colon: solid feces

what are the contraindications of valsalva manuever

· Although it assists with the passage of stool, you should caution patients with heart disease, glaucoma, increased intracranial pressure, or a new surgical wound to avoid this because it increases pressure in the abd cavity, raises blood pressure, and is associated with an increased risk for cardiac arrhythmias

1. Physiology

· Bowel elimination occurs as nutrients move through the GI tract via peristalsis from esophagus to rectum. Defecation is the process of bowel elimination. · 1. Chew food and Swallow (mouth—food starts being digested here) · 2. Passes through upper esophageal sphincter · 3. Esophagus (peristalsis begins here and ends at rectum) · 4. Lower Esophageal Sphincter (aka cardiac or gastroesophageal) § Sphincters prevent things from going backwards · 5. Stomach- food reservoir, enzymes break down into semi-liquid called chyme, regulates food emptying into the duodenum. (after food is in the stomach, it empties through the pyloric sphincter into the duodenum) · 6. Pyloric sphincter · 7. Small intestine (most nutrients from food digested and absorbed) · 8. Ileocecal valve · 9. Large intestine (has normal flora to prevent infections/bacteria interacts with chyme causing flatus/where most water is absorbed) · 10. Rectum- Defecation Reflex (caused by distention of intestinal walls-voluntary) - Anus

1. Bowel diversions

· Certain disease processes or injuries (cancer, Crohn's disease (where MD may have to take out a large or small portion of the bowel), ulcerative Colitis, etc.) may require a bowel diversion which may be permanent or temporary (can be reversed). This is the surgical redirecting of the small or large intestine through the abdominal wall, called an ostomy/stoma. (it protrudes out of the abdominal wall) § Temporary- to allow bowel to heal and rest after a surgical intervention. When healed reversed with reanastomosis (reconnection) to the bowel occurs with regular BM's. (when healed, MD comes back in and does a reversal) § Permanent- performed when bowel is dead or can't be salvaged due to disease process. (always will have colostomy) § Depends on what is going on w/ the person · Feces is then called effluent when empties into an ostomy bag/pouch. Name of ostomy is called by the part of the bowel used to create it, determines stool consistency, and if a pouch is needed. § Helps to determine what type of stool is coming out: solid, liquid, or semisolid (all depends on where it is coming out)

1. Which type of stoma would we irrigate and why?

· Colostomy irrigation is similar to giving an enema but requires special kit. · Performed to evacuate stool due to constipation, post-operatively, or to train a sigmoid colostomy to evacuate at the same time each day- takes one hour · Irrigating a colostomy—cone-shaped device you stick inside stoma; putting water through stoma into colon; The patient may use a special plastic sleeve over the stoma or an ostomy appliance to direct the output into the toilet. · irrigating a colostomy at the same time every day will help train your bowel to function on a regular schedule (could help control bowel evacuation/ possibly eliminate the need to wear an ostomy pouch) · Age related changes decrease the elasticity of abdominal walls which leads to decreased motility that leads to constipation. Educate on how to prevent (fiber, fluids, exercise) · Not used for ileostomies due to liquid output. Diarrhea leads to dehydration quickly - increase fluids (if pt has a lot of output, they could become dehydrated b/c it's like diarrhea) · Prime tube with 500-1000 mL of tap water before putting in prescribed irrigating solution; position in front of (or on) the toilet, or use a bedpan. § Water that is too cold will cause cramping, nausea, and discomfort. Water that is too hot will damage the intestinal mucosa. · Lubricate cone attached to tubing and gently insert into stoma. · Open clamp and slowly infuse over 10-15 minutes. Remove and evacuation should occur in 30 minutes. (effluent should come out into ostomy bag in about 30 mins) · ONLY IRRIGATE A COLOSTOMY (helps relieve constipation); DON'T IRRIGATE AN ILEOSTOMY (stoma above the descending colon) DUE TO LIQUID OUTPUT THAT CANNOT BE CONTROLLED!

1. What are some nursing diagnosis you may use for the GI system?

· Constipation § decreased frequency of BM's—dry, hard stool that is difficult to pass. (too much water absorbed) § Can be acute and chronic if last more than 3 months. § May lead to an impaction (blockage of stool) § Interventions: prune juice, hot solutions, timed BR breaks. § Complains of anorexia, abd. Pain, rectal pressure, headache, nausea, and indigestion. § Many elderly people are admitted for this, so keep an eye on pattern. § If constipation occurs, ask about diet, activity, medications, privacy issues, etc. § Can be a temporary problem, with symptoms resolving in a short time · Fecal impaction · Diarrhea · Fecal incontinence

1. What can or can't be delegated?

· DRE cannot be delegated · Irrigating a colostomy cannot be delegated initially (b/c it is a newly created colostomy); in some situations, it may be delegated, depending on agency policy · Can delegate the collection and testing of a stool sample for occult blood · Can delegate the placement and removal of a bedpan · Can delegate administering an enema · Can delegate changing an ostomy appliance if it is preexisitng (instruct UAP to report any changes or unusual findings, such as stoma color, swelling, peristomal redness), but not after immediate postop period · Can delegate the placement of a fecal drainage device if it is external (internal device is usually performed by RN, but may be delegated to LPN, depending on agency policy)

1. Fecal incontinence (unable to control BM's)—nursing dx

· Degree and severity varies · Rates higher in disoriented, confused clients, those with functional limitations (can't get to the toilet on time), and those with nerve damage innervating the rectal sphincter. · Embarrassing, low self-esteem, social isolation, and loss of sexuality occur. · As a nurse you will provide privacy, control odors (so they aren't embarrassed if visitors come), and let the patient (pt.) know you are nonjudgmental and there for support. · Assessment § Skin breakdown/redness (want to assess what is causing skin breakdown) § Causes of incontinence § Bowel pattern/Medical issues

1. Care of a stoma

· Depending on type may need to wear appliance/ bag. · Applying an appliance (different types) to determine correct faceplate opening size and projection size, stoma must be measured. (don't want to see very much skin; want to make sure skin stays intact) · New ostomies have card stock boards with circles of different sizes and the wafer has to be cut as it heals then faceplates/wafer come precut. Consult with WOCN; new ostomies are very swollen § One the stoma heals, it is permanent size, meaning you don't have to measure—you can order wafers that fit perfectly around the stoma · Some appliances are one piece (all intact applicance) or two pieces (two-part appliance). Odor proof/protective skin barrier. · Correct measurements: § Fits stoma with only 1/8 to ¼ of peristomal skin showing. (make sure it fits almost perfect around stoma) o If one side of the stoma is bigger than the other, you have to cut stock board out to put it over stoma so that it fits well

1. Bowel elimination

· Having regular bowel movements is important for the body to function properly. Any changes that occur could be the symptoms of something more serious. Everyone's bowel patterns are different. This can be embarrassing and emotional for the patient. (be empathetic/listening; control facial expressions) · Important body process that can affect other body processes: § anytime patient has a symptom take it seriously and evaluate it thoroughly and collect baseline data, so we know what is going on with that patient § also, so we know what vital signs are normal for that patient § treat people individually- what is going on with them? What should we do for them? What works for them?

1. Know about abnormal stools-

· If has decreased fluids/slow transit— stool becomes hard and can come out in balls or clumps · If transit time fast— liquid to semi-liquid · Consistency/shape- § Fiber will increase bulk § Increased fat- steatorrhea (GI tract is not absorbing fat the way it is supposed to) (undigested fat-fluffy, float, and foul odor) § Colon tumor- ribbon like (may be malignancy)—flat; could be cancerous § Inflammation/infection- mucus, pus, blood (Crohn's disease, GI bleed—anytime you see blood, it needs to be investigated—probably something serious) (ulcerative colitis) § Parasites- worms/eggs § Liver/gallbladder problems/GI issues- clay colored/pale stools (urine becomes darker d/t bilirubin); 2 systems affect each other-- a lot of times when you have liver problems, it can cause changes in urine and stool and vice versa o Bilirubin is what gives stool its color; Anytime you have problems in the GI tract, whether it's the Gallbladder, liver, etc , and with the bilirubin level, you will start seeing this (pale stools, darker urine) § Antacids/no bile/x-ray barium- white/clay colored § Red (blood), occult - hidden blood (guaiac test), and frank bleeding- visible, old blood coming from high in GI tract appears black/tarry (melena—if not on iron; don't mix these up b/c iron causes stool to be black/tarry as well) o Melena—GI bleed from high up in the tract § NOTE- any bleeding is serious and should be reported. § Need to tell patients that the medication or procedure will cause changes. What changes can they expect to see in stool? Make sure they know, so they don't freak out if they see

1. When to see MD?

· If symptoms last for more than 3 days or disabling. (unable to carry out ADL's) · Blood is in the stool (unless has history of hemorrhoids—normal to have blood in stools) · Severe stomach pain- keep NPO in case they have to go into surgery (nothing by mouth until we find out what is going on) · Change in bowel habits (normal, now all of a sudden they're constipated all the time) · Unintended weight loss (unless dieting; If not, and significant weight loss occurs, it needs to be reported—it could be a sign of cancer—anything over 3-5 lbs a month loss is the reason to be concerned) · Constipation not relieved by fiber, fluids, and exercise. · Adding more fiber to the diet does not help opioid induced constipation but may cause the person to develop a bowel obstruction. § There are medications people can be put on who are taking long term opioids to prevent Constipation § Fiber can cause a person on opioids to have a bowel obstruction because GI tract has been slowed down

1. Which foods do we teach patients to avoid that cause gas and blockages?

· In ostomy pt's, they can eat some of these foods (e.g., mushrooms, shrimp) if you cut them into small pieces and chew them very thoroughly. · As long as blockage does not occur, these foods should not necessarily be avoided but instead used carefully: § Foods with seeds (e.g., raspberries) § Foods with tough skins (e.g., corn, dried fruits, pears, tomatoes) § Mushrooms § Nuts, popcorn § Raw or minimally cooked fruits and vegetables (e.g., coleslaw, Chinese stir-fried vegetables, oranges, apple skins) § Shrimp, lobster § Stringy foods (e.g., celery, coconut, spinach, bean sprouts, green beans, orange pulp)

1. Diagnostic test

· Indirect studies- x-rays of GI tract. (not inserting anything in pt) · Direct studies- used for diagnostic and treatment. Invasive with the use of instruments. (contrast dye, cathether, etc.) · Need to see GI structures, so laxatives and/or enemas given until bowel clean. · May require person to be NPO (after midnight) § tell patient it is important they're NPO so they can get procedure done and they won't have to go back; want it to be a 1 and done · Will need a consent signed prior to any sedatives and ask about allergies to iodine/shellfish if contrast is used. (may need to be given in a smaller amount if the risks outweigh the benefits) · May need to check gag reflex after procedure prior to giving anything orally. (don't give patient anything to eat or drink until their gag reflex returns; If gag reflex is not working, patient will aspirate [when something enters airway or lungs by accident—could be food, liquid, or some other material])

1. Dietary changes with ostomy

· Initially- bland, low residue (low fiber) or soft for 1-2 months. (to make sure GI system is tolerating food) · Add one food at a time and eat 3 meals/day chew well and ^ fluids. · Causes Gas: Gum d/t (due to) swallowing air. Food that causes gas- ETOH's and carbonated drinks. Dairy- milk, cheese, and eggs. Melons and vegetables. · Controls Gas: buttermilk, yogurt, cranberry juice, parsley. · Blockages: avoid or use cautiously foods high in fiber (have to change amount of fiber in your diet based on how well GI system is tolerating it)- sweet corn, Chinese cabbage, popcorn, mushrooms, nuts, stringy foods, etc. · Causes diarrhea: ETOH, milk, prunes, raisins, raw fruits and vegetables, baked beans, cabbage, etc. · Alleviate Diarrhea: BRAT diet- bananas, white rice, applesauce, toast; starchy foods, cheese and creamy peanut butter. · Advise against: Vegetables- broccoli, asparagus, Brussel sprouts, cabbage, cucumbers (maybe seedless will be okay), garlic, onions, peas, etc.

1. Fecal incontinence (unable to control BM's)—nursing dx

· Interventions § Have a set time for BM's, assist with bedpan or with ambulation to bathroom. § Change clothes/linen as needed to prevent skin irritation and provide perineal care. o After each incontinence episode it is important to perform good care with soap and water, rinse well, and pat dry to prevent excoriation of the skin. Use barrier creams to prevent breakdown. o Changing attends as soon as they have BM to avoid skin breakdown o if fecal matter gets on linens, change them ASAP, so it doesn't get on patient skin o can put Shields on patients to help catch BM o do not walk by call light that is ringing § Apply skin protectants- creams and/or moisture barrier. Absorbent pads/shields/attends to prevent soiling clothes/linens. Moisture resistant pads under pt., plastic side toward mattress (dog pads; peri-pads or moisture resistant pads) · Make sure CNA's know the schedule and can assist. (assisting on teaching pt on how to control bowels; assisting pt to bathroom; assisting w/ cleaning pt up)

1. Review bowel assessment and how to perform.

· Involves a thorough assessment and data collection with the first encounter. · Assessment of bowel movements with documentation each shift. Documentation should include: § Color § Amount § consistency § unusual shapes and odors § medications pt is taking § what type of diet pt is on § physically active? § Having problems going to the bathroom in public? · Interventions include: § Increase activity § Increase fluid and fiber intake § Provide privacy § Ensure proper positioning § Make sure pt is in proper position when going to the bathroom

1. Assessment of a stoma

· May have an ostomy nurse but you are still responsible for assessment and care. · Assessment includes: § Patient's require thorough and ongoing monitoring of the stoma, output, and skin § reason for ostomy, when performed, type, use of appliance, when last changed (make sure pt knows how to d this) or emptied, and can client perform. § Note: contour and color of abd. scars, surgical site (what does it look like?), dressings, sutures, clamps, drains. Stoma appearance, color, size, edema, moisture level, peristomal skin (what does the skin around it look like?), effluent, and if appliance is intact (or if they have one). (is it an ileostomy or a colostomy?) § Pallor, cyanosis, or a dusty color indicates ischemia (impaired blood supply), while black indicates necrosis. - immediately report to surgeon (circulation is compromised going to the stoma) § Assess the effluent- type and amount- output from an ileostomy stoma is liquid and contains digestive enzymes. Colonostomy (or ostomy lower in GI tract)- will have a more solid output with less enzymes- enzymes are what increases the risk for skin breakdown (ileostomy); ileostomy= very liquidy effluent; colostomy= more solid and less enzymes

1. Know about enemas

· NOTE: NEVER instill in sitting position can damage mucosa/perforate the colon. · Patient receives initial installation of the fluid in the left lateral position. The client then moves to the dorsal recumbent position and then to the right lateral position for the remainder of the installation. This turning process allows the fluid to follow the shape of the large intestine · If having Constipation, it is safer to 1st use bulk agents such as Metamucil—mix well in 240 mL of water. habitual use of some meds can eventually cause Constipation because the person can't have a BM without taking something (can become dependent on it—only use laxatives or enemas when you absolutely have to—don't want to become dependent)

1. What is considered when determined if someone is having normal BM's? (normal defecation pattern)

· Normal Bowel Movement (BM) varies for everybody- some have a BM everyday, several times a day, every other day, every three days, and some once a week. · Normal is if you can have a BM without urgency (needing to rush to the toilet), without effort/straining, without blood loss, and without taking laxatives then they are normal! · Elderly pt's could become dependent on laxatives · Bowel elimination affects age groups differently · Bristol stool chart- talks about different types of BM's people can have based on if it is clumps of stool, ribbon-shaped, looks like sausage, etc.

1. What occurs during the Valsalva maneuver

· Occurs when someone is straining to have a BM · When a person is doing this, they can increase the pressure to expel feces by contracting the abd muscles (straining), while maintaining a closed airway (holding their breath) · Contracts the abd muscles and closes airway · Although it assists with the passage of stool, you should caution patients with heart disease, glaucoma, increased intracranial pressure, or a new surgical wound to avoid this because it increases pressure in the abd cavity, raises blood pressure, and is associated with an increased risk for cardiac arrhythmias · Occurs when a person contracts the abd. muscles with a closed airway when defecating. · Teach to avoid if pt has heart disease, glaucoma, increased intracranial pressure, or new surgical wound, as it can increase risk for cardia arrhythmias. · Produces a Vagal Response: stimulation of the vagus nerves that also stimulates the heart (heart rate drops 30-40 BPM, C/O chest pain/pressure (b/c it increases pressure in the thoracic cavity), dizziness, and nausea, clammy skin, pallor [pale]) and bronchioles (causes constriction and can't breathe). · S/S: if EVEN ONE of the listed symptoms occurs, stop and call for help! Put pt in supine position, assess pulse and B/P, skin color (pale), and if diaphoretic (sweating). If pulse less than 60, put in shock position (flat and raise up feet [chair])- head lower than feet and start oxygen at 2L/min via NC. If pt does not recover quickly, atropine is given to increase heart rate. · Take VS and monitor skin color

1. How do you assess for pin worms and how are they contracted?

· Parasites that are small, white, thread like worms that spread from human to humans through fecal-oral route directly or indirectly. · Common in children. · They live in the cecum and come out at night to deposit eggs around the anus (then go back up into rectum during the day) · To assess spread buttocks and see if visible to the naked eye, may need flashlight, on waking up, put a piece of scotch tape (sticky side toward anus) and press down (see if you see any worms on tape), or put a cotton swab 1-inch up rectum, remove, and smear on a slide (won't have a slide to do this in a facility—do this in a dr's office) · You can also check at night by using a flashlight. The test may need to be repeated on consecutive days · Accidentally swallowing or breathing in pinworm eggs (being around people who have them) causes a pinworm infection. The tiny (microscopic) eggs can be carried to your mouth by contaminated food, drink or your fingers (under fingernails—hand to mouth); by entry through the anus (when eggs attached to a person's fingers are transferred to the anal area by scratching or touching the anus) · A sign someone could have pinworms is if they are scratching their butt all the time

1. What education occurs if a stoma is continent/incontinent?

· Patient teaching is aimed at preparing the patient to complete this skill at home. She (or a caregiver) will need to be instructed in how to complete all the steps of the procedure · Assess the patient's self-care ability and assist the client to establish a routine for changing the stoma wafer/pouch. The client may need to stand in front of a mirror or sit to change her ostomy appliance if she is unable to view the stoma easily. · Teach the client that slight bleeding is normal when the stoma is washed. · The client should not use soaps and lotions containing oils. They decrease the adhesiveness of the wafer. · The appliance and the wafer cannot be flushed down the toilet. · Teach the client to report changes in the color or size of the stoma and/or the presence of peristomal irritation or skin breakdown to the primary care provider. · Provide information about ostomy supply vendors and community support groups, such as Ostomates

assessment (bowels)

· Post op : might have to assess BS, because there might not return for 24 to 48 hours after surgery · PA every shift to include inspection, auscultation, palpation, and percussion, of abd. (if we palpate before auscultate, can increase BS) · Elimination pattern- frequency/time of day/routines, weight gain/loss, · Abdomen- distended or soft, contour, shape, symmetry, and color. Look for masses, scars, peristaltic waves (obstruction), stoma, and lesions. · Rectum for hemorrhoids, lesions, discoloration, etc · Abd. that is firm and/or distended can be gas, constipation, or bowel obstruction. · If you hear no BS after listening for 5 minutes in each quad, document absent BS and call physician. · High pitched/tinkling BS in one quad and absent/decreased in left lower quad could be a bowel obstruction. · Decreased BS if developing constipation. · Percussion to identify organs/enlargement, lesions, fluid, tumors, etc. · Palpate for tenderness - supine relaxed position.

1. Diarrhea (nursing dx)

· Prevention § Wash hands! Know what foods cause diarrhea § Eat plain yogurt or take probiotics daily when on antibiotics. (helps prevent C. diff) · Monitoring Interventions § Impaired skin integrity can cause skin excoriation, dehydration, or electrolyte imbalance (esp. K+). (potential complications) § Assessment important with infants, children, and the elderly to prevent complications. (infants and elderly are at high risk for becoming dehydrated § Frequency of stools, color, consistency, amount § When person is having diarrhea, you need to do a good assessment—look for dehydration · Treatment: § MD may order clear liquid diet x 24 hours for infection and inflammation in order to let the bowel rest (or might start off by putting them on NPO for 24 hrs) § Clear liquids are electrolyte drinks (would want to avoid sugary electrolyte drinks if diabetic), clear broth, gelatin, and popsicles (smell and turn into clear liquid; can read a newspaper through it). Have pt. sip or consume slowly. NO APPLE JUICE (increases diarrhea—want to reduce inflammation) (pedialyte) § If pt has appetite give BRAT diet- bananas, Rice, Applesauce, and Toast. Advance diet as tolerated (DAT), gradually reintroducing fiber. § Limit caffeine but decaffeinated green/black/herbal teas at room temperature soothe bowels and slow peristalsis. (room temp because warm stimulates peristalsis) § Breastfed infants can continue with breast milk - has a protective effect against enteritis (protects GI tract). (inflammation of the small intestine) § Provide prompt hygiene care after any episode of diarrhea

1. Where are most nutrients absorbed from?

· Small intestine

1. How do you collect stool specimens for solid versus liquid? What are dietary/medication restrictions prior to guaiac testing? What does guaiac testing look for and how is it performed?

· Stool specimens may be analyzed to detect blood, infection, or parasitic infestation. · The client must void first and then defecate into a clean, dry bedpan, bedside commode, or a special container (half hat) placed under the toilet seat. · A small sample is obtained and sent to the laboratory for analysis or analyzed at the bedside. · To obtain a specimen from an infant or young child, you will collect freshly passed feces from a diaper. · Collecting a Stool Specimen: § MAKE SURE PT VOIDS BEFORE GETTING STARTED § *Collect supplies: tongue blade, specimen pan/BSC/bedpan, gloves, biohazard bag, stool specimen cup, and label. § If incontinent collect from attends/ and child collect from diaper. § Some stool samples require special preservatives (special container) or placed in refrigerator/or on ice and some need to be warm. § *Collect accurately, tell to not mix urine and stool or put toilet paper on specimen. (If you see anything abnormal, make sure you get a piece of it, so it can be evaluated) § Collect 1-2 inches from 2 different areas of formed feces using different sides of tongue blade and 20-30 ml of liquid (can't defecate in toilet and take it out (cannot be in water whatsoever—if stool comes in contact w/ water or urine, it may produce an inaccurate test result) § if blood, mucus, or purulent (pus, infected) material is present, be sure to include this with the sample. § Transport the specimen to the laboratory as soon as possible. If that is not possible, consult the laboratory for appropriate storage. Usually, you will need to refrigerate the specimen until it can be received in the lab. § esp. if abnormal (blood, ova). Take to lab within 15 minutes and document § Prior to collecting sample, have pt void and then defecate into a clean, dry container i.e. bedpan, BSC, half Hat. § Total care and incontinent will need to obtain from attends.

1. Physiology

· The faster peristalsis occurs, the looser the stool is going to be in the slower peristalsis occurs, the harder the stool will become · most people have BM after meals; 3-4 times a day · coffee and warm fluids also stimulate BM · Rectum is where defecation occurs · when internal and external sphincters are relaxed and are stimulated by the sympathetic nervous system, the sensation of the rectum being full causes a person to have the urge to defecate

1. Fecal incontinence (unable to control BM's)—nursing dx

· Treatment of fecal incontinence § If a patient develops Constipation, especially in elderly, on their MAR, you have to document everyday that they have had BM; If it's been 3 days, you need to start some type of treatment on patient, monitor them, increase fluids, etc § Chronic fecal incontinence can try a bowel training program. Place on commode at set times ex. When wakes up, after meals, before bed, etc. (most of the time this doesn't work) o Bowel Training- used for chronic constipation or fecal incontinence- involve pt. and caregiver in plan, need a dedicated, private, uninterrupted time for defecation. If constipation develops- add fiber to diet, then stool softener, followed by Dulcolax (Bisacodyl). Increase fluids, and modify plan as needed.

Digital Rectal Exam (DRE)

· can be performed when treating fecal impaction. This involves insertion of lubricated gloved index finger into anus to manually break up fecal mass, helps if retention enema given first. May need mild pain meds; may stimulate vagal response (stimulation of the vagus nerves that also stimulates the heart (heart rate drops 30-40 BPM, C/O chest pain/pressure (b/c it increases pressure in the thoracic cavity), dizziness, and nausea, clammy skin, pallor [pale]) and bronchioles (causes constriction and can't breathe). § DRE Cannot be delegated! (have to have Medical order b/c of high risk of perforating rectum/colon/GI mucosa) § first check WBC to make sure not immunocompromised, trim nails, baseline VS (b/c if changed, could mean you perforated GI mucosa; assess VS before and very closely afterwards), determine if has cardiac problems or other contraindications, monitor for vagal nerve response. § Monitor very closely after DRE for any other type of issue

If passage through the colon is faster than normal,

· less water is reabsorbed, and stools are watery.

1. Diarrhea (nursing dx)

· loose or watery stools that occur 2-3 times per day with cramping. (the passage of loose, unformed, watery stools) · Acute can be a response to infection, unusual foods/food poisoning, or medications. § Know what's causing the infection before taking anything to stop diarrhea because if you ate something with a foodborne pathogen, and needs to get out of your system § Wash your hands if handling raw meat on kitchen counters (not cleaning surfaces correctly), leaving food out in the microwave, and not cooking eggs and chicken correctly § Diarrhea related to food borne pathogens secondary to consumption of raw eggs AEB nausea, vomiting, diarrhea · Chronic if persist for more than 1 month. · Hot drinks can stimulate peristalsis. (coffee) · Treatment will depend on the cause. · How to check Fluid balance- I/O, skin turgor, daily weights, mucus membranes (be sure it's not cracked/dry) · *** fiber will not work in pt's who are constipated due to opioids

1. Know about enemas

· solution that is instilled in the colon to increase peristalsis for defecation, several types with different purposes. Fluid breaks up masses and stretches rectal wall. · Cleans out GI tract before surgeries/procedures · Used to treat constipation or impactions · Can help start bowel retraining program · Cleans: as prep for procedure and prior to surgeries of abdominal and some pelvic surgeries · Water temperature should be 105 F to 110 F · Place client in Sims position (left lateral). · Insert tip of tubing 3-4 inches (lubricated well) · If ordered to be LOW is standard procedure and HIGH insert half the solution with patient on left lateral position, then position in supine followed by right side lying to administer the rest. Allows fluid to follow shape of large intestine.

1. What is C Diff, what type of precautions are they on, why did it occur and how could it have been prevented, how do you cleanse your hands?

· when antibiotics are taken for long periods of time, these drugs tend to destroy (or kill) some of the normal, helpful bacteria in addition to the bacteria causing the infection, causing C. diff (gets diarrhea and very sick). · Without enough healthy bacteria, C. diff can quickly grow out of control · usually pt's in LTC on antibiotics take probiotics to prevent this from happening. · Caused by taking antibiotics (increased risk in the elderly) · Antibiotics- can kill good bacteria (normal flora), causing opportunistic infection. C-Diff occurs · the person needs to be on contact precautions · Hard to prevent spreading. · Must wash hands with soap and water! - no hand sanitizer · diagnosed with ELISA test. · Eat plain yogurt and take probiotics daily when on antibiotics

Normal Stool Characteristics

· which varies with diet, fluids, fiber, exercise, medications, exercise, etc. · color- light yellowish-brown to light brown · odor- slightly odiferous (not a pleasant smell—slight odor) · consistency- soft, formed, semisolid (approximately 75% water and 25% solid when expelled) · shape- slightly curved

* Osmotic laxatives ( type of stool softener)

à Draws water into the bowel from surrounding tissue that cause bowel distention—gives urge to have BM à Magnesium citrate, Milk of Mag, Fleet Phospo soda, MiraLAX, lactulose. à You can't buy Lactulose OTC (need rx) b/c it has given people problems w/ their liver; lactulose helps pull ammonia out of the system that has built up in blood (also given for constipation) à Used for acute emptying/may be used to treat chronic constipation.

* Bulking agents (bulk Forming medications)- type of stool softener

à NOT FOOD- nonfoods high in fiber. à They must be combined with sufficient fluid intake to be effective—mix 240 mL of water (have to drink all of it) and you will have BM in 12 to 24 hours. à Bulking agents increase fluids to prevent constipation; the fiber attracts fluid into the colon, and the increased bulk of the stool stimulates the urge to defecate. à (Fibercon, Metamucil, Citrucel- Drugs of choice for constipation may interfere with nutrient absorption—too much fiber can cause constipation) à These are considered the safest form of laxative, but may interfere with absorption of some medicines. They are the drug of choice for chronic constipation.

* Stool softeners-

à allows fat and moisture to enter stool making it soft and easier to pass. à (Ex. Docusate Sodium,Colace, Surfak) à Short term to decrease straining/ when on opioids also during pregnancy/immobility etc. à effectiveness of stool softeners in relieving chronic constipation is being questioned, but they are still in use à take 1-2 times a day à take when you notice bowel pattern has changed and gotten harder

* Stimulants Cathartics- ( type of stool softener)

à causes local irritation to intestines (bowel irritants)—they irritate the intestinal wall. Stimulating intense peristalsis à works in 6-8 hrs. à used during periods when one is getting GI tract evacuated of stool for dx test/surgery/procedures à chronic use causes fluid and electrolyte imbalances. à Senna, biscadoyl, and castor oil.

* Lubricant laxatives- ( type of stool softener)

à coats stool and GI tract with thin waterproof layer, which may interfere with proper absorption of nutrients needed. à e.g., Mineral oil- CAREFUL- not used in debilitated people and inhaled droplets can lead to pneumonia. (don't encourage pt's to use this)

* Chloride channel activators ( type of stool softener)

à increase intestinal fluid and motility to help stool pass.

* Combination laxatives ( type of stool softener)

à laxatives that contain more than one type of laxative ingredient. à The most common type is a combination stimulant laxative and stool softener.