Chapter 46 Bowel Elimination (Kish's Lecture)

case study This afternoon Mr. Gutierrez has telephoned his niece for the fourth time. He reports, "My bowels are locked up and haven't moved in the last 2 days." He ate a big meal the previous evening and now reports feeling "all gassed up." His niece tried to explain about eating foods containing fiber and more vegetables. She reminded Mr. Gutierrez that the nursing student was coming later this afternoon, and he could talk to the student about his problem.

Ask the class: What would you do if you were the student nurse and Mr. Gutierrez were your patient?]

ileoanal pouch anastomosis (slide 15)

Alternative approaches include an ileoanal pouch anastomosis, a Kock continent ileostomy, and a Macedo-Malone antegrade continence enema. Shown on this slide are drawings of ileoanal reservoirs (IARs). A, S-shaped configuration for IAR. Three 10-cm limbs of ileum are used, the antimesenteric surface of each limb is opened, and adjacent bowel walls are anastomosed. B, J-shaped configuration for IAR. Distal ileum is aligned in J shape, the antimesenteric surface of the J shape is opened, and adjacent bowel walls are anastomosed. Side-to-end anastomosis of bowel to the dentate line is evident. C, Lateral or side-by-side ileoanal pouch configuration. The ileoanal pouch anastomosis is a surgical procedure that is used in patients who need to have a colectomy for treatment of ulcerative colitis or familial polyps. In this procedure, the surgeon removes the colon, creates a pouch from the end of the small intestine, and attaches the pouch to the patient's anus. This pouch provides for the collection of waste material, which is similar to the rectum. The patient is continent of stool because stool is evacuated via the anus. When the ileal pouch is created, the patient has a temporary ileostomy to allow the anastomosis to heal. [Shown is Figure 46-9 from text p. 1094.]

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

Answer: B

Bowel Diversion Temporary or permanent artificial opening in the abdominal wall Stoma Surgical opening in the ileum or colon Ileostomy or colostomy The standard bowel diversion creates a stoma.

Certain diseases cause conditions that prevent normal passage of feces through the rectum. Treatment for these disorders results in the need for a temporary or permanent artificial opening (stoma) in the abdominal wall. Surgical openings are created in the ileum (ileostomy) or colon (colostomy), with the ends of the intestine brought through the abdominal wall to create the stoma. The standard bowel diversion creates a stoma, or the patient has reconstructive bowel surgery that uses the native sphincter for bowel continence. Reconstructive surgery includes a continent stoma procedure or an ileoanal pouch anastomosis (described later).

Construction of Kock Pouch

Construction of Kock continent ileostomy—Kock pouch. A, Two 15-cm limbs are used to create a pouch, and one 15-cm limb is used to fashion a nipple valve and stoma. B, Distal limb is intussuscepted into the reservoir to create a one-way valve and to accomplish continence. Sutures or staples or both are placed to stabilize and maintain the intussuscepted nipple. The anterior surface of the reservoir is anchored to the anterior peritoneal wall. [Shown is Figure 46-10 from text p. 1095.]

case study: Because Mr. Gutierrez has a small kitchen in his apartment, he is able to make some of his favorite foods. His diet consists of flour and corn tortillas, beans, and rice. He likes most meats, but he prefers chicken and as ado (made with pork). For breakfast, he usually has hues rancheros. He has been hospitalized only twice—once for the flu and once for placement of a pacemaker. He presently takes three medications: digoxin, Zestril, and Metamucil.

Discuss Mr. Gutierrez' diet, any food groups that may be missing from it, and what effect that could have on his bowel elimination.] [Discuss Mr. Gutierrez' medications and what effects they would have on bowel elimination.]

Scientific Knowledge Base Mouth: Digestion begins with mastication Stomach: stores food, mixes food, liquid, and digestive juices; moves food into small intestines Large intestine: The primary organ of bowel elimination Esophagus: Peristalsis moves food into the stomach Small Intestine: Duodenum, jejunum, and ileum Anus: Expels feces and flatus from the rectum

Here is a recap of major functions of the organs of the GI tract. These structures are necessary for the defecation process. Physiological factors critical to bowel function and defecation include normal GI tract function, sensory awareness of rectal distention and rectal contents, voluntary sphincter control, and adequate rectal capacity and compliance. Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, distention causes relaxation of the internal sphincter and awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out. Sometimes people use the Valsalva maneuver to assist in stool passage. The Valsalva maneuver exerts pressure to expel feces through voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool. Normal defecation is painless, resulting in passage of soft, formed stool.

Loop Colostomy

In this diagram of a loop colostomy, a loop of colon is exteriorized over a plastic rod for temporary fecal diversion. It is usually a temporary large stoma constructed in the transverse colon. A loop colostomy is usually performed in a medical emergency when health care providers anticipate closure of the colostomy. The surgeon pulls a loop of bowel onto the abdomen. An external supporting device such as a plastic rod, a bridge, or a rubber catheter is temporarily placed under the bowel loop to keep it from slipping back. The surgeon then opens the bowel and sutures it to the skin of the abdomen. A communicating wall remains between the proximal and distal bowel. The loop ostomy has two openings through one stoma. The proximal end drains stool, whereas the distal portion drains mucus. Within 7 to 10 days, the surgeon removes the supporting device. [Shown is Figure 46-6 from text p. 1093.]

Gastrointestinal Tract

Organs of the gastrointestinal (GI) tract are shown, with the heart as the reference point. The GI tract is a series of hollow mucous membrane-lined muscular organs. These organs absorb fluid and nutrients, prepare food for absorption and use by body cells, and provide for temporary storage of feces. The GI tract absorbs high volumes of fluids, making fluid and electrolyte balance a key function of the GI system. In addition to ingested fluids and foods, the GI tract receives secretions from the gallbladder and pancreas. Digestion begins in the mouth and ends in the small intestine. The mouth mechanically and chemically breaks down nutrients into a usable size and form. The teeth masticate food, breaking it down into a size suitable for swallowing. Saliva, produced by the salivary glands in the mouth, dilutes and softens the food in the mouth for easier swallowing. As food enters the upper esophagus, it passes through the upper esophageal sphincter, a circular muscle that prevents air from entering the esophagus and food from refluxing into the throat. The bolus of food travels down the esophagus and is pushed along by peristalsis, which propels it through the length of the GI tract. As food moves down the esophagus, it reaches the cardiac or lower esophageal sphincter, which lies between the esophagus and the upper end of the stomach. The sphincter prevents reflux of stomach contents back into the esophagus. The stomach performs three tasks: Storing of swallowed food and liquid Mixing of food, liquid, and digestive juices Emptying of its contents into the small intestine. It produces and secretes hydrochloric acid (HCl), mucus, the enzyme pepsin, and intrinsic factor. Pepsin and HCl facilitate the digestion of protein. Mucus protects the stomach mucosa from acidity and enzyme activity. Intrinsic factor is essential for the absorption of vitamin B12. [Shown is Figure 46-1 from text p. 1088.]

Assessment Physical assessment -Mouth, abdomen, and rectum Laboratory tests -Fecal characteristics -Fecal specimens Diagnostic examinations -Radiologic imaging, with or without contrast -Endoscopy -Ultrasound -Computed tomography (CT) or magnetic resonance imaging (MRI)

Physical assessment will include the examination of oral cavity, abdomen, rectum, and anus. Problems in any one of these areas will affect the GI system and proper functioning. Inspect the patient's teeth, tongue, and gums. Poor dentition or poorly fitting dentures influence the ability to chew. Sores in the mouth make eating not only difficult but also painful. Inspect all four abdominal quadrants for contour, shape, symmetry, and skin color. Note masses, peristaltic waves, scars, venous patterns, stomas, and lesions. Normally, you do not see peristaltic waves. Observable peristalsis is often a sign of intestinal obstruction. Check for abdominal distention, and auscultate all four abdominal quadrants. Gently palpate the abdomen for masses or areas of tenderness. Inspect the area around the anus for lesions, discoloration, inflammation, and hemorrhoids. Indirect and direct visualization of the lower GI tract requires cleansing of the bowel before the procedure. Laboratory and diagnostic examinations yield useful information concerning elimination problems. Laboratory analysis of fecal contents detects pathological conditions such as tumors, bleeding, parasites, and infection. Inspection of fecal characteristics reveals information about the nature of elimination alterations. Several factors influence each characteristic. Knowing whether any recent changes have occurred is key in assessment. The patient best provides this information during the nursing history. [See Table 46-4 on text p. 1100 Fecal Characteristics.] [Fecal specimens are discussed on the later slides.] [Table 46-3 on text p. 1098 presents laboratory tests and diagnostic examinations for bowel function.] A variety of radiological and diagnostic tests are used with the patient who is experiencing altered bowel elimination. Direct or indirect approaches are used to visualize GI structures. Many facilities use moderate sedation during these procedures. The types of drugs most commonly used to achieve moderate sedation include benzodiazepines and opiates. It is essential to understand the safety precautions involved concerning this form of anesthesia. In many institutions, special training is required. A crash cart must be present at the bedside, and you must monitor the patient continuously with pulse oximetry and frequent vital signs—usually every 15 minutes. [Review Box 46-6 on text p. 1101 Radiological and Diagnostic Tests.]

Vickie is the nursing student assigned to Mr. Gutierrez. She has been seeing him once a week for 5 weeks as a portion of a home health care clinical experience. They have developed a good rapport. Mr. Gutierrez' self-identified problems with his bowels are a frequent topic of conversation. As Vickie prepares to assess Mr. Gutierrez, she reflects on experiences with other patients in the home setting. She recalls one patient who had elimination problems resulting from a diet consisting mainly of high-fat and high-carbohydrate foods. She believes that her involvement with that patient is likely to help in Mr. Gutierrez' care.

Reflecting on previous experiences can help improve patient care. [Ask the class: What do you see as similarities and differences between the problems of Vickie's former patient and Mr. Gutierrez' bowel problems?]

Bowel Elimination

Regular elimination of bowel waste products is essential for normal body functioning. Alterations in bowel elimination are often early signs or symptoms of problems within the gastrointestinal (GI) or other body systems. Because bowel function depends on the balance of several factors, elimination patterns and habits vary among individuals. Understanding normal bowel elimination and factors that promote, impede, or cause alterations in elimination helps in management of patients' elimination problems. Supportive nursing care respects the patient's privacy and emotional needs. Measures designed to promote normal elimination need to minimize discomfort for the patient.

Continuing and Restorative Care Care of ostomies -Irrigating a colostomy Pouching ostomies -An effective pouching system protects the skin, contains fecal material, remains odor free, and is comfortable and inconspicuous. Nutritional considerations -Consume low fiber for the first weeks. -Eat slowly and chew food completely. -Drink 10 to 12 glasses of water daily. -Patient may choose to avoid gassy foods.

Regular elimination patterns need to begin for a patient to recover and return home or to an extended care facility. It is important to remember that ostomy care and bowel retraining are instituted in acute care settings. However, because these are long-term care needs, teaching is usually completed in restorative care settings. The location of an ostomy influences the consistency of the stool. Patients with temporary or permanent bowel diversions have unique elimination needs. An individual with an ostomy wears a pouch or appliance to collect effluent—stool discharged from the stoma. Skin breakdown occurs after repeated exposure to liquid stool. The patient needs to use meticulous skin care to prevent liquid stool from irritating the skin around the stoma. [Irrigating a colostomy is discussed on the next slide.] An ostomy requires a pouch to collect fecal material. A person wearing a pouch needs to feel secure enough to participate in any activity. Proper selection and use of an ostomy pouching system are necessary to prevent damage to the skin around the stoma. Many pouching systems are available. To ensure that a pouch fits well and meets the patient's needs, consider the location of the ostomy, type and size of the stoma, type and amount of ostomy drainage, size and contour of the abdomen, condition of the skin around the stoma, physical activities of the patient, patient's personal preference, age and dexterity, and cost of equipment. A wound ostomy continence nurse (WOCN) is specially educated to care for ostomy patients; the WOCN collaborates with staff nurses to make sure that the patient uses the correct pouching system, especially when the patient is ill or is experiencing health changes or problems with the ostomy. A pouching system consists of a pouch and a skin barrier. Assess the stoma color. A normal stoma is bright pink or brick red. Notify the health care provider if the stoma is blue, brown, or black, which indicates circulation problems to the stoma. You need to measure the stoma size carefully when selecting and cutting out the opening on the wafer skin barrier. Too tight of an opening constricts the stoma and causes irritation and necrosis. Subtle stoma changes occur over time. Encourage patients to visit their enterostomal nurse at least annually to ensure proper pouching and fit. A good skin barrier protects the skin, prevents irritation from repeated removal of the pouch, and is comfortable for the patient to wear. Patients with new stomas often feel vulnerable when they leave the hospital. To provide a smooth transition from hospital to home, offer help for the patient and family caregivers. Effective patient teaching helps patients with a new ostomy transition smoothly to home. [See also Box 46-10 on p. 1110 Patient Teaching: Teaching the Patient How to Provide Ostomy Care.] Nutritional therapy is important for patients with ostomies. During the first weeks after surgery, many health care providers recommend low-fiber diets, particularly for patients with ileostomies, because the small bowel requires time to adapt to the diversion. As ostomies heal, patients are able to eat almost any food. High-fiber foods such as fresh fruits and vegetables help ensure a more solid stool. Patients need to avoid blockages of the bowel. The surgical construction of the stoma affects the likelihood of blockage.

Continuing and Restorative Care Bowel training -Training program -Diet -Promotion of regular exercise -Management of hemorrhoids Skin integrity

The patient with incontinence is unable to maintain bowel control. A bowel training program helps some patients defecate normally, especially those who still have some neuromuscular control. The training program involves setting up a daily routine. By attempting to defecate at the same time each day and using measures that promote defecation, the patient gains control of bowel reflexes. The program requires time, patience, and consistency. The health care provider determines the patient's physical readiness and ability to benefit from bowel training. [Discuss the components of a successful program: Assessing the normal elimination pattern and recording times when the patient is incontinent Incorporating principles of gerontological nursing when providing bowel retraining programs for the older adult Choosing a time in the patient's pattern to initiate defecation control measures Giving stool softeners orally every day or a cathartic suppository at least half an hour before the selected defecation time (lower colon needs to be free of stool so suppository contacts intestinal mucosa) Offering a hot drink (hot tea) or fruit juice (prune juice) (or whatever fluids normally stimulate peristalsis for the patient) before the defecation time Helping the patient to the toilet at the designated time Avoiding medications such as opioids that increase constipation Providing privacy and setting a time limit for defecation (15 to 20 minutes) Instructing the patient to lean forward at the hips while sitting on the toilet, apply manual pressure with the hands over the abdomen, and bear down but not strain to stimulate colon emptying Not criticizing or conveying frustration if the patient is unable to defecate Maintaining normal exercise within the patient's physical ability] [See also Box 46-11 on p. 1111 Focus on Older Adults: Bowel Retraining.] In choosing a diet for promoting normal elimination, consider the frequency of defecation, the characteristics of feces, and the types of foods that impair or promote defecation. The patient with frequent constipation or impaction requires increased intake of high-fiber foods and more fluids. However, he or she needs to realize that diet therapy provides only long-term relief of elimination problems and does not give immediate relief from problems such as constipation. When diarrhea is a problem, recommend foods with low-fiber content and discourage foods that typically cause gastric upset or abdominal cramping. Diarrhea caused by illness is sometimes debilitating. If the patient cannot tolerate foods or liquids orally, intravenous therapy (with potassium supplements) is necessary. The patient returns to a normal diet slowly, often beginning with fluids. Excessively hot or cold fluids stimulate peristalsis, causing abdominal cramps and further diarrhea. As tolerance to liquids improves, the patient eats solid foods. A daily exercise program helps prevent elimination problems. Walking, riding a stationary bicycle, or swimming stimulates peristalsis. Patients who are sedentary at work are most in need of regular exercise. For a patient who is temporarily immobilized, attempt ambulation as soon as possible. If the condition permits, help the patient walk to a chair on the evening of the day of surgery. Have him or her walk farther each day. Some patients have difficulty passing stool because of weak abdominal and pelvic floor muscles. Exercises help patients who are confined to bed use a bedpan. The patient practices the exercises as follows: Lie supine; tighten the abdominal muscles as though pushing them to the floor. Hold the muscles tight to the count of three; relax. Repeat 5 to 10 times as tolerated. Flex and contract the thigh muscles by raising one knee slowly toward the chest. Repeat for each leg at least 5 times and increase frequency as tolerated. Pain results when hemorrhoid tissues are irritated directly. The primary goal for the patient with hemorrhoids is to have soft-formed, painless bowel movements. Proper diet, fluids, and regular exercise improve the likelihood of stools being soft. If the patient becomes constipated, passage of hard stools causes bleeding and irritation. An ice pack or a warm sitz bath provides temporary relief of swollen hemorrhoids. The patient with diarrhea or fecal incontinence is at risk for skin breakdown when fecal contents remain on the skin. The same problem exists for the patient with an ostomy that drains liquid stool. Liquid stool is usually acidic and contains digestive enzymes. Irritation from repeated wiping with toilet tissue aggravates skin breakdown. Bathing the skin after soiling helps, but sometimes it results in more breakdown unless the patient dries the skin thoroughly. When caring for a patient who is debilitated, incontinent, and unable to ask for assistance, check often for defecation. You can protect the anal areas with petrolatum, zinc oxide, or another ointment that holds moisture in the skin, preventing drying and cracking. Yeast infections of the skin often develop easily. Several powdered antifungal agents are effective against yeast. Do not use baby powder or cornstarch because they have no medical properties, often cake on the skin, are difficult to remove, and enhance fungal infections of the skin. [See also on text p. 1109 Box 46-9 Evidence-Based Practice: Recognition of Skin Problems.]

End Colostomy

This diagram shows a permanent (end) colostomy. The terminal end of the descending or sigmoid colon is brought out through the peritoneum and muscle and is sutured to the skin. The end colostomy consists of one stoma formed from the proximal end of the bowel, with the distal portion of the GI tract removed or sewn closed (called Hartmann's pouch) and left in the abdominal cavity. For many patients, end colostomies are a result of surgical treatment of colorectal cancer. In such cases, the rectum is usually removed. Patients with diverticulitis who are treated surgically often have a temporary end stoma with Hartmann's pouch. [Shown is Figure 46-7 from text p. 1094.]

Double Barrel Colostomy

This drawing shows a double-barrel colostomy. Both ends of the transected colon are brought out to the skin. Unlike the loop colostomy, the surgeon divides the intestine and brings proximal and distal ends through the abdominal incision to the abdominal surface when creating a double-barrel colostomy. A small incision is made in the proximal stoma for fecal drainage. The distal stoma leads to the inactive intestine and is left intact. When the intestinal injury has healed, the colostomy is reversed, and the divided ends are anastomosed to restore intestinal integrity. [Shown is Figure 46-8 from text p. 1094.]

Irrigating a Colostomy

This drawing shows an ostomy irrigation cone inserted into the stoma. Although this practice is not as common as it once was, some patients irrigate their left-sided colostomies to regulate colon emptying. Other patients do not want to spend the additional 60 to 90 minutes in the bathroom every day; thus they empty their pouch as necessary. Only colostomies can be irrigated. Never use an enema set to irrigate a colostomy. Instead use specific equipment, which includes a special cone-tipped irrigator to prevent bowel penetration and backflow of the irrigating solution. Help patients to schedule irrigations at times that fit within their daily routine. Before irrigating the stoma, patients usually sit on the toilet and place an irrigating sleeve over the stoma. The end of this sleeve extends into the bowl of the commode. The health care provider orders the amount and type of irrigation solution. For adults, the amount typically ranges from 500 to 700 mL of tap water. The patient instills the solution slowly through the lubricated cone tip. Irrigation usually takes 5 to 10 minutes. The patient then removes the cone tip and waits 30 to 45 minutes for the solution and feces to drain out of the irrigation sleeve. Once the drainage stops, the patient applies a stoma cap or a pouch. [Shown is Figure 46-19 from text p. 1109.]

Divisions of the large intestine

This figure shows divisions of the large intestine. The lower GI tract is called the large intestine (colon) because it is larger in diameter than the small intestine. The large intestine is shorter (1.5 to 1.8 m [5 to 6 feet]) but much wider than the small intestine. The large intestine is divided into the cecum, colon, and rectum. The large intestine is the primary organ of bowel elimination. It is positioned like a question mark, partially encircling the small intestine. Chyme enters the large intestine by waves of peristalsis through the ileocecal valve, a circular muscular layer that prevents regurgitation. The colon is divided into the ascending, transverse, descending, and sigmoid colons. The muscular tissue of the colon allows it to accommodate and eliminate large quantities of waste and gas (flatus). It has three functions: absorption, secretion, and elimination. The large intestine absorbs water, sodium, and chloride from digested food that has passed from the small intestine. Healthy adults absorb more than a gallon of water and an ounce of salt from the colon every 4 hours. The amount of water absorbed from chyme depends on the speed at which colonic contents move. Chyme is normally a soft, formed mass. If peristalsis is abnormally fast, there is less time for water to be absorbed, and the stool is watery. If peristaltic contractions slow, water continues to be absorbed, and a hard mass of stool forms, resulting in constipation. The secretory function of the colon aids in electrolyte balance. The colon secretes bicarbonate in exchange for chloride. The colon excretes about 4 to 9 me of potassium daily. Therefore serious alterations in colon function (e.g., diarrhea) cause severe electrolyte disturbances. Slow peristaltic contractions move contents through the colon. Intestinal content is the main stimulus for contraction. Mass peristalsis pushes undigested food toward the rectum. These mass movements occur only 3 or 4 times daily, with the strongest during the hour after mealtime. The rectum is the final portion of the large intestine. Here, bacteria convert fecal matter into its final form. Normally, the rectum is empty of waste products (feces) until just before defecation. It contains vertical and transverse folds of tissue that help to temporarily hold fecal contents during defecation. Each fold contains an artery and a vein that can become distended from pressure during straining. This distention often results in hemorrhoid formation. The body expels feces and flatus from the rectum through the anal canal and anus. Contraction and relaxation of the internal and external sphincters, innervated by sympathetic and parasympathetic stimuli, aid in control of defecation. The anal canal is richly supplied with sensory nerves that help to control continence. [Shown is Figure 46-3 from text p. 1089.]

Macedo-Malone Antegrade Continence Enema (MACE)

This is a diagram of four surgical techniques (A, B, C, D) for the Macedo-Malone antegrade continence enema (MACE) procedure. The MACE procedure improves continence in patients with fecal soiling associated with neuropathic or structural abnormalities of the anal sphincter. This procedure isolates a 3-cm (1.2-inch) flap on the left colon. A Foley catheter placed on the surface of the flap creates a tubular passage. This produces a continence valve mechanism. The surgeon takes the distal end of the tube and makes a V shape to the skin flap. Enema administration begins 7 to 10 days after surgery. Patients receive enemas daily. The volume of the enema varies from 250 to 800 mL, and the enema takes 45 to 60 minutes to administer. Colonic evacuation occurs within 30 to 60 minutes. [Shown is Figure 46-11 from text p. 1095.]

Segmented and Peristaltic Waves

This is a diagram of segmented and peristaltic waves. Segmentation and peristaltic movement in the small intestine facilitate both digestion and absorption. Chyme mixes with digestive juices (e.g., bile, amylase). Resorption in the small intestine is so efficient that, by the time the chyme reaches the end of the small intestine, it is pastelike in consistency. The small intestine has three sections: the duodenum, the jejunum, and the ileum. The duodenum is approximately 20 to 28 cm (8 to 11 inches) long and continues to process chyme from the stomach. The jejunum is approximately 2.5 m (8 feet) long and absorbs carbohydrates and proteins. The ileum is approximately 3.7 m (12 feet) long and absorbs water, fats, certain vitamins, iron, and bile salts. The duodenum and the jejunum absorb most of the nutrients and electrolytes. The intestinal wall also absorbs nutrients across the mucosa and into lymph fluids or blood vessels. Substances such as plant fiber, which the small intestine cannot digest, empty into the cecum at the lower right side of the abdomen. The large intestine begins at the cecum. [Shown is Figure 46-2 from text p. 1088.]

Case study Vickie returns to see Mr. Gutierrez 2 weeks later. Vickie is eager to determine whether her patient has made changes in his diet, and if his problems with bowel elimination have been progressing. Vickie is also eager to learn if his stove has been repaired. Mr. Gutierrez tells Vickie that he has been eating bran cereal in the morning, has been eating rice and/or beans for dinner, and has added one fruit each day to his diet. He has been walking twice a day through the long-term care center. Although he does not have a bowel movement each day, his stools are much softer and easier to pass, and he says he is less concerned. He has not taken a laxative for a stool since last talking with Vickie.

[Ask the class what Vickie should put in the documentation note. Discuss: Bowel elimination is improving. Abdomen is soft and nondistended; bowel sounds are normal and audible in all quadrants. After discussing the teaching plan, patient has agreed to alter his eating habits to include more fiber, fruit, and fluids. Although concern over bowel habits has not ceased, patient states that he feels "in better control" and has decreased his laxative use. Niece assists in having stove repaired.]

case study continued From their last visit, Vickie and Mr. Gutierrez have been able to communicate without difficulty. Mr. Gutierrez complains of feeling "full of gas" but has not "passed any wind" in the past 2 days. His stove has not been working well, and he has been unable to prepare rice and beans. Based on the nursing history, Vickie estimates that Mr. Gutierrez normally drinks about 1200 mL of fluid daily.

[Ask the class: What assessment steps will Vickie want to take?]

Mr. Gutierrez resides in an assisted-living apartment of a long-term care center. He keeps busy in his small garden plot and enjoys other activities of the center, such as nightly card games and outings to baseball games. He is 82 years old and widowed and has lived in the area for longer than 3 years. His family, with whom he is quite close, is scattered across the country. He has one niece, who lives in the same town. Mrs. Gutierrez feels he is in good health; as long as he eats green chili peppers every day, he believes he will remain healthy.

[Ask the class: What concerns would you have about Mr. Gutierrez' health?]

case study Vickie reviews her class notes on the anatomy and physiology of the GI system. Vickie reviews the physiological changes that aging produces within the GI system: loss of teeth, taste bud atrophy, decreased secretion of gastric acid, and a slight decrease in small intestine motility. Vickie will thoroughly assess Mr. Gutierrez' dietary intake with a 24-hour diet recall. Being familiar with his Hispanic heritage, Vickie anticipates certain food preferences. She knows he does not like the food served at the center and frequently requests "home-cooked" tortillas and green chili peppers from his niece.

[Ask the class: What do Mr. Gutierrez' symptoms indicate? How will Vickie determine a diagnosis?]

Ostomies Loop colostomy This is temporary in the transverse colon. End colostomy Proximal end forms stoma, and distal end is removed or sewn closed. Double-barrel colostomy Bowel is surgically cut, and both ends are brought through the abdomen.

[This slide presents a summary of the types of ostomies just shown.] The location of the ostomy will determine the consistency of the stool, which will range from liquid to formed. A loop colostomy is performed on an emergency basis. An end colostomy is performed for colorectal cancer and is a permanent procedure. In the double-barrel colostomy, the proximal end is active and the distal end is nonfunctioning, only producing mucus. The double barrel can be reversed.

Alternative Approaches Ileoanal pouch anastomosis -Pouch is a reservoir for wastes that are eliminated from the anus. Kock continent ileostomy -Small intestine forms a pouch, which is emptied several times a day. Macedo-Malone antegrade continence enema (MACE) -This procedure was developed for patients who have neuropathic or structural abnormalities of the anus. Psychological considerations

[This slide provides a summary of the three alternative approaches just reviewed.] A stoma causes serious body image changes, particularly if it is permanent. After the surgery, patients face a variety of anxieties and concerns, from learning how to manage their stoma to coping with conflicts of self-esteem and body image. Provide emotional support before and after surgery. Patients often perceive a stoma as invasive and disfiguring. However, a well-placed stoma usually does not interfere with the patient's activities and is concealed with clothing. Nonetheless, even though clothing conceals the ostomy, the patient feels different. Many patients have difficulty maintaining or initiating normal sexual relations. Important factors affecting reactions to the stoma include the character of fecal secretions and the ability to control them. Foul odors, spillage, or leakage of liquid stools and inability to regulate bowel movements cause the patient to lose self-esteem. The aging process often affects the ability to manage stomas, even in people who have had them for years. You need to recognize and intervene when problems resulting from advanced age such as skin changes, weight loss or gain, visual impairments, or changes in diet occur. Refer the patient to ostomy support groups such as the United Ostomy Associations of America at http://www.uoaa.org, which has discussion boards for various types of incontinent and continent diversions and networks. The Wound, Ostomy, and Continence Nurses Society (http://www. wocn.org) provides information and helps patients locate a wound, ostomy, continence nurse (WOCN).

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

physical examination. Assessment of bowel elimination patterns and abnormalities includes a nursing history, physical assessment of the abdomen, inspection of fecal characteristics, and review of relevant test results. In addition, determine the patient's medical history, patterns and types of fluid and food intake, chewing ability, medications, and recent illnesses and/or stressors. The nursing history provides a review of the patient's usual bowel pattern and habits. [Discuss the following points of assessment: Determination of the usual elimination pattern: include frequency and time of day Patient's description of usual stool characteristics Identification of routines followed to promote normal elimination Assessment of the use of artificial aids for home movement Presence and status of bowel diversions Changes in appetite: include changes in eating patterns and changes in weight (amount of loss or gain) Diet history: determine the patient's dietary preferences for a day Description of daily fluid intake: this includes the type and amount of fluid History of surgery or illnesses affecting the GI tract: Medication history: ask whether the patient takes medications that alter defecation or fecal characteristics Emotional state: the patient's emotions significantly alter the frequency of defecation History of exercise: ask the patient to specifically describe the type and amount of daily exercise. History of pain or discomfort: ask the patient whether there is a history of abdominal or anal pain. Social history: patients have many different living arrangements. Mobility and dexterity: evaluate patients' mobility and dexterity to determine whether they need assistive devices or help from personnel.] [Box 46-3 Nursing Assessment Questions on text p. 1098 presents questions you can ask.] [See also Figure 46-12 on p. 1096 Critical thinking model for elimination assessment and Box 46-2 on p. 1097 Cultural Aspects of Care Variables Influencing Colorectal Cancer Screening in African Americans.]