Module 7: Elimination and Nutrition
Aspiration precautions
- Assessing aspiration risk cannot be delegated! - Elevate HOB to 45 - 90 degrees - Place food on unaffected side of mouth - Verbal coaching - Feel on throat that patient has swallowed - Inspect mouth for "pockets" of food - Have patient sit up for at least 30 min after meal - Check I & O, percentage of meal eaten, weight
Evidence-based practice for residuals
- Check residuals ONLY for tubes ending in stomach (PEG/NG tubes), if ordered - Don't check residuals for tube ending in small intestine (jejunostomy tube) - Don't check residuals for small-bore tubes (Dobhoff tube) - Checking for residuals can sometimes cause tube clogging - New research: No correlation between high gastric residuals & signs of intolerance - Many facilities now do not require routine gastric residual volume checks
Safety tips for enteral feedings
- High glucose content of formula is a medium for bacteria! - For continuous feedings, change infusion sets (tubing) daily - **Do not allow formula to hang more than 24 hours**
State indications and precautions for various enema medications
- Hypotonic enemas put a large volume of water into the colon to stimulate peristalsis. The water also softens stool. 500-1000mL - Hypertonic enemas attracts water into the colon, thereby causing distention and stimulating peristalsis and defecation. 90-120mL - Isotonic enemas put a large volume of 0.9% NS in the colon which distends the colon, thereby stimulating peristalsis; some softening of stool also occurs. 500-1000mL - An oil enema softens the feces and lubricates the rectum. 90-120mL - Soap suds enemas cause intestinal irritation that stimulates peristalsis. - Carminative enemas provide relief from abdominal distention caused by flatus. 60-180mL - Cleansing enemas treat severe constipation/impaction and clear the colon for visualization procedures, starting a bowel-training program, and surgeries. - Retention enemas are solutions meant to be retained for a prolonged period (oil-retention, carminative, and medicated). - Return flow enemas (Harris flush) are ordered to help patients expel flatus and relieve abdominal distention. 100-200mL tap water or saline
digital stool removal
- Manually breaking up and removing hard stool - Stimulates vagus nerve which causes decline in HR, make sure patients don't pass out
What are some signs of intolerance of enteral feedings?
- N/V/D - abdominal cramping - hyperglycemia - gastric distention - coughing/choking/SOB - respiratory distress and inability to speak (sign tube is in respiratory tract)
Differentiate the different types of hospital diets and how they progress from NPO status to a regular diet
- NPO: no food or fluid, ordered before surgery to decrease aspiration risk, most well-nourished patients can tolerate NPO short term, IV fluids may be given, (NPO with ice chips also exists) - Clear liquids: provides fluids to prevent dehydration and supplies simple carbs to help meet energy needs - Full liquids: all clear liquids plus food items that are liquid at room temperature - Soft/low residual/GI soft diet: limits high fiber food, goal is to have fewer bowel movements - Regular diet: "house diet," pts without special nutritional needs, 2000 kcal/day Typically use diet progression for patients who have had bowel surgery, intestinal obstruction, diverticulitis, acute episode of N/V/D
Discuss factors that affect bowel elimination
- Personal and sociocultural factors: people may not be comfortable having a BM without full privacy, fast-paced lifestyles make it hard to notice the urge to defecate, parents of young kids may put it off out of fear of leaving their kids unattended, stress can cause diarrhea and constipation and is a major risk factor for IBS. - Calcium can constipate, magnesium can loosen stools, vitamin C can soften stools but can cause diarrhea if you're sensitive or have too much. - Immobility decreases GI motility and increases the risk for constipation. - Fluid and nutrition status can impact elimination (not enough water and fiber can cause constipation). - People who've had perineal surgery may fear pain or tearing their sutures and resist the urge to defecate. - People who've had anal sphincter surgery may have uncontrollable secretions.
State indications and precautions for various laxative medications
- Stool softeners enable moisture and fat to penetrate the stool, thereby softening it and making it easier to pass. Effectiveness of stool softeners in relieving chronic constipation is being questioned, but they are still in use. - Osmotic laxatives work by drawing water into the bowel from surrounding tissue, resulting in bowel distention. - Lubricant laxatives coat the stool and the gastrointestinal (GI) tract with a thin waterproof layer. Mineral oil is an example. Because the lubricant coats the entire GI tract, it may interfere with the absorption of nutrients. - Stimulant laxatives are bowel irritants. They irritate the intestinal wall, stimulating intense peristalsis. - Bulking agents are nonfoods, high in fiber. They must be combined with sufficient fluid intake to be effective. The fiber attracts fluid into the colon, and the increased bulk of the stool stimulates the urge to evacuate. - Chloride channel activators increase intestinal fluid and motility to help stool pass. - Combination laxatives are laxatives that contain more than one type of laxative ingredient. The most common type is a combination stimulant laxative and stool softener.
Describe the risks associated with enteral feedings
- The most serious risk/complication is aspiration (can lead to infection, pneumonia, abscess formation, adult respiratory distress syndrome, and death) - Bacterial growth from high glucose content - N/V/D, nasopharyngeal trauma, altered drug absorption and metabolism, various metabolic disturbances
What is a fecal impaction?
- prolonged retention or an accumulation of fecal material that forms a hardened mass in the rectum - Presence of a hard, dry, fecal mass in the rectum, making it impossible to pass stool from the body in the normal manner. This blockage sets up a cycle of further hardening, with new waste to backing up higher in the colon.
How should the nurse care for an NG tube?
- verify suction settings by checking the order (low intermittent or continuous suctioning) - flush intermittently with water if ordered - verify initial placement with a chest x-ray - secure to nose with tape or a tube fixation device - turn off suction or clamp tube to auscultate bowel sounds - keep client NPO - best practice: check NG tube placement and document every shift
Removing stool digitally - procedure steps
1. Determine whether lubricant containing lidocaine is to be used, and obtain the correct lubricant. 2. Drape the patient with the bath blanket. Assist him to turn on his left side, with his right knee flexed toward his head. Place the waterproof pad halfway beneath his left hip. 3. Don clean procedure gloves. 4. Expose the buttocks. 5. Open the packet of prepackaged disposable wipes, or have toilet tissue ready to cleanse the rectal area when you complete the procedure. 6. Generously lubricate either the gloved forefinger or the middle finger of your dominant hand. 7. Slowly slide one lubricated finger into the rectum. Observe for perianal irritation. 8. Gently rotate your finger around the mass and/or into the mass. 9. Begin to break the stool into smaller pieces. At this point, you may insert a second finger and gently "slice" apart the stool, using a scissoring motion. Remove pieces of stool via the rectum as it becomes separated, and place the pieces in the bedpan. 10. As you proceed, instruct the patient to take slow, deep breaths. 11. Continue to manipulate and remove pieces of stool, allowing the patient to rest at intervals. Reapply lubricant (containing lidocaine, if permitted) each time you reinsert your fingers. 12. Assess the patient's heart rate at regular intervals. Bradycardia is a sign of vagal stimulation. 13. When removal of stool is complete, cover the bedpan, and set it aside. Use a prepackaged disposable wipe and/or toilet tissue to cleanse the rectal area. 14. Assist the patient to return to a position of comfort. Note the color, amount, and consistency of the stool, and dispose of it properly. 15. Remove your gloves, and perform hand hygiene.
How should you elevate the head of the bed for enteral feedings?
30-45 degrees, but 90 is even better
Small-bore NG tubes
A small, flexible tube is preferred for feeding. The tube is inserted through one naris, passed through the nasopharynx into the esophagus, and finally into the stomach.
What is a colostomy?
A surgically created opening of the colon out onto the abdomen wall.
What should the nurse do before administering prescribed antidiarrheals?
Advise to use with caution. Review diet, fluid intake, and medicines. Work with the primary care provider to alter the preceding factors to encourage regular bowel movements. Consider the side effects (drowsiness).
Discuss nursing and collaborative interventions required for clients with constipation
Allow uninterrupted time for defecating after meals (ambulatory), provide privacy for using the toilet, advise not to avoid the urge to defecate, encourage eight to ten 8-oz glasses of water/day, increase intake of high fiber foods, increase physical activity. Monitor for anal fissures/hemorrhoids/bleeding/anorexia (signs of impaction), rectal ulcers, fecal seepage, skin integrity, pattern of BMs, severe abdominal pain (sign of complications). Administer laxatives as prescribed. Tx can include enemas or digital removal of stool.
What's the difference between an ileostomy and a colostomy?
An ileostomy is from the small intestine and has a smaller stoma. A colostomy is from the large intestine and has a larger stoma.
Guidelines for ostomy care (clinical insight 29-2)
Assess Stoma Appearance. ■ The stoma should be moist and red or pink. ■ Immediately report to the surgeon a stoma that is pale, dusky, or black in color; dry; or with sloughing tissues. These are signs of inadequate blood supply to, and possible necrosis of, the portion of intestine that has been externalized. ■ Protruding or retracted stomas will need special adjustments in wafer measurement and placement. It is normal for a new stoma to have yellow or blood-tinged mucus or dried blood on it. Preserve Peristomal Skin. ■ Preserving peristomal skin is critical because skin excoriation may cause an ineffective seal between the wafer and the skin and leakage of effluent. This, in turn, causes more skin and tissue damage. Leakage may indicate the need for a different type of pouch system or sealant. ■ Use recommended moisture-proof barrier creams and skin care products. Plan for and Change the Pouch as Scheduled. ■ Change the skin barrier pouch at times of lower effluent. ■ Avoid changing after meals, when the gastrocolic reflux increases chance of fecal effluent. Mucus secretion is normal. ■ Pouches are usually changed every 3 to 5 days, preferably before leakage occurs. Frequency also depends on the type of stoma, the type of equipment used (e.g., one- or two-piece pouch), the effluent, the patient's preference, and the climate (e.g., pouches are changed more frequently during the summer). ■ To decrease skin irritation, avoid changing the entire system. In a one-piece or two-piece pouching system, change the skin barrier only every 3 to 7 days, never daily. Assess the Patient's Self-Care Ability. ■ Patients with poor vision may need to use magnification mirrors and yellow-tinted sunglasses to help reduce glare and improve contrast when they perform stoma care. ■ Patients with immobility or spinal cord injury may need equipment that has a longer pouch that the patient can empty independently when sitting. ■ Impaired dexterity or vision may warrant the use of a one-piece system or precut pouch and skin barrier, whereas a two-piece system may be better for patients who need to keep the skin barrier in place for several days and change just the pouch. ■ Patients who are blind can be taught to change the equipment by themselves. Determine Whether the Ostomy Should be Irrigated. ■ Consult a peristomal nurse or the primary care provider to determine whether an ostomy should be irrigated. ■ Many patients with left-end colostomies may be safely irrigated as a method of continence management. An ileostomy, however, drains liquid containing high concentrations of sodium, chloride, potassium, magnesium, and bicarbonate. ■ Ileostomies should never be irrigated, except in cases of food blockage near the stomal outlet. Only a qualified person, such as an enterostomal therapy nurse, may perform a gentle lavage. For lavage, normal saline is preferred because excessive lavage could lead to a serious fluid and electrolyte imbalance.
How should the nurse care for an ostomy?
Assess skin around stoma Frequently check pouch for proper fit/leakage Report signs of ischemia/necrosis (dusky, purple, black, bluish color) Assess & document stoma color (ideal: beefy red) Consult wound/ostomy nurse Patient education - teach care of colostomy Address psychosocial concerns
Discuss nursing and collaborative interventions required for clients with bowel diversion
Assess the stoma, output, and skin condition. Educate about dietary changes that may be necessary and about the potential need for irrigations. Help the patient adjust to the presence of an ostomy. Find an enterostomal therapy nurse to assist patients with their ongoing care and to provide consultation on ostomy appliances.
What is used in a soapsuds enema?
Castile soap
What should you do before digitally disimpacting a patient and why?
Check baseline VS & check for history of heart disease before digitally disimpacting a patient because removal can stimulate the vagus nerve and cause bradycardia.
Chronic vs acute diarrhea
Chronic persists for more than 1 month. Acute is a response to infection or unusual foods.
Discuss nursing and collaborative interventions required for clients with diarrhea
Clear liquid diet, encourage pt to sip liquids, reduce amount of fiber in diet when solids are introduced, limit caffeine, advise a BRAT diet, breastfed infants should continue on breast milk, provide prompt hygiene care, plan freetime after meals to toilet if ambulatory, assist to bathroom or use bedpan if not ambulatory. Work with PCP to administer antidiarrheals or Pepto-Bismol.
What is constipation?
Decrease in the frequency of bowel movements accompanied by difficult or incomplete passage of stool and/or very hard, dry stool
What is used in a hypertonic enema?
Fleet, milk of molasses
What is a type of medication that can be used in a medication enema?
Kayexalate
Capnometry
Measure of expired carbon dioxide
Discuss nursing and collaborative interventions required for clients with bowel incontinence
Monitor the pattern of bowel movements and for skin breakdown, redness, or irritation. Designate uninterrupted time for defecation, provide bedpan or assist to bathroom in regular intervals, change soiled clothing/linens and provide hygiene as soon as possible, consider absorbent pads and shields and adult incontinence garments to keep from soiling clothing and linens. Work with the primary care provider to alter activity, diet, fluids, and medications to encourage regular bowel movements, collaborate with primary care provider to insert and care for fecal drainage devices, consider a bowel-training program.
What is the safest option for enemas?
Normal Saline
What is a paralytic ileus?
Obstruction of the intestine due to paralysis of the intestinal muscles
Administering an enema - patient teaching and home care
Patient Teaching ■ Teach the patient that dependence on enemas can disrupt the normal process that stimulates defecation. ■ Teach dietary and lifestyle changes that promote regular elimination (e.g., increased fluid intake, diet high in fiber, increased exercise). Home Care ■ Show the patient the box for a prepackaged enema, and instruct him that he may purchase this type of enema at a local grocery or pharmacy. ■ Assess the patient's ability to administer his own enema. If you determine that he will be unable to do so, encourage him to seek assistance and instruct the caregiver in the task. ■ Teach the patient or the caregiver proper handwashing. Encourage them to purchase nonsterile procedure gloves. Patients and caregivers may not be aware of the serious infections that can be caused by gram-negative intestinal bacteria. ■ If the patient will be attempting to self-administer a cleansing enema, help him determine how and where to hang the container so that it is at the proper height. ■ If a soapsuds enema is to be administered in the home setting, teach the patient which household soaps may be substituted for castile soap. Some soaps used in the home may be too harsh and irritating to the intestinal mucosa.
For clients who have no symptoms of or risk factors for nutrition problems, which dx label should you use?
Readiness for Enhanced Nutrition
Causes of constipation
Short-Term Constipation: Lifestyle factors such as: • Decreased activity (e.g., prescribed bedrest) • Medications that slow peristalsis (e.g., opioids) • Decreased fluid and fiber intake Long-Term Constipation: In addition to the preceding, physiological factors such as: • Dysfunctional anorectal musculature • Dysfunctional intestinal motility • Nervous system problems (e.g., spinal cord injury • Obstruction of the intestinal tract (e.g., tumor) Fecal Impaction: • Prolonged constipation is the primary cause.
Short term vs chronic constipation
Short-Term Constipation: temporary, symptoms resolve in a short period of time. Chronic Constipation: lasts for 3 months; may persist for years.
Symptoms of constipation
Subjective • Abdominal pain, tenderness • Loss of appetite • Feeling of rectal pressure • Fatigue • Headache • Indigestion Objective • Abdominal distention • Blood with stool • Decreased frequency of stools • Decreased volume of stools • Hard, formed stools • Hypo- or hyperactive bowel sounds
What is an enema?
The introduction of fluid into the rectum and lower colon to soften feces and distend the colon to stimulate peristalsis and evacuation of feces
What waist-to-hip ratio is considered obese? (clinical insight 27-2)
WHR > 1.0 in men and > 0.8 in women is considered obese.
Administering an enema - delegation
You may delegate this procedure to the UAP if the UAP is trained and the patient is stable.
What's the difference between a food allergy and a food intolerance?
a food allergy is caused by an immune response and a food intolerance is not; they have very similar GI symptoms
What is an ileostomy?
a surgical operation in which a piece of the ileum is diverted to an artificial opening in the abdominal wall.
Which type of ostomy should never be irrigated?
an ileostomy
At what temperature should you administer an enema?
around body temperature
Why are feces normally brown?
bile salts
What is gastrointestinal motility alteration?
broad label that encompasses an increase in, decrease in, ineffective, or absent peristaltic activity within the GI system
What is bowel incontinence?
change in normal bowel habits characterized by involuntary passage of stool
What kind of diarrhea is an antidiarrheal used for?
chronic diarrhea (not acute!)
total colectomy with ileoanal reservoir
colon is removed, pouch created from ileum, and ileum is connected to the rectum, patient evacuates on the toilet in the usual manner; continent but liquid stools
GI symptoms of a food allergy
constipation, diarrhea, red blistering rash around anus, abdominal discomfort, bloating, excessive gas, intestinal bleeding
Why might a patient need an enema?
constipation, fecal impaction, buildup of gas and bloating
Elemental formulas for enteral feedings
do not contain complex proteins; instead, they contain amino acids or peptides. They are reserved for patients with severe small bowel absorptive dysfunction. These formulas are fiber free and highly osmotic.
How are fecal impactions treated?
enemas and digital fecal removal
What can NG tubes be used for?
feeding or gastric decompression
Fiber-containing formulas for enteral feedings
fiber has a potential protective effect for multiple disease states, including diverticulosis, colon cancer, diabetes, and heart disease, fiber-containing formulas may be used for patients in long-term care facilities or patients who require enteral feedings for a prolonged period of time
High-protein formulas for enteral feedings
for clients who have a substantial need for protein, such as those with burns, open wounds, or malnutrition.
Renal formulas for enteral feedings
for clients who require tube feedings to meet nutritional needs but have renal failure or renal insufficiency. These formulas limit potassium, sodium, and nitrogen intake.
Diabetic formulas for enteral feeding
for clients who require tube feedings to meet nutritional needs but have type 1 or type 2 diabetes mellitus. These formulas control carbohydrate intake.
What is the valsalva maneuver?
forced expiration against a closed glottis, increased pressure helps expel feces
What kinds of tubes are preferred for long-term feedings?
gastrostomy tube (G-tube), percutaneous endoscopic gastrostomy tube (PEG), jejunostomy tube (J-tube, PEJ), or gastrostomy button (G-button)
Salem sump tubes
has a lumen for drainage and one to allow air to enter the stomach
What is diverticulitis?
inflammation/infection of the diverticula
Koch pouch/continent ileostomy
internal pouch/reservoir to collect ileal drainage, pt inserts a tube through the external stoma into the pouch to drain, avoids continuous drainage
In what position should the patient be in for an enema?
left lateral position
NE tube
longer than an NG tube, extending through the nose down into the duodenum or jejunum (if it extends into the jejunum, it is called an NJ tube). An NE tube may be used for feeding instead of an NG tube for patients at risk for aspiration
Large-bore NG tubes
made of polyvinyl chloride (PVC) are used when a nasogastric or orogastric tube is placed so the stomach can be emptied (lavaged). Large-bore tubes are less flexible, less comfortable. They are occasionally used for feeding but are converted to a smaller tube within the first 2 days.
What is diverticulosis?
mucosal tissues "balloon" because of increased pressure and fecal matter becomes trapped in the pouches
Can digital stool removal be delegated to a UAP?
no, it should not be delegated
What is used in a retention enema?
oil, antibiotics
What is an ostomy?
opening in the abdominal wall created for effluent to be expelled through (bowel diversion)
Who is at risk for diverticulitis?
people with diets low in fiber and high in processed foods, obese, and people who eat red meat
Indications for enteral feeding
preferred method of feeding for a patient who has a functioning intestinal tract but needs nutritional support (e.g., patients with high metabolic needs, such as those with burns or severe malnutrition; difficulty swallowing; anorexia nervosa; prematurity; failure to thrive).
Pulmonary formulas for enteral feedings
provide 55% of the calories as fat so that less CO2 is produced per unit of oxygen consumed. They are used, for example, for patients with lung disease.
loop colostomy
segment of bowel brought out to the abdominal wall, posterior wall of bowel remains intact but a plastic rod is wedged under to keep it from slipping back in
What is the consistency of normal stool?
soft, semisolid. 75% water 25% solid
What is diarrhea?
the passage of loose, unformed, or watery stools
Why is a tap water enema not recommended?
they run the risk of introducing new bacteria to the colon and causing water-intoxication and death
double barreled colostomy
two separate stomas that externalize the bowel on both sides of the portion that has been removed
Basic feeding formulas for enteral feeding
used for clients who have no significant nutritional deficits but are unable to eat or drink sufficiently. They provide 1 kcal/mL of solution and meet the needs of most clients. A standard formula contains 12% to 20% of kcal from protein, 45% to 60% of kcal from carbohydrates, and 30% to 40% of kcal from fats. They also contain vitamins and minerals. They are usually lactose free and contain complex forms of carbohydrates, fats, and proteins. Therefore, they require digestion and absorption.
Levin tube
used for drainage, has a single lumen, with holes in the tip and along the sides
How should you label the container for enteral feedings?
with patient name, room #, date, start time, formula type, feeding rate, and your initials
Can enteral feedings be delegated to a UAP or LPN?
yes if the patient is stable
What should you assess for in a patient who has diarrhea?
• Bowel pattern • Dietary pattern (highly spiced foods, high-fat foods, greasy snacks, or large quantities of raw fruits and vegetables) • Fever, nausea, vomiting, and abdominal pain (may indicate viral infection) • Skin and mucous membranes (turgor, moisture/dryness) • Abdominal cramping
Potential complications of diarrhea
• Fluid and Electrolyte Imbalance (especially K+) • Impaired Skin Integrity
Types of feeding systems
■ An open system is exposed to the environment. One example is to open cans of formula and use a syringe to inject the formula into the tube; alternatively, you can pour it into a reservoir (a bag for tube feeding formula). ■ A closed system is a prefilled system (bag or a bottle) that functions much like IV fluid. The nurse spikes the container with tubing that is attached to the feeding pump or run through a manually controlled drip chamber. These decrease the risk of infection.
Preparation for assisting patients with meals (clinical insight 27-4)
■ Assess for functional deficits that contribute to imbalanced nutrition or difficulty eating independently. ■ Monitor intake for nutritional adequacy. Some patients may need liquid oral supplements of protein and calories. ■ Collaborate with occupational and physical therapists in planning care. ■ Find out about rituals used before meals (blessing of food etc.). ■ Provide an opportunity for toileting, oral hygiene, and handwashing before meals. ■ Assist the patient to eat and drink only as necessary; encourage independence. ■ Provide privacy during meals if the patient is embarrassed; to further maintain dignity, use a napkin, not a bib, over the patient's clothes. ■ Check for proper fit of dentures. ■ Provide music during the meal if the patient wishes. ■ Demonstrate the use of assistive devices and alternative methods for eating and drinking.
Administering an enema - preprocedure assessments
■ Assess for history of bowel disorders (e.g., diverticulitis, ulcerative colitis, recent bowel surgery, abdominal pain, abdominal distention, hemorrhoids). ■ Inspect the abdomen for the presence of distention. ■ Review lab results, paying particular attention to blood urea nitrogen (BUN), creatinine, and electrolytes. ■ Note the date and time of the patient's last bowel movement, recent bowel movement pattern, and bowel sounds. ■ Assess the patient's cognitive level and mobility. ■ Assess the patient's rectal sphincter control. ■ Assess for fecal impaction.
Types of feeding schedules for enteral feedings
■ Continuous feedings provide a constant flow of formula and an even distribution of nutrition throughout the day. Continuous infusions are usually administered via small-bore NG, NJ, PEG, or PEJ tubes, or G-buttons, to patients in debilitated states who require intensive nutritional support. ■ Cyclic feedings are administered regularly; however, the infusion time is less than 24 hours per day. ■ Intermittent feedings are given to supplement oral intake or for patients for greater patient mobility. Feedings are given on a regular or periodic basis several times a day, usually over 30 to 60 minutes.
Removing stool digitally - evaluation
■ Determine whether evacuation of the retained stool was complete. Perform a rectal exam to assess for presence of stool. ■ Reassess vital signs, and compare the results to the initial assessment. Continue to monitor for 1 hour for bradycardia. ■ Assess bowel sounds. ■ Palpate the abdomen for tenderness and firmness. ■ Ask the patient whether he feels relief from rectal pressure or abdominal discomfort.
Prevent Injury to Rectal Sphincter and/or Rectal Mucosa (clinical insight 29-1)
■ Do not add air or fluid to the balloon port of the catheter. ■ Check the catheter frequently for kinks or obstructions. ■ Monitor for signs of complications, and notify the healthcare provider immediately if the patient experiences rectal pain, rectal bleeding, abdominal distention, or abdominal pain. ■ Monitor stool for change in consistency (solid or soft-formed stool cannot pass through the catheter and will cause an obstruction). ■ How to discontinue the catheter: 1. Attach a 60-mL syringe to the balloon inflation port, and deflate the retention balloon by pulling back on the plunger. 2. Grasp the catheter as close to the patient as possible, and slowly slide it out of the anus. 3. Dispose of the device, according to the agency policy for disposal of medical waste.
Administering an enema - documentation
■ Document on the nursing notes type of enema given and, if applicable, the amount of the solution instilled; patient's tolerance of the procedure; characteristics and amount of stool. ■ If the prescription is to administer enemas until the returns are clear, document the color of the return solution and the amount of stool seen. ■ For prepackaged enemas, some facilities require documentation on the medication administration record (MAR) of the time given and the nurse's initials.
Removing stool digitally - documentation
■ Document the bowel movement on the graphic record. ■ Document the procedure and the patient's tolerance for the procedure in the nursing notes. ■ Record the patient's pulse rate on the vital signs record. ■ Document any unusual characteristics of the stool (e.g., black or green color, blood, or mucus).
Aspirating stomach contents (clinical insight 27-5)
■ Don procedure gloves. This is a clean, not sterile, technique. ■ Just before feeding, draw up 10 to 30 mL of air in a 30- to 60-mL syringe, insert the syringe in the distal end of the feeding tube, and inject air. ■ With the same syringe, aspirate the air and 20 to 30 mL of stomach or intestinal contents. Use slow, gentle suction—over 3 to 5 min, if necessary. ■ If you could not aspirate any fluid, inject another 20 mL of air, and use a smaller syringe to aspirate again. ■ If you still do not aspirate fluid, repeat the procedure with this variation: Insert air with the large syringe; insert the small syringe into the end of the tubing, and leave it for 15 min to allow fluid to accumulate before aspirating. ■ If you are still unsuccessful, reposition the patient and try again after 20 min. ■ Aspirate stomach contents, as described above. Gastric contents are normally greenish brown and liquid. If the patient is receiving enteral feedings, gastric contents should be curdled and white or a greenish color; intestinal contents will be a more yellow (bile) color with no curdling.
Administering an enema - equipment
■ Enema administration container, correct enema solution, or prepackaged enema—depends on the type of enema ordered. ■ Enema kit: This may be a grouping of supplies that includes a small plastic bucket or a 1-liter plastic bag with attached tubing, disposable toweling, lubricant, and castile soap. ■ Prepackaged enema solution: If a prepackaged enema (e.g., Fleets) is ordered, you may need to obtain the preparation from the pharmacy or central supply department. ■ Prepackaged disposable wipes and/or toilet tissue ■ Bath blanket ■ Waterproof pad ■ Bedpan with cover or bedside commode, if needed ■ Water-soluble lubricant ■ Clean procedure gloves ■ IV pole
Prevent Transmission of Pathogens to Others (clinical insight 29-1)
■ Follow the agency protocol for hand hygiene. Always wear clean procedure gloves when handling the fecal management device. ■ Monitor stool cultures and implement isolation protocols, as indicated. If a stool sample is ordered, you may obtain it from the collection bag: 1. If the collection bag is more than 24 hours, old place a new collection bag before obtaining a sample. 2. Cut the collection bag at the bottom, and transfer stool to an appropriate container for transport to the lab. 3. Apply a new collection bag to the connector at the end of the catheter.
Activities for after you've helped the patient with a meal (clinical insight 27-4)
■ Help the patient to wash hands or use the rest room. ■ Record the amount of food and fluid the patient consumed. ■ Document feeding behaviors. ■ Document changes in nutritional status. ■ Document staffing and staff education, and availability of a supportive interdisciplinary team.
Assisting the patient with a meal (clinical insight 27-4)
■ If the patient must eat in bed, place the head of the bed at the highest tolerable level, and adjust the overbed table to be in easy reach. ■ If the patient can feed himself, prepare the food on the tray for him (e.g., open food containers, cut the meat, peel an orange, open the milk and butter containers, mash food, if needed). ■ If the client is visually impaired, identify the locations of the meal on the tray based on a clock face. ■ See that the patient has protein- and energy-enriched meals. ■ Provide mid-afternoon snacks. ■ Ensure the nutrition prescribed is actually implemented. Assign someone to be responsible for assisting the patient with meals, as necessary. Include this in your instructions to UAPs and other assistive personnel. ■ Do not interrupt meals with medications. Feeding the Patient ■ Encourage family members to share mealtimes. ■ If the patient's condition allows, encourage her to get out of bed for meals. ■ Feed the patient if she is unable to feed herself. ■ Sit down while feeding the patient; do not rush. ■ Position yourself so you can make eye contact. ■ Be sure to provide adequate time for her to chew and swallow. ■ If possible, ask the patient what food she would like next. ■ Serve one food at a time; serve small amounts. ■ Serve finger foods (e.g., fruit, bread) to promote independence. ■ Cue older adults, whenever possible, with words or gestures. ■ Have casual conversation with the patient while feeding her to make mealtime more pleasant and relaxed.
Measuring mid-upper arm circumference (clinical insight 27-2)
■ Keeping the client's dominant arm parallel to the body, bend the elbow 90°. ■ Using a tape measure, measure the distance between the acromion (the bony protrusion of the back of the upper shoulder) and the olecranon process (tip of the elbow). ■ Mark the midpoint between these two landmarks. ■ Ask the client to relax the arm so that it hangs loose and parallel to the body. ■ Position the tape around the upper arm at the marked midpoint. Make sure the tape is snug but not so tight as to indent or pinch the skin. ■ Record the circumference to the nearest 0.1 cm.
Maintain Perineal Skin Integrity or Prevent Wounds from Being Contaminated by Stool (clinical insight 29-1)
■ Monitor insertion site for leakage and signs of infection. ■ If perineal wounds are present, keep clean and dry; notify the primary provider if signs of infection are present. ■ Perform perineal care, according to agency policy.
Taking aspiration precautions includes: (clinical insight 27-3)
■ Monitor level of consciousness, cough reflex, gag reflex, and swallowing ability. ■ Position the patient upright 90° or as far as possible. ■ Keep suction setup available. ■ Feed in small amounts. ■ Avoid liquids. ■ Cut food into small pieces. ■ Keep HOB elevated for at least 30 to 45 min after feeding.
Maintain Free Flow of Liquid Stool (clinical insight 29-1)
■ Monitor the patient for changes in stool consistency. If the stool is no longer liquid and flowing, the device must be discontinued. ■ Make sure the tubing and bag remain below the level of the patient. ■ Irrigate the tube as often as necessary to maintain patency: 1. Fill a 60-mL syringe with room-temperature tap water. 2. Attach it to the irrigation port of the catheter and flush by depressing the plunger. Be sure you are using the irrigation port, not the balloon inflation port. 3. Be sure to subtract the irrigation fluid from the stool volume to maintain an accurate record of intake and output. ■ Change the collection bag when it is three-fourths full. 1. Remove the collection bag from the tubing. Snap the cap onto the used bag and dispose of it, according to agency policy for medical waste. 2. Snap new collection bag securely onto the device.
Administering an enema - evaluation
■ Observe the amount, color, and consistency of the stool. ■ Evaluate the patient's tolerance of the procedure (e.g., amount of cramping, discomfort). ■ Determine whether the prescriber's orders require subsequent enema administration. ■ Some bowel exams require repeated enemas or enemas administered until the returns are "clear." For the latter, you will need to examine the return and determine whether stool particles are still present. "Clear" does not mean absence of color but, rather, absence of stool particles and transparency of the liquid.
Elements of a bowel training program
■ Plan the program with the patient and caregiver. ■ Initiate a designated uninterrupted time for defecation, regardless of last BM or period of incontinence: usually after meals, especially in the morning. ■ Provide privacy for the patient during the designated time. ■ Develop a staged treatment plan if constipation develops. Usually additional fiber is added as a first measure. A stool softener is next, followed by a suppository such as bisacodyl (Dulcolax). ■ Gradually increase fiber in the diet while monitoring consistency of the stool. ■ Increase fluid intake to at least eight glasses of water per day, if not contraindicated. ■ Regularly modify the plan based on the patient's response.
Activities for providing nutritional support (clinical insight 27-3)
■ Position the patient in a full upright, 90°, if possible. ■ Provide/use assistive devices, as appropriate. ■ Avoid use of drinking straws. ■ Assist the patient to position head in forward flexion in preparation for swallowing (chin tuck). ■ Assist patient to place food at the back of the mouth and on the unaffected side. ■ Monitor the patient's tongue movements while she is eating. Frequently cue patient to chew and swallow. Patient may need to double swallow. ■ Check mouth for pocketing of food after eating. ■ Monitor body weight. ■ Monitor body hydration (e.g., intake, output, skin turgor, mucous membranes).
Removing stool digitally - equipment
■ Two pairs of clean procedure gloves ■ Water-soluble lubricant (containing lidocaine, if agency policy permits) ■ Bedpan and cover ■ Prepackaged disposable wipes (or moistened towelettes) ■ Bath blanket ■ Waterproof pad
Calculating waist-to-hip ratio (WHR) (clinical insight 27-2)
■ Use a tape measure to measure the circumference of the waist (at the umbilicus with stomach muscles relaxed). ■ Use a tape measure to measure the circumference of the hips at their widest point. ■ Calculate the WHR using the following formula: waist circumference (in.) ÷ hip circumference (in.)
