Chap 37 - Bowel Elimination

evacuation of bowel contents

- 1/3 to 1/2 of ingested food waste is normally excreted within 24 hours - the remainder within the next 24-48 hours

Classifications of Antidiarrheal Medications

- Action on GI smooth muscle - Absorbent - Antisecretory/antimicrobial

Stool softener laxatives (Colace)

- Agents with a detergent activity that allow H2O and fat to penetrate and lubricate the stool - Recommended for those who must avoid straining - Has lubricant component of drug that may interfere with absorption of fat-soluble vitamins

Nursing diagnoses for bowel elimination

- Bowel elimination as the problem - Bowel elimination as the etiology

Classifications of laxatives

- Bulk-forming - Stool softener - Emollient - Stimulant - Osmotic

Bulk-forming laxatives (Metamucil)

- Causes stool to absorb water and swell, stimulating peristalsis - Usually acts within 24 hours - May interfere with absorption of calcium + iron - Should not be given to bedridden pts - May cost $$$

Specimens for Pinworms

- Collect this specimen in the morning, immediately after the patient awakens and before the patient urinates, has a bowel movement, or a bath - Use clear cellophane tape to collect a specimen for pinworms - Apply gloves and press the tape against the anal opening, remove it immediately, and then place it on the slide.

Bowel elimination as the etiology

- Delayed growth and development - Deficient fluid volume related to prolonged diarrhea - Impaired skin integrity related to prolonged diarrhea, fecal incontinence - Ineffective coping related to inability to accept permanent ostomy

Osmotic (Miralax)

- Drug draws water into intestine, resulting in softer stool - Induces more frequent bowel movements - Is used when rapid cleansing is desired - May cause bloating or diarrhea - Can produce dehydration - Not recommended for pts with kidney disease or heart failure

Stimulant (Dulcolax)

- Drug promotes peristalsis by irritating the intestinal mucosa or stimulating nerve endings in the intestinal wall - Works more quickly than bulking agents - Are the most ABUSED laxatives on the market - Causes lazy bowel syndrome - May affect vitamin D and calcium absorption - Not recommended for elderly Alters electrolyte transport

Older adults - weakening of intestinal walls with greater incidence of diverticulitis

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

Older adults - slowing of gastrointestinal motility with increased stomach-emptying time

- Encourage small, frequent meals. - Discourage heavy activity after eating. - Encourage a high-fiber, low-fat diet. - Encourage adequate fluid intake. - Discourage regular use of laxatives. - Evaluate medication regimen for possible adverse effects.

Methods of eliminating feces

- Enemas - Suppositories - Oral intestinal lavage - Digital removal of stool

Emollient laxatives (Mineral oil)

- Lubricates the intestinal tract and retards the colonic absorption of water, softening the stool, making it easier to pass - Usually effective within 8 hours - May interfere with absorption of fat-soluble vitamins

Inspection

- Observe the contour of the abdomen - Note any masses, scars, or areas of distention

PICO

- Population - Intervention - Comparison - Outcome

Older adults - decreased muscle tone/incontinence

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

Promoting regular bowel habits

- Timing - Positioning - Privacy, - Nutrition - Exercise

indirect visualization studies

- Upper gastrointestinal (UGI) - Barium enema - Abdominal ultrasound - Magnetic resonance imaging (MRI) - Abdominal CT scan

Digital removal of stool

- Use if enemas fail to remove an impaction. - This is the last resort for constipation. - A health care provider's order is necessary to remove an impaction. - Could cause stimulation of the Vagus nerve, resulting in slowed HR. - Sitz or tub bath after to help soothe perineal area

Indwelling rectal tube

- Used in pt's with uncontrollable diarrhea. - Not recommended - Disadvantages include, leakage and perirectal skin damage, injury to the rectal mucosa and injury of anal sphincter.

Factors to Assess - Bowel Elimination

- Usual patterns of bowel elimination - Aids to elimination - Recent changes in bowel elimination - Problems with bowel elimination - Presence of artificial orifices

Colostomy and ileostomy care

- Usually changed every 3-7 days - Keep the pt free from odors as possible - Inspect the patient's stoma regularly - Note the size of the stoma - Keep the skin around the stoma site clean and dry - Measure the patients fluid intake - Explain the care to the pt - Record intake and output every 4 hours - Encourage pt to participate in care and look at the ostomy

Patient instructions when collecting stool

- Void first - Defecate into the required container, such as a clean or sterile bedpan, beside commode - Do not place tissue in the pan or specimen - Notify the nurse when specimen is available

Guaiac test (Hemoccult, Fecult)

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

stomach

- a hollow, J-shaped, muscular organ located in the upper abdomen - stores food during eating - secretes digestive fluids - churns food to aid in digestion - pushes partially digested food, called chyme, into the small intestine

bowel-training program

- a program that manipulates factors within a person's control (timing of defecation, exercise, diet) to produce a regular pattern of comfortable defecation without medication or enemas - pts with history of chronic constipation and those who are incontinent may benefit

Administration of an Oil-Retention Enema

- a small rectal tube is used - administer at body temperature - instruct pt to retain the oil for at least 30 minutes - a cleansing enema is often ordered after an oil-retention

lifestyle effects on elimination

- acceptance of bowel elimination as a normal life process - preoccupation with bowel elimination - feeling that bowel elimination is a "dirty" process

Privacy

- always respect pt's need to be alone while defecating - pull drapes - ask visitors to step outside - suggest a private restroom if needed

Clostridium difficile

- antibiotics can destroy normal flora - causes intestinal mucosal damage and inflammation - results in diarrhea and abdominal cramping - contact precautions

nervous system control

- autonomic nervous system innervates the muscles of the colon. - parasympathetic nervous system stimulates movement, while the sympathetic system inhibits movement.

Hypertonic enemas

- available commercially and administered in small volumes - 70-130 mL (adults) - these solutions draw water into the colon, stimulating defecation - may be contraindicated in pts where NA retention is a problem - also contraindicated for pts with renal impairment or reduced renal clearance - hyperphosphatemia is potential complication

Providing comfort measures

- be attentive of perineal hygiene - maintain skin integrity with warm, moist heat to soothe perineal area - encourage recommended diet (if pertinent) and exercise - use medications, such as laxatives and antidiarrheals, only as needed - apply ointments or astringents (witch hazel) - use suppositories that contain anesthetics

toddler

- between the ages of 18-24 months the internal and external sphincters become fully developed - voluntary defecation becomes possible - daytime bowel control is typically around 30 months - physiologic maturity is the first priority for successful bowel training

psychological variables

- blood is shunted away from the stomach and intestines during fight-or-flight response and during stress - people who chronically worry and those with certain personality types who tend to hold onto problems and negative feelings may experience frequent constipation.

occult blood

- blood present in such minute quantities that it cannot be detected with the unassisted eye - blood that is hidden in the specimen or cannot be seen on gross examination - black stools indicate upper gastrointestinal bleeding, such as from a peptic ulcer, due to a reaction between hemoglobin and gastric acid. - bright-red blood in the stool may indicate a lower gastrointestinal bleeding, such as from hemorrhoids or a polyp - black or reddish stools may be due to certain foods and medications

food and fluid

- both type and amount of foods influence elimination - high-fiber diet and daily fluid intake of 2,000-3,000 mL facilitate bowel elimination - bulkier feces increase pressure on the intestinal wall, stimulating peristalsis - keeping things moving reduces absorption time of toxins, hopefully decreasing chances of colon cancer

infant stool frequency

- breastfed babies can have 2-10 per day - formula-fed babies typically have 1-2 per day - at age 1, infants commonly pass 1-2 per day

infants

- breastfed babies have more frequent stools - the stools are yellow to golden and loose - usually have little odor - stools of formula-fed infants vary from yellow to brown - are paste-like consistency - have a stronger odor because of the decomposition of protein - both may have curds and mucus - infants have no control over bowel elimination

Fecal incontinence device

- can be secured via adhesive around the anal opening and attached to a gravity drainage allowing liquid stool to accumulate in a collection bag - best applied before the perianal area becomes excoriated - regular assessment and documentation is required - change the pouch AT LEAST EVERY 72 HOURS

surgery and anesthesia

- complete absence of peristaltic movement that may follow abdominal surgery or complete bowel obstruction - temporary stoppage of peristalsis normally lasts 3-5 days - If this condition persists, distention and symptoms of acute obstruction may occur, possibly resulting in the need for surgical intervention. -Inhaled general anesthetic agents also inhibit peristalsis by blocking the parasympathetic impulses to the intestinal musculature. - However, local and regional anesthetics have little effect on peristalsis.

certain foods have been associated with specific effects on bowel elimination

- constipating foods - foods with laxative effect - gas-producing foods

Bowel elimination as the problem

- constipation - diarrhea - bowel incontinence

Older adults problems

- constipation is often a chronic problem - diarrhea - fecal impaction - fecal incontinence

sigmoid colon

- contains feces - empties into the rectum (the last part of the large intestine)

school-aged children, adolescent, adult

- defecation patterns vary in quantity, frequency, and rhythmicity - emphasize that the use of over-the-counter laxatives and enemas can have serious consequences and that any problems prompting such use need to be evaluated.

factors affecting bowel elimination

- developmental age - daily patterns - amount and quality of fluid or food intake - the level of activity - lifestyle - emotional states - pathologic processes - medications and procedures - diagnostic tests and surgery

Timing

- encourage toileting at the pt's normal time during the day - offer assistance - often 1 hour after meals, when mass colonic peristalsis occurs - educate pt about using the bathroom when the urge comes

Teaching about food safety

- ensure that food is safe for consumption and prepared and stored properly - never purchase food with damaged packaging - take items that need refrigerating home immediately - wash hands and surfaces often - use separate cutting boards for meats and perishables - NEVER CUT MEAT ON A WOOD SURFACE - thoroughly wash all vegetables and fruit - do not wash meat, poultry, eggs to prevent spreading microorganisms - never use raw eggs - do not eat raw seafood - keep food hot after cooking - give only pasteurized fruit juices to small children

Administering a Hypotonic or Isotonic (Large-Volume) Solution

- equipment is usually commercially prepared - need a bedpan, disposable waterproof pad - do not warm hypertonic solution - place pt in side-left lying position or the knee-chest position - additional lubrication is recommended - 1-2 minutes to administer the enema - administer cautiously to pt with hemorrhoids

Flatulence

- excessive formation of gases in the stomach or intestines - gas-producing foods, such as beans, cabbage, onions, cauliflower, and beer, often predispose a person to flatulence and distention. - pts should ambulate after meals to promote peristalsis and the escape of flatus

Patient preparation for enema

- explain purpose - what to expect - how they can participate - provide privacy - side-left lying position or knee-chest position - avoid Fowler's (expulsion will occur rapidly)

Duodenum

- first part of the small intestine - digestive juices from the liver and pancreas enter the small intestine through the duodenum

Nutrition

- fluid intake of 2,000-3,000 mL and high fiber intake - water is recommended as the fluid of choice (caffeine and sugar can act as diuretics)

Valsalva maneuver

- forcible exhalation against a closed glottis, resulting in increased intrathoracic pressure - may be contraindicated in people with cardiovascular problems and other illnesses.

Daily patterns

- frequency, timing considerations, position, and place - changes in any of these patterns may upset a person's routine and lead to constipation. - the longer it is in the large intestine, the more water is absorbed from the fecal matter - leaning forward and squatting can help - may be interrupted with embarrassment in the hospital

Peristalsis

- involuntary waves of muscle contraction that keep food moving along in one direction through the digestive system - contractions of the circular and longitudinal muscles of the intestine, peristalsis, occur every 3 to 12 minutes, moving waste products along the length of the intestine continuously - mass peristaltic sweeps occur one to four times each 24-hour period - mass peristalsis often occurs after the food has been ingested, accounting for the urge to defecate that often occurs after meals

Irrigating a colostomy

- is a way of achieving fecal continence and control - irrigations are used to promote regular evacuation - may be indicated for those with left-sided colostomies in descending or sigmoid colons - contraindications include irritable bowel syndrome, peristomal hernia, post-radiation damage to the bowel, diverticulitis, and Crohn disease - ileostomies are NOT irrigated because the fecal content of the ileum is liquid and can't be controlled - water is inserted into the colostomy - the water and feces are expelled from the colostomy into the irrigation sleeve and then the toilet

ileoanal reservoir

- is an option when the large intestine is removed but the anus remains intact and disease-free - the terminal ileum is sutured directly to the anus - a colon-like pouch is created from the last several inches of the ileum - the pt is able to control expulsion of feces through the intact sphincter

Hypotonic and isotonic enemas

- large-volume enemas that result in rapid colonic emptying - using such large volumes may be dangerous to pts with weakened intestinal walls (bowel inflammation or bowel infection) - these often require special prep and equipment - 500-1000 mL (adults) - 150-250 mL (children)

maintaining an NG tube

- may be inserted to decompress or drain the stomach of fluid or unwanted stomach contents such as poison or medication and air, and when conditions are present in which peristalsis is absent - paralytic ileus - intestinal obstruction by tumor - hernia - also used before or after abdominal surgery to promote healing and are inserted to monitor GI bleeding - selective use should be reserved for pts with nausea, vomiting, and abdominal distention after surgery

infant diarrhea and constipation

- passing of more than 3 loose stools in a day - loose stools may be related to overfeeding - teach parents, as long as the stool is soft, the child is not constipated

People at high risk for constipation

- patients on bedrest or with decreased mobility who take medications that cause constipation (e.g., opioids, anticholinergics), - patients with reduced fluids, bulk, or fiber in their diet, - people who are depressed, and patients with CNS disease or local lesions that cause pain while defecating

Inspection of anus

- perform a superficial exam each time you wash a pt's anal area or assist with bowel evacuation - assess for lesions, ulcers, fissures and external hemorrhoids - ask the pt to bear down as though they are having a bowel movement - observe for a fecal mass that may distend the anus - inspect area for areas of skin irritation or breakdown

Cathartics and laxatives

- promotes evacuation of bowels - cathartics exert a stronger effect on the intestines than do laxatives - laxatives are sometimes necessary for people with limited activity or poor food intake - also used to empty the intestinal tract in preparation for surgery or diagnostic tests. - laxatives should not be taken when there is abdominal pain because an intestinal pathologic condition could be harmed by the increased peristalsis.

wireless capsule endoscopy

- pt swallows a capsule (about the size of a vitamin) - capsule contains a camera that emits a radio signal - camera takes 2 pictures/second - wires on pt's abdomen pick up radio signal from the capsule - pt wears a belt - 8 hour exam captures 55,000 pictures - capsule is excreted in 24-48 hours - pt is normally NPO for 10-12 hours prior to capsule ingestion - during 1st 2 hours, pt cannot eat or drink - after 2 hours the pt can consume small amounts of liquid - after 4 hours, pt can have a small meal - does not allow for biopsy

anal canal

- region, containing two sphincters, through which feces are expelled from the body - is about 2.5-3.8 (1-1.5 inches) long

Exercise

- regular exercise improves GI motility and aids in defecation - encourage all pts to exercise regularly for 2.5 hours or more each week - ambulate pts who are ill as soon as possible - educate pts about how inactivity can lead to constipation, distension, and impaction - bedside exercises for those who are immobile

activity and muscle tone

- regular exercise improves GI motility and muscle tone - inactivity decreases both - pts with prolonged bedrest need to MOVE!

small intestine

- responsible for digestion of food and absorption of nutrients into the bloodstream - about 20 feet long (6 m) - about 1 inch wide (2.2 cm) - made up of 3 parts (duodenum, jejunum, ileum) - secretes enzymes that digest proteins and carbs - digestive juices from the liver and pancreas enter the small intestine through the duodenum

Positioning

- sitting upright promotes defecation - sitting upright promotes a sense of normalcy - effects of gravity help to promote regular bowel movements - pts in bed, elevate bed as close to sitting as possible (at least 30 degrees) - offer pt moistened hand wipes - always empty, clean, and return bedpans to the pt's bedside stand

large intestine function

- the absorption of water - the formation of feces - the expulsion of feces from the body - bacteria that reside in the large intestine act on food residue while it makes its way through the large intestine - bacterial action produces vitamin K and some of the B-complex vitamins - about 1500 mL of chyme enters the large intestine daily - about 800-1000 mL of fluid is reabsorbed daily - if the stool remains in the large intestine too long, or if too much water is absorbed, the stool becomes dry and hard.

gastrointestinal tract

- the alimentary tract or canal - extends from the mouth to the anus - the outlet of the gastrointestinal tract

rectum

- the final section of the large intestine - terminating at the anus - is about 12 cm (5 inches) long - is about 2.5 cm (1 inch) wide - 3 transverse folds are present - vertical folds are also present (each contain and artery + vein) - is empty except right before defecation

Enema

- the introduction of a solution into the large intestine, usually to remove feces - the instilled solution distends the intestine and irritates the intestinal mucosa, thus increasing peristalsis - enemas are classified as cleansing or retention enemas

Changing and ostomy appliance

- the ostomy appliance should protect the skin, collect the fecal discharge, and control odor - a colostomy does not produce drainage until normal peristalsis returns, usually within 2-5 days - an ileostomy drains within 24-48 hours because of the liquid contents in the small intestine - a transparent 1-piece appliance is used in the initial post-op period to allow for visualization of the stoma - appliances can be drainable or closed - empty a pouch that can be drained with it is 1/3 full - replace every 3-7 days (or whenever seal comes away from skin) - remove and change non-drainable pouches when they are 1/2 full

large intestine

- the primary organ of bowel elimination - consists of 3+2 sections: ascending, transverse, descending, sigmoid, and anus - is the lower (distal) part of the GI tract - AKA the colon - extends from the ileocecal valve to the anus - is about 5 feet (1.5 m) long - width varies from 1-3 inches wide

defecation

- the process of bowel elimination; a bowel movement - the emptying of the large intestine - two centers govern the reflex to defecate, one in the medulla and a subsidiary one in the spinal cord. - When parasympathetic stimulation occurs, the internal anal sphincter relaxes and the colon contracts, allowing the fecal mass to enter the rectum.

ascending colon

- travels upward from the cecum to the undersurface of the liver - where the digestive contents enter

pathologic conditions and elimination

- tumor may produce narrow ribbon-like stools - child's stools that are frequent, bulky, greasy and foul smelling suggest cystic fibrosis - diarrhea: diverticulitis may produce diarrhea resulting in infection, malabsorption syndromes, neoplastic diseases, diabetic neuropathy, hyperthyroidism, and uremia - constipation: may result with diseases within the colon rectum or injury to or degeneration of the spinal cord and megacolon - outbreaks of food poisoning can result in severe GI symptoms - E. coli - hematologic and renal complications - microbial infection - servere abdominal cramping with water or bloody diarrhea - intestinal obstruction: occurs when blockage prevents the normal flow of intestinal contents - mechanical obstructions: result from pressure on the intestinal walls - mechanical obstructions: tumors, stenosis, adhesions, hernias, and strictures - functional obstructions: result from an inability of the intestinal musculature to move the contents through the bowels - functional obstructions: muscular dystrophy, diabetes mellitus, Parkinson's, manipulation during bowel surgery

When placing a specimen in a lab container

- use gloves and HH - use two clean tongue blades - 1 inch (2.5 cm) or 15-30 mL of stool is typically sufficient - be sure specimen is free of any barium or enema solution - send to lab immediately or refrigerate

Auscultation

- using the diaphragm of a warmed stethoscope - listen for bowel sounds in all abdominal quadrants - disconnect NG tube from suctioning if applicable - note the frequency and character of bowel sounds - intermittent audible clicks and gurgles - usually high-pitched, gurgling, and soft (indicating motility and peristalsis) - frequency ranges 5-30 sounds/minute

Palpation

- watch the pt's face for nonverbal signs of pain - palpate each quadrant in a systematic manner - note muscular resistance, tenderness, enlargement of the organs and/or masses - if pain exists, palpate this area last - if the pt's abdomen is distended, note the presence of firmness or tautness

intestinal distention (tympanites)

- when gas is not expelled from the stomach or intestines, stretching and inflation of the intestines

Bristol Stool Chart

1-2 is constipation 3-4 is ideal 5-7 is diarrhea, loose stools

Warning signs of colon cancer

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

Teaching about nutrition to avoid constipation

A combination of high-fiber, fluid intake, and exercise have proven to be effective in controlling constipation. - Fiber: 20-35 g daily - Fluid: 60-80 oz (1.8-24. L) daily Caution for the pt if they increase fiber intake without increasing fluid intake - This can lead to a bowel obstruction - Foods with high fiber include bran, fruits, veggies, and whole grains

Beside exercises for those using a bedpan

Abdominal setting - pt is lying in a supine position - tighten and hold the abs for 6 seconds and then relax - repeat several times each waking hour Thigh strengthening - flex thigh muscles and contract - slowly bring knees up to the chest one at a time, then lower back down - repeat several times for each knee each waking hour

Action on gastrointestinal smooth muscle Antidiarrheal medication - Opium (Paregoric) -

Action & Advantages - Increases smooth muscle tone - Decreases GI motility - Diminishes GI secretions - Effective Cautions - May be addictive due to morphine content - May cause drowsiness and lightheadedness - Should be discontinued as soon as diarrhea has diminished

Antisecretory/antimicrobial Antidiarrheal medication - Bismuth subsalicylate (Pepto-Bismol)

Actions & Advantages, Cautions - Decreases gastrointestinal tract secretion - Has antimicrobial action against bacterial and viral pathogens - No drowsiness - Check with physician if a child is taking aspirin - May decrease absorption of some meds

Oral intestinal lavage

An oral solution, such as GoLYTELY® or Colyte®, can be used to cleanse the intestine of feces. Onset - about 1 hour Duration - 4-6 hours A clear diet for 24 hours prior helps shorten duration Potassium replacement may be required before surgery Clear diet is K deficient, typically Carefully assess older pts for electrolyte imbalance

Retention enemas

Are retained in the bowel for a prolonged period for different reasons: - Oil-retention: lubricate the stool and intestinal mucosa, easing defecation - Carminative: help expel flatus from the rectum - Medicated: provide medications absorbed through the rectal mucosa - Anthelmintic: destroy intestinal parasites

Problems with bowel elimination

Are your bowels causing you any problem now? - Nature of disturbance - Onset and frequency - Causes (physical: food and fluid intake, exercise status, history of surgery or illnesses influencing gastrointestinal tract; psychosocial; medicine related) - Severity - Symptoms - Interventions attempted and results

hepatic flexure

Bend between the ascending colon and the transverse colon.

Testing for Fecal Occult Blood

Blue color is a positive result and should be reported.

medications and elimination

Cathartics - medications are available that can promote peristalsis Laxatives - inhibit peristalsis (antidiarrheal medications) Can cause constipation - opioids - antacids containing aluminum, iron sulfate - anticholinergic medications decrease GI motility Can cause diarrhea - antibiotics (Augmentin, amoxicillin) Can affect appearance of stools - GI bleeding - anticoagulants, aspirin make turn stools pink, red, black - iron salts result in black stools from oxidation of iron - antacids cause white discoloration - antibiotics cause green-gray discoloration of stools

chronic diarrhea

Causes - irritable bowel syndrome (Crohn's disease, ulcerative colitis) - malabsorption syndromes - bowel tumor - metabolic disease (diabetes, hyperthyroidism) - parasitic infection - side effects of drugs - laxative abuse - surgery - alcohol abuse - radiation - chemotherapeutic agents Characteristics - lasts for more than 3-4 weeks Treatment - usually involves pharmacologic intervention along with fluid and electrolyte replacement - antidiarrheal medications are usually reserved for treatment - eliminate the cause - Replace lost fluids and electrolytes with Gatorade, weak tea, water, bouillon, clear soup, and gelatin.

acute diarrhea

Causes - viral or bacterial - reaction from medication - alterations from diet Characteristics - sudden onset - lasts several hours to several days Treatment - rehydration is key - oral liquids may be used if tolerated - IV fluid replacement may be necessary - stress the importance of HH - avoid antidiarrheal agents until bacterial causation has been ruled out - eliminate the cause - Replace lost fluids and electrolytes with Gatorade, weak tea, water, bouillon, clear soup, and gelatin.

Traveler's diarrhea

Causes + recommendations - caused by bacterial enteropathogens, viruses, or parasites, is the most predictable travel-related illness - symptoms include more than three loose stools in a 24-hour period, fever, nausea, vomiting, and abdominal cramps and/or pain. - advise patients to peel fruits and vegetables, and consume dry foods and foods that are piping hot and cooked thoroughly. - tell travelers to avoid tap water, ice cubes, fruit juice, unpeeled raw fruits and vegetables, unpasteurized dairy products, open buffets, and undercooked or reheated foods - safe beverages include those that are bottled and sealed or carbonated. Treatment - maintain hydration - use antimotility agents such as loperamide (Imodium) and antibiotics - discuss travel with doctor prior to visiting foreign country - replace lost fluids and electrolytes with Gatorade, weak tea, water, bouillon, clear soup, and gelatin. - avoid spicy foods and high-fiber foods

Constipation

Constipation is - dry, hard stool - persistently difficult passage of stool - and/or the incomplete passage of stool Decreased gastric motility slows the passage of feces through the large intestine, resulting in increased fluid absorption from the fecal mass and causing dry, hard stool. Factors - Decreased fiber in diet - Decreased fluid intake - Inactivity - Delaying defecation when urge is present - Abuse of laxatives - Use of constipating medications (antacids, opioid analgesics, anticholinergics) - Change in routine - Pain associated with defecation Characteristics - Reports straining during defecation with little result - Passes small "marbles" of dry, hard stool - Decreased frequency - Decreased frequency of bowel sounds or changes in abdominal growling - Straining often results in small amount of bleeding from swollen external hemorrhoids - Reports feeling rectal fullness or pressure in rectum - Headache

pyloric sphincter

Controls passage of food from stomach to small intestine

ADMINISTERING A LARGE-VOLUME CLEANSING ENEMA

Delegations NAP/UAP - Allowed LPN/LVN - Allowed Notes - Generously lubricate the end of the rectal tube 2 to 3 inches (5-7 cm). - Lift the buttock to expose the anus. Ask the patient to take several deep breaths. Slowly and gently insert the enema tube 3 to 4 inches (7-10 cm) for an adult. Direct it at an angle pointing toward the umbilicus, not the bladder - Do not force entry of the tube - Introduce solution slowly over a period of 5 to 10 minutes. Hold the tubing all the time that the solution is being instilled. Assess for dizziness, lightheadedness, nausea, diaphoresis, and clammy skin during administration. If the patient experiences any of these symptoms, stop the procedure immediately, monitor the patient's heart rate and blood pressure, and notify the primary care provider.

IRRIGATING A NASOGASTRIC TUBE CONNECTED TO SUCTION

Delegations NAP/UAP - Not allowed LPN/LVN - Allowed Notes - Check placement of the NG tube. - If a Salem sump or double-lumen tube is used, make sure that the syringe tip is placed in the drainage port and not in the blue air vent. Hold the syringe upright and gently insert the irrigant, or allow the solution to flow in by gravity if facility policy or medical order indicates. - Do not force the solution into the tube. - If unable to irrigate the tube, reposition the patient and attempt irrigation again. Inject 10 to 20 mL of air and aspirate again (Fig. 5). If repeated attempts to irrigate the tube fail, consult with the primary care provider or follow facility policy.

CHANGING AND EMPTYING AN OSTOMY APPLIANCE

Delegations for emptying NAP/UAP - Allowed LPN/LVN - Allowed Delegations for changing NAP/UAP - Not allowed LPN/LVN - Allowed

Fecal occult blood tests

Detect GI bleeding

Preventing and treating diarrhea

Diarrhea (adults) - the passage of more than 3 loose stools a day - often associated with cramps - nausea and vomiting may occur - large amounts of fluid and electrolytes may be lost - avoid cold fluids and rich foods, especially sweets Additional nursing measures - answer call bell immediately - whenever possible, remove the cause of the diarrhea - if there is any indication of fecal impaction, further evaluation is necessary before giving anti-diarrheals - give special care around the anus (skin irritation); keep clean and dry (use skin creams, moisture barriers, ointments, or powders

Absorbent Antidiarrheal medication - Diphenoxylate and atropine (Lomotil) - - Loperamide (Imodium) - - Kaolin-pectin (Kaopectate) -

Diphenoxylate and atropine (Lomotil) Actions & Advantages, Cautions - Slows gastric motility through local effect on gastrointestinal wall - Effective - Addictive Loperamide (Imodium) Actions & Advantages, Cautions - Inhibits peristalsis via direct effect on gastrointestinal wall muscles - Not addictive - Longer duration than Lomotil - May cause drowsiness Kaolin-pectin (Kaopectate) Actions & Advantages, Cautions - Absorbs and soothes - No drowsiness - May interfere with absorption of nutrients

Aids to elimination

Do you use anything to help move your bowels? - Natural aids (liquids, food) - Pharmacologic aids (laxatives) - Enemas

scheduling for diagnostic studies

Follow a logical sequence when more than one test is required for accurate diagnosis: - Fecal occult blood tests: to detect GI bleeding - Barium studies: to visualize GI structures and reveal any inflammation, ulcers, tumors, strictures, or other lesions - Endoscopic examinations: to visualize an abnormality, locate a source of bleeding, and if necessary provide biopsy tissue samples A barium enema and routine radiography should precede an upper GI series because retained barium from an upper gastrointestinal series could take several days to pass through the gastrointestinal tract and cloud anatomic detail on the barium enema studies. Noninvasive procedures usually take precedence over invasive procedures, such as endoscopic studies, when sufficient diagnostic data can be obtained from them. In some instances, endoscopic studies may be done before barium studies to ensure visualization.

Dietary considerations for pts with an Ileostomy or Colostomy

Foods that may cause gas - alcohol and beer - carbonated drinks - chewing gum - chives - cucumbers - dried peas, beans, and lentils -eggs - broccoli, brussel sprouts, cabbage Fried food - melon - onions, peppers, pickles, sauerkraut Foods that may cause blockage Bean sprouts - Nuts - Cabbage - Olives - Carrots (raw) - Peas - Celery - Pickles - Coconut - Pineapple - Corn - Popcorn - Cucumbers - Seeds - Spinach Foods That May Help To Control Diarrhea - Applesauce - Bananas - Cheese - Creamy peanut butter - Oatmeal or oat bran - Potatoes - Soda crackers - Starchy foods (rice, pasta, barley) - Tapioca - Yogurt Foods that prevent odor - buttermilk - cranberry juice - parsley - yogurt

Recent changes in bowel elimination

Have you noticed any changes in your stool recently? Have you noticed any blood in your stool? (May need to ask the patient about color blindness.) Have you noted a difference in the appearance of your stool (narrowing, the presence of mucus)?

Usual patterns of bowel elimination

How often do you move your bowels? Any special time of the day? What does your stool look like: - Frequency - Time of day - Description of usual stool characteristics (amount, consistency, shape, color, odor)

abdominal assessment

Inspection Auscultation Palpation Percussion Inspection and Auscultation are performed before palpation because palpation may disturb normal peristalsis and bowel motility. Advanced practice professionals perform percussion and deep palpation of the abdomen Place the pt in a SUPINE position, with knees slightly flexed. Encourage pt to urinate prior to the examination.

Bowel sounds

Intestinal sounds heard from auscultating over the abdomen; hyperactive, hypoactive, diminished, absent, tympanic Hypoactive bowel sounds - indicate diminished bowel motility, commonly caused by abdominal surgery or late bowel obstruction. Hyperactive bowel sounds - indicate increased bowel motility, commonly caused by diarrhea, gastroenteritis, or early bowel obstruction. Decreased or absent bowel sounds, evidenced only after listening for 5 minutes (Jensen), signify the absence of bowel motility, commonly associated with peritonitis, paralytic ileus, and/or prolonged immobility. Describe bowel sounds as audible, hyperactive, hypoactive, or inaudible.

NG tubes

Levin and Salem Sump - require irrigation with 30-60 mL of normal saline to maintain patency - radiographic examination is used to confirm placement - check length - aspirate gastric contents - monitor CO2 using a capnograph - administer oral hygiene every 2-4 hours - lubricate lips and nares generously - analgesic lozenges - secure tube to pt's gown

astringents

Liquids that help remove excess oil on the skin.

Salem sump tube

NG tubes that are double-lumen tubes - one lumen empties the stomach - the other lumen provides continuous flow of air - the airflow lumen controls suction by preventing the drainage lumen from pulling stomach mucosa into the tube's opening - a one-way antireflux valve may be used to prevent reflux of gastric contents

stool volume

Normal finding: Variable The volume of the stool depends on the amount the person eats and the nature of the diet. For example, a diet high in roughage produces more feces than a soft, bland diet. Consistently large diarrheal stools suggest a disorder in the small bowel or proximal colon; small, frequent stools with urgency to pass them suggest a disorder of the left colon or rectum.

stool shape

Normal findings: - Formed stool is usually about 1 inch (2.5 cm) in diameter and has the tubular shape of the colon, but may be larger or smaller, depending on the condition of the colon. Considerations: - A gastrointestinal obstruction may result in a narrow, pencil-shaped stool. Rapid peristalsis thins the stool. - Increased time spent in the large intestine may result in a hard, marble-like fecal mass.

stool color

Normal findings: - Infant: Yellow to brown - Adult: Brown The brown color of the stool is due to stercobilin, a bile pigment derivative. The rapid rate of peristalsis in the breastfed infant causes the stool to be yellow. The color of the stool is influenced by diet. For example, the stool will be almost black if the person eats red meat and dark green vegetables, such as spinach. The stool will be light brown if the diet is high in milk and milk products and low in meat. The absence of bile may cause the stool to appear white or clay-colored. Certain drugs influence the color of the stool. For example, iron salts cause the stool to be black. Antacids cause it to be whitish. Bleeding high in the intestinal tract causes a stool to be black owing to the digestion of the blood. Bleeding low in the intestinal tract results in fresh blood in the stool. The stool darkens with standing.

stool constituents

Normal findings: - Waste residues of digestion: bile, intestinal secretions, shed epithelial cells, bacteria, and inorganic material (chiefly calcium and phosphates); seeds, meat fibers, and fat may be present in small amounts Considerations: - Internal bleeding, infection, inflammation, and other pathologic conditions may result in abnormal constituents. These include blood, pus, excessive fat, parasites, ova, and mucus. - Foreign bodies also may be found in the stool.

stool odor

Normal findings: Pungent; may be affected by foods ingested The characteristic odor of the stool is due to indole and skatole, caused by putrefaction and fermentation in the lower intestinal tract. The odor of the stool is influenced by its pH value, which normally is neutral or slightly alkaline. Excessive putrefaction causes a strong odor. The presence of blood in the stool causes a unique odor.

stool consistency

Normal findings: Soft, semisolid, and formed The consistency of the stool is influenced by fluid and food intake and gastric motility. The less time stool spends in the intestine (or the shorter the intestine), the more liquid the stool. Many pathologic conditions influence consistency.

Nursing interventions and outcome classifications for bowel management

Nursing Interventions - Plan bowel program with patient and appropriate others. - Monitor bowel movements including frequency, consistency, shape, volume, and color, as appropriate. - Monitor bowel sounds. - Teach patient about specific foods that are assistive in promoting bowel regularity. - Teach about foods that are assistive in promoting bowel regularity. - Ensure privacy. - Encourage adequate fluid intake. Nursing Outcomes - Bowel Elimination - Hydration - Gastrointestinal Function

chyme

Partially digested, semi-liquid food mixed with digestive enzymes and acids in the stomach

long-term ostomy care

Pt can return to full life with an ostomy Encourage pt to seek regular medical follow-up Pt education is essential for independence and self-care - explain reason - demonstrate self-care - describe follow-up care - report where supplies can be obtained - verbalize fears and concerns - demonstrate positivity During 1st 6-8 weeks after surgery - encourage pt to avoid high-fiber foods - also, avoid foods that cause diarrhea or flatulence - gradually add foods - fiber can cause blockages

Cleansing enema

Purpose - relieve constipation or fecal impaction - prevent involuntary escape of fecal material during surgical procedures - promote visualization of the intestinal tract - help establish regular bowel function during a bowel-training program Most common types - tap water - normal saline solution - soap solution - hypertonic solution

Recommendations for the patient preparing for a fecal occult blood test

Recommendations - Before stool testing, avoid the foods (for 4 days) and drugs (for 7 days) that may alter test results. - Do not use laxatives, enemas, or suppositories for 3 days before testing. - Postpone the test until 3 days after her period has ended if a woman is menstruating. - Postpone the test if hematuria or bleeding hemorrhoids are present. - Postpone the test if the patient has had a recent nose or throat bleed. - Caution a person who is color-blind to the color blue not to attempt to interpret the test results. False-positive result foods & medications - red meat, animal liver and kidneys, salmon, tuna, mackerel and sardines, tomatoes, cauliflower, horseradish, turnips, melon, bananas, and soybeans. - salicylate intake of more than 325 mg daily, steroids, and iron preparations, also may lead to false-positive readings - vitamin C

Levine tube

Single lumen tube used for gastric decompression connected to gravity drainage or intermittent suction - Lacks venting system - mucosal damage can occur if suction is applied consistently - Usually applied intermittently

Commonly used enema solutions

Tap water (hypotonic) Distends intestine, increases peristalsis, softens stool 500-1000 mL • 15 min Fluid and electrolyte imbalance, water intoxication Normal saline (isotonic) Distends intestine, increases peristalsis, softens stool 500-1000 mL • 15 min Fluid and electrolyte imbalance, sodium retention Soap Distends intestine, irritates intestinal mucosa, softens stool 500-1000 mL (concentrate at 3-5/L) • 10-15 min Rectal mucosa irritation or damage Hypertonic Distends intestine, irritates intestinal mucosa 70-130 mL • 5-10 min Sodium retention Oil (mineral, olive, cottonseed oil) Lubricates stool and intestinal mucosa 150-200 mL • 30 min

Abdominal CT Scan

Thin beams of x-rays are directed at and move around the abdomen, resulting in computer-manipulated pictures that are not obscured by overlying anatomy. Preparation An oral contrast is consumed before the study if the upper gastrointestinal tract is to be examined. Intravenous iodine contrast is usually administered. Assess for patient allergies to iodine, IV contrast, and/or shellfish. Prestudy preparation may be required if allergies are present. Assess for renal impairment; check laboratory values for elevated BUN and creatinine levels. Patient should be NPO for at least 4 hours before study. CT scan is contraindicated for pregnant patients. An informed consent is required. Metformin (Glucophage) must be discontinued prior to study and held after study to prevent renal failure. Consult with physician for patient medication modifications. Aftercare If intravenous contrast is used during study, monitor for sensitivity and adverse reactions. Monitor contrast injection site for signs of irritation, infection, and bruising. If prestudy sedation was given, monitor patient closely until sedation wears off to prevent injury.

Barium Enema

This involves a series of radiographs that examine the large intestine after rectal instillation of barium sulfate. Preparation An informed consent must be signed. Preparation may consist of dietary modifications, increased fluid intake, a cathartic, NPO after midnight, and enemas until clear before the test. Review the patient's history for any history of ulcerative colitis or active GI bleeding that would prohibit the use of the standard bowel preparation. Aftercare Encourage fluids to prevent dehydration. Inform the patient that the barium may lighten the color of the stools. A cathartic may be prescribed. Notify the physician or primary care provider if barium is not passed, usually within 2 days. Encourage rest because the bowel preparation and the test exhaust many patients.

Upper Gastrointestinal (UGI) and Small-Bowel Series

This involves fluoroscopic examination of the esophagus, stomach, and small intestine after ingestion of barium sulfate. Preparation Ensure that an informed consent is signed. Keep patient NPO after midnight the day of the test. Inform patient that a chalky-tasting barium contrast mixture will be given to drink before the test. Aftercare A post-test cathartic (e.g., Milk of Magnesia) is usually prescribed to prevent fecal impaction from barium sulfate that has hardened. Notify the physician or primary care provider if barium is not passed, usually within 2 days. Explain that the barium may lighten the color of stools for the next several days. After the barium is expelled, the stool color will return to normal

Magnetic Resonance Imaging (MRI)

This test provides physiologic information and detailed anatomic views of tissues using a superconducting magnet and radiofrequency signals. Preparation Evaluate the patient for need for sedation. Patients who are claustrophobic or unable to lie still during study may benefit from sedation. Patient may need to fast or consume only clear liquids prior to study. Patient should avoid alcohol, nicotine, caffeine, and iron supplements prior to the study. Patients with implanted surgical clips or other metallic structures and those with implanted electromechanical devices, such as cardiac pacemakers, drug infusion pumps, and cochlear implants, should not be exposed to MRI procedures. An informed consent is required. Pregnant patients are not routinely scanned because an increase in amniotic fluid/fetal temperature may be harmful. Aftercare If intravenous contrast is used during study, monitor for sensitivity and adverse reactions. Monitor contrast injection site for signs of irritation, infection, and bruising. If prestudy sedation was given, monitor patient closely until sedation wears off to prevent injury.

Abdominal Ultrasound

Uses ultrasound waves to visualize organs via a small transducer placed against the skin. Preparation Assure the patient that no radiation is employed and that the test is painless. Patient must be NPO for a minimum of 8 hours before the examination. Explain that gel will be applied to the skin and that a sensation of warmth or wetness may be felt. The gel does not stain, but avoid wearing nonwashable clothing. Abdominal ultrasound must be performed before studies involving barium, as retained barium may compromise the study. Aftercare Ensure that any residual gel is removed from the skin. Normal diet and fluids may be resumed, unless contraindicated by the test results.

Barium studies

Visualize GI structures and reveal any inflammation, ulcers, tumors, strictures, or other lesions

Endoscopic examinations

Visualize an abnormality, locate a source of bleeding, and if necessary provide biopsy tissue samples

Presence of artificial orifices (normal routine, history of problems)

What is your usual routine with your colostomy or ileostomy? Do you have any problems with it?

Suppository

a conical or oval solid substance shaped for easy insertion into a body cavity and designed to melt at body temperature - fecal softeners - substances that stimulate the rectal nerves - CO2 suppositories that liberate about 200 mL of gas

food intolerance

a negative reaction to food that doesn't involve the immune system

hemorrhoids

abnormally distended rectal veins

Loperamide

antidiarrheal (Imodium)

splenic flexure

area of the colon that bends downward near the spleen

diagnostic studies

can severely alter a pt's usual elimination patterns - barium enema - stress of hospitalization

Etiology

cause of disease

Foods with laxative effect

certain fruits and vegetables (e.g., prunes), bran, chocolate, spicy foods, alcohol, coffee

paralytic ileus

complete absence of peristaltic movement that may follow abdominal surgery or complete bowel obstruction

endoscopy

direct visualization of hollow organs of the body using an endoscope (a flexible, lighted tube)

stool

excreted feces

Diarrhea

frequent passage of loose, watery stools Factors - Adverse effects of pharmaceutical agents - Abuse of laxatives - Emotional stress - Intestinal infection - Colon disease and other diseases - Radiation Characteristics - At least three loose liquid stools per day, increased frequency - Urgency - Reports of abdominal pain and/or cramping - Hyperactive bowel sounds

flatus

internal gas

stoma

mouth (opening), artificial opening for waste excretion located on the body surface

stool characteristics

note and record - volume - color - odor - consistency - shape - constituents describe any unusual observations - lightheadedness - straining

stool culture

obtain prior to anti-infective therapy test for microorganisms present in feces - bacteria - virus - fungi - parasites

Gas-producing foods

onions, cabbage, beans, cauliflower

ileostomy

opening into the small intestine allows fecal content from the ileum to be eliminated through the stoma - may be temporary or permanent

Constipating foods

processed cheese, lean meat, eggs, pasta

perineal

region between the anus and external genitalia

Jejunum

second part of the small intestine

gastroesophageal sphincter

separates the esophagus from the stomach

external sphincter (anal canal)

skeletal muscle, voluntary

internal sphincter (anal canal)

smooth muscle, involuntary

feces

solid wastes; stool

GERD (gastroesophageal reflux disease)

solids and fluids return to the mouth from the stomach

Ostomy

surgical opening, usually used to refer to an opening created for the excretion of body wastes

Bowel incontinence

the inability to control the excretion of feces Causes - usually organic disease, resulting in mechanical condition - mental illness Factors - Dietary habits - General decline in muscle tone - Laxative abuse - Rectal sphincter abnormality - Cognitive impairment Characteristics - Involuntary passage of stool - Constant dribbling of soft stool Interventions - Note when incontinence is likely to occur - Keep skin clean and dry - Change bed linens - Confer with the physician about using a suppository or daily cleansing enema - Bowel-training programs might also be helpful

Ileum

the last and longest portion of the small intestine

putrefaction

the process of decay or rotting in a body or other organic matter

colostomy

the surgical creation of an artificial excretory opening between the colon and the body surface

Esophagogastroduodenoscopy (EGD)

visual examination of the esophagus, the stomach, and the duodenum by means of a long, flexible, fiber-optic-lighted scope. Preparation A signed consent form is required for this procedure. Fasting is required 6 to 12 hours before the test. Dentures need to be removed before the test. Remind patients that they will be awake but sedated and that a local anesthetic will be sprayed into the mouth and throat to depress the gag reflex. Aftercare Withhold food and fluids until the gag reflex returns. Check vital signs according to the protocol. Observe for signs of perforation: pain, persistent difficulty swallowing, vomiting blood, or black, tarry stools. Explain to the patient that it is normal to sense throat soreness and hoarseness for several days; saline gargles and lozenges may be helpful.

Colonoscopy

visual examination of the large intestine from the anus to the ileocecal valve It allows visual examination of the rectum, colon, and distal small bowel using a long, flexible, fiber-optic-lighted scope. Preparation Ensure that an informed consent is signed. Preparation prior to test may involve: Clear liquid diet (24-48 h before test) 2-day bowel preparation—strong cathartic and Dulcolax on day 1 and enema the day of the test, or 1-day bowel preparation—ingestion of a gallon of bowel cleanser Sedation will be given before the test. Aftercare Patient may experience flatulence or gas pains because air was used to distend the intestines for better visibility. Usual diet may be resumed once patient recovers from the sedation. Check vital signs according to agency protocol. Observe for signs of bowel perforation: rectal bleeding, abdominal pain and distention, fever, malaise.

Sigmoidoscopy

visual examination of the sigmoid colon, the rectum, and the anal canal through a flexible or rigid sigmoidoscope. Preparation Ensure that an informed consent is signed. Preparation usually consists of a light meal before the test and two Fleet enemas. Sedation is not usually required. Aftercare Patient may experience flatulence or gas pains because air was used to distend the intestines for better visibility. Observe for signs of bowel perforation. If biopsy was performed, patient should be informed that slight rectal bleeding may occur.