Chapter 40 Bowel Elimination

laxatives

ease defecation and stimulate bowel activity -types: bulk-forming agents, osmotics, salines, stimulants, and stool softeners.

What is a primary concern for the patient who is incontinent?

skin breakdown from exposure to urine and feces. Prompt cleansing and protecting of the skin is critical.

cathartics

strong laxatives that stimulate evacuation of the bowel by causing a change in GI transit time

temporary colostomy

1. Allows lower portion of colon to rest/heal 2. 1-2 openings (one drains feces, one drains mucus) 3. Required due to blockage by disease/scar tissue 4. Created to allow inflammation/operation site to heal 5. Reversed with minimal to no lass of intestinal function

hypoactive bowel sounds

Slow and sluggish. Present after surgery or bowel obstruction. -less than 5 sounds per min

What signs and symptoms are associated with diarrhea?

abnormal frequency and fluidity of fecal evacuations, hyperactive bowel sounds, urgency, abdominal pain, and cramping.

Transverse Colostomy

-1 or 2 openings, on upper abdomen in the middle or right side. -semiformed liquid, malodorous drainage bc some liquid has been reabsorbed. -no control over frequency of discharge of stool, appliances in place at all times.

gastrointestinal tract & abdominal assessment

-First inspect pts mouth, teeth, tongue and gums for sores, dentition and moisture. Poor Dentition, mucosal dryness and sores can cause pain or difficulty swallowing. -abdominal assessment should always start w/ inspection & ascultation, b/c palpation & percussion alter peristaltic activity -percussion; for nurses with special training.

loop colostomy

-Temporary colostomy, usually created in an emergency -Location: On the right abdomen -Has one stoma with two openings: the proximal end of the stoma discharges stool; the distal end may discharge mucus -Results in a large stoma that may be difficult to manage because of its size and inability to be covered with available ostomy products

when performing a bowel elimination assessment

-consider pts physical, mental and functional abilities, home environment and family & social support. -attention focuses on ID and prioritization of immediate problems and relief of symptoms before a full assessment is undertaken.

Ascending colostomies

-drainage is liquid and cannot be regulated. -digestive enzymes are present and cause an oder. -relatively rare -R side of abdomen.

bowel diversions

-for pts w/ conditions that prevent normal passage of feces from the rectum -location of the ostomy determines the consistency of the stool. ex: ileostomy; very liquidy stool. Descending colostomy; very formed stool.

large intestine (colon)

-primary organ of bowel elimination -Absorption (of water, electrolytes, sodium and chloride), Secretion (bicarbonate in exchange of chloride), and Elimination

flatulence

Production of a mixture of gases in the intestine; byproducts of the digestive process. Caused by air escaping. -normal body function, and an important signal of normal activity.

double barrel colostomy

Bowel is surgically severed and the two ends are brought out onto the abdomen with a proximal functioning and distal nonfunctioning stoma. -2 distinct stomas

esophagus

Transports solids and liquids from the mouth (where digestion begins, into the stomach.

How does the nurse promote bowel elimination for the patient who is immobile or cognitively impaired?

Warm liquids, adequate hydration, high-fiber foods, and proper positioning will aid in the process. Also stool softners

before diagnostic procedures of the bowel, pt may be placed on

a restricted diet or given cleansing enemas.

diarrhea

an intestinal disorder that is characterized by an abnormal frequency and fluidity of bowel movements. -ingested materials pass too quickly thru intestine resulting in a decrease in the amount of time for absorption of fluids and nutrients. -increased # of stools, w/ passage of liquid or unformed feces and finds it difficult to control urge to defecate.

stoma (mouth)

any body opening but usually refers to the actual exit point for a GI surgical ostomy, which forms a slight protuberance of mucosa through the skin.

Clostridium difficile (C. diff)

bacterium that causes severe diarrhea and inflammation of the colon. -results after use of antibiotics. -transmitted by contact; have become more difficult to treat. -clinical symptoms: foul smelling, watery diarrhea 3 or more times a day for 2 or more days, abdominal cramping and tenderness. -affects older adults in hospitals & long-term care facilites &

valsalva maneuver

bearing down while holding the breath; usually done while defecating. -pt exerting force against closed windpipe, increasing intrathoracic pressure. Causing rapid rise in BP, then fall in arterial BP. -dizziness, blurred vision, and fainting may result.

polyps

benign or malignant tissue growth in the colon.

The nurse recognizes that the major side effect from an upper or lower GI series is:

constipation from the barium.

risk factors for incontinence

dementia, acute confusion, and intellectual disability.

palpation

determines organ size, organ placement, masses, pain and presence of fluid. Light touch used. -painful areas palpated last. -abdomen should be soft, smooth in contour, and pain free. -pt should be relaxed -if pulsation noted on visual exam, do NOT palpate the area.

factors affecting bowel elimination

diet, age, environment, culture, physical activity, emotional health

bowel diversions or ostomies are created to

divert and drain fecal material.

absence of bowel sounds

established after listening for 5 full minutes. -may be sign of obstruction or paralytic ileus -requires immediate medical attention.

regular bowel elimination may be disrupted by

food & fluid intake, various illnesses and diseases, trauma and surgery, medications, immobility and psychological issues, -alteration in bowel elimination can become a life-threatening medical emergency.

What factors can influence bowel elimination?

food and fluid intake, various illnesses and diseases, trauma and surgery, medications, physical activity/immobility, psychological issues (anxiety, depression, eating disorders), personal habits/comfort, posture, pain, and diagnostic tests.

slowed intestinal peristalsis & infrequent bowel movements result in

increased water absorption in colon, leading to difficulty passing stool, excessive straining at defecation, the inability to defecate at will, hard feces and rectal pain.

constipation

infrequent or difficult bowel movements, or having 3 or fewer bowel movements per week. -may experience, abdominal cramping, pain, pressure, distention, anorexia, and headache. -straining may cause elevations in intraocular pressure, increased intracranial pressure, changes in cardiac rhythms and hemorrhoids.

Kock pouch

internal pouch created from the distal segment of the ileum to serve as a reservoir for stool or urine. -catheter or tube is inserted into the pouch several times a day to drain feces from reservior.

Small intestine

intestinal juices and bile from liver, gallbladder and pancreas mix w/ chyme for digestion and absorption of nutrients. -three segments; 1.Duodenum; secretes hormones to trigger pancreas to release pancreatic juice & bile. Secretes chemicals that neutralizes acidity of chyme. 2.Jejunum; controls carbohydrate & protein absorption 3.Ileum; absorption of fats, bile salts, and water.

normal bowel sounds are

irregular, high-pitched and gurgling and occur every 5 to 15 seconds.

incontinence

loss of voluntary control of the bladder, fecal & gaseous discharges through the anus. -impact persons body image, pt is often alert -at risk for skin breakdown and may suffer from social isolation.

Hyper active bowel sounds

loud, high pitched, and rushing, commonly heard with diarrhea or inflammatory disorders.

fecal occult blood test (FOBT)

measure for microscopic amounts of blood in the feces. -positive test indicates blood has been found in stool. -negative test indicates blood has not been found in stool. -requires collection of 3 small stool samples taken 1 day apart. (BC colon cancers may bleed intermittently.)

stomach

mixes food food w/ digestive juices, causing the chemical and mechanical breakdown of food into chyme before entering the small intestine. -Located in the UL quad of the abdomen, slightly inferior to the diaphragm. -Produces & secretes hydrochloric acids, pepsin, intrinsic factor, and mucus.

The patient with "gas" or flatus may be helped by

moving around in bed or ambulating, rocking, or insertion of a rectal tube, if necessary.

ostomy appliances are used to

protect skin, collect drainage, and control odor.

upper GI series

series of radiographic images taken of the pharynx, esophagus, stomach, and duodenum after the contrast agent barium liquid has been administered orally, which fills & coats intestinal lining. -pt should not drink or eat anything for 4 to 8 hrs -major side affect: constipation -barium has whitish appearance on stool for several days after test.

most common type of ostomy surgeries

sigmoid and descending colostomies. -Usually LL quad, descending higher than sigmoid colostomy. -Both produce solid fecal material. Odor usually can be controlled. -Frequency of discharge can be regulated, may not need to wear an appliance at all times.

paralytic ileus

stoppage of peristalsis, usually after anesthesia and intestinal surgery.

ileoanal pouch (pull-through, pelvic pouch, J-pouch)

surgical procedure when the patient needs the colon removed, the surgeon creates a pouch out of the small intestine and attaches it to the anus. the person is then continent of stool. -no stoma -pts with ulcerative colitis or familial polyps in whom the anal sphincter is still intact.

ostomy

surgically created opening in a GI, urinary, or respiratory organ that is exited onto the skin.

Colostomy

surgically created when a portion of the colon or rectum is removed and the remaining colon is brought through an opening created in the abdominal wall.

hemorrhoids

swollen and inflamed veins in the anus or lower rectum.

stool culture

test to detect parasites in stool & help determine the cause of diarrhea. -ordered if pt complains of diarrhea for several days or when blood or mucus is noted in loose stools.

defecation

the final act of digestion by which the solid, semisolid, or liquid waste is expelled by the body -time ranges from 2 to 3 /week to several times per day -when waste moves into the rectum, the nerves are stimulated so that the person becomes aware of the urge to defecate. -characteristics vary: diet, age, illness & meds

impaction

the presence of a hard fecal mass in the rectum or colon that the pt is unable to expel. -result of unresolved constipation; inability to pass stool for several days or longer. -continuous oozing of liquid stool w/ no normal stool. -loss of appetite, nausea, vomiting, distention, cramping, and rectal pain accompany condition. -diagnosis is by digital exam and palpation of fecal mass. -barium increases risk for impaction.

lab testing can help determine

the presence of bleeding, inflammation, or infection. -some test performed are: stool cultures, stools for occult blood, and a blood draw to test serum electrolytes.

ileostomy

the surgical creation of an artificial excretory opening between the ileum, at the end of the small intestine, and the outside of the abdominal wall -temporary or permanent and may involve removal of all or part of the colon. -stool is frequent and liquid and cannot be regulated. -drainage contains digestive enzymes; damage the skin where appliance continuously. -few bacteria present; no odor.

upper GI series assists in the diagnosis of

ulcers, tumors, hiatal hernias, scarring, blockage, and abnormalities of the GI tissues

colonoscopy

used to identify early signs of colorectal cancer & diagnose unexplained changes in bowel habits, abdominal pain, bleeding from anus, and weight loss. -clear liquid diet 1 to 3 days (no red or purple dye), laxative or enema night before procedure -lies on left side on exam table, light sedative and pain med given IV to promote relaxation. -long, flexible lighted tube with camera inserted thru rectum.

Permanent colostomy

usually involves the loss of part of the colon, most commonly the rectum; the end of the remaining portion of the colon is brought out to the abdominal wall to form the stoma.

endoscopy

visual examination of a body cavity or canal using a specialized lighted instrument called an endoscope (has a camera) -driving not permitted for 12 hrs after procedure -RN responsible for checking for return of the gag reflex before allowing the client to eat or drink after the procedure.

lavage

washing out an organ, irrigation.

digital exam, manipulation, and removal of fecal impaction are

within scope of practice for nurses although some agencies may require an order from a PCP.