NUR 226 Bowel Elimination

Two-piece pouch

#2 pictured. Must measure the client's stoma to cut the hole to fit. Stay in for 3-5 days. Depending on weather as well.

constipation

Antacids with ALUMINUM will cause..

diarrhea

Antacids with MAGNESIUM will cause..

lower GI motility

Anti-diarrhea medication will...

diarrhea

Antibiotics cause..

Lower GI study

Barium is instilled in the rectum and x-rays are obtained. Patients are advised to take laxatives to help move it out.

Cleansing Enemas

Broad name for enemas used to clean and remove feces from the colon. 3 kinds: Tap water enema Soap Suds Fleets (most common)

Pinworms

Come out of the anus at night to lay their eggs. Clear tape is put over the rectum to catch the pinworms. The tape is removed and sent to the lab for analyzation.

Colace

Common bowel medication. Adds water and fat to lubricate the stool. Helps soften stool (stool softener)

Metamucil

Common bowel medication. High fiber. Will stimulate peristalsis so client will have bowel movement.

Dulcolax

Common bowel medication. Irritant to intensinal mucousa. Will help promote peristalsis.

Emollient/Lubricant

Common bowel medication. Mineral oil that coats the fecal content and help promotes easier passage of stool.

Miralax

Common bowel medication. Saline-osmotic. Draws water into the intestine to soften stool.

Prevention/Treatment of diarrhea

Diarrhea can be caused by a viral infection, bacterial infection, or a reaction to a medication. Food poisoning can also cause this. Follow CDC food safety guidelines (Hand washing is important! Food is prepared safely. Unpasteurized food or raw seafood/eggs can cause illness) Avoid certain foods-raw seafood and uncooked eggs Hand washing Travel precautions (drinking contaminated water from other countries) Treatment: Treat the cause of diarrhea! Always start with oral rehydration fluids like gatorade. May need IV fluids. Skin care to prevent skin breakdown. Monitor electrolytes (sodium, potassium, and chloride levels) Medications: -Loperamide (Immodium), slow downs passage of stool. -Bismuth(Pepto-bismol) antimicrobial effects

Colostomy irrigation

Done to achieve fecal continence and control. NEVER use a enema set. Use a cone shaped irrigation set. Promotes the regular evacuation of stool. Works with only some ostomys, not all.

Preventing & Treating Constipation

Educate the client on the important of a routine. Encourage fiber intake. Encourage fluid intake Encourage ambulation if possible. If patient is on bedrest, increase fluids, fiber intake, and maybe even a stool softener. Laxative misuse will lead to constipation as well. (Fluids, exercise, fibers) Neurological conditions like people with spinal injuries will need to develop a bowel regimen because they will have life-long bowel issues.

Sterile technique is unnecessary. However, wear gloves. Must lubricate the tip. Explain the procedure. *Client must be positioned to the left side.* Know the length of time necessary to retain the solution before defection. *Large volume enemas are given slowly, over 5-10 minutes. Ask patient to hold fluid in for 10-15 min.* *Ask client to hold fleets for 15-20 min (low volume)* It can hard for clients to hold onto the enema, especially older clients.

Enema administration?

2-3 L

How much water should someone drink a day to prevent constipation?

Timing: Try toileting the client around the same time of their normal bowel schedule everyday. Positioning: If a patient can ambulate, get them up! it is much harder to promote bowel movement if they are laying down on a bedpan. Privacy: is important. Give pt enough privacy in the bathroom if they can. Pull the curtain, bring spray into the room, make it comfortable for them. Nutrition: Adequate fluid intake is important to promote movement of bowels (2-3L or 2000-3000 mL). Fiber, fruits, and bulk in the stool to prevent constipation. Exercise: Helps promote peristalsis. Get them moving if they have the activity order. If they can't ROM exercises can help while they are in bed.

How to promote regular bowel habits?

Digital removal of stool

If fecal impaction is suspected. Physician order is needed. Last resort if enema does not work. *Stimulates vagus nerve which decreases HR.* Can develop bradychardia Bowel routine for spinal chord (paraplegia) clients

Black stools, nausea, vomiting, diarrhea (less common), and abdominal cramps

Iron causes...

Upper GI study

Kind of barium study taken by mouth. Patient is advised to drink plenty of liquids the next day to promote excretion.

Fleets enema

Kind of cleansing enema. Most common type. Hypertonic enema. Draws water into the colon and stimulates peristalsis. 70-130 ml is usual amount. Much smaller than tap water or soap suds enema.

Tap water enema

Kind of cleansing enema. Plain water (usually luke-warm) inserted into rectum. Descends the colon and increases peristaliss. 500 ml - 1000 ml. Most common is between 500-700 ml.

Soap suds enema

Kind of cleansing enema. Soap irritates the intestinal mucousa and causes increase peristalsis. 500 ml - 1000 ml. Most common is between 500-700 ml.

Retention enemas

Kind of enema that introduces oil or medication into the rectum and sigmoid colon. Two types: Oil enema Medicated enema Client must hold into the bowel for a certain period of time (hence "retention")

Most cleansing

Large volume enemas are...?

Soften stool and promote peristalsis

Laxatives and cathartics will..

One piece pouching system

Must measure the client's stoma to cut the hole to fit. Stay in for 3-5 days. Depending on weather as well.

Increased gastric irritation (GI irritation -> GI bleed) Pt is at risk for bleeding

NSAIDs or aspirin causes...

*Diarrhea is defined as more than three loose stools a day.* Must assess & document: -The frequency -The consistency (watery, semi-formed?) -The color Answer call bells immediately! Remove the cause of diarrhea whenever possible (ex. medication, magnesium antibiotic, etc) Assess for fecal impaction Skin care like barrier cream can be important from preventing skin breakdown. Assess for dehydration in the young (infants and children) and old.

Nursing measures for the patent with diarrhea?

constipation (decreased peristalsis)

Opioids or any narcotic will cause..

GoLYTELY

Oral intestinal lavage given before a diagnostic test (such as colonoscopy or sigmoidoscopy) or bowel surgery. Helps clean bowel of any stool. Works within an hour. Usually takes 4-6 hours for clear return which indicates it has been successful and client can stop drinking it.

Inspection, Auscultation, Percussion, then palpation. Document hypoactive, hyperactive or absent/inaudible bowel sounds.

Order in which a physical assessment for a patient would go?

Wireless capsule endoscopy

Patient swallows video capsule that passes through stomach and small intestine. Video capsule transmits images to a recording device worn by the patient. The small bowel can be visualized in its entirety. Used to screen for small bowel carcinoma, but cannot biopsy the bowel wall or assess for dysplasia.

GI Test considerations

Preperation: NPO/Clear liquids or diet restriction Enemas (will be ordered for use at a certain time and a certain type) Informed consent must be signed. Procedure: Upper GI/barium swallow or barium enema will help with obtainment of scans, but will cause constipation Ultrasounds CT scan or MRI scan Colonoscopy or sigmoidoscopy Post-procedure care Diet restrictions Gag reflex is tested after a pt goes through a colonoscopy or a sigmoidoscopy because they are under sedation. Medications such as laxatives can be used.

What is your usual pattern? Aids for elimination? Any changes in habits or stool? Any problems with bowel elimination? Any problems right now?

Questions to ask for a focuses patient assessment on their bowel habits?

15 min to work effectively.

Small volume (like fleets and retention) must be held for...?

Rectal suppositories

Solid or semi-solid bullet shaped dosage forms. They melt at body temperature, dispersing the medication.

Ostomy care

Teach client to change appliance. (Every 3-5 days) Stoma care and assessment. (Should always be beefy red. May have some bleeding. Initially, stoma will be inflamed, but will shrink as time goes on. Nurses should always check size of stoma each time we measure for the bag. After 6 months, the stoma should be the size it's going to be) Emtpying of appliance. (In the bathroom, over the toilet. If the pt is bedbound, a bedpan can be used.) Explain nutritional impact (odor (asparagus, garlic, onions, egg, fish can cause odor. But parsley and yogurt can help the odor), flatulence, stool character) Attend to order (major concern for client). Drops/tablets can be put into bag to help decrease odor I&O during post-op period usually no output (stool) for first couple of days Discuss change in body image

Constipation

These products cause what? Milk products Cheese Lean meats Eggs

Laxative effect

These products have what kind of effect on the body? Fruit + veggies Chocolate Alcohol Beans Coffee

TRUE! Changes in bowel habits like diarrhea can indicate pathologic conditions like food poisoning, bacterial infection, parasitic infection, tumor, or even a malabsorption issue. Diseases of the colon and rectum can also cause constipation.

True or false? Diarrhea and constipation can be indicative of pathological conditions

Medicated enema

Type of retention enema. provide medications absorbed through the rectal mucusa. Client must hold into the bowel for a certain period of time (hence "retention")

Oil enema

Type of retention enema. lubricates stool for easier passage. Client must hold into the bowel for a certain period of time (hence "retention")

Developmental considerations (specifically older adults). *Older adults are more at risk for decreased motility and decreased peristalsis. They are also more at risk for constipation, incontinence, and fecal impaction.* Daily patterns (Frequency of bowel movements? Morning timing? What position do they prefer [bedpan? or ambulatory to toilet]) Food and Fluid (High fiber diet, and fluid intake of *2-3L of water* will help move stool through colon. Milk products, cheese, lean meats, eggs can make you constipated. *Fruit + veggies, chocolate, alcohol, beans, and coffee all have a laxative effect.* *Onions, cabbage, beans and cauliflower can make a pt gassy, this is something to look for with someone with an ostomy.*) Activity and muscle tone (will help bowel move better, promotes motility of intestine) Lifestyle (work, leisure activities, etc. will have an effect on timing of bowel movements) Psychological variables (anxiety can prevent bowel movements, Pt with depression can lead to constipation) Pathologic conditions (changes in bowel habits like diarrhea can indicate pathologic conditions like food poisoning, bacterial infection, parasitic infection, tumor, or even a malabsorption issue. Diseases of the colon and rectum can also cause constipation. Black tarry stools can indicate iron therapy or a upper GI bleed. Bright red stool is a lower GI bleed) Medications (Iron therapy can turn stools black) Diagnostic studies (Any study that contains barium. A upper GI study [patient drinks barium] or a lower GI study [enema of barium is placed into the rectum]. Barium becomes cement in a clients intestinal track. Patients with a upper GI study are told to drink plenty of fluid to help move it through. Pts in a lower GI study are given laxative. The barium helps doctors visualize the GI tracts to help diagnose any disorders of it) Surgery and anesthesia (Anesthesia will decrease peristalsis. This causes perilytic ileus. This is why pt's are usually NPO after surgey)

Variables influencing bowel elimination?

Black tarry stool can indicate a upper GI bleed or iron therapy.

What does black tarry stool mean? (Melana)

Bleed in lower GI tract

What does red streaked/bright red stool mean?

When there is pathological abdominal pain. Chronic laxative use can lead to chronic constipation.

When should laxatives NOT be used?

These foods can make them gassy!

Why is it important to monitor these foods in a patient with a ostomy bag? Onions Cabbage Beans Cauliflower

Occult blood

blood that cannot be seen in the stool but is positive on a fecal occult blood test. Small sample of stool is spread on developer paper. The developer liquid is dropped into the sample. *Paper will turn blue if blood is present.* If paper does not change, there is no blood. Sometimes nurses will do it, sometimes lab will.

Paralytic Ileus

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

Ilestomy

creation of an artificial opening into the ileum; liquid fecal content. Higher up in the colon.

Colonostomy

forming a new opening (mouth) in the colon. Feces will be more formed. Lower down in the colon.

NG Tube

nasal gastric tube. Used to decompress or drain the stomach. Treatment for paralytic ileus or intestinal obstruction. May help the bowel become unblocked when fluids and gas are removed. Can also drain stomach if a client is having N/S after surgery May be used for "bowel rest" before or after surgery. Salem sump Levin single lumen (pictured) with the blue air vent.

Bowel Diversions

surgery performed to develop a temporary or permanent artificial opening (stoma) in the abdominal wall for stool elimination. May be because of a tumor, bowel disease, etc. ex. Ileostomy: Liquid fecal content from the ileum of small intestines. Colonstomy: Formed feces from the colon Held in place by sutures. Asses the stoma for a beefy red color (normal) and no cyanosis. Also assess peristomal skin (skin around the stoma). Since feces can cause skin breakdown, keep the lookout for irritation.

Stool culture

test to identify microorganisms or parasites present in feces that are causing a infection. Obtained when a patient has a bowel movement. Put a hat on a toilet to catch the stool. Bedpan can also be used to collect stool Will be sent in a sterile specimen container immediately after

Endoscopy

visual examination within a hollow organ. Ex. include a colonoscopy (examination of the colon) and sigmoidoscopy (examination of the sigmoid colon, higher up) A wireless capsule endoscopy is noninvasive and can also be used. *With a colonoscopy and sigmoidoscopy, the gag reflex must be tested once the patient wakes up* A bowel prep must be assigned to clean up the bowels of stool before a colon or sigmoidoscopy. Client will be on clear liquids and NPO after midnight before the procedure.