Bowel Elimination(1,2,4,8)

Patient Centered Outcomes-Skin Integrity?

have pt verbalize how to maintain skin integrity

Patient Centered Outcomes-Establish Bowel Elimination?

pt passes stool

Patient Centered Outcomes-verbalize significance of changes in bowel elimination?

pt verbalizes significance of changes in bowel elimination

Patient Centered Outcomes-Identify relationship of food, fluid, activity to bowel elimination?

pt verbalizes the relationship of food, fluid, activity to bowel elimination

Stomach

The stomach is a hollow, J-shaped, muscular organ located in the left upper portion of the abdomen. The stomach stores food during eating, secretes digestive fluids, churns food to aid in digestion, and pushes the partially digested food, called chyme, into the small intestine. The pyloric sphincter, a muscular ring that regulates the size of the opening at the end of the stomach, controls the movement of chyme from the stomach into the small intestine.

Small Intestine

The small intestine is about 20 feet (6 m) long and about 1 inch (2.2 cm) wide. The small intestine is made up of three parts: the first is the duodenum, the middle section is the jejunum, and the distal section that connects with the large intestine is the ileum. The small intestine secretes enzymes that digest proteins and carbohydrates. Digestive juices from the liver and pancreas enter the small intestine through a small opening in the duodenum. The small intestine is responsible for digestion of food and absorption of nutrients into the bloodstream.

FOCUS ON THE OLDER ADULT NURSING STRATEGIES TO ADDRESS AGE-RELATED CHANGES AFFECTING BOWEL ELIMINATION

Age-related Changes Slowing of gastrointestinal motility with increased stomach-emptying time Nursing Strategies 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. Age-related Changes Decreased muscle tone/incontinence Nursing Strategies 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. Age-related Changes Weakening of intestinal walls with greater incidence of diverticulitis Nursing Strategies Encourage a high-fiber diet and adequate fluid intake. Teach patients not to ignore the urge to have a bowel movement. Encourage regular exercise.

Developmental Considerations-Toddler

Between the ages of 18 and 24 months, the nerve fibers innervating the internal and external anal sphincters become fully developed, at which point voluntary control of defecation becomes possible. Voluntary defecation requires intact muscular, sensory, and nervous structures. Successful bowel training also includes awareness by the toddler of the need to defecate, the ability to communicate this need, the wish to please the significant person involved in bowel training, and praise and reinforcement for the toddler's successful behavior. Daytime bowel control is normally attained by 30 months of age, but the age varies with each child. Help parents to understand that physiologic maturity is the first priority for successful bowel training. Discourage the use of punishment or shame for a lack of readiness to become toilet-trained or for elimination accidents. Toddlers who are toilet-trained often regress and experience soiling when hospitalized; scolding or acting disgusted only reinforces this behavior. Use a constructive approach by seeking the underlying cause.

Developmental Considerations-Older Adult

Constipation is often a chronic problem for older adults. Diarrhea, fecal impaction (prolonged retention or an accumulation of fecal material that forms a hardened mass in the rectum), or fecal incontinence (involuntary or inappropriate passing of stool or flatus) can also result from physiologic or lifestyle changes.

Defecation

Defecation refers to 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. The rectum becomes distended by the fecal mass, the primary stimulus for the defecation reflex. Rectal distention leads to an increase in intrarectal pressure, causing the muscles to stretch and thereby stimulating the defecation reflex and subsequently the urge to eliminate. The external anal sphincter, which is under voluntary control, is constricted or relaxed at will. If the urge to defecate is ignored, defecation often can be delayed voluntarily. During the act of defecation, several additional muscles aid in the process. Voluntary contraction of the muscles of the abdominal wall by holding one's breath, contracting the diaphragm, and closing the glottis increases intra-abdominal pressure up to four or five times the normal pressure, which helps expel feces. Simultaneously, the muscles on the pelvic floor contract and aid in expulsion of the fecal mass. Defecation is eased by flexing the thigh muscles, which increases abdominal pressure, and by the sitting position, which increases downward pressure on the rectum. When a person bears down to defecate, the increased pressures in the abdominal and thoracic cavities result in a decreased blood flow to the atria and ventricles, thus temporarily lowering cardiac output. Once bearing down ceases, the pressure is lessened, and a larger than normal amount of blood returns to the heart. This act may dangerously elevate the blood pressure in a person with hypertension. Therefore, this technique of bearing down, termed the Valsalva maneuver (forcible exhalation against a closed glottis, resulting in increased intrathoracic pressure), may be contraindicated in people with cardiovascular problems and other illnesses. The act of defecation is usually painless. If the bowels move at regular intervals and the stools are formed and soft, functional problems involving frequency of elimination seldom occur. Many people become concerned if they do not have a daily bowel movement. However, normal elimination patterns can vary widely among people. Although many adults pass one stool each day, other healthy people have more frequent or less frequent bowel movements. Some people have a bowel movement two or three times a week; others, two or three times a day.

Patient Centered Outcomes

Evaluating The nurse evaluates the effectiveness of the plan of care to promote regular bowel elimination by checking to see if the patient has met the individualized patient outcomes specified in the plan. Nursing care is considered effective if the patient expresses satisfaction with regular pattern of defecation and the ability to pass a soft, formed stool comfortably without the use of medications or laxatives. The plan of care is most successful when the patient is able to accomplish the following: Verbalize the relationships among bowel elimination and nutrition, fluid intake, exercise, and stress management. Develop a plan to modify any factors that contribute to current bowel problems or that might adversely affect bowel functioning in the future.

Patient Centered Outcomes-behaviors required for ostomy care

Explain the reason for bowel diversion and the rationale for treatment. Demonstrate self-care behaviors that effectively manage the ostomy. Describe follow-up care and existing support resources. Report where supplies may be obtained in the community. Verbalize related fears and concerns. Demonstrate a positive body image

Developmental Considerations-School-Aged Child, Adolescent, and Adult

From childhood into adulthood, defecation patterns vary in quantity, frequency, and rhythmicity. Many people worry needlessly about normal stool characteristics or bowel habits; others may not understand the significance of changes in bowel habits. 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.

Bowel Elimination as the Problem-

Nursing Diagnoses: Bowel Incontinence Related Factors: Dietary habits General decline in muscle tone Laxative abuse Rectal sphincter abnormality Cognitive impairment Sample Defining Characteristics: Involuntary passage of stool (stool characteristics vary) "I'm sorry, I couldn't get into the bathroom (or onto the bedpan) quickly enough." "It came so fast I couldn't hold it back." Constant dribbling of soft stool

Bowel Elimination as the Problem-Constipation

Nursing Diagnoses: Constipation Related 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 Sample Defining Characteristics: "I feel bloated and know I have to move my bowels but I can't." "Whenever I'm constipated I feel lethargic and lose my appetite." 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

Bowel Elimination as the Problem-Diarrhea

Nursing Diagnoses: Diarrhea Related Factors: Adverse effects of pharmaceutical agents Abuse of laxatives Emotional stress Intestinal infection Colon disease and other diseases Radiation Sample Defining Characteristics: At least three loose liquid stools per day, increased frequency Urgency Reports of abdominal pain and/or cramping Hyperactive bowel sounds

Bowel Elimination as the Etiology

Problems of bowel elimination may also affect other areas of human functioning. In the nursing diagnoses that follow, problems of bowel elimination are the etiology for other problems: Delayed Growth and Development related to child's inability to attain bowel control secondary to inconsistency and lack of adequate parental knowledge 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

Nervous System Control

The autonomic nervous system innervates the muscles of the colon. The parasympathetic nervous system stimulates movement, while the sympathetic system inhibits movement. Contractions of the circular and longitudinal muscles of the intestine, peristalsis (involuntary, progressive, wave-like movement of the musculature of the gastrointestinal tract), 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 in most people, propelling the fecal mass forward. This movement is different from the frequent peristaltic rushes that occur in the small intestine. Mass peristalsis often occurs after food has been ingested, accounting for the urge to defecate that often occurs after meals. Timing nursing interventions to evacuate bowel contents with this natural urge to defecate is helpful. One-third to one-half of ingested food waste is normally excreted in the stool within 24 hours, and the remainder within the next 24 to 48 hours. After passing through the sigmoid colon, the waste products enter the rectum, where they are stopped from exiting by the anal sphincters. The internal sphincter in the anal canal and the external sphincter at the anus control the discharge of feces and flatus (intestinal gas)he internal sphincter consists of involuntary smooth muscle tissue that is innervated by the autonomic nervous system. Motor impulses are carried by the sympathetic system (thoracolumbar) and inhibitory impulses by the parasympathetic system (craniosacral). These two divisions of the autonomic nervous system function antagonistically in a dynamic equilibrium. The external sphincter at the anus has striated muscle tissue and is under voluntary control. The levator ani muscle reinforces the action of the external sphincter and is controlled voluntarily.

Large Intestine

The connection between the ileum of the small intestine and the large intestine is the ileocecal, or ileocolic valve. This valve normally prevents contents from entering the large intestine prematurely and prevents waste products from returning to the small intestine. The large intestine, the primary organ of bowel elimination, is the lower, or distal, part of the gastrointestinal tract. The large intestine, also known as the colon, extends from the ileocecal valve to the anus. The colon in adults is about 5 feet (1.5 m) long, but variations in length are normal. Width also varies; at its narrowest point, the colon is about 1 inch (2.5 cm) wide; at its widest point, it is about 3 inches (7.5 cm). The diameter of the colon decreases from the cecum to the anus. From the cecum, the first part of the large intestine, the digestive contents enter the colon, which consists of several segments. The ascending colon extends from the cecum upward toward the liver, where it turns to cross the abdomen. This turn is called the hepatic flexure. Upon turning, this portion of the colon becomes the transverse colon, crossing the abdomen from right to left. The colon then turns at the splenic flexure to become the descending colon. The descending colon passes down the left side of the body to the sigmoid, or pelvic, colon. The sigmoid colon contains feces (intestinal waste products), solid waste products that have reached the distal end of the colon and are ready for excretion. Once excreted, feces are called stool. The sigmoid colon empties into the rectum, the last part of the large intestine. The rectum is about 12 cm (5 inches) long, 2.5 cm (1 inch) of which is the anal canal. In the rectum, three transverse folds of tissue are present that may help to hold the fecal material in the rectum temporarily. Vertical folds also are present, each of which contains an artery and a vein. If the veins become abnormally distended, hemorrhoids occur. The rectum is empty except immediately before and during defecation (emptying of the intestinal tract; synonym for bowel movement). Feces are excreted from the rectum through the anal canal, which is approximately 2.5 to 3.8 cm (1-1.5 inches) long, and out an opening called the anus. Functions of the large intestine include the absorption of water, the formation of feces, and 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. The products of digestion, chyme, move from the small intestine, passing through the ileocecal valve, and enter the cecum. Approximately 1,500 mL of chyme enters the large intestine daily. Its contents are liquid or watery. While passing through the large intestine, most water is absorbed. About 800 to 1,000 mL of liquid is absorbed daily by the intestinal tract, allowing for the formed, semisolid consistency of the normal stool. When absorption does not occur properly, such as when the waste products pass through the large intestine rapidly, the stool is soft and watery. Conversely, if the stool remains in the large intestine too long, or if too much water is absorbed, the stool becomes dry and hard.

Developmental Considerations-Infant

The stool characteristics depend on whether the infant is being fed breast milk or formula. Breast milk is easier for the infant's intestines to break down and absorb. Breastfed babies have more frequent stools; the stools are yellow to golden and loose, and usually have little odor. The stools of formula-fed infants vary from yellow to brown, are paste-like in consistency, and have a stronger odor because of the decomposition of protein. The stools of both breastfed and formula-fed infants may have curds and mucus. Infants have no voluntary control over bowel elimination. The number of stools infants pass varies greatly. For example, breastfed infants can pass from 2 to 10 stools daily, whereas bottle-fed infants typically pass 1 or 2 stools daily. At the age of 1 year, all infants commonly pass one or two stools a day. Parents may mistakenly interpret the infant's liquid stool as diarrhea (passage of liquid and unformed stools, passage of more than three loose stools a day). Loose stools may be related to overfeeding. Diarrhea is an increase in frequency, and a change in consistency, of stools. True diarrhea requires evaluation. Some children have bowel movements only once every 2 to 3 days. Teach parents that as long as the stools are soft, the child is not constipated. If constipation (dry, hard stool; persistently difficult passage of stool; and/or the incomplete passage of stool) occurs, dietary manipulation is the initial treatment. The consistent use of suppositories and laxatives is discouraged. Infants with persistent constipation require evaluation for structural defects.

Bowel Elimination as the Problem

When the analysis of assessment data points to a bowel elimination problem that can be prevented or resolved by independent nursing intervention, a nursing diagnosis is developed. If alterations in bowel elimination require new self-care behaviors—for example, colostomy management—Deficient Knowledge may be an appropriate nursing diagnosis.