Chapter 18: Fecal Elimination

Altered Bowel Function: Fecal Impaction

mass or collection of hardened feces in the folds of the rectum. It is caused by prolonged retention and accumulation of fecal material; unrelieved constipation and poor defacation habits Pt may experience passage of diarrhea and no normal stool -The liquid portion of the feces seeps out around the impacted mass

Altered Bowel Function: Flatulence

presence of excessive amount of gas or air in the stomach or intestines that leads to stretching of the intestines and in some cases, mild to moderate pain May be caused by: -conditions that slow GI motility (pain with the use of narcotics) -abdominal surgery --> during abdominal surgery, the stomach is pumped full of air, so things are more pronounced during surgery -Dietary intake --> chewing gum --> cabbage, onions

Defacation

aka bowel movement The elimination of the feces from the anus and rectum

Feces

aka: Stool Excreted waste products

Flatus

intestinal gas

What are the characteristics of normal feces?

1. Frequency - 1-2/day to 1 every 2-3 days 2. Color -Brown -due to presence of stercobilin and urobilin derived from bilirubin 3. Consistency -Soft, formed 4. Shape -Cylindrical 5. Amount -100-400g/day 6. Odor -Aromatic

What are the characteristics of abnormal feces?

1. Frequency - greater than 3/day (diarrhea) - less than 1 every 3 days (constipation) 2. Color -Black Tarry = upper GI bleed or taking iron -Red = lower GI bleed; rectal bleed; cancer -Clay colored = Bile obstruction -Orange or green = infection 3. Consistency -Loose, liquid -Hard -High mucous content --> irritable bowel --> crohn's 4. Shape -Narrow -Pencil-shaped: obstruction 5. Amount - less than 100g/day -greater than 400g/day 6. Odor -pungent; foul odor -C. diff

Feces are what percentage water?

75% -The more water you drink, the better formed and easier to excrete your feces

Altered Bowel Function: Constipation

< 3 stools per week Feces is hard, dry and formed. It causes straining, abdominal pain and pressure May result from: -decreased fiber intake -decreased fluid intake -decrease activity/immobility -irregular habits -lack of privacy -chronic use of laxatives: bowel cant move on their own because they;ve become dependent on taking the laxatives -medications -neurological conditions -lack of privacy To reverse this causes of constipation, do the opposite, includeing initiating a bowel management program where a predictable schedule trains the bowel

Clients should be taught that repeatedly ignoring the sensation of needing to defacate could result in which of the following?

Constipation

What symptoms may an older adult with constipation and with fecal impaction show?

Delirium -Sudden change in mental status

What factors influence defacation?

Diet and fluid intake -Fiber: fresh fruits and vegetables with skins and outer coverings intact, nuts, whole grain -Diary: milk can prevent defacation -Fluid: fluid intake is directly related to stool consistency -Storage time in the large intestine affects stool consistency --> *The longer food sits in your intestine, the harder the feces gets* -Flatus (passing gas) can stimulate bowel to move --> flatus stimulating foods include cabbage, cauliflowers, bananas, apples, prune Activity and Exercise -Promotes muscle tone and stimulate peristalsis -Strong abdominal and pelvic muscles increa intraabdominal pressure during defacation Psychological Factors -Anxiety increase peristalsis (nervous poops) -Depression decreases peristalsis (depression slows everything down) Pathological condition -head injuries can decrease sensory stimulation for defaction Lifestyle/Habit The need for privacy or regular time for defacation contributes to maintaining a pattern of elimination -Hospitalization alters habits pt needs privacy to poop -Culturally inhibited -Gastrocolic reflex greates after breakfast --> reflex causes everything to sleep at night and it wakes up after breakfast and then one needs to poop -ignoring defacation reflexes can lead to constipation Medications -Laxatives and cathartics soften stool and promote peristalsis --> Chronic use causes loss of muscle tone, dehydration and electrolyte depletion -Narcotics : decreases peristalsis and results in constipation --> *Always offer laxatives together with narcotics (opiod induced constipation)* -Medications can change stool color --> Black tarry: iron pills --> White: Antacids Diagnostic procedures -may restrict food/fluid intake for a procedure (colonoscopy) -can require cleansing enema (content must be clear as no food/fluid intake) Anesthesia and Surgery -May cause temporary inactivity of intestinal movement (peristalsis temporarily stops) -It last 24-48 hours --> ileus (pseudoobstruction) -*Anethesia may cause Ileus(temporary halt of peristalsis)* Pain -post surgical pain in combination with narcotics to reduce the pain impedes defacation Age and developmental stage -infants and older adults most susceptible to GI alterations

What are the nursing interventions (treatments) for fecal impaction?

Digital exam of the rectum -hardened mass can often be palpated Oil & cleansing enemas; suppositories Digital Removal

Newborn and infant Bowel Function

First stool is eliminated 1-2 days after birth *Meconium*: first stool is dark green-black, "tarry", sticky, odorless Day 3: stool reflects type of milk in diet -Breast milk: light yellow to gold; soft, uniformed; unobjectionable odor -Formula: dark yellow or tan; slightly more formed; strong somewhat objectionable odor An infant is unable to control bowel elimination Bowel starts changing when they start eating cereal

A client is cheduled for a colonoscopy. The nurse will [provide information the client about which type of enema?

High large volume

Enemas Solutions & Actions

Hypertonic (Fleets): 90-120mL -draws water into the colon Hypotonic (Tap water): 500-1000mL -distends colon; stimulates peristalsis; softens feces so stool can go through easily Isotonic (Saline): 500-1000mL -distends colon; stimulates peristalsis *Soapsuds: 500-1000mL -*Iritates the mucosa; expands mucosa; distends colon* Oil: 90-120mL -Lubricates feces -Lets it slide out easily

Which statement provides evidence that an older adult who is prone to constipation is in need of further teaching?

I need to take a laxative such as Milk of Magnesia if i dont have a BM everyday

Which of the following is most likely to validate that a client is experiencing intestinal bleeding

Semisoft, black colored stools -blood in the upper GI is this color

What are the nursing interventions (treatments) for Diarrhea?

Treat the underlying cause Encourage fluids and small amounts of bland food -BRAT: Bananas, Rice, Apple sauce & Toast Perineal care; watch skin integrity -irritated skin -diaper rash from passing high amounts of liquid stool.

Shapes of poop

Type 1: rabbit droppings Type 2: Bunch of grapes Type 3: Corn on the cob Type 4: Sausage Type 5: Chicken nuggets Type 6: Porrige Type 7: Gravy

Altered Bowel Function: Hemorrhoids

Varicose veins in the rectum Permanent dilation of rectal veins Caused by: -*increased venous pressure r/t straining* -Pregnancy -Decreased dietary fiber --> constipation --> straining -Chronic diarrhea or constipation

What are the nursing interventions (treatments/prevention) of hemorrhoids?

*Avoid straining with BM* -increase fiber, fluid intake, and increase activity (walking) Administer hemorrhoidal agains -suppositories that help with pain Monitor Bleeding -Bright red = hemorrhoids

Altered Bowel Function: Bowel (fecal) Incontinence

*Inability to control passage of feces and gas* via anal sphincter May be caused by any physiological or psychological condition that impairs the anal sphincter function -Nervous system disorder or tumors

Nursing interventions of Ostomies

-Assess stoma for color, moistness, irritation, bleeding -Assess peristomal skin -*Empty ostomy pouch when 1/3 to 1/2 full* --> weight of a full pouch can break the appliance seal --> air can be trapped in an ostomy, one needs to remove the air -*Change colostomy bag when the bowel is least likely to emit stool such as several hours after eating or drinking*

What are the nursing interventions (treatments) of flatulence?

-Limit carbonated drinks, straws, chewing gum -Administer anti-flatulence medication -Increase activity/mobility (*walking helps)* -Place rectal tubes -Administer return flow enemas -Provide naso-gastric tube for decompression

A client with a new stoma who has not had a bowel movement since surgery last week reports feeling nauseous. What is the appropriate nursing action?

After assessing the stoma and surrounding skin, notify the surgeon -this might be a complication of surgery

What psychological factors increase and decrease peristalsis?

Anxiety increased peristalsis (nervous poops) Depression decreases peristalsis (slows everything down)

A student nurse is assigned to care for a client with a sigmoidostomy. The student will assess which ostomy site?

Area 5

Nursing Assessment of Bowel Function

Assess the abdomen -Listen to abdominal sounds What is the patient's usual pattern of bowel elimination What are the usual characteristics of patient's stool? Which aids , if any, does the pt routinely use for defacation? When was the patient's last bowel movement (LBM) Assess dietary habits -adequacy of fiber and water Does pt ignore urge to defacate? Factors & conditions that alter mobility pattern Fear of pain on defacation? Lifestyle changes? Conditions of teeth? -Lose of teeth changes food consistency and thus bowel also changes with new consistency

Which nursing diagnosis is/are most applicable to a client with fecal incontinence? Select all that applies

Bowel incontinence Disturbed body image Social Isolation Risk for impaired skin integrity

Bowel Sounds

Bowel sounds are created by passage of air and fluid through the GI tract Listen with diaphragm in all 4 quadrants -normally, you should hear 5-35 sounds/min -Hypoactive = less than 5 sounds/min -Absent = no sounds in 3-5mins

Types of Enemas

Cleansing Enema -cleans out everything out of the intestines before a diagnostic test or surgery, including removal of feces in instances of constipation or impaction Carminative and Return flow Enema -used primarily to expel flatus Retention -introduces oil or medication into the rectum and sigmoid colon -pt retains the oil or medication in these regions

Altered Bowel Function: Diarrhea

Increase in the number of stools and passage of liquid, unformed feces Caused by: -diseases of the colon (Crohn's , ulcerative colitis) -diet -medications (too overuse of laxatives) -anxiety/stress (nervous poops) -Pathology: C-diff (bacterial infection, very contagious)

Which groups are most susceptible to GI alterations?

Infants -Due to immature digestive system -Food passes quickly (lots of dirty diapers -Less digestive enzymes Older Adults -Metabolism slows -Lose teeth; thus they eat diet that is mechanically changed and this could change bowel movement -Decreased gastric secretions

What are the nursing interventions for bowel (fecal) incontinence?

Initiate bowel management program -schedule when to go sit on the toilet Provide fecal collection devices -ex: rectal tube Colostomy

What are the nursing interventions for Ostomies?

Nurse must teach pt self-care management Assist in obtaining stomal appliances and fecal collection devices.

Patient Education to Promote Defacation

Nutrition: -increase intake of fiber and fresh fruits/veggies -dont introduce high fiber foods too quickly as it can cause excessive gas or diarrhea Fluid Intake: -2000 to 3000mL/day -Prune juice promotes bowel elimination --> *doctor order not required to give prune juice* -*Hot fluids, coffee, tea, or fruit juices increases GI motility* Activity and Exercise -Increase daily exercise to maintain normal bowel patterns (strengthens pelvic and abdominal muscles) -encourage isometric exercises Bowel Habits/Timing -Establish regular time for bowel elimination -Ignoring the urge to defacate can lead to constipation Positioning -*sitting or semi-squatting preferred*

What can a nurse offer to stimulate bowel movement if they do not have an order for laxative yet?

Offer foods that causes flatus (passing gas) such as: Bananas, Cauliflower, Prune, Apples

What is the difference between an old stoma and new stoma

Old Stoma: -Pink -Moist New Stoma: -Swollen -Bulging -Red

Adult and Older Adult Bowel Function

Older adults -increase fluids and high fiber foods to prevent hard stool to increase metabolism and peristalsis Weakened pelvic muscle and decreased activity --> constipation Long-term use of laxatives prevents poop from being able to move on its own without the laxative Strength of external sphincter muscles decreases --> decrease sphincter control --> fecal incontinence

Child and Adolescent Bowel Function

Poop resembles adult poop -Color: brown -Consistency: softly formed -Prefer privacy of own bathroom at home -Often delay going because of playing --> can result in constipation

The nurse assesses a client's abdomen several days after abdominal surgery. It is firm, distended and painful to palpate. The client reports feeling "bloated". The nurse consults with the surgeon, who orders and enema. The nurse prepares to give what kind of enema?

Return flow; carminative -removes flatus

Altered Bowel Function: Ostomies

Surgical opening made into the abdominal wall to allow passage of GI contents out of the stoma Requires special maintenance and skin care, dietary regulation and intervention for resulting psychological problems -Self care is important -Need to change out the bag -Keep skin clean

Which goal is the most appropriate for clients with diarrhea related to ingestion of an antibiotic for an upper respiratory infection?

The client will return to his or her previous fecal elimination pattern

End Colostomy

The diseased portion of bowel is remoed and a rectal pouch remains

Ostomy structure and Function

The location of the ostomy determines consistency of the stool Ileostomy -Surgical opening from ileum to the abdominal wall -Feces are liquid Colostomy -Surgical opening from colon (L. Intestines: ascending, descending/sigmoid, transverse) to the abdominal wall -Feces are more formed

The nurse is most likely to report which finding to the primary care provider for a client who has an established colostomy?

The stoma color is a deep red-purple

Toddler and Preschool Bowel Function

They normally have >1 BM/day They are curious about feces Privacy learned early Some control starts at 1.5-2yrs Most children attain daytime bowel control by 2.5 years.