Chapter 30 - Bowel Elimination Care

Which of the following would be the most accurate statement about digestion and elimination?

All individuals have at least one bowel movement daily.

Several medications have GI side effects and may lead to diarrhea or constipation. Indicate which of the following medications would be most likely to cause constipation in the patient.

Amphojel; Meperidine; Amoxicillin; Imodium AD

Alternate Bowel Elimination:

Colostomy: Stool consistency based on location of colostomy Ileostomy: Kock pouch or continent ostomy ostomy, is the opening that brings the outside of the body through the abdominal wall; stoma, is the mouth of the ostomy,

Factors Contributing to Constipation:

Decreased activity level; Changes in food intake; Decreased fluid intake; Medication side effects; Surgery; Pregnancy; Depression; Aging; Laxative overuse; Nerve damage or impairment

A female patient is recovering from abdominal surgery 2 days ago. Her abdomen is distended and firm, and she complains of moderate to severe cramping and abdominal discomfort. As of yet, she has been unable to pass much flatus rectally. Which type of enema would be most helpful to this patient?

Harris flush enema

Data Collection:

How often do your bowels normally move?; Do you have any current problems, such as diarrhea or constipation, and how long has it been occurring?; What is the normal number of stools you pass per day?; What is the normal color of your stools?; What is the normal consistency of your stools?; Is your stool formed or unformed?; Does abdominal cramping occur with or before a bowel movement?; Any anal burning or itching?; Is there pain with defecation?

Nursing Interventions: Constipation

Increase activity; Improve fluid and fiber intake; Provide privacy; Assist with positioning; Administer medications; Administer Enemas

Nursing Interventions: Fecal Impaction

Instill an oil retention enema. Review the facility's policy and procedures to determine which personnel are permitted to perform the procedure. Review patient's medical record.

Factors Contributing to Diarrhea:

Lactose Intolerance: unable to digest lactose Medications side effects: when the bodys normal flora is decreased (antibiotics), can lead to c.diff Anxiety/Stress: can cause increased peristalsis/intestinal mucus production Diverticulosis: muscular wall of the colon weakens and separates Inflammatory process: causes the mucosal lining to become edematous and increase mucus production Food allergies: causes inflammation and edema, which increases peristalsis, decreasing transit time, inhibiting absorption, resulting in diarrhea.

Which of the following factors is most likely to result in diarrhea?

Loss of intestinal normal flora

Nursing Interventions: Ostomies

Measuring a stoma; Selecting an ostomy appliance; Emptying the appliance; Providing skin care; Providing emotional support

Nursing Interventions: Diarrhea

Modify food intake and increase fluids; clear liquid diet for 24 hrs Administer medications Provide perineal care; prevent skin breakdown or irritation

Key Points:

Normal bowel elimination changes through the life span. Some adults may have one to two bowel movements daily, while others may go several days between movements. The urge to defecate commonly occurs 30 minutes to an hour after eating. Typical stools are soft, formed, light yellowish-brown to dark brown, slightly odiferous, and in a slightly curved shape. Abnormal characteristics include a variety of colors; foul odors; and a hard, dry consistency or a very loose to watery consistency. Various colors of bowel movement can be very significant. It may simply be due to foods the patient has eaten or can be indications of bleeding in various locations in the intestines. When performing a focused assessment of the bowels, ask about frequency, normal number of stools per day, normal color and consistency of stools, and if constipation or diarrhea is a current problem. Then auscultate bowel sounds and palpate the abdomen for firmness, distention, and pain. Constipation is the term for less frequent, hard, formed stools that are difficult to expel. Lack of fiber-rich foods and adequate fluids are often contributing factors, as well as a decrease in activity level, certain medicines and over-the-counter drugs, surgery, pregnancy, depression, aging, and nerve impairments. Nursing interventions for constipation include increasing activity, increasing fiber and fluid intake, providing privacy, and assisting with positioning to help facilitate a bowel movement. In addition, the health-care provider may order medications and enemas if necessary. Enemas are ordered to cleanse the bowel (tap water, normal saline, soapsuds, sodium phosphate, high enema, or milk and molasses), soften feces (oil retention), deliver medications (steroids or Kayexelate), and relieve gas (Harris flush, return flow, or siphon). Enemas should not be given to patients with rectal conditions, excessive bleeding potential, and certain heart conditions. Complications of enemas include a vagal response, which causes a slowed heartbeat and other symptoms, and perforation of the colon. Fecal impaction occurs when a very hard mass of stool blocks movement of feces through the intestines. Nursing interventions for this include administering an oil retention enema to soften it and then digitally removing the hard mass. Diarrhea is defined as loose or water stools occurring three or more times in a day that may be accompanied by cramping. It may be due to lactose intolerance, intestinal infections, certain medications, anxiety, stress, diverticulosis, inflammation and infection of the intestines, and food allergies. Nursing interventions for diarrhea include modifying food and fluid intake, providing probiotics, and administering prescribed medications. Fecal incontinence is the inability to control the bowels. Nursing interventions for this include treating the underlying cause if due to diarrhea, administering medications as ordered, bowel training, providing skin care, and providing emotional support. Stool specimens may be ordered to test for infection, parasites and their eggs, and hidden blood. Patients bringing in a stool specimen to be tested for blood must avoid certain substances for 48 hours prior to the testing. Alternative bowel elimination is necessary as a result of tumors, cancer, damage to the intestines, and intestinal diseases such as Crohn's and ulcerative colitis. If part of the colon is used to create a stoma, it is called a colostomy. If the last portion of the small intestine is used, it is called an ileostomy. A continent ileostomy is called a Kock pouch. The normal healthy stoma is pink to red in color, shiny, and moist. The skin around it (peristomal skin) should be free of irritation, excoriation, and erythema. Nurses may be specially trained to care for ostomies (enterostomal therapists), but all nurses must know how to empty, clean, and change an ostomy appliance. Colostomy irrigation is done to relieve constipation and for bowel training when the stoma is in the descending or sigmoid colon. The colon may be trained to empty once per day with an irrigation so the patient doesn't have to wear a bag all day.

Bowel Sounds and Their Significance:

Normal: (sounds) Soft gurgles, irregular clicks; (significance) Between 5 and 30 per minute Indicates normal bowel function Hypoactive: (sounds) Fewer than 5 per minute (significance) May indicate constipation Hyperactive: (sounds) More than 30 per minute or continuous; (significance) May be heard when the patient has diarrhea Borborygmi: (sounds) Excessively loud gurgling, May be high-pitched and tinkling in one quadrant and absent or decreased in the lower left quadrant; (significance) May indicate hunger or, if not hungry, can indicate bowel obstruction Avoid palpating the abdomen until after you have assessed the bowel sounds because palpation may stimulate bowel sounds that were not there naturally.

Stool Characteristics:

Normal: soft, formed consistency; longed curved shape, cylinderical; yellow in infants, light brown to dark brown in other; absence of pus, mucous fat; absence of parasites; slight odor Abnormal: semiliquid/liquids, watery, unformed, very hard/dry; balls, clumps, or broken chunks, flat or ribbon-like; bight red blood, black, coffee grounds appearance, pale, white, gray, or clay color; presence of pus, excessive mucus, foamy or floating in water; presence of worms or eggs; foul odor, strongly smelling odiferous, bloody or old blood smell, metallic smell

What of the following would be the best enema to administer to a patient before digital removal of an impaction?

Oil retention enema

Which of the following signs and symptoms may be an indication of vagal stimulation during the digital removal of an impaction?

Pulse rate of 42 beats per minute; Complaint of difficulty breathing; Moist skin; Complaint of feeling faint

Contraindications of Enemas:

Rectal surgery; Severe bleeding hemorrhoids; Ulcerative colitis or Crohn's disease; Rectal fissure; Rectal cancer; Excessive bleeding potential due to disease or medication; Certain heart conditions

Which of the following assessment data might indicate the patient is having difficulty accepting his or her new colostomy?

Refuses to attempt care, and tells you to "just do it"

The patient is to receive a cleansing enema for relief of constipation. Which of the following factors must be assessed prior to administration of the enema?

Type of solution to administer; Date of last bowel movement; Assessment of bowel sounds

Type of Enemas: Hypertonic Sodium Phosphate

Volume for Adults: 120 mL Purpose: Cleansing Mechanism of Action: Hypertonic; pulls fluid from interstitial spaces into the colon to soften the stool and increase peristalsis Nursing Considerations: Normally used only for adults.

Type of Enemas: Oil Retention

Volume for Adults: 120 mL Purpose: Softens hard stool (impaction) Mechanism of Action: Lubricates and softens hard stool mass, making it easier to remove Nursing Considerations: Normally used only for adults. Instill the enema 1 hour before removing an impaction.

Type of Enemas: Soapsuds (use castile soap only)

Volume for Adults: 5 mL of castile soap added to 1,000 mL of tap water or normal saline Purpose: Cleansing Mechanism of Action: Works by distending the colon and by irritating the walls of the colon, which further increases peristalsis Nursing Considerations: Safety: Mix castile soap in saline, not tap water, for infants, children, or patients with congestive heart failure.

Type of Enemas: High Enema

Volume for Adults: 500-1,000 mL Purpose: Cleanse higher up in the colon beyond the sigmoid Mechanism of Action: Distends the colon and moves up into the descending and transverse colon with position changes Nursing Considerations: Administer about half the fluid of a tap water or saline enema with patient in left Sim's position. Then turn patient to the back, then to the right side, and finish administering the fluid.

Type of Enemas: Tap Water

Volume for Adults: 500-1,000 mL Purpose: Cleansing Mechanism of Action: Hypotonic; allows fluid to move into interstitial fluid as well as be in the colon; distends colon and increases peristalsis Nursing Considerations: Hypotonic. Safety: Do NOT use for infants, children, or patients with congestive heart failure; Could result in fluid volume overload; Never give more than 3,000 mL total (i.e., three 1,000 mL enemas)

Type of Enemas: Normal Saline (NS) (0.9%)

Volume for Adults: 500-1,000 mL Purpose: Cleansing Mechanism of Action: Isotonic; adds fluid to the colon that does not move elsewhere; distends colon and increases peristalsis Nursing Considerations: Isotonic. Safe for use in children and congestive heart failure patients. Infants: use 50-150 mL / Toddlers: use 150-350 mL / School-age children: use 350-500 mL

Type of Enemas: Return Flow (also called Harris Flush and siphon enema)

Volume for Adults: 500-1000 mL Purpose: Remove flatus Mechanism of Action: Raising and lowering the enema container causes flatus to siphon back into the enema container Nursing Considerations: Prepare tap water or saline enema and administer 100-200 mL of solution and then lower the container below the level of the rectum for flatus to siphon out; repeat until no bubbles come back into the enema container.

Type of Enemas: Milk and Molasses

Volume for Adults: As ordered Purpose: Cleansing Mechanism of Action: Hypertonic solution that pulls fluid into the colon and softens hard stool Nursing Considerations: Milk and molasses must be heated together to mix well, and then must be cooled to body temperature before administration; effective but messy.

Type of Enemas: Medicated Enemas

Volume for Adults: As ordered Purpose: Exchange of substances and decreases inflammation Mechanism of Action: Steroid enemas decrease inflammation in the walls of the rectum and colon; Kayexelate enema pulls potassium from the body tissues and binds with it; excess potassium leaves the body when the enema is expelled Nursing Considerations: Must be retained for a specified period of time. May require a tube with a balloon to be inserted in the rectum to hold the medication in place.

Fecal Impaction:

a mass of dry, hard stool that remains packed in the rectum and cannot be expelled

Complications of Enemas: Perforation of Intestinal Wall

always be gentle when inserting an enema tube. NEVER force or insert the tube further that 4-6 inches. direct the tip toward the umbilicus to follow the natural sigmoid colon. If not careful can perforate or go through the intestinal wall, which can introduce bacteria into the sterile peritoneal cavity, bleeding or hemorrhage.

Focused Assessment:

performed to determine the objective signs. 1. Assess the shape of abdomen (round, flat, but not distended or inflated) 2. Auscultate the bowel sounds (listen to all 4 quadrants) Safety: An absence of bowel sounds indicates a problem and should always be reported to the health-care provider.

Tenesmus:

persistent desire to empty the bowl when no feces is present, causes straining

Normal Bowel Elimination:

process of elimination is known as defecation. should occur at least every 3 days to prevent constipation, hard stools that are difficult to pass. elimination commonly occurs 30 min-1hr after eating. It can cause constipation of ignore the urge

Assessment of Bowel Elimination:

should be performed and documented every shift: Color, Amount, Consistency, Usual shape, Usual odor

Complications of Enemas: Vagal Response

there is a possibility of stimulating the vagus nerve, which innervates not only the GI tract, but also the heart and bronchioles. Safety: When the vagus nerve is stimulated, it can drop the HR as low as 30-40 bpm and cause constriction of the bronchioles of the lungs. A HR of 30 -40 bpm is insufficient to support adequate BP and circulation for longer than a few minutes If the pt complains or exhibits any of these symptoms, you should immediately STOP the enema Signs/Symptoms of Vagus Nerve Stimulation: Chest pain, heaviness, pressure, shortness of breath, dizziness, nausea; pallor, clammy skin, pulse under 60 bpm

Steatorrhea:

undigested fat in the feces; frothy, foul-smelling fecal matter

Nursing Interventions: Fecal Incontinence

where the voluntary control is lost Provide bowel training; regularity Promote skin integrity; avoid skin breakdown Provide emotional support.