CNA Unit 9

Problems with Bowel Elimination

- Diarrhea: frequent loose or liquid stool - Constipation: infrequent or difficult passage of dry, hard stool - Fecal impaction: can occur if constipation not relieved. A mass of hard, dry stool that becomes lodged in the colon or rectum - Hemorrhoids: swelling and inflammation of veins in the anus and lower rectum. They can be painful, itch or bleed. - Notify the charge nurse if a resident has any of these bowel elimination problems.

Equipment used in elimination and bowel and bladder programs:

- Toilet - Bedside commode (portable toilet) - Bedpan - Urinals, use for male urination

Nursing assistant responsibilities with a bowel and bladder program

- check individual's care plan - record intake and output - positioning of the resident - schedule of voiding intervals - understand importance of accurate observations for plan effectiveness

Normal Urine

- clear (no mucus or sediment) - pale yellow - nearly odorless - urination usually occurs when the bladder contains 250 cc's or approximately one cup of urine

Psychosocial concerns of the incontinent resident:

- embarrassed - angry - isolated - agitated - loss of dignity - helpless - social withdrawal - interference with participation in activities

Describe reporting output for urine

- measure and record in cc's on the I&O sheet - if incontinent, follow facility procedures (number or weight of incontinent brief) - record the amounts in bedpans, commodes or drainage bags by emptying into a graduate

Describe reporting output for stool

- most facilities use check list charting - record amount as small, medium, or large - consistency is recorded as soft, hard, formed, or liquid - diarrhea may e measured in amounts and frequencies

Report diarrhea in infants:

- required immediate attention - infants can become dehydrated in a very short time - note the number of liquid stools and the time they occurred

NA's responsibilities when caring for an incontinent resident:

- respect resident - display understanding - check resident frequently as stated on care plan - provide skin care as directed on care plan - if applying incontinence disposable briefs, choose correct size

Physical concerns of the incontinent resident:

- skin irritation or breakdown - urinary tract infection - falls and fractures - sleep disturbances

Normal feces or stool

- soft - formed - brown - vary in frequency from daily to every three days - feces is passed without difficulty

Urination (voiding) in newborns

- will usually void 6-10 times a say - be certain to change diaper after each urination to prevent skin breakdown

Considerations when changing an infant's or small child's diaper:

1. Change diapers after each urination or bowel movement 2. Avoid skin irritation from urine and stool 3. Clean infant's genitals each diaper change with disposable wet cloths or mild soap and water, when using soap and water, rinse and pat dry - in females, remember front to back 4. Carefully observe the are that the diaper covers during each diaper change 5. Do not use pweders as they can cause respiratory problems 6. When using cloth diapers, rinse off stool in the toilet before placing in the diaper pail 7. Do not flush disposable diapers 8. Wash hands thoroughly after each diaper change - diarrhea is often caused by bacteria from unwashed hands after diaper change - the bacteria may be transferred to food surfaces

Inadequate diets (Factors that interfere with elimination)

1. Decreased fluid intake 2. Food with insufficient fiber 3. Food high in fat

Considerations for beginning a plan:

1. Explain procedure to each resident to ensure resident's cooperation 2. Never ridicule or embarrass residents because of their difficulties 3. Each resident - will vary with elimination frequency - may require an individualized plan

Observe color and consistency of the stools of small children:

1. Food eaten, especially vegetables, will affect the color of the stools 2. Some foods such as the skin of grapes and whole kernel corn are not completely digested 3. Report the swallowing of any foreign object to the supervisor according to the agency policy 4. Observe for and report to the supervisor any foreign objects found in the stool according to the agency's policy 5. Observe and report any pinworms or parasites to the supervisor 6. Report diarrhea, noting the time and number of loose stools

Process of digestion:

1. Food enters the mouth. It is broken up and mixed with saliva (digestion first step) 2. Food then passes through the esophagus into the stomach 3. Food is churned in the stomach with digestive juices 4. Partially digested food moves from the stomach into the small intestine where nutrients are absorbed into the bloodstream 5. Undigested food from the small intestine moves into the large intestine, the colon, where water is absorbed into the body 6. The last 5-6 inches of the colon is the rectum. It receives the undigested food as feces. The rectum stores it until the urge to have a bowel movement is felt then it is eliminated through the anus.

Considerations when caring for a resident with a catheter:

1. Infection control - maintains cleanliness according to care plan - wipe downward away from urethral opening, clean approximately 4 inches of catheter tubing - critical to wash from front to back if also doing pericare 2. Safety - tubing must not have any kinks - connections need to be tight - resident should not lay or sit on tubing - use care when moving residents with catheters - drainage bag must be lower than the level of the bladder so urine flows freely - never pull on catheter or tubing - drainage bag must be attached to bed frame (not the side rail) when resident is in bed - keep bag off floor and contained in covering according to facility policy - check care plan to see how or if catheter is secured to the resident's leg with a catheter strap - ambulatory residents may have drainage bad, usually called a leg bag, securely attached to their leg as indicated by care plan - correctly follow facility's procedure when emptying the drainage bag - usually empty at the end of shift and accurately record amount if on I&O - report anything unusual to the nurse

Urinary system (description)

1. Kidneys - filters the blood - the waste products filtered from the blood forms urine 2. Bladder: a balloon-like organ which stores the urine until it is emptied by urinating 3. Ureters: a tube from each kidney that connects to the bladder 4. Urethra: a tube that carries urine from the bladder out of the body 5. Urinary meatus: the external opening

Additional interference factors with elimination:

1. Lack of personal privacy during elimination 2. Stress can interfere with elimination patterns 3. Using the bedpan, urinal, or commode is not the usual way to have a bowel movement

Disease/disability (Factors that interfere with elimination)

1. Many residents have chronic illness which can interfere with elimination - ulcerative colitis - Crohn's disease - chronic cystitis - cancers 2. Nerves which signal need to eliminate may be weakened - no sensation of bladder or bowel fullness occurs - spinal cord injuries - multiple sclerosis

Medication (Factors that interfere with elimination)

1. Medications affect the elimination systems - diarrhea - constipation - urinary problems 2. Laxatives - should only be used when necessary - intestines become dependent on them - eventually a bowel movement may only happen if a laxative is taken - if constipated, suppositories or enemas may need to be given to aid in the elimination of stool

Aging (Factors that interfere with elimination)

1. Normal aging slows down body functions 2. Decreased physical strength makes elimination difficult 3. Feeling thirsty may decrease with aging, some elderly individuals do not get enough fluids 4. Blood flow to kidneys is decreased and the urinary system functions at a slower rate 5. Sensation of fullness in bladder and bowel may be decreased - some elderly individuals feel a great urgency to urinate or have a bowel movement - unexpected urination or bowel movement may occur quickly without much warning 6. Many older adults are incontinent of urine prior to nursing home admission. Urinary incontinence and related loss of independence are prominent reasons for admission to a nursing home.

Observe stools of the newborn and infant:

1. Note stool color and consistency with each diaper change - breast-fed babies will have yellow or mustard colored stools once or twice a day - infants who are breast-fed will have stools that are smooth and not formed - breast-fed baby's stool may change in color depending on the diet of the mother - bottle or formula fed infants will have yellow, brown, or mustard colored stools once to three times a day - infants who are bottle fed will have stools that are soft and lumpy and may look like there are tiny seeds in it

Benefit of successful bowel and bladder plan for residents:

1. Physical well-being, remaining continent 2. Mental well-being - dignity - self-respect - self-esteem

Identify special considerations when assisting clients with elimination in their home:

1. Review care plan and discuss related problems with agency supervisor 2. Identify the need for equipment - portable commode - raised toilet seat - urinal - bed pan 3. The supervisor will describe and demonstrate any special procedure that you may be required to do that is within the job description of the HHA

Bowel and Bladder Management Plans

1. When a resident is incontinent of urine upon admission or develops incontinence after admission, the nurse and the healthcare team complete an individualized assessment and develop a plan of care - Although many residents have used incontinence briefs prior to nursing home admission, and their use may be appropriate incontinence briefs should not be used as the primary long term approach. 2. Urinary incontinence may be reversible 3. Bladder and bowel programs provide a plan of assisting residents to the bathroom periodically 4. Goal is to establish regularity and prevent incontinence 5. Plan must be made according to each resident's elimination pattern: - Individualized assessment usually includes a 3 day voiding record - NA's will help in completing voiding record to detect urinary patterns or intervals between incontinence episodes and facilitate planning care to avoid or reduce the frequency of episodes.

Signs which may indicate the need for elimination:

1. When a resident is unable to communicate their needs, restlessness, and irritability may be a sign of their need to eliminate 2. Small, brown, watery rectal discharge may indicate a fecal impaction 3. Feelings of fullness in the lower abdomen may indicate a full bladder or hard fecal mass

Graduate

A container into which liquids can be poured. It has measurement numbers on the side

Parasite

An organism that lives in or on another and is found in the intestinal tract. Children ingest worms playing in dirt and sand and then put their fingers in their mouths. The parasite may be seen in their stool or diapers.

Foreign Objects or Foreign Bodies

Anything that is not a normal part of the body or body functioning. Infants and small children swallow foreign object such as coins or small toys. Small objects can usually travel the digestive tract and be found in the stool

Incontinent brief

Disposable absorbent pad designed to line undergarments

Defecate

Elimination of stool; also called a bowel movement

Meconium

First stool of newborn which is greenish-black to light brown, almost odorless and of a tarry consistency

Drainage

Fluids, such as blood or other body secretion, withdrawn or freely flowing from a wound or body cavity

Diarrhea

Frequent loose and liquid stools

Fecal Impaction

Hard, dry stool that becomes lodged in the intestine or rectum

Constipation

Having difficulty with bowel movement, dry hard stool and eliminating less often than the usual pattern

Catheter

Hollow tube which drains urine from the bladder

Incontinence

Inability to control or retain urine or stool

Flatus

Intestinal gas

Urine

Liquid waste excreted by the kidneys; mostly water and waste filtered from the blood

Elimination

Removal of waste products from the body; the body's way of removing waste products and toxic substances through the digestive and urinary systems

Feces

Semi-solid wastes eliminated from the intestines. Mostly indigestible ingredients from food. It is also called stool.

Output

Substances expelled or excreted from the body, such as urine and emesis

Perspiration

Sweat, a body waste product. The body's means of removing heat. Not usually measured but observed in saturated clothing or linens to evaluate dehydration and other conditions

Void

The act of eliminating urine; also called urination

Emesis

Vomiting

Catheters

a hollow tube which drains urine from the bladder, inserted through the urethra by a nurse 1. Indwelling catheters remain inside the bladder and urine is drained from the bladder into an attached drainage bag 2. Indwelling catheters are not routinely used as a solution for incontinency 3. Indwelling catheters create risk for urinary tract infection 4. Intermittent catheters are inserted into the bladder to drain the urine and promptly removed

Condom catheter

a latex sheath that fits over the penis and is connected to a urinary drainage bag 1. Should be removed every 24 hours to provide skin care as indicated on the care plan 2. Also called a Texas catheter or external catheter

Suprapubic catheters

are inserted directly into the bladder through the lower abdominal wall just above the pubic bone 1. Is a surgical procedure 2. Connected to a drainage bag

Inactivity (Factors that interfere with elimination)

when the body is inactive the digestive system slows down: - sleeping - after surgery