Fecal Elimination - Chapter 49

Nursing Responsibilities of Fecal Incontinence Pouch

(a) regular assessment and documentation of the perianal skin status, (b) changing the bag every 72 hours or sooner if there is leakage, (c) maintaining the drainage system, and (d) providing explanations and support to the client and support people.

Sample Defining Characteristics of Constipation

*decreased frequency of defecation *hard, formed stools *straining at stool; painful defecation *reports of rectal fullness or pressure or incomplete bowel evacuation *abdominal pain, cramps, or distention *anorexia, nausea *headache

Positioning on Slipper or Fracture Pan

. The slipper pan has a low back and is used for clients unable to raise their buttocks because of physical problems or therapy that contraindicates such movement. Many older adults benefit from the use of the slipper pan.

Bowel Diversion Ostomies are Classified According to

1. their status as permanent or temporary 2. their anatomic location 3. the construction of the stoma

Skill 49.1 Administering and Enema

1227

Lifespan Considerations, Administering and Enema

1230

Daily Fiber Recommendation: Women age 51 and older

21 grams

Daily Fiber Recommendation: Women age 50 and younger

25 grams

Daily Fiber Recommendation: Men age 51 and older

30 grams

Daily Fiber Recommendation: Men age 50 and younger

38 grams

Carminative Enema

A carminative enema is given primarily to expel flats. The solution instilled into the rectum releases gas, which in turn distends the rectum and the colon, thus stimulating peristalsis. For an adult, 60-80 mL of fluid is instilled.

Timing

A client should be encouraged to defecate when the urge is recognized.

Colostomy Irrigation

A colostomy irrigation, similar to an enema, is a form of stoma management used only for clients who have a sigmoid or descending colostomy.

High Enema

A high enema is given to cleanse as much of the colon as possible. The client changes from the left lateral position to the dorsal recumbent position and then to the right lateral position during administration so that the solution can follow the large intestine.

Nursing History

A nursing history for fecal elimination helps the nurse ascertain the clients normal pattern. The nurse elicits a description of usual feces and any recent changes and collects information about any past or current problems with elimination, the presence of an ostomy, and factors influencing the elimination pattern. When eliciting data about the client's defecation pattern, the nurse needs to understand that the time of defecation and the amount of feces expelled are as individual as the frequency of defecation.

Retention Enema

A retention enema introduces oil or medication into the rectum and sigmoid colon. The liquid is retained for a relatively long period (e.g. 1-3 hours). An oil retention enema acts to soften the feces and to lubricate the rectum and anal canal, thus facilitating passage of the feces.

Return-Flow Enema

A return-flow enema, also called a Harris flush, is occasionally used to expel flatus. Alternating flow of 100-200 mL of fluid into and out of the rectum and sigmoid colon stimulates peristalsis. This process is repeated five or six times until the flatus is expelled and abdominal distension is relieved. Keep in mind the client's discomfort with the gender of the caregiver and try to accommodate the client's preferences whenever possible.

Activity

Activity stimulates peristalsis, thus facilitating the movement of chyme along the colon. Weak muscles can result from lack of exercise, immobility, or impaired neurologic functioning. Clients confined to bed are often constipated.

Normal Color of Feces

Adult: brown Infant: yellow

Signs and Symptoms of Fecal Impaction

Along with fecal seepage and constipation, symptoms include frequent but non-productive desire to defecate and rectal pain. A generalized feeling of illness results; the client becomes anorexic, the abdomen becomes distended, and nausea and vomiting may occur.

Alpha-Galactosidase (Beano) for Gas

Alpha-galactosidase (beano) is effective for reducing flatulence caused by eating fermentable carbohydrates (beans, bran, fruit)

Treatment of Fecal Impaction

Although fecal impaction can generally be prevented, treatment of impacted feces is sometimes necessary. When fecal impaction is suspected, the client is often given an oil retention enema, a cleansing enema 2 to 4 hours later, and daily additional cleansing enemas, suppositories, or stool softeners. If these measures fail, manual removal is often necessary.

Positioning

Although the squatting position best facilitates defecation, on a toilet seat the best position for most people seems to be leaning forward. For clients who have difficulty sitting down and getting up from the toilet, and elevated toilet seat can be attached to a regular toilet.

Enema

An enema is a solution introduced into the rectum and large intestine. The action of an enema is to distend the intestine and sometimes to irritate the intestinal mucosal, thereby increasing peristalsis and the excretion of feces and flatus. The enema solution should be at 37.7°C (100°F) because a solution that is too cold or too hot is uncomfortable and causes cramping.

Ostomy Appliance

An ostomy appliance should protect the skin, collect stool, and control odor. The appliance consists of a skin barrier and a pouch. The pouch can be removed without removing the skin barrier when using a two-piece appliance.

Antiflatulent

Anti-flatulent agents such as simethicone do not decrease the formation of flatus but they do coalesce the gas bubbles and facilitate their passage by belching through the mouth or expulsion through the anus. Suppositories can also be given to relieve flatus by increasing intestinal motility.

Carminatives

Antiflatulant Carminatives are herbal oils known to act as agents that help expel gas from the stomach and intestines.

Insertion

Apply clean gloves and liberally lubricate the gloved index finger. Gently insert the index finger into the rectum and move the finger along the length of the rectum.

Normal Odor of Feces

Aromatic: effected by ingested food and individual's own bacterial flora

Positioning

Ask the client to assume a right or left side-lying position with the knees flexed and the back toward the nurse. When the person lies on the right side, the sigmoid colon is uppermost; thus gravity can aid removal of the feces. Positioning on the left side allows easier access to the sigmoid colon.

Diagnostic Procedures

Before certain diagnostic procedures, such as visualization of the colon (colonoscopy or sigmoidoscopy) the client is restricted from ingesting food or fluid.

Pre-Treatment of Digital Removal of Fecal Impaction

Before disimpaction it is suggested an oil retention enema be given and held for 30 minutes. After a disimpaction, the nurse can use various interventions to remove remaining feces, such as a cleansing enema or the insertion of a suppository. Because manual removal of an impaction can be painful, the nurse may use, if the agency permits, 1-2 mL of lidocaine (Xylocaine) gel on a gloved finger inserted into the anal canal as far as the nurse can reach. The lidocaine will anesthetize the anal canal and rectum and should be inserted 5 minutes before the disimpaction.

Bismuth Subsalicylate (Pepto-Bismol) for Gas

Bismuth subsalicylate (Pepto-Bismol) can be effective; however, it should not be used as a continuous treatment because it contains aspirin and could call salicylate toxicity.

Possible cause of red feces

Bleeding from lower gastrointestinal tract (e.g. rectum); some foods (beets)

Table 49.3 Types of Laxatives

Bulk forming Osmotic/saline Stimulant/irritant Stool softener or surfactant Lubricant

Clostridium difficile

C. difficile associated disease, which produces mucoid and foul-smelling diarrhea, has been increasing in recent years. Clients at the highest risk for the development of C. difficile include immunosuppressive individuals, clients on chemotherapy, and those who have recently used antimicrobial agents, usually fluoroquinolones. Older adults are at the greatest risk due to underlying diseases and greater exposure in hospitals and extended care facilities.

Stoma and Skin Care

Care of the stoma and skin is important for all clients who have ostomies. The fecal material from a colostomy or ileostomy is irritating to the periostmal skin. This is particularly true of stool from an ileostomy, which contains digestive enzymes. It is important to assess the peristomal skin for irritation each time the appliance is changed. The skin is kept clean by washing off any excretion and drying thoroughly.

The Most Common Categories of Medications Affecting Fecal Elimination

Cathartics Laxatives Suppositories Antidiarrheal Antiflatulent

Cathartics

Cathartics are drugs that induce defecation. They can have a strong, purgative affect. A laxative is mild in comparison to a cathartic, and it produces soft or liquid stools that are sometimes accompanied by abdominal cramps. Examples of cathartics are castor oil, cascara, phenolphthalein, and biscodyl.

Medications for Gas

Certain medication can decrease flatulence Probiotics Bismuth Subsalicylate (Pepto-Bismol) Alpha-Galactosidase (Beano)

Abnormal Colors of Feces

Clay or white Black or tarry Red Pale Orange or green

Four Groups of Enemas

Cleansing Enema Carminative Enema Retention Enema Return-Flow Enema

Cleansing Enemas

Cleansing enemas are intended to remove feces. They are given chiefly to: *Prevent the escape of feces during surgery. *Prepare the intestine for certain diagnostic tests such as x-ray or visualization tests (e.g. colonoscopy) *Remove feces in instances of constipation or impaction. *Use a variety of solutions. *Described by solution and position

Pain

Clients who experience discomfort when defecating (e.g. Following hemorrhoid surgery) often suppress the urge to defecate to avoid the pain. Such clients can experience constipation as a result. Clients taking narcotic analgesics for pain may also experience constipation as a side effect of the medication.

Fecal Elimination Problems

Constipation Fecal Impaction Diarrhea Bowel Incontinence Flatulance

Preventative Measures for constipation

Constipation can be relieved by increasing the fiber intake to 20 to 35 grams per day unless contraindicated. Adequate roughage in the diet, adequate exercise, and 6 to 8 glasses of fluid daily are other essential preventative measures for constipation.

Constipation

Constipation may be defined as fewer than three bowel movements per week. This infers the passage of dry, hard stool or the passage of no stool. It occurs when the movement of feces through the large intestine is slow, thus allowing time for additional reabsorption of fluid from the large intestine. It is important to define constipation in relation to the person's regular elimination pattern. Straining associated with constipation often is accompanied by holding the breath. This Valsalva maneuver can present serious problems to people with heart disease, brain injuries, or respiratory disease. Holding the breath while bearing down can increase intrathoracic pressure and vagal tone, slowing the pulse rate.

Normal Shape of Feces

Cylindrical (contour of rectum) about 2.5 cm (1 in) in diameter in adults

Defecation

Defecation is the expulsion of feces from the anus and rectum. It is also called a bowel movement. The frequency of defecation is highly individual, varying from several times per day to two or three times per week.

Factors that Affect Defecation

Development Diet Fluid Intake and Output Psychological Factors Defecation Habits Medications Diagnostic Procedures Anesthesia and Surgery Pathologic Conditions Pain

Diagnostic Studies

Diagnostic studies of the gastrointestinal tract include direct visualization techniques, indirect visualization techniques, and laboratory tests for abnormal constituents.

Diarrhea

Diarrhea refers to the passage of liquid feces and an increased frequency of defecation. It is the opposite of constipation and results from rapid movement of fecal contents through the large intestine

Osmotic/saline

Draws water into the intestine by osmosis, distends bowel and stimulates peristalsis. Almost no water or electrolytes are absorbed as solution moves through the intestines and the large fluid volume flushes feces from the colon Four major types of osmotic laxatives: lactulose, sodium phosphate (tablet form only requiring prescription; OsmoPrep, Visicol), magnesium salts (magnesium citrate), and Sodium sulfate (SUPREP) Electrolyte-free polyethylene glycol 3350 (PEG 3350) (Miralax) PEG-ES (GoLYTELY; NuLYTELY) May berated acting. Can cause fluid and electrolyte imbalance, particularly in older people and children with cardiac and renal disease. Use caution when giving to older adults. A laxative that is helpful in the treatment of constipation. It is a powder that is tasteless when mixed in a flavored liquid such as juice. Used for cleaning of the colon before a colonoscopy. Requires drinking a large volume (4L), which may be difficult for clients to tolerate. Has a bitter taste.

Possible cause of black or tarry feces

Drug (i.e. iron); bleeding from upper gastrointestinal tract (e.g. stomach, small intestine); diet high in red meat and dark green vegetables

Fluid Intake and Output

Even when fluid intake is in adequate or output (urine or vomitus) is excessive for some reason, the body continues to reabsorb fluid from the time as it passes along the colon. The chyme becomes drier than normal, resulting in hard feces. Healthy fecal lamination usually requires a daily fluid intake of 2000 - 3000 mL.

Fecal Impaction

Fecal impaction is a mass or collection of hardened feces in the folds of the rectum. Impaction results from prolonged retention and accumulation of fecal material. The causes of fecal impaction are usually poor defecation habits and constipation.

Flatulance

Flatulence is the presence of excess flatus in the intestines and leads to stretching and inflammation of the intestines (intestinal distention). Flatulence can occur in the colon from a variety of causes, such as food (e.g. cabbage, onions), abdominal surgery, or narcotics. If the gas is propelled by increased colon activity before it can be absorbed, it may be expelled through the anus. If excessive gas cannot be expelled through the anus, it may be necessary to insert a rectal tube to remove it.

Bowel Training Programs

For clients who have chronic constipation, frequent impactions, or fecal incontinence, bowel training programs may be helpful. The program is based on factors within the client's control and is designed to help the client establish normal defecation. Such matters as food and fluid intake, exercise, and defecation habits are all considered.

Fluid Amount Required for Colostomy Irrigation

For most clients, a relatively small amount of fluid (300-500 mL) stimulates evacuation. For others, up to 1000 mL may be needed because a colostomy has no sphincter and the fluid tend to return as it is instilled.

Types of Intestinal Ostomies

Gastrostomy Jejunostomy Ileostomy Colostomy

Anesthesia and Surgery

General anesthetics cause the normal colonic movements to cease or slow by blocking parasympathetic stimulation to the muscles of the colon. Surgery that involves direct handling of the intestines can cause temporary cessation of intestinal movement. This condition, called ileus, usually last 24 to 48 hours. Listening for bowel sounds that reflect intestinal motility is an important nursing assessment following surgery.

Abnormal Consistencies of Feces

Hard, dry Diarrhea

Types of Movements that Occur in the Large Intestine

Haustral Churning Peristalsis Mass Peristalsis

Types of Cleansing Enema

Hypertonic Solutions Hypotonic Solutions Isotonic Solutions Soapsuds Enemas High Enema Low Enema

Hypertonic Solutions

Hypertonic solutions exert osmotic pressure, which draw fluid from the interstitial space into the colon. The increased volume in the colon stimulates peristalsis and hence defecation. A commonly used hypertonic enema is the commercially prepared Fleet phosphate enema. e.g. Saline

Hypotonic Solutions

Hypotonic solutions (e.g. tap water) exert a lower osmotic pressure than the surrounding interstitial fluid, causing water to move from the colon into the interstitial space. Before the water moves from the colon, it stimulates peristalsis and defecation. Because the water moves out of the colon, the tap water in a much should not be repeated because of the danger of circulatory overload when the water moves from the interstitial space into the circulatory system. e.g. tap water

Defecation Habits

If a person ignores this urge to defecate, water continues to be reabsorbed, making the feces hard and difficult to expel. When the normal defecation reflexes are inhibited or ignored, these conditioned reflexes tend to be progressively weakened. When habitually ignored, the urge to defecate is ultimately lost.

Bulk forming laxative

Increase the fluid, gaseous, or solid bulk in the intestines Psyllium hyroliphic mucilloid (metamucil), methylcellulose (Citrucel) May take 12 or more hours to act. Sufficient fluid must be taken. Safe for long term use.

Stimulant/Irritant

Irritates the intestinal mucosa or stimulates nerve endings in the wall of the intestine, causing rapid propulsion of the contents. Bisacodyl (Dulcolax, Correctol), senna (Senkot, Ex-lax), cascara, castor oil Facts more quickly than bulk-forming agents. Fluid is passed with the feces. May cause cramps. Use only for short period of time. Prolonged use may cause fluid and electrolyte imbalance.

Isotonic Solutions

Isotonic solutions, such as physiologic normal saline, are considered the safest enema solutions to use. They exert the same osmotic pressure as the interstitial fluid surrounding the colon. Therefore, there is no fluid movement into or out of the colon. The instilled volume of saline in the colon stimulates peristalsis. e.g. physiological (normal) saline

Laxatives

Laxatives are contraindicated in the client who has nausea, cramps, colic vomiting, or undiagnosed abdominal pain. Continual use of laxatives to encourage Bowel evacuation weakens the bowels natural responses to fecal distention, resulting in chronic constipation. To eliminate chronic laxative use, it is usually necessary to teach the client about dietary fiber, regular exercise, taking sufficient fluids, and establishing regular defecation habits

Loosen and Dislodge Stool

Loosen and dislodge stool by gently massaging around it. Break up stool by working the finger into the hardened mass, taking care to avoid injury to the mucosa of the rectum. Carefully work stool downward to the end of the rectum and remove it in small pieces.

Lubricant

Lubricates the stool and colon mucosa. Mineral oil (Haley's M-O) Prolonged use inhibits the absorption of some fat-soluble vitamins

Possible cause of pale feces

Malabsorption of fats; diet high in milk and milk products and low in meat

Newborns and Infants

Meconium Transitional Stools

Infants

Meconium Transitional Stools Infants pass stool frequently, often after each feeding. Because the intestine is immature, water is not well absorbed in the stool is soft, liquid, and frequent. When the intestine matures, bacterial flora increase. After solid foods are introduced, the stool becomes less frequent and firmer.

Meconium

Meconium is the first fecal material passed by the newborn, normally up to 24 hours after birth. It is black, tarry, odorless, and sticky.

Movement

Movement stimulates peristalsis and the escape of flatus and reabsorption of gases in the intestinal capillaries

Possible Cause of Abnormal Constituents of Feces

Mucus Bacterial Infection Inflammatory Condition Gastrointestinal Bleeding Malabsorption Accidental Ingestion

Abnormal Shape of Feces

Narrow, pencil-shaped, or stringlike stool caused by obstructive condition of the rectum

Feces

Normal feces are made up of about 75% water and 25% solid materials. They are soft but formed. If the feces are propelled very quickly along the large intestine, there is not time for most of the water in the chyme to be reabsorbed and the feces will be more fluid, containing perhaps 95% water. Normal feces require a normal fluid intake; feces that contain less water may be hard and difficult to expel. Feces are normally brown, chiefly due to the presence of stercobilin and urobilin, which are derived from bilirubin (a red pigment in bile). Another factor that affects fecal color is the action of bacteria such as Escherichia coli or staphylococci, which are normally present in the large intestine. The action of microorganisms on the chyme is also responsible for the odor of feces.

Odor Control

Odor control is essential to client's self esteem. As soon as clients are ambulatory, they can learn to work with the ostomy in the bathroom to avoid odors at the bedside. An intact appliance contains odors. Most pouches contain odor-barrier material. Some pouches also have a pouch filter that allows gas out of the pouch but not the odor.

Signs and Symptoms of Diarrhea

Often, spasmodic cramps are associated with diarrhea. Bowel sounds are increased. With persistent diarrhea, irritation of the anal region extending to the perineum and buttocks generally results.

Promoting Regular Defecation

Privacy Timing Nutrition and Fluids Exercise Positioning

Privacy

Privacy during defecation is extremely important to many people.

Probiotics for Gas

Probiotics may be helpful in the management of flatulence and bloating

Implementing

Promoting Regular Defecation Medications Decreasing Flatulence Administering Enemas Digital Removal of a Fecal Impaction Bowel Training Programs Fecal Incontinence Pouch Ostomy Management Colostomy Irrigation

Abnormal Constituents of Feces

Pus Parasites Blood Large quantities of fat Foreign objects

Exercise

Regular exercise helps clients develop a defecation pattern. A client with weak abdominal and pelvic muscles (which impede normal defecation) may be able to strengthen them with the following isometric exercises: • in a supine position, the client tightens the abdominal muscles as though pulling them inward, holding them for about 10 seconds and then relaxing them. This should be repeated 5 to 10 times, four times a day, depending on the clients health. • Again in a supine position, the client can contract the thigh muscles and hold them contracted for about 10 seconds, repeating the exercise 5 to 10 times, four times a day. This helps the client confined to bed gain strength in the thigh muscles, thereby making it easier to use a bedpan.

School-Aged Children and Adolescents

School-age children and adolescents have bowel habits similar to those of adults. Patterns of defecation very in frequency, quantity, and consistency.

Constituents of Normal Feces

Small amounts of undigested roughage, sloughed dead bacteria and epithelial cells, fat, protein, dried constituents of digestive juices (e.g. bile pigments, inorganic matter)

Soapsuds Enemas

Soapsuds enemas stimulate peristalsis by increasing the volume in the colon and irritating the mucosa. Only pure soap (I.e. Castile soap) should be used in order to minimize mucosa irritation.

Stool Softener or surfactant

Softens and delays the drying of the stool; causes more water and fat to be absorbed into the stool. Docusate sodium (Colace), Docusate calcium (Surfak) Slow-acting; may take several days

Toddlers

Some control of defecation starts at 1 1/2 to 2 years of age. Daytime control is typically attained by age 2 1/2, after a process of toilet training.

Medications

Some drugs have side effects that can interfere with normal illumination. Some cause diarrhea; others, such as large doses of certain tranquilizers and repeated administration of morphine and codeine, cause constipation because they decrease gastrointestinal activity through their action on the central nervous system. Iron supplements act more locally on the bowel mucosa and can cause constipation or diarrhea.

Suppositories

Some laxatives are given in the form of suppositories. These act in various ways: by softening the feces, by releasing gases such as carbon dioxide to distend the rectum, or by stimulating the nerve endings in the rectal mucosa.

Psychological Factors

Some people who are anxious or angry experience increased peristaltic activity and subsequent nausea or diarrhea. In contrast, people who are depressed may experience slowed intestinal motility, resulting in constipation.

Pathologic Conditions

Spinal cord injuries and head injuries can decrease the sensory stimulation for defecation. Impaired mobility may limit the clients ability to respond to the urge to defecate and the client may experience constipation.

Diet

Sufficient bulk (cellulose, fiber) in the diet is necessary to provide fecal volume. In adequate intake of dietary fiber contributes to the risk of developing obesity, type two diabetes, coronary artery disease, and colon cancer.

Temporary Colostomies

Temporary colostomies are generally performed for traumatic injuries or inflammatory conditions of the bowel. They allow the distal diseased portion of the bowel to rest and heal.

Products of Digestion

The colon acts to transport along its lumen the products of digestion, which are eventually illuminated through the anal canal Flatus Feces or Stool

Feces or Stool

The excreted waste products are referred to as feces or stool

Large Intestine

The large intestine extends from the iliocecal (ileocolic) valve, which lies between the small and large intestines, to the anus. The colon (large intestine) in the adult is generally about 125-150cm (50-60 in) long. The longitudinal muscles are shorter than the colon and therefore cause the large intestine to form pouches, or haustra.

Anatomic Location of Ostomies

The location of the ostomy influences the character and management of the fecal drainage.

Low Enema

The low enema is used to clean the rectum and sigmoid colon only. The client maintains a left lateral position during administration.

Concerns with Laxative Use

The older adult should be warned that consistent use of laxatives inhibits natural defecation reflexes and is thought to cause rather than cure constipation. The habitual user of laxatives eventually requires a larger or stronger dose because the effect is progressively reduced with continual use. Laxatives may also interfere with the body's electrolyte balance and decrease the absorption of certain vitamins

Purpose of Colostomy Irrigation

The purpose of irrigation is to distend the bowel sufficiently to stimulate peristalsis, which stimulated evacuation. When a regular evacuation pattern is achieved, the wearing of a colostomy pouch is unnecessary.

Purpose of Fecal Incontinence Pouch

The purpose of the pouch is to prevent progressive perianal skin irritation and breakdown and frequent linen changes necessitated by incontinence.

Rectum and Anal Canal

The rectum in the adult is usually 10 to 15cm (4 to 6 in. long); the most distal portion, 2.5-5 cm (1 to 2in.) long is the anal canal. The rectum has folds that extend vertically. Each of the vertical folds contains a vein and an artery. It is believed that these folds help retain feces within the rectum.

Chyme

The waste products leaving the stomach through the small intestine and then passing through the ileocecal valve are called chyme. As much of 1500 mL of chyme passes into the large intestine daily and all but about 100 mL is reabsorbed in the proximal half of the colon. The 100 ml of fluid is excreted in the feces

Decreasing Flatulance

There are a number of ways to reduce or expel flatus, including exercise, moving in bed, ambulation, and avoiding gas producing foods. Movement Avoid Gas Producing Foods Medications

Antidiarrheal

These medications slow the motility of the intestine or absorb excess fluid in the intestine.

Fecal Incontinence Pouch

To collect and contain large volumes of liquid fees, the nurse may place a fecal incontinence collector pouch around the anal area In many agencies, the pouch is replacing the traditional approach to this problem; that is, inserting a large Foley catheter into the client's rectum and inflating the balloon to keep it in place- a practice that may damage the rectal sphincter and rectal mucosa. A rectal catheter also increases peristalsis and incontinence by stimulating sensory nerve fibers in the rectum.

Most Common Routine for Changing the Appliance

Twice weekly Ostomy appliances can provide a leak-proof seal for about 3-7 days. The pouch should be changed on a routine basis before leakage occurs. The most common routine for changing the appliance is twice weekly. Some manufacturers recommend removing the pouch and the skin barrier twice a week to clean and inspect the peristomal skin unless stool leaks onto the perisotmal skin, necessitating a change. IF the skin is erythematous, eroded, denuded, or ulcerated, the pouch should be changed every 24-48 hours to allow appropriate treatment of the skin. More frequent changes are recommended if the client complains of pain or discomfort. The type of ostomy and amount of output influence how often the pouch is emptied. The pouch is emptied when it is one their to one half full. If the pouch overfills, it can cause separation of the skin barrier from the skin and allow stool to come in contact with skin. This results in the entire appliance needing to be removed and a new one applied.

Older Adults

Up to half of all older adults suffer from constipation. This is due, in part, to reduced activity levels, inadequate fluid and fiber intake, and muscle weakness. Many older people believe that "regularity" means a bowel movement every day. Those who did not meet this criterion often seek over-the-counter preparations to relieve what they believe to be constipation. Older adults should be advised that a normal pattern maybe every other day; for others, twice a day.

Fluid and Electrolyte Concerns with Diarrhea

When the cause of diarrhea is irritants in the intestinal tract, diarrhea is thought to be a protective flushing mechanism. It can create serious fluid and electrolyte losses in the body, however, that can develop within frighteningly short periods of time, particularly in infants, small children, and older adults.

Hemorrhoids

When the veins in the rectum become distended, as can occur with repeated pressure, a condition known as hemorrhoids occurs. They can be external or internal.

Positioning on Bedside Commode

a portable chair with a toilet seat and a receptacle beneath that can be emptied, is often used for the adult client who can get out of bed but is unable to walk to the bathroom.

The Force of Flow of the Solution is Governed by

a) the height of the solution container, (b) size of the tubing, (c) viscosity of the fluid, and (d) resistance of the rectum. The higher the solution container is held above the rectum, the faster the flow and the greater the force (pressure) in the rectum. During most adult enemas, the solution container should be no higher than 30 cm (12 in) above the rectum. During a high cleansing enema, the solution container is usually held 30-49 (12 to 18 in) above the rectum because the fluid is instilled farther to clean the entire bowel.

Primary Sources of Flatulence

a. action of bacteria on the chyme in the large intestine b. swallowed air c. gas that diffuses between the bloodstream and the intestine

Digital Removal of a Fecal Impaction

a. contraindications b. pre-treatment c. for digital removal of fecal impaction

Ostomy Management

a. stoma and skin care b. ostomy appliance c. odor control d. most common routine for changing the appliance is twice weekly

Possible cause of clay or white feces

absence of bile pigment (bile obstruction); diagnostic study using barium

Bowel Incontinence

also called fecal incontinence, refers to the loss of voluntary ability to control fecal and gaseous discharges through the anal sphincter. Two types of bowel incontinence are described: partial and major. Fecal incontinence is generally associated with impaired functioning of the anal sphincter or it's nerve supply, such as in some neuromuscular diseases, spinal cord trauma, and tumors of the external anal sphincter muscle. Bowel incontinence is an emotionally distressing problem that can ultimately lead to social isolation.

Gastrostomy

an opening through the abdominal wall into the stomach generally performed to provide an alternate feeding route

Permanent Colostomies

are performed to provide a means of elimination when the rectum or anus is nonfunctional as a result of a birth defect or a disease such as cancer of the bowel.

Older Adults

are preoccupied with their bowels. People who have had a bowel movement once a day for 75 years can view missing one day as a serious problem.

Following disimpaction,

assist the client to clean the anal area and buttocks. Then assist the client onto a bedpan or commode for a short because digital stimulation of the rectum often induces the urge to defecate.

Pungent odor of feces

caused by infection, or blood

Contraindications of Digital Removal of Fecal Impaction

contraindicated for some people because it may cause an excessive vagal response resulting in cardiac arrhythmia Clinical Alert: clients with a history or cardiac disease and/or dysrhythmias may be at risk with digital stimulation to remove an impaction. If in doubt, the nurse should check with the primary care provider before performing the procedure.

Possible cause of hard, dry feces

dehydration; decreased intestinal motility resulting from lack of fiber in diet, lack of exercise, emotional upset, laxative abuse

Nutrition and Fluids for Diarrhea

encourage oral intake of fluids and bland food. Eating small amounts can be helpful because small amounts are more easily absorbed. Excessively hot or cold fluids should be avoided because they stimulate peristalsis. In addition, highly spiced foods and high fiber foods can aggravate diarrhea.

Transitional Stools

follow for about a week, are generally greenish yellow; they contain mucus and are loose.

Normal Consistency of Feces

formed, soft, semisolid, moist

Major phases of the program are as follows:

i. determine the client's usual bowel habits ii. design a plan with the client that includes the following o fluid intake of about 2,500 to 3000 mL/day o increase in fiber in diet o Intake of hot fluids, especially just before the usual defecation time o Increase in exercise iii. maintain the following daily routine for 2-3 weeks: teach the client to lean forward at the hips, to apply pressure on the abdomen with the hands, and to bear down for defecation. These measures increase pressure on the colon. Straining should be avoided because it can cause hemorrhoids.

For Digital Removal of Fecal Impaction

i. positioning ii. lubricate gloved index finger iii. loosen and dislodge stool iv. following disimpaction

An Ileostomy

ileostomy produces liquid fecal drainage. Drainage is constant and cannot be regulated. Ileostomy drainage contains some digestive enzymes, which are damaging to the skin. For this reason, ileostomy clients must wear an appliance continuously and take special precautions to prevent skin breakdown. Compared to colostomies, however, odor is minimal because fewer bacteria are present.

Infection Control for c. difficile

includes hand hygiene, contact precautions, and cleaning of services with a bleach solution. All individuals involved in the care of the client need to be reminded to wash their hands with soap and water because alcohol-based hand gels are not effective against C diff. Also, wearing gloves when coming into contact with soiled linens is needed to prevent the spread of the bacteria and spores that exist with c. difficile.

Physical Examination of the Abdomen in Relation to Fecal Elimination Problems

includes inspection, auscultation, percussion, and palpation.

Assessment of Fecal Elimination

includes taking a nursing history; performing a physical examination of the abdomen, rectum, and anus; and inspecting the feces. The nurse also should review any data obtained from relevant diagnostic tests.

Nutrition and Fluids for Constipation

increase daily fluid intake, and instruct the client to drink hot liquids, warm water with a squirt of fresh lemon, and fruit juices, especially prune juice. Include fiber in the diet, that is, food such as raw fruit, bran products, and whole-grain cereals and bread.

Possible cause of diarrhea

increased intestinal motility (e.g. due to irritation of the colon by bacteria)

Possible cause of orange or green feces

intestinal infection

Mass Peristalsis

involves a wave of powerful muscular contraction that moves over large areas of the colon. Usually mass peristalsis occurs after eating, stimulated by the presence of food in the stomach and small intestine. In adults, mass peristaltic waves occur only a few times a day.

Haustral Churning

involves movement of the chyme back-and-forth within the haustra.

Ostomy

is an opening for the gastrointestinal, urinary, or respiratory tract onto the skin.

Stoma

is generally red in color and moist. Initially, slight bleeding may occur when the stoma is touched and this is considered normal. A person does not feel the stoma because there are no nerve endings in the stoma.

Flatus

is largely air and the byproducts of the digestion of carbohydrates

Major Bowel Incontinence

is the inability to control feces of normal consistency.

Partial Bowel Incontinence

is the inability to control flatus or to prevent minor soiling

Peristalsis

is wavelike movement produced by the circular and longitudinal muscle fibers of the intestinal walls; It propels the intestinal contents forward.

Nutrition for Flatulence

limit carbonated beverages, the use of drinking straws, and chewing gum- all of which increase the ingestion of air. Gas0formulating foods, such as cabbage, beans, onions, and cauliflower should also be avoided.

Protective Function of Mucus

mucus contains large amounts of bicarbonate (HCO3) ions. Mucus: * protects the wall of the large intestine from trauma by the acids formed in the feces *serves as an adherent for holding the fecal material together. *protects the intestinal wall from bacterial activity

Colostomy

opens into the colon (large bowel)

Ileostomy

opens into the ileum (small bowel)

Jejunostomy

pens through the absominal wall into the jejunum generally performed to provide an alternate feeding route

Auscultation

precedes palpation because palpation can alter peristalsis

Main Function of Large Intestine

the absorption of water and nutrients, the mucoid protection of the intestinal wall, and fecal elimination

The farther along (more distal) the bowel

the more formed the stool (because the large bowel reabsorbs water from the fecal mass) and the more control over the frequency of stomal discharge can be established.

Normal Amount of Feces

varies with diet (about 100-400 g/day)

Client Teaching: Managing Diarrhea

• Eat foods with sodium and potassium. Most foods contain sodium. Potassium is found in meats and many vegetables and fruits, especially purple grape juice, tomatoes, potatoes, bananas, cooked peaches, and apricots. • Increase foods containing soluble fiber such as rice, oatmeal, and skinless fruit and potatoes. Avoid alcohol and beverages with caffeine, which aggravate the problem. • Limit foods containing insoluble fiber, such as high fiber whole wheat and whole grain breads and cereals, and raw fruits and vegetables. • Limit fatty foods. • Thoroughly clean and dry the perianal area after passing stool to prevent skin irritation and break down. Use soft toilet tissue to clean and dry the area. Apply a dimethicone-based cream or alcohol-free barrier film as needed. • If possible, discontinue medications that cause diarrhea. • When diarrhea has stopped, reestablish normal bowel for about eating fermented dairy products, such as yogurt or buttermilk. • Seek a primary care provider consultation right away if weakness, dizziness, or loose stool persists more than 48 hours.

Client Teaching: Healthy Defecation

• Establish a regular exercise regimen • Include high-fiber foods, such as vegetables, fruits, and whole grains, in the diet. • Maintain fluid intake of 2000-3000 mL/day • Do not ignore the urge to defecate • Allow time to defecate, preferably at the same time each day • Avoid OTC medications to treat constipation and diarrhea

Box 49.2 Guidelines for Using Antidiarrheal Medications

• If the diarrhea persists for more than 3-4 days, determine the underlying cause. Using a medication such as an opiate when the cause is an infection, toxin, or poison may prolong diarrhea. • Long-term use of OTC medications (e.g. loperimide, hydrochloride [Imodium]) can produce dependence. • Some antidiarrheal agents can cause drowsiness (e.g. diphenoxylate hydrochloride [Lomotil] and should not be used when driving an automobile or running machinery. • Kaolin-pectin preparations (e.g., Kaopectate) may absorb nutrients. • Bulk laxatives and other absorbaents may be used to help bind toxins and absorb excess bowel liquid. • Bismuth preparations (e.g., Pepto-Bismol), often used to treat "traveler's diarrhea" may contain aspirin and should not be given to children and teenagers with chickenpox, influenza, and other viral infections.

The major goals for clients with fecal elimination problems are to

• Maintain or restore normal bowel elimination pattern • Maintain or regain normal stool consistency • Prevent associated risks such as fluid and electrolyte imbalance, skin breakdown, abdominal distention, and pain