Fundamentals - bowel elimination

Bristol Stool Chart - type 7

watery, no solid pieces (entirely liquid)

peristaltic movements in the intestine

•Peristalsis is under control of the nervous system. •Contractions occur every 3 to 12 minutes. •One-third to one

Which food is a recommended for an older adult who is constipated? A. Cheese B. Fruit C. Cabbage D. Eggs

B. Fruit

shades of poop - Blood-stained or red

Blood in your poop could be a symptom of cancer. Always see a doctor right away if you find blood in your stool.

A nurse should recognize that nasogastric intubation is indicated to relieve gastric distension for which of the following patients? A) A 6 y.o child who drank a toxic substance B) A 60 y.o admitted with gastrointestinal hemorrhage C) A 40 y.o with post op bowel obstruction D) A 20 y.o with malabsorption syndrome

C) A 40 y.o with post op bowel obstruction. a nasogastric tube should be placed for decompression for the removal of secretions. this will assist in relieving abdominal distention

During report, a nurse is informed that a patient has a nasogastric tube connected to continuous suction. The nurse should recognize that this patient must have which of the following types of tube? A) Levin B) Sengstaken-Blakemore C) Salem Pump D) Ewald

C) Salem Pump A salem sump is the only type of tube that allows for continuous suction. The tube has two lumens; one removes gastric contents and the other serves as an air vent. The vent allows air to enter the stomach, allowing the tube to float freely and preventing damage to the gastric mucosa.

variables influencing bowel elimination - older adult

Constipation is often a chronic problem; diarrhea and fecal incontinence may result from physiologic or lifestyle changes.

variables influencing bowel elimination - child, adolescent, adult

Defecation patterns vary in quantity, frequency, and rhythmicity.

Shades of poop - yellow

Greasy, foul-smelling yellow poop indicates excess fat, which could be due to a malabsorption disorder like celiac disease.

shades of poop - Light-colored, white, or clay-colored

If it's not what you're normally seeing. It could mean a bile duct obstruction. Some meds could cause this too. See a doctor

Bristol Stool Chart - type 3

Like a sausage but with cracks on surface

variables influencing bowel elimination - toddler

Physiologic maturity is the first priority for bowel training.

A nurse is obtaining a health history from a young adult patient who has a colostomy. The patient reports frequent episodes of loose stools over the last month, but has no signs of infection or bowel obstruction. He reports that his concerns about leakage have limited social activities. Which of the following should the nurse recommend? a) Consume foods that are low in fiber content b) Take an ounce of mineral oil twice a day c) Add buttermilk and cranberry juice to the diet d) Increase water intake to 3 to 3.5 L per day

a) Consume foods that are low in fiber content. Foods low in fiber help thicken the stool; examples include rice, noodles, white bread, cream cheese, lean meats, fish, and poultry. Mineral oil produces laxative action by lubricating the stool and reducing water absorption from the stool. This will not relieve diarrhea. Buttermilk and cranberry juice can help control odor, but they do not relieve diarrhea.

A nurse is preparing to administer the first of two large volume, cleansing enemas prescribed for a patient in preparation for a diagnostic procedure. Which of the following is an appropriate step in the procedure? a) Warm the enema solution prior to instillation b) Prepare 1500 mL of enema fluid c) Use tap water as the enema fluid d) Hang the enema container 24 inches above the anus

a) Warm the enema solution prior to instillation. It is important to warm the enema solution because cold fluid can cause abdominal cramping. The solution should not be too hot, though, because hot fluid can injure the intestinal mucosa.

A patient who has bladder cancer tells the nurse that, of the various urinary diversion options the surgeon presented, she prefers one that will allow her to have some control over urinary elimination. The nurse should explain the option that will allow that is a) a Kock's pouch b) an ileal conduit c) a cutaneous ureterostomy d) a nephrostomy

a) a Kock's pouch. This is a continent ileal bladder conduit that does not require an external drainage collection device because the patient self-catheterizes every 2 to 4 hours to remove urine. The device will control the patient desires. An ileal conduit is a passageway for urine to flow from the kidneys to the outside of the body. With this type of diversion, urine flows as it is produces, so the patient will not be able to control it. A cutaneous ureterostomy allows urine to flow from a ureteral opening to the outside of the body. Urine flows through the stoma as it is produces, so the patient will not be able to control it. A nephrostomy allows urine to flow from the kidney to the outside of the body. Urine flows through the stoma as it is produced, so the patient will not be able to control it.

A young woman has just consumed a serving of ice cream pie and develops severe cramping and diarrhea. The school nurse suspects the woman is: a) lactose intolerant b) deficient in fiber c) experiencing infectious diarrhea d) allergic to sugar

a) lactose intolerant Many people have difficulty digesting lactose (the sugar contained in milk products). The breakdown of lactose into its component sugars, glucose and galactose, requires a sufficient quantity of the enzyme lactase in the small intestine. If a person is lactose-deficient, alterations of bowel elimination, including formation of gas, abdominal cramping, and diarrhea, can occur after ingestion of milk products.

A client with constipation has been instructed to increase their fluid intake. The nurse's best response is that the client should increase his intake of: a) water b) grape juice c) iced tea d) sports drinks

a) water Recommendations to promote regular defecation include a fluid intake of 2,000 to 3,000 mL. Water is recommended as the fluid of choice because fluids containing large amounts of caffeine from ice tea and coffee and sugar from juices may have a diuretic effect. Sports drinks are often used in re hydrate and water should be promoted over sports drinks.

A woman age 76 years has informed the nurse that she has begun using over-the-counter laxatives because her friend told her it was imperative to have at least one bowel movement daily. How should the nurse best respond to this client's statement? a) most older adults only have a bowel movement every 2 to 3 days, actually, so I'd encourage you to taper off your laxatives. b) Actually, people's bowel patterns can vary a lot and some people don't tend to go every day. c) That's correct, but be sure that you don't increase your laxative doses over time. d) Your friend is correct in her assessment, but it would likely be better to exercise and drink more instead of using medications.

b) Actually, people's bowel patterns can vary a lot and some people don't tend to go every day. Elimination patterns vary widely among individuals, and the expectation of a daily bowel movement is not realistic for many healthy people. This client may not require pharmacologic interventions.

A nurse is teaching a patient with a new ileostomy about incorporating preventive strategies at home. To prevent excoriation and breakdown of the peristomal skin, the nurse should instruct the patient to a) Apply hydrocortisone cream to the skin when changing the appliance b) Empty the pouch when it is no more than half full c) Wash the peristomal skin frequently with deodorizing soap and water d) Choose a time shortly after a meal for replacing the pouch

b) Empty the pouch when it is no more than half full. Waiting until the pouch is more than half full increases the risk of leakage. Ileostomy effluent is irritating to peristomal skin, so patients should replace the pouch when it is one third to one half full.Patients should avoid the use of soap, especially oil or lotion based soaps. They leave a residue that can interfere with pouch adhesion and increase the risk of leakage. They should cleanse the skin and warm tap water. For times when soap is essential and if their provider allows it, they should only use a mild, pH balanced soap.

A nurse is caring for a client with constipation. The incidence of constipation tends to be high among clients that follow which diet? a) a diet lacking in meat and poultry products b) a diet lacking in fruits and vegetables c) a diet lacking in glucose and water d) a diet consisting of whole grains, seeds, and nuts

b) a diet lacking in fruits and vegetables The incidence of constipation tends to be high among clients whose dietary habits lack sufficient rawa fruits adn vegetables, whole grains, seeds, and nuts, all of which contain adequate fiber. Dietary fiber, which becomes undigested cellulose, is important because it attracts water within tthe bowel, resulting in bulkier stool that is mroe quickly and easily eliminated. A diet lacking in glucose and water will cause dehydration first and then constipation, depending on other constituents of the diet. Diets consisting of whole grains, seeds, and nuts provide fiber, which helps in bowel movement. A diet lacking in meat and poultry products need not necessarily lead to constipation.

The home care nurse visits a client and is reviewing the medications that the client uses. Which medication would the nurse identify as acting directly on the intestine to slow bowel motility, or to absorb excess fluid in the bowel? a) laxative b) antidiarrheal agent c) suppository d) antiflatulence agent

b) antidiarrheal agent Antidiarrheal agents act directly on the intestine to slow bowel motility or to absorb excess fluid in the bowel. Antiflatulence agents are used to relieve gas. Laxatives promote evacuation of hardened stool from the bowel. Suppositories, when inserted into the rectum, melt and can be absorbed for systemic or local effects.

A nurse is assessing a client with diarrhea. During physical examination, the nurse inspects the abdomen. Which action would the nurse perform next? a) palpation b) auscultation c) percussion d) perirectal examination

b) auscultation The nurse should conduct auscultation after inspection, because palpation and percussion may disturb the bowel sounds. Auscultation of the abdomen must be performed before percussion or palpation. Percussion or palpation of the abdomen may stimulate intestinal activity, therefore changing the quality or frequency of bowel sounds. A perirectal examination is performed last.

Upon removing the lid of a tray for a client who is lactose intolerant, the nurse discovers which food is not permitted in this client's diet? a) lettuce salad b) custard c) baked potato d) chicken

b) custard The client should not be permitted to eat the custard because it is prepared using milk. Clients who are lactose intolerant cannot digest the simple sugar lactose found in milk and milk products. Chicken is a protein. Lettuce salad and potato are vegetables.

Which statement best explains why digital removal of stool is considered a last resort after other methods of bowel evacuation have been unsuccessful? a) it often causes rebound diarrhea and electrolyte loss b) digital removal of stool may cause parasympathetic stimulation c) most clients will not consent to have digital removal of stool d) nurses find the procedure distasteful and difficult to perform

b) digital removal of stool may cause parasympathetic stimulation The procedure may stimulate a vagal response, which increases parasympathetic stimulation

Which medical diagnosis is most likely to necessitate testing for fecal occult blood? a) cirrhosis of the liver b) peptic ulcer c) chronic constipation d) gastroesophageal reflux disease (GERD)

b) peptic ulcer Any health problem that involves bleeding of the GI tract, such as peptic ulcer disease, may require fecal occult blood testing (FOBT). Constipation does not indicate a need for FOBT unless hardened stool is suspected of causing GI trauma. Similarly, GERD may require FOBT only if esophageal bleeding is suspected. Liver disease is not a common indication for FOBT.

The nurse has presented an educational in-service about caring for clients who have newly created ostomies. The nurse asks participants, "How will you know when a client begins to accept the altered body image?" Which responses by participants indicates a correct understanding of the material? Select all that apply. a) the client uses spray deodorant several times an hour to mask odor. b) the client makes neutral or positive statements about the ostomy. c) the client agrees to take prescribed antidepressants. d) The client is willing to look at the stoma. e) the client expresses interest in learning self-care.

b) the client makes neutral or positive statements about the ostomy. d) The client is willing to look at the stoma. e) the client expresses interest in learning self-care. d) The client is willing to look at the stoma. e) the client expresses interest in learning self-care.

A nurse is assessing the stoma of a client with an ostomy. Which intervention should the nurse perform when providing peristomal care to the client to preserve skin integrity? a) avoid using commercial skin preparations b) wash it with a mild cleanser and water c) avoid applying a barrier substance d) clean it with a dry, cotton bandage

b) wash it with a mild cleanser and water Washing the stoma and surrounding skin with a mild cleanser and water, and patting it dry can preserve skin integrity. When using a cleanser, it is important to rinse the area thoroughly. Any residue left on the skin can cause problems with the wafer adhering. Another was to protect the skin is to apply barrier substances such as karaya, a plant substance that becomes gelatinous when moistened, and commercial skin preparations around the stoma. Cleaning the stoma with just a dry, cotton bandage is not the correct way of preserving skin integrity.

A nurse is administering an enema medicated with sodium polystyrene sulfonate (Kayexalate) to an older patient who has hyperkalemia. The nurse should insert the tip of the rectal tube a) 2.5 cm to 3.75 cm (1 to 1.5 in) b) 5 cm to 7.5 cm (2 to 3 in) c) 7.5 cm to 10 cm (3 to 4 in) d) 10 cm to 12.5 cm (4 to 5 in)

c) 7.5 cm to 10 cm (3 to 4 in)

Which client is most likely to require interventions in order to maintain regular bowel patterns? a) A client who has a history of atrial fibrillation requiring daily anticoagulants. b) A client with hypertension who takes a diuretic and adrenergic blocker each morning. c) A client whose neuropathic pain requires multiple doses of opioids each day. d) A woman 59 years of age has recently begun hormone replacement therapy.

c) A client whose neuropathic pain requires multiple doses of opioids each day. Opioids have a very high potential to cause constipation. Anticoagulants, hormone replacements, diuretics, and adrenergic blockers are not among the meditations commonly implicated in cases of constipation.

While a nurse is administering a cleansing enema, the patient reports abdominal cramping. Which of the following is the appropriate intervention? a) Measure the patient's vitals b) Notify the primary care provider c) Lower the enema fluid container d) Stop the enema instillation

c) Lower the enema fluid container. Some abdominal cramping is to be expected during enema administration. To ease the patient's discomfort, the nurse should slow the rate of instillation by reducing the height of the enema fluid container.

A nurse is providing preoperative teaching for a patient who has colon cancer. The surgeon informed the patient that his entire large intestine and rectum will be removed. The nurse should explain the type of ostomy he will have is a) a cecostomy b) a loop colostomy c) an ileostomy d) a decending colostomy

c) an ileostomy. After removing the entire large intestine and the rectum, the surgeon will create an ileostomy to divert feces from the small intestine to the abdominal surgace and into an ostomy pouch. A cecostomy is a surgical opening created in the cecum, the first section of the large intestine, with an opening to the abdominal wall for diversion of feces. This is not possible if the entire large intestine is removed. A loop colostomy involves a large and usually temporary stoma the surgeon creates by pulling a loop of intestine onto the abdominal wall and creating two openings in the loop. This is not possible if the entire large intestine is removed. A descending colostomy is created when the surgeon removes a portion of the descending colon and uses the remaining section to create a stoma on the outer surface of the abdomen. This is not possible if the entire large intestine is removed.

Which statement about ostomy irrigation is true? a) daily irrigation is necessary to assure passage of stool from an ileostomy b) clients who want to self-irrigate their colostomy must sign a contract and agree to use the equipment only for its intended use c) postoperative ostomy prolapse can be avoided by twice daily irrigation for the first 4 weeks after surgery d) For some clients, regularly scheduled colostomy irrigation can be used to establish a predictable pattern of elimination

d) For some clients, regularly scheduled colostomy irrigation can be used to establish a predictable pattern of elimination. This approach allows for the use of a small covering over the colostomy between irrigations, instead of a regular appliance

A nurse is preparing an older adult patient for an enema. The nurse should assist the patient to which of the following positions? a) Prone b) Dorsal recumbent c) Right lateral with both knees at chest d) Left lateral with the right leg flexed

d) Left lateral with the right leg flexed. This position makes it easier for the enema solution to flow by gravity into the sigmoid and descending colon. The flexed leg promotes exposure of the anus for insertion of the rectal tube.

A nurse is teaching a patient how to apply an extended wear skin barrier. Which of the following strategies should the nurse instruct the patient to use for maximal adherence? a) Use an oil based lotion on the peristromal area b) Apply the skin barrier while the skin is slightly moist c) Leave the residue from the previous appliance on the skin d) Press gently around the barrier for 1 to 2 minutes

d) Press gently around the barrier for 1 to 2 minutes. The pressure sensitive tackifiers and heat sensitive polymers of the skin barrier require adequate pressure and warmth (from the fingers) to ensure adherence.

During the inspection of a client's abdomen, the nurse notes that it is visibly distended. The nurse should proceed with the client's abdominal assessment by next performing: a) light palpation b) percussion c) deep palpation d) auscultation

d) auscultation When performing an abdominal assessment, the nurse should proceed from inspection to auscultation, since performing palpation or percussion to auscultation may disturb normal peristalsis and confound the assessment.

A client's last bowel movement was 4 days ago and oral laxatives and dietary changes have failed to prompt a bowl movement. How should the nurse position the client in anticipation of administering a cleansing enema? a) right side-lying b) supine c) prone d) left side-lying

d) left side-lying When administering a cleansing enema, the client is most often positioned in a left side-lying (Sims') position, though positioning has not been shown to appreciably alter the result of a cleansing enema.

A nurse is administering a prescribed solution of cottonseed oil to a client during an enema. What is the outcome of the use of cottonseed? a) distends rectum and moistens stool b) distends rectum and irritates local tissue c) irritates local tissue d) lubricates and softens stool

d) lubricates and softens stool Cottonseed, olive oil, or mineral oil lubricates and softens the stool so that it can be expelled more easily during a retention enema. Tap water and normal saline solution distend the rectum and moisten the stool, where as a soap and water solution not only distends the rectum and moistens the stool but also irritates the local tissue. A hypertonic saline solution irritates local tissue.

The nurse is caring for an older adult client with diarrhea. Which assessment finding requires immediate nursing intervention? a) heart rate 88 beats per minute b) temperature 99 degrees F c) blood pressure 120/70 mm Hg d) skin turgor response 6 seconds

d) skin turgor response 6 seconds. Skin turgor response that is greater than 3 seconds, especially in an older adult client, requires nursing intervention. Older adults with diarrhea can more easily become dehydrated and develop fluid and electrolyte imbalances. All other assessment findings are normal.

Medications Affecting Bowel Elimination

- Aspirin, anticoagulants: pink to red to black stool - Iron salts: black stool - Antacids: white discoloration or speckling in stool - Antibiotics: green-gray color

Foods Affecting Bowel Elimination

- Constipating foods: cheese, lean meat, eggs, pasta - Foods with laxative effect: fruits and vegetables, bran, chocolate, alcohol, coffee - Gas-producing foods: onions, cabbage, beans, cauliflower

variables influencing bowel elimination

- Developmental considerations - Daily patterns - Food and fluid - Activity and muscle tone - Lifestyle - Psychological variables - Pathologic conditions (chronic neurologic condition) - Medications - Diagnostic studies - Surgery and anesthesia

intake and output

- Important for patients with heart failure - Intake-bedside tray, irrigated fluid, IV fluid, blood - Output-Urinal, bedpan, Foley catheter, emesis basin, estimated blood loss, NG output - If incontinent-document times of voiding or BM - May weigh diapers or depends

nasogastric (NG) tube

- Inserted to decompress or drain the stomach - Allow the GI tract to rest before or after abdominal surgery to promote healing - Monitor gastrointestinal bleeding

Bristol Stool Chart - type 4

like a sausage or snake, smooth and soft

Bristol Stool Chart - type 2

sausage shaped but lumpy

bristol stool chart - type 1

separate hard lumps, like nuts (hard to pass)

When checking for nasogastric tube placement, he nurse should conduct which of the following procedures? A) Instill 20 mL of air into the tube and listen for a whooshing sound B) Aspirate stomach contents and check the pH C) Aspirate stomach contents and check the color D) Auscultate lung sounds

B) Aspirate stomach contents and check the pH

variables influencing bowel elimination - infants

Characteristics of stool and frequency depend on formula or breast feedings.

small and large intestine

Large Intestines: Primary organ of bowel elimination Extends from the ileocecal valve to the anus - Functions *Absorption of water *Formation of feces *Expulsion of feces from the body

Shades of poop - brown

you're fine. Poop is naturally brown due to the bile produced in your liver

Bristol Stool Chart - type 5

Soft blobs with clear-cut edges (passed easily)

The nurse is educating a client with a new colostomy about gas-producing food should the client avoid to prevent gas build-up in the colostomy bag? a) steamed rice b) cooked pasta c) baked beans d) fresh lettuce

c) baked beans The nurse should include information about eliminating gas-producing foods in this client's teaching plan to avoid excess gas formation and accumulation, which could cause the colostomy bag to overfill and possibly lead to detachment and leakage. Gas-producing foods include onions, cabbage, beans, cauliflower, and beer.

Methods of Emptying the Colon of Feces

- Diet Changes and Medications - Enemas (Cleansing; Retention: Oil-retention, Carminative (Flatus), Medicated, Anthelmintic (parasites)) - Rectal suppositories - Oral intestinal lavage - Digital removal of stool

Types of visualization studies - direct

- Esophagogastroduodenoscopy (EGD) - Colonoscopy-invasive (Explain what they do during procedure may relieve patient's anxiety) - Sigmoidoscopy * Non-invasive should be done first*

nasogastic tubes

- Inserted to decompress or drain the stomach of fluid or unwanted stomach contents - Used to allow the gastrointestinal tract to rest before or after abdominal surgery to promote healing - Inserted to monitor gastrointestinal bleeding

Physical assessment of the GI System

- Inspection: observe contour, any masses, scars, or distention - Auscultation: listen for bowel sounds in all quadrants (Note frequency and character, audible clicks, and flatus; Describe bowel sounds as hypoactive, hyperactive, absent or infrequent.) - Percussion and palpations: performed by advanced practice professionals - Rectal Exam: Lesions, ulcers, hemorrhoids, signs of incontinence or poor hygiene

guidelines for ostomy care

- Keep the patient as free of odors (as possible) - Inspect the patient's stoma regularly. - Note the size of the stoma, which usually stabilizes within 6 to 8 weeks. - Keep the skin around the stoma site (peri-stomal area) clean and dry. - Measure the patient's fluid intake and output. - Explain and begin self-care (Explain each aspect of care to the patient and explain what his or her role will be when he or she begins self-care) - Encourage the patient to participate in care and to look at the ostomy.

bowel-training program

- Manipulate factors within the patient's control. (Food and fluid intake, exercise, and time for defecation; eliminate a soft, formed stool at regular intervals without laxatives.) - When achieved, continue to offer assistance with toileting at the successful time.

Stool collection - procedure and process

- Medical aseptic technique is imperative. - Hand hygiene, before and after glove use, is essential. - Wear disposable gloves. - Do not contaminate outside of container with stool. - Obtain stool and package, label, and transport according to agency policy. - Void first so that urine is not in stool sample. - Defecate into the container rather than toilet bowl. - Do not place toilet tissue in the bedpan or specimen container. - Notify nurse when specimen is available.

Diarrhea - preventing food poisoning

- Never buy food with damaged packaging. - Take items requiring refrigeration home immediately. - Wash hands and surfaces often. - Use separate cutting boards for foods. - Thoroughly wash all fruits and vegetables before eating. - Do not wash meat, poultry, or eggs to prevent spreading microorganisms to sink and other kitchen surfaces. - Never use raw eggs in any form. - Do not eat seafood raw or if it has an unpleasant odor. - Use a food thermometer to ensure cooking food to safe internal temperature. - Keep food hot after cooking; maintain safe temperature of 140°F or above. - Give only pasteurized fruit juices to small children.

Ostomy

- Ostomy: a surgically formed opening from the inside of an organ to the outside - Stoma: the part of the ostomy that is attached to the skin, is formed by suturing the mucosa to the skin - Illeostomy & Colostomy

Promoting Regular Bowel Habits - patients

- Patients on bedrest taking constipating medicines - Patients with reduced fluids or bulk in their diet - Patients who are depressed - Patients with central nervous system disease or local lesions that cause pain while defecating

Verifying NG tube placement

- Radiographic examination - Measurement of aspirate pH - Visual assessment of aspirate - Measurement of tube length and measurement of tube marking - Monitoring of carbon dioxide - Auscultation of air injected into a NG tube has proved unreliable as an indicator of tube placement

Promoting Regular Bowel Habits

- Timing (1-3 days without pain) - Positioning -facilitate downward pressure - Privacy-public bathroom - Nutrition-fluids, fiber, diet - Exercise (Abdominal settings, Thigh strengthening) - Medication/CNS or other contributing condition - Report Changes in patterns/Risk Constipation

Types of visualization studies - indirect

- Upper gastrointestinal (UGI) - Small bowel series - Barium enema - Abdominal ultrasound - Magnetic resonance imaging (MRI) and CT * Non-invasive should be done first*

10 Tips to promote healthy bowel habits

- take probiotics - drink more water - eat fermented foods - avoid tea, coffee, alcohol - eat foods high in fiber - do not hold back stool - routine stool - reduce stress and think positively - daily exercise - take a fiber supplement

A nurse is performing a nasogastric intubation. Which of the following actions should the nurse take immediately after inserting the tube to the predetermined length? A) Inspect the oropharynx with a penlight and a tongue blade B) Obtain an x-ray examination of the chest and abdomen C) Tape the tube securely in place with a tube holder device D) Aspirate Gastric contents

A) Inspect the oropharynx with a penlight and a tongue blade. after insertion, the nurse should immediately inspect the oropharynx to check for kinks and to ensure that the tube is not coiled.

A nurse is caring for a patient who has a newly inserted nasogastric tube. Which of the following methods is appropriate for verifying the initial placement? A) x-ray examination of the chest and abdomen B) Auscultation of injected air C) pH measurement of contents D) color of gastric contents

A) X-ray examination of the chest and abdomen. x-ray exam is the gold standard for confirming the initial placement of a nasogastric tube

Tell whether the following statement is true or false. When collecting stool using the technique "timed specimen," the nurse should consider the first stool passed by the patient as the start of the collection period. A. True B. False

A. True When collecting stool using the technique "timed specimen," the nurse should consider the first stool passed by the patient as the start of the collection period.

A patient recovering from gastric surgery remains NPO and has a nasogastric tube connected to suction. which of the following actions should the nurse take to prevent dry mucous membranes? A) Allow t he patient to suck on ice chips B) Provide frequent mouth care C) Apply the petroleum jelly to the patient's naris D) Offer throat lozenges for the patient to sue

B) Provide frequent mouth care. frequent mouth care is a nursing intervention that prevents mucous membranes from drying.

A nurse is caring for a patient who has a nasogastric tube connected to suction. Which of the following should indicate to the nurse that the tube has become occluded? A) active bowel sounds B) passing flatus C) Increase gastric secretions D) Patient's report of nausea

D) Patient's report of nausea Tubes connected to suction decompress the GI tract. This is needed when peristalsis is absent. If gastric secretions are unable to move through the GI tract and if the nasogastric tube is unable to evacuate the stomach due to an occlusion, nausea and vomiting will result.

The nurse is preparing to auscultate the bowl sounds of a client with a nasogastric tube in place set to low intermittent suction. How shall the nurse approach the assessment of bowel sounds and manage the nasogastric tube? a) Disconnect the nasogastric tube from the suction for 1 hour prior to the assessment of bowel sounds b) Allow the low intermittent suction to continue during the assessment of bowel sounds c) Apply continuous suction to the nasogastric assessment of bowel sounds d) Disconnect the nasogastric tube from suction during the assessment of bowel sounds

Disconnect the nasogastric tube from suction during the assessment of bowel sounds If the client has a nasogastric tube in place, disconnect it from the suction during this assessment to allow for accurate interpretation of sounds

diarrhea

Exposure to infection and food borne - Prevention of "food poisoning" - Remove the cause of diarrhea whenever possible (e.g., medication or food poisoning). Nursing Care - Affects youngest and oldest more - Answer call bells immediately. - Give special care to the region around the anus.

Shades of poop - green

Food may be moving through your large intestine too quickly. Or you could have eaten lots of green leafy veggies, or green food coloring.

When using chilled normal saline solution during gastric lavage, the nurse should watch for which of the following complications?

Hypothermia(Iced normal saline can cause a raid loss of electrolytes) rapid infusion of chilled normal saline solution during gastric lavage can cause hypothermia. the nurse must be diligent in monitoring for signs and symptoms of hypothermia, such as bradycardia and cardiac dysrhythmias.

Shades of poop - black

It could mean that you're bleeding internally due to ulcer or cancer. Some vitamins containing iron or bismuth subsalicylate could cause black poop too. Pay attention if it's stinky, and see a doc if you're worried.

Physical assessment of the GI System - inspection and palpation

Lesions, ulcers, fissures (linear break on the margin of the anus), inflammation, and external hemorrhoids Ask the patient to bear down as though having a bowel movement. Assess for the appearance of internal hemorrhoids or fissures and fecal masses. Inspect perineal area for skin irritation secondary to diarrhea or fecal incontinence.

Bristol Stool Chart

Medical aid to classify stool. Types 1 and 2 indicate constipation, Types 3 and 4 indicate ideal stools, Types 5, 6 and 7 indicate diarrhea. Always look at your own stool. It is important to know what your normal is and what should be normal.

A nurse is preparing to administer a cleansing enema to a patient who is prone to fecal incontinence due to poor sphincter control and is unlikely to retain the enema solution. Which of the following interventions is appropriate for this patient? a) Place the patient in the dorsal recumbent position on a bedpan b) Administer the enema while the patient sits on the toilet c) Administer an antidiarrheal medication 3 hr prior to the enema d) Instill 200mL of fluid at 15 minute intervals times four

a) Place the patient in the dorsal recumbent position on a bedpan. A patient who has poor sphincter control might not be able to retain the enema solution at all. Repositioning the patient over the bedpan in the dorsal recombent position after insertion of the rectal tube will help contain the fluid likely to be expelled promptly and thus help maintain the patient's dignity.

A nurse assessing a client with an ostomy appliance documents the condition "prolapse" in the client chart and notifies the physician. Which statement describes this condition? a) The stoma is protruding into the bag and may become twisted. b) The peristomal skin is excoriated or irritated because the appliance is cut to large. c) The bag continues to come loose and become inverted. d) The system has leaks or poor adhesion leading to noticeable odor.

a) The stoma is protruding into the bag and may become twisted. During prolapse, the stoma is protruding into the bag. The nurse should have the client rest for 30 minutes and, if the stoma is not back to normal size within that time, notify the physician. If stoma stays prolapsed, it may twist, resulting in impaired circulation to the stoma.

A nurse has auscultated the abdomen in all four quadrants for 5 minutes and has not heard any bowel sounds. How would this be documented? a) Auscultated abdomen for bowel sounds. Bowel not functioning. b) All four abdominal quadrants auscultated. Inaudible bowel sounds. c) Client may have bowel sounds, but they can't be heard. d) Bowel sounds auscultated. Client has no bowel sounds.

b) All four abdominal quadrants auscultated. Inaudible bowel sounds. In the correct response, the nurse has documented what was done during the assessment and has noted that bowel sounds are inaudible. "Auscultated abdomen for bowel sounds. Bowel not functioning" is not appropriate as the nurse has diagnosed that the bowel is not functioning which is a medical diagnosis. The documentation lacks the assessment. "Bowel sounds auscultated. Client has no bowel sounds" is not appropriate does not indicate where bowel sounds were auscultated. "Client may have bowel sounds, but they can't be heard" is a subjective statement and does not document the assessment.

A client who is postoperative Day 1 has rung the call light twice during the nurse's shift in order to request assistance transferring to a bedside commode. In both cases, however, the client has been unable to defecate. In light of the fact that the client's last bowel movement was the morning of surgery, what action should the nurse first take? a) Obtain a diet change order to increase the amount of fiber in the client's meals. b) Facilitate a more private setting, such as assisting the client to a bathroom. c) Position the client on his side and administer a glycerin suppository. d) Administer a normal saline enema after obtaining the relevant order.

b) Facilitate a more private setting, such as assisting the client to a bathroom. The client's last bowel movement was one day earlier, so pharmacologic interventions such as suppositories or enemas are not likely warranted at this time. A change in diet may prove helpful, but the nurse's first action should be to provide a setting that is more conductive to having a bowel movement.

A nurse who is administering a return flow enema to a patient should instill 100mL of enema fluid and then a) Instruct the patient to retain the fluid b) Lower the container to allow the solution to flow back out c) Help the patient to the toilet or bedside commode d) Wait 5 min and instill another 100 mL of fluid

b) Lower the container to allow the solution to flow back out. Return flow enemas involve moving 100-200 mL of fluid into and out of the rectum. After instilling the solution, the nurse lowers the container to allow the solution to flow back into the container and then repeats the process five or six times.

A patient who is postoperative is experiencing abdominal distention and is having difficulty expelling flatus. The nurse should anticipate receiving an order from the provider for which of the following types of enemas? a) Cleansing b) Return flow c) Medicated d) Oil-retention

b) Return flow. Return flow enemas are used to expel flatus, stimulate peristalsis, and relieve abdominal distention.

A nurse is providing preoperative teaching for an older adult patient who has diverticulitis and is scheduled for a creation of a double barrel colostomy in the sigmoid colon. Which of the following instructions should the nurse include in the teaching? a) Irrigate both stomas periodically to promote drainage b) Tape a dry gauze pad over the distal stoma to collect drainage c) Change the proximal stroma's appliance every other day d) Expect liquid to drain from both stomas

b) Tape a dry gauze pad over the distal stoma to collect drainage. The distal stoma (also called a mucous fistula) secretes mucus; it does not drain feces. A dry gauze is usually sufficient. With a double barrel colostomy, irrigation might not be necessary at all. If it is, it would only apply to one stoma, not both. Ostomy appliances remain in place for up to 7 days and do not need to be replaced every other day.

An older adult woman who is incontinent of stool following a cerebrovascular accident will have which nursing diagnosis? a) diarrhea related to tube feedings, as evidenced by hyperactive bowel sounds and urgency b) bowel incontinence related to loss of sphincter control, as evidenced by inability to delay the urge to defecate c) fecal retention related to loss of sphincter control, and diminished spinal cord innervation related to hemiparesis d) constipation related to physiologic condition involving the deficit in neurologic innervation, as evidenced by fecal incontinence

b) bowel incontinence related to loss of sphincter control, as evidenced by inability to delay the urge to defecate The most appropriate nursing diagnosis addresses the client's fecal incontinence, related to loss of sphincter control innervation

While the nurse is teaching a patient how to replace her ostomy pouching system, the patient reports that removing the skin barrier is sometimes painful. Which of the following should the nurse suggest? a) Lift up on both sides of the skin barrier simultaneously. b) Release one corner of the barrier and pull it quickly over the stoma c) Push the skin away from the barrier while removing it d) Gently roll the barrier end over end across the stoma

c) Push the skin away from the barrier while removing it. Pushing the skin away from the barrier helps prevent skin stripping, which can be painful and make the skin sensitive to adhesive. If the patient is having difficulty with the initial release of the barrier, it may help if she starts in one corner and gently pulls across the stoma while pushing the skin away from the barrier. Lifting the skin from both sides at once will pull directly on the dermis and possibly traumatize the skin. Rolling the skin barrier end over end will pull directly on the dermis and possibly traumatize the skin.

A nurse is assessing and documenting the eating habits of a client with repeated reports of flatus. Which food item produces gas that could lead to flatus? a) fish b) chicken c) cabbage d) apples

c) cabbage Vegetables such as cabbage, cucumbers, and onions are commonly known for producing gas. Flatulence, or flatus, results from swallowing air while eating, or sluggish peristalsis. Another cause is the gas that forms as a byproduct of bacterial fermentation in the bowel. Apples, fish, and chicken do not produce gas and lead to flatus.

A client scheduled for a colonoscopy is scheduled to receive a hypertonic enema prior to the procedure. A hypertonic enema is classified as which type of enema? a) return-flow enema b) retention enema c) cleansing enema d) carminative enema

c) cleansing enema The most common types of solutions used for cleansing enemas are tap water, normal saline, soap solution, and hypertonic solution. Cleansing enemas are used to relieve constipation or fecal impaction; promote visualization of the intestinal tract by radiographic or instrument examination (colonoscopy); establish regular bowel function; and prevent the involuntary escape of fecal material during surgical procedures. Carminative enemas are classified as retention enemas and are used to expel flatus from the rectum and provide relief from gaseous distention. Return-flow enemas are also occasionally prescribed to expel flatus.

A nurse is performing an abdominal assessment of a client before administering a large-volume cleansing enema. Which assessment technique would be performed last? a) auscultation b) inspection c) palpation d) percussion

c) palpation The abdominal assessment should be performed in the following sequence: inspection, auscultation, percussion, palpation.

Which factor is related to developmental changes in bowel habits for older adult clients? a) milk products cause constipation in clients with lactose intolerance b) increase in dietary fiber can decrease peristalsis c) weakened pelvic muscles lead to constipation d) older adults should peel fruits before eating

c) weakened pelvic muscles lead to constipation Weakened pelvic muscles and decreased activity levels contribute to constipation in older adults. Increasing dietary fiber does not decrease peristalsis. Lactose intolerance is not a developmental change in older adults. Peeling fruit does not impact habits in the older adults.

A nurse is replacing the ostomy appliance for a patient whose newly created colostomy is functioning. After removing the pouch, which of the following should the nurse do first? a) Measure the stroma b) Cover the stroma with gauze c) Remove the backing on the skin barrier d) Cleanse the stoma and the peristomal skin

d) Cleanse the stoma and the peristomal skin. To facilitate the nurse's assessment of the stoma and the peristomal skin, the nurse must remove any effluent adhering to the area.

A nurse is preparing to administer an oil retention enema to a patient who has constipation. The nurse explains that the patient should try to retain the instilled oil for a) as long as it takes to complete the procedure b) about 10 to 15 minutes c) until the next time he feels the urge to defecate d) at least 30 minutes, but preferably as long as he can

d) at least 30 minutes, but preferably as long as he can. The enema will be most effective in softening the stool and lubricating its passageway if the patient retains the oil for as long as he can - 1 to 3 hr if possible. It takes between 30 min and 3 hrs for the oil to exert its therapeutic effect.

A client's recent diagnosis of colorectal cancer has required a hemicolectomy (removal of part of the bowel) and the creation of a colostomy. The nurse would recognize that the client's stoma is healthy when it appears what color? a) off-white or pale pink b) dark or purple-blue c) red and dry d) dark pink and moist

d) dark pink and moist A healthy stoma is dark pink to red and moist. Pallor may suggest anemia and a dark appearance may indicate ischemia.

A 60 year old client is experiencing pain that can be attributed to distention of the veins in her rectum. What health problem is this client most likely experiencing? a) paralytic ileus b) diarrhea c) constipation d) hemorrhoids

d) hemorrhoids Abnormal distention of the veins in the rectum results in the formation of hemorrhoids. This is unrelated to paralytic ileus or diarrhea; hemorrhoids may be a contributor to constipation if the individual ignores the urge to defecate. Constipation is a condition in which there is difficulty in emptying the bowels, usually associated with hardened feces. Diarrhea is a condition in which feces are discharged from the bowels frequently and in a liquid form. Paralytic ileus is an obstruction of the intestine due to paralysis of the intestinal muscles.

Bristol Stool Chart - type 6

fluffy pieces with ragged edges, a mushy stool