Bowel Elimination Test
diarrhea lasting longer than 24-36 hours
pt can be given full liquids, cooked fruit and vegetables such as applesauce or carrots. Also bananas and aged cheeses.
Stress Incontinence
raised abdominal pressure which causes urine to leak out of the bladder.
Cleansing Enemas
relieve constipation or empty bowels
Normal characteristics of feces
soft, formed, light yellowish-brown to dark brown, and slightly odiferous, and falls into a slightly curved shaped
high enema
starts same as regular enema. After instilling half of enema solution, reposition pt first to supine postion and then to the right lateral side lying position to administer remaining solution
The nurse is most likely to report which finding to the primary care provider for a client who has an established colostomy?
stoma color is deep red or purple
Kegels
strengthen pelvic floor
Ileostomy
surgical procedure that creates an opening from the ileum through the abdominal wall to function as an anus
Peristalsis
the process of wave-like muscle contractions of the alimentary tract that moves food along. Begins in esophagus and continues to rectum.
Steatorrhea
undigested fat, floats
Kayexalate Enema
used to lower a high potassium level
Oil Retention Enemas
used to soften hard stool of an impaction 90-120 mL should be instilled an hour before removal of impaction
Impaction
Presence of large or hard fecal mass in the rectum or colon
Total Incontinence
loss of urine w/ no warning
A client is scheduled for a colonoscopy. The nurse will provide information to the client about which type of enema?
low, small volume
Urge Incontinence
overactive bladder- inability to keep urine long enough to get to the restroom
Vagus nerve stimulation signs
pallor, clammy skin, PR <60 bpm ...
enema inducing vagal response
-Stop enema -Remove tube -Put pt supine -Assess pulse, skin color, and whether pt diaphoretic -Call for assisstance, but dont leave pt -Pulse below 60, then place pt in shock position, with head lower than feet -Assess BP as soon as cuff is available -Supply oxygen if needed
What are the steps in order of priority for application of an ostomy appliance?
1. Assess the stoma & skin 2. Remove the used pouch & barrier 3. Perform hand hygiene + don gloves 4. Cleanse the peristomal area with warm water 5. Press the adhesive backing of the pouch against the skin 6. Cut the opening of the appliance 1/16 of an inch larger than stoma
The nurse is preparing to administer an enema to an adult client. Which interventions should the nurse plan to perform for this procedure? Select all that apply.
Apply disposable gloves, Lubricate the enema tube and insert it approximately 4 inches.,Clamp the tubing if the client expresses discomfort during the procedure., Ensure that the temperature of the solution is between 100° F (37.8° C) and 105° F (40.5° C).
Which statement provides evidence that an older adult who is prone to constipation is in need of further teaching? A. "I need to drink one and a half to 2 quarts of liquid each day" B. "I need to take a laxative such as milk of magnesia or if I don't have a BM every day" C. "If my bowel pattern changes on its own, I should call you" D. "Eating my meals at regular times is likely to result in regular bowel movements"
B. I need to take a laxative such as milk of magnesia or if don't have a BM every day
A 6-month-old infant has severe diarrhea. The major problem associated with severe diarrhea is: A. Pain in the abdominal area B. Irritation of the perineal and rectal area C. Electrolyte and fluid loss D. Presence of excessive flatus
C. Electrolyte and fluid loss
Vagus Nerve stimulation symptoms
Complaints of chest pain ,chest heaviness or pressure,shortness of breath or inability to breathe,dizziness,feeling like he or she is going to faint,nausea,Only one sign or symptom required to stop and remove enema.
Clients should be taught that repeatedly ignoring the sensation of needing to defecate could result in which of the following?
Constipation
The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse should assist the client to which position?
Left Sims' position, with the head of the bed flat
hyperactive bowel sounds
More than 30 per minute or continuous
Which factors contribute to the problem of stress incontinence?
Obesity, sneezing
The chart describes characteristics of various types of enemas. Which type of enema has the highest risk of complications?
Tap water
Tap water emema
VOLUME - 500 to 1000 mL PURPOSE - cleaning RESTRICTIONS - hypotonic. Do not use for infants, children, or patients with congestive heart failure. Could result in fluid volume overload
stoma
a mouth or mouthlike opening (in reference to ostomy here)
chyme
a semiliquid mass of partially digested food that passes from the stomach through the pyloric sphincter into the duodenum
Melena
abnormally dark, tarry feces containing blood, or has old blood odor
Bladder training
assisting pt. to the bathroom @ set times of the day
Normal Flora
bacteria used to help prevent infection + maintain health
Overflow Incontinence
bladder is distended due to obstruction - prevents bladder from emptying properly
frank blood
blood that is bright red and visible to the naked eye
too much fiber
can cause flatus and constipation
Possible causes of constipation and diarrhea
change in activity level -change in dietary and fluid intake -side effects of medication -side effects of surgery -pregnancy -high stress levels and emotional problems -laxative abuse -aging process -structural changes -chemical changes -food allergies
Characteristics of feces
color, shape, consistency, odor, and frequency
gastroenteritis
common name for bacterial or viral infections of the GI trac
tenesmus
cramping identified by increased rectal pressure and a feeling of the need to defecate.
Bowel Sounds
Gurgles, clicks, and tinkling sounds in bowel.
An older client complains of chronic constipation. Which instructions should the nurse give to the client?
Increase fluids to at least eight glasses a day.
borborygmi bowel sounds
excessively loud and gurgling, with a noise like splashing
hypoactive bowel sounds
fewer than 5 per minute
diverticulosis
condition occurs when the muscular wall of the colon weakens and separates, allowing small pouches or pockets of the inner wall to protrude outward. Pouches easily trap fecal material and become inflamed.
Foods high in fiber content
-apples, unpeeled,artichokes, beans , blueberries ,broccoli,cabbage,carrots,cauliflower,cherries,corn,dried fruits,flax-seed,legumes ,nuts,oatmeal,oranges,pears, unpeeled,plums,popcorn,prunes,raisins,raspberries,strawberries,sunflower seeds,whole grain breads ,whole grain cereals ,whole grain flour
Contradictions to enemas
-rectal surgery -severe bleeding hemorrhoids -ulcerative colitis or Crohn's disease -rectal fissure -rectal cancer -excessive bleeding potential due to disease or medication -certain heart conditions such as myocardial infarction or unstable angina
Flatus
gas in the digestive tract or expelled through the anus
Occult blood
hidden blood
Which information should the nurse include when reinforcing client teaching regarding ostomy care? Select all that apply.
Empty pouch when 1/3 to ½ full.,The stoma should be moist and pink to red.,The skin barrier should be within 1/16 to 1/8 inch of the stoma., Change the appliance about every 3 days, or sooner if it is leaking effluent.
The nurse evaluates that there is a need for further teaching on bowel elimination when the client makes which statement?
I need to decrease fiber in my diet.
A client receiving iron supplements (ferrous sulfate) is complaining of constipation and the stool that is passed is black. Which information is appropriate for the nurse to share with the client? Select all that apply.
Increase your fluid intake.,Include more fiber in your diet.,Ferrous sulfate changes the color of stool to black, Iron slows colonic acid and often leads to constipation.
Soapsuds
increase peristalsis .. 5ml of pure castile soap per 1000 mL of water or normal saline
enema tube insertion
insert tip of tubing 3 to 4 inches
A client has been diagnosed with functional incontinence. Which interventions are appropriate to care for this type of incontinence? Select all that apply.
Schedule toileting every 2 hours.,Modify clothing for easy removal.,Assess environment for obstacles.,Set up schedule of cues such as mealtimes, awakening, and bedtime.
steatorrhea
the presence of greater than normal amounts of fat in the feces which are frothy and foul smelling and floating. EX. a symptom of disorders of fat metabolism and malabsorption syndrome such as Crohn's disease.
pyloric sphincter
the sphincter muscle of the pylorus that separates the stomach from the duodenum. Chyme passes through and into small intestine
