Ch.33 Bowel Elimination

meconium movement

(first 24 hours of newborn bowl movement) black, tarry, odorless and stick/loos

Colon

(large intestine) main function is absorption of water and nutrients after ingestion -mucus protects lining from acid in feces and from bacterial activity -excretes flatus (gas) and feces

Characteristics of feces

-75% water & 25% solids -Normal color is brown, resulting from chemical conversion of bilirubin, an orange or dark yellow bile pigment, into urobilin & stercobilin (brown pigments) -Characteristic odor comes from bacterial composition of proteins in the intestine -normally have soft consistency and cylindrical form that approximates the shape of the rectum -Normal bowel amount pattern is individualized

Nursing history assessment for bowel movement

-Client's normal pattern -Description of usual feces -Recent changes -Past problems with elimination -Presence of an ostomy -Factors influencing elimination pattern

Changing and ostomy appliance

-Determine the need for an appliance change -Unfasten belt (if being worn) -Empty the pouch and remove skin barrier -Assess the skin -Clean and dry the stoma (warm water and soap depending on agency policy) -Assess the skin -Prepare an apply skin barrier -Attach pouch (if two piece system) -Document

Ostomy management

-Patients need support -Many agencies have a wound ostomy continence nurse (WOCN) to assist patients -Care of the skin and stoma is important -Ostomy appliances are used to protect the skin, collect the stool and prevent odor -Can provide a leakproof seal for about 3-7 days

Related Nursing Diagnoses

-Risk for Deficient Fluid Volume -Risk for Electrolyte imbalance -Risk for Impaired Skin Integrity -Situational Low Self-esteem -Disturbed Body Image -Deficient Knowledge (Bowel Training, Ostomy Management) -Anxiety

Abnormal infant feces

-black or tarry -red -pale -orange or green

Nursing Diagnoses

-bowel incontinence -constipation -risk for constipation -perceived constipation -diarrhea -dysfunctional gastrointestinal motility

Double-barrel colostomy

-bowel is surgically cut -both ends brought through abdomen -CAN BE REVERSED as tissue heals!!

Inspecting the feces

-color -consistency -shape -amount -odor -abnormal constituents

NORMAL FREQUENCY BOWEL ELIMINATION

1-3 TIMES A DAY OR 2-3 TIMES A WEEK

NORMAL AMOUNT OF BOWEL

150 GRAMS PER DAY DEPENDING ON THE FOOD TYPE

Osmotic Agents

2-4 liters you have to drink. Cleans colon rapidly. Induces colon cleansing. Great prep for colon surgery. Example: colyte or polythylene glycol, "go-lyte"

TO HELP PROMOTE BOWEL ELIMINATION DRINK 6-8 GLASSES A DAY

2500 TO 3000 ML FLUIDS PER DAY

Constipation in Older Adults

3 times more common in females. Reglan is used for nausea/vomitting but now used to increase peristalsis. Common Risk Factors: drug side effects, degenerative diseases, decreased dietary intake, dementia, decreased mobility, dehydration, depression and defecatory dysfunction.

CONSTIPATION

A decrease in a person's normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of dry, hard stool

Fissure

A linear break on the margin of the anus

Which patient will the nurse assess most closely for an ileus?

A patient with surgery for bowel disease and anesthesia Any surgery that involves direct manipulation of the bowel temporarily stops peristalsis. Anesthesia can also cause cessation of peristalsis. This condition, called an ileus, usually lasts about 24 to 48 hours. Fecal impaction, cathartic abuse, and medication to suppress hydrochloric acid will have bowel sounds, but they may be hypoactive or hyperactive.

Barium swallow

AFTER what test should you increase fluids to facilitate passage of barium?

The nurse administers a cathartic to a patient. Which finding helps the nurse determine that the cathartic has a therapeutic effect? a. Reports decreased diarrhea. b. Experiences pain relief. c. Has a bowel movement. d. Passes flatulence.

ANS: C A cathartic is a laxative that stimulates a bowel movement. It would be effective if the patient experiences a bowel movement. The other options are not outcomes of administration of a cathartic. An antidiarrheal will provide relief from diarrhea. Pain medications will provide pain relief. Carminative enemas provide relief from gaseous distention (flatulence).

A 26-year-old woman is being evaluated for vomiting and abdominal pain. Which question from the nurse will be most useful in determining the cause of the patient's symptoms? a. "What type of foods do you eat?" b. "Is it possible that you are pregnant?" c. "Can you tell me more about the pain?" d. "What is your usual elimination pattern?"

ANS: C A complete description of the pain provides clues about the cause of the problem. Although the nurse should ask whether the patient is pregnant to determine whether the patient might have an ectopic pregnancy and before any radiology studies are done, this information is not the most useful in determining the cause of the pain. The usual diet and elimination patterns are less helpful in determining the reason for the patient's symptoms.

A 76-year-old patient with obstipation has a fecal impaction and is incontinent of liquid stool. Which action should the nurse take first? a. Administer bulk-forming laxatives. b. Assist the patient to sit on the toilet. c. Manually remove the impacted stool. d. Increase the patient's oral fluid intake.

ANS: C The initial action with a fecal impaction is manual disimpaction. The other actions will be used to prevent future constipation and impactions.

A 64-year-old woman who has chronic constipation asks the nurse about the use of psyllium (Metamucil). Which information will the nurse include in the response? a. Absorption of fat-soluble vitamins may be reduced by fiber-containing laxatives. b. Dietary sources of fiber should be eliminated to prevent excessive gas formation. c. Use of this type of laxative to prevent constipation does not cause adverse effects. d. Large amounts of fluid should be taken to prevent impaction or bowel obstruction.

ANS: D A high fluid intake is needed when patients are using bulk-forming laxatives to avoid worsening constipation. Although bulk-forming laxatives are generally safe, the nurse should emphasize the possibility of constipation or obstipation if inadequate fluid intake occurs. Although increased gas formation is likely to occur with increased dietary fiber, the patient should gradually increase dietary fiber and eventually may not need the psyllium. Fat-soluble vitamin absorption is blocked by stool softeners and lubricants, not by bulk-forming laxatives

A 73-year-old patient with diverticulosis has a large bowel obstruction. The nurse will monitor for a. referred back pain. b. metabolic alkalosis. c. projectile vomiting. d. abdominal distention.

ANS: D Abdominal distention is seen in lower intestinal obstruction. Referred back pain is not a common clinical manifestation of intestinal obstruction. Metabolic alkalosis is common in high intestinal obstruction because of the loss of HCl acid from vomiting. Projectile vomiting is associated with higher intestinal obstruction.

When caring for a patient with a history of a total gastrectomy, the nurse will monitor for a. constipation. b. dehydration. c. elevated total serum cholesterol. d. cobalamin (vitamin B12) deficiency.

ANS: D The patient with a total gastrectomy does not secrete intrinsic factor, which is needed for cobalamin (vitamin B12) absorption. Because the stomach absorbs only small amounts of water and nutrients, the patient is not at higher risk for dehydration, elevated cholesterol, or constipation.

FIRST NURSING ACTION WHEN STARTING A BOWEL TRAINING PROGRAM IS

ASSESS THE CLIENTS USUAL BOWEL HABITS

Constipation

Abnormal infrequency. Hard stools that are difficult to pass. It's a symptom, not a disease. Less than 3 times a week. Chronic would last greater than 3-4 weeks. Treat with medications but they could also cause.

Emollient: docusate sodium/colace & Senna/Peri-Colace

Action: slow acting, stool softener; has no laxative effect Adverse reactions: do not give within 2 hours of other laxatives; mild cramps

Flatulence

Air or gas in GI tract. Some causes are food like cabbage, cauliflower, beans. Surgery. Treatment in SEVERE cases can be rectal tube.

Exercises Promoting Defecation

Ambulation and physical activity. Range of motion. Thigh strengthening. For patient who is immobile try bringing knees to chest. Abdominal tightening: works core muscles. Have patient hold them.

Enema

An enema is a solution introduced into the rectum and large intestine -Action is to distend the intestine and to sometimes irritate the intestinal mucosa to increase peristalsis and the excretion of feces and flatus -Enema solution should be 100 degrees because a solution that is too hot or too cold can cause cramping -For clients with renal failure - do not use more than 1 enema in 24 hours

Oil retention

An enema that: -lubricates/softens stool -must be retain for 1-2 hours if possible

Carminative

An enema that: relieve gas distention

Diarrhea and Medications

Antibiotics. Over the counter antacids with magnesium which can interact with other meds which can alter distribution or absorption of other meds the patient is on. Antacids neutralize stomach acids.

Bulk Forming Laxative

Attract water into intestines, absorb excess water into the stool, stimulates the intestine and increases peristalsis. Do not use if someone has obstruction, pain or nausea/vomiting. Examples: Metamucil or psyllium. Citrucel or methylcelluose.

NORMAL BOWEL COLOR

BROWN OR YELLOW FOR INFANTS

Clostridium Difficile, C. Diff

Bacterium which infects and can make humans ill. Symptoms can range from diarrhea to serious and potentially fatal inflammation of the colon. Most hospital acquired, from antibiotic overuse and the staff causes epidemics.

Red feces possible cause

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

Occult Blood

Blood present in such minute quantities that it cannot be detected with unasissted eye

Age

Bowel elimination and peristalsis slows down with _____.

Defecation

Bowel movement, emptying of intestinal tract.

Diagnostic tests

Bowel prep is interrupted during what kind of tests?

Irritation

By cleansing, enema stimulates peristalsis by what?

RELATED FACTORS CONTRIBUTING TO CONSTIPATION

CNS depressant drugs include: Benzodiazepines such as Ativan, Valium, and Xanax Antiocholinergics include: Bentyl & Robinul Neurological Impairment: Spinal Cord Injuries Antidiarreals include: Pepto-Bismol, Motofen, Lomotil, Imodium, Octreotide, and Fibercon

characteristic of abnormal stool

COLOR CONSISTENCY ODOR SIZE/SHAPE COMPONENTS

BOWEL ELIMINATION PROBLEM

CONSTIPATION FECAL IMPACTION DIARRHEA INCONTINENCE

Factors Affecting: Meds and Anesthesia

Can cause constipation or diarrhea and stool color.

Pepto-bismol or bismuth subsalicylate

Can lead to increased bleeding time and bruising time if the patient is on coumadin, aspirin or NSAIDS. Can cause confusion in elderly.

When to notify Doctor

Change in bowel habits or patterns. This may indicate disease or dysfunction. Blood in stool, unless chronic hemorrhoid. Pain. Unintended weight loss. Persistent constipation.

LUBRICANT LAXATIVE MINERAL OIL

Coats outside of stool making it slippery and prevents fluid absorption from the stool. - ACTION LUBERCATES STOOL AND INCREASE EASE OF STOOL PASSAGE ADVERSE REACTION: AVOID PROLONG USE . INHIBITS ABSORBTION OF FAT = VITAMINE aded Over time, can interfere with absorption of fat soluble vitamins A-D-E-K. NURSING CONSIDERATIONS Tastes bad therefore-give with orange juice/root beer. Do not administer within two hours of a meal to keep from interfering with fat soluble vitamin absorption. Do not take lying down-risk for aspiration and pneumonia. TAKE WHEN SITTING DOWN - Do not give if client has difficulty swallowing-risk for aspiration and pneumonia. GIVE WITH JUICE SOMTHING PALATABLE

Fecal Impaction

Collection in the rectum of hardened feces that cannot be passed. Can cause patient to become confused, constipated. Seen in immobile patients. Patients are very uncomfortable. You may feel in rectal exam. Doctor may ask you to physically go in and dis-impact.

DIARRHEA INDEPENDENT INTERVENTION

DISCONTINUE SOLID FOODS TEACH PATIENT TO AVOID MILK, FAT, WHOLE GRAINS, FRESH FRUIT AND VEGIES GRADUALLY ADD SEMISOLIDS ( CRACKERS , YOGURT , RICE, BANNAN., APPELSAUCE) TO DIET FREQUENT HAND WASHING Hand washing is important to prevent Clostridium difficile. This is a cause agent of diarrhea and can be very mild to severe. Can be obtained through contact and antibiotics (due to overgrowth of organism) such as ampicillin and amoxicillin, surgery, and invasive procedures.

Factors Affecting Bowel Elimination

Diet, such as, yogurt increasing peristalsis. Fluid intake, such as, older adults have decreased thirst mechanism. High Fiber. Low Fiber. Age/Developmental Level, such as, infants have no control until 2-3 years old. Daily pattern, not everyone has a BM everyday. Lifestyle, such as, occupation, schedule, stress, anxiety. Exercise/Muscle tone, which promotes motility/stimulates peristalsis. Psychological/Pathological

Mouth

Digestion beings with mastication where?

Hemorrhoids

Dilation and engorgement of veins of rectum. Can be internal and external. May bleed. Causes: straining, pregnancy, sitting/standing long periods. Signs and symptoms: pain in anus, burning, itching, bleeding. Treatment include good hydration, avoid strain, warm compress, sitz bath, ointments, suppositories Can make BMs painful. If sever may have to be surgically removed. Common in older population.

Stool Softener

Doesn't cause you to go. Softens stool to make easier to pass. Safe for long term use. Use for post op bowel surgery because you wouldn't want to give a laxative that would weaken site Example: colace or docusate sodium.

Laxatives

Ease defecation. Examples are: bulk forming lax, saline agents, stimulants, stool softeners, osmotic agents

The nurse will anticipate which diagnostic examination for a patient with black tarry stools

Endoscopy Black tarry stools are an indication of bleeding in the GI tract; endoscopy would allow visualization of the bleeding. No other option (ultrasound, barium enema, and anorectal manometry) would allow GI visualization.

FECAL IMPACTION SIGNS AND SYMPTOMS

First sign is inability to pass stool with peristalsis Abdominal distention Small amounts of liquid BM, or oozing of liquid stool Continuous feeling or urge to defecate Rectal pain Nausea/vomiting SOB Hypertension Abdominal fullness Extends up to sigmoid colon. Those who are debilitated, confused, or unconscious are most at risk. There is no stool for several days or longer.

Small Volume Hyper-tonic Enema

Fleets enema. Drains water into colon. Good if patient can't tolerate large volumes. Watch with someone who has renal disease because fleets has sodium phosphate.

Valsalva Maneuver

Forcible exhalation against a closed glottis, resulting in increased thoracic pressure

Normal feces consistency

Formed, soft, semisolid, moist

Large Intestines

Forms bulk of your stool; absorption and elimination. Includes cecum, colon and rectum.

A nurse is assisting a patient in making dietary choices that promote healthy bowel elimination. Which menu option should the nurse recommend? a. Broccoli and cheese soup with potato bread b. Turkey and mashed potatoes with brown gravy c. Grape and walnut chicken salad sandwich on whole wheat bread d. Dinner salad topped with hard-boiled eggs, cheese, and fat-free dressing

GRAPE, WALNUT, CHICKEN SALAD SANDWHICH ON WHOLE WHEAT BREAD Grapes and whole wheat bread are high fiber and should be chosen. Cheese, eggs, potato bread, and mashed potatoes do not contain as much fiber as whole wheat bread. A healthy diet for the bowel should include foods high in bulk-forming fiber. Whole grains, fresh fruit, and fresh vegetables are excellent sources. Foods without much fiber and with high levels of fat can slow down peristalsis, causing constipation.

OBJECTIVE CHARACTERISTIC OF CONSTIPATION

Hard, dry, stool Abdominal distention Decreased frequency Straining at stool Flatulence Decreased volume Percussed abd.dullness Vomiting Hypo/hyperactive bowel sounds

Constipation: Complications

Hemorrhoids. Can cause a fissure.

3 to 6

How many BM's do babies usually have per day?

Diarrhea: Treatment

Imodium or loperamid, which is NOT for C.Diff patients. Pepto-bismol or bismuth subsalicylate.

Frequency

Infants up to 6 times a day. Adults can be daily or 2-3 times a week. Hyper-motility is multiple times a day. Hypo-motility is 1-2 times a week.

Flatus

Intestinal gas

Enema

Introduction of solution into lower bowel

Peristalsis

Involuntary, progressive, wave-like movement of the musculature of the GI tract

CONSTIPATION INFO

It's a symptom, not a disease; a decrease in stool frequency. Difficult passage of feces; hardness of stool or feeling of incomplete evacuation. Common causes of constipation--improper diet, reduced fluid intake, lack of exercise, and certain meds. It is the most common gastrointestinal complaint in the United States and accounts for 2 million annual visits to the doctor. Up to 60% report laxative abuse.

Guaiac Test

Looks for occult blood. Most common type of occult blood test.

Macedo -Malone antegrade continence enema

MACE procedure developed for client who has neuropathic or structural abnormality of the anus

Cathartics

Medications, laxatives, and ______ affect bowel elimination.

Low Fiber

Might slow peristalsis. Foods low in fiber include pasta, lean meats, diets high in cheese.

Factors Affecting: Pregnancy

Morning sickness can lead to dehydration. Weight of baby displaces uterus and causes pressure.

TEACH = WHO ARE YOU TEACHING

OLDER- DEMENTIA, MEDICATION , IMPORTANCE OF CAREGIVE

Constipation: Causes

Obstruction, disease, tumors, spinal cord injury

Factors Affecting: Comorbidities

Paralytic ileus is from surgery. No motility, nothing moving, no bowel sounds.

Diarrhea

Passage of liquid feces due to increased GI motility & rapid passage of fecal contents thru lower GI -High water content & increases mucus -Risk for skin breakdown and fluid and electrolyte imbalance (esp. infants, small children and older adults)

Psycho-social, Culture, Environmental Factors

Psycho-social: stress is primary risk factor. Anxiety/fear can lead to IBS and diarrhea. Depression can lead to constipation. Culture: Some cultures may be uncomfortable discussing BMS. Environmental: sharing a BR with strangers or when a doctor comes into BR or on a commode may be difficult for some patients.

Chyme

Pulpy, acidic fluid that passes from stomach to the small intestine, consisting of gastric juices and partially digested food.

A patient with a hip fracture is having difficulty defecating into a bedpan while lying in bed. Which action by the nurse will assist the patient in having a successful bowel movement?

RAISING THE HEAD OF THE BED Lying in bed is an unnatural position; raising the head of the bed assists the patient into a more normal position that allows proper contraction of muscles for elimination. Laxatives would not give the patient control over bowel movements. A barium enema is a diagnostic test, not an intervention to promote defecation. Pain relief measures should be given; however, preventative action should be taken to prevent constipation.

H2 Receptor Antagonists

Reduce but don't completely stop acid secretion. Most populate drugs fro treatments of many acid related disorders. Block H2 receptor of acid-producing parietal cells. Treats gerd, peptic ulcer disease, erosive esophagus. Has low side effects, safe, and available over the counter.

Kidney

Search for the right kidney by placing your hands together in a "duckbill" position at the person's right flank. Press your two hands firmly and ask the person to take a deep breath. With most people, you feel no change. Occasionally you may feel the lower pole of the right kidney as a round, smooth mass slide between your fingers. Either condition is normal. The left kidney sits 1 cm higher than the right kidney and normally is not palpable.

Position during defecation

Squatting is preferred.

A nurse is teaching a patient about the large intestine in elimination. In which order will the nurse list the structures, starting with the first portion? a. Cecum, ascending, transverse, descending, sigmoid, and rectum b. Ascending, transverse, descending, sigmoid, rectum, and cecum c. Cecum, sigmoid, ascending, transverse, descending, and rectum d. Ascending, transverse, descending, rectum, sigmoid, and cecum

The large intestine is divided into the cecum, ascending colon, transverse colon, descending colon, sigmoid colon, and rectum. The large intestine is the primary organ of bowel elimination.

Lavage

This NGT is for irrigating alcohol poisoining.

Compression

This NGT is to prevent internal bleeding and placed into the esophagus.

Large-bore (12-French and above)

This size of NGT is for gastric decompression ore removal of gastric secretions.

Fine/small bore

This size of NGT is for medication administration and enteral feedings.

Occult Blood Testing

What kind of test should be performed when there are concerns with patients bleeding in their intestines?

Antidiarrheal agents

What medications can be over the counter and be opiates?

Eructation

belching, burping

Ileus

cessation or slowing down of bowel activity-asses for flatus -bowel sounds should usually return 24-48 hours

Hemorrhoids

dilated, engorged veins in the lining of the rectum

Single colostomy

end or terminal colostomy

Anus

expels feces and flatus (gas) from the rectum

Flatus

gas

possible cause for abnormal amount of feces

infection, blood

Auscultate bowel sounds and vascular sounds of abdomen assessment

inspect , auscultate, palpate always auscultate before palpate to prevent increase peristalsis - use diaphragm = start in RLQ at ileocecal valve because bowel sounds are normally present here

orange or green feces possible cause

intestinal infection

aorta

just to the left of the midline in the upper abdomen 2 cm below the umbilicus it splits into the right and left arties

Treatment for fecal impaction

laxatives, enemas, suppositories and manual dis-impaction of stool

Ostomy

location determines consistency of stool

abnormal amount of feces

pungent

Ascending colostomy stool

similar to ileostomy. liquid stool, more odor

normal constituents of feces

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

toddler bowel movements

some control at 1.5-2 years

Colostomy

surgical opening in the colon **SOLID STOOL**

Divided colostomy

two separate stomas (colostomy and mucous fistula)

normal amount of feces

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

A patient expresses concerns over having black stool. The fecal occult test is negative. Which response by the nurse is most appropriate?

"Do you take iron supplements?" Certain medications and supplements, such as iron, can alter the color of stool (black or tarry). Since the fecal occult test is negative, bleeding is not occurring. The fecal occult test takes three separate samples over a period of time and is a fairly reliable test. A colonoscopy is health prevention screening that should be done every 5 to 10 years; it is not the nurse's initial priority. Stress alters GI motility and stool consistency, not color.

Permanent permanence

-For nonfunctional rectum or anus -Congenital defect or cancer

Bowel elimination problems

-constipation -fecal impaction -diarrhea -bowel incontinence -flatulence

Physical examination assessment for bowel movement

-examination of abdomen, rectum, and anus -auscultation before palpation because palpation alters peristalsis

abnormal feces consistency

-hard, dry -diarrhea

Incontinence

-inability to control passage of feces and gas to anus **CAN PRESENT DIARRHEA BUT STILL BE CONSTIPATED**

Diarrhea

-increase in # of stools -liquid, unformed stool CAUSES: C. dif & antibiotics

Newborns and infants bowel movements

-meconium -transitional stool -frequent passing of stool

possible cause of abnormal constituents of feces

-mucus -bacterial infection -inflammatory condition -gastrointestinal bleeding -malabsorption -accidental ingestion

Ostomy device management

-pouches can be open (for periodic draining) or closed to be discarded after use -care of a new ostomy cannot be delegated to a UAP -many patient will care for their own stomas/colostomies while in the hospital -let your patients teach you as well

older adult bowel movement

-preoccupied with bowels (encourage fluids, fibers, roughages) -respond to gastro-colic reflux (increased peristalsis of colon after meals) -educate about laxatives (overuse can result in constipation)

Large intestine

-primary organ of bowel elimination -absorbs H2O and electrolytes

End colostomy

-proximal end forms stoma -distal end is removed or sewn closed -PERMANENT -CANCER PATIENTS

abnormal constituents of feces

-pus -parasites -blood -large quantities of fat -foreign objects

Impaction

-results from unrelieved constipation -hardened feces in the rectum

Colostomies types

-single -loop -divided -double-barreled

Three sources of flatulence

-swallowed air -bacterial action in large intestine -diffusion from blood

Constipation

-symptom -NOT A DISEASE -infrequent BM's ------ LESS THAN EVERY 3 DAYS -difficulty passing stool

Assessment of abdomen subjective data

1. Change in appetite 2. Dysphagia (difficulty swallowing) 3. Food intolerance 4. Abdominal pain 5. Nausea/vomiting 6. Bowel habits 7. Rectal conditions 8. Past abdominal history (ulcer, gallbladder disease, hepatitis, appendicitis, colitis, hernia) 9. Medications (prescription, over-the-counter, including antacids) 10. Alcohol, drug, cigarette use 11. Nutritional assessment (24-hour recall)

Which patient is most at risk for increased peristalsis?

A 21-year-old female with three final examinations on the same day Stress can stimulate digestion and increase peristalsis, resulting in diarrhea; three finals on the same day is stressful. Ignoring the urge to defecate, depression, and age-related changes of the older adult (80-year-old man) are causes of constipation, which is from slowed peristalsis.

The nurse is managing bowel training for a patient. To which patient is the nurse most likely providing care?

A 70-year-old patient with stool incontinence The patient with chronic constipation or fecal incontinence secondary to cognitive impairment may benefit from bowel training, also called habit training. An ileostomy, diarrhea, and C. difficile all relate to uncontrollable bowel movements, for which no method can be used to set up a schedule of elimination.

The nurse is planning care for a group of patients. Which task will the nurse assign to the nursing assistive personnel (NAP)? a. Performing the first postoperative pouch change b. Maintaining a nasogastric tube c. Administering an enema d. Digitally removing stool

ADMINSTERING AN ENEMA The skill of administering an enema can be delegated to an NAP. The skill of inserting and maintaining a nasogastric (NG) tube cannot be delegated to an NAP. The nurse should do the first postoperative pouch change. Digitally removing stool cannot be delegated to nursing assistive personnel.

Achalasia

Absence of peristalsis in lower esophagus, preventing food from passing into stomach.

BULK FORMING NATURAL, LEAST IRRITATING METAMUCIL OR CITURCEL

Action: Stimulates peristalsis; effective in 12-24 hours; give with water-enhances action Adverse reactions: N/V/D; cramps Nursing considerations: make sure pt. can evacuate bowel before administering a bulk-forming laxative; always administer with a full glass of water; make sure bowel sounds are present and abdomen is not distended.

CONTIPATION INTERVENTIONS

Base intervention(s) on the etiology/factor(s) Teaching :(what, to whom, how evaluate) Monitor: (what, how often) (I) Patient will increase fluid intake. (I) Patient will increase fiber in diet. (I) Provide patient privacy when toileting. (D) Administer patient a stool softener, Colace. (D) Administer patient a laxative, Metamucil

black or tarry feces possible cause

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

Bowel Training

Goal to have client move stool regularly. Create a schedule of uninterrupted private time, generally mornings. Gradually increase fiber in patient diet.

High Fiber

Increase the bulk and increase the stool mass. Stretches bowel walls and stimulates. Need about 5 servings a day. Foods high in fiber include: figs, prunes, brans. May be laxative producing

Dyspepsia

Indigestion

If you identify a mass, first distinguish it from a normally palpable structure or an enlarged organ. Then note its:

Location 2. Size 3. Shape 4. Consistency (soft, firm, hard) 5. Surface (smooth, nodular) 6. Mobility (including movement with respirations) 7. Pulsatility 8. Tenderness

Fecal impaction

Mass or collection of hardened feces in folds of rectum -Passage of liquid fecal seepage and no normal stool -Usual causes -Poor defecation habits -Constipation -Confirm dx by detection of hardened stool in rectum on digital examination -Fecal impaction can cause morbidity and mortality

Stimulant Laxative

Most likely of all laxatives to cause dependence. Also used for preps. No milk of antacids within one hour because they are inter-coated. Examples: Dulcolax or bisacodyl. Sennekot or senna.

Proton Pump Inhibitors

Newest drug from treatment of acid-related disorders. More powerful than H2 receptor antagonists. Total blockage of hydrogen ion secretions from parietal cells. They're short term treatment of Ulcers. With antibiotics they treat H. Pylori. Can increase bleeding risk with coumadin.

Esophagus

Peristalsis moves food into the stomach from where?

A nurse is preparing a patient for a magnetic resonance imaging (MRI) scan. Which nursing action is most important? 1

Removing all of the patient's metallic jewelry. No jewelry or metal products should be in the same room as an MRI machine because of the high-power magnet used in the machine. The patient needs to be NPO 4 to 6 hours before the examination. Colon cleansing products are not necessary for MRIs. Pain medication is not needed before the examination is performed.

Enteral Feeding

The purpose of this NGT is for nutrition!

True

True or False: A doctor's order is necessary to remove an impaction.

True

True or False: Body gets used to the laxative that after D/C the laxative, the patient becomes constipated.

Imodium or loperamid

Usually for chronic. Adjust diet; electrolyte replacement. Only anti-diarrheal available over the counter. DO NOT GIVE TO C DIFF PATIENTS.

ETIOLOGY/FACTOR

WHAT IS CAUSING THE ALTERATION Ex.-If it is constipation, due to a lack of fiber, fluid intake, medication alteration, or lack of exercise Or due to diarrhea? Is it travel or medication?

Surgery & anesthesia

What slows or stops peristalsis?

Evaluation

What step of the nursing process describes the following? -Effectiveness of care depends on how successful the client is in achieving goals and outcomes. -Nursing interventions may be altered in necessary.

clay or white feces possible cause

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

Flatulence

accumulation of gas in the intestines causing the walls to stretch

normal shape of feces

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

school-age children and adolescent bowl movement

defecation may be delayed

valsalva maneuver

holding breath increases intrathoracic pressure and vagal tone-slowed heart rate

VALSALVA MANEUVER

increase intrathoracic pressure—bearing down action forces diaphragm downward, increases pressure, rectal distention and urge to evacuate.* However, also slows the pulse, increases venous pressure and decreases flow of blood to the heart. Also may cause an excessive vagal response resulting in cardiac arrhythmia. If can not get up to bathroom, may sit up or elevate head of bed and sit on a bed pan.

possible cause of diarrhea

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

abdomen

large oval cavity extending from the diaphragm down to the brim of the pelvis abdominal wall is divided into 4 quadrants by the vertical and horizontal line bisecting the umbilcus

DAILY PHYSICAL EXERCISE PROMOTES

muscle tone needed for fecal expulsion. It also increases circulation to the digestive system, promoting peristalsis and easier fecal evacuation

abnormal shape of feces

narrow, pencil-shaped, or sting like stool

Descending colostomy stool

normal/formed stool. frequency of discharge can be regulated

Ileoanal pouch anastomosis

pouch is a reservoir for wastes which are eliminated from the anus

Examples of Proton Pump Inhibitors

prevacid or lansoprazole. prilosec or omeprazole. protonix or pantoprazole. nexium or esomeprazole.

Transverse colostomy stool

produces more solid stools, malodorous

Deep palpation

pushing down about 5 to 8 cm (2 to 3 inches). Moving clockwise, explore the entire abdomen. Normally there is mild tenderness when palpating the sigmoid colon - left lower inguinal area . Any other tenderness should be investigated abnormal - Tenderness occurs with local inflammation; with inflammation of the peritoneum or underlying organ; and with an enlarged organ whose capsule is stretched.

establishing a routine fecal evacuation schedule TO PROMOTE BOWEL ELIMINATION BY DOING WHAT

rationale: training the bowel to evacuate at certain times ensures regularity of elimination

signs and symptoms of fecal impaction

subjective feeling of rectal & abdominal fullness, bloating, urge to defecate but inability, malaise, N&V, abdominal distention

Ileostomy

surgical opening in the ileum **LOOSE STOOL**

Examples of H2 Receptor Antagonists

tagamet or cimetidine. pepcid or famotidine. zantac or ranitidine.

Permanence

temporary or permanent

Stoma

temporary or permanent artificial opening in the abdominal wall

Double-barreled colostomy

two stomas sutured together

transitional stool

up to one week of newborn -greenish yellow, mucus; loos

Isotonic/NS enema

volume: 500-1000 ml action: distends colon, stimulates peristalsis and softens feces time: 15-20 min

Hypotonic enema

volume: 500-1000 ml tap water action: distends colon, stimulates peristalsis and softens feces time: 15-20 min adverse effect: fluid and electrolyte imbalance; water toxicity

Hypertonic/fleet enema

volume: 90-120 ml action: draws H2O into colon time: 5-10 min adverse effect: sodium retention

oil/mineral oil enema

volume: 90-120 ml action: lubricates the feces and the colonic mucosa time: 0.5-3 hours

Normal infant feces

yellow

Small intestine

-Duodenum, jejunum, ileum -Absorbs nutrients and electrolytes

DIARRHEA SIGNS AND SYMPTOMS

ABDOMINAL DISTENTION FLATULENCE n/v RECTAL BLEEDING ANOREXIA URGENCY FEVER MALAISE =DISCOMFORT . UNEASY FLUID AND ELECTROLYTE IMBALANCE

NORMAL SHAPE OF BOWEL

ABOUT 1 INCH

Incontinence

Loss of muscle tone in the elderly causes what?

FECAL IMPACTION DEPENDENT INTERVENTION

MINERAL OIL CLEANSING ENEMA

Clients confined to bed are often constipated. What can you do, if you can not get client up to get some physical exercise?

ROM

Common bowel elimination

The following are what kind of problems? Constipation Impaction Diarrhea Incontinence Flatulence Hemorrhoids

Routine Culture

Use hat to retrieve; looking for infections. Don't contaminate with urine or tissue.

Type 5

What type of stool is described by the following? Soft blobs with clear-cut edges---EASILY PASSED!!

Type 7

What type of stool is described by the following? Watery, no solid pieces!! LIQUID!!

Physical activity

__________promotes peristalsis.

Loop colostomy

bulky stoma with two openings (proximal or afferent and distal or efferent)

Stoma

opening created by ostomy

Colostomy

opening into the colon

Factors Affecting: Obesity

patients are not active, decreasing muscle tone and motility.

Shape, Consistency, Odor

Inflamed bowel may have narrow stool. May be narrow or liquidy from rapid peristalsis. Odor depends on diet. Bloody, or melena, stool is foul smelling.

Location of bowel diversion ostomies

-Influences character and management of fecal drainage -The farther along the bowel, the more formed the stool, and the more control possible over frequency of stomal discharge

Melena

Dark stool, foul smelling. Can be from iron supplements. Always check supplements when stool is dark.

Colostomy irrigation

For clients with a sigmoid or descending colostomy -Purpose is to distend the bowel as to stimulate peristalsis and evacuation -When done, need to be performed at the same time each day -300-500 mL of fluid -Long-term irrigation puts client at risk for peristomal hernias, bowel perforation, and electrolyte imbalance

Diarrhea: Nursing Interventions

Good hygiene, education, fluids

Nursing Implications for Bowel Incontinence

Monitor pattern. Provide toileting at regular intervals. Keep skin and linens clean. Monitor for skin breakdown. Review diet and medications. Bowel training. Incontinence is leading cause to admission to long term care facilities.

Physiology of GI System

Mouth, digestion starts with mastication. Esophagus, peristalsis moves food into stomach. Stomach: stores food, mixes food, liquid and digestive juices and moves food into small intestines. Large Intestines are the primary organ of bowel elimination, it produces potassium. Small Intestine, includes duodenum, jejunum and ileum. Anus expels feces and flatus from the rectum.

NORMAL PASSAGE OF STOOL

NO PAIN

FACTORS Contributing to Constipation

No established routine for defecation schedule Inability to maintain a normal sitting position for defecation Diet deficient of dietary fiber and/or fruits vegetables Insufficient intake of fluids Lack of daily exercise No privacy given when evacuating bowels Abdominal muscle weakness Depression Emotional distress CNS depressant drugs and anticholinergics Neurological impairment Overuse of antidiarrheal agents

NORMAL ODOR

PUNGANT AFFECTED BY BACTERIA

False

True or False: Sterile technique must be performed when administering enema.

Diarrhea

Unformed liquid feces with increased frequency. Depleted in potassium and causes stress. Can be acute or chronic. Causes: contaminated food, too much coffee, medications and can be from newer tube feedings. Elderly and infants at high risk, if severe may need IV fluid.

Isotonic

When using an enema, normal saline must be ______. It is the safest!

Fluid wave for ascites

Place the ulnar edge of another examiner's hand or the patient's own hand firmly on the abdomen midline (Fig. 14-7). Place your left hand on the person's right flank. With your right hand reach across the abdomen and give the left flank a firm strike. If ascites is present, the blow will generate a fluid wave through the abdomen and you Ascites occurs with heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis, and cancer. will feel a distinct tap on your left hand. If the abdomen is distended from gas or adipose tissue, you will feel no change. A positive fluid wave test occurs with large amounts of ascitic fluid.

Palpate liver

Place your left hand under the person's back, parallel to the 11th and 12th ribs, and lift up to support the abdominal contents. Place your right hand on the right upper quadrant (RUQ), with fingers parallel to the midline (Fig. 14-6). Push deeply down and under the right costal margin. Ask the person to take a deep breath. It is normal to feel the edge of the liver bump your fingertips as the diaphragm pushes it down during inhalation. It feels like a firm, regular ridge. The liver is often not palpable, and you may feel nothing firm.

Before administering a cleansing enema to an 80-year-old patient, the patient says "I don't think I will be able to hold the enema." Which is the next priority nursing action?

Positioning the patient in the dorsal recumbent position on a bedpan If you suspect the patient of having poor sphincter control, position on bedpan in a comfortable dorsal recumbent position. Patients with poor sphincter control are unable to retain all of the enema solution. Administering an enema with the patient sitting on the toilet is unsafe because it is impossible to safely guide the tubing into the rectum, and it will be difficult for the patient to retain the fluid as he or she is in the position used for emptying the bowel. Rolling the patient into right-lying Sims' position will not help the patient retain the enema. Use of a rectal plug to contain the solution is inappropriate and unsafe.

Signs and symptoms of diarrhea

abdominal cramping, immense urge to defecate, nausea, burning sensation in anus, fatigue, weakness, malaise, emaciation

Flatulence

accumulation of gas in the GI tract -Larger than usual quantities of flatus are result if increased colonic motility secondary to intestinal irritation -Colonic activity propels gases toward anus before they have time to be absorbed occurs from: -Foods (cabbage, onions, legumes, eggs) -Abdominal surgery -Narcotics

a patient has a fecal impaction. which portion of the colon will the nurse asses? a. descending b. transverse c. ascending d. rectum

d. rectum (manual dis-impaction)

gastro-colic reflex

increased peristalsis of colon after meals

Ileostomy

opening into the ileum (small bowel)

Jejunostomy

opening through the abdominal wall into the jejunum

Gastrostomy

opening through the abdominal wall into the stomach

Defecation

the expulsion of feces from the anus and rectum

The nurse is emptying an ileostomy pouch for a patient. Which assessment finding will the nurse report immediately?

Presence of blood in the stool Blood in the stool indicates a problem, and the health care provider should be notified. All other options are expected findings for an ileostomy. The stool should be liquid, there should be an odor, and the output should be continuous.

Fecal incontinence pouch

(pouch in the middle) -regular assessment and documentation of perineal skin status -changing bag q72 hours or sooner if there is leakage

factors affecting defecation

-Developmental stage -Diet- fiber -Fluid- 2-3K mL -Activity- regular -Psychologic factors- constipation or diarrhea -Defecation habits- don't ignore urge -Diagnostic procedures- NPO -Medications- many -Anesthesia and Surgery- Ileus!!! -Ileus - cessation or slowing down of bowel activity - assess for flatus -bowel sounds should usually return 24-48hrs -Pathologic conditions- other disorders -Pain

Manual dis-impaction

-Have second person assist -Side-lying position -Bedpan on bed for depositing removed feces -Drape patient -Wear clean gloves -Lubricate forefinger generously to reduce irritating the rectum -Insert finger into canal -Work finger around hardened mass to break it up and remove pieces -Know agency policy; not a routine nursing function today -Beware of excessive vagal response - may result in dysrhythmias

causes of constipation

-Insufficient fiber and fluid intake -Insufficient activity -Irregular bowel habits/ Habitual denial and ignoring urge to defecate -Changes in routine, lack of privacy -Chronic laxative or enema use -Irritable bowel syndrome (IBS) -Functional or neurologic conditions -Emotional disturbances -Medications

Plan

-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

Physiology of defecation

-Peristaltic waves move the feces into the sigmoid colon and the rectum -Sensory nerves in rectum are stimulated -Individual becomes aware of need to defecate -Feces move into the anal canal when the internal and external sphincter relax -External anal sphincter is relaxed voluntarily if timing is appropriate -Expulsion of the feces assisted by contraction of the abdominal muscles and the diaphragm -Moves the feces through the anal canal and expelled through anus -Facilitated by thigh flexion and a sitting position

Interventions

-Promoting regular defecation -nutrition and fluids -exercise -positioning -Teaching about medications (cathartics vs. laxatives) -Decreasing flatulence -Administering enemas (See skill 49-1) -Digital removal of a fecal impaction (if agency policy permits) -Instituting bowel training programs -Applying a fecal incontinence pouch -Ostomy management

Stomach

-Stores food -Mixes food, liquid, & digestive juices -Moves food into the small intestines

Major causes of Diarrhea

-Stress -Medications -Allergies -Infection - C. difficile -Intolerance of food or fluids -Disease of colon

Loop colostomy

-TEMPORARY ---- reversed -Transverse colon -Performed on emergency basis

Temporary permanence

-Traumatic injuries, inflammations -Allow distal diseased portion to heal

Signs and symptoms of abdominal distention

-abdominal fullness -discomfort -inability to pass flatus or stool

A patient with a fecal impaction has an order to remove stool digitally. In which order will the nurse perform the steps, starting with the first one? 1. Obtain baseline vital signs. 2. Apply clean gloves and lubricate. 3. Insert index finger into the rectum. 4. Identify patient using two identifiers. 5. Place patient on left side in Sims' position. 6. Massage around the feces and work down to remove.

4, 1, 5, 2, 3, 6 The steps for removing a fecal impaction are as follows: identify patient using two identifiers; obtain baseline vital signs; place on left side in Sims' position; apply clean gloves and lubricate; insert index finger into the rectum; and gently loosen the fecal mass by massaging around it and work the feces downward toward the end of the rectum.

A nurse is checking orders. Which order should the nurse question?

A Kayexalate enema for a patient with severe hypokalemia Kayexalate binds to and helps excrete potassium, so it would be contraindicated in patients who are hypokalemic (have low potassium). Normal saline enemas can be repeated without risk of fluid or electrolyte imbalance. Hypertonic solutions are intended for patients who cannot handle large fluid volume and are contraindicated for dehydrated patients. Oil retention enemas lubricate the feces in the rectum and colon and are used for constipation.

NORMAL BOWEL SOUNDS

ACTIVE 5-35 SOUNDS PER MINUTE

DEPENDENT DIARRHEA INVERVENTION

ADMINSTER PEPTO BISMOL ADMINSTER IMODIUM ( LOPERAMIDE) OPIATE Imodium OTC (Opiate-related agent for diarrhea): Opiates decrease intestinal motility, thereby decreasing peristalsis. Constipation is a common side effect of opium preparations. Loperamide is a derivative of Meperidine (Demerol) used only for diarrhea. Decreases intestinal motility & has no CNS effects. Lomotil Diphenoxylate with atropine sulfate, a derivative of meperidine (Demerol) used only for diarrhea. Diminishes abdominal cramping, while reducing loss of water and electrolytes. Side effects-anorexia, nausea, vomiting, dizziness, headache, and tachycardia; Toxic-respiratory depression; Can cause dizziness or drowsiness-use with caution if driving. Caution about taking too much - produce constipation.

A nurse is providing discharge teaching for a patient who is going home with a guaiac test. Which statement by the patient indicates the need for further education? a. "If I get a blue color that means the test is negative." b. "I should not get any urine on the stool I am testing." c. "If I eat red meat before my test, it could give me false results." d. "I should check with my doctor to stop taking aspirin before the test."

ANS: A A blue color indicates a positive guaiac, or presence of fecal occult blood; the patient needs more teaching to correct this misconception. Proper patient education is important for viable results. Be sure specimen is free of toilet paper and not contaminated with urine. The patient needs to avoid certain foods, like red meat, to rule out a false positive. While the health care provider should be consulted before asking a patient to stop any medication, if there are no contraindications, the patient should be instructed to stop taking aspirin, ibuprofen, naproxen or other nonsteroidal antiinflammatory drugs for 7 days because these could cause a false-positive test result.

Which menu choice by the patient with diverticulosis is best for preventing diverticulitis? a. Navy bean soup and vegetable salad b. Whole grain pasta with tomato sauce c. Baked potato with low-fat sour cream d. Roast beef sandwich on whole wheat bread

ANS: A A diet high in fiber and low in fats and red meat is recommended to prevent diverticulitis. Although all of the choices have some fiber, the bean soup and salad will be the highest in fiber and the lowest in fat.

A patient complains of gas pains and abdominal distention two days after a small bowel resection. Which nursing action is best to take? a. Encourage the patient to ambulate. b. Instill a mineral oil retention enema. c. Administer the ordered IV morphine sulfate. d. Offer the ordered promethazine (Phenergan) suppository.

ANS: A Ambulation will improve peristalsis and help the patient eliminate flatus and reduce gas pain. A mineral oil retention enema is helpful for constipation with hard stool. A return-flow enema might be used to relieve persistent gas pains. Morphine will further reduce peristalsis. Promethazine (Phenergan) is used as an antiemetic rather than to decrease gas pains or distention.

Which nursing action will be included in the plan of care for a 27-year-old male patient with bowel irregularity and a new diagnosis of irritable bowel syndrome (IBS)? a. Encourage the patient to express concerns and ask questions about IBS. b. Suggest that the patient increase the intake of milk and other dairy products. c. Educate the patient about the use of alosetron (Lotronex) to reduce symptoms. d. Teach the patient to avoid using nonsteroidal antiinflammatory drugs (NSAIDs).

ANS: A Because psychologic and emotional factors can affect the symptoms for IBS, encouraging the patient to discuss emotions and ask questions is an important intervention. Alosetron has serious side effects, and is used only for female patients who have not responded to other therapies. Although yogurt may be beneficial, milk is avoided because lactose intolerance can contribute to symptoms in some patients. NSAIDs can be used by patients with IBS.

A nurse is preparing to lavage a patient in the emergency department for an overdose. Which tube should the nurse obtain? a. Ewald b. Dobhoff c. Miller-Abbott d. Sengstaken-Blakemore

ANS: A Lavage is irrigation of the stomach in cases of active bleeding, poisoning, or gastric dilation. The types of tubes include Levin, Ewald, and Salem sump. Sengstaken-Blakemore is used for compression by internal application of pressure by means of inflated balloon to prevent internal esophageal or GI hemorrhage. Dobhoff is used for enteral feeding. Miller-Abbott is used for gastric decompression.

24. A patient is diagnosed with a bowel obstruction. Which type of tube is the best for the nurse to obtain for gastric decompression? a. Salem sump b. Small bore c. Levin d. 8 Fr

ANS: A The Salem sump tube is preferable for stomach decompression. The Salem sump tube has two lumina: one for removal of gastric contents and one to provide an air vent. When the main lumen of the sump tube is connected to suction, the air vent permits free, continuous drainage of secretions. While the Levin tube can be used for decompression, it is only a single-lumen tube with holes near the tip. Large-bore tubes, 12 Fr and above, are usually used for gastric decompression or removal of gastric secretions. Fine- or small-bore tubes are frequently used for medication administration and enteral feedings.

A nurse is performing an assessment on a patient who has not had a bowel movement in 3 days. The nurse will expect which other assessment finding? a. Hypoactive bowel sounds b. Increased fluid intake c. Soft tender abdomen d. Jaundice in sclera

ANS: A Three or more days with no bowel movement indicates hypomotility of the GI tract. Assessment findings would include hypoactive bowel sounds, a firm distended abdomen, and pain or discomfort upon palpation. Increased fluid intake would help the problem; a decreased intake can lead to constipation. Jaundice does not occur with constipation but can occur with liver disease.

A nurse is teaching a health class about colorectal cancer. Which information should the nurse include in the teaching session? (Select all that apply.) a. A risk factor is smoking. b. A risk factor is high intake of animal fats or red meat. c. A warning sign is rectal bleeding. d. A warning sign is a sense of incomplete evacuation. e. Screening with a colonoscopy is every 5 years, starting at age 50. f. Screening with flexible sigmoidoscopy is every 10 years, starting at age 50.

ANS: A, B, C, D Risk factors for colorectal cancer are a diet high in animal fats or red meat and low intake of fruits and vegetables; smoking and heavy alcohol consumption are also risk factors. Warning signs are change in bowel habits, rectal bleeding, a sensation of incomplete evacuation, and unexplained abdominal or back pain. A flexible sigmoidoscopy is every 5 years, starting at age 50, while a colonoscopy is every 10 years, starting at age 50.

A nurse is preparing a bowel training program for a patient. Which actions will the nurse take? (Select all that apply.) a. Record times when the patient is incontinent. b. Help the patient to the toilet at the designated time. c. Lean backward on the hips while sitting on the toilet. d. Maintain normal exercise within the patient's physical ability. e. Apply pressure with hands over the abdomen, and strain while pushing. f. Choose a time based on the patient's pattern to initiate defecation-control measures.

ANS: A, B, D, F A successful program includes the following: Assessing the normal elimination pattern and recording times when the patient is incontinent. Choosing a time based on the patient's pattern to initiate defecation-control measures. Maintaining normal exercise within the patient's physical ability. Helping the patient to the toilet at the designated time. Offering a hot drink (hot tea) or fruit juice (prune juice) (or whatever fluids normally stimulate peristalsis for the patient) before the defecation time. Instructing the patient to lean forward at the hips while sitting on the toilet, apply manual pressure with the hands over the abdomen, and bear down but do not strain to stimulate colon emptying.

Which information will the nurse include when teaching a patient how to avoid chronic constipation (select all that apply)? a. Many over-the-counter (OTC) medications can cause constipation. b. Stimulant and saline laxatives can be used regularly. c. Bulk-forming laxatives are an excellent source of fiber. d. Walking or cycling frequently will help bowel motility. e. A good time for a bowel movement may be after breakfast.

ANS: A, C, D, E Stimulant and saline laxatives should be used infrequently. Use of bulk-forming laxatives, regular early morning timing of defecation, regular exercise, and avoiding many OTC medications will help the patient avoid constipation.

A nurse is caring for a patient who has had diarrhea for the past week. Which additional assessment finding will the nurse expect? a. Distended abdomen b. Decreased skin turgor c. Increased energy levels d. Elevated blood pressure

ANS: B Chronic diarrhea can result in dehydration. Patients with chronic diarrhea are dehydrated with decreased skin turgor and blood pressure. Diarrhea also causes loss of electrolytes, nutrients, and fluid, which decreases energy levels. A distended abdomen could indicate constipation.

A patient is receiving opioids for pain. Which bowel assessment is a priority? a. Clostridium difficile b. Constipation c. Hemorrhoids d. Diarrhea

ANS: B Patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. C. difficile occurs from antibiotics, not opioids. Hemorrhoids are caused by conditions other than opioids. Diarrhea does not occur as frequently as constipation.

A 58-year-old man with blunt abdominal trauma from a motor vehicle crash undergoes peritoneal lavage. If the lavage returns brown fecal drainage, which action will the nurse plan to take next? a. Auscultate the bowel sounds. b. Prepare the patient for surgery. c. Check the patient's oral temperature. d. Obtain information about the accident.

ANS: B Return of brown drainage and fecal material suggests perforation of the bowel and the need for immediate surgery. Auscultation of bowel sounds, checking the temperature, and obtaining information about the accident are appropriate actions, but the priority is to prepare to send the patient for emergency surgery.

A 62- year-old man reports chronic constipation. To promote bowel evacuation, the nurse will suggest that the patient attempt defecation a. in the mid-afternoon. b. after eating breakfast. c. right after getting up in the morning. d. immediately before the first daily meAL

ANS: B The gastrocolic reflex is most active after the first daily meal. Arising in the morning, the anticipation of eating, and physical exercise do not stimulate these reflexes.

A 71-year-old male patient tells the nurse that growing old causes constipation so he has been using a suppository for constipation every morning. Which action should the nurse take first? a. Encourage the patient to increase oral fluid intake. b. Assess the patient about risk factors for constipation. c. Suggest that the patient increase intake of high-fiber foods. d. Teach the patient that a daily bowel movement is unnecessary.

ANS: B The nurse's initial action should be further assessment of the patient for risk factors for constipation and for his usual bowel pattern. The other actions may be appropriate but will be based on the assessment.

Which information about an 80-year-old man at the senior center is of most concern to the nurse? a. Decreased appetite b. Unintended weight loss c. Difficulty chewing food d. Complaints of indigestion

ANS: B Unintentional weight loss is not a normal finding and may indicate a problem such as cancer or depression. Poor appetite, difficulty in chewing, and complaints of indigestion are common in older patients. These will need to be addressed but are not of as much concern as the weight loss.

A patient is receiving a neomycin solution enema. Which primary goal is the nurse trying to achieve? a. Prevent gaseous distention b. Prevent constipation c. Prevent colon infection d. Prevent lower bowel inflammation

ANS: C A medicated enema is a neomycin solution, i.e., an antibiotic used to reduce bacteria in the colon before bowel surgery. Carminative enemas provide relief from gaseous distention. Bulk forming, emollient (wetting), and osmotic laxatives and cathartics help prevent constipation or treat constipation. An enema containing steroid medication may be used for acute inflammation in the lower colon.

The nurse is caring for a patient who had a colostomy placed yesterday. The nurse should report which assessment finding immediately? a. Stoma is protruding from the abdomen. b. Stoma is flush with the skin. c. Stoma is purple. d. Stoma is moist.

ANS: C A purple stoma may indicate strangulation/necrosis or poor circulation to the stoma and may require surgical intervention. A stoma should be reddish-pink and moist in appearance. It can be flush with the skin, or it can protrude.

Which finding by the nurse during abdominal auscultation indicates a need for a focused abdominal assessment? a. Loud gurgles b. High-pitched gurgles c. Absent bowel sounds d. Frequent clicking sounds

ANS: C Absent bowel sounds are abnormal and require further assessment by the nurse. The other sounds may be heard normally.

The nurse will irrigate a patient's nasogastric (NG) tube. Which action should the nurse take? a. Instill solution into pigtail slowly. b. Check placement after instillation of solution. c. Immediately aspirate after instilling fluid. d. Prepare 60 mL of tap water into Asepto syringe.

ANS: C After instilling saline, immediately aspirate or pull back slowly on syringe to withdraw fluid. Do not introduce saline through blue "pigtail" air vent of Salem sump tube. Checking placement before instillation of normal saline prevents accidental entrance of irrigating solution into lungs. Draw up 30 mL of normal saline into Asepto syringe to minimize loss of electrolytes from stomach fluids.

A nurse is providing care to a group of patients. Which patient will the nurse see first? a. A child about to receive a normal saline enema b. A teenager about to receive loperamide for diarrhea c. An older patient with glaucoma about to receive an enema d. A middle-aged patient with myocardial infarction about to receive docusate sodium

ANS: C An enema is contradicted in a patient with glaucoma; this patient should be seen first. All the rest are expected. A child can receive normal saline enemas since they are isotonic. Loperamide, an antidiarrheal, is given for diarrhea. Docusate sodium is given to soften stool for patients with myocardial infarction to prevent straining.

Which action will the nurse include in the plan of care for a 42-year-old patient who is being admitted with Clostridium difficile? a. Educate the patient about proper food storage. b. Order a diet with no dairy products for the patient. c. Place the patient in a private room on contact isolation. d. Teach the patient about why antibiotics will not be used.

ANS: C Because C. difficile is highly contagious, the patient should be placed in a private room and contact precautions should be used. There is no need to restrict dairy products for this type of diarrhea. Metronidazole (Flagyl) is frequently used to treat C. difficile. Improper food handling and storage do not cause C. difficile.

Which statement to the nurse from a patient with jaundice indicates a need for teaching? a. "I used cough syrup several times a day last week." b. "I take a baby aspirin every day to prevent strokes." c. "I use acetaminophen (Tylenol) every 4 hours for back pain." d. "I need to take an antacid for indigestion several times a week"

ANS: C Chronic use of high doses of acetaminophen can be hepatotoxic and may have caused the patient's jaundice. The other patient statements require further assessment by the nurse, but do not indicate a need for patient education.

An older adult's perineal skin is dry and thin with mild excoriation. When providing hygiene care after episodes of diarrhea, what should the nurse do? a. Thoroughly scrub the skin with a washcloth and hypoallergenic soap. b. Tape an occlusive moisture barrier pad to the patient's skin. c. Apply a skin protective ointment after perineal care. d. Massage the skin with light kneading pressure.

ANS: C Cleansing with a no-rinse cleanser and application of a barrier ointment should be done after each episode of diarrhea. Tape and occlusive dressings can damage skin. Excessive pressure and massage are inappropriate and may cause skin breakdown.

A patient had an ileostomy surgically placed 2 days ago. Which diet will the nurse recommend to the patient to ease the transition of the new ostomy? a. Eggs over easy, whole wheat toast, and orange juice with pulp b. Chicken fried rice with fresh pineapple and iced tea c. Turkey meatloaf with white rice and apple juice d. Fish sticks with sweet corn and soda

ANS: C During the first few days after ostomy placement, the patient should consume easy-to-digest soft foods such as poultry, rice, and noodles. Fried foods can irritate digestion. Foods high in fiber will be useful later in the recovery process but can cause food blockage if the GI tract is not accustomed to digesting with an ileostomy. Foods with indigestible fiber such as sweet corn, popcorn, raw mushrooms, fresh pineapple, and Chinese cabbage could cause this problem.

A guaiac test is ordered for a patient. Which type of blood is the nurse checking for in this patient's stool? a. Bright red blood b. Dark black blood c. Microscopic d. Mucoid

ANS: C Fecal occult blood tests are used to test for blood that may be present in stool but cannot be seen by the naked eye (microscopic). This is usually indicative of a gastrointestinal bleed. All other options are incorrect. Detecting bright red blood, dark black blood, and blood that contains mucus (mucoid) is not the purpose of a guaiac test.

Which action will the nurse take to reduce the risk of excoriation to the mucosal lining of the patient's nose from a nasogastric tube? a. Instill Xylocaine into the nares once a shift. b. Tape tube securely with light pressure on nare. c. Lubricate the nares with water-soluble lubricant. d. Apply a small ice bag to the nose for 5 minutes every 4 hours.

ANS: C The tube constantly irritates the nasal mucosa, increasing the risk of excoriation. Frequent lubrication with a water-soluble lubricant decreases the likelihood of excoriation and is less toxic than oil-based if aspirated. Xylocaine is used to treat sore throat, not nasal mucosal excoriation. While the tape should be secure, pressure will increase excoriation. Ice is not applied to the nose.

The nurse is caring for a patient with Clostridium difficile. Which nursing actions will have the greatest impact in preventing the spread of the bacteria? a. Appropriate disposal of contaminated items in biohazard bags b. Monthly in-services about contact precautions c. Mandatory cultures on all patients d. Proper hand hygiene techniques

ANS: D Proper hand hygiene is the best way to prevent the spread of bacteria. Soap and water are mandatory. Monthly in-services place emphasis on education, not on action. Biohazard bags are appropriate but cannot be used on every item that C. difficile comes in contact with, such as a human. Mandatory cultures are expensive and unnecessary and would not prevent the spread of bacteria.

A 27-year-old female patient is admitted to the hospital for evaluation of right lower quadrant abdominal pain with nausea and vomiting. Which action should the nurse take? a. Encourage the patient to sip clear liquids. b. Assess the abdomen for rebound tenderness. c. Assist the patient to cough and deep breathe. d. Apply an ice pack to the right lower quadrant.

ANS: D The patient's clinical manifestations are consistent with appendicitis, and application of an ice pack will decrease inflammation at the area. Checking for rebound tenderness frequently is unnecessary and uncomfortable for the patient. The patient should be NPO in case immediate surgery is needed. The patient will need to know how to cough and deep breathe postoperatively, but coughing will increase pain at this time.

After several days of antibiotic therapy, an older hospitalized patient develops watery diarrhea. Which action should the nurse take first? a. Notify the health care provider. b. Obtain a stool specimen for analysis. c. Teach the patient about handwashing. d. Place the patient on contact precautions.

ANS: D The patient's history and new onset diarrhea suggest a C. difficile infection, which requires implementation of contact precautions to prevent spread of the infection to other patients. The other actions are also appropriate but can be accomplished after contact precautions are implemented.

The nurse is caring for patients with ostomies. In which ostomy location will the nurse expect very liquid stool to be present? a. Sigmoid b. Transverse c. Ascending d. DescendinG

ASENDING THE PATH OF DIGESTION GOES FROMTHE ASCENDING ACROSS THE TRANSVERSE TO THE DESCENDING AND FINALLY TO SIGMOID THEREFOR THE LEAST FORMED STOOL - VERY LIQUID- WOULD BE THE ACENDING

Abdominal distention

Accumulation of excessive amounts of flatus or liquid or solid intestinal contents -Visually distended or convexly stretched abdomen-varies depending on amount of flatus -Obstruction blocks passage of flatus & intestinal chyme or feces (i.e. paralytic ileus or abdominal tumors) -Bedrest & Inactivity -Post-operative status -Result of constipation & fecal impaction

Irritant or Stimulant Cathartics: Dulcolax & Castor Oil

Action: Adverse Reactions: causes severe cramping; not for long-term use; causes fluid and electrolyte imbalance Nursing Considerations: be aware of dehydration ACTION OF STIMULANT/IRRITANT CATHARTICS Strongest, most abused. Act by irritating GI mucosa and pulling water into bowel lumen. Feces are moved too rapidly to allow colonic absorption of fecal water, so a watery stool is eliminated. Castor oil, sienna products, bisacodyl, and phenolphthalein. Glycerin suppository. If used for more than one week-large intestine loses tone.

LUBRICANT LAXATIVES - MINERAL OIL

Action: lubricates stool and increases ease of stool passage Adverse reactions: avoid prolonged use; inhibits absorption of fat soluble vitamins A, D, E, & K Nursing Considerations: take sitting up; do not give if patient has difficulty swallowing; give with juice or something palatable; do not administer within 2 hours of a meal to keep from interfering with fat soluble vitamin absorption

. Saline/Osmotic Cathartics: MOM & Fleets Enema

Action: short-term use; stimulates peristalsis and creates a semi-liquid stool Adverse Reactions: diarrhea; do not use long-term Nursing Considerations: be aware of dehydration ACTION of SALINE CATHARTICS: Made of poorly absorbed salts of magnesium or sodium, such as magnesium carbonate, oxide, citrate, hydroxide, or sulfate and sodium phosphate. Concentrated solutions of these salts attract water osmotically into the lumen of the large intestine. The resulting bulk stimulates peristalsis. Stool is semi-liquid. Empty bowel in 2 to 6 hours when given orally. Rectally empties bowel in 2 to 5 minutes. Patients with poor kidney functioning, cardiac patients, or inflammatory bowel disease should not be given Saline cathartics. A common adverse effect of cathartics is diarrhea.

FACTORS AFFECTIN BOWEL ELIMINATION

Age-muscle tone loss in perineal floor and anal sphincter, irregular bowel movements, difficulty controlling bowel evacuation, and at risk for incontinence; Diet-fiber, which provides bulk and regularity and softens stools. Foods high in fiber include: fruits (apples), veges, bran cereal, and nuts; Fluid Intake-6-8 glasses of water per day, or 1500-2000ml, and fruit juices, I &O; Physical Activity-Active vs. Non- Active—the more active the better; Psych-emotional stress—cause ulcers; Pain-surgery or hemorroids; PG-hemorroids; SURGREY & ANETHESIA-can cause temporary cessation of peristalsis for 24-48 hours; Medications-promote defecation (Dulcolax) or control diarrhea (Metamucil); Dx Tests—for example, a lower GI may cause a change in elimination, for example, increased gas or loose stools.

CULTURE AWARENESS

All factors that we discussed, earlier, such as decreased activity, fiber intake, and fluid intake all affect cultures. For example, Southeast Asia, "Hmong", lack roughage in their diet, which results in problems with constipation. African-American, deals with Colon Cancer, due to lack of routine visits to check for colorectal cancer by performing a screening and diets with high fat and not enough fruits and vegetables. Chinese, Indian, and Japanese cultures have a low incidence for prostate cancer and prostatitis because they use a squatting toilet. A squatting toilet is the best posture for passing stool. It is easier, faster, and complete.

Kayexalate

An enema used to decrease K+ levels.

CONSTIPATION RELATED TO

Anesthesia/surgical manipulation of bowel Disease processes that decrease metabolic rate Inability to perceive bowel cues Lack of knowledge about factors that promote normal bowel elimination

CONSTIPATION SUBJECTIVE COMPLAINT ANOREXIA AND RECTAL PRESSURE

Anorexia—due to loss of appetite Percuss abdominal dullness for possible mass

DIARRHEA ASSESSMENT

Assessment 1. Frequency (number of stools) in what period of time? When did it start Where have you been in last month, weeks, days How long have you had it 2. Characteristics of stool (frequent, small stools or large volume of water) 3. Accompanying signs/symptoms = abdominal pain, cramping, distention, flatus, nausea, vomiting, bleeding, anorexia, urgency, fever, malaise 3. Assess for signs of fluid loss, electrolyte loss 4. Try to determine cause of diarrhea (food, virus, parasite) 5. Recent exposure to infected people, recent travel, dietary and medication intake, existence of anxiety, stress, systemic disease. 6. Assess skin around anus—digestive enzymes and acid in stool; mouth for sores or dryness; abdomen sunken in, hyperactive bowel sounds Mild dehydration=dry mucous membranes, increased thirst Moderate dehydration=sunken eyes, decreased skin turgor, dry mucous membranes

Palpate Surface and Deep Areas, Liver Edge, Spleen, and Kidneys Light and Deep Palpation.

Begin with light palpation. With the four fingers close together, depress the skin about 1 cm. Make a gentle rotary motion, lift the fingers (do not drag them), and move clockwise. abnormal - Muscle guarding. Rigidity. Large masses. Tenderness. As you circle the abdomen, discriminate between voluntary muscle guarding and involuntary rigidity. Voluntary guarding occurs when the person is cold, tense, or ticklish. It is bilateral, and the muscles relax slightly during exhalation. Use relaxation measures to try to eliminate this type of guarding or it will interfere with deep palpation. If rigidity persists, it probably is involuntary. abnormal - Involuntary rigidity is a constant, boardlike hardness of the muscles. It is a protective mechanism accompanying acute inflammation of the peritoneum. It may be unilateral, and the same area usually becomes painful when the person increases intraabdominal pressure by attempting a sit-up.

FECAL IMPACTION INDEPENDENT INTERVENTION

CONFIRMATION IS MADE BY DIGITAL EXAM OF RECTUM WITH PALPATION OF FECAL MASS REMEMBER SAFETY See procedural guidelines. Stop the procedure if the heart race drops significantly or the rhythm changes. An order is necessary to perform this procedure. If severe, may need to go for an X-ray.

ABNORMAL STOOL CHACTERISTIC

Color: Black---Drug causes are Iron, bismuth or charcoal ingestion; Diet causes—red meat and/or dark green vegetables, such as spinach. Black and tarry-- Upper GI bleeding. Pale, light yellow to gray-Malabsorpation of fat, or diet high in milk and low in meat. Red-Lower GI bleed, hemorrhoids if red is smeared on surface of stool or beets, or Red wine in diet. Clay or white—absence of bile—need to check liver function. Orange or green—intestinal infection. Consistency—Liquid-diarrhea, or increased intestinal motility. Hard—Constipation. Odor-Noxious change—Blood in feces, or infection. Shape-Narrow, ribbon, pencil, or string may be caused by rectal/colon cancer Components-NO blood, fat, foreign objects, mucus, or pus in stool. The Bristol Stool Form Scale. Show different stools and pass around. Color-mucous/translucent, red, or black; Consistency-soft, formed, hard, or liquid; passage of stool or not; Shape-narrow, pebbles, or boulder; Odor-pungent, due to type of food eaten or old blood; Bowel Sounds active vs nonactive

Nutritional

Consider the following when continuing THIS restorative care: Consume low fiber for the first weeks. Eat slowly. Chew food COMPLETELY. Drink 10-12 glasses of water/day. Avoid, but necessary, gassy foods.

LAXATIVE HABIT

DEPENDENCY ON LAXATIVE USE DEVELOPMENT BEGINS UNINTENTIONALLY , USED TO LOSE WATER AND FOR EATING DISORDERS CONSEQUENCES - SHORT AND LONG TERM EFFECTS = HEADACHE, MOOD SWINGS, DIARRHEA, HAIR LOSS TX- DEVELOP BOWEL PROGRAM Laxative habit—dependency upon laxatives in order to move the bowel Development-It is unintentional; May simply start with the use of a stimulant laxative (Dulcolax or Castor Oil) to achieve overnight relief from constipation. Some reasons may be feelings of relief, lose water weight, and individuals with eating disorders to lose weight. Consequences-short and long term effects include: dries out tissue, weakens muscles, slows intestinal motility, failure of colon function, diarrhea, hair loss, vomiting, abdominal pain, low energy, thirst, dehydration, headaches, mood swings, and bone pain. Treatment-develop a bowel program. The goal is to recover normal bowel function and achieve regularity. Gradually wean off the laxative and discuss strategies to recover normal bowel function.

EMOLLIENT

DOCUATE SODIUM /COLACE ACTION: Decrease tension of fecal mass to allow water to penetrate into stool - SLOW ACTING , STOOL SOFTNER. NO LAXATIVE EFFECTS Acts as a detergent to facilitate admixing of fat and water to stool End result, stool softer and easier to expel ADVERSE REACTIONS Sometimes, stools become mushy, when client has decreased motility, cannot expel stool and must be digitally removed. Should not be used with patients with CHF r/t the sodium and possible increased fluid retention. Mild Cramps Do not give within 2 hours of other laxatives

2ND NURSING ACTION WHEN STARTING BOWEL TRAINING PROGRAM

Design a plan that includes: *Fluid intake of 2500 to 3000 mL per day *Increase Fiber in the Diet *Intake of hot drinks just before the usual defecation time *Increase in exercise

Factors Affecting: Pathologic

Diseases like diverticulitis/diverticulosis, IBS, tumors, inflammatory bowel disease, spinal cord disease which are prone to constipation, food poisoning, cystic fibrosis

Saline Agents Laxatives

Draws water into colon and produce watery stool within 3-6 hours. Only use short term because we don't want to throw off patients levels like hyperglycemia. Be careful with someone with renal disease because of elevated risk of magnesium. They work fast and are used for test prep. Examples: Milk of Magnesia or magnesium hydroxide. Citroma or magnesium citrate.

HOW MANY GLASSES OF WATER PER DAY TO PROMOTE BOWEL ELIMINATION

Drink 6 to 8 glasses of water per day. RATIONALE: Sufficient water available to the colon, softens the fecal mass assisting with ease of defecation

Nursing Implications of Enemas

Educate patient. Monitor speed of slow. Left side lying position: because of colon location. Stop right away if patient complains of pain/cramp. Don't hold enema bag more than one foot above. Teach patient to retain contents as long as they can.

Independent (I) Nursing Interventions:Client Teaching

Educate/Teach patient to never take laxatives when acute abdominal pain, nausea, or vomiting is present. Educate/Teach patient that after taking a strong laxative, it takes 2 to 3 days of normal eating to produce enough feces for a bowel movement. Educate/Teach patient that frequent use can cause laxative dependence and electrolyte imbalance

Small Intestines

Food mixes with digestive enzymes; nutrient absorption. It runs between stomach and large intestine. Includes duodenum, jejunum and ileum.

Tagamet or cimetidine

H2 receptor antagonist. Increases risk of drug interactions because it binds to enzymes in the liver that metabolize certain drugs. The drugs that have narrow therapeutic range tagamet can rise concentration. These drugs are coumadin, dilontin and theophylline.

Abdominal assessment

HI SUMPS Hair distribution Inspect contour - on the right side and look across abdomen determine profile from rib bone margin to pubic bone- normally flat to round- abnormal = abdominal distention - scaphoid occurs with malnourishment Symmetry - should be symmetric bilaterally note any bulges , mass or asymmetry - bulges or mass- hernia - protrusion of abdominal viscera thru abnormal opening in muscle wall Umbilicus- midline and inverted , no discoloration, inflammation or hernia. becomes everted with pregnancy or ascities or underlying mass, deeply sunken with obesity , enlarged and everted with umbilical hernia Movement and pulsation pulsation from aorta may show beneath skin in epigastria area in thin people with good muscle wall relaxation and respiratory movement also shown in abdomen in males marked pulsation of aorta with widen pulse - hypertension, aortic insufficiency , thyrotoxicosis and aortic aneurysm marked visible peristalsis together with distended abdomen indicates obstruction Skin - smooth and even with homogenous color - redness with localized inflammation, jaundice with hepatitis, glistening and taught with ascites Demeanor - comfortable person is relaxed and quiet has benign facial expression and slow even respiration restlessness and constant turning to find comfort occur with pain of gastroenteritis absolute stillness resisting any movement is demonstrated with pain of peritonitis Knee flexed up and facial grimacing and rapid uneven respiration also indicate pain note any lesions or scars and measure and document

Abdominal prep assessment

Have the person empty the bladder, saving a urine specimen if needed. • Keep the room warm. • Position the person supine, with the head on a pillow, knees bent or on a pillow, and arms at the sides or across the chest. 163 • Keep the stethoscope end piece warm, your hands warm, and your fingernails very short. • Examine any painful areas last to avoid any muscle guarding. • Use distraction: breathing exercises; emotive imagery; your low, soothing voice; and the person relating his or her abdominal history while you palpate.

BOWEL INCONTINENCE INVERVENTIONS

I - ASSIST PATIENT TO THE BATHROOM EVERY 4 HOURS AND AFTER MEALS D- IMPLEMENT/PUT PATIENT ON BOWEL TRAINING PROGRAM D- ADMINSTER IMODIUM D- ADMINSTER METAMUCIL I- PROVIDE PATIENT TEACHING , ADD FIBER TO DIET, INCREASE EXERCISE AND ACTIVITY

BOWEL INCONTINENCE DEFINED

INABILITY TO CONTROL PASSAGE OF FECES AND GAS FROM THE ANUS CAUSE FREQUENT LOOSE , LARGE VOLUME, WATERLY STOOLS

FECAL IMPACTION

INABLITY TO VOLUNTARY OR INVOLUNTARY PASS STOOL

DIARRHEA INDEPENDENT INTERVENTION

INCREASE ORAL FLUIDS TO EQUAL AMOUNT LOST - TEACH PATIENT TO MONITOR COLOR OF URINE ENCOURAGE LIQUIDS AT ROOM TEMPERATURE SUCH AS WATER , APPLE JUICE, FLAT GINGERALE EDUCATE PATIEN EFFECTS OF DIARRHEA ON HYDRATION

DIARRHEA

INDIVIDUAL EXPERIENCE OR RISK FOR FREQUENT PASSAGE OF LIQUID STOOL OR UNFORMED STOOL

PATIENT TEACHING INTERVENTION INDEPENDENT DIARREHA

INSTRUCT PATIN TO SEEK MEDICAL CARE IF THAT BLOOD IN STOOL OR FEVER OF 101 INSTRUCT PATIENT TO SEEK CARE IF DIARRHEA LAST LONGER THAN 5 DAYS STOP ANTIDIARRHEAL DRUGS WHEN DIARRHEA IN CONTROLED INSTRUCT PATIENT THAT THE USE OF ANTIDIARREAL DRUGS IS NOT ALWAYS DESIRABLE ( IRRITANTS , BACTERIA_ Contact Physician if: no relief from antidiarrheal meds stools are especially foul smelling contains flecks of blood or large amounts of mucus unable to take in sufficient replacement fluids (muscle weakness, fatigue, anorexia, vomiting, drowsiness, irritability) Teach your client to note precipitating events leading to diarrhea—Psychological stress, such as anxiety, can lead to diarrhea.

FIBER HELPS FOOD MOVE THRU

INTESTINES . FOOD HIGH IN FIBER ARE NUTS GRAINS VEGES AND FRUITS

Enemas

Installation of solution into intestine to remove stool.

DIARRHEA CHARECTERISTIC

LOOSE , LIQUID STOOL INCREASED FREQUENCY MORE THAN 3 TIMES A DAY Diarrhea can lead to dehydration Causes of Diarrhea 1. Foods that are spicy or spoiled 2. Fecal impaction 3. Bacteria or virus infection 4. Toxins in the digestive tract 5. Drug reaction 6. Laxative abuse 7. Malabsorption syndrome related to decrease of digestive enzymes (Cystic Fibrosis) 8. Stress and/or anxiety 9. Tumor in the digestive tract 10. Inflammatory bowel disease. (Crohn's)

Constipation: Treatment

Laxatives. Be careful of long term use of laxatives. Increase fiber intake. Alternative treatments like herbal and acupuncture.

A patient is using laxatives three times daily to lose weight. After stopping laxative use, the patient has difficulty with constipation and wonders if laxatives should be taken again. Which information will the nurse share with the patient?

Long-term laxative use causes the bowel to become less responsive to stimuli, and constipation may occur. Teach patients about the potential harmful effects of overuse of laxatives, such as impaired bowel motility and decreased response to sensory stimulus. Make sure the patient understands that laxatives are not to be used long term for maintenance of bowel function. Increasing fluid and fiber intake can help with this problem. Laxatives do not cause scarring. Even if malnourished, the body will produce waste if any substance is consumed.

Bowel incontinence

Loss of voluntary ability to control fecal and gaseous discharges generally associated with: -Impaired functioning of anal sphincter or its nerve supply -Neuromuscular diseases (e.g. - Multiple sclerosis) -Spinal trauma (e.g. - Spinal cord injury, spinabifida) -Tumor (lower GI tract or brain)

This is a major problem for new nursing home and hospital admits.

MAINTAIN PRIVACY , WHEN PRIVACY IS VIOLATED , ANXIETY CAN OCCUR CAUSING TENSION IN VOLUNTARY MUSCULATURE WHICH CAN SUPPRESS DEFECATION

dIEASE PROCESS DECREASE

METABOLIC RATE - SUCH AS MS , RHEUMATOID ARTHRITIS AND ANY TYPE OF DEGENERATIVE DIEASE

BULK FORMING

METAMUCIL Bulk-forming: (Prototype = Metamucil) Action - absorbs water from GI tract Stretches intestinal wall, stimulating peristalsis Effective in 12 to 24 hours, sometimes up to 72 Given in glass of water (8 ounces) Must drink more water with it-enhances action, avoid obstruction Can also be given for diarrhea to bulk up the stool Adverse reactions—N/V ,Cramps, intestinal or esophageal obstruction Nursing Considerations- Assess for abdominal distention—Presence of bowel sounds—and usual pattern of bowel function.— The nurse must be sure the patient is capable of evacuating the bowel before administering a bulk forming Laxative. Always administer with full glass of water and follow with an additional glass of fluid.

MONITOR

MONITOR AGAIST WHAT IS YOUR BASELINE - WHAT IS NORMAL FOR THE PATIENT DAILY BM

HOW MANY SERVINGS OF FRUIT AND VEGETABLES TO PROMOTE BOWEL ELIMINATION

Maintain a well-balanced diet high in fiber and at least four servings of fruits and vegetables. RATIONALE: Fiber, or indigestible dietary residue, provides fecal bulk and enhances absorption of water, which assists peristalsis and increases stimulation of the defecation reflex. Maintain a well-balanced diet high in fiber and at least four servings of fruits and vegetables.

Treatment for bowel incontinence

May not be reversed. Sometimes based on underlying cause -Surgical interventions: Sphincter repair, bowel diversion, or colostomy

SCIENTIFIC KNOWLEDGE

Mouth-decreased chewing & oral dryness; Esophagus-Reduced motility; Stomach-decreased acid secretions, motor activity and thickness; Small Intestine-decreased nutrient absorption; Large Intestine-increased pouches, constipation, and fecal incontinence; Liver-decreases in size; and Anus-muscle tone loss. These structures are necessary for the defecation process. Normal defecation begins in the left colon (descending colon) with movement of stools toward the anus. Clients with cardiovascular disease, glaucoma, increased intracranial pressure, surgical wounds, and elevated blood pressure need to avoid straining

Nursing Process

Must assess the following during _______. Nursing history Physical assessment ---- mouth, abdomen, rectum Lab tests --- fecal specimen, characteristics, occult tests Diagnostic exams---endoscopy, US, CT, barium swallow

40. Which nutritional instruction is a priority for the nurse to advise a patient about with an ileostomy? a. Keep fiber low. b. Eat large meals. c. Increase fluid intake. d. Chew food thoroughly.

NS: C Patients with ileostomies will digest their food completely but will lose both fluid and salt through their stoma and will need to be sure to replace this to avoid dehydration. A good reminder for patients is to encourage drinking an 8-ounce glass of fluid when they empty their pouch. This helps patients to remember that they have greater fluid needs than they did before having an ileostomy. A low-fiber diet is not necessary. Eating large meals is not advised. While chewing food thoroughly is correct, it is not the priority; liquid is the priority.

Stoma care

Normal stoma should appear red and slightly moist (similar in color to mucosal lining of inner cheek) -Very pale or darker-colored stoma with bluish/purplish hue indicate impaired circulation to area - notify surgeon immediately!!! -Slight bleeding may occur initially when stoma is touched. Provider should be notified if other bleeding occur -Assess the peri-stomal skin for irritation each time the appliance is changed -Treat any irritation or skin breakdown immediately -Keep skin clean by washing off any excretion and drying thoroughly -Protect skin, collect stool, and control odor with an ostomy appliance

spleen

Normally the spleen is not palpable and must be enlarged 3 times its normal size to be felt. Reach your left hand over the abdomen and behind the left side at the 11th and 12th ribs. Lift up for support. Place your right hand obliquely on the LUQ with the fingers pointing toward the left axilla and just inferior to the rib margin. Push your hand deeply down and under the left costal margin and ask the person to take a deep breath. You should feel nothing firm. When enlarged, the spleen slides out and bumps your fingertips.

Vascular sounds of abdomen assessment

Note the presence of any vascular sounds or bruits. Using firmer pressure, listen over the aorta, renal arteries, and iliac and femoral arteries, especially in people with hypertension (Fig. 14-3). Usually there is no such sound. abnormal - pitch, and timing of a vascular sound. A systolic bruit is a pulsatile, blowing sound and occurs with occlusion of an artery.

The nurse has attempted to administer a tap water enema for a patient with fecal impaction with no success. The fecal mass is too large for the patient to pass voluntarily. Which is the next priority nursing action?

Obtaining an order for digital removal of stool When enemas are not successful, digital removal of the stool may be necessary to break up pieces of the stool or to stimulate the anus to defecate. Tap water enemas should not be repeated because of risk of fluid imbalance. Positioning the patient on the left side does not promote defecation. A rectal tube is indicated for a patient with liquid stool incontinence or flatus but would not be applicable or effective for this patient.

A patient has a fecal impaction. Which portion of the colon will the nurse assess?

Rectum A fecal impaction is a collection of hardened feces wedged in the rectum that cannot be expelled. It results from unrelieved constipation. Feces at this point in the colon contain the least amount of moisture. Feces found in the ascending, transverse, and descending colon still consist mostly of liquid and do not form a hardened mass.

The nurse is performing a fecal occult blood test. Which action should the nurse take?

Report a positive finding to the provider. Abnormal findings such as a positive test (turns blue) should be reported to the provider. A fecal occult blood test is a clean procedure; sterile gloves are not needed. A thin specimen smear is all that is required. The quality control section should be developed after it is determined whether the sample is positive or negative.

CONSISTANCY NORMAL BOWEL

SOFT BUT FORMED

SUBJECTIVE CHARACTERISTIC OF CONSTIPATION

SUBJECTIVE - Abdominal pain Anorexia Rectal pressure Headache Increased abdominal pressure Nausea Pain with defecation

Hypo-tonic Enemas

Tap water enema. Evacuates the bowels before the fluid gets absorbed. Also distends the colon and softens the stool.

Common Enemas

Tap water which is hypotonic. Soap Suds which is cleansing and an example is castile, only soap suds allowed for enema. Normal Saline which is isotonic and the safest. Large volumes of isotonic NS causes distention of colon and stimulates peristalsis

Colon Cancer

The following are factors and guidelines in screening for what? -Over 50 years of age -Colonoscopy ever 10 years

bowel elimination

The following are functions of _____________. 1. Excrete waste products of digestion. 2. Maintaining this is essential to health and efficient body functions.

Factors affecting bowel elimination

The following are what? Personal habits Diet & Fluid intake Position during defecation Psychological Physical activity Surgery & Anesthesia Pregnancy Age Medications Diagnostic Tests

Cathartics & Laxatives

The following describes these types of medications: Tablet, powder, suppository Short-term If used long term, it will impair defecation reflex.

Diet & Fluid intake

The following example is what type of bowel elimination factor? -"Drink 1100-1400 mL/day" -Fiber & fluid increase stimulates peristalsis

Personal habits

The following example is what type of bowel elimination factor? -likes own restroom -busy life

Psychological factor

The following example is what type of bowel elimination factor? Stress can increase peristalsis! ***DIARRHEA***

Constipation Management

The following nursing measure are implementation for what? Monitor for s/s of constipation. Monitor for s/s of impaction. Monitor bowel movements -- frequency, consistency, shape, volume, color. Monitor bowel sounds. Consult with Dr. if decrease/increase in frequency of bowel sounds. Identify factors that contribute. Encourage intake of 2000-2500 mL/day unless contradicted. Teach of proper medication uses. Teach nutrition. Exercise programs!

Bowel Incontinence

The following nursing measures are implementation for what? Record fecal output. Wash perianal area with soap and water. Dry completely after each stool. Use non-ionic preparations --- PERI WASH. Keep bed and clothing clean. Implement training program. Place on incontinent pads. Implement diet and fluid requirements (BE SPECIFIC).

DUODENUM The duodenum and jejunum absorb most nutrients and electrolytes in the small intestine. The ileum absorbs certain vitamins, iron, and bile salts. Food is broken down in the stomach. The cecum is the beginning of the large intestine.

The nurse is teaching a health class about the gastrointestinal tract. The nurse will explain that which portion of the digestive tract absorbs most of the nutrients? a. Ileum b. Cecum c. Stomach d. Duodenum

The nurse is devising a plan of care for a patient with the nursing diagnosis of Constipation related to opioid use. Which outcome will the nurse evaluate as successful for the patient to establish normal defecation?

The patient reports eliminating a soft, formed stool. The nurse's goal is for the patient to take opioid medication and to have normal bowel elimination. Normal stools are soft and formed. Ceasing pain medication is not a desired outcome for the patient. Tenderness in the left lower quadrant indicates constipation and does not indicate success. Bowel sounds indicate that the bowels are moving; however, they are not an indication of defecation.

Decompression

The purpose of this NGT is to relieve abdominal distention. It is clear and THICKER!

False

True or False: Use digital removal of stool before using an enema.

False

True or False: When using an enema, hypertonic solutions must be used on HIGH volume.

Preventing Constipation

Urge patient to defecate. Have bowel routine. Dietary information. Exercise and activity. Abdominal toning exercises. Positioning and privacy. Educate regarding abuse of laxatives.

Which nursing intervention is most effective in promoting normal defecation for a patient who has muscle weakness in the legs?

Use a mobility device to place the patient on a bedside commode. The best way to promote normal defecation is to assist the patient into a posture that is as normal as possible for defecation. Using a mobility device promotes nurse and patient safety. Elevating the head of the bed is appropriate but is not the most effective; closer to 30 to 45 degrees is the proper position for the patient on a bedpan, and the patient is not on bed rest so a bedside commode is the best choice. Giving the patient a pillow may reduce discomfort, but this is not the best way to promote defecation. A soapsuds enema is indicated for a patient who needs assistance to stimulate peristalsis. It promotes non-natural defecation.

Neuromuscular structures

What structures are usually not developed until 2-3 years of age?

Type 6

What type of stool is described by the following? Fluffy pieces with ragged edges ---MUSHY!!

Type 2

What type of stool is described by the following? Sausage but LUMPY!

Type 3

What type of stool is described by the following? Sausage but with cracks on surface.

Type 4

What type of stool is described by the following? Sausage or snake, smooth & soft.

Type 1

What type of stool is described by the following? Separate hard lumps like nuts---difficult to pass!

Hypotonic

When using an enema, tap water must be ________ and not repeated.

Soapsuds

When using an enema, what causes intestinal irritation?

Pregnant women

Who are more prone to constipation due to pressure on abdominal organs and iron supplements?

Elderly

Who are prone to constipation with slowing of peristalsis and loss of muscle tone?

Bowel Diversions

__________ are tx for conditions that prevent normal passage of feces. Stoma Ileostomy Colostomy Ostomy

Ostomy

an opening from the gastrointestinal, urinary, or respiratory tract onto the skin

normal oder of feces

aromatic; affected by ingested food and individuals own bacterial flora

Normal adult feces

brown

Hemorrhoids are the most common complication of

chronic constipation. They result from venous engorgement caused by repeated Valsalva maneuvers (straining) and venous compression from hard, impacted stool.

return flow

classification of enema -also called a Harris Flush is used to expel flatus. 100-200 mL in and out of the rectum to stimulate peristalsis

retention

classification of enema -introduces oil or medication into the rectum and colon that is retained for a period of time. Oil enemas are an example. Antibiotic enemas are used to treat worms/parasites

cleansing

classification of enema -remove feces for pre-op and pre-test procedures

carminative

classification of enema -to expel flatus

Abnormal adult feces

clay or white color possible cause: absence of bile pigment (bile obstruction); diagnostic study using barium

constipation

decreased frequency of defecation (<3 BM per week) -passage of hard, dry, formed stools or no stool at all -straining at stools -painful defecation -anorexia and nausea -headaches and belly pain

possible cause of hard, dry feces

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

hypoactive sounds or absent sounds

follow abdominal surgery or occur with inflammation of the peritoneum or from late bowel obstruction

Ileostomy stool

liquid stool, constant drainage, cannot be regulated. Drainage contains digestive enzymes so very irritating to the skin. Minimal odor

hyperactive

loud high pitch rushing tinkling sounds that signal increase mobility can occur with early mechanical bowel obstruction gastroenteritis , brisk diarrhea, laxative use and subsiding paralytic ileus

WHAT POSITION DURING DEFECATION CAN PROMOTE BOWEL EMLIMINATION

maintaining a sitting position during defecation A squatting or sitting position straightens the angel between rectum and anal canal and increases efficiency of peristalsis (valsalva maneuver)

Pale feces possible cause

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

Bowel sounds

note character and frequency high-pitched gurgling cascade sound occur irregularly from 5-3.0 times per minute - judge if hypo or hyperactive - listen for 5 minutes before deciding bowel sound is absent

possible cause of abnormal shape to feces

obstructive condition of the rectum

Valsalva maneuver

often referred to as "bearing down," can facilitate defecation. During this maneuver, the person inspires deeply and holds the breath, closing the airway, while contracting abdominal muscles and bearing down. This increases both intraabdominal and intrathoracic pressures and reduces venous return to the heart. The heart rate temporarily decreases along with a decrease in cardiac output. This results in a transient drop in BP. When the patient relaxes, thoracic pressure falls, resulting in a sudden flow of blood into the heart, increased heart rate, and an immediate rise in BP. The Valsalva maneuver may be contraindicated in the patient with a head injury, eye surgery, cardiac problems, hemorrhoids, abdominal surgery, or liver cirrhosis with portal hypertension. Hemorrhoids are the most common complication of chronic constipation. They result from venous engorgement caused by repeated Valsalva maneuvers (straining) and venous compression from hard, impacted stool. Valsalva maneuver may have serious outcomes for patients with heart failure, cerebral edema, hypertension, and coronary artery disease. During straining, the patient inspires deeply and holds the breath while contracting abdominal muscles and bearing down. This increases both intraabdominal and intrathoracic pressures and reduces venous return to the heart. The heart rate temporarily decreases along with a decrease in cardiac output. This results in a transient drop in arterial pressure. When the patient relaxes, thoracic pressure falls, resulting in a sudden flow of blood into the heart, increased heart rate, and an immediate rise in arterial pressure. These changes may be fatal for the patient who cannot compensate for the sudden increased blood flow returning to the heart.

Bowl ostomies

performed to divert and drain fecal material -gastrostomy -jejunostomy -ileostomy -colostomy -stoma -permanence

Diagnostic studies

review any relevant data: -guaiac -xray -stool specimens

normally palpable abdominal structure

right kidney , normal liver edge, pulsatile aorta , recutus muscle lateral borders , cecum ascending colon, uterus gravid, full bladder, sacral promontory, sigmoid colon

Kock continent ileostomy

small intestines form a pouch which is emptied several times a day by intermitted catheterization

Soapsuds enema

volume: 500-1000 ml action: irritates mucosa, distends colon time: 10-15 min