CHAPTER 31 - BOWEL ELIMINATION

nursing interventions for elder abuse of laxatives

Power Pudding is natural alternative to laxatives Mix ingredients together and keep refrigerated- 1 cup wheat bran 1 cup applesauce 1 cup prune juice Take 1 tbsp./day, gradually increase amount until desired effect achieved

alteration in bowel elimination

Primary 1. Can be treated by nurse 2. Due to lifestyle factors: inactivity, inadequate fiber, ↓ fluid, ignoring urge Secondary 1. Due to pathological disorder IE: bowel obstruction Can be resolved Iatrogenic 1. Due to other treatments IE: prolonged use of narcotics slows peristalsis (dries stool) Pseudoconstipation 1. Pt believes they are constipated 2. Overuse of laxatives, enemas, suppositories, etc.

HEALTH EDUCATION

1) adults should identify their own patterns of bowel regularity; which can range from 3 times a day - 3 times a week 2) include regular daily exercise 3) eat high-fiber foods on a regular basis 4)drink 8-10 glasses of fluid (unless contraindicated), and respond to the urge to defecate as soon as possible NUTRITION NOTE: -fiber is found only in plant foods, most abundantly in wheat bran, whole grains (brown rice, whole wheat bread, oatmeal), dried peas, and beans (kidney, garbanzo, lentils), and the skins and seeds of fresh fruits and vegetables (pears and apples) -eating a variety of high-fiber foods is recommended. Americans consume 1/2 of the recommended amount of fiber dail. tolerance to a high fiber diet may improve by increasing gradually -adequate fluid intake is needed for max. benefit

bowel ostomy

A diversion of intestinal contents from their normal path Results in formation of an external opening called a stoma May be an internal tissue pouch with a valve opening Special procedures aid in effective, controlled elimination through the stoma

effects of aging on the intestinal tract

Atrophy of the villi Decreased absorption of fats, vitamin B12 Decrease in motility Bowel habits should not change in the normal healthy individual

probiotics

Beneficial bacteria in yogurt that contains live cultures Survive digestion and colonize within bowel, making contents more acidic Lowered intestinal pH creates hostile environment for unhealthy bacteria Consuming probiotics regularly regulate and improve elimination Reduces s/s of diarrhea, constipation, intestinal gas, bloating

DRAINING A CONTINENT ILEOSTOMY

CONTINENT OSTOMY (surgically created opening that controls the drainage of liquid stool or urine by siphoning it from an internal reservoir.) also referred to as a KOCK POUCH, after the surgeon who developed the technique. this type of ostomy requires no appliance; however the client must drain the accumulating liquid stool or urine approx. every 4-6 hours. client can use a gravity drainage system @ night.

common alterations in bowel elimination

Constipation Primary Secondary Iatrogenic Pseudoconstipation (Perceived Constipation)

nursing diagnoses

Constipation related to hypoactive bowel Diarrhea related to food intolerance Bowel incontinence related to loss of anal sphincter control Pain related to abdominal distention Self-care deficit, toileting related to traction Disturbed body image related to bowel incontinence Deficient knowledge related to factors that contribute to constipation

ostomy care skill

Observe stoma for infection Monitor I & O Assess bowel sounds First BM may take 7 days Purpose of Irrigation is to regulate timing of BM- to create a daily BM at same time of day Eating patterns influence regulation of BMs Odor control is a concern for pt Avoid fish, eggs, beans, cabbage, carbonated beverages, beer, chewing gum, spicy foods Fruits, fruit juices, and tomatoes have laxative effect Adding charcoal tablets to bag or drinking buttermilk, peppermint, or fennel tea decreases bag odor

how food is digested

PERISTALSIS->STORAGE->EXCRETION

colostomy appliance

Do not change appliance unless it needs changing Faceplate changed only every 3-5 days unless leaking Appliance change takes 20-30 minutes Gather supplies- soap, water, solvent, adhesives, skin prep, washcloths & towels, 4X4 or tampon, appliance, measuring device, new bag (drainable, non-drainable) and wafers (either attached or separate) Empty bag, rinse with squeeze bottle & water, add drop of mouth wash Assess and measure stoma using stoma guide Will shrink in size over 4-6 weeks post op Wafer 1/16 inch bigger than stoma, cannot touch stoma Warm wafer in hand to make pliable, pt lay down 15 minutes to allow a good seal

initial assessment

Does patient have a bowel problem? Usual bowel pattern Any measures used to promote defecation? Use of enemas or laxatives Usual eating habits and exercise Foods that produce diarrhea or constipation Disorders that contribute to constipation or diarrhea Physical assessment Shape of the abdomen with the patient supine Flat, Distended, Obese Auscultate for bowel sounds in all four quadrants Percuss for presence of excessive air/gas in the abdomen Palpate for masses or tenderness

colostomy irrigation

Follow procedure in skills Irrigation bag no higher than 12 inches above stoma Insert tubing 4-6 inches past cone Allow 5-10 minutes for water to infuse Clamp if pt c/o cramping Place irrigation sleeve into receptacle May take 30-60 minutes to get return

stool for ova and parasite questionnaire

Have you traveled outside USA? Where____ When______ Do you eat rare steak, poorly cooked fish, raw sausages, unwashed vegetables? Yes ___ No ___ Do you have diarrhea Yes__ No__ How long _____ Are you known carrier? What organism _________Treatment _______________ No laxatives, antacids, antidiarrheal at least 1 week before specimen collection Label container with name, DOB, date, time collected First pass urine, then collect stool in hat Urine must not touch stool Place stool in container using spoon provided Do not touch inside of jar or lid Container has SAF preservative-poisonous do not swallow Fill to line and stir stool and preservative Seal container in biohazard zip lock bag Bring to lab ASAP (within 18 hours of collection) Store at room temperature, do not refrigerate

hypoactive bowel

Indicates a decrease in peristalsis Usually results in constipation Causes Immobility Injury to the bowel Drugs Surgery A patient restricted to bed at risk for constipation Flatus (gas) accumulates in the intestinal tract when peristalsis reduced or absent

new continent ileostomy care

Indwelling cath Continuously drain first 3-4 weeks Advance to every 2 hours, then to bedtime and AM Do not eat or drink within 2 hours of bedtime Set to continuous drain during sleep Notify Enterostomal therapist to train pt first time Irrigate with 30 ml tap water 2-3 times daily If catheter fails to drain, rotate cath tip around If stool becomes too thick to drain Increase water intake to 10-12 eight ounce glasses/day Only use water soluble (KY jelly) to lubricate cath DRAINING: Assume sitting position Insert lubricated 22-28 French catheter Push past valve at about 2 inches Keep catheter 12 inches below stoma to drain into collection container To unplug cath-bear down (valsalva), rotate tip, or try milking catheter. If needed remove, rinse reinsert Remove, clean & dry skin, cover stoma with gauze Drain every 6-8 hours

CLIENT AND FAMILY TEACHING 31-1 PREP FOR COLLECTING A FECAL OCCULT BLOOD TEST

NURSES TEACHES CLIENT TO: omit taking NSAIDs (nonsteroidal anti-inflammatory drugs), such as more than one aspirin, ibuprofen, or naproxen for 7 days BEFORE self collecting stool. Acetaminophen (tylenol) can be taken as needed avoid taking > 250 mg of Vit. C or consuming citrus fruits or juices 3 days before testing eat a high fiber diet containing whole grains, cook vegetables and fruit well refrain from eating red meat for 3 days before testing; poultry and fish are allowed DO NOT eat turnips, radishes, broccoli, beets, carrots, cauliflower, cucumbers, or mushrooms for 2-3 days before testing _____________________________________________ Collect stool in a hat or bedpan. Avoid mixing urine and stool Don gloves and use tongue blade or applicator stick to collect specimen to decrease contamination with microorganisms Take sample from center area of stool A Sample from here is not significantly tainted with blood or urine Apply a thin smear of stool onto test area, covering the entire test space Place 2 drops of chemical reagent onto the test space Wait 60 seconds Close the card, open the back side and look for the blue color Blue indicates blood is present

functions of the intestines

Peristalsis moves chyme and gas through the intestines (causing bowel sounds) Normal transit time in intestine is 18 to 72 hours Feces is stored in the sigmoid colon until the gastrocolic reflex initiates defecation Defecation is under voluntary control and uses the Valsalva maneuver Stool is released when anal sphincters relax

bowel training program

Principles for establishing regular bowel elimination Adequate diet-high in fiber- wheat, bran, whole grains, fresh fruit, vegetables, dried peas, beans and nuts Sufficient fluids- at least 2500 ml daily Adequate exercise- at least walking or abdominal tightening Sufficient rest Establish regular time for evacuation Go to bathroom at regularly scheduled time Provide patient privacy, toilet, raised toilet seat, bedside commode May require digital stimulation to relax the anal sphincter Consult physician about inserting suppository or enema every 2-3 days to establish a regular pattern of elimination Avoid harsh chemical laxatives and enemas if possible

oil retention enema

Purpose is to lubricates and soften stool: Oil is retained 30 minutes or longer Can use commercially prepared Mineral Oil Enema Disposable Equipment: Insert a lubricated 14-22 French catheter into rectum Small funnel or large syringe is attached to tube Instill 100 to 200 ml of warmed mineral, cottonseed, or olive oil Instill slowly to avoid urge to defecate

ostemies

Reasons of ostomies Abdominal wall trauma (gunshot wounds, knife wounds, crush injuries Diseases of colon, ileum, ureters Irritable bowel syndrome Ulcerative colitis, Crohn's disease Congenital Defects Megacolon Imperforate anus TYPES OF OSTOMIES: Types Loop Ostomies, Single barrel, Double Barrel Ileostomy Diversion of the small bowel contents to a pouch or stoma; effluent is pasty liquid Colostomy Diversion of the colon Effluent may be liquid or solid depending on the site; may require irrigation ILEOSTOMY CARE Assess color of stoma Shiny, moist, beefy red or at least pink as inside of mouth White or pale indicates lack of blood flow to stoma Bluish purple indicates obstruction of blood flow in stoma Assess for prolapse or sinking back into abdominal cavity loop ostomies at highest risk for this Assess for stricture from scar tissue Assess for onset of bowel function Usually 3-4 days post-op Monitor drainage (Strict I & O) Watery, paste-like continuous drainage and cannot be regulated Risk for loss of fluid, electrolytes, sodium & potassium 8-10 glasses of water/daily to maintain normal output Replace B12 by nasal spray or injection Include liberal salt in diet Peristomal and Incisional Care Prevent skin excoriation Check appliance for leaks, do not get drainage on skin Wash peristomal area with soap & water, dry well Apply Karaya paste or powder Faceplate remains in place 3-5 days Empty pouch when 1/3 to ½ full to prevent leaks Every 2-3 hours or 4-5 times daily Foods Learn which foods cause gas Avoid eggs, fish, beans, cabbage Adding charcoal tablets to bag or drink buttermilk, peppermint, or fennel tea decreases bag odor Medications Need to be in form of elixirs or liquid preparation Avoid laxatives, time release or enteric coated capsules Warn pt meds may change color of stool drainage Check in pouch for unabsorbed drugs Monitor serum drug levels closely (quinidine, digoxin, asthma drugs, anti-seizure drugs)

ostomy colostomy care

Skin care Stoma should be above skin level, be shiny, moist, beefy red Stoma and skin washed with mild soap and water and patted dry Skin barrier paste is applied Applying an ostomy appliance Appliance is positioned with the stoma protruding through the opening in the center of the faceplate Irrigating a colostomy A solution is instilled into the colon via the stoma

functionss of the intestines

Small intestine -Processes chyme into a more liquid state -Adds bile from the liver to help break down fats -Villi on the small intestine walls absorb nutrients Large intestine -Absorbs water, sodium, chlorides -Waste material stored until expelled

structures involved in waste elimination

Small intestine (Duodenum, Jejunum, Ileum) -Carries chyme from the stomach to the large intestine -Pancreatic function begins when chyme enters the duodenum. -pH changes begin in the duodenum, causing the environment to become more alkaline and protect the small bowel lining. Ileocecal valve-controls flow of chyme into the large intestine -Chyme arrives at the ileocecal valve approximately 4 hours after a meal -Valve prevents backflow of the digestive product. Large intestine Ascending, Transverse, Descending, Sigmoid colon, Rectum, and Anus -Chyme enters the ascending colon on the waves that open the ileocecal valve. -Bacteria continue the breakdown and digestive process. -The final fecal product distends the rectum after 12 hours, but some portion may remain in the rectum for 3 days.

cleansing enema solution

Tap water 500-1000 ml Distends rectum, moistens stool Avoided in children Hypotonic can be absorbed causing electrolyte imbalance Normal Saline 500-1000 ml Distends rectum, moistens stool Soap & Water 500-1,000 ml 5 ml castile soap to 1,000 ml water (1:200) Distends rectum, moistens stool, irritates tissue Hypertonic Saline 120 ml Irritates local tissues and draws water into the bowel Fleets enema 4 oz (120 mL), warm before giving (set in cup of hot water) Be sure to remove the cover, the tip is lubricated but will add more Instill over 1-2 minutes, hold 5-15 minutes Clamp the tubing first Add warm (105-1100 F) tap water to bag followed by the 5 mL of castile soap Prime the tubing, reclamp tubing, Provide for privacy, place client in sims position, drape client, pad bed with waterproof pad and towel, have bedpan handy Wash hands, don gloves, place enema bag on pole 12-20 inches above the level of the anus Lubricate tip of tubing, separate buttocks, insert tube 3-4 inches in adult, direct toward umbilicus Hold tube in place with 1 hand and open tubing with other hand, open the clamp. If client is cramping, stop solution for a few minutes while client deep breathes Resume instillation, instill 500-1000 mL, encourage client to hold for 5-15 minutes

4 layers of intestinal wall

Walls of the intestine have four layers: Mucosa Submucosa Muscular layer Serous layer (serosa)

OSTOMY CARE

a surgically created opening to the bowel or other structure; requires additional care for promoting bowel eliminations. 2 ex. of ostomies: ileostomy: surgically created opening to the ilium colostomy: surgically created opening to the colon material enter/exit through the stoma (the entrance to the opening) most persons with an ostomy, also called ostomates wear an appliance ( a bag or collection device over the stoma) to collect stool depending on the type and location of the ostomy, client care may include: -peristomal care -applying an appliance -draining the continent ileostomy & clients with a colostomy -administering irrigations through the stoma.

GERONTOLOGIC NOTE

age related changes, such as loss of elasticity in the intestinal wall and slower motility throughout the GI tract, predispose older adults to constipation. such changes, alone, however do not cause constipation. Other factors, such as adverse medication effects, diminished physical activity, and diets that are low in fiber, fresh fruits, and vegetable, contribute to the development of constipation. -if older adults use laxatives or enemas, it is important to teach about healthier alternatives, such as increasing dietary fiber, for example by incorporating more fresh fruits and vegetables in the daily diet. a natural laxative, such as the "power pudding," consists of 1 cup wheat bran, 1 cup applesauce, and 1 cup prune juice. ingredients can be mixed thoroughly and refrigerated. the older person can begin with 1 tbsp per day and increase the amount by small increments daily until an ease of bowel movement is achieved and no disagreeable Sx occur. older adults may have a benign lesions such as hemorrhoids or polyps in their lower bowel, which may interfere with the passage of stool. if the digital removal of an impaction is required, gentle manipulation within the rectum should be used to prevent bleeding and tissue trauma diarrhea can easily lead to dehydration and electrolyte imbalances (especially hypokalemia) in older adults, who tend to have less body fluid reserve than younger people. -musculoskeletal disorders, such as arthritis of the hands or neurologic disorders, may interfere with an older person's ability to care for an ostomy appliance or perform colostomy irrigations. - an occupational or enterostomal therapist can offer suggestions for promoting self-care. Also, a wound, ostomy, and continence nurse may be available for consultation and pt teaching.

APPLYING AN OSTOMY APPLIANCE

all consist of a pouch for collecting stool, and a faceplate or disk, that attaches to the abdomen. stoma protrudes through an opening in the center of the appliance. pouch fastens into position when pressed over the circular support on the faceplate. plastic waist belt- helps to support the weight of fecal material and prevents the faceplate from being pulled away from the abdomen. the client empties the pouch by releasing the clamp at the bottom. face plate usually remains in place for 3-5 days unless it becomes loose or causes skin discomfort. pouches are emptied and rinsed or detached and replaced periodically. client empties the pouch when it is 1/3 to 1/2 full ; otherwise, it may become too heavy and pull the faceplate from the skin. although design and equip. varies, all types of appliances are usually changed similarly.

ELIMINATION PATTERNS

b/c various elimination patterns can be normal it is essential to determine: -usual patterns -effort required to expel stool -frequency of elimination -elimination aids, if any FACTORS AFFECTING ELIMINATION: TYPES OF FOOD CONSUMED influence color, odor, volume, consistency, and fecal velocity FLUID INTAKE influences moisture content DRUGS slow or speed motility EMOTIONS alter bowel motility NEUROMUSCULAR FUNCTION affects the ability to control rectal muscles ABDOMINAL MUSCLE TONE affects the ability to increase intra abdominal pressure (valsava maneuver) OPPORTUNITY FOR DEFECATION inhibits or facilitates elimination

LARGE INTESTNIE

bowel/colon 10% approx. a pint to a quart of water is removed from the remnants of digestion, causing the bowel's contents to become a consolidated mass of residue before being eliminated.

CONSTIPATION

elimination problem characterized by dry, hard stool that is difficult to pass. S/S -complaints of abdominal fullness/bloating -abdominal distention -c/o rectal fullness or pressure -pain on defecation -decreased frequency of bowel movements -inability to pass stool changes in stool characteristics such as oozing, liquid or hard, small stool 4 types: primary secondary iatrogenic pseudoconstipation incidence of constipation tends to be high among those whose dietary habits lack adequate fiber (i.e not eating sufficient raw fruits and veggies, whole grains, seeds and nuts) Dietary fiber (inc. undigested cellulose) is important b/c it attracts water within the bowel, resulting in bulkier stool that is more quickly and easily eliminated some researchers speculate that a shortened transit time- time between when a person eats food and eliminates stool- protects against serious medical disorders. its argued that the longer the stool is retained, the more contact with and absorption of toxic substances takes place that may contribute to the development of colorectal cancer. PRIMARY CONSTIPATION: (simple constipation) well within the treatment domain of nurses. results from lifestyle factors such as inactivity, inadequate intake of fiber, insufficient fluid intake, or ignoring the urge to defecate SECONDARY CONSTIPATION consequence of pathologic disorder such as a partial bowel obstruction. usually resolves when primary cause is treated. LATROGENIC CONSTIPATION occurs as a consequence of other medical treatments. For example, prolonged use of narcotic analgesia tends to cause constipation. These and other drugs slow peristalsis, delaying transit time. The longer the stool remains in the colon, the drier it becomes, making it more difficult to pass PSEUDOCONSTIPATION(perceived constipation) term used when clients believe themselves to be constipated, even though they are not may occur in those who are extremely concerned with having a daily bowel movement in their zeal for regularity, the y often overuse and abuse laxatives, suppositories, and enemas. this type of self treatment may actually cause vs treat constipation chronic purging eventually weakens bowel tone; consequently bowel elimination is less likely unless it is artificially stimulated C/O Fullness or Bloating Abdominal Distention C/O Rectal Pressure Pain on Defecation Changes in Stool Characteristics Inability to Pass Stool ↓ Frequency of Bowel Movements Narcotic analgesics Codeine, morphine, meperidine General anesthetics Diuretics Sedatives Anticholinergics Calcium channel blockers DRUGS USED TO TREAT CONSTIPATION Stool softeners Colace, Surfak, Dialose Bulk forming laxatives Fibercon, Metamucil, Citrucel Need to take with large amount water Irritant/stimulant laxatives Dulcolax, Neolid, Ex-lax, Correctol, Senokot Saline laxatives Citrate of magnesia, milk of magnesia, phospho-soda

ADMINISTERING AN ENEMA

enema- introduces solution into the rectum nurses give enemas to: -cleanse the bowel (most common reason) -soften feces -expel flatus -soothe irritated mucous membranes -outline the colon during diagnostic X-Rays -treat work and parasite infestations CLEANSING ENEMA: Stimulates peristalsis through distention and irritation of colon and rectum use different types of solution to remove feces from the rectum defecation usually occurs within 5-15 minutes after administration. large volume cleansing enemas may create discomfort due to causing distention to the lower bowel these enemas must be administered carefully, especially to those patients with intestinal disorders, such as colitis (inflammation of the colon. large-volume enemas may rupture the bowel or cause secondary complications. TAP WATER AND NS ENEMAS preferred for their nonirritating effects, especially for clients with rectal diseases or those being prepared fro rectal exams. appear to have the same degree of effectiveness as cleansing the bowel bc tap water is hypotonic, the can be absorbed through the bowel. consequently if several enemas are administered in succession, fluid and electrolyte imbalances may occur. for client safety, if stool continues to be expelled after three enemas, the nurse consults the MD before further administration SOAP SOLUTION ENEMAS: mixture of water & soap. 1 envelope of soap mixed with 1000 ml of water (quart) if the pre packaged packs are not available, the mix consists of 1 ml of mild liquid soap and 200 ml of solution, or a ratio of 1:200. therefore, 5 ml of soap is added to prepare a volume of 1000ml soap cause chemical irritation of the mucous membranes, adding too much soap or using strong soap can potentiate the irritating effect. HYPERTONIC SALINE ENEMAS sodium phosphate enema- draws fluid from body tissues into the bowel. increases the fluid volume in the intestine beyond what was originally instilled. the concentrated solution acts as a local irritant on the mucous membrane Hypertonic enema solutions are available in commercially prepared, disposable containers holding approx. 4 oz (120 ml) of solution the container which has a lubricated tip, substitutes for enema equipment and tubing ________________________________________ RETENTION ENEMAS : Softens stool as oil is absorbed uses a solution held within a the large intestine for a specific period, usually @ least 30 minutes, some are not expelled at all. oil retention - the fluid instilled is mineral, cottonseed, or olive oil. oils lubricate and soften the stool, so it can be expelled more easily. oil may come in a pre-filled container if disposable equipment is not available, the nurse lubricates the tip and inserts a 14-22 F tube in the rectum a small tunnel or large syringe is attached to the tube, & the nurse instills approx. 100-200 ml of warmed oil slowly to avoid stimulating an urge to defecate. premature defecation defeats the purpose of retaining the oil _______________________ Fluid introduced into rectum by means of a tube Stimulate peristalsis or wash out waste products Often given before a colonoscopy or an x-ray Volume of typical cleansing enema Infants: 20 to 150 mL Ages 3 to 5 years: 200 to 300 mL School-age: 300 to 500 mL Adults: 500 to 1000 mL Distention reduction enema (Slush Enema): Relieves discomfort from flatus causing distention Medicated enema Solution with drugs to reduce bacteria or remove potassium Disposable enema (small volume) Stimulates peristalsis by acting as irritant

PROVIDING PERISTOMAL CARE

enzymes in the stool can quickly cause EXCORIATION (chemical injury of the skin), which requires close attention in order to prevent skin breakdown. wash around stoma with mild soap and warm water, pat dry- this preserves skin integrity another way to preserve skin integrity is to apply barrier substances such as KARAYA ( a plant substance that becomes gelatinous when moistened, and commercial skin preparations around the stoma. an ENTEROSTOMAL THERAPIST, a nurse certified in caring for ostomies and related skin problems, may be consulted regarding skin and stomal care.

DEFECATION

expelling feces (stool) from the body

TESTING FOR COLORECTAL DISORDERS

incidence of colorectal cancer increase with age 3rd most common cancer diagnosed in men and women in the US most common cause of death from cancer early sign: change in bowel elimination patterns and stool characteristics. Melena (bloody stool) is an abn. characteristic which may be invisible to the naked eye. FECAL OCCULT TESTING: (FOBT) -self collecting screening test from three separate stools, may be obtained by clients to detect heme, an iron compound in blood present within stool as it passes through the small and large intestine. -requires some drug and dietary restrictions prior to collection FECAL IMMUNOCHEMICAL TEST: (FIT) -preferred alternative to FOBT -more specific than FOBT b/c is uses antibodies to detect GLOBIN (a protein removed from heme) which is present exclusively in the lower intestine advantages: no dietary restrictions no medication restrictions only 1-2 specimens are needed high rate of specificity for colorectal cancer STOOL DNA TEST: a self collected stool test known as cologuard FDA approved- 2014 used to detect mutant DNA from tumor cells present in stool collection does not require any preparation, diet or medication changes 92% detection of colon cancer and precancerous conditions false + , - are possible; if test is positive you must have an endoscopy examination performed. ENDOSCOPIC EXAMINATIONS Colonoscopy- visual inspection of the interior colon using a flexible lighted endoscope, which is considered the most accurate test for detecting colorectal cancer should begin @ age 50 and q10years thereafter colorectal cancer risk factors: -family Hx or colorectal cancer, or polyps should undergo colonoscopies earlier and more frequently. ALTERNATIVE to colonoscopy would be a Flexible Sigmoidoscopy (visual endoscopic inspection limited to the sigmoid portion of the large intestine, q 5-10 years. Barium Enema - q5years colonography- a CT scan w/out a colonoscope, sometimes referred to as a virtual colonoscopy, q5years.

STOOL CHARACTERISTICS

obtain objective data about stool characteristics through inspection or asking pt to describe its appearance. -COLOR brown is normal black, clay (tan), yellow, green is abnormal -ODOR aromatic is normal foul is abnormal -CONSISTENCY soft, formed is normal soft, bulky; hard, dry; watery; paste like =abn. -SHAPE round, full is normal unformed, flat is abnormal -UNUSUAL COMPONENTS undigested fiber is normal worms, bloods, pus, mucus is abn. any change in bowel elimination that does not respond to simple dietary or life style changes requires further investigation. ___________________________________________ NORMAL STOOL Color: light to dark brown Consistency: soft-formed in children and adults; consists of ¼ solids and ¾ water Appearance: affected by diet and metabolism Composition: Solid materials consist of 70% undigested roughage from carbohydrates, fat, protein, and inorganic matter, and 30% dead bacteria ABNORMAL STOOL Blood in the stool: most serious abnormality Fresh red blood: bleeding in colon Occult: upper GI bleed Black stool called melena Pale white or light gray stool: absence of bile in the intestine Large amounts of mucus, fat, pus, or parasites Steatorrhea -stool floats, foul smelling, high in fat

DIARRHEA (HYPERACTIVE BOWEL)

urgent passage of of watery stool and commonly accompanied by abdominal cramping. simple diarrhea: begins suddenly, & lasts for a short period of time. S/S - N/V -blood or mucus in the stools usually, diarrhea is a means of eliminating an irritating substance such as tainted food, or intestinal pathogens. may also result from emotional stress, dietary indiscretions, laxative abuse, or bowel disorders. resting the bowel temporarily may relieve simple diarrhea, meaning clear liquids, but avoids solid foods for 12-24 hrs. resumed eating begins with bland foods and those low in residue such as bananas, applesauce, & cottage cheese. if not relieved in 24 hours, call MD ______________________ Etiology (Causes): Inflammation of GI tract, infectious diseases, diseases such as: Diverticulitis Ulcerative colitis Crohn's disease Emotional Stress Effect of medications, dietary intake Drugs Many antibiotics kill normal bowel bacteria, resulting in diarrhea Patients who experience diarrhea from antibiotics should replace normal flora by: Eating yogurt Drinking buttermilk Taking acidophilus (available OTC) or Probiotics Pt with diarrhea may need electrolyte solution Gatorade, Pedialyte, Ricelyte Lactose Intolerance can cause diarrhea Avoid milk products PASSAGE OF WATERY STOOL: Increase in peristalsis, abdominal cramping, N/V Blood and mucus in stool Can start suddenly, last a short period Can lead to dehydration and electrolyte imbalance in elderly- hypokalemia Bodies way of getting rid of irritating intestinal pathogen TREATMENT Rest the bowel Clear liquids Avoid solid foods for 12-24 hours or longer Resume eating bland diet, low residue Applesauce, bananas, cottage cheese DRUGS USED TO CONTROL DIARRHEA Camphorated tincture of opium (paregoric) Diphenoxylate hydrochloride with atropine sulfate (Lomotil) Loperamide hydrochloride (Imodium) Difenoxin hydrochloride with atropine sulfate (Motofen) Instructions Do not take any meds prior to collecting stool for Ova and Parasites Do not use longer than 48 hours without calling physician

FECAL IMPACTION

occurs when a large, hardened mass of stool interferes with defecation, making it impossible for the client to pass feces from unrelieved constipation, retained barium from an intestinal X-Ray, dehydration, and weakness of abdominal muscles. clients with impactions usually report a frequent desire to defecate, but an inability to do so. rectal pain may result from unsuccessful efforts to evacuate the lower bowel. some clients with impactions pass liquid stool ,which is mistake for diarrhea. forceful muscular contractions of peristalsis in higher bowel areas, were the stool is still filled, cause the liquid stool. these contractions send the liquid around the margins of the impacted stool, but this passage of liquid stool does not relieve the initial condition. to determine if impaction is present , it may be necessary to insert a lubricated gloved finger into the rectum. if the rectum is filled with a mass of stool, the nurse administers enemas, first oil retention , and then cleansing. ___________________ FECAL IMP. ETIOLOGY Unrelieved constipation Retained barium Dehydration Weakness of abdominal muscles Polyps or internal hemorrhoids in lower rectum Symptoms Patient may report rectal pain Patient may report desire to defecate but unable to do so Liquid stool may pass around impaction REMOVING FECAL IMPACTION Wash hand, gather equipment, provide privacy, Don gloves, pad the bed, place patient in Sims position, place bedpan on bed Lubricate forefinger of glove of dominant hand, insert lubricated finger into rectum Move finger slowly and carefully about to break up stool Remove segments of stool and deposit in bedpan Provide rest periods but continue until mass has been removed Stop immediately if patient experiences bradycardia Stimulation of sphincter may cause vagal response Clean rectal area, dispose of stool and soiled gloves, wash hands

FLATULENCE

or flatus- an excessive accumulation of intestinal gas. results from swallowing air while eating or from sluggish peristalsis. another cause: gas that forms as a by-product of bacterial fermentation in the bowel. cabbage, cucumbers, and onions veggies known to produce gas. beans are other gas formers; eating beans creates intestinal gas b/c humans lack an enzyme to completely digest its particular form of complex carbohydrate. flatus may be expelled rectally, thus reducing intestinal accumulation and distention, however this is sometime not sufficient enough to eliminate the cramping pain or other symptoms, when clients are extremely uncomfortable and ambulating does not eliminate flatus, the nurse may insert a rectal tube to help the gas escape ______________________ Accumulation of intestinal gas Swallowing air, sluggish peristalsis Forms as a byproduct of bacterial fermentation in the bowel Cabbage, cucumbers, onions, beans Expelled rectally Reduces intestinal accumulation and distention Ambulation will help to move gas and eliminate rectally May need to use a rectal tube to help gas escape Lubricate 22-32 French cath, insert 4-6 inches into rectum Tape tube to buttocks, leave in place no longer than 20 minutes, open end to bag or chucks May reinsert every 3-4 hours Review Skill 31-1Inserting a rectal tube

NUTRITION NOTE

probiotics are beneficial bacteria present in some commercial products like yogurt that contain love cultures. these bacteria survive digestion and colonize within the bowel, making bowel contents more acidic. the lowered intestinal pH creates a hostile environment for unhealthy bacteria. Eating products containing probiotics is believed to regulate and improve elimination, thus reducing Sx of diarrhea, constipation, intestinal gas, and bloating.

PERISTALSIS

rhythmic contractions of the intestinal smooth muscle that facilitates defecation. moves fiber, water, and nutritional wastes along the ascending colon toward the rectum. becomes even more active during eating; this increased activity is called the gastrocolic reflex.

INSERTING A RECTAL SUPPOSITORY

suppository- oval or cone-shaped mass that melts at body temperature, inserted into a body cavity such as the rectum. most common reason: to deliver a drug that will promote the expulsion of feces _________________ Used to promote bowel movements Glycerin and Bisacodyl suppositories Promote bowel evacuation Stimulate the inner surface of the rectum and increasing the urge to defecate Form gas that expands the rectum Melt into a lubricating material to coat the stool for easier passage through the anal sphincter

FECAL INCONTINENCE

the inability to control the elimination of stool. does not imply stool is watery or loose in some cases, bowel function is normal. incontinence results from neurological changes that impair muscle activity, sensation, or thought processes. even a fecal impaction may be an underlying cause of incontinence may also occur when a person cannot reach the toilet in time, such as after taking a harsh laxative. chronic fecal incontinence can be devastating socially and emotionally. _____________________ Lack of voluntary control of fecal evacuation; inability to retain feces ETIOLGY Illness Cerebrovascular accident Traumatic injury Neurogenic dysfunction Distressing condition that causes a loss of dignity Feelings of being less of a person Loss of self-respect Embarrassed Anxiety or fear of losing control Disgusted

IRRIGATING A COLOSTOMY

used when clients with a colostomy whose stool is more solid sometimes requires the instillation of fluid to promote elimination. colostomy irrigation involves instilling the solution through the stoma into the colon, a process similar to administering an enema. PURPOSE: to remove formed stool and, in some cases, to regulate the timing of bowel movements. with regulation, a client with a sigmoid colostomy may not need to wear an appliance. the colostomy irrigation helps to TRAIN the bowel to eliminate formed stool following the irrigation. once the client has eliminated the stool, he or she will expel no more until the next irrigation. this mimics the pattern of natural bowel elimination for most people.

GASTROCOLIC REFLEX

usually precedes(goes before) defecation it's accelerated wavelike movements, sometimes perceived as alight abdominal cramping, propel stool forward, packing it within the rectum as the rectum distends the person feels the urge to defecate. stool is released when the ANAL SPHINCTERS (ring shaped band of muscles) relax. performing the VALSAVA MANEUVER- closing the glottis and contracting the pelvic and abdominal muscles to increase abdominal pressure- facilitates this process.

PHARMACOLOGIC CONSIDERATIONS

when clients experience constipation, diarrhea, loss of appetite, or other GI distress, always ask about medications taken. GI distress is one of the most frequent side effects of ANY drug. caution adults to avoid self-administration of mineral oil to relieve constipation as it interferes with absorption of fat-soluble ( A,D,E, & K) -laxative abuse is possible among older adults experiencing changes in bowel routine. some adults may become very bowel conscious and overuse laxatives or have sustained laxative abuse. bowel assessment can discover these issues for appropriate intervention -older adults can develop healthier bowel elimination habits through use of bulk-forming products containing psyllium or polycarbophil, which are more effective and less irritating than other types of laxatives. examples of these agents include metamucil (procter & gamble, cincinnati, OH) & FiberCon (Lederle laboratories, pearl river, NY) suppositories are used for both systemic and local effects: ANTIPYRETICS- are frequently used rectally when fever reduction cannot be managed daily CONSTIPATION- can be relieved locally in the rectum when used to soft or stimulate defecation. Medications released from the suppository can have local or systemic effects. depending on the drug, local effects may include softening and lubrication dry stool, irritating the wall of the rectum and anal canal to stimulate smooth muscle contraction, and liberating carbon dioxide, thus increasing rectal distention and the urge to defecate.