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Dian Adiningsih

Identify variables that influence bowel elimination. Identify appropriate nursing interventions to promote bowel elimination. Discuss nursing interventions for the incontinent patient. Discuss nursing interventions for the patient with a bowel diversion.

GI Tract is a series of hollow mucous membrane lined muscular organs Purpose is to absorb fluids & nutrients, prepare food for absorption & provide storage for feces

Mouth Esophagus Stomach Small Intestine Large Intestine Rectum

Digestion begins here Mechanical, chemical breakdown of nutrients Teeth-Mastication Salivary secretions-enzymes Food Bolus

Hollow, muscular tube for passage of food to stomach Peristaltic waves, contraction and relaxation of smooth muscle moves food down to stomach Sphincter control to prevent reflux

Food is temporarily stored and mechanically and chemically broken down Secretes HCL, mucus, pepsin, & intrinsic factor(Needed for Vitamin B12 absorption) Food is converted into chyme

1 inch in diameter 20 feet long Three divisions: Duodenum, Jejunum, Ileum Enzymes in small intestine (amylase, lipase, & bile) break down fats, proteins & carbs into basic elements Nutrients absorbed in duodenum & jejunum, ileum absorbs vitamins, iron, & bile salts

Lower GI tract Larger diameter, 5-6 feet in length 3 divisions: cecum, colon, rectum Responsible for absorption of water Primary organ of bowel elimination Cecum-chyme enters cecum via the ileocecal valve, valve prevents regurg back to small intestine, cecum ends with appendix

3 Divisions: Ascending, Transverse, Descending Colon Functions: Absorption, Protection, Secretion, & Elimination (stool and flatus)

Air swallowing Diffusion of gas from bloodstream into intestines Bacterial action on unabsorbable CHO (Beans) Fermentation of CHO (cabbage, onions Can stimulate peristalsis Adult forms 400-700 ml of flatus daily

Sigmoid colon Storage of feces Length varies with age When fecal mass or flatus moves into rectum, it distends and defecation begins Process involves involuntary (Internal sphincter) and voluntary control (external sphincter) Valsalva Maneuver- voluntary contraction of abdominal muscles

The large intestine is the primary organ of bowel elimination Approximately 5 feet long, beginning at the ileocecal valve and ending at the anus About 1500ml of chyme enters the large intestine each day 800-1000ml of fluid is reabsorbed, resulting in formed, semisolid feces The process of bowel elimination is called defecation. Peristalsis contractions of the muscles of the long intestine is controlled by the autonomic nervous system
Mass peristaltic sweeps occur 1 to 4 times in 24 hours, generally after eating.

Defecation is generally painless Valsalva maneuver the act of bearing down


May elevate blood pressure May stimulate the vagus nerve

Terms to know
Diarrhea excessively liquid stool Constipation dry, hard stool Hemorrhoids abnormally distended veins in the rectum

Age
Infants stool characteristics are diet dependent, no voluntary control Babies: 3 6 BMs/day Toddlers ability for voluntary control develops between 18 and 24 months
Neuromuscular structures not developed until 15 18 mos. Voluntary control 2 3 yrs.

School-age children to adults patterns vary greatly Older adult constipation is often a chronic problem Pregnant women prone to constipation
Pressure on abd. Organs Iron supplements

Elderly prone to constipation


Slowing of peristalsis

Dietary intake High-fiber diet( undigestible residue ) provides bulk


Absorbs fluid Increases stool mass Bowel wall stretches Peristalsis stimulated Defecation results

2000 to 3000 mls of fluid daily


fld= Liquifies stool Soft stool

Constipating foods cheese, lean meat, eggs Laxative effect certain fruits and veggies Gas-producing onions, cabbage, beans

Daily patterns Individualized patterns related to frequency, timing, position,

and place Personal habits Busy schedule, postpone BM, constipation Sitting or squatting facilitates defecation as this increases
abdominal pressure Lifestyle Normal life process Preoccupation with bowel elimination dirty process Activity Exercise improves GI motility and muscle tone Immobility decreases GI motility and muscle tone

Psychological variables
Anxiety seems to directly effect GI motility in some and may result in diarrhea Chronic worriers and controlling personalities may experience frequent constipation

Diagnostic studies
Fasting, stress and bowel cleansing can all interfere with normal patterns of elimination

Pathologic conditions
Bowel disturbances may be the first sign of a disease process Causes of diarrhea include diverticulitis, infection, malabsorption syndromes, cancer, diabetic neuropathy, and food poisoning Causes of constipation include disorders of the colon or rectum, spinal cord injury, and megacolon Intestinal obstructions may be mechanical or functional
Mechanical tumor, hernia, adhesions Functional muscular dystrophy, diabetes, Parkinsons

Medications
Constipating medications include opioids, codein, antacids, iron, and anticholinergics Medications that cause diarrhea as a side effect include antibiotics Several medications can affect the appearance of the stool.

Surgery and anesthesia


Anaesthetic causes temporary cessation of peristalsis
Paralytic ileus the temporary cessation of peristalsis after bowel manipulation Peristalsis may also be inhibited by general anesthesia

Direct manipulation of the bowel stops peristalsis

Patient history
You must take a complete history, even though most patients will be uncomfortable discussing their bowel habits!

Inspection
Peristalsis is generally not visible Is the abdomen distended? Are there any visible masses? Are there any hemorrhoids or areas of s

Auscultation
Are bowel sounds present in all 4 quadrants?
Hypoactive, hyperactive, absent

Percussion
Do you hear tympany over the abdomen and stomach? What might cause you to hear a dull sound?

Palpation
Is the abdomen soft or hard? Tender or nontender? Distended or non-distended? Do you feel any masses? Can you feel any masses or polyps in the rectum?

Stool characteristics
Bristol Stool Chart, etc Keep a record at the bedside.

Diagnostic studies
Specimen collection Occult blood Endoscopy Radiography

Bowel elimination as the problem ostomy management


Bowel Incontinence Constipation Diarrhea Impaired Skin Integrity Body Image Disturbance Altered bowel elimination Pain

Example,

Bowel elimination as the etiology


Example, fluid volume deficit

Examples
See page 1567

1. 2.

3. 4.

Constipation difficult passage of hard, dry stool; infrequent movements Fecal Impaction unrelieved constipation, feces wedged in rectum, no BM usually 3days, oozing of diarrheal stool develops Diarrhea- # liquid stool Flatulence abd. Distention & pain

Incontinence inability to control passage of stool Hemorrhoids


Dilated engorged veins Increased pressure when straining Internal / external Bleeding

Timing patients usual time every day Positioning sitting upright


Positioning of patient-squatting Positioning on bedpan

Privacy always respect this right unless patient is unstable Nutrition high fiber diet, 2000-3000ml of fluid daily Exercise improves motility and aids defecation Use of cathartics, laxatives Anti-diarrheal agents Enemas Digital removal of stool Ostomy care

Metamucil-bulk forming Colace, Surfak-emollient or wetting agent Fleets, MOM. Mag Sulfate-saline agent Dulcolax, Ex-Lax, Castor oil- stimulant cathartic Haleys MO, mineral oil- Lubricant

Cleansing enema Tap water Normal saline Hypertonic Solutions (Fleets enema) Soapsuds Oil Retention Medicated enemas (Kayexalate, Lactulose) Administering a Cleansing enema P&P pg. 1200-1201

More of a symptom than a disorder Decrease in frequency of BM Straining & pain on defecation is associated symptoms (Valsalva manuever) Can be significant health hazard (increase ICP, IOP, reopen surgical wounds, cause trauma, cardiac arrhythmias) Risk factors
Bedrest Constipating medications Reduced fluid intake Reduced bulk in the diet Depression CNS disease Painful, local lesions

Nutrition
A high-fiber diet, adequate intake and exercise is as effective in controlling constipation as medication

Laxatives and cathartics


For occasional use only overuse is most common cause of constipation!

Results from unrelieved constipation Collection of hardened feces wedged into rectum Can extend up to sigmoid colon Most at risk: depilated, confused, unconscious (all are at risk for dehydration)

When a continuous ooze of diarrheal stool develops, impaction should be suspected Associated S/S: Loss of appetite, abdominal distention, cramping, rectal pain

Nursing measures
Assist with toileting promptly Remove the cause if possible Rule out impaction Protect the skin around the anus Promote return of normal bowel flora

Nutrition
Educate on safe food handling and consumption

Increase in number of stools & the passage of liquid, unformed stool Intestinal contents pass through small & large intestines too quickly to allow for usual absorption of water & nutrients A protective response when caused by intestinal irritants If untreated, loss of fluids and electrolytes can be life-threatening. Symptom of disorders affecting digestion, absorption, & secretion of GI tract

Irritation can result in increased mucus secretion, feces become too watery, unable to control defecation Excess loss of colonic fluid can result in acidbase imbalances or fluid/electrolyte imbalances Can also result in skin breakdown

Emotional Stress Intestinal Infection (Clostridium difficile) Food Allergies Food Intolerance Tube Feedings (Enteral) Medications Laxatives Colon Disease Surgery

Treatment
Rehydration Medications, especially for chronic diarrhea Eliminate the cause

Inability to control passage of feces and gas from the anus Caused by conditions that create frequent, loose, large volume, watery stools or conditions that impair sphincter control or function Seldom life-threatening, may be very psychologically devastating.

Toileting the patient when incontinence is likely to occur Protecting the skin Changing linens as needed Applying fecal incontinence pouch Implementing a bowel training program

Gas accumulation in the lumen of intestines Bowel wall stretches and distends Common cause of abdominal fullness, pain, & cramping Gas escapes through mouth (belching), or anus (flatus)

Flatulence
Avoid gas-producing foods Ambulation promotes peristalsis and the passage of flatus

Dilated, engorged veins in the lining of the rectum External (Clearly visible) or Internal Caused by straining, pregnancy, CHF, chronic liver disease

1. A newly admitted client states that he has recently had a change in medications and reports that stools are now dry and hard to pass. This type of bowel pattern is consistent with:
A. Abnormal defecation B. Constipation C. Fecal impaction D. Fecal incontinence

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These patients have undergone surgery to create an opening in the abdominal wall for fecal elimination. An ileostomy allows liquid fecal material from the ileum to be eliminated through the stoma.
The continent ileostomy and ileoanal reservoir are alternatives to traditional surgery.

A colostomy permits formed feces in the colon to be eliminated via the stoma. They are classified by the part of the colon from which they originate. Ostomies may be temporary or permanent.

Location of ostomy determines consistency of stool Ileostomy bypasses the entire large intestine, stools are frequent & watery Ascending colostomy- liquid stool Sigmoid colostomy-most like normal stool

Loop colostomy- temporary, usually done on transverse colon 2 openings through stoma, proximal loop for stool, distal loop for mucus End colostomy- one stoma formed from the proximal end of the bowel with the distal portion removed or sewn shut (Hartmanns Pouch)

End colostomy usually done for colorectal cancer Ruptured diverticulum- temporary end colostomy with a Hartmanns Pouch Double barrel colostomy- Bowel is surgically severed, 2 ends are brought out onto abdomen with 2 distinct stomas (proximal & distal)

Ileoanal reservoir- restorative proctocolectomy, no outward stoma, no pouch wearing, clients have internal pouch created from the ileum Ileal pouches constructed in various configurations (S,J,W) End of the pouch is sewn or anastamosed to the anus

Several stages to surgery to create pouch May need temporary ostomy to allow time for pouch to heal Kegel exercises to increase pelvic floor muscle tone

Kock Continent Ileostomy-Internal reservoir or pouch is created using piece of small intestine Stoma brought out low on abdomen, end of internal part in pouch is a one way nipple valve to promote continence Valve only allows fecal contents to drain when an external catheter is place in stoma, no pouch required

Patient Education Care of stoma, appliance selection and use Body Image considerations Support groups (UOA) Enterostomal nursing- specialty within profession

Nursing History Physical Assessment Lab Tests Fecal characteristics Diagnostic evaluation- Endoscopy, Colonoscopy

Nursing measures
Control odor Inspect the stoma regularly Protect the skin around the stoma site Monitor intake and output Educate the patient on each step of the process Encourage self-care Change the appliance as needed
Appliances are either drainable or closed.

Irrigate the colostomy

Long-term ostomy care


Avoid high-fiber foods for the first 6 to 8 weeks Patients with ileostomies are prone to food blockages Avoid use of long-acting, sustained-release, and enteric-coated medications Colostomy patients may gain control over elimination with regular irrigations at the same time each day.

Privacy Squatting position Bedpan position Cathartics & laxatives Anti- diarrheal agents Enemas disimpaction

Bowel routine
Daily time clock Hot drinks Stool softeners Privavy Position and abdominal pressure Bearing down

Embarrassing & stressful


Usually urge to defecate 1hr. Pc

Bedpans
Metal or plastic Regular or fracture pan Cleanliness

Urinals Commode

Privacy- close door, Side rail as needed Recumbent with HOB Tissue Call bell Leave alone if possible Gloves Clean genitals

Remove pan and cover In & Out Specimens Clean pan Wash hands yours and clients Lower bed Client comfort

Cleaning of genitals , routine part of complete/ partial bed bath Incontinence

Regular patient
Simple explanation- laymans terms Privacy Gloves Dorsal recumbent position Incontinent pad under buttocks Warm soap and water Female separate labia

Avoid use of baby powder/ cornstarch


No medicinal purpose Can form clumps or will cake in creases Use vaseline/ zincoxide as skin barrier for incontinent clients

Check physicians order, protocol Left Lateral position Gloves Lubication Hold with thumb and index finger Insert with index finger (3 4) never force Deep breath = relaxes anal sphincter

Caution
Vagus nerve stimulation can cause heart rate to slow avoid excess manipulation

Main purpose
Promotion of defecation, stimulate peristalsis The fluid breaks up fecal mass, stretches the rectal wall & initiates the defecation reflex

Tap Water
Hypotonic Used only once Electrolyte imbalance
Water toxicity Circulatory overload ( concentration gradient)

Normal Saline
Used when more than one enema is needed Safest Isotonic Large volume to distend bowel

Hypertonic Solution
Smaller volume of fluid Draws from surrounding tissue into bowel to soften stool and stimulate peristalsis Fleets sodium phosphate
Low volume, concentrated solution

Soap suds
Less common Soap irritates the bowel 5 15 mls. Castile soap in 1000mls warm water

Oil Retention
Oil based solution Lubricates the rectum and colon Softens stool, easier to pass Retain 1 2 hrs if possible Follow with cleansing enema

Medicated
Instill meds. Rectal mucosa absorption Ex. Kayexalate to K (potassium). Absorbs K from the intestinal tract

Large Volume
500 1000mls. Container 12 18 in. above the bowel Lg. Volume stimulates & causes evacuation of stool

Small Volume
500 mls. Container 12 in.above bowel

Pre packaged
Fleet 150mls Microlax 5mls Hypertonic solution User friendly Hold for 5min.

Oral Fleet

Prepackaged used more than large volume because:


Works Less risk for electrolyte imbalance Rapid administration Less discomfort and distention Convenient and quick

Physicians order reads enemas to clear


No more than 3 total given Return solution will be highly colored but no solid stool Isotonic solution (normal saline)

Excess enema use seriously depletes fluid and electrolytes

Confirm Drs order, prepare client, verbal consent, equipment, privacy


Left lateral position ( fld. Flows by gravity) Drape, pad under buttocks Warm solution- stimulates peristalsis
Hot soln burns mucosa Cold soln causes cramping

Prime tube Lubricate tip Glove Insert 7 10 cm.(3-4in) adult


Do not force Deep breath Guide toward umbilicus

Container at appropriate height


Lg. = 12 18in Sm. = 12in 1000mls takes ~ 10 min to instill Higher the bag greater the pressure
C/O discomfort, lower bag, slow infusion, stop, then start again

Remain side lying to retain 5 10 min. or as long as possible

Assist to bathroom or give bedpan Evaluate results Document


Type & volume of enema Color, amount, consistency of fecal return Hygienic measures for client

Wash Hands

Certain diseases require surgical interventions to create an opening into the abdominal wall for fecal and urinary elimination Enterostomy the surgical procedure performed to produce the artificial stoma.

Ostomy = opening made to allow passage of urine or stool


Piece of intestine is brought out onto the clients abd. Lacks nerve endings Doesnt hurt to touch but has other implications

Stoma = mouth like opening in the abdominal wall to drain urine or stool

Effluent drainage from stoma Bowel ostomies


Cancer ( Ca) Drain fecal material Consistency depends on location
Higher up = more liquid Greater risk skin irritation b/c concentration of digestive enzymes

Ileostomy
End of small intestine By passes lg. Intestine = freq. Liquid stools

Colostomy
Large intestine More solid stool

Ostomies may be permanent


More common

temporary
Rest the bowel Crohns

Provide drainage of urine that bypasses the bladder = Urinary Diversion Ureterostomy
Ureter to abd. Wall Lt., Rt., Bilateral

6 8 in. ileum 1 end for external opening Other end closed off Ureters implanted into this piece of bowel Pouch Urine will have shred of mucus b/c bowel still produces same

Infection
Sterile ureters provide opening into system

Skin Breakdown
Continuous drainage Moisture on skin

Replace urinary pouch q 2-3 days

Effluent ( drainage ) may begin immediately Collects all effluent Protects the skin Stoma should be moist and reddish pink (same as other mucus membranes) Flush to skin or bud-like protrusion Black, purple, dry = inadequate circulation

Comfortable fit Cover skin surrounding stoma Good seal Post-op pouch should allow for visibility of stoma

One Piece Pouching System


Skin barriers preattached, precut, custom fit

Two Piece System


Skin barrier with flange ( plastic ring) Corresponding size pouch

Assess stoma
Measure correct size Change q 3-7 days Empty 1/3 to full, expel flatus prn

Supine position Wash hands, glove Remove pouch & skin barrier, push skin away from barrier Cleanse peristomal skin gently with warm tap water and clean cloth
Do not scrub, Avoid soap ( residue- pouch wont adher)

Correct sizing Cut opening 1/16 1/8 larger than stoma Remove backing Ileostomy- apply thin circle barrier paste around opening of pouch and allow to dry (if creases or bumps use barrier paste to even surface for pouch application)

Pouch should point to clients knees Maintain gentle finger pressure around barrier for 1-2 min. Picture frame flange with non allergic paper tape Ostomy deodorant for pouch Tub bath or shower

Normal stoma oozes blood if rubbed Actual bleeding into pouch is abnormal Pouch covers are available The client will be watching the nurse during ostomy care to gage reaction. Be conscious of facial expression & nonverbal cues

Education Counseling
Body image Self care Fear of rejection Sexual function Powerlessness over bowel regulation

Decompress GI tract in surgery, infection of GI tract, trauma to GI tract, conditions where peristalsis is absent N/G tube purposes- decompression, feeding, compression, & lavage Pliable tube inserted through nasopharynx into stomach Uncomfortable insertion

Types: Levin single lumen, different sizes used for feeding or decompression Salem Sump Most preferable for decompression, dual lumen, one for removal of gastric contents, one as an air vent, hooked to suction to achieve decompression

Confirm placement after insertion HOB at 30 degrees unless ordered otherwise Mark point where tube exits nose Tape tube securely to nose Tube Irrigation Nasal skin care Frequent oral hygeine Assess for abdominal distention Suction settings

Bowel training Maintenance of proper fluid & food intake Promotion of regular exercise Promotion of Comfort Maintenance of skin integrity Promotion of self concept

2. To maintain normal elimination patterns in the hospitalized client, you should instruct the client to defecate 1 hour after meals because: A. The presence of food stimulates peristalsis. B. Mass colonic peristalsis occurs at this time. C. Irregularity helps to develop a habitual pattern. D. Neglecting the urge to defecate can cause diarrhea.

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Did your client meet their goal?