302-- Bowel Elimination

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302-- Bowel Elimination
2012-09-24 23:53:01
302 Bowel Elimination

Exam 2
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  1. Primary Organ of Bowel Elimination
    Large Intestine
  2. The large intestine extends from the ____ to the ____
    Ileocecal valve; Anus
  3. Functions of the Large intestine:
    • –Completion of absorption
    • –Manufacture of some vitamins
    • –Formation of feces
    • –Expulsion of feces from the body
  4. If waste products pass through the large intestine rapidly, the stool is:
    Watery and Soft
  5. If wastes pass through the Large intestine slowly, the stool is...
    Dry and Hard
  6. Effects of Parasympathetic System on Peristalsis:
  7. Effects of Sympathetic N.S. on Parastalsis in the large intestine:
  8. How often do peristalsis contractions occur
    Every 3-12 minutes
  9. How much of food waste is excreted within 24 hrs:
    1/3 to 1/2 
  10. Variables Influencing Bowel Elimination:
    • •Developmental considerations
    • •Daily patterns
    • •Food and fluid
    • •Activity and muscle tone
    • •Lifestyle, psychological variables
    • •Pathologic conditions
    • •Medications
    • •Diagnostic studies
    • •Surgery and anesthesia
  11. Developmental Considerations Effecting Bowel elimination in INFANTS
    characteristics of stool and frequency depend on formula or breast feedings
  12. Developmental Considerations Effecting Bowel elimination in Toddlers:
    • physiologic maturity is first priority for bowel training
    • -Voluntary control of defecation possible between 18 and 24 months
  13. Developmental Considerations Effecting Bowel elimination in Child/Adolescent/Adult:
    Defecation patterns vary in quantity, frequency, and rhythmicity
  14. Developmental Considerations Effecting Bowel Elimination for OLDER ADULTS
    • Constipation is often a chronic problem
    • (older adults have a decrease in muscle tone)
  15. Individual Patterns:
    (very important to assess for the individual’s perceived normal bowelelimination pattern and compare that to the current bowel elimination pattern)
    • –Frequency
    • –Timing considerations (meal time)
    • –Position
    • •squatting or slightly forward-sitting position with the thighs flexed
    • –Place
    • –Privacy
  16. Which one of the following is a recommended food for an older adult who is constipated?
      A. Cheese     B. Fruit    C. Cabbage   D.  Eggs
    • B. Fruit (best option)
    • C. Cabbage
    • Fruits and vegetables have a laxative effect on the system. Cheese and eggs have a constipating effect and cabbage, although a vegetable, produces gas in the system
  17. Amount of Fluid Intake Suggested:
    2,000 to 3,000 ml of fluid/day
  18. Assume that ___ patients are ______
    ALL; Lactosintolerant
  19. Constipating Foods:
    Cheese, Lean Meat, Eggs, Pasta
  20. Foods with Laxative Effect:
    Fruits and Vegetables, Bran, Chocolate, Alcohol, Coffee
  21. Gas producing foods:
    Onions, Cabbage, Beans, Cauliflower
  22. Regular Exercise promotes....
    • –Gastrointestinal motility
    • –Muscle tone
  23. What should be respected when dealing with Bowel Elimination:
    • •Rituals
    • •Cleanliness considerations
    • •Language used
    • •Reluctance to discuss
    • •Individual responses to involuntary passage of flatus
  24. Psychologic Factors Effecting Bowel Elimination Patterns
    • •Anxiety : diarrhea accompanies periods of high anxiety
    • •Chronic worrying:  constipating effect
  25. •Numerous pathologic processes may change a person’s bowel elimination patterns…This is why: 
    ...it important to always assess for the pt’s individual pattern andvariations from normal.
  26. Cathartics/laxatives ____ peristalsis
  27. Antidiarrheal medications _____ peristalsis
  28. Common Side Effects of Medications given:
  29. Often times Antibiotics can cause...
  30. Aspirin, anticoagulants, cause the stool to be what color:
  31. Iron salts make the stool....
  32. Antacids make the stool....
    White discoloration or speckling in stool
  33. Antibiotics make the stool...
    green-gray color
  34. Bowel "Prep" involves...
    • –Go-lightly
    • –Enemas until clear (no more than 2x/hr)
  35. White chalk-like substance, that solidifies at room temperature…medium that patient must get into the colon to SEE the colon (radioactive)
    • BARIUM
    • **PUSH fluids with Barium to prevent the solidification of the substance within theircolon (prepare patient and tell them stool will be white/grey)
  36. Paralytic Ileus
    • Caused by direct manipulation of the bowel during surgery and/or effects of anesthesia.
    • –Temporary stoppage of peristalsis.
    • –Normally lasts 24 – 48 hours
    • •Pt must be kept NPO
    • •Narcotics for pain can exacerbate
    • •Distention and s/s of acute obstruction may occur
  37. **Listen to bowel sounds for a minimum of _____ if no sounds are heard
    5 min in each quadrant
  38. Nursing Process Involves:
    • •Nursing history:  very important
    • •Physical assessment:
    •   –Auscultation of bowel sounds
    •   –How long ea quadrant?
    •   --Documentation?

    • Find out normal elimination pattern***
    • “No bowel sounds heard over ____ min”
  39. Important things to remember about Stool Collection
    • *Stool specimens must be collected separate than urine
    • *Occult blood not clearly visible
  40. Direct Visualization Studies:
    • •Esophagogastroduodenoscopy --
    • visual exam of esoph., stomach, upper duodenum
    • •Colonoscopy-- 
    • visual exam of rectum, colon, and distal small bowel
    • •Sigmoidoscopy --
    • visual exam of distal sigmoid colon, rectum, anal canal
    • •Wireless capsule endoscopy
  41. Indirect (from the outside) Visualization Studies:
    • •Upper gastrointestinal (UGI)
    • •Small bowel series
    • •Barium enema
  42. Invasion Procedures reqiuire:
    • Informed Consent 
    • (ordered/administered by doctor--> nurses can only be co-witnesses)
  43. PRE-procedure for Esophagogastroduodenoscopy
    • Signed Consent Form
    • Fasting (6-12 hrs before)
    • Dentures Removed
    • Remind Patient that he/she will be awake but sedated
  44. Post-procedure care for Esophagogastroduodensocopy
    • Withhold food/fluids until the gag reflux returns
    • Check Vital Signs 
    • Observe for signs of perforation, pain, persistent difficulty swallowing, vomitting blood, different stools
    • Explain to patient that it is normal to have throat soreness
  45. Pre-procedure for Colonoscopy
    • Ensure informed consent is signed
    • Clear liquid diet (24-48 hours before)
    • 2 day bowel prep (strong cathartic)
    • OR
    • 1 day bowel prep (gallon of bowel cleansor...GoLytely)
    • Sedation will be given before test
  46. Post-procedure for Colonoscopy
    • Patient may experience flatulence or gas pains because air was used to distend the intestines for better visibility
    • Usual diet may be resumed after sedation
    • Check vital signs
    • Observe for signs of bowel perforation, rectal bleeding, abdominal pain, distention, fever and malaise
  47. Pre-procedure for Sigmoidoscopy
    • Ensure that informed consent is signed
    • Light meal before the test and 2 Fleet enemas
    • Sedation not usually required
  48. Post-procedure care for Sigmoidoscopy
    • Patient may experience flatulence/gas pains
    • Observe for bowel proliferations
    • If biopsy was performed, patient should be aware that rectal bleeding may occur
  49. Pre-procedure for UGI/Small Bowel Series
    • Informed Consent form
    • Keep Patient NPO after midnight the day of the test
    • Inform the patient that a chalky-tasting barium contrast mixture will be given to drink before the test
  50. Post-procedure for UGI/Small Bowel Series
    • Post-test cathartic (Milk of Magnesia)
    • Explain that barium may lighten the color of stools for the next several days, but it will go back to normal
  51. Pre-procedure for Barium Enema
    • Consent
    • Dietary modificaitions--> increased fluid intake, cathartic, NPO after midnight, enemas
    • Review patient history for any history of ulcerative colitis or active GI bleeding that would prohibit the use of the standard bowel prep
  52. Post-procedure for Barium Enema
    • Encourage fluids (prevent dehydration)
    • Inform patient about change in stool color
    • Encourage rest because the bowel prep and test exhause patients
  53. Scheduling
    • •1 — fecal occult blood test
    • •2 — barium studies (should precede UGI)
    • •3 — endoscopic examinations

    • Noninvasive procedures take precedence over invasive procedures
    • Attempt to gather as much data as possible via noninvasive procedures.
    • **Start with most un-invasive (fecal occult blood test)
  54. Outcome Identification and Planning
    •Have a soft, formed bowel movement q1-3 days without discomfort

    •Explain the relationship between bowel elimination and dietary fiber, fluid intake, and exercise

    •Relate the importance of seeking medical evaluation if changes in stool color or consistency persist.
  55. Bed-bound patients:
    –Abdominal settings:  lying in a supine position:  tighten and hold the abdominal muscles for 6 seconds and then relax them.  Repeat 3-4 times ea waking hour.

    Thigh strengthening:  thigh muscles are flexed and contracted by slowly bringing the knees up to the chest one at a time then lowering them to  the bed.  Perform 3-4 times ea knee ea waking hour
  56. Individuals with High Risk of Constipation:
    •Patients on bed rest

    •Patients on NPO status for extended periods of time

    •Patients taking constipating medicines

    •Patients with reduced fluids or bulk in their diet

    •Patients who are depressed

    •Patients with central nervous system disease or local lesions that cause pain
  57. What do you teach the patient to prevent constipation
    • –Nutrition
    • –*adequate hydration / *fiber
    • –Laxatives
    • –Exercise
  58. Hemorrhoids
    • •Distended and inflamed vein in the rectal area
    • •They don’t always hurt…sometimes there are no symptoms (pain, burning, itching, blood)
    • •Sometimes the patient will complain of pain and discomfort
    • •Patients with severe hemorrhoids will have chronic constipation
  59. Nursing Measures for Patients with Diarrhea
    • •Answer bell calls immediately (urgency)
    • •Remove the cause of diarrhea whenever possible (e.g., medication)
    • •If there is impaction, obtain physician older for rectal examination
    • •Give special care to the region around the anus
    • •After diarrhea stops, suggest the intake of fermented dairy products
    • *you must provide preventive care for patients with diarrhea (use ointment or cream), reapply after each bowel movement
    • *fermented dairy yogurt
  60. Ways to Prevent Food Poinsoning
    •Never buy food with damaged packaging

    •Never use raw eggs in any form

    •Do not eat ground meat uncooked

    •Never cut meat on a wooden surface

    •Do not eat seafood that is raw or has a strong unpleasant odor

    •Clean all vegetables and fruits before eating

    •Refrigerate leftovers within 2 hours of eating them

    •Give only pasteurized fruit juices to small children
  61. Teaching about acute diarrhea
    • –Sudden onset, lasts several hours to several days.
    • –Rehydration
    • –Avoid Antidiarrheal agents until bacterial causative agent has been ruled out.
  62. Teaching about chronic diarrhea
    • –Lasts 3 - 4 weeks
    • –Many possible causes
    • –Pharmacologic intervention necessary
    • –Fluid and electrolyte therapy usually indicated
    • –Antidiarrheal medications
    • –Must determine the cause
  63. Drugs that Act Directly on Smooth Muscle of GI
    • –Camphorated opium tincture (Paregoric)
    • –Loperamide (Imodium)
    • --Diphenoxylate hydrochloride (Lomotil)
  64. Drugs that act as absorbant and demulcent:
    • –Kaolin
    • Pectin (Kaopectate)
  65. Antimicrobial action and antisecretory effect
    •Bismuth subsalicylate (Pepto-Bismol)
  66. Inability to control flatulence or prevent minor soiling
    Partial Bowel Incontinence
  67. Inability to control feces of normal consistency
    Major Bowel Incontinence
  68. Causes for Bowel Incontinence
    • –Impaired neurological fx
    • –Diarrhea
    • –GI surgery that has altered the consistency of the stool.
    • *spinal injury patients may not be able to feel the sensation
  69. How to Decrease Flactulence:
    • –Position
    • •Side lying for rectal tube (left side)
    • •Prone with knees flexed under abdomen
    • –Decrease amt of swallowed air
    • 1.Avoid carbonated beverages
    • 2.Avoid hard candies
    • 3.Avoid the use of straws
    • 4.Avoid gum

    • •Avoid irritating foods
    • •Avoid reclining after meals
    • •Move around in bed and ambulate
    • •Nasogastric tube insertion
    • •Considerations with post-op discomfort associated with flatulenceà push fluids and get the patient up and walking
  70. –Distended veins in the anal area.  Internal or external. 
  71. S/S of Hemorrhoids
    asymptomatic, pain, itching, burning, blood in the stool (frank blood– very visible)
  72. Causes of Hemorrhoids
    • –Chronic constipation, straining during defecation
    • –Pregnancy
    • –Obesity
  73. Treatment for Hemorrhoids:
    • • astringents (causes hemorrhoids to shrink
    • and decrease swelling, local application/ointment/cream), stool softeners (makes hemorrhoid less painful and the patient is not straining)

    •Sitz bath may be beneficial (unless they have frank bleeding)

    • •Sometimes hemorrhoids are bad enough to where
    • they have to have surgery
  74. Methods of Emptying Colon of Feces:
    • •Enemas
    • •Rectal suppositories
    • •Rectal catheters
    • •Digital removal of stool
  75. Types of Enemas
    • •Cleansingà Irritiants: GoLytely, soap suds, tap water
    • •Retentionà 2tbsps … oil retention to help with lubrication
    • •Return-flowà certain type of medicine (with the bag)
  76. Retention Enemas
    •Oil-retention—lubricate the stool and intestinal mucosa easing defecation

    •Carminative—help expel flatus from rectum

    •Medicated—provide medications absorbed through rectal mucosa

    •Anthelmintic—destroy intestinal parasites

    •Nutritive—administer fluids and nutrition rectally
  77. S/S of Fecal Impaction
    • -Patient will have distended abdomen
    • -Bowel sounds will be hyperactive (trying to push the obstruction out)
    • -May be visible peristalsis on the body
    • -Alteration in bowel elimination pattern
    •   *No stool, pencil-shaped stool, liquid stool
    • -Abdominal Distention
    • -Abnormal bowel sounds
    •   *Hyperactive proximal to obstruction
    •   *Hypoactive distal to obstruction
    •   *Hypoactive throughout the abdomen
  78. Treatment for Fecal Impaction
    • •Laxative, stool softener, increase fluid intake if not contraindicated
    • •Oil retention enema followed by a cleansing enema
    • •Oil retention enema followed by digital removal of stool
    • •Prevention of future impaction
  79. Potential Complication by Digital Removal of Stool...
    Vagal Response (Decrease in HR, Decrease in Pressure…associated with digital removal)
  80. Procedure for Digital Removal of Stool
    • •-Oil
    • Retention enema
    • -Gloves, bring bedpan, water soluble lubricant
    •   (not vasaline)
    • -Bring towel, protective pad for bed linens
    • -Turn left side
    • -Proceed…
    • -Watch for s/s of complications (vagal response)
  81. Bowel Training Programs
    • •Manipulate factors within the patient’s control
    • •Food and fluid intake, exercise, time for defecation
    • •Eliminate a soft, formed stool at regular intervals without laxatives
    • •When achieved, discontinue use of suppository if one was used
  82. Types of Colostomy
    •Sigmoid colostomy

    •Descending colostomy

    •Transverse colostomy

    •Ascending colostomy

    •Ileostomy – liquid (hasn’t gone through large intestine)
  83. Colostomy Care
    •Keep patient as free of odors as possible; empty appliance frequently

    •Inspect the patient’s stoma regularly

    –Note the size, which should stabilize within 6 to 8 weeks

    –Keep the skin around the stoma site clean and dry

    •Measure the patient’s fluid intake and output

    •Explain each aspect of care to the patient and self-care role

    •Encourage patient to care for and look at ostomy
  84. Patient Teaching for Colostomy
    •Community resources are available for assistance

    •Initially encourage patients to avoid foods high in fiber

    •Avoid foods that cause diarrhea or flatus

    •Drink two quarts of water daily

    •Teach about medications

    •Teach about odor control (intake of dark green vegetables)

    •Resume normal activity including work and sexual relations
  85. Comfort Measures for Colostomy
    • •Encourage recommended diet and exercise
    • •Use medications only as needed
    • •Apply ointments or astringent (witch hazel)
    • •Use suppositories that contain anesthetics