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Personal habits: a person not wanting to go for an extended period of time can cause harm to their body and can make it harder to go later; they may not want to use those facilities
- Position during defecation: normal positioning for BM is sitting or squatting
- Pain: person may be hesitant about going if they think it will cause them pain; usually do to hemorrhoids, rectal surgery, or ABD surgery
- Pregnancy: the way the baby is lying on the mothers GI tract affects peristalsis by slowing it; this will affect if and how often the mother might go
- Surgery & anesthesia: affects defecation by the slowing of peristalsis or complete stoppage of it
- Medication: different meds affect BMs differently; some meds increase the process others may inhibit it or stop it completely
- Diagnostic tests: these affect the patient because they usually require them be NPO prior to it which in turn will limit their food intake which limits their BMs or stops them completely
What are the implications associated with the following common bowel elimination problems: constipation, impaction, diarrhea, incontinence, flatulence, and hemorrhoids?
- Constipation: decreased peristalsis; decreased frequency of BMs and/or prolonged or difficult passage of hard stools; this is something that is highly individualized (BM frequency ranges from 3x p/d - 3x p/w); Causes: decreased amount of food intake, decreased fluid intake, decreased muscle tone, insufficient exercise, ignoring the urge to go, laxative abuse; Implementation: respond to urge, help if needed, provide time & privacy, ensure adequate fluid intakes, provide appropriate positioning, increase overall activity, get adequate fiber.
- Impaction: stool that cannot be passed, unrelieved constipation; usually seen in bed bound patients and those who havent had BM in several days; Signs: oozing diarrhea around the mass, anorexia, abdominal distention, cramping, & rectal pain; implementation: for impaction physical removal of mass by hand (must have MD order) done with enema and lube; monitor vitals during this
- Diarrhea: increased perstalsis; increase in number of stools and passage of liquid & unformed feces; can lead to F/E imbalance; Causes: improper diet, ABX, enteral nutrition, food/allergy intolerances, C. difficile, surgery, diagnostic tests; implementation: remove the cause, respond to pt urge to go, be careful giving anti-diarrheal meds, maintain F/E balance, use moist wipes, promote dairy products to return to normal flora
- Incontinence: may be secondary to diarrhea; can cause body alterations, embarrassment, & skin breakdown; Causes: SCI, CVA, infection, impaction, depression, sedatives; implementation: assist if needed, note when it will occur, provide support and understanding, provide pericare, change linens, retrain bowel, maintain their dignity, give fecal caths
- Flatulence: intestinal gas; the inability to pass this can cause abdominal distention, SOB, fullness, or cramping; Causes: diet, opiates, general anesthesia, abdominal surgery, or immobility; implementation: avoid gas producing foods, increase activity, reposition, give return flow enema, NG tube, or rectal tube
- Hemorrhoids: distended rectal veins that can be internal or external; usually due to straining during defecation or other actions; Symptoms: itching, bleeding, & burning after defecation; implementation: promote soft stools in various ways, local heat/sitz baths, be careful with thermometers & enemas, use moist wipes, administer prescribed ointments/creams
What are the normal characteristics of stool/Bristol stool form scale and possible causes of abnormal changes?
- Normal fecal color: infants =yellow; adult=brown
- Normal fecal odor: pungent
- Normal fecal consistency: soft formed
- Normal fecal frequency: infants 4 to 6 times daily (breastfed) or 1to 3 times daily ( bottle fed. adults daily or two to three times a week
- Normal fecal amount: 150g/day for adults
- Normal fecal shape: resembles diameter of rectum
- Normal fecal constituents: Undigested food, dead bacteria, fat, bile pigment, cells lining intestinal mucosa, and water
When would a bowel diversion be necessary?
Certain diseases cause conditions that prevent normal passage of feces through the rectum. The treatment for these disorders results in the need for a temporary or permanent artificial opening (stoma) in the abdominal wall.
What are the different types of bowel diversions? What stool would the nurse expect to see at each site?
- Ileostomy: Surgical opening in the ileum; bypasses the entire large intestine; stool if frequent and liquid
- Colostomy: Surgical opening in the colon;
- Colostomy on the ascending colon has stool that is frequent and liquid
- Colostomy of the transverse colon generally results in a more solid, formed stool.
- Sigmoid colostomy releases near-normal stool.
- 3 Types of colostomies:
- 1. Loop
- 2. End
- 3. Double- barrel
What history would the nurse collect regarding a clients bowel pattern and habits?
- Shorter answer
- 1.History of surgery or illness
- 2. History of exercise
- 3. History of pain
- 4. Social history
- 5. Medication history
- 6. Diet history
- 7. Status of bowel diversions
- 8. Mobility and dexterity
- Longer answer
- Determination of the usual elimination pattern:
- Patient's description of usual stool characteristics:
- Assessment of the use of artificial aids at home:
- Presence and status of bowel diversions:
- Changes in appetite:
- Diet history:
- Description of daily fluid intake:
- History of surgery or illnesses affecting the GI tract:
- Medication history:
- Emotional state:
- History of exercise:
- History of pain or discomfort:
- Social history: Patients have many different living arrangements. Where patients live affects their toileting habits. If patients share to accommodate others. If patients live alone, can they ambulate safely to the toilet? When patients are not independent in bowel management, determine who assists them and how.
- Mobility and dexterity: Evaluate patients mobility and dexterity to determine if they need assistive devices or help from personnel.
What physical assessment would be performed by the nurse?
- Mouth: Inspect the patient's teeth, tongue, and gums. Poor dentition or poorly fitting dentures influence the ability to chew. Sores in the mouth make eating not only difficult but also painful.
- Abdomen: Inspect all four abdominal quadrants for contour, shape, symmetry, and skin color. Note masses, peristaltic waves, scars, venous patterns, stomas, and lesions. Normally you do not see peristaltic waves. Observable peristalsis is often a sign of intestinal obstruction. Abdominal distention appears as an overall outward protuberance of the abdomen. Auscultate the abdomen with a stethoscope to assess bowel sounds in each quadrant. Normal bowel sounds occur every 5 to 15 seconds and last a second to several seconds. Percussion identifies underlying abdominal structures and detects lesions, fluid, or gas within the abdomen. Gas or flatulence creates a tympanic note. Masses, tumors, and fluid are dull to percussion. Gently palpate the abdomen for masses or areas of tenderness. It is important for the patient to relax. Tensing abdominal muscles interferes with palpating underlying organs or masses.
- Rectum: Inspect the area around the anus for lesions, discoloration, inflammation, and hemorrhoids. Carefully record abnormalities.
What are common diagnostic tests of the GI system and the nurse's role in each?
- Shorter answer
- 1. Plain radiography
- 2. upper GI or barium swallow upper endoscopy
- 3. barium enema
- 4. ultrasonographic colonoscopy flexible sigmoidoscopy
- 5. computed tomography
- 6. magnetic resonance imaging enteroclysis
- Longer answer
- Radiological and Diagnostic Tests
- Plain Film of Abdomen/Kidneys, Ureter, Bladder
- A simple x-ray film of the abdomen requires no preparation.
- Upper Gastrointestinal/Barium Swallow
- An x-ray film examination using an opaque contrast medium (barium) examines the structure and motility of the upper gastrointestinal (GI) tract, including pharynx, esophagus, and stomach.
- Patient is ordered to have nothing by mouth (NPO) after midnight the night before the examination.
- Patient removes all jewelry or other metallic objects before facilitate passage of barium.
- Upper Endoscopy
- An endoscopic examination of the upper GI tract allows more direct visualization through a lighted fiber-optic tube that contains a lens, forceps, and brushes for biopsy.
- Preparation is similar to that for the upper GI.
- Light sedation is required ( Herman, 2010 ).
- Barium Enema with Air Contrast
- An x-ray film examination uses an opaque contrast medium and air that outlines the colon and rectum to examine the lower GI tract.
- Preparation includes NPO after midnight, a bowel preparation such as magnesium citrate, and in some instances enemas to empty out any remaining stool particles ( ACS, 2011b ).
- This technique uses high-frequency sound waves to echo off body organs, creating a picture.
- Preparation depends on the organ to be visualized and includes NPO or no preparation.
- An endoscopic examination of the entire colon uses a colonoscope inserted into the rectum.
- Preparation is similar to that for barium enema: clear liquids the day before and then some form of bowel cleanser such as GoLytely. Enemas until clear are also common.
- Light sedation is required.
- Flexible Sigmoidoscopy
- An examination of the interior of the sigmoid colon with a flexible or rigid lighted tube.
- Preparation is similar to that for a barium enema or colonoscopy.
- Light sedation is required
- Computerized Tomography Scan
- An x-ray film examination of the body from many angles uses a scanner analyzed by a computer.
- Preparation is usually NPO.
- The patient needs to lie very still. If claustrophobia is a problem, use light sedation.
- Magnetic Resonance Imaging
- A noninvasive examination uses magnet and radio waves to produce a picture of the inside of the body.
- Preparation is NPO 4 to 6 hours before examination.
- No metallic objects, including metal objects on clothes, are allowed in the room.
- Contrast material is introduced to jejunum, allowing entire small intestine to be studied.
- Preparation is 24 hours of clear liquid diet and colon cleansing such as GoLytely or enemas until clear.
What are the nursing diagnoses for clients with alterations in bowel elimination?
- Bowel incontinence
- Risk for constipation
- Perceived constipation
- Toileting self-care deficit
What are interventions for promotion of normal defecation?
- 1. Sitting position
- 2. Positioning on bed pan
- 3. Privacy
What are the types of enemas and the implications for patient care?
- Cleansing Enema: Promote the complete evacuation of feces from the colon
- Tap water enema: Exerts lower osmotic pressure than fluid in interstitial spaces. (Hypotonic)
- Normal saline enema: Exerts same osmotic pressure as fluid in interstitial spaces (safest)
- Hypertonic enema: Exerts osmotic pressure that pulls out interstitial spaces (Not for dehydrated patients or infants)
- Soapsuds enema: Stimulates peristalsis through interstitial irritation
- Oil retention enema: lubricates the colon and rectum for a softer stool.
- Carminative enema: Improves the ability to pass flatus (gas)
What are the steps in administering a cleansing enema and the rationale for each?