1. Basic Human Needs Bowel Elimination

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

3. GI Tract Anatomy Mouth Mouth Esophagus Esophagus Stomach Stomach Small Intestine Small Intestine Large Intestine Large Intestine Rectum Rectum

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

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

8. Stomach Food is temporarily stored and mechanically and chemically broken down Food is temporarily stored and mechanically and chemically broken down Secretes HCL, mucus, pepsin, & intrinsic factor(Needed for Vitamin B 12 absorption) Secretes HCL, mucus, pepsin, & intrinsic factor(Needed for Vitamin B 12 absorption) Food is converted into chyme Food is converted into chyme

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

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

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

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

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

15. Factors Affecting Bowel Elimination Age Age Infection Infection Diet Diet Fluid Intake Fluid Intake Physical Activity Physical Activity Psychological factors Psychological factors Personal Habits Personal Habits

16. Factors Affecting Bowel Elimination Position during Defecation Position during Defecation Pain Pain Surgery and Anesthesia Surgery and Anesthesia Medications Medications

17. Common Bowel Elimination Problems Constipation Constipation Impaction Impaction Diarrhea Diarrhea Incontinence Incontinence Flatulence Flatulence Hemorrhoids Hemorrhoids

18. Constipation More of a symptom than a disorder More of a symptom than a disorder Decrease in frequency of BM Decrease in frequency of BM Straining & pain on defecation is associated symptoms(Valsalva manuever) Straining & pain on defecation is associated symptoms(Valsalva manuever) Can be significant heath hazard (increase ICP, IOP, reopen surgical wounds, cause trauma, cardiac arrhythmias) Can be significant heath hazard (increase ICP, IOP, reopen surgical wounds, cause trauma, cardiac arrhythmias)

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

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

24. Diarrhea Increase in number of stools & the passage of liquid, unformed stool Increase in number of stools & the passage of liquid, unformed stool Symptom of disorders affecting digestion, absorption, & secretion of GI tract Symptom of disorders affecting digestion, absorption, & secretion of GI tract Intestinal contents pass through small & large intestines too quickly to allow for usual absorption of water & nutrients Intestinal contents pass through small & large intestines too quickly to allow for usual absorption of water & nutrients

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

26. Conditions that cause Diarrhea Emotional Stress Emotional Stress Intestinal Infection (Clostridium difficile) Intestinal Infection (Clostridium difficile) Food Allergies Food Allergies Food Intolerance Food Intolerance Tube Feedings (Enteral) Tube Feedings (Enteral) Medications Medications Laxatives Laxatives Colon Disease Colon Disease Surgery Surgery

28. Incontinence Inability to control passage of feces and gas from the anus 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 Caused by conditions that create frequent, loose, large volume, watery stools or conditions that impair sphincter control or function

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

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

31. Clicker Question 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: 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 A.Abnormal defecation B.Constipation B.Constipation C.Fecal impaction C.Fecal impaction D.Fecal incontinence D.Fecal incontinence 46 - 31

32. Bowel Diversions Certain diseases cause conditions that prevent normal passage of feces through rectum Certain diseases cause conditions that prevent normal passage of feces through rectum Creates need for temporary or permanent artificial opening (stoma) in the abdominal wall Creates need for temporary or permanent artificial opening (stoma) in the abdominal wall

33. Bowel Diversions Surgical openings (ostomy) are most commonly formed in the ileum (ileostomy) or the colon (colostomy) Surgical openings (ostomy) are most commonly formed in the ileum (ileostomy) or the colon (colostomy) Incontinent ostomy- need to wear appliance pouch Incontinent ostomy- need to wear appliance pouch Continent ostomy- have control through use of ostomy cap Continent ostomy- have control through use of ostomy cap

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

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

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

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

45. Continent Diversions Ileoanal Reservoir Several stages to surgery to create pouch Several stages to surgery to create pouch May need temporary ostomy to allow time for pouch to heal May need temporary ostomy to allow time for pouch to heal Kegel exercises to increase pelvic floor muscle tone Kegel exercises to increase pelvic floor muscle tone

47. Continent Diversions Kock Continent Ileostomy-Internal reservoir or pouch is created using piece of small intestine 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 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 Valve only allows fecal contents to drain when an external catheter is place in stoma, no pouch required

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

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

54. Nursing Diagnosis Bowel Incontinence Bowel Incontinence Constipation Constipation Diarrhea Diarrhea Impaired Skin Integrity Impaired Skin Integrity Body Image Disturbance Body Image Disturbance Altered bowel elimination Altered bowel elimination Pain Pain

55. Implementation Promoting Normal Defecation Positioning of patient-squatting Positioning of patient-squatting Positioning on bedpan Positioning on bedpan Use of cathartics, laxatives Use of cathartics, laxatives Anti-diarrheal agents Anti-diarrheal agents Enemas Enemas Digital removal of stool Digital removal of stool Ostomy care Ostomy care

59. Common Laxatives & Cathartics Metamucil-bulk forming Metamucil-bulk forming Colace, Surfak-emollient or wetting agent Colace, Surfak-emollient or wetting agent Fleets, MOM. Mag Sulfate-saline agent Fleets, MOM. Mag Sulfate-saline agent Dulcolax, Ex-Lax, Castor oil- stimulant cathartic Dulcolax, Ex-Lax, Castor oil- stimulant cathartic Haley’s MO, mineral oil- Lubricant Haley’s MO, mineral oil- Lubricant

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

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

62. Nasogastric Tubes Types: Levin – single lumen, different sizes used for feeding or decompression 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 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

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

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

69. Clicker Question 2.To maintain normal elimination patterns in the hospitalized client, you should instruct the client to defecate 1 hour after meals because: 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. A.The presence of food stimulates peristalsis. B.Mass colonic peristalsis occurs at this time. B.Mass colonic peristalsis occurs at this time. C.Irregularity helps to develop a habitual pattern. C.Irregularity helps to develop a habitual pattern. D.Neglecting the urge to defecate can cause diarrhea. D.Neglecting the urge to defecate can cause diarrhea. 46 - 69