Promoting Bowel Elimination

Promoting Bowel Elimination
Chapter 30 Promoting Bowel Elimination Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Learning Objectives Theory
Describe the process of normal bowel elimination. Identify abnormal characteristics of stool. Discuss the physiologic effects of hypoactive bowel and nursing interventions to assist patients with constipation. Analyze safety considerations related to giving a patient an enema. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Learning Objectives Clinical Practice
Summarize nursing measures to promote regular bowel elimination in patients. Collect a stool specimen. Perform a focused assessment of the bowel. Write a nursing care plan for a patient with bowel problems. Prepare to administer an enema. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Structures Involved in Waste Elimination
Small intestine Duodenum Jejunum Ileum Carries chyme from the stomach to the large intestine Small intestines attaches to large intestine at cecum Ileocecal valve Controls flow of chyme into 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. Chyme arrives at the ileocecal valve approximately 4 hours after the meal. Valve prevents backflow of the digestive product. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Structures Involved in Waste Elimination (cont’d)
Large intestine Ascending colon Transverse colon Descending colon Sigmoid colon Rectum 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. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Structures Involved in Waste Elimination (cont’d)
Walls of the intestine have four layers Mucosa Submucosa Muscular layer Serous layer (serosa) These layers give support and function to the digestive, absorption, and peristaltic activity of the bowel. Bowel sounds indicate the health state of these tissue layers and are an important assessment of a patient’s bowel health and overall well-being. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Functions of the Intestines
Small intestine Processes chyme into a more liquid state Adds bile from the liver to help break down fats(chyme) Villi on the small intestine walls absorb nutrients Large intestine Absorbs water, sodium, chlorides Waste material stored until expelled Contains bacteria that break down waste Can an individual live without a large intestine? (Yes, because the large intestine basically serves as a storage device for stool. Patients without large intestines have ileostomies). Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Functions of the Intestines (cont’d)
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 involuntary control at the internal sphincter and voluntary control and the external The slower transport allows reabsorption of minerals, electrolytes, and water. The pH continues to become more alkaline to neutralize the acid waste left by the digestive bacteria. The mucus secreted in the large bowel is sticky and allows the feces to form a solid mass. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 30-1: The intestinal system
Review the intestinal system Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

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 What healthy lifestyle changes can help decrease the effects of or help patients cope with aging on the intestinal tract? What are the signs and symptoms of aging effects on the intestinal tract? Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

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 Color is determined by bile, vitamins, drugs, or diet The chemical waste formed by intestinal bacteria give off fecal odor in the form of gas that is expelled as flatus. Identify patient situations in which flatus can be a positive indication of bowel function. What happens when flatus is not expelled? (It is usually reabsorbed for further breakdown.) Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Abnormal Stool Blood in the stool: most serious abnormality
Fresh red blood: bleeding in colon(no digestion) Occult: (hidden) upper GI bleed (black stool called melena) Should be reported immediately Causes Hemorrhoids (should resolve) Hemorrhage from ulcers Inflammation or irritation Cancer Eating foods that are red (dietary assessment necessary) A rule of thumb: the brighter the blood, the lower the bleeding source. What additional laboratory studies may be performed if gastrointestinal bleeding is suspected? Occult blood turns black due to the digestive process of the upper GI tract. Occult blood is not always obvious. It may give off a faint odor of blood but usually needs to be tested. What symptoms may indicate upper GI bleeding? (some pain and discomfort; the nurse should also look for signs and symptoms of decreased blood volume; i.e., fatigue, shortness of breath, pale conjunctivae, low blood pressure) Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Abnormal Stool continued
Pale white or light gray stool: absence of bile in the intestine due to obstruction Large amounts of mucus, fat, pus, or parasites Most common parasitic worm found in intestines tapeworm, pinworm, and roundworm (clinical cue pg. 574) First sign of colorectal cancer are changes in bowel patterns and stool characteristics Colonoscopy beginning at 50 and then every 10 years Annual occult blood test Copyright © 2014 by Elsevier Inc. All rights reserved.

Hypoactive Bowel Indicates a decrease in peristalsis Causes
Immobility Lack of fiber Injury to the bowel Drugs Surgery Paralytic ileus is when peristalsis stops because the bowel has been disturbed during surgery A patient restricted to bed at risk for constipation Health Promotion pg 575 Patients with hypoactive bowel function may undergo various contrast studies for examining the upper GI and lower GI tracts. Review the nurse’s role in patient teaching and patient preparation. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Hypoactive Bowel Continued
Flatus (gas) accumulates in the intestinal tract when peristalsis reduced or absent leading to distention Constipation (decreased frequency/dry hard feces) May occur with poor muscle tone When bowel movements are irregular Excessive worry, anxiety, or fear Bedridden Surgery Medications Copyright © 2014 by Elsevier Inc. All rights reserved.

Drugs That May Contribute to Constipation
Narcotic analgesics Codeine, morphine, meperidine General anesthetics Diuretics Sedatives Antidepressants Anticholinergics Calcium channel blockers Discuss why these drugs are necessary and may not be easily substituted. What are specific reasons that each of these medications may cause constipation? Discuss nursing interventions to minimize constipating effects of these medications. Patients with ongoing constipation may be ordered to have a diagnostic pH analysis of gastric contents as well as an examination of gastric motility. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Drugs Used for Constipation
Stool softeners Colace, Surfak, Dialose Bulk-forming laxatives Fibercon, Metamucil, Citrucel Irritant/stimulant laxatives Dulcolax, Neolid, Ex-Lax, Correctol, Senokot Saline laxatives Citrate of magnesia, milk of magnesia, phospho-soda Why would it be appropriate to use drugs, rather than diet and fiber, for constipation? What is appropriate patient teaching for each of these medications? Why should laxatives be used only as a last resort? Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Elder Care Points Eat more processed foods Insufficient fiber intake Decreased fluid intake Polypharmacy More likely to use laxatives Bulk forming laxatives better choice and Large amounts of Fluid should be Consumed. Copyright © 2014 by Elsevier Inc. All rights reserved.

Hyperactive Bowel Increase in peristalsis and food travels through too quickly resulting in diarrhea Does not allow for absorption of nutrients May be self-limiting and lead to incontinence Causes Inflammation of GI tract, infectious diseases, diseases such as: Diverticulitis Ulcerative colitis Crohn’s disease Patients with hyperactive bowel problems may undergo various endoscopy procedures such as upper GI fiberoscopy, sigmoidoscopy, or colonoscopy. Review the nurse’s role for patient teaching, patient preparation, and postprocedure care. What patient medications should be specifically assessed prior to these procedures? (medication with anticoagulant potential such as aspirin, or GI irritant potential such as antiinflammatories, arthritis medication, etc.) Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Hyperactive Bowel (cont’d)
Drugs Many antibiotics kill normal bowel bacteria, resulting in diarrhea Good hand hygiene is essential to prevent transmission of diarrhea organisms Patients who experience diarrhea from antibiotics should replace normal flora by: Eating yogurt Drinking buttermilk Taking acidophilus (available OTC) Additional diagnostic tests for patients with these symptoms may include CT and MRI for sectional examination, or ultrasound. Discuss patient teaching for the patient who wants to stop taking antibiotics before completion because of abdominal pain, cramping, and diarrhea. What interventions can be implemented to decrease the GI side effects of antibiotics? Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Hyperactive Bowel continued
Clear liquids Bland and low fiber foods Limit coffee, tea, soda Elderly can become dehydrated quicker Copyright © 2014 by Elsevier Inc. All rights reserved.

Medications Used to Control Diarrhea
Camphorated tincture of opium (paregoric) Diphenoxylate hydrochloride with atropine sulfate (Lomotil) Loperamide hydrochloride (Imodium) Difenoxin hydrochloride with atropine sulfate (Motofen) When and why would it be appropriate to use these drugs for diarrhea if some diarrhea may subside after 24 hours? What is the proper patient teaching for each of these medications? Ask students about bowel sound characteristics for the patient with diarrhea. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fecal Incontinence Lack of voluntary control of fecal evacuation; inability to retain feces Small amounts of watery incontinence might be sign of impaction Causes Illness Cerebrovascular accident Traumatic injury Neurogenic dysfunction Medications constipation 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 Review the assessment for the ability to engage in a bowel retraining program. What are the side effects if the patient does not adhere to a routine bowel evacuation regimen? Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Focus Assessment pg 577 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 Medications that contribute The patient’s privacy is very important because this may be a difficult and embarrassing subject. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Focus Assessment (cont’d)
Physical assessment Shape of the abdomen with the patient supine Flat, distended Auscultate for bowel sounds in all four quadrants Percuss for presence of excessive air/gas in the abdomen Palpate for masses or tenderness After the initial survey, a general rule is to auscultate bowel sounds after auscultating heart and lung sounds. This is because the abdomen has not been disrupted with movement and palpation, giving a more accurate assessment of bowel condition. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Data Collection Bowel status daily Regularity Every 2-3 days is ok Problems( must assess normal for patient to know if there is a problem) Abnormal characteristics of stool Distention (round tight) Percussion Areas of gas produce drum like sound Copyright © 2014 by Elsevier Inc. All rights reserved.

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 Bowel sounds should be auscultated before bowel palpation and percussion. Auscultating, palpating, or percussing the heart or lungs has no effect on bowel sounds. Ask students about documenting and reporting bowel sounds, including the absence of sound. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Planning Constipation will be relieved by Episodes of diarrhea will decrease by Patient will have improved bowel control within 2 months Pain from distention will be decreased from a 4 to a 2 within 24 hours Copyright © 2014 by Elsevier Inc. All rights reserved.

Implementation Use privacy and assist dependent patients Have patient sit up as much as possible Wear gloves Clean bedpan and bedside commode promptly If no BM in 3 days measures should be implemented Side rails can increase risk for injury in confused patients Check on patients every 2 hours or implement set schedule Copyright © 2014 by Elsevier Inc. All rights reserved.

Implementation continued
Noninvasive Encourage activity Adequate fluid intake Sufficient fiber 1-3 tablespoons of bran with applesauce Prune juice Hot water and lemon Prunes Copyright © 2014 by Elsevier Inc. All rights reserved.

More invasive Medications to soften stool Suppositories to stimulate urge Laxatives to stimulate bowel activity Enemas Require physician’s order Impaction may be prevented if constipation is treated early Skin assessment is nursing responsibility Skin care and barrier Petroleum jelly A&D ointment Zinc oxide Copyright © 2014 by Elsevier Inc. All rights reserved.

If bacteria is the thought cause let diarrhea run its course for 24 hours Clear liquid diet Teach patients who experience diarrhea from antibiotics to eat yogurt, drink buttermilk, or take probiotics when they begin antibiotic Self medication should not continue for more than 48 hours without consulting md Replace fluids and electrolytes lost to prevent dehydration Observe for signs and symptoms of dehydration Decreased skin turgor Dry mucous membranes Thick saliva Increased thirst Copyright © 2014 by Elsevier Inc. All rights reserved.

Evaluation Goal met. Constipation relieved. Patient with soft formed bowel movement x1 on Goal met. Patient with no diarrhea x 48 hours. Goal not met. Patient reports pain from distention remains at a 4 out of 10. Copyright © 2014 by Elsevier Inc. All rights reserved.

Learning Objectives Theory
Analyze safety considerations related to giving a patient an enema. (continued) Analyze the psychosocial implications for a patient who has an ostomy. Discuss the stoma and peristoma assessment and skin care. Describe three types of intestinal diversions. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Learning Objectives Clinical Practice
Assist and teach a patient with a bowel retraining program for incontinence. Evaluate the performance of a patient who is self-catheterizing a continent diversion. Provide ostomy care, including irrigation and changing the ostomy appliance. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Rectal Suppositories 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 Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Enemas Fluid introduced into rectum by means of a tube
Stimulate peristalsis and urge to defecate or wash out waste products Often given before a colonoscopy or an x-ray Can be given at any time of day but most often before morning bath Must be prescribed and varies based on patients age and condition, purpose, and preference 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 What equipment is usually used for a cleansing enema? Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Types of Enemas Page 581 Retention enema
Softens stool as oil is absorbed Between mL of warm oil instilled Retained for at least 20 minutes Cleansing enema (soapsuds) Stimulates peristalsis through distention and irritation of colon and rectum Distention reduction 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 What three factors determine the type of enema given to the patient? (the patient’s age and condition, the reason for the enema, and the physician’s preference) Review patient teaching for enemas. Discuss the importance of documentation. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Amount and Temperature of Solution
Disposable enema units Contain about 240 mL of solution May be given at room temperature, but work best when slightly warmed F Cleansing enema Adults is between 500 and 1000 mL; smaller amounts are used for children Instill from inches above Why should a cleansing enema not be given too rapidly? Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fecal Impaction The rectum and sigmoid colon becomes filled with hardened fecal material Most obvious sign is absence of bowel movement for more than 3 days or only a small amount of liquid or semisoft stool Occurs in Very ill On bed rest Not fully aware Very old or very young more prone Medications such as narcotics and diuretics Copyright © 2014 by Elsevier Inc. All rights reserved.

Fecal impaction continued
Nursing responsibility is daily bowel pattern assessment Easier to remove when an oil retention enema is ordered and given, then cleansing enema 2-3 hours later Digital removal gently watching for signs of vagal response Slow pulse Cardiac arrhythmia Alteration in blood pressure If vagal response develops stop procedure, place in supine position, monitor vitals, notify physician Copyright © 2014 by Elsevier Inc. All rights reserved.

Bowel Training for Incontinence
Treatment for bowel incontinence and helps regain self esteem Principles for establishing regular bowel elimination Adequate diet Sufficient fluids Adequate exercise Sufficient rest Regular time for evacuation should be established and goal to achieve within 1 hour All efforts must be made to provide patient with environment that is conducive to evacuation May require digital stimulation to relax the anal sphincter Insert gloved lubricated finger 1-2 cm and rotate for seconds Suppositories, stool softeners, and bulk laxatives used to assist in establishing a normal, regular bowel pattern One hour before evacuation time 2500 mL/day of fluid Factors that will help establish the time include prior bowel habits of the patient or the nurse’s observation of when incontinent movements tend to occur. Many bowel retraining programs are timed around a triggering meal when gastrocolic reflexes are the strongest. What should be considered when providing the patient with a conducive environment? Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Bowel Ostomy A diversion of intestinal contents from their normal path is ostomy Results in formation of an external opening called a stoma Usually constructed of bowel May be an internal tissue pouch with a valve opening Special procedures aid in effective, controlled elimination through the stoma Keep body language neutral Surgery is used to create the ostomy. The ostomy may be temporary or permanent. Volunteers from the American Cancer Society as well national and local ostomy clubs often visit patients to educate them about the quality of life postostomy. An ostomy may result from traumatic injury to the abdomen. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Bowel Ostomy Continued
Conditions that can require ostomy Cancer Abdominal trauma Congenital malformation Severe chronic Crohn disease Ulcerative colitis Copyright © 2014 by Elsevier Inc. All rights reserved.

Types of Ostomies Ileostomy Colostomy
Diversion of the small bowel contents to a pouch or stoma; lower bowel removed; effluent is liquid Colostomy Diversion of the colon Effluent may be liquid or solid depending on the site; may require irrigation It is important to determine the reason the patient received an elimination diversion. The patient may be scheduled to undergo chemotherapy, radiation treatment, or hospice after surgery. The placement of the ostomy determines the effluent characteristics. A good rule of thumb: the higher up into the bowel, the more liquid the effluent. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 30-6: Ileostomy Discuss the use of this type of colostomy and why this type is used instead of a different type. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 30-6: Sigmoid colostomy
Discuss the use of this type of colostomy and why this type is used instead of a different type. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Figure 30-6: Descending colostomy

Figure 30-6: Ascending colostomy

Figure 30-6: Double-barrel colostomy

Figure 30-6: Kock pouch Discuss the use of this type of colostomy and why this type is used instead of a different type. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Ostomy Care Dietary Guidelines pg 587
Assessment of stoma and periostomy Skin care 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 What color should the stoma be? It is essential that the appliance be the correct size for the patient’s stoma. Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

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