Textbook For Nursing Assistants

Textbook For Nursing Assistants
Chapter 20 – Assisting with Urinary and Bowel Elimination Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Assisting with Elimination
Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Some patients or residents may only need a steady arm to lean on during their trip to the bathroom; others will need more help The bathrooms in many health care facilities have special features that make them easier for people with physical disabilities to use Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Modifications allow many patients or residents to use the toilet in the bathroom with very little assistance from a nursing assistant Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Assisting with Elimination - Elimination Equipment
Some patients or residents may not be able to get out of bed at all, or they may be too weak or ill to walk to the bathroom. These people may need to use: Bedside commodes Bedpans Urinals Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Elimination Equipment - Bedside Commodes
The bedside commode consists of a chair frame with a toilet seat and a removable collection bucket For a person who is able to get out of bed, but who is not able to walk to the bathroom, a bedside commode can make toileting easier Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Elimination Equipment - Bedpans
A bedpan is used for elimination when a person is unable to get out of bed at all A woman who cannot get out of bed uses a bedpan to urinate, and for bowel movements. A man who cannot get out of bed uses a bedpan for bowel movements, and a urinal to urinate. Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Elimination Equipment - Fracture Pans
Arthritis can make using a bedpan very painful, as can fractures of the back or legs In such cases, when using a bedpan is uncomfortable or dangerous, a special bedpan called a fracture pan is used Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Elimination Equipment - Fracture Pans
The fracture pan, which is wedge-shaped, is placed underneath the person’s buttocks with the thin edge toward the person’s back Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Fracture Pans and Bedpans - Useful Tips
Warm a metal bedpan before offering it to the patient or resident by wrapping the bedpan in a warm towel, or running warm water over the seat area and then drying it before use Provide as much privacy as safely possible Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Fracture Pans and Bedpans - Useful Tips
If the person’s condition allows, raise the head of the bed to promote a more natural elimination position Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Elimination Equipment - Urinals
A man uses a urinal to urinate when he cannot get out of bed Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Elimination Equipment - Urinals
To urinate, the man puts his penis in the opening of the urinal If the man is very weak or disabled, you may need to place his penis inside the opening of the urinal for him Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Difficulty with Normal Elimination
A patient or a resident may have difficulty with elimination, if elimination occurs under conditions that are not as private as the person would like. In a health care facility, people may share a bathroom or use a bedpan while only being separated from other people in the room by a curtain Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Difficulty with Normal Elimination
Feelings of embarrassment and shame are made worse when patients or residents accidentally soil themselves, their bed linens, or their clothing with urine or feces. This might be due to: The effects of medications Being in a strange place Reluctance to ask for help Physical or mental disabilities Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Promoting Normal Elimination
Kindness, empathy, and a professional attitude can go a long way toward easing the patient’s or resident’s embarrassment Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Being in a health care facility can change a person’s normal elimination patterns, which can cause health problems The most effective method of treating urinary and bowel problems is to prevent them from happening in the first place Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Encourage plenty of fluids, unless the doctor has ordered against it Answer call lights promptly Encourage the person to call when he first feels the urge to void Offer people the chance to eliminate frequently Provide for privacy and comfort The sound of running water may help some people to urinate If a person is having difficulty moving his bowels, do not rush the person Regular exercise and foods containing insoluble fiber help promote regular bowel movements Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Obtaining Urine and Stool Specimens
The contents of a person’s urine or feces can provide a doctor with clues about the person’s overall health status A nursing assistant may be asked to obtain a urine or stool specimen (sample) for laboratory study Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Before collecting any specimen—of urine, feces, or any other body fluid—ask yourself the following questions: Do I have the right person? Do I have the right laboratory requisition slip? What method is to be used to collect the specimen? Do I have the right type of specimen cup? Is the specimen cup properly labeled? What is the correct date and time? What storage and delivery method must I use? Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Always remember to wear gloves when assisting with specimen collection and when handling the specimen cups Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

To perform urinalysis, a urine specimen must be obtained
Obtaining Urine and Stool Specimens - Urinalysis Urinalysis, or examination of the urine under a microscope and by chemical means, is a commonly used diagnostic tool in the health care setting Substances found in urine during urinalysis can help doctors diagnose kidney disease, certain metabolic diseases, and infections To perform urinalysis, a urine specimen must be obtained Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Obtaining Urine Specimens - Routine Urinalysis
For routine urinalysis, the person is asked to urinate directly into the specimen cup, if possible. If difficult, the person can urinate into a specimen collection device. The person must not have a bowel movement at the same time the urine is being collected. Do not place toilet paper in the collection device. Either of these actions will change the urinalysis results. Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

The urine flow is started, then stopped, then started again
Obtaining Urine Specimens- Midstream (“Clean Catch”) Urine Specimen This method of collecting urine prevents contamination of the urine by the bacteria that normally live in and around the urethra A midstream (“clean catch”) urine specimen is usually ordered when the doctor suspects a urinary tract infection When a midstream (“clean catch”) urine specimen is requested, the person is asked to clean the area around the urethral opening with a special cleansing wipe The urine flow is started, then stopped, then started again The urine sample is collected from the restarted flow Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Obtaining Urine Specimens - Testing
A type of routine urine testing involves dipping chemically treated paper strips into a urine sample Chemicals on the paper react with certain substances that may be found in the urine, causing the chemical blocks on the paper to change color if these substances are present in the urine The paper is then compared with a color chart that comes with the strips Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Obtaining Stool Specimens
Stool is analyzed for the presence of blood, pathogens (such as parasites or bacteria), fat, and other things that are not normally found in feces If a stool sample is needed, the person should be notified well in advance so that the specimen can be collected when it becomes available Ask the nurse if there are any particular collection methods that should be used Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Obtaining Stool Specimens
Stool can be collected in a bedpan, bedside commode, or in a collection device placed into a regular toilet. The person must not urinate at the same time the stool sample is being collected. Toilet paper must not be placed in the collection device. Both of these actions will change the test results. Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Urinary Elimination - Urinary System
The urinary system consists of the kidneys, urinary bladder, ureters, and urethra Blood is filtered by the kidneys, forming urine The urine is stored in the urinary bladder As the bladder fills, we begin to feel the urge to urinate Urine leaves the body through the urethra Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Urinary Elimination - Expressions
The process of passing urine from the body is known by several terms, including Urination Voiding Micturition Patients or residents will have their own terms for urinating, such as “peeing” or “passing water” When talking about urination, use words that the person is familiar with. This is especially important when talking with children. Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Urinary Elimination - Color and Odor
In healthy people, urine is: Clear, without cloudiness or particles Pale yellow, straw-colored, or dark gold (amber) in color, with a slight odor Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Urinary Elimination - Color and Odor
Foods and drugs can affect the color and odor of urine When you are helping a patient or resident with urination, observe the urine and report any abnormalities to the nurse Urine with an unusual odor or appearance could be a sign of illness or infection Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Urinary Elimination - Hematuria
A slight red tinge to the urine may indicate hematuria, or the presence of blood in the urine Sometimes hematuria is occult and must be detected using urinalysis Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Factors Affecting Urinary Elimination
Many factors influence a person’s urinary pattern, including: The amount of fluids the person drinks The types of medications the person takes The person’s age The person’s lifelong elimination habits A nursing assistant soon becomes aware of the urinary pattern that is normal for each person in her care This knowledge allows her to recognize any changes that may occur Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Urination - Frequency and Nocturia
Frequency is the term used to describe voiding that occurs more often than usual Frequency is often accompanied by a feeling of urgency, or the need to urinate immediately Nocturia is the need to get up more than once or twice during the night to urinate, to the point where sleep is disrupted Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Urination - Dysuria Dysuria is difficulty voiding that may or may not be associated with pain Some people describe the discomfort they feel during urination as a “burning” or “cramping” sensation Dysuria is often associated with bladder infections, prostate problems, and some sexually transmitted diseases (STDs) Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Measuring Urine Output
In a person maintaining a good fluid balance, urine output is neither too high nor too low. Complications associated with urine output are: Oliguria (the state of voiding a very small amount of urine over a given period of time) Polyuria (the state of excessive urine output) Anuria (the state of voiding less than 100 ml of urine over the course of 24 hours) Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Measuring Urine Output
People who have illnesses or take medications that may alter their body’s ability to maintain a healthy fluid balance will need to have their urine output measured regularly Some people who are critically ill will have their urine output measured and recorded every hour, but most people in the health care setting have routine orders for their urine output to be measured and recorded each shift Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Measuring Urine Output - Process
If a person uses a regular toilet, you will need to remind the person: To void into a specimen collection device (“commode hat”) To call you after he or she has finished voiding so that you can measure and record the amount of urine Specimen collection devices, urinals, and the drainage bags used with urinary catheters often have markings that make measuring urine output easy Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

If the urine output of one of your residents or patients is being monitored, you will need to keep a record of the amount of urine passed at each voiding This can be done using an intake and output (I&O) flow sheet, which has spaces to record the amount of each individual voiding To obtain the end-of-shift amount, simply add the individual amounts and record the total in the appropriate space Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Urinary Catheterization
Urinary catheterization is done when a person is unable to urinate using a toilet, bedpan, urinal, or bedside commode A urinary catheter is a tube that is inserted into the bladder through the urethra to allow the urine in the bladder to drain out Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Urinary Catheterization - Situations When a Urinary Catheter is Used
A urinary catheter is used in many different situations: A urinary catheter may be inserted to drain the bladder before or during a surgical procedure, during recovery from a serious illness or injury, or to collect urine for testing A urinary catheter may be used for a person who is incontinent of urine, if the person has wounds or pressure ulcers that would be made worse by contact with urine A urinary catheter is necessary when a person is unable to urinate because of an obstruction in the urethra Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Urinary Catheterization - Insertion of Urinary Catheter
Inserting a catheter is a procedure that requires sterile technique because it involves putting a foreign object (that is, the catheter) into a person’s body. Inserting a urinary catheter is usually beyond the scope of practice for a nursing assistant, although in some facilities, nursing assistants are provided with additional training that allows them to catheterize residents or patients. Regardless of whether or not you are trained to actually insert urinary catheters, caring for people who have urinary catheters in place will almost certainly be a part of your daily duties. Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

You will see many different types of urinary catheters in use
Urinary Catheterization - Types of Urinary Catheters You will see many different types of urinary catheters in use A straight catheter, also known as a Robinson, Rob-Nel, or Red Rubber catheter, is used when the catheter is to be inserted and removed immediately. An indwelling catheter, also known as a retention or Foley catheter, is left inside the bladder to provide continuous urine drainage. A suprapubic catheter is a type of indwelling catheter. The suprapubic catheter is inserted into the bladder through a surgical incision made in the abdominal wall, right above the pubic bone. Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Catheters Straight Indwelling Suprapubic
Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Urinary Catheterization - Caring for a Person with an Indwelling Urinary Catheter
Indwelling urinary catheters are connected by a length of tubing to a urine drainage bag The tubing is secured loosely to the person’s body near the insertion site using a catheter strap or adhesive tape Securing the tubing to the person’s body prevents the catheter from being accidentally pulled out during repositioning Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

A little bit of slack is left in the tubing to prevent the catheter from pulling against the bladder outlet and the urethral opening The remaining length of tubing is then gently coiled and secured to the bed linens using a plastic clip or safety pin Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Coiling the tubing prevents the tubing from becoming bent or kinked, which would stop the free flow of urine into the drainage bag. Coiling the tubing and securing it to the bed linens also keeps the weight of the tubing from pulling against the person’s body. The drainage bag is then secured to the bed frame or the back of the person’s wheelchair, at a level lower than the person’s bladder. Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

If the drainage bag and tubing are higher than the person’s bladder, then gravity could cause old, contaminated urine to run back down the tubing and into the person’s bladder, causing an infection. Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Urinary Catheterization - Providing Catheter Care
Nursing assistants are usually responsible for providing catheter care. Catheter care involves thorough cleaning of the perineal area and the catheter tubing that extends outside of the body, to prevent infection. Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Providing good catheter care is important because the presence of the catheter in the urethra provides a pathway for bacteria to travel up from the perineum into the bladder, where they can cause infection. In addition, having a catheter in place eliminates the “flushing” action of normal urination, which helps to remove bacteria from the urinary tract naturally. Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Because bacteria can be introduced into the body both when a urinary catheter is inserted and after it is in place, urinary tract infections in catheterized people are one of the most common nosocomial infections. In an effort to reduce the risk of nosocomial infection in people who are catheterized, many facilities require catheter care to be provided routinely. Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Urine drainage bags should also be emptied if they are full.
Urinary Catheterization - Emptying Urine Drainage Bags Urine drainage bags are routinely emptied and the urine measured at the end of each shift. Urine drainage bags should also be emptied if they are full. Leg bags need to be emptied frequently because they are smaller, and hold less urine. Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Urinary Catheterization - Preparing for Removal of an Indwelling Catheter
Use of an indwelling catheter can lead to temporary urinary incontinence when the catheter is removed, because the lack of activity can decrease the muscle tone of the bladder. To prepare the bladder for removal of the catheter, it is common to clamp the tubing of the catheter for a period of time to allow the urine to fill the bladder. The tubing is then unclamped and the urine is allowed to drain from the bladder. The procedure is repeated over a period of time, with the time intervals between clamping and emptying becoming increasingly longer. Then the catheter is removed and the person is allowed to void normally. Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Urinary Incontinence Urinary incontinence is the inability to hold one’s urine, or the involuntary loss of urine from the bladder. Urinary incontinence may be temporary or permanent. Temporary urinary incontinence can occur as a result of bladder infection, or after an indwelling catheter that has been in place for a long time is removed. Permanent urinary incontinence can be caused by many things, including: Decreased muscle tone in the bladder or the muscles that support the bladder, such as occurs after childbirth or from obesity Injuries or illnesses that affect the spinal cord, the brain, or the nerves that control bladder function Dementia Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Urinary Incontinence Urinary incontinence can be emotionally devastating for both the incontinent person and the person’s caregivers. For the person who is incontinent, having wet clothes or smelling like urine can be very embarrassing. In addition, being incontinent of urine places a person at risk for developing skin problems and for falling. For the caregiver, caring for a person who is incontinent of urine can be frustrating and emotionally draining. Because caring for an incontinent person can be so emotionally trying and time consuming, incontinence is the factor that most often leads family members to have a relative admitted to a long-term care facility. Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Urinary Incontinence - Types
There are many types of urinary incontinence Stress incontinence is the involuntary release of urine from the bladder when the person coughs, sneezes, or exerts herself. Urge incontinence is the involuntary release of urine right after feeling a strong urge to void. Functional incontinence occurs in the absence of physical or nervous system problems affecting the urinary tract. Overflow incontinence occurs when the bladder is too full of urine. Reflex incontinence occurs when there is damage to the nerves that enable the person to control urination. Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Urinary Incontinence - Managing Urinary Incontinence
Products available to help manage urinary incontinence include: Incontinence pads Incontinence briefs Condom catheters In addition, techniques such as bladder training may be used to help a person overcome certain types of incontinence For some people, temporary or permanent catheterization may be necessary to manage incontinence Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Urinary Incontinence - Managing Urinary Incontinence -Incontinence Pads and Briefs
Incontinence pads and briefs are specially made to absorb urine and hold it away from the person’s skin. Incontinence pads are placed inside the person’s underpants to prevent wetting of the clothes and to draw the moisture away from the person’s body. For a person who is confined to bed, bed protectors are used to help to keep the bed linens and mattress dry and to wick urine away from the person’s skin. Incontinence briefs tend to fit closely, which makes it difficult for air to reach the skin. Switching between briefs and bed protectors helps expose the skin to air at night. A nursing assistant must make sure that these incontinence products are changed frequently and that urine is cleaned from the skin whenever the change occurs. Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Urinary Incontinence - Managing Urinary Incontinence - Condom Catheters
A condom catheter consists of a soft plastic or rubber sheath, tubing, and a collection bag for the urine. The sheath is placed over the penis and the collection bag is attached to the leg. Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Urinary Incontinence - Managing Urinary Incontinence - Condom Catheters
The urine flows through the tubing into the collection bag, allowing the man to urinate at will. The condom must fit the penis and should be fastened securely enough to prevent leaking, but not so snugly as to restrict circulation. Adhesive material on the inside of the condom allows for a good seal Or, the condom is secured with elastic tape applied in a spiral fashion to allow for changes in the size of the penis Use of a condom catheter requires good skin care. The penis must be cleaned, and the condom apparatus changed, daily. Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Urinary Incontinence - Managing Urinary Incontinence - Bladder Training
Bladder training is commonly used to help people re-learn how to control their urinary elimination patterns. For example, a person may be encouraged to use the bedpan, urinal, or commode at scheduled times. Scheduling of elimination helps promote regular emptying of the bladder. The primary goal is for the person to be able to control involuntary urination. If this is not possible, then the person may still at least be able to get to the bathroom in time to avoid accidents. Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Bowel Elimination - Digestive System
The digestive tract consists of the mouth, esophagus, stomach, small intestine, large intestine, rectum, and anus Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

The rectum is actually part of the large intestine, and together, the large and small intestines are sometimes referred to as “bowels.” The food and fluids that we take in are broken down into smaller pieces and mixed together in the stomach, forming a partially digested food and fluid mixture known as chyme. From the stomach, the chyme passes slowly into the small intestine, where more digestion occurs and nutrients and fluid are absorbed, and then into the large intestine. Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Wave-like muscular movements, called peristalsis, move the chyme through the intestines. Finally, the chyme reaches the last part of the large intestine, called the rectum. At this point, all of the nutrients have been removed, and what remains is a semi-solid waste material, called feces. Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

The presence of feces in the rectum stimulates the urge to defecate and the feces leave the body through the anus. Flatus (or gas) is a natural byproduct of digestion, just as feces are. Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Bowel Elimination - Color and Odor
In healthy people, feces: Are soft, brown, and moist Have a distinct odor Certain foods and medications can affect the color and odor of feces When helping a patient or resident with defecation, observe the feces and report any abnormalities to the nurse Feces with an unusual odor or appearance could be a sign of illness or infection Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Factors Affecting Bowel Elimination
The factors that influence a person’s bowel elimination pattern include: The amount of fluid the person drinks The type of food he or she eats The types of drugs the person takes The person’s age The person’s level of activity A nursing assistant soon becomes aware of the bowel elimination pattern that is normal for each person in her care. This knowledge allows her to recognize any changes that may occur. Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Problems with Bowel Elimination
Problems with bowel elimination that are often seen in the health care setting include: Diarrhea Constipation Fecal impaction Flatulence Fecal (bowel) incontinence Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Diarrhea is the passage of liquid, unformed stool.
Problems with Bowel Elimination - Diarrhea Diarrhea is the passage of liquid, unformed stool. Diarrhea may occur frequently and can be accompanied by abdominal cramping. If diarrhea is frequent or excessive, the loss of fluid from the body can quickly cause dehydration, especially in young or elderly people. Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

When caring for a person with diarrhea:
Problems with Bowel Elimination - Diarrhea When caring for a person with diarrhea: Practice good infection control techniques Answer the call light quickly to provide access to the toilet, commode, or bedpan Provide gentle, thorough skin care after each bowel movement to prevent skin breakdown Make sure to record and report the frequency and amount of each incident of diarrhea Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Problems with Bowel Elimination - Constipation
Constipation occurs when the feces remain in the intestines for too long The delay allows too much fluid to be reabsorbed by the intestines, resulting in hard, dry feces that are difficult to pass Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Risk factors for developing constipation include:
Problems with Bowel Elimination - Constipation Risk factors for developing constipation include: Taking medications that slow peristalsis Not taking in enough dietary fiber or fluids Not getting enough exercise Delaying having a bowel movement Lack of privacy Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

There are many things a nursing assistant can do to help a patient or resident maintain normal bowel function and prevent constipation Encouraging fiber-rich foods Encouraging plenty of fluids Assisting with exercise Ensuring privacy Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

If a person is constipated and all other methods of promoting normal bowel function have failed, a laxative, stool softener, or fiber supplement may need to be used A laxative is a medication that chemically stimulates peristalsis so that material inside the intestines moves through at a faster pace Stool softeners help to keep fluid in the feces and are used to help prevent constipation for some people Fiber supplements, in the form of tablets or drink additives, can add bulk to the feces, causing it to hold fluid, and preventing constipation Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

A fecal impaction occurs when constipation is not relieved.
Problems with Bowel Elimination - Fecal Impaction A fecal impaction occurs when constipation is not relieved. The feces build up in the rectum and become harder and harder as more and more fluid is absorbed. Eventually, it becomes almost impossible to pass the feces normally. The impaction blocks the passage of normal stool, but liquid stool may go around the impacted mass. Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

The person’s abdomen may be swollen.
Problems with Bowel Elimination - Fecal Impaction A person with an impaction is usually very uncomfortable, and may complain of abdominal or rectal pain or of liquid feces “seeping” out of the anus. The person’s abdomen may be swollen. Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Problems with Bowel Elimination - Fecal Impaction
If a person is thought to have a fecal impaction, the nurse will perform a digital examination. During the digital examination, a finger is inserted into the person’s rectum to feel for the impacted mass (digital means “finger”). Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Problems with Bowel Elimination - Fecal Impaction
The impaction is removed by using the finger to break the impacted feces apart and scoop it out of the rectum piece by piece. The doctor may also order the use of an oil retention enema or drugs to help remove the impaction. Digital removal of a fecal impaction is very uncomfortable and embarrassing for most patients and residents. Many facilities require that a nurse remove an impaction, but your assistance will be necessary. If you are allowed to remove an impaction, make sure you have been adequately trained for the procedure and that it is part of your job description. Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Problems with Bowel Elimination - Flatulence
Flatulence is the presence of excessive amounts of flatus (gas) in the intestines, causing abdominal distension (swelling) and discomfort. People have difficulty passing flatus because of a lack of activity or a recent surgical procedure. Getting out of bed and walking might be all that is needed to help the person to expel the gas. If walking is not allowed, positioning the person on her left side may help. If the flatulence cannot be relieved with these methods, a nurse may insert a rectal tube to help the gas escape. Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Problems with Bowel Elimination - Fecal Incontinence
Fecal (bowel) incontinence is the inability to hold one’s feces, or the involuntary loss of feces from the bowel Like urinary incontinence, fecal incontinence can be temporary or permanent Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Problems with Bowel Elimination - Fecal Incontinence
Temporary fecal incontinence may be due to: A severe case of diarrhea An inability to get to the bathroom quickly enough Failure to answer call lights promptly Diseases or injuries that affect the nervous system can also result in temporary or permanent fecal incontinence A person who is unconscious will be incontinent of feces A person who has dementia will develop fecal incontinence as the disease progresses Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Problems with Bowel Elimination - Fecal Incontinence - Bowel Training
Bowel training is very similar to bladder training and works to promote regular, controlled bowel movements Offering the commode or bedpan at regular scheduled intervals is a common method of bowel training Bowel training is often started by keeping track of when an incontinent person usually has a bowel movement, then making sure to provide the appropriate toilet facilities during that time period Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Enemas An enema is the introduction of fluid into the large intestine by way of the anus for the purpose of removing stool from the rectum Enemas are used to Relieve constipation Relieve fecal impactions Empty the intestine of fecal material before surgery or certain diagnostic tests Sometimes enemas are used as part of a bowel training program Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Enemas - Types of enemas
Types of enemas used in the health care setting include: Cleansing enemas Oil retention enemas Commercial enemas Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Enemas - Cleansing Enemas
Cleansing enemas are primarily used to remove feces from the lower large intestine. Tap water enemas and saline (salt water) enemas help soften the stool and stimulate peristalsis. Soapsuds enemas consist of water and a small amount of a very gentle soap called castile soap. The soap solution irritates the lining of the bowel, stimulating peristalsis. Enemas containing these solutions should not be given repeatedly because the intestine can absorb the solution, causing a fluid imbalance in the body. Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Enemas - Oil Retention Enemas
An oil retention enema contains mineral, olive, or cottonseed oil. The oil lubricates the inside of the intestine and any stool that is present, making the stool easier to pass or remove. Oil retention enemas are useful for helping to remove fecal impactions. Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Enemas - Commercial Enemas
Commercially prepared and packaged enemas usually contain 120 ml of a solution that irritates the intestinal mucosa to promote peristalsis. Some commercial enemas contain a solution that is absorbed into the stool to make it softer and easier to pass. Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Enemas - Administering Enemas
Enemas are ordered by a doctor and usually given by a nurse. Some facilities allow nursing assistants to administer enemas after adequate training. Nursing assistants must make sure that They follow proper procedure and the doctor’s orders closely The solution is correct for the person The correct amount of solution is being administered The solution is at the proper temperature Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Enema solutions that are too cool can cause abdominal cramping and pain, while solutions that are too hot can cause serious injury and possibly even death When assisting with the administration of an enema, make sure that a bed protector and bedpan are in place, or that the path to the bathroom is clear Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

An enema is given with the person on her left side in Sims’ position When a person is lying on her left side in Sims’ position, the intestine is positioned to take the best advantage of gravity After the enema has been administered, the person is asked to hold the solution in the bowel for the specified amount of time, and then to expel the solution The doctor may order a cleansing enema to be administered “until clear,” which means that enemas are to be given until the enema return from the person does not contain any fecal material Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Ask the nurse how many enemas are allowed to be given during a particular session To make the procedure easier for the person, keep the person covered as much as possible and ensure that she has as much privacy as possible Having the person take a few slow, deep breaths as the enema tubing is inserted into the rectum may help to relax the person and make insertion easier Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

Rectal Suppositories A rectal suppository is a small, wax-like cone or oval that is inserted into the anus. The wax-like substance dissolves at body temperature, stimulating peristalsis or lubricating and softening the stool. Glycerin rectal suppositories are often used to help with bowel elimination before resorting to an enema. Some rectal suppositories also contain medication. These should only be inserted by a nurse. Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing Assistants.

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