CH 30 - Fundamentals of Nursing Care: Bowel Elimination and Care PDF

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CH 30: Bowel Elimination and Care I.

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Normal bowel elimination A. Bowel elimination occurs after nutrients are moved through the G.I. tract. Begins in the mouth and ends as the waste products are eliminated as feces via the anus - process of bowel elimination is known as defecation B. Frequency of elimination: changes throughout the lifespan- infants have 3 to 6 bowel movements daily, children have one or two per day which is usually maintain throughout adulthood 1. Constipation: peristalsis decreases as an individual ages, making elderly individuals more prone with hard stools that are difficult to pass 2. Some patients will normally have one bowel movement daily while others may go several days between movements, and others may even have several bowel movements each day - call of care is to maintain patient’s normal frequency a) Just make sure patient has had a bowel movement at least every three days to prevent constipation C. Timing of elimination: peristalsis begins with the introduction of food into the G.I. tract, urge to defecate commonly occurs 30 minutes to 1 hour after eating 1. If reflux is ignored and going to the bathroom is put off, the stall remains in the intestines longer than necessary and can become dry and hard which will contribute to constipation D. Characteristics of feces: Color, shape, consistency, odor, frequency. 1. Normal characteristics: soft, formed, light yellowish brown to dark brown, slightly odiferous, slightly curved shape. a) Sometimes may be a different color such as red or green because of variance in diet - spinach may result in greenish black streak, Iron supplements causes stools to be very dark brown or black b) Like frequency, expected color and consistency or different across lifespan (1) newborns: black, shiny, sticky stools called meconium (2) infants who breast-feed: bright yellow, pst, seedy appearing stool (3) infants who receive formula or cows milk: darker yellowish brown or tan colored stool much more firm and formed 2. Abnormal characteristics: a) If patient has in adequate fluid intake or if transit time is prolong: stool harder consistency and maybe passed in smaller balls or clumps rather than softer, longer, curved shape b) If transit time is short: stool will be liquid or semi liquid, rapid transit time does not allow bio to go through it’s typical chemical changes giving feces a green color c) Diarrhea: several liquid or watery stools per day. d) Consistency and shape may change due to variation in amount of fiber intake, increase amount of ingested fat, or change of structure of the intestine. Fiber intake affects bulk of stool e) Frank blood: visible to the naked eye f) Occult blood: hidden or not visible - guaiac test must be performed to determine. Indicates bleeding in digestive tract Assessment of bowel elimination A. Document: 1. Color, amount, consistency, unusual shape, unusual odor B. Data collection: ask the patient the following 1. How often do your bowels move? Do you have any current problems such as diarrhea or constipation, how long has it been occurring? what is the normal of number of stools per day? What is the normal color? What is the normal consistency? Is stool formed or unformed? 2. Do you experience any anal burning or itching? Do you experience anal cramping with or before? Is there pain? Do you feel urgency or pressure in the rectum? 3. Do you have allergies? Do you take routine meds? Have you experienced recent changes in appetite? How much fiber do you eat? Do you have regular meal times? How much fluid do you drink in a day? What are your usual beverages? Are you experiencing nausea or vomiting? Do you have any food intolerances? Do you have hemorrhoids? C. Focused assessment: perform focused assessment to determine the objective signs 1. First, assess shape of abdomen. Shape should be rounded or flat, not distended or inflated. Distention related to G.I. tract maybe sign of excessive gas, fluid, or stool. 2. Next auscultate the bell sounds using the diaphragm surface rather than the bell of your stethoscope to better hear sound, all four quadrants, bowel sounds should be assessed at least once per shift 3. If impaction or intestinal blockage occurs, peristalsis may increase or become hyper active proximal to the blockage. Intestinal contents will turn and mix as peristalsis pushes against the blockage - intestine proximal to blockage will do stand while intestine distal to blockage may empty a) Absence of vowel sounds indicates a problem and should be reported to healthcare provider b) Have very difficult to hear or quiet bowel sounds, must listen carefully and for an adequate period of time. 3 to 5 minutes in each of the four quadrants c) Do not palpate abdomen until after assessing bowel sounds because palpation may stimulate bowel sounds Alterations in bowel elimination A. Constipation: term used for less frequent, hard, formed stools that are difficult to expel may also include bloating 1. Patients with severe constipation may complain of loss of appetite, bloating, cramping, malaise, or not feeling well - others may make no complaints at all making it important to identify the length of time a) Elderly people who are not physically active are especially prone

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Factors contributing to constipation a) Decreased activity level: occurs when patient is ill or injured. Result in slower peristalsis, leading to constipation b) Changes in food intake: in adequate fiber intake decreases to math as well as decreasing peristalsis. Too much fiber can result in excess of flatus and can contribute to constipation (1) Eating at the regular times leads to irregularity of bowel movements and constipation c) Decreased fluid intake: two little fluid leads to heart or stools as a body absorbs the majority of fluid intake in attempt to maintain fluid and electrolyte balance. This leaves in adequate fluid in the colon to keep the stool soft d) Medication side effects: some over-the-counter medications containing aluminum and calcium carbonate can cause constipation. Iron supplements also cause constipation. Narcotic meds that contain opioids, such as codeine, hydrocodone, and oxycodone, cause severe slowing of peristalsis e) Surgery: especially surgery on G.I. tract, decrease peristalsis and increased risk for constipation. (1) Anesthesia drugs can slow or completely hot peristalsis. Manipulation of bowel changes chemistry of intestinal muscle cells. Postop pain can also suppress urge to defecate. f) Pregnancy: decrease in stimulation of the muscles of the digestive track and crowding of the sigmoid colon and the enlarging uterus both lend themselves to development of constipation g) Depression: depression can slow body processes including peristalsis, affect appetite and activity level, lead to constipation h) Aging: natural aging process brings changes in bowel function contributing to constipation greater risk for adults. esophageal emptying and peristalsis slow as we age. Muscle tone of smooth muscles of G.I. tract decrease i) Laxative overuse or abuse: Using laxatives too often they are no longer able to have a bowel movement naturally. If they do not take laxatives as frequently as usual they may become severely constipated or develop fecal impaction j) Nerve damage or impairment: nerves of the sigmoid colon, rectum, and both anal sphincter‘s must be in tact in order to sense the presence of the store in the rectum and they need to defecate (1) If these nerves are damaged or communication is interrupted patient will be unable to identify when defecation is imminent and will not possess control over the sphincter to voluntarily retain or expel stool Nursing interventions for constipation a) Increase activity: physical activity stimulates peristalsis. If allowed patient should be ambulated in hallways at least 3 to 4 times a day and sat up in chair for meals. (1) Make certain that the patient on bed rest is turned or repositioned every two hours b) Improve fluid and fiber intake: when fluid intake is in adequate, what are that has been ingested is absorbed from the bowel into the bloodstream to prevent dehydration. Without enough water stools become hard and difficult to expel (1) Fluid intake: 1500 to 2500 milliliters per day. (2) Find out what patient likes to drink and encourage water as well as other fluids such as coffee, tea, carbonated drinks, juice, sports drinks, flavor drink mixes, milk, broth. - provide assistance (3) Fiber intake generally should be 25 to 35 g per day encourage intake, whole grains fruits and vegetables. c) Provide privacy: be sure to provide privacy for elimination (1) If patient requires bedpan or bedside commode, shut the room door, pool privacy curtain, please bedpan or assist patient to the bedside commode, provide toilet tissue, wait outside of the curtain. If patient can be left unattended leave the room. (2) If patient is allowed bathroom privileges, make sure call light is within reach provide whatever privacy can be safely afforded. (3) Privacy should also be provided when discussing illumination. Avoid asking patient in the presence of visitors if they have had a bowel movement or to describe characteristics d) Assist with positioning: most comfortable and natural position for bowel elimination is to sit upright. If patient is allowed to ambulate a system to the bathroom. If they are unable to walk that far use a bedside commode (1) The patient is restricted to the bed, use the bedpan and please patient in high or semi Fowler‘s position e) Administer meds: for constipation may work by directly stimulating peristalsis, softening stool, or adding bulk to the store. (1) Stool softeners and those that add bulk are safer than laxatives. Important to collect information regarding meds used at home (2) Meds for constipation for hospitalized patients must be ordered. Nurses can try a variety of independent interventions to relieve constipation before requesting meds f) Administer enemas: Enemas are the instillation of a solution into the colon via the rectum to relieve the problem (1) Water temp: 105°F to 110°F - water too hot will burn the intestinal mucosal, water too cold will causes abdominal cramping and may restrict patient’s ability to retain water (2) Left Sims or left lateral side lying position, allowing gravity to help pull the solution into the

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intestine (3) 3 to 4 inches (4) Never attempt insertion of the tip of the tubing into the patient’s rectum while the patient is in a sitting position. (a) Angle of the natural curve of the rectum and sigmoid colon changes when sitting, this can cause tip of tubing to scrape the intestinal wall, possibly damaging the mucosal lining and increased risk of perforating the intestinal wall (5) Contraindications to enemas: (a) Rectal surgery (b) Severe bleeding hemorrhoids (c) Ulcerative colitis or Crohn’s disease (d) Rectal fissure (e) Rectal cancer (f) Excessive bleeding potential due to disease or medication (g) Certain heart conditions, such as MI or unstable angina (6) Complications of enemas: (a) Vagal response: possibility of stimulating the Vagus nerve, innervates not only the G.I. tract but also the heart and bronchioles. (i) When Vagus nerve is stimulated it can drop the heart rate is low is 30 to 40 BPM and causes constriction of bronchioles in the lung. (ii) If patient complains or exhibit any symptoms you should immediately: (a) Stop the enema, remove the tube from the rectum, please patient in supine position, assess pulse rate, assess skin color, assess whether or not patient is diaphoretic, call for immediate assistance do not leave patient, if pulse rate is below 60 BPM please patient in the shock position with the head lower than the feet, assess blood pressure, supply oxygen if needed (b) Perforation of the colon: be gentle when inserting enema tube never force or insert further than 4 to 6 inches. Direct the tip towards the umbilicus to follow the natural direction of the sigmoid colon (i) If you’re not careful it is possible to perforate the intestinal wall this can result in introduction of bacteria into the sterile peritoneal cavity, bleeding and even hemorrhage. Fecal impaction: impaction is the blockage of the movement of disease through the intestine by a mass of very hard stool may occur in rectum, sigmoid flexure, or any part of the large colon a) More common in elders, patients on bedrest, and severely dehydrated patients - common cause, especially in elderly patients is the abuse of laxatives. b) Sometimes small amounts of diarrhea earn indication of impaction, liquid IV from higher in the rectum or colon may seat down the solid impaction. c) If impaction is not relieved obstruction or perforation of the bowel wall can occur d) Nursing interventions for fecal impaction: (1) Usually requires digital removal before administering a cleansing enema- inserting the gloved index finger into the anus to manually break the fecal mass into small pieces and remove them from the rectum (a) Helpful to instill an oil retention enema one hour prior (b) Before removing the impaction, review facilities policy and procedures to determine which personnel are permitted to perform the procedure, review the patient’s medical record for all diagnoses, remember to monitor for signs of vagal nerve stimulation Diarrhea: loose or watery stools occurring three or more times a day, may or may not be accompanied by cramping a) Tenesmus: persisting desire to empty the bowel when no feces are present, causing ineffective straining efforts, may be due to inflammation in the rectum and may be experienced with bouts of diarrhea b) Elderly patients, infants, small children dehydrate much quicker than young or middle aged adults. Important to assess patients with diarrhea for dehydration, can lead to fluid and electrolyte loss c) Factors contributing to diarrhea: (1) Lactose intolerance: unable to digest lactose, the sugar found in milk and other dairy products. If they do you ingest lactose containing foods it will cause them to have diarrhea (2) Medication side effects: antibiotics can also kill some good bacteria specifically normal flora in the bowel. This allows other microorganisms to grow disproportionately causing an opportunistic infection (3) Anxiety and stress: high levels of stress or anxiety as well as other emotional problems can cause increased peristalsis and intestinal mucus production (4) Diverticulosis: occurs when the muscular wall of the colon weekends and separates, allowing small pouches or pockets of the inner wall to protrude outward. Pouches, called diverticulum, trap fecal material and become inflamed (a) Diverticulum have been known to rupture or perforate, allowing fecal material in

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bacteria to enter sterile peritoneum and cause peritonitis which is a lifethreatening infection (5) Inflammatory processes: occur in response to auto immune diseases such as Crohn’s disease or by infectious micro organisms such as bacteria and viruses. Common name for bacterial or viral infections is gastroenteritis (a) Inflammation causes mucosal lining and masculature of the intestinal tract to become edematous and increase mucus production - Adema and excessive mucus inhibit absorption and increase peristalsis, can be result of nausea, vomiting, cramping, diarrhea. (6) Food allergies: in response to food antigens, the body responds with allergic reactions that can cause Edema and inflammation in the intestinal wall with increased mucus production. Inflammation increases peristalsis which decreases transit time, inhibits absorption, and results in diarrhea d) Nursing interventions for diarrhea: (1) Modified food intake and increase fluids: liquid diet during the first 24 hours of diarrhea caused by infection and inflammation. Clear liquids help decrease G.I. tract digestive workload allowing it time to rest and heal. (a) Decaf green or black tea’s, herbal teas can be used to soothe inflamed colon and slow peristalsis. (b) Sports drinks containing electrolytes help replace fluid and electrolytes lost with diarrhea. Pedialyte is an over-the-counter electrolyte replacement drink design for infants and small children (c) During the first 24 hours avoid serving extremely hot or cold liquids both of which can increase peristalsis (d) After 24 to 36 hours full liquids along with any type of cooked fruits and vegetables such as applesauce or carrots may be given. - Apple juice will increase diarrhea (e) Aged cheeses and bananas considered therapeutic. Mashed bananas, applesauce, cooked carrots possible choices for infants with diarrhea. Yogurt containing active bacteria helps to replace normal flora and promote healing (2) Administer medications: various medications, over-the-counter and prescribed, who mucous membranes of the bowel, inhibit peristalsis, or treat disease or infectious process causing diarrhea. (a) Some meds stimulate absorption of intestinal fluids into bloodstream and bind the toxins of the diarrhea causing microbes so they are removed during defecation (b) Probiotics are micro organisms with health benefits which helped digest food and produce vitamin K - useful in helping to prevent diarrhea caused by antibiotics and infections and help prevent IBS (c) Lactobacillus acidophilus is a probiotic supplement that comes in several forms and can be used to replace normal flora. Also used as a treatment for diarrhea caused by rotavirus (3) Provide perineal care: if patient has diarrhea or is incontinent, provide good perineal care to prevent complications caused by feces on skin. Feces can damage skin and result in irritation and excortication if allowed to stay on the skin for extended periods of time (a) Cleanse skin around perineum, rectum, and buttocks after each store with a no rinse bathing products, peroneal wipe, or peroneal cleaning product rather than soap and water (i) Soap is alkaline and irritating to skin, mechanical friction of using washcloth can damage skin. Rinse well and dry Fecal incontinence colon voluntary control over bowel is lost. a) Nursing interventions for fecal incontinence: (1) Provide bowel training: The goal of bowel training is to establish regular bowel illumination assist patient to Commode or on bedpan: when the patient arises each day, after each meal, anytime the patient says that his or her bowels have to move (a) Maintain records of patient’s bowel activity. When a pattern of bowel illumination cannot be established, it’s recommended to attempt to train the bowels to move within one hour after breakfast - increase fiber and fluid (2) Promote skin integrity: risk for skin breakdown (a) Topical barrier creams help prevent excoriation but if it is not possible to keep patient clean and dry, fecal incontinence pouch may be the best choice to protect skin integrity (i) Pouch should be emptied emptied when half full to prevent spills. Designed to be changed every 2 to 3 days (3) Provide emotional support: whether or not fecal incontinence can be resolved, it’s important that you are professional and kind but also try to add extra compassion. (a) Teach staff and the patient’s family to avoid criticism or judge mental comments that could be hurtful. Because she is in nonverbal communication as well avoid actions or body language that may imply that the patient is to blame or that

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cleaning the patient is offensive (b) Never referred to pads used to protect patient as diapers because that can be traumatizing. Call them incontinence pads or briefs or depends 7. Obtaining a stool specimen: stool samples may be tested for presence of parasites, parasitic eggs called over, blood, micro organisms a) For alert and oriented patients you will need to explain the procedure. Use terminology that the patient understands when giving instructions. If the patient is infant or incontinent, collect a stool specimen directly from diaper or incontinence briefs Alternative bowel illumination A. Bowel diversion: redirection of the contents of the small or large intestine thro...