Chapter 29 Bowel elimination PDF

Preview

Summary

Bowel movement and elimination, with anatomy and physiology content....

Description

Chapter 29 Bowel elimination What is Bowel Elimination? - Bowel Elimination is a normal process by which we eliminate waste products from our bodies.

Anatomy of the Gastrointestinal Tract The Gastrointestinal Tract: - Length: approximately 10 meters or 30 feet long - Major Functions: digest food, absorb nutrients in food and eliminate food waste products as feces - Structures: mouth, pharynx, esophagus, stomach, small intestine, large intestine, rectum and anus. The Upper Gastrointestinal Tract - The upper GI tract consist of the mouth, pharynx, esophagus, and stomach. ● The Mouth: where mechanical digestion begins. ● The Pharynx: is the back part of the throat where food and air pass after chewing. ● The Esophagus: is a tube of smooth muscle, which alternates contracts and relaxes in waves of peristalsis to push the bolus toward the stomach. ● The Stomach: is a distensible sac that extends from the esophagus to the small intestine. The stomach stores food while it churns and mixes it, providing further mechanical breakdown. The Small Intestine ● Diameter: 2.5 cm (1 in.) ● Length: 6 meters (20 feet) long if fully extended ● Sections: ○ Duodenum: Processes chyme by mixing it and adding enzymes ○ Jejunum: the major function is to absorb carbohydrates and proteins ○ Ileum: is responsible for the absorption of fats, bile salts, some vitamins, minerals, and water. ● Functions: processes chyme, absorbs carbohydrates, proteins, fats, bile salts, some vitamins, minerals, and water The Large Intestine (Colon) - Diameter: 2.5 inches, Length: 5-6 feet - Seven Segments: cecum, ascending colon, transverse colon, descending colon, sigmoid colon, rectum, and anus - Functions: secretes mucus, which facilitates smooth passage of stool, and absorbs water, some vitamins, and minerals. The Rectum and Anus

●

●

The Rectum: is approximately 15 cm (6 in.) long and is continuous with the anus. ○ The rectum is free of waste products until just before defecation ○ The rectum is a highly vascular folded tube The Anus: is the last 2.5 cm (1 in.) of the colon. ○ Has two ring like muscles that function as sphincters: the internal sphincter and external sphincter

Way’s the Bowel Eliminates Waste ❖ The bowel eliminates waste by creating feces. ❖ Feces: The action of reabsorption of water from chyme in the large intestine resulting in a semisolid mass.. ➢ The feces color is usually brown due to bile salts, which help in digestion of fat then get expelled into the feces. Bacteria is the cause for the feces odor ➢ Bile is usually the color golden yellow, but the process of bacteria in the GI tract alters the color to brown Elimination Process ❖ Stretch receptors stimulate the start of contractions of the sigmoid colon and rectal muscles ❖ The internal anal sphincter then relaxes. ❖ Right at that very moment sensory impulses produce a conscious urge to defecate A normal stool is usually a soft semisolid with 75% water and 25% solid when expelled. Factors that Affect Bowel Elimination ● Developmental Stages ○ Infants- this age group usually have bowel eliminations very often, normally after feedings. ○ Children- this age group normally are toilet trained, however; most do not get toilet trained until the age of 2-3. ○ Adults- this age group are very aware of when they have use the restroom, but many older adults decrease their activity and fiber intake causing them to have irregular bowel eliminations. ● Personal and Sociocultural Factors ○ Privacy, Time, and Stress ● Nutrition, Hydration, and Activity Levels ○ Foods and Fiber, Dietary Supplements, Fluids, and Activity Factors Continued ● Medications ○ All medications have the potential to affect the function of the GI tract. ● Surgery and Procedures ○ Anesthesia, Stress, and Different types of surgery. ● Pregnancy ○ All pregnancies are different, however; most pregnancies cause women to experience constipation, decreased appetite, and also irregular food intake. ● Pathological Conditions ○ Food allergies, Food intolerance, and Diverticulosis.

Bowel Diversions What are Bowel Diversions: ● A surgically created opening for the elimination of digestive waste products ○ Stoma or Ostomy ○ Can be temporary or permanent ● Ileostomy: brings a portion of the ileum through a surgical opening in the abdomen, bypassing the large intestine completely.

●

●

●

●

●

○ Kock pouch (continent pouch) ○ Total colectomy with ileoanal reservoir Colostomy: surgical procedure that brings a portion of the colon through a surgical opening in the abdomen. ○ Close to the ascending colon and the ileocecal valve: more liquid and continuous the drainage ○ Close to the sigmoid colon: produce solid feces ○ Near the rectum: can be controlled by diet and irrigation and may not need to wear an ostomy appliance ○ Colostomy created in the transverse colon is usually temporary ● Double-barreled colostomy: Has two separate stomas, the proximal stoma is the functioning one that drains fecal material. The distal stoma may drain mucus which is also called a mucous fistula. ● Loop Colostomy: consists of a segment of bowel brought out to the abdominal wall while the posterior wall of the bowel remains intact. A plastic rod is wedged under the bowel to keep it from slipping back into the abdomen. Focused Nursing History: ○ Gather data on the client’s usual care of the stoma, use of appliances and adjustment. ○ Talk about medications, some may cause constipation: Iron supplements, Lithium, NSAIDs Focused Physical Assessment: ○ Listen for Normal Bowel Sounds, Hyperactive Bowel Sounds, Hypoactive Bowel Sounds, and Absent Bowel Sounds Diagnostic Tests: ○ Indirect Visualization Studies: radiographic views of the lower GI Tract ○ Direct Visualization Studies: invasive procedure used for diagnostic and treatment purposes. Laboratory Studies of Stool ○ Stool specimens may be analyzed to detect blood, infection or parasitic infestation ■ The test for occult (hidden) blood is called a guaiac or fecal occult blood test. ■ Pinworms are small white thread-like intestinal parasites that are pass by human to human transmission. They live in the cecum and deposit their eggs and the anal area during the night. They are transmitted by: ● Ingesting (swallowing) infectious pinworm eggs ● By entry through the anus

Common nursing diagnosis related to bowel elimination: ● Bowel Incontinence- a change in normal bowel habits characterized by involuntary passage of stool ● Constipation- decrease in the frequency of bowel movements resulting in the passage of hard, dry stool ● Chronic Constipation-constipation that typically lasts 3 months to years ● Fecal Impaction- When dry, hard stool is lodged in the rectum and cannot be passed. ● Risk for Constipation- diagnosis for clients that have an increased risk of constipation due to bedrest, medications such as opioids, or surgery. ● Perceived Constipation- diagnosis for a client who makes a self diagnosis of constipation and uses laxatives, suppositories , or enemas to have a daily bowel movement ● Diarrhea- the passage of loose, unformed, or watery stools ● Gastrointestinal Motility Altercation- a broad label that encompasses increased, decreased, ineffective, or absent peristaltic activity within the GI system Promoting Normal or Regular Defecation:

1. 2. 3. 4. 5. 6.

Provide Privacy Assist with Positioning Consider the Timing of Defecation Support Healthful Intake of Food and Fluid Encourage Exercise Manage Flatulence

Teach Clients When To See a Primary Care Provider ● Blood in the stool (unless they have hemorrhoids and this is an unusual occurrence for them) ● Severe stomach pain ● Change in bowel habits ● Unintended weight loss ● Constipation is not relieved after trying fiber, fluids, and exercise Interventions for Problems with Bowel Diversions What is your Primary Goal? 1. To promote normal bowel function 2. Preserve skin integrity 3. To minimize the patients embarrassment Diarrhea Constipation and Impaction

Bowel Incontinence

Interventions for Problems: Diarrhea ● Preventative Interventions: ○ Hand Hygiene ○ Provide information about foods that can cause diarrhea ○ Probiotics ● Monitoring Interventions ○ Monitor: ■ Stool ■ Fluid Balance ■ Electrolyte Levels ■ Skin Integrity ● Treatment Interventions ○ Diet: ■ Clear liquid/electrolyte replacement ■ Reduce Fiber ■ Limit caffeine ○ Toileting

Interventions for Problems: Constipation and Impaction ● Enemas: introduction of solution into the rectum to soften feces and distend or irritate the colon, to stimulate evacuation of feces ○ Cleansing Enemas ■ “High” and “Low” Enemas ○ Retention Enemas ■ Oil-retention enema ■ Carminative enema ■ Medicated enema

● ● ●

●

■ Nutritive enema ○ Return-Flow Enema Digital Removal of Stool: breaking up hardened mass into pieces and manually removing the pieces. Monitor: ○ Anal fissure, hemorroids, bleeding, rectal ulcers, fecal seepage, severe abdominal pain Diet and Fluid ○ Increase fiber intake ○ Encourage fluid intake Increase physical activity, if possible

Interventions for Problems: Bowel Incontinence 1. Monitor the pattern of their bowel movements to help: a. Designate times for defecation based off of the time of the recent occurrences b. Assist with patients toileting needs i. Examples: providing a bedpan or helping them abulate to the bathroom 2. Monitoring and Avoiding possible skin breakdown, redness or irritation a. Changing soiled clothing and bed linens i. Try absorbent pads to help prevent having to change linens so often 1. Be sure to change the pads as soon as possible! b. Provide hygiene care after every episode of incontinence c. Use products that help boost the skins protection i. Such as moisture barrier products or perineal cleansers Caring For a Patient With Bowel Diversions The Stoma The Ostomy Assess the Output Assess the Skin Helping Patients Adapt to the DIversion Colostomy Irrigation

● ● ● ● ● ●

•

Urinary System Organs The kidneys, ureters, bladder, and urethra help to excrete waste products in the blood and maintain a balance of chemicals and water.

•

Urine Formation During Filtration, blood enters the afferent arteriole and flows into the glomerulus where filterable blood components, such as water and nitrogenous waste, will move towards the inside of the

•

•

•

glomerulus, and nonfilterable components, such as cells and serum albumins, will exit via the efferent arteriole. These filterable components accumulate in the glomerulus to form the glomerular filtrate. The next step is Reabsorption, during which molecules and ions will be reabsorbed into the circulatory system. The fluid passes through the components of the nephron (the proximal/distal convoluted tubules, loop of Henle, the collecting duct) as water and ions are removed as the fluid osmolarity (ion concentration) changes. In the collecting duct, secretion will occur before the fluid leaves the ureter in the form of urine. During Secretion some substances such as hydrogen ions, creatinine, and drugs—will be removed from the blood through the peritubular capillary network into the collecting duct. The end result of all these processes is urine, which is essentially a collection of substances that has not been reabsorbed during glomerular filtration or tubular reabsorption. Process of Urine Elimination When the bladder contains 200 to 450 mL of urine (50 to 200 mL in children): 1. Distention activates stretch receptors in the bladder wall. 2. Stretch receptors send sensory impulses to the voiding reflex center in the spinal cord. 3. Motor impulses then cause the detrusor muscle to contract and the internal sphincter to relax for voiding, also called urination or micturition. 4. When the person is ready to urinate, the brain signals the external sphincter to relax, and urine flows through the urethra. 5. After the detrusor muscle relaxes, the bladder begins to fill with urine again.

Factors that affect Urinary Elimination 1. Developmental factors: Infants and children: • Timing of Toilet Training – Before toilet training can occur, toddlers must be able to control the external urethral sphincter; sense the urge to void; communicate their need to use the toilet; and remove their clothing. • Enuresis- Occasional involuntary passage of urine, normal in children, even in the early school years. • Nocturnal Enuresis- Night-time bedwetting is caused by insufficient level of ADH, pressure on the bladder, urinary infection, and emotional stress. This condition tends to run in families, and most often resolves without treatment. 2. Developmental Factors: Older Adults: • Age related changes in the kidneys - The size and functioning of the kidneys begin to decrease at about age 50, and by age 80, only about two-thirds of the functioning nephrons remain. • Other Physiological Changes of Aging include loss of elasticity and muscle tone in the bladder wall, loss of abdominal and perineal muscle tone in childbearing in woman, and prostate gland enlargement in men. • Drug Toxicity is a risk due to decreased kidney function. • Personal, Sociocultural, and Environmental Factors – anxiety, lack of time, lack of privacy, loss of dignity, and cultural influences • Nutrition, Hydration, and Activity Level – caffeine, alcohol • Medications – Analgesics, diuretics, anticholinergics, antidepressants, antispasmodics, and muscarinic receptor antagonists • Surgery and Anesthesia – Urinary tract surgeries, diagnostic and invasive procedures and childbirth, surgery in the pubic area, vagina, or rectum, surgery on the reproductive organs, and anesthetic agents • Pathological Conditions (disorders of the Urinary System) – Infection or inflammation, kidney stones or tumors, hypertrophy, (diseases in other systems) - cardiovascular and metabolic disorders, nervous system, systemic infection, immobility and impaired communication, and cognitive changes

•

Nursing assessment and Physical examination on urinary elimination To assess urinary elimination, you need the data from the nursing history (this is considered the initial assessment while interviewing the patient, ask open ended questions to receive subjective data since

• •

they may be humiliated regarding urinary issues), physical examination (examination of the system including the kidneys, bladder, urethra, and skin surrounding genitals) , and diagnostic/lab reports (urinalysis testing, blood studies aka blood urethra nitrogen, creatinine levels, and specific gravity of urine  all will be further explained later) Measuring urine output and conducting a variety of bedside tests. * Planning outcomes/evaluation pg 719

Measuring Intake and Output You want to ensure that the patient is comfortable with voiding 500 milliliters (mL) per day **this is the goal** • Record all fluid Input; anything the patient is consuming. (any oil or IV fluids, tube feeding, ice chips) Output; Urine that is voiding out (drainage from any wounds, diarrhea) • Ensure accuracy; Post a sign at the bed side or at the door as a reminder when possible when client assist you with monitoring. ask about this • Measure I&OUsually, the total I&O is collected at the end of each shift, however it varies on facility you work at. • Practice asepsis Use pre caution measures (handwashing, don gloving, collecting specimen, discard gloves, and wash hands) look over lecture about this

1.

2.

3.

4.

5.

6.

7.

Procedures for Obtaining Urine Specimens **Urine Sample Procedures** Urine studies -- Conducted to assess the many urinary system disorders through different urine sample procedures. Freshly Voided Specimen – A specimen that is poured into a specimen container labeled with the patient’s name, the date, and the time of collection. It is then transported to the specimen lab via agency policy. It is usually transported in a container that is moisture proof and any delay with the transportation, it is recommended to refrigerate the specimen. Clean-Catch Specimen – In this procedure the client cleanses their genitalia before voiding, then collect the specimen midstream to have the sample free of contamination from potential initial microbes. Used in many diagnostic tests. Sterile Urine Specimen do not do flashcard on this – This procedure uses a catheter or an indwelling catheter to receive (lecture says REMOVE, not receive) a specimen. You should never disconnect the catheter from the drainage tube to obtain a sample, as it creates a risk of contamination by creating a portal of entry for pathogens. 24-Hour Urine Collection – This procedure is prescribed for some renal disorders by showing kidney function during the day and night. A large container is used to collect and preserve the specimen during the 24-hour time period. (first need to empty their bladder and then the next emptying is when you start the collection) A routine urinalysis (UA) is commonly used as an overall screening test and an aid to diagnose and monitor several health conditions. (send to Lab ASAP) A UA requires a freshly voided sample through the means of a dipstick (bedside testing) or microscopic analysis (done in a lab). A dipstick, or bedside testing, determines the pH and specific gravity and the presence of protein, glucose, ketones, and blood in the urine. Kits are prepared commercially and have specific reagents for each of the tests. The reagent will change color when it comes in contact with the urine. (When patient voids a lot they lose K (potassium)) Specific Gravity – an indicator for urine concentration and can be measured with a reagent strip. When precise measurements are needed, you should use a refractometer instead of a reagent strip.

8. Refractometer -- a quick and easy method of measuring the specific gravity of a urine specimen, only needing a few drops. It measures the refractive index of a beam of light when it passes through urine. If the light is refracted more, concentrations of solids in the urine are higher. Diagnostic Testing for Urinary Elimination Problems 1. A Urinalysis is a diagnostic test that checks for many important characteristics of urine like pH, specific gravity, clarity, odor, protein, glucose, ketones, hemoglobin, bilirubin, bacteria, yeast, and parasites. Full details - (vol 2-592) The diagnostic procedures are usually performed in a operating or radiology room, the nurse prepare a client for the procedures, and assist them with specimen collection, and deliver after care. There are expected findings for each characteristic in a freshly voided sample. Variations to expected characteristics may indicate certain patient conditions based on the assessment of the variation. In other words, the variations will tell you what the patient might be experiencing or if things are normal. If it is looking for color, it could be looking for a dark tea color and if the urine can indicate liver disease. You are expecting the sample to be a pale yellow if they helps you. You can use the sample to look for bacterial parasites and if there is a presence of them, it can indicate UTI. 2. Blood studies: BUN and Creatinine - Tests for Blood urea nitrogen (BUN) and creatinine levels. Normal range for BUN is 8-21 mg/dL and normal range for Creatinine is 0.5-1.2 mg/dl Increased or decreased levels may indicate conditions the patient may have. **Studies of the urinary system can be conducted with direct visualization studies, or indirect visualization studies.** If it is a post procedure care, you are going to monitor vital sign and I&O 3. Direct Visualization Studies include Cystoscopy, and Cystometry. 4. Indirect Visualization Studies include Intravenous Pyelography (IVP) and Retrograde Pyelography, Ultrasonography, Computed Tomography, and Renal Biopsy. *Signed consent is needed for both direct and indirect visualization studies.

•

•

Direct Visualization Studies: A Cystoscopy is a direct visualization of the urethra, ...