Gastrointestinal Issues in Nursing

Diarrhea and Fecal Elimination

• Diarrhea is defined as liquid feces and an increased frequency of defecation
• Causes of diarrhea include:
  • Bowel incontinence, which is the loss of involuntary ability to control fecal and gaseous discharge from the anal sphincter
  • Flatus, which is the production of gas in the large intestine
  • Foods that can cause diarrhea, such as cabbage, onions, and abdominal surgery
  • Narcotics that can slow down bowel movement

Fecal Elimination Problems

• Constipation is defined as fewer than three bowel movements per week
• Characteristics of constipation include:
  • Decreased frequency of defecation
  • Hard, formed stools
  • Straining at stool or painful defecation
  • Reports of rectal fullness or pressure or incomplete bowel evacuation
  • Abdominal pain, cramps, or distention
  • Anorexia, nausea, or headache
• Causes of constipation include:
  • Decreased physical activity
  • Inadequate fluid intake
  • Medications, such as iron supplements, narcotics, and certain antidepressants
  • Poor diet, including low-fiber foods
  • Hormonal changes, such as pregnancy
  • Neurological disorders, such as spinal cord injuries or Parkinson's disease

Nursing Management

• Assessment:
  • Nursing history
  • Physical examination, including inspection, auscultation, percussion, and palpation
  • Inspecting the feces, including color, consistency, shape, amount, odor, and the presence of abnormal constituents
  • Diagnostic studies, including direct and indirect visualization techniques, laboratory tests, and imaging studies
• Diagnoses:
  • Constipation related to deficit knowledge on factors affecting defecation
  • Bowel incontinence
  • Perceived constipation
  • Diarrhea
  • Dysfunctional gastrointestinal motility
  • Risk for constipation or risk for deficient fluid volume and/or electrolyte imbalance
  • Risk for impaired skin integrity
  • Situational low self-esteem
  • Disturbed body image
  • Deficient knowledge
  • Anxiety

Diet and Nutrition

• Fiber:
  • Soluble fiber, such as oats, peas, and apples, which dissolves in water to form a gel-like material and helps lower blood cholesterol and glucose levels
  • Insoluble fiber, such as whole-wheat flour, wheat bran, and nuts, which promotes the movement of material through the digestive system and increases stool bulk
• Daily recommended amount of fiber:
  • Men aged 50 and younger: 38 grams
  • Men aged 51 and older: 30 grams
  • Women aged 50 and younger: 25 grams
  • Women aged 51 and older: 21 grams
• Bland diets and low-fiber foods, such as rice, eggs, and lean meat, move slowly through the intestinal tract and are insufficient to stimulate the reflex for defecation
• Increasing fluid intake can increase the movement of material through the digestive system
• Irregular eating can impair regular defecation
• Spicy foods, excessive sugar, and certain medications can cause diarrhea and flatus in some individuals

Fluid Intake and Output

• Inadequate fluid intake or excessive output, such as urine or vomitus, can lead to constipation
• Healthy fecal elimination requires 2000-3000 mL fluid daily intake
• If chyme moves abnormally quickly through the large intestine, less time is allowed for fluid absorption, and feces become soft and watery

Activity

• Physical activity can stimulate peristalsis and facilitate the movement of chyme along the colon
• Weak abdominal and pelvic muscles are often ineffective in increasing intra-abdominal pressure during defecation or controlling defecation
• Weak muscles can be caused by lack of exercise, immobility, or impaired neurologic functioning
• Bedridden patients often experience constipation due to decreased physical activity

Defecation and Fecal Elimination

• Defecation is the expulsion of feces from the anus and rectum, also known as bowel movement.

Factors that Influence Defecation

• Development:
  • Newborns and infants: Meconium (first fecal material, black, tarry, odorless, sticky) and transitional stool (greenish yellow, containing mucus, loose)
  • Infants: Frequent stool, often after each feeding, due to immature intestine and poor water absorption
  • Toddlers: Control of defecation starts at 1 ½ to 2 years old, with a desire to use the toilet and avoid soiled diapers
  • School-age children and adolescents: Bowel habits similar to adults, with varying frequency, quantity, and consistency
  • Older adults: Prone to constipation due to reduced activity, inadequate fluid and fiber intake, and muscle weakness

Nutrition and Fluids

• Sufficient bulk (cellulose, fiber) provides fecal volume
• Fiber:
  • Insoluble fiber: Promotes movement of material through the digestive system, increases stool bulk (whole-wheat flour, wheat bran, nuts, vegetables)
  • Soluble fiber: Dissolves in water, forms a gel-like material, helps lower blood cholesterol and glucose levels (oats, peas, beans, apples, citrus fruits, carrots, barley, psyllium)
• Daily fiber intake:
  • Men: 38g (ages 50 and younger), 30g (ages 51 and older)
  • Women: 25g (ages 50 and younger), 21g (ages 51 and older)

Responding to the Urge to Defecate

• Timing: Encourage defecation when the urge is recognized
• Gastrocolic reflex: Increased peristalsis of the colon after food enters the stomach, stimulating the urge to defecate

Elimination Problems

• Constipation:
  • Causes: Inadequate fluid intake, lack of exercise, ignoring the urge to defecate
  • Effects: Hard, dry stools, straining during defecation, hemorrhoids, anal fissures
• Diarrhea:
  • Causes: Infections, food poisoning, lactose intolerance, irritable bowel syndrome
  • Effects: Frequent, loose stools, abdominal cramps, dehydration, electrolyte imbalance

Enemas

• Types:
  • Cleansing enema: To cleanse the intestine, prepare for surgery or diagnostic tests
  • Carminative enema: To expel flatus
  • Retention enema: To administer medications, oil, or nutrients to the rectum and sigmoid colon
  • Return-flow enema (Harris Flush): To expel flatus, stimulate peristalsis, and relieve abdominal distension

Intervention Strategies

• Promoting regular defecation:
  • Privacy and comfort
  • Timing: Encourage defecation when the urge is recognized
  • Nutrition and fluids: Encourage a balanced diet, adequate fluid intake, and fiber
  • Exercise: Encourage physical activity, isometric exercises, and pelvic floor exercises
  • Fluid intake and output: Monitor and adjust fluid intake to prevent dehydration or electrolyte imbalance

Elimination

• Defecation is the expulsion of feces from the anus and rectum, also known as bowel movement.
• Normal bowel movement (BM) frequency varies, but it's recommended to go to the toilet 30 minutes after a meal, especially after breakfast, due to the gastrocolic reflex.

Factors Affecting Defecation

• Development: Newborns and infants have immature intestines, leading to frequent, soft, and liquid stools. As they grow, their intestines mature, and stools become less frequent and firmer.
• Lifestyle habits: Lack of exercise, inadequate fluid and fiber intake, and muscle weakness can lead to constipation.
• Diet: Sufficient bulk (cellulose, fiber) provides fecal volume, and fiber is essential for regular bowel movement. There are two types of fiber: soluble and insoluble.
• Insoluble fiber: Promotes the movement of material through the digestive system, increases stool bulk, and is found in whole-wheat flour, wheat bran, nuts, and vegetables.
• Soluble fiber: Dissolves in water, forms a gel-like material, and helps lower blood cholesterol and glucose levels. It is found in oats, peas, beans, apples, citrus fruits, carrots, and barley.
• Daily amount of fiber recommended:
  • Men aged 50 and younger: 38 grams
  • Men aged 51 and older: 30 grams
  • Women aged 50 and younger: 25 grams
  • Women aged 51 and older: 21 grams
• Irregular eating and certain foods can impair regular defecation.

Characteristics of Normal and Abnormal Feces

• Normal stool characteristics: Frequency, quantity, and consistency vary, but a normal BM is usually twice a day.
• Abnormal stool characteristics: Factors affecting defecation, such as constipation or diarrhea, can lead to abnormal stool characteristics.

Planning and Goals

• Maintain and restore normal bowel elimination patterns.
• Prevent associated risks, such as fluid and electrolyte imbalance, skin breakdown, and abdominal distention and pain.

Implementing

• Promoting regular defecation:
  • Provide privacy for the patient.
  • Encourage the patient to defecate when the urge is recognized.
  • Ensure adequate nutrition and fluids.
  • Incorporate exercise, such as isometric exercises, to help strengthen abdominal muscles.
• Managing constipation:
  • Increase daily fluid intake.
  • Encourage the patient to drink hot liquids, warm water with a squeeze of lemon, and fruit juice.
  • Add fiber to the diet, such as raw fruits, bran products, and whole-grain cereals.
• Managing diarrhea:
  • Encourage oral intake of fluids and bland food.
  • Avoid hot or cold fluids and spicy or high-fiber foods.

Nursing Management

• Assessing:
  • Nursing history: Ask the patient about their bowel habits, diet, and lifestyle.
  • Physical examination: Inspect, auscultate, percuss, and palpate the abdominal area, focusing on the intestinal tract.
  • Inspect the feces for color, consistency, shape, amount, odor, and abnormal constituents.
  • Diagnostic studies: Use direct visualization techniques, indirect visualization techniques, and laboratory tests to assess the gastrointestinal tract.
• Diagnoses related to bowel elimination:
  • Constipation
  • Bowel incontinence
  • Diarrhea
  • Dysfunctional Gastrointestinal Motility
  • Risk for Constipation
  • Risk for Deficient Fluid Volume
  • Risk for Electrolyte Imbalance
  • Risk for Impaired Skin Integrity
  • Situational Low Self-Esteem
  • Disturbed Body Image
  • Deficient Knowledge (bowel training, ostomy management)
  • Anxiety