Exam 13 - Elimination and Gastric Intubation

Urinary Elimination

• Urinary elimination is a process that clears the body of waste and helps maintain electrolyte balance.
• Issues with the urinary tract, such as infections, can lead to a health crisis.
• The urinary tract can be affected by problems with the kidneys, ureters, bladder, urethra, or surrounding organs.
• Neurologic deficits also may lead to problems with the urinary system.
• Patients at risk for problems with urine elimination include those who have undergone surgical procedures of the bladder, the prostate, or the vagina; patients with primary urologic problems, such as urethral stricture or tumor; neurologic trauma; and those who are critically ill with multisystem problems.
• A urinary catheter is often ordered to monitor urinary output and the urinary system.

Urinary Catheters

• Most urinary catheters are made of soft plastic or rubber and can be used for treatment and diagnosis.
• Catheters are used to maintain urine flow, to divert urine flow to facilitate healing postoperatively, to introduce medications by irrigation, and to dilate or prevent narrowing of some portions of the urinary tract.
• Catheters are available for intermittent and continuous urinary drainage.
• Urinary catheters can be placed in the bladder, the ureter, or the kidney.
• Catheterization of the bladder involves introducing a rubber or plastic tube (a urinary catheter) through the urinary meatus and the urethra into the urinary bladder.
• Catheterizing the ureters or kidneys is the responsibility of the health care provider.
• Catheters are measured by the French (Fr) system and range in size from 14-Fr to 24-Fr for adult patients.

Types of Catheters

• The type and size of urinary catheter used are determined by the location being catheterized and the cause of the urinary tract problem.
• The coudé catheter has a tapered tip and is used when enlargement of the prostate gland is suspected.
• The Foley catheter has a balloon near its tip that is inflated after insertion to hold the catheter in the urinary bladder for continuous drainage.
• Malecot and de Pezzer (mushroom) catheters are used to drain urine from the renal pelvis of the kidney.
• Robinson catheter has multiple openings in its tip to facilitate intermittent drainage.
• Catheters designed to be inserted into the ureters are long and slender to pass into the ureters more easily.
• In patients with blood in their urine, a whistle-tip catheter may be used because it has a slanted, larger orifice at its tip.
• The cystostomy, the vesicostomy, or the suprapubic catheter is inserted through the abdominal wall above the symphysis pubis to create a urinary diversion in cases of obstruction, strictures, or injury to the bony pelvis, the urinary tract, or surrounding organs.
• This catheter is inserted surgically, is connected to a sterile closed drainage system, and is secured to avoid accidental removal; the wound is covered with a sterile dressing.
• When the lower urinary tract has healed, the patient’s ability to void is tested, and when the patient’s residual urine is low enough, according to the health care provider, the catheter can be removed.
• The condom, or Texas, catheter is a drainage system connected to the external male genitalia, not a catheter.
• This noninvasive appliance is used for incontinent men to minimize skin irritation from urine.
• It is important to remove this appliance daily for cleansing and inspection of the skin.
• Use of the external condom catheter allows for a more normal lifestyle for the patient and limits the risk for infection that an indwelling catheter may cause.

Nursing Interventions

• Nursing interventions for the patient with a urinary drainage system are aimed at early detection and prevention of infection and trauma.
• Follow aseptic technique when inserting the catheter, and keep the collecting bag off the floor. This prevents the introduction of microorganisms into the body from the environment.
• Record fluid intake and urinary output (I&O), and check the drainage system for proper placement and function regularly. For precision monitoring, such as hourly urine output, add a urometer to the drainage system.
• Encourage the patient to drink plenty of fluids to flush the urinary tract.
• Do not open the drainage system after it is in place except to irrigate the catheter, and then only with a specific order from the health care provider.
• Perform catheter care twice daily and as needed, according to standard precautions. Inspect insertion site for blood or exudate that could indicate infection or trauma.
• Check the drainage system daily for leaks.
• Avoid placing the urinary drainage bag above the level of the catheter insertion.
• Secure the catheter to the patient to prevent tension on the system or backflow of urine.
• Have the patient ambulate, if possible, to facilitate urine flow.
• Avoid kinks or compression of the drainage tube to prevent pooling of urine within the system. Gently coil excess tubing and secure to the bottom bed linens with a clamp or pin to avoid dislodging the catheter.
• When urine specimens are ordered, collect specimens from the catheter by cleansing the drainage port with alcohol, then withdrawing the urine by using a sterile needle and 10-mL syringe according to standard precautions.
• Be sensitive to the patient’s feelings regarding the catheter and the constant drainage from the system, and answer patient’s questions and concerns when presented.

Self-Catheterization

• Self-catheterization is a potential option for the patient who has had a spinal cord injury or other neurologic disorders that interfere with urinary elimination.
• Intermittent self-catheterization promotes independence for the patient and eliminates the need for an indwelling urinary drainage system.
• In the home, there are fewer foreign microorganisms and therefore less risk of cross-contamination.
• It is necessary to instruct the patient to be alert for signs of infection, and the patient should be encouraged to have periodic evaluations by the health care provider.

Routine Catheter Care

• Patients should receive routine catheter care and perineal hygiene at east every 8 hours to prevent urinary tract infections.
• During catheter care, cleanse the first 2 inches of the catheter to remove any secretions or encrustations from the catheter.
• Look for inflammation at and around the urethral meatus and check for swelling or discharge from the urethra.
• Some facilities discourage the use of powders and lotions in the perineal area of patients with catheters because these can lead to the growth of microorganisms that could enter the urinary tract and cause urinary tract infections.
• Perform perineal and catheter care after bowel movements, especially if the patient is incontinent of stool.
• If a catheter strap or adhesive tape is used to secure the tubing to the abdomen or leg, it should be replaced after catheter care is given.
• If the tubing and collection device must be changed because of leakage, odor, or collection of sediment in the tubing or collection device, follow sterile technique.
• If patency of the catheter itself becomes interrupted by mucus, blood clots, or sediment, catheter irrigation may be necessary. This procedure requires a physician’s order in most facilities.

Catheter and Perineal Care

• Encourage patients to report any symptoms immediately.
• Instruct the patient on preventing UTIs by keeping the drainage bag below the bladder level.
• Discourage the use of lotions or powder during perineal care.
• Encourage using a leg bag during the day and a bedside drainage bag at night.
• Instruct patients to wear loose-fitting clothing to promote adequate drainage.
• Teach the patient about possible side effects from an indwelling catheter and to report them immediately.

Kegel Exercises

• Teach patients to perform Kegel exercises by trying to stop the flow of urine during voiding.
• Once patients correctly identify the muscles, they can perform these exercises by tightening the perineum muscles, holding for 10 seconds, and relaxing for 10 seconds, repeating multiple times daily.

Incontinence

• Incontinence is the inability to control urine or bowel elimination.
• Urinary incontinence can occur due to excess bladder pressure or weak sphincters.
• Stress incontinence involves leakage when laughing, coughing, or lifting heavy objects; urge incontinence involves constant leakage.
• Fecal incontinence can result from diarrhea or constipation, muscle/nerve damage, rectocele, or inactivity.

Bladder Training

• Bladder training focuses on regaining voluntary control over urination, often by strengthening perineal muscles.
• Before removing a urethral catheter, bladder training may involve a clamp-unclamp routine to improve bladder tone.
• Kegel exercises can also be used as part of a bladder training regimen to improve perineal muscle tone and sphincter control.
• Habit training involves establishing a voiding schedule, such as every 1.5 to 2 hours.
• Typical voiding times include upon rising, before each meal, and before bed.

Removal of Indwelling Catheter

• It's best to remove an indwelling catheter as soon as possible to reduce the risk of UTI.
• Catheters typically remain in place for 8 to 24 hours after surgery.
• The longer a catheter is in place, the greater the risk of infection.
• Symptoms of UTI may not appear for 2 or more days after removal, so patients should be informed about the risk and signs to watch for.
• Patients may experience difficulty voiding after catheter removal due to weakened sphincter muscles.
• Patients should void adequately within 8 hours of removal; if not, notify the health care provider.

Patient Teaching for Catheter Removal

• Explain that the bladder will take time to regain control.
• Teach patients how to collect and measure urine output.
• Explain the importance of drinking at least 2 liters of fluids daily to prevent UTI (unless contraindicated).
• Inform patients that it's normal to feel some burning or discomfort when first voiding.
• Emphasize the importance of reporting side effects immediately.
• Advise patients to limit over-the-counter medications like nasal decongestants or anticholinergics (e.g., diphenhydramine) that may cause urinary retention.

Nasogastric (NG) Tube Insertion and Maintenance

• NG tubes are flexible, hollow tubes inserted through the nasopharynx into the stomach.
• Uses include removing gas, fluids, or toxic substances; diagnosing gastrointestinal problems; administering fluids and nutrients; and preventing vomiting and abdominal distention.
• Types of NG tubes include percutaneous endoscopic gastrostomy (PEG), Button, and jejunal tubes.
• The physician determines the most appropriate tube for the patient.

Gastric Gavage

• Gastric gavage involves delivering fluids or nutrients through an NG tube.
• The head of the bed should be elevated at least 30 degrees to prevent aspiration or gastric reflux.
• Feedings should be started slowly and gradually increased to prevent dumping syndrome.

Gastric Lavage

• Gastric lavage is often used in cases of poisoning or to stop gastrointestinal bleeding.
• It involves instilling room-temperature medications or solutions into the stomach and then suctioning them back out.
• Iced or cooled solutions should not be used to avoid hypothermia, platelet impairment, and increased bleeding.

Gastric Decompression

• Gastric decompression removes air and fluids that accumulate when gastrointestinal motility is slowed.
• Often used after surgery to prevent abdominal distention, nausea, and vomiting.
• The NG tube is connected to intermittent gastric suction, and the nurse must regularly measure and evaluate suction canister contents.

Nursing Considerations for NG Tubes

• Maintain patient comfort by securing the tube properly and using comfort measures like lubrication and mouth care.
• Maintain tube patency by irrigating regularly with normal saline and a syringe.
• Monitor for residual feeding and report excess to the health care provider to prevent complications.

Bowel Elimination

• Bowel elimination is a basic human need essential for normal bodily function.
• Normal bowel elimination requires a balanced diet rich in fiber, adequate fluid intake (2000-3000 mL daily), and regular activity to promote muscle tone and peristalsis.
• Each person has an individual defecation pattern, but everyone should have a bowel movement at least every 1 to 3 days.
• Encourage patients to heed the urge to defecate and provide privacy to promote normal bowel function.
• Be aware of patient habits that may affect normal bowel function, such as long-term laxative use.

Patient Teaching for Gastric Tube Insertion

• Explain the purpose of the NG tube to the patient and family.
• Teach patients and families how to care for the NG tube at home.
• Explain and demonstrate proper mouth care to maintain moist mucous membranes.
• Explain the insertion technique and potential sensations to the patient.
• Address any patient questions and concerns.
• Ensure adequate lubrication of the tube to minimize discomfort.

Promoting Normal Bowel Elimination

• Establish a routine time for defecation and encourage patients to heed the urge.
• Allow patients to sit on a commode or in a Fowler’s position while in bed.
• Be aware of detrimental habits, such as long-term laxative use, and encourage patients to avoid them.
• Encourage patients to adopt their own rituals to facilitate bowel elimination.

Lifespan Considerations for Bowel Elimination in Older Adults

• Monitor heart rate and rhythm closely due to the risk of dysrhythmias related to vagal stimulation during defecation.
• Encourage older adults to increase dietary fiber intake (6-10 g per day) and establish a regular toileting routine.
• Keep a diary of meals and fluid intake to identify potential contributing factors to constipation.
• Provide education and support for older adults with constipation.

Bowel Elimination

• Encourage activity as tolerated to help maintain peristalsis and help prevent constipation.

Hemorrhoids

• Hemorrhoids are swollen and inflamed veins in the anus and lower rectum.
• Hemorrhoids can be internal (inside the rectum), or external (around the anus).
• Hemorrhoids are often a source of discomfort and can cause changes in elimination.
• Treatment goals for hemorrhoids:
  • Decrease pain
  • Prevent elimination problems
  • Prevent damage to the already swollen tissue.
• Patient management for hemorrhoids:
  • Maintain a proper diet high in fiber.
  • Ensure adequate fluid intake.
  • Participate in regular exercise.
  • Sitz baths or witch hazel pads can provide relief.
• Use caution when inserting rectal suppositories for patients with hemorrhoids:
  • Use liberal amounts of lubricant during insertion to prevent pain or trauma to the rectal tissue.
• Avoid using rectal thermometers or rectal tubes in patients with hemorrhoids.

Flatulence

• Flatulence refers to the presence of air or gas in the intestinal tract, typically caused by:
  • Consuming gas-producing foods and beverages (carbonated beverages, cabbage, beans).
  • Swallowing excessive amounts of air.
  • Constipation.
  • Decreased peristalsis.
  • Abdominal surgery.
  • Narcotic medications.
  • Decreased physical activity.
• Flatulence can cause abdominal distention and discomfort, which may be mild to moderate, and accompanied by abdominal cramping.
• Patient management for flatulence:
  • Encourage ambulation to promote peristalsis and passing of flatus.
  • If ambulation does not help relieve flatulence, a rectal tube may be needed.

Enemas

• Enemas are the instillation of a solution into the colon via the anus.
• Indications for enemas:
  • Promote defecation in a patient with constipation.
  • Cleanse the colon before a diagnostic procedure or abdominal surgery.
  • Manage constipation or fecal impaction.
  • Administer medication
• Types of enemas:
  • Cleansing enemas: Large volume, stimulate peristalsis, used to completely empty the colon (before surgery or a GI diagnostic procedure).
  • Oil retention enemas: Used to soften the stool and lubricate the bowel, make defecation easier, used when a fecal impaction is suspected.
  • Medicated enemas: Used for a variety of reasons, most frequently to bring down an extremely high potassium level (polystyrene sulfonate [Kayexalate] enema).
• Cautions with Enema Use:
  • Limit the number of enemas.
  • Repeated use can cause constipation, as the defecation reflex can become dependent on enemas.

Ostomies

• Ostomies are an artificial opening.
• The opening is called a stoma.
• Reasons for ostomies:
  • Trauma to the intestine.
  • Severe inflammation.
  • Diseases such as cancer, that involve part of the intestine.
• Characteristics of ostomy output:
  • ileostomy output is liquid, rectal output is solid.
  • Stoma location determines the consistency of the output
  • Fecal material in the ileum, cecum, and ascending colon tends to be more acidic and irritating to the skin.
  • As the stool moves through the large intestine, water is removed, making it more solid and less acidic, causing less irritation.

Types of Ostomies

• Ileostomy: Opening in the ileum, needed when the entire colon must be removed or bypassed.
• Colostomy: Surgical creation of a stoma on the abdominal wall.
• Urostomy: Diversion of urine away from a diseased or defective bladder through a surgically created opening in the skin.

Colostomy Care

• Two types of pouching systems:
  • One-pouch systems (pre-attached skin barrier and pouch)
  • Two-piece systems (separate pouch and wafer)
• When cutting skin barriers to fit the stoma:
  • Ensure the ostomy appliance opening is small enough to form a proper seal, 1/16 inch larger than the stoma.
  • Appliance must not cause pressure on the stoma (risk of pressure sore and potential gangrene)
• Colostomy irrigation:
  • Sometimes used to maintain a regular elimination pattern.
  • Requires special equipment and can have complications.
  • Equipment needed for irrigation:
    • Cone-tipped irrigation device
    • Irrigation sleeve
    • Irrigation solution
  • Procedure:
    • Place cone-tipped irrigation device into the stoma through the sleeve (to contain drainage).
    • Instill approximately 500 to 1000 mL slowly into the stoma.
    • Patient sits on the commode while the irrigation drains (approximately 30 minutes).
  • Complications of colostomy irrigation:
    • Bowel damage or perforation, leading to peritonitis.
    • Tissue damage from solution temperature.
    • Fluid and electrolyte imbalances.

Ostomy Considerations in Older Adults

• Evaluate the older adult’s cognitive status and ability to understand ostomy self-care instructions.
• Evaluate the older adult’s motor and visual ability to prepare ostomy equipment.
• Consider having barriers precut for patients who are unable to custom-cut their own.
• Avoid hot water and harsh soaps when washing the skin around the ostomy.
• Teach patients that the number of bowel movements may change daily depending on irrigation schedules.
• Cost of ostomy supplies and reimbursement are often concerns for older adults; refer to community resources as needed.

Patient Teaching for Ostomy Care

• Include family members or significant others in teaching.
• Use every pouch change as an opportunity to teach.
• It is not necessary to force the patient to look at the stoma; allow for a period of adjustment.
• Reinforce positive performance.
• If the patient is apprehensive about touching or looking at the stoma, have them hold a gauze pad over the stoma and clean around it.
• Some patients acknowledge a stoma with minimal emotional difficulty; some never completely adjust. Individualize care according to the patient’s situation and circumstances.
• Teach the patient to avoid constipation:
  • Eat a balanced diet or use a daily stool softener.
• Select a pouching system that can be easily managed for patients with limitations affecting dexterity.
• Provide a teaching manual or audiotaped instructions for patients with learning disabilities.
• Give the patient a list of equipment supplies and their contact information.
• Instruct patients to avoid leaving pouches in extremely hot or cold locations.

Patient Teaching for Urostomy Care

• Teach the patient to avoid touching the stoma with adhesive solvents to prevent irritation.
• Teach the patient to wick the urine with an absorbent, lint-free material to prevent leakage while changing the appliance.
• Teach the patient to remove hair from the stoma area with scissors or an electric razor.
• Teach the patient that the appliance should be able to remain in place 3 to 5 days.
• Teach the patient to empty the appliance through the drain valve when it is one third to one half full to prevent the weight of the urine from loosening the seal.
• Teach the patient to connect the appliance to a urine-collection container at night to prevent urine from stagnating.
• Teach sanitary and dietary measures to protect the skin around the ostomy and control odor.
• Offer positive reinforcement, written instructions, and videos.

Coordinated Care

• Applying a pouch to a fresh stoma requires the critical thinking and knowledge of a nurse.
• In some facilities, stoma nurse specialists are available to provide care.
• UAP who provide personal care are instructed to report any leakage of urine, breakdown of skin, and changes in the stoma to the nurse.
• The skill of irrigating a newly established colostomy requires the critical thinking and knowledge of a nurse.

### Home Care Considerations

• Consult with the health care provider to obtain a home health agency or visiting nurse referral before hospital discharge.
• Pouches that wear well in the hospital may not wear well when the patient resumes a normal routine.
• If an irrigation routine is required, assist the patient to adapt the procedure to the home setting.
• Ostomy products are usually available for purchase at local pharmacies.
• Encourage the patient to become involved with local ostomy organizations.
• Teach the patient to routinely inspect the stoma and the surrounding skin.
• Instruct patients not to flush ostomy pouches and barriers down the toilet, as they clog the pipes.
• Review the patient’s dietary pattern and help them learn types of foods to avoid to prevent problems with stoma drainage or odor.
• If water is not drinkable, it should not be used for irrigations.
• Evaluate the patient’s home toileting facilities:
  • Presence of adequate functioning and accessible toileting facilities
  • Number and location of toileting facilities
  • Number of other people living in the home who have to share the toileting facilities
  • The pattern of use of the toileting facilities by the other people living in the home (time of day and amount of time spent in bathroom)
• Evaluate the patient’s ostomy routine in relation to his or her usual lifestyle after discharge.
• Make sure the patient understands that it is not necessary to use sterile gauze to cleanse the stoma; using a washcloth is fine.

Urinary Catheters

• Urinary catheters are used to maintain, divert, and introduce medications into the urinary tract.
• Catheters are made of soft plastic or rubber and can be used for both treatment and diagnosis.
• Catheters are used for both intermittent and continuous urinary drainage.

Catheterization

• Most urinary catheters are placed in the bladder.
• The process of inserting a catheter into the bladder is usually the responsibility of the nurse.
• Ureter and Kidney catheterization is the responsibility of a healthcare provider.

Types of Urinary Catheters

• The type and size of urinary catheter used depends on the location and cause of the urinary tract problem.
• A Coudé catheter has a tapered tip and is used when an enlarged prostate gland is suspected.
• A Foley catheter has a balloon near its tip that is inflated after insertion to hold the catheter in place for continuous drainage.
• Malecot and de Pezzer (mushroom) catheters drain urine from the renal pelvis of the kidney.
• Robinson catheters, designed for intermittent drainage, have multiple openings in their tip.
• Cystostomy, vesicostomy, or suprapubic catheters are inserted through the abdominal wall above the symphysis pubis for urinary diversion in cases of obstruction, strictures, or injury.
• Condom catheters (Texas catheters), not a true catheter, are drainage systems connected to the external male genitalia used for incontinent men.

Nursing Interventions for Urinary Drainage Systems

• Aseptic technique is crucial during catheter insertion and when handling the drainage bag.
• Fluid intake and output (I&O) should be carefully monitored.
• Catheter care should be performed twice daily and as needed, observing insertion sites for signs of infection.
• The drainage bag should always be kept below the level of the catheter insertion to prevent backflow of urine.
• Urine specimens should be collected aseptically from the drainage port with a sterile needle and syringe.
• Ambulation should be encouraged to facilitate urine flow.

Lifespan Considerations

• Older adults with catheters are at increased risk for urinary tract infections (UTIs) and septicemia.
• Frequent ambulation is important for older adults with catheters.
• Intermittent self-catheterization may be an option for some older adults.

Self-Catheterization

• A potential option for patients with spinal cord injuries or neurologic disorders.
• Promotes independence and eliminates the need for indwelling catheters.
• Can be performed with clean technique in the home setting.

Routine Catheter Care

• Should be performed at least every 8 hours to prevent UTIs.
• Includes cleansing the first 2 inches of the catheter and inspecting the urethral meatus.
• Perineal care should be performed after bowel movements, especially if the patient is incontinent of stool.
• Catheter irrigation may be necessary if the catheter becomes obstructed.

Incontinence and Its Management

• Urinary incontinence can be caused by bladder pressure being too great or sphincters being too weak.
• Stress incontinence involves small urine leakage during activities like laughing, coughing, or lifting.
• Urge incontinence involves a constant leakage.
• Fecal incontinence can result from diarrhea, constipation, muscle weakness, nerve damage, or inactivity.

Bladder Training

• Involves developing voluntary control over voiding.
• Kegel exercises improve perineal muscle tone and sphincter control.
• Habit training involves establishing a regular voiding schedule.

Removal of an Indwelling Catheter

• Should be removed as soon as possible to reduce the risk of UTIs.
• Patients may have difficulty voiding after removal, especially with an overdistended bladder or altered sensory perception.
• It is crucial to inform patients of the risk of infection and instruct them on how to prevent it.

Patient Teaching: Urinary Bladder Control

• It takes time for the urinary bladder to regain voluntary control following procedures or medical conditions affecting the bladder.
• Patients should measure and collect urine output to monitor bladder function.
• Patients should drink at least 2 liters of fluid daily unless contraindicated, to prevent urinary tract infection.
• Some burning sensation or discomfort when voiding is common initially.
• Report any side effects to the healthcare provider immediately.
• Avoid over-the-counter medications like nasal decongestants and anticholinergics, as they can cause urinary retention.

Nasogastric (NG) Tube

• An NG tube is a flexible tube inserted into the stomach through the nasopharynx.
• Used for removing gas, fluids, or substances from the stomach, diagnosing gastrointestinal problems, obtaining secretions, and administering fluids and nutrients.
• Helps prevent vomiting and abdominal distention while allowing the digestive tract to rest and heal.
• Various types of NG tubes exist, and the physician determines the best type for the patient.
• During feeding, keep the head of the bed elevated to 30 degrees to prevent aspiration or reflux.
• Start tube feedings slowly and increase gradually to avoid dumping syndrome.
• Verify NG tube placement before administering anything through it.
• Check residual feeding regularly to monitor peristalsis and prevent complications.
• Gastric lavage involves instilling medications or solutions into the stomach and suctioning them out.
• Use room temperature solutions for lavage, and avoid iced or cooled solutions, especially in large amounts.

Gastric Decompression

• Aims to remove air and fluids from the stomach when gastrointestinal motility is impaired.
• Commonly used after surgery to prevent distention, nausea, and vomiting.
• NG tube is connected to intermittent gastric suction, and the nurse measures and evaluates the suction canister contents.
• Maintain patient comfort by securing the NG tube properly and providing mouth care.
• Ensure patency of the NG tube by irrigating it regularly with normal saline.
• States and facilities vary regarding who can insert and manage NG tubes.
• Nursing responsibilities include tube management, administering feedings, and removing the tube under proper guidelines.

Bowel Elimination

• Normal bowel elimination requires a balanced diet, high fluid intake, and exercise for muscle tone and peristalsis.
• Each patient has an individual defecation pattern, but at least one bowel movement every 1 to 3 days is expected.
• Establish a routine defecation time and encourage the patient to respond to their urge.
• Provide privacy and ensure a comfortable position for defecation.
• Be attentive to patient habits that may affect bowel function, such as excessive laxative use.
• Monitor older adults closely for heart rhythm changes associated with defecation.
• Encourage increased fiber intake and regular activity in older adults to prevent constipation.

Hemorrhoids

• Swollen and inflamed veins in the anus and lower rectum, often caused by straining, pregnancy, or heavy lifting.
• Can be internal or external, causing discomfort and potential alterations in bowel elimination.
• Goal for patients with hemorrhoids is to reduce pain, prevent elimination issues, and protect inflamed tissue.
• Encourage high-fiber diet, adequate fluid intake, and regular exercise.
• Sitz baths or witch hazel pads can provide relief.
• Use caution when inserting rectal suppositories and avoid rectal thermometers or tubes.

Flatulence

• Presence of air or gas in the intestines, caused by gas-producing foods, air swallowing, constipation, or medical conditions.
• May cause abdominal distention and discomfort.
• Encourage ambulation to promote peristalsis and gas passage.
• If flatulence persists, a rectal tube may be used to stimulate peristalsis and gas elimination.

Enemas

• Instillation of a solution into the colon via the anus.
• Primarily used to promote defecation in constipated patients.
• Cleansing enemas stimulate peristalsis by introducing large volumes of fluid.
• Oil retention enemas soften stool and lubricate the bowel.
• Medicated enemas are used for specific purposes, such as managing high potassium levels.
• Limit the frequency of enema use to avoid dependency and potential constipation.

Ostomies

• Artificial openings created on the abdominal wall.
• Can be temporary or permanent depending on the reason for creation.
• Stoma location determines the characteristics of fecal material.
• Ileostomy is an opening in the ileum, used for permanent or temporary colon removal or bypass
• Colostomy is an opening in the colon, used for conditions affecting the colon.
• Urostomy diverts urine from the bladder, often used for congenital anomalies or bladder removal.
• Ensure patient education regarding ostomy care, pouch systems, skin barriers, and appropriate product use.

Skin Barrier Care

• When fitting skin barriers over a stoma, the opening should be 1/16 inch larger than the stoma to ensure a proper seal.
• Pressure on the stoma should be avoided due to its blood and nerve supply, despite a lack of sensation.
• An ill-fitting appliance can cause pressure sores and lead to gangrene.

Colostomy Irrigation

• Used to help maintain a regular elimination pattern, but less frequently now, as many patients have regular bowel movements without irrigation.
• Irrigating a colostomy requires 60 to 90 minutes per day in the bathroom.
• Requires special equipment including a cone-tipped irrigation device, an irrigation sleeve, and irrigation solution or access to tap water.
• About 500 to 1000 mL of solution is slowly instilled into the stoma.
• The patient must sit on the commode for approximately 30 minutes as it drains out.
• Complications can include:
  • Damage or perforation of the bowel, potentially leading to peritonitis.
  • Tissue damage due to the temperature of the irrigating solution.
  • Fluid and electrolyte imbalances if too much tap water is used.

Older Adult Ostomy Care Considerations

• Evaluate older adults' cognitive status and ability to understand ostomy care instructions.
• Assess older adults' motor and visual capabilities related to preparing ostomy equipment.Consider precut barriers from suppliers or precut two-piece systems for individuals unable to custom cut barriers.
• Avoid hot water and harsh soaps when washing the skin around the ostomy.
• Educate patients on potential changes in the number of daily bowel movements, as irrigation routines might not be daily, leading to varying bowel movement patterns.
• Address cost concerns with ostomy supplies and reimbursement, potentially referring them to community resources.

General Patient Teaching for Ostomy Care

• Include family or significant others in teaching to increase patient readiness to learn.
• Use every pouch change as a teaching opportunity, even if the patient seems uninterested.
• Do not force patients to look at their stoma, allowing time for adjustment.
• Reinforce positive performance.
• Recognize some patients may need time to accept their ostomy and participate in care.
• Gauge patient readiness to learn based on their willingness to look at their stoma and ask questions.
• If apprehensive about touching or looking at the stoma, have the patient hold a gauze pad over it and clean around the stoma.
• Individualize care based on the patient's situation and circumstances.
• Teach patients to avoid constipation by maintaining a balanced diet or using a daily stool softener.
• Select an easily managed pouching system for patients with dexterity limitations.
• Provide a teaching manual with clear steps or audiotaped instructions.
• Picture books depicting ostomy care steps can be helpful for patients with learning disabilities.
• Give patients a list of equipment, and the name, address, and phone number of a supplier in their community.
• Patients can usually wear normal clothes; snug clothing does not interfere with ostomy function.
• Instruct patients to avoid storing pouches in extremely hot or cold environments as temperature can affect barrier and adhesive materials.

General Patient Teaching for Urostomy Care

• Teach patients and caregivers to avoid touching the stoma with adhesive solvents to prevent irritation.
• Teach patients and caregivers to wick urine with an absorbent, lint-free material to prevent a constant flow of urine during appliance changes.
• Teach patients and caregivers to remove hair from the stoma area with scissors or an electric razor to avoid irritation when removing the pouch.
• Teach patients and caregivers that the appliance should stay in place for 3 to 5 days.
• Teach patients and caregivers to empty the appliance through the drain valve when it is one-third to one-half full to prevent the weight of urine from loosening the seal.
• Teach patients and caregivers to connect the appliance to a urine collection container at night to prevent urine stagnation.
• Teach patients and caregivers about sanitary and dietary measures to protect the skin and control odor.
• Offer positive reinforcement, written instructions or videos.

Coordinated Care for Ostomy Care

• Applying a pouch to a fresh stoma needs a nurse's critical thinking and knowledge. Some facilities allow delegation of pouching an established ostomy.
• Instruct care providers on expected drainage amount, color, and consistency.
• Teach care providers to report changes in the stoma and surrounding skin integrity.
• Applying a pouch to an incontinent urinary diversion requires a nurse's critical thinking and knowledge. Some facilities have a stoma nurse specialist for this care.
• Unlicensed assistive personnel (UAP) providing personal care should report any urine leakage and skin breakdown to the nurse.
• Irrigating a newly established colostomy needs a nurse's critical thinking and knowledge. In some settings, UAP are trained to perform irrigations on established ostomies; review facility policies.

Home Care Considerations for Ostomy Care

• Consult with the health care provider to obtain a referral to a home health agency or visiting nurse before hospital discharge.
• Products that perform well in the hospital setting might not perform as well at home.
• Assist patients in adapting irrigation routines to the home setting.Consider hanging the irrigation solution container from a hook on the wall or a shower curtain rod instead of an IV pole.
• Urostomy, colostomy, and ileostomy products are usually sold at local pharmacies.
• Encourage patients to join local ostomy organizations.
• Teach patients and caregivers to routinely inspect the stoma and surrounding skin.
• A healthy stoma is moist, shiny, and dark pink to red with minimal bleeding.
• Teach patients and caregivers to report excessive bleeding, abnormal color, or swelling to the nurse or health care provider.
• Teach patients and caregivers to avoid using alcohol around the stoma, as it dilates capillaries causing bleeding and can excessively dry the skin.
• Teach patients and caregivers not to use lotions or creams around the stoma, as they can prevent pouch adhesion.
• Teach patients and caregivers not to use peroxide on or around the stoma as it can irritate the tissue.
• Instruct patients and caregivers to wash the skin around the stoma with mild soap and water, rinsing thoroughly; soap can be irritating.
• Pat or blot the skin dry.
• Evaluate patients' home toileting facilities:
  • Ensure adequate functioning and accessible toileting facilities.
  • Assess the number and location of toileting facilities.
  • Consider the number of other people sharing the toileting facilities.
  • Evaluate the toilet use pattern of others in the home (time of day and duration).
• Evaluate the patient's ostomy routine in relation to their usual lifestyle after discharge.
• Caution patients against flushing ostomy pouches and barriers down the toilet as they clog pipes. Dispose of used pouches according to local sanitation regulations.
• Ensure patients understand that sterile gauze is not needed to cleanse the stoma; any soft washcloth is suitable.
• Review the patient's dietary pattern and teach the patient and family about foods to avoid to prevent stoma drainage or odor problems.
• Teach patients that if the water is not drinkable, it should not be used for irrigations (e.g., when traveling to another country).

Test your knowledge on essential nursing procedures, particularly relating to patient care, catheterization, and infection prevention. This quiz covers crucial topics and steps involved in ensuring patient safety and effective care before, during, and after medical procedures.