8.ii) BOWEL ELIMINATION.docx

Sri Rahaya Nafitri Abdul Razak (U6240037) **ELIMINATION** **Learning Outcomes** After completing this topic students will be able to: 1. Distinguish normal from abnormal characteristics and constituents of feces 2. Identify factors that influence fecal elimination and patterns of defe...

Sri Rahaya Nafitri Abdul Razak (U6240037) **ELIMINATION** **Learning Outcomes** After completing this topic students will be able to: 1. Distinguish normal from abnormal characteristics and constituents of feces 2. Identify factors that influence fecal elimination and patterns of defecation 3. Identify common causes and effects of selected fecal elimination problems 4. Describe methods used to assess fecal elimination 5. Identify interventions for patients with elimination problems 6. Identify measures that maintain normal fecal elimination patterns 7. Describe the purpose and action of commonly used enema solutions 8. Demonstrate the steps used in: - Administering an enema 9. Demonstrate appropriate documentation and reporting related to fecal elimination I. **DEFECATION** - The expulsion of feces from the anus & rectum/bowel movement II. **CHARACTERISTICS OF NORMAL AND ABNORMAL FECES** III. **FACTORS THAT AFFECT DEFECATION** 1. Development - Newborns and infants - Meconium: first fecal material from newborn (24 hrs after birth), its black, tarry, odorless, sticky - Transitional stool followed about a week, greenish yellow, contain mucus and are loose - Infant pass stool frequently, often after each feeding, bcz intestine immature, water is not absorp well, stool soft, liquid, frequent - When intestine matures, bacteria flora increase - After solid food introduces, stool become less frequent, firmer - Infants who are breast feed have yellow to golden feces, infant taking formula have dark yellow/tan stool - Toddlers - Control of defecation starts at 1 ½ to 2 y/o, start learn walk and the nervous & muscular system well developed to permit bowel control - A desire control daytime bowel movement and to use the toilet starts when the child becomes aware of the discomfort caused by soiled diaper and the sensation that indicates the need for a bowel movement - Daytime control is typically attained by age 2 ½ y/o after toilet training - School-age children and adolescents - Bowel habits same like adults - Patterns defecation vary in frequency, quantity, consistency - Some may delay because of activity; play - Older adult - Mostly had suffered from constipation, due to reduce activity level, inadequate fluid and fiber intake, muscle weakness - Normal BO is twice a day - Prevent constipation; increase fiber intake, adequate exercise, 6-8 glasses of fluid daily or hot water/tea regularly in morning would help - Gastrocolic reflex (increased peristalsis of the colon after food has entered the stomach). Ex; toileting is recommended 30 mins after meal, especially after breakfast; gastrocolic reflex more stronger - Consistent use laxatives; inhibit natural defecation reflex, interfere body's electrolyte balance, decrease the absorption of certain vitamins - The reason for constipation can range from lifestyle habits ex; lack of exercise lead to serious malignant disorder ex; colorectal disorder - Change bowel habits over several weeks with or without weight loss, pain, fever shoul informed medical provider  2. Diet - Sufficient bulk (cellulose, fiber) can provide fecal volume - Fiber; soluble fiber and insoluble fiber - Insoluble fiber promotes the movement of material through the digestive system n increase stool bulk; whole-wheat flour, wheat bran, nuts, vegetables - Soluble fiber dissolves in water to form a gel-like material, helps lower blood cholesterol n glucose levels; oats, peas, beans, apples, citrus fruits, carrots, barley,psyllium - Daily amount fiber; - Men ages 50 n younger: 38grams - Men ages 51 n older: 30grams - Women ages 50 n younger: 25grams - Women ages 51 n older: 21grams - Bland diets and low fiber food (rice, eggs, leans meat move slowly through intestinal tract) is insufficient to stimulate the reflex for defecation - Increasing fluid intake increase the movement - Irregular eating can impair regular defecation - Spicy food, excessive sugar can cause diarrhea and flatus in some individuals - Food can influence bowel elimination: - Gas-producing foods; cabbage, onions, cauliflower, bananas, apples - Laxatives-producing foods; bran, prunes, figs, chocolate, alcohol - Constipation-producing foods; cheese, pasta, eggs, lean meal 3. Fluid intake and output - Fluid intake inadequate or output e.g; urine or vomitus is excessive for some reasons, body continues to reabsorb fluid from the chyme as it passes along the colon - The chyme becomes drier than normal, feces become hard - Healthy fecal requires 2000 to 3000mL fluid daily intake - If chyme moves abnormally quickly through large intestine, less time for fluid absorbed into blood; feces become soft and watery 4. Activity - Activity stimulate peristalsis, bcz facilitating the movement of chyme along the colon - Weak abd and pelvic muscles are often ineffective in increasing the intra abdominal pressure during defecation or in controlling defecation - Weak muscle; lack of exercise, immobility, impaired neurologic functioning - Pt confined to bed often constipated 5. Psychological factors - Anxious or angry experience peristaltic activity, subsequent nausea or diarrhea - People depressed experience slowed intestinal motility, becomes constipation - Different in emotional states of individual different in response of the enteric nervous system to vagal stimulation from the brain 6. Defecation habits - Early bowel training establish the habit of defecating at a regular time - Many people defecate after breakfast, the gastrocolic reflex causes mass peristaltic waves in the large intestine - If a person ignores this urge to defecate, water continues to be reabsorbed, making the feces hard and difficult to expel - When normal defecation reflexes are inhibited or ignored, these conditioned reflexes tend to be progressively weakened - Habit of ignored the urge of defecate is ultimately loss - Usually ignored is adult due to pressure of time and work, hospitalized pt due to embarrassment using bedpan, lack of privacy, because defecation is too uncomfortable 7. Medication - Side effect of drugs cause diarrhea - Large doses of certain tranquilizers and repeated administration of morphine and codeine cause constipation due to decrease gastrointestinal activity through their action on the central nervous system - Iron supplements act more locally on the bowel mucosa and can cause constipation or diarrhea - Laxatives -- meds to stimulates bowel activity and assist fecal elimination - Other meds soften stool, facilitating defecation - Certain meds suppress peristaltic activity and may be used to treat diarrhea - Meds affect the appearance of feces - Drug; aspirin cause gastrointestinal bleeding can cause the stool red or black - Iron salts leads to black stool because of the oxidation of iron; antibiotics cause gray-green discoloration; antacids can cause a whitish discoloration or white specks in the stool - Pepto-Bismol, a common OTC drug cause stool black 8. Diagnostic procedures - Before certain diagnostic procedures; visualization of the colon (colonoscopy or sigmoidoscopy), pt is restricted from ingesting food or fluid - Pt may given enema prior to examination, normal defecation usually will not occur until eating resumes 9. Anesthesia & surgery - General anesthetic cause the normal colonic movements to cease or slow by blocking parasympathetic stimulation to the muscle colon; usually pt with regional or spinal anesthesia - Ileus is surgery that involves direct handling of the intestines can cause temporary cessation of intestinal movement, usually last 24 to 48 hrs - Listening for bowel sounds that reflect intestinal motility is an important nursing assessment following surgery 10. Pathologic conditions - Spinal cord injuries or head injuries can decrease the sensory stimulation for defecation - Impaired mobility may limit the client's ability to respond to the urge to defecate and the client may experience constipation/ fecal incontinence because of poorly functioning anal sphincters 11. Pain - Client who experience discomfort when defecating ex; following hemorrhoid surgery often suppress the urge to defecate and the client may experience constipation - Client taking narcotic analgesic for pain may experience constipation due to its side effect IV. **FECAL ELIMINATION PROBLEMS** 1. **Constipation** - Defined as fewer than three bowel movements per week - The passage dry or hard stool or the passage of no stool - It occurs when the movement of feces through the large intestine is slow, thus allowing time for additional reabsorption of fluid from the large intestine - Constipations are difficult evacuation of stool and increased the effort or straining of the voluntary muscle of defecation - The person may feeling of incomplete stool evacuation after defecation, but its elimination pattern - Some people defecate only a few times a week other people defecate more than once a day i. **Characteristics of Constipation** - Decreased frequency of defecation - Hard, formed stools - Straining at stool; painful defecation - Reports of rectal fullness or pressure or incomplete bowel evacuation - Abdominal pain, cramps or distention - Anorexia, nausea - Headache ii. **Factors contribute to constipation** - Insufficient fiber intake - Insufficient fluid intake - Insufficient activity or immobility - Irregular defecation habits - Change in daily routine - Lack of privacy - Chronic use of laxatives or enemas - Irritable bowel syndrome (IBS) - Pelvic floor dysfunction or muscle damage - Poor motility or slow transit - Neurologic conditions; Parkinson's Disease, stroke, paralysis - Emotional disturbances; depression or mental confusion - Meds; opioids, iron supplements, antihistamine, antacids, antidepressants - Habitual denial and ignoring the urge of defecate - In children constipation is often associated with changes in activity, diet and toileting habits - Straining associated with constipation often is accompanied by holding the breath - This Valsalva maneuver can present serious problems to people with heart disease, brain ijuries or respiratory disease - Holding the breath while bearing down increases intrathoracic pressure and vagal tone, slowing the pulse rate - a mass / collection -- hardened feces in - folds of rectum - impaction results from prolonged retention and accumulation of fecal material - in severe, feces accumulate and extend well up into sigmoid colon and beyond - pt with fecal impaction will feel the passage of liquid fecal seepage(diarrhea) and no normal stool - impaction can also be assessed by digital examination of the rectum, during which the hardened mass can often be palpated - symptoms; frequent but nonproductive desire to defecate and rectal pain, anorexic, abdominal distended, nausea, vomit - causes of fecal impaction; poor defecation habits and constipation, meds; anticholinergics and antihistamines, barium that used in radiologic examination of upper and lower gastrointestinal; laxatives used to removed barium - digital examination should be gentle and carefully; rectal examination within scope **3. Diarrhea** - liquid feces & an increased frequency -- defecation i. Causes of diarrhea **4. Bowel Incontinence** - Fecal incontinences loss -- involuntary ability -- control fecal &gaseous discharge -- anal sphincter **5. Faltulence** a. Sources; - Action -- bacteria on -- chyme in -- large intestine - Swallowed air - Gas -- diffuses between -- bloodstream & intestine b. Causes occurs on colon - Foods; cabbage, onions - Abdominal surgery - Narcotics V. **NURSING MANAGEMENT** 1. Assessing i. Nursing history  ii. Physical examination - Inspection, auscultation, percussion, palpation with specific references to the intestinal tract - Auscultation precedes palpation because palpation can alter peristalsis - Examination anus and rectum by inspection and palpation iii. Inspecting the feces - Color, consistency, shape, amount, odor, the presence of abnormal constituents iv. Diagnostic studies \- the gastrointestinal tract include direct visualization techniques, indirect visualization techniques, laboratory test for abnormal constituents - Constipation related to deficit knowledge on factors affect defecation - Bowel incontinence - Constipation - Perceived constipation - Diarrhea - Dysfunctional Gastrointestinal Motility - Risk for Constipation; - Risk for deficient fluid volume and/ or risk for electrolyte imbalance related to a. Prolonged diarrhea b. Abnormal fluid loss through ostomy - Risk for impaired skin integrity related to a. Prolonged diarrhea b. Bowel incontinence c. Bowel diversion ostomy - Situational low self-esteem related to a. Ostomy b. Fecal incontinence c. Need for assistance with toileting - Disturbed body image related to a. Ostomy b. Bowel incontinence - Deficient knowledge (bowel training, ostomy management) related to lack of previous experience - Anxiety related to a. Lack of control of fecal elimination secondary to ostomy b. Response of others ostomy 3\. Planning/Goal - Maintain and restore normal bowel elimination pattern - Maintain or regain normal stool consistency - Prevent associated risk; fluid and electrolyte imbalance, skin breakdown, abdominal distention and pain - Planning for home care;  4\. Implementing I. Promoting regular defecation a. Privacy - Nurse should provide as much as privacy possible but for pt too weak should stay with them - Some pt prefer to wipe, wash and dry themselves, so nurse should prepare water, washcloth, towel b. Timing - Should encourage pt when the urge is recognized c. Nutrition & fluids - The diet pt need for regular normal elimination varies, depends on what kind of feces currently - Frequency of defecation, type of food assist normal defecation - Constipation; increase daily fluid intake, instruct the pt to drink hot liquids, warm water with a squirt of lemon, fruits juice, prune juice, fiber in diet; raw fruits, bran products, whole-grain cereal, breads - Diarrhea; encourage oral intake of fluids and bland food, eating small amounts, to be more absorbed, avoid hot/cold fluids cause it can stimulate peristalsis, avoid spicy and high fiber food d. Exercise (isometric exercise) - In supine position, tightens the abd muscles as though pulling them inward, holding them for about 10 sec and relaxing them. Repeat 5-10 times, four times a day depends on pt 's health - In supine position, contract the thigh muscles and hold them contracted for 10 secs, repeat it 5-10 times for four times a day. This help pt confined to bed gain strength in the thigh muscles, so pt easier use bedpan e. Positioning - Squatting - Leaning forward - Commode - Portable chair with toilet seat and receptacle beneath that can be emptied, is often used for adult pt who can get out of bed but unable to walk - Some have wheels and can slides over the base of regular toilet when the waste receptable is removed - Some commode have a seat and can be used as a chair - Potty chair for children - Bedpan \- for bed ridden \- a receptacle for urine and feces \- female use bedpan for feces and urination \- male use bedpan for feces, urinal for urine  I. laxatives - Type of laxatives - Form -- suppositories - Antidiarrheal medication  - Antiflatulent medications - Simethicone do not decrease the formation of flatus but they do coalesce the gas bubbles and facilitate their passage by belching through the mouth or expulsion through the anus - A combination simethicone and loperamide is effective in relieving abd bloating and gas associated with acute diarrhea but no convincing evidence for this method - Carminatives are herbal oils act as agents that help expel gas from the stomach and intestines - Suppositories can given to relieves flatus by increasing intestinal motility - Decreasing flatulence - Exercise, moving in bed, ambulation, avoiding gas producing food - Movement stimulates peristalsis and the escape of flatus and reabsorption of gases in the intestinal capillaries - Probiotics can manage flatulence and bloating - Bismuth subsalicylate is effective but can't used as continuous treatment bcs aspirin that cause salicylate toxicity - Alpha-galactosidase(Beano); eating fermentable carbohydrates; beans, bran, fruits II. Administering Enemas - enema - a solution introduced into -- rectum & large intestine - to distend -- intestine & irritate - intestinal mucosa -- peristalsis Eg; i. Cleansing enema - Prevent the escape of feces during surgery - Prepare intestine for certain diagnostic test; x-ray or visualization test (colonoscopy) - Remove feces in instances of constipation or impaction ii. Carminative enema - To expel flatus - The solution instilled into the rectum release gas, which in turn distends the rectum and the colon, stimulating peristalsis - Adult 60-80mL of fluid instilled iii. Retention enema - Oil/meds into the rectum and sigmoid colon - The liquid is retained for a relatively long period ex; 1-3 hrs - An oil retention enema acts to soften the feces and to lubricate the rectum and anal canal, facilitating passage of the feces - Antibiotic enemas are used to treat infection locally, anthelmintic enemas to kill helminths; worms and intestinal parasites, nutritive enemas to administer fluids and nutrients to the rectum iv. Return-flow enema (Harris Flush) - To expel flatus - Alternating flow of 100-200 mL of fluid into and out of the rectum and sigmoid colon stimulates peristalsis - This process repeated five or six times until the flatus is expelled and abd distension relieved - Before disimpaction - suggested an oil retention enema be given & held for 30 mins 1. If indicated, obtain assistance from a second person who can comfort the client during the procedure 2. Ask the client to assume a right or left side lying position, with the knees flexed and the back toward the nurse. When the person lies on the right side, the sigmoid colon is uppermost; gravity can aid removal of the feces. Positioning on the left side allows easier access to the sigmoid colon 3. Place a disposable absorbent pad under the client's buttocks and a bedpan nearby to receive stool 4. Drape the client for comfort and to avoid unnecessary exposure of the body 5. Apply clean gloves and liberally lubricate the glove index finger 6. Gently insert the index finger into the rectum and move the finger along the length of the rectum 7. Loosen and dislodge stool by gently massaging around it. Break up stool by working the finger into the hardened mass, taking care to avoid injury to the mucosa of the rectum 8. Carefully work stool downward to the end of the rectum and remove it in small pieces. Continue to remove as much fecal material as possible. Periodically assess the client for signs of fatigue; facial pallor, diaphoresis, change in pulse rate. Manual stimulation should be minimal 9. Following disimpaction, assist the client to clean the anal area for a short time because digital stimulation of the rectum often induces the urge of defecate **SKILL TO PERFORM**