Bowel Elimination 2022 PDF

Bowel elimination University of Pécs Faculty of Health Sciences Institute of Emergency Care, Health pedagogy and Nursing Sciences Bowel elimination Stool (faeces): the stool develops in the colon as a result of the gradual thickening of the chymus characteristic colour-stercob...

Bowel elimination University of Pécs Faculty of Health Sciences Institute of Emergency Care, Health pedagogy and Nursing Sciences Bowel elimination Stool (faeces): the stool develops in the colon as a result of the gradual thickening of the chymus characteristic colour-stercobilin physiologically stool contains: water, undigested waste materials (cellulose), digested nutrient residuals, anabsorbed gastric juice, bacteria, endodem cells, stercobilinogen and fatty acids (10- 12%) Bowel elimination: a fundamental physiological function-waste products are excreted reflex process- can be regulated voluntarily Intestinal gas (flatulence) fundamental physiological function of the colon – excretion of intestinal gas about 6-7 litres of gas pass through the GI tract daily, in the course of swallowing, or it diffuses from the intestinal cavities from the blood, intestinal bacteria produce them – flatulence- stomach and intestinal gas formation intestinal gas can escape from the stomach through the oesophagus, and oral cavity to the outside world, a part of it diffuses back to the blood, a small proportion of it is secreted through the rectum The observation of stool number and amount of elimination the colour of stool stool odour the consistency of stool the pathological components of stool The number and amount of elimination the normal defaecation habits may vary for different individuals faeces are excreted once or twice daily/or 3 or 4 times a week its normality is determined by the emptying frequency the amount of soft stool is 150-200g The colour of stool I. physiologically the colour of the stool is brownish Yellow - in infants (breast milk) Light-coloured, oily stool - fat digestion problems Dark green/and or yellow - excessive amount of bile excretion,constipation, consumption of vegetables rich in chlorophyl Light-coloured, white, clay-coloured -obstruction of the ductus coledochus, obstractional ileum, gall bladder mobility disorders, cholecystitis Slimy, transparent stool - spasmic diarrhea, ulcerative colitis The colour of the stool II. Types of bloody stool Black, tar-like stool is caused by bleeding coming from the middle section of the GI tract or by consumption of black pudding, offals, red wine, blackcurrant or some medicaments (iron, carbon tablets) Malaena is pitch-black, loose gelatinous stool caused by GI bleeding from the stomach or upper regions or as a complication of renal deficiency (on the hospital chart „M” is written) Reddish colour stool- GI bleeding or consumption of beetroot Stool with blood stripes - forced elimination or the rupture of haemorrhoids Bloody, mucous stool - inflammatory intestinal disease or neoplasm Stool odour Physiologically - characteristically unpleasant odour rotten like, very foul smell - protein digestive dysfunction sour smell of fermentation - carbohydrate indigestion stronger fermented smell - after the consumption of hard liquour, brandy sweetish, extremely foul smell - emptying malaena The consistency of stool formed stool - normal hard, berry - like stool-constipation, little fluid consumption regular, pasty stool - malabsorption, excessive food intake, fruit with mild laxative effect (appricot, plum) loose stool - emptied once or several times can be considered diarrhea bloody, mucoid stool - intestinal inflammations of non- infectious origin Bloody-watery diarrhea - dysentery The pathological components of stools too much water-diarrhea a large amount of fat-caused by pancreatitis, malabsorption syndrome, enteritis, a condition after an enterocolectomy surgery digested or fresh blood foreign body that can cause suppurative and bloody pathological change pus-enteritis mucin-in case of inflammation (colitis), irritation (swallowed objects), stress some bacteria-pathogens undigested food- shell of legumes, corn intestinal worms Examinations of bowel movement disorders Rectal digital examination Application of diary on digestion and nutrition Endoscopic examinations: rectoscopy, colonoscopy, sigmoidescopy Ultrasound examination X-ray examination: proctogramme, irrigoscopy, native abdominal X-ray Colontransit examination Evacuation proctography CT, MRI Anorectal manometry Balloon expulsive test Stool observation Stool sampling Examination of stool, aim and method for sampling lab series of test: chemical and microbiological tests microscopic examination the following features are tested: colour, odour, form, density, composition, pH, secretion, mucus, blood, fat, meatfibre, WBC, bile, sugar content Stool sampling sampling means: stool container (20cm3 content), two capsules for bacteria cultures, detecting toxin, parasite, virus antigen Use the spoon from sampling – two-thirds should be filled Send to the lab within 4 hrs Storage in fridge (max. 24 hrs) Ty-container - for collecting blood and faeces samples of typhoid patients Sampling from perianal area with tape and cellophane capped wand for detecting ovules Stool sampling For microbiological examination: Patient can perform the sampling faeces should be stooled in the bed pan, not in the toilet, because of the bacteria in it in case of home sampling stool should be taken from the uncontaminated parts (not contcact with the toilet) sampling should be made from 3 different stools, in 3 following days Stool sampling „F” container (in Hungary) bacterias, toxin, parasite, virus antigen There is a samplin spoone – two-thirds fill the container Send it within 4 hours to the lab storage in fridge „TY” container – typhoid patients + blood sample Fecal specimens- FOBT Fecal Occult Blood Test Detection of human blood: guaiac FOBT: based on pseudoperoxydase reaction (gFOBT) Fecal immunochemical FOBT methods using antihuman IG (iFOBT, FIT) - requires no preparation or dietary restrictions Guiac blood test guaiac test is filtered on paper, can be mailed, used frequently, repeat test at least 3 times on three seperate bowel movements 1. sample is put on a test paper saturated with reagent, 2. drop hydrogen peroxyde on it, and 3. read result in 1-2 min. (blue discolorization: positive result) special diet should be followed in order to avoid pseudopositive results (red meat, beetroot, mushroom for a few days) Documentation of stool vertical line - formed faeces slanted line - diarrhoea red line or letter „M”– melaena or faecal occult blood zero or crossed zero - omission of faeces letter „E”- enema Normal feces Diarrhea liquid, unformed stools is excreted more than 3 times or /and its amount is larger than 200 g during 24 hours Dehydration leading to fluid and electrolyte and acid- base imbalances Tenesmus: frequent or constant urge to defecate with little faeces or without Diarrhea - causes Infectious intestinal diseases Malignant tumor in the anus Irritable intestine syndrome Diverticulosis Short intestine syndrome Post-cholecystectomy condition-due to billiary acid absorption disorders Pancreatic diseases Systemic sclerosis, thyreoxotoxicosis in case of thyroid and adrenal diseases Type II diabetes mellitus Condition after stomach surgery Laxative abuse  Diarrhea - causes Food allergy and intolerance: lactose, glucose Diarrhoea due to infection Intestinal inflammation due to radiology Psychic disorders-stress, anxiety Drugs- contraceptives,anti-obesity drugs, some oral antidiabetics, beta blockers, serotonin reuptake inhibitors, laxative, iron supplements,antacids with magnesium,some diuretics, coffeine, chemotherapeutic drigs Metabolic diseases-hyperthyreosis Malabsorption disorders Contaminated water, or large consumption of mineral water Inappropriate social and economic conditions, hygienic Fecal incontinence Inability to control the passage of feces and gas from the anus (temporary-permanent) Conditions that create frequent, large- volumewatery stools predispose to fecal urgency and incontinence faeces may stay on the skin ammonium develeops – alkaline skin ph care of the perianal area avoid from friction and traction Means to collect faeces Chux pad: they absorb the liquid component of the faces but the solid components remain on the skin and irritate it Skin care: Avoid from dry toilet paper, soup, alcohol based agents and body powder Preffered ones: hypoallergenic creams, wet wipes Fecal collector: adhesive bags, can be administered to the cleaned and wiped dry area of the perineum optimal for immobile patients leaking may happen Means to collect feces Anal plug: Similar to suppositories Made from some foam-like material They can be placed on the rectum prevent the leaking in case of chronic diarrhea Means to collect feces Fecal system: In case of immobility and faecal incontinence Even for rinse The tip of the balloon is a silicone catheter Antidiarrhoeals absorbents, adstrigents (e.g. active charcoal) absorb toxic substances that cause infective diarrhoea, makes a protective film on the mucosa (adstirgent effect) to the care of the inflammation and secretion; methylcellulose is an absorbent anticholinergics reduce intestinal movement, secretion and are effective against both diarrhoea and accompanying cramping, opioids have this effect by the stimulation of the opioid receptors (eg. loperamid). Parasympatholytic agent is a substance or activity that reduces the activity of the parasympathetic nervous system by blocking muscarin receptors (eg. Reasec – diphenoxylat+atropin). Only in case of non-inflammatory diarrhoeas bile acid sequestrant (eg. cholestyramin) in case of diarrhoea caused by decreased bile acid absorption (eg. Crohn disease) Constipation dry, hard consistency,lumpy stool difficult to excrete excessive straining,pain, discomfort person does not feel that his gut is empty excretion is fewer than 3 bowel movements per week excretion lasts for more than 10 min. associated symptoms: pain in the stomach, cramps,loss of appetite,reduced gases may lead to hemorrhage rarely life-threatening may cause anxiety may reduce life quality  Constipation Rome IV-criteria Criteria fulfilled for the last three months with symptom onset at least six months prior to diagnosis 1. Must include two or more of the following: a) Straining during more than 25% of defecations b) Hard, lumpy stool (BSFS Type 1-2) more than 25% of excretions c) Sensation of incomplete evacuation more than 25 % of defecations d) Sansation of anorectal obstruction more than 25% of defecations e) Manual maneouvres to facilitate more than 25% of defecation f) The number of excretions is fewer than three in a week 2. Loose stools are rarely present without the use of laxatives 3. Insufficient criteria for irritable bowel syndrome Constipation Triggering factors for developing constipation: lifestyle factors: inadequate eating habits,lowdietary fibre intake, less wholemeal bread products, inadequate fluid intake,lack of exercise, enemas psychic factors: anxiety, depression,repression of defecation side-effects of drugs: antidepressants, antiepileptic drugs,antipsychotic drugs physiological changes: pregnancy, old age diseases: neurological conditions (Parkinson disease, spinal cord injury, SM, muscle dystrophy)Addison disease, anal ruptures,haemorrhages,colon tumor, inflammatoryGI diseases) changes in environment: holiday,travelling, hospitalisation Hemorrhoids Dilated,engorged veins in the lining of the rectum Increased venous pressure resulting from straining at defecation, pregnancy, and chronic illnesses Formed within the anal canal (internal) or through the opening of the anus (extermal) Passage of hard stool causes hemorrhoid tissue to stretch and bleed Tissue becomes onflamed and tender, itching and burning Defecation causes pain, patient ignores the urge to defecate, resulting in constipation Care of the constipation with medicaments conservative care, laxatives lifestyle advices, enema, removal of skyballum Constipation - laxatives Bulk-forming agents: increases frequency of bowel movements and softens stools by holding water in the stool dietary fibre, kolloids (pl. bran, linseed, plum, fig, psyllium) saline laxatives : have an osmotic effect that causes an increase in intraluminal volume and stimulates intestinal motility (magnesium, sulfate, phosphate, and citrate) hyperosmotic agents: increase intraluminal pressure and stimulate peristalsis (eg. glycerine, lactulose) Stool softeners: docusate, paraffin known as surfactant or stool softeners and ultimately making it easier to pass the stool Stimulant laxatives: diphenylmethane, anthraquinone derivatives stimulate intestinal motor function by affecting fluid and electrolyte transport Regularly used laxatives have serious side effects like inflammation of the bowel, electrolit disturbances, haemorrhoids, … Lifestyle changes consumption of high fibre content foods drinking 1.5-2 Liters of water physical activity writing a bowel diary defecation posture strengthening the pelvic muscles biofeedback treatment do not supress the urge Constipation – proper position  Types of enema based on main groups: osmolality: cleansing/ hypotonic evacuant enema hypertonic retention isotonic Promotes defecation by stimulating peristalsis. Fluid instilled breaks up fecal mass, stretches the wall, and begins the defecation reflex, softens stool  Enema Evacuant enema Indications: constipation, preoperative cleaning of the lower part of the rectum and sigmoid intestine, before delivery Classification: Based on the amount large –scale enema(500-1000ml), small-scale enema (50-200ml) Based on osmolality: hypotonic, isotonic, hypertonic Based on the affected intestine: high enema low enema Enema Soapsuds enema, SSPA Soapy water can be applied, its use is rare due to the irritating effect in the intestine Castile soap can be used, phytogenic based, less irritating Purgative enema Hypertonic solution: glycerol enema, mixture of glycerol and water (1:2), and glycerol and castor oil (1:1) Enema Cold enema Indications: Antipyretic treatment (fever, heat stroke) Antiinflammatory treatment (dysentery, diarrhoea, haemorrhages, ulcerative colitis) 10-20 C degree (27-32C) water  Enema (medicated enema) Retention enema the product should be held in the anus (30-60 min) in accordance with the regulations Mostly steroid-solution enema (for reducing intestinal inflammation in case of ulcerative colitis) antibiotic solution enema (in case of local bacterial infection) hypertonic solution can be applied Enema Antihelmintic enema: Goal: to eliminate and destroy worms First, evacuant enema is given Special, anthelmintic drug solution (250ml) astringent enema: Indication: ulcerative colitis and dysentery Agent of enema liquid: tannin, alum  Enema Barium enema Before the contrast X-ray examination Borium-sulphate is the only borium compound that is not toxic Oil enema Small amonut of solution is given should be held in the anus for longer time (30-60 min) Indication: treatment of conspitation following rectum surgery (haemorrhages) before the first bowel movement in order to prevent surgical wounds and tension of wound sutures Olive oli (180 ml) castor oil (60-120ml) gingelly oil (150-080ml) mixture of olive and castor oil (1:2) followed by large evacuant enema  Enema Emollient / starch enema Indication: soothing mucus irritation due to diarrhoea Enema liquid: starch, opium and starch mucoid water. Temperature: 37.8-40.5C Stimulating enema Indication: for treating fatigue, loss of fluid or collapse, opium poisonong Enema liquid: black coffee solution (1 tablespoon of ground black coffee, 300ml water, a pinch of salt, temperature: 42-43C Special coffee enema is used for treating cancer due to its detoxification effect Carminativ enema Small-scale enema is given with hypertonic solution (MGV solution: 30ml magnesium, 60ml glycerol, 90 ml water)  Enema Nourishing enema Indication: in case of atrophy, unconsciousness, nutrients are administered through the anus Dosage: 180-270ml in 4 hours, 1100-1700 ml in 24 hours, temperature: 38C Return-flow enema (Harris flush) Indication: removal of flatus (gas) and increasing peristalsis.It can be used after abdominal surgery for reducing intestinal distension and starting bowel movement Enema liquid: 200ml solution. Temperature: 40.5-43C (adults) 38C (children) Procedure: liquid should be ingested the rectum from a coantainer lifted above the height of rectum by 30-40cms (children:7.5cms) and the tube should be turned off. Then the container should be let below the level of the patient’s rectum by 30.5- 45.5cms and open the tube. After excretion, the tube should be turned off and the conatiner should be lifted above the level of the rectum by 30.5-45.5cms, open the tube and let 200ml fluid flow in the rectum. This procedure should be repeated 3 times Contraindications of enema enema should not be applied as a primary treatment of constipation diarrhoea arrhythmia, heart attack in case of non-diagnosed abdominal pain(may cause perforation) anus, intestine, prostate surgery bleeding or prolapse of the rectum (styptic enema can be indicated) hazardous: abdominal hernia, in 12 weeks after abdominal surgery, severe bloating, sanaemia, acute liver failure, aneurism, cancer of the colon, Crohn syndrome, (exception: steroid, tsyptic enema) ulcerative colitis, untreated HBP, congestive heart failure, Risks of enema addiction, fluid overload, intestinal irritation, reduction in muscle tone of anus sphincter (frequent enema) stimulating the vagus nerves causing arrhythmia (bradycardia) injury allergic reaction (due to latex tube) perforation pain, spasm, colon irritation upset electrolyte balance (phosphate enema) damage to colon (tapwater, chlorine,bacteria) repel intestinal flora (soapsud enema-antibacterial agents) liver damage (oil enema,vaseline, petroleum derivatives) addiction haemolysis, renal failure, rectum ulcer (glycerol enema) hyponatraemia (more than 1 enema a day under 10 years of age) anaemia (lon term application of coffee and glycerol enema:4-6 weeks) Fecal impaction Results from unrelieved constipation Unable to expel the hardened feces retrained in the rectum Inability to pass a stool for several days, despite the repeated urge to defecate impacted faeces can be removed by enema, but generally the digital removal of stool is the effective therapy the patient is in a Sims-position skyballum should be touched in a concentric way then carefully disconnect it from the intestinal wall, twist the finger into the faeces piece Stoma care The most common diseases (cancer, trauma, inflammation, diverticulis,perforation, congenital disorders) of the lower tract of the GI system may necessitate a temporary or permanent change in the physiological route of the stoolor the formation of eneterostoma Classification of enterostomas : According to sites colostoma coecostoma transversostoma sigmoideostoma ileostoma and continent ileostoma According to duration (temporary, permanent) According to forms (one-opening, double-spouted loop stoma) According to purpose: input output Stoma care appliances one-piece closed appliances Stoma care appliances one-piece open appliances Stoma care appliances two-piece appliance Stoma care appliances Accessoires which enhance the application time of the appliances: Belts Paste, adhesive tapes, rings Powders  Ostomy care and management guideline (2009. Toronto) Overall assessment of the patient including physical, psychological, spiritual, cultural and religious norms. Maintenance of interdisciplinary cooperation related to assessment. Application of individual care plan. Development of therapeutic relationship with patient. Preoperative treatment involves the physical and psychological preparation of the patient (identification of the stoma site) Postoperative treatment: preventing complications, their care, regulation of defecation Patient and relative education for care stoma Ongoing consultation with stomatherapeutist Promoting behaviour change to environment, life style Care of the patient with stoma Preoperative assessment: identification of the stoma site is an important task done by the stomatherapeutist Postoperative assessment Observation: Stoma (colour, opening, size, plethora Fixing suture Following the condition of the peristomal skin In case of double-spouted loop stoma the position of the bridge Checking defecation and its character Necrosis: if it is black and cold Blood circulation failure: stoma becomes purple or dark red Measuring stoma’s place The exchange of the stoma pouch The exchange of the stoma pouch Complications