Care Of Colon Elimination PDF

CARE OF COLONELIMINATION The healthy body rids itself of waste products that are not needed, in order to maintain homeostasis. Elimination of waste products is normally routine and uneventful, unless a change in habits or illness occurs. Changes in large intestine (colon, bowel) habit may be si...

CARE OF COLONELIMINATION The healthy body rids itself of waste products that are not needed, in order to maintain homeostasis. Elimination of waste products is normally routine and uneventful, unless a change in habits or illness occurs. Changes in large intestine (colon, bowel) habit may be signs of illness or they may cause illness. Assessing the patient\'s products of elimination (stool), observing colon function and assisting the patient facing a problem with thisfunction are fundamental nursing responsibilities. Stool is collected as part of nursing assessment and care. Becoming familiar with the normal characteristics of colon waste products and understanding the usual functions of elimination helps to identify variations or abnormalities when they occur. Regular elimination of colon waste products is essential for normal body functioning. Alterations in colon elimination are often early signsor symptoms of problems within either the gastrointestinal (GI) or other body systems. Because colon function depends on the balance of several factors, elimination patterns and habits vary among individuals. Understanding of physiological large intestine elimination and factors that promote, impedeor cause alterations in elimination helps to manage patient\'s elimination problems. Supportive nursing care respects the patient\'s privacy and emotional needs. Measures designed to promote normal colon elimination also need to minimize discomfort for the patient. 3.1 Factors influencing colon elimination There are many factors influencing the process of bowel elimination. Knowledge of such factors helps to anticipate measures required to maintain a normal elimination pattern. Some common factors include age, diet, life-style, personal elimination habits, health status, emotional state, etc. Age. Colon elimination patterns change throughout the life cycle. Changesare caused by continued physiologic development, then by age-related losses of function. Infants (birth to year) are unable to control defecation due to lack of neuromuscular maturity. Stool frequency and characteristics depend on the feeding method. Breastfed infants have loose, seedy, golden yellow stools, often after every feeding. Toddlers (ages 1 to 3 years) become physically readyto control bowel elimination between 18 and 24 months of age, cognitive and psychosocial readiness, also essential, is frequently achieved later. Adults establish characteristic individual bowel elimination patterns that vary with dietary, life-style, and other variables discussed later. Older adults (over age 65\) frequently experience constipation. Loss of muscle tone may also affect the internal anal sphincter and even though the external sphincteris still intact, some elderly persons experience difficulty controlling defecation. Diet. Regular daily food intake helps to maintain a regular pattern of peristalsisin the colon. Bulk-forming foods such as whole grains,fresh fruits and vegetables helpflush the fats and waste products from the body with more efficiency. Ingestion of a high-fiber diet improves the likelihood of a normal elimination pattern if other factors are normal. Hydration. Adequate fluid intake is crucial to healthy elimination. 1500 to 2000 ml of fluid per day is the normal requirement for an adult. Fluid is necessary for efficient movement of intestinal contents and for the absorption of nutrients and electrolytes. The 25 colon tract contributes to maintain thefluid balance. Theresulting decrease inthe orauid within the intestine slows peristalsis and hardens the feces. amount to regular elimination the abdominal and pelvic floor muscles that are used in defecation. Personal elimination habits. Colon elimination is a private matter and tousetheirowntoiletfacilities. most Any changeinenvironment,suchas routines. intake medications, all that contributes to altered elimination patterns. illness limits the patient\'s balance, activity tolerance the use of a bedpan or bedside commode. or physical activity and requires Pain. Pain may also influence the bowel function. Haemorrhoids. rectal and perineal surgery or abdominal surgery can cause discomfort duringdefecation. As a result, patients may suppress the urge to defecate and become constipated. Nurses should also be alert to other conditions that could create discomfortfor patients during defecation. Position on other possiblecauses of pain. the bedpan, pressure ulcers and pelvic and hip fracturesare Medications. Many medications can alterbowel function.For example,antibioticscan produce diarrhoeaand abdominalcramping.,narcoticanalgesicsand opiates decrease peristalsis with resulting constipation. Diuretics, which fluid, and iron preparations may cause make the bodyto eliminate constipation. When diarrhoeaor whereas Anaesthesia. General anaesthetics produce bowel during surgery often temporary taking. slowing of peristalsis. Diagnosfic procedures. Diagnostie procedures temporary loss of peristalsis. usuallyrequire that the bowel to evaluate is to be gastrointestinal function tests, Psychological factors.r constipation and peristalsis is increasedl oP stieemotional srew the digestiv e pib emparet may ocoum increased peristalsis are gaseous distention. A number of diseases of theGI tract are associated with stress. If apatient becomes depressed,the autonomic nervous system slows diarrhoea and decreases, resultingin constipation. impulses, peristalsis 3.2 Assessment of stool Dailynursing assessment that patientreports. The Pruthyhrhthttw:wecyteyeyy other consistency,amount,colour,shape, odourand the presence of nurse observes frequency and regularity of stool elimination,stool determinesthefrequency (how often) and regularity abnormal components. Frequency and regularityof stool elimination.Nursing data collection stools) ofan /includes observing the frequency and others,twice orthreetimes a week. 26individual patient\'s colon elimination. Some individuals defecate once (interval between to twice a day, Consistency. Consistency refers to stool firmness or density. Dietary intake and the quantity of fluid intake directly affect the stool\'s consistency. Normal stool is soft and formed. Speed of peristalsis will determine the liquid content and the shape of the stool. Decreased peristalsis results in small, hard, dry stools, increased peristalsis causes liquid, unformed stool. Liquid stools consist of coloured fluid (90%). Amount. The amount of stool passed every day will vary dependingon the dietary intake. Physiology amount of stool is an average of 60- 300 g of stool day, depending on the amount and nature of the food intake. Colour. Some medications or foods may alter stool colour. Normally, stool is vellowish-brown (due to the presence of bile). Anypathological change in colour suggests a change in gastrointestinal functioning or contents of the stool: Grey coloured stool (called as acholic stool) usually indicates that bile is miss- ing In the stool, often a sign of liver, gallbladder diseases or bile ducts obstruc- tion (e.g. with bile duct stone). Dark, black or tarry stool (called as melena) usually indicates the presence of digested blood, indicating bleeding high in the gastrointestinal tract (e.g. stom- ach ulcers) or swallowed blood from a mouth, nose or throat injury or disorder, may be a side effect of iron supplements. Bright (fresh) red blood (called as enterorrhagia) in the stool indicates rectal or lower colon part bleeding, often from haemorrhoids, rectumor colon cancer. Yellow or greenish in colour indicate the abnormal presence of microorgan- isms, suggesting infection. Shape. Generally, stoolshave the same shape as the colon interior: round, oval or cylindrical. For example, long, thin, pencil-like stools suggest narrowing of the rectum or anal opening, which could be caused by a tumor, separate hard lumps like nuts (difficult to pass) indicate dehydration of patient. Odour. Stools have characteristic odour. Sometimes, medications, strong flavoured foods or the presence of unusual microorganisms change the odour. The gaseous discharge that accompanies the bowel movement can have a very strong odour and is called flatus. Pathological smell includes, for example, acidic odour for some types of diarrhoea, sweet smell- in the case of melena (digested blood in stool), putrid odour- in dyspepsia (painful, difficult, disturbed digestion). Density. Stool density is the weight concentration of waste products in relation to water. Normally, stools are heavy enough to sink in water. Stools that float are less dense and suggest undigested fats, especially if they have a fattyor oily appearance. Abnormal components. The presence of pus or mucus in stool indicates inflammation or infection in the digestive system. The presence of undigested food products may suggest digestive system malfunction. Fresh red blood (enterorrhagia) suggests lower gastrointestinal bleeding. Black stool (melena) often indicate upper gastrointestinal or nasogastric bleeding. Tapeworms or segments of the worms can also appear in stool in case of intestinal parasites. 3.3 Colon elimination problems Caring for patients who have or are at risk for elimination problems because of emotional stress (anxiety or depression), changes in the GI tract, such as surgical 27 alteration of colon structures,inflammatory diseases, prescribed therapy or disorders impairing defecation is common in the lotising practice.Common colon eliminaton Colostomy tenesmus. It is problems include: Constipation is a decrease in the frequency of colon elimination, accompanied diseases. Stool by prolonged or difficult passage of hard and dry stool. It is a symptom, not a disease The signs of constipation include infrequent bowel movements (less thanevery 3 days). opening ston located in the difficulty passing stools, excessive straining,inabilitytodefecateat will and hard stool gases and stor Stool impaction results from unrelieved constipation. It is the accumulation of focus on emo stool into large, hard and dry mass (called scybalum) in the lower part of the colon patients to and rectum. if not resolved or removed, severe impaction often results in intestinal manage the obstruction. Patients who are elderly, immobile, confused or unconsciousare most at 3.4 Admi risk for impaction. Diarrhoea is anincrease in the number of stools and the passage of liquid, unformed stool. It is associated with disorders affecting digestion, absorption and secretion in the Enem GI tract. Intestinal contents pass through the small and large intestine too quickly to instillation allow for the usual absorption of fluid and nutrients. of large Stool incontinence is the inability to control elimination of stool, involuntary leakage this proce of stool and gases from the anus. Incontinence of stool occurs in case of pathologicala nurse however changes or impairments in nervous and muscular systems (paralysis), disorder in microor gastrointestinal tract. mental disorder. Stool management system (SMS) is safe and Th effective in long-term treatment of patients with stool incontinence at home, in hospice or in the hospital. SMS include the devices to prevent and contain stool leakage, pro rel in to manage odour and to prevent peri- anal skin damage (e.g. stool collectors, stool bag, anal pouches, rectal tubes, catheters, rectal trumpets, see Figure 23). SMS with odour barrier properties is intended for stool management by diverting and collecting liquid or semi- solu ene liquid stool in bedridden patients and to or provide access for the administration of medications (see Figure 24). in Meteorism. As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends. It is a com- Figure 23 Stool management system mon cause of abdominal distention, sharp pain, cramping if intestinal motili- ty is reduced because of opiates, general anaesthetics, abdominal surgery, immo- bilization or if more gas is swallowed. Tenesmus. Persistent and ineffec- tive painful straining to empty the co- lon in response to the sensation of a desire to defecate without producing a significant quantity of stool is called Figure 24 Stool management system application in rectum 28 It is clinical symptom of rectum or colontumnor or colon inflammation. Colostomy is called artificial anus in the abdominal wall for treatment of certain diseases. Stool passes through a temporary or permanent artificial stoma. The surgical opening- stoma is a small circular hole 2 - 5 cm in diameter. Colostomy is most often located in the left lower abdomen. The stoma IS an outlet for spontaneous passing of gases and stools to which a colostomy collection bag is attached. Nursing care should focus on emotional support, teaching ostomy self-care and diet education. Nurses refer patients to a stoma specialist(wound ostomy continence manage the colostomy. nurse) if assistance is needed to 3.4 Administration of enema Enema (an archaic word for enema is clyster) is the instillation of liquids throughrectum into the left lower part of large intestine or into its higher parts. In clinical practice this procedure is ordered by physician and is performed by a nurse or health assistant. Sterile technique is unnecessary, however, using the disposable devices to prevent the transmission microorganisms is necessary. The primaryreasons for an enema procedure are: promote defecation, remove stool from colon, rectum (in case of constipation, impaction, before surgery, endoscopy examination), administer medications directly into the intestines, instil the contrast medium into the rectum and colon (before diagnostic examinations colonography, rectography), support intestinal peristalsis. The commonly used fluids of enema are: water, saline Figure 25 Silicone rectal tubes solution, soapsuds, oil (castor, olive), glycerol. Soapsuds enemas are usually not given before a rectal examination or procedures involving viewing of the colon by a scope. The soapsuds solution IS irritating the bowel and can cause reddening. This would likely adversely influence the interpretation of the examination.   Age period Suitable size of rectal tube Infant 12 Preschool age 14- 16 School age 16- 18 Adulthood 22- 30 29 In clinical practice, the following different types of enema are used: Cleansing enema (includes high and low cleansing enemas) Microenema (includes medical and evacuant) Diagnostic enema 3.4.1 Cleansing enema administration Cleansing enema is administered in order to clean the intestines when constipated. as part of the preoperative preparation of the digestive tract, as part ofthe preparation for examination of the intestines or as the preparation for birth. The skill of administering a cleansing enema can be delegatedto nursing assistive personnel health assistants. The nurse must first assess the patient for specific need comfort and stable considerations such as for alternative positioning, vital signs before the procedure. High and low cleansing enemas are recognized. A low enema is used cleanse to the rectum and theleft lower part of large intestine and a high enema is usedto cleanse the upper sections of the large intestine. The volume of solution used in a high cleansing enema is as follows: infants up to 250 ml, toddlers and preschool children 500 ml, school age children 500- 1000 ml. adults 1000- 1500 ml. The low form of cleansing enema is administered using approximately half the recommended liquid volumes. In clinical practice, for adult patients a few tablespoons of castor oil can be added into warm liquid. The commonly used low form of cleansing enema is commercially prepared Yal solution (see Figure 26). It is recommended for cleansing the lower part of large intestine and rectum prior to endoscopic examinations (e.g. colonoscopy) and before examination of the kidneys, urinary and genital organs, where cleansing of the colon and rectum is a prerequisite. Yal can also be used for the preoperative Figure 26 Prefilled bottle with applicator preparation of the colon and rectum and as form of medical micro- enema in the treatment of severe cases of constipation. Preparation of nurse Verify the patient\'s name, form, reason and time of cleansing enema. Verify, whether the patient is allergic to any enema solutions, lubricants (e.g. mesocaine). Review the medical history, allergy, assessment and laboratory data thatmay influence cleansing enema. Assess the appropriateness of the cleansing enema forthe patient. Assess the patient\'s knowledge of the cleansingenema. If the patient has a lack of knowledge about procedure, this may be the appropriatetime to begin with education aboutthe cleansing enema. Assess and document actual health condition and condition of the patient\'s rectal area (such as redness, inflammation.1 bleeding, pain, haemorrhoids). Adhere to safety measures to prevent cross-contamination. Prepare the equipment, working environment a designated room (the enema is administered in patient for the cleansing enema. of in the patient\'s room using screens for immobile patients) and 30 Preparation of patient Mental preparation Explain the purpose of the cleansing enema using the language that the patient can understand, explain the procedure to the patient, help to minimize the patient\'s anxi- ety and to report any problems (feeling pain, defecation reflex, discomfort). Educate the patient about the necessity to cooperate when performing cleansing enema (proper position, breathing, relaxation, the need to hold the enema liquid 15 -20 min). Talk to the patient during the procedure explaining each step of the procedure (e.g. that you are going to insert rectal tube, to let flow solution, to remove rectal tube, to wipe anus). Physical preparation Routine daily personal hygiene, hygiene care of perineal and rectum area. Patient is relaxed and breaths slow deep. Patient is usually in Sim\'s left position on the bed with upper leg flexed, in the supine position on the bedpan with legs flexed or in knee-chest (genupectoral) posi- tion. if the patient can tolerate it. Equipment: clean gloves, waterproof pad for bed protection, absorbent pads, toilet tissue, irrigator kit with enema container filled with correct volume of warmed solution, tubing and clamp, appropriate size of rectal tube, water-soluble lubricant (e.g. mesocaine gel, vaseline), basin, bedpan, bedside commode or access to toilet, IV pole (infusion stand for hanging the irrigator kit). Implementation 1\. Identify the patient. Adjust the bed to comfortable working height. If right-handed, stand on the patient\'s right side. Hang the irrigator with enema solution on the IV pole, release clamp and allow solution to flow long enough to fill tubing, procedure removes air from tubing. Reclamp tubing. 2. Use a waterproof pad for bed protection. Assist the patient into the supine position on the bed (or bedpan) with legs flexed or in in left side-lying position (Sim\'s positi- on) on the bed with upper leg flexed. This position facilitates the flow of solution by gravitation into left lower part of the large intestine. Put basin in front of the rectum. Provide for patient privacy. Respect the patient\'s intimacy. 3. Perform hand hygiene. Put on clean gloves. Lubricate 6 to 8 cm of tip of the rectal tube with water-soluble lubricating gel. Lubricating allows smooth insertion of the rectal tube without risk of irritation or trauma to rectum mucosa. 4\. Separate the gluteal muscles with nondominant hand and locate anus. Instruct the patient to relax by breathing out slowly through mouth. 5. Insert the rectal tube slowly by pointing tip in direction of patient\'s umbilicus. Length of insertion varies: for adult 7- 10 cm, for adolescent 7- 10 cm, child \- 7 cm, infant 2.5- 3.5 cm deep. Wait for the passage of gas when administrating the rectal tube. 6. Connect the irrigator with the rectal tube, open clamp and slowly instil enema solution. Explain to the patient that feeling of distention IS normal. 31 7. If the patient complains of defecation reflex or cramping, stop the instillation for 4 CARI a short time. Then slowly instil solution. 8\. The at Clamp tubing after all solution is instilled. Place layers of toilet tissue around tube rectal tube. Remove the rectal tube and wipe it with at anus and gently withdraw the square wadding. Discard the rectal tube in basin. urethra, br A nurse 9. Ask the patient to clench the gluteal muscles together and hold for several seconds (in infants or young children. gently hold buttocks together for few minutes). In- expected form the patient of the need to hold the solution inside for at least 15- 20 minutes. urinary be open 10\. Assist the patient to bathroom or help to the position on bedpan. Normal squat- ting position promotes defecation. Observe or ask the patient about the results. 4.1 Fac Assist the patient as needed with washing anal area with warm soap and water (if administering perineal care, use gloves). 11\. Remove and discard gloves and perform hand hygiene. Record administration of the enema, the results and the patient\'s reactions. Document the type, volume of solution used. Report any complications to a physician immediately. Ma to urin: tract develo and di 3.4.2 Microenema administration includ affect The medical enema inserts a drug into the rectum, sometimes, it is the only way Unde to a a main give drug to patient, possibly because the patient is vomiting, unconsciousor has had mouth or throat surgery. It may also be the best way for a specific drug to plani take effect quickly because some drugs are rapidly absorbed by the colon\'s mucous membrane. Because this enema must be retained to ensure effective absorption, the 4.2 drug is combined with a small amount of oil or saline to reduce its irritating effect and to lessen the patient\'s desireto expel it. Before applying a therapeutic enema a cleansing enema is administered. Medical enema contains a small amount of solution (in adults imp 60 180 ml) with medication components. cla The evacuant enema (mineral oil enema, laxative enema) is used to promote nu bowel movement, to evacuate lower large intestine and anus of flatus and hard, dry stool (induct defecation) and thus relieve constipation. It contains a small amount of an oil-based solution, about 150- 250 ml. Evacuant enema is done with a Janette rectal syringe and an appropriate sized rectal tube (see Figure 27) or with prefilled Figure 27 Janette rectal syringe and rectal tube single dose squeeze bottle with an attached applicator. 3.4.3 Diagnostic enema administration It is a procedure which involves administering a contrast medium (e.g. barium sulphate) into the large intestine to diagnose intestine narrowing, widening, polypsor colon tumours.Barium agent iS a chalky, white liquid that coats the inside of the colon and shows its outline clearly on an X-ray (e.g. irrigography).