Module 14 Chapter 23.pdf

CHAPTER 13 Bowel Elimination FOCUSING ON PATIENT CARE This chapter will help you develop some of the skills related to bowel elimination necessary to care for the following patients. Hugh Levens, is a 64-year-old man who has been placed on a bowel program after a fall left him paralyzed from the waist down. Isaac Greenberg, age 9 years, has been having blood in his stools. He is scheduled for a colonoscopy as an outpatient. He and his mother need teaching about the preparation for the procedure, which includes a small-volume cleansing enema. Maria Blakely, age 26, has recently received an ileostomy. She is having problems with her appliances and is concerned about excoriation. LEARNING OBJECTIVES After studying this chapter, you will be able to: 1. Administer a large-volume cleansing enema. 5. Apply a fecal incontinence pouch. 2. Administer a small-volume cleansing enema. 6. Change and empty an ostomy appliance. 3. Administer a retention enema. 7. Irrigate a colostomy. 4. Remove stool digitally. 8. Irrigate a nasogastric tube connected to suction. KEY TERMS colostomy: artificial opening that permits feces from the colon to exit through the stoma constipation: passage of dry, hard stools defecation: emptying of the large intestine; also called a bowel movement diarrhea: passage of excessively liquid, nonformed stool enema: introduction of a solution into the large intestine fecal impaction: prolonged retention or an accumulation of fecal material that forms a hardened mass in the rectum 660 flatus: intestinal gas hemorrhoids: abnormally distended veins in the anal area ileostomy: artificial opening created to allow liquid fecal content from the ileum to be eliminated through a stoma ostomy: a surgically formed opening from the inside of an organ to the outside LWBK545_C13_p660-699.qxd 8/6/10 10:30 PM Page 661 Aptara CHAPTER 13 Bowel Elimination KEY TERMS 661 continued personal protective equipment (PPE): equipment and supplies necessary to minimize or prevent exposure to infectious material, including gloves, gowns, masks, and protective eye gear stoma: the part of the ostomy that is attached to the skin; formed by suturing the mucosa to the skin vagal stimulus or response: stimulation of the vagus nerve that causes an increase in parasympathetic stimulation, triggering a decrease in heart rate Valsalva maneuver: voluntary contraction of the abdominal wall muscles, fixing of the diaphragm, and closing of the glottis that increases intra-abdominal pressure and aids in expelling feces Elimination of the waste products of digestion is a natural process critical for human functioning. Patients differ widely in their expectations about bowel elimination, their usual pattern of defecation, and the ease with which they speak about bowel elimination or bowel problems. Although most people have experienced minor acute bouts of diarrhea or constipation, some patients experience severe or chronic bowel elimination problems affecting their fluid and electrolyte balance, hydration, nutritional status, skin integrity, comfort, and self-concept. Moreover, many illnesses, diagnostic tests, medications, and surgical treatments can affect bowel elimination. Nurses play an integral role in preventing and managing bowel elimination problems. This chapter will cover skills to assist the nurse in promoting and assisting with bowel elimination. Understanding the anatomy of the gastrointestinal (GI) system is integral to performing the skills in this chapter (Fundamentals Review 13-1). An abdominal assessment is required as part of the assessment related to many of the skills (Fundamentals Review 13-2). Fundamentals Review 13-3 summarizes factors that affect elimination. Fundamentals Review 18-1 in Chapter 18, Laboratory Specimen Collection, reviews the characteristics of stool. LWBK545_C13_p660-699.qxd 8/6/10 10:30 PM Page 662 Aptara 662 UNIT II Promoting Healthy Physiologic Responses Fundamentals Review 13-1 ANATOMY OF THE GASTROINTESTINAL TRACT The GI tract begins with the mouth and continues to the esophagus, the stomach, the small intestine, and the large intestine. It ends at the anus. From the mouth to the anus, the GI tract is approximately 9 m (30 feet) long. The small intestine consists of the duodenum, jejunum, and ileum. Liver The large intestine consists of the cecum, colon (ascending, transverse, descending, and sigmoid), and rectum. Accessory organs of the GI tract include the teeth, salivary glands, gallbladder, liver, and pancreas. Esophagus Stomach Hepatic duct Gallbladder Common bile duct Pancreas Pancreatic duct Duodenum Hepatic flexure Transverse colon Splenic flexure Jejunum Descending colon Ascending colon Ileocecal junction Ileum Cecum Appendix Anatomy of the gastrointestinal tract. Sigmoid colon Rectum CHAPTER 13 Bowel Elimination 663 Fundamentals Review 13-2 ASSESSMENT TECHNIQUES FOR THE ABDOMEN Place patient in a supine position with knees slightly flexed. When assessing an infant or toddler, you may want to place the child on the parent’s lap to prevent the child from becoming upset and crying. Perform the abdominal assessment in the following sequence: inspection, auscultation, percussion, palpation. – Inspection: Observe contour of abdomen; note any changes in skin or evidence of scars; inspect for any masses, bulges, or areas of distention. Observe the contour of the abdomen. Significant findings may include the presence of distention (inflation) or protrusion (projection). – Auscultation: Listen, using an orderly clockwise approach, in all abdominal quadrants with the diaphragm of the stethoscope; listen for bowel sounds (intermittent, soft click, and gurgles); note the frequency of bowel sounds (should be 5 to 34 sounds per minute). – Percussion: Percuss, using an orderly clockwise approach in all abdominal quadrants; expect to hear tympany over most regions. – Palpation: Lightly palpate over abdominal quadrants, first checking for any areas of pain or discomfort. Proceed to deep palpation, noting any muscular resistance, tenderness, enlargement of organs, or masses. Fundamentals Review 13-3 FACTORS THAT AFFECT BOWEL ELIMINATION Mobility: Movement and exercise help to move stool through the bowel. Diet: Foods high in fiber help keep stool moving through the intestines. High fluid intake keeps stools from becoming dry and hard. Adequate fluid also helps fiber to keep stool soft and bulky and prevents dehydration from being a contributing factor to constipation. 13-1 Medications: Antibiotics and laxatives may cause stool to become loose and more frequent. Diuretics may lead to dry, hard, and less frequent stools. Intestinal diversions: Ileostomies normally have liquid, foul-smelling stool. Sigmoid colostomies normally have pasty, formed stool. Administering a Large-Volume Cleansing Enema Cleansing enemas are given to remove feces from the colon. Some of the reasons for administering a cleansing enema include relieving constipation or fecal impaction, preventing involuntary escape of fecal material during surgical procedures, promoting visualization of the intestinal tract by radiographic or instrument examination, and helping to establish regular bowel function during a bowel training program. Cleansing enemas are classified as either large-volume or smallvolume. This skill addresses administering a large-volume enema. Small-volume enemas are addressed in Skill 13-2. Large-volume enemas are known as hypotonic or isotonic, depending on the solution used. Hypotonic (tap water) and isotonic (normal saline solution) enemas are largevolume enemas that result in rapid colonic emptying. However, using such large volumes of solution (adults: 500 to 1000 mL; infants: 150 to 250 mL) may be dangerous for patients with weakened intestinal walls, such as those with bowel inflammation or bowel infection. These solutions often require special preparation and equipment. See Table 13-1 for a list of commonly used enema solutions. (continued) LWBK545_C13_p660-699.qxd 8/6/10 10:30 PM Page 664 Aptara 664 UNIT II Promoting Healthy Physiologic Responses 13-1 T A B L E 13-1 Administering a Large-Volume Cleansing Enema continued COMMONLY USED ENEMA SOLUTIONS Time to Take Effect Solution Amount Action Adverse Effects Tap water (hypotonic) 500–1000 mL Distends intestine, increases peristalsis, softens stool 15 min Fluid and electrolyte imbalance, water intoxication Normal saline (isotonic) 500–1000 mL Distends intestine, increases peristalsis, softens stool 15 min Fluid and electrolyte imbalance, sodium retention Soap 500–1000 mL (concentrate at 3–5 mL/1000 mL) Distends intestine, irritates intestinal mucosa, softens stool 10–15 min Rectal mucosa irritation or damage Hypertonic 70–130 mL Distends intestine, irritates intestinal mucosa 5–10 min Sodium retention Oil (mineral, olive, or cottonseed oil) 150–200 mL Lubricates stool and intestinal mucosa 30 min EQUIPMENT Solution as ordered by the physician at a temperature of 105F to 110F (40C to 43C) for adults in the prescribed amount. (Amount will vary depending on type of solution, patient’s age, and patient’s ability to retain the solution. Average cleansing enema for an adult may range from 750 to 1000 mL.) Disposable enema set, which includes a solution container and tubing Water-soluble lubricant IV pole Necessary additives, as ordered Waterproof pad Bath thermometer (if available) Bath blanket Bedpan and toilet tissue Disposable gloves Additional PPE, as indicated Paper towel Washcloth, soap, and towel ASSESSMENT Ask the patient when he or she had the last bowel movement. Assess the patient’s abdomen, including auscultating for bowel sounds, percussing, and palpating. Because the goal of a cleansing enema is to increase peristalsis, which should increase bowel sounds, assess the abdomen before and after the enema. Assess the rectal area for any fissures, hemorrhoids, sores, or rectal tears. If present, added care should be taken while inserting the tube. Assess the results of the patient’s laboratory work, specifically the platelet count and white blood cell (WBC) count. An enema is contraindicated for patients with a low platelet count or low WBC count. An enema may irritate or traumatize the GI mucosa, causing bleeding, bowel perforation, or infection. Any unnecessary procedures that would place the patient at risk for bleeding or infection should not be performed. Assess for dizziness, lightheadedness, diaphoresis, and clammy skin. The enema may stimulate a vagal response, which increases parasympathetic stimulation, causing a decrease in heart rate. Do not administer enemas to patients who have severe abdominal pain, bowel obstruction, bowel inflammation or bowel infection, or after rectal, prostate, or colon surgery. LWBK545_C13_p660-699.qxd 8/6/10 10:30 PM Page 665 Aptara CHAPTER 13 Bowel Elimination 665 NURSING DIAGNOSIS Determine the related factors for the nursing diagnoses based on the patient’s current status. Appropriate nursing diagnoses may include: Acute Pain Risk for Constipation Constipation Risk for Injury OUTCOME IDENTIFICATION AND PLANNING The expected outcome to be met when administering a cleansing enema is that the patient expels feces. Other appropriate outcomes may include the following: the patient verbalizes decreased discomfort; abdominal distention is absent; and the patient remains free of any evidence of trauma to the rectal mucosa or other adverse effects. IMPLEMENTATION ACTION 1. Verify the order for the enema. Bring necessary equipment to the bedside stand or overbed table. R AT I O N A L E Verifying the physician’s order is crucial to ensuring that the proper enema is administered to the right patient. Bringing everything to the bedside conserves time and energy. Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse. 2. Perform hand hygiene and put on PPE, if indicated. Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions. 3. Identify the patient. Identifying the patient ensures the right patient receives the intervention and helps prevent errors. 4. Close curtains around the bed and close the door to the room, if possible. Explain what you are going to do and why you are going to do it to the patient. Discuss where the patient will defecate. Have a bedpan, commode, or nearby bathroom ready for use. This ensures the patient’s privacy. Explanation relieves anxiety and facilitates cooperation. The patient is better able to relax and cooperate if he or she is familiar with the procedure and knows everything is in readiness when the urge to defecate is felt. Defecation usually occurs within 5 to 15 minutes. 5. Warm solution in amount ordered, and check temperature with a bath thermometer, if available. If bath thermometer is not available, warm to room temperature or slightly higher, and test on inner wrist. If tap water is used, adjust temperature as it flows from faucet (Figure 1). Warming the solution prevents chilling the patient, adding to the discomfort of the procedure. Cold solution could cause cramping; a too-warm solution could cause trauma to intestinal mucosa. FIGURE 1. Preparing enema bag. (continued) LWBK545_C13_p660-699.qxd 8/6/10 10:30 PM Page 666 Aptara 666 UNIT II 13-1 Promoting Healthy Physiologic Responses Administering a Large-Volume Cleansing Enema ACTION continued R AT I O N A L E 6. Add enema solution to container. Release clamp and allow fluid to progress through tube before reclamping. This causes any air to be expelled from the tubing. Although allowing air to enter the intestine is not harmful, it may further distend the intestine. 7. Adjust bed to comfortable working height, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009). Position the patient on the left side (Sims’ position), as dictated by patient comfort and condition. Fold top linen back just enough to allow access to the patient’s rectal area. Place a waterproof pad under the patient’s hip. Having the bed at the proper height prevents back and muscle strain. Sims’ position facilitates flow of solution via gravity into the rectum and colon, optimizing solution retention. Folding back the linen in this manner minimizes unnecessary exposure and promotes the patient’s comfort and warmth. The waterproof pad will protect the bed. 8. Put on nonsterile gloves. Gloves prevent contact with contaminants and body fluids. 9. Elevate solution so that it is no higher than 18 inches (45 cm) above level of anus (Figure 2). Plan to give the solution slowly over a period of 5 to 10 minutes. Hang the container on an IV pole or hold it at the proper height. Gravity forces the solution to enter the intestine. The amount of pressure determines the rate of flow and pressure exerted on the intestinal wall. Giving the solution too quickly causes rapid distention and pressure, poor defecation, or damage to the mucous membrane. 10. Generously lubricate end of rectal tube 2 to 3 inches (5 to 7 cm). A disposable enema set may have a prelubricated rectal tube. Lubrication facilitates passage of the rectal tube through the anal sphincter and prevents injury to the mucosa. 11. Lift buttock to expose anus. Slowly and gently insert the enema tube 3 to 4 inches (7 to 10 cm) for an adult. Direct it at an angle pointing toward the umbilicus, not bladder (Figure 3). Ask patient to take several deep breaths. Good visualization of the anus helps prevent injury to tissues. The anal canal is about 1 to 2 inches (2.5–5 cm) long. The tube should be inserted past the external and internal sphincters, but further insertion may damage intestinal mucous membrane. The suggested angle follows the normal intestinal contour and thus will help to prevent perforation of the bowel. Slow insertion of the tube minimizes spasms of the intestinal wall and sphincters. Deep breathing helps relax the anal sphincters. FIGURE 2. Adjusting the height of the solution container until it FIGURE 3. Inserting enema tip into anus, directing tip toward is no more than 18 inches above the patient. umbilicus. 12. If resistance is met while inserting tube, permit a small amount of solution to enter, withdraw tube slightly, and then continue to insert it. Do not force entry of the tube. Ask patient to take several deep breaths. Resistance may be due to spasms of the intestine or failure of the internal sphincter to open. The solution may help to reduce spasms and relax the sphincter, thus making continued insertion of the tube safe. Forcing a tube may injure the intestinal mucosa wall. Taking deep breaths helps relax the anal sphincter. LWBK545_C13_p660-699.qxd 8/6/10 10:30 PM Page 667 Aptara 667 CHAPTER 13 Bowel Elimination ACTION R AT I O N A L E 13. Introduce solution slowly over a period of 5 to 10 minutes. Hold tubing all the time that solution is being instilled. Introducing the solution slowly helps prevent rapid distention of the intestine and a desire to defecate. 14. Clamp tubing or lower container if patient has desire to defecate or cramping occurs (Figure 4). Instruct the patient to take small, fast breaths or to pant. These techniques help relax muscles and prevent premature expulsion of the solution. 15. After solution has been given, clamp tubing (Figure 5) and remove tube. Have paper towel ready to receive tube as it is withdrawn. Wrapping tube in paper towel prevents dripping of solution. FIGURE 4. Holding bag lower to slow flow of enema solution. FIGURE 5. Clamping tubing before removing. 16. Return the patient to a comfortable position. Encourage the patient to hold the solution until the urge to defecate is strong, usually in about 5 to 15 minutes. Make sure the linens under the patient are dry. Remove your gloves and ensure that the patient is covered. This amount of time usually allows muscle contractions to become sufficient to produce good results. Promotes patient comfort. Removing contaminated gloves prevents spread of microorganisms. 17. Raise side rail. Lower bed height and adjust head of bed to a comfortable position. Promotes patient safety. 18. Remove additional PPE, if used. Perform hand hygiene. Removing PPE properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms. 19. When patient has a strong urge to defecate, place him or her in a sitting position on a bedpan or assist to commode or bathroom (Figure 6). Offer toilet tissues, if not in patient’s reach. Stay with patient or have call bell readily accessible. The sitting position is most natural and facilitates defecation. Fall prevention is a high priority due to the urgency of reaching the commode. 20. Remind patient not to flush the commode before you inspect results of enema. The results need to be observed and recorded. Additional enemas may be necessary if physician has ordered enemas “until clear.” 21. Put on gloves and assist patient, if necessary, with cleaning of anal area. Offer washcloths, soap, and water for handwashing. Remove gloves. Cleaning the anal area and proper hygiene deter the spread of microorganisms. Gloves prevent contact with contaminants and body fluids 22. Leave the patient clean and comfortable. Care for equipment properly. Bacteria that grow in the intestine can be spread to others if equipment is not properly cleaned. 23. Perform hand hygiene. Hand hygiene deters the spread of microorganisms. (continued) LWBK545_C13_p660-699.qxd 8/6/10 10:30 PM Page 668 Aptara 668 UNIT II 13-1 Promoting Healthy Physiologic Responses Administering a Large-Volume Cleansing Enema continued FIGURE 6. Offering toilet tissue to patient on bedside commode. EVALUATION The expected outcome is met when the patient expels feces; the patient verbalizes decreased discomfort; abdominal distention is absent; and the patient remains free of any evidence of trauma to the rectal mucosa or other adverse effect. DOCUMENTATION Guidelines Sample Documentation Document the amount and type of enema solution used; amount, consistency, and color of stool; pain assessment rating; assessment of perineal area for any irritation, tears, or bleeding; and patient’s reaction to procedure. 7/22/12 1310 800 mL warm tap water enema given via rectum. Large amount of soft, brown stool returned. No irritation, tears, or bleeding noted in perineal area. Patient complained of “stomach cramping” relieved when enema was released. Rates pain as 0 after evacuation of enema. —K. Sanders, RN UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS Solution does not flow into rectum: Reposition rectal tube. If solution will still not flow, remove tube and check for any fecal contents. Patient cannot retain enema solution for adequate amount of time: Patient may need to be placed on bedpan in the supine position while receiving enema. The head of the bed may be elevated 30 degrees for the patient’s comfort. Patient cannot tolerate large amount of enema solution: Amount and length of administration may have to be modified if patient begins to complain of pain. Patient complains of severe cramping with introduction of enema solution: Lower solution container and check temperature and flow rate. If the solution is too cold or flow rate too fast, severe cramping may occur. SPECIAL CONSIDERATIONS General Considerations Rectal agents and rectal manipulation, including enemas, should not be used with myelosuppressed patients and/or patients at risk for myelosuppression and mucositis. These interventions can lead to development of bleeding, anal fissures, or abscesses, which are portals for infection. If the patient experiences fullness or pain or if fluid escapes around the tube, stop administration. Wait 30 seconds to a minute and then restart the flow at a slower rate. If symptoms persist, stop administration and contact the patient’s physician. If enema has been ordered to be given “until clear,” check with the physician before administering more than three enemas. Severe fluid and electrolyte imbalances may occur if the patient receives more than three cleansing enemas. Results are considered clear whenever there are no more pieces of stool in enema return. The solution may be colored but still considered a clear return. CHAPTER 13 Bowel Elimination 669 Infant and Child Considerations When administering an enema to a child, ensure that the volume of solution is appropriate and the solution is at a temperature of 100F (37.7C). Insert tubing into the rectum 2 to 3 inches for children, 1 to 11⁄2 inches for infants. Older Adult Considerations Older adult patients who cannot retain the enema solution should receive the enema while on the bedpan in the supine position. For comfort, the head of the bed can be elevated 30 degrees, if necessary, and pillows used appropriately. 13-2 Administering a Small-Volume Cleansing Enema Cleansing enemas are given to remove feces from the colon. Some of the reasons for administering a cleansing enema include relieving constipation or fecal impaction, preventing involuntary escape of fecal material during surgical procedures, promoting visualization of the intestinal tract by radiographic or instrument examination, and helping to establish regular bowel function during a bowel training program. Small-volume enemas are also known as hypertonic enemas. Hypertonic solution preparations are available commercially and are administered in smaller volumes (adult: 70 to 130 mL). These solutions draw water into the colon, which stimulates the defecation reflex. They may be contraindicated in patients for whom sodium retention is a problem. They are also contraindicated for patients with renal impairment or reduced renal clearance, because these patients have compromised ability to excrete phosphate adequately, with resulting hyperphosphatemia (Bowers, 2006). EQUIPMENT ASSESSMENT Assess the patient’s abdomen, including auscultating for bowel sounds, percussing, and palpating. Because the goal of a cleansing enema is to increase peristalsis, which should increase bowel sounds, assess the abdomen before and after the enema. Inspect the rectal area for any fissures, hemorrhoids, sores, or rectal tears. If any of these are noted, added care should be taken while administering the enema. Check the results of the patient’s laboratory work, specifically the platelet count and WBC count. A normal platelet count ranges from 150,000 to 400,000/mm3. A platelet count of less than 20,000 may seriously compromise the patient’s ability to clot blood. Therefore, any unnecessary procedures that would place the patient at risk for bleeding or infection should not be performed. A low WBC count places the patient at risk for infection. Do not administer enemas to patients who have severe abdominal pain, bowel obstruction, bowel inflammation or bowel infection, or after rectal, prostate, and colon surgery. NURSING DIAGNOSIS Determine the related factors for the nursing diagnoses based on the patient’s current status. Appropriate nursing diagnoses may include: Acute Pain Risk for Constipation Constipation Risk for Injury OUTCOME IDENTIFICATION AND PLANNING The expected outcome to be met when administering a cleansing enema is that the patient expels feces and reports a decrease in pain and discomfort. In addition, the patient remains free of any evidence of trauma to the rectal mucosa. Commercially prepared enema with rectal tip Water-soluble lubricant Waterproof pad Bath blanket Bedpan and toilet tissue Disposable gloves Additional PPE, as indicated Paper towel Washcloth, soap, and towel (continued) LWBK545_C13_p660-699.qxd 8/6/10 10:31 PM Page 670 Aptara 670 UNIT II 13-2 Promoting Healthy Physiologic Responses Administering a Small-Volume Cleansing Enema continued IMPLEMENTATION ACTION 1. Verify the order for the enema. Bring necessary equipment to the bedside stand or overbed table. Warm the solution to body temperature in a bowl of warm water. R AT I O N A L E Verifying the physician’s order is crucial to ensuring that the proper enema is administered to the right patient. Bringing everything to the bedside conserves time and energy. Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse. A cold solution can cause intestinal cramping. 2. Perform hand hygiene and put on PPE, if indicated. Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions. 3. Identify the patient. Identifying the patient ensures the right patient receives the intervention and helps prevent errors. 4. Close curtains around bed and close the door to the room, if possible. Explain what you are going to do and why you are going to do it to the patient. Discuss where the patient will defecate. Have a bedpan, commode, or nearby bathroom ready for use. This ensures the patient’s privacy. Explanation relieves anxiety and facilitates cooperation. The patient is better able to relax and cooperate if he or she is familiar with the procedure and knows everything is in readiness when the urge to defecate is felt. Defecation usually occurs within 5 to 15 minutes. 5. Adjust bed to comfortable working height, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009). Position the patient on the left side (Sims’ position), as dictated by patient comfort and condition. Fold top linen back just enough to allow access to the patient’s rectal area. Place a waterproof pad under the patient’s hip. Having the bed at the proper height prevents back and muscle strain. Sims’ position facilitates flow of solution via gravity into the rectum and colon, optimizing retention of solution. Folding back the linen in this manner minimizes unnecessary exposure and promotes the patient’s comfort and warmth. The waterproof pad will protect the bed. 6. Put on nonsterile gloves. Gloves prevent contact with contaminants and body fluids. 7. Remove the cap and generously lubricate end of rectal tube 2 to 3 inches (5 to 7 cm) (Figure 1). Lubrication facilitates passage of the rectal tube through the anal sphincter and prevents injury to the mucosa. 8. Lift buttock to expose anus. Slowly and gently insert the rectal tube 3 to 4 inches (7 to 10 cm) for an adult. Direct it at an angle pointing toward the umbilicus, not bladder (Figure 2). Do not force entry of the tube. Ask patient to take several deep breaths. Good visualization helps prevent injury to tissues. The anal canal is about 1 to 2 inches (2.5 to 5 cm) long. Insert the tube past the external and internal sphincters; further insertion may damage intestinal mucous membrane. The suggested angle follows the normal intestinal contour, helping prevent perforation of the bowel. Forcing a tube may injure the intestinal mucosa wall. Taking deep breaths helps relax the anal sphincter. FIGURE 1. Removing cap from prepackaged enema solution container. FIGURE 2. Inserting tube into rectum, directing toward umbilicus. LWBK545_C13_p660-699.qxd 8/6/10 10:31 PM Page 671 Aptara 671 CHAPTER 13 Bowel Elimination ACTION R AT I O N A L E 9. Compress the container with your hands (Figure 3). Roll the end up on itself, toward the rectal tip. Administer all the solution in the container. Rolling the container aids administration of all of the contents of the container. FIGURE 3. Compressing the container. 10. After solution has been given, remove tube, keeping the container compressed. Have paper towel ready to receive tube as it is withdrawn. Encourage the patient to hold the solution until the urge to defecate is strong, usually in about 5 to 15 minutes. This amount of time usually allows muscle contractions to become sufficient to produce good results. 11. Remove gloves. Return the patient to a comfortable position. Make sure the linens under the patient are dry. Ensure that the patient is covered. Promotes patient comfort. Removing contaminated gloves prevents spread of microorganisms. 12. Raise side rail. Lower bed height and adjust head of bed to a comfortable position. Promotes patient safety. 13. Remove additional PPE, if used. Perform hand hygiene. Removing PPE properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms. 14. When patient has a strong urge to defecate, place him or her in a sitting position on a bedpan or assist to commode or bathroom. Stay with patient or have call bell readily accessible. The sitting position is most natural and facilitates defecation. Fall prevention is a high priority due to the urgency of reaching the commode. 15. Remind patient not to flush the commode before you inspect the results of the enema. The results need to be observed and recorded. Additional enemas may be necessary if physician has ordered enemas “until clear.” 16. Put on gloves and assist patient, if necessary, with cleaning of anal area. Offer washcloths, soap, and water for handwashing. Remove gloves. Cleaning the anal area and proper hygiene deter the spread of microorganisms. 17. Leave the patient clean and comfortable. Care for equipment properly. Bacteria that grow in the intestine can be spread to others if equipment is not properly cleaned. 18. Perform hand hygiene. EVALUATION Hand hygiene deters the spread of microorganisms. The expected outcome is met when the patient expels feces; the patient verbalizes decreased discomfort; abdominal distention is absent; and the patient remains free of any evidence of trauma to the rectal mucosa or other adverse effect. (continued) 672 UNIT II 13-2 Promoting Healthy Physiologic Responses Administering a Small-Volume Cleansing Enema continued DOCUMENTATION Guidelines Document the amount and type of enema solution used; amount, consistency, and color of stool; pain assessment rating; assessment of perineal area for any irritation, tears, or bleeding; and patient’s reaction to procedure. Sample Documentation 7/22/12 1310 210-mL Fleet enema given via rectum. Large amount of soft, brown stool returned. No irritation, tears, or bleeding noted in perineal area. Patient states “stomach fullness” relieved when enema was released. Rates pain as 0 after evacuation of enema. —K. Sanders, RN UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS Patient cannot retain enema solution for adequate amount of time: Patient may need to be placed on bedpan in the supine position while receiving enema. The head of the bed may be elevated 30 degrees for the patient’s comfort. SPECIAL CONSIDERATIONS General Considerations In myelosuppressed patients and/or patients at risk for myelosuppression and mucositis, rectal agents and manipulation, including enemas, are discouraged because they can lead to development of bleeding, anal fissures, or abscesses, which are portals for infection (NCI, 2006). Infant and Child Considerations Position the infant or toddler on the abdomen with knees bent. Position the child or adolescent on the left side with the right leg flexed toward chest (Kyle, 2008). Insert tubing into the rectum 1/2 to 1 inch for infants and 2 to 3 inches for children. Hold the child’s buttocks together for 5 to 10 minutes if needed to encourage retention of the enema (Kyle, 2008). Enemas containing phosphates should be used with caution in children under 12 years of age due to the potential for dehydration, electrolyte imbalances, and sodium phosphate toxicity (Bowers, 2006). Older Adult Considerations Enemas containing phosphates should be used with caution in frail older patients due to the potential for dehydration, electrolyte imbalances, and sodium phosphate toxicity (Bowers, 2006). 13-3 Administering a Retention Enema Retention enemas are ordered for various reasons. Oil-retention enemas help to lubricate the stool and intestinal mucosa, making defecation easier. Carminative enemas help to expel flatus from the rectum and relieve distention secondary to flatus. Medicated enemas are used to administer a medication rectally. Anthelmintic enemas are administered to destroy intestinal parasites. Nutritive enemas are administered to replenish fluids and nutrition rectally. EQUIPMENT Enema solution (varies depending on reason for enema), often prepackaged, commercially prepared solutions Nonsterile gloves Additional PPE, as indicated Waterproof pad Bath blanket Washcloth, soap, and towel Bedpan or commode Toilet tissue Water-soluble lubricant LWBK545_C13_p660-699.qxd 8/6/10 10:31 PM Page 673 Aptara CHAPTER 13 Bowel Elimination 673 ASSESSMENT Ask the patient when he or she had the last bowel movement. Assess the patient’s abdomen, including auscultating for bowel sounds, percussing, and palpating. Because the goal of a cleansing enema is to increase peristalsis, which should increase bowel sounds, assess the abdomen before and after the enema. Assess the rectal area for any fissures, hemorrhoids, sores, or rectal tears. If present, added care should be taken while inserting the tube. Assess the results of the patient’s laboratory work, specifically the platelet count and WBC count. An enema is contraindicated for patients with a low platelet count or low WBC count. An enema may irritate or traumatize the GI mucosa, causing bleeding, bowel perforation, or infection. Any unnecessary procedures that would place the patient at risk for bleeding or infection should not be performed. Assess for dizziness, lightheadedness, diaphoresis, and clammy skin. The enema may stimulate a vagal response, which increases parasympathetic stimulation, causing a decrease in heart rate. Enemas should not be administered to patients who have severe abdominal pain, bowel obstruction, bowel inflammation or bowel infection, or after rectal, prostate, and colon surgery. NURSING DIAGNOSIS Determine the related factors for the nursing diagnoses based on the patient’s current status. Appropriate nursing diagnoses may include: Constipation Risk for Infection Risk for Injury Imbalanced Nutrition, Less than Body Requirements Acute Pain OUTCOME IDENTIFICATION AND PLANNING The expected outcome to be met when administering a retention enema is that the patient retains the solution for the prescribed, appropriate length of time and experiences the expected therapeutic effect of the solution. Other appropriate outcomes may include the following: the patient verbalizes decreased discomfort; abdominal distention is absent; patient demonstrates signs and symptoms indicative of a resolving infection; patient exhibits signs and symptoms of adequate nutrition; and the patient remains free of any evidence of trauma to the rectal mucosa or other adverse effect. IMPLEMENTATION ACTION 1. Verify the order for the enema. Bring necessary equipment to the bedside stand or overbed table. Warm the solution to body temperature in a bowl of warm water. R AT I O N A L E Verifying the physician’s order is crucial to ensuring that the proper enema is administered to the right patient. Bringing everything to the bedside conserves time and energy. Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse. A cold solution can cause intestinal cramping. 2. Perform hand hygiene and put on PPE, if indicated. Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions. 3. Identify the patient. Identifying the patient ensures the right patient receives the intervention and helps prevent errors. 4. Close curtains around bed and close the door to the room, if possible. Explain what you are going to do and why you are going to do it to the patient. Have a bedpan, commode, or nearby bathroom ready for use. This ensures the patient’s privacy. Explanation relieves anxiety and facilitates cooperation. The patient is better able to relax and cooperate if he or she is familiar with the procedure and knows everything is in readiness if the urge to dispel the enema is felt. 5. Adjust bed to comfortable working height, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009). Position the patient on the left side (Sims’ position), as dictated by patient comfort and condition. Fold top linen back just enough to allow access to the patient’s rectal area. Place a waterproof pad under the patient’s hip. Having the bed at the proper height prevents back and muscle strain. Sims’ position facilitates flow of solution via gravity into the rectum and colon, optimizing retention of solution. Folding back the linen in this manner minimizes unnecessary exposure and promotes the patient’s comfort and warmth. The waterproof pad will protect the bed. (continued) LWBK545_C13_p660-699.qxd 8/6/10 10:31 PM Page 674 Aptara 674 UNIT II 13-3 Promoting Healthy Physiologic Responses Administering a Retention Enema ACTION continued R AT I O N A L E 6. Put on nonsterile gloves. Gloves prevent contact with blood and body fluids. 7. Remove cap of prepackaged enema solution. Apply a generous amount of lubricant to the tube. Lubrication is necessary to minimize trauma on insertion. 8. Lift buttock to expose anus. Slowly and gently insert rectal tube 3 to 4 inches (7 to 10 cm) for an adult. Direct it at an angle pointing toward the umbilicus (Figure 1). Ask patient to take several deep breaths. Good visualization of the anus helps prevent injury to tissues. The anal canal is about 1 to 2 inches (2.5 to 5 cm) long. The tube should be inserted past the external and internal sphincters, but further insertion may damage intestinal mucous membrane. The suggested angle follows the normal intestinal contour and thus will help to prevent perforation of the bowel. Slow insertion of the tube minimizes spasms of the intestinal wall and sphincters. Deep breathing helps relax the anal sphincters. FIGURE 1. Inserting tube into rectum, directing toward umbilicus. 9. If resistance is met while inserting the tube, permit a small amount of solution to enter, withdraw tube slightly, and then continue to insert it. Do not force entry of tube. Resistance may be due to spasms of the intestine or failure of the internal sphincter to open. The solution may help to reduce spasms and relax the sphincter, thus making continued insertion of the tube safe. Forcing a tube may injure the intestinal mucosa wall. 10. Slowly squeeze enema container, emptying entire contents. Compressing the container slowly allows the solution to enter the rectum and prevent rapid distention of the intestine and a desire to defecate. 11. Remove container while keeping it compressed. Have paper towel ready to receive tube as it is withdrawn. If container is released, a vacuum will form, allowing some of the enema solution to re-enter the container. 12. Instruct patient to retain enema solution for at least 30 minutes or as indicated, per manufacturer’s direction. Solution needs to dwell for at least 30 minutes, or per manufacturer’s direction, to allow for optimal action of solution. 13. Remove your gloves. Return the patient to a comfortable position. Make sure the linens under the patient are dry and ensure that the patient is covered. Removing contaminated gloves prevents spread of microorganisms. Promotes patient comfort. Removing contaminated gloves prevents spread of microorganisms. 14. Raise side rail. Lower bed height and adjust head of bed to a comfortable position. Promotes patient safety. 15. Remove additional PPE, if used. Perform hand hygiene. Removing PPE properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms. LWBK545_C13_p660-699.qxd 8/6/10 10:31 PM Page 675 Aptara CHAPTER 13 Bowel Elimination ACTION 675 R AT I O N A L E 16. If the patient has a strong urge to dispel the solution, place him or her in a sitting position on bedpan or assist to commode or bathroom. Stay with patient or have call bell readily accessible. The sitting position is most natural and facilitates defecation. Fall prevention is a high priority due to the urgency of reaching the commode. 17. Remind patient not to flush commode before you inspect results of enema, if used for bowel evacuation. Record character of stool, as appropriate, and patient’s reaction to enema. The results need to be observed and recorded. 18. Put on gloves and assist patient, if necessary, with cleaning of anal area. Offer washcloths, soap, and water for handwashing. Remove gloves. Cleaning the anal area and proper hygiene deter the spread of microorganisms. Removing PPE properly reduces the risk for infection transmission and contamination of other items. 19. Leave patient clean and comfortable. Care for equipment properly. Bacteria that grow in the intestine can be spread to others if equipment is not properly cleaned. 20. Perform hand hygiene. EVALUATION Hand hygiene deters the spread of microorganisms. The expected outcome is met when the patient expels feces without evidence of trauma to the rectal mucosa. Depending on the reason for the retention enema, other outcomes met may include patient verbalizes a decrease in pain after enema; patient demonstrates signs and symptoms indicative of a resolving infection; and patient exhibits signs and symptoms of adequate nutrition. DOCUMENTATION Guidelines Sample Documentation Document the amount and type of enema solution used; length of time retained by the patient; amount, consistency, and color of stool, as appropriate; pain assessment rating; assessment of perineal area for any irritation, tears, or bleeding; and patient’s reaction to procedure. 6/26/12 2030 100 mL of mineral oil administered as enema via rectum. Small amount of firm, black stool returned. Small (approx. 1 cm) tear noted at 2 o’clock position on anus. No erythema or bleeding noted. Physician notified of tear and stool color. Reports pain at 2 on a 0 to 10 rating scale after enema evacuated. —K. Sanders, RN UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS Solution does not flow into rectum: Reposition rectal tube; if solution still will not flow, remove and check for any fecal contents. Patient cannot retain enema solution for adequate amount of time: Patient may need to be placed on bedpan in supine position while receiving enema. Elevate the head of the bed 30 degrees for the patient’s comfort. If still unable to retain, notify physician. SPECIAL CONSIDERATIONS General Considerations In myelosuppressed patients and/or patients at risk for myelosuppression and mucositis, rectal agents and manipulation, including enemas, are discouraged because they can lead to development of bleeding, anal fissures, or abscesses, which are portals for infection (NCI, 2006). Infant and Child Considerations Insert tubing into the rectum 2 to 3 inches for children, 1 to 11⁄2 inches for infants. 676 UNIT II Promoting Healthy Physiologic Responses 13-4 Digital Removal of Stool When a patient develops a fecal impaction (prolonged retention or an accumulation of fecal material that forms a hardened mass in the rectum), the stool must sometimes be broken up manually. Digital removal of feces is considered as a last resort after other methods of bowel evacuation have been unsuccessful (Kyle et al., 2004). Patient discomfort and irritation of the rectal mucosa may occur. Many patients find that a sitz bath or tub bath after this procedure soothes the irritated perineal area. An oil-retention enema may be ordered to be given before the procedure to soften stool. EQUIPMENT ASSESSMENT Verify the time of the patient’s last bowel movement by asking the patient and checking the patient’s medical record. Assess the abdomen, including auscultating for bowel sounds, percussing, and palpating. Inspect the rectal area for any fissures, hemorrhoids, sores, or rectal tears. If any of these are noted, consult the prescriber for the appropriateness of the intervention. Assess the results of the patient’s laboratory work, specifically the platelet count and WBC count. Digital removal of stool is contraindicated for patients with a low platelet count or low WBC count. Digital removal of stool may irritate or traumatize the GI mucosa, causing bleeding, bowel perforation, or infection. Do not perform any unnecessary procedures that would place the patient at risk for bleeding or infection. Assess for dizziness, lightheadedness, diaphoresis, and clammy skin. Assess pulse rate and blood pressure before and after the procedure. The procedure may stimulate a vagal response, which increases parasympathetic stimulation, causing a decrease in heart rate and blood pressure. Do not perform digital removal of stool on patients who have bowel inflammation or bowel infection, or after rectal, prostate, and colon surgery. NURSING DIAGNOSIS Determine the related factors for the nursing diagnoses based on the patient’s current status. Appropriate nursing diagnoses may include: Constipation Risk for Injury Acute Pain OUTCOME IDENTIFICATION AND PLANNING The expected outcome to achieve when digitally removing stool is that the patient will expel feces with assistance. Other appropriate outcomes may include the patient verbalizes decreased discomfort; abdominal distention is absent; and the patient remains free of any evidence of trauma to the rectal mucosa or other adverse effect. Disposable gloves Additional PPE, as indicated Water-soluble lubricant Waterproof pad Bedpan Toilet paper, washcloth, and towel Sitz bath (optional) IMPLEMENTATION ACTION 1. Verify the order. Bring necessary equipment to the bedside stand or overbed table. R AT I O N A L E Digital removal of stool is considered an invasive procedure and requires a physician’s order. Verifying the medical order is crucial to ensuring that the proper procedure is administered to the right patient. Bringing everything to the bedside conserves time and energy. Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse. 2. Perform hand hygiene and put on PPE, if indicated. Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions. 3. Identify the patient. Identifying the patient ensures the right patient receives the intervention and helps prevent errors. LWBK545_C13_p660-699.qxd 8/6/10 10:31 PM Page 677 Aptara 677 CHAPTER 13 Bowel Elimination ACTION R AT I O N A L E 4. Close curtains around bed and close the door to the room, if possible. Explain what you are going to do and why you are going to do it to the patient. Discuss signs and symptoms of a slow heart rate. Instruct patient to alert you if any of these symptoms are felt during the procedure. Have a bedpan ready for use. This ensures the patient’s privacy. Explanation relieves anxiety and facilitates cooperation. The patient is better able to relax and cooperate if he or she is familiar with the procedure. 5. Adjust bed to comfortable working height, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009). Position the patient on the left side (Sims’ position), as dictated by patient comfort and condition. Fold top linen back just enough to allow access to the patient’s rectal area. Place a waterproof pad under the patient’s hip. Having the bed at the proper height prevents back and muscle strain. Sims’ position facilitates access into the rectum and colon. Folding back the linen in this manner minimizes unnecessary exposure and promotes the patient’s comfort and warmth. The waterproof pad will protect the bed. 6. Put on nonsterile gloves. This protects you from microorganisms in feces. The GI tract is not a sterile environment. 7. Generously lubricate index finger with water-soluble lubricant and insert finger (Figure 1) gently into anal canal, pointing toward the umbilicus. Lubrication reduces irritation of the rectum. The presence of the finger added to the mass tends to cause discomfort for the patient if the work is not done slowly and gently. 8. Gently work the finger around and into the hardened mass to break it up (Figure 2) and then remove pieces of it. Instruct patient to bear down, if possible, while extracting feces to ease in removal. Place extracted stool in bedpan. Fecal mass may be large and may need to be removed in smaller pieces. FIGURE 1. Inserting lubricated forefinger of dominant hand into FIGURE 2. Gently working finger around to break up stool mass. anal canal. 9. Remove impaction at intervals if it is severe. Instruct patient to alert you if he or she begins to feel lightheaded or nauseated. If patient reports either symptom, stop removal and assess patient. 10. Put on clean gloves. Assist patient, if necessary, with cleaning of anal area (Figure 3). Offer washcloths, soap, and water for handwashing. If patient is able, offer sitz bath. This helps to prevent discomfort, irritation, and vagal nerve stimulation. Cleaning deters the transmission of microorganisms and promotes hygiene. Sitz bath may relieve the irritated perianal area. (continued) LWBK545_C13_p660-699.qxd 8/6/10 10:31 PM Page 678 Aptara 678 UNIT II 13-4 Promoting Healthy Physiologic Responses Digital Removal of Stool ACTION continued R AT I O N A L E FIGURE 3. Helping to clean anal area with washcloth and soap. 11. Remove gloves. Return the patient to a comfortable position. Make sure the linens under the patient are dry. Ensure that the patient is covered. Removing contaminated gloves prevents spread of microorganisms. The other actions promote patient comfort. 12. Raise side rail. Lower bed height and adjust head of bed to a comfortable position. These promote patient safety. 13. Remove additional PPE, if used. Perform hand hygiene. EVALUATION Removing PPE properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms. The expected outcome is met when the fecal impaction is removed and the patient expels feces with assistance; the patient verbalizes decreased discomfort; abdominal distention is absent; and the patient remains free of any evidence of trauma to the rectal mucosa or other adverse effect. DOCUMENTATION Guidelines Sample Documentation Document the following: color, consistency, and amount of stool removed; condition of perianal area after procedure; pain assessment rating; and patient’s reaction to procedure. 6/29/12 1030 Large amount of hard, brown stool removed with digital examination. Perineal area remains free from tears, erythema, or bleeding. Patient denied any lightheadedness or nausea during procedure. Rates pain at 1 on a scale of 0 to 10. —K. Sanders, RN UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS Patient complains of being dizzy, lightheaded, or nauseated or begins to vomit: Stop digital stimulation immediately. Vagal nerve might have been stimulated. Assess heart rate and blood pressure. Notify physician. Patient experiences a large amount of pain during procedure: Stop procedure and notify physician. SPECIAL CONSIDERATIONS In myelosuppressed patients and/or patients at risk for myelosuppression and mucositis, rectal agents and manipulation, including enemas, are discouraged because they can lead to development of bleeding, anal fissures, or abscesses, which are portals for infection (NCI, 2006). CHAPTER 13 Bowel Elimination 13-5 679 Applying a Fecal Incontinence Pouch A fecal incontinence pouch is used to protect the perianal skin from excoriation due to repeated exposure to liquid stool. A skin barrier is applied before the pouch to protect the patient’s skin and improve adhesion. If excoriation is already present, the skin barrier should be applied before applying a pouch. EQUIPMENT ASSESSMENT Assess the amount and consistency of stool being passed. Also assess the frequency. Inspect the perianal area for any excoriation, wounds, or hemorrhoids. NURSING DIAGNOSIS Determine the related factors for the nursing diagnoses based on the patient’s current status. Appropriate nursing diagnoses may include: Bowel Incontinence Impaired Skin Integrity Risk for Impaired Skin Integrity Risk for Infection OUTCOME IDENTIFICATION AND PLANNING The expected outcome to achieve when applying a fecal incontinence pouch is that the patient expels feces into the pouch and maintains intact perianal skin. Other outcomes may include the following: patient demonstrates a decrease in the amount and severity of excoriation; patient verbalizes decreased discomfort; and patient remains free of any signs and symptoms of infection. Fecal incontinence pouch Disposable gloves Additional PPE, as indicated Washcloth and towel Urinary drainage (Foley) bag Scissors (optional) Skin protectant or barrier Bath blanket IMPLEMENTATION ACTION 1. Bring necessary equipment to the bedside stand or overbed table. R AT I O N A L E Bringing everything to the bedside conserves time and energy. Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse. 2. Perform hand hygiene and put on PPE, if indicated. Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions. 3. Identify the patient. Identifying the patient ensures the right patient receives the intervention and helps prevent errors. 4. Close curtains around bed and close the door to the room, if possible. Explain what you are going to do and why you are going to do it to the patient. This ensures the patient’s privacy. Explanation relieves anxiety and facilitates cooperation. Discussion promotes cooperation and helps to minimize anxiety. 5. Adjust bed to comfortable working height, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009). Position the patient on the left side (Sims’ position), as dictated by patient comfort and condition. Fold top linen back just enough to allow access to the patient’s rectal area. Place a waterproof pad under the patient’s hip. Having the bed at the proper height prevents back and muscle strain. Sims’ position facilitates access into the rectum and colon, optimizing retention of solution. Folding back the linen in this manner minimizes unnecessary exposure and promotes the patient’s comfort and warmth. The waterproof pad will protect the bed. 6. Put on nonsterile gloves. Cleanse perianal area. Pat dry thoroughly. Gloves protect nurse from microorganisms in feces. The GI tract is not a sterile environment. Skin must be dry for pouch to adhere securely. (continued) LWBK545_C13_p660-699.qxd 8/6/10 10:31 PM Page 680 Aptara 680 UNIT II 13-5 Promoting Healthy Physiologic Responses Applying a Fecal Incontinence Pouch ACTION continued R AT I O N A L E 7. Trim perianal hair with scissors, if needed. It may be uncomfortable if the perianal hair is pulled by adhesive from the fecal pouch. Trimming with scissors minimizes the risk for infection compared with shaving. 8. Apply the skin protectant or barrier and allow it to dry. Skin protectant aids in pouch adhesion and protects skin from irritation and injury from the adhesive. Skin must be dry for pouch to adhere securely. 9. Remove paper backing from adhesive of pouch (Figure 1). Removing the paper backing is necessary so that the pouch can adhere to the skin. 10. With nondominant hand, separate buttocks. Apply fecal pouch to anal area with dominant hand, ensuring that opening of bag is over anus (Figure 2). Opening should be over anus so that stool empties into bag and does not stay on patient’s skin, which could lead to skin breakdown. FIGURE 1. Removing paper backing from adhesive of rectal FIGURE 2. Applying pouch over anal opening. pouch. 11. Release buttocks. Attach connector of fecal incontinence pouch to urinary drainage bag (Figure 3). Hang drainage bag below patient (Figure 4). Bag must be dependent for stool to drain into bag. FIGURE 3. Attaching connector of fecal pouch to tubing of FIGURE 4. Checking that drainage bag is below the level of the drainage bag. patient. CHAPTER 13 Bowel Elimination ACTION 681 R AT I O N A L E 12. Remove gloves. Return the patient to a comfortable position. Make sure the linens under the patient are dry. Ensure that the patient is covered. Promotes patient comfort. Removing contaminated gloves prevents spread of microorganisms. 13. Raise side rail. Lower bed height and adjust head of bed to a comfortable position. Promotes patient safety. 14. Remove additional PPE, if used. Perform hand hygiene. EVALUATION Removing PPE properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms. The expected outcome is met when the patient expels feces into the pouch and maintains intact perianal skin; patient demonstrates a decrease in the amount and severity of excoriation; patient verbalizes decreased discomfort; and patient remains free of any signs and symptoms of infection. DOCUMENTATION Guidelines Document the date and time the fecal pouch was applied; appearance of perianal area; color of stool; intake and output (amount of stool out); and patient’s reaction to procedure. Sample Documentation 8/13/12 1210 Perianal area slightly erythematous. Fecal incontinence bag applied due to incontinence of large amounts of liquid stool and potential skin breakdown. Approximately 90 mL of liquid brown stool noted in drainage bag. —K. Sanders, RN UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS Perianal area becomes excoriated: Remove pouch. Thoroughly cleanse skin and apply skin barrier. Allow to dry completely. Reapply pouch. Monitor pouch adhesion and change pouch as soon as there is a break in adhesion. Stool does not drain from pouch into urinary drainage bag: Stool may be too thick. If stool no longer drains from pouch into drainage bag, remove pouch to prevent perianal skin breakdown. Stool is leaking from around sides of fecal pouch: Remove pouch. Thoroughly cleanse skin and apply skin barrier. Allow to dry completely. Reapply pouch. Monitor pouch adhesion and change pouch as soon as there is a break in adhesion. SPECIAL CONSIDERATIONS Remove fecal pouch at least every 72 hours to check for signs of skin breakdown. 13-6 Changing and Emptying an Ostomy Appliance The word ostomy is a term for a surgically formed opening from the inside of an organ to the outside. The intestinal mucosa is brought out to the abdominal wall, and a stoma, the part of the ostomy that is attached to the skin, is formed by suturing the mucosa to the skin. An ileostomy allows liquid fecal content from the ileum of the small intestine to be eliminated through the stoma. A colostomy permits formed feces in the colon to exit through the stoma. Colostomies are further classified by the part of the colon from which they originate. Ostomy appliances or pouches are applied to the opening to collect stool. They should be emptied promptly, usually when they are one-third to one-half full. If they are allowed to fill up, they may leak or become detached from the skin. Ostomy appliances are available in a one-piece (barrier backing already attached to the pouch) or two-piece (separate pouch that fastens to the barrier backing) system; they are usually changed every 3 to 7 days, although they could be changed more often. Proper application minimizes the (continued) LWBK545_C13_p660-699.qxd 8/6/10 10:31 PM Page 682 Aptara 682 UNIT II 13-6 Promoting Healthy Physiologic Responses Changing and Emptying an Ostomy Appliance continued risk for skin breakdown around the stoma. This skill addresses changing a one-piece appliance. A one-piece appliance consists of a pouch with an integral adhesive section that adheres to the patient’s skin. The adhesive flange is generally made from hydrocolloid. The accompanying Skill Variation addresses changing a two-piece appliance. Box 13-1 summarizes guidelines for care of the patient with a fecal diversion. BOX 13-1 GUIDELINES FOR OSTOMY CARE An ostomy requires specific physical care for which the nurse is initially responsible. Use the following guidelines to help promote the ostomy patient’s physical and psychological comfort: Keep the patient as free of odors as possible. The application of a temporary appliance after surgery or during the time of the first dressing change postoperatively can eliminate much of the fecal odor from a bulky dressing. Empty the ostomy appliance frequently. Inspect the patient’s stoma regularly. It should be dark pink to red and moist. A pale stoma may indicate anemia, and a dark or purple-blue stoma may reflect compromised circulation or ischemia. Bleeding around the stoma and its stem should be minimal. Notify the physician promptly if bleeding persists or is excessive, or if color changes occur in the stoma. Note the size of the stoma, which usually stabilizes within 6 to 8 weeks. Most stomas protrude 1⁄2 to 1 inch from the abdominal surface and may initially appear swollen and edematous. After 6 weeks, the edema has usually subsided. Depending on the surgical technique, the final stoma may be flush with the skin. Erosion of skin around the stoma area can also lead to a flush stoma. If an abdominal dressing is in place, check it frequently for drainage and bleeding. Keep the skin around the stoma site (peristomal area) clean and dry. If care is not taken to protect the skin around the stoma, irritation or infection may occur. EQUIPMENT A leaking appliance frequently causes skin erosion. Candida or yeast infections can also occur around the stoma if the area is not kept dry. Measure the patient’s fluid intake and output. Check the ostomy appliance for the quality and quantity of discharge. Initially after surgery, peristalsis may be inhibited. As peristalsis returns, stool will be eliminated from the stoma. Record intake and output every 4 hours for the first 3 days after surgery. If the patient’s output decreases while intake remains stable, report the condition promptly. Explain each aspect of care to the patient and explain what his or her role will be when he or she begins selfcare. Patient teaching is one of the most important aspects of colostomy care and should include family members, when appropriate. Teaching can begin before surgery, if possible, so that the patient has adequate time to absorb the information. Encourage the patient to participate in care and to look at the ostomy. Patients normally experience emotional depression during the early postoperative period. Help the patient cope by listening, explaining, and being available and supportive. A visit from a representative of the local ostomy support group may be helpful. Patients usually begin to accept their altered body image when they are willing to look at the stoma, make neutral or positive statements concerning the ostomy, and express interest in learning self-care. Basin with warm water Skin cleanser, towel, washcloth Silicone-based adhesive remover Gauze squares Washcloth or cotton balls Skin protectant, such as SkinPrep® One-piece ostomy appliance Closure clamp, if required, for appliance Stoma measuring guide Graduated container, toilet or bedpan Ostomy belt (optional) Disposable gloves Additional PPE, as indicated Small plastic trash bag Waterproof disposable pad LWBK545_C13_p660-699.qxd 8/6/10 10:31 PM Page 683 Aptara CHAPTER 13 Bowel Elimination 683 ASSESSMENT Assess current ostomy appliance, looking at product style, condition of appliance, and stoma (if bag is clear). Note length of time the appliance has been in place. Determine the patient’s knowledge of ostomy care. After removing the appliance, assess the skin surrounding the stoma. Assess any abdominal scars, if surgery was recent. Assess the amount, color, consistency, and odor of stool from ostomy. NURSING DIAGNOSIS Determine the related factors for the nursing diagnosis based on the patient’s current status. Appropriate nursing diagnoses may include: Risk for Impaired Skin Integrity Ineffective Coping Deficient Knowledge Constipation Disturbed Body Image Diarrhea OUTCOME IDENTIFICATION AND PLANNING The expected outcome to be met when changing and emptying an ostomy appliance is that the stoma appliance is applied correctly to the skin to allow stool to drain freely. Other outcomes may include the following: the patient exhibits a moist red stoma with intact skin surrounding the stoma; the patient demonstrates knowledge of how to apply the appliance; patient demonstrates positive coping skills; patient expels stool that is appropriate in consistency and amount for the ostomy location; and the patient verbalizes positive self-image. IMPLEMENTATION ACTION 1. Bring necessary equipment to the bedside stand or overbed table. R AT I O N A L E Bringing everything to the bedside conserves time and energy. Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse. 2. Perform hand hygiene and put on PPE, if indicated. Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions. 3. Identify the patient. Identifying the patient ensures the right patient receives the intervention and helps prevent errors. 4. Close curtains around bed and close the door to the room, if possible. Explain what you are going to do and why you are going to do it to the patient. Encourage the patient to observe or participate, if possible. This ensures the patient’s privacy. Explanation relieves anxiety and facilitates cooperation. Discussion promotes cooperation and helps to minimize anxiety. Having the patient observe or assist encourages self-acceptance. 5. Assist patient to a comfortable sitting or lying position in bed or a standing or sitting position in the bathroom. Either position should allow the patient to view the procedure in preparation to learn to perform it independently. Lying flat or sitting upright facilitates smooth application of the appliance. Emptying an Appliance 6. Put on disposable gloves. Remove clamp and fold end of pouch upward like a cuff (Figure 1). Gloves prevent contact with blood, body fluids, and microorganisms. Creating a cuff before emptying prevents additional soiling and odor. 7. Empty contents into bedpan, toilet, or measuring device (Figure 2). Appliances do not need rinsing because rinsing may reduce appliance’s odor barrier. 8. Wipe the lower 2 inches of the appliance or pouch with toilet tissue (Figure 3). Drying the lower section removes any additional fecal material, thus decreasing odor problems. 9. Uncuff edge of appliance or pouch and apply clip or clamp, or secure Velcro closure. Ensure the curve of the clamp follows the curve of the patient’s body. Remove gloves. Assist patient to a comfortable position. The edge of the appliance or pouch should remain clean. The clamp secures closure. Hand hygiene deters spread of microorganisms. Ensures patient comfort. (continued) LWBK545_C13_p660-699.qxd 8/6/10 10:31 PM Page 684 Aptara 684 UNIT II 13-6 Promoting Healthy Physiologic Responses Changing and Emptying an Ostomy Appliance ACTION FIGURE 1. Removing clamp, getting ready to empty pouch. continued R AT I O N A L E FIGURE 2. Emptying pouch into a measuring device. FIGURE 3. Wiping lower 2 inches of pouch with toilet tissue. 10. If appliance is not to be changed, remove additional PPE, if used. Perform hand hygiene. Removing PPE properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms. Changing an Appliance 11. Place a disposable pad on the work surface. Set up the wash basin with warm water and the rest of the supplies. Place a trash bag within reach. Protects surface. Organization facilitates performance of procedure. 12. Put on clean gloves. Place waterproof pad under the patient at the stoma site. Empty the appliance as described previously. Protects linens and patient from moisture. Emptying the contents before removal prevents accidental spillage of fecal material. 13. Gently remove pouch faceplate from skin by pushing skin from appliance rather than pulling appliance from skin. Start at the top of the appliance, while keeping the abdominal skin taut. Apply a silicone-based adhesive remover by spraying or wiping with the remover wipe (Figure 4). The seal between the surface of the faceplate and the skin must be broken before the faceplate can be removed. Harsh handling of the appliance can damage the skin and impair the development of a secure seal in the future. Silicone-based adhesive remover allows for the rapid and painless removal of adhesives and prevents skin stripping (Rudoni, 2008; Stephen-Haynes, 2008). 14. Place the appliance in the trash bag, if disposable. If reusable, set aside to wash in lukewarm soap and water and allow to air dry after the new appliance is in place. Thorough cleaning and airing of the appliance reduce odor and deterioration of appliance. For esthetic and infection-control purposes, discard used appliances appropriately. LWBK545_C13_p660-699.qxd 8/6/10 10:31 PM Page 685 Aptara CHAPTER 13 Bowel Elimination ACTION 685 R AT I O N A L E 15. Use toilet tissue to remove any excess stool from stoma (Figure 5). Cover stoma with gauze pad. Clean skin around stoma with mild soap and water or a cleansing agent and a washcloth. Remove all old adhesive from skin; use an adhesive remover, as necessary. Do not apply lotion to peristomal area. Toilet tissue, used gently, will not damage the stoma. The gauze absorbs any drainage from the stoma while the skin is being prepared. Cleaning the skin removes excretions and old adhesive and skin protectant. Excretions or a buildup of other substances can irritate and damage the skin. Lotion will prevent a tight adhesive seal. FIGURE 4. Removing appliance. FIGURE 5. Using toilet tissue to wipe around stoma. 16. Gently pat area dry. Make sure skin around stoma is thoroughly dry. Assess stoma and condition of surrounding skin (Figure 6). Careful drying prevents trauma to skin and stoma. An intact, properly applied urinary collection device protects skin integrity. Any change in color and size of the stoma may indicate circulatory problems. 17. Apply skin protectant to a 2-inch (5 cm) radius around the stoma, and allow it to dry completely, which takes about 30 seconds. The skin needs protection from the excoriating effect of the excretion and appliance adhesive. The skin must be perfectly dry before the appliance is placed to get good adherence and to prevent leaks. 18. Lift the gauze squares for a moment and measure the stoma opening, using the measurement guide (Figure 7). Replace the gauze. Trace the same-size opening on the back center of the appliance (Figure 8). Cut the opening 1/8 inch larger than the stoma size (Figure 9). The appliance should fit snugly around the stoma, with only 1/8 inch of skin visible around the opening. A faceplate opening that is too small can cause trauma to the stoma. If the opening is too large, exposed skin will be irritated by stool. FIGURE 6. Assessing stoma and peristomal skin. FIGURE 7. Using template to measure size of stoma. (continued) LWBK545_C13_p660-699.qxd 8/6/10 10:31 PM Page 686 Aptara 686 UNIT II 13-6 Promoting Healthy Physiologic Responses Changing and Emptying an Ostomy Appliance ACTION continued R AT I O N A L E FIGURE 8. Tracing the same-sized circle on the back and center FIGURE 9. Cutting the opening 1/8 inch larger than the stoma of skin barrier. size. 19. Remove the backing from the appliance (Figure 10). Quickly remove the gauze squares and ease the appliance over the stoma (Figure 11). Gently press onto the skin while smoothing over the surface. Apply gentle pressure to appliance for 5 minutes. The appliance is effective only if it is properly positioned and adhered securely. FIGURE 10. Removing paper backing on faceplate. FIGURE 11. Easing appliance over the stoma. 20. Close bottom of appliance or pouch by folding the end upward and using the clamp or clip that comes with the product, or secure Velcro closure. (Figure 12). Ensure the curve of the clamp follows the curve of the patient’s body. A tightly sealed appliance will not leak and cause embarrassment and discomfort for the patient. 21. Remove gloves. Assist the patient to a comfortable position. Cover the patient with bed linens. Place the bed in the lowest position. Provides warmth and promotes comfort and safety. 22. Put on clean gloves. Remove or discard equipment and assess patient’s response to procedure. Gloves prevent contact with blood, body fluids, and microorganisms that contaminate the used equipment. The patient’s response may indicate acceptance of the ostomy as well as the need for health teaching. LWBK545_C13_p660-699.qxd 8/6/10 10:31 PM Page 687 Aptara CHAPTER 13 Bowel Elimination ACTION 687 R AT I O N A L E FIGURE 12. Closing bottom of pouch. 23. Remove gloves and additional PPE, if used. Perform hand hygiene. EVALUATION Removing PPE properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms. The expected outcomes are met when the patient tolerates the procedure without pain and the peristomal skin remains intact without excoriation. Odor is contained within the closed system. The patient participates in ostomy appliance care, demonstrates positive coping skills, and expels stool that is appropriate in consistency and amount for the location of the ostomy. DOCUMENTATION Guidelines Sample Documentation Document appearance of stoma, condition of peristomal skin, characteristics of drainage (amount, color, consistency, unusual odor), and patient’s reaction to procedure. 7/22/12 1630 Colostomy appliance changed due to leakage. Stoma is pink, moist, and flat against abdomen. No erythema or excoriation of surrounding skin. Moderate amount of pasty, brown stool noted in bag. Patient asking appropriate questions during appliance application. States, “I’m ready to try the next one.” —B. Clapp, RN UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS Peristomal skin is excoriated or irritated: Make sure that the appliance is not cut too large. Skin that is exposed inside of the ostomy appliance will become excoriated. Assess for the presence of a fungal skin infection. If present, consult with prescriber to obtain appropriate treatment. Thoroughly cleanse skin and apply skin barrier. Allow to dry completely. Reapply pouch. Monitor pouch adhesion and change pouch as soon as there is a break in adhesion. Patient continues to notice odor: Check system for any leaks or poor adhesion. Clean outside of bag thoroughly when emptying. Bag continues to come loose or fall off: Thoroughly cleanse skin and apply skin barrier. Allow to dry completely. Reapply pouch. Monitor pouch adhesion and change pouch as soon as there is a break in adhesion. Stoma is protruding into bag: This is called a prolapse. Have patient rest for 30 minutes. If stoma is not back to normal size within that time, notify physician. If stoma stays prolapsed, it may twist, resulting in impaired circulation to the stoma. (continued) LWBK545_C13_p660-699.qxd 8/6/10 10:31 PM Page 688 Aptara 688 UNIT II 13-6 Promoting Healthy Physiologic Responses Changing and Emptying an Ostomy Appliance continued Skill Variation Applying a Two-Piece Appliance A two-piece colostomy appliance is composed of a pouch and a separate adhesive faceplate (Figure A). The faceplate left in place for a period of time, usually 2 to 5 days. During this period, when the colostomy appliance requires changing, only the bag needs to be replaced. There are two main types of twopiece appliance: those that ‘click’ together and those that ‘adhere’ together. The clicking Tupperware-type joining action provides extra security because there is a sensation when the appliance is secured, which the patient can feel. One problem with this type of system is that those with reduced manual dexterity may find it difficult to secure. Another disadvantage is that it is less discreet because the parts of the appliance that click together are more bulky than the one-piece system. Two-piece appliances with an adhesive system have the advantage that they are more discreet than conventional two-piece systems. They may also be simpler to use for those with poor manual dexterity. A potential disadvantage is that if the adhesive is not joined correctly and forms a crease, then feces or flatus may leak out, causing odor and embarrassment (Burch & Sica, 2007). Regardless of the type of two-piece appliance in use, the procedure to change is basically the same. 6. Place a disposable pad on the work surface. Set up the wash basin with warm water and the rest of the supplies. Place a trash bag within reach. 7. Put on clean gloves. Place waterproof pad under the patient at the stoma site. Empty the appliance as described previously in Skill 13-6. 8. Gently remove pouch faceplate from skin by pushing skin from appliance rather than pulling appliance from skin. Start at the top of the appliance, while keeping the abdominal skin taut. Apply a silicone-based adhesive remover by spraying or wiping with the remover wipe. Push the skin from the appliance rather than pulling the appliance from the skin. 9. Place the appliance in the trash bag, if disposable. If reusable, set aside to wash in lukewarm soap and water and allow to air dry after the new appliance is in place. 10. Use toilet tissue to remove any excess stool from stoma. Cover stoma with gauze pad. Clean skin around stoma with mild soap and water or a cleansing agent and a washcloth. Remove all old adhesive from skin; use an adhesive remover as necessary. Do not apply lotion to peristomal area. 11. Gently pat area dry. Make sure skin around stoma is thoroughly dry. Assess stoma and condition of surrounding skin. 12. Apply skin protectant to a 2-inch (5 cm) radius around the stoma, and allow it to dry completely, which takes about 30 seconds 13. Lift the gauze squares for a moment and measure the stoma opening, using the measurement guide. Replace the gauze. Trace the same-size opening on the back center of the appliance faceplate. Cut the opening 1/8 inch larger than the stoma size. FIGURE A. Two-piece appliance. 14. Remove the backing from the faceplate. Quickly remove the gauze squares and ease the faceplate over the stoma. Gently press onto the skin while smoothing over the surface. Apply gentle pressure to faceplate for 5 minutes (Figure B). 1. Bring necessary equipment to the bedside stand or overbed table. 2. Perform hand hygiene and put on PPE, if indicated. 3. Identify the patient. 4. Close curtains around the bed and close door to room, if possible. Explain what you are going to do and why you are going to do it to the patient. Encourage patient to observe or participate, if possible. 5. Assist patient to a comfortable sitting or lying position in bed or a standing or sitting position in the bathroom. FIGURE B. Gently press faceplate to skin. LWBK545_C13_p660-699.qxd 08/09/2010 11:57 AM Page 689 Aptara CHAPTER 13 Bowel Elimination Skill Variation Applying a Two-Piece Appliance 15. Apply the appliance pouch to the faceplate following manufacturer’s directions. If using a ‘click’ system, lay the ring on the pouch over the ring on the faceplate. Ask the patient to tighten stomach muscles, if possible. Beginning at one edge of the ring, push the pouch ring onto the faceplate ring (Figure C). A ‘click’ should be heard when the pouch is secured onto the faceplate. 689 continued 16. If using an ‘adhere’ system, remove the paper backing from the faceplate and pouch. Starting at one edge, carefully match the pouch adhesive with the faceplate adhesive. Press firmly and smooth the pouch onto the faceplate, taking care to avoid creases. 17. Close bottom of pouch by folding the end upward and using clamp or clip that comes with product, or secure Velcro closure. Ensure the curve of the clamp follows the curve of the patient’s body. 18. Remove gloves. Assist the patient to a comfortable position. Cover the patient with bed linens. Place the bed in the lowest position. 19. Put on clean gloves. Remove or discard equipment and assess patient’s response to procedure. 20. Remove gloves and additional PPE, if used. Perform hand hygiene. FIGURE C. Applying appliance pouch to faceplate. EVIDENCE FOR PRACTICE Skin irritation and damage can occur as a result of ostomy appliance removal. This skin stripping is a source of patient discomfort and pain, and can lead to peristomal skin breakdown. Related Research Rudoni, C. (2008). A service evaluation of the use of silicone-based adhesive remover. British Journal of Nursing, Stoma Care Supplement, 17(2), S4, S6, S8–S9. This study examined patients’ opinions regarding the use of a silicone-based adhesive remover when removing a stoma appliance. A silicone-based adhesive remover was distributed to patients who had their stomas, including colostomies, ileostomies, and urostomies, from 2 weeks to 15 years. Patients were instructed in the use of the product and completed questionnaires after using the product. Of the participants, 91% found their stoma appliance easier to remove with the adhesive remover and felt strongly that the product should continue to be made available to all ostomy patients. Relevance for Nursing Practice Nurses are in an important position to influence patient care practices. Results of this study suggest that patients experience great benefit from the use of a silicone-based adhesive remover. Nurses need to advocate the use of these products to prevent skin irritation and breakdown and to improve the quality of life for patients with ostomies. 690 UNIT II Promoting Healthy Physiologic Responses 13-7 Irrigating a Colostomy Irrigations are infrequently used to promote regular evacuation of some colostomies. Various factors, such as the site of the colostomy in the colon (sigmoid colostomy) and the patient’s and physician’s preferences, determine whether a colostomy is irrigated. Ileostomies are not irrigated because the fecal content of the ileum is liquid and cannot be controlled. When successful, colostomy irrigation can offer a regular, predictable elimination pattern for the patient, allowing for the use of a small covering over the colostomy between irrigations instead of a regular appliance (Karadag, Mentes, & Ayaz, 2005). EQUIPMENT ASSESSMENT Ask patient if he or she has been experiencing any abdominal discomfort. Ask patient about date of last irrigation and whether there have been any changes in stool pattern or consistency. If the patient irrigates his or her colostomy at home, ask if he or she has any special routines during irrigation, such as reading the newspaper or listening to music. Also determine how much solution the patient typically uses for irrigation. The normal amount of irrigation fluid varies, but is usually around 750 to 1000 mL for an adult. If this is a first irrigation, the normal irrigation volume is around 250 to 500 mL. Assess the ostomy, ensuring that the diversion is a colostomy. Note placement of colostomy on abdomen, color and size of ostomy, color and condition of stoma, and amount and consistency of stool. NURSING DIAGNOSIS Determine the related factors for the nursing diagnosis based on the patient’s current status. Possible nursing diagnoses may include: Deficient Knowledge Ineffective Coping Anxiety Disturbed Body Image Constipation Risk for Injury OUTCOME IDENTIFICATION AND PLANNING The expected outcome to be met when irrigating a colostomy is that the patient expels soft, formed stool. Other appropriate outcomes include the patient remains free of any evidence of trauma to the stoma and intestinal mucosa; the patient demonstrates the ability to participate in care; the patient voices increased confidence with ostomy care; and the patient demonstrates positive coping mechanisms. Disposable irrigation system and irrigation sleeve Waterproof pad Bedpan or toilet Water-soluble lubricant IV pole Disposable gloves Additional PPE, as indicated Lukewarm solution at a temperature of 105F to 110F (40C to 43C) (as ordered by physician; normally tap water) Washcloth, soap, and towels Paper towel New ostomy appliance, if needed, or stoma cover IMPLEMENTATION ACTION 1. Verify the order for the irrigation. Bring necessary equipment (Figure 1) to the bedside stand or overbed table. 2. Perform hand hygiene and put on PPE, if indicated. R AT I O N A L E Verifying the medical order is crucial to ensuring that the proper treatment is administered to the right patient. Bringing everything to the bedside conserves time and energy. Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse. Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions. LWBK545_C13_p660-699.qxd 8/6/10 10:31 PM Page 691 Aptara 691 CHAPTER 13 Bowel Elimination ACTION R AT I O N A L E Irrigating bag Irrigating sleeve Stoma cone FIGURE 1. Irrigating sleeve and bag. 3. Identify the patient. Identifying the patient ensures the right patient receives the intervention and helps prevent errors. 4. Close curtains around bed and close the door to the room, if possible. Explain what you are going to do and why you are going to do it to the patient. Plan where the patient will receive irrigation. Assist patient onto bedside commode or into nearby bathroom. This ensures the patient’s privacy. Explanation relieves anxiety and facilitates cooperation. Discussion promotes cooperation and helps to minimize anxiety. The patient cannot hold the irrigation solution. A large immediate return of irrigation solution and stool usually occurs. 5. Warm solution in amount ordered and check temperature with a bath thermometer, if available. If bath thermometer is not available, warm to room temperature or slightly higher, and test on inner wrist. If tap water is used, adjust temperature as it flows from faucet. If the solution is too cool, patient may experience cramps or nausea. Solution that is too warm or hot can cause irritation and trauma to intestinal mucosa. 6. Add irrigation solution to container. Release clamp and allow fluid to progress through tube before reclamping. This causes any air to be expelled from the tubing. Although allowing air to enter the intestine is not harmful, it may further distend the intestine. 7. Hang container so that bottom of bag will be at patient’s shoulder level when seated. Gravity forces the solution to enter the intestine. The amount of pressure determines the rate of flow and pressure exerted on the intestinal wall. 8. Put on nonsterile gloves. Gloves prevent contact with blood, body fluids, and microorganisms. 9. Remove ostomy appliance and attach irrigation sleeve (Figure 2). Place drainage end into toilet bowl or commode. The irrigation sleeve directs all irrigation fluid and stool into the toilet or bedpan for easy disposal. 10. Lubricate end of cone with water-soluble lubricant. This facilitates passage of the cone into the stoma opening. 11. Insert the cone into the stoma. Introduce solution slowly over a period of 5 to 6 minutes. Hold cone and tubing (or if patient is able, allow patient to hold) all the time that solution is being instilled (Figure 3). Control rate of flow by closing or opening the clamp. If the irrigation solution is administered too quickly, the patient may experience nausea and cramps due to rapid distention and increased pressure in the intestine. 12. Hold cone in place for an additional 10 seconds after the fluid is infused. This will allow a small amount of dwell time for the irrigation solution. 13. Remove cone. Patient should remain seated on toilet or bedside commode. An immediate return of solution and stool will usually occur, followed by a return in spurts for up to 45 more minutes. 14. After majority of solution has returned, allow patient to clip (close) bottom of irrigating sleeve and continue with daily activities. An immediate return of solution and stool will usually occur, followed by a return in spurts for up to 45 more minutes. (continued) LWBK545_C13_p660-699.qxd 8/6/10 10:31 PM Page 692 Aptara 692 UNIT II 13-7 Promoting Healthy Physiologic Responses Irrigating a Colostomy ACTION continued R AT I O N A L E A B FIGURE 2. Positioning of irrigation sleeve on abdomen. FIGURE 3. Colostomy irrigation. (A) Inserting irrigation cone. (B) Instilling irrigating fluid with sleeve in place. 15. After solution has stopped flowing from stoma, put on clean gloves. Remove irrigating sleeve and cleanse skin around stoma opening with mild soap and water. Gently pat peristomal skin dry. Gloves prevent contact with blood and body fluids. Peristomal skin must be clean and free of any liquid or stool before application of new appliance. 16. Attach new appliance to stoma or stoma cover (see Skill 13-6), as needed. Some patients will not require an appliance, but may use a stoma cover. Protects stoma. 17. Remove gloves. Return the patient to a comfortable position. Make sure the linens under the patient are dry, if appropriate. Ensure that the patient is covered. Promotes patient comfort. Removing contaminated gloves prevents spread of microorganisms. 18. Raise side rail. Lower bed height and adjust head of bed to a comfortable position, as necessary. Promotes patient safety. 19. Remove gloves and additional PPE, if used. Perform hand hygiene. EVALUATION Removing PPE properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms. The expected outcome is achieved when the irrigation solution flows easily into the stoma opening and the patient expels soft, formed stool; the patient remains free of any evidence of trauma to the stoma and intestinal mucosa; the patient participates in irrigation with increasing confidence; and the patient demonstrates positive coping mechanisms. DOCUMENTATION Guidelines Document the procedure, including the amount of irrigating solution used; color, amount, and consistency of stool returned; condition of stoma; degree of patient participation; and patient’s reaction to irrigation. CHAPTER 13 Bowel Elimination Sample Documentation 693 8/1/12 0945 1000 mL of warmed tap water used to irrigate colostomy. Large amount of soft, dark brown stool returned. Patient performed procedure with small amount of assistance from nurse. Stoma is pink and moist with no signs of bleeding. Patient tolerated procedure without incident. New ostomy bag applied. —B. Clapp, RN UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS Irrigation solution is not flowing or is flowing at a slow rate: Check clamp on tubing to make sure that the tubing is open. Gently manipulate cone in stoma; if stool or tissue is blocking opening of cone, this may block flow of fluid. Remove cone from stoma, clean the area, and gently reinsert. Alternately, assist the patient to a side-lying or sitting position in bed. Place a waterproof pad under the irrigation sleeve. Place the drainage end of the sleeve in a bedpan. SPECIAL CONSIDERATIONS In myelosuppressed patients, irrigation is contraindicated. Do not manipulate the stoma of a neutropenic patient (NCI, 2006). EVIDENCE FOR PRACTICE The amount of solution required for the irrigation of a colostomy, as well as other aspects of the procedure, varies in clinical practice. What is the evidence for the recommended procedure? Related Research Cesaretti, I., Santos, V., Schiftan, S., et al. (2008). Colostomy irrigation: review of a number of technical aspects. Acto Paulista de Enfermagem [online], 21(2), 338–344. Available www.scielo.br/scielo.php?. Accessed October 28, 2008. This literature review examined four technical aspects related to colostomy irrigation: volume of water to be instilled, postoperative moment to start the irrigation, maintenance of a 24-hour interval between the irrigations, and time spent for the execution of the procedure. The goal was to identify the most appropriate teaching and procedure. The authors identified 63 articles related to colostomy irrigation. They concluded that there is no consensus in the available literature. The volume of water for instillation varied from 500 mL to 1500 mL. It was noted in clinical practice that the average instilled irrigation volume is 1000 mL. The time period the procedure was introduced to patients ranged from 5 days to 6 months after surgery. The maintenance time of a 24-hour interval between irrigations varied from 2 weeks to 6 months. The time spent on the actual irrigation procedure ranged from 20 to 90 minutes. They concluded that there is no consensus in the available literature. Relevance for Nursing Practice 13-8 Nurses are in an important position to influence patient care practices. Results of this study suggest that more studies are needed to standardize the procedure of colostomy irrigation. Nurses should be encouraged to produce other studies related to colostomy irrigation and re-evaluate the procedure to achieve a standardization of the procedure. Irrigating a Nasogastric Tube Connected to Suction Nasogastric tubes can be used to decompress the stomach and to monitor for GI bleeding. The tube is usually attached to suction when used for these reasons or the tube may be clamped. The tube must be kept free from obstruction or clogging and is usually irrigated every 4 to 6 hours. EQUIPMENT NG tube connected to continuous or intermittent suction Normal saline solution for irrigation Nonsterile gloves Additional PPE, as indicated Irrigation set (or a 60-mL catheter-tip syringe and cup for irrigating solution) Clamp Disposable pad or bath towel (continued) LWBK545_C13_p660-699.qxd 8/6/10 10:31 PM Page 694 Aptara 694 UNIT II Promoting Healthy Physiologic Responses 13-8 Irrigating a Nasogastric Tube Connected to Suction continued Emesis basin Tape measure, or other measuring device pH paper and measurement scale ASSESSMENT Assess abdomen by inspecting for presence of distention, auscultating for bowel sounds, and palpating the abdomen for firmness or tenderness. If the abdomen is distended, consider measuring the abdominal girth at the umbilicus. If the patient reports any tenderness or nausea, confer with the physician. If the NG tube is attached to suction, assess suction to ensure that it is running at the prescribed pressure. Also, inspect drainage from NG tube, including color, consistency, and amount. NURSING DIAGNOSIS Determine the related factors for the nursing diagnosis based on the patient’s current status. Possible nursing diagnoses may include: Imbalanced Nutrition: Less than Body Requirements Risk for Injury Risk for Deficient Fluid Volume Deficit OUTCOME IDENTIFICATION AND PLANNING The expected outcome to achieve when irrigating a patient’s NG tube is that the tube will maintain patency with irrigation. In addition, the patient will not experience any trauma or injury. IMPLEMENTATION ACTION 1. Assemble equipment. Verify the medical order or facility policy and procedure regarding frequency of irrigation, solution type, and amount of irrigant. Check expiration dates on irrigating solution and irrigation set. R AT I O N A L E Assembling equipment provides for organized approach to task. Verification ensures patient receives correct intervention. Agency policy dictates safe interval for reuse of equipment. 2. Perform hand hygiene and put on PPE, if indicated. Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions. 3. Identify the patient. Identifying the patient ensures the right patient receives the intervention and helps prevent errors. 4. Explain the procedure to the patient and why this intervention is needed. Answer any questions as needed. Perform key abdominal assessments as described above. Explanation facilitates patient cooperation. Due to potential changes in patient’s condition, assessment is vital before initiating intervention. 5. Pull the patient’s bedside curtain. Raise bed to a comfortable working position, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009). Assist patient to 30- to 45-degree position, unless this is contraindicated. Pour the irrigating solution into container. Provide for privacy. Appropriate working height facilitates comfort and proper body mechanics for the nurse. This position minimizes risk for aspiration. Preparing the irrigation provides for organized approach to the task. 6. Put on gloves. Check placement of NG tube. (Refer to Skill 11-2.) Checking placement before the instillation of fluid is necessary to prevent accidental instillation into the respiratory tract if the tube has become dislodged. 7. Draw up 30 mL of saline solution (or amount indicated in the order or policy) into syringe (Figure 1). This delivers measured amount of irrigant through tube. Saline solution (isotonic) compensates for electrolytes lost through nasogastric drainage. 8. Clamp suction tubing near connection site (Figure 2). If needed, disconnect tube from suction apparatus and lay on disposable pad or towel, or hold both tubes upright in nondominant hand (Figure 3). Clamping protects patient from leakage of NG drainage. LWBK545_C13_p660-699.qxd 8/6/10 10:31 PM Page 695 Aptara 695 CHAPTER 13 Bowel Elimination ACTION FIGURE 1. Preparing syringe with 30 mL saline for irrigation. R AT I O N A L E FIGURE 2. Clamping suction tube while disconnecting it from NG tube. FIGURE 3. Holding both tubes upright to prevent backflow. 9. Place tip of syringe in tube. If Salem sump or

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