NF 30 Promoting Bowel Elimination PDF

c ha p t e r 30 Promoting Bowel Elimination http://evolve.elsevier.com/Williams/fundamental Objectives Upon completing this chapter, you should be able to do the following: Theory 1. Describe the process of normal bowel elimination. 2. Identify abnormal stool characteristics. 3. Summarize the phy...

c ha p t e r 30 Promoting Bowel Elimination http://evolve.elsevier.com/Williams/fundamental Objectives Upon completing this chapter, you should be able to do the following: Theory 1. Describe the process of normal bowel elimination. 2. Identify abnormal stool characteristics. 3. Summarize the physiologic effects of hypoactive bowel, as well as nursing interventions to assist patients with constipation. 4. Analyze safety considerations related to giving a patient an enema. 5. Analyze the psychosocial implications for a patient who has an ostomy. 6. Discuss the stoma and periostomal assessment and skin care. 7. Describe three types of intestinal diversions. Clinical Practice 1. Summarize nursing measures to promote regular bowel elimination in patients. 2. Collect a stool specimen. 3. Perform a focused assessment of bowel function. 4. Write a nursing care plan for a patient with bowel problems. 5. Prepare to administer an enema. 6. Assist and teach a patient with a bowel retraining program for incontinence. 7. Evaluate the performance of a patient who is selfcatheterizing a continent diversion. 8. Provide ostomy care, including irrigation and changing the ostomy appliance. Skills & Steps Skills Skill 30.1 Administering an Enema 582 Skill 30.2 Changing an Ostomy Appliance Steps 589 Steps 30.1 Removing a Fecal Impaction 584 Steps 30.2 Catheterizing a Continent Ileostomy Steps 30.3 Irrigating a Colostomy 590 Key Terms anus (Ā-nŭs, p. 573) appliances (p. 585) atrophy (Ă-trō-fē, p. 574) bile (BĪL, p. 574) bowel training program (p. 584) chyme (KĪM, p. 573) colostomy (kŏ-LŎS-tō-mē, p. 587) constipation (p. 575) defecate (DĔF-ĕ-kāt, p. 573) diarrhea (dī-ă-RĒ-ă, p. 576) effluent (ĕ-FLŪ-ĕnt, p. 587) excoriation (ĕks-kŏr-ē-Ā-shŭn, p. 579) fecal impaction (FĒ-kăl ĭm-PĂK-shŭn, p. 576) fecal incontinence (ĭn-KŎN-tĭ-nĕns, p. 576) feces (FĒ-sēz, p. 573) flatus (FLĀ-tŭs, p. 575) 572 gastrocolic reflex (găs-trō-KŎL-ĭk RĒ-lĕks, p. 573) hemorrhoid (HĔM-ō-rŏyd, p. 574) ileostomy (ĭl-ē-ŎS-tō-mē, p. 587) melena (MĔL-ĕh-nă, p. 574) occult (ŏ-KŬLT, p. 574) ostomy (ŎS-tō-mē, p. 585) paralytic ileus (păr-ă-LĪ-tĭk ĭl-e-ŭs, p. 574) periostomal (pĕr-ĭ-Ŏ-stō-mŭl, p. 587) peristalsis (pĕr-ĭ-stăl-sĭs, p. 573) rectum (RĔK-tŭm, p. 573) sphincter (SFĬNK-tĕr, p. 573) steatorrhea (STĒ-ă-tŏ-RĒ-ă, p. 574) stoma (STŌ-mă, p. 585) stool (p. 573) vagal response (VĀ-găl rĕ-SPŎNS, p. 584) Valsalva maneuver (văl-SĂL-vă mă-NŪ-vĕr, p. 573) 586 Promoting Bowel Elimination CHAPTER 30 Concepts Covered in This Chapter • • • • • • • • • • • Anxiety Culture Elimination Evidence Fluid and electrolyte balance Infection Inlammation Mobility Pain Patient education Safety The term bowel refers to the intestine. Bowel elimination, the excretion of solid waste, is the inal step in the process of digestion. The processing of nutrients through digestion is discussed in Chapter 26. There are ways to assist the patient in achieving and maintaining regular elimination of stool (waste matter from the bowel) and procedures to alleviate problems related to alterations in elimination. When an alternative for waste elimination is needed because of disease of the intestine, an ostomy (opening into the intestine for outlow) may be performed. OVERVIEW OF THE STRUCTURE AND FUNCTION OF THE INTESTINAL SYSTEM WHICH STRUCTURES OF THE INTESTINAL SYSTEM ARE INVOLVED IN WASTE ELIMINATION? • The small intestine—consisting of the duodenum, the jejunum, and the ileum—carries chyme (liqueied food and digestive juices) from the stomach to the large intestine. • The small intestine attaches to the large intestine at the cecum. The ileocecal valve controls the progress of substances into the large intestine. • The large intestine has four main sections: the ascending colon, transverse colon, descending colon, and sigmoid colon. It is larger in diameter than the small intestine but only about 59 inches (1.5 meters) long (Fig. 30.1). • The rectum (distal portion of the large intestine where feces are stored) connects to the anus (opening of the rectum at the skin). • The walls of the intestines have four layers: mucosa, submucosa, muscular layer, and a serous layer called the serosa. WHAT ARE THE FUNCTIONS OF THE INTESTINES? • The small intestine further processes chyme into a more liquid state. Food substances are absorbed into the bloodstream from the villi on the walls of the small intestine. • In the large intestine, water, sodium, and chlorides are reabsorbed, and waste material is propelled to the anus. 573 • The large intestine contains bacteria that break down waste products. Water is extracted from the waste during transit. • Peristalsis (wavelike movement through the intestines) moves chyme and gas formed by bacterial action through the intestines. The circular, longitudinal, and oblique muscle layers of the intestine expand and contract to accommodate and move the chyme. • The movement of liquid and gas causes the rumbling noise of bowel sounds. It takes about 18 to 72 hours for food to move from the mouth to the anus. • Feces (intestinal waste material) are stored in the sigmoid colon until they move into the rectum for expulsion through the anus. • As the rectum ills, the pressure on the sphincter (circular muscle that closes an oriice) of the anus increases until the urge to defecate (expel feces) occurs. • The abdominal muscles contract to help force the evacuation of the rectum. • The internal anal sphincter, located at the top of the anal canal, is under involuntary control; the external anal sphincter at the end of the anal canal is controlled voluntarily. • The gastrocolic (stomach to colon) reflex initiates peristalsis, which in turn initiates the urge to defecate; it is stimulated by eating. Relex emptying of the rectum can be stopped by tightening the voluntary anal sphincter. • Intra-abdominal pressure increases when a person holds the breath, closes the glottis, and tightens the abdominal muscles. This initiates voluntary defecation and is called the Valsalva maneuver. • The vermiform appendix attaches to the cecum of the ascending colon, and it has no known digestive function. Stomach Liver Spleen Gallbladder Pancreas Transverse colon Small intestine Ascending colon Descending colon Cecum Appendix Sigmoid colon Rectum Anus FIGURE 30.1 The intestinal system. 574 UNIT VI Meeting Basic Physiologic Needs WHAT EFFECT DOES AGING HAVE ON THE INTESTINAL TRACT? • Atrophy (decrease in size) of the villi in the small intestine may decrease the total absorptive surface. However, it has not been proven that decreased absorption of nutrients, other than fats and vitamin B12, actually occurs. • Sometimes twisting of blood vessels supplying the large intestine compromises the blood low to the large intestine. Motility in the large intestine may decrease in some individuals, but bowel habits do not change with aging in the healthy individual. CHARACTERISTICS OF STOOL Stool is another term for feces. Normal feces are onequarter solid material and three-quarters water. The solid material consists of about 30% dead bacteria and 70% undigested roughage from carbohydrate, fat, protein, and inorganic matter. The appearance of stool is inluenced by diet and metabolism. NORMAL CHARACTERISTICS OF STOOL Normal stool is light to dark brown, soft, and formed in children and adults. Infant stool may be dark yellow and unformed, depending on the type of feedings. The light to dark brown color is caused by bile (orange or yellow digestive luid produced by the liver). The color of feces may be changed by certain vitamins, drugs, or diet. Stool is usually tubular in shape and has a diameter of about 1 inch (2.5 cm). ABNORMAL CHARACTERISTICS OF STOOL The most serious abnormality is blood in the stool. Fresh blood in the stool is easily visible as bright red on the surface of the stool. Occult (hidden) or old blood is suspected when the stool changes from a normal brown appearance to a dark black color with a sticky appearance. The observance of blood in the stool should be reported promptly and recorded in the patient’s medical record. Clinical Cues A small amount of bleeding from a hemorrhoid (an enlarged vein inside or just outside the rectum) or an irritation caused by straining to defecate may clear up without any treatment. Ask your patient to describe the color and appearance of the stool. For example, formed brown stool (normal) that has small streaks of red blood on the outer surface of the stool suggests that the blood is associated with a hemorrhoid. Bright red blood mixed in the stool is a sign of a recent gastrointestinal (GI) bleeding that has occurred in the large intestine. The color indicates that the blood has not undergone digestion in the upper part of the bowel, nor has it been in the intestinal tract for a prolonged time. Eating red foods, such as beets, may make the stool appear red, so a dietary assessment is essential. As blood moves through the stomach or small intestine, it undergoes partial digestion, which changes it to a dark, tarry substance (melena). Pale white or light gray stool indicates an absence of bile in the intestine. This is usually due to an obstruction in the bile or common duct leading to the intestine from the liver and gallbladder. Other abnormal characteristics of feces are the presence of large amounts of mucus, fat, purulent matter, or parasites, such as worms. Unusual amounts of mucus in the stool indicate an irritation or inlammation of the inner surface of the intestines. The mucus coats the stool and gives it a slimy appearance. Stools with an abnormally high fat content (steatorrhea) are usually foul smelling and loat on water. The presence of purulent material indicates drainage of an ulcer that is inlamed or infected. The most common parasitic worms found in the intestines are the tapeworm, pinworm, and roundworm. Clinical Cues Pinworms Younger children may get pinworms, but may be unable to describe the itching sensation in the anal area. One way for parents to check for pinworms is to use a lashlight and observe the anus at night. The worms will appear as small threadlike ilaments around the anus and will withdraw when exposed to a lash of light. The irst signs of colorectal cancer are changes in bowel patterns and stool characteristics. In accordance with the Healthy People 2020 objectives to reduce colorectal cancers, patients should be encouraged to report these changes and to participate in colon cancer screening programs, which include an annual stool test for occult blood. Evidence-based practice indicates that, beginning at the age of 50, colonoscopy is recommended every 10 years (Hande, 2014). Those with risk factors may need more frequent testing starting at an earlier age (American Cancer Society, 2013). HYPOACTIVE BOWEL AND CONSTIPATION Conditions that cause blood in the stool include hemorrhage from ulcers in the stomach or duodenum; severe inlammation or irritation, as in ulcerative colitis or diverticulitis; and cancer. Collection of a stool specimen and testing for occult blood are presented in Chapter 24. An absence or reduction of peristaltic movement of the bowel results in a hypoactive bowel. Some injuries and diseases cause a hypoactive bowel, but often this condition is a complication of immobility. In addition, after abdominal surgery, patients can develop a paralytic ileus; peristalsis stops because Promoting Bowel Elimination CHAPTER 30 the bowel has been manipulated during surgery. In the normal person, lack of suficient dietary iber and decreased exercise may produce a sluggish or hypoactive bowel. Encouraging an increase in iber sources, such as fruit, vegetables, and whole grains, is in accordance with Healthy People 2020 objectives. Sometimes irritable bowel syndrome (IBS) causes hypoactivity of the bowel, although hyperactivity is more common. Health Promotion Promoting Regular Bowel Elimination Instruct the patient to: • Pay attention to the urge to defecate; frequently postponing defecation can lead to constipation. • Eat a diet high in iber. Foods that provide iber are bran, whole grain cereals, nuts, prunes, and other raw fruits and vegetables; cooked vegetables provide some iber (Hall, 2014) (see Table 26.1). Avoid excessive amounts of constipating foods such as cheese, pasta, eggs, and lean meat. • Drink at least eight 8-oz glasses of liquid each day. • Exercise every day; walking is excellent for stimulating bowel function. • Attempt to defecate when the gastrocolic relex is strongest (e.g., after breakfast). • Use aids such as drinking a hot cup of coffee, hot water and lemon juice, or prune juice to aid defecation. • Establish a pattern by attempting defecation at the same time each day. Constipation (decreased frequency of bowel movement or passage of hard, dry feces) is the most common problem of a hypoactive bowel. With constipation, feces become more compacted and hardened, making them more dificult to expel. Feces tend to back up into the colon. Constipation may occur when muscle tone is lacking; when bowel movements are irregular; or when excessive worry, anxiety, or fear is present. Poor abdominal muscle tone Immobility Anxiety or fear Hypoactive bowel Box 30.1 Medications that May Cause or Contribute to Constipation • Narcotic analgesics, especially codeine, morphine, and meperidine, depress central nervous system (CNS) activity and slow peristalsis. • General anesthetics slow peristalsis by depressing CNS activity. • Diuretics rid the body of luid. • Sedatives slow CNS activity and peristalsis. • Antidepressants alter CNS activity and have a drying effect. • Anticholinergics interfere with muscle activation, causing decreased tone in and motility of the gastrointestinal tract, and have drying effects. • Calcium channel blockers cause a blockade of calcium channels, which affects the smooth muscle of the intestine. Nurses must be aware of the potential of illnessinduced constipation. Any patient restricted to bed rest is at risk for constipation. Many medications (Box 30.1), barium x-ray studies, or recovery from surgery can contribute to constipation. Patients at risk for constipation should be identiied early (Concept Map 30.1). Abdominal distention is caused by flatus (gas) accumulation in the intestinal tract when peristalsis is reduced or absent. Just as fecal matter will collect in the hypoactive bowel, so will latus. Distention and gas pains occur frequently after abdominal surgery. The discomfort and pain are caused by the stretching of the intestinal wall and spasm of the muscle layers. Think Critically Your older female patient had abdominal surgery yesterday. You need to know when she starts passing gas and the frequency and consistency of bowel movements, but she says she would be too embarrassed to talk about this, even with a nurse. What could you say to her? Anesthesia and surgery Bed rest Lack of dietary fiber Hardened stool Barium x-ray films Constant vomiting Excessive fluid loss Narcotic pain medication Neurogenic problem 575 Constipation Insufficient fluid intake CONCEPT MAP 30.1 Factors contributing to constipation. Diuretics 576 UNIT VI Meeting Basic Physiologic Needs Life-Span Considerations Older Adult • Older adults who live alone tend to eat more processed convenience foods and do not take in suficient iber; therefore they may be more prone to constipation. • Many older adults decrease luid intake because they have urinary urgency or stress incontinence. The underlying problem may have to be addressed to establish better luid intake and softer stool. • Evidence-based practice indicates that older adult patients should be assessed for polypharmacy, which contributes to constipation. Older adults are also more likely to use over-the-counter laxatives to treat themselves (Rao, 2015). • Older adults who have been regularly taking mineral oil to aid evacuation must be told that mineral oil interferes with vitamin absorption. Bulk-forming laxatives containing psyllium are a better choice. • Products such as Metamucil and Beneiber are readily available without prescription. A large amount of fluid should be taken with these products to prevent constipation and fecal impaction (the rectum and sigmoid colon becoming illed with hardened fecal material). Box 30.2 lists common medications used for constipation. HYPERACTIVE BOWEL AND DIARRHEA Increased motility of the GI tract or increased peristalsis results in a hyperactive bowel. Causes of a hyperactive bowel include inlammation in the GI tract, certain drugs, infectious agents, and diseases such as diverticulitis, ulcerative colitis, Crohn disease, and IBS. Patients who have gastric bypass surgery may also experience diarrhea (frequent loose stool). Diarrhea occurs when increased peristalsis pushes food through the intestinal tract too quickly. The increased speed does not allow enough time for the absorption of nutrients, electrolytes, and water, and the feces are liquid or semiformed. Evacuations are more frequent, with an increased number of stools per day. Often, diarrhea is simply the body trying to rid itself of pathogens or toxins from spoiled food. Moderate diarrhea lasting a couple of days usually clears up by itself. At times, diarrhea can lead to temporary fecal incontinence (the lack of voluntary control over the anal sphincter) and inability to retain feces. See Box 30.2 for a list of common antidiarrheal medications. Cultural Considerations Hand Hygiene to Prevent Diarrhea Box 30.2 Common Medications Used for Constipation or Diarrhea MEDICATIONS USED FOR CONSTIPATION Stool Softeners • Docusate sodium (Colace) • Docusate calcium (Surfak) • Docusate potassium (Dialose) • Polyethylene glycol–electrolyte solution (MiraLAX) Bulk-Forming Laxatives • Polycarbophil (FiberCon) • Psyllium (Metamucil) • Methylcellulose (Citrucel) Irritant or Stimulant Laxatives • Bisacodyl (Dulcolax and Correctol) • Cascara sagrada • Senna (Senokot) • Sennosides (Ex-Lax) Saline Laxatives • Citrate of magnesia • Magnesium hydroxide (Milk of Magnesia) • Sodium phosphate (Phospho-Soda) Laxative for Chronic Constipation • Lubiprostone (Amitiza)* • Methylnaltrexone (Relistor) for opioid-induced constipation MEDICATIONS USED FOR DIARRHEA (ANTIDIARRHEALS) • Diphenoxylate hydrochloride with atropine sulfate (Lomotil) • Loperamide hydrochloride (Imodium) • Difenoxin hydrochloride with atropine sulfate (Motofen) • Paregoric • Opium tincture *Research suggests that Lubiprostone (Amitiza) may be appropriate for opioidinduced constipation without reduction in dosage pain medication (Prichard and Bharucha, 2015) According to the Centers for Disease Control and Prevention (CDC, 2013), 2195 children die of diarrheal disease every day. Preventing transmission of diarrheal organisms through good handwashing is essential. Kamm et al. (2014) conducted a study to determine the relationship between providing handwashing stations and soap and preventing diarrhea in Kenya. They found that having soap available reduced diarrhea, whereas handwashing stations alone did not decrease diarrhea. Most homes had soap, but almost none had a handwashing station. Use of culturally relevant information is important when conducting patient education, even for basic measures such as good handwashing with soap. Life-Span Considerations Older Adult Older adults become dehydrated more quickly than younger adults do. Observe closely for signs of dehydration and luid imbalance when diarrhea occurs. Commercial beverages such as Gatorade that contain sodium and potassium taken in small amounts (1 to 2 oz at a time) will help replace electrolytes if the patient has continuing diarrhea. Evidence-based practice indicates that consumption of caffeinated tea, coffee, or soda further contributes to dehydration (Harvard Health Letter, 2014). If the person becomes confused and dehydrated, a trip to the emergency department for luid replacement may be necessary. QSEN Considerations: Evidence-Based Practice Roles of the Nurse Evidence-based practice indicates that the bowel can be rested by consuming only clear liquids and avoiding solid food for a day or two (IFFGD, 2014). Resumption of solid foods should begin with bland, low iber foods, gradually adding other foods as tolerated. Cottage cheese, gelatin, applesauce, and bananas are usually tolerated well. Promoting Bowel Elimination CHAPTER 30 FECAL INCONTINENCE People of all ages may become incontinent of feces because of illness such as a stroke, traumatic injury, or neurogenic dysfunction. Incontinence is a distressing condition that causes a loss of dignity, embarrassment, or anxiety. People can also experience loss of self-respect or fear of loss of control. It is important to reassure them that there are measures available to assist them with the problem. Life-Span Considerations Older Adult Older adults have a higher incidence of fecal incontinence related to medications, constipation, or impaired neurologic or cognitive function. Institutionalized older adults are more likely to have problems compared with those who live at home (Gillibrand, 2012). Be aware that prolonged constipation can cause fecal impaction. Small amounts of watery incontinence that seep from around the stool plug can be a sign of impaction. 577 • Has there been any exposure to parasites or helminths (especially during travel outside the United States)? • Does diarrhea occur after eating milk products (may indicate lactose intolerance)? • Does diarrhea occur after eating wheat and other gluten products (may indicate sprue or gluten intolerance)? • Does the patient have any food sensitivities? Do spicy foods cause gas discomfort or diarrhea? • Has incontinence been brought on by a neurologic condition or stroke? • Is the incontinent patient receptive to a bowel training program? PHYSICAL ASSESSMENT • Observe the shape of the abdomen with the patient supine. • Auscultate for bowel sounds in all four quadrants. • Percuss for presence of excessive air (gas) in the bowel. • Gently palpate for masses or tenderness in all four quadrants. Clinical Cues APPLICATION OF THE NURSING PROCESS ASSESSMENT (DATA COLLECTION) Every patient is assessed regarding bowel status every day in an inpatient facility. Home care nurses assess bowel status at each visit. The patient is questioned about the regularity of bowel evacuation, problems, and any abnormal characteristics of the stool. If possible, the stool is visually examined. The Focused Assessment box provides guidelines for bowel assessment. Many people think that it is abnormal not to have a bowel movement every day, but having a bowel movement only every 2 or 3 days is normal for some people. Look at all the factors that affect bowel function and the patient’s normal pattern before determining whether there is a problem. Focused Assessment Assessment of the Bowel Use the following points or questions in assessing bowel function and habits. HISTORY • Determine the usual bowel pattern, time of defecation, and measures used to promote defecation, if any (e.g., a cup of coffee, breakfast, dose of Metamucil). • Inquire about use of enemas, laxatives, suppositories, and stool softeners. • Assess for changes in stool characteristics: alternating diarrhea and constipation, changes in stool shape, changes in stool color, stool loating in commode, or foul odor. • Determine usual eating habits and dietary intake. Is there suficient iber in the diet? Does the patient drink suficient luids? • How much exercise does the patient get? • Is the patient taking medications that may cause constipation or diarrhea? • Does the patient have a chronic disorder that contributes to constipation or diarrhea? Place the patient in a supine position. Auscultate for bowel sounds in all four quadrants. Absent or few bowel sounds indicate decreased motility and potential for constipation, or may signal an abnormal bowel blockage. Active bowel sounds are associated with the increased motility that occurs after eating. Loud hyperactive sounds, called borborygmi, can occur with diarrhea (IFFGD, 2015). Distention is revealed by an abdomen that is rounder and tighter in appearance than normal. The patient’s abdomen is assessed for distention by percussion, and the nurse gently palpates the four quadrants of the abdomen to check for tenderness and masses (Lewis et al., 2014). The patient may complain of abdominal discomfort and often describes it as gas pain. Percussion is used to detect abnormal amounts of gas. Areas of gas produce a drum-like, hollow tone. Review assessment of the abdomen in Chapter 22. NURSING DIAGNOSIS When assessment data indicate an intestinal problem, nursing diagnoses are based on the North American Nursing Diagnosis Association-International (NANDA-I) list. Possible choices include: • Constipation related to hypoactive bowel • Diarrhea related to food intolerance • Bowel incontinence related to loss of anal sphincter control • Acute pain related to abdominal distention • Self-care deicit, toileting related to body cast • Disturbed body image related to bowel incontinence • Deicient knowledge related to factors that contribute to constipation PLANNING A care plan is developed by writing short- or long-term expected outcomes for each nursing diagnosis chosen. 578 UNIT VI Meeting Basic Physiologic Needs Sample expected outcomes for the previous nursing diagnoses are: • Constipation will be relieved by walking 1 mile each day. • Episodes of diarrhea will decrease within 3 days. • Patient will improve bowel control within 2 months of starting a retraining program. • Pain from distention will be decreased within 24 hours. • Patient will use an over-the-bed trapeze and a urinal during this shift. • Body image will improve as incontinence lessens. • Patient will identify foods to add to the diet to increase iber during this shift. See Nursing Care Plan 30.1 for further examples of expected outcomes. Ordered treatments, such as enemas, may take extra time. When an incontinent patient is assigned, more time must be allotted for attempts at toileting, for cleaning the patient after accidents, and for bowel training, if appropriate. Assignment Considerations Patient Ambulation The task of assisting with ambulation is frequently assigned to the nursing assistant. If the patient resists the idea of getting out of bed or ambulating, support the nursing assistant by giving the patient some concrete examples of the beneits (e.g., getting up and walking decreases the risk of pneumonia, deep vein thrombosis, pressure injuries, and constipation). Remember to thank the assistant for his hard work and contributions to the patient’s well-being. IMPLEMENTATION You must assist the patient on bed rest with use of the bedpan or bedside commode. Privacy is important. Patients are often embarrassed by the sounds and smells accompanying defecation of feces. Patients should be Nursing Care Plan 30.1 Care of the Patient with Constipation SCENARIO Martina Svoboda, age 64, fractured her left hip in a fall a month ago. Her hip is healing, but she still has dificulty walking. While in the hospital, her usual bowel pattern became disrupted. She has had dificulty with constipation ever since (“having dificulty with bowels”). She is currently staying at her daughter’s home. The stool is hard and dry; she normally has a bowel movement every third day. PROBLEM/NURSING DIAGNOSIS Bowel movement pattern changed since hospitalization/Constipation related to immobility. Supporting Assessment Data Subjective: States … “is having dificulty with bowels.” Objective: Stool is hard and dry. Goals/Expected Outcomes Nursing Interventions Selected Rationale Evaluation Constipation will be relieved by medication within 2 days. Usual bowel pattern will be reestablished within 2 to 3 weeks. Obtain history of bowel pattern before accident and hip fracture. History provides baseline for choosing interventions. Is the patient making progress toward reestablishing the usual bowel pattern? Assess dietary and luid intake. Assists in determining whether enough luid and iber is being consumed. Teach ways to increase iber in the diet (e.g., raw fruits and vegetables; whole grain breads). Knowledge promotes correct food choices. States will have oatmeal for breakfast with fresh fruit. Increase luid intake to 1500 mL/day. Fluid keeps stool soft. Dislikes drinking too much water: “I don’t like plain water.” Use stool softeners at bedtime for 1 week. Stool softeners promote softer stool. Taking stool softener each evening. Encourage walking and abdominal muscle-setting exercises. Muscle strengthening assists with evacuation efforts. Attending physical therapy three times a week. Starting exercise program. Work with family in providing regular, unhurried bathroom time. Helps to establish a daily evacuation pattern. Progressing toward expected outcomes. Continue plan. CRITICAL THINKING QUESTIONS 1. Because the patient still has trouble walking, how could you promote exercise that will strengthen abdominal muscles and assist with bowel evacuation? 2. Ms. Svoboda tells you she does not like to drink water. She loves tea. What would you suggest in the way of increased luid intake? Promoting Bowel Elimination CHAPTER 30 helped into as much of a sitting position as their condition allows. The abdominal muscles and gravity can then assist with defecation. Always wear gloves when helping the patient off the bedpan. Check to see that the patient is thoroughly cleaned, especially if the patient cannot lift up off the pan to clean the anus and surrounding area. The bedpan should be thoroughly cleansed, dried, and put away. The bedside commode should be emptied and cleaned promptly after use. When the average patient has not experienced bowel evacuation within 3 days, measures should be taken to assist elimination. Assessment data guide the measures to be implemented. The least invasive measures are used irst. Encouraging and monitoring activity, adequate luid intake, and a diet with suficient iber may lead to regular bowel elimination. Cultural Considerations Toileting Practices Using a bedpan, a bedside commode, or even a typical American-style toilet may be unfamiliar or uncomfortable for your patient because in many other countries, squatting is a more typical position for elimination. A careful cultural assessment will help identify potential issues. With the help of a translator, explain the use and purpose of required and available equipment. QSEN Considerations: Safety, Evidenced-Based Practice Dangers of Safety Rails Side rails are intended to be a safety measure; however, evidence-based practice indicates that side rails can actually increase the risk for injury for confused patients, as they attempt to crawl around or over the side rails to get out of bed (Shanahan, 2012). Be aware that many incontinent patients are reluctant to call for help even if they understand and acknowledge the use of the call button because, “I didn’t want to bother you again.” Check on patients every 2 hours, or offer toileting on a set schedule, to decrease attempts to get out of bed unassisted. Noninvasive measures that can be used to promote bowel elimination include the consumption of 1 to 3 tablespoons of bran mixed with applesauce, small amounts of prune juice, warmed prune juice and cola, hot water with lemon juice, or stewed or dried prunes. Be careful because some people are particularly sensitive to the effects of prunes, and diarrhea may develop. If these actions are not successful, implement more invasive measures to promote bowel elimination. These measures include the administration of medications to soften the stool, suppositories to stimulate the urge to defecate, laxatives to stimulate bowel activity, and enemas to empty the rectum. All of these measures require a medical order for hospitalized patients. Measures to rid the bowel of barium are essential after a 579 patient has had a barium x-ray examination. Encourage an increase in luid intake of 3500 mL/day for the next 24 hours unless contraindicated. A laxative is often recommended. Encourage home care patients to telephone the nurse if they have not had a bowel movement in 3 days. Impaction may be prevented if constipation is treated early. The patient’s caregiver is taught how to insert a suppository or how to give a small-volume enema in case less invasive measures do not work. When the patient experiences incontinence, cleansing should occur as soon as possible. Skin care must be thorough and gentle because feces irritate the skin and can cause excoriation (abrasion of the skin). The patient who is having diarrheal stools may need a skin protectant around the anus to prevent skin breakdown. Products such as petroleum jelly, A & D ointment, cod liver oil ointments with zinc oxide, and commercial skin barriers are helpful to protect the skin. Gentle washing with soap and water, rinsing, and patting dry are essential. Moist cleansing wipes are useful during diarrheal episodes. QSEN Considerations: Teamwork & Collaboration Teamwork for Better Hygienic Care Hygienic care is usually assigned to the nursing assistant; however, when a bedridden patient has continuous diarrhea, help the assistant to clean the patient. The task of repeated cleaning is exhausting for the caregiver and the patient; it is much easier for two people to accomplish the job. In addition, the patient’s skin needs frequent assessment, and this is a nursing responsibility that cannot be delegated. When diarrhea is thought to be caused by bacteria or a virus, the primary care provider may want to let it run its course for at least 24 hours so that the body has a chance to rid itself of the offending organism. Diarrhea from other causes simply leads to luid and electrolyte loss and should not be allowed to continue for long periods. Treatment involves placing the patient on a clear liquid diet to rest the bowel, replacing luids and electrolytes, and seeking medication to stop the loose stools. Observe for signs of dehydration when the patient has severe diarrhea: decreased skin turgor, dry mucous membranes with thick saliva, and increased thirst. Self-medication for diarrhea should not continue for more than 48 hours without consulting a primary care provider. Patient Education Foods to Assist a Patient with Diarrhea Many antibiotics kill the normal bacteria that reside in the bowel, leading to diarrhea. Teach patients who experience diarrhea from antibiotics to eat yogurt, drink buttermilk, or take probiotics when they begin taking antibiotics. Replacing the normal bacteria with those contained in these food products reestablishes the right balance and stops the diarrhea (Hempel et al., 2012). 580 UNIT VI Meeting Basic Physiologic Needs EVALUATION Evaluation for patients with problems of bowel function is based on whether expected outcomes and goals have been met. If outcomes and goals are not being met, reconsider and revise the plan. Examples of evaluation statements are: • Patient is walking 1 mile a day. • Patient has increased luid intake to 3500 mL and is producing stool every other day. • Patient is participating in a bowel program and is assisted with toileting q 2 hr. • Patient reports less pain and abdominal distention compared with yesterday. • Patient is able to use the trapeze to lift self onto bedpan. • Patient feels better about self since bowel regimen has produced continent stool for 3 days in a row. • Patient recognized that white bread and noodles are contributing to constipation. Nursing Care Plan 30.1 provides other examples of evaluation. Documentation Document any changes in bowel habits, stool characteristics, episodes of constipation or diarrhea, and measures taken to remedy the problem. Document the patient education plan, times of each teaching session, and material covered. Evaluation of patient education is also noted. All measures to promote bowel elimination must be documented. Document the number and approximate amount of diarrheal stools on the appropriate low sheets (I & O and daily activity sheets). RECTAL SUPPOSITORIES Rectal suppositories used to promote bowel movements are glycerin and bisacodyl suppositories. Suppositories that promote bowel evacuation do so by (1) stimulating the inner surface of the rectum and increasing the urge to defecate, (2) forming gas that expands the rectum, or (3) melting into a lubricating material to coat the stool for easier passage through the anal sphincter. See Chapter 34 for the procedure to insert a rectal suppository. colonoscopy, or sigmoidoscopy, or when the bowel is distended by latus. The volume of a cleansing enema depends on the patient’s age: infant or toddler, 50 to 150 mL (normal saline only); ages 3 to 5 years, 200 to 300 mL; school age, 300 to 500 mL; adult, 500 to 1000 mL. Figure 30.2 shows the equipment used for a cleansing enema. An enema kit contains either a bag or a bucket for the solution. The commercially disposable enema, such as the Fleet enema, is convenient and easy to use when only a small amount of luid is needed to stimulate a bowel movement. Enemas can be given at any time, but it is best to try to give them before the morning bath and bed linen change. TYPES OF ENEMAS The type of enema to be given is prescribed by the primary care provider, and it varies depending on the patient’s age and condition, the purpose of the enema, and the primary care provider’s preference (Table 30.1). The commercially packaged enema may require more lubricant on the nozzle; other supplies needed are the same as for any type of enema. When other types of enemas are ordered, consult the facility’s procedure manual for the ingredients and the proportions to use. Retention Enema Often an oil-retention enema is ordered for a patient with constipation. The oil must be retained in the rectum to soften and coat the hardened feces. Instill between 120 and 180 mL of warm oil rectally in the same manner as the cleansing enema, except that the oil should be retained for at least 20 minutes. Prepackaged enemas are usually used for this purpose, but mineral oil or olive oil can be used. AMOUNT AND TEMPERATURE OF SOLUTION Disposable enema units contain about 240 mL of solution (Fig. 30.3). They may be given at room temperature, but work best when slightly warmed. No special Think Critically What time of day would be best for administering a rectal suppository to stimulate defecation? ENEMAS An enema is the introduction of luid into the rectum and colon by means of a tube. Enemas are given to stimulate peristalsis and the urge to defecate or to wash out waste products or feces. Cleansing enemas are given when the bowel is to be examined by x-ray, FIGURE 30.2 Enema equipment. Promoting Bowel Elimination CHAPTER 30 TABLE 30.1 581 Types of Enemas and Their Actions TYPES OF ENEMAS Retention enema EXAMPLES Mineral oil ACTIONS Softens stool as oil is absorbed Cleansing enema Soapsuds (5 mL castile soap in 1000 mL of water), tap water, and saline (500-1000 mL normal saline) Stimulates peristalsis through distention and irritation of colon and rectum Distention reduction enema Carminative (30 g magnesium sulfate, 60 g glycerin, and 90 mL warm water) Relieves discomfort from latus causing distention Medicated enema Sodium polystyrene (Kayexalate) (removes potassium) and neomycin (reduces bacteria) Solution with drugs to reduce bacteria or remove potassium Disposable enema (small volume) Sodium phosphate (Fleet) Stimulates peristalsis by acting as an irritant FIGURE 30.4 Position for giving an enema. QSEN Considerations: Safety Be Careful with “Enemas until Clear” FIGURE 30.3 Disposable enema. (Courtesy C.B. Fleet Co., Lynchburg, VA.) When an order to “give enemas until clear” is written, it means that the return luid must not have any fecal matter in it; however, no more than three large-volume enemas are given without checking with the primary care provider. Repeated enemas may deplete electrolytes and can be dangerous. Clinical Cues preparation is needed; they are ready for use when taken from the package. With the patient in the left Sims position, insert the prelubricated nozzle into the rectum, and instill the solution by squeezing the lexible plastic bottle. Rolling the bottle up from the bottom aids in instilling the entire contents. QSEN Considerations: Safety Not Too Hot, Not Too Cold The temperature of the enema solution should be about 105°F (40.5°C). If a bath thermometer is not available, test the temperature of the luid by pouring a small amount over the inner wrist. It should be warm to the touch but not hot. Solution that is too cool usually cannot be retained; hot solutions may damage the tissues of the rectum. The amount of solution used for a cleansing enema for adults is between 500 and 1000 mL. Hold the container approximately 12 to 18 inches above the patient’s anus and allow the warm solution to run in slowly; a greater height creates too much pressure because the luid runs in too rapidly and causes painful distention of the rectum and colon. This stimulates the urge to defecate immediately, so that the patient cannot retain the luid. If your older adult patient has trouble holding an enema, take a baby bottle nipple, cut off the tip and insert the enema tube through the nipple. Gently support the outer rim of the nipple with your gloved hand; this provides a temporary “plug” that helps the patient retain the enema. RECOMMENDED POSITION The position of choice when giving an enema is the left Sims position, with the hips slightly elevated (Fig. 30.4). This allows the luid, aided by the force of gravity, to low downward along the natural curve of the rectum and descending colon. If the patient is unable to turn to the side, the supine position can be used (Skill 30.1). RECTAL TUBE When a patient is uncomfortable because of latus in the lower bowel, a rectal tube can be inserted in the anus. The tube is similar to the enema tubing. This allows the gas to be expelled without the patient straining to open the anal sphincter. Oral medications to reduce gas have mostly eliminated the use of this tube. 582 UNIT VI Meeting Basic Physiologic Needs Skill 30.1 Administering an Enema An enema is given to evacuate the bowel. Tap water, soapsuds, or saline solution of 500 to 1000 mL is given to the adult with an enema bucket or bag. A disposable enema, consisting of 120 mL of hypertonic solution, may be ordered. An oil-retention enema may be required to soften stool for ease of evacuation. SUPPLIES • Enema container and tubing with clamp, or disposable enema • Bedpan or bedside commode • Underpad or Chux • Lubricant • Gloves • Enema solution and additives as ordered • Bath blanket • Paper towel and toilet tissue For Large-Volume Enema 4. Put on gloves. Fill the enema bag with the correct solution; temperature of the water should be between 100 and 105°F (37.8 and 40.5°C). Expel air from the tubing by opening the clamp and allowing the solution to run through. Use the bedpan or sink to collect the solution; reclamp the tube. (Water too hot may burn the patient; water too cool may cause cramping. Expelling air from tube prevents air from being introduced into the colon, which could cause the patient discomfort.) Review and carry out the Standard Steps in Appendix A. ACTION (RATIONALE) Assessment (Data Collection) 1. Check the primary care provider’s order. Determine what patient knows about the enema procedure. Check to see that a bedpan or bedside commode is on hand. (Ensures an enema order has been written. Determines how much explanation is needed. Bedpan or bedside commode may be needed immediately.) Planning 2. Plan time to give a large-volume enema without interruption. (A large-volume enema procedure may take as long as 30 minutes if the order is “enemas until clear.”) Implementation 3. If possible, place the patient in the left Sims position and drape with a bath blanket. Place the underpad under the buttocks. (Solution travels up the colon when the patient is lying on the left side.) Step 3 Step 4 5. Position the bedside commode or put the bedpan nearby. Generously lubricate the end of the enema tube and, while the patient takes a deep breath, gently insert it about 4 inches in the adult anus. Direct the tube toward the umbilicus. Ask the patient to take a deep breath through the mouth to relax the anal sphincter. Twisting the tube gently helps it pass through the sphincter. (There is a small amount of discomfort as the tube passes through the sphincter; deep breathing helps the patient relax. Excessive force may cause perforation of the rectum.) 6. With the container about 12 to 18 inches above the anus, open the clamp on the tube, steady the tube in place, and allow the solution to low slowly into the bowel over 5 to 10 minutes. Lowering slightly and again raising the container to this height will regulate the speed of the low. Slight pressure on the tubing with the clamp can also slow the low. When the patient expresses discomfort, stop the low by kinking the tubing or clamping it, and instruct the patient to take deep breaths by mouth until the cramping and urge to expel the luid pass. Continue until the patient can retain no more or the container is empty. Clamp the tubing and withdraw it, asking the patient to squeeze the sphincter Promoting Bowel Elimination CHAPTER 30 shut; place the soiled tube on a paper towel. (Instilling luid slowly prevents cramping and usually obtains the best result with the least discomfort. Some patients can hold only a few hundred milliliters of solution at a time; others can tolerate the entire volume.) For Disposable or Oil-Retention Enema 7. Add extra lubricant to the tip if the amount of prelubrication seems insuficient. Insert the tip into the anal opening as directed previously. Gently and slowly squeeze the bottle, and roll it up from the bottom as the contents enter the bowel. Squeeze as much of the luid into the patient as possible. Remove the tip slowly and hold the buttocks together. (The lubricant on the tip sometimes dries out. Disposable enemas contain approximately 120 to 240 mL of solution. An oil-retention enema is given in the same manner, but the patient should retain it for 20 minutes to 2 hours so that it will soften the stool.) 583 and toilet paper within reach. (Patient is likely to lush the toilet unless otherwise instructed.) 9. When the bowel contents have been expelled, assist the patient in cleaning the anal area; observe the results of the enema, noting the color, amount, and consistency of the stool. Remove and clean the bedpan or bedside commode. (Results of the enema are judged by the stool expelled.) 10. Restore the patient unit, lower the bed, and place the call bell within reach. (Provides safety.) Evaluation 11. Ask yourself: Was the patient able to hold suficient enema luid to lush the bowel? Did all the luid seem to return? Was there a normal amount of stool expelled? Does the patient feel relief from fullness and latus? (Answers determine whether enema was successful.) Documentation 12. Note date, time, type of enema, and amount of luid instilled; describe the result, as well as how the patient tolerated the procedure. (Documents the procedure and the results.) Documentation Example 10/12 0930 1000-mL tap water enema, given 500 mL at a time. No c/o severe cramping. Produced large amount of brown formed stool and returned luid. States feels much better. Bed into lowest position, call bell in reach. Resting. (Nurse’s time-stamped electronic signature.) Step 7 For Both Types of Enema 8. Assist the patient onto the bedpan or bedside commode. If the patient uses the toilet, request to see the result before lushing. If a bedpan is used, raise the head of the bed to a sitting position. Place call bell FECAL IMPACTION Fecal impaction means that the rectum and sigmoid colon become illed with hardened fecal material. The most obvious sign of fecal impaction is the absence of (or only a small amount of) bowel movement for more than 3 days in a patient who usually has a bowel movement more frequently. Impaction occurs in patients who are very ill, are on bed rest, or are not fully aware of their surroundings because of a state of confusion. The very young and very old are more prone to fecal impaction. Clinical Cues Passage of small amounts of liquid or semisoft stool onto the bed linens is a sign of fecal impaction. Bacterial action on the hardened surface of the fecal material causes liquefaction. Critical Thinking Questions 1. Why do you think that a patient who is taking a diuretic and is now in the hospital may become constipated and need an enema? 2. When an enema is ordered, how would you organize your work for the day if you were working the day shift? Life-Span Considerations Older Adult • The older adult who becomes dehydrated is very prone to fecal impaction. • Some medications also contribute to impaction, including narcotic pain medication and diuretics. Nursing responsibility includes prevention of fecal impaction by daily assessment of bowel patterns of all patients. Fecal impaction is easier to remove when an oil-retention enema is ordered and given, followed by a cleansing enema 2 to 3 hours later. Sometimes the primary care provider orders the impaction to be digitally broken up after the oil has had time to soften the stool (Steps 30.1). 584 UNIT VI Meeting Basic Physiologic Needs Steps 30.1 Removing a Fecal Impaction When a patient has impacted stool that cannot be lushed out with an oil-retention enema followed by cleansing enemas, manual removal of the impaction is required. The patient should be given analgesia before this procedure because it is painful. Review and carry out the Standard Steps in Appendix A. ACTION (RATIONALE) 1. Assess when the last bowel movement occurred, check risk factors that contribute to constipation, assess the abdomen, and determine whether small amounts of liquid stool have been passed. (Assessment data help in determining whether fecal impaction has occurred.) 2. Have patient assume a left lateral or Sims position. Perform hand hygiene, put on gloves, and arrange the bedpan and toilet tissue on a chair by the bed within reach. Lubricate the index inger. (Generous lubricant makes it easier for the inger to slide up and around the hardened stool and decreases patient discomfort. An oil-retention enema 20 minutes to 3 hours before impaction removal is helpful.) 3. Insert the index inger into the anus and along the wall of the rectum in a slightly curving motion. As the inger meets feces in the rectum, move the inger into the lower portion of the fecal mass, noting the consistency. (This action is uncomfortable for the patient, but you must assess the consistency of the fecal matter.) 4. With the examining index inger, dislodge or break off a small amount of fecal material and gently remove it, placing it in the bedpan. Re-lubricate the inger as needed. Continue removing as much fecal material as you can reach with your inger or until the patient’s discomfort or adverse effects such as palpitations or dizziness warrant discontinuing the procedure. After the patient has rested, re-glove and remove the remaining fecal material. Cleanse the rectal area. Remove gloves and dispose of them properly. (The stool is broken up so that it can be removed with less discomfort to the patient. This action may also trigger the urge to defecate, so the patient may wish to try to have a bowel movement.) 5. Make the patient comfortable, lower the bed, raise side rails (if appropriate), and restore the unit. (Provides safety.) Digital removal of a fecal impaction must be done gently, and the patient must be watched for signs of vagal response (activation of the vagal nerve) from stimulation of the sphincter and rectal wall (Fig. 30.5). The vagal response may cause a slow pulse and cardiac arrhythmia, and an alteration in blood pressure may develop. Should this occur, immediately stop the procedure, place the patient in a supine position, monitor vital signs, and notify the primary care provider. A dose of atropine may be ordered to counteract the vagal response. BOWEL TRAINING FOR INCONTINENCE The treatment for incontinence is training for bowel control. This is a long process, but it helps the patient regain self-esteem. A special effort should be made to help the very old patient overcome incontinence. Patients who require bowel training may be physically disabled or confused. In accordance with National Patient Safety Goals, ensure the safety of these patients and assist as needed to move to and from the toilet. A bowel training program is based on the principles for establishing regular bowel elimination: adequate diet, suficient luids, adequate exercise, and suficient rest (Box 30.3). A regular time for evacuation should be established. A reasonable goal is to achieve defecation within 1 hour of the established time. Factors that help establish the time include the patient’s prior bowel habits or the nurse’s observation of when incontinent FIGURE 30.5 Removing a fecal impaction. movements tend to occur. Many bowel retraining programs are timed around a triggering meal when gastrocolic relexes are the strongest, most commonly breakfast. After establishing a regular time for evacuation, provide the patient with an environment conducive to evacuation. Privacy and adequate time are only two parts of the environment that are considered. The patient must also feel safe in the environment and know that, if a problem occurs, the nurse is available to provide assistance. Provide the patient with toilet tissue, and remember to encourage hand hygiene after the evacuation. Promoting Bowel Elimination CHAPTER 30 Box 30.3 Interventions for Bowel Training • Assess for fecal impaction and remove if present (impaction may cause incontinent diarrhea). • Ensure the patient’s diet is high in bulk and iber. If teeth or improperly itting dentures prevent the consumption of high iber foods, refer to a dentist. • Increase luids to 1500 mL/day unless contraindicated by heart failure, chronic kidney disease, potential for increased intracranial pressure, or another disorder. • Perform a thorough assessment for 1 week to determine intake and output patterns, usual time of incontinent stool, and previous bowel pattern before incontinence began, including frequency of bowel movement, time of day, and surrounding events (e.g., while drinking coffee; use of commode, toilet, or bedpan). • Encourage regular toileting after meals. Toileting should be performed just before the time at which incontinent defecation has been occurring. • Use positive reinforcement for continent defecation. Refrain from use of negative reinforcement (e.g., shaming or scolding) at any time. • Provide privacy for toileting; position the patient comfortably on the commode, toilet, or bedpan with feet supported. • If diarrhea is present, assess and remedy the cause with diet or medications as ordered. • Begin an exercise program for the patient to strengthen abdominal muscles. • If other measures do not work, obtain an order for a suppository or an enema every 2 or 3 days to stimulate peristalsis and produce controlled defecation. QSEN Considerations: Safety Hand Hygiene To comply with The Joint Commission National Patient Safety Goals, nurses should practice and encourage hand hygiene, which is evidence-based practice, according to Centers for Disease Control and Prevention guidelines. Use alcohol-based cleaning agents and/or soap and water. Wash before and after gloving and avoid artiicial nails. Additional information can be obtained from the CDC at: www.cdc.gov/handhygiene/ Guidelines.html. Some patients with a neurogenic dysfunction may require digital stimulation to relax the anal sphincter. Using a gloved and lubricated inger, insert the inger 1 to 2 cm into the rectum and gently rotate the inger for 30 to 60 seconds. Suppositories, stool softeners, and bulk laxatives may be used to assist in establishing a normal, regular bowel pattern. The primary care provider’s order dictates the type of suppository. Suppositories are usually inserted about 1 hour before the triggering meal or the established evacuation time. In some bowel retraining programs, a suppository is used every day for the irst week, every other day for the second and third weeks, and, thereafter, only as needed 585 to maintain a regular movement every 2 or 3 days. To avoid intestinal obstruction, bulk-forming laxatives must be taken with suficient luid, and they generally should not be taken at bedtime (Gardiner & Hilton, 2016). In most cases, stronger laxatives and enemas are not considered part of a bowel training program. BOWEL OSTOMY Disease or trauma can damage the intestinal system and require surgical intervention, which alters the process of elimination. A diversion of intestinal contents from the normal path is called an ostomy. An ostomy results in the formation of an external stoma (opening) or an internal tissue pouch with a valve nipple opening. The internal pouch forming the continent ostomy is usually constructed from a segment of bowel (Fig. 30.6). This type of ostomy is emptied with a catheter (Steps 30.2). Patients with stoma ostomies use various appliances (devices to gather and contain output) and special procedures to aid in effective, controlled elimination through the stoma. Human elimination is a subject that many adults view with embarrassment or distaste. Physical conditions that create the need for an ostomy carry a heavy psychosocial burden for the patient and many new demands in handling elimination. Soiling, wetness, and odor from feces are all socially unacceptable in adult society, and such possibilities are often of grave concern to the new ostomy patient. There is also concern about ability to care for oneself and to return to work and recreational activities performed before surgery. Focus on keeping your body language neutral and not displaying any sign of distaste (even unconsciously) when caring for the ostomy patient. An attitude of acceptance is important. Conditions that can require ostomy include cancer, abdominal trauma, congenital bowel malformation, and severe chronic Crohn disease or ulcerative colitis. Patients facing an ostomy frequently experience fear, concern, and denial, followed by information seeking. Fear may focus on the loss of a normal body function and change in body image, the possibility of rejection by others, the loss of physical or sexual attractiveness, or the prospect of death from the underlying disease. The patient may be helped by a visit from a member of the United Ostomy Associations of America, which is a support network of people with ostomies. The patient needs a support system in place before discharge from the hospital. The local ofice of the American Cancer Society and the United Ostomy Associations are good sources of information about ostomy support groups or visitors in the area. 586 UNIT VI Meeting Basic Physiologic Needs Sigmoid colostomy Descending colostomy Double-barrel colostomy (transverse colostomy) Ileum Pouch Abdominal wall Ascending colostomy Ileostomy Kock pouch FIGURE 30.6 Types of bowel ostomies and intestin