Ch. 31 Bowel Elimination and Care PDF

Be prepared for questions such as: your pt has constipation (or diarrhea), what assessment (or intervention) would you do? If you understand how the GI system works/all the factors involved in making it “run smoothly” (sorry, poop joke there. See slide 3), and what lead to the problem (see slide 9)...

Be prepared for questions such as: your pt has constipation (or diarrhea), what assessment (or intervention) would you do? If you understand how the GI system works/all the factors involved in making it “run smoothly” (sorry, poop joke there. See slide 3), and what lead to the problem (see slide 9), then you will know what to do (see slide 20). Be able to teach your kids/spouse/dog/neighbor over the fence why fiber is important and where they can find it, how they can make sure they get “enough” fluids (what does that mean and how do we measure it) Fiber: The Superfood for Your Gut What is fiber? Imagine your body is a car. Fiber is like the oil that keeps it running smoothly. It's a special kind of plant food that our bodies can't digest. Why is it important? Fiber helps keep our tummy happy by making pooping easier. It also helps us feel full for longer, which is great for our waistlines. Plus, it can help protect us from getting sick. Where can we find it? Fiber is hidden in lots of yummy foods! Think fruits like berries and apples, veggies like carrots and broccoli, and whole grains like brown rice and whole-wheat bread. Even beans and nuts have lots of fiber. Hydration: Keeping Our Bodies Happy Why do we need water? Just like plants need water to grow, our bodies need water to function. It helps us think clearly, feel energized, and keep our body temperature just right. How much water do we need? It depends on how active we are and how hot it is outside. A good rule of thumb is to drink water throughout the day, especially before, during, and after activities. How can we tell if we're drinking enough? Pay attention to your pee! It should be pale yellow, like lemonade. If it's dark yellow, you might need to drink more water. Why Antibiotics Can Make Tummy Troubles Imagine your tummy is a garden with lots of different plants. Some plants are good, like the ones that help you digest your food. Others aren't so good. Antibiotics are like a special spray that kills the bad plants, but sometimes they can also kill the good ones. When this happens, your tummy gets upset and you might get diarrhea. Why Low-Sugar Sports Drinks Help When you have diarrhea, you lose a lot of water and important minerals. Low-sugar sports drinks can help replace these lost fluids and minerals, making you feel better faster. Why Do We Fart? Imagine your tummy is a busy factory. When you eat food, your tummy breaks it down into tiny pieces. But there's a little helper in your tummy called bacteria. These bacteria help break down the food even more, and sometimes they make a little bit of gas as they work. This gas needs to escape, and that's why we fart! Why is Poop Brown? Poop is a bit like leftover food that your body doesn't need. When your body finishes using the nutrients from your food, the leftovers are sent to your intestines. In your intestines, there are lots of bacteria that help break down the leftovers. These bacteria give poop its brown color. Seriously, you need to know this (I’m not kidding, it is relevant and will be in a test question). - Poop can be black due to iron or blood - Liver and spleen breakdown - High sugar/hot drinks irritate intestines and trigger peristalsis Function of Liver: to make and secrete bile and to process and purify the blood containing newly absorbed nutrients that are coming from the small intestine. Gallbladder: Stores bile (bile breaks down fats) Stomach: break down food and send it to the small intestine The stomach serves as a reservoir; some absorption of water and alcohol occurs here. The stomach will break down the bolus of food converting it to a semi-liquid mass of partly digested food and digestive secretions; this is known as chyme. Pancreas: Makes digestive enzymes, and insulin Spleen: Filter blood, removing old or damaged red blood cells, and acting as a key part of the immune system by detecting and fighting pathogens like bacteria and viruses Small intestine: Most nutrients are absorbed into the blood capillaries Large intestines: Water absorption occurs. The large intestine begins with the cecum followed by the ascending colon, transverse colon and the descending colon and finally the sigmoid colon When the stomach stretches it sends a signal to the brain to tell it that you are full and triggers peristalsis. What is the function of each part – thus, if that part does not do its job well (or is removed), how is the rest of the system affected? Example: a pt loses all of their teeth, has their gallbladder removed, or has inflammation to their duodenum. What specific problems will these issues cause? The gallbladder stores bile, which helps break down fat during digestion. After gallbladder removal, your liver continues to produce bile, but it drips directly into your small intestine instead of being stored. This means there's less concentrated bile available to digest fat After gallbladder removal, you should eat less fat because your body has less bile to digest it Defecation is the final act of digestion. Waves of muscular contractions known as peristalsis in the walls of the colon move fecal matter through the digestive tract towards the rectum. Peristalsis: think of what stimulates or slows this, what interventions or medications can have an effect on this. Rhythmic wavelike movements. Esophagus to rectum-becomes more active when eating. Contraction of the circular and longitudinal muscles in the walls of the GI tract Propels the bolus of food through the GI tract. Intestinal gas is always present throughout the gastrointestinal system. Swallowing an excess amount of air while eating or drinking and even chewing gum can cause gas to build up in the stomach and small intestine causing bloating and belching. Lower intestinal gas is the normal byproduct of bacterial action on food that cannot be broken down until getting to the colon. Certain foods that are not digested are beans, cabbage, cucumbers, dairy products, and artificial sweeteners. Sluggish peristalsis can also cause excessive gas. INTERVENTIONS: AMBULATION INSERTION OF A RECTAL TUBE - Iron changes color of BM (dark stool) and constipation -> dr. may order stool softener with iron. Understand all these factors: assessments and interventions all relate to these: The importance of fiber; the normal American diet only contains 12-to 15 grams of fiber per day. The recommendation is 25-30 grams of fiber per day. Too little fiber can cause constipation making the stool hard and dry. Think of some foods that contain fiber. Fiber can help with stool shape and prevent constipation. Raspberries, Pears, Apples, Bananas, Strawberries, Broccoli, Carrots, Brussels sprouts, Spinach, Whole-wheat bread, Brown rice, Oatmeal Food- consistency, volume, color Fluid intake- moisture content- Fluid intake is important as it aids in moving the stool throughout the colon. We need about 8-10 glasses of liquid per day. Drugs- slow or speed motility- Drugs can cause constipation or they can cause diarrhea. Narcotics, antihistamines, beta blockers (cardiac drugs), calcium supplements, and antidepressants are just some of the drugs that can cause constipation. Emotions, anxiety and stress (think of your own experiences) Stress-cortisol hormone Neuromuscular- control rectal muscles Abdominal muscle- ability to increase intra-abdominal pressure Opportunity- inhibits or facilitates; some individuals won’t “go” in a public bathroom (do you?). Pregnancy-due to hormone changes and the pressure of the expanding uterus. Age- slower motility and loss of elasticity in the intestinal walls Laxative abuse → pseudo constipation Assessment of Bowel Elimination: Characteristic Normal Abnormal Color Brown (although depending Black, clay colored, yellow, on what you eat BM color can green change Odor Aromatic Foul Consistency Soft, formed Bulky, hard, dry, watery, paste like Shape Round, full Unformed, flat, pencil-shaped(this can indicate narrowing of rectum caused by mass or tumor) Components Undigested fiber Worms, blood, pus, mucus The color of our stools can change based on some of the foods we eat, - Eating green foods such as spinach may result in greenish-black streaks in feces - Eating beets may result in red-tinted stools. - Black licorice and Pepto-Bismol can cause stools to look black. - Iron supplements can cause stools to look dark brown, dark green, black and tarry (like petroleum oil/tar). - Gray or clay colored- bile is missing, a sign of gallbladder disease, there could be a blockage in the bile duct of the liver and or gall bladder. - Dark, black or tarry stool- (melena), can indicate bleeding high in GI tract may be caused by a tear in the esophagus from violent vomiting or a bleeding ulcer - Yellow or green- can indicate infection Mucous blood or pus can indicate infection or inflammation of the stomach mucosa such as in conditions of ulcerative colitis. How can you tell if it's iron or blood in stool if black? Are they on iron supplements? When iron supplements are taken, the stool can appear dark or almost black. This is normal and not a sign of blood in the stool. The stool will not be tarry or have a foul odor. Blood in the stool is known as melena. Melena is characterized by stool that is black and tarry, with a sticky consistency and a strong odor. CONT. Assessment of Bowel Elimination: Inspect shape of abdomen, auscultate the bowel sounds, review terms/definition for charting, palpate the abdomen, and ask about pain!  - Inspect the shape of your patient’s abdomen. Ask about any surgeries or injuries they may have had. Ask about medications they take and diet and habits such as alcohol, coffee or smoking. Know the difference between “distended” and “rounded” – which one is just fat, and which one is a problem like ascites? - Round - soft - Distention - hard - palpate stomach to determine Alterations in Bowel Elimination: 1. Constipation 2. Diarrhea 3. Impaction 4. Fecal incontinence Ask yourself: what are the causes, and what can you (as the nurse) do about each? Constipation is an infrequent and difficult passage of hard and dry feces or stools. Causes of constipation: stress, travel, diet (low fiber), inactivity, decrease in fluid intake, delay going to the bathroom when you have the urge. PRIMARY - lifestyle (diet, activity level) SECONDARY – pathologic disorder (diverticulitis- have to treat disease to get rid of constipation) IATROGENIC - meds PSEUDOCONSTIPATION – false perception Fecal Impaction: LARGE HARDENED MASS THAT CAN’T BE PASSED VOLUNTARILY MAY BE A RESULT OF: Common Symptoms: Abdominal pain and discomfort: This can range from mild cramping to severe pain. Bloating: A feeling of fullness or pressure in the abdomen. Loss of appetite: This can be due to discomfort or nausea. Nausea and vomiting: In severe cases. Rectal pain and bleeding: Straining to pass stool can cause irritation and bleeding. Inability to pass stool: Despite the urge to defecate. Leakage of liquid stool: This can occur as liquid stool seeps around the impacted mass. INTERVENTIONS: Digital disimpaction, Laxatives, dietary modifications: Increasing fiber intake through fruits, vegetables, and whole grains. Adequate fluid intake to prevent dehydration, Regular bowel habits, encourage exercise, Stool softeners, Avoiding medications that can contribute to constipation Patient Education: Importance of hydration: Encourage patients to drink plenty of fluids. Dietary guidelines: Educate patients about the importance of a high-fiber diet. Bowel training: Teach patients techniques to establish regular bowel habits. Medication adherence: Remind patients to take prescribed medications as directed. Signs and symptoms of impaction: Causes: Dietary Factors: Low Fiber Intake: A diet low in fiber can lead to hard, dry stools. Insufficient Fluid Intake: Dehydration can harden the stool and make it difficult to pass. Medical Conditions: Neurological Disorders: Conditions like Parkinson's disease, multiple sclerosis, or spinal cord injuries can affect bowel control. Endocrine Disorders: Thyroid disorders and diabetes can impact bowel function. Colorectal Disorders: Conditions like irritable bowel syndrome (IBS) or inflammatory bowel disease (IBD) can contribute to constipation and impaction. Opioid Pain Medications, Anticholinergic Medications, Diuretics,Iron Supplements, Lack of Physical Activity, Aging Digital Removal: also known as bowel incontinence, is the inability to control bowel movements, leading to the involuntary loss of stool. This can range from occasional leakage to complete loss of bowel control. Diarrhea: Urgent passage of watery stool causes: Signs and Symptoms: adverse effects: skin, nutrition, emotion Nursing interventions: - Clear liquid diet → To rest and heal the GI tract - Push fluids → Gatorade and Pedialyte - BRAT Diet → Bananas, Rice, Applesauce and Toast - Yogurt and probiotics Why sports drinks verses water? What is the rationale for BRAT foods, yogurt, probiotics? - it is less acidic, easily breaks down in the digestive system, and causes fewer bowel movements. Fecal Incontinence: also known as bowel incontinence, is the inability to control bowel movements, leading to the involuntary loss of stool. This can range from occasional leakage to complete loss of bowel control. How does this impact the patient's skin integrity? Fluid and electrolyte status? Emotional status/socialization? Skin Integrity Direct Damage: Pressure ulcers cause direct damage to the skin and underlying tissues, leading to loss of skin integrity. Increased Risk of Infection: Damaged skin is more susceptible to infection, as bacteria can easily enter the wound. Infections can worsen the ulcer and spread to other parts of the body. Delayed Healing: Pressure ulcers can be slow to heal, especially in individuals with underlying health conditions, further compromising skin integrity. Fluid and Electrolyte Status Fluid Loss: Open wounds, such as pressure ulcers, can lead to significant fluid loss, particularly in larger ulcers. This fluid loss can disrupt the body's fluid and electrolyte balance. Infection: Infections associated with pressure ulcers can cause fever, which can lead to increased fluid loss through sweating. Malnutrition: Pressure ulcers can make it difficult for patients to maintain adequate nutrition, as they may experience pain or discomfort during eating. Malnutrition can further impair the body's ability to heal and maintain fluid and electrolyte balance. Emotional and Social Status Pain and Discomfort: Pressure ulcers can cause significant pain and discomfort, affecting the patient's quality of life and emotional well-being. Body Image: Visible wounds can negatively impact a patient's body image and self-esteem. Social Isolation: Pain, discomfort, and the appearance of pressure ulcers can lead to social isolation, as patients may withdraw from social activities. Dependency: Pressure ulcers can increase a patient's dependence on caregivers, which can impact their sense of independence and control. It's important to note that the impact of pressure ulcers on a patient's health can vary depending on the severity of the ulcer, the patient's overall health status, and the effectiveness of treatment. Early detection and prevention of pressure ulcers are crucial to minimizing their negative effects on a patient's well-being. Nursing Interventions At least 2,000 mL of water a day Abnormal Conditions of Stool: - Steatorrhea: stool containing abnormal amount of undigested fat, indicating malabsorption disorder such as Crohns (“fluffy and floats”) - Frank blood: bright red blood in the stool; may be caused by hemorrhoids, intestinal bleeding, or hemorrhage Occult blood: hidden blood in the stool Description? blood in the stool that can't be seen with the naked eye. (pg 709 & 710) - Hemoccult/Guaiac test: test for blood in the stool Laboratory Tests to Determine the Cause of Bowel Alterations - Culture and sensitivity (C&S): Identifies microorganisms infecting the stool and the antibiotics that will kill the microorganisms - Ova and parasite test (O&P): Tests for presence of parasitic worms and their eggs With collection of a specimen delivery should take place within 15 minutes to maintain freshness. Measures to Promote Bowel Elimination → Rectal Suppository → Enemas Why given: Enemas and stimulant laxatives may be used in cases where fiber, fluids, and stool softeners are not working. Types Cleansing Retention 30 min Solution Amount Mechanism of Action Tap Water Normal Saline Soapsuds Hypertonic Sol. Contraindications to an Enema: BE SURE TO ASSESS BEFOREHAND - Rectal surgery - Severely bleeding hemorrhoids - Ulcerative colitis or Crohn’s disease - Rectal fissure - Rectal cancer - Potential for excessive bleeding - Heart conditions i.e. MI, unstable angina Why? Enema Complications - Vagal Response Signs/symptoms Interventions Perforation of colon