Bowel Elimination And Care PDF

Bowel Elimination and Care Bowel elimination occurs after nutrients are moved through the gastrointestinal (GI) tract, also known as the alimentary canal. This process begins in the os, or mouth, and ends as the waste products are eliminated as feces, or stool, via the anus. The process of bowel eli...

Bowel Elimination and Care Bowel elimination occurs after nutrients are moved through the gastrointestinal (GI) tract, also known as the alimentary canal. This process begins in the os, or mouth, and ends as the waste products are eliminated as feces, or stool, via the anus. The process of bowel elimination is known as defecation. The propulsion of a bolus of food through the GI tract is the result of the rhythmic wavelike movements that begin in the esophagus and continue to the rectum, termed peristalsis. In the colon reside bacteria known as normal flora, whose purpose is to prevent infection and maintain health. The bacteria interact with the chyme, which produces a gas called flatus. As peristalsis moves the GI contents and flatus through the colon, it results in gurgles, clicks, and tinkling sounds, known as bowel sounds. Frequency of Elimination Frequency of bowel elimination changes throughout the life span. The frequency of bowel movements usually decreases to one or two bowel movements per day. This pattern usually is maintained throughout adulthood. However, peristalsis decreases as the individual ages, making older adults more prone to constipation, or hard stools that are difficult to pass.The goal of your elimination care is to maintain the patient s normal frequency pattern of bowel elimination, or as close to it as possible. (ays to prevent constipation) Timing of Elimination commonly occurs 30 minutes to 1 hour after eating.the stool remains in the intestines longer than necessary and can become dry and hard, contributing to the development of constipation. Characteristics of Feces Characteristics of stool include color, shape, consistency, odor, and frequency. Consistency Soft & formed consistency Liquid or semiliquid, watery, unformed, very hard and dry Shape Longer curved shape, cylindrical Balls, clumps, or broken-off chunks; flat or ribbon-like; pencil-like Color Yellow in infants & Light brown to dark brown in others Bright red blood, black, coffee grounds appearance, pale, white, gray, or clay color Presence of infection Absence of pus, mucus, fat Presence of pus, excessive mucus, foamy, or floating on water Odor Slight odor Foul odor, strongly odiferous, bloody or old-blood smell, metallic smell Several liquid or watery stools per day are classified as diarrhea. Frank blood is visible to the naked eye, and occult blood is hidden or not visible. To determine the presence of occult blood, a guaiac test must be performed on the stool sample. fluffy, floats on water, and has a foul odor is caused by an abnormally high content of undigested fat and is called steatorrhea. (cohn s disease) yellow and greasy. foul odor. pancreatitis. pancreatic cancer. Ribbon-shaped stool. colon cancer. r contains blood, mucus, pus inflammation or infection of the intestinal mucosa. threadlike worms & granules. pale or clay parasite eggs. lack of bile in the intestines Gaeceum liver or gallbladder disease (Large) bright red blood. (Large) maroon-colored blood hemorrhoids bleeding from the small intestines Gin black and tarry(Melena) with a foul odor bleeding from the stomach ASSESSMENT OF BOWEL ELIMINATION Documentation should always include the following: Color Amount Consistency Unusual shape Unusual odor Focused Assessment. objective signs First, assess the shape of the abdomen. The shape should be rounded or flat, but not distended or inflated Next, auscultate the bowel sounds using the diaphragm surface rather than the bell of your stethoscope to better hear the sounds. Bowels sounds should be assessed at least once per shift and more if indicated. If an impaction or intestinal blockage occurs, the peristalsis may increase or become hyperactive proximal to the blockage. The intestinal contents will churn and mix as the peristalsis pushes against the blockage. If you think that bowel sounds are absent, be certain to listen for at least 3 to 5 minutes in each of the four quadrants before declaring this.Avoid palpating the abdomen until after you have assessed the bowel sounds because palpation may stimulate bowel sounds that were not there naturally  Bowel sounds and their significance Normal: Soft gurgles, irregular clicks (betweeen 5-30min) —>. Indicates normal bowel function Hypoactive : >5 per min —> May indicate constipation Hyperactive: < 30 min per min or continuous—> May be heard when the patient has diarrhea Borborygmi : Excessively loud gurgling and May be high-pitched or tinkling in one qaurdrent or absent/decreased in Lower left quadrant—> may indicate hunger or bowel obstruction ALTERATIONS IN BOWEL ELIMINATION The most commonly seen alterations in bowel elimination include constipation, fecal impaction, diarrhea, and fecal incontinence. Constipation. Decreased activity level Changes in food intake Medication side effects Decreased fluid intake Surgery Pregnancy Depression Aging Laxative overuse or abuse Nerve damage or impairment Nursing interventions Increase activity: Physical activity stimulates peristalsis. If allowed, the patient should be ambulated in the hallways at least three to four times daily and sat up in a chair for meals. If not able to move from bed, turned, or repositioned, at least every 2 hours to help stimulate the normal peristalsis of the intestinal tract. Improve fluid & fiber intake fluid intake should be maintained between 1,500 and 2,400 mL per day in most adults. Teach your patient how much fluid intake they should have and why it is important. If your patient is not drinking adequately, do not simply document the lack of fluid intake; find out what the patient likes to drink and then provide an adequate supply of those fluids. It is important that the patient also has adequate fiber intake, generally 25 to 35 g per day. Provide privacy You shut the room door, pull the privacy curtain, place the bedpan or assist the patient to the BSC, provide toilet tissue, and wait outside the curtain if at all possible. Privacy should also be provided when discussing elimination with the patient. Avoid asking a patient in the presence of visitors if they had a bowel movement or to describe the characteristics of the stool. Assist with positioning The most comfortable and natural position for bowel elimination is the upright sitting position. Administer medications Medications for constipation may work by directly stimulating peristalsis, softening the stool, or adding bulk to the stool. Stool softeners and those that add bulk are safer than the laxatives that stimulate peristalsis. Administering enemas When medication does not relieve the problem of constipation, the health-care provider may order an enema The water temperature of enemas should be between 105°F and 110°F to avoid burning the intestinal mucosa. (cause abdominal cramping and may restrict the patient s ability to retain the water). Positioning the patient in the left semi-prone or left lateral side-lying position allows gravity to help pull the solution into the intestine. The normal length to insert the tip of the tubing is 3 to 4 inches for administration of a cleansing enema to an adult. Types of enemas Tap water —Cleansing— hypotonic/ increases peristalsis do not give to children, infants or heart failure and no more that 3,000 ml Normal saline— cleansing— isotonic ,adds fluid to the colon , increases peristalsis— safe for children, infants and heart failure - I : 50-150ml T: 250-350ml SA :300-500ml Soapsuds— cleansing— distribution+ irritating = increases peristalsis— Mix with saline not tap water for infants, children and heart failure Hypertonic sodium phosphate—cleansing—hypertonic, fluid from interstitial spaced into the colon that increases peristalsis- usually only for adults Oil retention— softens hard stools (impaction) & lubricates and softens to easier to remove— usually on adults ( 1 hour before removing an impaction) Medicated enemas— steroid enemas and decreases inflammation— may hire a tube with a balloon to be inserted in the rectum to hold it in. Milk & molasses— cleansing and hypertonic that softens hard stool— st be heated and mixed well and then cooled to body tempature. Return flow( Harrish flow)- remove flatus, raising and lowering enemas container flatus to siphon back- 100-200ml saline or water. High enema— cleanse higher up the colon beyond the sigmoid— patient to left semi-prone then turn back.  Contraindications to Enemas Rectal surgery Severe bleeding hemorrhoids Ulcerative colitis or Crohn s disease Rectal fissure Rectal cancer Excessive bleeding because of disease or medication certain heart conditions such as myocardial infraction or unstable angina. Complications of Enemas Two serious complications are the vagal response and perforation of the intestinal wall, which can result in hemorrhage and infection. Vagal response: stimulating the vagus nerve, which innervates not only the GI tract but also the heart and bronchioles. Can drop the heart rate as low as 30-40 bpm and cause constriction of the bronchioles of the lungs. Which this is going to lead to inadequate bp and circulation then inaffective of life. Perforation of the colon: If you are not careful, it is possible to perforate, or go through, the intestinal wall. This can result in introduction of bacteria into the sterile peritoneal cavity, bleeding, and even hemorrhage Fecal Impaction An impaction is a blockage of the movement of feces through the intestine by a mass of very hard stool. Fecal impaction may occur in the rectum, the sigmoid flexure, or any part of the large colon. It is more common in older adults, patients on bedrest, and severely dehydrated patients. Nursing intervention This involves insertion of the gloved index finger into the anus to manually break the fecal mass into small pieces and remove them from the rectum. Diarrhea Loose or watery stools occurring three or more times a day are classified as diarrhea and may or may not be accompanied by cramping. Tenesmus is a persistent desire to empty the bowel when no feces is present, causing ineffective straining efforts. It may be the result of inflammation in the rectum and may be experienced with bouts of diarrhea. Factors Contributing to Diarrhea Lactose intolerances Medication side effects Anxiety and stress Diverticulitis Inflammatory processes Food allergies Nursing interventions One important intervention is to modify food intake because the presence of food in the stomach can actually increase peristalsis and be very vigilant about encouraging fluids to replace what is lost. So in short words is modify food intake and increase fluids and preovide perineal care and administer medications. Fecal Incontinence Continence, or rectal compliance, is the ability to voluntarily maintain the stool in the rectum until a convenient time for a bowel movement, as opposed to bowel or fecal incontinence where the voluntary control is lost. Nursing interventions antidiarrheal medications may be ordered. If it is caused by seepage of stool around an impaction, the health-care provider may order removal of the impaction, enemas, and possibly stool softeners. In shorter words is provide bowel training, promote skin integrity and provide emotional support. Obtaining a Stool Specimen Stool samples may be tested for the presence of parasites, parasitic eggs called ova, blood, and microorganisms. Depending on facility policy, you may be the one to perform the test for hidden, or occult, blood, while other tests will be performed by laboratory personnel. The test for blood may be referred to as a hemoccult test, a guaiac test, or simply an occult blood test and can be performed in the patient s bathroom.  Certain disease processes and injuries can necessitate that a patient be provided with an alternative form of bowel elimination by surgically creating a bowel diversion. The fecal material, known as effluent, empties into an ostomy appliance, also called a bag or pouch. A need for a bowel diversion may be the result of: Cancerous tumor Infarcted area in which the bowel walls have become ischemic and died Disease process such as Crohn s disease Ruptured diverticulum Ulcerative colitis Traumatic abdominal injury Bowel perforation When the diversion is brought to the outside of the body through the abdominal wall, the new opening is called an ostomy, and the mouth of the ostomy is called a stoma. If the ileum, a part of the small intestine, is used, it is called an ileostomy. If a part of the large intestine, or colon, is used, it is called a colostomy. Colostomy A colostomy stoma will have a single opening, termed a single-barreled or end stoma, if the distal colon is permanently removed, as with cancer of the descending or sigmoid colon. When a colostomy is performed because of severe inflammatory disease, such as Crohn s disease, the distal portion of the colon may not need to be removed, only allowed time to rest and heal the diseased portion.  Stool Consistency Based on Location of the Colostomy The stool consistency will depend on the section of the colon in which the stoma is located. Ileostomy A diversion created in the ileum portion of the small intestine is known as an ileostomy A Kock pouch is created for an ileostomy to help control the effluent. It is a diversion that uses the terminal portion of the ileum to form an internal pouch, or reservoir, to collect and store the effluent before evacuation from the body. Nursing Care of Patients With Ostomies nurses not only provide direct patient care and teaching but also offer encouragement and emotional support, introduce the patient to ostomy support groups, serve as a resource person regarding different types of ostomy supplies, and serve as patient advocates. Assessment of the Ostomy collection of data Now you will assess the patient and the stoma for objective data, noting the following: Contour and color of the abdomen, scars, and the surgical site; the presence of a dressing, sutures/clamps, and drains Appearance of the stoma, including size and edema, color, and moisture level Appearance of peristomal skin, the skin surrounding the stoma Characteristics of the effluent/fecal drainage Fit of the faceplate and fullness of the appliance bag A new stoma should be pink to red, shiny, and moist Pallor, cyanosis, or a dusky color indicates impaired blood supply, while black depicts necrosis. MEASURING A STOMA The stoma size is determined using a stoma measuring device made of card stock.  SELECTING AN OSTOMY APPLIANCE. Some appliances are designed as a one-piece unit that has an attached adhesive disk that is applied directly to the patient s abdomen after the protective backing is peeled off the adhesive disk. The faceplate is changed every 3 to 5 days or sooner if the adhesive backing begins to loosen from the skin EMPTYING THE APPLIANCE Empty the ostomy appliance bag when it is one-third to one-half full to prevent leaking and odor. PROVIDING SKIN CARE make certain there is no irritation, excoriation, or ulceration. Then use a soft washcloth, warm water, and mild soap to wash the stoma and skin, rinse thoroughly, and pat dry. Irrigating a Colostomy Colostomies may be irrigated to evacuate stool because of constipation, or irrigation may be used postoperatively for stomas located in the descending or sigmoid colon. CHAPTER 31 Urinary Elimination and Care Void is another word for urinate. An older term that you may also hear is micturate, which also means to void or to urinate. Kidney filtration cleanses the blood of anything the body does not need. The kidneys eliminate these waste products before they become toxic to the body. The following are three waste products that must be removed:  Urea, which results from amino acid metabolism Uric acid, which results from the breakdown of RNA and DNA Creatinine, which is the waste product of muscle metabolism they eliminate excess electrolytes, hydrogen ions as needed, and toxins. Characteristics of Urine urine include color, clarity, amount, and odor. With the use of testing materials, the pH and specific gravity of urine can also be determined. Color and Clarity Normal urine is straw-colored and clear without sediment. the darker yellow the color, the lower the patient s hydration level. As dehydration worsens, the urine color may become dark yellow and then amber. Urine can be cloudy, or have increased turbidity, because of the presence of fat globules, red or white blood cells, or bacteria. When blood is present in the urine—either visible or microscopic blood— it is referred to as hematuria. When the pH of urine is excessively alkaline, it can result in turbidity and the formation of certain types of crystals. Odor Urine does have a very mild odor, described as slightly aromatic. Other odors, such as a sweet or fruity smell, a strong ammonia-like smell, or a foul odor, are abnormal findings. Amount The normal range of urine production is 1,000 to 3,000 mL in a 24- hour period. The acceptable minimal amount of urinary output per hour is 30 mL. The amount of urine an adult produces in a day is the result of many metabolic occurrences in the body. OLIGURIA POLYURIA ANURIA. output of less than. Output greater than The absence of 30 mL per hour. 3,000 ml per day. Excessive. Urine production Decrease fluid intake. Consumption of acohol Temporarily illness Dehydration, illness, Kidneys ability to reabsorb. Or urinary tract Urinary obstruction Water and diuretics Obstruction , kidney Renal failure Failure In more serious illnesses that shut down kidney function, the physician will order dialysis for the patient. Dialysis is the process of using a machine to filter waste products and salts and to remove excess fluid from the blood. Ph is normally 4.5-8.0 depending largely on diet. Specific gravity is the result of comparing the weight of a substance with the weight of an equal amount of water. The normal specific gravity for urine is 1.005 to 1.03. When high gravity urine is more concentrated When low gravity urine is Pg 644