Bowel Elimination PDF

Bowel elimination. Subject Objective: 1. Assists patient to make informed health care decision. 2. Manage time effectively and set priorities. 3. Measure critically the outcomes of nursing activities. 4. Apply communication skills effectively with surgical, nursing and medical staff in inter-...

Bowel elimination. Subject Objective: 1. Assists patient to make informed health care decision. 2. Manage time effectively and set priorities. 3. Measure critically the outcomes of nursing activities. 4. Apply communication skills effectively with surgical, nursing and medical staff in inter-professional, social and therapeutic context. 5. Use problem solving skills.   Outlines:  Introduction  General Principles:  Basic Facts in Relation to Anatomy and Physiology:  The act of defecation  Factors Influencing Bowel Elimination  Common Bowel Elimination Problems: 1. Constipation 2. Impaction 3. Diarrhea 4. Incontinence 5. Flatulence 6. Hemorrhoids  Nursing Management  Introduction:  Elimination is essential to rid the body of wastes and materials in excess of bodily needs. Elimination process is necessary to maintain high level of wellness and even life itself and must continue during illness in health. General Principles:  Efficient physiologic functioning requires that waste substances be eliminated from the body.  Patters of elimination from the large intestine vary among individuals.  Stress-producing situations and illness may interfere with normal habits of elimination.  Basic Facts in Relation to Anatomy and Physiology: 1. The large intestine is a tube leading from "' the small intestine to the external skin and is about 150 -180 cm in length. The ileocecal valve separates the small intestine from the large intestine. It opens in one direction; prevent the passage of material in the opposite direction 2. The large intestine is divided into:  The caucus: lies at the beginning of the large intestine.  The colon: lies between the caucus and the rectum and is divided into: The ascending colon goes up on the right side, the transverse colon crosses the abdomen and the descending colon goes down on the left side.  The sigmoid flexure ends at the rectum.  The rectum of the adult person is about 15-20 cm.  The gastro colic reflex: peristalsis is stimulated by the intake of food enters the duodenum (about half an hour after-eating or drinking) a mass peristaltic action occurs in the large intestine which is called the gastro colic reflex, and the need to defecate is felt.  The rectal reflex (defecating reflex): is stimulated by the presence of waste products in the rectum which is producing mechanical pressure. This leads to stimulation of sensory receptors and the need to defecate is felt.  Factors Influencing Bowel Elimination 1. Age  An infant has a small stomach capacity and less secretion of digestive enzymes. Food passes quickly through an infant’s intestinal tract because of rapid peristalsis.  Older adults often experience changes in the gastrointestinal system that impairs digestion and elimination. 1. Diet  Regular daily food intake helps maintain a regular pattern of peristalsis in the colon. Fiber, the non-digestible residue in the diet, provides the bulk of fecal material. Bulk-forming foods such as whole grains, fresh fruits, and vegetables help flush the fats and waste products from the body with more efficiency 1. Fluid Intake  An inadequate fluid intake or disturbances resulting in fluid loss (such as vomiting) affect the character of feces. Fluid liquefies intestinal contents, easing its passage through the colon. Reduced fluid intake slows passage of food through the intestine and results in hardening of stool contents. Unless there is a medical contraindication, an adult needs to drink at least 1100 to 1400 mL of fluid daily. Physical Activity Physical activity promotes peristalsis, whereas immobilization depresses it. Encourage early ambulation as illness begins to resolve or as soon as possible after surgery to promote maintenance of peristalsis and normal elimination. Maintaining tone of skeletal muscles used during defecation is important. Psychological Factors Prolonged emotional stress impairs the function of almost all body systems. During emotional stress the digestive process is accelerated, and peristalsis is increased. Side effects of increased peristalsis are diarrhea and gaseous distention. Personal Habits Personal elimination habits influence bowel function. Most people benefit from being able to use their own toilet facilities at a time that is most effective and convenient for them. A busy work schedule sometimes prevents the individual from responding appropriately to the urge to defecate, disrupting regular habits and causing possible alterations such as constipation  Chronically ill and hospitalized patients are not always able to maintain privacy during defecation. The sights, sounds, and odors associated with sharing toilet facilities or using bedpans are often embarrassing. This embarrassment often causes patients to ignore the urge to defecate, which begins a vicious cycle of constipation and discomfort. Position during defecation Squatting is the normal position during defecation. Modern toilets facilitate this posture, allowing the person to lean forward, exert intra- abdominal pressure, and contract the thigh muscles. Pain Normally the act of defecation is painless. However, a number of conditions such as hemorrhoids, rectal surgery, rectal fistulas, and abdominal surgery result in discomfort. Pregnancy As pregnancy advances, the size of the fetus increases, and pressure is exerted on the rectum. A temporary obstruction created by the fetus impairs passage of feces. Slowing of peristalsis during the third trimester often leads to constipation Surgery and Anesthesia General anesthetic agents used during surgery cause temporary cessation of peristalsis. Inhaled anesthetic agents block parasympathetic impulses to the intestinal musculature. The action of the anesthetic slows or stops peristaltic waves. Medications Some medications have certain expected actions on the bowel (e.g., there are medications to promote defecation or control diarrhea). In addition, medications prescribed for acute and chronic conditions often have secondary effects on the patient’s bowel elimination patterns. Diagnostic Tests Diagnostic examinations involving visualization of GI structures often require a prescribed bowel preparation (e.g., medications, and/or enemas) to ensure that the bowel is empty. In addition, the patient cannot eat or drink several hours before the examinations such as an endoscopy, colonoscopy, or other testing that requires visualization of the GI tract. Following the diagnostic procedure, changes in elimination such as increased gas or loose stools often occur until the patient resumes a normal eating pattern.  Common Bowel Elimination Problems 1. Constipation  Definition: The passage of unusually dry, hard stools produced by undue delay in the passage of feces.  Causes of constipation  Poor elimination habits. If the desire for defecation is ignored repeatedly, the feces become hard and dry because of increased water absorption.  Lack of sufficient roughage or bulk in diet.  Lack of enough fluid intakes.  Lack of muscle tone due to too much stimulation by irritating substances such as laxatives.  Interference with normal reflexes because of pain associated with defecation, e.g., piles, and fissure etc.  Lack of essential vitamins such as vitamin B. group or mineral as potassium.  Lack of exercise: o Decreased peristaltic movement. o Loss of muscle tone.  Actual mechanical obstruction caused by compression of a mass e.g., tumor or edema of the intestinal wall, hernia or fecal impaction.  Assessment of patient with constipation:  Passage of hard stools associated with a decrease in the usual frequency of defecation.  Feeling of rectal fullness.  Abdominal distension (the abdomen feels hard upon palpation) caused by accumulation of fecal matter as well as gases.  Complaints of tenesmus (frequent painful straining in attempts to defecate).  General symptoms: e.g. headache, malaise, anorexia, and bad breath.  Nursing management of constipation  Provide adequate fluid intake 500 – 2000 cc/day.  Provide a well-balanced diet with enough roughage from fruits and vegetables and vitamins.  Encourage regularity of time for defecation and prompt response to the desire of defecation.  Encourage regularity of meal's time  Provide adequate time for complete evacuation.  Provide privacy for patients to promote relaxation.  Provide posture (position) as close to normal as possible.  Provide physical and emotional comfort  Provide physical exercises especially for abdominal muscles.  Consider the patient's habit in relation to defecation. Prevention of constipation  Encourage exercise as walking.  Avoid excessive emotional stress.  Establish regularity of meals and defecation time.  Discourage unnecessary use of laxatives.  Intake of proper diet containing enough vegetables and vitamins.  sufficient fluids per day. Fecal impaction Definition: A prolonged retention or an accumulation of fecal material which forms a hardened mass in the rectum, it may be of sufficient size to prevent the passage of normal stools. Signs and symptoms Distended abdomen (hand upon palpation and feels rigid). Rectal pain due to pressure of the fecal mass. Passage of small amount of liquid stool due to mechanical irritation of the rectum.  Causes:  Prolonged constipation and poor habits of defecation.  Prolonged bed rest, vary in paralyzed or unconscious patients.  Prolonged use of anti-diarrheas drugs.  Following administration of Barium for x ray examination of the G.I.T. Nursing management  Administration of mineral oil by mouth especially in cases of prolonged constipation for regulation of habits.  Oil retention enema followed by cleansing enema. Digital manipulation of the fecal mass should be under physician order or supervision because it can stimulate vague nerve in the rectal wall which can slow patient's heart leading to cardiac arrhythmia, so observe patient's pulse rate, facial pallor and diaphoresis during manipulation Diarrhea: Definition: The passage of loose, watery stool and an increase in the frequency of bowel movements, diarrhea may or may not be accompanies by abdominal cramping. Causes: Many conditions cause diarrhea. Antibiotic use via any route of administration alters the normal flora in the GI tract. Patients receiving enteral nutrition are also at risk for diarrhea. Consult a dietitian when diarrhea occurs. Food allergies and intolerances increase peristalsis and cause diarrhea. Surgeries or diagnostic testing of the lower GI tract also cause diarrhea. The aim of treatment is to remove precipitating conditions and slow peristalsis.  Communicable food-borne pathogens also cause diarrhea. When diarrhea is the result of a food-borne virus, the goal usually is to rid the GI system of the pathogen rather than slow peristalsis. Signs and symptoms:  Generalized abdominal pain which is spasmodic in nature due to strong peristaltic action.  Pains are accompanied by feeling of urgency in the need to defecate.  Complaints of tenesmus and may pass a small watery discharge.  Increase in the frequency in the number of stool (stool is watery in nature).  Signs and symptoms of dehydration my occur if diarrhea is very severs or over a long time such as: poor skin turgor, thirst, and acute weight loss.  General weakness and general malaise 1. Assessment and observation of the patient, this includes:  Assessment of the stool in terms of frequency, consistency, odor and presence of foreign matter as mucous, pus, blood or undigested food. Observation of the patient for signs and symptoms of the dehydration and electrolyte loss. Diet: Provision of proper diet for maintenance of proper nutrition. Diet free from roughage. Rich in liquids.  Free from irritants and low in fat. Rich in proteins such as white meat boiled chicken and other. If diarrhea is psychogenic, provide for psychological comfort and relaxation. Assist the patient to identify the causes and act upon it. Provide for physical comfort and hygienic care. -Local irritation of the anal and region is common. Careful washing and drying after each movement is necessary. -Medicated creams will help prevent skin irritation, e.g., Zink oxide -Patient's clothes and bed linen must be dry and clean. -If diarrhea is due to infection, isolation technique must be followed: Stool should be disinfected immediately before being discarded. (N.B: All diarrheas should be considered infectious until proved). Incontinence: Definition: Fecal incontinence is the inability to control passage of feces and gas from the anus. Causes: Organic diseases causing weakness of the anal sphincter. Impingent in the nerve supply to the anal sphincter. (i.e. relaxed external sphincter).  Nursing care:  Supportive and encouraging attitude by the nurse should be initiated to eliminate embarrassment due to incontinence.  Special nursing care to prevent bad odor, skin irritation and bed sores.  Patient's clothing and bedding should be changed whenever necessary. Hemorrhoids Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal. External hemorrhoids are clearly visible as protrusions of skin. If the underlying vein is hardened, there is usually a purplish discoloration (thrombosis). This causes increased pain and often needs to be excised. Internal hemorrhoids have an outer mucous membrane. Increased venous pressure from straining at defecation, pregnancy, heart failure, and chronic liver disease causes hemorrhoids.  Inserting and Maintaining a Nasogastric Tube A patient’s condition or situation sometimes requires special interventions to decompress the GI tract. Such conditions include surgery, infections of the GI tract, trauma to the GI tract, and conditions in which peristalsis is absent.  Purposes of Nasogastric Intubation Purpose Description Type of tube Decompression Removal of secretions and gaseous substances from Salem sump, gastrointestinal (GI) tract; prevention or relief of Levin, abdominal distention Miller-Abbott Enteral feeding Instillation of liquid nutritional supplements or feedings Duo, Dobhoff, into stomach for patients unable to swallow fluid Levin Compression Internal application of pressure by means of inflated Sengstaken- balloon to prevent internal esophageal or GI hemorrhage Blakemore Lavage Irrigation of stomach in cases of active bleeding, Levin, Ewald, poisoning, or gastric dilation Salem sump