Dian Adiningsih

� Identify variables that influence bowel elimination.

� Identify appropriate nursing interventions to promote bowel elimination.

Discuss nursing interventions for the incontinent � Discuss nursing interventions for the incontinent patient.

� Discuss nursing interventions for the patient with a bowel diversion.

� GI Tract is a series of hollow mucous membrane lined muscular organs

� Purpose is to absorb fluids & nutrients, prepare food for absorption & provide storage for feces

� Mouth

� Esophagus

� Stomach

� Small Intestine

� Large Intestine

� Rectum

� Digestion begins here

� Mechanical, chemical breakdown of nutrients

� Teeth-Mastication

� Salivary secretions-enzymes

� Food Bolus

� Hollow, muscular tube for passage of food to stomach

� Peristaltic waves, contraction and relaxation of smooth muscle moves food down to stomach

� Sphincter control to prevent reflux

� Food is temporarily stored and mechanically and chemically broken down

� Secretes HCL, mucus, pepsin, & intrinsic factor(Needed for Vitamin B12 absorption)

� Food is converted into chyme� Food is converted into chyme

� 1 inch in diameter

� 20 feet long

� Three divisions: Duodenum, Jejunum, Ileum

� Enzymes in small intestine (amylase, lipase, & bile) break down fats, proteins & carbs into basic bile) break down fats, proteins & carbs into basic elements

� Nutrients absorbed in duodenum & jejunum, ileum absorbs vitamins, iron, & bile salts

� Lower GI tract

� Larger diameter, 5-6 feet in length

� 3 divisions: cecum, colon, rectum

� Responsible for absorption of water

Primary organ of bowel elimination� Primary organ of bowel elimination

� Cecum-chyme enters cecum via the ileocecal valve, valve prevents regurg back to small intestine, cecum ends with appendix

� 3 Divisions: Ascending, Transverse, Descending

� Colon Functions: Absorption, Protection, Secretion, & Elimination (stool and flatus)

� Air swallowing

� Diffusion of gas from bloodstream into intestines

� Bacterial action on unabsorbable CHO (Beans)

� Fermentation of CHO (cabbage, onions

Can stimulate peristalsis� Can stimulate peristalsis

� Adult forms 400-700 ml of flatus daily

� Sigmoid colon

� Storage of feces

� Length varies with age

� When fecal mass or flatus moves into rectum, it distends and defecation beginsdistends and defecation begins

� Process involves involuntary (Internal sphincter) and voluntary control (external sphincter)

� Valsalva Maneuver- voluntary contraction of abdominal muscles

The large intestine is the primary organ of bowel elimination

� Approximately 5 feet long, beginning at the ileocecal valve and ending at the anus

� About 1500ml of chyme enters the large intestine each day

� 800-1000ml of fluid is reabsorbed, resulting in formed, � 800-1000ml of fluid is reabsorbed, resulting in formed, semisolid feces

� The process of bowel elimination is called defecation.

� Peristalsis – contractions of the muscles of the long intestine – is controlled by the autonomic nervous system� Mass peristaltic sweeps occur 1 to 4 times in 24 hours, generally

after eating.

� Defecation is generally painless

� Valsalva maneuver – the act of bearing down� May elevate blood pressure

� May stimulate the vagus nerve

Terms to know� Terms to know� Diarrhea – excessively liquid stool

� Constipation – dry, hard stool

� Hemorrhoids – abnormally distended veins in the rectum

� Age � Infants – stool characteristics are diet dependent, no

voluntary control� Babies: 3 – 6 BM’s/day� Toddlers – ability for voluntary control develops

between 18 and 24 monthsbetween 18 and 24 months� Neuromuscular structures not developed until 15 – 18 mos.� Voluntary control 2 – 3 yrs.

� School-age children to adults – patterns vary greatly� Older adult – constipation is often a chronic problem� Pregnant women prone to constipation

� Pressure on abd. Organs� Iron supplements

� Elderly prone to constipation� Slowing of peristalsis

� Dietary intake

� High-fiber diet( undigestible residue ) provides bulk� Absorbs fluid

� Increases stool mass

� Bowel wall stretches

� Peristalsis stimulated� Peristalsis stimulated

� Defecation results

� 2000 to 3000 mls of fluid daily� ↑ fld= Liquifies stool

� Soft stool

� Constipating foods – cheese, lean meat, eggs

� Laxative effect – certain fruits and veggies

� Gas-producing – onions, cabbage, beans

� Daily patterns� Individualized patterns related to frequency, timing, position,

and place� Personal habits

� Busy schedule, postpone BM, constipation � Sitting or squatting facilitates defecation as this increases

abdominal pressureabdominal pressure

� Lifestyle� Normal life process� Preoccupation with bowel elimination� “dirty” process

� Activity� Exercise improves GI motility and muscle tone� Immobility decreases GI motility and muscle tone

� Psychological variables� Anxiety seems to directly effect GI motility in some and

may result in diarrhea

� Chronic worriers and controlling personalities may experience frequent constipationexperience frequent constipation

� Diagnostic studies� Fasting, stress and bowel cleansing can all interfere with

normal patterns of elimination

� Pathologic conditions� Bowel disturbances may be the first sign of a disease

process

� Causes of diarrhea include diverticulitis, infection, malabsorption syndromes, cancer, diabetic neuropathy, malabsorption syndromes, cancer, diabetic neuropathy, and food poisoning

� Causes of constipation include disorders of the colon or rectum, spinal cord injury, and megacolon

� Intestinal obstructions may be mechanical or functional� Mechanical – tumor, hernia, adhesions

� Functional – muscular dystrophy, diabetes, Parkinson’s

� Medications� Constipating medications include opioids, codein,

antacids, iron, and anticholinergics

� Medications that cause diarrhea as a side effect include antibiotics

� Several medications can affect the appearance of the stool.

� Surgery and anesthesia� Anaesthetic causes temporary cessation of peristalsis

� Paralytic ileus – the temporary cessation of peristalsis after bowel manipulation

� Peristalsis may also be inhibited by general anesthesia

� Direct manipulation of the bowel stops peristalsis

� Patient history� You must take a complete history, even though

most patients will be uncomfortable discussing their bowel habits!

� Inspection� Inspection� Peristalsis is generally not visible

� Is the abdomen distended? Are there any visible masses?

� Are there any hemorrhoids or areas of s

� Auscultation� Are bowel sounds present in all 4 quadrants?

� Hypoactive, hyperactive, absent

� Percussion� Do you hear tympany over the abdomen and stomach?

� What might cause you to hear a dull sound?

� Palpation� Is the abdomen soft or hard? Tender or nontender? � Is the abdomen soft or hard? Tender or nontender?

Distended or non-distended? Do you feel any masses?

� Can you feel any masses or polyps in the rectum?

� Stool characteristics� Bristol Stool Chart, etc

� Keep a record at the bedside.

� Diagnostic studies� Specimen collection

� Occult blood

� Endoscopy

� Radiography� Radiography

� Bowel elimination as the problem� Example, ostomy management� Bowel Incontinence

� Constipation

� Diarrhea� Diarrhea

� Impaired Skin Integrity

� Body Image Disturbance

� Altered bowel elimination

� Pain

� Bowel elimination as the etiology� Example, fluid volume deficit

� Examples� See page 1567

1. Constipation – difficult passage of hard, dry stool; infrequent movements

2. Fecal Impaction – unrelieved constipation, feces wedged in rectum, no BM usually 3days, oozing of diarrheal stool develops

3. Diarrhea- # liquid stool

4. Flatulence – ↑ abd. Distention & pain

� Incontinence – inability to control passage of stool

� Hemorrhoids� Dilated engorged veins

� Increased pressure when straining

� Internal / external� Internal / external

� Bleeding

� Timing – patient’s usual time every day

� Positioning – sitting upright� Positioning of patient-squatting� Positioning on bedpan

� Privacy – always respect this right unless patient is unstableunstable

� Nutrition – high fiber diet, 2000-3000ml of fluid daily

� Exercise – improves motility and aids defecation

� Use of cathartics, laxatives

� Anti-diarrheal agents

� Enemas

� Digital removal of stool

� Ostomy care

� Metamucil-bulk forming

� Colace, Surfak-emollient or wetting agent

� Fleets, MOM. Mag Sulfate-saline agent

� Dulcolax, Ex-Lax, Castor oil- stimulant cathartic

� Haley’s MO, mineral oil- Lubricant� Haley’s MO, mineral oil- Lubricant

� Cleansing enema

� Tap water

� Normal saline

� Hypertonic Solutions (Fleet’s enema)

� Soapsuds � Soapsuds

� Oil Retention

� Medicated enemas (Kayexalate, Lactulose)

� Administering a Cleansing enema P&P pg. 1200-1201

� More of a symptom than a disorder

� Decrease in frequency of BM

� Straining & pain on defecation is associated symptoms (Valsalva manuever)

� Can be significant health hazard (increase ICP, IOP, reopen surgical wounds, cause trauma, cardiac arrhythmias)surgical wounds, cause trauma, cardiac arrhythmias)

� Risk factors� Bedrest

� Constipating medications

� Reduced fluid intake

� Reduced bulk in the diet

� Depression

� CNS disease

� Painful, local lesions

� Nutrition� A high-fiber diet, adequate intake and exercise is as effective

in controlling constipation as medication

� Laxatives and cathartics� For occasional use only – overuse is most common cause of � For occasional use only – overuse is most common cause of

constipation!

� Results from unrelieved constipation

� Collection of hardened feces wedged into rectum

� Can extend up to sigmoid colon

� Most at risk: depilated, confused, unconscious (all are at risk for dehydration)at risk for dehydration)

� When a continuous ooze of diarrheal stool develops, impaction should be suspected

� Associated S/S: Loss of appetite, abdominal distention, cramping, rectal pain

� Nursing measures� Assist with toileting promptly

� Remove the cause if possible

� Rule out impaction

� Protect the skin around the anus� Protect the skin around the anus

� Promote return of normal bowel flora

� Nutrition� Educate on safe food handling and consumption

� Increase in number of stools & the passage of liquid, unformed stool� Intestinal contents pass through small &

large intestines too quickly to allow for usual absorption of water & nutrientsusual absorption of water & nutrients

� A protective response when caused by intestinal irritants

� If untreated, loss of fluids and electrolytes can be life-threatening.

� Symptom of disorders affecting digestion, absorption, & secretion of GI tract

� Irritation can result in increased mucus secretion, feces become too watery, unable to control defecation

Excess loss of colonic � Excess loss of colonic fluid can result in acid-base imbalances or fluid/electrolyte imbalances

� Can also result in skin breakdown

� Emotional Stress

� Intestinal Infection (Clostridium difficile)

� Food Allergies

� Food Intolerance

Tube Feedings (Enteral)� Tube Feedings (Enteral)

� Medications

� Laxatives

� Colon Disease

� Surgery

� Treatment� Rehydration

� Medications, especially for chronic diarrhea

� Eliminate the cause

� Inability to control passage of feces and gas from the anus

� Caused by conditions that create frequent, loose, large volume, watery stools or conditions that impair sphincter control or functionsphincter control or function

� Seldom life-threatening, may be very psychologically devastating.

� Toileting the patient when incontinence is likely to occur

� Protecting the skin

� Changing linens as needed

� Applying fecal incontinence pouch

� Implementing a bowel training program

� Gas accumulation in the lumen of intestines

� Bowel wall stretches and distends

� Common cause of abdominal fullness, pain, & cramping

� Gas escapes through mouth (belching), or anus � Gas escapes through mouth (belching), or anus (flatus)

� Flatulence� Avoid gas-producing foods

� Ambulation promotes peristalsis and the passage of flatus

� Dilated, engorged veins in the lining of the rectum

� External (Clearly visible) or Internal

� Caused by straining, pregnancy, CHF, chronic liver disease

1. A newly admitted client states that he has recently had a change in medications and reports that stools are now dry and hard to pass. This type of bowel pattern is consistent with:A. Abnormal defecationA. Abnormal defecation

B. Constipation

C. Fecal impaction

D. Fecal incontinence

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� These patients have undergone surgery to create an opening in the abdominal wall for fecal elimination.

� An ileostomy allows liquid fecal material from the ileum to be eliminated through the stoma.the ileum to be eliminated through the stoma.� The continent ileostomy and ileoanal reservoir are

alternatives to traditional surgery.

� A colostomy permits formed feces in the colon to be eliminated via the stoma. They are classified by the part of the colon from which they originate.

� Ostomies may be temporary or permanent.

� Location of ostomy determines consistency of stool

� Ileostomy bypasses the entire large intestine, stools are frequent & watery

Ascending colostomy- liquid stool� Ascending colostomy- liquid stool

� Sigmoid colostomy-most like normal stool

� Loop colostomy- temporary, usually done on transverse colon

� 2 openings through stoma, proximal loop for stool, distal loop for mucus

End colostomy- one stoma formed from the � End colostomy- one stoma formed from the proximal end of the bowel with the distal portion removed or sewn shut (Hartmann’s Pouch)

� End colostomy usually done for colorectal cancer

� Ruptured diverticulum- temporary end colostomy with a Hartmanns Pouch

� Double barrel colostomy- Bowel is surgically severed, 2 ends are brought out onto abdomen severed, 2 ends are brought out onto abdomen with 2 distinct stomas (proximal & distal)

� Ileoanal reservoir- restorative proctocolectomy, no outward stoma, no pouch wearing, clients have internal pouch created from the ileum

� Ileal pouches constructed in various configurations (S,J,W)configurations (S,J,W)

� End of the pouch is sewn or anastamosed to the anus

� Several stages to surgery to create pouch

� May need temporary ostomy to allow time for pouch to heal

� Kegel exercises to increase pelvic floor muscle tone

� Kock Continent Ileostomy-Internal reservoir or pouch is created using piece of small intestine

� Stoma brought out low on abdomen, end of internal part in pouch is a one way nipple valve to promote continencepromote continence

� Valve only allows fecal contents to drain when an external catheter is place in stoma, no pouch required

� Patient Education

� Care of stoma, appliance selection and use

� Body Image considerations

� Support groups (UOA)

� Enterostomal nursing- specialty within profession

� Nursing History

� Physical Assessment

� Lab Tests

� Fecal characteristics

� Diagnostic evaluation- Endoscopy, Colonoscopy

� Nursing measures� Control odor

� Inspect the stoma regularly

� Protect the skin around the stoma site

� Monitor intake and output� Monitor intake and output

� Educate the patient on each step of the process

� Encourage self-care

� Change the appliance as needed� Appliances are either drainable or closed.

� Irrigate the colostomy

� Long-term ostomy care� Avoid high-fiber foods for the first 6 to 8 weeks

� Patients with ileostomies are prone to food blockages

� Avoid use of long-acting, sustained-release, and � Avoid use of long-acting, sustained-release, and enteric-coated medications

� Colostomy patients may gain control over elimination with regular irrigations at the same time each day.

�Privacy

� Squatting position

�Bedpan position

�Cathartics & laxatives

�Anti- diarrheal agents

�Enemas

�disimpaction

�Bowel routine� Daily time clock

� Hot drinks

� Stool softeners

� Privavy� Privavy

� Position and abdominal pressure

� Bearing down

� Embarrassing & stressful� Usually urge to defecate 1hr. Pc

� Bedpans � Metal or plastic� Regular or fracture pan� Regular or fracture pan� Cleanliness

� Urinals

� Commode

� Privacy- close door,

� Side rail as needed

� Recumbent with HOB

� Tissue � Tissue

� Call bell

� Leave alone if possible

� Gloves

� Clean genitals

� Remove pan and cover

� In & Out

� Specimens

� Clean pan

� Wash hands yours and client’s

� Lower bed

� Client comfort

� Cleaning of genitals , routine part of complete/ partial bed bath

� Incontinence

� Regular patient� Simple explanation- layman’s terms

� Privacy

� Gloves

� Dorsal recumbent position� Dorsal recumbent position

� Incontinent pad under buttocks

� Warm soap and water

� Female – separate labia

� Avoid use of baby powder/ cornstarch� No medicinal purpose

� Can form clumps or will cake in creases

� Use vaseline/ zincoxide as skin barrier for incontinent clients clients

� Check physician’s order, protocol

� Left Lateral position

� Gloves

� Lubication

� Hold with thumb and index finger� Hold with thumb and index finger

� Insert with index finger (3 – 4”) never force

� Deep breath = relaxes anal sphincter

� Caution� Vagus nerve stimulation can cause heart rate to slow –

avoid excess manipulation

� Main purpose� Promotion of defecation, stimulate peristalsis

� The fluid breaks up fecal mass, stretches the rectal wall & initiates the defecation reflex

� Tap Water� Hypotonic

� Used only once

� Electrolyte imbalance � Water toxicity� Water toxicity

� Circulatory overload ( concentration gradient)

� Normal Saline� Used when more than one enema is needed

� Safest

� Isotonic

� Large volume to distend bowel� Large volume to distend bowel

� Hypertonic Solution� Smaller volume of fluid

� Draws from surrounding tissue into bowel to soften stool and stimulate peristalsis

� Fleets – sodium phosphate� Fleets – sodium phosphate� Low volume, concentrated solution

� Soap suds� Less common

� Soap irritates the bowel

� 5 – 15 mls. Castile soap in 1000mls warm water

� Oil Retention� Oil based solution

� Lubricates the rectum and colon

� Softens stool, easier to pass

� Retain 1 –2 hrs if possible� Retain 1 –2 hrs if possible

� Follow with cleansing enema

� Medicated� Instill meds.

� Rectal mucosa absorption

� Ex. – Kayexalate to K (potassium). Absorbs K from the intestinal tractintestinal tract

� Large Volume� 500 – 1000mls.

� Container 12 – 18 in. above the bowel

� Lg. Volume stimulates & causes evacuation of stool

� Small Volume� Small Volume� 500 mls.

� Container 12 in.above bowel

� Pre packaged� Fleet 150mls

� Microlax 5mls

� Hypertonic solution

� User friendly� User friendly

� Hold for 5min.

� Oral Fleet

� Prepackaged used more than large volume because:� Works

� Less risk for electrolyte imbalance

� Rapid administration

� Less discomfort and distention� Less discomfort and distention

� Convenient and quick

� Physician’s order reads “ enemas to clear”� No more than 3 total given

� Return solution will be highly colored but no solid stool

� Isotonic solution (normal saline)

Excess enema use seriously depletes fluid and electrolytesExcess enema use seriously depletes fluid and electrolytes

� Confirm Dr’s order, prepare client, verbal consent, equipment, privacy� Left lateral position ( fld. Flows by gravity)

� Drape, pad under buttocks

� Warm solution- stimulates peristalsis� Warm solution- stimulates peristalsis� Hot sol’n burns mucosa

� Cold sol’n causes cramping

� Prime tube

� Lubricate tip

� Glove

� Insert 7 – 10 cm.(3-4in) adultDo not force� Do not force

� Deep breath

� Guide toward umbilicus

� Container at appropriate height� Lg. = 12 – 18in� Sm. = 12in� 1000mls takes ~ 10 min to instill� Higher the bag – greater the pressure

C/O discomfort, lower bag, slow infusion, stop, then � C/O discomfort, lower bag, slow infusion, stop, then start again

� Remain side lying to retain 5 – 10 min. or as long as possible

� Assist to bathroom or give bedpan

� Evaluate results

� Document� Type & volume of enema

� Color, amount, consistency of fecal return� Color, amount, consistency of fecal return

� Hygienic measures for client

� Wash Hands

� Certain diseases require surgical interventions to create an opening into the abdominal wall for fecal and urinary elimination

� Enterostomy – the surgical procedure performed to produce the artificial stoma.to produce the artificial stoma.

� Ostomy = opening made to allow passage of urine or stool � Piece of intestine is brought out onto the client’s

abd.

� Lacks nerve endings� Lacks nerve endings

� Doesn’t hurt to touch but has other implications

� Stoma = mouth like opening in the abdominal wall to drain urine or stool

� Effluent – drainage from stoma

� Bowel ostomies� Cancer ( Ca)

� Drain fecal material

� Consistency depends on location� Consistency depends on location� Higher up = more liquid

� Greater risk skin irritation b/c concentration of digestive enzymes

� Ileostomy � End of small intestine

� By passes lg. Intestine = freq. Liquid stools

� Colostomy � Large intestine� Large intestine

� More solid stool

� Ostomies may be permanent � More common

� temporary� Rest the bowel

� Crohn’s� Crohn’s

� Provide drainage of urine that bypasses the bladder = Urinary Diversion

� Ureterostomy� Ureter to abd. Wall� Ureter to abd. Wall

� Lt., Rt., Bilateral

� 6 – 8 in. ileum

� 1 end for external opening

� Other end closed off

� Ureters implanted into this piece of bowel

� Pouch

� Urine will have shred of mucus b/c bowel still produces same

� Infection � Sterile ureters provide opening into system

� Skin Breakdown� Continuous drainage

� Moisture on skin� Moisture on skin

� Replace urinary pouch q 2-3 days

� Effluent ( drainage ) may begin immediately

� Collects all effluent

� Protects the skin

� Stoma should be moist and reddish pink (same as � Stoma should be moist and reddish pink (same as other mucus membranes)

� Flush to skin or bud-like protrusion

� Black, purple, dry = inadequate circulation

� Comfortable fit

� Cover skin surrounding stoma

� Good seal

� Post-op pouch should allow for visibility of stoma

� One Piece Pouching System� Skin barriers preattached, precut, custom fit

� Two Piece System� Skin barrier with flange ( plastic ring)

� Corresponding size pouch� Corresponding size pouch

� Assess stoma� Measure correct size

� Change q 3-7 days

� Empty 1/3 to ½ full, expel flatus prn

� Supine position

� Wash hands, glove

� Remove pouch & skin barrier, push skin away from barrier

� Cleanse peristomal skin gently with warm tap water � Cleanse peristomal skin gently with warm tap water and clean cloth� Do not scrub, Avoid soap ( residue- pouch won’t adher)

� Correct sizing

� Cut opening 1/16 – 1/8 larger than stoma

� Remove backing

� Ileostomy- apply thin circle barrier paste around opening of pouch and allow to dry (if creases or bumps opening of pouch and allow to dry (if creases or bumps use barrier paste to even surface for pouch application)

� Pouch should point to client’s knees

� Maintain gentle finger pressure around barrier for 1-2 min.

� Picture frame flange with non allergic paper tape

Ostomy deodorant for pouch� Ostomy deodorant for pouch

� Tub bath or shower

� Normal stoma oozes blood if rubbed

� Actual bleeding into pouch is abnormal

� Pouch covers are available

� The client will be watching the nurse during ostomy care to gage reaction.ostomy care to gage reaction.

� Be conscious of facial expression & nonverbal cues

� Education

� Counseling � Body image

� Self care

� Fear of rejection� Fear of rejection

� Sexual function

� Powerlessness over bowel regulation

� Decompress GI tract in surgery, infection of GI tract, trauma to GI tract, conditions where peristalsis is absent

� N/G tube purposes- decompression, feeding, compression, & lavagecompression, & lavage

� Pliable tube inserted through nasopharynx into stomach

� Uncomfortable insertion

� Types: Levin – single lumen, different sizes used for feeding or decompression

� Salem Sump – Most preferable for decompression, dual lumen, one for removal of gastric contents, dual lumen, one for removal of gastric contents, one as an air vent, hooked to suction to achieve decompression

� Confirm placement after insertion

� HOB at 30 degrees unless ordered otherwise

� Mark point where tube exits nose

� Tape tube securely to nose

� Tube Irrigation� Tube Irrigation

� Nasal skin care

� Frequent oral hygeine

� Assess for abdominal distention

� Suction settings

� Bowel training

� Maintenance of proper fluid & food intake

� Promotion of regular exercise

� Promotion of Comfort

� Maintenance of skin integrity

� Promotion of self concept

� 2. To maintain normal elimination patterns in the hospitalized client, you should instruct the client to defecate 1 hour after meals because:

� A. The presence of food stimulates peristalsis.

� B. Mass colonic peristalsis occurs at this time.� B. Mass colonic peristalsis occurs at this time.

� C. Irregularity helps to develop a habitual pattern.

� D. Neglecting the urge to defecate can cause diarrhea.

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� Did your client meet their goal?