Bowel Elimination Bowel Elimination GI Tract is a

Bowel Elimination

Bowel Elimination GI Tract is a series of hollow mucous membrane lined muscular organs n Purpose is to absorb fluids & nutrients, prepare food for absorption & provide storage for feces n

GI Tract Anatomy Mouth n Esophagus n Stomach n Small Intestine n Large Intestine n Rectum n

Mouth Digestion begins here n Mechanical, chemical breakdown of nutrients n Teeth-Mastication n Salivary secretions-enzymes n Food Bolus ﻣﻀﻐﺔ n

Esophagus Hollow, muscular tube for passage of food to stomach n Peristaltic waves, contraction and relaxation of smooth muscle moves food down to stomach n Sphincter control to prevent reflux n

Stomach Food is temporarily stored and mechanically and chemically broken down n Secretes HCL, mucus, pepsin, & intrinsic factor(Needed for Vitamin B 12 absorption) n Food is converted into chyme n

Small Intestine n n n 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 elements Nutrients absorbed in duodenum & jejunum, ileum absorbs vitamins, iron, & bile salts

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

Colon n 3 Divisions: Ascending, Transverse, Descending n Colon Functions: Absorption, Protection, Secretion, & Elimination (stool and flatus)

Rectum n n n Sigmoid colon Storage of feces Length varies with age When fecal mass or flatus moves into rectum, it distends and defecation begins Process involves involuntary (Internal sphincter) and voluntary control (external sphincter) Valsalva Maneuver - voluntary contraction of abdominal muscles

Factors Affecting Bowel Elimination Age n Infection n Diet n Fluid Intake n Physical Activity n Psychological factors n Personal Habits n

Factors Affecting Bowel Elimination Position during Defecation n Pain n Surgery and Anesthesia n Medications n

Common Bowel Elimination Problems Constipation n Impaction n Diarrhea n Incontinence n Flatulence n Hemorrhoids n

Constipation More of a symptom than a disorder n Decrease in frequency of BM n Straining & pain on defecation is associated symptoms(Valsalva manuever) n Can be significant heath hazard (increase ICP, IOP, reopen surgical wounds, cause trauma, cardiac arrhythmias) n

Impaction Results from unrelieved constipation n Collection of hardened feces wedged ﻋﺎﻟﻖ into rectum n Can extend up to sigmoid colon n Most at risk: confused, unconscious (all are at risk for dehydration) n

Impaction When a continuous ooze of diarrheal stool develops, impaction should be suspected n Associated S/S: Loss of appetite, abdominal distention, cramping, rectal pain n

Diarrhea n n n Increase in number of stools & the passage of liquid, unformed stool Symptom of disorders affecting digestion, absorption, & secretion of GI tract Intestinal contents pass through small & large intestines too quickly to allow for usual absorption of water & nutrients

Diarrhea n n n Irritation can result in increased mucus secretion, feces become too watery, unable to control defecation Excess loss of colonic fluid can result in acidbase imbalances or fluid/electrolyte imbalances Can also result in skin breakdown

Conditions that cause Diarrhea n n n n n Emotional Stress Intestinal Infection (Clostridium difficile) Food Allergies Food Intolerance Tube Feedings (Enteral) Medications Laxatives Colon Disease Surgery

Incontinence Inability to control passage of feces and gas from the anus n Caused by conditions that create frequent, loose, large volume, watery stools or conditions that impair sphincter control or function

Flatulence Gas accumulation in the lumen of intestines n Bowel wall stretches and distends n Common cause of abdominal fullness, pain, & cramping n Gas escapes through mouth (belching), or anus (flatus) n

Flatus Formation n n n Air swallowing Diffusion of gas from bloodstream into intestines Bacterial action on unabsorbable CHO (Beans) Fermentation of CHO (cabbage, onions Can stimulate peristalsis Adult forms 400 -700 ml of flatus daily

Flatulence Causes: Decreased peristalsis n Constipation n Medications n Surgery n Diet n Stress n Decreased activity n

Non. Invasive Interventions for Flatulence *Ambulation* n Knee chest position

Invasive Interventions for Flatulence n Glycerin Suppository n Harris Flush n Rectal Tube

Hemorrhoids Dilated, engorged veins in the lining of the rectum n External (Clearly visible) or Internal n Caused by straining, pregnancy, CHF, chronic liver disease n

Physical Assessment Inspection- observe contour of abd and note visible peristalsis n Auscultation- listen for bowel sounds all quadrants n Percussion- resonant or tympany over hollow organs…dullness over intestinal obstruction n Palpation- feel for masses, tenderness etc… n

Bowel Diversions Certain diseases cause conditions that prevent normal passage of feces through rectum n Creates need for temporary or permanent artificial opening (stoma) in the abdominal wall n

Bowel Diversions Surgical openings (ostomy) are most commonly formed in the ileum (ileostomy) or the colon (colostomy) n Incontinent ostomy- need to wear appliance pouch n Continent ostomy- have control through use of ostomy cap n

Ostomy Nursing Considerations Patient Education n Care of stoma, appliance selection and use n Body Image considerations n Support groups n Enterostomal nursing- specialty within profession n

Nursing Process Assessment Nursing History n Physical Assessment n Lab Tests n Fecal characteristics n Diagnostic evaluation- Endoscopy, Colonoscopy n

Nursing Diagnosis Bowel Incontinence n Constipation n Diarrhea n Impaired Skin Integrity n Body Image Disturbance n Altered bowel elimination n Pain n

Implementation Promoting Normal Defecation Positioning of patient-squatting n Positioning on bedpan n Use of cathartics, laxatives n Anti-diarrheal agents n Enemas n Digital removal of stool n Ostomy care n

Interventions: Promote Bowel Elimination n Laxatives and Cathartics n Enemas n Suppositories n Digital Removal

Types of Enemas

Enemas Cleansing enema n Tap water n Normal saline n Hypertonic Solutions (Fleet’s enema) n Soapsuds n Oil Retention n Medicated enemas (Kayexalate, Lactulose) n Administering a Cleansing enema P&P pg. 1200 -1201 n

Tap Water (TWE) Amount: 500 -1000 cc n Action: Distends, increases peristalsis n Time: 15 min. n Indicated: inflamed bowels/irritated colon n Contraindicated: Atonic bowels, fluid restrictions n

Normal Saline Amount: 500 -1000 cc n Action: Distends, increases peristalsis n Time: 15 min. n Indicated: Inflamed bowels/irritated colon n Contraindicated: Na retention problems, fluid restrictions n

Soap Amount: 500 -1000 cc (Castile 5 ml/1000 cc) n Action: Distends, Irritates n Time: 15 min. n Indicated: Constipation n Contraindicated: Prior to rectal exams n

Hypertonic Amount: 70 -130 cc solution n Action: Distends/Irritates n Time: 5 -10 min. n Indicated: Constipation, convenience n Contraindicated: Dehydration, Na problems n

Oil Retention n Amount: 120 -200 cc n Action: Lubricates n Time: 30 min. n Indicated: Fecal impaction n Contraindication: none

Colostomy nursing care n n 1. Wash hands. 2. Apply clean gloves. 3. Assemble irrigation kit: Attach cone or catheter to irrigation bag tubing. 4. Fill irrigation bag with 1000 cc tepid tap water

n n 5. Open clamp and let water from the irrigation bag fill the tubing. 6. Hang bottom of irrigation bag at height of client’s shoulder, or 18 inches above the stoma if the client is supine. 7. Check direction of intestine by inserting a gloved finger into orifice of stoma. 8. Place irrigation sleeve over stoma and hold in place with belt ﻳﻄﻮﻕ ﺑﺤﺰﺍﻡ

n n n 9. Spray inside of irrigation sleeve and bathroom with odor eliminator (usual dose is two sprays). 10. Cuff end of irrigation sleeve and place into toilet bowl (if client is in bathroom) or bedpan (if client is in bed or chair) (see Figure 6 -22 -5). 11. Lubricate the cone end of the irrigation tubing and insert into orifice of stoma through the top opening of irrigation sleeve

n n n 12. Close top of irrigation sleeve over the tubing. 13. Slowly run water through tubing into colon 14. Remove cone after all water has emptied out of irrigation bag. 15. Close end of irrigation sleeve by attaching it to the top of the sleeve. 16. Encourage client to ambulate to facilitate emptying of remaining stool from colon.

n n n 17. Remove irrigation sleeve after 20– 30 minutes or when stool is no longer emptying from colon. 18. Cleanse stoma and skin with warm tap water. Pat dry. 19. Place gauze pad over stoma to absorb mucus from stoma. 20. Secure gauze with hypoallergenic tape. 21. Remove gloves and wash hands.