Chapter 46 Bowel Elimination Copyright 2013 2009 2005

Organs of the Gastrointestinal (GI) Tract Copyright © 2013, 2009, 2005 by Mosby, an

Case Study Mr. Gutierrez resides in an assisted-living apartment of a long-term care center. He keeps busy in his small garden plot and enjoys other activities of the center, such as nightly card games and outings to baseball games. He is 82 years old and widowed and has lived in the area for longer than 3 years. His family, with whom he is quite close, is scattered across the country. He has one niece, who lives in the same town. Mrs. Gutierrez feels he is in good health; as long as he eats green chili peppers every day, he believes he will remain healthy. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 3

Segmented and Peristaltic Waves Copyright © 2013, 2009, 2005 by Mosby, an imprint of

Divisions of the Large Intestine Copyright © 2013, 2009, 2005 by Mosby, an imprint

Case Study (cont’d) Because Mr. Gutierrez has a small kitchen in his apartment, he is able to make some of his favorite foods. His diet consists of flour and corn tortillas, beans, and rice. He likes most meats, but he prefers chicken and as ado (made with pork). For breakfast, he usually has hues rancheros. He has been hospitalized only twice—once for the flu and once for placement of a pacemaker. He presently takes three medications: digoxin, Zestril, and Metamucil. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 6

Scientific Knowledge Base Mouth Esophagus Digestion begins with mastication. Peristalsis moves food into the stomach. Stomach Small intestine Stores food; mixes food, liquid, and digestive juices; moves food into small intestines Duodenum, jejunum, and ileum Large intestine Anus The primary organ of bowel elimination Expels feces and flatus from the rectum Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 7

Nursing Knowledge Base: Factors Affecting Bowel Elimination Age Fluid intake Diet Physical activity Psychological factors Personal habits Position during defecation Pain Pregnancy Surgery and anesthesia Medications, laxatives, and Diagnostic tests cathartics Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 8

Bristol Stool Form Scale Copyright © 2013, 2009, 2005 by Mosby, an imprint of

Common Bowel Elimination Problems Constipation Impaction A symptom, not a disease; infrequent stool and/or hard, dry, small stools that are difficult to eliminate Results from unrelieved constipation; a collection of hardened feces wedged in the rectum that a person cannot expel Diarrhea Incontinence an increase in the number of stools and the passage of liquid, unformed feces Inability to control passage of feces and gas to the anus Flatulence Hemorrhoids Accumulation of gas in the intestines causing the walls to stretch Dilated, engorged veins in the lining of the rectum Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 10

Case Study (cont’d) This afternoon Mr. Gutierrez has telephoned his niece for the fourth time. He reports, “My bowels are locked up and haven’t moved in the last 2 days. ” He ate a big meal the previous evening and now reports feeling “all gassed up. ” His niece tried to explain about eating foods containing fiber and more vegetables. She reminded Mr. Gutierrez that the nursing student was coming later this afternoon, and he could talk to the student about his problem. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 11

Bowel Diversion Temporary or permanent artificial opening in the abdominal wall Ø Surgical opening in the ileum or colon Ø Stoma Ileostomy or colostomy The standard bowel diversion creates a stoma. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 12

Loop Colostomy Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.

End Colostomy Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.

Double-Barrel Colostomy Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.

Ostomies Loop colostomy Ø End colostomy Ø This is temporary in the transverse colon. Proximal end forms stoma, and distal end is removed or sewn closed. Double-barrel colostomy Ø Bowel is surgically cut, and both ends are brought through the abdomen. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 16

Case Study (cont’d) Vickie is the nursing student assigned to Mr. Gutierrez. She has been seeing him once a week for 5 weeks as a portion of a home health care clinical experience. They have developed a good rapport. Mr. Gutierrez’ self-identified problems with his bowels are a frequent topic of conversation. As Vickie prepares to assess Mr. Gutierrez, she reflects on experiences with other patients in the home setting. She recalls one patient who had elimination problems resulting from a diet consisting mainly of high-fat and high-carbohydrate foods. She believes that her involvement with that patient is likely to help in Mr. Gutierrez’ care. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 17

Ileoanal Pouch Anastomosis Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier

Construction of Kock Pouch Copyright © 2013, 2009, 2005 by Mosby, an imprint of

Macedo-Malone Antegrade Continence Enema (MACE) Copyright © 2013, 2009, 2005 by Mosby, an imprint

Alternative Approaches Ileoanal pouch anastomosis Ø Kock continent ileostomy Ø Small intestine forms a pouch, which is emptied several times a day. Macedo-Malone antegrade continence enema (MACE) Ø Pouch is a reservoir for wastes that are eliminated from the anus. This procedure was developed for patients who have neuropathic or structural abnormalities of the anus. Psychological considerations Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 21

Case Study (cont’d) Vickie reviews her class notes on the anatomy and physiology of the GI system. Vickie reviews the physiological changes that aging produces within the GI system: loss of teeth, taste bud atrophy, decreased secretion of gastric acid, and a slight decrease in small intestine motility. Vickie will thoroughly assess Mr. Gutierrez’ dietary intake with a 24 -hour diet recall. Being familiar with his Hispanic heritage, Vickie anticipates certain food preferences. She knows he does not like the food served at the center and frequently requests “home-cooked” tortillas and green chili peppers from his niece. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 22

Quick Quiz! 1. A newly admitted patient 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 defecation. B. Constipation. C. Fecal impaction. D. Fecal incontinence. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 23

Case Study (cont’d) From their last visit, Vickie and Mr. Gutierrez have been able to communicate without difficulty. Mr. Gutierrez complains of feeling “full of gas” but has not “passed any wind” in the past 2 days. His stove has not been working well, and he has been unable to prepare rice and beans. Based on the nursing history, Vickie estimates that Mr. Gutierrez normally drinks about 1200 m. L of fluid daily. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 24

Nursing Process: Assessment Nursing history What a patient describes as normal or abnormal is often different from factors and conditions that tend to promote normal elimination. Ø Identifying normal and abnormal patterns, habits, and the patient’s perception of normal and abnormal with regard to bowel elimination allows you to accurately determine a patient’s problems. Ø Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 25

Assessment Physical assessment Ø Laboratory tests Ø Ø Mouth, abdomen, and rectum Fecal characteristics Fecal specimens Diagnostic examinations Ø Ø Radiologic imaging, with or without contrast Endoscopy Ultrasound Computed tomography (CT) or magnetic resonance imaging (MRI) Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 26

Case Study (cont’d) Determine when Mr. Gutierrez had his last bowel movement. He had his last bowel movement 2 days ago. The stool was brown and hard. “I took a laxative last night, and I think I need an enema. ” A medication history shows that Mr. Determine Mr. Gutierrez frequently resorts to taking Gutierrez’ medication history. laxatives. Establish Mr. Gutierrez’ dietary habits. Mr. Gutierrez eats a high intake of corn tortillas and cheese and a low intake of fruits. He states, “I really haven’t felt like eating today and have not eaten much for the last 4 days. ” Hypoactive bowel sounds in all four Assess Mr. Gutierrez’ abdomen. quadrants. Abdomen is soft but slightly distended. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 27

Fecal Occult Blood Testing Copyright © 2013, 2009, 2005 by Mosby, an imprint of

Fecal Occult Blood Testing (cont’d) Copyright © 2013, 2009, 2005 by Mosby, an imprint

Nursing Diagnosis and Planning Constipation Risk for constipation Perceived constipation Bowel incontinence Diarrhea Toileting selfcare deficit The Agency for Healthcare Research and Quality (AHRQ) provides guidelines on reduction of pressure ulcers that can also help you develop a plan of care for patients with bowel incontinence. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 30

Case Study (cont’d) Nursing diagnosis: Constipation related to less than adequate fluid and dietary intake and chronic laxative use Goals: Mr. Gutierrez will establish and maintain a normal defecation pattern within 1 month. Ø Mr. Gutierrez will identify practices that reduce the risk for or prevent constipation within 2 weeks. Ø Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 31

Implementations: Acute Care Health promotion Ø Promotion of normal defecation • Establish a routine an hour after a meal, or maintain the patient’s routine. Ø Ø Ø Sitting position Privacy Positioning on bedpan Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 32

Types of Bedpans Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier

Proper and Improper Position on a Bedpan Copyright © 2013, 2009, 2005 by Mosby,

Positioning Immobilized Patient on Bedpan Copyright © 2013, 2009, 2005 by Mosby, an imprint

Case Study (cont’d) Instruct Mr. Gutierrez in a weekly menu plan, including foods high in fiber: brown rice, beans and rice, tomatoes, and wheat tortillas. Add bran flakes, bran, or fiber supplement to Mr. Gutierrez’ diet. Consult with Mr. Gutierrez’ niece and long-term care center to have the patient’s stove repaired. Educate Mr. Gutierrez about the use of liquids to promote softening of stool and defecation; have him drink a decaffeinated beverage of choice. Encourage Mr. Gutierrez to try to establish a routine time for defecation, establishing a routine after breakfast or another meal. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 36

Acute Care: Medications Cathartics and laxatives Ø Ø Oral, tablet, powder, and suppository forms Excessive use increases risks for diarrhea and abnormal elimination. Antidiarrheal agents Ø Ø Over the counter Opiates used with caution Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 37

Enemas Types: Cleansing • Tap water • Normal saline (infants and children) • Hypertonic solutions • Soapsuds Ø Oil retention Ø Others: carminative and Kayexalate Ø Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 38

Enemas Enema administration Ø Ø Ø Sterile technique is unnecessary. Wear gloves. Explain the procedure, precautions to avoid discomfort, and length of time necessary to retain the solution before defecation. Digital removal of stool Ø Ø Ø Use if enemas fail to remove an impaction. This is the last resort for constipation. A health care provider’s order is necessary to remove an impaction. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 39

Inserting and Maintaining a Nasogastric Tube Purposes Ø Decompression, enteral feeding, compression, and lavage Categories of nasogastric (NG) tubes Fine- or small-bore for medication administration and enteral feedings Ø Large-bore (12 -French and above) for gastric decompression or removal of gastric secretions Ø Clean technique Maintaining patency Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 40

Quick Quiz! 2. To maintain normal elimination patterns in the hospitalized patient, you should instruct the patient to defecate 1 hour after meals because A. The presence of food stimulates peristalsis. 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. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 41

Continuing and Restorative Care of ostomies Ø Pouching ostomies Ø Irrigating a colostomy An effective pouching system protects the skin, contains fecal material, remains odor free, and is comfortable and inconspicuous. Nutritional considerations Consume low fiber for the first weeks. Eat slowly and chew food completely. Drink 10 to 12 glasses of water daily. Ø Patient may choose to avoid gassy foods. Ø Ø Ø Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 42

Irrigating a Colostomy Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier

Continuing and Restorative Care Bowel training Ø Ø Training program Diet Promotion of regular exercise Management of hemorrhoids Skin integrity Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 44

Case Study (cont’d) Review Mr. Gutierrez’ diary of foods, and ask him about his intake as well. Mr. Gutierrez describes likes and dislikes but admits to eating high-fat foods and few fruits and vegetables. Fluid intake averaged 1400 m. L daily for a week. Ask Mr. Gutierrez about his pattern of elimination over the past 2 weeks and laxative use. Mr. Gutierrez says, “I still go about the same” but states that he thinks he now goes about every 2 days. Mr. Gutierrez has not used any laxatives for a week. During follow-up visit, examine patient’s abdomen and observe stool (if possible). Patient reports that stool is formed but is “not hard like before. ” Bowel sounds are normal. Abdomen is soft and nontender with no distention. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 45

Evaluation Do you use medications such as laxatives or enemas to help you defecate? What barriers are preventing you from eating a diet high in fiber and participating in regular exercise? How much fluid do you drink in a typical day? What types of fluids do you normally drink? What challenges do you encounter when you change your ostomy pouch? Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 46

Case Study (cont’d) Vickie returns to see Mr. Gutierrez 2 weeks later. Vickie is eager to determine whether patient has made changes in his diet, and if his problems with bowel elimination have been progressing. Vickie is also eager to learn if his stove has been repaired. Mr. Gutierrez tells Vickie that he has been eating bran cereal in the morning, has been eating rice and/or beans for dinner, and has added one fruit each day to his diet. He has been walking twice a day through the long-term care center. Although he does not have a bowel movement each day, his stools are much softer and easier to pass, and he says he is less concerned. He has not taken a laxative for a stool since last talking with Vickie. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc. 47