Chapter 47 Bowel Elimination Copyright 2017 Elsevier Inc
Chapter 47 Bowel Elimination Copyright © 2017, Elsevier Inc. All Rights Reserved.
Giddens Concepts Elimination: the passage of stool through the intestinal tract and dispelling the stool by means of intestinal smooth muscle contraction. Copyright © 2017, Elsevier Inc. All Rights Reserved. 2
Scientific Knowledge Base Mouth Esophagus Stomach Small intestine Large intestine Anus Defecation Copyright © 2017, Elsevier Inc. All Rights Reserved. 3
Nursing Knowledge Base: Factors Affecting Bowel Elimination Age Diet Fluid intake Physical activity Psychological factors Personal habits Position during defecation Pain Pregnancy Surgery and anesthesia Medications Diagnostic tests Copyright © 2017, Elsevier Inc. All Rights Reserved. 4
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 © 2017, Elsevier Inc. All Rights Reserved. 5
Bowel Diversions Temporary or permanent artificial opening in the abdominal wall Ø Stoma Surgical opening in the ileum or colon Ø Ileostomy or colostomy Copyright © 2017, Elsevier Inc. All Rights Reserved. 6
Bowel Diversions (Cont. ) Ostomies Sigmoid colostomy Ø Transverse colostomy Ø Ileostomy Ø Loop colostomy Ø End colostomy Ø Copyright © 2017, Elsevier Inc. All Rights Reserved. 7
Other Approaches Ileoanal pouch anastomosis Continent ileostomy Antegrade continence enema Copyright © 2017, Elsevier Inc. All Rights Reserved. 8
Nursing Process: Assessment Through the patient’s eyes 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 © 2017, Elsevier Inc. All Rights Reserved. 9
Assessment (Cont. ) Elimination Factors Elimination pattern Surgery or illness Stool characteristics Medications Routines Emotional state Bowel diversions Exercise Appetite changes Pain or discomfort Diet history Social history Daily fluid intake Mobility and dexterity Copyright © 2017, Elsevier Inc. All Rights Reserved. 10
Assessment (Cont. ) Physical assessment Ø Mouth, abdomen, and rectum Laboratory tests Ø Fecal specimens Copyright © 2017, Elsevier Inc. All Rights Reserved. 11
Diagnostic Examinations Colonosopy at age 50 and every 10 years… Sigmoidoscopy at age 50 and every 5 years… Copyright © 2017, Elsevier Inc. All Rights Reserved. 12
Assessment (Cont. ) Copyright © 2017, Elsevier Inc. All Rights Reserved. 13
Nursing Diagnosis Some diagnoses that apply to patients with elimination problems include: Disturbed body image Ø Bowel incontinence Ø Constipation Ø Perceived constipation Ø Risk for constipation Ø Diarrhea Ø Nausea Ø Deficit knowledge (nutrition) Ø Copyright © 2017, Elsevier Inc. All Rights Reserved. 14
Planning Goals and outcomes Incorporate elimination habits or routines Ø Reinforce routines that promote health Ø Consider preexisting concerns Ø Setting priorities Ø Patients often have multiple diagnoses Teamwork and collaboration Copyright © 2017, Elsevier Inc. All Rights Reserved. 15
Implementation: Health Promotion Routine Colorectal cancer Promotion of normal defecation Sitting position Ø Privacy Ø Positioning on bedpan Ø Copyright © 2017, Elsevier Inc. All Rights Reserved. 16
Health Promotion (Cont. ) Positioning on bedpan (Cont. ) Prevent muscle strain and discomfort Ø Elevate head of the bed 30 to 45 degrees Ø Wear gloves when handling bedpans Ø Copyright © 2017, Elsevier Inc. All Rights Reserved. 17
Health Promotion (Cont. ) Positioning on bedpan (Cont. ) Ø When patients are immobile or it is unsafe to allow them to raise their hips, they remain flat and roll onto the bedpan. Copyright © 2017, Elsevier Inc. All Rights Reserved. 18
Acute Care Environment Cathartics and laxatives Cathartics have a stronger and more rapid effect on the intestines than laxatives Ø Suppositories may act more quickly than oral medications Ø Antidiarrheal agents Ø Opiates used with caution Copyright © 2017, Elsevier Inc. All Rights Reserved. 19
Acute Care (Cont. ) Enemas Ø Cleansing enemas • • Tap water Normal saline Hypertonic solutions Soapsuds Oil retention Ø Others types of enemas Ø • Carminative and Kayexalate Copyright © 2017, Elsevier Inc. All Rights Reserved. 20
Acute Care (Cont. ) Enema administration Skill 47 -1 Sterile technique is unnecessary. Ø Wear gloves. Ø Explain the procedure, positioning, precautions to avoid discomfort, and length of time necessary to retain the solution before defecation. Ø Digital removal of stool Use if enemas fail to remove an impaction. Ø Requires physician order. Ø Last resort in managing severe constipation. Ø Copyright © 2017, Elsevier Inc. All Rights Reserved. 21
Acute Care (Cont. ) Inserting and Maintaining a Nasogastric Tube Ø Purposes • Decompression, enteral feeding, compression, and lavage Ø Categories of nasogastric (NG) tubes • Fine- or small-bore for medication administration and enteral feedings • Large-bore (12 -French and above) for gastric decompression or removal of gastric secretions Clean technique Ø Maintaining patency Ø Copyright © 2017, Elsevier Inc. All Rights Reserved. 22
Continuing and Restorative Care of ostomies Pouching ostomies Nutritional considerations Psychological Considerations Copyright © 2017, Elsevier Inc. All Rights Reserved. 23
Continuing and Restorative Care (Cont. ) Bowel training Maintenance of proper fluid and food intake Promotion of regular exercise Management of the patient with fecal incontinence or diarrhea Maintenance of skin integrity Copyright © 2017, Elsevier Inc. All Rights Reserved. 24
Evaluation Through the patient’s eyes Ø The patient or caregiver determines which therapies were the most effective Patient outcomes Develop a therapeutic relationship Ø Evaluate a patient’s level of knowledge Ø Determine the extent to which the patient accomplishes normal defecation Ø Ask the patient to describe changes in diet, fluid intake, and activity to promote bowel health Ø Copyright © 2017, Elsevier Inc. All Rights Reserved. 25
Safety Guidelines For Nursing Skills Instruct patients who self-administer enemas to use the side-lying position. If a patient has cardiac disease or is taking cardiac or hypertensive medication, obtain a pulse rate, because manipulation of rectal tissue stimulates the vagus nerve and sometimes causes a sudden decline in pulse rate. Copyright © 2017, Elsevier Inc. All Rights Reserved. 26
- Slides: 26