Elimination wangkfsdu edu cn 0531 88382223 Section 2

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Elimination 王克芳 wangkf@sdu. edu. cn 0531 -88382223 山�大学�理学院

Elimination 王克芳 wangkf@sdu. edu. cn 0531 -88382223 山�大学�理学院

Section 2 Bowel Elimination v Anatomy and Physiology v Assessment of Bowel Elimination v

Section 2 Bowel Elimination v Anatomy and Physiology v Assessment of Bowel Elimination v Interventions for Bowel Elimination v Nursing Skills for Bowel Elimination 护理学基础 WKF SON SDU 1

Anatomy and Physiology v Large Intestines is a primary organ of bowel elimination Anatomy

Anatomy and Physiology v Large Intestines is a primary organ of bowel elimination Anatomy Functions Movement Defecation 护理学基础 WKF SON SDU 2

Anatomy Transverse Colon Ascending Colon Descending Colon Cecum Sigmoid Colon Rectum Anus 16 cm

Anatomy Transverse Colon Ascending Colon Descending Colon Cecum Sigmoid Colon Rectum Anus 16 cm 4 cm Normally is empty of feces Internal sphincter External sphincter

Functions v Absorption: Fluid, electrolyte and vitamins v Manufacture of some vitamins v Formation

Functions v Absorption: Fluid, electrolyte and vitamins v Manufacture of some vitamins v Formation of feces v Expulsion of feces from the body Anatomy and Physiology 护理学基础 WKF SON SDU 4

Movement of Large Intestines v 袋状往返运� a wavelike muscular contraction advances the colon contents

Movement of Large Intestines v 袋状往返运� a wavelike muscular contraction advances the colon contents 1/(3 -12)mins v 分� 或多袋推� 运� v 蠕� (Peristalsis ) v 集� 蠕� (Mass peristalsis ) Occurs about 1 hour after a meal 3 - 4 times / 24 hour Gastro-colic reflex Duodeno-colic reflex Anatomy and Physiology 护理学基础 WKF SON SDU 5

排便(Defecation) Fecal mass Peristalsis Rectum (sensor) impulse Defecation center impulse Defecation Center (Cerebral cortex)

排便(Defecation) Fecal mass Peristalsis Rectum (sensor) impulse Defecation center impulse Defecation Center (Cerebral cortex) Colon and rectum muscle contracts Internal sphincter relaxes External sphincter relaxes Desire to defecate Expulsion of feces

Assessment of Bowel Elimination Normal Defecation Factors Affecting Bowel Elimination Problems 护理学基础 WKF SON

Assessment of Bowel Elimination Normal Defecation Factors Affecting Bowel Elimination Problems 护理学基础 WKF SON SDU 7

Normal Defecation v Frequency v 1 -3 times/ day ----- 3 times /week v

Normal Defecation v Frequency v 1 -3 times/ day ----- 3 times /week v Amount v 100 -300 g/day in adult Shape Consistency v Fecal Characteristics Color Constituents Odor Normal Defecationt 护理学基础 WKF SON SDU 8

Fecal Characteristics Pencil shaped obstruction, rapid peristalsis, v Shape and Consistency v v Diameter

Fecal Characteristics Pencil shaped obstruction, rapid peristalsis, v Shape and Consistency v v Diameter of rectum Soft, formed v Color v Brown Liquid diarrhea with reduced absorption chestnut shaped, Hard White or clay – no bile constipation Black– bleeding in upper GI tract Red – bleeding in lower GI tract or hemorrhoids Pale with fat – mal-absorption of fat v Constituents v Undigested food, dead bacteria, fat, bile pigment, cells lining, mucosa, water v Odor v Affected by food type n. Abnormal – blood, pus, foreign bodies, mucus, worms Normal Defecationt 护理学基础 WKF SON SDU 9

Factors Affecting Bowel Elimination v Physiological factors v Social and psychological factors v Diet

Factors Affecting Bowel Elimination v Physiological factors v Social and psychological factors v Diet v Physical activity v Health Status Affecting Factors 护理学基础 WKF SON SDU 10

Physiological factors Age v Infant v v Adolescent v v v Small stomach capacity

Physiological factors Age v Infant v v Adolescent v v v Small stomach capacity Less secretion of digestive enzymes Inability to control Rapid growth of large intestine Typically eat more Elderly Peristalsis slows Choosing soft foods v Difficulties in chewing (loss teeth) v Reduced mobility v Low muscle tone v v Affecting Factors 护理学基础 WKF SON SDU 11

Physiological factors Personal habits v Time--Gastrocolic reflex usually most easily stimulated after meals v

Physiological factors Personal habits v Time--Gastrocolic reflex usually most easily stimulated after meals v Facilities v Positioning--Squat, lean forward v Exerts intra-abdominal pressure v Contracts thigh muscles v Impossible to contract muscles in supine position 护理学基础 WKF SON SDU 12

Social and psychological factors Social /Privacy environment Anxious, angry or afraid v Increased peristalsis

Social and psychological factors Social /Privacy environment Anxious, angry or afraid v Increased peristalsis v diarrhea Depressed v Slowed mobility v constipation 护理学基础 WKF SON SDU 13

Diet factors Fiber provides bulk v Absorbs fluid, increases stool mass; Stimulates peristalsis Gas

Diet factors Fiber provides bulk v Absorbs fluid, increases stool mass; Stimulates peristalsis Gas producing foods v Increase peristalsis; Distends intestinal walls Milk products v Lactose intolerance Fluid liquefies intestinal contents, easing it’s passage 2000 -3000 ml/day Affecting Factors 护理学基础 WKF SON SDU 14

Physical activity Promotes peristalsis Maintains tone of muscles used for defecation v A sedentary

Physical activity Promotes peristalsis Maintains tone of muscles used for defecation v A sedentary lifestyle decreases peristalsis v Weak abdominal and pelvic muscles impair ability to increase intra-abdominal pressure and control external sphincter Affecting Factors 护理学基础 WKF SON SDU 15

Health Status Diseases Medications Laxatives v Antibiotics v Anesthetic and narcotic analgesics v v

Health Status Diseases Medications Laxatives v Antibiotics v Anesthetic and narcotic analgesics v v Treatment and screening v Surgery--Pain Affecting Factors 护理学基础 WKF SON SDU 16

Bowel Elimination Problems Constipation(便秘) Fecal Impaction(�便嵌塞) Diarrhea(腹泻) Fecal Incontinence(大便失禁) Flatulence(��气) Altered Defecation 护理学基础 WKF

Bowel Elimination Problems Constipation(便秘) Fecal Impaction(�便嵌塞) Diarrhea(腹泻) Fecal Incontinence(大便失禁) Flatulence(��气) Altered Defecation 护理学基础 WKF SON SDU 17

Constipation Definition 1. A decrease in frequency of bowel movement 2. Prolonged or difficult

Constipation Definition 1. A decrease in frequency of bowel movement 2. Prolonged or difficult passage of hard and dry feces Altered Defecation 护理学基础 WKF SON SDU 18

Constipation Etiology: Lack of Fiber/ Water in diet Immobilization Irregular bowel habits Medications Neurological

Constipation Etiology: Lack of Fiber/ Water in diet Immobilization Irregular bowel habits Medications Neurological conditions Organ illnesses 护理学基础 WKF SON SDU 19

Constipation v Symptoms and Signs v Decreased frequency of bowel movements v Dry, hard

Constipation v Symptoms and Signs v Decreased frequency of bowel movements v Dry, hard feces v Headache, abdominal distention and cramping, poor digestion, fatigue, poor appetite, heavily coated tongue Altered Defecation 护理学基础 WKF SON SDU 20

Fecal Impaction v Fecal impaction is a collection of harden feces, wedged in the

Fecal Impaction v Fecal impaction is a collection of harden feces, wedged in the rectum, which cannot be expelled. v It usually results from unrelieved chronic constipation. Altered Defecation 护理学基础 WKF SON SDU 21

Fecal Impaction v Causes Results from unrelieved constipation v Hard stool wedged in rectum,

Fecal Impaction v Causes Results from unrelieved constipation v Hard stool wedged in rectum, cannot be expelled v v Symptoms and Signs v v v No stool for several days Continuous oozing of liquid stool Anorexia Abdominal distention and cramping Rectal pain Palpation: impacted mass ( a digital examination of the rectum) Altered Defecation 护理学基础 WKF SON SDU 22

Diarrhea v Frequent defecation v Passage of liquid, unformed feces. v affecting digestion, absorption,

Diarrhea v Frequent defecation v Passage of liquid, unformed feces. v affecting digestion, absorption, and secretion in the GI tract. Altered Defecation 护理学基础 WKF SON SDU 23

Diarrhea v Causes v v v v Intestinal infection or disease Food intolerance or

Diarrhea v Causes v v v v Intestinal infection or disease Food intolerance or allergies Overuses of laxatives Lack of development in digestive system Some endocrine diseases such as hyperthyroidism Emotional stress and anxiety. Symptoms and signs v v v Increased number of stools Liquid Abdominal pain, fatigue, nausea and vomit. Auscultation: hyperactive gurgling sounds. Unable to control the urge to defecate. Altered Defecation 护理学基础 WKF SON SDU 24

Fecal Incontinence v the anal sphincter is inability to control passage of feces, and

Fecal Incontinence v the anal sphincter is inability to control passage of feces, and lead to involuntary defecation. Altered Defecation 护理学基础 WKF SON SDU 25

Fecal Incontinence v v Causes v Pathological changes or impairments in nervous and muscular

Fecal Incontinence v v Causes v Pathological changes or impairments in nervous and muscular system, such as paralysis v Disorder in gastrointestinal tract v Mental disorder Symptoms and Signs v The patients defecate involuntarily v Impaired anal sphincter function or control v Frequent, loose stool Altered Defecation 护理学基础 WKF SON SDU 26

Flatulence v gas accumulates in the intestines v the gas cannot be expelled v

Flatulence v gas accumulates in the intestines v the gas cannot be expelled v the bowel wall stretches and distends. Altered Defecation 护理学基础 WKF SON SDU 27

Flatulence v Causes Ingestion more gas producing food v More gas swallowed v Slow

Flatulence v Causes Ingestion more gas producing food v More gas swallowed v Slow peristalsis v v v Intestinal obstruction and operation Symptoms and Signs v v v Abdominal fullness Distention and cramping Hiccup Percussion: drum sound Flatulence can press the diaphragm and thoracic cavity, and cause dyspnea Altered Defecation 护理学基础 WKF SON SDU 28

Interventions for Bowel Elimination v 便秘(Constipation) v �便嵌塞(Fecal Impaction) v 腹泻(Diarrhea) v 排便失禁(Fecal Incontinence)

Interventions for Bowel Elimination v 便秘(Constipation) v �便嵌塞(Fecal Impaction) v 腹泻(Diarrhea) v 排便失禁(Fecal Incontinence) v ��气(Flatulence) 护理学基础 WKF SON SDU 29

Constipation Provide privacy environment Habit Training (Time and position) Exercise Diet (dietary fiber/water )

Constipation Provide privacy environment Habit Training (Time and position) Exercise Diet (dietary fiber/water ) Physiotherapy(Abdominal Massage / warm water bath) Laxatives Enema Health education First & foremost is prevention !!! Constipation Management 护理学基础 WKF SON SDU 30

Laxative Therapy: v Stimulates peristalsis v Allow less time for water reabsorption v Produces

Laxative Therapy: v Stimulates peristalsis v Allow less time for water reabsorption v Produces a softer stool !!! The aim of laxative therapy is comfortable defecation !!! Short term use only. Constipation Management 护理学基础 WKF SON SDU 31

Fecal Impaction v Laxatives v Enema v v oil retention (first) v Cleaning (2~3

Fecal Impaction v Laxatives v Enema v v oil retention (first) v Cleaning (2~3 h later) Digital removal of stool v v It should be carefully used for the patients with cardiac disease or spinal injure because of excessive vagal response Health education Fecal Impaction Management 护理学基础 WKF SON SDU 33

Diarrhea v Remove the cause of diarrhea whenever possible v Rest on bed and

Diarrhea v Remove the cause of diarrhea whenever possible v Rest on bed and warm the abdomen v Diet management: v v Encourage oral intake of fluids and avoid bland food v A temporary fasting if serious diarrhea occurs Skin integrity v Give special care to the region around the anus. v Record fecal characteristics and frequency v Emotional support v Health education Diarrhea Management 护理学基础 WKF SON SDU 34

Fecal Incontinence v Emotional support v Maintain skin integrity Keep the skin clean and

Fecal Incontinence v Emotional support v Maintain skin integrity Keep the skin clean and dry, Keep the bed lines and clothing clean. Set up daily routine v Bowel training programs Timed Stool softener v Fluid intake Strengthen Pelvic Floor Muscles v Environment management v v Open the window and maintain fresh air Fecal Incontinence Management 护理学基础 WKF SON SDU 35

Flatulence v Establish eating habit v v slowly chewing and swallowing Remove the cause

Flatulence v Establish eating habit v v slowly chewing and swallowing Remove the cause of flatulence v avoid gas-producing foods and drinks v Exercise v Treatment v Mild Flatus: massage, acupuncture v Serious Flatus: medicine or rectal tube Flatulence Management 护理学基础 WKF SON SDU 36

Nursing Skills for Bowel Elimination 1. Enema v Main purpose v A solution introduced

Nursing Skills for Bowel Elimination 1. Enema v Main purpose v A solution introduced into the rectum and sigmoid colon Remove feces and/or flatus v Administer medication or nutrition v Temporary relief of constipation v Preparation for diagnostic tests or surgery v v Types of enema Large volume non-retention enema v Small volume non-retention enema v Retention enema v Enema 护理学基础 WKF SON SDU 37

Side effect of enema v Congestive heart failure/fluid, sodium retention v Vagal response—heart effect

Side effect of enema v Congestive heart failure/fluid, sodium retention v Vagal response—heart effect v Trauma 护理学基础 WKF SON SDU 41

Words: v Defecation Fecal Impaction v Cecum Diarrhea Fecal Incontinence v Colon v Rectum

Words: v Defecation Fecal Impaction v Cecum Diarrhea Fecal Incontinence v Colon v Rectum v Anus v Constipation Flatulence Laxatives Enema 护理学基础 WKF SON SDU 46