ch47: bowel elimination -- interventions Flashcards
check accuracy and completeness of each medication administration record
ensures that pt receives correct enema
don’t give enema with pt on toilet
sitting on toilet = unsafe bc curved rectal tubing can abrade rectal wall
place bedpan under pt
some pts who have poor sphincter control may have effluent
separate buttocks and examine perineal region
findings influence approach of enema tip; prolapse contraindicates enema
instruct pt to relax by breathing out slowly through mouth
breathing out promotes relaxation of external rectal sphincter
what to do when there is pain or resistance?
stop and discuss with healthcare provider
add warmed prescribed type of solution and amount to enema bag
hot water burns intestinal mucosa
cold water = abdominal cramping and difficult to retain
raise height of enema (bag) slowly to appropriate level (12inc above anus and 18in above mattress)
allows for cont, slow instillation of solution
if container too high = rapid instillation and possible painful distention of colon
–> patient will complain of cramping
observe stool character and solution
determines whether enema was effective
position pt upright in high fowlers position unless contraindicated (NG tube)
promotes pt ability to swallow during procedure
measure distance from tip of nose to earlobe to xyphoid process
most traditional method (length approximates distance from nose to stomach)
hand an alert pt cup of water for them to sip on
swallowing facilitates tube passage; tug may be felt as pt swallows = tube is following desired path
use penlight and tongue blade, check to be sure tube is not positioned or coiled in back of throat
tube could become coiled, kinked, enter trachea
order an xray for tube placement
radiography remains the gold standard for confirming placement
use pH paper to check pH of gastric secretion
gastric aspirate should be 1.0-4.0 to ensure that NG tube is in stomach
if resistance occurs, check for kinks and turn pt onto left side
tip of tube might lie against stomach lining; repositioning to left side = dislodge tube away from stomach lining
observe stoma for type, location, swelling, presence of sutures, trauma, and healing/irritation
stoma characteristics = influence selection of appropriate pouching system
have pt assume semi reclining/supine position when pouching ostomy
semi reclining = fewer skinfolds = easier application
remove used pouch and skin barrier gently by pushing skin away from barrier OR use adhesive releaser
reduces skin trauma; improper removal of pouch and barrier can = peri-stomal skin irritation or breakdown
have pt hold hand over pouch to apply heat to secure seal
pouch adhesives are heat + pressure sensitive and hold more securely at body temp
