ch47: bowel elimination -- interventions

Question 1

check accuracy and completeness of each medication administration record

Answer 1

ensures that pt receives correct enema

Question 2

don’t give enema with pt on toilet

Answer 2

sitting on toilet = unsafe bc curved rectal tubing can abrade rectal wall

Question 3

place bedpan under pt

Answer 3

some pts who have poor sphincter control may have effluent

Question 4

separate buttocks and examine perineal region

Answer 4

findings influence approach of enema tip; prolapse contraindicates enema

Question 5

instruct pt to relax by breathing out slowly through mouth

Answer 5

breathing out promotes relaxation of external rectal sphincter

Question 6

what to do when there is pain or resistance?

Answer 6

stop and discuss with healthcare provider

Question 7

add warmed prescribed type of solution and amount to enema bag

Answer 7

hot water burns intestinal mucosa

cold water = abdominal cramping and difficult to retain

Question 8

raise height of enema (bag) slowly to appropriate level (12inc above anus and 18in above mattress)

Answer 8

allows for cont, slow instillation of solution
if container too high = rapid instillation and possible painful distention of colon
–> patient will complain of cramping

Question 9

observe stool character and solution

Answer 9

determines whether enema was effective

Question 10

position pt upright in high fowlers position unless contraindicated (NG tube)

Answer 10

promotes pt ability to swallow during procedure

Question 11

measure distance from tip of nose to earlobe to xyphoid process

Answer 11

most traditional method (length approximates distance from nose to stomach)

Question 12

hand an alert pt cup of water for them to sip on

Answer 12

swallowing facilitates tube passage; tug may be felt as pt swallows = tube is following desired path

Question 13

use penlight and tongue blade, check to be sure tube is not positioned or coiled in back of throat

Answer 13

tube could become coiled, kinked, enter trachea

Question 14

order an xray for tube placement

Answer 14

radiography remains the gold standard for confirming placement

Question 15

use pH paper to check pH of gastric secretion

Answer 15

gastric aspirate should be 1.0-4.0 to ensure that NG tube is in stomach

Question 16

if resistance occurs, check for kinks and turn pt onto left side

Answer 16

tip of tube might lie against stomach lining; repositioning to left side = dislodge tube away from stomach lining

Question 17

observe stoma for type, location, swelling, presence of sutures, trauma, and healing/irritation

Answer 17

stoma characteristics = influence selection of appropriate pouching system

Question 18

have pt assume semi reclining/supine position when pouching ostomy

Answer 18

semi reclining = fewer skinfolds = easier application

Question 19

remove used pouch and skin barrier gently by pushing skin away from barrier OR use adhesive releaser

Answer 19

reduces skin trauma; improper removal of pouch and barrier can = peri-stomal skin irritation or breakdown

Question 20

have pt hold hand over pouch to apply heat to secure seal

Answer 20

pouch adhesives are heat + pressure sensitive and hold more securely at body temp