Chapter 47: Bowel Elimination Flashcards
The GI Tract
series of hollow, mucous membrane-lined, muscular organs
What is the function of the GI tract?
- Absorbs high volumes of fluid and nutrients - makes fluid and electrolyte balance a key function of this system
- Prepare food for absorption and use by body cells - receives secretions from the gallbladder and pancreas
- Provides for temporary storage of feces
Mouth
mastication and mixing with saliva and enzymes such as amylase
Esophagus
food enters esophagus via the esophageal sphincter
Stomach
Food mixes with HCL, mucus, enzyme pepsin and intrinsic factor.
HCL and pepsin aid in
the digestion of proteins
Intrinsic factor is essential for
absorption of Vit B12
Small Intestine has 3 sections, what are they?
Duodenum
Jejunum
Ileum
Duodenum
Approximately 8-11” long. Continues to process chyme.
Jejunum
Approximately 8 feet long. Absorbs carbohydrates and proteins.
What parts of the small intestine absorb most of the nutrients and electrolytes?
duodenum and jejunum
Ileum
Approximately 12 feet long. Absorbs water, fats, certain vitamins, iron and bile salts.
The Large Intestine (Colon)
Approximately 5-6 feet long.
Divided into the: cecum, colon and rectum
The colon is divided into
Ascending
Transverse
Descending
Sigmoid
Rectum
bacteria convert fecal matter into its final form
The large intestine has three functions
- Absorption- water, sodium and chloride
- Secretion- bicarbonate in exchange for chloride and potassium.
- Elimination
Anus
expels feces and flatus from the rectum
Physiological factors critical to bowel function and defecation include:
Normal GI tract function
Sensory awareness of rectal distention
Voluntary sphincter control
Adequate rectal capacity and compliance
What causes the awareness of the need to defecate?
when stool reaches the rectum, the distention causes relaxation of the internal sphincter and awareness of the need to defecate
Valsalva Maneuver
voluntary contraction of abdominal muscles while maintaining a forced expiration against a closed airway.
Valsalva Maneuver should be cautioned in patients with
Glaucoma
Increased intracranial pressure
New surgical wounds … at risk for cardiac dysrhythmias and HTN
What are factors that influence bowel elimination?
Age Diet Fluid Intake Physical Activity Psychological Factors Personal Habits Position During Defecation Pain Pregnancy Surgery and Anesthesia Medications Diagnostic tests
How does age influence bowel elimination?
in an older adult:
decreased peristalsis
esophageal emptying slows
decreased muscle tone in the perineal floor
nerve impulse to anal region slow (less aware of need to defecate)
How does diet influence bowel elimination?
Fiber
Gas producing foods also stimulate peristalsis
Food intolerance
Fiber
Provides the bulk of fecal matter.
Keeps food moving through the intestines.
Keeps stool soft.
Gas producing foods also stimulate peristalsis including
cauliflower and beans
Food intolerance can cause
diarrhea, cramps and flatulence
How does fluid intake influence bowel elimination?
Helps intestinal contents pass through the colon: decreased fluid intake slows passage of food causing hard stool
What is the recommended daily fluid intake for men and women?
3L/day for men
2.2L/day for women
How does physical activity influence bowel elimination?
physical actively promotes peristalsis
What psychological factors can influence bowel elimination?
Emotional Stress
Depressed Response
Associated with diseases of the GI tract
How does emotional stress influence bowel elimination?
increases peristalsis/digestive process
How does a depressed response influence bowel elimination?
decreases peristalsis leading to constipation
What diseases of the GI tract are associated with psychological factors?
Ulcerative colitis
Irritable Bowel Syndrome
Ulcers
Crohn’s Disease
How can personal habits influence bowel elimination?
privacy to avoid/minimize embarrassment
How does positioning during defecation influence bowel elimination?
Sitting upright or standing position.
Lying in bed may be impossible for some people.
How does pain influence bowel elimination?
Hemorrhoids/rectal surgery, rectal fistulas.
Abdominal surgery may make it difficult to bear down to defecate.
Fear of opening incision.
How does pregnancy influence bowel elimination?
Decreased motility/peristalsis
Common Bowel Elimination problems include
Constipation Impaction Diarrhea C. diff Incontinence Flatulence Hemorrhoids
Constipation
water absorbed from the bowel the longer it stays in the colon.
a hard mass of stool forms.
What can cause constipation?
-improper diet - low fiber, high in animal fats
stress
-reduced fluid intake
-lack of exercise
-chronic illnesses
-irregular bowel habits and ignoring the urge to defecate
-medications
Impaction
hard feces in the rectum that a person cannot expel
What are signs and symptoms of impaction?
N/V
Loss of appetite
Abdominal Distention and Cramping
Rectal Pain
Impaction can result in
intestinal obstruction
Patients most at risk for impaction include
confused
debilitated
unconscious
What may indicate an impaction?
continuous oozing of diarrhea stool may indicate impaction
Diarrhea is associated with
disorders affecting digestion, absorption and secretion in the GI tract
Diarrhea
increased in bowel irritation from diarrhea increases mucous secretion
makes stool watery
Thus, diarrhea can lead to
increased urge to defecate
increased risk for skin breakdown
increased risk for fluid and electrolyte imbalances
What can disrupt the normal GI flora?
antibiotics
When diarrhea is the result of a foodborne illness, the goal of the GI system is to
rid the body of the pathogen by increasing peristalsis
Clostridium Difficile is acquired in one of two ways
- Factors that can cause an overgrowth of C. diff
2. By contact with the C. diff organism
What factors can cause an overgrowth of C. diff?
Antibiotics
Bowel Preps
Chemotherapy disrupt normal bowel flora and may cause an overgrowth
How can people get C. diff through contact?
poor hand hygiene by caregivers or contact with contaminated surfaces
How can you remove c diff. from your hands?
only soap and water effectively removes the spores from the hands
How can you remove c diff from surfaces?
diluted bleach (1:10) used as an environmental disinfectant
Effect of incontinence on a patient
harms a patient’s body image
may lead to social isolation
Flatuelence
- causes abdominal distention
- assess patients on opiates, those recovering from general anesthesia, abdominal surgery or immobilization.
Hemorrhoids
dilated, engorged veins in the lining of the rectum
Hemorrhoids can be caused by
increased venous pressure from straining at defecation
pregnancy
heart failure
chronic liver disease
Ostomies include
Colostomy
Ileostomy
Ileoanal Pouch Anastomosis
Types of Colostomies
- loop
- end
- double-barrel
Loop Colostomy
usually performed in an emergency
End Colostomy
one stoma from proximal end of bowl with distal end removed, or sutured closed
Psychological Consideration for patients with ostomies
- Causes serious body image changes - emotional support
- Foul Odors
- Inability to regulate bowel movements
Ostomies
F. 47-2, 3, 4 p. 1153-4
Nursing Process: Assessment
Usual elimination patterns Stool characteristics T. 47-1 p. 1157 Routines to promote normal elimination Use of artificial aids Presence and status of bowel diversions Changes in appetite Diet history Daily fluid intake History of surgery/illnesses affecting the GI tract Box 46-5, p. 1100 Medication history Emotional state History of exercise Pain or discomfort
Stool Characteristics
Color Odor Consistency Frequency Shape Constituents
Normal Stool Color
adult: brown
infants: yellow
Abnormal Stool Color
white or clay
black or tarry (melena)
red
pale and oily
What causes the stool to be a white or clay color?
absence of bile
What causes the stool to be black or tarry?
iron ingestion or gastrointestinal bleeding
What causes the stool to be red?
GI bleeding
hemorrhoids
ingestion of beets
What causes the stool to be pale and oily?
malabsorption of fat
Normal frequency for stools
Varies:
In adults, 2 x daily to 3 times a week.
In infants 4-6 times daily (breastfed) or 1-3 times daily (bottle-fed).
Abnormal frequency for stools
Infants: more than 6 x daily or less than 1 -2 days
Adult: more than 3 times a day or less than once a week
What can cause an abnormal frequency of stools?
hypermotility or hypomotility
What is the usual shape of stool?
resembles the diameter of the rectum
What is an unusual shape for stool?
narrow, pencil shaped
What can cause an abnormal shape for stool?
obstruction, increased peristalsis
Normal constituents in stool
Undigested food Dead bacteria Fat Bile pigment Cells lining intestinal mucosa Water
Abnormal constituents in stool
Blood, pus, foreign bodies, mucus, worms
Oily stool
Mucus
What can cause blood, pus foreign bodies, mucus and worms in stool?
internal bleeding, infection, swallowed objects, irritation, inflammation and infestation of parasites
What can cause oily stool?
malabsorption syndrome, enteritis, pancreatic disease, surgical resection of intestine
What can cause mucus in the stool?
intestinal irritation
inflammation
infection
injury
Physical Assessment of the GI tract
Mouth
Abdomen
Rectum
Radiological/Diagnostic Tests
Abdomen assessment
a distended abdomen feels like a drum and the skin is taut and appears stretched
Radiological/Diagnostic Tests (B. 47-5 p. 1158)
Fecal Specimen (25% of stool is bacteria from the colon) Fecal Occult Blood (Guaiac) (B. 47-4 p. 1157)
Possible Nursing Diagnosis RT Bowel Elimination
Disturbed Body Image Bowel Incontinence Constipation Risk For Constipation Diarrhea Nausea Deficient Knowledge: Nutrition Toileting Self-care Deficit
Nursing Process: Planning
Consider preexisting health concerns
diet
activity
irregular bowel habits
Teamwork and Collaboration
Dietitians
WOCNs
Health Promotion
- Teach proper diet
- Effects of stress on peristalsis
If patients are a risk for falls always
stand by them or leave the door partially open to see them at all times
Nursing Process: Implementation
Provide normal positioning of defecation if possible.
Provide privacy if possible.
Implement measures in the acute care setting to promote defecation. (B. 47-9 p. 1164)
If a bedpan is necessary, what position should you sit the patient?
sit the patient up as high as possible
Implementation meausres in the acute care setting that promotes defecation includes
hydration
movement
pain control
Cathartics
Medications that stimulate the bowel motility.
i.e dulcolax
Laxatives (T. 47-2 p. 1165)
Medications that pull water into the bowel.
i.e mag citrate, correctol
Antidiarrheal Agents
prescription opiates
i.e lomotil
Enemas include
Cleansing enemas Tap Water Normal Saline Hypertonic Solutions Soapsuds Oil Retention
The digital removal of stool is usually (B,. 47-10 p. 1166)
a last resort if enemas fail
very uncomfortable to the patient
Caution for the digital removal of stool
bleeding and stimulation of the vagus nerve which results in slowing of the heart rate.
know your policy and procedure if MD order is necessary.
Nasogastric tubes are used for (T. 47-3 p. 1167)
- stomach decompression: gastric contents or gas
- feeding and hydration
- lavage
- compression
Lavage
poisoning
active bleeding
gastric dilation
Compression
internal, esophageal or GI hemorrhage
Wound Ostomy Continence Nurse (WOCN)
Specialist in ostomy and wound care
A normal ostomy is
bright pink.
Notify the MD if blue, brown or black.
Care of Ostomies (B. 47-11 p. 1167)
- Never use an enema set up to irrigate a colostomy
- Irrigate with cone shaped irrigator per manufacturer instructions
- Consider Psychological implications
Why should you never use an enema set up to irrigate a colostomy?
risk for bowel perforation
Bowel Training
using measures to promote defecation by setting up a normal daily routine.
Bowel Training includes
Assess normal elimination pattern
Incorporate principles of gerontology
Choose a time in the patients day to initiate defecation
Give stool softeners or cathartic ½ hour before desired time
Offer a hot drink to stimulate peristalsis
Help the patient to the toilet
Avoid medications such as opioids if an option
Provide privacy
Offer encouragement
What patients are usually at risk for impaired skin integrity?
every patient with fecal incontinence or prolonged diarrhea
Liquid stool contains
digestive enzymes which causes rapid skin breakdown
Repeated wiping can
further irritate the skin.
Fecal management systems are available for
short-term use
Meticulous perianal skin care is essential to
prevent skin breakdown
