Altered Bowel Elimination (Test 4)

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Abdominal Assessment

Subjective information
Inspection
Auscultation
Percussion
Palpation
A) light
B) deep

Altered Bowel Elimination

Problems with peristalisis
Problems with liquid content of the stool
Problems with control of stool
Altered path of stool

Hemorrhoids

Dilated, engorged veins lining the rectum
Externial: visible protrusions of the skin
Internal: not visible, but still painful
Stool may have streaks of blood
I

Causes of hemorrhoids

increased venous pressure due to pregnancy, straining at defecation, heart failure, chronic liver disease

Paralytic Ileus

Slowing of peristalsis due to parasympathetic stimulation

Causes of paralytic ileus

general anesthesia, surgery that involves direct manipulation of the bowel, any condition or medication that increases parasympathetic tone, immobility

Symptoms of Paralytic ileus

hypoactive or absent bowel sounds, inability to pass gas rectally, flatulence (build up of gas in the abdomen), belching, abdominal distension, tympanic abdomen on palpation, nausea, vomiting, reflux

Nasogastric Tubes

Pliable, hollow tube inserted through the nasopharynx into the stomach

Purpose of Nasogastric tubes

Decompression
Enteral feeding
Compression
Lavage

Size of Nasogastric Tubes

14Fr and larger for decompression or lavage

Salem sump

Used for decompression, lavage or feeding
Air vent
Intermittent or continuous suction

Levin tube

Used for decompression, lavage or feeding
No air vent
Intermittent suction only

Nursing care of the Client with a Nasogastric tube

Assess nares every shift markMARK location of tube at nare with permanent marker.
Check that tube is well secured every 4 hours
Change tape or device that secures tube daily
provide mouth care every 2 hours
Irrigate tube to promote patency
use normal saline
Obtain order before irrigating NG after gastric surgery

Type 1 stool

separate hard lumps ie rabbit poop

type 2 stool

sausage-shaped but lumpy Deer poop

Type 3 stool

like a sausage but with cracks on its surface

type 4 stool

sausage or snake, smooth and soft

type 5 stool

soft blobs with clear-cut edges (easily passed)

type 6 stool

fluffy pieces with ragged edges, a musy stool

type 7 stool

watery, no soild pieces entirely liquid

Constipation

A symptom, not a disease
Interruption in elimination pattern result in constipation(individuals have different eliminiation patterns several timems daily, daily, every few days)

Signs of constipation

infrequent bowel movements (> every 3 days) straining with bowel movements, inability to defecate at will, hard feces

Position during Defecation

Upright posture promotes evacuation

Causes of Constipation

Pregnancy, loss of large intestinal muscle tone, medications, inactivity, inadequate fiber&fluid, specific health problems

Prevention of Constipation

High fiber diet & adequate liquid intake
Fluid 1500-200ml/day
activity
position
provide privacy
record bowel mnt

To promote bowel elimination

consume at least 1500 ml of fluid daily

Fecal Impaction

occurs when so much water is reabsorbed from stool that is retained in the colon that it becomes dry, hard and wedged in the rectum

Symptoms of Fecal impaction

Fecal Fluid leak around hard mass
Digital exam
Loss of appetite, nausea, vomiting, abdominal distention and cramping
Rectal pain

Treatment of Fecal impaction

Enemas, manual disimpaction(caution Vagal nerve stimulation)

Indications for laxatives

Removal of intestinal parasites
Constipation
Binding with toxic substances
Preparation for colonic diagnostic procedures

Contraindications of Laxatives

drug allergy
Precautions: acute surgical abdomen, nausea and vomiting, fecal impaction (except mineral oil), intestinal obstruction

Bulk Forming Laxatives

Methyclellulose (Citrucel), Psyllium (Metamucil)

Action of bulk forming laxatives

Increase water absorption into the bowel and give bulk to the stool

Indications of bulk forming laxatives

: constipation, irritable bowel syndrome, diverticulitis

Adverse reactions of bulk forming laxatives

: gas formation, rare obstruction

drug interactions of bulk forming laxatives

: reduce absorption of antibiotics, digoxin, salicylates and oral anticoagulants

Nursing implications
for bulk forming laxatives

must mix with at least 8 ounces of water or can cause obstruction

Action of bulk forming laxatives

Onset: 12-24 hrs; peak and duration unknown

Emollient Laxatives

bock absorption of water from intestines/water softens turd.

Action of Emollient Laxatives

directly lubricate the stool (ie: mineral oil) or act as stool softeners (docusate sodium)

Indications of emollient laxatives

Constipation

Docusate Sodium

Emollient laxative
(Colace)Onset and duration: 1-3 days Peak:
unknown
Pregnancy category C

Colace

Emollient laxatives
Docusate SodiumOnset and duration: 1-3 days Peak: unknown
Pregnancy category C

Mineral Oil

Emollient LaxativeOnset 6-8 hrs (other pharmacokinetics unknown)
Precaution: Hinders absorption of fat soluble vitamins

Saline(Osmotic) Laxative

: increase osmotic pressure in the small intestine by inhibiting water absorption and increasing water and electrolyte secretion from the bowel wall into the intestinal lumen, increase water in stool, distend the bowel, and increase peristalsis

Saline (osmotic) Laxatives

Magnesium hydroxide (Milk of Magnesia or M.O.M.), Miralax (Polyethylene glycol 3350), Magnesium citrate, fleet phosphosoda, fleet enema Onset: 0.5-3 hr, peak 3 hr, duration: variable

: Magnesium hydroxide

Milk of Magnesia MOM---Saline (Osmotic) Laxatives

Miralax

polyethylene glycol3350---Saline (Osmotic) Laxatives

Fleet phosphosods, Fleet enema

Saline (Osmotic) Laxatives

Contraindications of Saline (Osmotic) Laxatives

renal insufficiency (may cause high magnesium levels)

Stimulant Laxatives

increase peristalsis and increase fluid in the bowel, result in stimulation of intestinal peristalsis; mainly for treatment of opioid induced constipation and for slow intestinal transit

Examples of stimulant laxatives

senna, biscodyl (Dulcolax- tablets and suppository)

Senna

Stimullant laxative
onset6-24 hr, Peak 24 hr; Duration: 24-36 hr

Hypotonic enemas

TWE- tap water enema-water absorbed quickly Tap water and soap suds

isotonic enemas

Safest to give Best for kids and elderly. No fluid change. NS is isotonic Normal Saline

Hypertonic enemas

pulls fluid out of interstitial spaces into the colon; good for pts who cannot tolerate large volumes of fluid(cardiac pts); only 4-6oz; aka fleet enema

Who is accountable for assessment of the quality and quantity of the stool

...

What kind of written communication systems are in place related to bowel elimination?

...

How can the licensed nursing assistant contribute to the care of the client with constipation?

...

Systems of Care to Document Bowel Elimination

BM Book
Stool chart
Electronic health records that carry forward the last BM
BM documented in I/O section of chart
Medication Administration Records that give a cue for PRN medication be given every 3 days without a BM

Causes of infectious Diarrhea

Viral
Bacterial
Parasitic

Viral Diarrhea

Norwalk virus
Rotavirus (vaccine)

Bacterial Diarrhea

E-coli: contaminated food
C. difficile:antibiotic therapy

Parasitic Diarrhea

Giardia lamblia

Assessment of Diarrhea

increased number of stools and passage of liquid, unformed feces.
Peri-rectal skin may become red, excoriated, or break down due to proximity to digestive enzymes

What may happen if a person has diarrhea?

Dehydration

alkalotic

Ph greater than 7.45
Alkaline

acidosis

condition of excessive acidity of body fluids

Why may diarrhea cause metabolc acidosis?

The intestinal juices are Alkolotic (Alkaline ph greater than 7.45)

metabolic acidosis

acidosis and bicarbonate concentration in the body fluids resulting either from the accumulation of acids or the abnormal loss of bases from the body (as in diarrhea or renal disease)

Nursing Diagnoses: Diarrhea

increased number of stools and passage of liquid, unformed feces.
Peri-rectal skin may become red, excoriated, or break down due to proximity to digestive enzymes

What is a Stool Chart/

includes TIME AMOUNT COMMENTSHelps track quantity and quality of stool
Especially important when there are multiple caregivers
Stool volume can be included in intake and output

Nursing Interventions: Risk for alteration in skin integrity r/t continuous exposure of peri-rectal area to liquid stool

Check for incontinence frequently
Clean skin with baby-wipe or soft washcloth
Avoid soap, Apply barrier cream to peri-rectal area after each stool. Apply fecal incontinence bagInsert rectal tube
Check around tube freq for leakage

Lactobacillus

reduces the likelihood of bacterial diarrhea and yeast infections that may complicate antibiotic therapy

Relation of Diarrhea/antibiotics

"Overgrowth" of organisms that live on the skin, in the bowel and in the vagina. Yeast infections, Clostridium difficile

Adsorbents

Coat walls of GI tract
Bind toxins and irritants so they are excreted in the stool. Should not be given with many other medication as they reduce absorption

Bismuth subsalicylate

Adsorbents
Kaopectate, Pepto-Bismal

Contraindications of Adsorbents

Check with physician before giving to children
Associated with Reye's syndrome
should not be given with many other medication as they reduce absorption

What affect of the adsorbents could be seen with Adsorbents?

May cause black stool

Onset peak and duration of adsorbents

0.5-2hr
2-5hr
Durationa nd half life variable

anticholinergics

medication that blocks the parasympathetic neurotransmitter acetylcholine

Parasympathetic nervous system

is responsible for "feeding and breeding"

Action of anticholinergics

slows peristalsis

Side affects of anticholinergic drugs

Should not be given with many other medication as they reduce absorption

Loperamide (Immodium A-D)

Anticholinergic

Action of Loperamide

: inhibits peristalsis and reduces intestinal secretion. Reduces number of stools and water content

Contraindications of Loperamide

Contraindications: ulcerative colitis, pseudomembranous colitis, infectious diarrhea

Half life, onset, peak, duration, pregnancy cat. of Loperamide

Half life:7-15 hrs
Onset: 1-3 hrs
Peak: 4 hrs
Duration: 40-50 hrs
Pregnancy Category B

Fluid volume deficit r/t diarrhea from intestinal infection: clostridium difficile

Institute contact precautions with soap and water hand washing Administer oral vancomycin or flagyl as prescribed Instruct family not to eat or drink in the client's room and the importance of hand washing Monitor intake and output Monitor daily weights Maintain stool chart Measure volume of stool document as output sourceTime, amount, character of stool Avoid anti-diarrheal medication Consider bulk-forming agent (Questran)

Ileoanal pouch

Colectomy
Pouch made from ileum,
Anastomosed to anal area
Acts as a rectum
Frequent loose stools rectally

Kock continent ileostomy

Spherical resevoir made from a potion of small bowel
Nipple valve is catherterized

Macedo-Malone Antegrade Continence Enema

Used for incontinence (NM disorder)
A 3cm flap of large instestine is made into a "flap"
A foley catheter is sutured into the "flap"
Enemas are given to evacuate the bowel

High risk for ineffective therapeutic regimen r/t insufficient knowledge of ostomy self-care EO: TPW demonstrated ostomy self-care by discharge

Assess readiness to learn
Ability to look at stoma
Promote success
Demonstrate
Practice with empty pouch and barrier
Increase awareness of need to empty pouch
Empty pouch when 1/3 to ½ full
Gas or stool
Either pull the barrier away from the skin promoting leaking
Change barrier before it leaks! (q 3-5 days)
VNA
Enterostomal nurse specialist

High risk for disturbed self-concept r/t effect of ostomy on body image and lifestyle

EO: TPW: communicate feelings about changes in body
Incorporate emotional support into teaching
Assess client ability to look at stoma
Validate that emotional responses are normal
United ostomy association of America
Ostomy support groups

ostomy changing a puch

remove, clean , dry, inspect, measure new whole change pouch every 3-5 days

Upper GI Endoscopy

...

Colonoscopy

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