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Altered Bowel Elimination (Test 4)

STUDY
PLAY
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
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What kind of written communication systems are in place related to bowel elimination?
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How can the licensed nursing assistant contribute to the care of the client with constipation?
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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
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Colonoscopy
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