B260: Fundamentals of Nursing

SCIENTIFIC KNOWLEDGE BASE

Scientific Knowledge Base Mouth Digestion begins with mastication. Esophagus Peristalsis moves food into the stomach. Stomach Stores food; mixes food, liquid, and digestive juices; moves food into small intestines Small intestine Duodenum, jejunum, and ileum Large intestine The primary organ of bowel elimination Anus Expels feces and flatus from the rectum

Scientific Knowledge Base – Generational Changes Mouth Decreased chewing and decreased salivation, including oral dryness. Esophagus Reduced motility, especially the lower third Stomach Decrease in acid secretions, motor activity, mucosal thickening, nutrient absorption Small intestine Decreased nutrient absorption, fewer absorbing cells Large intestine Increase in pouches on the weakened intestinal wall - Diverticulosis Liver Size decreased

Organs of the Gastrointestinal (GI) Tract

Segmented and Peristaltic Waves

Nursing Knowledge Base: Factors Affecting Bowel Elimination AgeDiet Fluid intakePhysical activity Psychological factors Personal habits Position during defecation Pain PregnancySurgery and anesthesia Medications, laxatives, and cathartics Diagnostic tests

Bristol Stool Form Scale

Common Bowel Elimination Problems Constipation A symptom, not a disease; infrequent stool and/or hard, dry, small stools that are difficult to eliminate Impaction Results from unrelieved constipation; a collection of hardened feces wedged in the rectum that a person cannot expel Diarrhea an increase in the number of stools and the passage of liquid, unformed feces Incontinence Inability to control passage of feces and gas to the anus Flatulence Accumulation of gas in the intestines causing the walls to stretch Hemorrhoids Dilated, engorged veins in the lining of the rectum

Elimination Habits that influence bowel function Busy work Schedule Lack of privacy in the hospital Sights, sounds, odors of facilities Embarrassment using a bedpan

Risk 1.Improper diet 2.Reduced fluid intake 3.Lack of exercise 4.Certain medications Signs and Symptoms 1.Infrequent bowel movements > 3 days 2.Difficulty passing stools 3.Excessive straining 4.Hard feces

Causes 1.Irregular bowel habits/ignoring the urge to defecate 2.Chronic illness (Parkinson’s, MS) 3.Low fiber diet high in animal fats 4.Anxiety, depression, cognitive impairment 5.Lengthy bed rest/lack of exercise 6.Laxative misuse 7.Generational changes 8.Medications

Fecal Impaction Collection of hardened feces that becomes wedged in the rectum

Increased number of stools and the passage of liquid associated with disorders affecting digestion, absorption, and secretion. Concerns: 1. Contamination/skin ulceration 2. Fluid, electrolyte, acid-base imbalance Causes mild diarrhea to severe colitis acquired by the use of antibiotics, chemotherapy, invasive bowel procedures, or with a health care worker’s hands or direct contact with environmental surfaces.

Fecal incontinence – Inability to control passage of feces Flatulence – Gas accumulation Hemorrhoids – swollen and inflamed veins in the anus and lower rectum

Bowel Diversion Temporary or permanent artificial opening in the abdominal wall Stoma Surgical opening in the ileum or colon Ileostomy Colostomy Double-Barrel

Ulcerative Colitis

Divisions of the Large Intestine

Diversions of the Large Intestine

Continuing and Restorative Care Care of ostomies Skin Care is number one priority Pouching ostomies An effective pouching system protects the skin, contains fecal material, remains odor free, and is comfortable and inconspicuous. Nutritional considerations Consume low fiber for the first weeks. Eat slowly and chew food completely. Drink 10 to 12 glasses of water daily. Patient may choose to avoid gassy foods.

NURSING ASSESSMENT

Nursing Process: Assessment Assessment History Determine usual elimination pattern Usual stool characteristics Routines to promote normal elimination Assessment of artificial aids Presence or status of bowel diversions Changes in appetite Diet history Description of daily fluid intake Medication history Exercise routine History of pain or discomfort

Abdominal Assessment All four quadrants for contour, shape, symmetry, and skin color Inspect Bowel sounds in all four quadrants Assess For masses or areas of tenderness Palpate Detect lesions, fluids, or gas Percussion

Fecal Occult Blood Testing

Fecal Occult Blood Testing (cont’d)

Common Radiologic & Diagnostic Tests KUB – abdominal X-ray Upper endoscopy Ultrasound Colonoscopy Flexible Sigmoidoscopy MRI

Nursing Diagnosis and Planning ConstipationRisk for constipation Perceived constipation Bowel incontinence DiarrheaToileting self-care deficit

Patient Goals 1.Patient will set regular defecation habits 2.Patient is able to list proper fluid and food intake need to achieve elimination 3.Patient implements a regular exercise program 4.Patient reports daily passage of soft, formed, brown stool 5.Patient does not report any discomfort associated with defication

Implementations: Acute Care Health promotion Promotion of normal defecation Establish a routine an hour after a meal, or maintain the patient’s routine. Sitting position Privacy Positioning on bedpan

Proper and Improper Position on a Bedpan

Positioning Immobilized Patient on Bedpan

Acute Care: Medications Cathartics and Laxatives Short term action of emptying bowel Antidiarrheal Opiate agents decrease intestinal muscle tone and slow passage of feces Enemas Provide temporary relief of constipation, emptying the bowel before tests

Positioning: Left Side-lying (Sims) position Provide a bedside commode Administer slowly to help with cramping Caution against giving more than 3 enemas in a row – can deplete fluids and electrolytes

Cleaning enemas promote complete evacuation of feces from the colon. Normal Saline Enema Safest Enema Solutions.It exerts the same osmotic pressure as fluid in interstitial spaces surrounding the bowel Tap Water Enema Hypotonic, and exerts lower osmotic pressure than fluid in interstitial spaces Hypertonic Enema Exert osmotic pressure that pulls out of interstitial spaces DO NOT GIVE to patients that are dehydrated or infants Soap Suds Creates interstitial irritation to stimulate peristalsis

Carminative (GAS) Medicated Kayexalate Exchanged Na for K Oil Retention (Softens)

Enemas Enema administration Sterile technique is unnecessary. Wear gloves. Explain the procedure, precautions to avoid discomfort, and length of time necessary to retain the solution before defecation. Digital removal of stool Use if enemas fail to remove an impaction. This is the last resort for constipation. A health care provider’s order is necessary to remove an impaction.

Complications of Excessive Rectal Manipulation 1.Can cause irritation to the mucosa 2.Can cause bleeding 3.Can cause stimulation of the vagus nerve, which results in a reflex slowing of the heart

Used for Suction or Feeding Measuring for placement Tip of nose – earlobe – xiphoid process Marking the tube Placement High fowlers Swallowing Securing Testing placement: Aspirated gastric contents – pH 0-4 Feeding Risk: Aspiration HOB > 30 degrees Monitor breathing and bowel sounds

Therapeutic Interventions Encourage fluid intake of at least 1500 ml/24hr Encourage activity: walk pt in hallway 4 times a day Encourage to defect whenever urge is felt Assist to BR, BSC or bedpan (put pt in high Fowlers) Provide for privacy Encourage to drink hot liquids in AM Administer laxatives or enemas as ordered Consult with HCP to check for impaction 39