Bowel Elimination Campus Skills Lab Mrs. April Page MSN ARNP FNPC NUR1213C INTERMEDIATE ADULT CARE GULF COAST STATE COLLEGE

TESTING STOOL FOR OCCULT BLOOD Hospital Nurse assists physcian

TESTING STOOL FOR OCCULT BLOOD PCP Order: Stool for Occult Blood x3

STOOL SPECIMEN USE A TONGUE DEPRESSOR TO TRANSFER THE STOOL SPECIMEN FROM THE COLLECTION CONTAINER TO THE SPECIMEN CONTAINER. A STOOL SPECIMEN MUST NOT BE CONTAMINATED WITH URINE.

At Home FOBT Patient Instructions/Education

The patient will collect some poop when they are at home to carry into the lab, office or wherever. First step is to plan. Three days before the test and during the test instruct the patient to not eat any citrus fruit or juice this includes vitamin C supplements. They will be testing three different poop specimens on three different days and collecting two samples from each of those three poop specimens.

This Must be done over ten days, if not the kit won't be analyzed This Must be done over ten days, if not the kit won't be analyzed. It is important for the patient to complete it all within ten days some people find it helpful to use a calendar, where they can mark the first day they took the sample to make sure they get all the samples taken before the ten days are up

Instruct the patient on doing the kit correctly Instruct the patient on doing the kit correctly. Unpack the kit and they should find the test, three sticks, two envelopes, the instructions and a lab requisition. Before they start instruct your patient to please make sure the front of the kit is labeled correctly. It should have their name, date of birth, etc.. the lab will not examine kits that aren't labeled properly and a person doesn’t want to go through all of this for nothing. The patient, when writing their name should make sure it's written exactly the same way as it is printed on the requisition that came with the kit. Write the name and date on the first sample, flush the toilet bowl to make sure it is clean. Do not use toilets with bowl cleaners the water should be clear not blue. Use a disposal paper plate, disposable pie pan, or line the toilet bowl with paper towels. Use the wooden stick to scoop a tiny amount of the poop from the surface of the poop. They only need a thin smear that fits within the test area. More is not any more accurate, it's just Messier. The screen will absorb any blood if there is any. Smear the poop inside the test flap area for the first scoop; use the same scoop to scoop a second poop sample from the surface of a different part of the poop and smear inside the test flap area to close the flap and put the card in the foil lined envelope and keep it at room temperature. Throw the stick and the disposable container away. Flush the toilet and you're done with the first of three samples. Repeat this for two more days making sure you write the name and date on your sample complete this within a 10 day time frame. It doesn't have to be days in a row it just has to be within the 10day period. Some people wonder why is this test so complicated why so many samples here's the answer the test is for blood that is not visible to the naked eye or occult blood. The blood comes from the large polyps or from the colon cancers that are on the wall of a persons colon, as the colon pushes the poop out the poop scrapes along the wall of the colon and picks up the blood from the cancer but the colon changes shape all the time while it's working so doing three sample days each with a bit of poop from two different spots increases the chances that any invisible blood will be found.

Final result before mailing, or taking to the lab or MDs office

REMOVING FECAL IMPACTION

Safety Guidelines When digital removal of impacted fecal material is ordered, Obtain patient baseline vital signs and Periodically monitor heart rate during the procedure When handling fecal matter, always use standard precautions.

Removing Fecal Impaction Digitally Impaction occurs in all age groups Digital removal is performed when enemas and suppositories are not successful Fecal impaction is the inability to pass a collection of hard stool. It occurs when there is a history of constipation. Physically and mentally incapacitated individuals and institutionalized older adults are at greatest risk for fecal impaction. Patients with acute stroke and spinal cord injuries are also at greater risk for fecal impaction. Functional constipation is defined as including two or more of the following factors for at least 3 months: (1) straining with defecation at least one-fourth of the time, (2) lumpy or hard stools (or both) one-fourth of the time, (3) sensation of anorectal blockage at least one-fourth of the time, (4) loose stools rarely present without the use of laxatives, or (5) three or fewer bowel movements in a week. Symptoms of fecal impaction include constipation, rectal discomfort, anorexia, nausea, vomiting, abdominal pain, diarrhea (leaking around the impacted stool), and urinary frequency. Prevention is the key to managing fecal impaction. With newer bowel management techniques, such as transanal irrigation, digital removal of fecal material is not needed. However, once impaction occurs, digital removal of stool is the only alternative.

Delegation and Collaboration The task of removing a fecal impaction digitally cannot be delegated to UAP The nurse directs UAP to: Help the nurse position the patient Observe stool for color, consistency, rectal bleeding, or bloody mucus, and report immediately to nurse Provide perineal care after each bowel movement

Special Considerations Gerontological Many older adults are especially prone to dysrhythmias and other problems related to vagal stimulation Adequate dietary fiber improves defecation Laxative use must be individualized Monitor heart rate and rhythm closely while performing digital removal of fecal impaction. For older adults, instituting a diet adequate in dietary fiber (6 to 10 g per day) adds bulk, weight, and form to stool and improves defecation. Laxative use for chronic constipation in the older adults must be individualized to patient’s cardiac and renal co-morbidities, drug interactions, and side effects.

SUPPOSITORIES

Suppositories A suppository is a cone-shaped, solid drug that is inserted into a body opening. It melts at body temperature. A rectal suppository is inserted into the rectum. A BM occurs about 30 minutes later. The doctor may order a suppository to stimulate a BM for: Constipation Fecal impaction Bowel training

SUPPOSITORY

ENEMAS

Administering an Enema Used to treat constipation or to empty the bowel before diagnostic procedures or certain types of abdominal surgery An enema is the instillation of a solution into the rectum and sigmoid colon to promote defecation by stimulating peristalsis. The volume or type of fluid that breaks up the fecal mass stretches the rectal wall and initiates the defecation reflex. Cleansing enemas promote complete evacuation of feces from the colon. They act by stimulating peristalsis through infusion of large volumes of solution. The volume or type of fluid that breaks up the fecal mass stretches the rectal wall and initiates the defecation reflex. Medicated enemas contain pharmacological therapeutic agents. Some are prescribed to reduce dangerously high serum potassium levels (e.g., sodium polystyrene sulfonate enema) or to reduce bacteria in the colon before bowel surgery. Copyright © 2018, Elsevier Inc. All rights reserved.

Enemas An enema is the introduction of fluid into the rectum and lower colon. Doctors order enemas to: Remove feces Relieve constipation, fecal impaction, or flatulence Clean the bowel of feces before certain surgeries and diagnostic procedures A doctor orders the enema solution. When giving enemas, you need to follow the: Safety and comfort measures for bowel elimination

Enemas (cont’d) The solution depends on the enema’s purpose cleansing, constipation, fecal impaction, or flatulence. Tap-water enema is obtained from a faucet. Saline enema is a solution of salt and water. Soapsuds enema (SSE) is a solution of castile soap and water. Small-volume enema is commercially prepared. Oil-retention enema is mineral, olive, or cottonseed oil. Other enema solutions may be ordered. Nurses give enemas that contain drugs. Consult with the nurse and the agency’s procedure manual to safely prepare and give enemas.

Enemas (cont’d) Cleansing enemas: Clean the bowel of feces and flatus Relieve constipation and fecal impaction Are needed before certain surgeries and diagnostic procedures Tap-water enemas can be dangerous. Saline enema solution is similar to body fluid. Soapsuds enemas irritate the bowel’s mucous lining. Cleansing enemas take effect in 10 to 20 minutes. The doctor may order enemas until clear. This means that enemas are given until the return solution is clear and free of stools. Always check agency policy, agency may allow repeating enemas 2 or 3 times. Only 1 tap-water enema is given. Do not repeat the enema.

Enemas (cont’d) Small-volume enemas irritate and distend the rectum. Often ordered for constipation Also ordered when the bowel does not need complete cleansing Oil-retention enemas relieve constipation and fecal impactions. Retaining oil softens feces and lubricates the rectum. Most oil-retention enemas are commercially prepared. When giving a small-volume enema, do not release pressure on the bottle or the solution will be drawn from the rectum back into the bottle. In oil-retention enemas, the oil is retained for 30 to 60 minutes or longer (1 to 3 hours).

Types of Cleansing Enema Solutions Amount (ml) Mechanism of Action Tap water 500-1000 Distends rectum, moistens stool Normal saline Soap and water Distends rectum, moistens stool, irritates local tissue Hypertonic saline (ie: Fleets) 120 Irritates local tissue and draws water into the bowel Mineral, olive, or cottonseed 120-180 Lubricates and softens stool

COMFORT AND SAFETY MEASURES SOLUTION TEMPERATURE SHOULD BE 105º ADULTS RECEIVE BETWEEN 500 – 1000CC OF SOLUTION POSITION PATIENT IN THE LEFT SIM’S POSITION THE ENEMA BAG IS RAISED 12 INCHES ABOVE THE ANUS OR 18 INCHES ABOVE THE BED LUBRICATE THE TUBING AND INSERT IT 3 – 4 INCHES INTO THE RECTUM GIVE THE SOLUTION SLOWLY ( OVER 10 – 15 MIN.) HAVE THE PERSON VOID BEFORE BEGINNING

COMFORT AND SAFETY MEASURES THE ENEMA TUBE IS HELD IN PLACE WHILE THE SOLUTION IS BEING GIVEN THE SOLUTION SHOULD BE RETAINED IN THE BOWEL FOR A CERTAIN LENGTH OF TIME THE BATHROOM MUST BE VACANT OBSERVE THE ENEMA RESULTS AND DOCUMENT THEM

FLEETS PACKAGE ENEMA COMES READY TO GIVE WARM IT UNDER RUNNING WATER INSERT 2 INCHES INTO THE RECTUM ROLL UP FROM THE BOTTOM – DO NOT RELEASE PRESSURE

Delegation and Collaboration The task of enema administration can be delegated to UAP How does the nurse direct UAP? What is the one type of pain the nurse does not need to be informed about? [Ask students: what is the one type of pain the nurse does not need to be informed about? Discuss: the exception is if a patient reports cramping.] The nurse directs the UAP about: How to properly position patients who have mobility restrictions or therapeutic equipment such as drains, intravenous (IV) catheters, or traction. Informing the nurse immediately about patient’s new abdominal pain (exception: a patient reports cramping) or rectal bleeding. Informing the nurse immediately about the presence of blood in the stool or around the rectal area or any change in vital signs. Copyright © 2018, Elsevier Inc. All rights reserved.

Recording and Reporting Record the type and volume of enema given, time of administration, characteristics of results, and patient’s tolerance of the procedure Record patient’s understanding through teach-back for self-administration of a Fleet enema Report the failure of patient to defecate and any adverse effects to health care provider Copyright © 2018, Elsevier Inc. All rights reserved.

Special Considerations Gerontological Use caution when enemas are ordered “until clear” in older adults Teach diet modification Patient may have difficulty with fluid retention Home care Assess ability and motivation to administer enema Gerontological Caution is necessary when enemas are ordered “until clear” in older adults. Some older adults become fatigued, are at risk for fluid and electrolyte imbalances, and experience changes in vital signs. Some older adults may have difficulty retaining fluid. The nurse may gently hold the buttocks together to help with retention of fluid. Home care Assess patient’s and primary caregiver’s ability and motivation to administer enema and provide instruction as needed. Copyright © 2018, Elsevier Inc. All rights reserved.

Applying a Fecal Management System Procedural Guideline 35-1 Protects the perineum from fecal enzymes and prevents feces from spreading to wounds Useful for patients with severe fecal incontinence Risks include rectal necrosis, loss of rectal tone, pressure ulcer, or fistula formation FMS systems are latex-free, indwelling rectal catheters, with a low-pressure balloon to hold the catheter in place in the rectum, and a soft flexible drainage tubing attached to a containment device. These systems have an irrigation port to maintain patency of the catheter and promote fecal drainage. Consultation with a health care provider is recommended to discuss options for patients and there are certain situations that contraindicate the use of a FMS. Copyright © 2018, Elsevier Inc. All rights reserved.

Delegation and Collaboration The skill of applying a topical (external) fecal containment device cannot be delegated to UAP The nurse directs the UAP to: Report to the nurse any instances of leakage or change in appearance of skin around device noted during routine care Report to the nurse immediately any increase in patient’s rectal pain or sensation of pressure or rectal bleeding The UAP can assist the nurse by helping with positioning of a patient during device application. Copyright © 2018, Elsevier Inc. All rights reserved.