Bowel Elimination NUR101 Fall 2008 Lecture # 23 K. Burger, MSEd, MSN, RN, CNE PPP By: Sharon Niggemeier RN MSN J Borrero 12/08

Functions of the GI Tract Prepare fluids and nutrients for absorption and use by cells via mechanical and chemical breakdown Absorb fluids and nutrients Receives secretions from organs (eg. gallbladder, pancreas)

Anatomy & Physiology Organs of the GI tract? Function of Large intestine: absorption Extends from Ileocecal valve to anus Chyme Peristalsis & Mass peristalsis Mouth, esophagus, stpomach, SI, LI, Rectum, Anal canal and anus. Large Intestine is the lower portion of the alimentary tract. Function: water absorption, formation and expulsion of feces. Ileocecal valve is the barrier between the sm. intestine & the lg. intest. Chyme : waste products of digestion received by the lg. Intse. Composed of liquid, watery state as it passes thru lg. intest. water is absorbed.800-1000cc/day. Diarrhea- chyme passes thru too fast not enough water absorption takes place. Constipation- chyme passes thru slowly, too much water is absorbed stool becomes hard, dry and difficult to pass. Peristalsis-contractions of intest. muscle that move the waste products along.3-12 min. Mass peristalsis - propels fecal mass forward 1-4 times /day

Act of Defecation Defecation reflex Valsalva maneuver Defecation Defecation Reflex- stimulated when the fecal mass stretches the rectum causing internal anal sphincter to relax and colon contracts …the external sphincter must then voluntarily be relaxed =elimination occurs If the external sphincter isn’t relaxed defecation will be delayed….delayed too often will lose the reflex entirely. Muscles that aid in defecation… Valsalva maneuver- additional muscles aid in the act of defecation, voluntary contraction of abd. muscles and diaphragm cause an increase in intraabd. pressure. “bearing down” Defecation- emptying of lg. Intest. Bowel Movement. Stool, feces, BM.Should be at REGULAR INTERVALS- varies greatly among individuals.

Alteration in Bowel Elimination Diarrhea Constipation Incontinence Fecal Impaction Flatulence Diarrhea-_liquid watery stools..deals with the consistency and frequency Constipation- less then 3 bm/week or what ever is less then the pt. Regular pattern of elimination Incontinence inability to control fecal discharge thru anal sphincter Fecal impaction- mass of hardened feces in rectum…recognized by seepage Flatulence- gas

Characteristics of Stool Volume Color Odor Consistency Shape Constituents Volume - varies Color- infants yellow, adults brown due to bile pigmentation. In absence of bile stool may be white (clay colored). Diet can effect color blackish if high red meat intake.Blackish stools (Tarry)could be from upper GI bleeding while (frank red)blood is lower GI bleeding. Greenish color if dk. green veg.eaten. Odor- Odor is due to the bact action of break down of digested foods. Aroma effected by foods digested, blood, pus, or bact. in stool. Consistency- soft, semisolid, formed, liquidly, hard. Influenced by diet/fluid intake, GI motility or malabsorption. Shape- depends on condition of colon. Usually tubular (formed to the rectal canal), but varies. Obstructions may produce narrow pencil thin stools, increased time in the colon may produce marble-like stool. Constituents - waste residue of digestion bile, secretions, bact, fat…abnormal constituents blood, helminths, parasites, mucus...

Factors That Influence Bowel Elimination Age Fluid Intake & Diet Daily Routine Activity Medications Health Status Stress Age- elderly bowel conscious, infants pass many stools etc. Fluid/diet- Intake 2000-3000cc/day and high fiber diet promote elimination Daily routine - time, position, place. Hospital less conducive to bowel elim. Activity - increases muscle tone and GI motility Medications- antibiotics can cause diarrhea, opiates (narcotics)constipation, laxatives, antidiarrheals Health status- tumors, infection of intestines, spinal cord injury Stress - anxiety-diarrhea, worry-constipation Dx test- bowel cleansing alters elimin.pattern Surgery & anesthesia- direct handling of bowels and slowing of peristalsis alter bowel elim.

Diet Laxative effect foods: High fiber foods: Legumes (beans) Spicy & greasy Bran/Chocolate Coffee/Alcohol Raw fruits & vegetables High fiber foods: Legumes (beans) Cereals Whole grains Raw Fruits Vegetables Fiber is of plant origin, a carbohydrate not digested by the GI tract. 25 grams/day is recommended High fiber foods increase peristalsis by forming bulk and having the feces move thru quickly. Laxative effect - will increase the frequency of BM :prunes

Assessing Elimination Status Usual pattern Changes in bowels Aids to eliminate Current problems Pattern -How often, when Changes- blood, mucus Aids - laxatives enemas Problems - food related, meds, physical, emotional, Artificial orifices, hemorrhoids (abnormally distended veins)..colostomy

Physical Assessment Inspection- observe contour of abd and note visible peristalsis Auscultation- listen for bowel sounds all quadrants Percussion- resonant or tympany over hollow organs…dullness over intestinal obstruction Palpation- feel for masses, tenderness etc… This is a different sequence for assessing since palpation may disrupt bowel motility and peristalsis

Stool Specimen Collection Routine specimen Occult blood Ova & parasite Timed specimens Routine- Use PPE…place in container…pt. Can obtain themselves…use bedpan /don’t place toilet tissue in bedpan….place in labeled container..transport in plastic bag with required lab slip on outside. Occult blood –hemacult cards/wipes test for blood…may have to be on a special diet several day prior… O & P lab sends up test tubes use applicator to place stool specimen in test tubes… Timed test sometimes all stools for 24hr/ or three stools in a row check with lab…

Nursing Dx R/T Bowel Elimination ? Nursing Dx Potential for constipation related to side effects of medication as evidenced by patient’s verbalization I feel blocked up..I haven’t gone in 4 days….. I usually go every morning after my coffee.. Bowel Incontinence related to loss of anal sphincter control as evidenced by inability to control bowels, 2 episodes of “accidents” every shift, pt. States” I feel like a baby and I don’t want to wear diapers” PAIn Diarrhea Impaired skin integrity FVD

Outcome Criteria Pt. will: Develop regular pattern of elimination Have less episodes of incontinence Incorporate fluids/diet that promote bowel elimination

Interventions to Promote Elimination Routine Positioning Privacy Comfort Activity Diet/Fluids Routine- Establish reg pattern of elimination at reg times. Pt. needs 10-15 min. (uninterrupted time). If urge to defecate is constantly ignored the defecation reflex will be lost, causing feces to remain longer in intest., increased water absorption, making feces hard and difficult to pass. Use communication skills to discuss bowel patterns. Positioning- comfortable position needed. Squatting position common. Assess need for elevated toilet, commode, Privacy- considered a very private act. Use BR if possible, pull drapes close doors. Comfort- provide quiet, comfortable as possible place. Activity- needed to promote GI activity and maintain reg. frequency.Teaching related to inactivity and constipation. Exercises for immobile client. Exercises to strengthen abd. and perineal muscles used for defecation.T & P ROM Diet/Fluids - High fiber foods, 2000cc fluids/day

Interventions: Promote Bowel Elimination Laxatives and Cathartics Enemas Suppositories Digital Removal Cathartics/laxatives - drugs that induce emptying of the intest. Habitual use of laxatives lead to constipation and irreg. frequency.Prep for procedures Cathartics have stronger effects. Enemas- solution introduced into the lg. Intest. For the purpose of removing feces. Suppositories - bullet shaped substance inserted into the rectum beyond the anal sphincter where it melts to aid in elimination. Digital removal- with prolonged retention of feces, fecal impaction occurs preventing passage of normal stool. Liquid fecal seepage around hard stool can occur. Oil retention enema is given prior to digital removal to soften stool.

Types of Enemas Cleansing- given to clean out the bowel for relief of constipation, fecal impaction, bowel prep prior to dx tests or surgery or bowel training. Enemas till clear -clear of feces fluid may still be slightly colored (3 is the limit). Retention -retained in the bowel for a prolonged period of time (lubricate stool, administer meds, (30min.) Return Flow- (Harris Flush) - used to expel flatus. Fill bag with 400 cc water, instill 100-2000cc using siphon process raise and lower bag to expel gas.

Enema Solutions Tap water (Hypotonic) Normal saline (Isotonic) Soap Hypertonic Oil Different types of solutions. Check order for appropriate solution based on client’s need Know Dx Instill solution as much as client can tolerate- will vary for each pt.

Tap Water (TWE) Amount: 500-1000cc Action: Distends, increases peristalsis Time: 15 min. Indicated: inflamed bowels/irritated colon Contraindicated: Atonic bowels, fluid restrictions Hypotonic

Normal Saline Amount: 500-1000cc Action: Distends, increases peristalsis Time: 15 min. Indicated:Inflamed bowels/irritated colon Contraindicated: Na retention problems, fluid restrictions Isotonic

Soap (SSE) Amount: 500-1000cc (Castile 5ml/1000cc) Action: Distends, Irritates Time: 15 min. Indicated: Constipation Contraindicated: Prior to rectal exams Soap combines with stool readily resulting in decreased water surface tension which allows for stool to be easily expelled. Castille soap is liquid soap prepackaged contained in enema kit.

Hypertonic Amount: 70-130 cc solution Action: Distends/Irritates Time: 5-10 min. Indicated: Constipation, convenience Contraindicated: Dehydration, Na problems Osmosis draws water into the colon aiding in elimination Fleets is an example

Oil Retention Amount: 120-200cc Action: Lubricates Time: 30 min. Indicated: Fecal impaction Contraindication: none Types of oil used mineral, cotton seed or olive Prepackaged Client retains for at least 30 min then attempts to expel solution Usually followed with TWE Other retention enemas given for medication administration and administer nutrients/fluids

Enema Administration PPE Position L Sims Linen protector Receptacle (bedpan, commode, toilet) IV pole Lubricant Enema bag with solution Tissue paper

Enema Administration Position L Sims Insert lubricated tip 4” Bag raised 18-20” above anal canal Administer slowly - 10 min. Administration is individualized. Pt. holds for 15 min. L sims -water flows more easily into descending colon Temp of solution usually above body temp to increase peristalsis. Except for retention enemas which we want to be held therefore they are given at below body temp. If cramping occurs…lower bag, stop flow…take deep breaths

Evaluation Solution given Amount expelled Characteristics of stool Passing of flatus Unusual findings blood, helminthes, pus etc. Client reaction: change in skin color, VS changes, fatigue

Medications Effecting Bowel Elimination Laxatives- induce emptying of GI tract Antidiarrheal- slow peristalsis, Pepto Bismol, Kaopectate Codeine/morphine/iron- cause constipation Antibiotics-may cause diarrhea Opiates: paragoric, lomotil- habit forming

Flatulence Causes: Decreased peristalsis Diet Stress Constipation Medications Surgery Diet Stress Decreased activity Decreased activity

NonInvasive Interventions for Flatulence *Ambulation* Knee chest position

Invasive Interventions for Flatulence Glycerin Suppository Harris Flush Rectal Tube Suppository - always lubricated, inserted past the anal sphincter Harris flush- Use siphoning process to relieve flatus. Fill enema bag with 400cc water raise bag and instill 200cc then lower the bag and allow water to return back into the bag with flatus. Should see bubbling as gas escapes Rectal Tube- inserted into rectum 22 fr-32 frtube in place for 20 min. acts as an escape route for flatus. Remove and reinsert 2-3 hrs. later. Can insert up to 3 times.Prolonged use can result in loss of sphincter control.

Evaluation of Bowel Function Achievement of regular defecation habits Patient’s understanding of normal elimination Maintenance of adequate food and fluid intake Regular exercise program Comfort Skin integrity

Gastrointestinal Charting Chuckles The patient had waffles for breakfast and anorexia for lunch. She stated that she had been constipated for most of her life until 1989, when she got a divorce. Bleeding started in the rectal area and continued all the way to Los Angeles. Rectal examination revealed a normal-size thyroid. The patient was to have a bowel resection. However, he took a job as a stockbroker instead. Fleet enema given with stool hard as pine knots. Patient complains of indigestion since last night when he ate a stake. Patient passed flatus . . . two short, one long. Patient was seen in consultation by the physician, who felt we should sit tight on the abdomen, and I agreed.