1. C.Collings NRS320/105_ 2011 Bowel Elimination Chapter 46

2. Why do we care? Alterations in elimination reflect problems in the GI tract or elsewhere Create problems for our patients If we understand ‘normal’ elimination and what factors cause alterations we can help patients manage alterations, promote normal elimination C.Collings NRS320/105_ 2011

3. The GI Tract Functions: –Prepare food for absorption & use – Absorb nutrients and fluid – Temporary storage of waste –Electrolyte balancing –Remove secretions [gallbladder, pancreas] C.Collings NRS320/105_ 2011

4. GI Tract Parts, Functions, and Essential Elements –Mouth: mechanical and chemical breakdown Saliva, teeth, tongue, swallowing –Esophagus: to stomach, airway protection 2 sphincters – upper and lower prevent reflux –Stomach: storage, mixing, emptying HCL, pepsin [protein breakdown], mucous [protection], intrinsic factor [B12] C.Collings NRS320/105_ 2011

5. GI Tract Small intestine: Digestion and Absorption of most nutrients –Duodenum, jejunum, ileum Duodenum [10”] processes chyme Jejunum [8’] absorbs carbs, protein Ileum [12’] absorbs H2O, fat, salts, vitamins, iron –Alterations in small intestine → malabsorption, nutrient deficiency, electrolyte imbalance C.Collings NRS320/105_ 2011

6. GI Tract Large Intestine: organ of elimination –ileocecal valve, 3 sections by location –Absorption of H2O, Na, Cl depends on speed –Bicarb exchanged for chloride, K+ excreted –Essential bacteria Anus: sphincters [CNS control] Elimination relies on GI function, CNS control and sensation, moderate peristalsis C.Collings NRS320/105_ 2011

7. Factors Affecting Elimination Age & Development –Infant: small capacity, ↑speed, no control –Older Adult: ↓efficiency/motility/sensation → ↓absorption, protein synthesis, constipation Diet: –fiber, gas-producing foods ↑motility –Lack of enzyme → food intolerance lactose, gluten C.Collings NRS320/105_ 2011

8. Factors Affecting Elimination Fluid [1500-2000ml/day for normal stool] Activity: promotes peristalsis, tone Psychosocial: stress, depression, access –Privacy, cleanliness and impaired ability may →ignoring urge, constipation; embarrassment may cause delay in seeking help Position [bedbound], Pain, Pregnancy Surgery, Anesthesia ↓ peristalsis, ileus C.Collings NRS320/105_ 2011

9. Factors Affecting Elimination Medications affecting Elimination –Analgesics: opiods slow peristalsis NSAIDS, ASA: irritation, bleeding, ↓protective mucous –Antibiotics: disrupt flora → diarrhea Elimination also Affects Medications motility may affect absorption, excretion; which affects timing & effectiveness, side effects C.Collings NRS320/105_ 2011

10. Alterations in Elimination Constipation Impaction Diarrhea Incontinence Flatulence Hemorrhoids Neurogenic Bowel – lack of innervation C.Collings NRS320/105_ 2011

11. Surgical Alterations G- tubes and J- tubes for feeding Ostomies for elimination –Name refers to site; ileostomy, colostomy Site determines consistency of effluent, nutritional deficiencies likely –May be reversed or permanent ACE procedure [antegrade continent enema] –(Malone) – creates opening for long term continent enemas using appendix Neurogenic bowel R/T neural defect, tethered cord C.Collings NRS320/105_ 2011

12. Nursing Dx for Elimination Altered Elimination: constipation/diarrhea Self- Care deficit Knowledge deficit [Risk for] Fluid/ Electrolyte imbalance Pain Nutrition: less than body requirements r/t altered digestion, elimination, absorption C.Collings NRS320/105_ 2011

13. Assessment Diet and intake Elimination pattern ‘usual’ and new bowel sounds, palpation & observation Medications Activity Age Appearance of stool – –Tarry/bright red smear – blood –Pale, claymucousfatty C.Collings NRS320/105_ 2011

14. Goals for Elimination Overall: return to normal elimination pattern –Pt reports passing soft, formed stool daily w/o pain Short term goals support modifiable factors: –Pt will increase fluid intake to 1500ml/ day –Pt will walk to end of hall and back 3X today C.Collings NRS320/105_ 2011

15. Goals for Altered Patterns Pt will correctly demonstrate ostomy care by end of week Pt will independently perform ACE after breakfast today Pt will demonstrate improved self-esteem R/T ostomy by next visit Pt will choose a nutritionally balanced diet incorporating gluten-free foods from a list C.Collings NRS320/105_ 2011

16. Nursing Interventions Promote normal Elimination when possible –Position, privacy, pain management, safety Advancing diets: clear, soft, regular, Special diets: lactose free, gluten free, high fiber, fluid restriction Activity Medications: laxatives, softeners, fiber, cathartics, antidiarrheals, C.Collings NRS320/105_ 2011

17. More Interventions Enemas Ostomy Care –Assessment, irrigation, change bag, skin care NG tubes: for decompression, removal of gas/secretions Bowel training Education: Pt and family –vagal response [cardiac], Fluid restriction, meds, diet, new Dx, post-op, when to call M.D C.Collings NRS320/105_ 2011

18. Evaluation Goal met? E.g., goal met: pt passed soft formed brown stool w/o pain today. Continue with plan of care Advance education as pt progresses in ability and comfort, general health C.Collings NRS320/105_ 2011