1. Bowel Elimination Assessment and Intervention July 17, 2008 Mary Sokolowski, BSN, RN, CEN

2. Objectives: Describe the normal physiology of bowel elimination Describe the normal physiology of bowel elimination Recognize causes of constipation Recognize causes of constipation Discuss assessment and interventions to achieve nursing outcomes for bowel elimination Discuss assessment and interventions to achieve nursing outcomes for bowel elimination

3. Physiology – Bowel Elimination GI Motility GI Motility Enzyme breakdown Enzyme breakdown Peristalsis Peristalsis Gastrocolic Reflex Gastrocolic Reflex Mucosal Transport Fluids & Electrolytes Fluids & Electrolytes Waste Waste (Bisanz, 2007)

4. Physiology – Bowel Elimination Defecation Reflex Sphincters Sphincters CNS Impulses CNS Impulses Rectal Distention Rectal Distention Mechanical Assistance Mechanical Assistance Anal Sphincter Muscles (Bisanz, 2007)

5. Research Review of the Literature Review of the LiteraturePositives: Bowel Management/Keys to Success (Cadd et al., 2000; Weeks, Hubbartt, & Michaels, 2000) (Cadd et al., 2000; Weeks, Hubbartt, & Michaels, 2000)Problems:Constipation (Hicks, 2001; Hinrichs, Huseboe, Tang, & Titler, 2001; George, Hayward, Lowe, & (Hicks, 2001; Hinrichs, Huseboe, Tang, & Titler, 2001; George, Hayward, Lowe, & Page, 1996;Grieve, 2006; Bisanz, 2007; Heitkemper & Wolff, 2007) Page, 1996;Grieve, 2006; Bisanz, 2007; Heitkemper & Wolff, 2007) Bowel Problem/Risk Management (Salcido, 2000; Zernike & Henderson, 1999) (Salcido, 2000; Zernike & Henderson, 1999)

6. Characteristics – Bowel Elimination Frequency Frequency Quantity Quantity Quality Quality Consistency Consistency Ease of Passage Ease of Passage

7. Tools for Stools Bristol Stool Scale Constipation Scoring System http://www.ncbi.nlm.nih.gov/pubmed/864957 http:// en.wikpedia.org./wiki/Bristol_stool_Chart

8. Precursors – Normal BM Good Health Intact CNS Less medications Good oral hygiene/dentures Regular Exercise/Movement Good muscle tone Stimulates appetite (Weeks, Hubbartt, & Michaels, 2000)

9. Precursors – Normal BM Fiber: Action: soft, bulky stools Types: plant food Insoluble – wheat bran, vegetables Soluble – oat bran, barley, beans, fruit (Weeks, Hubbartt, & Michaels, 2000) (Weeks, Hubbartt, & Michaels, 2000) Power pudding Amount: > 15-20 gms/day (Hinrichs, Huseboe, Tang, & Titler, 2001) (Hinrichs, Huseboe, Tang, & Titler, 2001)

10. Precursors – Normal BM Fluids Action: combines with fiber – moves stool Types:WaterJuices Decaffeinated beverages Amount: > 1500 cc/day (Weeks, Hubbartt, & Michaels, 2000) (Weeks, Hubbartt, & Michaels, 2000)

11. Precursors – Normal BM Timing Individual pattern Gastrocolic reflex – strongest after meals (Hinrichs, Huseboe, Tang, & Titler, 2001) (Hinrichs, Huseboe, Tang, & Titler, 2001)RegimePositioning (Kacmaz & Kasikci, 2007) (Kacmaz & Kasikci, 2007)Privacy (Weeks, Hubbartt, & Michaels, 2000) (Weeks, Hubbartt, & Michaels, 2000)

12. Constipation When in Rome... When in Rome... Rome III Criteria: Constipation Straining Lumpy hard stool Incomplete evacuation/Maneuvers Less than 3 BM’s/week (Heitkemper & Wolff, 2007)

13. CONSTIPATION Definition: decreased normal frequency of defecation accompanied by difficult or incomplete passage of excessively dry stool (Wilkinson, J.M., 2005) (Wilkinson, J.M., 2005)

14. Causes - Constipation P oor Intake Fluids NPO – tests, surgery Choices – juice, water Positioning Fiber Menu choices – fresh fruit, whole grains

15. Causes - Constipation O rthopedic Insult Casts, Traction Pain with movement Assistive devices Other diseases

16. Causes - Constipation O pen Door Policy ↓ Privacy – visitation policy Bathroom vs. Commode Disruption of Routine Disruption of Routine Therapy Therapy Tests/Surgery Tests/Surgery

17. Causes - Constipation P ain Medications Opiates – P.O. or PCA Other medications Other medications Antacids with aluminum, anticholinergics, Antacids with aluminum, anticholinergics, calcium channel blockers, phenothiazines, calcium channel blockers, phenothiazines, diuretics, sedatives, etc. diuretics, sedatives, etc. (Hinrichs, Huseboe, Tang, & Titler, 2001) (Hinrichs, Huseboe, Tang, & Titler, 2001)

18. Laxatives (+/-) Last resort: Bulk-forming → Bulk-forming → Stool softeners → Osmotic Laxatives → Stimulants → Suppository/Enema (Hinrichs, Huseboe, Tang, & Titler, 2001) (Hinrichs, Huseboe, Tang, & Titler, 2001)

19. Assessment AUDITS:Diagnosis Postoperative Day Medications +/- Bowel Movement Recorded INTERVIEWS:NursesLeadershipPatients

20. Interventional Tool Pictorial Diary Fluids – 8 servings Whole grains – 3 servings Fruits/vegetables – 5 servings Exercise – 3-4 x/day Bowel Movement - record

21. Interventional Tool Bowel Elimination Tool (BET)

22. Interventional Tool Directions: Mark your selections with an X Choose: 8 Glasses of Fluid: Best: Water or Juices; Decaffeinated drinks 3 Servings of Whole grain breads or cereal: Best: Whole wheat, oatmeal, bran cereals 5 Servings of Fruits or Vegetables: Best: Fresh fruits, vegetables with skin Exercise – 3-4 times per day Best: Walking, physical therapy, or exercises in bed Record your BM Difficult___ Easy___ Soft___ Hard___ Complete__

23. Nursing Outcomes 1) Cooperates for Bowel Management P artners for care – uses tool O ut of bed/ exercises – 3-4 x day O verview of diet >15 gm fiber; >1500 cc fluids P rivacy and respect – toileting regime (Moorhead, 2008) (Moorhead, 2008)

24. Nursing Outcomes 2) Constipation alleviated as indicated: Elimination pattern in expected range Stool soft and formed (soft/hard) Stool easy to pass (easy/difficult) Amount adequate for diet (yes/no) Feeling of evacuation (yes/no) (Moorhead, 2008) (Moorhead, 2008)

25. Implications for Practice AssessmentPrevention Partners with patients Nursing performance improvement