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Mel's Bowel Elimination Lecture Dec 2006


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Name two types of Nervous System control effecting the bowels
1) Parasympathetic: stimulates movement
2) Sympathetic: inhibits movement
Factors Affecting Bowel Elimination (13)
1) Age (elderly)
2) pathological conditions (e.g. infections, h.pyloris)
3) diet
4) fluid intake
5) physical activity
6) psychological factors (stress increases sympathetic nervous system)
7) "ignoring the urge"
8) position (e.g. bedpan)
9) pain (e.g. hemorrhoids)
10) anesthesia/surgery
11) diagnostic tests (swallowing the contrast medium can constipate)
12) medications
13) pregnancy (esp. 3rd trimester)
Name 5 reasons why bowel elimination may be compromised in the elderly
1. decreased muscle tone/sphincter control (internal and external sphincters)
2. less fluid intake
3. decreased saliva production
4. decreased motility in peristalsis
5. elderly more prone to diverticullitis
Name 3 ways abdominal surgery can effect bowel elimination
1) gas
2) touching bowels stops peristalsis
3) paralytic ileus
Name medications that can affect bowel elimination
1) antibiotics: diarrhea
2) NSAIDS: risk of small hemorrhagic intestinal irritations
3) chronic use of laxatives: bowel becomes less responsive
4) narcotics: decrease peristalsis
5) anticholinergics: decrease peristalsis
6) iron: black tarry stools
5 Most Common Bowel Elimination Problems
1. Constipation
2. Diarrhea
3. Flatulence
4. Incontinence
5. Hemorrhoids
Constipation: Signs and Symptoms
* decrease in the frequency of evacuation--hard, dry stool
* increase in straining
* rectal pain on elimination
Types of Enema Solutions
1) TAP WATER: stimulates and dilates bowel--hypotonic
2) SOAP SUDS: dilates, stimulates and irritates bowel--hypotonic
3) NORMAL SALINE: dilates, stimulates and irritates bowel (0.9% iso)
4) OIL: lubricates, softens
5) KAYEXALATE: medication reduces serum potassium (hypertonic)
6) ANTIBIOTIC: cleansing
7) HARRIS FLUSH: used to remove gas
8) CARMINATIVE/FLEETS: hypertonic--used as a prep for many tests
Describe Administration of Enema
* requires MD order
* medical asepsis
* explain retention (15- 20 min.) to client
* monitor response and prepare w bed pan, toilet tissue, call bell, etc.
* usually 500 - 1,000 mL fluid
Describe Digial Removal of Stool
*MD order
* explain procedure
* baseline vital signs
* Side lying position, knees flexed
* have bed pan available, double gloved lubricated finger
* advance slowly, loosen and remove
* assess heart rate and fatigue
* document what you obtained, v/s and patient response
Name 5 Antidiarrheals
1. opiates
2. codeine
3. pargoric (opium tincture)
4. Lomotil (usually drug of choice for most clients)
5. Kaopectate (Kaolin and Pectin)
Name 4 basic types of enemas
1. cleansing (tap, soap suds, n.s.) to evacuate bowel before diagnostic studies or surgery
2. retention: emollient to soften and lubricate stool for easy evacuation
3. carminative (return flow) with tap or saline for relief of distention due to flatus
4. medicated with saline or sterile water plus medication
3 Problems with straining (valsalva maneuver) during constipation
1) icreasing intercranial pressure can cause a stroke
2) evisceration after abdominal surgery (especially 2-3 weeks following surgery)
3) hemorrhoids
4 Common causes of chronic constipation
1) Age (peristaltic action decreases with age)
2) Diet/exercise
3) Neurological (ex: spinal cord injury)
4) Illness (ex: hypothyroidism, hypokalemia)
4 Common complications from constipation
1) fecal impaction (water keeps getting absorbed from hard stool--gets "stuck")
2) decreased appetite b/c of full feeling from abdominal distention
3) cramping
4) hemorrhoids
Common causes of diarrhea
1) infection
2) stress, anxiety
3) tube-feeding
4) food allergies/intolerance
5) disease/surgery (colitis,bowel resection)
6) medications (antibiotics, laxatives)
Common Complications of diarrhea
1) dehydration
2) skin integrity
How to treat diarrhea...
fluids, diet, meds, skin integrity
4 Common Causes of Fecal Incontinence
1) constipation with impaction
2) neurological (spinal cord injury)
3) diarrhea (ulcerive colitis)
4) cognitive impairment
3 Treatments for fecal incontinence
1) rectal indwelling catheter (not very successful, but an attempt at avoiding gastric enzymes on patient's skin)
2) fecal incontinence pouch (out of the rectum)
3) bowel training
How Bowel Training works
1) assess normal elimination time
2) stool softeners/cathartic suppositories 1/2 beforehand
3) hot drink or juice (apple or prune for example)
4) assist to toilet/privacy
5) time limit (10 - 15 min)
6) teaching: don't strain, fiber/fluid, activity (walking)
7) + reinforcement, no adult diapers
Medications/Treatments to assist with constipation
1) Cathartics/Laxatives (oral or suppository)
2) Bulk forming fiber (metamucil or psyllium fiber)
3) Emollients (stool softeners like Colace/Ducosate) detergent that allows water and fat to penetrate stool--not used for chronic constipation
4) Saline Mag Citrate or Fleets phosphosoda oral laxatives; Fleets has too much sodium for cardiac patients
Describe 6 common bowel stimulants
1) milk of magnesia: saline laxative pulls salt into intestine, water flushes bowels
2) bisacodyl (dulcolax) stool softener + causes contractions of l. intest.
3) pericolace: stool softener
4) phenolphthaein: laxative (possible carcinogen--being taken off U.S. market)
5) exlax (senokot)
6) castor oil
What does a bowel stimulant do?
irritates bowel to evacuate, sometimes increases fluids too
What does a bowel lubricant do?
coats the stool so it slips out--great for hemorrhoid patients--used to assist avoidance of straining--may effect fat soluble vitamins
What is an ostomy?
An ostomy is a surgical procedure in which a diseased part of the small or large intestine is removed and the remaining intestine is attached to an opening in the abdomen. It is often needed when a person has lost the normal function of the bladder or bowel due to birth defects, disease, injury or other disorders
What is a stoma?
An ostomy allows normal bodily wastes to be expelled through a round or oval opening in the abdomen wall known as the stoma (the Greek word for mouth)
What are the 3 main kinds of ostomies?
There are three basic types of ostomies and stomas: colostomy, ileostomy and urostomy.
GI Physical Assessment includes:
* mouth (dentures, gums, inflammation)
* inspect abdomen (distention, masses, persistaltic waves)
* auscultate bowel sounds (5 -15 per minute)
* percuss(tympanny=gas, hollow=obstruction)
* inspect rectum (ext. hemorrhoids)
GI Assessment: Nursing History includes
*usual elimination patterns, routines, change of habits
*description of stool,diet history, exercise history, use of aids for elimination
*GI surgery,meds, mobility, emotional state, living conditions
Assessment of Stool
Color, odor, consistency, frequency, amount, shape, unusual constituents
2 Types of Fecal Specimens
1) guaiac occult blood: food/drug restrictions 2/3 days, no urine in sample
2) hemoccult 2gtts solution: color change blue= +
Visualizes area (pt. under conscious sedation)using thin fiberoptic instrument passed through mouth or rectum
1) gastroscopy: gullet, stomach and duodenum
2) colonoscopy
3) sigmoidoscopy
*possibility of taking a biopsy; also possibility to be used to stop bleeding
Fiberoptic Colonoscopy: preparation
*colon cleansing with golytely laxative
*liquid diet x36 hrs then npo
* no meds
* no asa/nsaids x 2 weeks
*informed consent
Fiberoptic Colonoscopy: after procedure
* assess pain
* bleeding--for 1 day (black stools for up to 2 weeks)
* drowsiness
* resume fluids
Barium Enema XRay
* Contrast Media--Barium Enema contrast media inserted (hard to resist urge to push out)
*signed consent
*frequent position changes (to facilitate movement of media)
*monitor BM after test (risk of fecal impaction if medium not eliminated)

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