Unit 4

Factors affecting bowel elimination

● Age
○ Neonate: eliminates a lot due to having small bladder and. More peristalsis. Meconium changes color in umbilical cord
● Diet
● Fluid intake
● Physical activity
○ More active more peristalsis
● Psychological factors
● Personal habits
● Position during defecation
● Pain
● Pregnancy
○ Increased pressure decreases peristalsis
● Surgery and anesthesia
● Medications
○ Calcium channel blockers can cause constipation
● Diagnostic tests

A. Health history
● Changes in bowel pattern
● Consistency of feces
● Prescience of blood or pus in the feces
● Diet and fluid intake
● Physical activity

Assessment (abdomen)
Inspection
● Country of abdomen, color, lesions,

Auscultation
● Normoactive bowel sound: more than 5 (hyperactive) less than 5 (hypoactive)
● Right lower quadrant start

Percussion
● Checking for
● Right lower quadrant start
● Fluid: dull
● Tympanic: normal

Palpation
 ● Pain

Assessment (anus and rectum)

Inspection
● Redness
● Swelling
● Bleeding
● Distention

Palpation
● Patency
● Mass
● Polyps
● For men: checking for enlarged prostate

Stool examination
● Test done (on stool sample) to diagnose certain conditions affecting the digestive tract
● The stool will be checked for color, consistency, weight (volume), shape, odor, and constituents.
● Purposes:
○ Determine the prescience of occult blood
○ Analyze dietary products and digestive secretions
○ Detective the prescience of ovarian and parasites
○ Detect the presence of bacteria and viruses

Instructions for collecting stool specimen

● Void first
● Defecate into required container - use tongue blades to get a sample
○ About pea size
○ If liquid, collect about 15 to 30 ml
● Do not place tissue on the stool specimen
● Wash hands
● Label container

Assessment for the color of stool

 ● Normal: waste residues of digestion
● Abnormal
○ Pus
○ Mucus
○ Parasites Open Image in Modal
○ Blood
○ Large quantities of fat: sign of GI bleeding
○ Foreign object

For Fecal Occult Blood Test (FOBT)

About three days before
● Avoid certain fruits and vegetables including broccoli and turnips
● Red meat
● Vitamin c supplements
For about 7 days prior to the test if possible, avoid taking the following meds
● Acetylsalicylic and unfractionated or low molecular weight heparin, warfarin, clopidogrel, NSAIDS, selective serotonin reactive inhibitors

Timed specimens
● Consider the first stool passed as the start of collection period
● Collect a specimen of every stool passed within designated periods
● Save the whole specimen or only a sample

Specimen for pinworms

Tape test
● Press clear cellophane tape against the anal opening
● Collect the specimen on the morning after the patient awakens and before the patient has a bowel movement or bath
● Pinworms hatch at night

Direct visualization
Endoscopy
● Through the mouth
● Visualizes abdomen to duodenum to see bleeding, polyps, and other abnormalities
● A fiber optic endoscope is used
● Invasive

Nursing responsibilities
● Signed consent
● Fasting instructed 6 to 12 hours prior to the procedure
● Remove dentures
● Sedation, local anesthesia is sprayed into the mouth
● NPO till gag reflex present
● Monitor vs
● Observe signs of perforation, pain, persistent difficulty swallowing, vomiting black tarry stool
● Check vomitus if there’s blood

Capsule endoscopy
● Patient drinks pill like then defecates so we can see the inside
Colonoscopy
● Preparation
○ Consent
○ Preparation for the test
◆ Clear liquid diet 24-48 hrs before the test
○ 2 day bowel preparation
◆ Cathartic/ dulcolax on day 1
◆ Enema on the day of the test
○ 1 day bowel preparation- gallon of bowel cleanser- short period of time
○ Sedation: before the test
 ○ Expect flatulence or gas pains
○ Usual diet resumed once the patient recovers
○ Check vs
○ Observe signs of perforation: abdominal pain, rectal bleeding, fever
○ Sims, left side lying

Sigmoidoscopy
● Visualization of distal sigmoidoscopy colon, rectum, anal canal
● Masses may be seen (may be cancerous)
● Preparation
○ Consent
○ Light meal before the test
○ 2 times fleet enema
○ Sedation is not necessarily done
○ May experience flatulence or gas pain
○ If biopsy is performed, there may be rectal bleeding
◆ Monitor blood manifesting

Indirect visualization
Upper gastrointestinal and small bowel series
● Fluoroscopic examination of the esophagus, stomach, and small intestine
● Barium sulfate
● Preparation
○ Consent
○ NPO post midnight
○ Inform barium will be given (tastes like chalk) before the test
○ Milk of magnesia, protects the lining given after procedure to prevent constipation
○ Explain that barium may lighten stool for several days

Barium enema
● Consent
● Increase oral fluid intake
● Laxative is given
● NPO post midnight
● Enema until clear
● Review patient history of GI fluid
● Increase fluid intake
● Explain that barium may lighten stool for several days
● Rest, the test in exhausting

Abdominal ultrasound
● Sound waves to visualize internal organs
● Indications
 ○ Abdominal pain
○ Suspicion of enlargement of one or more organs tumors
○ Abdominal trauma
○ An obvious or suspected abdominal mass

Nursing responsibility
● Depends on the nature of the problem
● No food or drinks several hours before the procedure (abdomen). Whole abdomen.
● Consent
● Full bladder (KUB)
● Explain that the gel is applied over the area where the transducer is placed. Inform to bring tissue

Constipation
● Diet, less activity, stress, pregnancy, medications

Common elimination problems of pregnant women and children

● Lack of privacy
● Emotional disturbances such as depression or mental confusion

Flatulence
● Presence of excessive flatus in the intestines
● Common cause of abdominal fullness, pain and cramping

Hemorrhoids
● Dilated, engaged, protruding veins
● Causes (increased venous pressure)

Diarrhea
● Celiac disease: damage in the small intestine
● Increased passage of stools and passage of liquid
● Causes
○ Bacterial and viral infection
● Allergies and intolerances to certain foods
○ Celiac disease
○ Lactose intolerance
● Medications
○ Antibiotic
○ Antacids with magnesium
○ Carboprost
○ Oxytocin
● Pregnancy

Fecal impaction
 ● Result of unrelieved constipation
● At risk: debilitated, confused or unconscious
● Water content is absorbed, built in the rectum
● Rectal suppository is given
● Signs of fecal impaction
○ Inability to pass stool for several days despite the prescience of urge
○ Anorexia:
○ Abdominal distention and cramping
○ Rectal pain
○ Passage of liquid fecal seepage

Fecal incontinence
● Cannot control
● Inability to control passage of feces and gas from the anus
● Neuromuscular disease
● Sphincter problem, prescience of tumor in the sphincter

Nursing diagnosis
Preventing and treating constipation
● Laxative
● Cathartics
○ Stronger laxative
● Increased fluid intake
Rectal suppositories
● Place the suppository past the internal anal sphincter and against the rectal mucosa
● Invasive procedure
● Female patient: ask if it’s alright for you to be the one administering
● If the patient does not want you to do it. You can instruct the patient well to do it themselves
● Left sims side lying

Digital removal of fecal impaction

● Manual removal of impaction
● Breaking up of the fecal mass digitally and removing it in portions
● Requires a physicians order
● Before dis impaction is suggested, oil retention enema may be given and held for 30 mins
● The nurse may use 1-2 ml of xylocaine gel on a gloved finger
● Disadvantages: injury in the rectum, stimulate the vagal nerve that can lead to cardiac dis-
● Massage sides of the anus, then put finger inside and manually remove feces

Rectal indwelling catheter

● Large Foley catheter is inserted in the patients rectum and inflating the balloon to keep in place - may damage the rectal sphincter
● It also increases peristalsis and incontinence by stimulating sensory nerve fibers in the rectum
● Colostomy bag when there’s surgery

Fecal incontinence pouch (rectal pouch)

● Used to collect and contain large column of feces. Places around the anal area nd my or may not be attached to drainage.

Nursing Responsibilities:
○ Regular assessment and documentation of the perianal skin status
○ Changing the bag every 72 hours or sooner if there is leakage
○ Maintaining the drainage system
○ Providing explanation and support to the client and support people

Enema
● Hyper-osmotic solutions are inserted in the rectum
● Fluid is pushed to promote peristalsis, promoting defecation
● Breaks fecal mass and rectal wall is stretched to accommodate
● Cleansing enema: in a pitcher with tube. The higher you put it, the higher area is affected
Carminative enema

Retention enema
● Introduction of oil and medications
● Retain medications
● Involves the introduction of oil and medication into the rectum and sigmoid colon.
Antibiotic enema - used to treat infection locally
Anti-helmentic enema - to kill helminths; oil retention - soften the feces
nutritive enema to administer fluid and nutrients.
● Retained for a long period (1-3 hours)

Return flow enema

● Harris flush
● 100-200 ml up to six times until flatus is expelled or distention is gone
● Used to expel flatus.
● Alternating few of 100-200 ml of solution 1s administered into and dut of the rectum and signold colon to stimulate peristalsis.
Procedure is repeated five to sir times until flatus is expelled or abdominal distention is relieved

Barium enema
● It is used as a diagnostic procedure in which a series of radiographs are taken to examine the large intestine after rectal instillation of barium sulfate,
1. Timing
2. Squatting best position
3. Privacy
4. Nutrition and fluids. Increase
5. Activity. Exercise