226- GU/Bowel - zimmer- Drexel ace

Factors Affecting Bowel Elimination - ANS-● Age- control by 2-3

○ older adult: decreased chewing, peristalsis declines, and esophageal emptying slows- impairs
absorbtion by intestinal mucosa
- Increased risk of constipation

Backend-Muscle tone in the perineal floor and anal sphincter weakens, and may cause difficulty
in controlling defecation.

● Diet, fluid intake

○ Make sure patients have the proper nutrients and fiber

● Physical activity
○ If a patient is immobile/inactive → more prone to constipation

● Psychological factors
•Prolonged emotional stress impairs the function of almost all body systems. During emotional
stress, the digestive process is accelerated and peristalsis is increased.

● Personal habits
○ Some individuals can't have a bowel movement at work, at school or away at vacation
○ This promotes a situation that could increase risk for constipation

● Position during defecation

○ It's very difficult to have a bowel movement while on a bed pan

● Pain
○ Rectal surgery, bowel surgery or hemorrhoids → discomfort, straining
■ Will cause patient to ignore urge to defecate

● Pregnancy
○ Puts pressure on the abdominal area/GI system → increase risk for constipation

● Surgery and anesthesia

○ Anesthesia stops peristalsis for a period of time
○ Need to monitor return of bowel sounds and asking patients if they have passed gas/flatus

● Medications, laxatives and cathartics

Opiods- constipation
● Diagnostic tests
○ Endoscopy and colonoscopy require bowel prep to clear GI tract in order to visualize properly
•Following the diagnostic procedure, changes in elimination such as increased gas or loose
stools often occur until the patient resumes a normal eating pattern.

Order of GI - ANS-1. Mouth

2. Stomach
3. Small intestine- Duodenum
4. Small intestine- Jejunum
5. Small intestine- Ileum
6. LI- Cecum
7. LI- Ascending colon
8. LI- transverse colon
9. LI- descending
10. LI- Sigmoid colon
11. rectum
12. Anus

What are feces made of? - ANS-of fiber, undigested food, inorganic matter, bacteria and water

A lot of water (75%)

constipation - ANS-•Constipation is a symptom, not a disease, and there are many possible
causes. Improper diet, reduced fluid intake, lack of exercise and certain medications can cause
constipation. When intestinal motility slows, the fecal mass becomes exposed over time to the
intestinal walls and most of the fecal water content is absorbed. Little water is left to soften and
lubricate the stool. Constipation is a significant source of discomfort and the nurse should
assess the need for intervention before the defecation becomes painful or the stool is impacted.

Fecal impaction - ANS-•Fecal impaction results from unrelieved constipation. In cases of severe
impaction, the mass extends up into the sigmoid colon. If not resolved or removed, severe
impaction can result in intestinal obstruction. Patients who are debilitated, confused, or
unconscious are most at risk for impaction. The nurse should suspect an impaction when a
continuous oozing of liquid stool occurs. The liquid portion of feces located higher in the colon
seeps around the impacted mass.

Diahhrea - ANS-•Diarrhea is an increase in the number of stools and the passage of liquid,
unformed feces. Intestinal contents pass through the small and large intestine too quickly to
allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased
mucus secretion. As a result, feces become watery and the patient may have difficulty
controlling the urge to defecate. Excess loss of colonic fluid can result in dehydration with fluid
and electrolyte or acid-base imbalances if the fluid is not replaced. Meticulous skin care and
containment of fecal drainage is necessary to prevent skin breakdown. Some causes of
diarrhea include Clostridium difficile, communicable foodborne pathogens (ecoli), surgeries or
diagnostic testing of the lower GI tract, and food intolerances.

Fecal incontinence - ANS-•Fecal incontinence is the inability to control passage of feces and
gas from the anus. Many conditions cause fecal incontinence or diarrhea and it is important to
identify precipitating conditions and refer to health care providers for medication management.

Hemmroids - ANS-•Hemorrhoids are dilated, engorged veins in the lining of the rectum and can
be either external or internal. Increased venous pressure from straining at defecation,
pregnancy, heart failure, and chronic liver disease causes hemorrhoids.

Flatus vs flatulence - ANS-Flatus- GAS

Flatulence- excessive gas, abnormal cramping, abdominal distention

Hemorrhoid formation - ANS-•The rectum contains vertical and transverse folds of tissue that
help to control expulsion of fecal contents during defecation. Each fold contains veins that can
become distended from pressure during straining. This distention results in hemorrhoid
formation.

Life lesson - ANS-- Regular bowel elimination is essential for the maintenance of a healthy body
state

- Individuals of any age can experience changes in intestinal elimination

Common Bowel Elimination Problems: Constipation - ANS-A symptom, not a disease;

infrequent stool and/or hard, dry, small stools that are difficult to eliminate

○ When bowel movements go beyond 3 days in between OR a patient goes every day but has
hard, small stools

○ Changes for patient

■ Drink at least eight 8 ounce glasses of water/day
■ Increase intake of high fiber foods
■ Go to the bathroom to evacuate after meals

Common Bowel Elimination Problems: Impaction - ANS-○ Results from unrelieved constipation,
a collection of hardened feces wedged in the rectum that a person cannot expel
○ Generally required a practitioner to digitally break up the stool to try and remove this
○ One of the main signs of this is frequent small amounts of liquid stool continuously

Common Bowel Elimination Problems: diarrhea - ANS-○ An increase in the number of stools
and the passage of liquid, unformed feces
○ This can be from medicines or GI conditions
- Frequent, loose, watery stools
- Increase in number of stools
- Nursing management:

o Assess and monitor

§ Fluid and electrolyte balance and skin
o Fluids/diets
§ Encourage clear fluids
§ 2-3 L of fluid per day
§ BRAT diet (bananas, rice, applesauce, toast)
§ Avoid: greasy, fatty, spicy foods

o Antidiarrheal medications
§ Avoid if experiencing acute diarrhea (understand why)
§ Imodium or Lomotil

Common Bowel Elimination Problems: incontinance - ANS-○ Inability to control passage of

feces and gas to the anus
○ This is usually related to patients with diarrhea, IBS, Chron's
○ Can be seen with patients who have functional limitations → dementia, Parkinson's, arthritis

- Involuntary passage of stool

- Causes:
o Uncontrolled diarrhea
o Impaction resulting in leakage of stool
o Cognitive or emotional changes
o Functional limitations
o Medications or treatments

- Nursing management:
o Monitor pattern of BMs
o Toilet at intervals
o Prompt hygiene after many episodes

§ Prevent and monitor for breakdown

o Consider bowel training
o Incontinence pads
o Fecal collection devices

§ Fecal management systems

Common Bowel Elimination Problems: flatulence - ANS-○ Accumulation of gas in the intestines
causing the walls to stretch
○ Over and above flatus: normal passage of gas
■ Flatulence causes distention

Common Bowel Elimination Problems: hemorrhoids - ANS-○ Dilated, engorged veins in the
lining of the rectum d/t straining during bowel movements
○ Can be seen in pregnancy, IBS, constipated patients
elderly

Common Bowel Elimination Problems: Paralytic ileus - ANS-- Paralytic ileus

o Severely decreased or absent peristalsis
§ Think about slowed GI motility
o Bowel obstruction

- Nursing management:
o KEEP PATIENT NPO
o Bowel rest is needed
o NG tube is placed and connected to suction

Bowel Diversion - ANS-● These are surgically created openings for elimination
○ Can be temporary or permanent
○ Used when there is a problem with an intestine → damage, tumor, inflammation
○ Stool characteristics will be different based on the location of ostomy and which part of the
bowel was removed
■ Ascending > transverse > descending, thickening stool
■ Mushy > toothpaste-like > formed

Bowel Diversion: Stoma or ostomy - ANS-● opening created with bowel (intestine) through the
abdominal wall
○ Should be beefy red
○ If white or blue, there is an oxygenation issue and the surgeon needs to be called right away

Bowel Diversion: illeostomy - ANS-● bowel diversion using part of the ileum
○ Bypasses entire large intestine
○ This stool is liquid

2 types of diversion - ANS-Iileostomy (ileum)

- bypass entire large intestine

Colostomy (colon)

Bowel Diversion: colostomy - ANS-● bowel diversion using part of the colon
○ This stool is formed
Bowel Diversion: illeoanal anastomosis - ANS-● surgical removal of colon and small pouch
made from small intestine attached to anus, pouch serves for reservoir for stool
○ Bowel training is provided, patient is continent for stool as they are still using their anus for
defecation
○ This is used if the whole colon needs to be removed (i.e. bad cases of ulcerative colitis)

Caring for a bowel diversion - ANS-- Stoma assessment and care

o At least every shift
o Should be red, not pale or bluish
o Skin care/peristomal skin assessment
o Monitor amount and type of effluent
o Change dressings on the skin every 3-5 days
o Patients are at high risk for skin breakdown

§ Use a barrier around opening created

- Be attentive to client's psychosocial needs
o Professionalism, acceptance
o Odor control

§ Sprays/drops that can go into ostomy bag

o Address client participation in ostomy care
o Assess patient's coping

§ Find teachable moments

- Patient teaching for home care
- Wound/ostomy nurse

Continuing and restorative care for bowel elimination - ANS-- Bowel training
o Determine pattern
o Use short-term laxatives (long-term will actually cause constipation)

- Maintenance of proper fluid and food intake

- Promotion of regular exercise
- Management of the patient with fecal incontinence or diarrhea
- Ostomy care
- Maintenance of skin integrity

Assessment of Bowel Elimination: nursing history - ANS-Nursing history BOX 47.3

o When was your last BM?

o What is your normal bowel schedule?
o What do they look like?
o What does your diet consist of?
o How's your water intake?

● Nursing history
○ Diet → including water intake
○ Baseline for metabolism/bowel movement frequency
■ Stool appearance and size
○ When any issues began, any aggravating factors, etc.

Assessment of Bowel Elimination: laboratory****/diagnostic - ANS-● 3 positives to definitively

say patient has GI bleed

Uses guaiac paper, pout a dab of stool on one side, close the paper and turn it over
● If developer changes color- stool is positive for blood

● Laboratory examination
○ Fecal specimens → test for blood or bacteria
○ Fecal occult blood test → at bedside or send to lab
- culture, fat, or O&P (ova and parasites)

■ Patients can do these at home as well

● False positives
○ The patient's diet includes foods that can cause false positives (fish, poultry, raw vegetables)

■ We place a patient on special diet before taking next test

○ The patient is menstruating
○ The client takes high doses of vitamin C
○ Also want pt off ibuprofen and steroids before repeating test

■ Use clean technique (gloves)→ stool is NOT sterile to begin with

Assessment of Bowel Elimination- diagnostic exam (gold standard)**** - ANS-○ Direct

visualization
■ Uses a camera (either endoscopy or colonoscopy) to visualize either the upper or lower GI
tract
■ Examples: sigmoidoscopy, colonoscopy

○ Indirect visualization
■ Examples: x-ray of abdomen, barium enema with SBFT, CT, MRI

○ Bowel preparation
■ Patients who are getting some of these tests done have to have their bowels completely
evacuated
■ Have a clear liquid diet the night before and then nothing PO for 12 hours
■ Patients take laxatives and often enemas or liquid preparations to evacuate all stool from
bowels
■ This allows for proper visualization
■ For this → be prepared for dehydration

Assessment of Bowel Elimination: physical assessment - ANS-● Physical assessment

○ Think about abdominal assessment
○ Assess for bowel sounds in all 4 quadrants
○ Assess for distention and tenderness
○ If pain or bleeding w/ bowel movement → look at rectum/anus
■ Hemorrhoids: can cause bleeding
■ Fissures: cracks that can be seen in patients w/ constipation and pregnant women
○ If patient has colostomy → look at stoma
■ Pink is good/baseline
■ Blue, pale or purple indicates issue
■ Make sure surrounding skin is intact

Assessment of Bowel Elimination: bloodwork - ANS-bloodwork

○ Hbt/Hct
■ If low, patient is anemic→ can tell us there may be a possible GI bleed if no other obvious
reason

● Can also be d/t heavy period or diet

○ Liver function studies

Bristol stool chart - ANS-bristol stool chart

Potential Nursing Diagnoses - ANS-● Risk for constipation

○ Post-op patients
○ Bed bound patients
○ Patients on opiods

● Constipated
● Perceived constipation
○ Pattern of bowel movements is different than patient is used to

● Diarrhea

● Bowel incontinence
○ Patients with diarrhea of functional limitations

● Toileting self-care deficit

● Dysfunctional gastrointestinal motility
○ Post-op patients if they have hypoactive bowel sounds
○ 12-24 hours since surgery and patient still has not had flatus, bowel sounds are still absent

● Nausea
● Pain (acute or chronic)
● Deficient knowledge (nutrition)
● Imbalanced nutrition: less than body requirements
● Fluid volume deficit

● Electrolyte imbalance
○ This is big w/ diarrhea, especially extended diarrhea bouts

● Disturbed body image

Health Promotion - ANS-● Diet

○ All fruits w/ P → prunes, plums, peaches
○ Adequate fluid intake

● Exercise
○ Importance on moving around/exercise

● Promotion of normal defecation

○ Timing → try and get on a schedule where a bowel movement is at the same time each day
○ Privacy
○ Sitting position
○ Positioning on a bedpan

■ 2 types of bedpans
● Smaller one → for patients with hip or lower extremity fractures
○ This can be used on other patients as well
○ Place small end of bedpan towards the patient's waist
○ Is easier to get on, so can be used for older patients

● Larger one → used for other patients

■ Lifting hips onto the bed pan is the best
● If unable, roll patient on side, reposition bed pan under them and roll patient back onto bed
pan while holding it to patient

● As soon as patient is on bedpan, get head of bed up

■ Make sure the side rail on the opposite side from where you are working/standing is raised

Acute Care/ hospitals - ANS-● Environment

○ Privacy
■ Roommates
■ smell/embarrassment
■ Can lead to patient not removing stool from their body

● Medications
○ Laxatives

■ All stool softeners are laxatives, but not all laxatives are stool softeners

○ Cathartics → stronger laxatives w/ quicker and more intense results

○ Antidiarrheals

■ This is contraindicated if patient has bacterial/viral cause for diarrhea

● We want this to be flushed out

● Enema types
○ Typically CANNOT be dictated as this is an order
○ Cleansing → purpose is to instill fluid and then create some irritation in the rectum so that the
rectum will be stimulated to evacuate stool

1. Tap water
● This is hypotonic in relation to a person's fluid to their body
● Keep an eye on patients intake, output and fluid electrolytes

2. Normal saline → most physiologic/natural

● This is safest esp w/ children and elderly

3. Hypertonic solutions
● Want to keep an eye on intake, output and fluid electrolytes

4. Soap suds
● This is a special castile soap, comes w/ an enema kit
● This has a special pH

○ Oil retention → help soften stools that are hard

■ Does NOT have fluid volume, only has lubricating effect

○ Carminative → helps break up stool/soften it

■ Allows pt to evacuate easier

○ Medication
■ Kayexalate → used for patients who have an extremely high potassium levels
● Uses sodium ions to help patient get rid of excess potassium
Laculose
○ Administration of enema
■ Place patient on left side
■ Insert enma
■ Have patient hold this in for allotted time
■ Have bedside commode ready to go if patient unable to ambulate
■ If patient having pain or abdominal distention→ discontinue enema

● Impaction removal
○ This is the LAST resort
○ Requires an order
■ Can be done by nursing if easy/close to the rectum, otherwise removed by the provider
■ Use digit to gently remove impaction

○ Impac

Evaluation - ANS-- Through the patient's eyes

- Patient or caregiver determines which therapies were most effective
- Patient outcomes:
o Evaluate patient's level of knowledge
o Determine extent to which patient accomplishes normal defecation
o Ask patient to describe changes in diet, fluid intake, activity to promote bowel health