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assisting with elimination
Bowel Elimination ASSISTING WITH ELIMINATION OBJECTIVES Identify procedures for promoting bowel elimination. Assist the patient in evacuation of feces and flatus through the use of enema, rectal tube or Harris Flush. Assist or teach the patient with a colostomy or ileostomy to irrigate the bowel. SKILLS FOR GASTROINTESTINAL DISORDERS Bowel Elimination Elimination of bowel waste (defecation) is a basic human need and is essential for normal body function. Normal bowel elimination depends on several factors: a balanced diet, including high-fiber foods; a daily fluid intake of 2000 to 3000 mL; and activity to promote muscle tone and peristalsis. Normal stool (feces) is described for documentation as moderate in amount, brown, and soft in consistency and is expelled every 1 to 3 days. PHYSIOLOGY OF DEFECATION The muscles of the pelvic floor and the external sphincter are under voluntary control The bowel has its own nerve network that stimulates peristalsis when it is distended Disorders of the central nervous system and spinal cord do not impair bowel control as much as they do bladder control The fecal mass enters the rectum by mass movement Feces in the rectum creates a desire to defecate Defecation occurs when the anal sphincter relaxes and the rectum contracts Figure 23-5 ASSESSMENT Chief complaint Determine usual bowel pattern, changes, stool characteristics, and related symptoms, such as pain or cramping Bowel pattern Document usual frequency of bowel movements Characteristics of stools Assess stools consistency, color, and constituents of ASSESSMENT Review of systems Functional assessment Problems that may be related to fecal incontinence, such as motor, sensory, or cognitive impairments Habits that may be related to bowel function, including diet, fluid intake, exercise or activity pattern Physical examination Inspect and palpate the abdomen for distention and auscultate for bowel sounds Inspect the perianal area for irritation or breakdown SKILLS FOR GASTROINTESTINAL DISORDERS Care of the Patient with Hemorrhoids The patient with hemorrhoids has pain when hemorrhoidal tissues are directly irritated from the passage of hard stool. The primary goal for the patient with hemorrhoids is soft, formed stools. Proper diet, fluids, and regular exercise improve the likelihood of soft stools. Local heat provides temporary relief to swollen hemorrhoids; sitz bath is the most effective means of heat application. SKILLS FOR GASTROINTESTINAL DISORDERS Flatulence This is the presence of air or gas in the intestinal tract. It may occur when a person consumes gasproducing liquids and foods, such as carbonated beverages, cabbage, or beans; swallows excessive amounts of air; or has constipation. In hospitalized patients, flatulence is often caused by decreased peristalsis, abdominal surgery, some narcotic medications, and decreased physical activity. SKILLS FOR GASTROINTESTINAL DISORDERS Flatulence (continued) May cause distention of the stomach and abdomen and mild to moderate abdominal cramping and pain One of the most effective measures to promote peristalsis and passage of flatus is walking Rectal tube may be used SKILLS FOR GASTROINTESTINAL DISORDERS Constipation Condition characterized by infrequent bowel movements with hard stools that are passed with difficulty Can be the result of; Dehydration Improper diet Medication FECAL IMPACTION Definition Causes symptoms FECAL INCONTINENCE Fecal incontinence is less common than urinary incontinence, but it can be very distressing for patients Usually related to anal sphincter dysfunction caused by anal surgery, trauma during childbirth, Crohn’s disease affecting the anus, or diabetic neuropathy Some experience temporary incontinence with severe diarrhea because they do not have time to reach the toilet Incontinent diarrhea may also be present with fecal impaction Diminished muscle strength with aging also a factor SKILLS FOR GASTROINTESTINAL DISORDERS Fecal Incontinence The first step in care of the patient with fecal incontinence is to assess whether fecal impaction is the cause. An impaction involves the presence of a fecal mass too large or hard to be passed voluntarily. Either constipation or diarrhea can suggest the presence of an impaction. An oil retention enema lubricates the rectum and colon, softens the feces, and facilitates defecation. It can be used alone or with manual removal of a fecal impaction. TYPES OF FECAL INCONTINENCE Neurogenic incontinence Defecation is not voluntarily delayed One or two formed stools occur after meals Medical treatment Scheduled toileting based on usual time of defecation Medications TYPES OF FECAL INCONTINENCE Fecal overflow incontinence Caused by constipation in which the rectum is constantly distended Medical treatment Immediate relief of the constipation and long-term control of the problem Cleanse the colon Regular evacuation TYPES OF FECAL INCONTINENCE Symptomatic incontinence Result of colorectal disease Medical treatment Identify and treat the cause Anorectal incontinence Nerve damage that causes the muscles of the pelvic floor to be weak Medical treatment Pelvic muscle exercises; sometimes biofeedback INTERVENTIONS Enemas Pouches Drug therapy Biofeedback Dietary changes SKILLS FOR GASTROINTESTINAL DISORDERS Ostomies Colostomy A surgical creation of an artificial anus on the abdominal wall formed by incising the colon and bringing it out to form a stoma on the abdominal surface Performed for patients with cancer of the colon, intestinal obstructions, intestinal trauma, or inflammatory diseases of the colon May be permanent or temporary until intestinal healing occurs SKILLS FOR GASTROINTESTINAL DISORDERS Ostomies (continued) Ileostomy A surgical formation of an opening of the ileum onto the surface of the abdomen through which fecal matter is emptied Performed for patients with inflammatory bowel conditions and cancer of the large intestine Stoma looks like a colostomy, but it is smaller and located lower on the abdomen Patient wears a pouch to collect the semiliquid fecal matter Colostomy vs. ileostomy Reason Expected output Urostomy COLOSTOMY IRRIGATION Time consuming Requires special supplies Irrigation amount: 500-700mL of tap water IRRIGATING A COLOSTOMY Ostomy pouches and skin barriers. SKILLS FOR GASTROINTESTINAL DISORDERS Administering an Enema This involves the instillation of a solution into the rectum and sigmoid colon. Primary reason for an enema is promotion of defecation. The volume and type of fluid instilled can lubricate or break up the fecal mass, stretch the rectal wall, and initiate the defecation reflex. Patients should not rely on enemas to maintain bowel regularity because enemas do not treat the cause. Frequent enemas disrupt normal defecation reflexes, resulting in dependency on enemas for elimination. DIAGNOSTIC TESTS AND PROCEDURES Evaluation of fecal incontinence may include Assessment of rectal sphincter tone Laboratory examination of a stool specimen for blood or pathogens Endoscopic or radiologic procedures to detect underlying problems NURSING DIAGNOSIS Constipation Acute pain Impaired Skin Integrity Situational Low SelfEsteem Anxiety Ineffective coping
