Lecture 4 Part 2- Bowel Elimination

‭Small and Large Intestines‬ ‭●‬ ‭Small intestine: 23 ft long‬ ‭●‬ ‭Large intestine/colon: 5 ft long‬ ‭●‬ ‭Duodenum‬ ‭●‬ ‭Jejunum‬ ‭●‬ ‭Ileum‬ ‭‬ ● ‭●‬ ‭●‬ ‭●‬ ‭●‬ ‭ scending colon‬ A ‭Transverse colon‬ ‭Descending colon‬ ‭Sigmoid colon‬ ‭Rectum‬ ‭Large Intestine‬ ‭●‬ ‭Primary organ of bowel elimination‬ ‭●‬ ‭Extends of ileocecal valve to the anus‬ ‭●‬ ‭Functions:‬ ‭○‬ ‭Absorption of water‬ ‭○‬ ‭Formation of feces‬ ‭○‬ ‭Manufacture of some vitamins (vit K)‬ ‭■‬ ‭Low in infants‬ ‭■‬ ‭Bleeding tendencies‬ ‭○‬ ‭Expulsion of feces from the body‬ ‭Process of Peristalsis‬ ‭●‬ ‭Involuntary contraction and relaxation‬ ‭●‬ ‭Peristalsis is under control of the parasympathetic nervous system‬ ‭○‬ ‭Acetylcholine is the major neurotransmitter‬ ‭○‬ ‭Cholinergic: Activates parasympathetic function‬ ‭■‬ ‭Digestion, relaxation, bowel movements, urination‬ ‭○‬ ‭If low → constipation‬ ‭●‬ ‭Contractions occur every 3-12 minutes‬ ‭●‬ ‭Mass peristalsis sweeps occur 1-4 times each 24-hour period‬ ‭●‬ ‭⅓-½ of food waste is excreted in the stool within 24 hours‬ ‭Age Influencing Bowel Elimination‬ ‭●‬ ‭Infants‬ ‭○‬ ‭Breastfed (less odor, golden, more frequent, looser, 2-10 times a day)‬ ‭○‬ ‭Formula (less frequent, 1-2 times a day, more odor, brownish)‬ ‭○‬ ‭All should be soft (hard stool could mean constipation)‬ ‭●‬ ‭Toddlers‬ ‭○‬ ‭Becomes voluntary‬ ‭○‬ ‭Bowel training in 18-24 months‬ ‭○‬ ‭Positive reinforcement; no shaming‬ ‭●‬ ‭Children, adolescents, adults‬ ‭○‬ ‭Defecation patterns vary in quantity and frequency‬ ‭○‬ ‭Find out what is normal for that patient‬ ‭●‬ ‭Older adult‬ ‭○‬ ‭Fecal incontinence, diarrhea, constipation, fecal impaction‬ ‭○‬ ‭Muscles get weaker, slow GI motility‬ ‭Other Variables Influencing Bowel Elimination‬ ‭●‬ ‭Food: Fiber and fluid‬ ‭●‬ ‭Activity and muscle tone: Higher activity lessens constipation‬ ‭●‬ ‭Lifestyle, psychological variables‬ ‭●‬ ‭Pathologic conditions‬ ‭●‬ ‭Medications: Effects vary by medication‬ ‭●‬ ‭Diagnostic studies: Limits food intake by having NPO‬ ‭●‬ ‭Surgery and anesthesia: Slows peristalsis or can stop it, constipation‬ ‭Question:‬‭Which of the following is recommended for‬‭a constipated older adult?‬ ‭a.‬ ‭Cheese‬ ‭b.‬ ‭Fruit‬ ‭c.‬ ‭Cabbage‬ ‭d.‬ ‭Eggs‬ ‭Foods‬ ‭●‬ ‭Constipating foods: Processed cheese, lean meat, eggs, pasta, rice, white bread, iron,‬ ‭calcium supplements‬ ‭●‬ ‭Food with laxative effects: Certain fruits and vegetables (eg. prunes), whole grains, bran,‬ ‭dried peas, beans, chocolate, spicy foods, alcohol, coffee‬ ‭●‬ ‭Gas-producing foods: Onions, cabbage, beans, cauliflower‬ ‭Effect of Medications on Stools‬ ‭●‬ ‭Aspirin and anticoagulants: Pink, red, or black stool‬ ‭●‬ ‭Iron: Black stool‬ ‭●‬ ‭Antacids: White discoloration or speckling in stool‬ ‭●‬ ‭Antibiotics: Green-gray color‬ ‭●‬ ‭Barium: White or gray color‬ ‭ uestion:‬‭A 6-month-old infant has severe diarrhea. The major problem associated with severe‬ Q ‭diarrhea is…‬ ‭a.‬ ‭Pain in the abdominal area‬ ‭b.‬ ‭Irritation of perineal and rectal area‬ ‭c.‬ ‭Electrolyte and fluid loss‬ ‭d.‬ ‭Presence of excessive flatus‬ ‭Promoting Regular Bowel Habits‬ ‭●‬ ‭Timing: 1 hour post-meal‬ ‭●‬ ‭Positioning: Use gravity, knees above hips‬ ‭●‬ ‭Privacy: Including guests‬ ‭●‬ ‭Nutrition: Dietary analysis, high fiber, fluids‬ ‭●‬ ‭Exercise: Abdominal settings (palpation), thigh strengthening (isometric)‬ ‭Related Factors of Constipation‬ ‭●‬ ‭Decreased fiber intake‬ ‭○‬ ‭25-38 g increases bulk in fecal material‬ ‭○‬ ‭Bulkier feces increases pressure on intestinal wall → more‬ ‭feces motility‬ ‭●‬ ‭Decreased fluid intake‬ ‭○‬ ‭At least 2,000-3,000 mL to facilitate elimination‬ ‭●‬ ‭Abuse of laxatives‬ ‭○‬ ‭Can lead to chronic constipation‬ ‭○‬ ‭Indicative of an eating disorder‬ ‭●‬ ‭Inactivity‬ ‭○‬ ‭Most common in patients on prolonged bed rest and with decreased mobility‬ ‭○‬ ‭Allows stool to pass easily‬ ‭●‬ ‭Delaying defecation when urge is present‬ ‭○‬ ‭Water will continue to get absorbed from the retained feces, making it dry‬ ‭●‬ ‭Use of constipating medications (ex. Antacids, opioids, anticholinergics)‬ ‭○‬ ‭Increased reabsorption of fluid‬ ‭○‬ ‭Aluminum-based antacid → constipation‬ ‭○‬ ‭Magnesium-based antacid → diarrhea‬ ‭●‬ ‭Changes in routine‬ ‭○‬ ‭Encourage patients to use the bathroom at their usual time‬ ‭●‬ ‭Pain associated with defecation (eg. hemorrhoids)‬ ‭Individuals at High Risk for Constipation‬ ‭●‬ ‭Patients on bedrest taking constipating medicines‬ ‭●‬ ‭●‬ ‭●‬ ‭●‬ ‭○‬ O ‭ pioids (enteric neurons), antacids with Al, Fe-SO‬‭4‬ ‭(iron pulls water from the‬ ‭stool), anticholinergics (block acetylcholine)‬ ‭Patients with reduced fluids or bulk in their diet‬ ‭○‬ ‭Without bulk/fiber less water absorption into stool‬ ‭Patients who are depressed/stressed‬ ‭○‬ ‭Decreased serotonin (stimulates the sympathetic NS) linked to slowed GI tract‬ ‭Patients with CNS disease (decreased bowel stimulation) or local lesions that cause pain‬ ‭(nerve damage)‬ ‭Older patients; patients undergoing surgery (anesthesia → stasis)‬ ‭Terms‬ ‭Hemi‬ ‭Para‬ ‭Quadri/Tetra‬ ‭Paresis‬ ‭Hemiparesis‬ ‭Paraparesis‬ ‭Quadriparesis‬ ‭Paralysis‬ ‭Hemiplegia‬ ‭Paraplegia‬ ‭Quadriplegia‬ ‭Digital Removal of Fecal Impaction (DRF)‬ ‭●‬ ‭Condition in which stool is too hard to pass‬ ‭●‬ ‭Check vital signs to monitor vagus nerve activation‬ ‭○‬ ‭Decreased heart rate‬ ‭●‬ ‭Especially occurs in people with paresis‬ ‭●‬ ‭Rectal bleeding, hemorrhoids, infection, fissure, rectal perforation‬ ‭○‬ ‭Fissure: Small tear of mucous membrane‬ ‭○‬ ‭Perforation: Puncture‬ ‭Related Factors for Diarrhea‬ ‭●‬ ‭Food intolerance (coarse, greasy, or spicy foods): Lack digestive enzymes‬ ‭●‬ ‭Food or drug allergies: Triggers antibodies leading to diarrhea‬ ‭●‬ ‭Abuse of laxatives: Increased motility, irritation, and drawn in water‬ ‭●‬ ‭Alteration in normal bacterial flora of the intestine (antibiotic therapy):‬ ‭Antibiotics may lead to an overgrowth of microorganisms inducing diarrhea‬ ‭●‬ ‭Emotional stress: Anxiety and stress release hormones/neurotransmitters‬ ‭●‬ ‭Intestinal infection: Inflammation in the stomach/intestines‬ ‭●‬ ‭Colon disease: Inflammation of lining impairs fluid absorption‬ ‭●‬ ‭Surgical alterations: Dumping syndrome‬ ‭○‬ ‭Rapid gastric emptying‬ ‭Related Factors for Bowel Incontinence‬ ‭●‬ ‭Gross constipation with impaction and subsequent overflow‬ ‭○‬ ‭Hardened stool becomes stuck, leading to pressure‬ ‭‬ ● ‭●‬ ‭●‬ ‭●‬ ‭ rganic changes in neural innervation of the rectum‬ O ‭Extreme debiiltation: Physical impairment‬ ‭Cognitive impairments: Alzheimers, dementia, depression‬ ‭Incontinence-associated dermatitis (IAD): Skin condition; prolonged contact with feces‬ ‭Fecal Incontinence‬ ‭●‬ ‭Rectal indwelling catheter‬ ‭●‬ ‭Fecal incontinence‬ ‭Collecting a Stool Sample‬ ‭●‬ ‭Void first so sample does not contain urine; can cause inaccurate results‬ ‭●‬ ‭Defecate into bedside commode or bedpan; toilet water can affect results‬ ‭●‬ ‭Do not place toilet paper or wipes into container‬ ‭●‬ ‭Use medical aseptic technique, gloves, and perform hygiene before and after‬ ‭●‬ ‭Be careful not to contaminate the exterior of the container with stool (biohazard)‬ ‭●‬ ‭Avoid contact with soaps and detergents; contamination‬ ‭●‬ ‭Notify the nurse and package/label the sample for transport‬ ‭Fecal Occult Blood Test (Guaiac Test)‬ ‭●‬ ‭When internal bleeding is suspected‬ ‭●‬ ‭Test for blood in the stool‬ ‭●‬ ‭When the Guaiac paper strip detects hemoglobin, it turns from green to blue‬ ‭Types of Direct Visualization Studies‬ ‭●‬ ‭Esophago-gastro-duodenoscopy (EGD): Insertion of small microscope through mouth‬ ‭●‬ ‭Colonoscopy: Microscope inserted through anus to colon‬ ‭●‬ ‭Sigmoidoscopy: Microscope inserted through anus to sigmoid (left side of colon)‬ ‭ uestion:‬‭Which of the following direct visualization‬‭tests uses a long, flexible,‬ Q ‭fiber-optic-lighted scope to visualize the rectum, colon, and distal small bowel?‬ ‭a.‬ ‭Esophago-gastro-duodenoscopy‬ ‭b.‬ ‭Colonoscopy‬ ‭c.‬ ‭Sigmoidoscopy‬ ‭d.‬ ‭UGI series‬ ‭Indirect Visualization Studies‬ ‭●‬ ‭Fluroscopic exam: Video-like x-ray, allowing visualization of movement‬ ‭○‬ ‭Use contrast (barium); enough fluid consumed after to flush out‬ ‭●‬ ‭Upper gastrointestinal (UGI) and small bowel series‬ ‭○‬ ‭Barium enema to administer within colon‬ ‭ ‬ ‭Patient rolls side to side and stands to distribute barium throughout colon‬ ○ ‭○‬ ‭Expels as much through defecation as possible; check for residue in x-ray‬ ‭ ‬ ‭Abdominal ultrasound‬ ● ‭●‬ ‭Magnetic resonance imaging (MRI)‬ ‭●‬ ‭Abdominal CT scan‬ ‭Methods of Emptying the Colon of Feces‬ ‭●‬ ‭Cathartics and laxatives‬ ‭●‬ ‭Rectal suppositories: Solid preparation of medication inserted through rectum‬ ‭●‬ ‭Enemas‬ ‭●‬ ‭Oral intestinal lavage (Colyte)‬ ‭○‬ ‭A gallon of fluid including electrolytes, may be taken before colonoscopy‬ ‭●‬ ‭Digital removal of stool (fecal impaction)‬ ‭Types of Laxatives‬ ‭●‬ ‭Bulk-forming: Metamucil‬ ‭○‬ ‭Has natural fibers to increase weight and consistency of stool‬ ‭●‬ ‭Emollient (stool softener): Colace‬ ‭○‬ ‭Causes stool to absorb water and soften‬ ‭●‬ ‭Lubriant: Mineral oil‬ ‭○‬ ‭Lubricates bowel and mucous membrane‬ ‭●‬ ‭Stimulant: Ducolax‬ ‭○‬ ‭Stimulates nerve endings of bowel wall‬ ‭●‬ ‭Osmotic: Glycerin suppositories, lactulose, milk of magnesium (MOM)‬ ‭○‬ ‭The bowel itself absorbs water through osmosis‬ ‭Types of Enemas‬ ‭●‬ ‭Cleansing: To empty bowels‬ ‭○‬ ‭Pre-operative procedure‬ ‭○‬ ‭Tap water, soap solution, normal saline solution, hypertonic solution (~150 mL)‬ ‭○‬ ‭How much: 500-1000 mL‬ ‭○‬ ‭Position: Sim’s (left)‬ ‭■‬ ‭To reach sigmoid colon‬ ‭○‬ ‭Direction of catheterization: Umbilicus‬ ‭○‬ ‭How long to insert: 3-4 inches‬ ‭○‬ ‭How long to hold: 5-10 minutes‬ ‭●‬ ‭Retention: Has therapeutic purposes; meant to remove‬ ‭Retention Enemas‬ ‭●‬ ‭Oil-retention enema: Lubricate the stool and intestinal mucosa easing defecation‬ ‭‬ C ● ‭ arminative enema: Help expel flatus from rectum‬ ‭●‬ ‭Medicated enema: provides medications absorbed through rectal mucosa‬ ‭○‬ ‭Ex. Kayexalate (sodium polystyrene sulfonate): Expel high levels of potassium‬ ‭●‬ ‭Anthelmintic enema: Destroy intestinal parasites‬ ‭Question:‬‭Which one of the following would be used‬‭for a patient with intestinal parasites?‬ ‭a.‬ ‭Oil-retention enema‬ ‭b.‬ ‭Carminative enema‬ ‭c.‬ ‭Medicated enema‬ ‭d.‬ ‭Athelmintic enema‬ ‭Ileus‬ ‭●‬ P ‭ ainful obstruction of the ileum‬ ‭●‬ ‭Lack of peristalsis‬ ‭●‬ ‭Adhesions, hernias, tumors, impacted stool‬ ‭○‬ ‭Adhesions:‬ ‭○‬ ‭Hernias: Part is coming out of wall‬ ‭○‬ ‭Tumors, impacted stool‬ ‭●‬ ‭Symptoms: No bowel sound, pain, bloating, constipation‬ ‭●‬ ‭Can lead to conditions like ischemia‬ ‭●‬ ‭Treatment: NPO, NG tube, surgery‬ ‭Paralytic Ileus‬ ‭●‬ ‭Pseudo-obstruction‬ ‭●‬ ‭Abdominal surgery, decreased blood supply‬ ‭●‬ ‭May be felt due to anesthesia‬ ‭●‬ ‭Symptoms: No bowel sound, pain, bloating, constipation‬ ‭●‬ ‭Treatment: NPO, NG tube, ambulation, chewing gum‬ ‭Types of Colostomies‬ ‭●‬ ‭Stoma: Artificial opening in the body‬ ‭●‬ ‭Ostomy: Procedure to create a stoma‬ ‭●‬ ‭Sigmoid colostomy‬ ‭●‬ ‭Descending colostomy‬ ‭●‬ ‭Transverse colostomy‬ ‭●‬ ‭Ascending colostomy‬ ‭●‬ ‭Ileostomy‬ ‭Stoma Appearance‬ ‭●‬ ‭Should be moist, red,‬ ‭●‬ ‭Affected by anemia…‬ ‭Colostomy Care‬ ‭●‬ ‭Encourage the patient to look at/care for ostomy‬ ‭○‬ ‭Inspect regularly‬ ‭○‬ ‭Note size; should stabilize in 6-8 weeks‬ ‭○‬ ‭Maintain cleanm dry skin around the stoma‬ ‭●‬ ‭Educate patient on odor control and fluid intake:‬ ‭○‬ ‭Diet: Avoid beans, eggs, and fish; add‬ ‭apples, parsley, and citrus‬ ‭○‬ ‭Drink enough water‬ ‭○‬ ‭Empty ostomy bag regularly‬ ‭○‬ ‭Odor eliminators‬ ‭○‬ ‭Record intake and output every 4 hours for 3 days after surgery‬ ‭●‬ ‭Encourage your patient to carry out their normal activities unless contraindicated‬