Transcript Chapter 30
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Chapter 30
Bowel Elimination and Care
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Gastrointestinal (GI) Tract
Mouth
Anus
Waste products—feces or stool
Process of bowel elimination—defecation
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Peristalsis
Consists of rhythmic wavelike movements
beginning in the esophagus and continuing to
the rectum
Involves contraction of the circular and
longitudinal muscles in the walls of the GI
tract
Propels the bolus of food through the GI tract
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Process of Digestion, Absorption,
and Metabolism of Nutrients
Bowel elimination occurs after nutrients are moved
through the GI tract
In the stomach, enzymes break down the bolus of
food, converting it to chyme
The chyme passes through the pyloric sphincter and
into the small intestine, where the nutrients are
absorbed
The remaining chyme passes through the illeocecal
valve into the large intestine to be passed as stool
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Changes Through Life Cycle
Infants—three to six bowel movements
(BM)/day
Children—one to two/day
Elderly—peristalsis slows—more prone to
constipation or hard stools that are difficult to
pass
At least every three days
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Timing of Elimination
Introduction of food stimulates peristalsis
Urge to defecate
30 minutes to 1 hour after eating
If ignore feeling
More water absorbed from stool—dry and hard
Resulting in constipation
Toileting after meals
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Characteristics of Feces
Color, shape, consistency, odor, and frequency
Diet, amount of fiber and fluids, exercise,
medications, and other habits
Disease process can change characteristics
Assessment is important
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Normal
Soft, formed, light yellowish-brown to dark
brown, and slightly odiferous and slightly
curved shape
Color—vary by dietary intake
Spinach—greenish-black streaks
Beets—red
Iron—very dark brown or black
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Abnormal Characteristics
Small balls or clumps
Inadequate fluid intake
Transit time is prolonged
Liquid or semiliquid
Transit time is extremely short
Diarrhea
Three or more liquid or watery stools/day
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Fundamentals of Nursing Care: Concepts, Connections, & Skills
Abnormal Characteristics
Other factors affecting consistency or shape
Amount of fiber intake
Bulk up
Increase in amount of ingested fat
Steatorrhea—high amount of undigested fat in stool
Fluffy, float on water and foul odor
Malabsorbption disorder—Crohn’s disease
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Abnormal Characteristics
Ribbon shaped stool
Compression of the colon
Tumor
Mucus, blood or pus in stool
Inflammation
Infection
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Abnormal Characteristics
Examples
Ulcerative colitis
Slimy or mucus coated stool
Traces of blood or pus
Parasites, worms or eggs
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Fundamentals of Nursing Care: Concepts, Connections, & Skills
Abnormal Characteristics
Clay colored or pale white stools
Absence of bile in intestines
Antacids or x-ray barium
Bright red blood visible to naked eye
Frank blood
Blood in stool not visible naked eye
Occult blood
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Fundamentals of Nursing Care: Concepts, Connections, & Skills
Abnormal Characteristics
Blood in stool
Specks or traces of bright red blood
Torn hemorrhoid
Large amounts of frank blood
Bleeding or hemorrhage from the colon
Blood from higher in digestive tract—stomach
Partially digested, old blood odor, black, tarry
appearance--melena
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Abnormal Characteristics
Bleeding from small intestine
Maroon-colored
Large hemorrhage from stomach or intestines
Large volume of bright red or frank blood
All bleeding serious until proven otherwise
Report to physician
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Alterations in Bowel Elimination
Constipation
Diarrhea
Fecal Impaction
Fecal Incontinence
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Fundamentals of Nursing Care: Concepts, Connections, & Skills
Constipation
Less frequent, hard, formed stools
Difficult to expel
Degrees of severity—no complaints to…….
Bloated feeling
Malaise
Cramping
Anorexia
Not feeling well
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Constipation
Important to know when was last bowel
movement (BM)
Elderly at increased risk
But with proper nursing care
Should be minimal
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Diarrhea
Loose or watery stools occurring three or
more times/day
May or may not have cramping or tenesmus
(increased rectal pressure—feeling of need to
defecate)
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Fundamentals of Nursing Care: Concepts, Connections, & Skills
Problems Associated with Diarrhea
Perianal skin excoriation
Dehydration
Electrolyte imbalance
Most at risk
Elderly and very young
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation / Diarrhea
Change in activity level
Change in dietary intake
Change in water source
Change in fluid volume intake
Side effects of medication
Side effects of surgery
Pregnancy
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Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation / Diarrhea
High stress levels and emotional
problems
Laxative abuse
Aging process
Structural changes
Chemical changes
Food allergies
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation/Diarrhea
Changes in activity level
Physical activity stimulates peristalsis
Hospitalized—decreased activity
Slower peristalsis
Increased risk of constipation
Carefully track and document patient’s BM’s
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation/Diarrhea
Changes in dietary and fluid intake
Foods that slow peristalsis
Processed sugar products
Low fiber foods
Decreases stool mass and peristalsis
Increasing risk for constipation
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation/Diarrhea
Changes in dietary and fluid intake
Fiber is good—25 to 35 g/day
Whole grains, fruits, vegetables
GRADUALLY increase
Too much fiber
Excessive flatus
Can actually constipate if not enough fluid intake
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Foods High in Fiber
Fruit—especially raw
Apples (unpeeled), blueberries, cherries, oranges,
pears (unpeeled), plums, prunes, raisins,
raspberries and strawberries
Vegetables—especially raw
Artichokes, beans, broccoli, cabbage, carrots,
cauliflower, corn and legumes
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Foods High in Fiber
Whole-grain breads, cereals and flour
Dried fruits
Flaxseed
Nuts
Oatmeal
Popcorn
Sunflower seeds
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes in Constipation/Diarrhea
Eating at irregular intervals = irregularity of
BM’s
Three meals/day at regular intervals
More regular patterns with BM’s
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation/Diarrhea
Lactose intolerance
Inability to digest dairy products
can cause diarrhea when dairy products
consumed
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation/Diarrhea
Fluid Intake
Not enough fluid intake
Harder stool
Body absorbs the fluid to maintain fluid and
electrolyte balance
Result—not enough fluid in colon to keep stool
soft
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation/Diarrhea
Side effects of medication
Over the counter
Maalox—may cause diarrhea
Tums—may cause constipation
Iron supplement
Constipation
Usually prescribed stool softener
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation/Diarrhea
Narcotic pain medication
Slows intestinal peristalsis
Increased risk of constipation
Antibiotics
Kill good bacteria—normal flora
Opportunistic infections can develop
Result—diarrhea
Example--_____________________
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation/Diarrhea
Side effects of surgery
Anesthesia
Slow or completely stop peristalsis
GI surgery
Handling of bowel—slows peristalsis
Post-op pain
Pain medicine
Decreased activity
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation/Diarrhea
Pregnancy
↓ stimulation of muscles in digestive tract
Crowding of sigmoid colon
Result—constipation
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation/Diarrhea
High stress and emotional problems
Stress
↑ peristalsis and mucus production—diarrhea
Emotional problems
Depression
↓ peristalsis--constipation
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation/Diarrhea
Laxative abuse
Laxative use to promote daily BM’s
Physically and/or psychologically dependent
Bowel loses muscle tone and natural
contractibility
BM is then dependent on laxative
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation/Diarrhea
Structural changes
Diverticulosis—wall of colon weakens and form
pouches (diverticulum)
Not completely understood but high pressure
exerted on intestinal walls
High fiber diet—stool bulky and easily moves
through colon
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation/Diarrhea
Diet low in fiber—colon exerts more pressure
moving small, hard stool
Low fiber—stool remains in bowel longer which
adds to the pressure
Most people with diverticulosis do not have
symptoms
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation/Diarrhea
Pouches can trap fecal matter
Pouch becomes inflamed
Diverticulitis
Diarrhea and severe cramping
If not treated—diverticuli can rupture
Fecal matter spills into abdominal cavity
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation/Diarrhea
Peritonitis
Life-threatening infection
s/s—malaise, anorexia, nausea, vomiting,
abdominal distention, ↓ or absent bowel sounds
and fever (or hypothermia if more advanced)
Abdominal pain may be mild or severe—classic
sign of peritonitis—constant intense pain that
worsens with movement
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation/Diarrhea
Nerves of sigmoid colon, rectum and anal
sphincters—sense the presence of stool in the
rectum and need to defecate
Nerves damaged or severed
Unable to sense need to defecate
No control over sphincters to retain or expel stool
Result– constipation, impaction and/or
incontinence
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation/Diarrhea
Chemical changes
Inflammatory processes
Autoimmune disorders
Bacteria or viruses (gastroenteritis)
Inflammation causes edema and ↑ mucus
production
Inhibits absorption and ↑ peristalsis
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation/Diarrhea
Result
Nausea
Vomiting
Cramping
Diarrhea
Dehydration
Malnutrition
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation/Diarrhea
Allergies
Food
Environmental
Can cause edema and inflammation
↑ peristalsis—diarrhea
Inhibit absorption
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Fecal Impaction
The blockage of the movement of contents
through the intestines by a bulk mass of very
hard stool
May occur in the rectum, sigmoid flexure or
any part of the large colon
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Fecal Impaction
Elderly, inactive patient’s, severely dehydrated
Common cause—abuse of laxatives
Possible indication—liquid stool
Differentiate between diarrhea and impaction
Complication—obstruction or perforation of
bowel
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Fecal Incontinence
Voluntary control is lost
Beyond patient’s control
Spinal cord injury
Disoriented patient’s
Source of guilt, embarrassment, and
destruction of self-esteem
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Fecal Incontinence
What can be done?
Bowel training
Proper cleansing and barrier creams
Fecal incontinence pouch
Maintain patient’s dignity—never refer to as
diapers
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Nursing Responsibilities
Assessment of BM and documentation
Color
Amount
Consistency
Unusual shape
Unusual odor
Know date of last bowel movement
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Nursing Interventions to Promote
Bowel Function
Increase physical activity
Ensure adequate fluid: up to 2,500 mL/day
Increase fiber intake to 20 to 30 g/day (gradually!!)
Provide privacy
Position patient upright for elimination
Provide stimulants that “cue” bowel function at
home, such as a cup of hot coffee before breakfast
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Subjective Assessment
On admission to hospital
Subjective information of patient’s normal
bowel habits
Any current problems with BM’s
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Objective Assessment
Physical assessment
Shape of abdomen
Normal—rounded or flat
Abnormal—distended or inflated
Distention—excessive gas, fluid, or stool
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Objective Assessment
Auscultate bowel sounds
Diaphragm portion of stethoscope
Listen in all four quadrants
Once per shift or more often if indicated
Soft gurgles or irregular clicks
Between 5 and 30/minute
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Objective Assessment
Bowel sounds
<5/minute—hypoactive bowel sounds
>30/minute or continuous—hyperactive bowel
sounds
May indicate obstruction—high pitched, tinkling
sounds in one area and absent or decreased
sounds in the distal portion
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Bowel Sounds
http://www.youtube.com/watch?v=kmLqONG248
http://www.practicalclinicalskills.com/abdomi
nal-lessonauscultation.aspx?coursecaseorder=6&coursei
d=120
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Objective Assessment
An absence of bowel sounds indicates a
problem and should always be reported to the
physician
To determine absent bowel sounds—listen 3
to 5 minutes in each quadrant
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Objective Assessment
Assessment of abdomen
Inspection
Auscultation
Palpation
Palpation
Normal—soft
Abnormal—firm or hard—excessive gas,
constipation, or obstruction
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Management
Universal precautions
Possibility of contact with feces
Incontinent patient
Emptying bedpan or bedside commode
Removing an impaction
Collecting stool specimen
Administering enema
Providing colostomy care
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Management
Altering dietary intake related to diarrhea
Clear liquid diet first 24 hours
Decaffeinated green or black teas or herbal teainflammation, slow peristalsis
Sports drinks—replace electrolytes
Avoid extremely hot or cold liquids first 24 hours
Longer than 24 to 36 °--full liquids and cooked
fruits or vegetables
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Management
Diarrhea due to loss of normal flora—yogurt
Concurrent use with antibiotics—prevent the
loss of normal flora
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Management
Medications
Coat the mucous membranes of the bowel
Inhibit peristalsis
Treat the disease or infectious process
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Management
Lactobacillus acidophilus
Supplement
Replace normal flora
Medications for constipation
Increase peristalsis
Soften stool
Add bulk to stool
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Management
Enema
Instillation of solution into the colon via the
rectum
Temperature—between 105 to 110° F—to avoid
burning intestinal mucosa
Test—should feel warm, NOT HOT
Too cool—cause cramping—decrease retention
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Management
Position*
Left lateral side-lying or Sims’
Insert tip of tubing 3 to 4 inches (adult)
Rectum, sigmoid colon, and descending colon
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Management
Cleansing enema
Relief of constipation
Empty and cleanse the bowel prior to surgery or
testing
Large volume enema—500 to 1,000 ml
Small volume enema--<250 ml, usually 90 to 120
ml
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Management
Order—enemas til clear
Enemas administered until the expelled solution
no longer contains feces and is relatively clear
Within a LIMIT of three 1,000 ml enemas
Avoid giving more than 3 large volume enemas
consecutively
Cause fatigue and irritation of intestinal lining
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Management
Types of solutions
Tap water
Normal saline
Soapsuds
Commercially prepackaged small volume oil or
sodium phosphate solutions
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Management
Soapsuds
Castile soap—5 ml/1,000m of solution—no
substitutes—other soaps too harsh—damage
intestinal lining
Distends intestine and irritates the walls of
intestines to further stimulate peristalsis
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Management
Tap water
Hypotonic!—body absorbs—fluid overload
High risk individuals?
Infants, children, pt. with CHF, fluid retention
Normal Saline
Isotonic
Safe for high risk individuals
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Management
Hypertonic
May be used in small volumes for adults
Fleet’s enema
Not used in large volume enemas—increased risk
of fluid and electrolyte imbalances
Milk and molasses enema—hypertonic—
persistent constipation or impaction removal—
follow agency policy
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Management
Oil retention
Soften hard stool of an impaction to ease removal
Small volume—90 to 120 ml
Allow time to soften stool—approx. one hour
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Management
Medicating enema
Steroid—decrease inflammation
Kayexalate enema—to lower a very high
potassium level
Must retain in bowel—solution pulls K+ from
bloodstream into solution to be expelled
Follow agency policy
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Management
Return flow enemas
Aka Harris flush
Remove flatus or gas
Tap water or saline
Small volume—100 to 200 ml
Then lower container below level of rectum—fluid
and gas returned—bubbles—continue til no
bubbles—Follow agency policy
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Management
If a high enema is ordered
Start with patient on left side—instill half of
solution—supine—then right lateral side for rest
of solution
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Enema
Check order
Contraindications?
Activity and cognitive level of patient
(preparation)
GI assessment
Gather supplies
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Enema
Close clamp
Fill container
Castile soap (5 ml/1000 ml)
Prime tubing
Lubricate tubing
Insert 3 to 4 inches toward umbilicus
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Enema
Patient’s hip level—open clamp
Gradually elevate container
Instill slowly
Too fast—unable to hold, cramping,
discomfort
C/O cramping—clamp, breathing, wait
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Enema
Monitor for s/s vagal stimulation
When completed—clamp—remove tubing
Cover end of tubing
Instruct patient to hold solution at least 15 to
20 minutes
Document results ……
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Digital Removal of Impaction
Can be embarrassing and painful
Oil retention enema or pain med
Prior to procedure
Delegate? Need an order?
Review patient history—contraindications?
Monitor for s/s of vagus nerve stimulation
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Digital Removal of Impaction
Privacy
Proper position and safety
Underpad
Receptacle
Gloves
Lubricant
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Digital Removal of Impaction
GENTLY insert finger
Place finger between outside of the fecal and
mass the intestinal wall
Bend finger inward toward fecal mass
Break up mass—gently
Remove small pieces
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Digital Removal of Impaction
Monitor patient throughout procedure
Clean patient and supplies
Document
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Contraindications
Rectal surgery
Severe bleeding hemorrhoids
Ulcerative colitis or Crohn’s disease
Rectal fissure or rectal cancer
Excessive bleeding potential due to disease or
medication
Certain heart conditions
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Complications
Two serious complications
Vagal response
Perforation of intestinal wall
Vagus nerve
Innervates heart, bronchioles, as well as the
gastrointestinal (GI) tract
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Complications
Insertion of the enema tube or a finger for
impaction removal can stimulate the vagus
nerve
When stimulated—can drop the heart rate to
30 to 40 bpm and cause constriction of the
bronchioles of the lungs
If continues longer than a few minutes—
inadequate blood pressure and circulation
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Complications
S/S of vagus nerve stimulation
Chest pain or chest heaviness or pressure
Shortness of breath or inability to breathe
Dizziness
Feel like fainting
Nausea
Pallor
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Complications
S/S of vagus nerve stimulation
Clammy skin
Pulse rate <60 bpm
STOP enema or removal of impaction
Remove the tube or finger from the rectum
Position supine
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Complications
Assess pulse rate, skin color, and is patient
diaphoretic?
Call for assistance—do not leave patient
If pulse <60—place in shock position—head
lower than feet
Assess blood pressure
Supply oxygen if needed
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Complications
Perforation of colon
GENTLY insert tubing
Never force
Do not insert further than 4 to 6 inches
Direct tip of tubing toward umbilicus—follows
natural direction of colon
Proper positioning
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Laboratory Tests to Determine the
Cause of Bowel Alterations
Guaiac test (occult blood test)
Tests for presence of blood in the stool
Culture and sensitivity (C&S)
Identifies microorganisms infecting the stool and
the antibiotics that will kill the microorganisms
Ova and parasite test (O&P)
Tests for presence of parasitic worms and their
eggs
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Collection
Clean and dry bedpan or collection container
Can not mix specimen with urine
Wear gloves
Clean tongue blade
Collect from 2 different areas of stool—
especially an abnormal appearing areas
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Collection
If incontinent collect from depends
Properly identify specimen
Properly package
Specimen sent to lab upon collection
Document type of specimen collected,
characteristics, date and time of collection and
sent to lab
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Important Read…….
Skill 30-1, pg. 698-699
Skill 30-2, pg. 700
Skill 30-3, pg. 701
Skill 30-4, pg. 702
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
True/False Question
The nurse administering an enema to a
patient knows that the tip of the tubing
should be inserted into the rectum while the
patient is in a sitting position, as on the toilet.
A. True
B. False
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Answer
B. False
Rationale: The nurse should never attempt insertion
of the tip of the tubing into the patient’s rectum
while the patient is in a sitting position. The angle of
the natural curve of the rectum and sigmoid colon
changes when sitting. This can cause the tip of the
tubing to scrape the intestinal wall, possibly
damaging the mucosal lining, and increases risk of
perforating the intestinal wall.
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Multiple Choice Question
A nurse is ordered to administer an enema to
a patient to soften an impacted stool. Which
type of enema would typically be used?
A. Cleansing enema
B. Oil retention enema
C. Medicating enema
D. Return flow enema
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Answer
B. Oil retention enema
Rationale: Oil retention enemas are
administered to soften the hard stool of an
impaction so that it can be removed more
easily and with less discomfort for the patient.
Copyright © 2011 F.A. Davis