Transcript Textbook For Nursing Assistants

Textbook For Nursing
Assistants
Chapter 20 – Assisting with
Urinary and Bowel
Elimination
Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing
Assistants.
Slide 1
Assisting with Elimination
Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing
Assistants.
Slide 2
Assisting with Elimination
Some patients or residents may only need
a steady arm to lean on during their trip to
the bathroom; others will need more help
The bathrooms in many health care
facilities have special features that make
them easier for people with physical
disabilities to use
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Slide 3
Assisting with Elimination
Modifications allow
many patients or
residents to use the
toilet in the
bathroom with very
little assistance
from a nursing
assistant
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Slide 4
Assisting with Elimination - Elimination
Equipment
Some patients or residents may not be
able to get out of bed at all, or they may be
too weak or ill to walk to the bathroom.
These people may need to use:
Bedside commodes
Bedpans
Urinals
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Slide 5
Elimination Equipment - Bedside Commodes
The bedside commode
consists of a chair frame with
a toilet seat and a removable
collection bucket
For a person who is able to get out of bed,
but who is not able to walk to the
bathroom, a bedside commode can make
toileting easier
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Slide 6
Elimination Equipment - Bedpans
A bedpan is used for elimination when a
person is unable to get out of bed at all
A woman who cannot get out of bed uses
a bedpan to urinate, and for bowel
movements. A man who cannot get out of
bed uses a bedpan for bowel movements,
and a urinal to urinate.
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Slide 7
Elimination Equipment - Fracture
Pans
Arthritis can make using a bedpan very
painful, as can fractures of the back or
legs
In such cases, when using a bedpan is
uncomfortable or dangerous, a special
bedpan called a fracture pan is used
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Slide 8
Elimination Equipment - Fracture
Pans
The fracture pan,
which is wedgeshaped, is placed
underneath the
person’s buttocks
with the thin edge
toward the person’s
back
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Slide 9
Fracture Pans and Bedpans - Useful
Tips
Warm a metal bedpan before offering it to
the patient or resident by wrapping the
bedpan in a warm towel, or running warm
water over the seat area and then drying it
before use
Provide as much privacy as safely
possible
Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing
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Slide 10
Fracture Pans and Bedpans - Useful
Tips
If the person’s
condition allows,
raise the head of
the bed to promote
a more natural
elimination position
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Slide 11
Elimination Equipment - Urinals
A man uses a urinal to
urinate when he
cannot get out of bed
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Slide 12
Elimination Equipment - Urinals
To urinate, the man puts his penis in the
opening of the urinal
If the man is very weak or disabled, you
may need to place his penis inside the
opening of the urinal for him
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Slide 13
Difficulty with Normal Elimination
A patient or a resident may have difficulty
with elimination, if elimination occurs
under conditions that are not as private as
the person would like.
In a health care facility, people may share
a bathroom or use a bedpan while only
being separated from other people in the
room by a curtain
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Slide 14
Difficulty with Normal Elimination
Feelings of embarrassment and shame
are made worse when patients or
residents accidentally soil themselves,
their bed linens, or their clothing with urine
or feces. This might be due to:
The effects of medications
Being in a strange place
Reluctance to ask for help
Physical or mental disabilities
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Slide 15
Promoting Normal Elimination
Kindness, empathy, and a professional
attitude can go a long way toward easing
the patient’s or resident’s embarrassment
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Slide 16
Promoting Normal Elimination
Being in a health care facility can change
a person’s normal elimination patterns,
which can cause health problems
The most effective method of treating
urinary and bowel problems is to prevent
them from happening in the first place
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Slide 17
Promoting Normal Elimination
Encourage plenty of fluids, unless the doctor has
ordered against it
Answer call lights promptly
Encourage the person to call when he first feels the
urge to void
Offer people the chance to eliminate frequently
Provide for privacy and comfort
The sound of running water may help some people to
urinate
If a person is having difficulty moving his bowels, do
not rush the person
Regular exercise and foods containing insoluble fiber
help promote regular bowel movements
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Slide 18
Obtaining Urine and Stool Specimens
The contents of a person’s urine or feces
can provide a doctor with clues about the
person’s overall health status
A nursing assistant may be asked to
obtain a urine or stool specimen (sample)
for laboratory study
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Slide 19
Obtaining Urine and Stool Specimens
Before collecting any specimen—of urine, feces,
or any other body fluid—ask yourself the
following questions:
Do I have the right person?
Do I have the right laboratory requisition slip?
What method is to be used to collect the specimen?
Do I have the right type of specimen cup?
Is the specimen cup properly labeled?
What is the correct date and time?
What storage and delivery method must I use?
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Slide 20
Obtaining Urine and Stool Specimens
Always remember to wear gloves when
assisting with specimen collection and
when handling the specimen cups
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Slide 21
Obtaining Urine and Stool Specimens - Urinalysis
Urinalysis, or examination of the urine under a
microscope and by chemical means, is a
commonly used diagnostic tool in the health
care setting
Substances found in urine during urinalysis can
help doctors diagnose kidney disease, certain
metabolic diseases, and infections
To perform urinalysis, a urine specimen must be
obtained
Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing
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Slide 22
Obtaining Urine Specimens - Routine Urinalysis
For routine urinalysis, the person is asked
to urinate directly into the specimen cup, if
possible. If difficult, the person can urinate
into a specimen collection device.
The person must not have a bowel
movement at the same time the urine is
being collected. Do not place toilet paper
in the collection device. Either of these
actions will change the urinalysis results.
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Slide 23
Obtaining Urine Specimens- Midstream (“Clean Catch”)
Urine Specimen
This method of collecting urine prevents contamination
of the urine by the bacteria that normally live in and
around the urethra
A midstream (“clean catch”) urine specimen is usually
ordered when the doctor suspects a urinary tract
infection
When a midstream (“clean catch”) urine specimen is
requested, the person is asked to clean the area
around the urethral opening with a special cleansing
wipe
The urine flow is started, then stopped, then started
again
The urine sample is collected from the restarted flow
Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing
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Slide 24
Obtaining Urine Specimens - Testing
A type of routine urine testing
involves dipping chemically treated
paper strips into a urine sample
Chemicals on the paper react with certain
substances that may be found in the urine,
causing the chemical blocks on the paper to
change color if these substances are present in
the urine
The paper is then compared with a color chart
that comes with the strips
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Slide 25
Obtaining Stool Specimens
Stool is analyzed for the presence of blood,
pathogens (such as parasites or bacteria), fat,
and other things that are not normally found in
feces
If a stool sample is needed, the person should
be notified well in advance so that the specimen
can be collected when it becomes available
Ask the nurse if there are any particular
collection methods that should be used
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Slide 26
Obtaining Stool Specimens
Stool can be collected in a bedpan,
bedside commode, or in a collection
device placed into a regular toilet.
The person must not urinate at the same
time the stool sample is being collected.
Toilet paper must not be placed in the
collection device. Both of these actions will
change the test results.
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Assistants.
Slide 27
Urinary Elimination
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Slide 28
Urinary Elimination - Urinary System
The urinary system consists of the
kidneys, urinary bladder, ureters,
and urethra
Blood is filtered by the kidneys,
forming urine
The urine is stored in the urinary
bladder
As the bladder fills, we begin to
feel the urge to urinate
Urine leaves the body through the
urethra
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Slide 29
Urinary Elimination - Expressions
The process of passing urine from the body is
known by several terms, including
Urination
Voiding
Micturition
Patients or residents will have their own terms
for urinating, such as “peeing” or “passing water”
When talking about urination, use words that the
person is familiar with. This is especially
important when talking with children.
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Slide 30
Urinary Elimination - Color and Odor
In healthy people, urine is:
Clear, without cloudiness or particles
Pale yellow, straw-colored, or dark gold
(amber) in color, with a slight odor
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Slide 31
Urinary Elimination - Color and Odor
Foods and drugs can affect the color and
odor of urine
When you are helping a patient or resident
with urination, observe the urine and
report any abnormalities to the nurse
Urine with an unusual odor or appearance
could be a sign of illness or infection
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Slide 32
Urinary Elimination - Hematuria
A slight red tinge to the urine may indicate
hematuria, or the presence of blood in the
urine
Sometimes hematuria is occult and must
be detected using urinalysis
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Slide 33
Factors Affecting Urinary Elimination
Many factors influence a person’s urinary
pattern, including:
The amount of fluids the person drinks
The types of medications the person takes
The person’s age
The person’s lifelong elimination habits
A nursing assistant soon becomes aware of the
urinary pattern that is normal for each person in
her care
This knowledge allows her to recognize any
changes that may occur
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Slide 34
Urination - Frequency and Nocturia
Frequency is the term used to describe
voiding that occurs more often than usual
Frequency is often accompanied by a
feeling of urgency, or the need to urinate
immediately
Nocturia is the need to get up more than
once or twice during the night to urinate, to
the point where sleep is disrupted
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Slide 35
Urination - Dysuria
Dysuria is difficulty voiding that may or
may not be associated with pain
Some people describe the discomfort they
feel during urination as a “burning” or
“cramping” sensation
Dysuria is often associated with bladder
infections, prostate problems, and some
sexually transmitted diseases (STDs)
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Slide 36
Measuring Urine Output
In a person maintaining a good fluid
balance, urine output is neither too high
nor too low. Complications associated with
urine output are:
Oliguria (the state of voiding a very small
amount of urine over a given period of time)
Polyuria (the state of excessive urine output)
Anuria (the state of voiding less than 100 ml
of urine over the course of 24 hours)
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Slide 37
Measuring Urine Output
People who have illnesses or take medications
that may alter their body’s ability to maintain a
healthy fluid balance will need to have their urine
output measured regularly
Some people who are critically ill will have their
urine output measured and recorded every hour,
but most people in the health care setting have
routine orders for their urine output to be
measured and recorded each shift
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Slide 38
Measuring Urine Output - Process
If a person uses a regular toilet, you will need to
remind the person:
To void into a specimen collection device (“commode
hat”)
To call you after he or she has finished voiding so that
you can measure and record the amount of urine
Specimen collection devices, urinals, and the
drainage bags used with urinary catheters often
have markings that make measuring urine
output easy
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Slide 39
Measuring Urine Output - Process
Urine output can also
be measured by
pouring it into a
graduate
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Slide 40
Measuring Urine Output - Process
If the urine output of one of your residents or
patients is being monitored, you will need to
keep a record of the amount of urine passed at
each voiding
This can be done using an intake and output
(I&O) flow sheet, which has spaces to record the
amount of each individual voiding
To obtain the end-of-shift amount, simply add
the individual amounts and record the total in the
appropriate space
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Slide 41
Urinary Catheterization
Urinary catheterization is done when a
person is unable to urinate using a toilet,
bedpan, urinal, or bedside commode
A urinary catheter is a tube that is inserted
into the bladder through the urethra to
allow the urine in the bladder to drain out
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Slide 42
Urinary Catheterization - Situations When a Urinary
Catheter is Used
A urinary catheter is used in many
different situations:
A urinary catheter may be inserted to drain
the bladder before or during a surgical
procedure, during recovery from a serious
illness or injury, or to collect urine for testing
A urinary catheter may be used for a person
who is incontinent of urine, if the person has
wounds or pressure ulcers that would be
made worse by contact with urine
A urinary catheter is necessary when a
person is unable to urinate because of an
obstruction in the urethra
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Slide 43
Urinary Catheterization - Insertion of Urinary Catheter
Inserting a catheter is a procedure that requires sterile
technique because it involves putting a foreign object
(that is, the catheter) into a person’s body.
Inserting a urinary catheter is usually beyond the scope
of practice for a nursing assistant, although in some
facilities, nursing assistants are provided with additional
training that allows them to catheterize residents or
patients.
Regardless of whether or not you are trained to actually
insert urinary catheters, caring for people who have
urinary catheters in place will almost certainly be a part
of your daily duties.
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Slide 44
Urinary Catheterization - Types of Urinary Catheters
You will see many different types of urinary
catheters in use
A straight catheter, also known as a Robinson, RobNel, or Red Rubber catheter, is used when the
catheter is to be inserted and removed immediately.
An indwelling catheter, also known as a retention or
Foley catheter, is left inside the bladder to provide
continuous urine drainage.
A suprapubic catheter is a type of indwelling catheter.
The suprapubic catheter is inserted into the bladder
through a surgical incision made in the abdominal
wall, right above the pubic bone.
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Slide 45
Catheters
Straight
Indwelling
Suprapubic
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Slide 46
Urinary Catheterization - Caring for a Person
with an Indwelling Urinary Catheter
Indwelling urinary catheters are connected
by a length of tubing to a urine drainage
bag
The tubing is secured loosely to the
person’s body near the insertion site using
a catheter strap or adhesive tape
Securing the tubing to the person’s body
prevents the catheter from being
accidentally pulled out during repositioning
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Slide 47
Urinary Catheterization - Caring for a Person
with an Indwelling Urinary Catheter
A little bit of slack is left in the tubing to
prevent the catheter from pulling against
the bladder outlet and the urethral opening
The remaining length of tubing is then
gently coiled and secured to the bed linens
using a plastic clip or safety pin
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Slide 48
Urinary Catheterization - Caring for a Person
with an Indwelling Urinary Catheter
Coiling the tubing prevents the tubing from
becoming bent or kinked, which would stop the
free flow of urine into the drainage bag. Coiling
the tubing and securing it to the bed linens also
keeps the weight of the tubing from pulling
against the person’s body.
The drainage bag is then secured to the bed
frame or the back of the person’s wheelchair, at
a level lower than the person’s bladder.
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Slide 49
Urinary Catheterization - Caring for a Person
with an Indwelling Urinary Catheter
If the drainage bag and tubing are higher
than the person’s bladder, then gravity
could cause old, contaminated urine to run
back down the tubing and into the
person’s bladder, causing an infection.
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Slide 50
Urinary Catheterization - Providing Catheter
Care
Nursing assistants are usually responsible
for providing catheter care.
Catheter care involves thorough cleaning
of the perineal area and the catheter
tubing that extends outside of the body, to
prevent infection.
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Slide 51
Urinary Catheterization - Providing Catheter
Care
Providing good catheter care is important
because the presence of the catheter in the
urethra provides a pathway for bacteria to travel
up from the perineum into the bladder, where
they can cause infection.
In addition, having a catheter in place eliminates
the “flushing” action of normal urination, which
helps to remove bacteria from the urinary tract
naturally.
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Slide 52
Urinary Catheterization - Providing Catheter
Care
Because bacteria can be introduced into the
body both when a urinary catheter is inserted
and after it is in place, urinary tract infections in
catheterized people are one of the most
common nosocomial infections.
In an effort to reduce the risk of nosocomial
infection in people who are catheterized, many
facilities require catheter care to be provided
routinely.
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Slide 53
Urinary Catheterization - Emptying Urine
Drainage Bags
Urine drainage bags are routinely emptied
and the urine measured at the end of each
shift.
Urine drainage bags should also be
emptied if they are full.
Leg bags need to be emptied frequently
because they are smaller, and hold less
urine.
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Slide 54
Urinary Catheterization - Preparing for Removal
of an Indwelling Catheter
Use of an indwelling catheter can lead to temporary urinary
incontinence when the catheter is removed, because the lack of
activity can decrease the muscle tone of the bladder.
To prepare the bladder for removal of the catheter, it is common to
clamp the tubing of the catheter for a period of time to allow the
urine to fill the bladder.
The tubing is then unclamped and the urine is allowed to drain from
the bladder.
The procedure is repeated over a period of time, with the time
intervals between clamping and emptying becoming increasingly
longer.
Then the catheter is removed and the person is allowed to void
normally.
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Slide 55
Urinary Incontinence
Urinary incontinence is the inability to hold one’s urine,
or the involuntary loss of urine from the bladder.
Urinary incontinence may be temporary or permanent.
Temporary urinary incontinence can occur as a result of
bladder infection, or after an indwelling catheter that has
been in place for a long time is removed.
Permanent urinary incontinence can be caused by many
things, including:
Decreased muscle tone in the bladder or the muscles that
support the bladder, such as occurs after childbirth or from
obesity
Injuries or illnesses that affect the spinal cord, the brain, or the
nerves that control bladder function
Dementia
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Slide 56
Urinary Incontinence
Urinary incontinence can be emotionally devastating for
both the incontinent person and the person’s caregivers.
For the person who is incontinent, having wet clothes or
smelling like urine can be very embarrassing. In addition,
being incontinent of urine places a person at risk for
developing skin problems and for falling.
For the caregiver, caring for a person who is incontinent
of urine can be frustrating and emotionally draining.
Because caring for an incontinent person can be so
emotionally trying and time consuming, incontinence is
the factor that most often leads family members to have
a relative admitted to a long-term care facility.
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Slide 57
Urinary Incontinence - Types
There are many types of urinary incontinence
Stress incontinence is the involuntary release of urine from
the bladder when the person coughs, sneezes, or exerts
herself.
Urge incontinence is the involuntary release of urine right
after feeling a strong urge to void.
Functional incontinence occurs in the absence of physical
or nervous system problems affecting the urinary tract.
Overflow incontinence occurs when the bladder is too full
of urine.
Reflex incontinence occurs when there is damage to the
nerves that enable the person to control urination.
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Slide 58
Urinary Incontinence - Managing Urinary
Incontinence
Products available to help manage urinary
incontinence include:
Incontinence pads
Incontinence briefs
Condom catheters
In addition, techniques such as bladder training
may be used to help a person overcome certain
types of incontinence
For some people, temporary or permanent
catheterization may be necessary to manage
incontinence
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Slide 59
Urinary Incontinence - Managing Urinary Incontinence Incontinence Pads and Briefs
Incontinence pads and briefs are specially made to absorb
urine and hold it away from the person’s skin.
Incontinence pads are placed inside the person’s underpants
to prevent wetting of the clothes and to draw the moisture
away from the person’s body.
For a person who is confined to bed, bed protectors are used
to help to keep the bed linens and mattress dry and to wick
urine away from the person’s skin.
Incontinence briefs tend to fit closely, which makes it difficult
for air to reach the skin. Switching between briefs and bed
protectors helps expose the skin to air at night.
A nursing assistant must make sure that these incontinence
products are changed frequently and that urine is cleaned
from the skin whenever the change occurs.
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Slide 60
Urinary Incontinence - Managing Urinary Incontinence Condom Catheters
A condom catheter
consists of a soft
plastic or rubber
sheath, tubing, and a
collection bag for the
urine. The sheath is
placed over the penis
and the collection bag
is attached to the leg.
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Slide 61
Urinary Incontinence - Managing Urinary Incontinence Condom Catheters
The urine flows through the tubing into the collection
bag, allowing the man to urinate at will.
The condom must fit the penis and should be fastened
securely enough to prevent leaking, but not so snugly as
to restrict circulation.
Adhesive material on the inside of the condom allows for a good
seal
Or, the condom is secured with elastic tape applied in a spiral
fashion to allow for changes in the size of the penis
Use of a condom catheter requires good skin care. The
penis must be cleaned, and the condom apparatus
changed, daily.
Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing
Assistants.
Slide 62
Urinary Incontinence - Managing Urinary Incontinence Bladder Training
Bladder training is commonly used to help people relearn how to control their urinary elimination patterns.
For example, a person may be encouraged to use the
bedpan, urinal, or commode at scheduled times.
Scheduling of elimination helps promote regular
emptying of the bladder.
The primary goal is for the person to be able to control
involuntary urination. If this is not possible, then the
person may still at least be able to get to the bathroom in
time to avoid accidents.
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Assistants.
Slide 63
Bowel Elimination
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Slide 64
Bowel Elimination - Digestive System
The digestive tract
consists of the mouth,
esophagus, stomach,
small intestine, large
intestine, rectum, and
anus
Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing
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Slide 65
Bowel Elimination - Digestive System
The rectum is actually part of the large intestine,
and together, the large and small intestines are
sometimes referred to as “bowels.”
The food and fluids that we take in are broken
down into smaller pieces and mixed together in
the stomach, forming a partially digested food
and fluid mixture known as chyme.
From the stomach, the chyme passes slowly into
the small intestine, where more digestion occurs
and nutrients and fluid are absorbed, and then
into the large intestine.
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Slide 66
Bowel Elimination - Digestive System
Wave-like muscular movements, called
peristalsis, move the chyme through the
intestines.
Finally, the chyme reaches the last part of
the large intestine, called the rectum.
At this point, all of the nutrients have been
removed, and what remains is a semi-solid
waste material, called feces.
Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing
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Slide 67
Bowel Elimination - Digestive System
The presence of feces in the rectum
stimulates the urge to defecate and the
feces leave the body through the anus.
Flatus (or gas) is a natural byproduct of
digestion, just as feces are.
Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing
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Slide 68
Bowel Elimination - Color and Odor
In healthy people, feces:
Are soft, brown, and moist
Have a distinct odor
Certain foods and medications can affect the
color and odor of feces
When helping a patient or resident with
defecation, observe the feces and report any
abnormalities to the nurse
Feces with an unusual odor or appearance
could be a sign of illness or infection
Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing
Assistants.
Slide 69
Factors Affecting Bowel Elimination
The factors that influence a person’s bowel
elimination pattern include:
The amount of fluid the person drinks
The type of food he or she eats
The types of drugs the person takes
The person’s age
The person’s level of activity
A nursing assistant soon becomes aware of the
bowel elimination pattern that is normal for each
person in her care. This knowledge allows her to
recognize any changes that may occur.
Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing
Assistants.
Slide 70
Problems with Bowel Elimination
Problems with bowel elimination that are
often seen in the health care setting
include:
Diarrhea
Constipation
Fecal impaction
Flatulence
Fecal (bowel) incontinence
Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing
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Slide 71
Problems with Bowel Elimination - Diarrhea
Diarrhea is the passage of liquid,
unformed stool.
Diarrhea may occur frequently and
can be accompanied by abdominal
cramping.
If diarrhea is frequent or excessive,
the loss of fluid from the body can
quickly cause dehydration, especially
in young or elderly people.
Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing
Assistants.
Slide 72
Problems with Bowel Elimination - Diarrhea
When caring for a person with diarrhea:
Practice good infection control techniques
Answer the call light quickly to provide access
to the toilet, commode, or bedpan
Provide gentle, thorough skin care after each
bowel movement to prevent skin breakdown
Make sure to record and report the frequency
and amount of each incident of diarrhea
Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing
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Slide 73
Problems with Bowel Elimination - Constipation
Constipation occurs when the feces
remain in the intestines for too long
The delay allows too much fluid to be
reabsorbed by the intestines, resulting in
hard, dry feces that are difficult to pass
Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing
Assistants.
Slide 74
Problems with Bowel Elimination - Constipation
Risk factors for developing constipation
include:
Taking medications that slow peristalsis
Not taking in enough dietary fiber or fluids
Not getting enough exercise
Delaying having a bowel movement
Lack of privacy
Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing
Assistants.
Slide 75
Problems with Bowel Elimination - Constipation
There are many things a nursing assistant
can do to help a patient or resident
maintain normal bowel function and
prevent constipation
Encouraging fiber-rich foods
Encouraging plenty of fluids
Assisting with exercise
Ensuring privacy
Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing
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Slide 76
Problems with Bowel Elimination - Constipation
If a person is constipated and all other methods
of promoting normal bowel function have failed,
a laxative, stool softener, or fiber supplement
may need to be used
A laxative is a medication that chemically stimulates
peristalsis so that material inside the intestines moves
through at a faster pace
Stool softeners help to keep fluid in the feces and are
used to help prevent constipation for some people
Fiber supplements, in the form of tablets or drink
additives, can add bulk to the feces, causing it to hold
fluid, and preventing constipation
Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing
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Slide 77
Problems with Bowel Elimination - Fecal Impaction
A fecal impaction occurs when constipation is
not relieved.
The feces build up in the rectum and become
harder and harder as more and more fluid is
absorbed. Eventually, it becomes almost
impossible to pass the feces normally.
The impaction blocks the passage of normal
stool, but liquid stool may go around the
impacted mass.
Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing
Assistants.
Slide 78
Problems with Bowel Elimination - Fecal Impaction
A person with an impaction is usually very
uncomfortable, and may complain of
abdominal or rectal pain or of liquid feces
“seeping” out of the anus.
The person’s abdomen may be swollen.
Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing
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Slide 79
Problems with Bowel Elimination - Fecal Impaction
If a person is thought to
have a fecal impaction,
the nurse will perform a
digital examination.
During the digital
examination, a finger is
inserted into the
person’s rectum to feel
for the impacted mass
(digital means “finger”).
Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing
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Slide 80
Problems with Bowel Elimination - Fecal Impaction
The impaction is removed by using the finger to break
the impacted feces apart and scoop it out of the rectum
piece by piece.
The doctor may also order the use of an oil retention
enema or drugs to help remove the impaction.
Digital removal of a fecal impaction is very
uncomfortable and embarrassing for most patients and
residents.
Many facilities require that a nurse remove an impaction,
but your assistance will be necessary.
If you are allowed to remove an impaction, make sure
you have been adequately trained for the procedure and
that it is part of your job description.
Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing
Assistants.
Slide 81
Problems with Bowel Elimination - Flatulence
Flatulence is the presence of excessive amounts of
flatus (gas) in the intestines, causing abdominal
distension (swelling) and discomfort.
People have difficulty passing flatus because of a lack of
activity or a recent surgical procedure.
Getting out of bed and walking might be all that is
needed to help the person to expel the gas.
If walking is not allowed, positioning the person on her
left side may help.
If the flatulence cannot be relieved with these methods, a
nurse may insert a rectal tube to help the gas escape.
Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing
Assistants.
Slide 82
Problems with Bowel Elimination - Fecal
Incontinence
Fecal (bowel) incontinence is the inability
to hold one’s feces, or the involuntary loss
of feces from the bowel
Like urinary incontinence, fecal
incontinence can be temporary or
permanent
Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing
Assistants.
Slide 83
Problems with Bowel Elimination - Fecal
Incontinence
Temporary fecal incontinence may be due to:
A severe case of diarrhea
An inability to get to the bathroom quickly enough
Failure to answer call lights promptly
Diseases or injuries that affect the nervous system can
also result in temporary or permanent fecal incontinence
A person who is unconscious will be incontinent of feces
A person who has dementia will develop fecal
incontinence as the disease progresses
Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing
Assistants.
Slide 84
Problems with Bowel Elimination - Fecal
Incontinence - Bowel Training
Bowel training is very similar to bladder training
and works to promote regular, controlled bowel
movements
Offering the commode or bedpan at regular
scheduled intervals is a common method of
bowel training
Bowel training is often started by keeping track
of when an incontinent person usually has a
bowel movement, then making sure to provide
the appropriate toilet facilities during that time
period
Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing
Assistants.
Slide 85
Enemas
An enema is the introduction of fluid into the
large intestine by way of the anus for the
purpose of removing stool from the rectum
Enemas are used to
Relieve constipation
Relieve fecal impactions
Empty the intestine of fecal material before surgery or
certain diagnostic tests
Sometimes enemas are used as part of a bowel
training program
Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing
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Slide 86
Enemas - Types of enemas
Types of enemas used in the health care
setting include:
Cleansing enemas
Oil retention enemas
Commercial enemas
Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing
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Slide 87
Enemas - Cleansing Enemas
Cleansing enemas are primarily used to remove feces
from the lower large intestine.
Tap water enemas and saline (salt water) enemas help
soften the stool and stimulate peristalsis.
Soapsuds enemas consist of water and a small amount
of a very gentle soap called castile soap. The soap
solution irritates the lining of the bowel, stimulating
peristalsis.
Enemas containing these solutions should not be given
repeatedly because the intestine can absorb the
solution, causing a fluid imbalance in the body.
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Slide 88
Enemas - Oil Retention Enemas
An oil retention enema contains mineral,
olive, or cottonseed oil.
The oil lubricates the inside of the intestine
and any stool that is present, making the
stool easier to pass or remove.
Oil retention enemas are useful for helping
to remove fecal impactions.
Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing
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Slide 89
Enemas - Commercial Enemas
Commercially prepared and packaged
enemas usually contain 120 ml of a
solution that irritates the intestinal mucosa
to promote peristalsis.
Some commercial enemas contain a
solution that is absorbed into the stool to
make it softer and easier to pass.
Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing
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Slide 90
Enemas - Administering Enemas
Enemas are ordered by a doctor and usually
given by a nurse.
Some facilities allow nursing assistants to
administer enemas after adequate training.
Nursing assistants must make sure that
They follow proper procedure and the doctor’s orders
closely
The solution is correct for the person
The correct amount of solution is being administered
The solution is at the proper temperature
Copyright © 2005. Lippincott Williams & Wilkins. Instructor's Manual to Accompany Lippincott's Textbook for Nursing
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Slide 91
Enemas - Administering Enemas
Enema solutions that are too cool can
cause abdominal cramping and pain, while
solutions that are too hot can cause
serious injury and possibly even death
When assisting with the administration of
an enema, make sure that a bed protector
and bedpan are in place, or that the path
to the bathroom is clear
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Assistants.
Slide 92
Enemas - Administering Enemas
An enema is given with the person on her left side in
Sims’ position
When a person is lying on her left side in Sims’ position,
the intestine is positioned to take the best advantage of
gravity
After the enema has been administered, the person is
asked to hold the solution in the bowel for the specified
amount of time, and then to expel the solution
The doctor may order a cleansing enema to be
administered “until clear,” which means that enemas are
to be given until the enema return from the person does
not contain any fecal material
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Slide 93
Enemas - Administering Enemas
Ask the nurse how many enemas are allowed to
be given during a particular session
To make the procedure easier for the person,
keep the person covered as much as possible
and ensure that she has as much privacy as
possible
Having the person take a few slow, deep breaths
as the enema tubing is inserted into the rectum
may help to relax the person and make insertion
easier
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Slide 94
Rectal Suppositories
A rectal suppository is a small, wax-like cone or
oval that is inserted into the anus.
The wax-like substance dissolves at body
temperature, stimulating peristalsis or lubricating
and softening the stool.
Glycerin rectal suppositories are often used to
help with bowel elimination before resorting to
an enema.
Some rectal suppositories also contain
medication. These should only be inserted by a
nurse.
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Assistants.
Slide 95
End of Presentation
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Assistants.
Slide 96