Transcript Problems with Bowel Elimination ppt w notesx

Elimination:
Problems of Bowel Elimination
REVIEW of GI Processes – Lower GI:
 Intestinal phase (duodenum)
Secretin – inhibits acid production and motility
Absorption –H20, electrolytes, fats, sugars

◦ Pancreas – enzymes (trypsin, amylase, lipase)to
digest CHO, fat, proteins; production of insulin and
glucagon
◦ Liver/gallbladder
Bile production and storage (emulsifies fat)
Vitamin and mineral storage
Protein , CHO metabolism –stores/releases
glycogen
Stores fatty acids, triglycerides
Elimination Needs
Jejunum – absorption of
sugars, proteins
Ileum – absorption of B12,
chloride, bile salts
(3-10 hrs for passage 6-19ft.
Long)
Colon – appendix/ileocecal
valve -Cecumascending, transverse,
descending, sigmoid
Electrolyte,H20 absorption
(3-4 days transit)
Rectum-Storage and
elimination of wastes.
REVIEW of GI Processes – Lower GI:
Begin with Patient Assessment
History
Demographic data, family / personal hx, genetic risk
Medications, previous surgery, laxative /enemas,
travel hx
Diet history – anorexia, wt changes, dyspepsia,
allergies, lactose intolerance, alcohol and caffeine
intake, smoking
 Changes with aging:
< absorption, < HCL, < Iron and Vit B 12
absorption,
< motility, < drug metabolism, > bacteria
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Current Symptoms
Presentation and duration of sx
Pattern, Color and consistency of bowel movement
frank blood or tarry stools, gas, distention
Pain, Weight loss, appetite changes
Patient Assessment
Colon = large intestine is 5-6 feet in length;
consists of the cecum, the colon (ascending,
transverse, descending and sigmoid) and
rectum
 Colon = has 3 functions: absorption (water,
Na, & Cl), secretion (of bicarbonate) and
elimination of wastes
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Elimination Needs
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Mouth and pharynx
Abdomen and extremities
◦ Inspection (Cullen’s sign-ecchymosis around
umbilicus)
◦ Auscultation, look for peristalsis
◦ Percussion
◦ Palpation - no if suspect appendicitis or
aneurysm
Blumberg’s sign?
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Skin
◦ Discolorations, rashes (jaundice)
◦ Increased bleeding, bruising (petechiae,
ecchymosis)
◦ Itching
GI Assessment
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Laboratory Testing R/T GI Assessment:
CBC – anemia, infection
Electrolytes – vomiting/diarrhea loss,
malabsorption
Coagulation studies
Hepatitis antibodies, titers
Liver enzymes - AST , ALT
◦ Bilirubin: the primary pigment in bile
◦ Ammonia – cirrhosis, hepatitis
Serum amylase and lipase – pancreatitis
Onconal fetal antigens – CA 19-9, CEA
Urine –bilirubin ?, Ketones ?
Stool exams – culture –( C-diff, giardia) Ova
and parasites, occult blood, fats
Laboratory Testing
 Upper
Series
GI and Small Bowel
Before test:
◦ Maintain NPO for 8 hr.
◦ Withhold analgesics and anticholinergics for 24
hr.
◦ Consent form required for invasive testing
Client drinks 16 ounces of barium, Rotate
exam table,
takes about 30 min.
 After test:
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◦ Push Fluids, administer laxative/stool softner
◦ Stools chalky white 24-72 hrs
Diagnostic GI Testing:
Barium enema enhances radiographic
visualization of the large intestine. Gas
patterns, tumors, obstructions, volvulus
 Before Test:
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◦ Bowel cleansing, clears liquid diet, NPO night
before
◦ Barium instilled via rectal catheter with inflated
balloon, pt must hold and change postitions –
takes 45 min. – 1 hr.
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After Test: expel the barium, push fluids,
laxative/ stool softner, stool is chalky
white for 24-72 hr.
Diagnostic Testing – Lower GI:
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Percutaneous Transhepatic
Cholangiography
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X-ray study of the biliary duct system
Before Test: Laxative , NPO X 12 hrs , coagulation
studies, check allergies to iodine/seafood
Under sedation, percutaneous needle into liver via
X-ray visualization, dye injected to visualize biliary
tree, dye aspirated when completed.
Major risks = hemorrhage / sepsis
Post –Test:
Bedrest for several hours after procedure
Assessment of vital signs
Client positioned on right side with a firm pillow or
sandbag placed against the lower ribs and abdomen
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Diagnostic Testing – Lower GI:
Visual and radiographic examination of the
liver, gallbladder, bile ducts, and pancreas
 NPO for 6 to 8 hr before test, conscious
sedation
 Dye used – check for allergies
◦ Post test:
assessment of VS q 15 min, Return of gag
reflex
Colicky abdominal pain due to instilled air
 Possible Complications – cholanghitis,
perforation, pancreatitis – report any
post-test abd pain, fever, N/V
Endoscopic Retrograde
Cholangiopancreatography (ERCP)
Visualization of the small intestine to
locate source of bleeding
 Only water for 8 to 10 hr before test
 NPO for first 2 hr of the testing, then
normal diet and activity
 Application of belt with sensors and
recorder.
Takes 8 hrs to complete, capsule excreted
in stool
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Small Bowel Capsule Enteroscopy
Colonoscopy
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Colonoscopy: Endoscopic examination of
the entire large bowel
Before Test -Liquid diet for 12 to 24 hr , NPO
for 6 to 8 hr before procedure
Requires bowel cleansing routine
Done under conscious sedation
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After Test - Assessment of vital signs q 15
min cramping, flatus, feeling of fullness =
normal for few hrs. Small amt blood possible
in stool if polypectomy or tissue biopsy
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Watch for signs of perforation or hemorrhage
Colonoscopy
Endoscopic examination of only the
rectum and sigmoid colon
 Prep is the same as for Colonoscopy
 Sedation not used, otherwise before and
after care is the same as with a
Colonoscopy
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Less expensive (no anesthesia) but Not as
comprehensive as colonoscopy – may be
used for interim screening in some cases,
or when other issues don’t allow
colonoscopy.
Proctosigmoidoscopy/
Flexible Sigmoidoscopy
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Ultrasonography
painless, noninvasive,
no radiation
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Liver-spleen scan ,
HIDA scan
Nuclear medicine
studies, minimal
radiation
may take 1-4 hrs
Other Tests
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CONSTIPATION
CONSTIPATION
is a condition
characterized by
difficulty in
passing stool or
infrequent
passage of hard
stool.
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Fluid Intake –
reduced fluid intake
may contribute to
constipation;
Ingestion of milk
products slows
peristalsis; adequate
water & fruit juice
promote normal
bowel function
Factors Affecting Bowel Function
Physical Activity – physical activity promotes
peristalsis; immobility can lead to loss of
muscle tone, constipation, ileus, bowel
obstruction…
 Psychological Factors – stress response may
stimulate peristalsis and digestion  diarrhea
or gas; depression slows peristalsis and may
promote constipation; strong link of
psychological influences on ulcerative colitis
and Crohn’s disease
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Factors Affecting Bowel Function
Age – neuromuscular control of bowel
elimination not developed until age 2 or 3
years; older adults loose muscle tone in
perineal floor and anal sphincter; aging causes
slowing of nerve impulse to signal need for
defecation
 Diet – regular eating patterns support regular
bowel habits; fiber provides bulk to fecal
material and stimulates peristalsis; some
foods produce gas causing intestinal
distention
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Factors Affecting Bowel Function
Position during defecation – sitting or
squatting aids increased intra-abdominal
pressure and contraction of pelvic floor
muscles. Hospitalization and imposed use
of bedpans, or bedside commode may
inhibit client’s bowel elimination
 Pain – surgery, hemorrhoids, rectal
fistulas, etc. may make defecation painful
– causing client to suppress urge 
constipation
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Factors Affecting Bowel Function
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Medications –
laxatives &
cathartics promote
peristalsis & fluid
retention in the
bowel promoting
defecation; opioid
analgesics suppress
peristalsis;
medications to treat
diarrhea primarily
suppress peristalsis
Factors Affecting Bowel Function
 Personal
Habits –
privacy,
convenience,
regular habits;
 The
gastrocholic
reflex = response
to defecate
approx. 30 - 60
min. after meals.
Factors Affecting Bowel Function
 Pregnancy
– growing uterus exerts
pressure on rectum, peristalsis slows in
3rd trimester, constipation is common &
may lead to development of
hemorrhoids
 Surgery & Anesthesia – general
anesthetics causes temporary cessation
of peristalsis (which is why clients are
NPO just before & after surgery)
Factors Affecting Bowel Function
How does constipation occur?
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Scenario: Bears
hibernate in the winter.
They don’t eat – drink –
or move about much at all.
Body functions slow down
– as a result, it is possible
for a bear to wake up
from hibernation quite
constipated and cranky!
Constipation
Apply the Nursing Process to the Bear – begin
with ASSESSMENT –
 Objective data is information you can see,
touch, measure, prove
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◦ No evidence of bowel movement in expected time
frame; hypoactive bowel sounds; lower abdomen
may be distended and firm; rectal exam reveals
presence of firm stool in rectum.
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Subjective data is information that the
“patient” tells you about his experience
◦ Patient may c/o abdominal cramping, feeling of
“fullness”, pressure in abdomen or rectum; even
nausea and feeling “cold and clammy” at times.
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Constipation
Subjective data:
“I don’t feel so
hot…my belly hurts!
“I can’t poop!”
“I really feel like I
need to GO!!!!”
“Grrrrrrr!!!”
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Objective Data:
Facial grimacing
Clutching lower
abdomen
No evidence of BM
for 3 months
Hypoactive bowel
sounds
Abdomen feels firm
and is moderately
distended to
palpation
Constipation
 5-step
Nursing Process:
◦ASSESSMENT
◦ANALYSIS & DIAGNOSIS
◦PLANNING
◦IMPLEMENTATION
◦EVALUTAION
Constipation
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Step II of the Nursing
process begins with
ANALYSIS of data and
ends with formulating
the NURSING
DIAGNOSIS
statement.
Look at the patient
history, home
medications, physical
assessment…..what
does it all mean?
Constipation
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Make a problem list.
Set priorities
Express priority
problems in a nursing
diagnosis statement
Constipation
After analysis of your patient’s problems –
and which are priority nursing issues –
you begin to construct a nursing
diagnosis statement.
 The nursing diagnosis statement identifies
the patient’s priority problem (that is
within the scope of practice) – makes
clear what caused the problem – and
supports the problem with evidence of the
problem (signs & symptoms)
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Constipation
 Build
a Nursing
Dx Statement:
 Nursing Diagnosis
– uses the P-E-S
format
 P = Problem +
 E = Etiology +
 S = Signs &
Symptoms of the
problem
Constipation
 Nursing Diagnosis:
 [P] Constipation…
Related to…
 [E] Inactivity, inadequate fluid intake
and inadequate fiber intake (secondary
to winter hibernation)
◦
As Evidenced by…
 [S]
States “I can’t poop” – hypoactive
BS – firm, distended abdomen – facial
grimacing – no BM x 3 months
Constipation
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Constipation
Constipation R/T
inactivity,
inadequate fluid &
fiber intake AEB
hypoactive BS, firm
& distended
abdomen, client
states “I can’t poop”
and no evidence of
BM x 3 months
Constipation
 The
first step in any plan is to establish
the GOAL or OUTCOME
 A GOAL STATEMENT is written in
terms of OBJECTIVE, OBSERVABLE
PATIENT BEHAVIORS which are
MEASURABLE and REALISTIC
 The GOAL/OUTCOME is designed to
help resolve the problem identified in
the Nsg Dx
Constipation
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The Bear will have a
BM within 24 hours
The Bear will state
that his abdominal
pain is  3 (0/10) in
48 hours.
The Bear will have
regular BMs at least
3x/wk within 1
month
Constipation
 Part
of Planning is selecting
INTERVENTIONS which are
directed to help achieve the GOAL
or OUTCOME
 Adjust interventions to fit the
patient – individualize to suit the
patient, situation and available
resources
 Include frequencies, amounts, time
lines…details… USE REFERENCES!!!
Constipation
 GOAL/
Outcome:
 The Bear
will have a
BM within
24 hours
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Constipation
Administer PO Colace Q
AM as ordered
Instruct Bear to drink 500
ml water every 6 hours
Encourage Bear to ambulate
50’ or more twice a day
Instruct Bear to eat at
least 2 servings of raw
fruit daily
Administer jumbo-size
Fleets enema if no BM in
24 hours
Constipation
 Implementation
– Just Do It
 Perform the interventions as planned
 Monitor patient responses to care
 Document interventions and patient
response
 Continue to assess and collect data for
the ongoing nursing process!
 “Git
‘er done!”
Constipation
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The final step in the Nursing Process is
EVALUATION:
◦ Was the GOAL met?
 Yes / No?
 Partially? Sorta?
Not really!
◦ Is the problem in the Nsg Dx
resolved?
◦ Have the problems changed?
◦ Have the priorities changed?
◦ What should happen next?
Constipation
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The EVALUATION step is not a “yes” or “no”
response; it is a summary statement about
progress toward the desired outcome.
Start by addressing the patient’s progress
toward the goal
Describe how the patient responded to the
planned interventions
Provide a summary and recommendation for what
should happen next: where do we go from here in
terms of this plan of care? Even if the goal was
achieved – few plans of care are just closed….
There is opportunity for reinforcement and
patient teaching. Tell the reader what should
happen next.
Constipation
Constipation
 GOAL:
 The
Bear
will have
a BM
within 24
hours
“Goal met. Bear had large
soft-formed B.M. at 1800 hrs
today. Bear stated that
abdominal discomfort is now
resolved.”
 Plan to continue to reinforce
fluid intake of 1500 – 2000
ml/day; intake of 2+ servings
of raw fruit or vegetables/day
and walking 50+ feet twice
daily.
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Constipation
GOAL:
 “Goal not met. No BM noted.
 The Bear
However, Bear is passing
will have a flatus and complying with
BM within dietary and activity
24 hours
interventions. No increase

in symptoms of discomfort.
Plan to continue plan as
written and re-evaluate in
12 hours.”
Constipation
GOAL:
 The Bear
will have a
BM within
24 hours
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“Goal not met. No evidence of
BM after 24 hours. Abdominal
distention slightly increased
and verbal complaints of
discomfort are voiced more
often.”
 Revise the Plan – notify the
physician of continued
constipation. Manually examine
for fecal impaction and
remove. Administer Soap Suds
Enemas until clear.
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Constipation
What medications can help prevent or treat
constipation?
 Stool softeners like Colace and Surfak pull
fluid from the circulating blood volume into
the colon
 Fiber-additives such as Citrecel or Fibercon
provide some of the non-digestible bulk
needed to promote normal defecation.
 Items like mineral oil and
glycerin suppositories try to
make stool passage easier
(lubrication).
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Constipation
Pre-packaged enemas, such as Fleets,
deliver medications directly to the colon.
These may stimulate peristalsis, add liquid
to soften stool or provide lubrication for
stool passage.
 Laxatives such as milk of magnesia,
Correctol, Ex-Lax, Dulcolax, Magnesium
Citrate and Lactulose stimulate
peristalsis of the colon.
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Assess abdomen for
changes in baseline
assessment
Schedule activity &
exercise daily
Stool softeners or
laxatives as Rx
Encourage toileting at
same time of day – 60
min after meals
Provide privacy for
toileting
Try to wean patient
from opioid pain
medications as early as
tolerated
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Monitor bowel
movements for
frequency &
characteristics
Provide  fiber intake
Position sitting
upright for BMs if
possible
Fluid intake 
◦ Fruit juice
◦ Water
◦ Hot beverages
Interventions to promote defecation
The End … of constipation…