Transcript Chapter_046 Module L bowel elimination student copyx

Chapter 46
Bowel Elimination
 Mr. Gutierrez resides in an assisted-living apartment of
a long-term care center. He keeps busy in his small
garden plot and enjoys other activities of the center,
such as nightly card games and outings to baseball
games. He is 82 years old and widowed and has lived in
the area for longer than 3 years. His family, with whom
he is quite close, is scattered across the country. He has
one niece, who lives in the same town. Mrs. Gutierrez
feels he is in good health; as long as he eats green chili
peppers every day, he believes he will remain healthy.
 Because Mr. Gutierrez has a small kitchen in his
apartment, he is able to make some of his favorite
foods. His diet consists of flour and corn tortillas,
beans, and rice. He likes most meats, but he prefers
chicken and as ado (made with pork). For breakfast, he
usually has hues rancheros. He has been hospitalized
only twice—once for the flu and once for placement of
a pacemaker.
 He presently takes three medications: digoxin, Zestril,
and Metamucil.
Mouth
Esophagus
Digestion begins with
mastication.
Peristalsis moves food into
the stomach.
Stomach
Small intestine
Stores food; mixes food,
liquid, and digestive juices;
moves food into small
intestines
Duodenum, jejunum, and
ileum
Large intestine
Anus
The primary organ of bowel
elimination
Expels feces and flatus
from the rectum
Age
Fluid intake
Diet
Physical activity
Psychological factors
Personal habits
Position during defecation
Pain
Pregnancy
Surgery and anesthesia
Medications, laxatives,
and cathartics
Diagnostic tests
Constipation
Impaction
A symptom, not a disease;
infrequent stool and/or hard, dry,
small stools that are difficult to
eliminate
Results from unrelieved
constipation; a collection of
hardened feces wedged in the
rectum that
a person cannot expel
Diarrhea
Incontinence
an increase in the number of
stools and the passage of liquid,
unformed feces
Inability to control passage of
feces and gas to the anus
Flatulence
Hemorrhoids
Accumulation of gas in the
intestines causing the walls to
stretch
Dilated, engorged veins in the
lining of the rectum
 This afternoon Mr. Gutierrez has telephoned his niece
for the fourth time. He reports, “My bowels are locked
up and haven’t moved in the last 2 days.” He ate a big
meal the previous evening and now reports feeling “all
gassed up.”
 His niece tried to explain about eating foods containing
fiber and more vegetables. She reminded Mr. Gutierrez
that the nursing student was coming later this
afternoon, and he could talk to the student about his
problem.
 Temporary or permanent artificial opening in the
abdominal wall
 Stoma
 Surgical opening in the ileum or colon
 Ileostomy or colostomy
 The standard bowel diversion creates a stoma.
 Loop colostomy
 This is temporary in the transverse colon.
 End colostomy
 Proximal end forms stoma, and distal end is removed
or sewn closed.
 Double-barrel colostomy
 Bowel is surgically cut, and both ends are brought
through the abdomen.
 Vickie is the nursing student assigned to Mr. Gutierrez. She has
been seeing him once a week for 5 weeks as a portion of a home
health care clinical experience. They have developed a good
rapport. Mr. Gutierrez’ self-identified problems with his bowels are
a frequent topic of conversation.
 As Vickie prepares to assess Mr. Gutierrez, she reflects on
experiences with other patients in the home setting. She recalls
one patient who had elimination problems resulting from a diet
consisting mainly of high-fat and high-carbohydrate foods. She
believes that her involvement with that patient is likely to help in
Mr. Gutierrez’ care.
 Ileoanal pouch anastomosis
 Pouch is a reservoir for wastes that are eliminated from the
anus.
 Kock continent ileostomy
 Small intestine forms a pouch, which is emptied several times a
day.
 Macedo-Malone antegrade continence enema (MACE)
 This procedure was developed for patients who have
neuropathic or structural abnormalities of the anus.
 Psychological considerations
 Vickie reviews her class notes on the anatomy and physiology of
the GI system. Vickie reviews the physiological changes that aging
produces within the GI system: loss of teeth, taste bud atrophy,
decreased secretion of gastric acid, and a slight decrease in small
intestine motility.
 Vickie will thoroughly assess Mr. Gutierrez’ dietary intake with a
24-hour diet recall. Being familiar with his Hispanic heritage,
Vickie anticipates certain food preferences. She knows he does not
like the food served at the center and frequently requests “homecooked” tortillas and green chili peppers from his niece.
1. A newly admitted patient states that he has recently
had a change in medications and reports that stools
are now dry and hard to pass. This type of bowel
pattern is consistent with
A. Abnormal defecation.
B. Constipation.
C. Fecal impaction.
D. Fecal incontinence.
 From their last visit, Vickie and Mr. Gutierrez have
been able to communicate without difficulty. Mr.
Gutierrez complains of feeling “full of gas” but has
not “passed any wind” in the past 2 days. His stove
has not been working well, and he has been unable
to prepare rice and beans. Based on the nursing
history, Vickie estimates that Mr. Gutierrez
normally drinks about 1200 mL of fluid daily.
 Nursing history
 What a patient describes as normal or abnormal is
often different from factors and conditions that tend
to promote normal elimination.
 Identifying normal and abnormal patterns, habits,
and the patient’s perception of normal and abnormal
with regard to bowel elimination allows you to
accurately determine a patient’s problems.
 Physical assessment
 Mouth, abdomen, and rectum
 Laboratory tests
 Fecal characteristics
 Fecal specimens
 Diagnostic examinations
 Radiologic imaging, with or without contrast
 Endoscopy
 Ultrasound
 Computed tomography (CT) or magnetic resonance imaging
(MRI)
Determine when Mr.
Gutierrez had his
last bowel
movement.
He had his last bowel movement 2 days
ago. The stool was brown and hard. “I took
a laxative last night, and I think I need an
enema.”
Determine Mr.
Gutierrez’
medication history.
A medication history shows that Mr.
Gutierrez frequently resorts to taking
laxatives.
Establish Mr.
Gutierrez’ dietary
habits.
Mr. Gutierrez eats a high intake of corn
tortillas and cheese and a low intake of
fruits. He states, “I really haven’t felt like
eating today and have not eaten much for
the last 4 days.”
Hypoactive bowel sounds in all four
Assess Mr.
Gutierrez’ abdomen. quadrants. Abdomen is soft but slightly
distended.
Constipation
Bowel
incontinence
Risk for
constipation
Diarrhea
Perceived
constipation
Toileting selfcare deficit
 The Agency for Healthcare Research and Quality
(AHRQ) provides guidelines on reduction of
pressure ulcers that can also help you develop a
plan of care for patients with bowel incontinence.
 Nursing diagnosis: Constipation related to less than
adequate fluid and dietary intake and chronic
laxative use
 Goals:
 Mr. Gutierrez will establish and maintain a normal
defecation pattern within 1 month.
 Mr. Gutierrez will identify practices that reduce the
risk for or prevent constipation within 2 weeks.
 Health promotion
 Promotion of normal defecation
 Establish a routine an hour after a meal, or maintain the
patient’s routine.
 Sitting position
 Privacy
 Positioning on bedpan
 Instruct Mr. Gutierrez in a weekly menu plan, including




foods high in fiber: brown rice, beans and rice,
tomatoes, and wheat tortillas.
Add bran flakes, bran, or fiber supplement to Mr.
Gutierrez’ diet.
Consult with Mr. Gutierrez’ niece and long-term care
center to have the patient’s stove repaired.
Educate Mr. Gutierrez about the use of liquids to
promote softening of stool and defecation; have him
drink a decaffeinated beverage of choice.
Encourage Mr. Gutierrez to try to establish a routine
time for defecation, establishing a routine after
breakfast or another meal.
 Cathartics and laxatives
 Oral, tablet, powder, and suppository forms
 Excessive use increases risks for diarrhea and
abnormal elimination.
 Antidiarrheal agents
 Over the counter
 Opiates used with caution
 Types:
 Cleansing
 Tap water
 Normal saline (infants and children)
 Hypertonic solutions
 Soapsuds
 Oil retention
 Others: carminative and Kayexalate
 Enema administration
 Sterile technique is unnecessary.
 Wear gloves.
 Explain the procedure, precautions to avoid
discomfort, and length of time necessary to retain
the solution before defecation.
 Digital removal of stool
 Use if enemas fail to remove an impaction.
 This is the last resort for constipation.
 A health care provider’s order is necessary to remove
an impaction.
 Purposes
 Decompression, enteral feeding, compression, and
lavage
 Categories of nasogastric (NG) tubes
 Fine- or small-bore for medication administration
and enteral feedings
 Large-bore (12-French and above) for gastric
decompression or removal of gastric secretions
 Clean technique
 Maintaining patency
2. To maintain normal elimination patterns in the
hospitalized patient, you should instruct the patient
to defecate 1 hour after meals because
A. The presence of food stimulates peristalsis.
B. Mass colonic peristalsis occurs at this time.
C. Irregularity helps to develop a habitual pattern.
D. Neglecting the urge to defecate can cause diarrhea.
 Care of ostomies
 Irrigating a colostomy
 Pouching ostomies
 An effective pouching system protects the skin, contains fecal
material, remains odor free, and is comfortable and
inconspicuous.
 Nutritional considerations
 Consume low fiber for the first weeks.
 Eat slowly and chew food completely.
 Drink 10 to 12 glasses of water daily.
 Patient may choose to avoid gassy foods.
 Bowel training
 Training program
 Diet
 Promotion of regular exercise
 Management of hemorrhoids
 Skin integrity
Review Mr. Gutierrez’
diary of foods, and ask
him about his intake as
well.
Mr. Gutierrez describes likes and
dislikes but admits to eating high-fat
foods and few fruits and vegetables.
Fluid intake averaged 1400 mL daily
for a week.
Ask Mr. Gutierrez about
his pattern of
elimination over the past
2 weeks and laxative use.
Mr. Gutierrez says, “I still go about
the same” but states that he thinks he
now goes about every 2 days.
Mr. Gutierrez has not used any
laxatives for a week.
During follow-up visit,
examine patient’s
abdomen and observe
stool (if possible).
Patient reports that stool is formed
but is “not hard like before.” Bowel
sounds are normal. Abdomen is soft
and nontender with no distention.
 Do you use medications such as laxatives or
enemas to help you defecate?
 What barriers are preventing you from eating a
diet high in fiber and participating in regular
exercise?
 How much fluid do you drink in a typical day?
What types of fluids do you normally drink?
 What challenges do you encounter when you
change your ostomy pouch?
 Vickie returns to see Mr. Gutierrez 2 weeks later. Vickie is eager to
determine whether her patient has made changes in his diet, and if
his problems with bowel elimination have been progressing. Vickie
is also eager to learn if his stove has been repaired.
 Mr. Gutierrez tells Vickie that he has been eating bran cereal in the
morning, has been eating rice and/or beans for dinner, and has
added one fruit each day to his diet.
 He has been walking twice a day through the long-term care center.
Although he does not have a bowel movement each day, his stools
are much softer and easier to pass, and he says he is less concerned.
He has not taken a laxative for a stool since last talking with Vickie.