Group G

CHAPTER 21 - Fecal EliminationPhysiology of Defecationfeces (stool) - excreted waste products of digestionLarge IntestineCharacteristicsextends from ileocecal valve to the anusadult is generally 50-60 inches longhas seven parts:cecumascending colontransverse colondescending colonsigmoid colonrectumanusa muscular tube lined with mucous membranecircular and longitudinal muscle fibers that form haustrahaustra - pouches of the small intestineMain functionsabsorption of water and nutrientsfood from previous 4 daysmost waste products are excreted within 48 hours of ingestioningestion - the act of taking foodchyme - waste products that leaves the stomach through the small intestine and passes through the ileocecal valve1,500 mL chyme per day passes through colononly 100 mL is excretedmucoid protection of intestinal wallcontains large amounts of bicarbonate ionsprotects the wall of large intestine from trauma by acids in the feces and serves as adherent for holding fecal material togetherprotects intestinal wall from bacterial activityfecal eliminationtransport of flatus and feces for elimination through the anal canalflatus - air that is a by-product of digestion of carbohydrateshaustral churning - movement of the chyme back and forth within the haustra that aids in the absorption of water and moves the contents forward to the next haustraperistalsis - wavelike movement produced by the circular and longitudinal muscle fibers of the intestinal walls that propels the intestinal contents forward; very sluggish in the colonmass peristalsis - a wave of powerful muscular contraction that moves over large areas of the colon; usually occurs after eating, stimulated by the presence of food in the stomach and small intestine; occurs only a few times a dayRectum and Anal Canaladult is usually 4-6 in longanal canal is distal portion of rectum 1-2 in longeach vertical fold in rectum contains an artery and a vein; functions to retain feces within the rectumhemorrhoids - a condition that occurs when the veins in the rectum become distended as can occur with repeated pressureanal canalbounded by an internal and an external sphincter muscleinternal - involuntary; innervated by the ANSexternal - voluntary; innervated by the somatic nervous systemDefecationdefecation - the expulsion of feces from the anus and rectum; bowel movementfrequency is highly individual; several times per day to 2-3 times per weekamount also variesperistaltic waves move feces into sigmoid colon and rectum; sensory nerves are stimulatedinternal anal sphincter relaxes - feces move into anal canalexternal anal sphincter is relaxed voluntarilyexpulsion of feces assisted by abdominal muscles and diaphragm - increase abdominal pressurecontraction of pelvic floor muscles - moves feces through anal canalnormal defecation facilitated by:thigh flexionsitting positionif defecation reflex is ignored:urge to defecate normally disappears for a few hours before occurring againrepeated inhibition results in:expansion of rectumloss of sensitivity to the need to defecatemay lead to constipationFecesnormal feces75% water25% solid materialssoft, but formedif propelled quickly, no time for reabsorption of water and may have 95% waterrequire a normal fluid intakebrowndue to stercobilin and urobilin (derived from bilirubin - red bile pigment)action of E. coli or staphodor due to action of microorganisms on the chymeflatus (gas)7-10 L every 24 hoursCO2, CH3, H2, O2, N2from swallowed gas or formed through bacterial action on chyme or diffused from bloodCHARACTERISTICNORMALABNORMALPOSSIBLE CAUSEColorAdult: brownInfant: yellowClay or whiteAbsence of bile pigment (bile obstruction); diagnostic study using bariumBlack or tarryDrug (e.g. iron); bleeding from upper GI; diet high in red meat and dark green vegetables (e.g. spinach)RedBleeding from lower GI (e.g. rectum); some foods (e.g., beets)PaleMalabsorption of fats; diet high in milk and milk products and low in meatOrange or greenIntestinal infectionConsistencyFormed, soft, semisolid, moistHard, dryDehydration; decreased intestinal motility resulting from lack of fiber in diet, lack of exercise, emotional upset, laxative abuseDiarrheaIncreased intestinal motility (e.g. due to irritation of the colon by bacteria)ShapeCylindrical (contour of rectum) about 1 in in diameter in adultsNarrow, pencil-shaped, or stringlike stoolObstructive condition of the rectumAmountVaries with diet (about 100-400g per day)OdorAromatic; affected by ingested food and person’s own bacterial floraPungentInfection, bloodConstituentsSmall amounts of undigested roughage, slogged dead bacteria and epithelial cells, fat, protein, dried consistence of digestive juices (e.g., bile, pigments, inorganic matter)PusBacterial infectionMucusInflammatory conditionParasitesBloodGastrointestinal bleedingLarge quantities of fatMalabsorptionForeign objectsAccidental ingestionFactors That Affect DefecationDevelopmentNewborns and Infantsmeconium - the first fecal material passed by the newborn, normally up to 24 hours after birth; it is black, tarry, odorless, and stickytransitional stoolsfollow meconium for about a week - greenish-yellow, contains mucus, looseinfantspass stool frequently, after each feedingintestine is immature = stool is soft, liquid and frequentbacterial flora increase as intestines maturesolid foods = stool becomes less frequent and firmerbreast-fed - light yellow to golden fecesformula-fed - dark yellow or tan stool, more formedToddlerscontrol of defecationstarts at 1.5-2 years of agedesire to control daytime BM starts when child becomes aware of:discomfort caused by a soiled diapersensation that indicates the need for a BMtypically attained by 2.5 y/o after toilet trainingSchool-Age Children and Adolescentshave BM habits similar to adultspatterns vary in frequency, quantity, and consistencymay delay defecation because of an activity such as playOlder Adultsconstipationsignificant health problem in older adults due to:reduced activity levelsinadequate amount of fluid and fiber intakemuscle weaknessmay be relieved by increasing fiber intake to 20-35 grams per daypreventive measures for constipation:adequate roughage in the dietadequate exercise6-8 glasses of fluidcup of hot water/tea at a regular time in the morningresponding to gastrocolic reflex (i.e. 30 minutes after meals)gastrocolic reflex - increased peristalsis of the colon after food has entered the stomach; strongest after breakfastshould be warned that consistent laxative use may cause constipationmay also interfere with body’s electrolyte balancemay decrease absorption of certain vitaminscauses of constipationlifestyle habitsserious malignant disordersCLINICAL MANIFESTATIONS: COLORECTAL CANCERRISK FACTORSNonmodifiableAgeRaceFamily historyModifiableCigarette smokingPoor diet (e.g., low in fiber and high in fat)Lack of physical activityRegular consumption of alcoholSYMPTOMSA change in bowel habits such as diarrhea, constipation, or narrowing of the stool that lasts for more than a few daysA feeling of needing to have a BM that is not relieved by doing soRectal belleding or blood in the stool (often, though, stool will look normal)Cramping or steady abdominal painWeakness and fatigueUnexpected weight lossDietsufficient bulk (cellulose, fiber)necessary for adequate fecal volumeinadequate fiber contributes to risk of developingobesitytype 2 diabetescoronary artery diseasecolon cancerinsoluble fiberpromotes movement of material through digestive system and increases stool bulkex: whole wheat flour, wheat bran, nuts, many vegetablessoluble fiberforms a gel when mixed with waterlowers blood cholesterol and glucose levelsex: oats, peas, beans, apples, citrus fruits, carrots, barley, psylliumdrink plenty of waterlow-residue foodsmove more slowlyneed to increase fluid intake with such foods to increase rate of movementex: rice, eggs, lean meatscertain foods are difficult or impossible for some people to digestresults in digestive upsetsmay cause passage of watery stoolsirregular eatingimpairs regular defecationfoods that may influence bowel eliminationspicy foods - diarrhea and flatusexcessive sugar - diarrheagas-producing foods - cabbage, onions, cauliflower, bananas, appleslaxative-producing foods - bran, prunes, figs, chocolate, alcoholconstipation-producing foods - cheese, pasta, eggs, lean meatRECOMMENDED DAILY INTAKE OF FIBERMen50 and younger38 grams51 and older30 gramsWomen50 and younger25 grams51 and older21 gramsFluidbody continues to reabsorb fluid from chyme even when fluid intake is inadequate or output is excessivereduced fluid intake slows passage and further increases fluid reabsorptionhealthy fecal elimination requires intake of 2,000-3,000 mLif chyme moves abnormally quickly, less fluid is absorbed - feces are soft or wateryActivitystimulates peristalsis - facilitates movement of chyme along colonweak abdominal and pelvic muscles are ineffective in assisting defecationresults from lack of exercise, immobility, or impaired neurologic functioningconfined to bed = constipationPsychological Factorsanxiety/anger - increased peristaltic activity causing nausea or diarrheadepression - slowed intestinal motility causing constipationDefecation Habitsearly bowel training may establish habit of defecating at a regular timewhen normal defecation reflexes are inhibited or ignored, reflexes tend to be progressively weakenedwhen habitually ignored, urge to defecate is ultimately lostreasons adults/patients ignore reflexespressures of time or workembarrassment about using a bedpanlack of privacydefecation too uncomfortableMedicationsdrug side effects may interfere with normal eliminationdiarrheaconstipationmorphine, codeine (decrease GI activity through CNS effect)iron tablets - astringent effect, act more locally on bowel mucosasome medications directly affect eliminationlaxatives - medications that stimulate bowel activity and assist fecal eliminationstool softeners facilitate defecationcertain medications suppress peristaltic activity - treats diarrheaaffect appearance of fecesGI bleeding (e.g. aspirin products) - red or blackiron salts - blackantibiotics - gray-greenantacids - whitish or white specksPepto-Bismol - black stoolsDiagnostic Proceduressome procedures (colonoscopy or sigmoidoscopy)require NPOcleansing enemanormal defecation will not occur until eating resumesAnesthesia and Surgerygeneral anesthesianormal colonic movements cease or slow by blocking parasympathetic stimulationregional/spinal anesthesia less likely to experience this problemsurgerydirect intestinal handling - causes temporary cessation of intestinal movement or ileum (lasts 24-48 hours)listen for bowel sounds - intestinal motility, important nursing assessmentPathologic Conditionsspinal cord injuiries/head injuries - may decrease sensory stimulation for defecationimpaired mobilitymay limit ability to respond to urgemay cause constipationmay cause client to experience fecal incontinence due to poorly functioning anal sphinctersPaindiscomfort when defecating - may cause client to suppress urge to defecate; may cause constipationnarcotic analgesics for pain - may cause constipationFecal Elimination ProblemsConstipationconstipation - defined as fewer than three bowel movements per week, or the passage of dry, hard stool or no stoolDefining Characteristics:decreased frequency of defecationhard, dry, formed stoolsstraining at stool; painful defecationreports of rectal fullness or pressure or incomplete bowel evacuationabdominal pain, cramps, or distentionanorexia, nauseaheadacheImportant to define constipation in relation to the person’s regular elimination patternCauses and Factors that contribute to constipation:insufficient fiber intakeinsufficient fluid intakeinsufficient activity or immobilityirregular defecation habitschange in daily routinelack of privacychronic use of laxatives or enemasirritable bowel syndrome (IBS)pelvic floor dysfunction or muscle damagepoor motility or slow transitneurologic conditions, stroke, or paralysisemotional disturbances such as depression or mental confusionmedications such as opioids, iron supplements, antihistamines, antacids, and antidepressantshabitual denial and ignoring the urge to defecateIn children, constipation is associated with changes in:activitydiettoileting habitsValsalva maneuverstraining associated with constipation accompanied by holding the breathcan present serious problems to people with heart disease, brain injuries or respiratory diseaseFecal Impactionfecal impaction - a mass or collection of hardened feces in the folds of the rectum; results from prolonged retention and accumulation of fecal materialsevere impaction - accumulation well up into sigmoid colon and beyondSymptomswill experience passage of liquid fecal seepage and no normal stoolfrequent but nonproductive desire to defecate and rectal painresults in a generalized feeling of illnessanorexia, distention of abdomen, nausea and vomiting may occurmay be assessed by digital examination of the rectumCausespoor defecation habitsconstipationadministration of medications such as anticholinergics and antihistaminesbarium used in radiologic examinations of upper and lower GITreatmentoil retention enema followed by a cleansing enema 2-4 hrs later, daily cleansing enemas, suppositories/stool softenersdigital removalDiarrheadiarrhea - the passage of liquid feces and an increased frequency of defecationopposite of constipationresults from rapid movement of fecal contents through the large intestineSymptomsstool is relatively unformed and excessively liquidfinds it difficult or impossible to control the urge to defecateoften accompanied by spasmodic crams and increased bowel soundspersistent diarrhea irritates anal region and buttocksprolonged diarrhea results in fatigue, weakness, malaise, and emaciationCausesirritants in the intestinal tract - protective flushing; can create serious fluid and electrolyte losses (especially in infants, small children, and older adults)Clostridium difficile-associated diseaseproduces mucoid and foul-smelling diarrheahighest risk: immunosuppressed persons, clients on chemotherapy, those who have recently used antimicrobial agents (fluoroquinolones)greatest risk: elderlyinfection control: hand hygiene with soap and water, contact precautions, cleaning of surfaces with bleachCAUSEPHYSIOLOGICAL EFFECTPsychological stress (e.g. anxiety)Increased intestinal motility and mucous secretionMedicationsInflammation and infection of mucosa due to overgrowth of pathogenic intestinal microorganismsAntibioticsIrritation of intestinal mucosaIronIrritation of intestinal mucosaCatharticsIncomplete digestion of food or fluidAllergy to food, fluid, drugsIncreased intestinal motility and mucous secretionIntolerance of food or fluidReduced absorption of fluidsDiseases of the colon (e.g., malabsorption syndrome, Crohn’s disease)Inflammation of the mucosa often leading to ulcer formationincreased risk for skin breakdownskin around anal region should be kept clean and dry; use zinc oxideuse a fecal collectorBowel Incontinencebowel incontinence (fecal incontinence) - the loss of voluntary ability to control fecal and gaseous discharges through the anal sphincter may occur at specific times or irregularlytwo types:partial - inability to control flatus or to prevent minor soilingmajor - inability to control feces of normal consistencyassociated with impaired functioning of anal sphincter or nerve supply (in neuromuscular diseases, spinal cord trauma, and tumors of the external anal sphincter muscle)prevalence increases with ageemotionally distressing and may lead to social isolationTreatmentrepair of sphincterbowel diversion/colostomyFlatulencePrimary sourcesaction of bacteria on the chyme in the large intestineswallowed airgas that diffuses between the bloodstream and the intestinemost swallowed gases are expelled by eructation/belchinggas may accumulate in the stomach - gastric distentiongases formed in the large intestine - absorbed into circulationflatulence - the presence of excessive flatus in the intestines and leads to stretching and inflation of the intestines (intestinal distention)Causesfood (cabbage, onions)abdominal surgerynarcoticsReliefif gas is propelled by increased colon activity before it is absorbed, it is expelled through the anususe of a rectal tube to remove the gasBowel Diversion Ostomiesostomy - an opening for the gastrointestinal, urinary, or respiratory tract onto the skinAlternate feeding routegastrostomy - an opening through the abdominal wall into the stomachjejunostomy - a type of ostomy that opens through the abdominal wall into the jejunumBowel ostomies - to divert and drain fecal materialileostomy - a type of ostomy that opens into the ileum (small bowel)colostomy - a type of ostomy that opens into the colon (large bowelClassificationby permanent or temporary statusby anatomic locationby construction of the stomastoma - the opening created in the abdominal wall by the osmotic; generally red in color and moistmay bleed when touchedhas no nerve endingsPermanenceTemporary ostomies - allows distal diseased portion to healtraumatic injuriesinflammatory conditionsPermanent ostomies - provide a means of elimination when the rectum or anus is nonfunctionalbirth defectsdisease such as cancer of the bowelAnatomic Locationlocation influences the character and management of fecal drainagethe farther along, the more formed the stool, the more control over frequency of dischargelength of time ostomy is in place also causes stool to become more formedremaining functioning portions tend to compensate by increasing water absorption ileostomy - empties from distal end of small intestineproduced liquid fecal drainageconstant drainage, cannot be regulatedcontains skin-damaging digestive enzymesappliance must be worn continuouslyodor is minimal compared to colostomiescecostomy - empties from the cecumascending colostomy - empties from ascending colonsimilar to an ileostomydrainage is liquid, cannot be regulated, digestive enzymes presentodor is a problemtransverse colostomy - empties from transverse colonmalodorous, mushy drainageusually no controldescending colostomy - empties from descending colonincreasingly solid drainagesigmoidostomy - empties from the sigmoid colonnormal/formed consistencyfrequency of discharge can be regulatedmay not need to wear an appliance at all timesodors can usually be controlledSurgical Construction of the Stomaend or terminal colostomy - a type of colostomy that has a singe stoma created when one end of bowel is brought out through an opening onto the anterior abdominal wall; the stoma is permanentloop colostomy - a type of colostomy where a loop of bowel is brought out onto the abdominal wall and supported by a plastic bridge, or a piece of rubber tubing; the stoma has two ends: an active proximal end, and an inactive distal endusually for emergenciesstoma is bulky and more difficult to managedivided colostomy - consists of two edges of bowel brought out onto the abdomen but separated from each other; the proximal end is the colostomy and the distal end is the mucous fistulaused where spillage of feces into distal end needs to be avoideddouble-barreled colostomy - resembles a double-barreled shotgun; the proximal and distal loops of bowel are sutured together for about 10 cm (4 in) and both ends are brought up onto the abdominal wallNursing ManagementAssessingNursing Historyascertains client’s normal bowel patterndescription of usual fecesrecent changespast or current problems with eliminationpresence of an osmoticfactors influencing the elimination patternpattern depends on early training and conveniencePhysical Examinationphysical exam of the abdomeninspectionauscultationpercussionpalpationphysical exam of the rectum and anusinspectionpalpationInspecting the Fecesobserve client’s stoolcolorconsistencyshapeamountodorpresence of abnormal constituentsDiagnostic Studiesdirect visualization techniquesindirect visualization techniqueslaboratory tests for abnormal constituentsDiagnosing (LOOK THESE UP IN ACKLEY)Bowel IncontinenceConstipationRisk for ConstipationPerceived ConstipationDiarrheaDysfunctional Gastrointestinal MotilityFecal Elimination problems as etiologiesRisk for Deficient Fluid Volume and/or Risk for Electrolyte Imbalance r/t:Prolonged diarrheaAbnormal fluid loss through osmoticRisk for Impaired Skin Integrity r/tProlonged diarrheaBowel incontinenceBowel diversion ostomySituational Low Self-Esteem r/tOstomyFecal incontinenceNeed for assistance with toilingDisturbed Body Image r/tOstomyBowel incontinenceDeficient Knowledge (Bowel Training, Ostomy Management) r/t lack of previous experienceAnxiety r/tLack of control of fecal elimination secondary to ostomyResponse of others to ostomyPlanningMajor GoalsMaintain or restore normal bowel elimination patternMaintain or regain normal stool consistencyPrevent associated risks such as fluid and electrolyte imbalance, skin breakdown, abdominal distention, and painAlso identify appropriate preventive and corrective nursing interventions associated with goalsSelect specific nursing activities associated with each intervention to meet client needsPlanning for Home CareContinuing Care in the Home Setting for clients with:bowel diversion ostomiespouchesother ongoing elimination problemsDischarge preparation:Assess client’s and family’s ability to meet specific care needsTeaching plan based on dataImplementingPromoting Regular DefecationPrivacyprovide as much privacy as possible for clients to come it is extremely importantmay need to stay with those who are too weaksome clients prefer to wipe, was and dry after - provide water, washcloth, towelTimingencourage defecation when urge is recognizeddiscuss when mass peristalsis occurs to establish regular bowel eliminationsome have well-established routineother activities should not interfere with defecation timeNutrition and Fluidsdiet needed for regular normal elimination varies according to kind of feces, frequency of defecation and types of foods that assist client to defecate normallyFor Constipationincreased daily fluid intakehot liquidsfruit juice especially prune juiceinclude fiber in the dietFor Diarrheaencourage oral fluid intake and bland foodeat small amountsavoid excessively hot or cold fluids - may stimulate peristalsisavoid highly spiced foods and high-fiber foodsFor Flatulencelimit carbonated beverages, drinking straws and chewing gumavoid gas-forming foodsExerciseregular exercise helps develop regular defecation patternexercises for weak abdominal and pelvic floor muscles, which impede normal defecationin supine position, tighten abdominal muscles, holding for 10 seconds and relaxing; repeat 5-10 times q.i.d. depending on client’s healthin supine position, contract thigh muscles, holding for 10 seconds; repeat 5-10 times q.i.d. This helps client confined to bed to make it easier to use a bedpanPositioningsquatting best facilitates defecationon a toilet seat, best for most is to lean forwardelevated toilet seat - for those who have difficulty sitting down and getting up from toiletcommode - a portable chair with a toilet seat and a receptacle beneath that can be emptied; used for the adult client who can get out of bed but is unable to walk to the bathroombedpan - a receptacle for urine and feces for the female client; for feces for the male client (urinal for urine)2 types of bedpans:regular high-backslipper or fracture pan - low back for clients unable to raise their buttocksTeaching About MedicationsCathartics and Laxativescathartics - drugs that induce defecation that can have a strong, purgative effectlaxative is mild in comparisonproduces soft or liquid stools accompanied by abdominal crampsex: castor oil, cascara, phenolphthalein, bisacodyllaxativescontraindicated in client who has nausea, cramps, colic, vomiting, undiagnosed abdominal paindangers of laxative useweakens bowel’s natural responses to fecal distention - results in chronic constipationeliminate chronic laxative useeat fiberexercise regularlytake sufficient fluidsestablish regular defecation habitssuppositories - drugs inserted through the rectumsome laxatives are given in this formsoftens the feces by:releasing gases such as CO2 to distend the rectumstimulating nerve endings in rectal mucosainsert 30 minutes before usual defecation time or when peristalsis is greatest - after breakfastAntidiarrheal Medicationsslow motility of the intestine or absorb excess fluid in the intestineAntiflatulent Medicationscoalesce the gas bubbles and facilitate passage by belching or expulsion through the anus (i.e. simethicone)simethicone and loperamide - relieves abdominal bloating and gas associated with acute diarrhea; not for common flatulencecarminatives - herbal oils known to act as agents that help expel gas from the stomach and intestinessuppositories may relieve flatus by increasing intestinal motilityDecreasing FlatulenceAvoid gas-producing foodsExerciseMoving in bedAmbulationMovement stimulates peristalsis and escape of flatus and reabsorption of gasesCertain medications - probiotics; bismuth subsalicylate/Pepto-Bismol (may cause salicylate toxicity); alphagalactosidase (Beano)Administering Enemasenema - a solution introduced into the rectum and large intestine that distends the intestine and sometimes irritates the intestinal mucosa to increase peristalsis and the excretion of feces and flatussolution should be at 37.7?C (100?F) - too cold/hot may cause crampingFour classes:Cleansing enemaIntended to remove fecesGiven to:Prevent the escape of feces during surgeryPrepare the intestine for certain diagnostic tests such as x-ray or visualization tests (e.g., colonoscopy)Remove feces in instances of constipation or impactionHypertonic solutions - draws fluid into colonex: Fleet phosphate enemaHypotonic solution - causes water to move into interstitial space; stimulates peristalsis and defecation before water movesex: tap water enemaIsotonic solution - safest; no fluid movement; instilled volume stimulates peristalsisex: physiological/normal salineSoupsuds enema - stimulates peristalsis by increasing the volume in the colon and irritating the mucosause only pure soap (Castile soap) to minimize mucosa irritationLarge volume vs small volumeHigh enema - given to cleanse as much of the colon as possible; change positions to follow intestineLow enema - used to clean rectum and sigmoid onlyForce of flow depends on:height of the solution containersize of tubingviscosity of fluidresistance of rectumMost adult enemas - no higher than 12 in above rectumHigh cleansing - 12-18 in above rectumCarminative EnemaGiven to expel flatusSolution releases gas, distends rectum and colon and stimulates peristalsisRetention enemaIntroduces oil or medication into rectum and sigmoidretained for a long period (1-3 hrs)oil - softens feces and lubricates rectum and anal canal to facilitate passage of fecesantibiotic enemas - treats infections locallyanihelmintic enemas - kills helminths (worms, intestinal parasites)nutritive - to administer fluids and nutrients Return-Flow Enemaaka Harris flush - occasionally used to expel flatusalternating flow of 100-200 mL of fluid into and out of rectum and sigmoid stimulates peristalsisrepeated 5-6 times until flatus is expelled and abdominal distention is relievedclient may perceive that enema is a significant violation of personal spaceconsider cultural sensitivityconsider genre of caregiver and client’s potential discomfort - try to accommodate the client’s preferencesgentle, matter of fact approachmay trigger memories of past abusemonitor for emotional responses (subtle and extreme)may indicate history of trauma and require appropriate referral to counselingask client to describe experienceREVIEW SKILL 1: ADMINISTERING AN ENEMADigital Removal of a Fecal ImpactionInvolves breaking up fecal mass digitally and removing it in portionsContraindicated for some people - may cause excessive vagal response resulting in cardiac arrhythmiaOil retention enema (30 min) before disimpactionCleansing enema or suppository after disimpactionMay use lidocaine gel if permitted 5 minutes before disimpactionProcedure:If indicated, obtain assistanceRight-lying - sigmoid is uppermost, so gravity can aid in removal of fecesLeft-lying - allows easier access to sigmoidAbsorbent pad under buttocks and a bedpanDrape for comfortApply clean gloves and lubricate index fingerinsert into rectum and move along its lengthLoosen and dislodge stool, break up stool taking care to avoid injuring mucosaWork stool downward to end of rectum and remove in small piecesAssist client to clean anal area and buttocks, assist onto bedpanBowel Training ProgramsFor chronic constipation, frequent impactions of fecal incontinenceHelps client establish normal defecationMajor phases:Determine usual bowel habits and factors that help and hinderDesign plan with the client that includes:Fluid intake 2,500-3,000 mL per dayIncrease fiberIntake of hot drinks, especially before defecation timeIncrease exerciseMaintain daily routine for 2-3 wksAdminister cathartic suppository 30 min before defecation timeAt urge to defecate, assist to toilet/commode/bedpan, note timeProvide privacy for 30-40 minutesTeach to lean forward at the hips, apply pressure on abdomen, bear down, do not strainProvide positive feedbackOffer encouragementFecal Incontinence PouchTo collect and contain large volumes of liquid fecesPrevents progressive perianal skin irritation and breakdown and frequent linen changes due to incontinenceFecal collector secured around anal openingBest applied before perianal skin excoriationIf excoriation is presentapply skin barrier cream on skin until it heals, then apply pouchapply skin barrier underneath pouch to achieve best sealNursing responsibilities for clients with pouch:regular assessment and documentation of the perianal skin statuschange bag every 72 hours or sooner if there is leakagemaintain drainage systemprovide explanation and support to client and familyPost-stroke/post-trauma/quadriplegia/paraplegiasurgical repairartificial bowel sphinctercuffpressure-regulating balloonpumpenemas and rectal meds may be contraindicatedOstomy ManagementStoma and Skin CareCare of stoma and skin is important for all clients with osmoticfecal material is irritating to peristomal skin, particularly with an ileostomyassess peristomal skin for irritation each time appliance is changedirritation or skin breakdown needs to be treated immediatelykeep skin clean by washing off any excretion and drying thorouglyostomy appliancefunctions: protect skin, collect stool, control odorparts: skin barrier, pouch, ostomy belt (optional)may be one or two-piececlosed or drainable pouchdrainable - used by those who need to empty it more than twice a dayclosed - used by those who have a regular stoma discharge (sigmoid) only have to empty it 1-2 times/dayodor controlappliance is intactpouches with odor-barrier materialpouches with filter that allows gas out but not odorchanging the applianceup to 7 daysneed to be changed routinely before leakage occurschange at least once a weekremove pouch and skin barrier twice a week to clean and inspect peristomal skinchange whenever stool leaks into skinif skin is erythematous, eroded, denuded, or ulcerated, change pouch every 24-48 hours or more frequently if client complains of pain/discomfortempty pouch when it is 1/3 to 1/2 fulloverfilling can cause separation of skin barrier from skin and allow stool to touch skin - entire appliance needs to be removed and new one appliedREVIEW SKILL 2: CHANGING A BOWEL DIVERSION OSTOMY APPLIANCEColostomy IrrigationSimilar to an enemaUsed for sigmoid/descending colostomyDistend bowel to stimulate peristalsis and evacuation - to achieve regular evacuation pattern: wearing a pouch is unnecessarySome prefer to control time of elimination through rigid dietary regulation instead of irrigationSmall amount (300-500 mL) is enough for most, some need up to 1,000 mL because fluid returns as it is instilled - reduced by use of a coneMay be prone to peristomal hernias, bowel perforation, electrolyte imbalanceEvaluatingIf outcomes are not achieved, explore the ff questions:Were the client’s fluid intake and diet appropriate?Was the client’s activity level appropriate?Are prescribed medications or other factors affecting the gastrointestinal function?Do the client and family understand the provided instructions well enough to comply with the required therapy?Were sufficient physical and emotional support provided?

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