FPCC Bowel Study Guide Bowel elimination Bowel diversion- when the bowel cannot pass feces in the normal routine. Clostridium difficile- Antibiotics knocked out normal flora then c. diff came in & grew in the colon. Leads to sepsis. Destroys the colon. Usually gets people into Isolation. Spore We also discuss several other topics like hydroiodic acid and barium hydroxide
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based, so wash hands with soap & water. To prevent infection spreading or reinfection, while cleaning utilize a 1:10 ratio of bleach & water. 1 cup of bleach +9 cups of water made fresh daily. Keep the surface wet with solution for ten minutes. Colostomy- when the ostomy is formed in the colon. Constipation- decrease in the frequency of bowel movements with the passage of hard, dry stool. Defecation- pooping Diarrhea- increase in number of stools, passing liquids, & unformed stool. Causes the problem that it is passing through the gut so fast that we cannot get water & nutrients out that the body needs. Enema- procedure in which liquid or gas is injected into the rectum, typically to expel its contents, but also to introduce drugs or permit X-ray imaging. Fecal impaction- will occur in a patient who has been constipated for some time & the feces has become so rock hard, pebble like & dried out that it cannot move through the bowel to pass. Painful. Hemorrhoids- pressure sensors that are inside the rectum. They let you know whether it is okay to pass gas or if you pass gas you will poop your pants. Inflamed hemorrhoids are the reason hemorrhoids have a bad name. prevent by restricting straining. Use cooling bags (cause vasoconstriction that will help shrink the swollen vessels back down) or use sitz bath which cleans the feces off with water, instead of wiping & irritating it. Ileostomy- surgically removing the ilium & opening up the skin/surface of the abdomen. Can be temporary or permanent. feces will be loose, liquidy, draining continuously, & hard to control. Patient will need a bag. Occult blood- occult=hidden. It is hidden blood in the stool. Ostomy- stoma, a surgically made opening. Paralytic ileus- cessation (stopping of peristalsis) after surgery. Paralytic like you are paralyzed & ilieus like the ilium of the small bowel. This is normal, we expect this to happen after abdominal surgery for 24-48 hours. But if it is happening in a different setting for longer than that, then we become concerned about that. Peristalsis- involuntary constriction and relaxation of the muscles of the intestine or another canal, creating wavelike movements that push the contents forward. Stoma- ostomy, a surgically made opening Valsalva maneuver- holding a deep breath & bearing down, can be dangerous, why people people die on the toilet trying to poop. You will see this with patients who have heart problems, heart rate drops when pooping. When you leave class, you should be able to: Examine the factors that affect bowel elimination. - Frequency & appearance o Ask client what is normal for them. “how often do you go & what does it look like? When was your last bowel movement? What did it look like, was it normal for you? was it more frequent, different in color or consistency?” - Normal varies between patient to patient. - 2-3 times a day to 2-3 times a week can be normal depending on the client. - Normal color for most people is brown from bile salts that we are getting rid of. - Normal consistency is soft & semi-poor - Personal habits o “do you have a private place to go to the restroom? Are you able to go when you need to go? Is it normal for you to go in the morning after coffee & breakfast, or do you go after you exercise, after lunch?” o if patient does not feel comfortable going to the bathroom & they wont, & the longer we don’t go, the more water that is absorbed from the feces back into the body, then the stool becomes harder & harder. - Heath history o Surgeries - especially bowel surgeries are going to cause the colon/GI tract to slow down (peristalsis). - This happens because the medications that we give to some extent, the anesthetics, & then the pain meds on the opioids can cause peristalsis to slow so patient can not get bowels to move. - When we have cessation (stopping of peristalsis) after surgery we call that a paralytic ileus. - The symptoms/Clinical manifestations of paralytic ileus - bowel sounds are very diminished or maybe even absent, - patient will feel bloated & gassy & uncomfortable, - they aren’t moving things along in there & it feels uncomfortable.o Emotion stress- assessed related to normal bowel function. Stress can cause either constipation or diarrhea. It will either increase or decrease the motility/ motion of the peristalsis of the GI tract. - Depression usually slows things down so those clients are at higher risk for decreased peristalsis & constipation that results from that. - - Pain- should not hurt to poop. - Continence- “do you have problems controlling your bowels? Are you able to remain continent of stool or are you incontinent?” o Expect to see continence at ages 2-3, then through adulthood, then older adults sometimes have loss of sphincter control. They are at higher risk for incontinence. - Do not ever say it is normal to have a bowel accident because you are older, because it’s not. Bowel control is not equated with aging & is not inevitably going to happen. - Meds o How often do they take laxatives or something to help with stool? - If using every day & become dependent, muscles will lose their tone & they wont go poop without it. - Basically become physically addicted to laxatives. o Opioid analgesics result in constipation. o Antibiotics cause diarrhea, & you look for C. Diff. o iron causes constipation, It makes stool look black & sticky & it can also cause cramping, nausea. - Think about anemic patients & pregnant patients who need iron supplements. o Calcium supplements cause constipation, Magnesium causes diarrhea & is found in a lot of laxatives. - Diet- “do you eat on a regular schedule?”o when a client eats regularly, they are less likely to have bowel problems like constipation or diarrhea. o Also ask about fiber intake. need to take 25 grams for females & 38 grams for males a day. - Hard to measure, so ask instead “lets go to 5 servings of high fiber food a day” like vegetables with skin & are fresh, beans, whole grain bread, nuts, & corn. - Fiber helps us to have soft stool, decreases risk of cancer, & is important to keeping the stool soft enough to not get constipated. Fluid intake is also important. - Activity Level- activity increases peristalsis. o The more we get our patients moving, the more promotion of normal bowel function we have. - Changes - Really important when patient says their bowel movements have changed. o Red flag area that we need to dig deeper & ask questions. “what has changed? The frequency? The color? Consistency? Shape?” & find out & report that to the provider. - Normal rules you can use for everyone o can get to the toilet without rushing to have a bowel movement o don’t have a lot of straining when you get there o do not have blood loss when you poop o can accomplish all of this without using laxatives. Identify appropriate nursing history questions and assessment techniques to assess bowel elimination problems, & Describe the pre- and post-procedure nursing care for patients undergoing diagnostic tests that identify bowel elimination problems. - Physical assessment o Abdomen - Normal appearing abdomen should be flat or slightly rounded. When palpating you would expect it to be soft & non-tender. - Not normal- If abdomen is distended, firm, bowel sounds are hyperactive or absent o Stool - if stool is discolored, think gallbladder disease.- Could be the patient may have blocking the bile duct - Iron makes it look black & sticky & so does blood & bleeding. - Melena- If there is blood going up higher somewhere like not close to the rectal area, sigmoid, but way on up, & it is coming down through the colon, it will often make stool look sticky & like tar, except it may have a reddish/black tent to it. - Before assuming a patient has blood in their GI tract, ask if they have taken iron. - Sometimes you will see brown stool & it looks like mucous-y strings are on it, it might even have blood streaking on it, so maybe there is an infection of some sort going on. - Hematochezia- Poop is coming out bright red, blood looking. Blood is low enough down that it is not getting broken down like it is in the tar-y stool. - Can get ideas of where the client is bleeding based on the stool. - Consistency- is it hard, soft, or is it liquid. - Stool labs o Occult Blood Guiac or FOBT (fecal occult blood test) - Use this when we do not see the tar or bright red stool, but can check for the chemicals/chemistry of the blood in the stool. - So a patient with abdominal pain, a female patient with pelvic pain, you want to see what's going on so the provider/NP/Physcian may do a rectal exam (so have gloves & lubricant) & you will get a card & developer. - Assist patient to the side, & after doing the rectal exam with the finger the provider will have you open the card so they can wipe the stool on the card. Then the card will be closed on one side, flipped to the other, & we will put the drops of the hemo-occult developer on the other side. - If it turns blue, we see there is blood in the stool that we could not see with our eyes. - After you hit 50, it is done every year. o Patients can collect stool as a routine screening for colon cancer at different ages.- Patient may be sent home with the card & told to collect the stool & return it for testing - If they are sent home do to this, teach patient to reduce protein intake & be careful with raw green leafy vegetables for 3-7 days if possible because they may cause false results. - Vitamin C is another to caution to avoid because it could cause a false negative. o Stool cultures- if you see mucousy crud looking sticky stuff on stool or diarrhea you may need a stool culture. - may also collect for O&P- ova & parasites. Checking for bugs that may be causing the diarrhea or abdominal pain or whatever it happens to be. - Stool specimens need to be fresh. Need to collect & get to lab ASAP. - Do not collect stool specimens that are mixed with the water in the toilet or with urine. - If it is formed stool, you need an inch. If it is liquid, 15-30 mLs. - If you are testing for O&P poop needs to be warm & fresh to see the living organisms in the stool. Diagnostic tests- nurses assist, prepare patients, teach the patients to be prepared for the exam. - Direct Visualization- primarily done for cancer screening, FOBT, sigmoidoscopy, colonoscopy. o Oscopy- taking a tube with camera on it, & the doctor will go in & actually look in the area needed with the scope. o Looking through the scope with light to see if there are tissues, polyps, ulcers, tumors. o Sometimes you can remove polyps & get them sent to be biopsied to see if they are cancerous & it may be used to do procedures to stop bleeding. o Do need to have a separate consent for these studies. o Ideally the patient needs drink clear liquids 24 hours prior to procedure, then needs to be NPO after midnight, preferably 12 hours prior to the procedure. o After the procedure the client will start back out with clear liquids, then advance as tolerated. o Often will complain of feeling gassy because often gas is injected in there to help dilate & see better. Patient will be bloated & uncomfortable. o With any of these test, it is possible for the tube to perforate, poke a hole through the area. - Want to be aware of things like EGB, sudden shortness of breath, change in lung sounds. Abdominal pain, bleeding. o The tube that goes down back of the throat can leave you feeling sore, so maybe suggest hard candies, throat lossages, or warm salt water gargles to ease it. o If it is done outpatient, client will not be able to drive home because they had been sedated. - So before it starts make sure there is someone there to drive patient home. Withhold sedation medication until you physically see them. o The 3 test: - Sigmoidoscopy- Looks at the sigmoid colon. The S part. Does not go far up into the colon. - Patient will receive bowl prep by using laxatives & have them keep going into the bathroom until you can not poop anymore. - Take a laxative by mouth, maybe something to drink (magnesium citrate) - Nurse may perform an enema to help clean out the other end. - If you work in ICU, usually clients will go to a special procedure room to have this done. - Will receive sedation to help them forget the procedure. - Never give patient anything to eat or drink until gag reflex is returned, as you will with any sedation. - Not done as often, but guideline is to get it done every 5 years after turning 50. - Colonoscopy- look at the whole bowel even into the proximal part of the small bowel. Much more extensive. - After turning 50, do this every 5 years. - Upper Endoscopy (EGD)- looks over the GI tract. If patient is vomiting blood, having trouble swallowing, they will take a scope & go through the mouth to look through the esophophagus & into the stomach. - Non-directly looking through the scope o KUB- flat plate- KUB, urinary bladder, very basic simple x-ray. X-rat plate is placed behind the undressed client & a picture is taken with the x-ray machine.o Barium- Swallow & enema- shows up on x-ray to see where the barium is filling/shape it is taking. - If there is a tumor in there, we will not see the barium fil that space. - If the patient has a barium enema or swallow they HAVE to drink lots of fluids due to it being very constipating. - Stool will look gray, white until they have completely gotten it out of their system. o Ultrasound- done with tons of different problems the patient may have. Abdominal pains of all sorts. - Sound waves show whether it is a solid or liquid. o Computed tomography (CT) – done a lot. - When talking about the GI system, you will have clients who are given contrast to drink sometimes because we want to see all the structures as it goes through. - But you may also see contrast through the vein, so ask patient if they have allergies to shellfish or iodine. - Two lab values you check before you let patient roll down the hall to have test done are BUN & Creatinine. - Because the dye will stress the kidneys & we need to make sure kidneys are healthy enough to handle that. - Lots of fluids after, NPO before if possible. o Magnetic resonance imaging (MRI)- done a lot. - sensitive for tumors, blood flow, bleeding. - Dye can be given with an MRI but it is not iodine based dye, so do have to worry about that with this. - Do need to make sure patient has no metal/ jewelry on. - Patient has to lie really still in a really noisy & loud tube. May need to give patient something for claustrophobia. Formulate nursing diagnoses associated with altered bowel elimination. - Perceived constipation o A lot of time older adults forget the frequency of normal bowel movements. They want to have one every day, & that just may not be normal for them. - Constipation- decrease in the frequency of bowel movements with the passage of hard dry stool. o common because it makes people miserable. Also increases complications. It is usually a symptom of a disease. o short term constipation is caused by being poop shy, fighting the urge to poop. - Travelers who don’t want to stop the car to go poop, diets low in fiber, activity changes, medications like iron & calcium, & decrease in fluid intake. o chronic constipation we will often see with chronic illness patients like with Parkinson's, neuromuscular problems, depression, thyroid, hypothyroidism. o Common in people with decreased motility that goes along with aging, someone who used laxatives so much their bowl is dependent on them to go. o CM- do not have stool often, hard to get stool to come out, painful, have to strain, can lead to dangerous problems. o When you take a deep breath & bear down like you are trying really hard to poop, you are decreasing venous return because you have increased in thoracic pressure & suddenly let go there could be a huge whoosh back in & the heart cant handle it if there is already a heart problem going on – - Valsalva maneuver- holding a deep breath & bearing down. Can be dangerous. Why people die on the toilet trying to poop. You will see patients with heart problems heart rate drop when pooping. o When trying to pass rock hard stool it can tear tissues around there. o Fissures, swollen hemorrhoids can develop. Can be significant health hazard in a lot of ways. o Bearing down to poop increases intraocular pressure & intracranial pressure so stroke risk increases. Can also stimulate the valgus nerve, this will cause heart rate to drop. If heart rate drops & cardiac output drops, you can pass tf out. - Risk for constipation o Related to diarrhea - Outcomes o Patient will report passing soft, formed stool without straining within 24 hours. o Patient will increase dietary fiber intake to 20 grams/day within 10 days. Compare and contrast the nursing care of patients with common bowel elimination problems: flatulence, stool incontinence, constipation, diarrhea, and impaction. - Constipation- Most important is to prevent constipation from happening. o Increase fiber diet, exercise, fluid. Go when you need to go. o Promote normal bowel movements. - If patient has a routine, help patient to maintain that routine. If they do not have a routine, help them to establish one. - Give them privacy. - The normal position for all of us is sitting. - Eating often will trigger peristalsis, so that means we may be able to have a bowel movement. - Ask the patient if they need to go within an hour or so after eating. - Reassure patient to call you when they feel like they need to go to avoid constipation & you having to do enemas. o If these fail, you may need to give medicine. Think of it as most normal to least normal. o Bulk stool medications like Metamucil's is most common, is just a bulk of fiber you are adding to their diet. - They will take a tsp or tbs or an ounce or whatever in a certain amount of liquid & this will increase the fiber which causes bowel distension & stimulates the patient to need to be able to go. - Least irritating & safest. - Precautions- if not give with enough fluid, it will cause blockage. Give it with plenty of fluid. o Stool softeners- allow water to get into stool & make it softer. Docusate sodium is most common, colace is a brand name. mineral oils, lubricant, lactulose is an osmotic diuretic o Stimulants/laxatives- harder on bowel, patient, just harsher. Do this last. Irritate wall of colon to stimulate peristalsis. Dulcolax is most common. Ducolax suppositories usually but also comes in pills. o Understand that is patient is completely & totally plugged up, yes we will go to the big guns, but if you have someone you can work with then ideally start with bulk, then stool, then laxatives if patients situation allows us to. - Fecal impaction- If you have a client who has been constipated for some time & it has become rock hard & dried out that they cannot move or pass it, & it is painful & terrible & impacted. Feels like pebbles, rock hard.o CM - prolonged constipation that has turned into impaction/ blockage. Patient can not pass stool - Oozing of loose stool. Loose stool from up above it is sometimes able to seep around it & they ooze & leak stool. This isnt normal, it is loose stool able to get around blockage. - Anorexia- appetite will be bad, Nausea, cramping, abdominal distention. - Rectal pain because you have pebbles up in there. o Dangers - If patient is impacted, they are at risk for a true bowel obstruction. Can kill the patient. - Vagal stimulation- in the process of trying to pass it & you are straining so hard trying to get it to move, you get into vagal stimulation which causes patients to get bradycardic, drops cardiac output, & maybe even have them pass out or have a stroke. o Treatment- remove it. - DRE- digital rectal exam. As nurse you get gloves & KY(lubricant) & insert finger into the patients butthole to see if you can feel that hard stool just sitting there. - Then you notify the provider & get an order for digital disimpassion. - Never dis-impact patient without an order. - Digital disimpaction- Once you have an order, you use your finger to break it up in there & get it into small enough pieces that you can scoop a little out or the patient is able to start passing it out. - Careful monitoring of the patient. If they look pale, & feel light headed, you will immediately take your finger out of their butthole & stop what you are doing, recheck block pressure & vital signs - Diarrhea- Increase in number of stools, passing liquid unformed stool.o Problem that it is passing through gut so fast we can not get water & nutrients out that the body needs. o Causes-viral, bacterial, over use of laxatives, IBS, food poisoning, food intolerances, antibiotics by any route alters normal flora. o Dangers - When you are rapidly losing stool, you are rapidly losing bicarbonates from the body. If you lose this, your body will have too much acid by comparison. Patient is at risk for metabolic acidosis. - Losing lots of fluid - Contamination- whatever is going on in there & you share it with someone else. Whether it is C. Diff or whatever it happens to be - Skin breakdown o Treatment- replace fluid as quickly as possible. - Give pedialyte by mouth. - Clear liquids. Really slow things down in there. - Avoid caffeine. - Lots of skin care, may need a rectal tube if it is really bad. o Why would we not stop diarrhea sometimes? - Because body is trying to get rid of something for a reason. Maybe an infection. We want to be cautious. Don’t want to get into an acid base imbalance, fluid volume deficit. o If you have diarrhea for multiple days, you should get a stool culture done & look at reason for it. - Flatulence- gassy. Abdominal distension. Medications like opioids, anesthetics. Treat cause. Increase activity to get things moving & gas passing. - Stool incontinence- Inability to control the passage of feces & gas o Caused by anything that causes you to lose control of the sphincter & not be able to keep the stool from passing. Neuromuscular disease. o Danger- skin break down, social isolation- when you aren’t sure when you will poop or pass gas you will not go anywhere because you are embarrassed o Treatment- skin care, if there is a cause we can approach, work on that. Patient may use rectal bag or tube to help control it if it is really bad. Bowel training. Summarize safety concerns to be considered during digital removal of impacted stool. See treatment for fecal impaction. Differentiate between the different types of bowel diversions and associated nursing care. - Ileostomy o Removing the ilium causing an opening of the surface on the abdomen. o Done surgically. o it is usually loose, liquidy, & hard to control. Patient will need a bag. o Purpose of a wafer is to protect the skin from the stool. Patient will empty bag & care for it. o Treatments to give the patient continence- - Kock pouch- bring a loop of it through the skin & inside & there is a pouch & it holds the stool as a reservoir - they can not constantly have to be draining the bag. This is a continent stoma that is drained intermittently by the patient or us. - Illoanal reservoir- part of ileum Is taken down & connected to the rectal area. - If patient has good sphincter control, then they can pass their bowels reasonably normally. - Continent because stool is evacuated through the anus. - Colostomy- When the ostomy is formed in the colon. o liquid drainage from colostomy will be more formed & depend on where in the colon is formed. o These are reversible/temporary. o Loop Colostomy- In some cases there will be a little opening on the abdominal wall, they will bring a little loop of the bowel out & the side of the bowel that is toward the belly will have a little opening in it. - The surgeon will slide something under it to keep it from falling back into the abdomen. This is temporary, so maybe trauma patients. o Double Barrel - Sometimes we need to do treatment or healing & repair & we know we will need to take it out, so they will take part of the colon, remove the middle section, bring both sections out to the service of the abdomen. - The side coming up will be draining stool, the side that is the dead end side will still bring stuff out, it will just be mucous-y looking stuff. - Whenever the situation is resolved, they will take those two ends & reanastomos them (hook them back together) - Astomoses means to attach together. o Both temporary & reversible of colostomy’s. o End colostomy- Permanent or end stoma- patient had to have whole body revised. - the sigmoid colon is removed. - Stool should be formed, more easily able to handle/ manage. But still is not considered continent. - Biggest reason it is done is for cancer. - Ostonomy care o Normal stoma is moist, shiny, pink (brick red) - If it is dry there is danger of skin break down. If it is changing colors to blue, brown, or black, then there is probably lost circulation. o Assess output, how loose, formed, how much. Skin around stoma is at high risk for break down, so assess the peri-stomal skin is intact & not developing any irritation. o Nutrition- after stoma is formed, a lot of the time the patient will do a low fiber diet, & once it is well established the client can eat whatever they want to eat. - They may find if they form a lot of gas they want to avoid those kinds of foods because the gas will fill their bag & embarrass them. - There really are not a whole lot of restrictions for stoma once it has adapted well. o Never underestimate the psychosocial aspect. There are a lot of different clothing's that can be worn to hide the stoma which allows them to have intimate relationships, go to the beach, & feel comfortable doing a lot of things like that. o You can irrigate a colostomy, so if it is continent ostomy that needs to be emptied, the patient can tell you how to do it. It can be done but not often at all. - Never use an enema bag to do it. Use a special irrigation set to do it. o Pouching an ostomy purpose is to protect the skin, contain fecal material, control odor to help patient feel more comfortable & allows it to be inconspicuous. - Examine how alterations in bowel elimination affect the client’s self-concept and self-esteem. - Could cause patient to go into social isolation o if patient is embarrassed to go out because they are worried about controlling their continence, gas, or have a colostomy bag which could possibly smell bad. o This is very bad for the self-esteem & concept to be worried all the time. - Decreases both Describe how to safely insert and use nasogastric tubes for gastric lavage, compression, and decompression. - 4 reasons we will take a tube, put it in patients nose, & into stomach. Enteral feedings, lavage, compression, & decompression. - Lavage- to wash. Irrigation. Patient has something in stomach, blood, pills, something we want to get out of there. o we may insert a tube down their nose into their stomach & use the same process of measuring & securing & all of that, but this time irrigate it like crazy with lots of water or saline. - Compression- wont see much anymore at all. Saline pump you have put down the patient has balloons on it. o Surgeon will insert it & they will inflate balloon & they will use it for pressure to stop bleeding. - Maybe there is a vessel in the esophagus that is swollen & bleeding profusely, life threatening. If they can put pressure on it & get it to stop bleeding long enough to get into the OR, it’s a good stop measure. o Decompression- use all the time. - The patient needs to not use their stomach. It needs to rest. - We need to keep fluids from building up & prevent nausea. - Put tube down, hook it up to wall suction. Suck out all the secretions stomach puts out & monitor what is going on. Might be emptying blood, green yellow bile stuff out, mucous-y stuff, whatever is in there we are getting out. - Reason to do it: resting after surgery, protractive nausea patient (patient cannot stop throwing up), pancreatitis patients, post op - for decompression, use - clean technique - Maintaining patency by irrigating it as needed, flush with saline & then pull back out or let it be pulled back to the wall suction. - Blue pig tail is used is an air vent. Allows air to come in to replace space you are pulling out through the other end of the tube. - Never block, irrigate, never put anything down the blue pig tail area. - If it does get backed up, take the anti-reflux valve, take the blue end & put it in the blue pig tail. It does not block air, but it blocks secretions from coming out & making a mess. - Complications- pressure ulcers where it is attached, becoming displaced, acid base & electrolyte imbalances - Comfort- these patients are NPO, so oral hygiene. - Reposition tube, to maybe a little different tape of the nose as irritation increases. - throat losages/ice chips if the back of their throat is bothering them. Evaluate the client's response to interventions related to bowel elimination.