Fundamental Nursing Skills and Concepts

1
Fundamental Nursing Skills and Concepts

• Chapter 31
• Page 680

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Bowel Elimination

• Defecation is the act of expelling feces or stool
  from the body. Feces is stool.
• Peristalsis is the rhythmic contractions of
  intestinal smooth muscle. Wastes pass along the
  ascending, transverse, desending and sigmoid
  colon to the rectum. Peristalsis becomes even
  more active during eating, this increased
  peristaltic activity is gastrocolic reflex.
  Gastrocolic reflex usually precedes defecation.
• Valsalvas maneuver, closing of the glottis and
  contracting the pelvic and abdominal muscles to
  increase abdominal pressure, facilitates the
  process of defecation.

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Bowel elimination

• Table 31-1 factors affecting bowel elimination
  (681A)
• Table 31-2 characteristics of stool (681B)
• Stools appear abnormal, a sample is saved in a
  covered labeled container for the Doctor to see.
• LVNs do collect stool to test for occult blood.
  Usually the collection is sent to the lab for
  analysis.
• Test for occult blood- page 681B
• Nursing guidelines 31-1 page 681

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ASSESSMENT OF BOWEL ELIMINATION

• Elimination Patterns
• Frequency of elimination
• Effort required to expel stool
• What elimination aids are utilized
• Stool Characteristics-Description of appearance

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COMMON ALTERATIONS IN BOWEL ELIMINATION

• CONSTIPATION- Elimination problem characterized
  by dry, hard stool that is not easily passed. May
  present with distention, fullness, pressure,
  pain, decrease in frequency and changes in stool.
  May have fever as well.
• TYPES OF CONSTIPATION
• PRIMARY CONSTIPATION-Within treatment domain of
  nursing. It is due to lifestyle factors such as
  inactivity, inadequate intake of fiber,
  insufficient fluid intake, or ignoring the urge
  to defecate.

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COMMON ALTERATIONS IN BOWEL ELIMINATION

• SECONDARY CONSTIPATION-A consequence of a
  pathologic disorder such as partial bowel
  obstruction which resolves when the primary cause
  is treated or resolved. Ileus- post surgery-
  intestines did not wake up.
• IATROGENIC CONSTIPATION-Occurs as a consequence
  of other medical treatment. Narcotic use slows
  peristalsis, delays transit time. The longer it
  is in the colon the more fluid is absorbed, the
  drier the stool, the harder to pass it becomes.
• PSEUDOCONSTIPATION-Referred to as perceived
  constipation by NANDA. A client believes they are
  constipated even when they are not. They are
  fixated on the idea they are constipated. Overuse
  laxatives to overcome constipation, and this
  overuse instead of treating constipation is now
  the cause of constipation. This purging makes the
  muscle tone weak and then there is a need for
  laxatives.

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COMMON ALTERATIONS IN BOWEL ELIMINATION

• FECAL IMPACTION-Large, hardened mass of stool
  interferes with defecation, making it impossible
  to pass feces voluntarily.
• Unrelieved constipation- retained barium,
  dehydrated patient or muscle weakness. Large
  hardened mass of stool. Liquid stool seeps from
  higher in the bowel. May appear as diarrhea.
• Nursing guidelines for removing a fecal impaction
  page 683, 31-2.
• Figure 31-2 removing a fecal impaction top pg.
  683B

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COMMON ALTERATIONS IN BOWEL ELIMINATION

• FLATULENCE-Excessive accumulation of intestinal
  gas or flatus results from swallowing air while
  eating or sluggish peristalsis. Can also develop
  from gas producing foods. Vegetables, cabbage,
  cucumber or onions may cause flatus. May be a by
  product of bacterial fermentation. Ambulating
  helps to relieve flatus, if not, a rectal tube
  may be needed. Skill 31-1 page 691. Insert 4-6.
  Left in place 20 minutes. Every 3-4 hours.

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COMMON ALTERATIONS IN BOWEL ELIMINATION

• DIARRHEA-Urgent passage of watery stool and
  commonly accompanied by abdominal cramping.
  Usually lasts short period of time. Body is
  trying to get rid of tainted food, intestinal
  pathogens or irritating substances. May also be a
  result of emotional stress, dietary
  indiscretions, laxative abuse or bowel disorders.
  Maybe relieved by resting the bowel. Drink clear
  liquids for 12-24 hours. Start with bland foods
  low in residue, (bananas, apple-sauce, cottage
  cheese, jello). Teach if diarrhea lasts longer
  than 24 hours, contact the physician. Can get
  dehydrated easily.

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COMMON ALTERATIONS IN BOWEL ELIMINATION

• FECAL INCONTINENCE-Inability to control
  elimination of stool. May be neurologic changes
  (stroke) that impair muscle activity, sensation,
  or thought process. Person cannot postpone
  elimination. Socially and emotionally
  devastating. A lot of support and understanding
  needed in dealing with it. Patient guidelines
  managing fecal incontinence page 684, 31-1.

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MEASURES TO PROMOTE BOWEL ELIMINATION

• RECTAL SUPPOSITORY-Oval or cone-shaped mass that
  melts at body temperature and is inserted into
  the rectum. It has medication that will promote
  the expulsion of feces. Either by softening and
  lubricating dry stool, irritating the wall of the
  rectum and anal canal to stimulate smooth muscle
  contraction or liberating carbon dioxide
  increasing rectal distention. This is an example
  of a local effect. An example of a systemic
  effect is inserting a vistaril supp. to overcome
  vomiting. Taking a med orally would only have the
  chance of being vomited up. A suppository is a
  good alternative. They are designed to melt at
  body temperature. If the supp. is held too long
  by the nurse the shape may change or totally
  melt. So be ready for insertion when you pick it
  up.

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Cont.

• Check orders and MARS.
• Compare label 3 times, before, during, and after
  preparation.
• Determine patients understanding
• Administer on time
• ID patient
• Provide for privacy
• Position and drape patient. Wash hands, don
  gloves.

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Cont.

• Lubricate the supp. And the index finger of the
  predominant hand. Separate buttocks, reveal anus.
  Instruct pt. to deep slow breathe.
• Insert tapered end of lubricated suppository,
  beyond the internal sphincter about the distance
  of the finger. Avoid placing supp. In stool.
• Wipe lubricant from anus. Instruct pt. to retain
  for 15 minutes. Premature urge, contract gluteal
  muscles, breathe slowly. Try to hold for 15
  minutes.
• Instruct to wait to flush after defecating for
  inspection. Remove gloves, wash hands.

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MEASURES TO PROMOTE BOWEL ELIMINATION

• ENEMA-Introduces a solution into the rectum to
  cleanse the lower bowel, most common reason,
  soften feces, expel flatus, soothe irritated
  mucous membranes, outline the colon during
  diagnostic x-rays, treat worm and parasitic
  infestations
• Cleansing enemas are given to remove feces from
  the rectum. Defecation usually occurs in 5-15
  minutes after their administration. Large volume
  cleansing enemas may create discomfort because of
  distention. Administer causiously to pts. with
  intestinal disorders, because an enema may
  rupture the bowel or cause other complications.
• Skill 31,3 page 695

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TYPES OF ENEMAS

• Tap Water and Normal Saline Enemas- distends
  rectum, moistens stool. Non-irritating tap water
  is hypotonic and can be absorbed causing fluid
  and electrolyte imbalances. To ensure pt. safety,
  if stool continues after administering 3 enemas,
  consult the physician for administration of any
  more. 500-1000 mls.
• Page 684, table 31.3 types of cleansing enema
  solutions
• Soap Solution Enema- chemical irritation of bowel
  is the mechanism of action. (aka. SS enema)

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TYPES OF ENEMAS

• Hypertonic Saline Enemas-local irritation, draws
  more water into the bowel. 4 ounces or 120 ml,
  disposable, lubricated tip, less fatiguing,
  easily self administered.
• Retention Enema- mineral, olive, cottonseed oil,
  lubricates and softens the stool. Give slowly to
  enhance the retention time. A retention enema is
  held with in the large intestine at least 30
  minutes. 100-200 mls of warmed oil is
  instilled.

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OSTOMY CARE

• Surgically created opening to the bowel or other
  structure
• Two types of intestinal ostomies

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OSTOMY CARE

• ILEOSTOMY- AN OPENING SURGICALLY CREATED IN TO
  THE ILEUM. WHAT WILL THE RETURN IN AN ILEOSTOMY
  BAG LOOK LIKE________?
• COLOSTOMY- AN OPENING SURGICALLY CREATED IN TO A
  PORTION OF THE COLON. WHAT WILL THE RETURN LOOK
  LIKE IN A COLOSTOMY BAG________?
• Most ostomates, wear an appliance (bag or
  collection device over the stoma)
• Faceplate left in place 3-5 days, unless it
  loosens or there is discomfort, or becomes soiled
  beneath plate.

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OSTOMY

• STOMA- ORIFICE OR ENTRANCE TO THE OPENING
• APPLIANCE- BAG OR COLLECTION DEVICE OVER THE
  STOMA WHICH COLLECTS STOOL. POUCH IS EMPTIED WHEN
  1/3 TO ½ FULL. FIG. 31-5. PAGE 687.
• EXCORIATION- CHEMICAL INJURY OF SKIN.
• ENZYMES IN THE STOOL CAUSES SKIN BREAKDOWN.
• KARAYA PASTE, A PLANT SUBSTANCE THAT BECOMES
  GELATINOUS WHEN MOISTENED, AND COMMERCIAL SKIN
  PREPS CAN BE APPLIED AROUND THE STOMA TO PROTECT
  THAT SKIN SURFACE.

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APPLYING AN OSTOMY APPLIANCE

• Pouch for collecting stool and a faceplate or
  disk
• Pouch fastens into position when pressed over the
  circular support on the faceplate
• Can be fastened to a belt worn around the waist
  for extra support
• The client is able to empty the re-useable pouch
  by removing the clamp, emptying and then
  re-clamping the pouch. Disposable pouches can be
  removed and the face plate cleansed and another
  disposable pouch re-applied. Disposable pouches
  do not have an open end or clamp at the distal
  end.

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APPLYING AN OSTOMY APPLIANCE

• The client empties the pouch by releasing the
  clamp at the bottom of the re-usable pouch,
  cleansing the stoma and pouch and re-applying.
  Always making sure the pouch is secured on both
  ends.
• Remember that the stoma should be pink and moist.
• Measurement is important to protect the skin
  around the stoma (1/8 to ¼ inch) larger than
  the stoma.
• Body image disturbance is a factor for the
  patient. Ostomates think everyone knows, It
  pouches , It smells , It is noisey.
• CONTINENT OSTOMY-Surgically created opening that
  controls the drainage of liquid stool or urine by
  siphoning it from an internal reservoir (KOCK
  POUCH). This type of ostomy requires no
  appliance and the client drains stool or urine
  every 4-6 hours.

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Continent Ostomy, (KOCK POUCH)

• Is an internal reservoir that gets drained by
  siphoning. Keeps the patient continent. No pouch
  is worn.
• The disadvantage of the Kock pouch is that it
  must be tapped every 4-6 hours. The more solid
  the return, fluid might need to be administered
  to make the stool more fluid. Page 689 teaching.

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IRRIGATING A COLOSTOMY

• Clients with colostomy whose stool is more solid
  and sometimes requires the instillation of fluid
  to promote elimination.
• Purpose of the irrigation is to remove formed
  stool and in some cases to regulate the timing of
  bowel movements.
• With regulation, a client with a sigmoid
  colostomy may not need to wear an appliance.
• The colostomy irrigation helps to train the bowel
  to eliminate formed stool following the
  irrigation.

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NURSING IMPLICATIONS NURSING DIAGNOSES

• Constipation
• Risk for Constipation
• Perceived Constipation
• Diarrhea
• Bowel Incontinence
• Toileting Self-Care Deficit
• Situational Low Self-Esteem

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GERONTOLOGICAL CONSIERATIONS

• Age-related changes results in loss of elasticity
  in intestinal walls and slower motility
  throughout the gastrointestinal tract
• Implementation of home remedies to treat
  constipation
• Poor eating habits increase risk of constipation
  or diarrhea
• Instruct the client on the need to consume
  fruits, vegetables, and fluids
• Provide fiber supplements
• Incidence of colorectal cancer increases with age
• Musculoskeletal disorders interfere with the
  clients ability to care for an ostomy appliance