Bowel Care

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Bowel Care

• Yangama Jokwiro
• BScNS
• MSc Physiology
• Certificate IV in Training and Assessment

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Gastrointestinal System

• Mouth
• Esophagus
• Stomach
• Small Intestine
• Duodenum
• Jejunum
• Ileum

• Colon
• Ascending
• Transverse
• Descending
• Sigmoid Colon
• Rectum

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Gastrointestinal System
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Assessment of Gastrointestinal System

• Note nutritional status as well as condition of
  teeth (denture fit) and mouth
• Ask client about diet, appetite and bowel
  patterns note date and time of last bowel
  movement
• Note history of diarrhea or constipation
  (hemorrhoids)
• Abdomen for bowel sound (passing wind)

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Bowel Assessment

• Presence of desire to defecate
• Signs of discomfort
• Food and fluid levels
• Full rectum
• Skin problems due to leakage
• medications that may contribute to constipation

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Defecation Act of expelling feces

• Facilitated by peristalsis (wavelike muscular
  contractions of large and small intestine)
• Movement of food and H2O as well as waste through
  intestines toward sigmoid colon and rectum
• Rectum distends
• Anal sphincter (bands of muscle) relaxes
• Defecation occurs

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Valsalva Maneuver

• Bearing down by contracting pelvis and abdominal
  muscles facilitates process of defecation
• Also increases intra-cerebral and intra-ocular
  pressures therefore contraindicated in
• Client with increased intracranial pressure (ICP)
• Client with glaucoma
• Has vagal effect stimulates vagus nerve may
  cause bradycardia therefore contraindicated in
• Client following Myocardial Infarction (MI)

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Nausea

• A sense of wanting to vomit medulla contains
  centre in brain for vomiting
• Multiple causes
• Post-operatively takes 24 48 hours for
  peristalsis to return distention of duodenum
• Medication sensitivities
• Chemotherapy
• Migraines
• Myocardial Infarctions (MI)
• Bowel obstruction

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Stool Characteristics

• Color generally brown but may be black,
  clay-colored, green or yellow
• Odor foul smelling
• Consistency soft and formed but may be hard,
  dry, watery, paste-like
• Shape round/full or may have no shape
• Other components may include blood, mucous or pus
• High fat content heavy stool
• Fiber content right- floating stool

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What is Constipation?

• Constipation is difficulty or straining on
  defecation of dry, hard stool
• infrequent bowel movements over an extended
  period of time, with the sensation of incomplete
  evacuation of the bowel

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Constipation

• Dry hard stools that are not easily passed caused
  by
• Inadequate intake of fluids
• Diet low in fibre
• Slow peristalsis
• Medications i.e. Codeine
• Signs and symptoms
• Abdominal distention
• Pain on defecation
• Decreased number of bowel movements
• Inability to pass stool or straining to pass
  stool
• May have oozing of stool if becoming impacted

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Types of Constipation

• Primary
• inadequate dietary fibre/ dehydration
• reduced mobility/ reduced muscle tone
• withholding faecal evacuation
• Secondary
• partial bowel obstruction
• spinal cord compression
• conditions such as hypercalcaemia

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Types of Constipation

• Iatrogenic
• induced by the administration of drug therapies
  such as
• anti-inflammatory
• anticholinergics
• antidepressants
• opioids
• aluminium and calcium antacids
• diretics

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Principles of Bowel Care

• Initial assessment to be performed to identify
  what are normal bowel habits for each individual
  resident.
• Daily assessment - includes residents treatment
  preferences, history of bowel habits and
  management
• Ongoing assessment

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Principles of Bowel Care

• Prompt and individually tailored treatments
• Minimization of interventions that can cause loss
  of dignity
• Comfort for the resident

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Symptoms of Constipation

• Nausea and vomiting
• Straining during defecation
• Infrequent bowel movement
• Feelings of incomplete emptying after bowel
  movements
• Frequent small amounts of diarrhoea

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Symptoms

• Rectal pain on defecation
• Stomach pain, distension or discomfort
• Hard stools
• Faecal incontinence

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Pharmacological Management

• Prophylaxis - essential part of management
• prophylactic aperients should be routinely
  prescribed with opioids
• combination of softening agent and stimulant is
  best choice eg. coloxyl with senna

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Pharmacological Management

• Bulk laxatives when combined with suppositories
  associated with low rates of faecal incontinence
• Suppositories after bowel clearing can prevent
  recurring constipation
• Consider compensatory measures for dehydration
  and electrolyte depletion

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Non-pharmacological approaches

• Toileting ensuring
• comfort
• privacy
• timeliness - gastric reflux occurs after eating
• Encourage fluid, fibre intake
• Low intensity exercise

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Effective bowel evacuation

• Diet (meal before hand or hot drink stimulates
  gastro colic reflex)
• Gravity
• Massage and straining (Massage abdomen right to
  left and deep breathing and straining)
• Digital stimulation

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Digital bowel stimulator
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Digital StimulationGloved hand

• Inserting a well lubricated gloved finger or
  adaptive device into the rectum
• With a circular motion, massage the anal muscle
  until it relaxes (15 to 60 seconds)
• May be needed every 5-10minutes allowing stool to
  pass through the anal muscle

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Digital Removal of Stool

• Indications for disimpaction
• Procedure
• Explain to client
• Position client on left side
• Drape
• Have bedpan or plastic bag available
• Apply clean gloves and lubricate index finger
• Gently insert finger into rectum and advance
  slowly toward umbilicus
• Gently loosen fecal mass
• Remove stool and provide perianalcare

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Diarrhoea

• Urgent passage of watery or liquid stool may be
  accompanied by abdominal cramping as well as
  nausea and vomitting
• Causes
• Diet allergies
• Emotional stress
• Laxative abuse
• Bowel disorders
• Intestinal pathogens i.e. food poisoning
  gastroenteritis
• IBS

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Is it overflow diarrhoea

• Severe constipation and result in impaction
• Thin feacal fluid can pass through hard stools
• Thin fluid with no fibre or solid substances

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Flatulence (flatus)

• Excessive accumulation of intestinal gas
• Caused by
• Swallowing air while eating
• Sluggish peristalsis
• Intolerance to foods i.e. lactose intolerance
• Ingestion of particular foods i.e. cabbage,
  cucumbers, onions, beans

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Hemorrhoids

• Perianal varicose veins
• Internal inside rectum not visible
• External protrude outside rectum
• Pain, itching and bleeding
• Caused by increased intra-abdominal pressure
• Pregnancy
• Constipation prolonged straining
• Obesity
• Cirrhosis portal hypertension
• Prolonged sitting or standing

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Treatment of hemorrhoids

• Treat constipation high fiber diet, fluids,
  exercise
• Stool softeners laxatives
• Topical analgesia
• Cold packs
• Sitz baths 3 4 X per day
• Surgery Hemorroidectomy vein excised surgically

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Suppositories

• Oval shaped cone that melts at body temperature
• May deliver medication i.e. antiemetic,
• anti-inflammatory, analgesic
• Useful to soften and lubricate stool i.e.
  glycerin suppository
• Contact suppositories i.e. Biscodyl (Dulcolax)
  increase fluid and electrolyte volume in colon
  which promotes defecation

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Enemas

• Hypotonic less osmotic pressure than fluid in
  surrounding tissue
• Tap water
• Isotonic same osmotic pressure as surrounding
  tissue
• Normal Saline (0.9 NaCl)
• Hypertonic greater osmotic pressure than fluid in
  surrounding tissue
• Sodium Phosphate enemas (Fleet)

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Enemas

• Instillation of a solution into the rectum and
  sigmoid colon to promote defecation stimulates
  peristalsis or to administer medications
• Large volume enemas
• Low volume enemas
• Oil retention enemas
• Medications

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Large Volume Enemas

• Tap Water/Soap Suds (Hypotonic)
• Normal Saline (Isotonic)
• Small Volume Enemas
• NaPhosphate or Fleet (Hypertonic)

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Administration of Enemas

• Equipment required
• Clean gloves
• Water soluble lubricant
• Waterproof pads
• Toilet tissue
• Bedpan or alternative
• IV pole
• Enema container with tubing and clamp/rectal tube

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Administration of Enemas

• Ensure enema prescribed
• Assess client (make sure enema not
  contraindicated for individual)
• Explain procedure to client
• Ensure privacy
• Raise bed to an appropriate height
• Prepare enema
• Place waterproof pads under buttocks have
  bedpan or commode nearby
• Position client on left side

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Low Volume NaPhosphate (Fleet)

• Prepackaged remove tip cover pre-lubricated
  but requires additional lubricant
• Proper positioning- left side
• Separate buttocks, locate rectum, insert tip
  gently toward umbilicus 3-4 inches
• (7.5 10 cm for an adult)
• Squeeze bottle until all solution administered
• Instruct client to hold enema for 2-5 minutes if
  possible

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Large Volume Normal Saline

• Warm solution check temperature on wrist
• Raise container prime tubing clamp it
• Lubricate 7.5-10 cm (3-4 inches) of tip with
  lubricating jelly
• Proper position left side
• Separate buttocks visualize rectum
• Instruct client to breath easily through mouth
• Gently insert tip in direction of the umbilicus
  7.5-10 cm (3-4 inches)

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Large Volume Normal Saline

• Open clamp have container at hip level
• Raise container slowly to appropriate level above
  rectum (IV pole may be used)
• High enema 12-18 inches (30-45 cm)
• Regular enema 12 inches (30 cm)
• Low enema 3 inches (7.5 cm)
• Hold tubing in rectum until fluid instillation is
  completed
• Lower container if client has pain or cramping
• Clamp tubing gently withdraw
• Explain that client should hold for as long as
  possible
• Discard container
• Inspect color, consistency, amount of stool passed

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Autonomic dysreflexia

• Occur in clients with spinal cord injuries
• Sacral nerves affected 2,3 and 4
• Range of mild problems to a life threatening
  emergency
• Caused by a full bladder or Bowel
• Results in severe hypertention or seizures

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Signs and symptoms

• High blood pressure
• Pounding headache
• Pulse
• Sweating
• Flushing
• Goose pimples
• Chills without fever
• anxiousness

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First aid

• Sit client up with legs in a supported position
• Remove all restrictive clothing
• Help to evacuate bladder or rectum

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Rectal prolapse

• Part of the bowels slides out
• Partial
• Complete
• Internal
• With a gloved finger gently slide the bowel back
  inside

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Documentation

• Note on clinical record BM date
• In narrative notes that an enema was given
• Type of enema used
• Results from the enema or lack of results
• How client tolerated the procedure