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Elimination: Problems of Bowel Elimination REVIEW of GI Processes – Lower GI: Intestinal phase (duodenum) Secretin – inhibits acid production and motility Absorption –H20, electrolytes, fats, sugars ◦ Pancreas – enzymes (trypsin, amylase, lipase)to digest CHO, fat, proteins; production of insulin and glucagon ◦ Liver/gallbladder Bile production and storage (emulsifies fat) Vitamin and mineral storage Protein , CHO metabolism –stores/releases glycogen Stores fatty acids, triglycerides Elimination Needs Jejunum – absorption of sugars, proteins Ileum – absorption of B12, chloride, bile salts (3-10 hrs for passage 6-19ft. Long) Colon – appendix/ileocecal valve -Cecumascending, transverse, descending, sigmoid Electrolyte,H20 absorption (3-4 days transit) Rectum-Storage and elimination of wastes. REVIEW of GI Processes – Lower GI: Begin with Patient Assessment History Demographic data, family / personal hx, genetic risk Medications, previous surgery, laxative /enemas, travel hx Diet history – anorexia, wt changes, dyspepsia, allergies, lactose intolerance, alcohol and caffeine intake, smoking Changes with aging: < absorption, < HCL, < Iron and Vit B 12 absorption, < motility, < drug metabolism, > bacteria Current Symptoms Presentation and duration of sx Pattern, Color and consistency of bowel movement frank blood or tarry stools, gas, distention Pain, Weight loss, appetite changes Patient Assessment Colon = large intestine is 5-6 feet in length; consists of the cecum, the colon (ascending, transverse, descending and sigmoid) and rectum Colon = has 3 functions: absorption (water, Na, & Cl), secretion (of bicarbonate) and elimination of wastes Elimination Needs Mouth and pharynx Abdomen and extremities ◦ Inspection (Cullen’s sign-ecchymosis around umbilicus) ◦ Auscultation, look for peristalsis ◦ Percussion ◦ Palpation - no if suspect appendicitis or aneurysm Blumberg’s sign? Skin ◦ Discolorations, rashes (jaundice) ◦ Increased bleeding, bruising (petechiae, ecchymosis) ◦ Itching GI Assessment Laboratory Testing R/T GI Assessment: CBC – anemia, infection Electrolytes – vomiting/diarrhea loss, malabsorption Coagulation studies Hepatitis antibodies, titers Liver enzymes - AST , ALT ◦ Bilirubin: the primary pigment in bile ◦ Ammonia – cirrhosis, hepatitis Serum amylase and lipase – pancreatitis Onconal fetal antigens – CA 19-9, CEA Urine –bilirubin ?, Ketones ? Stool exams – culture –( C-diff, giardia) Ova and parasites, occult blood, fats Laboratory Testing Upper Series GI and Small Bowel Before test: ◦ Maintain NPO for 8 hr. ◦ Withhold analgesics and anticholinergics for 24 hr. ◦ Consent form required for invasive testing Client drinks 16 ounces of barium, Rotate exam table, takes about 30 min. After test: ◦ Push Fluids, administer laxative/stool softner ◦ Stools chalky white 24-72 hrs Diagnostic GI Testing: Barium enema enhances radiographic visualization of the large intestine. Gas patterns, tumors, obstructions, volvulus Before Test: ◦ Bowel cleansing, clears liquid diet, NPO night before ◦ Barium instilled via rectal catheter with inflated balloon, pt must hold and change postitions – takes 45 min. – 1 hr. After Test: expel the barium, push fluids, laxative/ stool softner, stool is chalky white for 24-72 hr. Diagnostic Testing – Lower GI: Percutaneous Transhepatic Cholangiography X-ray study of the biliary duct system Before Test: Laxative , NPO X 12 hrs , coagulation studies, check allergies to iodine/seafood Under sedation, percutaneous needle into liver via X-ray visualization, dye injected to visualize biliary tree, dye aspirated when completed. Major risks = hemorrhage / sepsis Post –Test: Bedrest for several hours after procedure Assessment of vital signs Client positioned on right side with a firm pillow or sandbag placed against the lower ribs and abdomen Diagnostic Testing – Lower GI: Visual and radiographic examination of the liver, gallbladder, bile ducts, and pancreas NPO for 6 to 8 hr before test, conscious sedation Dye used – check for allergies ◦ Post test: assessment of VS q 15 min, Return of gag reflex Colicky abdominal pain due to instilled air Possible Complications – cholanghitis, perforation, pancreatitis – report any post-test abd pain, fever, N/V Endoscopic Retrograde Cholangiopancreatography (ERCP) Visualization of the small intestine to locate source of bleeding Only water for 8 to 10 hr before test NPO for first 2 hr of the testing, then normal diet and activity Application of belt with sensors and recorder. Takes 8 hrs to complete, capsule excreted in stool Small Bowel Capsule Enteroscopy Colonoscopy Colonoscopy: Endoscopic examination of the entire large bowel Before Test -Liquid diet for 12 to 24 hr , NPO for 6 to 8 hr before procedure Requires bowel cleansing routine Done under conscious sedation After Test - Assessment of vital signs q 15 min cramping, flatus, feeling of fullness = normal for few hrs. Small amt blood possible in stool if polypectomy or tissue biopsy Watch for signs of perforation or hemorrhage Colonoscopy Endoscopic examination of only the rectum and sigmoid colon Prep is the same as for Colonoscopy Sedation not used, otherwise before and after care is the same as with a Colonoscopy Less expensive (no anesthesia) but Not as comprehensive as colonoscopy – may be used for interim screening in some cases, or when other issues don’t allow colonoscopy. Proctosigmoidoscopy/ Flexible Sigmoidoscopy Ultrasonography painless, noninvasive, no radiation Liver-spleen scan , HIDA scan Nuclear medicine studies, minimal radiation may take 1-4 hrs Other Tests CONSTIPATION CONSTIPATION is a condition characterized by difficulty in passing stool or infrequent passage of hard stool. Fluid Intake – reduced fluid intake may contribute to constipation; Ingestion of milk products slows peristalsis; adequate water & fruit juice promote normal bowel function Factors Affecting Bowel Function Physical Activity – physical activity promotes peristalsis; immobility can lead to loss of muscle tone, constipation, ileus, bowel obstruction… Psychological Factors – stress response may stimulate peristalsis and digestion diarrhea or gas; depression slows peristalsis and may promote constipation; strong link of psychological influences on ulcerative colitis and Crohn’s disease Factors Affecting Bowel Function Age – neuromuscular control of bowel elimination not developed until age 2 or 3 years; older adults loose muscle tone in perineal floor and anal sphincter; aging causes slowing of nerve impulse to signal need for defecation Diet – regular eating patterns support regular bowel habits; fiber provides bulk to fecal material and stimulates peristalsis; some foods produce gas causing intestinal distention Factors Affecting Bowel Function Position during defecation – sitting or squatting aids increased intra-abdominal pressure and contraction of pelvic floor muscles. Hospitalization and imposed use of bedpans, or bedside commode may inhibit client’s bowel elimination Pain – surgery, hemorrhoids, rectal fistulas, etc. may make defecation painful – causing client to suppress urge constipation Factors Affecting Bowel Function Medications – laxatives & cathartics promote peristalsis & fluid retention in the bowel promoting defecation; opioid analgesics suppress peristalsis; medications to treat diarrhea primarily suppress peristalsis Factors Affecting Bowel Function Personal Habits – privacy, convenience, regular habits; The gastrocholic reflex = response to defecate approx. 30 - 60 min. after meals. Factors Affecting Bowel Function Pregnancy – growing uterus exerts pressure on rectum, peristalsis slows in 3rd trimester, constipation is common & may lead to development of hemorrhoids Surgery & Anesthesia – general anesthetics causes temporary cessation of peristalsis (which is why clients are NPO just before & after surgery) Factors Affecting Bowel Function How does constipation occur? Scenario: Bears hibernate in the winter. They don’t eat – drink – or move about much at all. Body functions slow down – as a result, it is possible for a bear to wake up from hibernation quite constipated and cranky! Constipation Apply the Nursing Process to the Bear – begin with ASSESSMENT – Objective data is information you can see, touch, measure, prove ◦ No evidence of bowel movement in expected time frame; hypoactive bowel sounds; lower abdomen may be distended and firm; rectal exam reveals presence of firm stool in rectum. Subjective data is information that the “patient” tells you about his experience ◦ Patient may c/o abdominal cramping, feeling of “fullness”, pressure in abdomen or rectum; even nausea and feeling “cold and clammy” at times. Constipation Subjective data: “I don’t feel so hot…my belly hurts! “I can’t poop!” “I really feel like I need to GO!!!!” “Grrrrrrr!!!” Objective Data: Facial grimacing Clutching lower abdomen No evidence of BM for 3 months Hypoactive bowel sounds Abdomen feels firm and is moderately distended to palpation Constipation 5-step Nursing Process: ◦ASSESSMENT ◦ANALYSIS & DIAGNOSIS ◦PLANNING ◦IMPLEMENTATION ◦EVALUTAION Constipation Step II of the Nursing process begins with ANALYSIS of data and ends with formulating the NURSING DIAGNOSIS statement. Look at the patient history, home medications, physical assessment…..what does it all mean? Constipation Make a problem list. Set priorities Express priority problems in a nursing diagnosis statement Constipation After analysis of your patient’s problems – and which are priority nursing issues – you begin to construct a nursing diagnosis statement. The nursing diagnosis statement identifies the patient’s priority problem (that is within the scope of practice) – makes clear what caused the problem – and supports the problem with evidence of the problem (signs & symptoms) Constipation Build a Nursing Dx Statement: Nursing Diagnosis – uses the P-E-S format P = Problem + E = Etiology + S = Signs & Symptoms of the problem Constipation Nursing Diagnosis: [P] Constipation… Related to… [E] Inactivity, inadequate fluid intake and inadequate fiber intake (secondary to winter hibernation) ◦ As Evidenced by… [S] States “I can’t poop” – hypoactive BS – firm, distended abdomen – facial grimacing – no BM x 3 months Constipation Constipation Constipation R/T inactivity, inadequate fluid & fiber intake AEB hypoactive BS, firm & distended abdomen, client states “I can’t poop” and no evidence of BM x 3 months Constipation The first step in any plan is to establish the GOAL or OUTCOME A GOAL STATEMENT is written in terms of OBJECTIVE, OBSERVABLE PATIENT BEHAVIORS which are MEASURABLE and REALISTIC The GOAL/OUTCOME is designed to help resolve the problem identified in the Nsg Dx Constipation The Bear will have a BM within 24 hours The Bear will state that his abdominal pain is 3 (0/10) in 48 hours. The Bear will have regular BMs at least 3x/wk within 1 month Constipation Part of Planning is selecting INTERVENTIONS which are directed to help achieve the GOAL or OUTCOME Adjust interventions to fit the patient – individualize to suit the patient, situation and available resources Include frequencies, amounts, time lines…details… USE REFERENCES!!! Constipation GOAL/ Outcome: The Bear will have a BM within 24 hours Constipation Administer PO Colace Q AM as ordered Instruct Bear to drink 500 ml water every 6 hours Encourage Bear to ambulate 50’ or more twice a day Instruct Bear to eat at least 2 servings of raw fruit daily Administer jumbo-size Fleets enema if no BM in 24 hours Constipation Implementation – Just Do It Perform the interventions as planned Monitor patient responses to care Document interventions and patient response Continue to assess and collect data for the ongoing nursing process! “Git ‘er done!” Constipation The final step in the Nursing Process is EVALUATION: ◦ Was the GOAL met? Yes / No? Partially? Sorta? Not really! ◦ Is the problem in the Nsg Dx resolved? ◦ Have the problems changed? ◦ Have the priorities changed? ◦ What should happen next? Constipation The EVALUATION step is not a “yes” or “no” response; it is a summary statement about progress toward the desired outcome. Start by addressing the patient’s progress toward the goal Describe how the patient responded to the planned interventions Provide a summary and recommendation for what should happen next: where do we go from here in terms of this plan of care? Even if the goal was achieved – few plans of care are just closed…. There is opportunity for reinforcement and patient teaching. Tell the reader what should happen next. Constipation Constipation GOAL: The Bear will have a BM within 24 hours “Goal met. Bear had large soft-formed B.M. at 1800 hrs today. Bear stated that abdominal discomfort is now resolved.” Plan to continue to reinforce fluid intake of 1500 – 2000 ml/day; intake of 2+ servings of raw fruit or vegetables/day and walking 50+ feet twice daily. Constipation GOAL: “Goal not met. No BM noted. The Bear However, Bear is passing will have a flatus and complying with BM within dietary and activity 24 hours interventions. No increase in symptoms of discomfort. Plan to continue plan as written and re-evaluate in 12 hours.” Constipation GOAL: The Bear will have a BM within 24 hours “Goal not met. No evidence of BM after 24 hours. Abdominal distention slightly increased and verbal complaints of discomfort are voiced more often.” Revise the Plan – notify the physician of continued constipation. Manually examine for fecal impaction and remove. Administer Soap Suds Enemas until clear. Constipation What medications can help prevent or treat constipation? Stool softeners like Colace and Surfak pull fluid from the circulating blood volume into the colon Fiber-additives such as Citrecel or Fibercon provide some of the non-digestible bulk needed to promote normal defecation. Items like mineral oil and glycerin suppositories try to make stool passage easier (lubrication). Constipation Pre-packaged enemas, such as Fleets, deliver medications directly to the colon. These may stimulate peristalsis, add liquid to soften stool or provide lubrication for stool passage. Laxatives such as milk of magnesia, Correctol, Ex-Lax, Dulcolax, Magnesium Citrate and Lactulose stimulate peristalsis of the colon. Assess abdomen for changes in baseline assessment Schedule activity & exercise daily Stool softeners or laxatives as Rx Encourage toileting at same time of day – 60 min after meals Provide privacy for toileting Try to wean patient from opioid pain medications as early as tolerated Monitor bowel movements for frequency & characteristics Provide fiber intake Position sitting upright for BMs if possible Fluid intake ◦ Fruit juice ◦ Water ◦ Hot beverages Interventions to promote defecation The End … of constipation…