NSG 202: week 1: (Elimination with meds)

How does nutrition affect elimination?

• Diet can affect elimination 

  • fiber, opioids, gluten, lactose intolerance 

• May not get enough fluids and electrolytes

How does cognition affect elimination?

• Dementia, Anxiety, Kids & Elderly get FOMO (they dont want to use the bathroom & miss anything)

• Routined toileting 

• spinal cord or brain injury

How does mobility affect elimination?

• lack of movement decreases peristalsis 

How do fluids and electrolytes affect elimination?

• increase in hydration = good balance of electrolytes

• Diarrhea may cause dehydration and lead to electrolyte imbalances 

  • metabolic acidosis 

    • worried abt cardiac, respiratory, muscles, etc

Bristol Stool Chart

type 7: worried about cdiff

• cdiff has no form

What causes diarrhea?

• ask abt meds

  • antibiotics, laxative use

  • dont forget to ask abt OTC meds

• if caused by infectious agent, we may want a stool culture, sometimes we may not want to stop diarrhea 

• stress can give you IBS

Diarrhea

• Watery and without form

  • More than 3 times per day

Diarrhea can lead to:

• Leads to 

  • Skin breakdown 

  • Changes in daily activities 

  • Changes in social relationships

Diarrhea Nursing Considerations

• Assume diarrhea is contagious unless it has been proven otherwise

  • use proper PPE

  • wash your hands 

  • consider a bedside commode if patient is sharing the bathroom with another patient 

  • consider moving patient into isolation if sharing room

• patient may need to be in isolation precaution

  • contact plus 

    • you need to use bleach to clean it, normal disinfectants don't clean cdiff as well

• anyone on long term antibiotics can be seen for cdiff  

• we need to keep patient hydrated 

  • put in an IV if needed 

    • call doctor 

• we need to keep it from spreading 

• Do we or don’t we want to stop diarrhea?

  • whats causing it? is it infectious?

  • we still need to take meds to kill parasites 

  • you still need fiber + fluids

• Can the patient access the bathroom? 

  • do they need a bedpan or commode?

  • try to make patient as comfortable as possible 

• you need to look for skin breakdown 

  • you can use a barrier cream to prevent breakdown 

  • fecal management system 

    • A fecal management system (FMS) is a temporary medical device used to collect and contain liquid or semi-liquid stool from bedridden, immobile, or critically ill patients. It diverts waste away from the body through a soft silicone catheter into an external collection bag, protecting fragile skin and preventing infection spread. 

• assess for dehydration 

Diarrhea Clinical Manifestations

• abdomen: IAPP

• subjective data: how often do you go, patterns, describe the stool’s characteristic

  • is there any blood in there? 

• fatty greyish looking stool

  • steatorrhea 

    • gallbladder issues 

• diarrhea: hyperactive bowel sounds 

• high pitched bowel sounds: borborygmi 

Diarrhea: 

• HR speeds up due to dehydration

• pulses are weak & thready due to dehydration

• severe dehydration may lead to a fever

• patients may even experience delirium 

  • some of it may be due to F&E imbalances 

    • you need to be aware of patient’s baseline cognition, especially in older patients 

  • BP may initially begin to increase to compensate, but it may decrease again due to fluid loss

  • Perfusion may decrease

  • patient may be at risk for an AKI (which could be as a result of a decrease in perfusion)

    • every patient in a hospital may be at risk for an AKI

Assessment for Diarrhea

• Bowel Sounds

  • Hyperactive

  
  

• Abdomen

  • Palpate for distension & tenderness

  
  

• Incontinence

  • Assess perianal area for skin & tissue breakdown

  • Redness/hyperpigmentation

  • Fungal infection

  • Check for hemorrhoids r/t frequency

    • bleeding doesn’t always have to be from GI

      • could be hemorrhoids, cancer, ruptured polyp, etc

      • we need to find out why

Interventions for Diarrhea

• Check for underlying problem

  • Tx that if identified

  
  

• Monitor F&E

  • Watch for imbalances

  
  

• Monitor I&O

  • Watch for s/s of dehydration

  
  

• Dietary teaching

  • High fiber and fluids

    • make sure older adults aren’t drinking too much fluids before bed

      • especially men (BPH)

  
  

• Medications

  • Teach appropriate use

  
  

• Toileting

  • To establish a normal pattern

  • Provide for privacy

Think like a nurse; Diarrhea

• Big worry with dehydration: we are mainly worried abt the heart 

• look for change of level on consciousness 

• hemoglobin is high when dehydrated and lower when hydrated 

• hemoglobin vs hematocrit 

  • Hemoglobin measures the amount of oxygen-carrying protein inside red blood cells, while hematocrit measures the percentage of overall blood volume made up of red blood cells 

  • If body is dehydrated hemoglobin & hematocrit are high 

• urine specific gravity and urine osmolality 

  • both high in dehydration 

  • urine is going to be dark

• we need to check kidney function

  • creatinine, GFR, BUN

• We are worried about metabolic acidosis with diarrhea 

• We would want to get an IV started 

  • IV fluid may be based on F&E 

Think like a Nurse: Nursing Interventions

• we may need to monitor weight 

• I&O

  • how much water are they drinking 

  • 30ml an hour

ABGs 

• Make sure we have an order for fluids

• monitor oxygenation 

• watch diabetics, can go into DKA

• severe dehydration may cause seizure 

Everything connects 

• watch skin turgor 

• every patient in a hospital is at risk for an AKI

Diarrhea: Clinical Management

• Hydration

• Adequate dietary fiber

• Regular toileting practices 

• Regular exercise 

• Skin care

• you may have to contact dietician and nutrition 

• monitor their skin: 

  • how are we cleaning that area? 

    • no soap & water. it would add to the burns and breakdown 

    • pat dry 

Constipation

• Hard, dry stool that is difficult to pass through the rectum.
  
  

• Potential Complications:

  • Hemorrhoids

  • Anal fissures

  • Fecal impaction

  • Rectal prolapse

Bowel Retention/Constipation

• Causes: Ignoring the “urge to go” or decreased peristalsis

  
  

• Leads to retention of stool in the rectum → Stool dries out → Constipation happens → Complications can result

Constipation Risk Factors

• All individuals, regardless of age, gender, or race, are potentially at risk 

• Populations at greatest risk:

  • Children

    • Lack of sphincter/muscle control

    • Unable to identify the urge

    • Environment

  • Pregnant Women

    • Fetus size can impact peristalsis/cause constipation

    • Prenatal vitamins

  • Older Adults

    • Atrophy of smooth muscle in colon

    • Decreased mucous production

    • Older adults have an altered thirst mechanism and may not drink enough water

      • they also have decreased mobility and naturally have decreased peristalsis

    • Medications

      • antidepressants, opioids, iron, calcium supplements, antacids (with aluminum or calcium), anticholinergic meds may cause constipation 

• does the patient have some sort of malignancy, parkinsons, mobility issues,muscular dystrophy, ANS changes, multiple sclerosis?

  • these are all things that may affects your bowels

• modifiable factors: diet, exercise 

• nonmodifiable factors: age 

Some causes of constipation

• a change in their routines may also be a reason 

Causes of Constipation: Med side effects

• Anticholinergics

• Opioids & Others

Anticholinergic Drugs and Drugs With Anticholinergic Side Effects Used in the Elderly

• Don’t memorize just realize how much the patient may be on

Assessment for Constipation

• Bowel Sounds

  • Hypoactive

  
  

• Abdomen

  • Palpate for distention & tenderness

  
  

• Straining

  • Check for tears

  • Check for bleeding

  • Check for hemorrhoids

  • Check for rectal prolapse

• Check for the underlying issue

Interventions for Constipation

• Check for underlying problem

  • Tx that if identified

  
  

• Nutrition

  • Fruits, vegetables, whole grains, adequate fluid

  
  

• Prevention

  • How to prevent using diet, fluids, regular toileting

  
  

• Toileting

  • To establish a normal pattern

  • Provide privacy & uninterrupted time

  
  

• Medications

  • Teach proper use

  
  

• Enema

  • Teach proper use

  • patient shouldn’t be hooked on enemas and need one every time they have to poop

Pharmacotherapy for Constipation

• Laxatives

  • Bulk-forming agents

    • metamucil is not addictive 

    • metamucil = contains psyllium or fiber, patients need to take a lot of water 

      • may take a few days to see results 

      • doesn’t replace eating so we may still need fiber 

  • Bowel stimulants

  • Lubricants

  • Saline laxatives

    • docusate sodium (Dulcolax)

• Stool softeners

• Antibiotics

• Antispasmodics

• Analgesics

Common Diagnostic Tests for Bowel Issues

• Laboratory tests 

  • Stool culture, occult blood

• Radiographic tests and scans

  • X-rays, computed tomography (CT) scans, magnetic resonance imaging (MRI), ultrasound 

• Direct observation tests

  • Colonoscopy

  • colonoscopy is the gold standard

    • free of red meat for 24-48 hrs

    • free of red or blue dyes for 24-48 hrs 

    • drink prep for that

    • they can’t be having stools 

    • about every ten years is standard unless there's an issue or family history 

    • virtual colonoscopy: swallow a camera

      • can’t get a culture; may not be the best 

Clinical Management: Collaborative Interventions

• The most common strategies include:

  • Pharmacotherapy

  • Incontinence management

  • Alternative & Complementary Tx

    • Stress reducing activities

  • Skin Care

  • Potential surgery

    • no bowel sounds are always an emergency unless they're post surgical 

      • can take about 24 hrs, sometimes even a little more, for bowel sounds to return due to anesthetics

• Ask good questions:

  • have they had any abdominal trauma? 

  • are they pregnant? 

• You can also work with physician and dietitian 

Surgical Interventions: Bowel Elimination

• Colectomy

• Colostomy or ileostomy

• Rectal prolapse repair

• Hemorrhoidectomy

Other Lower Gastrointestinal Problems

• Appendicitis

  
  

• Peritonitis

  
  

• Gastroenteritis 

  
  

• IBS

  
  

• UC

  
  

• Crohn’s

Appendicitis

• Inflammation that occurs when the lumen (opening) of the appendix becomes obstructed (blocked), leading to bacterial infection that invades the appendix wall. The obstruction is usually caused by fecaliths (very hard pieces of feces). When blocked, mucosa secretes fluid, increasing internal pressure and restricting blood flow, resulting in right lower quadrant (RLQ) pain.

  
  

• Classic presentation: Cramping pain in the epigastric or periumbilical area that progresses and shifts to the RLQ at McBurney's point (between the anterior iliac crest and umbilicus). Abdominal pain is followed by nausea and vomiting. Anorexia is also frequent.

  
  

• Complications: Gangrene and sepsis can occur within 24-36 hours. Perforation may develop within 24 hours but risk increases rapidly after 48 hours, resulting in peritonitis.

Peritonitis

• Inflammation of the peritoneum (the membrane lining the abdominal cavity). Can result from appendix perforation. Presents with temperature greater than 101°F (38.3°C) and increased pulse rate. This is a serious, life-threatening complication.

• Abdomen may feel rigid, boardlike, distended 

Gastroenteritis

• An inflammatory condition of the gastrointestinal tract. The textbook materials distinguish it from appendicitis by symptom sequence: nausea or vomiting before abdominal pain suggests gastroenteritis, while abdominal pain followed by nausea and vomiting suggests appendicitis

Small Bowel Obstruction

• Abd discomfort/pain (could come in "waves")

  
  

• Upper or epigastric abd distension

  
  

• Nausea (earlier)

  
  

• Vomiting (may contain fecal material)

  
  

• Obstipation

  • obstipation: severe or complete constipation 

    
    

• Severe F&E disturbances

  
  

• Metabolic alkalosis (not always)

Large Bowel Obstruction

• Intermittent lower abd cramping

  
  

• Lower abd distension

  
  

• Minimal or no vomiting

  
  

• Obstipation or ribbon like stools

  
  

• No major F&E imbalance

  
  

• Metabolic acidosis (not always)

Intestinal Obstructions

• when you have an obstruction, you have to be really good about bowel sounds. Intestines may strangulate and cut of blood supply which is a medical emergency, patient needs to go to OR and get that fixed. That may lead to necrosis which then may lead to sepsis and death. 

  
  

• If there's an obstruction in the bowel, the patient may have an issue with fluids (fluid retention in the intestine), which may lead to hypotension and hypovolemic shock. 

Diverticulosis

• presence of abnormal pouchlike herniations in the wall of the intestine

• Asymptomatic diverticular disease where diverticula (pouches) are present in the intestinal wall. The patient typically has no signs or symptoms, and the condition often goes undiagnosed unless pain or bleeding develops. Diverticula are most often discovered during routine colonoscopy.

Diverticulitis

• inflammation or infection of the diverticula

• they may get peritonitis 

  • abdomen may feel rigid, board-like, distended 

• Inflammation of diverticula that occurs in approximately 10-15% of diverticular disease cases. When undigested food or bacteria become trapped in a diverticulum, blood supply to that area is reduced, bacteria invade the diverticulum, resulting in diverticulitis.

What can cause or contribute to constipation?

• Adverse drug effects

  
  

• Insufficient fiber/fluids

  
  

• Lifestyle

  •  insufficient food or fiber

    
    

• Hypothyroidism

• Neurogenic disorders

  • any type of brain or spinal cord injuries

    
    

• Emotions

  • anxious or stress

    
    

• Age

  • Older Adult

Constipation Clinical Manifestations

• Fewer than 3 stools per week

  
  

• Straining

  • straining can lead to hemorrhoids 

    
    

• Sensation of incomplete evacuation

  
  

• Sensation of anorectal blockage

  
  

• Hard stools

  
  

• Manual evacuation

  • putting in your finger and manually taking out stool

    • pts can vasovagal = they can have a low syncopal response 

Constipation Non-pharmacological Interventions

• Increase fluid intake

  
  

• Increase fiber intake

  
  

• Increase physical activity

Drug Types to Treat Constipation 

• Laxatives

  • Bulk-forming

  • Lubricant (emollient)

  • Surfactant agents (stool softeners)

  
  

• Cathartics

  • Saline

  • Stimulant agents

  
  

• Miscellaneous agents

Laxatives - Bulk-Forming

• increase the bulk of the stool which will increase the urge to have a bowel movement

• acts in a similar way to fiber

• the size stimulates parestalysis

• only meds ok for long term use

  • if it pulls fluid into the colon pts need to increase their fluid

    • stool can become too hard if pt doesnt take enough fluids

Laxatives – Bulk-Forming Examples

• Psyllium

  • Metamucil

  • Natural Fiber

  
  

• Lubricant

  • Mineral Oil

  
  

• Methylcellulose

  • Citrucel

  
  

• Polycarbophil

  • FiberCon

  • Fiber-Lax

Bulk stimulants Mechanism of Action

• Increase Gl motility by increasing size of fecal matter

  
  

• Helps pull more fluid into intestines

  
  

• Stimulates local stretch receptors to activate local activity (i.e. peristalsis)

Laxatives – Bulk-Forming Indications for use

• Occasional constipation or bowel irregularity

  
  

• Post MI or CVA

  • To prevent straining

  
  

• Long term use in patients who are:

  • Debilitated

  • Older

  • Unable/unwilling to eat adequate diet

Laxatives – Bulk-Forming Avoid in patients with:

• Difficulty swallowing

• GI tract strictures

  • narrowing of the GI

    • in an obstructure we dont want to give any laxatives bc it wont do anything 

• Unable/unwilling to drink adequate fluids

Bulk stimulants: Adverse Effects

• Abd cramping

  
  

• Severe flatulence

  
  

• Bloating

  
  

• Esophageal obstruction

  
  

• Impaction

• Diarrhea

Bulk stimulants: Nursing implications

• Must take with plenty of water

  • at least 8oz

  • if we dont take enough water we may get esophageal or intestinal obstructions

Lubricant Laxatives: Examples

• Mineral Oil

• Fleet Oil

Lubricant Laxatives: Mechanism of Action

• Not absorbed into system

  
  

• Lubricates the stool and the intestinal mucosa and prevents water reabsorption from the bowel lumen

  
  

• The increased fluid content of feces increases peristalsis

Lubricant Laxatives: Indications for use

• Fecal Impaction

  • Generally as an enema

  • May be used orally - but not method of choice

  
  

• Should not be used long-term

Lubricant Laxatives: Adverse Effects

• Oral

  • Decreased absorption of fat soluble vitamins & drugs

  • Lipid pneumonia if aspirated

  • N/V/D

  • Abdominal cramping

  
  

  • we dont want to use these long term

  • if aspirated its a problem bc it goes to the lung 

Lubricant Laxatives: Nursing Implications

• Should not be used regularly

  
  

• Best results as a retention enema

  • ask patient to hold it in as long as they can

Surfactant Laxatives (Stool softeners) Example

Docusate Sodium (Colace)

Surfactant Laxatives (Stool softeners) Mechanism of Action

• Decreases surface tension of fecal mass

  
  

• Allows water to penetrate stool

  
  

• Also acts to facilitate mixing fat and water in the stool

  
  

• Stools are softer and easier to expel

Surfactant Laxatives (Stool softeners)
Indications for use

• Need to avoid straining

  • Recent surgery

  • Hemorrhoids

  • Post-MI or CVA

  
  

• Reduce constipation associated with opiate use

  
  

Surfactant Laxatives (Stool softeners)
Adverse effects

• N/V

  
  

• Abd cramps

  
  

• Fecal Impaction

  
  

• Intestinal obstruction

Stimulant cathartics Example

• Bisacodyl (Dulcolax)

  
  

• Glycerin

  
  

• Senna

  • Senokot

  • Ex-lax maximum strength

  
  

• Castor oil

• stimulates you to go

• these work a lot faster

Stimulant cathartics Indications for use

• Bowel prep

  
  

• General Constipation

  • Not for long term use

  
  

• Neurogenic bowel dysfunction

Stimulant cathartics Mechanism of action

• Irritate Gl mucosa

  
  

• Pull water into bowel lumen

  
  

• Increases peristalsis and stool is more watery (softer)

Stimulant cathartics Contraindications

• Avoid in acute bowel disorders; can lead to ruptures

  • Diverticulitis

  • Gastric retention

  • Colitis

  • Bowel obstruction

• Avoid in undiagnosed abdominal problem

  
  

• Renal Disease

  • Risk for Na, Mg, K, Phos retention

  
  

• HTN

  • Can increase BP r/t sodium retention

Stimulant cathartics Adverse Effects

• N/D

  
  

• Abd cramping

• Weakness

  • vagal nerve stimulation bc of suppository or enema, pt can complain of weakness

Stimulant cathartics Nursing Implications:

• Do not take within 1 hour of ingesting milk

  
  

• Should not use longer than one week

  
  

• Take on empty stomach or at bedtime

  • if pt has diarrhea then we may not give it at bed time 

    
    

• Swallow drug whole

• we want pt to lay down

Saline cathartics Examples

• MAGNESIUM CITRATE

  
  

• MILK OF MAGNESIA

  
  

• POLYETHYLENE GLYCOL-ELECTROLYTE SOLUTION

  • GOLYTELY

  
  

• POLYETHYLENE GLYCOL

  • MIRALAX

• these are used to really empty the bowel:

  • used for bowel prep

Saline cathartics Mechanism of Action

• Draws water into the intestinal tract

  
  

• Increases intestinal bulk

  
  

• Produces diarrhea

Saline Cathartics Indication for Use

• Constipation

  • Short-term treatment

  
  

• Bowel prep

  • GoLytely

  
  

• Not safe for long term use

  • May produce F&E (Fluid & electrolyte) imbalances

Lactulose

• synthetic hyperosmotic laxative

• For Hepatic Encephalopathy: The drug-induced acidic environment also reduces blood ammonia levels by converting ammonia to ammonium. Ammonium is a water-soluble cation that is trapped in the intestines and cannot be reabsorbed into the systemic circulation. This effect has proved helpful in reducing serum ammonia levels in patients with hepatic encephalopathy

• Used in patients with elevated ammonia levels

Lactulose Adverse Effects

Electrolyte imbalance & dehydration

Sorbitol

Sometimes given with:

• Kayexalate – reduce potassium

• Charcoal – eliminate toxins

• Also found in sugar free candies

Acute Diarrhea

• Sudden onset in a previously healthy person

• Lasts from 3 days to 2 weeks

Chronic Diarrhea

• Lasts for more than 3-4 weeks

Non Pharmacological Therapies For Diarrhea

• Replace F&E

• Clear Liquids

• Bland Foods

  • BRAT diet

Clear Liquids

• Flat ginger ale, tea, gelatin, broth

• Avoid caffeine

BRAT Diet

• bananas, rice, applesauce, toast

  • helps firm up and slow diarrhea

Diphenoxylate with atropine (Lomotil) & Loperamide (Imodium A-D)

• Opiate-related antidiarrheals

Diphenoxylate with atropine (Lomotil)

• Opiate-related antidiarrheal

• Controlled Substance

• Requires prescription

• Atropine diminishes euphoric effect 

  • prevents abuse

Loperamide (Imodium A-D)

• Opiate-related antidiarrheal

• Not Controlled Substance

  • doesnt have opioid in it, but it is related

  • doesnt affect the CNS

• OTC

Opiate-related antidiarrheals Mechanism of action

• Slows perastalysis

• Acts on the smooth muscles in the intestine

Diphenoxylate with atropine (Lomotil) Adverse effects

• Tachycardia

• Dizziness

• Headache

• Flushing 

• N/V

• Dry Skin and Mucous Membranes

• Urinary Retension

• Hypotension and respiratory depression

  • At high doses

Loperamide (Imodium AD) Adverse effects

• Dizziness

• Drowsiness

• Abd Pain

• N/V

• Constipation

Loperamide (Imodium AD) Black Box Warning

• Torsades de Points

• Cardiac arrest

• Death

Contraindications for Lomotil & Imodium

• Diarrhea caused by infectious organisms

  
  

• Antibiotic associated colitis

  
  

• Bloody/tarry stools

  
  

• Undiagnosed abdominal pain

Interactions for Lomotil

• Alcohol + Lomotil

  • Causes increased sedation/CNS depression

Lomotil Patient Teaching

• Stop taking once diarrhea resolves

• Drink 2-3 quarts of fluid

• Avoid laxative fresh fruits

• Use with caution if driving

Bismuth subsalicylate (Pepto-Bismol)

Adjuvant antidiarrheal medication

• we give this for H. Pylori as well

  • we give this with PPI and abx

• Helps with travelers diarrhea, cramping, abdominal distention 

Antidiarrheal Bismuth subsalicylate (Pepto-Bismol)

• Coats the walls of the gastrointestinal tract

  
  

• Tx of diarrhea

  • Traveler's diarrhea

  
  

• Do NOT take with ASA

• If patient has allergy to aspirin we cant give pepto-bismol 

Antidiarrheal: Bismuth subsalicylate
Adverse Effects

• Increased bleeding time

  • dark stools

• Constipation,

• Confusion

• Tinnitus

  • salicylate toxicity 

• Metallic taste

• Blue tongue

  • mixes with sulfur in saliva 

Probiotics

• Probiotics: replaces good gut bacteria 

  • found in yogurt (especially plain)

• Also known as intestinal flora modifiers and bacterial replacement drugs

L. acidophilus (Bacid)

Antidiarrheal Probiotics

What is our physical assessment focus when treating diarrhea?

• GI

  • Abd auscultation

  • Abd palpation

• Cardiac

  • Tachycardia

• Integumentary

  • Tenting

  • Dry mucous membranes

What should you remember when doing your assessment for diarrhea?

• hyperactive bowel sounds with diarrhea

• IAPP (inspect, auscultate, palpate, percuss)

Diarrhea Patient Teaching

• Teaching

  • Medications

  • BRAT Diet

    • avoid fruit like berries

  • Rest

  • Infection control