Bowel Elimination

Bristol Stool Form Scale

-Type 1: separate hard lumps like nuts (difficult to pass)

-Type 2: sausage shaped but lumpy

-Type 3: like sausage but with cracks on surface

-Type 4: like a sausage or snake, smooth and soft

-Type 5: soft blobs with clear-cut edges (passed easily)

-Type 6: fluffy pieces with ragged edges, a mushy stool

-Type 7: watery, no solid pieces (entirely liquid)

Normal Bristol stool score

2-4

Constipation Bristol stool score

1

Diarrhea Bristol stool score

5-7

What are some factors that affect defecation

-age

-diet

-fluid

-physical activity

-psychological

-personal habits

-pain

-anesthesia and surgery

-medications

-diagnostic tests

Why are older adults at risk for elimination alterations

-weaker muscle tone in the perineal floor and anal sphincter

-nerve impulses to the anal region slow

-slower peristalsis

-medication induced problems

What does fiber do

Flushes fats and waste to decrease risk of colon cancer

Non-digestible residue

Whole grains, fresh fruits and veggies

diet factors influencing bowel movement

• Gas producing foods distend intestinewalls

• Food intolerances - lactose

• Celiac - Autoimmune related

Why is physical activity important for elimination

-promotes peristalsis

-encourage early annulation after surgery and when able with illness

-muscle tone is sometimes weakened or lost increasing risk of constipation

What psychological factors influence elimination

-stress accelerates digestive process and peristalsis is increased (causes diarrhea and gas distention)

-inflammatory conditions

-depression slows impulses and decreases peristalsis

personal habits influencing bm

• home vs work timing

• privacy with hospitalized pt

• sights, sounds, odors associated with bedpans causes embarrassment

• patients ignore urge and begin cycle of constipation

How does pain affect bowel elimination?

we don't like pain, so if it hurts, we avoid it (decreases)

Opioids effect on bowel elimination

Slows peristalsis (constipation)

Antibiotics effect on bowel elimination

Diarrhea

NSAIDS and aspirin effect on bowel elimination

risk for upper GI bleeding

Iron effect on bowel elimination

Black stools, N/V, constipation, and abdominal cramping

• can look like GI bleed

Laxatives effect on bowel elimination

-can be used safely

-chronic use can cause the intestine to become less responsive

-overuse can cause diarrhea leading to dehydration and electrolyte imbalance

How does general anesthesia affect peristalsis

Slows down or stops peristalsis

• advise movement to stimulate GIT

Paralytic ileus

Motor activity of bowel is impaired, usually without the presence of a physical obstruction, major surgery risk

stool analysis

• Aid in diagnosing disorders related to gastrointestinal (GI) bleeding or medication therapy that results in bleeding

• Assist in the diagnosis of pseudomembranous enterocolitis following the use of broad-spectrum antibiotic therapy

• Help diagnose suspected inflammatory bowel syndrome (IBS)

• Identify the cause of diarrhea of unknown origin

• Investigate disorders of protein digestion

• Screen for colorectal cancer

• Screen for cystic fibrosis

• Determine intestinal parasitic infestation, as indicated by diarrhea of unknown cause

• Evaluate the effectiveness of therapeutic regimen for intestinal malabsorption or pancreatic insufficiency

What assessment should you do to check if a post op patient is having paralytic ileus

Listen to bowel sounds

No bowel sounds that lasts hours-days = paralytic ileus

unusual stool appearance

• Mucous: Intestinal wall inflammation

• Bloody: Excessive intestinal wall irritation or malignancy

• Frothy or bulky: Malabsorption

• Ribbonlike or slender: Obstruction

increased abnormal results

• Blood: related to GI bleeding

• Occult blood: Diverticular disease, esophagitis, gastritis, esophageal varices, anal fissure, hemorrhoids, infectious diarrhea, IBD, polyps, tumors, ulcers

• Leukocytes: Inflammation of the intestines related to bacterial

infection

• Epithelial cells: Inflammatory bowel disorders

general abdomen assessment

• Usual pattern

• Routines

• Use of aids at home

• Change in appetite

• Diet and fluid history

• Medications

• Weight Loss (unintentional)

When should you do a focused abdomen assessment

-nausea and vomiting

-nocturnal BM

-indigestion

-diarrhea

-constipation

-previous GI problems or abdominal surgery

Colorectal cancer red flags

-change in bowel habits

-consistent feeling of need to have BM

-rectal bleeding or blood in stool

-cramping or steady abdominal pain

-weakness and fatigue

-unexplained weight loss

Colon cancer risk factors

-Age > 50

-Family hx

-Crohns or UC

-Diet: high fat, high red meat, low fruits, low fiber

-Blacks

-Smoking

-Obesity

-Diabetes mellitus

objective signs assessment purpose

Inspection

• waves of peristalsis = obstruction

• Venous patterns, distention = increased gas or fluid

Auscultation

• absent or hypoactive = paralytic ileus

• high pitched tinkling = obstruction

Percussion

• Helps detect cause of distension

• Locates stool burdon

Palpation

• soft vs firm, tender to palpation?

Example of a goal for an abnormal bowel pttern

Return patient to a normal bowel elimination pattern

Outcome criteria for abnormal bowel elimination pattern

The patient reports passage of a soft, formed, brown stool

Constipation

Less than 3 BM/week

What is the normal bowel elimination patterns

Once a day to every 3-5 days

What are some common causes of constipation

Older age, immobility, lack of fluid intake, opioid drugs, impaired neuro function

Complications of constipation

hemorrhoids, impaction, vagal response

What is a common treatment of constipation

Increased fluids, physical activity, laxatives, enemas

Fecal impaction

Collection of a hardened stool in the rectum

(Worst care scenario because patient can no longer pass this on their own)

Common causes of fecal impaction

constipation, medication

S/s of fecal impaction

Continuous oozing or small diarrhea, loss of appetite, nausea or vomiting, abdominal distention, cramping and rectal pain

How to assess if a patient has a fecal impaction

Digital rectal exam

What is a common treatment of a fecal impaction

Enemas, digital removal (with order if enema doesn’t work)

obstruction

occurs when intestinal contents are prevented from moving forward due to an obstacle or barrier that blocks the lumen

Cause of mechanical obstruction

Tumors, diverticular disease

Non-mechanical cause of obstruction

Paralytic ileus - absence of physiological motility

of the intestines

S/s of obstruction

Nausea and vomiting, abdominal distention and pain, inability to pass flats, absent bowel sounds or high pitched hypoactive

Paralytic ileus care

Place NGT, encourage early mobilization, assess and monitor bowel sounds, encourage food and fluid, monitor bowel and ability to pass flatus

Diarrhea

Passage of liquid feces and increased frequency of defecation

Causes of diarrhea

Infection, medications, bacteria, virus, tube feedings, stress, food

Complications of diarrhea

Skin breakdown, dehydration, electrolyte imbalance, nutritional concerns

C diff

Clostridium difficile = overgrowth of bacteria

once established, C diff…

produces toxings that attack lining of intestines, destroy cells, produce patches of inflammatory cells

What are some causes of c diff

Antibiotics, chemotherapy, invasive bowel surgery, health care worker contamination

Contact precautions for c diff

Strict CONTACT PERCAUTIONS wear gown and gloves at all times NO MASK. When washing hands use soap and water NOT hand sanitizer

Use bleach wipes

C diff risk factors

Antibiotic therapy, >65, long term care facility resident, chemotherapy, immunocompromised, GI procedure, IVS, previous c diff infection

S/s of c diff

-Watery diarrhea >3x in 2 days

-Abdominal cramping/pain

-Fever

-Blood, pus, mucous in stool

-weight loss, dehydration, anorexia

Complications of c diff

dehydration, kidney failure, bowel perforation, toxic megacolon, death

Diagnosis of c diff

stool culture

Treatment of c diff

Flagyl, vancomycin, probiotics, surgery, fecal transplant

antibiotics

• don’t give anti-diarrhetic because body is already trying to get rid of it!!!

Hemorrhoids

dilated, engorged veins in the lining of the rectum; external or internal

Causes of hemorrhoids

Straining/constipation, pregnancy, heart failure, chronic liver disease

mild hemorrhoid treatment

topical steroid, restoration of healthy bowel elimination

thrombosis causes sever pain and needs to be excised

Stoma

Artificial opening in the abdominal wall

Colostomy

creation of an artificial opening into the colon with a bag; ascending, transverse, descending

Illeostomy

surgical opening of the ileum; stool is more liquid, stool characteristics depend on stoma location

Bowel health promotion in the hospital

-Constipation: high fiber food, increase fluids

-Diarrhea: low fiber, start diet slowly, avoid hot or cold foods, BRAT diet

-Ambulated patient - ASAP, often

-Incontinence: maintain skin integrity, maintain dignity, infection risk w urinary catheter

bowel regimen meds

• bulk forming laxatives

• stimulant laxatives

• saline laxatives

• lubricants

• emollients

• anti-diarrheal agents

bulk forming laxatives

• Psyllium Husk, Miralax

• Mix with water

• Can be used long term

stimulant laxatives

• Bisocodyl, X-Lax

• Short term constipation relief

• Causes cramping

saline laxatives

• Mag Citrate

• Short term constipation relief

• Bowel prep for procedure

lubricants

• Mineral Oil

• Coats stool for easy passage and prevention

of straining

emollients

• Stool softeners such as Colace

• Common after surgery to prevent straining

anti-diarrheal agents

• Immodium, Paragoric

• Some have opiate properties and have potential for abuse

• Never give if suspected C-Diff, confirm with stool culture

suppositories

• Small round/cone shaped object that can be placed rectally/vaginally

• Will then be broken down by the body

• Can be given for constipation (as less invasive method), prior to enemas

• Medications can also be given this route

tap water (large volume enema)

• Hypotonic fluid shift, risk for overload or electrolyte imbalance

• Stimulates a bowel movemen

saline (large volume enema)

• Volume stimulates bowel movement, is isotonic with minimal fluid

shift

soapsuds enema

• irritant that stimulates peristalsis

• caution with large volume infusions

fleet enema (small volume, hypertonic)

pulls fluid from intersitial spaces, caution with repeated use

mineral oil enema

• lubricates for easy passage

• small volume

medicated enema

• Vancomycin for C-Diff

• Kayexelate for hyperkalemia

• Lactulose for liver failue/encepholpathy

molasses aka “brown cow”

• Mix of molasses & whole milk

• The high sugar content of the molasses allows the hard impacted stool to be

softened so that it can pass easier.

rectal enema procedure

Equipment Needed:

• Gloves, gown, IV pole, lubricant, enema bag, pads for under patient, bedpan, bedside commode, cleansing cloths

Patient Positioning:

• Sim’s Position = Left lateral side lying with knee bent

enema procedure

• fill bag and tubing with warm solution

• clamp tubin

• lubricate tip

• instruct pt to breath slowly and insert tip toward umbilicus about 3-4 inches

• hold tubing in rectum throughout procedure and place bag height 12 inches from anus

• open clamp slowly

enema complications

• Fluid and electrolyte imbalance

• Tissue trauma

• Vagal nerve stimulation

• Abdomen becomes rigid

• Abdominal pain or cramping

• Bleeding

• Perforation

enema interventions

Stop enema if abdomen becomes rigid

Decrease height of bag to slow rate for

pain or cramping

Instruct patient to take slow deep breaths

for pain or cramping

Stop enema if bleeding occurs

digital impaction removal

• Must have provider order

• Usually after enemas have failed

• Nurse uses finger to break up fecal mass and remove in sections

• Complications:

• Very painful

• Causes irritation with bleeding

• Vagal response

• Perforation

NG tubes

• Used to decompress & remove gastric secretions the GI tract

• Used when peristalsis is absent such as paralytic ileus

• Accurate suction orders

• Intermittent vs Continuous

• LWS vs high suction

• Monitor output, abdominal exam, nares

ostomy care

• Pouching systems

• One piece or two piece

• Assess stoma

• Raised, Color: pink-red, Output characteristics

• Teaching

• Eat low fiber foods, Drink plenty of water, Avoid gas and odor causing foods

stoma assessment

• should be pink to red and moist

• pallor, cyanosis, or dusky indicates poor blood suplly

• black indicates necrosis

• might be edema initially

• assess for cuts, ulcerations, or abnormal findings

• not redness or irritation