Lesson 1 Abdominal Assessment & Bowel Elimination

Mouth function

Entry point for food

Parotid gland

Largest salivary gland located near ear

Sublingual gland

Salivary gland under tongue

Submandibular gland

Salivary gland under jaw

Pharynx

Throat; connects mouth to esophagus

Esophagus

Muscular tube carrying food to stomach

Diaphragm

Muscle separating chest from abdomen

Liver location

Right upper abdomen; largest internal organ

Gallbladder function

Stores bile; attached to liver

Stomach function

Receives food from esophagus; begins digestion

Spleen location

Left upper abdomen (not digestive organ)

Pancreas location and function

Behind stomach; produces digestive enzymes

Duodenum

First part of small intestine; connects to stomach

Small intestine function

Long, coiled tube for nutrient absorption

Large intestine (transverse colon)

Runs across abdomen

Sigmoid colon

S-shaped section before rectum

Cecum

Pouch at beginning of large intestine

Appendix

Small pouch attached to cecum

Rectum

Stores feces before elimination

Anus

Exit point for waste

Common bile duct

Carries bile from liver/gallbladder to duodenum

Abdominal assessment - inspection

Assess color, shape, peristalsis, pulsations, visible masses, lesions

Abdominal assessment - palpation & percussion

Apply pressure to 1-2 cm; assess masses, distention, tenderness

Abdominal assessment - auscultation

Divide into 4 quadrants; listen for gurgles and clicks (5-15 sec)

Hyperactive bowel sounds

Increased bowel sounds

Hypoactive bowel sounds

Decreased bowel sounds

Absent bowel sounds

No bowel sounds; listen for 1 minute or more

Right upper quadrant contents

Pylorus, duodenum, liver, right kidney and adrenal gland, hepatic flexure of colon, head of pancreas

Left upper quadrant contents

Stomach, spleen, left kidney and adrenal gland, splenic flexure of colon, body of pancreas

Right lower quadrant contents

Cecum, appendix, right ovary and fallopian tube (female), right ureter and lower kidney pole, right spermatic cord (male)

Left lower quadrant contents

Sigmoid colon, left ovary and fallopian tube (female), left ureter and lower kidney pole, left spermatic cord (male)

Midline abdominal contents

Urinary bladder, urethra (female)

Flatulence

Accumulation of gas in the GI tract

Flatulence causes

Swallowed air, undigested foods in large intestine, normal bi-product of bacterial breakdown of undigested carbohydrate

Distention

When gas accumulates

Melena

Dark/black stools; sign of upper GI bleed

Clay or white-colored stools

From lack of bile; difficulty with digestion of fat

Daily fiber recommendation

25-38g fiber/day

Daily fluid recommendation

2000 mL/day of fluid

Water reabsorption location

Large intestines

Bedrest effect on defecation

Makes defecation difficult

Exercise effect on GI system

Improves GI motility and muscle tone

Inactivity effect on GI system

Decreases GI motility and muscle tone; causes constipation

Defecation definition

Emptying of large intestine

Defecation reflex mechanism

Parasympathetic nervous system signals relaxation of internal anal sphincter and colon contracts; fecal matter enters rectum; rectum becomes distended; muscles stretch and trigger defecation reflex resulting in urge to eliminate

Constipation definition

Relative to patient's normal patterns

Constipation causes

Certain neurological/neuromuscular conditions, medications, narcotic use, iron preparations

Constipation nursing care

Educate about side effects of medications; promote healthy bowel habits (fiber + H2O + activity)

Diarrhea definition

Increase in frequency; 3 or more stools a day and/or change in consistency

Diarrhea symptoms

Accompanied by intestinal cramps, nausea and vomiting; high water and electrolyte content

Diarrhea skin risk

Skin breakdown from acidity and frequency of stool

Diarrhea possible causes

Hyperthyroidism, medications (antibiotics), infection, malabsorption syndromes, diabetes

Diarrhea RN care

Keep area dry and clean to prevent irritation and breakdown; answer call bell ASAP to prevent falling out of bed to get to bathroom

Bowel/fecal incontinence

Loss of voluntary control of defecation

Fecal incontinence possible causes

Loss of anal sphincter tone, neurologic injury, spinal cord injury, local trauma, inflammation due to infection

Fecal incontinence nursing care

Keep skin clean and dry; use protective barriers to promote skin integrity; change linens as needed; often embarrassing for patients; need for bowel training

Fecal impaction

Prolonged retention or accumulation of fecal material; hardened mass in the rectum

Fecal impaction hallmark sign

Seepage or incontinence of liquid stool with no signs of normal feces

Fecal impaction treatment

Oil-retention enemas, digital removal of impaction

Manual removal of fecal impaction technique

Insert gloved and lubricated finger into fecal mass; slowly and gently use finger to break up hardened mass; break off a section; remove a section

Enema mechanism of action

Distends bowel, irritates bowel mucosa, increases peristalsis, lubricates stool and mucosa

Enema contraindications

Bowel obstruction, paralytic ileus, risk of thrombocytopenia, risk of leukopenia, immunocompromised patients

Enema nursing consideration - infection risk

Fissures/abscesses can occur as result of administration; portal for infection

Enema purposes

Given to evacuate feces; retained in bowel to lubricate mucosa, relieve gas, administer medications to be absorbed through mucosa

Hypertonic enema amount

70-130 mL

Hypertonic enema retention time

Retain for 5-10 minutes

Hypertonic enema mechanism

Distends bowel by pulling H2O into colon

Oil-based enema types

Mineral, olive oil, cotton seed oil

Oil-based enema amount

150-200 mL

Oil-based enema mechanism

Lubricates stool and intestinal mucosa

Retention enema duration

30-60 minutes

Medicated enemas

Provide medications that are absorbed through rectal mucosa

Carminative enemas

Help to expel flatus from the rectum and provide relief from gaseous distention

Carminative enema common solutions

Milk and molasses enema (equal parts), soap-solution enema

Large volume enema amount

~500-1L

Large volume enema retention time

Try to retain about 15 minutes to work

Tap water enema mechanism

Distends bowel, increases peristalsis, softens stool

Saline enema mechanism

Distends bowel, increases peristalsis, softens stool

Soap suds enema mechanism

Distends bowel, softens stool, and irritates mucosa; irritated mucosa stimulates peristalsis

Soap suds enema soap type

Castile soap only

Tap water enema amount

500-1,000 mL

Tap water enema onset

15 minutes

Tap water enema cautions

Can lead to fluid and electrolyte imbalance and water intoxication; should not be used in children

Normal saline enema amount

500-1,000 mL

Normal saline enema onset

15 minutes

Normal saline enema benefits

Generally safer than tap water for preventing electrolyte imbalances

Soap solution enema amount

500-1,000 mL (concentrate at 3-5 mL per 1,000 mL)

Soap solution enema onset

10-15 minutes

Soap solution enema cautions

Must only use castile soap; other soaps will cause significant rectal mucosa irritation or damage

Phosphate solution enema amount

70-130 mL

Phosphate solution enema mechanism

Draws fluids out of interstitial space into colon leading to distention which stimulates peristalsis; commonly used as commercially prepared solutions

Phosphate solution enema onset

5-10 minutes

Phosphate solution enema cautions

Avoid dehydrated patients or where phosphate retention could be a concern; can be irritating to rectum

Oil-based enema amount

150-200 mL

Oil-based enema onset

30 minutes

Oil-based enema special consideration

Patient may need to hold solution for 30-60 minutes for maximum effectiveness

Enema nursing considerations - positioning

Position patient left side down

Enema nursing considerations - tubing

Flush tubing of air

Enema nursing considerations - insertion

Insert ~4 inches toward umbilicus

Enema nursing considerations - breathing for insertion

Deep breaths for inserting