Week 13 Bowel elimination and enteral feedings

Upper GI tract structures

Food and fluids are ingested, mix with salivary enzymes and food/fluids are moved through the upper GI tract to begin the digestive process), Mouth, Pharynx, Esophagus, Stomach

Lower GI tract structures

Small intestine (3-10 hours, absorbs nutrients), Duodenum, Jejunum, Ileum, Ileocecal valve (slows movement of undigested food into the large intestine allowing for more time for absorption of nutrients and prevent backflow of fecal contents from large intestine)

Large intestine structures

Cecum, Colon, Ascending, Transverse, Descending, Sigmoid, Rectum (expands to accommodate stool), Anus (internal and external sphincter)

Function of the Intestine: motility

Assists with absorption and transportation of waste products over the full length of the intestines. Includes segmentation and peristalsis.

Segmentation of the intestine

Alternating contraction and relaxation of the intestinal smooth muscle occur. Slows the passage of intestinal contents to permit more complete digestion and absorption of nutrients

Peristalsis

•Propels the intestinal content along the entire length of the small and large intestines. Intestinal walls reflexively induce peristalsis but stimulated when digested flood enters the duodenum form the stomach (duodenocolic reflex). Influenced by the autonomic nervous system (sympathetic slows peristalsis while parasympathetic increases bowel motility and emptying

Function of the intestine: absorption

Begins in the small intestine with nutrients and fluids, Vitamins iron and fluid absorbed in the ileum, Fluid and electrolyte occurs in the large intestine (duodenum and ileum), Rate of absorption depends upon speed of movement through the colon (slower equals greater absorption), Ascending colon = liquid, Transverse colon = semisolid and mushy feces

Function of the intestine: Defecation

Rectal distention caused by peristalsis propelling feces into the rectum. Smooth muscle responses trigger bowel evacuation. Parasympathetic nerve fiber in the sacral segment of the spinal cord are stimulated. Defecation reflex: Involuntary contraction of the descending and sigmoid colon, rectum and anus and relaxation of the internal anal sphincter.

Defecation

voluntary contraction controls the external anal sphincter

Valsalva's maneuver

Taking a deep breath against a closed glottis, Contracting the abdominal muscles and Contracting the pelvic floor muscles. BEWARE: Cardiovascular effect can happen which can cause hypotension and/or bradycardia

Characteristics of Normal Feces

75% water, 25% solids. Includes bacteria, undigested fiber, fat, inorganic materials, protein. Smaller amount of dietary fiber= less stool. Color is normally brown, Chemical conversion of bilirubin into urobilin and stercobilin by intestinal bacteria and enzymes. Color can be influenced by foods that are ingested (ex: beets). Certain medications can change stool color and consistency (ex: Iron). Odor is caused by bacterial decomposition of proteins in the intestine. Amount: 100-300 g/day

Bristol stool chart type 1

separate hard lumps like nuts (hard to pass)

Bristol stool chart type 2

lumpy sausage shaped

Bristol stool chart type 3

like a sausage but with cracks on the surface

Bristol stool chart type 4

like a sausage or snake, smooth and soft

Bristol stool chart type 5

soft blobs with clear cut edges

Bristol stool chart type 6

fluffy pieces with ragged edges, a mushy stool

Bristol stool chart type 7

watery, no solid pieces, entirely liquid

What is c diff infection? (CDI)

Clostridioides difficile is a spore-forming bacterium that causes diarrhea and inflammation of the colon (colitis). Causes almost a half a million infections in the US each year. About 1 in 6 patients who get C Diff will get it again in the subsequent 2-8 weeks. 1 in 11 people over age 65 diagnoses with a healthcare-associated C Diff infection die within one month. Not reimbursable by CMS if patient tests positive after inpatient Day 3

Risk factors for CDI

Antibiotic use, Being 65 or older, Recent stay at hospital or nursing home, Weakened immune system (HIV, cancer, organ transplant, taking immunosuppressive medications), Previous Infection with C Diff or known exposure

Symptoms of CDI

•Diarrhea (Bristol Stool 6 or 7), Fever, Abdominal tenderness or pain, Loss of appetite, Nausea, Diagnosed through stool testing

Management of CDI

Institute contact/enteric precautions (gown, gloves and disposable equipment, whenever possible), Soap and water hand hygiene (alcohol-based hand sanitizer will not kill spores), Disinfect surfaces with bleach products (other alcohol-based disinfecting products will not kill spores), Oral Vancomycin (believe it or not, even though C Diff can be caused by antibiotic use, it is also treated with an antibiotic), Recurrent infections can be treated with fecal microbiota transplant where stool from a health donor is instilled into the colon of a patient with recurrent CDI, Monitor fluid and electrolytes carefully, Measure stool volume, Chemistry panels to monitor renal function (BUN, creatinine), electrolytes; especially sodium, chloride, potassium and magnesium (lost in stool), Monitor vital signs (especially BP, HR and temp), Replace fluids and electrolytes parenterally, as needed

Factors affecting bowel elimination - nutrition

•Optimal is 25 to 30 g of dietary fiber from fresh fruits, vegetables, grains. Food intolerances (lactose, gluten) can cause gas, diarrhea and decreased absorption of nutrients

Factors affecting bowel elimination - fluid intake

•2000 mL/day necessary for cells and soft stool consistency, Decreased fluid intake contributes to harder stool which is more difficult to pass

Factors affecting bowel elimination - activity and exercise

•Promotes muscle tone and peristalsis, Decreased activity from normal promotes constipation (long-term care patients commonly affected by this)

Factors affecting bowel elimination - Body Position

•Sitting or semi-squatting is optimal—think gravity. Recumbent position on bedpan difficult

Factors affecting bowel elimination - Ignoring Urge to Defecate

Defecation reflex subsides after a few minutes if the initial urge is ignored, Intestinal mucosa absorb water from the feces making it harder and more difficult to pass, Defection reflex can weaken if ignored regularly, can lead to persistent use of laxative or enemas to void

Factors affecting bowel elimination - lifestyle

Patterns are created that are "normal" for that individual, Deviations in lifestyle (vacations, hospitalization, stress) can alter elimination patterns, Long-term depression and chronic stress slow bowel activity

Factors affecting bowel elimination - pregnancy

•Constipation common due to hormonal changes that relax muscles, Iron supplements common in this population; increasing risk of constipation

Factors affecting bowel elimination - medications

Constipating: opioids, iron, frequent use of antidiarrheal meds. Diarrhea causing: antibiotics, frequent use of laxatives, stool softeners and enemas

Factors affecting bowel elimination - diagnostic procedures

•Radiologic and endoscopic procedures usually require bowel prep to remove excess fecal material through cleansing process which can result in altered elimination for up to 2-3 days. Barium is used in some radiologic procedures as a contrast material. Can be constipating if not eliminated well afterward

Factors affecting bowel elimination - surgery

General anesthesia slows bowel motility for 1 to 2 days. Abdominal surgery often requires bowel preparation for removing excess fecal material and then bowel motility slows for 3-4 days post op. Opioids used for pain management post op slow bowel motility. Pain, decreased mobility, NPO status pre and post-op slow bowel motility. Research demonstrates safety and no increase in complications with early post-op feeding but surgeon practice has been slow to change the practice of keeping patients NPO until return of bowel motility

Factors affecting bowel elimination - Fecal diversion

Surgical of parts or all of the large intestine, Examples include cancer, inflammatory bowel disease, necrotic bowel tissue, Part of the intestine is removed and the proximal part of the remaining bowel is redirected through the abdominal wall creating a "stoma" in which fecal material is expelled, Can be permanent or temporary, Colostomy: large colon is used to create the stoma, stool is usually soft in consistency and the patient can be continent through bowel irrigation techniques, Ileostomy: ileum is used to create the stoma, stool is liquid and contains large quantities of electrolytes, Stoma management and irrigation necessary

Alterations in bowel function - constipation

Common definition difficult as quantity and quality of stool are often used to characterize. Rome III Criteria (see Craven Box 33-1) helps to provide common defining characteristics for adults, children and infants. More common in women, children under age 4 and lower socioeconomic populations. Common causes: withholding defection, slow transit, difficult or incomplete defecation. Influencing factors: nutrition, fluids, medications, activity. Can lead to fecal impaction.

Interventions for constipation

Treat underlying cause: Increase fiber and fluids in the diet, increase activity if possible, avoid constipating medications including opioids. Use oral laxatives or suppositories...see Craven pp 1086-7. Use enemas (small-volume, large-volume, return flow)....see Craven pp 1088-9

Alterations in bowel function - fecal impaction

Stool is lodged or stuck in the rectum and the patient is unable to voluntarily evacuate, Liquid stool can pass around the impaction and the patient can be incontinent, Feeling of abdominal fullness or bloating, urge to defecate but inability to do so, Nausea and vomiting can be experienced

Common Causes of fecal impaction

chronic constipation, chronic opioid use, un-expelled barium after radiologic procedure

Fecal impaction Interventions

Treat underlying cause of impaction, Digital disimpaction may be required to remove impacted stool..See Craven pp 1089

Alterations in bowel function - diarrhea

•Frequent evacuation of watery stools, Defined more by the consistency of the stool (watery, less formed) than the frequency of the bowel movements, Increased bowel motility, Loss of water, electrolytes (especially potassium) and acid can cause dehydration and electrolyte imbalance

Common causes of diarrhea

microorganisms, toxins, lifestyle changes, stress, lactose and gluten intolerance, food allergies, travel to areas with poor water and food preparation, Hyperosmolality of parenteral tube feedings can cause diarrhea

Diarrhea interventions

Treat the cause, Antibiotics for microbial infection, Antidiarrheal agents contraindicated with presence of viral or bacterial infections, Steroids to decrease inflammation

Alterations in bowel function - fecal incontinence

involuntary passing of bowel contents, Can be caused by neurologic, mental or emotional impairments. Patients with cerebral cortex injury, sacral spinal cord injury, neurologic disease and dementia can be affected. Urgency of diarrhea can contribute to incontinence

Interventions of fecal incontinence

Treat the cause and/or bowel training, if possible...See Craven pp 1175. Maintain skin integrity with the presence of liquid stool, Fecal management device

Gastrointestinal and Bowel Elimination Assessment

Normal pattern identification (What is patient's normal frequency of bowel movements? What is the patient's normal bowel consistency? Recent changes?), risk identification (Dietary fiber intake, Mobility, Medications, Recent radiologic procedures and barium), Dysfunction identification (Determining patient's concept of "normal" compared to THEIR current pattern).

Physical assessment for GI

•Inspecting Contour and symmetry of abdomen, typically flat or slightly rounded and symmetric. Auscultation with Bowel sounds in all quadrants every 5-15 seconds (Normoactive, hypoactive, hyperactive. Listen for at least 30-60 seconds in each quadrant if no bowel sounds heard in order to determine "absence" of bowel sounds, Percussion (Hollow, tympany normal in LUQ R/T stomach), •Palpation (Perform this last as palpation can induce changes in auscultation and percussion, Typically soft), Measurement of abdominal girth (Measure at the point of greatest distention, follow measurements over time to determine extent, helpful in assessing for presence of fluid accumulation in the peritoneum known as ascites), Perirectal exam (Perianal skin should be intact, check for impacted stool through digital exam, check for presence of hemorrhoids)

Paralytic ileus

condition in which the bowels is temporarily paralyzed and distention occurs; indicated by absence of bowel sounds beyond 72 hours after abdominal surgery

Diagnostic tests and procedures

collecting a stool specimen, fecal occult blood test, stool culture, radiologic procedures, Endoscopic examination, Lower GI scope

collecting a stool specimen

Use a "hat" in the toilet or bedside commode to collect stool for ambulatory patients. Use a bedpan for non-ambulatory patients. Collect from a brief from an incontinent patient. Best if not mixed with urine

Fecal occult blood test

Evaluates for hidden blood in the stool. Stool is placed on the hemoccult card and a chemical developer is placed on the test paper with a blue color change indicating blood in the stool. False positives can be caused by: ingestion of red meat, iron, aspirin, bismuth compounds, steroids and NSAIDS with 72 hours of test. False negatives can be caused by: Vitamin C in excess of 250 mg/day. Used as a screening tool for colon cancer and diagnostic tool for anemia

Stool culture

Used to distinguish between normal GI flora and infectious organisms, Can be used to check for C-Diff, Ova and parasites (stool needs to be warm when examined)

Radiologic procedures

Xray imaging using a radiopaque substance such as barium either swallowed or given rectally, Abnormal findings include tumors, diverticula, obstructions, Bowel should be empty first through the use of laxatives and/or enemas, Be sure to eliminate barium afterward to avoid hardening and potential for impaction

Endoscopic examination

Helpful in diagnosing inflammation, ulceration, tumors, Tissue can be extracted and biopsied, Upper GI scope, Esophagogastroduodenosocopy (EGD): examines the esophagus, stomach, and duodenum, Clear liquids the night before, Endoscope is passed through the mouth with patient in the left lateral position

Lower GI scope

Sigmoidoscopy: examines rectum and sigmoid colon, Colonoscopy: examines the colon up the ileocecal valve, Bowel prep required with clear liquid diet the night before, Endoscope is inserted into the rectum with the patient in a side-lying position, Pain control and sedation provided

Nasogastric (NG) intubation

•Inserted into the nose and advanced into the stomach. Size is called french (larger the number, larger diameter). Typical for adult is 14-18 french. Mm marking on the tube serve as a guide for depth.

How to insert an NG tube

have PT in high fowlers, measure from tip of nose to earlobe to xiphoid process and mark. Lubricase, have PT tilt head forward and SWALLOW CONTINUOUSLY (otherwise it'll go into lungs). Temporarily affix to nose, aspirate and check pH. Confirm placement with xray, use tape to attach device to nose. Observe nostril and surrounding tissue for pressure injury regularly.

How to verify NG insertion

xray is gold standard, aspiration of stomach contents with pH test of 5 or less (this can be influenced by active treatment with antacids). Air bolus with auscultation over the stomach should no longer be used

Purpose for NG tube

gastric decompression that drains stomach and relieves pressure from stomach and intestines caused by air and fluid. It's connected to a tube for intermittent or continuous suction (high is 80-120 mm HG, low is 20-40 mm Hg). It's indicated for bowel obstruction, paralytic ileus or after stomach or intestinal surgery. The tube must contain an air vent (salem sump) allowing air to flow continually into the stomach, preventing adherence and sucking gastric mucosa during suction. Tube may be irrigated with 20 mL of water to dislodge particles or viscous contents (sterile not required). Air vent can be irrigated with air and/or fluid followed by 10 mL air, Monitor for fluid and electrolyte imbalances

Gastric lavage

Irrigation of stomach contents, Used with accidental or intentional poisoning or overdose, Aspirates gastric contents and instill a rinsing solution, Iced saline lavage can be used with active gastric bleeding to remove blood and slow the source of bleeding through vasoconstriction

Gastric feeding

•For patients who cannot take in nutrition orally, Tubes are narrower and made of more pliable material, Do not include an air vent/pigtail

Administering enteral tube feedings: nasogastric flexible type of tube

nasogastric flexible, small-bore feeding tube (nose → stomach, secured at nose, placement confirmed via xray and monitored fq, used for short term, typically 8-10 french, most have weighted distal tip and inserted using removable stylet).

Administering enteral tube feedings: Gastrostomy or jejunostomy type of tube

Inserted percutaneously through the abdominal wall into the stomach (gastrostomy) or small intestine (jejunostomy) Dual lumen tubes into both the stomach (used for medications) and small intestine (used for feedings) available for patients at risk for aspiration or with poor gastric absorption. Secured with an internal or external fixation device to avoid migration of the tube. Care for the skin at the site through cleansing with soap and water and clean gauze dressing as needed. Used for longer-term feeding

Administering Enteral Tube Feedings

enteral formulas are Commercially-available, Nutritionally balanced, Vary in calories, nutrient proportions and digestibility, Ready to use formula should be discarded 24 hours after opening to reduce bacterial contamination, Reconstituted formula (mixed at the point of administration) should be discarded after 4 hours

Intermittent enteral tube feedings

May be infused via a pump or via gravity, Small amounts of volume delivered at designated times throughout the day

Continuous enteral tube feedings

Infused via a pump, may be given throughout the day and night or for designated periods (overnight only, for example)

Complications with Enteral Tube Feedings

Nausea and vomiting (More common with high osmolarity formulas, Give scheduled free water boluses to combat this side effect), aspiration (More common with high gastric residual volumes, Elevate the HOB to at least 45 degrees at all times, interrupt feedings when HOB needs to be flat or with transferring of patient). Fluid electrolyte imbalance (More common with high osmolarity formulas, Give scheduled free water boluses to combat this side effect). Diarrhea and insteinal cramping (More common with high osmolarity formulas. Give scheduled free water boluses to combat this side effect), tube occlusion (•Flush well with water intermittently and with medications), Hyperglycemia (check BG frequently with diabetic patients, especially when initiating feedings). Gastric Residual Volumes (Aspirate gastric contents using a catheter-tipped syringe, One form of assessment to determine tolerance of enteral feedings, Large gastric residual volumes put patient at risk for aspiration and sometimes these patients will be fed via the jejunum if this is persistent. There is no consistent volume used as indicator for stopping or holding enteral feedings, however, typically more than 400-500 mL is used as a guide)

Recognize how the anatomy and function of the gastrointestinal tract influences bowel elimination

The GI tract moves and absorbs food through coordinated actions of the upper tract (ingestion, mixing with enzymes) and lower tract (nutrient absorption in the small intestine, fluid/electrolyte absorption and stool formation in the large intestine). Motility patterns—segmentation and peristalsis—slow or propel contents, affecting stool consistency and frequency. Proper bowel elimination depends on intact motility, absorption, and the defecation reflex, which relies on rectal distention, parasympathetic stimulation, and voluntary sphincter control.

Recognize normal stool consistency and state nursing management for abnormal stool patterns to include CDI

Normal stool is brown, soft, formed, and 75% water, with Bristol types 3-4 being ideal. Abnormal patterns include hard, dry stool (constipation), watery stool (diarrhea), or liquid leakage around impaction. Nursing management includes adjusting fiber, fluids, activity, and medications, and protecting skin. CDI presents with watery stool (types 6-7), fever, and abdominal pain; management includes contact/enteric precautions, soap-and-water hygiene, bleach cleaning, stool monitoring, electrolyte replacement, and treatment with oral vancomycin or fecal transplant for recurrent infection.

Identify alterations in bowel function to include diagnostic and physical assessment and nursing management for them

Alterations include constipation, fecal impaction, diarrhea, and fecal incontinence. Assessments include history of normal patterns, risk factors, diet, medications, abdominal inspection, auscultation, palpation, and digital rectal exam. Diagnostics include stool specimens, fecal occult blood tests, cultures, radiologic studies, and endoscopy. Management targets the cause—laxatives or enemas for constipation/impaction, replacing fluids/electrolytes for diarrhea, treating infection if present, bowel training for incontinence, and maintaining skin integrity.

State the purpose of and procedure for nasogastric intubation

An NG tube decompresses the stomach to relieve pressure from obstruction, ileus, or post-op conditions. The nurse measures nose→ear→xiphoid, lubricates the tube, inserts with the patient swallowing, secures it, verifies placement (x-ray is gold standard), and connects to appropriate suction. Salem sump tubes require monitoring of the air vent, flushing to maintain patency, and close monitoring of fluid/electrolyte balance.

Identify the process of enteral feeding and complications that may occur

Enteral feeding delivers nutrition through NG, gastrostomy, or jejunostomy tubes when oral intake isn't adequate. Formulas may be continuous or intermittent and must be discarded within safe time frames. Nursing care includes verifying placement, elevating the head of bed ≥45°, flushing to prevent occlusion, giving free-water boluses as ordered, and monitoring for nausea, vomiting, diarrhea, cramping, aspiration, electrolyte imbalance, hyperglycemia, or high gastric residuals (>400-500 mL as a general guide).