Bowel Elimination Notes - week 4 for quiz 5
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- Topic: Bowel Elimination (Chapter 43) from Wolters Kluwer notes. Sets the framework for anatomy, physiology, assessment, diagnostics, interventions, and ostomy care related to bowel elimination.
- Purpose: Prepare for exam by detailing key concepts across anatomy, peristalsis, factors affecting elimination, assessment techniques, diagnostic tests, nursing interventions, and patient education.
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- The Large Intestine:
- VPrimary organ of bowel elimination.
- Extends from the ileocecal valve to the anus.
- Functions:
- Absorption of water.
- Formation of feces.
- Expulsion of feces from the body.
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- The Small and Large Intestines (anatomical overview shown):
- Duodenum
- Jejunum
- Ilium
- Ileocecal valve
- Appendix
- Rectum
- Anal canal
- Anus
- Ascending, Transverse, Descending, Sigmoid colon
- Left colic (splenic) flexure; Right colic (hepatic) flexure
- Tenia coli (longitudinal bands) in the colon
- Anal sphincter muscles and layers involved in defecation
- Note: Diagrammatic relationships among small and large intestines and rectum are shown; conceptually, these segments coordinate digestion, absorption, and elimination.
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- Process of Peristalsis:
- Peristalsis is under control of the nervous system.
- Contractions occur every 3 \text{ to } 12\;\text{minutes}.
- Mass peristalsis sweeps occur 1 \text{ to } 4 \;\text{times each } 24\text{-hour period}.
- One-third to one-half of food waste is excreted in stool within 24 hours.
- Significance: Coordinated neural control and rhythmic motility determine stool frequency and consistency; disrupted peristalsis can lead to constipation or diarrhea.
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- Peristaltic Movements in the Intestine (section header/illustration).
- Key idea: Peristalsis moves contents through the GI tract; timing and intensity vary with diet, activity, and health status.
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- (No content provided on this slide; placeholder for visuals or further notes.)
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- Variables Influencing Bowel Elimination:
- Developmental considerations
- Daily patterns
- Food and fluid intake
- Activity and muscle tone
- Lifestyle
- Psychological variables
- Pathologic conditions
- Medications
- Diagnostic studies
- Surgery and anesthesia
- These factors interact to influence stool frequency, consistency, and ease/difficulty of elimination.
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- Developmental Considerations:
- Infants: Stool characteristics and frequency depend on formula vs. breastfeeding; small stomach capacity; immature intestines; liquid stool normal.
- Toddlers: Bowel training goals; physiological maturity is priority; bowel control typically achieved by ages 2–3 with proper training.
- Child, adolescent, adult: Defecation patterns vary in quantity, frequency, and rhythmicity.
- Older adult: Constipation is often chronic; slower GI motility; decreased peristalsis; increased constipation risk.
- Implications: Age-specific strategies are needed for teaching, monitoring, and interventions.
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- Daily Patterns:
- Most people have a preferred time for elimination (often after meals).
- Changes in routine can disrupt normal elimination.
- Nurses should encourage a consistent toileting schedule.
- Food and Fluid Intake:
- Fiber: Promotes peristalsis and stool bulk (e.g., fruits, vegetables, whole grains).
- Fluids: Approximately 2000 \text{ to } 3000\;\text{mL/day} are needed for soft stool.
- Diets low in fiber or high in processed foods can contribute to constipation.
- Practical note: Diet and hydration are primary, modifiable factors for bowel regularity.
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- Activity and Muscle Tone:
- Physical activity stimulates intestinal activity.
- Prolonged immobility weakens abdominal and pelvic muscles.
- Bedrest can reduce bowel motility.
- Lifestyle Factors:
- Fast-paced life can cause people to ignore urge to defecate.
- Long-term suppression of bowel urges can lead to constipation.
- Privacy, time, and routine are important considerations for bowel elimination.
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- Psychological Variables:
- Stress and anxiety can cause diarrhea or increased frequency.
- Depression can decrease intestinal motility, causing constipation.
- Emotional state has a direct impact on GI health.
- Pathologic Conditions:
- Diseases such as IBS, Crohn's, Celiac, colon cancer alter elimination.
- Neurologic conditions (e.g., MS, spinal cord injury) affect nerve control of elimination.
- Painful defecation (e.g., hemorrhoids) can lead to avoidance and stool retention.
- Clinical implication: Holistic assessment should include mental health and neurologic status when addressing bowel elimination.
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- Medications:
- Laxatives: Stimulate bowel activity.
- Constipating meds: Opioids, iron, and some antacids (with calcium/aluminum).
- Antibiotics: Can lead to diarrhea or alter gut flora (risk for C. difficile).
- Diagnostic Studies:
- Bowel prep may involve enemas or laxatives.
- Procedures like colonoscopy or barium enema temporarily alter regular elimination.
- Residual contrast media (e.g., arium) can cause constipation post-study.
- Clinical takeaway: Medication review and pre/post-procedure care are essential for bowel function.
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- Surgery and Anesthesia:
- Anesthesia temporarily halts peristalsis.
- Postoperative ileus is a common complication after abdominal surgery.
- Pain medications and immobility further decrease bowel motility.
- Clinical implication: Plan for bowel management during postoperative recovery.
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- (No content provided on this slide.)
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- Foods Affecting Bowel Elimination:
- Constipating foods: cheese, lean meat, eggs, pasta.
- Foods with laxative effect: fruits and vegetables, bran, chocolate, alcohol, coffee.
- Gas-producing foods: onions, cabbage, beans, cauliflower.
- Practical takeaway: Dietary patterns can be tailored to manage constipation and bloating.
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- Effect of Medications on Stool:
- Aspirin, anticoagulants: pink to red to black stool.
- Iron salts: black stool.
- Bismuth subsalicylate (used for diarrhea) can cause black stools.
- Antacids: white discoloration or speckling in stool.
- Antibiotics: green-gray color.
- Clinical relevance: Stool color changes can indicate medication effects or underlying issues; document and assess.
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- Question #1: Which food is recommended for an older adult who is constipated?
- A. Cheese
- B. Fruit
- C. Cabbage
- D. Eggs
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- Answer to Question #1: B. Fruit
- Rationale: Fruits and vegetables have a laxative effect; cheese and eggs tend to constipate; cabbage can cause gas.
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- Physical Assessment of the Abdomen:
- Assessment sequence: inspection, auscultation, percussion, then palpation.
- Inspection: observe contour, masses, scars, distention.
- Auscultation: listen to bowel sounds in all quadrants; note frequency, character, audible clicks, flatus; describe as hypoactive, hyperactive, absent, or infrequent.
- Percussion and palpation: typically performed by advanced practice professionals.
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- Physical Assessment of the Anus and Rectum:
- Inspection and palpation for lesions, ulcers, fissures (linear break on anus margin), inflammation, external hemorrhoids.
- Have patient bear down as during defecation to assess internal hemorrhoids, fissures, and fecal masses.
- Inspect perineal area for skin irritation from diarrhea or fecal incontinence.
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- Stool Collection:
- Medical aseptic technique is imperative.
- Hand hygiene before and after glove use; wear disposable gloves.
- Do not contaminate outside of container with stool.
- Obtain stool; package, label, and transport according to agency policy.
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- Patient Guidelines for Stool Collection:
- Void first to prevent urine contamination.
- Defecate into the container, not the bedpan/toilet bowl.
- Do not place toilet tissue in bedpan or specimen container.
- Avoid contact with soaps, detergents, and disinfectants (they may affect results).
- Notify nurse when specimen is available.
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- Question #2: Tell whether the following statement is true or false. When collecting stool using the technique “timed specimen,” the nurse should consider the first stool passed by the patient as the start of the collection period.
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- Answer to Question #2: A. True
- Rationale: The first stool marks the start of the collection period for timed specimens.
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- Types of Direct Visualization Studies (Endoscopy):
- Esophagogastroduodenoscopy (EGD)
- Colonoscopy
- Sigmoidoscopy
- Wireless capsule endoscopy
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- Question #3: Which direct visualization test uses a long, flexible, fiberoptic–lighted scope to visualize the rectum, colon, and distal small bowel?
- A. Esophagogastroduodenoscopy
- B. Colonoscopy
- C. Sigmoidoscopy
- D. UGI series
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- Answer to Question #3: B. Colonoscopy
- Rationale:
- Colonoscopy visualizes the rectum, colon, and bowel with a lighted scope.
- Esophagogastroduodenoscopy examines the esophagus, stomach, and upper duodenum.
- Sigmoidoscopy examines distal sigmoid colon, rectum, and anal canal.
- UGI series is fluoroscopic examination after ingestion of barium for the esophagus, stomach, and small intestine.
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- Indirect Visualization Studies:
- Upper GI (UGI) Series or Barium Swallow
- Small bowel series
- Barium enema
- Abdominal ultrasound
- Magnetic resonance imaging (MRI)
- Abdominal CT scan
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- Upper GI (UGI) Series / Barium Swallow:
- Diagnostic imaging of the upper digestive system: esophagus, stomach, duodenum.
- Patient drinks barium solution; X-rays taken as it moves through.
- Barium coats lining to visualize abnormalities.
- NPO (nothing by mouth) for typically 6–8 hours before test.
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- Small Bowel Series:
- Diagnostic imaging of the small intestine with X-rays and contrast (barium).
- Indications: obstructions, Crohn’s disease, tumors/polyps, ulcers, malabsorption, fistulas/structural abnormalities.
- Patient drinks barium; X-rays at intervals (every 15–30 minutes).
- Test can last 1–4 hours depending on transit time.
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- Barium Enema (Lower GI Series):
- Diagnostic test for colon and rectum using X-rays and barium.
- Evaluates polyps, diverticula, colon cancer, inflammatory bowel diseases, structural abnormalities.
- Barium inserted via enema; sometimes air is introduced after for a double-contrast view.
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- Abdominal Ultrasound:
- Non-invasive imaging using high-frequency sound waves.
- Assesses liver, gallbladder, pancreas, spleen, kidneys, bladder, abdominal aorta and vessels.
- Detects gallstones, kidney stones, liver disease, masses, cysts, fluid accumulation, aneurysms.
- Procedure: apply gel; move transducer over abdomen; real-time images displayed.
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- Magnetic Resonance Imaging (MRI):
- Non-invasive, uses strong magnets and radio waves to create detailed images.
- Purposes: soft tissue injuries, CNS/brain abnormalities, tumors, liver and bowel conditions, obstructions, fistulas, abscesses in GI tract; vascular structures with contrast.
- Procedure: patient lies in a tunnel-like scanner; magnetic field aligns hydrogen atoms; radio waves produce signals for images.
- May involve gadolinium contrast for enhanced detail.
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- Abdominal CT Scan (CAT Scan):
- Diagnostic imaging using X-rays and computer processing to produce cross-sectional images.
- Purposes: abdominal organs (intestines, liver, pancreas, kidneys); inflammation/infection; obstructions/perforations; tumors/abscesses; trauma.
- Procedure: patient lies on table; CT scanner rotates; computer reconstructs cross-sections.
- May use oral/IV/rectal contrast.
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- Scheduling Diagnostic Tests:
- 1: Fecal occult blood test
- 2: Barium studies (these should precede UGI)
- 3: Endoscopic examinations
- Principle: Noninvasive procedures generally take precedence over invasive procedures when scheduling (inpatient vs. outpatient considerations).
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- Patient Outcomes for Normal Bowel Elimination:
- A soft, formed bowel movement every 1 \text{ to } 3 \text{ days} without discomfort.
- The relationship between bowel elimination and diet, fluids, and exercise is explained to the patient.
- Medical evaluation should be sought if changes in stool color or consistency persist.
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- Promoting Regular Bowel Habits:
- Timing
- Positioning
- Privacy
- Nutrition
- Exercise
- Abdominal settings
- Thigh strengthening
- Practical strategies: encourage consistent routines, maximize comfortable position for defecation, and support abdominal and pelvic floor fitness.
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- Individuals at High Risk for Constipation:
- Patients on bedrest taking constipating medications.
- Patients with reduced fluids or bulk in their diet.
- Patients who are depressed.
- Patients with CNS disease or local lesions causing pain on defecation.
- Implication: Identify at-risk patients and implement preventive strategies (diet, hydration, activity, and medication review).
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- Nursing Measures for the Patient With Diarrhea:
- Answer call bells immediately.
- Remove the cause of diarrhea when possible (e.g., review/adjust medications).
- If there is impaction, obtain physician order for rectal examination.
- Provide special care to the perianal region to prevent skin irritation.
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- Preventing Food Poisoning #1:
- Do not buy damaged packaging.
- Refrigerate items promptly.
- Wash hands and surfaces often.
- Use separate cutting boards for foods.
- Thoroughly wash all fruits and vegetables before eating.
- Do not wash meat, poultry, or eggs to prevent spreading microorganisms.
- Never use raw eggs.
- Do not eat seafood raw or with unpleasant odor.
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- Preventing Food Poisoning #2:
- Use a food thermometer to ensure safe internal temperatures.
- Keep food hot after cooking; maintain at least 140^{\circ}\text{F} or above.
- Give only pasteurized fruit juices to small children.
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- Methods of Emptying the Colon of Feces:
- Enemas
- Rectal suppositories
- Oral intestinal lavage
- Digital removal of stool
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- Types of Enemas:
- Cleansing
- Retention
- Oil
- Carminative
- Medicated
- Anthelmintic
- Additional types: Nutritive enemas (administer fluids and nutrition rectally).
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- Retention Enemas Details:
- Oil-retention: lubricate stool and mucosa to ease defecation.
- Carminative: helps expel flatus from the rectum.
- Medicated: medications absorbed via rectal mucosa.
- Anthelmintic: destroys intestinal parasites.
- Nutritive enemas: administer fluids and nutrition rectally.
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- Question #4: Which enema would be used for a patient with intestinal parasites?
- A. Oil-retention enema
- B. Carminative enema
- C. Nutritive enema
- D. Anthelmintic enema
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- Answer to Question #4: D. Anthelmintic enema
- Rationale: Anthelmintic enemas destroy intestinal parasites. Oil-retention lubricates; Carminative expels flatus; Nutritive enema provides fluids/nutrition rectally.
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- Bowel-Training Programs:
- Manipulate factors within the patient’s control (food/fluid intake, exercise, defecation timing).
- Aim for a soft, formed stool at regular intervals without laxatives.
- When achieved, continue to offer assistance with toileting at the successful time.
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- Nasogastric Tubes:
- Inserted to decompress or drain the stomach or to rest the GI tract before/after abdominal surgery to promote healing.
- Inserted to monitor GI bleeding.
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- Feeding tube overview:
- Esophagus → Stomach (nasogastric feeding tube).
- Nasojejunal feeding tube (advanced beyond stomach).
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- Epiglottis:
- When you swallow, the epiglottis moves to block the entrance of food particles into the larynx and lungs.
- The laryngeal muscles assist by pulling upward and closing during swallowing to prevent aspiration.
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- Types of Ostomies:
- Sigmoid colostomy
- Descending colostomy
- Transverse colostomy
- Ascending colostomy
- Ileostomy
- Note: Ostomies alter normal stool passage and require changing appliance and stoma care.
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- Slide credits: JOY HOOPER; JAA INDEPENDENT EXPERT (context for visuals).
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- Ostomy locations (visual references):
- Right Colostomy
- Transverse Colostomy
- Jejunostomy
- Ileostomy
- Left Colostomy
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- Location of (A) Sigmoid Colostomy and (B) Descending Colostomy (labelled as B).
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- Location of (C) Transverse Colostomy and (D) Ascending Colostomy (labels C and D).
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- Location of an Ileostomy (E).
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- Colostomy Care:
- Keep the patient as odor-free as possible; empty the appliance frequently.
- Inspect the stoma regularly; observe size stabilization (approx. 6–8 weeks).
- Keep skin around the stoma clean and dry.
- Measure fluid intake and output.
- Explain each aspect of care to the patient and their self-care role.
- Encourage the patient to care for and view the ostomy.
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- Comparison of Stomal Appearance (visual reference slide).
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- Patient Teaching for Colostomies:
- Explain the reason for bowel diversion and the treatment rationale.
- Demonstrate self-care behaviors for ostomy management.
- Describe follow-up care and support resources.
- Inform where supplies may be obtained in the community.
- Address fears and concerns; foster a positive body image.
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- Proving Ostomy Care (step-by-step care procedure):
- Place a waterproof barrier under the stoma appliance.
- Empty the ostomy appliance using proper technique.
- Remove the appliance carefully; avoid skin damage; use adhesive remover if applicable.
- Dispose of the appliance according to policy.
- Remove excess stool from the stoma site with toilet tissue; clean skin around the site (soap and water, soft cloth).
- Pat dry.
- Assess the stoma site and surrounding skin.
- If skin protectant is applicable, apply before placing the skin barrier.
- Measure the stoma site and cut the barrier slightly larger by \tfrac{1}{8} \text{ inch} to fit.
- Remove the paper backing, apply barrier around the site, press to seal.
- Attach the appliance pouch to the barrier and ensure the pouch is closed.