Self-Taught Know-It-All: Health Differences: Bowel Elimination, Ch 38

Health Differences
Bowel Elimination, Ch 38
Taylor's Fundamentals of Nursing

Anatomy and Physiology
The GI Tract is also known as the alimentary canal and extends from the mouth to the anus. The major organ associated with bowel elimination is the large intestine.

Stomach:

hollow, j-shaped, muscular organ
located in left upper portion of abdomen
stores food during eating
secretes digestive fluids
churns food to aid in digestion
pushes partially digested food called chyme into small intestine
pyloric sphincter controls movement of chyme from stomach to small intestine

Small Intestine:

~ 20 ft long
~ 1 inch wide
Made up of 3 parts: duodenum (beginning), jejunum (middle), ileum (end)
Secretes enzymes that digest proteins and carbs
Digestive juices from liver and pancreas enter the small intestine through an opening in the duodenum
The small intestine is responsible for digestion of food an absorption of nutrients into the blood stream

Large Intestine:

The connection between the small intestine an large intestine is the ileocecal valve
This valve prevents contents from entering the large intestine prematurely and prevents waste products from returning to the small intestine
Is the primary organ of bowel elimination
Also known as the colon
Extends from ileocecal valve to the anus
~5 ft long
Diameter decreases from cecum to anus
Ascending colon, hepatic fissure, transverse colon, splenic fissure, descending colon, sigmoid colon
Sigmoid colon contain feces that are ready for excretion
Once excreted feces are called stool
If veins in the rectum become abnormally distended, hemorrhoids occur.
Rectum is empty except for immediately before and during a bowel movement
Functions of the large intestine include: (1) absorption of water, (2) formation of feces, (3) expulsion of feces from body
When water absorption does not occur properly, stool is soft and watery
If stool remains in large intestine too long or not enough water is absorbed, stool becomes dry and hard

Nervous System Control:

Autonomic nervous system innervates the muscles of the colon
Parasympathetic system stimulates movement
Sympathetic system inhibits movement
Peristalsis occurs q3-12 minutes
Mass peristaltic sweeps occur 1-4 times q24h
One third to one half of ingested food waste is normally excreted within 24 hours

Defecation:

Refers to the emptying of the large intestine
Two centers govern the reflex to defecate: one in the medulla and one in the spinal cord
The external anal sphincter is under voluntary control
When an individual bears down to defecate, the increased pressures (4-5 times normal pressure) in the abdominal an thoracic cavities result in a decreased blood flow to the atria an ventricles, thus temporarily lowering cardiac output
Once the bearing down ceases, the pressure is lessened, and a larger than normal amount of blood returns to the heart which can elevate blood pressures so the Valsalva maneuver may be contraindicated in some pts for this reason
Defecation is usually painless
Frequency can vary from two or three times a week to two or three times a day

Factors Affecting Bowel Elimination

Various factors can affect bowel elimination
Irregularity can occur during times of earth or illness
Can be affected by developmental stage, patterns, amount and quality of fluid and food intake, level of activity, emotional states, pathologic processes, medications, diagnostic tests, and surgery

Developmental Considerations

Infant:

stool characterstics depend on whether infant is being fed breast milk or formula
Breast milk is easier for the intestines to break down and absorb
Breast fed babies have more frequent stools, that are yellow to golden, with little odor
Formula fed stools are yellow to brown and paste-like in consistency and have a stronger odor because of the break down of protein
Both may have curds and mucus
Infants do not have voluntary control over bowel elimination
At age 1 year, infants pass 1-2 stools/day
Loose stools may be related to over feeding or too much corn syrup in the diet
If constipation occurs, dietary manipulation is the initial treatment
Consistent use of suppository and laxatives is discouraged
Infants with persistent constipation should be evaluated of structural defects

Toddler:

between 18-24 months the nerve fibers that innervate the internal and external sphincters become fully developed and voluntary control of defecation becomes possible
voluntary defecation requires intact muscular, sensory, and nervous structures
bowel training requires awareness by toddler of need to defecate
voluntary bowel control is normally gained by 30 months of age but varies with each child
physiologic maturity is the first priority for successful bowel training
discourage use of punishment or shaming
toilet trained toddlers can regress during hospitalizations or when stressed

School Aged Child, Adolescent, and Adult:

patterns vary in quantity, frequency, and rhythmicity

Older Adult:

constipation is often a chronic problem
diarrhea, fecal impaction, fecal incontinence can result from physiological or lifestyle changes

Focus on the older adult:

Chronic Constipation can be caused by:

decreased GI motility, effect of medications (like antacids, opioids, and antihypertensives), decreased fluid intake, inadequate fiber intake, incomplete emptying of the bowel. Can lead to laxative abuse.

Diarrhea can be caused by:

laxative abuse, effects of medications, effects of tube feedings. Can lead to life threatening dehydration and electrolyte imbalance.

Fecal impaction can be caused by:

chronic constipation, may be precede by oozing liquid feces- often mistaken for diarrhea. Can lead to distended abdomen, abdominal pain, and complete bowel obstruction

Fecal incontinence can be caused by:

decreased muscle tone, alteration in nervous system innervation to rectum, altered cognition. Can lead to skin break down and depression.

Daily Patterns:

most people have patterns of bowel elimination involving frequency, timing, position, and place.
when routines are interrupted it can lead to constipation
when the urge to defecate is ignored, the feces remain in the rectum until the reflex is again initiated. meanwhile, water continues to be absorbed from the unexcelled feces, which makes the stool dry, hard, and painful to pass.

Food and Fluid:

a high fiber and high fluid daily intake facilitate bowel elimination
high fiber foods include- shoe grains and bran, dried peas and beans, fresh fruits and vegetables and increase bulk
bulkier feces increase abdominal pressure which increases peristalsis resulting in quicker movement through the colon, allowing less time for water to be absorbed
this also decreases the amount of time toxins are spent in the colon and is thought to play a role in colon cancer prevention
food intolerance can alter bowel elimination resulting in diarrhea, gaseous distention, and cramping
constipating foods: cheese,lean meats, eggs, pasta
laxative effect: certain fruits and veggies (prunes), bran, chocolate, spicy foods, alcohol, coffee
gas producing foods: onions, cabbage, beans, cauliflower

Self Care Education for Bowel Elimination:

Promoting healthy bowel habits include:

accept individual patterns of defecation
eat a balanced diet including high fiber foods
follow a regular exercise program
do not ignore the urge to defecate
establish a routine, 1 hour after meals is best
avoid prolonged use of over the counter enemas or laxatives
drink 8-10 glasses of water/day
seek medical assistance for any change in characteristics of stool or blood in stool

Pathologic Conditions affecting Bowel Elimination:

changes in stool characteristics or frequency may be one of the first signs of disease
pathologic causes of diarrhea: diverticulitis, infection, malabsorption syndromes (the inability to absorb vitamins, minerals, or nutrients), neoplastic diseases, diabetic neuropathy, hyperthyroidism, uremia (retention of urea in the blood)
pathologic causes of constipation: diseases within the colon or rectum and injury or degeneration of the spinal cord and megacolon (extremely dilated colon).
outbreaks of food poisoning can result in severe GI symptoms
severe abdominal cramping followed by watery or bloody diarrhea could be a microbial infection
intestinal obstruction- blockage of normal flow of intestinal contents
mechanical obstruction results from pressure on intestinal walls (tumors, stenosis, adhesions, hernias, and strictures)
functional obstruction results from inability of intestinal musculature to move the intestinal contents (muscular dystrophy, diabetes mellitus, parkinson's, manipulation of bowel during surgery

Medications affect on Bowel Elimination

medications that promote peristalsis- cathartics and laxatives
medications that inhibit peristalsis- antidiarrheal medication
other meds that affect elimination and stool characteristics and cause constipation and decrease intestinal motility: opioids, antacids containing aluminum, iron sulfate, anticholinergic meds
meds that cause diarrhea as side effect: Augmentin (amoxicillin clavulanate), meds with magnesium
drugs that cause GI bleeding: anticoagulants, aspirin. May cause stool to appear pink to red to black
iron salts may result in black stool from the oxidation of the iron
antacids may cause white discoloration or speckling
antibiotics may cause green grey color related to impaired digestion
pts receiving antibiotics are at greater risk for c.diff, which causes intestinal mucosal damage and inflammation, resulting in diarrhea and abdominal cramping
treatment with broad spectrum antibiotics disrupts normal intestinal flora an fallows microorganisms to flourish within the intestine
c. diff spores are relatively resistant to disinfectants and can be easily spread on hands
infected c. diff pts should be on contact precautions

Diagnostic Studies (Bowel Elimination):

elimination patterns may be affected by diagnostic studies
barium enemas can cause constipation
stress and change in food intake can cause an alteration in elimination patterns
cathartics or enemas prior to studies of GI tract can interfere with bowel patterns

Surgery and Anethesia's Effect on Bowel Elimination:

paralytic ileus- a condition that inhibits peristalsis caused by direct manipulation of the bowel during abdominal surgery. Normally lasts 24-48 hours during which time food and fluids are withheld.
narcotics for post-op pain can exacerbate paralytic ileus
inhaled general anesthetic agents block the parasympathetic impulses to the intestinal musculature

The Nursing Process for Patients with Bowel Elimination Disturbances:

Nursing History:

initiate questions regarding bowel history because pts are not likely to bring it up
record daly bowel status of critically ill or cognitively impaired pts to look for clues of impending problems
ask pts, "When did you move your bowels last?"

Physical Assessment:

Physical assessment of abdomen, anus, and rectum. Examination techniques that are helpful in assessing the functioning of the GI tract are:

ABDOMEN:

inspection
auscultation
percussion
palpation

Inspection:

Observe the contour of the abdomen noting any masses, scars, or area of distention
when an obstruction is present, the waves of peristalsis may be seen up to the point of obstruction
look for presence of distention or protrusion

Auscultation:

listen for bowel sounds in all abdominal quadrants using a systemic, clockwise approach
if pt has NG, disconnect it from suction during assessment
keep in mind timing of pts last meal or a full bladder
note frequency and character of bowel sounds
Significant findings include: hypoactive bowel sounds, diminished rate of sounds, hyperactive bowel sounds, increased frequency in sounds, an absent or infrequent sounds
hypoactive indicates: diminished bowel motility (abdominal surgery, obstruction)
hyperactive indicates: increased motility (diarrhea, gastroenteritis, early bowel obstruction)
decreased or absent (after 5 minutes) indicate: absence of motility (peritonitis, paralytic ileus, prolonged immobility)
describe sounds as: audible, hypoactive, hyperactive, or inaudible

Percussion:

percuss all quadrants in systematic, clockwise manner to identify massess, fluid, or air in abdomen
expect resonant sound or tympani
hyperresonance- flatus
dull- obstruction
increased dullness- fluid, mass, or tumor

Palpation:

Perform both light and deep palpation in each quadrant
note muscular resistance, tenderness, enlargement of organs, and masses
if distended, note presence of firmness or tautness

ANUS AND RECTUM:

Perform superficial evaluation each time you wash or assist in bowel evacuation. If rectal exam is to be performed, place pt in left Sims position. Inspect for cracks, nodules, hemorrhoids, masses, or polyps. Observe for fecal mass which may distend the anus. Inspect fro skin breakdown 2/2 diarrhea or fecal incontinence. With gloved and lubricated finger inspect for sphincter tone and smoothness of mucosal lining.

NORMAL STOOL CHARACTERISTICS:

Volume- Variable
Color- Infant: yellow to brown, Adult: Brown
Odor- Pungent, may be affected by food ingested
Consistency- soft, semisolid, and formed
Shape- 1 to 2 inches in diameter and tubular shape of colon
Consituents- waste residues of digestion: bile, intestinal secretion, shed epithelial cells, bacteria, inorganic material (calcium and phosphates), seeds, meat fibers, and fat in small amounts

ABNORMAL STOOL CHARACTERISTICS:

Volume- consistently large diarrheal stools suggests a disorder in the small bowel or proximal colon; small, frequent stools, with urgency to pass them suggests a disorder of the left colon or rectum
Color- the brown color is due to stercobilin, a bile pigment derivative. The rapid rate of peristalsis in infant causes the stool to be yellow. Color is influenced by diet. Black- red meant and dark green veggies. Light brown- high milk and milk product, low meat. Absence of bile- white or clay colored. Iron salts- black. Antacids- whitish. Bleeding high in GI tract, black. Low in GI tract, red.
Odor- odor is due to indole and skatole, caused by putrification and fermentation in bowel. Odor is influenced by pH. Blood causes unique odor.
Consistency- influenced by food intake and gastric motility. The less time is the intestine, the more liquid the stool.
Shape- GI obstruction can caused narrow, pencil shaped stools.
Constituents- bleeding, infection, inflammation, and other pathologic conditions can lead to abnormal constituents. Blood, pus, parasites, ova, and mucus.

STOOL COLLECTION:

Nurse is responsible for obtaining specimen, labeling specimen, ensuring specimen is transported to lab in timely manner.
Do not place toilet tissue in specimen or bedpan.
Occult blood- blood that is hidden in the specimen or cannot be seen on gross examination
Color of stool may reflect source of bleeding
Hemitest and guaiac test are used to detect occult blood
Ingestion of certain substances can give false positive- red meat, animal liver, salmon, tuna, mackerel, sardines, tomatoes, cauliflower, horseradish, turnips, melon, bananas, and soybeans.
Before testing avoid foods (4 days) and drugs (7 days) that could alter results
Female who is menstruating should postpone until 3 days post bleeding
Postpone if hematuria or bleeding hemorrhoids are present

Specimens for Pinworms:

adult pinworms, parasitic intestinal worms, live in the cecum
they migrate to the anal area at night to lay eggs and retreat to anal canal during day
most common symptom is anal itching
collect specimen in morning immediately after pt wakes and before pt urinates, has had bm, or bath
use clear cellophane tape to collect specimen bc frosted tape makes examination difficult

INDIRECT VISUALIZATION STUDIES:

Upper GI exam and bowel series, pt drink barium sulfate like milkshake. Barium coats esophagus, stomach and small intestine
In barium enema or lower GI exam, barium is instilled into large intestine through rectal tube inserted through anus
Flouroscopy projects continuous X-ray images for continuous observation of flow of barium
Noninvasive procedures take precedence over invasive procedures

NANDA Nursing Diagnoses:

Constipation- decreased fiber in diet, decreased fluid intake, inactivity, delaying defecation when urge is present, abuse of laxatives, use of constipating meds, change in routine, pain associated with defecation. "I feel bloated and i know I have to move my bowels but I can't."
Risk for Constipation- habitually ignores urge to defecate, inactivity, inadequate fluid and fiber "Im in such a rush in the morning so I don't go to the bathroom." Straining, dry hards stools, feels bloated

Nutrition:

General dietary reccs of 2-3,000mL of luis daily to promote regular defecation
water is recommended as fluid of choice
increasing fiber intake without sufficient fluid intake can result in severe GI problems including fecal impaction
regular exercise improves GI motility and aids in defecation

Preventing and Treating Constipation:

Constipation is dry hard stool; persistently difficult passage of still; and /or incomplete passage of stool
decreased gastric motility slows passage of feces through GI tract, resulting in increased fecal absorption and causing dry hard stool
Individuals at risk for constipation include:

pts on bed rest who take constipating meds
pts with reduced fluids or reduced bulk in their diets
pts who are depressed
pts with CNS diseases or local lesions that cause pain

Teaching About Laxatives:

Cathartics and laxatives are drugs that induce emptying of the intestinal tract
Cathartics exert a stronger effect on intestines than laxatives
Some act by chemically stimulating peristalsis

castor oil, senna, phenolphthalein, bisacodyl (Dulcolax)

Some increase bulk which promotes additional mechanical stimulation of intestine

psyllium, Metamucil

Some soften fecal material

castor oil, docustate sodium (Colace)

Saline Osmotics (draw water into intestine to promote peristalsis)

milk of magnesia, sodium phosphate (Phospho-Soda)

Classification of Laxatives:

Bulk forming (Metamucil)

psyllium grain or synthetic product that causes stool to absorb water and swell, thus stimulating peristalsis
usually acts within 24 hours
may interfere with absorption of calcium, iron, and certain drugs
should not be given to bedridden pts or those with intestinal stricture

Stool softener (Colace)

agents with detergent activity that allow water and fat to penetrate stool
recommended for those who must avoid straining
has lubricant component of drug that may interfere with absorption of fat soluble vitamins

Emollient, lubricant (mineral oil)

lubricates the intestinal tract and retards colonic absorption of water, softening the stool, making it easier to pass
usually effective within 8 hours
may interfere with absorption of fat soluble vitamins
can be aspirated possibly leading to a pneumonia

Stimulant (Dulcolax)

drug promotes peristalsis by irritating the intestinal mucosa or stimulating nerve endings in intestinal wall
works more quickly than bulking agents
are the most abused laxatives on the market
cause lazy bowel syndrome
may affect absorption of vitamin D and calcium
not recommended for elderly pts
alters electrolyte transport

Saline Osmotic (MOM)

drug draws water into intestine and stimulates peristalsis
is used when rapid cleansing is desired
should not be used by elderly
can produce dehydration
not for pts with kidney disease or heart failure

*** Although many people take laxatives because they believe they are constipated, most are unaware that habitual use of laxatives is the most common cause of constipation.

Preventing Traveler's Diarrhea (lovingly referred to as 'The Revenge of Montezuma") :)

caused by bacterial enteropathogens, viruses or parasites
is most common lines of travelers to underdeveloped countries
symptoms include more than 3 loose stools in 24 hrs, fever, nausea, vomiting and abdominal cramps
advise pts to peel fruits, consume dry foods and foods that are piping hot, and cooked thoroughly
avoid tap water, ice cubes, fruit juice, fresh salads, open buffets
treatment includes- maintaing hydration with bottled water or fluids containing rehydration salts, anti motility agents i.e. loperamide (Immodium), and antibiotics

Teaching for Diarrhea:

treatment depends on whether diarrhea is acute or chronic
Acute diarrhea may result from viral or bacterial infection, reaction to a med, or alteration in diet

characterized by sudden onset and lasts several hours to several days
rehydration is key
oral liquids may used if pt can tolerate, other IV rehydration may be necessary
stress importance of hand hygiene
antidiarrhela agents are avoided in acute diarrhea until a bacterial causative agen thaw been ruled out

Chronic diarrhea usually last 3-4 weeks

has many possible causes
Chron's disease, ulcerative colitis, malabsorption syndromes, bowel tumor, parasitic infection, laxative abuse, surgery, alcohol abuse, chemotherpaeutic agents all can contribute
antidiarrheal meds can be used

Whatever the type of diarrhea, every effort must be made to identify and eliminate the underlying cause

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Health Differences: Bowel Elimination, Ch 38