Lecture Notes on Bowel Elimination / Enema Administration & Colostomy CarePrepared By: Mark Fredderick R Abejo R.N, MAN Clinical Instructor Increased fluid intake Sufficient bulk in diet Adequate activity and exercise Diarrhea Refers to frequent evacuation of watery stools. It is NURSING SKILLS associated with increased gastrointestinal motility and a rapid passage of fecal contents through the lower GI tract. BOWEL ELIMINATION Nursing Interventions to Relieve Diarrhea Lecturer: Mark Fredderick R. Abejo RN,MAN Replace fluid and electrolyte ____________________________________ Provide good perianal careNormal Characteristics of the Stool Promote rest Diet: Color Yellow or golden brown - small amounts of bland foods Odor Aromatic upon defecation - low fiber diet Amount Approx. 150 – 300 grams per day - BRAT diet Consistency Soft and formed - avoid excessively hot or cold fluids Shape Cylindrical - potassium-rich foods and fluids Frequency Variable; usual range 1-2 / day Anti diarrheal medications as orderedAlteration on the Characteristics of Stool Alcholic Stool : Gray, pale or clay colored stool due to Note: absence of stercobilin caused by bilary obstruction. Do not administer antidiarrheal at the start of Hematochezia : Passage of stool with bright red blood. diarrhea. Diarrhea is the body’s protective mechanism to rid Due to lower gastrointestinal bleeding. itself of bacteria and toxins Melena : Passage of black, tarry stool due to upper GI bleeding. Steatorrhea : Greasy, bulky, foul-smelling stool. Due Flatulence to presence of undigested fats. Is the presence of excessive gas in the intestines. This may be due to swallowed air, bacterial action in theCommon Fecal Elimination Problem large intestine and diffusion from blood. Causes:Constipation - constipation - codeine, barbiturates and other medications that dec. Refers to the passage of small dry, hard stool or the intestinal motilitypassage of no stool for a period of time. - anxiety - eating gas-forming foodsNursing Intervention to Prevent and Relieve Constipation - rapid food or fluid ingestion - improper use of drinking straw - excessive drinking of carbonated beverages Adequate fluid intake, between 1,500 – 2,000 mls. / day - gum chewing, candy sucking and smoking High fiber diet - abdominal surgery Established regular pattern of defecation Nursing Interventions to Relieve Flatulence Respond immediately to the urge to defecate Minimize stress Avoid gas-forming food Adequate activity and exercise Provide warm fluids to drink Assume sitting ad semi squatting position Early ambulation among post op client Administered laxatives as ordered Adequate activity and exercise Limit carbonated beverages, use of drinking straws andFecal Impaction chewing gum Is the mass or collection of hardened, putty-like Rectal tube insertion as ordered:feces in the folds of the rectum. The stool is lodged or stuck - Place client in left lateral positionin the rectum, the person is unable to voluntarily evacuate - Insert 3-4 inches of the lubricated rectal tube, gently inthe stool. rotating motion. - Use of rectal tube Fr. 22-30 Nursing Interventions to Relieve Fecal Impaction - Retain rectal tube for max. of 30 minutes Carminative enema as ordered Manual extraction or fecal disimpaction as ordered Administer cholinergics as ordered.
Lecture Notes on Bowel Elimination / Enema Administration & Colostomy CarePrepared By: Mark Fredderick R Abejo R.N, MAN Clinical Instructor For Large Volume EnemaFecal Incontenence - Solution container - Rectal tube of correct size Adult: Fr. 22 – 32 Is the involuntary elimination of bowel contents, it is Children: Fr. 14 -18 often associated with neurological, mental or emotional Infant: Fr. 12 impairments. - Tube clamp Clients with cerebral cortex injury may be unable to - Correct solution, amount and temperature perceive distended rectum or unable to initiate the motor For Small Volume Enema response required to inhibit defecation voluntarily - Prepackaged container of enema solution with lubricated Clients who are disoriented or confused may have lost tip ( Fleet Enema ) the social inhibition that prevents immediate fecal evacuation. People who have sustained sacral spinal cord injury experience impaired nerve supply to the rectum and anal sphinctersAdministering EnemasPurposes: To relieve constipation and fecal impaction To relieve flatulence To administer medication Steps / Procedure Rationale To evacuate feces in preparation for diagnostic Identify and inform the procedure or surgery To allay anxiety client and explain the procedure.Types of Enema Wash hands, apply clean gloves and observed 1. Cleansing Enema : Stimulates peristalsis by appropriate infection irritating the colon and rectum and or by distending control the intestine with the volume of fluid introduced. - High enema, clean as much of the colon, Provide client privacy 1000 mls. of sol. are introduced Position the client: Facilitate the flow of sol. by Note: Container should be 12-18 inches Adult: Left lateral gravity as the sigmoid colon above the rectum Infant/small children: is on the left side - Low enema, clean rectum and the Dorsal recumbent sigmoid only, 500 mls. of sol. are introduced Note: Container should be 12 inches above the rectum 2. Carminative Enema : To expel flatus, 60 to 180 mls. of fluids is introduced. 3. Retention : Introduces oil into the rectum and the sigmoid, oil is retained in 1 to 3 hours. Act to soften the feces and to lubricate the rectum and the anal canal, facilitating passage of feces. 4. Return Flow Enema / Colonic Irrigation Lubricate the tube about - Done to expel flatus, 100 to 200 mls. of fluid is 5 cm ( 2 in ) introduced into and out of the large intestines to Allow the solution to This prevent introduction of stimulate peristalsis and promote expulsion of flow through the air into the colon flatus. connecting tubing and - The solution container is lowered so that the fluid rectal tube to expel air backs out through the rectal tube into the container. before insertion of the - The process is repeated 5 – 6 times rectal tube. - Replace the solution several times during the Insert 7 – 10 cm ( 3 to 4 To prevent irritation of anal procedure as it becomes thick with feces. inches) or rectal tube and rectal tissues - This procedure may take 15 – 20 minutes to be gently in rotating motion effective. If resistance is felt, ask To relax the internal anal the client to take deep sphincterEquipment; breath, then run a small- Disposable linen pad (optional ) amount of sol, through- Bedpan or commode the tube- Clean gloves- Water soluble lubricant- Paper towel
Lecture Notes on Bowel Elimination / Enema Administration & Colostomy CarePrepared By: Mark Fredderick R Abejo R.N, MAN Clinical Instructor Placing a regular bedpan against the client’s buttocks. Do perianal care Make relevant documentation Assuming a left lateral position for a commercially prepare enema (fleet enema) Colostomy Management Introduce solution To prevent sudden slowly stimulation of peristalsis- Raise the solution The locations of bowel diversion ostomies.container and open the The higher the solutionclamp to allow fluid to flow container is held above theHigh Enema: 12-18 inches rectum, the faster the flowabove the rectum and the greater the pressureLow Enema: 12 inches in the rectumabove the rectum If the client complains of fullness or pain, use the Decrease the likelihood of clamp to stop the flow for intestinal spasm and 30 sec. and then restart premature ejection of the flow at a slower rate solution If High Enema, change the position to distribute sol. wellIf Low Enema, remain in leftlateral position If the order is cleansing enema:- give the enema 3x Colostomy is the opening in the Gastrointestinal- alternate hypotonic sol. To prevent water tract for the purpose of diverting and draining fecalwith isotonic sol. intoxication materials After all the solution has been stilled or when the Temporary Colostomies, generally performed for traumatic clients fells the desire to injuries or inflammatory conditions of the bowel. It allows defecate, close the clamp the bowel to rest and heal. and remove the rectal Permanent Colostomies, are performed to provide a means tube, disposed properly of elimination when the rectum or anus is nonfunctional as a Encourage the client to result of birth defect or a disease. retain the enema, ask the client to remain lying Type of Discharge down Ileostomy Liquid fecal drainage Assist the client to Drainage is constant and cannot defecate be regulated- Assist in sitting position Contains some digestive- Ask the client who is using enzymesthe toilet not to flush it The nurse need to observe Odor is minimal bec.of fewer the feces bacteria are present Ascending Liquid fecal drainage Colostomy Drainage is constant and cannot be regulated Odor is a problem requiring control Transverse Malodorous, mushy drainage Colostomy Descending Solid fecal drainage Colostomy Sigmoidostomy Normal fecal characteristics
Lecture Notes on Bowel Elimination / Enema Administration & Colostomy CarePrepared By: Mark Fredderick R Abejo R.N, MAN Clinical Instructor Equipment and Supplies: Disposable gloves Electric or safety razor Bedpan Solvent Moisture-proof bag Cleaning materials, including tissues, warm water, mild soap (optional), washcloth or cotton balls, and towel Tissue or gauze pad Skin barrier Stoma measuring guide Pen or pencil and scissors Clean ostomy appliance, with optional belt Tail closure clamp Special adhesive, if needed Stoma guide strip, if needed Deodorant (liquid or tablet) for a nonodor-proof colostomy bag Note: Select an appropriate time to change the appliance: Avoid times close to meal or visiting hours. Avoid times immediately after meals or the administration of any medications that may stimulate bowel evacuation.Changing a Ostomy Appliance ProcedurePurposes: To assess and care for the peristomal skin Rationale To collect effluent for assessment of the amount and Explain to the client what you To allay anxiety type of output. are going to do, why it is To minimize odors for the client’s comfort and self- necessary, and how she can esteem cooperate. Wash hands and observe otherAssessment appropriate infection control procedures. Apply clean gloves.Stoma Colors Provide for client privacy.- should appear red, similar to the mucosal linin of the Assist the client to a comfortable May avoid wrinkles oninner cheek. sitting or lying position in bed the ostomy appliance- very pale or darker-colored stomas with a bluish or or,purplish shades indicate impaired blood circulation to the preferably, a sitting or standingarea. position in the bathroom. Unfasten the belt, if the client isStoma Size and Shape wearing one.- most stomas protrude slightly from the abdomen Empty and remove the ostomy appliance:- new stomas normally appear swollen, but swelling Empty the contents of the pouch through the bottomgenerally decreases over 2-3 weeks up to 6 weeks. opening into a bedpan.- failure of swelling to recede may indicate problem like Assess the consistency and the amount of effluent.blockage. Peel the bag off slowly while holding the client’s skin taut. If the appliance is disposable, discard it in a moisture-Stomal Bleeding proof bag.- slight bleeding initially when the stoma is touched is Clean and dry the peristomal skinnormal, but other bleeding should be reported. and stoma. Use toilet tissue to remove excess stool.Peristomal Skin Use warm water, mild soap- any redness and irritation of the peristomal skin 5 – 13 cm (optional), and cotton balls or a washcloth and towel to( 2-5 in ) of skin surrounding the stoma should be noted. clean the skin and stoma.- transient redness after removal of adhesive is normal. Use a special skin cleanser to remove dried, hard stool.Note: Dry the area thoroughly by patting with a towel or Burning sensation under the faceplate may indicate cotton balls.skin breakdown
Lecture Notes on Bowel Elimination / Enema Administration & Colostomy CarePrepared By: Mark Fredderick R Abejo R.N, MAN Clinical InstructorAssess the stoma and peristomal skin. other side of the adhesive disc. Inspect the stoma for color, size,shape, and Center the faceplate over the stoma and skin barrier, then bleeding. press and hold the faceplate against the client’s skin for a Inspect the peristomal skin for any redness, few minutes, to secure the seal. ulceration, or irritation. Press the adhesive around the circumference of the Place a piece of tissue or gauze pad over the stoma, adhesive disc. and change it as needed. Tape the faceplate to the client’s abdomen using four orApply paste-type skin barrier, if eight 7.5-cm (3-in) strips of hypoallergenic tape. Placeneeded. Allow the paste to dry the strips around the faceplate in a “picture-framing”for 1 to 2 minutes, or as manner, onerecommended by the strip down each side, one across the top, and one acrossmanufacturer. the bottom. The additional four strips can be placedFor a Solid Water or Disc Skin Barrier diagonally over the other tapes to secure the seal.Use the guide to measure the size of the stoma. Stretch the opening on the back of the pouch, andOn the backing of the skin barrier, trace a circle the position it over the base of the faceplate. Ease it over thesame size as the stomal opening. faceplate flange.Cut out the traced stoma pattern to make an opening in Place the lock ring between the pouch and the faceplatethe skin barrier. Make the opening no more than 0.3–0.4 flange, to seal the pouch against the faceplate.cm (1/8–1/6 in) larger than the stoma. Close the base of the pouch with theRemove the backing to expose the appropriate clamp.sticky adhesive side. Variation: Applying the Skin Barrier and Appliance asCenter the skin barrier over the stoma, and gently press One Unitit onto the client’s skin, smoothing out any wrinkles or Prepare the skin barrier by measuring the size of thebubbles. stoma, tracing a circle on the backing of the skin barrier, and cutting out the traced stoma pattern to make an A guide for measuring stoma. opening in the skin barrier. Prepare the appliance by cutting an opening 0.3–0.4 cm (1/8–1/6 in) larger than the stoma size (if not already present) and peeling off the backing from the adhesive seal. Center the opening of the pouch over the skin barrier. Remove the skin barrier backing to expose the sticky adhesive side. Center the skin barrier and appliance over the stoma, and press it onto the client’s skin. Dispose of equipment, or clean reusable equipment.For Liquid Skin Sealant Discard a disposable bag in a plastic bag before placing in the wasteEither wipe or apply the product evenly around the container.peristomal skin to form a thin layer of the liquid plastic If feces are liquid, measure the volume. Note thecoating to the same area. feces’ character, consistency, and color beforeAllow the skin sealant to dry until it no longer feels emptying the feces into a toilet or hopper.tacky. Wash reusable bags with cool water and mild soap,For a Disposable Pouch with Adhesive Square rinse, and dry.If the appliance does not have a precut opening, trace a Wash a soiled belt with warm water and mild soap,circle 0.3–0.4 cm (1/8–1/6 in) larger than the stoma size rinse, and dry.on the appliance’s adhesive square. Remove and discard gloves.Peel off the backing from the adhesive seal.Center the opening of the pouch over he client’s stoma,and apply it directly onto the skin barrier. Document the procedure in the client’s record:Gently press the adhesive backing onto the skin, and Pertinent assessments and interventionssmooth out any wrinkles, working from the stoma Any increase in stoma sizeoutward. Change in color indicative of circulatoryRemove the air from the pouch. impairmentClose the pouch by turning up the bottom a few times, Presence of skin irritation or erosionfanfolding its end lengthwise, and securing it with a tail Discoloration of the stomaclosure clamp. Appearance of the peristomal skinVariation: Applying a Reusable Pouch with Detachable Amount and type of drainageFaceplate Client reaction to the procedure Client’s experience with the ostomyApply a skin sealant to the faceplate before attaching the Skills learned by the clientadhesive disc.Remove the protective paper strip from one side of thedouble-faced adhesive disc.Apply the sticky side to the back of the faceplate.Remove the remaining protective paper strip from the