DEFECATION•Defecation is the expulsion of feces from the anus and rectum.• Also known as bowel movement
Defecation reflex• Intrinsic defecation reflex • Feces enter rectum distension of rectal walls initiates signal through mesenteric plexus initiate peristaltic waves (descending, sigmoid colon, rectum)anus internal sphincter inhibited from closing relaxed external sphincter defecation• Parasympathetic defecation reflex
Common Bowel Elimination ProblemsConstipation. Decreased frequencyof bowel movements accompaniedby prolonged or difficult passage ofdry hard stoolImpaction. Collection of hardenedfeces wedged in the rectumDiarrhea. Increase in number ofstools and the passage of liquid,unformed feces.IncontinenceFlatulenceHemorrhoids
FACTORS PROMOTING FACTORS IMPAIRING ELIMINATION ELIMINATION Stress free environment Emotional anxiety Ability to follow personal Failure to heed defecation bowel habits, privacy reflex, lack of time and privacy High fiber diet High carbohydrate, Normal fluid intake (fruit high fat diet juice, warm liquid) Reduced fluid intake Exercise (walking) Immobility and inactivityAbility to assume squatting Inability to squat because of position immobility, musculoskeletal Properly administered deformity; pain during laxatives defecation Overuse of cathartics, narcotic analgesics
FACTORS AFFECTING DEFECATION Age Diet Fluid intake Physical Activity Psychological Factors Personal Habits Position During Defecation Pain Pregnancy Surgery and Anesthesia Medications Diagnostic Tests
AssessmentNursing History Usual pattern of elimination, frequency and time of the day. Normal routines followed to promote normal elimination. Description of any recent change in elimination pattern. Description of usual characteristics of stool. Diet history Daily fluid intake History of surgery or illness affecting the GI tract. Medication history Emotional state.
Assessment of the GITNursing History : Subjective Data1. General Data a. presence of dental prosthesis, comfort of usage b. difficulty eating or digesting food c. nausea or vomiting d. weight loss e. pain – may be caused by distention or sudden contraction of any part of the GIT - specify the area, describe the pain2. Specific data if symptoms are present a. situations or events that effect symptoms b. onset, possible cause, location, duration, character of symptoms c. relationship of specific foods, smoking or alcohol to severity of symptoms d. how the symptoms was managed before seeking medical help MTCAT 09
Assessment of theGIT 3. Normal pattern of bowel elimination a. frequency and character of stool b. use of laxatives, enemas 4. Recent changes in normal patterns a. changes in character of stool (constipation, diarrhea, or alternating constipation and diarrhea) b. changes in color of stool melena - black tarry stool (upper GI bleeding) hematochezia – fresh blood in the stool (lower GI bleeding) c. drugs /medications being taken d. measures taken to relieve symptoms MTCAT 09
Assessment of the GITB. Physical Examination : Objective Dataa.) Mouth and Pharynx 1. lips – color, moisture, swelling, cracks or lesions 2. teeth – completeness (20 in children, 32 in adults), caries, loose teeth, absence of teeth impair adequate chewing 3. gums – color, redness, swelling, bleeding, pain (gingivitis) 4. mucosa – color (light pink) examine for moisture, white spots or patches, areas of bleeding, or ulcers white patches – due to candidiasis (oral thrush) white plaques w/in red patches may be malignant lesions 5. tongue – color, mobility, symmetry, ulcerations / lesions or nodules 6. pharynx – observe the uvula, soft palate, tonsils, posterior pharynx signs of inflammation (redness, edema, ulceration, thick yellowish secretions), assess also for symmetry of uvula and palate MTCAT 09
Assessment of the GITb.) Abdomen - assess for the presence or absence of tenderness,organ enlargement, masses, spasm or rigidity of theabdominal muscles, fluid or air in the abdominal cavityAnatomic Location of OrgansRUQ – liver, gallbladder, duodenum, right kidney, hepaticflexure of colonRLQ - cecum, appendix, right ovary and fallopian tubeLUQ – stomach, spleen, left kidney, pancreas, splenicflexure of colonLLQ – sigmoid colon, left ovary and tube MTCAT 09
Assessment of the GIT1. Inspection assess the skin for color, texture, scars, striae, engorged veins, visible peristalsis (intestinal obstruction), visible pulsations (abdominal aorta), visible masses (hernia) assess contour (flat, protuberant, globular) abdominal distension, measure abdominal girth or circumference at the level of umbilicus or 2-5 cm. below MTCAT 09
Assessment of the GIT2. Auscultation presence or absence of peristalsis or bowel sounds Normoactive – every 5-20 secs. Hypoactive – 1 or 2 sounds in 2 mins. Absent – no sounds in 3-5 mins. peritonitis, paralytic ileus, Hyperactive – 5-6 sounds in less than 30 sec. diarrhea, gastroenteritis, early intestinal obstruction MTCAT 09
Assessment of the GIT3. Percussion done to confirm the size of various organs to determine presence of excessive amounts of air or fluid Normal – tympany dullness or flatness – area of liver and spleen, solid structure – tumor4. Palpation to determine size of liver, spleen, uterus, kidneys – if enlarged determine presence and chac. of abdominal masses determine degree of tenderness and muscle rigidity (rebound or direct)c.) Rectum perineal skin and perianal skin assess for presence of pruritus, fissures, external hemorrhoids, rectal prolapse MTCAT 09
FECAL STUDIES For blood, fat, infectious organisms • A freshly passed, warm stool is the best specimen. • From fat or infections organisms, collect three separate specimens and label day # 1, day #2, day # 3.
Stool examination(fecalysis) Stool for occult blood (Guaiac Test) o GI bleeding o No red meat, turnips, horseradish, steroids, NSAIDS, iron Stool for Ova and parasites proper collection
UPPER GI SERIES (BARIUM SWALLOW)• Fluoroscopic examination of upper GI tract to determine structural problems and gastric emptying time.• Client must swallow barium sulfate• Sequential films taken as it moves through the system.Barium – is a radiopaque substance that when ingested or given by enema in solution, outlines the passage ways of the GIT for viewing by x-ray or fluoroscopy
UPPER GI SERIES (BARIUM SWALLOW) for identification disorders of esophagus, stomach, duodenum – esophageal lesions, hiatal hernia, esophageal reflux, tumors, ulcers, inflammation Pt. swallows a flavored barium solution and the radiologist observes the progress of the barium through the esophagus and take x-ray films NPO for 6-8 hrs Post procedure: o Increase fluid intake o Laxative o Stool – white for 24-72 hrs. o Observe for: impaction, distended abdomen, constipation
LOWER GI SERIES (BARIUM ENEMA)• Barium is instilled into the colon by enema• Client retains the contrast medium while x-rays are taken to identify structural
Nursing care: pretest •NPO for 8 hours pretest •Give enemas until clear the morning of the test. •Administer laxative or suppository. •Explain that cramping may be experienced during procedure.Nursing care: posttest •Administer laxatives and
ESOPHAGOGASTRODUODENOSCOPY (EGD) • Direct visualization of the esophagus, stomach, and duodenum by insertion of a lighted fiberscope. • Used to observe structures, ulcerations, inflammation, tumors; may include biopsy.
directly visualize the GIT by the use of a fiberscape fiberscope – has a thin, flexible shaft that can pass through and around bends in the GIT, transmit light and the image can be seen in the monitor
ESOPHAGOGASTRODUODENOSCOPY (EGD) Nursing care: •NPO for 6-8 hours •Ensure consent form has been signed • Explain that a local anesthetic will be used to ease comfort and that speaking during the
Nursing care: posttest • NPO until return of gag reflex. • Assess vital signs and for pain, dysphagia, bleeding • Administer
COLONOSCOPY• to visualize the colon• useful to identify tumors, colonic cancer, colonic polyps• not done when there is active bleeding or inflammatory disease
ColonoscopyPreparation : • clear liquid diet 24 hrs. before fleet or cleansing enema • dulcolax tabs • NPO 8 hrs. prior to procedure • Position: left side, knees flexedPost-procedure : • provide rest, monitor VS (vasovagal response- HR,BP) • assess for sudden abdominal pain (perforation), fever, active • bleeding • Hot sitz bath
SIGMOIDOSCOPYSigmoidoscopy – examination of sigmoid colon, rectum and anus Proctoscopy – examination of rectum and anus used as a screening test for persons 40 yrs old and above, with history of colonic cancer used for pt with lower GI bleeding or inflammatory diseasePreparation : light dinner and light breakfast - dulcolax tab. Fleet enema or cleansing enemaPost-procedure : provide rest period assess for sudden abdominal pain, bleeding
GASTRIC ANALYSIS • to quantify gastric acidity Normal 1-5 mEq / L gastric acid : gastric cancer, pernicious anemia gastric acid : duodenal ulcer Normal gastric acid : gastric ulcerNursing care: pretest NPO 6- 8 hours pretest Advise client about no smoking, anticholinergic medications, antacids 24 hours prior to test Inform client that tube will be inserted into the stomach via the nose, and instruct to expectorate saliva to prevent buffering of secretions.Nursing care: posttest Provide frequent mouth care.
STOOL CHARACTERISTICSCHARACTERISTICS NORMAL ABNORMAL CAUSE Color Infant yellow: White or clay; Black Absence of bile Iron Adult brown or tarry ingestion or upper GI bleeding Red Lower GI bleeding, hemorrhoids Pale Malabsorption of fat Odor Aromatic; affected Noxious change; Blood in feces or by food type Pungent infection Consistency Soft; formed; Liquid Diarrhea, reduced semisolid Hard absorption; constipation Frequency Varies: 4-6 More than 6 x daily or Hypo/Hypermotility (breastfed); 1-3 less than once every (bottle fed) 1-2 days; more than Adult: Several 3x a day times per day to 2- 3 times per week
STOOL CHARACTERISTICSCharacteristics Normal Abnormal Cause Amount 150 g/day (adult) varies with diet Shape Resembles Narrow, pencil Obstruction, diameter of shaped, rapid peristalsis rectum stringlike (Cylindrical) Constituents Undigested food, Blood pus, Intestinal dead bacteria, foreign bodies, bleeding, fat, bile pigment, mucus worms, infection, cells lining large quantities swallowed intestinal mucosa of fat objects, irritation, and water inflammation
Stool Characteristics •Tarry black color •Bright or dark red •Streaking of blood on the surface of the stool • Bulky, greasy • Clay colored • Mucus threads
Alteration on the characteristics of stool • Acholic stool. Gray, pale due to absence of urobilin caused by biliary obstruction. • Hematochezia. Passage of stool with bright red blood. • Melena. Passage of black tarry stool • Steatorrhea. Greasy, bulky, foul smelling stool. Presence of undigested fats like in hepatobiliary-pancreatic obstruction/disorders
Foods & meds that alter stool color • Meat protein - dark brown • Spinach - green • Carrots & beets - red • Cocoa - Dark red or brown • Iron, charcoal - Black • Barium - milky white
Common Causes of Constipation• Irregular bowel habits and ignoring the urge to defecate can cause constipation• Client who have a low-fiber diet high in animal fats and refined sugar often have constipation problems. Also low fluid intake slows peristalsis• Lengthy bed rest or lack of regular exercise causes constipation.• Heavy laxative use causes loss of normal defecation reflex. In addition, the lower colon is completely emptied, requiring a time to refill with bulk.• Tranquilizers, opiates, anticholinergics, and iron can cause constipation• Older adult experience slowed peristalsis, loss of abdominal muscle elasticity, and reduce intestinal mucous secretion. Older adults often live alone and eat low-fiber foods.• Constipation is also caused by GI abnormalities such as bowel obstruction, paralytic ileus, and diverticulitis• Neurological Conditions that block nerve impulses to the colon can cause constipation.
Interventions to prevent and relieve constipation • Adequate fluid intake. • High-fiber diet. • Establish regular pattern of defecation • Respond immediately to the urge to defecate. • Minimize stress. – Sympathetic response. • Promote adequate activity and exercise. • Assume sitting or squatting position. • Administer laxatives as ordered • TYPES: • Chemical irritants- provide chemical stimulation to intestinal wall- increase peristalsis . Ex. Dulcolax, castor oil, senokot (senna) • Stool lubricants – mineral oil • Stool softeners – Colace (Na Docussate) • Bulk formers – Metamucil • Osmotic agents – Milk of magnesia, duphalac
Conditions that cause DIARRHEAEmotional stressIntestinal infectionFood allergiesFood intolerance (greasy foods, coffee, alcohol, spicy foods)Medications (Iron, Antibiotics)
Manifestation & Complications of Diarrhea• Increase in volume, frequency and consistency• Very large watery to very frequent small stools/ containing blood, mucus or exudate• Depends on the course, duration and severity• May result to vascular collapse and hypovolemic shock & hypokalemia
Interventions to relieve diarrhea • Monitor I & O. Assess for: urine- frequency, color, consistency and volume Stools Vomitus • Replace fluid and electrolyte losses. • Provide good perianal care • Promote rest. • Diet: Small amounts of bland foods Low fiber diet BRAT Avoid excessive hot or cold fluids. Potassium rich foods and fluid. • Antidiarrheal medications.
Dietary Management• Fluid replacement Oresol• Avoid food in the first 24 hours to provide bowel rest, after that time, frequent small feedings• Milk are temporary withheld• Avoid raw fruits and vegetables, fried foods, spices coffee.
Nursing CareDirected toward identifying the cause, relieving symptoms, preventing complications and if infectious, preventing the spread of infection to others.RISK FOR FLUID VOLUME DEFICIT • RECORD I & O • Monitor v/s and record including orthostatic hypotension • Provide fluid and electrolyte replacement solutions as indicated- increase OFI as tolerated
NURSING DIAGNOSIS• Altered nutrition less than body requirements R/T • Status of nothing by mouth • Excessive dieting • Anorexia • Self-induced vomiting • Alcoholism • Excessive use of enemas or laxatives • Food fads • Alternative diet forms• Altered nutrition more than body requirements • Excessive caloric intake• Altered nutrition: potential for more body requirements related to: • Dysfunctional eating patterns • Closely spaced pregnancies• Feeding self-care deficit related to: • Impaired mobility of both arms• Impaired swallowing related to: • Surgical trauma • Muscular weakness
RISK FOR IMPAIRED SKIN INTEGRITY Provide good skin care Assist in cleaning the perianal area Apply protective ointment to the perianal area
Flatulence Presence of excessive gas or tympanites in the intestines. COMMON CAUSES OF FLATULENCE • Constipation • Anxiety • Eating gas-forming foods • Rapid food and fluid ingestion • Improper use of drinking straw • Excessive drinking of carbonated beverages • Chewing gum, candy sucking, smoking
DECREASING FLATULENCEOne method of treating flatulence involves the insertion of a rectal tube.Guidelines:• Use rectal tube (Fr 22-30) for adults and a smaller size for children.• Have the client assume a side-lying position.• Lubricate the rectal tube to reduce mucous membrane irritation.• Expose the anus and insert the rectal tube into the rectum 10cm (4in). The rectal tube will stimulate peristalsis. If no flatus is expelled, insert the tube another inch or so. Do not force the tube if it does not insert easily.• Wrap an abdominal or incontinence pad around the end of the rectal tube to catch any liquid that may be expelled. Or, placing the end of the tube into a receptacle filled with fluid.• Leave the tube in no longer than 3 minutes to avoid irritation of the rectal mucosa. If abdominal distention is not relieved, the tube may be inserted every 2 to 3 hours.• Encourage the client to assume various positions in bed.
TEACHING ABOUT MEDICATIONS Cathartics and Laxatives Cathartics are drugs that induce defecation. They can have strong, purgative effect. A laxative is mild in comparison to a cathartic, and it produces soft or liquid stools that are sometimes accompanied by abdominal cramps. Cathartics: Castor oil, cascara, phenolphthalein and bisacodyl. Laxatives are contraindicated in the client who has nausea, cramps. Colic, vomiting, or undiagnosed abdominal pain. Clients need to be informed about the dangers of laxative use.
TYPES OF LAXATIVES TYPE ACTION EXAMPLES BULK-FORMING INCREASES THE FLUID, GASEOUS, OR PSYLLIUM HYDROPHILIC SOLID BULK IN THE INTESTINES MUCILLOID (METAMUCIL), METHYLCELLULOSE (CITRUCEL)EMOLIENT/STOOL SOFTENS AND DELAYS THE DRYING OF DOCUSATE SODIUM (COLACE) SOFTENER THE FECES; PERMITS FATS AND WATER TO PENETRATE FECES STIMULANT/ IRRITATES THE INTESTINAL MUCOSA OR BISACODYL (DULCOLAX, IRRITANT STIMULATES NERVE ENDINGS IN THE CORRECTOL), SENNA WALL OF THE INTESTINE, CAUSING (SENOKOT, EX-LAX), RAPID PROPULSION OF THE CONTENTS CASCARA, CASTOR OIL LUBRICANT LUBRICATES THE FECES IN THE COLON MINERAL OIL (HALEY’S M-O)SALINE/OSMOTIC DRAWS WATER INTO THE INTESTINE BY EPSOM SALTS, MAGNESIUM OSMOSIS, DISTENDS THE BOWEL, AND HYDROXIDE (MILK OF STIMULATES PERISTALSIS MAGNESIA), MAGNESIUM CITRATE, SODIUM PHOSPATE (FLEET PHOSPODA)
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