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  1. 1. ELIMINATION <br />FECAL<br />Ma. Tosca Cybil A. Torres, RN, MAN<br />
  2. 2. DEFECATION<br /><ul><li>Defecation is the expulsion of feces from the anus and rectum.
  3. 3. Also known as bowel movement</li></li></ul><li>Defecation reflex<br /><ul><li>Intrinsic defecation reflex
  4. 4. 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
  5. 5. Parasympathetic defecation reflex</li></li></ul><li>Common Bowel Elimination Problems<br />Constipation. Decreased frequency of bowel movements accompanied by prolonged or difficult passage of dry hard stool<br />Impaction. Collection of hardened feces wedged in the rectum<br />Diarrhea. Increase in number of stools and the passage of liquid, unformed feces.<br />Incontinence<br /> Flatulence<br /> Hemorrhoids<br />
  6. 6.
  7. 7. FACTORS AFFECTING DEFECATION<br />Age<br />Diet<br />Fluid intake<br />Physical Activity<br />Psychological Factors<br />Personal Habits<br />Position During Defecation<br />Pain <br />Pregnancy<br />Surgery and Anesthesia<br />Medications<br />Diagnostic Tests<br />
  8. 8. Assessment<br />Nursing History<br /><ul><li>Usual pattern of elimination, frequency and time of the day.
  9. 9. Normal routines followed to promote normal elimination.
  10. 10. Description of any recent change in elimination pattern.
  11. 11. Description of usual characteristics of stool.
  12. 12. Diet history
  13. 13. Daily fluid intake
  14. 14. History of surgery or illness affecting the GI tract.
  15. 15. Medication history
  16. 16. Emotional state.</li></li></ul><li>Assessment of the GIT<br />MTCAT &apos;09<br />Nursing History : Subjective Data<br />1. General Data<br />presence of dental prosthesis, comfort of usage<br />difficulty eating or digesting food<br />nausea or vomiting<br />weight loss<br />pain – may be caused by distention or sudden contraction of any part of the GIT<br /> - specify the area, describe the pain<br />2. Specific data if symptoms are present<br />situations or events that effect symptoms<br />onset, possible cause, location, duration, character of symptoms<br />relationship of specific foods, smoking or alcohol to severity of symptoms<br />how the symptoms was managed before seeking medical help<br />
  17. 17. Assessment of the GIT<br />MTCAT &apos;09<br />3. Normal pattern of bowel elimination<br />frequency and character of stool<br />use of laxatives, enemas<br />4. Recent changes in normal patterns<br />changes in character of stool (constipation, diarrhea, or alternating constipation and diarrhea)<br />changes in color of stool <br />melena - black tarry stool (upper GI bleeding)<br />hematochezia – fresh blood in the stool (lower GI bleeding)<br />c. drugs /medications being taken<br />d. measures taken to relieve symptoms<br />
  18. 18. Assessment of the GIT<br />MTCAT &apos;09<br />B. Physical Examination : Objective Data<br />a.) Mouth and Pharynx<br />lips – color, moisture, swelling, cracks or lesions<br />teeth – completeness (20 in children, 32 in adults), caries, loose teeth, absence of teeth  impair adequate chewing<br />gums – color, redness, swelling, bleeding, pain (gingivitis)<br />mucosa – color (light pink)<br /><ul><li>examine for moisture, white spots or patches, areas of bleeding, or ulcers
  19. 19. white patches – due to candidiasis (oral thrush)
  20. 20. white plaques w/in red patches may be malignant lesions</li></ul>tongue – color, mobility, symmetry, ulcerations / lesions or nodules<br />pharynx – observe the uvula, soft palate, tonsils, posterior pharynx <br /><ul><li> signs of inflammation (redness, edema, ulceration, thick yellowish secretions), assess also for symmetry of uvula and palate</li></li></ul><li>Assessment of the GIT<br />MTCAT &apos;09<br />b.) Abdomen<br /> - assess for the presence or absence of tenderness, organ enlargement, masses, spasm or rigidity of the abdominal muscles, fluid or air in the abdominal cavity<br />Anatomic Location of Organs<br />RUQ – liver, gallbladder, duodenum, right kidney, hepatic flexure of colon<br />RLQ - cecum, appendix, right ovary and fallopian tube<br />LUQ – stomach, spleen, left kidney, pancreas, splenic flexure of colon<br />LLQ – sigmoid colon, left ovary and tube<br />
  21. 21. Assessment of the GIT<br />MTCAT &apos;09<br />
  22. 22. Assessment of the GIT<br />MTCAT &apos;09<br />1. Inspection<br /><ul><li>assess the skin for color, texture, scars, striae, engorged veins, visible peristalsis (intestinal obstruction), visible pulsations (abdominal aorta), visible masses (hernia)
  23. 23. assess contour (flat, protuberant, globular)
  24. 24. abdominal distension, measure abdominal girth or circumference at the level of umbilicus or 2-5 cm. below</li></li></ul><li>Assessment of the GIT<br />MTCAT &apos;09<br />2. Auscultation<br /><ul><li>presence or absence of peristalsis or bowel sounds
  25. 25. Normoactive – every 5-20 secs.
  26. 26. Hypoactive – 1 or 2 sounds in 2 mins.
  27. 27. Absent – no sounds in 3-5 mins.</li></ul>  peritonitis, paralytic ileus, <br /><ul><li>Hyperactive – 5-6 sounds in less than 30 sec.</li></ul> diarrhea, gastroenteritis, early intestinal <br /> obstruction<br />
  28. 28. Assessment of the GIT<br />MTCAT &apos;09<br />3. Percussion<br /><ul><li>done to confirm the size of various organs
  29. 29. to determine presence of excessive amounts of air or fluid
  30. 30. Normal – tympany
  31. 31. dullness or flatness – area of liver and spleen, solid structure </li></ul> – tumor<br />4. Palpation<br /><ul><li>to determine size of liver, spleen, uterus, kidneys – if enlarged
  32. 32. determine presence and chac. of abdominal masses
  33. 33. determine degree of tenderness and muscle rigidity (rebound or direct)</li></ul>c.) Rectum<br /><ul><li>perineal skin and perianal skin
  34. 34. assess for presence of pruritus, fissures, external</li></ul> hemorrhoids, rectal prolapse<br />
  35. 35. FECAL STUDIES<br />For blood, fat, infectious organisms<br /><ul><li>A freshly passed, warm stool is the best specimen.
  36. 36. From fat or infections organisms, collect three separate specimens and label day # 1, day #2, day # 3.</li></li></ul><li>Stool examination (fecalysis)<br /><ul><li>Stool for occult blood(Guaiac Test)
  37. 37. GI bleeding
  38. 38. No red meat, turnips, horseradish, steroids, NSAIDS, iron
  39. 39. Stool for Ova and parasites
  40. 40. proper collection of specimen  should not be mixed with water or urine, should be sent immediately to the laboratory</li></li></ul><li>UPPER GI SERIES (BARIUM SWALLOW)<br /><ul><li>Fluoroscopic examination of upper GI tract to determine structural problems and gastric emptying time.
  41. 41. Client must swallow barium sulfate
  42. 42. Sequential films taken as it moves through the system.</li></ul>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<br />
  43. 43. UPPER GI SERIES (BARIUM SWALLOW)<br /><ul><li>for identification disorders of esophagus, stomach, duodenum – esophageal lesions, hiatal hernia, esophageal reflux, tumors, ulcers, inflammation
  44. 44. Pt. swallows a flavored barium solution and the radiologist observes the progress of the barium through the esophagus and take x-ray films
  45. 45. NPO for 6-8 hrs
  46. 46. Post procedure:
  47. 47. Increase fluid intake
  48. 48. Laxative
  49. 49. Stool – white for 24-72 hrs.
  50. 50. Observe for: impaction, distended abdomen, constipation</li></li></ul><li>LOWER GI SERIES (BARIUM ENEMA)<br /><ul><li>Barium is instilled into the colon by enema
  51. 51. Client retains the contrast medium while x-rays are taken to identify structural abnormalities of the large intestine or the colon.</li></li></ul><li>Nursing care: pretest<br /><ul><li>NPO for 8 hours pretest
  52. 52. Give enemas until clear the morning of the test.
  53. 53. Administer laxative or suppository.
  54. 54. Explain that cramping may be experienced during procedure.</li></ul>Nursing care: posttest<br /><ul><li>Administer laxatives and fluids to assist in expelling the barium</li></li></ul><li>
  55. 55.
  56. 56. ESOPHAGOGASTRODUODENOSCOPY (EGD)<br /><ul><li>Direct visualization of the esophagus, stomach, and duodenum by insertion of a lighted fiberscope.
  57. 57. Used to observe structures, ulcerations, inflammation, tumors; may include biopsy.</li></li></ul><li><ul><li> directly visualize the GIT by the use of a fiberscape
  58. 58. fiberscope – has a thin, flexible shaft that can pass through and</li></ul> around bends in the GIT, transmit light and the image can be seen in<br /> the monitor<br />
  59. 59.
  60. 60.
  61. 61. ESOPHAGOGASTRODUODENOSCOPY (EGD)<br />Nursing care:<br /><ul><li>NPO for 6-8 hours
  62. 62. Ensure consent form has been signed
  63. 63. Explain that a local anesthetic will be used to ease comfort and that speaking during the procedure will not be possible; the client should expect hoarseness and a sore throat for several days.</li></li></ul><li>Nursing care: posttest<br /><ul><li>NPO until return of gag reflex.
  64. 64. Assess vital signs and for pain, dysphagia, bleeding
  65. 65. Administer warm normal saline gargles for relief of sore throat.</li></li></ul><li>COLONOSCOPY<br /><ul><li> to visualize the colon
  66. 66. useful to identify tumors, colonic cancer, colonic polyps
  67. 67. not done when there is active bleeding or inflammatory disease </li></li></ul><li>Colonoscopy<br />Preparation : <br /><ul><li>clear liquid diet 24 hrs. before fleet or cleansing enema
  68. 68. dulcolax tabs
  69. 69. NPO 8 hrs. prior to procedure
  70. 70. Position: left side, knees flexed</li></ul>Post-procedure : <br /><ul><li> provide rest, monitor VS (vasovagal response-  HR,BP)
  71. 71. assess for sudden abdominal pain (perforation), fever, active
  72. 72. bleeding
  73. 73. Hot sitz bath</li></li></ul><li>
  74. 74.
  75. 75. SIGMOIDOSCOPY<br />Sigmoidoscopy– examination of sigmoid colon, rectum and anus<br />Proctoscopy– examination of rectum and anus<br /><ul><li> used as a screening test for persons 40 yrs old and above, with history of colonic cancer
  76. 76. used for pt with lower GI bleeding or inflammatory disease</li></ul>Preparation : <br /><ul><li>light dinner and light breakfast -
  77. 77. dulcolax tab.
  78. 78. Fleet enema or cleansing enema</li></ul>Post-procedure : <br /><ul><li>provide rest period
  79. 79. assess for sudden abdominal pain, bleeding</li></li></ul><li>
  80. 80. GASTRIC ANALYSIS<br /><ul><li>to quantify gastric acidity Normal 1-5 mEq / L</li></ul> gastric acid : gastric cancer, pernicious anemia<br /> gastric acid : duodenal ulcer<br /> Normal gastric acid : gastric ulcer<br />Nursing care: pretest<br />NPO 6- 8 hours pretest<br />Advise client about no smoking, anticholinergic medications, antacids 24 hours prior to test<br />Inform client that tube will be inserted into the stomach via the nose, and instruct to expectorate saliva to prevent buffering of secretions.<br />Nursing care: posttest<br />Provide frequent mouth care.<br />
  81. 81. MTCAT &apos;09<br />
  84. 84. Stool Characteristics<br /><ul><li>Tarry black color
  85. 85. Bright or dark red
  86. 86. Streaking of blood on the surface of the stool
  87. 87. Bulky, greasy
  88. 88. Clay colored
  89. 89. Mucus threads</li></li></ul><li>Alteration on the characteristics of stool<br /><ul><li>Acholic stool. Gray, pale due to absence of urobilin caused by biliary obstruction.
  90. 90. Hematochezia. Passage of stool with bright red blood.
  91. 91. Melena. Passage of black tarry stool
  92. 92. Steatorrhea. Greasy, bulky, foul smelling stool. Presence of undigested fats like in hepatobiliary-pancreatic obstruction/disorders</li></li></ul><li>Foods & meds that alter stool color <br /><ul><li>Meat protein - dark brown
  93. 93. Spinach - green
  94. 94. Carrots & beets - red
  95. 95. Cocoa - Dark red or brown
  96. 96. Iron, charcoal - Black
  97. 97. Barium - milky white</li></li></ul><li>Common Causes of Constipation<br /><ul><li>Irregular bowel habits and ignoring the urge to defecate can cause constipation
  98. 98. Client who have a low-fiber diet high in animal fats and refined sugar often have constipation problems. Also low fluid intake slows peristalsis
  99. 99. Lengthy bed rest or lack of regular exercise causes constipation.
  100. 100. Heavy laxative use causes loss of normal defecation reflex. In addition, the lower colon is completely emptied, requiring a time to refill with bulk.
  101. 101. Tranquilizers, opiates, anticholinergics, and iron can cause constipation
  102. 102. 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.
  103. 103. Constipation is also caused by GI abnormalities such as bowel obstruction, paralytic ileus, and diverticulitis
  104. 104. Neurological Conditions that block nerve impulses to the colon can cause constipation.</li></li></ul><li>
  105. 105. Interventions to prevent and relieve constipation<br /><ul><li>Adequate fluid intake.
  106. 106. High-fiber diet.
  107. 107. Establish regular pattern of defecation
  108. 108. Respond immediately to the urge to defecate.
  109. 109. Minimize stress. – Sympathetic response.
  110. 110. Promote adequate activity and exercise.
  111. 111. Assume sitting or squatting position.
  112. 112. Administer laxatives as ordered
  113. 113. TYPES:
  114. 114. Chemical irritants- provide chemical stimulation to intestinal wall- increase peristalsis . Ex. Dulcolax, castor oil, senokot (senna)
  115. 115. Stool lubricants – mineral oil
  116. 116. Stool softeners – Colace (Na Docussate)
  117. 117. Bulk formers – Metamucil
  118. 118. Osmotic agents – Milk of magnesia, duphalac</li></li></ul><li>Conditions that cause DIARRHEA<br />Emotional stress<br />Intestinal infection<br />Food allergies<br />Food intolerance (greasy foods, coffee, alcohol, spicy foods)<br />Medications (Iron, Antibiotics)<br />
  119. 119. Manifestation & Complications of Diarrhea<br /><ul><li>Increase in volume, frequency and consistency
  120. 120. Very large watery to very frequent small stools/ containing blood, mucus or exudate
  121. 121. Depends on the course, duration and severity
  122. 122. May result to vascular collapse and hypovolemic shock & hypokalemia</li></li></ul><li>Interventions to relieve diarrhea<br /><ul><li>Monitor I & O. Assess for:
  123. 123. urine- frequency, color, consistency and volume
  124. 124. Stools
  125. 125. Vomitus
  126. 126. Replace fluid and electrolyte losses.
  127. 127. Provide good perianal care
  128. 128. Promote rest.
  129. 129. Diet:
  130. 130. Small amounts of bland foods
  131. 131. Low fiber diet
  132. 132. BRAT
  133. 133. Avoid excessive hot or cold fluids.
  134. 134. Potassium rich foods and fluid.
  135. 135. Antidiarrheal medications.</li></li></ul><li>Dietary Management<br /><ul><li>Fluid replacement
  136. 136. Oresol
  137. 137. Avoid food in the first 24 hours to provide bowel rest, after that time, frequent small feedings
  138. 138. Milk are temporary withheld
  139. 139. Avoid raw fruits and vegetables, fried foods, spices coffee.</li></li></ul><li>Nursing Care<br />Directed toward identifying the cause, relieving symptoms, preventing complications and if infectious, preventing the spread of infection to others.<br />RISK FOR FLUID VOLUME DEFICIT<br /><ul><li>RECORD I & O
  140. 140. Monitor v/s and record including orthostatic hypotension
  141. 141. Provide fluid and electrolyte replacement solutions as indicated- increase OFI as tolerated</li></li></ul><li>NURSING DIAGNOSIS<br /><ul><li>Altered nutrition less than body requirements R/T
  142. 142. Status of nothing by mouth
  143. 143. Excessive dieting
  144. 144. Anorexia
  145. 145. Self-induced vomiting
  146. 146. Alcoholism
  147. 147. Excessive use of enemas or laxatives
  148. 148. Food fads
  149. 149. Alternative diet forms
  150. 150. Altered nutrition more than body requirements
  151. 151. Excessive caloric intake
  152. 152. Altered nutrition: potential for more body requirements related to:
  153. 153. Dysfunctional eating patterns
  154. 154. Closely spaced pregnancies
  155. 155. Feeding self-care deficit related to:
  156. 156. Impaired mobility of both arms
  157. 157. Impaired swallowing related to:
  158. 158. Surgical trauma
  159. 159. Muscular weakness</li></li></ul><li><ul><li>RISK FOR IMPAIRED SKIN INTEGRITY
  160. 160. Provide good skin care
  161. 161. Assist in cleaning the perianal area
  162. 162. Apply protective ointment to the perianal area</li></li></ul><li>Flatulence<br />Presence of excessive gas or tympanites in the intestines.<br />COMMON CAUSES OF FLATULENCE<br /><ul><li>Constipation
  163. 163. Anxiety
  164. 164. Eating gas-forming foods
  165. 165. Rapid food and fluid ingestion
  166. 166. Improper use of drinking straw
  167. 167. Excessive drinking of carbonated beverages
  168. 168. Chewing gum, candy sucking, smoking</li></li></ul><li>DECREASING FLATULENCE <br />One method of treating flatulence involves the insertion of a rectal tube.<br />Guidelines: <br /><ul><li>Use rectal tube (Fr 22-30) for adults and a smaller size for children.
  169. 169. Have the client assume a side-lying position.
  170. 170. Lubricate the rectal tube to reduce mucous membrane irritation.
  171. 171. 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.
  172. 172. 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.
  173. 173. 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.
  174. 174. Encourage the client to assume various positions in bed. </li></li></ul><li>TEACHING ABOUT MEDICATIONS <br />Cathartics and Laxatives <br /><ul><li>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.
  175. 175. Cathartics: Castor oil, cascara, phenolphthalein and bisacodyl.
  176. 176. 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. </li></li></ul><li>TYPES OF LAXATIVES <br />
  177. 177. Critical Thinking Exercise<br /> Adam, 1 year old infant was admitted in the hospital due to fever with temperature of 38 C, vomiting and diarrhea for 2 days duration. The nurse reported that the infant defecated 3 times as many stool as usual with watery consistency. Initially, it is apparent that the child is mildly dehydrated because of stool losses secondary to acute infectious diarrhea. <br />What appropriate nursing care plans could you formulate for Adam. Supplement necessary assessment findings significant to the patient’s case.<br /> Eve, 15 year old rider, was admitted in the hospital due to vehicular accident. She reportedly loss her consciousness when she was brought to ER thus upon admission, she was placed initially on NPO. After a few days, on a balance skeletal traction to treat fracture. She does not want to eat because according to her, she lost her appetite every time she sees other patients. She had not defecated also for 5 days already.<br />Formulate appropriate nursing care plan for Eve. Supplement necessary assessment findings significant to the patient’s case.<br />