ELIMINATION FECAL Ma. Tosca Cybil A. Torres, RN, MAN
Defecation is the expulsion of feces from the anus and rectum.
Also known as bowel movement
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 Problems Constipation. Decreased frequency of bowel movements accompanied by prolonged or difficult passage of dry hard stool Impaction. Collection of hardened feces wedged in the rectum Diarrhea. Increase in number of stools and the passage of liquid, unformed feces. Incontinence Flatulence Hemorrhoids
FACTORS AFFECTING DEFECATION Age Diet Fluid intake Physical Activity Psychological Factors Personal Habits Position During Defecation Pain Pregnancy Surgery and Anesthesia Medications Diagnostic Tests
Assessment Nursing 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.
Daily fluid intake
History of surgery or illness affecting the GI tract.
Assessment of the GIT MTCAT '09 Nursing History : Subjective Data 1. General Data presence of dental prosthesis, comfort of usage difficulty eating or digesting food nausea or vomiting weight loss pain – may be caused by distention or sudden contraction of any part of the GIT - specify the area, describe the pain 2. Specific data if symptoms are present situations or events that effect symptoms onset, possible cause, location, duration, character of symptoms relationship of specific foods, smoking or alcohol to severity of symptoms how the symptoms was managed before seeking medical help
Assessment of the GIT MTCAT '09 3. Normal pattern of bowel elimination frequency and character of stool use of laxatives, enemas 4. Recent changes in normal patterns changes in character of stool (constipation, diarrhea, or alternating constipation and diarrhea) 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
Assessment of the GIT MTCAT '09 B. Physical Examination : Objective Data a.) Mouth and Pharynx lips – color, moisture, swelling, cracks or lesions teeth – completeness (20 in children, 32 in adults), caries, loose teeth, absence of teeth impair adequate chewing gums – color, redness, swelling, bleeding, pain (gingivitis) 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
tongue – color, mobility, symmetry, ulcerations / lesions or nodules 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
Assessment of the GIT MTCAT '09 b.) Abdomen - 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 Anatomic Location of Organs RUQ – liver, gallbladder, duodenum, right kidney, hepatic flexure of colon RLQ - cecum, appendix, right ovary and fallopian tube LUQ – stomach, spleen, left kidney, pancreas, splenic flexure of colon LLQ – sigmoid colon, left ovary and tube
Assessment of the GIT MTCAT '09
Assessment of the GIT MTCAT '09 1. Inspection
Client retains the contrast medium while x-rays are taken to identify structural abnormalities of the large intestine or the colon.
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 fluids to assist in expelling the barium
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 procedure will not be possible; the client should expect hoarseness and a sore throat for several days.
Nursing care: posttest
NPO until return of gag reflex.
Assess vital signs and for pain, dysphagia, bleeding
Administer warm normal saline gargles for relief of sore throat.
to visualize the colon
useful to identify tumors, colonic cancer, colonic polyps
not done when there is active bleeding or inflammatory disease
Colonoscopy Preparation :
clear liquid diet 24 hrs. before fleet or cleansing enema
NPO 8 hrs. prior to procedure
Position: left side, knees flexed
provide rest, monitor VS (vasovagal response- HR,BP)
assess for sudden abdominal pain (perforation), fever, active
Hot sitz bath
SIGMOIDOSCOPY Sigmoidoscopy– 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 disease
light dinner and light breakfast -
Fleet enema or cleansing enema
provide rest period
assess for sudden abdominal pain, bleeding
to quantify gastric acidity Normal 1-5 mEq / L
gastric acid : gastric cancer, pernicious anemia gastric acid : duodenal ulcer Normal gastric acid : gastric ulcer Nursing 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.
Tarry black color
Bright or dark red
Streaking of blood on the surface of the stool
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.
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
Chemical irritants- provide chemical stimulation to intestinal wall- increase peristalsis . Ex. Dulcolax, castor oil, senokot (senna)
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
Replace fluid and electrolyte losses.
Provide good perianal care
Small amounts of bland foods
Low fiber diet
Avoid excessive hot or cold fluids.
Potassium rich foods and fluid.
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 Care Directed 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
Altered nutrition less than body requirements R/T
Status of nothing by mouth
Excessive use of enemas or laxatives
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:
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
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 FLATULENCE One 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
Critical Thinking Exercise 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. What appropriate nursing care plans could you formulate for Adam. Supplement necessary assessment findings significant to the patient’s case. 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. Formulate appropriate nursing care plan for Eve. Supplement necessary assessment findings significant to the patient’s case.