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Fundamental Nursing Skills and Concepts

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Wastes pass along the ascending, transverse, desending and sigmoid colon to the rectum. ... a solution into the rectum to cleanse the lower bowel, most common reason, ... – PowerPoint PPT presentation

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Title: Fundamental Nursing Skills and Concepts


1
Fundamental Nursing Skills and Concepts
  • Chapter 31
  • Page 680

2
Bowel Elimination
  • Defecation is the act of expelling feces or stool
    from the body. Feces is stool.
  • Peristalsis is the rhythmic contractions of
    intestinal smooth muscle. Wastes pass along the
    ascending, transverse, desending and sigmoid
    colon to the rectum. Peristalsis becomes even
    more active during eating, this increased
    peristaltic activity is gastrocolic reflex.
    Gastrocolic reflex usually precedes defecation.
  • Valsalvas maneuver, closing of the glottis and
    contracting the pelvic and abdominal muscles to
    increase abdominal pressure, facilitates the
    process of defecation.

3
Bowel elimination
  • Table 31-1 factors affecting bowel elimination
    (681A)
  • Table 31-2 characteristics of stool (681B)
  • Stools appear abnormal, a sample is saved in a
    covered labeled container for the Doctor to see.
  • LVNs do collect stool to test for occult blood.
    Usually the collection is sent to the lab for
    analysis.
  • Test for occult blood- page 681B
  • Nursing guidelines 31-1 page 681

4
ASSESSMENT OF BOWEL ELIMINATION
  • Elimination Patterns
  • Frequency of elimination
  • Effort required to expel stool
  • What elimination aids are utilized
  • Stool Characteristics-Description of appearance

5
COMMON ALTERATIONS IN BOWEL ELIMINATION
  • CONSTIPATION- Elimination problem characterized
    by dry, hard stool that is not easily passed. May
    present with distention, fullness, pressure,
    pain, decrease in frequency and changes in stool.
    May have fever as well.
  • TYPES OF CONSTIPATION
  • PRIMARY CONSTIPATION-Within treatment domain of
    nursing. It is due to lifestyle factors such as
    inactivity, inadequate intake of fiber,
    insufficient fluid intake, or ignoring the urge
    to defecate.

6
COMMON ALTERATIONS IN BOWEL ELIMINATION
  • SECONDARY CONSTIPATION-A consequence of a
    pathologic disorder such as partial bowel
    obstruction which resolves when the primary cause
    is treated or resolved. Ileus- post surgery-
    intestines did not wake up.
  • IATROGENIC CONSTIPATION-Occurs as a consequence
    of other medical treatment. Narcotic use slows
    peristalsis, delays transit time. The longer it
    is in the colon the more fluid is absorbed, the
    drier the stool, the harder to pass it becomes.
  • PSEUDOCONSTIPATION-Referred to as perceived
    constipation by NANDA. A client believes they are
    constipated even when they are not. They are
    fixated on the idea they are constipated. Overuse
    laxatives to overcome constipation, and this
    overuse instead of treating constipation is now
    the cause of constipation. This purging makes the
    muscle tone weak and then there is a need for
    laxatives.

7
COMMON ALTERATIONS IN BOWEL ELIMINATION
  • FECAL IMPACTION-Large, hardened mass of stool
    interferes with defecation, making it impossible
    to pass feces voluntarily.
  • Unrelieved constipation- retained barium,
    dehydrated patient or muscle weakness. Large
    hardened mass of stool. Liquid stool seeps from
    higher in the bowel. May appear as diarrhea.
  • Nursing guidelines for removing a fecal impaction
    page 683, 31-2.
  • Figure 31-2 removing a fecal impaction top pg.
    683B

8
COMMON ALTERATIONS IN BOWEL ELIMINATION
  • FLATULENCE-Excessive accumulation of intestinal
    gas or flatus results from swallowing air while
    eating or sluggish peristalsis. Can also develop
    from gas producing foods. Vegetables, cabbage,
    cucumber or onions may cause flatus. May be a by
    product of bacterial fermentation. Ambulating
    helps to relieve flatus, if not, a rectal tube
    may be needed. Skill 31-1 page 691. Insert 4-6.
    Left in place 20 minutes. Every 3-4 hours.

9
COMMON ALTERATIONS IN BOWEL ELIMINATION
  • DIARRHEA-Urgent passage of watery stool and
    commonly accompanied by abdominal cramping.
    Usually lasts short period of time. Body is
    trying to get rid of tainted food, intestinal
    pathogens or irritating substances. May also be a
    result of emotional stress, dietary
    indiscretions, laxative abuse or bowel disorders.
    Maybe relieved by resting the bowel. Drink clear
    liquids for 12-24 hours. Start with bland foods
    low in residue, (bananas, apple-sauce, cottage
    cheese, jello). Teach if diarrhea lasts longer
    than 24 hours, contact the physician. Can get
    dehydrated easily.

10
COMMON ALTERATIONS IN BOWEL ELIMINATION
  • FECAL INCONTINENCE-Inability to control
    elimination of stool. May be neurologic changes
    (stroke) that impair muscle activity, sensation,
    or thought process. Person cannot postpone
    elimination. Socially and emotionally
    devastating. A lot of support and understanding
    needed in dealing with it. Patient guidelines
    managing fecal incontinence page 684, 31-1.

11
MEASURES TO PROMOTE BOWEL ELIMINATION
  • RECTAL SUPPOSITORY-Oval or cone-shaped mass that
    melts at body temperature and is inserted into
    the rectum. It has medication that will promote
    the expulsion of feces. Either by softening and
    lubricating dry stool, irritating the wall of the
    rectum and anal canal to stimulate smooth muscle
    contraction or liberating carbon dioxide
    increasing rectal distention. This is an example
    of a local effect. An example of a systemic
    effect is inserting a vistaril supp. to overcome
    vomiting. Taking a med orally would only have the
    chance of being vomited up. A suppository is a
    good alternative. They are designed to melt at
    body temperature. If the supp. is held too long
    by the nurse the shape may change or totally
    melt. So be ready for insertion when you pick it
    up.

12
Cont.
  • Check orders and MARS.
  • Compare label 3 times, before, during, and after
    preparation.
  • Determine patients understanding
  • Administer on time
  • ID patient
  • Provide for privacy
  • Position and drape patient. Wash hands, don
    gloves.

13
Cont.
  • Lubricate the supp. And the index finger of the
    predominant hand. Separate buttocks, reveal anus.
    Instruct pt. to deep slow breathe.
  • Insert tapered end of lubricated suppository,
    beyond the internal sphincter about the distance
    of the finger. Avoid placing supp. In stool.
  • Wipe lubricant from anus. Instruct pt. to retain
    for 15 minutes. Premature urge, contract gluteal
    muscles, breathe slowly. Try to hold for 15
    minutes.
  • Instruct to wait to flush after defecating for
    inspection. Remove gloves, wash hands.

14
MEASURES TO PROMOTE BOWEL ELIMINATION
  • ENEMA-Introduces a solution into the rectum to
    cleanse the lower bowel, most common reason,
    soften feces, expel flatus, soothe irritated
    mucous membranes, outline the colon during
    diagnostic x-rays, treat worm and parasitic
    infestations
  • Cleansing enemas are given to remove feces from
    the rectum. Defecation usually occurs in 5-15
    minutes after their administration. Large volume
    cleansing enemas may create discomfort because of
    distention. Administer causiously to pts. with
    intestinal disorders, because an enema may
    rupture the bowel or cause other complications.
  • Skill 31,3 page 695

15
TYPES OF ENEMAS
  • Tap Water and Normal Saline Enemas- distends
    rectum, moistens stool. Non-irritating tap water
    is hypotonic and can be absorbed causing fluid
    and electrolyte imbalances. To ensure pt. safety,
    if stool continues after administering 3 enemas,
    consult the physician for administration of any
    more. 500-1000 mls.
  • Page 684, table 31.3 types of cleansing enema
    solutions
  • Soap Solution Enema- chemical irritation of bowel
    is the mechanism of action. (aka. SS enema)

16
TYPES OF ENEMAS
  • Hypertonic Saline Enemas-local irritation, draws
    more water into the bowel. 4 ounces or 120 ml,
    disposable, lubricated tip, less fatiguing,
    easily self administered.
  • Retention Enema- mineral, olive, cottonseed oil,
    lubricates and softens the stool. Give slowly to
    enhance the retention time. A retention enema is
    held with in the large intestine at least 30
    minutes. 100-200 mls of warmed oil is
    instilled.

17
OSTOMY CARE
  • Surgically created opening to the bowel or other
    structure
  • Two types of intestinal ostomies

18
OSTOMY CARE
  • ILEOSTOMY- AN OPENING SURGICALLY CREATED IN TO
    THE ILEUM. WHAT WILL THE RETURN IN AN ILEOSTOMY
    BAG LOOK LIKE________?
  • COLOSTOMY- AN OPENING SURGICALLY CREATED IN TO A
    PORTION OF THE COLON. WHAT WILL THE RETURN LOOK
    LIKE IN A COLOSTOMY BAG________?
  • Most ostomates, wear an appliance (bag or
    collection device over the stoma)
  • Faceplate left in place 3-5 days, unless it
    loosens or there is discomfort, or becomes soiled
    beneath plate.

19
OSTOMY
  • STOMA- ORIFICE OR ENTRANCE TO THE OPENING
  • APPLIANCE- BAG OR COLLECTION DEVICE OVER THE
    STOMA WHICH COLLECTS STOOL. POUCH IS EMPTIED WHEN
    1/3 TO ½ FULL. FIG. 31-5. PAGE 687.
  • EXCORIATION- CHEMICAL INJURY OF SKIN.
  • ENZYMES IN THE STOOL CAUSES SKIN BREAKDOWN.
  • KARAYA PASTE, A PLANT SUBSTANCE THAT BECOMES
    GELATINOUS WHEN MOISTENED, AND COMMERCIAL SKIN
    PREPS CAN BE APPLIED AROUND THE STOMA TO PROTECT
    THAT SKIN SURFACE.

20
APPLYING AN OSTOMY APPLIANCE
  • Pouch for collecting stool and a faceplate or
    disk
  • Pouch fastens into position when pressed over the
    circular support on the faceplate
  • Can be fastened to a belt worn around the waist
    for extra support
  • The client is able to empty the re-useable pouch
    by removing the clamp, emptying and then
    re-clamping the pouch. Disposable pouches can be
    removed and the face plate cleansed and another
    disposable pouch re-applied. Disposable pouches
    do not have an open end or clamp at the distal
    end.

21
APPLYING AN OSTOMY APPLIANCE
  • The client empties the pouch by releasing the
    clamp at the bottom of the re-usable pouch,
    cleansing the stoma and pouch and re-applying.
    Always making sure the pouch is secured on both
    ends.
  • Remember that the stoma should be pink and moist.
  • Measurement is important to protect the skin
    around the stoma (1/8 to ¼ inch) larger than
    the stoma.
  • Body image disturbance is a factor for the
    patient. Ostomates think everyone knows, It
    pouches , It smells , It is noisey.
  • CONTINENT OSTOMY-Surgically created opening that
    controls the drainage of liquid stool or urine by
    siphoning it from an internal reservoir (KOCK
    POUCH). This type of ostomy requires no
    appliance and the client drains stool or urine
    every 4-6 hours.

22
Continent Ostomy, (KOCK POUCH)
  • Is an internal reservoir that gets drained by
    siphoning. Keeps the patient continent. No pouch
    is worn.
  • The disadvantage of the Kock pouch is that it
    must be tapped every 4-6 hours. The more solid
    the return, fluid might need to be administered
    to make the stool more fluid. Page 689 teaching.

23
IRRIGATING A COLOSTOMY
  • Clients with colostomy whose stool is more solid
    and sometimes requires the instillation of fluid
    to promote elimination.
  • Purpose of the irrigation is to remove formed
    stool and in some cases to regulate the timing of
    bowel movements.
  • With regulation, a client with a sigmoid
    colostomy may not need to wear an appliance.
  • The colostomy irrigation helps to train the bowel
    to eliminate formed stool following the
    irrigation.

24
NURSING IMPLICATIONS NURSING DIAGNOSES
  • Constipation
  • Risk for Constipation
  • Perceived Constipation
  • Diarrhea
  • Bowel Incontinence
  • Toileting Self-Care Deficit
  • Situational Low Self-Esteem

25
GERONTOLOGICAL CONSIERATIONS
  • Age-related changes results in loss of elasticity
    in intestinal walls and slower motility
    throughout the gastrointestinal tract
  • Implementation of home remedies to treat
    constipation
  • Poor eating habits increase risk of constipation
    or diarrhea
  • Instruct the client on the need to consume
    fruits, vegetables, and fluids
  • Provide fiber supplements
  • Incidence of colorectal cancer increases with age
  • Musculoskeletal disorders interfere with the
    clients ability to care for an ostomy appliance
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