Elimination

1. ELIMINATION Ma. Tosca Cybil A. Torres, RN, MAN FECAL

2. DEFECATION Defecation is the expulsion of feces from the anus and rectum. Also known as bowel movement

3. 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

4. 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

5. FACTORS PROMOTING ELIMINATION FACTORS IMPAIRING ELIMINATION Stress free environment Ability to follow personal bowel habits, privacy High fiber diet Normal fluid intake (fruit juice, warm liquid) Exercise (walking) Ability to assume squatting position Properly administered laxatives Emotional anxiety Failure to heed defecation reflex, lack of time and privacy High carbohydrate, high fat diet Reduced fluid intake Immobility and inactivity Inability to squat because of immobility, musculoskeletal deformity; pain during defecation Overuse of cathartics, narcotic analgesics

6. FACTORS AFFECTING DEFECATION Age Diet Fluid intake Physical Activity Psychological Factors Personal Habits Position During Defecation Pain Pregnancy Surgery and Anesthesia Medications Diagnostic Tests

7. 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. Diet history Daily fluid intake History of surgery or illness affecting the GI tract. Medication history Emotional state.

8. 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

9. 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

10. 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

11. 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

12. Assessment of the GIT MTCAT '09

13. Assessment of the GIT MTCAT '09 1. 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

14. Assessment of the GIT MTCAT '09 2. 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

15. Assessment of the GIT MTCAT '09 3. 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 – tumor 4. 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

16. 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.

17. Stool examination ( fecalysis ) Stool for occult blood ( Guaiac Test) GI bleeding No red meat, turnips, horseradish, steroids, NSAIDS, iron Stool for Ova and parasites proper collection of specimen  should not be mixed with water or urine, should be sent immediately to the laboratory

18. 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

19. 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 : Increase fluid intake Laxative Stool – white for 24-72 hrs. Observe for: impaction, distended abdomen, constipation UPPER GI SERIES (BARIUM SWALLOW)

20. 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 abnormalities of the large intestine or the colon.

21. 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

22. 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.

23. 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

24. 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 . ESOPHAGOGASTRODUODENOSCOPY (EGD)

25. 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.

26. COLONOSCOPY to visualize the colon useful to identify tumors, colonic cancer, colonic polyps not done when there is active bleeding or inflammatory disease

27. Colonoscopy Preparation : clear liquid diet 24 hrs. before fleet or cleansing enema dulcolax tabs NPO 8 hrs. prior to procedure Position: left side, knees flexed Post-procedure : provide rest, monitor VS ( vasovagal response-  HR,BP) assess for sudden abdominal pain (perforation), fever, active bleeding Hot sitz bath

28. 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 Preparation : light dinner and light breakfast - dulcolax tab. Fleet enema or cleansing enema Post-procedure : provide rest period assess for sudden abdominal pain, bleeding

29. 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 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.

30. MTCAT '09

31. STOOL CHARACTERISTICS CHARACTERISTICS NORMAL ABNORMAL CAUSE Color Infant yellow: Adult brown White or clay; Black or tarry Red Pale Absence of bile Iron ingestion or upper GI bleeding Lower GI bleeding, hemorrhoids Malabsorption of fat Odor Aromatic; affected by food type Noxious change; Pungent Blood in feces or infection Consistency Soft; formed; semisolid Liquid Hard Diarrhea, reduced absorption; constipation Frequency Varies: 4-6 (breastfed); 1-3 (bottle fed) Adult: Several times per day to 2-3 times per week More than 6 x daily or less than once every 1-2 days; more than 3x a day Hypo/ Hypermotility

32. Characteristics Normal Abnormal Cause Amount 150 g/day (adult) varies with diet Shape Resembles diameter of rectum (Cylindrical) Narrow, pencil shaped, stringlike Obstruction, rapid peristalsis Constituents Undigested food, dead bacteria, fat, bile pigment, cells lining intestinal mucosa and water Blood pus, foreign bodies, mucus worms, large quantities of fat Intestinal bleeding, infection, swallowed objects, irritation, inflammation STOOL CHARACTERISTICS

33. Stool Characteristics Tarry black color Bright or dark red Streaking of blood on the surface of the stool Bulky, greasy Clay colored Mucus threads

34. 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

35. 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

36. 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.

37. 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

38. Conditions that cause DIARRHEA Emotional stress Intestinal infection Food allergies Food intolerance ( greasy foods, coffee, alcohol, spicy foods ) Medications ( Iron, Antibiotics )

39. 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

40. 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.

41. 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.

42. 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

43. 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

44. RISK FOR IMPAIRED SKIN INTEGRITY Provide good skin care Assist in cleaning the perianal area Apply protective ointment to the perianal area

45. 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

46. 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.

47. 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.

48. TYPES OF LAXATIVES TYPE ACTION EXAMPLES BULK-FORMING INCREASES THE FLUID, GASEOUS, OR SOLID BULK IN THE INTESTINES PSYLLIUM HYDROPHILIC MUCILLOID (METAMUCIL), METHYLCELLULOSE (CITRUCEL) EMOLIENT/STOOL SOFTENER SOFTENS AND DELAYS THE DRYING OF THE FECES; PERMITS FATS AND WATER TO PENETRATE FECES DOCUSATE SODIUM (COLACE) STIMULANT/ IRRITANT IRRITATES THE INTESTINAL MUCOSA OR STIMULATES NERVE ENDINGS IN THE WALL OF THE INTESTINE, CAUSING RAPID PROPULSION OF THE CONTENTS BISACODYL (DULCOLAX, CORRECTOL), SENNA (SENOKOT, EX-LAX), CASCARA, CASTOR OIL LUBRICANT LUBRICATES THE FECES IN THE COLON MINERAL OIL (HALEY’S M-O) SALINE/OSMOTIC DRAWS WATER INTO THE INTESTINE BY OSMOSIS, DISTENDS THE BOWEL, AND STIMULATES PERISTALSIS EPSOM SALTS, MAGNESIUM HYDROXIDE (MILK OF MAGNESIA), MAGNESIUM CITRATE, SODIUM PHOSPATE (FLEET PHOSPODA)

49. 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.