ELIMINATION

Ma. Tosca Cybil A. Torres, RN, MAN

FECAL

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 Problems

Constipation. Decreased frequency of bowel movements accompanied by prolonged or difficult passage of dry hard stoolImpaction. Collection of hardened feces wedged in the rectumDiarrhea. Increase in number of stools and the passage of liquid, unformed feces.IncontinenceFlatulenceHemorrhoids

FACTORS PROMOTING ELIMINATION

FACTORS IMPAIRING ELIMINATION

Stress free environment

Ability to follow personal bowel habits,

privacyHigh fiber diet

Normal fluid intake (fruit juice, warm liquid)

Exercise (walking)Ability to assume

squatting positionProperly administered

laxatives

Emotional anxietyFailure to heed

defecation reflex, lack of time and privacy

High carbohydrate, high fat diet

Reduced fluid intakeImmobility and inactivity

Inability to squat because of immobility,

musculoskeletal deformity; pain during

defecationOveruse of cathartics, narcotic analgesics

FACTORS AFFECTING DEFECATION

AgeDietFluid intakePhysical ActivityPsychological FactorsPersonal HabitsPosition During DefecationPain PregnancySurgery and AnesthesiaMedicationsDiagnostic 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 historyDaily fluid intakeHistory of surgery or illness affecting the GI

tract.Medication historyEmotional state.

MTCAT '09

Assessment of the GITNursing History : Subjective Data1. General Data

a. presence of dental prosthesis, comfort of usageb. difficulty eating or digesting foodc. nausea or vomitingd. weight losse. 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 presentf. situations or events that effect symptomsg. onset, possible cause, location, duration, character of

symptomsh. relationship of specific foods, smoking or alcohol to

severity of symptomsi. how the symptoms was managed before seeking

medical help

MTCAT '09

Assessment of the GIT

3. Normal pattern of bowel eliminationa. frequency and character of stoolb. use of laxatives, enemas

4. Recent changes in normal patternsc. changes in character of stool (constipation,

diarrhea, or alternating constipation and diarrhea)

d. 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 takend. measures taken to relieve symptoms

MTCAT '09

Assessment of the GIT

B. Physical Examination : Objective Dataa.) Mouth and Pharynx

1. lips – color, moisture, swelling, cracks or lesions2. teeth – completeness (20 in children, 32 in adults), caries,

loose teeth, absence of teeth impair adequate chewing3. 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

lesions5. tongue – color, mobility, symmetry, ulcerations / lesions or

nodules6. 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 GIT

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 OrgansRUQ – liver, gallbladder, duodenum, right kidney, hepatic flexure of colonRLQ - cecum, appendix, right ovary and fallopian tubeLUQ – stomach, spleen, left kidney, pancreas, splenic flexure of colonLLQ – sigmoid colon, left ovary and tube

MTCAT '09

Assessment of the GIT

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 GIT

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

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 – 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

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 bleedingo 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

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

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 intakeo Laxativeo Stool – white for 24-72 hrs.o Observe for: impaction, distended

abdomen, constipation

UPPER GI SERIES (BARIUM SWALLOW)

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.

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

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

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)

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.

COLONOSCOPY

• 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

• 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

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

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: pretestNPO 6- 8 hours pretestAdvise client about no smoking, anticholinergic

medications, antacids 24 hours prior to testInform client that tube will be inserted into the

stomach via the nose, and instruct to expectorate saliva to prevent buffering of secretions.

Nursing care: posttestProvide frequent mouth care.

MTCAT '09

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 bleedingLower GI bleeding,

hemorrhoids Malabsorption of

fat

Odor Aromatic; affected by food

type

Noxious change; Pungent

Blood in feces or infection

Consistency Soft; formed; semisolid

LiquidHard

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

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

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

volumeStoolsVomitus• Replace fluid and electrolyte losses.• Provide good perianal care• Promote rest.• Diet:Small amounts of bland foodsLow fiber dietBRATAvoid 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 INTEGRITYProvide 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 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 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)

Critical Thinking ExerciseAdam, 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.