Craven, Chap.42:bowel Elimination

Front 1

How long does it take for the contents of the small intestine to enter into the large intestine?

Back 1

About three to ten hours.

Front 2

What comprises the large intestines?

Back 2

Cecum, colon, rectum and anus.

Front 3

What are the names of the four parts of the colon?

Back 3

Ascending, descending, transverse and sigmoid.

Front 4

What are the two types of of motility that occur within the intestine? Define.

Back 4

Segmentation and peristalsis.
Persistalsis: Propelling motion particularly stimulated when partially digested food enters the duodenum.

Segmentation: alternating contraction and relaxation of the intestinal smooth wall muscle.

Front 5

Define chyme.

Back 5

Partially digested food from the stomache.

Front 6

FACTOID: Most nutrient and electrolyte absorption occurs in the duodenum and jejunum.

Back 6

FACTOID: Some vitamins, iron and fluid are absorbed in the ileum.

Front 7

FACTOID: The longer the intestinal contents remain in the colon, the greater the absorption of fluid and electrolytes.

Back 7

FACTOID: Intestinal contents entering the ascending colon are liquid and when they leave the transverse colon are semisolid and mushy. Feces is created!

Front 8

FACTOID: Defecation begins when peristalsis propels feces into the rectum and causes rectal distention.

Back 8

FACTOID: Once stool enters the rectum parasympathetic nerve fibers in the sacral area of the spinal cord are stimulated, thus causing contraction of the descending and sigmoid colon, rectum and anus and relation of the internal anal sphincter.

Front 9

What keeps the defecation reflex from staining your tidy whities?

Back 9

The external sphincter. The sphincter can remain contracted until its owner decides that they are in the right place...the person can voluntarily relax the external anal sphincter. Hard to do this in a dirty gas station bathroom though.

Front 10

Describe the Valsalva maneuver.

Back 10

Assisting defecation by taking a deep breath against a closed epiglottis which helps move the diaphragm down, contracting the abdominal muscles (pressure) and contracting the pelvic floor muscles--pushes feces downward. Feces is born!

Front 11

Describe the content of feces.

Back 11

75% water, 25% solids which consists of bacteria, undigested fiber, fat, inorganic matter, some protein and corn. Just joking about the corn.

Front 12

FACTOID: The more you eat, the more you poop!

Back 12

FACTOID: The less you eat, the less you poop!

Front 13

FACTOID: Feces gets its warm brown coloring from bilirubin as it is mixed with intestinal bacteria and enzymes.

Back 13

FACTOID: Ingestion of certain medications can change the color and consistency of stool. As does corn!

Front 14

FACTOIDS:
The fine scent of feces comes from bacterial decomposition of protein in the intestine.
We produce 150 and 300 grams of feces daily.

Back 14

FACTOID: But producing it and passing it are two different stories!
Frequency: 1-2x per day or
once every two to three days.

Front 15

What is the normal color of feces? What is not?

Back 15

Good: brown.
Abnormal: black, tarry, reddish-brown, maroon, clay-colored and yellow-green. Not good.

Front 16

What is the consistency of feces? This is a visual assessment.

Back 16

Good: soft and formed
Abnormal: Hard, loose, liquid, high mucus content.

Front 17

Shape of feces?

Back 17

Cylindrical is good. Narrow and pencil-thin, not so good.

Front 18

What is the normal odor of feces? Wouldn't it be nice if it could just remain a visual assessment?

Back 18

Good (?): Aromatic;pungent.
Not so good: Foul, objectionable.
As a CNA I can assure you that you will notice the difference when you meet up with foul feces. Suggest you breathe through your mouth and get pt. cleaned up quickly!

Front 19

FACTOID: As we age our gastrointestinal motility slows thus our bowel frequency --decreases.

Back 19

FACTOID: Older people really ought to increase their fluids and high fiber intake to prevent the formation of harder stool.

Front 20

FACTOID: Older persons may resort to laxatives to restore their 'normal' pattern of bowel evacuation.

Back 20

FACTOID: These laxative junkies must be educated that there are better ways to eliminate. See two cards prior.

Front 21

FACTOID: On the flipside, the external sphincter muscle- strength weakens and this increases fecal incontinence.

Back 21

Pull-up panties slogan: "I'm a big kid now!"

Front 22

FACTOID: If you consume 20-30 g of dietary fiber from fruit and vegetables you will most likely have enough bulk in the stools to defecate nicely.

Back 22

FACTOID: Food intolerances such as lactose intolerance may alter bowel function. Some people can not digest gluten and will instead find that they retain carbohydrates and fats creating a sense of bloating, abdominal digestion and diarrhea that looks like bulky and greasy stools.

Front 23

FACTOID: When the body needs to conserve fluid it will absorb more water from the large intestine to meet its needs.

Back 23

FACTOID: 2000 mL fl. per day is needed to meet cellular needs and have enough left over to promote a softer stool. Ahhh.

Front 24

FACTOID: Physical activity and regular physical exercise promote muscle tone and facilitate peristalsis.
This is what 'morning constitutional' refers to.

Back 24

FACTOID: If you don't get enough activity, you run the risk of constipation.

Front 25

FACTOID: Sitting, or semi-sitting position is the most advantageous for defecation.

Back 25

FACTOID: This preference makes it difficult for the bedridden to move their bowels if they are in a reclined position-- and IMO the bedpan should always be called a fracture pan because it can hurt.

Front 26

THINK ABOUT IT: If a person dreads going to the bathroom they often choose to postphone the moment and this can lead to constipation.

Back 26

FACTOID: So really there are many alterations in a persons lifestyle that can have an impact on bowel elimination.
These include: traveling, stress, depression.

Front 27

Discuss anal fissures and hemorrhoids.

Back 27

Anal fissures are ulcerous cracks in the anal mucosa. So, your crack can have a crack!
Hemorrhoids are enlarged varicose veins in the anal canal.--When cleaning a patient TOUCH THESE GENTLY!!! Very painful and can bleed red, red blood!!!

Front 28

FACTOID:Medications can increase a person's risk for bowel elimination problems.
ex: Narcotics, iron, antacids, laxative junkies, antidiarrheals.

Back 28

FACTOID: A thorough cleansing of the large bowel alters the normal pattern of elimination for 2-3 days after the test that called for the cleansing of the bowel.
Note: Barium enema stools appear chalkly white and can cause constipation. Laxatives are recommended.

Front 29

FACTOID: Clients with abdominal surgery may require 3-4 days for bowel activity to return to normal.

Back 29

What is the name of the portion of the INTESTINE brought through the abdominal wall?

Front 31

Another type of fecal diversion is called colostomy. What part of the intestine is brought out into the abdominal wall?

Back 31

Colon.

Front 32

So, guess what part of the intestine is brough forth in an ileostomy? Wait, just to make it harder, is this part of the intestine the small or large part?

Back 32

Yep, the ileum.
It is small intestine.

Front 33

So, now name the three parts of the small intestine.

Back 33

The duodenum, jejunum and the ileum.

Front 34

And the large intestine?

Back 34

Cecum, colon, rectum and anus.

Front 35

And the colon has four parts--what are they?

Back 35

The transverse, ascending, descending and sigmoid colon.

Front 36

FACTOID: With ileostomies and colostomies fecal material is passed through the stoma created for it.

Back 36

FACTOID: The length of functioning intestine that remains determines the consistency of the stool.

Front 37

What is constipation?

Back 37

Infrequent, sometimes painful passage of hard, dry stool.

Front 38

List three risk factors that contribute to constipation.

Back 38

1. Inadequate calorie intake.
2. Inadequate fiber intake.
3. Large intake of refined foods or other low-residue foods.
4. Low fluid intake.
5. Delay of bowel evacuation (the gas station scenario)
6. Chronic stress
7. Decreased physical activity.
8. Medications and their side effects
9. Aging intestinal motility
10.Continual use of laxatives.
11. Neurological conditions or diseases: Parkinson's, MS, spinal cord injuries, hypothyroidism.

Front 39

What is fecal impaction and what is the cause?

Back 39

Accumulation of hardened feces in the rectum.
Usually the result of untreated and unrelieved constipation.

Front 40

How do you diagnose fecal impaction?

Back 40

History of absence of a regular bowel movement for more than 3-5 days, followed by the passage of incontinent liquid or semi liquid stool.

Front 41

How does one confirm the detection of hardened stool?

Back 41

Digital examination.

Front 42

List some subjective symptoms of fecal impaction.

Back 42

Feeling of rectal and abdominal fullness or bloating, urge to defecate with no reward, generalized feeling of malaise. Loss of appetite, nausea, vomiting may be reported.

Front 43

Name some measures to remove fecal impaction.

Back 43

Laxatives, enemas, manual removal.

Front 44

FACTOID: Diarrhea is defined more by the consistency of the stool. It is less formed, more watery and maybe more mucousy.

Back 44

Symptoms include: abdominal cramping, nausea, and often a painful burning sensation at the anus because it is highly acidic.

Front 45

What keeps the growth of C, difficile at bay in the human body? What can cause proliferation of C. difficile?

Back 45

Normal intestinal flora keeps C. difficile in check but broad-spectrum antibiotics can alter the normal flora and cause C. difficile to abound. Specifically broad-spectrum antibiotics like cephalosporins.

Front 46

When I traveled abroad and got diarrhea, what caused my traveling diarrhea?

Back 46

E. coli, usually a waterborn, foreign strain. Refer to our Urinary chapter and remember that E coli can cause the dreaded yeast infection.

Front 47

What exactly is fecal incontinence?

Back 47

An involunatry passing of bowel contents that is associated with neurologic, mentalm or emotional impairments.

Front 48

What is flatus?

Back 48

Accumulation of gastrointestinal tract gas. Air that is swallowed usually revisits us as a belch, but 'flatus from the anus' is gas produced by bacterial activity in the large intestine

Front 49

What is distention? Name some causes. And, some subjective complaints regarding distention.

Back 49

Accumulation of excessive amounts of flatus or liquid or solid intestinal contents that causes distention. Usually an obstruction that prevents flatus, chyme of feces fom passage. Pt Cx of abdominal fullness, discomfort, inability to pass flatus or stool.

Front 50

List some questions you should ask a patient in order to assess his elimination habits.

Back 50

What is your usual pattern of elimination?
What does your stool look like?
Do you use anything to aid with defecation? (Not books, people, --laxatives, etc.)
When was your last bowel movement?
Have you noticed any recent changes?

Front 51

NOTE: People's concept of whether or not they have an elimination problem is based on their beliefs of what a normal bowel elimination is and if their current patter fits their beliefs.

Back 51

FACTOID: Borborygmi in NOT an origami fold but IT IS the embarrassing stomach growls.

Front 52

How do you physically assess the abdomen, perirectal area?

Back 52

Ausculatation, percussion and palpitation, measuring abdominal girth and inspection.

Front 53

INSPECTION: observe abdomen for contour and symmetry.
abnormal findings: hollow or scaphoid, distended, asymmetric.

Back 53

AUSCULATATION: using stethescope start on the pts right lower quadrant --ileocecal junction. Normally bowel sounds are heard within 5-15 seconds. Nurses clinically declare absence of bowel sounds when none are heard for 30 seconds in each quadrant.

Front 54

NOTE: Clients who have undergone abdominal surgery may have hypoactive or absent bowel sounds for 1-3 days postoperatively.

Back 54

NOTE: Paralytic ileus is a condition in which the bowel is temorarily paralyzed and distention occurs.

Front 55

Where there is a hypoactive there is a hyperactive definition. Hyper means a lot. In this case it would be bowel sounds every 5 seconds or even continously.

Back 55

PERCUSSION: Used to identitfy air, fluid or solid masses in the abdomen. Duller sounds are heard over the fluid-filled areas. A mass or feces produces a dull sound.

Front 56

PALPITATION: Perform palpitation in all quadrants of the abdomen in a systematic manner, saving the painful part for last!!! Pt can flex knees to help relax abdominal walls.

Back 56

MEASUREMENT OF GIRTH: measure the girth over time to determine whether the distension is increasing, decreasing or remaining unchanged. Do you think we will learn more about this in L&D?

Front 57

PERIRECTAL EXAMINATION:VISUAL
Side lying position for patient.
Observe area.

Back 57

Abnormal remarks:
Excoriation--red, bleeding, tender skin
Hemorrhoids, bleeding.

Front 58

PERIRECTAL AREA: PALPITATION
Insert gloved and lubbed finger into anus and rectum, directing finger towards umbilicus. Is there stool? Is it hard or soft?

Back 58

DIAGNOSTIC TESTS AND PROCEDURES:
Two laboratory tests:
FOBT and the stool culture.

Front 59

FOBT: Fecal occult blood test, aka: guaiac of hemmocult test--hidden blood in stool tests. Simple stool sample on paper with blue color change signifying blood is in this stool!!!

Back 59

Stool samples performed to distinguish atypical intestinal organisms present. These would include Salmonella and Shigella and C. difficile, sometimes testing for parasites like Giarda lablia.
Warm stools req'd for parasitic testing.

Front 60

Radiologic procedures: X-ray imaging, such as barium, techs watch the passage of barium from esophagus to ileum. Lower intestines can be monitiored through use of barium introduced through enemas.

Back 60

Purpose of barium testing: assess for abnormalities in shape, motility and functioning.

Front 61

What are some nursing responsibilities BEFORE a barium enema is given?

Back 61

Educating client about the preparatory regimen, purpose for the procedure, administering the laxatives and/or enemas and maintaining clients NPO status.

Front 62

What are some nursing responsibilities after the procedure in this case?

Back 62

Providing liquid and food as ordered, administering a laxative until those little white stools mentioned earlier are gone before they turn into plaster rockets stuck in the poor patient.

Front 63

ENDOSCOPIC EXAMINATION:
Procedures that are helpful in diagnosing inflammation, ulceration or tumors. Tissues may also be extracted via these procedures for biopsy.

Back 63

Proctoscopy aka sigmoidscopy examines the rectum and sigmoid colon.

Front 64

Colonoscopy can visualize the colon up to the ileocecal valve.

Back 64

Name the the news reporter who had a colonoscopy live on television to make colon awareness more...visual.
Katy Couric.

Front 65

Name the journalist who had her colonoscopy live on t.v..
Katy Couric.
(Not in Craven. Probably found that in People or something. I missed that event.)

Back 65

A polypectomy is a complete surgical removal of a colonic lesion.
Polly pecked it out of me.

Front 66

Observe patient for rectal bleeding or onset of continous, dull abdominal pain which could indicate colonic perforation. Provide rest and food and fluids as allowed.

Back 66

NANDA NURSING DIAGNOSES:
constipation, perceived constipation, risk for constipation, diarrhea, and bowel incontinence.

Front 67

OID:
Promoting an acceptable bowel elimination pattern is a long-term goal. In reality due to restrictions of clinical practice, client teaching and education is necessary to achieve this goal.

Back 67

Health promotion:
Diet: Nurse should assist pt with planning a diet with sufficient daily intake of high fiber foods.

Front 68

Name some high fiber foods.

Back 68

Fresh or cooked fruits and vegetables with their skins, whole-grained breads and cereals, fruit and vegetable juices.

Front 69

What is the suggested daily intake of fiber?

Back 69

800 g

Front 70

What is the suggested fluid intake?

Back 70

1500 to 2000 mL perday to promote normal elimination patterns. Or 8-1o glasses of fluid per day.

Front 71

Exercise promotes normal intestinal functioning.
What is isotonic versus isometric exercise?

Back 71

Isometric involves muscle contraction without a change in muscle length.Resistance is usually involved. (Mostly internal-- ME-resistance.)
Isotonic is dynamic with constant muscle tension, muscle contraction and active movement. That takes a TON of effort.

Front 72

Many paramedics will tell you that people have been hurt (heart attacks, strokes, head injuries) while having bowel movements. Why is that?

Back 72

Straining while defecating or performing the Valsalva maneuver can lead to cardiac dysrhythmias, increased cranial pressure and syncope in high risk clients.

Front 73

Colorectal screening should be recommended for clients over 50 years of age, family history of issues, previous colorectal cancer, ulcerative colitis, Crohn's disease, or hisotry of adenoma.

Back 73

Adenoma=polyps
Colorectal screening=digital rectal examination, fecal occult blood testing, flexible endoscipic exams
EvErY ThReE YeArS! AHHhhhh...

Front 74

What is a suppository and how should it be administered?

Back 74

It is a medication prepared in a base that when inserted into the rectum will melt and be absorbed for systemic or local effects.
It is inserted in anus and past the internal sphincter--about four inches--with pt in side-lying position. Finger is aimed towards umbilicus. (So there is a reason for a belly button!)
usually take effect in 15-60 minutes.
Don't push suppository into stool!

Front 75

An enema is the cleansing of a portion of the bowel by insertion of fluid rectally. Name some types of enemas and their purpose.

Back 75

Small-volume enemas=commercially prepared, administered after oral laxatives fail. Hypertonically draws water from colonic mucosa to cause water retention in the lower colon. Increases peristalsis.

Front 76

Oil retention enema= usually given when fecal impaction is suspected. (Another type of small volume enema.)

Back 76

Pt usually experiences the urge to defecate within 5 - 10 minutest after administration enema.

Front 77

Large volume enemas= cleanse bowel of stool with as much as 1000mL of fluid. usually warm tap water or saline. Defecation urge is stimulated by the distention and stimulation of the defecation reflex.

Back 77

Pt is in side lying position on left side, tubing is inserted 4 inches and fluid slowly instilled. Do not force tubing or go in to far: DAMAGE OR PERFORATION MAY OCCUR!

Front 78

Large volume enemas may be repeated up to three times. More than that could lead up to fluid and electrolyte imbalances.

Back 78

Return flow enema: Used for flatus relief. Use 500mL. When patient feels discomfort or cramping, lower enema tubing and allow the water to return into the tubing. Gassy water bubbles. Repeat until relief. May take 15-20 minutes.

Front 79

Rectal tube insertion is used for relieving flatulence. It is basically the principle of blowing bubbles through a straw. Four inches in, leave in no longer than 15-20 minutes. Bag collects flatus.

Back 79

Fecal impaction may be relieved digitally and is a nursing responsibility.

Front 80

Describe fecal impaction removal:

Pt in side-lying position, double-gloved, lubbed index finger into rectum. Gentle hooking motion-watch that vagal stimulation! avoid damaging sensitive tissues!

Back 80

Bowel training: long term approach for those in rehabilitation phase of a neurologic injury--stroke, spinal cord or paralysis.

Front 81

Bowel training consists of: maintaining stool consistency, same time, same routine.

Back 81

Nurses are responsible for stoma management. Stoma assessment: stoma should be a healthy pink. REPORT TO PHYSICIAN IMMEDIATELY IF ANY OTHER COLOR!

Front 82

Fecal collection: liquid stool is collected in bags that are placed over the stoma to collect feces.

Back 82

Ostomy bags should:
cut to the right size, emptied at 1/4 to 1/3 full, skin by stoma should be cleaned and dried.

Front 83

What is an ostomate?

Back 83

Clients with an ostomy!

Front 84

Bowel training consists of: maintaining stool consistency, same time, same routine.

Back 84

Nurses are responsible for stoma management. Stoma assessment: stoma should be a healthy pink. REPORT TO PHYSICIAN IMMEDIATELY IF ANY OTHER COLOR!

Front 85

Fecal collection: liquid stool is collected in bags that are placed over the stoma to collect feces.

Back 85

Ostomy bags should be:
cut to the right size, emptied at 1/4 to 1/3 full, skin by stoma should be cleaned and dried.

Front 86

What is an ostomate?

Back 86

Clients with an ostomy!