week 6 Flashcards
(46 cards)
Bowel Elimination Information Gather
Subjective
*Last BM
*Nausea
*Description BM
*Other descriptors
*Passing gas ( flatus)
*Fullness or bloating aka
distention
- Objective: BW
Last BM
*Character of BMs
*% of meals taken
*Intake of fluids
*Emesis
*Physical assessment:
Abdominal Inspection
Landmarks
- RUQ
- LUQ
- RLQ
- LLQ
*Epigastric region
*Umbilical region
*Suprapubic region
Order of assessment for abdomen
“Look, Listen, Feel”
Inspection/Auscultation/Palpation of abdomen
*Inspection first
*Auscultation next- diaphragm of
stethoscope
*Bowel sounds are high pitched
*Auscultate all 4 quadrants
*Palpate next; lightly
Bowel Sounds
*Active (normal):
* Irregular, gurgling, tinkling
* Every 5-15 sec (5-30 per minute).
*Hyperactive:
* Loud, high pitched, >every 5-15 sec (>30 per minute) .
*Hypoactive:
* Faint sounds.
* < every 5 sec (<5 per minutes).
* May not be in all quads
oAbsent
Palpation
All Four Quadrants
Light palpation
* Normal:
- soft, non-tender, pain free
* Abnormal
* - guarding
- rigid, tense, firm
- tenderness, pain
Deep Palpation
Deep Palpation- usually physicians only
Abnormal Abdominal Complications:
*“DO NOT PALPATE”: Examples
*Appendicitis (when your appendix becomes sore, swollen, and diseased)
*Acute abdomen
*Known or suspected AAA (abdominal aortic aneurysm)
Large Abdomen Vs. Distension
Large abdomen
Large:
* Inspection:
* Uniformly rounded.
* Umbilicus deeply sunken
* Auscultation:
* + bowel sounds
* Palpation:
* Soft, non-tender
*Distended:
* Inspection:
* Single rounded curve.
* Umbilicus may flatten or
protrude.
* Skin may “glisten”
* Auscultation: varies
* Palpation: Firm or rigid,
tenderness/pain, guarding
Large Abdomen Vs. Distension
Distension
Large:
* Inspection:
* Uniformly rounded.
* Umbilicus deeply sunken
* Auscultation:
* + bowel sounds
* Palpation:
* Soft, non-tender
*Distended:
* Inspection:
* Single rounded curve.
* Umbilicus may flatten or
protrude.
* Skin may “glisten”
* Auscultation: varies
* Palpation: Firm or rigid,
tenderness/pain, guarding
“Ileus” or “paralytic ileus”
Definition: Loss of forward flow of intestinal
contents due to decreased peristalsis, secondary to anesthesia, handling of the intestines during surgery, electrolyte imbalance, infection or ischemic bowel.
Signs: abdominal pain, distention, absent bowel sounds, vomiting
*Interventions; detection, notify MD, ambulate, hydrate, GI rest, limit opioids, NG tube to suction, oral care
Ileus is a term used to describe a condition where the intestines don’t move food and waste through the way they normally should. It’s like a temporary “traffic jam” in your digestive system. This can happen after surgery, when you’re sick, or due to other reasons. It can lead to symptoms like bloating, stomach discomfort, and a lack of bowel movements.
Bowel Elimination
Defecation
*Defecation reflex: not under voluntary
control
*Internal anal sphincter: not under
voluntary control, smooth muscle
*External anal sphincter: is under
voluntary control
Characteristics of Normal Feces
*75% water, 25% solids
*Frequency: varies, 1- 2/day to 1- 3 days
*Color: brown
*Consistency: soft
*Shape: cylindrical
*Odor: bacterial decomposition of proteins
*Flatulence: gas, flatus
*What is the pt’s normal pattern
Factors Affecting Bowel Elimination
- Nutrition:
- Fiber intake: 20–30 Gm/day
- Fluid intake: 2.5-3.5 L/day
- Activity
- Promotes peristalsis
- Lifestyle: schedule, laxatives
Factors Affecting Bowel Elimination: cont.
*Position: Bed rest (prolonged bed rest can lead to constipation or difficulty with bowel movements)
*Pregnancy
*Medications ( opioids, can slow down bowel movements and lead to constipation.)
*Therapeutics:
*Diagnostic tests – bowel preps (clean out the bowel and ensure that it’s empty for the test )
*Surgery
Age Related Changes
*Geriatric Populations
*Constipation
*Diarrhea
Criteria for Constipation
*2 or more:
*Straining during >25% of bms
*Lumpy or hard stools > 25% of the time
*Sensation of incomplete evacuation >
25% of the time
*Manual maneuvers to facilitate
evacuation >25% of the time
*< 2-3 movements per week
Constipation
Associated S/S sign and symstom:
*Painful passage of stool
*Abdominal & rectal fullness, bloating
*Malaise (uneasiness) & loss of appetite
Fecal Impaction: Secondary to constipation
*No BM in 3-5 days
*Passage of liquid/semi-liquid stool around area of impaction
*Assess pt - differentiate diarrhea or
constipation.
Enemas - Rationale
Requires physician order:
*Cleanse portion of the large bowel
*Surgical or diagnostic procedures
*Treat constipation/fecal impaction
*Bowel training
*Relieve gaseous distension
*Administer medication
Enemas - Types
*Small volume: approx. 150 mL, ex.-fleets,
oil retention
Large volume: up to 1000 mL water or
saline. Ex.-Tap H20, soap suds
*Medicated Enema:
*Kayexalate( Its primary purpose is to treat high levels of potassium in the blood, a condition known as hyperkalemia. Kayexalate works by binding to excess potassium in the intestines, allowing it to be removed from the body through bowel movements.)
Enema Procedure
- Assess need for enema
- Enema may or may not be considered a “medication”
- Explain procedure
- Privacy
- Position patient, L side, (Sim’s position)
- Gloves
- Have supplies/enema ready/ towel, lubricant, bedpan, BSC,
or BR - Insert tip 3-4 inches into rectum depending on type
“Harris Flush”
Procedure – Return flow enema; 300-500
mLs./ aka
*For return flow procedure, lower enema bag and allow solution & air bubbles to return.
*Monitor for adverse affects
*Abdominal pain
*Excess vagal stimulation
*Bradycardia
*Hypotension
Digital Disimpaction
*Physician’s order required.
*V.S. prior to procedure (increased risk vagal
stimulation)
*Gloves (several pair), lubricant (lots), gown,
bedpan or commode.
*Gentle hooking motion with finger(s).
*Monitor for adverse affects. Vagal stimulation
(bradycardia, hypotension).
*Avoid injury to mucosal tissue
