07.06 Bowel Elimination

Overview

  1. Elimination
    1. Nursing care priorities
    2. External aids
    3. Internal aids
    4. Surgical interventions

Nursing Points

General

  1. Nursing care priorities
    1. Dignity
      1. Provide comfort
      2. Provide privacy
    2. Safety
      1. Reduction of infection
      2. Skin care
    3. Measure output
      1. Measure every device
    4. Fecal output
      1. Check for consistent bowel output
      2. Address concerns with providers as necessary and promptly
      3. Use stool softeners and laxatives appropriately
  2. External aids
    1. Bedside toilet
      1. Use for ambulatory patients
      2. Check for safety
        1. Reduce fall risk
    2. Bedpan
      1. Ideal for patients who have reduced mobility
      2. Use fracture pans for ortho patients
  3. Internal aids
    1. Fecal containment device
      1. Device for fecal incontinence
        1. Must be liquid stool
        2. Use for concern for skin integrity
        3. Ensure appropriateness
          1. Cannot be used for certain bowel surgery patients
        4. Use if concern for C. diff
        5. Device names
          1. Flexi-seal
          2. Malecott
  4. Surgical interventions
    1. Ostomies
      1. Used at varying areas of bowel
        1. Dependent on area of illness or injury
      2. Provide stoma care
      3. Stool will look different depending on the level of stoma
        1. Ileostomy
          1. Yellow liquid
        2. Colostomy
          1. Loose to firm stool
          2. Appears similar to normal color, especially the closer to the rectum to the ostomy is placed.

Assessment

  1. Assess for patient knowledge regarding elimination aids
  2. Assess output based on the type of device used
  3. Check skin integrity frequently
  4. Determine if device is still necessary

Nursing Concepts

  1. Elimination
  2. Safety
  3. Functional Ability
  4. Comfort

Patient Education

  1. Educate patient on the type of device necessary for care
  2. Educate patient on need to notify the nurse for elimination needs
    1. Provide call light, and educate patient on use
    2. Observe patient using call light appropriately
  3. Educate patient on long term use of devices such, as ostomies.
    1. Provide teaching for ostomy and stoma management
    2. Utilize teaching methods such as the teach back in reducing the probability of complication

Reference Links

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Video Transcript

Today we’re going to talk about bowel elimination and what it means for your patients.

Now I know we’ve covered a lot of information in the urinary elimination lesson so be sure to check that out. But again I want to reiterate some really important points for your patient.

Anytime or patient deals with bathroom issues make sure that we are providing privacy and dignity to make sure that we’re being safe about their care. Want to make sure that we’re keeping them from getting any skin breakdown by making sure will keeping them clean if they’re having to stool frequently.

To make sure that your measuring your patient’s stool, and how often they are actually going. You’re going to have to label it and measure it, but make sure that you keeping tabs on so that we can make sure that their bowels are working. This is really important later in the lesson when we talk about ostomies. Also, be sure you’re watching the color, quality and consistency of the poop! If you notice something out of the ordinary, let your provider know!

Also, know the difference between a stool softener and laxative. Stool softeners like Colace soften the stool, and laxatives make them go. Miralax is a laxative.

One final tip is to make sure that if you have a real concern with your patient’s stool, please let your provider know and don’t hesitate. The last thing we want for our patients are more problems.

Just like with our urinary elimination aids, bowel elimination aids are pretty much the same stuff. You have your bedside toilet, which will help your patient go to the restroom easier, especially if they’re ambulatory.

The big one here though is going to be the bedpan and especially for your non-ambulatory patients. When we focus on safety, we want to make sure that they can safely get up and go to the restroom. And if they can’t, this is where the bedpan comes in. For most patients the regular bedpan is going to be fine, but if they have an orthopedic injury like a pelvic fracture, they may not be able to place the same amount of pressure directly in a bedpan so make sure you something like a fracture bedpan. Remember to measure your output of your patient when they go.

Now let’s look at some internal aids.
Now I know I have a picture of a Foley here, but the type of devices that we used to contain the stool for our patients are similar. They’re usually a tube connected to a drainage bag, that is inserted into the rectum.

There are some key points that I do want to bring up. If your patient has a normal firm stool, you can’t use these. The stool won’t pass through the tube, it can create blockages and constipation. If your patient has liquid stool, or your concern for something like Clostridium difficile or C diff, then this is a perfect for them. Always make sure that you’re checking your patients skin integrity whenever they have one of these devices in, and that they’re not leaking stool around the tube. If not, they can get skin breakdown.

You typically can’t use these after rectal surgery, so double check to see if your patient is good for it. The two types that we use are a Malecott or a Flexi-seal. A Malecott looks like a tube with four prongs, and they’re made of silicone. But they stay in pretty well. The Flexi-seal is basically a rectal foley. It’s got the tube and the balloon, and it’ll drain the stool into the bag. I’ve used these a ton when I discovered my patient’s stool running off the side of the bed onto the floor. Yeah, I know, gross. But they saved the day for sure.
Now the last thing I want to talk about are types of bowel surgery. Ostomies are just the general term for creating a bowel opening through the abdomen at varying levels of the entire intestinal system. Patients will need them for a variety of reasons, but there are a few key things that you need to know about ostomies.

The first is where is it at, because it’s going to tell you a couple of things. It’s going to tell you the color that the stool is going to be, it’s going to tell you the where the location of the stoma should be, and it’s also going to tell you the consistency of the stool should look normally.

For instance an ileostomy is going to occur kind of in the right upper quadrant to right lower quadrant and is going to have a yellow, liquid stool. Whereas a colostomy occurring at the descending colon, is going to have a much firmer type stool, and it’s going to look like normal stool and probably be brown.

The other really important point about bowel surgeries and ostomies is taking care of the patient’s stoma. Your patient’s stoma should be beefy red and if it at any point looks dusky or looks like it’s not getting the right blood flow, you need to make sure that you’re getting in touch with your provider so that they can do something about it. It also needs to not be protruding out of the abdomen, so if it looks anything other than red and slightly raised, then call the provider. The other thing that you want to do is monitor for output, regularity, and also start talking to your patients about stoma care. Your patients are going to need to know about how to take care of it, how to change their ostomy bags, so make sure that you start introducing these concepts to them early. The other person you can talk to are your Wound-Care Ostomy Nurses…they’re great resources and most hospitals have them. They’re all things Ostomy!

Today we really focused on our nursing concepts of elimination and functional ability, and we really want to drive home that idea of safety by reducing the risk of infection.
Okay, so let’s recap.

Your patient may not always be able to eliminate on their own, so if they have a device make sure that that device is staying clean and free of infection.

External devices are great for your patients that have the ability to get up and move, so we don’t have to use any sort of internal devices.

Only use your internal devices when you absolutely need to and make sure that you take them out as soon as possible.

Surgical interventions are last resort, but sometimes they are absolutely necessary. So make sure that you know where the ostomy starts so you know what to expect.

Always let your providers know if there are changes to your patient’s stoma, or if there is concern so then we can protect our patients and make sure they don’t have any real complications.

That’s it for our lesson on bowel elimination. Make sure you check out all the resources attached to this lesson. Now, go out and be your best selves today. And, as always, happy nursing!!

Read more

  • Question 1 of 5

A 68-year-old client complains to the nurse that she has been struggling with constipation. The nurse is discussing the different causes of constipation with this client. Which of the following best describes slow-transit constipation? Select all that apply.

  • Question 2 of 5

The nurse is caring for a client who suffers from chronic constipation. The nurse asks questions to evaluate whether the client uses laxatives to manage this condition. Which of the following best describes the rationale for this action?

  • Question 3 of 5

A patient with a feeding tube has developed constipation as a result of inactivity. Which nursing intervention would most likely help to resolve this complication?

  • Question 4 of 5

A nurse is providing discharge teaching to a client who has had a colostomy surgically placed during the hospital stay. What information would the nurse most likely include about the stoma for this clent? Select all that apply.

  • Question 5 of 5

The nurse is caring for a client with an ileostomy. During assessment of the client, the nurse notes that the pouch opening is 1/2 inch larger than the stoma site. Which of the following poses a risk for this client?

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