Intestinal EliminationIntestinal Elimination

Dr.Karima ElshamyDr.Karima Elshamy

Outline:Outline:

�� Introduction.Introduction.

�� General principles.General principles.

�� Basic facts on relation to anatomy Basic facts on relation to anatomy

and physiology.and physiology.

�� The acts of defecation.The acts of defecation.

�� Personal habits.Personal habits.

�� Factors influencing fecal elimination.Factors influencing fecal elimination.

��Common problems of intestinal Common problems of intestinal

elimination:elimination:

�� Constipation.Constipation.

�� Fecal impaction.Fecal impaction.

�� Intestinal, distension (tympani is).Intestinal, distension (tympani is).

�� Diarrhea.Diarrhea.

�� Anal incontinence.Anal incontinence.

Introduction:Introduction:

Elimination is essential to rid the body of Elimination is essential to rid the body of

wastes and materials in excess of bodily wastes and materials in excess of bodily

needs. needs.

Elimination process is necessary to maintain Elimination process is necessary to maintain

high level of wellness and even life itself high level of wellness and even life itself

and must continue during illness in health.and must continue during illness in health.

General Principles:General Principles:

�� Efficient physiologic functioning requires Efficient physiologic functioning requires

that waste substances be eliminated from the that waste substances be eliminated from the

body.body.

�� Patters of elimination from the large intestine Patters of elimination from the large intestine

vary among individuals.vary among individuals.

�� StressStress--producing situations and illness may producing situations and illness may

interfere with normal habits of elimination.interfere with normal habits of elimination.

Basic Facts in Relation to Anatomy Basic Facts in Relation to Anatomy

and Physiology:and Physiology:

1.1. The large intestine is a tube leading from "' the The large intestine is a tube leading from "' the

small intestine to the external skin and is about 150 small intestine to the external skin and is about 150

--180 cm in length . 180 cm in length .

The ileocecal valve separates the small intestine The ileocecal valve separates the small intestine

from the large intestine. from the large intestine.

It opens in one direction; prevent the passage of It opens in one direction; prevent the passage of

material in the opposite direction. (Fig: 1).material in the opposite direction. (Fig: 1).

2.2. The large intestine is divided into:The large intestine is divided into:

�� The caucus: lies at the beginning of the The caucus: lies at the beginning of the

large intestine.large intestine.

�� The colon: lies between the caucus and the The colon: lies between the caucus and the

rectum and is divided into:rectum and is divided into:

–– The ascending colon goes up on the The ascending colon goes up on the

right side.right side.

–– The transverse colon crosses the The transverse colon crosses the

abdomen. abdomen.

–– The descending colon goes down on the The descending colon goes down on the

left side.left side.

�� The sigmoid flexure ends at the rectum.The sigmoid flexure ends at the rectum.

�� The rectum of the adult person is about The rectum of the adult person is about

1515--20 cm.20 cm.

3.3. The anal canal is about 2.5 cm, and has The anal canal is about 2.5 cm, and has

two sphincters. two sphincters. The internal sphincterThe internal sphincter

and and the external sphincterthe external sphincter at the anus, at the anus,

the external sphincter has striated the external sphincter has striated

muscles and is under voluntary control.muscles and is under voluntary control.

The anal canalThe anal canal

4.4. The large intestine, including the anal canal The large intestine, including the anal canal

is innervated by autonomic nerve supply:is innervated by autonomic nerve supply:

�� Stimulation of the parasympathetic Stimulation of the parasympathetic

system promotes peristalsis and increases system promotes peristalsis and increases

muscle tone.muscle tone.

�� Stimulation of the sympathetic nerves Stimulation of the sympathetic nerves

inhibits peristalsis and decreases tone. inhibits peristalsis and decreases tone.

5.5. There are two localThere are two local--reflexes involved in reflexes involved in

intestinal elimination:intestinal elimination:

�� The gastro colic reflex:The gastro colic reflex: peristalsis is peristalsis is

stimulated by the intake of food enters the stimulated by the intake of food enters the

duodenum (about half an hour afterduodenum (about half an hour after--eating eating

or drinking) a mass peristaltic action or drinking) a mass peristaltic action

occurs in the large intestine which is occurs in the large intestine which is

called the gastro colic reflex, and the need called the gastro colic reflex, and the need

to defecate is felt.to defecate is felt.

The rectal reflex (defecating The rectal reflex (defecating

reflex):reflex):

is stimulated by the presence of waste is stimulated by the presence of waste

products in the rectum which is products in the rectum which is

producing mechanical pressure. This producing mechanical pressure. This

leads to stimulation of sensory leads to stimulation of sensory

receptors and the need to defecate is receptors and the need to defecate is

felt.felt.

The act of defecation:The act of defecation:

The act of defecation:The act of defecation:

Defecation:Defecation:

Is an evacuation of the intestines and is Is an evacuation of the intestines and is

often referred to as a bowel movement. often referred to as a bowel movement.

When a certain amount of fecal matter When a certain amount of fecal matter

accumulates in the rectum it becomes accumulates in the rectum it becomes

distended and the intradistended and the intra--rectal pressure rectal pressure

rises.rises.

Sensory nerve endings are stimulated Sensory nerve endings are stimulated

(parasympathetic), the internal and (parasympathetic), the internal and

external sphincter relaxes, and the external sphincter relaxes, and the

colon contracts ,the result is a desire colon contracts ,the result is a desire

to defecate. to defecate.

During the act of defecation During the act of defecation several several

additional muscles help in the additional muscles help in the

process:process:

�� Voluntary contraction of the additional Voluntary contraction of the additional

muscles and closing of the glottis and muscles and closing of the glottis and

increasing intraincreasing intra--abdominal pressure that abdominal pressure that

aids in expelling the feces.aids in expelling the feces.

�� Simultaneously, the muscles of the Simultaneously, the muscles of the

pelvic floor contracts and aid in pushing pelvic floor contracts and aid in pushing

the fecal mass out. the fecal mass out.

Personal Habits:Personal Habits:

�� Regularity and frequency of a bowel Regularity and frequency of a bowel

movement vary from one person to another movement vary from one person to another

e.g. most adults pass one stool each day, e.g. most adults pass one stool each day,

others have more or less frequent bowel others have more or less frequent bowel

movements. movements.

�� Some persons have a bowel movement two Some persons have a bowel movement two

or three times a week, others as often as two or three times a week, others as often as two

or three times a day. or three times a day.

�� Some people may be used to have the bowel Some people may be used to have the bowel

movement after drinking morning coffee or movement after drinking morning coffee or

tea...or even having their breakfast. tea...or even having their breakfast.

�� Immediate response to a felt desire is Immediate response to a felt desire is

important in establishing regularity of habit.important in establishing regularity of habit.

�� Continues inhibitions of the desire to Continues inhibitions of the desire to

defecate will lead to chronic constipation.defecate will lead to chronic constipation.

Factors Influencing Fecal Elimination:Factors Influencing Fecal Elimination:

1.1. Diet:Diet:

�� It is one of the most important factors It is one of the most important factors

effecting changes in the secretion and effecting changes in the secretion and

motility of the alimentary canal.motility of the alimentary canal.

�� It also influences the type and amount of It also influences the type and amount of

bacteria entering the digestive system. This in bacteria entering the digestive system. This in

turn will affect the fecal characteristics.turn will affect the fecal characteristics.

Balanced food content with Balanced food content with

varied bulk is important to varied bulk is important to

the production of feces and the production of feces and its movement along the its movement along the

intestinal tract. Fluid intake intestinal tract. Fluid intake has to do with stool has to do with stool

consistency. consistency.

2.2. Psychological Factors:Psychological Factors:

In period of stressIn period of stress

caused by fear,caused by fear,

grief, or anger, grief, or anger,

or peristaltic activityor peristaltic activity

and muscle spasmsand muscle spasms

may increase ormay increase or

decrease, diarrhea, decrease, diarrhea,

or occasionally,or occasionally,

constipation may result.constipation may result.

AngerAnger

2.2. Psychological Factors:Psychological Factors:

Constipation isConstipation is

often secondaryoften secondary

to psychiatricto psychiatric

conditions (e.g.conditions (e.g.

depression, depression,

chronic psychoseschronic psychoses

, and anorexia nervosa)., and anorexia nervosa).

3.3. Physical Activity:Physical Activity:

�� Physical activity influences elimination Physical activity influences elimination

by promoting the development of muscle by promoting the development of muscle

tone as well as by stimulating appetite tone as well as by stimulating appetite

and peristalsis.and peristalsis.

�� Increased activity will stimulate the Increased activity will stimulate the

colon.colon.

3.3. Physical Activity Cont:Physical Activity Cont:

�� Immobility or sleep will depress the colon.Immobility or sleep will depress the colon.

�� Changes in posture, such as standing up, Changes in posture, such as standing up,

lying down, or sitting during a bowel lying down, or sitting during a bowel

movement influences ease of emptying the movement influences ease of emptying the

rectum.rectum.

4.4. Neutrogena Conditions:Neutrogena Conditions:

�� Neutrogena conditions caused by Neutrogena conditions caused by

traumatic lesions and organic diseases traumatic lesions and organic diseases

of the nervous system, such as multiple of the nervous system, such as multiple

sclerosis, brain and cord tumours, and sclerosis, brain and cord tumours, and

meningitis, frequently leave a person meningitis, frequently leave a person

with chronic constipation.with chronic constipation.

5.5. Muscular Condition:Muscular Condition:

�� Abdominal, pelvic, and diaphragmatic Abdominal, pelvic, and diaphragmatic

muscles play an important role in muscles play an important role in

initiating and completing defecation.initiating and completing defecation.

�� Injuries or other conditions affecting the Injuries or other conditions affecting the

strength of these muscles will therefore strength of these muscles will therefore

make evacuation difficult.make evacuation difficult.

�� Weakness from muscle atony may be Weakness from muscle atony may be

caused by laxative abuse or severe caused by laxative abuse or severe

malnutrition.malnutrition.

6.6. Mechanical Obstruction: Mechanical Obstruction:

�� Obstruction that results in an abnormal Obstruction that results in an abnormal

physical state of the bowel content may physical state of the bowel content may

retard propulsion and cause constipation or retard propulsion and cause constipation or

distension.distension.

�� Actual physical blockage or narrowing of Actual physical blockage or narrowing of

the intestine's interior may be caused by the intestine's interior may be caused by

neoplasm and inflammatory lesions.neoplasm and inflammatory lesions.

�� Haemorrhoids, fissures, and abscesses can Haemorrhoids, fissures, and abscesses can

inhibit voluntary muscle relaxation and inhibit voluntary muscle relaxation and

result in constipation.result in constipation.

7.7. Malabsorbation:Malabsorbation:

�� It is a common cause of diarrhoea, It is a common cause of diarrhoea,

may involve significant excess or may involve significant excess or

deficiency in intake of fat, protein, deficiency in intake of fat, protein,

carbohydrates, vitamins and carbohydrates, vitamins and

minerals. minerals.

8.8. Disease Conditions:Disease Conditions:

�� E.g. inflammatory disease caused by E.g. inflammatory disease caused by

pathogenic organisms such as salmonella, pathogenic organisms such as salmonella,

amoebas, and enter viruses, or by ulcerative amoebas, and enter viruses, or by ulcerative

colitis or by cathartics may produce colitis or by cathartics may produce

diarrhoea.diarrhoea.

9.9. Constipation may be Constipation may be

present in several present in several

disease conditions disease conditions

including carcinoma including carcinoma

of the large bowel, of the large bowel,

Hemorrhoids, and Hemorrhoids, and

fissure, and perineal fissure, and perineal

abscess.abscess.

9.9. Drugs:Drugs:

�� e.g. Constipation is e.g. Constipation is

often attributed.often attributed.

1)1) Constipation:Constipation:

The passage of unusually The passage of unusually

dry, hard stools produced dry, hard stools produced

by undue delay in the by undue delay in the

passage of feces. passage of feces.

Common Problems of Intestinal Common Problems of Intestinal Elimination:Elimination:

CausesCauses

�� Poor elimination habits. If the desire for Poor elimination habits. If the desire for

defecation is ignored repeatedly, the feces defecation is ignored repeatedly, the feces

become hard and dry because of increased become hard and dry because of increased

water absorption.water absorption.

�� Lack of sufficient roughage or bulk in diet.Lack of sufficient roughage or bulk in diet.

�� Lack of enough fluid intake.Lack of enough fluid intake.

�� Lack of muscle tone due to too much Lack of muscle tone due to too much

stimulation by irritating substances such as stimulation by irritating substances such as

laxatives.laxatives.

�� Emotional Tension may cause the Emotional Tension may cause the gastrointestinal tract to become spastic gastrointestinal tract to become spastic and fecal content is not moved along and fecal content is not moved along the large intestine sufficiently well.the large intestine sufficiently well.

�� Interference with normal reflexes Interference with normal reflexes because of pain associated with because of pain associated with defecation, e.g., piles, and fissure etcdefecation, e.g., piles, and fissure etc

�� Lack of essential vitamins such as Lack of essential vitamins such as vitamin B. group or mineral as vitamin B. group or mineral as potassium. potassium.

�� Lack of exercise:Lack of exercise:

oo Decreased peristaltic movement.Decreased peristaltic movement.

oo Loss of muscle tone.Loss of muscle tone.

�� Actual mechanical obstruction Actual mechanical obstruction

caused by compression of a mass caused by compression of a mass

e.g., tumor or edema of the e.g., tumor or edema of the

intestinal wall, hernia or fecal intestinal wall, hernia or fecal

impaction. impaction.

Assessment of Patient with ConstipationAssessment of Patient with Constipation

�� Passage of hard stools associated with a Passage of hard stools associated with a

decrease in the usual frequency of decrease in the usual frequency of

defecation.defecation.

�� Feeling of rectal fullness.Feeling of rectal fullness.

�� Abdominal distension (the abdomen feels Abdominal distension (the abdomen feels

hard upon palpation) caused by hard upon palpation) caused by

accumulation of fecal matter as well as accumulation of fecal matter as well as

gases.gases.

�� Complaints of tenesmus (frequent Complaints of tenesmus (frequent

painful straining in attempts to painful straining in attempts to

defecate ).defecate ).

�� General symptoms: e.g. headache, General symptoms: e.g. headache,

malaise, anorexia, and bad breath. malaise, anorexia, and bad breath.

Nursing Management of ConstipationNursing Management of Constipation

�� Provide adequate fluid intake 500 Provide adequate fluid intake 500 -- 2000 2000 cc/day.cc/day.

�� Provide a wellProvide a well--balanced diet with enough balanced diet with enough roughage from fruits and vegetables and roughage from fruits and vegetables and vitamins.vitamins.

�� Encourage regularity of time for defecation Encourage regularity of time for defecation and prompt response to the desire of and prompt response to the desire of defecation.defecation.

�� Encourage regularity of meal's time.Encourage regularity of meal's time.

Provide adequate time for complete Provide adequate time for complete evacuation.evacuation.

Provide privacy for patients to promote Provide privacy for patients to promote relaxation.relaxation.

Provide posture (position) as close to normal Provide posture (position) as close to normal as possible.as possible.

Provide physical and emotional comfort and Provide physical and emotional comfort and alleviation of pain.alleviation of pain.

Provide physical exercises especially for Provide physical exercises especially for abdominal muscles.abdominal muscles.

Consider the patient's habit in relation to Consider the patient's habit in relation to defecation. defecation.

Prevention of ConstipationPrevention of Constipation

�� Encourage exercise as walking.Encourage exercise as walking.

�� Avoid excessive emotional stress.Avoid excessive emotional stress.

�� Establish regularity of meals and defecation Establish regularity of meals and defecation

time.time.

�� Discourage unnecessary use of laxatives.Discourage unnecessary use of laxatives.

�� Intake of proper diet containing enough Intake of proper diet containing enough

vegetables and vitamins.vegetables and vitamins.

�� Intake of sufficient fluids per day.Intake of sufficient fluids per day.

2.2. Fecal Impaction:Fecal Impaction:

DefinitionDefinition

A prolonged retention or an A prolonged retention or an accumulation of fecal material which accumulation of fecal material which forms a hardened mass in the rectum, it forms a hardened mass in the rectum, it may be of sufficient size to prevent the may be of sufficient size to prevent the passage of normal stools. (fig: 2) passage of normal stools. (fig: 2)

Signs and SymptomsSigns and Symptoms

�� Distended abdomen (hand upon palpation Distended abdomen (hand upon palpation

and feels rigid).and feels rigid).

�� Rectal pain due to pressure of the fecal Rectal pain due to pressure of the fecal

mass. mass.

�� Passage of small amount of liquid stool due Passage of small amount of liquid stool due

to mechanical irritation of the rectum.to mechanical irritation of the rectum.

Causes Causes

�� Prolonged constipation and poor habits of Prolonged constipation and poor habits of

defecation.defecation.

�� Prolonged bed rest, vary in paralyzed or Prolonged bed rest, vary in paralyzed or

unconscious patients.unconscious patients.

�� Prolonged use of antiProlonged use of anti--diarrheas drugs.diarrheas drugs.

�� Following administration of Barium for xFollowing administration of Barium for x--

ray examination of the G.I.T.ray examination of the G.I.T.

Nursing ManagementNursing Management

�� Administration of mineral oil by mouth Administration of mineral oil by mouth especially in cases of prolonged especially in cases of prolonged constipation for regulation of habits.constipation for regulation of habits.

�� Oil retention enema followed by cleansing Oil retention enema followed by cleansing enema.enema.

�� Digital manipulation of the fecal mass Digital manipulation of the fecal mass should be under physician order or should be under physician order or supervision because it can stimulate vague supervision because it can stimulate vague nerve in the rectal wall which can slow nerve in the rectal wall which can slow patient's heart leading to cardiac patient's heart leading to cardiac arrhythmia, so observe patient's pulse rate, arrhythmia, so observe patient's pulse rate, facial pallor and diaphoresis during facial pallor and diaphoresis during manipulationmanipulation. .

PreventionPrevention

�� Careful observation of the patient's Careful observation of the patient's

bowel movements in terms of bowel movements in terms of amount, consistency, and frequency.amount, consistency, and frequency.

�� Prevention of constipation.Prevention of constipation.

�� Special attention to patients who Special attention to patients who

received barium for xreceived barium for x--ray of the G.I.T ray of the G.I.T

EnemasEnemas

Are fluid solutions introduced into the Are fluid solutions introduced into the

rectum and colon.rectum and colon.

The most common reason for giving The most common reason for giving

enemas is to stimulate the urge to defecate. enemas is to stimulate the urge to defecate.

PurposePurpose

�� To empty the rectum and the lower colon To empty the rectum and the lower colon

when constipation is present.when constipation is present.

�� To relieve gas from colon and rectum.To relieve gas from colon and rectum.

�� To provide nutrients for a patient who To provide nutrients for a patient who

cannot take food orally.cannot take food orally.

PurposePurpose

�� To administer medications.To administer medications.

�� PrePre--operative, especially in intestinal tract operative, especially in intestinal tract

operations to remove fecal.operations to remove fecal.

�� To soothe irritated intestinal wall. In To soothe irritated intestinal wall. In

diagnosis e.g. Barium enemadiagnosis e.g. Barium enema..

3)3) Intestinal Distension (tympanitis):Intestinal Distension (tympanitis):

DefinitionDefinition

Excessive formation and accumulation Excessive formation and accumulation

of gases in the intestines of gases in the intestines

CausesCauses

�� Excessive intake of gas forming foods.Excessive intake of gas forming foods.

�� Prolonged constipation or impaction.Prolonged constipation or impaction.

�� Inability of the small intestines to expel Inability of the small intestines to expel

gases due to weakness e.g., in postgases due to weakness e.g., in post--

operative periods after abdominal surgery.operative periods after abdominal surgery.

CausesCauses

�� Lack of exercise and prolonged" bedLack of exercise and prolonged" bed--rest.rest.

�� Drugs which slow down the intestinal Drugs which slow down the intestinal

peristalsis such as sedatives and peristalsis such as sedatives and

tranquilizers.tranquilizers.

�� Swallowing large amount of air while Swallowing large amount of air while

eating or drink or tube feeding (in very old eating or drink or tube feeding (in very old

and children).and children).

Signs and SymptomsSigns and Symptoms

�� Distended abdomen that gives a drum like Distended abdomen that gives a drum like

sounds upon percussion.sounds upon percussion.

�� Colicky pain that is generalized in the Colicky pain that is generalized in the

abdomen. abdomen.

�� Shortness of breath and Shortness of breath and dyspneadyspnea may result may result

if distention causes pressure on the if distention causes pressure on the

diaphragm and the thoracic cavity, (e.g. diaphragm and the thoracic cavity, (e.g.

bedridden patients).bedridden patients).

Nursing InterventionNursing Intervention

�� Prevention of the cause.Prevention of the cause.

�� Encourage exercises in bed or ambulate Encourage exercises in bed or ambulate

patients for short walk.patients for short walk.

�� Avoid gas forming foods.Avoid gas forming foods.

4)4) Diarrhoea:Diarrhoea:

DefinitionDefinition

The passage of loose, watery stool and an The passage of loose, watery stool and an

increase in the frequency of bowel increase in the frequency of bowel

movements, diarrhea may or may not be movements, diarrhea may or may not be

accompanies by abdominal cramping.accompanies by abdominal cramping.

CausesCauses

Due to several causes either organic disease Due to several causes either organic disease

or psychic factors:or psychic factors:

Signs and symptomsSigns and symptoms

�� Generalized abdominal pain which is Generalized abdominal pain which is

spasmodic in nature due to strong spasmodic in nature due to strong

peristaltic action. peristaltic action.

�� Pains are accompanied by feeling of Pains are accompanied by feeling of

urgency in the need to defecate. urgency in the need to defecate.

�� Complaints of Complaints of tenesmustenesmus and may pass a and may pass a

small watery discharge. small watery discharge.

Increase in the frequency in the Increase in the frequency in the

number of stool (stool is watery in number of stool (stool is watery in

nature). nature).

Signs and symptoms of dehydration Signs and symptoms of dehydration

my occur if diarrhea is very severs or my occur if diarrhea is very severs or

over a long time such as: poor skin over a long time such as: poor skin

turgorturgor, thirst, and acute weight loss. , thirst, and acute weight loss.

General weakness and general General weakness and general

malaise. malaise.

There may be nausea, vomiting, There may be nausea, vomiting,

Nursing care of patients with diarrheaNursing care of patients with diarrhea

�� Assessment and observation of the patient, Assessment and observation of the patient,

this includes:this includes:

�� Assessment of the stool in terms of Assessment of the stool in terms of

frequency, consistency, odor and presence frequency, consistency, odor and presence

of foreign matter as mucous, pus, blood or of foreign matter as mucous, pus, blood or

undigested food.undigested food.

�� Observation of the patient for signs and Observation of the patient for signs and

symptoms of the dehydration and symptoms of the dehydration and

electrolyte loss. With diarrhea there is acute electrolyte loss. With diarrhea there is acute

loss of potassium and sodium chloride. loss of potassium and sodium chloride.

Diet: Provision of proper diet for Diet: Provision of proper diet for

maintenance of proper nutrition.maintenance of proper nutrition.

•• Diet free from roughage. Diet free from roughage.

•• Rich in liquids. Rich in liquids.

•• Free from irritants and low in fat. Free from irritants and low in fat.

•• Rich in proteins such as white meat Rich in proteins such as white meat

boiled chicken and other. boiled chicken and other.

If diarrhea is psychogenic, provide for If diarrhea is psychogenic, provide for psychological comfort and relaxation.psychological comfort and relaxation.

•• Assist the patient to identify the causes Assist the patient to identify the causes and act upon it.and act upon it.

Provide for physical comfort and Provide for physical comfort and hygienic care.hygienic care.

•• Local irritation of the anal and region Local irritation of the anal and region is common. Careful washing and is common. Careful washing and drying after each movement is drying after each movement is necessary.necessary.

•• Medicated creams will help prevent Medicated creams will help prevent skin irritation, e.g., Zink oxide.skin irritation, e.g., Zink oxide.

Patient's clothes and bed linen must Patient's clothes and bed linen must

be dry and clean.be dry and clean.

If diarrhea is due to infection, If diarrhea is due to infection,

isolation technique must be followed:isolation technique must be followed:

•• Stool should be disinfected Stool should be disinfected

immediately before being discarded.immediately before being discarded.

( N.B: All diarrheas should be ( N.B: All diarrheas should be

considered infectious until proved).considered infectious until proved).

6)6) Anal Incontinence: Anal Incontinence:

DefinitionDefinition

�� Inability of the Inability of the aoaspomaeraoaspomaer to control the to control the

discharge offers, i.e. loss of voluntary discharge offers, i.e. loss of voluntary

control over the act of defecation.control over the act of defecation.

CausesCauses

�� Organic diseases causing weakness of the Organic diseases causing weakness of the

anal sphincter.anal sphincter.

�� Impingent in the nerve supply to the anal Impingent in the nerve supply to the anal

sphincter.sphincter.

(i.e. relaxed external sphincter). (i.e. relaxed external sphincter).

Nursing careNursing care

�� Supportive and encouraging attitude by the Supportive and encouraging attitude by the

nurse should be initiated to eliminate nurse should be initiated to eliminate

embarrassment due to incontinence.embarrassment due to incontinence.

�� Special nursing care to prevent bad odor, Special nursing care to prevent bad odor,

skin irritation and bed sores.skin irritation and bed sores.

�� Patient's clothing and bedding should be Patient's clothing and bedding should be

changed whenever necessary.changed whenever necessary.

Reasons to Treat PainReasons to Treat Pain

It is the human thing to do

Ethical, moral, and legal obligation

Unrelieved pain causes unnecessary harm and suffering

Pain diminishes activity, appetite, sleep, and quality of life

Pain further debilitates already weakened patients

Goals of Pain ControlGoals of Pain Control

Enhance quality of life

Maintain autonomy, dignity, emotional, and cognitive capacity

Control depression and anxiety related to poorly controlled pain

Preservation of function and rehab potential

PAINPAIN

The patient’s self report is the Gold Standard of measurement

The Clinician must accept the patient’s report of pain

Painful FactsPainful Facts

Pain affects more Americans than DM, heart Pain affects more Americans than DM, heart disease & cancer combineddisease & cancer combined

75 million people today have severe disabling 75 million people today have severe disabling persistent pain another 25 million experience acute persistent pain another 25 million experience acute pain each year pain each year

Pain is the number one reason people seek Pain is the number one reason people seek healthcare, but only 1 in 4 receive adequate pain healthcare, but only 1 in 4 receive adequate pain treatment treatment

Over 75% of cancer patients experience moderate Over 75% of cancer patients experience moderate to severe painto severe pain--Less than half get pain reliefLess than half get pain relief

Obstacles to Successful Pain Obstacles to Successful Pain Management : Health Care ProviderManagement : Health Care Provider

Lack of knowledge (ignorance) or understanding of pain physiology & management

Lack of or inadequate assessment

Under treatment

Obstacles to Successful Pain Obstacles to Successful Pain Management : Health Care ProviderManagement : Health Care Provider

Inadequate knowledge of medications or other treatment options

Fear of addiction

Legal barriers-regulatory scrutiny

False judgment of patient

Mild pain(0-3)

Moderate pain(4-6)

Severe pain(7-10)

By the mouth

By the clockBy the ladder

Acetaminophen

Codeine

Morphine

WHO pain ladder

Tolerance & DependenceTolerance & Dependence

Tolerance-Physical Phenomenon

-Expected neuroadaptation to

continuous opioid use

–Effectiveness/duration of analgesia is reduced over time therefore higher doses are needed

– In long term therapy the need for escalation of drugs usually slows & then trends downward

Physical DependencePhysical DependenceDependenceDependence--Physical PhenomenonPhysical Phenomenon

-Natural adaptation of the body to

prolonged use of drug

-Abstinence syndrome develops if drug is

withdrawn sharply or if antagonist added

-Difficulties avoided through proper

management-taper doses before

discontinuing drug, do not co-administer

antagonist or agonist antagonist drugs

Obstacles to Successful Pain Obstacles to Successful Pain Management : Health Care ProviderManagement : Health Care Provider

Concerns about opioids:

Addiction: hallmark of addiction is using despite harm to self and others

Respiratory depression: “No patient has succumbed to respiratory depression while awake.” (APS), 1999)

Sedation: precedes respiratory depression; therefore sedation is a vital component of monitoring and assessment of patients with PCA.” (Hagle et al, 2004)

Increased morbidity and mortality

Unrelieved pain causes a stress response which initiates a cascade of events

Increased catabolic demand; poor wound healing, weakness, and muscle breakdown

PHYSIOLOGIC EFFECTS OF PAINPHYSIOLOGIC EFFECTS OF PAIN

PSYCHOLOGICPSYCHOLOGIC EFFECTS OF EFFECTS OF PAINPAIN

Negative emotions: anxiety, fear, hopelessness, and depressionSleep deprivationExistential suffering: may lead to patients seeking end of lifeDecreased quality of lifeDecreased coping skills

Assessment Facts & Assessment Facts & Considerations:Considerations:

The general goals of pain management include prevention and reduction of pain, improvement in function, improvement in mood and sleep patterns, and anticipation and treatment of side effects.

Assessment Facts & Assessment Facts & Considerations:Considerations:

Pain management goals do not include reducing the analgesic dose to as low a level as possible….

the dose that relieves the patient’s pain and allows them to meet their goals is the appropriate dose

What causes pain in the person What causes pain in the person with cancer?with cancer?

Tumor involvementTumor involvementTreatmentTreatment--relatedrelatedUnrelated to cancerUnrelated to cancer

American Medical Association. Pain Management Part 4: Cancer Pain and End-of-Life Care, December 2003; p 6-9.

Pain may be acute, persistent or intermittentPain may be nociceptive, neuropathic or mixed

Factors Influencing Pain Severity1,2Factors Influencing Pain Severity1,2

Type of CancerType of Cancer

Stage of DiseaseStage of Disease

Cancer TherapyCancer Therapy

Pain ThresholdPain Threshold

1American Medical Association. Pain Management Module 10: Overview and Assessment of Cancer Pain. December 2005.2National Cancer Institute. Pain, modified 1/23/07; p 5-8.

Antineoplastic TherapyAntineoplastic Therapy

SurgerySurgery

ChemotherapyChemotherapy

RadiotherapyRadiotherapy

Biological TherapiesBiological Therapies

Combination TherapyCombination Therapy

National Cancer Institute. Cancer topics. Available at: http://cancer.gov/cancerinfo. Accessed 3-7-07.

Evaluate Pain Mechanism To Evaluate Pain Mechanism To Determine Treatment OptionsDetermine Treatment Options

Follow the example of auscultation

* Know what to listen for

*Appreciate the significance of what

you hear

* Develop appropriate treatment plan

* Listen for changes in report

Is it to diagnose and eliminate the pain by removing the source?

Is it palliative? A plan to improve comfort and quality of life?

The first step in the assessment of pain The first step in the assessment of pain is to determine the goal of treatmentis to determine the goal of treatment

Pain TypesPain Types

Breakthrough

Chronic

Neuropathic Acute

Referred

Visceral

Somatic

Types

Pain Quality Pain Quality

Nocioceptive

Somatic

LocalizedThrobbing

AchingSoreSharp

Stabbing

Visceral

DeepCrampingReferredAching

Gnawing

Pain QualityPain Quality

Neuropathic

Central Peripheral

BurningPiercingElectric Pricking

NumbSharp

Pain AssessmentPain Assessment

Remember, pain ratings above 3 significantly

interfere with activity and mood; above 5 interfere with quality of life.

OLD CARTOLD CART

O= OnsetO= Onset - When did the pain start? How often does it occur? Has its intensity changed?

L= LocationL= Location – Where is your pain? Does it radiate or travel to other sites? Touch where your pain is. (There may be multiple sites)

PAIN ASSESSMENT (Cont.)PAIN ASSESSMENT (Cont.)

D= DurationD= Duration - How long does the pain last? Is it constant? Is it intermittent?

C= CharacteristicsC= Characteristics –– What words What words describe your pain? What does your describe your pain? What does your pain feel like? 0pain feel like? 0--10; Quality?10; Quality?

NeuropathicNeuropathic or nerve (sharp, or nerve (sharp, shooting, burning, electrical) shooting, burning, electrical)

NociceptiveNociceptive Somatic (dull, aching); Somatic (dull, aching); Visceral (cramping, squeezing) Visceral (cramping, squeezing)

PAIN ASSESSMENT: (Cont.)PAIN ASSESSMENT: (Cont.)

A= Aggravating FactorsA= Aggravating Factors – What makes your pain worse? (Moving, Walking, Sitting, Turning, Chewing, Breathing, Defecating, Urinating, Swallowing,

R= Relieving FactorsR= Relieving Factors - What makes pain better? What medical and non-medical interventions relieve the pain?

Pain Assessment: (Cont.)Pain Assessment: (Cont.)

T=TreatmentT=Treatment – Medications –What meds have you tried for your pain?-Current pain management regimen?

****Past medication use ACTUALPast medication use ACTUAL

Nonpharmacological interventions (e.g., heat cold massage, distraction, etc)

Number versus FunctionNumber versus Function

On a On a scale of 0 scale of 0 --1010, with 0 being no , with 0 being no

pain and 10 being the worst pain you pain and 10 being the worst pain you

can imagine, how would you rate your can imagine, how would you rate your

pain pain right nowright now??

How would you rate it at itHow would you rate it at it’’s s worstworst? ?

How would you rate it at itHow would you rate it at it’’s s besbestt? ?

When was it When was it best controlledbest controlled??

Was your Was your goagoall pain score?pain score?

Evaluation of PainEvaluation of Pain

Simple Descriptive ScaleSimple Descriptive Scale

Numeric ScaleNumeric Scale

Visual Analog ScaleVisual Analog Scale

1100 22 33 44 55 66 77 88 99 1010

no painno pain worst painworst pain

nonenone mildmild moderatemoderate severesevere v severev severe worstworst

Psychosocial AssessmentPsychosocial Assessment

Effect of pain on patient, family, caregivers, and other significant relationships

Financial impact of pain and treatment

Patient’s usual coping response

Mood changes

Preference of pain method management

Psychosocial AssessmentPsychosocial Assessment

How does the pain affect your physical and social function?

How does the pain impact sleep, mood, or activities?

Meaning of pain to patient

Non-verbal clues

Psychosocial Assessment Psychosocial Assessment

(cont.)(cont.)

Effect and understanding of diagnosis/treatment on patient and caregiver

Past experiences with pain and patient’s interpretation

Patient and family member’s concerns about use of opioids or controlled substances

Intubated and/or unconscious Intubated and/or unconscious

personspersons

Self report limited by:Self report limited by:

–– DeliriumDelirium

–– Cognitive and communication limitationsCognitive and communication limitations

–– Level of consciousnessLevel of consciousness

–– Presence of an endotracheal tubePresence of an endotracheal tube

–– SedativesSedatives

–– Neuromuscular blocking agentsNeuromuscular blocking agents

Intubated and/or unconscious Intubated and/or unconscious

personspersons

Existing medical conditionExisting medical condition

Traumatic injuriesTraumatic injuries

Surgical/medical proceduresSurgical/medical procedures

Invasive instrumentationInvasive instrumentation

Blood drawsBlood draws

Routine care such as suctioning, Routine care such as suctioning,

turning, positioning, drain and turning, positioning, drain and

catheter removal, and wound carecatheter removal, and wound care

Intubated and/or unconscious Intubated and/or unconscious

personspersonsFacial tension Facial tension

GrimacingGrimacing

FrowningFrowning

Wincing Wincing

Physical movementPhysical movement

ImmobilityImmobility

Increased muscle toneIncreased muscle tone

Tearing and diaphoresis in the sedated Tearing and diaphoresis in the sedated paralyzed and ventilated patient represents paralyzed and ventilated patient represents autonomic responses to discomfort autonomic responses to discomfort

Ongoing Pain AssessmentOngoing Pain Assessment

At regular intervals after initiation of At regular intervals after initiation of

the treatment planthe treatment plan

With each new report of painWith each new report of pain

At a suitable interval after each At a suitable interval after each

pharmacologic or nonpharmacologic pharmacologic or nonpharmacologic

interventionintervention

Continue or alter drug therapy based Continue or alter drug therapy based

on assessment findings and treatment on assessment findings and treatment

planplan

Pain should be assessed and documented:

Joint Commission. Assessment of persons with pain. In: Joint Commission, ed. Pain Assessment and Management: an organizational approach. Oakbrook Terrance, IL: Joint Commission; 2000: 13-25.

Nonpharmacologic InterventionsNonpharmacologic Interventions

Physical ModalitiesPhysical Modalities–– Physical Therapy / ExercisePhysical Therapy / Exercise–– AcupunctureAcupuncturePsychosocial ModalitiesPsychosocial Modalities–– Relaxation and imageryRelaxation and imagery–– DistractionDistraction–– EducationEducation–– Counseling and/or support groupsCounseling and/or support groups–– HypnosisHypnosis

PharmacologicPharmacologic InterventionsInterventions

AcetaminophenAcetaminophen

Nonsteroidal antiNonsteroidal anti--inflammatory drugs inflammatory drugs (NSAIDs)(NSAIDs)

AntidepressantsAntidepressants

AnticonvulsantsAnticonvulsants

Topical anestheticsTopical anesthetics

OpioidsOpioids

MedicationsMedications

May require increasing doses due to May require increasing doses due to tolerancetolerance-- NOT addictionNOT addiction

May need to use more than one type of May need to use more than one type of pain medication pain medication

LongLong--acting medicationsacting medications

Breakthrough medicationsBreakthrough medications

Opioid DosingOpioid Dosing

Breakthrough dose should be 10Breakthrough dose should be 10--15% 15%

of 24 Hour long acting doseof 24 Hour long acting dose

To titrate opioid, increase by at least To titrate opioid, increase by at least

50% or calculate the amount of 50% or calculate the amount of

breakthrough doses given and add to breakthrough doses given and add to

the 24H dosethe 24H dose

Although all Although all Clinical Pearl: Clinical Pearl: opioids are opioids are ““equivalentequivalent”” at at

equianalgesic doses, there is equianalgesic doses, there is significant intersignificant inter--patient patient

variability.variability.

If appropriate dose escalations If appropriate dose escalations pain control, it pain control, it inadequateinadequateyield yield

is logical to SWITCH to a is logical to SWITCH to a different opioid!different opioid!

Common MistakesCommon Mistakes

TransdermalTransdermal Fentanyl Fentanyl

Withdrawal SyndromeWithdrawal Syndrome

Medication reconciliationMedication reconciliation

OverdoseOverdose

Under dose opioidUnder dose opioid

Concurrent use of two long acting agentsConcurrent use of two long acting agents

Managing Side EffectsManaging Side Effects

ConstipationConstipation-- never develop a tolerance never develop a tolerance

NauseaNausea

DrowsinessDrowsiness

ItchingItching

OthersOthers

PLANPLAN

Develop a multimodal plan involving client Develop a multimodal plan involving client in all areas. Educate client.in all areas. Educate client.

Give the client a sense of control in pain Give the client a sense of control in pain management. Educate client.management. Educate client.

Consider financial status/ reimbursementConsider financial status/ reimbursement

for pain medication prescriptions. Educate for pain medication prescriptions. Educate

client. client.