Bowel Elimination Assessment and Intervention July 17, 2008 Mary Sokolowski, BSN, RN, CEN.
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Transcript of Bowel Elimination Assessment and Intervention July 17, 2008 Mary Sokolowski, BSN, RN, CEN.
Bowel Bowel EliminationElimination
Assessment and Assessment and InterventionIntervention
July 17, 2008July 17, 2008
Mary Sokolowski, BSN, RN, CENMary Sokolowski, BSN, RN, CEN
Objectives:Objectives:
Describe the normal physiology of Describe the normal physiology of bowel eliminationbowel elimination
Recognize causes of constipation Recognize causes of constipation
Discuss assessment and Discuss assessment and interventions to achieve nursing interventions to achieve nursing outcomes for bowel eliminationoutcomes for bowel elimination
Physiology – Bowel Physiology – Bowel EliminationElimination
GI MotilityGI Motility Enzyme breakdownEnzyme breakdown PeristalsisPeristalsis Gastrocolic ReflexGastrocolic Reflex
Mucosal TransportMucosal Transport Fluids & ElectrolytesFluids & Electrolytes WasteWaste(Bisanz, 2007)(Bisanz, 2007)
Physiology – Bowel Physiology – Bowel EliminationElimination
Defecation ReflexDefecation Reflex SphinctersSphincters CNS ImpulsesCNS Impulses Rectal DistentionRectal Distention Mechanical AssistanceMechanical Assistance
Anal Sphincter MusclesAnal Sphincter Muscles(Bisanz, 2007)(Bisanz, 2007)
ResearchResearch
Review of the LiteratureReview of the LiteraturePositives:Positives:
Bowel Management/Keys to Bowel Management/Keys to SuccessSuccess (Cadd et al., 2000; Weeks, Hubbartt, & Michaels, 2000)(Cadd et al., 2000; Weeks, Hubbartt, & Michaels, 2000)
Problems:Problems:ConstipationConstipation
(Hicks, 2001; Hinrichs, Huseboe, Tang, & Titler, 2001; George, Hayward, (Hicks, 2001; Hinrichs, Huseboe, Tang, & Titler, 2001; George, Hayward, Lowe, &Lowe, &
Page, 1996;Grieve, 2006; Bisanz, 2007; Heitkemper & Wolff, 2007)Page, 1996;Grieve, 2006; Bisanz, 2007; Heitkemper & Wolff, 2007)
Bowel Problem/Risk ManagementBowel Problem/Risk Management (Salcido, 2000; Zernike & Henderson, 1999)(Salcido, 2000; Zernike & Henderson, 1999)
Characteristics – Bowel Characteristics – Bowel EliminationElimination
FrequencyFrequency
QuantityQuantity
QualityQuality
ConsistencyConsistency
Ease of PassageEase of Passage
Tools for StoolsTools for Stools
Bristol Stool ScaleBristol Stool Scale
Constipation Scoring System http://www.ncbi.nlm.nih.gov/pubmed/864957
http:// en.wikpedia.org./wiki/Bristol_stool_Chart
Precursors – Normal BMPrecursors – Normal BM
Good HealthGood HealthIntact CNSIntact CNSLess medicationsLess medicationsGood oral hygiene/denturesGood oral hygiene/dentures
Regular Exercise/Movement Good muscle tone Stimulates appetite(Weeks, Hubbartt, & Michaels, 2000)
Precursors – Normal BMPrecursors – Normal BM
Fiber:Fiber:Action: soft, bulky stoolsAction: soft, bulky stools
Types: plant foodTypes: plant food
Insoluble – wheat bran, Insoluble – wheat bran, vegetablesvegetables
Soluble – oat bran, barley, beans, Soluble – oat bran, barley, beans, fruitfruit
(Weeks, Hubbartt, & Michaels, 2000)(Weeks, Hubbartt, & Michaels, 2000)
Power puddingPower pudding
Amount: > 15-20 gms/dayAmount: > 15-20 gms/day (Hinrichs, Huseboe, Tang, & Titler, 2001)(Hinrichs, Huseboe, Tang, & Titler, 2001)
Precursors – Normal BMPrecursors – Normal BM
FluidsFluidsAction: combines with fiber – Action: combines with fiber – moves stoolmoves stool
Types: Types:
WaterWater
JuicesJuices
Decaffeinated beveragesDecaffeinated beverages
Amount: > 1500 cc/dayAmount: > 1500 cc/day (Weeks, Hubbartt, & Michaels, 2000)(Weeks, Hubbartt, & Michaels, 2000)
Precursors – Normal BMPrecursors – Normal BM
TimingTimingIndividual patternIndividual patternGastrocolic reflex – strongest after Gastrocolic reflex – strongest after mealsmeals
(Hinrichs, Huseboe, Tang, & Titler, 2001)(Hinrichs, Huseboe, Tang, & Titler, 2001)
RegimeRegimePositioningPositioning
(Kacmaz & Kasikci, 2007)(Kacmaz & Kasikci, 2007)
PrivacyPrivacy (Weeks, Hubbartt, & Michaels, 2000)(Weeks, Hubbartt, & Michaels, 2000)
ConstipationConstipation
When in Rome . . . When in Rome . . .
Rome III Criteria: ConstipationStrainingLumpy hard stoolIncomplete
evacuation/ManeuversLess than 3 BM’s/week
(Heitkemper & Wolff, 2007)
CONSTIPATIONCONSTIPATION
Definition: decreased normal Definition: decreased normal frequency of defecation frequency of defecation accompanied by difficult or accompanied by difficult or incomplete passage of incomplete passage of excessively dry stoolexcessively dry stool
(Wilkinson, J.M., 2005)(Wilkinson, J.M., 2005)
Causes - ConstipationCauses - Constipation
PPoor Intakeoor IntakeFluidsFluids
NPO – tests, surgeryNPO – tests, surgeryChoices – juice, waterChoices – juice, waterPositioningPositioning
Fiber Menu choices – fresh fruit, whole
grains
Causes - ConstipationCauses - Constipation
OOrthopedic Insultrthopedic Insult
Casts, TractionCasts, Traction
Pain with movementPain with movement
Assistive devicesAssistive devices
Other diseases Other diseases
Causes - ConstipationCauses - Constipation
OOpen Door Policypen Door Policy
↓ ↓ Privacy – visitation policyPrivacy – visitation policy
Bathroom vs. CommodeBathroom vs. Commode
Disruption of RoutineDisruption of Routine TherapyTherapy
Tests/SurgeryTests/Surgery
Causes - ConstipationCauses - Constipation
PPain Medicationsain MedicationsOpiates – P.O. or PCAOpiates – P.O. or PCA
Other medicationsOther medications Antacids with aluminum, Antacids with aluminum, anticholinergics,anticholinergics, calcium channel blockers, calcium channel blockers, phenothiazines,phenothiazines,
diuretics, sedatives, etc.diuretics, sedatives, etc. (Hinrichs, Huseboe, Tang, & Titler, 2001)(Hinrichs, Huseboe, Tang, & Titler, 2001)
Laxatives (+/-)Laxatives (+/-)
Last resort:Last resort:
Bulk-forming →Bulk-forming →Stool softeners → Stool softeners →
Osmotic Laxatives →Osmotic Laxatives →Stimulants →Stimulants →
Suppository/Suppository/EnemaEnema
(Hinrichs, Huseboe, (Hinrichs, Huseboe, Tang, & Titler, 2001)Tang, & Titler, 2001)
AssessmentAssessment
AUDITS: AUDITS: DiagnosisDiagnosisPostoperative DayPostoperative DayMedications +/-Medications +/-Bowel Movement RecordedBowel Movement Recorded
INTERVIEWS: INTERVIEWS: NursesNursesLeadershipLeadershipPatientsPatients
Interventional ToolInterventional Tool
Pictorial DiaryPictorial DiaryFluids – 8 servingsFluids – 8 servingsWhole grains – 3 servingsWhole grains – 3 servingsFruits/vegetables – 5 servingsFruits/vegetables – 5 servingsExercise – 3-4 x/dayExercise – 3-4 x/day
Bowel Movement - recordBowel Movement - record
Interventional ToolInterventional Tool
Bowel Elimination Tool (BET)Bowel Elimination Tool (BET)
Interventional ToolInterventional ToolDirections:Directions:
Mark your selections with an X
Choose: 8 Glasses of Fluid: Best: Water or Juices; Decaffeinated drinks 3 Servings of Whole grain breads or cereal: Best: Whole wheat, oatmeal, bran cereals 5 Servings of Fruits or Vegetables: Best: Fresh fruits, vegetables with skin Exercise – 3-4 times per day Best: Walking, physical therapy,
or exercises in bed
Record your BM Difficult___ Easy___
Soft___ Hard___ Complete__
Nursing OutcomesNursing Outcomes
1) Cooperates for Bowel 1) Cooperates for Bowel ManagementManagementPPartners for care – uses toolartners for care – uses tool
OOut of bed/ exercises – 3-4 x dayut of bed/ exercises – 3-4 x day
OOverview of dietverview of diet
>15 gm fiber; >1500 cc fluids>15 gm fiber; >1500 cc fluids
PPrivacy and respect – toileting rivacy and respect – toileting regimeregime
(Moorhead, 2008)(Moorhead, 2008)
Nursing OutcomesNursing Outcomes
2) Constipation alleviated as 2) Constipation alleviated as indicated:indicated:
Elimination pattern in expected Elimination pattern in expected rangerange
Stool soft and formed (soft/hard)Stool soft and formed (soft/hard)Stool easy to pass (easy/difficult)Stool easy to pass (easy/difficult)Amount adequate for diet (yes/no)Amount adequate for diet (yes/no)Feeling of evacuation (yes/no)Feeling of evacuation (yes/no)
(Moorhead, 2008)(Moorhead, 2008)
Implications for PracticeImplications for Practice
AssessmentAssessment
PreventionPrevention
Partners with patientsPartners with patients
Nursing performance Nursing performance improvementimprovement