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)


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)


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)


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


OOrthopedic Insultrthopedic Insult

Casts, TractionCasts, Traction

Pain with movementPain with movement

Assistive devicesAssistive devices

Other diseases Other diseases


OOpen Door Policypen Door Policy

↓ ↓ Privacy – visitation policyPrivacy – visitation policy

Bathroom vs. CommodeBathroom vs. Commode

Disruption of RoutineDisruption of Routine TherapyTherapy

Tests/SurgeryTests/Surgery


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

Bowel Elimination Assessment and Intervention July 17, 2008 Mary Sokolowski, BSN, RN, CEN.

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