Transcript Nursing Fundamentals Bowel Elimination Pgs 684-702 &

Nursing Fundamentals
Bowel Elimination
Pgs 684-702
&
Chapter 29 G.I. Intubation
Measures to promote bowel
elimination
• Nurses use 2 interventions:
• 1. Suppositories
• 2. enemas
Suppository
• Oval or cone shaped mass of medication
that melts at body temperature
Local effects of suppositories
• LOCAL EFFECTS – include
administering the suppository and it
lubricating and softening dry stool. The
supp. Irritates the wall of the rectum and
anal canal and stimulates smooth muscle
contraction to increase rectal distention and
increasing the urge to defecate
Systemic Effects of Suppositories
• Systemic Effects - These are taken by
mouth where they work internally to
increase motor activity in the G.I. Tract to
cause defecation
Administering Enemas
•
•
•
•
•
•
•
An enema introduces a solution into the rectum to:
Cleanse the lower bowel (most common use)
To soften feces
To expel flatus
To sooth irritated mucous membranes
To outline the colon during diagnostic x-rays
To treat worm and parasite infestations (antihelminth – remember in ch 5 Disease?)
Cleansing Enemas
• Are used to cleanse the lower bowel before
a procedure or surgery or for constipation
• With a cleansing enema, defecation should
occur within 15-20 minutes after
administration
Cleansing Enemas
• Usually involves large volumes of liquid
entering the lower bowel causing distention
or cramping
• Nurse must administer these slowly as to
not rupture the bowel
Types of cleansing enemas
• Tap water and normal saline enemas
• Soap solution enema
• Hypertonic saline enema
• Keep these in for 15-20 minutes, then expel
Types of retaining enemas
• Sometimes oil enemas
• Always foam enemas like the steroid types
• Keep these in for 30 minutes then expel
except the foam enemas usually dissolve in
the instestin and nothing comes out
Tap Water and Normal Saline
Enema
• These are preferred due to the less amount
of irritation that these have
• Tap water and saline enemas have the same
degree of effectiveness for cleansing the
bowel
Problems with Tap water enemas
• Because tap water is hypotonic, fluid is
absorbed through the bowel. If several
enemas are given, fluid and electrolyte
imbalances can occur.
• ONLY 3 ENEMAS CAN BE GIVEN AT A
TIME to prevent this fluid imbalance from
occurring
Soap Suds enema
• Usually 1 packet of soap is combined with
up to 1000ml of water. If concentrations are
not correct and solution is too concentrated,
it will cause irritation to the rectum
Hypertonic Saline Solutions
• These use sodium phosphate as their main
ingredient
• This is a FLEETS enema, when given, it draws
water into the colon to aid in defecation. The pts
output will be more than what was instilled. This
too, is a rectal irritant
• Solutions such as FLEETS can be purchased OTC
and in 4oz increments
Retention Enemas
• These include solutions usually made of oil
or steroids.
• Pt is to retain or hold the solution for at
least 30 minutes and some retention enemas
are not expelled at all
• Oil filled enemas come pre-filled and can be
bought OTC also, these oil enemas lubricate
and soften the stool for easier expulsion
Cleansing Enema(AV)
Equipment
EQUIPMENT NEEDED
•
•
•
•
•
•
Always have gloves (non-sterile)
Lubrication (surgi-lube) in individ. Packets
Chux pads
Bed pan or bedside commode
The ordered enema bottle, or kit for soap
suds enema
When NOT to administer an
enema
• Never perform this technique while pt is
sitting on toilet, too difficult to administer
• Never to be used daily, pt will rely on this to
stool, bad
• Never administer with N/V or abdominal
pain d/t possibility of perforating intestine
Ostomy
• An ostomy is a surgically created opening
into a body structure
• Some patients have had surgery to repair or
remove part or most of their intestines
• Once surgery has taken place, the intestine
needs to recover (in many cases)
• A ulcerated intestine can be removed and either
reconnected (anastamosis) or the working portion
of the intestine is pulled through the abdominal
wall and stitched there. The other end is left just
inside the abdominal wall to rest. An opening is
created in the inner abd. wall and the working end
of the intestine is pulled through to the outside
• You now have an ostomy and that ostomy must
collect into a bag
Ostomy Care
• See page 687 in book for pictures of stomas and
their locations
• Persons with a stoma wear an appliance which is a
bag or collection device over the stoma
• Many patients can care for this themselves
however, nurses can also care for stomas
What to assess
• Check the condition of the skin around the
actual stoma for redness or excoriation
• The stoma itself should be beefy red and
look like organ meat, no blood should be
present, if so, notify RN or Dr.immediately
• Stoma should not be cyanotic, call Dr.
STAT
Providing peristomal care
• Preventing skin breakdown is a major
challenge of ostomy care
• Enzymes in stool can quickly excoriate the
skin. Excoriation is a chemical injury of the
skin, if not properly cared for, infection will
occur
Washing
• Washing the actual stoma and skin around
the stoma with mild soap and water and
patting it dry will preserve the skin
• Companies also make special skin care
pastes to be used in peristomal care
Applying the ostomy appliance
• Stomal appliances come in all shapes ans sizes but
they all come with a foam like faceplate or disk or
donut. This portion actually sticks to the skin
around the stoma and the beefy stoma pokes
through the middle of this piece.
• A plastic bag with a lid –type edge snaps over the
faceplate like the lid on a butter container. There
is a clamp at the bottom of the plastic bag for
emptying of the stomal contents
Problems…
• The faceplate is supposed to stay intact for
3-5 days however… the face plate often
becomes loose and leaks stool around the
appliance causing much stress and
frustration for the pt and the nurse
» Some try and tape the loose area of the faceplate, but
often times, this is not sufficient
When to empty the stoma
• The client or nurse empties the stoma when
it is 1/3 to ½ full; otherwise it will become
too heavy and the faceplate will pull away
from the skin
Types of appliances
• Some appliances use stoma paste and powder to
adhere the faceplate. This type becomes messy
and doesn’t always stick.
• Others just peel away the backing and apply the
faceplate to clean, dry skin. These don’t always
work either.
• When skin is even slightly reddened, appliances
don’t stick well
• Some stoma bags contain a charcoal filter that
keeps the stool’s odor in
Sounds of a stoma
• If you are standing near a person with a stoma,
you will most likely be able to hear growls,
gurgles and the passing of gas into the stoma bag.
• Most patients, especially teens, are quite
embarrassed by this. It is important that you act
professional and that you provide support to the
patient. Most facilities have an E.T. nurse
(enterostomal) that is available. Use her, she is a
pro at stomas and really helps the patient
Draining a continent ileostomy
• There are procedures that are done that
bypass the colon for defecation. The Dr.
makes a pouch in the abdominal cavity
where the stool collects until the patient
manually drains it. The patients takes a
lubricated 22-28 french rectal tube and
inserts it into the belly button carefully
• The pt has a valve just inside the belly
button area that keeps the stool in until he
caths it. He advances the catheter about 2
inches while bearing down or exhaling. He
empties the stool into a graduate container
and he can also irrigate this tube with tap
water to clean it. Infection rate can be high
in these patients
Colostomy
• The stool in this area is _______________
• Water may be needed to irrigate the colon
somewhat to loosen it up
• Pts with a sigmoid colostomy may not need to
wear an appliance, he may be able to irrigate his
colostomy before defecation to remove the stool,
sort of a bowel training technique
NANDA Diagnoses
•
•
•
•
•
•
•
Constipation
Risk for constipation
Diarrhea
Bowel Incontinence
Toileting-Self care deficit
Depression
Situational low Self-esteem
THE END
of
Bowel Elimination
Chapter 20
G.I. Intubation
Who receives a gastrointestinal tube?
•
LAVAGE/LEAVING or
DECOMPRESSION
• Pts undergoing gastrointestinal
or stomach surgery especially
• The use of a G.I. Tube reduces
or eliminates problems
associated with surgery or
conditions affecting the GI
tract such as impaired
peristalsis, vomiting, or gas
accumulation
•
GAVAGE/GIVING or FEEDING
• Pts may also receive a
tube to help nourish them
with liquid feedings for
those who cannot eat
such as anorexics, infants
or children and the
elderly
Intubation
• Means the placement of a tube into a body
structure
Types of NG tubes
• See handout please
•
•
•
•
Orogastric
Nasogastric
Nasointestinal
Transabdominal
Different types of tubes
• Orogastric – insertion of a tube through the mouth into the
stomach. Such as when having stomach pumped (Lavage)
Ewald
• Nasogastric – insertion of a tube through the nose into the
stomach. Such as the basic NG tube Salem-sump
(Decompression)
• Nasointestinal – insertion of a tube through the nose into the intestine,
this type of tube requires a guided wire and a weight on the end of the tube.
An x-ray is done after the tube is in to check placement, this tube flows
down into the duodenum with the help of the weighted end. In some
institutions, only a Dr. can insert this tube. (Gavage) Keofeed or Dobhoff
Purpose of G.I. Intubation
• Gavage – providing nourishment (giving)
• Lavage – washing out of a cavity, irrigation
(leaving)
• Obtain secretions/decompression - tubing is
connected to a suction machine and a collection
container, removes air, gastrointestinal juices
Size of the intubation tube
• Again, size matters…
• The outside diameter of the tube (its thickness) is
measured using the “French Scale”, indicated by
the letter “F”
• Each number on the French scale = .33mm. The
larger the number on the package, the larger in
diameter the tube is. 18F is bigger than a 10F tube
• You must decide on how big of a tube your pt
should have, the tube must fir loosely into the
nares
Orogastric tubes - Ewald
• Inserted into the mouth and down into the stomach
• These are used to lavage out toxic substances that
have been ingested as in a Tylenol overdose
• These tubes are large in diameter to remove pill
fragments and stomach debris
• Because the size is so large, this tube is entered
into the mouth rather than the nose
Nasogastric Tube – Salem-Sump
• This tube is places into the nose and down into the
stomach is smaller in diameter but longer in length
• NG tubes can have more than 1 lumen, sort of like
a Y’d tubing. One side goes to the pts nose and
then to the container to drain and the other lumen
(tube) hangs freely an acts as a vent so the NG
will drain properly. If you plug up the vent, no
drainage will occur
NGT’s
• Can stay in for a length of time to decompress or
to aid in feedings
• These tubes cause the throat to become sore as in
having strep throat sore. Many pts attempt to pull
out their tubes while asleep because it’s a natural
instinct to want that tube out
• NGT’s must be taped well, in place, especially in
infants and children while tube feeds are running
to avoid misplacement and choking
• NGT’s are easier to place when pt is asleep, not
always possible though
Insertion of the tube
(explanation of procedure)
• The nurse must first explain the procedure to the
patient.
• Many pts refuse this placement, you can be the
advocate to the pt and calm and ease their fears
concerning the NG Tube
• Tell the pt that the diameter of the tube is smaller
than most pieces of food and all they have to do is
swallow
• Not always possible to do
Assess the nares
• You are looking for nasal
debris, tell pt to blow nose
into Kleenex to clear the
way
• Assess for patency of the
nares, inspect for shape,
and size, deviated septum
or nasal polyps
• If any of these are present,
notify the RN or Dr.
Measurement of tube
• Use the N.E.X. method:
• Measure from the pts Nose to the Earlobe
to the Xiphoid process, this is how much
tubing you will insert into the pt’s nose
• Mark the tubing with a permanent marker
Tube Placement
• The nurse’s job is to minimize discomfort to
the pt. This can be difficult to do if the pt is
not cooperative
• The nurse must also try and preserve the
integrity of the nasal tissue
• The nurse must place the tube into the
stomach NOT the respiratory passages
What should the patient do
• The patient should sit completely up in the bed
• Tuck their chin to their chest and sip in water,
swallowing it as the nurse slowly pushes the tube
into the nose and back towards the pharynx and
the gag reflex
• The nurse can stop at any time to comfort the
patient, movement of the tube should be consistent
and slow, not jamming it in roughly
Problems that can occur during
placement of the tube
• During the technique of trying to pass the
tube, a pt may alert you that the tube is
coming out of their mouth, you should
immediately stop and remove the tube.
• The tube can also become coiled up in the
throat while it’s on its way down, again,
tube must be removed and reattempted
Checking placement of the tube
• Once the tube is at its final mark, the nurse
needs to verify that it is really in place
• There are a few techniques to check tube
placement…
3 methods of checking tube
placement
• 1)Aspirate fluid from the tube using a
syringe
• 2)Aspirate fluid using a syringe and test Ph
• 3) Auscultate abdomen listening for air
3 methods of Tube Placement
•
•
•
•
•
•
•
•
•
•
•
1) Aspirate fluid –
using a syringe,
pull back and see
if clear, brownishyellow or green
fluid can be
aspirated, the
nurse can
presume that
the tube is in
the stomach.
• 2) Ausciltate the abdomen
– the nurse instills 10ml of
air or more using a syringe
and listens over the
“stomach area” of the
abdomen with a
stethoscope. If a
swooshing sound is heard,
the can presume that the
tube is in place (most
popular way of checking)
Tube placement
• 3) Testing the PH of aspirated fluids – testing the
PH confirms 100% that the tube is placed
correctly.
• Other than obtaining a chest x-ray, THE PH TEST
IS THE MOST ACCURATE TECHNIQUE FOR
CHECKING NGT PLACEMENT (this is not used
in all facilities)
Misplaced tubes
• 1) If the NGT is in the esophagus, the pt will belch
• 2) If no swoosh sound is heard, the tube may be coiled
• 3) If the tube is in the respiratory passage somewhere, the
pt should immediately cough, this is a clear and immediate
response to a foreign object entering into the resp. passages
(no mistaking this)
• 4) If the tube comes out of the pt’s mouth, obviously, it’s
not in the correct place
NGT used for Decompression
• When bellies are full of fluid or gas after
surgery when peristalsis has not returned,
pts will have N/V, NGTs are to be
connected to suction and THEY MUST BE
WORKING CORRECTLY in order to give
the pt relief
NGTs for decompression
• Tubing is connected to
suction at:
• 1) Low to medium
suction (40-60mm hg)
• 2) At intermediate
suction. If you put an
NGT to continuous
suction, it will suck
and suck and suck
causing GI irritation to
the lining of the
stomach wall. Blood
will be seen in the
drainage container
Continuous Suctioning
• Can be used when the nurse is irrigating the
NG with normal saline
Irrigating an NGT
• Often times, pts will c/o nausea and may even
vomit. Persons with an NGT should not vomit.
• Secretions in stomach may be thick esp. after days
of having tube in place.
• NGT can be irrigated with NORMAL SALINE
ONLY to help loosen up the thick secretions
Why use normal saline (NS) to
irrigate
• NS is isotonic = has equal
• ingredients as the body does
• If you use sterile water, it is hypotonic, what do
the electrolytes want to do? They want to help
make the solutions more equal therefore if you
give sterile water, too many electrolytes will be
lost
In the body IN GENERAL…
• Normal Saline (NS) is the irrigating fluid to be
used for any type of irrigation
• It best meets the same needs of the body, it is most
equal to the body’s fluids
• We never offer ice or water to pt’s with an NGT,
the fluid will get suctioned out immediately and if
B.S. are not present, pt will become nauseous
• NCLEX Question
Giving Meds to a pt with an NGT
• If meds MUST be given, you must turn off the
suction for up to 1 hour to allow medication to be
absorbed however…
• Pts without B.S. means that nothing will move on
through to the intestines and pt is likely to have
N/V.
• If no B.S. are present, don’t bother giving meds
via NGT, when you resume suction, you’ll just see
the meds being suctioned out into the canister,
then the pt didn’t get the meds ordered…not good
Securing the NGT
• There are several
• Ways to secure an NGT
• Gently tape the NGT to the cheek of the same side
of the nare where the tube is placed
• Wrap the tubing around the upper part of the ear
and allow the NGT to hang down from behind the
ear. Steri-strips are used to secure the tube or
plain tape
• Wrap tape around the tube right at the site of entry
into the nare and then apply tape to the cheek.
Watch children with tubes, they pull them out
Deciding to remove the NGT
• If the pt’s bowel sounds return and the pt is
recovering well, the Dr. may order the NGT to be
clamped for up to 6 hours before removal of the
tube is ordered
• Simply disconnect the tubing from the suction
machine to allow pt to get OOB and tuck the
coiled tube up and place in the pocket of the pt
gown. Wait from 1-6 hours as ordered, pt usually
starts to drink clear fluids and if pt has no N/V,
tube can be removed. WAIT FOR THE DR.s
ORDER
Removing the NGT
• Explain to the pt that they are having their tube
discontinued
• Pt will usually be thrilled and may help you
remove it
• Remove all tape GENTLY, (tape can hurt).
• Don non-sterile gloves and pinch off the tubing
gently pull on tube, using both hands to walk it out
of the nare. Pinching off tube will help to not
make GI contents drip into nose or mouth. I
usually have a chux pad ready and I lay it on the
pt’s chest to catch the end of the tube. The pt may
sneeze when it is out completely, the nose may run
or bleed, offer tissue to the pt
Transabdominal tube
Transabdominal tubes
• Otherwise known as feeding tubes for
enteral nutrition
• Enteral – within or by way of the intestine.
Nourishment provided via the stomach or
small intestine rather than by the oral route
Types of enteral tubes
• Gastrostomy tube - A.K.A. G-tube, this tube
enters the stomach. Can be used for feedings and
medications
• Jejunostomy tube - A.K.A J-tube, this tube
enters through the jejunostomy and bi-passes the
stomach and enters the small intestine
• PEG tube (percutaneous endoscopic
gastrostomy tube) – is a G-tube, is used for feeds
and meds. Performed under endoscopy and tube
is pulled out of the body
• (These tubes are used when a pt needs feeding
longer than 1 month and cannot eat P.O.)
G-Tube
PEG tube
Checking residual of these tubes
is important
• Once a pt is fed via one of the
tubes, residual or amount of
food undigested, must be
assessed before feeding again
• Pts can have slow digestion and
their belly may still be full from
the last fees, if you re-feed
them, they may have vomiting
d/t too full of a belly
Performing a tube feeding
• Assess the skin around the tube site. Is it
red, does it need to be cleaned.
• Aspirate fluid from the tube to determine if
the volume of feeds exceeds the pts
physiologic capacity
• Overfilling of the stomach leads to gastric
reflux, regurgitation and vomiting and
aspiration into lungs = pneumonia
Rule of thumb
• The gastric residual should be no more than 100ml
or no more than 20% of the previous hours tube
feeding volume
• When aspirating the residual, YOU MUST TAKE
THE TOTAL AND RETURN THE ASPIRATED
LIQUID BACK TO THE PT. This aspirate is
filled with electrolytes and belongs to the pt. You
would note the amount and report it to the RN or
Dr. Perhaps the next feed will be held d/t the
aspirated amount
What to do to speed up digestion
and movement through the tube
• Try and sit pt up
• Try and place pt on their right side to
increase faster emptying of the stomach
• Reglan can be given
• Class: GI stimulant, anti-emetic
TUBE FEEDING PUMP
Once a patient has an NGT or
feeding tube…
• Pt is automatically placed on I’s & O’s, you want
to record all that goes in and all that comes out
• Be sure to follow the order and provide the correct
feeding at the correct rate
• Be sure to flush the NGT or feeding tube when
feed is completed with tap water
Bolus Feeds
• Instillation of liquid nourishment 4 - 6 x’s
/day in less than 30 minutes
• The usual bolus feed is 250-400ml of
formula
• This type and amount of feed can distend
the stomach rapidly, can cause gastric
discomfort, can increase the risk of reflux
and aspiration
Be careful….
• If gastric emptying is delayed or the pt is
unconscious or is developmentally delayed,
the pt is at greater risk for vomiting and
aspiration with this method of feeding
Intermittent Feedings
• 250-400 ml is given 4-6xs/day like the
bolus feeds except the intermittent feeds are
given over 30-60 mins, not less than 30
mins. These feed drip in by gravity
• It’s a little slower of a feed to reduce the
feeling of bloating
Changing feeding bags
• You must rinse out a feeding bag between
EVERY use and open a new bag every 24
hours due to the possible growth of
microorganisms
Cyclic Feedings
• Continuous feedings of liquid nourishments for 812 hours with a 12-16 hr rest of no feeds
• These pts receive these types of feeds overnight
and attempt to eat orally during the day
• Problems occur when the pt tries to sleep and
peristalsis slows down and you try and feed your
pt during the night. Bloating, nausea, vomiting
and possible aspiration can occur
Continuous Feedings
• The instillation of liquid nourishment without
interruption
• The rate is usually at 1.5ml/minute, a pump is
needed to regulate this small amount
• The formula is delivered right to the small
intestine through a J tube or PEG tube
• This type of feed reduces the amt of bloating, N/V,
aspiration.
• The pump must go wherever the pt goes, sort of
inconvenient
Continuous Feeds
• You can only put 4 hours worth of liquid
feed into the bag at one time to reduce the
possibility of microbes that may grow.
Medication
• The nurse can instill medication in liquid form
into the tube during a tube feed
• The nurse MUST STOP THE FEED PUMP OR
GRAVITY DRIPPING FEED, flush the tubing ,
then push each medication separately with a
syringe into the feeding tube. You must flush with
saline in between every med. When the meds are
instilled, flush the tube again with water and
resume the feed
Complications of tube feeds
• 1) ASPIRATION
• Keep HOB up at all times, this becomes
uncomfortable in pts who are getting continuous
tube feeds, they want to lay down
• Check for residual and distention before every
feed if intermittent and every 2 hours in feed is
continuous
• Notify RN or Dr. if distention, N/V is noted. Tube
feed may be with held
Complications of tube feeds
• 2.) DUMPING SYNDROME
• Happens when there is a large amount of caloriedense nutrients rapidly dumped into the small
intestine
• Symptoms include: dizziness, sweating, N/V – this
is caused by fluid shifts from the circulating blood
to the intestine and low blood sugar related to a
surge of insulin, diarrhea also occurs =
dehydration and dry mucosa
Complications of tube feeds
• 3) Clogging up of the tube itself, some meds clog
tubes easily, you can try the following:
• Using a bubbly clear soda like ginger ale or 7-up
and try to use a small syringe and push and pull
back on the syringe trying to push the soda into
the tube. Sometimes, nurses use cranberry juice
and it works!
• Using meat tenderizer works, it breaks up fat in
meat and it breaks up a clog in a tube, mix it with
water and use the syringe method like the clear
soda method
NANDA Diagnoses
• Imbalanced Nutrition: Less that body
requirements
• Self care deficit: Feeding
• Risk for aspiration
• Impaired oral mucous membranes
• Diarrhea
• Constipation
THE END