BOWEL ELIMINATION
BOWEL ELIMINATION
The gastrointestinal tract is composed of the stomach, small intestine, large intestine, and rectum. The small intestine absorbs nutrients, the large intestine absorbs fluids and the remaining nutrients, and the distal portion of the large intestine collects and stores the remaining solid waste until elimination occurs.
Bowel Elimination
The process of normal fecal elimination is not completely understood. Continence primarily relies on the consistency of the stool (fecal material), intestinal motility, compliance and contractility of the rectum, and competence of the anal sphincters.
Structures of the
Gastrointestinal Tract
The gastrointestinal system (alimentary canal) begins at the mouth and ends at the anus. The small intestine in the adult is approximately
The colon is approximately 5 to
Intestinal Motilityand Rectal Accommodation
Fecal continence relies on regular delivery of small boluses of stool that are stored in the rectum before elimination. The transit time from ingestion of food to passage of stool from the bowels varies. Typically, at least 80% of intake that is not absorbed by the body is excreted from the bowel within 5 days following ingestion. Transit time is significantly affected by the type of foods ingested, subsequent dietary intake, exercise, and stress-related factors. Filling of the rectum causes a growing awareness of the presence of stool, which is stored until an appropriate opportunity for defecation (evacuation of stool from the rectum) is identified. In the continent individual, an initial awareness of stool in the rectum is identified at 150 ml. The desire to defecate is typically transient, diminishing as the rectum accommodates larger volumes of stool. When 400 ml or more of stool is collected in the rectum, this urge becomes strong, and the call to defecate becomes more persistent. Failure to heed the call to defecate may lead to overdistension of the rectum with hardening of the stool and subsequent constipation.
Anal Sphincter Mechanism
The anal sphincter is divided into two mechanisms, called the internal and external sphincters (Figure 39-3). An internal anal sphincter is primarily made up of smooth muscle bundles that are connected to the smooth muscle of the rectum. It begins in the distal portion of the rectum and extends approximately
Sensory receptors located at the proximal anal canal affect anal function. These specialized sensory receptors are able to “sample” fecal contents, allowing the individual to differentiate among solid stool, liquid stool, and gas. Distension of the rectum causes a reflex inhibition of the internal anal sphincter and contraction of the external sphincter. The proximal anal sphincter then samples the contents of the rectum, and the individual perceives the desire to defecate. If the person postpones defecation, rectal accommodation occurs and the desire to defecate is postponed. If the desire to defecate is heeded, the person voluntarily relaxes the external anal sphincter and evacuates the bowel of feces. The significance of rectal contractions during defecation remains unclear. Many persons strain to defecate, and abdominal force is readily transmitted to the rectum, creating an effective expulsive force. The continent individual is able to simultaneously increase abdominal pressure by straining and maintain external anal sphincter relaxation, allowing effective evacuation of feces from the bowel.
INSERTING AND MAINTAINING A
NASOGASTRIC TUBE
OVERVIEW OF THE SKILL
Nasogastric (NG) tubes are used for several purposes, including feeding for nutrition when the client is comatose, semiconscious, or unable to consume sufficient nutrition orally. Nasogastric suction tubes are used for
decompression of gastric content after gastrointestinal surgery, and to obtain gastric specimens for diagnosis of peptic ulcer. Tubes are used for irrigation to clean and flush the stomach after oral ingestion of poisonous substances. Finally, NG tubes are used to document the presence of blood in the stomach, monitor the amount of bleeding from the stomach, and identify the recurrence of bleeding in the stomach. The two most commonly used NG tubes are the single lumen Levin’s tube, and the double lumen Salem sump tube. The gastrointestinal tract is considered to be a clean area rather than a sterile one. The procedure to place an NG tube is performed using clean technique unless it is performed in conjunction with gastrointestinal surgery.
ASSESSMENT
1. Assess client’s consciousness level to determine the ability of the client to cooperate during the NG tube removal.
2. Check the client’s chart for orders to remove the tube. Reduces the risk for a nursing error and the need to reinsert the tube.
3. Use a penlight to assess nostrils for irritation and dryness. Establishes a baseline and identifies the risk for nasal irritation and bleeding.
DIAGNOSIS
1.6.1.4 Risk for Aspiration
1.6.2.1.1 Altered Mucous Membranes
9.1.1 Pain
1.6.2.1.2.1 Impaired Skin Integrity
PLANNING
Expected Outcomes:
1. Client will be able to tolerate the removal of the tube without undue anxiety, nausea, pain, or distress.
2. Client will understand the reasons for tube removal.
3. Skin around the tube will remain intact, with no redness or blisters.
4. Client will understand signs and symptoms to report of potential complications.
Equipment Needed
• Syringe with catheter tip or adapter, 20–50 ml
• Towel and tissue, or disposable waterproof pad
• Emesis basin
• Tongue blade
• Stethoscope
• Disposable gloves (nonsterile), gargle, gown
• Penlight or flashlight
CLIENT EDUCATION NEEDED:
1. Inform the client of the reason the NG tube is being removed.
2. Explain the procedure and any expected discomfort. Tell the client removing the tube will not be nearly as uncomfortable or lengthy a procedure as the NG tube insertion was.
3. Establish and clarify a “hand signal” to indicate the need to temporarily stop the NG tube removal.
4. Explain how the client can cooperate during tube removal.
5. Explain potential complications, such as gastric distention or vomiting, if there is a possibility that the tube might need to be reinserted.
EVALUATION
• The client was able to tolerate the removal of the tube without undue anxiety, nausea, pain, or distress.
• The client understands the reasons for tube removal.
• Skin around the tube remained intact, with no redness or blisters.
• Client understands signs or symptoms to report of complications.
DOCUMENTATION
Nurses’Notes
• Document NG tube removal and the client’s responses.
• Document any signs of irritation around the nares or complaints of nose or throat pain.
Intake and Output Record
• If the NG tube was attached to suction or a feeding pump, record the amount of intake or drainage.
CRITICAL THINKING SKILL
Introduction
The nurse must continuously reassess the client’s condition and symptoms.
Possible Scenario
Mrs. Marino is a very demanding client. Everything the nurses do seems to cause her pain, and nothing is ever quite right.The NG tube that has been in place for approximately 1 week has been a major source of complaint, and the nurses are finding it difficult to listen and respond with much compassion.As predicted, removing the tube causes screams of anguish.The nurse quickly wipes Mrs.Marino’s nose, offers a tissue, and leaves the room with the tube.
Possible Outcome
Upon discarding the tube, the nurse notices it has blood on the outside. Reassessing the client, she discovers a very red and eroded area just inside the nostril. She reports her findings, and upon further assessment, another ulcerated area at the back of her throat is discovered. The client requires additional treatment for complications from the NG tube.
Prevention
Nurses caring for this client needed to conduct daily assessments of the condition of the nares, look for signs of developing pressure sores from the tube, reposition the tube if needed, and listen to complaints of pain from the client.
t VARIATIONS
Geriatric Variations:
• Make sure the elderly client can hear and understand your instructions and education regarding removal of the tube.
• Elderly skin is more delicate and fragile. After tube removal, be especially careful to assess for skin breakdown around the nares and to provide good cleaning and care of the nares.
Pediatric Variations:
• A parent may need to assist to hold the child while the tube is being removed. A toddler especially will find the procedure frightening. Sitting on a parent’s lap will help the child feel a sense of trust and security.
• An older child can help by holding the emesis basin and tissue. An older child will feel less anxiety if provided choices and information about the procedure.
• The child may prefer to close their eyes while the tube is being removed.
Home Care Variations:
• Make sure the home care provider knows what signs and symptoms to assess for after the tube is removed.
Long-Term Care Variations:
• Long-term NG tube placement increases the risk of complications such as sinusitis, esophagitis, and gastric ulceration. Make sure staff members in a long-term care facility understand how to assess for these complications even after the tube is removed.
COMMON ERRORS—ASK YOURSELF
Possible Error:
Forgetting to coil the tube around your hand while removing the tube may cause the spillage of gastric content.
Ask Yourself:
How do I prevent this error?
Prevention:
Remove the towel and the tube immediately. Change the client’s gown and any soiled bed linen to remove the pill.
Possible Error:
Forgetting to clear the tube of gastric secretions or feeding solution could cause these liquids to be aspirated into the lungs as the tube is being removed.
Ask Yourself:
How do I prevent this error?
Prevention:
Assess the client for signs of choking or coughing. Notify the physician or qualified practitioner immediately if aspiration is suspected.
NURSING TIPS
• Adjust the height of bed to eliminate back strain when removing the tube.
• This can be an anxiety-provoking procedure. Remind the client that tube removal is quick and painless compared to tube insertion.
• Carefully observe client’s verbal and nonverbal responses during the entire procedure.
• Assess the lungs and breathing carefully after an NG tube has been removed. There is a risk for aspiration. Also, the presence of the tube may suppress the client’s coughing and attempts to clear secretions from the throat, which could cause respiratory complications. These complications may not appear until after the tube is removed.
Removing aNasogastric Tube
OVERVIEW OF THE SKILL
Once the reason for the nasogastric tube (NG) has been resolved, the physician or qualified practitioner will order the tube removed. Prior to removal, the nurse should check the orders and assess the client. If the tube was placed to keep the stomach empty during and after surgery, auscultate all four quadrants of the abdomen to verify that peristalsis is present. Ask the client if he or she is passing gas, or flatus. If the tube was in place to measure and monitor gastric bleeding, make sure that little or no blood is being produced. Make sure the tube is not draining large amounts of gastric secretions, which could indicate poor gastric emptying, obstruction, or ileus. If any problems are noted, report these findings and verify the order to remove the tube before proceeding.
After the removal, the nurse should monitor the client’s condition, watching especially for signs that the tube may need to be reinserted.Nausea, vomiting, abdominal distention, vomiting blood, and complaints of pain or gastric distress are all signs that should be reported. If the tube has been in place for more than a few days, the potential for complications from the tube arises. Gastric ulceration occurs when the suction from the tube erodes he gastric wall. Sinusitis and esophagitis can occur from irritation from the NG tube.
> ASSESSMENT
1. Assess client’s consciousness level to determine the ability of the client to cooperate during the NG tube removal.
2. Check the client’s chart for orders to remove the tube. Reduces the risk for a nursing error and the need to reinsert the tube.
3. Use a penlight to assess nostrils for irritation and dryness. Establishes a baseline and identifies the risk for nasal irritation and bleeding.
> DIAGNOSIS
1.6.1.4 Risk for Aspiration
1.6.2.1.1 Altered Mucous Membranes
9.1.1 Pain
1.6.2.1.2.1 Impaired Skin Integrity
> PLANNING
Expected Outcomes:
1. Client will be able to tolerate the removal of the tube without undue anxiety, nausea, pain, or distress.
2. Client will understand the reasons for tube removal.
3. Skin around the tube will remain intact, with no redness or blisters.
4. Client will understand signs and symptoms to report of potential complications.
Equipment Needed:
• Syringe with catheter tip or adapter, 20–50 ml
• Towel and tissue, or disposable waterproof pad
• Emesis basin
• Tongue blade
• Stethoscope
• Disposable gloves (nonsterile), gargle, gown
• Penlight or flashlight
CLIENT EDUCATION NEEDED:
1. Inform the client of the reason the NG tube is being removed.
2. Explain the procedure and any expected discomfort. Tell the client removing the tube will not be nearly as uncomfortable or lengthy a procedure as the NG tube insertion was.
3. Establish and clarify a “hand signal” to indicate the need to temporarily stop the NG tube removal.
4. Explain how the client can cooperate during tube removal.
5. Explain potential complications, such as gastric distention or vomiting, if there is a possibility that the tube might need to be reinserted.
EVALUATION
• The client was able to tolerate the removal of the tube without undue anxiety, nausea, pain, or distress.
• The client understands the reasons for tube removal.
• Skin around the tube remained intact, with no redness or blisters.
• Client understands signs or symptoms to report of complications.
> DOCUMENTATION
Nurses’Notes
• Document NG tube removal and the client’s responses.
• Document any signs of irritation around the nares or complaints of nose or throat pain.
Intake and Output Record
• If the NG tube was attached to suction or a feeding pump, record the amount of intake or drainage.
> CRITICAL THINKING SKILL
Introduction
The nurse must continuously reassess the client’s condition and symptoms.
Possible Scenario
Mrs. Marino is a very demanding client. Everything the nurses do seems to cause her pain, and nothing is ever quite right.The NG tube that has been in place for approximately 1 week has been a major source of complaint, and the nurses are finding it difficult to listen and respond with much compassion.As predicted, removing the tube causes screams of anguish.The nurse quickly wipes Mrs.Marino’s nose, offers a tissue, and leaves the room with the tube.
Possible Outcome
Upon discarding the tube, the nurse notices it has blood on the outside. Reassessing the client, she discovers a very red and eroded area just inside the nostril. She reports her findings, and upon further assessment, another ulcerated area at the back of her throat is discovered. The client requires additional treatment for complications from the NG tube.
Prevention
Nurses caring for this client needed to conduct daily assessments of the condition of the nares, look for signs of developing pressure sores from the tube, reposition the tube if needed, and listen to complaints of pain from the client.
VARIATIONS
Geriatric Variations:
• Make sure the elderly client can hear and understand your instructions and education regarding removal of the tube.
• Elderly skin is more delicate and fragile. After tube removal, be especially careful to assess for skin breakdown around the nares and to provide good cleaning and care of the nares.
Pediatric Variations:
• A parent may need to assist to hold the child while the tube is being removed. A toddler especially will find the procedure frightening. Sitting on a parent’s lap will help the child feel a sense of trust and security.
• An older child can help by holding the emesis basin and tissue. An older child will feel less anxiety if provided choices and information about the procedure.
• The child may prefer to close their eyes while the tube is being removed.
Home Care Variations:
• Make sure the home care provider knows what signs and symptoms to assess for after the tube is removed.
Long-Term Care Variations:
• Long-term NG tube placement increases the risk of complications such as sinusitis, esophagitis, and gastric ulceration. Make sure staff members in a long-term care facility understand how to assess for these complications even after the tube is removed.
COMMON ERRORS—ASK YOURSELF
Possible Error:
Forgetting to coil the tube around your hand while removing the tube may cause the spillage of gastric content.
Ask Yourself:
How do I prevent this error?
Prevention:
Remove the towel and the tube immediately. Change the client’s gown and any soiled bed linen to remove the spill.
Possible Error:
Forgetting to clear the tube of gastric secretions or feeding solution could cause these liquids to be aspirated into the lungs as the tube is being removed.
Ask Yourself:
How do I prevent this error?
Prevention:
Assess the client for signs of choking or coughing. Notify the physician or qualified practitioner immediately if aspiration is suspected.
NURSING TIPS
• Adjust the height of bed to eliminate back strain when removing the tube.
• This can be an anxiety-provoking procedure. Remind the client that tube removal is quick and painless compared to tube insertion.
• Carefully observe client’s verbal and nonverbal responses during the entire procedure.
• Assess the lungs and breathing carefully after an NG tube has been removed. There is a risk for aspiration. Also, the presence of the tube may suppress the client’s coughing and attempts to clear secretions from the throat, which could cause respiratory complications. These complications may not appear until after the tube is removed.
ADMINISTERING AN ENEMA
OVERVIEW OF THE SKILL
An enema is a solution inserted into the rectum and sigmoid colon for the purpose of removing feces and/or flatus. Enemas can also be used to instill medications or nutrition. A cleansing enema is probably the most common type of enema. This type of enema stimulates peristalsis via irritation of the colon/rectum and by causing intestinal distention with fluid. The solution used in a cleansing enema must be chosen with care. Some solutions, such as tap-water-based solutions, draw fluid and electrolytes out of the body. They should not be used in clients with preexisting fluid and electrolyte imbalances. There are two general types of cleansing enemas: the large-volume enema and the smallvolume enema. A large-volume enema is designed to clean the colon of as much feces as possible. In a large-volume enema between 500 and 1000 cc of fluid is instilled into the rectum/colon and the client is asked to retain the fluid as long as possible. This allows the fluid to soften and loosen the feces. The large volume of fluid also distends the bowel, stimulating peristalsis. Largevolume enemas are the traditional intervention for constipation. Traditionally soapsuds enemas were used, and many large-volume enema kits still come with a small packet of liquid soap to be dissolved in the enema solution. Soapsuds enemas are very irritating to the colon and are rarely ordered anymore. Large-volume enemas are often ordered prior to procedures or surgeries that require visualization of the colon. When used for this reason, the physician or qualified practitioner will often order “enemas until clear.” This indicates that large-volume enemas are to be given until the fluid returned is clear of fecal matter Most institutions have guidelines regarding the maximum number of large-volume enemas that can be administered to a client. Small-volume enemas are designed to clear the rectum and the sigmoid colon of fecal matter. Smallvolume enemas can be delivered with the traditional enema kit using 50 to 200 cc of solution, but most frequently they are administered using a prepackaged disposable enema. There are a number of prepackaged small enemas available. These enemas work by using a hypertonic rectal stimulant that stimulates peristalsis and draws fluid from the intestinal walls to soften the feces. Because these enemas use the body’s own fluid to lubricate the stool, this type of enema is contraindicated in clients who are dehydrated. Prepackaged enemas are easily administered and available over the counter in most drug stores. This makes them ideal for home care use.
There are several types of enemas used for purposes other than cleansing. An oil retention enema is a small-volume enema that instills oil into the rectum. The oil is retained for up to an hour and is designed to soften very hard stool. It is often followed by a large-volume cleansing enema. Medications can be administered by enema as well. A small-volume enema can deliver a medicated solution directly to the rectal mucosa. This method of medication administration is useful when the rectum is the area to be medicated if the client is unable to take oral medications or if rapid absorption of the medication is required. The return-flow enema is used to remove flatus and stimulate peristalsis. It is frequently used following abdominal surgery to reduce intestinal distention and to stimulate the resumption of bowel function. Many different solutions are used for enemas, including tap water, normal saline, hypertonic solutions, soap solutions, oil, and carminative solutions. Tap water is a hypotonic solution. Because it is a less concentrated solution than the body’s cells, it is drawn into the body and may cause water toxicity, electrolyte imbalance, or circulatory overload. Normal saline is an isotonic solution. It is the same concentration as the body’s own fluids and is considered to be a safe enema solution. It is important that children and infants only be giveormal saline enemas since their small size predisposes them to fluid imbalances. Prepackaged smallvolume enemas use hypertonic solutions to draw fluid from the body to lubricate the stool and distend the rectum. Hypertonic solutions are contraindicated in dehydrated clients and small children. Carminative solutions are used to provide relief from gas. An example of a carminative enema is
MGW solution, which is 30 cc of magnesium, 60 cc of glycerin, and 90 cc of water. Enemas are contraindicated in clients with bowel obstruction, inflammation, or infection of the abdomen or if the client has had recent rectal or anal surgery. If the nurse has any question regarding the advisability of administering an enema, she should consult the client’s physician or qualified practitioner.
ASSESSMENT
1. Identify the type of enema ordered as well as the rationale for the enema. Allows the nurse to verify the appropriateness of the type of enema ordered.
2. Assess the physical condition of the client. Determine if the client has bowel sounds. Assess for a history of constipation, hemorrhoids, or diverticulitis. Determine if the client will be able to hold a side-lying or knee-chest position or be able to retain the enema solution. Allows the nurse to plan the procedure with the client’s limitations in mind.
3. Assess the client’s mental state, including ability to understand and cooperate with the procedure, the client’s knowledge level regarding the procedure, and any preexisting fears the client may have regarding the procedure. Knowing if the client can comprehend and cooperate with the procedure will help the nurse plan ahead. Many clients have preexisting fears and beliefs regarding enemas and their administration.
> DIAGNOSIS
1.3.1.1 Constipation
1.4.1.2.2.2 Risk for Fluid Volume Deficit
7.1.2 Situational Low Self-Esteem related to embarrassment over exposure and procedures in the rectal area
> PLANNING
Expected Outcomes:
1. The client’s rectum will be free of feces and flatus.
2. The client will experience a minimum of trauma and embarrassment from the procedure.
Equipment Needed (see Figure 6-19-2):
Large Volume, Cleansing Enema
• Absorbent pad for the bed
• Disposable gloves
• Bedside commode or bedpan if client will not be able to ambulate to bathroom (see Figure 6-19-3)
• Lubricant
• Enema container
• Tubing with clamp and nozzle
• Thermometer for enema solution
• Toilet tissue
• IV pole
• Washcloth, towel, and basin
There are several types of enemas used for purposes other than cleansing. An oil retention enema is a small-volume enema that instills oil into the rectum. The oil is retained for up to an hour and is designed to soften very hard stool. It is often followed by a large-volume cleansing enema. Medications can be administered by enema as well. A small-volume enema can deliver a medicated solution directly to the rectal mucosa. This method of medication administration is useful when the rectum is the area to be medicated if the client is unable to take oral medications or if rapid absorption of the medication is required. The return-flow enema is used to remove flatus and stimulate peristalsis. It is frequently used following abdominal surgery to reduce intestinal distention and to stimulate the resumption of bowel function. Many different solutions are used for enemas, including tap water, normal saline, hypertonic solutions, soap solutions, oil, and carminative solutions. Tap water is a hypotonic solution. Because it is a less concentrated solution than the body’s cells, it is drawn into the body and may cause water toxicity, electrolyte imbalance, or circulatory overload. Normal saline is an isotonic solution. It is the same concentration as the body’s own fluids and is considered to be a safe enema solution. It is important that children and infants only be giveormal saline enemas since their small size predisposes them to fluid imbalances. Prepackaged smallvolume enemas use hypertonic solutions to draw fluid from the body to lubricate the stool and distend the rectum. Hypertonic solutions are contraindicated in dehydrated clients and small children. Carminative solutions are used to provide relief from gas. An example of a carminative enema is MGW solution, which is 30 cc of magnesium, 60 cc of glycerin, and 90 cc of water. Enemas are contraindicated in clients with bowel obstruction, inflammation, or infection of the abdomen or if the client has had recent rectal or anal surgery. If the nurse has any question regarding the advisability of administering an enema, she should consult the client’s physician or qualified practitioner.
Small Volume, Prepackaged Enema (see Figure 6-19-4)
• Prescribed prepackaged enema
• Lubricant if the tip is not prelubricated
• Toilet tissue
• Bedpan or commode if the client cannot use the bathroom
• Absorbent pad for bed
• Gloves
Return-Flow Enema
• Absorbent pad for the bed
• Disposable gloves
• Bedside commode or bedpan if client will not be able to ambulate to bathroom
• Prescribed solution
• Lubricant
• Enema container
• Tubing with clamp and nozzle
• Thermometer
• Toilet tissue
CLIENT EDUCATION NEEDED:
1. Explain rationale for enema (to clear the bowel of feces).
2. Explain the procedure and steps involved.
3. Explain need to retain enema solution for prescribed time period to ensure success.
4. Clients should be taught that enemas should not be used to treat constipation on a routine basis.
5. Clients should be instructed not to flush the toilet until the nurse can observe the contents.
6. Clients who are unfamiliar with enema administration should be warned about the feeling of fullness or need to evacuate as the enema is administered.
7. Clients should be instructed to inform the nurse if cramps or abdominal pain occurs.
8. Clients should be instructed that lying on the back with knees and hips flexed toward the chest may make it easier to self-administer an enema.
> EVALUATION
• The client’s rectum is free of feces or flatus.
• The client experienced a minimum of trauma and embarrassment from the procedure.
> DOCUMENTATION
Nurses’Notes
• Record the time and date of the procedure.
• Document the type of enema given, the amount of fluid infused and returned, and the amount and description of the feces expelled.
• Note the client’s tolerance for the procedure and any complaints or unusual findings.
Medication Administration Record (MAR)
• If this is a medicated enema be sure to note it on the MAR.
Intake and Output Record
• If the amount of fluid returned is significantly less than the amount infused, note this on the I&O record.
> CRITICAL THINKING SKILL
Introduction
A client’s preconceptions may obstruct good care. Education is essential when assisting the client with independent care.
Possible Scenario
You are evaluating a new home health client. She is an elderly woman who recently fell and broke her ankle. Because of the injury, she is not as mobile as she was previously. She is complaining of constipation and reports that she has been giving herself prepackaged, small-volume enemas daily to relieve this.
Possible Outcome
The nurse explains that frequent enemas decrease bowel tone rather than increase it, but she is unable to offer any acceptable alternatives. The client continues to give herself daily enemas.When she is finally able to resume her previous activity level, the client finds that she is unable to stop using the daily enemas due to rebound constipation.
Prevention
The nurse questions the client regarding her need to use enemas daily, explaining that bowel movements every 2 or 3 days is “normal” and daily bowel movements are not required. They discuss the client’s reduced activity level and talk about ways to increase her activity without stressing her ankle. They discuss stool softeners and bulk-producing products as ways to improve her bowel function without the use of enemas. The nurse asks about the nature of the client’s “constipated” stools and discovers that they are soft and formed. The nurse reassures the client that she is not constipated, but that her reduced activity has reduced the frequency of her bowel movements. The nurse makes a note to herself to follow up with the client regarding her “constipation.”Many people believe that they must have daily bowel movements to be normal. They need to be educated that as long as their stools are soft and formed they are not constipated even if their bowel movements occur every 2 or 3 days. If a client is concerned or truly suffering from occasional constipation, there are lifestyle changes they can make that are far superior to frequent enemas, which can damage the bowel. Some lifestyle changes include drinking at least 8 glasses of water a day, going for daily walks, and increasing the amount of fiber in their diet.
Geriatric Variations:
• Elderly clients may have impaired mobility, thus having difficulty maintaining an acutely flexed right leg as well as having difficulty quickly walking to the bathroom.
• The client may need encouragement to maintain the position desired, and a bedside commode or bedpan may be required.
• Elderly clients may not be able to hear instructions well, especially if you are facing away from the client or have a soft voice. Make sure to communicate at eye level and allow the client to see your lips as you speak. Establish hand signals prior to the procedure to use if the client cannot hear you while you are administering the enema.
• Take extra precautions to protect privacy and dignity if you must speak in a loud voice to communicate with the client.
Pediatric Variations:
• The child may be too young to understand why an enema is being administered, which may cause increased anxiety on the child’s part.
• Have a parent administer the enema if reasonable, or have the parent present to comfort the child and facilitate cooperation.
• Care must be taken to ensure that the temperature of the solution is maintained to prevent damaging the child or make the child uncomfortable.
• It is important that the enema nozzle be well lubricated and that it is inserted only
• Be aware of the volumes required for different body sizes in infants and children.
• Only isotonic solutions should be used in infants and children.
• Children who are not toilet trained will not be able to retain the enema solution. Give the enema on an absorbent pad or while the child is on the bedpan.
Home Care Variations:
• Clients can be taught to administer the enemas to themselves if needed.
• Enema kits are easily available and may be easier for the client to use without assistance.
• Clients may find that lying on their backs with their knees flexed and legs raised or using the knee-chest position are easier positions for self-administration of the enema.
• Clients should be instructed not to use the same nozzle for douching and enemas. Douche bags often come with an enema tip and the bag can be used for either purpose, but the tips are not interchangeable.
• Clients should not use enema/douche bags that hold the solution under pressure and forcefully expel the fluid into the rectum.
VARIATIONS
Long-Term Care Variations:
• Constipation is a common concern in the long-term setting. Clients at risk must be monitored regarding their bowel habits.
• Long-term care clients may develop rituals regarding their bowel habits. As long as the rituals are not unhealthy, a client should be allowed to perform any ritual that will help maintain bowel regularity.
COMMON ERRORS—ASK YOURSELF
Possible Error:
Giving a prepackaged enema that is cooler than body temperature.
Ask Yourself:
How do I prevent this error?
Prevention:
Think about what happens when cooler than body temperature fluid is infused into the rectum. Be sure to warm all fluids infused into the rectum. An enema is an unpleasant procedure for most clients, and the cramping caused by fluids that are too cool only increases the client’s discomfort. Since many prepackaged enemas are designed to stimulate peristalsis, the client may experience severe cramping from the cool fluid. If this is a medicated enema that the client should retain, the cramping induced by the cool water may cause the client to expel the fluid and the medication.
NURSING TIPS
• Assess the client’s room to ensure that there is a clear, easy path to the bathroom.
• The order “Enemas until clear” means that enemas are to be repeated until the client passes fluid that contains no fecal matter, not until the fluid returned is not cloudy. Although disposable enema kits may come with prelubricated tips, additional lubricant may be needed (see Figure 6-19-19).
• The enema should be stopped immediately if severe cramping or sudden abdominal pain occurs. In the event this happens, the client should be assessed for possible bowel perforation and bleeding.
• An enema should be used as a last resort for the treatment of constipation. Oral medication, suppositories, increased fluids, and exercise, if appropriate, should be attempted first.
• If the client is unable to retain the enema solution during the procedure, the enema can be given with the client lying on his back on the bedpan. This method is not as effective as retaining the solution, but it may be enough to stimulate peristalsis and flush the stool out of the client’s rectum.
Figure 6-19-19 Many prepackaged enemas come with prelubricated tips. Check the enema for this type of tip. Bring аdditional lubricant to the bedside.
Digital Removal of Fecal Impaction
OVERVIEW OF THE SKILL
Sometimes, due to severe constipation from immobility, surgery (see Figure 6-20-2), medications, or neurologic deficit, the feces becomes so hard and large that it will not pass through the anus without tissue damage. When this happens, the nurse is called upon to remove the fecal mass manually. This is done by inserting one or two gloved fingers into the rectum and manually breaking up the fecal impaction. The nurse then removes the hard stool and disposes of it appropriately. This procedure can be uncomfortable and embarrassing for the client.Manipulating the rectal mucosa can cause local trauma and possibly bleeding. The vagus nerve is easily stimulated rectally and may cause the client’s heart rate to slow dangerously. This procedure should be performed with caution in clients with a history of cardiac disease, dysrhythmias, or recent rectal or pelvic surgery.
ASSESSMENT
1. Assess the date and quality of client’s last bowel movement to avoid procedure if it is not necessary.
2. Assess the client for signs of fecal impaction. These signs include complaints of nausea or anorexia, abdominal fullness, abdominal pain or cramps, an absence of formed stool for 3 days or longer, a palpable mass in the lower abdomen, and incontinence of liquid stool. This helps to differentiate between the need for manual disimpaction and a cleansing enema.
3. Assess the condition of the client’s perianal area. Check for anal irritation, hemorrhoids, fissures, or breaks in skin integrity. This will allow the nurse to determine if there is a preexisting alteration in skin integrity.
4. Auscultate bowel sounds. This will allow the nurse to determine if the client is experiencing an alteration in gastrointestinal function other than severe constipation.
> DIAGNOSIS
1.3.1.1 Constipation
1.6.2.1.2.2 Risk for Impaired Skin Integrity
8.1.1 Knowledge Deficit, related to elimination
9.1.1 Pain
> PLANNING
Expected Outcomes:
1. The client’s rectum will be free of feces.
2. The client will experience a minimum of discomfort and embarrassment during the
procedure.
3. The client will not experience any adverse side effects during or as a result of this procedure.
Equipment Needed (see Figure 6-20-3):
• Disposable absorbent pads
• Bed pan
• Clean gloves
• Water-soluble lubricant
• Washcloth, towel
• Basin of water or perianal cleanser
• Odor eliminator spray (optional to decrease odor, which may increase client embarrassment over procedure)
• Toilet tissue
CLIENT EDUCATION NEEDED:
1. Teach the client the importance of proper dietary intake and bulk to prevent constipation.
2. Note the importance of exercise in promoting peristalsis.
3. Teach the importance of responding to the urge to defecate when it occurs.
4. Teach the client that drinking plenty of fluids will help reduce the possibility of constipation.
Estimated time to complete the skill: 10–20 minutes
EVALUATION
• The client’s rectum is free of feces.
• The client experienced a minimum of discomfort and embarrassment during the procedure.
• The client did not experience any adverse side effects during or as a result of the procedure.
> DOCUMENTATION
Narrative Notes
• Document the procedure. Indicate the date and time the procedure was performed.
• Note the client’s tolerance of the procedure; indicate if the client had any significant complications from the procedure, such as slowing of heart rate or rectal bleeding.
• Indicate the color, consistency, odor, and amount of stool removed. Note any alterations in perianal skin integrity that were found.
> CRITICAL THINKING SKILL
Introduction
Client teaching is an essential part of nursing care.
Possible Scenario
Mr. Jeanperre was admitted to the hospital following an automobile accident. He was in skeletal traction secondary to several fractures. After 2 days of hospitalization Mr. Jeanperre’s nurse became concerned that he had not had a bowel movement. She offered him the bedpan but he politely refused. By his fourth day of hospitalization, Mr. Jeanperre’s nurse started to insist that he try to use the bedpan. He allowed her to place the bedpan but it was apparent that he would not use it. After 5 days without a bowel movement, Mr. Jeanperre’s nurse discussed this issue with his physician. His physician performed a rectal exam and discovered a large hard mass of stool in Mr. Jeanperre’s rectum. He noted that it was too large for Mr. Jeanperre to pass without damage to the sphincter so he ordered manual removal of the hardened stool.
Possible Outcome
When the nurse approached Mr. Jeanperre and explained the procedure and the reason it was needed, he was visibly upset.He explained that he had not used the bedpan earlier due to his intense embarrassment and to have to undergo this procedure would be much more humiliating. The nurse was empathetic and assured Mr. Jeanperre that his privacy would be respected as much as possible, but she was insistent that this was a necessary procedure. Mr. Jeanperre finally consented to the procedure. He tolerated the procedure well despite tightly clenched teeth. After the nurse had finished, he thanked her for her patience and gentleness and noted that in the future he would use the bedpan in a timely manner.
Prevention
Client teaching and timely intervention could have saved Mr. Jeanperre discomfort. If the nurse had discussed the need for regular bowel movements with Mr. Jeanperre when she first became concerned, this incident may have been avoided. She could have offered alternatives that may have been more acceptable to the client. He might have been more comfortable with a male nurse assisting him. He might have accepted a family member assisting him rather than a staff member. The nurse needs to take an active role in problem solving to provide the best care possible for her clients.
t VARIATIONS
Geriatric Variations:
• Elderly clients may have a very fragile rectal mucosa. Be sure to use an adequate amount of lubrication and perform this task gently.
• Elderly clients may be confused and unable to understand what you are doing and why.
• You may need assistance to safely complete the procedure.
Pediatric Variations:
• Do not explain too much in advance to a younger child, as this will only cause needless fear. Explain each step as you start to perform it.
• Be aware of the child’s smaller anatomy. Break the pieces of stool up very small to prevent trauma to the anal sphincter. Use your little finger to protect small child or infant from injury.
• Be aware that a younger child may see this invasive procedure as punishment. Reassure the child that he or she has not done anything wrong, and that this procedure will help him or her feel better.
Home Care Variations:
• If fecal impaction is a frequent problem for the home care client, a caregiver or the client may need to be taught the procedure.
• Encourage the home care client to develop a bowel routine to prevent fecal impaction. Find out what cues and rituals help stimulate the urge to defecate and encourage to incorporate them into the daily routine.
Long-Term Care Variations:
• Long-term care clients are at a high risk for impaction. If their mobility is impaired, impaction may be a frequent problem. Frequent monitoring of the client’s bowel status and ongoing client teaching regarding the importance of regular bowel movements are important in this setting. • Long-term care clients may simply resign themselves to having this procedure done on a regular basis rather than try to maintain a regular schedule of bowel movements. Be sure to encourage these clients to develop as “normal” a pattern of elimination as possible.
COMMON ERRORS—ASK YOURSELF
Possible Error:
Missing the cues of extended period of time without a bowel movement.
Ask Yourself:
How do I prevent this error?
Prevention:
Read the client’s medical record if client is unable to provide accurate history of bowel habits.
> NURSING TIPS
• Manual stimulation of rectum may cause excessive vagal nerve stimulation and subsequent cardiac arrhythmia;
monitor for signs of vasovagal reaction.
• If the client’s anal skin integrity is impaired prior to the procedure, care must be takeot to contaminate the open area with stool.
• This procedure must be done gently. The rectal mucosa is thin and easily damaged. Tearing the rectal mucosa can introduce Escherichia coli into the client’s bloodstream.
• Use of Xylocaine gel to lubricate fingers will help decrease pain. Beware that it may impair the client’s ability to perceive and report injury to the tissues.
Inserting a Rectal Tube
> OVERVIEW OF THE SKILL
The insertion of a rectal tube is done to manage flatulence (gas) following abdominal surgery and/or reduce abdominal distention due to flatulence. It can be used to alleviate dyspnea due to abdominal distention. Finally, it is used to control diarrhea that cannot be controlled with medical management and/or the use of rectal pouches, pads, or diapers due to extensive skin breakdown. The use of a rectal tube is a short.term solution.
ASSESSMENT
1. Auscultate bowel sounds. Allows the nurse to determine if the client is experiencing reduced or increased
peristalsis and establishes a baseline for comparisons after the procedure.
2. Assess fluid intake and output status. Enables the nurse to determine possible changes in the client’s oral intake that need to be addressed.
3. Assess nutritional intake. Enables the nurse to determine possible changes in the client’s food intake that need to be addressed.
4. Inspect the perianal skin. Allows the nurse to determine if there is a preexisting alteration in skin integrity.
5. Assess for complaints of cramping, pain, or abdominal distention, which may indicate the presence of gas and reduced peristalsis.
> DIAGNOSIS
1.3.1.3 Bowel Incontinence
1.6.2.1.2.1 Impaired Skin Integrity
1.2.1.1 Risk for Infection
9.1.1 Pain
1.6.1 Risk for Injury
> PLANNING
Expected Outcomes:
1. Elimination pattern returns to normal.
2. Client’s abdominal girth will return to a size withiormal limits for client’s body type.
3. Client’s skin integrity will not be damaged by the procedure.
Equipment Needed (see Figure 6-21-2):
• Rectal tube or catheter, 22 to 30 French
• Water-soluble lubricant
• Bedside drainage bag (optional, if rectal tube used to manage diarrhea)
• Ostomy odor eliminator or similar product (optional)
• Clean gloves
• Disposable pads or towels
Estimated time to complete the skill: 3 –5 minutes
> CLIENT EDUCATION NEEDED:
1. Explain rationale regarding need of tube and its short duration of use.
EVALUATION
• Elimination pattern returned to normal.
• Client’s abdominal girth returned to a size withiormal limits for client’s body type.
• Client’s skin was not damaged by the procedure.
DOCUMENTATION
Nurses’Notes
• Description of bowel sounds
• Abdominal girth
• Insertion and removal of rectal tube
• Color and amount of diarrhea, if present
• Presence of flatus release
• Appearance of perianal skin
• Client tolerance of the procedure
> CRITICAL THINKING SKILL
Introduction
A client is unable to evacuate flatus in the normal manner due to physiologic disease.
Possible Scenario
A 70-year-old male is 3 days status post repair of ruptured abdominal aortic aneurysm. He complains of increasing respiratory difficulty, and the nursing notes indicated that his abdomen appears distended.He has not passed flatus or stool since 48 hours prior to admission and surgery. Examination of the abdomen reveals diminished bowel sounds.
Possible Outcome
An astute nurse would realize that the client has a possible partial ileus, which could result in retaining flatulence, increased abdominal girth, and possible bowel obstruction. The physician should be immediately informed of the client’s condition. Temporary placement of a rectal tube may be indicated.
Prevention
Early ambulating of patient will facilitate peristalsis. The client should be observed frequently and gastrointestinal and respiratory status assessed.
VARIATIONS
Geriatric Variations:
• Elderly clients may have more friable rectal mucosa. If a balloon is used to hold the rectal tube in place, deflate the balloon and reposition the catheter frequently.
• Confused clients may become agitated by the presence of the tube, believing they need to move their bowels.
Pediatric Variations:
• Use a tube that is the appropriate size for the child.
• Leaving a rectal tube in place may not be appropriate for very small children.
• Teenagers may be acutely embarrassed by passing flatus. Be sensitive to their developing body image.
Home Care Variations:
• Rectal tubes are not generally used in the home care setting.
Long-Term Care Variations:
• Rectal tubes are not generally used in the long-term care setting.
COMMON ERRORS—ASK YOURSELF
Possible Error:
Missing the cues of decreased bowel sounds and increased abdominal distention.
Ask Yourself:
How do I prevent this error?
Prevention:
Assess gastrointestinal system (auscultation of bowel sounds) and include abdominal girth in the case of diminished or absent bowel sounds. Ask client questions appropriate to ascertaining status of gastrointestinal tract (i.e., “Have you passed any gas today or belched?” “Are you having any cramping in your stomach/abdomen?”). Also always do an accurate review of client’s medical record, including assessment of gastrointestinal status.
> NURSING TIPS
• Rectal tube may be reinserted every 2 to 3 hours.
• Deflate balloon of tube every hour for 5 to 10 minutes to decrease possible bowel wall necrosis from compression of microvasculature.
• Discontinue rectal tube when stool is no longer liquid or when gas is relieved.
• Use of an external collection system is preferred, particularly if client’s integument is intact.
• Odor and noise are good ways to determine if flatulence is being removed. Be aware, however, that these may be acutely embarrassing to the client.
• A rectal tube is contraindicated for clients with rectal disease or neutropenia, and for those who are immunocompromised or receiving anticoagulation therapy.
Irrigating and Cleaning a Stoma
> OVERVIEW OF THE SKILL
The purpose of a colostomy irrigation is to empty the large colon of stool. The colostomy irrigation can be performed at the bedside or in the bathroom. This process is similar to performing an enema. This procedure is not commonly done in many facilities. Check with the qualified practitioner, facility procedure manual, or nursing supervisor if you are uncertain.
> ASSESSMENT
1. Inspect the stoma for color and texture. This allows the nurse to determine the viability and turgor of the stoma.
2. Inspect the condition of the skin surrounding the stoma. Alterations in skin integrity prohibit a closed drainage system from adhering to the skin.
3. Determine the direction of the intestine by digitalization of the stoma. This allows the nurse to know the direction of the intestinal tract prior to beginning the irrigation, which will prevent possible perforation of the bowel.
4. Measure the dimensions of the stoma prior to obtaining an ostomy appliance system from central supply. This alleviates the problem of obtaining the wrong size equipment.
> DIAGNOSIS
1.3.1.3 Bowel Incontinence
1.6.2.1.2.2 Risk for Impaired Skin Integrity
6.5.4 Toileting Self Care Deficit
7.1.1 Body Image Disturbance
> PLANNING
Expected Outcomes:
1. Client will experience bowel movement after irrigation of colon (colostomy).
2. Client and/or caregiver will demonstrate skill in performing irrigation of colon (colostomy).
3. Periostomal skin integrity will remain intact.
4. Irritated or denuded periostomal skin integrity will heal.
5. Client will acknowledge the change in body image.
6. Client will express positive feelings about self.
7. Client will maintain fluid balance.
Equipment Needed (see Figure 6-22-2):
• Colostomy irrigation kit
• Gauze 4 3 4 or stoma cover
• Tape, if gauze is used
• Clean gloves
• Ostomy odor eliminator
• Bedpan, toilet, or basin
> CLIENT EDUCATION NEEDED:
1. Instruct the client on the frequency of colostomy irrigation.Most clients irrigate their colostomy every day to every other day.
2. Clients with a normal bowel habit of movements every 2–3 days are more easily regulated with colostomy irrigation than those individuals with 2–3 bowel movements per day.
3. Instruct the client on changes in skin condition or stoma to report to enterostomal/ostomy care nurse.
EVALUATION
• Client experiences a bowel movement after irrigation of colon (colostomy).
• Client or caregiver is able to demonstrate skill in performing irrigation of colon (colostomy).
• Peristomal skin integrity remains intact.
• Irritated or denuded peristomal skin integrity is healed.
• Client acknowledges the change in body image.
• Client expresses positive feelings about self.
• Client maintains fluid balance.
> DOCUMENTATION
Nurses’Notes
• Document assessment of peristomal skin.
• Document assessment of stoma.
• Document stoma measurements (length, width, height).
• Document amount of water used for irrigation.
• Document amount of stool flushed from colon.
• Document peristomal skin care if alteration in skin integrity was noted.
• Document type of dressing or ostomy pouch applied following irrigation.
REAL WORLD ANECDOTES
A 78-year-old female has had her colostomy for 20 years because of rectal cancer. Following a short recovery room stay after surgery, she had radiation therapy. She has irrigated her own colostomy for the past 20 years. She is now complaining of severe intestinal cramping that is not relieved by colostomy irrigation and she is having persistent diarrhea. The client continued to irrigate the colostomy until seen by the enterostomy/ostomy nurse who reviewed the basic guidelines for performing colostomy irrigation with the client. The client discontinued irrigation of the colostomy after learning that it is not appropriate to irrigate when experiencing diarrhea.
CRITICAL THINKING SKILL
Introduction
Look at a scenario in which the client with a colostomy is ieed of a colostomy irrigation.
Possible Scenario
A 54-year-old male is recovering from an abdominal perineal resection and is requesting information on colostomy irrigation. He is 5 days postsurgery and is scheduled to begin chemotherapy and radiation therapy within the next 6 weeks.
Possible Outcome
If the client were to begin colostomy irrigatioow, there is the possibility that he would become discouraged with the process once he began chemotherapy and radiation therapy. It takes approximately 6–12 weeks for the bowel to become acclimated to the irrigation process and this is the time when the client would be receiving his cancer therapies. Both chemotherapy and radiation will cause changes in the bowel, resulting in diarrhea, which is a contraindication to colostomy irrigation.
Prevention
The nurse should provide the client with information on colostomy irrigation and the rationale for waiting to begin the learning process after completion of cancer therapies. A second nursing action is to consult the enterostomal/ostomy care nurse.
VARIATIONS
Geriatric Variations:
• A client who is too old to do the cleaning and maintenance procedures without assistance will need regular help from a caregiver. Instruct the caregiver, and “backup” caregivers if available, how to do the procedure.
Pediatric Variations:
• A client who is too young (less than 5 years old) to do the procedure without assistance will need help from a parent. Instruct the parents how to do the procedure.
Home Care Variations:
• If the client performs the procedure at home, assess the environment for safety. In the event the client feels weak or faint during the procedure, he should know how to stop the procedure and lie down.
VARIATIONS continued
Long-Term Care Variations:
• Make periodic assessments of the condition of the colostomy.
• Provide periodic refreshers on the procedures and technique for the cleaning and maintenance of a colostomy.
• When reviewing the colostomy procedures with the client, reinforce the need to maintain good hygiene.
> NURSING TIPS
• Client teaching is easily incorporated into the care of the ostomy by encouraging the client to be your assistant during the irrigation process.
• Clients who irrigate their colostomy still need to learn how to apply an ostomy appliance.
• Clients should always be instructed to use the cone adapter for irrigation and not a catheter, so as to avoid possible bowel perforation.
COMMON ERRORS—ASK YOURSELF
Possible Error:
Client complains of severe cramping during irrigation of colostomy.
Ask Yourself:
How do I prevent this error?
Prevention:
Slow infusion of tepid water into colostomy and hang irrigation bag no higher than 12 to
Changing a Bowel Diversion Ostomy Appliance:
Pouching a Stoma
> OVERVIEW OF THE SKILL
A colostomy is an opening surgically created from the ascending, transverse, or descending colon to the abdominal wall. An ileostomy is an opening from the ileum to the abdominal wall. Colostomies and ileostomies function to discharge waste (liquids, solids, and gases) to the outside of the body. Pouching a fecal diversion ensures that the client’s peristomal skin remains intact and provides the client with artificial continence. The purpose of creating ileostomies and colostomies is to improve survival and the quality of life. Anger, grief, body image disturbances, socialization disturbances, depression, and helplessness often accompany these procedures.
ASSESSMENT
1. Inspect the stoma for color and texture. Allows the nurse to determine the viability and turgor of the stoma.
2. Inspect the condition of the skin surrounding the stoma. Alterations in skin integrity will prohibit a closed drainage system from adhering to the skin.
3. Measure the dimensions of the stoma prior to obtaining an ostomy appliance system from central supply. Alleviates the problem of obtaining the wrong size equipment.
> DIAGNOSIS
1.6.2.1.2.2 Risk for Impaired Skin Integrity
1.6.2.1.2.1 Impaired Skin Integrity
7.1.1 Body Image Disturbance
> PLANNING
Expected Outcomes:
1. Peristomal skin integrity will remain intact.
2. Irritated or denuded peristomal skin integrity will heal.
3. Client will acknowledge the change in body image.
4. Client will express positive feelings about self.
5. Client will maintain fluid balance.
Equipment Needed (see Figures 6-23-2 to6-23-4):
• Clean washcloth or 4 3 4 gauze pads
• Warm tap water
• Appropriate drainable ostomy appliance
• Scissors
• Pen or pencil
• Clean gloves
> CLIENT EDUCATION NEEDED:
1. Instruct client on pouch application, including frequency of change.Most pouching systems can be maintained for a minimum of 3 days to a maximum of 7 days.
2. Instruct client on changes in skin condition to report to wound/ostomy care nurse (ET nurse).
3. Provide the client with a list of equipment and product numbers as well as a list of retailers where supplies can be purchased.
4. List of reasons and situations on when to call physician and/or qualified practitioner.
EVALUATION
• Peristomal skin integrity remains intact.
• Irritated or denuded peristomal skin integrity is healed.
• Client acknowledges the change in body image.
• Client expresses positive feelings about self.
• Client maintains fluid balance.
DOCUMENTATION
Nurses’Notes
• Assessment of peristomal skin
• Assessment of stoma
• Stoma measurements (length, width, height)
• Color and amount of drainage
• Peristomal skin care if alteration in skin integrity was noted
• Type of ostomy pouch applied
> CRITICAL THINKING SKILL
Introduction
A client is postoperative abdominal perineal surgery with a permanent colostomy for rectal cancer.
Possible Scenario
A 78-year-old male is recovering from an abdominal perineal resection with a permanent colostomy for rectal cancer.He asks his nurse, “When will the surgeon remove this?” pointing to the colostomy. Upon further conversation with the client, the nurse learns that the client had been told an ostomy might not be needed if the surgeon “got everything” during the surgery.
Possible Outcome
The astute nurse will recognize the client’s clue that he is not aware of the permanence of the colostomy given the surgical procedure he recently underwent. It is possible that the client has not fully recovered from the anesthetic agents used during surgery or the client is experiencing some confusion regarding details of the surgery.
Prevention
Review with the client the type of surgery he had and the permanence of the ostomy. Report any of your concerns regarding the client’s understanding of the surgery and ostomy to the physician.
VARIATIONS
Geriatric Variations:
• If a client has arthritic hands, it is best to use either a one-piece appliance that is precut or a twopiece appliance that is adaptive to decreases in hand dexterity.
Pediatric Variations:
• A child’s ostomy bag needs to be very flexible, so it can bend with the client’s movement without becoming nonadherent.
• Adolescents need careful assessment and intervention to help them adjust to changes in body images related to the stoma and appliance.
Home Care Variations:
• Assess the client’s home for an appropriate setting in which to change the ostomy appliance and proper means to dispose of the contaminated items.
Long-Term Care Variations:
• Consider the ongoing stress of a slowly healing colostomy and the potential changes to body image large scars and marks will cause even after they have healed. Connect the client with support groups or further assessment if needed.
COMMON ERRORS—ASK YOURSELF
Possible Error:
The appliance chosen is too small for the stoma’s dimensions.
Ask Yourself:
How do I prevent this error?
Prevention:
Measure the dimensions of the stoma prior to obtaining and preparing a pouch for application. If the error has occurred, remove the leaking appliance and remeasure the stoma dimensions before reapplying the ostomy appliance.
COMMON ERRORS—ASK YOURSELF continued
Possible Error:
The ostomy pouch is always full of liquid stool and the pouch has come unsnapped from the wafer several times.
Ask Yourself:
How do I prevent this error?
Prevention:
Increase the frequency of checking and emptying the pouch. If increasing the frequency of emptying the pouch is impractical, it is best to change the pouch from a drainable system to a urinary pouch, which can be attached to bedside drainage.
> NURSING TIPS
• Recognize that all stomas are not the same. Each stoma must be treated individually, which requires that the nurse assess the dimensions, the location in relation to the client’s body movements (i.e., sitting, bending), and the peristomal skin’s condition.
• Client teaching is easily incorporated into the care of the ostomy by encouraging the client to assist the nurse during the application process.
• Use of an ostomy appliance that is intact, comfortable, and easy to use will increase the client’s comfort level and thereby their participation in self-care activities and socialization.
• Costs to the client and the health care institution are reduced when simplistic ostomy care is provided. Simplistic ostomy care excludes the daily use of pectin powder, pectin, paste, and skin sealant.
