Nursing Fundamentals

1. Nursing Fundamentals Bowel Elimination Pgs 684-702 & Chapter 29 G.I. Intubation

2. Measures to promote bowel elimination • Nurses use 2 interventions: • 1. Suppositories • 2. enemas

3. Suppository • Oval or cone shaped mass of medication that melts at body temperature

4. 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

5. 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

6. 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 (anti-helminth – remember in ch 5 Disease?)

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

19. 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

20. 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

21. 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)

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. NANDA Diagnoses • Constipation • Risk for constipation • Diarrhea • Bowel Incontinence • Toileting-Self care deficit • Depression • Situational low Self-esteem

36. THE ENDofBowel Elimination

37. Chapter 20G.I. Intubation

38. 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 Who receives a gastrointestinal tube?

39. Intubation • Means the placement of a tube into a body structure

40. Types of NG tubes • See handout please • Orogastric • Nasogastric • Nasointestinal • Transabdominal

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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. Assess the nares

49. 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

50. 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