question

Cleansing Enemas

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these are given to remove feces from the colon commonly to relieve constipation or fecal impaction, prevent involuntary escape of fecal material during surgical procedures, promote visualization of the intentional tract by radiographic or instrument examination, and help establish regular bowel function during a bowel training program.

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4 Types of Cleansing Enemas

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-Hypertonic -Tap Water (Hypotonic) -Normal Saline (Isotonic) -Soap Suds Enema

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Hypertonic

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Distends intestine, irritates intentional mucosa, pulls fluid out of interstitial spaces. Causes fluid shifting Low volume: 70-130mL Fleets Do not give to dehydrated patients, infants, patients with renal disease or kidney failure Takes 5-10 to take effect

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Tap Water (hypotonic)

answer

Distends intentine, increases peristalsis, and softens stool. Causes fluid shifting Large Volume 500-1000mL Not to be repeated or used on infants or children Takes 15min to take effect

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Normal Saline (Isotonic 0.9 sodium chloride)

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Safest Safe for children and infants Distends intestines, increases peristalsis and softens stool. Saline is reflective to our body fluids Do not cause fluid shifting 500-1000mL Time to take effect 15 min

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Oil Retention

answer

lubricates the stool and intentional mucosa making defecation easier. about 200mL can be mineral, olive or cottonseed oil Time to take effect 30 min

question

Inappropriate times to administer Hypertonic and tap water enemas

answer

These two types cause fluid shifting so it is not safe for dehydrated patients, very young infants and children, patients with renal disease or kidney failure. Or patients with sodium retention

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What is the correct type of soap that should be used when administering soapsuds enema

answer

Pure castile soap

question

What is the correct position that a patient should be placed in before administering an enema and why

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A reclining position specifically left side lying position (Sims position) or the knee to the chest position. It helps distribute the solution throughout the lower intentional tract. Sims position facilitates the flow of solution via gravity into the rectum colon optimizing fluid retention

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How high should the nurse hold the large volume enema container to administer a large volume cleansing enema

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12- 18 inches above the level of the anus

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What temperature should be the solution be for enema administration

answer

Warm to room temp or slightly higher test on inner wrist 103-110

question

Prioritize the nurses actions if a patient complains of abdominal discomfort and cramping during enema administration

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Clamp the tubing or lower the container, encourage patient to take small deep breaths and pant, also can check water temperature

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How far does the nurse insert the enema tip into the rectum of an adult

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3-4 inches

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What nursing assessment needs to be performed after enema administration

answer

Asses for dizziness, diaphoresis, and clammy skin. The enema may stimulate vaginal responses which increases parasympathetic stimulation causing a decrease in heart rate.

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Factors that affect bowel elimination

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Mobility Diet Medications Intentional diversions

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How might anxiety or stress affect bowel elimination

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may experience constipation

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How might the location of the bathroom affect bowel elimination

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Some people may hold it in

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How might Surgery and anesthesia affect bowel elimination

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inhibit peristalsis

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How might physical activity affect bowel elimination

answer

constipation

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How might the following factors affect bowel elimination in older adult patients: decreased peristalsis and decreased physical activity

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constipation and fecal impaction

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How do the abuse of medications such as laxatives, stool softeners, and enemas affect bowel elimination

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People can become dependent and it will cause your body to not be able to stimulate peristalsis on its on Laxatives should not be taken when their is abdominal pain because of an intestinal pathologic condition Habitual use can cause chronic constipation body loses natural ability to defecate

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Constipation

answer

dry hard stool, difficult to pass, or incomplete passage of stool. Straining typically occurs during defecation

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Fecal Impaction

answer

prolonged retention or accumulation of fecal material that forms hardened mass in the rectum. Collection of hardened feces

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Diarrhea

answer

passage of more than 3 loose stools a day. often associated with intentional cramps. nausea and vomitting may occur

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Paralytic Ileus

answer

postoperative ileus- paralysis of intestinal peristalsis. Abdominal incisions and direct manipulation during abdominal surgery inhibit peristalsis causing this condition. The temporary stoppage of peristalsis lasts 3-5 days. During this time food and drink are witheld

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Potential risks with severe diarrhea might experience

answer

large amonts of fluids and electrolytes are lost very quick , which can put patients at high risk for life threatening complications such as dehydration and electrolyte imbalance and skin breakdown

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Nursing Intervention Constipation

answer

increase movement and exercise High fiber foods: whole grains, bran, fruits, and vegetables Fluid intake 2 liters a day- warm (avoid dairy) do not ignore urge to go teach about laxative abuse

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Nursing intervention for Diarrhea

answer

answer call light immediately avoid high fiber foods avoid spicy foods do not increase activity after eating hand hygiene stay hydrated (fluids at room temp) eat yogurt, cheese, soymilk. use of electrolytes teach about food safety eat eggs, well cooked meat, fish , poultry, juices without pulp, reminded bread and cereal, well cooked fruits and vegetables BRAT diet is no longer recommended

question

Nursing interventions for fecal incotinence

answer

offer tolieting ever 2 hours change bed linens and clothing frequently keep skin clean and dry protective undergarments as long as they are not on bedrest

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Nursing Intervention for Flatulence

answer

use warm blankets increased movement avoid gas producing foods such as beans, broccoli, cauliflower, and onions. avoid reclining after meals avoid gums and straws avoid carbonated drinks

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External Hemorrhoids

answer

sitz bath

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High Fiber Foods

answer

whole grain bran dreid peas fresh fruits and veggies

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Low Fiber Foods

answer

Eggs well cooked meat poultry juices without pulp refined bread and cereal well cooked fruits and vegetables

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How do hot or cold fluids affect peristalsis

answer

Warm or Hot increases peristalsis Cold decreases peristalsis

question

How do spicy foods affect peristalsis

answer

increase and have laxative effect

question

What types of foods and fluids are recommend for a patient experiencing diarrhea

answer

Fluids: water, gatorade, weak tea, and all at room temp Foods: foods low in fiber. If they are experiencing alterations in fluids and electrolyte balance they need fluids containing sodium chloride, potassium and glucose

question

What types if foods and fluids are recommended to prevent constipation

answer

High fiber foods such as bran, fruits, veggies, and whole grains Fluids: warm fluids and at least 2 liters a day

question

What temp of fluid is recommended to prevent diarrhea versus to treat constipation

answer

Diarrhea:room temp Constipation: warm to increase peristalsis

question

Should disposable undergarments like spends be used for bowel incontinent patients

answer

No because they cause skin breakdown

question

What might you teach a patient to promote normal bowel function

answer

-encourage tolieting at the patients usual time of day -sitting upright on a toilet or commode promotes defecation -provide privacy -adequate nutrition for normal defecation fluid intake of 2000-3000mL -high fiber intake -water is the recommended fluid -reguar exercise improves gastrointestinal motility and aids in defecation -do not ignore the urge to go

question

Peristalsis

answer

contractions of the circular and longitudinal muscles of the intestine occur every 3 to 12 minutes moving waste products along the length of the intestine continuously

question

Chyme

answer

semifluid state that food is in when it leaves the stomach

question

Hemorrhoids

answer

abnormally listened rectal vein

question

Valsalva Manevuer

answer

bearing down to defecate

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Cathartic

answer

medication that strongly increases gastrointestinal motility and promotes defecation

question

What might an ileostomy be located on the abdomen

answer

-Last part of small bowel (ileum) -Will bring ileum out of the abdomen -Right lower quad -Lage bowel not functioning -Effluent: very liquid and occurs frequently

question

When might the following colostomies be located on the abdomen Ascending Transverse Descending Sigmoid

answer

Colostomy: large intestine Ascending: right lower or right upper Transverse (across)- upper left or upper right Descending: left lower or left upper Sigmoid: Left lower

question

Stool consistencies of the following colostomies Ascending Transverse Descending Sigmoid

answer

Ascending Effluent: liquid Transverse: slightly thicker or mushy Descending: more formed/semi-solid Sigmoid: near normal

question

What is the difference between the ileoanal pouch anastomosis and Kock content ileostomy

answer

Ileoanal Pouch Anastomosis: pouch is created from end of small intestine and attached to anus. Large bowel completely removed. Ileum attached to anus Pouch will act as reservoir to collect feces. anal sphincter still intact. NO OSTOMY OR STOMA bowel will be watery. this is permeant. Possible usage ulcerative colitis and familia polyps. Kock Continent Ileostomy: removes large bowel, sew ileum on to itself to make a holding pouch and the pull the stoma out of the abdomen . In stoma put one way valve. Will not continuously flow out effluent because they are content. They will control when their bowels move. A special cath will be placed to drain out bowel. They will not wear and appliance Permenant. Make the feel like they have more control

question

Normal healthy stoma

answer

Dark pink to red moist shiny rounded mucous membrane protrude 1/2 to 1 inch

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What does purple or dusky color stoma mean

answer

Pale stoma: anemia Dark Purple or Blue: compromised circulation or ischemia

question

What are possible psychological and social interactions a nurse should assess with a patient with a new stoma

answer

-psychologically help with coping -sexual functioning -visit from local group -altered body image -looking at stoma -make neutral or positive statements concerning the stoma -express intrest in learning self-care -diet teaching -odor control

question

How to prevent skin breakdown around the stoma

answer

-clean and dry -when changing the appliance clean skin around stoma, remove self adhesive excretions or buildup can cause skin breakdown -an intact properly applied protects skin integrity -apply skin protectant to 2in radius around stoma -fitting appliance snuggly around stoma with only 1/8inch of skin visible -no wafer or uneven edges

question

When should an ostomy pouch system be emptied

answer

when it is 1/3 to 1/2 full

question

How often should an ostomy pouch system be changed when not leaking

answer

every 3-7 days or whenever the seal comes away from the skin

question

Foods and Fluids for new ostomy

answer

-Avoid foods high in fiber -Foods that cause stomal blockage such as nuts, beans, carrots, etc -Foods that produce odor: asparagus, beans, lentils, eggs, garlic. -Foods that help control diarrhea: applesauce, bananas, cheese, peanut butter, oatmeal, oat bran, potatoes, yogurt, starchy foods -Natural Odorizers: buttermilk, parsley, and YOGURT

question

Recommendations for patient who complains of odor with ostomy

answer

-using odor tablets -bag is clean and sealed well -avoid foods that cause odor -encourage intake of dark green vegetables -Buttermilk, cranberry juice, parsley, and yogurt

question

What type of ostomy can be irrigated

answer

Patients who have left sided colostomies in descending or signed colon Must be mentally alert, have adequate vision, and have adequate mania dexterity

question

Supplies needed for irrigation

answer

waterproof pad, bedpan or toilet, water-soluble lubricant, IV pole, disposable gloves, solution at room temp, new ostomy, cone tipped applicator

question

Irrigating

answer

daily 5-10 min install solution 1 HOUR TO HOUR AND HALF TO PROCESS

question

Traditional Constructions

answer

Loop End Double Barrel

question

Loop

answer

loop of transverse bowel pulled into abdomen and the incision is made like filet to expose the bowel leaving 2 openings Proximal- effluent will drain Distal- nothing Temporary to let bowel rest May see crossbar/ supporting device to keep stoma from going back into abdomen

question

End

answer

One stoma Proximal: brought to abdominal wall Bowel cut in 2 Distal: sewn closed or taken out

question

Double

answer

2 stomas Cut in 2 Proximal end- drain effluent Distal: nothing temporary to rest bowel

question

Support Groups

answer

-United Ostomy Association -National Foundation for Ileitis and colitis

question

Prevent or minimize aspiration when feeding a patient with dysphagia

answer

-30 min to rest prior to mealtime -Sit pt upright/ HOB 90 -Mouth care before meals -avoid rushed or forced feeding -adjust rate and size of bites -inspect oral cavity for retained food -avoid or minimize the use of sedatives and hypotonic -assess for signs of aspiration -alternate solids and liquids -reduce and eliminate distractions

question

What is the order that diets usually advance starting with clear liquid

answer

Clear liquid Full liquid diet or Pureed Soft or mechanically altered

question

Clear liquid diet

answer

initial post op diet preparation of bowel surgery after acute illness

question

Pureed Diet

answer

after oral or facial surgery

question

Mechanically altered diet

answer

chewing or swallowing difficulties

question

What type of patients would the nurse anticipate a prescription for enteral feedings

answer

increased nutritional requirements NPO for more than 2 days Dysphagia Inability to eat Needing supplemental nutrition stroke

question

Why must a patient have a functioning gastrointestinal tract for enteral feedings to be administered

answer

food will not move through

question

Advantages of Gastrostomy/jejunostomy or percutaneous endoscopic gastrostomy/jejunostimy for enteral feedings versus NG OR NI tubes

answer

-Less likely to aspirate -No embarrassment -Less likely to irritate skin -can be immersed in water -less likely to become dislodged -has a cap

question

Intermittent Feedings

answer

preferred method of gastric feedings delivered at regular intervals in equal portions Introduced slowly over a set period of time by gravity or feeding pump resemble more of normal pattern movement between feedings Higher risk of dumping syndrome and aspiration over distention nausea diarrhea camping

question

What time period should an intermittent feeding be administered over

answer

regulate drop to medical order or allow to run over 30 min

question

Maximum amount of enteral feeding that should be given at one time if administering an intermittent feeding

answer

150-250mL

question

How might the nurse safely increase the flow rate on a continuous enteral feeding

answer

increase by 10-25 ML per hour every 8 -12 hours until desired rate is achieved

question

HOB when receiving enteral nutrition

answer

30 to 45 degrees

question

Appropriate method to confirm nasogastric or nasointestional tube placement which is most accurate

answer

Visual Assessment: stomach green pH: Less than 5.5 Measure tube length Radiographic most accurate

question

When is gastric residual checked

answer

Intermittent: before each feeding Continous: every 4 to 6 hours

question

How long can a feeding bag be safely hung before needing to be discarded

answer

24 hours to prevent contamination

question

Solution temp

answer

room temp/ if too warm or col it will affect peristalsis

question

Why should the nurse clean the top of the can before opening

answer

minimizes risk for conatmination

question

Why do we shake the can

answer

to ensure it is mixed well

question

When should intermittent enteral feedings be flushed

answer

Part of ordered amount before feedings remained when feeding is nearly complete

question

When should continuous drip enteral feedings be flushed

answer

every 4 hours after withdrawing aspirate

question

What is appropriate solution type to flush with

answer

water or normal saline

question

Preventing Pulmonary Aspiration

answer

check tube placement elevate hob to 30-45 gastric residual

question

Preventing Diarrhea

answer

prevent bacterial contamination change delivery system clean formula can dispose of opened cans in refrigerator after 24hr limit hang time to 8 hours hand hygiene slow feedings

question

Preventing Tube Occlusion

answer

flush before and after every 4 hours conintuous after residual instill 30 mL of warm water with 50 or 60 ml syringe to attempt to unclog Only use meds in liquid form

question

What should the nurse do if the patient complains of abdominal discomfort

answer

lower the height of shrine

question

Gastric residual less than 200mL

answer

return and flush with 30mL of water

question

Gastric residual greater than 200mL

answer

call the dr do not replace

question

What is the priority nursing action to implement if a patient starts coughing or vomiting with intermittent feedings

answer

stop the feeding

question

Common lab values for enteral nutrition

answer

Glucose every 6 hours 60-110mg Serum Albumin 3.5-5 Pre-albumin 15-36mg

question

Why would a non diabetic pt have to have finger stick blood glucose monitoring performed

answer

test tolerance of feeding/ making sure the pancreas is keeping up

question

Assessments a nurse would monitor to determine the effectiveness of internal nutrition

answer

GI, respiratory, I and Os, pt weight

question

Levin Tube

answer

1 lumin large feeding and meds

question

Dobhoff Tube

answer

Smaller

question

Salem Sump

answer

has air vent 2 lumens

question

Nasogastric Tubes used for

answer

short term less than 4 weeks

question

Nasointestional Tube

answer

through nose into small intestine

question

Fecal Occult Blood test

answer

blood hidden in special or can not be seen by gross examination

question

Nasoenteric

answer

decompression/ used for feeding

question

Decompression

answer

drain or suction unwanted fluid tube ends in stomach salem sump levin miller abbott

question

Gavage

answer

giving a patient liquid nutrition

question

Lavage

answer

washing washing or irrigating out the stomach

question

Compression

answer

adding pressure

question

Pigtail

answer

continous flow of air

question

Measure nasogastric

answer

tip of nose to earlobe and from earlobe xiphoid process

question

curve end of salem sump Ng

answer

aids in insertion

question

Ng tube needs to be lubed how much

answer

at least 2-4

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