Nursing FundamentalsBowel Elimination

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Chapter 29 G.I. Intubation

Measures to promote bowel elimination

• Nurses use 2 interventions:

• 1. Suppositories

• 2. enemas

Suppository

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

Local effects of suppositories

• LOCAL EFFECTS – include administering the suppository and it lubricating and softening dry stool. The supp. Irritates the wall of the rectum and anal canal and stimulates smooth muscle contraction to increase rectal distention and increasing the urge to defecate

Systemic Effects of Suppositories

• Systemic Effects - These are taken by mouth where they work internally to increase motor activity in the G.I. Tract to cause defecation

Administering Enemas

• An enema introduces a solution into the rectum to:• Cleanse the lower bowel (most common use)• To soften feces• To expel flatus• To sooth irritated mucous membranes• To outline the colon during diagnostic x-rays• To treat worm and parasite infestations (anti-

helminth – remember in ch 5 Disease?)

Cleansing Enemas

• Are used to cleanse the lower bowel before a procedure or surgery or for constipation

• With a cleansing enema, defecation should occur within 15-20 minutes after administration

Cleansing Enemas

• Usually involves large volumes of liquid entering the lower bowel causing distention or cramping

• Nurse must administer these slowly as to not rupture the bowel

Types of cleansing enemas

• Tap water and normal saline enemas

• Soap solution enema

• Hypertonic saline enema

• Keep these in for 15-20 minutes, then expel

Types of retaining enemas

• Sometimes oil enemas

• Always foam enemas like the steroid types

• Keep these in for 30 minutes then expel except the foam enemas usually dissolve in the instestin and nothing comes out

Tap Water and Normal Saline Enema

• These are preferred due to the less amount of irritation that these have

• Tap water and saline enemas have the same degree of effectiveness for cleansing the bowel

Problems with Tap water enemas

• Because tap water is hypotonic, fluid is absorbed through the bowel. If several enemas are given, fluid and electrolyte imbalances can occur.

• ONLY 3 ENEMAS CAN BE GIVEN AT A TIME to prevent this fluid imbalance from occurring

Soap Suds enema

• Usually 1 packet of soap is combined with up to 1000ml of water. If concentrations are not correct and solution is too concentrated, it will cause irritation to the rectum

Hypertonic Saline Solutions

• These use sodium phosphate as their main ingredient

• This is a FLEETS enema, when given, it draws water into the colon to aid in defecation. The pts output will be more than what was instilled. This too, is a rectal irritant

• Solutions such as FLEETS can be purchased OTC and in 4oz increments

Retention Enemas

• These include solutions usually made of oil or steroids.

• Pt is to retain or hold the solution for at least 30 minutes and some retention enemas are not expelled at all

• Oil filled enemas come pre-filled and can be bought OTC also, these oil enemas lubricate and soften the stool for easier expulsion

Cleansing Enema(AV)

Equipment

EQUIPMENT NEEDED

• Always have gloves (non-sterile)

• Lubrication (surgi-lube) in individ. Packets

• Chux pads

• Bed pan or bedside commode

• The ordered enema bottle, or kit for soap suds enema

•

When NOT to administer an enema

• Never perform this technique while pt is sitting on toilet, too difficult to administer

• Never to be used daily, pt will rely on this to stool, bad

• Never administer with N/V or abdominal pain d/t possibility of perforating intestine

Ostomy

• An ostomy is a surgically created opening into a body structure

• Some patients have had surgery to repair or remove part or most of their intestines

• Once surgery has taken place, the intestine needs to recover (in many cases)

• A ulcerated intestine can be removed and either reconnected (anastamosis) or the working portion of the intestine is pulled through the abdominal wall and stitched there. The other end is left just inside the abdominal wall to rest. An opening is created in the inner abd. wall and the working end of the intestine is pulled through to the outside

• You now have an ostomy and that ostomy must collect into a bag

Ostomy Care

• See page 687 in book for pictures of stomas and their locations

• Persons with a stoma wear an appliance which is a bag or collection device over the stoma

• Many patients can care for this themselves however, nurses can also care for stomas

What to assess

• Check the condition of the skin around the actual stoma for redness or excoriation

• The stoma itself should be beefy red and look like organ meat, no blood should be present, if so, notify RN or Dr.immediately

• Stoma should not be cyanotic, call Dr. STAT

Providing peristomal care

• Preventing skin breakdown is a major challenge of ostomy care

• Enzymes in stool can quickly excoriate the skin. Excoriation is a chemical injury of the skin, if not properly cared for, infection will occur

Washing

• Washing the actual stoma and skin around the stoma with mild soap and water and patting it dry will preserve the skin

• Companies also make special skin care pastes to be used in peristomal care

Applying the ostomy appliance

• Stomal appliances come in all shapes ans sizes but they all come with a foam like faceplate or disk or donut. This portion actually sticks to the skin around the stoma and the beefy stoma pokes through the middle of this piece.

• A plastic bag with a lid –type edge snaps over the faceplate like the lid on a butter container. There is a clamp at the bottom of the plastic bag for emptying of the stomal contents

Problems…

• The faceplate is supposed to stay intact for 3-5 days however… the face plate often becomes loose and leaks stool around the appliance causing much stress and frustration for the pt and the nurse

» Some try and tape the loose area of the faceplate, but often times, this is not sufficient

When to empty the stoma

• The client or nurse empties the stoma when it is 1/3 to ½ full; otherwise it will become too heavy and the faceplate will pull away from the skin

Types of appliances

• Some appliances use stoma paste and powder to adhere the faceplate. This type becomes messy and doesn’t always stick.

• Others just peel away the backing and apply the faceplate to clean, dry skin. These don’t always work either.

• When skin is even slightly reddened, appliances don’t stick well

• Some stoma bags contain a charcoal filter that keeps the stool’s odor in

Sounds of a stoma

• If you are standing near a person with a stoma, you will most likely be able to hear growls, gurgles and the passing of gas into the stoma bag.

• Most patients, especially teens, are quite embarrassed by this. It is important that you act professional and that you provide support to the patient. Most facilities have an E.T. nurse (enterostomal) that is available. Use her, she is a pro at stomas and really helps the patient

Draining a continent ileostomy

• There are procedures that are done that bypass the colon for defecation. The Dr. makes a pouch in the abdominal cavity where the stool collects until the patient manually drains it. The patients takes a lubricated 22-28 french rectal tube and inserts it into the belly button carefully

• The pt has a valve just inside the belly button area that keeps the stool in until he caths it. He advances the catheter about 2 inches while bearing down or exhaling. He empties the stool into a graduate container and he can also irrigate this tube with tap water to clean it. Infection rate can be high in these patients

Colostomy

• The stool in this area is _______________

• Water may be needed to irrigate the colon somewhat to loosen it up

• Pts with a sigmoid colostomy may not need to wear an appliance, he may be able to irrigate his colostomy before defecation to remove the stool, sort of a bowel training technique

NANDA Diagnoses

• Constipation

• Risk for constipation

• Diarrhea

• Bowel Incontinence

• Toileting-Self care deficit

• Depression

• Situational low Self-esteem

THE ENDof

Bowel Elimination

Chapter 20G.I. Intubation

Who receives a gastrointestinal tube?

• LAVAGE/LEAVING or DECOMPRESSION

• Pts undergoing gastrointestinal or stomach surgery especially

• The use of a G.I. Tube reduces or eliminates problems associated with surgery or conditions affecting the GI tract such as impaired peristalsis, vomiting, or gas accumulation

• GAVAGE/GIVING or FEEDING

• Pts may also receive a tube to help nourish them with liquid feedings for those who cannot eat such as anorexics, infants or children and the elderly

Intubation

• Means the placement of a tube into a body structure

Types of NG tubes

• See handout please

• Orogastric

• Nasogastric

• Nasointestinal

• Transabdominal

Different types of tubes

• Orogastric – insertion of a tube through the mouth into the stomach. Such as when having stomach pumped (Lavage) Ewald

• Nasogastric – insertion of a tube through the nose into the stomach. Such as the basic NG tube Salem-sump (Decompression)

• Nasointestinal – insertion of a tube through the nose into the intestine, this type of tube requires a guided wire and a weight on the end of the tube. An x-ray is done after the tube is in to check placement, this tube flows down into the duodenum with the help of the weighted end. In some institutions, only a Dr. can insert this tube. (Gavage) Keofeed or Dobhoff

Purpose of G.I. Intubation

• Gavage – providing nourishment (giving)

• Lavage – washing out of a cavity, irrigation (leaving)

• Obtain secretions/decompression - tubing is connected to a suction machine and a collection container, removes air, gastrointestinal juices

Size of the intubation tube

• Again, size matters…

• The outside diameter of the tube (its thickness) is measured using the “French Scale”, indicated by the letter “F”

• Each number on the French scale = .33mm. The larger the number on the package, the larger in diameter the tube is. 18F is bigger than a 10F tube

• You must decide on how big of a tube your pt should have, the tube must fir loosely into the nares

Orogastric tubes - Ewald

• Inserted into the mouth and down into the stomach

• These are used to lavage out toxic substances that have been ingested as in a Tylenol overdose

• These tubes are large in diameter to remove pill fragments and stomach debris

• Because the size is so large, this tube is entered into the mouth rather than the nose

Nasogastric Tube – Salem-Sump

• This tube is places into the nose and down into the stomach is smaller in diameter but longer in length

• NG tubes can have more than 1 lumen, sort of like a Y’d tubing. One side goes to the pts nose and then to the container to drain and the other lumen (tube) hangs freely an acts as a vent so the NG will drain properly. If you plug up the vent, no drainage will occur

NGT’s

• Can stay in for a length of time to decompress or to aid in feedings

• These tubes cause the throat to become sore as in having strep throat sore. Many pts attempt to pull out their tubes while asleep because it’s a natural instinct to want that tube out

• NGT’s must be taped well, in place, especially in infants and children while tube feeds are running to avoid misplacement and choking

• NGT’s are easier to place when pt is asleep, not always possible though

Insertion of the tube (explanation of procedure)

• The nurse must first explain the procedure to the patient.

• Many pts refuse this placement, you can be the advocate to the pt and calm and ease their fears concerning the NG Tube

• Tell the pt that the diameter of the tube is smaller than most pieces of food and all they have to do is swallow

• Not always possible to do

Assess the nares

• You are looking for nasal debris, tell pt to blow nose into Kleenex to clear the way

• Assess for patency of the nares, inspect for shape, and size, deviated septum or nasal polyps

• If any of these are present, notify the RN or Dr.

Measurement of tube

• Use the N.E.X. method:

• Measure from the pts Nose to the Earlobe to the Xiphoid process, this is how much tubing you will insert into the pt’s nose

• Mark the tubing with a permanent marker

Tube Placement

• The nurse’s job is to minimize discomfort to the pt. This can be difficult to do if the pt is not cooperative

• The nurse must also try and preserve the integrity of the nasal tissue

• The nurse must place the tube into the stomach NOT the respiratory passages

What should the patient do

• The patient should sit completely up in the bed• Tuck their chin to their chest and sip in water,

swallowing it as the nurse slowly pushes the tube into the nose and back towards the pharynx and the gag reflex

• The nurse can stop at any time to comfort the patient, movement of the tube should be consistent and slow, not jamming it in roughly

Problems that can occur during placement of the tube

• During the technique of trying to pass the tube, a pt may alert you that the tube is coming out of their mouth, you should immediately stop and remove the tube.

• The tube can also become coiled up in the throat while it’s on its way down, again, tube must be removed and reattempted

Checking placement of the tube

• Once the tube is at its final mark, the nurse needs to verify that it is really in place

• There are a few techniques to check tube placement…

3 methods of checking tube placement

• 1)Aspirate fluid from the tube using a syringe

• 2)Aspirate fluid using a syringe and test Ph

• 3) Auscultate abdomen listening for air

3 methods of Tube Placement• 1) Aspirate fluid – • using a syringe, • pull back and see • if clear, brownish-• yellow or green • fluid can be • aspirated, the • nurse can • presume that • the tube is in • the stomach.

• 2) Ausciltate the abdomenAusciltate the abdomen – the nurse instills 10ml of air or more using a syringe and listens over the “stomach area” of the abdomen with a stethoscope. If a swooshing sound is heard, the can presume that the tube is in place (most popular way of checking)

Tube placement

• 3) Testing the PH of aspirated fluids – testing the PH confirms 100% that the tube is placed correctly.

• Other than obtaining a chest x-ray, THE PH TEST IS THE MOST ACCURATE TECHNIQUE FOR CHECKING NGT PLACEMENT (this is not used in all facilities)

Misplaced tubes

• 1) If the NGT is in the esophagus, the pt will belch

• 2) If no swoosh sound is heard, the tube may be coiled

• 3) If the tube is in the respiratory passage somewhere, the pt should immediately cough, this is a clear and immediate response to a foreign object entering into the resp. passages (no mistaking this)

• 4) If the tube comes out of the pt’s mouth, obviously, it’s not in the correct place

NGT used for Decompression

• When bellies are full of fluid or gas after surgery when peristalsis has not returned, pts will have N/V, NGTs are to be connected to suction and THEY MUST BE WORKING CORRECTLY in order to give the pt relief

NGTs for decompression• Tubing is connected to

suction at:• 1) Low to medium

suction (40-60mm hg)• 2) At intermediate

suction. If you put an NGT to continuous suction, it will suck and suck and suck causing GI irritation to the lining of the stomach wall. Blood will be seen in the drainage container

Continuous Suctioning

• Can be used when the nurse is irrigating the NG with normal saline

Irrigating an NGT

• Often times, pts will c/o nausea and may even vomit. Persons with an NGT should not vomit.

• Secretions in stomach may be thick esp. after days of having tube in place.

• NGT can be irrigated with NORMAL SALINE ONLY to help loosen up the thick secretions

Why use normal saline (NS) to irrigate

• NS is isotonic = has equal • ingredients as the body does• If you use sterile water, it is hypotonic, what do

the electrolytes want to do? They want to help make the solutions more equal therefore if you give sterile water, too many electrolytes will be lost

In the body IN GENERAL…

• Normal Saline (NS) is the irrigating fluid to be used for any type of irrigation

• It best meets the same needs of the body, it is most equal to the body’s fluids

• We never offer ice or water to pt’s with an NGT, the fluid will get suctioned out immediately and if B.S. are not present, pt will become nauseous

• NCLEX Question

Giving Meds to a pt with an NGT

• If meds MUST be given, you must turn off the suction for up to 1 hour to allow medication to be absorbed however…

• Pts without B.S. means that nothing will move on through to the intestines and pt is likely to have N/V.

• If no B.S. are present, don’t bother giving meds via NGT, when you resume suction, you’ll just see the meds being suctioned out into the canister, then the pt didn’t get the meds ordered…not good

Securing the NGT

• There are several• Ways to secure an NGT• Gently tape the NGT to the cheek of the same side

of the nare where the tube is placed• Wrap the tubing around the upper part of the ear

and allow the NGT to hang down from behind the ear. Steri-strips are used to secure the tube or plain tape

• Wrap tape around the tube right at the site of entry into the nare and then apply tape to the cheek. Watch children with tubes, they pull them out

Deciding to remove the NGT

• If the pt’s bowel sounds return and the pt is recovering well, the Dr. may order the NGT to be clamped for up to 6 hours before removal of the tube is ordered

• Simply disconnect the tubing from the suction machine to allow pt to get OOB and tuck the coiled tube up and place in the pocket of the pt gown. Wait from 1-6 hours as ordered, pt usually starts to drink clear fluids and if pt has no N/V, tube can be removed. WAIT FOR THE DR.s ORDER

Removing the NGT• Explain to the pt that they are having their tube

discontinued• Pt will usually be thrilled and may help you

remove it • Remove all tape GENTLY, (tape can hurt). • Don non-sterile gloves and pinch off the tubing

gently pull on tube, using both hands to walk it out of the nare. Pinching off tube will help to not make GI contents drip into nose or mouth. I usually have a chux pad ready and I lay it on the pt’s chest to catch the end of the tube. The pt may sneeze when it is out completely, the nose may run or bleed, offer tissue to the pt

Transabdominal tube

Transabdominal tubes

• Otherwise known as feeding tubes for enteral nutrition

• Enteral – within or by way of the intestine. Nourishment provided via the stomach or small intestine rather than by the oral route

Types of enteral tubes

• Gastrostomy tube - A.K.A. G-tube, this tube enters the stomach. Can be used for feedings and medications

• Jejunostomy tube - A.K.A J-tube, this tube enters through the jejunostomy and bi-passes the stomach and enters the small intestine

• PEG tube (percutaneous endoscopic gastrostomy tube) – is a G-tube, is used for feeds and meds. Performed under endoscopy and tube is pulled out of the body

• (These tubes are used when a pt needs feeding longer than 1 month and cannot eat P.O.)

G-Tube

PEG tube

Checking residual of these tubes is important

• Once a pt is fed via one of the tubes, residual or amount of food undigested, must be assessed before feeding again

• Pts can have slow digestion and their belly may still be full from the last fees, if you re-feed them, they may have vomiting d/t too full of a belly

Performing a tube feeding

• Assess the skin around the tube site. Is it red, does it need to be cleaned.

• Aspirate fluid from the tube to determine if the volume of feeds exceeds the pts physiologic capacity

• Overfilling of the stomach leads to gastric reflux, regurgitation and vomiting and aspiration into lungs = pneumonia

Rule of thumb

• The gastric residual should be no more than 100ml or no more than 20% of the previous hours tube feeding volume

• When aspirating the residual, YOU MUST TAKE THE TOTAL AND RETURN THE ASPIRATED LIQUID BACK TO THE PT. This aspirate is filled with electrolytes and belongs to the pt. You would note the amount and report it to the RN or Dr. Perhaps the next feed will be held d/t the aspirated amount

What to do to speed up digestion and movement through the tube

• Try and sit pt up

• Try and place pt on their right side to increase faster emptying of the stomach

• Reglan can be given

• Class: GI stimulant, anti-emetic

TUBE FEEDING PUMP

Once a patient has an NGT or feeding tube…

• Pt is automatically placed on I’s & O’s, you want to record all that goes in and all that comes out

• Be sure to follow the order and provide the correct feeding at the correct rate

• Be sure to flush the NGT or feeding tube when feed is completed with tap water

Bolus Feeds

• Instillation of liquid nourishment 4 - 6 x’s /day in less than 30 minutes

• The usual bolus feed is 250-400ml of formula

• This type and amount of feed can distend the stomach rapidly, can cause gastric discomfort, can increase the risk of reflux and aspiration

Be careful….

• If gastric emptying is delayed or the pt is unconscious or is developmentally delayed, the pt is at greater risk for vomiting and aspiration with this method of feeding

Intermittent Feedings

• 250-400 ml is given 4-6xs/day like the bolus feeds except the intermittent feeds are given over 30-60 mins, not less than 30 mins. These feed drip in by gravity

• It’s a little slower of a feed to reduce the feeling of bloating

Changing feeding bags

• You must rinse out a feeding bag between EVERY use and open a new bag every 24 hours due to the possible growth of microorganisms

Cyclic Feedings

• Continuous feedings of liquid nourishments for 8-12 hours with a 12-16 hr rest of no feeds

• These pts receive these types of feeds overnight and attempt to eat orally during the day

• Problems occur when the pt tries to sleep and peristalsis slows down and you try and feed your pt during the night. Bloating, nausea, vomiting and possible aspiration can occur

Continuous Feedings

• The instillation of liquid nourishment without interruption

• The rate is usually at 1.5ml/minute, a pump is needed to regulate this small amount

• The formula is delivered right to the small intestine through a J tube or PEG tube

• This type of feed reduces the amt of bloating, N/V, aspiration.

• The pump must go wherever the pt goes, sort of inconvenient

Continuous Feeds

• You can only put 4 hours worth of liquid feed into the bag at one time to reduce the possibility of microbes that may grow.

Medication

• The nurse can instill medication in liquid form into the tube during a tube feed

• The nurse MUST STOP THE FEED PUMP OR GRAVITY DRIPPING FEED, flush the tubing , then push each medication separately with a syringe into the feeding tube. You must flush with saline in between every med. When the meds are instilled, flush the tube again with water and resume the feed

Complications of tube feeds

• 1) ASPIRATION• Keep HOB up at all times, this becomes

uncomfortable in pts who are getting continuous tube feeds, they want to lay down

• Check for residual and distention before every feed if intermittent and every 2 hours in feed is continuous

• Notify RN or Dr. if distention, N/V is noted. Tube feed may be with held

Complications of tube feeds

• 2.) DUMPING SYNDROME• Happens when there is a large amount of calorie-

dense nutrients rapidly dumped into the small intestine

• Symptoms include: dizziness, sweating, N/V – this is caused by fluid shifts from the circulating blood to the intestine and low blood sugar related to a surge of insulin, diarrhea also occurs = dehydration and dry mucosa

Complications of tube feeds

• 3) Clogging up of the tube itself, some meds clog tubes easily, you can try the following:

• Using a bubbly clear soda like ginger ale or 7-up and try to use a small syringe and push and pull back on the syringe trying to push the soda into the tube. Sometimes, nurses use cranberry juice and it works!

• Using meat tenderizer works, it breaks up fat in meat and it breaks up a clog in a tube, mix it with water and use the syringe method like the clear soda method

NANDA Diagnoses

• Imbalanced Nutrition: Less that body requirements

• Self care deficit: Feeding

• Risk for aspiration

• Impaired oral mucous membranes

• Diarrhea

• Constipation

THE END