Complications of enteral nutrition

Complications of enteral nutrition

1. the osmolality of a liquid substance means the number of particles per kg of solution

2. substance with high osmolality reaches intestines draw fluid from blood to dilute formula (osmosis) diarrhea, weakness

3. aspiration in the lungs can get pneumonia, keep bed at 30 degrees

4. tube may become clogged or confused patient may pull out tube

5. placement of the tube should be checked initially with x-ray, air bubble or check pH

6. gastric pH check or by ascultation

7. keep bed elevated

Parenteral Nutrition

1. provides nutrients via IV

2. used if the gastrointestinal tract is not functional & normal feeding not adequate

3. Total Parenteral Nutrition (TPN) or hyperalimentation = total nutrition

4. peripheral vein used if only 2 weeks or less. If more than 2 weeks, use picc line.

5. Central vein used when extended period of time ie. TPN 6 mos. +

6. high blood flow facilitates quick dilution of highly concentrated TPN reducing risk of phlebitis & thrombophlebitis

Complications of Parenteral Nutrition

1. infection at site of catheter - blood infected = sepsis

2. bacterial or fungal infections develop in solutions

3. abnormal electrolyte levels phlebitis or blood clots (thrombosis) travel

4. enormous increase in energy needed for healing process to occur

5. protein needs may be as high as 1.5-3.0 or more grams / kg wt.

6. fat intake may be 15-20% of non-protein calories

7. high protein, high calorie diet

8. watch blood sugar

Clients with Infections

1. fever is hypermetabolic state each degree of fever on F scale raises basal metabolic

   scale by 7%

2. If extra calories are not provided, body uses stores of energy. ie glycogen

3. protein intake should be increased

4. minerals are needed to help build and repair body tissue to maintain pH & electrolytes

5. extra vitamins are also necessary for the increased metabolic rate and help fight infection

6. extra liquid needed to replace losses

Dumping syndrome

Dumping syndrome

1. after gastric surgery

2. characterized by dizziness, weakness, cramps, vomiting, diarrhea, shortly after eating

3. caused by food moving too quickly from stomach to small intestine

4. to prevent, eat a diet high in protein & fat, restrict CHO's

5. complex CHO's reintroduce gradually

6. fluids limited to 4oz at meals

7. total daily food served as several small meals to avoid overloading stomach

The Client Receiving Enteral Nutrition

1. includes the forms of feeding that bring nutrients directly into GI tract

2. tube feedings may be necessary in clients due to unconsciousness, surgery, stroke (can't pass swallow test), severe malnutrition, & extensive burns

3. nasogastric tube (NG) through nose into stomach or small intestine

4. gastrostomy (opening into stomach) or jejunostomy (opening to jejunum) surgically if needed longer than 6 weeks

5. numerous commercial formulas

6. polymeric formulas (1-2 calories / mL) clients who can digest & absorb nutrients normally

7. elemental or hydrolyzed formulas (1.0 calorie / mL) clients who have limited ability to digest or absorb nutrients

8. modular formulas (3.8-4.0 calories / mL) supplements developed customized formulas

Methods of Administration

1. continuous ongoing 16-24 hours

2. intermittent supplemented at night, food eaten in daytime

3. bolus short period 15-30 minutes

Marasmus

Marasmus

1. affects very young children

2. results from severe malnutrition

3. lack of energy, protein, minerals, vitamins

4. emaciated look, no edema

5. hair dull, dry, skin thin & wrinkled
   
   

Kwashiorkor severe lack of sufficient protein

1. sudden or recent lack of protein-containing food happens in children & adults

2. fat accumulates in liver

3. lack of protein & hormones

4. results in edema, painful skin lesions, changes in skin, hair pigmentation, ↑mortality

Nutritional care of the surgical client

1. if the surgery is elective, want to have nutritional status evaluated before surgery

2. extra protein, CHO, vitamins, & minerals may be needed

3. for overweight clients, improved nutritional status lose weight, especially with knee & hip

4. clients will usually be NPO after midnight prevent regurgitation / aspiration

Nutritional care after surgery

1. in most cases, patients receive intravenous solution after surgery

2. solutions contain water, 5-10% dextrose, vitamins, medications, & antibiotics

3. adults after surgery need 35-45 calories / per kg body weight additional for healing

4. maximum calories supplied by solutions 400-500 calories in 24 hr. period (calorie deficit)

5. a high protein diet may be recommended because of protein loss

6. extra minerals, vitamins

7. when peristalsis returns, start on ice-chips, then clear-liquids

8. progress to a regular diet

9. some clients may need a parenteral or enteral feeding

Positive nitrogen balance

Positive nitrogen balance exists when N⁺ intake exceeds N⁺ excreted

1. pregnancy

2. growth period

3. building muscles

4. rebuilding of tissue after trauma, illness

Negative nitrogen balance exists when more N⁺ lost than consumed (protein lost)

1. fever

2. injury

3. surgery

4. burns

5. starvation

6. immobilization

Protein Deficiency

1. muscle wasting

2. albumen deficiency causes edema

3. loss of appetite

4. strength ↓, weight ↓

5. lethargy, depression, slow wound healing

Protein Energy Malnutrition (PEM)

1. Have lack of protein & energy rich foods

2. found in developing countries

3. shortages of protein & energy rich foods cause stomach growth in children

4. mental retardation may occur if born to mothers with protein deficiency

Functions of Proteins

Functions of Proteins

1. build & repair

2. regulating body functions

   a. metabolism

   b. digestion

   c. fluid & electrolyte balance

   d. development of antibodies

3. providing energy each gram of protein provides 4 calories

Digestion and Absorption

1. Mechanical digestion

   a. mouth

   b. grind break up

2. Chemical digestion

   a. stomach HCL prepares stomach

   b. enzyme pepsin reduces protein to polypeptide

   c. polypeptide is 10+ amino acids bonded together

   d. in small intestine, three pancreatic enzymes: trypsin, chymotrypsin, & carboxypeptidase aids

   absorption through villi

Metabolism & Elimination

1. amino acids are broken down

2. nitrogen-containing amine group is stripped off "deamination" →ammonia produced

3. liver picks up ammonia convert to urea

4. kidneys filter urea

5. remaining parts are used for energy or converted to CHO or fats & stored as glycogen or adipose

   tissue

Dietary Requirements

1. determined by size, age, sex, physical, & emotional condition

2. the National Research Council of the National Academy of Sciences considers the average daily

   requirement is 0.8 grams protein for each kg body weight

Protein Excess

1. saturated fats and cholesterol found in complete protein contribute to heart disease

2. connection to colon cancer

3. substitute meat for vegetable or fruit

4. increased demand on kidney & liver

5. National Research Council recommends that protein intake represent no more than 15-20% of one's daily caloric intake. (should not exceed double the amount in table of daily recommended allowances)

Nitrogen Balance: nitrogen intake = nitrogen excreted

Dietary Recommendations

Dietary Recommendations:

1. Deficiency symptoms occur when fats provide less than 10% of total daily calories

2. the Food and Nutrition Board's Committee on Diet and Health recommends people ↓fat to 30%

   of total calories

3. American Heart Association's newest recommendations is to consume or =" to"

   fats, 8% of polyunsaturated fats, and 15% of monosaturated fats

4. at present, 36% of calories (in U.S.) from fat

5. an excess of fat in diet can result in obesity, heart disease, & cancer

Protein Facts

1. of the six nutrient groups, only protein can make new cells & rebuild tissue

2. need throughout lifespan

3. proteins are the basic material of every body cell

4. also only nutrient with nitrogen

Amino Acids

1. proteins composed of amino acids

2. amino acids are nitrogen-containing compounds

3. essential amino acids must be provided in diet

4. 8 essential amino acids in adults and two more in children

5. nonessential amino acids can be produced by body

Classifications

1. complete

   a. high quality

   b. contain 10 amino acids

2. incomplete

   a. lack one or more amino acids

   b. cannot build tissue without help

3. complementary proteins

   a. occur when a combination of incomplete proteins combine with all amino acids complete

   b. ie. corn & beans, rice & beans, bread & peanut butter, bread & split pea soup, bread &

   cheese, bread & baked beans, macaroni & cheese, cereal & milk

Food Sources

1. Animal food sources

   a. meats complete protein

   b. fish, poultry, eggs, cheese

2. Plant food sources

   a. incomplete protein

   b. ie. corn, grain, nuts, sunflower seeds, sesame seeds, legumes

3. Analogues

   a. meat alternatives made from soy protein

   b. tofu is a soft product made from soybeans

   c. helpful to strict vegetarians

Metabolism and Excretion

Metabolism and Excretion

1. the liver controls fat metabolism in the cells

2. fatty acids are broken down to CO₂ & H₂O , releasing energy

3. fat not needed stored as adipose

4. CO₂ & H₂O are removed as waste products from circulatory, respiratory & excretory systems

Phospholipids

1. found in both plants & animal foods, synthesized in liver

2. natural emulsifier helps transport fats in bloodstream -ie. lecithin

Fat alternatives

Olestra in potato chips

1. made from CHO's & fats

2. FDA approved for use in snack food but don't know long-term effects

3. Gov't requires that food labels indicate olestra inhibits absorption of some vitamins. & other nutrients

4. should be used in moderation or get side effects cramps & diarrhea

5. contains no calories

Simplesse

1. made from egg white & milk protein

2. can be used only in cold foods

Oatrim

1. CHO-based (oat fiber)

2. can be used in baking, but not frying

Lipoproteins

Lipoproteins

1. in the initial stages of fat absorption, bile joins with products of fat digestion to carry fat

2. later protein combines with final products of fat digestion to form special carriers called

   lipoproteins

3. lipoproteins carry the fat into body cells

4. classified according to mobility & density

Lipoprotein Types:

1. chylomicrons
   

   a. first lipoprotein identified after eating

b. largest lipoprotein

c. lightest in wt.

d. composed of 80-90% triglycerides

2.Very-low-density lipoproteins (VLDL's)

a. made by liver and transports lipids throughout body

b. composed of 55-65% triglycerides

c. carry triglycerides & other lipids to all cells

d. as the VLDL loses triglycerides, they pick up cholesterol from other lipoproteins in the blood

and become LDL's

3. Low-density lipoproteins (LDL's)

a. composed of 45% cholesterol, few triglycerides

b. carry most of the blood cholesterol from liver to cells

c. elevated blood levels > 130 mg/dL contribute to heart disease

4. High-density lipoproteins (HDL's)

a. carry cholesterol from the cells to liver for eventual excretion

b. levels of HDL > than 35 mg/dL thought to ↓ risk of heart disease

c. exercise, maintain desireable wt. & give up smoking are all ways to ↑ HDL's in body

d. HDL's are good cholesterol

Trans Fatty Acids

Trans Fatty Acids TFA's

1. produced when hydrogen atoms are added to mono or polyunsaturated fats & produces semi-soft product., ie. margarine & shortening

2. TFA's raise LDL's & total cholesterol

3. major source: baked goods, cookes, brownies, restaurant foods

Hydrogenated fats

1. Polyunsaturated veg. oils to which H⁺ is added commercially to make solid at room temp.

2. this product, called hydrogenation turns polyunsaturated veg oils into saturated fats

3. margarine & shortening made from vegetable oil

Cholesterol

1. cholesterol is a sterol or fat-like substance

2. exists in animal foods & body cells

3. essential for synthesis of bile, sex hormone, cortisone, vit. D

4. every cell needs

5. daily intake should be 300

Digestion and Absorption

1. 95% of ingested fats are digested through complex process

2. chemical digestion of fats mainly in small intestine

3. no digestion of fats occurs in mouth

4. slight digestion in stomach where gastric lipase works on certain fats ie. cream, egg yolk

5. digestion in small intestine

   a. bile emulsifies fat

   b. the enzyme pancreatic lipase reduces fat to fatty acids and glycerol

   c. the body subsequently absorbs through villi of small intesting

Fatty Acid Classification

Fatty Acid Classification may be classified by the body's need for them:

1. essential fatty acid "EFA's"

2. non-essential fatty acids

May be classified by degree of saturation with hydrogen atoms:

1. saturated

2. unsaturated

   a. monosaturated

   b. polysaturated

Essential Fatty Acids cannot be synthesized by body, must be obtained by diet

Two families:

1. Omega 3

2. Omega 6

3. Non-essential fatty acids synthesized by body Omega 3 + Omega 6 = Omega 9

Saturated Fats

1. each of its carbon atoms carries a hydrogen atom

2. in general, animal foods contain more saturated saturated fatty acids than unsaturated

3. usually solid at room temperature

4. examples: meat, poultry, egg yolks, whole milk, cream, butter, chocolate, coconut

Monosaturated fats

1. have one place among the carbon atoms where there are fewer hydrogen atoms attached than in saturated fats

2. can lower "low-density lipoproteins" (LDL's or bad cholesterol)

3. example: olive oil, canola oil, avocado, cashews

Polyunsaturated fats

1. have two or more places among the carbon atoms where there are fewer H⁺ atoms attached

   than saturated fats

2. examples: cooking oils made from sunflower, safflower, sesame seeds, soft margarine with major ingredient is oil from corn & soybeans

3. foods containing high proportion of polyunsaturated fats are soft & oily

4. Omega 3 fatty acids found in fish can ↓heart disease risk

5. Omega 6 fatty acids also have cholesterol ↓ effect

6. recommended: 8% or less in diet

Sources of Polysaccharides

Sources of Polysaccharides:

1. starch potatoes, corn, yams, noodles, beans

2. glycogen glucose stored in liver, muscles

3. cellulose wheat bran, whole grain, cereals, fruits, green leafy vegetables

4. hemicellulose whole grains

Digestion & Absorption of Monosaccharides

1. simple sugars directly absorbed into bloodstream

2. carried to liver fructose & galactose changed to glucose & this is carried to cells

Digestion and Absorption of disaccharides

1. enzymes sucrase, maltase, & lactase change sucrose, maltose & lactose to glucose

2. simple sugars absorbed directly into bloodstream

3. glucose carried to cells

Digestion and Absorption of Polysaccharides

1. more complex, digestibility varies

2. cellulose wall broken down, starch Δ'd to dextrin →maltose →glucose

3. starch digestion begins in the mouth (salivary amylase changes starch to dextrin)

Metabolism

1. Islets of Langerhans pancreas secretes insulin (hormone that controls glucose metabolism)

2. insulin is the hormone

3. impaired or absent insulin secretion (glucose ↑ = hyperglycemia)

4. low blood glucose level (not eating, insulin ↑ = hypoglycemia)

Dietary Requirements Food and Nutrition Board of the National Research Council recommends:

1. need half of energy requirements come from CHO's preferably (complex) polysaccharides

2. weight loss & fatigue can result from diet ↓ in CHO's

3. severe deficiency in ketosis

4. surplus becomes fat

5. excessive CHO intake can lead to obesity, dental caries, digestive disturbances

Fat Facts:

1. fats belong to a group of organic compounds called lipids

2. greasy substances insoluble in water

3. each gram of fat contains 9 calories

4. composed of carbon, hydrogen, and oxygen (has ↓ O₂ than CHO's)

Functions of Fats

1. provide energy

2. carry fat-soluble vits. A, D, E, & K

3. supply essential fatty acids

4. protect & support of organs & bones

5. insulate from cold

6. provide satiety after meal

Food Sources

1. Animal

a. fatty meats, fish (shrimp)

b. dairy products

c. whole milk

d. egg yolk

2. Plant

a. vegetable oil & margarine

b. nuts & olives

c. chocolate

d. avocado

Visible fats fats in foods that are purchased & used as fats butter, margarine, lard, cooking oil

Invisible fats fats that are not immediately noticeable egg yolks, cheese, cream, & salad dressing

Classifications

A. Triglycerides

1. most lipids in the body 95%

2. composed of three fatty acids attached to glycerol framework

B. Phospholipids similar to triglycerides, but have 2 fatty acids & peptide group

C. Sterols lipid = cholesterol

Disaccharides

Disaccharides

1. pairs of monosaccharides

2. must be changed to simple sugars by hydrolysis before absorption

3. sucrose, maltose, & lactose

Sucrose composed of glucose & fructose

a. form of CHO present is granulated, powdered, brown sugar, & molasses

b. one of the sweetest & least expensive sugars

c. sources sugar cane, sugar beets, male syrup, candy, jams, jellies

Maltose

a. intermediary product in hydrolysis of starch

b. also created during fermentation process for alcohol / beer

c. found in some infant formulas, malt beverages, beer

d. not as sweet as glucose, sucrose

Lactose

a. sugar found in milk

b. distinct from other sugars, not found in plants

c. helps body absorb calcium

d. not as sweet as monosaccharides or other disaccharides

Polysaccharides complex carbohydrates, compounds of many monosaccharides

Important polysaccharides in nutrition starch, glycogen, & fiber

Starch

1. found in vegetables, potatoes, & grains

2. storage form of glucose in plants

3. supplies energy over a longer period of time because it takes longer to digest (poly's. take longer to digest than disacc's, which take longer than mono's to digest)

Glycogen

1. sometimes called animal starch (storage form of glucose in body)

2. hormone glucagon help liver convert glycogen to glucose as needed

Fiber

1. it is indigestible

2. insoluble - not readily dissolved in H₂O (cellulose, hemicellulose (whole grain), lignins (woody part of vegetables, strawberry seeds

3. soluble partially dissolves in H₂O - gums, pectins, some hemicellulose

Provide fiber

Provide fiber

1. dietary fiber vegetables, fruit, grain

2. recommended intake 20-35 grams / day

3. fiber lowers blood glucose levels: prevent some colon cancers, prevent constipation hemmorhoids, diverticular disease by softening stools

Sources of CHO's principal sources are plant foods:

1. vegetables

2. fruits

3. whole grains

4. nuts

5. beans, legumes, sugars

the only substantial animal source is milk

Classifications: Monosaccharides - simplest form of CHO's absorbed directly into bloodstream from small intestine

Glucose (dextrose)

1. all other forms are converted to glucose

2. berries, grapes, sweet corn, corn syrup

3. central nervous system (brain uses glucose for fuel) and RBC's use

Fructose (levulose)

1. ripe fruits, honey, soft drinks

2. sweetest of all monosaccharides

Galactose

1. product of digestion of milk

2. not found naturally

3. source is lactose

Nutrients and their Functions carbohydrates facts

Nutrients and their Functions carbohydrates facts:

1. primary energy source

2. least expensive and most abundant of the energy nutrients

3. named for the chemical elements they are composed of CHO

Functions

1. provide energy each gram of CHO is 4 calories

2. body needs a constant energy supply

3. a half-day's supply of CHO's stored in liver & muscles for use as needed

4. stored form- glycogen (has protein-sparing function)

Protein-sparing action the primary function of proteins is to build & rebuild tissues. When enough CHO's are ingested (50-100 grams/day), proteins are spared to be used for primary function

Normal fat metabolism

1. without an adequate supply of CHO's, fat is metabolized to meet energy requirements

2. ketones are produced as a by-product of fat metabolism, because fat is not fully oxidized in cell

   can lead to coma, death, (need to get acid/base in balance)

3. ketosis may result condition in which acids called ketones accumulate in blood, upsets the

acid/base balance, results from insulin-dependent diabetes, starvation, extreme low CHO diet

can lead to coma, death

Biochemical Tests used for nutrition

Biochemical Tests used for nutrition

1. serum albumin level

   a. main protein in blood

   b. determines protein status

2. serum transferrin level

   a. normal range for iron-carrying protein in blood

   b. too high iron stores are low

   c. too low body lacks protein

3. Blood urea nitrogen (BUN) renal failure, insufficient renal blood supply, blocked urinary tract

4. Serum creatinine amount of creatinine in blood (renal function evaluated creatine excretion)

5. Creatinine excretion check creatinine excreted in urine over 24 hr. period for estimating body muscle mass. If muscle mass is low (malnutrition) then level of creatinine is low.

6. other tests:

   Hemoglobin (Hgb) hematocrit

   Red blood cells (RBC's)

   White blood cells

   Lipid profile

   Urinalysis

Dietary and Social History

1. Evaluation of food habits

a. 24 hour recall - patient interviewed and tells what they ate & amount

b. food diary - written record of all food you eat over certain time

c. computer diet analysis determine nutrient deficiency or toxicity

2. Social History

a. consideration of financial resources can individual obtain needed food & store it (homeless

can't cook or store food)

b. Food-drug interaction can lead to malnutrition

Cumulative Effects of Nutrition Over Time

Cumulative Effects of Nutrition Over Time

1. Excesses for extended period

   intake of saturated fats leads to atheleroscerosis, obesity, hypertension, diabetes, gall bladder disease, some cancers

2. Deficiencies for extended period

   ↓iron (anemia),↓Thiamin (Berri-Berri), ↓Vit C (scurvy), ↓Ca & Vit D (osteomalacia),

   ↓Ca, Vit. D, Ph, Mg, Fl (osteoporosis), ↓Ca & Vit D (rickets), ↓Iodine (goiter)

Nutrient deficiencies

1. Primary: inadequate dietary intake

2. Secondary: causes other than dietary intake, ie. body not absorb it, cerebral palsy (not metabolize fat)

both primary & secondary result in malnutrition

Nutritional Assessment Tools

1. Nutritional assessment best way to determine deficiencies that can result from lack of

   nutrients

2. Anthropometric measurements

   a. height

   b. weight

   c. head, chest, & abdominal circumference (children)

   d. upper arm indication of skeletal muscle mass / fat / bone

   e. skinfold use calipers to measure fat & muscle

3. Clinical examination

   a. pallor, blue half circles beneath eyes possible deficiency of iron, copper, zinc, B₁₂, B_6, biotin

   b. edema deficiency of protein possible

   c. bumpy "gooseflesh" - deficiency in Vit. A

   d. lesions at corner of mouth, deficiency of riboflavin

   e. glossitis possible deficiency of folic acid, folate

   f. numerous "black & blue" spots & tiny pin-prick red hemorrhages under skin = low vit C

   g. emaciation-possible deficiency: Carbohydrates, proteins, and calories

   h. poorly shaped bones or teeth or (delayed appearance) deficiency in vit C scurvy

   I. slow blood clotting vit K deficiency (green leafy vegs. have vit K, with coumadin, avoid)

   j. unusual nervousness, dermatitis, diarrhea niacin deficiency

   k. tetany deficiency in Ca², K, and Na

   l. goiter deficiency in iodine

Relationship between health and nutrition

Relationship between health and nutrition

A. Characteristics of good nutritional status

1. shiny hair

2. clear skin

3. clear eyes

4. erect posture

5. alert

6. firm flesh on well-developed bone structures

7. pink gums and well-developed teeth

8. normal weight for height

9. firm abdomen

10. emotional stability

11. good stamina; seldom ill

12. healthy appetite

13. healthy normal sleep habits

14. normal elimination

Characteristics of Poor Nutritional Status

1. apathy � flat affect

2. dull, lifeless hair

3. dull, rimmed eyes

4. red, puffy receding gum lines

5. swollen abdomen

6. underdeveloped, flabby muscles

7. overweight or underweight

8. easily irritated, depressed, poor attention span

9. easily fatigued; frequently ill

10. insomnia at night, fatigued in daytime

11. constipation or diarrhea

Malnutrition

1. overnutrition � excess of energy & nutrient intake

2. undernutrition � deficient energy & nutrient intake

3. overnutrition is a larger problem in U.S.

4. the supersizing, fast food industry contributes to overnutrition

Colostomy Care

Colostomy Care

• Keep patient as free of odors as possible; empty appliance frequently

• Inspect the patient's stoma regularly

• Note the size, which should stabilize within 6 to 8 weeks

• Keep the skin around the stoma site clean and dry

• Measure the patient's fluid intake & output

• Explain each aspect of care to the patient and self-care role

• Encourage patient to care for and look at ostomy

Normal-Appearing Stoma

Patient Teaching for Colostomies

• Community resources are available for assistance

• Initially encourage patients to avoid foods high in fiber

• Avoid foods that cause diarrhea or flatus

• Drink two quarts of water daily

• Teach about medications

• Teach about odor control (intake of dark green vegetables helps control odor)

• Resume normal activity including work and sexual relations

Comfort Measures

• Encourage recommended diet and exercise

• Use medications only as needed

• Apply ointments or astringent (witch hazel)

• Use suppositories that contain anesthetics

Bowel Training Programs

Bowel Training Programs

• Manipulate factors within the patient's control

• Food and fluid intake, exercise, time for defecation

• Eliminate a soft, formed stool at regular intervals without laxatives

• When achieved, discontinue use of suppository if one was used

Types of Colostomies – each has different stool consistency

• Sigmoid colostomy

• Descending colostomy

• Transverse colostomy

• Ascending colostomy

• Ileostomy

Methods of Emptying the Colon of Feces

Methods of Emptying the Colon of Feces

• Enemas

• Rectal suppositories

• Rectal catheters

• Digital removal of stool

Types of Enemas

• Cleansing – high volume

• Retention - oil

• Return-flow – bag of solution taken in (100-300 ml fluid) for pt with gas

Retention Enemas

• Oil-retention—lubricate the stool and intestinal mucosa easing defecation

• Carminative—help expel flatus from rectum

• Medicated—provide medications absorbed through rectal mucosa

• Anthelmintic—destroy intestinal parasites

• Nutritive—administer fluids and nutrition rectally

Nursing Measures for the Patient With Diarrhea

Nursing Measures for the Patient With Diarrhea

• Answer call lights immediately

• Remove the cause of diarrhea whenever possible (e.g., medication)

• If there is impaction, obtain physician order for rectal examination

• Give special care to the region around the anus

• After diarrhea stops, suggest the intake of fermented dairy products

• Fecal seepage may indicate impaction

Preventing Food Poisoning

• Never buy food with damaged packaging

• Never use raw eggs in any form

• Do not eat ground meat uncooked

• Never cut meat on a wooden surface

• Do not eat seafood that is raw or has unpleasant odor

• Clean all vegetables and fruits before eating

• Refrigerate leftovers within 2 hours of eating them

• Give only pasteurized fruit juices to small children

Promoting Regular Bowel Habits

Promoting Regular Bowel Habits

• Timing -attend to urges promptly

• Positioning – have pt. sit up, gravity aids in BM

• Privacy – close door & pull curtain

• Nutrition

• Exercise – abdominal muscles & thighs

• Abdominal settings

• Thigh strengthening

Individuals at High Risk for Constipation

• Patients on bed rest taking constipating medications

• Patients with reduced fluids or bulk in their diet

• Patients who are depressed

• Patients with central nervous system disease or local lesions that cause pain

*Valsalva maneuver (straining & holding breath) ↑intrathoracic / intracranial pressure – possible brain injury

Indirect Visualization Studies

Indirect Visualization Studies

• Upper gastrointestinal (UGI)

• Small bowel series

• Barium enema

Scheduling Diagnostic Tests

• 1 — fecal occult blood test

• 2 — barium studies (should precede UGI) make sure ALL barium is removed*

• 3 — endoscopic examinations

Noninvasive procedures take precedence over invasive procedures

Patient Outcomes for Normal
Bowel Elimination

• Patient has a soft-formed bowel movement every 1-3 days without discomfort

• The relationship between bowel elimination and diet, fluid, and exercise is explained

• Patient should seek medical evaluation if changes in stool color or consistency persist

Stool Collection

Stool Collection

• Medical aseptic technique is imperative

• Wear disposable gloves

• Wash hands before and after glove use

• Do not contaminate outside of container with stool

• Obtain stool and package, label, and transport according to agency policy

Patient Guidelines for Stool Collection

• Void first so urine is not in stool sample

• Defecate into the container rather than toilet bowl

• Do not place toilet tissue in bedpan or specimen container

• Notify nurse when specimen is available

• get to lab quickly (30 min) if anything viable in sample ie. parasites, C-diff. etc

Types of Direct Visualization Studies

• Esophagogastroduodenoscopy (EGD)

• Colonoscopy

• Sigmoidoscopy

• Wireless capsule endoscopy

Physical Assessment of the Abdomen

Physical Assessment of the Abdomen

• Inspection—observe contour, any masses, scars, or distension

• Auscultation—listen for bowel sounds in all quadrants

• Note frequency and character, audible clicks, and flatus

• Describe bowel sounds as audible, hyperactive, hypoactive, or inaudible

Physical Assessment of the Abdomen (cont.)

• Percussion—expect resonant sound or tympany

• Areas of increased dullness may be caused by fluid, a mass, or tumor

• Palpation—note any muscular resistance, tenderness, enlargement of organs, masses

Physical Assessment of the
Anus and Rectum

• Inspection and palpation

• Examine anal area for cracks, nodules, distended veins, masses or polyps, fecal mass

• Insert gloved finger into anus to assess sphincter tone & smoothness of mucosal lining

• Inspect perineal area for skin irritation secondary to diarrhea

Developmental Considerations

Developmental Considerations

• Infants—characteristics of stool and frequency depend on formula or breast feedings

• Toddler physiologic maturity is first priority for bowel training (1 ½ – 2 yrs)

• Child, adolescent, adult—defecation patterns vary in quantity, frequency, and rhythmicity

• Older adult—constipation is often a chronic problem

Foods Affecting Bowel Elimination

• Constipating foods cheese, lean meat, eggs, & pasta

• Foods with laxative effect—fruits and vegetables, bran, chocolate, alcohol, coffee

• Gas-producing foods—onions, cabbage, beans, cauliflower

Effect of Medications on Stool

• Aspirin, anticoagulants pink, red, or black stool

• Iron salts—black stool

• Antacids white discoloration or speckling in stool

• Antibiotics—green-gray color

Variables Influencing Bowel Elimination

Peristalic Movements in the Intestine – Colonic peristalsis is slow. Mass peristalsis is strong, few waves per day, stimulated by food in small intestine.

Variables Influencing Bowel Elimination

• Developmental considerations

• Daily patterns

• Food and fluid (need to drink 2L per day fluid)

• Activity and muscle tone

• Lifestyle, psychological variables

• Pathologic conditions

• Medications ie. pain meds relax muscles. black stool: blood or iron present

• Diagnostic studies - barium

• Surgery and anesthesia

Bowel Elimination

The Large Intestine

• Primary organ of bowel elimination

• Extends from the ileocecal valve to the anus

• Functions

• Completion of absorption of H₂O, Nutrients (chyme from sm. intest. - 1-1.5 L)

• Manufacture of some vitamins

• Formation of feces

• Expulsion of feces from the body

The Small and Large Intestines

Process of Peristalsis

• Peristalsis is under control of nervous system

• Contractions occur every 3 to 12 minutes

• Mass peristalsis sweeps occur 1 to 4 times each 24-hour period

• One-third to one-half of food waste is excreted in stool within 24 hours