1) Bowel
a) Teaching regarding straining during bowel movements
i) The rectum is the final part of the large intestine
(1) Normally the rectum is empty of fecal matter until just before defecation.
(2) It contains vertical and transverse folds of tissue that help to control expulsion of
fecal contents during defecation.
ii) Each fold contains veins that can become distended from pressure during straining.
This distention results in hemorrhoid formation.
(1) Normally defecation is painless, resulting in passage of soft, formed stool.
iii) Straining while having a bowel movement indicates that the patient may need
changes in diet or fluid intake or that there is an underlying disorder in GI function.
(1) A pregnant woman’s frequent straining during defecation or delivery may result in
formation of hemorrhoids. distended.
iv) Increased venous pressure from straining at defecation, pregnancy, heart failure, and
chronic liver disease causes hemorrhoids.
b) Which patients require a bedpan
i) For a patient immobilized in bed, defecation is often difficult.
ii) In a supine position it is hard to effectively contract the muscles used during
defecation.
iii) If a patient’s condition permits, raise the head of the bed to help him or her to a more
normal sitting position on a bedpan, enhancing the ability to defecate.
iv) When patients are disabled or debilitated by illness.
v) When patients are restricted to bed or need help to ambulate, offer a bedpan or help
them reach the bathroom in a timely manner.
vi) Patients restricted to bed use bedpans for defecation. (postoperative)
vii) Women use bedpans to pass both urine and feces, whereas men use bedpans only for
defecation.
viii) Sitting on a bedpan is often uncomfortable. Help position patients comfortably.
ix) Two types of bedpans are available.
(1) The regular bedpan, made of plastic, has a curved smooth upper end and a sharper-
edged lower end and is about 5 cm (2 inches) deep.
(2) The smaller fracture pan, designed for patients with lower-extremity fractures, has a
shallow upper end about 2.5 cm (1 inch) deep.
(3) The shallow end of the pan fits under the buttocks toward the sacrum; the deeper
end, which has a handle, goes just under the upper thighs.
(4) The pan needs to be high enough that feces enter it. patients to roll them on to the
bedpan.
x) Always wear gloves when handling a bedpan. Provide perineal and hand hygiene for
patient as necessary after using a bedpan. Give the enema with the patient positioned
on the bedpan.
c) Assessment finding with an ileostomy
i) Certain diseases or surgical alterations make the normal passage of intestinal contents
throughout the small and large intestine difficult or inadvisable.
ii) When these conditions are present, a temporary or permanent opening (stoma) is
created surgically by bringing part of the intestine out through the abdominal wall.
, (1) These surgical openings are called an ileostomy or colostomy, depending on which
part of the intestinal tract is used to create the stoma.
iii) Newer surgical techniques allow more patients to have parts of their small and large
intestine removed and the remaining parts reconnected, so they will continue to
defecate through the anal canal.
iv) With an ileostomy the fecal effluent leaves the body before it enters the colon,
creating frequent, liquid stools.
(1) A continent ileostomy involves creating a pouch from the small intestine.
(2) The pouch has a continent stoma on the abdomen created with a valve that can be
drained only when the patient places a large catheter into the stoma.
v) The patient empties the pouch several times a day. This procedure is rarely performed
now.
vi) The ileoanal pouch anastomosis is a surgical procedure for patients who need to have
a colectomy for treatment of ulcerative colitis or familial adenopolyposis
(1) In this procedure the surgeon removes the colon, creates a pouch from the end of the
small intestine, and attaches the pouch to the patient’s anus
(2) This pouch provides for the collection of fecal material, which simulates the function
of the rectum.
(3) The patient is continent of stool because stool is evacuated via the anus.
vii) When the ileal pouch is created, the patient has a temporary ileostomy to divert the
effluent and allow the suture lines in the pouch to heal.
(1) Patients with ileostomies digest their food completely but lose both fluid and salt
through their stoma and need to be sure to replace this to avoid dehydration.
(a) A good reminder for patients is to encourage drinking an 8-ounce glass of
fluid when they empty their pouch.
(i) This helps them remember that they have greater fluid needs than they did
before having an ileostomy.
(b) A condition that occurs infrequently with people with ileostomies is called a
food blockage.
(i) Foods with indigestible fiber such as sweet corn, popcorn, raw
mushrooms, fresh pineapple, and Chinese cabbage can cause this problem.
(ii) However, if patients eat these foods in small quantities, drink fluids with
the food, and chew it well, they are unlikely to experience any difficulty.
viii) A patient with diarrhea, fecal incontinence, or an ileostomy is at risk for skin
breakdown when fecal contents remain on the skin.
ix) Liquid stool usually contains digestive enzymes, which causes rapid skin breakdown.
Irritation from repeated wiping with toilet tissue or frequent ostomy pouch changes
further irritate the skin.
(1) Meticulous perianal skin care and frequent removal of fecal drainage is necessary to
prevent skin breakdown
(a) Clean the skin with a no-rinse cleanser and apply a barrier ointment after each
episode of diarrhea.
x) If a patient is incontinent, check on the patient frequently and change absorbent
products immediately after providing thorough but gentle skin cleansing.
(1) Patients with ostomies are often unaware of the skin irritation under their ostomy
wafer or think that this is a normal part of having an ostomy.
, xi) Education about skin breakdown and its management are important roles for the
ostomy nurse
xii) Changes in a patient’s fluid status, mobility patterns, nutrition, and sleep cycle affect
regular bowel habits.
(1) After surgery it usually takes a few days for patients with new ostomies to feel that
their appetite has returned to normal.
(2) Small servings of soft foods are typically more appetizing, as they would be for any
patient who has had an abdominal surgery.
d) Nutrition and wound healing
i) Tissue receives oxygen and nutrients and eliminates metabolic wastes via the blood.
ii) Pressure or other factors that interfere with blood flow in turn interfere with cellular
metabolism and the function or life of the cells.
(1) Prolonged, intense pressure affects cellular metabolism by decreasing or obliterating
blood flow, resulting in tissue ischemia and ultimately tissue death.
(2) The ability of tissue to endure pressure depends on the integrity of the tissue and the
supporting structures.
(3) The extrinsic factors of shear, friction, and moisture affect the ability of the skin to
tolerate pressure: the greater the degree to which the factors of shear, friction, and
moisture are present, the more susceptible the skin will be to damage from pressure.
iii) The second factor related to tissue tolerance is the ability of the underlying skin
structures (blood vessels, collagen) to help redistribute pressure.
(1) Systemic factors such as poor nutrition, aging, hydration status, and low blood
pressure affect the tolerance of the tissue to externally applied pressure.
iv) When an incision fails to heal properly, the layers of skin and tissue separate.
(1) This most commonly occurs before collagen formation (3 to 11 days after injury).
(2) Dehiscence is the partial or total separation of wound layers.
v) A patient who is at risk for poor wound healing (e.g., poor nutritional status,
infection, or underlying diseases such as diabetes mellitus or peripheral vascular
disease) is at risk for dehiscence.
vi) Obese patients have a higher risk of wound dehiscence because of the constant
strain placed on their wounds and the poor healing qualities of fat tissue
vii) Dehiscence can happen in abdominal surgical wounds and occurs after a sudden
strain such as coughing, vomiting, or sitting up in bed.
(1) Patients often report feeling as though something has given way.
(2) When there is an increase in serosanguineous drainage from a wound in the first few
days after surgery, be alert for the potential for dehiscence.
viii) The Braden Scale contains six subscales: sensory perception, moisture, activity,
mobility, nutrition, and friction/shear.
(1) The total score ranges from 6 to 23; a lower total score indicates a higher risk for
pressure injury development.
(2) In addition to previously discussed risk factors of impaired sensation, impaired
mobility, shear, friction, and moisture, a patient’s nutrition, tissue perfusion,
infection, or age may increase the risk for pressure injury and poor wound healing.
ix) Normal wound healing requires proper nutrition
(1) Deficiencies in any of the nutrients result in impaired or delayed healing
a) Teaching regarding straining during bowel movements
i) The rectum is the final part of the large intestine
(1) Normally the rectum is empty of fecal matter until just before defecation.
(2) It contains vertical and transverse folds of tissue that help to control expulsion of
fecal contents during defecation.
ii) Each fold contains veins that can become distended from pressure during straining.
This distention results in hemorrhoid formation.
(1) Normally defecation is painless, resulting in passage of soft, formed stool.
iii) Straining while having a bowel movement indicates that the patient may need
changes in diet or fluid intake or that there is an underlying disorder in GI function.
(1) A pregnant woman’s frequent straining during defecation or delivery may result in
formation of hemorrhoids. distended.
iv) Increased venous pressure from straining at defecation, pregnancy, heart failure, and
chronic liver disease causes hemorrhoids.
b) Which patients require a bedpan
i) For a patient immobilized in bed, defecation is often difficult.
ii) In a supine position it is hard to effectively contract the muscles used during
defecation.
iii) If a patient’s condition permits, raise the head of the bed to help him or her to a more
normal sitting position on a bedpan, enhancing the ability to defecate.
iv) When patients are disabled or debilitated by illness.
v) When patients are restricted to bed or need help to ambulate, offer a bedpan or help
them reach the bathroom in a timely manner.
vi) Patients restricted to bed use bedpans for defecation. (postoperative)
vii) Women use bedpans to pass both urine and feces, whereas men use bedpans only for
defecation.
viii) Sitting on a bedpan is often uncomfortable. Help position patients comfortably.
ix) Two types of bedpans are available.
(1) The regular bedpan, made of plastic, has a curved smooth upper end and a sharper-
edged lower end and is about 5 cm (2 inches) deep.
(2) The smaller fracture pan, designed for patients with lower-extremity fractures, has a
shallow upper end about 2.5 cm (1 inch) deep.
(3) The shallow end of the pan fits under the buttocks toward the sacrum; the deeper
end, which has a handle, goes just under the upper thighs.
(4) The pan needs to be high enough that feces enter it. patients to roll them on to the
bedpan.
x) Always wear gloves when handling a bedpan. Provide perineal and hand hygiene for
patient as necessary after using a bedpan. Give the enema with the patient positioned
on the bedpan.
c) Assessment finding with an ileostomy
i) Certain diseases or surgical alterations make the normal passage of intestinal contents
throughout the small and large intestine difficult or inadvisable.
ii) When these conditions are present, a temporary or permanent opening (stoma) is
created surgically by bringing part of the intestine out through the abdominal wall.
, (1) These surgical openings are called an ileostomy or colostomy, depending on which
part of the intestinal tract is used to create the stoma.
iii) Newer surgical techniques allow more patients to have parts of their small and large
intestine removed and the remaining parts reconnected, so they will continue to
defecate through the anal canal.
iv) With an ileostomy the fecal effluent leaves the body before it enters the colon,
creating frequent, liquid stools.
(1) A continent ileostomy involves creating a pouch from the small intestine.
(2) The pouch has a continent stoma on the abdomen created with a valve that can be
drained only when the patient places a large catheter into the stoma.
v) The patient empties the pouch several times a day. This procedure is rarely performed
now.
vi) The ileoanal pouch anastomosis is a surgical procedure for patients who need to have
a colectomy for treatment of ulcerative colitis or familial adenopolyposis
(1) In this procedure the surgeon removes the colon, creates a pouch from the end of the
small intestine, and attaches the pouch to the patient’s anus
(2) This pouch provides for the collection of fecal material, which simulates the function
of the rectum.
(3) The patient is continent of stool because stool is evacuated via the anus.
vii) When the ileal pouch is created, the patient has a temporary ileostomy to divert the
effluent and allow the suture lines in the pouch to heal.
(1) Patients with ileostomies digest their food completely but lose both fluid and salt
through their stoma and need to be sure to replace this to avoid dehydration.
(a) A good reminder for patients is to encourage drinking an 8-ounce glass of
fluid when they empty their pouch.
(i) This helps them remember that they have greater fluid needs than they did
before having an ileostomy.
(b) A condition that occurs infrequently with people with ileostomies is called a
food blockage.
(i) Foods with indigestible fiber such as sweet corn, popcorn, raw
mushrooms, fresh pineapple, and Chinese cabbage can cause this problem.
(ii) However, if patients eat these foods in small quantities, drink fluids with
the food, and chew it well, they are unlikely to experience any difficulty.
viii) A patient with diarrhea, fecal incontinence, or an ileostomy is at risk for skin
breakdown when fecal contents remain on the skin.
ix) Liquid stool usually contains digestive enzymes, which causes rapid skin breakdown.
Irritation from repeated wiping with toilet tissue or frequent ostomy pouch changes
further irritate the skin.
(1) Meticulous perianal skin care and frequent removal of fecal drainage is necessary to
prevent skin breakdown
(a) Clean the skin with a no-rinse cleanser and apply a barrier ointment after each
episode of diarrhea.
x) If a patient is incontinent, check on the patient frequently and change absorbent
products immediately after providing thorough but gentle skin cleansing.
(1) Patients with ostomies are often unaware of the skin irritation under their ostomy
wafer or think that this is a normal part of having an ostomy.
, xi) Education about skin breakdown and its management are important roles for the
ostomy nurse
xii) Changes in a patient’s fluid status, mobility patterns, nutrition, and sleep cycle affect
regular bowel habits.
(1) After surgery it usually takes a few days for patients with new ostomies to feel that
their appetite has returned to normal.
(2) Small servings of soft foods are typically more appetizing, as they would be for any
patient who has had an abdominal surgery.
d) Nutrition and wound healing
i) Tissue receives oxygen and nutrients and eliminates metabolic wastes via the blood.
ii) Pressure or other factors that interfere with blood flow in turn interfere with cellular
metabolism and the function or life of the cells.
(1) Prolonged, intense pressure affects cellular metabolism by decreasing or obliterating
blood flow, resulting in tissue ischemia and ultimately tissue death.
(2) The ability of tissue to endure pressure depends on the integrity of the tissue and the
supporting structures.
(3) The extrinsic factors of shear, friction, and moisture affect the ability of the skin to
tolerate pressure: the greater the degree to which the factors of shear, friction, and
moisture are present, the more susceptible the skin will be to damage from pressure.
iii) The second factor related to tissue tolerance is the ability of the underlying skin
structures (blood vessels, collagen) to help redistribute pressure.
(1) Systemic factors such as poor nutrition, aging, hydration status, and low blood
pressure affect the tolerance of the tissue to externally applied pressure.
iv) When an incision fails to heal properly, the layers of skin and tissue separate.
(1) This most commonly occurs before collagen formation (3 to 11 days after injury).
(2) Dehiscence is the partial or total separation of wound layers.
v) A patient who is at risk for poor wound healing (e.g., poor nutritional status,
infection, or underlying diseases such as diabetes mellitus or peripheral vascular
disease) is at risk for dehiscence.
vi) Obese patients have a higher risk of wound dehiscence because of the constant
strain placed on their wounds and the poor healing qualities of fat tissue
vii) Dehiscence can happen in abdominal surgical wounds and occurs after a sudden
strain such as coughing, vomiting, or sitting up in bed.
(1) Patients often report feeling as though something has given way.
(2) When there is an increase in serosanguineous drainage from a wound in the first few
days after surgery, be alert for the potential for dehiscence.
viii) The Braden Scale contains six subscales: sensory perception, moisture, activity,
mobility, nutrition, and friction/shear.
(1) The total score ranges from 6 to 23; a lower total score indicates a higher risk for
pressure injury development.
(2) In addition to previously discussed risk factors of impaired sensation, impaired
mobility, shear, friction, and moisture, a patient’s nutrition, tissue perfusion,
infection, or age may increase the risk for pressure injury and poor wound healing.
ix) Normal wound healing requires proper nutrition
(1) Deficiencies in any of the nutrients result in impaired or delayed healing
