Sunday, March 10, 2019

MANAGE NURSING CARE AT HOME, "Ch. 14 Gastro-Intestinal System


    Incredibly simplified, this system could be described as one large tube that begins with the consuming of food at the mouth and ends where it is fully processed and eliminated as stool.  When food enters the oral cavity (mouth), digestion is initiated.  Food is then processed with saliva and mastication (chewing), flows to the pharynx to the esophagus via swallowing and peristalsis (an involuntary, wavelike muscular movement to propel contents forward), where it eventually arrives at the stomach. 

While in the stomach, muscular action and gastric juices further break down the food into a liquid mass (chyme).  Various substances, such as enzymes from the pancreas, gallbladder, and liver are added as chyme flows to the small intestines, again by peristalsis.  In the small intestines (where “small” denotes diameter and not length), nutrients are microscopically absorbed.  The non-absorbed material is then propelled via peristalsis to the large intestines or colon (large in diameter but not length compared to the small intestine).  The large colon takes out all usable fluid to return it back to the body, and removes what the body cannot utilize, waste, in the form of stool, which is excreted.  

Some of the various gastro-intestinal system conditions and care considerations that may be experienced in the home-care setting appear below.

Colostomy:  is a surgical procedure that takes a piece of the large intestine and routes it through the abdominal wall via an opening (stoma) outside the body.  Stool is then excreted via the stoma into a containing bag (appliance) outside the body. This bypasses the normal defecation process, which would utilize the entire large colon, rectum, and anus.  The farther (distal) part of the removed (resected) colon is closed and becomes non-functional to allow healing to that site.  A colostomy can usually be performed at any area of the large colon, to allow elimination of feces when the normal route is suspended due to severe illness, infection, cancer, obstruction, perforation or any similar process that requires the bowel to rest and heal. 

A colostomy may be temporary or permanent, depending on the underlying illness that requires this intervention.   Temporary colostomies are performed to allow healing, for example, when a part of the large intestine has been removed (resected) and requires rest. Once the two ends are appropriately healed, these ends might be reattached to each other (anastomosis), and normal bowel function may be achieved.  However, permanent colostomies are necessary at times. 

Depending on the location of the resection, and with bowel retraining, a new normal elimination pattern can be resumed via the outside appliance, and with it, normal functioning for the patient. If the location of the colostomy is at the descending or sigmoid colon, a bowel training program may be undertaken to evacuate the colon at a routine time.  This is called Bowel Irrigation.  Its purpose is to empty the colon of gas, mucus, and feces at daily scheduled times to establish regularity and decrease elimination throughout the day.  This is achieved by instilling fluids into the colostomy daily and at a consistent time to prompt evacuation.  It is not a guaranteed procedure, but it has often been effective in providing learned evacuation, depending on patient cooperation and reliability.  Areas proximal (earlier on in the digestive tract) have decreased bowel training possibilities.  The area of the colon that is affected or resected largely determines the success of bowel training.

Care Considerations for Colostomies:
1) Bowel function typically resumes 3 to 6 days post-surgery.  The effluent (discharge) will initially be liquid regardless of where the colostomy was placed.  Continue with fluids, including water and substances that provide electrolytes, as these will be lost in the effluent and require replacement.   Abstain from alcohol, caffeinated beverages, and any liquids that have diuretic actions. 
2) Change in effluent over time is typical and dependent on the colostomy site.  A major function of the large intestine is to remove water from processed food material and return it to the body.  If a colostomy is performed close to the small intestine, effluent will be liquid because the large intestine has had minimal opportunity to recapture water.  The farther along in the digestive tract the colostomy is performed, the more water is removed, and the stool becomes more formed.  Generally, you can expect that if the colostomy was performed in the transverse colon, because water remains in the stool, the effluent will be soft, mushy and with potential irritation to the stoma if leakage occurs.  If the colostomy is at the descending or sigmoid colon, effluent will be more solid, since more fluid was extracted by the colon, and less irritating to the stoma, because it is less liquid and irritating. 
3) The stoma requires constant assessment.  The stoma is made from a piece of the large intestine that is repositioned to protrude above the skin surface.  The newly formed, surgically made stoma functions to eliminate waste via medical equipment for containment rather than evacuation via the rectum and anus.  The stoma should be assessed for irritation, abrasions or trauma (excoriation) from dressings or effluent discharge.  The stoma, itself, should be smooth, cherry red, with a slight amount of edema.  Discoloration, excessive edema and discharge, signs of infection, fever, and foul smell may be indications of decreases in stoma viability.  Consult medical professionals.
4) Because of the surgical manipulation and delicate tissue, this stoma site must receive the utmost care.  Gently cleanse with mild soap and dry thoroughly.  Apply the drainage bag and adhesives ring so the fit is close to the stoma and makes a firm seal to prevent leakage of effluent.  Watch for constricting the stoma, however.   Use skin barriers before applying the drainage bag and cover the skin around the stoma site.  But do not treat the stoma itself with any kind of barrier.  These actions help to create seals, protect surrounding skin, and ensure stoma remains intact, healthy, and functional. 
5) Application of the bag requires time and patience to assure firm seal and smooth application of drainage pouch.  It takes practice.  Allow time to master this task.  
6)  Bathing requires consideration and preparation.  Tape bag securely in place to protect the stoma.  Use mild soap, rinse, and dry thoroughly without rubbing.  Change the appliance after bathing. Always protect the skin around the stoma, as well as the stoma itself, by cleansing with a soft cloth and mild soap to remove the adhesives, intestinal enzymes and fecal residual. If the stoma is placed in the upper colon, and once the site is healed, consider placement of a tampon to temporarily contain fecal discharge.     
7) Monitor amount of effluent and discharge contained in the appliance bag.  Consider changing bag when it’s approximately 1/3 full or before the weight of the bag causes any separation. 
8)  Post-surgical diet will change over time.  Initially, eat a low-fiber diet (includes only cooked skinless vegetables – no salads and nothing raw; canned fruit; juices without fiber; white refined flours, breads and pasta – no nuts, whole grains, or seeds; lean proteins).  Add new foods gradually and observe effects.  Avoid anything that may cause gas, foul smells. 
9)  Assess and note changes in effluent.  Soon after placement, there should be some uniformity and consistency in the stool, dependent on details of the surgical placement of the colostomy.  Placement of the colostomy dictates stool consistency.  As noted above, a stoma placed closer to the rectum will form more solid stools and one farther from there will have stools that will be more liquid.  Be aware of changes in stool color and consistency outside of this norm.  Changes can be indications of potential problems with colostomy function or with diet.   
    10) Assess patient functional ability, willingness, and commitment to perform treatment.  Motor skills and visual abilities are necessary to provide stoma care and manipulate appliances.  Proper skin care technique to the stoma and surrounding tissue is essential.  Home situations should lend to privacy, especially if irrigation will be completed.  A separate bathroom is ideal, allowing for privacy and unconstrained time, perhaps more than one-hour uninterrupted time to fully complete bowel irrigation and evacuation. 
11)  Monitor and beware of nutrition.  Fluid shifts are common leading to dehydration.  Foods, including vitamins and medications, may be processed differently. 
12)  Body image and self-esteem are often greatly diminished.  Lack of such a bodily function often leads to fear in social situations, embarrassment, and decreased self-respect due to lack of bodily control.  Reassure patient that with understanding, patience, and obtaining a new normal, whether using a temporary or permanent colostomy, life is usually impacted much less than is initially anticipated.  

Dysphagia: is a term indicating difficulty or inability to swallow.  The act of swallowing requires use of nerves as well as voluntary and involuntary muscles associated with the jaw, tongue, pharynx, and esophagus.  Dysphagia can occur for numerous reasons and is often limited to affecting either the esophagus or the pharynx.  Esophageal dysphagia affects involuntary muscles and can be caused by spasms, narrowing of the esophagus (esophageal strictures) which greatly slows forward progression of food, tumors, and achalasia, in which the sphincter between the esophagus and stomach doesn’t relax, resulting in actual trapping of food in the lower esophagus.  Pharyngeal dysphagia often affects voluntary muscles, which may be damaged by neurological disorders, such as Parkinson’s disease, multiple sclerosis, muscular dystrophy, or damage from strokes, traumatic brain injuries, and spinal cord injuries.  Complications of dysphagia include malnutrition, weight loss, and dehydration.  However, often respiratory complications result when food enters the pulmonary system via the trachea instead the esophagus.  Aspiration pneumonia and respiratory infections often result.

Care Considerations for Dysphagia:
1)  Evaluate ability to swallow effectively prior to eating each meal.  Check for drooling, speech problems, and patient willingness.  Lack of oral control can be an indicator for aspiration potential.  Verify patient ability to cough on command.  If aspiration should occur, the gag reflex and coughing are essential to decrease aspiration.
2)  Food placement and patient positioning is often critical to enhance swallowing effectiveness.  Sit patient in upright position to increase effect of gravity, as well as have patient tip head back when chewing and swallowing.  If dysphagia is due to a neurological deficiency, then place food on the unaffected side of the mouth to enhance chewing ability. 
3) Mealtime often becomes a chore for patients with dysphagia.  The work required to eat, as well as changes to diet, frequently eliminates satisfaction and enjoyment of this social time.  Suggest a swallowing technique that includes gently placing the patient’s hand on the throat to feel the action of swallowing.  Feeling the motion often leads to enhanced swallowing effort.  Additionally, sometimes swallowing two times in quick succession proves effective.  Decrease noise and distractions to enhance the effort and concentration of eating.  Provide coaching and verbal step-by-step reminders for patients with neurological deficits.  This might include: open mouth; feel food in your mouth; chew food until the food is soft without big pieces; tilt head up; swallow; swallow again, etc.
4) Food texture plays an important role with dysphagia.  Liquids are often not given, as they are difficult to control in the mouth, and along with solids, liquids pose the most aspiration threat.  Often, the best consistency is that of mashed potatoes, which can be controlled in the mouth and allow some chewing but can also slide down the throat.  This is considered a puree diet which can be further categorized into thin, thick, pre-mashed, or fork-mashed puree.  The diet selected by the physician will be dependent on the patient’s willingness and ability.
5)  Severe cases of dysphagia may require procedures to widen the esophagus, for example, or placement of a feeding tube when swallowing food or liquids poses a threat to patient’s safety, and/or when malnutrition and fluid deficits are advanced.  If a feeding tube is utilized, ensure that the patient’s liquid diet is well balanced and provides all nutritional requirements. Numerous types and selections are available.  Keep records of all feedings, water, and liquids that are given to the patient to ensure satiety, caloric intake, and hydration.  Monitor and clean the feeding tube site as recommended by the physician.  Be alert to leakage of stomach contents and acids which are caustic to the skin.  Obtaining patient weight at frequent intervals is often recommended to ensure too much weight isn’t lost or gained. 
6) Understand that eating provides not only nutritional benefits, but also social time and personal pleasures.  There are losses associated with drastic diet changes.  The act of eating and chewing provides an individual release and satiety that is often associated with shared personal experiences.  With dysphagia, food consistencies are usually altered to soft foods, often discouraging the eating of favorite foods or eating from menu items.  Eating pleasures are initially considered restricted.  Understand that while these meal-time limitations may initially decrease eating pleasure, social and basic satisfaction of the shared meal need not be denied. 

Altered Bowel Elimination:  elimination is simply the removal (defecation) of waste products from the body via the large intestine.  The product of defecation is stool.  This is achieved by the coordinated efforts of involuntary and voluntary muscular movements of the digestive system, starting with eating and ending with defecating.  Involuntary muscles, of which the individual has no control, contract and relax to push contents (either food or stool) forward by muscular action (peristalsis). Voluntary muscles, controlled by the individual, allow for self-determined relaxation and contraction of sphincters to finally release stool via the anus.  Individual elimination of stool varies and may occur once per day, a few times daily, or once every other day.   What matters most is that an individual has consistent bowel movements that are neither hard and require straining to expel, nor loose or watery stool.  Incidences of constipation or liquid bowel movements should be addressed with a physician. 

    Often patients with ongoing care are prone to bowel irregularities which may affect the quantity and/or quality of their stool.  Reasons for this include multiple medications which can cause various gastrointestinal side-effects, restricted mobility due to illness or injury, changes in eating habits or nutrition or cognition impairments.  This can range from constipation to diarrhea, both of which are at opposite ends of the normal bowel elimination spectrum.

Care Considerations for Constipation:
1)  It is often not easy to ascertain the cause of constipation, which is a decrease in regularity, difficult passage of hard, dry stool, and often with incomplete elimination of feces.  Determining the cause not only helps to select the best treatment option, it also aids in eliminating ongoing constipation patterns.
2) Medications often cause constipation.  Pain-relieving drugs, such as opiates, so frequently cause constipation that it’s common that a mild stool softener or laxative is suggested when these drugs are prescribed.  Anti-depressants and some cardiac drugs can also affect bowel elimination.  Because these medications are usually prescribed long-term, artificial measures to resolve constipation should be as minimal as possible due to the potential negative long-term effects of laxative use. 
3) Some disease processes can contribute to constipation.  Hypothyroidism or other metabolic disorders can decrease functionality of the bowels.  A chronic heart failure patient often has fluid intake restrictions which could lead to hard stools that are difficult to pass.  Patients may exhibit gastrointestinal uniqueness such as slow transit constipation (a process in which peristalsis is slower than normal), have a longer than usual colon with overlapping segments (redundant colon) or may have a colon that anatomically twists and turns more than usual making stool passage difficult.  Ensure constipation issues are discussed with the physician and follow appropriate guidelines.
4) Constipation due to lack of fiber can easily be resolved.  Dietary fiber adds bulk to stool to aid passage through the large intestine because bulk doesn’t fully digest.   Most plant foods have both soluble and insoluble fiber.  An additional benefit of insoluble fiber is that stool also retains some water, which helps to keep stool soft for easier passage.   However, fiber can also be added to a diet by using over-the-counter fiber supplements, such as Citrucel or Metamucil for example.  These capsules, or powders added to fluid, taken daily can increase fiber intake.  Supplements are often used for a patient who is unable to eat or for individuals that can’t or won’t increase dietary fiber due to the increase of food that is required or from distaste of food that provides it.
5) A major function of the large intestine is to retrieve and return fluid from waste back to the body for use.  When there is insufficient fluid intake, more water is removed from waste.  Feces then become harder, more difficult, and perhaps more painful to pass.  This all leads to increased risk for constipation. Fluid should be drunk often.  There is no standard amount to drink, but a rule of thumb is that when one feels thirsty, one is already exhibiting signs of fluid dehydration.  Decrease caffeinated beverages such as coffee, tea, and cola. Juices increase fluids but also increase sugar.  Water is often the preferred beverage to consume.
6)  Sedentary lifestyle, often the case for a home-care patient, contributes greatly to constipation.  The elimination of feces is largely controlled by involuntary muscular movements.  When the body remains at rest, the body minimizes metabolism, peristalsis decreases, and bodily functions revert to a lower level of expenditure and usage.  Simple movement, such as walking, promotes increased involuntary muscular functions, as well as all the additional health benefits associated with exercise.  In addition, when one is sedentary, food consumption that maintained a normal weight may now be more caloric than is necessary.   A sedentary patient may also experience boredom.  Often, eating resolves that emotional feeling.  Unfortunately, the snacks desired are usually those that do not provide increased fiber to the diet.    For a bed-ridden patient, range of motion exercise decrease sustained loss of muscle mass.  Decreasing the amount of caloric intake, as well as increasing fluids, should be considered.
7)  Various types of over-the-counter laxatives are available to help resolve constipation.  However, they may have side effects such as bloating, gas, or cramping for example.  Stool softeners, such as Colace (docusate sodium) or Miralax (glycolax), increase water in the bowels.  With the additional water, stools pass more easily and without a great amount of strain.  The additional fluid also helps to promote and stimulate bowel movements.  These medications do not damage the normal action of the colon and are not addicting.  Other laxatives, such as Senokot (senna) and Dulcolax enhance the action of the large intestine to increase forward movement and release of stool.  This works to promote the large intestines’ normal function.  Because this is artificially increasing the colon’s peristalsis, long term use could be detrimental.  Therefore, these, and any other laxative assisting medications should be used as infrequently as possible.    Another type of laxative is to be used infrequently and with physician consult: saline laxatives take fluid from the body, due to their composition, and return it to the colon.  However, with the fluid, essential electrolytes necessary for cardiac function, for example, are also removed.  These laxatives are often prescribed as bowel prep for testing and procedures, such as a colonoscopy when the colon needs to be free and clean of all feces.  Before administering, consult with the patient’s physician.
8)  Digital disimpaction may be necessary at times when previous methods to resolve constipation are ineffective.  This procedure is often both embarrassing and uncomfortable to the patient.  It also has adverse complications, such as vagal nerve stimulation, which decreases heart rate.  Additionally, the digital irritation can cause bleeding as well as discomfort in passing stool.  A gloved hand with a lubricated finger is inserted into the anus to gently but firmly remove stool from the rectum.  Often that will stimulate a bowel movement.  If it doesn’t, stool removal may provide some relief for the patient.
9)  Enemas, inserted into the anus to provide lubrication up to the rectum, are used break up stool for elimination.  They are used as a last effort to relieve constipation, partially due to the discomfort and embarrassment they may cause to the patient.  However, they are also detrimental to the body as they disrupt the normal bodily process and cause dependence.  Frequent use of enemas causes shut-down of effort, and just a few usages sometimes decreases the body’s ability to normally expel feces.  Enemas should only be used when all other interventions fail to evacuate the patient’s bowel.  For an enema using small amount of fluid, place the patient on the left side with right leg over the left for support and both knees flexed to chest.  Ensure towels, bedpan, and cleaning items are readily available.  Have the patient breathe out though the mouth, which helps to relax the external sphincter.  Assess for hemorrhoids that could decrease visual ability for placing the enema tube and/or increase risk for bleeding.  Lubricate tip of enema tube, separate buttocks, and insert tip of enema tube into the anus to instill fluid.  The fluid should be retained for a period as indicated per package or physician instructions for best results.  When the process is complete according to directions, provide full and gentle hygiene to the genitourinary and anal areas.  Be aware that embarrassment and apprehension may be more paramount than the actual discomfort of the process.  Provide gentle care and explain procedural details throughout the process. 

Care Considerations for Diarrhea:
1) Diarrhea is the presence of unformed stools that may be loose to watery that occur frequently and are unusual for the patient.  Besides the loss of water that is unable to be recaptured normally by the large intestine, essential electrolytes are lost.  Ultimately, the patient may exhibit dehydration, heart arrhythmias when the condition is long-lasting, and skin breakdown from recurrent presence and cleaning of stool.  This condition can be caused, for example, by diet, infection, food consumption, or medications.
2) Cause needs to be determined.  Due to the rapid passing of the stools through the large colon, there is insufficient time for the colon to return water from stools back to the body.  When water is not recovered by the colon, other essential chemicals, such as electrolytes which aid in cardiac function, are also lost.  Look for dietary changes, gastrointestinal infections, additions of medications such as antibiotics, and changes due to traveling. 
3)  Diarrhea may be caused by recent administration of antibiotics which destroy the normal flora of the GI tract.  Often administration of yogurt or other over-the-counter probiotics will help remedy this cause. 
4)   Dehydration is often exhibited.  Headaches, decreases in consciousness, decreases in urinary output, and hyperventilation (increased rate of breathing) often occur.   Fluid intake needs to offset the fluid lost due to diarrhea.  Consult physician should any of these be noted. 
5)   Assess the stool for consistency, color, and volume.  This should also be reported to the physician.
6)  Skin breakdown is common with diarrhea.  Check the outer skin for any signs of breakdown such as non-blanchable skin, lack of normal skin tension, or discoloration.  Separate the buttocks to view the anus and inner-lying areas for excoriation, abrasions, redness, irritation, or breakdown.  Wash and dry gently in a patting motion – do not rub.  Apply protective ointments such as A+D Ointment.
7)  Anti-diarrheal medications can be given but caution should be used to ensure their administration does not cause constipation.  Home and over-the-counter remedies include strong tea, rice, whey, Pepto-Bismol.  When bouts of diarrhea have decreased, resume the normal diet slowly to further calm and allow healing of the irritated intestinal mucosa (lining) until fully healed. 


Contact information:
Diane R. Beggin, RN
40 Sycamore Drive
Montgomery, NY 12549

Web site:

Book: HOW TO MANAGE NURSING CARE AT HOME, by Cooper and Beggin

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