N105: Essentials of Nursing Care - Health Differences

Essentials of Nursing Study Guide

©2017 Achieve Test Prep Page 45 of 160 Maintain patient privacy (environment should be conducive to elimination); position the patient in a squatting position ; instruct on recognition of the urge to defecate/ normal gastrocolic reflex; adequate intake of fiber (assist client in planning a high fiber diet); encourage daily fluid intake appropriate to patient’s developmental level; encourage hygiene and asepsis, performing Kegel exercises, and appropriate use of medications (laxatives are contraindicated in the client who has nausea, cramps, colic, vomiting, or undiagnosed abdominal pain); antidiarrheal meds are reserved for treatment of chronic diarrhea, which occurs for more than 3 to 4 weeks; perform bladder catheterizations and irrigations; administer enema, laxatives, stool softener; provide bladder and bowel retraining ; encourage ambulation; provide range-of-motion exercises 2.5 Enemas Types of Enemas • Cleansing enemas : used to prevent the escape of feces during surgery, prepare the intestine for certain diagnostic tests, and remove feces of constipation or impaction; establishes regular bowel function; cleansing enema is also called a highenema • Hypertonic solutions: exert osmotic pressure which draws fluid from the interstitial space into the colon; the increased volume in the colon stimulates peristalsis anddefecation • Hypotonic solutions: exert a lower osmotic pressure; water moves from the colon into the interstitial space; before the water moves, it stimulates peristalsis and defecation; this should not be repeated because of the danger of circulatoryoverload • Isotonic solutions: the safest to use (normal saline); there is no osmotic pressure change; the instilled volume of saline stimulates peristalsis • Carminative enema: given primarily to expel flatus; 60-80ml of fluid is instilled into the rectum; the gas distends the colon and rectum to stimulate peristalsis • Oil retention enema: acts to soften the feces and to lubricate the rectumand anal canal to facilitate passage of feces; oil is administered via enema and is to be retained for 1-4 hours to soften feces and lubricate the rectum/anal canal and ease the passage of stool; antibiotic Nursing Procedures • Assessment: Check history; performa physical examination of the abdomen, rectum, and anus (inspecting the feces for color, consistency, shape, amount, odor and the presence of abnormal constituents); auscultation precedes palpation because palpation can alter peristalsis • Planning: Maintain or restore normal bowel elimination pattern; maintain or regain normal stool consistency (patient will pass a soft, formed stool at regular intervals); prevent associated risks such as fluid and electrolyte imbalance, skin breakdown, abdominal distention and pain; patient will remain free of infection; patient will verbalize understanding of perineal floor exercises • Interventions : Maintain or enhance fecal elimination to include constipation/impaction management, bowel incontinence care, bowel management, bowel training, diarrhea management, coping enhancement, and ostomy care • Implementation: