Bowel Elimination
What is the goal of bowel elimination care?
maintain normal frequency pattern
You listen to your client's bowel sounds in all 4 quadrants and note low-pitched gurgles every 50 seconds, how would you document this?
hypoactive bowel sounds
Your client has been diagnosed with a fecal impaction, what are some subjective and objective data you may find with this client?
small amounts of diarrhea
anorexia
N/V
firm distended abdomen
palpable rectal mass, abdominal mass
no bm over several days
You need to obtain a clean catch urine specimen for your client, what teaching will you provide in order to obtain the specimen properly?
Female- clean front to back
Male- clean meatus and shaft with circular motion
then have the client void into the container
not sterile
What is the cause of the mechanical retention of urine?
stones
tumor
enlarged prostate
Name 5 subjective data questions you will ask your client regarding bowel elimination
pattern/frequency
laxative/enema use
diet/fiber/water
exercise
Health--GI problem, surgery
Stress
Pain
Age
changes in bowel pattern
You percuss your client's abdomen in the right upper quadrant and note a dull sound, what could this be indicative of?
organ---liver
Your client complains of excess flatus, what teaching can you provide to help reduce excess gas for this client?
avoid the use of straws
avoid gas-producing foods
don't eat food too quickly
24 hour urine must be restarted
Name the non-invasive nursing interventions that can help promote voiding
privacy
run water
positioning
warm water
crede's method--apply pressure to bladder
Lower the height of the solution container.
What is an intervention if when giving an enema, the client experiences crampins?
When is palpation of the abdomen contraindicated?
abdominal aortic aneurysm
organ transplant
suspected or known Wilm's tumor
Name 5 causes of diarrhea
anxiety/stress
medication SE
food allergy
food/drug intolerance
inflammatory disease
infectious
30 ml/hour anything lower than that- needs to be reported to the doctor
What is the minimum urine output?
what urinary catheter would be appropriate for your client that requires accurate urine output measurements?
indwelling foley catheter
What nursing interventions can you implement to promote bowel elimination? Name 5.
Positioning
hydration/offer fluids
privacy
exercise
fiber
administer medications per order
A nurse should perform the abdominal data collection using in what sequence?
inspection, auscultation, percussion, palpation
What can lead to social isolation in your client?
fecal incontience
Dark amber color, foul odor, presence of leukocytes.
What are sign of a UTI?
What is the goal of nursing care when your client is ordered a triple-lumen catheter with CBI?
to prevent blood clots from obstructing the flow of the irrigation fluid into the bladder and back out again
Name 5 factors that can affect bowel elimination
timing/routine
bulk fiber---to much
immobility
surgery/anesthesia
opioids
age/pregnancy
dehydration
medication SE
Your client has hyperactive bowel sounds, you know this could be related to?
diarrhea, laxatives, intestinal infection
What are important nursing interventions for your client with diarrhea?
fluids, electrolytes
keep skin clean and dry
probiotics
anti-diarrheals
stress reduction
follow diet restrictions, BRAT diet
bedrest
What nursing interventions can be implemented to help prevent urinary incontinence?
bladder training
kegel exercises
urinal/commode at bedside (urge)
call light in reach
Catheter placed after trauma or surgery to the urethra
suprapubic catheter