1. List qualities of stool and identify signs and symptoms about stool to report

1. 1. List qualities of stool and identify signs and symptoms about stool to report • Define the following term: • defecation • the act of passing feces from the large intestine out of the body through the anus.

2. 1. List qualities of stool and identify signs and symptoms about stool to report • NAs should observe and report these signs and symptoms about stool: • Whitish, black, or red stools • Diarrhea • Constipation • Flatulence/gas • Pain when having a bowel movement • Blood, pus, mucus, or discharge in stool • Fecal incontinence

3. 2. List factors affecting bowel elimination Define the following term: peristalsis involuntary contractions that move food through the gastrointestinal system.

4. Transparency 17-1: Factors Affecting Bowel Elimination • Normal changes of aging - Peristalsis slows. - Digestion takes longer and is less efficient. - Possible tooth loss and less saliva affect digestion. - Medication use and dulled sense of taste may result in poor appetite. • Psychological factors - Stress, anger, and fear increase peristalsis. - Depression decreases peristalsis. - A lack of privacy can greatly affect elimination. • Food and fluids - Fiber improves elimination. - Animal fats and low-fiber foods can cause constipation. - Some foods cause gas, which can help with elimination. - Proper fluid intake helps elimination.

5. Transparency 17-1: Factors Affecting Bowel Elimination (cont’d) • Physical activity - Regular activity helps elimination. - Immobility weakens muscles and may slow elimination. • Personal habits - Time of day varies, but it usually occurs after meals. - Supine position causes most trouble for bowel elimination. - Best position for elimination is squatting and leaning forward. • Medications - Laxatives help elimination. - Pain relievers can slow elimination. - Antibiotics may cause diarrhea.

6. 3. Describe common diseases and disorders of the gastrointestinal system NAs should know these facts about constipation: Occurs when feces moves too slowly through the intestine Can result from decreased fluid, poor diet, inactivity, medications, aging, certain diseases, or ignoring urge to eliminate Symptoms are abdominal swelling, gas, irritability, and record of no recent bowel movement Treatment involves increasing fiber in diet and increasing activity, as well as medication (enemas and suppositories may be ordered to help). Documentation of bowel movements is important.

7. 3. Describe common diseases and disorders of the gastrointestinal system NAs should know these facts about fecal impaction: Results from unrelieved constipation Symptoms include no stool for several days, oozing of liquid stool, cramping, abdominal swelling, and rectal pain Treatment is doctor or nurse breaking the mass into fragments Prevention involves high-fiber diet, increased fluids and activity, and, possibly, medication.

8. 3. Describe common diseases and disorders of the gastrointestinal system NAs should know these facts about hemorrhoids: Results from straining during bowel movements, chronic constipation, obesity, pregnancy, and sitting for long periods of time on the toilet Symptoms include rectal itching, burning, pain, and bleeding. Treatment may include medications, compresses, sitz baths, and possibly surgery. NAs should be careful to avoid causing pain while cleaning anal area.

9. 3. Describe common diseases and disorders of the gastrointestinal system NAs should know these facts about diarrhea: Results from bacterial and viral infections, microorganisms in food and water, irritating foods, and medications Treatment involves medication, increase in certain fluids, and change of diet.

10. 3. Describe common diseases and disorders of the gastrointestinal system NAs should know these facts about fecal incontinence: Causes are constipation, muscle and nerve damage, loss of storage capacity in the rectum, and diarrhea. Treatment includes a change in diet, medication, bowel training, or surgery.

11. 3. Describe common diseases and disorders of the gastrointestinal system NAs should know these facts about flatulence: Causes include swallowing air while eating, eating high-fiber foods, eating foods that a person cannot tolerate (eating dairy products if a person has lactose intolerance, for example), antibiotics, colitis, or malabsorption Treatment includes change of diet, medication, and reducing the amount of air swallowed.

12. 3. Describe common diseases and disorders of the gastrointestinal system NAs should know these facts about gastroesophageal reflux disease (GERD): Heartburn is most common symptom. Treatment involves medication; serving the evening meal three to four hours before bedtime; not lying down until two to three hours after eating; using extra pillows to keep the body more upright during sleep; serving the largest meal of the day at lunchtime; eating smaller meals throughout the day; reducing fast foods, fatty foods, and spicy foods; stopping smoking; not drinking alcohol; and wearing loose clothing.

13. 3. Describe common diseases and disorders of the gastrointestinal system NAs should know these facts about peptic ulcers: Caused by excessive acid production Symptoms include pain after eating, belching, and vomiting. Treatment involves medications, avoiding smoking, alcoholic drinks, and caffeine, and change of diet.

14. 3. Describe common diseases and disorders of the gastrointestinal system NAs should know these facts about ulcerative colitis and colitis: Symptoms include cramping, diarrhea, pain occurring on one side of the lower abdomen, rectal bleeding, and loss of appetite. Treatment includes medications and surgical treatment (a colostomy). Colitis, or irritable bowel syndrome, is milder and is controlled by diet and/or medication.

15. 3. Describe common diseases and disorders of the gastrointestinal system NAs should know these facts about colorectal cancer: Symptoms include changes in normal bowel patterns, cramps, abdominal pain, and rectal bleeding. Treatment is surgery

16. Handout 17-1: Procedure: Giving a Rectal Suppository Giving a Rectal Suppository Equipment: gloves, suppository, lubricant, bath blanket, toilet paper 1. Identify yourself by name. Identify the resident by name. 2. Wash your hands. 3. Explain procedure to the resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible. 4. Provide for resident’s privacy with curtain, screen, or door. 5. Adjust bed to a safe level, usually waist high. Lock bed wheels. 6. Help resident into left-sided Sims’ position. Cover with a bath blanket. 7. Uncover resident enough to expose buttocks only. 8. Unwrap the suppository. 9. Put on gloves. 10. Lubricate suppository as needed. 11. Spread buttocks to expose anal area. 12. Insert the suppository, using your index finger. Place the suppository past the rectal sphincter against the wall of the colon. 13. Ask the resident to take deep breaths, as it will help him or her relax and retain the suppository. 14. Withdraw the finger and briefly hold toilet paper against the anus. 15. Remove and discard gloves.

17. Handout 17-1: Procedure: Giving a Rectal Suppository (cont’d) 16. Wash your hands. 17. Remove bath blanket and cover the resident. Ask the resident to retain the suppository as long as possible. Make resident comfortable. 18. Provide a bedpan or assistance to the bathroom when needed. 19. Return bed to lowest position. Remove privacy measures. 20. Place call light within resident’s reach. 21. Report any changes in resident to the nurse. 22. Document procedure using facility guidelines.

18. 4. Discuss how enemas are given There are several different types of enemas: Tap water enema Soapsuds enema Saline enema Commercially-prepared enema

19. 4. Discuss how enemas are given NAs should follow these guidelines when assisting with an enema: Keep bedpan nearby or make sure bathroom is vacant before assisting with enema. Resident will be placed in Sims’ position. Enema solution should be warm. Enema bag should not be raised above the height listed in the care plan. Tip of tubing should be lubricated. Unclamp tube and allow a small amount of solution to run through, then reclamp. This removes air that could cause cramping.

20. 4. Discuss how enemas are given Guidelines when assisting with an enema (cont’d): Solution should flow in slowly. Hold tubing in place while giving the enema. Stop immediately if the resident has pain or you feel resistance. Report to the nurse. Resident should take slow, deep breaths. Report any of the following to the nurse: Resident could not tolerate enema due to cramping. Enema had no results. Amount of stool was very small. Stool was hard, streaked with red, very dark, or black.

21. Giving a cleansing enema • Equipment: bath blanket, IV pole, enema solution, tubing and clamp, protective pad, bedpan, lubricating jelly, bath thermometer, tape measure, toilet paper, disposable wipes, robe, non-skid footwear, towel, supplies for perineal care, paper towel, 2 pair of gloves 1. Identify yourself by name. Identify the resident by name. 2. Wash your hands.

22. Giving a cleansing enema 3. Explain procedure to the resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible. 4. Provide for resident’s privacy with curtain, screen, or door. 5. Adjust bed to a safe level, usually waist high. Lock bed wheels. 6. Help resident into left side-lying Sims’ position. Cover with a bath blanket. 7. Place the IV pole beside the bed.

23. Giving a cleansing enema 8. Clamp the enema tube. Prepare the enema solution. Fill bag with 500-1000 mL of warm water (105°F), and mix the solution. Check water temperature with bath thermometer. 9. Unclamp the tube. Let a small amount of solution run through the tubing. Re-clamp the tube. 10. Hang the bag on IV pole. Using the tape measure, make sure the bottom of the enema bag is not more than 12 inches above the resident’s anus.

24. Giving a cleansing enema 11. Put on gloves. 12. Place protective pad under resident. Ask resident to remove undergarments or help him do so. Place bedpan close to resident’s body. 13. Lubricate tip of tubing with lubricating jelly. 14. Ask the resident to breathe deeply. This relieves cramps during procedure.

25. Giving a cleansing enema • Place one hand on the upper buttock. Lift to expose the anus. Ask the resident to take a deep breath and exhale. Using other hand, gently insert the tip of the tubing two to four inches into the rectum. Stop immediately if you feel resistance or if the resident complains of pain. If this happens, clamp the tubing. Tell the nurse immediately.

26. Giving a cleansing enema 16. Unclamp the tubing. Allow the solution to flow slowly into the rectum. Ask resident to take slow, deep breaths. If resident complains of cramping, clamp the tubing and stop for a couple of minutes. Encourage him to take as much of the solution as possible.

27. Giving a cleansing enema 17. Clamp the tubing before the bag is empty when the solution is almost gone. Gently remove the tip from the rectum. Place the tip into the enema bag. Do not contaminate yourself, the resident, or the bed linens. 18. Ask the resident to hold the solution inside as long as possible.

28. Giving a cleansing enema 19. Help resident to use bedpan, commode, or get to the bathroom. If the resident uses a commode or toilet, put on robe and non-skid footwear. Lower the bed to its lowest position before the resident gets up. 20. Remove and discard gloves. Wash your hands.

29. Giving a cleansing enema 21. Place toilet paper and disposable wipes within resident’s reach. Ask the resident to clean his hands with the hand wipe when finished if he is able. If the resident is using the toilet, ask him not to flush it when finished. 22. Place the call light within resident’s reach. Ask resident to signal when done. Leave the room and close the door. 23. When called by the resident, return and put on clean gloves.

30. Giving a cleansing enema 24. Lower the head of the bed. Make sure resident is still covered. 25. Remove bedpan carefully and cover bedpan. 26. Provide perineal care if help is needed. Wipe female residents from front to back. Dry the perineal area with a towel. Help the resident put on undergarment. Cover the resident and remove the bath blanket. 27. Place the towel and bath blanket in a hamper or bag, and discard disposable supplies.

31. Giving a cleansing enema 28. Take bedpan to the bathroom. Call the nurse to observe the enema results. Empty the contents of bedpan carefully into the toilet. 29. Turn the faucet on with a paper towel. Rinse the bedpan with cold water and empty it into the toilet. Flush the toilet. Place bedpan in proper area for cleaning or clean it according to facility policy. 30. Remove and discard gloves. 31. Wash your hands.

32. Giving a cleansing enema 32. Make resident comfortable. 33. Return bed to lowest position. Remove privacy measures. 34. Place call light within resident’s reach. 35. Report any changes in resident to the nurse. 36. Document procedure using facility guidelines.

33. Giving a commercial enema • Equipment: bath blanket, standard or oil retention commercial enema kit, protective pad, bedpan, lubricating jelly, toilet paper, disposable wipes, robe, non-skid footwear, towel, supplies for perineal care, 2 pair of gloves 1. Identify yourself by name. Identify the resident by name. 2. Wash your hands. 3. Explain procedure to the resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible.

34. Giving a commercial enema 4. Provide for resident’s privacy with curtain, screen, or door. 5. Adjust bed to a safe level, usually waist high. Lock bed wheels. 6. Help resident into left-sided Sims’ position. Cover with a bath blanket. 7. Put on gloves. 8. Place protective pad under resident. Ask resident to remove undergarments or help him do so. Place bedpan close to resident’s body.

35. Giving a commercial enema 9. Uncover resident enough to expose anus only. 10. Lubricate tip of bottle with lubricating jelly. 11. Ask resident to breathe deeply to relieve cramps during procedure. 12. Place one hand on the upper buttock. Lift to expose the anus. Ask the resident to take a deep breath and exhale. Using other hand, gently insert the tip of the tubing about one and a half inches into the rectum. Stop if you feel resistance or if the resident complains of pain. Tell the nurse immediately.

36. Giving a commercial enema 13. Slowly squeeze and roll the enema container so that the solution runs inside the resident. Stop when the container is almost empty. 14. Gently remove the tip from the rectum, and place the bottle inside the box upside down. 15. Ask the resident to hold the solution inside as long as possible.

37. Giving a commercial enema • Help resident use bedpan or commode, or get to the bathroom. If the resident uses a commode or toilet, put on robe and non-skid footwear. Lower the bed to its lowest position before the resident gets up. 17. Remove and discard gloves. Wash your hands.

38. Giving a commercial enema 18. Place toilet paper and disposable wipes within resident’s reach. Ask the resident to clean his hands with the hand wipe when finished if he is able. If the resident is using the toilet, ask him not to flush it when finished. 19. Place the call light within resident’s reach. Ask resident to signal when done. Leave the room and close the door. 20. When called by the resident, return and put on clean gloves.

39. Giving a commercial enema 21. Lower the head of the bed. Make sure resident is still covered. 22. Remove bedpan carefully and cover bedpan. 23. Provide perineal care if help is needed. Wipe female residents from front to back. Dry the perineal area with a towel. Help the resident put on undergarment. Cover the resident and remove the bath blanket. 24. Place the towel and bath blanket in a hamper or bag, and discard disposable supplies.

40. Giving a commercial enema 25. Take bedpan to the bathroom. Call the nurse to observe the enema results. Empty the contents of bedpan carefully into the toilet. 26. Turn the faucet on with a paper towel. Rinse the bedpan with cold water and empty it into the toilet. Flush the toilet. Place bedpan in proper area for cleaning or clean it according to facility policy. 27. Remove and discard gloves. 28. Wash your hands.

41. Giving a commercial enema 29. Make resident comfortable. 30. Return bed to lowest position. Remove privacy measures. 31. Place call light within resident’s reach. 32. Report any changes in resident to the nurse. 33. Document procedure using facility guidelines.

42. 5. Demonstrate how to collect a stool specimen NAs should remember these points about stool specimens: Stool is tested for blood, pathogens, and other things. Stool must be warm if being tested for ova and parasites. Urine or tissue in a stool sample can ruin the sample.

43. Collecting a stool specimen • Equipment: specimen container with completed label (labeled with resident’s name, date of birth, room number, date, and time) and lid, specimen bag, 2 pairs of gloves, 2 tongue blades, bedpan (if resident cannot use portable commode or toilet), hat for toilet (if resident uses portable commode or toilet), plastic bag, toilet paper, disposable wipes, paper towels, supplies for perineal care, lab slip 1. Identify yourself by name. Identify the resident by name. 2. Wash your hands.

44. Collecting a stool specimen 3. Explain procedure to the resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible. 4. Provide for resident’s privacy with curtain, screen, or door. 5. Put on gloves. 6. Fit hat to toilet or commode, or provide resident with bedpan.

45. Collecting a stool specimen 7. When the resident is ready to move bowels, ask him not to urinate at the same time and not to put toilet paper in with the sample. Provide a plastic bag to discard toilet paper separately. 8. Place toilet paper and disposable wipes within resident’s reach. Ask resident to clean his hands with a wipe when finished if he is able. 9. Remove and discard gloves. Wash your hands.

46. Collecting a stool specimen 10. Place the call light within resident’s reach. Ask resident to signal when done. Leave the room and close the door. 11. When called by the resident, return and put on clean gloves. Provide perineal care if help is needed. 12. Using the two tongue blades, take about two tablespoons of stool and put it in the container. Without touching the inside of the container, cover it tightly. Apply label and place container in a clean specimen bag.

47. Collecting a stool specimen 13. Wrap the tongue blades in toilet paper and put them in plastic bag with used toilet paper. Discard bag in proper container. 14. Empty the bedpan or container into the toilet. Turn the faucet on with a paper towel. Rinse the bedpan with cold water and empty it into the toilet. Flush the toilet. Place equipment in proper area for cleaning or clean it according to facility policy. 15. Remove and discard gloves.

48. Collecting a stool specimen 16. Wash your hands. 17. Remove privacy measures. 18. Place call light within resident’s reach. 19. Report any changes in resident to the nurse. 20. Take specimen and lab slip to proper area. Document procedure using facility guidelines. Note amount and characteristics of stool.

49. 6. Explain occult blood testing Define the following term: occult hidden; difficult to see or observe.

50. 6. Explain occult blood testing REMEMBER: Blood in the stool may be a sign of a serious problem, such as cancer. There are different tests that can be used to check for occult blood.