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Nursing Skills
Test 5 - Elimination/Bowel
| Question | Answer |
|---|---|
| A large mass of dry, hard stool that can develop in the rectum due to chronic constipation. | Impaction |
| Obstruction of the intestine due to paralysis of the intestinal muscles. Leads to functional blockage of the intestine. | Paralytic ileus |
| What are three examples of things that cause paralytic ileus? | Pain meds, anesthesia, if the bowel if bowel is “touched” (very common post op |
| Stasis (an abnormal state in which the normal flow of is slowed or stopped) of the bowel can produce | Distention and pain |
| Can stool pass around a bowel obstruction and be mistaken for diarrhea? | Yes |
| How much daily fiber is recommended? | 25-30 g/day |
| A low fat diet decreases the risk of | Colorectal cancer |
| How many ml of fluids are recommended a day? | 2000-3000 if not contraindicated |
| How does activity impact the bowel? | More movement gets the bowel going |
| How does opioid use impact the bowel? | Decreases the mobility of bowel and causes constipation |
| What are reasons for using enemas? (6) | Promote defecation, presence of decreased sphincter control, cleansing, to clear bowel in prep for surgery/testing, to relieve flatus, to reduce bacteria |
| How do enemas promote defecation? | By installation of fluid to lubricate/break up fecal mass in rectum and sigmoid colon |
| How do you relieve flatus with enema? | 1-200 ml into rectum-lower container and flatus is expelled-repeat as needed |
| How can enemas help maintain electrolyte imbalance? | They can help pull out excess electrolytes |
| What two areas is a fleet enema instilled into? | Rectum and sigmoid colon |
| Can an enema be used to maintain bowel regularity? | No |
| Can an enema cause fluid and electrolyte imbalances? | Yes |
| What can stimulation of the vagus nerve cause? | Arrhythmias |
| How many ml to small volume fleet enemas have? | 90-120 ml of solution |
| Enemas works by | Distending the colon via water retention and increasing peristalsis |
| How long do you hold a fleet enema? | 5-10 min |
| What can a hypertonic type enema cause? | Sodium retention |
| How many mL does a large volume enema hold? | 500-1000 mL |
| How long do you hold a large volume enema? | 5-10 min |
| What is a side effect of enema use? | May cause fluid or electrolyte imbalance |
| The volume of an enema for children or elderly should be | Smaller |
| Can enemas be ordered “until clear”? | Yes |
| When using an enema with a cardiac patient, what should you avoid? | Valsalvar maneuver due to vagus problem |
| Adding soap to an enema helps stimulate peristalsis by what two things? | Irritating and distending the colon |
| How much soap/water is used for a soap enema? | 5 mL of soap in 500 mL of fluid |
| How long do you hold the soap enema | 5-10 min |
| A side effect of the soap enema is that it can be | Very irritating |
| An oil retention enema works by | Softens and lubricates the stool to allow the stool to slide out more easily-may be used to remove fecal impaction |
| What type of oil is used for oil enema? | Mineral |
| What volume is used for oil enema? | 90-120 mL |
| How long do you hold an oil enema? | 30 min |
| When completing an abdominal assessment for complaint of difficulty with bowel movements, what should be checked? (4) | Check last BM, presence of bowel tones, distention, abdominal pain, patients limits of mobility |
| Do you need a doctor order to give a client and enema? Why or why not? | Yes due to possible vagus nerve stimulation |
| What temperature should enema solution be? | Warm |
| To help the patient relax his rectal sphincter he should | Breathe out |
| Is feeling of distention normal when having an enema inserted? | Yes |
| What position should patient be in when having enema inserted? | Left side lying |
| End of rectal tube should be lubricated with | KY Jelly |
| How far do you insert enema for adult? | 3-4 inches past the internal sphincter |
| The tip of the enema should be pointed in the direction of | The patient’s umbilicus |
| When emptying enema, patient may experience | Cramping |
| How far should you insert an enema for a child? | 2-3 inches |
| How far should you insert an enema for an infant? | 1-1.5 inches |
| The container should be ____ inches above rectum | 18-Dec |
| What do you do if you get resistance from the rectum? | Permit a small amount of solution to enter, withdraw the tube slightly and reinsert |
| What do you do if you see rectal bleeding/hemorrhoids? | You will still give the enema but do not force it, make sure you are visualizing where you are going |
| If cramping occurs, what should you do? | Slow the rate of the fluid |
| If patient can’t retain fluid, what should you do? | Place patient on bedpan and give enema while he is on the bedpan |
| If patient is impacted with stool, what do you do before inserting enema? | Remove manually |
| After giving an enema, what should you do? | Document the patient’s ability to tolerate the procedures and results |
| Before manually removing impacted stool, what three things should you assess? | Bleeding status, cardiac risk, abdominal assessment |
| Before inserting glove to remove impacted stool, | Lubricate gloved index finger |
| What position is patient in when you are removing impacted stool? | Lying on left side (Sims) |
| How far should you insert fingers when removing impacted stool | 3-4 inches |
| Stimulation by nurse during the removal of impacted stool can often cause peristalsis. True/False | TRUE |
| Temporary or permanent bypassing of a segment of bowel by surgical procedure | Bowel Diversion |
| What are three reasons why a bowel might be diverted? | Tissue damage to the bowel from disease (cancer), trauma, or inflammation (Cohn’s disease) |
| Can either the large or small intestine be diverted? | Yes |
| Diversion of a part of the bowel results in the creation of a | Stoma |
| Surgical opening in intestine to allow passage of stool through stoma in abdomen Permanent or temporary | Ostomy |
| Portion of intestine brought out onto abdomen | Stoma |
| Surgical procedure which produces a stoma | Enterostomy |
| Opening from small bowel (ileum) | Ileostomy |
| Opening from large bowel | Colostomy |
| This type of ostomy will have the loosest drainage of stool and a drainage bag is always required | Ileostomy |
| Will some people with an ileostomy have their entire colon removed? | Yes |
| What are the four types of colostomies | Ascending, Transverse, Descending, Sigmoid |
| Two stomas for one fecal diversion. One stoma is present for passing the effluent to the outside and the other stoma is used as a mucus fistula. | Double barreled colostomy |
| Part of double barrel colostomy that is closest to the patient and functioning. | Proximal portion |
| Part of the double barrel colostomy that is further away from the patient and acting as the mucous fistula | Distal position |
| What six things should be included in the assessment of a stoma? | Edema/ shape, Color, Moistness, Surrounding skin, Irritation / ulceration, drainage |
| It is normal for the shape of a stoma to change within the first | 6-8 weeks |
| What should a healthy stoma look like? | Moist, light pink, without irritation or infection |
| What three conditions should you watch out for that could develop in a person with a colostomy stoma? | Allergic contact dermatitis, Irritant dermatitis, Irritant dermatitis |
| During the first 24-46 hours, what drains from the stoma? | Old blood and flatus |
| When does still begin to come out of the stoma? | By third day post op |
| If the pouch and flange are attached it is considered______ if detached it is considered)______. | One piece, two piece |
| Empty the pouch when how full? | 1/3 to ½ |
| What are the six steps to emptying the pouch? | Apply gloves, Remove clamp , Empty pouch into pan or toilet, Clean the end of the pouch with tissue, The end of the pouch is turned over 1 time, Replace clamp |
| How often do you change the appliance? | Every 3-7 days |
| Before removing the pouch first do this | Empty it |
| Do you reuse the clamp? | Yes |
| What do you was the peristomal skin with | Warm tap water |
| How do you determine the proper size bag? | By measuring size of stoma |
| Before applying the pouch, first do this | Apply skin barrier |
| What are the reasons why an ostomy would be irrigated? (3) | Establish a pattern of regular bowel elimination after ostomy surgery, Cleanse the bowel of feces before tests or surgery, Relieve constipation |
| Are ileostomies irrigated? | No! |
| What temp should irrigation bag be? | Warm |
| How many mL of solution should be used to irrigate an adult ostomy? | 750-1000 mL |
| When hanging the ostomy irrigation bag, do so such that bottom of the bag is at | The patient’s shoulder level |
| Is the ostomy appliance on or off during ostomy irrigation? | Off |
| The ostomy irrigation sleeve is placed over the | Stoma |
| The end of the cone of should be lubricated with | Water soluble lubricant |
| The cone gets inserted into the | Stoma |
| How long do you instill solution for colostomy irrigation? | 5-6 min |
| What should you do with the tubing while instilling irrigation solution? | Hold it |
| What do you do if cramping occurs while instilling irrigation solution? | Lower the bag or stop |
| After you have instilled the solution for colostomy irrigation, what should you do? | Hold the cone in place for 10 sec |
| For a colostomy irrigation where should the patient sit and where does the solution return to? | They sit on the toilet and the solution dumps into the toilet |
| An herb or preparation that either prevents formation of gas in the gastrointestinal tract or facilitates the expulsion of said gas, thereby combating flatulence | Carminative |
| The further along the ostomy is in the tract, the more/less firm it becomes. | More |
| How much larger should the flange be that the stoma? | 1/8 to 1/16 larger |
Created by:
anastasia158
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