第十一章 排泄 Elimination 王克芳 wangkf@sdu.edu.cn 0531-88382223 山东大学护理学院

Bowel Elimination Section 2 Anatomy and Physiology Assessment of Bowel Elimination Interventions for Bowel Elimination Nursing Skills for Bowel Elimination

Anatomy and Physiology Large Intestines is a primary organ of bowel elimination Anatomy Functions Movement Defecation

Normally is empty of feces Anatomy Transverse Colon Ascending Colon Descending Colon Cecum Sigmoid Colon Rectum Anus 16cm Normally is empty of feces 4cm Internal sphincter External sphincter  

Anatomy and Physiology Functions Absorption: Fluid, electrolyte and vitamins Manufacture of some vitamins Formation of feces Expulsion of feces from the body Anatomy and Physiology

Movement of Large Intestines 袋状往返运动 分节或多袋推进运动 蠕动(Peristalsis ) 集团蠕动(Mass peristalsis ) a wavelike muscular contraction advances the colon contents 1/(3-12)mins Occurs about 1 hour after a meal 3 - 4 times / 24hour Gastro-colic reflex Duodeno-colic reflex Anatomy and Physiology

排便(Defecation) Fecal mass Defecation center Rectum (sensor) Peristalsis impulse Rectum (sensor) Defecation center impulse Defecation Center （Cerebral cortex） Colon and rectum muscle contracts Internal sphincter relaxes External sphincter relaxes Desire to defecate Expulsion of feces

Assessment of Bowel Elimination Normal Defecation Factors Affecting Bowel Elimination Bowel Elimination Problems

Normal Defecation Fecal Characteristics Frequency Amount Shape 1-3 times/ day ----- 3 times /week Amount 100-300 g/day in adult Fecal Characteristics Shape Consistency Color Constituents Odor Normal Defecationt

Fecal Characteristics Pencil shaped obstruction, rapid peristalsis, Liquid diarrhea with reduced absorption chestnut shaped, Hard constipation Shape and Consistency Diameter of rectum Soft, formed Color Brown Constituents Undigested food, dead bacteria, fat, bile pigment, cells lining, mucosa, water Odor Affected by food type White or clay – no bile Black– bleeding in upper GI tract Red – bleeding in lower GI tract or hemorrhoids Pale with fat – mal-absorption of fat Abnormal – blood, pus, foreign bodies, mucus, worms Normal Defecationt

Factors Affecting Bowel Elimination Physiological factors Social and psychological factors Diet Physical activity Health Status Affecting Factors

Physiological factors Age Infant Small stomach capacity Less secretion of digestive enzymes Inability to control Adolescent Rapid growth of large intestine Typically eat more Elderly Peristalsis slows Choosing soft foods Difficulties in chewing (loss teeth) Reduced mobility Low muscle tone Affecting Factors

Physiological factors Personal habits Time--Gastrocolic reflex usually most easily stimulated after meals Facilities Positioning--Squat, lean forward Exerts intra-abdominal pressure Contracts thigh muscles Impossible to contract muscles in supine position

Social and psychological factors Social /Privacy environment Anxious, angry or afraid Increased peristalsis diarrhea Depressed Slowed mobility constipation

Diet factors Fiber provides bulk Gas producing foods Milk products Absorbs fluid, increases stool mass; Stimulates peristalsis Gas producing foods Increase peristalsis; Distends intestinal walls Milk products Lactose intolerance Fluid liquefies intestinal contents, easing it’s passage 2000-3000 ml/day Affecting Factors

Physical activity Promotes peristalsis Maintains tone of muscles used for defecation A sedentary lifestyle decreases peristalsis Weak abdominal and pelvic muscles impair ability to increase intra-abdominal pressure and control external sphincter Affecting Factors

Health Status Diseases Medications Treatment and screening Laxatives Antibiotics Anesthetic and narcotic analgesics Treatment and screening Surgery--Pain Affecting Factors

Bowel Elimination Problems Constipation（便秘） Fecal Impaction（粪便嵌塞） Diarrhea（腹泻） Fecal Incontinence（大便失禁） Flatulence（肠胀气） Altered Defecation

Constipation Definition A decrease in frequency of bowel movement Prolonged or difficult passage of hard and dry feces Altered Defecation

Constipation Etiology: Lack of Fiber/ Water in diet Immobilization Irregular bowel habits Medications Neurological conditions Organ illnesses

Constipation Symptoms and Signs Decreased frequency of bowel movements Dry, hard feces Headache, abdominal distention and cramping, poor digestion, fatigue, poor appetite, heavily coated tongue Altered Defecation

Fecal Impaction Fecal impaction is a collection of harden feces, wedged in the rectum, which cannot be expelled. It usually results from unrelieved chronic constipation. Altered Defecation

Fecal Impaction Causes Symptoms and Signs Results from unrelieved constipation Hard stool wedged in rectum, cannot be expelled Symptoms and Signs No stool for several days Continuous oozing of liquid stool Anorexia Abdominal distention and cramping Rectal pain Palpation: impacted mass ( a digital examination of the rectum) Altered Defecation

Diarrhea Frequent defecation Passage of liquid, unformed feces. affecting digestion, absorption, and secretion in the GI tract. Altered Defecation

Diarrhea Causes Symptoms and signs Intestinal infection or disease Food intolerance or allergies Overuses of laxatives Lack of development in digestive system Some endocrine diseases such as hyperthyroidism Emotional stress and anxiety. Symptoms and signs Increased number of stools Liquid Abdominal pain, fatigue, nausea and vomit. Auscultation: hyperactive gurgling sounds. Unable to control the urge to defecate. Altered Defecation

Fecal Incontinence the anal sphincter is inability to control passage of feces, and lead to involuntary defecation. Altered Defecation

Fecal Incontinence Causes Symptoms and Signs Pathological changes or impairments in nervous and muscular system, such as paralysis Disorder in gastrointestinal tract Mental disorder Symptoms and Signs The patients defecate involuntarily Impaired anal sphincter function or control Frequent, loose stool Altered Defecation

Flatulence gas accumulates in the intestines the gas cannot be expelled the bowel wall stretches and distends. Altered Defecation

Flatulence Causes Symptoms and Signs Ingestion more gas producing food More gas swallowed Slow peristalsis Intestinal obstruction and operation Symptoms and Signs Abdominal fullness Distention and cramping Hiccup Percussion: drum sound Flatulence can press the diaphragm and thoracic cavity, and cause dyspnea Altered Defecation

Interventions for Bowel Elimination 便秘(Constipation) 粪便嵌塞(Fecal Impaction) 腹泻(Diarrhea) 排便失禁(Fecal Incontinence) 肠胀气(Flatulence)

Constipation Management Provide privacy environment Habit Training (Time and position) Exercise Diet (dietary fiber/water ) Physiotherapy(Abdominal Massage / warm water bath） Laxatives Enema Health education First & foremost is prevention !!! Constipation Management

Constipation Management Laxative Therapy: Stimulates peristalsis Allow less time for water reabsorption Produces a softer stool !!! The aim of laxative therapy is comfortable defecation !!! Short term use only. Constipation Management

bulk-forming laxatives 果导、番泻叶、大黄、比沙可啶 能通过刺激肌间神经丛引起肌肉节律性收缩，从而增加肠蠕动，还能促进水分泌入肠腔 刺激性泻剂 stimulant laxatives 润滑剂 stool softeners 渗透性泻剂 osmotic laxatives 膨胀性泻剂 bulk-forming laxatives 石蜡油、甘油、蓖麻油(口服/灌肠) 包绕粪块、软化粪便、润滑肠腔，促进粪便排出 山梨醇、乳果糖、镁盐、钠盐（一般做灌肠用） 高渗可使大量水分进入肠腔，刺激肠蠕动 洋车前子、麸皮、甲基纤维素 肠道内可吸水膨胀成润滑性凝胶，使肠内容物易于通过；同时可使肠内容物体积增大，增强胃肠蠕动而促进排便 一般需服用几天后才能发挥作用

Fecal Impaction Management Laxatives Enema oil retention (first) Cleaning (2~3h later) Digital removal of stool It should be carefully used for the patients with cardiac disease or spinal injure because of excessive vagal response Health education Fecal Impaction Management

Diarrhea Remove the cause of diarrhea whenever possible Rest on bed and warm the abdomen Diet management: Encourage oral intake of fluids and avoid bland food A temporary fasting if serious diarrhea occurs Skin integrity Give special care to the region around the anus. Record fecal characteristics and frequency Emotional support Health education Diarrhea Management

Fecal Incontinence Management Emotional support Maintain skin integrity Keep the skin clean and dry, Keep the bed lines and clothing clean. Bowel training programs Fluid intake Environment management Open the window and maintain fresh air Set up daily routine Timed Stool softener Strengthen Pelvic Floor Muscles Fecal Incontinence Management

Flatulence Management Establish eating habit slowly chewing and swallowing Remove the cause of flatulence avoid gas-producing foods and drinks Exercise Treatment Mild Flatus: massage, acupuncture Serious Flatus: medicine or rectal tube Flatulence Management

1.Enema Nursing Skills for Bowel Elimination Main purpose A solution introduced into the rectum and sigmoid colon Remove feces and/or flatus Administer medication or nutrition Temporary relief of constipation Preparation for diagnostic tests or surgery Types of enema Large volume non-retention enema Small volume non-retention enema Retention enema Enema

大量不保留灌肠 【目的】 【灌肠溶液】 解除便秘、肠胀气。 清洁肠道。为肠道手术、检查或分娩作准备 稀释并清除肠道内的有害物质，减轻中毒 灌入低温液体，为高热患者降温。 【灌肠溶液】 常用0.1-0.2%的肥皂水，生理盐水。 用量：成人：500-1000ml；小儿：200-500ml 温度：一般为39-41℃，降温：28-32 ℃，中暑：4 ℃。 尽量保留5-10min后再排便 降温灌肠要保留30min，排便后30min测量体温并记录。 40-60cm 7-10cm

小量不保留灌肠 【目的】 【灌肠溶液】 软化粪便，解除便秘。 排出肠道内气体，减轻腹胀。 “1、2、3”溶液（50%硫酸镁30ml，甘油60ml，温开水90ml）; 甘油50ml加等量温开水；各种植物油120-180ml。 温度：38℃。 尽量保留10-20min后再排便 <30cm 7-10cm

保留灌肠 【目的】 【灌肠溶液】 镇静、催眠。 治疗肠道感染。 镇静、催眠用10%的水合氯醛 抗肠道感染用0.5-1%新霉素或其他抗生素溶液 用量：<200ml 温度：38℃。 保留1h以上 15-20cm

Side effect of enema Congestive heart failure/fluid, sodium retention Vagal response—heart effect Trauma

2、口服高渗溶液清洁肠道 高渗溶液进入肠道，在肠道形成高渗环境，使肠道内水分大量增加，从而软化粪便，刺激肠蠕动，加速排便，达到清洁肠道的目的。 适用于直肠、结肠检查和手术前肠道准备。 甘露醇法：20%甘露醇500ml+ 5%葡萄糖1000ml 硫酸镁法：50%硫酸镁100ml+ 5%葡萄糖100ml

3、简易通便法 适用于体弱、老人和久病卧床便秘者。 开塞露法 甘油栓法 肥皂栓法

4、肛管排气法 【定义】 【目的】 【注意】 是将肛管从肛门插入直肠，以排除肠腔内积气的方法。 帮助患者排除肠腔积气，减轻腹胀。 保留肛管不超过20min。长期留置会 降低括约肌的反应，甚至导致肛门括约 肌永久性松弛

5、粪便标本采集 【常规标本】 【培养标本】 【隐血标本】 【寄生虫或虫卵标本】 用于检查粪便的性状、颜色、细胞等。 用于检查粪便中的致病菌。 【隐血标本】 用于检查粪便内肉眼不能察见的微量血液。 【寄生虫或虫卵标本】 用于检查粪便中的寄生虫、幼虫以及虫卵计数检查。

Words: Defecation Cecum Colon Rectum Anus Constipation Fecal Impaction Diarrhea Fecal Incontinence Flatulence Laxatives Enema

案例1： 小凯过去一般间隔三天以上大便一次，腹部胀满，经常吃泻药或 者到医院灌肠。自今年年初，小凯一个月最多大便三次，最长的一次 间隔20多天，并且排便困难，腹部饱胀，泻药和灌肠作用不明显。 案例2： 张女士，今年26岁。由于工作的原因，每天总是坐着，运动量小 ，而且精神压力大，作息起居不规律。大便通常3-4天排便一次，而 且粪便坚硬成栗子状，而且每次都感觉排便费力，有排不尽的感觉。 案例3： 张奶奶的孙子小明伤食后出现腹泻，每天稀水便六七次。张奶奶 认为孩子越吃越拉，决定给他禁食，饿得孩子哭闹不止，腹泻症状也 无减轻。

教学目标 了解： 与排便有关的解剖与生理。 熟悉： 影响排便的因素。 掌握： 对排便活动的评估及护理。