Module 1: Bowel Elimination

Colostomy

Handling the colostomy requires a clean technique.

Stoma: the stoma of a colostomy is normally pinkish, moist, and shiny. If post-op, it is expected to also be blood-streaked, painful, and slightly edematous. Refer if persistent. A bluish discoloration points to cyanosis, black discoloration points to necrosis, and a pale color points to anemia.
Contraindicated Foods: follow a low-fiber diet for colostomies, and no-seed diet for ileostomy.
- Avoid gas-forming foods to avoid abdominal distention.
  - Cruciferous Vegetables: Broccoli, Cauliflower, Cabbage, Lettuce, etc.
  - Root Crops: Sweet Potato, Carrots, Turnips, Radish
- Controlling Odor: (mn. CYAM) Charcoal, Yogurt (best choice), A Green Leafy Vegetable, Milk
Skin Protection
- Karaya, in the form of paste or powder placed around the stoma.
- Skin films or adhesive films placed on the skin around the stoma.
There are no activity restrictions except for: contact sports and heavy-weight lifting.
Double-Barreled Colostomy: e.g. for Hirschsprung Disease (Aganglionic Megacolon). Placed across the transverse colon, with two stoma: proximal and distal. Proximal drainage contains feces, while distal drainage contains mucus.

Primarily used for pre-colonoscopy or pre-operative stages. It is a procedure that requires clean technique.

Cleansing Enema, also known as “Non-retention Enema” is used to (1) stimulate peristalsis, (2) prepare for diagnostic (e.g. Colonoscopy) and surgical procedures (e.g. Hemorrhoidectomy). Example solutions used for this type include:
- Hypertonic Solutions
- Isotonic Solutions
- NSS + Soap Sud, sometimes Medicated enema
- Fleet Enema, commercially available enema
- Clean-water Enema has been used, but is no longer used because of the high potential for electrolyte imbalance.
Retention Enema, also known as Oil-based Enema:
- Stool Lubrication: Mineral oil; cotton seed oil. Olive oil may be used.
- Stimulate Peristalsis: Castor oil
Carminative Enema used to expel flatus. This enema is composed of:
- Magnesium sulfate (30 ml)
- Glycerin (60 ml)
- H₂O (90 ml)

Positioning: position the patient in a Sim’s Left Lateral or Side-Lying position.
Volume: depends on the age of the patient, generally divided between:
- Adults: 750 to 1000 mL
- Children: 500 to 700 mL
- Infant: 100 to 20 mL
Temperature: the solution must be warm (100 to 105F, maximum of 100F for children to prevent rectal discomfort).
Length of Rectal Tube: also depends on age. Avoid rectal discomfort; never exceed limitations on length. Insertion requires KY (water-based) Jelly. Use a generous amount.
- Adults: 3” to 4”
- Children: 2” to 3”
- Infant: 1” to 1.5”
Types and Differences:

Characteristics	Non-Retention	Retention
Height	18”	12”
Duration	10 to 15 mins.	1 to 3 hours (based on manufacturer)

Complications:
- During transfusion, cramps and pain may occur. Stop the transfusion and notify the physician.
- For children, avoid separation anxiety. Have a parent or caretaker stay with the child during transfusion.

Blood transfusions are sterile procedures.

Information: name of the patient, blood type, blood product, and cross-matching for any products with RBC.
Blood Types: A, B, AB (universal recipient), and O (universal donor).
Blood Products: whole blood and packed RBC has a maximum infusion time of 4 hours. Platelets clot easily, and is only infused for 30 minutes.
- Whole Blood
- Packed RBC
- Platelets
Gauge: the best gauge is 18 (green). Maximum is 20 (pink)
Solution: the only adjust solution to blood is NSS.
Reactions: when any reactions occur, (a) stop the BT line, (b) then continue the NSS line. (c) Measure vital signs then refer to the physician.
- Allergic/Anaphylactic Reaction: hives, rashes, urticaria, pruritus; Diphenhydramine or Benadryl are regularly used to counteract these manifestations.
- Febrile Reaction: fever
- Hemolytic Reaction: low back pain; flank pain
- Fluid Overload: distended neck vein
- Cardiogenic Reaction: difficulty of breathing
Cross-Matching Technique: O is the universal donor, while AB is the universal recipient. The following diagram shows the flowchart of who is able to donate to who; all blood types can donate to their own blood type. O receives from O; A receives from O and A; B receives from O and B; and AB receives from O, A, B, and AB.

flowchart LR
O-->A
O-->B
A-->AB
O-->AB
B-->AB

Also known as IV Hyperalimentation Feeding. This is used for cases like severe malnutrition and post-GI surgeries.

Components:
- Carbohydrates (CHO): glucose makes up 60% to 70% of the bag.
- Proteins (CHON): amino acids (amino acids are complete in egg whites)
- Fats: lipids. Unsaturated fats are good; high-density lipoproteins. Examples include salmon, tuna, anchovies, avocado, sardines (not canned), catfish.
- Vitamins and Minerals
  - Vitamin C helps with wound healing.
- Fluids and Electrolytes
Access Point: (a) Subclavian Vein (safer; more common) and (b) Internal Jugular Vein
Complications:
- Hyperglycemia, one of the early manifestations. Keep regular insulin by bedside as antidote.
- Infection or Sepsis, usually appearing after 2 to 4 weeks. Treated with broad-spectrum antibiotics.
Nursing Considerations:
- Vital Signs q4hr. The most important sign to watch out for is temperature (36.5C to 37.5C), as it indicates infection.
- Blood Glucose Monitoring (BGM) q6hr. Normal values range from 80 to 120 mg/dL. For Filipinos, values range from 70 to 110 mg/dL.
- Don’t stop TPN abruptly; taper gradually to prevent rebound hypoglycemia.
- Observe absolute sterile technique due to the risk of infection. Glucose is highly nourishing for bacteria.
- Timeline: change solutions in 24 hours.