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Intestinal EliminationIntestinal Elimination
Dr.Karima ElshamyDr.Karima Elshamy
Outline:Outline:
�� Introduction.Introduction.
�� General principles.General principles.
�� Basic facts on relation to anatomy Basic facts on relation to anatomy
and physiology.and physiology.
�� The acts of defecation.The acts of defecation.
�� Personal habits.Personal habits.
�� Factors influencing fecal elimination.Factors influencing fecal elimination.
��Common problems of intestinal Common problems of intestinal
elimination:elimination:
�� Constipation.Constipation.
�� Fecal impaction.Fecal impaction.
�� Intestinal, distension (tympani is).Intestinal, distension (tympani is).
�� Diarrhea.Diarrhea.
�� Anal incontinence.Anal incontinence.
Introduction:Introduction:
Elimination is essential to rid the body of Elimination is essential to rid the body of
wastes and materials in excess of bodily wastes and materials in excess of bodily
needs. needs.
Elimination process is necessary to maintain Elimination process is necessary to maintain
high level of wellness and even life itself high level of wellness and even life itself
and must continue during illness in health.and must continue during illness in health.
General Principles:General Principles:
�� Efficient physiologic functioning requires Efficient physiologic functioning requires
that waste substances be eliminated from the that waste substances be eliminated from the
body.body.
�� Patters of elimination from the large intestine Patters of elimination from the large intestine
vary among individuals.vary among individuals.
�� StressStress--producing situations and illness may producing situations and illness may
interfere with normal habits of elimination.interfere with normal habits of elimination.
Basic Facts in Relation to Anatomy Basic Facts in Relation to Anatomy
and Physiology:and Physiology:
1.1. The large intestine is a tube leading from "' the The large intestine is a tube leading from "' the
small intestine to the external skin and is about 150 small intestine to the external skin and is about 150
--180 cm in length . 180 cm in length .
The ileocecal valve separates the small intestine The ileocecal valve separates the small intestine
from the large intestine. from the large intestine.
It opens in one direction; prevent the passage of It opens in one direction; prevent the passage of
material in the opposite direction. (Fig: 1).material in the opposite direction. (Fig: 1).
2.2. The large intestine is divided into:The large intestine is divided into:
�� The caucus: lies at the beginning of the The caucus: lies at the beginning of the
large intestine.large intestine.
�� The colon: lies between the caucus and the The colon: lies between the caucus and the
rectum and is divided into:rectum and is divided into:
–– The ascending colon goes up on the The ascending colon goes up on the
right side.right side.
–– The transverse colon crosses the The transverse colon crosses the
abdomen. abdomen.
–– The descending colon goes down on the The descending colon goes down on the
left side.left side.
�� The sigmoid flexure ends at the rectum.The sigmoid flexure ends at the rectum.
�� The rectum of the adult person is about The rectum of the adult person is about
1515--20 cm.20 cm.
3.3. The anal canal is about 2.5 cm, and has The anal canal is about 2.5 cm, and has
two sphincters. two sphincters. The internal sphincterThe internal sphincter
and and the external sphincterthe external sphincter at the anus, at the anus,
the external sphincter has striated the external sphincter has striated
muscles and is under voluntary control.muscles and is under voluntary control.
The anal canalThe anal canal
4.4. The large intestine, including the anal canal The large intestine, including the anal canal
is innervated by autonomic nerve supply:is innervated by autonomic nerve supply:
�� Stimulation of the parasympathetic Stimulation of the parasympathetic
system promotes peristalsis and increases system promotes peristalsis and increases
muscle tone.muscle tone.
�� Stimulation of the sympathetic nerves Stimulation of the sympathetic nerves
inhibits peristalsis and decreases tone. inhibits peristalsis and decreases tone.
5.5. There are two localThere are two local--reflexes involved in reflexes involved in
intestinal elimination:intestinal elimination:
�� The gastro colic reflex:The gastro colic reflex: peristalsis is peristalsis is
stimulated by the intake of food enters the stimulated by the intake of food enters the
duodenum (about half an hour afterduodenum (about half an hour after--eating eating
or drinking) a mass peristaltic action or drinking) a mass peristaltic action
occurs in the large intestine which is occurs in the large intestine which is
called the gastro colic reflex, and the need called the gastro colic reflex, and the need
to defecate is felt.to defecate is felt.
The rectal reflex (defecating The rectal reflex (defecating
reflex):reflex):
is stimulated by the presence of waste is stimulated by the presence of waste
products in the rectum which is products in the rectum which is
producing mechanical pressure. This producing mechanical pressure. This
leads to stimulation of sensory leads to stimulation of sensory
receptors and the need to defecate is receptors and the need to defecate is
felt.felt.
The act of defecation:The act of defecation:
The act of defecation:The act of defecation:
Defecation:Defecation:
Is an evacuation of the intestines and is Is an evacuation of the intestines and is
often referred to as a bowel movement. often referred to as a bowel movement.
When a certain amount of fecal matter When a certain amount of fecal matter
accumulates in the rectum it becomes accumulates in the rectum it becomes
distended and the intradistended and the intra--rectal pressure rectal pressure
rises.rises.
Sensory nerve endings are stimulated Sensory nerve endings are stimulated
(parasympathetic), the internal and (parasympathetic), the internal and
external sphincter relaxes, and the external sphincter relaxes, and the
colon contracts ,the result is a desire colon contracts ,the result is a desire
to defecate. to defecate.
During the act of defecation During the act of defecation several several
additional muscles help in the additional muscles help in the
process:process:
�� Voluntary contraction of the additional Voluntary contraction of the additional
muscles and closing of the glottis and muscles and closing of the glottis and
increasing intraincreasing intra--abdominal pressure that abdominal pressure that
aids in expelling the feces.aids in expelling the feces.
�� Simultaneously, the muscles of the Simultaneously, the muscles of the
pelvic floor contracts and aid in pushing pelvic floor contracts and aid in pushing
the fecal mass out. the fecal mass out.
Personal Habits:Personal Habits:
�� Regularity and frequency of a bowel Regularity and frequency of a bowel
movement vary from one person to another movement vary from one person to another
e.g. most adults pass one stool each day, e.g. most adults pass one stool each day,
others have more or less frequent bowel others have more or less frequent bowel
movements. movements.
�� Some persons have a bowel movement two Some persons have a bowel movement two
or three times a week, others as often as two or three times a week, others as often as two
or three times a day. or three times a day.
�� Some people may be used to have the bowel Some people may be used to have the bowel
movement after drinking morning coffee or movement after drinking morning coffee or
tea...or even having their breakfast. tea...or even having their breakfast.
�� Immediate response to a felt desire is Immediate response to a felt desire is
important in establishing regularity of habit.important in establishing regularity of habit.
�� Continues inhibitions of the desire to Continues inhibitions of the desire to
defecate will lead to chronic constipation.defecate will lead to chronic constipation.
Factors Influencing Fecal Elimination:Factors Influencing Fecal Elimination:
1.1. Diet:Diet:
�� It is one of the most important factors It is one of the most important factors
effecting changes in the secretion and effecting changes in the secretion and
motility of the alimentary canal.motility of the alimentary canal.
�� It also influences the type and amount of It also influences the type and amount of
bacteria entering the digestive system. This in bacteria entering the digestive system. This in
turn will affect the fecal characteristics.turn will affect the fecal characteristics.
Balanced food content with Balanced food content with
varied bulk is important to varied bulk is important to
the production of feces and the production of feces and its movement along the its movement along the
intestinal tract. Fluid intake intestinal tract. Fluid intake has to do with stool has to do with stool
consistency. consistency.
2.2. Psychological Factors:Psychological Factors:
In period of stressIn period of stress
caused by fear,caused by fear,
grief, or anger, grief, or anger,
or peristaltic activityor peristaltic activity
and muscle spasmsand muscle spasms
may increase ormay increase or
decrease, diarrhea, decrease, diarrhea,
or occasionally,or occasionally,
constipation may result.constipation may result.
AngerAnger
2.2. Psychological Factors:Psychological Factors:
Constipation isConstipation is
often secondaryoften secondary
to psychiatricto psychiatric
conditions (e.g.conditions (e.g.
depression, depression,
chronic psychoseschronic psychoses
, and anorexia nervosa)., and anorexia nervosa).
3.3. Physical Activity:Physical Activity:
�� Physical activity influences elimination Physical activity influences elimination
by promoting the development of muscle by promoting the development of muscle
tone as well as by stimulating appetite tone as well as by stimulating appetite
and peristalsis.and peristalsis.
�� Increased activity will stimulate the Increased activity will stimulate the
colon.colon.
3.3. Physical Activity Cont:Physical Activity Cont:
�� Immobility or sleep will depress the colon.Immobility or sleep will depress the colon.
�� Changes in posture, such as standing up, Changes in posture, such as standing up,
lying down, or sitting during a bowel lying down, or sitting during a bowel
movement influences ease of emptying the movement influences ease of emptying the
rectum.rectum.
4.4. Neutrogena Conditions:Neutrogena Conditions:
�� Neutrogena conditions caused by Neutrogena conditions caused by
traumatic lesions and organic diseases traumatic lesions and organic diseases
of the nervous system, such as multiple of the nervous system, such as multiple
sclerosis, brain and cord tumours, and sclerosis, brain and cord tumours, and
meningitis, frequently leave a person meningitis, frequently leave a person
with chronic constipation.with chronic constipation.
5.5. Muscular Condition:Muscular Condition:
�� Abdominal, pelvic, and diaphragmatic Abdominal, pelvic, and diaphragmatic
muscles play an important role in muscles play an important role in
initiating and completing defecation.initiating and completing defecation.
�� Injuries or other conditions affecting the Injuries or other conditions affecting the
strength of these muscles will therefore strength of these muscles will therefore
make evacuation difficult.make evacuation difficult.
�� Weakness from muscle atony may be Weakness from muscle atony may be
caused by laxative abuse or severe caused by laxative abuse or severe
malnutrition.malnutrition.
6.6. Mechanical Obstruction: Mechanical Obstruction:
�� Obstruction that results in an abnormal Obstruction that results in an abnormal
physical state of the bowel content may physical state of the bowel content may
retard propulsion and cause constipation or retard propulsion and cause constipation or
distension.distension.
�� Actual physical blockage or narrowing of Actual physical blockage or narrowing of
the intestine's interior may be caused by the intestine's interior may be caused by
neoplasm and inflammatory lesions.neoplasm and inflammatory lesions.
�� Haemorrhoids, fissures, and abscesses can Haemorrhoids, fissures, and abscesses can
inhibit voluntary muscle relaxation and inhibit voluntary muscle relaxation and
result in constipation.result in constipation.
7.7. Malabsorbation:Malabsorbation:
�� It is a common cause of diarrhoea, It is a common cause of diarrhoea,
may involve significant excess or may involve significant excess or
deficiency in intake of fat, protein, deficiency in intake of fat, protein,
carbohydrates, vitamins and carbohydrates, vitamins and
minerals. minerals.
8.8. Disease Conditions:Disease Conditions:
�� E.g. inflammatory disease caused by E.g. inflammatory disease caused by
pathogenic organisms such as salmonella, pathogenic organisms such as salmonella,
amoebas, and enter viruses, or by ulcerative amoebas, and enter viruses, or by ulcerative
colitis or by cathartics may produce colitis or by cathartics may produce
diarrhoea.diarrhoea.
9.9. Constipation may be Constipation may be
present in several present in several
disease conditions disease conditions
including carcinoma including carcinoma
of the large bowel, of the large bowel,
Hemorrhoids, and Hemorrhoids, and
fissure, and perineal fissure, and perineal
abscess.abscess.
9.9. Drugs:Drugs:
�� e.g. Constipation is e.g. Constipation is
often attributed.often attributed.
1)1) Constipation:Constipation:
The passage of unusually The passage of unusually
dry, hard stools produced dry, hard stools produced
by undue delay in the by undue delay in the
passage of feces. passage of feces.
Common Problems of Intestinal Common Problems of Intestinal Elimination:Elimination:
CausesCauses
�� Poor elimination habits. If the desire for Poor elimination habits. If the desire for
defecation is ignored repeatedly, the feces defecation is ignored repeatedly, the feces
become hard and dry because of increased become hard and dry because of increased
water absorption.water absorption.
�� Lack of sufficient roughage or bulk in diet.Lack of sufficient roughage or bulk in diet.
�� Lack of enough fluid intake.Lack of enough fluid intake.
�� Lack of muscle tone due to too much Lack of muscle tone due to too much
stimulation by irritating substances such as stimulation by irritating substances such as
laxatives.laxatives.
�� Emotional Tension may cause the Emotional Tension may cause the gastrointestinal tract to become spastic gastrointestinal tract to become spastic and fecal content is not moved along and fecal content is not moved along the large intestine sufficiently well.the large intestine sufficiently well.
�� Interference with normal reflexes Interference with normal reflexes because of pain associated with because of pain associated with defecation, e.g., piles, and fissure etcdefecation, e.g., piles, and fissure etc
�� Lack of essential vitamins such as Lack of essential vitamins such as vitamin B. group or mineral as vitamin B. group or mineral as potassium. potassium.
�� Lack of exercise:Lack of exercise:
oo Decreased peristaltic movement.Decreased peristaltic movement.
oo Loss of muscle tone.Loss of muscle tone.
�� Actual mechanical obstruction Actual mechanical obstruction
caused by compression of a mass caused by compression of a mass
e.g., tumor or edema of the e.g., tumor or edema of the
intestinal wall, hernia or fecal intestinal wall, hernia or fecal
impaction. impaction.
Assessment of Patient with ConstipationAssessment of Patient with Constipation
�� Passage of hard stools associated with a Passage of hard stools associated with a
decrease in the usual frequency of decrease in the usual frequency of
defecation.defecation.
�� Feeling of rectal fullness.Feeling of rectal fullness.
�� Abdominal distension (the abdomen feels Abdominal distension (the abdomen feels
hard upon palpation) caused by hard upon palpation) caused by
accumulation of fecal matter as well as accumulation of fecal matter as well as
gases.gases.
�� Complaints of tenesmus (frequent Complaints of tenesmus (frequent
painful straining in attempts to painful straining in attempts to
defecate ).defecate ).
�� General symptoms: e.g. headache, General symptoms: e.g. headache,
malaise, anorexia, and bad breath. malaise, anorexia, and bad breath.
Nursing Management of ConstipationNursing Management of Constipation
�� Provide adequate fluid intake 500 Provide adequate fluid intake 500 -- 2000 2000 cc/day.cc/day.
�� Provide a wellProvide a well--balanced diet with enough balanced diet with enough roughage from fruits and vegetables and roughage from fruits and vegetables and vitamins.vitamins.
�� Encourage regularity of time for defecation Encourage regularity of time for defecation and prompt response to the desire of and prompt response to the desire of defecation.defecation.
�� Encourage regularity of meal's time.Encourage regularity of meal's time.
Provide adequate time for complete Provide adequate time for complete evacuation.evacuation.
Provide privacy for patients to promote Provide privacy for patients to promote relaxation.relaxation.
Provide posture (position) as close to normal Provide posture (position) as close to normal as possible.as possible.
Provide physical and emotional comfort and Provide physical and emotional comfort and alleviation of pain.alleviation of pain.
Provide physical exercises especially for Provide physical exercises especially for abdominal muscles.abdominal muscles.
Consider the patient's habit in relation to Consider the patient's habit in relation to defecation. defecation.
Prevention of ConstipationPrevention of Constipation
�� Encourage exercise as walking.Encourage exercise as walking.
�� Avoid excessive emotional stress.Avoid excessive emotional stress.
�� Establish regularity of meals and defecation Establish regularity of meals and defecation
time.time.
�� Discourage unnecessary use of laxatives.Discourage unnecessary use of laxatives.
�� Intake of proper diet containing enough Intake of proper diet containing enough
vegetables and vitamins.vegetables and vitamins.
�� Intake of sufficient fluids per day.Intake of sufficient fluids per day.
2.2. Fecal Impaction:Fecal Impaction:
DefinitionDefinition
A prolonged retention or an A prolonged retention or an accumulation of fecal material which accumulation of fecal material which forms a hardened mass in the rectum, it forms a hardened mass in the rectum, it may be of sufficient size to prevent the may be of sufficient size to prevent the passage of normal stools. (fig: 2) passage of normal stools. (fig: 2)
Signs and SymptomsSigns and Symptoms
�� Distended abdomen (hand upon palpation Distended abdomen (hand upon palpation
and feels rigid).and feels rigid).
�� Rectal pain due to pressure of the fecal Rectal pain due to pressure of the fecal
mass. mass.
�� Passage of small amount of liquid stool due Passage of small amount of liquid stool due
to mechanical irritation of the rectum.to mechanical irritation of the rectum.
Causes Causes
�� Prolonged constipation and poor habits of Prolonged constipation and poor habits of
defecation.defecation.
�� Prolonged bed rest, vary in paralyzed or Prolonged bed rest, vary in paralyzed or
unconscious patients.unconscious patients.
�� Prolonged use of antiProlonged use of anti--diarrheas drugs.diarrheas drugs.
�� Following administration of Barium for xFollowing administration of Barium for x--
ray examination of the G.I.T.ray examination of the G.I.T.
Nursing ManagementNursing Management
�� Administration of mineral oil by mouth Administration of mineral oil by mouth especially in cases of prolonged especially in cases of prolonged constipation for regulation of habits.constipation for regulation of habits.
�� Oil retention enema followed by cleansing Oil retention enema followed by cleansing enema.enema.
�� Digital manipulation of the fecal mass Digital manipulation of the fecal mass should be under physician order or should be under physician order or supervision because it can stimulate vague supervision because it can stimulate vague nerve in the rectal wall which can slow nerve in the rectal wall which can slow patient's heart leading to cardiac patient's heart leading to cardiac arrhythmia, so observe patient's pulse rate, arrhythmia, so observe patient's pulse rate, facial pallor and diaphoresis during facial pallor and diaphoresis during manipulationmanipulation. .
PreventionPrevention
�� Careful observation of the patient's Careful observation of the patient's
bowel movements in terms of bowel movements in terms of amount, consistency, and frequency.amount, consistency, and frequency.
�� Prevention of constipation.Prevention of constipation.
�� Special attention to patients who Special attention to patients who
received barium for xreceived barium for x--ray of the G.I.T ray of the G.I.T
EnemasEnemas
Are fluid solutions introduced into the Are fluid solutions introduced into the
rectum and colon.rectum and colon.
The most common reason for giving The most common reason for giving
enemas is to stimulate the urge to defecate. enemas is to stimulate the urge to defecate.
PurposePurpose
�� To empty the rectum and the lower colon To empty the rectum and the lower colon
when constipation is present.when constipation is present.
�� To relieve gas from colon and rectum.To relieve gas from colon and rectum.
�� To provide nutrients for a patient who To provide nutrients for a patient who
cannot take food orally.cannot take food orally.
PurposePurpose
�� To administer medications.To administer medications.
�� PrePre--operative, especially in intestinal tract operative, especially in intestinal tract
operations to remove fecal.operations to remove fecal.
�� To soothe irritated intestinal wall. In To soothe irritated intestinal wall. In
diagnosis e.g. Barium enemadiagnosis e.g. Barium enema..
3)3) Intestinal Distension (tympanitis):Intestinal Distension (tympanitis):
DefinitionDefinition
Excessive formation and accumulation Excessive formation and accumulation
of gases in the intestines of gases in the intestines
CausesCauses
�� Excessive intake of gas forming foods.Excessive intake of gas forming foods.
�� Prolonged constipation or impaction.Prolonged constipation or impaction.
�� Inability of the small intestines to expel Inability of the small intestines to expel
gases due to weakness e.g., in postgases due to weakness e.g., in post--
operative periods after abdominal surgery.operative periods after abdominal surgery.
CausesCauses
�� Lack of exercise and prolonged" bedLack of exercise and prolonged" bed--rest.rest.
�� Drugs which slow down the intestinal Drugs which slow down the intestinal
peristalsis such as sedatives and peristalsis such as sedatives and
tranquilizers.tranquilizers.
�� Swallowing large amount of air while Swallowing large amount of air while
eating or drink or tube feeding (in very old eating or drink or tube feeding (in very old
and children).and children).
Signs and SymptomsSigns and Symptoms
�� Distended abdomen that gives a drum like Distended abdomen that gives a drum like
sounds upon percussion.sounds upon percussion.
�� Colicky pain that is generalized in the Colicky pain that is generalized in the
abdomen. abdomen.
�� Shortness of breath and Shortness of breath and dyspneadyspnea may result may result
if distention causes pressure on the if distention causes pressure on the
diaphragm and the thoracic cavity, (e.g. diaphragm and the thoracic cavity, (e.g.
bedridden patients).bedridden patients).
Nursing InterventionNursing Intervention
�� Prevention of the cause.Prevention of the cause.
�� Encourage exercises in bed or ambulate Encourage exercises in bed or ambulate
patients for short walk.patients for short walk.
�� Avoid gas forming foods.Avoid gas forming foods.
4)4) Diarrhoea:Diarrhoea:
DefinitionDefinition
The passage of loose, watery stool and an The passage of loose, watery stool and an
increase in the frequency of bowel increase in the frequency of bowel
movements, diarrhea may or may not be movements, diarrhea may or may not be
accompanies by abdominal cramping.accompanies by abdominal cramping.
CausesCauses
Due to several causes either organic disease Due to several causes either organic disease
or psychic factors:or psychic factors:
Signs and symptomsSigns and symptoms
�� Generalized abdominal pain which is Generalized abdominal pain which is
spasmodic in nature due to strong spasmodic in nature due to strong
peristaltic action. peristaltic action.
�� Pains are accompanied by feeling of Pains are accompanied by feeling of
urgency in the need to defecate. urgency in the need to defecate.
�� Complaints of Complaints of tenesmustenesmus and may pass a and may pass a
small watery discharge. small watery discharge.
Increase in the frequency in the Increase in the frequency in the
number of stool (stool is watery in number of stool (stool is watery in
nature). nature).
Signs and symptoms of dehydration Signs and symptoms of dehydration
my occur if diarrhea is very severs or my occur if diarrhea is very severs or
over a long time such as: poor skin over a long time such as: poor skin
turgorturgor, thirst, and acute weight loss. , thirst, and acute weight loss.
General weakness and general General weakness and general
malaise. malaise.
There may be nausea, vomiting, There may be nausea, vomiting,
Nursing care of patients with diarrheaNursing care of patients with diarrhea
�� Assessment and observation of the patient, Assessment and observation of the patient,
this includes:this includes:
�� Assessment of the stool in terms of Assessment of the stool in terms of
frequency, consistency, odor and presence frequency, consistency, odor and presence
of foreign matter as mucous, pus, blood or of foreign matter as mucous, pus, blood or
undigested food.undigested food.
�� Observation of the patient for signs and Observation of the patient for signs and
symptoms of the dehydration and symptoms of the dehydration and
electrolyte loss. With diarrhea there is acute electrolyte loss. With diarrhea there is acute
loss of potassium and sodium chloride. loss of potassium and sodium chloride.
Diet: Provision of proper diet for Diet: Provision of proper diet for
maintenance of proper nutrition.maintenance of proper nutrition.
•• Diet free from roughage. Diet free from roughage.
•• Rich in liquids. Rich in liquids.
•• Free from irritants and low in fat. Free from irritants and low in fat.
•• Rich in proteins such as white meat Rich in proteins such as white meat
boiled chicken and other. boiled chicken and other.
If diarrhea is psychogenic, provide for If diarrhea is psychogenic, provide for psychological comfort and relaxation.psychological comfort and relaxation.
•• Assist the patient to identify the causes Assist the patient to identify the causes and act upon it.and act upon it.
Provide for physical comfort and Provide for physical comfort and hygienic care.hygienic care.
•• Local irritation of the anal and region Local irritation of the anal and region is common. Careful washing and is common. Careful washing and drying after each movement is drying after each movement is necessary.necessary.
•• Medicated creams will help prevent Medicated creams will help prevent skin irritation, e.g., Zink oxide.skin irritation, e.g., Zink oxide.
Patient's clothes and bed linen must Patient's clothes and bed linen must
be dry and clean.be dry and clean.
If diarrhea is due to infection, If diarrhea is due to infection,
isolation technique must be followed:isolation technique must be followed:
•• Stool should be disinfected Stool should be disinfected
immediately before being discarded.immediately before being discarded.
( N.B: All diarrheas should be ( N.B: All diarrheas should be
considered infectious until proved).considered infectious until proved).
6)6) Anal Incontinence: Anal Incontinence:
DefinitionDefinition
�� Inability of the Inability of the aoaspomaeraoaspomaer to control the to control the
discharge offers, i.e. loss of voluntary discharge offers, i.e. loss of voluntary
control over the act of defecation.control over the act of defecation.
CausesCauses
�� Organic diseases causing weakness of the Organic diseases causing weakness of the
anal sphincter.anal sphincter.
�� Impingent in the nerve supply to the anal Impingent in the nerve supply to the anal
sphincter.sphincter.
(i.e. relaxed external sphincter). (i.e. relaxed external sphincter).
Nursing careNursing care
�� Supportive and encouraging attitude by the Supportive and encouraging attitude by the
nurse should be initiated to eliminate nurse should be initiated to eliminate
embarrassment due to incontinence.embarrassment due to incontinence.
�� Special nursing care to prevent bad odor, Special nursing care to prevent bad odor,
skin irritation and bed sores.skin irritation and bed sores.
�� Patient's clothing and bedding should be Patient's clothing and bedding should be
changed whenever necessary.changed whenever necessary.
Reasons to Treat PainReasons to Treat Pain
It is the human thing to do
Ethical, moral, and legal obligation
Unrelieved pain causes unnecessary harm and suffering
Pain diminishes activity, appetite, sleep, and quality of life
Pain further debilitates already weakened patients
Goals of Pain ControlGoals of Pain Control
Enhance quality of life
Maintain autonomy, dignity, emotional, and cognitive capacity
Control depression and anxiety related to poorly controlled pain
Preservation of function and rehab potential
PAINPAIN
The patient’s self report is the Gold Standard of measurement
The Clinician must accept the patient’s report of pain
Painful FactsPainful Facts
Pain affects more Americans than DM, heart Pain affects more Americans than DM, heart disease & cancer combineddisease & cancer combined
75 million people today have severe disabling 75 million people today have severe disabling persistent pain another 25 million experience acute persistent pain another 25 million experience acute pain each year pain each year
Pain is the number one reason people seek Pain is the number one reason people seek healthcare, but only 1 in 4 receive adequate pain healthcare, but only 1 in 4 receive adequate pain treatment treatment
Over 75% of cancer patients experience moderate Over 75% of cancer patients experience moderate to severe painto severe pain--Less than half get pain reliefLess than half get pain relief
Obstacles to Successful Pain Obstacles to Successful Pain Management : Health Care ProviderManagement : Health Care Provider
Lack of knowledge (ignorance) or understanding of pain physiology & management
Lack of or inadequate assessment
Under treatment
Obstacles to Successful Pain Obstacles to Successful Pain Management : Health Care ProviderManagement : Health Care Provider
Inadequate knowledge of medications or other treatment options
Fear of addiction
Legal barriers-regulatory scrutiny
False judgment of patient
Mild pain(0-3)
Moderate pain(4-6)
Severe pain(7-10)
By the mouth
By the clockBy the ladder
Acetaminophen
Codeine
Morphine
WHO pain ladder
Tolerance & DependenceTolerance & Dependence
Tolerance-Physical Phenomenon
-Expected neuroadaptation to
continuous opioid use
–Effectiveness/duration of analgesia is reduced over time therefore higher doses are needed
– In long term therapy the need for escalation of drugs usually slows & then trends downward
Physical DependencePhysical DependenceDependenceDependence--Physical PhenomenonPhysical Phenomenon
-Natural adaptation of the body to
prolonged use of drug
-Abstinence syndrome develops if drug is
withdrawn sharply or if antagonist added
-Difficulties avoided through proper
management-taper doses before
discontinuing drug, do not co-administer
antagonist or agonist antagonist drugs
Obstacles to Successful Pain Obstacles to Successful Pain Management : Health Care ProviderManagement : Health Care Provider
Concerns about opioids:
Addiction: hallmark of addiction is using despite harm to self and others
Respiratory depression: “No patient has succumbed to respiratory depression while awake.” (APS), 1999)
Sedation: precedes respiratory depression; therefore sedation is a vital component of monitoring and assessment of patients with PCA.” (Hagle et al, 2004)
Increased morbidity and mortality
Unrelieved pain causes a stress response which initiates a cascade of events
Increased catabolic demand; poor wound healing, weakness, and muscle breakdown
PHYSIOLOGIC EFFECTS OF PAINPHYSIOLOGIC EFFECTS OF PAIN
PSYCHOLOGICPSYCHOLOGIC EFFECTS OF EFFECTS OF PAINPAIN
Negative emotions: anxiety, fear, hopelessness, and depressionSleep deprivationExistential suffering: may lead to patients seeking end of lifeDecreased quality of lifeDecreased coping skills
Assessment Facts & Assessment Facts & Considerations:Considerations:
The general goals of pain management include prevention and reduction of pain, improvement in function, improvement in mood and sleep patterns, and anticipation and treatment of side effects.
Assessment Facts & Assessment Facts & Considerations:Considerations:
Pain management goals do not include reducing the analgesic dose to as low a level as possible….
the dose that relieves the patient’s pain and allows them to meet their goals is the appropriate dose
What causes pain in the person What causes pain in the person with cancer?with cancer?
Tumor involvementTumor involvementTreatmentTreatment--relatedrelatedUnrelated to cancerUnrelated to cancer
American Medical Association. Pain Management Part 4: Cancer Pain and End-of-Life Care, December 2003; p 6-9.
Pain may be acute, persistent or intermittentPain may be nociceptive, neuropathic or mixed
Factors Influencing Pain Severity1,2Factors Influencing Pain Severity1,2
Type of CancerType of Cancer
Stage of DiseaseStage of Disease
Cancer TherapyCancer Therapy
Pain ThresholdPain Threshold
1American Medical Association. Pain Management Module 10: Overview and Assessment of Cancer Pain. December 2005.2National Cancer Institute. Pain, modified 1/23/07; p 5-8.
Antineoplastic TherapyAntineoplastic Therapy
SurgerySurgery
ChemotherapyChemotherapy
RadiotherapyRadiotherapy
Biological TherapiesBiological Therapies
Combination TherapyCombination Therapy
National Cancer Institute. Cancer topics. Available at: http://cancer.gov/cancerinfo. Accessed 3-7-07.
Evaluate Pain Mechanism To Evaluate Pain Mechanism To Determine Treatment OptionsDetermine Treatment Options
Follow the example of auscultation
* Know what to listen for
*Appreciate the significance of what
you hear
* Develop appropriate treatment plan
* Listen for changes in report
Is it to diagnose and eliminate the pain by removing the source?
Is it palliative? A plan to improve comfort and quality of life?
The first step in the assessment of pain The first step in the assessment of pain is to determine the goal of treatmentis to determine the goal of treatment
Pain TypesPain Types
Breakthrough
Chronic
Neuropathic Acute
Referred
Visceral
Somatic
Types
Pain Quality Pain Quality
Nocioceptive
Somatic
LocalizedThrobbing
AchingSoreSharp
Stabbing
Visceral
DeepCrampingReferredAching
Gnawing
Pain QualityPain Quality
Neuropathic
Central Peripheral
BurningPiercingElectric Pricking
NumbSharp
Pain AssessmentPain Assessment
Remember, pain ratings above 3 significantly
interfere with activity and mood; above 5 interfere with quality of life.
OLD CARTOLD CART
O= OnsetO= Onset - When did the pain start? How often does it occur? Has its intensity changed?
L= LocationL= Location – Where is your pain? Does it radiate or travel to other sites? Touch where your pain is. (There may be multiple sites)
PAIN ASSESSMENT (Cont.)PAIN ASSESSMENT (Cont.)
D= DurationD= Duration - How long does the pain last? Is it constant? Is it intermittent?
C= CharacteristicsC= Characteristics –– What words What words describe your pain? What does your describe your pain? What does your pain feel like? 0pain feel like? 0--10; Quality?10; Quality?
NeuropathicNeuropathic or nerve (sharp, or nerve (sharp, shooting, burning, electrical) shooting, burning, electrical)
NociceptiveNociceptive Somatic (dull, aching); Somatic (dull, aching); Visceral (cramping, squeezing) Visceral (cramping, squeezing)
PAIN ASSESSMENT: (Cont.)PAIN ASSESSMENT: (Cont.)
A= Aggravating FactorsA= Aggravating Factors – What makes your pain worse? (Moving, Walking, Sitting, Turning, Chewing, Breathing, Defecating, Urinating, Swallowing,
R= Relieving FactorsR= Relieving Factors - What makes pain better? What medical and non-medical interventions relieve the pain?
Pain Assessment: (Cont.)Pain Assessment: (Cont.)
T=TreatmentT=Treatment – Medications –What meds have you tried for your pain?-Current pain management regimen?
****Past medication use ACTUALPast medication use ACTUAL
Nonpharmacological interventions (e.g., heat cold massage, distraction, etc)
Number versus FunctionNumber versus Function
On a On a scale of 0 scale of 0 --1010, with 0 being no , with 0 being no
pain and 10 being the worst pain you pain and 10 being the worst pain you
can imagine, how would you rate your can imagine, how would you rate your
pain pain right nowright now??
How would you rate it at itHow would you rate it at it’’s s worstworst? ?
How would you rate it at itHow would you rate it at it’’s s besbestt? ?
When was it When was it best controlledbest controlled??
Was your Was your goagoall pain score?pain score?
Evaluation of PainEvaluation of Pain
Simple Descriptive ScaleSimple Descriptive Scale
Numeric ScaleNumeric Scale
Visual Analog ScaleVisual Analog Scale
1100 22 33 44 55 66 77 88 99 1010
no painno pain worst painworst pain
nonenone mildmild moderatemoderate severesevere v severev severe worstworst
Psychosocial AssessmentPsychosocial Assessment
Effect of pain on patient, family, caregivers, and other significant relationships
Financial impact of pain and treatment
Patient’s usual coping response
Mood changes
Preference of pain method management
Psychosocial AssessmentPsychosocial Assessment
How does the pain affect your physical and social function?
How does the pain impact sleep, mood, or activities?
Meaning of pain to patient
Non-verbal clues
Psychosocial Assessment Psychosocial Assessment
(cont.)(cont.)
Effect and understanding of diagnosis/treatment on patient and caregiver
Past experiences with pain and patient’s interpretation
Patient and family member’s concerns about use of opioids or controlled substances
Intubated and/or unconscious Intubated and/or unconscious
personspersons
Self report limited by:Self report limited by:
–– DeliriumDelirium
–– Cognitive and communication limitationsCognitive and communication limitations
–– Level of consciousnessLevel of consciousness
–– Presence of an endotracheal tubePresence of an endotracheal tube
–– SedativesSedatives
–– Neuromuscular blocking agentsNeuromuscular blocking agents
Intubated and/or unconscious Intubated and/or unconscious
personspersons
Existing medical conditionExisting medical condition
Traumatic injuriesTraumatic injuries
Surgical/medical proceduresSurgical/medical procedures
Invasive instrumentationInvasive instrumentation
Blood drawsBlood draws
Routine care such as suctioning, Routine care such as suctioning,
turning, positioning, drain and turning, positioning, drain and
catheter removal, and wound carecatheter removal, and wound care
Intubated and/or unconscious Intubated and/or unconscious
personspersonsFacial tension Facial tension
GrimacingGrimacing
FrowningFrowning
Wincing Wincing
Physical movementPhysical movement
ImmobilityImmobility
Increased muscle toneIncreased muscle tone
Tearing and diaphoresis in the sedated Tearing and diaphoresis in the sedated paralyzed and ventilated patient represents paralyzed and ventilated patient represents autonomic responses to discomfort autonomic responses to discomfort
Ongoing Pain AssessmentOngoing Pain Assessment
At regular intervals after initiation of At regular intervals after initiation of
the treatment planthe treatment plan
With each new report of painWith each new report of pain
At a suitable interval after each At a suitable interval after each
pharmacologic or nonpharmacologic pharmacologic or nonpharmacologic
interventionintervention
Continue or alter drug therapy based Continue or alter drug therapy based
on assessment findings and treatment on assessment findings and treatment
planplan
Pain should be assessed and documented:
Joint Commission. Assessment of persons with pain. In: Joint Commission, ed. Pain Assessment and Management: an organizational approach. Oakbrook Terrance, IL: Joint Commission; 2000: 13-25.
Nonpharmacologic InterventionsNonpharmacologic Interventions
Physical ModalitiesPhysical Modalities–– Physical Therapy / ExercisePhysical Therapy / Exercise–– AcupunctureAcupuncturePsychosocial ModalitiesPsychosocial Modalities–– Relaxation and imageryRelaxation and imagery–– DistractionDistraction–– EducationEducation–– Counseling and/or support groupsCounseling and/or support groups–– HypnosisHypnosis
PharmacologicPharmacologic InterventionsInterventions
AcetaminophenAcetaminophen
Nonsteroidal antiNonsteroidal anti--inflammatory drugs inflammatory drugs (NSAIDs)(NSAIDs)
AntidepressantsAntidepressants
AnticonvulsantsAnticonvulsants
Topical anestheticsTopical anesthetics
OpioidsOpioids
MedicationsMedications
May require increasing doses due to May require increasing doses due to tolerancetolerance-- NOT addictionNOT addiction
May need to use more than one type of May need to use more than one type of pain medication pain medication
LongLong--acting medicationsacting medications
Breakthrough medicationsBreakthrough medications
Opioid DosingOpioid Dosing
Breakthrough dose should be 10Breakthrough dose should be 10--15% 15%
of 24 Hour long acting doseof 24 Hour long acting dose
To titrate opioid, increase by at least To titrate opioid, increase by at least
50% or calculate the amount of 50% or calculate the amount of
breakthrough doses given and add to breakthrough doses given and add to
the 24H dosethe 24H dose
Although all Although all Clinical Pearl: Clinical Pearl: opioids are opioids are ““equivalentequivalent”” at at
equianalgesic doses, there is equianalgesic doses, there is significant intersignificant inter--patient patient
variability.variability.
If appropriate dose escalations If appropriate dose escalations pain control, it pain control, it inadequateinadequateyield yield
is logical to SWITCH to a is logical to SWITCH to a different opioid!different opioid!
Common MistakesCommon Mistakes
TransdermalTransdermal Fentanyl Fentanyl
Withdrawal SyndromeWithdrawal Syndrome
Medication reconciliationMedication reconciliation
OverdoseOverdose
Under dose opioidUnder dose opioid
Concurrent use of two long acting agentsConcurrent use of two long acting agents
Managing Side EffectsManaging Side Effects
ConstipationConstipation-- never develop a tolerance never develop a tolerance
NauseaNausea
DrowsinessDrowsiness
ItchingItching
OthersOthers
PLANPLAN
Develop a multimodal plan involving client Develop a multimodal plan involving client in all areas. Educate client.in all areas. Educate client.
Give the client a sense of control in pain Give the client a sense of control in pain management. Educate client.management. Educate client.
Consider financial status/ reimbursementConsider financial status/ reimbursement
for pain medication prescriptions. Educate for pain medication prescriptions. Educate
client. client.