1
Q
?
Normal process in which our body eliminates (defecation) waste products in the form of feces
A
Bowel elimination
2
Q
Motility —> movement
A
That allows chyme to travel through the small and large intestine through contraction and dilation of smooth muscles (peristalsis)
3
Q
Normal Defecation
What’s Normal?
A
Frequency - several times/day to once/week
Minimal effort - NO straining
NO blood; no use of laxatives
4
Q
If one passes stools
- without excessive urgency (running to bathroom)
- with minimal effort and no straining
- without blood loss
- without the use of laxatives
A
Normal Stool
- Soft, formed, semisolid, approx 75% water and 25% solid
- If passage through colon is slower more water is absorbed from the feces, making it dry and hard, more difficult to pass
- If passage through colon faster than normal, less water is absorbed from feces and stools are watery
5
Q
Factors Affecting Bowel Elimination
* Developmental Stage
Adults
A
- Patterns set in childhood continue through to adulthood
- Dependent on diet (fiber intake), fluid intake, and activity level
- Peristalsis, intestinal smooth muscle tone, perineal muscle tone, and sphincter control decrease with age
6
Q
Infant
? - green, black, tarry, sticky, odorless stools
? - golden yellow stools
? - tan stools
Stools tend to be watery d/t immature large intestine… as normal flora (bacteria) develops stools become firmer
A
Meconium
Breastfeed
Formula-fed
7
Q
Children
A
2-3 years age develops ability to control defecation
Requires neural and muscular control as well as conscious effort
8
Q
Factors Affecting Bowel Elimination cont’d
* Personal & sociocultural factors
Privacy
- Time to have a bowel movement
- New parents
- Fast-paced jobs
- Embarrassment/public bathrooms
A
Stress
- Diarrhea or constipation
- Primary risk factor for Irritable Bowel Syndrome
9
Q
* Nutrition, hydration, & activity level
Diet
- Food promotes peristalsis (green leafy vegetables)
- High-fiber food increases peristalsis
- Yogurt
Supplements
- Calcium (can cause constipation), magnesium, Vitamin C (these 2 loosen stool)
A
Hydration
- 6-8 eight ounce glasses of fluid/day (1500-2000 mL)
Activity
- Physical activity promotes peristalsis
- Sedentary living leads to weak abdominal muscles
10
Q
Factors Affecting Bowel Elimination cont’d
* Medications
Antacids
- Neutralize stomach acid; used for heartburn; SLOW peristalsis
- Milk of magnesia, Maalox, Mylanta, Alka Seltzer
Aspirin & other NSAIDs
- Naproxen, Ibuprofen, celecoxib (Celebrex)
- Irritate stomach; over usage may lead to ulcerations of the stomach or duodenum
A
Antibiotics
- Destroy bacteria but also destroy bacteria normally found in the intestinal flora - this leads to diarrhea
- To maintain colon bacteria client may use supplemental probiotics (Acidophilus) or yogurt
Iron
- Clients who take supplemental iron to treat anemia for example may have constipation; iron also changes stool color to black
- If taken on an empty stomach may cause nausea
Pain Medications
- Opioids (narcotics) slow peristaltic movement and leads to constipation
11
Q
Factors Affecting Bowel Elimination cont’d
Antimotility Drugs
- Used to treat diarrhea; they slow peristalsis by direct action on the lining of the GI tract by either inhibiting local reflexes (Bismuth), direct action on the muscles of the GI tract to slow activity (loperamide), or action on CNS that causes GI tract to spasm and slow motility (diphenoxylate)
A
- Diphenoxylate (Lomotil), loperamide (Imodium), Bismuth subsalicylate
- Adverse effects: GI discomfort, distention, dry mouth, nausea, constipation, dizziness, drowsiness, tiredness
12
Q
Laxatives or cathartic
- Short-term treatment of constipation
A
- Stimulates peristalsis
* Prevent straining (MI patients)
* Help evacuate bowel for certain diagnostic procedures
> Chemical stimulant
> Bulking agents
> Osmotic laxatives
> Stool softeners
> Lubricant laxatives
13
Q
Chemical Stimulants
- Irritate plexus nerve leading to increased peristalsis
- Senna (Senokot), Bisacodyl (Dulcolax), castor oil (blocks absorption of fats)
A
Chemical Stimulants cont’d
- Adverse effect…diarrhea, abdominal cramping, nausea, and cathartic dependence
- Because they interfere with timing and process of absorption, should be taken 30 minutes apart from other medications
14
Q
Bulking Agents
- Non-foods high in FIBER - increase motility by increasing fluid into the intestine - this enlarges bulk & stimulates stretch receptors
A
Bulking Agents cont’d
- MUST be taken with plenty fluid
* Fiber attracts fluid into colon and increased bulk stimulates urge to defecate
* DRUG OF CHOICE FOR TREATMENT OF CONSTIPATION
* Metamucil, Citrucel, FiberCon, psyllium
* Adverse effects: diarrhea, abdominal cramps, nausea, dizziness, weakness may be r/t loss of fluid and electrolyte imbalance
15
Q
Osmotic laxatives
- Add water to bowel thus distending bowel
- Polyethylene glycol (MiraLax), lactulose, magnesium citrate, magnesium hydroxide (MOM)
A
Pregnancy
- Morning sickness leads to loss of fluid leading to less fluid in the bowel - constipation
- As uterus gets bigger intestines get displaced - constipation
- Progesterone also decreases motility
16
Q
Stool softeners
- Allow moisture and fat to penetrate stool
- Docusate sodium
A
Lubricant laxatives
- Coat stool & GI tract with thin waterproof layer, interfering with absorption (also impedes absorption of nutrients)
- Mineral oil
- Used with clients with hemorrhoids, or recent rectal surgery; also used with clients who shouldn’t strain d/t diseases like MI
- Adverse effects: diarrhea, abdominal cramps, nausea, dizziness, headache, weakness may be r/t loss of fluid and electrolyte imbalance
17
Q
Surgery & Procedures
Anesthesia
- General anesthesia as well as pain medications administered pre & post-op slow motility - constipation
Stress
- Stress caused by the operative process leads to activation of general adaptation syndrome (GAS), autonomic nervous system, and endocrine responses which all lead to slowing down of the peristaltic movements
A
Surgery & Procedures cont’d
Bowel manipulation during surgery
- Abdominal surgery or pelvic surgeries where bowel is manipulated may lead to paralytic ileus - cessation of peristalsis movement; bowel continues to produce secretions - secretions remain stagnant, cause distention and discomfort, usually these patients end up with an NGT to low-constant or intermittent suction to remove secretions until bowel movements resume
18
Q
Surgery & Procedures cont’d
Decreased mobility
- r/t pain
Perineal surgery
- Episiotomy… fear of pain or tearing sutures when moving bowels
A
Surgery & Procedures cont’d
Anal sphincter surgery
- Uncontrolled rectal drainage after surgery
19
Q
Pathological Conditions
?
- “an adverse health effect arising from an immune response that occurs reproducibly on exposure to a certain food”
- Common allergens: dairy, egg whites, shellfish, gluten, peanuts, citrus fruits, & soy
- Immune response trigger reactions mild rash to anaphylactic shock
- Common GI symptoms: constipation, diarrhea, red blister rash to anus, abdominal discomfort, bloating, excessive gas and intestinal bleeding
A
food allergies
20
Q
Pathological Conditions cont’d
Food intolerances
- Difference between food allergy and food intolerance is that food intolerance is ?
- Discomfort, pain, gas, bloating, diarrhea, constipation…AFTER consuming certain foods
A
specifically linked to the GI system
21
Q
?
Enzyme lactase deficiency…needed for the breakdown of milk sugar (lactose)
Can mimic a food allergy but it’s not immune-related…sometimes r/t lack of something (enzyme) in our body
A
Lactose Intolerance
22
Q
Pathological Conditions cont’d
?
- Areas of the colon that balloon out from increased force on mucosal tissues…happens when colon must repeatedly push highly compacted fecal matter making the muscles work harder thus enlarging the muscles
- Sometimes the sac-like pouches become infected and ___ (inflammation) occurs
- Risk factors include low fiber diet, high intake of red meats, and obesity
A
Diverticulosis
Diverticulitis
23
Q
Assessment of Bowel Elimination
Focused nursing history
- What’s normal?
- Look at client reactions
> Embarrassment
> Appropriate language that makes patient comfortable
> Ask about any medications, including over-the-counter - especially calcium or iron supplements associated with constipation
A
24
Q
Medications that are associated with constipation
- Antacids containing aluminum hydroxide (Mylanta or Gaviscon) or calcium carbonate (Caltrate or Tums)
- Anticholinergic drugs (belladonna, ipratropium (Atrovent), tiotropium (Sipriva), tolterodine (Detrol)
- Anticonvulsants (phenytoin)
- Antidiarrheals (loperamide)
- Antihistamines (diphenhydramine)
- Antiparkinsons (amantadine hydrochloride)
A
Medications that are associated with constipation cont’d
- Antipsychotic (chlorpromazine)
- Calcium channel blockers (verapamil); calcium supplements
- Diuretics (furosemide)
- Iron supplements; lithium
- NSAIDs (ibuprofen); opioids (morphine)
- Sympathomimetics (ephedrine); tricyclic antidepressants (nortriptyline)
25
Assessment
Focused physical assessment
- Examination of abdomen, rectum, anus
\* Shape, size, & contour of abdomen
\* Listen to bowel sounds
- Characteristics of normal and abnormal stool
\* Frequency, color, quantity, shape, consistency, odor
Characteristics of normal and abnormal stool
Frequency
- daily - 2-3 BMs/week
- hypomotility \<1 stool/week
- hypermotility \>6 stools/day
26
Characteristics of normal and abnormal stool cont'd
Color
- Brown d/t bile pigment
- Bile r/t obstructed bile ducts or antacid use - turns stool a clay-color or white
- Light brown - high milk diet and low meat
- Pale fatty stool indicates fat malabsorption
- Black tarry stools (melena) - indicate use of iron supplements or upper GI bleed
- Consuming large quantities of red meat, dark green veggies, and spinach may cause black stools
- Bright red stool may indicate lower GI bleed or hemorrhoids
- REMEMBER that the longer the stool remains in the bowel the darker it gets
Characteristics of normal and abnormal stool cont'd
Quantity
- About 150 g/day
Shape
- Diameter of rectum 2.5 cm or 1 in
27
Characteristics of normal and abnormal stool cont'd
Consistency
- NORMAL is formed soft and moist
- Will depend on motility, fluid, and food
- Hard stool indicates constipation...dehydration
- Liquid stool diarrhea, rapid peristalsis
Characteristics of normal and abnormal stool cont'd
Odor
- Pungent depends on the food intake - r/t putrefaction and fermentation of the lower GI tract
- Also influenced by pH of stool - normal neutral or slightly alkalotic
- Strong, foul odors may indicate blood or infection
28
Assessment
Focused physical assessment
INSPECT
- Abdomen: size, shape, contour
PALPATE
- Abdomen: tenderness
- Anus/Rectum: presence of stool or masses
Assessment cont'd
AUSCULTATE
- Bowel sounds (high-pitched about 5-15 gurgles/min)
\* Normal/active
\* Hyperactive BS... associated with bowel obstruction or inflammatory bowel disease
\* Hypoactive BS... indicates decreased peristalsis - constipation
\* Absent BS... indicates lack of intestinal activity example...from surgery or paralytic ileus
29
Assessment cont'd
?
\> 15 high-pitch... r/t small bowel obstruction, inflammatory disorders like diverticulitis that lead to diarrhea
?
\< 5 low-pitch...decreased peristalsis leads to constipation
?
Indicates no bowel sounds... listen for 3-5 min in each quadrant... abdominal surgery or paralytic ileus
Hyperactive
Hypoactive
Absent
30
Assessment cont'd
Review diagnostic data
Indirect visualization
- Abdominal xray (AP - anterior/posterior) visualizes gallstones or fecal impaction
- Abdominal ultrasound
Assessment cont'd
Direct visualization
- Insertion of various scopes to examine interior cavity (endoscopy, colonoscopy)
- Invasive procedure
- Performed by gastroenterologist
- Nurses role would involve prepping the client:
\* Pre-procedure would involve consent - administration of medication like sedatives, starting IV
\* Intra-procedure - assisting client into proper position; monitor patient's tolerance to the exam; vital signs; support
\* Post-procedure - vital signs; monitor until client is alert and effects of sedatives have subsided; education on any medications like (acetaminophen) Tylenol for any discomfort
31
Assessment cont'd
Review laboratory data
Stool specimens
- Blood, infection, parasitic infestation
- **Always have client void first** and then obtain sample via clean and dry bedpan, bedside commode, or toilet half hat
Assessment cont'd
Review laboratory data
How to handle stool sample?
What's first?
- ALWAYS WASH HANDS & wear gloves
- Formed stool need 1 in (2.5 cm); loose stool need 20-30 mL
- If blood, pus, mucous present, include this too in the sample
- Use tongue blades to collect stool and place in specimen container without contaminating the outside
- Send to lab ASAP
- May need to refrigerate (follow facility protocol)
32
Assessment cont'd
Stool specimens
- Guaiac Fecal Occult Blood Test (gFOBT)
\* According to American Cancer Society (2019) recommendations for FOBT
\> Client's average risk - every year starting at age 45 up to age 75 of good health and life expectancy over 10 years
\> Age 76-85 dependent on overall health, client preference, life expectancy
\> Over the age of 85 no longer needs
Stool specimens cont'd
- Blood may be visible (bright red if there is a lower bowel bleed) or OCCULT (occult or black tarry stool usually from upper bowel bleed)
- Requires special REAGENT to detect presence of PEROXIDASE (enzyme found in hemoglobin)
- Small smear is required
- Foods and medications to avoid before testing
\> NSAIDs (7 days prior); Vitamin C (change in chemicals in reagent for 3 days); red meats (3 days)
33
Testing Knowledge
The nurse knows that the results of a fecal occult blood test can be inaccurate if
a. The client has had an excessive intake of red meat
b. The female client is menstruating
c. The client takes high doses of vitamin C
d. All of the above
Answer: d
34
Review laboratory data cont'd
Parasites?
? - small, white thread-like worms
\> Ingestion of eggs
\> Entry through anus (fingers in anus)
- Worms live in cecum but travel down to anal area to deposit eggs during the night and they travel back up to cecum during the day
- Test for presence of eggs in AM with tape to anal area and collecting eggs present or use swab or at night with flashlight
Pinworms
35
Analysis/Nursing Diagnosis
- Bowel incontinence
- Constipation
- Chronic constipation (\>3 months)
- Fecal Impaction
- Risk for constipation
- Perceived constipation
Analysis/Nursing Diagnosis cont'd
- Diarrhea
- Gastrointestinal motility alteration
- Search social isolation related to embarrassment secondary to bowel incontinence
- Skin integrity impairment related to irritating effects of feces secondary to diarrhea
- Body image disturbance related to bowel diversion
36
Promoting Regular or Normal Elimination
- Provide privacy
- Assist with positioning (bedpan, bedside commode)
- Timing of defecation
- Healthy food and adequate fluid intake
Promoting Regular or Normal Elimination cont'd
- Encourage exercise
- Manage flatulence
- Educate on when to seek medical advice (sudden change in bowel habits)
37
Examples of Abnormal Bowel Elimination
?
- Caused by contaminated food, viral infection, diet change, or side effect of medication
- Leads to fluid and electrolyte imbalances - top nursing priority - **?** & impaired skin integrity
Prevention
- HANDWASHING...Viruses
- EDUCATE DIET...spicy...high fat...greasy snack...raw fruits and veggies in large amounts
- Yogurt when on antibiotic tx
Monitor ACUTE episodes
- Stool - frequency, amount, color, consistency
- Fluid balance - I&O, body weight, vital signs, SKIN TURGOR & MUCOUS MEMBRANES (oral mucosa) = ?
- Electrolyte balance
- Skin integrity - assess perineal area for irritation & excoriations
Diarrhea
dehydration
dehydration
38
Diarrhea - Treatments
Antidiarrheal Medications
- Opiate derivatives (paregoric) and loperamide (Imodium) can be used to control - act to SLOW peristalsis... but CAUTION may cause drowsiness
- Bismuth subsalicylate (Pepto-Bismol) may also be used - antimicrobial & antisecretory properties
\> Common effects: darkening of the stools, ringing in the ears and rapid respirations
\> Careful when taking other products that contain aspirin (also a salicylate - can lead to overdose)
Diarrhea - Treatments
Antidiarrheal Medications (cont'd)
- Anti-diarrheal medications should be avoided with ACUTE diarrhea...why?
\> Usually acute episodes are r/t a virus or side effect of a medication or food... it's the natural way of the body to get rid of the pathogen or food or medication
39
Diarrhea - Treatments (cont'd)
Diet & fluids during acute episodes
\* Start with clear liquid diet and replace electrolytes (Pedialyte or Gatorade); clear broth or gelatin can also be used
\* Sip liquids or ice chips
\* Reduce fiber in diet
\* Limit foods with caffeine, coffee, tea, and cola
\* Avoid sudden intake of large amounts of food...stimulates peristalsis
Diarrhea - Treatments (cont'd)
\* Plain yogurt or probiotics... to help reestablish intestinal flora after antibiotic use
\* ADVISE on BRAT diet (especially in children); bananas, white rice, apple sauce, and toast; easy to digest and provide calories without irritation
\* Prompt hygiene after episodes of diarrhea
40
Examples of Abnormal Bowel Elimination - Constipation
Risk Factors
- Decreased activity/bedrest
- Opioid medications
- Decreased fluid and fiber intake
- Physiological factors (nervous system)
- Older adults...due to dependence on others for assistance or impaired cognition
Subjective symptoms - abdominal pain & tenderness; loss of appetite; feeling rectal pressure; fatigue/headache/indigestion
Objective symptoms - abdominal distension; blood in stool; decrease frequency of stools; decrease volume of stools; hard formed stools; hypo - or hyperactive BS
Examples of Abnormal Bowel Elimination - Constipation cont'd
Treatment
- High fiber diet (RDA 25-38 g) and fluid intake (8-10 (8) oz glasses of water - 2,000-2,400 mL; minimum 1,500 mL or 50 oz per day)
- Increase physical activity; provide privacy
- Proper positioning (seated or squatting, semi-Fowlers if bedrest)
- Allow uninterrupted time on toilet, especially after meals
- Educate not to ingore urge
- Assess for complications...hemorrhoids or impaction
- Chronic constipation may need laxatives or bulking agents (fiber in powder or pill form = Metamucil add water)
**Treatment for abnormal bowel elimination should always start with lifestyle changes, diet, fluid intake, exercise**
BEFORE introducing medications like cathartics (laxatives) or stool softeners...because these may lead to dependency
41
?
- Hard fecal mass in rectum
- Liquid stool may leak or seep around hard mass
- Client may feel full, bloated, decrease appetite
Fecal impaction
42
?
- Involves breaking up of hardened stool into pieces and then manually extracting the pieces
- CAREFUL because may stimulate vagus nerve and lead to sudden bradycardia hypotension and syncope...SO need a primary care provider order
Digital stool removal
43
- Administering ? - solution introduced into rectum with goal of softening stool; distend or irritate colon, and stimulate peristalsis and expel stool
enema(s)
44
?
- To treat severe constipation
- Used to clear colon for procedures such as colonoscopy or before colon surgery/pelvic surgery
- Empty colon for bowel training program
Cleansing enema
45
Cleansing enema cont'd
?
- (saline, tap water, and soap) large volume 500-1000 mL of fluid introduced into rectum; volume distends and leads to evacuation of stool; i.e. Soap Suds Enema acts by irritating intestinal mucosa and promoting peristalsis; CAREFUL with clients who have weak intestinal walls
Hypotonic
46
?
- i.e. sodium phosphate (FLEET enema); smaller volume 90-120 mL; attracts water into colon and leads to distension and peristalsis and defecation; because it leads to retention of fluid and sodium this is contraindicated in clients who have renal failure and congestive heart failure
Hypertonic
47
?
- Solution is kept for prolonged periods of time; volume used 90-120 mL
- Oil-kept enemas (90-120 mL); oil instilled into rectum to soften and lubricate rectum
- ? : mixed solution magnesium sulfate, glycerin, water; 60-180 mL amount; used to expel flatus and relieve bloating and distention; used after pelvic or abdominal surgery
- Medicated enemas - antibiotics or anthelmintic medications used to treat intestinal worms or parasites
- Nutritive enemas - fluid and nutrition through rectum for dehydrated or frail clients; mostly used during hospice care
Retention enemas
Carminative enema
48
?
- Also known as HARRIS-FLUSH; saline or tap water instilled (100-200 mL) into rectum with rectal tube and then the container is lowered below rectum level to allow solution to flow out; this is repeated several times until distension is relieved
Return-flow enema
49
?
Inability to control elimination of feces and flatus
- Physiological conditions
\* Nervous system disorders/injury (quadriplegia)
\* Severe uncontrolled diarrhea
\* Impaction with seepage around stool
\* Cognitive disorders; dementia and inability to perceive urge
\* Functional limitations; not being able to ambulate or access toilet
Bowel incontinence
50
- At risk for impaired skin integrity; moisture and stool enzymes
\* Monitor bowel habits
\* Toilet at regular intervals and after meals
\* Change clothing ASAP or bed linens
\* Use absorbent pads/briefs; NEVER call diapers; degrading; lowers self-esteem; embarrassing
\* Monitor for skin breakdown; use barriers, creams
\* Review diet, fluid, activity, medications
51
?
Collects liquid stool from immobilized clients; soft, latex-free catheter and collection bag; catheter is introduced, and balloon is inflated
- Can only be used for 29 days; not in children
- Contraindicated in clients with hemorrhoids, recent bowel/anal/rectal sx, tumors, or stricture or stenosis
Indwelling drainage devices
52
?
Little pouch applied to anus and to collect feces; a moisture-proof barrier is applied around anus and then the pouch is secured to the barrier; NOT USED ON ACTIVE CLIENTS due to dislodging of the pouch and leading to skin breakdown
- Assess device frequently; dislodging or leakage
- Change pouch every 72 hours or according to facility protocol
- Empty pouch one third to one half full too heavy
- Assess perianal skin
External collection devices
53
?
Used in clients with chronic constipation, impaction, bowel incontinence
- Plan a staged program with patient
\> Starts with increase of fiber
\> Add stool softener followed by bisacodyl (Dulcolax) suppository
- Gradually increase fiber diet
- Increase fluid (CAREFUL WITH HEART FAILURE)
- Designate uninterrupted defecation times; after meals
- Provide privacy
Bowel training programs
54
?
What & Why?
- Opening created surgically for the elimination of digestive waste products (through abdomen)
- Client does not eliminate via anus - the effluent (fecal matter) is eliminated via this opening (abdominal wall) - called ___ or \_\_\_
- May be temporary (until healing occurs then ___ - reconnection of bowel) or permanent (bowel is necrotic or severe disease or trauma that requires a permanent alternative)
- Occurs with certain pathologies like cancer, severe diverticulitis, or with bowel injuries like perforation
Bowel diversion
stoma; ostomy
Reanastomosis
55
?
Portion of the colon is connected to abdominal wall
Location will determine the consistency of the stool
- Those closer to ascending colon and ileocecal valve the more liquid and continuous the drainage
- Those near sigmoid colon will produce more solid feces and may be controlled via diet and irrigation and may not need appliance
Colostomy
56
?
Portion of the ileum is connected to abdominal wall bypassing large intestine
Majority of water absorption occurs in large intestine therefore feces will be liquid and continuous
Ileostomy
57
Bowel Diversion - Nursing Care
Goal is to assume self-care
Assess SSS (?)
Stoma, Stool output, Skin
58
?
Around stoma (peristomal); signs of irritation like redness, tenderness, breakdown and/or drainage
Skin
59
?
Deep pink to brick red; shiny and moist
Pallor and dark blue (indicates ischemia), brown-black (indicates necrosis)
After surgery will be swollen and enlarged; should shrink by 6-8 weeks after sx
Should still protrude above abdominal level by 1.3-2.5 cm (0.5-1 in)
An ileostomy ___ is usually smaller than a colostomy \_\_\_
Stoma
60
?
Depending on the level varies from liquid to solid
- Ileostomy more digestive enzymes = more skin breakdown
- Colostomy = less digestive enzymes = less risk of skin breakdown
Stool output
61
Bowel Diversion - Nursing Care cont'd
Adapting to a diversion
- 1st step: adjusting to presence of ostomy - acceptance - self care
- Diet changes d/t no longer controlling their sphincter
\> Foods to avoid that may cause gas, that may control gas, high-fiber that may cause blockage, that cause loose stools, foods that alleviate diarrhea (BRAT) [Wilkinson & Treas p. 763 Box 29.2]
- Life-long care of stoma and appliances
Colostomy irrigation
- May be used in clients with an ostomy in descending or sigmoid colon to control bowel elimination and eliminate use of appliance; similar to enema
- Ostomy stomas above the descending colon - NOT irrigated d/t liquid output that cannot be controlled
NUR 101 Assessment #3
flashcards
Decks in class (11)
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