Clinical Review: Bowel, Wound Care, and End-of-Life Nursing Skills

Posted on Nov 25, 2025 in Medicine & Health

Bowel and Bladder Care Fundamentals

Small Intestine Function and Anatomy

  • Primary site of digestion and nutrient absorption.
  • 3 sections: Duodenum, Jejunum, and Ileum.
  • Absorbs 90% of nutrients and fluids.

Vagal Response

  • Manifestations: Bradycardia, dizziness, diaphoresis (sweating), and hypotension.
  • Causes: Rectal stimulation (digital removal of stool, enemas) or straining.

Assessing Bowel Sounds

  • Listen for 5 minutes total (1 minute per quadrant) before declaring sounds absent.
  • Hyperactive Sounds: Indicate diarrhea, early obstruction, or gastroenteritis.

Ostomy Care Procedures

  • Cut the faceplate 1/8″ larger than the stoma.
  • Assessment: Color (should be pink/red), moisture, output, and peristomal skin integrity.
  • Alert the provider if the stoma is pale, purple, blue, or retracted (signs of ischemia or retraction).

Enema Administration

  • Position: Left Sims.
  • Purpose: Stimulate bowel movement.
  • Fluid Volume (Adults): Approximately 500–1000 mL.
  • Monitor For: Vagal response, fluid, and electrolyte imbalances.

Diarrhea Management

Monitor patients with diarrhea for:

  • Dehydration
  • Electrolyte loss
  • Skin breakdown (perianal area)

Causes of Fecal Incontinence

  • Neurological disorders
  • Dementia
  • Muscle damage (e.g., sphincter damage)

Gastrointestinal Medications

Antidiarrheals

  • Purpose: Slow motility and reduce frequency of bowel movements.
  • Loperamide (Imodium): Decreases peristalsis and increases fluid absorption. (Contraindicated for C. difficile infection).
  • Bismuth Subsalicylate (Pepto-Bismol): Acts as an antimicrobial; can turn stool black. (Avoid in children with viral illness due to Reye’s syndrome risk).

Bulk-Forming Laxatives

  • Example: Psyllium (Metamucil).
  • Mechanism: Absorbs water and increases stool bulk.
  • Administration Note: Must be taken with plenty of water to prevent esophageal or bowel obstruction.

Constipation Prevention and Education

Patient education should focus on:

  • Increasing fiber intake.
  • Increasing fluid intake.
  • Increasing physical activity.
  • Avoiding ignoring the urge to defecate.

Rectal Suppositories

Suppositories stimulate the rectal wall, triggering peristalsis and resulting in a bowel movement.

Colorectal Cancer Screening

Colonoscopy: Recommended to start at age 45, or earlier if the patient has specific risk factors.

Key Terms in Elimination

Occult Blood
Hidden blood (e.g., indicative of GI bleed or cancer).
Steatorrhea
Fatty, foul-smelling stool, often a sign of malabsorption.
Normal Voiding
Every 3–4 hours, with output ≥30 mL/hr.
Urine Control
Maintained by external and internal sphincters.
Kegel Exercises
Strengthen pelvic floor muscles to improve continence.
Daily Fluid Needs
2,000–2,500 mL.

Wound Care Management

Phases of Wound Healing

  1. Hemostasis: Immediate phase involving vasoconstriction and clotting after injury.
  2. Inflammatory (Days 1–4): Characterized by redness, swelling, and pain. White blood cells (WBCs) clean the wound bed.
  3. Proliferative (Days 4–21): Granulation tissue forms, and fibroblasts produce collagen.
  4. Maturation (Up to 1+ year): Collagen reorganizes, and the scar strengthens.

Wet-to-Damp Dressing Purpose

  • Gently removes slough (non-viable tissue).
  • Keeps the wound bed moist, promoting healing.
  • Considered less traumatic than the older wet-to-dry method.

Common Wound Infection Organism

The most common organism is Staphylococcus aureus (including MRSA).

Therapies and Healing Barriers

Cold Therapy

Reduces swelling and pain, especially in the early inflammatory phase.

Causes of Delayed Wound Healing

  • Infection
  • Diabetes Mellitus
  • Poor nutrition
  • Smoking
  • Steroid use
  • Repeated trauma to the site

Wound Assessment Terminology

Evisceration
Protrusion of internal organs through the wound opening. Action: Cover immediately with sterile moist gauze and notify the provider.
Dehiscence
Partial or total separation of wound layers (wound reopens).
Purulent Drainage
Thick, yellow, or green drainage, indicating infection.
Serosanguineous Drainage
Pink-clear fluid (a normal finding).
Debridement
Removal of dead, non-viable tissue.
Hematoma
A localized collection of clotted blood under the skin.
Excoriation
Skin breakdown caused by moisture or friction.

Local Signs of Wound Infection

  • Redness (Erythema)
  • Warmth
  • Swelling (Edema)
  • Pain
  • Foul drainage (Purulent)
  • Delayed healing
  • Fever (Systemic sign)

Wound Drains: Jackson-Pratt (JP)

  • A closed suction bulb drain.
  • Patient Education: Keep the bulb compressed (to maintain suction), measure output accurately, and avoid pulling on the tubing.

Common Dressing Types

  • Dry Sterile: Used for clean wounds with minimal drainage.
  • Wet-to-Dry: Used for mechanical debridement (now considered an older, less preferred method).
  • Wet-to-Damp: Used for moist wound care and gentle removal of slough.

Loss, Grief, and End-of-Life Care

Core Definitions

Loss
The absence of someone or something valued.
Grief
The emotional response to loss.
Bereavement
The period of mourning following a death.

Types of Grief

  • Anticipatory Grief: Experienced before the actual loss occurs.
  • Dysfunctional Grief: Grief that is prolonged, unresolved, or interferes significantly with functioning.

Common Symptoms of Grief

  • Emotional: Sadness, anger, anxiety.
  • Physical: Fatigue, changes in sleep or appetite.
  • Cognitive: Forgetfulness, difficulty concentrating, or temporary hallucinations.

Kübler-Ross Stages of Grief (DABDA)

  1. Denial
  2. Anger
  3. Bargaining
  4. Depression
  5. Acceptance

Signs of Impending Death

  • Decreased appetite and urine output.
  • Mottled, cool extremities.
  • Weak or thready pulse.
  • Cheyne-Stokes breathing (periods of deep breathing alternating with apnea).

Hospice vs. Palliative Care

  • Palliative Care: Focuses on comfort and quality of life at any stage of a serious illness; can be provided alongside curative treatment.
  • Hospice Care: Specialized end-of-life care, typically for patients with a prognosis of less than 6 months; curative treatment is stopped.

Rights of the Dying Patient

  • The right to be treated with dignity.
  • The right to effective pain management and emotional support.
  • The right to say goodbye and participate in care decisions.

Therapeutic Communication

  • Use therapeutic communication techniques.
  • Be compassionate and supportive toward the patient and family members.

Legal and Ethical Concepts in End-of-Life Care

Advance Directive
Legal documents specifying a patient’s care preferences.
Durable Power of Attorney (DPOA) for Health Care
A person appointed to make medical decisions for the patient if they become incapacitated.
Passive Euthanasia
Withholding life-sustaining treatment (e.g., discontinuing IV fluids or ventilation).
Active Euthanasia
Direct action taken to cause death (illegal in most jurisdictions).
Assisted Suicide
Providing the means for a patient to end their own life.

Postmortem Care

  • The nurse prepares the body respectfully.
  • Respect family rituals and ensure privacy.
  • Assist with required documentation, including the death certificate.

Memory Tips and Mnemonics

“DEAD PAIN” – Wound Infection Signs

  • Drainage (Purulent)
  • Erythema (Redness)
  • Approximation poor
  • Delayed healing
  • Pain
  • Appetite loss (Systemic sign)
  • Increased WBC/Temperature (Fever)
  • Necrotic tissue

“DABDA” – Stages of Grief

  1. Denial
  2. Anger
  3. Bargaining
  4. Depression
  5. Acceptance