End-of-Life Care and Grief Management for Nurses, Exams of Nursing

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Chapter 37

• Loss is an inevitable part of life. Accompanying each loss are feelings of grief and sadness.
• As a student you need to know that you are capable of providing what patients and families need most at the end of life: compassion, attentiveness, and patient-centered care.
• Whether it is educating patients and families about advance directives, managing patients’ symptoms, or simply holding a hand, nurses care for the dying every day. It is the caring actions of nursing that assist the patient and family during these times.

Scientific Knowledge Base: Loss

• Illness’s effect on a person can change their functioning and therefore their job, family role, income level, and overall quality of life.
• [Review Table 37-1, Types of Loss, with students.]
• As people age, they learn that change always involves a necessary loss. They learn to expect that most necessary losses are eventually replaced by something different or better.
• A maturational loss is a form of necessary loss and includes all normally expected life changes across the life span. Maturational losses associated with normal life transitions help people develop coping skills to use when they experience unplanned, unwanted, or unexpected loss.
• Sudden, unpredictable external events bring about situational loss.
• Losses may be actual or perceived.
  • An actual loss occurs when a person can no longer feel, hear, see, or know a person or object.
  • A perceived loss is uniquely defined by the person experiencing the loss and is less obvious to other people.
• Each person responds to loss differently. The type of loss and the person’s perception of it influence the depth and duration of the grief response.
• A person’s culture, spirituality, personal beliefs, and values, previous experiences with death, and degree of social support influence the way he or she approaches death.

Scientific Knowledge Base: Grief

• It is very personal. No two people grieve the same way to the same loss, nor do they journey through grief in the same way.

• Coping with grief involves a period of mourning. Bereavement involves both grief and mourning.
• Normal grief is uncomplicated. This type of grief a common and universal reaction characterized by complex emotional, cognitive, social, physical, behavioral, and spiritual responses to loss and death.

• A person experiences anticipatory grief before the actual loss or death occurs, especially in situations of prolonged or predicted loss like caring for patients diagnosed with dementia or ALS.
• People experience disenfranchised grief when their relationship to the deceased person is not socially sanctioned, cannot be openly shared, or seems of lesser significance. - Ambiguous loss, a type of disenfranchised grief, occurs when the lost person is physically present but is not psychologically available, as in cases of severe dementia or severe brain injury.
• In complicated grief, a person has a prolonged or significantly difficult time moving forward after a loss. He or she experiences a chronic and disruptive yearning for the deceased; has trouble accepting the death and trusting others; and/or feels excessively bitter, emotionally numb, or anxious about the future. - A person with chronic grief experiences a normal grief response except it extends for a longer period of time. - A person with an exaggerated grief response often exhibits self-destructive or maladaptive behavior, obsessions, or psychiatric disorders. Suicide is a risk for these individuals. - A person’s grief response is unusually delayed or postponed because the loss is so overwhelming that the person must avoid the full realization of the loss. - Masked grief is when a grieving person behaves in ways that interfere with normal functioning but is unaware that the disruptive behavior is a result of the loss and ineffective grief resolution

Theories of Grief and Mourning

• Grief theorists describe the physical, psychological, and social reactions to loss.
• Criticism exists for the stages and task theories because they fail to capture the complexity and diversity of the experience.
• The more recent grief theories take into consideration that human beings construct their own experiences and truths differently and make their own meanings when confronted with loss and death.
• No one’s grief follows a predetermined path, nor is it linear. Grief is cyclical with movement forward and backwards.
• Educating grievers about the cyclical pattern of grief work prepares them for difficult days among the better days. Knowing that these feelings will come and go help the griever to be prepared for them and allow for the necessary self-care.

Nursing Knowledge Base

• Nurses need to develop a plan of care to assist patients and family members who undergo loss, grief, or death experiences.

• Based on nursing research, practice evidence, nursing experience, and patient and family preferences, nurses implement plans of care in acute care, nursing home, hospice, home care, and community settings.
• Extensive nursing education programs support the improvement of end-of-life care.

• Organizations have information readily available to assist nurses with this planning.
• The End-of-Life Nursing Consortium (ELNEC) provides basic and advanced curriculum for loss, grief, death, and bereavement.
• The American Nurses Association (ANA) has developed the Scope and Standards for Hospice and Palliative Nursing Practice.
• American Society of Pain Management Nurses and the American Association of Critical Care Nurses offer evidence-based practice guidelines for managing clinical and ethical issues at the end of life in many health care settings.

Factors Influencing Loss and Grief

• Patient age and stage of development affect the grief response.
  • School-age children understand the concepts of permanence and irreversibility but do not always understand the causes of a loss.
  • Young adults undergo many necessary developmental losses related to their evolving future.
  • For older adults the aging process leads to necessary and developmental losses.
• [Review Box 37-1, Focus on Older Adults: Grief Considerations in Older Adults, with students.]
• When loss involves another person, the quality and meaning of the lost relationship influence the grief response. Grievers experience less depression when they have highly satisfying personal relationships and friends to support them in their grief.
• Exploring the nature of a loss will help us understand the effect of the loss on the patient’s behavior, health, and well-being. Encouraging patients to share information about the loss will help us better develop appropriate interventions that meet the individualized needs of our patients.
• The losses patients face from the time they were children formulate the coping skills they will use when faced with larger and more painful losses in adulthood. Nurses provide support by assessing patient’s coping strategies, educate about new and healthy strategies, and encourage use of these strategies.
• Socioeconomic status influences a person’s grief process in direct and indirect ways.
• During times of loss and grief patients and families draw on social and spiritual practices of their culture to find comfort, expressions, and meaning in the experience. So as to provide the best care possible it is necessary for us to ask about cultural beliefs and practices.
• Consider the influence of sexual orientation, socioeconomic status, and family make-up (blended vs. nuclear) when assessing cultural influence on grief practices and death rituals.
• Like cultural influences, spirituality and/or religious practices and beliefs provide a framework to navigate, understand, and heal from loss, death, and grief.

• We must remain open to the varying views and beliefs that are in contrast to our own in order to best support and care for our patients’ and their families.

• Caring for the patient in a holistic approach, which includes the spirit, ensures that we are providing patients with the best possible individualized care.
• a multidimensional concept considered to be a component of spirituality, energizes and provides comfort to individuals experiencing personal challenges. Hopefulness gives a person the ability to see life as enduring or having meaning or purpose.

Critical Thinking

• Grieving people use their own unique history, context, and resources to make meaning out of their loss experiences. Listen as patients share the experience in their own way.
• When developing a plan of care, make sure to access current practice guidelines for assistance.

Assessment

• A trusting, helping relationship with grieving patients and family members is essential to the assessment process.
• Assess the wishes of the terminally ill patient and family for end-of-life care, including the preferred place for death, desired level of intervention, and expectations for pain and symptom management.
• Assessment of grief responses extends throughout the course of an illness into the bereavement period following a death.
• Discuss end-of-life care preferences early in the assessment phase of the nursing process.
• Speak to patients and family members using honest and open communication, remembering that cultural practices influence how much information the patient shares.
• Anticipate common grief responses, but allow patients to describe their experiences in their own words. Open-ended questions such as “What do you understand about your diagnosis?” or “You seem sad today. Can you tell me more?” may open the door to a patient-centered discussion.
• Conversations about the meaning of loss to a patient often leads to other important areas of assessment, including the patient’s coping style, the nature of family relationships, social support systems, the nature of the loss, cultural and spiritual beliefs, life goals, family grief patterns, self-care, and sources of hope.
• [Review Box 37-3, Nursing Assessment Questions, with students.]
• If a grieving patient describes loneliness and difficulty falling asleep, consider all factors surrounding the loss in context.
• As you gather assessment data, summarize and validate your impressions with the patient or family member.
• Most grieving people show some common outward signs and symptoms.

• Analyze assessment data and identify possible related causes for the signs and symptoms that you observe.
• Loss takes place in a social context; thus family assessment is a vital part of your data gathering.

• Assess the family’s response to loss and recognize that sometimes they are dealing with their grief at a different pace.

Diagnosis

• Use critical thinking to cluster assessment data cues, identify defining characteristics, draw conclusions regarding the patient’s actual or potential needs or resources, and identify nursing diagnoses applicable to the patient’s situation.
• [Review Box 37-5, Nursing Diagnostic Process: Hopelessness Related to Deteriorating Physiological Conditions, with students.]
• You cannot make accurate nursing diagnoses on the basis of just one or two defining characteristics. Carefully review your patient’s assessment data to consider if more than one diagnosis applies.
• As part of the diagnostic process, identify the appropriate “related to” factor for each diagnosis. Clarification of the related factors ensures that you select appropriate interventions.
• When identifying nursing diagnoses related to a patient’s grief or loss, you sometimes identify other related diagnoses.

Planning

• Nurses provide holistic, physical, emotional, social, and spiritual care to patients experiencing grief, death, or loss.
• The use of critical thinking ensures a well-designed care plan that supports a patient’s self-esteem and autonomy by including him or her in the planning process.
• Consider a patient’s own resources such as physical energy and activity tolerance, family support, and coping style.
• The goals of care for a patient experiencing loss are either short or long term, depending on the nature of the loss and the patient’s condition.
• Encourage patients and family members to share their priorities for care at the end of life. Patients at the end of life or with advanced chronic illness are more likely to want their comfort, social, or spiritual needs met than to pursue medical cures.
• Give priority to a patient’s most urgent physical or psychological needs while also considering his or her expectations and priorities.
• When comfort needs have been met, you can address other issues important to the patient and family.
• A patient’s condition at the end of life often changes quickly; therefore maintain an ongoing assessment to revise the plan of care according to patient needs and preferences.
• Use a concept map for multiple diagnoses.

• A team of nurses, physicians, social workers, spiritual care providers, nutritionists, pharmacists, physical and occupational therapists, patients, and family members works together to provide palliative care, grief care, and care at the end of life.

• As a patient’s care needs change, team members take a more or less active role, depending on the patient’s shifting priorities. Team members communicate with one another on a regular basis to ensure coordination and effectiveness of care.
• [Review Figure 37-3, Critical thinking model for loss, death, and grief planning, with students.]
• [Review Figure 37-4, Concept map for Mrs. Allison, with students.]

Implementation: Health Promotion

• Health promotion in serious chronic illness or death focuses on facilitating successful coping and optimizing physical, emotional, and spiritual health. Many people continue to look for and find meaning even in difficult life circumstances.
• [Review Box 37-6, Patient Teaching: Maintaining Self-Care, with students.]
• Patients and families can benefit greatly from the specialized approach of palliative care. This holistic method to prevention and reduction of symptoms promotes quality of life and whole-person well-being through care of the mind, body, and spirit.
• Palliative care focuses on the prevention, relief, reduction, or soothing of symptoms of disease or disorders throughout the entire course of an illness. It can also include, but is not solely, care of the dying. The primary goal of palliative care is to help patients and families achieve the best possible quality of life.
• Although it is especially important in advanced or chronic illness, palliative care is appropriate for patients of any age, with any diagnosis, at any time, and in any setting.
• The World Health Organization (2015) summarizes palliative care philosophy as follows:
  • Affirms life and regards dying as a normal process.
  • Neither hastens or postpones death.
  • Integrated psychological and spiritual aspects of patient care.
  • Offers a support system to help patients live as actively as possible until death.
  • Enhances the quality of life.
  • Uses a team approach to meet the needs of patients and families.
• When the goals of care change and cure for illnesses becomes less likely, the focus shifts to more palliative care strategies and ideally transition to hospice care, a more specialized form of palliative care for the dying.
• Hospice care is a philosophy and model for the care of terminally ill patients and their families at the end of life. It gives priority to managing a patient’s pain and other symptoms; comfort; quality of life; and attention to physical, psychological, social, and spiritual needs and resources.
• The cornerstone of hospice care is trusting relationship between the hospice team and the patient and family. Knowing expectations, desired location of care, and family dynamics help the hospice team provide individualized care at the end of life.
• Unlike traditional care, hospice patients are active participants in all aspects of care, and caregivers prioritize care according to patient wishes.
• Hospice programs are built on the following core beliefs and services:

• Patient and family are the unit of care.

• Coordinated home care with access to inpatient and nursing home beds when needed.
• Symptom management.
• Physician-directed services.
• Provision of an interdisciplinary care team.
• Medical and nursing services available at all times.
• Bereavement follow-up after patient’s death.
• Use of trained volunteers for visitation and respite support.
• To be eligible for home hospice services, a patient must have a family caregiver to provide care when the patient is no longer able to function alone.
• Nurses providing hospice care use therapeutic communication, offer psychosocial care and expert symptom management, promote patient dignity and self-esteem, maintain a comfortable and peaceful environment, provide spiritual comfort and hope, protect against abandonment or isolation, offer family support, assist with ethical decision making, and facilitate mourning.

Implementation: Health Promotion (Cont.)

• The heart of nursing care is the establishment of a caring and trusting relationship with our patient. This patient-focused approach allows us to respond to patients, rather than react, and encourages the sharing of important information.
• Feelings of sadness, numbing, or anger make talking about these situations especially difficult.
• If you are reassuring and respectful of a patient’s privacy, a therapeutic relationship likely develops. Sometimes patients need to begin resolving their grief privately before they discuss their loss with others, especially strangers.
• Do not avoid talking about a topic. When you sense that a patient wants to talk about something, make time to do so as soon as possible.
• Above all, remember that a patient’s emotions are not something you can “fix.” Instead view emotional expressions as an essential part of the patient’s adjustment to significant life changes and development of effective coping skills.
• Patients at the end of life experience a range of psychological symptoms, including anxiety, depression, powerlessness, uncertainty, and isolation. We can alleviate some worry and fear by providing information to our patients about their condition, the course of their disease, and the benefits and burdens of treatment options.
• Managing the multiple symptoms commonly experienced by chronically ill or dying patients remains a primary goal of palliative care nursing. Maintain an ongoing assessment of the patient’s pain and response to interventions. Reassure the family repeatedly of the need for pain control even if the patient does not appear in pain.
• Remain alert to the potential side effects of opioid administration: constipation, nausea, sedation, respiratory depression, or myoclonus. Education is necessary to helping families understand the need for appropriate use of opioid medications.

• [Review Table 37-3, Promoting Comfort in the Terminally Ill Patient, with students.]

• A sense of dignity includes a person’s positive self-regard, the ability to find meaning in life, to feel valued by others, and by how one is treated by caregivers. Nurses promote patients’ self-esteem and dignity by respecting patients as a whole person (i.e., as people with feelings, accomplishments, and passions independent of the illness experience) not just as a diagnosis.
• A comfortable, clean, pleasant environment helps patients relax, promotes good sleep patterns, and minimizes symptom severity. Keep a patient comfortable through frequent repositioning, making sure that bed linens are dry, and controlling extraneous environmental noise and offensive odors. Patient-preferred forms of complementary therapies offer noninvasive methods to increase comfort and well-being at the end of life.
• Patients are comforted when they have assurance that some aspect of their lives will transcend death, so helping patients make connections to their spiritual practice or cultural community can be a useful intervention. Draw on the resources of spiritual care providers in an institutional setting or collaborate with the patient’s own spiritual or religious leaders and communities.
• The spiritual concept of hope takes on special significance near the end of life. Nursing strategies that promote hope are often quite simple: be present and provide whole- person care.
• Many patients with terminal illness fear dying alone. Patients feel more hopeful when others are near to help them. Nurses in institutional settings need to answer call lights promptly and check on patients often to reassure them that someone is close at hand.
• When family members do visit, inform them of the patient’s status and share meaningful insights or encounters that you have had with the patient.
• In palliative and hospice care, patients and family members constitute the unit of care. When a patient becomes debilitated or approaches the end of life, family members also suffer.
• Family members caring for people with serious life-limiting illness need attention and support early and consistently throughout the experience of illness and death.
• Educate family members in all settings about the symptoms that the patient will likely experience and the implications for care.
• [Review Box 37-7, Evidence-Based Practice: Use of Antimuscarinic Drugs to Control Respiratory Secretions, with students.]
• Family members who have limited prior experience with death do not know what to expect. Whenever possible, communicate news of a patient’s declining condition or impending death when family members are together so they can support each other. Provide information privately and stay with the family as long as needed or desired.
• Reduce family member anxiety, stress, or fear by describing what to expect as death approaches. Become familiar with common manifestations of impending death (Box 37- 8), remembering that patients usually experience some but not all of these changes.

• [Review Box 37-8, Physical Changes Hours or Days Before Death, with the students.]
• During the dying process check frequently on families offering support, information, and if appropriate encouragement to continue touching and talking with their loved ones.

• After death assist the family with decision making such as notification of a funeral home, transportation of family members, and collection of the patient’s belongings.
• [Shown is Figure 37-5: Skin mottling.]
• Patients and families must decide about which treatments to continue and which treatments to forgo, to enroll in hospice or stay in the hospital, to transfer to a nursing home, in-patient unit, or to go home.
• We are able to support and educated patients and families as they identify, contemplate, and ultimately decide how to best journey to the end of life.
• Difficult ethical decisions at the end of life complicate a survivor’s grief, create family divisions, or increase family uncertainty at the time of death. When ethical decisions are handled well, survivors achieve a sense of control and experience a meaningful conclusion to their loved one’s death.
• Helpful strategies for assisting grieving persons include the following:
  • Help the survivor accept that the loss is real. Discuss how the loss or illness occurred or was discovered, when, under what circumstances, who told the survivor about it, and other factual topics to reinforce the reality of the event and put it in perspective.
  • Support efforts to adjust to the loss. Use a problem-solving approach. Have survivors make a list of their concerns or needs, help them prioritize, and lead them step-by-step through a discussion of how to proceed. Encourage survivors to ask for help.
  • Encourage establishment of new relationships. Reassure people that new relationships do not mean that they are replacing the person who has died. Encourage involvement in nonthreatening group social activities (e.g., volunteer activities or church events).
  • Allow time to grieve. “Anniversary reactions” (i.e., renewed grief around the time of the loss in subsequent years) are common. A return to sadness or the pain of grief is often worrisome. Openly acknowledge the loss, provide reassurance that the reaction is normal, and encourage the survivor to reminisce.
  • Interpret “normal” behavior. Being distractible, having difficulty sleeping or eating, and thinking that they have heard the deceased’s voice are common behaviors following loss. These symptoms do not mean that an individual has an emotional problem or is becoming ill. Reinforce that these behaviors are normal and will resolve over time.
  • Provide continuing support. Survivors need the support of a nurse with whom they have bonded for a time following a loss, especially in home care or hospice nursing. The nurse has filled an important role in the deceased’s life and death and has helped them through some very intimate and memorable times. Attachment for a period of time after the death is appropriate and healing for

both the survivor and the nurse. However, it is imperative that professional boundaries always be maintained.

• Be alert for signs of ineffective, potentially harmful coping mechanisms such as alcohol and substance abuse or excessive use of over-the-counter analgesics or sleep aids.
• Federal and state laws require institutions to develop policies and procedures for certain events that occur after death: requesting organ or tissue donation, performing an autopsy, certifying and documenting the occurrence of a death, and providing safe and appropriate postmortem care. In accordance with federal law, a specially trained professional (e.g., transplant coordinator or social worker) makes requests for organ and tissue donation at the time of every death.
• Nurses provide support and reinforce or clarify explanations given to them during the request process.
• Family members give consent for an autopsy to determine the exact cause and circumstances of death or discover the pathway of a disease.
• Documentation of a death provides a legal record of the event. Follow agency policies and procedures carefully to provide an accurate and reliable medical record of all assessments and activities surrounding a death. Documentation also validates success in meeting patient goals or provides justification for changes in treatment or expected outcomes.
• [Review Box 37-9, Documentation of End-of-Life Care, with students.]
• When a patient dies in an institutional or home care setting, nurses provide or delegate postmortem care, the care of a body after death. Above all, a deceased person’s body deserves the same respect and dignity as a living person’s body and needs to be prepared in a manner consistent with the patient’s cultural and religious beliefs.
• Maintaining the integrity of cultural and religious rituals and mourning practices at the time of death gives survivors a sense of fulfilled obligations and promotes acceptance of the patient’s death.
• [Review Box 37-10, Cultural Aspects of Care: Care of the Body Aker Death, with the students.]
• [Review Box 37-11, Procedural Guidelines: Care of the Body Aker Death, with the students.]

Evaluation

• The success of the evaluation process depends partially on the bond that you have formed with the patient. Patients are more likely to share personal expectations or their wishes if you form a trusting relationship with them.
• A patient’s responses and perceptions of the effectiveness of the interventions determine whether the existing plan of care is effective, or if different strategies are necessary.
• Continue to evaluate the patient’s progress, the effectiveness of the interventions, and patient and family interactions. Even when a patient is not seeking care specifically related to a loss, be alert for signs and symptoms of grief. They provide the criteria for

evaluating whether a patient is coping with a loss and how he or she is moving through the grief process.

• Critical thinking ensures that the evaluation process accurately reflects the patient’s situation and desired outcomes.
• A patient’s responses and perceptions of the effectiveness of the interventions determine if the existing plan of care is effective or if different strategies are necessary.
• The following questions help us validate achievement of goals and expectations:
  • What is the most important thing I can do for you at this time?
  • Are your needs being addressed in a timely manner?
  • Are you getting the care for which you hoped?
  • Would you like me to help you in a different way?
  • Do you have a specific request that I have not met?
• Especially in home care settings, include family members in the evaluation process.
• The short- and long-term outcomes that signal a family’s recovery from a loss guide your evaluation. - Short-term outcomes indicating effectiveness of grief interventions include talking about the loss without feeling overwhelmed, improved energy level, normalized sleep and dietary patterns, reorganization of life patterns, improved ability to make decisions, and finding it easier to be around other people. - Long-term achievements include the return of a sense of humor and normal life patterns, renewed or new personal relationships, and decrease of inner pain.
• [Review Figure 37-6, Critical thinking model for loss, death, and grief evaluation, with students.]

Chapter 47

Scientific Knowledge Base

• The GI tract is a series of hollow mucous membrane–lined muscular organs. These organs absorb fluid and nutrients, prepare food for absorption and use by body cells, and provide for temporary storage of feces. The GI tract absorbs high volumes of fluids, making fluid and electrolyte balance a key function of the GI system. In addition to ingested fluids and foods, the GI tract also receives secretions from the gallbladder and pancreas.
• The mouth mechanically and chemically breaks down nutrients into usable size and form.
• As food enters the upper esophagus, it passes through the upper esophageal sphincter. The bolus of food travels down the esophagus with the aid of peristalsis, which is a contraction that propels food through the length of the GI tract. The food moves down the esophagus and reaches the cardiac sphincter, which lies between the esophagus and

the upper end of the stomach. The sphincter prevents reflux of stomach contents back into the esophagus.

• The stomach performs three tasks: the storage of the swallowed food and liquid; the mixing of food with digestive juices into a substance called chyme; and the regulated emptying of its contents into the small intestine.

• Movement within the small intestine, occurring by peristalsis, facilitates both digestion and absorption. Chyme comes into the small intestine as a liquid material and mixes with digestive enzymes. Reabsorption in the small intestine is so efficient that by the time the fluid reaches the end of the small intestine, it is a thick liquid with semisolid particles in consistency. The small intestine is divided into three sections: the duodenum, the jejunum, and the ileum.
• The large intestine is divided into the cecum, ascending colon, transverse colon, descending colon, sigmoid colon, and rectum. The large intestine is the primary organ of bowel elimination. The colon has three functions: absorption, secretion, and elimination. Peristaltic contractions move contents through the colon. Mass peristalsis pushes undigested food toward the rectum. These mass movements occur only three or four times daily, with the strongest during the hour after mealtime.
• The rectum contains vertical and transverse folds of tissue that help to control expulsion of fecal contents during defecation. Each fold contains veins that can become distended from pressure during straining. This distention results in hemorrhoid formation.
• The body expels feces and flatus from the rectum through the anus.
• Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out. Normally, defecation is painless, resulting in passage of soft, formed stool. Straining while having a bowel movement indicates that the patient may need changes in diet or fluid intake or that there is an underlying disorder in GI function.
• [Shown is Figure 47-1: Organs of gastrointestinal tract. (From Monahan FD, Neighbors M: Medical-surgical nursing, ed 2, Philadelphia, 1998, Saunders.)]

Nursing Knowledge Base:

Factors Affecting Bowel Elimination

• Many factors influence the process of bowel elimination. Knowledge of these factors helps to anticipate measures required to maintain a normal elimination pattern.
• Age influences bowel elimination. Infants have a smaller stomach capacity, less secretion of digestive enzymes, and more rapid intestinal peristalsis. The ability to control defecation does not occur until 2 to 3 years of age. Adolescents experience rapid growth and increased metabolic rate. There is also rapid growth of the large intestine and increased secretion of gastric acids to digest food fibers and act as a bactericide against swallowed organisms. Older adults may have decreased chewing ability. Peristalsis declines and esophageal emptying slows. This impairs absorption by the intestinal mucosa. Muscle tone in the perineal floor and anal sphincter weakens, and may cause difficulty in controlling defecation.

• Regular daily food intake helps maintain a regular pattern of peristalsis in the colon. Fiber in the diet provides the bulk in the fecal material. Bulk-forming foods help remove

the fats and waste products from the body. Some foods may also produce gas, which distends the intestinal walls and increases colonic motility.

• While individual fluid needs vary with the person, a fluid intake of 3 L per day for men and 2.2 L per day for women is recommended. Fluid liquefies intestinal contents by absorbing into the fiber from the diet and creating a larger, softer stool mass. This increases peristalsis and promotes movement of stool through the colon.
• Physical activity promotes peristalsis.
• Prolonged emotional stress impairs the function of almost all body systems. During emotional stress, the digestive process is accelerated and peristalsis is increased.
• Personal elimination habits influence bowel function. A busy work schedule sometimes prevents the individual from responding appropriately to the urge to defecate, disrupting regular habits and causing possible alterations such as constipation.
• Squatting is the normal position during defecation. For the patient immobilized in bed, defecation is often difficult. If the patient’s condition permits, raise the head of the bed to assist the patient to a more normal sitting position on a bedpan, enhancing the ability to defecate.
• A number of conditions such as hemorrhoids, rectal surgery, anal fissures (which are painful linear splits in the perianal area), and abdominal surgery result in discomfort. In these instances, the patient often suppresses the urge to defecate to avoid pain, contributing to the development of constipation.
• As pregnancy advances, the size of the fetus increases and pressure is exerted on the rectum. A temporary obstruction created by the fetus impairs passage of feces. Slowing of peristalsis during the third trimester often leads to constipation. A pregnant woman’s frequent straining during defecation or delivery may result in formation of hemorrhoids.
• General anesthetic agents used during surgery cause temporary cessation of peristalsis. The patient who receives a local or regional anesthetic is less at risk for elimination alterations because this type of anesthesia generally affects bowel activity minimally or not at all. Any surgery that involves direct manipulation of the bowel temporarily stops peristalsis. This condition, called an ileus, usually lasts about 24 to 48 hours. If the patient remains inactive or is unable to eat after surgery, return of normal bowel elimination is further delayed.
• Many medications prescribed for acute and chronic conditions have secondary effects on the patient’s bowel elimination patterns. Some medications are used primarily for their action on the bowel and will promote defecation such as laxatives or cathartics or control diarrhea.
• Diagnostic examinations involving visualization of GI structures often require a prescribed bowel preparation (e.g., laxatives, and/or enemas) to ensure that the bowel is empty. Usually, the patient cannot eat or drink several hours before examinations such as an endoscopy, colonoscopy, or other testing that requires visualization of the GI tract. Following the diagnostic procedure, changes in elimination such as increased gas or loose stools often occur until the patient resumes a normal eating pattern.