Diarrhoea is an increase in the frequency, volume, and luid content of the faeces resulting from increased motility of the intestines (Tortora & Derrickson 2012). Conse-quently there is also decreased absorption of water, nutri-ents and electrolytes and the faeces will be semi-formed or liquid. Diarrhoea may also lead to temporary faecal incontinence (deWit & O’Neill 2014). Diarrhoea can be classed as acute or chronic depending on the cause and how long it lasts. Acute diarrhoea is common and usually self-limiting within 2 weeks, chronic diarrhoea lasts longer than 2 weeks and may be the result of an underlying disease. Women presenting with acute diarrhoea may need to be put into ‘Source Isolation’ (see Chapter 8) until infec-tion is ruled out as a cause. Fluid and electrolyte replace-ment and maintenance of a luid balance chart should be considered, as the woman may be dehydrated with an electrolyte imbalance.
Factors increasing defaecation, predisposing to diarrhoea
•
During the onset and early part of labour (this could result in defaecation being delayed in the irst 48 hours after delivery).•
Infection, e.g. helminths.•
Diet: excessive intake of certain foods, e.g. fruit, alcohol, coffee, chocolate (Dempsey et al 2014), or food intolerance, e.g. lactose intolerance.•
Stress.•
Drugs, e.g. antibiotics, iron supplements, laxatives.•
Disease, e.g. irritable bowel syndrome, diverticulitis.|
16| Chapter
Principles of elimination management: defaecation
•
Increasing mobility: constipation is associated with decreased mobility, so mild exercise will help.•
Easy access to clean toilet facilities: avoid using the bedpan which increases straining and oxygen consumption.•
Treating haemorrhoids.•
Using a suitable barrier cream to prevent anal excoriation.•
Use of oral laxatives, but these should not be the irst course of action.•
Suppositories and microenemas (see Chapter 22) may provide immediate but short-term relief ofconstipation; the cause of constipation should also be treated.
Other measures include:
•
Conditioning: sitting on the toilet following a meal may help bowel habits be relearned, especially after breakfast, as Dempsey et al (2014) suggest this is when the gastrocolic and duodenocolic relexes cause mass propulsive movements within the large intestine.•
Privacy, so that the sounds and smell of defaecation are not noticed – wherever possible allow the woman to use the toilet rather than a commode or bedpan.•
Education: advice on care of the perineum and likelihood of causing damage to a sutured perineum;reassurance of expected changes and return to normal bowel function following birth.
•
Use of soft toilet paper, as this may help psychologically.SELF-ASSESSMENT EXERCISES
The answers to the following questions may be found in the text:
1. Describe the physiology of defaecation.
2. What factors inluence the ability to defaecate?
3. How can the midwife promote defaecation?
ROLE AND RESPONSIBILITIES OF THE MIDWIFE These can be summarized as:
• asking the woman about her bowel habits as part of the antenatal and postnatal examination; this should be undertaken in such a way so as not to embarrass the woman
• any dificulties with defaecation should be discussed and advice given to promote defaecation
• a record of any problems, advice given and evaluation of the advice should be recorded in the woman’s case notes
• any drugs given to assist defaecation should be in accordance with the standards for medicine management (NMC 2007)
• if dificulties with defaecation do not resolve, the midwife should refer the woman for further investigation.
SUMMARY
•
Defaecation is primarily under conscious control (in the adult).•
Inhibition of defaecation can lead to constipation.•
Defaecation can be promoted by a number of different factors.REFERENCES
Amselem, C., Puigdollers, A., Azpiroz, F., et al., 2010. Constipation: a potential cause of pelvic loor damage?
Neurogastroenterol. Motil. 22 (2), 150–153.
Blackburn, S.T., 2013. Maternal, Fetal, &
Neonatal Physiology, fourth ed.
Elsevier, Maryland Heights, p. 402.
Brown, H., Crisford, M., Fernandes, A., et al., 2011. Elimination. In:
Dougherty, L., Lister, S. (Eds.), The Royal Marsden Hospital Manual of
Clinical Nursing Procedures, eighth ed. Wiley Blackwell, Oxford, pp. 239–320.
Brown, S., 2013. Bowel Elimination.
In: Koutoukidis, G., Stainton, K., Hughson, J. (Eds.), Tabbner’s Nursing Care. Theory and Practice, sixth ed.
Churchill Livingstone, Chatswood, pp. 696–717.
Connor, A., 2010. Valsalva-related retinal venous dilation caused by
defaecation. Acta Ophthalmol.
88 (4), e149. doi:10.1111/
j.1755–3768.2009.01624.x.
Dempsey, J., Hillege, S., Hill, R., 2014. Fundamentals of Nursing and Midwifery A Person-Centred Approach to Care, second ed.
Australian and New Zealand edn. Lippincott, Williams &
Wilkins Pty Ltd, Sydney, pp. 1132–1168.
deWit, S., O’Neill, P., 2014. Fundamental Concepts and Skills For Nursing,
fourth ed. Elsevier, St. Louis, pp. 570–571.
Hurnauth, C., 2011. Management of faecal incontinence in acutely ill patients. Nurs. Stand. 25 (22), 48–56.
Jackson, P., 2011. Morbidity following childbirth. In: McDonald, S., Magill-Cuerden, J. (Eds.), Mayes’
Midwifery, fourteenth ed. Elsevier, Edinburgh.
Jefferson, A., Croton, J., 2013. Using wheat bran ibre to improve bowel habits during pregnancy – a call to action. Br. J. Midwifery 21 (5), 331–341.
Murray, I., Hassell, J., 2014. Change and adaptation in pregnancy. In:
Marshall, J., Raynor, M. (Eds.), Myles Textbook for Midwives, sixteenth ed.
Elsevier, Edinburgh, pp. 163–164.
NICE (National Institute for Health and Care Excellence), 2007. Faecal Incontinence: The Management of Faecal Incontinence in Adults CG 49.
NICE, London. Available online:
<www.nice.org.uk> (accessed 3 March 2015).
NICE (National Institute for Health and Care Excellence), 2008. Antenatal Care CG 62. NICE, London. Available online: <www.nice.org.uk> (accessed 3 March 2015).
NMC (Nursing and Midwifery Council), 2007. Standards for medicines management. Available online:
<http://www.nmc-uk.org/
Publications/Standards/> (accessed 3 March 2015).
Qui, C., Coughlin, K., Frederick, I., et al., 2008. Dietary ibre in early
pregnancy and risk of subsequent preeclampsia. Am. J. Hypertens. 21 (8), 903–909.
Thibodeau, G., Patton, K., 2012.
Structure & Function of the Body, fourteenth ed. Elsevier Mosby, St. Louis, p. 365.
Tortora, G., Derrickson, B., 2012.
Principles of Anatomy and Physiology, thirteenth ed. Wiley, Hoboken, p. 1040.
Zhang, C., Liu, S., Solomon, C., Hu, F., 2006. Dietary iber intake, dietary glycemic load and the risk for gestational diabetes mellitus. Diabetes Care 29 (10), 2223–2230.
Zhou, L., Lin, Z., Lin, L., et al., 2010.
Functional constipation: implications for nursing interventions. J. Clin.
Nurs. 19, 1838–1843.
Principles of elimination management: obtaining urinary and stool specimens
Chapter
results can be considered to have greater validity than if any of these steps have been compromised. Midwives take a large number of urine specimens; this chapter reviews the correct way to do this. Stool specimens are also discussed.
GOOD PRACTICE
Good practice for the taking of all specimens should include:
•
Correct identiication of the woman (asking her to state her name and date of birth) and the granting of consent. Some specimens require the woman to take more action than others. In each instance, she needs to understand what is being tested, why and how the specimen is obtained.•
Clinical assessment: is the specimen necessary? Is it appropriate to the current clinical condition? In what way will the result impact care?•
Is this a repeat specimen? Taking specimens unnecessarily is costly and can be stressful for the woman. Will a repeat specimen add to her plan of care?•
Is it being collected at the right time, in the right way (avoiding contamination) using the correctequipment, the correct sample pot and labelled as per locally agreed policy? Failure at any of these stages wastes resources and can lose patient conidence in the service.
•
Is the specimen being taken in a manner that protects all staff including the midwife, transportation and laboratory services? Is it sealed and labelled ‘high risk’ if appropriate? Has adherence to standard precaution and infection control protocols been upheld?17
CHAPTER CONTENTS
Learning outcomes 137
Good practice 137
Catheter specimens of urine (CSU) 138 PROCEDURE: catheter specimen of urine 139 Midstream specimens of urine (MSU) 139
PROCEDURE: midstream specimen
of urine 139
24-hour urine collection 140
Urine specimens from the baby 140 Obtaining stool specimens 140 PROCEDURE: stool specimen (adult) 140 PROCEDURE: stool specimen (baby) 141 Role and responsibilities of the midwife 141
Summary 141
Self-assessment exercises 142
References 142
LEARNING OUTCOMES
Having read this chapter, the reader should be able to:
•
describe the procedure for obtaining a catheter specimen, a midstream specimen and a neonatal specimen of urine•
describe how a 24-hour urine collection is taken•
describe how a stool specimen is obtained•
summarize the midwife’s role and responsibility in relation to specimen collection.If specimens are taken in the correct manner and are dis-patched promptly with the correct request form, their
•
maintaining a closed drainage system means that only the drainage port should be used and that specimens should only be taken when absolutely necessary•
fresh urine is screened.The type of catheter or urinary drainage bag (depending upon which manufacturer) will determine the way in which the specimen is taken:
•
a resealing rubber ‘window’ port in the tubing•
a needleless port in some part of the tubing or drainage bag (Fig. 17.1).In maintaining an aseptic technique, the port should be cleansed with a locally approved wipe, often 70%
alcohol/2% chlorhexidine, and allowed to dry. Aseptic Non Touch Technique (ANTT) (Rowley & Clare 2011) advo-cates using four corners of a wipe and the middle, each for approximately 5 seconds, generating friction. This is the recommendation for intravenous ports (p. 89); it would seem sensible to apply the same practice to urinary catheter ports. Loveday et al (2014) also state that non-sterile gloves should be worn before any manipulation of a catheter.