Because immobility reduces the energy requirements of cells and slows metabolic processes, gastrointestinal function is impaired, affecting both the ingestion of food and the elimination of wastes.
At prolonged rest, nitrogen balance in the human is reserved to a negative state. Anabolic and catabolic activities are not eqqual-the balance is upset: catabolism is increased, and protein loss is accompanied by mechanical and psychological disturbances in gastrointestinal function as the desire for food diminishes.
Anorextia results in a loss of nutrients and is likely to prolong whatever disease process or dysfunction caused the immobilization in the first place. Though loss of appetite is an adaptive mechanism in response to decreased metabolic requirements, sufficient nutrients for basal metabolism and for compensation of catabolic losses must be maintained if healing is to make place.
Adequate amounts of the basic 4 food groups served in small, frequent feedings may help encourage the patient to eat. Personal preferences and cultural variations in food habits may need to be considered, and food should be appetizing and served appropriately hot or cold. Food becomes for the immobilized person a source of comfort, a symbol of the caring of others, a welcome break in the day`s routine.
Elimination is the other significant gastrointestinal function affected by prolonged rest. The combination of smooth and skeletal muscle activity with complex reflex action provides for successful defecation. Loss may occur in any of these mechanisms. Lack of muscle tone occuring during immobility is reflected in a weakening of the abdominal mescles needed for the expulsion of stool. Dehydration may cause fecal material to be dry and hard. Suppression of the urge to defecate often occurs. The patient is in an unfamiliar environment; privacy is minimal; the usual pattern of living has been disrupted. Often the must asume an unnatural position to defecate. If the gastrocolic reflex that moves the fecal contents from the sigmoid into the rectum is ignored repeatedly, it will become less strong until it possibly disappears altogether and chronic constipation develops.
Fecal impaction can and does frequently occur in immobilized persons, regardless of age, unless nursing intervention has been preventive rather than curative. Increased fluid intake. A daily serving of prune juice in anticipation of prolonged bedrest, and preservation of muscle tone are measures that will prevent constipation and mechanical intervention. The addition of fiber foods, such as bran cereals, whole wheat breads, nuts, and raw vegetables, is helpful in maintaining bowel tone. Teach immobilized patients to select menus that will include not only essential nutrients but also foods that supply bulk and roughage as tolerated. The elderly patient with a stroke or fractured hip, the patient in casts or traction regardless of age, or anyone confined to bed for an extended period for any reason are all persons for whom an early assessment of bowel habits and a preventive plan of care are essential.
Patient teaching is important since many persons do not understand what constitutes a normal bowel pattern. Misconceptions about the frequency, amount, and characteristics of a normal stool must be clarified. What is normal for one person will not be for another. The idea that a daily bowel movement is necessary for all people may need to be explored with the patient, since cultural groups vary in their emphasis upon this and other body functions. It is not how often defecation occurs but what its characteristics are that determines healthy gastrointestinal function. If the stool is soft, formed, and easily expelled, the frequency is not significant. Evacuation twice a week in sufficient amounts and of soft consistency is considered to indicate normal bowel function in the immobilized patient.
Many pharmaceutical stool softeners are available for patients who may need help in getting a bowel pattern established, but the use of laxatives and enemas should be discouraged. In any bowel-training program, the patient`s habits prior to immobility should be investigated and incorporated into the plan. Peristalsis sufficient to move bowel contents into the rectum usually occurs most strongly after breakfast. Therefore, following that meal the patient should be encouraged to use the bedpan, commode, or lavatory, allowing about 15 minutes for the process. Sometimes digital stimulation of the anal sphincter or the use of a suppository may be helpful in establishing this pattern.
If an acceptable pattern for defecation has not been established and a fecal impaction occurs, the cardinal symptom will be the frequent passing of liquid fecal material from around the impacted stool. When this is suspected, a rectal examination should be done; and if there is an impaction, is must be dislodged and removed by gentle digital manipulation. An oil retention enema given above the mass an hour prior to digital removal will prevent undue discomfort for the patient. Cleansing enemas are usually used following removal of the impaction. Health teaching to promote an improved intestinal tone through diet, increased fluid intake, and activity is essential to prevent a recurrence.
References :
Browse, N.L., Physiology and Pathology of Bedrest. Springfield, III.: Charles C. Thomas, Publisher, 1965.
Olson, Edith V., “The Hazards of Immobility”, American Journal of Nursing, 67: No.4, 1971.
Murray, RB and Zentner JP., Nursing Concepts for Health Promotion, Second Edtion, Prentice-Hall, Inc, Englewood Cliffs, N.J, 1979.
