ࡱ> npklm~{q` bjbjqPqP K::IxxxxxxxdF +BBBZ6^ (44KMMMMMM$h:qxoooqxx4[[[oxp4LxK[oK[[x[ 01(|Bi[ 0[ # [[ x [qq9"ooooZ6Z6Z6Z>AZ6Z6Z6> B xxxxxx Running Head: CONCEPT ANALYSIS OF BOWEL ELIMINATION Concept Analysis of Bowel Elimination Mary Sokolowski Kent State University Abstract Constipation is a pervasive problem in hospitalized patients. In an orthopedic population, the problem is compounded by issues of forced immobility, pain with movement, and the use of opiates and other medications to control pain. Additionally, systems issues may interfere with optimum functioning in the postoperative period. The concept of bowel elimination is a normal physiologic process that may be supported through early assessment and prevention to optimize bowel functioning. The purpose of the project was to conduct a concept analysis for the problem of altered bowel elimination (constipation). Initial assessment was followed by education for patients and nurses. The nursing intervention, a patient self-management tool, was developed and implemented for postoperative orthopedic patients. It consisted of a pictorial pyramid which served as a visual reminder to help patients participate in choices for their care, using the antecedents of fluids, fiber, and activity to promote bowel elimination. A nursing performance improvement project supported systems changes that had been identified as roadblocks to normal bowel elimination. In a group of 8 patients, 50% had a bowel movement after introduction of the tool. Patients also demonstrated changes in behavior to impact their own care, using the tool to make better choices to promote normal bowel elimination. Nurses were able to use evidence based practice to supplement systems changes with patient education and feedback to prevent constipation. Concept Analysis of Bowel Elimination Normal bowel elimination involves a series of physiologic processes which results in the evacuation of the end products of digestion in the form of stool. Psychologic, biologic, iatrogenic, and nutritional factors may affect the process. In the hospitalized orthopedic patient, alterations of several of these factors may overlap to cause constipation. Early assessment and a standardized approach are keys to prevention of this problem. Introduction of a patient self-management tool helps the patient to participate in care, using simple instructions to individualize choices that will affect bowel elimination. The purpose of this discussion is to describe the concept of bowel elimination for the problem of constipation in postoperative orthopedic patients. An intervention was developed and implemented, consisting of a pictorial pyramid, representing the antecedents of normal bowel elimination. Problem Constipation has various descriptions in the literature and many are quite subjective in nature. Patterns of bowel elimination are established over the course of a lifetime and are unique to each individual. In an American Gastroenterological Society guideline (American Gastroenterological Society, 2000), it was noted that physicians often focus on decreased frequency in the definition of constipation, while it is not uncommon for patients to complain of constipation, even while moving their bowels once a day. In an attempt to standardize diagnostic criteria, the Rome Coordinating Committee on Functional Gastrointestinal Disorders established the Rome III criteria for constipation (Heitkemper & Wolff, 2007). Although intended to describe chronic constipation, the symptoms are common throughout the literature. Two or more of the following symptoms for the past 3 months with symptom onset greater than 6 months, were adopted as a guideline if present > 25% of the time: 1) straining during bowel movements, 2) lumpy, hard stool, 3) feeling of incomplete evacuation, 4) feeling of anorectal blockage, and 5) use of manual maneuvers to assist bowel movements. The guidelines include less than 3 bowel movements per week (Heitkemper & Wolff, 2007). Constipation is a universal health problem with statistics that vary among different populations from 20% to 50% (Kacmaz & Kasikci, 2007). DeSouza (2002) estimated that 40% of the adult orthopedic population experiences constipation. Risk factors in orthopedic patients include immobility of varying types, pain associated with movement, and the use of pain medications, especially opiates, which decrease intestinal motility. The inherent changes in routine that affect all hospitalized patients include a lack of food and fluid preferences and disruption of the normal toileting regime. Additionally, preexisting physical and psychiatric conditions and multiple medications complicate the picture. Aging, in and of itself, does not cause constipation, but the multitude of diseases and issues of polypharmacy increase the risk in this population, who are often undergoing orthopedic procedures (Hicks, 2001). Population In interviews with the Clinical Nurse Specialist (CNS) at MetroHealth Medical Center in Cleveland, Ohio, it was anecdotally noted by several nurses on a postoperative orthopedic floor that their patients complained of constipation. This was verified by the rehabilitation unit receiving these orthopedic patients where many nurses interviewed stated, your patients are always constipated. Additionally the Nurse Manager noted that with recent transfers, the receiving facilities would not accept the patient unless they had a bowel movement (BM). This led to a clinical audit on 3 occasions. It was noted that several patients had not had a BM charted for 2-6 days postoperatively. The CNS did not feel it was a problem with charting, as most orthopedic patients require assistance to the bathroom and the charts are stored outside each room. Three patients interviewed initially confirmed that they had not had a BM for several days with common complaints of I feel too full to eat, poor appetite, dislike of hospital food and fluid choices, and problems ambulating. Two patients stated they didnt want to bother the nurses to get up to the chair or bathroom. Some tests required them to be NPO (nothing by mouth) and the Physical Therapy department came at varying times in the morning. Audits revealed a variety of medications relating to preexisting conditions and use of opiate pain control for most patients. Nurses confirmed that there was no set process for assessment and prevention of constipation. Their new admission form had been revised and omitted the question of last BM that had been on prior forms. It was noted that nurses did not include a review of the past days elimination pattern as part of their report to the next shift. They also mentioned a lack of privacy with double rooms and curtains between patients with liberal visiting hours throughout the day. The management team, CNS, unit educator and nurses agreed that constipation was a problem on this unit and they were interested in pursuing a PI project. Nursing Diagnosis The nursing diagnosis of constipation or risk for constipation is related to immobility and use of opiates for pain control in this population. It includes a definition of decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool or passage of excessively hard, dry stool (Wilkinson & Wilkinson, 2005). Although a population of hospitalized orthopedic patients was identified by staff and through audits, other surgical patients with issues of immobility, cancer patients with various medications (including opiates), and elderly hospitalized patients could benefit from this intervention. The nurses and educators would work on a nursing process improvement while use of an interventional tool would compliment the process. The tool is a simple pictorial pyramid, intended to track some of the more commonly known antecedents for bowel elimination, including fluids, fiber, exercise, and positioning. There are directions and suggestions on the back of the tool, including a section to record parameters for a bowel movement. The instructions are very basic and require only that an X is marked when the patient uses the tool. Risks might include discomfort speaking about bowel elimination among nurses or patients. Specific directions would also be needed in regard to exercise both in and out of bed to reduce the risk of injury. Concept Definition The concept of bowel elimination may be explored by dividing the term. In the biologic sense, bowel refers to the intestine. Other definitions speak to the interior parts, deep or remote, as in the bowels of the earth (http:www.merriam-webster.com/dictionary/bowel). According to dictionary.com (http://dictionary.reference.com/browse/bowel), the term originated in the 14th century and came from the Latin botellus meaning sausage. It also had archaic origins and was used to describe feelings of pity or compassion. Elimination is defined as to get rid of, remove; to leave out or omit; to reject or to excrete (http://www.thefreedictionary.com/elimination). Elimination is mentioned in Wikpedia as part of chemistry in combining to form a larger organic product, in pharmacy to remove a foreign agent from the body, and in tennis as the process of single or double elimination (http://en.wikpedia.org/wiki/Elimination). A bloggers description of journalistic constipation is defined as suppressing a story out of political correctness (http://www.politicalaffairs.net/article.net/article/articleview/2558/1/144). Excluding pity or compassion, these terms can be combined to define bowel elimination as the end product of something from the interior. The opposite, constipation, is the suppression of the act. Review of the Literature A review of the literature highlights the dearth of information on the natural process of bowel elimination. Cadd et al. (2000) explored a bowel care management program incorporating patient preferences by eliciting information in a palliative population and Weeks, Hubbartt, & Michaels (2000) listed the keys to bowel success in a rehab population. All other sources used the words constipation (George, Hayward, Lowe, & Page, 1996; Grieve, 2006; Heitkemper & Wolff, 2007; Hicks, 2001; Hinrichs, Huseboe, Tang, & Titler, 2001; Richmond, 2003), bowel problem (Salcido, 2000), and risk management (Zernike & Henderson, 1999). Although the process of bowel elimination was discussed in the articles, it was the prevention and management of the problem, constipation, which was the focus of various interventions. The American Gastroenterological Societys medical position statement even speaks to a guideline for constipation (American Gastroenterological Society, 2000). Physiologic Theory Adequate functioning of several physiologic processes is required for normal bowel elimination. These include gastrointestinal motility, mucosal transport, the defecation reflex, and anal sphincter muscle relaxation (Bisanz, 2007). Gastrointestinal (GI) Motility Digestion begins in the mouth as food moves through the esophagus and into the stomach. Bowel elimination in its strictest form begins in the small intestine. Secretions from the salivary glands, stomach, liver, biliary system, and pancreas break down and digest food. It then moves into the small intestine where enzymes assist with digestion and absorption of nutrients. As muscles along the GI tract contract, peristalsis takes place. Contractions in the small intestine are continuous while those in the large intestine are periodic, occurring 1-3 times per day (Bisanz, 2007). Approximately 5-15 minutes after a meal, the gastrocolic reflex is stimulated, causing the ileocecal valve to open and stimulate contraction and movement of undigested residue into the large intestine. From the cecum, it moves through the ascending colon, transverse colon, and descending colon where it is processed into feces over the course of 18-72 hours (Salcido, 2000). Mucosal Transport Nutrients, water, and electrolytes pass through the mucosa of the small intestine and are released into the bloodstream. The waste that remains passes into the large intestine, where it continues to lose water and turns into formed stool. The longer it remains in the large intestine, the more water that will be lost, resulting in hardened stool (Bisanz, 2007). Defecation Reflex A series of valves and anatomical folds holds the feces in place at the point of the sigmoid colon. Internal and external sphincters lie at the distal end of the sigmoid colon at the rectal vault (Salcido, 2000). The defecation reflex is controlled by transmission of impulses from the central nervous system. When enough stool has entered the rectum, the defecation reflex is stimulated by rectal distention, signaling the need for a bowel movement (Bisanz, 2007). Mechanical assistance is provided by squatting or sitting, which increases intra-abdominal pressure. Additionally, the Valsalva maneuver causes pressures that are higher than the intraluminal pressure in the bowel (Salcido, 2000). Anal Sphincter Muscles The rectocolic reflex causes opening of the sigmoid vault and valves and relaxation of the external sphincter for the elimination of stool. If the defecation reflex is ignored, the urge to defecate will be suppressed until more stool enters the rectum (Bisanz, 2007). Attributes In describing the concept, it is difficult to find attributes, or characteristics, ascribed to normal bowel elimination. Most sources focus on descriptions and definitions of constipation. Nursing outcomes criteria use indicators of bowel elimination including color of stool (without blood, mucus, or fat), stool soft and formed, stool amount for diet, ease of stool passage, and passage of stool without aids (Moorhead, 2008). Other attributes which may be described in opposition to constipation include a feeling of complete evacuation and absence of anorectal obstruction. These attributes coincide with normal elimination in that feces with sufficient bulk will pass through the intestines with normal peristalsis, producing stool which is soft, formed and easy to pass. If sufficient stool is in the rectal vault and the defecation reflex is heeded, with adequate sympathetic innervation, evacuation of stool will be complete. Additionally, objective criteria will include the presence of active bowel sounds and a soft, non-distended abdomen (Salcido, 2000). In summary, the attributes of normal bowel elimination are soft, formed stool which is adequate for diet and passes easily without aids, with a sense of complete evacuation. Antecedents Antecedents are precursors to the development of a concept. Positive antecedents for normal bowel elimination include good health, with less reliance on medication, mobility, adequate fiber and fluids, and maintenance of a regular toileting regime. Health Good health may be stated as the absence of disease. Many diseases predispose patients to constipation, including renal, endocrine, nervous system, and GI disorders. An intact central nervous system is required for impulse transmission to the intestines as well (Hinrichs et al., 2001). Good oral hygiene and well-fitting dentures facilitate enjoyment of a well-balanced meal. Mobility An active lifestyle helps maintain good muscle tone which is necessary for defecation. In immobile patients, bedside exercises and turning every 2 hours will aid in peristalsis. Additionally, exercise stimulates the appetite (Kacmaz & Kasikci, 2007). Medications Many medications can slow peristalsis or affect the neurologic system, including anticholinergics, calcium channel blockers, diuretics, iron supplements, and narcotics, among others. Good general health with fewer medications helps ensure adequate bowel functioning (Richmond, 2003). Laxative use may increase bowel elimination in the short term, but chronic use will slow intestinal motility (Hinrichs et al., 2001). Fiber Fiber is a natural part of plant products. It provides bulk and absorbs water, producing bulkier softer stool which moves quickly through the intestines (Hinrichs et al., 2001). Fiber recommendations vary among different sources and include both soluble and insoluble fiber. Insoluble fiber includes wheat bran, vegetables, and whole grains. It does not dissolve in fluid and is the most helpful in bowel elimination. Soluble fiber includes oat bran, barley, beans, fruit, and some vegetables. It forms a gel to move stool but is less helpful than insoluble fiber (Vickery, 1997). Fiber must be introduced slowly as sudden increases may cause mineral imbalances with diarrhea (Hicks, 2001). General recommendations range from 15 g/day to 26 g/day (Richmond, 2003). Fluids Fluids must be considered as an essential adjunct to fiber. Normal stool is 70% water. Adequate intake of fluids such as water and juice ensures ease of passage. General recommendations are at least 1500 cc/day, avoiding caffeinated products and alcohol due to their diuretic properties. Prune juice or hot lemon water is often recommended to stimulate a bowel movement (Hinrichs et al., 2001). Toileting Regime A routine pattern of toileting is recommended 5-15 minutes after meals, especially breakfast, when the gastrocolic reflex is strongest (Hinrichs et al., 2001). The sitting position is preferred, as lying prone on a bedpan decreases the pressure in the rectal vault that is necessary for defecation (Richmond, 2003). Assistive devices, such as bedside commodes and seat extenders may aid in providing comfortable positioning (Kacmaz & Kasikci, 2007). Privacy and planned toileting ensure that the urge to defecate is not suppressed, as ignoring the urge may lead to further buildup of hardened stool (Richmond, 2003). Model Case The model case exemplifies all of the attributes and antecedents of normal bowel elimination. John Jones is an active 40 year old personal trainer who is admitted to the orthopedic floor after a total knee replacement (TKR). He is in his first postoperative day and has actively participated in his first physical therapy session. He talks about limiting his use of pain medications as he feels they are unnatural. He has already started to use light weights and is doing isometric exercises in bed. He has no known medical problems and takes no medications. His healthy diet at home includes 5 servings of fruits and vegetables and 6-8 servings of whole grains per day. His wife will be bringing in food from home. He drinks at least 8 glasses of water and limited amounts of juice and declines caffeinated beverages. He has had 1 soft formed stool of an average amount for him this morning after ambulating to the bathroom with his walker. Discussion Positive antecedents for bowel elimination include good general health, limited use of pain medications, and participation in exercise activities. Mr. Jones intake of fluids and fiber meets the minimum daily suggested requirements of at least 1500 cc of fluid and 18 grams of fiber to prevent constipation (Richmond, 2003). He limits caffeinated beverages, which are known to have a diuretic effect, causing hardened stool. He has already had 1 soft formed stool. Contrary Case The contrary case has all of the negative antecedents for bowel elimination, resulting in constipation. Jenny Craig is a 67 year old homemaker who is in her 2nd postoperative day after a total hip replacement. She is crying after the physical therapist attempted to help her sit up in bed. She has a PCA pump with Morphine and has used Percocet for breakthrough pain approximately every 4 hours. She states she was never one for exercise and declines attempts to sit on a bedside commode stating just give me the bedpan. Her past medical history includes hypertension, diabetes mellitus, and depression. She takes a calcium channel blocker, an antidepressant, and is insulin-dependent. She doesnt like the food here and her sister brings donuts and snack foods. She hates water and drinks coffee and pop. Her abdomen is slightly distended and she is nauseated. She normally has a BM every 3 days and has not had one since 2 days prior to admission. She uses laxatives and enemas at home at least twice a month. Discussion Negative antecedents for this patient include multiple preexisting diseases in addition to the use of medications known to cause constipation, including opiates. She is not participating in exercise activities, nor is she sitting up to defecate. Her food and fluid choices are poor, with a lack of fiber and a preference for caffeinated drinks. She has a history of constipation and chronic laxative use. It has been 4 days since her last bowel movement. Consequences include a distended abdomen and nausea. It is likely at this point that additional aids (stool softeners, enemas, or manual maneuvers) may be required for the evacuation of stool. Intervention Nursing Diagnosis The contrary case demonstrates antecedents for the nursing diagnosis of constipation related to immobility associated with surgery and pain medications in the postoperative orthopedic population. Immobility affects gastrointestinal (GI) muscle tone and peristalsis (Bisanz, 2007). Positioning may be a problem, depending on the type of orthopedic insult, as upper extremity injuries present a different problem than lower extremity injuries. Upper extremity injuries may limit the use of eating utensils, crutches, or walkers, while lower extremity injuries may limit the ability to sit naturally on a toilet. Mechanical assistance for bowel elimination is provided by sitting or squatting, which increases the intraabdominal pressure necessary for defecation (Bisanz, 2007). There may be significant pain associated with the injury itself, as well as the movement required to go from the bed to the bathroom or bedside commode. Pain control in this population is often managed with opiates. Opiates affect all segments of the bowel, particularly the colon, causing decreased intestinal motility and increased anal sphincter tone, causing dry hardened stool and difficult evacuation (Cadd et al., 2000). The contrary case demonstrates the limitations imposed on all hospital patients. Lack of adequate fluids and fiber due to limited choices or preparation for testing leads to less bulky stools and more difficult passage (Hinrichs, 2001). The toileting regime may be dictated by therapy or tests, which interrupt timing. Additionally, there is an inherent lack of privacy in the hospital setting. This may cause the patient to suppress the urge to defecate, which leads to further buildup of hardened stool (Richmond, 2003). The patients own medical diagnoses and medications further complicate the picture. Nursing Outcomes Nursing outcomes include bowel elimination and symptom control. Bowel elimination is the passage of stool. Indicators include: 1) stool amount for diet, 2) stool soft and formed, 3) ease of stool passage, and 4) complete evacuation (Moorhead, 2008). Behavioral outcomes may be demonstrated by symptom control, defined as personal actions to minimize perceived adverse changes in physical and emotional functioning (Wilkinson, 2005). Indicators for symptom control incorporate behaviors that promote bowel elimination, including adequate fluids, fiber, mobility, and a toileting regime. These could be applied to the contrary case example, Jenny Craig, to intervene in addressing her poor intake, immobility, and interruption of her routine. Overview of Intervention The nursing intervention chosen for this project encompasses the antecedents for normal bowel elimination and includes a section to record the bowel movement. The intervention is a pictorial reminder in the form of an inverted pyramid (see Appendix A). It was developed by this author with the USDA food pyramid in mind (http://www.mypyramid.gov/). Pictures depict the ideal number of servings of fluids, whole grains, and fruits and vegetables to maintain normal bowel elimination. A picture of a toilet reinforces the importance of the toileting regime. Directions on the back give suggestions for each choice (see Appendix B). A section to record the BM (if present), uses the indicators of: 1) soft/hard, 2) easy/difficult, and 3) complete evacuation (Yes/No). It was felt to be too difficult to quantify the amount of stool. Complete evacuation is the sensation that the rectal vault has been emptied. Theoretical Basis The theoretical basis for the intervention is supported by the physiology of normal bowel elimination. Gastrointestinal motility is dependent on contraction of the muscles along the GI tract. Those in the small intestine are continuous while those in the large intestine are periodic, occurring 1 3 times per day. Peristalsis depends on these contractions (Bisanz, 2007). Movement and exercise increase GI tone and thus, the movement of stool through the GI tract. The gastrocolic reflex occurs approximately 5-15 minutes after a meal, moving undigested waste into the large intestines. Nutrients and water are absorbed in the large intestine. Stool that remains too long loses more water and becomes hardened (Bisanz, 2007). Fiber, a natural part of plant products, provides bulk and absorbs water. This results in bulkier, softer stools which move quickly through the intestines with the aid of sufficient fluids (Hinrichs, et al., 2001). When enough stool moves into the sigmoid colon, the sphincters open into the rectal vault. Rectal distention triggers the defecation reflex, which signals the need for a bowel movement. Sitting provides the mechanical assistance needed to increase intraabdominal pressure. The rectocolic reflex then causes opening of the sigmoid valves and vaults and relaxation of the external sphincters for the elimination of stool. If this urge to defecate is ignored, it will be suppressed until more stool enters the rectum. This causes overdistention and hardened stool. This supports the importance of positioning and a toileting regime. Empirical Support A review of research literature on constipation reiterates all of the basic tenets for normal bowel elimination including fluids, fiber, a toileting regime, positioning, and movement. Most of the recent literature focuses on better assessment and prevention of constipation in different populations and looks at various supplements to enhance bowel elimination. A study by Cadd et al. (2000) used a questionnaire to determine if patient preferences were elicited on admission, documented in notes, and included in the bowel care regimen. Data were collected from 100 patients in 2 palliative care units in Australia. Part One of the questionnaire contained general questions while Part Two used followup questions to elicit more detailed information about patient preferences. Of the 69 patients who stated they had been asked about their bowels on admission, 63 stated they had only been asked about bowel function, not management. Further questioning revealed that 23 patients had been asked about their home management but only 15 had continued that bowel routine while hospitalized. Of the total, 59 stated they used diet as integral to their home regimen, including fruits, vegetables, and cereals. Exercise was listed as very important in 21 cases. The study concluded that nurses seem to be following the traditional medical model in assessing bowel function according to frequency. They need to assess and include all facets of bowel management, with patient preferences for fluids and fiber, to achieve optimum bowel management. A study by Grieve (2006) used the Joanna Briggs Institute Practical Application of Clinical Guidance (PACES) program to implement a process of audit and feedback to improve practice in regard to prevention and management of constipation. The focus group was comprised of 43 older adults in a residential aged care facility over a period of time from February 2005 to June 2005. Audits of 83 care staff included documentation of assessment and staff training. Documentation of high fiber meals, fluid intake, regular toileting, and bowel habits was audited. Bowel management criteria were noted as well. An action plan used best practice standards to improve compliance. The results showed a significant improvement in the criteria for staff education in the organization overall (P< 0.00001). Documentation of high fiber meals and fluid intake improved, while regular toileting documentation had mixed results in different areas. The results overall showed a significant improvement in practice in this facility. In a study of a medical elderly unit conducted in 1996 by George, Hayward, Lowe, and Page, 34 patients from 6 wards were studied with regard to a laxative prescribing audit. It was found that laxatives were prescribed according to familiarity, rather than individual assessment. Guidelines were established for the prescription of laxatives, but it was decided to include a focus on dietary issues. A constipation knowledge assessment included assessment of 35 patients. The average score was 40 % for physicians and 33 % for nurses. This resulted in development of a constipation assessment form to help nurses focus on nutritional, educational, psychosocial, and pharmaceutical issues. A study in 1999 by Zernicke and Henderson introduced a constipation risk assessment scale and accompanying bowel management protocol in a 30-bed acute medical ward. Sixty-nine patients were included in the study. The scale consisted of 5 risk factors including inadequate fiber intake, fluid intake, activity, and some medications. Frequency and type of bowel motion was the last category. A score obtained from the risk assessment determined if a patient was high, medium, or low risk. A protocol was used according to risk and included fluids, fiber and referral to a dietitian. The results of the study found that the tools were most effective for those defined as high risk whereas no significant changes were noted in medium or low risk patients. A study of the effectiveness of dietary fiber in prevention of constipation in postoperative orthopedic patients undergoing joint replacement surgery by Oellet, Turner, Pond, Knorr, and McLaughlin (1997) yielded information about bowel elimination patterns. This was part of a larger study with a quasi-experimental design. This study of 81 participants introduced a 20 gm All Bran supplement to the treatment group. All participants drank at least 6 glasses of water per day. In the study group, 55 % of the participants experienced constipation while it was noted in 87.8% of the control group. Patterns of bowel elimination were identified and became part of the conclusions of the study, in addition to the positive effect of fiber on bowel elimination. A study by Kacmaz and Kasikci (2006) examined the effectiveness of planned nursing interventions, including a bran supplement, on the bowel management of older orthopedic patients. Using a quasiexperimental design, 60 non-random patients were recruited from a postoperative orthopedic population in Turkey. Thirty patients assigned to the experimental group received planned interventions including: 1) assessment of bowel habits, 2) planned toileting time, 3) fluid intake > 1500 cc/day, 4) a fiber packet and 5) daily activity therapy. The control group received a water diet for the first day and then progressed to a normal diet with a laxative agent ordered as needed, as per their usual care routine at this hospital. Results showed significant differences in bowel elimination with 50% of those in the control group and 30 % of the experimental group having no BM by the fifth postoperative day. Of those who defecated, 20 % of the control group and 86 % of the experimental group had done so in amounts normal for them. It was concluded that individualized nursing interventions are more effective than routine nursing interventions. An Australian study by Stumm, Thomas, Coombs, Greenhill, and Hay (2001) examined the laxative requirement and bowel function of 89 elderly orthopedic patients. They were compared for intake of 150 ml of pear juice twice daily (n=32); intake of a bran, prune, oat, and apple supplement (n=24); or controls (n=33). Laxative use was not reduced with either treatment but the rate of bowel elimination was greater with the pear juice treatment when the length of stay was > 6 days. The positive response to pear juice (52%) versus fiber (13%) supports pear juice as a natural alternative. A randomized trial in 2006 compared psyllium with a bowel recipe consisting of wheat bran, applesauce, and prune juice (Drewes, Dreadin, Hull, Atnip, Nihira, McIntire, Roshanaravan, & Schaffer, 2006). Of 82 patients, 53 completed the study. Both products improved bowel function, but it was noted that the cost of the bowel recipe was $8.65, while psyllium cost was $16.72 over a 6-week period. The conclusion was that the bowel recipe is an effective and economical stool bulking agent to treat constipation. Comparison of Research In comparing the research, consistent themes emerged. The importance of prevention was noted in all of the studies. Planned nursing interventions included all of the basic components of normal bowel elimination, including fluids, fiber, mobility, and a toileting regime. Audits noted a need for staff training, both for nurses and physicians. Risk assessment was quantified in one study and led to the initiation of a bowel management program. One study introduced fiber and had the unanticipated outcome of describing bowel elimination patterns. Different types of fiber were compared to look at the cost factor in another research study. Fiber was noted to be important in all of the research, although different types and quantities of fiber were mentioned. Fluids are an essential part of bowel elimination, especially in regard to increasing fiber. Most studies mentioned 6-8 glasses per day (1500-2000 cc/day). The importance of a toileting regime was noted in many studies. One of the gaps in the literature is the influence of mobility on bowel elimination. No research was found which quantified how much exercise is necessary or introduced one form of exercise as compared to another in any controlled setting. ANA Scope and Standards The American Nurses Association (ANA) has developed statements describing the scope and standards of practice to outline the expectations of the professional role for registered nurses (American Nurses Association [ANA], 2004). The scope of nursing practice incorporates the science and art of nursing. Using the best available evidence and critical thinking, nurses are not bound to a problem-focused orientation. Nurses view the patient as an individual and focus on the promotion of health and the prevention of disease, illness, and disability (ANA, 2004). This intervention uses scientific evidence and both restorative practices, to modify the impact of disease, and promotive practices, to mobilize patterns of healthy living. Constipation in the orthopedic population can be managed with a holistic approach, incorporating fluids, fiber, activity, and a toileting regime to allow patients some input in managing their own care. The incorporation of patient preferences with scientific evidence supports evidence based practice that is at the core of the profession. Standards reflect the priorities of the nursing profession and describe the responsibilities for which practitioners are responsible. Ongoing assessment and evaluation leads to more comprehensive care for our patients. This intervention supports several of the standards of nursing practice described by the American Nursing Association (ANA, 2004). Assessment is initially required to collect data about the patients normal bowel routine and practices at home. The diagnosis of risk for constipation facilitates planning to prevent complications. The plan has some basic tenets, based on research, but includes patient-specific choices. Outcomes are identified, using the tool, and are quantifiable. Health promotion and health teaching involve collaboration with patients in their care. The intervention for this project was shared with nurses caring for orthopedic patients, which promotes collegiality. Ongoing evaluation uses the information gathered to continually update and refine the tool. Description of the Intervention The intervention consisted of a patient self-management tool in the form of an inverted pyramid. The pyramid was intended as a pictorial reminder of all of the precursors for normal bowel elimination. The front of the tool has 5 sections depicting each of these components with brightly colored pictures (see Figure 1). The back of the tool gives simple directions and suggestions for optimum choices within each of the categories (see Figure 2). The first section of Figure 1 depicts 8 glasses of water (based on an 8 ounce glass) as research suggests that 1500 2000 ccs of fluid per day is sufficient for adequate bowel elimination, in addition to fiber (Hinrichs, Huseboe, Tang, & Titler, 2001). The directions on the back stress the importance of water, juice, and decaffeinated fluids as caffeine is a diuretic that would cause more water absorption in the large intestine and result in hardened stool (Hinrichs, et al., 2001). The next section depicts whole grains. Although the Recommended Daily Allowance (RDA) of whole grains is 6-11 servings (http://www.mypyramid.gov/), 3 servings of whole grain and 5 servings of fruits and vegetables combine for 20 grams of dietary fiber (www.ext.vt.edu/pubs/nutrition.348-050/348-050.html) which falls within the minimum recommendations of 15-26 grams of fiber for bowel elimination (Richmond, 2003). The lower amount was chosen as it is very difficult to find whole grain selections on the standard hospital menu. Additionally it has been noted that introducing large quantities of fiber suddenly can lead to abdominal bloating, flatulence, and nausea (Hicks, 2001). Suggestions for whole grains, on the back of the tool, include oatmeal and whole grain bread. The picture of 5 servings of fruits and vegetables reminds the patient to choose any fruit or vegetable. Fruits and vegetables vary in their fiber content but the directions remind the patient that fresh fruit is preferred over canned for its increased fiber content. This is an oversimplification of the concept of fiber content, but it allows the patient to make choices without using mathematics to quantify fiber in grams. Mobility is represented using the arbitrary number of 4 walking men. This is simply a means for the patient to track the number of times they exercise, including bed exercises, physical therapy, movement to the chair, or ambulation. These are noted in the directions on the back. Exercise helps maintain GI tone and stimulate appetite (Kacmaz & Kasikci, 2007). The picture of the toilet is a simple reminder of the toileting regime. This also reminds the patient to flip to the back of the tool to record a bowel movement. The bowel movement is further delineated by the indicators of 1) soft/hard, 2) easy/difficult, and 3) complete (noting complete evacuation). These indicators represent the Rome III Criteria for constipation (Heitkemper & Wolff, 2007). Implementation of the Intervention An audit tool was used to select patients from the postoperative orthopedic population. This tool (see Appendix A) looked at the diagnosis, postoperative day, medications known to cause constipation and those ordered to relieve constipation. Recorded BM, fluids, diet, and perceived constipation were considered. Patients who were scheduled for discharge were not considered for the intervention. The step by step directions given to the patient for use of the pyramid tool were as follows: 1) This pyramid is a picture of all of the things that are important in order to have a normal bowel movement, with a suggested number of servings. Each set of pictures has some suggestions on the back; 2) Circle each time you have a serving or complete an exercise; 3) The toilet is a reminder of how important it is to position yourself for a bowel movement and to have a routine; 4) If you have a bowel movement, turn the tool over and make an X in each of the categories. If you feel that you have completely emptied your bowels, make an X by the category of complete. After a brief talk with the patient about the problem of constipation in an orthopedic population, we focused on the patients experience with bowel elimination prior to hospitalization and what constituted their normal routine. As they were shown each step of the pictorial pyramid, we talked about how their preferences could fit in to prevention of constipation. For those who had definite regimes with foods or fluids not available from the hospital cafeteria, we discussed the possibilities of these being brought in from home. We incorporated their hospital menu in looking at healthy choices that were available. Mobility was discussed as being something as simple as turning every 2 hours for those who are bedfast to ambulation for those who have more mobility. Patients were advised to sit up for toileting, as best as was possible according to their limitations. This could be on the bedpan, bedside commode, or, optimally, the toilet in the bathroom. Evaluation of the Intervention The effectiveness of the intervention was based on several parameters. The clinical parameters for bowel elimination were the production of a bowel movement and behavioral changes to affect bowel elimination. These were captured on a constipation outcomes assessment tool (see Appendix B) and transferred to a bowel elimination outcomes tool (see Appendix C) for further evaluation. Financial and emotional costs to implement the intervention were considered in order to support a change in practice. Limitations associated with evaluation of this intervention are related to time constraints. Clinical Parameters The nursing outcomes indicators for production of stool were used with patients who had a bowel movement (see Appendix C). Those indicators included 1) stool of adequate amount for diet, 2) stool soft and formed, 3) ease of stool passage, and 4) complete evacuation. It was decided to delete the indicator of stool amount for diet, as in the time spent with patients, prior diet had not been calculated. It has also been noted that patient recall of past events is inferior to actual calculation. The Rome III criteria describe complete evacuation as a sense of completely emptying the rectal vault, which is uniquely quantifiable by the individual (Heitkemper & Wolff, 2007). Of the 8 subjects studied, 4 had a bowel movement. Of those 4 patients, 3 had stool that was described as soft and easy to pass, but 1 of those 3 patients stated elimination was incomplete. The remaining patient described a BM that was hard and difficult to pass but with a sense of complete evacuation. This demonstrates that it is not necessarily true that all soft stool results in complete evacuation or that hard stool will not be completed evacuated. The behavioral indicators measured personal actions for symptom control. This was captured by looking at participation in activities to prevent constipation with adequate consumption of fluids, whole grains, and fruits and vegetables as quantified by the number of servings suggested throughout the literature and incorporated into the interventional tool. Exercise activity was measured by the number of times per day the patients stated they participated in exercise, including physical therapy, range of motion exercises, and ambulation to the chair or further. The data in Appendix C describe the parameters for elimination, both with behavioral choices and production of a bowel movement. The data was gathered approximately 6 hours post-intervention and reflects an adequate participation by all but one participant at that point in the day. The outlier was so severely constipated that the physician had begun to restrict fluids and had ordered laxatives, suppositories, and an enema (see Appendix C, Patient #7). She was selected for the intervention as it was anticipated that constipation would be a problem both while hospitalized and at home. The information given would help prevent further constipation throughout her recuperation. Figure 2 is a graph comparing each individual patients choices regarding antecedents for bowel elimination, using the quantities described in the constipation outcomes assessment tool (see Appendix B). The indicators of BM consistency, BM difficulty, and BM evacuation are depicted in Figures 4a, 4b, and 4c in regard to those who had a bowel movement. It is noted that 50% of the time, patients had a BM post-intervention. Cost Analysis The financial cost to the organization is depicted in Appendix D and was broken down according to CNS time, nursing personnel cost, and cost of materials. The total cost reflects the time for research and development of the tool, which would not be required if this tool were used in the future. The nursing personnel cost would be in copying the article for employees and attendance at inservices or a CE presentation. The materials cost would be the cost of printing the article for nurses and those costs associated with the color printing of the interventional tool. Any food brought from home would affect the financial impact to the patient and would be individual, based on preferences. The intellectual cost for nurses using the tool includes nursing time to study the problem and participation in education. The nurses had already identified constipation as a problem on their unit. This unit has a unit-based educator, who is one of the RNs who had agreed to work on unit-specific topics of education identified by their practice council. They are additionally supported by a Clinical Nurse Specialist. There is a good rapport between this education team, nursing management, and the nurses on the unit. The plan for their PI project is to incorporate a short article on constipation, which introduces the concepts important for bowel elimination, with an action plan for their unit. This plan will be reinforced by inservices. The nurses will take the information to the bedside to assess and educate patients and promote involvement in their own care. Education of the nurses supports buy-in and a sense of comfort speaking to patients and their families. Intellectual cost for patients is based on their level of education and willingness to embrace new information. The tool itself has a simple pictorial form, which eliminates the need to read. However, directions on the back of the tool are written. These would need to be verbally reviewed by the nurse. Emotional cost to both nurses and patients involves difficulty approaching the topic of bowel elimination, both due to myths and stereotypes, and a general feeling of unease talking openly about this subject (Hicks, 2001). This is not a subject for polite conversation among strangers. Gender and culture issues may further complicate the dialogue between nurses and patients. Part of the plan on this orthopedic floor is to introduce the topic on the first postoperative day, during initial assessment, while discussing other bodily functions. The bowel elimination pyramid will be part of the patients bedside book, as part of an introduction and education for orthopedic patients. Limitations Limitations of this project include the time spent with patients on the floor and the ability to initiate changes within the confines of 6 to 8 hours. Bowel elimination involves the absorption of nutrients, fluids, and electrolytes and processing the undigested waste into feces over the course of 18 to 72 hours (Salcido, 2000). The fact that a patient had a BM after introduction of the intervention may be due to chance. The focus of the intervention was to help patients make healthy choices to prevent constipation. They did consume adequate servings of fluids, whole grains, and fruits and vegetables. However, we were unable to incorporate preferences, as menus reflected choices made the day before. Families had not yet been involved to bring favorite healthy foods from home. Exercise included those dictated by the physical therapy regimen and focused on those that patients could manage on their own or with minimal assistance. Equipment and staffing issues had not yet been addressed and continued to impact positioning for optimum bowel elimination. The incorporation of the tool and performance improvement initiatives by nurses on the floor, as part of routine care, would be a better way implement and evaluate this intervention to impact the problem of constipation in this orthopedic population. Conclusion This concept analysis project explored normal bowel elimination and the impact of hospitalization for a population of postoperative orthopedic patients. An intervention was introduced to address the problem of constipation and outcomes were evaluated. Concept Bowel elimination is the evacuation of the end products of digestion, which depends on the adequate functioning of several physiologic processes. Gastrointestinal motility and the defecation reflex are affected by a number of physical, psychological, and iatrogenic factors. Attributes of normal bowel elimination include soft, formed stool that is adequate for diet and passes easily, with a sense of complete evacuation. Precursors to support this include overall good health and an active lifestyle to maintain GI motility. An adequate intake of fluids and fiber promotes bulky, soft stool that passes quickly through the intestines. A toileting regime ensures timing and privacy so that the defecation reflex is not ignored, leading to the buildup of stool. Proper positioning provides mechanical assistance for the evacuation of stool. Problem In a postoperative orthopedic population, issues of forced immobility, pain with movement, use of pain medications, and a change in routine have a negative impact on bowel elimination, leading to a risk for constipation. The intervention that was introduced was a simple pictorial tool that reminded patients of the antecedents for normal bowel elimination, while allowing them choices for self-management. Clinical Nurse Specialist practice is targeted toward quality outcomes for patients, by influencing nurses and organizations across 3 spheres (National Association of Clinical Nurse Specialists, 2004). In the patient/client sphere, the tool supported patient preferences, as they learned options to alter behavior to promote normal bowel elimination. Nurses participated in the process and used current evidence to support a practice change, both with the interventional tool, and their own performance improvement (PI) project. In the organization/system sphere, a cost-effective tool was introduced that would support better patient outcomes and prevent delays in the recovery process. Conclusions The interventional tool had a positive impact on bowel elimination, with 50% of patients having a BM after introduction of the tool. Patients demonstrated choices for their care, which would continue to affect them throughout their recovery. Nurses were able to use the best available evidence and incorporate this tool, in addition to systems changes, to provide better assessment and prevention of constipation for their postoperative orthopedic patient population. Evidence The current literature supports fluids, fiber, mobility, and a toileting regime as important antecedents for bowel elimination. Much of the literature speaks to the problem of constipation and the use of fiber supplements or laxatives to address the problem. No single interventional tool was found to support early assessment and prevention, incorporating patients into the process. Future Recommendations Suggestions for future investigation would be to include an increased focus on patients as partners for care. Bowel elimination is a normal physiologic process that can be supported by incorporating the tenets of normal bowel elimination from the time of admission. Nurses can use the best evidence from the literature to effect a practice change, gathering data and developing and testing tools that allow for a nurse-patient partnership. Organizations can support these efforts by encouraging nurses to participate in bedside research for better patient outcomes. Figure 1    Pyramid Tool (Front) Figure 2  Pyramid Tool (Back) Appendix A Bowel Elimination Audit Tool Pt #UE/LEAgePO DayGenderMeds-CMeds-LBMFluids - aDiet - aMobility - aPerceived Constipation1UE735F++12000NBRPY2LE442M++01500NBRPN3LE642M++02000NBR N4LE523F++01500NBSCY5LE682M++02000NBSCY6LE482F++02000NBSCN7LE423F++0100NBSCY8LE824F++02000NBSCY Note: Audit tool used to capture those patients with risk factors for developing constipation: UE = upper extremity; LE = lower extremity; PO Day = postoperative day; Meds C = medications causing constipation; Meds L = laxative medications; BM is used to describe recorded bowel movement. Antecedents for normal bowel elimination before the intervention include: Fluids a = fluids before intervention; Diet a = diet before intervention; Mobility a = mobility before; N = normal; BR = bedrest; BRP = bathroom privileges. Appendix B Constipation Outcome Assessment Tool Uses tool to record fluids, fruits/vegetables, exercise, bowel movement: 1 2 Records fluids consumed No Yes Records whole grain intake No Yes Records fruit/vegetable intake No Yes Records exercise No Yes Participates in activities to prevent constipation: 1 2 3 4 Consumes fluids (servings) 1-2 3-4 5-6 7-8 Consumes whole grains (servings) 0 1 2 3 Consumes fruits/vegetables (servings) 0-1 2-3 4 5 Exercise activity (x/day) 1 2 3 4 Bowel Elimination: N/A 1 2 Complete Evacuation N/A Incomplete Complete Soft, formed stool N/A Hard Soft Easy stool passage N/A Difficult Easy Appendix C Bowel Elimination Outcomes Tool Pt #FluidsGrainsF/VMobilityPO DayConstipationBMS/HD/EC/I143225YNNNN243222NYSEC332222NYHDC432223YNNNN532122YNNNN633222NNNNN712123YYSEC833114YYSEIN's4No BM4No BM4No BM4Y's4Soft3Easy3Complete3Hard1Difficult1Incomplete1 Note: Antecedents for normal bowel elimination: fluids, grains, fruits/vegetables (F/V), mobility. PO Day = postoperative day; BM = bowel movement. Bowel movement descriptors include: S/H = soft/hard; D/E = difficult/easy; C/I = complete/incomplete. = SHAPE \* MERGEFORMAT  Appendix D COST ANALYSIS Financial: TOTAL: $ 1385.80 CNS time: (Average salary for CNS is $77,279 by 2080 hrs/yr = $37.15/hr) Research 8 hrs X $37.15/hr = $ 297.20 Meeting with CNS/Educator 4 hrs X $3.157/hr = $148.60 Tool development: Audit tool - .5 hr X $37.15/hr = $ 18.58 Interventional tool 4 hr X 37.15/hr = $148.60 Outcome tool - .5 hr X $37.15/hr = $18.58 Dev. of powerpoint 6 hrs x $37.15 = $222.90 CE presentation 1 hr X $37.15/hr = $37.15 TOTAL: $ 891.61 Nursing Personnel: (Average RN salary - $61, 250 2080 hrs/yr = $29.44/hr) RN educator Meetings with student 4 hrs X $29.44/hr = $117.76 Copy article for employees 1 hr X $29.44 = $29.44 Inservices 6 X .5/hr = 3 hrs X $29.44 = $88.32 CE Attendance by RN 8 nurses X 1 hr X $29.44/hr = $235.52 TOTAL: $ 471.04 Materials: Article for nurses 3 pages X $.05/page X 30 nurses = $.45 Audit Tool (10) + Outcomes Tool (10) = 20 X $.10/page = $.20 Intervention Tool 2-sided X $1.00 = $2.00 X 10 tools = $20.00 Plastic covers 10 @ $.25 = $2.50 TOTAL: $ 23.15 References American Gastroenterological Association Medical Position Statement: Guidelines on Constipation. Gastroenterology 2000, 119: 1761-1778. American Nurses Association (2004). Nursing scope and standards of practice (4th ed.). Silver Springs, MD: American Nurses Association. Bisanz, A. (2007). Chronic constipation. American Journal of Nursing, 107(4): Hospital Extra), 72B-72F-H. Cadd, A., Keatinge, D., Henssen, M., O'Brien, L., Parker, D., Rohr, Y., et al. (2000). Assessment and documentation of bowel care management in palliative care: Incorporating patient preferences into the care regimen. Journal of Clinical Nursing, 9(2), 228-235. DeSouza. (2002). Effectiveness of nursing interventions in alleviating perceived problems among orthopaedic patients. Journal of Orthopaedic Nursing, 6(4), 211-219. Electronic reference formats recommended by the American Psychological Association. (2000, October 12). 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Challenges in chronic constipation management. Nurse Practitioner: American Journal of Primary Health Care, 32(4), 36-43. Hicks, A. (2001). The prevention and management of constipation. Journal of Orthopaedic Nursing, 5(4), 208-211. Hinrichs, M., Huseboe, J., Tang, J. H., & Titler, M. G. (2001). Research-based protocol. management of constipation. Journal of Gerontological Nursing, 27(2), 17-28. Kacmaz, Z., & Kasikci, M. (2007). Effectiveness of bran supplement in older orthopaedic patients with constipation. Journal of Clinical Nursing, 16(5), 928-936. Moorhead, S. (2008). Nursing outcomes classification (NOC) (4th ed.). St. Louis, Mo.: Mosby Elsevier. National Association of Clinical Nurse Specialists. (2004). Statement on Clinical Nurse Specialist practice and education. Harrisburg, PA: Author. Richmond, J. (2003). Continuing professional development: Continence. prevention of constipation through risk management. Nursing Standard, 17(16), 39-48. Salcido, R. (2000). Bowel problems in older adults. Topics in Geriatric Rehabilitation, 16(1), 92-96. Vickery, G. (1997). Basics of constipation. Gastroenterology Nursing, 20(4), 125-8 154. Weeks, S. K., Hubbartt, E., & Michaels, T. K. (2000). Keys to bowel success. Rehabilitation Nursing, 25(2), 66-9, 79-80. Wilkinson, J. M., & Wilkinson, J. M. (2005). Prentice hall nursing diagnosis handbook with NIC interventions and NOC outcomes (8th ed.). Upper Saddle River, N.J.: Pearson/Prentice Hall. Zernike, W., & Henderson, A. (1999). Evaluation of a constipation risk assessment scale. International Journal of Nursing Practice, 5(2), 106-109.     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( ( " F4(EMF+*@$??FEMF+@ CompObjiObjInfoWorkbookDOlePres000 Oh+'0@Hdp School of NursingKSUMicrosoft Excel@Xy@ ՜.+,0 PXx  Kent State University'  \pKSU Ba=X<S= <X@"1%Calibri1%Calibri1%Calibri1%Calibri1%Calibri1%Calibri1h8%Cambria1,8%Calibri18%Calibri18%Calibri1%Calibri1%Calibri1<%Calibri1>%Calibri1?%Calibri14%Calibri14%Calibri1 %Calibri1 %Calibri1%Calibri1%Calibri1 %Calibri1%Arial1%Arial1%Arial1%Arial1%Arial1%Arial1%Arial1%Arial1%Arial1%Arial1%Arial1%Arial1%Arial1%Arial1%Arial1%Arial1%Arial"$"#,##0_);\("$"#,##0\)!"$"#,##0_);[Red]\("$"#,##0\)""$"#,##0.00_);\("$"#,##0.00\)'""$"#,##0.00_);[Red]\("$"#,##0.00\)7*2_("$"* #,##0_);_("$"* \(#,##0\);_("$"* "-"_);_(@_).))_(* #,##0_);_(* \(#,##0\);_(* "-"_);_(@_)?,:_("$"* #,##0.00_);_("$"* \(#,##0.00\);_("$"* "-"??_);_(@_)6+1_(* #,##0.00_);_(* \(#,##0.00\);_(* "-"??_);_(@_)                                                                       ff + ) , *     P  P        `            a>  "8 " #  20% - Accent1 20% - Accent2 20% - Accent3 20% - Accent4 20% - Accent5 20% - Accent6 40% - Accent1 40% - Accent2 40% - Accent3 40% - Accent4 40% - Accent5 40% - Accent6 60% - Accent1 60% - Accent2 60% - Accent3 60% - Accent4 60% - Accent5! 60% - Accent6 "Accent1 #Accent2 $Accent3 %Accent4 &Accent5 'Accent6(Bad) Calculation* Check Cell+,-./Explanatory Text 0Good1 Heading 12 Heading 23 Heading 34 Heading 4 5Input6 Linked Cell 7Neutral 8Note 9Output: ;Title <Total= Warning Text`Chart4Sheet1RBSheet2CSheet3"ZR3 A@@  >Pt #FluidsGrainsF/VMobilityPO Day ConstipationYNBMS/HD/EC/ISECHDIN'sY'sNo BMSoftHard DifficultEasyComplete Incomplete" R)yW   "??3` #3$` #3%` Q&` Q'x03)dd23 M NM4 3QQ ; Q ; Q3_43_ O +  MM< 4E4D $% M`%3O&%Q4$% M`%3O&$Q4FA}K3OSK3" 3_ M NM  MM< 444% J~MP 3OG&&Q  BM Difficulty'4% -R(@M 3O &'Q'4% @M 3O&'Q'44eNo BMEasy Difficulte@@?e> )d    dMbP?_*+%&ffffff?'ffffff?(?)?MRoom 204?dXXLetter.HP LaserJet 4000 Series PCL 62xeKkAu4E|c 36AY h!a&3sQ.]A~/\A.[ԥ{2x/}@$(8XNP)Ӽ)Kx| =wa7mYg t:ݨ44{bq6JEp ^ԂSڻ!><AϊI π18a="p $!WwQgoŸ#`FC @{q |g%D8 _,xG`!ȟڌ큾ooM5Q-K.FjrȮ;sRDSvZ;WmuVV$iv:TMOy>3X4Ε"Y]n^].HoPg"dXX333333?333333?U} ` } @ } Column IX ,>???????? ? ?   > > > > >> > > >  > >  > >  > > $???@?@?@?@?~ ?@ ? ? ?  ? ?  ? ? ?$?@?@?@?@?@?~ ?@ ? ? ?  ? ?  ? ? ?$?@?@?@???@?~ ?@ ? ? ?  ? ?  ? ? ?$?@?@?@?@?@?~ ?@ ? ? ?  ? ?  ? ? ?$?@?@?@?@?@?~ ?@ ? ? ?  ?  ?  ? ? ?$?@?@?@?@?@?~ ?@ ? ? ?  ? ?  ? ? ?$?@???@???@?~ ?@ ? ? ?  ?  ?  ? ? ?$? @?@?@?????~ ?@ ? ? ?  ?  ?  ? ? ?$ ??????????????? ??????? @& ?@ %NAZ @& ?@ % NAZ ?& ?@ % NAZ ?& ?@ %NAZ  @& ?@ %YAZ @& ?@ % SAZ ?& ?@ % EAZ ?& ?@ %CAZ  @& ?? % HAZ ?& ?? % DAZ ?& ?? %IAZ ((  j  0NMM? r$]`e   "e??3` #3` #3` #3` #3@=3d23 M NM4 3Q: FluidsQ ;QQ3_ O   MM<4E4 3Q: GrainsQ ;QQ3_ O   MM<4E4 3Q:  F/VQ ;QQ3_ O   MM<4E4 3Q: MobilityQ ;QQ3_ O   MM<4E4D $% M`%3O&Q4$% M`%3O&Q4FA 3OBP 8 3 b#M43*#M! M4% WM3Og&Q  Patient Number'4523  43"  >.3O >% M>3OQ4444% ^MMP 3O &Q F!Antecedents for Bowel Elimination'44eee rj  0NMM?%y*;]`)@0017ggD    dMbP?_*+%&ffffff?'ffffff?(?)?"333333?333333?nU>@7ggD    dMbP?_*+%&ffffff?'ffffff?(?)?"333333?333333?nU>@7ggD 3) | | &WMFCl1,% EMF@F, EMF+@``F\PEMF+"@ @ $@ 0@?!@ @     !" !" !  " !  &% '%     +% % " !% %   % % " !% %   &% ( '% (     /(cPO'3f% (  3f/(cPO'% (  /(cP% % " !% %   Rp Arial p7.)0r G1)0p 3)0p 0p Dݓ0(3 CalibriJ 0\  G\ G p\dv% % % % % % % % " !% % %    Q:   TL2AA LhBM Difficulty  % % % % % " !% % %   % % % " !% % %   Rp Arial 7.)0 G1)0 3)0 0 Dݓ0(3 CalibriJ 0\  G\ G \dv% % % % % % % % " !% % %   g  TljAAjLXNo BM  % % % % % " !% % %   % % % % % % % " !% % %   o $  TdrAArLTEasy % % % % % " !% % %   % % % % % % % " !% % %   j  TnAAn L`Difficult % % % % % " !% % %   % % % " !% % %   &% ( % (     +% % ( % " !  " !  " F4(EMF+*@$??FEMF+@     '' ' ,--  --'-- ,--'-- ,--   OQd3f- 3f OQd-  Qd--'-- , Arial-"System-------'--- ,:Q   2  BM Difficulty  -----'--- ,---'--- , Arial--------'--- ,g 2 jNo BMF  -----'--- ,-------'--- ,$ o  2 rEasy -----'--- ,-------'--- ,j 2 n Difficultu -----'--- ,---'--- ,--  ---' ' 'NANISummaryInformation(DocumentSummaryInformation8@_1268555853!Fp(|P!(|Ole  Sheet1Sheet2Sheet3Chart4  WorksheetsCharts !FMicrosoft Office Excel ChartBiff8Excel.Chart.89q Oh+'0@Hdp EPRINTxCompObjiObjInfoWorkbookfDl!! 3) EMFx&U"F, EMF+@XXF\PEMF+"@ @ $@ 0@?!@ @     !" !" !  Rp[ Arial *7.)0*&1)0* 03)0* 0* ݓ0)S 5iJ 0`a &a s!*1)0dv% % % % % Rp Arial +7.)0+&Z1)0+ 03)0+ 0+ ݓ0)S 5iJ 0` '& 's!+1)0dv% % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % % " !%    &% '%   +!! % % % " !% % %    % % % " !% % %   !! &% ( '% (   /(w@ @ '3f% ( /(w@8 @'% ( /(w@ 8% % % " !% % %    % % % % % % % % " !% % %   sRa  Tz5UU@@zLhBM Consistencyw.wee\.\7\e\Z% % % % % " !% % %    % % % " !% % %    % % % % % % % % " !% % %   Z   Tls UU@@sLXNo BMH8CS% % % % % " !% % %    % % % % % % % " !% % %   -  TdUU@@LTSoftC8% % % % % " !% % %    % % % % % % % " !% % %    =  TdUU@@LTHardH8!8% % % % % " !% % %    % % % " !% % %    &% ( % (   +!! % % ( % "  !  " !  ( ( " F4(EMF+*@$??FEMF+@       !"#5&'()*+,-./0123PQ789:;<=>?@ABCDEFGHIJKLMNOmzSTUVWXYZ[\]^_`abcdefghijklopqrstuvwxy}~  \pKSU Ba= %;= <X@"1%Calibri1%Calibri1%Calibri1%Calibri1%Calibri1%Calibri1h8%Cambria1,8%Calibri18%Calibri18%Calibri1%Calibri1%Calibri1<%Calibri1>%Calibri1?%Calibri14%Calibri14%Calibri1 %Calibri1 %Calibri1%Calibri1%Calibri1 %Calibri1%Arial1%Arial1%Arial1%Arial1%Arial1%Arial1%Arial1%Arial1%Arial1%Arial1%Arial1%Arial1%Arial1%Arial1%Arial1%Arial1%Arial"$"#,##0_);\("$"#,##0\)!"$"#,##0_);[Red]\("$"#,##0\)""$"#,##0.00_);\("$"#,##0.00\)'""$"#,##0.00_);[Red]\("$"#,##0.00\)7*2_("$"* #,##0_);_("$"* \(#,##0\);_("$"* "-"_);_(@_).))_(* #,##0_);_(* \(#,##0\);_(* "-"_);_(@_)?,:_("$"* #,##0.00_);_("$"* \(#,##0.00\);_("$"* "-"??_);_(@_)6+1_(* #,##0.00_);_(* \(#,##0.00\);_(* "-"??_);_(@_)                                                                       ff + ) , *     P  P        `            a>  "8 " #  20% - Accent1 20% - Accent2 20% - Accent3 20% - Accent4 20% - Accent5 20% - Accent6 40% - Accent1 40% - Accent2 40% - Accent3 40% - Accent4 40% - Accent5 40% - Accent6 60% - Accent1 60% - Accent2 60% - Accent3 60% - Accent4 60% - Accent5! 60% - Accent6 "Accent1 #Accent2 $Accent3 %Accent4 &Accent5 'Accent6(Bad) Calculation* Check Cell+,-./Explanatory Text 0Good1 Heading 12 Heading 23 Heading 34 Heading 4 5Input6 Linked Cell 7Neutral 8Note 9Output: ;Title <Total= Warning Text`Chart3Sheet1ASheet2(CSheet3"ZR3 A@@  >Pt #FluidsGrainsF/VMobilityPO Day ConstipationYNBMS/HD/EC/ISECHDIN'sY'sNo BMSoftHard DifficultEasyComplete Incomplete" R)yW   "??3` #3$` #3%` Q&` Q'@s03)dd23 M NM4 3QQ ; Q ; Q3_43_ O +  MM< 4E4D $% M`%3O&%Q4$% M`%3O&$Q4FAfK3OL K3" 3_ M NM  MM< 444% )JMMP 3OW&&Q  BM Consistency'4% @M 3O&'Q'44eNo BMSoftHarde@@?e> )d    dMbP?_*+%&ffffff?'ffffff?(?)?MRoom 204?dXXLetter.HP LaserJet 4000 Series PCL 62xeKkAu4E|c 36AY h!a&3sQ.]A~/\A.[ԥ{2x/}@$(8XNP)Ӽ)Kx| =wa7mYg t:ݨ44{bq6JEp ^ԂSڻ!><AϊI π18a="p $!WwQgoŸ#`FC @{q |g%D8 _,xG`!ȟڌ큾ooM5Q-K.FjrȮ;sRDSvZ;WmuVV$iv:TMOy>3X4Ε"Y]n^].HoPg"dXX333333?333333?U} ` } @ } Column IX ,>???????? ? ?   > > > > >> > > >  > >  > >  > > $???@?@?@?@?~ ?@ ? ? ?  ? ?  ? ? ?$?@?@?@?@?@?~ ?@ ? ? ?  ? ?  ? ? ?$?@?@?@???@?~ ?@ ? ? ?  ? ?  ? ? ?$?@?@?@?@?@?~ ?@ ? ? ?  ? ?  ? ? ?$?@?@?@?@?@?~ ?@ ? ? ?  ?  ?  ? ? ?$?@?@?@?@?@?~ ?@ ? ? ?  ? ?  ? ? ?$?@???@???@?~ ?@ ? ? ?  ?  ?  ? ? ?$? @?@?@?????~ ?@ ? ? ?  ?  ?  ? ? ?$ ??????????????? ??????? @& ?@ %NAZ @& ?@ % NAZ ?& ?@ % NAZ ?& ?@ %NAZ  @& ?@ %YAZ @& ?@ % SAZ ?& ?@ % EAZ ?& ?@ %CAZ  @& ?? % HAZ ?& ?? % DAZ ?& ?? %IAZ ((  j  0NMM? r$]`o   "o??3` #3` #3` #3` #3@=3d23 M NM4 3Q: FluidsQ ;QQ3_ O   MM<4E4 3Q: GrainsQ ;QQ3_ O   MM<4E4 3Q:  F/VQ ;QQ3_ O   MM<4E4 3Q: MobilityQ ;QQ3_ O   MM<4E4D $% M`%3O&Q4$% M`%3O&Q4FA 3OBP 8 3 b#M43*#M! M4% WM3Og&Q  Patient Number'4523  43"  >.3O >% M>3OQ4444% ^MMP 3O &Q F!Antecedents for Bowel Elimination'44eee rj  0NMM?%y*;]`p   "p??3` #3` #3` #3s@=3d23 M NM4 3QQ ; Q ; Q3_43_ O +  MM< 4E4D $% M`%3O&Q4$% M`%3O&Q4FA3 3OX 3" 3_ M NM  MM< 444% ,MPMP 3Og&Q  BM Consistency'44eee rj  0NMM?<?S ]` q   " q??3` #3` #3 ` #3!?y@=3d23 M NM4 3QQ ; Q ; Q3_43_ O +  MM< 4E4D $% M`%3O&!Q4$% M`%3O& Q4FA 3OT 3" 3_ M NM  MM< 444% MMP 3OS&Q  BM Difficulty'44eee rj  0NMM?SlTi]`q   "q??3` #3` #3"` #3#x@=3d23 M NM4 3QQ ; Q ; Q3_43_ O +  MM< 4E4D $% M`%3O&Q4$% M`%3O&"Q4FA 3OR 3" 3_ M NM  MM< 444% BMMP 3Ob&#Q  BM Evacuation'44eee >)@0017ggD    dMbP?_*+%&ffffff?'ffffff?(?)?"333333?333333?nU>@7ggD    dMbP?_*+%&ffffff?'ffffff?(?)?"333333?333333?nU>@7ggD OlePres000%SummaryInformation(DocumentSummaryInformation8"@_1268555852#!FP!(|0%(|)3)b n n &WMFCblW0,% EMF@F, EMF+@``F\PEMF+"@ @ $@ 0@?!@ @     !" !" !  " !  &% '%     +% % " !% %   % % " !% %   &% ( '% (     /(_PO'3f% (  3f/(_PO'% (  /(_P% % " !% %   Rp Arial p7.)0r P1)0p 3)0p 0p Dݓ0(3 CalibriJ 0  P B *p\dv% % % % % % % % " !% % %    a:   T\2AALhBM Consistency % % % % % " !% % %   % % % " !% % %   Rp Arial 7.)0 P1)0 3)0 0 Dݓ0(3 CalibriJ 0  P B *\dv% % % % % % % % " !% % %   c  TlfAAfLXNo BM  % % % % % " !% % %   % % % % % % % " !% % %   q $  TdtAAtLTSoft % % % % % " !% % %   % % % % % % % " !% % %   j  TdnAAnLTHard  % % % % % " !% % %   % % % " !% % %   &% ( % (     +% % ( % " !  " !  " F4(EMF+*@$??FEMF+@     '' ' ,--  --'-- ,--'-- ,--   OQ`3f- 3f OQ`-  Q`--'-- , Arial-"System-------'--- ,:a   2 BM Consistency -----'--- ,---'--- , Arial--------'--- ,c 2 fNo BMF  -----'--- ,-------'--- ,$ q  2 tSoft -----'--- ,-------'--- ,j  2 nHard  -----'--- ,---'--- ,--  ---' ' 'NANISchool of NursingKSUMicrosoft Excel@Xy@ ՜.+,0 PXx  Kent State University' Sheet1Sheet2Sheet3Chart3  WorksheetsChartsOle 'EPRINT "63CompObj(iObjInfo!%*l!!=" EMF3~U"F, EMF+@XXF\PEMF+"@ @ $@ 0@?!@ @     !" !" !  Rpv Arial 7.)0&1)0 03)0 0 ݓ0)S 5iJ 0`R &R !1)0dv% % % % % RpArial <7.)0>&<1)0< 03)0< 0< ݓ0)S 5iJ 0` &  !<1)0dv% Rp Arial `07.)0b0&Y1)0`0 03)0`0 0`0 ݓ0)S 5iJ 0`x &x !`01)0dv% % % % % % % % % % % % % % % % % % % % " !%   (&% '%   +!!% % % " !% % %   ('% ( % (   V0   &% % % % " !% % %     [l  6 y6 y6 o6 o6 f6 f6 \6 \6 % % % " !% % %   ( [l&% (   6 6 66% % % " !% % %   (% % % " !% % %   !!% % % " !% % %    % % % " !% % %    &% ( '% (   V0*Wy/\t\t//\V0W\\\V0!ap&fkfk&&fV0afffV0agfbfbfV0afffV0 t]  yX yX   yV0 a  f f   f'% ( V0oatffttfV0a:f5f5fV0fjkookkoV0j1o,o,oV0]jboobboV0a' f" f" fV0S j X o o X X oV0 a  f f   f'% ( V0joooV00j5ozoz55oV0joooV0'jv,oqoq,,oV0tyyyV0 jl " og og " " oV0 t  y y   yV0 tc  y^ y^   y'% ( V0jHoCoCoV0ujzoozzoV0j?o:o:oV0ljqooqqoV0j6o1o1oV0b j g o o g g oV0 j-  o( o(   oV0Y t ^ y y ^ ^ y% % % " !% % %    % % % " !% % %   (&% (   6% 66y6y6o6o6f6f6\6\66 6w6w6n6n6e6e 6 \ 6\  6 % % % % % % % % " !% % %   I 3  Tm UU@@m!LAntecedents for Bowel Elimination`T.MMMTMT.M&.T6&dToM&&\&&{&TM.&TT% % % % % " !% % %   (% % % " !% % %   (% % % % " !% % %   (  TT[UU@@[LP0%T`m UU@@mLT0.5%%TTQUU@@QLP1%T`mUU@@mLT1.5%%TTGUU@@GLP2%T`m UU@@mLT2.5%%TT>UU@@>LP3%T`mUU@@mLT3.5%%TT4~UU@@4LP4%T`mUU@@mLT4.5%%% % % " !% % %   (% % % " !% % %   (  TTUU@@LP1%TT#GUU@@#LP2%TTUU@@LP3%TT>UU@@LP4%TTUU@@LP5%TT 5 UU@@ LP6%TT  UU@@ LP7%TT + UU@@ LP8%% % % " !% % %   (% % % % % % % % " !% % %   yZ  T7LUU@@7LhPatient Number@5 5; E;U;5%% % % % % " !% % %   (% '% (   + [k% % % " !% % %    \k% % % " !% % %    \k&% ( '% (   +2 {Z  Tpk kUU@@k kLXFluids)%%"% % % " !% % %    \k% % % " !% % %    \k&% ( '% (   +2 Z  Tpk /UU@@k LXGrains4%%"% % % " !% % %    \k% % % " !% % %    \k&% ( '% (   +2 MZ u T`k = UU@@k =LTF/V)-% % % " !% % %    \k% % % " !% % %    \k&% ( '% (   +2 Z  T|k LUU@@k L\Mobility7%%!% % % " !% % %    \k% % % " !% % %   (% % % " !% % %   (&% ( % (   +!!% % ( % " (!  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( ( ( " F4(EMF+*@$??FEMF+@  !FMicrosoft Office Excel ChartBiff8Excel.Chart.89q Oh+'0@Hdp School of NursingKSUMicrosoft Excel@Xy@ WorkbookR5OlePres000$&+$SummaryInformation(',DocumentSummaryInformation80@  \pKSU Ba==% :] 8X@"1%Calibri1%Calibri1%Calibri1%Calibri1%Calibri1%Calibri1h8%Cambria1,8%Calibri18%Calibri18%Calibri1%Calibri1%Calibri1<%Calibri1>%Calibri1?%Calibri14%Calibri14%Calibri1 %Calibri1 %Calibri1%Calibri1%Calibri1 %Calibri1%Arial1%Arial1%Arial1%Arial1%Arial1%Arial1%Arial1%Arial"$"#,##0_);\("$"#,##0\)!"$"#,##0_);[Red]\("$"#,##0\)""$"#,##0.00_);\("$"#,##0.00\)'""$"#,##0.00_);[Red]\("$"#,##0.00\)7*2_("$"* #,##0_);_("$"* \(#,##0\);_("$"* "-"_);_(@_).))_(* #,##0_);_(* \(#,##0\);_(* "-"_);_(@_)?,:_("$"* #,##0.00_);_("$"* \(#,##0.00\);_("$"* "-"??_);_(@_)6+1_(* #,##0.00_);_(* \(#,##0.00\);_(* "-"??_);_(@_)                                                                       ff + ) , *     P  P        `            a>  "8 "  20% - Accent1 20% - Accent2 20% - Accent3 20% - Accent4 20% - Accent5 20% - Accent6 40% - Accent1 40% - Accent2 40% - Accent3 40% - Accent4 40% - Accent5 40% - Accent6 60% - Accent1 60% - Accent2 60% - Accent3 60% - Accent4 60% - Accent5! 60% - Accent6 "Accent1 #Accent2 $Accent3 %Accent4 &Accent5 'Accent6(Bad) Calculation* Check Cell+,-./Explanatory Text 0Good1 Heading 12 Heading 23 Heading 34 Heading 4 5Input6 Linked Cell 7Neutral 8Note 9Output: ;Title <Total= Warning Text`%Chart1Sheet113Sheet2o4Sheet3"ZR3 A@@  'Pt #FluidsGrainsF/VMobilityPO Day ConstipationYNBMS/HD/EC/ISECHDI Ry   "??3` #3` #3` # ` # 03/dd23 M NM4 3Q: FluidsQ ;QQ3_ O   MM<4E4 3Q: GrainsQ ;QQ3_ O   MM<4E4 3Q:  F/VQ ;QQ3_ O   MM<4E4 3Q: MobilityQ ;QQ3_ O   MM<4E4D $% M`%3O&Q4$% M`%3O&Q4FA mu  3OF9 3 b#M43*#M! 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