Basic Human Needs Bowel Elimination

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Basic Human NeedsBowel Elimination
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Bowel Elimination

• GI Tract is a series of hollow mucous membrane
  lined muscular organs
• Purpose is to absorb fluids nutrients, prepare
  food for absorption provide storage for feces

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GI Tract Anatomy

• Mouth
• Esophagus
• Stomach
• Small Intestine
• Large Intestine
• Rectum

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Colon

• 3 Divisions Ascending, Transverse, Descending
• Colon Functions Absorption, Protection,
  Secretion, Elimination (stool and flatus)

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Flatus Formation

• Air swallowing
• Diffusion of gas from bloodstream into intestines
• Bacterial action on unabsorbable CHO (Beans)
• Fermentation of CHO (cabbage, onions
• Can stimulate peristalsis
• Adult forms 400-700 ml of flatus daily

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Factors Affecting Bowel Elimination

• Age
• Infection
• Diet
• Fluid Intake
• Physical Activity
• Psychological factors
• Personal Habits

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Factors Affecting Bowel Elimination

• Position during Defecation
• Pain
• Surgery and Anesthesia
• Medications

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Common Bowel Elimination Problems

• Constipation
• Impaction
• Diarrhea
• Incontinence
• Flatulence
• Hemorrhoids

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Constipation

• More of a symptom than a disorder
• Decrease in frequency of BM
• Straining pain on defecation is associated
  symptoms(Valsalva maneuver)
• Can be significant heath hazard (increase ICP,
  IOP, reopen surgical wounds, cause trauma,
  cardiac arrhythmias)

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Impaction

• Results from unrelieved constipation
• Collection of hardened feces wedged into rectum
• Can extend up to sigmoid colon
• Most at risk depilated, confused, unconscious
  (all are at risk for dehydration)

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Impaction

• When a continuous ooze of diarrheal stool
  develops, impaction should be suspected
• Associated S/S Loss of appetite, abdominal
  distention, cramping, rectal pain

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Diarrhea

• Increase in number of stools the passage of
  liquid, unformed stool
• Symptom of disorders affecting digestion,
  absorption, secretion of GI tract
• Intestinal contents pass through small large
  intestines too quickly to allow for usual
  absorption of water nutrients

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Diarrhea

• Irritation can result in increased mucus
  secretion, feces become too watery, unable to
  control defecation
• Excess loss of colonic fluid can result in
  acid-base imbalances or fluid/electrolyte
  imbalances
• Can also result in skin breakdown

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Conditions that cause Diarrhea

• Emotional Stress
• Intestinal Infection (Clostridium difficile)
• Food Allergies
• Food Intolerance
• Tube Feedings (Enteral)
• Medications
• Laxatives
• Colon Disease
• Surgery

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Incontinence

• Inability to control passage of feces and gas
  from the anus
• Caused by conditions that create frequent, loose,
  large volume, watery stools or conditions that
  impair sphincter control or function

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Flatulence

• Gas accumulation in the lumen of intestines
• Bowel wall stretches and distends
• Common cause of abdominal fullness, pain,
  cramping
• Gas escapes through mouth (belching), or anus
  (flatus)

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Hemorrhoids

• Dilated, engorged veins in the lining of the
  rectum
• External (Clearly visible) or Internal
• Caused by straining, pregnancy, CHF, chronic
  liver disease

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Clicker Question

• 1. A newly admitted client states that he has
  recently had a change in medications and reports
  that stools are now dry and hard to pass. This
  type of bowel pattern is consistent with
• A. Abnormal defecation
• B. Constipation
• C. Fecal impaction
• D. Fecal incontinence

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Bowel Diversions

• Certain diseases cause conditions that prevent
  normal passage of feces through rectum
• Creates need for temporary or permanent
  artificial opening (stoma) in the abdominal wall

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Bowel Diversions

• Surgical openings (ostomy) are most commonly
  formed in the ileum (ileostomy) or the colon
  (colostomy)
• Incontinent ostomy- need to wear appliance pouch
• Continent ostomy- have control through use of
  ostomy cap

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Incontinent Ostomy

• Location of ostomy determines consistency of
  stool
• Ileostomy bypasses the entire large intestine,
  stools are frequent watery
• Ascending colostomy- liquid stool
• Sigmoid colostomy-most like normal stool

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Incontinent Ostomies

• Loop colostomy- temporary, usually done on
  transverse colon
• 2 openings through stoma, proximal loop for
  stool, distal loop for mucus
• End colostomy- one stoma formed from the proximal
  end of the bowel with the distal portion removed
  or sewn shut (Hartmanns Pouch)

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Incontinent Ostomies

• End colostomy usually done for colorectal cancer
• Ruptured diverticulum- temporary end colostomy
  with a Hartmanns Pouch
• Double barrel colostomy- Bowel is surgically
  severed, 2 ends are brought out onto abdomen with
  2 distinct stomas (proximal distal)

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Continent Diversions

• Ileoanal reservoir- restorative proctocolectomy,
  no outward stoma, no pouch wearing, clients have
  internal pouch created from the ileum
• Ileal pouches constructed in various
  configurations (S,J,W)
• End of the pouch is sewn or anastamosed to the
  anus

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Continent DiversionsIleoanal Reservoir

• Several stages to surgery to create pouch
• May need temporary ostomy to allow time for pouch
  to heal
• Kegel exercises to increase pelvic floor muscle
  tone

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Continent Diversions

• Kock Continent Ileostomy-Internal reservoir or
  pouch is created using piece of small intestine
• Stoma brought out low on abdomen, end of internal
  part in pouch is a one way nipple valve to
  promote continence
• Valve only allows fecal contents to drain when an
  external catheter is place in stoma, no pouch
  required

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Ostomy Nursing Considerations

• Patient Education
• Care of skin stoma, appliance selection and use
• Body Image considerations
• Support groups (UOA)
• Enterostomal nursing- specialty within profession

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Nursing ProcessAssessment

• Nursing History
• Physical Assessment
• Lab Tests
• Fecal characteristics
• Diagnostic evaluation- Endoscopy, Colonoscopy

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Nursing Diagnosis

• Bowel Incontinence
• Constipation
• Diarrhea
• Impaired Skin Integrity
• Body Image Disturbance
• Altered bowel elimination
• Pain

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ImplementationPromoting Normal Defecation and
Acute Care Management

• Positioning of patient-squatting
• Positioning on bedpan
• Use of cathartics, laxatives
• Anti-diarrheal agents
• Enemas
• Digital removal of stool
• Ostomy care
• Fecal Incontinence Devices
• Fiber Fluids

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Common Laxatives Cathartics

• Metamucil-bulk forming
• Colace, Surfak-emollient or wetting agent
• Fleets, MOM. Mag Sulfate-saline agent
• Dulcolax, Ex-Lax, Castor oil- stimulant cathartic
• Haleys MO, mineral oil- Lubricant

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Enemas

• Cleansing enema
• Tap water
• Normal saline
• Hypertonic Solutions (Fleets enema)
• Soapsuds
• Oil Retention
• Medicated enemas (Kayexalate, Lactulose)
• Administering a Cleansing enema PP pg. 1200-1201

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Nasogastric Tubes

• Decompress GI tract in surgery, infection of GI
  tract, trauma to GI tract, conditions where
  peristalsis is absent
• N/G tube purposes- decompression, feeding,
  compression, lavage
• Pliable tube inserted through nasopharynx into
  stomach
• Uncomfortable insertion

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Nasogastric Tubes

• Types Levin single lumen, different sizes used
  for feeding or decompression
• Salem Sump Most preferable for decompression,
  dual lumen, one for removal of gastric contents,
  one as an air vent, hooked to suction to achieve
  decompression

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Care of Nasogastric Tubes

• Confirm placement after insertion
• HOB at 30 degrees unless ordered otherwise
• Mark point where tube exits nose (AACN 2005)
• Tape tube securely to nose
• Tube Irrigation
• Nasal skin care
• Frequent oral hygeine
• Assess for abdominal distention
• Suction settings

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Restorative Care

• Bowel training
• Maintenance of proper fluid food intake
• Promotion of regular exercise
• Promotion of comfort
• Maintenance of skin integrity
• Promotion of self concept

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Clicker Question

• 2. To maintain normal elimination patterns in the
  hospitalized client, you should instruct the
  client to defecate 1 hour after meals because
  
• A. The presence of food stimulates peristalsis.
• B. Mass colonic peristalsis occurs at this time.
• C. Irregularity helps to develop a habitual
  pattern.
• D. Neglecting the urge to defecate can cause
  diarrhea.

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