Bowel Elimination

1
Bowel Elimination

• NUR 115
• October 9, 2007
• Lee Ann Mitchell, MSN

2
Objectives

• Identify variables that influence bowel
  elimination.
• Identify appropriate nursing interventions to
  promote bowel elimination.
• Discuss nursing interventions for the incontinent
  patient.
• Discuss nursing interventions for the patient
  with a bowel diversion.

3
AP review

• The large intestine is the primary organ of bowel
  elimination
• Approximately 5 feet long, beginning at the
  ileocecal valve and ending at the anus
• About 1500ml of chyme enters the large intestine
  each day
• 800-1000ml of fluid is reabsorbed, resulting in
  formed, semisolid feces
• The process of bowel elimination is called
  defecation.
• Peristalsis contractions of the muscles of the
  long intestine is controlled by the autonomic
  nervous system
• Mass peristaltic sweeps occur 1 to 4 times in 24
  hours, generally after eating.

4
AP review

• Defecation is generally painless
• Valsalva maneuver the act of bearing down
• May elevate blood pressure
• May stimulate the vagus nerve
• Terms to know
• Diarrhea excessively liquid stool
• Constipation dry, hard stool
• Hemorrhoids abnormally distended veins in the
  rectum

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Factors affecting bowel elimination

• Age
• Infants stool characteristics are diet
  dependent, no voluntary control
• Toddlers ability for voluntary control develops
  between 18 and 24 months
• School-age children to adults patterns vary
  greatly
• Older adult constipation is often a chronic
  problem
• Daily patterns
• Individualized patterns related to frequency,
  timing, position, and place
• Sitting or squatting facilitates defecation as
  this increases abdominal pressure

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Factors affecting bowel elimination

• Dietary intake
• High-fiber diet
• 2000 to 3000 mls of fluid daily
• Constipating foods cheese, lean meat, eggs
• Laxative effect certain fruits and veggies
• Gas-producing onions, cabbage, beans
• Lifestyle
• Normal life process
• Preoccupation with bowel elimination
• dirty process

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Factors affecting bowel elimination

• Activity
• Exercise improves GI motility and muscle tone
• Immobility decreases GI motility and muscle tone
• Psychological variables
• Anxiety seems to directly effect GI motility in
  some and may result in diarrhea
• Chronic worriers and controlling personalities
  may experience frequent constipation
• Diagnostic studies
• Fasting, stress and bowel cleansing can all
  interfere with normal patterns of elimination

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Factors affecting bowel elimination

• Pathologic conditions
• Bowel disturbances may be the first sign of a
  disease process
• Causes of diarrhea include diverticulitis,
  infection, malabsorption syndromes, cancer,
  diabetic neuropathy, and food poisoning
• Causes of constipation include disorders of the
  colon or rectum, spinal cord injury, and
  megacolon
• Intestinal obstructions may be mechanical or
  functional
• Mechanical tumor, hernia, adhesions
• Functional muscular dystrophy, diabetes,
  Parkinsons

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Factors affecting bowel elimination

• Medications
• Constipating medications include opioids,
  antacids, iron, and anticholinergics
• Medications that cause diarrhea as a side effect
  include antibiotics
• Several medications can affect the appearance of
  the stool.
• Surgery and anesthesia
• Paralytic ileus the temporary cessation of
  peristalsis after bowel manipulation
• Peristalsis may also be inhibited by general
  anesthesia

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Assessment

• Patient history
• You must take a complete history, even though
  most patients will be uncomfortable discussing
  their bowel habits!
• Inspection
• Peristalsis is generally not visible
• Is the abdomen distended? Are there any visible
  masses?
• Are there any hemorrhoids or areas of s
• Auscultation
• Are bowel sounds present in all 4 quadrants?
• Hypoactive, hyperactive, absent

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Assessment

• Percussion
• Do you hear tympany over the abdomen and stomach?
• What might cause you to hear a dull sound?
• Palpation
• Is the abdomen soft or hard? Tender or nontender?
  Distended or non-distended? Do you feel any
  masses?
• Can you feel any masses or polyps in the rectum?
• Stool characteristics
• Table 44-1 page 1562
• Keep a record at the bedside.

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Assessment

• Diagnostic studies
• Specimen collection
• Occult blood page 1563
• Endoscopy Box 44-2, page 1565
• Radiography

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Diagnosis

• Bowel elimination as the problem
• Example, ostomy management
• Bowel elimination as the etiology
• Example, fluid volume deficit

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Outcome identification

• Examples
• See page 1567

15
implementation

• Promote regular bowel habits
• Timing patients usual time every day
• Positioning sitting upright
• Privacy always respect this right unless
  patient is unstable
• Nutrition high fiber diet, 2000-3000ml of
  fluid daily
• Exercise improves motility and aids defecation

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implementation

• Constipation
• Risk factors
• Bedrest
• Constipating medications
• Reduced fluid intake
• Reduced bulk in the diet
• Depression
• CNS disease
• Painful, local lesions
• Nutrition
• A high-fiber diet, adequate intake and exercise
  is as effective in controlling constipation as
  medication
• Laxatives and cathartics
• For occasional use only overuse is most common
  cause of constipation!

17
implementation

• Diarrhea
• A protective response when caused by intestinal
  irritants
• If untreated, loss of fluids and electrolytes can
  be life-threatening.
• Nursing measures
• Assist with toileting promptly
• Remove the cause if possible
• Rule out impaction
• Protect the skin around the anus
• Promote return of normal bowel flora
• Nutrition
• Educate on safe food handling and consumption

18
implementation

• Diarrhea
• Treatment
• Rehydration
• Medications, especially for chronic diarrhea
• Eliminate the cause
• Flatulence
• Avoid gas-producing foods
• Ambulation promotes peristalsis and the passage
  of flatus

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implementation

• Enema
• Instilling a solution into the large intestine,
  generally to remove feces.
• Three types
• Cleansing
• Retention
• Return-flow
• Cleansing enemas are used to
• Relieve constipation or fecal impaction
• Prevent involuntary escape of feces during
  surgery

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implementation

• Cleansing enemas cont.
• Promote visualization of the intestinal tract
  during diagnostic testing
• As part of a bowel training program
• Common solutions used for cleansing enemas
  include tap water, normal saline, soap suds, and
  hypertonic (Fleets).
• Tap water, normal saline and soap suds enemas use
  large volumes of solution and result in rapid
  emptying of the colon.
• Hypertonic solutions are small volumes that draw
  water into the colon to stimulate the defecation
  reflex.

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implementation

• Retention enemas have different preparations for
  different purposes
• Oil-retention used to lubricate the stool and
  mucosa
• Carminative - promote passage of flatus and
  relieve abdominal distention
• Medicated deliver medications that are absorbed
  by the rectal mucosa
• Return-flow enemas are used to expel flatus
• Procedure show and tell

22
implementation

• Rectal suppositories a solid substance or
  medication shaped for easy insertion into a body
  cavity and melt at body temperature.
• Oral intestinal lavage may also be called a
  bowel prep. The patient drinks a solution like
  Colyte that stimulates peristalsis, resulting in
  emptying of the colon.
• Digital removal of stool
• Fecal impaction occurs when fecal material forms
  a hardened mass in the rectum.
• Manual removal of the stool is performed with a
  doctors order after other efforts to remove the
  impaction have failed. See page 1576

23
implementation

• Bowel incontinence
• The inability of the anal sphincter to control
  the discharge of feces and flatus.
• Seldom life-threatening, may be very
  psychologically devastating.
• Nursing measures include
• Toileting the patient when incontinence is likely
  to occur
• Protecting the skin
• Changing linens as needed
• Applying fecal incontinence pouch
• Implementing a bowel training program

24
implementation

• Managing a nasogastric tube
• NG tubes are used to decompress or drain the
  stomach and to allow the GI tract to rest after
  surgery
• NG tubes are flexible with either a single or
  double lumen. They are inserted through the
  nasopharynx into the stomach.
• The NG tube is hollow, allowing gastric
  secretions to be removed and other solutions
  instilled into the stomach.
• Salem sump NG tubes are double-lumen and are the
  safest choice for continuous suction.
• Placement should be verified prior to the
  instillation of fluid or medications.
• The skin and oral mucosa need to be protected
  from breakdown.

25
implementation

• Bowel diversions
• These patients have undergone surgery to create
  an opening in the abdominal wall for fecal
  elimination.
• An ileostomy allows liquid fecal material from
  the ileum to be eliminated through the stoma.
• The continent ileostomy and ileoanal reservoir
  are alternatives to traditional surgery.
• A colostomy permits formed feces in the colon to
  be eliminated via the stoma. They are classified
  by the part of the colon from which they
  originate.
• Ostomies may be temporary or permanent.

26
implementation

• Nursing measures
• Control odor
• Inspect the stoma regularly
• Protect the skin around the stoma site
• Monitor intake and output
• Educate the patient on each step of the process
• Encourage self-care
• Change the appliance as needed
• Appliances are either drainable or closed.
• Irrigate the colostomy

27
implementation

• Long-term ostomy care
• Avoid high-fiber foods for the first 6 to 8 weeks
• Patients with ileostomies are prone to food
  blockages
• Avoid use of long-acting, sustained-release, and
  enteric-coated medications
• Colostomy patients may gain control over
  elimination with regular irrigations at the same
  time each day.

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Evaluation

• Did your client meet their goal?