Fundamental Nursing Chapter 31 Bowel Elimination

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Fundamental NursingChapter 31 Bowel
Elimination
Inst. Dr. Ashraf El - Jedi
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Defecation

• Defecation (bowel elimination) is the act of
  expelling feces (stool) from the body. To do so,
  all structures of the gastrointestinal tract,
  especially the components of the large intestine
  (also referred to as the or ), must function in
  a coordinated manner (Fig. 31-1). In the large
  intestine, a remarkable volume of water is
  removed from the remnants of digestion, causing
  the bowel's contents to become a consolidated
  mass of residue before being eliminated.

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Figure 31-1 The large intestine
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• Peristalsis means the rhythmic contractions of
  intestinal smooth muscle that facilitate
  defecation. Peristalsis moves fiber, water, and
  nutritional wastes along the ascending,
  transverse, descending, and sigmoid colon toward
  the rectum. Peristalsis becomes even more active
  during eating this increased peristaltic
  activity is termed the gastrocolic reflex.

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• The gastrocolic reflex usually precedes
  defecation. Its accelerated wavelike movements,
  sometimes perceived as slight abdominal cramping,
  propel stool forward, packing it within the
  rectum. As the rectum distends, the person feels
  the urge to defecate. Stool is eventually
  released when the anal sphincters (ring-shaped
  bands of muscles) relax. Performing the Valsalva
  maneuver (closing the glottis and contracting the
  pelvic and abdominal muscles to increase
  abdominal pressure) facilitates this process.
  Several dietary, physical, social, and emotional
  factors can influence the bowel's mechanical
  function (Table 31-1).

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Assessment of Bowel Elimination

• Elimination Patterns
• Because various elimination patterns can be
  normal, it is essential to determine the client's
  usual patterns, including frequency of
  elimination, effort required to expel stool, and
  what elimination aids, if any, he or she uses.

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Assessment of Bowel Elimination

• Stool Characteristics
• Information that is particularly diagnostic
  includes stool color, odor, consistency, shape,
  and unusual components (Table 31-2).

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Common Alterations in Bowel Elimination

• Constipation
• Constipation is an elimination problem
  characterized by dry, hard stool that is
  difficult to pass. Various accompanying signs and
  symptoms include the following
• Complaints of abdominal fullness or bloating
• Abdominal distention
• Complaints of rectal fullness or pressure
• Pain on defecation
• Decreased frequency of bowel movements
• Inability to pass stool
• Changes in stool characteristics such as oozing
  liquid stool or hard small stool

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• The incidence of constipation tends to be high
  among those whose dietary habits lack adequate
  fiber (such as not eating sufficient raw fruits
  and vegetables, whole grains, seeds, and nuts).
  Dietary fiber, which becomes undigested
  cellulose, is important because it attracts water
  within the bowel, resulting in bulkier stool that
  is more quickly and easily eliminated.

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• Constipation is classified into one of four
  distinct types (primary, secondary, iatrogenic,
  and pseudoconstipation), according to the
  underlying cause.

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Primary Constipation

• Primary or simple constipation is well within the
  treatment domain of nurses. It results from
  lifestyle factors such as inactivity, inadequate
  intake of fiber, insufficient fluid intake, or
  ignoring the urge to defecate.

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Secondary Constipation

• Secondary constipation is a consequence of a
  pathologic disorder such as a partial bowel
  obstruction. It usually resolves when the primary
  cause is treated.

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Iatrogenic Constipation

• Iatrogenic constipation occurs as a consequence
  of other medical treatment. For example,
  prolonged use of narcotic analgesia tends to
  cause constipation. These and other drugs slow
  peristalsis, delaying transit time. The longer
  the stool remains in the colon, the drier it
  becomes, making it more difficult to pass.

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Pseudoconstipation

• Pseudoconstipation, also referred to as perceived
  constipation, is a term used when clients believe
  themselves to be constipated even though they are
  not.

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Fecal Impaction

• Fecal impaction occurs when a large, hardened
  mass of stool interferes with defecation, making
  it impossible for the client to pass feces
  voluntarily. Fecal impactions result from
  unrelieved constipation, retained barium from an
  intestinal x-ray, dehydration, and weakness of
  abdominal muscles.
• Some clients with an impaction pass liquid stool,
  which they may misinterpret as diarrhea.

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Flatulence

• Flatulence or flatus (excessive accumulation of
  intestinal gas) results from swallowing air while
  eating or sluggish peristalsis. Another cause is
  the gas that forms as a byproduct of bacterial
  fermentation in the bowel. Vegetables such as
  cabbage, cucumbers, and onions are commonly known
  for producing gas. Beans are other gas formers.

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Diarrhea

• Diarrhea is the urgent passage of watery stool
  and commonly is accompanied by abdominal
  cramping. Simple diarrhea usually begins suddenly
  and lasts for a short period. Other associated
  signs and symptoms include nausea and vomiting
  and blood or mucus in the stools.

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• Usually diarrhea is a means of eliminating an
  irritating substance such as tainted food or
  intestinal pathogens. Diarrhea may also result
  from emotional stress, dietary indiscretions,
  laxative abuse, or bowel disorders.

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Fecal Incontinence

• Fecal incontinence is the inability to control
  the elimination of stool.

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Measures to Promote Bowel Elimination

• Nurses commonly use two interventionsinserting
  suppositories and administering enemasto promote
  elimination when it does not occur naturally or
  when the bowel must be cleansed for other
  purposes, such as preparation for surgery and
  endoscopic or x-ray examinations.

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Inserting a Rectal Suppository

• Medications released from the suppository can
  have local or systemic effects. Depending on the
  drug, local effects may include softening and
  lubricating dry stool, irritating the wall of the
  rectum and anal canal to stimulate smooth muscle
  contraction, and liberating carbon dioxide, thus
  increasing rectal distention and the urge to
  defecate.

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Administering an Enema

• An enema introduces a solution into the rectum
  Nurses give enemas to
• Cleanse the lower bowel (most common reason).
• Soften feces.
• Expel flatus.
• Soothe irritated mucous membranes.
• Outline the colon during diagnostic x-rays.
• Treat worm and parasite infestations.

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Cleansing Enemas

• Cleansing enemas use different types of solution
  to remove feces from the rectum (Table 31-3).

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Retention Enemas

• A retention enema uses a solution held within the
  large intestine for a specified period, usually
  at least 30 minutes. Some retention enemas are
  not expelled at all. One type of retention enema
  is called an because the fluid instilled is
  mineral, cottonseed, or olive oil. Oils lubricate
  and soften the stool, so it can be expelled more
  easily.

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Ostomy Care

• A client with an ostomy (surgically created
  opening to the bowel or other structure requires
  additional care for promoting bowel elimination.
  Two examples of intestinal ostomies are an
  ileostomy (surgically created opening to the
  ileum) and a colostomy (surgically created
  opening to a portion of the colon Fig. 31-4).
  Materials enter and exit through a stoma
  (entrance to the opening).

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• Most persons with an ostomy, also called
  ostomates, wear an appliance (bag or collection
  device over the stoma) to collect stool.
  Depending on the type and location of the ostomy,
  client care may involve providing peristomal
  care, applying an appliance, draining a continent
  ileostomy, and, for clients with a colostomy,
  administering irrigations through the stoma.

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Figure 31-5 An ostomy appliance faceplate and
pouch.
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Providing Peristomal Care

• Preventing skin breakdown is a major challenge in
  ostomy care. Enzymes in stool can quickly cause
  excoriation (chemical injury of skin). Washing
  the stoma and surrounding skin with mild soap and
  water and patting it dry can preserve skin
  integrity.

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Nursing Implications

• Constipation
• Risk for Constipation
• Perceived Constipation
• Diarrhea
• Bowel Incontinence
• Toileting Self-Care Deficit
• Situational Low Self-Esteem