Bowel Elimination

Bowel Elimination (Defecation) is a natural process by which the soiled waste products of digestion (feces or stool) are eliminated from the bowel.

The Large Intestine

Primary organ of bowel elimination
Extends from the ileocecal valve to the anus

Functions

Completion of absorption of H2O, Nutrients (chyme from sm. intest. – 1-1.5 L)
Manufacture of some vitamins
Formation of feces
Expulsion of feces from the body

The Small and Large Intestines

Process of Peristalsis

Peristalsis is under control of nervous system
Contractions occur every 3 to 12 minutes
Mass peristalsis sweeps occur 1 to 4 times each 24-hour period
One-third to one-half of food waste is excreted in stool within 24 hours

Peristalic Movements in the Intestine – Colonic peristalsis is slow. Mass peristalsis is strong, few waves per day, stimulated by food in small intestine.

Factors that influence Bowel Elimination

Age
Diet
Position
Pregnancy
Fluid Intake
Activity
Psychological
Personal Habits
Pain
Medications
Surgery/Anesthesia

Developmental Considerations

Infants—characteristics of stool and frequency depend on formula or breast feedings
Toddler physiologic maturity is first priority for bowel training (1 ½ – 2 yrs)
Child, adolescent, adult—defecation patterns vary in quantity, frequency, and rhythmicity
Older adult—constipation is often a chronic problem

Foods Affecting Bowel Elimination

Constipating foods cheese, lean meat, eggs, & pasta
Foods with laxative effect—fruits and vegetables, bran, chocolate, alcohol, coffee
Gas-producing foods—onions, cabbage, beans, cauliflower

Effect of Medications on Stool

Aspirin, anticoagulants pink, red, or black stool
Iron salts—black stool
Antacids white discoloration or speckling in stool
Antibiotics—green-gray color

Physical Assessment of the Abdomen

Inspection—observe contour, any masses, scars, or distension
Auscultation—listen for bowel sounds in all quadrants
Note frequency and character, audible clicks, and flatus
Describe bowel sounds as audible, hyperactive, hypoactive, or inaudible Percussion—expect resonant sound or tympany
Areas of increased dullness may be caused by fluid, a mass, or tumor
Palpation—note any muscular resistance, tenderness, enlargement of organs, masses

Physical Assessment of the Anus and Rectum

Inspection and palpation
Examine anal area for cracks, nodules, distended veins, masses or polyps, fecal mass
Insert gloved finger into anus to assess sphincter tone & smoothness of mucosal lining
Inspect perineal area for skin irritation secondary to diarrhea

Stool Collection

Medical aseptic technique is imperative
Wear disposable gloves
Wash hands before and after glove use
Do not contaminate outside of container with stool
Obtain stool and package, label, and transport according to agency policy

Patient Guidelines for Stool Collection

Void first so urine is not in stool sample
Defecate into the container rather than toilet bowl
Do not place toilet tissue in bedpan or specimen container
Notify nurse when specimen is available
get to lab quickly (30 min) if anything viable in sample ie. parasites, C-diff. etc

Types of Direct Visualization Studies

Esophagogastroduodenoscopy (EGD)
Colonoscopy
Sigmoidoscopy
Wireless capsule endoscopy

Indirect Visualization Studies

Upper gastrointestinal (UGI)
Small bowel series
Barium enema

Scheduling Diagnostic Tests

1 — fecal occult blood test
2 — barium studies (should precede UGI) make sure ALL barium is removed*
3 — endoscopic examinations

Noninvasive procedures take precedence over invasive procedures

Patient Outcomes for Normal Bowel Elimination

Patient has a soft-formed bowel movement every 1-3 days without discomfort
The relationship between bowel elimination and diet, fluid, and exercise is explained
Patient should seek medical evaluation if changes in stool color or consistency persist

Promoting Regular Bowel Habits

Timing -attend to urges promptly
Positioning – have pt. sit up, gravity aids in BM
Privacy – close door & pull curtain
Nutrition
Exercise – abdominal muscles & thighs
Abdominal settings
Thigh strengthening

Individuals at High Risk for Constipation

Patients on bed rest taking constipating medications
Patients with reduced fluids or bulk in their diet
Patients who are depressed
Patients with central nervous system disease or local lesions that cause pain

*Valsalva maneuver (straining & holding breath) ↑intrathoracic / intracranial pressure – possible brain injury

Nursing Measures for the Patient With Diarrhea

Answer call lights immediately
Remove the cause of diarrhea whenever possible (e.g., medication)
If there is impaction, obtain physician order for rectal examination
Give special care to the region around the anus
After diarrhea stops, suggest the intake of fermented dairy products
Fecal seepage may indicate impaction

Preventing Food Poisoning

Never buy food with damaged packaging
Never use raw eggs in any form
Do not eat ground meat uncooked
Never cut meat on a wooden surface
Do not eat seafood that is raw or has unpleasant odor
Clean all vegetables and fruits before eating
Refrigerate leftovers within 2 hours of eating them
Give only pasteurized fruit juices to small children

Methods of Emptying the Colon of Feces

Enemas
Rectal suppositories
Rectal catheters
Digital removal of stool

Types of Enemas

Cleansing – high volume
Retention – oil
Return-flow – bag of solution taken in (100-300 ml fluid) for pt with gas

Retention Enemas

Oil-retention—lubricate the stool and intestinal mucosa easing defecation
Carminative—help expel flatus from rectum
Medicated—provide medications absorbed through rectal mucosa
Anthelmintic—destroy intestinal parasites
Nutritive—administer fluids and nutrition rectally

Bowel Training Programs

Manipulate factors within the patient’s control
Food and fluid intake, exercise, time for defecation
Eliminate a soft, formed stool at regular intervals without laxatives
When achieved, discontinue use of suppository if one was used

Types of Colostomies – each has different stool consistency

Sigmoid colostomy
Descending colostomy
Transverse colostomy
Ascending colostomy
Ileostomy

Location of (A) a Sigmoid Colostomy and (B) a Descending Colostomy
Location of (C) a Transverse Colostomy and (D) an Ascending Colostomy
Location of an Ileostomy

Colostomy Care

Keep patient as free of odors as possible; empty appliance frequently
Inspect the patient’s stoma regularly
Note the size, which should stabilize within 6 to 8 weeks
Keep the skin around the stoma site clean and dry
Measure the patient’s fluid intake & output
Explain each aspect of care to the patient and self-care role
Encourage patient to care for and look at ostomy

Normal-Appearing Stoma

Patient Teaching for Colostomies

Community resources are available for assistance
Initially encourage patients to avoid foods high in fiber
Avoid foods that cause diarrhea or flatus
Drink two quarts of water daily
Teach about medications
Teach about odor control (intake of dark green vegetables helps control odor)
Resume normal activity including work and sexual relations

Comfort Measures

Encourage recommended diet and exercise
Use medications only as needed
Apply ointments or astringent (witch hazel)
Use suppositories that contain anesthetics

Characteristics of Normal Stool

Color – varies from light to dark brown foods & medications may affect color
Odor – aromatic, affected by ingested food and person’s bacterial flora
Consistency – formed, soft, semi-solid; moist
Frequency – varies with diet (about 100 to 400 g/day)
Constituents – small amount of undigested roughage, sloughed dead bacteria and epithelial cells, fat, protein, dried constituents of digestive juices (bile pigments); inorganic matter (calcium, phosphates)

Common Bowel Elimination Problems

Constipation – abnormal frequency of defecation and abnormal hardening of stools
Impaction – accumulated mass of dry feces that cannot be expelled
Diarrhea – increased frequency of bowel movements (more than 3 times a day) as well as liquid consistency and increased amount; accompanied by urgency, discomfort and possibly incontinence
Incontinence – involuntary elimination of feces
Flatulence – expulsion of gas from the rectum
Hemorrhoids – dilated portions of veins in the anal canal causing itching and pain and bright red bleeding upon defecation.