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.