Chapter 22 Bowel Elimination All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Bowel Elimination Bowel elimination is the excretion of wastes from the gastro- intestinal (GI) system. Factors affecting bowel elimination include: Privacy Habits Age Diet and fluids Exercise and activity Drugs Bowel elimination is a basic physical need. Gastro-intestinal system (GI system) in Chapter 7. Promoting normal bowel elimination is important. You assist residents in meeting elimination needs. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 2

Normal Bowel Elimination Feces move through the intestines by peristalsis. Feces move through the large intestine to the rectum. Feces are stored in the rectum until excreted from the body. Defecation (bowel movement [BM]) is the process of excreting feces from the rectum through the anus. Frequency and time of bowel movements vary from person to person. Partially digested food and fluids are called chyme. Feces refers to the semi-solid mass of waste products in the colon that is expelled through the anus. Peristalsis is the alternating contraction and relaxation of intestinal muscles. Stool refers to excreted feces. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 3

Stool Stools are normally brown, soft, formed, moist, and shaped like the rectum. They have a normal odor. Observe and report the following: Color Amount Consistency Presence of blood or mucus Odor Shape Frequency of defecation Complaints of pain or discomfort Bleeding in the stomach and small intestine causes black or tarry stools. Bleeding in the lower colon and rectum causes red-colored stools. Diseases and infection can cause clay-colored or white, pale, orange-colored, or green-colored stools. The normal odor is caused by bacterial action in the intestines. Certain foods and drugs also cause odors. Ask the nurse to observe abnormal stools. Review Focus on Communication: Observations on p. 374. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 4

Factors Affecting Bowel Elimination The nurse considers the following factors when using the nursing process to meet the person’s elimination needs: Privacy Habits Diet Fluids Activity Drugs Aging Disability The care plan includes measures to meet the person’s elimination needs. It may involve diet, fluids, and exercise. Review Box 22-1 on p. 375. Review Teamwork and Time Management: Safety and Comfort on p. 375. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 5

Common Problems Constipation is the passage of a hard, dry stool. Constipation occurs when feces move slowly through the bowel. A fecal impaction is the prolonged retention and buildup of feces in the rectum. Feces are hard or putty-like. Symptoms include abdominal discomfort, abdominal distention (swelling), nausea, cramping, and rectal pain; older persons may have poor appetite, confusion, or even a fever. Fecal impaction results if constipation is not relieved. Common causes of constipation include a low-fiber diet, ignoring the urge to have a BM, decreased fluid intake, inactivity, drugs, aging, and certain diseases. Dietary changes, fluids, and activity prevent or relieve constipation. So do drugs and enemas. In fecal impaction, the person cannot defecate. Report signs and symptoms to the nurse. The nurse does a digital exam to check for an impaction. A lubricated, gloved finger is inserted into the rectum to feel for a hard mass (see Fig. 22-1 on p. 376). The digital exam often causes the urge to have a BM. Sometimes the nurse removes the fecal mass with a gloved finger. This is called digital removal of an impaction. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 6

Diarrhea and Dehydration Diarrhea is the frequent passage of liquid stools. Feces move through the intestines rapidly, causing fluid loss. If fluid is not replaced, dehydration occurs. Dehydration can lead to death. Clostridium difficile is a microbe that causes diarrhea. Signs of dehydration Pale or flushed skin, dry skin, coated tongue Urine is dark and scant in amount. Thirst, weakness, dizziness, confusion Falling blood pressure and increased pulse Preventing the spread of infection is important! Good hand hygiene Standard Precautions and Bloodborne Pathogen Standard With diarrhea, the need for a BM is urgent. Abdominal cramping, nausea, and vomiting may occur. Causes of diarrhea include infections, some drugs, irritating foods, and microbes in food and water. Dehydration is the excessive loss of water from tissues. Microbes can cause diarrhea. The C-dif microbe is found in feces. A person becomes infected by touching items or surfaces contaminated with feces and then touching his or her mouth or mucous membranes. You can spread the microbes if your contaminated hands or gloves touch a person or contaminate surfaces. Review Promoting Safety and Comfort: Diarrhea on p. 376. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 7

Fecal Incontinence Fecal incontinence is the inability to control the passage of feces and gas through the anus. Fecal incontinence affects the person emotionally. The person with fecal incontinence may need: Bowel training Help with elimination after meals and every 2 to 3 hours Incontinence products to keep garments and linens clean Good skin care Fecal incontinence affects the person emotionally. Causes may include intestinal distress, nervous system diseases and injuries, fecal impaction, diarrhea, some drugs, chronic illness, aging, mental health problems or dementia (see Chapters 43 and 44). The person may not recognize the need or act for having a BM, not answering call light when help is needed for elimination, getting to the bathroom in time, and finding the bathroom in a new setting. Review Residents with Dementia: Fecal Incompetence on p. 376. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 8

Flatulence Flatulence is the excessive formation of gas or air in the stomach and intestines. Gas and air passed through the anus is called flatus. If flatus is not expelled, the intestines distend. Abdominal cramping or pain, shortness of breath, and a swollen abdomen occur. Review the causes listed on p. 377 in the textbook. Doctors may order enemas and drugs to relieve flatulence. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 9

Bowel Training Bowel training is used to Gain control of bowel movements. Develop a regular pattern of elimination. Fecal impaction, constipation, and fecal incontinence are prevented. The person’s usual time of day for a BM is noted on the care plan. The nurse tells you about a person’s bowel training program. Offer help with elimination at the times noted on the person’s care plan. Factors that promote elimination are part of the care plan and bowel training program. These include a high-fiber diet, increased fluids, warm fluids, activity, and privacy. The doctor may order a suppository to stimulate a BM. A suppository is a cone-shaped, solid drug that is inserted into a body opening. It melts at body temperature. A nurse inserts a suppository into the rectum (Fig. 22-2 on p. 377). A BM occurs about 30 minutes later. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 10

Enemas The introduction of fluid into the rectum and lower colon is called an enema. Doctors order enemas: To remove feces To relieve constipation, fecal impaction, or flatulence To clean the bowel of feces before certain surgeries and diagnostic procedures The doctor orders the enema solution. Safety and comfort measures for bowel elimination are practiced when giving an enema. Water temperature should be body temperature (98.6 F [Fahrenheit] or 37 C [Centigrade]); sometimes warmer temperatures (105 F [40.5 C]) are used for adults. Review Box 22-1 on p. 375. Review Box 22-2 on p. 377. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 11

Enema Solutions The solution depends on the enema’s purpose. Tap water enema (obtained from a faucet) Saline enema (a solution of salt and water) Soapsuds enema (SSE) Small-volume enema Oil-retention enema Do not give enemas that contain drugs. Other enema solutions may be ordered. Consult with the nurse and use the center’s procedure manual to safely prepare and give enemas. You do not give enemas that contain drugs. Nurses give them. Review Delegation Guidelines: Enemas on p. 378. Review Promoting Safety and Comfort: Enemas on p. 378. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 12

Cleansing Enemas Cleansing enemas: Clean the bowel of feces and flatus Relieve constipation and fecal impaction Are needed before certain surgeries and diagnostic procedures Tap water enemas can be dangerous. The saline enema solution is similar to body fluid. Soapsuds enemas irritate the bowel’s mucous lining. Small-volume enemas irritate and distend the rectum. They are often ordered for constipation. They are ordered when the bowel does not need complete cleansing. Oil-retention enemas relieve constipation and fecal impactions. Cleansing enemas take effect in 10 to 20 minutes. The doctor may order enemas until clear. This means that enemas are given until the return solution is clear and free of stools. Ask the nurse how many enemas to give. Center policy may allow repeating enemas two or three times. Review the Giving a Cleansing Enema procedure on pp. 379-380. Review Giving a Small-Volume Enema procedure on pp. 381-382. Review Promoting Safety and Comfort: The Oil-Retention Enema on p. 382. Review the Giving an Oil-Retention Enema procedure on pp. 382-383. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 13

The Person with an Ostomy An ostomy is a surgically created opening for the elimination of body wastes. The opening is called a stoma. The person wears a pouch over the stoma to collect stools and flatus. Colostomy With a permanent colostomy, the diseased part of the colon is removed. A temporary colostomy gives the diseased or injured bowel time to heal. The colostomy site depends on the site of disease or injury. Stool consistency depends on the colostomy site. Skin care prevents skin breakdown around the stoma. Sometimes part of the intestines is removed surgically for different reasons, such as cancer, bowel disease, or trauma. Feces and flatus pass through the stoma instead of the anus. The colostomy site depends on the site of disease or injury (Fig. 22-7 on p. 383). Stools irritate the skin. The skin is washed and dried. Then a skin barrier is applied around the stoma. It prevents stools from having contact with the skin. The skin barrier is part of the pouch or a separate device. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 14

Ileostomy Basics Ileostomy The entire colon is removed. Liquid stools drain constantly from an ileostomy. The ileostomy pouch must fit well. Stools must not touch the skin. Good skin care is required. An ileostomy is a surgically created opening (stomy) between the ileum (small intestine [ileo]) and the abdominal wall. Part of the ileum is brought out onto the abdominal wall, and a stoma is made. The entire colon is removed (Fig. 22-8 on p. 384). Water is not absorbed because the colon was removed. Feces in the small intestine contain digestive juices that are very irritating to the skin. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 15

Ostomy Pouches Ostomy pouches are emptied when stools are present. The pouch is opened when it balloons or bulges with flatus. The drain is wiped with toilet tissue before it is closed. The pouch is changed every 3 to 7 days and when it leaks. Frequent pouch changes can damage the skin. The person can wear normal clothes. Showers and baths are delayed for 1 to 2 hours after applying a new pouch to allow the adhesive to seal to the skin. Do not flush pouches down the toilet. The pouch has an adhesive backing that is applied to the skin (Fig. 22-9 on p. 384). Sometimes pouches are secured to ostomy belts. Odors are prevented by good hygiene, emptying the pouch, avoiding gas-forming foods, and putting deodorants into the pouch. (The nurse tells you what to use.) Follow center policy for disposing of pouches. Review Delegation Guidelines: Ostomy Pouches and Promoting Safety and Comfort: Ostomy Pouches on pp. 384-385. Review the Changing an Ostomy Pouch procedure on pp. 385-386. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 16

Quality of Life Protect the person’s rights. Assist with bowel elimination as directed by the nurse and the care plan. Do all you can to protect the person’s right to privacy. Residents have the right to personal choice. Bowel control is important to people. Physical and mental well-being are related to normal bowel function. Normal bowel elimination is not always possible. Constipation, fecal impaction, diarrhea, fecal incontinence, and flatulence are common problems. Persons with ostomies manage their own care if able. Some have had ostomies for a long time. They have their own routines and care measures. All items and derived items © 2015, 2011 by Mosby, Inc., an imprint of Elsevier Inc. All rights reserved. 17