Bowel Elimination and Care Chapter 30 Bowel Elimination and Care

Terminology Related to Bowel Elimination Defecation: process of bowel elimination Constipation: hard stools; difficulty passing stools Diarrhea: several liquid stools per day Fecal impaction: stool obstruction Flatus: gas

Gastrointestinal (GI) Tract Mouth Anus Waste products—feces or stool Process of bowel elimination—defecation

Peristalsis Consists of rhythmic wavelike movements beginning in the esophagus and continuing to the rectum Involves contraction of the circular and longitudinal muscles in the walls of the GI tract Propels the bolus of food through the GI tract

Process of Digestion, Absorption, and Metabolism of Nutrients Bowel elimination occurs after nutrients are moved through the GI tract In the stomach, enzymes break down the bolus of food, converting it to chyme The chyme passes through the pyloric sphincter and into the small intestine, where the nutrients are absorbed The remaining chyme passes through the illeocecal valve into the large intestine to be passed as stool

Changes Through Life Cycle Infants—three to six bowel movements (BM)/day Children—one to two/day Elderly—peristalsis slows—more prone to constipation or hard stools that are difficult to pass At least every three days

Characteristics of Feces Color, shape, consistency, odor, and frequency Diet, amount of fiber and fluids, exercise, medications, and other habits Disease process can change characteristics Assessment is important

Normal Soft, formed, light yellowish-brown to dark brown, and slightly odiferous and slightly curved shape Color—vary by dietary intake Spinach Beets Iron

Abnormal Characteristics Table 30-1, pg. 678 Inadequate fluid intake Transit time Fiber Increased amount of fat Steatorrhea—fluffy, float, foul odor

Abnormal Characteristics Malabsorption disease—Chron’s Ribbon-like stools Mucus , blood, or pus Parasites, worms, or eggs Clay colored or pale white stools Frank blood—visible to naked eye

Abnormal Characteristics Occult blood—hidden blood All bleeding is considered serious until proven otherwise Must be reported to physician

Abnormal Characteristics of Stool Liquid, watery, unformed, hard, dry Balls, clumps, flat or ribbonlike, pencil-like Bright red blood, black, coffee-ground appearance, pale, white, gray, or claylike Presence of pus or mucus; floating on water Presence of worms or eggs Foul odor, bloody, or metallic smell

Factors Affecting Bowel Elimination Change in activity level Change in dietary intake Change in water source Change in fluid volume intake Side effects of medication Side effects of surgery Pregnancy

Factors Affecting Bowel Elimination (cont.) High stress levels and emotional problems Laxative abuse Aging process Structural changes Chemical changes Food allergies

Common Alterations in Bowel Elimination Constipation Diarrhea Impaction Fecal incontinence

Constipation Less frequent, hard, formed stools—difficult to expel Bloated feeling Degrees of severity Impaction—blockage due to mass of very hard stool

Constipation Impaction Loss of appetite Bloating Cramping Malaise Just not feeling well

Constipation Possibly no complaints Always note when was patient’s last BM Assess elderly and those from long term care setting for s/s of constipation or impaction

Diarrhea Loose or watery stools occurring three or more times/day Cramping—may or may not be present Monitor for possible complications Excoriated perianal skin Dehydration and electrolyte imbalance Especially infants, young children, and elderly

Fecal Impaction Rectum, sigmoid flexure, or any part of large colon Elderly, inactive patient’s, severely dehydrated Common cause—abuse of laxatives Possible indication—liquid stool Complication—obstruction or perforation of bowel

Digital Removal of Impaction Can be embarrassing and painful Oil retention enema or pain med Prior to procedure Delegate? Need an order? Review patient history—contraindications? Monitor for s/s of vagus nerve stimulation

Fecal Incontinence Voluntary control is lost Beyond patient’s control Spinal cord injury Disoriented patient’s Source of guilt, embarrassment, and destruction of self-esteem

Fecal Incontinence What can be done? Bowel training Proper cleansing and barrier creams Fecal incontinence pouch Maintain patient’s dignity—never refer to as diapers

Bowel Elimination Assessment of BM and documentation Color Amount Consistency Unusual shape Unusual odor

Nursing Interventions to Promote Bowel Function Increase physical activity Ensure adequate fluid: up to 2,500 mL/day Increase fiber intake to 20 to 30 g/day (gradually!!) Provide privacy Position patient upright for elimination Provide stimulants that “cue” bowel function at home, such as a cup of hot coffee before breakfast

Subjective Assessment On admission to hospital Subjective information of patient’s normal bowel habits Any current problems with BM’s

Objective Assessment Physical assessment Shape of abdomen Normal—rounded or flat Abnormal—distended or inflated Distention—excessive gas, fluid, or stool

Objective Assessment Auscultate bowel sounds Diaphragm portion of stethoscope Listen in all four quadrants Once per shift or more often if indicated Soft gurgles or irregular clicks Between 5 and 30/minute

Objective Assessment Bowel sounds <5/minute—hypoactive bowel sounds >30/minute or continuous—hyperactive bowel sounds May indicate obstruction—high pitched, tinkling sounds in one area and absent or decreased sounds in the distal portion

Objective Assessment An absence of bowel sounds indicates a problem and should always be reported to the physician To determine absent bowel sounds—listen 3 to 5 minutes in each quadrant

Objective Assessment Assessment of abdomen Inspection Auscultation Palpation Normal—soft Abnormal—firm or hard—excessive gas, constipation, or obstruction

Importance of… Increased activity Adequate fluid intake Adequate fiber intake Privacy during elimination Positioning during elimination

Management Universal precautions Possibility of contact with feces Incontinent patient Emptying bedpan or bedside commode Removing an impaction Collecting stool specimen Administering enema Providing colostomy care

Management Altering dietary intake related to diarrhea Clear liquid diet first 24 hours Decaffeinated green or black teas or herbal tea Sports drinks—replace electrolytes Avoid extremely hot or cold liquids first 24 hours Longer than 24 to 36 °--full liquids and cooked fruits or vegetables

Management Diarrhea due to loss of normal flora—yogurt Concurrent use with antibiotics—prevent the loss of normal flora

Management Medications Coat the mucous membranes of the bowel Inhibit peristalsis Treat the disease or infectious process

Management Lactobacillus acidophilus Medications for constipation Supplement Replace normal flora Medications for constipation Increase peristalsis Soften stool Add bulk to stool

Management Enema Instillation of solution into the colon via the rectum Temperature—between 105 to 110° F—to avoid burning intestinal mucosa Test—should feel warm, NOT HOT Too cool—cause cramping

Management Position* Insert tip of tubing 3 to 4 inches (adult) Left lateral side-lying or Sims’ Insert tip of tubing 3 to 4 inches (adult) Rectum, sigmoid colon, and descending colon

Management If a high enema is ordered Start with patient on left side—instill half of solution—supine—then right lateral side for rest of solution

Management Cleansing enema Relief of constipation Empty and cleanse the bowel prior to surgery or testing Large volume enema—500 to 1,000 ml Small volume enema--<250 ml, usually 90 to 120 ml

Management Order—enemas til clear Enemas administered until the expelled solution no longer contains feces and is relatively clear Within a LIMIT of three 1,000 ml enemas Avoid giving more than 3 large volume enemas consecutively Cause fatigue and irritation of intestinal lining

Management Types of solutions Tap water Normal saline Soapsuds Commercially prepackaged small volume oil or sodium phosphate solutions

Management Soapsuds Castile soap—5 ml/1,000m of solution—no substitutes—other soaps too harsh—damage intestinal lining Distends intestine and irritates the walls of intestines to further stimulate peristalsis

Management Tap water Normal Saline Hypotonic! High risk individuals? Isotonic

Management Hypertonic May be used in small volumes for adults Fleet’s enema Not used in large volume enemas—increased risk of fluid and electrolyte imbalances Milk and molasses enema—hypertonic—persistent constipation or impaction removal—follow agency policy

Management Oil retention Soften hard stool of an impaction to ease removal Small volume—90 to 120 ml Allow time to soften stool—approx. one hour

Management Medicating enema Steroid—decrease inflammation Kayexalate enema—to lower a very high potassium level Must retain in bowel—solution pulls K+ from bloodstream into solution to be expelled Follow agency policy

Management Return flow enemas Aka Harris flush Remove flatus or gas Tap water or saline Small volume—100 to 200 ml Then lower container below level of rectum—fluid and gas returned—bubbles—continue til no bubbles—Follow agency policy

Contraindications Rectal surgery Severe bleeding hemorrhoids Ulcerative colitis or Crohn’s disease Rectal fissure or rectal cancer Excessive bleeding potential due to disease or medication Certain heart conditions

Complications Two serious complications Vagus nerve Vagal response Perforation of intestinal wall Vagus nerve Innervates heart, bronchioles, as well as the gastrointestinal (GI) tract

Complications Insertion of the enema tube can stimulate the vagus nerve When stimulated—can drop the heart rate to 30 to 40 bpm and cause constriction of the bronchioles of the lungs If continues longer than a few minutes—inadequate blood pressure and circulation

Complications S/S of vagus nerve stimulation Chest pain or chest heaviness or pressure Shortness of breath or inability to breathe Dizziness Feel like fainting Nausea Pallor

Complications S/S of vagus nerve stimulation Clammy skin Pulse rate <60 bpm STOP enema or removal of impaction Remove the tube or finger from the rectum Position supine

Complications Assess pulse rate, skin color, and is patient diaphoretic? Call for assistance—do not leave patient If pulse <60—place in shock position—head lower than feet Assess blood pressure Supply oxygen if needed

Complications Perforation of colon GENTLY insert tubing Never force Do not insert further than 4 to 6 inches Direct tip of tubing toward umbilicus—follows natural direction of colon Proper positioning

Laboratory Tests to Determine the Cause of Bowel Alterations Guaiac test (occult blood test) Tests for presence of blood in the stool Culture and sensitivity (C&S) Identifies microorganisms infecting the stool and the antibiotics that will kill the microorganisms Ova and parasite test (O&P) Tests for presence of parasitic worms and their eggs

Collection Clean and dry bedpan or collection container Can not mix specimen with urine Wear gloves Clean tongue blade Collect from 2 different areas of stool—especially an abnormal appearing areas

Collection If incontinent collect from depends Properly identify specimen Properly package Specimen sent to lab upon collection Document type of specimen collected, characteristics, date and time of collection and sent to lab

Important Read……. Skill 30-1, pg. 698-699 Skill 30-2, pg. 700

True/False Question The nurse administering an enema to a patient knows that the tip of the tubing should be inserted into the rectum while the patient is in a sitting position, as on the toilet. A. True B. False

Answer B. False Rationale: The nurse should never attempt insertion of the tip of the tubing into the patient’s rectum while the patient is in a sitting position. The angle of the natural curve of the rectum and sigmoid colon changes when sitting. This can cause the tip of the tubing to scrape the intestinal wall, possibly damaging the mucosal lining, and increases risk of perforating the intestinal wall.

Multiple Choice Question A nurse is ordered to administer an enema to a patient to soften an impacted stool. Which type of enema would typically be used? A. Cleansing enema B. Oil retention enema C. Medicating enema D. Return flow enema

Answer B. Oil retention enema Rationale: Oil retention enemas are administered to soften the hard stool of an impaction so that it can be removed more easily and with less discomfort for the patient.