By Purwaningsih

Objectives Recognize causes of constipation Describe the normal physiology of bowel elimination Recognize causes of constipation Discuss assessment and interventions to achieve nursing outcomes for bowel elimination

Bowel Elimination GI Tract is a series of hollow mucous membrane lined muscular organs Purpose is to absorb fluids & nutrients, prepare food for absorption & provide storage for feces

GI Tract Anatomy Mouth Esophagus Stomach Small Intestine Large Intestine Rectum

Main function is absorption Small intestine Made up of three parts: ileum, jejunum, and duodenum. Main function is absorption

Small intestine Small intestine

Colon 3 Divisions: Ascending, Transverse, Descending Colon Functions: Absorption, Protection, Secretion, & Elimination (stool and flatus)

Rectum Sigmoid colon Storage of feces Length varies with age When fecal mass or flatus moves into rectum, it distends and defecation begins Process involves involuntary (Internal sphincter) and voluntary control (external sphincter) Valsalva Maneuver- voluntary contraction of abdominal muscles

Physiology – Bowel Elimination GI Motility Enzyme breakdown Peristalsis Gastrocolic Reflex Mucosal Transport Fluids & Electrolytes Waste (Bisanz, 2007)

Physiology – Bowel Elimination Defecation Reflex Sphincters CNS Impulses Rectal Distention Mechanical Assistance Anal Sphincter Muscles (Bisanz, 2007)

Characteristics – Bowel Elimination Frequency Quantity Quality Consistency Ease of Passage

Constipation Scoring System Tools for Stools Bristol Stool Scale http:// en.wikpedia.org./wiki/Bristol_stool_Chart Constipation Scoring System http://www.ncbi.nlm.nih.gov/pubmed/864957

Factors Affecting Bowel Elimination Age Infection Diet Fluid Intake Physical Activity Psychological factors Personal Habits

Factors Affecting Bowel Elimination Position during Defecation Pain Surgery and Anesthesia Medications

Common Bowel Elimination Problems Constipation Impaction Diarrhea Incontinence Flatulence Hemorrhoids

CONSTIPATION Definition: decreased normal frequency of defecation accompanied by difficult or incomplete passage of excessively dry stool (Wilkinson, J.M., 2005)

Menu choices – fresh fruit, whole grains Causes - Constipation Poor Intake Fluids NPO – tests, surgery Choices – juice, water Positioning Fiber Menu choices – fresh fruit, whole grains

Orthopedic Insult Casts, Traction Other diseases Causes - Constipation Pain with movement Assistive devices Other diseases

Open Door Policy ↓ Privacy – visitation policy Disruption of Routine Causes - Constipation Open Door Policy ↓ Privacy – visitation policy Bathroom vs. Commode Disruption of Routine Therapy Tests/Surgery

Pain Medications Other medications Causes - Constipation Pain Medications Opiates – P.O. or PCA Other medications Antacids with aluminum, anticholinergics, calcium channel blockers, phenothiazines, diuretics, sedatives, etc. (Hinrichs, Huseboe, Tang, & Titler, 2001)

Last resort: Suppository/Enema Laxatives (+/-) Bulk-forming → Stool softeners → Osmotic Laxatives → Stimulants → Suppository/Enema (Hinrichs, Huseboe, Tang, & Titler, 2001)

Assessment AUDITS: INTERVIEWS: Nurses Leadership Patients Diagnosis Postoperative Day Medications +/- Bowel Movement Recorded INTERVIEWS: Nurses Leadership Patients

Pictorial Diary Fluids – 8 servings Interventional Tool Whole grains – 3 servings Fruits/vegetables – 5 servings Exercise – 3-4 x/day Bowel Movement - record

Interventional Tool Bowel Elimination Tool (BET)

Interventional Tool Directions: Mark your selections with an X Choose: 8 Glasses of Fluid: Best: Water or Juices; Decaffeinated drinks 3 Servings of Whole grain breads or cereal: Best: Whole wheat, oatmeal, bran cereals 5 Servings of Fruits or Vegetables: Best: Fresh fruits, vegetables with skin Exercise – 3-4 times per day Best: Walking, physical therapy, or exercises in bed Record your BM Difficult___ Easy___ Soft___ Hard___ Complete__ Interventional Tool Directions:

1) Cooperates for Bowel Management Nursing Outcomes 1) Cooperates for Bowel Management Partners for care – uses tool Out of bed/ exercises – 3-4 x day Overview of diet >15 gm fiber; >1500 cc fluids Privacy and respect – toileting regime (Moorhead, 2008)

2) Constipation alleviated as indicated: Nursing Outcomes 2) Constipation alleviated as indicated: Elimination pattern in expected range Stool soft and formed (soft/hard) Stool easy to pass (easy/difficult) Amount adequate for diet (yes/no) Feeling of evacuation (yes/no) (Moorhead, 2008)