1. Chapter 23 Bowel Elimination Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

2. Bowel Elimination  Bowel elimination is the excretion of wastes from the gastro-intestinal (GI) system.  Factors affecting bowel elimination include:  Privacy  Habits  Age  Diet  Exercise and activity  Fluids  Drugs Slide 2 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

3. Normal Bowel Elimination  Time and frequency of bowel movements vary.  Stools normally:  Are brown  Are soft, formed, moist, and shaped like the rectum  Have a normal odor caused by bacterial action in the intestines Slide 3 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

4. Normal Bowel Elimination (cont’d)  Observe and report the following to the nurse. If allowed to chart, also record the following:  Color  Amount  Consistency  Presence of blood or mucus  Odor  Shape  Frequency of BMs  Complaints of pain or discomfort Slide 4 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

5. Factors Affecting Bowel Elimination  Normal, regular elimination is the goal.  Factors affecting stool frequency, consistency, color, and odor  Privacy  Habits  Diet—high-fiber foods  Diet—other foods  Fluids  Activity  Drugs  Disability  Aging Slide 5 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

6. Common Problems  Constipation is the passage of a hard, dry stool.  Constipation occurs when feces move slowly through the bowel.  Fecal impaction is the prolonged retention and build-up of feces in the rectum.  Feces are hard or putty-like.  Fecal impaction results in constipation if not relieved.  Symptoms include abdominal discomfort, abdominal distention (swelling), nausea, cramping, and rectal pain. Older persons may have poor appetite, confusion, or even a fever. Slide 6 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

7. Common Problems (cont’d)  The nurse does a digital (finger) exam to check for an impaction. The digital exam often causes the urge to have a BM. The digital exam often causes the urge to have a BM.  Sometimes the fecal mass is removed with a gloved finger. This is called digital removal of an impaction. This is called digital removal of an impaction.  Checking for and removing impactions is very dangerous. The vagus nerve can become stimulated, which slows the heart rate. The vagus nerve can become stimulated, which slows the heart rate. Heart rate can slow to unsafe levels in some persons. Heart rate can slow to unsafe levels in some persons. Slide 7 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

8.  Diarrhea is the frequent passage of liquid stools.  Feces move through the intestines rapidly.  Diet and drugs are ordered to reduce peristalsis.  You need to: Assist with elimination needs promptly. Assist with elimination needs promptly. Dispose of stools promptly. Dispose of stools promptly. Give good skin care. Give good skin care.  Fluid lost through diarrhea must be replaced. Otherwise dehydration occurs. Otherwise dehydration occurs.  Always follow Standard Precautions and the Bloodborne Pathogen Standard when in contact with stools. Slide 8 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Common Problems (cont’d)

9.  Fecal incontinence is the inability to control the passage of feces and gas through the anus.  Fecal incontinence affects the person emotionally.  The person may need: Bowel training Bowel training Help with elimination after meals and every 2 to 3 hours Help with elimination after meals and every 2 to 3 hours Incontinence products to keep garments and linens clean Incontinence products to keep garments and linens clean Good skin care Good skin care Slide 9 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Common Problems (cont’d)

10.  Flatulence is the excessive formation of gas or air in the stomach and intestines.  Gas or air passed through the anus is called flatus.  If flatus is not expelled, the intestines distend.  The following help produce flatus: Exercise Exercise Walking Walking Moving in bed Moving in bed The left side-lying position The left side-lying position  Doctors may order enemas and drugs to relieve flatulence. Slide 10 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Common Problems (cont’d)

11. Bowel Training  Bowel training has two goals, to:  Gain control of bowel movements.  Develop a regular pattern of elimination.  Factors that promote elimination are part of the care plan and the bowel-training program. These include:  High-fiber diet  Increased fluids  Warm fluids  Activity  Privacy Slide 11 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

12. Suppositories  A suppository is a cone-shaped, solid drug that is inserted into a body opening. It melts at body temperature.  A rectal suppository is inserted into the rectum.  A BM occurs about 30 minutes later.  The doctor may order a suppository to stimulate a BM for:  Constipation  Fecal impaction  Bowel training Slide 12 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

13. Enemas  An enema is the introduction of fluid into the rectum and lower colon.  Doctors order enemas to:  Remove feces  Relieve constipation, fecal impaction, or flatulence  Clean the bowel of feces before certain surgeries and diagnostic procedures  A doctor orders the enema solution. Slide 13 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

14. Enemas (cont’d)  The solution depends on the enema’s purpose cleansing, constipation, fecal impaction, or flatulence. Tap-water enema is obtained from a faucet. Tap-water enema is obtained from a faucet. Saline enema is a solution of salt and water. Saline enema is a solution of salt and water. Soapsuds enema (SSE) is a solution of castile soap and water. Soapsuds enema (SSE) is a solution of castile soap and water. Small-volume enema is commercially prepared. Small-volume enema is commercially prepared. Oil-retention enema is mineral, olive, or cottonseed oil. Oil-retention enema is mineral, olive, or cottonseed oil. Other enema solutions may be ordered. Other enema solutions may be ordered.  Nurses give enemas that contain drugs. Slide 14 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

15.  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.  Saline enema solution is similar to body fluid.  Soapsuds enemas irritate the bowel’s mucous lining. Slide 15 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Enemas (cont’d)

16.  Small-volume enemas irritate and distend the rectum.  Often ordered for constipation  Also ordered when the bowel does not need complete cleansing  Oil-retention enemas relieve constipation and fecal impactions.  Retaining oil softens feces and lubricates the rectum.  Most oil-retention enemas are commercially prepared. Slide 16 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. Enemas (cont’d)

17. The Person with an Ostomy  An ostomy is a surgically created opening for the elimination of body wastes.  The opening seen through the abdominal wall is called a stoma.  The person wears a pouch over the stoma to collect stools and flatus. Slide 17 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

18. The Person with an Ostomy (cont’d)  Colostomy  A colostomy is a surgically created opening between the colon and abdominal wall.  With a permanent colostomy, the diseased part of the colon is removed.  A temporary colostomy gives the diseased or injured bowel time to heal. After healing, surgery is done to reconnect the bowel. After healing, surgery is done to reconnect the bowel.  The colostomy site depends on the site of disease or injury.  Ileostomy  An ileostomy is a surgically created opening between the ileum (small intestine) and the abdominal wall.  Liquid stools drain constantly from an ileostomy. Slide 18 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved.

19.  Ostomy pouches  The pouch has an adhesive backing applied to the skin.  Sometimes pouches are secured to ostomy belts.  Many pouches have a drain at the bottom that close with a clip, clamp, or wire closure. The drain is opened to empty the pouch. The drain is opened to empty the pouch. The pouch is emptied when stools are present. The pouch is emptied when stools are present. It is opened when it balloons or bulges with flatus. It is opened when it balloons or bulges with flatus. Wipe the drain with toilet tissue before it is closed. Wipe the drain with toilet tissue before it is closed.  The pouch is changed every 3 to 7 days and when it leaks.  Do not flush pouches down the toilet. Slide 19 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. All rights reserved. The Person with an Ostomy (cont’d)