1. Bowel Elimination
Pamela Llana, MSN, RN

2. Factors Affecting Bowel Elimination
Age: 2-3 yrs old gain control of bowels; bowels before bladder; GI motility decreases with age
Diet: 25% of stool = cellulose/fiber. More fiber = BM, Less = BM
Fluid Intake: Need 2000 mL/day for soft BM
Physical Activity: Promotes muscle tone & increases peristalsis---more constipation in nursing homes
Psychological Factors: Privacy important from early age
Lifestyle/Personal Habits: Some have a routine/pattern. Others just go when the urge hits. Alterations in routine: travel, stress, depression lead to changes in bowel habits.

3. Factors Affecting Bowel Elimination
Body Position: Sitting or semi-squatting. Gravity increases ease. Bedpan makes it harder to go.
Pain: May put off defecating if painful—hemorrhoids, fissures, episiotomy, surgical incision.
Pregnancy: Pressure on intestines; FeSO₄ (iron) pills constipate
Surgery & Anesthesia: Bowels go to sleep too; May take days to wake up. Then pain meds also constipating.
Medications: SE of opioids and Fe = Constipation. May need laxatives, stools softeners, anti-diarrhea agents
Diagnostic Procedures: May need to empty colon before. If BA is used, laxatives ordered afterwards—stool will be chalky and light colored after BE.

4. Altered Bowel Function
Constipation
Decreased frequency of BMs and/or prolonged or difficult passage of hard stools
“Normal” frequency is highly individualized, however “normal” frequency has been suggested as anywhere from 3x/day to 3x/week
May be due to decreased bulk, fluid intake, or muscle tone, insufficient exercise, ignoring the defecation reflex, or laxative abuse

5. Altered Bowel Function
Fecal Impaction: Accumulation of hardened feces in the rectum; lodged or stuck
Unrelieved constipation
Signs include oozing diarrhea, anorexia, abdominal distension, cramping, N/V, and/or rectal pain.
Usually a history of no BM for several days
Can also be caused by Barium

6. Altered Bowel Function
Diarrhea
Increased number of stools and passage of liquid, unformed feces
Can lead to F/E imbalance (F/E = fluid electrolyte)
Possible causes – ABT, enteral nutrition, food allergies/intolerances, C. difficile, surgery, diagnostic tests
ABT kill the normal flora of the gut (ABT= antibiotic therapy)

7. Altered Bowel Function
Fecal Incontinence
May be secondary to diarrhea
Possible causes include SCI, CVA, infection, impaction, depression, sedatives, etc.
Can cause body image alterations, embarrassment, or skin breakdown

8. Altered Bowel Function
Flatulence – certain foods increase amount of gas: cabbage, onions, beans, high fiber foods
Intestinal gas
Inability to pass flatus can cause abdominal distension, SOB, feeling of fullness or cramping; abdomen may look large or distended.
Possible causes include opiates, general anesthesia, abdominal surgery, or immobility

9. Altered Bowel Function
Hemorrhoids
Distended rectal veins
May be due to repeated straining at stool passage
Symptoms may include itching, bleeding, or burning after defecation, pain when sitting.

10. Assessment Nursing History
Usual bowel elimination patterns: daily or q 2-3 days?
Symptoms of altered bowel elimination patterns
Factors affecting bowel elimination
Ask: What is usual pattern? Characteristics of usual stool? Any aids used? When was last BM? Any changes in BM?

11. Assessment Physical Assessment
Inspection of abdomen – Is it flat? Convex? Contour? Concave? Distended? Symmetry?
Ascultation – Listen for 5 full minutes p “no BS’s”. Are the BS hypo/hyper active?
Palpation – Light only for beginners
Measurement of abdominal girth – “X” mark, tape measure.
Peri-rectal examination – side lying, knees flexed. Fissures? Hemmorhoids? Bleeding? DRE – use lubed, gloved finger. Feel walls of rectum, feel for stool.

12. Assessment Fecal Characteristics – Table 32-1 on page 1071 Abnormal
Normal Color – brown
Consistency – soft is normal
Shape – cylindrical
Odor – pungent, aromatic
Amount – gms/day is normal
Frequency – varies greatly
Abnormal
Black/tarry – indicates upper GI bleed or meds
Red – lower GI bleed or rectum/hemorrhoids
White/clay colored – barium or blocked bile system
Bloody mucus – Clostridium difficile or parasites

13. Assessment Specimen Collection
Must be properly collected, labeled in correct container, and preservatives added if necessary.
Hand washing and gloves; use tongue blade when collecting
Make sure specimen is not mixed with urine or toilet paper.
Need 1” of formed stool or mL of liquid stool.
Label with the date, time, and your initials

14. Assessment Diagnostic Tests & Procedures
Fecal Occult Blood Test (Occult = hidden, not obvious)
Screening test for colon CA
Detects microscopic or occult blood in stool
May also be used to detect blood in stomach contents
Often referred to as Hemoccult
Should avoid certain foods and drugs as may cause false positive
Usually repeated a total of three times.
Know Procedure 32-1 on pp

16. Assessment Diagnostic Tests and Procedures
Stool for culture- looking for causes like Shigella, Salmonella, Clostridium difficile
Stool for ova and parasites—like Giardia and Entamoeba histolytica. Send specimen to lab while still warm.

17. Assessment Diagnostic Tests & Procedures (continued) Radiographic
Barium swallow – looks at upper GI
Barium enema – looks at Lower GI tract
Endoscopic
Sigmoidoscopy – rectum and sigmoid colon
Colonoscopy – colon up to the ileocecal valve
Esophogastroduodenoscopy (EGD) – thru the mouth
Nursing Actions for these: Bowel prep, NPO teaching
After barium, laxatives until no more white stools

18. Nursing Diagnosis Constipation
Perceived Constipation—patient makes self diagnosis and ensures a BM by taking laxatives
Risk for Constipation
Diarrhea
Bowel Incontinence

19. Implementation
Constipation – Nurse is responsible for teaching how to avoid bowel problems.
Response to the urge to defecate – don’t ignore
Privacy and sufficient time – be sure to provide
Adequate fluid intake – 1, mL/d
Positioning – upright as possible
Activity – increases peristalsis
Fiber – Increase bulk to increase stools
Laxatives, suppositories, and enemas – teach to use sparingly; Table 32-4 pg, 1088

20. Implementation Fecal Impaction Must have an MD order
Avoid forceful pressure as it can cause mucosal irritation and bleeding
Monitor vital signs – HR can decrease with vagal stimulation
Enema: small vol = 150 mL, large vol = 1000 mL
Lubrication with oil-retention enemas

21. Implementation Diarrhea Remove cause
Respond promptly – dehydration or F/E imbalance possible
Antidiarrheal agents pg. 1088, table 32-5
Maintain fluid/electrolyte balance
Skin barriers
Avoid irritation
Promote return to normal bowel flora – yogurt, acidophyllus milk
Flexi-seal tube, if no relief

22. Implementation Flatulence Increased activity Avoid gas-producing foods
Positioning
Return-flow enema
NGT or rectal tube
Anti-flatulence agents – Gaviscon, Beano, etc.

23. Implementation Hemorrhoids Promote soft, formed stools
Local heat or sitz bath
Thermometers/enemas
Moist wipes for cleansing
Prescribed ointments/creams

24. Bowel Diversion Defecate – bowel exits through abdominal wall
“Stoma” should be healthy pink
Ileostomy – stool more liquid
Transverse or Sigmoid Colostomy – stool soft to firmer stool
Ostomy Appliance – cut to fit around stoma
Check skin around stoma frequently