1. Terms and Definitions
• Bowel obstruction – a blockage in the intestine
• Constipation – the passage of unusually dry, hard stools
• Defecation – passing feces from the body
• Diarrhea – frequent passage of liquid stool
• Distention – the state of being inflated or enlarged
• Feces – waste products in the bowel; same as stool or BM
• Flatus – gas in the bowel
• Hemorrhoids – varicose veins in the rectum that can become swollen and painful and may itch and bleed
• Impaction – hard stool that cannot pass from the rectum normally
• Peristalsis – wavelike movement of the digestive tract that pushes food along intestinal tract
• Suppository – a semisolid substance that may contain medicine that dissolves when inserted into the rectum or vagina

2. Digestive System (See Figure 2.1.)
• Organs
Mouth
Salivary glands
Esophagus
Liver
Gall bladder
Stomach
Pancreas
Large and small intestines
Appendix
Rectum
Anus

3. Figure 2.1 – The Digestive System

4. Digestive System • Functions
Ingests and prepares food for use by the body
Excretes wastes
• Aging process
Need for calories decreases, but nutritional needs remain the same or increase.
Constipation occurs due to slower peristalsis.
• Related health problems
Diarrhea
Constipation
Impaction
Incontinence

5. Digestive System • Nursing care
Encourage adequate fluid intake – 2,000 to 3,000 cc per day.
Encourage residents to eat foods on their tray that are high in fiber to minimize constipation.
Encourage the resident to be active to improve peristalsis.
Monitor frequency and consistency of stools.
Provide good peri care for dependent resident.

6. Factors That Maintain Normal Bowel Elimination
• Diet containing fiber
Fiber holds water in the wastes in the colon and makes the stool softer.
Fibrous foods are slightly irritating to the bowel and move wastes along more rapidly.
Nursing responsibilities – Encourage residents to eat foods on their tray that are high in fiber to minimize constipation.
• Fresh fruits
• Fresh vegetables
• Prunes
• Bran

7. Factors That Maintain Normal Bowel Elimination
• Fluids
Fluids make the stool softer and increase the bulkiness of the stool.
Nursing responsibilities
• Provide 2,000-3,000 cc of fluids per 24 hours.
• Maintain I&O record as ordered.
• Activity
Physical activity, such as ambulation, produces a “massaging” action of the abdominal muscles to the intestines, promoting peristalsis.

8. Factors That Maintain Normal Bowel Elimination
Nursing responsibilities
• Encourage ambulation, if possible.
• If resident is on bed rest or confined to a W/C, encourage active ADL, ROM, and change position every 2 hours, or according to care plan.

9. Factors That Maintain Normal Bowel Elimination
• Habit
Each individual defecates at a certain time of day, sometimes more easily after eating or drinking certain foods or fluids.
Usually has more success if privacy is offered
Nursing responsibilities
• Find out from resident or family member past bowel habits – how often, time of day, any routine assistance from suppositories/enemas/medications.
• Provide privacy and try to maintain past habits.

10. Characteristics of Normal Stool
• Color – light to dark brown
• Consistency – soft and formed
• Frequency – three times a day to every other day; varies with each individual
• Amount – approximately a 3-inch circle of fecal material as an example of a small amount, a 6-inch circle for moderate, and a 12-inch circle for a large amount (Some facilities refer to cup size for amount of stool.)

11. Characteristics of Abnormal Stool
• Smells unusual
• Is not brown (green, black, white, or yellow)
• Black stool may be caused from bleeding in the gastrointestinal tract or stomach (ulcers)
• Contains undigested food, blood, or mucus
• Is very large or small or pencil shaped
• Is liquid
• Is hard

12. Nursing Responsibilities
• Maintain privacy with resident when inquiring about BMs.
• Notify the charge nurse if a resident does not have a BM for 2 days.
• Document all BMs per facility policy.
• Notify the charge nurse of any abnormalities as listed in section V.

13. Conditions That Cause Abnormal Bowel Function
• Constipation – passage of unusually dry, hard stools. When stool is in rectum for too long, water is absorbed from it.
• Impaction – hard mass of stool forms in the bowel that cannot be passed normally
Liquid stool passes around the blockage.
May also note stool incontinence, pain, discomfort, and abdominal distention.
A licensed nurse may give an enema or digital exam to assist in removal.

14. Conditions That Cause Abnormal Bowel Function
• Diarrhea – frequent passage of liquid stools
Note color, consistency, amount, and frequency of stool. Report to charge nurse if stool smells unusual; is not dark brown; contains undigested food, blood, or mucus; or is liquid or hard.
Encourage p.o. fluids if not vomiting, preferably clear liquids.
Keep perineal area clean and dry.
• Hemorrhoids – a varicose vein in the rectum, which may protrude from the anus and may be very tender and may bleed from irritation.
Can be aggravated by straining due to constipation.
Lay term is “piles.”
Note resident’s complaint of pain and itching or any blood on outside of stool. Report to charge nurse.

15. Conditions That Cause Abnormal Bowel Function
• Bowel obstruction – a blockage in the bowel; stool cannot pass through
Twisting of bowel, tumor, or large impaction of stool may cause bowel obstruction.
Note resident’s complaint of pain, abdominal distention, no passing of stool for 2 days. Report to charge nurse.
• Bowel incontinence – inability to stop or control passage of stool. Factors that can lead to bowel incontinence are the following:
Confusion – unable to understand where/when resident is passing stool
Sphincter muscle weakness allows stool to pass.
Damage to nervous system may prevent message from getting to resident’s brain when feeling urge.

16. Conditions That Cause Abnormal Bowel Function
• Limited mobility and lack of assistance in getting to the bathroom – Resident has a problem with meeting normal need to defecate because he/she cannot hold stool if not taken to bathroom as soon as he/she feels the urge.
• Some residents may be candidates for bowel retraining. See Unit VI, Lesson 3, Bladder & Bowel (B&B) Retraining, for further information.

17. Factors That Can Lead to Constipation
• Bed rest – inactivity and difficulty in using bedpan due to position. It is difficult to pass stool with legs straight out rather than being in a sitting position.
• Inadequate fluid intake – Fluid that is in stool is absorbed by the body from the bowel.
• Lack of fibrous food in diet
• General lack or limited activity
• Unable to defecate at usual time or place or without privacy
• Medications can cause constipation, e.g., codeine.
• Depression – The entire body is slowed down.

18. Special Measures for Abnormal Bowel Function
These measures must be ordered by the physician:
• Medications – administered by a licensed nurse or medication technician
Laxatives – taken by mouth
Rectal suppository – to increase peristalsis and empty the bowel
• Enema – infusion of fluid into the rectum to remove stool; administered by a licensed nurse

19. Special Measures for Abnormal Bowel Function
• Colostomy/ileostomy – creating of an artificial opening in the abdominal wall (called a stoma) and bringing a section of the colon or ileum to it; the elimination of feces through a stoma
The location of the ostomy determines whether the stool is formed, soft and mushy, semiliquid, or liquid. (See Figure 2.2.)
Depending on the consistency of the stool, the stoma may be covered with a simple dressing, a drainage pouch called an appliance, or any ostomy bag that is attached over the stoma.
Proper stoma care is required to maintain healthy tissue. If a resident has an ileostomy, the drainage contains digestive enzymes that are irritating to the skin.

20. Figure 2.2 – Ostomy Locations

21. Special Measures for Abnormal Bowel Function
The nurse assistant should observe for:
• Leakage
• Odor
• Redness or skin irritation around the stoma
• Bleeding
Care of the ostomy – Keep the area clean and dry and apply the fecal ostomy pouch.
NOTE: See the updated procedures for care/application of a fecal ostomy pouch.
CAUTION: The nurse assistant may provide care ONLY for an established colostomy, never for a new colostomy that requires care given by the licensed nurse.

22. Conclusion
The elimination of stool is usually a daily occurrence for each resident. Remember to respect his/her privacy and not embarrass the resident by your comments or actions. Also remember the nursing measures to promote proper bowel functioning. It is vital for the comfort of your resident.

23. Steps of Procedure for Colostomy Care/Application of a Fecal Ostomy Pouch (Uncomplicated Established Colostomy)
1. Gather equipment.
2. Identify and greet resident. Identify self.
3. Provide privacy.
4. Explain what you are going to do.
5. Wash your hands and put on gloves.
6. Raise bed to HIGH position.
7. Place bath blanket over resident and fold top linens down to hips. Follow manufacturer’s directions regarding equipment.
8. Remove old pouch by pushing against skin as you pull off the pouch. Discard in plastic bag, saving the clip. Note the amount and type of drainage and feces.

24. Steps of Procedure for Colostomy Care/Application of a Fecal Ostomy Pouch (Uncomplicated Established Colostomy)
9. Cleanse area around stoma with warm water and soap. Clean the skin of the stoma and rinse with gentle strokes. Pat dry. (See Figure 2.3)
10. Observe skin around the stoma for redness or breakdown.
Figure 2.3 – Cleaning Stoma Area
11. Measure stoma with measuring guide. Cut pouch 1/8 inch larger than measurement to prevent pressure to stoma.
12. Apply skin barrier paste to peristomal area. Wet gloved fingers and spread paste around stoma.

25. Steps of Procedure for Colostomy Care/Application of a Fecal Ostomy Pouch (Uncomplicated Established Colostomy)
13. Remove paper from adhesive area on pouch. Center and apply clean pouch over stoma. See Figure 2.4.
14. Press adhesive around stoma to form a wrinkle-free seal.
Figure 2.4 – Securing Pouch
15. Secure end of pouch with plastic clip. (Some pouches have clips; others do not.)
16. Remove gloves and wash hands.
17. Make resident comfortable and place call signal within reach.
18. Report completion of procedure and observations to the charge nurse.