1. Chapter 46 Bowel Elimination
Regular elimination of bowel waste products is essential for normal body functioning. Alterations in bowel elimination are often early signs or symptoms of problems within the gastrointestinal (GI) or other body systems. Because bowel function depends on the balance of several factors, elimination patterns and habits vary among individuals.
Understanding normal bowel elimination and factors that promote, impede, or cause alterations in elimination helps in management of patients’ elimination problems. Supportive nursing care respects the patient’s privacy and emotional needs. Measures designed to promote normal elimination need to minimize discomfort for the patient.

2. Organs of the Gastrointestinal (GI) Tract
Organs of the gastrointestinal (GI) tract are shown, with the heart as the reference point.
The GI tract is a series of hollow mucous membrane–lined muscular organs. These organs absorb fluid and nutrients, prepare food for absorption and use by body cells, and provide for temporary storage of feces.
The GI tract absorbs high volumes of fluids, making fluid and electrolyte balance a key function of the GI system. In addition to ingested fluids and foods, the GI tract receives secretions from the gallbladder and pancreas.
Digestion begins in the mouth and ends in the small intestine. The mouth mechanically and chemically breaks down nutrients into a usable size and form. The teeth masticate food, breaking it down into a size suitable for swallowing. Saliva, produced by the salivary glands in the mouth, dilutes and softens the food in the mouth for easier swallowing.
As food enters the upper esophagus, it passes through the upper esophageal sphincter, a circular muscle that prevents air from entering the esophagus and food from refluxing into the throat. The bolus of food travels down the esophagus and is pushed along by peristalsis, which propels it through the length of the GI tract.
As food moves down the esophagus, it reaches the cardiac or lower esophageal sphincter, which lies between the esophagus and the upper end of the stomach. The sphincter prevents reflux of stomach contents back into the esophagus.
The stomach performs three tasks:
Storing of swallowed food and liquid
Mixing of food, liquid, and digestive juices
Emptying of its contents into the small intestine. It produces and secretes hydrochloric acid (HCl), mucus, the enzyme pepsin, and intrinsic factor. Pepsin and HCl facilitate the digestion of protein. Mucus protects the stomach mucosa from acidity and enzyme activity. Intrinsic factor is essential for the absorption of vitamin B12.
[Shown is Figure 46-1 from text p ]

3. Case Study
Mr. Gutierrez resides in an assisted-living apartment of a long-term care center. He keeps busy in his small garden plot and enjoys other activities of the center, such as nightly card games and outings to baseball games. He is 82 years old and widowed and has lived in the area for longer than 3 years. His family, with whom he is quite close, is scattered across the country. He has one niece, who lives in the same town. Mrs. Gutierrez feels he is in good health; as long as he eats green chili peppers every day, he believes he will remain healthy.
[Ask the class: What concerns would you have about Mr. Gutierrez’ health?]

4. Segmented and Peristaltic Waves
This is a diagram of segmented and peristaltic waves.
Segmentation and peristaltic movement in the small intestine facilitate both digestion and absorption. Chyme mixes with digestive juices (e.g., bile, amylase). Resorption in the small intestine is so efficient that, by the time the chyme reaches the end of the small intestine, it is pastelike in consistency. The small intestine has three sections: the duodenum, the jejunum, and the ileum. The duodenum is approximately 20 to 28 cm (8 to 11 inches) long and continues to process chyme from the stomach. The jejunum is approximately 2.5 m (8 feet) long and absorbs carbohydrates and proteins. The ileum is approximately 3.7 m (12 feet) long and absorbs water, fats, certain vitamins, iron, and bile salts. The duodenum and the jejunum absorb most of the nutrients and electrolytes. The intestinal wall also absorbs nutrients across the mucosa and into lymph fluids or blood vessels. Substances such as plant fiber, which the small intestine cannot digest, empty into the cecum at the lower right side of the abdomen. The large intestine begins at the cecum.
[Shown is Figure 46-2 from text p ]

5. Divisions of the Large Intestine
This figure shows divisions of the large intestine.
The lower GI tract is called the large intestine (colon) because it is larger in diameter than the small intestine. The large intestine is shorter (1.5 to 1.8 m [5 to 6 feet]) but much wider than the small intestine. The large intestine is divided into the cecum, colon, and rectum. The large intestine is the primary organ of bowel elimination. It is positioned like a question mark, partially encircling the small intestine.
Chyme enters the large intestine by waves of peristalsis through the ileocecal valve, a circular muscular layer that prevents regurgitation. The colon is divided into the ascending, transverse, descending, and sigmoid colons. The muscular tissue of the colon allows it to accommodate and eliminate large quantities of waste and gas (flatus). It has three functions: absorption, secretion, and elimination.
The large intestine absorbs water, sodium, and chloride from digested food that has passed from the small intestine. Healthy adults absorb more than a gallon of water and an ounce of salt from the colon every 4 hours. The amount of water absorbed from chyme depends on the speed at which colonic contents move. Chyme is normally a soft, formed mass. If peristalsis is abnormally fast, there is less time for water to be absorbed, and the stool is watery. If peristaltic contractions slow, water continues to be absorbed, and a hard mass of stool forms, resulting in constipation.
The secretory function of the colon aids in electrolyte balance. The colon secretes bicarbonate in exchange for chloride. The colon excretes about 4 to 9 me of potassium daily. Therefore serious alterations in colon function (e.g., diarrhea) cause severe electrolyte disturbances.
Slow peristaltic contractions move contents through the colon. Intestinal content is the main stimulus for contraction. Mass peristalsis pushes undigested food toward the rectum. These mass movements occur only 3 or 4 times daily, with the strongest during the hour after mealtime.
The rectum is the final portion of the large intestine. Here, bacteria convert fecal matter into its final form. Normally, the rectum is empty of waste products (feces) until just before defecation. It contains vertical and transverse folds of tissue that help to temporarily hold fecal contents during defecation. Each fold contains an artery and a vein that can become distended from pressure during straining. This distention often results in hemorrhoid formation.
The body expels feces and flatus from the rectum through the anal canal and anus. Contraction and relaxation of the internal and external sphincters, innervated by sympathetic and parasympathetic stimuli, aid in control of defecation. The anal canal is richly supplied with sensory nerves that help to control continence.
[Shown is Figure 46-3 from text p ]

6. Case Study (cont’d)
Because Mr. Gutierrez has a small kitchen in his apartment, he is able to make some of his favorite foods. His diet consists of flour and corn tortillas, beans, and rice. He likes most meats, but he prefers chicken and as ado (made with pork). For breakfast, he usually has hues rancheros. He has been hospitalized only twice—once for the flu and once for placement of a pacemaker.
He presently takes three medications: digoxin, Zestril, and Metamucil.
[Discuss Mr. Gutierrez’ diet, any food groups that may be missing from it, and what effect that could have on his bowel elimination.]
[Discuss Mr. Gutierrez’ medications and what effects they would have on bowel elimination.]

7. Scientific Knowledge Base
Mouth
Digestion begins with mastication.
Esophagus
Peristalsis moves food into the stomach.
Stomach
Stores food; mixes food, liquid, and digestive juices; moves food into small intestines
Small intestine
Duodenum, jejunum, and ileum
Large intestine
The primary organ of bowel elimination
Anus
Expels feces and flatus from the rectum
Here is a recap of major functions of the organs of the GI tract.
These structures are necessary for the defecation process.
Physiological factors critical to bowel function and defecation include normal GI tract function, sensory awareness of rectal distention and rectal contents, voluntary sphincter control, and adequate rectal capacity and compliance. Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, distention causes relaxation of the internal sphincter and awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out.
Sometimes people use the Valsalva maneuver to assist in stool passage. The Valsalva maneuver exerts pressure to expel feces through voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway.
Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool. Normal defecation is painless, resulting in passage of soft, formed stool.

8. Nursing Knowledge Base: Factors Affecting Bowel Elimination
Age
Diet
Fluid intake
Physical activity
Psychological factors
Personal habits
Position during defecation
Pain
Pregnancy
Surgery and anesthesia
Medications, laxatives, and cathartics
Diagnostic tests
Many factors influence the process of bowel elimination. Knowledge of these factors helps to anticipate measures required to maintain a normal elimination pattern.
Mechanical breakdown of food elements, gastrointestinal motility, and selective absorption and secretion of substances by the large intestine influence the character of feces.
Food high in fiber content and increased fluid intake keep feces soft.
Developmental changes affect elimination. Infants have small stomach capacity and rapid peristalsis.
Systemic changes in the function of digestion and in absorption of nutrients result from changes in older patients’ cardiovascular and neurological systems, rather than their GI system.
[See also Table 46-1 on text p Normal Age-Related Changes in the Gastrointestinal Tract.]
Diet and fluid intake will alter elimination. Fiber, the nondigestible residue in the diet, provides the bulk of fecal material. Bulk-forming foods such as whole grains, fresh fruits, and vegetables help flush fats and waste products from the body with greater efficiency. Food intolerance is not an allergy but rather relates to a particular food that causes the body distress within a few hours of ingestion.
The body needs adequate fluid intake to liquefy intestinal contents. Unless a medical contraindication is known, an adult needs to drink six to eight glasses (1500 to 2000 mL) of fluid daily.
Physical activity promotes peristalsis.
During emotional stress, the digestive process is accelerated, and peristalsis is increased. Stress can be a causative factor for colitis, irritable bowel syndrome (IBS), ulcers, and Crohn’s disease.
If a person becomes depressed, the autonomic nervous system slows impulses; peristalsis decreases, resulting in constipation.
Personal habits will influence elimination. Many people prefer their own bathroom facilities and want to use those facilities when possible.
A busy work schedule sometimes prevents the individual from responding appropriately to the urge to defecate, disrupting regular habits and causing possible alterations such as constipation.
Chronically ill and hospitalized patients do not always have privacy, which may affect the defecation process.
Another factor related to defecation is the preferred position. Squatting is the normal position during defecation. Modern toilets facilitate this posture, allowing the person to lean forward, exert intra-abdominal pressure, and contract the thigh muscles. In a supine position, it is impossible to contract the muscles used during defecation. If the patient’s condition permits, raise the head of the bed to assist the patient to a more normal sitting position on a bedpan, enhancing the ability to defecate.
Conditions that cause pain (such as hemorrhoids) often cause the patient to suppress the urge to defecate to avoid pain, contributing to the development of constipation.
As pregnancy advances, the size of the fetus will put pressure on the rectum, which can cause an obstruction. Slowing of peristalsis during the third trimester often leads to constipation.
General anesthetic agents used during surgery cause temporary cessation of peristalsis. Any surgery that involves direct manipulation of the bowel temporarily stops peristalsis. This condition, called paralytic ileus, usually lasts about 24 to 48 hours. If the patient remains inactive or is unable to eat after surgery, return of normal bowel elimination is further delayed.
The use of medications can affect bowel functioning. Even though laxatives and cathartics promote peristalsis, when used inappropriately, the intestines lose muscle tone and become less responsive to medication stimulation.
Following the diagnostic procedure, changes in elimination such as increased gas or loose stools often occur until the patient resumes a normal eating pattern.
[Review Table 46-2 on text p Medications and the Gastrointestinal System.]
Diagnostic examinations such as endoscopy or colonoscopy require bowel preparation. Before and after the procedure, the patient will experience gas and loose stools until a normal eating pattern is resumed.

9. Bristol Stool Form Scale
This diagram shows the Bristol Stool Form Scale.
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or a laxative to prevent constipation. Signs of constipation include infrequent bowel movements (less often than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feces.
When intestinal motility slows, the fecal mass becomes exposed over time to the intestinal walls, and most of the fecal water content is absorbed. Little water is left to soften and lubricate the stool. Passage of a dry, hard stool causes rectal pain.
Constipation is a significant health hazard. Straining during defecation causes problems for the patient with recent abdominal, gynecological, or rectal surgery. The effort to pass a stool often causes sutures to separate, reopening the wound. In addition, patients with a history of cardiovascular disease, diseases causing elevated intraocular pressure (glaucoma), or increased intracranial pressure need to prevent constipation and avoid using the Valsalva maneuver.
Vagal stimulation, which slows the heart rate, occurs during straining while defecating, taking rectal temperatures, completion of enemas, and digital removal of impacted stool.
[See also Box 46-1 on text p Common Causes of Constipation.]
[Shown is Figure 46-4 from text p ]

10. Common Bowel Elimination Problems
Constipation
A symptom, not a disease; infrequent stool and/or hard, dry, small stools that are difficult to eliminate
Impaction
Results from unrelieved constipation; a collection of hardened feces wedged in the rectum that
a person cannot expel
Diarrhea
an increase in the number of stools and the passage of liquid, unformed feces
Incontinence
Inability to control passage of feces and gas to the anus
Flatulence
Accumulation of gas in the intestines causing the walls to stretch
Hemorrhoids
Dilated, engorged veins in the lining of the rectum
Alterations in bowel elimination result from a variety of factors. (See previous slide for discussion of constipation.)
If impaction is unrelieved, it can result in intestinal obstruction.
The greatest danger from diarrhea is development of fluid and electrolyte imbalance. Antibiotics, chemotherapy, and invasive bowel procedures such as surgery or colonoscopy disrupt normal bowel flora and cause an overgrowth of Clostridium difficile; symptoms range from mild diarrhea to severe colitis.
Communicable foodborne pathogens also cause diarrhea. Hand hygiene following use of the bathroom, before and after preparing foods, and when cleaning and storing fresh produce and meats greatly reduces the risk of foodborne illness.
Using an anal bag or a bowel management system for incontinence helps to prevent perineal skin breakdown.
[See Figure 46-5 on text p ]
Flatulence causes abdominal distention and severe, sharp pain if intestinal motility is reduced because of opiates, general anesthetics, abdominal surgery, or immobilization.
Increased venous pressure from straining at defecation, pregnancy, heart failure, and chronic liver disease causes hemorrhoids.

11. Case Study (cont’d)
This afternoon Mr. Gutierrez has telephoned his niece for the fourth time. He reports, “My bowels are locked up and haven’t moved in the last 2 days.” He ate a big meal the previous evening and now reports feeling “all gassed up.”
His niece tried to explain about eating foods containing fiber and more vegetables. She reminded Mr. Gutierrez that the nursing student was coming later this afternoon, and he could talk to the student about his problem.
[Ask the class: What would you do if you were the student nurse and Mr. Gutierrez were your patient?]

12. Bowel Diversion
Temporary or permanent artificial opening in the abdominal wall
Stoma
Surgical opening in the ileum or colon
Ileostomy or colostomy
The standard bowel diversion creates a stoma.
Certain diseases cause conditions that prevent normal passage of feces through the rectum. Treatment for these disorders results in the need for a temporary or permanent artificial opening (stoma) in the abdominal wall. Surgical openings are created in the ileum (ileostomy) or colon (colostomy), with the ends of the intestine brought through the abdominal wall to create the stoma.
The standard bowel diversion creates a stoma, or the patient has reconstructive bowel surgery that uses the native sphincter for bowel continence. Reconstructive surgery includes a continent stoma procedure or an ileoanal pouch anastomosis (described later).

13. Loop Colostomy
In this diagram of a loop colostomy, a loop of colon is exteriorized over a plastic rod for temporary fecal diversion. It is usually a temporary large stoma constructed in the transverse colon.
A loop colostomy is usually performed in a medical emergency when health care providers anticipate closure of the colostomy. The surgeon pulls a loop of bowel onto the abdomen. An external supporting device such as a plastic rod, a bridge, or a rubber catheter is temporarily placed under the bowel loop to keep it from slipping back. The surgeon then opens the bowel and sutures it to the skin of the abdomen. A communicating wall remains between the proximal and distal bowel. The loop ostomy has two openings through one stoma. The proximal end drains stool, whereas the distal portion drains mucus. Within 7 to 10 days, the surgeon removes the supporting device.
[Shown is Figure 46-6 from text p ]

14. End Colostomy
This diagram shows a permanent (end) colostomy. The terminal end of the descending or sigmoid colon is brought out through the peritoneum and muscle and is sutured to the skin.
The end colostomy consists of one stoma formed from the proximal end of the bowel, with the distal portion of the GI tract removed or sewn closed (called Hartmann’s pouch) and left in the abdominal cavity. For many patients, end colostomies are a result of surgical treatment of colorectal cancer. In such cases, the rectum is usually removed. Patients with diverticulitis who are treated surgically often have a temporary end stoma with Hartmann’s pouch.
[Shown is Figure 46-7 from text p ]

15. Double-Barrel Colostomy
This drawing shows a double-barrel colostomy. Both ends of the transected colon are brought out to the skin.
Unlike the loop colostomy, the surgeon divides the intestine and brings proximal and distal ends through the abdominal incision to the abdominal surface when creating a double-barrel colostomy. A small incision is made in the proximal stoma for fecal drainage. The distal stoma leads to the inactive intestine and is left intact. When the intestinal injury has healed, the colostomy is reversed, and the divided ends are anastomosed to restore intestinal integrity.
[Shown is Figure 46-8 from text p ]

16. Ostomies Loop colostomy End colostomy Double-barrel colostomy
This is temporary in the transverse colon.
End colostomy
Proximal end forms stoma, and distal end is removed or sewn closed.
Double-barrel colostomy
Bowel is surgically cut, and both ends are brought through the abdomen.
[This slide presents a summary of the types of ostomies just shown.]
The location of the ostomy will determine the consistency of the stool, which will range from liquid to formed.
A loop colostomy is performed on an emergency basis.
An end colostomy is performed for colorectal cancer and is a permanent procedure.
In the double-barrel colostomy, the proximal end is active and the distal end is nonfunctioning, only producing mucus. The double barrel can be reversed.

17. Case Study (cont’d)
Vickie is the nursing student assigned to Mr. Gutierrez. She has been seeing him once a week for 5 weeks as a portion of a home health care clinical experience. They have developed a good rapport. Mr. Gutierrez’ self-identified problems with his bowels are a frequent topic of conversation.
As Vickie prepares to assess Mr. Gutierrez, she reflects on experiences with other patients in the home setting. She recalls one patient who had elimination problems resulting from a diet consisting mainly of high-fat and high-carbohydrate foods. She believes that her involvement with that patient is likely to help in Mr. Gutierrez’ care.
Reflecting on previous experiences can help improve patient care.
[Ask the class: What do you see as similarities and differences between the problems of Vickie’s former patient and Mr. Gutierrez’ bowel problems?]

18. Ileoanal Pouch Anastomosis
Alternative approaches include an ileoanal pouch anastomosis, a Kock continent ileostomy, and a Macedo-Malone antegrade continence enema.
Shown on this slide are drawings of ileoanal reservoirs (IARs).
A, S-shaped configuration for IAR. Three 10-cm limbs of ileum are used, the antimesenteric surface of each limb is opened, and adjacent bowel walls are anastomosed.
B, J-shaped configuration for IAR. Distal ileum is aligned in J shape, the antimesenteric surface of the J shape is opened, and adjacent bowel walls are anastomosed. Side-to-end anastomosis of bowel to the dentate line is evident.
C, Lateral or side-by-side ileoanal pouch configuration.
The ileoanal pouch anastomosis is a surgical procedure that is used in patients who need to have a colectomy for treatment of ulcerative colitis or familial polyps. In this procedure, the surgeon removes the colon, creates a pouch from the end of the small intestine, and attaches the pouch to the patient’s anus. This pouch provides for the collection of waste material, which is similar to the rectum. The patient is continent of stool because stool is evacuated via the anus.
When the ileal pouch is created, the patient has a temporary ileostomy to allow the anastomosis to heal.
[Shown is Figure 46-9 from text p ]

19. Construction of Kock Pouch
Construction of Kock continent ileostomy—Kock pouch. A, Two 15-cm limbs are used to create a pouch, and one 15-cm limb is used to fashion a nipple valve and stoma. B, Distal limb is intussuscepted into the reservoir to create a one-way valve and to accomplish continence. Sutures or staples or both are placed to stabilize and maintain the intussuscepted nipple. The anterior surface of the reservoir is anchored to the anterior peritoneal wall.
[Shown is Figure from text p ]

20. Macedo-Malone Antegrade Continence Enema (MACE)
This is a diagram of four surgical techniques (A, B, C, D) for the Macedo-Malone antegrade continence enema (MACE) procedure.
The MACE procedure improves continence in patients with fecal soiling associated with neuropathic or structural abnormalities of the anal sphincter. This procedure isolates a 3-cm (1.2-inch) flap on the left colon. A Foley catheter placed on the surface of the flap creates a tubular passage. This produces a continence valve mechanism. The surgeon takes the distal end of the tube and makes a V shape to the skin flap.
Enema administration begins 7 to 10 days after surgery. Patients receive enemas daily. The volume of the enema varies from 250 to 800 mL, and the enema takes 45 to 60 minutes to administer. Colonic evacuation occurs within 30 to 60 minutes.
[Shown is Figure from text p ]

21. Alternative Approaches
Ileoanal pouch anastomosis
Pouch is a reservoir for wastes that are eliminated from the anus.
Kock continent ileostomy
Small intestine forms a pouch, which is emptied several times a day.
Macedo-Malone antegrade continence enema (MACE)
This procedure was developed for patients who have neuropathic or structural abnormalities of the anus.
Psychological considerations
[This slide provides a summary of the three alternative approaches just reviewed.]
A stoma causes serious body image changes, particularly if it is permanent.
After the surgery, patients face a variety of anxieties and concerns, from learning how to manage their stoma to coping with conflicts of self-esteem and body image. Provide emotional support before and after surgery. Patients often perceive a stoma as invasive and disfiguring. However, a well-placed stoma usually does not interfere with the patient’s activities and is concealed with clothing. Nonetheless, even though clothing conceals the ostomy, the patient feels different. Many patients have difficulty maintaining or initiating normal sexual relations.
Important factors affecting reactions to the stoma include the character of fecal secretions and the ability to control them. Foul odors, spillage, or leakage of liquid stools and inability to regulate bowel movements cause the patient to lose self-esteem. The aging process often affects the ability to manage stomas, even in people who have had them for years. You need to recognize and intervene when problems resulting from advanced age such as skin changes, weight loss or gain, visual impairments, or changes in diet occur.
Refer the patient to ostomy support groups such as the United Ostomy Associations of America at which has discussion boards for various types of incontinent and continent diversions and networks. The Wound, Ostomy, and Continence Nurses Society ( wocn.org) provides information and helps patients locate a wound, ostomy, continence nurse (WOCN).

22. Case Study (cont’d)
Vickie reviews her class notes on the anatomy and physiology of the GI system. Vickie reviews the physiological changes that aging produces within the GI system: loss of teeth, taste bud atrophy, decreased secretion of gastric acid, and a slight decrease in small intestine motility.
Vickie will thoroughly assess Mr. Gutierrez’ dietary intake with a 24-hour diet recall. Being familiar with his Hispanic heritage, Vickie anticipates certain food preferences. She knows he does not like the food served at the center and frequently requests “home-cooked” tortillas and green chili peppers from his niece.
[Ask the class: What do Mr. Gutierrez’ symptoms indicate? How will Vickie determine a diagnosis?]

23. Quick Quiz!
1. A newly admitted patient states that he has recently had a change in medications and reports that stools are now dry and hard to pass. This type of bowel pattern is consistent with A. Abnormal defecation. B. Constipation. C. Fecal impaction. D. Fecal incontinence.
Answer: B

24. Case Study (cont’d)
From their last visit, Vickie and Mr. Gutierrez have been able to communicate without difficulty. Mr. Gutierrez complains of feeling “full of gas” but has not “passed any wind” in the past 2 days. His stove has not been working well, and he has been unable to prepare rice and beans. Based on the nursing history, Vickie estimates that Mr. Gutierrez normally drinks about 1200 mL of fluid daily.
[Ask the class: What assessment steps will Vickie want to take?]

25. Nursing Process: Assessment
Nursing history
What a patient describes as normal or abnormal is often different from factors and conditions that tend to promote normal elimination.
Identifying normal and abnormal patterns, habits, and the patient’s perception of normal and abnormal with regard to bowel elimination allows you to accurately determine a patient’s problems.
Focus assessment of elimination patterns on bowel habits, factors that normally influence defecation, recent changes in elimination, and a physical examination.
Assessment of bowel elimination patterns and abnormalities includes a nursing history, physical assessment of the abdomen, inspection of fecal characteristics, and review of relevant test results. In addition, determine the patient’s medical history, patterns and types of fluid and food intake, chewing ability, medications, and recent illnesses and/or stressors.
The nursing history provides a review of the patient’s usual bowel pattern and habits.
[Discuss the following points of assessment:
Determination of the usual elimination pattern: include frequency and time of day
Patient’s description of usual stool characteristics
Identification of routines followed to promote normal elimination
Assessment of the use of artificial aids for home movement
Presence and status of bowel diversions
Changes in appetite: include changes in eating patterns and changes in weight (amount of loss or gain)
Diet history: determine the patient’s dietary preferences for a day
Description of daily fluid intake: this includes the type and amount of fluid
History of surgery or illnesses affecting the GI tract:
Medication history: ask whether the patient takes medications that alter defecation or fecal characteristics
Emotional state: the patient’s emotions significantly alter the frequency of defecation
History of exercise: ask the patient to specifically describe the type and amount of daily exercise.
History of pain or discomfort: ask the patient whether there is a history of abdominal or anal pain.
Social history: patients have many different living arrangements.
Mobility and dexterity: evaluate patients’ mobility and dexterity to determine whether they need assistive devices or help from personnel.]
[Box 46-3 Nursing Assessment Questions on text p presents questions you can ask.]
[See also Figure on p Critical thinking model for elimination assessment and Box 46-2 on p Cultural Aspects of Care Variables Influencing Colorectal Cancer Screening in African Americans.]

26. Assessment Physical assessment Laboratory tests
Mouth, abdomen, and rectum
Laboratory tests
Fecal characteristics
Fecal specimens
Diagnostic examinations
Radiologic imaging, with or without contrast
Endoscopy
Ultrasound
Computed tomography (CT) or magnetic resonance imaging (MRI)
Physical assessment will include the examination of oral cavity, abdomen, rectum, and anus. Problems in any one of these areas will affect the GI system and proper functioning.
Inspect the patient’s teeth, tongue, and gums. Poor dentition or poorly fitting dentures influence the ability to chew. Sores in the mouth make eating not only difficult but also painful.
Inspect all four abdominal quadrants for contour, shape, symmetry, and skin color. Note masses, peristaltic waves, scars, venous patterns, stomas, and lesions. Normally, you do not see peristaltic waves. Observable peristalsis is often a sign of intestinal obstruction. Check for abdominal distention, and auscultate all four abdominal quadrants. Gently palpate the abdomen for masses or areas of tenderness.
Inspect the area around the anus for lesions, discoloration, inflammation, and hemorrhoids.
Indirect and direct visualization of the lower GI tract requires cleansing of the bowel before the procedure.
Laboratory and diagnostic examinations yield useful information concerning elimination problems. Laboratory analysis of fecal contents detects pathological conditions such as tumors, bleeding, parasites, and infection.
Inspection of fecal characteristics reveals information about the nature of elimination alterations. Several factors influence each characteristic. Knowing whether any recent changes have occurred is key in assessment. The patient best provides this information during the nursing history.
[See Table 46-4 on text p Fecal Characteristics.]
[Fecal specimens are discussed on the later slides.]
[Table 46-3 on text p presents laboratory tests and diagnostic examinations for bowel function.]
A variety of radiological and diagnostic tests are used with the patient who is experiencing altered bowel elimination. Direct or indirect approaches are used to visualize GI structures.
Many facilities use moderate sedation during these procedures. The types of drugs most commonly used to achieve moderate sedation include benzodiazepines and opiates. It is essential to understand the safety precautions involved concerning this form of anesthesia. In many institutions, special training is required. A crash cart must be present at the bedside, and you must monitor the patient continuously with pulse oximetry and frequent vital signs—usually every 15 minutes.
[Review Box 46-6 on text p Radiological and Diagnostic Tests.]

27. Case Study (cont’d)
Determine when Mr. Gutierrez had his last bowel movement.
He had his last bowel movement 2 days ago. The stool was brown and hard. “I took a laxative last night, and I think I need an enema.”
Determine Mr. Gutierrez’ medication history.
A medication history shows that Mr. Gutierrez frequently resorts to taking laxatives.
Establish Mr. Gutierrez’ dietary habits.
Mr. Gutierrez eats a high intake of corn tortillas and cheese and a low intake of fruits. He states, “I really haven’t felt like eating today and have not eaten much for the last 4 days.”
Assess Mr. Gutierrez’ abdomen.
Hypoactive bowel sounds in all four quadrants. Abdomen is soft but slightly distended.
[Ask the class: What nursing diagnosis would Vickie choose? What goals would she set?]

28. Fecal Occult Blood Testing
The photo shows equipment for performing fecal occult blood testing.
The nurse ensures that specimens are obtained accurately, labeled properly in appropriate containers, and transported to the laboratory on time. Institutions provide special containers for fecal specimens. Some tests require that specimens are placed in chemical preservatives.
Use medical aseptic technique during collection of stool specimens. Because about 25% of the solid portion of a stool consists of bacteria from the colon, wear clean gloves when handling specimens.
Hand hygiene is necessary for anyone who comes in contact with the specimen. Often the patient is able to obtain the specimen if properly instructed. Teach the patient to avoid mixing feces with urine or water. The patient defecates into a clean, dry bedpan or a special container under the toilet seat. Tests performed by the laboratory for occult (microscopic) blood in the stool and stool cultures require only a small sample.
Collect about 2.54 cm (1 inch) of formed stool or 15 to 30 mL of liquid diarrhea stool. Tests for measuring the output of fecal fat require a 3- to 5-day collection of stool. You need to save all fecal material throughout the test period.
After obtaining a specimen, label and tightly seal the container, and complete all laboratory requisition forms. Record specimen collections in the patient’s medical record. It is important to avoid delays in sending specimens to the laboratory. Some tests such as measurement for ova and parasites require the stool to be warm. When stool specimens remain at room temperature, bacteriological changes that alter test results may occur.
[Shown is Figure from text p ]

29. Fecal Occult Blood Testing (cont’d)
A common laboratory test that patients perform at home or nurses perform at the patient’s bedside is the fecal occult blood test (FOBT), or guaiac test, which measures microscopic amounts of blood in feces.
These photos show two of the steps in FOBT. On the left is the application of a fecal specimen on guaiac paper. On the right is the application of Hemoccult developing solution on guaiac paper on the reverse side of the test kit.
It is useful as a diagnostic screening tool for colon cancer. The noninvasive FOBT is one of five colorectal cancer screening regimens recommended by the American Cancer Society. Three types of FOBT are available to date. They include the most commonly used guaiac fecal occult blood test (gFOBT), the immunochemical fecal occult blood test (iFOBT), and the stool deoxyribonucleic acid (DNA) test.
One positive gFOBT result does not confirm GI bleeding. You need to repeat the test at least 3 times while the patient refrains from ingesting foods (e.g., some raw vegetables, red meat, poultry, fish) and medications (e.g., vitamin C, aspirin, nonsteroidal anti-inflammatory drugs) that cause false-positive results.
Patients who take anticoagulants or who have a bleeding disorder or a GI disorder known to cause bleeding (e.g., intestinal tumor, bowel inflammation, ulcerations) need regular screening for fecal occult blood.
[Review Box 46-4 on p Procedural Guidelines: Performing a Guaiac Fecal Occult Blood Test; and Box 46-5 on p Screening for Colon Cancer.]

30. Nursing Diagnosis and Planning
The Agency for Healthcare Research and Quality (AHRQ) provides guidelines on reduction of pressure ulcers that can also help you develop a plan of care for patients with bowel incontinence.
Constipation
Risk for constipation
Perceived constipation
Bowel incontinence
Diarrhea
Toileting self-care deficit
Examples of diagnoses that apply to patients with elimination problems are shown on the slide.
Rely on professional standards when planning. Guidelines on incontinence assist in protecting the patient’s skin, promoting continence, and reducing the embarrassment associated with incontinence.
Help patients establish goals and outcomes by incorporating their elimination habits or routines as much as possible and reinforcing the routines that promote health.
[See also Box 46-7 on text p Nursing Diagnostic Process: Diarrhea Related to Food Intolerance; Figure on text p Critical thinking model for elimination planning; Nursing Care Plan on p Constipation Related to Opiate-Containing Pain Medication and Decreased Fiber Intake; and Figure Concept map on p ]

31. Case Study (cont’d)
Nursing diagnosis: Constipation related to less than adequate fluid and dietary intake and chronic laxative use
Goals:
Mr. Gutierrez will establish and maintain a normal defecation pattern within 1 month.
Mr. Gutierrez will identify practices that reduce the risk for or prevent constipation within 2 weeks.
[Ask the class: What expected outcomes would Vickie set to demonstrate achievement of these goals?
Discuss:
Mr. Gutierrez will have a bowel movement within 48 hours.
Mr. Gutierrez’ abdomen will be soft, nondistended, and nontender within 24 hours.
Mr. Gutierrez will pass soft, formed stools at least every 3 days.
Mr. Gutierrez will identify the need to increase the fiber content of his diet within 1 week.
Mr. Gutierrez will immediately discontinue laxative use and will use fiber supplements when needed.
Mr. Gutierrez will identify the need to drink eight 8-ounce glasses of noncaffeinated beverages within 3 days.]

32. Implementations: Acute Care
Health promotion
Promotion of normal defecation
Establish a routine an hour after a meal, or maintain the patient’s routine.
Sitting position
Privacy
Positioning on bedpan
Successful nursing interventions improve patients’ and family members’ understanding of bowel elimination. Teach the patient and family about proper diet, adequate fluid intake, and factors that stimulate or slow peristalsis such as emotional stress. This is often best done during the patient’s mealtime. Patients need to learn the importance of establishing regular bowel routines, performing regular exercise, and taking appropriate measures when elimination problems develop.
One of the most important habits to teach regarding bowel habits is taking time for defecation. To establish regular bowel habits, a patient needs to know when the urge to defecate normally occurs. Advise the patient to begin establishing a routine during a time when defecation is most likely to occur, usually an hour after a meal. When patients are restricted to bed or need help to ambulate, offer a bedpan, or help them reach the bathroom in a timely manner.
Many patients have established routines for defecation. In a hospital or long-term care facility, make certain that treatment routines do not interfere with the patient’s routine. It is important to provide privacy. When patients forced to use a bedpan share rooms with other people, pull the curtain around the area so patients are able to relax, knowing that interruptions will not occur. Always place the call light and toilet tissue within the patient’s reach. When patients are at risk for falls, stand near them or leave the door partially open so you can see them at all times.
A number of interventions stimulate the defecation reflex, affect the character of feces, or increase peristalsis to help patients evacuate bowel contents normally and without discomfort.
Assist patients who have difficulty sitting because of muscular weakness and mobility problems. Place an elevated seat on the toilet when patients are unable to lower themselves to a sitting position because of joint- or muscle-wasting disease. These seats require patients to use less effort to sit or stand.
Maintain the patient’s privacy during bowel elimination. This is especially important for the patient who is using a bedpan. The call light and a supply of toilet paper need to be within easy reach. When the patient finishes, respond to the call signal immediately and remove the pan. The patient often requires assistance with wiping. To remove the pan, ask the patient to roll off to the side or to raise the hips. While wearing gloves, hold the pan steady to avoid spilling. Avoid pulling or shoving it from under the patient’s hips because this pulls the patient’s skin and causes tissue injury such as shearing. Remove the pan and clean the perineum from front to back.
After assessing the stool, immediately empty the contents of the bedpan into the toilet or into a special receptacle in the utility room. A spray faucet attached to most toilets provides the ability to rinse the bedpan thoroughly. The patient uses the same bedpan each time. Finally, document the characteristics of the feces.
Offer the bedpan often. Patients will accidentally soil bedclothes if forced to wait. Many patients try to avoid using a bedpan because it is embarrassing and uncomfortable. They often try to get to the bathroom even though their condition prohibits ambulation. Warn patients about the risks of falls or accidents.
(Positioning on a bedpan is discussed in the next few slides.)

33. Types of Bedpans
This photo shows the two types of bedpans. On the left is a regular bedpan, and on the right is a fracture bedpan.
The regular bedpan (on the left), made of plastic, has a curved smooth upper end and a sharper-edged lower end and is about 5 cm (2 inches) deep. The smaller fracture pan, designed for patients with lower extremity fractures, has a shallow upper end about 1.3 cm (1 2 inch) deep. The shallow end of the pan fits under the buttocks toward the sacrum; the deeper end, which has a handle, goes just under the upper thighs.
Patients restricted to bed use bedpans for defecation. Women use bedpans to pass both urine and feces, whereas men use bedpans only for defecation. Sitting on a bedpan is extremely uncomfortable. Help position patients comfortably. The pan needs to be high enough that feces enter it. When positioning a patient, it is important to prevent muscle strain and discomfort. Never try to lift a patient onto a bedpan.
Never place a patient on a bedpan and then leave with the bed flat unless activity restrictions demand it. If the bed is flat, the hips remain hyperextended.
[Shown is Figure from text p ]

34. Proper and Improper Position on a Bedpan
Proper positioning on a bedpan allows the patient to assume a position similar to squatting without experiencing muscle strain.
This drawing shows proper (top) and improper (bottom) positions on a bedpan. The proper position shown on top reduces patients’ back strain.
The bottom improper position is not conducive to defecation.
The best method for bedpan placement is to first be sure that the patient is positioned high in bed. Then raise the patient’s head about 30 degrees to prevent hyperextension of the back and provide support to the upper torso.
The patient then raises the hips by bending the knees and lifting the hips upward. Place a hand palm up under the patient’s sacrum, resting the elbow on the mattress and using it as a lever to help in lifting while slipping the pan under the patient. Patients who have undergone abdominal surgery are hesitant to exert strain on suture lines and often have difficulty positioning on a pan.
Always wear gloves when handling a bedpan.

35. Positioning Immobilized Patient on Bedpan
When patients are immobile or it is unsafe to allow them to raise their hips, they remain flat and roll onto the bedpan by using the following steps:
1. Lower the head of the bed flat, and help the patient roll onto one side, backside toward the nurse.
2. Apply a small amount of powder to back and buttocks, or cover bedpan edge with tissue to prevent skin from sticking to the pan.
3. Place the bedpan firmly against the buttocks, down into the mattress, with the open rim toward the patient’s feet.
4. Keeping one hand against the bedpan, place the other around the patient’s fore hip. Ask the patient to roll back onto the pan, flat in the bed. Do not shove the pan under the patient.
5. With the patient positioned comfortably, raise the head of the bed 30 degrees.
6. Place a rolled towel or a small pillow under the lumbar curve of the patient’s back for added comfort.
7. Raise the knee gatch or ask the patient to bend the knees to assume a squatting position. Do not raise the knee gatch if contraindicated.

36. Case Study (cont’d)
Instruct Mr. Gutierrez in a weekly menu plan, including foods high in fiber: brown rice, beans and rice, tomatoes, and wheat tortillas.
Add bran flakes, bran, or fiber supplement to Mr. Gutierrez’ diet.
Consult with Mr. Gutierrez’ niece and long-term care center to have the patient’s stove repaired.
Educate Mr. Gutierrez about the use of liquids to promote softening of stool and defecation; have him drink a decaffeinated beverage of choice.
Encourage Mr. Gutierrez to try to establish a routine time for defecation, establishing a routine after breakfast or another meal.
[Discuss with the class the rationale for each intervention:
High-fiber foods increase the bulk of fecal contents, which, in turn, increases peristalsis and improves the movement of intestinal contents through the GI tract.
Bran as flakes or fiber supplements add bulk to the feces and increase the number of soft-formed stools. Dietary fiber, through diet or supplement, reduces the need for laxatives.
Cooking facilities are necessary for preparation of selected food preferences.
Caffeinated beverages cause the body to increase excretion of fluids and dehydrate the patient. Fluids help to keep the fecal mass soft and increase stool bulk, causing an increase in colon peristalsis.
With aging, some normal changes are noted in rectal sensation, and the body needs larger volumes to elicit the sensation to defecate. Using the normal gastrocolic reflex, which results in movement of colon contents approximately 1 hour a meal, assists in establishing routine bowel habits.]

37. Acute Care: Medications
Cathartics and laxatives
Oral, tablet, powder, and suppository forms
Excessive use increases risks for diarrhea and abnormal elimination.
Antidiarrheal agents
Over the counter
Opiates used with caution
Changes in the patient’s fluid status, mobility patterns, nutrition, and sleep cycle, as well as surgical interventions, affect regular bowel habits.
Ongoing use of cathartics, laxatives, and enemas affects and delays normal defecation reflexes.
Cathartics, laxatives, and occasionally an enema are used to resolve constipation; antidiarrheal preparations help the patient to resolve diarrhea. Caution patients not to use these over-the-counter medications on a prolonged basis without consulting their health care provider.
Often a patient is unable to defecate normally because of pain, constipation, or impaction. Cathartics and laxatives have the short-term action of emptying the bowel. They are prescribed for bowel evacuation for patients undergoing GI tests and abdominal surgery. Although the terms cathartic and laxative are often used interchangeably, cathartics have a stronger effect on the intestines. Five types of laxatives and cathartics are available.
[See Table 46-5 Common Types of Laxatives and Cathartics.]
Cathartics and laxatives are available in oral, tablet, powder, and suppository dosage forms. Although the oral route is most commonly used, suppositories are more effective because of their stimulant effect on the rectal mucosa.
Excessive use of laxatives, enemas, and/or bulk-forming agents increases the patient’s risks for diarrhea and abnormal bowel elimination.
In chronically ill or older adult patients, weakness and the frequent need to use toilet facilities result in increased risks for falls and other injuries.
For patients with diarrhea, frequent passage of liquid stools becomes a problem. Many patients use over-the-counter agents such as Imodium to relieve common diarrhea.
However, the most effective antidiarrheal agents are prescriptive opiates such as codeine phosphate, opium tincture (Paregoric), and diphenoxylate (Lomotil). Antidiarrheal opiate agents decrease intestinal muscle tone to slow the passage of feces. Opiates inhibit peristaltic waves that move feces forward, but they also increase segmental contractions that mix intestinal contents. As a result, the intestinal walls absorb more water.
Use antidiarrheal agents with caution because opiates are habit forming. Patients with diarrhea lasting longer than 2 days need a stool culture and an evaluation of diet and fluid intake for intolerance of foods and fluids (e.g., excessive use of fruits, lactose).

38. Enemas Types: Cleansing Oil retention
Tap water
Normal saline (infants and children)
Hypertonic solutions
Soapsuds
Oil retention
Others: carminative and Kayexalate
An enema is the instillation of a solution into the rectum and sigmoid colon. The primary reason for an enema is to promote defecation by stimulating peristalsis. The volume of fluid instilled breaks up the fecal mass, stretches the rectal wall, and initiates the defecation reflex. Enemas are also a vehicle for medications that exert a local effect on rectal mucosa. The most common use for an enema is temporary relief of constipation. Other indications include removing impacted feces, emptying the bowel before diagnostic tests or surgery, and beginning a program of bowel training.
Cleansing enemas promote the complete evacuation of feces from the colon. They act by stimulating peristalsis through infusion of a large volume of solution or through local irritation of the mucosa of the colon.
Infants and children receive only normal saline because they are at risk for fluid imbalance.
Tap water is hypotonic and exerts an osmotic pressure lower than fluid in interstitial spaces. After infusion into the colon, tap water escapes from the bowel lumen into interstitial spaces. The net movement of water is low. The infused volume stimulates defecation before large amounts of water leave the bowel. Do not repeat tap water enemas because water toxicity or circulatory overload develops if the body absorbs large amounts of water.
Physiologically normal saline is the safest solution to use because it exerts the same osmotic pressure as fluids in interstitial spaces surrounding the bowel. The volume of infused saline stimulates peristalsis. Giving saline enemas does not create the danger of excess fluid absorption.
Hypertonic solutions infused into the bowel exert osmotic pressure that pulls fluids out of interstitial spaces. The colon fills with fluid, and the resultant distention promotes defecation. Patients unable to tolerate large volumes of fluid benefit most from this type of enema, which is by design low volume. This type of enema is contraindicated for patients who are dehydrated and for young infants. A hypertonic solution of 120 to 180 mL (4 to 6 oz) is usually effective. The commercially prepared Fleet enema is the most common.
Add soapsuds to tap water or saline to create the effect of intestinal irritation to stimulate peristalsis. Use only pure castile soap that comes in liquid form and is included in most soapsuds enema kits. Use soapsuds enemas with caution in pregnant women and older adults because they cause electrolyte imbalance or damage to the intestinal mucosa.
The health care provider sometimes orders a high or low cleansing enema. The terms high and low refer to the height from which, and hence the pressure with which, the fluid is delivered. High enemas cleanse the entire colon. After the enema is infused, ask the patient to turn from left lateral to dorsal recumbent, over to the right lateral position. This position change ensures that fluid reaches the large intestine. A low enema cleanses only the rectum and sigmoid colon.
Oil retention enemas lubricate the rectum and colon. The feces absorb the oil and become softer and easier to pass. To enhance the action of the oil, the patient retains the enema for several hours if possible.
Carminative enemas provide relief from gaseous distention.
Medicated enemas contain drugs. An example is sodium polystyrene sulfonate (Kayexalate), which is used to treat patients with dangerously high serum potassium levels. This drug contains a resin that exchanges sodium ions for potassium ions in the large intestine. Another medicated enema is neomycin solution, an antibiotic that is used to reduce bacteria in the colon before bowel surgery.

39. Enemas Enema administration Digital removal of stool
Sterile technique is unnecessary.
Wear gloves.
Explain the procedure, precautions to avoid discomfort, and length of time necessary to retain the solution before defecation.
Digital removal of stool
Use if enemas fail to remove an impaction.
This is the last resort for constipation.
A health care provider’s order is necessary to remove an impaction.
You will review the steps for enema administration in the skills lab.
Sterile technique is unnecessary because the colon normally contains bacteria.
However, wear gloves to prevent the transmission of fecal microorganisms.
Explain the procedure, including the position to assume, precautions to take to avoid discomfort, and the length of time necessary to retain the solution before defecation.
If the patient needs to take the enema at home, explain the procedure to a family member.
Often the health care provider orders “enemas until clear.” This means that the enema is repeated until the patient passes fluid that is clear and contains no fecal material. It is often necessary to give as many as three enemas, but caution the patient against using more than three. Excessive enema use seriously depletes fluids and electrolytes. If the enema fails to return a clear solution after 3 times (check agency policy), or if the patient seems to not be tolerating the rigors of repeated enemas, notify the health care provider.
Giving an enema to a patient who is unable to contract the external sphincter poses difficulties. Give the enema with the patient positioned on the bedpan. Giving the enema with the patient sitting on the toilet is unsafe because the curved rectal tubing scrapes the rectal wall.
[See Box 46-8 on text p Procedural Guidelines: Digital Removal of Stool.]
For a patient with an impaction, the fecal mass is sometimes too large to pass voluntarily. If enemas fail, break up the fecal mass with the fingers, and remove it in sections.
Digital removal is a last resort in the management of severe constipation and is practiced when all other methods have failed. The procedure is very uncomfortable for the patient. Excessive rectal manipulation causes irritation to the mucosa, bleeding, and stimulation of the vagus nerve, which results in a reflex slowing of the heart rate.
Because of the potential complications of the procedure, a health care provider’s order is necessary to remove a fecal impaction.
Dangers during digital removal of stool include traumatizing the rectal mucosa and promoting vagal stimulation.

40. Inserting and Maintaining a Nasogastric Tube
Purposes
Decompression, enteral feeding, compression, and lavage
Categories of nasogastric (NG) tubes
Fine- or small-bore for medication administration and enteral feedings
Large-bore (12-French and above) for gastric decompression or removal of gastric secretions
Clean technique
Maintaining patency
You will learn to insert and maintain a nasogastric (NG) tube in the skills lab.
A patient’s condition or situation sometimes requires special interventions to decompress the GI tract. Such conditions include surgery, infection of the GI tract, trauma to the GI tract, and conditions in which peristalsis is absent.
An NG tube is a pliable hollow tube that is inserted through the patient’s nasopharynx into the stomach.
[Review Table 46-6 on text p Purposes of Nasogastric Intubation.]
NG intubation decompresses gastric contents by removing secretions and gaseous products from the GI tract.
The purposes of gastric decompression are to keep the GI tract free of secretions, reduce nausea and gas, and decrease risks of vomiting and aspiration.
Levin and Salem sump tubes are most common for stomach decompression. The Levin tube is a single-lumen tube with holes near the tip. You connect it to a drainage bag or to an intermittent suction device to drain stomach secretions.
The Salem sump tube is preferable for stomach decompression. The tube has two lumina: one for removal of gastric contents and one to provide an air vent. A blue “pigtail” is the air vent that connects with the second lumen. When the main lumen of the sump tube is connected to suction, the air vent permits free, continuous drainage of secretions. Never clamp off the air vent, connect it to suction, or use it for irrigation.
NG tube insertion does not require sterile technique. Simply use clean technique. The procedure is uncomfortable. The patient experiences a burning sensation as the tube passes through the sensitive nasal mucosa. When it reaches the back of the pharynx, the patient sometimes begins to gag. Help him or her relax to make tube insertion easier. Some institutions allow you to use Xylocaine jelly when inserting the tube because it enhances patient comfort during the procedure.
One of the greatest problems in caring for a patient with an NG tube is maintaining comfort. Because the tube constantly irritates the nasal mucosa, you assess the condition of the patient’s nares and mucosa for inflammation and excoriation. The tape or fixation device used to anchor the tube often becomes soiled. Change it every day to lessen irritation. Frequent lubrication of the nares minimizes excoriation. With one naris is occluded, the patient breathes through the mouth. Frequent mouth care (at least every 2 hours) helps minimize dehydration.
A glass of cool water is useful for rinsing, but the patient who is allowed nothing by mouth (NPO) should not swallow the water. The patient frequently complains of a sore throat. An ice bag applied externally to the throat helps. If ordered by the health care provider, the patient gargles with topical Xylocaine jelly and/or uses lozenges to minimize irritation.
After you insert the tube, you need to maintain its patency. Sometimes the tip of the tubing rests against the stomach wall, or the tube becomes blocked with thick secretions. Therefore regular irrigation is necessary. Flushing the tube with normal saline by way of a catheter-tipped syringe clears blockages in the tube. If an NG tube continues to drain improperly after irrigation, reposition it by advancing or withdrawing it slightly. Any change in tube position requires you to verify its placement in the patient’s GI tract.
The NG tube sometimes causes distention. Its presence causes many patients to swallow large volumes of air. Channels of gastric secretions form along the walls of the stomach and bypass the suction holes. Turning the patient regularly helps to collapse the channels and promotes emptying of stomach contents.

41. Quick Quiz!
2. To maintain normal elimination patterns in the hospitalized patient, you should instruct the patient to defecate 1 hour after meals because
A. The presence of food stimulates peristalsis.
B. Mass colonic peristalsis occurs at this time.
C. Irregularity helps to develop a habitual pattern.
D. Neglecting the urge to defecate can cause diarrhea.
Answer: B

42. Continuing and Restorative Care
Care of ostomies
Irrigating a colostomy
Pouching ostomies
An effective pouching system protects the skin, contains fecal material, remains odor free, and is comfortable and inconspicuous.
Nutritional considerations
Consume low fiber for the first weeks.
Eat slowly and chew food completely.
Drink 10 to 12 glasses of water daily.
Patient may choose to avoid gassy foods.
Regular elimination patterns need to begin for a patient to recover and return home or to an extended care facility.
It is important to remember that ostomy care and bowel retraining are instituted in acute care settings. However, because these are long-term care needs, teaching is usually completed in restorative care settings.
The location of an ostomy influences the consistency of the stool.
Patients with temporary or permanent bowel diversions have unique elimination needs. An individual with an ostomy wears a pouch or appliance to collect effluent—stool discharged from the stoma.
Skin breakdown occurs after repeated exposure to liquid stool.
The patient needs to use meticulous skin care to prevent liquid stool from irritating the skin around the stoma.
[Irrigating a colostomy is discussed on the next slide.]
An ostomy requires a pouch to collect fecal material. A person wearing a pouch needs to feel secure enough to participate in any activity.
Proper selection and use of an ostomy pouching system are necessary to prevent damage to the skin around the stoma.
Many pouching systems are available. To ensure that a pouch fits well and meets the patient’s needs, consider the location of the ostomy, type and size of the stoma, type and amount of ostomy drainage, size and contour of the abdomen, condition of the skin around the stoma, physical activities of the patient, patient’s personal preference, age and dexterity, and cost of equipment.
A wound ostomy continence nurse (WOCN) is specially educated to care for ostomy patients; the WOCN collaborates with staff nurses to make sure that the patient uses the correct pouching system, especially when the patient is ill or is experiencing health changes or problems with the ostomy.
A pouching system consists of a pouch and a skin barrier.
Assess the stoma color. A normal stoma is bright pink or brick red. Notify the health care provider if the stoma is blue, brown, or black, which indicates circulation problems to the stoma. You need to measure the stoma size carefully when selecting and cutting out the opening on the wafer skin barrier. Too tight of an opening constricts the stoma and causes irritation and necrosis. Subtle stoma changes occur over time.
Encourage patients to visit their enterostomal nurse at least annually to ensure proper pouching and fit.
A good skin barrier protects the skin, prevents irritation from repeated removal of the pouch, and is comfortable for the patient to wear. Patients with new stomas often feel vulnerable when they leave the hospital. To provide a smooth transition from hospital to home, offer help for the patient and family caregivers. Effective patient teaching helps patients with a new ostomy transition smoothly to home.
[See also Box on p Patient Teaching: Teaching the Patient How to Provide Ostomy Care.]
Nutritional therapy is important for patients with ostomies. During the first weeks after surgery, many health care providers recommend low-fiber diets, particularly for patients with ileostomies, because the small bowel requires time to adapt to the diversion.
As ostomies heal, patients are able to eat almost any food. High-fiber foods such as fresh fruits and vegetables help ensure a more solid stool. Patients need to avoid blockages of the bowel. The surgical construction of the stoma affects the likelihood of blockage.

43. Irrigating a Colostomy
This drawing shows an ostomy irrigation cone inserted into the stoma.
Although this practice is not as common as it once was, some patients irrigate their left-sided colostomies to regulate colon emptying. Other patients do not want to spend the additional 60 to 90 minutes in the bathroom every day; thus they empty their pouch as necessary. Only colostomies can be irrigated.
Never use an enema set to irrigate a colostomy. Instead use specific equipment, which includes a special cone-tipped irrigator to prevent bowel penetration and backflow of the irrigating solution. Help patients to schedule irrigations at times that fit within their daily routine.
Before irrigating the stoma, patients usually sit on the toilet and place an irrigating sleeve over the stoma. The end of this sleeve extends into the bowl of the commode. The health care provider orders the amount and type of irrigation solution. For adults, the amount typically ranges from 500 to 700 mL of tap water. The patient instills the solution slowly through the lubricated cone tip. Irrigation usually takes 5 to 10 minutes. The patient then removes the cone tip and waits 30 to 45 minutes for the solution and feces to drain out of the irrigation sleeve. Once the drainage stops, the patient applies a stoma cap or a pouch.
[Shown is Figure from text p ]

44. Continuing and Restorative Care
Bowel training
Training program
Diet
Promotion of regular exercise
Management of hemorrhoids
Skin integrity
The patient with incontinence is unable to maintain bowel control. A bowel training program helps some patients defecate normally, especially those who still have some neuromuscular control.
The training program involves setting up a daily routine. By attempting to defecate at the same time each day and using measures that promote defecation, the patient gains control of bowel reflexes. The program requires time, patience, and consistency. The health care provider determines the patient’s physical readiness and ability to benefit from bowel training.
[Discuss the components of a successful program:
Assessing the normal elimination pattern and recording times when the patient is incontinent
Incorporating principles of gerontological nursing when providing bowel retraining programs for the older adult
Choosing a time in the patient’s pattern to initiate defecation control measures
Giving stool softeners orally every day or a cathartic suppository at least half an hour before the selected defecation time (lower colon needs to be free of stool so suppository contacts intestinal mucosa)
Offering a hot drink (hot tea) or fruit juice (prune juice) (or whatever fluids normally stimulate peristalsis for the patient) before the defecation time
Helping the patient to the toilet at the designated time
Avoiding medications such as opioids that increase constipation
Providing privacy and setting a time limit for defecation (15 to 20 minutes)
Instructing the patient to lean forward at the hips while sitting on the toilet, apply manual pressure with the hands over the abdomen, and bear down but not strain to stimulate colon emptying
Not criticizing or conveying frustration if the patient is unable to defecate
Maintaining normal exercise within the patient’s physical ability]
[See also Box on p Focus on Older Adults: Bowel Retraining.]
In choosing a diet for promoting normal elimination, consider the frequency of defecation, the characteristics of feces, and the types of foods that impair or promote defecation.
The patient with frequent constipation or impaction requires increased intake of high-fiber foods and more fluids. However, he or she needs to realize that diet therapy provides only long-term relief of elimination problems and does not give immediate relief from problems such as constipation.
When diarrhea is a problem, recommend foods with low-fiber content and discourage foods that typically cause gastric upset or abdominal cramping. Diarrhea caused by illness is sometimes debilitating. If the patient cannot tolerate foods or liquids orally, intravenous therapy (with potassium supplements) is necessary.
The patient returns to a normal diet slowly, often beginning with fluids. Excessively hot or cold fluids stimulate peristalsis, causing abdominal cramps and further diarrhea. As tolerance to liquids improves, the patient eats solid foods.
A daily exercise program helps prevent elimination problems. Walking, riding a stationary bicycle, or swimming stimulates peristalsis. Patients who are sedentary at work are most in need of regular exercise. For a patient who is temporarily immobilized, attempt ambulation as soon as possible. If the condition permits, help the patient walk to a chair on the evening of the day of surgery. Have him or her walk farther each day.
Some patients have difficulty passing stool because of weak abdominal and pelvic floor muscles. Exercises help patients who are confined to bed use a bedpan. The patient practices the exercises as follows:
Lie supine; tighten the abdominal muscles as though pushing them to the floor. Hold the muscles tight to the count of three; relax. Repeat 5 to 10 times as tolerated.
Flex and contract the thigh muscles by raising one knee slowly toward the chest. Repeat for each leg at least 5 times and increase frequency as tolerated.
Pain results when hemorrhoid tissues are irritated directly. The primary goal for the patient with hemorrhoids is to have soft-formed, painless bowel movements. Proper diet, fluids, and regular exercise improve the likelihood of stools being soft. If the patient becomes constipated, passage of hard stools causes bleeding and irritation. An ice pack or a warm sitz bath provides temporary relief of swollen hemorrhoids.
The patient with diarrhea or fecal incontinence is at risk for skin breakdown when fecal contents remain on the skin. The same problem exists for the patient with an ostomy that drains liquid stool. Liquid stool is usually acidic and contains digestive enzymes. Irritation from repeated wiping with toilet tissue aggravates skin breakdown. Bathing the skin after soiling helps, but sometimes it results in more breakdown unless the patient dries the skin thoroughly.
When caring for a patient who is debilitated, incontinent, and unable to ask for assistance, check often for defecation. You can protect the anal areas with petrolatum, zinc oxide, or another ointment that holds moisture in the skin, preventing drying and cracking.
Yeast infections of the skin often develop easily. Several powdered antifungal agents are effective against yeast. Do not use baby powder or cornstarch because they have no medical properties, often cake on the skin, are difficult to remove, and enhance fungal infections of the skin.
[See also on text p Box 46-9 Evidence-Based Practice: Recognition of Skin Problems.]

45. Case Study (cont’d)
Review Mr. Gutierrez’ diary of foods, and ask him about his intake as well.
Mr. Gutierrez describes likes and dislikes but admits to eating high-fat foods and few fruits and vegetables. Fluid intake averaged 1400 mL daily for a week.
Ask Mr. Gutierrez about his pattern of elimination over the past 2 weeks and laxative use.
Mr. Gutierrez says, “I still go about the same” but states that he thinks he now goes about every 2 days.
Mr. Gutierrez has not used any laxatives for a week.
During follow-up visit, examine patient’s abdomen and observe stool (if possible).
Patient reports that stool is formed but is “not hard like before.” Bowel sounds are normal. Abdomen is soft and nontender with no distention.
[Ask the class: How would you document achievement of outcomes with these results?
Discuss:
Mr. Gutierrez’ intake of high-fiber foods is still limited. Fluid intake is improving.
He has bowel movements approximately every 2 days.
He is successfully avoiding use of laxatives.
Stool is softer in character.
His abdomen is less distended.]

46. Evaluation
Do you use medications such as laxatives or enemas to help you defecate?
What barriers are preventing you from eating a diet high in fiber and participating in regular exercise?
How much fluid do you drink in a typical day? What types of fluids do you normally drink?
What challenges do you encounter when you change your ostomy pouch?
Optimally, the patient will be able to have regular, pain-free defecation of soft-formed stools. The patient is the only one who is able to determine whether bowel elimination problems have been relieved, and which therapies were most effective.
If the nurse establishes a therapeutic relationship with the patient, the patient feels comfortable in discussing the intimate details often associated with bowel elimination.
Evaluate a patient’s level of knowledge regarding establishing a normal elimination pattern, caring for an ostomy, and promoting skin integrity.
Also determine the extent to which the patient accomplishes normal defection.
Ask the patient to describe changes in diet, fluid intake, and activity to promote bowel health. Ask the questions on the slide when a patient’s outcomes are not met.
[See also Figure on text p. XXX Critical thinking model for elimination evaluation.]

47. Case Study (cont’d)
Vickie returns to see Mr. Gutierrez 2 weeks later. Vickie is eager to determine whether her patient has made changes in his diet, and if his problems with bowel elimination have been progressing. Vickie is also eager to learn if his stove has been repaired.
Mr. Gutierrez tells Vickie that he has been eating bran cereal in the morning, has been eating rice and/or beans for dinner, and has added one fruit each day to his diet.
He has been walking twice a day through the long-term care center. Although he does not have a bowel movement each day, his stools are much softer and easier to pass, and he says he is less concerned. He has not taken a laxative for a stool since last talking with Vickie.
[Ask the class what Vickie should put in the documentation note. Discuss:
Bowel elimination is improving. Abdomen is soft and nondistended; bowel sounds are normal and audible in all quadrants. After discussing the teaching plan, patient has agreed to alter his eating habits to include more fiber, fruit, and fluids. Although concern over bowel habits has not ceased, patient states that he feels “in better control” and has decreased his laxative use. Niece assists in having stove repaired.]