1. Bowel Elimination NUR101 Fall 2008 Lecture # 23
K. Burger, MSEd, MSN, RN, CNE
PPP By: Sharon Niggemeier RN MSN
J Borrero 12/08

2. Functions of the GI Tract
Prepare fluids and nutrients for absorption and use by cells via mechanical and chemical breakdown
Absorb fluids and nutrients
Receives secretions from organs (eg. gallbladder, pancreas)

3. Anatomy & Physiology Organs of the GI tract?
Function of Large intestine: absorption
Extends from Ileocecal valve to
anus
Chyme
Peristalsis & Mass peristalsis
Mouth, esophagus, stpomach, SI, LI, Rectum, Anal canal and anus.
Large Intestine is the lower portion of the alimentary tract.
Function: water absorption, formation and expulsion of feces.
Ileocecal valve is the barrier between the sm. intestine & the lg. intest.
Chyme : waste products of digestion received by the lg. Intse. Composed of liquid, watery state as it passes thru lg. intest. water is absorbed cc/day.
Diarrhea- chyme passes thru too fast not enough water absorption takes place.
Constipation- chyme passes thru slowly, too much water is absorbed stool becomes hard, dry and difficult to pass.
Peristalsis-contractions of intest. muscle that move the waste products along.3-12 min.
Mass peristalsis - propels fecal mass forward 1-4 times /day

4. Act of Defecation Defecation reflex Valsalva maneuver Defecation
Defecation Reflex- stimulated when the fecal mass stretches the rectum causing internal anal sphincter to relax and colon contracts …the external sphincter must then voluntarily be relaxed =elimination occurs
If the external sphincter isn’t relaxed defecation will be delayed….delayed too often will lose the reflex entirely.
Muscles that aid in defecation… Valsalva maneuver- additional muscles aid in the act of defecation, voluntary contraction of abd. muscles and diaphragm cause an increase in intraabd. pressure. “bearing down”
Defecation- emptying of lg. Intest. Bowel Movement. Stool, feces, BM.Should be at REGULAR INTERVALS- varies greatly among individuals.

5. Alteration in Bowel Elimination
Diarrhea
Constipation
Incontinence
Fecal Impaction
Flatulence
Diarrhea-_liquid watery stools..deals with the consistency and frequency
Constipation- less then 3 bm/week or what ever is less then the pt. Regular pattern of elimination
Incontinence inability to control fecal discharge thru anal sphincter
Fecal impaction- mass of hardened feces in rectum…recognized by seepage
Flatulence- gas

6. Characteristics of Stool
Volume
Color
Odor
Consistency
Shape
Constituents
Volume - varies
Color- infants yellow, adults brown due to bile pigmentation. In absence of bile stool may be white (clay colored). Diet can effect color blackish if high red meat intake.Blackish stools (Tarry)could be from upper GI bleeding while (frank red)blood is lower GI bleeding. Greenish color if dk. green veg.eaten.
Odor- Odor is due to the bact action of break down of digested foods. Aroma effected by foods digested, blood, pus, or bact. in stool.
Consistency- soft, semisolid, formed, liquidly, hard. Influenced by diet/fluid intake, GI motility or malabsorption.
Shape- depends on condition of colon. Usually tubular (formed to the rectal canal), but varies. Obstructions may produce narrow pencil thin stools, increased time in the colon may produce marble-like stool.
Constituents - waste residue of digestion bile, secretions, bact, fat…abnormal constituents blood, helminths, parasites, mucus...

7. Factors That Influence Bowel Elimination
Age
Fluid Intake & Diet
Daily Routine
Activity
Medications
Health Status
Stress
Age- elderly bowel conscious, infants pass many stools etc.
Fluid/diet- Intake cc/day and high fiber diet promote elimination
Daily routine - time, position, place. Hospital less conducive to bowel elim.
Activity - increases muscle tone and GI motility
Medications- antibiotics can cause diarrhea, opiates (narcotics)constipation, laxatives, antidiarrheals
Health status- tumors, infection of intestines, spinal cord injury
Stress - anxiety-diarrhea, worry-constipation
Dx test- bowel cleansing alters elimin.pattern
Surgery & anesthesia- direct handling of bowels and slowing of peristalsis alter bowel elim.

8. Diet Laxative effect foods: High fiber foods: Legumes (beans)
Spicy & greasy
Bran/Chocolate
Coffee/Alcohol
Raw fruits & vegetables
High fiber foods:
Legumes (beans)
Cereals
Whole grains
Raw Fruits
Vegetables
Fiber is of plant origin, a carbohydrate not digested by the GI tract.
25 grams/day is recommended
High fiber foods increase peristalsis by forming bulk and having the feces move thru quickly.
Laxative effect - will increase the frequency of BM :prunes

9. Assessing Elimination Status
Usual pattern
Changes in bowels
Aids to eliminate
Current problems
Pattern -How often, when
Changes- blood, mucus
Aids - laxatives enemas
Problems - food related, meds, physical, emotional, Artificial orifices, hemorrhoids (abnormally distended veins)..colostomy

10. Physical Assessment
Inspection- observe contour of abd and note visible peristalsis
Auscultation- listen for bowel sounds all quadrants
Percussion- resonant or tympany over hollow organs…dullness over intestinal obstruction
Palpation- feel for masses, tenderness etc…
This is a different sequence for assessing since palpation may disrupt bowel motility and peristalsis

11. Stool Specimen Collection
Routine specimen
Occult blood
Ova & parasite
Timed specimens
Routine-
Use PPE…place in container…pt. Can obtain themselves…use bedpan /don’t place toilet tissue in bedpan….place in labeled container..transport in plastic bag with required lab slip on outside.
Occult blood –hemacult cards/wipes test for blood…may have to be on a special diet several day prior…
O & P lab sends up test tubes use applicator to place stool specimen in test tubes…
Timed test sometimes all stools for 24hr/ or three stools in a row check with lab…

12. Nursing Dx R/T Bowel Elimination?
Nursing Dx
Potential for constipation related to side effects of medication as evidenced by patient’s verbalization I feel blocked up..I haven’t gone in 4 days….. I usually go every morning after my coffee..
Bowel Incontinence related to loss of anal sphincter control as evidenced by inability to control bowels, 2 episodes of “accidents” every shift, pt. States” I feel like a baby and I don’t want to wear diapers”
PAIn
Diarrhea
Impaired skin integrity
FVD

13. Outcome Criteria Pt. will: Develop regular pattern of elimination
Have less episodes of incontinence
Incorporate fluids/diet that promote bowel elimination

14. Interventions to Promote Elimination
Routine
Positioning
Privacy
Comfort
Activity
Diet/Fluids
Routine- Establish reg pattern of elimination at reg times. Pt. needs min. (uninterrupted time). If urge to defecate is constantly ignored the defecation reflex will be lost, causing feces to remain longer in intest., increased water absorption, making feces hard and difficult to pass. Use communication skills to discuss bowel patterns.
Positioning- comfortable position needed. Squatting position common. Assess need for elevated toilet, commode,
Privacy- considered a very private act. Use BR if possible, pull drapes close doors.
Comfort- provide quiet, comfortable as possible place.
Activity- needed to promote GI activity and maintain reg. frequency.Teaching related to inactivity and constipation. Exercises for immobile client. Exercises to strengthen abd. and perineal muscles used for defecation.T & P ROM
Diet/Fluids - High fiber foods, 2000cc fluids/day

15. Interventions: Promote Bowel Elimination
Laxatives and Cathartics
Enemas
Suppositories
Digital Removal
Cathartics/laxatives - drugs that induce emptying of the intest. Habitual use of laxatives lead to constipation and irreg. frequency.Prep for procedures
Cathartics have stronger effects.
Enemas- solution introduced into the lg. Intest. For the purpose of removing feces.
Suppositories - bullet shaped substance inserted into the rectum beyond the anal sphincter where it melts to aid in elimination.
Digital removal- with prolonged retention of feces, fecal impaction occurs preventing passage of normal stool. Liquid fecal seepage around hard stool can occur. Oil retention enema is given prior to digital removal to soften stool.

16. Types of Enemas
Cleansing- given to clean out the bowel for relief of constipation, fecal impaction, bowel prep prior to dx tests or surgery or bowel training. Enemas till clear -clear of feces fluid may still be slightly colored (3 is the limit).
Retention -retained in the bowel for a prolonged period of time (lubricate stool, administer meds, (30min.)
Return Flow- (Harris Flush) - used to expel flatus. Fill bag with 400 cc water, instill cc using siphon process raise and lower bag to expel gas.

17. Enema Solutions Tap water (Hypotonic) Normal saline (Isotonic) Soap
Hypertonic
Oil
Different types of solutions.
Check order for appropriate solution based on client’s need
Know Dx
Instill solution as much as client can tolerate- will vary for each pt.

18. Tap Water (TWE) Amount: 500-1000cc
Action: Distends, increases peristalsis
Time: 15 min.
Indicated: inflamed bowels/irritated colon
Contraindicated: Atonic bowels, fluid restrictions
Hypotonic

19. Normal Saline Amount: 500-1000cc
Action: Distends, increases peristalsis
Time: 15 min.
Indicated:Inflamed bowels/irritated colon
Contraindicated: Na retention problems, fluid restrictions
Isotonic

20. Soap (SSE) Amount: 500-1000cc (Castile 5ml/1000cc)
Action: Distends, Irritates
Time: 15 min.
Indicated: Constipation
Contraindicated: Prior to rectal exams
Soap combines with stool readily resulting in decreased water surface tension which allows for stool to be easily expelled.
Castille soap is liquid soap prepackaged contained in enema kit.

21. Hypertonic Amount: 70-130 cc solution Action: Distends/Irritates
Time: 5-10 min.
Indicated: Constipation, convenience
Contraindicated: Dehydration, Na problems
Osmosis draws water into the colon aiding in elimination
Fleets is an example

22. Oil Retention Amount: 120-200cc Action: Lubricates Time: 30 min.
Indicated: Fecal impaction
Contraindication: none
Types of oil used mineral, cotton seed or olive
Prepackaged
Client retains for at least 30 min then attempts to expel solution
Usually followed with TWE
Other retention enemas given for medication administration and administer nutrients/fluids

23. Enema Administration PPE Position L Sims Linen protector
Receptacle (bedpan, commode, toilet)
IV pole
Lubricant
Enema bag with solution
Tissue paper

24. Enema Administration Position L Sims Insert lubricated tip 4”
Bag raised 18-20” above anal canal
Administer slowly - 10 min.
Administration is individualized.
Pt. holds for 15 min.
L sims -water flows more easily into descending colon
Temp of solution usually above body temp to increase peristalsis. Except for retention enemas which we want to be held therefore they are given at below body temp.
If cramping occurs…lower bag, stop flow…take deep breaths

25. Evaluation Solution given Amount expelled Characteristics of stool
Passing of flatus
Unusual findings blood, helminthes, pus etc.
Client reaction: change in skin color, VS changes, fatigue

26. Medications Effecting Bowel Elimination
Laxatives- induce emptying of GI tract
Antidiarrheal- slow peristalsis, Pepto Bismol, Kaopectate
Codeine/morphine/iron- cause constipation
Antibiotics-may cause diarrhea
Opiates: paragoric, lomotil- habit forming

27. Flatulence Causes: Decreased peristalsis Diet Stress Constipation
Medications
Surgery
Diet
Stress
Decreased activity
Decreased activity

28. NonInvasive Interventions for Flatulence
*Ambulation*
Knee chest position

29. Invasive Interventions for Flatulence
Glycerin Suppository
Harris Flush
Rectal Tube
Suppository - always lubricated, inserted past the anal sphincter
Harris flush- Use siphoning process to relieve flatus. Fill enema bag with 400cc water raise bag and instill 200cc then lower the bag and allow water to return back into the bag with flatus. Should see bubbling as gas escapes
Rectal Tube- inserted into rectum 22 fr-32 frtube in place for 20 min. acts as an escape route for flatus. Remove and reinsert 2-3 hrs. later. Can insert up to 3 times.Prolonged use can result in loss of sphincter control.

30. Evaluation of Bowel Function
Achievement of regular defecation habits
Patient’s understanding of normal elimination
Maintenance of adequate food and fluid intake
Regular exercise program
Comfort
Skin integrity

31. Gastrointestinal Charting Chuckles
The patient had waffles for breakfast and anorexia for lunch.
She stated that she had been constipated for most of her life until 1989, when she got a divorce.
Bleeding started in the rectal area and continued all the way to Los Angeles Rectal examination revealed a normal-size thyroid.
The patient was to have a bowel resection. However, he took a job as a stockbroker instead.
Fleet enema given with stool hard as pine knots.
Patient complains of indigestion since last night when he ate a stake.
Patient passed flatus two short, one long.
Patient was seen in consultation by the physician, who felt we should sit tight on the abdomen, and I agreed.