1. Chapter 46: Bowel Elimination
Bonnie M. Wivell, MS, RN, CNS

2. Scientific Knowledge Base
Mouth
Digestion begins with mastication; saliva dilutes and softens food
Esophagus
Peristalsis moves food bolus into the stomach
Stomach
Stores food & liquid; 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
STOMACH: produces and secretes HCL, mucus, the enzyme pepsin, and the intrinsic factor
SMALL INTESTINES:
Duodenum is approx inches long and continues to process the chyme
Jejunum is approx. 8 feet long and absorbs carbs and proteins
Ileum is approx. 12 feet long and absorbs water, fats, and bile salts
LARGE INTESTINES:
Cecum, colon, and rectum
Ascending, transverse, descending, sigmoid colon
Bicarb is secreted in exchange for Chloride
The colon excretes about 4-9 mEq of K daily
Serous alterations in function can cause severe electrolyte disturbances
RECTUM: bacteria convert fecal matter into its final form
VALSALVA MANUEVER: Voluntary contraction of abd. Muscles while maintaining forced expiration against a closed airway. Clients with cardiovascular disease, glaucoma, increased intracranial pressure, or new surgical wounds are at risk of cardiac irregularities and elevated blood pressure hence they need to avoid straining. 2

3. Factors Affecting Bowel Elimination
Age
Infants: small stomach capacity; less secretion of digestive enzymes; rapid peristalsis; lack neuromuscular development so cannot control bowels
Older adults: arteriosclerosis which causes decreased mesenteric blood flow, decreasing absorption in small intestine; decrease in peristalsis; loose muscle tone in perineal floor and anal sphincter thus are at risk for incontinence; slowing nerve impulses in the anal region make older adults less aware of need to defecate leading to irregular BMs and risk of constipation

4. Factors Affecting Bowel Elimination
Diet: fiber such as whole grains, fresh fruits and vegies help flush the fats and waste products from the body with more efficiency; decreased fiber → increased risk of polyps; be aware of food intolerances
Fluid intake: 6-8 glasses of noncaffeinated fluid daily; liquifies intestinal contents easing passage through colon
Physical activity: promotes peristalsis
Psychological factors: stress increases peristalsis resulting in diarrhea and gaseous distention; ulcerative colitis; IBS; gastric and duodenal ulcers; crohn’s disease
Personal habits: fear of defecating away from home
Position during defecation: squatting is the normal position

5. Factors Affecting Bowel Elimination
Pain: hemorrhoids, rectal surgery, rectal fistulas and abd. surgery
Pregnancy: increased pressure; slowing peristalsis in third trimester
Surgery and Anesthesia: lows or stops peristalsis; paralytic ileus = direct manipulation of the bowel and lasts hours
Medications: laxatives and cathartics; laxative overuse can decrease muscle tone and can cause diarrhea which can result in dehydration and electrolyte imbalance; see Table 46-2
Diagnostic tests: bowel prep; barium

6. Common Bowel Elimination Problems
Constipation
Causes: improper diet, reduced fluid intake, lack of exercise, and certain meds
A significant health hazard
Impaction
Causes: unrelieved constipation
Debilitated, confused, and unconscious more at risk
Continuous ooze of diarrhea is a suspect sign
Diarrhea
Causes: antibiotics via any route; enteral nutrition; food allergies or intolerance; surgeries or diagnostic testing of the lower GI tract; C. difficile; communicable food-borne pathogens
NURSING INTERVENTIONS FOR IMPACTION
DIGITAL EXAMINATION OF THE RECTUM
NOTIFY PHYSICIAN
MAY POSSIBLY NEED TO MANUALLY REMOVE STOOL
SEVERE IMPACTION MAY REQUIRE SURGERY
DIARRHEA: Usually a symptom of some underlying disease or disorder characterized by frequent, unformed stools
Complications: Dehydration, electrolyte imbalance, skin excoriation, potential for infection
Nursing interventions: assess for underlying cause, assess for dehydration (skin turgor, dry mucus membranes), evaluate labs, administer IV fluids and meds as ordered, assist pt. with remaining clean and dry

7. Common Bowel Elimination Problems
Incontinence
Causes: physical conditions that impair anal sphincter function or control
Flatulence
Causes: certain foods; decreased intestinal motility
Can become severe enough to cause abd distention and severe sharp pain
Hemorrhoids = dilated, engorged veins; internal or external
Causes: straining with defecation; pregnancy; heart failure; chronic liver disease

8. Bowel Diversions
Ostomies: Certain disease /conditions prevent normal passage of stool; temporary or permanent artificial opening in the abd wall; location determines consistency of stool
Loop colostomy: Usually done emergently; temporary; usually involves transverse colon; two openings through one stoma – stool and mucus; external supporting device usually removed in 7-10 days
End colostomy: one stoma formed from the proximal end of the bowel and distal portion of the GI tract removed or sewn closed (Hartman’s pouch); common in colorectal cancer and rectum is usually removed; temporary in surgery for diverticulitis
Double-barrel colostomy: bowel is surgically severed and two ends brought out onto the abd; proximal stoma functions and distal stoma is nonfunctioning

10. Loop Colostomy

11. Double-Barrel Colostomy

12. Double-Barrel Colostomy

14. End Colostomy

16. Bowel Diversions Cont’d.
Alternative procedures
Ileoanal pouch: colon removed for tx of ulcerative colits or familial polyps; pouch is formed from distal end of small intestines and attached to anus; pouch acts as rectum so pt. is continent; has temporary ileostomy while healing
Kock continent ileostomy: consists of a reservoir constructed from small bowel and nipple valve which keeps contents of reservoir inside body; permits entry of external catheter to drain pouch
Macedo-Malone Antegrade Continence Enema (MACE); for improving continence in pts with neuropathic or structural abnormalities of the anal sphincter

17. Ileoanal Pouch Anastomosis

18. Kock Continent Ileostomy

19. Care of the Patient With a Bowel Diversion
“Bagging” the ostomy
Assessing stoma and skin
Assessing stool output
New stoma vs. Old stoma
Patient education and counseling

20. Psychological Considerations
Body image changes
Face a variety of anxieties and concerns
Must learn how to manage stoma
Cope with conflicts of self-esteem and body image
Can be concealed with clothing but pt. aware of its presence
Difficulty with intimacy/sexual relations
Foul odors, leakage, spills and inability to control or regulate passage of gas and stool is embarrassing
Ostomy support:
United Ostomy Association
National Foundation for Ileitis and Colitis

23. Nursing Process and Bowel Elimination
Assessment
Nursing history (see Box 46-2)
Usual elimination pattern
Usual stool characteristics
Routines to promote normal elimination
Use of artificial aids
Presence/status of bowel diversions
Changes in appetite
Diet history
Daily fluid intake
History of surgery or illnesses of GI tract
Medication history
Emotional state
History of exercise
Pain or discomfort
Social history
Mobility and dexterity

24. Nursing Process and Bowel Elimination
Physical assessment of the abdomen
Mouth: poor dentition, dentures, mouth sores
Abdomen: inspect, auscultate, palpate, percuss
Rectum: inspect
Inspection of fecal characteristics
Review of relevant test results
Fecal specimens: cannot mix feces with urine or water
Stool for occult blood (FOBT or guiac) see Box 46-3
Fecal fat requires 3-5 days of collection
Ova & Parasites (O&P)
Labs: bilirubin, ALK, Amylase, CEA
Diagnostic Exams: KUB, endoscopy, colonoscopy, barium enema, barium swallow, US, MRI, CT scan (may require pre-procedure preparation)
Hypoactive sounds = less than 5 sounds per minute
Hyperactive = 35 or more sounds per minutes
KUB = Kidneys, Ureters, Bladder

25. Nursing Diagnosis Bowel incontinence Constipation
Risk for constipation
Perceived constipation
Diarrhea
Toileting self-care deficit
Body image, disturbed

26. Planning Goals and outcomes Setting Priorities
Client sets regular defecation habits
Client is able to list proper fluid and food intake needed to achieve bowel elimination
Client implements a regular exercise program
Client reports daily passage of soft, formed brown stool
Client doesn’t report any discomfort associated with defecation
Setting Priorities
Collaborative Care - WOCN
Priorities: coping with new dx of cancer and its tx precede the client’s need to independently manage bowel diversion
Coping with the changes in body image often becomes a high priority

27. Implementation Health Promotion: establish routine Acute Care
Promotion of normal defecation
Sitting position
Position on bedpan – see pg. 1196
Privacy
Acute Care
Meds
Cathartics and laxatives
Antidiarrheal agents
Enemas

28. Types of Enemas Cleansing enemas Oil Retention
Tap water
Normal saline
Hypertonic solutions
Soapsuds
Oil Retention
Carminative – Mag, gylcerin and water; relieves gaseous distention
Medicated enemas – Kayexalate

29. Implementation Cont’d.
Enema administration
“Enemas till clear”
See pages
Digital removal of stool – last resort
Can cause irritation to the mucosa, bleeding and stimulation of vagus nerve
Inserting and maintaining a nasogastric tube

31. NG Tubes
Levine or salem sump tubes are most common for stomach decompression or lavage
See pages for insertion procedure
Connected to intermittent suction (LIS)
Air vent should NEVER be clamped, connected to suction or used for irrigation
Not a sterile technique
Care of pt. with NG
Comfort
Frequent mouth care/gargling
Maintain patency of tube
Turn client frequently to allow for adequate emptying

32. Continuing and Restorative Care
Care of ostomies
Irriating a colostomy
Pouching ostomies (see pages )
Nutritional considerations with ostomies
Bowel training
Proper fluid and food intake
Regular exercise
Hemorrhoids
Skin integrity
Care of ostomies and pouching ostomies requires special equipment. Please check with your health care facility for specific equipment as well as polices and procedures. You should also seek the assistance of the health care facility ostomy/wound care nurse.
The bowel training program will be individualized to the specific needs of the client.
The skin needs to be maintained. The use of mild soap and warm water with a soft towel will help you when cleaning the area. A barrier may also be applied. 32

33. Evaluation
The effectiveness of care depends on how successful the client is in achieving goals and outcomes
Optimally the client will be able to have regular, pain-free defecation of soft-formed stools
It is necessary to ask questions so establishing a therapeutic relationship is VERY important
Nursing interventions may be altered if necessary 33