1. Bowel Elimination

2. Bowel Elimination
GI Tract is a series of hollow mucous membrane lined muscular organs
Purpose is to absorb fluids & nutrients, prepare food for absorption & provide storage for feces

3. GI Tract Anatomy Mouth Esophagus Stomach Small Intestine
Large Intestine
Rectum

5. Mouth Digestion begins here
Mechanical, chemical breakdown of nutrients
Teeth-Mastication
Salivary secretions-enzymes
Food Bolus مضغة

6. Esophagus Hollow, muscular tube for passage of food to stomach
Peristaltic waves, contraction and relaxation of smooth muscle moves food down to stomach
Sphincter control to prevent reflux

8. Stomach
Food is temporarily stored and mechanically and chemically broken down
Secretes HCL, mucus, pepsin, & intrinsic factor(Needed for Vitamin B12 absorption)
Food is converted into chyme

9. Small Intestine 1 inch in diameter 20 feet long
Three divisions: Duodenum, Jejunum, Ileum
Enzymes in small intestine (amylase, lipase, & bile) break down fats, proteins & carbs into basic elements
Nutrients absorbed in duodenum & jejunum, ileum absorbs vitamins, iron, & bile salts

10. Large Intestine Lower GI tract Larger diameter, 5-6 feet in length
3 divisions: cecum, colon, rectum
Responsible for absorption of water
Primary organ of bowel elimination
Cecum-chyme enters cecum via the ileocecal valve, valve prevents regurg back to small intestine, cecum ends with appendix

11. Colon 3 Divisions: Ascending, Transverse, Descending
Colon Functions: Absorption, Protection, Secretion, & Elimination (stool and flatus)

13. Rectum Sigmoid colon Storage of feces Length varies with age
When fecal mass or flatus moves into rectum, it distends and defecation begins
Process involves involuntary (Internal sphincter) and voluntary control (external sphincter)
Valsalva Maneuver - voluntary contraction of abdominal muscles

14. Factors Affecting Bowel Elimination
Age
Infection
Diet
Fluid Intake
Physical Activity
Psychological factors
Personal Habits

15. Factors Affecting Bowel Elimination
Position during Defecation
Pain
Surgery and Anesthesia
Medications

16. Common Bowel Elimination Problems
Constipation
Impaction
Diarrhea
Incontinence
Flatulence
Hemorrhoids

17. Constipation More of a symptom than a disorder
Decrease in frequency of BM
Straining & pain on defecation is associated symptoms(Valsalva manuever)
Can be significant heath hazard (increase ICP, IOP, reopen surgical wounds, cause trauma, cardiac arrhythmias)

20. Impaction Results from unrelieved constipation
Collection of hardened feces wedged عالق into rectum
Can extend up to sigmoid colon
Most at risk: confused, unconscious (all are at risk for dehydration)

21. Impaction
When a continuous ooze of diarrheal stool develops, impaction should be suspected
Associated S/S: Loss of appetite, abdominal distention, cramping, rectal pain

23. Diarrhea
Increase in number of stools & the passage of liquid, unformed stool
Symptom of disorders affecting digestion, absorption, & secretion of GI tract
Intestinal contents pass through small & large intestines too quickly to allow for usual absorption of water & nutrients

24. Diarrhea
Irritation can result in increased mucus secretion, feces become too watery, unable to control defecation
Excess loss of colonic fluid can result in acid-base imbalances or fluid/electrolyte imbalances
Can also result in skin breakdown

25. Conditions that cause Diarrhea
Emotional Stress
Intestinal Infection (Clostridium difficile)
Food Allergies
Food Intolerance
Tube Feedings (Enteral)
Medications
Laxatives
Colon Disease
Surgery

27. Incontinence
Inability to control passage of feces and gas from the anus
Caused by conditions that create frequent, loose, large volume, watery stools or conditions that impair sphincter control or function

28. Flatulence Gas accumulation in the lumen of intestines
Bowel wall stretches and distends
Common cause of abdominal fullness, pain, & cramping
Gas escapes through mouth (belching), or anus (flatus)

29. Flatus Formation Air swallowing
Diffusion of gas from bloodstream into intestines
Bacterial action on unabsorbable CHO (Beans)
Fermentation of CHO (cabbage, onions
Can stimulate peristalsis
Adult forms ml of flatus daily

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

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

32. 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.

33. Hemorrhoids Dilated, engorged veins in the lining of the rectum
External (Clearly visible) or Internal
Caused by straining, pregnancy, CHF, chronic liver disease

34. 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

35. Bowel Diversions
Certain diseases cause conditions that prevent normal passage of feces through rectum
Creates need for temporary or permanent artificial opening (stoma) in the abdominal wall

36. Bowel Diversions
Surgical openings (ostomy) are most commonly formed in the ileum (ileostomy) or the colon (colostomy)
Incontinent ostomy- need to wear appliance pouch
Continent ostomy- have control through use of ostomy cap

41. Ostomy Nursing Considerations
Patient Education
Care of stoma, appliance selection and use
Body Image considerations
Support groups
Enterostomal nursing- specialty within profession

42. Nursing Process Assessment
Nursing History
Physical Assessment
Lab Tests
Fecal characteristics
Diagnostic evaluation- Endoscopy, Colonoscopy

44. Nursing Diagnosis Bowel Incontinence Constipation Diarrhea
Impaired Skin Integrity
Body Image Disturbance
Altered bowel elimination
Pain

45. Implementation Promoting Normal Defecation
Positioning of patient-squatting
Positioning on bedpan
Use of cathartics, laxatives
Anti-diarrheal agents
Enemas
Digital removal of stool
Ostomy care

49. 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.

50. 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.

51. Enemas Cleansing enema Tap water Normal saline
Hypertonic Solutions (Fleet’s enema)
Soapsuds
Oil Retention
Medicated enemas (Kayexalate, Lactulose)
Administering a Cleansing enema P&P pg

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

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

54. Soap 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.

55. 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

56. 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

57. Colostomy nursing care
1. Wash hands.
2. Apply clean gloves.
3. Assemble irrigation kit: Attach cone or catheter to irrigation bag tubing.
4. Fill irrigation bag with 1000 cc tepid tap water

58. 5. Open clamp and let water from the irrigation bag fill the tubing.
6. Hang bottom of irrigation bag at height of client’s shoulder, or 18 inches above the stoma if the client is supine.
7. Check direction of intestine by inserting a gloved finger into orifice of stoma.
8. Place irrigation sleeve over stoma and hold in place with beltيطوق بحزام

59. 9. Spray inside of irrigation sleeve and bathroom with odor eliminator (usual dose is two sprays).
10. Cuff end of irrigation sleeve and place into toilet bowl (if client is in bathroom) or bedpan (if client is in bed or chair) (see Figure ).
11. Lubricate the cone end of the irrigation tubing and insert into orifice of stoma through the top opening of irrigation sleeve

60. 12. Close top of irrigation sleeve over the tubing.
13. Slowly run water through tubing into colon
14. Remove cone after all water has emptied out of irrigation bag.
15. Close end of irrigation sleeve by attaching it to the top of the sleeve.
16. Encourage client to ambulate to facilitate emptying of remaining stool from colon.

61. 17. Remove irrigation sleeve after 20–30 minutes or when stool is no longer emptying from colon.
18. Cleanse stoma and skin with warm tap water. Pat dry.
19. Place gauze pad over stoma to absorb mucus from stoma.
20. Secure gauze with hypoallergenic tape.
21. Remove gloves and wash hands.