ENEMA
Very sluggish and thought to move the
Course Outline
 DEFECATION PHYSIOLOGY
 DEFECATION/ BOWEL MOVEMENT
 FACTORS THAT AFFECT DEFECATION
 FECAL ELIMINATION PROBLEMS
 FACTORS THAT CONTRIBUTE CONSTIPATION
 NURSING DIAGNOSIS FOR FECAL
ELIMINATION PROBLEMS
 MEDICATIONS
 ADMINISTERING ENEMA
 CLEANSING ENEMA
 COMMON ENEMA SOLUTION
 CLASSIFICATION OF ENEMA
DEFECATION [BOWEL MOVEMENT] PHYSIOLOGY
 Elimination of waste is very essential.
 Excreted waste = feces/stool
Large Intestine
- Extends from ileocecal valve to the anus
DEFECATION/ BOWEL MOVEMENT
- Colon: 125 to 150cm long [50 to 60 inches]
- Cecum, transverse, descending colon, sigmoid colon,
rectum and anus
- Haustra: pouches of large intestine due to short
longitudinal muscles
- Absorption of water and nutrients, mucoid protection
of the intestinal wall and fecal elimination
- Contents: food ingested over previous 4 days
- Lumen > flatus/feces
- Chyme: stomach > small intestine > ileocecal valve
- Ileocecal: prevents backflow of chyme and regulates
the flow of chyme.
- Colon: serves as protective function in that its secreted
mucus. It also acts to transport along its lumen the
products of digestion.
- Mucus: serves to protect the wall of the large intestine
from trauma by the acids formed in the feces, and it
serves as an adherent for holding the fecal material
together. Mucus also protects the intestinal wall from
bacterial activity.
TYPES OF MOVEMENT IN LARGE INTESTINE
FACTORS THAT AFFECT DEFECATION
 Haustral churning
o Movement of chyme back and forth within
the haustra.
o Mixing the contents, aids the absorption of
water & moves to the next haustra.
 Colon peristalsis
o Wavelike movement produced by longitudinal
muscle fibers.
o Propels intestinal contents forward.
o
chyme very little.
 Mass Peristalsis
o Wave of powerful muscular contraction that
moves over large areas of colon.
o Occurs after eating stimulated by the
presence of food in the stomach and small
intestine.
Rectum & Anal Canal
- R: 10 to 15cm [4 to 6 inches]
- A: 2.5 to 5cm [1 to 2 inches]
- Anal canal: external and internal sphincter
- Hemorrhoids occur when veins are distended due to
the repeated pressure.
- Each vertical folds of rectum have a vein and an artery
and these folds keeps retaining the feces within the
rectum.
 Expulsion of feces from the anus.
 When peristaltic waves move the feces into the sigmoid
colon and the rectum, the sensory nerves in the rectum
are stimulated and the individual becomes aware of the
need to defecate.
 It is facilitated by thigh flexion, that increases pressure
within the abdomen and sitting position, that increases
the downward pressure on the rectum.
 Normal feces
- 75% water
- 25% solid
- Brown due to presence of stercobilin and urobilin
which derived from bilirubin
- Odor: action of bacteria (Escherichia coli or
staphylococci)
 Microorganisms + chyme = odor
 Flatus: largely air and the by-products of digestion of
CHO
 An adult usually forms 7 to 10L of flatus in the large
intestine q24h.
(1) DEVELOPMENT
 Newborn & Infants
- Meconium: black tarry, odorless, and
sticky
- Transitional stool: greenish yellow
- Breast-fed: light yellow to golden feces.
- Formula: dark yellow or tan stool.
 - Intestine is immature, water is not well
absorbed and stool is soft, liquid, and
frequent.
 Toddlers
- Desire to control during daytime bowel
movements
- Toilet training
- Childs starts to become aware, feeling of
discomfort by soiled diaper and sensation
that need to go to toilet.
 School-Age & Adolescent
- SA: may delay defecation during d/t
playing
- Similar bowel movement to adults
 Older Adults
- 50% suffer from constipation
- Due to less activity, low fiber and fluid
intake, and muscle weakness
- MUST: adequate roughage in diet,
adequate exercise, and 6 to 8 glasses of
fluid daily.
- Gastrocolic reflex [increase peristalsis to
the colon]
(2) DIET
 Inadequate fiber intake increases the risk for
having obesity, diabetes mellitus type 2, coronary
artery disease and colon cancer.
 Diarrhea and flatus: spicy and high sugar
 Works with plenty of water
 Bland and low fiber diets are lack in bulk and it
moves more slowly so it needs to increase fluid
intake to increase their rate of movement.
 Insoluble Fiber
- Promotes movement
- Increase stool bulk
- Whole-wheat flour, wheat bran, nuts,
many vegetables
 Soluble Fiber
- Dissolves in water = gel like
- Decrease blood cholesterol
- Decrease glucose level
- Oats, peas, beans, apples, citrus fruits,
carrots, barley and psyllium
(3) FLUID INTAKE & OUTPUT
 2000 to 3000 mL/day
 The body continues to reabsorb fluid from the
chyme as it passes along the colon.
 Reduced fluid intake slows the chyme’s passage
along the intestines, further increasing the
reabsorption of fluid from the chyme.
 Abnormal quick movement of chyme in the large
intestine makes the feces soft or even watery due
to less time of fluid absorption.
(4) ACTIVITY
 Stimulates peristalsis (Movement of chyme to
colon)
 Weak muscles can result from lack of exercise,
immobility, or impaired neurologic functioning.
 Bed ridden: risk for constipation/ constipated
(5) PSYCHOLOGICAL
 Angry/Anxious
- Increase peristaltic activity
- Subsequent nausea and vomiting
 Depressed
- Slow intestinal motility
- Constipation
(6) DEFECATION HABITS
 Establish habit of defecating at a regular time.
 Ignores defecating can result to constipation.
(7) MEDICATIONS
 Large doses of tranquillizers, repeated
administration of morphine and codeine decrease
the GI motility and can make the patient
constipated.
 Iron tablets have an astringent effect that act more
locally on the bowel mucosa to cause constipation.
 Laxatives stimulate bowel activity and assist fetal
elimination.
 Iron salts can make the stool black as well as Pepto-
Bismol, a common OTC drug.
 Antibiotics may cause gray-green discoloration
 Antacids can cause whitish discoloration or specs in
the stool.
(8) DIAGNOSTIC PROCEDURE
 Sigmoidoscopy/ colonoscopy: the patient is
restricted from ingesting food or fluid.
 The patient will be given cleansing enema prior to
the procedure.
(9) ANESTHESIA & SURGERY
 General Anesthetics
- Cause normal colonic movements to cease
or to slow by blocking the parasympathetic
stimulation.
 Ileus [cessation of intestinal movement] that lasts
24-48 hours
 Listening for bowel sounds that reflect intestinal
motility is important nursing assessment following
surgery.
(10) PATHOLOGIC CONDITIONS
 Spinal cord and head injuries can decrease sensory
stimulation of defecation
  Impaired mobility can limit pt to respond to urge FACTORS THAT CONTRIBUTE CONSTIPATION
and experience constipation.
(11) PAIN (1) Insufficient Fiber Intake
 Pt who experienced pain during defecating often (2) Insufficient fluid intake
suppress the urge to defecate (3) Immobility
 Resulting into constipation (4) Irregular defecation Habits
 Narcotic analgesic can make the client constipation (5) Change in Daily Routine
(6) Lack of Privacy
(7) Chronic use of laxative or enema
(8) IBS
FECAL ELIMINATION PROBLEMS
(9) Pelvic floor dysfunction/ muscle damage
(10) Poor motility
CONSTIPATION (11) Neurologic Conditions
 Less than 3 bowel movements. (12) Emotional Disturbances
 Bowel movement to the large intestine is slow + the (13) Medications
reabsorption of water. (14) Habitual ignoring the urge
 Fecal Impaction
NURSING DIAGNOSIS FOR FECAL ELIMINATION PROBLEMS
- Mass collection of hardened feces in folds of
rectum.
- Oil retention enema is given if fetal impaction is  Bowel incontinence
suspected.  Constipation
- Causes: poor defecation habits and constipation  Risk for constipation
resulting into prolonged retention and  Perceived constipation
accumulation of fetal material, administration of  Diarrhea
anticholinergics & antihistamine, and barium  Dysfunctional G.I. motility
used in radiologic examination of GI tract.  Risk for deficient fluid volume or Risk for Electrolyte
Imbalance
DIARRHEA  Risk for Impaired Skin Integrity
 Liquid feces  Situational Low Self Esteem
 Increase frequency if defecation  Disturbed body image
 Spasmodic cramps  Deficient knowledge
 Increase bowel sounds  Anxiety
 Fatigue, weakness, malaise and emaciation
MEDICATIONS

BOWEL INCONTINENCE CATHARTICS

 Loss of voluntary control of fecal and gaseous
 Drugs that induce defecation
discharge
 They can have strong, purgative effect
 Impaired anal sphincter or nerve supply
LAXATIVE
FLATULENCE
 Produces soft or liquid stools
 Intestinal distention
 Sometimes accompanied by abdominal cramps
 Excessive flatus that leads to stretching and inflation of
 Contraindicated in the client who has nausea, cramps,
infection.
colic, vomiting, or undiagnosed abdominal pain.
 Three primary sources of flatus:
 Continual use of laxatives to encourage bowel
(1) Action of bacteria on the chyme
evacuation weakens the bowel’s natural responses to
(2) Swallowed air
fecal distention, resulting in chronic constipation.
(3) Gas diffuses between bloodstream and intestine
 Teach the client about dietary fiber, regular exercise,
taking sufficient fluids, and establishing regular
defecation habits.
ANTIDIARRHEALS
COMMON ENEMA SOLUTIONS
 Slow the motility of the intestine
 Absorb excess fluid in the intestine HYPERTONIC Draws water in the colon
 Using a medication such as an opiate when the cause
is an infection, toxin, or poison may prolong diarrhea.
HYPOTONIC Distends colon, stimulates peristalsis,
 Longer use of OTC antidiarrheals can produce
softens feces
dependence.
 Some drugs can cause drowsiness and should not me
used when driving or running machinery. ISOTONIC Distends colon, stimulates peristalsis,
 Kaolin-pectin preparations may absorb nutrients. softens feces.
 Bulk laxatives 7 other absorbents may use to help bind
toxins & absorb excess bowel liquid.
SOAP SUDS Irritates mucosa, distends colon
 Pepto-Bismol used to treat “traveler’s diarrhea” it
may contain aspirin so it’s should not be given to
children or teens with chicken pox, influenza, and OIL Lubricates the feces and the colonic
other viral infection. mucosa.

ANTIFLATULENCE
CLASSIFICATION OF ENEMA
 Do not decrease flatus formation but they coalesce the
gas bubbles.  Prevent escape of feces during
 Facilitate their passage by belching through mouth or pregnancy
anus. CLEANSING  Prepare intestine for certain
 Combination of simethicone & loperamide diagnostic tests
[Imodium Advance] is effective in abdominal  Remove feces in instances of
bloating & gas associated with acute diarrhea. constipation or impaction.

ADMINISTERING ENEMA
CARMINATIVE  To expel flatus
ENEMA – solution introduced to the rectum and large intestine  Adult: 60 to 80mL

Action: distend the intestine and irritate the intestinal mucosa

RETENTION  Oil or medication
that increase peristalsis = excretion of feces and flatus.
 Retained for 1 to 3 hours
Temperature: 37.7 degrees Celsius or 100 degrees Fahrenheit

 The force of solution is controlled by:  Harris flush

RETURN-FLOW  Expel flush
o Height of solution container
ENEMAS  100 to 200mL fluid into & out
o Size of tubing rectum & sigmoid colon
o Viscosity of fluid  Repeated 5 to 6 times
o Rectum resistance
(a) HIGH ENEMA – give cleanse as much of the colon as
possible.
(b) LOW ENEMA – rectum and sigmoid colon only left lateral
position.

CLEANSING ENEMA

 Intended to remove feces.

 Prevent escape of feces during surgery.
 Preparation for diagnostic tests.
 Remove feces in occurrence of constipation or
impaction.