Chapter 46: Bowel Elimination

Bonnie M. Wivell, MS, RN, CNS

 Scientific Knowledge Base
Mouth
Digestion begins with
mastication; saliva dilutes
and softens food
Stomach
Stores food & liquid; mixes
food, liquid and digestive
juices; moves food into small
intestines
Large intestine
The primary organ of bowel
elimination
Esophagus
Peristalsis moves food
bolus into the stomach
Small intestine
Duodenum, jejunum, and
ileum
Anus
Expels feces and flatus
from the rectum
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
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
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 24-48 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
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
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
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
Loop Colostomy
Double-Barrel Colostomy
Double-Barrel Colostomy
End Colostomy
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
Ileoanal Pouch Anastomosis
Kock Continent Ileostomy
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
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
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
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)
Nursing Diagnosis

• Bowel incontinence
• Constipation
• Risk for constipation
• Perceived constipation
• Diarrhea
• Toileting self-care deficit
• Body image, disturbed
Planning
• Goals and outcomes
– 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
Implementation
• Health Promotion: establish routine
– Promotion of normal defecation
• Sitting position
• Position on bedpan – see pg. 1196
• Privacy
• Acute Care
– Meds
– Cathartics and laxatives
– Antidiarrheal agents
– Enemas
Types of Enemas
• Cleansing enemas
– Tap water
– Normal saline
– Hypertonic solutions
– Soapsuds
• Oil Retention
• Carminative – Mag, gylcerin and water;
relieves gaseous distention
• Medicated enemas – Kayexalate
Implementation Cont’d.

• Enema administration
– “Enemas till clear”
– See pages 1200-1202
• Digital removal of stool – last resort
– Can cause irritation to the mucosa, bleeding
and stimulation of vagus nerve
• Inserting and maintaining a nasogastric
tube
NG Tubes
• Levine or salem sump tubes are most common for
stomach decompression or lavage
• See pages 1204-1209 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
Continuing and Restorative Care
• Care of ostomies
• Irriating a colostomy
• Pouching ostomies (see pages 1211-1215)
• Nutritional considerations with ostomies
• Bowel training
• Proper fluid and food intake
• Regular exercise
• Hemorrhoids
• Skin integrity
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