Bowel Elimination

Bowel Elimination (Defecation) is a natural process by which the soiled waste products of digestion (feces or stool) are eliminated from the bowel.

The Large Intestine

• Primary organ of bowel elimination
• Extends from the ileocecal valve to the anus

Functions

• Completion of absorption of H2O, Nutrients (chyme from sm. intest. – 1-1.5 L)
• Manufacture of some vitamins
• Formation of feces
• Expulsion of feces from the body

The Small and Large Intestines

Process of Peristalsis

• Peristalsis is under control of nervous system
• Contractions occur every 3 to 12 minutes
• Mass peristalsis sweeps occur 1 to 4 times each 24-hour period
• One-third to one-half of food waste is excreted in stool within 24 hours

Peristalic Movements in the Intestine – Colonic peristalsis is slow. Mass peristalsis is strong, few waves per day, stimulated by food in small intestine.

Factors that influence Bowel Elimination

1. Age
2. Diet
3. Position
4. Pregnancy
5. Fluid Intake
6. Activity
7. Psychological
8. Personal Habits
9. Pain
10. Medications
11. Surgery/Anesthesia

Developmental Considerations

• Infants—characteristics of stool and frequency depend on formula or breast feedings
• Toddler physiologic maturity is first priority for bowel training (1 ½ – 2 yrs)
• Child, adolescent, adult—defecation patterns vary in quantity, frequency, and rhythmicity
• Older adult—constipation is often a chronic problem

Foods Affecting Bowel Elimination

• Constipating foods cheese, lean meat, eggs, & pasta
• Foods with laxative effect—fruits and vegetables, bran, chocolate, alcohol, coffee
• Gas-producing foods—onions, cabbage, beans, cauliflower

Effect of Medications on Stool

• Aspirin, anticoagulants pink, red, or black stool
• Iron salts—black stool
• Antacids white discoloration or speckling in stool
• Antibiotics—green-gray color

Physical Assessment of the Abdomen

• Inspection—observe contour, any masses, scars, or distension
• Auscultation—listen for bowel sounds in all quadrants
• Note frequency and character, audible clicks, and flatus
• Describe bowel sounds as audible, hyperactive, hypoactive, or inaudible Percussion—expect resonant sound or tympany
• Areas of increased dullness may be caused by fluid, a mass, or tumor
• Palpation—note any muscular resistance, tenderness, enlargement of organs, masses

Physical Assessment of the Anus and Rectum

• Inspection and palpation
• Examine anal area for cracks, nodules, distended veins, masses or polyps, fecal mass
• Insert gloved finger into anus to assess sphincter tone & smoothness of mucosal lining
• Inspect perineal area for skin irritation secondary to diarrhea

Stool Collection

• Medical aseptic technique is imperative
• Wear disposable gloves
• Wash hands before and after glove use
• Do not contaminate outside of container with stool
• Obtain stool and package, label, and transport according to agency policy

Patient Guidelines for Stool Collection

• Void first so urine is not in stool sample
• Defecate into the container rather than toilet bowl
• Do not place toilet tissue in bedpan or specimen container
• Notify nurse when specimen is available
• get to lab quickly (30 min) if anything viable in sample ie. parasites, C-diff. etc

Types of Direct Visualization Studies

• Esophagogastroduodenoscopy (EGD)
• Colonoscopy
• Sigmoidoscopy
• Wireless capsule endoscopy

Indirect Visualization Studies

• Upper gastrointestinal (UGI)
• Small bowel series
• Barium enema

Scheduling Diagnostic Tests

• 1 — fecal occult blood test
• 2 — barium studies (should precede UGI) make sure ALL barium is removed*
• 3 — endoscopic examinations

Noninvasive procedures take precedence over invasive procedures

Patient Outcomes for Normal Bowel Elimination

• Patient has a soft-formed bowel movement every 1-3 days without discomfort
• The relationship between bowel elimination and diet, fluid, and exercise is explained
• Patient should seek medical evaluation if changes in stool color or consistency persist

Promoting Regular Bowel Habits

• Timing -attend to urges promptly
• Positioning – have pt. sit up, gravity aids in BM
• Privacy – close door & pull curtain
• Nutrition
• Exercise – abdominal muscles & thighs
• Abdominal settings
• Thigh strengthening

Individuals at High Risk for Constipation

• Patients on bed rest taking constipating medications
• Patients with reduced fluids or bulk in their diet
• Patients who are depressed
• Patients with central nervous system disease or local lesions that cause pain

*Valsalva maneuver (straining & holding breath) ↑intrathoracic / intracranial pressure – possible brain injury

Nursing Measures for the Patient With Diarrhea

• Answer call lights immediately
• Remove the cause of diarrhea whenever possible (e.g., medication)
• If there is impaction, obtain physician order for rectal examination
• Give special care to the region around the anus
• After diarrhea stops, suggest the intake of fermented dairy products
• Fecal seepage may indicate impaction

Preventing Food Poisoning

• Never buy food with damaged packaging
• Never use raw eggs in any form
• Do not eat ground meat uncooked
• Never cut meat on a wooden surface
• Do not eat seafood that is raw or has unpleasant odor
• Clean all vegetables and fruits before eating
• Refrigerate leftovers within 2 hours of eating them
• Give only pasteurized fruit juices to small children

Methods of Emptying the Colon of Feces

• Enemas
• Rectal suppositories
• Rectal catheters
• Digital removal of stool

Types of Enemas

• Cleansing – high volume
• Retention – oil
• Return-flow – bag of solution taken in (100-300 ml fluid) for pt with gas

Retention Enemas

• Oil-retention—lubricate the stool and intestinal mucosa easing defecation
• Carminative—help expel flatus from rectum
• Medicated—provide medications absorbed through rectal mucosa
• Anthelmintic—destroy intestinal parasites
• Nutritive—administer fluids and nutrition rectally

Bowel Training Programs

• Manipulate factors within the patient’s control
• Food and fluid intake, exercise, time for defecation
• Eliminate a soft, formed stool at regular intervals without laxatives
• When achieved, discontinue use of suppository if one was used

Types of Colostomies – each has different stool consistency

• Sigmoid colostomy
• Descending colostomy
• Transverse colostomy
• Ascending colostomy
• Ileostomy

Location of (A) a Sigmoid Colostomy and (B) a Descending Colostomy
Location of (C) a Transverse Colostomy and (D) an Ascending Colostomy
Location of an Ileostomy

Colostomy Care

• Keep patient as free of odors as possible; empty appliance frequently
• Inspect the patient’s stoma regularly
• Note the size, which should stabilize within 6 to 8 weeks
• Keep the skin around the stoma site clean and dry
• Measure the patient’s fluid intake & output
• Explain each aspect of care to the patient and self-care role
• Encourage patient to care for and look at ostomy

Normal-Appearing Stoma

Patient Teaching for Colostomies

• Community resources are available for assistance
• Initially encourage patients to avoid foods high in fiber
• Avoid foods that cause diarrhea or flatus
• Drink two quarts of water daily
• Teach about medications
• Teach about odor control (intake of dark green vegetables helps control odor)
• Resume normal activity including work and sexual relations

Comfort Measures

• Encourage recommended diet and exercise
• Use medications only as needed
• Apply ointments or astringent (witch hazel)
• Use suppositories that contain anesthetics

Characteristics of Normal Stool

1. Color – varies from light to dark brown foods & medications may affect color
2. Odor – aromatic, affected by ingested food and person’s bacterial flora
3. Consistency – formed, soft, semi-solid; moist
4. Frequency – varies with diet (about 100 to 400 g/day)
5. Constituents – small amount of undigested roughage, sloughed dead bacteria and epithelial cells, fat, protein, dried constituents of digestive juices (bile pigments); inorganic matter (calcium, phosphates)

Common Bowel Elimination Problems

1. Constipation – abnormal frequency of defecation and abnormal hardening of stools
2. Impaction – accumulated mass of dry feces that cannot be expelled
3. Diarrhea – increased frequency of bowel movements (more than 3 times a day) as well as liquid consistency and increased amount; accompanied by urgency, discomfort and possibly incontinence
4. Incontinence – involuntary elimination of feces
5. Flatulence – expulsion of gas from the rectum
6. Hemorrhoids – dilated portions of veins in the anal canal causing itching and pain and bright red bleeding upon defecation.