Chapter 46: Bowel Chapter 46: Bowel EliminationElimination

Bonnie M. Wivell, MS, RN, CNSBonnie M. Wivell, MS, RN, CNS

Scientific Knowledge Scientific Knowledge BaseBase

MouthMouthDigestion begins with Digestion begins with mastication; saliva mastication; saliva dilutes and softens fooddilutes and softens food

EsophagusEsophagusPeristalsis moves food Peristalsis moves food bolus into the stomachbolus into the stomach

StomachStomachStores food & liquid; Stores food & liquid; mixes food, liquid and mixes food, liquid and digestive juices; moves digestive juices; moves food into small intestinesfood into small intestines

Small intestineSmall intestineDuodenum, jejunum, Duodenum, jejunum, and ileumand ileum

Large intestineLarge intestineThe primary organ of The primary organ of bowel eliminationbowel elimination

AnusAnusExpels feces and flatus Expels feces and flatus from the rectumfrom the rectum

Factors Affecting Bowel Factors Affecting Bowel EliminationElimination• AgeAge

– Infants: small stomach capacity; less secretion of Infants: small stomach capacity; less secretion of digestive enzymes; rapid peristalsis; lack digestive enzymes; rapid peristalsis; lack neuromuscular development so cannot control neuromuscular development so cannot control bowelsbowels

– Older adults: arteriosclerosis which causes Older adults: arteriosclerosis which causes decreased mesenteric blood flow, decreasing decreased mesenteric blood flow, decreasing absorption in small intestine; decrease in absorption in small intestine; decrease in peristalsis; loose muscle tone in perineal floor and peristalsis; loose muscle tone in perineal floor and anal sphincter thus are at risk for incontinence; anal sphincter thus are at risk for incontinence; slowing nerve impulses in the anal region make slowing nerve impulses in the anal region make older adults less aware of need to defecate leading older adults less aware of need to defecate leading to irregular BMs and risk of constipationto irregular BMs and risk of constipation

Factors Affecting Bowel Factors Affecting Bowel EliminationElimination• Diet:Diet: fiber such as whole grains, fresh fruits and fiber such as whole grains, fresh fruits and

vegies help flush the fats and waste products from vegies help flush the fats and waste products from the body with more efficiency; decreased fiber the body with more efficiency; decreased fiber → → increased risk of polyps; be aware of food intolerancesincreased risk of polyps; be aware of food intolerances

• Fluid intake:Fluid intake: 6-8 glasses of noncaffeinated fluid 6-8 glasses of noncaffeinated fluid daily; liquifies intestinal contents easing passage daily; liquifies intestinal contents easing passage through colonthrough colon

• Physical activity:Physical activity: promotes peristalsis promotes peristalsis• Psychological factors:Psychological factors: stress increases peristalsis stress increases peristalsis

resulting in diarrhea and gaseous distention; resulting in diarrhea and gaseous distention; ulcerative colitis; IBS; gastric and duodenal ulcers; ulcerative colitis; IBS; gastric and duodenal ulcers; crohn’s diseasecrohn’s disease

• Personal habits:Personal habits: fear of defecating away from home fear of defecating away from home• Position during defecation:Position during defecation: squatting is the normal squatting is the normal

positionposition

Factors Affecting Bowel Factors Affecting Bowel EliminationElimination• Pain:Pain: hemorrhoids, rectal surgery, rectal hemorrhoids, rectal surgery, rectal

fistulas and abd. surgeryfistulas and abd. surgery• Pregnancy:Pregnancy: increased pressure; slowing increased pressure; slowing

peristalsis in third trimesterperistalsis in third trimester• Surgery and Anesthesia:Surgery and Anesthesia: lows or stops lows or stops

peristalsis; paralytic ileus = direct peristalsis; paralytic ileus = direct manipulation of the bowel and lasts 24-48 manipulation of the bowel and lasts 24-48 hourshours

• Medications:Medications: laxatives and cathartics; laxatives and cathartics; laxative overuse can decrease muscle tone laxative overuse can decrease muscle tone and can cause diarrhea which can result in and can cause diarrhea which can result in dehydration and electrolyte imbalance; see dehydration and electrolyte imbalance; see Table 46-2Table 46-2

• Diagnostic tests: Diagnostic tests: bowel prep; bariumbowel prep; barium

Common Bowel Elimination Common Bowel Elimination ProblemsProblems• ConstipationConstipation

– Causes: improper diet, reduced fluid intake, Causes: improper diet, reduced fluid intake, lack of exercise, and certain medslack of exercise, and certain meds

– A significant health hazardA significant health hazard• ImpactionImpaction

– Causes: unrelieved constipationCauses: unrelieved constipation– Debilitated, confused, and unconscious more at Debilitated, confused, and unconscious more at

riskrisk– Continuous ooze of diarrhea is a suspect signContinuous ooze of diarrhea is a suspect sign

• DiarrheaDiarrhea– Causes: antibiotics via any route; enteral Causes: antibiotics via any route; enteral

nutrition; food allergies or intolerance; nutrition; food allergies or intolerance; surgeries or diagnostic testing of the lower GI surgeries or diagnostic testing of the lower GI tract; C. difficile; communicable food-borne tract; C. difficile; communicable food-borne pathogenspathogens

Common Bowel Elimination Common Bowel Elimination ProblemsProblems

• IncontinenceIncontinence– Causes: physical conditions that impair anal Causes: physical conditions that impair anal

sphincter function or controlsphincter function or control

• FlatulenceFlatulence– Causes: certain foods; decreased intestinal motility Causes: certain foods; decreased intestinal motility – Can become severe enough to cause abd Can become severe enough to cause abd

distention and severe sharp paindistention and severe sharp pain

• Hemorrhoids = dilated, engorged veins; Hemorrhoids = dilated, engorged veins; internal or externalinternal or external– Causes: straining with defecation; pregnancy; Causes: straining with defecation; pregnancy;

heart failure; chronic liver diseaseheart failure; chronic liver disease

Bowel DiversionsBowel Diversions• Ostomies: Certain disease /conditions prevent Ostomies: Certain disease /conditions prevent

normal passage of stool; temporary or normal passage of stool; temporary or permanent artificial opening in the abd wall; permanent artificial opening in the abd wall; location determines consistency of stoollocation determines consistency of stool– Loop colostomy: Usually done emergently; Loop colostomy: Usually done emergently;

temporary; usually involves transverse colon; two temporary; usually involves transverse colon; two openings through one stoma – stool and mucus; openings through one stoma – stool and mucus; external supporting device usually removed in 7-10 external supporting device usually removed in 7-10 daysdays

– End colostomy: one stoma formed from the proximal End colostomy: one stoma formed from the proximal end of the bowel and distal portion of the GI tract end of the bowel and distal portion of the GI tract removed or sewn closed (Hartman’s pouch); removed or sewn closed (Hartman’s pouch); common in colorectal cancer and rectum is usually common in colorectal cancer and rectum is usually removed; temporary in surgery for diverticulitisremoved; temporary in surgery for diverticulitis

– Double-barrel colostomy: bowel is surgically severed Double-barrel colostomy: bowel is surgically severed and two ends brought out onto the abd; proximal and two ends brought out onto the abd; proximal stoma functions and distal stoma is nonfunctioningstoma functions and distal stoma is nonfunctioning

Loop ColostomyLoop Colostomy

Double-Barrel ColostomyDouble-Barrel Colostomy

Double-Barrel ColostomyDouble-Barrel Colostomy

End ColostomyEnd Colostomy

Bowel Diversions Cont’d.Bowel Diversions Cont’d.– Alternative proceduresAlternative procedures

• Ileoanal pouch: colon removed for tx of Ileoanal pouch: colon removed for tx of ulcerative colits or familial polyps; pouch is ulcerative colits or familial polyps; pouch is formed from distal end of small intestines and formed from distal end of small intestines and attached to anus; pouch acts as rectum so pt. attached to anus; pouch acts as rectum so pt. is continent; has temporary ileostomy while is continent; has temporary ileostomy while healing healing

•Kock continent ileostomy: consists of a Kock continent ileostomy: consists of a reservoir constructed from small bowel and reservoir constructed from small bowel and nipple valve which keeps contents of reservoir nipple valve which keeps contents of reservoir inside body; permits entry of external catheter inside body; permits entry of external catheter to drain pouchto drain pouch

•Macedo-Malone Antegrade Continence Enema Macedo-Malone Antegrade Continence Enema (MACE); for improving continence in pts with (MACE); for improving continence in pts with neuropathic or structural abnormalities of the neuropathic or structural abnormalities of the anal sphincteranal sphincter

Ileoanal Pouch AnastomosisIleoanal Pouch Anastomosis

Kock Continent IleostomyKock Continent Ileostomy

Care of the Patient With aCare of the Patient With aBowel DiversionBowel Diversion

• ““Bagging” the ostomyBagging” the ostomy

• Assessing stoma and skin Assessing stoma and skin

• Assessing stool outputAssessing stool output

• New stoma vs. Old stomaNew stoma vs. Old stoma

• Patient education and counselingPatient education and counseling

Psychological Psychological ConsiderationsConsiderations• Body image changesBody image changes• Face a variety of anxieties and concernsFace a variety of anxieties and concerns• Must learn how to manage stomaMust learn how to manage stoma• Cope with conflicts of self-esteem and body Cope with conflicts of self-esteem and body

imageimage• Can be concealed with clothing but pt. aware of Can be concealed with clothing but pt. aware of

its presenceits presence• Difficulty with intimacy/sexual relationsDifficulty with intimacy/sexual relations• Foul odors, leakage, spills and inability to Foul odors, leakage, spills and inability to

control or regulate passage of gas and stool is control or regulate passage of gas and stool is embarrassingembarrassing

• Ostomy support: Ostomy support: – United Ostomy AssociationUnited Ostomy Association– National Foundation for Ileitis and ColitisNational Foundation for Ileitis and Colitis

Nursing Process and Bowel Nursing Process and Bowel EliminationElimination• AssessmentAssessment

– Nursing history (see Box 46-2)Nursing history (see Box 46-2)• Usual elimination patternUsual elimination pattern• Usual stool characteristicsUsual stool characteristics• Routines to promote normal eliminationRoutines to promote normal elimination• Use of artificial aidsUse of artificial aids• Presence/status of bowel diversionsPresence/status of bowel diversions• Changes in appetiteChanges in appetite• Diet historyDiet history• Daily fluid intakeDaily fluid intake• History of surgery or illnesses of GI tractHistory of surgery or illnesses of GI tract• Medication historyMedication history• Emotional stateEmotional state• History of exerciseHistory of exercise• Pain or discomfortPain or discomfort• Social historySocial history• Mobility and dexterityMobility and dexterity

Nursing Process and Bowel Nursing Process and Bowel EliminationElimination

– Physical assessment of the abdomenPhysical assessment of the abdomen• Mouth: poor dentition, dentures, mouth soresMouth: poor dentition, dentures, mouth sores• Abdomen: inspect, auscultate, palpate, percussAbdomen: inspect, auscultate, palpate, percuss• Rectum: inspectRectum: inspect

– Inspection of fecal characteristics Inspection of fecal characteristics – Review of relevant test resultsReview of relevant test results

• Fecal specimens: cannot mix feces with urine or waterFecal specimens: cannot mix feces with urine or water– Stool for occult blood (FOBT or guiac) see Box 46-3Stool for occult blood (FOBT or guiac) see Box 46-3– Fecal fat requires 3-5 days of collectionFecal fat requires 3-5 days of collection– Ova & Parasites (O&P)Ova & Parasites (O&P)

• Labs: bilirubin, ALK, Amylase, CEALabs: bilirubin, ALK, Amylase, CEA• Diagnostic Exams: KUB, endoscopy, colonoscopy, barium Diagnostic Exams: KUB, endoscopy, colonoscopy, barium

enema, barium swallow, US, MRI, CT scan (may require enema, barium swallow, US, MRI, CT scan (may require pre-procedure preparation)pre-procedure preparation)

Nursing DiagnosisNursing Diagnosis

• Bowel incontinenceBowel incontinence

• ConstipationConstipation

• Risk for constipationRisk for constipation

• Perceived constipationPerceived constipation

• DiarrheaDiarrhea

• Toileting self-care deficitToileting self-care deficit

• Body image, disturbedBody image, disturbed

PlanningPlanning

• Goals and outcomesGoals and outcomes– Client sets regular defecation habitsClient sets regular defecation habits– Client is able to list proper fluid and food intake Client is able to list proper fluid and food intake

needed to achieve bowel eliminationneeded to achieve bowel elimination– Client implements a regular exercise programClient implements a regular exercise program– Client reports daily passage of soft, formed Client reports daily passage of soft, formed

brown stoolbrown stool– Client doesn’t report any discomfort associated Client doesn’t report any discomfort associated

with defecationwith defecation

• Setting PrioritiesSetting Priorities• Collaborative Care - WOCNCollaborative Care - WOCN

ImplementationImplementation

• Health Promotion: establish routine Health Promotion: establish routine – Promotion of normal defecationPromotion of normal defecation

• Sitting positionSitting position

• Position on bedpan – see pg. 1196Position on bedpan – see pg. 1196

• PrivacyPrivacy

• Acute CareAcute Care– MedsMeds– Cathartics and laxativesCathartics and laxatives– Antidiarrheal agentsAntidiarrheal agents– EnemasEnemas

Types of EnemasTypes of Enemas

• Cleansing enemasCleansing enemas– Tap waterTap water– Normal salineNormal saline– Hypertonic solutionsHypertonic solutions– SoapsudsSoapsuds

• Oil RetentionOil Retention• Carminative – Mag, gylcerin and water; Carminative – Mag, gylcerin and water;

relieves gaseous distentionrelieves gaseous distention• Medicated enemas – Kayexalate Medicated enemas – Kayexalate

Implementation Cont’d.Implementation Cont’d.

• Enema administrationEnema administration– ““Enemas till clear”Enemas till clear”– See pages 1200-1202 See pages 1200-1202

• Digital removal of stool – last resortDigital removal of stool – last resort– Can cause irritation to the mucosa, Can cause irritation to the mucosa,

bleeding and stimulation of vagus nervebleeding and stimulation of vagus nerve

• Inserting and maintaining a Inserting and maintaining a nasogastric tubenasogastric tube

NG TubesNG Tubes

• Levine or salem sump tubes are most common Levine or salem sump tubes are most common for stomach decompression or lavagefor stomach decompression or lavage

• See pages 1204-1209 for insertion procedureSee pages 1204-1209 for insertion procedure• Connected to intermittent suction (LIS)Connected to intermittent suction (LIS)• Air vent should NEVER be clamped, connected to Air vent should NEVER be clamped, connected to

suction or used for irrigationsuction or used for irrigation• Not a sterile techniqueNot a sterile technique• Care of pt. with NGCare of pt. with NG

– ComfortComfort– Frequent mouth care/garglingFrequent mouth care/gargling– Maintain patency of tubeMaintain patency of tube– Turn client frequently to allow for adequate emptyingTurn client frequently to allow for adequate emptying

Continuing and Restorative Continuing and Restorative CareCare•Care of ostomiesCare of ostomies

•Irriating a colostomyIrriating a colostomy

•Pouching ostomies (see pages 1211-Pouching ostomies (see pages 1211-1215)1215)

•Nutritional considerations with ostomiesNutritional considerations with ostomies

•Bowel trainingBowel training

•Proper fluid and food intakeProper fluid and food intake

•Regular exerciseRegular exercise

•HemorrhoidsHemorrhoids

•Skin integritySkin integrity

EvaluationEvaluation•The effectiveness of care depends on The effectiveness of care depends on

how successful the client is in achieving how successful the client is in achieving goals and outcomesgoals and outcomes

•Optimally the client will be able to have Optimally the client will be able to have regular, pain-free defecation of soft-regular, pain-free defecation of soft-formed stoolsformed stools

•It is necessary to ask questions so It is necessary to ask questions so establishing a therapeutic relationship is establishing a therapeutic relationship is VERY importantVERY important

•Nursing interventions may be altered if Nursing interventions may be altered if necessarynecessary