1. Bowel Elimination
Regular elimination of bowel waste products is essential for normal body functioning. Alterations in bowel elimination are often early signs or symptoms of problems within the gastrointestinal (GI) or other body systems. Because bowel function depends on the balance of several factors, elimination patterns and habits vary among individuals.
Understanding normal bowel elimination and factors that promote, impede, or cause alterations in elimination helps in management of patients’ elimination problems. Supportive nursing care respects the patient’s privacy and emotional needs. Measures designed to promote normal elimination need to minimize discomfort for the patient.

2. Scientific Knowledge Base
Mouth
Digestion begins with mastication.
Esophagus
Peristalsis moves food into the stomach.
Stomach
Stores food; mixes food, liquid, and digestive juices; moves food into small intestines
Small intestine
Duodenum, jejunum, and ileum
Large intestine
The primary organ of bowel elimination
Anus
Expels feces and flatus from the rectum
Here is a recap of major functions of the organs of the GI tract.
These structures are necessary for the defecation process.
Physiological factors critical to bowel function and defecation include normal GI tract function, sensory awareness of rectal distention and rectal contents, voluntary sphincter control, and adequate rectal capacity and compliance. Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, distention causes relaxation of the internal sphincter and awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out.
Sometimes people use the Valsalva maneuver to assist in stool passage. The Valsalva maneuver exerts pressure to expel feces through voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway.
Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool. Normal defecation is painless, resulting in passage of soft, formed stool.

3. Nursing Knowledge Base: Factors Affecting Bowel Elimination
Age
Diet
Fluid intake
Physical activity
Psychological factors
Personal habits
Position during defecation
Pain
Pregnancy
Surgery and anesthesia
Medications, laxatives, and cathartics
Diagnostic tests
Many factors influence the process of bowel elimination. Knowledge of these factors helps to anticipate measures required to maintain a normal elimination pattern.
Mechanical breakdown of food elements, gastrointestinal motility, and selective absorption and secretion of substances by the large intestine influence the character of feces.
Food high in fiber content and increased fluid intake keep feces soft.
Developmental changes affect elimination. Infants have small stomach capacity and rapid peristalsis.
Systemic changes in the function of digestion and in absorption of nutrients result from changes in older patients’ cardiovascular and neurological systems, rather than their GI system.
[See also Table 46-1 on text p Normal Age-Related Changes in the Gastrointestinal Tract.]
Diet and fluid intake will alter elimination. Fiber, the nondigestible residue in the diet, provides the bulk of fecal material. Bulk-forming foods such as whole grains, fresh fruits, and vegetables help flush fats and waste products from the body with greater efficiency. Food intolerance is not an allergy but rather relates to a particular food that causes the body distress within a few hours of ingestion.
The body needs adequate fluid intake to liquefy intestinal contents. Unless a medical contraindication is known, an adult needs to drink six to eight glasses (1500 to 2000 mL) of fluid daily.
Physical activity promotes peristalsis.
During emotional stress, the digestive process is accelerated, and peristalsis is increased. Stress can be a causative factor for colitis, irritable bowel syndrome (IBS), ulcers, and Crohn’s disease.
If a person becomes depressed, the autonomic nervous system slows impulses; peristalsis decreases, resulting in constipation.
Personal habits will influence elimination. Many people prefer their own bathroom facilities and want to use those facilities when possible.
A busy work schedule sometimes prevents the individual from responding appropriately to the urge to defecate, disrupting regular habits and causing possible alterations such as constipation.
Chronically ill and hospitalized patients do not always have privacy, which may affect the defecation process.
Another factor related to defecation is the preferred position. Squatting is the normal position during defecation. Modern toilets facilitate this posture, allowing the person to lean forward, exert intra-abdominal pressure, and contract the thigh muscles. In a supine position, it is impossible to contract the muscles used during defecation. If the patient’s condition permits, raise the head of the bed to assist the patient to a more normal sitting position on a bedpan, enhancing the ability to defecate.
Conditions that cause pain (such as hemorrhoids) often cause the patient to suppress the urge to defecate to avoid pain, contributing to the development of constipation.
As pregnancy advances, the size of the fetus will put pressure on the rectum, which can cause an obstruction. Slowing of peristalsis during the third trimester often leads to constipation.
General anesthetic agents used during surgery cause temporary cessation of peristalsis. Any surgery that involves direct manipulation of the bowel temporarily stops peristalsis. This condition, called paralytic ileus, usually lasts about 24 to 48 hours. If the patient remains inactive or is unable to eat after surgery, return of normal bowel elimination is further delayed.
The use of medications can affect bowel functioning. Even though laxatives and cathartics promote peristalsis, when used inappropriately, the intestines lose muscle tone and become less responsive to medication stimulation.
Following the diagnostic procedure, changes in elimination such as increased gas or loose stools often occur until the patient resumes a normal eating pattern.
[Review Table 46-2 on text p Medications and the Gastrointestinal System.]
Diagnostic examinations such as endoscopy or colonoscopy require bowel preparation. Before and after the procedure, the patient will experience gas and loose stools until a normal eating pattern is resumed.

4. Bristol Stool Form Scale
This diagram shows the Bristol Stool Form Scale.
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or a laxative to prevent constipation. Signs of constipation include infrequent bowel movements (less often than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feces.
When intestinal motility slows, the fecal mass becomes exposed over time to the intestinal walls, and most of the fecal water content is absorbed. Little water is left to soften and lubricate the stool. Passage of a dry, hard stool causes rectal pain.
Constipation is a significant health hazard. Straining during defecation causes problems for the patient with recent abdominal, gynecological, or rectal surgery. The effort to pass a stool often causes sutures to separate, reopening the wound. In addition, patients with a history of cardiovascular disease, diseases causing elevated intraocular pressure (glaucoma), or increased intracranial pressure need to prevent constipation and avoid using the Valsalva maneuver.
Vagal stimulation, which slows the heart rate, occurs during straining while defecating, taking rectal temperatures, completion of enemas, and digital removal of impacted stool.
[See also Box 46-1 on text p Common Causes of Constipation.]
[Shown is Figure 46-4 from text p ]

5. Common Bowel Elimination Problems
Constipation
A symptom, not a disease; infrequent stool and/or hard, dry, small stools that are difficult to eliminate
Impaction
Results from unrelieved constipation; a collection of hardened feces wedged in the rectum that
a person cannot expel
Diarrhea
an increase in the number of stools and the passage of liquid, unformed feces
Incontinence
Inability to control passage of feces and gas to the anus
Flatulence
Accumulation of gas in the intestines causing the walls to stretch
Hemorrhoids
Dilated, engorged veins in the lining of the rectum
Alterations in bowel elimination result from a variety of factors. (See previous slide for discussion of constipation.)
If impaction is unrelieved, it can result in intestinal obstruction.
The greatest danger from diarrhea is development of fluid and electrolyte imbalance. Antibiotics, chemotherapy, and invasive bowel procedures such as surgery or colonoscopy disrupt normal bowel flora and cause an overgrowth of Clostridium difficile; symptoms range from mild diarrhea to severe colitis.
Communicable foodborne pathogens also cause diarrhea. Hand hygiene following use of the bathroom, before and after preparing foods, and when cleaning and storing fresh produce and meats greatly reduces the risk of foodborne illness.
Using an anal bag or a bowel management system for incontinence helps to prevent perineal skin breakdown.
[See Figure 46-5 on text p ]
Flatulence causes abdominal distention and severe, sharp pain if intestinal motility is reduced because of opiates, general anesthetics, abdominal surgery, or immobilization.
Increased venous pressure from straining at defecation, pregnancy, heart failure, and chronic liver disease causes hemorrhoids.

6. Common Bowel Elimination Problems
Constipation
A symptom, not a disease; infrequent stool and/or hard, dry, small stools that are difficult to eliminate
Signs of constipation
infrequent bowel movements (less often than every 3 days)
difficulty passing stools
excessive straining
inability to defecate at will
hard feces.

7. Nursing Diagnosis (Risk for) Constipation R/T Opiate containing meds
Decreased fiber intake
Decreased fluid intake
Recent anesthesia
Stress
Inactivity (immobility)
Eating a large amount of dairy products
AEB no stool in 3 days
Outcome: Pt will have a soft, formed stool in 24 hours.

8. Assessments Assess for s/s of constipation Assess bowel sounds
Decrease in frequency of bowel movements
Consistency of stool
Anorexia
Abdominal distention and pain
Feeling of fullness or pressure in rectum
Straining during defecation
Assess bowel sounds

9. Therapeutic Interventions
Encourage fluid intake of at least 1500 ml/24hr
Encourage activity: walk pt in hallway 4 times a day
Encourage to defect whenever urge is felt
Assist to BR, BSC or bedpan (put pt in high Fowlers)
Provide for privacy
Encourage to drink hot liquids in AM
Administer laxatives or enemas as ordered
Consult with HCP to check for impaction

10. Teaching Teach to increase intake of foods high in fiber
Teach importance of activity
Teach reasons for changing opioid medication to a non-opioid medication

11. Common Bowel Elimination Problems
Impaction
Digital removal of stool
Results from unrelieved constipation; a collection of hardened feces wedged in the rectum that
a person cannot expel
A health care provider’s order is necessary to remove an impaction.
Digital removal of stool
Use if enemas fail to remove an impaction.
This is the last resort for constipation.
A health care provider’s order is necessary to remove an impaction.
For a patient with an impaction, the fecal mass is sometimes too large to pass voluntarily. If enemas fail, break up the fecal mass with the fingers, and remove it in sections.
Digital removal is a last resort in the management of severe constipation and is practiced when all other methods have failed. The procedure is very uncomfortable for the patient. Excessive rectal manipulation causes irritation to the mucosa, bleeding, and stimulation of the vagus nerve, which results in a reflex slowing of the heart rate.
Because of the potential complications of the procedure, a health care provider’s order is necessary to remove a fecal impaction.
Dangers during digital removal of stool include traumatizing the rectal mucosa and promoting vagal stimulation.
Digital removal of stool

12. Common Bowel Elimination Problems
Diarrhea
an increase in the number of stools and the passage of liquid, unformed feces

13. Nursing Diagnoses Diarrhea Risk for impaired skin integrity
Risk for Electrolyte imbalance
Risk for imbalanced fluid volume
Risk for falls

14. Common Bowel Elimination Problems
Incontinence
Inability to control passage of feces and gas to the anus
Nursing Diagnosis
Impaired Body Image
Impaired Social Interaction
Common causes of fecal incontinence include diarrhea, constipation, and muscle or nerve damage.
Spinal cord injury
Multiple Sclerosis
Stroke
Intestinal obstruction
Seizures

15. Common Bowel Elimination Problems
Flatulence
Accumulation of gas in the intestines causing the walls to stretch
Causes
Swallowed air
Foods and beverages
Medicines or nutritional supplements
Bowel obstruction
Nursing Diagnoses
Pain
Impaired body image
Examples of gas-producing foods are:
Vegetables such as artichokes, asparagus, broccoli, brussels sprouts, cabbage, cauliflower, cucumbers, green peppers, onions, peas, radishes, and raw potatoes.
Beans and other legumes.
Fruits such as apricots, bananas, melons, peaches, pears, prunes, and raw apples.
Wheat and wheat bran.
Eggs.
Carbonated drinks, fruit drinks, beer, and red wine.
Fried and fatty foods.
Sugar and sugar substitutes.
Milk and other dairy products, especially in people who have trouble digesting lactose, the main sugar found in milk.
Packaged foods that contain lactose, such as breads, cereal, and salad dressing.

16. Common Bowel Elimination Problems
Hemorrhoids
Dilated, engorged veins in the lining of the rectum
Causes
Diarrhea
Constipation
Pregnancy
Cirrhosis of the Liver
Nursing Diagnosis
Pain

17. Bowel Diversion
Temporary or permanent artificial opening in the abdominal wall
Stoma
Surgical opening in the ileum or colon
Ileostomy or colostomy
The standard bowel diversion creates a stoma.
Certain diseases cause conditions that prevent normal passage of feces through the rectum. Treatment for these disorders results in the need for a temporary or permanent artificial opening (stoma) in the abdominal wall. Surgical openings are created in the ileum (ileostomy) or colon (colostomy), with the ends of the intestine brought through the abdominal wall to create the stoma.
The standard bowel diversion creates a stoma, or the patient has reconstructive bowel surgery that uses the native sphincter for bowel continence. Reconstructive surgery includes a continent stoma procedure or an ileoanal pouch anastomosis (described later).

18. End Colostomy
This diagram shows a permanent (end) colostomy. The terminal end of the descending or sigmoid colon is brought out through the peritoneum and muscle and is sutured to the skin.
The end colostomy consists of one stoma formed from the proximal end of the bowel, with the distal portion of the GI tract removed or sewn closed (called Hartmann’s pouch) and left in the abdominal cavity. For many patients, end colostomies are a result of surgical treatment of colorectal cancer. In such cases, the rectum is usually removed. Patients with diverticulitis who are treated surgically often have a temporary end stoma with Hartmann’s pouch.

19. Double-Barrel Colostomy
This drawing shows a double-barrel colostomy. Both ends of the transected colon are brought out to the skin.
Unlike the loop colostomy, the surgeon divides the intestine and brings proximal and distal ends through the abdominal incision to the abdominal surface when creating a double-barrel colostomy. A small incision is made in the proximal stoma for fecal drainage. The distal stoma leads to the inactive intestine and is left intact. When the intestinal injury has healed, the colostomy is reversed, and the divided ends are anastomosed to restore intestinal integrity.

20. Ostomies End colostomy Double-barrel colostomy End ileostomy
Proximal end forms stoma, and distal end is removed or sewn closed.
Double-barrel colostomy
Bowel is surgically cut, and both ends are brought through the abdomen.
The location of the ostomy will determine the consistency of the stool, which will range from liquid to formed.
A loop colostomy is performed on an emergency basis.
An end colostomy is performed for colorectal cancer and is a permanent procedure.
In the double-barrel colostomy, the proximal end is active and the distal end is nonfunctioning, only producing mucus. The double barrel can be reversed.

21. Psychological Considerations
Nursing Diagnosis:
Disturbed body image
A stoma causes serious body image changes, particularly if it is permanent.
After the surgery, patients face a variety of anxieties and concerns, from learning how to manage their stoma to coping with conflicts of self-esteem and body image. Provide emotional support before and after surgery. Patients often perceive a stoma as invasive and disfiguring. However, a well-placed stoma usually does not interfere with the patient’s activities and is concealed with clothing. Nonetheless, even though clothing conceals the ostomy, the patient feels different. Many patients have difficulty maintaining or initiating normal sexual relations.
Important factors affecting reactions to the stoma include the character of fecal secretions and the ability to control them. Foul odors, spillage, or leakage of liquid stools and inability to regulate bowel movements cause the patient to lose self-esteem. The aging process often affects the ability to manage stomas, even in people who have had them for years. You need to recognize and intervene when problems resulting from advanced age such as skin changes, weight loss or gain, visual impairments, or changes in diet occur.

22. Continuing and Restorative Care
Irrigating a Colostomy
This drawing shows an ostomy irrigation cone inserted into the stoma.
Although this practice is not as common as it once was, some patients irrigate their left-sided colostomies to regulate colon emptying. Other patients do not want to spend the additional 60 to 90 minutes in the bathroom every day; thus they empty their pouch as necessary. Only colostomies can be irrigated.
Never use an enema set to irrigate a colostomy. Instead use specific equipment, which includes a special cone-tipped irrigator to prevent bowel penetration and backflow of the irrigating solution. Help patients to schedule irrigations at times that fit within their daily routine.
Before irrigating the stoma, patients usually sit on the toilet and place an irrigating sleeve over the stoma. The end of this sleeve extends into the bowl of the commode. The health care provider orders the amount and type of irrigation solution. For adults, the amount typically ranges from 500 to 700 mL of tap water. The patient instills the solution slowly through the lubricated cone tip. Irrigation usually takes 5 to 10 minutes. The patient then removes the cone tip and waits 30 to 45 minutes for the solution and feces to drain out of the irrigation sleeve. Once the drainage stops, the patient applies a stoma cap or a pouch.

23. Continuing and Restorative Care
Pouching ostomies
An effective pouching system protects the skin, contains fecal material, remains odor free, and is comfortable and inconspicuous.

24. Continuing and Restorative Care
Nutritional considerations
Consume low fiber for the first weeks.
Eat slowly and chew food completely.
Drink 10 to 12 glasses of water daily.
Patient may choose to avoid gassy foods.
Regular elimination patterns need to begin for a patient to recover and return home or to an extended care facility.
It is important to remember that ostomy care and bowel retraining are instituted in acute care settings. However, because these are long-term care needs, teaching is usually completed in restorative care settings.
The location of an ostomy influences the consistency of the stool.
Patients with temporary or permanent bowel diversions have unique elimination needs. An individual with an ostomy wears a pouch or appliance to collect effluent—stool discharged from the stoma.
Skin breakdown occurs after repeated exposure to liquid stool.
The patient needs to use meticulous skin care to prevent liquid stool from irritating the skin around the stoma.
[Irrigating a colostomy is discussed on the next slide.]
An ostomy requires a pouch to collect fecal material. A person wearing a pouch needs to feel secure enough to participate in any activity.
Proper selection and use of an ostomy pouching system are necessary to prevent damage to the skin around the stoma.
Many pouching systems are available. To ensure that a pouch fits well and meets the patient’s needs, consider the location of the ostomy, type and size of the stoma, type and amount of ostomy drainage, size and contour of the abdomen, condition of the skin around the stoma, physical activities of the patient, patient’s personal preference, age and dexterity, and cost of equipment.
A wound ostomy continence nurse (WOCN) is specially educated to care for ostomy patients; the WOCN collaborates with staff nurses to make sure that the patient uses the correct pouching system, especially when the patient is ill or is experiencing health changes or problems with the ostomy.
A pouching system consists of a pouch and a skin barrier.
Assess the stoma color. A normal stoma is bright pink or brick red. Notify the health care provider if the stoma is blue, brown, or black, which indicates circulation problems to the stoma. You need to measure the stoma size carefully when selecting and cutting out the opening on the wafer skin barrier. Too tight of an opening constricts the stoma and causes irritation and necrosis. Subtle stoma changes occur over time.
Encourage patients to visit their enterostomal nurse at least annually to ensure proper pouching and fit.
A good skin barrier protects the skin, prevents irritation from repeated removal of the pouch, and is comfortable for the patient to wear. Patients with new stomas often feel vulnerable when they leave the hospital. To provide a smooth transition from hospital to home, offer help for the patient and family caregivers. Effective patient teaching helps patients with a new ostomy transition smoothly to home.
[See also Box on p Patient Teaching: Teaching the Patient How to Provide Ostomy Care.]
Nutritional therapy is important for patients with ostomies. During the first weeks after surgery, many health care providers recommend low-fiber diets, particularly for patients with ileostomies, because the small bowel requires time to adapt to the diversion.
As ostomies heal, patients are able to eat almost any food. High-fiber foods such as fresh fruits and vegetables help ensure a more solid stool. Patients need to avoid blockages of the bowel. The surgical construction of the stoma affects the likelihood of blockage.

25. Implementations: Acute Care
Health promotion
Promotion of normal defecation
Establish a routine an hour after a meal, or maintain the patient’s routine.
Sitting position
Privacy
Positioning on bedpan
Successful nursing interventions improve patients’ and family members’ understanding of bowel elimination. Teach the patient and family about proper diet, adequate fluid intake, and factors that stimulate or slow peristalsis such as emotional stress. This is often best done during the patient’s mealtime. Patients need to learn the importance of establishing regular bowel routines, performing regular exercise, and taking appropriate measures when elimination problems develop.
One of the most important habits to teach regarding bowel habits is taking time for defecation. To establish regular bowel habits, a patient needs to know when the urge to defecate normally occurs. Advise the patient to begin establishing a routine during a time when defecation is most likely to occur, usually an hour after a meal. When patients are restricted to bed or need help to ambulate, offer a bedpan, or help them reach the bathroom in a timely manner.
Many patients have established routines for defecation. In a hospital or long-term care facility, make certain that treatment routines do not interfere with the patient’s routine. It is important to provide privacy. When patients forced to use a bedpan share rooms with other people, pull the curtain around the area so patients are able to relax, knowing that interruptions will not occur. Always place the call light and toilet tissue within the patient’s reach. When patients are at risk for falls, stand near them or leave the door partially open so you can see them at all times.
A number of interventions stimulate the defecation reflex, affect the character of feces, or increase peristalsis to help patients evacuate bowel contents normally and without discomfort.
Assist patients who have difficulty sitting because of muscular weakness and mobility problems. Place an elevated seat on the toilet when patients are unable to lower themselves to a sitting position because of joint- or muscle-wasting disease. These seats require patients to use less effort to sit or stand.
Maintain the patient’s privacy during bowel elimination. This is especially important for the patient who is using a bedpan. The call light and a supply of toilet paper need to be within easy reach. When the patient finishes, respond to the call signal immediately and remove the pan. The patient often requires assistance with wiping. To remove the pan, ask the patient to roll off to the side or to raise the hips. While wearing gloves, hold the pan steady to avoid spilling. Avoid pulling or shoving it from under the patient’s hips because this pulls the patient’s skin and causes tissue injury such as shearing. Remove the pan and clean the perineum from front to back.
After assessing the stool, immediately empty the contents of the bedpan into the toilet or into a special receptacle in the utility room. A spray faucet attached to most toilets provides the ability to rinse the bedpan thoroughly. The patient uses the same bedpan each time. Finally, document the characteristics of the feces.
Offer the bedpan often. Patients will accidentally soil bedclothes if forced to wait. Many patients try to avoid using a bedpan because it is embarrassing and uncomfortable. They often try to get to the bathroom even though their condition prohibits ambulation. Warn patients about the risks of falls or accidents.
(Positioning on a bedpan is discussed in the next few slides.)

26. Fecal Occult Blood Testing

27. Acute Care: Medications
Cathartics and laxatives
Bulk Forming
Psyllium (Metamucil)
Emollient or Wetting
Docusate Sodium (Colace)
Saline
Magnesium Hydroxide (Milk of Magnesia)
Sodium phosphate (Fleet enema)
Stimulant
Bisacodyl (Dulcolax)
Casanthranol (Peri-Colace)
Changes in the patient’s fluid status, mobility patterns, nutrition, and sleep cycle, as well as surgical interventions, affect regular bowel habits.
Ongoing use of cathartics, laxatives, and enemas affects and delays normal defecation reflexes.
Cathartics, laxatives, and occasionally an enema are used to resolve constipation; antidiarrheal preparations help the patient to resolve diarrhea. Caution patients not to use these over-the-counter medications on a prolonged basis without consulting their health care provider.
Often a patient is unable to defecate normally because of pain, constipation, or impaction. Cathartics and laxatives have the short-term action of emptying the bowel. They are prescribed for bowel evacuation for patients undergoing GI tests and abdominal surgery. Although the terms cathartic and laxative are often used interchangeably, cathartics have a stronger effect on the intestines. Five types of laxatives and cathartics are available.
[See Table 46-5 Common Types of Laxatives and Cathartics.]
Cathartics and laxatives are available in oral, tablet, powder, and suppository dosage forms. Although the oral route is most commonly used, suppositories are more effective because of their stimulant effect on the rectal mucosa.
Excessive use of laxatives, enemas, and/or bulk-forming agents increases the patient’s risks for diarrhea and abnormal bowel elimination.
In chronically ill or older adult patients, weakness and the frequent need to use toilet facilities result in increased risks for falls and other injuries.
For patients with diarrhea, frequent passage of liquid stools becomes a problem. Many patients use over-the-counter agents such as Imodium to relieve common diarrhea.
However, the most effective antidiarrheal agents are prescriptive opiates such as codeine phosphate, opium tincture (Paregoric), and diphenoxylate (Lomotil). Antidiarrheal opiate agents decrease intestinal muscle tone to slow the passage of feces. Opiates inhibit peristaltic waves that move feces forward, but they also increase segmental contractions that mix intestinal contents. As a result, the intestinal walls absorb more water.
Use antidiarrheal agents with caution because opiates are habit forming. Patients with diarrhea lasting longer than 2 days need a stool culture and an evaluation of diet and fluid intake for intolerance of foods and fluids (e.g., excessive use of fruits, lactose).

28. Implementations: Acute Care
Health promotion
Promotion of normal defecation
Establish a routine an hour after a meal, or maintain the patient’s routine.
Sitting position
Privacy
Positioning on bedpan
Successful nursing interventions improve patients’ and family members’ understanding of bowel elimination. Teach the patient and family about proper diet, adequate fluid intake, and factors that stimulate or slow peristalsis such as emotional stress. This is often best done during the patient’s mealtime. Patients need to learn the importance of establishing regular bowel routines, performing regular exercise, and taking appropriate measures when elimination problems develop.
One of the most important habits to teach regarding bowel habits is taking time for defecation. To establish regular bowel habits, a patient needs to know when the urge to defecate normally occurs. Advise the patient to begin establishing a routine during a time when defecation is most likely to occur, usually an hour after a meal. When patients are restricted to bed or need help to ambulate, offer a bedpan, or help them reach the bathroom in a timely manner.
Many patients have established routines for defecation. In a hospital or long-term care facility, make certain that treatment routines do not interfere with the patient’s routine. It is important to provide privacy. When patients forced to use a bedpan share rooms with other people, pull the curtain around the area so patients are able to relax, knowing that interruptions will not occur. Always place the call light and toilet tissue within the patient’s reach. When patients are at risk for falls, stand near them or leave the door partially open so you can see them at all times.
A number of interventions stimulate the defecation reflex, affect the character of feces, or increase peristalsis to help patients evacuate bowel contents normally and without discomfort.
Assist patients who have difficulty sitting because of muscular weakness and mobility problems. Place an elevated seat on the toilet when patients are unable to lower themselves to a sitting position because of joint- or muscle-wasting disease. These seats require patients to use less effort to sit or stand.
Maintain the patient’s privacy during bowel elimination. This is especially important for the patient who is using a bedpan. The call light and a supply of toilet paper need to be within easy reach. When the patient finishes, respond to the call signal immediately and remove the pan. The patient often requires assistance with wiping. To remove the pan, ask the patient to roll off to the side or to raise the hips. While wearing gloves, hold the pan steady to avoid spilling. Avoid pulling or shoving it from under the patient’s hips because this pulls the patient’s skin and causes tissue injury such as shearing. Remove the pan and clean the perineum from front to back.
After assessing the stool, immediately empty the contents of the bedpan into the toilet or into a special receptacle in the utility room. A spray faucet attached to most toilets provides the ability to rinse the bedpan thoroughly. The patient uses the same bedpan each time. Finally, document the characteristics of the feces.
Offer the bedpan often. Patients will accidentally soil bedclothes if forced to wait. Many patients try to avoid using a bedpan because it is embarrassing and uncomfortable. They often try to get to the bathroom even though their condition prohibits ambulation. Warn patients about the risks of falls or accidents.
(Positioning on a bedpan is discussed in the next few slides.)

29. Acute Care: Medications
Cathartics and laxatives
Bulk Forming
Psyllium (Metamucil)
Emollient or Wetting
Docusate Sodium (Colace)
Saline
Magnesium Hydroxide (Milk of Magnesia)
Sodium phosphate (Fleet enema)
Stimulant
Bisacodyl (Dulcolax)
Casanthranol (Peri-Colace)

30. Acute Care: Medications
Antidiarrheal agents
Diphenoxylate (Lomotil)
Over the counter (Imodium)
Opiates used with caution
Changes in the patient’s fluid status, mobility patterns, nutrition, and sleep cycle, as well as surgical interventions, affect regular bowel habits.
Ongoing use of cathartics, laxatives, and enemas affects and delays normal defecation reflexes.
Cathartics, laxatives, and occasionally an enema are used to resolve constipation; antidiarrheal preparations help the patient to resolve diarrhea. Caution patients not to use these over-the-counter medications on a prolonged basis without consulting their health care provider.
Often a patient is unable to defecate normally because of pain, constipation, or impaction. Cathartics and laxatives have the short-term action of emptying the bowel. They are prescribed for bowel evacuation for patients undergoing GI tests and abdominal surgery. Although the terms cathartic and laxative are often used interchangeably, cathartics have a stronger effect on the intestines. Five types of laxatives and cathartics are available.
[See Table 46-5 Common Types of Laxatives and Cathartics.]
Cathartics and laxatives are available in oral, tablet, powder, and suppository dosage forms. Although the oral route is most commonly used, suppositories are more effective because of their stimulant effect on the rectal mucosa.
Excessive use of laxatives, enemas, and/or bulk-forming agents increases the patient’s risks for diarrhea and abnormal bowel elimination.
In chronically ill or older adult patients, weakness and the frequent need to use toilet facilities result in increased risks for falls and other injuries.
For patients with diarrhea, frequent passage of liquid stools becomes a problem. Many patients use over-the-counter agents such as Imodium to relieve common diarrhea.
However, the most effective antidiarrheal agents are prescriptive opiates such as codeine phosphate, opium tincture (Paregoric), and diphenoxylate (Lomotil). Antidiarrheal opiate agents decrease intestinal muscle tone to slow the passage of feces. Opiates inhibit peristaltic waves that move feces forward, but they also increase segmental contractions that mix intestinal contents. As a result, the intestinal walls absorb more water.
Use antidiarrheal agents with caution because opiates are habit forming. Patients with diarrhea lasting longer than 2 days need a stool culture and an evaluation of diet and fluid intake for intolerance of foods and fluids (e.g., excessive use of fruits, lactose).

31. Enemas Enema administration Sterile technique is unnecessary.
Wear gloves.
Explain the procedure, precautions to avoid discomfort, and length of time necessary to retain the solution before defecation.
The health care provider sometimes orders a high or low cleansing enema. The terms high and low refer to the height from which, and hence the pressure with which, the fluid is delivered. High enemas cleanse the entire colon. After the enema is infused, ask the patient to turn from left lateral to dorsal recumbent, over to the right lateral position. This position change ensures that fluid reaches the large intestine. A low enema cleanses only the rectum and sigmoid colon.

32. Enemas Cleansing Enemas Tap water
is hypotonic and exerts an osmotic pressure lower than fluid in interstitial spaces. After infusion into the colon, tap water escapes from the bowel lumen into interstitial spaces. The net movement of water is low. The infused volume stimulates defecation before large amounts of water leave the bowel. Do not repeat tap water enemas because water toxicity or circulatory overload develops if the body absorbs large amounts of water.
Normal saline
safest solution to use because it exerts the same osmotic pressure as fluids in interstitial spaces surrounding the bowel. The volume of infused saline stimulates peristalsis. Giving saline enemas does not create the danger of excess fluid absorption

33. Enemas Cleansing Enemas Hypertonic solution
infused into the bowel exert osmotic pressure that pulls fluids out of interstitial spaces. The colon fills with fluid, and the resultant distention promotes defecation. Patients unable to tolerate large volumes of fluid benefit most from this type of enema, which is by design low volume. This type of enema is contraindicated for patients who are dehydrated and for young infants. A hypertonic solution of 120 to 180 mL (4 to 6 oz) is usually effective. The commercially prepared Fleet enema is the most common.
Soapsuds
to create the effect of intestinal irritation to stimulate peristalsis. Use only pure castile soap that comes in liquid form and is included in most soapsuds enema kits. Use soapsuds enemas with caution in pregnant women and older adults because they cause electrolyte imbalance or damage to the intestinal mucosa.

34. Enemas Oil Retention Enemas
lubricate the rectum and colon. The feces absorb the oil and become softer and easier to pass. To enhance the action of the oil, the patient retains the enema for several hours if possible.
Carminative Enema
provide relief from gaseous distention
Medication enemas
Kayexalate
Neomycin
Lactolosis
An example is sodium polystyrene sulfonate (Kayexalate), which is used to treat patients with dangerously high serum potassium levels. This drug contains a resin that exchanges sodium ions for potassium ions in the large intestine. Another medicated enema is neomycin solution, an antibiotic that is used to reduce bacteria in the colon before bowel surgery.

35. Continuing and Restorative Care
Bowel training
Training program
Diet
Promotion of regular exercise
Management of hemorrhoids
Skin integrity
The patient with incontinence is unable to maintain bowel control. A bowel training program helps some patients defecate normally, especially those who still have some neuromuscular control.
The training program involves setting up a daily routine. By attempting to defecate at the same time each day and using measures that promote defecation, the patient gains control of bowel reflexes. The program requires time, patience, and consistency. The health care provider determines the patient’s physical readiness and ability to benefit from bowel training.
[Discuss the components of a successful program:
Assessing the normal elimination pattern and recording times when the patient is incontinent
Incorporating principles of gerontological nursing when providing bowel retraining programs for the older adult
Choosing a time in the patient’s pattern to initiate defecation control measures
Giving stool softeners orally every day or a cathartic suppository at least half an hour before the selected defecation time (lower colon needs to be free of stool so suppository contacts intestinal mucosa)
Offering a hot drink (hot tea) or fruit juice (prune juice) (or whatever fluids normally stimulate peristalsis for the patient) before the defecation time
Helping the patient to the toilet at the designated time
Avoiding medications such as opioids that increase constipation
Providing privacy and setting a time limit for defecation (15 to 20 minutes)
Instructing the patient to lean forward at the hips while sitting on the toilet, apply manual pressure with the hands over the abdomen, and bear down but not strain to stimulate colon emptying
Not criticizing or conveying frustration if the patient is unable to defecate
Maintaining normal exercise within the patient’s physical ability]
[See also Box on p Focus on Older Adults: Bowel Retraining.]
In choosing a diet for promoting normal elimination, consider the frequency of defecation, the characteristics of feces, and the types of foods that impair or promote defecation.
The patient with frequent constipation or impaction requires increased intake of high-fiber foods and more fluids. However, he or she needs to realize that diet therapy provides only long-term relief of elimination problems and does not give immediate relief from problems such as constipation.
When diarrhea is a problem, recommend foods with low-fiber content and discourage foods that typically cause gastric upset or abdominal cramping. Diarrhea caused by illness is sometimes debilitating. If the patient cannot tolerate foods or liquids orally, intravenous therapy (with potassium supplements) is necessary.
The patient returns to a normal diet slowly, often beginning with fluids. Excessively hot or cold fluids stimulate peristalsis, causing abdominal cramps and further diarrhea. As tolerance to liquids improves, the patient eats solid foods.
A daily exercise program helps prevent elimination problems. Walking, riding a stationary bicycle, or swimming stimulates peristalsis. Patients who are sedentary at work are most in need of regular exercise. For a patient who is temporarily immobilized, attempt ambulation as soon as possible. If the condition permits, help the patient walk to a chair on the evening of the day of surgery. Have him or her walk farther each day.
Some patients have difficulty passing stool because of weak abdominal and pelvic floor muscles. Exercises help patients who are confined to bed use a bedpan. The patient practices the exercises as follows:
Lie supine; tighten the abdominal muscles as though pushing them to the floor. Hold the muscles tight to the count of three; relax. Repeat 5 to 10 times as tolerated.
Flex and contract the thigh muscles by raising one knee slowly toward the chest. Repeat for each leg at least 5 times and increase frequency as tolerated.
Pain results when hemorrhoid tissues are irritated directly. The primary goal for the patient with hemorrhoids is to have soft-formed, painless bowel movements. Proper diet, fluids, and regular exercise improve the likelihood of stools being soft. If the patient becomes constipated, passage of hard stools causes bleeding and irritation. An ice pack or a warm sitz bath provides temporary relief of swollen hemorrhoids.
The patient with diarrhea or fecal incontinence is at risk for skin breakdown when fecal contents remain on the skin. The same problem exists for the patient with an ostomy that drains liquid stool. Liquid stool is usually acidic and contains digestive enzymes. Irritation from repeated wiping with toilet tissue aggravates skin breakdown. Bathing the skin after soiling helps, but sometimes it results in more breakdown unless the patient dries the skin thoroughly.
When caring for a patient who is debilitated, incontinent, and unable to ask for assistance, check often for defecation. You can protect the anal areas with petrolatum, zinc oxide, or another ointment that holds moisture in the skin, preventing drying and cracking.
Yeast infections of the skin often develop easily. Several powdered antifungal agents are effective against yeast. Do not use baby powder or cornstarch because they have no medical properties, often cake on the skin, are difficult to remove, and enhance fungal infections of the skin.
[See also on text p Box 46-9 Evidence-Based Practice: Recognition of Skin Problems.]