1. Basic Human Needs Bowel Elimination

2. Bowel Elimination
GI Tract is a series of hollow mucous membrane lined muscular organs
Purpose is to absorb fluids & nutrients, prepare food for absorption & provide storage for feces

3. GI Tract Anatomy Mouth Esophagus Stomach Small Intestine
Large Intestine
Rectum

6. Colon 3 Divisions: Ascending, Transverse, Descending
Colon Functions: Absorption, Protection, Secretion, & Elimination (stool and flatus)

8. Flatus Formation Air swallowing
Diffusion of gas from bloodstream into intestines
Bacterial action on unabsorbable CHO (Beans)
Fermentation of CHO (cabbage, onions
Can stimulate peristalsis
Adult forms ml of flatus daily

9. Factors Affecting Bowel Elimination
Age
Infection
Diet
Fluid Intake
Physical Activity
Psychological factors
Personal Habits

10. Factors Affecting Bowel Elimination
Position during Defecation
Pain
Surgery and Anesthesia
Medications

11. Common Bowel Elimination Problems
Constipation
Impaction
Diarrhea
Incontinence
Flatulence
Hemorrhoids

12. Constipation More of a symptom than a disorder
Decrease in frequency of BM
Straining & pain on defecation is associated symptoms(Valsalva maneuver)
Can be significant heath hazard (increase ICP, IOP, reopen surgical wounds, cause trauma, cardiac arrhythmias)

14. Impaction Results from unrelieved constipation
Collection of hardened feces wedged into rectum
Can extend up to sigmoid colon
Most at risk: depilated, confused, unconscious (all are at risk for dehydration)

15. Impaction
When a continuous ooze of diarrheal stool develops, impaction should be suspected
Associated S/S: Loss of appetite, abdominal distention, cramping, rectal pain

17. Diarrhea
Increase in number of stools & the passage of liquid, unformed stool
Symptom of disorders affecting digestion, absorption, & secretion of GI tract
Intestinal contents pass through small & large intestines too quickly to allow for usual absorption of water & nutrients

18. Diarrhea
Irritation can result in increased mucus secretion, feces become too watery, unable to control defecation
Excess loss of colonic fluid can result in acid-base imbalances or fluid/electrolyte imbalances
Can also result in skin breakdown

19. Conditions that cause Diarrhea
Emotional Stress
Intestinal Infection (Clostridium difficile)
Food Allergies
Food Intolerance
Tube Feedings (Enteral)
Medications
Laxatives
Colon Disease
Surgery

21. Incontinence
Inability to control passage of feces and gas from the anus
Caused by conditions that create frequent, loose, large volume, watery stools or conditions that impair sphincter control or function

22. Flatulence Gas accumulation in the lumen of intestines
Bowel wall stretches and distends
Common cause of abdominal fullness, pain, & cramping
Gas escapes through mouth (belching), or anus (flatus)

23. Hemorrhoids Dilated, engorged veins in the lining of the rectum
External (Clearly visible) or Internal
Caused by straining, pregnancy, CHF, chronic liver disease

24. Clicker Question
1. A newly admitted client states that he has recently had a change in medications and reports that stools are now dry and hard to pass. This type of bowel pattern is consistent with:
A. Abnormal defecation
B. Constipation
C. Fecal impaction
D. Fecal incontinence
Answer: B

25. Bowel Diversions
Certain diseases cause conditions that prevent normal passage of feces through rectum
Creates need for temporary or permanent artificial opening (stoma) in the abdominal wall

26. Bowel Diversions
Surgical openings (ostomy) are most commonly formed in the ileum (ileostomy) or the colon (colostomy)
Incontinent ostomy- need to wear appliance pouch
Continent ostomy- have control through use of ostomy cap

31. Incontinent Ostomy Location of ostomy determines consistency of stool
Ileostomy bypasses the entire large intestine, stools are frequent & watery
Ascending colostomy- liquid stool
Sigmoid colostomy-most like normal stool

33. Incontinent Ostomies
Loop colostomy- temporary, usually done on transverse colon
2 openings through stoma, proximal loop for stool, distal loop for mucus
End colostomy- one stoma formed from the proximal end of the bowel with the distal portion removed or sewn shut (Hartmann’s Pouch)

34. Incontinent Ostomies End colostomy usually done for colorectal cancer
Ruptured diverticulum- temporary end colostomy with a Hartmanns Pouch
Double barrel colostomy- Bowel is surgically severed, 2 ends are brought out onto abdomen with 2 distinct stomas (proximal & distal)

39. Continent Diversions
Ileoanal reservoir- restorative proctocolectomy, no outward stoma, no pouch wearing, clients have internal pouch created from the ileum
Ileal pouches constructed in various configurations (S,J,W)
End of the pouch is sewn or anastamosed to the anus

40. Continent Diversions Ileoanal Reservoir
Several stages to surgery to create pouch
May need temporary ostomy to allow time for pouch to heal
Kegel exercises to increase pelvic floor muscle tone

42. Continent Diversions
Kock Continent Ileostomy-Internal reservoir or pouch is created using piece of small intestine
Stoma brought out low on abdomen, end of internal part in pouch is a one way nipple valve to promote continence
Valve only allows fecal contents to drain when an external catheter is place in stoma, no pouch required

44. Ostomy Nursing Considerations
Patient Education
Care of skin & stoma, appliance selection and use
Body Image considerations
Support groups (UOA)
Enterostomal nursing- specialty within profession

46. Nursing Process Assessment
Nursing History
Physical Assessment
Lab Tests
Fecal characteristics
Diagnostic evaluation- Endoscopy, Colonoscopy

50. Nursing Diagnosis Bowel Incontinence Constipation Diarrhea
Impaired Skin Integrity
Body Image Disturbance
Altered bowel elimination
Pain

51. Implementation Promoting Normal Defecation and Acute Care Management
Positioning of patient-squatting
Positioning on bedpan
Use of cathartics, laxatives
Anti-diarrheal agents
Enemas
Digital removal of stool
Ostomy care
Fecal Incontinence Devices
Fiber & Fluids

56. Common Laxatives & Cathartics
Metamucil-bulk forming
Colace, Surfak-emollient or wetting agent
Fleets, MOM. Mag Sulfate-saline agent
Dulcolax, Ex-Lax, Castor oil- stimulant cathartic
Haley’s MO, mineral oil- Lubricant

57. Enemas Cleansing enema Tap water Normal saline
Hypertonic Solutions (Fleet’s enema)
Soapsuds
Oil Retention
Medicated enemas (Kayexalate, Lactulose)
Administering a Cleansing enema P&P pg

58. Nasogastric Tubes
Decompress GI tract in surgery, infection of GI tract, trauma to GI tract, conditions where peristalsis is absent
N/G tube purposes- decompression, feeding, compression, & lavage
Pliable tube inserted through nasopharynx into stomach
Uncomfortable insertion

59. Nasogastric Tubes
Types: Levin – single lumen, different sizes used for feeding or decompression
Salem Sump – Most preferable for decompression, dual lumen, one for removal of gastric contents, one as an air vent, hooked to suction to achieve decompression

62. Care of Nasogastric Tubes
Confirm placement after insertion
HOB at 30 degrees unless ordered otherwise
Mark point where tube exits nose (AACN 2005)
Tape tube securely to nose
Tube Irrigation
Nasal skin care
Frequent oral hygeine
Assess for abdominal distention
Suction settings

65. Restorative Care Bowel training
Maintenance of proper fluid & food intake
Promotion of regular exercise
Promotion of comfort
Maintenance of skin integrity
Promotion of self concept

66. Clicker Question
2. To maintain normal elimination patterns in the hospitalized client, you should instruct the client to defecate 1 hour after meals because:
A. The presence of food stimulates peristalsis.
B. Mass colonic peristalsis occurs at this time.
C. Irregularity helps to develop a habitual pattern.
D. Neglecting the urge to defecate can cause diarrhea.
Answer: B