1. 1 Second semester 15 - 16 Chapter 31 Bowel Elimination Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Bowel Elimination

2. 2 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Bowel Elimination Defecation Defecation (bowel elimination): is the act of expelling feces (stool) from the body. To do so, all structures of the gastrointestinal tract, especially the components of the large intestine (also referred to as the bowel or colon), must function in a coordinated manner (Fig. 31-1).Fig. 31-1 In the large intestine, a remarkable volume of water is removed from the remnants of digestion, causing the bowel's contents to become a consolidated mass of residue before being eliminated.

3. 3 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Bowel Elimination Figure 31-1 The large intestine

4. 4 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Bowel Elimination Peristalsis Peristalsis is : The rhythmic contractions of intestinal smooth muscle that facilitate defecation. Peristalsis moves fiber, water, and nutritional wastes along the ascending, transverse, descending, and sigmoid colon toward the rectum. gastrocolic reflex: Increased peristaltic activity occurring during food consumption

5. 5 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Bowel Elimination The gastrocolic reflex usually precedes defecation. Its accelerated wavelike movements, sometimes perceived as slight abdominal cramping, push stool forward, packing it within the rectum. As the rectum distends, the person feels the urge to defecate. Stool is eventually released when the anal sphincters relax. Valsalva maneuver "bear down" : increasing abdominal muscle pressure to facilitate defecation Several dietary, physical, social, and emotional factors can influence the bowel's mechanical function (Table 31-1).Table 31-1

6. 6 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Bowel Elimination

7. 7 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Bowel Elimination Assessment of Bowel Elimination Elimination Patterns It is essential to determine the client's usual patterns, including frequency of elimination, effort required to expel stool, and what elimination aids, if any, he or she uses. Stool Characteristics Color, odor, consistency, shape, unusual components

8. 8 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Bowel Elimination

9. 9 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Bowel Elimination Common Alterations in Bowel Elimination Constipation : Is an elimination problem characterized by dry, hard stool that is difficult to pass. Various accompanying signs and symptoms include the following: Complaints of( C/O ) abdominal fullness or bloating Abdominal distention Complaints of( C/O ) rectal fullness or pressure Pain on defecation Decreased frequency of bowel movements Inability to pass stool Changes in stool characteristics such as oozing liquid stool or hard small stool

10. 10 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Bowel Elimination The incidence of constipation tends to be high among those whose dietary habits lack adequate fiber (such as not eating sufficient raw fruits and vegetables, whole grains, seeds, and nuts). Dietary fiber, which becomes undigested cellulose, is important because it attracts water within the bowel, resulting in bulkier stool that is more quickly and easily eliminated. Constipation is classified into one of four distinct types (primary, secondary, iatrogenic, and pseudo constipation), according to the underlying cause.

11. 11 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Bowel Elimination 1.Primary or simple constipation Is well within the treatment domain of nurses. It results from lifestyle factors such as inactivity, inadequate intake of fiber, insufficient fluid intake, or ignoring the urge to defecate. 2.Secondary constipation Is a consequence of a pathologic disorder such as a partial bowel obstruction. It usually resolves when the primary cause is treated. Types of Constipation

12. 12 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Bowel Elimination 3.Iatrogenic constipation As a consequence of other medical treatment. For example, prolonged use of narcotic analgesia tends to cause constipation. These and other drugs slow peristalsis, delaying transit time. The longer the stool remains in the colon, the drier it becomes, making it more difficult to pass. 4.Pseudoconstipation (perceived constipation): A term used when clients believe they are constipated even though they are not (often overuse laxatives, suppositories or enemas). Types of Constipation (cont‘d)

13. 13 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Bowel Elimination Common Alterations in Bowel Elimination (cont’d) Fecal impaction occurs when a large, hardened mass of stool interferes with defecation, making it impossible for the client to pass feces voluntarily. result from unrelieved constipation, retained barium from an intestinal x-ray, dehydration, and weakness of abdominal muscles. Some clients with an impaction pass liquid stool, which they may misinterpret as diarrhea.

14. 14 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Bowel Elimination Flatulence or flatus : Excessive accumulation of intestinal gas, results from swallowing air while eating or sluggish peristalsis. gas that forms as a byproduct of bacterial fermentation in the bowel. Vegetables such as cabbage, cucumbers, and onions are commonly known for producing gas. Beans are other gas formers. Common Alterations in Bowel Elimination (cont’d)

15. 15 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Bowel Elimination Diarrhea is : The urgent passage of watery stool and commonly is accompanied by abdominal cramps. Simple diarrhea usually begins suddenly and lasts for a short period. Other associated signs and symptoms include nausea and vomiting and blood or mucus in the stools. Usually diarrhea is a means of eliminating an irritating substance such as tainted food or intestinal pathogens. Diarrhea may also result from emotional stress, dietary indiscretions, laxative abuse, or bowel disorders. Common Alterations in Bowel Elimination (cont’d)

16. 16 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Bowel Elimination Fecal incontinence : is the inability to control the elimination of stool.

17. 17 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Bowel Elimination Measures to Promote Bowel Elimination Two physician-ordered interventions to promote elimination when not naturally occurring or when the bowel must be cleansed for other purposes, such as preparation for surgery and endoscopic or x-ray examinations 1. Insert a rectal suppository 2. Administer an enema Cleansing enemas o Tap water, normal saline o Soapsuds, hypertonic saline Retention Enemas

18. 18 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Bowel Elimination Measures to Promote Bowel Elimination (cont’d) Inserting a Rectal Suppository Medications released from the suppository can have local or systemic effects. Depending on the drug, local effects may include softening and lubricating dry stool, irritating the wall of the rectum and anal canal to stimulate smooth muscle contraction, and liberating carbon dioxide, thus increasing rectal distention and the urge to defecate.

19. 19 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Bowel Elimination Measures to Promote Bowel Elimination (cont’d) Administering an Enema An enema introduces a solution into the rectum to : 1. Cleanse the lower bowel (most common reason). 2. Soften feces. 3. Expel flatus. 4. Soothe irritated mucous membranes. 5. Outline the colon during diagnostic x-rays. 6. Treat worm and parasite infestations.

20. 20 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Bowel Elimination Cleansing Enemas It is used to remove feces from the rectum (Table 31-3). SolutionAmount (ml)Mechanism of Action Tap water500-1000Distends rectum, moistens stool Normal saline500-1000Distends rectum, moistens stool Soap and water500-1000Distends rectum, moistens stool, irritates local tissue Hypertonic saline (ie: Fleets) 120Irritates local tissue and draws water into the bowel Mineral, olive, or cottonseed 120-180Lubricates and softens stool

21. 21 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Bowel Elimination Administer an enema (cont’d) Retention enemas o Oil retention enema  Mineral, cottonseed, or olive oil  Retained at least 30 minutes  Lubricate and soften stool to ease stool expulsion Measures to Promote Bowel Elimination (cont’d)

22. 22 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Bowel Elimination Ostomy Care A client with an ostomy (surgically created opening to the bowel or other structure; requires additional care for promoting bowel elimination. Types of Ostomies 1. ileostomy (surgically created opening to the ileum) 2. colostomy (surgically created opening to a portion of the colon; Fig. 31-4).Fig. 31-4

23. 23 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Bowel Elimination Locations of intestinal Ostomies

24. 24 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Bowel Elimination Most persons with an ostomy, also called ostomates, wear an appliance (bag or collection device over the stoma) to collect stool. Depending on the type and location of the ostomy, client care may involve providing peristomal care, applying an appliance, draining a continent ileostomy, and, for clients with a colostomy, administering irrigations through the stoma.

25. 25 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Bowel Elimination Figure 31-5 An ostomy appliance: faceplate and pouch.

26. 26 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Bowel Elimination Ostomy Care Preventing skin breakdown is a major challenge in ostomy care. Enzymes in stool can quickly cause excoriation (chemical injury of skin). Providing peristomal care Applying an ostomy appliance Draining a continent ileostomy Irrigating a colostomy

27. 27 Second semester 15 - 16 Bader A. EL Safadi BSN, MSc Fundamental of Nursing – B Bowel Elimination Nursing Implications Constipation Risk for Constipation Perceived Constipation Diarrhea Bowel Incontinence Toileting Self-Care Deficit Situational Low Self-Esteem