1. Promoting Bowel Elimination
Chapter 30
Promoting Bowel Elimination
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

2. Chapter 30
Lesson 30.1
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3. Learning Objectives Theory
Describe the process of normal bowel elimination.
Identify abnormal characteristics of stool.
Discuss the physiologic effects of hypoactive bowel and nursing interventions to assist patients with constipation.
Analyze safety considerations related to giving a patient an enema.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

4. Learning Objectives Clinical Practice
Summarize nursing measures to promote regular bowel elimination in patients.
Collect a stool specimen.
Perform a focused assessment of the bowel.
Write a nursing care plan for a patient with bowel problems.
Prepare to administer an enema.
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5. Structures Involved in Waste Elimination
Small intestine
Duodenum
Jejunum
Ileum
Carries chyme from the stomach to the large intestine
Ileocecal valve
Controls flow of chyme into the large intestine
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6. Structures Involved in Waste Elimination (cont’d)
Large intestine
Ascending colon
Transverse colon
Descending colon
Sigmoid colon
Rectum
Anus
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7. Figure 30-1: The intestinal system
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8. Structures Involved in Waste Elimination (cont’d)
Walls of the intestine have four layers
Mucosa
Submucosa
Muscular layer
Serous layer (serosa)
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9. Functions of the Intestines
Small intestine
Processes chyme into a more liquid state
Adds bile from the liver to help break down fats
Villi on the small intestine walls absorb nutrients
Large intestine
Absorbs water, sodium, chlorides
Waste material stored until expelled
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10. Functions of the Intestines (cont’d)
Peristalsis moves chyme and gas through the intestines (causing bowel sounds)
Normal transit time in intestine is 18 to 72 hours
Feces is stored in the sigmoid colon until the gastrocolic reflex initiates defecation
Defecation is under voluntary control and uses the Valsalva maneuver
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11. Effects of Aging on the Intestinal Tract
Atrophy of the villi
Decreased absorption of fats, vitamin B12
Decrease in motility
Bowel habits should not change in the normal healthy individual
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12. Normal Stool Color: light to dark brown
Consistency: soft-formed in children and adults; consists of ¼ solids and ¾ water
Appearance: affected by diet and metabolism
Composition: solid materials consist of 70% undigested roughage from carbohydrates, fat, protein, and inorganic matter, and 30% dead bacteria
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13. Abnormal Stool Blood in the stool: most serious abnormality
Fresh red blood: bleeding in colon
Occult: upper GI bleed (black stool called melena)
Pale white or light gray stool: absence of bile in the intestine
Large amounts of mucus, fat, pus, or parasites
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14. Hypoactive Bowel Indicates a decrease in peristalsis
Usually results in constipation
Causes
Immobility
Injury to the bowel
Drugs
Surgery
A patient restricted to bed at risk for constipation
Flatus (gas) accumulates in the intestinal tract when peristalsis reduced or absent
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15. Drugs That May Contribute to Constipation
Narcotic analgesics
Codeine, morphine, meperidine
General anesthetics
Diuretics
Sedatives
Anticholinergics
Calcium channel blockers
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16. Drugs Used for Constipation
Stool softeners
Colace, Surfak, Dialose
Bulk-forming laxatives
Fibercon, Metamucil, Citrucel
Irritant/stimulant laxatives
Dulcolax, Neolid, Ex-Lax, Correctol, Senokot
Saline laxatives
Citrate of magnesia, milk of magnesia, phospho-soda
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17. Hyperactive Bowel Increase in peristalsis Usually results in diarrhea
May be self-limiting
Causes
Inflammation of GI tract, infectious diseases, diseases such as:
Diverticulitis
Ulcerative colitis
Crohn’s disease
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18. Hyperactive Bowel (cont’d)
Drugs
Many antibiotics kill normal bowel bacteria, resulting in diarrhea
Patients who experience diarrhea from antibiotics should replace normal flora by:
Eating yogurt
Drinking buttermilk
Taking acidophilus (available OTC)
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19. Medications Used to Control Diarrhea
Camphorated tincture of opium (paregoric)
Diphenoxylate hydrochloride with atropine sulfate (Lomotil)
Loperamide hydrochloride (Imodium)
Difenoxin hydrochloride with atropine sulfate (Motofen)
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20. Fecal Incontinence
Lack of voluntary control of fecal evacuation; inability to retain feces
Causes
Illness
Cerebrovascular accident
Traumatic injury
Neurogenic dysfunction
Distressing condition that causes a loss of dignity
Feelings of being less of a person
Loss of self-respect
Embarrassed
Anxiety or fear of losing control
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21. Initial Assessment Does patient have a bowel problem?
Usual bowel pattern
Any measures used to promote defecation?
Use of enemas or laxatives
Usual eating habits and exercise
Foods that produce diarrhea or constipation
Disorders that contribute to constipation or diarrhea
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22. Initial Assessment (cont’d)
Physical assessment
Shape of the abdomen with the patient supine
Flat, distended
Auscultate for bowel sounds in all four quadrants
Percuss for presence of excessive air/gas in the abdomen
Palpate for masses or tenderness
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23. Nursing Diagnoses Constipation related to hypoactive bowel
Diarrhea related to food intolerance
Bowel incontinence related to loss of anal sphincter control
Pain related to abdominal distention
Self-care deficit, toileting related to traction
Disturbed body image related to bowel incontinence
Deficient knowledge related to factors that contribute to constipation
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24. Question 1 The most serious abnormality in the stool is: mucus.
pale white appearance.
parasites.
blood.
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25. Question 2 Which patient is at the greatest risk for constipation?
A 70-year-old active male
An 80-year-old active female
A 3-year-old child
An 18-year-old female patient with a fractured pelvis
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26. Question 3
Which two groups may become dehydrated very quickly if diarrhea persists?
Infant, school-age children
School-age children, adults
Infant, elderly
School-age and elderly
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27. Chapter 30
Lesson 30.2
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28. Learning Objectives Theory
Analyze safety considerations related to giving a patient an enema. (continued)
Analyze the psychosocial implications for a patient who has an ostomy.
Discuss the stoma and peristoma assessment and skin care.
Describe three types of intestinal diversions.
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29. Learning Objectives Clinical Practice
Assist and teach a patient with a bowel retraining program for incontinence.
Evaluate the performance of a patient who is self-catheterizing a continent diversion.
Provide ostomy care, including irrigation and changing the ostomy appliance.
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30. Rectal Suppositories Used to promote bowel movements
Glycerin and bisacodyl suppositories
Promote bowel evacuation
Stimulate the inner surface of the rectum and increasing the urge to defecate
Form gas that expands the rectum
Melt into a lubricating material to coat the stool for easier passage through the anal sphincter
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31. Enemas Fluid introduced into rectum by means of a tube
Stimulate peristalsis or wash out waste products
Often given before a colonoscopy or an x-ray
Volume of typical cleansing enema
Infants: 20 to 150 mL
Ages 3 to 5 years: 200 to 300 mL
School-age: 300 to 500 mL
Adults: 500 to 1000 mL
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32. Figure 30-2: Enema equipment
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33. Figure 30-4: Position for giving an enema
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34. Types of Enemas Retention enema Cleansing enema
Softens stool as oil is absorbed
Cleansing enema
Stimulates peristalsis through distention and irritation of colon and rectum
Distention reduction enema
Relieves discomfort from flatus causing distention
Medicated enema
Solution with drugs to reduce bacteria or remove potassium
Disposable enema (small volume)
Stimulates peristalsis by acting as irritant
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35. Amount and Temperature of Solution
Disposable enema units
Contain about 240 mL of solution
May be given at room temperature, but work best when slightly warmed
Cleansing enema
Adults is between 500 and 1000 mL; smaller amounts are used for children
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36. Bowel Training for Incontinence
Principles for establishing regular bowel elimination
Adequate diet
Sufficient fluids
Adequate exercise
Sufficient rest
Regular time for evacuation should be established
All efforts must be made to provide patient with environment that is conducive to evacuation
May require digital stimulation to relax the anal sphincter
Suppositories, stool softeners, and bulk laxatives used to assist in establishing a normal, regular bowel pattern
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37. Bowel Ostomy A diversion of intestinal contents from their normal path
Results in formation of an external opening called a stoma
May be an internal tissue pouch with a valve opening
Special procedures aid in effective, controlled elimination through the stoma
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38. Types of Ostomies Ileostomy Colostomy
Diversion of the small bowel contents to a pouch or stoma; effluent is liquid
Colostomy
Diversion of the colon
Effluent may be liquid or solid depending on the site; may require irrigation
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39. Figure 30-6: Sigmoid colostomy
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40. Figure 30-6: Descending colostomy
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41. Figure 30-6: Ascending colostomy
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42. Figure 30-6: Double-barrel colostomy
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43. Figure 30-6: Ileostomy
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44. Figure 30-6: Kock pouch
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45. Ostomy Care Skin care Applying an ostomy appliance
Stoma and skin washed with mild soap and water and patted dry
Skin barrier paste is applied
Applying an ostomy appliance
Appliance is positioned with the stoma protruding through the opening in the center of the faceplate
Irrigating a colostomy
A solution is instilled into the colon via the stoma
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46. Question 4
Barbara’s patient is trying to understand the difference between an ileostomy and a colostomy. Barbara explains to her patient:
an ileostomy is an opening into the colon and a colostomy is an opening into the ileum.
an ileostomy has more effluent than a colostomy, which has more liquid fecal matter.
an ileostomy has more liquid effluent and a colostomy has effluent that is more formed.
diet will not adversely affect the ileostomy or colostomy patient.
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47. Question 5
Stacy is working in a home health care situation and trying to establish bowel training with her patient. Her patient asks how long it usually takes to establish bowel training. Stacy’s correct response would be that a bowel training program can take:
a couple of days or longer.
a couple of weeks or longer.
a couple of months or longer.
years or may not even be successful.
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