1. Chapter 23 BOWEL ELIMINATION

2. Bowel Elimination Bowel elimination is the excretion of wastes from the gastro-intestinal (GI) system. Factors affecting bowel elimination include: ◦Privacy ◦Habits ◦Age ◦Diet ◦Exercise and activity ◦Fluids ◦Drugs

3. Normal Bowel Elimination Time and frequency of bowel movements vary. Stools normally: ◦Are brown ◦Are soft, formed, moist, and shaped like the rectum ◦Have a normal odor caused by bacterial action in the intestines

4. Normal Bowel Elimination (cont’d)  Observe and report the following to the nurse. If allowed to chart, also record the following:  Color  Amount  Consistency  Presence of blood or mucus  Odor  Shape  Frequency of BMs  Complaints of pain or discomfort

5. Factors Affecting Bowel Elimination  Normal, regular elimination is the goal.  Factors affecting stool frequency, consistency, color, and odor  Privacy  Habits  Diet—high-fiber foods  Diet—other foods  Fluids  Activity  Drugs  Disability  Aging

6. Common Problems  Constipation is the passage of a hard, dry stool.  Constipation occurs when feces move slowly through the bowel.  Fecal impaction is the prolonged retention and build-up of feces in the rectum.  Feces are hard or putty-like.  Fecal impaction results in constipation if not relieved.  Symptoms include abdominal discomfort, abdominal distention (swelling), nausea, cramping, and rectal pain. Older persons may have poor appetite, confusion, or even a fever.

7. Common Problems (cont’d) ◦The nurse does a digital (finger) exam to check for an impaction. ◦The digital exam often causes the urge to have a BM. ◦Sometimes the fecal mass is removed with a gloved finger. ◦This is called digital removal of an impaction. ◦Checking for and removing impactions is very dangerous. ◦The vagus nerve can become stimulated, which slows the heart rate. ◦Heart rate can slow to unsafe levels in some persons.

8. Common Problems (cont’d)  Diarrhea is the frequent passage of liquid stools.  Feces move through the intestines rapidly.  Diet and drugs are ordered to reduce peristalsis.  You need to:  Assist with elimination needs promptly.  Dispose of stools promptly.  Give good skin care.  Fluid lost through diarrhea must be replaced.  Otherwise dehydration occurs.  Always follow Standard Precautions and the Bloodborne Pathogen Standard when in contact with stools.

9. Common Problems (cont’d)  Fecal incontinence is the inability to control the passage of feces and gas through the anus.  Fecal incontinence affects the person emotionally.  The person may need:  Bowel training  Help with elimination after meals and every 2 to 3 hours  Incontinence products to keep garments and linens clean  Good skin care

10. Common Problems (cont’d)  Flatulence is the excessive formation of gas or air in the stomach and intestines.  Gas or air passed through the anus is called flatus.  If flatus is not expelled, the intestines distend.  The following help produce flatus:  Exercise  Walking  Moving in bed  The left side-lying position  Doctors may order enemas and drugs to relieve flatulence.

11. Bowel Training  Bowel training has two goals, to:  Gain control of bowel movements.  Develop a regular pattern of elimination.  Factors that promote elimination are part of the care plan and the bowel- training program. These include:  High-fiber diet  Increased fluids  Warm fluids  Activity  Privacy

12. Suppositories  A suppository is a cone-shaped, solid drug that is inserted into a body opening. It melts at body temperature.  A rectal suppository is inserted into the rectum.  A BM occurs about 30 minutes later.  The doctor may order a suppository to stimulate a BM for:  Constipation  Fecal impaction  Bowel training

13. Enemas  An enema is the introduction of fluid into the rectum and lower colon.  Doctors order enemas to:  Remove feces  Relieve constipation, fecal impaction, or flatulence  Clean the bowel of feces before certain surgeries and diagnostic procedures  A doctor orders the enema solution.

14. Enemas (cont’d) ◦The solution depends on the enema’s purpose cleansing, constipation, fecal impaction, or flatulence. ◦Tap-water enema is obtained from a faucet. ◦Saline enema is a solution of salt and water. ◦Soapsuds enema (SSE) is a solution of castile soap and water. ◦Small-volume enema is commercially prepared. ◦Oil-retention enema is mineral, olive, or cottonseed oil. ◦Other enema solutions may be ordered. ◦Nurses give enemas that contain drugs.

15. Enemas (cont’d) Cleansing enemas: ◦Clean the bowel of feces and flatus ◦Relieve constipation and fecal impaction ◦Are needed before certain surgeries and diagnostic procedures Tap-water enemas can be dangerous. Saline enema solution is similar to body fluid. Soapsuds enemas irritate the bowel’s mucous lining.

16. Enemas (cont’d)  Small-volume enemas irritate and distend the rectum.  Often ordered for constipation  Also ordered when the bowel does not need complete cleansing  Oil-retention enemas relieve constipation and fecal impactions.  Retaining oil softens feces and lubricates the rectum.  Most oil-retention enemas are commercially prepared.

17. The Person with an Ostomy  An ostomy is a surgically created opening for the elimination of body wastes.  The opening seen through the abdominal wall is called a stoma.  The person wears a pouch over the stoma to collect stools and flatus.

18. The Person with an Ostomy (cont’d)  Colostomy  A colostomy is a surgically created opening between the colon and abdominal wall.  With a permanent colostomy, the diseased part of the colon is removed.  A temporary colostomy gives the diseased or injured bowel time to heal.  After healing, surgery is done to reconnect the bowel.  The colostomy site depends on the site of disease or injury.  Ileostomy  An ileostomy is a surgically created opening between the ileum (small intestine) and the abdominal wall.  Liquid stools drain constantly from an ileostomy.

19. The Person with an Ostomy (cont’d)  Ostomy pouches  The pouch has an adhesive backing applied to the skin.  Sometimes pouches are secured to ostomy belts.  Many pouches have a drain at the bottom that close with a clip, clamp, or wire closure.  The drain is opened to empty the pouch.  The pouch is emptied when stools are present.  It is opened when it balloons or bulges with flatus.  Wipe the drain with toilet tissue before it is closed.  The pouch is changed every 3 to 7 days and when it leaks.  Do not flush pouches down the toilet.

20. Ostomy Changing Supplies