1. Chapter 31
Bowel Elimination

2. Defecation Defecation: the act of expelling feces from the body
Peristalsis: rhythmic contractions of intestinal smooth muscle to facilitate defecation
Gastrocolic reflex: increased peristaltic activity occurring during food consumption
Valsalva maneuver: increasing abdominal muscle pressure to facilitate defecation
WHAT IS DEFECATION?—SEE ABOVE ANSWER IS 1ST NOTE—STOOL = FECES
LARGE INTESTINE = BOWEL OR COLON– A REMARKABLE VOLUME OF WATER IS REMOVED FROM THE REMINANTS OF DIGESTION, CAUSING THE BOWEL’S CONTENTS TO BECOME CONSOLIDATED MASS OF RESIDUE BEFORE BEING ELIMINATED. PERISTALSIS– THE RHYTHMIC CONTRACTIONS OF INTESTINAL SMOOTH MUSCLE THAT FACILITATE DEFECATION. PERISTALSIS MOVES FIBER, WATER, NUTRITIONAL WASTE ALONG THE ASCENDING COLON, TRANSVERSE, DESCENDING AND SIGMOID COLON TOWARD THE RECTUM. BECOMES EVEN MORE ACTIVE DURING EATING—THIS INCREASED PERISTALIC ACTIVITY IS TERMED—GASTROCOLIC REFLEX ON TEST!!!!!!!!!
GASTROCOLIC REFLEX USUALLY PRECEEDS DEFECATION. AS THE RECTUM DISTENDS—YOU FEEL URGE TO
DEFECATE—STOOL IS RELEASED WHEN THE ANAL SPHINCTERS (RING-SHAPED BANDS OF MUSCLE) RELAX.
PERFORMING THE VALSALVA MANEUVER (CLOSING THE GLOTTIS AND CONTRACTING THE PELVIC AND ABDOMINAL MUSCLES TO INCREASE ABDOMINAL PRESSURE) FACILITATES THIS PROCESS.

3. Question Is the following statement true or false?
For defecation to take place, all structures of the abdominal tract must function in a coordinated manner.
Answer is True

4. Answer
True.
For defecation to take place, all structures of the gastrointestinal tract, especially the components of the large intestine, must function in a coordinated manner.

5. Common Factors Affecting Bowel Elimination

6. Assessment of Bowel Elimination
Elimination patterns
Stool characteristics
Nurse show ask questions (subjective data) about the clients bowel habits such as: color, odor, consistency, shape and unusual components.
Nurse looks at stool (objective data)
If stool is abnormal—collect a sample
May have to check for blood.—occult blood testing.

7. Characteristics of Stool
CHARACTERISTICS NORMAL ABNORMAL
COLOR BROWN BLACK—IRON
CLAY-COLORED (TAN)
YELLOW (FOOD)
GREEN (FOOD)
ODOR AROMATIC FOUL (INFECTION)
CONSISTENCY SOFT, FORMED SOFT, BULKY, HARD,
DRY (DEHYDRATION)
WATERY (DIARRHEA, BUG)
SHAPE ROUND, FULL UNFORMED, FLAT,PENCIL SHAPED
STONE LIKE
COMPONENTS UNDIGESTED FIBER WORMS
BLOOD
PUS
MUCUS

8. Testing Stool for Occult Blood
Know this!!!!!!!
SHOW CARDS AND LIQUID IF WE HAVE ANY!!!
IF PT. HAS VISIBLE BLOOD-HEMMORROIDS, THIS WOULD INVALIDATE THIS TEST (FALSE POSITIVE)
USE HAT TO COLLECT STOOL, USE TONGUE BLADE TO SMEAR SAMPLE ON CARD.

9. Common Alterations in Bowel Elimination
Introduction
Constipation
Primary
Secondary
Iatrogenic
CONSTIPATION—AN ELIMINATION PROBLEM CHARATERIZED BY DRY, HARD STOOL THAT IS DIFFICULT TO PASS
S/S= C/O ABDOMINAL FULLNESS OR BLOATING, ABDOMINAL DISTENTION, C/O RECTAL FULLNESS OR PRESSURE, PAIN ON DEFECATION,
DECREASED FREQUENCY OF BOWEL MOVEMENTS, INABILITY TO PASS STOOL AND THE CHANGES IN STOOLCHARACTERISTICS AS OOZING LIQUID STOOL OR HARD SMALL STOOL (IMPACTION)
PRIMARY RESULTS FROM INACTIVITY, INADEQUATEINTAKE OF FIBER, INSUFFICINET FLUID INTAKE OR IGNORING THE URGE TO DEFECATE.
NURSE CAN HELP TREAT THIS PROBLEM ON TEST!!!!
SECONDARY CONSEQUENCE OF A PATHOLOGIC DISORDER SUCHAS A PARTAIL BOWEL OBSTRUCTION. IT USUALLY RESOLVES WHEN THE PRIMARY CAUSE IS TREATED. ON TEST!!!!!!!!!!!!!
IATROGENIC OCCURS AS A CONSEQUENCE OF OTHER MEDICAL TREATMENT. EXAMPLE—PROLONGED USE OF NARCOTICS.

10. Question Is the following statement true or false?
Constipation is higher among those whose dietary habits lack adequate fiber.
ANSWER IS TRUE

11. Answer
True.
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.

12. Common Alterations in Bowel Elimination (cont’d)
Constipation (cont’d)
Pseudoconstipation
Fecal impaction
Flatulence
Diarrhea
Fecal incontinence
INFREQUENT ELIMINATION OF STOOL DOESN’T MEAN YOU ARE CONSTIPATED AND SOME PEOPLE MAY BE CONSTIPATED EVEN THOUGH THEY
HAVE A DAILY BOWEL MOVEMENT, WHERE AS OTHERS WHO DEFECATE IRREGULARLY MAY HAVE NORMAL BOWEL FUNCTION.
PSEUDOCONSTIPATION---ALSO CALLED PERCEIVED CONSTIPATION BY NANDA—WHEN CLIENTS BELIEVE THEMSELVES TO BE CONSTIPATED EVEN THOUGH THEY ARE NOT. THEY ARE EXTREMELY CONCERNED ABOU HAVING A BOWEL MOVEMENT. THEY OFTEN TIME OVERUSE LAXATIVES, SUPPOSITORIES AND ENEMAS.
FECAL IMPACTION-----DIFFERENT THAN CONSTIPATION—OCCURS WHEN A LARGE, HARDENED MASS OF STOOL INTERFERS WITH DEFECATION, MAKING IT IMPOSSIBLE FOR THE CLIENT TO PASS FECES VOLUNATARILY. THEY USUALLY REPORT A FREQUENT DESIRE TO DEFECATE BUT AN INABILITY TO DO SO. MAY HAVE RECTAL PAIN. SOME CLIENTS WITH AN IMPACTION PASS LIQUID STOOL, WHICH THEY MAY MISINTERPRET AS DIARRHEA. IT MAY BE NECESSARY TO CHECK FOR IMPACTION WITH DIGITAL EXAM.
NURSE SOMETIMES ADMINISTER OIL RETENTION ENEMAS IST AND THEN CLEANSING ENEMAS. ON TEST!!!!!!!!!!!!!!!!
FLATULENCE—(FLATUS)EXCESSIVE ACCUMULATION OF INTESTINAL GAS THAT RESULTS FROMSWALLOWING AIR WHILE EATING OR FROM SLUGGISH PERISTALSIS. SOME VEGETABLES (CABBAGE, CUCUMBERS, ONIONS) CAUSE GAS. BEANS WE LACK ENZYME TO COMPLETELY DIGEST THEIR PARTICULAR FORM OF COMPLEX CARBOHYDRATE. NURSE CAN INSERT RECTALTUBE TO EXPEL GAS.
DIARRHEA----URGENT PASSAGE OF WATERY STOOL AND COMMONLY IS ACCOMPAINED BY ABDOMINAL CRAMPING. IS MENAS OF ELIMINATING AN IRRATING SUBSTANCE SUCH AS TAINTED FOOD OR INTESTINAL PATHOGENS. CAN BE CAUSED BY EMOTIONAL STRESS, DIETARY INDISCRETIONS, LAXATIVE ABUSE OR BOWEL DISORDERS. RESTING THE BOWEL TEMPORARILY MAY RELIEVE SIMPLE DIARRHEA.
—THIS MEANS THE PERSON DRINKS CLEAR LIQUIDS BUT AVOIDS SOLID FOODS FOR 12 TO 24 HOURS. ON TEST!!!!!!!!!!!!!!
RESUMED EATING BEGINS WITH BLAND FOODS AND THOSE LOW IN RESIDUE (DECREASE FIBER)SUCH AS BANANAS, APPLESAUCE AND COTTAGE CHEESE.
FECAL INCONTINENCE-----THE INABILITY TO CONTROL THE ELIMINATION OF STOOL. CAN COME FROM NEUROLOGICAL CHANGES THAT IMPAIR MUSCLE ACTIVITY, SENSATION OR THOUGHT PROCESSES. ALSO MAY OCCUR WHEN A PERSON CAN’T REACHA TOILET IN TIME TO ELIMINATE SUCH AS AFTER TAKING A HARSH LAXATIVE.

13. Removing Fecal Impaction

14. Inserting a Rectal Tube
(Refer to Skill 31-1 in the textbook.)

15. Question Is the following statement true or false?
Incontinence can result from neurologic changes.
ANSWER IS TRUE

16. Answer
True.
Incontinence can result from neurologic changes that impair muscle activity, sensation, or thought processes.

17. Managing Fecal Incontinence

18. Measures to Promote Bowel Elimination
Two physician-ordered interventions to promote elimination when not naturally occurring
Insert a rectal suppository
Administer an enema
Cleansing enemas
Tap water, normal saline
Soapsuds, hypertonic saline
2 WAYS TO PROMOTE ELIMINATION NOT DONE NATURALLY---
1) INSERT A RECTAL SUPP.—CLIENT ALWAYS PLACED IN SIMS POSITION FOR GRAVITY PAGE 749
2) ADMINISTER AN ENEMA—REASONS—CLEANSE BOWEL, SOFTEN FECES, EXPEL FLATUS, SOOTHE IRRITATED MUCOUS MEMBRANES, OUTLINE
THE COLON DURING DIAGNOSTIC XRAYS AND TREAT WORMS AND PARASITE INFESTATIONS.
CLEANSING ENEMAS---KNOW TABE 31-3 ON PAGE 741
DEFECATION USUALLY OCCURS WITHIN 5-15 MINUTES AFTER ADMINISTRATION.
LARGE VOLUME CLEANISNG ENEMAS MAY CREATE DISCOMFORT BECAUSE THEY DISTEND THE LOWER BOWEL. ADMINISTER
CAUTIOUSLY BECAUSE OF PROBLEMS LIKE COLITIS BECAUSE YOU COULD RUPTURE THE BOWEL OR CAUSE OTHER SECONDARY
COMPLICATIONS.
TAP WATER AND NORMAL SALINE ENEMAS-----
BECAUSE THE WATER IS HYPOTONIC—THE FLUID CAN BE ABSORBED THROUGH THE BOWEL. CONSEQUENTLY IF SEVERAL ENEMAS ARE
GIVEN IN SUCCESSSION, FLUID AND ELECTROLYTE IMBALANCES MAY OCCUR. ON TEST!!!!!!!!!!!!!!
TO ENSURE CLIENT SAFTEY, IF STOOL CONTINUES TO BE EXPELLED AFTER THE 3RD ENEMA (OUR LIMIT IS 3) IS GIVEN CALL THE
DOCTOR BEFORE GIVING ANY MORE ENEMAS. ON TEST!!!!!!!!!!!!
HYPERTONIC ENEMAS (SODIUM PHOSPHATE) ENEMA DRAWS FLUID FROM THE BODY TISSUE INTO THE BOWEL. THIS INCREASES IN
THE FLUID VOLUME IN THE INTESTINE BEYOND WHAT WAS ORIGINALLY INSTILLED. IT ACTS AS A LOCAL IRRITANT ON THE
MUCOUS MEMBRANES.

19. Inserting a Rectal Suppository
(Refer to Skill 31-2 in the textbook.)

20. Administering a Cleansing Enema
(Refer to Skill 31-3 in the textbook.)
WHEN YOU INSERT AN ENEMA MAKE SURE IT GOES IN 3-4 INCHES. ON TEST!!!!!!!!!!!!!

21. Administering a Hypertonic Enema Solution

22. Measures to Promote Bowel Elimination (cont’d)
Administer an enema (cont’d)
Retention enemas
Oil retention enema
Mineral, cottonseed, or olive oil
Retained at least 30 minutes
Lubricate and soften stool to ease stool expulsion
RETENTION ENEMAS-----USES A SOLUTION HELD WITHIN THE LARGE INTESTINE FOR A SPECIFIC PERIOD OF TIME., USUALLY 30 MINUTES.
SOME AREN’T EXPELLED AT ALL. ONE TYPE OF RETENTION ENEMA IS AN OIL RETENTION ENEMA BECAUSE THE FLUID INSTILLED
IS MINERAL, COTTONSEED, OR OLIVE OIL. OILS LUBRICATE AND SOFTEN THE STOOL, SO IT CAN BE EXPELLED MORE EASILY.
APPX ML OF WARMED OIL SLOWLY TO AVOID STIMULATING AN URGE TO DEFECATE.PREMATURE DEFECATION DEFEATS THE
PURPOSE OF RETAINING THE OIL

23. Ostomy Care Ileostomy: surgically created opening to the ileum
Colostomy: surgically created opening to the colon
Providing peristomal care
Applying an ostomy appliance
Draining a continent ileostomy
Irrigating a colostomy
PREVENTING SKIN BREAKDOWN IS A MJOR CHALLENGE IN OSTOMY CARE. ENZYMES INSTOOL CAN QUICKLY CAUSE EXCORIATION (CHEMICAL INJURY OF SKIN.) WASHING THE STOMA AND SURROUNDING SKIN WITH MILD SOAP AND WATER AND PATTING IT DRY CAN PRESERVE SKIN INTEGRITY.
ENTERSTOMAL THERAPISTS—NURSE CERTIFIED IN CARING FOR OSTOMIES AND RELATED SKIN PROBLEMS.

24. Question
Which type of constipation occurs as a consequence of other medical treatment?
a. Iatrogenic constipation
b. Secondary constipation
c. Pseudoconstipation
d. Primary constipation
ANSWER IS A.

25. Answer a. Iatrogenic constipation
Prolonged use of narcotic analgesia for example, 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.

26. An Ostomy Appliance
FACEPLATE USUALLY REMAINS IN PLACE FOR 3-5 DAYS UNLESS IT BECOMES LOOSE OR CAUSE SKIN DISCOMFORT. THE CLIENT EMPTIES THE POUCH WHEN IT IS 1/3RD TO ½ FULL, OTHERWISE IT MAY BECOME TO HEAVY AND PULL THE FACEPLATE FROM THE SKIN.

27. Changing an Ostomy Appliance
(Refer to Skill 31-4 in the textbook.)

28. Draining a Continent Ileostomy
CONTINENT OSTOMY---SURGICALLY CREATED OPENING THAT CONTROLS THE DRAINAGE OF LIQUID STOOL OR URINE BY SIPHONING IT FROM AN INTERAL RESERVOIR. ALSO KNOW AS A KOCK POUCH. REQUIRES NO APPLIANCE BUTDOES REQUIRE THE CLIENT TO DRAIN THE ACCUMULATING LIQUID STOOL OR URINE APPX. EVERY 4-6 HRS.

29. Irrigating a Colostomy
(Refer to Skill 31-5 in the textbook.)
CLIENTS WITH A COLOSTOMY WHSOE STOOL IS MORE SOLID SOMETTIMES REQUIRE THE INSTILLATION OF FLUID TO PROMOTE ELIMINATION.. THE PURPOSE OF IRRIGATION IS TO REMOVE FORMED STOOL AND IS SOME CASES TO REGULATE THE TIMING OF BOWEL MOVEMENTS. WITH REGULATION, A CLEINT WITH A SIGMOID COLOSTOMY MAY NOT NEED TO WEAR AN APPLIANCE. ONCE THE CLIENT HAS ELIMINATED THE STOOL, HE/SHE WILL EXPEL NO MORE UNTIL THE NEXT IRRIGATION. THIS MIMICS NORMAL BOWEL HABITS.

30. Nursing Implications Potential nursing diagnoses:
Constipation, risk for constipation, perceived constipation
Diarrhea, bowel incontinence
Toileting self-care deficit
Situational low self-esteem

31. General Gerontologic Considerations
Age-related changes predispose older adults to constipation, as do medication effects, diminished physical activity, and inadequate fluid and fiber intake
Older adults likely to implement home remedies to promote bowel elimination
Educate older adults about risk for constipation and effective bowel regimen
PRUNE JUICE OR HOT WATER TO PROMOTE ELIMINATION, EATING BRAN CEREAL OR ADDING IT TO OTHER FOODS FOR OLDER ADULTS

32. General Gerontologic Considerations (cont’d)
Some older adults overuse laxatives or have long-standing habit of laxative abuse; encourage use of bulk-forming products to promote effective bowel elimination
Prolonged use of mineral oil to prevent/ relieve constipation interferes with absorption of fat-soluble vitamins (A, D, E, and K)

33. General Gerontologic Considerations (cont’d)
Change in bowel habits and stool characteristics can signal colorectal cancer; recommend regular endoscopic bowel exams after 50 years of age
Diarrhea can quickly lead to dehydration and electrolyte imbalance
Hemorrhoids or polyps in older adults may interfere with stool passage; gently perform digital removal of impaction, if ordered