Promoting Bowel Elimination: Normal Process, Abnormal Characteristics, and Nursing Interventions

1. Chapter 30 Promoting Bowel Elimination

2. Chapter 30 Lesson 30.1

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

4. Learning Objectives Clinical Practice • Use nursing measures to promote regular bowel elimination in patients • Collect a stool specimen • Perform a focused assessment of the bowel • Assist RN in identifying appropriate nursing diagnoses for a patient with bowel problems

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

6. Structures Involved in Waste Elimination • Large intestine • Ascending colon • Transverse colon • Descending colon • Sigmoid colon • Rectum • Anus

7. Figure 30-1: The intestinal system

8. Structures Involved in Waste Elimination • Walls of the intestine have four layers • Mucosa • Submucosa • Muscular layer • Serous layer (serosa)

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

10. Functions of the Intestines • 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

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

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

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

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

15. Drugs That May Contribute to Constipation • Narcotic analgesics • Codeine, morphine, meperidine • General anesthetics • Diuretics • Sedatives • Anticholinergics • Calcium channel blockers

16. Drugs Used for Constipation • Stool softeners • Colace, Surfak, Dialose • Bulk forming laxatives • Fibercon, Metamusil, Citrucel • Irritant/stimulant laxatives • Ducolax, Neolid, Ex-lax, Correctol, Senokot • Saline laxatives • Citrate of magnesia, milk of magnesia, phospho-soda

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

18. Hyperactive Bowel • 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)

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)

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

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

22. Initial Assessment • 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

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

24. Chapter 30 Lesson 30.2

25. Learning Objectives Theory • List safety considerations related to giving a patient an enema • Describe three types of intestinal diversions • Discuss the stoma and peristomal assessment and skin care • Discuss the psychosocial implications for a patient who has an ostomy

26. Learning Objectives Clinical Practice • Prepare to administer an enema • Assist and teach the patient who is incontinent with a bowel retraining program • Provide ostomy care, including irrigation and changing the ostomy appliance • Assist a patient to catheterize a continent diversion

27. 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

28. 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

29. Figure 30-2: Enema equipment

30. Figure 30-4: Position for giving an enema

31. Types of Enemas • Retention 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

32. 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

33. 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

34. 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

35. Types of Ostomies • Ileostomy • 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

36. Figure 30-6: Sigmoid colostomy

37. Figure 30-6: Descending colostomy

38. Figure 30-6: Ascending colostomy

39. Figure 30-6: Double-barrel colostomy

40. Figure 30-6: Ileostomy

41. Figure 30-6: Kock’s pouch

42. Ostomy Care • Skin care • 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