Chapter 30

1. Chapter 30 Bowel Elimination and Care

2. Terminology Related to Bowel Elimination • Defecation: process of bowel elimination • Constipation: hard stools; difficulty passing stools • Diarrhea: several liquid stools per day • Fecal impaction: stool obstruction • Flatus: gas

3. Gastrointestinal (GI) Tract • Mouth • Anus • Waste products—feces or stool • Process of bowel elimination—defecation

4. Peristalsis • Consists of rhythmic wavelike movements beginning in the esophagus and continuing to the rectum • Involves contraction of the circular and longitudinal muscles in the walls of the GI tract • Propels the bolus of food through the GI tract

5. Process of Digestion, Absorption, and Metabolism of Nutrients • Bowel elimination occurs after nutrients are moved through the GI tract • In the stomach, enzymes break down the bolus of food,converting it to chyme • The chyme passes through the pyloric sphincter and into the small intestine,where the nutrients are absorbed • The remaining chyme passes through the illeocecal valve into the large intestine to be passed as stool

6. Changes Through Life Cycle • Infants—three to six bowel movements (BM)/day • Children—one to two/day • Elderly—peristalsis slows—more prone to constipation or hard stools that are difficult to pass • At least every three days

7. Characteristics of Feces • Color, shape, consistency, odor, and frequency • Diet, amount of fiber and fluids, exercise, medications, and other habits • Disease process can change characteristics • Assessment is important

8. Normal • Soft, formed, light yellowish-brown to dark brown, and slightly odiferous and slightly curved shape • Color—vary by dietary intake • Spinach • Beets • Iron

9. Abnormal Characteristics • Table 30-1, pg. 678 • Inadequate fluid intake • Transit time • Fiber • Increased amount of fat • Steatorrhea—fluffy, float, foul odor

10. Abnormal Characteristics • Malabsorption disease—Chron’s • Ribbon-like stools • Mucus , blood, or pus • Parasites, worms, or eggs • Clay colored or pale white stools • Frank blood—visible to naked eye

11. Abnormal Characteristics • Occult blood—hidden blood • All bleeding is considered serious until proven otherwise • Must be reported to physician

12. Abnormal Characteristics of Stool • Liquid, watery, unformed, hard, dry • Balls, clumps, flat or ribbonlike, pencil-like • Bright red blood, black, coffee-ground appearance, pale, white, gray, or claylike • Presence of pus or mucus; floating on water • Presence of worms or eggs • Foul odor, bloody, or metallic smell

13. Factors Affecting Bowel Elimination • Change in activity level • Change in dietary intake • Change in water source • Change in fluid volume intake • Side effects of medication • Side effects of surgery • Pregnancy

14. Factors Affecting Bowel Elimination (cont.) • High stress levels and emotional problems • Laxative abuse • Aging process • Structural changes • Chemical changes • Food allergies

15. Common Alterations in Bowel Elimination • Constipation • Diarrhea • Impaction • Fecal incontinence

16. Constipation • Less frequent, hard, formed stools—difficult to expel • Bloated feeling • Degrees of severity • Impaction—blockage due to mass of very hard stool

17. Constipation • Impaction • Loss of appetite • Bloating • Cramping • Malaise • Just not feeling well

18. Constipation • Possibly no complaints • Always note when was patient’s last BM • Assess elderly and those from long term care setting for s/s of constipation or impaction

19. Diarrhea • Loose or watery stools occurring three or more times/day • Cramping—may or may not be present • Monitor for possible complications • Excoriated perianal skin • Dehydration and electrolyte imbalance • Especially infants, young children, and elderly

20. Fecal Impaction • Rectum, sigmoid flexure, or any part of large colon • Elderly, inactive patient’s, severely dehydrated • Common cause—abuse of laxatives • Possible indication—liquid stool • Complication—obstruction or perforation of bowel

21. Digital Removal of Impaction • Can be embarrassing and painful • Oil retention enema or pain med • Prior to procedure • Delegate? Need an order? • Review patient history—contraindications? • Monitor for s/s of vagus nerve stimulation

22. Fecal Incontinence • Voluntary control is lost • Beyond patient’s control • Spinal cord injury • Disoriented patient’s • Source of guilt, embarrassment, and destruction of self-esteem

23. Fecal Incontinence • What can be done? • Bowel training • Proper cleansing and barrier creams • Fecal incontinence pouch • Maintain patient’s dignity—never refer to as diapers

24. Bowel Elimination • Assessment of BM and documentation • Color • Amount • Consistency • Unusual shape • Unusual odor

25. Nursing Interventions to Promote Bowel Function • Increase physical activity • Ensure adequate fluid: up to 2,500 mL/day • Increase fiber intake to 20 to 30 g/day (gradually!!) • Provide privacy • Position patient upright for elimination • Provide stimulants that “cue” bowel function at home, such as a cup of hot coffee before breakfast

26. Subjective Assessment • On admission to hospital • Subjective information of patient’s normal bowel habits • Any current problems with BM’s

27. Objective Assessment • Physical assessment • Shape of abdomen • Normal—rounded or flat • Abnormal—distended or inflated • Distention—excessive gas, fluid, or stool

28. Objective Assessment • Auscultate bowel sounds • Diaphragm portion of stethoscope • Listen in all four quadrants • Once per shift or more often if indicated • Soft gurgles or irregular clicks • Between 5 and 30/minute

29. Objective Assessment • Bowel sounds • <5/minute—hypoactive bowel sounds • >30/minute or continuous—hyperactive bowel sounds • May indicate obstruction—high pitched, tinkling sounds in one area and absent or decreased sounds in the distal portion

30. Objective Assessment • An absence of bowel sounds indicates a problem and should always be reported to the physician • To determine absent bowel sounds—listen 3 to 5 minutes in each quadrant

31. Objective Assessment • Assessment of abdomen • Inspection • Auscultation • Palpation • Palpation • Normal—soft • Abnormal—firm or hard—excessive gas, constipation, or obstruction

32. Importance of… • Increased activity • Adequate fluid intake • Adequate fiber intake • Privacy during elimination • Positioning during elimination

33. Management • Universal precautions • Possibility of contact with feces • Incontinent patient • Emptying bedpan or bedside commode • Removing an impaction • Collecting stool specimen • Administering enema • Providing colostomy care

34. Management • Altering dietary intake related to diarrhea • Clear liquid diet first 24 hours • Decaffeinated green or black teas or herbal tea • Sports drinks—replace electrolytes • Avoid extremely hot or cold liquids first 24 hours • Longer than 24 to 36 °--full liquids and cooked fruits or vegetables

35. Management • Diarrhea due to loss of normal flora—yogurt • Concurrent use with antibiotics—prevent the loss of normal flora

36. Management • Medications • Coat the mucous membranes of the bowel • Inhibit peristalsis • Treat the disease or infectious process

37. Management • Lactobacillus acidophilus • Supplement • Replace normal flora • Medications for constipation • Increase peristalsis • Soften stool • Add bulk to stool

38. Management • Enema • Instillation of solution into the colon via the rectum • Temperature—between 105 to 110° F—to avoid burning intestinal mucosa • Test—should feel warm, NOT HOT • Too cool—cause cramping

39. Management • Position* • Left lateral side-lying or Sims’ • Insert tip of tubing 3 to 4 inches (adult) • Rectum, sigmoid colon, and descending colon

40. Management • If a high enema is ordered • Start with patient on left side—instill half of solution—supine—then right lateral side for rest of solution

41. Management • Cleansing enema • Relief of constipation • Empty and cleanse the bowel prior to surgery or testing • Large volume enema—500 to 1,000 ml • Small volume enema--<250 ml, usually 90 to 120 ml

42. Management • Order—enemas til clear • Enemas administered until the expelled solution no longer contains feces and is relatively clear • Within a LIMIT of three 1,000 ml enemas • Avoid giving more than 3 large volume enemas consecutively • Cause fatigue and irritation of intestinal lining

43. Management • Types of solutions • Tap water • Normal saline • Soapsuds • Commercially prepackaged small volume oil or sodium phosphate solutions

44. Management • Soapsuds • Castile soap—5 ml/1,000m of solution—no substitutes—other soaps too harsh—damage intestinal lining • Distends intestine and irritates the walls of intestines to further stimulate peristalsis

45. Management • Tap water • Hypotonic! • High risk individuals? • Normal Saline • Isotonic

46. Management • Hypertonic • May be used in small volumes for adults • Fleet’s enema • Not used in large volume enemas—increased risk of fluid and electrolyte imbalances • Milk and molasses enema—hypertonic—persistent constipation or impaction removal—follow agency policy

47. Management • Oil retention • Soften hard stool of an impaction to ease removal • Small volume—90 to 120 ml • Allow time to soften stool—approx. one hour

48. Management • Medicating enema • Steroid—decrease inflammation • Kayexalate enema—to lower a very high potassium level • Must retain in bowel—solution pulls K+ from bloodstream into solution to be expelled • Follow agency policy

49. Management • Return flow enemas • Aka Harris flush • Remove flatus or gas • Tap water or saline • Small volume—100 to 200 ml • Then lower container below level of rectum—fluid and gas returned—bubbles—continue til no bubbles—Follow agency policy

50. Contraindications • Rectal surgery • Severe bleeding hemorrhoids • Ulcerative colitis or Crohn’s disease • Rectal fissure or rectal cancer • Excessive bleeding potential due to disease or medication • Certain heart conditions