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Chapter 46: Bowel Elimination


Chapter 46: Bowel Elimination Bonnie M. Wivell, MS, RN, CNS * STOMACH: produces and secretes HCL, mucus, the enzyme pepsin, and the intrinsic factor SMALL INTESTINES ... – PowerPoint PPT presentation

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Title: Chapter 46: Bowel Elimination

Chapter 46 Bowel Elimination
  • Bonnie M. Wivell, MS, RN, CNS

Scientific Knowledge Base
Mouth Digestion begins with mastication saliva dilutes and softens food Esophagus Peristalsis moves food bolus into the stomach
Stomach Stores food liquid mixes food, liquid and digestive juices moves food into small intestines Small intestine Duodenum, jejunum, and ileum
Large intestine The primary organ of bowel elimination Anus Expels feces and flatus from the rectum
Factors Affecting Bowel Elimination
  • Age
  • Infants small stomach capacity less secretion
    of digestive enzymes rapid peristalsis lack
    neuromuscular development so cannot control
  • Older adults arteriosclerosis which causes
    decreased mesenteric blood flow, decreasing
    absorption in small intestine decrease in
    peristalsis loose muscle tone in perineal floor
    and anal sphincter thus are at risk for
    incontinence slowing nerve impulses in the anal
    region make older adults less aware of need to
    defecate leading to irregular BMs and risk of

Factors Affecting Bowel Elimination
  • Diet fiber such as whole grains, fresh fruits
    and vegies help flush the fats and waste products
    from the body with more efficiency decreased
    fiber ? increased risk of polyps be aware of
    food intolerances
  • Fluid intake 6-8 glasses of noncaffeinated fluid
    daily liquifies intestinal contents easing
    passage through colon
  • Physical activity promotes peristalsis
  • Psychological factors stress increases
    peristalsis resulting in diarrhea and gaseous
    distention ulcerative colitis IBS gastric and
    duodenal ulcers crohns disease
  • Personal habits fear of defecating away from
  • Position during defecation squatting is the
    normal position

Factors Affecting Bowel Elimination
  • Pain hemorrhoids, rectal surgery, rectal
    fistulas and abd. surgery
  • Pregnancy increased pressure slowing
    peristalsis in third trimester
  • Surgery and Anesthesia lows or stops
    peristalsis paralytic ileus direct
    manipulation of the bowel and lasts 24-48 hours
  • Medications laxatives and cathartics laxative
    overuse can decrease muscle tone and can cause
    diarrhea which can result in dehydration and
    electrolyte imbalance see Table 46-2
  • Diagnostic tests bowel prep barium

Common Bowel Elimination Problems
  • Constipation
  • Causes improper diet, reduced fluid intake, lack
    of exercise, and certain meds
  • A significant health hazard
  • Impaction
  • Causes unrelieved constipation
  • Debilitated, confused, and unconscious more at
  • Continuous ooze of diarrhea is a suspect sign
  • Diarrhea
  • Causes antibiotics via any route enteral
    nutrition food allergies or intolerance
    surgeries or diagnostic testing of the lower GI
    tract C. difficile communicable food-borne

Common Bowel Elimination Problems
  • Incontinence
  • Causes physical conditions that impair anal
    sphincter function or control
  • Flatulence
  • Causes certain foods decreased intestinal
  • Can become severe enough to cause abd distention
    and severe sharp pain
  • Hemorrhoids dilated, engorged veins internal
    or external
  • Causes straining with defecation pregnancy
    heart failure chronic liver disease

Bowel Diversions
  • Ostomies Certain disease /conditions prevent
    normal passage of stool temporary or permanent
    artificial opening in the abd wall location
    determines consistency of stool
  • Loop colostomy Usually done emergently
    temporary usually involves transverse colon two
    openings through one stoma stool and mucus
    external supporting device usually removed in
    7-10 days
  • End colostomy one stoma formed from the proximal
    end of the bowel and distal portion of the GI
    tract removed or sewn closed (Hartmans pouch)
    common in colorectal cancer and rectum is usually
    removed temporary in surgery for diverticulitis
  • Double-barrel colostomy bowel is surgically
    severed and two ends brought out onto the abd
    proximal stoma functions and distal stoma is

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Loop Colostomy
Double-Barrel Colostomy
Double-Barrel Colostomy
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End Colostomy
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Bowel Diversions Contd.
  • Alternative procedures
  • Ileoanal pouch colon removed for tx of
    ulcerative colits or familial polyps pouch is
    formed from distal end of small intestines and
    attached to anus pouch acts as rectum so pt. is
    continent has temporary ileostomy while healing
  • Kock continent ileostomy consists of a reservoir
    constructed from small bowel and nipple valve
    which keeps contents of reservoir inside body
    permits entry of external catheter to drain pouch
  • Macedo-Malone Antegrade Continence Enema (MACE)
    for improving continence in pts with neuropathic
    or structural abnormalities of the anal sphincter

Ileoanal Pouch Anastomosis
Kock Continent Ileostomy
Care of the Patient With a Bowel Diversion
  • Bagging the ostomy
  • Assessing stoma and skin
  • Assessing stool output
  • New stoma vs. Old stoma
  • Patient education and counseling

Psychological Considerations
  • Body image changes
  • Face a variety of anxieties and concerns
  • Must learn how to manage stoma
  • Cope with conflicts of self-esteem and body image
  • Can be concealed with clothing but pt. aware of
    its presence
  • Difficulty with intimacy/sexual relations
  • Foul odors, leakage, spills and inability to
    control or regulate passage of gas and stool is
  • Ostomy support
  • United Ostomy Association
  • National Foundation for Ileitis and Colitis

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Nursing Process and Bowel Elimination
  • Assessment
  • Nursing history (see Box 46-2)
  • Usual elimination pattern
  • Usual stool characteristics
  • Routines to promote normal elimination
  • Use of artificial aids
  • Presence/status of bowel diversions
  • Changes in appetite
  • Diet history
  • Daily fluid intake
  • History of surgery or illnesses of GI tract
  • Medication history
  • Emotional state
  • History of exercise
  • Pain or discomfort
  • Social history
  • Mobility and dexterity

Nursing Process and Bowel Elimination
  • Physical assessment of the abdomen
  • Mouth poor dentition, dentures, mouth sores
  • Abdomen inspect, auscultate, palpate, percuss
  • Rectum inspect
  • Inspection of fecal characteristics
  • Review of relevant test results
  • Fecal specimens cannot mix feces with urine or
  • Stool for occult blood (FOBT or guiac) see Box
  • Fecal fat requires 3-5 days of collection
  • Ova Parasites (OP)
  • Labs bilirubin, ALK, Amylase, CEA
  • Diagnostic Exams KUB, endoscopy, colonoscopy,
    barium enema, barium swallow, US, MRI, CT scan
    (may require pre-procedure preparation)

Nursing Diagnosis
  • Bowel incontinence
  • Constipation
  • Risk for constipation
  • Perceived constipation
  • Diarrhea
  • Toileting self-care deficit
  • Body image, disturbed

  • Goals and outcomes
  • Client sets regular defecation habits
  • Client is able to list proper fluid and food
    intake needed to achieve bowel elimination
  • Client implements a regular exercise program
  • Client reports daily passage of soft, formed
    brown stool
  • Client doesnt report any discomfort associated
    with defecation
  • Setting Priorities
  • Collaborative Care - WOCN

  • Health Promotion establish routine
  • Promotion of normal defecation
  • Sitting position
  • Position on bedpan see pg. 1196
  • Privacy
  • Acute Care
  • Meds
  • Cathartics and laxatives
  • Antidiarrheal agents
  • Enemas

Types of Enemas
  • Cleansing enemas
  • Tap water
  • Normal saline
  • Hypertonic solutions
  • Soapsuds
  • Oil Retention
  • Carminative Mag, gylcerin and water relieves
    gaseous distention
  • Medicated enemas Kayexalate

Implementation Contd.
  • Enema administration
  • Enemas till clear
  • See pages 1200-1202
  • Digital removal of stool last resort
  • Can cause irritation to the mucosa, bleeding and
    stimulation of vagus nerve
  • Inserting and maintaining a nasogastric tube

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NG Tubes
  • Levine or salem sump tubes are most common for
    stomach decompression or lavage
  • See pages 1204-1209 for insertion procedure
  • Connected to intermittent suction (LIS)
  • Air vent should NEVER be clamped, connected to
    suction or used for irrigation
  • Not a sterile technique
  • Care of pt. with NG
  • Comfort
  • Frequent mouth care/gargling
  • Maintain patency of tube
  • Turn client frequently to allow for adequate

Continuing and Restorative Care
  • Care of ostomies
  • Irriating a colostomy
  • Pouching ostomies (see pages 1211-1215)
  • Nutritional considerations with ostomies
  • Bowel training
  • Proper fluid and food intake
  • Regular exercise
  • Hemorrhoids
  • Skin integrity

  • The effectiveness of care depends on how
    successful the client is in achieving goals and
  • Optimally the client will be able to have
    regular, pain-free defecation of soft-formed
  • It is necessary to ask questions so establishing
    a therapeutic relationship is VERY important
  • Nursing interventions may be altered if necessary