Faculty of Health Sciences

Nursing Department

Dr. Jawad Abu-Shennar

 Lecture- fifteen

BOWEL ELIMINATION
 Stomach:
Performs three tasks:
Storing Swallowed Food
And Liquid; Mixing Food, Liquid, And Digestive Juices;
Emptying İts Contents İnto The Small İntestine.

Produces and secretes:

Hydrochloric Acid (HCl),
Mucus,
The Enzyme Pepsin
The İntrinsic Factor.
- Pepsin and HCl facilitate the digestion of protein.
-The Mucus protects the stomach mucosa from acidity and enzyme activity.
-The intrinsic factor is essential for the absorption of vitamin B12.
 Small Intestine:
 Segmentation and peristaltic movement in the small intestine facilitate both
digestion and absorption.
 The small intestine has three sections: the duodenum, the
jejunum, and the ileum.

 The jejunum is approximately 2.5 m long and absorbs

carbohydrates and proteins.

 The ileum is approximately 3.7 m (12 feet) long and absorbs

water, fats, certain vitamins, iron, and bile salts.

 The duodenum and jejunum absorb most of the nutrients and

electrolytes.
 The Large Intestine:

 The primary organ of bowel elimination

 Extends from the ileocecal valve to the anus

 The Large Intestine:
 The colon is divided into the ascending, transverse,
descending, and sigmoid colons.
 The muscular tissue of the colon allows it to
accommodate and eliminate large quantities of waste and
gas (flatus).
 It has three functions:
-Absorption,
-Secretion,
-Elimination.
 Absorption:

 The large intestine absorbs water, sodium, and chloride

from the digested food that has passed from the small
intestine.

 Healthy adults absorb more than a gallon of water and an

ounce of salt from the colon every 4 hours.
 Secretion:

 The secretory function of the colon aids in electrolyte balance.

 The colon secretes bicarbonate in exchange for chloride.

 The colon also excretes about 4 to 9 mEq of potassium daily.

 Therefore serious alterations in colon function (e.g., diarrhea)

cause severe electrolyte disturbances
 Slow peristaltic contractions move contents through the colon.

 Intestinal content is the main stimulus for contraction.

 Mass peristalsis pushes undigested food toward the rectum.

 These mass movements occur only three or four times daily, with the strongest during
the hour after mealtime.
 Elimination:

 The rectum is the final portion of the large intestine.

 Here bacteria convert fecal matter into its final form.

 Normally the rectum is empty of waste products

(feces) until just before defecation.
 Process of Defecation:

• When the Peristaltic waves move the feces into the sigmoid colon and rectum, the
sensory nerves in the rectum are stimulated and the individual becomes aware of
the need to defecate.

• When the internal anal sphincter relaxes, feces move into the anal canal ,the
external anal sphincter is relaxed voluntary.

• Expulsion of feces is assisted by contraction of the abdominal muscle, and the

downward pressure on the rectum.
 Factors Affecting Bowel Elimination:
1. Age
2. Diet
3. Daily patterns
4. Food and fluid intake
5. Physical activity and muscle tone
6. Lifestyle, psychological factors
7. Pathologic conditions
8. Diagnostic studies
9. Pain
10. Medications, surgery and anesthesia
 Age
 Infants: small stomach capacity; less secretion of digestive enzymes; rapid
peristalsis; lack neuromuscular development so cannot control bowels

 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 constipation
 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; crohn’s
disease

 Personal habits: fear of defecating away from home

 Position during defecation: squatting is the normal position

 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

 Healty Defecation

 Establish a regular exercise regimen.

 Include high-fiber foods, such as vegetables, fruits, and
whole grains, in the diet.
 Maintain fluid intake of 2000 to 3000 mL/day.
 Do not ignore the urge to defecate.
 Allow time to defecate, preferably at the same time each day.
 Avoid over-the-counter medicine (OTC) medications to treat
constipation and diarrhea.
 Common Bowel Elimination Problems:

1. Constipation:

A symptom, not a disease.

Causes: Improper diet, reduced fluid intake, lack of exercise, and certain
medications can cause constipation.

The signs of constipation include infrequent bowel movements (less than every 3
days), difficulty passing stools, excessive straining, inability to defecate at will, and
hard feces

A significant health hazard

 Individuals at High Risk for Constipation

 Patients on bed rest taking constipating medicines such as opioids, iron,

antacids.

 Patients with reduced fluids or bulk in their diet.

 Patients who are depressed.

 Patients with central nervous system disease or local lesions that cause
pain.
 Treatment for constipation:

 Increase fluid and fiber intake

 Increase activity level

 Administer enema

 May require laxative, stool softeners

 Evaluate medication profile for GI side effects

2. Impaction:
Causes: unrelieved constipation

Fecal impaction results from unrelieved

constipation.
It is a collection of hardened feces wedged in the
rectum that a person cannot expel.
 Abnormal feces:

 Clay or white color may indicate of absence of bile or bile

obstruction.
 Black, tarry stool may indicate of bleeding from upper
gastrointestinal tract or drug.
 Red: may indicate of bleeding from lower gastrointestinal tract.
 Pale may indicated to mal absorption.
 Green may indicate intestinal infection.
 Dry, hard: dehydration decreased intestinal motility.
 Pus: bacterial infection.
3. Diarrhea is
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 pathogens
an increase in the number of stools and the passage of liquid, unformed
feces.
It is associated with disorders affecting digestion, absorption, and
secretion in the GI tract.
Excess loss of colonic fluid results in serious fluid and electrolyte or
acid-base imbalances.
Many conditions cause diarrhea. Antibiotic use via any route of
administration alters the normal flora in the GI tract
4. Incontinence:
Causes: physical conditions that impair anal sphincter function or control

Fecal incontinence is the inability to control passage of feces and gas from
the anus. Incontinence harms a patient’s body image.

5. Flatulence:
Causes: certain foods; decreased intestinal motility
Can become severe enough to cause abd. distention and severe sharp pain
 Nursing Measures for the Patient With Diarrhea

 Increase the fluid intake ( 8 glasses of water/day)

 Remove the cause of diarrhea whenever possible (e.g., medication).

 Limit fatty foods and beverages with caffeine.

 Limit food containing high fibers such as cereals and whole grain breads,
raw fruits & vegetables.

 Give special care to the region around the anus.

 After the diarrhea stops, suggest the intake of fermented dairy products
such as yogurt.
 Abnormal feces:

 Clay or white color may indicate of absence of bile or bile

obstruction.
 Black, tarry stool may indicate of bleeding from upper
gastrointestinal tract or drug.
 Red: may indicate of bleeding from lower gastrointestinal tract.
 Pale may indicated to mal absorption.
 Green may indicate intestinal infection.
 Dry, hard: dehydration decreased intestinal motility.
 Pus: bacterial infection.
6.Hemorrhoids: dilated, engorged veins; internal or external
Causes: straining with defecation; pregnancy; heart failure; chronic
liver disease
 Bowel Diversions:
 Surgical openings created on the surface of the abdomen to allow stool to exit
body.

 Certain diseases cause conditions that prevent normal passage of feces through
the rectum.

 The treatment for these disorders results in the need for a temporary or
permanent artificial opening (stoma) in the abdominal wall.

 Surgical openings are created in the ileum (ileostomy) or colon (colostomy),

with the ends of the intestine brought through the abdominal wall to create the
stoma.
Ostomy: An opening on the abdominal wall for the elimination of
feces or urine.

There are many types of ostomies:

Gastrostomy: is an opening through the abdominal wall in
to the stomach.
Jejunostomy: is an opening through abdominal wall in to
jejunum.
Ileostomy: is an opening in to the ileum.
Colostomy: is an opening in the colon.
 There are three types of colostomy construction: loop, end, and double-barrel.
 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 (Hartman’s 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 nonfunctioning
STOMA PROLABSE
 Ostomy Care:

 Irrigation

 Pouching

 Skin barriers and care

 Nutritional considerations
 https://coursewareobjects.elsevier.com/objects/elr/Potter/funda
mentals9e/videos/?ch=47
 Ostomy Management

■ Stoma and Skin Care

• Wash hands and use gloves

• Client sitting or lying in bed; sitting or

standing in bathroom

• Unfasten belt, empty pouch

• Remove skin barrier; clean and dry skin

• Assess stoma and peristomal skin

• Place tissue or gauze over stoma and change as
needed until new appliance is in place.
 Ostomy Management

■ Stoma and Skin Care

• Skin barrier and pouch

• One- or two-piece (A)

• Closed (A) or drainable pouch (B)

• Empty 1-2 times/day (1/3 to 1/2 full)
• Change appliance twice weekly or at least
Q 7 days or with leakage.
(B)
Ostomy Management
 Ostomy Management

• Prepare and Apply Skin Barrier

• Measure stoma with stoma guide
• Trace and cut skin barrier material to be no more than
1/8 to 1/4 inch larger than the stoma
• Remove barrier backing
• Press adhesive side onto skin, avoiding wrinkles; hold
for 30 seconds
• For 2-piece, remove tissue and snap appliance onto the
flange or skin barrier wafer
• Apply closed drainable pouches per instructions
• Document care
 Ostomy Management
■ Colostomy Irrigation
• Similar to enema

• Only for sigmoid or descending colostomy

• Used to stimulate evacuation, control time of elimination so pouch will not nee
to be worn

• Fluid varies from 300 mL to 1 L

• Cone may be used to retain fluid in bowel before evacuation

• Long-term irrigation puts client at risk for peristomal hernias, bowel perforation
electrolyte imbalance
 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 embarrassing
 Ostomy support:
 United Ostomy Association
 National Foundation for Ileitis and Colitis
 Promotion of Normal Defecation:

Sitting Position.
Assist patients who have difficulty sitting because of muscular
weakness and mobility problems.

Place an elevated seat on the toilet when patients are unable to lower
themselves to a sitting position because of joint- or muscle-wasting
diseases.

These seats require patients to use less effort to sit or stand.

 Promotion of Normal Defecation:

Positioning on Bedpan:
Patients restricted to bed use bedpans for defecation.

Women use bedpans to pass both urine and feces, whereas men use bedpans only for
defecation.

Sitting on a bedpan is extremely uncomfortable. Help position patients comfortably.

Two types of bedpans are available The regular bedpan, made of plastic, has a curved
smooth upper end and a sharper-edged lower end and is about 5 cm (2 inches) deep.
 Assessment: Nursing History

 Elimination pattern
 Characteristics of stool
 Routines
 Use of medications or enemas
 Presence of bowel diversion
 Changes in appetite
 Diet and fluid intake
 Assessment: Nursing History (cont'd)

 Prior medical history and use of medications

 Emotional state

 Exercise patterns

 Presence of discomfort

 Social history

 Mobility and dexterity

Nurses need to give client the following instruction:

Defecate in a clean bedpan.

Don’t contaminate the specimen if possible by urine.

Don’t replace the toileting paper in the bedpan.

Notify the nurse after defecation.

 Nursing Diagnoses
 Constipation
 Bowl incontinence related to fecal impaction.
 Constipation related to immobility.
 Risk for constipation insufficient fiber intake.
 Diarrhea related to spoiled food.
 Risk for fluid volume deficit related to diarrhea.
 Risk for impaired skin integrity related to colostomy.
 Self esteem disturbances related to bowl diversion.

Mosby items and derived items © 2005 by Mosby, Inc.

 Planning
 Maintain normal bowel elimination pattern.
 Maintain normal stool consistency
 Goals and outcomes
 Client sets regular defecation habits
 Client implements a regular exercise program
 Setting priorities
 Continuity of care

Mosby items and derived items © 2005 by Mosby, Inc.

 Implementation: Health Promotion

Promote regular defecation by:

Privacy
 Timing.
Nutrition: high fiber diet
Increase fluid intake to 2L per day.
Exercise
Positioning: squatting position best facilities defecation.
 Teaching about medication. Antidiarrhreal medication or laxative medication.

 Administrating enema: is a solution introduced in the rectum and the large

intestine.

 Decreasing flatulus by avoid gas – producing food, exercise, moving in bed

and ambulation.

 Bowel training program.

 ostomy management by stoma color, size and shape, bleeding and amount
and type of feces
 Enemas:

 Types: tap water, saline, hypertonic, soapsuds, oil

retention, other

 Administration: client preparation, equipment

 You are caring for Mr. Miner, an 82-year-old male who reports experiencing
constipation. He is hard of hearing and has bilateral cataracts. He admits to
using laxatives and/or enemas at least on a biweekly basis. What assessment
questions and teaching strategies, approaches, and tools do you use to enhance
Mr. Miner’s learning and ability to prevent constipation?

 Answer: Mr. Miner is probably experiencing frustration because of the constipation.

Therefore it is important to be empathetic and develop a trusting relationship with
him Assess his dietary habits, fluid intake, activity, and the medications he routinely
takes. You need to build on his knowledge and implement a teaching plan that he can
understand. Ask him if he would like to include his wife in the teaching session.
Reinforce information that he already knows and clarify information that he does not
understand. Make sure that the room is quiet and well lit. Speak to him in a lower
pitch. Speak slowly while pronouncing your words clearly and while facing him.
Ensure that the teaching sheets are written in a print large enough for him to see.
 Teaching About Medications

 The most common categories of medications affecting fecal

elimination are cathartics and laxatives, antidiarrheals, and
antiflatulents.

 Cathartics and Laxatives

 Cathartics are drugs that induce defecation. They can have a strong,
emptying effect. A laxative is mild in comparison to a cathartic, and it
produces soft or liquid stools that are sometimes accompanied by
abdominal cramps.
 Teaching About Medications

 Laxatives are contraindicated in the client who has nausea, cramps, colic,
vomiting, or undiagnosed abdominal pain. Clients need to be informed
about the dangers of laxative use. Continual use of laxatives to encourage
bowel evacuation weakens the bowel’s natural responses to fecal distention,
resulting in chronic constipation.

 To eliminate chronic laxative use, it is usually necessary to teach the client

about dietary fiber, regular exercise, taking sufficient fluids, and
establishing regular defecation habits. In addition, any medication regimen
should be examined to see whether it could cause constipation.