Bowel Elimination: Chapter 39

Bowel Elimination

• Chapter 39 is about bowel elimination

GI Tract/Alimentary Tract

• The large intestine (colon) is about 5 feet long
• The ileocecal valve connects the small and large intestine
• The colon functions as the primary organ for bowel elimination
• The ascending, transverse, and descending portions lead to the sigmoid colon, which contains feces
• The rectum is the last part of the large intestines
• The rectum is empty except immediately before and during defecation

Large Intestine Functions

• The large intestine absorbs water
• The large intestine is where the formation and expulsion of feces occurs

Nervous System Control

• The Autonomic Nervous System (ANS) innervates the muscles of the colon
• The Parasympathetic Nervous System (PNS) stimulates movement
• The Sympathetic Nervous System (SNS) inhibits movement
• Peristalsis involves contractions of the muscles of the colon
• Peristalsis occurs every 3-12 minutes
• Peristalsis continually moves waste products through the intestine

Mass Peristaltic Sweeps

• Mass peristaltic sweeps occur 1-4 times in a 24-hour period
• Mass peristaltic sweeps propel fecal mass forward
• Mass peristaltic sweeps often occur after food has been ingested
• Mass peristaltic sweeps account for the urge to defecate after meals
• About 1/3 to 1/2 of food is excreted in 24 hours with the remainder in the next 24-48 hours

Valsalva Maneuver

• Bearing down increases the pressure in abdominal and thoracic cavities
• Increased pressure results in decreased blood flow to the atria and ventricles, lowering cardiac output
• Once bearing down ceases, the pressure is lessened and a larger than normal amount of blood returns to the heart
• Slowed heart rate and syncope can result
• The Valsalva maneuver is contraindicated in people with certain heart problems/illnesses

Older Adults and Bowel Elimination

• Constipation is often a problem
• Rectal receptors have a decreased response to stretching
• A decreased urge to relieve bowels can occur despite a large amount of stool in the rectum
• Fecal impaction is a hardened mass of stool in the rectum
• Fecal incontinence is involuntary passing of stool
• Older adults may experience slowing of gastrointestinal motility with increased stomach emptying time
• Small, frequent meals is recommended, along with adequate fluid intake
• Discourage laxative use
• Develop a bowel routine and evaluate medication regime
• Decreased muscle tone/incontinence is a consideration with aging
• Assistive devices (raised toilet seat, walker) may be required
• Ensure safety when ambulating (nonskid socks)
• Encourage participation in bowel retraining programs
• Older adults can experience a weakening of intestinal walls with a greater incidence of diverticulitis
• Encourage a high-fiber diet with adequate fluid intake
• Avoid ignoring the urge to have a bowel movement
• Encourage regular exercise

Factors Affecting Elimination Patterns

• When routine changes, feces remains in rectum until defecation reflex is stimulated again
• Water continues to be absorbed by the colon and the stool becomes hard and painful to pass
• Embarrassment can inhibit defecation

Activity and Lifestyle

• Family and sociocultural variables can affect elimination habits
• Feelings about elimination habits should be considered
• Occupation/lifestyles contribute to schedules
• Good health behaviors/modeling assists regular habits
• Anxiety can have an effect on GI motility
• Chronic worriers or people who hold in problems and negative feelings often experience constipation

Food and Fluid

• Type and amount of foods eaten affect elimination
• High-fiber foods (grains/fruits/vegies) increase bulk in fecal matter
• Increased pressure on intestine walls stimulates peristalsis
• Feces moves more quickly allowing less time for water reabsorption
• Food intolerance may alter bowel elimination resulting in diarrhea, gas distention, cramping (lactose)
• Constipating foods include cheese, lean meat, eggs, rice, and pasta
• Laxative effects can come from certain fruits and vegies, bran, chocolate, spicy foods, coffee, and alcohol
• Gas producing foods like onions, cabbage, beans, and cauliflower

Pathology

• Changes in stool characteristics or frequency may be the first signs of disease
• Certain pathologies show specific symptoms
• CF: indicated by greasy, foul-smelling stool
• Changes to habits can also occur with Diverticula, Infection or poisoning

Medications

• Medications may change the color of stool
• Anticoagulants/aspirin: can cause a pink/red/black color
• Iron results in black stool
• Bismuth gives black stools
• Antacids result in a whitish discoloration/speckling
• Antibiotics may cause green-gray stool

Diagnostic Studies

• May require a barium enema
• Barium enema can cause constipation or impaction if it is not eliminated completely after the procedure
• Bowel preparations (Go Lytely) for certain diagnostic studies cause large amounts of watery diarrhea
• Clients should stay close to the bathroom

Stool Specimen Collection

• Have patient void first because study may be inaccurate if stool contains urine
• Stool culture needs to be obtained before giving anti-infectives
• Occult blood is blood hidden in the stool that cannot be seen on examination
• A fecal occult blood testing is used to detect occult blood in the stool

Direct Visualization Studies

• Endoscopy includes EGD, colonoscopy, and sigmoidoscopy
• A long, flexible tube is seen on a screen
• Pincers can be inserted through the tube to collect specimens
• Direct visualization is helpful in diagnosing inflammation, ulcerative and infective diseases, malignant neoplasms and other lesions

Indirect Visualization Studies

• Radiography is used to detect obstructions, strictures, inflammation, tumors, ulcer, lesions, and diagnosing hiatal hernia
• Patients may drink barium sulfate to enhance visualization (upper GI)
• Lower GI tract studies involve barium instilled into colon via rectal tube
• Other methods include MRI, CT, and abdominal ultrasounds

Nursing Actions to Promote Regular Bowel Habits

• Encourage toileting at the patient's usual time each day
• Encourage an upright sitting position
• Privacy by pulling drapes and asking visitors to step out is vital
• Adequate hydration is important- encourage 2000-3000ml water with high fiber diet
• Regular exercise improves GI motility

Who is At Risk for Constipation

• Bedrest
• Decreased mobility
• Taking meds that cause constipation
• Reduced fluids, bulk, or fiber in diet
• Depression
• CNS disease
• Local lesions that cause pain when defecating

Preventing and Treating Constipation

• Laxatives are drugs that induce emptying of the intestine
• Occasional use is not harmful in most people
• Habitual use of laxatives can cause chronic constipation
• Overuse can be a sign of other disease processes such as anorexia nervosa

Diarrhea

• Diarrhea is the passage of more than 3 loose stools a day
• Diarrhea can be a protective response to an irritant in the intestinal tract
• Large amounts of fluid and electrolytes can be lost quickly
• Treatment includes eating bland foods in small portions (no sugary drinks or spicy foods)
• Rule out impaction before treating with anti-diarrheal medication

Dehydration Related to Diarrhea

• Metabolic acidosis can result from loss of bicarbonate
• Monitor for weak and rapid pulse, hypotension, poor skin turgor, and elevated body temperature
• Hypernatremia symptoms are muscle weakness, lethargy, and a swollen red tongue
• Hypokalemia can cause leg cramps, muscle weakness, N/V, and dysrhythmias
• Replace fluids and electrolytes

Fecal Incontinence

• Fecal incontinence is the inability to control defecation
• Provide perineal care after each stool
• Apply a moisture barrier
• A fecal incontinence pouch/system can be prescribed to collect stool and prevent contact with the skin

Bowel Diversions

• Ostomy involves a surgically formed opening from the inside of an organ to the outside
• Intestinal mucosa is brought out to the abdominal wall
• A stoma (opening of ostomy attached to skin) is formed by suturing the mucosa to the skin

Types of Diversions

• Ileostomy allows liquid fecal content from the ileum of the small intestine to be eliminated through the stoma
• Colostomy permits formed feces in the colon to exit through the stoma
• May be either temporary or permanent
• Reconnection is done after the bowel rests (inflammation/infection)
• Permanent colostomies are usually due to cancer or debilitating intestinal diseases.

Ostomy Care

• Physical and psychological support are needed before and after surgery
• Keep patient as free of odors as possible
• Inspect stoma regularly making sure it is dark pink to red and moist
• Pale (anemia) or dark purple/blue (compromised circulation) are signs of concern
• Stoma should protrude ½-1 inch from the abdomen surface
• Keep skin around the stoma site clean and dry
• Encourage patient to participate in care

Ileostomies

• Food blockages, especially with high fiber foods can occur causing cramping, distention, and foul smelling output
• Adequate fluid intake is important to avoid dehydration and electrolyte imbalances (high output of K+ and Na+)
• Dark green vegies, yogurt, buttermilk, parsley, and cranberry juice can reduce odor

Ostomy Appliances

• Ostomy appliances protect skin, collect fecal discharge, and control odor
• An adhesive barrier protects the surrounding skin from stoma output
• Appliances may be drainable or closed
• Drainable pouches should be emptied when 1/3 full and replace every 3-7 days
• Non-drainable pouches should be emptied when ¹½ full

Surgery and Bowel Elimination

• Manipulation of the bowels during surgery inhibits peristalsis
• This can lead to a post-operative paralytic ileus
• Temporary stoppage of peristalsis for 3-5 days
• Food and oral fluids are withheld initially
• Opioids often given for pain makes paralysis worse
• If it continues, distention and symptoms of acute obstruction occur, needing surgical intervention
• Inhaled anesthetic agents can inhibit peristalsis by blocking impulses from the parasympathetic nervous system to the intestinal musculature