Bowel Elimination: Chapter 39

• Bowel elimination is detailed in Chapter 39.

GI Tract/Alimentary Tract

• The large intestine (colon) is approximately 5 feet long
• The ileocecal valve connects the small and large intestines
• The colon is the main organ responsible for bowel elimination
• The ascending, transverse, and descending portions of the colon lead to the sigmoid colon, which contains feces
• The rectum is the final section of the large intestines
• The rectum remains empty except immediately before and during defecation

Large Intestine Functions

• Absorption of water
• Formation of feces
• Expulsion of feces from the body

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, which involves contractions of the colon muscles, occurs every 3-12 minutes
• Peristalsis continually moves waste products through the intestine

Mass Peristaltic Sweeps

• Occur 1-4 times in a 24-hour period
• Mass peristaltic sweeps propels fecal mass forward
• Mass peristaltic sweeps often occurs after food ingestion
• Accounts for the urge to defecate after meals
• 1/3-1/2 of food is excreted in 24 hours, with the remainder excreted in the next 24-48 hours

Valsalva Maneuver

• Bearing down increases pressure in the abdominal and thoracic cavities
• This results in decreased blood flow to the atria and ventricles, lowering cardiac output
• Once bearing down stops, the pressure lessens, and a larger amount of blood returns to the heart
• The Valsalva Maneuver can cause the heart rate to slow and may cause syncope
• Valsalva Maneuver is is contraindicated in people with certain heart problems/illnesses

Older Adults

• Constipation is often a problem
• Rectal receptors have a decreased response to stretching
• This can lead to a decreased urge to relieve bowels, even with a large amount of stool in the rectum
• Fecal impaction is a hardened mass of stool in the rectum
• Fecal incontinence is the involuntary passing of stool

Older Adults: Gastrointestinal Motility

• Older adults experience slowing of gastrointestinal motility with increased stomach emptying time
• Small, frequent meals are recommended
• Adequate fluid intake will help with bowel movements
• Discourage laxative use
• Develop a bowel routine to help regulate bowel movements
• Evaluate medication regime

Older Adults: Muscle Tone

• Decreased muscle tone or incontinence is common
• Use assistive devices, such as raised toilet seats or walkers
• Ensure safety when ambulating with nonskid socks
• Encourage participation in bowel retraining programs

Older Adults: Intestinal Walls

• Weakening of intestinal walls with a greater incidence of diverticulitis is common
• A high-fiber diet with adequate fluid intake will help with bowel movements
• Older adilts should be thought to not ignore the urge to have a bowel movement
• Regular exercise will assist in bowel motion

Elimination Patterns

• Most people have a routine
• If altered, feces remains in the rectum until the defecation reflex is stimulated
• Water continues to be absorbed by the colon, stool becomes hard and painful to pass
• Embarrassment can inhibit defecation

Activity and Lifestyle

• Family and sociocultural variables can affect elimination habits
• If elimination is perceived as "dirty" this can effect bowel habits
• Occupation and lifestyles contributes to schedules
• Good health behaviors and modeling is benefical
• Anxiety can affect 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
• Increasing pressure on intestine walls stimulates peristalsis
• Feces move more quickly, allowing less time for water reabsorption

Food and Fluids: Alterations

• Food intolerance may alter bowel elimination causing diarrhea, gas distention, cramping (lactose)
• Cheese, lean meat, eggs, rice, and pasta are constipating foods
• Certain fruits, vegies, bran, chocolate, spicy foods, coffee, and alcohol have laxative effects
• Onions, cabbage, beans, and cauliflower are considered gas producing foods

Pathologic Conditions

• May change a person’s usual bowel elimination habits
• Changes in stool characteristics or frequency may be one of the first signs of disease
• In CF, greasy, foul-smelling stool is common
• Diverticula, infection and poisoning will all effect the GI tract

Look of Stool: Medications

• Anticoagulants/aspirin can cause pink, red, or black colored stool
• Iron can cause black stools
• Bismuth can cause black stools
• Antacids can cause whitish discoloration/speckling
• Antibiotics can cause green-gray stools

Diagnostic Studies

• May require a barium enema
• This can cause constipation or impaction if its not eliminated completely after the procedure
• Bowel preparations, such as GoLytely, for studies, cause large amounts of watery diarrhea
• Clients should stay close to the bathroom

Diagnostic Studies: Stool

• Stool specimen collection requires voiding first to prevent urine contamination
• Stool culture ensures not to give anti-infectives beforehand
• Occult blood is blood hidden in the stool that cannot be seen on examination
• Fecal occult blood testing detects occult blood in stool

Direct Visualization Studies

• Including Endoscopy, EGD, colonoscopy, and sigmoidoscopy
• These studies use a long, flexible tube that is seen on a screen
• Pincers can be inserted through the tube to collect specimens
• 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- barium instilled into colon via rectal tube is more likely to be used
• MRI, CT, and abdomenal ultrasounds are typically used

Regular Bowel Habits

• Encourage toileting at consistent times each day is best
• Clients should be position sitting upright if possible. Raise the HOB if using a bedpan
• Provide privacy
• Nutrition that consist of 2000-3000ml water with high fiber diet is optimal
• Exercise can improve GI motility

Risk Factors for Constipation

• Bedrest
• Decreased mobility
• Taking medications that cause constipation
• Reduced fluids, bulk, or fiber in diet
• Depressed
• 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

• Passage of more than 3 loose stools a day
• Can be a protective response to an irritant in the intestinal tract
• Large amounts of fluid and electrolytes can be lost quickly
• Eat bland foods in small portions (no sugary drinks or spicy foods)
• A leakage of liquid stool around an impaction can make it seem like a patient has diharrhea

Diarrhea Dehydration

• Metabolic acidosis from loss of bicarbonate is a concern
• Monitor for weak, rapid pulse, hypotension, poor skin turgor, and elevated body temperature
• Muscle weakness, lethargy, and a swollen red tongue are signs of hypernatremia
• Hypokalemia shows signs of leg cramps, muscle weakness, N/V, and dysrhythmias
• Replace fluids and electrolytes

Fecal Incontinence

• Characterized by Inability to control defecation
• Provide perineal care after each stool
• Apply a moisture barrier
• Can prescribe a fecal incontinence pouch/system to collect stool and prevent contact with the skin

Bowel Diversions

• An ostomy is 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

Bowel Diversions: Types

• An ileostomy allows liquid fecal content from the ileum of the small intestine to be eliminated through the stoma

• A colostomy permits formed feces in the colon to exit through the stoma

• Can be either temporary or permanent

• Reconnection is done after the bowel rests, such as after inflammation/infection

• Permanent colostomies are usually due to cancer or debilitating intestinal diseases

Ostomy Care

• Provide physical and psychological support before and after surgery
• Keep patient as free of odors as possible
• Inspect stoma regularly, it should be dark pink to red and moist
• Paleness suggests anemia, dark purple/blue suggests compromised circulation
• It should protrude ½-1 inch from the abdomen surface
• Keep skin around stoma site clean and dry
• Encourage patient to participate in care

Ileostomies consideration

• Can develop food blockages, especially with high-fiber foods (cramping, distention, foul-smelling output)
• Adequate fluid intake prevents dehydration and electrolyte imbalances (high output of K+ and Na+)
• Dark green vegies, yogurt, buttermilk, parsley, and cranberry juice helps to reduce odor

Ostomy appliances

• Protects skin, collects fecal discharge, and controls odor
• It has an adhesive barrier hat protects the surrounding skin from stoma output
• Drainable or closed systems
• Drainable appliances should be when 1/3 full and replace every 3-7 days or when the seal comes away from the skin
• Non-drainable appliances should be emptied when ¹⁄₂ full

Surgery: General Information

• Manipulation of the bowels during surgery inhibits peristalsis
• Can lead to a post-operative paralytic ileus
• A temporary stoppage of peristalsis can be expected for 3-5 days
• Food and oral fluids withheld
• Avoid Opioids given for pain, makes things worse
• If 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