Bowel Elimination

• Bowel Elimination

Learning Objectives

• Describe the process of defecation.
• Name components of a bowel elimination assessment.
• List common alterations in bowel elimination.
• Name types of constipation.
• Identify measures within the scope of nursing practice for treating constipation.
• Identify interventions that promote bowel elimination when it does not occur naturally.
• Name categories of enema administration.
• List common solutions used in a cleansing enema.
• Explain the purpose of an oil retention enema.
• Describe nursing activities involved in ostomy care.

Gerontologic Considerations

• Age-related changes like loss of elasticity in intestinal walls and slower GI motility, predispose older adults to constipation.
• Other factors are adverse medication effects, diminished physical activity, and low fiber diets.
• Teach older adults about healthier alternatives to laxatives/enemas, such as increasing dietary fiber.
• "Power pudding" is a natural laxative made of wheat bran, applesauce, and prune juice; start with 1 tbsp per day and increase until ease of bowel movement is achieved.
• Older adults may have benign lesions (hemorrhoids/polyps) in the lower bowel that interfere with stool passage.
• Gentle manipulation should be used if digital removal of impaction is required to prevent bleeding and tissue trauma.
• Diarrhea can easily lead to dehydration and electrolyte imbalances in older adults.
• Musculoskeletal/neurologic disorders may interfere with ostomy care/colostomy irrigations.
• Occupational/enterostomal therapists, wound, ostomy, and continence nurses can offer self-care suggestions.

Defecation

• Defecation is the act of expelling feces/stool from the body.
• The GI tract, especially the large intestine/colon/bowel, must function in a coordinated manner.
• 10% or approximately a pint to a quart of water is removed from remnants of digestion, causing bowel contents to become a consolidated mass of residue before being eliminated.
• Peristalsis is the rhythmic contractions of intestinal smooth muscle that facilitate defecation.
• It moves fiber, water, and nutritional wastes toward the rectum.
• Peristalsis becomes more active during eating, termed the gastrocolic reflex, which usually precedes defecation.
• The accelerated wave-like movements propel stool forward, packing it within the rectum; the person feels the urge to defecate as the rectum distends.
• Stool is released when the anal sphincters relax.
• Performing the Valsalva maneuver (closing the glottis and contracting pelvic and abdominal muscles) facilitates process.
• Several dietary, physical, social, and emotional factors influence bowel's mechanical function.

Assessment of Bowel Elimination

• A comprehensive assessment involves collecting data about the client's elimination patterns/bowel habits, and the actual characteristics of the feces.

Elimination Patterns

• Determine the client's usual patterns to assess bowel elimination.
• These usual patterns include frequency of elimination, effort required to expel stool, and elimination aids.
• Adults should:
  • Identify their own patterns of bowel regularity (3x/day to 3x/week).
  • Include daily exercise.
  • Eat high-fiber foods on a regular basis.
  • Drink 8-10 glasses of liquid a day, unless contraindicated.
  • Respond to the urge to defecate ASAP.

Nutrition Notes

• Fiber is found only in plant foods, most abundantly in wheat bran, whole grains, dried peas/beans, and skins/seeds of fresh fruits/vegetables.
• Eating a variety of high-fiber foods is recommended.
• Most Americans consume approximately half the recommended amount of fiber daily.
• Adequate fluid is needed for maximum benefit.

Stool Characteristics

• Obtain objective stool data.
• Inspect stool or ask the client to describe appearance. Information includes stool color, odor, consistency, shape, and unusual components.
• Any change in bowel elimination that does not respond to simple dietary/lifestyle changes requires further investigation.

Characteristics of stool: Normal vs Abnormal

• Color: Normal is brown, abnormal is black, clay colored, yellow, or green.
• Odor: Normal is aromatic, abnormal is foul.
• Consistency: Normal is soft and formed, abnormal is soft/bulky, hard/dry, watery, or paste like.
• Shape: Normal is round and full, abnormal is unformed, flat, or pencil shaped.
• Components: Normal is undigested fiber, abnormal is worms, blood, pus, or mucus.
• Save abnormal stool samples in a covered container for the physician's inspection.
• Nurses may independently perform screening tests on stool samples, such as those that determine the presence of blood.

Stool for Occult Blood

• Collect stool within a toilet liner or bedpan to prevent mixing with water/urine.
• Put on gloves and use an applicator stick to collect specimen to reduce microorganism transmission.
• Take a sample from the center area of the stool for more diagnostic value.
• Apply a thin smear of stool onto the test area supplied with the kit to ensure thorough contact with the chemical reagent.
• Cover entire test space to ensure more accurate findings.
• Place two drops of the chemical reagent onto test space to promote a reaction.
• Wait for 60 seconds for chemical interaction with stool.
• Observe for a blue color that indicates blood.
• Report the results to the physician.

Testing for Colorectal Disorders

• The incidence of colorectal cancer increases with age; it is the third most common cancer diagnosed in the US and the second most common cause of death from cancer
• The death rate from colorectal cancer has decreased in the past several decades due to screening and early removal of polyps.

Fecal Occult Blood Test

• Fecal occult blood test (FOBT) is a self-collected screening test from three separate stools and detects heme.
• An FOBT requires drug and dietary restrictions before stool collection.

Preparation for Collecting a Fecal Occult Blood Test

• Stop taking NSAIDs for 7 days before self-collecting stool.
• Avoid taking more than 250 mg of vitamin C or consuming citrus fruits/juices for 3 days before beginning test.
• Eat a high-fiber diet containing whole grains; cook vegetables and fruits well.
• Refrain from eating red meat for 3 days before testing; poultry and fish are allowed.
• Do not eat raw turnips, radishes, broccoli, beets, carrots, cauliflower, cucumbers, or mushrooms for 2-3 days before the test.

Fecal Immunochemical Test

• A fecal immunochemical test (FIT) uses antibodies to detect blood in the stool and is done once a year, like an FOBT.
• The FIT is more specific than an FOBT because it uses antibodies to detect globin, a protein removed from heme and present exclusively in the lower intestine.
• The Advantages of the FIT test are there are no dietary or medication restrictions; only one or two specimens need to be collected; and it has a high rate of specificity for colorectal cancer.
• Collection of the specimen and application to a test card are similar to FOBT.

Stool DNA Test

• The FIT-DNA test/stool DNA test combines FIT with a test that detects altered DNA in the stool.
• The Entire bowel movement is collected, and it is checked for cancer cells.
• Clinical studies have shown a 92% detection of colon cancers as well as precancerous conditions.
• Collection does not require any preparation, diet, or medication changes.

Endoscopic Examinations

• Older asymptomatic adults are advised to have regular colonoscopy examinations (a visual inspection of the interior colon using a flexible lighted endoscope), which is the most accurate test for detecting colorectal cancer.
• Colonoscopy examinations should begin at 50 and every 10 years thereafter.
• Schedule flexible sigmoidoscopy visual endoscopic inspection limited to the sigmoid portion of the large intestine, every 5 to 10 years
• Other alternatives recommended by the American Cancer Society include: a barium enema every 5 years or a colonography

Common Alterations in Bowel Elimination

• Clients often have temporary/chronic problems with bowel elimination and intestinal function, such as constipation, fecal impaction, flatulence, diarrhea, and fecal incontinence.
• By analyzing assessment findings, nurses may help physicians diagnose a medical problem or use conclusions to identify alterations within the independent scope of nursing management.
• If these conditions are a component of a serious disorder, nurses and physicians collaborate to address them.

Constipation

• Constipation is an elimination problem characterized by dry, hard stool that is difficult to pass.
• Accompanying signs and symptoms:
  • Reports of abdominal fullness or bloating.
  • Abdominal distention.
  • Reports of rectal fullness or pressure.
  • Pain with defecation.
  • Decreased frequency of bowel movements.
  • Inability to pass stool.
  • Changes in stool characteristics, such as oozing, liquid stool, or hard, small stool.
• Classified into primary, secondary, and iatrogenic types.
• The infrequent elimination of stool does not necessarily indicate constipation.

Nutrition Notes

• Incidence of constipation is high among those whose dietary habits lack adequate fiber.
• Dietary fiber attracts water within the bowel, resulting in bulkier stool that is more quickly/easily eliminated.
• Fiber intake should be increased gradually to improve tolerance to a high fiber intake
• Some researchers speculate that a shortened transit time protects against serious medical disorders.

Pharmacologic Considerations

• Always ask about medications when clients experience constipation, diarrhea, or loss of appetite.
• GI distress is one of the most frequent side effects with many drugs.

Primary Constipation

• Primary/simple constipation is well within the treatment domain of nurses. It results from lifestyle factors.
• Examples are inactivity, inadequate fiber intake, insufficient fluid intake, or ignoring the urge to defecate.

Secondary Constipation

• Secondary constipation is a consequence of a pathologic disorder, such as a partial bowel obstruction.
• Usually resolves when primary cause is treated.

Pharmacologic Considerations

• Avoid mineral oil to relieve constipation as it interferes with absorption of fat-soluble vitamins (A, D, E, and K).

latrogenic Constipation

• Iatrogenic constipation is a consequence of other medical treatments.
• Prolonged use of narcotic analgesia slows peristalsis, delaying transit time.

Concept Mastery Alert

• Encourage the client to stop laxative misuse.
• Laxatives lead to dependence with long-term use.

Pharmacologic Considerations in older adults

• Laxative misuse is common among older adults with changes in bowel routine, so assess.
• Use bulk-forming products containing psyllium/polycarbophil.

Fecal Impaction

• Occurs when a large, hardened mass of stool interferes with defecation, making it impossible for the client to pass feces voluntarily.
• Results from unrelieved constipation, retained barium from an intestinal X-ray, dehydration, and weakness of abdominal muscles.
• Clients with fecal impaction report frequent desire to defecate but inability to do so.
• Liquid stool may be misinterpreted as diarrhea.
• Insert a lubricated, gloved finger into rectum to determine if fecal impaction is present.

Flatulence

• Flatulence/flatus is an excessive accumulation of intestinal gas (from swallowing air while eating or sluggish peristalsis).
• Gas forms as a byproduct of bacterial fermentation in the bowel.
• The Gas-producing vegetables are cabbage, cucumbers, and onions.
• Eating beans creates intestinal gas because humans lack an enzyme to completely digest its particular form of complex carbohydrate.
• Flatus may be expelled rectally to reduce accumulation/distention.

Diarrhea

• Diarrhea is the urgent passage of watery stool and is commonly accompanied by abdominal cramping.
• Simple diarrhea begins suddenly and lasts a short period.
• Associated signs/symptoms include nausea, vomiting, blood/mucus in the stools.

Nutrition Notes

• Probiotics are beneficial bacteria that colonize within the bowel, making bowel contents more acidic and creating a hostile environment for unhealthy bacteria.
• Usually, diarrhea is a means of eliminating an irritating substance.
• ItMay also result from emotional stress, dietary indiscretions, laxative misuse, or bowel disorders.
• Resting the bowel temporarily may relieve simple diarrhea, avoiding solid foods for 12-24 hours.
• Resume eating with bland foods and those low in residue e.g. bananas, applesauce, and cottage cheese.

Fecal Incontinence

• Fecal incontinence is the inability to control the elimination of stool.
• Incontinence results from neurologic changes that impair muscle activity, sensation, or thought processes.
• Incontinence may occur when a person cannot reach a toilet in time to eliminate, such as after taking a harsh laxative.

Measures to promote bowel elimination

• Nurses use interventions, such as inserting suppositories and administering enemas.

Inserting a Rectal Suppository

• A suppository (oval/cone shaped mass that melts at body temperature) is inserted into a body cavity, such as the rectum.
• The most common reason is to deliver a drug that will promote expulsion of feces.

Client and Family Teaching for Managing Fecal Incontinence

• Teach the client and the family to:
  • Eat regularly and nutritiously.
  • Monitor the pattern of incontinence to determine whether it occurs at a similar time each day.
  • Sit on the toilet or bedside commode before the time elimination tends to occur.
  • Consult the physician about inserting a suppository or administering an enema every 2 to 3 days to establish a pattern for bowel elimination.
  • Use moisture-proof undergarments and absorbent pads to protect clothing and bed linens.
  • Teach caregivers to not blame the client for incontinence and avoid anything that connotes diapering.

Pharmacologic Considerations

• Suppositories are used for both systemic and local effects.
  • Antipyretics are frequently used rectally when fever reduction cannot be managed orally.
  • Constipation can be relieved locally in the rectum when used to soften or stimulate defecation.
  • Medications released from the suppository can have local or systemic effects.

Administering an Enema

• An enema introduces a solution into the rectum. Nurses give enemas to:
  • Cleanse the lower bowel (most common reason).
  • Soften feces.
  • Expel flatus.
  • Soothe irritated mucous membranes.
  • Outline the colon during diagnostic X-rays.
  • Treat worm and parasite infestations.

Cleansing Enemas

• Cleansing enemas use different types of solutions to remove feces from the rectum. Defecation usually occurs within 5-15 minutes after administration.
• Large-volume cleansing enemas may create discomfort. Administer cautiously to clients with intestinal disorders because it may rupture the bowel or cause other secondary complications.
• Commercially prepared disposable administration sets have become the method of choice for cleansing the bowel.

Tap Water and Normal Saline Enemas

• Tap water and normal saline solutions are nonirritating effects.
• Tap water is hypotonic and its fluid can be absorbed through the bowel.

Soap Solution Enemas

• A soap solution enema is a mixture of water and soap.
• Disposable enema kits contain an envelope of soap, mixed with up to 1 quart (1,000mL) of water.
• Soap causes chemical irritation of mucous membranes.
• Adding too much soap or using strong soap can potentiate the irritating effect.

Hypertonic Saline Enemas

• A hypertonic saline (sodium phosphate) enema draws fluid from body tissues into the bowel.
• Increases the fluid volume in the intestine beyond what was originally instilled.
• The concentrated solution also acts as a local irritant on the mucous membranes.
• Hypertonic enema solutions are available in commercially prepared disposable containers holding approximately 4 oz (120 mL) of solution.

Retention Enemas

• A retention enema uses a solution held within the large intestine for a specified period, usually at least 30 minutes.
• An oil retention enema fluids instilled is mineral, cottonseed, or olive oil. Lubricate and soften the stool, so it can be expelled more easily.

Administering a Hypertonic Enema Solution

• Warm the container of solution if it is cold to promote comfort.
• Assist the client into a Sims position or use a knee-chest position to promote gravity distribution of solution.
• Wash hands or use an alcohol-based hand rub and put on gloves to reduce microorganism transmission
• Remove the cover from the lubricated tip to. facilitate administration.
• Cover the tip with additional lubricant to ease insertion.
• Invert the container and compress the fluid toward the enema tip . This step causes air in the container to rise toward the upper end.
• Insert the full length of the tip within the rectum . This positions the tip at a level that promotes effectiveness.
• Apply gentle, steady pressure on the solution container for 1 to 2 minutes or until the solution has been completely administered. This method instills a steady stream of solution.
• Encourage the client to retain the solution for 5 to 15 minutes.
• This duration promotes effectiveness.
• Clean the client and position for comfort to demonstrate concern for the client's well-being
• Discard the container, remove gloves, and perform hand hygiene measures to follow the principles of medical asepsis

Ostomy Care

• Client with an ostomy (surgically created opening to the bowel/structure) requires additional care to promote bowel elimination.
• Examples of intestinal ostomies are an ileostomy (surgically created opening to the ileum) and a colostomy (surgically created opening to a portion of the colon).
• Materials enter and exit through a stoma (the entrance to the opening).

Nutrition Notes

• The risk of fluid/electrolyte imbalances increases as the length of the remaining colon decreases.
• Clients with ileostomies are encouraged to consume 8-10 glasses of fluid daily to maintain urine output/reduce risk of renal calculi. Excessive fluids are excreted through the kidneys, not the stoma.
• Because ileostomies are placed before the terminal ileum where vitamin B12 is absorbed, nasal sprays/parenteral injections of B12 are necessary to prevent vitamin B12 deficiency anemia.

Providing Peristomal Care

• Preventing skin breakdown is a major challenge in ostomy care.
• Enzymes in the stool cause excoriation (chemical injury of the skin). Washing the stoma and the surrounding skin with mild soap and water/patting it dry can preserve skin integrity.

Draining a Continent lleostomy

• A continent ostomy (surgical opening that controls drainage of liquid stool/urine by siphoning it from internal reservoir).
• This type of ostomy requires no appliance.
• The client must drain accumulating liquid stool/urine approximately every 4-6 hours.

Irrigating a Colostomy

• Clients with colostomies whose stool is more solid sometimes require the instillation of fluid to promote elimination. The colostomy irrigation involves instilling the solution through the stoma into the colon and administering an enema.

Nursing Implications

• While assessing/caring for clients with altered bowel elimination, nurse may identify 1/more of the following nursing diagnoses:
  • Constipation.
  • Constipation risk.
  • Perceived constipation.
  • Diarrhea.
  • Fecal impaction.
  • Bowel incontinence.
  • Toileting activity of daily living deficit.
  • Situational low self-esteem.

Nursing Care Plan

• Constipation is defined as infrequent, irregular, or difficult evacuation of the bowels.