Bowel Elimination: Observations and Factors

Bowel Elimination Basics

• Normal stool characteristics include being brown, soft, formed, moist, and shaped like the rectum.
• Normal bowel movement patterns vary in time and frequency from person to person.
• For most people this is every day, or every 2 to 3 days.
• Constipation is not defined by the number of bowel movements but by characteristics of the stool.

Observations of Bowel Movements

• Observing stool before disposal is important.
• Ask a nurse to observe any stools you suspect may be abnormal.
• Confirm that the nurse doesn't need to collect stools before disposal.
• A Bristol Stool Chart is used to describe stool types in a consistent way.
• When observing and reporting bowel movements, note colour, amount, pain or discomfort, frequency of defecation, consistency, shape, and size.

Factors Affecting Bowel Movements

• Factors affecting bowel movements include privacy, personal habits, diet, fluid intake, activity level, medications, aging, and disabilities.

Comfort and Safety During Defecation

• Follow standard practices for client care.
• Assist clients to the toilet or commode, or provide a bedpan promptly when requested.
• Promote privacy by assisting clients to the bathroom and closing doors, curtains and shades.
• Position the commode and client correctly, ensuring skin is not pinched.
• Make sure the bedpan is warm and cover the client for warmth and privacy.
• Allow the client enough time for defecation.
• Keep the call bell and toilet tissue within reach.
• Stay nearby if the client is weak or unsteady.
• Provide perineal care and dispose of stools promptly
• Assist with hand washing and follow the care plan for fecal incontinence.

Constipation

• Constipation is the passage of a hard, dry stool with less frequency than normal.
• Constipation arises when feces moves slowly through the bowel, leading to excessive water absorption and harder stools.
• Constipation causes include a low-fibre diet, ignoring the urge to defecate, decreased fluid intake, inactivity, medications, aging, and certain diseases.
• Hemorrhoids, swollen veins in the anal canal, are often a result of constipation and straining.
• Prevention or relief of constipation includes dietary changes, increased fluid intake, activity, medications, and enemas.
• Constipation prevention is easier than treating it.

Fecal Impaction

• Fecal impaction is the prolonged retention and build-up of feces in the rectum.
• Fecal impaction results if constipation is not relieved.
• A digital (finger) exam can be done by a doctor or nurse to check for an impaction.
• Sometimes the fecal mass is removed manually with a gloved finger in a procedure is called digital removal of an impaction.
• It can be very dangerous
• Possible signs include severe abdominal discomfort, abdominal swelling, cramping, feeling of fullness or pain in the rectum, nausea or vomiting, fever, increased urge or decreased ability to urinate, and liquid feces seeping from the anus.
• Report possible fecal impaction signs to the nurse.

Diarrhea

• Diarrhea is the frequent passage of liquid stools.
• Liquid is not absorbed because feces move through the intestines too rapidly.
• Management includes adjusting diet and medications to reduce peristalsis.
• You need to assist with elimination needs and dispose of stools promptly.
• Giving very good skin care due to the high risk of skin breakdown with loose stools.
• Fluid lost through diarrhea should be replaced since dehydration can cause death quickly, especially in elderly or very sick patients.

Fecal Incontinence

• Fecal incontinence is the inability to control the passage of feces and gas through the anus.
• Fecal incontinence affects the client emotionally.
• Resistance to care is a common problem, making washing and changing the client difficult.
• Follow the client’s care plan.

Flatulence

• Gas or air passed through the anus is called flatus.
• Flatulence is the excessive formation of gas or air in the stomach and intestines.
• The Intestines distend if flatus is not expelled.
• Strategies for helping to expel flatus include exercise, walking, moving in bed, and the left side-lying position.

Bowel Training

• Bowel training aims to gain control of bowel movements and develop a regular pattern of elimination.
• Factors promoting elimination are part of the care plan and the bowel training program.

Enemas

• An enema involves introducing fluid into the rectum and lower colon.
• Enemas are ordered by doctors to remove feces, relieve constipation, fecal impaction, or flatulence, and clean the bowel before surgeries and diagnostic procedures.
• Commercial enemas stimulate and distend the rectum to cause defecation.
• The solution used is usually administered at room temperature.
• This procedure is a delegated act.

Rectal Tubes

• A tube is inserted into the rectum to relieve flatulence and intestinal distension.
• Rectal tubes are usually inserted about 10 cm and left in place for 20 to 30 minutes.
• Rectal tubes can be re-inserted every 2 to 3 hours.

Clients with an Ostomy

• An ostomy is a surgically created opening and the opening is called a stoma.
• The client wears a pouch over the stoma to collect stools and flatus.
• A colostomy is a surgically created opening between the colon and the abdominal wall.
• With a permanent colostomy, the diseased part of the colon is removed.
• A temporary colostomy allows the diseased or injured bowel time to heal.
• The colostomy site depends on the site of disease or injury.
• An ileostomy is a surgically created opening between the ileum and the abdominal wall, the entire colon is removed.
• Liquid stools drain constantly because very little water is absorbed.

Ostomy Pouches

• The pouch has an adhesive backing that is applied to the skin so it has to be changed every 3 to 7 days, or when it leaks.
• Some pouches have a drain at the bottom that opens and closes.
• Sometimes pouches are secured to ostomy belts, and never flush the pouches down the toilet.
• The pouch is emptied when stools are present.

Stool Specimens

• Stools are checked and studied for blood, fat, microbes, worms, and other abnormal contents.
• The stool specimen must not be contaminated with urine and some tests require a warm stool.

Testing Stools for Blood

• Stools may contain blood for many reasons.
• Red bloody stools indicate bleeding in the lower bowels.
• Black, tarry stools (melena) indicate bleeding in the stomach or upper gastro-intestinal tract.
• Occult blood is blood that is present but cannot be seen because it occurs in very small amounts.
• Occult blood is tested for with special equipment.

Key Points

• Each client will have different patterns and frequency of bowel movements.
• Report any changes in your client's normal routine, colour, amount, odour, shape, size, or frequency of stools.
• Follow Standard Practices when in contact with feces which may contain pathogens.
• Factors such as privacy, personal habits, diet, fluids, activity, medications, aging, and disability, can affect bowel movements.
• Untreated constipation can lead to fecal impaction; if fecal impaction is not treated, it can lead to a bowel obstruction, which is a very serious condition.
• It is important to replace fluids lost through diarrhea, vomiting, or both otherwise dehydration can result.
• You play a very important role, as a support worker, since you most closely observe how much fluid the client is losing, therefore, accurate reporting and recording is very important so that your supervisor can adjust the care plan to replace the fluids lost.
• Bowel training can help your client gain control of bowel movements and develop a regular pattern of elimination, which will prevent fecal impaction, constipation, and fecal incontinence.
• Administering enemas is a delegated act, which you must be taught by a nurse.
• When dealing with all aspects of bowel elimination with your clients, remember the DIPPS principles because it can be very embarrassing for them.