Bowel Elimination: Types, Assessments, Interventions

Bowel Elimination

• Defecation involves expelling stool from the body

Bowel Elimination Assessment Components

• Elimination patterns include frequency and effort to expel stool, plus any elimination aids
• Stool characteristics are assessed by inspecting stool or asking the client about color, odor, consistency, shape, and unusual components
• Testing is used for colorectal disorders

Common Alterations in Bowel Elimination

• Constipation
• Fecal impaction
• Flatulence
• Diarrhea
• Fecal incontinence

Types of Constipation

• Primary
• Secondary
• Iatrogenic
• Pseudoconstipation

Interventions for Bowel Elimination

• Utilizing suppositories
• Administering enemas

Cleansing Enemas

• Common solutions include tap water, normal saline, soap and water, hypertonic saline, or mineral, olive, or cottonseed oil

Oil Retention Enema

• The purpose is to lubricate and soften the stool for easier expulsion

Enemas

• Enemas are quick and effective for removing feces or flatus, or instilling nutrients or medication
• Enema administration involves instilling a solution into the rectum and sigmoid colon to stimulate peristalsis and defecation
• Peristalsis is the involuntary constriction and relaxation of intestinal muscles, creating wave-like movements to push contents forward

Types of Enemas

• Cleansing
• Oil retention
• Return-flow
• Medicated

Enema Solutions

• Tap water (hypotonic)
• Normal saline
• Soap suds
• Hypertonic
• Carminative
• Medicated
• Oil

Enema Administration

• Sims position (left side-lying with right knee flexed) allows the solution to flow downward by gravity along the curve of the sigmoid colon and rectum, improving effectiveness
• Insert the enema tube into the rectum with the tip pointed in the direction of the umbilicus

Enema Tube Insertion Length by Age

• Adult: 3 to 4 inches
• Adolescent: 3 to 4 inches
• Child: 2 to 3 inches
• Infant: 1 to 1.5 inches
• If resistance or pain occurs, stop, have the client take a deep breath, and instill a small amount of fluid to relax the sphincter or soften stool

Special Considerations for Enemas

• For presurgery clients, repeat the enema until the fluid is clear, with a limit of 3 enemas to avoid fluid or electrolyte imbalances

Cleansing Enemas

• Used for constipation, can be large or small volume, and typically take 10 to 15 minutes to work

0.9% Sodium Chloride (Normal Saline) Enema

• Isotonic solution doesn't shift fluids or electrolytes, reducing imbalance risk. Only normal saline enemas should be used on children and infants.

Tap Water/ Hypotonic Solutions Enema

• It exerts osmotic pressure, causing water to move into the interstitial space. There is a risk of water toxicity or circulatory overload if repeated

Sodium Phosphate/ Hypertonic Solutions Enema

• Pulls fluid from interstitial space into the colon and should be avoided in young infants and dehydrated clients

Small-Volume Cleansing Enemas

• Small-volume cleansing enemas or oil-retention enemas with hypertonic solutions draw fluids into the colon from interstitial spaces to stimulate peristalsis. Administer at room temperature, taking effect within 5 to 10 minutes

Small-Volume Enema Supplies

• Plastic container with prefilled solution with rectal tip attached
• Water-soluble lubricant (if not pre-lubricated)
• Gloves

Large-Volume Enemas

• Given to expel intestinal gas, instilling small increments (100 to 200mL) to stimulate peristalsis, then lowering the container to allow the solution to flow back, increasing peristalsis and relieving flatus

Large-Volume Supplies

• Container or bag of fluid with rectal tube attached
• Solution to be instilled
• Water-soluble lubricant
• Gloves
• IV pole to hang container/bag

Large Volume Guidelines

• Infant: 150 to 250mL
• Toddler: 250 to 350mL
• Child: 300 to 500mL
• Adolescent: 500 to 750mL
• Adult: 750 to 1,000mL

Soapsud Enema

• Stimulate peristalsis through intestinal irritation; use pure castile soap, mixing 5mL of soapsuds to 1 L of solution. Harsh soaps can cause bowel inflammation and should be used cautiously in pregnant clients and older adults due to risk of electrolyte imbalance and intestinal damage

Oil Retention Enema

• Slowly softens hardened stool and relieves constipation symptoms. Oil is absorbed by feces at room temperature, making them softer and easier to pass. Instruct patient to retain for 30 minutes minimum

Return-Flow Enema

• A "flush" or carminative solution to relieve gaseous distention and stimulate bowel function, often used post-surgery

Medicated Enema

• It is given for local effect on the rectal mucosa, such as neomycin to reduce bacteria before surgery and only administered by a nurse. It can also have systemic effects; for example, sodium polystyrene sulfonate to treat high serum potassium.

Carminative Enema

• Relieves flatus and abdominal distention. A small amount of fluid is instilled into the rectum, typically with additives like magnesium and glycerin to distend the rectum and stimulate peristalsis

Commode

• It is a bedside toilet used when a client can get out of bed but cannot walk to the bathroom

Bedpan

• Used when clients are on bedrest or immobilized

Bedpan Types

• Regular: hard plastic, used when patients can lift hips unassisted who have no restrictions in lower extremities
• Fracture: hard plastic with flat upper end, used when patients have body or leg casts, lower extremity fractures, or cannot raise their hips