HCA Guide to Digestion and Bowel Elimination

• This workbook educates Health Care Assistants (HCAs) working in Fraser Health residential care homes
• The purpose is to educate about the digestive system, digestion, Bristol Stool Tool, risk factors for abnormal bowel elimination, rectal suppositories, and enemas.
• HCAs must read the booklet, answer quiz questions (100% passing score), print enema and suppository competency check lists and be observed by a nurse signing off on competency check lists

Digestive System

• The digestive system is a set of organs involved in digesting food
• Digestion breaks food into smaller parts for easy transportation and absorption

Role of the Digestive System

• Digests food
• Absorbs nutrients into the bloodstream
• Excretes waste products

Normal Digestion

• Foods/fluids move through the stomach, small intestine, and large intestine. Fluids are absorbed from feces in the large intestine.
• Peristalsis (involuntary, wavelike contractions) moves feces.
• Excretion of waste/defecation is the final function
• Food takes 1-3 days to process; 90% of processing completed in the colon
• Feces is stored in the intestine until evacuation via the anus.
• Defecation timing is voluntarily controlled but should be regular to prevent backup.
• Stimulation of peristalsis/colon contractions occurs after the first meal combined with physical activity, leading to the feeling of needing to empty bowels.
• Bowel habits vary among individuals

Bristol Stool Scale

• The Bristol Stool Form Scale classifies stool consistency/form
• Seven stool types exist
• Types 1-2 indicate constipation
• Types 3-4 are considered normal, and Type 5 is easiest to pass
• Types 6-7 indicate loose stools or diarrhea

Risk Factors for Abnormal Bowel Elimination

• Age: Peristalsis slows down in older adults (over 65)
• Psychological factors: Anxiety and depression can affect GI function
• Diet: Low fiber causes constipation
• Fluid intake: Less than 1200-1500 ml daily can cause constipation
• Physical activity: Lack of activty impairs bowel elimination
• Pain: Narcotic opioids increase constipation risk
• Ignoring the need to defecate and inability to communicate
• Environmental factors: Reduced privacy and inaccessible toilets
• Inappropriate positioning: Feet not touching a firm surface

Constipation

• Constipation is common and involves difficult, incomplete, painful elimination of hard, dry stools (Type 1 and 2 on the Bristol scale).
• Slow stool movement disturbs the resident's life, causing abdominal distension and unusual behavior
• Report any signs/symptoms to the nurse.

Promoting Normal Bowel Elimination

• Implement a personalized elimination schedule.
• Maintain a healthy, high-fiber diet (e.g., fruitlax)
• Increase fluid intake
• Promote physical activity.
• Allow adequate privacy and time for bowel elimination.
• Proper positioning: Raise the head of the bed if the resident cannot get out of bed; squatting and leaning forward is the optimal elimination position
• Use assessed/ordered interventions like stool softeners, enemas, and suppositories; document administration on the monthly bowel record and report to the nurse.

Rectal Suppository Administration

• Check resident's bowel record, protocol, and care plan, and collaborate with the nurse
• Wash hands
• Gather equipment and perform the 1st check of five rights including the right person, suppository, time, amount, and route
• Supplies include: Prescribed rectal suppository, water-soluble lubricant, clean gloves, paper towel, and incontinent pad
• Greet and identify the resident and explain the procedure
• Arrange equipment on a paper towel on the over-bed table, perform the 2nd check of five rights, and provide privacy
• Lower the bed (if possible) and position the resident on their left side with the right knee flexed (Sim's position); this is the 3rd check of five rights
• Open the lubricant and suppository on a paper towel, then apply gloves
• Place the incontinent pad under the resident's buttocks and remove clothing/briefs to expose the perineal area
• To administer: Pick up the suppository, apply lubricant, gently separate the buttocks, ask the resident to breathe deeply to relax, and insert the suppository full length into the anus along the rectal wall
• Encourage resident to retain the suppository for 15–60 minutes
• Discard used equipment, remove gloves, and wash hands
• Return the resident to a comfortable position, lowering the bed/raising the side rail if needed
• Assist the resident to the toilet when ready, asking them not to flush when done, and keep a call bell within reach
• When toileting is complete, apply gloves, assist with wiping/cleaning the perineal area, and observe suppository results (amount, color, consistency)
• Remove gloves and assist the resident to return to a comfortable position
• Apply gloves, clean/replace equipment, remove gloves, and wash hands
• Record observations on the monthly bowel record and report to the nurse

Enema Administration

• Check the resident's bowel record, protocol, and care plan, and collaborate with the nurse for enema requirements
• Wash hands
• Gather equipment, performing the 1st check of five rights: person, enema, time, amount, and route
• Supplies include: Prescribed disposable enema, water-soluble lubricant, clean gloves, incontinent pad, bedpan/commode, toilet tissue, and 3 paper towels
• Greet and identify the resident and explain the procedure
• Arrange the equipment on paper towels on the over-bed table, preform the 2nd check of five rights
• Place toileting equipment (bedpan/commode) at the bedside in an accessible spot and provide privacy
• Lower the head of the bed and side rails, if present and position resident on left side with right knee flexed (Sim's position) and complete the 3rd check of five rights
• Warm the enema to body temperature by testing on your wrist and apply gloves
• Position the resident on an incontinent pad and remove clothing/briefs to expose the perineal area

Steps to Administer an Enema

• Remove plastic cover from enema tip and lubricate the tip (if not already lubricated)
• Separate buttocks to expose anus and ask resident to breathe deeply to relax
• Insert enema tip its full length into the anus
• Slowly squeeze enema to instill the solution into the rectum
• Hold buttocks together if the solution spills out of the anus
• Encourage the resident to retain the enema for 3-5 minutes, assist to the toilet when ready and ask them not to flush for observation after
• Discard disposable equipment, remove gloves, and wash hands
• Assist resident with wiping/cleaning the perineal area and observe enema results (amount, color, consistency)
• Assist resident to return to a comfortable position
• Remove gloves and wash hands
• Clean and replace equipment
• Wash hands
• Record observations on the monthly bowel record and report to the nurse

Monthly Bowel Movement Record

• A Monthly Bowel Movement Record for HCAs must be printed and initiated by a nurse when a new resident is admitted
• The HCA observes and records stool type/amount on the record and initials the entry
• If a resident requires a suppository/enema for constipation management: a nurse identifies the need, gives direction to the HCA to administer and upon completion, the HCA reports back to the nurse and initials the Monthly Bowel Movement Record
• If a nurse gives the suppository or enema, they document it on the resident’s Monthly Medication Administration Record (MAR)
• The Monthly Bowel Movement Record for HCAs located in the bowel binder on each neighborhood, then filed in the resident’s chart near the monthly bowel MAR. It is a permanent part of the chart

Decision Algorithm

• The nursing staff uses a protocol to determine the next step if an intention is not identified and if it is, the LPN/RN/RPN will provide direction
• The HCA will administer Glycerin, Dulcolax, Microlax, or Fleet Enema
• The HCA will document the administration of the enema or suppository on the monthly bowel movement record and in turn, reports back to the nurse
• The HCA documents the bowel movement on the monthly bowel movement and reports to the nurse
• The nursing staff documents notable results on the progress reports