Bowel Elimination PDF

# Bowel Elimination ## Fundamentals of Nursing - Elimination - Learning objectives: - Describe the anatomy and physiology of the gastrointestinal tract - Describe factors affecting bowel elimination - Identify common bowel elimination problems - Discuss nursing in...

# Bowel Elimination ## Fundamentals of Nursing - Elimination - Learning objectives: - Describe the anatomy and physiology of the gastrointestinal tract - Describe factors affecting bowel elimination - Identify common bowel elimination problems - Discuss nursing interventions for selected alterations in bowel function - Explain bowel diversion ostomies - Introduction: - Elimination is essential to rid the body of wastes and materials in excess of bodily needs. - Elimination process is necessary to maintain a high level of wellness and life itself and must continue during illness as in health. - Anatomy and physiology of the GIT - Mouth: The mouth mechanically and chemically breaks down nutrients into usable size and form. Digestion begins in the mouth and ends in the small intestine. - Esophagus: As food enters the upper esophagus, it passes the esophageal sphincter. This sphincter is a circular muscle that prevents food from entering the esophagus and food from refluxing into the throat. - Stomach: Has three functions: - the storage of swallowed food and liquid, - mixing of food, liquid, and digestive juices, and - emptying its contents into the small intestine. The stomach produces and secretes hydrochloric acids (HCL), mucus (protective), pepsin, and intrinsic factor (for absorption of vitamin B12). - Small intestine: Is divided into the duodenum (2 feet), the jejunum (9 feet), and the ileum (12 feet). Most nutrients and electrolytes are absorbed in the small intestine. - Large intestine (lower GIT): Is divided into the cecum, colon, and rectum. The colon has three tasks: absorption, secretion, and elimination. - Anus: Is the place where feces is expelled out of the body. The anal canal is richly supplied with sensory nerves that help to control continence. - The act of defecation: - Defecation is an evacuation of the intestines and is often referred to as a bowel movement. - When a certain amount of fecal matter accumulates in the rectum it becomes distended and the intra-rectal pressure rises. Sensory nerve endings are stimulated (parasympathetic), the internal and external sphincter relaxes, and the colon contracts. - The result is a desire to defecate. - During the act of defecation, several additional muscles help in the process: - voluntary contraction of these muscles - closing of the glottis - increasing intra-abdominal pressure that aid in expelling the feces. - Simultaneously, the muscles of the pelvic floor contracts and aid in pushing the fecal mass out. - Factors affecting defecation - 1-Age: - Infant: meconium is the first fecal material passed by the newborn, normally up to 24 hr. after newborn. Its black, tarry, odorless which contains mucous. - Infant pass stool frequently often each after feeding because the intestine is immature. - Infants: - small stomach capacity - less secretion of digestive enzymes - rapid peristalsis - lack neuromuscular development so cannot control bowels. - Ability to control defecation occurs at the age of 2-3 years. - In older adults, peristalsis declines, esophageal emptying slows. Muscle tone in the perianal floor and anal sphincter weakens, causing difficulty in controlling defecation. - Older adults: - arteriosclerosis which causes decreased mesenteric blood flow, decreasing absorption in the small intestine; - decrease in peristalsis - loose muscle tone in perineal floor and anal sphincter thus are at risk for incontinence - slowing nerve impulses in the anal region, causing older adults to be less aware of the need to defecate, leading to irregular BMs and a risk of constipation. - 2- Diet: - Regular daily food intake, high-fiber foods, raw or cooked fruits, vegetables, and cereals and bread promote peristalsis. - Low-fiber foods (lean meats, milk) slow peristalsis. - Gas-producing foods (broccoli, cauliflower, onions, dried beans) can stimulate peristalsis. - 3- Fluid intake: - Water liquefies intestinal contents for easier passage. - Hot beverages and fruit juices soften stool and increase peristalsis. - Large quantities of milk may slow peristalsis and cause constipation. - The reduced fluid intake may cause hardening of stool. - Healthy fecal elimination requires 2000 to 3000ml/day. - 4- Position during defecation: - Squatting allows a person to lean forward, exert intraabdominal pressure, and contract thigh muscles to normally defecate. - Immobilized clients using a bedpan cannot contract muscles to defecate. - 5- Pregnancy: - Pressure adds to the rectum leading to constipation, slowing peristalsis in the third trimester. - 6- Activity: - Immobilization depresses colon motility. - Regular physical exercise promotes peristalsis. - 7- Psychological factors: - Anxiety or fear can accelerate digestion and peristalsis. - Diarrhea may result. - 8- Pain: Can suppress defecation resulting in constipation - 9- Diagnostic tests: Examination of the GIT structures requires emptying of bowel contents. NPO status, bowel evacuants, and cleansing enemas are factors that interfere with normal elimination. - 10- Medications: Laxatives and cathartics, laxative overuse can decrease muscle tone and can cause diarrhea which can result in dehydration and electrolyte imbalance. - 11- Psychological factors: Stress increases peristalsis resulting in diarrhea and gaseous distention, ulcerative colitis - 12. Pathological condition: Spinal cord injury and head injury can decrease sensory stimulation for defecation. - Common Bowel Elimination Problems: - 1. Constipation: Is infrequent and difficult passage of hardened stool. - Causes: - Certain medications (i.e., antidepressants, antihypertensives, opioids, antacids with aluminum, and iron) - Rectal or anal disorders (e.g., hemorrhoids, fissures) - Obstruction (e.g., cancer of the bowel) - Metabolic and neuromuscular conditions (e.g., diabetes mellitus, multiple sclerosis) - Endocrine disorders (e.g., hypothyroidism, pheochromocytoma) - Other causes include weakness, immobility, and an inability to increase intraabdominal pressure to facilitate the passage of stools. - Constipation results from dietary habits (ie, low consumption of fiber and inadequate fluid intake), lack of regular exercise, Irregular defecation habits and a stress-filled life. - Nursing management of constipation: - Provide adequate fluid intake 1500-2000cc/d - Provide a well-balanced diet with enough roughage from fruits and vegetables and vitamins - Encourage of regularity of time for defecation - Encourage regularity of meal's time - Provide adequate time for complete evacuation - Provide privacy for patients to promote relaxation - Provide posture as close to normal as possible - Provide physical and emotional comfort and alleviate pain - Provide physical exercise especially for abdominal muscles - Consider the patient's habit in relation to defecation - 2. Fecal Impaction: An accumulation of fecal material which forms a hardened mass in the rectum. - Impaction: Results from unrelieved constipation, whereby hardened faeces cannot be expelled for several days despite repeated urge to defecate. - Impaction develops in patients who are unconscious, badly constipated, or those with interrupted nerve supply to bowel. - Sign and symptom - Liquid production of the feces seep. - Generalized feeling of illness. - Rectal pain. - Abdominal distention. - Nausea and vomiting occur - Causes: - Prolonged constipation and poor habits of defecation. - Prolonged bed rest - Prolonged use of anti-diarrheal drugs - Following administration of barium for x-ray examination of the Git - Nursing management: - Administration of mineral oil by mouth especially in cases of prolonged constipation for regulation of habits. - Oil retention enema followed by cleansing enema - Digital manipulation of fecal mass should be under physician order or supervision because it can stimulate vagus nerve in the rectal wall which can slow patient's heart leading to cardiac arrhythmia, so observe patient's pulse, facial pallor and diaphoresis during manipulation. - 3. Diarrhea: Refers to the passage of liquid feces and increased frequency of defecation. It results from rapid movement of fecal content through the large intestine. Diarrhea may or may not be accompanied by abdominal cramping. - Causes: - The most common types are due to irritation of the gastrointestinal tract - 1. Irritation by bacteria (acute diarrhea) - E.g. Clostridium, Escherichia coli, Salmonella, Shigella - 2. Irritating by parasites - 3. Irritation by mechanical means: - Excessive amount of coarse foods - Foreign bod - Fecal impaction - Tumor - 4. Irritation by chemical means: - Poisons - Laxatives - Hot foods. - 5. Allergic diarrhea - 6. Diarrhea due to inflammation of the intestines - 7. Psychological stress (anxiety). - 8. Medication (antibiotic). - 9. Allergy of food. - 10. Disease of the colon - Signs and symptoms: - Generalized abdominal pain which is spasmodic in nature due to strong peristaltic action - Pain are accompanied by feeling of urgency in the need to defecate - Complaints of tenesmus and may pass a small watery discharge - Increase in frequency in the number of stools - Signs and symptoms of dehydration may occur if diarrhea is very severe. - Generalized weakness and general malaise - Anorexia, nausea, vomiting and sometimes increase body temperature. - Nursing care of diarrhea: - Assess odor, color, amount, frequency, consistency and presence of foreign material and mucous, pus and undigested food. - Observe signs and symptoms of dehydration and electrolyte loss - Diet free from roughage, rich in liquids, free from irritants and low in fat. Rich in portions such as white meat - Provide physical comfort and hygiene care - Medicated creams to prevent skin irritation e.g. zinc oxide - Patient's clothes and bed linen must be dry and clean - If diarrhea is due to infection, isolation techniques must be applied. - N.B: All diarrheas should be considered infectious until proven. - 4. Fecal incontinence: Inability of the anal sphincter to control the discharge of feces i.e. loss of voluntary control over the act of defecation. - Causes: - Vaginal deliveries, requiring the use of forceps, are likely to damage the anal sphincter mechanism. - Physical conditions that impair anal sphincter function or control - Nursing care: - Supportive and encouraging attitude by the nurse should be initiated to eliminate embarrassment - Special nursing care to prevent bad odor, skin irritation and bed sores - Patient's clothing and bedding should be changed whenever necessary. - 5: Flatulence: Excessive formation and accumulation of gases in the intestines - Causes: - Excessive intake of gas forming foods - Prolonged constipation or impaction - Inability of the intestine to expel gases due to weakness e.g. post-operative periods after abdominal surgery - Lack of exercise and prolonged bed rest - Swallowing large amount of air while eating or drinking or tube feeding (in very old and children) - Signs and symptoms: - Distended abdomen that gives a drum like sounds upon percussion - Colicky pain that is generalized in the abdomen - Shortness of breath and dyspnea due to pressure on diaphragm and thoracic cavity (e.g. bedridden patients) - Nursing care: - Prevention of the cause - Encourage exercises in the bed or ambulate patients for short walk. - Avoid gas forming foods - Heat application to the abdomen either alone or in conjunction with other measures such as the rectal tube can increase peristalsis and expel flatus - Bowel diversion ostomies: - Stoma: temporary or permanent artificial opening in the abdominal wall. - Certain disease /conditions prevent normal passage of stool; temporary or permanent artificial opening in the abdominal wall; location determines consistency of stool. - Ileostomy-opening in Ileum - Colostomy-opening in colon - Three types of colostomies - Loop Colostomy - End (single) Colostomy - Double-Barrel Colostomy - Enemas: Are fluid solutions introduced into the rectum and colon. The most common reason for giving enemas is to stimulate the urge to defecate - Purposes: - To empty the rectum and the lower colon when constipation is present - To relieve gas from the colon and rectum - To administer medications - Pre-operatively, especially in intestinal tract operations to remove fecal material from intestines. - Expulsion of intestinal warms - Aids in diagnoses e.g. barium enema - Types of Enemas: - Type | Solution | Indications - :--- | :--- | :---: - Cleansing | Tap water Soap suds Nor mal saline | Evacuate lower bowel before diagnostic studies or surgery - Retention | Emollient (oil) | Soften and lubricate stool for easy evacuation - Carminative (gas expulsion) | Tap water Normal saline | Relief of distension due to flatus # Bowel Elimination ## Fundamentals of Nursing - A diagram of the stomach, duodenum, transverse colon, ascending colon, jejunum, ileostomy, descending colon, ileum, sigmoid colon, and rectum.