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Bowel Elimination
Scientific Knowledge Base
Mouth
Esophagus
Digestion begins with
mastication.
Peristalsis moves food into
the stomach.
Stomach
Small intestine
Stores food; mixes food,
liquid, and digestive juices;
moves food into small
intestines
Duodenum, jejunum, and
ileum
Large intestine
Anus
The primary organ of bowel
elimination
Expels feces and flatus
from the rectum
Nursing Knowledge Base:
Factors Affecting Bowel Elimination
Age
Fluid intake
Diet
Physical activity
Psychological factors
Personal habits
Position during defecation
Pain
Pregnancy
Surgery and anesthesia
Medications, laxatives,
and cathartics
Diagnostic tests
Bristol Stool Form Scale
Common Bowel Elimination Problems
Constipation
Impaction
A symptom, not a disease;
infrequent stool and/or hard, dry,
small stools that are difficult to
eliminate
Results from unrelieved
constipation; a collection of
hardened feces wedged in the
rectum that
a person cannot expel
Diarrhea
Incontinence
an increase in the number of stools
and the passage of liquid, unformed
feces
Inability to control passage of
feces and gas to the anus
Flatulence
Hemorrhoids
Accumulation of gas in the
intestines causing the walls to
stretch
Dilated, engorged veins in the
lining of the rectum
Common Bowel
Elimination Problems
Constipation
A symptom, not a
disease; infrequent stool
and/or hard, dry, small
stools that are difficult to
eliminate
Signs of constipation
• infrequent bowel
movements (less often
than every 3 days)
• difficulty passing stools
• excessive straining
• inability to defecate at
will
• hard feces.
Nursing Diagnosis
• (Risk for) Constipation R/T
– Opiate containing meds
– Decreased fiber intake
– Decreased fluid intake
– Recent anesthesia
– Stress
– Inactivity (immobility)
– Eating a large amount of dairy products
AEB no stool in 3 days
• Outcome: Pt will have a soft, formed stool in 24 hours.
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Assessments
• Assess for s/s of constipation
– Decrease in frequency of bowel movements
– Consistency of stool
– Anorexia
– Abdominal distention and pain
– Feeling of fullness or pressure in rectum
– Straining during defecation
• Assess bowel sounds
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Therapeutic Interventions
• Encourage fluid intake of at least 1500 ml/24hr
• Encourage activity: walk pt in hallway 4 times a
day
• Encourage to defect whenever urge is felt
• Assist to BR, BSC or bedpan (put pt in high
Fowlers)
• Provide for privacy
• Encourage to drink hot liquids in AM
• Administer laxatives or enemas as ordered
• Consult with HCP to check for impaction
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Teaching
• Teach to increase intake of foods high in fiber
• Teach importance of activity
• Teach reasons for changing opioid medication
to a non-opioid medication
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Common Bowel
Elimination Problems
Impaction
Digital removal of stool
Results from unrelieved
constipation; a collection of
hardened feces wedged in the
rectum that
a person cannot expel
A health care provider’s order
is necessary to remove an
impaction.
Digital removal
of stool
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Common Bowel
Elimination Problems
Diarrhea
an increase in the
number of stools
and the passage of
liquid, unformed
feces
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Nursing Diagnoses
•
•
•
•
•
Diarrhea
Risk for impaired skin integrity
Risk for Electrolyte imbalance
Risk for imbalanced fluid volume
Risk for falls
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Common Bowel
Elimination Problems
Incontinence
Inability to control
passage of feces and
gas to the anus
Nursing Diagnosis
Impaired Body Image
Impaired Social
Interaction
• Common causes of fecal
incontinence include
diarrhea, constipation,
and muscle or nerve
damage.
–
–
–
–
–
Spinal cord injury
Multiple Sclerosis
Stroke
Intestinal obstruction
Seizures
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Common Bowel
Elimination Problems
Flatulence
Accumulation of gas in
the intestines causing
the walls to stretch
Causes
• Swallowed air
• Foods and beverages
• Medicines or nutritional
supplements
• Bowel obstruction
• Nursing Diagnoses
– Pain
– Impaired body image
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Common Bowel
Elimination Problems
Hemorrhoids
Dilated, engorged veins
in the lining of the
rectum
Causes
•
•
•
•
Diarrhea
Constipation
Pregnancy
Cirrhosis of the Liver
• Nursing Diagnosis
– Pain
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Bowel Diversion
• Temporary or permanent artificial opening
in the abdominal wall
– Stoma
• Surgical opening in the ileum or colon
– Ileostomy or colostomy
• The standard bowel diversion creates a
stoma.
End Colostomy
Double-Barrel Colostomy
Ostomies
• End ileostomy
• End colostomy
– Proximal end forms stoma, and distal end is
removed or sewn closed.
• Double-barrel colostomy
– Bowel is surgically cut, and both ends are
brought through the abdomen.
Psychological Considerations
• Nursing Diagnosis:
–Disturbed body image
Continuing and Restorative Care
• Irrigating a Colostomy
Continuing and Restorative Care
• Pouching ostomies
– An effective
pouching system
protects the skin,
contains fecal
material, remains
odor free, and is
comfortable and
inconspicuous.
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Continuing and Restorative Care
• Nutritional considerations
– Consume low fiber for the first weeks.
– Eat slowly and chew food completely.
– Drink 10 to 12 glasses of water daily.
– Patient may choose to avoid gassy foods.
Implementations: Acute Care
• Health promotion
– Promotion of normal defecation
• Establish a routine an hour after a meal, or maintain
the patient’s routine.
– Sitting position
– Privacy
– Positioning on bedpan
Fecal Occult Blood Testing
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Acute Care: Medications
• Cathartics and laxatives
– Bulk Forming
• Psyllium (Metamucil)
– Emollient or Wetting
• Docusate Sodium (Colace)
– Saline
• Magnesium Hydroxide (Milk of Magnesia)
• Sodium phosphate (Fleet enema)
– Stimulant
• Bisacodyl (Dulcolax)
• Casanthranol (Peri-Colace)
Implementations: Acute Care
• Health promotion
– Promotion of normal defecation
• Establish a routine an hour after a
meal, or maintain the patient’s
routine.
– Sitting position
– Privacy
– Positioning on bedpan
Acute Care: Medications
• Cathartics and laxatives
– Bulk Forming
• Psyllium (Metamucil)
– Emollient or Wetting
• Docusate Sodium (Colace)
– Saline
• Magnesium Hydroxide (Milk of Magnesia)
• Sodium phosphate (Fleet enema)
– Stimulant
• Bisacodyl (Dulcolax)
• Casanthranol (Peri-Colace)
Acute Care: Medications
• Antidiarrheal agents
– Diphenoxylate (Lomotil)
– Over the counter (Imodium)
– Opiates used with caution
Enemas
• Enema administration
– Sterile technique is
unnecessary.
– Wear gloves.
– Explain the procedure,
precautions to avoid
discomfort, and length
of time necessary to
retain the solution
before defecation.
Enemas
Cleansing Enemas
Tap water
•is hypotonic and exerts an osmotic pressure lower than
fluid in interstitial spaces. After infusion into the colon, tap
water escapes from the bowel lumen into interstitial
spaces. The net movement of water is low. The infused
volume stimulates defecation before large amounts of
water leave the bowel. Do not repeat tap water enemas
because water toxicity or circulatory overload develops if
the body absorbs large amounts of water.
Normal saline
safest solution to use because it exerts the same osmotic
pressure as fluids in interstitial spaces surrounding the
bowel. The volume of infused saline stimulates
peristalsis. Giving saline enemas does not create the
danger of excess fluid absorption
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Enemas
Cleansing Enemas
Hypertonic solution
•infused into the bowel exert osmotic pressure that pulls
fluids out of interstitial spaces. The colon fills with fluid,
and the resultant distention promotes defecation. Patients
unable to tolerate large volumes of fluid benefit most from
this type of enema, which is by design low volume. This
type of enema is contraindicated for patients who are
dehydrated and for young infants. A hypertonic solution of
120 to 180 mL (4 to 6 oz) is usually effective. The
commercially prepared Fleet enema is the most common.
Soapsuds
•to create the effect of intestinal irritation to stimulate
peristalsis. Use only pure castile soap that comes in liquid
form and is included in most soapsuds enema kits. Use
soapsuds enemas with caution in pregnant women and
older adults because they cause electrolyte imbalance or
damage to the intestinal mucosa.
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Enemas
Oil Retention Enemas
•lubricate the rectum and colon. The feces absorb
the oil and become softer and easier to pass. To
enhance the action of the oil, the patient retains the
enema for several hours if possible.
Carminative Enema
provide relief from gaseous distention
Medication enemas
Kayexalate
Neomycin
Lactolosis
An example is sodium polystyrene sulfonate (Kayexalate),
which is used to treat patients with dangerously high
serum potassium levels. This drug contains a resin that
exchanges sodium ions for potassium ions in the large
intestine. Another medicated enema is neomycin
solution, an antibiotic that is used to reduce bacteria in
the colon before bowel surgery.
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Continuing and Restorative Care
• Bowel training
– Training program
– Diet
– Promotion of regular exercise
– Management of hemorrhoids
• Skin integrity