Chapter 45
Bowel Elimination
The esophagus is a long muscular tube, which moves food from the mouth to the
stomach.
The abdomen contains all of the digestive organs.
The stomach, situated at the top of the abdomen, normally holds just over 3 pints (about
1500 ml) of food from a single meal. Here the food is mixed with an acid that is
produced to assist in digestion. In the stomach, acid and other digestive juices are
added to the ingested food to facilitate breakdown of complex proteins, fats and
carbohydrates into small, more absorbable units.
A valve at the entrance to the stomach from the esophagus allows the food to enter
while keeping the acid-laden food from "refluxing" back into the esophagus,
causing damage and pain.
The pylorus is a small round muscle located at the outlet of the stomach and the
entrance to the duodenum (the first section of the small intestine). It closes the
stomach outlet while food is being digested into a smaller, more easily absorbed
form. When food is properly digested, the pylorus opens and allows the contents
of the stomach into the duodenum.
The small intestine is about 15 to 20 feet long (4.5 to 6 meters) and is where the
majority of the absorption of the nutrients from food takes place. The small
intestine is made up of three sections: the duodenum, the jejunum and the ileum.
The duodenum is the first section of the small intestine and is where the food is mixed
with bile produced by the liver and with other juices from the pancreas. This is
where much of the iron and calcium is absorbed.
The jejunum is the middle part of the small intestine extending from the duodenum to
the ileum; it is responsible for digestion.
The last segment of the intestine, the ileum, is where the absorption of fat-soluble
vitamins A, D, E and K and other nutrients are absorbed.
Another valve separates the small and large intestines to keep bacteria-laden colon
contents from coming back into the small intestine.
In the large intestines, excess fluids are absorbed and a firm stool is formed. The colon
may absorb protein, when necessary.
Structures of the Gastrointestinal
Tract (alimentary canal) Related to
Bowel Elimination
– Small intestine
– Ileocecal valve
– Large bowel (colon)
– Ileocecal sphincter
– Anal sphincter
Physiology of Bowel Elimination

Continence
– Consistency of the stool (fecal material)
– Intestinal motility
– Compliance and contractility of the rectum
– Competence of the anal sphincters
Intestinal Motility and Rectal
Accommodation
– Rectal filling
– Rectal contractions
– Rectal accommodation
– Postponement of defecation
– Constipation

Anal Sphincter Mechanism
– Internal and external sphincters
– Striated muscle fibers
– Sensory receptors
Factors Affecting Elimination
Age
 Diet
 Exercise
 Medications

Alterations in Bowel Elimination
Constipation
 Diarrhea
 Fecal Incontinence

Bowel Retention

Constipation is infrequent and difficult
passage of hardened stool.
– Dietary factors, dehydration
– Inadequate dietary bulk
– Diverticular disease
– Neuropathic conditions
– Functional limitations
Bowel Retention

Fecal Impaction
– Bolus of hardened stool
– Further slows colonic transit time and passage
of further fecal contents
Bowel Retention

Perceived constipation is influenced by
psychological and emotional stress.
Alterations in Bowel Elimination

Diarrhea is the passage of liquefied stool
with increased frequency and consistency.

Primary Causes of Diarrhea
– Malabsorption syndromes
– Inflammatory bowel disease
– Short bowel syndrome
– Side effects of drugs
– Laxative or enema misuse

Infectious diarrhea is caused by a
pathogen.

Bowel (fecal) Incontinence
– Dysfunction of the anal sphincter
– Disorders of the delivery of stool to the
rectum
– disorders of rectal storage
– Anatomic defects
Assessment

Health History
– Elimination habits
– Type of incontinence
– Complicating factors
Assessment

Physical Examination
– Mental status
– Mobility and dexterity
– Inspection of perineum for skin integrity
– Inspection of vaginal vault
– Pelvic support
– Perineal sensation
– Perianal area, digital rectal exam

Diagnostic and Laboratory Data
– Stool culture
– Defecography
– Anorectal ultrasonography
Nursing Diagnoses
Constipation
 Perceived Constipation
 Diarrhea
 Bowel Incontinence

Other Nursing Diagnoses
Low Self-Esteem
 Deficient Knowledge
 Risk for Infection
 Risk for Impaired Skin Integrity
 Toileting Self-Care Deficit

Outcome Identification and
Planning

Target outcomes center around restoring
and maintaining regular elimination habits
and preventing complications.
Implementation

Maintain Elimination Health
– Fluid intake
– Diet
– Lifestyle and Prevention
Lifestyle and Prevention
– Alcohol and tobacco use
– Stress management
– Weight reduction
– Elimination habits
– Positioning
Lifestyle and Prevention
– Initiate pelvic muscle exercise regimen
– Suggest environmental modifications
– Initiate behavioral intentions
– Monitor skin integrity
Rectal pouch and rectal tube

Initiate Diet and Fluid Therapy

Administer Enemas
– Cleanse the lower bowel
– Assist in evacuation
– Instill medication
Initiate Rectal Stimulation
 instruction

Various types
of enema
equipment and
solutions


equipment

Monitor Elimination Diversions
– Bowel Diversions
 Ileostomy
 Colostomy
 Ileoanal reservoir (usually done only for ulcerative colitis
and familial Polyposis patients. A reservoir is made from the
ileum (small bowel) and connected directly to the anus. The
sphincter muscle is in place. A temporary Ileostomy is
performed to allow the reservoir to heal. Later the Ileostomy
is closed and feces exits normally through the anus. )

ileostomy
Surgical Management
– Implanted devices
– Surgical reconstruction
– Surgical closure of fistulae and ectopia
– Endoscopy, other procedures to alleviate
obstruction or dyssynergia
Complementary Therapies
– Holistic approach to effective elimination of
waste products and toxins
 Diuretics
 Antimicrobials
 Antiseptics
 Stimulants and Cathartics
Evaluation
Client’s level of maintenance or restoration
of elimination patterns and return to an
appropriate level of independence
 Prevention of skin breakdown and
infection
 Client understanding of procedures and
self-care


coloscopy