Chapter 38 Bowel Elimination Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright © 2019 Wolters Kluwer • All Rights Reserved The Large Intestine Primary organ of bowel elimination Extends from the ileocecal valve to the anus Functions o Absorption of water o Formation of feces o Expulsion of feces from the body Copyright © 2019 Wolters Kluwer • All Rights Reserved The Small and Large Intestines Copyright © 2019 Wolters Kluwer • All Rights Reserved Process of Peristalsis Peristalsis is under control of the nervous system. Contractions occur every 3 to 12 minutes. Mass peristalsis sweeps occur one to four times each 24hour period. One-third to one-half of food waste is excreted in stool within 24 hours. Copyright © 2019 Wolters Kluwer • All Rights Reserved Peristaltic Movements in the Intestine Copyright © 2019 Wolters Kluwer • All Rights Reserved Variables Influencing Bowel Elimination Developmental considerations Daily patterns Food and fluid Activity and muscle tone Lifestyle Psychological variables Pathologic conditions Medications Diagnostic studies Surgery and anesthesia Copyright © 2019 Wolters Kluwer • All Rights Reserved Developmental Considerations Infants: Characteristics of stool and frequency depend on formula or breast feedings. Toddler: Physiologic maturity is the first priority for bowel training. Child, adolescent, adult: Defecation patterns vary in quantity, frequency, and rhythmicity. Older adult: Constipation is often a chronic problem; diarrhea and fecal incontinence may result from physiologic or lifestyle changes. Copyright © 2019 Wolters Kluwer • All Rights Reserved Question #1 Which food is a recommended for an older adult who is constipated? A. Cheese B. Fruit C. Cabbage D. Eggs Copyright © 2019 Wolters Kluwer • All Rights Reserved Answer to Question #1 Answer: B. Fruit Rationale: Fruits and vegetables have a laxative effect on the system. Cheese and eggs have a constipating effect and cabbage, although a vegetable, produces gas in the system. Copyright © 2019 Wolters Kluwer • All Rights Reserved Foods Affecting Bowel Elimination Constipating foods: cheese, lean meat, eggs, pasta Foods with laxative effect: fruits and vegetables, bran, chocolate, alcohol, coffee Gas-producing foods: onions, cabbage, beans, cauliflower Copyright © 2019 Wolters Kluwer • All Rights Reserved Effect of Medications on Stool Aspirin, anticoagulants: pink to red to black stool Iron salts: black stool Bismuth subsalicylate used to treat diarrhea can also cause black stools. Antacids: white discoloration or speckling in stool Antibiotics: green-gray color Copyright © 2019 Wolters Kluwer • All Rights Reserved Physical Assessment of the Abdomen The sequence for abdominal assessment proceeds from inspection, auscultation, and percussion to palpation. Inspection: observe contour, any masses, scars, or distention Auscultation: listen for bowel sounds in all quadrants o Note frequency and character, audible clicks, and flatus. o Describe bowel sounds as hypoactive, hyperactive, absent or infrequent. Percussion and palpations: performed by advanced practice professionals Copyright © 2019 Wolters Kluwer • All Rights Reserved Physical Assessment of the Anus and Rectum Inspection and palpation o Lesions, ulcers, fissures (linear break on the margin of the anus), inflammation, and external hemorrhoids o Ask the patient to bear down as though having a bowel movement. Assess for the appearance of internal hemorrhoids or fissures and fecal masses. o Inspect perineal area for skin irritation secondary to diarrhea or fecal incontinence. Copyright © 2019 Wolters Kluwer • All Rights Reserved Stool Collection Medical aseptic technique is imperative. Hand hygiene, before and after glove use, is essential. Wear disposable gloves. Do not contaminate outside of container with stool. Obtain stool and package, label, and transport according to agency policy. Copyright © 2019 Wolters Kluwer • All Rights Reserved Patient Guidelines for Stool Collection Void first so that urine is not in stool sample. Defecate into the container rather than toilet bowl. Do not place toilet tissue in the bedpan or specimen container. Avoid contact with soaps, detergents, and disinfectants as these may affect test results. Notify nurse when specimen is available. Copyright © 2019 Wolters Kluwer • All Rights Reserved Question #2 Tell whether the following statement is true or false. When collecting stool using the technique “timed specimen,” the nurse should consider the first stool passed by the patient as the start of the collection period. A. True B. False Copyright © 2019 Wolters Kluwer • All Rights Reserved Answer to Question #2 Answer: A. True Rationale: When collecting stool using the technique “timed specimen,” the nurse should consider the first stool passed by the patient as the start of the collection period. Copyright © 2019 Wolters Kluwer • All Rights Reserved Types of Direct Visualization Studies (Endoscopy) Esophagogastroduodenoscopy Colonoscopy Sigmoidoscopy Wireless capsule endoscopy Copyright © 2019 Wolters Kluwer • All Rights Reserved Question #3 Which of the following direct visualization tests uses a long, flexible, fiberoptic–lighted scope to visualize the rectum, colon, and distal small bowel? A. Esophagogastroduodenoscopy B. Colonoscopy C. Sigmoidoscopy D. UGI series Copyright © 2019 Wolters Kluwer • All Rights Reserved Answer to Question #3 Answer: B. Colonoscopy Rationale: A colonoscopy visualizes the rectum, colon, and bowel using a lighted scope. An esophagogastroduodenoscopy examines the esophagus, stomach, and upper duodenum through an optic scope. A sigmoidoscopy examines the distal sigmoid colon, rectum, and anal canal through a flexible or rigid sigmoidoscope. UGI series involves fluoroscopic examination of the esophagus, stomach, and small intestine after ingestion of barium sulfate. Copyright © 2019 Wolters Kluwer • All Rights Reserved Indirect Visualization Studies Upper gastrointestinal (UGI) Small bowel series Barium enema Abdominal ultrasound Magnetic resonance imaging (MRI) Abdominal CT scan Copyright © 2019 Wolters Kluwer • All Rights Reserved Scheduling Diagnostic Tests 1: fecal occult blood test 2: barium studies (should precede UGI) 3: endoscopic examinations Noninvasive procedures take precedence over invasive procedures Copyright © 2019 Wolters Kluwer • All Rights Reserved Patient Outcomes for Normal Bowel Elimination Patient has a soft, formed bowel movement every 1 to 3 days without discomfort. The relationship between bowel elimination and diet, fluid, and exercise is explained. Patient should seek medical evaluation if changes in stool color or consistency persist. Copyright © 2019 Wolters Kluwer • All Rights Reserved Promoting Regular Bowel Habits Timing Positioning Privacy Nutrition Exercise o Abdominal settings o Thigh strengthening Copyright © 2019 Wolters Kluwer • All Rights Reserved Individuals at High Risk for Constipation Patients on bedrest taking constipating medicines Patients with reduced fluids or bulk in their diet Patients who are depressed Patients with central nervous system disease or local lesions that cause pain while defecating Copyright © 2019 Wolters Kluwer • All Rights Reserved Nursing Measures for the Patient With Diarrhea Answer call bells immediately. Remove the cause of diarrhea whenever possible (e.g., medication). If there is impaction, obtain physician order for rectal examination. Give special care to the region around the anus. Copyright © 2019 Wolters Kluwer • All Rights Reserved Preventing Food Poisoning #1 Never buy food with damaged packaging. Take items requiring refrigeration home immediately. Wash hands and surfaces often. Use separate cutting boards for foods. Thoroughly wash all fruits and vegetables before eating. Do not wash meat, poultry, or eggs to prevent spreading microorganisms to sink and other kitchen surfaces. Never use raw eggs in any form. Do not eat seafood raw or if it has an unpleasant odor. Copyright © 2019 Wolters Kluwer • All Rights Reserved Preventing Food Poisoning #2 Use a food thermometer to ensure cooking food to safe internal temperature. Keep food hot after cooking; maintain safe temperature of 140°F or above. Give only pasteurized fruit juices to small children. Copyright © 2019 Wolters Kluwer • All Rights Reserved Methods of Emptying the Colon of Feces Enemas Rectal suppositories Oral intestinal lavage Digital removal of stool Copyright © 2019 Wolters Kluwer • All Rights Reserved Types of Enemas Cleansing Retention o Oil o Carminative o Medicated o Anthelmintic Large volume Small volume Copyright © 2019 Wolters Kluwer • All Rights Reserved Question #4 Which enema would be used for a patient with intestinal parasites? A. Oil-retention enema B. Carminative enema C. Nutritive enema D. Anthelmintic enema Copyright © 2019 Wolters Kluwer • All Rights Reserved Answer to Question #4 Answer: D. Anthelmintic enema Rationale: Antihelmintic enemas destroy intestinal parasites. Oil-retention enemas lubricate the stool and intestinal mucosa, making defecation easier. Carminative enemas help expel flatus from the rectum. Nutritive enemas administer fluids and nutrition rectally. Copyright © 2019 Wolters Kluwer • All Rights Reserved Retention Enemas Oil-retention: lubricate the stool and intestinal mucosa, easing defecation Carminative: help expel flatus from the rectum Medicated: provide medications absorbed through the rectal mucosa Anthelmintic: destroy intestinal parasites Copyright © 2019 Wolters Kluwer • All Rights Reserved Bowel-Training Programs Manipulate factors within the patient’s control. o Food and fluid intake, exercise, and time for defecation o Eliminate a soft, formed stool at regular intervals without laxatives. When achieved, continue to offer assistance with toileting at the successful time. Copyright © 2019 Wolters Kluwer • All Rights Reserved Nasogastric Tubes Inserted to decompress or drain the stomach of fluid or unwanted stomach contents Used to allow the gastrointestinal tract to rest before or after abdominal surgery to promote healing Inserted to monitor gastrointestinal bleeding Copyright © 2019 Wolters Kluwer • All Rights Reserved Types of Ostomies Sigmoid colostomy Descending colostomy Transverse colostomy Ascending colostomy Ileostomy Copyright © 2019 Wolters Kluwer • All Rights Reserved Location of (A) a Sigmoid Colostomy and (B) a Descending Colostomy Copyright © 2019 Wolters Kluwer • All Rights Reserved Location of (C) a Transverse Colostomy and (D) an Ascending Colostomy Copyright © 2019 Wolters Kluwer • All Rights Reserved Location of an Ileostomy Copyright © 2019 Wolters Kluwer • All Rights Reserved Colostomy Care Keep the patient as free of odors as possible; empty the appliance frequently. Inspect the patient’s stoma regularly. o Note the size, which should stabilize within 6 to 8 weeks. o Keep the skin around the stoma site clean and dry. Measure the patient’s fluid intake and output. Explain each aspect of care to the patient and self-care role. Encourage patient to care for and look at ostomy. Copyright © 2019 Wolters Kluwer • All Rights Reserved Comparison of Stomal Appearance Copyright © 2019 Wolters Kluwer • All Rights Reserved Patient Teaching for Colostomies Explain the reason for bowel diversion and the rationale for treatment. Demonstrate self-care behaviors that effectively manage the ostomy. Describe follow-up care and existing support resources. Report where supplies may be obtained in the community. Verbalize related fears and concerns. Demonstrate a positive body image. Copyright © 2019 Wolters Kluwer • All Rights Reserved Comfort Measures Encourage recommended diet and exercise. Use medications only as needed. Apply ointments or astringent (witch hazel). Use suppositories that contain anesthetics. Copyright © 2019 Wolters Kluwer • All Rights Reserved
