Bowel Elimination
 Anatomy and Physiology of GI Tract
 Review this section
 ____________ maneuver: voluntary contraction of abdominal muscles while maintaining a forced
expiration against closed airway.
 People with cardiovascular disease, glaucoma, increased intracranial pressure or a new surgical
wound are at risk with this maneuver and it should be avoided
 Be aware that this topic is embarrassing to many patients and needs to be discussed with sensitivity.
Also be aware of their need for privacy during elimination.
 Factors Influencing Bowel Elimination
 Age
 Control of defection usually by 2-3 years old
 Elders: Constipation is common problem due to slowed peristalsis
 Many erroneously think regularity = daily BM
 Laxative overuse CAUSES constipation
 Teach: fiber, fluids, exercise, respond to reflex
 Diet (fiber and fluids present? __________ intolerance can lead to diarrhea & cramping)
 Position during defecation
 Pregnancy: constipation is common
 Diagnostic tests (barium can cause serious constipation)
 Activity (exercise promotes peristalsis)
 Psychological factors:
 Anxious/angry -> diarrhea
 Depressed -> constipation
 Defecation habits:
 Best: early AM bowel training in response to reflex
 In hospital, lack of privacy leads to ignoring the urge
 Many Meds Affect BMs:
 Narcotics: constipation
 Antibiotics: diarrhea
 Iron: black stools
 Surgery and anesthesia
 Slows or halts peristalsis
 Common Elimination Problems
 Constipation:
 Defining characteristics:
 less than 3 BMs/week
 Hard, dry formed stools
 Straining at stool; painful
 Feeling of incomplete emptying
 Abdominal pain, cramps or distension
 Decreased appetite
 Common Causes (low fiber and fluids; irregular bowel habits & ignoring urge; chronic illnesses,
stress, immobility, heavy use of laxatives)
 Valsalva maneuver can be deadly to some patients
 Impaction
 Unrelieved constipation resulting in collection of hard feces wedged in rectum that patient cannot
expel
 Especially at risk: confused or unconscious
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Signs: inability to pass stool for several days; continuous oozing of diarrhea stool; anorexia,
abdominal distension, nausea, vomiting
Diarrhea: increased frequency of loose stools
 Common causes: stress, infection, allergies, food intolerance, tube feedings, meds
 Rapid movement of contents so less water is absorbed; Can cause serious fluid and electrolyte
imbalances, especially in elderly and children
 Acidity causes skin breakdown in anal region
 First aim of treatment is to maintain hydration
Incontinence
 Inability to control passage of feces or flatus
 Treatment is based on cause
 Can lead to social isolation, change in body image
Flatulence
 3 sources:
 Action of bacteria on chyme in lg intestine
 Swallowed air
 Gas that diffuses b/t bloodstream and intestine
 Causes: foods, surgery, narcotics
 Can be severe causing abdominal distension and sharp pain
Hemorrhoids
 Mass of dilated blood vessels beneath skin of anus
 Causes: Straining, pregnancy, chronic disease like CHF and liver disease
 Passage of hard stool causes bleeding, itching and burning
 Bowel diversions
 Ostomies
 Ileostomy (ileum)
 Frequent liquid stools
 Acidic
 Colostomy (colon)
 Stool at regular intervals
 Depends on location and condition
 3 types
 Loop, end, double barrel
 Nursing Assessment
 History
 Usual pattern
 Usual characteristics of stool
 Specific routines to promote elimination
 Use of laxatives, enemas
 Presence of ostomies?
 Change in appetite
 Diet history
 Daily fluid intake
 History of illnesses, surgeries or meds
 Emotional state
 Exercise
 Any pain or discomfort?
 Any assistance required?
 Physical Exam
 Oral cavity & chewing
 Mobility: any need for assistance?
 Abdomen: observe, auscultate, palpate
 Stool characteristics
 Diagnostic Studies (see tutorials)
 Fecal Occult Blood Test (Hemoccult)– a screening tool
 Colonoscopy, Endoscopy, X-ray with contrast
 Barium Enema
 Stool specimens:
 Occult blood (Hemoccult); “positive” = blood present
 Stool Culture
 Ova and Parasites (O&P)
 Serum chemistry panel (“Chem 7”):
 If diarrhea, check electrolytes
 Nursing Diagnoses
 Bowel Incontinence
 Constipation
 Risk for Constipation
 Diarrhea
 Toileting Self Care Deficit
 Important to establish correct “related to” factor in order to select appropriate interventions
 Planning: Goals
 Maintain or restore normal bowel elimination pattern
 Maintain or regain normal stool consistency
 Prevent associated risks such as fluid/volume imbalance, skin breakdown, abdominal distension, pain
 Nursing Interventions
 Nutrition/Fluids
 If Constipation: increase fiber, fluids, prune juice
 If Diarrhea: fluids, small amts bland food, avoid spice, dairy products, fried foods
 If Flatulence: avoid gas producing foods (or increase slowly), carbonated fluids, straws, chewing
gum
 Exercise
 Timing and Privacy
 Promote normal defecation with positioning and paying attention to defecation reflex
 If on bedpan raise HOB to __________________
 Teach about side effects of meds
 Especially narcotics
 Monitor: Always ask “when was your last BM?”
 Bowel Training (for chronic constipation)
 Involves setting up a normal routine with measures to promote defection to gain control of reflexes
 For 2-3 weeks:
 Admin suppository 30 mins before designated time
 When feel urge, assist to toilet
 Provide privacy; allow 20-30 mins
 Teach: Lean forward, bear down, pressure on abdomen
 Medications R/T Bowel Elimination
 Bulk-forming: Ex: Psyllium (Metamucil)
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 Combines with water in intestinal contents to promote peristalsis
 Safe to use daily; can be used for chronic constipation or watery diarrhea
 take with plenty of water, works in 1-3 days
Stool softeners: (safe to use daily)
 Ex: Docusate sodium (Colace):
 PO prevents constipation by promoting incorporation of water into stool; works in 24-48 hrs
 Can also be used as rectal enema for impaction
Enemas (Ex: water or Fleet’s Enema)
 Often used for impactions
 Phosphat/biphosphate (Fleet’s enema): onset 2-5 minutes
 Used to treat constipation or as bowel prep
Laxatives: (only for short term therapy)
 Stimulant: Ex: Bisacodyl (Dulcolax)
 Treats constipation by stimulating peristalsis by altering fluid/electrolyte transport into colon
 PO: Onset 6-12 hours; Suppositories 15-60 minutes
 Osmotic: Ex: Milk of Magnesia (MOM)
 PO Magnesium salts osmotically draw water into intestine, distends bowel, stimulates peristalsis
in 3-6 hours
 Polyethylene glycol (Miralax)
 PO powder to dissolve in 8 oz of water; works in 2-4 days; may be used up to 2 weeks
 Polyethylene glycol/electrolyte (GoLYTLELY)
 Used for bowel cleansing in prep for GI procedures; PO; onset 1 hr
 Pt should fast 3-4 hrs prior to administration and only have clear liquids after administration
Anti-diarrheals
 Loperamide (Imodium):
 inhibits peristalsis and prolongs transit time by direct effect on nerves in intestinal wall
 Adults: 4mg PO initially then 2mg after each loose stool; can be used up to 10 days up to max
daily dose
 Bismuth subsalicylate (Pepto-Bismol):
 promotes intestinal absorption of fluids, contains aspirin; may turn stools black; contraindicated
in patients with impaction
 Psyllium (Metamucil): absorbs excess liquid
Antiflatulent
 Simethicone: coalesces gas bubbles and facilitates passage
 Evaluation
 Evaluate success of interventions
 Did you meet patient’s expectations?
 Optimally patient should be able to eliminate soft formed stools regularly
 Patient should have information to establish normal pattern