Chapter 46
Bowel Elimination
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
Organs of the Gastrointestinal (GI)
Tract
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Case Study

Mr. Gutierrez resides in an assisted-living apartment
of a long-term care center. He keeps busy in his
small garden plot and enjoys other activities of the
center, such as nightly card games and outings to
baseball games. He is 82 years old and widowed and
has lived in the area for longer than 3 years. His
family, with whom he is quite close, is scattered
across the country. He has one niece, who lives in
the same town. Mrs. Gutierrez feels he is in good
health; as long as he eats green chili peppers every
day, he believes he will remain healthy.
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Segmented and Peristaltic Waves
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Divisions of the Large Intestine
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Case Study (cont’d)


Because Mr. Gutierrez has a small kitchen in his
apartment, he is able to make some of his favorite
foods. His diet consists of flour and corn tortillas,
beans, and rice. He likes most meats, but he prefers
chicken and as ado (made with pork). For breakfast,
he usually has hues rancheros. He has been
hospitalized only twice—once for the flu and once for
placement of a pacemaker.
He presently takes three medications: digoxin, Zestril,
and Metamucil.
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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
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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
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Bristol Stool Form Scale
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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
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Case Study (cont’d)


This afternoon Mr. Gutierrez has telephoned his
niece for the fourth time. He reports, “My bowels are
locked up and haven’t moved in the last 2 days.” He
ate a big meal the previous evening and now reports
feeling “all gassed up.”
His niece tried to explain about eating foods
containing fiber and more vegetables. She reminded
Mr. Gutierrez that the nursing student was coming
later this afternoon, and he could talk to the student
about his problem.
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Bowel Diversion

Temporary or permanent artificial opening in
the abdominal wall


Surgical opening in the ileum or colon


Stoma
Ileostomy or colostomy
The standard bowel diversion creates a
stoma.
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Loop Colostomy
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End Colostomy
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Double-Barrel Colostomy
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Ostomies

Loop colostomy


End colostomy


This is temporary in the transverse colon.
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.
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Case Study (cont’d)


Vickie is the nursing student assigned to Mr. Gutierrez. She has
been seeing him once a week for 5 weeks as a portion of a
home health care clinical experience. They have developed a
good rapport. Mr. Gutierrez’ self-identified problems with his
bowels are a frequent topic of conversation.
As Vickie prepares to assess Mr. Gutierrez, she reflects on
experiences with other patients in the home setting. She recalls
one patient who had elimination problems resulting from a diet
consisting mainly of high-fat and high-carbohydrate foods. She
believes that her involvement with that patient is likely to help in
Mr. Gutierrez’ care.
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Ileoanal Pouch Anastomosis
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Construction of Kock Pouch
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Macedo-Malone Antegrade
Continence Enema (MACE)
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Alternative Approaches

Ileoanal pouch anastomosis


Kock continent ileostomy


Small intestine forms a pouch, which is emptied several
times a day.
Macedo-Malone antegrade continence enema
(MACE)


Pouch is a reservoir for wastes that are eliminated from the
anus.
This procedure was developed for patients who have
neuropathic or structural abnormalities of the anus.
Psychological considerations
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Case Study (cont’d)


Vickie reviews her class notes on the anatomy and physiology
of the GI system. Vickie reviews the physiological changes that
aging produces within the GI system: loss of teeth, taste bud
atrophy, decreased secretion of gastric acid, and a slight
decrease in small intestine motility.
Vickie will thoroughly assess Mr. Gutierrez’ dietary intake with a
24-hour diet recall. Being familiar with his Hispanic heritage,
Vickie anticipates certain food preferences. She knows he does
not like the food served at the center and frequently requests
“home-cooked” tortillas and green chili peppers from his niece.
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Quick Quiz!
1. A newly admitted patient states that he has
recently had a change in medications and
reports that stools are now dry and hard to
pass. This type of bowel pattern is consistent
with
A. Abnormal defecation.
B. Constipation.
C. Fecal impaction.
D. Fecal incontinence.
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Case Study (cont’d)

From their last visit, Vickie and Mr. Gutierrez
have been able to communicate without
difficulty. Mr. Gutierrez complains of feeling
“full of gas” but has not “passed any wind” in
the past 2 days. His stove has not been
working well, and he has been unable to
prepare rice and beans. Based on the nursing
history, Vickie estimates that Mr. Gutierrez
normally drinks about 1200 mL of fluid daily.
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Nursing Process: Assessment

Nursing history


What a patient describes as normal or abnormal is
often different from factors and conditions that
tend to promote normal elimination.
Identifying normal and abnormal patterns, habits,
and the patient’s perception of normal and
abnormal with regard to bowel elimination allows
you to accurately determine a patient’s problems.
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Assessment

Physical assessment


Laboratory tests



Mouth, abdomen, and rectum
Fecal characteristics
Fecal specimens
Diagnostic examinations




Radiologic imaging, with or without contrast
Endoscopy
Ultrasound
Computed tomography (CT) or magnetic resonance imaging
(MRI)
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Case Study (cont’d)
Determine when
Mr. Gutierrez had
his last bowel
movement.
He had his last bowel movement 2 days
ago. The stool was brown and hard. “I
took a laxative last night, and I think I
need an enema.”
Determine Mr.
Gutierrez’
medication history.
A medication history shows that Mr.
Gutierrez frequently resorts to taking
laxatives.
Establish Mr.
Gutierrez’ dietary
habits.
Mr. Gutierrez eats a high intake of corn
tortillas and cheese and a low intake of
fruits. He states, “I really haven’t felt like
eating today and have not eaten much
for the last 4 days.”
Assess Mr.
Gutierrez’
abdomen.
Hypoactive bowel sounds in all four
quadrants. Abdomen is soft but slightly
distended.
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Fecal Occult Blood Testing
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Fecal Occult Blood Testing (cont’d)
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Nursing Diagnosis and Planning
Constipation
Bowel
incontinence

Risk for
constipation
Diarrhea
Perceived
constipation
Toileting selfcare deficit
The Agency for Healthcare Research and
Quality (AHRQ) provides guidelines on
reduction of pressure ulcers that can also
help you develop a plan of care for patients
with bowel incontinence.
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Case Study (cont’d)


Nursing diagnosis: Constipation related to
less than adequate fluid and dietary intake
and chronic laxative use
Goals:


Mr. Gutierrez will establish and maintain a normal
defecation pattern within 1 month.
Mr. Gutierrez will identify practices that reduce the
risk for or prevent constipation within 2 weeks.
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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
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Types of Bedpans
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Proper and Improper Position on a
Bedpan
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Positioning Immobilized Patient on
Bedpan
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Case Study (cont’d)





Instruct Mr. Gutierrez in a weekly menu plan,
including foods high in fiber: brown rice, beans and
rice, tomatoes, and wheat tortillas.
Add bran flakes, bran, or fiber supplement to Mr.
Gutierrez’ diet.
Consult with Mr. Gutierrez’ niece and long-term care
center to have the patient’s stove repaired.
Educate Mr. Gutierrez about the use of liquids to
promote softening of stool and defecation; have him
drink a decaffeinated beverage of choice.
Encourage Mr. Gutierrez to try to establish a routine
time for defecation, establishing a routine after
breakfast or another meal.
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Acute Care: Medications

Cathartics and laxatives



Oral, tablet, powder, and suppository forms
Excessive use increases risks for diarrhea and
abnormal elimination.
Antidiarrheal agents


Over the counter
Opiates used with caution
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Enemas

Types:



Cleansing
• Tap water
• Normal saline (infants and children)
• Hypertonic solutions
• Soapsuds
Oil retention
Others: carminative and Kayexalate
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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.
Digital removal of stool



Use if enemas fail to remove an impaction.
This is the last resort for constipation.
A health care provider’s order is necessary to
remove an impaction.
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Inserting and Maintaining a
Nasogastric Tube

Purposes


Categories of nasogastric (NG) tubes




Decompression, enteral feeding, compression,
and lavage
Fine- or small-bore for medication administration
and enteral feedings
Large-bore (12-French and above) for gastric
decompression or removal of gastric secretions
Clean technique
Maintaining patency
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Quick Quiz!
2. To maintain normal elimination patterns in the
hospitalized patient, you should instruct the
patient to defecate 1 hour after meals
because
A. The presence of food stimulates peristalsis.
B. Mass colonic peristalsis occurs at this time.
C. Irregularity helps to develop a habitual pattern.
D. Neglecting the urge to defecate can cause diarrhea.
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Continuing and Restorative Care

Care of ostomies


Pouching ostomies


Irrigating a colostomy
An effective pouching system protects the skin, contains
fecal material, remains odor free, and is comfortable and
inconspicuous.
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.
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Irrigating a Colostomy
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Continuing and Restorative Care

Bowel training





Training program
Diet
Promotion of regular exercise
Management of hemorrhoids
Skin integrity
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Case Study (cont’d)
Review Mr. Gutierrez’
diary of foods, and ask
him about his intake as
well.
Mr. Gutierrez describes likes and
dislikes but admits to eating high-fat
foods and few fruits and vegetables.
Fluid intake averaged 1400 mL daily
for a week.
Ask Mr. Gutierrez about
his pattern of
elimination over the
past 2 weeks and
laxative use.
Mr. Gutierrez says, “I still go about
the same” but states that he thinks
he now goes about every 2 days.
Mr. Gutierrez has not used any
laxatives for a week.
During follow-up visit,
examine patient’s
abdomen and observe
stool (if possible).
Patient reports that stool is formed
but is “not hard like before.” Bowel
sounds are normal. Abdomen is soft
and nontender with no distention.
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Evaluation




Do you use medications such as laxatives or
enemas to help you defecate?
What barriers are preventing you from eating
a diet high in fiber and participating in regular
exercise?
How much fluid do you drink in a typical day?
What types of fluids do you normally drink?
What challenges do you encounter when you
change your ostomy pouch?
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Case Study (cont’d)



Vickie returns to see Mr. Gutierrez 2 weeks later. Vickie is eager
to determine whether her patient has made changes in his diet,
and if his problems with bowel elimination have been
progressing. Vickie is also eager to learn if his stove has been
repaired.
Mr. Gutierrez tells Vickie that he has been eating bran cereal in
the morning, has been eating rice and/or beans for dinner, and
has added one fruit each day to his diet.
He has been walking twice a day through the long-term care
center. Although he does not have a bowel movement each day,
his stools are much softer and easier to pass, and he says he is
less concerned. He has not taken a laxative for a stool since last
talking with Vickie.
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