Basic Human Needs
Bowel Elimination
Bowel Elimination
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GI Tract is a series of hollow mucous
membrane lined muscular organs
Purpose is to absorb fluids & nutrients, prepare
food for absorption & provide storage for feces
GI Tract Anatomy
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Mouth
Esophagus
Stomach
Small Intestine
Large Intestine
Rectum
Mouth
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Digestion begins here
Mechanical, chemical breakdown of nutrients
Teeth-Mastication
Salivary secretions-enzymes
Food Bolus
Esophagus
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Hollow, muscular tube for passage of food to
stomach
Peristaltic waves, contraction and relaxation of
smooth muscle moves food down to stomach
Sphincter control to prevent reflux
Stomach
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Food is temporarily stored and mechanically and
chemically broken down
Secretes HCL, mucus, pepsin, & intrinsic
factor(Needed for Vitamin B12 absorption)
Food is converted into chyme
Small Intestine
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1 inch in diameter
20 feet long
Three divisions: Duodenum, Jejunum, Ileum
Enzymes in small intestine (amylase, lipase, & bile)
break down fats, proteins & carbs into basic elements
Nutrients absorbed in duodenum & jejunum, ileum
absorbs vitamins, iron, & bile salts
Large Intestine
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Lower GI tract
Larger diameter, 5-6 feet in length
3 divisions: cecum, colon, rectum
Responsible for absorption of water
Primary organ of bowel elimination
Cecum-chyme enters cecum via the ileocecal valve,
valve prevents regurg back to small intestine, cecum
ends with appendix
Colon
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3 Divisions: Ascending, Transverse, Descending
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Colon Functions: Absorption, Protection,
Secretion, & Elimination (stool and flatus)
Flatus Formation
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Air swallowing
Diffusion of gas from bloodstream into intestines
Bacterial action on unabsorbable CHO (Beans)
Fermentation of CHO (cabbage, onions
Can stimulate peristalsis
Adult forms 400-700 ml of flatus daily
Rectum
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Sigmoid colon
Storage of feces
Length varies with age
When fecal mass or flatus moves into rectum, it
distends and defecation begins
Process involves involuntary (Internal sphincter) and
voluntary control (external sphincter)
Valsalva Maneuver- voluntary contraction of abdominal
muscles
Factors Affecting Bowel
Elimination
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Age
Infection
Diet
Fluid Intake
Physical Activity
Psychological factors
Personal Habits
Factors Affecting Bowel
Elimination
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Position during Defecation
Pain
Surgery and Anesthesia
Medications
Common Bowel Elimination
Problems
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Constipation
Impaction
Diarrhea
Incontinence
Flatulence
Hemorrhoids
Constipation
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More of a symptom than a disorder
Decrease in frequency of BM
Straining & pain on defecation is associated
symptoms(Valsalva maneuver)
Can be significant heath hazard (increase ICP,
IOP, reopen surgical wounds, cause trauma,
cardiac arrhythmias)
Impaction
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Results from unrelieved constipation
Collection of hardened feces wedged into
rectum
Can extend up to sigmoid colon
Most at risk: depilated, confused, unconscious
(all are at risk for dehydration)
Impaction
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When a continuous ooze of diarrheal stool
develops, impaction should be suspected
Associated S/S: Loss of appetite, abdominal
distention, cramping, rectal pain
Diarrhea
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Increase in number of stools & the passage of liquid,
unformed stool
Symptom of disorders affecting digestion, absorption,
& secretion of GI tract
Intestinal contents pass through small & large intestines
too quickly to allow for usual absorption of water &
nutrients
Diarrhea
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Irritation can result in increased mucus secretion, feces
become too watery, unable to control defecation
Excess loss of colonic fluid can result in acid-base
imbalances or fluid/electrolyte imbalances
Can also result in skin breakdown
Conditions that cause Diarrhea
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Emotional Stress
Intestinal Infection (Clostridium difficile)
Food Allergies
Food Intolerance
Tube Feedings (Enteral)
Medications
Laxatives
Colon Disease
Surgery
Incontinence
Inability to control passage of feces and gas
from the anus
 Caused by conditions that create frequent, loose,
large volume, watery stools or conditions that
impair sphincter control or function
Flatulence
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Gas accumulation in the lumen of intestines
Bowel wall stretches and distends
Common cause of abdominal fullness, pain, &
cramping
Gas escapes through mouth (belching), or anus
(flatus)
Hemorrhoids
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Dilated, engorged veins in the lining of the
rectum
External (Clearly visible) or Internal
Caused by straining, pregnancy, CHF, chronic
liver disease
Clicker Question
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1. A newly admitted client 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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Bowel Diversions
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Certain diseases cause conditions that prevent
normal passage of feces through rectum
Creates need for temporary or permanent
artificial opening (stoma) in the abdominal wall
Bowel Diversions
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Surgical openings (ostomy) are most commonly
formed in the ileum (ileostomy) or the colon
(colostomy)
Incontinent ostomy- need to wear appliance
pouch
Continent ostomy- have control through use of
ostomy cap
Incontinent Ostomy
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Location of ostomy determines consistency of stool
Ileostomy bypasses the entire large intestine, stools are
frequent & watery
Ascending colostomy- liquid stool
Sigmoid colostomy-most like normal stool
Incontinent Ostomies
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Loop colostomy- temporary, usually done on transverse
colon
2 openings through stoma, proximal loop for stool,
distal loop for mucus
End colostomy- one stoma formed from the proximal
end of the bowel with the distal portion removed or
sewn shut (Hartmann’s Pouch)
Incontinent Ostomies
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End colostomy usually done for colorectal cancer
Ruptured diverticulum- temporary end colostomy with
a Hartmanns Pouch
Double barrel colostomy- Bowel is surgically severed, 2
ends are brought out onto abdomen with 2 distinct
stomas (proximal & distal)
Continent Diversions
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Ileoanal reservoir- restorative proctocolectomy, no
outward stoma, no pouch wearing, clients have internal
pouch created from the ileum
Ileal pouches constructed in various configurations
(S,J,W)
End of the pouch is sewn or anastamosed to the anus
Continent Diversions
Ileoanal Reservoir
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Several stages to surgery to create pouch
May need temporary ostomy to allow time for
pouch to heal
Kegel exercises to increase pelvic floor muscle
tone
Continent Diversions
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Kock Continent Ileostomy-Internal reservoir or pouch
is created using piece of small intestine
Stoma brought out low on abdomen, end of internal
part in pouch is a one way nipple valve to promote
continence
Valve only allows fecal contents to drain when an
external catheter is place in stoma, no pouch required
Ostomy Nursing Considerations
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Patient Education
Care of stoma, appliance selection and use
Body Image considerations
Support groups (UOA)
Enterostomal nursing- specialty within
profession
Nursing Process
Assessment
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Nursing History
Physical Assessment
Lab Tests
Fecal characteristics
Diagnostic evaluation- Endoscopy,
Colonoscopy
Nursing Diagnosis
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Bowel Incontinence
Constipation
Diarrhea
Impaired Skin Integrity
Body Image Disturbance
Altered bowel elimination
Pain
Implementation
Promoting Normal Defecation and
Acute Care Management
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Positioning of patient-squatting
Positioning on bedpan
Use of cathartics, laxatives
Anti-diarrheal agents
Enemas
Digital removal of stool
Ostomy care
Fecal Incontinence Devices
Common Laxatives & Cathartics
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Metamucil-bulk forming
Colace, Surfak-emollient or wetting agent
Fleets, MOM. Mag Sulfate-saline agent
Dulcolax, Ex-Lax, Castor oil- stimulant cathartic
Haley’s MO, mineral oil- Lubricant
Enemas
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Cleansing enema
Tap water
Normal saline
Hypertonic Solutions (Fleet’s enema)
Soapsuds
Oil Retention
Medicated enemas (Kayexalate, Lactulose)
Administering a Cleansing enema P&P pg. 12001201
Nasogastric Tubes
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Decompress GI tract in surgery, infection of GI
tract, trauma to GI tract, conditions where
peristalsis is absent
N/G tube purposes- decompression, feeding,
compression, & lavage
Pliable tube inserted through nasopharynx into
stomach
Uncomfortable insertion
Nasogastric Tubes
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Types: Levin – single lumen, different sizes used for
feeding or decompression
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Salem Sump – Most preferable for decompression, dual
lumen, one for removal of gastric contents, one as an
air vent, hooked to suction to achieve decompression
Care of Nasogastric Tubes
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Confirm placement after insertion
HOB at 30 degrees unless ordered otherwise
Mark point where tube exits nose (AACN 2005)
Tape tube securely to nose
Tube Irrigation
Nasal skin care
Frequent oral hygeine
Assess for abdominal distention
Suction settings
Restorative Care
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Bowel training
Maintenance of proper fluid & food intake
Promotion of regular exercise
Promotion of Comfort
Maintenance of skin integrity
Promotion of self concept
Clicker Question
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2. To maintain normal elimination patterns in
the hospitalized client, you should instruct the
client 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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