Chapter 31
Bowel Elimination Bader A. EL Safadi BSN , MSc Fundamental of Nursing - B Asepsis 1 First semester 19 - 20
Islamic University of Gaza Faculty of Nursing
2 Bader A. EL Safadi BSN , MSc Fundamental of Nursing – B Bowel Elimination
Defecation
Defecation (bowel elimination):
Is the act of expelling feces (stool) from the body.
To do so, all structures of the gastrointestinal tract,
especially the components of the large intestine (also
referred to as the bowel or colon), must function in a
coordinated manner (Fig. 31-1).
In the large intestine, a remarkable volume of water is
removed from the remnants of digestion, causing the
bowel's contents to become a consolidated mass of
residue before being eliminated.
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Figure 31-1 • The large intestine
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Peristalsis
Peristalsis
Means the rhythmic contractions of intestinal
smooth muscle that facilitate defecation.
Peristalsis moves fiber, water, and nutritional
wastes along the ascending, transverse,
descending, and sigmoid colon toward the
rectum.
Gastrocolic reflex:
Increased peristaltic activity occurring during
eating
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The gastrocolic reflex usually precedes defecation.
Its accelerated wavelike movements, sometimes perceived as slight abdominal cramping, push stool forward, packing it within the rectum.
As the rectum distends, the person feels the urge to defecate.
Stool is eventually released when the anal sphincters relax.
Valsalva maneuver (closing the glottis and contracting the pelvic and
abdominal muscles to increase abdominal pressure)
It facilitates Defecation process
Several dietary, physical, social, and emotional factors can influence the bowel's mechanical function (Table 31-1).
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6 Bader A. EL Safadi BSN , MSc Fundamental of Nursing – B Bowel Elimination First semester 19 - 20
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Assessment of Bowel Elimination
A comprehensive assessment of bowel elimination
involves collecting data about the client’s elimination
patterns (bowel habits) and the actual characteristics of
the feces.
Elimination Patterns
It is essential to determine the client's usual patterns,
including frequency of elimination, effort required to
expel stool, and what elimination aids, if any, he or she
uses.
Stool Characteristics
Color, odor, consistency, shape, unusual components
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Common Alterations in Bowel Elimination
Constipation
Is an elimination problem characterized by dry, hard
stool that is difficult to pass. Various accompanying signs
and symptoms include the following:
Complaints of(C/O ) abdominal fullness or bloating
Abdominal distention
Complaints of(C/O ) rectal fullness or pressure
Pain on defecation
Decreased frequency of bowel movements
Inability to pass stool
Changes in stool characteristics such as oozing liquid
stool or hard small stool
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The incidence of constipation tends to be high among
those whose dietary habits lack adequate fiber (such as
not eating sufficient raw fruits and vegetables, whole
grains, seeds, and nuts).
Dietary fiber, which becomes undigested cellulose, is
important because it attracts water within the bowel,
resulting in bulkier stool that is more quickly and
easily eliminated.
Constipation is classified into one of four distinct types
(primary, secondary, iatrogenic, and pseudo
constipation), according to the underlying cause.
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1. Primary or simple constipation
Is well within the treatment domain of nurses.
It results from lifestyle factors such as inactivity,
inadequate intake of fiber, insufficient fluid intake, or
ignoring the urge to defecate.
2. Secondary constipation
Is a consequence of a pathologic disorder such as a
partial bowel obstruction.
It usually resolves when the primary cause is treated.
Types of Constipation
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3. Iatrogenic constipation
Occurs as a consequence of other medical treatment.
For example, prolonged use of narcotic analgesia tends
to cause constipation.
These and other drugs slow peristalsis, delaying transit
time.
The longer the stool remains in the colon, the drier it
becomes, making it more difficult to pass.
4. Pseudoconstipation (perceived constipation):
A term used when clients believe they are
constipated even though they are not (often overuse
laxatives, suppositories or enemas).
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Fecal impaction
Occurs when a large, hardened mass of stool
interferes with defecation, making it impossible for
the client to pass feces voluntarily.
Result from unrelieved constipation, retained barium
from an intestinal x-ray, dehydration, and weakness
of abdominal muscles.
Clients with a fecal impaction usually report a
frequent desire to defecate but an inability to do so.
Some clients with an impaction pass liquid stool,
which they may misinterpret as diarrhea.
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Flatulence or flatus :
Excessive accumulation of intestinal gas, results from:
1. swallowing air while eating or slow peristalsis
2.gas that forms as a byproduct of bacterial
fermentation in the bowel.
Vegetables such as cabbage, cucumbers, and onions are
commonly known for producing gas. Beans are other
gas formers.
Regardless of its cause, flatus may be expelled rectally,
thus reducing intestinal accumulation and distention.
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Diarrhea is :
“The urgent passage of watery stool and commonly is
accompanied by abdominal cramps”.
Simple diarrhea usually begins suddenly and lasts for
a short period.
Other associated signs and symptoms include nausea
and vomiting and blood or mucus in the stools.
Usually diarrhea is a means of eliminating an irritating
substance such as tainted food or intestinal pathogens.
Diarrhea may also result from emotional stress,
dietary indiscretions, laxative abuse, or bowel
disorders.
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Fecal incontinence:
is the inability to
control the elimination
of stool.
It does not necessarily
imply that stool is
loose or watery,
although that may be
the case.
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Measures to Promote Bowel Elimination
Nurses commonly use two interventions( inserting
suppositories and administering enemas) to promote
elimination when not naturally occurring or when the
bowel must be cleansed for other purposes, such as
preparation for surgery and endoscopic or x-ray
examinations
1. Insert a rectal suppository
2. Administer an enema
“ An enema introduces a solution into the rectum”
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Inserting a Rectal Suppository
Medications released from the suppository can have
local or systemic effects.
Depending on the drug, local effects may include
softening and lubricating dry stool, irritating the wall of
the rectum and anal canal to stimulate smooth muscle
contraction, and liberating carbon dioxide, thus
increasing rectal distention and the urge to defecate.
Lie on side with lower leg straightened out and upper leg bent
forward toward stomach.
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Administering an Enema
An enema introduces a solution into the rectum to :
1. Cleanse the lower bowel (most common reason).
2. Soften feces.
3. Expel flatus.
4. Soothe irritated mucous membranes.
5. Outline the colon during diagnostic x-rays.
6. Treat worm and parasite infestations.
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Cleansing Enemas
It is used to remove feces from the rectum (Table 31-3).
Solution Amount (ml) Mechanism of Action
Tap water 500-1000 Distends rectum, moistens
stool
Normal saline 500-1000 Distends rectum, moistens
stool
Soap and water 500-1000 Distends rectum, moistens
stool, irritates local tissue
Hypertonic saline
(ie: Fleets)
120 Irritates local tissue and draws
water into the bowel
Mineral, olive, or
cottonseed
120-180 Lubricates and softens
stool
21 Bader A. EL Safadi BSN , MSc Fundamental of Nursing – B Bowel Elimination
Retention enemas
o A retention enema uses a solution held within the
large intestine for a specified period, usually at least
30 minutes.
o Some retention enemas are not expelled at all.
o One type of retention enema is called an oil retention
enema because the fluid instilled is mineral,
cottonseed, or olive.
o Oils lubricate and soften the stool, so it can be
expelled more easily.
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Ostomy Care
A client with an ostomy (surgically created
opening to the bowel or other structure) requires
additional care for promoting bowel elimination.
Types of Ostomies
1. ileostomy (surgically created
opening to the ileum)
2. colostomy (surgically created
opening to a portion of the
colon; Fig. 31-4).
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Locations of intestinal Ostomies
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Most persons with an ostomy, also called ostomates,
wear an appliance (bag or collection device over the
stoma) to collect stool.
Depending on the type and location of the ostomy,
client care may involve providing peristomal care,
applying an appliance, draining a continent ileostomy,
and, for clients with a colostomy, administering
irrigations through the stoma.
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Figure 31-5 • An ostomy appliance: faceplate and pouch .
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Ostomy Care
Preventing skin breakdown is a major
challenge in ostomy care.
Enzymes in stool can quickly cause
excoriation (chemical injury of skin).
Providing peristomal care Applying an ostomy appliance
Draining a continent ileostomy
Irrigating a colostomy
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