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Chapter 46
Bowel Elimination
Organs of the Gastrointestinal (GI)
Tract
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.
Segmented and Peristaltic Waves
Divisions of the Large
Intestine
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
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
Bristol Stool Form Scale
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
Bowel Diversion
 Temporary or permanent artificial opening in the
abdominal wall
 Stoma
 Surgical opening in the ileum or colon
 Ileostomy or colostomy
 The standard bowel diversion creates a stoma.
Loop Colostomy
End Colostomy
Double-Barrel Colostomy
Ostomies
 Loop colostomy
 This is temporary in the transverse colon.
 End colostomy
 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.
Alternative Approaches
 Ileoanal pouch anastomosis
 Pouch is a reservoir for wastes that are eliminated from the anus.
 Kock continent ileostomy
 Small intestine forms a pouch, which is emptied several times a
day.
 Macedo-Malone antegrade continence enema (MACE)
 This procedure was developed for patients who have
neuropathic or structural abnormalities of the anus.
 Psychological considerations
Continuing and Restorative Care
 Care of ostomies
 Irrigating a colostomy
 Pouching ostomies
 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.
Irrigating a Colostomy
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.
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.
Assessment
 Physical assessment
 Mouth, abdomen, and rectum
 Laboratory tests
 Fecal characteristics
 Fecal specimens
 Diagnostic examinations




Radiologic imaging, with or without contrast
Endoscopy
Ultrasound
Computed tomography (CT) or magnetic resonance imaging
(MRI)
Fecal Occult Blood Testing
Fecal Occult Blood Testing (cont’d)
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.
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.
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
Proper and Improper Position on a
Bedpan
Positioning Immobilized Patient on
Bedpan
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.
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
Enemas
 Types:
 Cleansing




Tap water
Normal saline (infants and children)
Hypertonic solutions
Soapsuds
 Oil retention
 Others: carminative and Kayexalate
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.
Continuing and Restorative Care
 Bowel training




Training program
Diet
Promotion of regular exercise
Management of hemorrhoids
 Skin integrity
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.
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?
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.
Nursing Diagnosis
 (Risk for) Constipation R/T
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Opiate containing meds
Decreased fiber intake
Decreased fluid intake
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Recent anesthesia
Stress
Inactivity (immobility)
Eating a large amount of dairy products
AEB no stool in 3 days
 Outcome: Pt will have a soft, formed stool in 24 hours.
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Assessments
 Assess for s/s of constipation






Decrease in frequency of bowel movements
Consistency of stool
Anorexia
Abdominal distention and pain
Feeling of fullness or pressure in rectum
Straining during defecation
 Assess bowel sounds
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Therapeutic Interventions
 Encourage fluid intake of at least 1500 ml/24hr
 Encourage activity: walk pt in hallway 4 times a day
 Encourage to defect whenever urge is felt
 Assist to BR, BSC or bedpan (put pt in high Fowlers)
 Provide for privacy
 Encourage to drink hot liquids in AM
 Administer laxatives or enemas as ordered
 Consult with HCP to check for impaction
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Teaching
 Teach to increase intake of foods high in fiber
 Teach importance of activity
 Teach reasons for changing opioid medication to a
non-opioid medication
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