Download Bowel Elimination_

Pamela Llana, MSN, RN
Factors Affecting Bowel Elimination
• Age: 2-3 yrs old gain control of bowels; bowels before bladder; GI motility
decreases with age
• Diet: 25% of stool = cellulose/fiber. More fiber = BM, Less = BM
• Fluid Intake: Need 2000 mL/day for soft BM
• Physical Activity: Promotes muscle tone & increases peristalsis--more constipation in nursing homes
• Psychological Factors: Privacy important from early age
• Lifestyle/Personal Habits: Some have a routine/pattern. Others
just go when the urge hits. Alterations in routine: travel, stress,
depression lead to changes in bowel habits.
Factors Affecting Bowel Elimination
• Body Position: Sitting or semi-squatting. Gravity increases ease.
Bedpan makes it harder to go.
• Pain: May put off defecating if painful—hemorrhoids, fissures,
episiotomy, surgical incision.
• Pregnancy: Pressure on intestines; FeSO₄ (iron) pills constipate
• Surgery & Anesthesia: Bowels go to sleep too; May take days to wake
up. Then pain meds also constipating.
• Medications: SE of opioids and Fe = Constipation. May need laxatives,
stools softeners, anti-diarrhea agents
• Diagnostic Procedures: May need to empty colon before. If BA is used,
laxatives ordered afterwards—stool will be chalky and light colored
after BE.
Altered Bowel Function
• Constipation
– Decreased frequency of BMs and/or prolonged or
difficult passage of hard stools
– “Normal” frequency is highly individualized,
however “normal” frequency has been suggested
as anywhere from 3x/day to 3x/week
– May be due to decreased bulk, fluid intake, or
muscle tone, insufficient exercise, ignoring the
defecation reflex, or laxative abuse
Altered Bowel Function
• Fecal Impaction: Accumulation of hardened feces
in the rectum; lodged or stuck
– Unrelieved constipation
– Signs include oozing diarrhea, anorexia,
abdominal distension, cramping, N/V, and/or
rectal pain.
– Usually a history of no BM for several days
– Can also be caused by Barium
Altered Bowel Function
• Diarrhea
– Increased number of stools and passage of liquid,
unformed feces
– Can lead to F/E imbalance (F/E = fluid electrolyte)
– Possible causes – ABT, enteral nutrition, food
allergies/intolerances, C. difficile, surgery,
diagnostic tests
– ABT kill the normal flora of the gut
(ABT= antibiotic therapy)
Altered Bowel Function
• Fecal Incontinence
– May be secondary to diarrhea
– Possible causes include SCI, CVA, infection,
impaction, depression, sedatives, etc.
– Can cause body image alterations,
embarrassment, or skin breakdown
Altered Bowel Function
• Flatulence – certain foods increase amount of gas:
cabbage, onions, beans, high fiber foods
– Intestinal gas
– Inability to pass flatus can cause abdominal
distension, SOB, feeling of fullness or cramping;
abdomen may look large or distended.
– Possible causes include opiates, general
anesthesia, abdominal surgery, or immobility
Altered Bowel Function
• Hemorrhoids
– Distended rectal veins
– May be due to repeated straining at stool passage
– Symptoms may include itching, bleeding, or
burning after defecation, pain when sitting.
Assessment
• Nursing History
– Usual bowel elimination patterns: daily or q 2-3 days?
– Symptoms of altered bowel elimination patterns
– Factors affecting bowel elimination
– Ask: What is usual pattern? Characteristics of
usual stool? Any aids used? When was last BM?
Any changes in BM?
Assessment
• Physical Assessment
– Inspection of abdomen – Is it flat? Convex? Contour?
Concave? Distended? Symmetry?
– Ascultation – Listen for 5 full minutes p “no BS’s”. Are
the BS hypo/hyper active?
– Palpation – Light only for beginners
– Measurement of abdominal girth – “X” mark, tape
measure.
– Peri-rectal examination – side lying, knees flexed.
Fissures? Hemmorhoids? Bleeding? DRE – use lubed,
gloved finger. Feel walls of rectum, feel for stool.
Assessment
• Fecal Characteristics – Table 32-1 on page 1071
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Normal Color – brown
Consistency – soft is normal
Shape – cylindrical
Odor – pungent, aromatic
Amount – 100-300 gms/day is normal
Frequency – varies greatly
• Abnormal
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Black/tarry – indicates upper GI bleed or meds
Red – lower GI bleed or rectum/hemorrhoids
White/clay colored – barium or blocked bile system
Bloody mucus – Clostridium difficile or parasites
Assessment
• Specimen Collection
– Must be properly collected, labeled in correct
container, and preservatives added if necessary.
– Hand washing and gloves; use tongue blade when
collecting
– Make sure specimen is not mixed with urine or
toilet paper.
– Need 1” of formed stool or 15-30 mL of liquid
stool.
– Label with the date, time, and your initials
Assessment
• Diagnostic Tests & Procedures
– Fecal Occult Blood Test (Occult = hidden, not
obvious)
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Screening test for colon CA
Detects microscopic or occult blood in stool
May also be used to detect blood in stomach contents
Often referred to as Hemoccult
Should avoid certain foods and drugs as may cause false
positive
• Usually repeated a total of three times.
• Know Procedure 32-1 on pp. 1100-1101
Assessment
• Diagnostic Tests and Procedures
– Stool for culture- looking for causes like Shigella,
Salmonella, Clostridium difficile
– Stool for ova and parasites—like Giardia and
Entamoeba histolytica. Send specimen to lab
while still warm.
Assessment
• Diagnostic Tests & Procedures (continued)
– Radiographic
• Barium swallow – looks at upper GI
• Barium enema – looks at Lower GI tract
– Endoscopic
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Sigmoidoscopy – rectum and sigmoid colon
Colonoscopy – colon up to the ileocecal valve
Esophogastroduodenoscopy (EGD) – thru the mouth
Nursing Actions for these: Bowel prep, NPO teaching
After barium, laxatives until no more white stools
Nursing Diagnosis
• Constipation
• Perceived Constipation—patient makes self
diagnosis and ensures a BM by taking laxatives
• Risk for Constipation
• Diarrhea
• Bowel Incontinence
Implementation
• Constipation – Nurse is responsible for teaching
how to avoid bowel problems.
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Response to the urge to defecate – don’t ignore
Privacy and sufficient time – be sure to provide
Adequate fluid intake – 1,500-2000 mL/d
Positioning – upright as possible
Activity – increases peristalsis
Fiber – Increase bulk to increase stools
Laxatives, suppositories, and enemas – teach to use
sparingly; Table 32-4 pg, 1088
Implementation
Fecal Impaction
– Must have an MD order
– Avoid forceful pressure as it can cause mucosal
irritation and bleeding
– Monitor vital signs – HR can decrease with vagal
stimulation
– Enema: small vol = 150 mL, large vol = 1000 mL
– Lubrication with oil-retention enemas
Implementation
• Diarrhea
– Remove cause
– Respond promptly – dehydration or F/E imbalance
possible
– Antidiarrheal agents pg. 1088, table 32-5
– Maintain fluid/electrolyte balance
– Skin barriers
– Avoid irritation
– Promote return to normal bowel flora – yogurt,
acidophyllus milk
– Flexi-seal tube, if no relief
Implementation
• Flatulence
– Increased activity
– Avoid gas-producing foods
– Positioning
– Return-flow enema
– NGT or rectal tube
– Anti-flatulence agents – Gaviscon, Beano, etc.
Implementation
• Hemorrhoids
– Promote soft, formed stools
– Local heat or sitz bath
– Thermometers/enemas
– Moist wipes for cleansing
– Prescribed ointments/creams
Bowel Diversion
• Defecate – bowel exits through abdominal wall
• “Stoma” should be healthy pink
• Ileostomy – stool more liquid
• Transverse or Sigmoid Colostomy – stool soft to
firmer stool
• Ostomy Appliance – cut to fit around stoma
• Check skin around stoma frequently