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Fundamentals of Nursing Care: Concepts, Connections, & Skills
Chapter 30
Bowel Elimination and Care
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Gastrointestinal (GI) Tract
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Mouth
Anus
Waste products—feces or stool
Process of bowel elimination—defecation
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Peristalsis
 Consists of rhythmic wavelike movements
beginning in the esophagus and continuing to
the rectum
 Involves contraction of the circular and
longitudinal muscles in the walls of the GI
tract
 Propels the bolus of food through the GI tract
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Process of Digestion, Absorption,
and Metabolism of Nutrients
 Bowel elimination occurs after nutrients are moved
through the GI tract
 In the stomach, enzymes break down the bolus of
food, converting it to chyme
 The chyme passes through the pyloric sphincter and
into the small intestine, where the nutrients are
absorbed
 The remaining chyme passes through the illeocecal
valve into the large intestine to be passed as stool
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Changes Through Life Cycle
 Infants—three to six bowel movements
(BM)/day
 Children—one to two/day
 Elderly—peristalsis slows—more prone to
constipation or hard stools that are difficult to
pass
 At least every three days
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Timing of Elimination
 Introduction of food stimulates peristalsis
 Urge to defecate
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30 minutes to 1 hour after eating
If ignore feeling
More water absorbed from stool—dry and hard
Resulting in constipation
 Toileting after meals
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Characteristics of Feces
 Color, shape, consistency, odor, and frequency
 Diet, amount of fiber and fluids, exercise,
medications, and other habits
 Disease process can change characteristics
 Assessment is important
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Normal
 Soft, formed, light yellowish-brown to dark
brown, and slightly odiferous and slightly
curved shape
 Color—vary by dietary intake
 Spinach—greenish-black streaks
 Beets—red
 Iron—very dark brown or black
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Abnormal Characteristics
 Small balls or clumps
 Inadequate fluid intake
 Transit time is prolonged
 Liquid or semiliquid
 Transit time is extremely short
 Diarrhea
 Three or more liquid or watery stools/day
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Abnormal Characteristics
 Other factors affecting consistency or shape
 Amount of fiber intake
 Bulk up
 Increase in amount of ingested fat
 Steatorrhea—high amount of undigested fat in stool
 Fluffy, float on water and foul odor
 Malabsorbption disorder—Crohn’s disease
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Abnormal Characteristics
 Ribbon shaped stool
 Compression of the colon
 Tumor
 Mucus, blood or pus in stool
 Inflammation
 Infection
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Abnormal Characteristics
 Examples
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Ulcerative colitis
Slimy or mucus coated stool
Traces of blood or pus
Parasites, worms or eggs
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Abnormal Characteristics
 Clay colored or pale white stools
 Absence of bile in intestines
 Antacids or x-ray barium
 Bright red blood visible to naked eye
 Frank blood
 Blood in stool not visible naked eye
 Occult blood
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Abnormal Characteristics
 Blood in stool
 Specks or traces of bright red blood
 Torn hemorrhoid
 Large amounts of frank blood
 Bleeding or hemorrhage from the colon
 Blood from higher in digestive tract—stomach
 Partially digested, old blood odor, black, tarry
appearance--melena
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Abnormal Characteristics
 Bleeding from small intestine
 Maroon-colored
 Large hemorrhage from stomach or intestines
 Large volume of bright red or frank blood
 All bleeding serious until proven otherwise
 Report to physician
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Alterations in Bowel Elimination
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Constipation
Diarrhea
Fecal Impaction
Fecal Incontinence
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Constipation
 Less frequent, hard, formed stools
 Difficult to expel
 Degrees of severity—no complaints to…….
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Bloated feeling
Malaise
Cramping
Anorexia
Not feeling well
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Constipation
 Important to know when was last bowel
movement (BM)
 Elderly at increased risk
 But with proper nursing care
 Should be minimal
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Diarrhea
 Loose or watery stools occurring three or
more times/day
 May or may not have cramping or tenesmus
(increased rectal pressure—feeling of need to
defecate)
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Problems Associated with Diarrhea
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Perianal skin excoriation
Dehydration
Electrolyte imbalance
Most at risk
 Elderly and very young
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation / Diarrhea
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Change in activity level
Change in dietary intake
Change in water source
Change in fluid volume intake
Side effects of medication
Side effects of surgery
Pregnancy
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation / Diarrhea
 High stress levels and emotional
problems
 Laxative abuse
 Aging process
 Structural changes
 Chemical changes
 Food allergies
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation/Diarrhea
 Changes in activity level
 Physical activity stimulates peristalsis
 Hospitalized—decreased activity
 Slower peristalsis
 Increased risk of constipation
 Carefully track and document patient’s BM’s
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation/Diarrhea
 Changes in dietary and fluid intake
 Foods that slow peristalsis
 Processed sugar products
 Low fiber foods
 Decreases stool mass and peristalsis
 Increasing risk for constipation
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation/Diarrhea
 Changes in dietary and fluid intake
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Fiber is good—25 to 35 g/day
Whole grains, fruits, vegetables
GRADUALLY increase
Too much fiber
 Excessive flatus
 Can actually constipate if not enough fluid intake
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Foods High in Fiber
 Fruit—especially raw
 Apples (unpeeled), blueberries, cherries, oranges,
pears (unpeeled), plums, prunes, raisins,
raspberries and strawberries
 Vegetables—especially raw
 Artichokes, beans, broccoli, cabbage, carrots,
cauliflower, corn and legumes
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Foods High in Fiber
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Whole-grain breads, cereals and flour
Dried fruits
Flaxseed
Nuts
Oatmeal
Popcorn
Sunflower seeds
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes in Constipation/Diarrhea
 Eating at irregular intervals = irregularity of
BM’s
 Three meals/day at regular intervals
 More regular patterns with BM’s
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation/Diarrhea
 Lactose intolerance
 Inability to digest dairy products
 can cause diarrhea when dairy products
consumed
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation/Diarrhea
 Fluid Intake
 Not enough fluid intake
 Harder stool
 Body absorbs the fluid to maintain fluid and
electrolyte balance
 Result—not enough fluid in colon to keep stool
soft
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation/Diarrhea
 Side effects of medication
 Over the counter
 Maalox—may cause diarrhea
 Tums—may cause constipation
 Iron supplement
 Constipation
 Usually prescribed stool softener
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation/Diarrhea
 Narcotic pain medication
 Slows intestinal peristalsis
 Increased risk of constipation
 Antibiotics
 Kill good bacteria—normal flora
 Opportunistic infections can develop
 Result—diarrhea
 Example--_____________________
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation/Diarrhea
 Side effects of surgery
 Anesthesia
 Slow or completely stop peristalsis
 GI surgery
 Handling of bowel—slows peristalsis
 Post-op pain
 Pain medicine
 Decreased activity
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation/Diarrhea
 Pregnancy
 ↓ stimulation of muscles in digestive tract
 Crowding of sigmoid colon
 Result—constipation
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation/Diarrhea
 High stress and emotional problems
 Stress
 ↑ peristalsis and mucus production—diarrhea
 Emotional problems
 Depression
 ↓ peristalsis--constipation
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation/Diarrhea
 Laxative abuse
 Laxative use to promote daily BM’s
 Physically and/or psychologically dependent
 Bowel loses muscle tone and natural
contractibility
 BM is then dependent on laxative
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation/Diarrhea
 Structural changes
 Diverticulosis—wall of colon weakens and form
pouches (diverticulum)
 Not completely understood but high pressure
exerted on intestinal walls
 High fiber diet—stool bulky and easily moves
through colon
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation/Diarrhea
 Diet low in fiber—colon exerts more pressure
moving small, hard stool
 Low fiber—stool remains in bowel longer which
adds to the pressure
 Most people with diverticulosis do not have
symptoms
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation/Diarrhea
 Pouches can trap fecal matter
 Pouch becomes inflamed
 Diverticulitis
 Diarrhea and severe cramping
 If not treated—diverticuli can rupture
 Fecal matter spills into abdominal cavity
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation/Diarrhea
 Peritonitis
 Life-threatening infection
 s/s—malaise, anorexia, nausea, vomiting,
abdominal distention, ↓ or absent bowel sounds
and fever (or hypothermia if more advanced)
 Abdominal pain may be mild or severe—classic
sign of peritonitis—constant intense pain that
worsens with movement
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation/Diarrhea
 Nerves of sigmoid colon, rectum and anal
sphincters—sense the presence of stool in the
rectum and need to defecate
 Nerves damaged or severed
 Unable to sense need to defecate
 No control over sphincters to retain or expel stool
 Result– constipation, impaction and/or
incontinence
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation/Diarrhea
 Chemical changes
 Inflammatory processes
 Autoimmune disorders
 Bacteria or viruses (gastroenteritis)
 Inflammation causes edema and ↑ mucus
production
 Inhibits absorption and ↑ peristalsis
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation/Diarrhea
 Result
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Nausea
Vomiting
Cramping
Diarrhea
Dehydration
Malnutrition
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Causes of Constipation/Diarrhea
 Allergies
 Food
 Environmental
 Can cause edema and inflammation
 ↑ peristalsis—diarrhea
 Inhibit absorption
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Fecal Impaction
 The blockage of the movement of contents
through the intestines by a bulk mass of very
hard stool
 May occur in the rectum, sigmoid flexure or
any part of the large colon
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Fecal Impaction
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Elderly, inactive patient’s, severely dehydrated
Common cause—abuse of laxatives
Possible indication—liquid stool
Differentiate between diarrhea and impaction
Complication—obstruction or perforation of
bowel
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Fecal Incontinence
 Voluntary control is lost
 Beyond patient’s control
 Spinal cord injury
 Disoriented patient’s
 Source of guilt, embarrassment, and
destruction of self-esteem
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Fecal Incontinence
 What can be done?
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Bowel training
Proper cleansing and barrier creams
Fecal incontinence pouch
Maintain patient’s dignity—never refer to as
diapers
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Nursing Responsibilities
 Assessment of BM and documentation
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Color
Amount
Consistency
Unusual shape
Unusual odor
 Know date of last bowel movement
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Nursing Interventions to Promote
Bowel Function
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Increase physical activity
Ensure adequate fluid: up to 2,500 mL/day
Increase fiber intake to 20 to 30 g/day (gradually!!)
Provide privacy
Position patient upright for elimination
Provide stimulants that “cue” bowel function at
home, such as a cup of hot coffee before breakfast
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Subjective Assessment
 On admission to hospital
 Subjective information of patient’s normal
bowel habits
 Any current problems with BM’s
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Objective Assessment
 Physical assessment
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Shape of abdomen
Normal—rounded or flat
Abnormal—distended or inflated
Distention—excessive gas, fluid, or stool
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Objective Assessment
 Auscultate bowel sounds
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Diaphragm portion of stethoscope
Listen in all four quadrants
Once per shift or more often if indicated
Soft gurgles or irregular clicks
Between 5 and 30/minute
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Objective Assessment
 Bowel sounds
 <5/minute—hypoactive bowel sounds
 >30/minute or continuous—hyperactive bowel
sounds
 May indicate obstruction—high pitched, tinkling
sounds in one area and absent or decreased
sounds in the distal portion
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Bowel Sounds
 http://www.youtube.com/watch?v=kmLqONG248
 http://www.practicalclinicalskills.com/abdomi
nal-lessonauscultation.aspx?coursecaseorder=6&coursei
d=120
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Objective Assessment
 An absence of bowel sounds indicates a
problem and should always be reported to the
physician
 To determine absent bowel sounds—listen 3
to 5 minutes in each quadrant
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Objective Assessment
 Assessment of abdomen
 Inspection
 Auscultation
 Palpation
 Palpation
 Normal—soft
 Abnormal—firm or hard—excessive gas,
constipation, or obstruction
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Management
 Universal precautions
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Possibility of contact with feces
Incontinent patient
Emptying bedpan or bedside commode
Removing an impaction
Collecting stool specimen
Administering enema
Providing colostomy care
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Management
 Altering dietary intake related to diarrhea
 Clear liquid diet first 24 hours
 Decaffeinated green or black teas or herbal teainflammation, slow peristalsis
 Sports drinks—replace electrolytes
 Avoid extremely hot or cold liquids first 24 hours
 Longer than 24 to 36 °--full liquids and cooked
fruits or vegetables
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Management
 Diarrhea due to loss of normal flora—yogurt
 Concurrent use with antibiotics—prevent the
loss of normal flora
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Management
 Medications
 Coat the mucous membranes of the bowel
 Inhibit peristalsis
 Treat the disease or infectious process
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Management
 Lactobacillus acidophilus
 Supplement
 Replace normal flora
 Medications for constipation
 Increase peristalsis
 Soften stool
 Add bulk to stool
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Management
 Enema
 Instillation of solution into the colon via the
rectum
 Temperature—between 105 to 110° F—to avoid
burning intestinal mucosa
 Test—should feel warm, NOT HOT
 Too cool—cause cramping—decrease retention
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Management
 Position*
 Left lateral side-lying or Sims’
 Insert tip of tubing 3 to 4 inches (adult)
 Rectum, sigmoid colon, and descending colon
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Management
 Cleansing enema
 Relief of constipation
 Empty and cleanse the bowel prior to surgery or
testing
 Large volume enema—500 to 1,000 ml
 Small volume enema--<250 ml, usually 90 to 120
ml
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Management
 Order—enemas til clear
 Enemas administered until the expelled solution
no longer contains feces and is relatively clear
 Within a LIMIT of three 1,000 ml enemas
 Avoid giving more than 3 large volume enemas
consecutively
 Cause fatigue and irritation of intestinal lining
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Management
 Types of solutions
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Tap water
Normal saline
Soapsuds
Commercially prepackaged small volume oil or
sodium phosphate solutions
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Management
 Soapsuds
 Castile soap—5 ml/1,000m of solution—no
substitutes—other soaps too harsh—damage
intestinal lining
 Distends intestine and irritates the walls of
intestines to further stimulate peristalsis
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Management
 Tap water
 Hypotonic!—body absorbs—fluid overload
 High risk individuals?
 Infants, children, pt. with CHF, fluid retention
 Normal Saline
 Isotonic
 Safe for high risk individuals
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Management
 Hypertonic
 May be used in small volumes for adults
 Fleet’s enema
 Not used in large volume enemas—increased risk
of fluid and electrolyte imbalances
 Milk and molasses enema—hypertonic—
persistent constipation or impaction removal—
follow agency policy
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Management
 Oil retention
 Soften hard stool of an impaction to ease removal
 Small volume—90 to 120 ml
 Allow time to soften stool—approx. one hour
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Management
 Medicating enema
 Steroid—decrease inflammation
 Kayexalate enema—to lower a very high
potassium level
 Must retain in bowel—solution pulls K+ from
bloodstream into solution to be expelled
 Follow agency policy
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Management
 Return flow enemas
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Aka Harris flush
Remove flatus or gas
Tap water or saline
Small volume—100 to 200 ml
Then lower container below level of rectum—fluid
and gas returned—bubbles—continue til no
bubbles—Follow agency policy
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Management
 If a high enema is ordered
 Start with patient on left side—instill half of
solution—supine—then right lateral side for rest
of solution
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Enema
 Check order
 Contraindications?
 Activity and cognitive level of patient
(preparation)
 GI assessment
 Gather supplies
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Enema
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Close clamp
Fill container
Castile soap (5 ml/1000 ml)
Prime tubing
Lubricate tubing
Insert 3 to 4 inches toward umbilicus
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Enema
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Patient’s hip level—open clamp
Gradually elevate container
Instill slowly
Too fast—unable to hold, cramping,
discomfort
 C/O cramping—clamp, breathing, wait
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Enema
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Monitor for s/s vagal stimulation
When completed—clamp—remove tubing
Cover end of tubing
Instruct patient to hold solution at least 15 to
20 minutes
 Document results ……
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Digital Removal of Impaction
 Can be embarrassing and painful
 Oil retention enema or pain med
 Prior to procedure
 Delegate? Need an order?
 Review patient history—contraindications?
 Monitor for s/s of vagus nerve stimulation
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Digital Removal of Impaction
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Privacy
Proper position and safety
Underpad
Receptacle
Gloves
Lubricant
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Digital Removal of Impaction
 GENTLY insert finger
 Place finger between outside of the fecal and
mass the intestinal wall
 Bend finger inward toward fecal mass
 Break up mass—gently
 Remove small pieces
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Digital Removal of Impaction
 Monitor patient throughout procedure
 Clean patient and supplies
 Document
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Contraindications
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Rectal surgery
Severe bleeding hemorrhoids
Ulcerative colitis or Crohn’s disease
Rectal fissure or rectal cancer
Excessive bleeding potential due to disease or
medication
 Certain heart conditions
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Complications
 Two serious complications
 Vagal response
 Perforation of intestinal wall
 Vagus nerve
 Innervates heart, bronchioles, as well as the
gastrointestinal (GI) tract
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Complications
 Insertion of the enema tube or a finger for
impaction removal can stimulate the vagus
nerve
 When stimulated—can drop the heart rate to
30 to 40 bpm and cause constriction of the
bronchioles of the lungs
 If continues longer than a few minutes—
inadequate blood pressure and circulation
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Complications
 S/S of vagus nerve stimulation
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Chest pain or chest heaviness or pressure
Shortness of breath or inability to breathe
Dizziness
Feel like fainting
Nausea
Pallor
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Complications
 S/S of vagus nerve stimulation
 Clammy skin
 Pulse rate <60 bpm
 STOP enema or removal of impaction
 Remove the tube or finger from the rectum
 Position supine
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Complications
 Assess pulse rate, skin color, and is patient
diaphoretic?
 Call for assistance—do not leave patient
 If pulse <60—place in shock position—head
lower than feet
 Assess blood pressure
 Supply oxygen if needed
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Complications
 Perforation of colon
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GENTLY insert tubing
Never force
Do not insert further than 4 to 6 inches
Direct tip of tubing toward umbilicus—follows
natural direction of colon
 Proper positioning
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Laboratory Tests to Determine the
Cause of Bowel Alterations
 Guaiac test (occult blood test)
 Tests for presence of blood in the stool
 Culture and sensitivity (C&S)
 Identifies microorganisms infecting the stool and
the antibiotics that will kill the microorganisms
 Ova and parasite test (O&P)
 Tests for presence of parasitic worms and their
eggs
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Collection
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Clean and dry bedpan or collection container
Can not mix specimen with urine
Wear gloves
Clean tongue blade
Collect from 2 different areas of stool—
especially an abnormal appearing areas
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Collection
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If incontinent collect from depends
Properly identify specimen
Properly package
Specimen sent to lab upon collection
Document type of specimen collected,
characteristics, date and time of collection and
sent to lab
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Important Read…….
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Skill 30-1, pg. 698-699
Skill 30-2, pg. 700
Skill 30-3, pg. 701
Skill 30-4, pg. 702
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
True/False Question
The nurse administering an enema to a
patient knows that the tip of the tubing
should be inserted into the rectum while the
patient is in a sitting position, as on the toilet.
A. True
B. False
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Answer
B. False
Rationale: The nurse should never attempt insertion
of the tip of the tubing into the patient’s rectum
while the patient is in a sitting position. The angle of
the natural curve of the rectum and sigmoid colon
changes when sitting. This can cause the tip of the
tubing to scrape the intestinal wall, possibly
damaging the mucosal lining, and increases risk of
perforating the intestinal wall.
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Multiple Choice Question
A nurse is ordered to administer an enema to
a patient to soften an impacted stool. Which
type of enema would typically be used?
A. Cleansing enema
B. Oil retention enema
C. Medicating enema
D. Return flow enema
Copyright © 2011 F.A. Davis
Fundamentals of Nursing Care: Concepts, Connections, & Skills
Answer
B. Oil retention enema
Rationale: Oil retention enemas are
administered to soften the hard stool of an
impaction so that it can be removed more
easily and with less discomfort for the patient.
Copyright © 2011 F.A. Davis