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Chapter 46: Bowel Elimination
Bonnie M. Wivell, MS, RN, CNS
Scientific Knowledge Base
Digestion begins with
mastication; saliva dilutes
and softens food
Peristalsis moves food
bolus into the stomach
Small intestine
Stores food & liquid; mixes
Duodenum, jejunum, and
food, liquid and digestive
juices; moves food into small
Large intestine
The primary organ of bowel
Expels feces and flatus
from the rectum
Factors Affecting Bowel Elimination
• Age
– Infants: small stomach capacity; less secretion of
digestive enzymes; rapid peristalsis; lack
neuromuscular development so cannot control bowels
– Older adults: arteriosclerosis which causes decreased
mesenteric blood flow, decreasing absorption in small
intestine; decrease in peristalsis; loose muscle tone in
perineal floor and anal sphincter thus are at risk for
incontinence; slowing nerve impulses in the anal
region make older adults less aware of need to
defecate leading to irregular BMs and risk of
Factors Affecting Bowel Elimination
• Diet: fiber such as whole grains, fresh fruits and vegies
help flush the fats and waste products from the body
with more efficiency; decreased fiber → increased risk of
polyps; be aware of food intolerances
Fluid intake: 6-8 glasses of noncaffeinated fluid daily;
liquifies intestinal contents easing passage through colon
Physical activity: promotes peristalsis
Psychological factors: stress increases peristalsis
resulting in diarrhea and gaseous distention; ulcerative
colitis; IBS; gastric and duodenal ulcers; crohn’s disease
Personal habits: fear of defecating away from home
Position during defecation: squatting is the normal
Factors Affecting Bowel Elimination
• Pain: hemorrhoids, rectal surgery, rectal fistulas
and abd. surgery
Pregnancy: increased pressure; slowing
peristalsis in third trimester
Surgery and Anesthesia: lows or stops
peristalsis; paralytic ileus = direct manipulation
of the bowel and lasts 24-48 hours
Medications: laxatives and cathartics; laxative
overuse can decrease muscle tone and can
cause diarrhea which can result in dehydration
and electrolyte imbalance; see Table 46-2
Diagnostic tests: bowel prep; barium
Common Bowel Elimination
• Constipation
– Causes: improper diet, reduced fluid intake, lack of
exercise, and certain meds
– A significant health hazard
• Impaction
– Causes: unrelieved constipation
– Debilitated, confused, and unconscious more at risk
– Continuous ooze of diarrhea is a suspect sign
• Diarrhea
– Causes: antibiotics via any route; enteral nutrition;
food allergies or intolerance; surgeries or diagnostic
testing of the lower GI tract; C. difficile;
communicable food-borne pathogens
Common Bowel Elimination
• Incontinence
– Causes: physical conditions that impair anal sphincter
function or control
• Flatulence
– Causes: certain foods; decreased intestinal motility
– Can become severe enough to cause abd distention
and severe sharp pain
• Hemorrhoids = dilated, engorged veins; internal
or external
– Causes: straining with defecation; pregnancy; heart
failure; chronic liver disease
Bowel Diversions
• Ostomies: Certain disease /conditions prevent
normal passage of stool; temporary or
permanent artificial opening in the abd wall;
location determines consistency of stool
– Loop colostomy: Usually done emergently;
temporary; usually involves transverse colon; two
openings through one stoma – stool and mucus;
external supporting device usually removed in 7-10
– End colostomy: one stoma formed from the proximal
end of the bowel and distal portion of the GI tract
removed or sewn closed (Hartman’s pouch); common
in colorectal cancer and rectum is usually removed;
temporary in surgery for diverticulitis
– Double-barrel colostomy: bowel is surgically severed
and two ends brought out onto the abd; proximal
stoma functions and distal stoma is nonfunctioning
Loop Colostomy
Double-Barrel Colostomy
Double-Barrel Colostomy
End Colostomy
Bowel Diversions Cont’d.
– Alternative procedures
• Ileoanal pouch: colon removed for tx of ulcerative
colits or familial polyps; pouch is formed from
distal end of small intestines and attached to anus;
pouch acts as rectum so pt. is continent; has
temporary ileostomy while healing
• Kock continent ileostomy: consists of a reservoir
constructed from small bowel and nipple valve
which keeps contents of reservoir inside body;
permits entry of external catheter to drain pouch
• Macedo-Malone Antegrade Continence Enema
(MACE); for improving continence in pts with
neuropathic or structural abnormalities of the anal
Ileoanal Pouch Anastomosis
Kock Continent Ileostomy
Care of the Patient With a
Bowel Diversion
• “Bagging” the ostomy
• Assessing stoma and skin
• Assessing stool output
• New stoma vs. Old stoma
• Patient education and counseling
Psychological Considerations
Body image changes
Face a variety of anxieties and concerns
Must learn how to manage stoma
Cope with conflicts of self-esteem and body image
Can be concealed with clothing but pt. aware of its
• Difficulty with intimacy/sexual relations
• Foul odors, leakage, spills and inability to control or
regulate passage of gas and stool is embarrassing
• Ostomy support:
– United Ostomy Association
– National Foundation for Ileitis and Colitis
Nursing Process and Bowel
• Assessment
– Nursing history (see Box 46-2)
Usual elimination pattern
Usual stool characteristics
Routines to promote normal elimination
Use of artificial aids
Presence/status of bowel diversions
Changes in appetite
Diet history
Daily fluid intake
History of surgery or illnesses of GI tract
Medication history
Emotional state
History of exercise
Pain or discomfort
Social history
Mobility and dexterity
Nursing Process and Bowel
– Physical assessment of the abdomen
• Mouth: poor dentition, dentures, mouth sores
• Abdomen: inspect, auscultate, palpate, percuss
• Rectum: inspect
– Inspection of fecal characteristics
– Review of relevant test results
• Fecal specimens: cannot mix feces with urine or water
– Stool for occult blood (FOBT or guiac) see Box 46-3
– Fecal fat requires 3-5 days of collection
– Ova & Parasites (O&P)
• Labs: bilirubin, ALK, Amylase, CEA
• Diagnostic Exams: KUB, endoscopy, colonoscopy, barium enema,
barium swallow, US, MRI, CT scan (may require pre-procedure
Nursing Diagnosis
• Bowel incontinence
• Constipation
• Risk for constipation
• Perceived constipation
• Diarrhea
• Toileting self-care deficit
• Body image, disturbed
• Goals and outcomes
– Client sets regular defecation habits
– Client is able to list proper fluid and food intake
needed to achieve bowel elimination
– Client implements a regular exercise program
– Client reports daily passage of soft, formed brown
– Client doesn’t report any discomfort associated with
• Setting Priorities
• Collaborative Care - WOCN
• Health Promotion: establish routine
– Promotion of normal defecation
• Sitting position
• Position on bedpan – see pg. 1196
• Privacy
• Acute Care
Cathartics and laxatives
Antidiarrheal agents
Types of Enemas
• Cleansing enemas
– Tap water
– Normal saline
– Hypertonic solutions
– Soapsuds
• Oil Retention
• Carminative – Mag, gylcerin and water;
relieves gaseous distention
• Medicated enemas – Kayexalate
Implementation Cont’d.
• Enema administration
– “Enemas till clear”
– See pages 1200-1202
• Digital removal of stool – last resort
– Can cause irritation to the mucosa, bleeding
and stimulation of vagus nerve
• Inserting and maintaining a nasogastric
NG Tubes
• Levine or salem sump tubes are most common for
stomach decompression or lavage
See pages 1204-1209 for insertion procedure
Connected to intermittent suction (LIS)
Air vent should NEVER be clamped, connected to suction
or used for irrigation
Not a sterile technique
Care of pt. with NG
Frequent mouth care/gargling
Maintain patency of tube
Turn client frequently to allow for adequate emptying
Continuing and Restorative Care
• Care of ostomies
• Irriating a colostomy
• Pouching ostomies (see pages 1211-1215)
• Nutritional considerations with ostomies
• Bowel training
• Proper fluid and food intake
• Regular exercise
• Hemorrhoids
• Skin integrity
• The effectiveness of care depends on how
successful the client is in achieving goals and
• Optimally the client will be able to have
regular, pain-free defecation of soft-formed
• It is necessary to ask questions so
establishing a therapeutic relationship is VERY
• Nursing interventions may be altered if