Bowel Elimination CSULB School of Nursing

Introduction Elimination of bowels is essential to normal function just like urinary tract. GI changes may be a sign of problems in the GI tract or other organ systems nausea, emesis, constipation, and diarrhea. These are warning signs that something is going on with the GI tract like GERD, irritable bowel syndrome- no inflammation, irritable bowel diseases- ulcerative colitis and Crohn’s disease. Pt with heart failure have constipation, pt with infectious diseases have diarrhea and pt with renal

disease are more prone to gi bleeding. Affected by illness, diagnostic testing, surgical interventions & the aging process Different diagnostic test like barium that needs to be ingested or NPO for period of time. This can change GI function as well as aging process- as we age we have decreased amt of intake and roughage of fiber. Our teeth aren’t the same- more difficult to chew and we also get lazy with our meals. Surgery to GI tract- essential for us as nurses to have knowledge about the structure and function of GI tract and understand and promote healthy bowel elimination. The longer they hold it the more they will become dehydrated. Be concerned if pt wants to wait until they get home to go to bathroom. They need to do it now! Knowledgeable about the structure & function of the GI tract is important Scientific Knowledge Base The Digestive process Mouth Where digestion begins with mastication. Saliva helps dilute and soften the food bolus.

Esophagus Peristaltic waves going from the mouth carrying the full bolus down into the stomach. The stomach is where we have production and secretion of hydrochloric acid of mucus of pepsin of that intrinsic factor that is very important to avoid pernicious anemia

Stomach Where the food bolus is stored. It’s starting to mix with these digestive enzymes.

Small Intestine When the bile, amylase, tripsin starts this digestive process and 90% of the food bolus is absorbed in the small intestine. Starts in duodenum jejunum and then the ileum. It is long- 23 ft.

Large Intestine This is when we have absorption and 10% of the absorption of food is at this stage and secretion of bicarbonates, chloride and potassium. Most ingestion of plant fibers happen here. 4-5 ft long

Anus Expels feces and flatus from the rectum. Pt who I am concerned of good bowel sounds because of NG tube. Ask them if they are passing any gas or burping because that is a good indication of bowel sounds. Most individuals have bowel sounds from a couple times a day to 2-3x a week. By 5,6,7 yr old we have regular bowel eliminations. It is concerning if there is any difference in normal BM frequency in individual.

Factors affecting bowel elimination

• Age as infants we have very frequent, involuntary passages. Very soft liquid excrement. Because they have immature intestine and the formula they are taking. By 2 years old where urinary continence develops. We have an association with rectum pressure with needing a BM. Develop more tone as well. Remind school aged children to go to the bathroom as well. As we get older, we lose tone in our rectal area and we are more prone to constipation and the decreased roughage and decreased activity.

• Diet & fluid intake need 2-3 L of fluid intake and 25-35 g of fiber on a daily basis to increase efficiency.

• Physical activity the more activity the better peristalsis is and helps promote regular defecation

• Psychological factors stress, some individuals with irritable bowel syndrome like ulcerative colitis go to bathroom frequently and don’t want to go anywhere social like the beach because bathrooms are not readily available

• Personal habits do they need their own toilet, a certain time, do they

need a cup of coffee and a cigarette before this event happens? Whatever the individual does to excite that gastro colonic reflex. Story: Konrad’s toilet in Thailand.

• Pain can suppress the urge and make individual more constipated • Position during defecation most people need to lean forward and

contract thighs and ab muscles when we defecate. So when we ask pt to go on bedpan laying flat supine. So what position can you get them to safely in the hospital?

• Pregnancy the fetus tends to decrease peristalsis, especially during 3rd trimester. So during end of pregnancy, you’ll here more complaints of constipation

• Surgery & anesthesia with general surgery when we are doing surgery to abdominal area will cause decreased peristalsis and actually block the parasympathetic nervous system like opioids.

• Medications & laxatives Antibiotics can cause diarrhea in some pt. Aspirin, Plavix, blood thinners, especially those NSAIDs if they are taken regularly and without food. Iron tablets tend to be constipating to pt and turns pt stool a black color. Antacids decrease peristalsis. Also changes color of stool as well. Laxatives increase peristalsis

• Diagnostic tests Look at upper or lower endoscopy to visualize the GI tract. Abdominal X-rays for structures. Not very many lab or diagnostic tests that we can do that assesses GI tract. So we tend to look at electrolytes and H&H to see if pt is well- nourished.

• Pathologic conditions Common Bowel Elimination Problems

Constipation Infrequent bowel movements. Difficulty passing the stool are excessive straining usually because of pt decreased mobility, narcotic usage or even spinal cord injury. Definition: Less than 3 bowel movements per week.

Impaction Result from the constipation if it is not relieved. It is a collection of hard feces in the rectum

Diarrhea Can be associated with spasmotic cramping. Associated with digestion and absorption and secretion problems like C. dificile, gastroenteritis. Definition: Passage of liquid stool with increased frequency.

Incontinence Inability or involuntary control either the passage or feces or the passage of flatulence (gas). This could be because of an impaired anal sphincter or some type of nerve damage

Flatulence Accumulation of gas in the intestines causing the walls of the GI tract to stretch caused by bacteria, air, swallowing food or GI procedures. Anti-flatulence medications will try to change surface tension area of those gas bubbles so larger bubbles will break down into smaller bubbles,

Hemorrhoids We can have internal or external. External are the ones we visualize and internal we cannot visualize without endoscopy. Very painful. Caused by pregnancy, especially last trimester. Increased straining. Pt with heart disease and liver disease.

Bowel Diversions Ò The standard bowel diversion creates a stoma

Stoma a beefy red color. Part of the intestine. Could be duodenum, jejunum or ileum. It’s most likely to be the ileum or part of the large intestine. It should be moist, does not have sensation to it. The area around the stoma is referred to as the peri-stomal skin, which is extremely important to keep intact. Because we are going to put an appliance over this. If stool is leaking out of the stoma, then skin break down. Then we have to put this with a

strong adhesive and it makes it difficult for skin to heal so best thing is to never let peri-stomal skin break down. Can have this temporary: 6 months. Ideally we would like to re-anastimose it (hoo  k back together).

Ò Some are Temporary or permanent. They get their name depending on what part of the intestine was brought through the abdominal wall

Ò Jejunostomy Ò Ileostomy Ò Colostomy

This picture has a flesh colored one. But in the hospital they are clear because we need to assess the stoma especially if it is a new stoma to make sure it is beefy red in color. Also assess if it is effluent, which is the name of the bowel movement that comes out of a stoma. What color, thickness blood in it?

• Position during

defecation

• Pregnancy

• Surgery & anesthesia

• Medications & laxatives

• Diagnostic tests

• Pathologic conditions

Types of Ostomies 4 main types of bowel diversions. This is re-routing the feces in the GI tract. Usually because there is some type of GI disease or GI trauma. Friend in Detroitit

that knew old people with colostomies for gunshot wounds. End colostomy the proximal end is brought through the incision thru abdominal wall. The edges turned back on itself and sewn down to abdomen on outside of stomach making the stoma. One part is sewn in two places or remove the whole thing. Usually remove it and for pt with colo-recto cancer. 1 stoma will put out effluent. Almost always permanent because most of the time we remove part of rectum due to cancer.

Loop colostomy usually done in emergency, trauma, knife to abdomen or gunshot wound. The proximal end will put out effluent. The distal end will only put out some mucus. The rectum is left intact and pt could have mucoid BM. The food will not come out here. Food comes out of proximal loop. 2 stomas. The line is where they make some type of abridged support. For individual who had bullet thru this area. Open it up. Let it heal. 6 months later, re-anastimose it or suture it back together. These stomas are difficult to have appliances fit on because the shape is not a nice circle. So be very careful with peri-stomal skin.

Divided colostomy when you have edges of bowel brought up. Similar to loop colostomy but removed part of a section here. The proximal end will put out the effluent. Distal end will just put out some mucus. On this individual we will have 2 appliances. Hopefully this will be intact or have mucoid discharge outside of rectum and hopefully we can re-anastimose it or put it back together,

Double-barrel colostomy looks like a double barrel of a shot-gun. They’ve taken a loop colostomy and sewn 5-10cm together. The 2 edges of intestine are sewn together. This is not done as frequently. One of these- the most proximal end will remove the waste from the food products. The other end will have a little mucus out there End and loop colostomies are seen the most frequently Stoma output

As far as where along the GI tract the stoma is, is going to have relation to what type of effluent is coming out. If this is ileostomy meaning food bolus is not going to large intestine at all it will look more liquid in nature. The bottom right picture is over on the left side more towards the descending colon and looks more like formed stool. So you should have idea of what the stool or effluent will look like depending on where in GI it is from. The closer it is to the rectum, the more it will look like normal stool. The higher up the GI tract, the more liquid. In the hospitals they look clear that way we can see the stoma and we can see the effluent coming out as well. When pt goes home, they order different type of bag because they don’t want to look at

their stool and if their top were to come up, people feel very self conscious about that.

Care of stomas Ò The appliance & supplies  

Ò Skin integrity Ò Nutritional considerations Ò Bowel training

A new stoma- it will take a month to 6 weeks for stoma to shrink down to a normal size. For that reason- we use these cut to fit type appliances. They do make appliances that are already in those shapes in the top right. Most stomas are not perfectly round like oblong. But to make the patient know. The pt says my arthritis is so bad there is no way that I will do that. Reassure them the stoma will go down to normal size and there are appliances precut. But in hospital there are ones that we need to cut because stomas are different size. Place pattern over the stoma to figure out which is the closest. Now cut it on the bag here. Need to decide if bag is facing down towards their feet or if bag is facing towards their side. Most of the time, nursing, we are taking care of this. We   will hook this bag where it empties over to the side, that way we can put canister underneath it and let it empty. If pt is taking care of this themselves or we are teaching them how to take care of it themselves you want to tell them to keep bag pointed down so they can open it over their toilet or container. And then the other thing is that we need to cut this. When you cut this it is easy to cut the outside pouch, so make sure you pull that outside pouch so that when you cut it you are not cutting on the outside of it. Each of these bags run about $8-12 and we leave them on for about 5 days and change it. But if this thing is leaking then never ever reinforce it. Take it off and change it. Do not put tape over it, because we have stool on the skin and we cannot have stool on the skin. Take the whole appliance off. Wipe peristomal skin with ready wipes and put piece of gauze or washcloth over that stoma because it keeps putting stuff out. So you don’t want stool to get on skin. Use pattern- cut to fit. And put the two different products. One product looks like alcohol wipe but it isn’t because it is for skin barrier and wipe around peristomal area. Cut thing out. 2 options: Stoma adhesive paste and a powder. Paste is preferred. After cut out, you peel off the circle lines and you are left with sticky side. When you cut this you want appliance 1/8 inch larger than the stoma. You don’t want appliance hitting stoma. Stomas are easy to bleed if we touch them. We don’t want 1 inch or ½ inch of gap because then the stool will get on the skin. Cut it as close as you can. Put skin prep on (looks like alcohol wipe) You pull the paper off for the sticky part. Then you put stoma adhesive round in a circle. This stuff will smush so don’t put too close to edge because you don’t want stoma adhesive to get on stoma when you push it on. The last piece is tape in a circle and you can adjust it. *Take care of peristomal skin and if this is a new stoma you must make sure that it is beefy red and it is not turning pale on you. Ostomy Awareness: Models are bringing awareness to colostomies by taking pictures with their bag on their abdomen and not letting this slow them down. It takes a lot of support and education. Ostomy awareness. Ostomy Barbie and Ostomy baby dolls. Appliance bags with paisley on and plaid just to put a style to it. Napoleon Bonapart had a colostomy. Fred Astaire. Dwight Eisenhower. Ed Sullivan. Tosh.0 had someone who had an ostomy. Nursing Process & Bowel Elimination

Ò Assessment assess if you have good nutrition, what type of food fluids are you able to chew and swallow effectively. Do you have teeth. Their dentures are ill fitting. They just have soft foods and no roughage that is there. What type of meds are they taking especially medications related to GI tract. Are they taking a lot of laxatives or anti-diarrheal

Ò Nursing history Ò Physical assessment of abdomen look at mouth to rectum.

Visualization and auscultation Ò Laboratory tests there are no tests specific to GI tract. So

look at H&H. Does pt have enough nutrients to make red blood cells. Occult blood in stool and GUIAC test at bedside to see if there is occult blood. Look for fat, bacteria, the amylase and lipase lab levels specific to pancreas. Liver enzymes: ALT and AST

Ò Diagnostic examinations endoscopies. Upper and lower GI procedures, ERCP, CAT scans or MRI to look at structure

Ò Related medical history that pertains to GI tract you should investigate

Nursing Diagnosis Ò The nursing assessment will help you select the appropriate nursing

diagnosis Ò Dysfunctional gastrointestinal motility Ò Bowel incontinence – ideally you would like to schedule them

or make a plan with them: every day between 11 and 12 I am incontinent of stool so let’s have a plan that at 9 or 10 we can get you on toilet and get you newspaper and cup of coffee to excite that gastro colonic reflex. With dysfunctional gastrointestinal mobility, you want a schedule. Also anticipate it. If you feel it coming on, do something about it and know what your triggers are like warm to drink or sitting position with TIME magazine.

Ò Constipation increase the fluids, increase the activity and decrease the narcotic intake

Ò Diarrhea increase fluids to replace fluids lost, be careful with very hot and very cold things because this could excite the person to have another BM. Avoid spicy foods, alcohol, and caffeine

Ò Risk for electrolyte imbalance make sure they check electrolyte sand well-hydrated

Ò Impaired skin Integrity keep them clean and dry and use the protective creams. Also important to tell pt if they have leakage of urine or stool to let the nurse know so that the nurse can clean them up. Remind pt that they are not bothering you.

Ò Disturbed body image Ò Deficient knowledge, ostomy management

Planning Ò Establish goals & outcomes with client Ò Incorporate elimination habits Ò Reinforce elimination routines Ò Overall goals:

Ò Regular defecation habits Ò Client lists fluid & food intake needed for bowel elimination Ò Daily (regular) passage of soft, formed brown stool

Implementation   Ò Defecation promotion

Ò Promote normal defecation Ò Sitting position Ò Positioning on bedpan Ò Privacy Ò Nutrition & fluids nutrition, especially 25-35 g of fiber and 2-3

L of fluid. Ò Exercise as tolerated in the hospital. Walk to sink and

hallway Very difficult going to the bathroom laying down like that on the bed with the bedpan. So get their head up or to a bedside commode. Sitting position is preferred. The position of bed pan. Full bed pan or fractured bed pan for hip fractures. It is ideal f we have powder to put powder on edges so it doesn’t stick so much. Nurses clean this, so if you don’t need a sample of BM put toilet paper at the bottom so that when you empty it, you can throw it away.

  Implementation – acute care

Ò Cathartics & laxatives cathartics accelerate defecation. It has a strong purging effect. Ex. Lactulose or sorbitol. Laxatives ease defecation: duculox, and Colace.

Ò Antidiarrheal agents help prevent diarrhea. Ex Lomotil- slows GI tracts motility and causes increased fluid reabsorption so client is less likely to get dehydrated

Ò Digital removal last resort. For some hospitals you need physicians order. Be careful on pt who have vasovagal response which could come with bradycardia. So while performing this, have them on the left-hand side and assess rectum laying on left lateral side.

Enemas promotes peristalsis via large amounts of volume or because we are irritating the GI tract. Ideally o be in left lateral position or left sims position. Ideally the temperature of the enema needs be 100 degrees to help prevent cramping or discomfort during it.

Cleansing Ò Tap water enema with water from

the tap. It is hypotonic. The body will absorb the water that we put in the GI tract. Usually putting in 500 mL to a 1L. Sometimes you see orders to repeat until the bowels are clear. Be careful. Do not repeat this in individual with problem of CHF or renal disease because the water you are giving, part of it is going to be absorbed. It is not all going to come right back

out because it is hypotonic. Ò Normal saline referred to as isotonic. Stimulates

the bowels via the fluid. 500mL to 1 L. It will soften the feces there and with extra pressure when individual does release it. It is ideal if they hold the enema in and keep them laying on left side

Ò Hypertonic solutions a much smaller volume. About 100 mL of fluid we put in. This causes distention. The hypertonic solution draws fluids outside of the GI tract inside the GI tract to help expel this

Ò Soapsuds Pure castile soap originally came from Spain, primarily an olive oil based. Mix soap with 500mL- 1 L. Promotes defecation by irritation. Soap irritates it and the volume will soften up feces

Ò Oil retention Ò Carminative & Kayexalate Carminative is a laxative that helps relieve

pressure from gas. Kavexalate helps to exchange sodium for potassium. Some aren’t specifically designed to cleanse bowel, but they will end up happening because we are removing the gas. Pt comes into hospital and have a potassium rate of 7.0 which is very high. We have give Kavexelate-drink it or enema, which will bind to potassium and hopefully removed in GI tract.

Evaluation Ò Where goals obtained? Ò Was client successful in achieving outcome? If you weren’t why not? Ò Alter nursing interventions if necessary

Review Questions A nurse is instructing a patient on how to self administer a fleets enema pre-op. What is important for the nurse to discuss?

A. Insert the tube 4 inches into the rectum beyond the internal sphincter 4 inches is too far B. Retain the enema solution to promote evacuation C. Lay on the right side for best results- NO we want to lay on the left side D. Warm in the microwave for 1 minute to promote comfort we don’t know the temperature

A patient reports a recent problem with constipation. What should the nurse instruct the patient to do to minimize the problem?

A. Drink 1 quart of fluid a day we should have more than that B. Decrease your daily physical activity no the opposite C. Hold your breath when bearing down to have a bowel movement might predispose client to a vasovagal response, bradycardia and pass out D. Try to have a bowel movement after drinking a warm liquid in the morning

A nurse is caring for a client who had a colostomy placed 6 hours ago. Which action is the most important?

A. Assess the color of the stoma B. Explain that bowel function returns in 24 hours bowel function may not

return in 24 hours, it may be 24 hours before they have bowel sounds. They probably won’t take any fluids in. they may have an NG tube for 3 or 4 days and then they will have some liquids.

C. Empty the appliance when it is full empty this before it is full 1/3 or ½ way full. This fills up with gas- so let gas out of it. If not, the gas will allow the appliance to separate from the skin.

D. Clean the peristomal skin with normal saline & peroxide do not use normal saline. Use peri wipes

A nurse identifies that a client may have a fecal impaction. Which clinical manifestation is most specific to this problem?

A. Lack of bowel movement X 3 days B. Distention of the abdomen C. Feeling of rectal fullness D. Passage of a small amount of brown liquid from the rectum

because with impaction, the stool will leak around the outside of it. Look this up in book!!

Which nursing interventions are associated with caring for a client that is constipated?

A. Ambulating the client TID B. Encouraging intake of prunes C. Responding immediately to the urge to defecate D. Encouraging pain control with narcotics

A nurse is caring for a client who id admitted for an UGIB. Which clinical indicator is associated with GI bleeding?

A. Pale, clay colored stool because there is problem with biliary system and no bile. Peptobismol will make stool pale colored

B. Yellow, greenish stool example of someone who has C. dificile or infection. Also see differences in stool by what you eat. Girl scout cookies with thin mints. Eating carrots, yams, sweet potatoes will come out that color. Color of stool isn’t always pathological

C. Hard, dry brown stool D. Black, tarry stool if it is an upper GI bleed that means the blood has

gone thru the GI tract and has been digested, that’s why it is black and tarry. If it lower GI bleed, it will look more like blood, so it depends on where in the GI tract it is coming from.

In which of the following bowel diversions would the nurse anticipate the most formed stool?

A. Ascending Colostomy B. Jejunostomy C. Ileostomy D. Descending colostomy