Bowel Bowel EliminationElimination

Bowel EliminationBowel Elimination GI Tract is a series of hollow GI Tract is a series of hollow

mucous membrane lined muscular mucous membrane lined muscular organsorgans

Purpose is to absorb fluids & Purpose is to absorb fluids & nutrients, prepare food for nutrients, prepare food for absorption & provide storage for absorption & provide storage for fecesfeces

GI Tract AnatomyGI Tract Anatomy MouthMouth EsophagusEsophagus StomachStomach Small Intestine Small Intestine Large IntestineLarge Intestine RectumRectum

MouthMouth Digestion begins hereDigestion begins here Mechanical, chemical breakdown of Mechanical, chemical breakdown of

nutrientsnutrients Teeth-MasticationTeeth-Mastication Salivary secretions-enzymesSalivary secretions-enzymes Food Bolus Food Bolus مضغةمضغة

EsophagusEsophagus Hollow, muscular tube for passage Hollow, muscular tube for passage

of food to stomachof food to stomach Peristaltic waves, contraction and Peristaltic waves, contraction and

relaxation of smooth muscle moves relaxation of smooth muscle moves food down to stomachfood down to stomach

Sphincter control to prevent refluxSphincter control to prevent reflux

StomachStomach Food is temporarily stored and Food is temporarily stored and

mechanically and chemically broken mechanically and chemically broken downdown

Secretes HCL, mucus, pepsin, & Secretes HCL, mucus, pepsin, & intrinsic factor(Needed for Vitamin intrinsic factor(Needed for Vitamin BB12 12 absorption)absorption)

Food is converted into chymeFood is converted into chyme

Small IntestineSmall Intestine 1 inch in diameter1 inch in diameter 20 feet long20 feet long Three divisions: Duodenum, Jejunum, Three divisions: Duodenum, Jejunum,

IleumIleum Enzymes in small intestine (amylase, Enzymes in small intestine (amylase,

lipase, & bile) break down fats, proteins & lipase, & bile) break down fats, proteins & carbs into basic elementscarbs into basic elements

Nutrients absorbed in duodenum & Nutrients absorbed in duodenum & jejunum, ileum absorbs vitamins, iron, & jejunum, ileum absorbs vitamins, iron, & bile saltsbile salts

Large IntestineLarge Intestine Lower GI tractLower GI tract Larger diameter, 5-6 feet in lengthLarger diameter, 5-6 feet in length 3 divisions: cecum, colon, rectum3 divisions: cecum, colon, rectum Responsible for absorption of waterResponsible for absorption of water Primary organ of bowel eliminationPrimary organ of bowel elimination Cecum-chyme enters cecum via the Cecum-chyme enters cecum via the

ileocecal valve, valve prevents regurg ileocecal valve, valve prevents regurg back to small intestine, cecum ends with back to small intestine, cecum ends with appendixappendix

ColonColon 3 Divisions: Ascending, Transverse, 3 Divisions: Ascending, Transverse,

DescendingDescending

Colon Functions: Absorption, Colon Functions: Absorption, Protection, Secretion, & Elimination Protection, Secretion, & Elimination (stool and flatus)(stool and flatus)

RectumRectum Sigmoid colonSigmoid colon Storage of fecesStorage of feces Length varies with ageLength varies with age When fecal mass or flatus moves into When fecal mass or flatus moves into

rectum, it distends and defecation beginsrectum, it distends and defecation begins Process involves involuntary (Internal Process involves involuntary (Internal

sphincter) and voluntary control (external sphincter) and voluntary control (external sphincter)sphincter)

Valsalva Maneuver - voluntary contraction Valsalva Maneuver - voluntary contraction of abdominal musclesof abdominal muscles

Factors Affecting Bowel Factors Affecting Bowel EliminationElimination

AgeAge InfectionInfection DietDiet Fluid IntakeFluid Intake Physical ActivityPhysical Activity Psychological factorsPsychological factors Personal HabitsPersonal Habits

Factors Affecting Bowel Factors Affecting Bowel EliminationElimination

Position during DefecationPosition during Defecation PainPain Surgery and AnesthesiaSurgery and Anesthesia MedicationsMedications

Common Bowel Common Bowel Elimination ProblemsElimination Problems

ConstipationConstipation ImpactionImpaction DiarrheaDiarrhea IncontinenceIncontinence FlatulenceFlatulence HemorrhoidsHemorrhoids

ConstipationConstipation More of a symptom than a disorderMore of a symptom than a disorder Decrease in frequency of BMDecrease in frequency of BM Straining & pain on defecation is Straining & pain on defecation is

associated symptoms(Valsalva associated symptoms(Valsalva manuever)manuever)

Can be significant heath hazard Can be significant heath hazard (increase ICP, IOP, reopen surgical (increase ICP, IOP, reopen surgical wounds, cause trauma, cardiac wounds, cause trauma, cardiac arrhythmias)arrhythmias)

ImpactionImpaction Results from unrelieved constipationResults from unrelieved constipation Collection of hardened feces wedged Collection of hardened feces wedged into rectuminto rectum عالقعالق

Can extend up to sigmoid colonCan extend up to sigmoid colon Most at risk: confused, unconscious Most at risk: confused, unconscious

(all are at risk for dehydration)(all are at risk for dehydration)

ImpactionImpaction When a continuous ooze of diarrheal When a continuous ooze of diarrheal

stool develops, impaction should be stool develops, impaction should be suspectedsuspected

Associated S/S: Loss of appetite, Associated S/S: Loss of appetite, abdominal distention, cramping, abdominal distention, cramping, rectal painrectal pain

DiarrheaDiarrhea Increase in number of stools & the Increase in number of stools & the

passage of liquid, unformed stoolpassage of liquid, unformed stool Symptom of disorders affecting digestion, Symptom of disorders affecting digestion,

absorption, & secretion of GI tractabsorption, & secretion of GI tract Intestinal contents pass through small & Intestinal contents pass through small &

large intestines too quickly to allow for large intestines too quickly to allow for usual absorption of water & nutrientsusual absorption of water & nutrients

DiarrheaDiarrhea Irritation can result in increased mucus Irritation can result in increased mucus

secretion, feces become too watery, secretion, feces become too watery, unable to control defecationunable to control defecation

Excess loss of colonic fluid can result in Excess loss of colonic fluid can result in acid-base imbalances or fluid/electrolyte acid-base imbalances or fluid/electrolyte imbalancesimbalances

Can also result in skin breakdownCan also result in skin breakdown

Conditions that cause Conditions that cause DiarrheaDiarrhea

Emotional StressEmotional Stress Intestinal Infection (Clostridium difficile)Intestinal Infection (Clostridium difficile) Food AllergiesFood Allergies Food IntoleranceFood Intolerance Tube Feedings (Enteral)Tube Feedings (Enteral) MedicationsMedications LaxativesLaxatives Colon DiseaseColon Disease SurgerySurgery

IncontinenceIncontinence Inability to control passage of feces Inability to control passage of feces

and gas from the anusand gas from the anus Caused by conditions that create Caused by conditions that create

frequent, loose, large volume, frequent, loose, large volume, watery stools or conditions that watery stools or conditions that impair sphincter control or functionimpair sphincter control or function

FlatulenceFlatulence Gas accumulation in the lumen of Gas accumulation in the lumen of

intestinesintestines Bowel wall stretches and distendsBowel wall stretches and distends Common cause of abdominal Common cause of abdominal

fullness, pain, & crampingfullness, pain, & cramping Gas escapes through mouth Gas escapes through mouth

(belching), or anus (flatus)(belching), or anus (flatus)

Flatus FormationFlatus Formation Air swallowingAir swallowing Diffusion of gas from bloodstream into Diffusion of gas from bloodstream into

intestinesintestines Bacterial action on unabsorbable CHO Bacterial action on unabsorbable CHO

(Beans)(Beans) Fermentation of CHO (cabbage, onionsFermentation of CHO (cabbage, onions Can stimulate peristalsisCan stimulate peristalsis Adult forms 400-700 ml of flatus dailyAdult forms 400-700 ml of flatus daily

FlatulenceCauses:

Decreased peristalsis

Constipation Medications Surgery

Diet Stress Decreased

activity

NonInvasive Interventions for Flatulence

*Ambulation*

Knee chest position

Invasive Interventions for Flatulence

Glycerin Suppository

Harris Flush

Rectal Tube

HemorrhoidsHemorrhoids Dilated, engorged veins in the lining Dilated, engorged veins in the lining

of the rectumof the rectum External (Clearly visible) or InternalExternal (Clearly visible) or Internal Caused by straining, pregnancy, Caused by straining, pregnancy,

CHF, chronic liver diseaseCHF, chronic liver disease

Physical Assessment

Inspection- observe contour of abd and note visible peristalsis

Auscultation- listen for bowel sounds all quadrants

Percussion- resonant or tympany over hollow organs…dullness over intestinal obstruction

Palpation- feel for masses, tenderness etc…

Bowel DiversionsBowel Diversions Certain diseases cause conditions Certain diseases cause conditions

that prevent normal passage of feces that prevent normal passage of feces through rectumthrough rectum

Creates need for temporary or Creates need for temporary or permanent artificial opening (stoma) permanent artificial opening (stoma) in the abdominal wallin the abdominal wall

Bowel DiversionsBowel Diversions Surgical openings (ostomy) are Surgical openings (ostomy) are

most commonly formed in the ileum most commonly formed in the ileum (ileostomy) or the colon (colostomy)(ileostomy) or the colon (colostomy)

Incontinent ostomy- need to wear Incontinent ostomy- need to wear appliance pouchappliance pouch

Continent ostomy- have control Continent ostomy- have control through use of ostomy capthrough use of ostomy cap

Ostomy Nursing Ostomy Nursing ConsiderationsConsiderations

Patient EducationPatient Education Care of stoma, appliance selection Care of stoma, appliance selection

and useand use Body Image considerationsBody Image considerations Support groupsSupport groups Enterostomal nursing- specialty Enterostomal nursing- specialty

within professionwithin profession

Nursing ProcessNursing ProcessAssessmentAssessment

Nursing HistoryNursing History Physical AssessmentPhysical Assessment Lab TestsLab Tests Fecal characteristicsFecal characteristics Diagnostic evaluation- Endoscopy, Diagnostic evaluation- Endoscopy,

ColonoscopyColonoscopy

Nursing DiagnosisNursing Diagnosis Bowel IncontinenceBowel Incontinence ConstipationConstipation DiarrheaDiarrhea Impaired Skin IntegrityImpaired Skin Integrity Body Image DisturbanceBody Image Disturbance Altered bowel elimination Altered bowel elimination PainPain

ImplementationImplementationPromoting Normal DefecationPromoting Normal Defecation

Positioning of patient-squattingPositioning of patient-squatting Positioning on bedpanPositioning on bedpan Use of cathartics, laxativesUse of cathartics, laxatives Anti-diarrheal agentsAnti-diarrheal agents EnemasEnemas Digital removal of stoolDigital removal of stool Ostomy careOstomy care

Interventions: Promote Bowel Elimination

Laxatives and CatharticsEnemasSuppositoriesDigital Removal

Types of Enemas

C lean s in g R eten tion R etu rn F low

Typ es o f E n em as

EnemasEnemas Cleansing enemaCleansing enema Tap waterTap water Normal salineNormal saline Hypertonic Solutions (Fleet’s enema)Hypertonic Solutions (Fleet’s enema) Soapsuds Soapsuds Oil RetentionOil Retention Medicated enemas (Kayexalate, Medicated enemas (Kayexalate,

Lactulose)Lactulose) Administering a Cleansing enema P&P Administering a Cleansing enema P&P

pg. 1200-1201pg. 1200-1201

Tap Water (TWE) Amount: 500-1000cc Action: Distends, increases

peristalsis Time: 15 min. Indicated: inflamed

bowels/irritated colon Contraindicated: Atonic bowels,

fluid restrictions

Normal Saline

Amount: 500-1000cc Action: Distends, increases

peristalsis Time: 15 min. Indicated:Inflamed

bowels/irritated colon Contraindicated: Na retention

problems, fluid restrictions

Soap Amount: 500-1000cc (Castile

5ml/1000cc) Action: Distends, Irritates Time: 15 min. Indicated: Constipation Contraindicated: Prior to rectal

exams

Hypertonic Amount: 70-130 cc solution Action: Distends/Irritates Time: 5-10 min. Indicated: Constipation,

convenience Contraindicated: Dehydration,

Na problems

Oil Retention

Amount: 120-200ccAction: LubricatesTime: 30 min. Indicated: Fecal impactionContraindication: none

Colostomy nursing care

1. Wash hands. 2. Apply clean gloves. 3. Assemble irrigation kit: Attach

cone or catheter to irrigation bag tubing.

4. Fill irrigation bag with 1000 cc tepid tap water

5. Open clamp and let water from the irrigation bag fill the tubing.

6. Hang bottom of irrigation bag at height of client’s shoulder, or 18 inches above the stoma if the client is supine.

7. Check direction of intestine by inserting a gloved finger into orifice of stoma.

8. Place irrigation sleeve over stoma and hold in place with belt بحزام يطوق

9. Spray inside of irrigation sleeve and bathroom with odor eliminator (usual dose is two sprays).

10. Cuff end of irrigation sleeve and place into toilet bowl (if client is in bathroom) or bedpan (if client is in bed or chair) (see Figure 6-22-5).

11. Lubricate the cone end of the irrigation tubing and insert into orifice of stoma through the top opening of irrigation sleeve

12. Close top of irrigation sleeve over the tubing.

13. Slowly run water through tubing into colon

14. Remove cone after all water has emptied out of irrigation bag.

15. Close end of irrigation sleeve by attaching it to the top of the sleeve.

16. Encourage client to ambulate to facilitate emptying of remaining stool from colon.

17. Remove irrigation sleeve after 20–30 minutes or when stool is no longer emptying from colon.

18. Cleanse stoma and skin with warm tap water. Pat dry.

19. Place gauze pad over stoma to absorb mucus from stoma.

20. Secure gauze with hypoallergenic tape.

21. Remove gloves and wash hands.