BOWEL Elimination .pptx

Regular elimination of bowel
products is essential for
normal body functioning.

ANATOMY OF
DIGESTIVE TRACT
& FORMATION OF
STOOL

● Food taken in to the mouth is chewed & broken
in to small particles that are swallowed & enter
the stomach.
● In stomach, the food gets mixed with gastric
secretions by peristaltic action & gets further
liquefied before passing in to the intestines.

● Small intestine has got three parts:
DUODENUM, JEJUNUM & ILEUM.
● The duodenum is attached to the stomach
● The jejunum lies between the duodenum &
the ileum.
● Ileum, which is the end of the small
intestine is joined with the large intestine.

● The large intestine or colon has got a
number of sections.
● They are CAECUM, ASCENDING COLON,
DESCENDING COLON, TRANSVERSE
COLON, SIGMOID COLON RECTUM &
ANUS.

FECES, EXCRETA
or STOOL…..
Waste from the intestines is composed mainly of
indigestible food substances, secretions from the
digestive tract, dead cells, bacteria & water to keep it
soft. This waste material is called FECES, EXCRETA
or STOOL.

DEFECATION
The physiological factors critical to bowel
function & defecation include normal GI
function, sensory awareness of rectal
distention & rectal contents, voluntary
sphincter control & adequate rectal capacity &
compliance.

VALSALVA MANEUVER
Pressure exerted to expel feces through a
voluntary contraction of the abdominal
muscles while maintaining forced expiration
against a closed airway.

TERMINOLOGIES
RELATED TO
ELIMINATION OF FECES

● ELIMINATION : It is the expulsion of waste
from the body by way of lungs, skin,
rectum, & urinary bladder
● DEFECATION : It is the act of expelling
fecal materials from the rectum.
● FECES : It is the content of the large
bowel waste products.
● CONSTIPATION : It is the infrequent or
difficult evacuation of hard feces.

● DIARRHOEA : It is the passage of liquid
feces in more than normal frequency.
● ENEMA (CLYSIS) : It is the introduction of
fluid into the rectum.
● COLONIC IRRIGATION : It is the total
flushing of the large intestine.
● FLATULENCE( TYMPANITES or
METEORISM) : It is the condition of having
flatus or gas in the GI tract.

INCONTINENCE : It is the inability to control
the sphincter which guards the rectum or
bladder.
MALENA : It refers to stools that are very dark
or black because of the presence of old blood.
SUPPOSITORY : It is a cone shaped fusible
medicated mass to be introduced into the
rectum.
TENESMUS : It is the ineffectual & painful
straining during defecation or voiding.

PRINCIPLES RELEVANT
TO BOWEL
FUNCTIONING

● The function of the bowels is to eliminate the
waste products of digestion.
● Normal bowel elimination is essential for
efficient body functioning.
● The body’s fluid & electrolyte balance can be
seriously affected by disturbances in bowel
functioning.
● Obstruction of the bowel poses a serious threat
to life.
● The oral intake of food or fluids stimulates a
mass peristaltic action in the GI tract.

● The urge to defecate results from stimulation of
the rectal reflux by distention of the lower
colon & rectum.
● The act of defecation is normally under
voluntary control after the age of 3 years.
● The necessary neuromuscular structures are not
sufficiently developed for voluntary control
over bowel elimination until the age of 15 to 18
months.
● Once achieved, control over defecation is an
important area of independent functioning for
the individual.

● The number of stools the infant has per day
varies considerably. (4-7 per day).
● The normal pattern of bowel elimination in an
individual after infancy varies from 1 bowel
movement every 2-3 days to 3 bowel
movements per day.
● Patterns of bowel elimination & consistency of
feces are highly dependent on an individual’s
food & fluid intake.
● Stress, anxiety & other strong emotions may
interfere with bowel elimination.

FACTORS AFFECTING
BOWEL ELIMINATION

● AGE
● DIET
● FLUID INTAKE
● PHYSICAL
ACTIVITY
● PSYCHOLOGICAL
FACTORS
● PERSONAL
HABITS
● POSITION
DURING
DEFECATION
● PAIN
● PREGNANCY
● SURGERY &
ANESTHESIA
● MEDICATIONS
● DIAGNOSTIC
TESTS

ALTERATIONS
IN BOWEL
ELIMINATION

CONSTIPATION
CONSTIPATION IS A SYMPTOM, NOT A DISEASE.
● It is the infrequent, sometimes painful, passage
of hard dry stools.
● A fluid intake of less than 1000 ml per day
contributes to drier stool.
● Straining during defecation causes problems to
the patients with recent abdominal,
gynecological or rectal surgeries.

● Patients with histories of cardiovascular
diseases, diseases causing elevated
intraocular pressure, & increased
intracranial pressure need to prevent
constipation & avoid using valsalva
maneuver.

SIGNS OF CONSTIPATION
● Infrequent bowel movements (less than every 3
days)
● hard , dry & formed stools
● Straining at stools
● Difficulty in passing stools
● Inability to defecate at will
● Abdominal pain, cramps, or distention
● Decreased appetite
● Abdominal & rectal pain

NURSING Mx OF PATIENTS WITH
CONSTIPATION
● Advise the patient to have a routine during a time
when defecation is most likely to occur.
● Attempts are made to defecate at times when mass
colonic peristalsis occurs.
● Provide bedpan to patient if it is required & assist with
the patient to ambulate before the urge disappears.
● Provide good privacy

● Increase the intake of high fibre foods. Added
fluids should be accompanied. Vegetables,
fresh fruits, green leafy vegetables, cereals &
whole wheat breads have high fibre content.
● Those patients with poor dentition & difficulty
in swallowing, offer chopped & mashed foods.
Liquids such as fruit juices & hot tea are
beneficial.

FECAL IMPACTION
● It results from unrelieved constipation.
● It is a collection of hardened feces, wedged in
the rectum that a person cannot expel.
● In severe impaction, the mass extends up into
the sigmoid colon.
● Patients who are at risk are: DEBILITATED,
CONFUSED or UNCONSCIOUS.

SIGNS OF FECAL IMPACTION
● Inability to pass stool for several days
● Anorexia
● Nausea & vomiting
● Abdominal distension
● Cramping
● Rectal pain.

MANAGEMENT
● The same measures as for prevention &
management of constipation.
● Perform a DIGITAL EVACUATION to expel
the impacted feces.

DIARRHEA
● It is an increase in the number of stools & the
passage of liquid , unformed stools.
● It is associated with disorders affecting digestion &
secretion in the digestive tract.
● It is associated with increased gastrointestinal
motility & therefore, there is rapid passage of fecal
contents through the lower GI tract.

CAUSES OF DIARRHEA
● Psychological stress or anxiety
● Medications ( antibiotics, iron, cathartics)
● Allergies to certain food
● Diseases of the colon ( malabsorption
syndrome)
● Surgical procedures
● Imbalance in intestinal flora.
● Common causative agent: CLOSTRIDIUM
difficile

SIGNS & SYMPTOMS
● Stools are relatively unformed. The patient
finds it difficult & impossible to control the
urge to defecate..
● Spasmodic & piercing abdominal cramps
● Sometimes passage of excessive mucus &
blood in stools
● Nausea & vomiting
● Irritation of anal & perineal region
● Fatigue, weakness & malaise due to prolonged
diarrhea.

NURSING MEASURES TO
RELIEVE DIARRHEA

● Discontinue foods or medications that
causes diarrhea.
AFTER DIARRHEA STOPS CONTINUE THE
FOLLOWING MEASURES
● Give fermented dairy products like yogurt
& buttermilk to reestablish the normal
flora
● Avoid giving spicy & high fibre foods
● If the patient has lactose intolerance, avoid
giving milk & milk products

● Increase the intake of low fibre foods
● If diarrhea causes serious fluid loss,replace
this loss with water, ORAL REHYDRATION
SOLUTION(ORS)

FECAL INCONTINENCE
● It is the inability to control the passage of feces & gas
from the anus.
● That is, the involuntary elimination of bowel contents
often associated with neurologic, mental or
emotional impairments.

NURSING MANAGEMENT
● Maintain skin integrity
● Promote self concept
● Promote adequate fluid intake
● Initiate a bowel training program

FLATULENCE
● It is the presence of excessive flatus(gas) in the intestine
& leads to stretching & inflation of the intestine.
● It is often referred as TYMPANITES.
● It is the common cause for abdominal fullness, pain &
cramping.
● Causes are: reduction in intestinal motility resulting from
opiates, general anesthesia, abdominal surgery or
immobilisation.

NURSING MANAGEMENT
● Decrease air swallowing by advising the
patient not to drink carbonated drinks, not to
use straws for drinking & not to chew hard
candies.
● Advise to avoid gas forming foods
● Encourage the patient to walk after meals
● If flatulence is severe due to decreased
peristalsis, insert a nasogastric tube for
decompression
● When conservative measures fail, use a
FLATUS TUBE

HEMORRHOIDS
● They are masses of dilated blood vessels that lie
beneath the lining of the anal mucosa.
● Increased venous pressure resulting from straining,
at defecation, advanced pregnancy, congestive heart
failure & chronic liver disease can leads to the
development of hemorrhoids.

HELMINTHS
● Common parasitic worms/helminths that infest the
intestines are the HOOKWORM, ROUNDWORM,
PINWORM & TAPEWORM.
● They cause faulty digestion, intestinal inflammation,
obstruction & anemia.

BOWEL DIVERSIONS
● Certain disease conditions can prevent normal passage of
feces through the rectum.
● The treatment of these problems require a temporary or
permanent artificial opening (STOMA) in the abdominal
wall.
● Surgical openings are created in the ileum (ILEOSTOMY)
or colon (COLOSTOMY) with the ends of the intestine
brought through the abdominal wall to create the stoma.

OSTOMIES
● The location of an ostomy determines the consistency
of stool.
● An ILEOSTOMY bypasses the entire large intestine. As
a result, stools are frequent & liquid.
● The same is for the colostomy of the ascending colon.
● A colostomy of the transverse colon generally results in
a more solid, formed stool.

● The sigmoid colostomy releases near-
normal stool.
● There are 3 types of COLOSTOMY
CONSTRUCTION, they are:-
1. LOOP COLOSTOMY
2. END COLOSTOMY
3. DOUBLE-BARREL COLOSTOMY

LOOP COLOSTOMY
● It is usually performed in a medical emergency to
anticipate the closure of the colostomy
● These are usually temporary large stomas
constructed in the transverse colon.

END COLOSTOMY
● The end colostomy consists of one stoma formed
from the proximal end of the bowel with the distal
portion of the GI tract either removed or sewn
closed( called HARTMANN’S POUCH) & left in the
abdominal cavity.

DOUBLE-BARREL COLOSTOMY
● Here the bowel is is surgically severed in a double-
barrel colostomy & the two ends are brought out onto
the abdomen.
● The double-barrel colostomy consists of 2 distinct
stomas: THE PROXIMAL FUNCTIONING STOMA &
THE DISTAL NON FUNCTIONING STOMA.

CARE OF OSTOMIES
● Persons with an ostomy wear a pouch to collect
effluent from the stomas
● The stool discharged from an ostomy us called
EFFLUENT.
● Patients require meticulous skin care to prevent
liquid stool from irritating the skin around the stoma.

IRRIGATION OF A
COLOSTOMY
● The healthcare provider orders the amount & type
of solution to be used for irrigation.
● For adults, the amount ranges from 500-700ml of
tap water .
● The solution is instilled slowly through the
lubricated cone tip.
● Irrigation usually takes 5-10 mns.

● The patient removes the cone tip & waits 30-
45 mns for the solution & feces to drain out if
the irrigation sleeve.
● After the drainage stops, patient can apply a
stoma cap or a pouch.

NUTRITIONAL CONSIDERATIONS
FOR PATIENTS WITH OSTOMIES
● During the first week of surgery, it is recommended
to follow low -fibre diet, because the small bowel
requires time to adapt the diversion.
● Low fibre foods include bread, noodles, rice, cream
cheese, eggs, strained fruit juices, lean meats, fish &
poultry.

● As Ostomies heal, patients are able to eat
almost any foods.
● High fibre diet such as fresh fruits &
vegetables help ensure a more solid
needed to achieve success at irrigation.
● Avoiding blockage is important.

● Patients with ileostomy need to eat slowly
& chew food completely.
● Drinking 10-12 glasses of water daily also
prevents blockage.
● Avoid gas forming foods such as broccolis,
cauliflower, dried beans.

● Participate in Bowel training program.
● Maintain proper fluid & food intake.
● Promotion of regular exercises
● Maintain skin integrity.

LABORATORY &
DIAGNOSTIC TESTS
FOR BOWEL
FUNCTION

RADIOLOGICAL & DIAGNOSTIC
TESTS
● X-ray of abdomen,
kidneys, ureter, bladder
● Upper GI/ Barium
swallow
● Upper Endoscopy
● Barium Enema
● Ultrasound
● Colonoscopy
● Flexible
Sigmoidoscopy
● CT scan
● MRI
● Enteroclysis

MEASURES TO FACILITATE
NORMAL DEFECATION

● Sitting position
● Positioning on Bedpan
● Provide adequate privacy

ACUTE CARE OF
PATIENTS WITH
ELIMINATION
PROBLEMS

MEDICATIONS
● There are some medications that can initiate &
facilitate bowel elimination.
● CATHARTICS, LAXATIVES & ENEMA are used to
control constipation, & ANTIDIARRHEAL AGENTS
are used to resolve diarrhea.

CATHARTICS & LAXATIVES
● They have the short term action of emptying the
bowel.
● They are prescribed for bowel evacuation for clients
undergoing GI tests & abdominal surgery.
● They are available in oral tablet, powder,
suppository dosage forms.
● Cathartic suppositories such as
BISACODYL(DULCOLAX) act within 30minutes.

The 5 types of cathartics & laxatives used
are:-
1. BULK FORMING (Methyl
cellulose,Psyllium)
2. EMOLIENT or WETTING (Docusate
sodium,Docusate Calcium)
3. SALINE (Magnesium citrate, Magnesium
hydroxide)
4. STIMULANT CATHARTICS ( Dulcolax)
5. LUBRICANTS (Mineral oil)

ANTIDIARRHEAL AGENTS
● Opiates like Codiene phosphate, opium tincture &
Diphenoxylate.
● They inhibit peristaltic waves that moves feces
forward, but they also increase segmental
contractions that mix intestinal contents. Hence the
intestinal walls absorb more water.

ENEMAS
● An Enema is the instillation of a solution into the
rectum & sigmoid colon.
● It promotes defecation by stimulating peristalsis.
● The volume of fluid instilled breaks up the fecal
mass, stretches the rectal wall, & initiates the
defecation reflex.

1. The most common use is temporary relief
of constipation.
2. Other indications are:-
● Removing impacted feces
● Emptying the bowel before diagnostic
tests & surgery
● Beginning a program of bowel training

TYPES OF ENEMA
1. CLEANSING ENEMA
● TAP WATER
● NORMAL SALINE
● HYPERTONIC SOLUTIONS
● SOAPSUDS
2. OIL RETENTION ENEMA

CLEANSING ENEMAS
● Cleansing enemas promote the complete evacuation
of feces from the colon.
● They act by stimulating peristalsis through the
infusion of a large volume of solution or through
local irritation of the colon’s mucosa.

OIL RETENTION ENEMAS
● Oil retention enemas lubricate the colon & rectum.
● The feces absorb the oil & become softer easier to
pass.
● To enhance the action of oil, the patient retains the
enema for several hours if possible.

CARMINATIVE ENEMA
● These enemas provide relief from gaseous
distension.
● They improve the ability to pass flatus.
● Eg: MGW solution, which contains 30ml of Mg,
60ml of glycerin & 90 ml of water.

MEDICATED ENEMAS
● Medicated enemas contains drugs.
● Eg: Sodium polystyrene sulfonate, used to treat
patients with dangerously high serum potassium
levels.

DIGITAL REMOVAL OF STOOL
● For patients with fecal impaction, fecal mass is
sometimes too large for them to pass voluntarily.
● If enemas fail, break up the fecal mass with the
fingers & remove it in sections
● Excess rectal manipulation can cause irritation to the
mucosa, bleeding & stimulation of vagus nerve.

INSERTION OF NASOGASTRIC
TUBE
● This is to decompress the GI tract.
● Such conditions include surgery, infections of
the GI tract, trauma to the GI tract & conditions
in which peristalsis is absent.

TYPES &
COLLECTION OF
SPECIMEN OF FECES

● Replace the equipments
● Document time of specimen collection
& transport to laboratory.

2. FECAL OCCULT
BLOOD TESTING or
GUAIC TEST

PROCEDURES
RELATED TO BOWEL
ELIMINATION

DEFINITION
Insertion of rectal catheter or flatus tube
through the rectum to relieve flatulence.

PURPOSE :
1. To relieve flatulence
2. To relieve abdominal distension
EQUIPMENTS:-
● Number 22 or 24 rectal tube
● Water-soluble lubricant
● Bedpan or container with approximately
30ml of water
● Soap and warm water, basin, tissues,
washcloth, and towels
● Disposable nonsterile gloves

PROCEDURE:
1. Explain the procedure to the
patient/caregiver.
2. Assist the patient to lie on the left side
and expose the anal area.
3. Drape the patient for privacy.
4. Place the outflow tip of the rectal tube
into the bedpan or container so that it is
covered with water.
5. Lubricate the tip of the rectal tube.

6. Gently insert the rectal tube into the rectum
(approximately 3 to 5 inches; do not force the
tube.)
7. Leave rectal tube in place for
approximately 20 minutes.
8. Observe for expulsion of flatus.
9. Gently remove the rectal tube.
10. Clean and replace the equipment. Discard
disposable items in a plastic trash bag.
11. Document procedure and results on
patient visit report.

Definition
A suppository is a solid or semi-solid pellet
which is inserted into the rectum for medicinal
purposes.
Indications:-
● To relieve constipation
● To evacuate the bowel prior to surgery or
investigations
● To treat haemorrhoids or anal pruritis
● To administer medications eg antibiotics,
analgesics

Contraindications :
1. Rectal bleeding
2. Paralytic ileus
3. Colonic obstruction
4. Following gastrointestinal surgery

EQUIPMENTS:
A tray containing
● Clean or sterile gloves
● Lubricating jelly
● Prescribed suppository
● Bedpan
● Mackintosh
● Draw sheet

PROCEDURE
● Check the doctor’s written order.
● Identify the patient correctly using the
3 checks.
● Perform the SEVEN RIGHTS of
medication administration;
1. The right patient
2. The right medication (drug)
3. The right dose

4. The right route
5. The right time
6. The right reason
7. The right documentation

● The label on the medication must be checked
for name, dose, and route, and compared with
the MAR at three different times:
1. When the medication is taken out of the drawer
2. When the medication is being poured
3. When the medication is being put away/or at
bedside

● If possible, have patient defecate prior to rectal
medication administration.
● Explain the procedure to the patient. If patient
prefers to self-administer the suppository/enema,
give specific instructions to patient on correct
procedure.
● Raise bed to working height.

● Provide privacy
● Position patient on left side with upper leg
flexed over lower leg toward the waist (Sims
position).

● Provide privacy and drape the patient with only the
buttocks and anal area exposed.
● Place a drape underneath the patient’s buttocks
● Apply clean non-sterile gloves.
● Assess patient for diarrhea or active rectal bleeding

● Remove wrapper from suppository and
lubricate rounded tip of suppository and
index finger of dominant hand with
lubricant.

● Separate buttocks with non-dominant hand and,
using gloved index finger of dominant hand, insert
suppository (rounded tip toward patient) into rectum
toward umbilicus while having patient take a deep
breath, exhale through the mouth, and relax anal
sphincter.

● With your gloved finger, insert suppository along
wall of rectum about 5 cm beyond anal sphincter.
Do not insert the suppository into feces
● Remove finger and wipe patient’s anal area.
● Ask patient to remain on side for 5 to 10 minutes.

● Discard gloves by turning them inside out and
disposing of them and any used supplies as per
biomedical waste management.
● Provide a bedpan or assist the patient to the
washroom.
● Document procedure and include patient’s
tolerance of administration.

NURSING DIAGNOSIS
● CONSTIPATION RELATED TO DECREASED FIBRE
INTAKE
● RISK FOR CONSTIPATION RELATED TO
IMMOBILITY
● DIARRHEA RELATED TO FOOD INTOLERANCE
● TOILETING SELF CARE DEFICIT
● BOWEL INCONTINENCE
● DYSFUNCTIONAL GASTROINTESTINAL
MOTILITY

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