Basic Human Basic Human NeedsNeedsBowel 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 BolusFood Bolus

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)

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

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

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

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

Clicker QuestionClicker Question

1.1. A newly admitted client states that A newly admitted client states that he has recently had a change in he has recently had a change in medications and reports that stools are medications and reports that stools are now dry and hard to pass. This type of now dry and hard to pass. This type of bowel pattern is consistent with:bowel pattern is consistent with:

A.A. Abnormal defecationAbnormal defecation B.B. ConstipationConstipation C.C. Fecal impactionFecal impaction D.D. Fecal incontinenceFecal incontinence

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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

Incontinent OstomyIncontinent Ostomy Location of ostomy determines Location of ostomy determines

consistency of stoolconsistency of stool Ileostomy bypasses the entire large Ileostomy bypasses the entire large

intestine, stools are frequent & wateryintestine, stools are frequent & watery Ascending colostomy- liquid stoolAscending colostomy- liquid stool Sigmoid colostomy-most like normal stoolSigmoid colostomy-most like normal stool

Incontinent OstomiesIncontinent Ostomies Loop colostomy- temporary, usually done Loop colostomy- temporary, usually done

on transverse colonon transverse colon 2 openings through stoma, proximal loop 2 openings through stoma, proximal loop

for stool, distal loop for mucusfor stool, distal loop for mucus End colostomy- one stoma formed from End colostomy- one stoma formed from

the proximal end of the bowel with the the proximal end of the bowel with the distal portion removed or sewn shut distal portion removed or sewn shut (Hartmann’s Pouch)(Hartmann’s Pouch)

Incontinent OstomiesIncontinent Ostomies End colostomy usually done for colorectal End colostomy usually done for colorectal

cancercancer Ruptured diverticulum- temporary end Ruptured diverticulum- temporary end

colostomy with a Hartmanns Pouchcolostomy with a Hartmanns Pouch Double barrel colostomy- Bowel is Double barrel colostomy- Bowel is

surgically severed, 2 ends are brought out surgically severed, 2 ends are brought out onto abdomen with 2 distinct stomas onto abdomen with 2 distinct stomas (proximal & distal)(proximal & distal)

Continent DiversionsContinent Diversions Ileoanal reservoir- restorative Ileoanal reservoir- restorative

proctocolectomy, no outward stoma, no proctocolectomy, no outward stoma, no pouch wearing, clients have internal pouch wearing, clients have internal pouch created from the ileumpouch created from the ileum

Ileal pouches constructed in various Ileal pouches constructed in various configurations (S,J,W)configurations (S,J,W)

End of the pouch is sewn or anastamosed End of the pouch is sewn or anastamosed to the anusto the anus

Continent DiversionsContinent DiversionsIleoanal ReservoirIleoanal Reservoir

Several stages to surgery to create Several stages to surgery to create pouch pouch

May need temporary ostomy to allow May need temporary ostomy to allow time for pouch to healtime for pouch to heal

Kegel exercises to increase pelvic Kegel exercises to increase pelvic floor muscle tonefloor muscle tone

Continent DiversionsContinent Diversions Kock Continent Ileostomy-Internal Kock Continent Ileostomy-Internal

reservoir or pouch is created using piece reservoir or pouch is created using piece of small intestineof small intestine

Stoma brought out low on abdomen, end Stoma brought out low on abdomen, end of internal part in pouch is a one way of internal part in pouch is a one way nipple valve to promote continencenipple valve to promote continence

Valve only allows fecal contents to drain Valve only allows fecal contents to drain when an external catheter is place in when an external catheter is place in stoma, no pouch requiredstoma, no pouch required

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 groups (UOA)Support groups (UOA) 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

Common Laxatives & Common Laxatives & CatharticsCathartics

Metamucil-bulk formingMetamucil-bulk forming Colace, Surfak-emollient or wetting Colace, Surfak-emollient or wetting

agentagent Fleets, MOM. Mag Sulfate-saline Fleets, MOM. Mag Sulfate-saline

agentagent Dulcolax, Ex-Lax, Castor oil- Dulcolax, Ex-Lax, Castor oil-

stimulant catharticstimulant cathartic Haley’s MO, mineral oil- LubricantHaley’s MO, mineral oil- Lubricant

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

Nasogastric TubesNasogastric Tubes Decompress GI tract in surgery, Decompress GI tract in surgery,

infection of GI tract, trauma to GI infection of GI tract, trauma to GI tract, conditions where peristalsis is tract, conditions where peristalsis is absentabsent

N/G tube purposes- decompression, N/G tube purposes- decompression, feeding, compression, & lavagefeeding, compression, & lavage

Pliable tube inserted through Pliable tube inserted through nasopharynx into stomachnasopharynx into stomach

Uncomfortable insertionUncomfortable insertion

Nasogastric TubesNasogastric Tubes Types: Levin – single lumen, different Types: Levin – single lumen, different

sizes used for feeding or decompressionsizes used for feeding or decompression

Salem Sump – Most preferable for Salem Sump – Most preferable for decompression, dual lumen, one for decompression, dual lumen, one for removal of gastric contents, one as an air removal of gastric contents, one as an air vent, hooked to suction to achieve vent, hooked to suction to achieve decompressiondecompression

Care of Nasogastric Care of Nasogastric TubesTubes

Confirm placement after insertionConfirm placement after insertion HOB at 30 degrees unless ordered HOB at 30 degrees unless ordered

otherwiseotherwise Mark point where tube exits noseMark point where tube exits nose Tape tube securely to noseTape tube securely to nose Tube IrrigationTube Irrigation Nasal skin careNasal skin care Frequent oral hygeineFrequent oral hygeine Assess for abdominal distentionAssess for abdominal distention Suction settingsSuction settings

Restorative CareRestorative Care Bowel trainingBowel training Maintenance of proper fluid & food Maintenance of proper fluid & food

intakeintake Promotion of regular exercisePromotion of regular exercise Promotion of ComfortPromotion of Comfort Maintenance of skin integrityMaintenance of skin integrity Promotion of self concept Promotion of self concept

Clicker QuestionClicker Question 2.2. To maintain normal elimination patterns in To maintain normal elimination patterns in

the hospitalized client, you should instruct the the hospitalized client, you should instruct the client to defecate 1 hour after meals because:client to defecate 1 hour after meals because:

A.A. The presence of food stimulates peristalsis.The presence of food stimulates peristalsis. B.B. Mass colonic peristalsis occurs at this time.Mass colonic peristalsis occurs at this time. C.C. Irregularity helps to develop a habitual Irregularity helps to develop a habitual

pattern.pattern. D.D. Neglecting the urge to defecate can cause Neglecting the urge to defecate can cause

diarrhea.diarrhea.

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