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.