chapter 47 bowel elimination understanding normal bowel elimination and factors that promote impede or cause alterations and elimination will help the nurse manage the patient's elimination problems measures designed to promote normal elimination need to minimize the patient's discomfort and embarrassment the gi tract is an alimentary canal and its accessory organs the elementary canal is a single tube that extends from the mouth to the anus and includes the mouth esophagus stomach and intestines the accessory organs are the teeth tongue salivary glands liver pancreas and gallbladder these organs also absorb fluid and nutrients prepare food for absorption and use by cells provide for temporary storage of feces the gi tract absorbs high volumes of fluids making fluid and electrolyte balance a key function it also receives secretions from the gallbladder and the pancreas the mouth mechanically and chemically breaks down nutrients into usable size and form teeth chew through the food breaking it down suitable for swallowing saliva that is produced by the salivary glands dilute and soften food in the mouth for easier swallowing the esophagus when food enters the upper esophagus it passes through the esophageal sphincter which is a circular muscle that prevents air from entering the esophagus and food from refluxing into the throat the food bolus will travel down the esophagus with the aid of peristalsis and reach the cardiac sphincter this lies between the esophagus and the upper end of the stomach the sphincter prevents reflux of stomach contents back into the esophagus the stomach performs three tasks the storage of swallowed food and liquid mixing a food with digestive juices into a substance known as chyme and regulates the emptying of contents into the small intestine the stomach produces and secretes hydrochloric acid mucus the enzyme pepsin and the intrinsic factor the pepsin and hydrochloride help digest the protein the mucus protects the stomach mucosa from the acidity and the enzyme activity the intrinsic factor is essential in the absorption of vitamin b12 for the small intestine the movement occurs by peristalsis that facilitates both digestion and absorption chyme comes into the small intestine as liquid material and mixes with digestive enzymes the reabsorption in the small intestine is efficient by the time the fluid reaches the end of the small intestine it is thick liquid with some semi-solid particles the small intestine is divided into three sections the duodenum jejunum and ilium the duodenum is 20 to 28 inches long and continues to process fluid from the stomach the jejunum is 8 feet long and absorbs carbohydrates and proteins the ilium is 12 feet long it absorbs water fats and bio salts the duodenum and the jejunum absorb most nutrients and electrolytes the ilium absorbs certain vitamins iron and bile salts digestive enzymes and bile enter the small intestine from the pancreas and the liver to further break down the nutrients into a usable form by the body the large intestine is also known as the lower gi tract or the colon it is larger in diameter than the small intestine its length is five to six feet it is divided into the cecum ascending colon transverse colon descending colon sigmoid colon rectum and its prime it is the primary organ of bowel elimination the digestive fluid enters the large intestine by peristalsis through the ileocecal valve which is a circular muscle layer that prevents regurgitation back into the small intestine the colon's muscular tissue accommodates and eliminates large quality quantities of water and gas the colon has three functions absorption secretion and elimination the colon re reabsorbs large volumes of water up to 1.5 liters as well as sodium and chloride daily normal fecal matter becomes soft formed solid or semi-solid mass if peristalsis is abnormally fast there is less time for the water to be absorbed and the stool will be watery if the peristalsis slows down the water continues to be absorbed and a hard mass of food storms that can result in constipation peristaltic contractions move the contents mass peristalsis pushes undigested food toward the rectum and occurs three to four times daily with the strongest peristaltic action occurring during the hour after meal time the rectum is the final part of the large intestine normally the rectum is empty of fecal matter until just before defecation so it contains vertical and transverse folds of tissue that help control the expulsion of the fecal contents during defecation each fold contains veins that can become distended from pressure during straining and have and then the individual will have hemorrhoid formation the anus expels feces and flatus from the rectum contraction and relaxation of internal and external sphincters aid in control of defecation the anal canal contains a rich supply of sensory nerves that allow identification of solid liquid or gas that needs to be expelled and aids and maintain incontinence defecation the physiological factors are essential to bowel function and defecation include normal gi tract function sensory awareness of rectal distension and rectal contents voluntary sphincter control and adequate rectal capacity and compliance normal defecation begins with movement in the left colon moving the stool toward the anus when the stool reaches the rectum dissension causes relaxation of the internal sphincter sphincter and the awareness of the need to defecate occurs the time of defecation the external sphincter relaxes and the abdominal muscles contract increasing intrarectal pressure and forcing the stool out normal defecation is painless resulting in the passage of soft formed stool what concerns would you have about the patient's health are there any food groups that may be missing from the patient's diet and if there are might this have an effect on the patient's bowel elimination infants have a smaller stomach capacity and less secretion of digestive enzymes and more rapid intestinal peristalsis the ability to control defecation does not occur until two to three years of age older adults may have decreased chewing ability partially chewed food is not digested easily peristalsis also declines and esophageal emptying slows during older age regular daily food intake helps maintain a regular pattern of peristalsis in the colon fiber in the diet provides the bulk in the fecal matter an individual needs fluid and it varies with each person a fluid intake of 3.7 liters per day for men and 2.7 liters per day for women is highly recommended physical activity promotes peristalsis immobilization depresses peristalsis prolonged emotional stress impairs the function of almost all the board body systems during emotional stress stress the digestive process is accelerated and peristalsis is increased side effects of increased peristalsis may include diarrhea and gaseous distension personal elimination habits influence bowel functioning most people benefit from being able to use their own toilet facilities at the time that is most effective and convenient for them squatting is the normal position used in defecation modern toilets facilitate this posture allowing a person to lean forward exert intra-abdominal pressure and contract the gluteal muscles routinely the act of defecation is painless as pregnancy advances the size of the fetus will increase and pressure is exerted on the rectum a temporary obstruction is created by the fetus that impairs the passage of feces the slowing of peristalsis during the third trimester often will lead to constipation a pregnant woman's frequent frequent straining during defecation or delivery may result in the formation of hemorrhoids general anesthetic agents used during surgery can cause temporary cessation of peristalsis inhaled anesthetic agents block parasympathetic impulses to the intestinal musculature the action of the anesthetic slows or stops the peristaltic waves many medications prescribed for both acute and chronic conditions have secondary effects on the patient's bowel elimination patterns there are common causes of constipation irregular bowel habits and ignoring the urge to defecate chronic illnesses like parkinson's multiple sclerosis rheumatoid arthritis chronic bowel diseases depression low fiber and animal fats and low fluid intake stress physical inactivity medications especially opiates changes in life or routine neurologic conditions that block nerve impulses to the colon like a stroke or a spinal cord injury chronic bowel dysfunction like irritable bowel syndrome these all are factors that may promote constipation fecal impaction can result when a patient has unrelieved constipation and is unable to expel the hardened feces in the rectum diarrhea is the increase in the number of stools and the passage of liquid unformed feces that is associated with disorders that affect digestion absorption and secretion in the gi tract there are dehydration signs with the adult first less frequent urination dark colored urine dry skin fatigue dizziness and lightheadedness there are specific signs with infants and young children a dry mouth and tongue no tears when crying no wet diapers for three hours or more sunken eyes or cheeks or the soft spot in the skull a high fever listlessness or irritability fecal incontinence is the inability to control the passage of feces and gas from the anus incontinence harms a patient's body image as gas accumulates in the lumen of the intestines the bowel wall stretches and descends flatulence is a common cause of abdominal fullness pain and cramping normally intestinal gas escapes through the mouth or through the anus hemorrhoids are dilated and engorged veins in the lining of the rectum they can be either external or internal external hemorrhoids are clearly visible as protrusions of skin what do you think the student nurse should do for this patient a stoma is a temporary or permanent opening that is created surgically by bringing part of the intestine out through the abdominal wall the surgical openings are called an ileostomy or colostomy depending on the part of the intestinal tract that is used to create the stoma ostomies to look the location will determine the stool consistency a sigmoid colostomy will have more formed stool a transverse colostomy will be thick liquid to soft consistencies these are easiest to perform surgically and routinely done as temporary means to divert the bowel from the area of the trommel trauma or any perianal wounds in ileostomy the fecal effluent leaves the body before it enters the colon creating frequent and liquid stools loop colostomies are reversible stomas constructed in the ilium or the colon the surgeon will pull a loop of intestine onto the abdomen and place a plastic rod or a rubber catheter temporarily under the bowel loop to keep it from slipping back then opens the bowel and sutures it to the skin of the abdomen a loop ostomy has two openings through the stoma the proximal end will drain fecal effluent and the distal end will drain mucous mucus an ilioanal pouch anastomosis this is a surgical treatment that is performed for treatment of ulcerative colitis or familial adenopoliposis the surgeon removes the colon creates a pouch from the end of the small intestine and attaches the pouch to the patient's anus this pouch provides for the collection of fecal material which will stimulate the functioning of the rectum what are similarities that you notice when reading this between the student's former patient and the student's patient that she has currently in bow elimination intricate knowledge from nursing in other disciplines is necessary to understand the patient's response to bowel elimination alterations the experience in caring for patients with elimination alterations will help the nurse provide an appropriate care plan what do the patient's symptoms indicate what diagnosis might you determine a newly admitted patient states that he has recently had a change in medications and reports that his stools are now dry and hard to pass this type of bowel pattern is consistent with abnormal defecation constipation fecal impaction or fecal incontinence the answer is b improper diet reduced fluid intake lack of exercise and some medications may cause constipation when intestinal motility motility slows the fecal mass becomes exposed to the intestinal walls over time and the majority of the water is absorbed little water is then left to soften and lubricate the stool constipation is a significant source of discomfort and the nurse should assess the need for intervention before the defecation becomes painful or the stool becomes impacted what assessment steps would you take if you were this student patients expect nurses to answer all the questions regarding diagnostic tests and the preparation for tests patients are concerned about discomfort and exposure of their perianal area bowel problems are a source of discomfort and embarrassment for them fecal and urinary incontinence in older people is often a reason for admission to long-term care facilities and the rate of development of both fecal and urinary incontinence after admission to along to a long-term care facility is 28 percent at six months 42 percent at one year and 61 percent two years after admission the mouth the nurse should inspect the teeth tongue and gums poor dentition or poorly fitting dentures will influence the ability to chew sores in the mouth make eating difficult and painful for the abdomen the nurse should inspect all four abdominal quadrants for contour shape symmetry and skin color the nurse should note masses peristaltic waves scars venous patterns stomas and lesions abdominal distension will appear as an overall outward protuberance of the abdomen intestinal gas large tumors or fluid in the peritoneal cavity will cause distension a distended abdomen will feel tight like a drum the skin is taut and appears stretched normal bowel sounds will occur every 5 to 15 seconds and lasts 1 second to several seconds absent or no auscultated vowel sounds or hypoactive sounds will occur with an ileus after abdominal surgery high pitched and hyperactive vowel sounds occur with small intestine obstruction and inflammatory disorders a test for occult blood in the stool and stool cultures require a small sample of stool the nurse will collect about three centimeters or one inch of formed stool or 15 to 30 milliliters of liquid stool the test for measuring the output of fecal fat requires a three to five day collection of stool the nurse will need to save all the fecal material throughout the test period what nursing diagnosis would you choose for this patient what goals would you set associated problems such as age body image or skin breakdown require interventions that are unrelated to bowel function impairment it is important to establish the correct related to factor for a diagnosis this will depend on the thoroughness of the nursing assessment and the nurse's recognition of the assessment findings and factors that will impair elimination the nurse will assist the patient to establish goals and outcomes by incorporating their elimination habits or routines as much as possible and reinforcing the routines that promote their health the overall goal of returning a patient to normal bowel elimination pattern will include the following outcomes the patient establishes a regular defecation schedule the patient lists proper food and fluid intake necessary to soften the stool and promote regular bowel elimination the patient implements a regular exercise program the patient reports daily passage of soft formed brown stool the patient does not report straining or any discomfort that is associated with defecation the anticipated outcomes that will demonstrate achievement of these goals that are listed are mr gutierrez will have a bowel movement within 48 hours mr gutierrez abdomen will be soft non-descended and non-tender within 48 within 24 hours mr gutierrez will pass soft form stools at least every three days mr gutierrez will identify the need to increase the fiber content of his diet within one week mr gutierrez will immediately discontinue laxative use and will use fiber supplements when necessary mr gutierrez will identify the need to drink eight eight ounce classes of non-caffeinated beverages within three days there are various risk factors for colon cancer age over 50 family history of colorectal cancer familial adeno adenopoliposis hereditary non-polyposis colon cancer a personal history of colorectal cancer or colorectal polyps or irritable irritable inflammatory bowel disease race african americans have the highest colon cancer rates diet is a high intake of red meat and processed meat such as lunch meat or hot dogs obesity and physical inactivity smoking and heavy alcohol consumptions the warning signs for cancer are a change in bowel habits rectal bleeding or blood in the stool sensation of incomplete evacuation unexplained abdominal or back pain remember when positioning a patient for defecation it is important to prevent muscle strain and discomfort never try to lift a patient onto a bedpan never place the patient on a bedpan and leave with the bed flat unless activity restrictions demand it because this forces the patient to hyper extend the back to lip lift the hips onto the pan when patients are immobile or if it is unsafe to allow them to raise their hip it is safest for both caregivers and patients to roll them onto the bedpan these are the rationale for the interventions listed high fiber foods increase the bulk of fecal contents this will increase the peristalsis and improve the movement of the intestinal contents through the gi tract brand whether flakes or fiber supplements add bulk to feces and increase the number of soft formed stools cooking facilities are necessary for the preparation of selective food preferences caffeinated beverages will cause the body to increase the excretion of fluids and dehydrate the patient fluids will actually help keep the fecal mass soft and increase the stool bulk causing an increase in the peristalsis with routine or normal aging there are changes that are noted in rectal sensation and the body actually needs larger volumes to elicit the sensation to defecate using the normal gastrocolic reflux which results in the movement of the colon contents appropriately one hour after meal will establish a routine bowel habit with some acute bowel illnesses the gi system will become affected changes in the patient's fluid status mobility patterns nutrition and the sleep cycle will all affect regular bowel habits surgical interventions on the gi tract will affect bowel elimination there are medications that initiate and facilitate stool passage laxatives and cathartics have short-term action of emptying the bowel these also are used to help cleanse the bowel for patients that may be undergoing gi tests or abdominal surgery anti-diarrheal agents will decrease the intestinal muscle tone to slow the passage of feces because of this the body will absorb more water through the intestinal walls an enema is an installation of a solution into the rectum and the sigmoid colon the primary reason for this is to promote defecation by stimulating peristalsis the volume of the fluid in still will break up the fecal mass stretch the rectal wall and initiate the defecation reflex enemas are also a method of medications these will can exert a local effect on the rectal mucosa they can be used for immediate relief of constipation emptying the bowel before diagnostic testing or surgery and if beginning a bowel training program cleansing enemas will promote the complete evacuation of feces from the colon these enemas act by stimulating peristalsis through the infusion of a large volume of solution or through local irritation of the mucosa of the colon tap water is hypotonic this exerts an osmotic pressure that is lower than the fluid in the interstitial spaces after water is infused into the colon the water will escape from the bowel lumen into the interstitial spaces normal saline is considered the safest solution because it exerts the same osmotic pressure as the fluids in the interstitial spaces that surround the bowel the volume of the infused saline will stimulate the peristalsis providing a saline enema will lessen the danger of excess fluid absorption hypertonic solutions when they're infused into the bowel they exert osmotic pressure that pulls fluid out of the interstitial spaces the colon then will fill with fluid and the resultant dissension promotes defecation patients are unable to tolerate large volumes of fluid most often benefit from this type of enema which is designed to be a low volume a soap says enema this is when the nurse will add soap suds to tap water or saline to create the effect of intertestinal irritation and stimulate the peristalsis for soap suds the only soap that is used is castile soap in a liquid form it is often included in the enema kits that are named as soap suds oil retention enemas are used to lubricate the feces in the rectum and the colon feces will absorb some of the oil and become softer and easier to pass to actually increase the action of the oil the patient is to retain the enema for several hours if they are able a carminative enema provides relief from gaseous distension these enemas will improve the patient's ability to pass the flatus or the gas for the patient that has an impaction the fecal mass can be too large to pass voluntarily if a digital rectal exam reveals a hard stool mass in that rectum it may be necessary to manually remove it by breaking it up and bringing it out a section at a time excessive rectal manipulation will cause irritation to the mucosa bleeding and stimulation of the vagus nerve sometimes this will result in a reflex that slows the rate of the heart a patient's condition or situation sometimes needs special interventions to decompress the gi tract think about surgeries gi obstruction trauma to the gi tract all of these will change the peristalsis and decrease it make it making it absent a nasogastric tube is an actual pliable hollow tube that is inserted through the patient's nasopharynx and into the stomach the levine and salem sump tubes are most commonly used for stomach decompression the levine tube is a single lumen tube that has holes near the tip this is connected to a drainage bag or an intermittent suction device to drain stomach contents the salem sump tube is the preferred tube for stomach decompression the tube has two lumina one for the removal of the gastric contents and one to provide the air vent the blue pigtail displayed here in the image is the air vent that connects with the second lumen when the main lumen of the sump tube is connected to suction the air vent permits free continuous drainage of secretions do not clamp off the air vent if the tube is connected to suction you need to consider skill 47.2 if a patient has a nasogastric tube the nurse should assess the condition of the patient's nerves and throat for inflammation the tape or the fixation device that is used to anchor the tube will become soiled or loosened and it needs to be changed as necessary to prevent the tube from increasing or decreasing meaning that it goes into the stomach further or it comes out of the stomach area to maintain normal elimination patterns in the hospitalized patient you should instruct the patient to defecate one hour after meals because the presence of food stimulates peristalsis mass colonic peristalsis occurs at this time irregularity helps to develop a habitual pattern neglecting the urge to defecate can cause diarrhea the answer is b mass peristalsis pushes undigested food toward the rectum these mass movements occur only three to four times daily with the strongest during the hour after meal time patients with temporary or permanent bowel diversions have specific elimination needs a patient that has an ostomy wear pouch to collect the effluent or the output from the stoma pouches are designed to be odor proof and have a protective skin barrier that surround the stoma the pouch should be empty when it is one third to one half full changing the pouch system approximately every three to seven days will be necessary depending on the patient's needs the stoma color should be assessed it should be pink or red the nurse should observe the skin at each pouch change for signs of irritation or skin breakdown skin protection is vital because the effluent has the digestive enzymes in it that can cause irritant dermatitis if there is actual leakage onto the parastomal skin some patients will irrigate their sigmoid colostomies to help them regulate colon emptying this process will take about an hour a day to complete but usually that means the patient wears what's called a mini pouch to absorb mucus from the stoma and contain the gas the pouch system consists of the pouch and a skin barrier that is separate pouches come as one piece or two piece systems and they are flat patients that have colostomys have no diet restrictions other than the diet discussed for normal healthy bowel functioning they need adequate fiber and fluids to keep the stool softly formed patients that have ileostomies digest their food completely but will lose fluids and salts through their stoma and they need to be sure to replace these lost fluids and salts to avoid dehydration after ostomy surgery the patients face a variety of anxiety and concern from learning to manage their new stoma to coping with self-esteem body image and sexuality as nurses we need to provide emotional support before and after surgery adjustment for the patient to the stoma will take time and it is very individual so it will change from patient to patient an older adult may need bowel retraining older adults they have a risk for having constipation constipation will affect nursing home residents between 50 to 74 of those residents actually use laxatives increasing the fiber in the diet with whole grains legumes fruits and vegetables will help there should be a minimum of 1500 milliliters of fluid intake per day this will help decrease the risk of constipation if holding a paper cup is a problem consider using a light plastic cup and filling it only half full and refilling it frequently for the individual the nurse will encourage regular exercise within limitations the patients need to feel at ease whenever they're eliminating they need to have privacy because the lack of privacy can leading to the patients ignoring their urge to defecate think about how to document the achievement of these outcomes mr gutierrez intake of high fiber foods is still limited fluid take is improving has bowel movements approximately every two days successfully avoiding use of laxatives stool is softer in character his abdomen is less descended the effectiveness of care will depend on success in meeting the expected outcomes of the patient's self-care a patient will be able will be able to have regular pain-free defecation of soft formed the patient or the caregiver is the only individual to determine whether the bowel elimination problems have been relieved what should be documented in the nursing note abdomen soft non-descended vowel sounds audible normal active times four quadrants when thinking of the sideline patient with the patient that has enema think of the sims position that is our left side lying position that is used frequently in nursing