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Chapter 46: Bowel Elimination PowerPoint PPT Presentation


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Chapter 46: Bowel Elimination. Bonnie M. Wivell, MS, RN, CNS. Scientific Knowledge Base. Factors Affecting Bowel Elimination. Age Infants: small stomach capacity; less secretion of digestive enzymes; rapid peristalsis; lack neuromuscular development so cannot control bowels

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Chapter 46: Bowel Elimination

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Chapter 46 bowel elimination l.jpg

Chapter 46: Bowel Elimination

Bonnie M. Wivell, MS, RN, CNS


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Scientific Knowledge Base


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Factors Affecting Bowel Elimination

  • Age

    • Infants: small stomach capacity; less secretion of digestive enzymes; rapid peristalsis; lack neuromuscular development so cannot control bowels

    • Older adults: arteriosclerosis which causes decreased mesenteric blood flow, decreasing absorption in small intestine; decrease in peristalsis; loose muscle tone in perineal floor and anal sphincter thus are at risk for incontinence; slowing nerve impulses in the anal region make older adults less aware of need to defecate leading to irregular BMs and risk of constipation


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Factors Affecting Bowel Elimination

  • Diet: fiber such as whole grains, fresh fruits and vegies help flush the fats and waste products from the body with more efficiency; decreased fiber → increased risk of polyps; be aware of food intolerances

  • Fluid intake: 6-8 glasses of noncaffeinated fluid daily; liquifies intestinal contents easing passage through colon

  • Physical activity: promotes peristalsis

  • Psychological factors: stress increases peristalsis resulting in diarrhea and gaseous distention; ulcerative colitis; IBS; gastric and duodenal ulcers; crohn’s disease

  • Personal habits: fear of defecating away from home

  • Position during defecation: squatting is the normal position


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Factors Affecting Bowel Elimination

  • Pain: hemorrhoids, rectal surgery, rectal fistulas and abd. surgery

  • Pregnancy: increased pressure; slowing peristalsis in third trimester

  • Surgery and Anesthesia: lows or stops peristalsis; paralytic ileus = direct manipulation of the bowel and lasts 24-48 hours

  • Medications: laxatives and cathartics; laxative overuse can decrease muscle tone and can cause diarrhea which can result in dehydration and electrolyte imbalance; see Table 46-2

  • Diagnostic tests: bowel prep; barium


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Common Bowel Elimination Problems

  • Constipation

    • Causes: improper diet, reduced fluid intake, lack of exercise, and certain meds

    • A significant health hazard

  • Impaction

    • Causes: unrelieved constipation

    • Debilitated, confused, and unconscious more at risk

    • Continuous ooze of diarrhea is a suspect sign

  • Diarrhea

    • Causes: antibiotics via any route; enteral nutrition; food allergies or intolerance; surgeries or diagnostic testing of the lower GI tract; C. difficile; communicable food-borne pathogens


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Common Bowel Elimination Problems

  • Incontinence

    • Causes: physical conditions that impair anal sphincter function or control

  • Flatulence

    • Causes: certain foods; decreased intestinal motility

    • Can become severe enough to cause abd distention and severe sharp pain

  • Hemorrhoids = dilated, engorged veins; internal or external

    • Causes: straining with defecation; pregnancy; heart failure; chronic liver disease


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Bowel Diversions

  • Ostomies: Certain disease /conditions prevent normal passage of stool; temporary or permanent artificial opening in the abd wall; location determines consistency of stool

    • Loop colostomy: Usually done emergently; temporary; usually involves transverse colon; two openings through one stoma – stool and mucus; external supporting device usually removed in 7-10 days

    • End colostomy: one stoma formed from the proximal end of the bowel and distal portion of the GI tract removed or sewn closed (Hartman’s pouch); common in colorectal cancer and rectum is usually removed; temporary in surgery for diverticulitis

    • Double-barrel colostomy: bowel is surgically severed and two ends brought out onto the abd; proximal stoma functions and distal stoma is nonfunctioning


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Loop Colostomy


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Double-Barrel Colostomy


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Double-Barrel Colostomy


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End Colostomy


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Bowel Diversions Cont’d.

  • Alternative procedures

    • Ileoanal pouch: colon removed for tx of ulcerative colits or familial polyps; pouch is formed from distal end of small intestines and attached to anus; pouch acts as rectum so pt. is continent; has temporary ileostomy while healing

    • Kock continent ileostomy: consists of a reservoir constructed from small bowel and nipple valve which keeps contents of reservoir inside body; permits entry of external catheter to drain pouch

    • Macedo-Malone Antegrade Continence Enema (MACE); for improving continence in pts with neuropathic or structural abnormalities of the anal sphincter


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Ileoanal Pouch Anastomosis


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Kock Continent Ileostomy


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Care of the Patient With aBowel Diversion

  • “Bagging” the ostomy

  • Assessing stoma and skin

  • Assessing stool output

  • New stoma vs. Old stoma

  • Patient education and counseling


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Psychological Considerations

  • Body image changes

  • Face a variety of anxieties and concerns

  • Must learn how to manage stoma

  • Cope with conflicts of self-esteem and body image

  • Can be concealed with clothing but pt. aware of its presence

  • Difficulty with intimacy/sexual relations

  • Foul odors, leakage, spills and inability to control or regulate passage of gas and stool is embarrassing

  • Ostomy support:

    • United Ostomy Association

    • National Foundation for Ileitis and Colitis


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Nursing Process and Bowel Elimination

  • Assessment

    • Nursing history (see Box 46-2)

      • Usual elimination pattern

      • Usual stool characteristics

      • Routines to promote normal elimination

      • Use of artificial aids

      • Presence/status of bowel diversions

      • Changes in appetite

      • Diet history

      • Daily fluid intake

      • History of surgery or illnesses of GI tract

      • Medication history

      • Emotional state

      • History of exercise

      • Pain or discomfort

      • Social history

      • Mobility and dexterity


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Nursing Process and Bowel Elimination

  • Physical assessment of the abdomen

    • Mouth: poor dentition, dentures, mouth sores

    • Abdomen: inspect, auscultate, palpate, percuss

    • Rectum: inspect

  • Inspection of fecal characteristics

  • Review of relevant test results

    • Fecal specimens: cannot mix feces with urine or water

      • Stool for occult blood (FOBT or guiac) see Box 46-3

      • Fecal fat requires 3-5 days of collection

      • Ova & Parasites (O&P)

    • Labs: bilirubin, ALK, Amylase, CEA

    • Diagnostic Exams: KUB, endoscopy, colonoscopy, barium enema, barium swallow, US, MRI, CT scan (may require pre-procedure preparation)


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Nursing Diagnosis

  • Bowel incontinence

  • Constipation

  • Risk for constipation

  • Perceived constipation

  • Diarrhea

  • Toileting self-care deficit

  • Body image, disturbed


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Planning

  • Goals and outcomes

    • Client sets regular defecation habits

    • Client is able to list proper fluid and food intake needed to achieve bowel elimination

    • Client implements a regular exercise program

    • Client reports daily passage of soft, formed brown stool

    • Client doesn’t report any discomfort associated with defecation

  • Setting Priorities

  • Collaborative Care - WOCN


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Implementation

  • Health Promotion: establish routine

    • Promotion of normal defecation

      • Sitting position

      • Position on bedpan – see pg. 1196

      • Privacy

  • Acute Care

    • Meds

    • Cathartics and laxatives

    • Antidiarrheal agents

    • Enemas


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Types of Enemas

  • Cleansing enemas

    • Tap water

    • Normal saline

    • Hypertonic solutions

    • Soapsuds

  • Oil Retention

  • Carminative – Mag, gylcerin and water; relieves gaseous distention

  • Medicated enemas – Kayexalate


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Implementation Cont’d.

  • Enema administration

    • “Enemas till clear”

    • See pages 1200-1202

  • Digital removal of stool – last resort

    • Can cause irritation to the mucosa, bleeding and stimulation of vagus nerve

  • Inserting and maintaining a nasogastric tube


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NG Tubes

  • Levine or salem sump tubes are most common for stomach decompression or lavage

  • See pages 1204-1209 for insertion procedure

  • Connected to intermittent suction (LIS)

  • Air vent should NEVER be clamped, connected to suction or used for irrigation

  • Not a sterile technique

  • Care of pt. with NG

    • Comfort

    • Frequent mouth care/gargling

    • Maintain patency of tube

    • Turn client frequently to allow for adequate emptying


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Continuing and Restorative Care

Care of ostomies

Irriating a colostomy

Pouching ostomies (see pages 1211-1215)

Nutritional considerations with ostomies

Bowel training

Proper fluid and food intake

Regular exercise

Hemorrhoids

Skin integrity


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Evaluation

The effectiveness of care depends on how successful the client is in achieving goals and outcomes

Optimally the client will be able to have regular, pain-free defecation of soft-formed stools

It is necessary to ask questions so establishing a therapeutic relationship is VERY important

Nursing interventions may be altered if necessary


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