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1. Bowel elimination

2. Defecation (bowel elimination) Is the act of expelling feces (stool) from the body. In the large intestine, a remarkable volume of water is removed from the remnants of digestion, causing the bowel’s contents to become a consolidated mass of residue before being eliminated. Peristalsis Means the rhythmic contractions of intestinal smooth muscle that facilitate defecation. Peristalsis moves fiber, water, and nutritional wastes along the ascending, transverse, descending, and sigmoid colon toward the rectum.

3. Peristalsis becomes even more active during eating; this increased peristaltic activity is termed the gastrocolic reflex. The gastrocolic reflex: It’s accelerated wavelike movements, sometimes perceived as slight abdominal cramping, propel stool forward, packing it within the rectum. As the rectum distends, the person feels the urge to defecate. Stool is eventually released when the anal sphincters (ring-shaped bands of muscles) relax. Performing the Valsalva maneuver (closing the glottis and contracting the pelvic and abdominal muscles to increase abdominal pressure) facilitates this process. Several dietary, physical, social, and emotional factors can influence the bowel’s mechanical function.

4. Assessment of bowel elimination 1- Elimination Patterns Because various elimination patterns can be normal, it is essential to determine the client’s usual patterns, including frequency of elimination effort required to expel stool What elimination aids used. 2- Stool Characteristics Health care providers can obtain objective data about stool characteristics by inspecting the stool or asking the client to describe its appearance. Information that is particularly diagnostic includes stool color, odor, consistency, shape, and unusual components .

5. Whenever stool appears abnormal A sample is saved in a covered container for the physician’s inspection. Nurses may independently perform screening tests on stool samples, such as presence of blood. Nurses then report the results, which can be falsely positive, to the physician, who may order more specific laboratory or diagnostic tests. By analyzing assessment findings, nurses may help physicians to diagnose a medical problem or use the conclusions to identify alterations within the scope of nursing management.

6. 1- Constipation : An elimination problem characterized by dry , hard stool that is difficult to pass with various accompanying signs and symptoms include • Complaints of abdominal fullness or bloating • Abdominal distention • Complaints of rectal fullness or pressure • Pain on defecation • Decreased frequency of bowel movements • Inability to pass stool Changes in stool characteristics such as oozing liquid stool or hard small stool Infrequent elimination of stool does not necessarily indicate that a person is constipated. Some people may be constipated even though they have a daily bowel movement, whereas others who defecate irregularly may have normal bowel function. The incidence of constipation tends to be high among those whose dietary habits lack adequate fiber (such as not eating sufficient raw fruits and vegetables, whole grains, seeds, and nuts). Dietary fiber, which becomes undigested cellulose , is important because it attracts water within the bowel, resulting in bulkier stool that is more quickly and easily eliminated. The longer stool is retained, the more contact with and absorption of toxic substances takes place. 5- Common alterations in bowel elimination

7. Constipation is classified into (primary, secondary, iatrogenic, and pseudoconstipation ), according to the underlying cause. Primary/ simple Constipation Results from lifestyle factors such as inactivity, inadequate intake of fiber, insufficient fluid intake, or ignoring the urge to defecate. Secondary Constipation It is a consequence of a pathologic disorder such as a partial bowel obstruction. It usually resolves when the primary cause is treated. Iatrogenic Constipation It occurs as a consequence of other medical treatment . as, prolonged use of narcotic analgesia tends to cause constipation. These and other drugs slow peristalsis, delaying transit time. The longer the stool remains in the colon, the drier it becomes, making it more difficult to pass Pseudo/ perceived constipation It is a term used when clients believe themselves to be constipated even though they are not. It may occur in people who are extremely concerned about having a daily bowel movement. In their zeal for regularity, they often overuse or abuse laxatives, suppositories, and enemas. Such self treatment may ultimately cause rather than treat constipation. Chronic purging eventually weakens bowel tone; consequently, bowel elimination

8. 2- Fecal Impaction Occurs when a large, hardened mass of stool interferes with defecation, making it impossible for the client to pass feces voluntarily. Result from unrelieved constipation, retained barium from an intestinal x-ray, dehydration, and weakness of abdominal muscles. Clients with impaction usually report a frequent desire to defecate but an inability to do so. Rectal pain may result from unsuccessful efforts to evacuate the lower bowel. Some clients with an impaction pass liquid stool , which they may misinterpret as diarrhea. Forceful muscular contractions of peristalsis in higher bowel areas, where the stool is still fluid, cause the liquid stool. These contractions send the liquid around the margins of the impacted stool, but this passage of liquid stool does not relieve the initial condition.

9. To determine whether or not fecal impaction is present, it may be necessary to insert a lubricated, gloved finger into the rectum. If the rectum is filled with a mass of stool, the nurse implements measures for its removal. To resolve impaction nurses may administer 1- enemas(oil retention then cleansing). 2- to remove the stool digitally.

10. 3- Flatulence / flatus An excessive accumulation of intestinal gas results from 1- swallowing air while eating 2- sluggish (slow) peristalsis 3 - the gas that forms as a byproduct of bacterial fermentation in the bowel. 4 - gas forming food as (cabbage, cucumbers, Beans and onions) . As it creates intestinal gas because humans lack an enzyme to completely digest their particular form of complex carbohydrate. Regardless of its cause, flatus may be expelled through 1-ambulation 2- Insertion of rectal tube to thus reducing the cramping pain or other symptoms occur when clients are extremely uncomfortable.

11. 4- Diarrhea is the urgent passage of watery stool and commonly is accompanied by abdominal cramping. Simple diarrhea usually begins suddenly and lasts for a short period . Other associated signs and symptoms include nausea and vomiting and blood or mucus in the stools. Usually diarrhea is a means of eliminating an irritating substance such as tainted food or intestinal pathogens. Diarrhea may also result from emotional stress, dietary indiscretions, laxative abuse, or bowel disorders. Management : 1- Resting the bowel temporarily may relieve simple diarrhea 2- drinks clear liquids but avoids solid foods for 12 to 24 hours 3- Resumed eating begins with bland foods and those low in residue such as bananas, applesauce, and cottage cheese. If diarrhea is not relieved within 24 hours, it is best to consult a physician

12. 5- Fecal Incontinence inability to control the elimination of stool. It does not necessarily imply that stool is loose or watery, although that may be the case. In some instances, bowel function is normal, but incontinence results from neurologic changes that impair muscle activity, sensation, or thought processes. Even a fecal impaction may be an underlying cause of incontinence. Incontinence also may occur when a person cannot reach a toilet in time to eliminate, such as after taking a harsh laxative. Chronic fecal incontinence can be devastating socially and emotionally. Clients who cope with chronic fecal incontinence and their families require much support and understanding.

13. Measures to promote bowel elimination 1- inserting suppositories 2- administering enemas to promote elimination when it does not occur naturally or when the bowel must be cleansed for other purposes, such as preparation for surgery and endoscopic or x-ray examinations. Inserting a Rectal Suppository A suppository (oval or cone-shaped mass that melts at body temperature) is inserted into a body cavity such as the rectum that will promote expulsion of feces . Other medications, such as drugs to control vomiting and to reduce fever, also are available in suppository form. Medications released from the suppository can have local or systemic effects . Depending on the drug, local effects may include softening and lubricating dry stool, irritating the wall of the rectum and anal canal to stimulate smooth muscle contraction, and liberating carbon dioxide, thus increasing rectal distention and the urge to defecate. Drugs administered in suppository form to achieve systemic effects are chosen when clients have difficulty retaining or absorbing oral medications because of chronic vomiting or an impaired ability to swallow.

14. Administering an Enema An enema introduces a solution into the rectum to • Cleanse the lower bowel (most common reason). • Soften feces. • Expel flatus. • Soothe irritated mucous membranes. • Outline the colon during diagnostic x-rays. • Treat worm and parasite infestations. Cleansing Enemas Use different types of solution to remove feces from the rectum. Defecation usually occurs within 5 to 15 minutes after administration. Large-volume cleansing enemas may create discomfort because they distend the lower bowel . Nurses must administer them cautiously to clients with intestinal disorders such as colitis (inflammation of the colon) because large volume enemas may rupture the bowel or cause other secondary complications. In many health agencies and in the home, commercially prepared disposable administration sets have become the method of choice for cleansing the bowel. Their smaller volume makes them less fatiguing and distressing than large-volume enemas, and they can be easily self-administered.

15. Tap water and normal saline enemas. Tap water and normal saline solutions are preferred for their nonirritating effects, especially for clients with rectal diseases or those being prepared for rectal examinations . Tap water and normal saline appear to have about the same degree of effectiveness for cleansing the bowel. Because tap water is hypotonic, the fluid can be absorbed through the bowel. Consequently, if several enemas are administered in succession, fluid and electrolyte imbalances may occur. Therefore , to ensure client safety, if stool continues to be expelled after the administration of three enemas, the nurse consults the physician before administering any more. Soap solution enemas. is a mixture of water and soap. Many disposable enema kits contain an envelope of soap mixed with up to 1 quart (1,000 mL) of water. If these soap packets are not available, a comparable mixture is 1 mL of mild liquid soap per 200 mL of solution, or a 1:200 ratio. Therefore , 5 mL of soap is added to prepare a volume of 1,000 mL. Soap causes chemical irritation of the mucous membranes . Adding too much soap or using strong soap can potentiate the irritating effect.

16. Hypertonic saline (sodium phosphate) enemas. Draws fluid from body tissues into the bowel. This increases the fluid volume in the intestine beyond what was originally instilled. The concentrated solution also acts as a local irritant on the mucous membranes. It is available in commercially prepared, disposable containers holding approximately 4 oz (120 mL) of solution. The container, which has a lubricated tip, substitutes for enema equipment and tubing.

17. oil retention enema is A type of retention enema in which the fluid instilled is mineral, cottonseed, or olive oil. Oils lubricate and soften the stool, so it can be expelled more easily. The oil may come in a prefilled container similar to those that contain hypertonic saline. If disposable equipment is not available, the nurse lubricates and inserts a 14 to 22 F tube in the rectum. A small funnel or large syringe is attached to the tube, and the nurse instills approximately 100 to 200 mL of warmed oil slowly to avoid stimulating an urge to defecate. Premature defecation defeats the purpose of retaining the oil. Retention Enemas uses a solution held within the large intestine for a specified period, usually at least 30 minutes. Some of them are not expelled at all.

18. Ostomy care an ostomy (surgically created opening to the bowel or other structure) requires additional care for promoting bowel elimination. Two examples of intestinal ostomies are an ileostomy (surgically created opening to the ileum) and a colostomy (surgically created opening to a portion of the colon). Materials enter and exit through a stoma (entrance to the opening). Most persons with an ostomy, wear an appliance (bag or collection device over the stoma) to collect stool. Depending an ostomy type & location, client care may involve providing peristomal care applying an appliance draining a continent ileostomy administering colostomy irrigations through the stoma.

19. Providing peristomal Care Preventing skin breakdown is a major challenge in ostomy care. Enzymes in stool can quickly cause excoriation (chemical injury of skin). Washing the stoma and surrounding skin with mild soap and water and patting it dry can preserve skin integrity. Another way to protect the skin is to apply barrier substances such as karaya , a plant substance that becomes gelatinous when moistened, and commercial skin preparations around the stoma. An enterostomal therapist, a nurse certified in caring for ostomies and related skin problems, may be consulted regarding skin and stomal care.

20. Applying an Ostomy Appliance Various appliances are available, but all consist of a pouch for collecting stool and a faceplate , or disk, that attaches to the abdomen. The stoma protrudes through an opening in the center of the appliance. The pouch fastens into position when pressed over the circular support on the faceplate. Some clients prefer a type that also is fastened to an elastic belt worn around the waist. The belt helps to support the weight of the fecal material and prevents the faceplate from being pulled away from the abdomen. The client empties the pouch by releasing the clamp at the bottom. The faceplate usually remains in place for 3 to 5 days unless it becomes loose or causes skin discomfort. Pouches are emptied and rinsed or detached and replaced periodically. The client empties the pouch when it is one-third to one-half full. If it become too heavy it will pull the faceplate from the skin. Although design of the equipment varies, almost all types of appliances are changed similarly.

21. Draining a Continent Ileostomy A continent ostomy (surgically created opening that controls the drainage of liquid stool or urine by siphoning it from an internal reservoir) also is referred to as a Kock pouch, after the surgeon who developed the technique. This type of ostomy requires no appliance; however, the client must drain the accumulating liquid stool or urine approximately every 4 to 6 hours. The client can use a gravity drainage system at night.

22. Irrigating a Colostomy Clients with a colostomy whose stool is more solid sometimes require the instillation of fluid to promote elimination. Colostomy irrigation involves instilling solution through the stoma into the colon, a process similar to administering an enema. The purpose of the irrigation is to remove formed stool and in some cases to regulate the timing of bowel movements. With regulation, a client with a sigmoid colostomy may not need to wear an appliance. The colostomy irrigation helps to train the bowel to eliminate formed stool following the irrigation. Once the client has eliminated the stool, he or she will expel no more until the next irrigation. This mimics the pattern of natural bowel elimination for most people. Because of the predictability of bowel elimination, some clients with a sigmoid colostomy feel it is unnecessary to wear an appliance.

23. NURSING IMPLICATIONS While assessing and caring for clients with altered bowel elimination, the nurse may identify one or more of the following nursing diagnoses: • Constipation • Risk for Constipation • Perceived Constipation • Diarrhea • Bowel Incontinence • Toileting Self-Care Deficit • Situational Low Self-Esteem

24. Question #1 When a client tells the nurse that he cannot have a bowel movement without taking a daily laxative, what information is essential for the nurse to explain? 1. Chronic use of laxatives impairs natural bowel tone. 2. Stool softeners are likely to be less harsh. 3. Daily enemas are more preferable than laxatives. 4. Dilating the anal sphincter may aid bowel elimination .

25. Which of the following assessments is the best indication that a client has a fecal impaction? 1. The client passes liquid stool frequently. 2. The client has extremely offending bad breath. 3. The client requests medication for a headache. 4. The client has not been eating well lately. Question #2