nursing management of client with bowel elimination problems

The presentation outlines the diferent management of cllients with elimination problem

1. Bowel EliminationBowel Elimination

2. Learning objectivesLearning objectives

Define bowel elimination Define bowel elimination

Explain the characteristics of normal Explain the characteristics of normal
faecesfaeces

Explain the mechanisms that control bowel Explain the mechanisms that control bowel
elimination elimination

Explain factors affecting the normal bowel Explain factors affecting the normal bowel
elimination elimination

3. Learning objectivesLearning objectives

Explain the common problems with bowel Explain the common problems with bowel
function function

Describe the diagnostic procedures for Describe the diagnostic procedures for
altered bowel function altered bowel function

Explain the management of patients with Explain the management of patients with
various bowel elimination problems various bowel elimination problems

4. GI Tract AnatomyGI Tract Anatomy

MouthMouth

EsophagusEsophagus

StomachStomach

Small Intestine Small Intestine

Large IntestineLarge Intestine

RectumRectum

5. IntroductionIntroduction

GI Tract is a series of GI Tract is a series of
hollow mucous hollow mucous
membrane lined membrane lined
muscular organsmuscular organs

Purpose is to absorb Purpose is to absorb
fluids & nutrients, fluids & nutrients,
prepare food for prepare food for
absorption & provide absorption & provide
storage for faecesstorage for faeces

7. Anatomy and physiology of Anatomy and physiology of
GITGIT
MouthMouth

Mechanically and chemically breaks down food Mechanically and chemically breaks down food
into usable size and forminto usable size and form

Digestion begins hereDigestion begins here
OesophagusOesophagus

Passage of food from the mouth through to the Passage of food from the mouth through to the
stomachstomach

Oesophageal sphincter prevents air entry into Oesophageal sphincter prevents air entry into
oesophagus and food reflux into the throat. oesophagus and food reflux into the throat.

8. Anatomy and physiology of Anatomy and physiology of
GITGIT
StomachStomach

For storage of swallowed food and liquidFor storage of swallowed food and liquid

A stomach
 that functions properly will empty in
A stomach
 that functions properly will empty in
4 to 6 hours4 to 6 hours

For mixing of food, liquid and digestive juices For mixing of food, liquid and digestive juices
and emptying its contents into the small and emptying its contents into the small
intestineintestine

Produces and secretes Hydrochloric acid Produces and secretes Hydrochloric acid
(HCL), mucus, pepsin and intrinsic factor(HCL), mucus, pepsin and intrinsic factor

9. Anatomy ctd......Anatomy ctd......
Small IntestinesSmall Intestines

DuodenumDuodenum

JejunumJejunum

Ileum Ileum

Small intestines are for absorption of nutrients Small intestines are for absorption of nutrients
and electrolytesand electrolytes

Takes approx 3-10hours for contents to leave Takes approx 3-10hours for contents to leave
small intestines and enter large intestines.small intestines and enter large intestines.

11. Anatomy ctd........Anatomy ctd........
Large IntestinesLarge Intestines

CaecumCaecum

ColonColon

RectumRectum

Anus Anus

12. ColonColon

Has 4 divisions: Ascending, Transverse, Has 4 divisions: Ascending, Transverse,
Descending, SigmoidDescending, Sigmoid

Colon Functions: Absorption, Secretion & Colon Functions: Absorption, Secretion &
Elimination (stool and flatusElimination (stool and flatus))

14. RectumRectum

Joins sigmoid colonJoins sigmoid colon

About 12 cm longAbout 12 cm long

For storage of stoolFor storage of stool
AnusAnus

5cm long5cm long

Expels faeces out of the Expels faeces out of the
bodybody

Has sensory nerves to Has sensory nerves to
control continencecontrol continence
Internal SphincterInternal Sphincter

Smooth anal muscle within Smooth anal muscle within
anus and is under anus and is under
involuntary neural controlinvoluntary neural control

15. External SphincterExternal Sphincter

Surrounds and Surrounds and
extends beyond extends beyond
the internal the internal
sphinctersphincter

16. Definitions Definitions

DefecationDefecation: the act of expelling feces from : the act of expelling feces from
the bodythe body

Defecation is the process by which the solid Defecation is the process by which the solid
waste products of digestion are eliminated waste products of digestion are eliminated
from the bowel in the form of stools/faecesfrom the bowel in the form of stools/faeces

PeristalsisPeristalsis: rhythmic contractions of : rhythmic contractions of
intestinal smooth muscle to facilitate intestinal smooth muscle to facilitate
defecation defecation

17. 
Gastrocolic reflexGastrocolic reflex: increased peristaltic : increased peristaltic
activity occurring during food consumptionactivity occurring during food consumption

Valsalva maneuverValsalva maneuver: increasing : increasing
abdominal muscle pressure to facilitate abdominal muscle pressure to facilitate
defecationdefecation

18. Mechanism that control Mechanism that control
Bowel elimination Bowel elimination

Peristalsis propels faeces into the rectum and Peristalsis propels faeces into the rectum and
causes rectal distentioncauses rectal distention

Rectal distention with stools stimulates Rectal distention with stools stimulates
parasympathetic afferent nerve fibers in the parasympathetic afferent nerve fibers in the
sacral segment of the spinal cordsacral segment of the spinal cord

Contraction of descending, sigmoid colon, Contraction of descending, sigmoid colon,
rectum, anus, relaxation of internal anal sphincterrectum, anus, relaxation of internal anal sphincter

19. 
Defecation automatically followsDefecation automatically follows

With defecation reflex, the external anal With defecation reflex, the external anal
sphincter can remain contracted until person sphincter can remain contracted until person
decides appropriate time and placedecides appropriate time and place

Person then voluntarily relax the external Person then voluntarily relax the external
anal sphincter anal sphincter

Defecation is assisted by taking a deep Defecation is assisted by taking a deep
breath against a closed glottis ( to move the breath against a closed glottis ( to move the
diaphragm down), contracting the diaphragm down), contracting the
abdominal muscles abdominal muscles

20. ( to increase intra-abdominal pressure) and ( to increase intra-abdominal pressure) and
contracting the pelvic floor muscles to contracting the pelvic floor muscles to
push the faeces downwardpush the faeces downward

These actions together are called Valsalva These actions together are called Valsalva
Maneuver.Maneuver.

21. Characteristics of Normal Characteristics of Normal
FaecesFaeces
CHARACTERISTIC NORMAL ABNORMAL
Frequency 1-2/day to 1 every 2-3
days
Depends on usual
pattern
Colour Brown Black, tarry
Reddish brown
Maroon
Clay coloured
Yellow, green
Consistency Soft, semi solid Hard, Loose, liquid
High mucus content
Shape Cylindrical Narrow, pencil thin
Amount 100-300g/day <100g/day
>300g/day
Odour Aromatic, Pungent Foul

22. Composition of Normal Composition of Normal
FaecesFaeces
CONSTITUENT PERCENT
Water 75
Solid 25
Bacteria (E. Coli, E. Aerogens) 30
Fat 10-20
Inorganic matter 10-20
Protein 3
Undigested food fiber and dried
constituents of digestive juices
30

23. Colour of FaecesColour of Faeces
Brown colour- Brown colour-

The chemical conversion of bilirubin ( a The chemical conversion of bilirubin ( a
breakdown product of hemoglobin
  from red
breakdown product of hemoglobin
  from red
blood cells) into urobilin and stercobilin blood cells) into urobilin and stercobilin
(brown pigments) by intestinal bacteria and (brown pigments) by intestinal bacteria and
enzymes. enzymes.
Black, foul-smelling stoolBlack, foul-smelling stool: :

intestinal bleeding (typically from the stomach intestinal bleeding (typically from the stomach
and upper small intestine) due to ulcers, and upper small intestine) due to ulcers,
tumors; ingestion of iron tumors; ingestion of iron

24. Maroon stool: Maroon stool:

intestinal bleeding (from the middle intestinal bleeding (from the middle
intestine or proximal colon) due to ulcers, intestine or proximal colon) due to ulcers,
tumorstumors
Clay -colored stoolClay -colored stool: lack of bile due to : lack of bile due to
blockage of the main bile ductblockage of the main bile duct
Pale yellow, greasy, foul-smelling stoolPale yellow, greasy, foul-smelling stool: :
malabsorption of fat e.g due to pancreatic malabsorption of fat e.g due to pancreatic
insufficiency, as seen with
 pancreatitis.
insufficiency, as seen with
 pancreatitis.

25. Bright redBright red

Bleeding in the lower intestinal tract, such as Bleeding in the lower intestinal tract, such as
the large intestine or rectum, often from the large intestine or rectum, often from
hemorrhoids.hemorrhoids.
GreenGreen

Food may be moving through the large Food may be moving through the large
intestine too quickly, such as due to diarrhea. intestine too quickly, such as due to diarrhea.
As a result, bile doesn't have time to break As a result, bile doesn't have time to break
down completely. Leafy dietdown completely. Leafy diet

26. Lifespan considerations Lifespan considerations
Newborns and InfantsNewborns and Infants

1-2 days newborns evacuate soft formed 1-2 days newborns evacuate soft formed
dark greenish stools called dark greenish stools called Meconium.Meconium.

Meconium is the partially dried intestinal Meconium is the partially dried intestinal
secretions that accumulate in the large secretions that accumulate in the large
intestine before birth.intestine before birth.

33
rdrd
day stools reflect type of milk in the diet day stools reflect type of milk in the diet

Breast milk- bright yellow, soft, unobjectionable Breast milk- bright yellow, soft, unobjectionable
odorodor

27. 
Formula fed- dark yellow or tan, stronger Formula fed- dark yellow or tan, stronger
objectionable odorobjectionable odor

Immature GI makes stools to quickly pass Immature GI makes stools to quickly pass
hence less firmhence less firm

Less control of bowel elimination until Less control of bowel elimination until
central nervous system matures. central nervous system matures.

28. Toddlers and preschoolerToddlers and preschooler

Duodenocolic reflex is strong- any food Duodenocolic reflex is strong- any food
ingestion stimulate bowl eliminationingestion stimulate bowl elimination

Privacy- hide in a room or behind a chairPrivacy- hide in a room or behind a chair
School age and adolescentSchool age and adolescent

Needs privacyNeeds privacy

Defer defecation because of playingDefer defecation because of playing

29. Adults and Older adults Adults and Older adults

GI motility slows with age- decreases frequency GI motility slows with age- decreases frequency
of bowel movementof bowel movement

Weakened pelvic musclesWeakened pelvic muscles

Decreased activityDecreased activity

Chronic healthy conditions, meds useChronic healthy conditions, meds use

Decrease in strength of striated external Decrease in strength of striated external
sphincter muscles lead to increases in sphincter muscles lead to increases in
incontinenceincontinence

30. Factors Affecting Bowel Factors Affecting Bowel
EliminationElimination

AgeAge

Illness Illness

DietDiet

Fluid IntakeFluid Intake

Physical ActivityPhysical Activity

Psychological factorsPsychological factors

Personal HabitsPersonal Habits

Diagnostic proceduresDiagnostic procedures

31. Factors Affecting Bowel Factors Affecting Bowel
EliminationElimination

Position during DefecationPosition during Defecation

PainPain

Surgery and AnesthesiaSurgery and Anesthesia

MedicationsMedications

32. 1. Age 1. Age

Neuromuscular structures develop Neuromuscular structures develop
between 15-18monthsbetween 15-18months

Ability to control defecation starts at the Ability to control defecation starts at the
age of 2-3yearsage of 2-3years

The elderly are prone to constipationThe elderly are prone to constipation

Slow peristalsisSlow peristalsis

Slow oesophageal emptyingSlow oesophageal emptying

Decreased muscle tone in the peri-anal floorDecreased muscle tone in the peri-anal floor

Weakening of the anal sphincterWeakening of the anal sphincter

33. 2. Activity 2. Activity

Exercises maintain muscle toneExercises maintain muscle tone

Regular physical exercise promotes Regular physical exercise promotes
peristalsis peristalsis

Immobilization/ inactivity depresses colon Immobilization/ inactivity depresses colon
motilitymotility

34. 3. Position during defecation3. Position during defecation

Squatting/ sitting position while leaning Squatting/ sitting position while leaning
forwardforward

Sitting with hip and knees flexed allows Sitting with hip and knees flexed allows
easy exertion of intra-abdominal pressure easy exertion of intra-abdominal pressure
and contracting of the thigh muscles to and contracting of the thigh muscles to
normally defecatenormally defecate

Facilitates gravitational forceFacilitates gravitational force

35. 4. Diet/ nutrition 4. Diet/ nutrition

Regular daily food intakeRegular daily food intake

High fiber foods: raw or cooked fruits, High fiber foods: raw or cooked fruits,
vegetables, cereals and bread promote vegetables, cereals and bread promote
peristalsis. May cause loose stoolsperistalsis. May cause loose stools

Low fiber diet slows peristalsis- lean meat, Low fiber diet slows peristalsis- lean meat,
milkmilk

Gas forming foods- onions, beans, cabbage, Gas forming foods- onions, beans, cabbage,
potatoes, eggs stimulate peristalsispotatoes, eggs stimulate peristalsis

36. 4. Diet / nutrition4. Diet / nutrition

More fluids soften stoolsMore fluids soften stools

Fatty diet – diarrhoea or constipationFatty diet – diarrhoea or constipation

Food intoleranceFood intolerance

Lactose- into glucose and galactose ( Lactase) Lactose- into glucose and galactose ( Lactase)
causes abdominal cramps and diarrhoea causes abdominal cramps and diarrhoea

Inability to digest gluten protein found in wheat Inability to digest gluten protein found in wheat

Causes abdominal distention , bloated feeling, Causes abdominal distention , bloated feeling,
diarrhea, greasy stools due to retention of diarrhea, greasy stools due to retention of
carbohydrates and fats as they cannot be digestedcarbohydrates and fats as they cannot be digested

37. Diet ctd......Diet ctd......

Hot, spicy food increases peristaltic Hot, spicy food increases peristaltic
movementsmovements

Large quantities of milk may slow Large quantities of milk may slow
peristalsis and cause constipationperistalsis and cause constipation

Caffeinated beverages stimulate gastric Caffeinated beverages stimulate gastric
motilitymotility

38. 5. Fluid intake5. Fluid intake

Intake of 1500-3000ml/day necessary for Intake of 1500-3000ml/day necessary for
normal bowel function normal bowel function

Water liquiefies intestinal contents for Water liquiefies intestinal contents for
easier passageeasier passage

Hot beverages and fruit juices soften stool Hot beverages and fruit juices soften stool
and increase peristalsisand increase peristalsis

High fever, profuse diaphoresis makes High fever, profuse diaphoresis makes
stools harder and difficult to passstools harder and difficult to pass

39. 6. Psychological factors 6. Psychological factors
Privacy Privacy

Needed during defecation although partly Needed during defecation although partly
it is involuntaryit is involuntary

The external anal sphincter is under The external anal sphincter is under
voluntary control and a person can ignore voluntary control and a person can ignore
the urge to defecate until she feels secure the urge to defecate until she feels secure
to defecate.to defecate.

40. Anxiety, Anger or FearAnxiety, Anger or Fear

Accelerates digestion and peristalsis.Accelerates digestion and peristalsis.

Diarrhoea or constipation may ariseDiarrhoea or constipation may arise
New EnvironmentNew Environment

Difficult to defecate in new areaDifficult to defecate in new area

Vacations Vacations

Hospitalization Hospitalization
Chronic StressChronic Stress

ExamsExams

41. 7. Illness 7. Illness

Pain suppresses defecation resulting in Pain suppresses defecation resulting in
constipationconstipation

Tumours Tumours

Rectum Rectum

Hemorrhoids Hemorrhoids

42. Surgery Surgery

General anaesthesia may slow GI motility General anaesthesia may slow GI motility
causing surgical patient to experience causing surgical patient to experience
decreased bowel functioning for 1-2 days decreased bowel functioning for 1-2 days
after surgery.after surgery.

Abdominal surgery- 3-4days bowel activity Abdominal surgery- 3-4days bowel activity
return normal- enemas given prior surgeryreturn normal- enemas given prior surgery

Manipulation of bowels and exposure to Manipulation of bowels and exposure to
air intra-operativelyair intra-operatively

43. Surgery Surgery

Post op use of opioid analgesics Post op use of opioid analgesics

Reduced activityReduced activity

Fear of pain after surgeryFear of pain after surgery

Pre and post op starvation Pre and post op starvation

44. Lifestyle and HabitsLifestyle and Habits

Timing of bowel elimination – early in the Timing of bowel elimination – early in the
morning or after consumption of foodmorning or after consumption of food

Smoking – stimulates bowels and Smoking – stimulates bowels and
increases motility leading to diarrhoeaincreases motility leading to diarrhoea

45. Medications Medications
DIARRHOEA CONSTIPATION SLOW COLON
FUNCTION AND
CONTROL
DIARRHOEA
Laxative Morphine Loperamide
Antibiotics Codeine
Antiacids Iron
Antiacids

46. Diagnostic proceduresDiagnostic procedures

Some radiologic and endoscopic procedures Some radiologic and endoscopic procedures
require cleansing fecal material from the large require cleansing fecal material from the large
bowel before procedurebowel before procedure

The thorough cleansing alters bowel function The thorough cleansing alters bowel function
for 2-3days after the testfor 2-3days after the test

Barium swallow causes chalky white stool until Barium swallow causes chalky white stool until
fully eliminatedfully eliminated

Barium if left in colon it hardens stool- treat Barium if left in colon it hardens stool- treat
with laxativewith laxative

47. Pregnancy Pregnancy

Hormonal changes relaxes the muscles of Hormonal changes relaxes the muscles of
the GI- constipationthe GI- constipation

Iron supplements causes constipationIron supplements causes constipation

Fear of pain post deliveryFear of pain post delivery

Growing fetus puts pressure on the Growing fetus puts pressure on the
intestines affecting bowel functionintestines affecting bowel function

48. Ignoring urge to defecateIgnoring urge to defecate

Privacy Privacy

Defecation reflex and urge subside after a Defecation reflex and urge subside after a
few minutes if initial urge is ignoredfew minutes if initial urge is ignored

More water is absorbed from the stool in More water is absorbed from the stool in
the colon hardening the stoolsthe colon hardening the stools

Constipation ariseConstipation arise

49. Common Bowel Elimination Common Bowel Elimination
ProblemsProblems

ConstipationConstipation

ImpactionImpaction

DiarrheaDiarrhea

IncontinenceIncontinence

FlatulenceFlatulence

HemorrhoidsHemorrhoids

50. 1. Constipation1. Constipation

Decrease in frequency of BMDecrease in frequency of BM

Infrequent and sometimes painful passage Infrequent and sometimes painful passage
of hard, dry stool of hard, dry stool

Straining & pain on defecation is Straining & pain on defecation is
associated symptoms(Valsalva maneuver)associated symptoms(Valsalva maneuver)

Can be significant heath hazard (increase Can be significant heath hazard (increase
ICP, IOP, reopen surgical wounds, cause ICP, IOP, reopen surgical wounds, cause
trauma, cardiac arrhythmias)trauma, cardiac arrhythmias)

52. 
Slow colonic movement. Food stays too Slow colonic movement. Food stays too
long in LIlong in LI
Causes:Causes:

Low fiber intakeLow fiber intake

Inadequate water intakeInadequate water intake

Delayed defecationDelayed defecation

StressStress

Decreased activityDecreased activity

54. Fecal ImpactionFecal Impaction

Results from unrelieved constipationResults from unrelieved constipation

Collection of hardened feces wedged into Collection of hardened feces wedged into
rectumrectum

Can extend up to sigmoid colonCan extend up to sigmoid colon

Followed by passage of liquid or semi-liquid Followed by passage of liquid or semi-liquid
stoolstool

Incontinent of liquid stool, unable to feel urge Incontinent of liquid stool, unable to feel urge

Most at risk: confused, unconscious (all are Most at risk: confused, unconscious (all are
at risk for dehydration)at risk for dehydration)

55. ImpactionImpaction

When a continuous ooze of diarrheal stool When a continuous ooze of diarrheal stool
develops, impaction should be suspecteddevelops, impaction should be suspected

Ooze results from seepage of unformed Ooze results from seepage of unformed
fecal contents around impacted stool in fecal contents around impacted stool in
rectumrectum

Associated S/S: Loss of appetite, malaise, Associated S/S: Loss of appetite, malaise,
abdominal distention, cramping, rectal pain, abdominal distention, cramping, rectal pain,
inability to pass stool despite urge, bloating inability to pass stool despite urge, bloating
or fullness feeling, nausea and vomitingor fullness feeling, nausea and vomiting

57. DiarrhoeaDiarrhoea

Increase in number of stools & the passage Increase in number of stools & the passage
of liquid, unformed stool (highly acidic).of liquid, unformed stool (highly acidic).

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 usual large intestines too quickly to allow for usual
absorption of water & nutrientsabsorption of water & nutrients

The rapidity and excess volume distends The rapidity and excess volume distends
rectum resulting in intense urgerectum resulting in intense urge

58. DiarrheaDiarrhea

Irritation can result in increased mucus secretion, Irritation can result in increased mucus secretion,
feces become too watery, unable to control feces become too watery, unable to control
defecationdefecation

Excess loss of colonic fluid can result in acid-Excess loss of colonic fluid can result in acid-
base imbalances or fluid/electrolyte imbalancesbase imbalances or fluid/electrolyte imbalances

Can also result in skin breakdownCan also result in skin breakdown

59. 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)

Medications-abxMedications-abx

LaxativesLaxatives

Colon DiseaseColon Disease

SurgerySurgery

Fruit juice- apple juiceFruit juice- apple juice

Travelling (E-coli)Travelling (E-coli)

60. IncontinenceIncontinence
Inability to control passage of feces and Inability to control passage of feces and
gas from the anusgas from the anus

Caused by conditions that create frequent, Caused by conditions that create frequent,
loose, large volume, watery stools or loose, large volume, watery stools or
conditions that impair sphincter control or conditions that impair sphincter control or
functionfunction

Associated with mental, neurologic or Associated with mental, neurologic or
emotional impairementsemotional impairements

61. Incontinence Incontinence

Cerebral cortex injury may have difficulties Cerebral cortex injury may have difficulties
perceiving a distended rectum or initiating the perceiving a distended rectum or initiating the
motor response required to inhibit defecation motor response required to inhibit defecation
voluntarily.voluntarily.

Sacral spinal cord injury, neurologic Sacral spinal cord injury, neurologic
diseases- impair the nerve supply to rectum diseases- impair the nerve supply to rectum
and anal sphincterand anal sphincter

Diarrhoea – so large volume makes intense Diarrhoea – so large volume makes intense
urge and difficult to maintain sphincter controlurge and difficult to maintain sphincter control

62. 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

63. FlatulenceFlatulence

Gas accumulation in the lumen of intestinesGas accumulation in the lumen of intestines

Caused by swallowed air, diffusion of air Caused by swallowed air, diffusion of air
from blood, air from bacterial actions in LI.from blood, air from bacterial actions in LI.

Bowel wall stretches and distendsBowel wall stretches and distends

Common cause of abdominal fullness, pain, Common cause of abdominal fullness, pain,
& cramping& cramping

Gas escapes through mouth (belching), or Gas escapes through mouth (belching), or
anus (flatus)anus (flatus)

64. Flatulence Flatulence

Predisposing factorsPredisposing factors

Rapid ingestion of food/ fluidsRapid ingestion of food/ fluids

Improper use of drinking strawsImproper use of drinking straws

Ingestion of carbonated beveragesIngestion of carbonated beverages

Chewing gumChewing gum

SmokingSmoking

Gas forming foods- beans, onions, cabbage, Gas forming foods- beans, onions, cabbage,
eggs, potatoeseggs, potatoes

65. HemorrhoidsHemorrhoids

Dilated, engorged veins in the lining of the Dilated, engorged veins in the lining of the
rectumrectum

External (Clearly visible) or InternalExternal (Clearly visible) or Internal

Caused by straining, pregnancy, CHF, Caused by straining, pregnancy, CHF,
chronic liver diseasechronic liver disease

66. Clicker QuestionClicker Question

A newly admitted client states that he has A newly admitted client states that he has
recently had a change in medications and recently had a change in medications and
reports that stools are now dry and hard to reports that stools are now dry and hard to
pass. This type of bowel pattern is consistent pass. This type of bowel pattern is consistent
with:with:

A.A.Abnormal defecationAbnormal defecation

B.B.ConstipationConstipation

C.C.Fecal impactionFecal impaction

D.D.Fecal incontinenceFecal incontinence
46 - 66

67. Bowel DiversionsBowel Diversions

Certain diseases cause conditions that Certain diseases cause conditions that
prevent normal passage of feces through prevent normal passage of feces through
rectum- Bowel obstructionrectum- Bowel obstruction

Creates need for temporary or permanent Creates need for temporary or permanent
artificial opening (stoma) in the abdominal artificial opening (stoma) in the abdominal
wallwall

68. Bowel DiversionsBowel Diversions

Surgical openings (ostomy) are most Surgical openings (ostomy) are most
commonly formed in the ileum (ileostomy) commonly formed in the ileum (ileostomy)
or the colon (colostomy)or the colon (colostomy)

Incontinent ostomy- need to wear Incontinent ostomy- need to wear
appliance pouchappliance pouch

Continent ostomy- have control through Continent ostomy- have control through
use of ostomy capuse of ostomy cap

70. Types of Colostomies Types of Colostomies
LocationLocation
Descending
Ascending
Sigmoid

71. Types of Colostomies: Types of Colostomies:
ConstructionConstruction

Loop Colostomy: Loop Colostomy:

Medical Emergency; Medical Emergency;

Usually temporary, large Usually temporary, large
stomas constructed of stomas constructed of
transverse colon. transverse colon.

Two openingsTwo openings

Proximal opening: Proximal opening:
drains stooldrains stool

Distal opening: drains Distal opening: drains
mucusmucus

72. Loop colostomy Loop colostomy

,,,,,,

73. Types of Colostomies: Types of Colostomies:
ConstructionConstruction

End ColostomyEnd Colostomy: :

One stoma One stoma
formed at formed at
proximal end of proximal end of
bowel; distal bowel; distal
portion of GI portion of GI
tract is removed tract is removed
or sewn closed; or sewn closed;
rectum removedrectum removed

77. Types of Colostomies: Types of Colostomies:
ConstructionConstruction

Double barrelDouble barrel

Bowel is surgically Bowel is surgically
severed.severed.

Two ends brought out Two ends brought out
to abdomen; 2 stomasto abdomen; 2 stomas

Proximal stoma: Proximal stoma:
Functioning stomaFunctioning stoma

Distal stoma: Distal stoma:
Nonfunctioning stomaNonfunctioning stoma

78. 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

82. Ostomy Nursing Ostomy Nursing
ConsiderationsConsiderations

Patient EducationPatient Education

Care of skin & stoma, appliance selection Care of skin & stoma, appliance selection
and useand use

Body Image considerationsBody Image considerations

Support groupsSupport groups

84. Nursing ProcessNursing Process
AssessmentAssessment

Nursing HistoryNursing History

Physical AssessmentPhysical Assessment

Lab TestsLab Tests

Fecal characteristicsFecal characteristics

Diagnostic evaluation- Endoscopy, Diagnostic evaluation- Endoscopy,
ColonoscopyColonoscopy

85. Lab testsLab tests
1.1.Fecal occult blood test Fecal occult blood test
FOBTFOBT
•(evaluate for blood)(evaluate for blood)
2.2.Stool CultureStool Culture
•(identify (identify
microorganisms) (10-microorganisms) (10-
20mL)20mL)
3. Stool analysis 3. Stool analysis
•(ova & parasites)(ova & parasites)
Considerations:Considerations:

Collection from Collection from
more than 1 bowel more than 1 bowel
movementmovement

Send while stool is Send while stool is
still WARMstill WARM

89. Nursing DiagnosisNursing Diagnosis

Impaired Skin IntegrityImpaired Skin Integrity

Body Image DisturbanceBody Image Disturbance

Altered bowel elimination, constipation, Altered bowel elimination, constipation,
diarrhoea diarrhoea

Altered comfort ,PainAltered comfort ,Pain

90. ImplementationImplementation
Promoting 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

Fecal Incontinence DevicesFecal Incontinence Devices

Fiber & FluidsFiber & Fluids

92. EnemasEnemas

The insertion of a liquid into the rectum The insertion of a liquid into the rectum
or colon through the anusor colon through the anus
Two main types:Two main types:
A. Therapeutic enemaA. Therapeutic enema

Done to clean colonDone to clean colon

Relieves constipationRelieves constipation

Treats diseases –inflammatory bowel diseaseTreats diseases –inflammatory bowel disease

Types of Therapeutic EnemasTypes of Therapeutic Enemas: Tap Water : Tap Water
(hypotonic), Normal Saline, Hypertonic, (hypotonic), Normal Saline, Hypertonic,
Soapsuds, Oil RetentionSoapsuds, Oil Retention

93. EnemaEnema
B. Diagnostic enemaB. Diagnostic enema

Done to diagnose certain conditions of the colon Done to diagnose certain conditions of the colon
eg. Barium enema to diagnose the coloneg. Barium enema to diagnose the colon

Purpose: cleansing of large bowel.Purpose: cleansing of large bowel.

Small volume: commercially prepared, oil or Small volume: commercially prepared, oil or
water, approximately 150cc. water, approximately 150cc.

Large volume: warm tap water or saline; Large volume: warm tap water or saline;
1000cc for adult, 240cc-350cc for child, 15cc-1000cc for adult, 240cc-350cc for child, 15cc-
60cc infant. 60cc infant.

94. Enema procedureEnema procedure

EquipmentEquipment

Enema solution Giving setEnema solution Giving setRectal catheterRectal catheter

Gloves Gloves Lubricant LubricantDirty linen bagDirty linen bag

MackintoshMackintosh Bedpan Bedpan Air freshenerAir freshener

Toilet paperToilet paper Clean linen Clean linenBinBin

Explain procedure to patientExplain procedure to patient

Screen bedScreen bed

Open nearby windows for fresh airOpen nearby windows for fresh air

95. Enema ProcedureEnema Procedure

Wash hands/ wear glovesWash hands/ wear gloves

Identify patient Identify patient

Fill bag with fluidFill bag with fluid

Place patient in left lateral position with Place patient in left lateral position with
knees flexedknees flexed

Place mackintosh under patient and move Place mackintosh under patient and move
buttocks to side of bedbuttocks to side of bed

Run solution to expel air in the tubingRun solution to expel air in the tubing

96. 
Insert lubricated end of enema tubing 7-Insert lubricated end of enema tubing 7-
10cm into rectum10cm into rectum

Hang/ hold enema bag 30-45cm above Hang/ hold enema bag 30-45cm above
patientpatient

Allow the solution in slowlyAllow the solution in slowly

Ask the patient to pant for easy entry of fluidAsk the patient to pant for easy entry of fluid

If cramping occurs stop the flow until it If cramping occurs stop the flow until it
ceasesceases

97. 
Gently withdraw catheter and allow patient Gently withdraw catheter and allow patient
to retain fluid for 2-3 min or longerto retain fluid for 2-3 min or longer

Turn patient o his backTurn patient o his back

Place on bedpan or toilet. Place on bedpan or toilet.

Make patient comfortable.Make patient comfortable.

Wash handsWash hands

98. Ostomy CareOstomy Care

Objectives:Objectives:

Keep patient free from odourKeep patient free from odour

Reduce risk of infection on stoma and Reduce risk of infection on stoma and
ulcerationulceration

To measure intake and outputTo measure intake and output

To facilitate proper disposal of fecal matterTo facilitate proper disposal of fecal matter

99. 
Equipment Equipment

Colostomy bagColostomy bagSterile gauzeSterile gauze

Warm saline waterWarm saline waterMeasuring jugMeasuring jug

Receiver for dirty swabsReceiver for dirty swabs Gloves Gloves

Antimicrobial powderAntimicrobial powderMild soap (Lifebouy)Mild soap (Lifebouy)

Bin Bin Scissors Scissors

Explain procedure to patientExplain procedure to patient

Assess patient’s readiness to view stoma and Assess patient’s readiness to view stoma and
learning about its care to promote self-carelearning about its care to promote self-care

100. Care of the OstomyCare of the Ostomy

Screen bed for privacyScreen bed for privacy

Wash hands and don on glovesWash hands and don on gloves

Position in semi-fowlersPosition in semi-fowlers

Assess stoma regulalry for color, intactness of stoma, skin, suture lineAssess stoma regulalry for color, intactness of stoma, skin, suture line

Red colour- viabilityRed colour- viability

Dark dusty or black color- impaired circulationDark dusty or black color- impaired circulation

Observe for secretions: Observe for secretions:

Mucus- immediately after surgeryMucus- immediately after surgery



Measure stoma size and cut opening. Measure stoma size and cut opening.

Emotional supportEmotional support

101. 
Mucoid ad serosanguious- 24 to 48 hoursMucoid ad serosanguious- 24 to 48 hours

Liquid fecal drainage- after 48hoursLiquid fecal drainage- after 48hours

Remove the appliance, remove excess Remove the appliance, remove excess
feces and mucus from the stomafeces and mucus from the stoma

Clean the surrounding gentlyClean the surrounding gently

Dry the skin for stoma bag to stick betterDry the skin for stoma bag to stick better

Encourage patient to watch procedure and Encourage patient to watch procedure and
explain each step to herexplain each step to her

102. 
Cut a hole on the pattern line about Cut a hole on the pattern line about
1/8inch larger than the stoma to give a 1/8inch larger than the stoma to give a
good sealgood seal

Apply the clean stoma bag to the skinApply the clean stoma bag to the skin

Protect the skin using powderProtect the skin using powder

Dispose wastes appropriatelyDispose wastes appropriately

Document Document

103. Colostomy IrrigationColostomy Irrigation

The process of emptying the colon by The process of emptying the colon by
running a stream of water into the colon running a stream of water into the colon
through the stomathrough the stoma

Objective Objective

To stimulate emptying of colon at a convinient To stimulate emptying of colon at a convinient
and regular time.and regular time.

104. 
Equipment Equipment

Irrigation solution Irrigation solution Bag with tubing and clampBag with tubing and clamp

LubricantLubricantToilet tissueToilet tissue

Colostomy bagColostomy bagMackintoshMackintosh

Soap and waterSoap and waterIrrigation sleeveIrrigation sleeve

Remove old pouchRemove old pouch

Clean skin and stoma with warm water to Clean skin and stoma with warm water to
prevent gastrointestinal spasmsprevent gastrointestinal spasms

Apply irrigation sleeve and beltApply irrigation sleeve and belt

105. 
Fill bag with desired amount of tepid water Fill bag with desired amount of tepid water
(250-1000mls)(250-1000mls)

Hang bag so that bottom of it is at shoulder Hang bag so that bottom of it is at shoulder
heightheight

Remove air from tubingRemove air from tubing

Gently insert irrigating cone into stoma holding Gently insert irrigating cone into stoma holding
it parallel to the floorit parallel to the floor

Let water run in slowly until patient identifies Let water run in slowly until patient identifies
need to expel stoolneed to expel stool

106. 
Remove cone and allow solution to drain into Remove cone and allow solution to drain into
containercontainer

When most stool is expelled (about 15min) When most stool is expelled (about 15min)
rinse sleeve with water and close up bottom rinse sleeve with water and close up bottom
endend

Encourage activity to complete bowel Encourage activity to complete bowel
emptying (about 30-45min)emptying (about 30-45min)

Remove sleeve and apply clean pouchRemove sleeve and apply clean pouch

Decontaminate and documentDecontaminate and document

107. Health education Health education

Read and make notesRead and make notes esp on diet for esp on diet for
colostomy patientcolostomy patient

Read on gastric lavage and gastric Read on gastric lavage and gastric
decompression decompression