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CH-38: Bowel Elimination


Stomach = very acidic environment

Small intestine = where most nutrients are absorbed (the duodenum, the jejunum, and the ileum)
The presence of fats in the duodenum stimulates the release of bile to emulsify fat
Large intestine = primary organ of bowel elimination
The anal canal is richly supplied with sensory and motor nerve fibers to help control continence
thats why infants cannot control defecation because their neuromuscular isnt fully developed
yet. Older adults nerve impulses slow down at the anal region and they may lose
awareness/sensation of the need to defecate irregular bowel movements, constipation.
Factors that Affect Bowel Elimination:
o Age:
In the infant, some foods (e.g. complex carbs) are tolerated poorly because they
have less digestive enzymes than the adult. Also, they lack neuromuscular
development and cannot control defecation until 2-3 years of age.
Older adults lose muscle tone in the perineal floor and the anal sphincter, they
have difficulty controlling bowel evacuation and are at risk for incontinence. Their
nerve impulses slow down at the anal region and they may lose
awareness/sensation of the need to defecate irregular bowel movements,
constipation. Older women are at risk for:
Cystocele: dropping of the bladder into the vagina
Rectocele: the pouching of the feces-filled rectum into the vagina
Uterine Prolapse: the complete expulsion of the uterus from the vagina
These problems can be prevented with Kegel exercises to strengthen the pelvis
o Diet: fiber provides the bulk of fecal matter. A high-fibre diet increases regular bowel
elimination patter. Fibre should be taken with adequate fluid intake because fibre retains
fluid in the GI tract. Bulk-forming foods (grains, fruits, vegetables) absorb fluids and
increase stool mass.
o Fluid Intake: an adult should drink 6-8 glasses of water a day. Too much fruit juice can
cause diarrhea in children. Older adults are at greater risk for dehydration and
o Physical Activity: physical activity promotes peristalsis. Early ambulation is encouraged
as soon as a clients illness begins to resolve or as soon as after a surgery, in order to
promote peristalsis. Pts with neurological disease or long-term illness that weakens nerve
transmission are at risk for constipation.
o Psychological Factors: stress can cause several GI diseases such as ulcerative colitis,
gastric/duodenal ulcers, and Crohns Disease. Depression slows the ANS, causing slower
peristalsis and constipation.
o Position during Defecation: it is impossible to contract the muscles used for defecation
while in a supine position. Raise the head of the bed to a more normal sitting position,
especially while on a bedpan.
o Pain: pain caused by hemorrhoids, rectal surgery, abdominal surgery, and rectal fistulas
can discourage a person from wanting to defecate constipation/impaction
o Pregnancy & Labor: slowing of peristalsis during Third Trimester can lead to
constipation because the fetus exerts pressure on the rectum and can obstruct the
passage of feces. Also, constant straining by the pregnant woman during defecation or
delivery can result in hemorrhoids.
o Surgery & Anaesthesia: General anaesthesia used during surgery, some analgesics,
and opioids reduce peristalsis constipation. Therefore, after surgery, the surgeons
post-op orders usually include bowel routine with laxatives/enemas if there is no BM
within 2-3 days. Early post-op ambulation stimulates the evacuation of flatus and

stimulates peristalsis. Any surgery that causes manipulation of the bowel temporarily
stops peristalsis (paralytic ileus) that lasts for 1-2 days.
o Medications: Laxatives stimulate evacuation of formed stool from the rectum. Cathartics
(e.g. bisacodyl [Dulcolax])stimulate evacuation of watery fecal matter from the entire
colon (stronger effect than laxative). Overuse of laxatives can cause serious diarrhea
dehydration/electrolyte imbalances. Overuse of cathartics can cause the large intestine to
lose muscle tone. Mineral oil is also a laxative.
o Diagnostic Tests: tests that involve visualization of GI structures usually require
emptying of the bowels the Pt has to drink 4L of a solution, usually containing
polyethylene glycol (pegLYTE?). Cathartics or enemas may also be used.
Colonoscopy, endoscopy & other tests that require visualization of the lower GI
require NPO after midnight of the day preceding the exam.
See p.1158, Box 45-5 for Diagnostic Tests:
Upper GI Barium Swallow: Pt is NPO after midnight of the day
preceding the exam. After the test, the Pt must increase fluid intake to
eliminate the barium.
Lower GI Barium Enema: NPO after midnight, a bowel preparation (i.e.
magnesium citrate), and/or enemas to empty any remaining stools.
Upper Endoscopy: preparation same as upper GI barium swallow.
Colonoscopy: examination of the entire colon. Clear liquids the day
before, followed by a bowel cleanser (GoLYTELY), and/or enemas until
the bowel is empty. Light sedation required.
CT scan: NPO may or may not be required. Slight sedation required for
those who are claustrophobic.
MRI: NPO 4-6 hours before the test. No metallic objects allowed in the
Common Bowel Elimination Problems:
o Constipation: may be caused by drugs such as Aspirin, antihistamines, diuretics,
tranquilizers, hypnotics, antacids with aluminum/calcium, opiates, and anti-Parkinsons
drugs. Increasing fluid intake and laxatives may relieve constipation. Fruit juices such as
pear, prune, or apple juice, may also help. Long-term Tx: regular physical activity, dietary
fiber, whole grains, fruits, and vegetables.
Patients who should especially avoid becoming constipated and using the
Valsalva maneuver (applying strain while voiding), are those with cardiovascular
disease, glaucoma, ICP, or a new surgical wound (can cause wound
dehiscence). The Valsalva maneuver affects the return of blood up the inferior
vena cava. It can be avoided by exhaling through the mouth during straining.
o Impaction: hardened feces in the rectum that cannot be expelled. Pts who are
debilitated, confused, or unconscious are at risk. Digital examination of the rectum may
be necessary.
o Diarrhea: may be caused by antibiotics because they alter the normal flora in the GI tract
advise Pts to eat active-culture yogurt, or to take a lactobacillus supplement to
reintroduce the normal flora of the colon. Diarrhea may also be caused by enteral
feedings, diseases, surgeries, laxatives, chemotherapy, radiotherapy, diagnostic testing
of the lower GI tract, food-borne pathogens, and C.diff. (As soon as C.diff is suspected,
isolation/contact precautions must be initiated). Diarrhea can cause severe fluid,
electrolyte, and acid-base imbalances.
o Incontinence: the inability to control the passage of gas/feces from the anus. Can harm
a clients body image and cause social isolation.
o Hemorrhoids: dilated, engorged veins in the lining of the rectum, caused by increased
venous pressure as a result of pregnancy, heart failure, chronic liver disease, or straining
at defecation. Baby wipes may reduce irritation.
Bowel Diversions:
Ileostomy: bypasses the entire large intestine, therefore, stools are frequent and liquid.

Colostomy of the transverse colon: results in solid, formed stool.

o Loop Colostomy: usually constructed at the transverse colon; a loop of the bowel is
pulled through the abdomen and is supported by a plastic rod or bridge. 2 openings: the
proximal end drains stool; the distal end drains mucus.
o End Colostomy: one stoma is formed from one end of the stoma, while the other end is
removed or sewn closed (Hartmanns Pouch).
o Double-Barrel Colostomy: 2 ends of the colon are brought out into the abdomen to form
2 stomas; 1 functional (proximal) and 1 nonfunctional (distal).
o Ileoanal Pouch Anastomosis: the colon is removed, a pouch/reservoir is created from
the end of the small intestine and the pouch is attached to the anus. May be done in pts
with ulcerative colitis or familial polyps.
o Kock Continent Ileostomy: the small intestine is used to create a small pouch with a
nipple-like valve that drains into an external catheter (the pouch is emptied several times
a day. The stoma is covered with a protective dressing/stoma cap.

PSYCHOLOGICAL CONSIDERATIONS: body image problems; difficulties maintaining

sexual relations.


Abdominal Distension: may be caused by intestinal gas, fluid in the peritoneal cavity, or large
tumours. The abdomen feels tight & skin appears taut, as if stretched.
Bowel Sounds: Normal bowel sounds occur every 5-15 seconds. Lack of bowel sounds or the
presence of hypoactive sounds (<5 sounds/minute) = paralytic ileus. High-pitched or hyperactive
bowel sounds (>35 sounds/minute) = obstruction of small intestine or inflammatory disorders.
Fecal Occult Blood Testing (FOBT) or Guaiac Test: measures microscopic amounts of blood in
the feces. Diagnostic tool for colon cancer; Pts who receive anticoagulants, have GI bleeding
disorders that cause bleeding (e.g. intestinal tumours, bowel inflammation, or ulcerations) should
be regularly screened. Test is repeated at least 3 times. >50 yrs old: every 2 years.
o avoid delays in sending specimen to the lab, because the bacteriological changes that
occur to the stool as it cools down may change the test results.
Relevant Lab Tests:
o Total bilirubin: levels = hepatobiliary diseases, obstructions of the bile duct, anemias,
and reactions to blood transfusions.
o Alkaline phosphatase: levels = hepatobiliary diseases, hepatobiliary carcinomas,
bone tumours, or healing fractures.
o Amylase: levels = abnormalities of the pancreas (inflammation, tumours, cholecystitis,
necrotic bowel, DKA.
o Carcinoembryonic Antigen: levels = cancer, inflammation of the GI tract, or
hepatobiliary organs.
See Table 45-4, p.1158 for Fecal Characteristics


Constipation (e.g. Constipation r/t to opiate-containing pain medication and decreased fiber
intake, as evidenced by)
Risk for constipation
Perceived constipation
Bowel Incontinence
Difficulty coping with changes in body image
Difficulty managing his/her bowel diversion (ostomy)


The Goal of returning the client to a normal bowel elimination pattern may involve the
following Outcomes:
o The Pt practices regular defecation habits.
o The Pt lists the proper fluid and food intake needed to achieve regular bowel elimination.
o The Pt implements a regular exercise program.
o The Pt reports daily passage of soft, formed, brown stool.
o The Pt does not report any discomfort associated w/ defecation.


Assist Pt to sitting position (if possible), including when using a bedpan (raise the head of bed to
30). Place a rolled towel or small pillow under the lumbar curve of the Pts back for added
Ensure Pts privacy.
Offer the commode or bedpan often.
Cathartics and Laxatives: provide short-term action of emptying the bowel (i.e. for clients unable
to defecate due to pain, constipation, or impaction). See Table 45-5, p.1164 for Common Types of
Enemas: the fluid breaks up the fecal mass, stretches the rectal wall, and initiates the defecation
reflex; stimulates peristalsis. Also used as a vehicle to administer medications.
o Cleansing Enemas: (tap water, normal saline, or soapsuds) promote the complete
evacuation of feces from the colon.
High enemas are used to cleanse the ENTIRE colon. After the enema is infused,
the client must turn from the left lateral position, to the dorsal recumbent position,
to the right lateral position, in order to ensure that fluid reaches all of the large
Low enemas cleanse only the rectum and sigmoid colon.
Tap water is hypotonic should NOT be repeated because water toxicity or
circulatory overload can develop if large amounts of water are absorbed.
Normal Saline is the safest method.
Hypertonic solutions (i.e. Fleet Enema) exerts osmotic pressure that pulls fluid
OUT OF the intestinal spaces, causing distension,

Soapsuds may be added to tap water or normal saline to create the effect of
intestinal irritation that will cause peristalsis.
Oil-retention enemas lubricate the rectum and colon. The client should retain
the enema for several hours in order to enhance the action of the oils.
Medicated enemas, such as Kayexalate (sodium polystyrene sulphonate) is used to

treat clients with K+ levels. It contains a resin that exchanges Na+ for K+ ions in the
large intestine. Another medicated enema is neomycin solution, which is an antibiotic
used to reduce bacteria in the colon before bowel surgery.
o When the physician orders enemas until clear, it means repeat the enema (UP TO 3
TIMES) until the client passes fluid that is contains no fecal material (fluid may still be
o Giving the enema with the client sitting on the toilet is UNSAFE b/c the curved rectal
tubing can abrade the rectal wall.
o Enemas are contraindicated for pts with ICP, glaucoma, and recent rectal/prostate
o Enemas should be administered with the Pt in Sims position. The Pt should relax by
breathing out slowly through the mouth during the insertion.
o The rectal tube (attached to the enema bag) should be inserted slowly by pointing the tip
in the direction of the Pts umbilicus. If the tube does not pass easily, do not force it.
Allow a small amount of fluid to infuse and then try reinserting the tube slowly.
Lengths: Adult: 7.5-10 cm; Child: 5-7.5 cm; Infant: 2.5-3.75 cm (same applies for a
pre-packaged disposable container). Allow the solution to enter slowly with the enema
bag at the Pts hip level.
o For a pre-packaged disposable container: instruct the client to retain the solution for 2-5
minutes, or until the urge to defecate occurs. For an infant/child, hold the buttocks
together for a few minutes.
o If bleeding occurs: stop the enema administration; notify the physician; obtain vital signs
o If there is rigidity or distension of the abdomen: stop the enema; notify the physician;
obtain vital signs.
o If there is abdominal pain or cramping: slow the rate of instillation.
o See Skills 45-1, p.1166-1168.
Anti-diarrheal Agents:
o Immodium
o Oral Rehydration Therapy (ORT): boiled water mixed with a low-cost package of salts
(sodium, potassium chloride, citrate or bicarbonate, and glucose). Used in many
developing countries to replace water and salts lost through diarrhea.
Also, use for pediatrics because they are sensitive to fluid and
electrolyte imbalances.
Digital Removal of Stool: If enemas fail, you may break the fecal mass with your fingers and
remove it in sections. Requires a physicians order! Excess renal manipulation may cause
irritation to the mucosa, bleeding, and stimulation of the vagus nerve, WHICH CAN SLOW THE
HEART RATE. Remember: this is a PAINFUL procedure.
NG Tube for decompression: the removal of secretions and gas from the GI tract to
prevent/relieve abdominal distension. The Levin and Salem sump tubes are the most common
tubes for stomach decompression. The Salem pump is preferable; it has 2 lumina: one for
removal of gastric contents, the other (the blue pigtail) to provide air vent. When the sump
tubes main lumen is connected to suction, the air vent permits free, continuous drainage of
secretions. The air vent should never be clamped off, connected to suction, or used for irrigation.
The air vent should be positioned above the waist.

If the tip of the tubing rests against the stomach wall or if the tubing becomes blocked,
regular irrigation is necessary (flush with normal saline through a catheter-tipped
syringe). If the NG tube continues to drain improperly after irrigation, reposition it by
either advancing it or withdrawing it slightly verification of the tube placement is
o The NG tube may cause distension turn the client regularly to get rid of gas and
promote emptying of stomach contents.
o See Skill 45-3, p.1171-1176, Potter & Perry, for Inserting & Maintaining an NG tube.
o Lewis et al., 2010:
Insertion is easier if the Pt relaxes, takes deep breaths, and swallows when
Once the tube is in place, it is important to 1) confirm placement of the tube (e.g.
by aspiration of gastric contents), 2) ensure tube is properly secured to prevent
dislodgement, and 3) provide mouth and nasal care.
NG tubes should be checked q4h for patency.
The NG tube may be placed either to low intermittent wall suction to facilitate
removal of gastric contents or to straight drainage.
Pale yellow to dark green bile drainage = most likely after an abdominal surgery.
Odorous thick drainage with food particles may be seen with bowel obstructions.
Hemolyzed sanguinous drainage (coffee grounds) or fresh sanguineous
drainage should be reported immediately to the physician.
Excessive losses (>500-1000mL/24hr) may have to be replaced w/ IV fluids &
NG tubes may be removed once normal bowel function returns (passing of gas
and stool) and the Pt is no longer vomiting.
Ostomy Care: Skill 45-3, p.1177-1180
o effluent = the discharge collected from the Ostomy.
o Irrigating Lt-sided colostomies is optional (very time-consuming). Never irrigate using an
enema. Irrigate with 500-700 mL of tap water; wait 30-45 min for the solution & feces to
drain out of the irrigation sleeve.
o One-piece pouching systems have the skin barrier (wafer skin barrier) permanently
attached, and the opening may be pre-cut by the manufacturer. Good for patients who
have difficulty using their hands or who have limited vision. Use skin sealant wipes on the
skin directly under the adhesive skin barrier; allow to dry.
o Two-piece pouching systems allow the skin barrier to remain on the Pts stoma for
several days. Apply the flange (the barrier with adhesive), then snap on the pouch.
o Intact skin barriers (for either system) with no evidence of leakage do NOT need to be
changed daily this minimizes skin damage from too-frequent removal. Change a oneor two-piece pouch every 3-7 days unless it is leaking. A pouch can remain in place for
bath or shower.
o Pt should be standing or in supine when applying the Ostomy system.
o Change the pouch BEFORE a meal (preferably) avoids increased peristalsis and the
chance of evacuation during a pouch change.
o The opening around the barrier should not be more than 2 mm larger than the stoma.
o The stoma should be moist, shiny, and pink. Stoma that is of purple or black
discoloration, dryness, failure to bleed, or sloughing of tissue, may indicate necrosis
assess circulation to the stoma, observe for excessive edema or tension on the bowel
suture line, immediately report to the physician.
o The skin around the stoma (peristomal area) should be of normal skin tone. Use mild
soap and water to clean peristomal area; avoid use of creams, ointments, baby wipes, or

other moist towelettes, b/c they may prevent the pouch from adhering to the clients skin.
If the peristomal skin is discolored, itchy, or sore, refer the Pt to an Ostomy specialist.
o For an ileostomy, apply a thin circle of barrier paste around the opening in the pouch.
o You put a small amount of Ostomy deodorant into the pouch. Do NOT use home
remedies, such as aspirin, to control the odor.
Document color of stoma q8-12h for the first 72 hours (twice a day, for the first 3 days). That is
when necrosis is more likely to occur.
Swelling of the stoma in the beginning is expected should subside after 4-6 weeks.
Openings to the traditional skin barrier should be cut 3-4 mm larger than the base of the stoma, to
allow for normal stoma peristalsis.
Colostomy irrigations can be used to:
1) Regulate bowel function habituate the bowel to function at a specific time every
day or every other day. Sign that control has been achieved: there is little or no spillage
between irrigations; Pt may only need to wear a pad or small pouch over the stoma
2) Treat constipation, and
3) Prepare the bowel for surgery.

Colostomies in the sigmoid or the descending colon have semiformed or formed stools and
can sometimes be regulated by irrigation.

Nutrition for Ileostomies:

o Low-fibre diet during the first weeks after surgery (the small bowel requires time to adjust
to the diversion).
o Eat slowly, chew food completely, and drink 10-12 glasses of water/day.
o Avoid foods that cause gas/odour: broccoli, cauliflower, dried beans, brussel sprouts.
o As ostomies heal, fresh fruits and vegetables help ensure solid stool.
o Drink at least 1.5-2 L of fluids/day.
Bowel Training: may help Pts develop a normal defecation routine; especially good for Pts who
still have some neuromuscular control.
o record the timings when the Pt is incontinent these timings may be used to initiate
defecation-control measures in order to establish the Pts regular bowel routine.
o Give stool softeners at least 30 min before selected defecation time
o Offer a hot drink, fruit juice (prune) or another fluid before the selected defecation time
o Assist the Pt to the toilet before the designated time.
o Instruct the Pt to avoid analgesics because they can cause constipation.
o Provide privacy.
o Set a time limit for the defecation (15-20 min).
o Instruct the Pt to bear down and lean forward, BUT DO NOT STRAIN.
o May require a team-approach, especially for cognitively-impaired Pts.
Maintenance of proper food and fluid intake
Promotion of regular exercise
Maintenance of Skin Integrity


The Pt will be able to have regular, pain-free defecation of soft, formed stool.
The Pt will be able to demonstrate informed learning regarding establishment of a normal bowel
elimination pattern.

The Pt will be able to demonstrate skill such as ostomy protocols and skin protection.
Reduced fear/embarrassment.


Lewis: p. 1062-1159
Nausea & Vomiting

Regurgitation partially-digested food is brought up from the stomach

Projectile Vomiting forceful expulsion of stomach contents w/out nausea a sign of CNS
Color of emesis:
o coffee grounds appearance bleeding in the stomach
o Bright red blood active bleeding, possibly from a tear in the mucosal lining of the lower
esophagus or the fundus of the stomach.
Tx: Find the cause first. Drugs that control N&V:
o Antihistamines (e.g. Gravol)
o domperidone (e.g. Motilium)
o antagonists to the serotonin (5-HT) receptors, such as ondansetron (Zofran)
o Dexamethasone (Decadron) used in the management of cancer chemotherapy-induced
emesis, usually in combination with other antiemetics.
o IV therapy w/ glucose and electrolyte replacement for severe vomiting
o NG tube for decompression
o Once the symptoms have subsided, oral nourishment beginning with clear liquids is
o Carbonated drinks, at room temp and with the carbonation gone are well-tolerated.
o Warm tea
o Dry toast and crackers
o A diet high in carbohydrates and low in fatty foods.

Gastroesophageal Reflux Disease (GERD)


r/t the reflux of gastric contents into the lower esophagus, when the defences of the lower
esophagus are overwhelmed by the reflux of the stomach acid contents into the esophagus.
No single cause.
o Heartburn relieved by milk, alkaline substances, and water.
o Respiratory symptoms (e.g. wheezing, coughing, and dyspnea)
o Regurgitation
o Bloating after a meal.
o Foods that may aggravate symptoms: fatty foods, chocolate, coffee, tea, milk products
(milk increases gastric acid secretion), tomato-based products, orange juice. Eat small,
frequent meals. Avoid late-night snacking,
o Drug therapy starts w/ antacids and OTC histamine H2-receptor (H2R) blockers and then
progress to prescription H2R blockers, then finally to proton-pump-inhibitors (PPI).
Antacids short-term relief of heartburn by neutralizing HCl
(thereby increasing the pH). Should be taken 1-3 hrs after a meal
and at bedtime. (e.g. aluminum hydroxide [Gaviscon])

OTC H2R blockers (e.g. ranitidine [Zantac], famotidine [Pepsid],

nizatidine [Axid]) decrease the secretion of HCl by the stomach
by blocking the action of histamine on H2 receptors.
PPIs (e.g. pantoprazole [Pantoloc] and lansoprazole [Prevacid],
and rabeprazole [Pariet]) decrease stomach HCl secretion by
inhibiting the proton pump mechanism responsible for the
secretion of H+ ions by blocking the enzyme adenosine
triphosphotase (ATPase)..

The step-down approach involves starting with a PPI and over time titrating down to
prescription H2R blockers, then to OTC H2R blockers and antacids.

Food Poisoning

Acute GI symptoms such as N&V, diarrhea, and colicky abdominal pain caused by an intake of
contaminated food (mostly food with micro-organisms).
See Table 43-27, p. 1105 for various bacterial agents, food sources, S&S, and how to treat)
o Correction of fluid and electrolyte imbalance.
o For Botulism (caused by toxin from Clostridium botulinum; ingested toxin is absorbed
from gut and blocks acetylcholine at neuromuscular junction), additional assessment and
care r/t neurological symptoms is needed. CNS symptoms include: headache, dizziness,
muscular incoordination, weakness, inability to talk/swallow, diplopia, breathing
difficulties, paralysis, delirium, and coma. Tx: maintenance of ventilation, polyvalent
antitoxin, guanidine hydrochloric acid (enhances acetylcholine release).

Abdominal Trauma

As a result of blunt trauma (e.g. MVA) or penetration injuries (i.e. gunshot wounds, stab wounds).
Common injuries: lacerated liver, ruptured spleen, pancreatic trauma, mesenteric artery tears,
diaphragmatic rupture, bladder rapture).
Surgery must be performed ASAP to repair damaged organs and stop the bleeding. Common
consequences of intrabdominal trauma are peritonitis and sepsis, particularly when the bowel is
o Guarding and splinting of the abdominal wall
o A hard, distended abdomen (may indicate intra-abdominal bleeding)
o or absent bowel sounds
o Contusions, abrasions, or bruising over the flanks of the abdomen
o Severe abdominal pain
o Pain over the scapula (shoulder blade) caused by irritation of the phrenic nerve by free
blood in the abdomen.
o Hematemesis and hematuria
o Signs of hypovolemic shock
o Cullens Sign ecchymotic discoloration around the umbilicus can indicate intraabdominal or retroperitoneal hemorrhage.
o Establish patent airway & adequate breathing
o Fluid replacement & prevention of hypovolemic shock
IV lines are inserted, volume expanders or blood is given if the Pt
is hypotensive.


NG tube to decompress the stomach and prevent the aspiration of vomitus.

Immediate laparotomy