BOWEL ELIMINATION

Defecation
 Defecation (bowel elimination) is the act of
expelling feces (stool) from the body. To do
so, all structures of the gastrointestinal
tract, especially the components of the large
intestine must function in a coordinated
manner (Fig. 31-1). In the large intestine, a
remarkable volume of water is removed from
Assessment of Bowel Elimination
the remnants of digestion, causing the
 Elimination Patterns
bowel's contents to become a consolidated
 Because various elimination patterns
mass of residue before being eliminated.
can be normal, it is essential to
determine the client's usual patterns,
including frequency of elimination,
effort required to expel stool, and
what elimination aids, if any, he or
she uses.
 Stool Characteristics
 Information that is particularly
diagnostic includes stool color, odor,
consistency, shape, and unusual
Fig. 31 - 1
components
 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. Peristalsis becomes even
more active during eating; this increased
peristaltic activity is termed the gastrocolic
reflex.
 The gastrocolic reflex usually precedes
defecation .Its accelerated wavelike
movements, sometimes perceived as slight
abdominal cramping, propel stool forward,
Common Alterations in Bowel Elimination
packing it within the rectum .As the rectum
 Constipation
distends, the person feels the urge to
 Constipation is an elimination
defecate .Stool is eventually released when
problem characterized by dry, hard
the anal sphincters (ring-shaped bands of
stool that is difficult to pass.
muscles) relax. Performing the Valsalva
Various accompanying signs and
maneuver (closing the glottis and contracting
symptoms include the following:
the pelvic and abdominal muscles to increase
 Complaints of abdominal
abdominal pressure) facilitates this process.
fullness or bloating
Several dietary, physical, social, and
 Abdominal distention
emotional factors can influence the bowel's
 Complaints of rectal fullness
mechanical function
or pressure
 Pain on defecation
 Decreased frequency of bowel
movements
 Inability to pass stool

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  Changes in stool
characteristics such as oozing
liquid stool or hard small
stool
 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.
 Constipation is classified into one of four
distinct types (primary, secondary,
iatrogenic, and pseudoconstipation), according
to the underlying cause.
Primary Constipation
 Primary or simple constipation is well within
the treatment domain of nurses. It results
from lifestyle factors such as inactivity,
inadequate intake of fiber, insufficient fluid
intake, or ignoring the urge to defecate.
Secondary Constipation
 Secondary constipation is a consequence of a
pathologic disorder such as a partial bowel
obstruction. It usually resolves when the
primary cause is treated.
Iatrogenic Constipation
 Iatrogenic constipation occurs as a
consequence of other medical treatment. For
example, 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.
Pseudoconstipation
 Pseudoconstipation, also referred to as
perceived constipation, is a term used when
clients believe themselves to be constipated
even though they are not.
Fecal Impaction
 Fecal impaction occurs when a large,
hardened mass of stool interferes with
defecation, making it impossible for the
client to pass feces voluntarily. Fecal
impactions result from unrelieved
constipation, retained barium from an
intestinal x-ray, dehydration, and weakness
of abdominal muscles.
 Some clients with an impaction pass liquid
stool, which they may misinterpret as
diarrhea.
Flatulence
 Flatulence or flatus (excessive accumulation
of intestinal gas) results from swallowing air
while eating or sluggish peristalsis. Another
cause is the gas that forms as a byproduct
of bacterial fermentation in the bowel.
Vegetables such as cabbage, cucumbers, and
onions are commonly known for producing
gas. Beans are other gas formers.
Diarrhea
 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.
Fecal Incontinence
 Fecal incontinence is the inability to control
the elimination of stool.
Measures to Promote Bowel Elimination
 Nurses commonly use two interventions—
inserting suppositories and 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
 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.
Administering an Enema
 An enema introduces a solution into the
rectum Nurses give enemas to:
 Cleanse the lower bowel(most
common reason.)
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  Soften feces.  Most persons with an ostomy, also called
 Expel flatus. ostomates, wear an appliance (bag or
 Soothe irritated mucous membranes. collection device over the stoma) to collect
 Outline the colon during diagnostic x- stool. Depending on the type and location of
rays. the ostomy, client care may involve providing
 Treat worm and parasite peristomal care, applying an appliance,
infestations. draining a continent ileostomy, and, for
Cleansing Enemas clients with a colostomy, administering
 Cleansing enemas use different types of irrigations through the stoma.
solution to remove feces from the rectum

Providing Peristomal Care

 Preventing skin breakdown is a major
challenge in ostomy care. Enzymes in stool
Retention Enemas
can quickly cause excoriation (chemical injury
 A retention enema uses a solution held
of skin). Washing the stoma and surrounding
within the large intestine for a specified
skin with mild soap and water and patting it
period, usually at least 30 minutes. Some
dry can preserve skin integrity.
retention enemas are not expelled at all.
Nursing Implications
One type of retention enema is called an
 Constipation
because the fluid instilled is mineral,
 Risk for Constipation
cottonseed, or olive oil. Oils lubricate and
 Perceived Constipation
soften the stool, so it can be expelled more
 Diarrhea
easily.
 Bowel Incontinence
Ostomy Care
 Toileting Self-Care Deficit
 A client with an ostomy (surgically created
 Situational Low Self-Esteem
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).

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 URINARY ELIMINATION
Process of Urination
• Depends on effective functioning of
– Upper urinary tract (kidneys,
ureters)
– Lower urinary tract (bladder,
urethra, pelvic floor)
– Cardiovascular system
– Nervous system
Urine Formation
• Nephron
– Functional unit of the kidney
– Urine is formed here
• Glomerulus
– Tuft of capillaries surrounded by
Bowman’s capsule
– Fluids and solutes move across
endothelium of capillaries into the
capsule
• Bowman’s capsule
– Filtrate moves from here into the
tubule of the nephron
• Proximal convoluted tubule
– Most of water and electrolytes
reabsorbed
• Loop of Henle
– Solutes such as glucose reabsorbed
– Other substances secreted
• Distal convoluted tubule
– Additional water and sodium
reabsorbed here under control of
hormones
• Formed urine then moves to:
– Calyces of the renal pelvis
– Ureters (valve prevents reflux)
– Bladder (detrusor muscle, trigone)
Process of Micturition
• Micturition = voiding = urination
• Urine collects in bladder
• Pressure stimulates special stretch receptors
in bladder wall
• Stretch receptors transmit impulses to
spinal cord voiding reflex center
• Internal sphincter relaxes, stimulating urge
to void
• If appropriate, conscious portion of the brain
relaxes external urethral sphincter muscle
• Urine is eliminated through urethra at the
meatus
• Pelvic floor tone aids voluntary control
Female and Male Urinary Bladder and Urethras
• See box, Female and Male Urinary Bladder
and Urethras
Factors Affecting Voiding
• Developmental factors (enuresis, nocturnal
enuresis, nocturnal frequency)
• Psychosocial factors
• Fluid and food intake
• Medications (especially diuretics)
• Muscle tone
• Pathologic conditions
• Surgical and diagnostic procedures
Altered Urine Production
• Polyuria (diuresis), may follow polydipsia
• Oliguria
• Anuria (requires dialysis)
• Urinary frequency
• Nocturia
• Urgency
• Dysuria, associated with urinary hesitancy
• Enuresis
• Urinary incontinence
– Transient (acute)
– Established (chronic)
• Urinary retention
• Neurogenic bladder
Assessing
• Nursing history
• Physical assessment and hydration status
• Examination of urine
• Related data from diagnostic tests and
procedures
Nursing History
• Normal voiding patterns
• Appearance of urine
• Recent changes
• Past or current problems
• Presence of ostomy
• Factors influencing elimination pattern
Physical Assessment
• Percussion of kidneys to detect tenderness
• Palpation and percussion of bladder
• Inspection of urethral meatus for swelling,
discharge, inflammation
• Inspect skin for color, texture, turgor, signs
of irritation, edema
Assessing Urine
• 96% water; 4% solutes
• Organic solutes include urea (chief solute),
ammonia, creatinine, and uric acid
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 • Inorganic solutes include sodium, chloride,
potassium sulfate, magnesium, and
phosphorus
• Volume
• Color, clarity
• Odor
• Sterility
• pH
• Specific gravity
• Glucose
• Ketone bodies
• Blood
• Measure urinary output
• Measure residual urine
• Diagnostic tests
– Blood urea nitrogen (BUN)
– Creatinine clearance
Nursing Diagnoses
• Impaired Urinary Elimination
• Readiness for Enhanced Urinary Elimination
• Functional Urinary Incontinence
• Overflow Urinary Incontinence
• Reflex Urinary Incontinence
• Stress Urinary Incontinence
• Urge Urinary Incontinence
• Risk for Urge Urinary Incontinence
• Urinary Retention
Urinary Elimination May Become Etiology
• Risk for Infection
• Situational Low Self-Esteem
• Risk for Impaired Skin Integrity
• Toileting Self-Care Deficit
• Risk for Deficient Fluid Volume or Excess
Fluid Volume
• Disturbed Body Image
• Urinary Elimination May Become Etiology
(cont'd)
• Deficient Knowledge
• Risk for Caregiver Role Strain
• Risk for Social Isolation
Planning
• Maintain or restore a normal voiding pattern
• Regain normal urine output
• Prevent associated risks such as infection,
skin breakdown, fluid and electrolyte
imbalance, and lowered self-esteem
• Perform toilet activities independently with
or without assistive devices
• Contain urine with the appropriate device,
catheter, ostomy appliance, or absorbent
product
Implementing
• Maintaining normal urinary elimination
– Promoting fluid intake
– Maintaining normal voiding habits
– Assisting with toileting
• Preventing urinary tract infections
• Teaching to prevent UTIs
– Drink eight 8-oz glasses of water per
day
– Practice frequent voiding (every 2 -
4 hours)
– Avoid harsh soaps, bubble baths,
powder or sprays in perineal area
– Avoid tight-fitting clothing
– Wear cotton, not nylon, underclothes
– (Girls and women) - always wipe
perineal area from front to back
following urination or defecation
– Take showers rather than baths if
recurrent urinary infections are a
problem)
• Managing urinary incontinence
– Providing continence training (bladder
training, habit training, prompted
voiding)
– Pelvic muscle exercises
– Maintaining skin integrity
– Applying external urinary drainage
devices
• Managing urinary retention (flaccid bladder,
Crede’s maneuver)
• Condom catheter preferred because less risk
of UTI
Catheterization and Infection
• Insertion of urinary catheters is one of most
common causes of hospital-acquired
(nosocomial) infections
Implementing: Nursing Care for Clients with
Indwelling Catheters
• Encourage large amounts of fluid intake
• Provide foods that create acidic urine
• Give routine perineal care; prevent
contamination with feces in incontinent
clients
• Change catheter and tubing when necessary
(sediment, impaired drainage)
• Maintain sterile closed-drainage system
• Remove catheter as soon as possible after
purpose achieved
• Provide bladder retraining if needed
• Follow good handwashing techniques
Implementing: Ongoing Assessments of Clients with
Indwelling Catheters
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 • Ensure tubing is free of obstructions
• Ensure there is no tension on catheter or
tubing
• Ensure gravity drainage is maintained, with
no loops in tubing below entry to drainage
bag
• Ensure system is well sealed or closed
• Keep drainage receptacle below level of
client’s bladder
• Observe flow of urine q 2 - 3 hours
• Note color, odor, abnormal constituents
• If sediment is present, check more often
Implementing: Removing Indwelling Catheter
• Obtain receptacle for catheter; place client
in supine position; remove catheter-securing
device
• Insert syringe into injection port and
withdraw fluid from balloon
• After all fluid removed, withdraw catheter
and place in receptacle
• Dry perineal area
• Remove gloves
• Measure and record amount of urine in
drainage bag
• Document removal of catheter
• Provide urinal, commode, or collection device
• Monitor for first voiding and amount voided
in first 8 hours; monitor I&O
• Observe for dysfunctional voiding behaviors
Implementing: Teaching Clean Intermittent Self-
Catheterization
• Performed by clients with neurogenic bladder
dysfunction
• Clean or medical aseptic technique
• Before teaching, establish
– Client voiding pattern, volume
voided, fluid intake, residual amounts
Implementing: Bladder Irrigations
• Bladder irrigation
– To wash out bladder
– To provide medication to bladder
lining
• Catheter irrigation
– To maintain or restore patency of
catheter
• Closed method preferred; open method
occasionally required but adds risk for
infection
Implementing: Suprapubic Catheter Care
• Inserted surgically through abdominal wall
above symphysis pubis
• Care includes
– Regular assessment of urine, fluid
intake, and comfort
– Maintaining patent system
– Maintaining skin around site,
trimming pubic hair as needed
– Periodic clamping preparatory to
removal
Urinary Diversions
• Incontinent
– Ureterostomy
– Nephrostomy
– Vesicostomy
– Ileal conduit
• Continent
– Kock pouch
– Neobladder
Implementing: Nursing Care for Clients with Urinary
Diversions
• Assess intake and output
• Note any changes in urine color, odor, or
clarity (mucus shreds are commonly seen in
urine of clients with ileal diversion)
• Frequently assess condition of stoma and
surrounding skin
• Consult with wound ostomy continence nurse
(WOCN) as needed
Evaluating
• Nurse collects data to evaluate the
effectiveness of nursing activities
• If desired outcomes not achieved, explore
the reasons before modifying the care plan
– Client perception and understanding,
access to toilet, ability to manipulate
clothing, Kegel exercises
– Review schedule for voiding, fluid
intake (including caffeine, etc.),
diuretics
– Lighting, mobility aids, continence
aids