FECAL ELIMINATION o 100 ml is reabsorbed and 100 ml of
fluid is excreted in the feces
PHYSIOLOGY OF DEFACATION
o Elimination of waste products of
digestion from the body is essential
o Feces or stool – excreted waste
products
LARGE INTESTINES
o Extend from the iloecal valve to the
anus
o Has 7 parts:
 Cecum
 Ascending colon
 Transverse colon
 Descending colon
 Sigmoid colon
 Rectum
 Anus
o A muscular tube lined with mucous
membrane
o The muscle fibers are both circular
and longitudinal
o Longitudinal muscle are shorter than
the colon and cause the large
intestine to form pouches or haustra
o Main function:
 Absorption of water and
nutrients
 Mucoid protection of the
intestinal wall
 Fecal elimination
 Ingestion – act of taking in food
 Chyme
- Waste products leaving the
stomach through the small
intestine and then passing
through the ileocal value
 Ileocal valve
- Regulates the flow of chime
into the large intestine and
prevents backflow into the
ileum
o Colon serves as a protective
function in that it secretes mucous
o Mucous secretion is stimulated by
excitation of parasympathetic nerves
o During extreme stimulation large
amounts of mucous secreted,
resulting in the passage of stringy
mucous with little or no feces
o Mucous serves to protect the wall of
the large intestine from trauma
o It serves and adherent for holding
the fecal material together
- Mucous also protects the
intestinal wall from bacterial
activity
o Colon acts as transport along its
lumen the product of digestion –
flatus and feces
 Flatus
- Largely air and the by-
products of the digestion of
carbohydrates
 Haustra churning
- Involves movement of the
chyme back and forth within
the haustra
- This action aids in the
absorption of water and
moves the contents to the
next haustra
 Peristalsis
- Wave-like movement
produced the circular and
longitudinal muscle fibers
- It propels the intestinal
contents forward
- Colon peristalsis is very
sluggish and is thought to
move the chyme very little
along large intestine
 Mass peristalsis
 - Involves a wave of powerful o When internal anal sphincter
muscular contraction that relaxes, feces move into the anal
moves over large areas of canal
colon o Expulsion of the feces is assisted by
- Occurs after eating contraction of the abdominal muscle
and diaphragm
RECTUM AND ANAL CANAL
o Normal defecation is assisted:
 Rectum  Thigh flexion, increases the
- Has folds that extend pressure within the abdomen
vertically  Sitting position, increases the
- Each of the vertical folds downward pressure on the
contains a vein and an artery rectum
- These folds help retain feces o If defecation reflex is ignored, the
within rectum urge to detach normally disappears
 Hemorrhoids
FECES
- When veins become
distended, as can occur with o Made of 75% water and 25% solid
repeated pressure material
 Anal canal o If quickly propelled = not time for
- Bounded by an internal and most of the water in the chyme to be
external sphincter reabsorbed
- Internal sphincter is under o Normal feces require a normal fluid
involuntary control and intake
innervated by the autonomic o Feces that contain less water may
nervous system be difficult to expel
- External sphincter is under o Feces are normally brown, due to
voluntary control and the presence of stercobilin and
innervated by the somatic urobilin
nervous system o Another factor that affects fecal color
DEFECATION is the actionof bacteria
o Action of microorganism on the
o Expulsion of the feces from the anus chyme is responsible for the odor of
and rectum the feces
o Also called bowel movement o Gases:
o Frequency of defecation is highly  Carbon dioxide
individual  Methane
o Amount defecated also varies from  Hydrogen
person to person  Oxygen
o Peristaltic waves move the feces  Nitrogen
into the sigmoid colon and the
FACTORS
rectum, sensory nerves in the
rectum are stimulated and becomes DEVELOPMENT
aware of the need to defecate
NEWBORN AND INFANTS OLDER ADULT

 Meconiun o Up to half of all older adults suffer

- First fecal material passed by from constipation
the newborn o Due to:
- Black, tarry, odourless, and  Reduced activity levels
sticky  Inadequate fluid and fiber
- Transitional stools are intake
greenish yellow; they contain  Muscle weakness
mucous and are loose o Older adults should be advised that
o Infants pass stool frequently often normal patterns of bowel movement
after each feeding vary considerably
o Intestine is immature, water is not o Constipation can be relieved by
well absorbed and stool is soft, increasing the fiber intake to 20-35
liquid, and frequent grams per day, unless
o When matures, bacterial flora contraindicated
increase o Preventive measures:
o Infants who are breast-fed have light  Adequate roughage in the
yellow to golden feces diet
o Infants taking formula will have a  Adequate exercise
dark yellow or tan stool  6-8 glass of fluid daily
 Cup of hot water or tea at
TODDLERS regular time
 Gastrocolic reflex
o Nervous and muscular system are
- Increased peristalsis of the
sufficiently well developed to permit
colon after food has entered
bowel control
the stomach
o Desire to control day time movement
o Consistent use laxatives inhibits
use the toilet when:
natural defecation reflex
 Discomfort caused by a
o Laxatives may interfere with
soiled diaper
 Sensation that indicates the electrolyte balance and decrease the
need for bowel movement absorption of certain vitamins
o Day time control is attained by age 2 o Nurse should evaluate any
½ after process of toilet training complaints of constipation
o Change in bowel habits over several
SCHOOL-AGE AND ADOLESCENTS weeks with or without weight loss,
pain, or fever should referred to
o Have bowel habits similar to those of primary care provider
adults
o Patterns of defecation vary in ACTIVITY
frequency, quantity, and consistency
o Activity stimulates peristalsis
o Some school age may delay
defecation because of an activity
such as play
 o Weak abdominal and pelvic muscle through the digestive
are ineffective in increasing the intra- system
abdominal persn  Increase stool bulk
o Weak muscle can result from:  Sources: whole
 Lack of exercise wheat, wheat bran,
 Immobility nuts, and vegetables
 Neurologic functioning  Soluble fibers
o Clients confined to bed are often  Dissolves in water to
constipated form gel-like material
 Help lower blood
FLUID INTAKE AND OUTPUT cholesterol and
glucose level
o Even when fluid intake is inadequate
 Sources: oats, peas,
or output is excessive, the body beans, apples, citrus
continuous to reabsorb fluid from the fruits, carrots, barley,
chyme as it passes along the colon psyllium
o Chyme becomes drier resulting in o Daily amount of fibers:
hard feces  Men ages 50 and younger =
o Reduced fluid intake slows the 38 grams
chymes passage along the  Men ages 51 and older = 30
intestines, increasing reabsorption of grams
fluid  Women ages 50 and
o Healthy fecal elimination requires younger = 25 grams
daily fluid intake of 2,000 to 3,000 ml  Women ages 51 and older =
o If chyme moves abnormally quickly, 21 grams
less time for fluid to be absorbed into o Important to drink plenty of water
the blood; the feces are soft or even because fiber works best when it
watery absorbs water
o Bland diets and low-fiber diets are
DIET
lacking in bulk and creates
o Sufficient bulk (cellulose, fiber) in the insufficient residue of waste
diet is necessary provide fecal products to stimulate reflex for
volume defecation
o Inadequate intake of dietary fiber o Low residue foods move more
contributed to the risk of developing: slowly through the intestinal tract
 Obesity thus increase fluid intake
 Type 2 diabetes o Irregular eating can also impair
 Coronary artery disease regular defecation
 Colon cancer o Spicy foods can produce diarrhea
o 2 types of fiber: and flatus
 Insoluble fibers o Excessive sugar can also cause
 Promotes the diarrhea
movement of material o Foods that influence bowel
movement:
  Gas-producing o Early bowel training may establish
 Laxative-producing the habit of defecating at a regular
 Constipation-producing time
o Many people defecate after
PSYCHOLOGICAL FACTOR
breakfast, when gastrocolic reflex
o Anxiety and anger increase cause mass peristaltic waves in the
peristaltic activity and subsequent large intestine
nausea or diarrhea o Normal defecation reflex is ignored,
o People who are depressed may reflexes tend to progressively
experience slowed intestinal motility weakened
= constipation o Habitually ignored, urge to defecate
o Responses to these emotional is ultimately lost
states is the result of individual o Adult may ignore these reflexes
differences in the response of the because of the pressure of time or
enteric nervous system to vagal work
stimulation from the brain o Hospitalized client may suppress the
urge because of embarrassment
MEDICATION about using a bedpan, lack of
privacy, or defecation us too
o Repeated administration of
uncomfortable
morphine and codeine, cause
constipation because they decrease DIAGNOSTIC PROCEDURE
gastrointestinal activity through their
action on the CNS o Before certain diagnostic procedure,
o Iron supplements act more locally on the client is restricted from ingesting
the bowel mucosa and can cause food or fluid
constipation or diarrhea o Client may also be given a cleansing
 laxatives – stimulate bowel activity enema prior to the examination
and so assist fecal elimination o In these instances normal defecation
o drug that causes gastrointestinal usually will not occur until eating
bleeding can cause the stool to be resumes
red or black
PATHOLOGIC CONDITION
o iron salts lead to black stool because
of oxidation of the iron o Spinal cord injuries and head injuries
o antibiotics cause gray-green can decrease the sensory
discoloration stimulation for defecation
o antacids can cause whitish o Impaired mobility may limit client’s
discoloration or white specks ability to respond to the urge to
 Pepto-Bismol – causes stools to be defecate and the client may
black experience constipation
o Client may experience fecal
DEFACATION HABIT
incontinence because of poorly
functioning anal sphincters
ANESTHESIA AND SURGERY
o Cause the normal colonic
movements to cease or slow by
blocking parasympathetic stimulation
to the muscles of the colon
o Regional or spinal anesthesia are
less likely to experience this problem
o Surgery that involves direct handling
of the intestines can cause
temporary cessation of intestinal
movement last 24-48 hrs – ileus
o Listening for bowel sounds that
reflect intestinal motility is an
important nursing assessment
following surgery
PAIN
o Discomfort when defecating often
suppress the urge to defecate to
avoid the pain
o Clients taking narcotic analgesics for
pain may also experience
constipation as a side effect of the
medication
FECAL ELIMINATION PROBLEMS
CONSTIPATION
o Fewer than three bowel movement
per week
o Infers the passage of dry, hard stool,
FECAL IMPACTION
or the passage of no stool
o Occur when movement of feces
through the large intestine is slow
o Associated with constipation:
 Difficult evacuation of stool
 Increased effort or straining
of the voluntary muscles of
defecation
 Feeling of incomplete stool
evacuation
o Careful assessment of the person’s
habits is necessary before a
diagnosis of constipation is made
o Causes and factors:
 Insufficient fiber intake
 Insufficient fluid intake
 Insufficient activity or mobility
 Irregular defecation habits
 Change in daily routine
 Lack of privacy
 Chronic use of laxatives or
enemas
 Irritable bowel syndrome
 Pelvic floor dysfunction
 Poor motility
 Neurologic condition
 Emotional disturbance
 Medication
 Habitual denial and ignoring
urge
o In children, constipation is often
associated with changes in activity,
diet, and toileting habits
o Valsalva maneuver can present
serious problem to people with heart
disease, brain injuries, or respiratory
disease
o Holding the breath while bearing
down increases intrathoracic
pressure and vagal tone, slowing
pulse rate
o Mass or collection of hardened feces
in the folds of the rectum
o Results from prolonged retention
and accumulation of fecal material
o Severe impactions, the feces
accumulate and extend up into the
sigmoid colon and beyond
o Client will experience the passage of
liquid fecal seepage (diarrhea) and
no normal stool
 o Assessed by digital examination of o Spasmodic cramps are associated
the rectum with diarrhea
o Symptoms: o Bowel sounds are increased
 Frequent but non-productive  Persistent diarrhea – irritation of
desire to defecate the anal region extending to the
 Rectal pain perineum and buttocks
o Generalized feelings of illness:  Prolonged diarrhe – fatigue,
 Anorexic weakness, malaise, and emaciation
 Abdomen becomes are results
distended o Cause is irritants:
 Nausea and vomiting  Is thought to be a protective
o Causes of fecal impaction: flushing mechanism
 Poor defecation habit  Can create serious fluid and
 Constipation electrolyte losses
 Medication (anticholinergic  Clostridium Difficile
and antihistamines) - Produces mucoid and foul-
 Barium – used in radiologic smelling diarrhea
examination - Highest risk:
o Client is often given:  Immunosuppressed
 Oil retention enema individual
 Cleansing enema  Client on
 Daily additional cleansing chemotherapy
enema  Used antimicrobial
 Suppositories agent
 Stool softness - Older adult are at great risk
o If these measures fails, manual - Infection control:
removal is often necessary  Hand hygiene (soap
and water)
DIARRHEA  Contact precautions
 Cleaning with bleach
o Passage of liquid feces and an
solution
increased frequency of defecation
o Irritating effects of diarrhea stool
o Results from rapid movement of
increases the risk of skin breakdown
fecal contents through the large
o Area around the anal region should
intestines
be kept clean and dry and protected
o Reduces the time available for the
with zinc oxide or other ointment
large intestines to reabsorb
o Fecal collector can be used
electrolyte and water
o Diarrhea is not present unless the BOWEL INCONTINENCE
stool is relatively unformed and
excessively liquid o Also called fecal incontinence
o Finds it difficult or impossible to o Loss of voluntary ability to control
control the urge to defecate fecal and gaseous discharges
through anal sphincter
 o Two types of bowel incontinence:
 Partial incontinence
- Inability to control
flatus or to prevent
minor soiling
 Major incontinence
- Inability to control
feces of normal
consistency
o Associated with impaired function of
the anal sphincter or its nerve supply
o Prevalence of bowel incontinence
increase with age
o Bowel incontinence is emotionally
distressing problem that can lead to
social isolation
o Several surgical procedures are
used for the treatment:
 Repair of the sphincter
 Colostomy (bowel diversion)
FLATULENCE
o 3 primary sources:
 Action of bacteria on the
chyme in the colon
 Swallowed air
 Gas that diffuses between
the bloodstream and the
intestine
 Most gases that are
swallowed are expelled
through the mouth by
eructation (belching)
 Presence of excessive flatus
in the intestines and leads to
stretching and inflation of the
intestines
 Can occur in the colon from
variety of causes
 If gas is propelled by
increase colon activity, it may
be expelled through the anus
 If not, insert rectal tube to
remove it
BOWEL DIVERSION OSTOMIES
 Ostomy – opening for the GI,
urinary, respiratory tract on the skin
 Gastrostomy – opening through
abdominal wall into the stomach
 Jejunostomy – abdominal wall into
jejunum
 Ileostomy – opens into the ileum
 Colostomy – opens into the colon
o Provide alternate route for food
o Purpose: divert and drain fecal
material
o Classification:
 Permanent or temporary
 Anatomic location
 Construction of stoma
 Stoma
 Opening creased the
abdominal all by ostomy
 Red in color and moist
 No nerve endings
PERMANENCE
o Temporary colostomies are
generally performed for traumatic
injuries or inflammatory conditions of
bowel
 Allow the distal diseased
portion of the bowel to rest
and heal
o Permanent colostomies are
performed to provide means of
elimination hen the rectum or anus is
nonfunctional
ANATOMICAL LOCATION
 Ileostomy – empties from the distal
end of the small intestine
 Cecostomy – empties from the
cecum
 Ascending colostomy – empties
from the ascending colon
 o Location of the ostomy influences
the character and management of
the fecal drainage
o The farther along the bowel, the
more formed the stool and more
control over the frequency of stomal
discharge can be establish
 Ileostomy
 Produces liquid fecal
drainage
 Constant and cannot be
regulated
 Contains digestive enzyme
 Odor is minimal
 Ascending colostomy
 Drainage is liquid and cannot
be regulated
 Odor is a problem requiring
control
 Transverse colostomy
 Malodorous, mushy drainage
 Usually no control
 Descending colostomy
 Solid fecal drainage
 Formed consistency, and
frequency of discharge can
be regulated
o Length of time also helps to
determine the consistency of the
stool
SURGICAL CONSTRUCTION OF STOMA
o Described as single, loop, divided, or
double-barrelled colostomies
o Single stoma is created when one
end of bowel is brought out through
an opening onto the anterior
abdominal wall
 Referred to as an end or
terminal colostomy; stoma is
permanent
 Loop colostomy
 Loop of bowel is brought out
onto the abdominal wall and
supported by a plastic bridge
or by a piece of rubbing tube
 Usually performed in
emergency procedure and
often situated on the right
transverse colon
 Bulky stoma is more difficult
to manage than a single
stoma
 Loop stoma has two
openings:
 Proximal / Afferent –
active
 Distal / Efferent -
inactive
 Divided colostomy
 Consist of two edges of
bowel brought out onto the
abdomen but separated from
each other
 Opening from the digestive
or proximal end is the
colostomy
 Distal end is called/referred
as mucous fistula
 Often used in situation where
spillage feces into the distal
end of the bowel needs to be
avoided
 Double-barrelled colostomy
 Resembles a double-
barrelled shotgun
 Proximal and distal loops of
bowels are sutured together
and both ends are brought
up unto the abdominal wall
NURSING MANAGEMENT
ASSESSING
NURSING HISTORY
 o Helps the nurse ascertain the client’s DIAGNOSING
normal pattern
o Diagnostic labels for fecal
o Elicits a description of usual feces
and any recent changes and collects elimination:
information about any past or current  Bowel incontinence
problems about elimination, the  Constipation
presence of anostomy, and factors  Risk for constipation
influencing elimination pattern  Perceived constipation
o Nurse needs to understand that the  Diarrhea
 Dysfunctional GI motility
time of defecation and the amount of
o Etiology:
feces expelled are as individual as
the frequency of defecation  Risk for Deficient Fluid
o Patterns individual follow depend Volume and/or Risk for
Electrolyte Imbalance
largely on early training and on
 Prolonged diarrhea
convenience
 Abnormal fluid loss
PHYSICAL EXAMINATION through ostomy
 Risk for Impaired Skin
o Physical examination includes Integrity
inspection, auscultation, percussion,  Prolonged diarrhea
and palpation  Bowel incontinence
o Auscultation precedes palpation  Bowel diversion
because palpation can alter ostomy
peristalsis  Situational Low Self-Esteem
o Examination of rectum and anus  Ostomy
includes inspection and palpation  Fecal incontinence
 Need for assistance
INSPECTING FECES with toileting
 Disturbed Body Image
o Observe:
 Ostomy
 Color
 Bowel incontinence
 Consistency
 Deficient Knowledge
 Shape
 Anxiety
 Amount
 Lack of control of
 Odor
fecal elimination
 Presence of abnormal
 Response of others to
constituents
ostomy
DIAGNOSTIC STUDIES
PLANNING
o Diagnostic studies of GI tact:
o Major goals:
 Direct visualization technique
 Maintain or restore normal
 Indirect visualization
bowel elimination pattern
technique
 Maintain or regain normal
 Laboratory tests for abnormal
stool consistency
constituents
  Prevent associated risk
o Appropriate preventive and
corrective nursing interventions that
relate to these must be identified
o Specific nursing intervention can be
selected to meet the client’s
individual needs
PLANNING FOR HOMECARE
o In preparation for discharge, the
nurse needs to assess the clients
and family’s ability to met specific
care needs
o The nurse designs a teaching plan
for the client and family
IMPLEMENTING
PROMOTING REGULAR DEFACATION
PRIVACY
o Nurse should provide as much
privacy as possible but may need to
stay with those who are too weak
EXERCISE
o Some clients prefer to wipe, wash,
and dry themselves after defecating
o Nurse may need to provide water,
washcloth, and towel
TIMING
o Client should be encouraged to
POSITIONING
defecate when urge is recognize
o To establish regular elimination, the
client and nurse can discuss when
mass peristalsis usually occur and
provide time for defecation
NUTRITION AND FLUIDS
o The diet a client needs for regular
normal elimination
o Depending:
 Kind of feces
 Frequency of defecation
 Types of foods to assist
client with normal defecation
 For constipation
 Increase daily fluid intake
 Drink hot liquids
 Warm water with squirt of
fresh water
 Include fiber in diet
 For diarrhea
 Encourage oral intake of
fluids and bland food
 Eating small amounts can be
helpful
 Excessively hot or cold
should be avoided
 Highly spiced food and high
fiber can aggravate diarrhea
 For flatulence
 Limit carbonated beverages
 Use of drinking straw
 Chewing gum
 Gas forming foods should be
avoided
o Helps clients develop a regular
defecation pattern
o Client with weak abdominal and
pelvic muscles may be strengthen
through isometric contraction
o Squatting position best facilitates
defecating
o For clients who have difficult sitting
down and getting up, an elevated
seat can be attached to a regular
toilet
 Bedside commode
 Portable chair with a toilet
seat and a receptacle
beneath that can be emptied
 Bedpan
  Receptacle for urine and
feces
 Two main types:
 High-back pan
 Slipper pan – used for
clients unable to raise
their buttocks
TEACHING MEDICATIONS
CATHARTICS AND LAXATIVES
 Cathartics
 Drugs that induce defecation
 Can have strong, purgative
effect
 Examples:
 Castor oil
 Cascara
 Phenolphthalein
 bisacodyl
 Laxatives
 Is mild and produces soft or
liquid stools that
sometimes accompanied by
abdominal cramps
 Contraindicated in the client
who has nausea, cramps,
colic, vomiting,
undiagnosed abdominal pain
 Clients need to be informed
about danger of laxative use
 Continual use of laxative
weakens the bowel’s natural
responses to fecal distention,
resultingto chronic
constipation
 To eliminate chronic laxative
use:
 Teach about dietary
fiber
 Regular exercise
 Taking sufficient
fluids
 Establish regular
defecation habits
o Suppositories
 Softening the feces by:
 Releasing gas to
distend the rectum
 Stimulate the nerve
endings in the rectal
mucosa
ANTIDIARRHEAL MEDICATION
o Show the motility of the insertion or
absorb excess fluid in the intestine
ANTIFLATULENT MEDICATIONS
o They also coalesce the gas bubbles
and facilitate their passage by
belching through the mouth or
expulsion to the arms
o Combination of simithicone and
loperamide is effective in relieving
are abdominal bloating and gas
associated with acute diarrhea
 Carminatives
 Herbal oils known to act as
agents that help expel gas
or from the stomach and
intestines
o Suppositories can also be given to
relieve flatus by increasing intestinal
motility
DECREASING FLATULENCE
o Ways to reduce or expel flatus:
 Exercise
 Moving in bed
 Ambulation
 Avoiding gas-producing
foods
o Movement stimulates peristalsis and
the escape of flatus and
reabsorption of gases in the
intestinal capillaries
  Probiotics  Remove feces
 Helpful in the management of in the
flatulence and bloating instances of
 Helpful for various GI constipation or
disorders impaction
 Bismuth Subsalicylate  Carminative enema
 Can be effective but should - Given primarily to
not be used as a continuous expel flatus
treatment because it contains - Solution instilled into
aspirine and could cause the rectum release
salicylate toxicity gas, which distend
 Alpha-galactosidase the rectum and colon,
 Effective for reducing stimulating peristalsis
flatulence caused by eating  Retention enema
fermentable carbohydrates - Introduces oil or
medication into the
ADMINISTERING ENEMAS rectum and sigmoid
colon
 Enema - Acts to soften the
 Solution introduced into the feces and to lubricate
rectum and large intestine the rectum and anal
 Distend the intestine and canala
irritate the intestinal mucosa, - Antibiotic enemas –
increasing the peristalsis and treat infection
the excretion of feces and - Anthelmintic – kill
flatus hemlinths
 Enema solution should be at - Nutritive –administer
37.7°C because a solution fluids and nutrients
that is too hot or too cold is into the rectum
uncomfortable and cause  Return-flow enema
cramping - Called a Harris Flush
o 4 groups: - Used to expel flatus
 Cleansing enema - Repeated for 5-6
- Intended to remove times until flatus is
feces expelledand
- Given chiefly to: abdominal distention
 Prevent is relieved
escape of
feces during
surgery
 Prepare the
intestine for
certain
diagnostic test