Chapter 45

Bowel Elimination

The esophagus is a long muscular tube, which moves food from the mouth to the stomach. The abdomen contains all of the digestive organs. The stomach, situated at the top of the abdomen, normally holds just over 3 pints (about 1500 ml) of food from a single meal. Here the food is mixed with an acid that is produced to assist in digestion. In the stomach, acid and other digestive juices are added to the ingested food to facilitate breakdown of complex proteins, fats and carbohydrates into small, more absorbable units. A valve at the entrance to the stomach from the esophagus allows the food to enter while keeping the acid-laden food from "refluxing" back into the esophagus, causing damage and pain. The pylorus is a small round muscle located at the outlet of the stomach and the entrance to the duodenum (the first section of the small intestine). It closes the stomach outlet while food is being digested into a smaller, more easily absorbed form. When food is properly digested, the pylorus opens and allows the contents of the stomach into the duodenum. The small intestine is about 15 to 20 feet long (4.5 to 6 meters) and is where the majority of the absorption of the nutrients from food takes place. The small intestine is made up of three sections: the duodenum, the jejunum and the ileum. The duodenum is the first section of the small intestine and is where the food is mixed with bile produced by the liver and with other juices from the pancreas. This is where much of the iron and calcium is absorbed. The jejunum is the middle part of the small intestine extending from the duodenum to the ileum; it is responsible for digestion. The last segment of the intestine, the ileum, is where the absorption of fat-soluble vitamins A, D, E and K and other nutrients are absorbed. Another valve separates the small and large intestines to keep bacteria-laden colon contents from coming back into the small intestine. In the large intestines, excess fluids are absorbed and a firm stool is formed. The colon may absorb protein, when necessary.

Structures of the Gastrointestinal Tract (alimentary canal) Related to Bowel Elimination

Small intestine Ileocecal valve Large bowel (colon) Ileocecal sphincter Anal sphincter

Physiology of Bowel Elimination

Continence
Consistency of the stool (fecal material) Intestinal motility Compliance and contractility of the rectum Competence of the anal sphincters

Intestinal Motility and Rectal Accommodation

Rectal filling Rectal contractions Rectal accommodation Postponement of defecation Constipation

Anal Sphincter Mechanism

Internal and external sphincters Striated muscle fibers Sensory receptors

Factors Affecting Elimination

Age Diet Exercise Medications

Alterations in Bowel Elimination

Constipation Diarrhea Fecal Incontinence

Bowel Retention

Constipation is infrequent and difficult

passage of hardened stool.
Dietary factors, dehydration Inadequate dietary bulk Diverticular disease Neuropathic conditions Functional limitations

Bowel Retention

Fecal Impaction
Bolus of hardened stool Further slows colonic transit time and passage of further fecal contents

Bowel Retention

Perceived constipation is influenced by

psychological and emotional stress.

Alterations in Bowel Elimination

Diarrhea is the passage of liquefied stool

with increased frequency and consistency.

Primary Causes of Diarrhea

Malabsorption syndromes Inflammatory bowel disease Short bowel syndrome Side effects of drugs Laxative or enema misuse

Infectious diarrhea is caused by a pathogen.

Bowel (fecal) Incontinence

Dysfunction of the anal sphincter Disorders of the delivery of stool to the rectum disorders of rectal storage Anatomic defects

Assessment

Health History
Elimination habits Type of incontinence Complicating factors

Assessment

Physical Examination
Mental status Mobility and dexterity Inspection of perineum for skin integrity Inspection of vaginal vault Pelvic support Perineal sensation Perianal area, digital rectal exam

Diagnostic and Laboratory Data

Stool culture Defecography Anorectal ultrasonography

Nursing Diagnoses
Constipation Perceived Constipation Diarrhea Bowel Incontinence

Other Nursing Diagnoses

Low Self-Esteem Deficient Knowledge Risk for Infection Risk for Impaired Skin Integrity Toileting Self-Care Deficit

Outcome Identification and Planning

Target outcomes center around restoring and maintaining regular elimination habits and preventing complications.

Implementation

Maintain Elimination Health

Fluid intake Diet Lifestyle and Prevention

Lifestyle and Prevention

Alcohol and tobacco use Stress management Weight reduction Elimination habits Positioning

Lifestyle and Prevention

Initiate pelvic muscle exercise regimen Suggest environmental modifications Initiate behavioral intentions Monitor skin integrity

Rectal pouch and rectal tube

Initiate Diet and Fluid Therapy

Administer Enemas
Cleanse the lower bowel Assist in evacuation Instill medication

Initiate Rectal Stimulation instruction

Various types of enema equipment and solutions

equipment

Monitor Elimination Diversions

Bowel Diversions
Ileostomy Colostomy Ileoanal reservoir (usually done only for ulcerative colitis and familial Polyposis patients. A reservoir is made from the ileum (small bowel) and connected directly to the anus. The sphincter muscle is in place. A temporary Ileostomy is performed to allow the reservoir to heal. Later the Ileostomy is closed and feces exits normally through the anus. )

ileostomy

Surgical Management
Implanted devices Surgical reconstruction Surgical closure of fistulae and ectopia Endoscopy, other procedures to alleviate obstruction or dyssynergia

Complementary Therapies
Holistic approach to effective elimination of waste products and toxins
Diuretics Antimicrobials Antiseptics Stimulants and Cathartics

Evaluation
Clients level of maintenance or restoration of elimination patterns and return to an appropriate level of independence Prevention of skin breakdown and infection Client understanding of procedures and self-care

coloscopy