Bowel EliminationBowel Elimination

Chapter 45Chapter 45

The esophagus is a long muscular tube, which moves food from the mouth to the The esophagus is a long muscular tube, which moves food from the mouth to the stomach. stomach.

The abdomen contains all of the digestive organs. The abdomen contains all of the digestive organs. The stomach, situated at the top of the abdomen, normally holds just over 3 pints 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 (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 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 digestive juices are added to the ingested food to facilitate breakdown of complex proteins, fats and carbohydrates into small, more absorbable units. 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 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 enter while keeping the acid-laden food from "refluxing" back into the esophagus, causing damage and pain. esophagus, causing damage and pain.

The pylorus is a small round muscle located at the outlet of the stomach and the 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 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 the stomach outlet while food is being digested into a smaller, more easily absorbed form. When food is properly digested, the pylorus opens and absorbed form. When food is properly digested, the pylorus opens and allows the contents of the stomach into the duodenum. 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 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 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 intestine is made up of three sections: the duodenum, the jejunum and the ileum. ileum.

The duodenum is the first section of the small intestine and is where the food is 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 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. 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 The jejunum is the middle part of the small intestine extending from the duodenum to the ileum; it is responsible for digestion. duodenum to the ileum; it is responsible for digestion.

The last segment of the intestine, the ileum, is where the absorption of fat-soluble 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. vitamins A, D, E and K and other nutrients are absorbed.

Another valve separates the small and large intestines to keep bacteria-laden Another valve separates the small and large intestines to keep bacteria-laden colon contents from coming back into the small intestine. colon contents from coming back into the small intestine.

In the large intestines, excess fluids are absorbed and a firm stool is formed. The In the large intestines, excess fluids are absorbed and a firm stool is formed. The colon may absorb protein, when necessary. colon may absorb protein, when necessary.

Structures of the Structures of the Gastrointestinal Tract Gastrointestinal Tract

(alimentary canal) Related to (alimentary canal) Related to Bowel EliminationBowel Elimination

– Small intestineSmall intestine– Ileocecal valveIleocecal valve– Large bowel (colon)Large bowel (colon)– Ileocecal sphincterIleocecal sphincter– Anal sphincterAnal sphincter

Physiology of Bowel Physiology of Bowel EliminationElimination

Continence Continence – Consistency of the stool (fecal material)Consistency of the stool (fecal material)– Intestinal motilityIntestinal motility– Compliance and contractility of the Compliance and contractility of the

rectum rectum – Competence of the anal sphinctersCompetence of the anal sphincters

Intestinal Motility and Rectal Intestinal Motility and Rectal AccommodationAccommodation

– Rectal filling Rectal filling – Rectal contractionsRectal contractions– Rectal accommodationRectal accommodation– Postponement of defecationPostponement of defecation– ConstipationConstipation

Anal Sphincter MechanismAnal Sphincter Mechanism– Internal and external sphinctersInternal and external sphincters– Striated muscle fibersStriated muscle fibers– Sensory receptorsSensory receptors

Factors Affecting Factors Affecting EliminationElimination

AgeAge DietDiet ExerciseExercise MedicationsMedications

Alterations in Bowel Alterations in Bowel EliminationElimination

ConstipationConstipation DiarrheaDiarrhea Fecal IncontinenceFecal Incontinence

Bowel RetentionBowel Retention

ConstipationConstipation is infrequent and is infrequent and difficult passage of hardened stool.difficult passage of hardened stool.– Dietary factors, dehydrationDietary factors, dehydration– Inadequate dietary bulkInadequate dietary bulk– Diverticular diseaseDiverticular disease– Neuropathic conditionsNeuropathic conditions– Functional limitationsFunctional limitations

Bowel RetentionBowel Retention

Fecal ImpactionFecal Impaction– Bolus of hardened stoolBolus of hardened stool– Further slows colonic transit time and Further slows colonic transit time and

passage of further fecal contentspassage of further fecal contents

Bowel RetentionBowel Retention

Perceived constipationPerceived constipation is influenced is influenced by psychological and emotional by psychological and emotional stress.stress.

Alterations in Bowel Alterations in Bowel EliminationElimination

DiarrheaDiarrhea is the passage of liquefied is the passage of liquefied stool with increased frequency and stool with increased frequency and consistency.consistency.

Primary Causes of DiarrheaPrimary Causes of Diarrhea– Malabsorption syndromesMalabsorption syndromes– Inflammatory bowel diseaseInflammatory bowel disease– Short bowel syndromeShort bowel syndrome– Side effects of drugsSide effects of drugs– Laxative or enema misuseLaxative or enema misuse

Infectious diarrhea is caused by a Infectious diarrhea is caused by a pathogen.pathogen.

Bowel (fecal) IncontinenceBowel (fecal) Incontinence– Dysfunction of the anal sphincterDysfunction of the anal sphincter– Disorders of the delivery of stool to the Disorders of the delivery of stool to the

rectumrectum– disorders of rectal storagedisorders of rectal storage– Anatomic defectsAnatomic defects

AssessmentAssessment

Health HistoryHealth History– Elimination habitsElimination habits– Type of incontinenceType of incontinence– Complicating factorsComplicating factors

AssessmentAssessment

Physical ExaminationPhysical Examination– Mental statusMental status– Mobility and dexterityMobility and dexterity– Inspection of perineum for skin integrityInspection of perineum for skin integrity– Inspection of vaginal vault Inspection of vaginal vault – Pelvic supportPelvic support– Perineal sensationPerineal sensation– Perianal area, digital rectal examPerianal area, digital rectal exam

Diagnostic and Laboratory DataDiagnostic and Laboratory Data

– Stool cultureStool culture– DefecographyDefecography– Anorectal ultrasonographyAnorectal ultrasonography

Nursing DiagnosesNursing Diagnoses

ConstipationConstipation Perceived ConstipationPerceived Constipation DiarrheaDiarrhea Bowel IncontinenceBowel Incontinence

Other Nursing DiagnosesOther Nursing Diagnoses

Low Self-EsteemLow Self-Esteem Deficient KnowledgeDeficient Knowledge Risk for InfectionRisk for Infection Risk for Impaired Skin IntegrityRisk for Impaired Skin Integrity Toileting Self-Care DeficitToileting Self-Care Deficit

Outcome Identification and Outcome Identification and PlanningPlanning

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

ImplementationImplementation

Maintain Elimination HealthMaintain Elimination Health– Fluid intakeFluid intake– DietDiet– Lifestyle and PreventionLifestyle and Prevention

Lifestyle and PreventionLifestyle and Prevention

– Alcohol and tobacco useAlcohol and tobacco use– Stress managementStress management– Weight reductionWeight reduction– Elimination habitsElimination habits– PositioningPositioning

Lifestyle and PreventionLifestyle and Prevention

– Initiate pelvic muscle exercise regimenInitiate pelvic muscle exercise regimen– Suggest environmental modificationsSuggest environmental modifications– Initiate behavioral intentionsInitiate behavioral intentions– Monitor skin integrityMonitor skin integrity

Rectal pouch and rectal tubeRectal pouch and rectal tube Initiate Diet and Fluid TherapyInitiate Diet and Fluid Therapy

Administer EnemasAdminister Enemas– Cleanse the lower bowelCleanse the lower bowel– Assist in evacuationAssist in evacuation– Instill medicationInstill medication

Initiate Rectal StimulationInitiate Rectal Stimulation instructioninstruction

Various types Various types

of enema of enema

equipment and equipment and

solutionssolutions

equipmentequipment

Monitor Elimination DiversionsMonitor Elimination Diversions– Bowel DiversionsBowel Diversions

IleostomyIleostomy ColostomyColostomy Ileoanal reservoir (uIleoanal reservoir (usually done only for ulcerative sually done only for ulcerative

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

ileostomyileostomy

Surgical ManagementSurgical Management

– Implanted devicesImplanted devices– Surgical reconstructionSurgical reconstruction– Surgical closure of fistulae and ectopiaSurgical closure of fistulae and ectopia– Endoscopy, other procedures to Endoscopy, other procedures to

alleviate obstruction or dyssynergiaalleviate obstruction or dyssynergia

Complementary TherapiesComplementary Therapies

– Holistic approach to effective Holistic approach to effective elimination of waste products and toxinselimination of waste products and toxins DiureticsDiuretics AntimicrobialsAntimicrobials AntisepticsAntiseptics Stimulants and CatharticsStimulants and Cathartics

EvaluationEvaluation

Client’s level of maintenance or Client’s level of maintenance or restoration of elimination patterns restoration of elimination patterns and return to an appropriate level of and return to an appropriate level of independenceindependence

Prevention of skin breakdown and Prevention of skin breakdown and infection infection

Client understanding of procedures Client understanding of procedures and self-careand self-care

coloscopycoloscopy