Bowel Elimination

Lecture Notes on Bowel Elimination / Enema Administration & Colostomy Care

Prepared By: Mark Fredderick R Abejo R.N, MAN

Clinical Instructor

NURSING SKILLS

BOWEL ELIMINATION

Lecturer: Mark Fredderick R. Abejo RN,MAN

____________________________________ Normal Characteristics of the Stool

Color Yellow or golden brown

Odor Aromatic upon defecation

Amount Approx. 150 – 300 grams per day

Consistency Soft and formed

Shape Cylindrical

Frequency Variable; usual range 1-2 / day

Alteration on the Characteristics of Stool

Alcholic Stool : Gray, pale or clay colored stool due to

absence of stercobilin caused by bilary obstruction.

Hematochezia : Passage of stool with bright red blood.

Due to lower gastrointestinal bleeding.

Melena : Passage of black, tarry stool due to upper GI

bleeding.

Steatorrhea : Greasy, bulky, foul-smelling stool. Due

to presence of undigested fats.

Common Fecal Elimination Problem

Constipation

Refers to the passage of small dry, hard stool or the

passage of no stool for a period of time.

Nursing Intervention to Prevent and Relieve Constipation

Adequate fluid intake, between 1,500 – 2,000 mls. / day

High fiber diet

Established regular pattern of defecation

Respond immediately to the urge to defecate

Minimize stress

Adequate activity and exercise

Assume sitting ad semi squatting position

Administered laxatives as ordered

Fecal Impaction

Is the mass or collection of hardened, putty-like

feces in the folds of the rectum. The stool is lodged or stuck

in the rectum, the person is unable to voluntarily evacuate

the stool.

Nursing Interventions to Relieve Fecal Impaction

Manual extraction or fecal disimpaction as ordered

Increased fluid intake

Sufficient bulk in diet


Diarrhea

Refers to frequent evacuation of watery stools. It is

associated with increased gastrointestinal motility and a

rapid passage of fecal contents through the lower GI tract.

Nursing Interventions to Relieve Diarrhea

Replace fluid and electrolyte

Provide good perianal care

Promote rest

Diet:

- small amounts of bland foods

- low fiber diet

- BRAT diet

- avoid excessively hot or cold fluids

- potassium-rich foods and fluids

Anti diarrheal medications as ordered

Note:

Do not administer antidiarrheal at the start of

diarrhea. Diarrhea is the body’s protective mechanism to rid

itself of bacteria and toxins

Flatulence

Is the presence of excessive gas in the intestines.

This may be due to swallowed air, bacterial action in the

large intestine and diffusion from blood.

Causes:

- constipation

- codeine, barbiturates and other medications that dec.

intestinal motility

- anxiety

- eating gas-forming foods

- rapid food or fluid ingestion

- improper use of drinking straw

- excessive drinking of carbonated beverages

- gum chewing, candy sucking and smoking

- abdominal surgery

Nursing Interventions to Relieve Flatulence

Avoid gas-forming food

Provide warm fluids to drink

Early ambulation among post op client


Limit carbonated beverages, use of drinking straws and

chewing gum

Rectal tube insertion as ordered:

- Place client in left lateral position

- Insert 3-4 inches of the lubricated rectal tube, gently in

rotating motion.

- Use of rectal tube Fr. 22-30

- Retain rectal tube for max. of 30 minutes

Carminative enema as ordered

Administer cholinergics as ordered.



Clinical Instructor

Fecal Incontenence

Is the involuntary elimination of bowel contents, it is

often associated with neurological, mental or emotional

impairments.

Clients with cerebral cortex injury may be unable to

perceive distended rectum or unable to initiate the motor

response required to inhibit defecation voluntarily

Clients who are disoriented or confused may have lost

the social inhibition that prevents immediate fecal

evacuation.

People who have sustained sacral spinal cord injury

experience impaired nerve supply to the rectum and anal

sphincters

Administering Enemas

Purposes:

To relieve constipation and fecal impaction

To relieve flatulence

To administer medication

To evacuate feces in preparation for diagnostic

procedure or surgery

Types of Enema

1. Cleansing Enema : Stimulates peristalsis by

irritating the colon and rectum and or by distending

the intestine with the volume of fluid introduced.

- High enema, clean as much of the colon,

1000 mls. of sol. are introduced

Note: Container should be 12-18 inches

above the rectum

- Low enema, clean rectum and the

sigmoid only, 500 mls. of

sol. are introduced

Note: Container should be 12 inches

above the rectum

2. Carminative Enema : To expel flatus, 60 to 180

mls. of fluids is introduced.

3. Retention : Introduces oil into the rectum and the

sigmoid, oil is retained in 1 to 3 hours. Act to

soften the feces and to lubricate the rectum and the

anal canal, facilitating passage of feces.

4. Return Flow Enema / Colonic Irrigation

- Done to expel flatus, 100 to 200 mls. of fluid is

introduced into and out of the large intestines to

stimulate peristalsis and promote expulsion of

flatus.

- The solution container is lowered so that the fluid

backs out through the rectal tube into the container.

- The process is repeated 5 – 6 times

- Replace the solution several times during the

procedure as it becomes thick with feces.

- This procedure may take 15 – 20 minutes to be

effective.

Equipment;

- Disposable linen pad (optional )

- Bedpan or commode

- Clean gloves

- Water soluble lubricant

- Paper towel

For Large Volume Enema

- Solution container

- Rectal tube of correct size

Adult: Fr. 22 – 32

Children: Fr. 14 -18

Infant: Fr. 12

- Tube clamp

- Correct solution, amount and temperature

For Small Volume Enema

- Prepackaged container of enema solution with lubricated

tip ( Fleet Enema )

Steps / Procedure Rationale

Identify and inform the

client and explain the

procedure.

To allay anxiety

Wash hands, apply clean

gloves and observed

appropriate infection

control

Provide client privacy

Position the client:

Adult: Left lateral

Infant/small children:

Dorsal recumbent

Facilitate the flow of sol. by

gravity as the sigmoid colon

is on the left side

Lubricate the tube about

5 cm ( 2 in )

Allow the solution to

flow through the

connecting tubing and

rectal tube to expel air

before insertion of the

rectal tube.

This prevent introduction of

air into the colon

Insert 7 – 10 cm ( 3 to 4

inches) or rectal tube

gently in rotating motion

To prevent irritation of anal

and rectal tissues

If resistance is felt, ask

the client to take deep

breath, then run a small

amount of sol, through

the tube

To relax the internal anal

sphincter



Clinical Instructor

Assuming a left lateral position for a commercially

prepare enema (fleet enema)

Introduce solution

slowly

- Raise the solution

container and open the

clamp to allow fluid to flow

High Enema: 12-18 inches

above the rectum

Low Enema: 12 inches

above the rectum

To prevent sudden

stimulation of peristalsis

The higher the solution

container is held above the

rectum, the faster the flow

and the greater the pressure

in the rectum

If the client complains of

fullness or pain, use the

clamp to stop the flow for

30 sec. and then restart

the flow at a slower rate

Decrease the likelihood of

intestinal spasm and

premature ejection of

solution

If High Enema, change

the position to distribute

sol. well

If Low Enema, remain in left

lateral position

If the order is cleansing

enema:

- give the enema 3x

- alternate hypotonic sol.

with isotonic sol.

To prevent water

intoxication

After all the solution has

been stilled or when the

clients fells the desire to

defecate, close the clamp

and remove the rectal

tube, disposed properly

Encourage the client to

retain the enema, ask the

client to remain lying

down

Assist the client to

defecate

- Assist in sitting position

- Ask the client who is using

the toilet not to flush it

The nurse need to observe

the feces

Placing a regular bedpan against the client’s buttocks.

Do perianal care

Make relevant

documentation

Colostomy Management

The locations of bowel diversion ostomies.

Colostomy is the opening in the Gastrointestinal

tract for the purpose of diverting and draining fecal

materials

Temporary Colostomies, generally performed for traumatic

injuries or inflammatory conditions of the bowel. It allows

the bowel to rest and heal.

Permanent Colostomies, are performed to provide a means

of elimination when the rectum or anus is nonfunctional as a

result of birth defect or a disease.

Type of Discharge

Ileostomy Liquid fecal drainage

Drainage is constant and cannot

be regulated

Contains some digestive

enzymes

Odor is minimal bec.of fewer

bacteria are present

Ascending

Colostomy Liquid fecal drainage

Drainage is constant and cannot

be regulated

Odor is a problem requiring

control

Transverse

Colostomy Malodorous, mushy drainage

Descending

Colostomy Solid fecal drainage

Sigmoidostomy Normal fecal characteristics



Clinical Instructor

Changing a Ostomy Appliance

Purposes:

To assess and care for the peristomal skin

To collect effluent for assessment of the amount and

type of output.

To minimize odors for the client’s comfort and self-

esteem

Assessment

Stoma Colors

- should appear red, similar to the mucosal linin of the

inner cheek.

- very pale or darker-colored stomas with a bluish or

purplish shades indicate impaired blood circulation to the

area.

Stoma Size and Shape

- most stomas protrude slightly from the abdomen

- new stomas normally appear swollen, but swelling

generally decreases over 2-3 weeks up to 6 weeks.

- failure of swelling to recede may indicate problem like

blockage.

Stomal Bleeding

- slight bleeding initially when the stoma is touched is

normal, but other bleeding should be reported.

Peristomal Skin

- any redness and irritation of the peristomal skin 5 – 13 cm

( 2-5 in ) of skin surrounding the stoma should be noted.

- transient redness after removal of adhesive is normal.

Note:

Burning sensation under the faceplate may indicate

skin breakdown

Equipment and Supplies:

Disposable gloves

Electric or safety razor

Bedpan

Solvent

Moisture-proof bag

Cleaning materials, including tissues, warm water, mild soap (optional), washcloth or cotton balls, and towel

Tissue or gauze pad

Skin barrier

Stoma measuring guide

Pen or pencil and scissors

Clean ostomy appliance, with optional belt

Tail closure clamp

Special adhesive, if needed

Stoma guide strip, if needed

Deodorant (liquid or tablet) for a nonodor-proof colostomy bag

Note:

Select an appropriate time to change the appliance:

Avoid times close to meal or visiting hours.

Avoid times immediately after meals or the administration

of any medications that may stimulate bowel evacuation.

Procedure

Rationale

Explain to the client what you

are going to do, why it is

necessary, and how she can

cooperate.

To allay anxiety

Wash hands and observe other

appropriate infection control

procedures. Apply clean gloves.

Provide for client privacy.

Assist the client to a comfortable

sitting or lying position in bed

or,

preferably, a sitting or standing

position in the bathroom.

May avoid wrinkles on

the ostomy appliance

Unfasten the belt, if the client is

wearing one.

Empty and remove the ostomy appliance: Empty the contents of the pouch through the bottom

opening into a bedpan. Assess the consistency and the amount of effluent. Peel the bag off slowly while holding the client’s skin

taut. If the appliance is disposable, discard it in a moisture-

proof bag.

Clean and dry the peristomal skin

and stoma.

Use toilet tissue to remove excess stool.

Use warm water, mild soap (optional), and cotton balls or a washcloth and towel to

clean the skin and stoma.

Use a special skin cleanser to remove dried, hard

stool.

Dry the area thoroughly by patting with a towel or

cotton balls.



Clinical Instructor

Assess the stoma and peristomal skin.

Inspect the stoma for color, size,shape, and

bleeding.

Inspect the peristomal skin for any redness,

ulceration, or irritation.

Place a piece of tissue or gauze pad over the stoma,

and change it as needed.

Apply paste-type skin barrier, if

needed. Allow the paste to dry

for 1 to 2 minutes, or as

recommended by the

manufacturer.

For a Solid Water or Disc Skin Barrier

Use the guide to measure the size of the stoma.

On the backing of the skin barrier, trace a circle the

same size as the stomal opening.

Cut out the traced stoma pattern to make an opening in

the skin barrier. Make the opening no more than 0.3–0.4

cm (1/8–1/6 in) larger than the stoma.

Remove the backing to expose the sticky adhesive side.

Center the skin barrier over the stoma, and gently press

it onto the client’s skin, smoothing out any wrinkles or

bubbles.

A guide for measuring stoma.

For Liquid Skin Sealant

Either wipe or apply the product evenly around the

peristomal skin to form a thin layer of the liquid plastic coating to the same area.

Allow the skin sealant to dry until it no longer feels

tacky.

For a Disposable Pouch with Adhesive Square

If the appliance does not have a precut opening, trace a

circle 0.3–0.4 cm (1/8–1/6 in) larger than the stoma size

on the appliance’s adhesive square.

Peel off the backing from the adhesive seal.

Center the opening of the pouch over he client’s stoma,

and apply it directly onto the skin barrier.

Gently press the adhesive backing onto the skin, and

smooth out any wrinkles, working from the stoma outward.

Remove the air from the pouch.

Close the pouch by turning up the bottom a few times,

fanfolding its end lengthwise, and securing it with a tail closure clamp.

Variation: Applying a Reusable Pouch with Detachable

Faceplate

Apply a skin sealant to the faceplate before attaching the

adhesive disc.

Remove the protective paper strip from one side of the

double-faced adhesive disc.

Apply the sticky side to the back of the faceplate.

Remove the remaining protective paper strip from the

other side of the adhesive disc.

Center the faceplate over the stoma and skin barrier, then

press and hold the faceplate against the client’s skin for a

few minutes, to secure the seal.

Press the adhesive around the circumference of the

adhesive disc.

Tape the faceplate to the client’s abdomen using four or

eight 7.5-cm (3-in) strips of hypoallergenic tape. Place

the strips around the faceplate in a “picture-framing”

manner, one strip down each side, one across the top, and one across

the bottom. The additional four strips can be placed diagonally over the other tapes to secure the seal.

Stretch the opening on the back of the pouch, and

position it over the base of the faceplate. Ease it over the faceplate flange.

Place the lock ring between the pouch and the faceplate

flange, to seal the pouch against the faceplate.

Close the base of the pouch with the appropriate clamp.

Variation: Applying the Skin Barrier and Appliance as

One Unit

Prepare the skin barrier by measuring the size of the

stoma, tracing a circle on the backing of the skin barrier,

and cutting out the traced stoma pattern to make an

opening in the skin barrier.

Prepare the appliance by cutting an opening 0.3–0.4 cm

(1/8–1/6 in) larger than the stoma size (if not already

present) and peeling off the backing from the adhesive seal.

Center the opening of the pouch over the skin barrier.

Remove the skin barrier backing to expose the sticky

adhesive side.

Center the skin barrier and appliance over the stoma, and

press it onto the client’s skin.

Dispose of equipment, or clean reusable equipment.

Discard a disposable bag in a plastic bag before

placing in the waste container. If feces are liquid, measure the volume. Note the

feces’ character, consistency, and color before emptying the feces into a toilet or hopper.

Wash reusable bags with cool water and mild soap,

rinse, and dry.

Wash a soiled belt with warm water and mild soap,

rinse, and dry.

Remove and discard gloves.

Document the procedure in the client’s record:

Pertinent assessments and interventions

Any increase in stoma size

Change in color indicative of circulatory

impairment

Presence of skin irritation or erosion

Discoloration of the stoma

Appearance of the peristomal skin

Amount and type of drainage

Client reaction to the procedure

Client’s experience with the ostomy

Skills learned by the client

Bowel Elimination

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