Promoting Fecal elimination

Digestion is the process by which insoluble food, consisting of large molecules

is broken down into soluble compounds

- Digestion starts at the mouth and ends at the anus

Absorption is the movement of digested food molecules through the walls of

the small intestine.

- Digested food molecules move through the walls of the small intestine via
diffusion and active transport.
- Undigested food molecules are too large to move through the walls of the
small intestine.
- Finger-like projections in the wall of the small intestine provide a large
surface-area for absorption of digested food molecules.
- Absorption is the movement of digested food molecules through the walls
of the small intestine.

Elimination occurs when the undigested materials and water are eliminated
from the body in a solid waste form of feces or stool.

- The process of elimination is a bowel movement or defecation.

Defecation is the expulsion of feces from the anus and rectum.

- Also called bowel movement, the act of eliminating solid or semisolid

waste materials (feces) from the digestive tract.
- In human beings, wastes are usually removed once or twice daily, but the
frequency can vary from several times daily to three times weekly and
remain within normal limits.
- Muscular contractions (peristaltic waves) in the walls of the colon move
fecal material through the digestice tract to the rectum
Physiology of Defecation

- Elimination of the waste products of digestion from the body is essential

to health.
- The excreted waste products are referred to as feces or stool.

Large Intestine

● The large intestine extends from the ileocecal valve which lies between
the small and large intestines, to the anus.
● The colon in the adult is generally about 125 to 150 cm (50 to 60 in.)
long.
● It has seven parts: the cecum; ascending, transverse, descending colon;
sigmoid colon; rectum; and anus.
● The large intestine is a muscular tube lined with mucous membrane.
● The muscle fibers are both circular and longitudinal, permitting the
intestine to enlarge and contract in both width and length.
● The longitudinal muscles are shorter than the colon and therefore cause
the large intestine to form pouches, or haustra.
● The colon main functions are (a) the absorption of water and nutrients,
(b) the mucoid protection of the intestinal wall, (c) and fecal elimination.
● The contents of the colon normally represent foods ingested over the
previous 4 days, although most of the waste products are excreted within
48 hours of ingestion.
● The waste products leaving the stomach through the small intestine, and
then passing through the ileocecal valve are called chyme.
● As much as 1,500 mL of chyme passes into the large intestine daily, and
all but about 100 mL is reabsorbed in the proximal half of the colon.
● The 100 mL of fluid is excreted in the feces.

Other Functions

The colon also serves a protective function in that it secretes mucus.

i. This mucus contains large amounts of bicarbonate ions.
ii. The mucous secretion is stimulated by excitation of parasympathetic nerves.
iii. Mucus serves to protect the wall of large intestine from trauma by the acids
formed in the feces, and it serves as an adherent for holding the fecal material
together.
iv. Mucus protects the intestinal wall from bacterial activity.

• The colon acts to transport along its lumen the products of digestion, which
are eventually eliminated through the anal canal.

• These products are flatus and feces.

3 types of movements occur in the large intestine

1. Haustral churning - involves movement of the chyme back and forth

within the haustra.
2. Peristalsis - is a wavelike movement provided by the circular and
longitudinal muscle fibers of the intestinal walls; it propels the intestinal
contents forward.
3. Mass peristalsis - involves a wave of powerful muscular contraction that
moves over large areas of the colon.

Rectum and Anal Canal

● The rectum in the adults is usually 10 to 15 cm (4 to 6 in.) long; the most
distal portion, 2.5 to 5 cm (1 to 2 in.) long, is the anal canal.
● The rectum has folds that extend vertically.
● It is believed that these folds help retain feces within the rectum.
● When the veins become distended, as can occur with repeated pressure,
a condition known as hemorrhoids.
● The anal canal is bounded by an internal and an external sphincter.
● The internal sphincter is under involuntary control, and the external
sphincter normally is voluntarily controlled.
● The internal sphincter is innervated by the autonomic nervous system;
the external sphincter is innervated by the somatic nervous system.

Defecation
● It is the expulsion of feces from the anus and rectum.
● It is also called bowel movement.
● When peristaltic waves move the feces into the sigmoid colon and the
rectum, the sensory nerves in the rectum are stimulated and the
individual becomes aware of the need to defecate.
● When the internal anal sphincter relaxes, feces move into the anal canal.
● After the individual is seated on a toilet or bedpan, the external anal
sphincter is relaxed voluntarily.
● Expulsion of the feces is assisted by contraction of the abdominal muscles
and the diaphragm, which increases abdominal pressure, and by
contraction of the muscle of the pelvic floor, which moves the feces
through the anal canal.
● Normal defecation is facilitated by (a) thigh flexion, (b) sitting position.
● If the defecation reflex is ignored constipation can be the ultimate result.

Feces
➔ Normal feces are made of about 75% water and 25% solid materials.
➔ They are soft but formed.
➔ If the feces are propelled very quickly along the large intestine, there is
no time for most of the water in the chyme to be reabsorbed and the
feces will be more fluid, containing perhaps 95% water.
 ➔ Feces are normally brown, chiefly due to stercobilin and urobilin, which
are derived from bilirubin (a red pigment in bile).
➔ Another factor that affects fecal color is the action of bacteria such as
Escherichia coli or staphylococci, which are normally present in the large
intestine.
➔ The amount of gas produced per day varies among individuals, passing
gas around 13 to 21 times a day is normal.
➔ The gases include carbon dioxide, methane, hydrogen, oxygen, and
nitrogen.
➔ Some are swallowed with food and fluids taken by mouth, others are
formed through the action of bacteria on the chyme in the large intestine,
and other gas diffuses from the blood into the gastrointestinal tract.

Characteristics of Normal and Abnormal Feces

Characteris Normal Abnormal Possible Cause

tic

Color Adult: brown Clay or white Absence of blue pigment (bile

obstructon); diagnostic study
Black or tarry Red using barium

Infant: yellow Pale Drug (e.g., iron); bleeding

fromupper gastrointestinal
Orange or green tract (e.g., stomach, small
intestine); diet high in red
meat and dark green
vegetables (e.g., spinach)

Bleeding from lower GIT (e.g.,

rectum); somefoods (e.g.,
beets)

Malabsorption of fats; diet

high in milk andmilkproducts
and low in mea

Intestinal infection

Consistency Formed, soft, Hard, dry Dehydration; decreased

semisolid, moist intestinal motilityfromlack of
Diarrhea fiber in the diet; lack of
exercise, emotional upset,
laxative abuse Increased
intestinal motility (e.g.,
duetoirritationof the colon by
bacteria)

Shape Cylindrical (contour Narrow, pencil- Obstructive of the rectum

 of rectum) about 2.5 shaped or
cm (1 in.) in diameter stringlike stool
in adults

Amount Varies with diet

(about 100-400 g/day)

Odor Aromatic: affected by Pungent Infection, blood

ingested food and
individual own
bacterial flora

Constituent Small amounts of Pus Mucus

s undigested roughage,
sloughed dead Parasites Bacterial infection
bacteria and
epithelial cells, fat, Blood Inflammatory condition
protein, dried
constituents of Large quantities of Gastrointestinal bleeding
digestive juices (e.g., fat
Malabsorption
bile pigments,
Foreign objects
inorganic matter) Accidental ingestion

Factors Affecting Defecation

I. DEVELOPMENT

A. Newborns - Meconium is the first fecal material passed by the

newborn, normally up to 24 hours after birth. - It is black, tarry,
odorless, and sticky. - Transitional stools, which follow for about a
week, are generally greenish yellow; they contain mucus and are
loose.

B. Infants - Infants pass stool frequently, often after each feeding. -

When the intestine matures, bacterial flora increase. - After solid
foods are introduced, the stool becomes less frequent and firmer. -
Infants who are breast-fed have light yellow to golden feces, and
infants who are taking formula will have dark yellow or tan stool
that is more formed.

C. Toddlers - Some control of defecation starts at 1 1/2 to 2 years

age of age. - A desire to control daytime bowel movements and use
of toi let generally starts when the child b e c o m e s a w a r e o f
( a ) t h e discomfort caused by a soiled diaper and (b) the
sensation that indicates the need for a bowel movement. - Daytime
control is typically by age 2 1/2, after a process of toilet training.

D. School Age Children and Adolescents - Patterns of defecation

vary in frequency, quantity, and consistency. - Some school-age
children may delay defecation because of an activity such as play.
 E. Older Adults - (Toner and Claros, 2012) state that up to half of all
older adults suffer from constipation.

- Many older people believe that regularity means a bowel

movement every day.
- Older adults should be advised that normal patterns may be every
other day; for others, twice a day.
- Constipation can be relieved by increasing the fiber intake to 20
to 35 grams per day, unless contraindicated.
- Adequate roughage in the diet, adequate exercise, and 6 to 8
glasses of fluid daily are other essential preventive measures for
constipation.
- Responding to the gastrocolic reflex is an important
consideration.
- The reasons for constipation can range from lifestyle habits (e.g.,
lack of exercise) to serious malignant disorders (e.g., colorectal
cancer).
- The nurse should evaluate any complaints of constipation
carefully for each individual.
- A change in bowel habits over several weeks with or without
weight loss, pain, or fever should be referred to a primary care
provider for a complete medical evaluation.

II. DIET - Sufficient bulk (cellulose, fiber) inthedietisnecessary to provide fecal

volume.

- Inadequate intake of dietary fiber contributestotherisk of developing

obesity, type 2 diabetes, coronaryartery disease, and colon cancer.
- - Fibers is classified into two categories: insoluble fiber and soluble fiber.

Sources of Insoluble Fibers

• whole-wheat flour
• wheat bran
• nuts, and many vegetables

Sources of Soluble Fibers

• oats
• peas
• beans
• apples
• citrus fruits
• carrots
• barley
• psyllium

- Spicy foods can produce diarrhea and flatus in some individuals.

- Other foods that may influence bowel elimination include the following:

• Gas-producing foods, such as cabbage, onions, cauliflower, bananas,

and apples
• Laxative-producing foods, such as bran, prunes, figs, chocolate, and
alcohol
• Constipation-producing foods, such as cheese, pasta, eggs, and lean
meat
 Recommended Daily Amount of Fiber
Men ages 50 and younger: 38 grams
Men ages 51 and older: 30 grams
Women ages 50 and younger: 25 grams
Women ages 51 and older: 21 grams

- It is important to drink plenty of water because fiber works best when it is

absorbed by water.

- Bland diets and low-fiber diets are lacking in bulk and therefore create
insufficient residue of waste products to stimulate the reflex for defecation.
Low-Residue Foods: rice, eggs, and lean meats

III. Fluid Intake and Output

- Even when fluid intake is inadequate or output is excessive for some

reason, the body continues to absorb fluid from the chyme as it passes
along the colon.
- The chyme becomes drier than normal, resulting in hard feces.
- In addition, reduced fluid intake slows the chyme's passage along the
intestines, further increasing the absorption of fluid from the chyme.
- Healthy fecal elimination usually requires a daily fluid intake of 2000 mL
to 3000 mL.

IV. Activity

- Activity stimulates peristalsis, thus facilitating the movement of chyme

along the colon. • Weak abdominal and pelvic muscles are often
ineffective in increasing the intra-abdominal pressure during defecation
or in controlling defecation. • Clients confined to bed are often
constipated.

V. Psychological Factors

- Some people who are very anxious or angry experience increased

peristaltic activity and subsequent nausea or diarrhea.
- • In contrast, people who are depressed may experience slowed intestinal
motility, resulting in constipation.

VI. Defecation Habits

- Early bowel training may establish the habit of defecating at a regular

time.
- Many people defecate after breakfast, when the gastrocolic reflex causes
mass peristaltic waves in the large intestine.
- Adults may ignore these reflexes because of the pressures of time or
work.

VII. Medications

- Some drugs have side effects that can interfere with normal elimination.
- Some cause diarrhea; others, such as large doses of certain tranquilizers
and repeated administration of morphine and codeine, cause
constipation.
 - Iron supplements act more locally on the bowel mucosa and can cause
constipation or diarrhea.
- Laxatives are medications that stimulate bowel activity and assist fecal
elimination.
- Certain medications can suppress peristaltic activity and may be used to
treat diarrhea.
- Medications can also affect the appearance of the feces.
- Any drug that causes GI bleeding (e.g., aspirin products) can cause the
stool to be red or black. • Iron salts lead to black stool because of the
oxidation of the iron.
- Antibiotics may cause a gray-green discoloration.
- Antacids can cause a whitish discoloration or white pecks in the stool.
- Pepto-Bismol, a common OTC drug, causes stool to be black.

IX. Anesthesia and Surgery

- General anesthetics cause the normal colonic movements to cease or slow

by blocking parasympathetic stimulation to the muscles of the colon.
- Cl ient s who have regional or spinal anesthesia are less likely to
experience this problem.
- Surgery that involves direct handling of the intestines can cause
temporary cessation of intestinal movement.
- Listening for bowel sounds that reflect intestinal motility is an important
nursing assessment following surgery.

X. Pathologic Conditions

- Spinal cord injuries and head injuries can decrease the sensory
stimulation for defecation.
- Impaired mobility may limit the client's ability to respond to the urge to
defecate, and the client may experience constipation.
- A client may experience fecal incontinence because of poorly functioning
anal sphincters.

XI. Pain

- Clients who experience discomfort when defecating(e.g., following

hemorrhoid surgery) often suppress their urge to defecate to avoid the
pain.
- Clients taking narcotic analgesics for pain may also experience
constipation as a side effect of the medication.

Fecal Elimination Problems

1. Constipation

- Defined as fewer than three bowel movements per week.

- This infers the passage of dry, hard stool or the passage of no stool.
- It occurs when the movement of feces through the large intestine is slow,
thus allowing time for additional reabsorption of fluid from the large
intestine.
 - Associated with constipation are difficult evacuation of stool and
increased effort or straining of the voluntary muscles of defecation.
- The person may also have the feeling of incomplete stool evacuation after
defecation.
- Careful assessment of the person's habits is necessary before a dx of
constipation is made.

Sample Defining Characteristics of Constipation:

● Decreased frequency of defecation

● Hard, formed stools
● Straining of stool; painful defecation
● Reports of rectal fullness or pressure or incomplete bowel
evacuation
● Abdominal pain, cramps, or distention
● Anorexia, nausea
● HA

Causes and Factors Contribute to Constipation

● Insufficient fiber intake

● Insufficient fluid intake
● Insufficient activity or immobility
● Irregular defecation habits
● Change in daily routine
● Lack of privacy
● Chronic use of laxatives or enemas
● Irritable bowel syndrome (IBS)
● Pelvic floor dysfunction or muscle damage
● Poor motility or slow transit
● Neurologic conditions (e.g., Parkinson's disease), stroke, or paralysis
● Emotional disturbances such as depression or mental confusion
● Medications such as opioids, iron supplements, antihistamines, antacids,
and antidepressants
● Habitual denial and ignoring the urge to defecate. In children, constipation is
associated with changes in activity, diet, and toileting habits.
● Straining associated with constipation often is accompanied by holding the breath.
● The Valsalva maneuver can present serious problems to people with heart disease,
brain injuries, or respiratory disease.

2. Fecal Impaction

● It is a mass of hardened feces in the folds of the rectum.

● It results from prolonged retention and accumulation of fecal material.
● Impaction can also be assessed by digital examination of the rectum,
during which the hardened mass can often be palpated.
● Along with fecal seepage and constipation, symptoms include frequent
but nonproductive desire to defecate and rectal pain.
● A generalized feeling of illness results; the client becomes anorexic, the
abdomen becomes distended,and nausea and vomiting occur. The causes
of fecal impaction are usually poor defecation, constipation, and
administrationofme d i c a t i o n s, s u c h a s a n t i c h o l i ner gi
csandantihistamines; the barium used in radiologic examinations of the
upper and lower GITs.
 ● Digital examination of the impaction through the rectum should be done
gently and carefully.
● Although fecal impaction can generally be prevented, treatment of
impacted feces is sometimes necessary.
● When fecal impaction is suspected, the client is often given an oil
retention enema, a cleansing enema 2 to 4 hours later, and daily
additional cleansing enemas, suppositories, or stool softeners.
● If these measures fail, manual removal is often necessary.

3. Diarrhea

● It refers to the passage of liquid feces and an increased frequency of

defecation.
● Rapid passage of chyme reduces the time available for the large intestine
to reabsorb water and electrolytes.
● Often, spasmodic cramps are associated with diarrhea.
● Bowel sounds are increased.
● With persistent diarrhea, irritation of theanal regionextending to the
perineum and buttocks generally results, and fatigue, weakness, malaise,
and emaciation are the results of prolonged diarrhea.
● When the cause of diarrhea is irritants in the intestinal tract, diarrhea is
thought to be a protective flushing mechanism.
● Clostridium difficile- associated disease, which produces mucoid and foul-
smelling diarrhea, has been increasing in recent years.
● Clients at the highest risk for the development of [Link] include
immunosuppressed individuals, clients on chemotherapy, and those who
have recently used antimicrobial agents, usually fluoroquinolones.
● Older adults are the greatest risk due to underlying disease (s) and
greater exposure in hospitals and extended care facilities. Infection
control against C. difficile infection includes hand hygiene, contact
precautions, and cleaning of surfaces with a bleach solution.
● The irritating effects of diarrhea increase the risk for skin breakdown.
Therefore, the area aroundtheanal regionshould be kept clean and dry
and be protected with zinc oxide or other ointment.

Major Causes of Diarrhea

Cause Physiological effect

Psychological stress (e.g., anxiety) Increased intestinal motility and

Medications mucous secretion
Antibiotics Inflammation and infection of the
Iron mucosa due to overgrowth of
Cathartics pathogenic intestinal microorganisms
Allergy to food, fluid, drugs Irritation of the intestinal mucosa
Intolerance of food or fluid Irritation of the intestinal mucosa
Diseases of the colon (e.g., Incomplete digestion of food and fluid
malabsorption syndrome, Crohn's Increased intestinal motility and
disease) mucous secretion
Reduced absorption of fluids
Inflammation of the mucosa often
 leading to ulcer formation

4. Bowel Incontinence
- Bowel incontinence, also called fecal incontinence, refers to the loss of
voluntary ability to control fecal and gaseous discharges through the anal
sphincter.
- The incontinence may occur at specific times, such as after meals, or it
may occur irregularly.
Two types
1. Partial incontinence is the inability to control flatus or to prevent
minor soiling.
2. Major incontinence - is the inability to control feces of normal
consistency.
- Fecal incontinence is generally associated with impaired functioning of the anal
sphincter or its nerve supply, such as in some neuromuscular diseases, spinal
cord trauma, and tumors of the external anal sphincter muscle.
- Several surgical procedures are used for the treatment of fecal incontinence
(e.g., repair of the anal sphincter and bowel diversion or colostomy).

5. Flatulence
- The three primary sources of flatus are:
(1) action of bacteria on the chyme in the large intestine,
(2)swallowed air,
(3) gas that diffuses between the bloodstream and the intestine.

- Most gases that are swallowed are expelled through the mouth by eructation.•
Flatulence is the presence of excessive flatus in the intestines and leads to
stretching and inflation of the intestines (intestinal distention).
- If the gas is propelled by increased colonic activity before it can be absorbed, it
may be expelled through the anus.

Bowel Diversion Ostomies

An ostomy is an opening for the gastrointestinal, urinary, or respiratory tract onto the
skin.

Types of intestinal ostomies

i. A gastrostomy is an opening through the abdominal wall into the stomach.
ii. A jejunosotomy - opens through the abdominal wall into the jejunum.
iii. An ileostomy - opens into the ileum of the colon (small bowel).
iv. A colostomy - opens into the colon (large bowel).

Gastrostomies and jejunostomies are generally performed to provide an alternate

feeding route.
- The purpose of bowel ostomies is to divert and drain fecal material.
- Bowel diversion ostomies are classified according to (a) their status, permanent
or temporary, (b) their anatomic location, (c) the construction of stoma.
- A stoma is generally red in color and moist. - Slight bleeding may occur when the
stoma is touched, and this is considered normal.
 - A person does not feel the stoma because there are no nerve endings in the
stoma.

Permanence
● Temporary colostomies- are generally performed for traumatic injuries or
inflammatory conditions of the bowel.
● Permanent colostomies- are performed to provide a means of elimination when
the rectum or anus is nonfunctional as a result of a birth defect or a disease such
as cancer of the bowel.

Anatomic Location
● The location of the ostomy influences the character and management of the fecal
drainage.
● The farther along the bowel, the more formed the stool, and the frequency of
stomal discharge can be established.

For example
i. An ileostomy
- Produces liquid fecal drainage.
- Drainage is constant and cannot be regulated.
- Drainage contains some digestive enzymes, which are damaging to the skin.
- Odor is minimal.

ii. An ascending colostomy

- Similar to an ileostomy in that the drainage is liquid and cannot be regulated,
and digestive enzymes are present.
- Odor is a problem requiring control.

iii. A transverse colostomy

- Produces a malodorous, mushy drainage because some of the liquid has been
reabsorbed. There is usually no control.

iv. A descending colostomy

- Produces increasingly solid fecal drainage.
- Stools from a sigmoidostomy are of normal or formed consistency, and the
frequency of discharge can be regulated.
- People with a sigmoidostomy may not have to wear an appliance at all times, and
odor can usually be controlled.

● The length of time that an ostomy is in place also helps to determine the
consistency of the stool, particularly with transverse and descending
colostomies.
● Over time, the stool becomes more formed because the remaining functioning of
the colon tend to compensate by increasing water reabsorption.

Surgical Construction of the Stoma

- Stoma constructions are described as single, loop, divided, or double-barreled
colostomies.
i. The single stoma - is created when one end of the bowel is brought out through an
opening onto the anterior abdominal wall. This is referred to as an end or terminal
colostomy; the stoma is permanent.

ii. The loop colostomy - a loop of bowel is brought out into the abdominal wall and
supported by a plastic bridge or by a piece of rubber tubing.

- A loop stoma has two openings: (1) the proximal or afferent end, which is active,
and (2) the distal or efferent end, which is inactive.
- The loop colostomy is usually performed in an emergency procedure and is often
situated on the right transverse colon.
- It is a bulky stoma that is more difficult to manage than a single stoma.

iii. The divided colostomy - consists of two edges of bowel brought out onto the
abdomen but separated from each other.

- The opening from the digestive or proximal end is the colostomy.

- The distal end in this situation is often referred to as a mucous fistula, since this
section of bowel continues to secrete mucus.
- The divided colostomy is often used in situations where spillage of feces into the
distal end of the bowel needs to be avoided.

iv. The double-barreled colostomy - resembles a double-barreled shotgun.

- The proximal and distal loops of bowel are sutured together for about 10 cm (4
in.), and both ends are brought up onto the abdominal wall.

Nursing Management

I. Assessing Nursing History

- A nursing history for fecal elimination helps the nurse ascertain the client's
normal pattern.
- The nurse elicits a description of usual feces and any recent changes and collects
information about any past or current problems with elimination, the presence of
an ostomy, and factors influencing the elimination pattern.
- When eliciting data about the client’s defecation pattern, the nurse needs to
understand that the time of defecation and the amount of feces expelled are
individual as the frequency of defecation.

Assessment Interview
I. DEFECATION PATTERN
• When do you usually have a bowel movement?
• Has this pattern changed recently?

II. DESCRIPTION OF FECES AND ANY CHANGES

• Have you noticed any changes in the color, texture (hard, soft, watery), shape, or odor
of your stool recently?

III. FECAL ELIMINATION PROBLEMS

• What problems have you had or do you now have with your bowel movements
(constipation, diarrhea, excessive flatulence, seepage, or incontinence?
• When and how often does it occur?
• What do you think causes it (food, fluids, exercise, emotions, medications, disease,
surgery)?
• What have you tried to solve the problem, and how effective was it?
IV. FACTORS INFLUENCING ELIMINATION
• Use of elimination aids. What routines do you follow to maintain your usual defecation
pattern? Do you use natural aids such as specific foods or fluids (e.g., a glass of hot
lemon juice before breakfast), laxatives, or enemas to maintain elimination?

• Diet. What foods do you believe affect defecation? What foods do you typically eat?
what foods do you avoid? Do you take meals at regular times?

• Fluid. What amount and kind of fluid do you take each day (e.g., 6 glasses of water, 2
cups of coffee)?

• Exercise. What is your usual daily exercise pattern? (obtain specifics about exercise
rather than asking whether it is sufficient; ideas of what is sufficient vary among
individuals.)

• Medications. Have you taken any medications that could affect the intestinal tract
(e.g., iron, antibiotics)?

• Stress. Are you experiencing any stress? Do you think this affects your defecation
pattern? How?

V. PRESENCE AND MANAGEMENT OF OSTOMY

• What is your usual routine with your colostomy/ileostomy?
• What type of appliance do you wear and did you bring a spare with you?
• What problems, if any, do you have with it?
• How can the nurses help you manage your colostomy/ileostomy?

Physical Examination
● Physical examination of the abdomen in relation to fecal elimination problems
includes inspection, auscultation, percussion, and palpation with specific
reference to the intestinal tract.
● Auscultation precedes palpation because palpation can alter peristalsis.
● Examination of the rectum and anus includes inspection and palpation.

Inspecting the Feces

• Observe the client's stool for color, consistency, shape, amount, odor, and the
presence of abnormal constituents.

Diagnostic Studies
• Diagnostic studies of the GIT include direct visualization techniques, indirect
visualization techniques, and laboratory tests for abnormal constituents.

II. Diagnosing
• NANDA International includes the following diagnostic labels for fecal elimination
problems:
i. Bowel Incontinence
ii. Constipation
iii. Risk for Constipation
iv. Perceived Constipation
v. Diarrhea
vi. Dysfunctional Gastrointestinal Motility
• Fecal elimination problems may affect many other areas of human functioning and as
consequence, may be the etiology of other NANDA diagnoses.

i. Risk for Deficient Fluid Volume and/ or Risk for Electrolyte Imbalance related
to:
a. Prolonged Diarrhea
b. Abnormal fluid loss through ostomy

ii. Risk for Impaired Skin Integrity related to

a. Prolonged diarrhea
b. Bowel incontinence
c. Bowel diversion ostomy

iii. Situational Low Self-Esteem related to

a. Ostomy
b. Fecal incontinence
c. Need for assistance with toileting

iv. Disturbed Body Image related to

a. Ostomy
b. Bowel incontinence

v. Deficient knowledge (Bowel Training Ostomy Management) related to lack of

previous experience

vi. Anxiety related to

a. Lack of control of fecal elimination secondary to ostomy
b. Response of others to ostomy

III. Planning
The major goals for clients with fecal elimination problems
i. Maintain or restore normal bowel elimination pattern.
ii. Maintain or regain normal stool consistency.
iii. Prevent associated risks such as fluid and electrolyte imbalance, skin breakdown,
abdominal distention, and pain.

• Appropriate preventive and corrective nursing interventions that relate to these must
be identified.
• Specific nursing activities associated with each of these interventions can be selected
to meet the client's individual needs.

Planning Home Care

• Clients who have bowel diversion ostomies, who wear pouches, or who have
other ongoing elimination problems will need continuing care in the home
setting.

• In preparation for discharge, the nurse needs to assess the client's and family's
ability to meet specific care needs.

Home Care Assessment

I. Client and Environment manipulate clothing for toileting,

to perform toileting hygiene, and
• Self-care abilities for toileting: to flush the toilet.
ability to get to the toilet, to
 • Mechanical aids required:
walker, cane, wheelchair, raised II. Family
toilet seat, grab bars, bedpan,
commode. • Caregiver availability and
skills: people able to assist with
toileting, medications, ostomy
• Mechanical barriers that limit care, or other prescribed
access to the toilet or are unsafe: therapeutic measures.
poor lighting, cluttered pathway
to bathroom, narrow doorway for • Family role changes and
wheelchair, and so on. coping: effect on financial status,
parenting, and spousal roles,
• Bowel elimination problem: sexuality, social roles.
alterations in characteristics of
feces, diarrhea, constipation, • Alternate potential primary or
incontinence, presence of respite caregivers: for example,
ostomy, and methods of handling other family members,
these. volunteers, church members,
paid caregivers or housekeeping
• Level of knowledge: planned services; available community
bowel management or training respite care (adult day care,
program, prescribed senior centers).
medications, ostomy care,
dietary alterations, and fluid and
exercise requirements or III. Community
restrictions.
• Availability of and familiarity
• Facilities: adequacy of with possible sources of
bathroom facilities to facilitate assistance: equipment and supply
toileting hygiene and ostomy companies, financial assistance,
care and to contain potentially home health agencies.
infectious fecal effluent or stool.

Client Teaching
Fecal Elimination

I. Facilitating Toileting • Instruct the client, if

appropriate, to keep a record of
• Ensure safe and easy access to time and frequency of stool
the toilet. Make sure lighting is passage, any associated pain,
appropriate, scatter rugs are and color and consistency of the
removed or securely fastened, stool.
and so on.

• Facilitate instruction as needed III. Dietary Alterations

about transfer techniques.
• Provide information about
• Suggest ways that garments required food and fluid
can be adjusted to make alterations to promote defecation
disrobing easier for toileting or to manage diarrhea.
(e.g., Velcro closing on clothing).
IV. Medication

II. Monitoring Bowel Elimination • Discuss problems associated

Pattern with overuse of laxatives, if
inappropriate, and the use of
 alternatives to laxatives, • Provide information about
suppositories, and enemas. companies where durable
medical equipment (e.g., raised
• Discuss the addition of a fiber toilet seats, commodes, bedpans,
supplement if the client is taking urinals) can be purchased,
a constipating medication. rented, or obtained free of
charge, and where medical
supplies, such as incontinence
V. Measures Specific to Elimination pads or ostomy irrigating
Problem supplies and appliances can be
obtained.
• Provide instructions associated
with specific elimination • Suggest additional sources of
problems and treatment, such as information and help such as
constipation, diarrhea, ostomy ostomy self-help and support
care. groups or clubs.

VI. Community Agencies and other

Sources of Help IV. Implementing
Promoting Regular Defecation
• Make appropriate referrals to
home care or community care for Healthy Defecation
assistance with resources such • Establish a regular exercise regimen.
as installation of grab bars and • Include high-fiber foods, such as
raised toilet seats, structural vegetables, fruits, and whole grains, in
alterations for wheelchair access, the diet.
homemaker or home health aide • Maintain fluid intake of 2,000 mL to
and services to assist with ADLs, 3,000 mL/day.
and an enterostomal therapy • Do not ignore the urge to defecate.
nurse for assistance with stoma • Allow time to defecate, preferably at
care and selection of stomy the same time each day.
appliances. • Avoid OTC medications to treat
constipation and diarrhea.

i. Privacy constipation, for diarrhea, and for

• The nurse should therefore provide as flatulence).
much privacy as possible for such
clients but may need to stay with those iv. Exercise
who are too weak to be left alone.
• Some clients also prefer to wipe, • Regular exercise helps clients develop
wash, and dry themselves after a regular defecationpattern.
defecating.
• A client with weak abdominal and
ii. Timing pelvic muscles maybeabletostrengthen
• To establish regular bowel them with the following isometric
elimination, the client and nurse can exercises:
discuss when mass peristalsis normally
occurs and provide time for defecation. • In a supine position, the client
tightens the abdominal
musclesasthough pulling them
iii. Nutrition and Fluids inward, holding themfor about
• The diet a client needs for regular 10secondsandthen relaxing
normal elimination varies, depending on them. This should be repeated 5
the kind of feces the client currently to 10 times, fourtimesaday,
has, the frequency of defecation, and depending on the client's health.
the types of foods that the client finds
assist with normal defecation (e.g., for
 • Again in a supine position, the toilet seat the best position for
client can contract most people seems to be leaning
thethighmusclesand hold them forward.
contracted for about 10 seconds, - For clients who have difficulty
repeatingtheexercise5 to 10 sitting down and getting up from
times, four times a day. This the toilet, an elevated toilet seat
helps the client can be attached to a regular
confinedtobedgain strength in toilet.
the thigh muscles, thereby - A bedside commode, a portable
makingit easier touseabedpan. chair with a toilet seat and a
receptacle beneath that can be
emptied, is often used for the
adult client who can get out of
iv. Positioning bed but is unable to walk in the
bathroom.
- Although the squatting position - Clients restricted to bed may
best facilitates defecation, on a need to use a bedpan, a
receptacle f
- or urine and feces.

Teaching About Medications

I. Cathartics and Laxatives

- Cathartics are drugs that induce defecation.

- A laxative is mild in comparison to a cathartic, and it produces soft or liquid
stools that are sometimes accompanied by abdominal cramps.
- Examples of cathartics: castor oil, cascara, phenolphthalein, and bisacodyl.
- Laxatives are contraindicated in the client who has nausea, cramps, colic,
vomiting, or unexplained abdominal pain.
- Some laxatives are given in the form of suppositories.
- The best results can be obtained by inserting the suppository 30 minutes before
the client's usual defecation time or when the peristaltic action is greatest, such
as after breakfast.

Type Action Examples Pertinent teaching

Information

Bulk forming Increases the fluid, Psyllium hydrophilic May take 12 or more hours to
gaseous, or solid bulk in mucilloid (Metamucil), act. Sufficientfluid must be
the intestines. methylcellulose taken. Safe for long-termuse.
(Citrucel)

Osmotic/ Draws water into the Four major types of May be rapid acting. Can
saline intestine by osmotic laxatives; cause fluid and
osmosis,distends bowel, lactulose, sodium electrolyteimbalance,
and stimulates peristalsis. phosphate (tablet form particularly in older people
Almost no water or only requiring a andchildrenwithcardiac and
electrolytes are absorbed prescription; renal disease. Use caution
as solution moves OsmoPrep, Visicol), when giving to older adults. A
through the intestines magnesium salts laxative that is helpful in the
and the large fluid (magnesium citrate), treatment of constipation. It is
volume flushes feces from and sodium sulfate a powder that is tasteless
the colon. (SUPREP) Electrolyte- whenmixedina flavor liquid
free polyethylene such as juice. Usedfor
glycol 3350 (PEG cleaningof the colon before
 3350) MiraLAX) PEG- colonoscopy
ES (GoLYTELY;
NuLYTELY)

Stimulant/ Irritates the intestinal Bisacodyl (Dulcolax, Acts more quickly than buk-
Irritant mucosa or stimulates Correctol), senna formingagents. Fluid is
nerve endings in the wall (Senokot), Ex-Lax), passed with the feces. May
of the intestine, causing cascara, castor ol cause the cramps. Use only
rapid propulsion of the for short periods of time.
contents. Prolonged use may causefluid
andelectrolyteimbalance.

Stool softener Softens and delays the Docusate sodium Slow-acting; may take several
or surfactant drying of the stool; (Colace) Docusate days.
causes more water and calcium (Surfak)
fat to be absorbed into
the stool.

Lubricant Lubricates the stool and Mineral oil (Haley's M- Prolonged use inhibits the
colon mucosa O) absorptionof comefat-soluble
vitamins.

II. Antidiarrheal Medications

- These medications slow the motility of the intestine or absorb excess fluid in the
intestine.

Guidelines for Using Antidiarrheal Medications

- If the diarrhea persists for more than 3 to 4 days, determine the underlying
cause.
- Using a medication such as a narcotic when the cause is an infection, toxin, or
poison may prolong diarrhea.
- Long-term use of OTC medications (e.g., loperamide HCL) can produce
dependence.
- Some antidiarrheal agents can cause drowsiness (e.g., diphenoxylate HCL) and
should not be used when driving an automobile or running machinery.
- Kaolin-pectin preparations (e.g., Kaopectate) may absorb nutrients.
- Bulk laxatives and other absorbents may be used to help bind toxins and ansorb
excess bowel liquid.
- Bismuth preparations (e.g., Pepto-Bismol), often used to treat “traveler's
diarrhea, ” may containaspirinandshould not be given to children and teenagers
with chickenpox, influenza, and other viral infections.

III. Antiflatulent Medications

- Antiflatulent agents such as simethicone do not decrease the formation of flatus,

but they do coalesce the gas bubbles and facilitate their passage by belching
through the mouth or expulsion through the anus.
- A combination of simethicone and loperamide (Imodium Advanced) is effective in
relieving abdominal bloating and gas associated with acute diarrhea; however,
no convincing evidence has been shown for common flatulence.
 - Carminatives are herbal oils known to act as agents that help expel gas from the
stomach and intestines. • Suppositories can also be given to relieve flatus by
increasing intestinal motility.

Decreasing Flatulence

- There are a number of ways to reduce or expel flatus, including exercise, moving
in bed, ambulation, and avoiding gas-producing foods.
- Certain medications can decrease flatulence. - e,g., Probiotics, Bismuth
Subsalicylate {Pepto-Bismol}, Alpha-galactosidase {Beano}Page 93

Administering Enemas

- An enema is a solution introduced into the rectum and large intestine.

- The action of an enema is to distend the intestine and sometimes irritate the
intestinal mucosa, thereby increasing peristalsis and the excretion of feces and
flatus.
- The enema solution should be at 37.7 oC (100 oF).
- Enemas are classified into four groups: cleansing, carminative, retention, and
return-flow enemas

Cleansing Enema Indications

i. Prevent the escape of feces during surgery.

ii. Prepare the intestine to certain diagnostic tests, such as X-ray or visualization tests
(e.g., colonoscopy).

iii. Remove feces in instances of constipation or impaction.

- Some are large volume (i.e., 500 to 1000 mL) for an adult, and others are small
volume (90 to 120 mL), including hypertonic solution.
- The amount of solution administered for a high-volume enema will depend on the
age and medical condition of the individual

For example, clients with certain cardiac or renal disease would be adversely affected
by significant fluid retention that might result from large-volume hypotonic enemas.

Cleansing enemas may also be described as high or low. A high-enema is given to

cleanse as much of the colon as possible. The low enema is used to clean the rectum
and sigmoid colon only.

The force of flow of the solution is governed by (a) the height of the solution container,
(b) size of the tubing, (c) the viscosity of the fluid, (d) the resistance of the rectum.

During most adult enemas, the solution container should be no higher than 30 cm (12
in.) above the rectum.
During a high cleansing enema, the solution container is usually held30to49cm (12 to
18 in.) above the rectum.

Solution Contituents Action Time To Adverse Effects

Take Effect

Hypertonic 90 to 120 mL Draws water 5-10 mins Retention of

of solution into the colon. sodium
(e.g., sodium
phosphate
{Fleet})

Hypotonic 500-1000 mL Distends colon, 15-20 mins Fluid and

of tap water stimulates electrolyte
peristalsis, and imbalances;
softens feces. water
intoxication

Isotonic 500-1000 mL Distends colon, 15-20 mins Possible sodium

of normal stimulates retention
saline peristalsis, and
softens stool.

Soapsuds 500-1000 mL rritates 10-15 mins Irritates and may

(3-5 mL soap to mucosa, damage mucosa
1000 mL distends colon
water)

Oil (mineral, 90-120 mL Lubricates the 0.5-3 h

olive, feces and the
cottonseed) colonic mucosa

Carminative Enema

- A carminative enema is given primarily to expel flatus.

- The solution instilled into the rectum releases gas, which in turn distends the
rectum and the colon, thus stimulating peristalsis.
- For an adult, 60 to 80 mL of fluid is instilled.

Retention Enema

- A retention enema introduces oil or medication into the rectum and sigmoid
colon.
- The liquid is retained for a relatively long period (e.g., 1 to 3 hours).
- An oil retention enema acts to soften the feces and to lubricate the rectum and
anal canal, thus facilitating passage of the feces.
- Antibiotic enemas are used to treat infections locally, antihelminthic enemas to
kill helminths such as worms and intestinal parasites, and nutritive enemas to
administer fluids and nutrients to the rectum.

Return-Flow Enema

- A return-flow enema, also called a Harris flush, is occasionally used to expel

flatus.
- Alternating flow of 100 to 200 mL of fluid into and out of the rectum and sigmoid
colon stimulates peristalsis.
 - This process is repeated five to six times until the flatus and abdominal
distention are relieved.

Skills Instruction Demonstration

Please watch these videos on Insertion of Rectal Suppository and Enema

Administration. Rectal Suppository Insertion (Pediatric)
[Link] Rectal Suppository Insertion (Adult)
[Link] Enema Administration Child/Adult
(Instructional video) [Link]
[Link]

Digital Removal of a Fecal Impaction

- Digital removal involves breaking up the fecal mass digitally and removing it in
portions.
- Rectal stimulation is contraindicated for some people because it may cause an
excessive vagal response resulting in cardiac arrhythmia.
- Before disimpaction, it is suggested an oil retention enema can be given and held
for 30 minutes.
- After disimpaction, the nurse can use various interventions to remove remaining
feces, such as a cleansing enema or the insertion of a suppository.
- Because manual removal of an impaction can be painful, the nursemayuse1to2
mL of lidocaine (Xylocaine) gel on a gloved finger inserted intotheanal canalas
far as the nurse can reach.

For Digital Removal of a Fecal Impaction

i. If indicated, obtain assistance from a second person who can comfort the client during
the procedure.

ii. Ask the client to assume a right or left side-lying position, with the knees flexed and
the back toward the nurse.

iii. Place a disposable absorbent pad under the client's buttocks and a bedpan near the
toilet to receive stool.

iv. Drape the client for comfort and to avoid unnecessary exposure of the body.

v. Apply clean gloves and liberally lubricate the gloved index finger.

vi. Gently insert the index finger into the rectum and move the finger along the length of
the rectum.

vii. Loosen and dislodge stool by gently massaging around it. break up stool by working
the finger into the hardened mass, taking care to avoid injury to the mucosa of the
rectum.

viii. Carefully work the stool downward to the end of the rectum and remove it in small
pieces. Continue to remove as much fecal material as possible. Periodically, assess the
client for signs of fatigue, such as pallor, diaphoresis, or a change in pulse rate.
ix. Following disimpaction, assist the client to clean theanal areaandbuttocks. Then
assist the client onto a bedpan or commode for a short time because digital stimulation
of the rectum often induces the urge to defecate.

SKILL BUILDING: Collecting a stool sample

- STOOL IS COLLECTED to determine the presence of blood, ova, and parasites,

bile, fat, pathogens, or substances such as ingested drugs. Additional studies
include fecal urobilinogen, nitrogen, Clostridiumdifficile, fecal leukocytes,
calculation of stool osmolar gap, food residues, and other substances requiring
lab evaluation. Gross examination of stool characteristics, such as color,
consistency, and odor, can reveal such conditions as gastrointestinal bleeding
and steatorrhea (excess fat

- Stool specimens are collected randomly or for specific periods, such as 24 to72
hours. Some tool collections require the patient to follow a specific diet or refrain
fromtakingcertainmedications before the collection.

- Thorough and accurate patient education regarding a specific stool study prior
tocollectiongreatly increases the accuracy of the study results.

- Because stool specimens can't be obtained on demand, proper collection

requirescarefulinstruction to the patient to ensure an uncontaminated specimen.

- Fecal occult blood testing (FOBT) is one of the most commonly performed stool
tests. Itcanbe useful in initial screening for several disorders, although it's used
more frequentlyinearlycancer detection programs. FOBT can be performed at
the bedside, in the lab, or at [Link] there's a risk for false-positive or
false-negative results, patient preparationandspecimen collection must be
followed explicitly (see Factors that can interferewithFOBT).

Special considerations

- If stool must be obtained with an enema, use only tapwater or normal saline
solution. Never place a stool specimen in a refrigerator that contains food or
medication to prevent contamination. Notify the healthcare provider if the stool
specimen looks unusual.

Factors that can interfere with FOBT False-positive results Drugs and substances that
may cause a false-positive FOBT result include:

1. aspirin
2. steroids
3. indomethacin
4. nonsteroidal anti-inflammatory drugs
5. boric acid
6. bromides
7. colchine
8. iodine or povidone-iodine.

Foods that may cause a false-positive result include:

1. red meats, including processed meats and liver

 2. vegetables and fruits with peroxidase activity, such as turnips, horseradish,
mushrooms, broccoli, radishes, apples, bananas, and cantaloupe. False-negative
results

Substances that may cause a false-negative result include:

1. ascorbic acid (vitamin C) in excess of 250 mg/day

2. iron supplements that contain over 250 mg vitamin C

Skills Instruction DemonstrationPlease watch these videos on stool specimen

[Link]://[Link]/watch?v=J6rzYVZWv-o
[Link]

Bowel Training Programs

- The program is based on factors within the client's control and is designed
tohelptheclientestablish normal defecation.
- Before beginning, client must understand it and want to be involved.

The major phases of the program are as follows:

i. Determine the client's usual bowel habits and factors that help hinder normal
defecation.

ii. Design a plan with the client that include the following:
a. Fluid intake of about 2,500 to 3,000 mL/day
b. Increase in fiber in the diet.
c. Intake of hot drinks, especially just before the usual defecation time.
d. Increase in exercise.

iii. Maintain the following daily routine for 2 to 3 weeks:

a. Administer a cathartic suppository (e.g., Dulcolax) 30 minutes before

the client’s defecation time to stimulate peristalsis.

b. When the client experiences the urge to defecate, assist the client to
the toilet or commode or onto a bedpan. Note the length of time between
the insertion of the suppository and the urge to defecate.

c. Provide the client with privacy for defecation and a time limit;
30to40minutesisusually sufficient.

d. Teach the client to lean forward at the hips, to apply pressure on the
abdomen with the hands, and to bear down for defecation.

- Provide positive feedback when the client successfully defecates.

Refrainfromnegative feedback if the client fails to defecate.
- Offer encouragement to the client and convey that patience is required. Fecal
Incontinence Pouch
- To collect and contain large volumes of liquid feces, the nurse may place a fecal
incontinence collector pouch around the anal area.
- The purpose of the pouch is to prevent progressive perianal skin irritation and
breakdown and frequent linen changes necessitated by incontinence.
- A fecal collector is secured around the anal opening and may or may not be
attached to drainage.
- Pouches are best applied before the perianal skin become excoriated.
 - Some cl ients (e.g., post-stroke, post-trauma, quadriplegia, or paraplegia) may be
treated for fecal incontinence with surgical repair of a damaged sphincter or an
artificial bowel sphincter.
- If perianal skin excoriation is present, the nurse either

(a) applies adimethicone-based moisture barrier or alcohol film to the skin

to protect it fromfecesuntil itheals and then applies the pouch, or

(b) applies a skin barrier or hydrocolloidbarrier underneath the pouch to

achieve the best possible seal.

Nursing Responsibilities
i. Regular assessment and documentation of the perianal skin status.
ii. Changing the bag every 72 hours or sooner if there is leakage.
iii. Maintaining the drainage system.
iv. Providing explanations and support to the client and support people.

Ostomy Management

- Clients with fecal diversions need considerable psychological support,

instruction, and physical care.
- If possible, clients should meet with the WOCN prior to the surgery to assist in
the placement of the colostomy.
- National organizations have support groups whose mission is to improve the
quality of life of people who have, or will have, an ostomy.
- Talking with another person who has gone through a similar experience may
help the client realize that he or she is not alone and others are willing to listen
and help.

Stoma and Skin Care

- Care of the stoma and skin is important for all clients who have ostomies.
- Assess the peristomal skin for irritation each time the appliance is changed.
- The skin is kept clean by washing off any excretion and drying thoroughly.
- Some clients may also prefer to wear an adjustable ostomy belt,which attaches to
an ostomy pouch to hold the pouch firmly in place.

One-Piece / Two-Piece Ostomy Appliance

 ● Odor control is essential to client's self-esteem.
● Ostomy appliances can provide a leakproof seal for about 3 to 7 days
● The pouch should be changed on a routine basis, before leakage occurs.
If thed be changed every 24 to 48 hours to allow the appropriate
treat skin is erythematous, eroded, denuded, or ulcerated, the pouch
shoulment of the skin.
More frequent changes are recommended if the client complains of pain
or discomfort.
● The type of ostomy and amount of output influence how often the
pouch is emptied.

Colostomy Irrigation

● A colostomy irrigation, similar to an enema, is a form of stoma management

used only for clients who have sigmoid or descending colostomy.
● The purpose of irrigation is to distend the bowel sufficiently to stimulate
peristalsis, which stimulates evacuation.
● When a regular evacuation pattern is achieved, the wearing of colostomy pouch
is unnecessary.
● Routine daily irrigations for control of the time of elimination ultimately become
the client's decision.
● When regulation by irrigation is chosen, it should be done at the same time each
Day.
● Control by irrigations also necessitates some control of the diet.
● For most clients, a relatively small amount of fluid (300mLto500mL)stimulates
evacuation. Others, up to 1000 mL may be needed because a colostomy has no
sphincter and the fluid tends to return as it is instilled.
● This problem is reduced by the use of a cone on the irrigating catheter.
● Clients who choose to practice colostomy irrigation need to be motivated to

Skills Instruction Demonstration

Please watch these videos on Colostomy Irrigation and Ostomy Bag
Pouch Change.
[Link]
[Link]

Page 98
V. Evaluating

- The goals established during the planning phase are evaluated according to
specific desired outcomes, also established in that phase.
- If outcomes are not achieved, the nurse should explore the reasons: and
consider some of the following questions:

i. Were the client's fluid intake and diet appropriate?

ii. Was the client's activity level appropriate?
iii. Are prescribed medications or other factors affecting the GI function?
iv. Do the client and family understand the provided instructions well enough to
comply with the required therapy?
v. Were sufficient physical and emotional support provided?