Chapter 29- Bowel Needs

Flatulence, Gas, and Ostomies

Flatulence

Flatulence is the excessive formation of gas or air in the stomach or intestines.
Gas and flatus refer to gas or air passed through the anus (a fart).

Ostomies

An ostomy is a surgically created opening that connects an internal organ to the body's surface.
Types of ostomies include:
- Colostomy: connected to the large intestine (colon).
- Ileostomy: connected to the small intestine.
A stoma is the surgically created opening seen on the body's surface, which is part of the ostomy.

Bowel Elimination

Bowel elimination is a basic physical need where wastes are excreted through the gastrointestinal (GI) tract.
Normal bowel elimination is important, and problems can easily occur.
Foods and fluids are ingested through the mouth and partially digested in the stomach.
Partially digested food and fluids are called chyme.
Chyme passes from the stomach into the small intestine where further digestion and nutrient absorption occurs.
Chyme then passes into the large intestine (colon), where fluid is absorbed.
As chyme passes through the large intestine, it becomes less fluid and more solid.
Feces, stools, or stool refers to the semisolid waste expelled through the anus.
Feces move through the intestines via peristalsis (alternating contraction and relaxation of intestinal muscles).
Feces move to the rectum, are stored, and then excreted from the body through defecation.

Normal Bowel Movements

Normal bowel movements vary from person to person (daily, 2-3 times a day, or every 2-3 days).
Breastfed infants have thick, liquid to very soft yellow stools.
Bottle-fed infants have yellowish-brown liquid or greenish-brown pasty stools.
Stool color and consistency change with the introduction of solid foods.
Newborns may have a bowel movement after every feeding, with frequency changing as they grow older.

Abnormal Stools

Carefully observe stools and report/record any abnormalities.
Color:
- Beets, tomato juice, or soup can cause red-colored stools.
- Green vegetables can cause green stools.
- Diseases and infections can cause clay-colored, white, pale, orange-colored, or green-colored stools.
- Darker stools may indicate internal bleeding.
Amount:
- Record amount as small, medium, or large.
- Liquidy stools are measured in milliliters.
Mucus:
- Normally none, but may be present in cases of diseases and infections.
Signs of bleeding:
- Bleeding in the stomach and small intestines can cause black or tarry stools.
- Bleeding in the lower colon and rectum results in red-colored stools.
Odor:
- Stool usually has a normal odor caused by bacteria in the intestines.
- Certain foods and drugs can cause changes in odor.
Shape and Consistency:
- Note whether stools are formed, moist, or shaped like the rectum.
Record the time of bowel movements, frequency, and any complaints of pain.

Questions to Ask

When inquiring about bowel movements, use professional language:
- "Did you have a bowel movement today?"
- "Please tell me if you need to use the restroom."
- "When did you have your bowel movement?"
- "What was the amount?"
Follow care plan for appropriate terminology.
Observe and report all relevant information to the nurse, including any subjective complaints like pain.

Charting Bowel Movements

Use flow sheets or charting sheets to record bowel eliminations.
Include the day, time (using military time), shape and consistency, color, amount, presence of pain, odor, and any other relevant notes.
Note any straining or other problems, and report observations to the nurse.
Charting sheets are used for various patient activities (urinary elimination, food intake, range of motion exercises, etc.).

Factors Affecting Bowel Movements

Privacy: Lack of privacy can inhibit the urge to have a bowel movement.
Habits: Many people have bowel movements after breakfast due to stimulation of peristalsis.
Diet:
- High-fiber foods create bulk and prevent constipation.
- Gas-forming foods (onions, beans, cabbage, cauliflower, radishes, cucumbers) can stimulate peristalsis.
Fluids: Drink 8-10 glasses of water to promote normal bowel movements; warm fluids increase peristalsis.
Activity: Regular exercise promotes bowel movement.
Drugs: Certain drugs can affect bowel movements.
Disability: Some individuals have no control over bowel movements (fecal incontinence).

Monitored Restroom Use

Follow nurse's instructions and care plan regarding privacy.
Check on the person every five minutes, or more frequently if directed by the care plan.
Provide perineal care as needed.
Dispose of stools promptly to reduce odors and prevent the spread of microbes.
Assist the person with hand hygiene.

Common Bowel Problems

Constipation: Passage of hard, dry stools due to slow movement of feces through the bowel, allowing for excessive water absorption. Common causes include low-fiber diet, ignoring the urge to defecate, inactivity, decreased fluid intake, drugs, aging, and certain diseases.
Fecal Impaction: Prolonged buildup of feces in the rectum, resulting from unrelieved constipation. Liquid feces may pass around the hardened mass and seep through the anus. Symptoms include frequent straining, abdominal discomfort/swelling, cramping, rectal pain, poor appetite, confusion, and fever (especially in older adults).
Diarrhea: Frequent passage of liquid stools due to rapid movement through the large intestine, not allowing for fluid absorption. Causes include infections, drugs, irritating foods, and microbes in food or water. Fluid loss during diarrhea can lead to dehydration.
Fecal Incontinence: Inability to control the passage of feces through the anus. Causes include intestinal diseases, nervous system disorders, fecal impaction or diarrhea, some drugs, chronic illnesses, aging, mental health disorders, or dementia. Can be highly distressing for the individual.
Flatulence: Excessive formation of gas or air in the stomach and small intestines, resulting in the passage of flatus (gas). Common causes include swallowing air, bacterial action, gas-forming foods, constipation, bowel/abdominal surgeries, and drugs that decrease peristalsis.

Medical Interventions

The doctor will order one of the following:
Stool softeners to soften feces.
Laxatives to promote bowel elimination.
- Increase the bulk of feces.
- Soften the feces.
- Lubricate the intestinal walls.
Drugs to relieve constipation, may consist of suppositories and enemas.

Digital Examination

The nurse will perform the procedure. If done, the nurse will insert a lubricated gloved finger into the rectum to feel for hard mass as well as remove any feces.
This procedure is dangerous and the vagus nerve stimulates the heart rate.

Interventions: Digital Removal

Digital removal of impaction is done, meaning they are hooking around what is causing the impaction massed feces and pull it out with their finger until the impaction is gone.
After each time the nurse pulls out an amount of feces, drop the feces in a nearby bedpan.

Safety and Precautions

Safety in mind, checking for fecal impaction presents dangers. The vagus nerve can be stimulated, which can slow the heart rate down to dangerous levels and Rectal bleeding can occur.
For fecal incontinence, you need to follow your standard precautions.
The need for bowel movements is urgent for someone with diarrhea.
Answer call lights promptly, assist with hygiene and garment changes as needed.
Do not judge them because they cannot control their bowel movements.
If a patient in your care has diarrhea, it is important to be aware of the risk of C. Diff (Clostridium difficile), a microbe that causes diarrhea and intestinal infections.
To prevent the spread of C. Diff, it is crucial to clean surfaces and equipment thoroughly with appropriate disinfectants.
Always wear gloves when cleaning surfaces, especially those frequently touched by the patient (e.g., call lights, TV remotes, bedside rails).

Bowel Training

Bowel training aims to gain control of bowel movements and develop a regular pattern of elimination.
Strategies include:
- Assisting with elimination after meals (especially breakfast).
- Noting the person's usual time for bowel movements according to their care plan and regular time.
- Ensuring access to the appropriate restroom facilities (commode, bedpan, or restroom).
- Being aware of special diets.

Suppository

A suppository is a cone-shaped solid drug inserted into the rectum and it is very small. You do not insert the suppository into the stoma, instead into the rectal wall.
The suppository will melt from the body temperature inside of the insertion.
- This medication is given for constipation, fecal impaction and bowel training.
- The nurse knows what lubricants to use and how soon to expect a bowel movement, also you need to record or report any observations to the nurse.

Procedure:

The person must be in sims position which is you assist the patient to the left side of the bed. The position is held around 15 to 20 mins

Enemas

Types of Enemas

An enema is the introduction of fluid into the rectum and lower colon. Enemas are ordered to remove feces, relieve constipation, fecal impaction, or flatulence, and to clean the bowel of feces before certain surgeries or diagnostic procedures.
- Cleansing enemas
  - Tap water enemas
  - Saline enemas
  - Soap sud enemas
- Small volume enemas
- Oil retention enemas

Enema Procedures

For adults, the enema is only inserted 2 to 4 inches into the rectum.
Lubricate the enema tip before inserting it.
If resistance, pain, or bleeding occurs, stop insertion.
For adults, the enema bag is held about 12 inches above the anus.
Give about 750 to 1000 mL over 10 to 15 minutes.
Follow the nurse's requests and the agency's instructions about safely preparing and administering enemas. Do not administer medications that contain drugs.

Implementation Reminders

If you’re going over a certain amount per minute, decrease the rate to match an even amount.
The solution should be 98.6 to 100 degree Fahrenheit per minute.
Sim’s position or laying left side allows for easier entrance.

Enema specifics:

Cleansing enemas will effect in about 10 to 20 mins. And “Enemas until clear” are where the return solution is clear (Free of stools).
Tap water:
- You have 1 tap water enema max because Tap water can create a fluid imbalance if the colon absorbs it into the bloodstream.
Saline
- The sodium and water is the most body fluid compared to the human fluids. So there’s a minimum chance of getting contaminated from this procedure.
Soap spuds:
- Use approximately 3 to 5mL of castile soap, a vegetable oil, instead of the stronger and less safe soap options.
  - With the soap it irritates the bowels mucus lining and damages if done often.

Innermost in children

The nurse tells you the amount to give and the guidelines given are as follow:
- Infants get 120 mL to 240 mL, children to four get 240 to 360 mL, children 4 to 10 around 360 to 480mL, and 11 plus get 480 to 720mL.
- Insert the tub no more than 1 inch for infants and 4 for the older children.
- Be very careful about the procedure being too rough of infant since they can’t tell you if it hurts, instead you can assume they have high pitched cries and the need drawls to the sky.
For children, it will take effect in 2 to 5 minutes.
Small volume irritated and distend the bowels so the patient’s bowel movement will cause the rectum. These are used for constipation only or no need for any cleaning
- Put the tip 2 in for small volume enemas, then roll out the small plastic bottle until the medicine is gone.
  - DON’T take your pressure off so the contents can’t get back into the bottle from the bowel.
  - Urge the person to retain this content until they get the urge ( Around 5 to 10 mins). Always in Sims position for best and quickest effectiveness.
For oral retention enemas, these can help with any constipation and hard to eliminate matter.
- So the oils soften the rectal wall and can pass around easier, may take 30mins to 3 hours to affect.

Ostomies

An ostomy is a surgically created opening of an internal organ that is brought to the body's surface.
The surgically created opening that is seen is a stoma.
The ostomy pouch is worn over a stoma to collect stools and flatus, meaning your your gas and your feces.
A colostomy is an ostomy, but it is a surgically created opening that connects the large intestine to the body surface, so specifically the colon.
An ileostomy, essentially, it is the same thing, only difference being it is connected to the small intestine. They do not have a a colon anymore. Their large intestine is gone. Liquid stools drain constantly from these ileostomies Water is not absorbed because the colon is not there anymore. Feces in the small intestine can contain digestive juices that can be very irritating to the skin. The ostomy pouch must fit well. Stools must not touch the skin, and good skin care is required.
Stools irritate the skin. You need to make sure good skin care is is given to prevent the breakdown around the stoma. The skin is washed and dried. A skin barrel applied around the stoma prevents stool contact with the skin.
The skin barrier is part of the pouch or a separate device.

Colostomy

Good hygiene is necessary when breaking it down.

Pouches

They are secured with ostomy belts
Outlet where a the tool exist without poking a hole into it
Outlet with some sort of clamping on it to safely seal it. And the pouch when full lets out a fart. Always do that for them.
Pouches change bi weekly, which the frequent changes can irritate the skin though so careful!
To present odors use pouches with Oder safety build and preform good hygiene when cleaning.
Showers are delayed for adhesive sealing
Empty a child’s stomy pouch is as delegated to you but depending on the type. Depending on either you deal with coleo and ileo.
Empty a child’s pouch as long as it isn't 1/3 or ½ full. Emptoy the poutch ever 2 to 5 days
- Children can have ostomies as well.
Don’t cut corners, find someone to help if you don’t think you’ll cut it so ask the nurse to give you guidance.