Fecal Elimination Notes

Physiology of Defecation

  • Defecation, also known as a bowel movement, is the expulsion of feces from the anus and rectum.

  • Frequency varies from several times a day to two or three times per week.

  • Sensory nerves are stimulated when feces reach the sigmoid colon and rectum, creating awareness of the need to defecate.

  • The internal anal sphincter relaxes, and feces move into the anal canal.

  • Voluntary relaxation of the external anal sphincter occurs when seated on a toilet or bedpan.

  • Expulsion is aided by:

    • Contraction of abdominal muscles and the diaphragm (increases abdominal pressure).

    • Contraction of pelvic floor muscles (moves feces through the anal canal).

Normal and Abnormal Characteristics of Feces

  • Normal defecation is facilitated by:

    • Thigh flexion (increases abdominal pressure).

    • Sitting position (increases downward pressure on the rectum).

  • The urge to defecate may disappear temporarily if the defecation reflex is ignored or consciously inhibited.

  • Repeated inhibition can lead to:

    • Rectal expansion.

    • Loss of sensitivity to the need to defecate.

    • Constipation.

Feces Composition

  • Normal feces: 75% water, 25% solid materials; soft but formed.

  • Rapid transit through the large intestine results in more fluid feces (approximately 95% water), as there's less time for water reabsorption.

  • Insufficient fluid intake leads to hard, difficult-to-expel feces.

  • Brown color is due to stercobilin and urobilin, derived from bilirubin.

  • Bacteria like Escherichia coli and staphylococci influence fecal color.

  • Normal gas passage: 13 to 21 times a day.

  • Gas sources:

    • Swallowed air.

    • Bacterial action on chyme.

    • Diffusion from blood into the gastrointestinal tract.

Table 49-1: Characteristics of Normal and Abnormal Feces

  • Color:

    • Normal:

      • Adult: Brown

      • Infant: Yellow

    • Abnormal:

      • Clay or white: Absence of bile pigment (bile obstruction); diagnostic study using barium

      • Black or tarry: Drug (e.g., iron); bleeding from upper gastrointestinal tract; diet high in red meat and dark green vegetables

      • Red: Bleeding from lower gastrointestinal tract; some foods (e.g., beets)

      • Pale: Malabsorption of fats; diet high in milk and milk products and low in meat

      • Orange or green: Intestinal infection

  • Consistency:

    • Normal: Formed, soft, semisolid, moist

    • Abnormal:

      • Hard, dry: Dehydration; decreased intestinal motility resulting from lack of fiber in diet, lack of exercise, emotional upset, laxative abuse

      • Diarrhea: Increased intestinal motility (e.g., due to irritation of the colon by bacteria)

  • Shape:

    • Normal: Cylindrical (contour of rectum), about 2.5 cm (1 in.) in diameter in adults

    • Abnormal: Narrow, pencil-shaped, or stringlike stool: Obstructive condition of the rectum

  • Amount: Varies with diet (about 100-400 g/day)

  • Odor: Aromatic; affected by ingested food and individual's own bacterial flora; Pungent - Infection, blood

  • Constituents:

    • Normal: Small amounts of undigested roughage, sloughed dead bacteria and epithelial cells, fat, protein, dried constituents of digestive juices (e.g., bile pigments, inorganic matter)

    • Abnormal:

      • Pus: Bacterial infection

      • Parasites: Inflammatory condition

      • Blood: Gastrointestinal bleeding

      • Large quantities of fat: Malabsorption

      • Foreign objects: Accidental ingestion

Factors Affecting Defecation

  • Development:

    • Newborns and Infants:

      • Meconium: First fecal material passed, black, tarry, odorless, and sticky, up to 24 hours after birth.

      • Transitional stools: Greenish yellow, contain mucus, and are loose, following meconium for about a week.

      • Frequent stools: Often after each feeding due to immature intestine and poor water absorption.

    • Older Adults:

      • Constipation: Common due to reduced activity, inadequate fluid and fiber intake, and muscle weakness.

  • Diet:

    • Fiber: Sufficient bulk is necessary for fecal volume.

    • Inadequate fiber: Contributes to obesity, type 2 diabetes, coronary artery disease, and colon cancer.

    • Types of Fiber:

      • Insoluble fiber: Promotes movement through the digestive system and increases stool bulk (e.g., whole-wheat flour, wheat bran, nuts, and many vegetables).

    • Irregular eating impairs regular defecation.

  • Fluid Intake and Output:

    • Inadequate fluid intake: Leads to drier chyme, resulting in hard feces.

    • Reduced fluid intake slows chyme passage, further increasing fluid reabsorption.

    • Healthy elimination: Requires 2,000 to 3,000 mL daily.

  • Activity:

    • Stimulates peristalsis, facilitating chyme movement.

    • Weak muscles from lack of exercise or immobility can cause constipation.

  • Psychological Factors:

    • Anxiety/anger: Increased peristaltic activity and diarrhea.

    • Depression: Slowed intestinal motility and constipation.

  • Defecation Habits:

    • Regular bowel training establishes regular defecation time.

    • Gastrocolic reflex: Causes mass peristaltic waves after breakfast.

    • Ignoring the urge leads to water reabsorption, making feces hard and difficult to expel.

  • Medications:

    • Side effects can interfere with normal elimination.

    • Tranquilizers, morphine, and codeine cause constipation by decreasing gastrointestinal activity.

    • Iron supplements cause constipation or diarrhea.

    • Laxatives stimulate bowel activity.

  • Diagnostic Procedures:

    • Restrictions prior to procedures (e.g., colonoscopy): Food and fluid restrictions.

    • Cleansing enema may be administered.

    • Normal defecation resumes after eating resumes.

  • Anesthesia and Surgery:

    • General anesthetics slow colonic movements by blocking parasympathetic stimulation.

    • Post-surgery assessment: Listening for bowel sounds.

  • Pathologic Conditions:

    • Spinal cord injuries and head injuries: Decrease sensory stimulation for defecation.

  • Pain:

    • Discomfort during defecation (e.g., hemorrhoid surgery): Suppressing the urge can cause constipation.

    • Narcotic analgesics: Can cause constipation.

Fecal Elimination Problems

  • Common problems: Constipation, fecal impaction, diarrhea, bowel incontinence, and flatulence.

  • Constipation:

    • Fewer than three bowel movements per week.

    • Passage of dry, hard stool or no stool.

    • Slow movement of feces through the large intestine, allowing additional fluid reabsorption.

    • Associated with difficult evacuation, increased effort, or straining.

    • Feeling of incomplete stool evacuation.

    • Causes and Factors:

      • 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 (depression or mental confusion).

      • Medications (opioids, iron supplements, antihistamines, antacids, and antidepressants).

      • Habitual denial and ignoring the urge to defecate.

  • Fecal Impaction:

    • Mass or collection of hardened feces in the folds of the rectum.

    • Results from prolonged retention and accumulation of fecal material.

    • Severe impactions extend into the sigmoid colon and beyond.

    • Symptoms: Passage of liquid fecal seepage (diarrhea) without normal stool.

    • Assessment: Digital examination of the rectum to palpate the hardened mass.

    • Other symptoms: Frequent but nonproductive desire to defecate, rectal pain, anorexia, abdominal distention, nausea, and vomiting.

    • Causes: Poor defecation habits, constipation, medications (anticholinergics and antihistamines), and barium from radiologic examinations.

  • Diarrhea:

    • Passage of liquid feces and increased frequency of defecation.

    • Results from rapid movement of fecal contents through the large intestine.

    • Reduced time for water and electrolyte reabsorption.

    • Symptoms: Difficult or impossible to control the urge to defecate, spasmodic cramps, increased bowel sounds.

    • Prolonged diarrhea: Fatigue, weakness, malaise, and emaciation.

    • Irritation of the anal region: Increases risk for skin breakdown.

    • Management: Keep area clean and dry, protect with zinc oxide or other ointment.

Table 49-2: Major Causes of Diarrhea

  • Psychological stress (e.g., anxiety): Increased intestinal motility and mucous secretion

  • Medications:

    • Antibiotics: Inflammation and infection of mucosa due to overgrowth of pathogenic intestinal microorganisms

    • Iron: Irritation of intestinal mucosa

    • Cathartics: Irritation of intestinal mucosa

  • Allergy to food, fluid, drugs: Incomplete digestion of food or fluid.

  • Intolerance of food or fluid: Increased intestinal motility and mucous secretion

  • Diseases of the colon (e.g. malabsorption syndrome, Crohn's disease): Inflammation of the mucosa often leading to ulcer formation, Reduced absorption of fluids

  • Bowel Incontinence:

    • Also called fecal incontinence.

    • Loss of voluntary ability to control fecal and gaseous discharges.

    • May occur at specific times or irregularly.

    • Types:

      • Partial incontinence: Inability to control flatus or prevent minor soiling.

      • Major incontinence: Inability to control feces of normal consistency.

    • Associated with impaired functioning of the anal sphincter or its nerve supply (neuromuscular diseases, spinal cord trauma, and tumors).

  • Flatulence:

    • Sources:

      1. Action of bacteria on chyme in the large intestine.

      2. Swallowed air.

      3. Gas that diffuses between the bloodstream and the intestine.

    • Swallowed gases expelled through eructation (belching), otherwise accumulate in the stomach (gastric distention).

    • Intestinal gases absorbed through intestinal capillaries into the circulation.

    • Flatulence: Excessive flatus in the intestines, leading to intestinal distention.

    • Causes: Foods (cabbage, onions), abdominal surgery, or narcotics.

    • Management: Rectal tube insertion if excessive gas cannot be expelled.

Bowel Diversion Ostomies

  • Ostomy: Opening for the gastrointestinal, urinary, or respiratory tract onto the skin.

  • Types of intestinal ostomies:

    • Gastrostomy: Opening through the abdominal wall into the stomach (alternate feeding route)

    • Jejunostomy: Opens through the abdominal wall into the jejunum (alternate feeding route).

    • Ileostomy: Opens into the ileum (small bowel); divert and drain fecal material

    • Colostomy: Opens into the colon (large bowel); divert and drain fecal material

  • Classifications of Bowel Diversion Ostomies:

    1. Status: Permanent or temporary.

    2. Anatomic location.

    3. Construction of the stoma.

  • Stoma appearance: Red, moist, and may bleed slightly when touched (normal). No nerve endings in the stoma.

  • Permanence:

    • Colostomies: Temporary or permanent.

    • Temporary: For traumatic injuries or inflammatory conditions, allowing the bowel to rest and heal.

    • Permanent: For nonfunctional rectum or anus due to birth defects or diseases (cancer of the bowel).

  • Anatomic Location:

    • Ileostomy: Empties from the distal end of the small intestine.

    • Cecostomy: Empties from the cecum.

    • Ascending colostomy: Empties from the ascending colon.

    • Transverse colostomy: Empties from the transverse colon.

    • Descending colostomy: Empties from the descending colon.

    • Sigmoidostomy: Empties from the sigmoid colon.

Figure 49-4: The locations of bowel diversion ostomies.

  • Character and management of fecal drainage depend on ostomy location.

  • The farther along the bowel, the more formed the stool and the more control over stomal discharge.

  • Ileostomy: Liquid fecal drainage (constant and unregulated), contains digestive enzymes damaging to the skin. Requires continuous appliance use.

  • Ascending colostomy: Similar to ileostomy, liquid and unregulated drainage, digestive enzymes present, odor control is a problem.

  • Transverse colostomy: Malodorous, mushy drainage due to some liquid reabsorption. Usually no control.

  • Descending colostomy: Increasingly solid fecal drainage.

  • Sigmoidostomy: Normal or formed consistency stools, regulated discharge frequency. May not require appliance at all times, odors can usually be controlled.

  • Stool becomes more formed over time due to increased water reabsorption in the remaining functioning colon.

  • Surgical Construction of the Stoma

    • Descriptions: single, loop, divided, or double-barreled colostomies.

    • Single stoma: One end of bowel brought out onto the anterior abdominal wall (end or terminal colostomy), permanent.

    • Loop colostomy: A loop of bowel is brought out onto the abdominal wall and supported by a plastic bridge or by a piece of rubber tubing. Has two openings: proximal (active) and distal (inactive).
      Figure 49–6 ■: Loop colostomy

    • Divided colostomy: 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.
      Figure 49–7 ■: Divided colostomy with two separated stomas.

    • Double-barreled colostomy: 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.
      Figure 49–8 ■: Double-barreled colostomy.

Nursing Management

  • Assessment:

    • Nursing history: Ascertain the client’s normal pattern, usual feces, and any recent changes; past or current problems with elimination, ostomy presence, and factors influencing the elimination pattern.

    • Physical examination: Abdomen, rectum, and anus inspection.
      *Inspecting the Feces: Observe the client’s stool for color, consistency, shape, amount, odor, and the presence of abnormal constituents.

    • Diagnostic studies: Direct and indirect visualization techniques, and laboratory tests for abnormal constituents

Examples of Nursing Diagnoses:

  • NANDA International includes the following diagnostic labels for fecal elimination problems:

    • Bowel Incontinence

    • Constipation

    • Risk for Constipation

    • Perceived Constipation

    • Diarrhea

    • Dysfunctional Gastrointestinal Motility

  • Fecal elimination problems may affect human functioning and be the etiology of other NANDA diagnoses:

    • Risk for Deficient Fluid Volume and/or Risk for Electrolyte Imbalance related to prolonged diarrhea or abnormal fluid loss through ostomy.

    • Risk for Impaired Skin Integrity related to prolonged diarrhea, bowel incontinence, or bowel diversion ostomy.

    • Situational Low Self-Esteem related to ostomy, fecal incontinence, or need for assistance with toileting.

    • Disturbed Body Image related to ostomy or bowel incontinence.

    • Deficient Knowledge (Bowel Training, Ostomy Management) related to lack of previous experience.

    • Anxiety related to lack of control of fecal elimination secondary to ostomy or response of others to ostomy.

Measures That Maintain Normal Fecal Elimination Patterns

  • Implementing:

    • Promoting Regular Defecation: By provision of privacy, timing, nutrition and fluids, exercise, and positioning.

    • Client Teaching: Healthy Defecation

      • Establish a regular exercise regimen.

      • Include high-fiber foods, such as vegetables, fruits, and whole grains, in the diet.

      • Maintain fluid intake of 2,000 to 3,000 mL/day.

      • Do not ignore the urge to defecate.

      • Allow time to defecate, preferably at the same time each day.

      • Avoid OTC medications to treat constipation and diarrhea.

  • For Constipation:

    • Increase daily fluid intake: Hot liquids, warm water with lemon, and fruit juices (prune juice).

    • Include fiber in the diet: Raw fruit, bran products, whole-grain cereals, and bread.

  • For Diarrhea:

    • Encourage oral intake of fluids and bland food: Small amounts are more easily absorbed.

    • Avoid excessively hot or cold fluids because they stimulate peristalsis. In addition, highly spiced foods and high fiber foods can aggravate diarrhea.

  • For Flatulence:

    • Limit carbonated beverages, drinking straws, and chewing gum (increase air ingestion).

    • Avoid gas-forming foods: Cabbage, beans, onions, and cauliflower.

Client Teaching Managing Diarrhea
* Drink at least 8 glasses of water per day to prevent dehydration.
* Consider drinking a few glasses of electrolyte replacement fluids a day.
* Eat foods with sodium and potassium. Most foods contain sodium. Potassium is found in meats and many vegetables and fruits, especially purple grape juice, tomatoes, potatoes, bananas, cooked peaches, and apricots.
* Increase foods containing soluble fiber, such as rice, oatmeal, and skinless fruits and potatoes.
* Avoid alcohol and beverages with caffeine, which aggravate the problem.
* Limit foods containing insoluble fiber, such as high-fiber whole-wheat and whole-grain breads and cereals, and raw fruits and vegetables.
* Limit fatty foods.
* Thoroughly clean and dry the perianal area after passing stool to prevent skin irritation and breakdown. Use soft toilet tissue to clean and dry the area. Apply a dimethicone-based cream or alcohol-free barrier film as needed.
* If possible, discontinue medications that cause diarrhea.
* When diarrhea has stopped, reestablish normal bowel flora by eating fermented dairy products, such as yogurt or buttermilk.
* Seek a primary care provider consultation right away if weakness, dizziness, or loose stools persist more than 48 hours.

  • Exercise

  • Regular exercise: Helps clients develop a regular defecation pattern.

    • Isometric exercises to strengthen abdominal and pelvic muscles:

      • Supine position: Tighten abdominal muscles, hold for 10 seconds, relax. Repeat 5 to 10 times, four times a day.

      • Supine position: Contract thigh muscles, hold for 10 seconds, repeat 5 to 10 times, four times a day.

  • Positioning

    • Squatting position best facilitates defecation. On a toilet seat, leaning forward is best.

    • Elevated toilet seat: Eases sitting down and getting up.

    • Bedside commode: Portable chair with a toilet seat and receptacle for those who can get out of bed but cannot walk to the bathroom. Clients who are restricted to bed may need to use a bedpan.

  • Teaching About Medications

    • Common categories affecting fecal elimination: Cathartics and laxatives, antidiarrheals, and antiflatulents.

    • Cathartics: Drugs that induce defecation with a strong, purgative effect.

    • Laxatives: Milder than cathartics, produce soft or liquid stools, sometimes with abdominal cramps. Examples of cathartics castor oil, cascara.

  • Administering Enemas
    *Enema: A solution introduced into the rectum and large intestine. The action of an enema is to distend the intestine and sometimes to irritate the intestinal mucosa, thereby increasing peristalsis and the excretion of feces and flatus.

    • Enema solution temperature: 37.7°C (100°F).

    • Enema classifications: Cleansing, carminative, retention, and return-flow enemas.

  • Cleansing Enema:

    • Intended to remove feces; given chiefly to:

      • Prevent the escape of feces during surgery.
        *Prepare the intestine for certain diagnostic tests such as x-ray or visualization tests (e.g., colonoscopy).

      • Remove feces in instances of constipation or impaction.

    • Volume:

      • Large volume: 500 to 1,000 mL (adults).

      • Small volume: 90 to 120 mL.

    • Types:

      • High enema: Cleanses as much of the colon as possible. Client changes positions (left lateral, dorsal recumbent, right lateral).

      • Low enema: Cleans the rectum and sigmoid colon only. Client maintains a left lateral position.

Table 49-4: Commonly Used Enema Solutions

  • Hypertonic: 90-120 mL of solution (e.g., sodium phosphate [Fleet]). draws water into the colon. Takes 5-10 min to take effect. Adverse effect is retention of sodium

  • Hypotonic: 500-1,000 mL of tap water. Distends colon, stimulates peristalsis, and softens feces. Takes 15-20 min to take effect. Adverse effects are Fluid and electrolyte imbalance, water intoxication.

  • Isotonic: 500-1,000 mL of normal saline. Distends colon, stimulates peristalsis, and softens feces. Takes 15-20 mm to take effect. Adverse effect is Possible sodium retention

  • Soapsuds: 500-1,000 mL (3-5 mL soap to 1,000 mL water). Irritates mucosa, distends colon. Takes 10-15 min to take effect. Adverse effects are Irritates and may damage mucosa

  • Oil (mineral, olive, cottonseed): 90-120 mL. Lubricates the feces and the colonic mucosa. Takes 0.5-3 h to take effect.

  • Carminative Enema:

    • Given primarily to expel flatus.

    • Solution releases gas, distending the rectum and colon, stimulating peristalsis.

    • Volume: 60 to 80 mL (adults).

  • Retention Enema:

    • Introduces oil or medication into the rectum and sigmoid colon.

    • Retained for a relatively long period (1 to 3 hours).

    • Oil retention enema: Softens feces and lubricates the rectum and anal canal.

    • Antibiotic/anthelmintic/nutritive enemas: Treat infections, kill helminths, administer fluids/nutrients.

  • Return-Flow Enema:

    • Also called a Harris flush; expels flatus.

    • Alternating flow of 100 to 200 mL of fluid into and out of the rectum and sigmoid colon stimulates peristalsis.

    • Repeated five or six times until flatus is expelled and abdominal distention is relieved.

Bowel Training Programs

  • Helpful for clients with chronic constipation, frequent impactions, or fecal incontinence.

  • Based on factors within the client’s control and designed to establish normal defecation.

    • Determine the client’s usual bowel habits and factors that help and hinder normal defecation.

    • Design a plan with the client:

      • Fluid intake: 2,500 to 3,000 mL/day.

      • Increase fiber in the diet.

      • Intake of hot drinks, especially just before the usual defecation time.

  • Maintain the following daily routine for 2 to 3 weeks:

    • Administer a cathartic suppository (e.g., bisacodyl) 30 minutes before the client’s defecation time to stimulate peristalsis.

    • 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.

    • Provide the client with privacy for defecation and a time limit; 30 to 40 minutes is usually sufficient.

    • Teach the client to lean forward at the hips, to apply pressure on the abdomen with the hands, and to bear down for defecation. These measures increase pressure on the colon. Straining should be avoided because it can cause hemorrhoids.

    • Provide positive feedback when the client successfully defecates. Refrain from negative feedback if the client fails to defecate.

    • Offer encouragement to the client and convey that patience is often required. Many clients require weeks or months of training to achieve success.

Stoma and Skin Care

  • Assess peristomal skin for irritation each time the appliance is changed.

  • Treat any irritation or skin breakdown immediately. Keep skin clean and dry.

  • Routine appliance change: Twice weekly.
    *Change the pouch every 24 to 48 hours if the skin is erythematous, eroded, denuded, or ulcerated.

  • Recommended if the client complains of pain or discomfort.

  • Empty the pouch when it is one-third to one-half full.