Chapter 47: Bowel Elimination Notes

Chapter 47: Bowel Elimination

🧠 Slide 2 – Scientific Knowledge Base

This slide introduces the organs involved in digestion and bowel elimination. Here's a beginner-friendly breakdown:

🔄 Major Organs in the Process of Bowel Elimination:

1. Mouth – Where digestion begins. Saliva breaks down food.

2. Esophagus – A tube that moves food from the mouth to the stomach.

3. Stomach – Mixes food with acids and enzymes to start digestion.

4. Small Intestine – Absorbs nutrients from digested food.

5. Large Intestine – Absorbs water and forms stool (poop).

6. Anus – The opening where stool leaves the body.

7. Defecation – The process of eliminating stool from the rectum through the anus.

📝 Quick Tip:

Think of the GI tract as a long tunnel. Food enters through the mouth and exits as waste through the anus, with nutrients getting absorbed along the way.

🚽 Slide 4–5 – Factors Influencing Bowel Elimination

These are the things that affect how we poop — simple as that!

🔑 Factors That Influence Bowel Elimination:

1. Age

   • Babies: Underdeveloped control.

   • Elderly: Slower GI movement → constipation risk.

2. Diet

   • High fiber (veggies, fruits, whole grains) = better bowel movements.

   • Low fiber/junk food = constipation.

3. Fluid Intake

   • More water = softer stool.

   • Dehydration = hard, dry stool.

4. Physical Activity

   • Movement (walking, exercise) helps bowel function.

   • Inactivity slows things down.

5. Psychological Factors

   • Stress = diarrhea or constipation.

   • Depression = slowed bowels.

6. Personal Habits

   • Ignoring the urge to go = constipation.

   • Daily routines help regularity.

7. Position During Defecation

   • Squatting/sitting upright helps.

   • Lying down or poor posture makes it harder.

8. Pain

   • Pain (from hemorrhoids, surgery, etc.) can make people avoid going.

9. Pregnancy

   • Baby presses on intestines = constipation.

   • Hormones slow GI movement.

10. Surgery & Anesthesia

• Slows bowel movement for a while after surgery.

11. Medications

• Some meds = constipation (e.g., opioids).

• Others = diarrhea (e.g., antibiotics).

12. Diagnostic Tests

• Some tests require bowel prep (like colonoscopies), which affect elimination.

📝 Simple Summary:
Your poop habits can change depending on age, what you eat and drink, how active you are, stress, pain, pregnancy, meds, or even surgery.

🚫💩 Slide 6 – Common Bowel Elimination Problems

These are the most common poop-related issues patients might face:

1. Constipation

• Hard, dry, or infrequent stool.

• Can happen from:

  • Not enough fiber or fluids

  • Inactivity

  • Ignoring the urge to go

  • Certain medications (like opioids)

2. Diarrhea

• 💧 Frequent, loose, or watery stools.

• Can lead to dehydration.

• Causes:

  • Infection

  • Food intolerance

  • Stress

  • Antibiotics

3. Incontinence

• 🚽 Inability to control bowel movements.

• May result in accidents.

• Causes:

  • Muscle or nerve damage

  • Severe diarrhea

  • Cognitive issues

4. Flatulence

• 💨 Excess gas in the intestines.

• Leads to bloating and discomfort.

• Caused by:

  • Swallowed air

  • Certain foods (beans, cabbage)

  • Constipation

5. Hemorrhoids

• 🔴 Swollen blood vessels in or around the anus.

• Can cause pain, bleeding, and itching.

• Often related to:

  • Straining during pooping

  • Chronic constipation

  • Pregnancy

📝 Quick Tip: These are common in hospital patients, so nurses need to know how to identify, prevent, and manage them.

🔄 Slide 7 – Bowel Diversions & Other Procedures

These are surgical changes made to how stool leaves the body — often due to disease or injury.

🚨 Bowel Diversions:

Ostomies

• A surgical opening created in the abdomen to allow stool to exit the body.

• The opening is called a stoma.

• Types:

  • Colostomy – part of the large intestine (colon) is brought to the surface.

  • Ileostomy – part of the small intestine (ileum) is brought to the surface.

• Stool is collected in a pouch attached to the skin.

📝 Used for: Colon cancer, bowel obstruction, injury, or inflammatory diseases like Crohn’s.

🛠 Other Procedure:

🔄 Ileoanal Pouch Anastomosis

• A surgical procedure that removes the colon and creates a pouch from the small intestine.

• This pouch is attached to the anus, allowing more normal defecation without a permanent ostomy.

• Often used for ulcerative colitis or familial polyposis.

📌 Reminder: Patients with bowel diversions need special care, especially with:

• Skin around the stoma

• Pouching techniques

• Nutrition

• Emotional support

🧠 Slide 8 – Critical Thinking in Bowel Elimination

This slide reminds nurses to think deeply and make smart, patient-centered decisions when caring for someone with bowel problems.

💡 What to Keep in Mind:

1. Use knowledge from different areas

   • Combine what you know from nursing, science, psychology, and even your own experience to understand how the patient is feeling and responding.

2. Experience helps

   • The more you work with patients who have bowel issues, the better you’ll get at creating effective care plans.

3. Practice critical thinking skills like:

   • Fairness – Don’t judge; listen to your patient.

   • Confidence – Trust your knowledge and decision-making.

   • Discipline – Stay focused, organized, and detail-oriented.

4. Follow standards of care

   • Use evidence-based guidelines and your nursing training when choosing what actions to take.

📝 Nursing Tip:
Critical thinking isn’t just knowing what to do — it’s about why you’re doing it, how it affects your patient, and what you can do better.

🧠 Slide 9 – More on Critical Thinking (continued)

Although the slide title isn't repeated, this content expands on critical thinking from Slide 8. Here's the simplified breakdown of what it says:

🧠 How Critical Thinking Helps in Bowel Elimination Care:

1. Use your experience

   • If you’ve worked with patients who had bowel issues before, use what you’ve learned from them to guide your care now.

2. Create a care plan that fits the patient

   • Not all patients are the same. Think about what's best for THIS specific patient (their age, habits, pain, meds, etc.).

3. Think like a nurse

   • Use your critical thinking "attitudes" like:

     • Fairness – Treat every patient equally.

     • Confidence – Trust yourself and your training.

     • Discipline – Stay focused and careful with every step you take.

4. Apply professional standards

   • Follow proper nursing guidelines when choosing what interventions or treatments to use (like choosing the right type of enema, or when to notify the provider).

📝 Key Reminder:
Critical thinking = Not just what you do, but why you do it — always with the patient in mind.

Assessment + Nursing Diagnosis (Slides 12 & 13)

🔍 Step 1 of the Nursing Process: Assessment

This is where you gather information about the patient's bowel habits and health.

What to Assess:

1. Through the Patient’s Eyes👀

   • Ask the patient how they feel about their bowel patterns.

   • Respect their privacy, embarrassment, and concerns.

   • Example questions:

     • "How often do you usually have a bowel movement?"

     • "Have you noticed any changes recently?"

2. Nursing History📖

   • Bowel routine (how often they go)

   • Diet & fluid intake

   • Activity level

   • Medications

   • Past or current issues (constipation, diarrhea, pain)

3. Environmental Factors🏡

   • Can they access a toilet easily?

   • Do they avoid going because of lack of privacy?

4. Physical Assessment👄👀

   • Mouth: Look for issues that affect eating (dentures, sores).

   • Abdomen: Inspect, listen, and feel for:

     • Distention (swelling)

     • Tenderness

     • Abnormal bowel sounds

5. Lab Tests & Diagnostics

   • Fecal Specimens: To check for:

     • Blood in stool (hidden or visible)

     • Parasites

     • Infection

   • Diagnostic Exams: Like colonoscopy or x-ray to see the GI tract.

🧠 Step 2 of the Nursing Process: Analysis & Nursing Diagnosis

Now that you have the information, identify the nursing problems.

⚠ Common Nursing Diagnoses:

1. Constipation

   • Hard, dry stools; fewer bowel movements than normal.

2. Fecal Impaction

   • Stool is stuck and may need to be manually removed.

3. Bowel Incontinence

   • Inability to control when the patient poops.

4. Impaired Defecation

   • Problems with the muscles or nerves that help with pooping.

5. Lack of Knowledge of Dietary Regime

   • Patient doesn’t know which foods or fluids affect their bowel health.

📝 Tip for Clinical Judgment:
Use your findings to create personalized care plans. Every patient is different, so think critically about why they’re having the issue and what you can do about it.

🗂 Slide 14 – Planning and Outcome Identification

This is Step 3 in the Nursing Process: After figuring out the problem, now we plan what we want to happen and how we’ll get there.

🎯 Planning Goals (Outcomes):

• Set realistic, patient-centered goals.

• Example:

  • “Patient will have a soft, formed bowel movement within 24 hours.”

  • “Patient will verbalize understanding of a high-fiber diet by end of shift.”

⏳ Setting Priorities:

• What’s most important right now?

  • Example: A patient with fecal impaction needs help before a patient who’s just asking diet questions.

• Use Maslow’s hierarchy (safety, elimination, etc.) to guide urgency.

🤝 Teamwork and Collaboration:

• Work with:

  • Dietitians (for high-fiber diets)

  • Doctors (for medications like laxatives or enemas)

  • CNAs (to help position or ambulate the patient)

  • WOC nurses (for patients with ostomies)

📝 Quick Tip:
Make sure goals are SMART:

• Specific

• Measurable

• Achievable

• Realistic

• Time-based

📝 Quick Tip: Make Your Goals SMART

Set goals that are:

• Specific – Clearly states what will happen

• Measurable – You can track progress or results

• Achievable – Realistic for the patient

• Realistic – Fits the patient's condition and resources

• Time-based – Has a clear deadline

✅ SMART Goal Example:

“The patient will have one soft, formed bowel movement within 24 hours of receiving a prescribed stool softener.”

• Specific: One soft, formed bowel movement

• Measurable: We can observe and document it

• Achievable: With stool softener and hydration, it's realistic

• Realistic: Matches the patient's current issue (constipation)

• Time-based: Must happen within 24 hours

💡 Slide 15 – Implementation: Health Promotion

This is Step 4 of the Nursing Process: You take action to help the patient reach their goals — especially focusing on preventing problems and keeping bowel function normal.

🥗 1. Promotion of Normal Defecation

Nurses can help patients poop regularly by encouraging:

• Proper diet

  • High in fiber (fruits, veggies, whole grains)

• Adequate fluid intake

  • Encourage 1.5–2 L per day (unless restricted)

• Physical activity

  • Even light movement helps bowel function

• Routine

  • Set a schedule for using the toilet (e.g., after meals)

• Privacy & comfort

  • Provide a quiet, relaxed space to go

• Correct positioning

  • Sitting upright (or squatting position) helps stool move out easier

🎗 2. Colorectal Cancer Risk Reduction

Educate patients about:

• Screenings (colonoscopy usually starts at age 45–50)

• Warning signs:

  • Blood in stool

  • Unexplained weight loss

  • Changes in bowel habits

• Healthy lifestyle habits to reduce risk:

  • Eat fiber

  • Stay active

  • Limit red/processed meat

  • Don’t smoke or overuse alcohol

📝 Nursing Tip:
Health promotion isn’t just about fixing problems — it’s also about preventing them and teaching patients how to stay healthy.

🛏 Slide 16 – Implementation: Acute Care

This section is about hands-on nursing care for patients currently dealing with bowel elimination issues.

1. Positioning Patients on a Bedpan

• For patients who can’t walk to the bathroom:

  • Raise head of bed 30–45° if possible (helps gravity and comfort).

  • Keep knees slightly bent, feet flat if possible.

  • Use gloves and provide privacy.

• Never leave a patient flat on a bedpan — it’s uncomfortable and can make it harder to poop.

💊 2. Medications That Help with Bowel Elimination

a. Cathartics and Laxatives (table 47.2 on the book)

• Help move stool through the intestines.

• Types:

  • Bulk-forming (e.g., Metamucil)

  • Stimulant (e.g., Dulcolax)

  • Osmotic (e.g., Milk of Magnesia)

  • Stool softeners (e.g., Colace)

💡 Used for constipation, post-surgery, or immobility.

b. Antidiarrheal Agents

• Help slow down bowel movements.

• Example: Loperamide (Imodium)

• Used when a patient has frequent, watery stools (diarrhea), but only if not caused by infection.

📝 Nursing Tip:
Always assess the cause of bowel problems before giving meds — for example, you don’t want to stop diarrhea caused by an infection.

💉 Slide 18 – Enemas (Part of Acute Care Implementation)

An enema is a solution inserted into the rectum to stimulate stool passage. It helps relieve constipation or clear the bowel before a procedure.

1. Cleansing Enemas

These remove feces from the colon.

Common Types:

• Tap Water (Hypotonic)

  • Stimulates bowel movement by stretching the colon.

  • Use with caution – can cause water toxicity if repeated.

• Normal Saline (Isotonic)

  • Safest for children and older adults.

  • Mimics body fluids → no water shifts.

• Hypertonic Solutions

  • Pull water into colon to stimulate stool.

  • Small volume (good for patients who can’t tolerate large ones).

  • Avoid in dehydrated patients.

• Soapsuds Enema

  • Made by adding castile soap to water or saline.

  • Irritates colon → triggers defecation.

  • May cause irritation if overused.

🛢 2. Other Types of Enemas

• Oil Retention

  • Lubricates the rectum and softens stool.

  • Must be retained for 30–60 minutes before passing.

• Carminative

  • Used to relieve gas (flatulence).

• Kayexalate Enema

  • Removes potassium from the body (used for patients with high potassium levels, like in kidney failure).

📝 Nursing Tip:
Always assess:

• When the patient last had a BM

• Abdominal distention or pain

• If they have any cardiac issues (vagal stimulation can cause bradycardia)

🚨 Slide 19 – IMPLEMENTATION More Acute Care: Enemas, NG Tubes, and Incontinence

These are more hands-on interventions nurses use when patients have serious bowel problems.

💧 1. Enema Distribution

• Make sure the patient is in the left side-lying (Sims') position — this allows the enema to flow into the sigmoid colon.

• Insert enema 2.5- 3 inches into rectum (adult).

• hold the bag at a height of 12 to 18 inches above the level of the rectum to facilitate gravity flow and ensure effective administration.

• Go slow with fluid — too fast can cause cramping.

• Encourage the patient to hold it in for as long as they can (ideally 5–10 minutes).

✋ 2. Digital Removal of Stool

• Used only if fecal impaction can't be cleared any other way.

• Procedure:

  • it needs a doctor's order

  • Gently insert a gloved, lubricated finger into the rectum to break up stool.

  • Monitor for signs of vagal response (↓ heart rate, faintness).

• It’s uncomfortable, so explain the process and get permission first.

🤢 3. Inserting & Maintaining a Nasogastric (NG) Tube

• NG tubes are used to:

  • Remove stomach contents (like in bowel obstruction)

  • Decompress the GI tract

• Nursing care:

  • Confirm placement with x-ray first.

  • Secure the tube to the nose.

  • Keep the patient’s head of bed elevated (at least 30°) to prevent aspiration.

  • Monitor for nausea, vomiting, or blockage.

💩 4. Managing Fecal Incontinence or Diarrhea

• Prevent skin breakdown (clean thoroughly & apply barrier creams).

• Monitor fluid and electrolyte levels.

• Promote a low-fiber diet (temporarily) to slow bowel movements.

• Document frequency, consistency, and amount of stool.

📝 Nursing Tip:
Always protect your patient’s dignity and skin — bowel issues can be embarrassing, but good care makes all the difference.

🌀 Slide 20 - IMPLEMENTATION

Continuing and Restorative Care: Ostomy Management

This focuses on patients who have a stoma (ostomy) — a surgically created opening that allows stool to leave the body through the abdomen.

1. Care of Patients with Ostomies

• Be gentle, respectful, and supportive — body image and emotions are often affected.

• Observe the stoma:

  • Should look pink or red and moist.

  • Report if it’s pale, blue, or has signs of infection.

🚿 2. Irrigating a Colostomy

• Similar to an enema, but done through the stoma (only for some colostomies — not ileostomies).

• Helps create a predictable bowel routine.

• Use a cone-tip irrigator and warm water.

👜 3. Pouching Ostomies

• Use an ostomy appliance (bag) to collect stool.

• Tips:

  • Empty when 1/3 to 1/2 full.

  • Change the entire pouch every 3–7 days or when it leaks.

  • Measure the stoma and cut the skin barrier 1/8 inch larger than stoma size.

🥗 4. Nutritional Considerations

• Teach the patient to avoid foods that cause:

  • Gas (beans, cabbage)

  • Odor (eggs, onions, garlic)

• Encourage small, frequent meals and lots of fluids.

• Chew food well to prevent blockage (especially with ileostomies).

❤ 5. Psychological Considerations

• Patients may feel embarrassed or depressed.

• Encourage:

  • Open conversation

  • Support groups

  • Body-positive language

• Involve a WOC (Wound Ostomy Continence) nurse for specialized support.

📝 Nursing Tip:
A little education and emotional support goes a long way. Patients with ostomies can live full, healthy lives — and you can help them feel confident again.

🔄 Slide 21 – Bowel Training & Ongoing Care

This part of implementation focuses on helping patients get regular and maintain healthy bowel function — especially after illness, surgery, or chronic issues.

🕐 1. Bowel Training

• Goal: Help the patient have regular, predictable bowel movements.

• How to do it:

  • Set a regular time to try (usually after meals).

  • Encourage sitting on the toilet for 15–20 minutes.

  • Use techniques like:

    • Privacy

    • Gentle abdominal massage

    • Warm fluids to stimulate movement

💧 2. Proper Fluid and Food Intake

• Encourage:

  • 2–3 liters of fluid/day (unless restricted).

  • A high-fiber diet: fruits, veggies, whole grains.

• Teach patients what foods cause constipation or diarrhea for them personally.

🏃‍♂ 3. Promote Regular Exercise

• Physical movement stimulates bowel activity.

• Even simple walking helps.

• Encourage activity based on the patient’s ability.

4. Maintain Skin Integrity

• Especially important for:

  • Patients with diarrhea

  • Incontinence

  • Ostomies

• Use:

  • Barrier creams

  • Gentle cleansing

  • Frequent skin checks

📝 Nursing Tip:
Restorative care is about teaching and empowering your patient to care for themselves safely and confidently.

✅ Slide 22 – Evaluation

This is Step 5 of the Nursing Process: After you’ve done your interventions, now it’s time to see if they worked!

1. Through the Patient’s Eyes

• Ask the patient:

  • “How do you feel about your bowel routine now?”

  • “Was the plan comfortable and helpful?”

• Always include their feedback and experience in your evaluation.

📊 2. Patient Outcomes

• Did the goals you set actually happen? If not:

  • What can be changed?

  • Should you try a different intervention?

✅ How to Know if It Worked:

• Constipated patient had a BM? ✔

• Diarrhea is under control? ✔

• Patient is using an ostomy bag independently? ✔

• Skin is intact? ✔

• Patient verbalizes understanding of high-fiber foods? ✔

📝 Nursing Tip:
Evaluation isn’t the end — it’s a loop. If the outcome wasn’t met, go back, reassess, and update the care plan. 💡

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