Elimination

Pattern
Bowel
Elimination

ELIMINATION
Small intestine (22 feet)
digestion and absorption of nutrients, vitamins,
minerals, fluids and electrolytes
Ileocecal valve
controls emptying of contents from small
intestine into the colon

ELIMINATION
Colon(5-6 feet - 59 inches, 1 - 3
inches diameter)
collect, concentrate,
transport and eliminate
waste
cecum, ascending colon,
transverse colon, sigmoid
colon, and anal canal

ELIMINATION
Chyme - waste products of digestion that moves from small
intestine to large intestine; 1,500 mL/day processed by large
intestine, most absorbed in proximal portion of colon - 100
mL in feces

1/3 - 1/2 of ingested food normally excreted in stool

within 24 hours, remainder in next 24 - 48 hours

ELIMINATION
Feces: body waste discharged from the intestine
Peristalsis: the rhythmic smooth muscle
contractions of the intestinal wall that propel the
intestinal contents forward. Q 3-12 times minutes;
mass peristalic sweeps 1-4 times/24 hr.
Flatus: the gas normally found in the GI tract &
passed through the anus

ELIMINATION
Defecation: expulsion of feces from anus and rectum
Moves into sigmoid colon and rectum
Sensory nerves signals need to defecate
Internal sphincter relaxes
Moves into anal canal
External sphincter relaxes voluntarily
Contraction of abdominal muscles and the diaphragm
increases abdominal pressure; contraction of levator
ani muscles pelvic floor

Factors Affecting Bowel Elimination

Lifestyle Factors
Personal Habits:
Daily patterns frequency, regular
time, position, place;
schedule, occupation,
leisure activities affect
pattern; ignore harder expel, urge lost

Factors Affecting Bowel Elimination

Lifestyle Factors
Nutrition & Fluids:
Food (type & amt.) bulk, restricted (bland, low-fiber),
low residue, irregular eating, difficult to digest, spicy,
excessive sugar; lactose intolerance

Factors Affecting Bowel Elimination

Lifestyle Factors
Nutrition & Fluids:
Gas-producing: onions, cabbage, beans, cauliflower
Laxative-producing: fruits & vegetables (eg. Prunes),
bran, chocolate, spicy foods, alcohol, coffee

Factors Affecting Bowel Elimination

Lifestyle Factors
constipationproducing:
processed cheese,
lean meat eggs,
pasta
Fluids - low fluids, hard
feces; healthy fecal
elimination need daily
fluid intake 2000 3000 mL

Factors Affecting Bowel Elimination

Lifestyle Factors
Exercise & muscle tone:
stimulates peristalsis;
weak abdominal
muscles, diaphragm,
and perineal muscles
result in ineffective
abdominal pressure

Factors Affecting Bowel Elimination

Cultural Factors: rules
about when & under
what conditions
defecation can take
place; privacy, avoid
discussion of bowel
activity, anxiety if
forced to seek out
health professional or
avoid seeking help out
of embarrassment

Factors Affecting Bowel Elimination

Developmental Factors:
age plays role in
establishing bowel
patterns
child acquires through
toilet training
infant cannot control:
color, consistency breastfeed versus
formula

Factors Affecting Bowel Elimination

Developmental Factors:
adolescent usually do not have a problem
elderly have vulnerability to GI disturbance
cancer occurs more frequently, diverticulosis occurs
nutritional intake changes - inadequate dentition,
foods not well chewed
reduced digestive enzymes in saliva & gastric acids
lower GI deficiencies in proteins, vitamins, &
minerals
muscular decline and internal/external sphincters not
controlled normally

Factors Affecting Bowel Elimination

Physiological Factors:
Motor & Sensory
Disturbances: spinal
cord, head injury, CVA,
neurological disease, or
any condition that causes
immobility or otherwise
interferes with
motor/sensory stimulation

Factors Affecting Bowel Elimination

Physiological Factors:
Intestinal Pathologies:
cancer, adhesion,
malabsorption syndrome,
diabetic neuropathy,
diverticulosis - blockage;
colitis - hypermotility;
food poisoning

Factors Affecting Bowel Elimination

Physiological
Factors:
Pregnancy:
pressure on rectum,
slows passage of
feces; exertion
cause hemorrhoids;
iron & vitamins
cause constipation

Bowel
Obstruction

Crohns Disease

Peptic Ulcer Disease

Appendicitis

Factors Affecting Bowel Elimination

Physiological Factors:
Medications: constipation, diarrhea common side effect
promote peristalsis: direct effects with laxatives,
cathartics, stool softeners; antibiotics
suppressants motility - antidiarrheal, opioids, antacids
(aluminum), anticholinergic
diarrhea as side effect
change color, i.e. anticoagulant - red, pinkish; iron black stool; antacids - white discoloration; antibiotics
- green-gray with impaired digestion

Factors Affecting Bowel Elimination

Surgical Procedures:
surgery & anesthesia general anesthetics
cause cessation
colonic movements
(paralytic ileus);
handling intestines 24-48 hrs; fecal
diversion - ostomy

Factors Affecting Bowel Elimination

Diagnostic Tests: stress of
hospitalization, wait for
study results, with changes
in food intake, alter usual
elimination pattern; bowel
cleansing for studies
Psychosocial Factors:
anxious, angry results
increased peristalsis diarrhea; depressed,
slower intestinal motility constipation

HISTORY
Pattern of elimination: What is your normal bowel
elimination pattern, including time of day & frequency?
Appearance: What do your feces look like, including
amount, color, consistency, constituents, frequency,
odor, & shape?
Medications: What medications do you take? How
often do you use laxatives or bowel elimination aids?
Has your use of bowel elimination aids changed
recently?
Recent changes in elimination: Have you noticed any
changes in your bowel elimination pattern?

HISTORY
Dietary & fluid intake: What is your normal dietary
intake for a day? Has it changed recently? What is
your normal fluid intake for a day? Has it changed
recently?
Exercise: What kind of exercise or physical activity
do you get? Has it changed recently?
Past or current problems: Have you had any surgery
pertinent to bowel elimination? eg. presence of
ostomies; any problem now - type, onset, causes, S&S
Emotional state: How is your current emotional state?
Is it different from your normal?

ASSESSMENT
Abdominal assessment
Inspection: contour, masses, distention
Auscultation: bowel sounds - absent, 5 minutes
Percussion: identify masses, fluid, air - resonance
palpation: muscular resistance, masses, enlargement
Stool characteristics
Volume
- Constitutents
Color
- Odor
Consistency
- Shape

Problems of Bowel Elimination

Constipation: a condition in which feces are abnormally hard
& dry & evacuation is abnormally infrequent. Less than 3
bowel movements/week
Definition includes: character of stool, frequency of
defecation, time required for passage of stool through the
intestinal tract (intestinal transit time), & difficulty expelling
rectal contents through the anal sphincter
Hazard from Valsalva maneuver - can cause angina pectoris
(chest pain) or even cardiac arrest in cardiac disease;

Problems of Bowel Elimination

Constipation: detrimental to person with head injuries
(increased intracranial pressure), respiratory disease
(increased intrathoracic pressure), or thromboembolic
disorders (cause thrombi to dislodge); contribute to
development of hemorrhoids, disrupt suture line
Causes
Decreased fiber
- Lack of privacy
Decreased fluid
- Emotional disturbance
Decreased activity
- Medication: laxatives,
Irregular habits
antacids, opioids,
Change in daily routine - Pain with defecation

Problems of Bowel Elimination

Fecal impaction: a collection of putty-like or hardened
feces in the rectum or sigmoid colon that prevents the
passage of normal stool & becomes more & more hardened
as the colon continues to absorb water from it
Diarrhea: the rapid movement of fecal material through
the intestine, resulting in poor absorption of water,
nutrients, & electrolytes & producing abnormally frequent
evacuation of watery stools

Problems of Bowel Elimination

increased intestinal motility, rapid transit time,
preventing normal amounts of water from being
removed; irritation of mucosal walls stimulates increased
secretions
Causes:
Stress
Food/drug allergy
Disease:colon
Medication
Food/fluid intolerance
Surgery
Altered flora

Problems of Bowel Elimination

Flatulence: the
presence of abnormal
amounts of gas in the
GI tract, causing
abdominal distention
& discomfort.
Belching: the
expulsion of gas from
the upper GI tract

Problems of Bowel Elimination

Continence: Factors contribute to
Consistency of stool
Intestinal motility
Compliance and contractility of the rectum
Competence of the anal sphincters

Problems of Bowel Elimination

Bowel (fecal) incontinence: the inability to voluntarily
control the passage of feces & gas
Causes:
Dysfunction of anal sphincter
Disorders of the delivery of stool to rectum
Disorders of rectal storage
Anatomic defects -Cognitive impairment
Partial incontinence - inability to control flatus or to
prevent minor soiling
Major incontinence - inability to control feces of normal
consistency

NURSING DIAGNOSIS
Bowel incontinence r/t
Gross constipation with impaction & subsequent
overflow
Local causes (inflammation, cancer of rectum,
prolapsed anus, semifluid stool)
Extreme debilitation
Cognitive impairment

NURSING DIAGNOSIS
Constipation r/t
Decreased fiber in diet
Decreased fluid intake
Inactivity
Delaying defecation when urge is present
Abuse of laxatives
Use of constipating medications (antacids, narcotic
analgesics, anticholinergics)
Change in routine
Pain associated with defectation

NURSING DIAGNOSIS
Risk for constipation r/t
Habitually ignores urge to defecate
Inactivity
Decreased fiber in diet
Inadequate fluid intake
Use of pharmacolgic agents that can result in
constipation (iron, opioids, anticholinergics)
Stress, confusion

NURSING DIAGNOSIS
Perceived constipation r/t
Culture
Family health beliefs
Faulty appraisal
Impaired thought processes

NURSING DIAGNOSIS
Diarrhea r/t
Food intolerance (coarse, greasy, or spicy foods)
Food or drug allergies
Abuse of laxatives
Alteration in normal bacterial flora of the intestine
(antibiotic therapy)
Emotional stress
Intestinal infection
Colon disease & other diseases
Dumping Syndrome

NURSING DIAGNOSIS
As etiology
Altered Growth & Development r/t parents
misconceptions about bowel & bladder training
Altered Nutrition: Less Than Body Requirements r/t
loss of appetite from flatulence or impaction
Anxiety related to lack of voluntary control of fecal
elimination & significant others response to ostomy
Body Image Disturbance r/t ostomy, need to wear
disposable adult briefs
Fluid Volume Deficit r/t prolonged diarrhea

NURSING DIAGNOSIS
As etiology
Impaired Skin Integrity r/t
prolonged diarrhea
bowel incontinence
Ineffective Individual Coping r/t inability to accept
permanent ostomy
Knowledge Deficit: Bowel Training r/t no previous
experience
Pain r/t intestinal distention, prolonged constipation or
impaction, fecal incontinence, hemorroids
Self-Care Deficit: Toileting r/t mobility deficit,
weakness, confusion

NURSING DIAGNOSIS
As etiology
Self-Esteem
Disturbance r/t need
for assistance with
toileting, fecal
incontinence
Sexual Dysfunction
r/t perceived change in
body image, lack of
interest, loss of selfesteem

Expected Outcomes
Client with Constipation:
Have a soft, formed bowel movement every 1 to 3
days without discomfort
Listing foods with high-fiber content
Explaining the importance of exercise in relation to
the GI system
Stating the types of laxatives available
Identifying side effects & contraindications of bowel
laxatives
Administering appropriate laxatives to maintain
normal bowel elimination

Expected Outcomes
Client with Diarrhea:
The client will be clean & dry
The client will avoid foods that contribute to
diarrhea
The client will note the frequency & amount of
diarrhea

PLANNING
Goal: Maintain or restore a regular pattern of
elimination
outcomes
increase fluid intake to 2000 ml/day
include fiber in at least 1 meal/day
walk 20 minutes at least 3x/week
verbalizes relief of constipation by 2 weeks

Interventions
Goal: To Promote Healthy
Elimination
Teaching about bowel needs &
care
Toilet habits: availability of
bathroom, time constraints,
response to stimulation;
frequency - normal 3xs/week
to 3xs/day; less than one/week
- a problem; amount & type
varies with type of food
ingested, fluid intake, &
frequency of bowel evacuation;
promote response to urge

Interventions
To Promote Healthy
Elimination
Diet: High fiber diet
increases weight &
water content of
feces; speeds progress
of feces through GI
tract; prevent disease
fruits, vegetables,
whole-grain cereals
& bread

Interventions
To Promote Healthy
Elimination

Fluids: 1,200 - 1,500

mL/day reasonable
minimum (may be
restriction -renal, heart
disease); avoid liquids
that constipate - milk;
to promote elimination
prune juice, apricot,
lemonade,
cranberry, orange,
hot liquids

Interventions
To Promote Healthy Elimination

Exercise: improves
muscle tone, strengthen
muscles used in
defecation - isometric
Abdominal setting:
lying in supine
position, tighten &
hold abdominal
muscles 6 seconds &
relaxes; repeat several
times each waking
hour

Interventions
To Promote Healthy
Elimination

Thigh strengthening:
thigh muscles flexed
& contracted slowly
bringing the knees
up to the chest one at
a time & lowering
them to the bed.
Perform several
times for each knee
each waking hour

Interventions
To Promote Healthy
Elimination
Positioning the client:

facilitates contraction of
abdominal muscles squatting best facilitates,
sitting with leaning
forward; precautions for
surgery - eg. Hip
surgery; bathroom,
bedside commode
preferred

Interventions
To Promote Healthy
Elimination
Promoting relaxation
& privacy: anxious
about odor, sounds;
not interrupt; relief of
pain
Use of laxatives:
short-acting, not to be
used on routine basis

Interventions
To manage constipation
Administering medications:
Cathartics
intestinal lubricant (mineral oil):
use: short term laxative - effective within 8 hours
side effects: impairs nutrition - fat-soluble
vitamins ADEK
irritants (castor oil)
irritates intestinal mucosa
side effects: taste

Interventions
Bulk-forming
psyllium hydrophilic (metamucil)
hemicellulose swells acts as a demulcent and
softens stool; onset - 10-24h, peak 1-3 d
Calcium polycarbophil (FiberCon)
Methylcellose (Citrucel)
side effect: slow acting- n&v, cramps, diarrhea;
interferes with absorption of calcium, iron, & some
drugs

Interventions
Emollient: stool softener
docusate sodium (Colace); with casanthranol (Peri-Colace)
docusate calcium (Surfak); docusate potassium (Dialose)

wetting agent - detergent activity allows water & fat

to penetrate & lubricate the stool
side effects: rare, lubricate component may interfere
with fat-soluble vitamin absorption
Contact - Stimulant (Ducolax):
irritates intestinal mucosa or stimulates nerve endings
in intestinal wall
side effects: occasional cramping; cause lazy bowel
syndrome; may affect absorption Vit. D, Calcium

Interventions
Laxative: Osmotic
Draws water into intestine & stimulates peristalsis; not
use by elderly - produce dehydration
glycerin (suppository)
Lactulose (Chephulac)
Magnesium citrate (milk of magnesia)
Magnesium hydroxide (Mag-Ox)
Magnesium sulfate (Epsom salts)
Sodium Phosphate (Fleet Phospho-soda)
polyethylene glycol-electrolyte solution (GoLYTELY,
Colyte)

Interventions
Enemas - Sodium Phosphate with sodium
biphosphate (Fleet enema), soap suds, oil
retention, tap water (discussion in clinical
conference)
Removing an impaction: oil retention enema
followed by volume cleansing enema; digital
removal - may use topical anesthetic to reduce
discomfort

Interventions
To alleviate diarrhea
Administering medications:
Bismuth subsalicylate (Pepto-Bismol): antisecretory,
antimicrobial, antiinflammatory effects
kaolin & pectin (Kaopectate) - bind & remove
irritants from GI tract & form soothing, protective
coating on the mucosa
Opiate derivative: paregoric, loperamide (Imodium),
diphenoxylate with atropine/difenoxin with atropine
(Lomotil): inhibits gastric motility
intestinal sedative for chronic diarrhea
sedative effects, depression, weakness

Interventions
To alleviate diarrhea
Administering
medications:

Eliminate
antibiotics that may
cause
Reestablish flora:
fermented dairy
products - yogurt,
buttermilk, or
bacillus-containing
medications lactinex

Interventions
To alleviate diarrhea
Limiting food intake:
diet modification to counteract decreased absorption laxative effects of raw fruits, vegetables, highly
spiced foods

Interventions
To alleviate diarrhea
Restoring fluids &
electrolytes:
Oral or parenteral
replacement; Infants
deplete rapidly
Replace lost fluids &
electrolytes with weak
tea, water, bouillon,
clear soup, gelatin

Interventions
To alleviate diarrhea
Preventing skin
breakdown: soft
material to wipe, wash
perianal area with soap
& water
Ensuring privacy:
frequency & urgency
cause fatigue &
embarassment

Do NOT
Disturb
!

Dumping Syndrome

Interventions
To Manage Bowel Incontinence
Note when incontinence is most like to occur - place on
bedpan at this time; if no pattern, offer bedpan at regular
intervals
Keep skin clean & dry by using hygienic measures
Change bed linens & clothing as necessary to avoid
odor, skin irritation, & embarrassment
Confer with physician about using a suppository or daily
cleansing enema - to empty lower colon regularly &
help decrease incontinence; use of bowel training
program
Rectal indwelling catheter for uncontrollable diarrhea

Interventions
To Meet Needs of Patient with Bowel Diversions
Colostomy
Ileostomy
(Discussion in Clinical Conference)

EVALUATION
If outcomes not achieved, explore reasons:
Were the clients fluid intake and diet appropriate?
Was the clients activity level appropriate?
Are prescribed medications or other factors affecting the
gastrointestinal function?
Do the client and family understand the provided
instructions well enough to comply with the required
therapy?
Were sufficient physical and emotional support
provided?

EVALUATION
Able to verbalize the relationships among bowel
elimination & nutrition, fluid intake, exercise, & stress
management.
Develops a plan to modify any factors that contribute to
current bowel problems or that might adversely affect
bowel functioning in the future.