Bowel elimination is a basic physical need. It is the excretion of wastes from the gastro-intestinal system (GI) (Chapter 9). Many factors affect bowel elimination. They include privacy, habits, age, diet, exercise and activity, fluids, and drugs. Problems easily occur. Promoting normal bowel elimination is important. You assist residents in meeting elimination needs.

Normal bowel elimination

Foods and fluids are partially digested in the stomach. The partially digested food and fluids are called chyme. Chyme passes from the stomach into the small intestine. It enters the large intestine (large bowel or colon) where fluid is absorbed. Chyme becomes less fluid and more solid in consistency. Feces refers to the semi-solid mass of waste products in the colon that is expelled through the anus.

Feces move through the intestines by peristalsis. Peristalsis is the alternating contraction and relaxation of intestinal muscles. The feces move through the large intestine to the rectum. Feces are stored in the rectum until excreted from the body. Defecation (bowel movement [BM]) is the process of excreting feces from the rectum through the anus. Stool refers to excreted feces.

Some people have a BM every day. Others have one every 2 to 3 days. Some people have 2 or 3 BMs a day. Many people have a BM after breakfast. Others do so in the evening. Many older persons expect to have a BM every day. They are very concerned if they do not do so. The nurse teaches them about normal elimination.

Stools are normally brown. Bleeding in the stomach and small intestine causes black or tarry stools. Bleeding in the lower colon and rectum causes red-colored stools. So do beets, tomato juice or soup, red Jell-O, and foods with red food coloring. A diet high in green vegetables can cause green stools. Diseases and infection can cause clay-colored or white, pale, orange-colored, or green-colored stools.

Stools are normally soft, formed, moist, and shaped like the rectum. They have a normal odor caused by bacterial action in the intestines. Certain foods and drugs also cause odors.

Observations

Your observations are used for the nursing process. Carefully observe stools before disposing of them. Ask the nurse to observe abnormal stools. Observe and report the following to the nurse. If allowed to chart, also record the following:

• Color

• Amount

• Consistency

• Presence of blood or mucus

• Odor

• Shape

• Frequency of BMs

• Complaints of pain or discomfort

See Focus on Communication: Observations.

FOCUS ON COMMUNICATION

Observations

Many residents tend to their own bowel elimination needs. However, information is still needed for the person’s record and the nursing process. You may need to ask these questions:

• “Did you have a bowel movement today?”

• “Please tell me about your bowel movement.”

• “When did you have a bowel movement?”

• “What was the amount?”

• “Were the stools formed or loose?”

• “What was the color?”

• “Did you have any bleeding, pain, or problems having a bowel movement?”

• “Did you pass any gas?”

• “How much gas did you pass?”

• “Do you need to pass more gas?”

• “Do you need help cleaning yourself?”

Factors affecting bowel elimination

These factors affect stool frequency, consistency, color, and odor. The nurse considers them when using the nursing process to meet the person’s elimination needs. Normal, regular elimination is the goal.

• Privacy. Bowel elimination is a private act. Odors and sounds are embarrassing. Lack of privacy can prevent a BM despite having the urge. Some people ignore the urge when others are present.

• Habits. Many people have a BM after breakfast. Some drink a hot beverage, read, or take a walk. These activities are relaxing. A BM is easier when a person is relaxed, not tense.

• Diet—high-fiber foods. High-fiber foods leave a residue for needed bulk. Fruits, vegetables, and whole grain cereals and breads are high in fiber. Many people do not eat enough fruits and vegetables. Some cannot chew these foods. They may not have teeth. Or dentures may fit poorly. Some people think that they cannot digest fruits and vegetables. So they refuse to eat them. In nursing centers, bran may be added to cereal, prunes, or prune juice. These foods provide fiber and prevent constipation.

• Diet—other foods. Milk and milk products can cause constipation or diarrhea. Chocolate and other foods cause similar reactions. Spicy foods can irritate the intestines. Frequent stools or diarrhea can result. Gas-forming foods stimulate peristalsis, which aids a BM. Such foods include onions, beans, cabbage, cauliflower, radishes, and cucumbers.

• Fluids. Feces contain water. Stool consistency depends on the amount of water absorbed in the colon. The amount of fluid intake, urine output, and vomiting are factors. Feces harden and dry when large amounts of water are absorbed or when fluid intake is poor. Hard, dry feces move slowly through the colon. Constipation can occur. Drinking 6 to 8 glasses of water daily promotes normal bowel elimination. Warm fluids—coffee, tea, hot cider, warm water—increase peristalsis.

• Activity. Exercise and activity maintain muscle tone and stimulate peristalsis. Irregular elimination and constipation often occur from inactivity and bedrest. Inactivity may result from disease, surgery, injury, and aging.

• Drugs. Drugs can prevent constipation or control diarrhea. Other drugs have diarrhea or constipation as side effects. Drugs for pain relief often cause constipation. Antibiotics (used to fight or prevent infections) often cause diarrhea. Diarrhea occurs when the antibiotics kill normal flora in the colon. Normal flora is needed to form feces.

• Disability. Some people cannot control bowel movements. They have a BM whenever feces enter the rectum. A bowel training program is needed (p. 359).

• Aging. Aging causes changes in the GI tract. Feces pass through the intestines at a slower rate. Constipation is a risk. Some older persons lose bowel control. Older persons may not completely empty the rectum. They often need to have another BM about 30 to 45 minutes after the first BM. Older persons are at risk for intestinal tumors and disorders.

Safety and comfort

The care plan includes measures to meet the person’s elimination needs. It may involve diet, fluids, and exercise. Follow the measures in Box 23-1 to promote safety and comfort.

Box 23-1

Safety and Comfort During Bowel Elimination

• Follow Standard Precautions and the Bloodborne Pathogen Standard.

• Provide for privacy. Ask visitors to leave the room. Close doors, privacy curtains, and window coverings.

• Help the person to the toilet or commode. Or provide the bedpan as soon as requested.

• Wheel the person into the bathroom on the commode if possible. Place the commode over the toilet. This provides privacy. Remember to lock the commode wheels.

• Make sure the bedpan is warm.

• Position the person in a normal sitting or squatting position.

• Cover the person for warmth and privacy.

• Allow enough time for a BM.

• Place the signal light and toilet tissue within reach.

• Leave the room if the person can be alone. Check on the person every 5 minutes.

• Stay nearby if the person is weak or unsteady.

• Provide perineal care.

• Dispose of stools promptly. This reduces odors and prevents the spread of microbes.

• Assist the person with hand washing after elimination.

• Follow the care plan if the person has fecal incontinence. The care plan tells you when to assist with elimination.

See Teamwork and Time Management: Safety and Comfort.

TEAMWORK AND TIME MANAGEMENT

Safety and Comfort

The need to have a BM may be urgent. Answer signal lights promptly. Also help co-workers answer signal lights. Residents must not be left sitting on toilets, commodes, or bedpans. They must not be left sitting or lying in stools.

Common problems

Common problems include constipation, fecal impaction, diarrhea, fecal incontinence, and flatulence.

Constipation

Constipation is the passage of a hard, dry stool. The person usually strains to have a BM. Stools are large or marble-size. Large stools cause pain as they pass through the anus. Constipation occurs when feces move slowly through the bowel. This allows more time for water absorption. Common causes of constipation include:

• A low-fiber diet

• Ignoring the urge to have a BM

• Decreased fluid intake

Dietary changes, fluids, and activity prevent or relieve constipation. So do drugs and enemas.

Fecal impaction

A fecal impaction is the prolonged retention and build-up of feces in the rectum. Feces are hard or putty-like. Fecal impaction results if constipation is not relieved. The person cannot defecate. More water is absorbed from the already hard feces. Liquid feces pass around the hardened fecal mass in the rectum. The liquid feces seep from the anus.

The person tries many times to have a BM. Abdominal discomfort, abdominal distention (swelling), nausea, cramping, and rectal pain are common. Older persons may have poor appetite or confusion. Some persons may have a fever. Report these signs and symptoms to the nurse.

The nurse does a digital (finger) exam to check for an impaction. A lubricated, gloved finger is inserted into the rectum to feel for a hard mass (Fig. 23-1). The mass is felt in the lower rectum. Sometimes it is higher in the colon and out of reach. The digital exam often causes the urge to have a BM. The doctor may order drugs and enemas to remove the impaction.

Fig. 23-1 A gloved index finger is used to check for a fecal impaction.

Sometimes the nurse removes the fecal mass with a gloved finger. This is called digital removal of an impaction.

Diarrhea

Diarrhea is the frequent passage of liquid stools. Feces move through the intestines rapidly. This reduces the time for fluid absorption. The need for a BM is urgent. Some people cannot get to a bathroom in time. Abdominal cramping, nausea, and vomiting may occur.

Causes of diarrhea include infections, some drugs, irritating foods, and microbes in food and water. Diet and drugs are ordered to reduce peristalsis. You need to:

• Assist with elimination needs promptly.

• Dispose of stools promptly. This prevents odors and the spread of microbes.

• Give good skin care. Liquid stools irritate the skin. So does frequent wiping with toilet tissue. Skin breakdown and pressure ulcers are risks.

Fluid lost through diarrhea is replaced. Otherwise dehydration occurs. Dehydration is the excessive loss of water from tissues. The person has pale or flushed skin, dry skin, and a coated tongue. The urine is dark and scant in amount (oliguria). Thirst, weakness, dizziness, and confusion also occur. Falling blood pressure and increased pulse and respirations are serious signs. Death can occur. The nursing process is used to meet the person’s fluid needs. The doctor may order IV (intravenous) fluids in severe cases (Chapter 25).

Microbes can cause diarrhea. Preventing the spread of infection is important. Always follow Standard Precautions and the Bloodborne Pathogen Standard when in contact with stools.

See Promoting Safety and Comfort: Diarrhea.

PROMOTING SAFETY AND COMFORT

Diarrhea

Safety

Death is a risk when dehydration is not recognized and treated. Older persons are at risk for dehydration. The amount of body water decreases with aging. Therefore diarrhea is very serious in older persons. Report signs of diarrhea at once. Ask the nurse to observe the stool.

Clostridium difficile

Clostridium difficile (C. difficile [CDI]) is a microbe that causes diarrhea and intestinal infections. It can cause death. Persons at risk include persons who are older, ill, or need the prolonged use of antibiotics. Signs and symptoms include:

• Watery diarrhea with a foul odor

• Fever

• Loss of appetite

• Nausea

• Abdominal pain or tenderness

The microbe is found in feces. A person becomes infected by touching items or surfaces contaminated with feces and then touching his or her mouth or mucous membranes. You can spread the microbe if your contaminated hands or gloves:

• Touch a person

• Contaminate surfaces

You must practice good hand hygiene. Alcohol-based hand rubs are not effective against C. difficile. You must wash your hands with soap and water. Also follow Standard Precautions.

Fecal incontinence

Fecal incontinence is the inability to control the passage of feces and gas through the anus. Causes include:

• Intestinal diseases

• Nervous system diseases and injuries

• Mental health problems or dementia (Chapters 43 and 44)—the person may not recognize the need for or act of having a BM

• Not answering signal lights when help is needed with elimination

• Not getting to the bathroom in time

• Not finding the bathroom when in a new setting

Fecal incontinence affects the person emotionally. Frustration, embarrassment, anger, and humiliation are common. The person may need:

• Bowel training

• Help with elimination after meals and every 2 to 3 hours

• Incontinence products to keep garments and linens clean

• Good skin care

See Residents With Dementia: Fecal Incontinence.

RESIDENTS WITH DEMENTIA

Fecal Incontinence

Persons with dementia may smear stools on themselves, furniture, and walls. Some are not aware of having BMs. Some resist care. Follow the person’s care plan. The measures for urinary incontinence (Chapter 22) may be part of the care plan. Be patient. Ask for help from co-workers. Talk to the nurse if you have problems keeping the person clean.

Flatulence

Gas and air are normally in the stomach and intestines. They are expelled through the mouth (burping, belching, eructating) and anus. Gas or air passed through the anus is called flatus. Flatulence is the excessive formation of gas or air in the stomach and intestines. Causes include:

• Swallowing air while eating and drinking. This includes chewing gum, eating fast, drinking through a straw, and drinking carbonated beverages. Tense or anxious people may swallow large amounts of air when drinking.

• Bacterial action in the intestines.

• Gas-forming foods (onions, beans, cabbage, cauliflower, radishes, and cucumbers).

• Constipation.

• Bowel and abdominal surgeries.

• Drugs that decrease peristalsis.

If flatus is not expelled, the intestines distend. That is, they swell or enlarge from the pressure of gases. Abdominal cramping or pain, shortness of breath, and a swollen abdomen occur. “Bloating” is a common complaint. Exercise, walking, moving in bed, and the left-side lying position often produce flatus. Doctors may order enemas and drugs to relieve flatulence.

Bowel training

Bowel training has two goals:

• To gain control of bowel movements.

• To develop a regular pattern of elimination. Fecal impaction, constipation, and fecal incontinence are prevented.

Meals, especially breakfast, stimulate the urge for a BM. The person’s usual time of day for a BM is noted on the care plan. So is toilet, commode, or bedpan use. Offer help with elimination at the times noted. Factors that promote elimination are part of the care plan and bowel training program. These include a high-fiber diet, increased fluids, warm fluids, activity, and privacy. The nurse tells you about a person’s bowel training program.

The doctor may order a suppository to stimulate a BM. A suppository is a cone-shaped, solid drug that is inserted into a body opening. It melts at body temperature. A nurse inserts a rectal suppository into the rectum (Fig. 23-2, p. 360). A BM occurs about 30 minutes later.