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Chapter 32
BOWEL ELIMINATION
Key Terms
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Normal Bowel Movements
- Normally, people have a bowel movement every day or every 2 to 3 days.
- Stools are normally brown in colour.
- Certain foods and medications also cause odours in the stools.
Observations
- Your careful observations about the clients stools are important for the
care planning process.
- In a facility, its essential that you accurately chart your clients BM during
your shift so that your team can decide if adjustments in diet or medication
may be necessary.
FACTORS AFFECTING BOWEL MOVEMENT
- Normal, regular defecation, including frequency, consistency, colour, and
odour of stools, can be affected by many factors:
1. Privacy- Lack of privacy deters many people from defecating despite having
the urge. Some clients ignore the urge to defecate when others are
present, which can lead to constipation.
2. Personal habit- Many clients routinely have a bowel movement after
breakfast.
3. Fluids- Stool consistency depends on the amount of water absorbed in the
colon. Feces become hard and dry when large amounts of water are
absorbed by the colon and when fluid intake is poor.
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4. Activity- Exercise and activity maintain muscle tone and stimulate
peristalsis. Irregular elimination and constipation often occur due to
inactivity and bed rest resulting from disease, surgery, injury, and aging.
5. Medications-On the one hand, medications can prevent constipation or
control diarrhea; on the other hand, some medication can cause diarrhea
or constipation as side effect.
6. Aging- as people age, feces tend to pass through their intestines at slower
rate, resulting in constipation.
7. Disability- Some clients with disabilities are not able to control their bowel
moments and defecate whenever feces enter the rectum.
COMFORT AND SAFETY
- The care plan list comfort and safety measures to meet the clients
elimination needs.
COMMON PROBLEMS
- Common problems that affect normal bowel movement include
constipation, fecal impaction, diarrhea, fecal incontinence, and flatulence.
Constipation
Constipation-is a condition in which bowel movements are less frequent than
usual, and the stool is hard, dry, and difficult to pass, causing the client to strain
to have a bowel movement.
Fecal Impaction
Fecal Impaction- is the prolonged retention and accumulation of feces in the
rectum. Feces impaction results if constipation is not relieved.



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If a client shows any of the following signs or symptoms of a fecal impaction,
report it at once:
1. Abdominal discomfort, which can be sever, cause swelling, or both
2. Cramping
3. A feeling of fullness or pain in the rectum
4. Nausea or vomiting; vomitus that smells like stool
5. Fever
6. Increased urge or decreased ability to urinate
7. Liquid feces seeping from the anus. Seepage may look like diarrhea but is,
in fact, liquid feces passing around hardened fecal mass.
A physician or nurse performs a digital (finger) exam to check for impaction.
Diarrhea
Diarrhea- is frequent passage of liquid stools.
- Diet and medications reduce peristalsis and stop the diarrhea.
You need to:
1. Assist with the clients elimination needs promptly
2. Dispose of stools promptly to prevent odours and the spread of microbes
3. Provide good skin care, as liquid feces and frequent wiping with toilet tissue
can irritate the skin, which may lead to skin breakdown and pressure ulcers.
Fluid lost through diarrhea must be replaced, as this loss may lead to
dehydration- the excessive loss of water from tissues.
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FOCUS ON CHILDREN
Dehydration
The bodies of infant and young children contain large amounts of water. Infants
and children are at risk for dehydration, and death from dehydration can occur
quickly in them. Report any liquid or watery stool immediately. Note the number
of wet diapers in 24 hours. Infants wet less when dehydration. Fewer than six
diapers in 24 hours may indicate that an infant is dehydrated. Report any
concerns immediately.
FOCUS ON OLDER ADULTS
Dehydration
Older adults are at risk for dehydration, as the amount of body water decreases
with aging. Diarrhea is, therefore, very serious in older adults, and any signs of
diarrhea should be reported immediately, as death can result from unrecognized
and untreated dehydration.
Fecal Incontinence
Fecal incontinence (or anal incontinence) is the inability to control the passage of
feces and gas through the anus due to intestinal and nervous system disease,
injuries, fecal impaction, diarrhea, and some medications.
Flatulence
Flatulence- is the excessive formation of gas or air in the stomach and intestines.


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Common causes are:
1. Swallowing air while eating and drinking, especially when chewing gum,
eating quickly, drinking through a straw, and drinking carbonated
beverages. Tense or anxious people tend to swallow large amounts of air
when drinking.
2. Bacterial action in the intestines
3. Gas-forming food (onion, beans, cabbage, cauliflower, radish, cucumber)
4. Constipation
5. Bowel and abdominal surgeries
6. Medications that decrease peristalsis
BOWEL TRAINING
- Bowel training two goals:
1. To gain control of bowel movement
2. To develop a regular pattern of elimination, which will prevent fecal
impaction, constipation, and fecal incontinence
Factors that promote elimination are part of the care plan and bowel training
program.
Suppository- is a cone-shape, solid medication that is inserted into a body
opening.
ENEMAS
Enemas- the introduction of fluids into the rectum and lower colon- is ordered by
physicians to remove feces and relieve constipation or fecal impaction.

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If you are delegated to perform an enema, these are the questions you need to
answer:
1. Do your provincial or territorial laws and employers policies allow you to
perform the procedure?
2. Do you have the necessary education and training?
3. Have you reviewed the procedure with a nurse?
4. Is a nurse available to answer questions and to supervise you?
The Commercial Enema
- Commercial enemas stimulate and distend the rectum and cause
defecation.
- They are often ordered to relieve constipation or when complete cleansing
of the bowel is not needed.
- Encourage the client to retain the solution until the urge to defecate is felt.
- The enema usually takes 5 to 10 minutes to take effect.
- Remaining in Sims on the left side helps the client retain the enema longer.
RECTAL TUBES
- A nurse inserts a rectal tube into the rectum to relieve flatulence and
intestinal distension.
- Flatus is passed without effect or staining.
- The rectal tube is usually inserted 10cm (4in.) into the adult rectum.
- Its left in place for 20 to 30 minutes, which helps prevent rectal irritation.
THE CLIENT WITH AN OSTOMY
Following the surgery, an ostomy- the surgical creation of an opening (stoma) - is
sometimes needed. The client wears a pouch over the stoma to collect feces and
flatus.
Colostomy
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Colostomy- is the surgically created opening (stomy) between the colon (colo)
and abdominal wall. Part of the colon is brought out onto the abdominal wall, and
a stoma is created.
Ileostomy
Ileostomy is the surgically created opening (stomy) between the ileum (small
intestine ileo) and the abdominal wall.
Ostomy Pouches
- The pouch has an adhesive backing that is applied to the skin.
- The pouch is changed every 3 to 7 days whenever it leaks.
Odours can be prevented by the following:
1. Good hygiene
2. Emptying the pouch regularly
3. Avoiding gas-forming foods
4. Placing deodorants into the pouch (The care plan tells you which products
to use.)

STOOL SPECIMENS
- The stool specimen must not be contaminated with urine.
- Some tests require warm (fresh) stools.
- The specimen is taken to the laboratory immediately in that case.

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Testing Stools for Blood
- Blood can appear in stools for many reasons, including ulcers, colon cancer,
and hemorrhoid.
- Stools are black and tarry (melena) if there is bleeding in the stomach or
upper GI tract.
- When reporting blood in the stool, you must describe the colour, as it may
be an important clue when investigating the source.
- Numerous types of tests are available.