Overview of Bowel Elimination

Question 1

Structures Involved in Waste Elimination

Small intestine consists of the:
Duodenum
Jejunum
Ileum

Answer 1

Small intestine carries chyme(liquefied food and
digestive juices) from the stomach to the large
intestine.
Chyme arrives at the Ileocecal valve
approximately 4 hours after the meal.
Valve- Controls flow of chyme into the large
intestine

Question 2

Functions of the Small Intestines

Answer 2

For the small intestine
-Processes chyme into a more liquid state»
Food substances are absorbed into the
bloodstream from the villi on the walls of the small
intestine. Adds bile from the liver to help break
down fats
Villi – finger like on the small intestine walls absorb
nutrients, tiny projections on the inner surface of
the small intestine which help in absorbing the
digested food. These helps to increase the surface
area of intestinal walls.

Question 3

The small intestine is where most of the long process of digestion
takes place. It:

Answer 3

● Systematically breaks food down.
● Absorbs nutrients.
● Extracts water.
● Moves food along the gastrointestinal tract.
There’s a lot involved in all this. The process can take up to five
hours.

Question 4

Structures Involved in
Waste Elimination

Answer 4

Large intestine has four main sections:
Large intestine is a large organ located in the digestive system
that is often referred to as the colon
Ascending colon
Transverse colon
Descending colon
Sigmoid colon
Rectum- distal portion of the large intestine feces are stored
Anus. Connects to the anus (opening of the rectum at the skin)
Large Intestine is larger in diameter than the small intestine but
only about 59 inches (1.5 meters long).

Question 5

Functions of the Large Intestines Cont.

Answer 5

Peristalsis moves chyme and gas through
the intestines (causing bowel sounds)
Normal transit time in intestine is 18 to 72
hours> The slower transport allows reabsorption of minerals,
electrolytes, and water.
Feces is stored in the sigmoid colon until the
gastrocolic reflex initiates defecation
Defecation is under voluntary control and
uses the Valsalva maneuver- A simple technique
that involves breathing out of the nose and mouth while they are
closed. This raises the pressure inside the chest and middle ear
and can equalize pressure in the ears and help reduce some heart

Question 6

Large Intestine Functions

Answer 6

1. Formation and elimination of feces
2. Absorption of vitamins
3. Absorption of water and electrolytes
4. Antibody production
5. In large intestine, water, sodium, chlorides
   are reabsorbed.
6. Waste material stored until expelled.
   Class Discussion:
   Can an individual live without a large intestine?
   Reference:
   https://www.news-medical.net/health/What-Does-the-Large-Inte
   stine-Do.aspx

Slide 12

Question 7

Structures Involved in Waste Elimination

Answer 7

Walls of the intestine have four layers:
Mucosa-this layer secretes substances that help keep the
innermost parts of the intestine lubricated.
Submucosa- This layer contains blood vessels and
nerves.
Muscular layer- This is a layer of muscle cells that
create peristalsis and segmentation. It is responsible for gut
movement (also called peristalsis).
Serous layer called serosa- Lying on the
outside of the large intestine, the serous layer expels
substances to keep the intestine lubricated against
surrounding organs.

Question 8

Effects of Aging on the Intestinal Tract

Answer 8

Atrophy of the villi – decrease of the villi in the
small intestine may decrease the total absorptive
surface.

Decreased absorption of fats, vitamin B12 occurs.
Decrease in motility in some individuals but bowel
habits should not change in the normal healthy
individual

Question 9

Normal Stool and Abnormal Stool

Answer 9

Normal Stool
Another term- is feces
Color: light to dark brown
Consistency: soft-formed in children and
adults; consists of 1⁄4 solids and 3⁄4 water
Infant stool- maybe dark or yellow and
unformed depending on the type of
feedings.
Light dark brown color is caused by bile.
Appearance: affected by diet and
metabolism
Stool is usually tubular in shape and
diameter about 1 inch.
Composition: solid materials consist of
70% undigested roughage from
carbohydrates, fat, protein, and inorganic
matter, and 30% dead bacteria

Abnormal Stool
Most serious is the presence of
blood.
Fresh blood in the stool is easily
visible as bright red on the
surface of the blood.
Occult (hidden)- or old blood is
suspected when the stool
changes from a normal brown
appearance to a dark black color
with a sticky appearance.
Should be promptly recorded in
the patient’s chart and reported.

Question 10

Abnormal Stool cont.

Answer 10

Blood in the stool: most serious abnormality
Fresh red blood: bleeding in colon, sign of a
recent GI bleeding in the large intestine.
A rule of thumb: the brighter the blood, the lower
the bleeding source.
Occult: upper GI bleed (black stool called melena)
Pale white or light gray stool: absence of bile in the
intestine > obstruction in the bile or common duct
leading to the intestine from the liver to the gall
bladder.
Large amounts of mucus, fat, pus, or parasites such
as worms.

Slide 17

Question 11

Signs of Upper GI Bleed

Answer 11

What symptoms may indicate upper GI
bleeding?
Some pain and discomfort
the nurse should also look for signs and
symptoms of decreased blood volume; i.e.,
fatigue, shortness of breath, pale conjunctivae,
low blood pressure.

Question 12

Colorectal Cancer

Answer 12

Initial sign🡪 Changes in bowel patterns and
stool characteristics.
Healthy people 2020 objectives to reduce
colorectal cancers, should encouraged
patients to report these changes and to
participate in colon cancer screening
programs that include annual stool test for
occult blood.
Colonoscopy at the age of 50 then every 10
years if normal or more frequent those with
risk factors (American Cancer Society, 2013).

Question 13

Hypoactive Bowel and Constipation

Answer 13

Indicates a decrease in peristalsis
▪ Usually results in constipation

Causes
Immobility
Injury to the bowel
Drugs
After abdominal surgery> develop paralytic ileus> peristalsis.
stops due to bowel has been manipulated during surgery.
A patient restricted to bed at risk for constipation.

Question 14

Drugs That May Contribute to Constipation

Answer 14

Narcotic analgesics
▪ Codeine, morphine, meperidine
▪ General anesthetics- slows peristalsis by depressing
CNS activity.
▪ Diuretics- rid the body fluid
▪ Sedatives- slow CNS activity and peristalsis.
▪ Anticholinergics- alter CNS activity and peristalsis.
▪ Calcium channel blockers- cause a blockade of
calcium channels which affect the smooth muscle of
the intestine

Question 15

Drugs Used for Constipation

Answer 15

Stool softeners

Colace, Surfak, Dialose
⬤ Bulk-forming laxatives

Fibercon, Metamucil, Citrucel
⬤ Irritant/stimulant laxatives

Dulcolax, Neolid, Ex-Lax, Correctol, Senokot

⬤ Saline laxatives

Citrate of magnesia, milk of magnesia,
phospho-soda

Question 16

Increase in peristalsis in hyperactive bowel.
Usually results in diarrhea
May be self-limiting

Answer 16

May be self-limiting
Causes
Inflammation of GI tract, infectious diseases,
diseases such as:
Diverticulitis- small, bulging pouches that can form in the lining
of the digestive system. They are found most often in the lower part
of the large intestine (colon).
Ulcerative colitis- causes inflammation outside of
the large intestine.
Crohn’s disease- A chronic inflammation of the digestive tract
that leads to abdominal pain, severe diarrhea, fatigue, weight loss

Question 17

Hyperactive Bowel and Diarrhea

Answer 17

Drugs
✔ Many antibiotics kill normal bowel bacteria,
resulting in diarrhea
✔ Patients who experience diarrhea from
antibiotics should replace normal flora by:
Eating yogurt
Drinking buttermilk
Taking acidophilus (available OTC)
Acidophilus a bacterium that is used to make
yogurt and to supplement the intestinal flora

Question 18

Drug-Induced Diarrhea

Answer 18

Laxatives are meant to cause diarrhea

Antacids that have magnesium in them may
also cause diarrhea or make it worse.

Antibiotics also can produce diarrhea.
Chemotherapy medicines used to treat cancer
Metformin cause diarrhea

Question 19

Medications Used to Control

Diarrhea

Answer 19

Camphorated tincture of opium (paregoric)
Diphenoxylate hydrochloride with atropine
sulfate (Lomotil)
Loperamide hydrochloride (Imodium)
Difenoxin hydrochloride with atropine sulfate
(Motofen)

Class Discussion

What is the bowel sound characteristics for the
patient with diarrhea?

Question 20

Fecal Incontinence

Answer 20

Lack of voluntary control of fecal evacuation; inability to
retain feces
> Causes
Illness
Cerebrovascular accident
Traumatic injury
Neurogenic dysfunction
> Distressing condition that causes a loss of dignity
Feelings of being less of a person
Loss of self-respect
Embarrassed
Anxiety or fear of losing control

Question 21

Initial Assessment cont.

Answer 21

Physical assessment
Shape of the abdomen with the patient supine
Flat, distended
Auscultate for bowel sounds in all four quadrants
» Bowel sounds should be auscultated before bowel
palpation and percussion. Auscultating, palpating, or
percussing the heart or lungs has no effect on bowel
sounds.
Percuss for presence of excessive air/gas in the
abdomen
Palpate for masses or tenderness

Question 22

The most serious abnormality in the stool is:

Answer 22

4) Blood.

Question 23

Which two groups may become dehydrated
very quickly if diarrhea persists?

Answer 23

3) Infant, elderly

Question 24

Ostomy, Stoma, and Peristoma Care

Answer 24

Clinical Practice
6) Assist and teach a patient with a bowel
retraining program for incontinence.
7) Evaluate the performance of a patient who is
self-catheterizing a continent diversion.
8) Provide ostomy care, including irrigation and
changing the ostomy appliance.

Question 25

Rectal Suppositories

Answer 25

Used to promote bowel movements
⬤ Glycerin and bisacodyl suppositories
⬤ Promote bowel evacuation

Stimulate the inner surface of the rectum and
increasing the urge to defecate
Form gas that expands the rectum
Melt into a lubricating material to coat the stool for
easier passage through the anal sphincter

Question 26

Enemas

Answer 26

Fluid introduced into rectum by means of a
tube
Stimulate peristalsis or wash out waste
products
Often given before a colonoscopy or an x-ray
Volume of typical cleansing enema
✔ Infants: 20 to 150 mL
✔ Ages 3 to 5 years: 200 to 300 mL
✔ School-age: 300 to 500 mL
✔ Adults: 500 to 1000 mL

Question 27

Fluid introduced into rectum by means of a
tube
Stimulate peristalsis or wash out waste
products
Often given before a colonoscopy or an x-ray
Volume of typical cleansing enema
✔ Infants: 20 to 150 mL
✔ Ages 3 to 5 years: 200 to 300 mL
✔ School-age: 300 to 500 mL
✔ Adults: 500 to 1000 mL

Question 28

Types of Enemas

Answer 28

Retention enema

Softens stool as oil is absorbed

⬤ Cleansing enema

Stimulates peristalsis through distention and irritation of
colon and rectum

⬤ Distention reduction enema

Relieves discomfort from flatus causing distention

⬤ Medicated enema

Solution with drugs to reduce bacteria or remove
potassium

⬤ Disposable enema (small volume)
Stimulates peristalsis by acting as irritant

Question 29

Amount and Temperature of Solution

Answer 29

Disposable enema units

Contain about 240 mL of solution
May be given at room temperature, but work best
when slightly warmed
⬤ Cleansing enema

Adults is between 500 and 1000 mL; smaller
amounts are used for children
Fyi.Why should a cleansing enema not be given too rapidly?
Causes painful distention of the rectum and colon. This
stimulates the urge to defecate immediately, so that the patient
cannot retain the fluid.

Question 30

Fecal Impaction

Answer 30

Means that the rectum and sigmoid colon become
filled with hardened fecal material
Most obvious sign is the absence of (or only a small
amount of) bowel movement for more than 3 days in
a patient who usually has a bowel movement more
frequently
Important»>Passage of small amounts of liquid or
semisoft stool onto the bed linens is a sign of fecal
impaction.
Occurs in patients who are very ill, are on bed rest,
or are confused

Question 31

Bowel Training for Incontinence

Answer 31

Principles for establishing regular bowel elimination
✔ Adequate diet
✔ Sufficient fluids
✔ Adequate exercise
✔ Sufficient rest
✔ Regular time for evacuation should be established
✔ All efforts must be made to provide patient with
environment that is conducive to evacuation
✔ May require digital stimulation to relax the anal sphincter
✔ Suppositories, stool softeners, and bulk laxatives used to
assist in establishing a normal, regular bowel pattern
✔ Many bowel retraining programs are timed around a triggering meal
when gastrocolic reflexes are the strongest.

Question 32

Bowel Ostomy

Answer 32

A diversion of intestinal contents from their normal path
Results in formation of an external opening called a stoma;
maybe temporary or permanent.
May be an internal tissue pouch with a valve opening
Special procedures aid in effective, controlled elimination
through the stoma.
An ostomy may result from traumatic injury to the abdomen.
Volunteers from the American Cancer Society as well national
and local ostomy clubs often visit patients to educate them
about the quality-of-life post ostomy.

Question 33

Types of Ostomies

Answer 33

Ileostomy
Diversion of the small bowel contents to a pouch
or stoma; effluent is liquid

Colostomy
Diversion of the colon
Effluent may be liquid or solid depending on the
site; may require irrigation

Question 34

Sigmoid colostomy

Answer 34

Sigmoid colostomy is a surgical
procedure that involves removing the
sigmoid colon and connecting the
descending colon with the anus.
❖ It is usually done when cancer or
diverticulitis is found in the sigmoid colon
to prevent the spread of disease and
prevent additional injury.
❖ The sigmoid colon is located in the lower
part of the large intestine and is
responsible for storing fecal matter until it
is ready to be eliminated

Question 35

Descending colostomy

Answer 35

In this surgery, the descending or sigmoid
colon is used to create a stoma, typically
on the left lower abdomen.
➔ This is the most common type of
colostomy surgery and generally produces
stool that is semi-formed to well-formed
because it has passed through the
ascending and transverse colon.

Question 36

Ascending colostomy

Answer 36

This colostomy has an opening created from the ascending colon and is created
on the right side of the abdomen. ‘
➔ Because the stoma is created from the first section of the colon, stool passed
through the stoma is more liquid and contains digestive enzymes that irritate
the skin.
➔ This type of colostomy surgery is the least common.

Question 37

Double-barrel colostomy

Answer 37

This surgery may result in either
one or two openings in the upper
abdomen, middle, or right side that
are created from the transverse
colon.
★ If there are two openings in the
stoma (called a double-barrel
colostomy), one is used to pass
stool and the other is used to pass
mucus.
★ The stool that is eliminated
through the stoma has passed
through the ascending colon, so it
tends to be liquid or semi-formed.3

Question 38

Ileostomy

Answer 38

Surgeons perform ileostomies when
the large intestine cannot be used to
store and move waste.

Question 39

Kock pouch

Answer 39

The K-pouch is an ileal
pouch that attaches to
your stoma on the inside.
➔ The Kock pouch collects
your stool inside your
body until you’re ready to
drain it.
➔ You can drain it into the
toilet by inserting a
catheter into your stoma.

Question 40

Ostomy Care

Answer 40

Skin care

Stoma and skin washed with mild soap and water
and patted dry
Skin barrier paste is applied
⬤ Applying an ostomy appliance

Appliance is positioned with the stoma protruding
through the opening in the center of the faceplate

⬤ Irrigating a colostomy

A solution is instilled into the colon via the stoma

Question 41

Question 4

Answer 41

An ileostomy has more liquid effluent and a colostomy
has effluent that is more formed.

Question 42

Question 5

Answer 42

a couple of months or longer.