Chapter 26

Bowel Elimination

Objectives

Key Abbreviations

BMBowel movement
CMSCenters for Medicare & Medicaid Services
GIGastro-intestinal
IDIdentification
IVIntravenous
mLMilliliter
ozOunce
SSESoapsuds enema

Bowel elimination is a basic physical need. Wastes are excreted from the gastro-intestinal (GI) system (Chapter 10). Many factors affect bowel elimination—privacy, habits, age, diet, exercise and activity, fluids, drugs, disability. Problems easily occur. Normal bowel elimination is important. You assist patients and residents to meet elimination needs.

See Body Structure and Function Review: The Gastro-Intestinal Tract.

See Delegation Guidelines: Bowel Elimination.

See Promoting Safety and Comfort: Bowel Elimination.

imageBody Structure and Function Review

The Gastro-Intestinal Tract

The GI tract is part of the digestive system (Chapter 10). Bowel elimination is the excretion of wastes through the GI tract. Food and fluids are normally taken in through the mouth. They are partially digested in the stomach. The partially digested food and fluids are called chyme.

Chyme passes from the stomach into the small intestine (small bowel). Further digestion and absorption of nutrients occur as the chyme passes through the small bowel. The chyme enters the large intestine (large bowel or colon) where fluid is absorbed. Chyme becomes less fluid and more solid in consistency. Feces (stool or stools) 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 and excreted from the body (Fig. 26-1). Defecation (bowel movement) is the process of excreting feces from the rectum through the anus. Stool refers to excreted feces.

image
FIGURE 26-1 Digestive system.

Delegation Guidelines

Bowel Elimination

Your state and agency may not allow you to perform the procedures in this chapter. Before performing a procedure, make sure that:

Normal Bowel Elimination

Some people have a bowel movement (BM) every day. Others do so 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.

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. Green vegetables can cause green stools. Diseases and infection can cause clay-colored or white, pale, orange-colored, or green-colored stools and stools with mucus. Figure 26-2, p. 424 shows a color chart for stools.

image
FIGURE 26-2 Color chart for stools.

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

See Focus on Children and Older Persons: Normal Bowel Elimination, p. 424.

Observations

Your observations are used for the nursing process. Ask the nurse to observe abnormal stools. Report and record the following.

See Focus on Communication: Observations.

Factors Affecting BMs

These factors affect BM frequency, consistency, color, and odor. They are part of the nursing process to meet the person's elimination needs. Normal, regular elimination is the goal.

See Focus on Children and Older Persons: Factors Affecting BMs.

Safety and Comfort

The care plan has measures for meeting elimination needs. It may involve diet, fluids, and exercise. The measures in Box 26-1 promote safety and comfort.

See Focus on Communication: Safety and Comfort.

See Teamwork and Time Management: Safety and Comfort.

Focus on Communication

Safety and Comfort

Odors and sounds are common with BMs. You must control your verbal and nonverbal responses. Always be professional. Do not laugh at or make fun of a person. Your words and actions must promote comfort, dignity, and self-esteem.

Teamwork and Time Management

Safety and Comfort

BM needs may be urgent. Answer call lights promptly. Also help co-workers answer call lights. Listen closely for bathroom call lights. The sound and color are different from call lights in rooms. Respond at once. Do not leave patients and residents sitting on toilets, commodes, or bedpans. Do not leave them sitting or lying in stools.

Common Problems

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

image Fecal Impaction

A fecal impaction is the prolonged retention and buildup of feces in the rectum. Feces are hard or putty-like. Fecal impaction results if constipation is not relieved. The person cannot have a BM. More water is absorbed from the already hard feces. Liquid feces pass around the hardened fecal mass in the rectum and 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 have a fever. Report such 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 in the lower rectum (Fig. 26-5). Sometimes it is out of reach higher in the colon. The digital exam often causes the urge to have a BM. The doctor may order drugs, suppositories, or enemas to remove the impaction.

image
FIGURE 26-5 A gloved index finger is used to check for and remove a fecal impaction.

Sometimes digital removal of an impaction is done. A lubricated, gloved finger is hooked around a piece of feces. Then the finger and feces are removed. The stool is dropped into the bedpan. The process is repeated as needed. The procedure can be uncomfortable and embarrassing.

Checking for and removing impactions are very dangerous. The vagus nerve can be stimulated. Stimulation of the vagus nerve slows the heart rate. The heart rate can slow to unsafe levels in some persons.

See Focus on Long-Term Care and Home Care: Fecal Impaction.

See Delegation Guidelines: Fecal Impaction.

See Promoting Safety and Comfort: Fecal Impaction.

See procedure: Checking For and Removing a Fecal Impaction, p. 428.

image Checking For and Removing a Fecal Impaction

Quality of Life

Pre-Procedure

  1. 1 Follow Delegation Guidelines:
  2. See Promoting Safety and Comfort:
  3. 2 Practice hand hygiene.
  4. 3 Collect the following.
  5. 4 Practice hand hygiene.
  6. 5 Identify the person. Check the ID (identification) bracelet against the assignment sheet. Use 2 identifiers (Chapter 13). Also call the person by name.
  7. 6 Provide for privacy.
  8. 7 Raise the bed for body mechanics. Bed rails are up if used.

Procedure

  1. 8 Lower the bed rail near you if up.
  2. 9 Cover the person with a bath blanket. Fan-fold top linens to the foot of the bed.
  3. 10 Position the person in Sims' position or in a left side-lying position (Chapter 17).
  4. 11 Check the person's pulse (Chapter 29). Note the rate and rhythm.
  5. 12 Practice hand hygiene. Put on the gloves.
  6. 13 Place the waterproof under-pad under the buttocks.
  7. 14 Expose the anal area.
  8. 15 Lubricate your gloved index finger.
  9. 16 Ask the person to take a deep breath through his or her mouth.
  10. 17 Insert the gloved finger while the person is taking a deep breath.
  11. 18 Check for a fecal mass. Remove your finger and go to step 20 if:
  12. 19 Remove the impaction.
  13. 20 Wipe the anal area with toilet tissue.
  14. 21 Remove and discard the gloves. Practice hand hygiene. Put on clean gloves.
  15. 22 Help the person onto the bedpan. Raise the head of the bed and raise the bed rail if used. Or assist the person to the bathroom or commode. The person wears a robe and non-skid footwear when up. The bed is in a low position safe and comfortable for the person.
  16. 23 Place the call light and toilet tissue within reach. Remind the person not to flush the toilet.
  17. 24 Discard disposable items.
  18. 25 Remove and discard the gloves. Practice hand hygiene.
  19. 26 Leave the room if the person can be left alone.
  20. 27 Return when the person signals. Or check on the person every 5 minutes. Knock before entering.
  21. 28 Practice hand hygiene and put on gloves. Lower the bed rail if up.
  22. 29 Observe stools for amount, color, consistency, shape, and odor.
  23. 30 Provide perineal care as needed.
  24. 31 Remove the waterproof under-pad.
  25. 32 Empty, rinse, clean, and disinfect equipment. If the person had a BM, flush the toilet after the nurse observes it.
  26. 33 Return equipment to its proper place.
  27. 34 Remove and discard the gloves. Practice hand hygiene after removing and discarding the gloves.
  28. 35 Assist with hand-washing. Wear gloves for this step. Practice hand hygiene after removing and discarding the gloves.
  29. 36 Cover the person. Remove the bath blanket.

Post-Procedure

  1. 37 Provide for comfort. (See the inside of the front cover.)
  2. 38 Place the call light and other needed items within reach.
  3. 39 Lower the bed to a safe and comfortable level for the person. Follow the care plan.
  4. 40 Raise or lower bed rails. Follow the care plan.
  5. 41 Unscreen the person.
  6. 42 Complete a safety check of the room. (See the inside of the front cover.)
  7. 43 Follow agency policy for used linens and used supplies.
  8. 44 Practice hand hygiene.
  9. 45 Report and record your observations.

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:

Fluid lost through diarrhea must be replaced to prevent dehydration. Dehydration is the excessive loss of water from tissues. The person has pale or flushed skin, dry skin, and a coated tongue. 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 fluid needs. The doctor may order IV (intravenous) fluids in severe cases (Chapter 28).

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 Focus on Children and Older Persons: Diarrhea.

See Promoting Safety and Comfort: Diarrhea.

Suppositories

A suppository is a cone-shaped, solid drug that is inserted into a body opening. It melts at body temperature. A rectal suppository is inserted into the rectum (Fig. 26-6). A BM occurs about 30 minutes later.

image
FIGURE 26-6 A, The rectal suppository is not inserted into feces. B, The suppository is inserted along the rectal wall. (Modified from deWit SC: Fundamental concepts and skills for nursing, ed 3, Philadelphia, 2009, Saunders.)

The doctor may order a suppository for:

See Delegation Guidelines: Suppositories.

See Promoting Safety and Comfort: Bowel Elimination, p. 423.

Enemas

An enema is the introduction of fluid into the rectum and lower colon. Doctors order enemas to:

Safety and comfort measures for bowel elimination are practiced when giving enemas (see Box 26-1). So are the rules in Box 26-2.

The doctor orders the enema solution. The solution depends on the enema's purpose—cleansing, constipation, fecal impaction, or flatulence.

Other enema solutions may be ordered. Consult with the nurse and use the agency's procedure manual to safely prepare and give enemas. You do not give enemas that contain drugs. Nurses give them.

See Focus on Math: Enemas.

See Delegation Guidelines: Enemas, p. 432.

See Promoting Safety and Comfort: Enemas, p. 432.

imageFocus on Math

Enemas

Cleansing enemas are given over 10 to 15 minutes. The nurse tells you the amount of solution to give and the amount of time to give it in. As you give the solution, monitor how fast the fluid flows. To calculate the amount to give per minute, divide the total amount (in mL) by the time (in minutes). Each minute as you give the enema, subtract this amount to gauge if the rate is too fast or too slow.

For example, you are to give a 750 mL saline enema over 15 minutes. Divide 750 mL by 15 minutes. The fluid in the bag should decrease by about 50 mL each minute.

750 mL÷15 minutes=50 mL/minute

image

Note the start time. Check the amount at least each minute. At 1 minute, the solution should be at the 700 mL mark.

750 mL−50 mL=700 mL (at 1​  minute)

image

At 2 minutes, the solution should be about half-way between the 700 mL and 600 mL marks (650 mL).

700 mL−50 mL=650 mL (at 2 minutes)

image

At 3 minutes, the solution should be at the 600 mL mark, and so on.

650 mL−50 mL=600 mL (at 3 minutes)

image

If the solution is flowing too fast, clamp the tube and call for the nurse. The nurse may lower the bag to slow the flow. If the solution is flowing too slowly, call for the nurse. The nurse may adjust the tube or raise the bag to quicken the flow.

Delegation Guidelines

Enemas

If giving an enema to an adult is delegated to you, make sure the conditions in Delegation Guidelines: Bowel Elimination (p. 423) are met. If those conditions are met, you need this information from the nurse.

image The Cleansing Enema

Cleansing enemas clean the bowel of feces and flatus. They relieve constipation and fecal impaction. They are given before certain surgeries and diagnostic procedures. Cleansing enemas take effect in 10 to 20 minutes.

The doctor orders a tap water, saline, or soapsuds enema. An enemas until clear order means that enemas are given until the return solution is clear and free of stools. Agency policy may allow repeating enemas 2 or 3 times. The nurse tells you what enema to give and how many times to repeat the enema.

See Focus on Children and Older Persons: The Cleansing Enema.

See procedure: Giving a Cleansing Enema.

image Giving a Cleansing Enema imageimage

Quality of Life

Pre-Procedure

  1. 1 Follow Delegation Guidelines:
  2. See Promoting Safety and Comfort:
  3. 2 Practice hand hygiene.
  4. 3 Collect the following before going to the person's room.
  5. 4 Arrange items in the person's room and bathroom.
  6. 5 Practice hand hygiene.
  7. 6 Identify the person. Check the ID bracelet against the assignment sheet. Use 2 identifiers (Chapter 13). Also call the person by name.
  8. 7 Put on gloves.
  9. 8 Collect the following.
  10. 9 Remove and discard the gloves. Practice hand hygiene. Put on clean gloves.
  11. 10 Provide for privacy.
  12. 11 Raise the bed for body mechanics. Bed rails are up if used.

Procedure

  1. 12 Lower the bed rail near you if up.
  2. 13 Cover the person with a bath blanket. Fan-fold top linens to the foot of the bed.
  3. 14 Position the IV pole so the enema bag is 12 inches above the anus. Or it is at the height directed by the nurse.
  4. 15 Raise the bed rail if used.
  5. 16 Prepare the enema.
  6. 17 Lower the bed rail near you if up.
  7. 18 Position the person in Sims' position or in a left side-lying position.
  8. 19 Place a waterproof under-pad under the buttocks.
  9. 20 Expose the anal area.
  10. 21 Place the bedpan behind the person.
  11. 22 Position the enema tube in the bedpan. Remove the cap from the tubing.
  12. 23 Open the clamp. Let solution flow through the tube to remove air. Clamp the tube.
  13. 24 Lubricate the tube 2 to 4 inches from the tip.
  14. 25 Separate the buttocks to see the anus.
  15. 26 Ask the person to take a deep breath through the mouth.
  16. 27 Insert the tube gently 2 to 4 inches into the adult's rectum (Fig. 26-7). Do this when the person is exhaling. Stop if the person complains of pain, you feel resistance, or bleeding occurs.
    image
    FIGURE 26-7 Enema tubing inserted into the adult rectum.
  17. 28 Check the amount of solution in the bag.
  18. 29 Unclamp the tube. Give the solution slowly (Fig. 26-8).
    image
    FIGURE 26-8 Giving an enema. The person is in Sims' position. The enema bag hangs from an IV pole. The bag is 12 inches above the anus and 18 inches above the mattress.
  19. 30 Ask the person to take slow, deep breaths. This helps the person relax.
  20. 31 Clamp the tube if the person needs to have a BM, has cramping, or starts to expel the solution. Also, clamp the tube if the person is sweating or complains of nausea or weakness. Unclamp when symptoms subside.
  21. 32 Give the amount of solution ordered. Stop if the person cannot tolerate the procedure.
  22. 33 Clamp the tube before it is empty. This prevents air from entering the bowel.
  23. 34 Hold toilet tissue around the tube and against the anus. Remove the tube.
  24. 35 Discard toilet tissue into the bedpan.
  25. 36 Wrap the tubing tip with paper towels. Place it inside the enema bag.
  26. 37 Encourage retention of the enema for the time ordered.
  27. 38 Assist the person to the bathroom or commode. The person wears a robe and non-skid footwear when up. The bed is at a low level that is safe and comfortable for the person. Or help the person onto the bedpan. Raise the head of the bed. Raise or lower bed rails according to the care plan.
  28. 39 Place the call light and toilet tissue within reach. Remind the person not to flush the toilet.
  29. 40 Discard disposable items.
  30. 41 Remove and discard the gloves. Practice hand hygiene.
  31. 42 Leave the room if the person can be left alone.
  32. 43 Return when the person signals. Or check on the person every 5 minutes. Knock before entering the room or bathroom.
  33. 44 Practice hand hygiene and put on gloves. Lower the bed rail if up.
  34. 45 Observe enema results for amount, color, consistency, shape, and odor. Call the nurse to observe the results.
  35. 46 Provide perineal care as needed.
  36. 47 Remove the waterproof under-pad.
  37. 48 Empty, rinse, clean, and disinfect equipment. Flush the toilet after the nurse observes the results.
  38. 49 Return equipment to its proper place.
  39. 50 Remove and discard the gloves. Practice hand hygiene.
  40. 51 Assist with hand-washing. Wear gloves for this step. Practice hand hygiene after removing and discarding the gloves.
  41. 52 Cover the person. Remove the bath blanket.

Post-Procedure

  1. 53 Provide for comfort. (See the inside of the front cover.)
  2. 54 Place the call light and other needed items within reach.
  3. 55 Lower the bed to a safe and comfortable level for the person. Follow the care plan.
  4. 56 Raise or lower bed rails. Follow the care plan.
  5. 57 Unscreen the person.
  6. 58 Complete a safety check of the room. (See the inside of the front cover.)
  7. 59 Follow agency policy for used linens and used supplies.
  8. 60 Practice hand hygiene.
  9. 61 Report and record your observations.

image The Small-Volume Enema

Small-volume enemas irritate and distend the rectum. This causes a BM. They are ordered for constipation or when the bowel does not need complete cleansing.

These enemas are ready to give. This solution is usually given at room temperature. To give the enema, squeeze and roll up the plastic container from the bottom. Do not release pressure on the bottle. Otherwise, solution is drawn from the rectum back into the bottle.

Urge the person to retain the solution until he or she needs to have a BM. This usually takes 5 to 10 minutes. Staying in the Sims' or left side-lying position helps retain the enema.

See procedure: Giving a Small-Volume Enema.

image Giving a Small-Volume Enema image

Quality of Life

Pre-Procedure

  1. 1 Follow Delegation Guidelines:
  2. See Promoting Safety and Comfort:
  3. 2 Practice hand hygiene.
  4. 3 Collect the following before going to the person's room.
  5. 4 Arrange items in the person's room.
  6. 5 Practice hand hygiene.
  7. 6 Identify the person. Check the ID bracelet against the assignment sheet. Use 2 identifiers (Chapter 13). Also call the person by name.
  8. 7 Put on gloves.
  9. 8 Collect the following.
  10. 9 Remove and discard the gloves. Practice hand hygiene. Put on clean gloves.
  11. 10 Provide for privacy.
  12. 11 Raise the bed for body mechanics. Bed rails are up if used.

Procedure

  1. 12 Lower the bed rail near you if up.
  2. 13 Cover the person with a bath blanket. Fan-fold top linens to the foot of the bed.
  3. 14 Position the person in Sims' or left side-lying position.
  4. 15 Place the waterproof under-pad under the buttocks.
  5. 16 Expose the anal area.
  6. 17 Position the bedpan near the person.
  7. 18 Remove the cap from the enema tip.
  8. 19 Separate the buttocks to see the anus.
  9. 20 Ask the person to take a deep breath through the mouth.
  10. 21 Insert the enema tip 2 inches into the adult's rectum (Fig. 26-9). Do this when the person is exhaling. Insert the tip gently. Stop if the person complains of pain, you feel resistance, or bleeding occurs.
    image
    FIGURE 26-9 The small-volume enema tip is inserted 2 inches into the rectum.
  11. 22 Squeeze and roll up the container gently. Release pressure on the bottle after you remove the tip from the rectum.
  12. 23 Put the container into the box, tip first. Discard the container and box.
  13. 24 Assist the person to the bathroom or commode when he or she has the urge to have a BM. The person wears a robe and non-skid footwear when up. The bed is at a low level that is safe and comfortable for the person. Or help the person onto the bedpan and raise the head of the bed. Raise or lower bed rails according to the care plan.
  14. 25 Place the call light and toilet tissue within reach. Remind the person not to flush the toilet.
  15. 26 Discard disposable items.
  16. 27 Remove and discard the gloves. Practice hand hygiene.
  17. 28 Leave the room if the person can be left alone.
  18. 29 Return when the person signals. Or check on the person every 5 minutes. Knock before entering the room or bathroom.
  19. 30 Practice hand hygiene. Put on gloves.
  20. 31 Lower the bed rail if up.
  21. 32 Observe enema results for amount, color, consistency, shape, and odor. Call the nurse to observe the results.
  22. 33 Provide perineal care as needed.
  23. 34 Remove the waterproof under-pad.
  24. 35 Empty, rinse, clean, and disinfect equipment. Flush the toilet after the nurse observes the results.
  25. 36 Return equipment to its proper place.
  26. 37 Remove and discard the gloves. Practice hand hygiene.
  27. 38 Assist with hand-washing. Wear gloves for this step. Practice hand hygiene after removing and discarding the gloves.
  28. 39 Cover the person. Remove the bath blanket.

Post-Procedure

  1. 40 Provide for comfort. (See the inside of the front cover.)
  2. 41 Place the call light and other needed items within reach.
  3. 42 Lower the bed to a safe and comfortable level for the person. Follow the care plan.
  4. 43 Raise or lower bed rails. Follow the care plan.
  5. 44 Unscreen the person.
  6. 45 Complete a safety check of the room. (See the inside of the front cover.)
  7. 46 Follow agency policy for used linens and used supplies.
  8. 47 Practice hand hygiene.
  9. 48 Report and record your observations.

image The Oil-Retention Enema

Oil-retention enemas relieve constipation and fecal impaction. The oil softens feces and lubricates the rectum so feces pass with ease. The oil is retained for 30 minutes to 1 to 3 hours. Most oil-retention enemas are ready-to-use.

See Promoting Safety and Comfort: The Oil-Retention Enema.

See procedure: Giving an Oil-Retention Enema.

image Giving an Oil-Retention Enema image

Quality of Life

Pre-Procedure

  1. 1 Follow Delegation Guidelines:
  2. See Promoting Safety and Comfort:
  3. 2 Practice hand hygiene.
  4. 3 Collect the following.
  5. 4 Arrange items in the person's room.
  6. 5 Practice hand hygiene.
  7. 6 Identify the person. Check the ID bracelet against the assignment sheet. Use 2 identifiers (Chapter 13). Also call the person by name.
  8. 7 Provide for privacy.
  9. 8 Raise the bed for body mechanics. Bed rails are up if used.

Procedure

  1. 9 Put on gloves.
  2. 10 Follow steps 12 through 23 in procedure: Giving a Small-Volume Enema, p. 435.
  3. 11 Cover the person. Leave him or her in the Sims' or left side-lying position.
  4. 12 Encourage retention of the enema for the time ordered.
  5. 13 Place more waterproof under-pads on the bed if needed.
  6. 14 Remove and discard the gloves. Practice hand hygiene.

Post-Procedure

  1. 15 Provide for comfort. (See the inside of the front cover.)
  2. 16 Place the call light and other needed items within reach.
  3. 17 Lower the bed to a safe and comfortable level for the person. Follow the care plan.
  4. 18 Raise or lower bed rails. Follow the care plan.
  5. 19 Unscreen the person.
  6. 20 Complete a safety check of the room. (See the inside of the front cover.)
  7. 21 Follow agency policy for used linens and used supplies.
  8. 22 Practice hand hygiene.
  9. 23 Report and record your observations.
  10. 24 Check the person often.

The Person With an Ostomy

Sometimes part of the intestines is removed surgically. Cancer, bowel disease, and trauma (stab or bullet wounds) are common reasons. An ostomy is sometimes necessary. An ostomy is a surgically created opening that connects an internal organ to the body's surface. The surgically created opening seen on the body's surface is called a stoma (Fig. 26-10). A pouch is worn over the stoma to collect stools and flatus.

image
FIGURE 26-10 A stoma on the surface of the body.

Colostomy

A colostomy is a surgically created opening (stomy) between the colon (colo) and the body's surface. Part of the colon is brought out onto the body's surface and a stoma is made. Feces and flatus pass through the stoma instead of the anus.

With a permanent colostomy, the diseased part of the colon is removed. A temporary colostomy gives the diseased or injured bowel time to heal. After healing, the bowel is surgically reconnected. The colostomy site depends on the site of disease or injury (Fig. 26-11). Stool consistency—liquid to formed—depends on the colostomy site. The more colon remaining to absorb water, the more solid and formed the stool. If the colostomy is near the end of the colon, stools are formed.

imageimageimageimage
FIGURE 26-11 Colostomy sites. Shading shows the part of the bowel surgically removed. A, Sigmoid or descending colostomy. B, Transverse colostomy. C, Ascending colostomy. D, Double-barrel colostomy has 2 stomas. One allows for the excretion of feces. The other is for the introduction of drugs to help the bowel heal. This type is usually temporary.

Stools irritate the skin. Skin care prevents skin breakdown around the stoma. The skin is washed and dried. Then a skin barrier is applied around the stoma. It prevents stools from having contact with the skin. The skin barrier is part of the pouch or a separate device.

Ileostomy

An ileostomy is a surgically created opening (stomy) between the ileum (small intestine [ileo]) and the body's surface. Part of the ileum is brought out onto the body's surface and a stoma is made. The entire colon is removed (Fig. 26-12, p. 438).

image
FIGURE 26-12 An ileostomy. The entire large intestine is surgically removed.

Liquid stools drain constantly from an ileostomy. Water is not absorbed because the colon was removed. Feces in the small intestine contain digestive juices that are very irritating to the skin. The ileostomy pouch must fit well. Stools must not touch the skin. Good skin care is required.

image Ostomy Pouches

A plastic pouch with an adhesive backing is applied to the skin. Some pouches are secured to ostomy belts (Fig. 26-13).

image
FIGURE 26-13 The ostomy pouch is secured to an ostomy belt. The pouch is emptied by directing it into the toilet and opening the end.

Pouches have a drain at the bottom that closes with a clip, clamp, or wire closure. The drain is opened to empty the pouch. The pouch is emptied when stools are present. It is opened when it balloons or bulges to release flatus. The drain is wiped with toilet tissue before closing.

The pouch is changed every 2 to 7 days and when it leaks. Frequent pouch changes can damage the skin.

Odors are prevented by:

The person wears normal clothes. However, tight garments can prevent feces from entering the pouch. Also, bulging from stools and flatus can be seen with tight clothes.

Peristalsis increases after eating and drinking. Therefore stomas are usually quiet after sleep. That is, expelling feces is less likely at this time. If the person showers or bathes with the pouch off, it is best done before breakfast. Showers and baths are delayed for 1 to 2 hours after applying a new pouch. This gives adhesive time to seal to the skin.

Do not flush pouches down the toilet. Follow agency policy for disposal.

See Focus on Children and Older Persons: Ostomy Pouches.

See Delegation Guidelines: Ostomy Pouches.

See Promoting Safety and Comfort: Ostomy Pouches.

See procedure: Changing an Ostomy Pouch.

image imageimageChanging an Ostomy Pouch

Quality of Life

Pre-Procedure

  1. 1 Follow Delegation Guidelines:
  2. See Promoting Safety and Comfort:
  3. 2 Practice hand hygiene.
  4. 3 Collect the following before going to the person's room.
  5. 4 Place the paper towels on the over-bed table. Arrange supplies on top of the paper towels.
  6. 5 Practice hand hygiene.
  7. 6 Identify the person. Check the ID bracelet against the assignment sheet. Use 2 identifiers (Chapter 13). Also call the person by name.
  8. 7 Put on gloves.
  9. 8 Collect the following.
  10. 9 Remove and discard the gloves. Practice hand hygiene. Put on clean gloves.
  11. 10 Provide for privacy.
  12. 11 Raise the bed for body mechanics. Bed rails are up if used.

Procedure

  1. 12 Lower the bed rail near you if up.
  2. 13 Cover the person with a bath blanket. Fan-fold linens to the foot of the bed.
  3. 14 Place the waterproof under-pad under the buttocks.
  4. 15 Disconnect the pouch from the belt if one is worn. Remove the belt.
  5. 16 Remove and place the pouch and skin barrier in the bedpan. Gently push the skin down and lift up on the barrier. Use adhesive remover wipes if necessary.
  6. 17 Wipe the stoma and around it with a gauze pad. This removes excess stool and mucus. Discard the gauze pad into the disposable bag.
  7. 18 Wet the gauze pads or washcloth.
  8. 19 Wash the stoma and the skin around it with a gauze pad or washcloth. Wash gently. Do not scrub or rub the skin.
  9. 20 Pat dry with a gauze pad or the towel.
  10. 21 Observe the stoma and the skin around the stoma. Report bleeding, skin irritation, or skin breakdown.
  11. 22 Remove the backing from the new pouch.
  12. 23 Apply a thin layer of paste around the pouch opening. Let it dry following the manufacturer's instructions.
  13. 24 Pull the skin around the stoma taut. The skin must be wrinkle-free.
  14. 25 Center the pouch over the stoma. The drain is downward.
  15. 26 Press around the pouch and skin barrier so it seals to the skin. Apply gentle pressure with your fingers. Start at the bottom and work up around the sides to the top.
  16. 27 Maintain the pressure for 1 to 2 minutes. This allows the adhesive on the skin barrier to activate. Follow the manufacturer's instructions.
  17. 28 Tug downward on the pouch gently. Make sure the pouch is secure.
  18. 29 Add deodorant to the pouch (if needed).
  19. 30 Close the pouch at the bottom. Use a clamp, clip, or wire closure.
  20. 31 Attach the ostomy belt if used. The belt should not be too tight. You should be able to slide 2 fingers under the belt.
  21. 32 Remove the waterproof under-pad.
  22. 33 Discard disposable supplies into the disposable bag.
  23. 34 Remove and discard the gloves. Practice hand hygiene.
  24. 35 Cover the person. Remove the bath blanket.

Post-Procedure

  1. 36 Provide for comfort. (See the inside of the front cover.)
  2. 37 Place the call light and other needed items within reach.
  3. 38 Lower the bed to a safe and comfortable level for the person. Follow the care plan.
  4. 39 Raise or lower bed rails. Follow the care plan.
  5. 40 Unscreen the person.
  6. 41 Practice hand hygiene. Put on gloves.
  7. 42 Take the bedpan and disposable bag into the bathroom.
  8. 43 Empty the pouch and bedpan into the toilet. Observe the color, amount, consistency, and odor of stools. Flush the toilet.
  9. 44 Discard the pouch into the disposable bag. Discard the disposable bag.
  10. 45 Empty, rinse, clean, and disinfect equipment. Return equipment to its proper place.
  11. 46 Remove and discard the gloves. Practice hand hygiene.
  12. 47 Complete a safety check of the room. (See the inside of the front cover.)
  13. 48 Follow agency policy for used linens.
  14. 49 Practice hand hygiene.
  15. 50 Report and record your observations.

Focus on Pride

The Person, Family, and Yourself

Personal and Professional Responsibility

You are responsible for knowing the legal limits of your role. Some states and agencies allow nursing assistants to insert some types of suppositories. If your state and agency allow this, you must know your limits. You cannot insert all types.

For example, you may be allowed to insert suppositories only in persons who use them regularly for constipation. You cannot give a suppository for fever or vomiting. Know what you are and are not allowed to do. Never perform a task beyond the legal limits of your role.

Rights and Respect

Bowel elimination is typically done in private. Illness, disease, surgery, and aging can affect this private act. Some persons may feel embarrassed to have a BM in a strange setting. To promote comfort and privacy:

Independence and Social Interaction

Persons with ostomies manage their care if able. Some have had ostomies for a long time. They may have special routines or care measures. Do not react to things that seem odd to you. When you assist, ask what they prefer. Listen to their requests. Follow their choices in ostomy care. To promote independence, allow personal choice and control as much as safely possible.

Delegation and Teamwork

The nurse may delegate a task to you that you have not done before. Giving an enema is an example. Never attempt a task that you are not comfortable doing. Make sure your state and agency allow you to perform the procedure. If those conditions are met, you can politely say: “I'm sorry, but I have never done that task before. I am not comfortable doing it on my own. Would you please show me how it is done?” Take pride in making the right choice to tell the nurse about your delegation concern.

Ethics and Laws

Leaving a person sitting or lying in urine or feces is neglect. It is a form of physical abuse. State laws, the Omnibus Budget Reconciliation Act of 1987 (OBRA), and the CMS require the reporting and investigating of abuse.

If found guilty of abuse, neglect, or mistreatment, you will lose your job. The offense is noted on your registry. You cannot work in a nursing center or on a skilled care nursing unit in a hospital. Protect yourself from being accused of neglect. Check on your patients or residents often. Do not leave them sitting or lying in urine or feces.

Focus on Pride: Application

You are asked to do an unfamiliar task. Do you seek help? Do you try to do it alone? Does asking for help bother you?

Supervision is part of the nurse's role in delegation. The nurse needs to know your comfort level with tasks. Never be ashamed to ask for supervision.

Review Questions

Circle the BEST answer

1. Which is true?

a A person must have a BM every day.

b Stools are normally brown, soft, and formed.

c Diarrhea occurs when feces move slowly through the bowel.

d Constipation occurs when feces move quickly through the bowel.

2. Which should you ask the nurse to observe?

a A black and tarry stool

b The person's first BM of the day

c Stool with an odor

d Liquid stool from an ileostomy

3. The prolonged retention and buildup of feces in the rectum is called

a Constipation

b Fecal impaction

c Diarrhea

d Fecal incontinence

4. These measures promote normal BMs. Which is outside your role limits?

a Provide oral fluids according to the care plan.

b Assist with activity according to the care plan.

c Give drugs to control diarrhea.

d Provide privacy for bowel elimination.

5. A person has C. difficile. You should

a Disinfect care items with soap and water

b Use an alcohol-based hand rub before leaving the room

c Wear a gown and gloves

d Refuse to care for the person

6. Bowel training is aimed at

a Bowel control and regular elimination

b Ostomy control

c Promoting toilet use

d Preventing bleeding

7. Your state and agency allow you to insert rectal suppositories. You insert a suppository

a Into the feces

b Into the stoma

c Along the rectal wall

d With an enema tube

8. Which is used for a cleansing enema?

a Mineral, olive, or cottonseed oil

b A suppository

c A 120 mL bottle of solution

d Tap water, saline, or a soapsuds enema

9. Which is used for cleansing enemas in children?

a Soapsuds

b Saline

c Oil

d Tap water

10. When giving an enema

a Use a cool solution

b Place the person in the supine position

c Have the person void after giving the enema

d Give the solution slowly

11. In adults, the enema tube is inserted

a 2 to 4 inches

b 6 to 8 inches

c 12 inches

d Until you feel resistance

12. A small-volume enema is retained

a For 2 minutes

b At least 10 to 20 minutes

c At least 30 minutes

d Until the urge to have a BM is felt

13. Which care measure for an ostomy should you question?

a Use deodorant in the pouch.

b Perform good skin care around the stoma.

c Change the pouch daily.

d Apply a skin barrier around the stoma.

14. An ostomy pouch is usually emptied

a Every 4 to 6 hours

b When it is full

c Every 2 to 7 days

d When stools are present

See Review Question Answers at the back of the text.

Focus on Practice

Problem Solving

A resident shares a bathroom with a roommate. You respond to the resident's call light. He says he needs to have a BM urgently. The bathroom is occupied. What do you do?