N310.BowelElimination

Mouth

Digestion begins with mastication.

Anus

Expels feces and flatus from the rectum

Incontinence

Inability to control passage of feces and gas to the anus

Ileostomy or colostomy

The standard bowel diversion creates a stoma.

soapsuds

to tap water or saline to create the effect of intestinal irritation to stimulate peristalsis. Use only pure castile soap that comes in liquid form and is included in most soapsuds enema kits. Use soapsuds enemas with caution in pregnant women and older adults because they cause electrolyte imbalance or damage to the intestinal mucosa.

CONSTIPATION AND DIARRHEA

For healthy clients, constipation and diarrhea are not serious. But for older adult clients and clients with pre-existing health problems, constipation and diarrhea can be serious.

Nursing Knowledge Base:Factors Affecting Bowel Elimination

Many factors influence the process of bowel elimination. Knowledge of these factors helps to anticipate measures required to maintain a normal elimination pattern. Mechanical breakdown of food elements, gastrointestinal motility, and selective absorption and secretion of substances by the large intestine influence the character of feces. Food high in fiber content and increased fluid intake keep feces soft. Developmental changes affect elimination. Infants have small stomach capacity and rapid peristalsis. Systemic changes in the function of digestion and in absorption of nutrients result from changes in older patients' cardiovascular and neurological systems, rather than their GI system. Diet and fluid intake will alter elimination. Fiber, the nondigestible residue in the diet, provides the bulk of fecal material. Bulk-forming foods such as whole grains, fresh fruits, and vegetables help flush fats and waste products from the body with greater efficiency. Food intolerance is not an allergy but rather relates to a particular food that causes the body distress within a few hours of ingestion. The body needs adequate fluid intake to liquefy intestinal contents. Unless a medical contraindication is known, an adult needs to drink six to eight glasses (1500 to 2000 mL) of fluid daily. Physical activity promotes peristalsis. During emotional stress, the digestive process is accelerated, and peristalsis is increased. Stress can be a causative factor for colitis, irritable bowel syndrome (IBS), ulcers, and Crohn's disease. If a person becomes depressed, the autonomic nervous system slows impulses; peristalsis decreases, resulting in constipation. Personal habits will influence elimination. Many people prefer their own bathroom facilities and want to use those facilities when possible. A busy work schedule sometimes prevents the individual from responding appropriately to the urge to defecate, disrupting regular habits and causing possible alterations such as constipation. Chronically ill and hospitalized patients do not always have privacy, which may affect the defecation process. Another factor related to defecation is the preferred position. Squatting is the normal position during defecation. Modern toilets facilitate this posture, allowing the person to lean forward, exert intra-abdominal pressure, and contract the thigh muscles. In a supine position, it is impossible to contract the muscles used during defecation. If the patient's condition permits, raise the head of the bed to assist the patient to a more normal sitting position on a bedpan, enhancing the ability to defecate. Conditions that cause pain (such as hemorrhoids) often cause the patient to suppress the urge to defecate to avoid pain, contributing to the development of constipation. As pregnancy advances, the size of the fetus will put pressure on the rectum, which can cause an obstruction. Slowing of peristalsis during the third trimester often leads to constipation. General anesthetic agents used during surgery cause temporary cessation of peristalsis. Any surgery that involves direct manipulation of the bowel temporarily stops peristalsis. This condition, called paralytic ileus, usually lasts about 24 to 48 hours. If the patient remains inactive or is unable to eat after surgery, return of normal bowel elimination is further delayed. The use of medications can affect bowel functioning. Even though laxatives and cathartics promote peristalsis, when used inappropriately, the intestines lose muscle tone and become less responsive to medication stimulation. Following the diagnostic procedure, changes in elimination such as increased gas or loose stools often occur until the patient resumes a normal eating pattern. [Review Table 46-2 on text p. 1091 Medications and the Gastrointestinal System.] Diagnostic examinations such as endoscopy or colonoscopy require bowel preparation. Before and after the procedure, the patient will experience gas and loose stools until a normal eating pattern is resumed.

Nursing Process: Assessment

Nursing history What a patient describes as normal or abnormal is often different from factors and conditions that tend to promote normal elimination. Identifying normal and abnormal patterns, habits, and the patient's perception of normal and abnormal with regard to bowel elimination allows you to accurately determine a patient's problems. Focus assessment of elimination patterns on bowel habits, factors that normally influence defecation, recent changes in elimination, and a physical examination. Assessment of bowel elimination patterns and abnormalities includes a nursing history, physical assessment of the abdomen, inspection of fecal characteristics, and review of relevant test results. In addition, determine the patient's medical history, patterns and types of fluid and food intake, chewing ability, medications, and recent illnesses and/or stressors. The nursing history provides a review of the patient's usual bowel pattern and habits. [Discuss the following points of assessment: Determination of the usual elimination pattern: include frequency and time of day Patient's description of usual stool characteristics Identification of routines followed to promote normal elimination Assessment of the use of artificial aids for home movement Presence and status of bowel diversions Changes in appetite: include changes in eating patterns and changes in weight (amount of loss or gain) Diet history: determine the patient's dietary preferences for a day Description of daily fluid intake: this includes the type and amount of fluid History of surgery or illnesses affecting the GI tract: Medication history: ask whether the patient takes medications that alter defecation or fecal characteristics Emotional state: the patient's emotions significantly alter the frequency of defecation History of exercise: ask the patient to specifically describe the type and amount of daily exercise. History of pain or discomfort: ask the patient whether there is a history of abdominal or anal pain. Social history: patients have many different living arrangements. Mobility and dexterity: evaluate patients' mobility and dexterity to determine whether they need assistive devices or help from personnel.]

Organs of the Gastrointestinal (GI) Tract

Organs of the gastrointestinal (GI) tract are shown, with the heart as the reference point. The GI tract is a series of hollow mucous membrane-lined muscular organs. These organs absorb fluid and nutrients, prepare food for absorption and use by body cells, and provide for temporary storage of feces. The GI tract absorbs high volumes of fluids, making fluid and electrolyte balance a key function of the GI system. In addition to ingested fluids and foods, the GI tract receives secretions from the gallbladder and pancreas. Digestion begins in the mouth and ends in the small intestine. The mouth mechanically and chemically breaks down nutrients into a usable size and form. The teeth masticate food, breaking it down into a size suitable for swallowing. Saliva, produced by the salivary glands in the mouth, dilutes and softens the food in the mouth for easier swallowing. As food enters the upper esophagus, it passes through the upper esophageal sphincter, a circular muscle that prevents air from entering the esophagus and food from refluxing into the throat. The bolus of food travels down the esophagus and is pushed along by peristalsis, which propels it through the length of the GI tract. As food moves down the esophagus, it reaches the cardiac or lower esophageal sphincter, which lies between the esophagus and the upper end of the stomach. The sphincter prevents reflux of stomach contents back into the esophagus. The stomach performs three tasks: Storing of swallowed food and liquid Mixing of food, liquid, and digestive juices Emptying of its contents into the small intestine. It produces and secretes hydrochloric acid (HCl), mucus, the enzyme pepsin, and intrinsic factor. Pepsin and HCl facilitate the digestion of protein. Mucus protects the stomach mucosa from acidity and enzyme activity. Intrinsic factor is essential for the absorption of vitamin B12.

Stoma

Surgical opening in the ileum or colon

Oil retention enemas

lubricate the rectum and colon. The feces absorb the oil and become softer and easier to pass. To enhance the action of the oil, the patient retains the enema for several hours if possible.

OSTOMY CARE: Equipment

› Pouch system (skin barrier and pouch) › Pouch closure clamp › Barrier pastes (optional) › Gloves › Washcloths › Towel › Warm water › Scissors › Pen

Preparation for Diagnostic Test

■ Protocols vary with the provider and the facility, but generally include clear liquids only and a bowel cleanser. ■ Clients receive moderate (conscious) sedation and may not drive home afterwards.

Kayexalate

(used potassium problems)

Alternative Approaches

A stoma causes serious body image changes, particularly if it is permanent. A stoma causes serious body image changes, particularly if it is permanent. After the surgery, patients face a variety of anxieties and concerns, from learning how to manage their stoma to coping with conflicts of self-esteem and body image. Provide emotional support before and after surgery. Patients often perceive a stoma as invasive and disfiguring. However, a well-placed stoma usually does not interfere with the patient's activities and is concealed with clothing. Nonetheless, even though clothing conceals the ostomy, the patient feels different. Many patients have difficulty maintaining or initiating normal sexual relations. Important factors affecting reactions to the stoma include the character of fecal secretions and the ability to control them. Foul odors, spillage, or leakage of liquid stools and inability to regulate bowel movements cause the patient to lose self-esteem. The aging process often affects the ability to manage stomas, even in people who have had them for years. You need to recognize and intervene when problems resulting from advanced age such as skin changes, weight loss or gain, visual impairments, or changes in diet occur. Refer the patient to ostomy support groups such as the United Ostomy Associations of America at http://www.uoaa.org, which has discussion boards for various types of incontinent and continent diversions and networks. The Wound, Ostomy, and Continence Nurses Society (http://www. wocn.org) provides information and helps patients locate a wound, ostomy, continence nurse (WOCN).

Constipation

A symptom, not a disease; infrequent stool and/or hard, dry, small stools that are difficult to eliminate

Flatulence

Accumulation of gas in the intestines causing the walls to stretch

FACTORS AFFECTING BOWEL ELIMINATION

Age: › Infants: » Breast milk stools - watery and yellow brown » Formula stools - pasty and brown › Toddlers: bowel control at 2 to 3 years old › Older adults: decreased peristalsis, relaxation of sphincters Diet: › Fiber requirement: 25 to 30 g/day › Lactose intolerance: difficulty digesting milk products Fluids: › Fluid requirement: 2,000 to 3,000 mL/day from fluid and food sources Physical activity: › Stimulates intestinal activity Psychosocial factors: › Emotional distress increasing peristalsis and exacerbating chronic conditions (colitis, Crohn's disease, ulcers, irritable bowel syndrome) › Depression decreases peristalsis and can lead to constipation. Personal habits: › Use of public toilets, false perception of the need for "one-a-day" bowel movements, lack of privacy when hospitalized Positioning: › Normal: squatting › Immobilized client: difficulty defecating Pain: › Normal defecation is painless. Discomfort leads to suppression of the urge to defecate. › Opioid use contributing to constipation Pregnancy: › Growing fetus compromising intestinal space › Slower peristalsis › Straining increasing the risk of hemorrhoids Surgery and anesthesia: › Temporary slowing of intestinal activity › Paralytic ileus - rationale for auscultating bowel sounds before advancing diet Medications: › Laxatives - to soften stool › Cathartics - to promote peristalsis › Laxative abuse leading to diarrhea and dehydration

Common Bowel Elimination Problems

Alterations in bowel elimination result from a variety of factors. (See previous slide for discussion of constipation.) If impaction is unrelieved, it can result in intestinal obstruction. The greatest danger from diarrhea is development of fluid and electrolyte imbalance. Antibiotics, chemotherapy, and invasive bowel procedures such as surgery or colonoscopy disrupt normal bowel flora and cause an overgrowth of Clostridium difficile; symptoms range from mild diarrhea to severe colitis. Communicable foodborne pathogens also cause diarrhea. Hand hygiene following use of the bathroom, before and after preparing foods, and when cleaning and storing fresh produce and meats greatly reduces the risk of foodborne illness. Using an anal bag or a bowel management system for incontinence helps to prevent perineal skin breakdown. Flatulence causes abdominal distention and severe, sharp pain if intestinal motility is reduced because of opiates, general anesthetics, abdominal surgery, or immobilization. Increased venous pressure from straining at defecation, pregnancy, heart failure, and chronic liver disease causes hemorrhoids.

Continuing and Restorative Care

Care of ostomies Irrigating a colostomy Pouching ostomies An effective pouching system protects the skin, contains fecal material, remains odor free, and is comfortable and inconspicuous. Nutritional considerations Consume low fiber for the first weeks. Eat slowly and chew food completely. Drink 10 to 12 glasses of water daily. Patient may choose to avoid gassy foods. Regular elimination patterns need to begin for a patient to recover and return home or to an extended care facility. It is important to remember that ostomy care and bowel retraining are instituted in acute care settings. However, because these are long-term care needs, teaching is usually completed in restorative care settings. The location of an ostomy influences the consistency of the stool. Patients with temporary or permanent bowel diversions have unique elimination needs. An individual with an ostomy wears a pouch or appliance to collect effluent—stool discharged from the stoma. Skin breakdown occurs after repeated exposure to liquid stool. The patient needs to use meticulous skin care to prevent liquid stool from irritating the skin around the stoma. [Irrigating a colostomy is discussed on the next slide.] An ostomy requires a pouch to collect fecal material. A person wearing a pouch needs to feel secure enough to participate in any activity. Proper selection and use of an ostomy pouching system are necessary to prevent damage to the skin around the stoma. Many pouching systems are available. To ensure that a pouch fits well and meets the patient's needs, consider the location of the ostomy, type and size of the stoma, type and amount of ostomy drainage, size and contour of the abdomen, condition of the skin around the stoma, physical activities of the patient, patient's personal preference, age and dexterity, and cost of equipment. A wound ostomy continence nurse (WOCN) is specially educated to care for ostomy patients; the WOCN collaborates with staff nurses to make sure that the patient uses the correct pouching system, especially when the patient is ill or is experiencing health changes or problems with the ostomy. A pouching system consists of a pouch and a skin barrier. Assess the stoma color. A normal stoma is bright pink or brick red. Notify the health care provider if the stoma is blue, brown, or black, which indicates circulation problems to the stoma. You need to measure the stoma size carefully when selecting and cutting out the opening on the wafer skin barrier. Too tight of an opening constricts the stoma and causes irritation and necrosis. Subtle stoma changes occur over time. Encourage patients to visit their enterostomal nurse at least annually to ensure proper pouching and fit. A good skin barrier protects the skin, prevents irritation from repeated removal of the pouch, and is comfortable for the patient to wear. Patients with new stomas often feel vulnerable when they leave the hospital. To provide a smooth transition from hospital to home, offer help for the patient and family caregivers. Effective patient teaching helps patients with a new ostomy transition smoothly to home. [See also Box 46-10 on p. 1110 Patient Teaching: Teaching the Patient How to Provide Ostomy Care.] Nutritional therapy is important for patients with ostomies. During the first weeks after surgery, many health care providers recommend low-fiber diets, particularly for patients with ileostomies, because the small bowel requires time to adapt to the diversion. As ostomies heal, patients are able to eat almost any food. High-fiber foods such as fresh fruits and vegetables help ensure a more solid stool. Patients need to avoid blockages of the bowel. The surgical construction of the stoma affects the likelihood of blockage.

Acute Care: Medications

Cathartics(enema) and laxatives Antidiarrheal agents Over the counter(fleets enema: dangerous to person with kidney disease) Changes in the patient's fluid status, mobility patterns, nutrition, and sleep cycle, as well as surgical interventions, affect regular bowel habits. Ongoing use of cathartics, laxatives, and enemas affects and delays normal defecation reflexes. Cathartics, laxatives, and occasionally an enema are used to resolve constipation; antidiarrheal preparations help the patient to resolve diarrhea. Caution patients not to use these over-the-counter medications on a prolonged basis without consulting their health care provider. Often a patient is unable to defecate normally because of pain, constipation, or impaction. Cathartics and laxatives have the short-term action of emptying the bowel. They are prescribed for bowel evacuation for patients undergoing GI tests and abdominal surgery. Although the terms cathartic and laxative are often used interchangeably, cathartics have a stronger effect on the intestines. Five types of laxatives and cathartics are available. Cathartics and laxatives are available in oral, tablet, powder, and suppository dosage forms. Although the oral route is most commonly used, suppositories are more effective because of their stimulant effect on the rectal mucosa. Excessive use of laxatives, enemas, and/or bulk-forming agents increases the patient's risks for diarrhea and abnormal bowel elimination. In chronically ill or older adult patients, weakness and the frequent need to use toilet facilities result in increased risks for falls and other injuries. For patients with diarrhea, frequent passage of liquid stools becomes a problem. Many patients use over-the-counter agents such as Imodium to relieve common diarrhea. However, the most effective antidiarrheal agents are prescriptive opiates such as codeine phosphate, opium tincture (Paregoric), and diphenoxylate (Lomotil). Antidiarrheal opiate agents decrease intestinal muscle tone to slow the passage of feces. Opiates inhibit peristaltic waves that move feces forward, but they also increase segmental contractions that mix intestinal contents. As a result, the intestinal walls absorb more water. Use antidiarrheal agents with caution because opiates are habit forming. Patients with diarrhea lasting longer than 2 days need a stool culture and an evaluation of diet and fluid intake for intolerance of foods and fluids (e.g., excessive use of fruits, lactose).

Hemorrhoids

Dilated, engorged veins in the lining of the rectum

Small intestine

Duodenum, jejunum, and ileum

Implementations: Acute Care

Health promotion Promotion of normal defecation Establish a routine an hour after a meal, or maintain the patient's routine. Sitting position Privacy Positioning on bedpan Successful nursing interventions improve patients' and family members' understanding of bowel elimination. Teach the patient and family about proper diet, adequate fluid intake, and factors that stimulate or slow peristalsis such as emotional stress. This is often best done during the patient's mealtime. Patients need to learn the importance of establishing regular bowel routines, performing regular exercise, and taking appropriate measures when elimination problems develop. One of the most important habits to teach regarding bowel habits is taking time for defecation. To establish regular bowel habits, a patient needs to know when the urge to defecate normally occurs. Advise the patient to begin establishing a routine during a time when defecation is most likely to occur, usually an hour after a meal. When patients are restricted to bed or need help to ambulate, offer a bedpan, or help them reach the bathroom in a timely manner. Many patients have established routines for defecation. In a hospital or long-term care facility, make certain that treatment routines do not interfere with the patient's routine. It is important to provide privacy. When patients forced to use a bedpan share rooms with other people, pull the curtain around the area so patients are able to relax, knowing that interruptions will not occur. Always place the call light and toilet tissue within the patient's reach. When patients are at risk for falls, stand near them or leave the door partially open so you can see them at all times. A number of interventions stimulate the defecation reflex, affect the character of feces, or increase peristalsis to help patients evacuate bowel contents normally and without discomfort. Assist patients who have difficulty sitting because of muscular weakness and mobility problems. Place an elevated seat on the toilet when patients are unable to lower themselves to a sitting position because of joint- or muscle-wasting disease. These seats require patients to use less effort to sit or stand. Maintain the patient's privacy during bowel elimination. This is especially important for the patient who is using a bedpan. The call light and a supply of toilet paper need to be within easy reach. When the patient finishes, respond to the call signal immediately and remove the pan. The patient often requires assistance with wiping. To remove the pan, ask the patient to roll off to the side or to raise the hips. While wearing gloves, hold the pan steady to avoid spilling. Avoid pulling or shoving it from under the patient's hips because this pulls the patient's skin and causes tissue injury such as shearing. Remove the pan and clean the perineum from front to back. After assessing the stool, immediately empty the contents of the bedpan into the toilet or into a special receptacle in the utility room. A spray faucet attached to most toilets provides the ability to rinse the bedpan thoroughly. The patient uses the same bedpan each time. Finally, document the characteristics of the feces. Offer the bedpan often. Patients will accidentally soil bedclothes if forced to wait. Many patients try to avoid using a bedpan because it is embarrassing and uncomfortable. They often try to get to the bathroom even though their condition prohibits ambulation. Warn patients about the risks of falls or accidents.

Loop Colostomy

In this diagram of a loop colostomy, a loop of colon is exteriorized over a plastic rod for temporary fecal diversion. It is usually a temporary large stoma constructed in the transverse colon. A loop colostomy is usually performed in a medical emergency when health care providers anticipate closure of the colostomy. The surgeon pulls a loop of bowel onto the abdomen. An external supporting device such as a plastic rod, a bridge, or a rubber catheter is temporarily placed under the bowel loop to keep it from slipping back. The surgeon then opens the bowel and sutures it to the skin of the abdomen. A communicating wall remains between the proximal and distal bowel. The loop ostomy has two openings through one stoma. The proximal end drains stool, whereas the distal portion drains mucus. Within 7 to 10 days, the surgeon removes the supporting device.

Evaluation: Do you use medications such as laxatives or enemas to help you defecate? What barriers are preventing you from eating a diet high in fiber and participating in regular exercise? How much fluid do you drink in a typical day? What types of fluids do you normally drink? What challenges do you encounter when you change your ostomy pouch?

Optimally, the patient will be able to have regular, pain-free defecation of soft-formed stools. The patient is the only one who is able to determine whether bowel elimination problems have been relieved, and which therapies were most effective. If the nurse establishes a therapeutic relationship with the patient, the patient feels comfortable in discussing the intimate details often associated with bowel elimination. Evaluate a patient's level of knowledge regarding establishing a normal elimination pattern, caring for an ostomy, and promoting skin integrity. Also determine the extent to which the patient accomplishes normal defection. Ask the patient to describe changes in diet, fluid intake, and activity to promote bowel health. Ask the questions on the slide when a patient's outcomes are not met.

Esophagus

Peristalsis moves food into the stomach.

Assessment: Describe how you would use these "measurements" in your assessment:

Physical assessment: Assess-Aus--Pal-Per Physical assessment will include the examination of oral cavity, abdomen, rectum, and anus. Problems in any one of these areas will affect the GI system and proper functioning. Inspect the patient's teeth, tongue, and gums. Poor dentition or poorly fitting dentures influence the ability to chew. Sores in the mouth make eating not only difficult but also painful. Inspect all four abdominal quadrants for contour, shape, symmetry, and skin color. Note masses, peristaltic waves, scars, venous patterns, stomas, and lesions. Normally, you do not see peristaltic waves. Observable peristalsis is often a sign of intestinal obstruction. Check for abdominal distention, and auscultate all four abdominal quadrants. Gently palpate the abdomen for masses or areas of tenderness. Inspect the area around the anus for lesions, discoloration, inflammation, and hemorrhoids. Indirect and direct visualization of the lower GI tract requires cleansing of the bowel before the procedure. Laboratory tests A variety of radiological and diagnostic tests are used with the patient who is experiencing altered bowel elimination. Direct or indirect approaches are used to visualize GI structures. Diagnostic examinations Many facilities use moderate sedation during these procedures. The types of drugs most commonly used to achieve moderate sedation include benzodiazepines and opiates. It is essential to understand the safety precautions involved concerning this form of anesthesia. In many institutions, special training is required. A crash cart must be present at the bedside, and you must monitor the patient continuously with pulse oximetry and frequent vital signs—usually every 15 minutes.

Bowel Elimination

Regular elimination of bowel waste products is essential for normal body functioning. Alterations in bowel elimination are often early signs or symptoms of problems within the gastrointestinal (GI) or other body systems. Because bowel function depends on the balance of several factors, elimination patterns and habits vary among individuals. Understanding normal bowel elimination and factors that promote, impede, or cause alterations in elimination helps in management of patients' elimination problems. Supportive nursing care respects the patient's privacy and emotional needs. Measures designed to promote normal elimination need to minimize discomfort for the patient.

Impaction

Results from unrelieved constipation; a collection of hardened feces wedged in the rectum that a person cannot expel

Segmented and Peristaltic Waves

Segmentation and peristaltic movement in the small intestine facilitate both digestion and absorption. Chyme mixes with digestive juices (e.g., bile, amylase). Resorption in the small intestine is so efficient that, by the time the chyme reaches the end of the small intestine, it is pastelike in consistency. The small intestine has three sections: the duodenum, the jejunum, and the ileum. The duodenum is approximately 20 to 28 cm (8 to 11 inches) long and continues to process chyme from the stomach. The jejunum is approximately 2.5 m (8 feet) long and absorbs carbohydrates and proteins. The ileum is approximately 3.7 m (12 feet) long and absorbs water, fats, certain vitamins, iron, and bile salts. The duodenum and the jejunum absorb most of the nutrients and electrolytes. The intestinal wall also absorbs nutrients across the mucosa and into lymph fluids or blood vessels. Substances such as plant fiber, which the small intestine cannot digest, empty into the cecum at the lower right side of the abdomen. The large intestine begins at the cecum.

Stomach

Stores food; mixes food, liquid, and digestive juices; moves food into small intestines

Bowel Diversion

Temporary or permanent artificial opening in the abdominal wall Certain diseases cause conditions that prevent normal passage of feces through the rectum. Treatment for these disorders results in the need for a temporary or permanent artificial opening (stoma) in the abdominal wall. Surgical openings are created in the ileum (ileostomy) or colon (colostomy), with the ends of the intestine brought through the abdominal wall to create the stoma. The standard bowel diversion creates a stoma, or the patient has reconstructive bowel surgery that uses the native sphincter for bowel continence. Reconstructive surgery includes a continent stoma procedure or an ileoanal pouch anastomosis (described later).

Nursing Diagnosis and Planning

The Agency for Healthcare Research and Quality (AHRQ) provides guidelines on reduction of pressure ulcers that can also help you develop a plan of care for patients with bowel incontinence. Constipation-Risk for constipation-Perceived constipation Bowel incontinence-Diarrhea-Toileting self-care deficit Examples of diagnoses that apply to patients with elimination problems are shown on the slide. Rely on professional standards when planning. Guidelines on incontinence assist in protecting the patient's skin, promoting continence, and reducing the embarrassment associated with incontinence. Help patients establish goals and outcomes by incorporating their elimination habits or routines as much as possible and reinforcing the routines that promote health Nursing Diagnostic Process: Diarrhea Related to Food Intolerance Critical thinking model for elimination planning; Nursing Care Plan Constipation Related to Opiate-Containing Pain Medication and Decreased Fiber Intake

high and low cleansing enema

The health care provider sometimes orders a high or low cleansing enema. The terms high and low refer to the height from which, and hence the pressure with which, the fluid is delivered. High enemas cleanse the entire colon. After the enema is infused, ask the patient to turn from left lateral to dorsal recumbent, over to the right lateral position. This position change ensures that fluid reaches the large intestine. A low enema cleanses only the rectum and sigmoid colon.

Divisions of the Large Intestine

The lower GI tract is called the large intestine (colon) because it is larger in diameter than the small intestine. The large intestine is shorter (1.5 to 1.8 m [5 to 6 feet]) but much wider than the small intestine. The large intestine is divided into the cecum, colon, and rectum. The large intestine is the primary organ of bowel elimination. It is positioned like a question mark, partially encircling the small intestine. Chyme enters the large intestine by waves of peristalsis through the ileocecal valve, a circular muscular layer that prevents regurgitation. The colon is divided into the ascending, transverse, descending, and sigmoid colons. The muscular tissue of the colon allows it to accommodate and eliminate large quantities of waste and gas (flatus). It has three functions: absorption, secretion, and elimination. The large intestine absorbs water, sodium, and chloride from digested food that has passed from the small intestine. Healthy adults absorb more than a gallon of water and an ounce of salt from the colon every 4 hours. The amount of water absorbed from chyme depends on the speed at which colonic contents move. Chyme is normally a soft, formed mass. If peristalsis is abnormally fast, there is less time for water to be absorbed, and the stool is watery. If peristaltic contractions slow, water continues to be absorbed, and a hard mass of stool forms, resulting in constipation. The secretory function of the colon aids in electrolyte balance. The colon secretes bicarbonate in exchange for chloride. The colon excretes about 4 to 9 me of potassium daily. Therefore serious alterations in colon function (e.g., diarrhea) cause severe electrolyte disturbances. Slow peristaltic contractions move contents through the colon. Intestinal content is the main stimulus for contraction. Mass peristalsis pushes undigested food toward the rectum. These mass movements occur only 3 or 4 times daily, with the strongest during the hour after mealtime. The rectum is the final portion of the large intestine. Here, bacteria convert fecal matter into its final form. Normally, the rectum is empty of waste products (feces) until just before defecation. It contains vertical and transverse folds of tissue that help to temporarily hold fecal contents during defecation. Each fold contains an artery and a vein that can become distended from pressure during straining. This distention often results in hemorrhoid formation. The body expels feces and flatus from the rectum through the anal canal and anus. Contraction and relaxation of the internal and external sphincters, innervated by sympathetic and parasympathetic stimuli, aid in control of defecation. The anal canal is richly supplied with sensory nerves that help to control continence.

Continuing and Restorative Care: How would you go about teaching these to a patient? Bowel training Skin integrity (Maintaining)

The patient with incontinence is unable to maintain bowel control. A bowel training program helps some patients defecate normally, especially those who still have some neuromuscular control. The training program involves setting up a daily routine. By attempting to defecate at the same time each day and using measures that promote defecation, the patient gains control of bowel reflexes. The program requires time, patience, and consistency. The health care provider determines the patient's physical readiness and ability to benefit from bowel training. [Discuss the components of a successful program: Assessing the normal elimination pattern and recording times when the patient is incontinent Incorporating principles of gerontological nursing when providing bowel retraining programs for the older adult Choosing a time in the patient's pattern to initiate defecation control measures Giving stool softeners orally every day or a cathartic suppository at least half an hour before the selected defecation time (lower colon needs to be free of stool so suppository contacts intestinal mucosa) Offering a hot drink (hot tea) or fruit juice (prune juice) (or whatever fluids normally stimulate peristalsis for the patient) before the defecation time Helping the patient to the toilet at the designated time Avoiding medications such as opioids that increase constipation Providing privacy and setting a time limit for defecation (15 to 20 minutes) Instructing the patient to lean forward at the hips while sitting on the toilet, apply manual pressure with the hands over the abdomen, and bear down but not strain to stimulate colon emptying Not criticizing or conveying frustration if the patient is unable to defecate Maintaining normal exercise within the patient's physical ability] [See also Box 46-11 on p. 1111 Focus on Older Adults: Bowel Retraining.] In choosing a diet for promoting normal elimination, consider the frequency of defecation, the characteristics of feces, and the types of foods that impair or promote defecation. The patient with frequent constipation or impaction requires increased intake of high-fiber foods and more fluids. However, he or she needs to realize that diet therapy provides only long-term relief of elimination problems and does not give immediate relief from problems such as constipation. When diarrhea is a problem, recommend foods with low-fiber content and discourage foods that typically cause gastric upset or abdominal cramping. Diarrhea caused by illness is sometimes debilitating. If the patient cannot tolerate foods or liquids orally, intravenous therapy (with potassium supplements) is necessary. The patient returns to a normal diet slowly, often beginning with fluids. Excessively hot or cold fluids stimulate peristalsis, causing abdominal cramps and further diarrhea. As tolerance to liquids improves, the patient eats solid foods. A daily exercise program helps prevent elimination problems. Walking, riding a stationary bicycle, or swimming stimulates peristalsis. Patients who are sedentary at work are most in need of regular exercise. For a patient who is temporarily immobilized, attempt ambulation as soon as possible. If the condition permits, help the patient walk to a chair on the evening of the day of surgery. Have him or her walk farther each day. Some patients have difficulty passing stool because of weak abdominal and pelvic floor muscles. Exercises help patients who are confined to bed use a bedpan. The patient practices the exercises as follows: Lie supine; tighten the abdominal muscles as though pushing them to the floor. Hold the muscles tight to the count of three; relax. Repeat 5 to 10 times as tolerated. Flex and contract the thigh muscles by raising one knee slowly toward the chest. Repeat for each leg at least 5 times and increase frequency as tolerated. Pain results when hemorrhoid tissues are irritated directly. The primary goal for the patient with hemorrhoids is to have soft-formed, painless bowel movements. Proper diet, fluids, and regular exercise improve the likelihood of stools being soft. If the patient becomes constipated, passage of hard stools causes bleeding and irritation. An ice pack or a warm sitz bath provides temporary relief of swollen hemorrhoids. The patient with diarrhea or fecal incontinence is at risk for skin breakdown when fecal contents remain on the skin. The same problem exists for the patient with an ostomy that drains liquid stool. Liquid stool is usually acidic and contains digestive enzymes. Irritation from repeated wiping with toilet tissue aggravates skin breakdown. Bathing the skin after soiling helps, but sometimes it results in more breakdown unless the patient dries the skin thoroughly. When caring for a patient who is debilitated, incontinent, and unable to ask for assistance, check often for defecation. You can protect the anal areas with petrolatum, zinc oxide, or another ointment that holds moisture in the skin, preventing drying and cracking. Yeast infections of the skin often develop easily. Several powdered antifungal agents are effective against yeast. Do not use baby powder or cornstarch because they have no medical properties, often cake on the skin, are difficult to remove, and enhance fungal infections of the skin. [See also on text p. 1109 Box 46-9 Evidence-Based Practice: Recognition of Skin Problems.]

Large intestine

The primary organ of bowel elimination

Bowel Elimination: Scientific Knowledge Base

These structures are necessary for the defecation process. Physiological factors critical to bowel function and defecation include normal GI tract function, sensory awareness of rectal distention and rectal contents, voluntary sphincter control, and adequate rectal capacity and compliance. Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, distention causes relaxation of the internal sphincter and awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out. Sometimes people use the Valsalva maneuver to assist in stool passage. The Valsalva maneuver exerts pressure to expel feces through voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool. Normal defecation is painless, resulting in passage of soft, formed stool. DM px: stomach problems

End Colostomy

This diagram shows a permanent (end) colostomy. The terminal end of the descending or sigmoid colon is brought out through the peritoneum and muscle and is sutured to the skin. The end colostomy consists of one stoma formed from the proximal end of the bowel, with the distal portion of the GI tract removed or sewn closed (called Hartmann's pouch) and left in the abdominal cavity. For many patients, end colostomies are a result of surgical treatment of colorectal cancer. In such cases, the rectum is usually removed. Patients with diverticulitis who are treated surgically often have a temporary end stoma with Hartmann's pouch.

Double-Barrel Colostomy

This drawing shows a double-barrel colostomy. Both ends of the transected colon are brought out to the skin. Unlike the loop colostomy, the surgeon divides the intestine and brings proximal and distal ends through the abdominal incision to the abdominal surface when creating a double-barrel colostomy. A small incision is made in the proximal stoma for fecal drainage. The distal stoma leads to the inactive intestine and is left intact. When the intestinal injury has healed, the colostomy is reversed, and the divided ends are anastomosed to restore intestinal integrity.

Irrigating a Colostomy

This drawing shows an ostomy irrigation cone inserted into the stoma. Although this practice is not as common as it once was, some patients irrigate their left-sided colostomies to regulate colon emptying. Other patients do not want to spend the additional 60 to 90 minutes in the bathroom every day; thus they empty their pouch as necessary. Only colostomies can be irrigated. Never use an enema set to irrigate a colostomy. Instead use specific equipment, which includes a special cone-tipped irrigator to prevent bowel penetration and backflow of the irrigating solution. Help patients to schedule irrigations at times that fit within their daily routine. Before irrigating the stoma, patients usually sit on the toilet and place an irrigating sleeve over the stoma. The end of this sleeve extends into the bowl of the commode. The health care provider orders the amount and type of irrigation solution. For adults, the amount typically ranges from 500 to 700 mL of tap water. The patient instills the solution slowly through the lubricated cone tip. Irrigation usually takes 5 to 10 minutes. The patient then removes the cone tip and waits 30 to 45 minutes for the solution and feces to drain out of the irrigation sleeve. Once the drainage stops, the patient applies a stoma cap or a pouch.

Colonoscopy

You will all get a chance to go to GI Lab and probably see a colonoscopy. Prep is extremely important. They are often given a gallon to drink to clean them out. This is a tedious process and many patients get nauseous and have rectal pain due to excoriation. It is important to give meticulous skin care, medicate, and give emotional support.

Diarrhea

an increase in the number of stools and the passage of liquid, unformed feces

Meeting the Needs of Older Adults: BOWEL ELIMINATION: CONSTIPATION AND DIARRHEA

and they are more at risk for developing fecal impaction. ● Adequate fluid and fiber intake and exercise are very important. ● Older adult clients are less able to compensate for fluid lost due to diarrhea.

Medicated enemas

contain drugs. An example is sodium polystyrene sulfonate (Kayexalate), which is used to treat patients with dangerously high serum potassium levels. This drug contains a resin that exchanges sodium ions for potassium ions in the large intestine. Another medicated enema is neomycin solution, an antibiotic that is used to reduce bacteria in the colon before bowel surgery.

Hypertonic solutions

infused into the bowel exert osmotic pressure that pulls fluids out of interstitial spaces. The colon fills with fluid, and the resultant distention promotes defecation. Patients unable to tolerate large volumes of fluid benefit most from this type of enema, which is by design low volume. This type of enema is contraindicated for patients who are dehydrated and for young infants. A hypertonic solution of 120 to 180 mL (4 to 6 oz) is usually effective. The commercially prepared Fleet enema is the most common.

Tap water

is hypotonic and exerts an osmotic pressure lower than fluid in interstitial spaces. After infusion into the colon, tap water escapes from the bowel lumen into interstitial spaces. The net movement of water is low. The infused volume stimulates defecation before large amounts of water leave the bowel. Do not repeat tap water enemas because water toxicity or circulatory overload develops if the body absorbs large amounts of water.

Enemas

is the instillation of a solution into the rectum and sigmoid colon. The primary reason for an enema is to promote defecation by stimulating peristalsis. The volume of fluid instilled breaks up the fecal mass, stretches the rectal wall, and initiates the defecation reflex. Enemas are also a vehicle for medications that exert a local effect on rectal mucosa. The most common use for an enema is temporary relief of constipation. Other indications include removing impacted feces, emptying the bowel before diagnostic tests or surgery, and beginning a program of bowel training.

Physiologically normal saline

is the safest solution to use because it exerts the same osmotic pressure as fluids in interstitial spaces surrounding the bowel. The volume of infused saline stimulates peristalsis. Giving saline enemas does not create the danger of excess fluid absorption.

Cleansing enemas

promote the complete evacuation of feces from the colon. They act by stimulating peristalsis through infusion of a large volume of solution or through local irritation of the mucosa of the colon. Infants and children receive only normal saline because they are at risk for fluid imbalance.

Carminative enemas

provide relief from gaseous distention - (EX: magnesium, glycerine & water). worms

Visualization of the bowel: Colonoscopy

the provider visualizes and may collect tissue for biopsy or remove polyps from the colon and sometimes a portion of the lower small bowel.

Visualization of the bowel: Sigmoidoscopy

the provider visualizes and may collect tissue for biopsy or remove polyps from the sigmoid colon and rectum.

SPECIMEN COLLECTION: Equipment

› Appropriate specimen container › Soap/cleansing solution or wipe › Gloves › Specimen label › Fecal occult blood test cards › Wooden applicator or tongue depressor › Developer solution › Stool collection container (bedside commode, bedpan, receptacle in toilet)

Patient-Centered Care: PROMOTING HEALTHY BOWEL ELIMINATION: Equipment

› Bedpans » Fracture pan - for supine clients and clients in body casts or leg casts » Regular pan - for seated clients › Beside commode › Toilet › Adequate fiber in the diet › Adequate fluid intake - minimum of 1,500 mL/day of water and/or juices › Adequate activity - walking 15 to 20 min/day if mobile and exercises in bed or chair (pelvic tilt, single leg lifts, lower trunk rotation)

Patient-Centered Care: PROMOTING HEALTHY BOWEL ELIMINATION: Procedure

› Encourage the client to set aside time to defecate - sometimes after a meal works best. › If not contraindicated or restricted, encourage the client to drink plenty of fluids and to consume a diet high in fiber to prevent constipation. › Wear gloves when addressing toileting needs. › Provide privacy. › Assist the client to a sitting position whether using a regular bedpan, commode, or toilet. › For clients using a fracture pan, raise the head of the bed to 30°. › If the client cannot lift his hips to get the bedpan under him, roll him onto one side, position the bedpan over his buttocks, and roll the client back onto the bedpan. › Encourage the client to decrease stress when sitting or rising by using an elevated toilet seat or a footstool. › Never leave a client lying flat on a regular bedpan. › After the client defecates, provide skin care to the perianal area.

SPECIMEN COLLECTION: Procedure

› Fecal occult blood testing (guaiac test) » Explain the procedure to the client. » Ask the client to collect a specimen in the toilet receptacle, bedpan, or bedside commode. » Apply gloves, and, with a wooden applicator, place small amounts of stool on the windows of the test card or as directed. » Follow the facility's procedures for handling. › Apply a label to the cards and send them to the laboratory for processing. › Or, if for point-of-care testing, place a couple of drops of developer on the opposite side of the card. A blue color is positive for blood. » Remove the gloves and perform hand hygiene. › Stool for culture, parasites, and ova » Explain the procedure to the client. » Ask the client to collect the specimen in the toilet receptacle, bedside commode, or bedpan. » Put on gloves. » Use a wooden tongue depressor to transfer the stool to a specimen container. » Label the container with the client's identifying information. » Remove the gloves. » Perform hand hygiene. » Transport the specimen to the laboratory.

CLEANSING ENEMA: The height of the bag above the rectum determines the depth of cleansing: Equipment

› Gloves › Lubricant › Absorbent, waterproof pads › Bedpan, beside commode, or toilet › IV pole › Enema bag with tubing or prepackaged enema › Solutions and additives - vary with the type of enema » Tap water or hypotonic solution › Stimulates evacuation › Never repeated due to potential water toxicity » Soapsuds › Pure castile soap in tap water or normal saline › Acts as an irritant to promote bowel peristalsis » Normal saline › Safest due to equal osmotic pressure › Volume stimulates peristalsis » Low-volume hypertonic › Good for clients who cannot tolerate high-volume enemas › Fleet® - a commercially prepared hypertonic enema » Oil retention - lubricates the rectum and colon for easier passage of stool » Medicated enemas - contains medications to retain

OSTOMY CARE: Procedure

› If a wound ostomy continence nurse is not available, educate the client about stoma care. › Perform hand hygiene. › Put on gloves. › Remove the pouch from the stoma. › Inspect the stoma. It should appear moist, shiny, and pink. The peristomal area should be intact, and the skin should appear healthy. › Use mild soap and water to cleanse the skin, then dry it gently and completely. Moisturizing soaps can interfere with adherence of the pouch. › Apply paste if necessary. › Measure and draw where to cut the skin barrier, allowing only the stoma to appear through the opening. › Cut the opening in the skin barrier. › If necessary, apply barrier pastes to creases. › Apply the skin barrier and pouch. › Fold the bottom of the pouch and place the closure clamp on the pouch. › Dispose of the used pouch. Remove the gloves and perform hand hygiene.

CLEANSING ENEMA: The height of the bag above the rectum determines the depth of cleansing: Procedure

› Perform hand hygiene. › Prepare and warm the enema solution. › Pour the solution into the enema bag, allowing it to fill the tubing, and then close the clamp. › Explain the procedure to the client. › Provide privacy. › Provide quick access to a commode or bedpan. › Place absorbent pads under the client to protect the bed linens. › Position the client on the left side with the right leg flexed forward. › Put on gloves. › Lubricate the rectal tube or nozzle. › Slowly insert the rectal tube 7.5 to 10 cm (3 to 4 in). For a child, insert the tube 5 to 7.5 cm (2 to 3 in). › With the bag level with the client's hip, open the clamp. › Raisethebag30to45cm(12to18in)abovethe anus, depending on the level of cleansing. › Slow the flow of solution by lowering the container if the client reports cramping, or if fluid leaks around the tube at the anus. › If using a prepackaged solution, insert the lubricated tip into the rectum and squeeze the container to instill all of the solution. › Ask the client to retain the solution for the prescribed amount of time, or until the client is no longer able to retain it. › Discard the enema bag and tubing. › Assist the client to the appropriate position to defecate. › Remove the gloves. › Perform hand hygiene. › For clients who have little or no sphincter control, administer the enema on a bedpan. › Document the results and the client's tolerance of the procedure.

Patient-Centered Care: BOWEL ELIMINATION: CONSTIPATION AND DIARRHEA

● Closely monitor fluid status. Record of intake and output. ● Monitor for dehydration. ● Closely monitor elimination pattern. ● Observe and document the character of bowel movements. ● Carefully check for blood or pus. For diarrhea, measure the volume of the stools. ● Administer laxatives and/or enemas. ● Encourage fluids (especially water), fiber, and exercise. ● After diarrhea stops, suggest eating yogurt to help re-establish an intestinal balance of beneficial bacteria.

Bowel Elimination Needs and Specimen Collection

● Collect stool specimens for serial fecal occult blood (guaiac) testing three times from three different defecations. Stool samples should come from fresh stools that are not contaminated with water or urine. ● Bowel diversions through ostomies are temporary or permanent openings (stomas) in the abdominal wall to allow fecal matter to pass. ● End stomas are a result of colorectal cancer or some types of bowel disease. Colostomies end in the colon, and ileostomies end in the ileum. ● Loop colostomies help resolve a medical emergency and are temporary. ● Double-barrel colostomies consist of two abdominal stomas - one proximal and one distal.

Complications: BOWEL ELIMINATION: CONSTIPATION AND DIARRHEA

● Complications of constipation include: ◯ Fecal impaction. ◯ Hemorrhoids, rectal fissures. ◯ Bradycardia, hypotension, syncope associated with the Valsalva maneuver (occurs with straining/ bearing down). ◯ Interventions ■ Monitor for constipation. Instruct clients not to strain to have bowel movements. Encourage measures to treat and prevent constipation. ■ Remove fecal impactions. Administering a glycerin or bisacodyl (Dulcolax) suppository might help. ● Complications of diarrhea include: ◯ Dehydration and fluid and electrolyte disturbances (metabolic acidosis from excessive loss of bicarbonate). ◯ Skin breakdown around the anal area. ◯ Interventions ■ Replace losses. ■ Provide care and treatment for any skin breakdown.

Complications of Bowel Elimination

● Constipation ◯ Bowel pattern of difficult and infrequent evacuation of hard, dry feces. ◯ May be the result of improper diet, decreased fluid intake, lack of exercise, or side effects of medications. ◯ Increase fiber and water consumption before treating constipation with laxatives. ◯ Give bulk-forming products before stool softeners, stimulants, or suppositories to promote bowel elimination. ◯ Enemas are a last resort for stimulating defecation. ● Impaction ◯ Stool that is wedged into the rectum with diarrhea fluid leaking around the impacted stool. ◯ Use a gloved, lubricated finger for digital removal of stool. ◯ Loosen the stool around the edges and then remove it in small pieces, allowing the client to rest as necessary. ◯ When evacuating the rectum, be careful to avoid stimulating the vagus nerve. ● Diarrhea ◯ Frequent, liquid stools caused by various disorders. ◯ Help determine and treat the cause. ◯ Administer medications to slow peristalsis. ◯ Provide perineal care after each stool and apply a moisture barrier. ◯ Clients and caregivers should perform hand hygiene frequently. ● Fecal Incontinence ◯ Inability to control defecation, often caused by diarrhea. ◯ Assess for causes, such as medications, infections, or impaction. ◯ Provide perineal care after each stool and apply a moisture barrier. ● Flatulence ◯ Distention of the bowel from gas accumulation (may cause cramping or a feeling of fullness) ■ Assess for abdominal distention and the ability to pass gas through the anus. ■ Encourage ambulation to promote the passage of flatus. ■ Notify the provider if the problem continues. ● Hemorrhoids ◯ Engorged, dilated blood vessels in the rectal wall from difficult defecation, pregnancy, liver disease, and heart failure. ■ Hemorrhoids may be itchy, painful, and bloody after defecation. ■ Use moist wipes for cleansing the perianal area. ■ Apply ointments or creams.

ATI.Bowel Elimination Overview

● Interventions such as surgery, immobility, medications, and therapeutic diets can affect bowel elimination. ● Constipation is having bowel movements that are infrequent, hard or dry, and difficult to pass. ● Diarrhea is an increased number of loose, liquid stools. ● There are objective ways to assess for the presence of constipation or diarrhea, but individual bowel patterns vary greatly. ● Various disease processes necessitate the creation of bowel diversions to allow fecal elimination to continue. ● Stool specimens are collected both for screening and for diagnostic tests, such as for the detection of occult blood, bacteria, or parasites.

Assessment/Data Collection: BOWEL ELIMINATION: CONSTIPATION AND DIARRHEA

● Monitor for constipation. ◯ Abdominal bloating ◯ Abdominal cramping ◯ Straining at defecation ● Monitor for diarrhea. ◯ Dehydration (postural hypotension, dizziness when changing positions) ◯ Frequent loose stools ◯ Abdominal cramping ● Collect assessment data. ◯ Perform a physical examination of the abdomen (bowel sounds, tenderness) daily. ◯ Assess for fluid deficit. ◯ Assess skin integrity around the anal area. ◯ Collect a detailed history of diet, exercise, and bowel habits. ● Perform specimen collection and diagnostic testing. ◯ Fecal occult blood test - obtain a fecal sample using medical asepsis while wearing disposable gloves. Some foods (red meat, fish, poultry, raw vegetables) and medications can cause false positive results. Bleeding can be a sign of cancer, which can be a contributing factor for constipation. ◯ Digital rectal examination for impaction - position on the left side with the knees flexed. The examiner inserts a gloved, lubricated index finger gently into the rectum. During the procedure, monitor vital signs and response. ◯ Specimens for stool cultures - obtain using medical asepsis while wearing disposable gloves. Label the specimen and promptly send it to the laboratory. Intestinal bacteria can cause diarrhea.

Causes of constipation include:

◯ Frequent use of laxatives. ◯ Advanced age. ◯ Inadequate fluid intake. ◯ Inadequate fiber intake. ◯ Immobilization due to injury. ◯ A sedentary lifestyle.

Causes of diarrhea include:

◯ Viral gastroenteritis. ◯ Bacterial gastroenteritis. ◯ Overuse of laxatives. ◯ Antibiotic therapy. ◯ Inflammatory bowel disease. ◯ Irritable bowel syndrome. ◯ Foodborne pathogens.