Elimination – Terminology, Constipation,
Diarrhea, Fecal Impaction and Flatulence
The elimination of waste from the bowel and bladder is an essential body function. The major nursing responsibilities associated with bowel and bladder elimination include assessing the bowel and bladder functions, promoting normal bowel and bladder health and, management of altered bowel and bladder functions.
Terminology
Antidiarrhoeal agents are medications that act directly on the intestine to slow the bowel motility or to absorb excess fluid in the bowel.
Anuria is the formation and excretion of less than 100 ml of urine in 24 hours.
Bowel incontinence is the state in which a person experiences a change in normal bowel habits characterized by involuntary passage of stool.
Colonic irrigation is a thorough flushing of the large intestine.
Constipation is the frequent, sometimes painful passage of hard, dry stool.
Defecation is the process by which the solid waste products of digestion, known as faeces or stool, are eliminated from the bowel.
Diarrhea is a state in which a person experiences a change in normal bowel habits characterized by frequent passage of loose, fluid, unformed stools.
Dysuria is the difficulty in voiding; it may or may not be associated with pain; the feeling of warm local irritation occurring during voiding is called burning.
Elimination: it is the expulsion of the wastes from the body by way of lungs, skin, rectum and urinary bladder.
Enema or clysis: an enema is the cleaning of a portion of the large bowel by insertion of fluid rectally.
Enuresis is the involuntary voiding with no underlying patho physiologic origin after the age when bladder control is usually achieved.
Faeces: the waste products that have reached the distal end of the colon and are ready for excretion. Once excreted, faeces are called stool.
Flatulence is the excessive formation of gases in the stomach or intestine.
Functional incontinence is the inability of unwillingness or a person with normal bladder and sphincter control to reach the bathroom in time to void.
Incontinence is the inability to control the sphincter which guards the rectum or bladder.
Melaena refers to stool that are very dark or black because of the presence of blood.
Micturition/voiding/urination is the process of emptying the urinary bladder.
Nocturia is voiding during normal sleeping hours.
Oliguria is the formation and excretion of decreased amount of urine or urine output less than 500 ml in 24 hours.
Polyuria is the formation and excretion of excessive amounts of urine in the absence of a concurrent increase in fluid intake. Urinary output greater than 2500-3000 ml in 24 hours is considered polyuria.
Proctoclysis is a slow injection of a large quantity of fluid into the rectum for absorption into the body.
Pyuria means that the urine contains pus, which is the accumulation of the end products of an inflammatory response.
Reflex incontinence is an involuntary loss of urine that occurs at somewhat predictable intervals, when a specific bladder volume is reached. It is seen in clients with neurologic impairment such as spinal cord lesion, CVA or brain tumor.
Straining at stool usually happens when a person is constipated. It is the force used in the expulsion of the stool.
Straining of stool is a process in which the stool is strained through a sieve in order to detect the presence of a parasital object e.g., a client who takes the tapeworm treatment should have his stool strained to detect the head of the tapeworm to ensure its expulsion. The clients who have swallowed small objects may have their stool strained to ensure its expulsion.
Stress incontinence is the sudden involuntary loss of small amounts (that’s 50 ml) of urine that accompanies a sudden increase in intra-abdominal pressure e.g., coughing, sneezing, laughing, lifting and jumping.
Suppository is a medication prepared in a base (glycerin), when inserted into the rectum, melts and gets absorbed for local or systemic effects, or it is conical or oval solid substance shaped for easy insertion into a body cavity and designed, to melt at body temperature.
Total incontinence is the continuous, involuntary, unpredictable loss of urine from a non-distended bladder.
Urge incontinence is the involuntary loss of urine after a strong feeling of the need to urinate. Frequency, dysuria and nocturia commonly accompany urge incontinence.
Urinary incontinence is the involuntary loss of urine from the bladder. It can be stress, urge, reflex, functional and total incontinence.
Urinary retention is the inability to empty the bladder of urine. In this, either the person is unable to perceive the feeling of bladder fullness or is unable to relax the bladder neck and external urethral sphincter to allow urine to pass from the body.
Urinary retention with overflow is the loss of small amounts of urine from an over distended bladder.
Constipation
Constipation occurs when stool moves through the large intestine too slowly or remains in the large intestine for too long. Constipation is referred to the person’s normal defecation pattern and involves a change in stool consistency (harder and drier than usual) and a change in defecation frequency (less than usual).
Causes
1. Inadequate, irregular and restricted diet.
2. Insufficient fluid intake.
3. Insufficient intake of roughage in the diet so that there is little residue available to form the bulk of the fecal matter.
4. No established habit pattern especially regarding timing and the failure to respond to the reflex impulse.
5. Lack of exercises and prolonged rest.
6. Emotional upset – nervous tension, worry, anger, fear etc.
7. Unnatural position for defecation.
8. Overuse of laxatives, suppositories and enemas.
9. Surgery involving the intestines and rectum.
10. Malformations and obstruction of the colon.
11. Systemic disorders such as cancer, heart failure, thyroid deficiency, acute infectious diseases etc.
12. Haemorrhoids and other lesions in the anal canal.
13. Strange situations such as lack of privacy change of place.
14. Pendulous abdominal wall.
15. Use of certain drugs e.g., sedatives.
16. Excessive use of beverages such as coffee, tea etc.
17. Faecal impaction. When the faecal mass remains in contact with the bowel mucosa, it loses fluid through absorption. The result is a firm large mass of stool that cannot be mechanically expelled from the anal canal.
18. Large intake of refined foods or other low residue food.
19. Slower motility of the G.I. tract associated with ageing.
20. Embarrassment about using a bedpan.
The complications develop due to straining at stool as a result of the constipation. They are haemorrhoids, fissures, ulcers, rectal prolapsed, heart attacks in a cardiac client etc.
Prevention and Management of Constipation
Health Teaching
Any person suffering from constipation must understand the physiology of defecation and the factors affecting the defecation.
Adequate Intake of Diet
If the dietary intake is too little, it may not stimulate the peristalsis.
Adequate Intake of Roughage in Diet
Foods containing high fibrous content should be included in the diet such as raw and cooked vegetables, raw and cooked fruits, whole grain cereals etc. The quantity and quality of breakfast is more important to prevent constipation. One purpose of the breakfast is to produce a vigorous gastrocolic reflex and expulsion of the faecal matter.
Establishing a Habit Pattern
Usually the defecation reflex is found immediately after a full breakfast. So the person should find time to sit on the toilet immediately after the breakfast.
Relaxation
Have an environment conductive to relaxation because tension, anger, worry, hurry, fear etc., interfere with the defecation reflex. Reassure the nervous client.
Privacy
A squatting position is most effective posture during defecation because the individual can increase intra-abdominal pressure, necessary for expelling the faeces. Unless contraindicated a sitting position with the feet flat on the floor should be used for all persons.
Exercise
Any activity that improves the muscle tone of the abdominal and perineal muscles should be encouraged.
Adequate amount of Fluid Intake
Normally, an individual should take 2000 to 3000 ml of fluid in 24 hours.
Use of Laxatives, Suppositories and Enemas
As far as possible, these should be avoided because they are habit forming. When all the other preventive measures are falling, one of these methods may be used but their continued use must be discouraged.
Diarrhea
Diarrhea is manifested by frequent evacuation of watery stools. Due to increased gastrointestinal motility, there is rapid passage of faecal contents through the lower gastrointestinal tract. This reduces the time available for the large intestine to reabsorb water and electrolytes. It is the consistency of the stool (less formed and more watery) that is more definitive of diarrhea than the increased frequency of defecation. Along with the high water content, diarrheal stools also may contain mucus which contributes to increased volume. The extra volume and rapidity with which it reaches the rectum causes rectal distension, resulting in intense urge to defecate. Color of the stool can vary from light brown to yellow to green.
Besides the intense urge to defecate, there may be abdominal cramps, nausea and painful burning sensations at the anus. As the diarrheal stools are acidic, frequent passage of this acidic stool can cause anal soreness and inflammation of the skin around the anus, leading to bleeding and breakdown of the perineal tissue.
Causes of Diarrhea
Intestinal Infection (Enteritis)
Diarrhea is caused by mucosal damage by the organisms or their toxins, e.g., salmonellosis, ulcerative colitis, amoebiasis and food poisoning.
Nervous Tension
This type of emotional or psychogenic diarrhea results from excessive stimulation of the parasympathetic nervous system which increases both mobility and secretions of the colon.
Dietary Indiscretions
Individuals vary in their tolerances to some foods and fluids. Some people may have allergies to certain foods and respond with diarrhea to the allergen.
Medications
Some medications are irritants to the gastrointestinal tract and cause diarrhea as side effects e.g., antibiotics, iron preparations.
Abuse of Cathartics
Excessive irritation of the colon from overuse of cathartics leads to diarrhea.
Other Causes
Many other conditions cause diarrhea such as malabsorption syndromes, post vagotomy, irritable colon, narcotic withdrawal etc.
Diarrheal responses may be precipitated by lactase deficiency, gluten intolerance or a specific food allergy.
Nursing Care in Diarrhea
Replacement of fluid and electrolytes:
This fluid loss from the body should be replaced immediately to prevent shock and collapse of the client. When oral fluids are tolerated by the client, the fluids may be given in plenty orally. If there is marked dehydration, the fluids are given by the I.V. route.
Potassium losses may be great with diarrhea and therefore food and fluids containing potassium should be encouraged.
Small frequent feedings of blend food may be helpful to meet the nutritional requirements of the client. Avoid foods containing chilies, spices, excessive hot and cold foods etc., because they stimulate peristalsis.
Make arrangement for the use of bedpan or commode which is placed in a convenient and accessible place.
Care of the skin: skin excoriation around the anal region can be prevented by proper cleaning and drying of the area after each defecation.
Adequate rest: reducing the physical activity is helpful in lessening the bowel activity.
Psychological support: if the cause of diarrhea is sustained anxiety, the client should be reassured.
Medications: The usual medications which are administered to the clients with diarrhea are antidiarrhetics, demulcents, astringents, intestinal antiseptics, sedative and antispasmodics.
Fecal Impaction
It is the accumulation of the hardened faeces in the rectum, as a result of which the person is unable to voluntarily evacuate the stool. Usually this condition develops in persons with untreated or unrelieved constipation. As the feces remains in the rectum and sigmoid colon, the water is reabsorbed making the feces harder, drier and more difficult to pass. More feces continue to be produced, which get accumulated in the colon proximal to the impacted stool.
Fecal impaction must be suspected when a client gives the history of constipation for 3 to 5 days or more followed by passage of liquid or semi liquid stool. Passage of semi liquid stool results from the seepage of unformed fecal contents around the impacted stool in the rectum, the pressure from the large mass of accumulated fecal contents.
Signs and symptoms: a subjective feeling of fullness of rectum and abdomen, bloating of abdomen, an urge for defecation but an inability to pass stool and a generalized feeling of malaise. There may be also loss of appetite and nausea or vomiting. Abdominal distension also may be apparent.
Management: laxatives, enema and manual removal of the stool (digital evacuation).
Fecal incontinence: it is the involuntary elimination of bowel contents; often associated with neurologic, mental or emotional impairments.
Flatulence
Flatulence is the accumulation of excessive amounts of gas (flatus) in the gastrointestinal tract, leading to distension of the abdomen. This is also referred to as tympanites. Large amount of air and other gases can accumulate in the stomach resulting in gastric distension.
Causes of Flatulence
Excessive swallowing of air sometimes occurs with anxiety, rapid food or fluid ingestion, improper use of drinking straws, ingestion of large amounts of carbonated beverages, gum chewing, candy sucking and smoking. Swallowed air is usually eliminated by burping or belching.
Gases produced by bacterial activity in the large intestine are eliminated through the anus. Other causes of flatulence can be certain gas forming foods such as cabbage, onions etc. and medications that decrease intestinal motility. Flatulence is noticed post operatively due to the effects of anaesthesia, narcotics, dietary changes and reduction in actitivity.
Gas that diffuses from the blood stream into the intestine.