7.3 Bowel Elimination

Tracy M. Christianson, RN, BSN, MN, DHEd, CCNE; Kimberley Morris, RN, BN, MN

7.3 Bowel Elimination

Normal Bowel Elimination

The stomach breaks down ingested food by means of stomach acid and enzymes. This product is called chyme. Chyme is passed into the small intestine through peristalsis. Chemical digestion and absorption of nutrients is the main function of the small intestine. The large intestine continues to absorb nutrients and fluid. The resulting waste is called feces and is stored in the colon and rectum until the urge to defecate is felt. The HCA should monitor the client’s bowel movements and note the frequency, consistency, colour, odour and any pain or discomfort experienced during bowel movements. This will assist the nurse in adjusting the client’s diet or medications.

Watch the video:

How Your Digestive System Works – Emma Bryce, from TED-Ed (2017).

Watch the video:

What is Peristalsis? by Mister Science (2018).

Characteristics of Normal Bowel Movements

There is a range of normal when considering the frequency of bowel movements. It is important to know what is normal for your client. Some people have bowel movements daily, for others normal is every 2–3 days. The frequency of a person’s bowel movements can be affected by many factors, such as activity, age, medications, diet, fluid intake, and elimination habits. The Bristol Stool Chart (Figure 7.3.1) can assist you in identifying the consistency of the bowel movement.

**Figure 7.3.1** Bristol Stool Chart [Image description]

**Table 7.3.1** Characteristics of Normal Bowel Elimination
Characteristic:	What is Normal?
Colour	Normally brown due to presence of bile.
Amount	Normal can range from 3 times a day to 3 times a week. It is important to know what is normal for an individual, so changes can be identified.
Consistency	Normal is soft and formed.
Odour	Normal feces have a distinct odour.
Shape	Should be tube shaped, like the colon.
Size	Can vary depending on diet and elimination habits.
Pain or Discomfort	There should not be pain or discomfort felt with normal elimination.

Abnormal Bowel Elimination

**Table 7.3.2** Characteristics of Abnormal Bowel Elimination
Characteristic	Abnormal	Possible Causes
Colour	Black, red, green or other	Black stool: Clients on iron supplements are likely to have black, tarry (sticky and unformed) stool. Bleeding higher up in the digestive tract will also cause this. Red stool: Bleeding in lower digestive tract, or eating beets will cause red coloured stool. Pale or clay coloured: Can indicate disease or infection. Green: may be diet related or disease/infection.
Amount	Any increase or decrease from the client’s normal should be reported and monitored	Increased: Can indicate infection (gastrointestinal virus or bacteria), diet related, or related to some medications. Decreased: Constipation, medications
Consistency/Shape	See Bristol Stool Chart (Figure 7.3.1) for variations in consistency/shape	Harder consistency can indicate lack of fluids/fibre in diet. Loose consistency can indicate infection, changes in diet, allergies or intolerances, or other disease processes. A thinner shape could indicate also indicate disease process.
Odour	Foul; different from usual stool	Foul or unusual odour can be the result of changes in diet, medications or infection
Size	Increase or decrease in normal should be monitored	Smaller stool: Could indicate constipation. Larger stool: Could indicate change in diet, or infrequent bowel movements.
Pain or Discomfort	Abdominal pain, cramping, rectal pain	Any pain or discomfort with defecation should be reported, as there are a variety of factors and causes.

Assisting with Bowel Elimination

The Health Care Assistant plays an important role in assisting clients to maintain normal elimination patterns. By following the guidelines below, you can support independence and prevent constipation. Always ensure to check the care plan.

Guidelines for Assisting with Bowel Elimination

Follow routine practices when assisting with elimination.
Encourage fluids and appropriate fibre in diet as per the client’s care plan.
Encourage exercise as appropriate.
Provide assistance promptly. This is particularly important with the urge to defecate. If the client is not attended to promptly, the result may be that the urge goes away for several hours, contributing to constipation. The other result may be incontinence.
Encourage clients to call when feeling the need to defecate.
Provide for comfort and privacy as necessary.
Ensure optimal positioning. If possible the client’s knees should be slightly higher than their hips.
Utilize adaptive devices as per the care plan (raised toilet seat, mechanical lifts, commode, bedpan).
Ensure safety of the client (provide the call bell and stand by if the client is unsteady).
Provide peri-care after if the client is unable to do it themselves.
Ensure to wash the client’s hands afterwards as well as your own.
Record and report the time and amount of stool and anything abnormal to supervisor.

Problems with Bowel Elimination

Constipation

Constipation is a common problem experienced in older adults. Many factors contribute to constipation: age, medications, lack of adequate fluids or fibre, lack of exercise, delaying urge to defecate, lack of privacy. Frequent or constant constipation can lead to a variety of other health issues such as hemorrhoids, fecal impaction, and bowel obstruction. HCAs play an important role in preventing constipation in clients. Although prevention is key, HCAs may be involved in assisting with or caring for clients who have required other measures to address the constipation such as rectal suppositories, enemas or disimpaction.

Rectal suppositories and enemas are restricted activities taught in the HCA curriculum that an HCA could only perform if:

It is delegated to the HCA by a regulated health professional (i.e., a registered nurse)
It is delegated for a specific client
The HCA performing the restricted activity is over the age of 19
It is indicated in the client’s care plan

**Table 7.3.3** Procedure: Administering a Rectal Suppository or Enema^[1]
STEP	ACTION	REASON
1.	Check the client’s care plan.	Ensures you have information specific to this client’s care.
2.	Perform hand hygiene before preparing supplies.	Following routine practices prevents the spread of pathogens.
3.	Assemble equipment and supplies: non-sterile gloves water-soluble lubricant incontinent pad or waterproof pad	Gloves are needed for contact with blood/body fluids. Lubricant reduces friction as the suppository enters rectal canal. Incontinent pad or waterproof pad protects bed linens.
4.	Explain the procedure to the client. If client prefers to self-administer the suppository/enema, give specific instructions to client on correct procedure.	Clients have a right to information about their care. Client may feel more comfortable self-administering suppository. If so provide glove, lubricant, and instructions.
5.	Raise bed to working height. Position client on left side with upper leg flexed over lower leg toward the waist (Sim’s position). Provide privacy and drape the client with only the buttocks and anal area exposed. Place an incontinent pad or waterproof pad underneath the client’s buttocks.	Positioning helps prevent injury to the HCA administering the suppository. This protects client’s privacy and facilitates relaxation. Some literature suggests that left side-lying Sim’s position lessens the likelihood of the suppository being expelled. Incontinent or waterproof pad protects linens from potential fecal drainage.
6.	Apply clean, non-sterile gloves.	Figure 7.3.2 Gloves Gloves protect the HCA from contact with mucous membranes and body fluids.
7.	Remove wrapper from suppository/tip of enema and lubricate rounded tip of suppository and index finger of dominant hand with lubricant. Lubricate rounded tip of suppository or tip of enema.	Figure 7.3.3 Disposable enema Figure 7.3.4 Lubricant Lubricant reduces friction as suppository/enema enters rectal canal. Inserting the rounded top promotes client comfort.
8.	Separate buttocks with non-dominant hand and, using gloved index finger of dominant hand, insert suppository (rounded tip toward client) into rectum toward umbilicus while having client take a deep breath, exhale through the mouth, and relax anal sphincter. If enema: Expel air from enema and then insert tip of enema into rectum toward umbilicus while having client take a deep breath, exhale through the mouth, and relax anal sphincter.	Ensure the suppository is removed from the package. Upon insertion, you should feel the anal sphincter close around your finger. Forcing the suppository/enema through a clenched sphincter will cause pain.
9.	With your gloved finger, insert suppository along wall of rectum about 5 cm beyond anal sphincter. Do not insert the suppository into feces. If enema: Roll plastic bottle from bottom to tip until all solution has entered rectum and colon.	Suppository should be against rectal mucosa for absorption and therapeutic action. Inserting suppository into feces will decrease its effectiveness. If the client experiences cramping during enema administration, stop. Ask the client to take a deep breath. Resume administration when cramps subside. Hold buttock cheeks together if client feels immediate need for a bowel movement.
10.	Remove finger and wipe client’s anal area.	Wiping removes excess lubricant and provides comfort to the client.
11.	Ask the client to remain on side for 5–10 minutes.	This position helps prevent the expulsion of suppository.
12.	Discard gloves by turning them inside out and disposing of them and any used supplies as per agency policy. Perform hand hygiene.	Using gloves reduces transfer of microorganisms. Figure 7.3.5 Dispose of gloves Figure 7.3.6 Using an ABHR
13.	Ensure call bell is nearby and bedpan or commode is available and close by. Client may need assistance; refer to care plan.	If suppository is a laxative or stool softener, client will require a bedpan/commode or close proximity to toilet. Figure 7.3.7 Ensure call bell is available to client
14.	Document procedure as per agency policy and include client’s tolerance of administration.	Timely and accurate documentation promotes client safety.