Bowel Elimination

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Anatomy and physiology of GIT…

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 Bowel Elimination

 Bowel Elimination (Defecation) is a natural

process by which the soiled waste products of
digestion (feces or stool) are eliminated from
the bowel.
 It relies on the consistency of the stool (fecal
material), intestinal motility, compliance and
contractility of the rectum, and competence of
the anal sphincters.

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 Fecal Elimination
Defecation
o Is the expulsion of feces from the anus and rectum.
o It is also called a bowel movement.
o It is normally initiated by two defecation reflexes.
1. As the peristaltic waves approach the anus, the
internal anal sphincter becomes inhibited from closing
and if the external sphincter is relaxed defecation
occurs this is called the intrinsic defecation reflex.
2. The second reflex called parasympathetic
defecation reflex
 When the nerve fibers in the rectum are stimulated ;
signals are transmitted to the spinal cord. 4
 Nursing intervention

Promoting Regular Defecation by promoting:

1. Provision of privacy
2. Timing
3. Nutrition and fluids
4. Exercise
5. Positioning
6. Administering Enemas
Bedside commode
often used for the adult client who can get out
of bed but is unable to walk to the bathroom. 5
 .…Nursing intervention
 Commonly two intervention is used;
 Pharmaceutical: inserting suppositories
 Administering enemas
 They administered to promote elimination when:
 It does not occur naturally
 To cleans bowel for other purposes - preparation for
surgery and endoscopic or x-ray examinations.

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 Enema
 Is the introduction of fluid into rectum and
sigmoid colon for cleansing, therapeutic or
diagnostic purposes.
Purpose:
o For emptying-Soap solution enema
o For diagnostic purpose- (Barium enema)
o For introducing drug/substance - (retention
enema)

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 Purpose of Administering enema
 An enema is introduction of a solution into the rectum to:
o Cleanse the lower bowel (most common reason).
o Soften impacted fecal matter.
o Expel flatus.
o Soothe irritated mucous membranes.
o Outline the colon during diagnostic x-rays
o To supply the body with fluid.
o To give medication
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 Enema solution
 Hypertonic solutions(Fleet phosphate)
 exert osmotic pressure, draws fluid from the interstitial space
into the colon
 The ↑ the volume in the colon stimulates peristalsis and hence
defecation.
 Hypotonic solutions (tap water)
 Exert a lower osmotic pressure than the surrounding
interstitial fluid causing water to move from the colon into the
interstitial space
 Isotonic solutions(physiological (normal) saline)
 They exert the same osmotic pressure as the interstitial
fluid surrounding the colon
 Idea and safest solution 9
 Cont…
– Normal saline
– Soap solution - soap 1gm in 20ml of H2O
– Epsom salt 15gm-120gm in 1000ml of H2O
Mechanisms of some solutions used in enema
Tap water: increase peristalsis by causing
mechanical distension of the colon
Soap solution: increases peristalsis due to irritating
effect of soap to the luminal mucosa of colon.
Epsom salt:- causes flow of ECF(extra cellular
fluid) to the lumen causing mechanical distension
resulting peristalsis
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Solution used

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 Enema solution…
 The force of flow of the solution is governed by the:

1. Height of the solution container

2. Size of the tubing

3. Viscosity of the fluid

4. Resistance of the rectum.

The higher the solution container is held above the rectum,
the faster the flow and the greater the force (pressure) in
the rectum.
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 Enema solution…
The amount of solution to be administered depends
on:
o Kind of enema
o The age of the person
o The person’s ability to retain the solution
o Condition of the pt
 Enema for adults are usually given at 40-43OC and
children at 37 OC
 Hot-cause injury to the bowel mucous
 Cold- may trigger a spasm of the sphincter muscles 13
 Types of enema

Return- flow
Retention

Carminative

Cleansing

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 Cleansing Enema
 Intended to remove feces. They are given chiefly to:
 Remove feces in instances of constipation or impaction
 To stimulate peristalsis and remove feces or flatus
 For incontinent patients to keep the colon empty

 To cleanse the bowel prior to surgery, childbirth, or

diagnostic examination.
 For diagnostic test
o Before certain x-ray exam – barium enema
o To promote visualization of intestinal tract by x-ray/ colonoscopy
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Types of liquid used for cleansing enema
1. Tape water = 500 to 1000 cc
2. Soap solution= 500 to 1000 cc
3. Normal saline - made by mixing one teaspoon of salt in
a liter of water usually contain 1000cc of normal saline.
4. Epsom salt 15 gm - 120 gm in 1000 cc of water

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 Cont…
Age Amount
• 18months 50-200ml
• 18mont-5yrs 200-300ml
• 5-12 yrs 300-500ml
• 12yrs and older 500-1000ml
 The rectal tube should be appropriate: is measured in
French scale
Age Size
 Infants/small child------------10 -12fr
 Toddler --------------14 -16fr
 Scholl age child----------------16 -18fr
 Adult’s -------------------22-30fr 17
 Precautions
 No need to use too much soap - this may produce sever
irritation of the membrane of the colon.
 Tap water must be administered consciously for infants
or adults who have altered kidney or cardiac reserve
this is to avoid water intoxication.
Contraindications
o Rectal surgery
o Rectal /anal/ cancer
o Rectal infection
o for a patient with appendicitis
o Rectal /Anal/ fissure

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Equipment
1.Container for solution
2.Solution at temperature for adult 40-430c
3.Bath thermometer for infant (37.70c)
4.Water proof material /mackintosh/
5.Screen, bath blanket, towel
6.Enema cane with tube
7.Gauze to apply lubricant /swab/
8.Bed pan and toilet tissue
9.IV pole/stand
10. Gloves
11. Receiver /kidney dish/
12. Lubricant
13. Rectal tube /catheter /
14. Clamp, connector, funnel 19
 Procedure
o Inform the patient about the procedure.
o Put bed side screen for privacy.
o Attach rubber tube with enema cane with
nozzle/syringe/ and stop cock or clamp.
o Place the patient in the lateral position with the
right leg flexed for adequate exposure of the anus
(facilitate the flow of solution by gravity in to the
sigmoid and descending colon which are on the
side).
o Fill the enema cane with 1000cc of solution for
adults.
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 Cont…
o Lubricate about 5cm of the rectal tube facilitate insertion
through the sphincter and minimize trauma.
o Hung the cane at least 45cm from bed or 30cm from
patient on the IV stand.
o Place a piece of mackintosh under the bed
o Make the tube air free by releasing the clamp and
allowing the fluid to run down little to the bed pan and
clamp to prevents unnecessary distention.
o Lift the upper buttock to visualize the anus.

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 Cont’d…
o Insert the tube
7-10cm in adult smoothly and slowly.
5-7.5 cm in the child.
2.5-3.75cm in an infant.
o Raise the solution container and open the clamp to allow
fluid to flow.
o Administer the fluid slowly. if client complains of
fullness or pain stop the flow for 30 second and restart
the flow at a slower rate

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 Cont…
o Do not allow all the fluid to go as there is a
possibility of air entering the rectum or when the
client cannot hold any more and wants to defecate
o Remove bed pan clean the rectal tube.
o Document the procedure.
Note
 If resistance is encountered at internal sphincter, ask
the clients to take a deep breath then run a small
amount of solution (relaxes the internal anus
sphincter)

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 Retention Enema

 Administration of solution to be retained in rectum and

sigmoid colon for short or long period(1-3 hrs)
Purpose
 For lubrication the rectum and anal canal to facilitate
defecation (oil retention enema)
 to treat infections locally(antibiotic/anthelmintic enema)
 To administer fluids and nutrients to the rectum(nutritive
enemas)

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Principles: Retention Enema
o Is given slowly by means of a rectal tube
o The amount of fluid is usually 150-200cc
o Cleansing enema is given after the retention time is
over
o Temperature of enema fluid is 37.4 c or body temp
o Other equipment is similar except the tube for
retention enema is smaller in width.
Procedure of retention enema
o Similar with the cleansing enema but the enema
should be administered very slowly and always be
preceded by passing a flatus tube 25
 Cont…
Note
o Most medicated retention enema must be preceded by a
cleansing enema/flatus tube
o Elevate foot bed to help patient retain enema.
o Kinds of solution used are plain water, normal saline,
glucose 5% , soda bicarbonate 2-5%.
o Olive oil 100-200cc to be retained for 6-8hours is given
for sever constipation.

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Carminative enema
 is given primarily to expel flatus.
 Relieving gas in the alimentary tract
 Medication that prevents the formation of gas in the
alimentary tract or eases its passing
Return-flow enema(Harris flush)
 is occasionally used to expel flatus
 Repeated 5-6 times until the flatus is expelled and abdominal
distention is relieved

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 Rectal washout (siphoning enema)
o Colon irrigation or colonic flush
o is the process of introducing large amount of fluid in to
large bowel for flush and allow return or wash out fluid
Purpose
 To prepare the patient for x-ray exam and sigmoid-
oscopy
 To prepare the patient for rectum surgery and allow
return or wash out fluid

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 Cont’d… rectal wash out
Solution Used
 Normal saline
 Soda-bi-carbonate solution(to remove excess mucus)
 Tap water
 KMNO4 solution. 1:6000 for dysentery or weak tannic
acid
 Tr.Asafetida in 1:1000 to relieve distention

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Equipment for rectal washout
1. Pitcher
2. Newspaper
3. small jug
4. Large mug for fluid
5. Bucket
6. Funnel
7. Bedpan
8. Tubing and glass connecting
9. Rectal tube or catheter and clamp
10. lotion thermometer
11. Mackintosh and towel
12. swab and Vaseline
13. Solution of (40 co)
14. glove 30
 Procedure of Rectal washout
o Insert the tube like the cleansing enema.
o The client lies on the bed with hips close to the side of
the bed (client assumes a right side lying position for
siphoning).
o Open the clamp and allow running about 1000cc of fluid
in the bowel then siphon back into the bucket.
o Carry on the procedure until the fluid return is clear.

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 Cont’d … rectal washout
Note
 The procedure should not take>2hours.
 Should be finished 1hour before exam or x-ray to give
time for the large intestine to absorb the rest of the
fluid.
 Give cleansing enema ½ hour before the rectal
wash out
 Allow the fluid to pass slowly
 Amount of solution 5-6 liters until the wash out
rectum fluid becomes clear.

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 Passing a flatus tube
o The insertion of a rectal tube is done to manage
flatulence (gas) following abdominal surgery and/or
reduce abdominal distention due to flatulence.
Purpose
o Used before giving a retention enema
o Used to alleviate abdominal distention.
o Used to control diarrhea that cannot be
controlled with medication

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Equipments for passing a flatus tube

1. Rectal tube or catheter, 22 to 30 French

2. Water-soluble lubricant
3. Bedside drainage bag (optional, if rectal tube used to
manage diarrhea)
4. Ostomy odor eliminator or similar product (optional)
5. Clean gloves
6. Disposable pads or towels

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 Procedure
o Place the patient in the left lateral position.
o Lubricate the tube about 15cm.
o Separate the rectum and insert 12-15cm into
the rectum and tape it.
o Connect the free end to extra tubing by the
glass connecter.
o The end of the tube should reach the tape water
solution in the bowel.

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 Cont’d…procedure
o The amount of air passed can be seen bubbling through
the solution
o Teach client to avoid substance that cause flatulent.
o Leave the rectal tube in place for no longer than 20
minute. b/se it affect the ability to voluntarily control
the sphincter if placement is prolonged.
o Reinsert the rectal tube every 2-3 hour if the distention
has been unrelieved or re-accumulates

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