BOWEL ELIMINATION

DEFINITION BOWEL ELIMINATION

• It is also known as defecation. Bowel elimination is a natural process critical
to human functioning in which body excretes waste products of digestion. It
is a essential component of the healthy body functioning.

• Defecation (bowel elimination) is the act of expelling feces (stool) from the
body. To do so, all structures of the gastrointestinal tract, especially the
components of the large intestine must function in a coordinated manner
 REVIEW OF PHYSIOLOGY OF BOWEL ELIMINATION
• Gl tract also known as alimentary canal. It is a hollow muscular tube that
extend from the mouth to the anus.
• Food is broken down in the stomach in to a semi liquid mass called
chyme.
• Chyme leaves the stomach and enter in to the small intestine which is
divided in to three part i.e. Duodenum (10 inches long. Receive bile and
pancreatic enzyme), Jejunum (it mixes with digestive enzyme and most
nutrients are absorbed) and ileum (unabsorbed chyme enters in to the
intestine through ileum).
• Through large intestine and colon chyme expel out from the body
through anus.
 PROCESS OF DEFICATION/defecation reflex
1.PARASYMPATHETIC STIMULATION FROM
MEDULLA AND SPINAL CORD
• 2.INTERNAL ANAL SPHINCTER RELAXES

3.COLON CONTRACTS

4.DEFECATION REFLEX STIMULATED BY FECAL MASS

IN RECTUM

5.RECTUM DISTENDED

6.INCREASE INTERNAL PRESSURE

7.DEFECATION REFLEX STIMULATED BY MUSCLE

STRETCH

8.DESIRE TO ELIMINATE
 FACTORS AFFECTING BOWEL ELIMINATION
1. AGE AND DEVELOPMENT: There is a marked difference between the
stools of an infant and an older person. The very young are unable to
control elimination until the neuromuscular system is developed,
usually between the ages of 2 to 3 years.
2. DAILY PATTERNS: Most people have regular patterns of bowel
elimination which include frequency, timing considerations, position
and place changes in any of these may upset a person routine and
actually lead to constipation.
3. LIFESTYLES: The long-term effect of bowel training, the availability of
toilet facilities, embarrassment about a odors and need to privacy,
also affect the fecal elimination patterns.
4. FLUIDS: Both the type and amount of fluid ingested affect elimination.
Healthy fecal elimination is facilitated by a daily intake of 2000 to 3000
mL.
5. ACTIVITY AND MUSCLE TONE: Regular exercise improves
 Cont…
6.PSYCHOLOGICAL FACTORS: Persons with anxiety causes increased
intestinal motility and persons with depression causes slower intestinal
motility resulting in constipation mobility limits the patient's ability to
respond to the urge to defecate. Ribbon like stools in appearance due to
tumour in the colon
7.MEDICATIONS: Narcotic analgesics cause constipation by decreased
gastrointestinal mobility. Many medications have diarrheal as undesirable
side effect.
8.DIAGNOSTIC PROCEDURE: Barium salts used in radio- logic examinations.
It Hardens, if allowed to remain in the colon, producing constipation and
sometimes an impaction.
9.SURGERY AND ANESTHESIA: Direct manipulation of the bowel during
abdominal surgery inhibits peristalsis causing a condition termed as
paralytic lieu's. General C anesthetic agents that are inhaled also inhibit
peristalsis
10. IRRITANTS: Spicy, foods, bacterial toxins and poisons can irritate the
intestinal tract and produce diarrhea and often large
 COMPOSITION OF NORMAL FECES
Feces contains up to 3/4th of water, that is around 75% of the feces is
composed of water.
The rest 1/4th or 25% of the feces is solid waste.
Feces also contain some amount of roughage, which is undigested. It also
contains unabsorbed food.
There may also be presence of some intestinal secretions. In addition to
that, digestive juices such as bile and bile pigments and salts are also
present in the excreta.
The normal flora and bacteria such as Escherichia coli gets excreted with
the feces. Moreover, the dead epithelial cells also constitute the feces.
 CHARACTERISTICS OF NORMAL AND ABNORMA
CHARACTERISTICS NORMAL
LFECES
ABNORMAL
COLOR ADULT-BROWN TARRY BLACK-MELENA-DUE TO UPPER GI BLEED
CHILDREN-YELLOW [BILEPIGMENT] BRIGHT/DARKRED-INDICATE LOWER GI BLEED
GREEN DUE TO DIGESTIVE DISORDER
CLAY COLORED –BILIARY OBSTRUCTION OR JAUNDICE
BLACK STOOL-ADMINISTRATION OF IRON
YELLOW AND FOUL SMELL-FAT IN STOOL AND MAL
ABSORPTION
CONSISTENCY Soft moist,
semisolid,cylindrical,represents the
contour of rectum
shape Cylindrical ,represents the contour of RIBBON SHAPE suggest hirschsprung’s disease
rectum Tape like stool suggest tapeworm infestation

odor May depend upon kind of food

ingested. Generally aromatic in nature
constituents Fat ,protein, undigested roughage,
epithelial cells,dead bacteria and dried
out constituents of digestive juice
COMMON ALTERATION IN BOWEL ELIMINATION

1. Constipation
2. Fecal impaction
3. Flatulence
4. Diarrhea
5. Fecal incontinence
 1. CONSTIPATION
• Constipation is an elimination problem characterized by dry, hard stool that
is difficult to pass.
• A condition in which you have fewer than three bowel movement a week.
SIGNS AND SYMPTOMS
Complaints of abdominal fullness or bloating
Abdominal distention.
Complaints of rectal fullness or pressure
 Pain on defecation
Decreased frequency of bowel movements
Inability to pass stool
 Changes in stool characteristics such as hard small stool
CAUSES OF CONSTIPATION
Diet restrictions Exploitation of drugs like
Insufficient fiber and morphine, codeine
roughage in diet Intake of caffeine
Insufficient fluid intake containing beverages in
Any changes in the excess
defecation habits Any injuries or trauma to
No establishment of the anal canal
defecation pattern, the Conditions such as
timings. haemorrhoids
Lack of privacy, for instance Excess use of laxatives,
in the hospitals. enemas or suppositories.
CLASSIFICATION
• Constipation is classified into one of four distinct types
1. Primary
2. Secondary
3. latrogenic and
4. Pseudo constipation
 CLASSIFICATION
1.PRIMARY OR SIMPLE CONSTIPATION
• Primary or simple constipation is well within the treatment domain of
nurses. It results from lifestyle factors such as inactivity, inadequate intake
of fiber, insufficient fluid intake, or ignoring the urge to defecate.
2.SECONDARY CONSTIPATION
• Secondary constipation is a consequence of a pathologic disorder such as a
partial bowel obstruction. It usually resolves when the primary cause is
treated.
 CONT… CLASSIFICATION OF CONSTIPATION
3.IATROGENIC CONSTIPATION
• Iatrogenic constipation occurs as a consequence of other medical
treatment. For example, prolonged use of narcotic analgesia tends to cause
constipation. These and other drugs slow peristalsis, delaying transit time.
The longer the stool remains in the colon, the drier it becomes, making it
more difficult to pass.
4.PSEUDOCONSTIPATION
• Pseudo constipation, also referred to as perceived constipation, is a term
used when clients believe themselves to be constipated even though they
are not.
PREVENTION & MANAGEMENT OF CONSTIPATION
• Health teaching
• Adequate intake of diet & fluid
• Adequate intake of fibre in diet
• Establishing a habit pattern
• Relaxation
• Privacy
• Posture
• Exercise
• Use of laxatives, suppositories & enemas
MEDICATION TO TREAT CONSTIPATION
• Medications to treat constipation include the following: -
1. Bulk-forming agents (fibers; e.g., psyllium): Arguably the best and least
expensive medication for long-term treatment.
2. Emollient stool softeners (e.g., docusate): Best used for short-term
prophylaxis (e.g., postoperative).
3. Rapidly acting lubricants (e.g., mineral oil): Used for acute or sub acute
management of constipation
4. Prokinetics (e.g., tegaserod): Proposed for use with severe constipation-
predominant symptoms.
5. Stimulant laxatives (e.g., senna): Over-the-counter agents commonly but
inappropriately used for long- term treatment of constipation.
 2.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
•Develops usually R/T untreated or
unrelieved constipation
•As the faeces remains in the rectum &
sigmoid colon, the water is reabsorbed
making the faeces harder, drier & more
difficult to pass
•More faeces continued to produced, which
get accumulated in the colon proximal to
the impacted stool
SIGNS & SYMPTOMS

 Feeling of fullness of rectum & abdomen.

 Swelling or tightness/Bloating of abdomen.
Urge of defecation but an inability to pass stool
Feeling of malaise-general discomfort
 Loss of appetite
 Nausea & vomiting
 MANAGEMENT
ENEMA:-A warm tap water enema can help soften and lubricate the
stool. Enemas can be used at home or in a healthcare provider's office.

MANUAL DISIMPACTION:-A medical professional inserts a gloved finger into the

rectum to break up the stool into smaller pieces. This process is called digital
disimpaction.

LAXATIVES:-An over-the-counter laxative or a polyethylene glycol (PEG)

solution can help cleanse the colon.
SURGERY:-In severe cases, surgery may be required, especially if there is
bleeding due to a tear in the bowel.

ORAL LAVAGE:-Polyethylene glycol solutions with electrolytes can be used to

soften or wash out stool in the proximal area.
After treatment, steps are taken to prevent future fecal impactions.
 3.FLATULENCE
• Flatulence or tympanites can be defined as the condition in which gas is
accumulated in the GI tract.
• The accumulation of gas is excessive. The gas accumulated is called flatus.
The accumulated gas can result in the distention of abdomen.

CAUSES
• Excessive swallowing of air with anxiety or rapid food or fluid ingestion, (usually
eliminated by burping)
• Gases produced by bacterial activity in large intestine (eliminated through anus)
• Certain gases from foods such as cabbage, onions etc
• Post operative patients because of effect of anaesthesia
• Gas that diffuses from blood stream into the intestine
TREATMENT
• Flatulence, or gas, can be treated with lifestyle changes, over-
the-counter medications, and other remedies: LIKE
Lifestyle changes
Eat smaller meals more often, chew food thoroughly, and avoid swallowing air
by not chewing gum or drinking through a straw. You can also try:
Limiting foods that cause gas
Reducing milk consumption if you're lactose intolerant
Exercising regularly to improve digestion
Staying hydrated to avoid constipation
Eating probiotic-rich foods
 4.DIARRHOEA
• Diarrhoea is defined as the passage of 3 or more loose or liquid stools per day
(or more frequent passage than is normal for the individual).

• Diarrhoea is usually a symptom of an infection in the intestinal tract, which can

be caused by a variety of bacterial, viral and parasitic organisms. Infection is
spread through contaminated food or drinking-water, or from person-to-person
as a result of poor hygiene.

There are 3 clinical types of diarrhoea:

• acute watery diarrhoea – lasts several hours or days and includes cholera
• acute bloody diarrhoea – also called dysentery
• persistent diarrhoea – lasts 14 days or longer.
 CAUSES OF DIARRHOEA
Acute diarrhoea usually caused by bacteria, viral or parasite infections.
Chronic diarrhoea is usually related to a functional disorder such as irritable bowel
syndrome or an intestinal disease called crohns disease.
The most common causes of diarrhea include the following:
1. BACTERIAL INFECTIONS. Several types of bacteria consumed through
contaminated food or water can cause diarrhea. Common culprits include
CAMPYLOBACTER, SALMONELLA, SHIGELLA, AND ESCHERICHIA COLI (E.
COLI).
2. VIRAL INFECTIONS. Many viruses cause diarrhea, including ROTAVIRUS,
NOROVIRUS, CYTOMEGALOVIRUS, HERPES SIMPLEX VIRUS, AND VIRAL
HEPATITIS. Infection with the rotavirus is the most common cause of acute
diarrhea in children. Rotavirus diarrhea usually resolves in 3 to 7 days but
can cause problems digesting lactose for up to a month or longer.
3. PARASITES. Parasites can enter the body through food or water and
settle in the digestive system. Parasites that cause diarrhea include
GIARDIA LAMBLIA, ENTAMOEBA HISTOLYTICA, AND
CRYPTOSPORIDIUM.
 FECAL INCONTINENCE
• It is definned as the loss of voluntary control over the passage of the feces
and gaseous discharge from the anal sphincter.
• Fecal incontinence is the result of impaired sphincters or impairment of
nerve supply , conditions may include tumor, trauma to muscle and
sphincter.

TYPE OF INCONTINENCE:-
1. Partial:-It is defined as the conditions in which the patient cannot
voluntarily control the flatus, which may be result in the minor soiling.
2. Major incontinence:-it is the inability to control feces
 CAUSES OF FECAL INCONTINENCE
Muscle or nerve damage: This can be caused by aging, childbirth, injuries,
tumours' or radiation.
Chronic conditions: These include diabetes, multiple sclerosis, and
dementia.
Digestive issues: These include diarrhoea, constipation, inflammatory bowel
disease, irritable bowel syndrome, or severe haemorrhoids.
Surgery: This includes anal surgery, colectomy, or surgery that separates or
widens the anal sphincters.
Other factors: These include birth defects, spinal cord injuries, rectal
prolapsed, fecal impaction, long-term laxative use, or vitamin D deficiency.
Foods and beverages: Alcohol, caffeine, and dairy can cause or worsen fecal
incontinence.
 MANAGEMENT
1. MEDICATION: Loperamide (Imodium) can help reduce stool frequency and
improve urgency. Laxatives can help with constipation.
2. DIETARY CHANGES: A high-fiber diet is often recommended.
3. PELVIC FLOOR EXERCISES: These can help strengthen the pelvic floor muscles.
4. ELECTRICAL STIMULATION: A small device is implanted near nerves to help
control bowel movements.
5. ANAL PLUG: A removable device that can help you control when you go to the
toilet.
6. SURGERY: This may be necessary to improve bowel function or fix a structural
problem. Surgical options include surgical muscle repair, nerve stimulation,
and surgical colostomy.
7. INJECTIONS: A substance can be injected into the anal canal to bulk it up and
strengthen the anal muscles.
8. MAGNETIC BEAD IMPLANT: This can tighten the sphincter.
HEMORRHOIDS
Hemorrhoids are painful, swollen veins in the lower portion of the
rectum or anus.
SIGN ANDSYMPTOMS
• Painless bright red blood from the rectum
• Anal itching
• Anal ache or pain, especially while sitting
• Pain during bowel movements
• One or more hard or tender lumps near the anus
ETIOLOGY
Straining and constipation.
Pregnancy.
 Obesity.
 Prolonged sitting.
Portal hypertension and ano rectal varices.
Chronic diarrhea
CLASSIFICATION
• Depending on anal origin within anal canal and relation to dentate
line haemorrhoids divided in two
1. INTERNAL HAEMORRHOIDS.
2. EXTERNAL HAEMORRHOIDS
  Internal haemorrhoids are enlarged
1. INTERNAL veins that form in the anus or lower
rectum.
HAEMORRHOIDS
They're usually not visible or felt, and
they rarely cause discomfort.
SYMPTOMS
• Bright red blood in stool
• Pain: You may feel pain or discomfort around
the anus, especially when sitting
• Itching at anus
• Lumps hard tender in anal region
• Prolapse: A hemorrhoid may protrude from
the anus during a bowel movement. It can
retract on its own or be pushed back in with
pressure.
• Pressure: You may feel a sense of pressure
or incomplete evacuation.
 2.EXTERNAL
HAEMORRHOID
• External haemorrhoids are swollen
veins that form under the skin
around the anus.
SYMPTOMS
• Itching or irritation,
• Pain or discomfort,
• Swelling around the anus,
• Bleeding.
 CONSERVATIVE TREATMENTS
FIBER: Increasing the amount of fiber in your diet can help
soften stools and reduce straining. A recommended amount
is 25–35 grams per day.
STOOL SOFTENERS: These laxatives help prevent
straining by making stools easier to pass.
WATER: Drinking more water can help ensure that stools
are soft and not just bulky.
SITZ BATHS: Sitting in warm water for 3–10 minutes, 3
times a day, can help with pain and itching.
PAIN RELIEVERS: You can take pain relievers by mouth.
 Cont..
TOPICAL TREATMENTS
• You can use creams or ointments to help with discomfort and
itching.
• Ice packs, Applying ice to the anal area for 10 minutes at a time
can help reduce swelling.
• Haemorrhoid surgery, also known as a haemorrhoidectomy, is
a surgical procedure to remove enlarged haemorrhoids. It's the
most effective treatment for severe or recurring haemorrhoids.
1.HEALTH HISTORY
Elimination habits:-
• Determine patient's usual pattern of bowel elimination.
• Determine the frequency and time.
• Find out the characteristics of the stool like stool is watery, soft, hard
and typical colour.
 2. PHYSICAL EXΑΜΙΝΑΤΙON
MENTAL STATUS EXAMINATION:- It can be evaluated by
listening to the client's responses to questions and by
observing interaction with others.
Mobility & Dexterity:- Mobility may be evaluated by observing
the client undress or move onto a table, chair or bed.
Dexterity assessed by observing the client remove clothing:
particular attention paid to the manipulation of zippers,
buttons, shoestrings and snaps.
INSPECTION:- Rectal examination are particularly important
for both men and women. The cheeks of the buttocks should
be pulled apart and the anus & surrounding area visually
inspected.
The client may asked to bear down and anus inspected for
 3. DIAGNOSTIC TEST
• DEFECOGRAPHY:- X-rays images of rectum and anal sphincter
obtained during defecation
• ANORECTAL ULTRASONOGRAPHY:- It is vital accepted popular
imaging motility for evaluating lower rectum, inner sphincter and
pelvic floor in patient with various anorectal disease
• COLONOSCOPY:- It is used to visualization of the colon
FACILITATING BOWEL ELIMINATION
1. ENEMA
2. RECTAL SUPPOSITORIES
3. COLOSTOMIES
 TYPES OF ENEMA SOLUTION
SOLUTION AMOUNT[ML] TEMPERATURE
1 EVACUANT ENEMA
A SIMPLE ENEMA Normal saline ,tap water,soap and water Adult-500-1000 Adult-105-
Children-250-500 110degree F
Infant-<250
B MEDICATED ENEMA
OIL ENEMA OLIVE OIL,GINGERLY OIL,CASTROL OIL AND 115-175ML 100 degree F
OLIVE OIL[1:2]
PURGATIVE ENEMA Glycerin 15-30 ml 100 Degree F
Glycerin + water-1:2
Glycerin + castor oil-1:1
Magnesium sulphate 60-120 ml

ASTRINGENT Tannic acid 2gram in 600 ml of water NOT >600ML

ENEMA Alum-30g in 600 ml water
Silver nitrate 2% in 600 ml of water
Antihelmintic 15gm of quassia in 600 ml of water 250ml
enema Hypertonic saline
 Solution amount temperature
Carminative Turpentine8-60 ml in 600-1200 ml of soap
enema or solution
antispasmodic 8-18 ml of transfoetida mixed in 600-1200 of
enema soap solution
C COLD ENEMA Cold water as per prescription
2 RETENTION ENEMA
STIMULANT Black coffie-1 table spoon coffee powder in 180-250 ml 108degree F
ENEMA 300 ml of water
Brandy 15 ml in 120-180 ml of glucose saline
SEDATIVE AND Agent as per prescription of physician
ANESTHETIC
ENEMA
EMOLLIENT Rice water 120-180 ml 100-102 degree
ENEMA F
NUTRIENT ENEMA GLUCOSE SALINE 2-5% 1101-1700 100 DEGREE F
PEPTONIZED MILK ML IN A DAY
BEFORE GIVING ENEMA
• The use of appropriate catheter should be ensued. The size The catheter
must be taken into consideration.
• A 22 no. tubes used for adults for giving cleansing enema, and no. 12
French is used for infants.
• A sharp tube should not be used, because of its potential to injure the
cavity.
• The tube must be smooth and flexible.
• • Before insertion of tube, any lubricant such as Vaseline/xylocaine jelly
should be applied on the tube.
• Before the enema is given, the solution should be checked for its
temperature.
• The temperature shouldn't exceed 105°F-110°F.* Ensure that no air enters
the rectum.
• Don't ignore if the client complains of any discomfort.
 EVACUANT ENEMA [Cleansing Enema]
An evacuant enema is a procedure that helps
the body expel stool or gas, along with the
contents of the enema. It's used to: Relieve
constipation, Empty the colon before a
colonoscopy, and Prepare the bowel for
abdominal surgery.
This type of enema is given to clean the bowel
and patient holds it for 5-10 minutes minimum.
Left lateral position is the most suitable
position for any enema. However, in case of
high bowel enema, knee chest position may be
given.
SIMPLE ENEMA
This enema is given for many
purposes such as for the
stimulation of defecation, and for
the treatment of constipation.
PURPOSES:
To relieve flatulence.
 Helps in relieving urinary
retention
Before surgeries or X-ray, to clean
the bowel.
For stimulation of uterus and
initiating contractions.
 In this enema, either soap water
or normal saline can be used
2.MEDICATED • A medicated enema is a medical
procedure that involves injecting
ENEMA medication into the rectum for
absorption.
• Medicated enema is when addition
of some agent is done in the water
like glycerine or oils.
I.OIL ENEMA
 In case the patient is suffering from
Severe Constipation, oil enema can be
provided to soften the fecal matter.
This enema is also given in post rectal
surgeries to facilitate the first bowel the
movement, to avoid strain and injury.
 Oil enema has to be followed by soap and
water enema
MEDICATED ENEMA CONT…
II PURGATIVE ENEMA
 The enema which helps in increasing the intestinal motility (contraction
of bowel) for active evacuation of bowel contents is purgative enema.
 This results in the irritation of the mucus lining and stimulation of gut
movements.
Enema, solutions such PURE GLYCERINE, GLYCERINE ALONG WITH
WATER, OR GLYCERINE ALONG WITH CASTOR OIL can be given.
 There is a special classification of this enema, called the 1-2-3 enema.
In this MAGNESIUM SULFATE, GLYCERINE AND WATER ARE USED IN THE
QUANTITIES OF 30 ML, 60 ML AND 90 ML respectively.
 MEDICATED ENEMA CONT..
IV.ANTHELMINTIC ENEMA
III.ASTRINGENT ENEMA
If there is presence of worms
In case the inner lining of gut is inside the intestine, this enema
inflamed or is bleeding, this is given as a treatment.
enema helps in lessening mucus
discharge, contracting the blood  After cleansing the bowel with
vessels and providing temporary soap and water enema, the
relief from the inflammation. worms can come directly in
contact with an anthelmintic
Such symptoms are present in enema.
case the patient has dysentery
or colitis. A HYPERTONIC SALINE OR
QUASSIA INFUSION can be used
 ALUM, TANNIC ACID OR 2% for this enema.
SILVER NITRATE can be used in
these enemas.
MEDICATED ENEMA CONT..
V.CARMINATIVE ENEMA OR
ANTISPASMODIC ENEMA
This enema is used for the release
contents of abdomen and thus
helps in the relieving of distension.

For the administration of this

enema, solutions such as
TURPENTINE, TR.
ASAFOETIDA[HING] AND MILK
AND MOLASSES can be used.
MEDICATED ENEMA CONT…
VI.COLD ENEMA:
When a patient suffers from high body temperature, most probably
this enema is given.
This enema is also given if a patient suffers from Heat stroke.
However, this can lead to an extreme decrease in body temperature
leading to hypothermia.
ADMINISTRATION OF ENEMA PROCEDURE
PURPOSES
1. To stimulate peristalsis.
2. To promote defecation.
3. To relieve constipation and gaseous distension.
4. To empty the bowel before a diagnostic procedure.
5. To establish normal bowel function during bowel training program
6. To remove the contract medium given during upper or lower GI
series.
7. To reduce fever and cerebral edema.
CONTRAINDICATIONS
 Acute renal failure
 Acute myocardial infarction and cardiac problems
Appendicitis
Obstetrical contraindications such as antepartumhemorrhage and
leaking membranes.
 Recent surgical procedure involving lower intestine tract
 Intestinal obstruction
 Inflammation and infection of abdomen.
TEMPERATURE AND AMOUNT OF SOLUTION
• Age group temperature amount
• Adult -105-110 F ( 40-43*c) 750-1000ml
• children 100*F (37.1*c) Less than 500ml
NURSING ASSESSMENT
A. Assess when the patient had last bowel movement – the amount,
color, and consistency.
B. Assess for presence of abdominal distension.
C. C. Assess the ability of the patient to use toilet
 PREPARATION OF EQUIPEMENTS
 A TRAY CONTAINING, SOLUTION AS ORDERED.
 Disposable gloves Hypertonic – sodium phosphate
Water-soluble lubricant Hypotonic – tap water
Bath thermometer Isotonic –physiological saline ( 1
Soap and water teaspoon of table salt in 500ml of
tap water)
 Toilet tissue  Others – 3-5ml of concentrated
Enema can with tubing and soap solution in 1000ml of water.
glass connection  Mackintosh
Clamp  Bedpan- for bedridden patient
Kidney tray– 2 nos Screen
 Iv stand  Extra linen as per need
 Jug with water
Kettle with warm water
NURSING PROCEDURE
Check the doctors order.
Assemble all the equipments near the bedside.
 Explain the procedure to the patient.
 Provide privacy.
 Raise the bed to a comfortable working height.
 Wash hands and wear gloves.
 Roll the draw sheet to the opposite side, if there is no mackintosh place one.
 Prepare the solution; attach the rectal tube to the tubing and clamp the tube.
Pour the solution into the can; release the clamp; allow the solution to flow till
the tip of the tube, clamp the tube.
 Suspend or hand the enema can with the solution onto the IV stand and adjust
the height to 18 inches above the bed.
CONT….
Position the patient in left lateral position. Position the patient near the
edge of the bed.
Keep the basin over the mackintosh.
Lubricate 3-4 inches of the rectal tube
Using gauze, separate the buttocks; ask the patient to take a deep breath
and insert the rectal tube to a distance of 3-4 inches; do not force the
tube.
 Open the screw or release the clamp.
Hold the rectal tube in place. Observe the can for the level of solution.
 If the patient has severe cramps or urge to defecate, stop temporarily and
then continue.
 Once the solution is nearly over, clamp the tube.
Ask the patient to hold the fluid for 10-15mints;remove the rectal tube
and place it in the k basin.
Assist the patient to toilet or provide bed pan as per need.
SUPPOSITORIES
• Suppositories are defined as a
form of medication, solid in
nature, which melts or dissolves
inside the body due to the body's
temperature.
• The suppositories are inserted
inside the body's cavities, such
as rectum, vagina, and urethra.
• Since the suppositories are
semisolid and meant to melt at
room temperature, they are
stored in cool places, such as
refrigerator.
• If not kept inside the refrigerator,
insertion becomes difficult.
PROCEDURE OF ADMINISTRATION OF SUPPOSITORIES
• Explain the procedure to the client.
• Place the client in a position which is most suited for the procedure and the client is
comfortable.
• Wash hands. Wear gloves. Take the suppository package and remove the suppository.
• Hold the suppository in right hand between two fingers.
• Buttocks are to be separated with the left hand and insert the suppository inside the
anus.
• It is worth considering that the suppository must pass the external sphincter and it
should be pushed beyond the internal sphincter using index finger.
• Patient can also insert the suppository if nurse is confident that patient is capable of
following the instructions
• Instruct the client to retain the suppository for at least 20-30 minutes, or even longer if
comfortable.
POST-PROCEDURE NURSING RESPONSIBILITY

• It is the responsibility of the nurse to make the patient comfortable

after the procedure.
• Clean and tidy up the patient.
• Observe the patient.
• Document about the type of suppository, timing of insertion and the
effect of suppository, what is the timing of evacuation of bowel.
DIGITAL EVACUATION OF IMPACTED FECES
It is defined as the process in which the fecal material is broken into
portions digitally and then removed in portions.
This procedure, although useful, can have deleterious effects on the mucus
membrane of the gut.
This procedure can potentially injure the mucosa.
Before this procedure is initiated, it is suggested that oil enema should be
given and the patient must hold it for 30 minutes.
 After the digital evacuation is done, remaining fecal matter can be
removed using a cleansing enema or by using a suppository.
The finger is inserted inside the rectum, gently.
The finger is then moved along the rectal length.
Break the stool using the finger. The hardened stool is dislodged. Consider
that the mucosa shouldn't be injured in this process.
As the stool is dislodged, work in a way that the stool is brought
downwards. Keep removing the feces, as much as possible.
 BOWEL WASH
• Bowel wash is defined as the procedure in which the colon is cleared off of the
fecal matter using large volumes of solutions.
• It is, basically, the washing of the colon. Bowel wash is also called colonic lavage,
colon irrigation, or enteroclysis.

PURPOSES OF BOWEL WASH

• It can be done pre- or post-surgery so as to perform any diagnostic
procedure.
• To relieve inflammatory responses.
• To initiate peristaltic movements.
• For the removal of toxins from the gut.
• In case of fecal incontinence.
• Wash off the feces or gas present in gut.
• For the treatment of any other medical condition.
CONTRAINDICATIONS OF BOWEL
WASH ARTICLES REQUIRED FOR BOWEL WASH
• Anal fistula • A tray containing Mackintosh and towel
• Anal fissures • Rectal tube
• Infection • Kidney tray
• Rectal tumour • Funnel and tubing
• Damaged sphincters • Lubricant
• Haemorrhoids • Gauze pieces
SOLUTION USED FOR BOWEL WASH • Water (hot and cold)
Tap or cold water Normal saline • Other solution, as prescribed by the
doctor
 Alum 1:100
• Clean bed sheet
Tannic acid 1:100
• Bucket
Soda -bicarb 1-2%
• Bath thermometer
Boric solution 1-2%
 PRE PREPARATION OF PATIENT
• Check if the patient has been ordered for the bowel wash.
• See if there is any contraindication.
• Prepare all the articles before the procedure.
• Explain the procedure and the necessity of the procedure to the client.
• Using the curtains or screens, the client has to be provided with privacy.
• Gather all the articles near the bed side of the patient.
• Spread mackintosh and towel under the patient's buttocks. Position the
client in left lateral position
PROCEDURE OF BOWEL WASH
 Perform hand hygiene
 Prepare the solution as prescribed by the doctor
The rectal tube and tubing are attached to the funnel
Check for any leaks.
 The tip of the tubing is lubricated with Vaseline.
Separate buttocks and after visualizing the anal opening, Insert the
tubing 3-5 inches and allow fluid to move in.
 After the solution is moved inside the rectum, the tubing and funnel are
moved to a level that is below the rectum and return flow is allowed in
bed pan or toilet.
Repeat the procedure until the back flow is clear.
* Remove the tube after the flow is cleared using rag pieces.
POST PROCEDURE[BOWEL WASH]
• Discard all the rag pieces.
• Provide patient a comfortable position.
• Offer the bedpan.
• Wash hands thoroughly.
• Document the procedure.
BOWEL DIVERSION

• Bowel diversion, also known as ostomy surgery or fecal diversion, is a

surgical procedure that alters how the intestines empty the body.
• It's performed when the large intestine is removed or needs time to
heal due to injury or disease.
PURPOSE OF OSTOMY
• The basic purpose of the bowel diversion ostomies is the diversion of pathway
of the fecal matter and helping it drain into some other cavity.
• The conditions due to which diversion is required can be: Any disease
condition of the bowel, like Crohn's disease.
• Ulcerative colitis
• Tumours
• Infarction of the bowel
• Injuries
• Congenital anomaly like Hirschsprung's disease, imperforated anus.
 CLASSIFICATION OF OSTOMY
• The bowel diversion ostomy can be classified according to their
permanence status, their anatomical locations and according to the
construction of stoma.
1.BASED ON DURATION
a. TEMPORARY
b. PERMANENT
 TEMPORARY OSTOMY: as the name suggests, is constructed when the bowel
isn't functional due to temporary reasons, such as an injury.
 Created for short period of time- weeks/months or even years.
 Purpose is to give rest to the intestine and promote healing in the distal part of
colostomy like in case of trauma or inflammatory conditions.
 PERMANENT OSTOMY: If the rectum or anus is damaged permanently, their
function is carried forward by a permanent ostomy.
 Created for lifelong
 Purpose is to divert the stool passage due to non-functional portion of
colon/rectum/anus* Bowel function is permanently damaged.
 Cont…
2.BASED ON ANATOMICAL LOCATION:-
The anatomical condition influences how the fecal matter is managed.
If the ostomy is created far inside the bowel, the stool is more hard and
solid.
If the ostomy is created nearer to the large intestine, the Stool will be
watery.

3.SURGICAL CONSTRUCTION OF STOMA:

Depending on the surgical construction, the stoma can be of various
types,
1. Single,
2. Loop,
3. Divided Or Double Barrelled Colostomies .
 Cont..
SINGLE-BARREL: It is the stoma through which an end of the bowel is
brought out. The opening is made into the abdominal wall anteriorly and
through this opening, the bowel is brought out. This is a permanent type
of stoma.
LOOP: This stoma has two openings, out of which a loop of bowel is
made to bring out through one opening and it is supported by a plastic
bridge. One end is active while the other is inactive.
DIVIDED: In this stoma, two ends of bowel are brought out, but they
remain separated from each other.
 DOUBLE-BARREL: In this, both ends are brought out through the
abdominal wall and are sutured together.
 ROLE OF NURSE IN CARING FOR THE PATIENT
WITH OSTOMY
1. Skin care
2. Psychological support
3. Nutrition
4. Education
5. Medication
6. Odor control