Bowel Elimination

Bowel Elimination

Bowel elimination can be defined as the expulsion of faeces from the anus and the rectum. The frequency of defecation is highly individual, varying from several times per day to two or three time per week. Elimination of waste products of digestion is a natural process. The peristalsis waves move the faeces into the sigmoid colon and the rectum; the sensory nerves in the rectum are stimulated and the individual becomes aware of the need to defecate. Patients differ widely in their expectations about bowel elimination, their usual pattern of defecation, and the ease with which they speak of bowel problems. Although most people have experienced minor acute bouts of diarrhea or constipation, some patients experience severe or chronic alterations in bowel elimination that affect their fluid and electrolyte balance, hydration, nutritional status, skin integrity, comfort and self-concept. Moreover, many illness, diagnostic tests, medications and surgical treatments can affect bowel elimination. Nurses need to be knowledgeable about measures for preventing and managing bowel elimination problems.

Factors Affecting Bowel Elimination

Although elimination is a natural process, several factors influence bowel elimination process.

Some of the factors that influence are as follows:

Age: There is a marked difference between the stools of an infant and an older person. Very young children are unable to control elimination until the neuromuscular system is developed, usually between the ages of 2 to 3 years and as age increases peristalsis decreases which decreases the frequency of stool. Elderly people experience reduced muscle tone, causing difficulty in elimination leading to constipation.

Daily Patterns: Most people have regular patterns of bowel elimination which include frequency, timing considerations, positions and place changes. Any of these may upset a person's routine and actually lead to constipation.

Diet: It is the main factor that affects this process. High fiber diets and fruits enhance elimination. Low fiber foods cause constipation.

Fluid: Equally important as diet; more fluid means less constipation and proper bowel movements and vice versa.

Life Styles: Many individuals, family and socio cultural variables influence a person's usual elimination habits. The long term effect of bowel training, the availability of toilet facilities, embarrassment about odours and need to privacy also affect the fecal elimination patterns.

Fluids: Both the type and amount of fluid ingested affect elimination. Healthy fecal elimination is facilitated by a daily intake of 2000 ml to 3000 ml.

Activity and Muscle Tone: Regular exercise improves gastrointestinal motility and muscle tone while inactivity decreases both. Adequate tone in the abdominal muscles, the diaphragm and the perinea muscles is essential to case in defection.

Psychological Factors: Emotional stress affects the body in many ways. Persons with anxiety causes increased intestinal motility and persons with depression causes slower intestinal motility resulting in constipation.

Pregnancy: As pregnancy advances, the size of the fetus increases, and pressure is exerted on the rectum. A temporary obstruction repeated by the fetus impairs passage of feces.

Physical Factors: Physical activity aids in maintaining proper muscle tone

Pathological Conditions: Spinal cord and head injuries decrease sensory stimulation for defecation. Impaired mobility limits the patient's ability to respond to the urge to defecate. Ribbon like stool is appearing due to tumor in the colon.

Medications: Narcotic analgesics cause constipation by decreased gastrointestinal mobility. Many medications have diarrhoea as undesirable side effect.

Surgery and Anesthesia: Direct manipulation of the bowel during abdominal surgery inhibits peristalsis causing a condition termed as paralytic. Ileu's general anesthetic agents that are inhaled also inhibit peristalsis by blocking the parasympathetic impulses to the intestinal muscles.

Irritants: Spicy foods, bacterial toxins and poisons can irritate the intestinal tract and produce diarrhoea and often large amounts of flatus.

Temperature: Elevated temperature results in dehydration and consequently constipation.

Common Problems in Bowel Elimination

Abdominal Distention

Distension is an abnormal enlargement of any structure. Abnormal enlargement of abdomen due to excessive amount of gas, fluid and solid in the abdominal cavity is called abdominal distension. Distention is a more serious condition than bloating, and it can be caused by three different things:

• Air
• Fluid
• Tissue

Causes

There are several factors responsible for abdominal distention and bloating:

• Bowel obstruction
• Prolong bed rest
• Ascites
• Slowed peristalsis due to anesthesia & bowel manipulation.
• Constipation and fecal impact.
• Enlargement of abdominal organ and tumors.
• Incorrect eating habits, erratic lifestyle, gastric reflux disease and excessive use of antacids result in gaseous distension and flatulence.
• Sedentary lifestyle with no exercise is a significant cause.
• A long interval between two meals, eating very heavy and greasy meals, having late lunches and dinners.
• Smoking or consumption of tobacco products: Smoking can lead to irritation of the gastric mucosa, resulting in increased production of gastric acid. This in turn may lead to gassy stomach. Alcohol also has a similar effect, particularly when consumed on an empty stomach.
• Hormonal changes
• Poor sleep

Sign and Symptoms

• Abdominal tightness or stretched abdomen
• Discomfort
• When the patient is asked to roll on his side, the flanks will bulge if it is due to fluid.
• The flanks do not bulge if it is due to gas.

Ways of Relieving Distention

• Ambulation: Ambulation means to make the patient walk. We should ambulate the patient from 1st or 2nd post-operative day according to type of operation. Ambulation helps to stimulate the return to peristalsis and also helps to pass gas if patient has gas pain.
• Oral fluid: Patient should be encouraged to take adequate fluid intake. This helps to soften fecal material so that it is easy to pass stool during bowel elimination. Fruit juices, warm liquids & soda water help to expel gases and thus relieve distension.
• Avoid soft drinks and carbonated beverages. The carbon dioxide can become trapped in your stomach, causing bloating.
• Eat natural fresh foods. Packaged foods contain more preservatives and are harder to digest.
• Roughage diet: Eat foods containing more roughage such as vegetables, fruits and food with natural fibers like whole wheat flour, whole roasted soya bean, etc. It helps to easy pass of stool.
• Flatus tube: Flatus tube is a rubber tube with a small opening on the tip of the tube and a big opening on the other end. It is passed through the rectum for the expulsion of flatus or gas from the lower bowel to reduce abdominal distension.
• Enema: An enema administration is a technique used to stimulate stool evacuation.
• Life style Modifications to treat gassy stomach.
  • Avoid smoking.
  • Limit the intake to tea, soda drinks and coffee, especially on an empty stomach. These drinks can irritate the gastric mucosa, resulting in increased production of gastric acids.
  • Simple exercises and Yoga can be helpful in improving gastric functions.
  • Avoid erratic dietary practices. 

Constipation

The delayed and difficult evacuation of stool is known as constipation. It is a common gastrointestinal condition. It occurs when the colon is unable to remove waste through the rectum. People with this condition have three or fewer bowel movements over a seven-day period. Though occasional constipation is very common, some people experience chronic constipation that can interfere with their ability to go about their daily tasks. Constipation is a very common condition that affects people of all ages. Waste moves more slowly through system, so more water is reabsorbed. It is a symptom, not a disease.

Causes: The causes of constipation can be divided in to congenital, primary and secondary.

• Changes in routine such as irregular bowel habit and ignoring urge to defecate. If individuals ignore the urge to have a bowel movement, the urge can gradually go away until the individual no longer feels the need to go. The longer it is delayed, the drier and harder the stool will become.
• Environmental effect: Lack of privacy, change in place/ unnatural position.
• Eating problems
• Eating disorders
• Inadequate and irregular diet.
• Lack of fiber in the diet and high in animal fat e.g. meat, diary product.
• Insufficient fluid intake which slows peristalsis.
• Insufficient exercises/Insufficient activity or immobility.
• Psychological stress, anxiety, depression.
• Problems with the pelvic muscles involved in having a bowel movement may cause The chronic constipation. These problems may include:
  •  Inability to relax the pelvic muscles to allow for a bowel movement (anismus)
  •  Pelvic muscles don't coordinate relaxation and contraction correctly (dyssynergia)
  •  Congenital weakness of muscles
• Problems with the colon or rectum
• Tumors can compress or restrict the passages and cause constipation. Also, scar tissue, diverticulosis, and abnormal narrowing of the colon or rectum, known as colorectal stricture.
• People with Hirschsprung disease are susceptible to constipation.
• chronic bowel disease, Irritable bowel syndrome
• Problems with the nerves around the colon and rectum: Neurological problems can affect the nerves that cause muscles in the colon and rectum to contract and move stool through the intestines. Causes include:
  •   Autonomic neuropathy
  •   Multiple sclerosis
  •   Parkinson's disease
  •   Spinal cord injury
  •   Stroke
• Aging: Along with the increase in age, metabolism slows down, resulting in less intestinal activity.
• Post diarrheal effect.
• Excessive use of laxatives. Laxatives can be habit forming. When we become dependent on them there is a significant risk of constipation when we stop taking them.
• Abdominal surgery.
• Effect of drugs e.g. Narcotics, Pain killer.
• Hormonal effect: Hormones help balance fluids in your body. Diseases and conditions that upset the balance of hormones may lead to constipation, including: Diabetes, hyperparathyroidism, hypothyroidism
• Pregnancy. Due to hormonal changes, women are more susceptible to constipation and uterus may compress the intestine, slowing down the passage of the food.

Sign and Symptoms 

• Passing fewer than three stools a week.
• Having lumpy or hard stools.
• Strain to have bowel movements.
• Feeling as though there's a blockage in rectum that prevents bowel movements.
• Feeling as though you can't completely empty the stool from your rectum.
• Headache/Nausea
• Pain in abdomen
• Restlessness
• Abdominal distension
• Anorexia
• Insomnia
• Coated tongue
• Lethargy
• Needing help to empty your rectum, such as using your hands to press on your abdomen and using a finger to remove stool from your rectum.

Treatment

In the majority of cases, constipation resolves itself without any treatment or risk to health. The treatment of recurring constipation can include lifestyle changes such as doing more exercise, eating more fiber, and drinking more water. Usually, laxatives will successfully treat most cases of constipation - but should be used with care and only when necessary. In more difficult cases, the person may need a prescription medication. Only use these laxatives as a last resort:

• Stimulants: These make the muscles in the intestines contract rhythmically. These include Correctol, Dulcolax, and Senokot.
• Lubricants: These help the stool move down the colon more easily. These include mineral oil and Fleet. Jowod oldatiz ad
• Stool Softeners: These moisten the stool. Stool softeners include Colace and Surfak.
• Fiber Supplements: These are perhaps the safest laxatives. They are also called bulk laxatives. They include FiberCon, Metamucil, Konsyl, Serutan, and Citrucel and should be taken with plenty of water.
• Osmotics: These facilitate the movement of fluids through the colon. These include Cephulac, Sorbitol, and Miralax.
• Saline Laxatives: These draw water into the colon and include milk of magnesia.
• Chloride Channel Activators: These require a prescription and include lubiprostone (Amitiza).
• 5-HT-4 Agonists: They increase the secretion of fluid in the intestines and speed up at which food passes through the colon. They include Prucalopride. Istrisib J201 the rate
• If the constipation does not respond to any treatment, as a last resort, surgery to remove part of the colon may be undertaken.

Ways of Relieving Constipation

There are a few ways to ease the symptoms of constipation without using medication.

• Identify the underlying reason, then treat the patient accordingly.
• Increasing fiber consumption: Constipation sufferers should consume between 18 and 30 grams of fiber daily. High fiber foods include fresh produce, fortified cereals, and fruits and vegetables. A natural laxative is fiber. It makes stool more hydrated and gives it more volume.
• Water consumption: Drinking plenty of water might assist in rehydrating the body.
• Bulking agents: Including them in your diet can aid in softening stools and facilitating their passage. The bulking agent wheat bran is an example.
• Regular exercise: This can assist to regulate body functions, such as bowel movements.
• Routine: Setting aside time at a specific location and time of day to use the restroom without having to stoop. Patients should be urged to practice regular bowel habits. Decide on a time for defecation; most people do it in the morning.
• Not holding stools in: In order to lessen the effects of constipation, it's important to react to the body's natural urges to evacuate feces when they occur.
• Avoid dairy products and cheese. Many people are extremely sensitive to lactose, which is typically found in cheese and dairy products. Some people may experience constipation, bloating, and gas as a result of this lactose. Cheese, milk, and the majority of other dairy products should be eliminated from your diet until you feel better if you are experiencing constipation.
• Don't eat anything processed. Foods that have been processed and "fast" eating might aggravate chronic constipation. These foods don't provide much nutrients and are frequently high in fat and low in fiber. Junk food, sausage, red meat, potato chips, french fries, white bread, and pastries are among the things to avoid.
• Attempt shifting positions. Squatting is a common bowel movement position for Aboriginal people and can be beneficial.
• Everyone needs their own space to urinate. Give the sufferer his space and respect his privacy.
• Laxatives, suppositories, and enema usage should be avoided because they can become habit-forming. Utilizing laxatives excessively, particularly stimulant laxatives, can make the body dependent on them.
• If you suffer from chronic constipation, you may need a more powerful remedy than what you can find in at-home cures.

Complication of Constipation

Anal Fissure: It is small tear in the skin around the anus that is often accompanied by itchiness, pain, and bleeding. A large or hard stool can cause tiny tears in the anus.

Hemorrhoid: Dilatation of veins of rectum which causes painless bleeding with stool. Straining to have a bowel movement may cause swelling in the veins in and around your anus.

Fecal Impaction: Chronic constipation may cause an accumulation of hardened stool that gets stuck in your intestines.

Rectal Prolapse: Straining to have a bowel movement can cause a small amount of the rectum to stretch and protrude from the anus.