7.3 Bowel Elimination

Tracy M. Christianson, RN, 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, color, odour and any pain or discomfort experienced during bowel movements. This will assist the LPN/RN in adjusting the client’s diet or medications.

Watch the video, How Your Digestive System Works – Emma Bryce, from TED-Ed (2017), on YouTube.

Watch the video, What is Peristalsis? by Mister Science (2018) on YouTube.

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 (see Figure 7.3.1) can assist you in identifying the consistency of the bowel movement.

**Figure 7.3.1** Bristol Stool Chart (Image courtesy of John C Bullas,/Flickr.) CC BY-NC-ND 2.0

Normal Bowel Elimination

**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 colored stool. Pale or clay colored: 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

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, bed pan).
Ensure safety of the client (provide the call bell and stand by if the client is unsteady).
Provide peri-care after if client unable to do themselves.
Ensure to wash the client’s hands afterwards as well as your own.
Record and report time and amount of stool and anything abnormal to supervisor.

Problems with Bowel Elimination

Constipation

Constipation (presence of hard, dry stool that is difficult to pass) is a common problem experienced in older adults. Many factors contribute to constipation; age, medications, lack of adequate fluids, fibre, and 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 had other measure to address the constipation such as suppositories, enemas or disimpaction.

Follow agency policy to ensure ensure this is within your scope of practice as an HCA at your facility/agency.

**Table 7.3.2** Procedure: Administering a Rectal Suppository or Enema
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 fluides Lubricant reduces friction as suppository enters rectal canal. Incontinent pad or waterproof pad protects bed linens.
4.	Explain the procedure to the patient. If patient prefers to self-administer the suppository/enema, give specific instructions to patient on correct procedure.	Client’s 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 (Sims’ 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 patient’s privacy and facilitates relaxation. Some literature suggests that left side-lying Sims’ 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 (Image courtesy of CDC/Wikimedia Commons) Public Domain 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 (Image courtesy of Helena4780/Wikimedia Commons.) CC-BY-SA-4.0 Figure 7.3.4 Lubricant (Image courtesy of Anderson, Doyle and McCutcheon, 2018/ BCCampus). CC BY 4.0 Lubricant reduces friction as suppository/enema enters rectal canal. Inserting the rounded top promotes patient comfort.
8.	Separate buttocks with non-dominant hand and, using gloved index finger of dominant hand, insert suppository (rounded tip toward patient) 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 patient experiences cramping during enema administration, stop. Ask the client to take a deep breath. Resume administration when cramps subside. Hold buttock cheeks together if patient feels immediate need for BM.
10.	Remove finger and wipe client’s anal area.	Wiping removes excess lubricant and provides comfort to the client
11.	Ask client to remain on side for 5 to 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 (Image courtesy of Anderson, Doyle and McCutcheon, 2018/ BCCampus). CC BY 4.0 Figure 7.3.6 Using an ABHR (Image courtesy of Kelly Sikkema/Unsplash.) Unsplash License
13.	Ensure call bell is nearby and bedpan or commode is available and close by. Client may need assistance depending; refer to care plan.	If suppository is a laxative or stool softener, patient will require a bedpan/commode or close proximity to toilet. Figure 7.3.7 Ensure Call Bell is Available to Client (Image courtesy of Kim Morris, HCA Program/ Thompson Rivers University.) CC BY 2.0
14.	Document procedure as per agency policy and include client’s tolerance of administration.	Timely and accurate documentation promotes client safety.