27.4 Common Conditions Affecting Bowel Elimination

Clinical Manifestations

Constipation disrupts the normal process of bowel elimination, leading to various physiological and psychological effects. Physiologically, constipation manifests as infrequent and difficult bowel movements, often defined as fewer than three bowel movements per week (Cleveland Clinic, 2023a). Bowel movements become challenging to pass, requiring increased straining and exertion. This condition is accompanied by abdominal discomfort and pain, characterized by cramping sensations and bloating. The accumulation of gas and stool in the intestines exacerbates this discomfort.

The Bristol Stool Chart is a diagnostic medical tool designed to classify the form of human feces into seven categories (Figure 27.6). These categories range from type 1, which indicates constipation, to type 7, which indicates diarrhea. The chart provides a visual reference for healthcare professionals to assess and discuss bowel movements with patients, helping to diagnose and manage various GI conditions. Each type of stool is described based on its appearance and consistency, allowing for better communication and understanding between patients and healthcare providers regarding bowel health. Types 1 and 2 are associated with constipation. Type 1 consists of separate hard lumps, while type 2 is characterized by lumpy, sausage-like stools with a hard consistency.

Figure 27.6 The Bristol Stool Chart is used to assess the characteristics of stools according to seven types, ranging from constipation to diarrhea. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Other symptoms of constipation include changes in bowel pattern, such as alternating between hard, formed stool and liquid stool, as well as hypoactive bowel sounds. The straining with defecation can lead to complications such as a hemorrhoids (swollen and inflamed vein in the rectum and anus that can cause discomfort, itching, and bleeding) or an anal fissure (a small tear or cut in the lining of the anus, which can cause pain, bleeding, and discomfort during bowel movements). The accumulation of stool in the colon can also lead to distension, gas, and bloating (sensation of fullness or swelling in the abdomen), contributing to abdominal discomfort. Chronic constipation may result in fecal impaction, where a large mass of hardened stool becomes lodged in the rectum, resulting in a palpable abdominal mass and rectal pressure due to the buildup of stool, making it difficult or impossible to pass stool normally (Cleveland Clinic, 2023a). In severe cases, constipation may result in vomiting due to the backup of stool in the digestive tract.

Psychologically, constipation can lead to feelings of frustration, embarrassment, and anxiety. Individuals may become preoccupied with their bowel habits, leading to decreased quality of life and social isolation. Fear of experiencing pain or discomfort during bowel movements may also result in avoidance behaviors, exacerbating the problem.

Nursing Management

Nursing management of constipation requires a comprehensive approach to address the varied aspects of the condition. Nurses begin by conducting thorough assessments to identify the underlying causes and contributing factors specific to each patient. This involves exploring dietary habits, fluid intake, medication regimens, mobility levels, and any existing medical conditions that may exacerbate constipation.

After performing an assessment, nurses play a crucial role in patient education, sharing knowledge about the significance of fiber-rich diets, adequate hydration, and regular physical activity in promoting bowel regularity. Nurses provide personalized guidance on dietary modifications, emphasizing the importance of incorporating fruits, vegetables, whole grains, and other high-fiber foods into daily meals. Some food sources (e.g., prune juice, prunes, apricots) are helpful in preventing constipation. Certain medications (e.g., opioids, antacids, antidepressants, diuretics) can cause constipation as a side effect. Nurses inform patients about these potential side effects and advise them on strategies to manage or mitigate constipation risk factors while taking these medications.

Nurses facilitate open communication with other healthcare providers to address medication-related concerns or explore alternative treatment options when necessary. In addition to lifestyle modifications, constipation management may involve the use of medications and interventions such as stool softeners, laxatives, suppositories, enemas, and digital disimpaction.

A medication used to alleviate constipation by adding moisture to the stool, making it softer and easier to pass, is called a stool softener (e.g., docusate sodium [Colace]). Stool softeners work by drawing water into the stool, which helps to soften it and increase its bulk. This moisture retention in the stool makes it less dry and hard, reducing the need for straining during bowel movements and decreasing the likelihood of constipation. Stool softeners are particularly useful for individuals who need to avoid straining caused by medical conditions (e.g., hemorrhoids, anal fissures) or after certain surgeries. Unlike laxatives, stool softeners are generally gentler and do not stimulate bowel contractions or increase bowel movements. They are often recommended for long-term use in individuals prone to constipation or those who need to prevent the recurrence of hard stools. However, other methods (e.g., increasing fiber consumption, increasing activity) are typically more effective. Stool softeners are available over the counter or by prescription and come in various forms, including oral capsules, tablets, and liquid formulations.

A commonly used medication to manage constipation by promoting bowel movements is called a laxative. They come in various forms and work through different mechanisms to alleviate symptoms. Bulk-forming laxatives containing fiber (e.g., psyllium powder [Metamucil], methylcellulose [Citrucel]) increase the bulk and water content of stool, facilitating its passage. Stimulant laxatives (e.g., Dulcolax, Senokot) stimulate the muscles of the intestines, encouraging bowel contractions and movements. Osmotic laxatives (e.g., polyethylene glycol [MiraLAX], magnesium hydroxide [Milk of Magnesia]) draw water into the intestines, softening stool and increasing bowel movements. Stool softeners help soften stool by enhancing water absorption. While laxatives can provide relief from constipation, they should be used cautiously and under the guidance of a healthcare provider to avoid dependence and potential complications, and they are typically recommended for short-term use rather than as long-term solutions.

A suppository is a solid medication inserted into the rectum, where it dissolves to release medication locally. Suppositories may contain laxatives or stool softeners and work by softening stool and stimulating bowel movements. Suppositories offer a targeted approach to managing constipation, bypassing the digestive system and delivering medication directly to the site of action. Like other interventions for constipation, suppositories should be used cautiously and under medical guidance to ensure safe and effective relief. They are typically recommended for short-term use to address acute constipation, with attention to individual needs and potential adverse effects.

An enema is another intervention used to manage constipation, involving the introduction of a liquid solution into the rectum to stimulate bowel movements and evacuate stool. Enemas may contain saline solution, mineral oil, or medications, working by softening stool, lubricating the rectum, and prompting bowel contractions. While enemas can provide rapid relief from severe constipation, they should be used judiciously and under medical supervision because of the risk of electrolyte imbalances, rectal irritation, and dependence. Enemas are typically considered for short-term use to address acute constipation, with careful consideration of individual circumstances and potential contraindications.

A medical procedure performed to manually remove impacted stool from the rectum and lower colon using a lubricated, gloved finger is called digital disimpaction (Cleveland, 2023c). It is typically used as a last resort when other methods of relieving constipation, such as laxatives, enemas, or stool softeners, have been ineffective. Indications for digital disimpaction include severe fecal impaction that is causing symptoms such as severe abdominal pain, bloating, inability to pass stool, or rectal discomfort. It may also be necessary if there is a risk of bowel obstruction or if the patient is unable to evacuate stool on their own due to physical or neurological impairment.

To perform digital disimpaction, the patient is usually positioned in a side-lying or knee-chest position for easier access to the rectum. The healthcare provider then gently inserts a lubricated, gloved finger into the rectum and manually breaks up the impacted stool, gradually dislodging it and allowing it to be expelled. It is essential to use gentle and slow movements to avoid causing injury or discomfort to the patient. After the procedure, the patient may be instructed to take a warm sitz bath to soothe any discomfort or irritation and to promote relaxation of the pelvic muscles. Depending on the severity of the impaction and the patient’s condition, additional treatments or interventions may be necessary to prevent recurrence and manage underlying causes of constipation.

Digital disimpaction should only be performed by trained healthcare professionals in a clinical setting because it carries risks of injury, bleeding, and infection if not performed correctly. It is crucial to follow proper hygiene protocols and use appropriate techniques to ensure patient safety and comfort throughout the procedure. Through continuous monitoring and evaluation, nurses track the effectiveness of interventions, make adjustments as needed, and offer ongoing support to patients as they work toward optimal bowel health and comfort.

Clinical Manifestations

Diarrhea affects bowel elimination by altering the normal pattern and consistency of stool. Clinical manifestations of diarrhea include frequent, loose, and watery stools, often accompanied by urgency and a sense of incomplete evacuation. Individuals may experience abdominal cramping, bloating, and discomfort caused by increased intestinal motility. Hyperactive bowel sounds may be audible as the intestines work to expel stool rapidly. In some cases, individuals may experience bowel urgency, leading to a greater than usual number of stools in a twenty-four-hour period. Dehydration is a common complication of diarrhea, characterized by symptoms such as thirst, dry mouth, dark urine, fatigue, and dizziness. In severe cases, diarrhea can lead to electrolyte imbalances, malnutrition, and weight loss.

Nursing Management

The focus of nursing management and treatment of diarrhea is on addressing the symptoms, restoring fluid and electrolyte balance, and identifying and treating the underlying cause. Nurses closely monitor patients for signs of dehydration and electrolyte imbalances, providing oral rehydration solutions (e.g., sports drinks) or intravenous (IV) fluids as needed to replenish lost fluids and electrolytes. Nurses offer supportive care to alleviate symptoms such as abdominal cramping and discomfort, often through the administration of antispasmodic medications and dietary modifications. Nutrition therapy may involve recommending a bland diet to ease digestive discomfort and avoid exacerbating symptoms. Foods such as bananas, plain rice, applesauce, and toast (BRAT diet) are commonly recommended. Avoiding spicy, greasy, and high-fiber foods may also help.

If diarrhea is caused by a bacterial or parasitic infection, antibiotics or antiparasitic medications may be prescribed to treat the underlying infection. Antidiarrheal medications like loperamide (Imodium) can help reduce stool frequency and improve stool consistency. However, these should be used cautiously and avoided in certain cases, such as when diarrhea is caused by bacterial or parasitic infections. Probiotics and prebiotics, which contain beneficial bacteria, may help restore the balance of gut flora and reduce the duration and severity of diarrhea, especially if it is caused by antibiotics or certain GI conditions. Medications such as antispasmodics or antiemetics may be prescribed to alleviate symptoms such as abdominal cramping or nausea.

In healthcare settings, infection control measures are paramount to prevent the spread of infectious diarrhea, with nurses enforcing strict hand hygiene protocols and isolation precautions as necessary. If diarrhea persists or is recurrent, further evaluation may be needed to determine the underlying cause. This may involve diagnostic tests (e.g., stool cultures. imaging studies) to identify infectious agents, inflammatory conditions, or other GI disorders. In some cases, rectal tubes may be prescribed to collect watery stool. However, strict monitoring is required because of possible damage to the rectal mucosa.

Clinical Manifestations

Fecal incontinence manifests through a variety of clinical indications that disrupt normal bowel control and function. Individuals grappling with fecal incontinence often endure episodes of involuntary stool leakage, gas, or mucus discharge from the rectum, causing distress and social discomfort. Accompanying this is a pervasive sense of urgency, where the sudden and uncontrollable need to defecate leads to difficulties reaching a restroom in time, resulting in accidents. These incidents of accidental bowel movements can occur during routine activities, disrupting daily life and eroding confidence. Moreover, prolonged exposure to fecal matter can precipitate skin irritation, inflammation, and susceptibility to infections in the perianal area, exacerbating physical discomfort and complicating care. Beyond the physical toll, fecal incontinence exacts a heavy psychological toll, often fostering feelings of shame, embarrassment, anxiety, and social withdrawal.

Nursing Management

Nursing management of fecal incontinence encompasses a multifaceted approach aimed at addressing both the physical and emotional aspects of the condition. Nurses play a pivotal role in providing supportive care, education, and interventions to help individuals manage fecal incontinence and optimize bowel elimination. This includes conducting thorough assessments to identify underlying causes and contributing factors, such as neurological disorders, pelvic floor dysfunction, or medication side effects.

Based on these assessments, nurses develop individualized care plans that may incorporate dietary modifications, bowel management strategies, pelvic floor exercises, and medications to improve bowel control and stool consistency. Dietary modifications may involve adjustments such as increasing fiber intake to regulate bowel movements and avoiding foods and beverages that can irritate the digestive system (e.g., alcohol, caffeine, dairy products, greasy foods, spicy foods, gluten, artificial sweeteners).

Bowel training strategies help establish a regular bowel routine, enhancing predictability and reducing the risk of accidents. A bowel retraining involves teaching the body to have a bowel movement at a certain time of the day. This also includes encouraging the patient to go to the bathroom when feeling the urge to do so and not ignoring it. For some people, it is helpful to schedule this consistent time in the morning when the natural urge occurs after drinking warm fluids or eating breakfast. For other people, especially those with a neurological cause, a laxative may be scheduled every three days to stimulate the urge to have a bowel movement (Medline Plus, 2022).

Pelvic floor exercises (e.g., Kegel exercises) are used to strengthen the muscles of the pelvic floor, improving muscle tone and coordination. Additionally, medications may be prescribed to address underlying causes or manage symptoms, such as antidiarrheal medications to reduce stool frequency or bulking agents to improve stool consistency. In cases where conservative measures are ineffective, advanced treatments such as biofeedback therapy, sacral nerve stimulation, or surgical interventions may be considered to address specific underlying causes or improve bowel control (Medline Plus, 2022).

Additionally, nurses offer guidance on skin care and hygiene practices to prevent skin breakdown and infection in the perianal area. Education is a cornerstone of nursing management, as nurses provide information and support to help individuals understand their condition, manage symptoms, and access appropriate resources. They also play a vital role in addressing the psychosocial effect of fecal incontinence, offering empathy, reassurance, and counseling to alleviate feelings of embarrassment, shame, and isolation.