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EARNING
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UTCOME
1
Describe the physiology of defecation.
Concepts for Lecture
1. Defecation is the expulsion of feces from the anus and rectum. When
peristaltic waves move the feces into the sigmoid colon and the
rectum, the sensory nerves in the rectum are stimulated and the indi-
vidual becomes aware of the need to defecate.
When the internal anal sphincter relaxes, feces move into the
L
EARNING
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UTCOME
2
Distinguish normal from abnormal characteristics and constituents of feces.
Concepts for Lecture
1. Normal feces are made of about 75% water and 25% solid materials.
Some normal characteristics of fecal matter include: feces in
2.5-cm (1–in.) diameter; amount varies with diet (about 100 to 400
g/day); aromatic odor that is affected by ingested food and individual
bacterial flora; constituents include small amounts of undigested
L
EARNING
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UTCOME
3
Identify factors that influence fecal elimination and patterns of defecation.
Concepts for Lecture
1. Factors that affect defecation include developmental stage, diet, fluid
intake, activity, psychological factors, defecation habits, medica-
C
HAPTER
49
FECAL ELIMINATION
S
UGGESTIONS FOR
C
LASSROOM
A
CTIVITIES
•
Review the related anatomy of the structures
involved in defecation.
S
UGGESTIONS FOR
C
LASSROOM
A
CTIVITIES
•
Have students review various fecal tests (fecal
cultures, testing for occult blood) in the labor-
atory/diagnostic manual used in the
curriculum.
various disease conditions.
S
UGGESTIONS FOR
C
LASSROOM
A
CTIVITIES
• Discuss additional pathologic conditions that
may influence fecal elimination.
•
Discuss the signs and symptoms of colorectal
cancer.
S
UGGESTIONS FOR
C
LINICAL
A
CTIVITIES
• Have students discuss factors that have altered
368 CHAPTER 49 / Fecal Elimination
Newborns, infants, children, and older adults are groups within
which members have similarities in elimination patterns (e.g., new-
Sufficient bulk (cellulose, fiber) is necessary to provide fecal
volume. Therapeutic diets may affect fecal elimination, as may
individual difficulties in digesting certain foods and the effects of
certain foods (e.g., spicy, gas–forming).
Healthy elimination requires 2,000–3,000 mL per day of fluid.
Activity stimulates peristalsis, facilitating the movement of
chyme. Weak abdominal muscles from lack of exercise, immobility,
or neurological impairment can lead to alterations in fecal elimina-
tion.
Some medications have side effects that interfere with normal
elimination. Some directly affect elimination (laxatives). Some med-
ications appear in the feces.
For accuracy of certain diagnostic procedures, food and fluids
may be restricted and enemas may need to be administered.
General anesthesia can block the parasympathetic nervous
L
EARNING
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UTCOME
4
Identify common causes and effects of selected fecal elimination problems.
Concepts for Lecture
2. Defining characteristics for constipation include decreased frequency
of defecation; hard, dry, formed stools; straining with defecation;
painful defecation; reports of rectal fullness or pressure or incom-
S
UGGESTIONS FOR
C
LASSROOM
A
CTIVITIES
•
Review common medications, including over-
the-counter medications, used in treatment of
constipation and diarrhea. Stress the appropri-
ate use and misuse of these medications and
associated client education related to use of
S
UGGESTIONS FOR
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LINICAL
A
CTIVITIES
3. Fecal impaction is a mass or collection of hardened feces in the folds
of the rectum. Fecal impaction can be recognized by the passage of
liquid fecal seepage (diarrhea) and no normal stool. The liquid por-
4. Diarrhea refers to the passage of liquid feces and an increased
frequency of defecation. Often spasmodic cramps occur, and bowel
sounds are increased. Irritation of the anal region extending to the
5. Bowel incontinence, also called fecal incontinence, refers to the loss
of voluntary ability to control fecal and gaseous discharges through
the anal sphincter. Incontinence may occur at specific times or it
6.
Flatulence is the presence of excessive flatus in the intestines and leads
L
EARNING
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UTCOME
5
Describe methods used to assess fecal elimination.
Concepts for Lecture
1. Assessment of fecal elimination includes taking a nursing history;
2. A nursing history helps the nurse ascertain the client’s normal
pattern, a description of usual feces, and any recent changes. The
3. Physical examination of the abdomen, rectum, and anus is discussed
in Chapter 30. Auscultation precedes palpation because palpation
S
UGGESTIONS FOR
C
LASSROOM
A
CTIVITIES
• Have students practice obtaining a nursing
history related to fecal elimination on another
student using the Assessment Interview: Fecal
Elimination in the textbook.
•
Divide students into groups and assign each a
diagnostic test related to fecal elimination.
• Have students gather appropriate assessment
data concerning fecal elimination for their
370 CHAPTER 49 / Fecal Elimination
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EARNING
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Concepts for Lecture
1. NANDA includes the following diagnostic labels for fecal elimina-
2. Fecal elimination problems may affect many other areas of human
functioning and as a consequence may be the etiology of other
3. The major goals for clients with fecal elimination problems are to
maintain or restore a normal bowel elimination pattern, maintain or
4. Appropriate preventive and corrective nursing interventions that
relate to these must be identified. Specific nursing activities associ-
ated with each of these interventions can be selected to meet the
L
EARNING
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UTCOME
7
Identify measures that maintain normal fecal elimination patterns.
Concepts for Lecture
1. The nurse can help clients achieve regular defecation by attending to
provision of privacy, timing, nutrition and fluids, exercise, and
positioning.
time for defecation. Other activities should not interfere with defeca-
tion time.
The diet a client needs for regular normal elimination varies,
depending on the kind of feces the client currently has, the frequency
of defecation, and the types of foods that the client finds assist with
S
UGGESTIONS FOR
C
LASSROOM
A
CTIVITIES
• Have students review the definitions, defining
•
Have students develop care plans for clients who
have fecal elimination problems.
S
UGGESTIONS FOR
C
LASSROOM
A
CTIVITIES
•
Divide students into groups and ask each to
develop a teaching aid or guide to assist an
adult to maintain normal
fecal elimination patterns.
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UGGESTIONS FOR
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LINICAL
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CTIVITIES
tern. Weak abdominal and pelvic muscles may be strengthened with
isometric exercises.
Although the squatting position best facilitates defecation, the
best position for most individuals seems to be leaning
forward on a toilet seat.
L
EARNING
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UTCOME
8
Describe the purpose and action of commonly used enema solutions.
Concepts for Lecture
1. Table 49–4 lists commonly used enema solutions and actions.
Hypertonic solutions draw water into the colon. A commonly
2. There are four types of enemas: cleansing, carminative, retention,
and return-flow enemas.
Cleansing enemas are given to prevent escape of feces during
L
EARNING
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UTCOME
9
Describe essentials of fecal stoma care for clients with an ostomy.
Concepts for Lecture
1. Care of the stoma is important for all clients who have ostomies. The
fecal material from a colostomy or ileostomy is irritating to the peri-
stomal skin. This is particularly true of the stool from an ileostomy,
which contains digestive enzymes.
S
UGGESTIONS FOR
C
LASSROOM
A
CTIVITIES
• Show a videotape or DVD of administration of
enemas and insertion of rectal tubes and have
students practice these skills on manikins.
•
Review the safety measures associated with
enema administration (e.g., temperature of
solutions).
•
Review the procedure for removing a fecal
• Review the procedures used for administering
enemas in the agency.
•
Assign students to administer enemas when-
S
UGGESTIONS FOR
C
LASSROOM
A
CTIVITIES
• Show a videotape or DVD on the care of osto-
mies.
•
Show equipment used in care of the stoma.
S
UGGESTIONS FOR
C
LINICAL
A
CTIVITIES
• Invite the enterostomal nurse to discuss the
types of ostomies, care of ostomies, and
372 CHAPTER 49 / Fecal Elimination
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EARNING
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Concepts for Lecture
1. Administration of some enemas may be delegated to unlicensed
assistive personnel (UAP). However, the nurse must ensure the
personnel are competent in the use of standard precautions. Abnor-
2.
Care of a new ostomy is not delegated to UAP. However, aspects of
L
EARNING
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UTCOME
11
Verbalize the steps used in:
a. Administering an enema
b. Changing a bowel diversion ostomy appliance
Concepts for Lecture
ESSENTIAL/
CRITICAL
ELEMENT?
COMPETENCY
DEMONSTRATED?
Yes
No
ESSENTIAL/
CRITICAL
ELEMENT?
SKILL 49–2: CHANGING A BOWEL DIVERSION OSTOMY
APPLIANCE
COMPETENCY
DEMONSTRATED?
Yes
No
1. Introduced self and verified the client’s identity.
3. Gathered the appropriate equipment.
control procedures.
5. Applied clean gloves.
6. Provided for client privacy.
7. Assisted the client to a comfortable sitting or lying position in the
bed or preferably in a sitting or standing position in the bathroom.
8. Unfastened the belt if the client was wearing one.
9. Emptied the pouch and removed the ostomy skin barrier.
a. Emptied the contents of the drainable pouch through the bot-
tom opening into the bedpan or toilet.
e. Discarded the disposable pouch in a moisture-proof bag.
10. Cleaned and dried the peristomal skin and stoma.
a. Used the toilet tissue to remove excess stool.
b. Used warm water, mild soap, and a washcloth to clean the skin
and stoma. Checked the agency practice on use of soap.
11. Assessed the stoma and peristomal skin.
a. Inspected stoma for color, size, shape, and bleeding.
12. Placed a piece of tissue or gauze over the stoma and changed it as
needed.
13. Prepared and applied the skin barrier.
a. Used the measuring guide to measure the size of the stoma.
b. On the backing of the skin barrier, traced a circle the same size as
the stomal opening.
c. Cut out the traced stoma pattern to make an opening in the skin
barrier.
For a One-Piece Pouching System: Centered the one-piece skin barrier
over the stoma and gently pressed onto the client’s skin for 30 seconds.
and discarded gloves. Performed hand hygiene.
For a Two-Piece Pouching System: Centered the skin barrier over the
a. Emptied the pouch when it was one-third to one-half full of stool
or gas.
b. Held the pouch outlet over the bedpan or toilet while wearing
gloves. Lifted the lower edge of the pouch up.
c. Unclamped or unsealed the pouch.
d. Drained the pouch. Loosened any feces from the sides of the
pouch by moving fingers down the pouch.
e. Cleaned the inside of the tail of the pouch with tissue or a
premoistened towelette.
g. Disposed of the used supplies.
h. Removed and discarded gloves. Performed hand hygiene.
i. Documented the amount, consistency, and color of the stool.
CHAPTER 49 / Fecal Elimination 375
L
EARNING
O
UTCOME
12
Demonstrate appropriate documentation and reporting related to fecal
elimination.
Concepts for Lecture
1. When documenting enemas, include the type of solution; length of
time solution was retained; the amount, color, and consistency of the
2.
When documenting stoma care, report and record pertinent assessments
and interventions. Report any increase in stoma size, change in color