1. Lecture Notes on Bowel Elimination / Enema Administration & Colostomy Care
Prepared By: Mark Fredderick R Abejo R.N, MAN
Clinical Instructor
Increased fluid intake
Sufficient bulk in diet
Adequate activity and exercise
Diarrhea
Refers to frequent evacuation of watery stools. It is
NURSING SKILLS associated with increased gastrointestinal motility and a
rapid passage of fecal contents through the lower GI tract.
BOWEL ELIMINATION
Nursing Interventions to Relieve Diarrhea
Lecturer: Mark Fredderick R. Abejo RN,MAN
Replace fluid and electrolyte
____________________________________
Provide good perianal care
Normal Characteristics of the Stool Promote rest
Diet:
Color Yellow or golden brown
- small amounts of bland foods
Odor Aromatic upon defecation - low fiber diet
Amount Approx. 150 – 300 grams per day - BRAT diet
Consistency Soft and formed - avoid excessively hot or cold fluids
Shape Cylindrical - potassium-rich foods and fluids
Frequency Variable; usual range 1-2 / day
Anti diarrheal medications as ordered
Alteration on the Characteristics of Stool
 Alcholic Stool : Gray, pale or clay colored stool due to Note:
absence of stercobilin caused by bilary obstruction. Do not administer antidiarrheal at the start of
 Hematochezia : Passage of stool with bright red blood. diarrhea. Diarrhea is the body’s protective mechanism to rid
Due to lower gastrointestinal bleeding. itself of bacteria and toxins
 Melena : Passage of black, tarry stool due to upper GI
bleeding.
 Steatorrhea : Greasy, bulky, foul-smelling stool. Due Flatulence
to presence of undigested fats.
Is the presence of excessive gas in the intestines.
This may be due to swallowed air, bacterial action in the
Common Fecal Elimination Problem large intestine and diffusion from blood.
Causes:
Constipation - constipation
- codeine, barbiturates and other medications that dec.
Refers to the passage of small dry, hard stool or the intestinal motility
passage of no stool for a period of time. - anxiety
- eating gas-forming foods
Nursing Intervention to Prevent and Relieve Constipation - rapid food or fluid ingestion
- improper use of drinking straw
- excessive drinking of carbonated beverages
Adequate fluid intake, between 1,500 – 2,000 mls. / day - gum chewing, candy sucking and smoking
High fiber diet - abdominal surgery
Established regular pattern of defecation Nursing Interventions to Relieve Flatulence
Respond immediately to the urge to defecate
Minimize stress Avoid gas-forming food
Adequate activity and exercise Provide warm fluids to drink
Assume sitting ad semi squatting position Early ambulation among post op client
Administered laxatives as ordered Adequate activity and exercise
Limit carbonated beverages, use of drinking straws and
Fecal Impaction chewing gum
Is the mass or collection of hardened, putty-like Rectal tube insertion as ordered:
feces in the folds of the rectum. The stool is lodged or stuck - Place client in left lateral position
in the rectum, the person is unable to voluntarily evacuate - Insert 3-4 inches of the lubricated rectal tube, gently in
the stool. rotating motion.
- Use of rectal tube Fr. 22-30
Nursing Interventions to Relieve Fecal Impaction - Retain rectal tube for max. of 30 minutes
Carminative enema as ordered
Manual extraction or fecal disimpaction as ordered Administer cholinergics as ordered.

2. Lecture Notes on Bowel Elimination / Enema Administration & Colostomy Care
Prepared By: Mark Fredderick R Abejo R.N, MAN
Clinical Instructor
For Large Volume Enema
Fecal Incontenence - Solution container
- Rectal tube of correct size
Adult: Fr. 22 – 32
Is the involuntary elimination of bowel contents, it is Children: Fr. 14 -18
often associated with neurological, mental or emotional Infant: Fr. 12
impairments. - Tube clamp
Clients with cerebral cortex injury may be unable to - Correct solution, amount and temperature
perceive distended rectum or unable to initiate the motor For Small Volume Enema
response required to inhibit defecation voluntarily - Prepackaged container of enema solution with lubricated
Clients who are disoriented or confused may have lost tip ( Fleet Enema )
the social inhibition that prevents immediate fecal
evacuation.
People who have sustained sacral spinal cord injury
experience impaired nerve supply to the rectum and anal
sphincters
Administering Enemas
Purposes:
To relieve constipation and fecal impaction
To relieve flatulence
To administer medication Steps / Procedure Rationale
To evacuate feces in preparation for diagnostic
Identify and inform the
procedure or surgery To allay anxiety
client and explain the
procedure.
Types of Enema
Wash hands, apply clean
gloves and observed
1. Cleansing Enema : Stimulates peristalsis by
appropriate infection
irritating the colon and rectum and or by distending
control
the intestine with the volume of fluid introduced.
- High enema, clean as much of the colon, Provide client privacy
1000 mls. of sol. are introduced Position the client: Facilitate the flow of sol. by
Note: Container should be 12-18 inches Adult: Left lateral gravity as the sigmoid colon
above the rectum Infant/small children: is on the left side
- Low enema, clean rectum and the Dorsal recumbent
sigmoid only, 500 mls. of
sol. are introduced
Note: Container should be 12 inches
above the rectum
2. Carminative Enema : To expel flatus, 60 to 180
mls. of fluids is introduced.
3. Retention : Introduces oil into the rectum and the
sigmoid, oil is retained in 1 to 3 hours. Act to
soften the feces and to lubricate the rectum and the
anal canal, facilitating passage of feces.
4. Return Flow Enema / Colonic Irrigation Lubricate the tube about
- Done to expel flatus, 100 to 200 mls. of fluid is 5 cm ( 2 in )
introduced into and out of the large intestines to Allow the solution to This prevent introduction of
stimulate peristalsis and promote expulsion of flow through the air into the colon
flatus. connecting tubing and
- The solution container is lowered so that the fluid rectal tube to expel air
backs out through the rectal tube into the container. before insertion of the
- The process is repeated 5 – 6 times rectal tube.
- Replace the solution several times during the Insert 7 – 10 cm ( 3 to 4 To prevent irritation of anal
procedure as it becomes thick with feces. inches) or rectal tube and rectal tissues
- This procedure may take 15 – 20 minutes to be gently in rotating motion
effective. If resistance is felt, ask To relax the internal anal
the client to take deep sphincter
Equipment; breath, then run a small
- Disposable linen pad (optional ) amount of sol, through
- Bedpan or commode the tube
- Clean gloves
- Water soluble lubricant
- Paper towel

3. Lecture Notes on Bowel Elimination / Enema Administration & Colostomy Care
Prepared By: Mark Fredderick R Abejo R.N, MAN
Clinical Instructor
Placing a regular bedpan against the client’s buttocks.
Do perianal care
Make relevant
documentation
Assuming a left lateral position for a commercially
prepare enema (fleet enema)
Colostomy Management
Introduce solution To prevent sudden
slowly stimulation of peristalsis
- Raise the solution The locations of bowel diversion ostomies.
container and open the The higher the solution
clamp to allow fluid to flow container is held above the
High Enema: 12-18 inches rectum, the faster the flow
above the rectum and the greater the pressure
Low Enema: 12 inches in the rectum
above the rectum
If the client complains of
fullness or pain, use the Decrease the likelihood of
clamp to stop the flow for intestinal spasm and
30 sec. and then restart premature ejection of
the flow at a slower rate solution
If High Enema, change
the position to distribute
sol. well
If Low Enema, remain in left
lateral position
If the order is cleansing
enema:
- give the enema 3x Colostomy is the opening in the Gastrointestinal
- alternate hypotonic sol. To prevent water tract for the purpose of diverting and draining fecal
with isotonic sol. intoxication materials
After all the solution has
been stilled or when the Temporary Colostomies, generally performed for traumatic
clients fells the desire to injuries or inflammatory conditions of the bowel. It allows
defecate, close the clamp the bowel to rest and heal.
and remove the rectal Permanent Colostomies, are performed to provide a means
tube, disposed properly of elimination when the rectum or anus is nonfunctional as a
Encourage the client to result of birth defect or a disease.
retain the enema, ask the
client to remain lying Type of Discharge
down Ileostomy Liquid fecal drainage
Assist the client to Drainage is constant and cannot
defecate be regulated
- Assist in sitting position Contains some digestive
- Ask the client who is using enzymes
the toilet not to flush it The nurse need to observe Odor is minimal bec.of fewer
the feces bacteria are present
Ascending Liquid fecal drainage
Colostomy Drainage is constant and cannot
be regulated
Odor is a problem requiring
control
Transverse Malodorous, mushy drainage
Colostomy
Descending Solid fecal drainage
Colostomy
Sigmoidostomy Normal fecal characteristics

4. Lecture Notes on Bowel Elimination / Enema Administration & Colostomy Care
Prepared By: Mark Fredderick R Abejo R.N, MAN
Clinical Instructor
Equipment and Supplies:
Disposable gloves
Electric or safety razor
Bedpan
Solvent
Moisture-proof bag
Cleaning materials, including
tissues, warm water, mild soap
(optional), washcloth or cotton
balls, and towel
Tissue or gauze pad
Skin barrier
Stoma measuring guide
Pen or pencil and scissors
Clean ostomy appliance, with
optional belt
Tail closure clamp
Special adhesive, if needed
Stoma guide strip, if needed
Deodorant (liquid or tablet) for a
nonodor-proof colostomy bag
Note:
Select an appropriate time to
change the appliance:
Avoid times close to meal or visiting hours.
Avoid times immediately after meals or the administration
of any medications that may
stimulate bowel evacuation.
Changing a Ostomy Appliance
Procedure
Purposes:
To assess and care for the peristomal skin Rationale
To collect effluent for assessment of the amount and Explain to the client what you To allay anxiety
type of output. are going to do, why it is
To minimize odors for the client’s comfort and self- necessary, and how she can
esteem cooperate.
Wash hands and observe other
Assessment appropriate infection control
procedures. Apply clean gloves.
Stoma Colors Provide for client privacy.
- should appear red, similar to the mucosal linin of the Assist the client to a comfortable May avoid wrinkles on
inner cheek. sitting or lying position in bed the ostomy appliance
- very pale or darker-colored stomas with a bluish or or,
purplish shades indicate impaired blood circulation to the preferably, a sitting or standing
area. position in the bathroom.
Unfasten the belt, if the client is
Stoma Size and Shape wearing one.
- most stomas protrude slightly from the abdomen Empty and remove the ostomy appliance:
- new stomas normally appear swollen, but swelling  Empty the contents of the pouch through the bottom
generally decreases over 2-3 weeks up to 6 weeks. opening into a bedpan.
- failure of swelling to recede may indicate problem like  Assess the consistency and the amount of effluent.
blockage.  Peel the bag off slowly while holding the client’s skin
taut.
 If the appliance is disposable, discard it in a moisture-
Stomal Bleeding proof bag.
- slight bleeding initially when the stoma is touched is Clean and dry the peristomal skin
normal, but other bleeding should be reported. and stoma.
 Use toilet tissue to remove excess stool.
Peristomal Skin  Use warm water, mild soap
- any redness and irritation of the peristomal skin 5 – 13 cm (optional), and cotton balls or a washcloth and towel to
( 2-5 in ) of skin surrounding the stoma should be noted. clean the skin and stoma.
- transient redness after removal of adhesive is normal.  Use a special skin cleanser to remove dried, hard
stool.
Note:  Dry the area thoroughly by patting with a towel or
Burning sensation under the faceplate may indicate cotton balls.
skin breakdown

5. Lecture Notes on Bowel Elimination / Enema Administration & Colostomy Care
Prepared By: Mark Fredderick R Abejo R.N, MAN
Clinical Instructor
Assess the stoma and peristomal skin. other side of the adhesive disc.
 Inspect the stoma for color, size,shape, and Center the faceplate over the stoma and skin barrier, then
bleeding. press and hold the faceplate against the client’s skin for a
 Inspect the peristomal skin for any redness, few minutes, to secure the seal.
ulceration, or irritation. Press the adhesive around the circumference of the
 Place a piece of tissue or gauze pad over the stoma, adhesive disc.
and change it as needed. Tape the faceplate to the client’s abdomen using four or
Apply paste-type skin barrier, if eight 7.5-cm (3-in) strips of hypoallergenic tape. Place
needed. Allow the paste to dry the strips around the faceplate in a “picture-framing”
for 1 to 2 minutes, or as manner, one
recommended by the strip down each side, one across the top, and one across
manufacturer. the bottom. The additional four strips can be placed
For a Solid Water or Disc Skin Barrier diagonally over the other tapes to secure the seal.
Use the guide to measure the size of the stoma. Stretch the opening on the back of the pouch, and
On the backing of the skin barrier, trace a circle the position it over the base of the faceplate. Ease it over the
same size as the stomal opening. faceplate flange.
Cut out the traced stoma pattern to make an opening in Place the lock ring between the pouch and the faceplate
the skin barrier. Make the opening no more than 0.3–0.4 flange, to seal the pouch against the faceplate.
cm (1/8–1/6 in) larger than the stoma. Close the base of the pouch with the
Remove the backing to expose the appropriate clamp.
sticky adhesive side. Variation: Applying the Skin Barrier and Appliance as
Center the skin barrier over the stoma, and gently press One Unit
it onto the client’s skin, smoothing out any wrinkles or Prepare the skin barrier by measuring the size of the
bubbles. stoma, tracing a circle on the backing of the skin barrier,
and cutting out the traced stoma pattern to make an
A guide for measuring stoma. opening in the skin barrier.
Prepare the appliance by cutting an opening 0.3–0.4 cm
(1/8–1/6 in) larger than the stoma size (if not already
present) and peeling off the
backing from the adhesive seal.
Center the opening of the pouch over the skin barrier.
Remove the skin barrier backing to expose the sticky
adhesive side.
Center the skin barrier and appliance over the stoma, and
press it onto the client’s skin.
Dispose of equipment, or clean
reusable equipment.
For Liquid Skin Sealant  Discard a disposable bag in a plastic bag before
placing in the waste
Either wipe or apply the product evenly around the  container.
peristomal skin to form a thin layer of the liquid plastic  If feces are liquid, measure the volume. Note the
coating to the same area. feces’ character, consistency, and color before
Allow the skin sealant to dry until it no longer feels emptying the feces into a toilet or hopper.
tacky.  Wash reusable bags with cool water and mild soap,
For a Disposable Pouch with Adhesive Square rinse, and dry.
If the appliance does not have a precut opening, trace a  Wash a soiled belt with warm water and mild soap,
circle 0.3–0.4 cm (1/8–1/6 in) larger than the stoma size rinse, and dry.
on the appliance’s adhesive square.  Remove and discard gloves.
Peel off the backing from the adhesive seal.
Center the opening of the pouch over he client’s stoma,
and apply it directly onto the skin barrier. Document the procedure in the client’s record:
Gently press the adhesive backing onto the skin, and  Pertinent assessments and interventions
smooth out any wrinkles, working from the stoma  Any increase in stoma size
outward.  Change in color indicative of circulatory
Remove the air from the pouch. impairment
Close the pouch by turning up the bottom a few times,  Presence of skin irritation or erosion
fanfolding its end lengthwise, and securing it with a tail  Discoloration of the stoma
closure clamp.  Appearance of the peristomal skin
Variation: Applying a Reusable Pouch with Detachable  Amount and type of drainage
Faceplate  Client reaction to the procedure
 Client’s experience with the ostomy
Apply a skin sealant to the faceplate before attaching the  Skills learned by the client
adhesive disc.
Remove the protective paper strip from one side of the
double-faced adhesive disc.
Apply the sticky side to the back of the faceplate.
Remove the remaining protective paper strip from the