Unit 2 - Promoting Intestinal Elimination
Gastointestinal System
Structure of the Gastrointestinal System
1. Mouth
➔ includes lips, cheeks, hard and soft palates, gums, tongue, tonsils, and salivary glands
➔ structures move in concert to chew food (mastication), mix food with saliva to form a
rounded mass of food (bolus), and move the bolus toward the posterior pharynx where it is
swallowed
2. Esophagus
➔ collapsible muscular tube that extends from the posterior pharynx, through an opening in the
diaphragm, to the stomach
➔ secretes mucus and facilitates movement of food from the mouth to the stomac
3. Stomach
➔ elongated C-shaped pouch mainly in the epigastric area of the abdomen. The cardiac
sphincter is at the connection between the esophagus and the upper portion of the stomach;
the pyloric sphincter is at the connection between the duodenum and the lower portion of the
stomach
➔ stores and liquefies food
➔ secretes gastric juices (e.g., gastrin, pepsin, hydrochloric acid, intrinsic factor, and mucin)
4. Small Intestine
➔ tubular structure approximately 1 inch in diameter and 28 feet long that progresses from the
duodenum, to the jejunum, to the ileum
➔ involved with digestion and absorption of nutrients
➔ secretes the enzymes sucrose, lactase, and maltase
➔ secretes cholecystokinin, which stimulates the gallbladder to release bile
➔ receives secretions from the liver, gallbladder, and pancreas.
5. Large Intestine
➔ Tubular structure approximately 2.5 inches in diameter and 5.5 feet long that progresses
from the cecum, to the ascending colon, transverse colon, descending colon, sigmoid colon,
rectum, and anus
➔ absorbs water and sodium ions and temporarily stores feces
➔ produces mixing movements and wave-like movements (peristalsis) that create a fecal
mass, move waste product toward the anus, and promote defecation.
6. Vermiform Appendix
➔ blind-end small tubular structure at the cecum beyond the ileocecal valve
➔ part of the immune system
7. Liver
➔ large structure located in the upper right quadrant of the abdomen that consists of thousands
of lobules that drain bile through the hepatic duct
➔ involved in protein, carbohydrate, and fat metabolism; secretes bile, which emulsifies fats,
acts as a vehicle for excretion of bile pigments and cholesterol, and facilitates the absorption
of the fat-soluble vitamins A, D, E, and K.
8. Gallbladder
➔ small sac that lies underneath the liver; the cystic duct exists the gallbladder and connects
with the hepatic duct; the cystic and hepatic ducts unite and form the common bile duct,
which drains bile through the sphincter of Oddi into the duodenum
➔ concentrates and stores bile.
9. Pancreas
➔ comma-shaped structure that extends from the duodenal curve to the spleen in the
epigastric and upper left areas of the abdomen
➔ secretes the enzymes trypsin, lipase, and amylase, which are transported to the duodenum
via the pancreatic duct
➔ contains Islets of Langerhans
◆ alpha cells secrete the hormone glucagon, which promotes an increase in the
amount of blood glucose
◆ beta cells secrete insulin, which decreases the amount of blood glucose and
facilitates the metabolism of carbohydrates, proteins, and fats
Functions of the GI System
1. Digestion
➔ Mechanical digestion: Changes the consistency of food by mastication and mixing it with
saliva and moves it through the GI system by swallowing and peristalsis
➔ Chemical digestion: Splits compounds into small segments in preparation for absorption
and metabolism (hydrolysis).
2. Absorption
➔ small molecules that result from hydrolysis move against a concentration gradient (active
transport) through the intestinal mucosa into the circulatory system
➔ most nutrients are absorbed in the small intestine; most water is absorbed in the large
intestine.
3. Metabolism
➔ includes all the chemical reactions involved in energy production and expenditure
◆ Anabolism: synthesis of larger compounds from smaller compounds
◆ Catabolism: complex compounds are broken down into simple compounds releasing
energy for further body processes (e.g., muscle contraction, heat production).
➔ metabolism requires energy
◆ carbohydrates are the preferred source of fuel for energy; cells catabolize glucose
first, sparing proteins and fats; most cells catabolize fats next, sparing protein (amino
acids)
◆ excess glucose is converted to glycogen and stored in the liver (glycogenesis)
◆ the liver converts protein or fat into glucose (gluconeogenesis)
◆ when blood glucose decreases, gluconeogenesis increases and glycogen from the
liver breaks down releasing glucose (glycogenolysis)
Factors Affecting Bowel Elimination
1. Developmental Level
➔ Toddlers: develop intestinal control at about 2 to 3 years of age
➔ Pregnant Women: enlarged uterus imposes on intestinal structures, resulting in decreased
peristalsis
➔ Older Adults: experience decreased peristalsis
Changes in Defecation throughout the Lifespan
2. Emotional and Cultural Factors
➔ emotional and cultural factors
➔ lack of privacy: Some cultures are open and others prefer privacy when attending to bodily
functions
➔ inadequate amount of time to defecate
➔ Embarrassment: fecal elimination is often associated with sights and odors that may be
offensive to others and make the patient self-conscious
3. Nutrition
➔ Lack of fiber and excessive milk: results in a decrease in peristalsis
➔ Irregular eating patterns: can interfere with regularity of bowel movements or decrease
peristalsis
➔ caffeine and fiber promote peristalsis.
4. Fluid Intake
➔ need 6 to 8 glasses of water daily
➔ decreased fluid intake causes constipation
5. Activity
➔ activity increases muscle tone and stimulates peristalsis
➔ inactivity contributes to decreased muscle tone and constipation
6. Medications
➔ antibiotics destroy normal intestinal flora
➔ antacids often slow peristalsis
➔ iron causes constipation
➔ analgesics, opioids, and antimotility drugs slow peristalsis
➔ laxatives and cathartics increase peristalsis
7. Perioperative Issues
➔ anesthesia and handling of the bowel during surgery may slow motility and cause cessation
of peristalsis
8. Medical Problems
➔ common problems include GI infections, food allergies, cancer, diverticulosis and
diverticulitis, irritable bowel syndrome, and malabsorption syndromes
Assessment
History
1. Elimination pattern and any changes in pattern or bowel habits
2. Patient’s dietary habits, use of supplements, change in appetite, and daily fluid intake
3. Level of activity, mobility, and exercise
4. Ability to self-toilet
5. Pain or discomfort
6. Past and present illnesses, injury, and surgery that might affect GI function
7. Medication use that can affect GI function, such as antibiotics, iron, laxatives, cathartics, antacids, and
analgesics
8. Emotional status and current stressors
9. Social history (e.g., number of people using one bathroom, cultural background)
Physical Assessment
1. Inspect the contour, shape, and symmetry of the abdomen.
2. Inspect the anus and perianal area.
3. Auscultate bowel sounds in all four quadrants, listening for 1 minute in each quadrant; usually, 3 to 35
gurgles per minute. a. Hyperactive: High pitched and more than 35 gurgles per minute. b. Hypoactive: Low
pitched, quiet, infrequent, or absent gurgles.
4. Percuss the abdomen to detect dullness, indicating fluid, gas, or a mass in the abdomen.
5. Palpate the abdomen, which should be soft, firm, and tender.
Stool Assessment
1. Characteristics of stool are influenced by factors such as dietary and fluid intake, exercise, medications,
and disease processes.
2. Characteristics of stool include color, consistency, quantity, shape, odor, and constituents
Characteristics of Normal and Abnormal Feces
Diagnosing
Examples of nursing diagnoses for clients with fecal eliminal problems can include bowel incontinence,
constipation, and diarrhea.
Fecal elimination problems may affect many other areas of human functioning and as a consequence may
be the etiology of other nursing diagnoses. Examples include: Potential for decreased fluid volume or
potential for altered electrolytes related to prolonged diarrhea, potential for developing altered skin integrity
related to prolonged diarrhea or bowel incontinence, impaired self-esteem related to fecal incontinence,
lack of knowledge (bowel training, ostomy management) related to lack of previous experience.
Diagnostic Tests
1. Stool Examination
a. Gross and microscopic stool examination in the laboratory.
Gross examination: Assesses stool for consistency, color, presence of blood, mucus, excess fat,
and pus.
Microscopic examination: Identifies constituents, such as WBCs, unabsorbed fat, and parasites.
b. Culture and sensitivity Culture assesses stool for presence of pathogens
c. Occult blood (guaiac, Hemoccult) Assesses stool for microscopic amounts of blood in feces
d. Ova and parasites Assessment via a stool specimen/tape test
2. Barium Studies
➔ Upper GI series: radiologic examination in which the patient drinks contrast medium and films are
taken every 20 minutes until the medium reaches the terminal ileum b.
➔ Lower GI series (barium enema) fluoroscopic radiologic examination of the colon after a contrast
medium is instilled rectally
3. Endoscopy
a. Upper GI endoscopy (esophagogastroduodenoscopy)
insertion of a flexible endoscope through the mouth to visualize the mucous membrane lining of the
esophagus, stomach, and duodenum.
b. Colonoscopy: insertion of a flexible endoscope through the anus to visualize the entire colon
c. Sigmoidoscopy: insertion of a tubular speculum for examination of the sigmoid colon and rectum
4. X-ray
➔ radiographic views of the abdomen, such as abdominal flat plate, anterior, and posterior views; can
identify impaction or distended bowel
Common Responses Related to the GI System
Diarrhea
➔ intestinal hypermotility that precipitates passage of fluid and unformed stool
➔ frequency of stool occurs three or more times a day
Clinical Manifestations
● Frequent loose stools.
● Abdominal cramps, pain, or urgency.
● Abdominal distention.
● Hyperactive bowel sounds or flatus.
● Anorexia, nausea, and vomiting.
● Blood in the stool (frank, occult).
● Clinical manifestations of fluid volume deficit, such as weight loss; thready pulse; hypotension;
decreased tissue turgor; furrows of the tongue; flushed, dry skin and mucous membranes; sunken
eyeballs; decreased urine output; atonic muscles; and mental confusion.
● Electrolyte imbalances, such as hyponatremia and hypokalemia.
● Stool possibly positive for causative pathogen or helminthic.
● With Clostridium difficile, characteristic odor and green-colored stool
Precipitating Factors
a. Viral, bacterial, or parasitic gastroenteritis.
b. Spicy or greasy food.
c. Raw seafood.
d. Contaminated food and water.
e. Excessive dietary fiber.
f. Anxiety or other emotional disturbance.
g. Drug side effects: Antibiotics suppress normal GI flora; antineoplastics and laxatives irritate the mucous
membranes of the intestines increasing peristalsis.
h. Enteral nutrition (nasogastric or gastrostomy); hypertonic formula or too-rapid administration precipitates
peristalsis.
i. Health problems, such as lactose intolerance, irritable bowel syndrome, malabsorption syndrome, and
celiac disease.
j. Ingestion of heavy metals, such as lead or mercury.
k. Inflammatory bowel diseases, such as ulcerative colitis or Crohn’s disease
Consitipation
➔ instestinal hypomotility that precipitates two or less stools a week
➔ hard, dry feces
Obstipation
➔ intractable constipation
Perceived Constipation
➔ self-diagnosed constipation
Fecal Impaction
➔ hard, dry stool firmly wedged in the rectal vault that cannot be passed
Clinical Manefestations
● Hypoactive bowel sounds.
● Distended abdomen.
● Rectal pressure or back pain.
● Straining at stool.
● Anorexia.
● Blood-streaked stool.
● Possible fluid and electrolyte imbalances.
● For fecal impaction: Oozing diarrhea around an impaction; fecal mass confirmed by digital
examination
Precipitating Factors
a. Elimination habits.
(1) Laxative or enema abuse.
(2) Urge ignored because of inaccessible bathroom or anticipation of pain because of hemorrhoids,
rectal or anal fissures, or other rectal or anal problems.
b. Inadequate fluid intake (less than 2 L/day).
c. Inadequate intake of fiber (e.g., whole grains, fruits, vegetables) in diet.
d. Side effects of opioids, iron, or anesthesia.
e. Developmental level.
(1) Child: Stool withholding behavior.
(2) Pregnant woman: Uterine compression of intestine, decreasing peristalsis.
(3) Older adult: Decreased peristalsis.
f. Inadequate physical activity.
g. Presence of mechanical obstruction or anal lesion.
h. Weak abdominal muscles; pelvic floor dysfunction or damage.
i. Anxiety or other emotional disturbance. j. Cultural and family health beliefs, such as daily use of a laxative
or cathartic.
Fecal Incontinence
➔ involuntary passage of feces and flatus from the anus
➔ extent of incontinence ranges from partial (e.g., occasional episodes of seepage of stool) to total
(e.g., complete loss of control of bowel movements) loss of control of the passage of stool
Clinical Manefestations
● Inability to control exit of feces from the body
Precipitating Factors
a. Inability to recognize the urge to defecate or the presence of rectal fullness due to altered thought
processes
b. Impaired anal sphincter control or its nerve supply (e.g., brain attack and spinal cord damage)
c. Decreased muscle tone
d. Diarrhea
Hemorrhoids
➔ engorged, painful, bleeding veins in the lining of the rectum and anus
➔ can be internal or external
Clinical Manifestations
● Rectal pressure, burning and pain
● Frank red blood from the anus
Precipitating Factors
● Constipation or straining on defecation
● Situations that increase venous pressure, such as pregnancy, weightlifting, standing for long periods
of time, heart failure, and chronic liver disease
Flatulence
Flatus
➔ gas in the stomach and intestines as a natural by-product of digestion
➔ expelled through the anus
Flatulence
➔ excessive gas in the stomach and intestines that leads to distention of these organs precipitating
physical comfort
Clinical Manefistations
● Hyperactive bowel sounds
● Cramping and/or abdominal pain
● Abdominal distention
Precipitating Factors
a. Absent or decreased GI motility due to such factors as inadequate fiber in the diet, immobility,
anesthesia, and opioids.
b. Gas-forming foods and fluids, such as beans, peas, cabbage, onions, cauliflower, highly spicy foods, milk
and milk products, and carbonated beverages.
c. Swallowing of air that accompanies the intake of food and fluid.
Planning
