After completing the chapter, you will be able to accomplish the following:

1. Administer a large-volume cleansing enema.
2. Administer a small-volume cleansing enema.
3. Administer a retention enema.
4. Remove stool digitally.
5. Apply a fecal incontinence collection device.
6. Empty and change an ostomy appliance.
7. Irrigate a colostomy.
8. Insert a nasogastric tube.
9. Irrigate a nasogastric tube connected to suction.
10. Remove a nasogastric tube.

• Assessment
• Clinical Decision Making/Clinical Judgment
• Elimination
• Functional Ability
• Safety

• colostomy
• constipation
• defecation
• diarrhea
• enemas
• fecal impaction
• fissures
• flatus
• hemorrhoids
• ileostomy
• ostomy
• stoma
• vagal response or stimulus

Elimination of the waste products of digestion is a natural process critical for human functioning. Patients differ widely in their expectations about bowel elimination, their usual pattern of defecation, and the ease with which they speak about bowel elimination or bowel problems. Although most people have experienced minor acute bouts of diarrhea or constipation, some patients experience severe or chronic bowel elimination problems affecting their fluid and electrolyte balance, hydration, nutritional status, skin integrity, comfort, and self-concept. Moreover, many illnesses, diagnostic tests, medications, and surgical treatments can affect bowel elimination. Nurses play an integral role in preventing and managing bowel elimination problems.

This chapter covers skills the nurse may use to promote bowel elimination. Understanding the anatomy of the gastrointestinal (GI) system is integral to performing the skills in this chapter (Fundamentals Review 13-1). An abdominal assessment is required as part of providing the interventions outlined in many of these skills. Refer to Skill 3-7 in Chapter 3. Fundamentals Review 13-2 summarizes factors that may affect bowel elimination. Fundamentals Review 18-2 in Chapter 18 reviews the characteristics of stool.

1. This procedure is very uncomfortable and may cause great discomfort to the patient as well as irritation of the rectal mucosa and bleeding. Digital removal of a fecal mass can stimulate the vagus nerve, resulting in a slowed heart rate, as well as nausea, diaphoresis, lightheadedness, and/or dizziness. If the patient experiences any of these symptoms, stop the procedure immediately; monitor the patient's heart rate, blood pressure, and symptoms. Maintain the patient in a supine position, provide reassurance, and notify the health care team.
2. Hypertonic (phosphate and sodium citrate) solution preparations are available commercially and are administered in smaller volumes (adult: 118 to 197 mL). These solutions draw water into the colon, which stimulates the defecation reflex. This enema is packaged in a flexible bottle containing hypertonic solution with an attached prelubricated firm tip about 2 to 3 inches (5 to 7.5 cm) long and is easy to use. Explain the purpose and what they can expect. Use developmentally appropriate terms for a 9-year-old. Isaac and his mother should plan to administer the enema in or near the bathroom, so Isaac is not worried about being incontinent or getting to the toilet in time. Reinforce that the procedure will not hurt. Isaac will feel some pressure from the tube in his rectum, and in his belly. Explain that a child or adolescent should be positioned on the left side with the right leg flexed toward chest (Cincinnati Children's, 2018). Explain to Isaac's mother that she should generously lubricate the end of the rectal tube 2 to 3 inches before administering. She should direct it at an angle pointing toward the umbilicus, not the bladder. She should ask Isaac to take several deep breaths when inserting it to help relax the anal sphincter. She should encourage Isaac to hold the solution until the urge to defecate is strong. Finally, the mother should hold the child's buttocks together, if needed, to encourage retention of the enema.
3. Explain that Maria should cut the opening only 1/8 inch larger than the stoma size. Creating a larger opening will expose the already irritated peristomal skin to further irritation from stool. Advise Maria to contact her ostomy nurse specialist or her health care provider to rule out a superimposed fungal infection, which would require treatment with an antifungal medication. Reinforce basic teaching with Maria. Ensure she understands the routine care of her ostomy. Explain that she should empty the ostomy appliance frequently. This prevents excess pressure on the adhesive that could pull the adhesive plate off her skin and allow fecal material to come in contact with peristomal skin. Instruct Maria to keep the skin around the stoma site (peristomal area) clean and dry. If care is not taken to protect the skin around the stoma, irritation or infection may occur. A leaking appliance frequently causes skin erosion. Candida or yeast infections can also occur around the stoma if the area is not kept dry. If an appliance is leaking from underneath the skin barrier, ring, or wafer, the bag will have to be removed, the skin cleaned, and a new bag applied. The act of removing an appliance from the skin can result in skin stripping, removal of the outer, loosely bound, epidermal cell layers. This can be uncomfortable for the patient or, at worst, very painful. The cumulative effects of skin stripping over time can result in peristomal skin breakdown. The use of silicone-based adhesive remover loosens the adhesive bond to make removal easier and less likely to damage the skin and is particularly beneficial for patients with fragile skin/those at increased risk for medical adhesive-related skin injury/stripping (Collier, 2019; LeBlanc et al., 2019; Swift et al., 2020). Instruct Maria to use adhesive remover when removing her appliance, to prevent further skin damage. Explain that she should thoroughly cleanse the peristomal skin with a gentle cleanser, and then thoroughly dry it. The use of a skin barrier is important, as well as ensuring good adhesion when the appliance is replaced.