1. FECAL
Ma. Tosca Cybil A. Torres, RN,
MAN

2. DEFECATION
•Defecation is
the expulsion of
feces from the
anus and
rectum.
• Also known as
bowel
movement

3. Defecation reflex
• Intrinsic defecation reflex
• Feces enter rectum distension of rectal
walls initiates signal through mesenteric
plexus initiate peristaltic waves
(descending, sigmoid colon, rectum)anus
internal sphincter inhibited from closing
relaxed external sphincter defecation
• Parasympathetic defecation reflex

4. Common Bowel Elimination Problems
Constipation. Decreased frequency
of bowel movements accompanied
by prolonged or difficult passage of
dry hard stool
Impaction. Collection of hardened
feces wedged in the rectum
Diarrhea. Increase in number of
stools and the passage of liquid,
unformed feces.
Incontinence
Flatulence
Hemorrhoids

5. FACTORS PROMOTING FACTORS IMPAIRING
ELIMINATION ELIMINATION
Stress free environment Emotional anxiety
Ability to follow personal Failure to heed defecation
bowel habits, privacy reflex, lack of time and privacy
High fiber diet High carbohydrate,
Normal fluid intake (fruit high fat diet
juice, warm liquid) Reduced fluid intake
Exercise (walking) Immobility and inactivity
Ability to assume squatting Inability to squat because of
position immobility, musculoskeletal
Properly administered deformity; pain during
laxatives defecation
Overuse of cathartics,
narcotic analgesics

6. FACTORS AFFECTING DEFECATION
Age
Diet
Fluid intake
Physical Activity
Psychological Factors
Personal Habits
Position During Defecation
Pain
Pregnancy
Surgery and Anesthesia
Medications
Diagnostic Tests

7. Assessment
Nursing History
 Usual pattern of elimination, frequency and time of
the day.
 Normal routines followed to promote normal
elimination.
 Description of any recent change in elimination
pattern.
 Description of usual characteristics of stool.
 Diet history
 Daily fluid intake
 History of surgery or illness affecting the GI tract.
 Medication history
 Emotional state.

8. Assessment of the GIT
Nursing History : Subjective Data
1. General Data
a. presence of dental prosthesis, comfort of usage
b. difficulty eating or digesting food
c. nausea or vomiting
d. weight loss
e. pain – may be caused by distention or sudden contraction
of any part of the GIT
- specify the area, describe the pain
2. Specific data if symptoms are present
a. situations or events that effect symptoms
b. onset, possible cause, location, duration, character of
symptoms
c. relationship of specific foods, smoking or alcohol to
severity of symptoms
d. how the symptoms was managed before seeking medical
help
MTCAT '09

9. Assessment of the
GIT
3. Normal pattern of bowel elimination
a. frequency and character of stool
b. use of laxatives, enemas
4. Recent changes in normal patterns
a. changes in character of stool (constipation,
diarrhea, or alternating constipation and
diarrhea)
b. changes in color of stool
melena - black tarry stool (upper GI bleeding)
hematochezia – fresh blood in the stool (lower
GI bleeding)
c. drugs /medications being taken
d. measures taken to relieve symptoms
MTCAT '09

10. Assessment of the
GIT
B. Physical Examination : Objective Data
a.) Mouth and Pharynx
1. lips – color, moisture, swelling, cracks or lesions
2. teeth – completeness (20 in children, 32 in adults), caries, loose
teeth, absence of teeth  impair adequate chewing
3. gums – color, redness, swelling, bleeding, pain (gingivitis)
4. mucosa – color (light pink)
 examine for moisture, white spots or patches, areas of
bleeding, or ulcers
 white patches – due to candidiasis (oral thrush)
 white plaques w/in red patches may be malignant lesions
5. tongue – color, mobility, symmetry, ulcerations / lesions or
nodules
6. pharynx – observe the uvula, soft palate, tonsils, posterior
pharynx
 signs of inflammation (redness, edema, ulceration, thick
yellowish secretions), assess also for symmetry of uvula and
palate
MTCAT '09

11. Assessment of the GIT
b.) Abdomen
- assess for the presence or absence of tenderness,
organ enlargement, masses, spasm or rigidity of the
abdominal muscles, fluid or air in the abdominal cavity
Anatomic Location of Organs
RUQ – liver, gallbladder, duodenum, right kidney, hepatic
flexure of colon
RLQ - cecum, appendix, right ovary and fallopian tube
LUQ – stomach, spleen, left kidney, pancreas, splenic
flexure of colon
LLQ – sigmoid colon, left ovary and tube
MTCAT '09

12. Assessment of the GIT
MTCAT '09

13. Assessment of the GIT
1. Inspection
 assess the skin for color, texture, scars,
striae, engorged veins, visible peristalsis
(intestinal obstruction), visible pulsations
(abdominal aorta), visible masses (hernia)
 assess contour (flat, protuberant, globular)
 abdominal distension, measure abdominal
girth or circumference at the level of
umbilicus or 2-5 cm. below
MTCAT '09

14. Assessment of the GIT
2. Auscultation
 presence or absence of peristalsis or bowel sounds
 Normoactive – every 5-20 secs.
 Hypoactive – 1 or 2 sounds in 2 mins.
 Absent – no sounds in 3-5 mins.
 peritonitis, paralytic ileus,
 Hyperactive – 5-6 sounds in less than 30 sec.
 diarrhea, gastroenteritis, early intestinal
obstruction
MTCAT '09

15. Assessment of the GIT
3. Percussion
 done to confirm the size of various organs
 to determine presence of excessive amounts of air or fluid
 Normal – tympany
 dullness or flatness – area of liver and spleen, solid structure
– tumor
4. Palpation
 to determine size of liver, spleen, uterus, kidneys – if enlarged
 determine presence and chac. of abdominal masses
 determine degree of tenderness and muscle rigidity (rebound or
direct)
c.) Rectum
 perineal skin and perianal skin
 assess for presence of pruritus, fissures, external
hemorrhoids, rectal prolapse
MTCAT '09

16. FECAL STUDIES
For blood, fat, infectious organisms
• A freshly passed, warm stool is the best
specimen.
• From fat or infections organisms, collect
three separate specimens and label day # 1,
day #2, day # 3.

17. Stool examination
(fecalysis)
Stool for occult
blood (Guaiac Test)
o GI bleeding
o No red meat,
turnips,
horseradish,
steroids, NSAIDS,
iron
Stool for Ova and
parasites
proper collection

18. UPPER GI SERIES (BARIUM SWALLOW)
• Fluoroscopic examination of upper GI tract to
determine structural problems and gastric emptying
time.
• Client must swallow barium sulfate
• Sequential films taken as it moves through the
system.
Barium – is a radiopaque substance that when ingested
or given by enema in solution, outlines the passage
ways of the GIT for viewing by x-ray or fluoroscopy

19. UPPER GI SERIES (BARIUM SWALLOW)
 for identification disorders of esophagus, stomach,
duodenum – esophageal lesions, hiatal hernia,
esophageal reflux, tumors, ulcers, inflammation
 Pt. swallows a flavored barium solution and the
radiologist observes the progress of the barium
through the esophagus and take x-ray films
 NPO for 6-8 hrs
 Post procedure:
o Increase fluid intake
o Laxative
o Stool – white for 24-72 hrs.
o Observe for: impaction, distended abdomen,
constipation

20. LOWER GI SERIES
(BARIUM ENEMA)
• Barium is instilled
into the colon by
enema
• Client retains the
contrast medium
while x-rays are
taken to identify
structural

21. Nursing care: pretest
•NPO for 8 hours pretest
•Give enemas until clear the
morning of the test.
•Administer laxative or
suppository.
•Explain that cramping may be
experienced during
procedure.
Nursing care: posttest
•Administer laxatives and

24. ESOPHAGOGASTRODUODENOSCOPY (EGD)
• Direct visualization of the
esophagus, stomach, and
duodenum by insertion of
a lighted fiberscope.
• Used to observe
structures, ulcerations,
inflammation, tumors;
may include biopsy.

25.  directly visualize the GIT by the use of a fiberscape
 fiberscope – has a thin, flexible shaft that can pass through and
around bends in the GIT, transmit light and the image can be seen in
the monitor

28. ESOPHAGOGASTRODUODENOSCOPY (EGD)
Nursing care:
•NPO for 6-8 hours
•Ensure consent
form has been
signed
• Explain that a
local anesthetic
will be used to
ease comfort and
that speaking
during the

29. Nursing care:
posttest
• NPO until
return of gag
reflex.
• Assess vital
signs and for
pain, dysphagia,
bleeding
• Administer

30. COLONOSCOPY
• to visualize the
colon
• useful to identify
tumors, colonic
cancer, colonic
polyps
• not done when there
is active bleeding or
inflammatory
disease

31. Colonoscopy
Preparation :
• clear liquid diet 24 hrs. before fleet or cleansing
enema
• dulcolax tabs
• NPO 8 hrs. prior to procedure
• Position: left side, knees flexed
Post-procedure :
• provide rest, monitor VS (vasovagal response- 
HR,BP)
• assess for sudden abdominal pain (perforation),
fever, active
• bleeding
• Hot sitz bath

34. SIGMOIDOSCOPY
Sigmoidoscopy – examination of sigmoid colon, rectum and anus
Proctoscopy – examination of rectum and anus
 used as a screening test for persons 40 yrs old and above, with
history of colonic cancer
 used for pt with lower GI bleeding or inflammatory disease
Preparation :
 light dinner and light breakfast -
 dulcolax tab.
 Fleet enema or cleansing enema
Post-procedure :
 provide rest period
 assess for sudden abdominal pain, bleeding

36. GASTRIC ANALYSIS
• to quantify gastric acidity Normal 1-5 mEq / L
 gastric acid : gastric cancer, pernicious anemia
 gastric acid : duodenal ulcer
Normal gastric acid : gastric ulcer
Nursing care: pretest
NPO 6- 8 hours pretest
Advise client about no smoking, anticholinergic
medications, antacids 24 hours prior to test
Inform client that tube will be inserted into the stomach
via the nose, and instruct to expectorate saliva to
prevent buffering of secretions.
Nursing care: posttest
Provide frequent mouth care.

37. MTCAT '09

38. STOOL CHARACTERISTICS
CHARACTERISTICS NORMAL ABNORMAL CAUSE
Color Infant yellow: White or clay; Black Absence of bile Iron
Adult brown or tarry ingestion or upper GI
bleeding
Red Lower GI bleeding,
hemorrhoids
Pale Malabsorption of fat
Odor Aromatic; affected Noxious change; Blood in feces or
by food type Pungent infection
Consistency Soft; formed; Liquid Diarrhea, reduced
semisolid Hard absorption;
constipation
Frequency Varies: 4-6 More than 6 x daily or Hypo/Hypermotility
(breastfed); 1-3 less than once every
(bottle fed) 1-2 days; more than
Adult: Several 3x a day
times per day to 2-
3 times per week

39. STOOL CHARACTERISTICS
Characteristics Normal Abnormal Cause
Amount 150 g/day
(adult) varies
with diet
Shape Resembles Narrow, pencil Obstruction,
diameter of shaped, rapid peristalsis
rectum stringlike
(Cylindrical)
Constituents Undigested food, Blood pus, Intestinal
dead bacteria, foreign bodies, bleeding,
fat, bile pigment, mucus worms, infection,
cells lining large quantities swallowed
intestinal mucosa of fat objects, irritation,
and water inflammation

40. Stool Characteristics
•Tarry black color
•Bright or dark red
•Streaking of blood
on the surface of
the stool
• Bulky, greasy
• Clay colored
• Mucus threads

41. Alteration on the characteristics of stool
• Acholic stool. Gray, pale due to
absence of urobilin caused by
biliary obstruction.
• Hematochezia. Passage of stool
with bright red blood.
• Melena. Passage of black tarry
stool
• Steatorrhea. Greasy, bulky, foul
smelling stool. Presence of
undigested fats like in
hepatobiliary-pancreatic
obstruction/disorders

42. Foods & meds that alter stool color
• Meat protein - dark brown
• Spinach - green
• Carrots & beets - red
• Cocoa - Dark red or brown
• Iron, charcoal - Black
• Barium - milky white

43. Common Causes of Constipation
• Irregular bowel habits and ignoring the urge to defecate can cause
constipation
• Client who have a low-fiber diet high in animal fats and refined
sugar often have constipation problems. Also low fluid intake slows
peristalsis
• Lengthy bed rest or lack of regular exercise causes constipation.
• Heavy laxative use causes loss of normal defecation reflex. In
addition, the lower colon is completely emptied, requiring a time to
refill with bulk.
• Tranquilizers, opiates, anticholinergics, and iron can cause
constipation
• Older adult experience slowed peristalsis, loss of abdominal muscle
elasticity, and reduce intestinal mucous secretion. Older adults
often live alone and eat low-fiber foods.
• Constipation is also caused by GI abnormalities such as bowel
obstruction, paralytic ileus, and diverticulitis
• Neurological Conditions that block nerve impulses to the colon can
cause constipation.

45. Interventions to prevent and relieve constipation
• Adequate fluid intake.
• High-fiber diet.
• Establish regular pattern of defecation
• Respond immediately to the urge to
defecate.
• Minimize stress. – Sympathetic response.
• Promote adequate activity and exercise.
• Assume sitting or squatting position.
• Administer laxatives as ordered
• TYPES:
• Chemical irritants- provide chemical
stimulation to intestinal wall- increase
peristalsis . Ex. Dulcolax, castor oil, senokot
(senna)
• Stool lubricants – mineral oil
• Stool softeners – Colace (Na Docussate)
• Bulk formers – Metamucil
• Osmotic agents – Milk of magnesia, duphalac

46. Conditions that cause DIARRHEA
Emotional stress
Intestinal infection
Food allergies
Food intolerance
(greasy foods, coffee,
alcohol, spicy foods)
Medications (Iron,
Antibiotics)

47. Manifestation & Complications of Diarrhea
• Increase in volume, frequency
and consistency
• Very large watery to very
frequent small stools/
containing blood, mucus or
exudate
• Depends on the course,
duration and severity
• May result to vascular
collapse and hypovolemic
shock & hypokalemia

48. Interventions to relieve diarrhea
• Monitor I & O. Assess for:
urine- frequency, color, consistency and volume
Stools
Vomitus
• Replace fluid and electrolyte losses.
• Provide good perianal care
• Promote rest.
• Diet:
Small amounts of bland foods
Low fiber diet
BRAT
Avoid excessive hot or cold fluids.
Potassium rich foods and fluid.
• Antidiarrheal medications.

49. Dietary Management
• Fluid replacement
 Oresol
• Avoid food in the first 24 hours to provide bowel rest, after
that time, frequent small feedings
• Milk are temporary withheld
• Avoid raw fruits and vegetables, fried foods, spices coffee.

50. Nursing Care
Directed toward identifying
the cause, relieving
symptoms, preventing
complications and if
infectious, preventing the
spread of infection to
others.
RISK FOR FLUID VOLUME
DEFICIT
• RECORD I & O
• Monitor v/s and record
including orthostatic
hypotension
• Provide fluid and electrolyte
replacement solutions as
indicated- increase OFI as
tolerated

51. NURSING DIAGNOSIS
• Altered nutrition less than body requirements R/T
• Status of nothing by mouth
• Excessive dieting
• Anorexia
• Self-induced vomiting
• Alcoholism
• Excessive use of enemas or laxatives
• Food fads
• Alternative diet forms
• Altered nutrition more than body requirements
• Excessive caloric intake
• Altered nutrition: potential for more body requirements
related to:
• Dysfunctional eating patterns
• Closely spaced pregnancies
• Feeding self-care deficit related to:
• Impaired mobility of both arms
• Impaired swallowing related to:
• Surgical trauma
• Muscular weakness

52. RISK FOR IMPAIRED
SKIN INTEGRITY
 Provide good skin care
 Assist in cleaning the
perianal area
 Apply protective ointment to
the perianal area

53. Flatulence
Presence of excessive gas or tympanites in the
intestines.
COMMON CAUSES OF FLATULENCE
• Constipation
• Anxiety
• Eating gas-forming foods
• Rapid food and fluid ingestion
• Improper use of drinking straw
• Excessive drinking of carbonated beverages
• Chewing gum, candy sucking, smoking

54. DECREASING FLATULENCE
One method of treating flatulence involves the insertion of a rectal
tube.
Guidelines:
• Use rectal tube (Fr 22-30) for adults and a smaller size for children.
• Have the client assume a side-lying position.
• Lubricate the rectal tube to reduce mucous membrane irritation.
• Expose the anus and insert the rectal tube into the rectum 10cm
(4in). The rectal tube will stimulate peristalsis. If no flatus is
expelled, insert the tube another inch or so. Do not force the tube if
it does not insert easily.
• Wrap an abdominal or incontinence pad around the end of the rectal
tube to catch any liquid that may be expelled. Or, placing the end of
the tube into a receptacle filled with fluid.
• Leave the tube in no longer than 3 minutes to avoid irritation of the
rectal mucosa. If abdominal distention is not relieved, the tube may
be inserted every 2 to 3 hours.
• Encourage the client to assume various positions in bed.

55. TEACHING ABOUT MEDICATIONS
Cathartics and Laxatives
 Cathartics are drugs that induce defecation. They can
have strong, purgative effect. A laxative is mild in
comparison to a cathartic, and it produces soft or liquid
stools that are sometimes accompanied by abdominal
cramps.
 Cathartics: Castor oil, cascara, phenolphthalein and
bisacodyl.
 Laxatives are contraindicated in the client who has
nausea, cramps. Colic, vomiting, or undiagnosed
abdominal pain. Clients need to be informed about the
dangers of laxative use.

56. TYPES OF LAXATIVES
TYPE ACTION EXAMPLES
BULK-FORMING INCREASES THE FLUID, GASEOUS, OR PSYLLIUM HYDROPHILIC
SOLID BULK IN THE INTESTINES MUCILLOID (METAMUCIL),
METHYLCELLULOSE
(CITRUCEL)
EMOLIENT/STOOL SOFTENS AND DELAYS THE DRYING OF DOCUSATE SODIUM (COLACE)
SOFTENER THE FECES; PERMITS FATS AND WATER
TO PENETRATE FECES
STIMULANT/ IRRITATES THE INTESTINAL MUCOSA OR BISACODYL (DULCOLAX,
IRRITANT STIMULATES NERVE ENDINGS IN THE CORRECTOL), SENNA
WALL OF THE INTESTINE, CAUSING (SENOKOT, EX-LAX),
RAPID PROPULSION OF THE CONTENTS CASCARA, CASTOR OIL
LUBRICANT LUBRICATES THE FECES IN THE COLON MINERAL OIL (HALEY’S M-O)
SALINE/OSMOTIC DRAWS WATER INTO THE INTESTINE BY EPSOM SALTS, MAGNESIUM
OSMOSIS, DISTENDS THE BOWEL, AND HYDROXIDE (MILK OF
STIMULATES PERISTALSIS MAGNESIA), MAGNESIUM
CITRATE, SODIUM PHOSPATE
(FLEET PHOSPODA)

57. Critical Thinking Exercise
Adam, 1 year old infant was Eve, 15 year old rider, was
admitted in the hospital due to admitted in the hospital due to
fever with temperature of 38 C, vehicular accident. She
vomiting and diarrhea for 2 days reportedly loss her
duration. The nurse reported that consciousness when she was
the infant defecated 3 times as brought to ER thus upon
many stool as usual with watery admission, she was placed
consistency. Initially, it is initially on NPO. After a few
apparent that the child is mildly days, on a balance skeletal
dehydrated because of stool traction to treat fracture. She
losses secondary to acute does not want to eat because
infectious diarrhea. according to her, she lost her
What appropriate nursing appetite every time she sees
other patients. She had not
care plans could you defecated also for 5 days
formulate for Adam. already.
Supplement necessary Formulate appropriate
assessment findings nursing care plan for Eve.
significant to the patient’s Supplement necessary
case. assessment findings
significant to the
patient’s case.