The large intestine absorbs water and electrolytes and moves stool toward the rectum by peristalsis. When stool distends the rectum, the defecation reflex creates the urge; the client relaxes the external sphincter voluntarily. The gastrocolic reflex — increased colon movement after eating, strongest after breakfast — is the best time to schedule bowel training.

Factors affecting elimination: age, fiber and fluid intake, activity, privacy and positioning, pain (e.g., hemorrhoids), pregnancy, surgery and anesthesia (reduce peristalsis), medications (opioids, anticholinergics, iron, calcium, aluminum antacids cause constipation; antibiotics and magnesium cause diarrhea), and ignoring the urge to defecate.

Common problems

• Constipation: infrequent, hard, or difficult-to-pass stool. Rome IV functional constipation requires two or more of these six: straining, lumpy or hard stools, sensation of incomplete evacuation, sensation of anorectal blockage, manual maneuvers to pass stool (each in more than 25% of defecations), or fewer than 3 spontaneous bowel movements per week. Criteria must be met for the last 3 months with onset at least 6 months before diagnosis; loose stools are rare without laxatives, and criteria for irritable bowel syndrome are not met.
• Fecal impaction: a hardened mass in the rectum; may present as liquid stool oozing around the mass, abdominal discomfort, and in older adults, confusion or urinary retention.
• Diarrhea: 3 or more loose or liquid stools a day (or stool weight above about 200 g/day); risks are fluid and electrolyte loss (hypokalemia, metabolic acidosis) and skin breakdown.
• Fecal incontinence: loss of voluntary control; risks are skin damage and social isolation.
• Flatulence and hemorrhoids.

Stool characteristics

The Bristol Stool Form Scale grades stool from type 1 (separate hard lumps) to type 7 (entirely liquid); types 3 and 4 are normal, type 4 ("like a sausage or snake, smooth and soft") being ideal.

• History: usual frequency and time, stool form (Bristol), straining, pain, blood, color, recent change, diet, fluid, activity, medications (especially opioids), laxative and enema use, ostomy
• Abdomen — order: inspect, auscultate, percuss, palpate (palpation before auscultation can alter bowel sounds)
• Bowel sounds: normal are irregular high-pitched gurgles, about 5–35 per minute; hypoactive with ileus, opioids, after surgery; hyperactive with diarrhea or early obstruction. Listen for a total of about 5 minutes (commonly at least 1 minute per quadrant) before documenting absent bowel sounds.
• Distension, tympany (gas), tenderness
• Rectal area: hemorrhoids, fissures, skin breakdown. A digital rectal examination assesses the anal canal and lower rectum (and prostate in men); it cannot reach higher lesions such as diverticula of the sigmoid colon.

Laxatives and antidiarrheals — drug safety

Clients on regular opioids should start a bowel regimen (commonly a stimulant with or without a softener) at the same time — tolerance to opioid constipation does not develop.

Enemas

1. Monitor for serious problems first: absent bowel sounds with distension and vomiting (obstruction or ileus), blood in stool, signs of dehydration with diarrhea.
2. Administering an enema
   • Place the client in left Sims' position (follows the anatomy of the rectum and sigmoid colon) with the right knee flexed.
   • Warm the solution to about 40.5–43 °C (105–110 °F) for adults, per policy — cold solution causes cramping; hot solution burns the mucosa.
   • Lubricate the tip; insert 7.5–10 cm (3–4 in) in adults, directed toward the umbilicus.
   • Hang the container 30–45 cm (12–18 in) above the anus; infuse slowly — fast infusion causes cramping and early expulsion.
   • If cramping occurs, lower the container or clamp the tubing briefly, and ask the client to breathe slowly.
   • Ask the client to retain the solution as long as possible (several minutes for cleansing enemas).
3. Suppositories: lubricate and insert past the internal sphincter (about 7–10 cm or 3–4 in in adults), placing it against the rectal wall, not into stool.
4. Digital removal of impaction (only with an order or per protocol): use a lubricated gloved finger; stop if the client develops bradycardia, dizziness, pain, or bleeding — rectal stimulation can trigger a vagal response. An oil-retention enema beforehand softens stool. Monitor pulse in clients with heart disease.
5. Bowel training: schedule toileting at the same time daily, usually 20–30 minutes after a meal to use the gastrocolic reflex; provide privacy and a sitting position with feet supported (squatting posture helps); combine with fiber, fluids, and activity. Clients should still be taught not to ignore the urge.
6. Abdominal massage for constipation follows the colon: start in the right lower quadrant, move up to the right upper, across to the left upper, and down to the left lower — that is, clockwise as seen when facing the client's abdomen.
7. Diarrhea care: replace fluids and electrolytes (oral rehydration solution); record stool frequency and volume; contact precautions and soap-and-water hand hygiene for suspected C. difficile (alcohol does not kill spores); dietitian input.
8. Perineal skin protection: clean promptly after each episode with a soft cloth and pH-balanced cleanser, pat dry, apply a moisture barrier; avoid harsh scrubbing and alcohol-based products; consider a fecal management system for severe liquid diarrhea.
9. Ostomy care
   • A healthy stoma is pink to red and moist; pale, dusky, purple, or black indicates poor blood supply — report immediately.
   • Measure the stoma and cut the skin barrier opening about 1.5–3 mm (1/16–1/8 in) larger than the stoma — never smaller (constricts the stoma) and not much larger (exposes skin to effluent). Remeasure weekly for the first 6–8 weeks as swelling decreases.
   • Empty the pouch when one-third to one-half full to prevent leakage and pulling on the seal.
   • Change the barrier every 3–7 days or if leaking; clean skin with warm water and dry well.
   • Ileostomy: continuous liquid output — risk of dehydration and electrolyte loss; drink extra fluids; chew well and limit high-fiber foods that can block the stoma (nuts, popcorn, corn); avoid extended-release tablets that may pass unabsorbed.

• Fiber 25–35 g/day from whole grains, fruits, vegetables, and legumes; increase gradually to limit gas.
• Fluids about 1.5–2 L/day unless restricted; regular physical activity such as walking.
• Respond to the urge to defecate; set a regular time after breakfast.
• Avoid long-term routine stimulant laxative use without guidance.
• With an ostomy: odor control, pouch emptying, diet, clothing, sexuality, and support groups; report stoma color change, no output for 4–6 hours with cramping (ileostomy), or high output.
• Report black or bloody stools, a persistent change in bowel habits, or unexplained weight loss.

• Bristol types 3–4 = normal; type 4 ideal
• Clay-colored stool = biliary obstruction; black tarry = upper GI bleeding
• Abdominal assessment: inspect, auscultate, percuss, palpate; normal bowel sounds about 5–35/min
• Rome IV criteria include fewer than 3 spontaneous bowel movements per week
• Opioids are a leading drug cause of constipation — start a bowel regimen with them
• gFOBT: avoid red meat, NSAIDs, and vitamin C beforehand; FIT needs no restrictions
• Enema: left Sims', 7.5–10 cm insertion, container 30–45 cm above the anus, infuse slowly, lower the bag for cramping
• Repeated tap water enemas → water intoxication; phosphate enemas risky in kidney disease
• Impaction removal can cause bradycardia (vagal) — stop if it occurs
• Abdominal massage runs clockwise along the colon (RLQ → RUQ → LUQ → LLQ)
• Ostomy barrier slightly larger (1.5–3 mm) than the stoma; empty at one-third to one-half full
• C. difficile: soap and water, contact precautions; avoid loperamide