14.3 Bowel Care, Constipation, and Ostomy Observation
Key Takeaways
- Track the last bowel movement. Report hard stool, straining, no BM for several days, and hypoactive bowels as constipation signs.
- Oozing liquid stool around a suspected mass is a possible impaction — report it immediately. Do not digitally remove stool unless the CNA has RN-deemed expanded-scope competency and an order.
- Diarrhea needs peri-care, hydration support, and a report. Occult blood, black tarry stool, and frank red blood are reports, not something to rinse away.
- Enema, suppository, and digital stimulation are Colorado expanded-scope tasks only if an RN has deemed the CNA competent (Chapter 3) and the client is stable and not high risk.
- Every CNA observes the stoma (moist pink or red is expected; dusky or black is an emergency report), output character, leaking appliance, and peristomal skin. Changing the bag is expanded scope if deemed competent. Do not puncture a bag to let gas out unless taught and assigned.
14.3 Bowel Care, Constipation, and Ostomy Observation
Quick Answer: Track the last bowel movement (BM). Constipation — hard stool, straining, no BM for several days, hypoactive bowels — is a report. Impaction can look like oozing liquid around a mass; report immediately. Do not dig it out unless you have RN-deemed expanded-scope competency and an order. Diarrhea: peri-care, hydration, report. Occult blood, black tarry stool, or frank red blood — report. Enema, suppository, and digital stimulation are expanded scope only if an RN has deemed you competent (Chapter 3) on a stable, not high-risk client. Ostomy bag changes are the same expanded-scope gate. Every CNA observes the stoma: it should be moist pink or red; dusky or black is an emergency report. Also watch output character, a leaking appliance, and skin around the stoma. Do not puncture the bag to let gas out unless you were taught and assigned. Bowel training: same time daily, privacy, sit upright if able.
Why bowel care is its own written cluster
Leaf I.A.3 Elimination is not only urine. Stool frequency, constipation, diarrhea, blood, and ostomy appearance show up as ADL and as data-collection items. Colorado adds a scope overlay the national outline does not print: 3 CCR 716-1.10 I.3 lists digital stimulation, suppository, enema, and changing ostomy bags as expanded-scope tasks. Chapter 3 taught the gates. This section teaches what you see, what you report, and what you must not improvise.
Track the last BM
Bowel history is basic CNA data collection. Know when the person last had a stool, what it looked like (amount, color, hard or liquid), and whether it took straining or produced pain. Facilities chart this on the ADL sheet or the bowel record. A blank row for three days is not a paperwork problem — it is a clinical one.
Ask, look at the commode or pan before you dump it, and write the time. Do not guess had a good one because the person sat on the toilet. Do not flush a black or bloody stool before the nurse sees it.
Constipation — report, do not invent a treatment
Constipation is hard, dry stool that is difficult to pass, or a stretch of days without a BM that is not normal for that person. Teaching signs:
- Hard stool or pellet stool
- Straining, pain, or a sense of incomplete emptying
- No BM for several days (many care plans flag day three; follow the person's usual and the nurse's window)
- Hypoactive bowel sounds if you are present when the nurse listens, or a soft, bloated abdomen the person says feels stuck — you report the abdomen and the missing BM; you do not diagnose an ileus
- Poor appetite, extra gas, and irritability that line up with the missing stool
You report. You offer the toileting position (upright, feet supported if possible), privacy, time, and the fluids and fiber already on the tray and the care plan. You do not decide to give prune juice as a medication, a store-bought laxative from the family purse, or an enema from the supply closet.
Impaction — liquid can be a lie
Fecal impaction is a hard mass of stool in the rectum that the person cannot pass. Liquid stool may ooze around the mass. The exam trap is to chart diarrhea and walk away. Oozing liquid around a suspected mass is an immediate report. The person may also have cramping, a swollen abdomen, small frequent smears, and restlessness.
Do not dig it out. Digital removal of impacted stool is not basic Colorado CNA scope. It sits with digital stimulation / suppository / enema in the expanded-scope list, and even then it requires:
- An RN who has deemed you competent (teach, demonstrate, risks, what to report, return demonstration, signed document, HPPP update — Chapter 3)
- A stable, not high-risk client
- An order / assignment to do that procedure on this person today
- A facility policy that actually allows it
If any gate is closed, you report the suspected impaction and you stay in role. Untrained digging can vagal the person (a sudden pulse drop), tear the rectum, and miss a surgical emergency.
Diarrhea, blood, and hydration
Diarrhea is frequent liquid or very loose stool. Your job:
- Peri-care after every episode — skin around the anus breaks down fast
- Hydration support: offer assigned fluids, record intake if assigned, report poor intake
- Report the frequency, color, amount, cramping, fever, and whether the person is dizzy
- Barrier cream only if assigned
- Infection control: gloves, hand hygiene, and whatever isolation the nurse has posted — you do not decide it is only something they ate
Blood in the stool is always a report:
| Appearance | Classic teaching name | CNA action |
|---|---|---|
| Hidden blood the lab card detects | Occult blood | Collect the specimen as assigned (Chapter 10); you do not interpret the card as a diagnosis |
| Black, tarry, sticky stool | Melena (often upper-GI blood) | Report immediately; save the stool if you can; do not assume it is only iron |
| Bright or dark frank red blood on the stool, in the water, or on the tissue | Lower-GI or hemorrhoidal bleeding until the nurse says otherwise | Report immediately; do not flush |
Iron and some foods can darken stool. You still tell the nurse what you saw. You do not decide it is the vitamin and skip the report. Frank red clots, a coffee-ground mix, or a large black tarry stool with weakness or low blood pressure signs are stay-with-the-person reports.
Enema, suppository, digital stimulation — expanded scope only
3 CCR 716-1.10 I.3 groups digital stimulation, suppository, enema, or another medically acceptable procedure to produce a bowel movement as expanded scope. Chapter 3 is the legal chapter. The elimination reminder is practical:
- No competency document, no procedure.
- Unstable or high-risk client, no procedure — the licensed nurse does it.
- Facility ban, no procedure, even if your HPPP still lists the task from a prior job.
- A standing I always give the 3-east residents an enema on day three is not an order.
If you are deemed competent and assigned, you still report pain, bleeding, a sudden pale sweaty client, and failure to produce stool. You do not increase the volume, switch solutions, or add soap because last time it worked better.
Ostomy — every CNA observes; bag changes are gated
An ostomy is a surgically created opening. A colostomy (colon) and ileostomy (ileum) bring bowel to the abdomen; a urostomy brings urine. The visible bud is the stoma. The pouch is the appliance.
Changing ostomy bags is an I.3 expanded-scope task: RN-deemed competence, stable not-high-risk client, employer permission. A new postoperative stoma, a retracted or bleeding stoma, or a person in shock is not your first independent pouch change.
Every CNA, with or without that competency, still looks:
| Observation | Expected | Report now |
|---|---|---|
| Stoma color | Moist pink or red, like healthy mucosa | Dusky, purple, brown, or black — emergency report; the tissue may be dying |
| Stoma surface | Moist, not dry and crusted | Dry, sloughing, or a stoma that has pulled back or prolapsed a new amount |
| Output character | Matches the type (ileostomy more liquid; descending colostomy more formed) and the person's usual | Sudden stop, huge liquid flood, blood in the pouch, or a color change the nurse has not seen |
| Appliance | Intact, not leaking onto skin or linen | Leaking pouch, frequent blowouts, or a full bag left to pull on the wafer |
| Skin around the stoma (peristomal) | Intact, not raw | Red, weeping, yeast-looking rash, or stool sitting on the skin |
A stoma has no nerve endings for sharp pain, but the skin around it hurts. Leaks burn that skin. Empty an assigned pouch when it is about one-third to one-half full so the weight does not break the seal — emptying an established pouch into the toilet is often basic assigned care; changing the wafer and bag is the expanded task. Follow the assignment sheet if your facility draws that line more tightly.
Do not puncture the bag to let gas out unless you were taught and assigned a specific venting method for that product. A random pin-hole leaks stool, ruins the filter if the pouch has one, and sprays organisms. If the bag balloons, report and use the method on the care plan — a manufactured vent, a filter, or a competent pouch change — not a ballpoint pen.
You do not dilate a stoma, cut a wafer opening by guess on a brand-new surgical site, or tell the family the cancer is back because the output changed.
Bowel training
Bowel training is a restorative plan to help the person have a BM on a predictable schedule. It is basic-scope support even when enemas are not.
- Same time daily — often after a meal, when the gastrocolic reflex helps, at the time the care plan names
- Privacy — curtain, door, enough time; you do not stand in the doorway chatting
- Sit upright if able — toilet or commode, feet supported; a bedpan is a last choice for training because the position is wrong
- Offer the toilet even if the last two days were dry; skipping the sit trains the bowel to wait
- Report what happened. Do not increase a laxative. Do not skip the offer because the unit is busy
Privacy plus an upright sit is also ordinary toileting dignity. Training just makes the clock consistent.
Colorado scenario
You work a day shift in a Colorado Springs nursing facility. Mr. Delgado has had no BM for four days, he is straining, and this morning you find small liquid smears on the brief and a firm abdomen. A coworker says, Just glove up and hook the mass out so he is comfortable before therapy, then punch a hole in Ms. Ruiz's ostomy bag — it is puffed with gas. Ms. Ruiz's stoma looks dusky, almost gray-purple, and the wafer is leaking onto raw skin. Another aide offers you a ready-to-give enema because you watched one in class.
You do not digitally remove the suspected impaction. Oozing liquid around a mass is an immediate report, not a CNA extraction. You have no RN-deemed expanded-scope file for digital removal or for an enema on this unit, and even if you did, Mr. Delgado's four-day blockage is not a casual hallway procedure. You report constipation signs (hard time, four days, straining, hypoactive story, liquid overflow) to the licensed nurse and you save the brief if the nurse wants to see it.
For Ms. Ruiz you do not puncture the bag. You report a dusky stoma as an emergency, plus the leak and the broken peristomal skin. If you are not deemed competent to change the appliance, you do not peel it off to take a better look. You keep her covered, keep stool off the skin as assigned, and stay until the nurse is at the bedside. If you are deemed competent and the nurse assigns a pouch change on a now-stable day, that is Chapter 3 paperwork plus today's order — not a freelance pin-hole.
You also check the bowel book: three other residents have blank BM rows. You offer bowel training sits at the planned time, upright, private, and you write what you offered and what happened. A black tarry stool in the next commode is a report, not a flush.
Exam traps
- Treating four days without a BM as a charting nuisance.
- Calling overflow liquid around an impaction simple diarrhea and digging it out.
- Giving an enema, a suppository, or digital stimulation without RN-deemed competency, stability, and an assignment.
- Ignoring occult, tarry, or frank red blood, or blaming iron without a report.
- Treating every CNA as cleared to change ostomy bags.
- Missing a dusky or black stoma, or waiting until the next shift.
- Puncturing a pouch to vent gas without teaching and an assignment.
- Bowel training in a hallway, flat in bed, or at random times when the care plan names a daily hour.
A client has had no bowel movement for several days. This morning the brief shows oozing liquid stool and the abdomen is firm. What should the Colorado CNA do?
Which statement about ostomy care is correct for a Colorado CNA?
Which bowel-care practices match Colorado CNA scope and NNAAP written items?