elimination, nursing

NURSING FUNDAMENTALS FOCUS IX

Elimination Needs

OBJECTIVES:SOLID

Describe the physiology of stool formation and the elimination process.

List the common problems of bowel elimination. Discuss nursing responsibilities involved with

each problem. Define and explain some of the basic but

important measures to promote normal bowel elimination.

Compare and contrast the different types of altered means of bowel elimination.

Identify the procedures/technical skills and related nursing responsibilities.

Identify the common diagnostic procedures related to the bowel elimination need and the associated nursing responsibilities

OBJECTIVES:FLUID

Describe the normal micturition process mechanism. Discuss common conditions /situations responsible

for a disruption in the normal micturition process. List the commonly recognizable signs (behaviors)

indicating a disruption in urinary elimination. Compare and contrast the altered means of urinary

elimination and explain the related procedures and nursing responsibilities.

Report the basic but important nursing interventions to promote normal urinary elimination.

Examine the common diagnostic procedures related to urinary elimination and the associated nursing responsibilities.

BLADDER AND BOWEL FUNCTION

Overview: The human body eliminates waste of

metabolism through urine and stool. Normal function depends on these factors: - anatomic integrity - intact neurologic components for both

voluntary and synergistic emptying - a predictable pattern of waste production - physical and mental ability and the psycho-

social willingness to carry out toileting related tasks

STRUCTURES AND FUNCTIONS RELATED TO BOWEL ELIMINATIONDIGESTIONHTTP://WWW.MEDTROPOLIS.COM/VBODY.ASP

Structures and Functions Related To Bowel Elimination

http://www.medtropolis.com/VBody.asp

STRUCTURES AND FUNCTIONS RELATED TO BOWEL ELIMINATION

Amylase released

Releases bile toduodenum

HCL, Pepsin Intrinsic factor Mucus CHYME

Bolus with Ptyalin

Nutrients, electrolytes, vitamins absorbed

Absorption, secretion, protection, elimination

Defecation process

Physiology of Defecation

Peristaltic waves move the feces into the sigmoid colon and the rectum

Sensory nerves in rectum are stimulated Individual becomes aware of need to

defecate Feces move into the anal canal when

the internal and external sphincter relax

External anal sphincter is relaxed voluntarily if timing is appropriate

Expulsion of the feces assisted by contraction of the abdominal muscles and the diaphragm

Moves the feces through the anal canal and expelled through anus

Facilitated by thigh flexion and a sitting position

Lifestyle Personal habits Nutrition and fluid intake Physical activity

Culture Norms of western culture

Age Infancy Elders

FACTORS AFFECTING BOWEL ELIMINATION

FACTORS AFFECTING BOWEL ELIMINATION

Physiological factors Pregnancy Motor and or sensory disturbance Intestinal pathology Medications Surgery and anesthesia

Psychosocial factors Anxiety Depression

Color Odor Consistency Frequency Amount Shape Constituents

CHARACTERISTICS OF NORMAL STOOL

SELECTED FECAL ELIMINATIONPROBLEMS

Constipation Diarrhea Bowel incontinence Flatulence

CONSTIPATION A symptom not a disease Decreased frequency of defecation Hard, dry, formed stools Straining at stools Painful defecation Causes include: Insufficient fiber and fluid intake Insufficient activity Irregular habits

FECAL IMPACTION

Mass or collection of hardened feces in folds of rectum that cannot be expelled

Passage of liquid fecal seepage and no normal stool

Causes usually: Poor defecation habits Results from unrelieved constipation

Treatment Removed manually Must have physician order Monitor patient for Valsalva reaction

DIARRHEA

Passage of liquid feces and increased frequency of defecation Spasmodic cramps, increased bowel sounds Fatigue, weakness, malaise, emaciation A symptom of disorders affecting digestion,

absorption, and secretion of the GI tract. Major causes:

Stress, medications, allergies, intolerance of food or fluids, disease of colon

FECAL INCONTINENCE

Loss of voluntary ability to control fecal and gaseous discharges

Generally associated with: Impaired functioning of anal sphincter or nerve

supply Neuromuscular diseases Spinal trauma Tumor

Nursing Considerations Incontinence can harm a clients body image Incontinence predisposes the skin to breakdown

FLATUENCE

Excessive flatus in intestines Leads to stretching and

inflation of intestines Can occur from variety of

causes: Foods Abdominal surgery Narcotics

ASSESSMENT OF BOWEL FUNCTION

History of bowel prior patterns usual time frequency of stool past reliance on aids

Present status and pattern Time Characteristics of stool

Medications that may affect bowel functioning sedatives diuretics antihistamines

ASSESSMENT OF BOWEL FUNCTION

Infection, trauma, or stress may affect stool formation

Physical Abdominal Assessment Inspection Auscultation Palpitation

determine abdominal discomfort palpable obstruction would indicate need for

rectal exam

ABDOMINAL QUADRANTS AND ORGANS

ABDOMEN

Subjective Assessments: Any abdominal pain? N/V? Appetite good? Last BM? Stool formed/loose?

ABDOMEN-OBJECTIVE ASSESSMENT

Normal soft non-tender non-distended normoactive bowel sounds in all 4

quadrants Normal bowel sounds

2-3 every 15sec or 10-30 every min

ABDOMEN – ABNORMAL ASSESSMENTS Distended Rigid Tender Hypoactive bowel sounds (<10/min) Hyperactive bowel sounds (>30/min) Absence of bowel sounds Presence of mass Ascities Abnormal pulsations Tubes, drains, ostomies

AIDS TO NORMAL BOWEL ELIMINATION

Fluid intake and fiber:

Adequate fiber Adequate fluid intake Upright posture

CONSTIPATION

Managing constipation: Diet

25 -35 G of fiber + WATER!

Medications Laxatives cathartics

Enemas high – cleanse entire colon low – cleanse rectum and sigmoid colon hypotonic and isotonic

– immediate large colonic emptying hypertonic and mineral - fleets

FECAL INCONTINENCE

Assessment key factors: Is the problem correctable or

manageable? What is the timeline or duration of

situation? Any associated symptoms?

NANDA NURSING DIAGNOSIS

Bowel Incontinence Constipation Risk for Constipation Perceived Constipation Diarrhea

RELATED NURSING DIAGNOSIS

Risk for Deficient Fluid Volume Risk for Impaired Skin Integrity Low Self-esteem Disturbed Body Image Deficient Knowledge

Bowel Training Ostomy Management Anxiety

DESIRED OUTCOMES

Maintain or restore normal bowel elimination pattern

Maintain or regain normal stool consistency

Prevent associated risks such as fluid and electrolyte imbalance, skin breakdown, abdominal distention and pain

NURSING CONSIDERATIONS

Promoting regular defecations Teaching about medications Decreasing flatulence Administering enemas Digital removal of a fecal impaction

(if agency policy permits) Instituting bowel training programs Applying a fecal incontinence pouch Ostomy management

FECAL ELIMINATION PATTERNS

Privacy Timing Nutrition and fluids Exercise Positioning

ALTERED MEANS OF BOWEL ELIMINATION


Ileostomy


StomaForm- ation


Stoma

STOMA CARE FOR CLIENTS WITH AN OSTOMY

Normal stoma should appear red and may bleed slightly when touched

Assess the peristomal skin for irritation each time the appliance is changed

Treat any irritation or skin breakdown immediately

Keep skin clean by washing off any excretion and drying thoroughly

Protect skin, collect stool, and control odor with an ostomy appliance

COMMON TESTS

Direct Visualization fiber optic endoscopic instruments introduced through

the mouth or rectum to inspect integrity of mucosa blood vessels, and organs.

UGI Endoscopy

Colonoscopyhttp://www.swarminteractive.com/patient_ed_animations.html

http://www.swarminteractive.com/patient_ed_animations.html

http://www.swarminteractive.com/patient_ed_animations.html

COMMON TESTS

Fecal specimens Ova and Parasites

Guaiac testing Hidden (occult) blood

Urinary Elimination

http://www.youtube.com/watch?v=chhNaLi9P3E

Urine Formationhttp://www.argosymedical.com/flash/urine_formation/landing.html

KIDNEYS

http://www.youtube.com/watch?v=chhNaLi9P3E

http://www.argosymedical.com/flash/urine_formation/landing.html

http://www.argosymedical.com/flash/urine_formation/landing.html

Micturition The process of emptying the bladder Contraction of detrusor muscle Increases pressure on bladder to produce urge

to urinate Pressure overcomes the internal sphincter Urine enters urethra Requires relaxation of external sphincter

consciously relaxed or contracted

Urinary Elimination

NORMAL MICTURITION MECHANISM AND RELATED BODY STRUCTURES

URINE FORMATION

Nephron Functional unit of the kidney Urine is formed here Glomerulus Tuft of capillaries surrounded by Bowman’s capsule Fluids and solutes move across endothelium of the

capillaries into the capsule Bowman’s Capsule Filtrate move from here into the tubule of the

nephron

Daily fluid intake Urine produced = fluid consumed Need 6 to 8 glasses per day of WATER

Activity External sphincter is part of pelvic floor muscle Tone needed to maintain voluntary control

Personal Habits Relaxation Distractions

Aids to Normal Urinary Elimination

Characteristics of normal urine:

Color Clarity Odor

STRUCTURES AND FUNCTIONS RELATED TO FLUID ELIMINATION

Oliguria Diminished, scanty amount <30cc

Anuria absence of urine

Polyuria >1500 cc/24 hours consider intake

Enuresis

ALTERED AMOUNT

Dysuria Painful urination:

Frequency

Hesitancy

Urgency

COMMON DISRUPTIONS IN URINARY ELIMINATION

Urinary Tract Infection (UTI) Can occur anywhere in the urinary tract

Cystitis Ureteritis Pyleonephritis More common in women than men



Urinary retention: Inability to pass

part of the urine in bladder

Common in older men with benign prostate Hyperplasia

Urinary obstructionUrolithiasis

- Stones calculi block or partially block kidney, Ureters, or bladder

- Obstruction from strictures, tumors, edema


Urinary Incontinence:

Failure of major smooth muscle strength of Detrusor muscle of the bladder, instability or obstruction. Incontinences divided into 4 types. Pt may have mixed pattern:

FORMS OF INCONTINENCE

Urge Incontinence Urgency following strong sense to void

Decreased bladder capacity Alcohol or caffeine ingestion infection

Stress Incontinence Small amts with laughing, sneezing, coughing

Urgency, frequency


Overflow Incontinence: Retention

Functional Incontinence: Intact urinary and nervous system

Change in environment Sensory, cognitive or mobility deficit

Void before reaching bathroom


Nursing ASSESSMENT of Urinary Incontinence: Confirm factors related to episodes Determine cognitive function and the ability of

patient to participate interventions Make observations during caregiving regarding

the amount and frequency of loss of urine and situations surrounding incontinent episodes

Assess abdominal and suprapubic palpation for tenderness and fullness

Determine hydration status and possibility of constipation

Ask specific questions regarding situations that lead to urine loss

LOSS OF URINARY CONTROL

ALTERED MEANS OF URINARY ELIMINATION

Catheters

urethral suprapubic condom

FOLEY CATHETER

FOLEY CATHETERS

FOLEY

http://www.youtube.com/watch?v=tynS0E4hBn0

http://www.youtube.com/watch?v=tynS0E4hBn0

CONDOM/TEXAS CATHETER

BEDSIDE DRAINAGE BAGS

SUPRAPUBIC CATHETER

ALTERED MEANS OF URINARY ELIMINATION

Urinary diversion - surgical creations

Ureterostomy - (transureterostomy)Bring Ureters to abdominal

surface

Uterosigmoidostomy Ilea conduit or loop

Implant ureter into ileum Form stoma Form pouch

Need occasional catheterization to empty

Kock pouch

ILEAL CONDUIT

A NEOBLADDER

NEPHROSTOMY TUBE

THE KOCK POUCH—A CONTINENT URINARY DIVERSION

COMMON TESTS

BUN http://video.google.com/videoplay?docid=7519331476907982001&q=urinary+system&total=83&start=0&n

um=10&so=0&type=search&plindex=0

Creatinine Clearance

Urinalysis

http://video.google.com/videoplay?docid=7519331476907982001&q=urinary+system&total=83&start=0&num=10&so=0&type=search&plindex=0

http://video.google.com/videoplay?docid=7519331476907982001&q=urinary+system&total=83&start=0&num=10&so=0&type=search&plindex=0

COMMON TESTS

Visualization procedures KUBAn X-ray showing the kidney, ureter, and bladder. This is in reality a plain

abdominal X-ray and includes other structures such as the diaphragm above and the pelvis below.

http://trismus1.files.wordpress.com/2007/04/eg-kub_2_1withpaint.jpg

Retrograde Pyleography

CT scan



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