Chapter 39 Elimination Fundamentals of Nursing: Standards & Practices, 2E.
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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
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
ABDOMINAL QUADRANTS AND ORGANS
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
ALTERED MEANS OF BOWEL ELIMINATION
Ileostomy
ALTERED MEANS OF BOWEL ELIMINATION
StomaForm- ation
ALTERED MEANS OF BOWEL ELIMINATION
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
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
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
COMMON DISRUPTIONS IN URINARY ELIMINATION
COMMON DISRUPTIONS IN URINARY ELIMINATION
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
COMMON DISRUPTIONS IN URINARY ELIMINATION
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
FORMS OF INCONTINENCE
Overflow Incontinence: Retention
Functional Incontinence: Intact urinary and nervous system
Change in environment Sensory, cognitive or mobility deficit
Void before reaching bathroom
FORMS OF INCONTINENCE
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
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
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