37-2Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Physiology of Urinary Elimination
Urinary Elimination (voiding, urination)• The kidneys form the urine.• The ureters carry urine to the bladder.• The bladder acts as a reservoir for the urine.• The urethra is the passageway for the urine
to exit the body.
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Physiology of Urinary Elimination
Continence in the Adult • Anatomic integrity of the urinary system• Nervous control of the detrusor muscle• Competent sphincter mechanism
Urinary Incontinence• Uncontrolled loss of urine • Abnormalities of one or more factors
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Physiology of Urinary Elimination
Structures of the Upper Urinary Tract• Kidneys • Nephrons• Parenchyma• Hilus of kidney• Renal pelvis• Ureter
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Physiology of Urinary Elimination
Both the renal pelvis and ureters consist primarily of smooth muscle.
Peristalsis (muscular contraction) moves urine from the upper to the lower urinary tract.
Occurs during the prolonged phases of bladder filling and storage.
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Physiology of Urinary Elimination
Structures of the Lower Urinary Tract• Bladder• Detrusor (smooth muscle bundles in the
upper portion of the bladder)• Urethra (sphincter mechanism)• Pelvic muscles (slow-twitch fibers and fast-
twitch fibers)
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Physiology of Urinary Elimination
Nervous Control of the Detrusor Muscle• Central nervous system• Peripheral nervous system• Sympathetic nervous system• Parasympathetic nervous system• Micturition center
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Physiology of Urinary Elimination
Urethral Sphincter Mechanism• Urethral compression• Bladder filling• Urinary storage• Urethral tension• Supportive structures
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Physiology of Bowel Elimination
Continence • Consistency of the stool (fecal material)• Intestinal motility• Compliance and contractility of the rectum • Competence of the anal sphincters
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Physiology of Bowel Elimination
Structures of the Gastrointestinal Tract (alimentary canal) Related to Bowel Elimination• Small intestine• Ileocecal valve• Large bowel (colon)• Ileocecal sphincter• Anal sphincter
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Physiology of Bowel Elimination
Intestinal Motility and Rectal Accommodation• Rectal filling • Rectal contractions• Rectal accommodation• Postponement of defecation• Constipation
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Physiology of Bowel Elimination
Anal Sphincter Mechanism• Internal and external sphincters• Striated muscle fibers• Sensory receptors
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Factors Affecting Elimination
Age Diet Exercise Medications
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Common Alterations in Elimination
Urinary Elimination• Acute urinary incontinence• Chronic urinary incontinence
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Common Alterations in Elimination
Stress Urinary Incontinence (SUI)• Uncontrolled loss of urine caused by
physical exertion in the absence of a detrusor muscle contraction
• Associated with urethral hypermobility or intrinsic sphincter deficiency
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Common Alterations in Elimination
Urgency and Urge Urinary Incontinence (overactive bladder syndrome)• Involuntary leakage accompanied by urge to
void
Functional Urinary Incontinence• Altered mobility, manual dexterity• Ability to access toilet• Cognitive changes
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Common Alterations in Elimination
Extraurethral Incontinence• Uncontrolled loss of urine that exists when
the sphincter mechanism has been bypassed
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Common Alterations in Elimination
Urinary Retention• Bladder outlet obstruction• Deficient detrusor muscle
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Alterations in Bowel Elimination
Constipation Diarrhea Fecal Incontinence
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Bowel Retention
Constipation is infrequent and difficult passage of hardened stool.• Dietary factors, dehydration• Inadequate dietary bulk• Diverticular disease• Neuropathic conditions• Functional limitations
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Bowel Retention
Fecal Impaction• Bolus of hardened stool• Further slows colonic transit time and
passage of further fecal contents
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Bowel Retention
Perceived constipation is influenced by psychological and emotional stress.
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Alterations in Bowel Elimination
Diarrhea is the passage of liquefied stool with increased frequency and consistency.
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Alterations in Bowel Elimination
Primary Causes of Diarrhea• Malabsorption syndromes• Inflammatory bowel disease• Short bowel syndrome• Side effects of drugs• Laxative or enema misuse
Infectious diarrhea is caused by a pathogen.
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Alterations in Bowel Elimination
Bowel (fecal) Incontinence• Dysfunction of the anal sphincter• Disorders of the delivery of stool to the
rectum• disorders of rectal storage• Anatomic defects
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Assessment
Health History• Elimination habits• Type of incontinence• Complicating factors• Bladder and bowel management strategies
used by client
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Assessment
Physical Examination• Mental status• Mobility and dexterity• Inspection of perineum for skin integrity• Inspection of vaginal vault • Pelvic support• Perineal sensation• Perianal area, digital rectal exam
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Assessment
Diagnostic and Laboratory Data• Urinalysis• Stool culture• Defecography• Anorectal ultrasonography
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Nursing Diagnoses
Impaired Urinary Elimination Stress Urinary Incontinence Reflex Urinary Incontinence Urge Urinary Incontinence Functional Urinary Incontinence Urinary Retention
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Nursing Diagnoses
Constipation Perceived Constipation Diarrhea Bowel Incontinence
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Other Nursing Diagnoses
Low Self-Esteem Deficient Knowledge Risk for Infection Risk for Impaired Skin Integrity Toileting Self-Care Deficit
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Outcome Identification and Planning
Target outcomes center around restoring and maintaining regular elimination habits and preventing complications.
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Implementation
Maintain Elimination Health• Fluid intake• Diet• Lifestyle and Prevention
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Implementation
Lifestyle and Prevention• Alcohol and tobacco use• Stress management• Weight reduction• Elimination habits• Positioning
37-35Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.
Implementation
Lifestyle and Prevention• Initiate pelvic muscle exercise regimen• Bladder training for urge incontinence• Management of urinary retention• Management of functional urinary
incontinence• Suggest environmental modifications
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Implementation
Lifestyle and Prevention • Initiate behavioral intentions• Monitor skin integrity
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Implementation
Apply a Containment Device• Condom catheter• Incontinence and dribble pads• Rectal pouch and rectal tube
Initiate Diet and Fluid Therapy
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Implementation
Administer Medications• Over the Counter (OTC)• Prescription
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Implementation
Perform Catheterization Intermittent Catheterization
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Implementation
Administer Enemas• Cleanse the lower bowel• Assist in evacuation• Instill medication
Initiate Rectal Stimulation
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Implementation
Various types of enema equipment and solutions
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Implementation
Monitor Elimination Diversions• Urinary Diversions
- Ileal conduit- Continent urinary diversion
• Bowel Diversions- Ileostomy- Colostomy- Ileoanal reservoir
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Implementation
Surgical Management• Bladder suspension• Artificial urinary sphincter device• Implanted devices• Surgical reconstruction• Surgical closure of fistulae and ectopia• Endoscopy, other procedures to alleviate
obstruction or dyssynergia
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Implemenation
Complementary Therapies• Holistic approach to effective elimination of
waste products and toxins- Diuretics- Antimicrobials- Antiseptics- Stimulants and Cathartics
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