Elimination
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Elimination

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Elimination Elimination Presentation Transcript

  • Elimination
  • Basic Principles
    • Wash Hands & Wear Gloves
      • Infection control, your protection & your client’s protection
    • Privacy
      • Embarrassing
    • Positions for urination
      • Independence
  • Functions of Urinary System
    • Remove wastes from blood to form urine
    • Remove nitrogenous waste products of cellular metabolism
    • Regulates fluid and electrolyte balance
    • The nephron = functional unit of the kidney and forms the urine
  • Goal of Urinary System
    • To maintain chemical homeostasis of the blood.
      • Filtration by the Nephrons
        • H2O, glucose, amino acids, urea, creatinine, major electrolytes
        • Not normally large proteins or blood cells
          • Proteinuria is a sign of glomerular injury
    • Normal adult 24hr output = 1500-1600ml.
  • Overview of Urinary System
    • Kidneys
      • Bean shaped organs
      • Either side of vertebral columns T12 – L3
      • Right kidney lower due to liver
      • Urine produced with filtration of blood through nephrons
      • Major role in fluid & electrolyte balance
    • Ureters
      • Connect kidneys to bladder
      • 10 -12 in length, ½ in diameter in adult
      • Peristaltic waves
        • Renal colic
    • Micturition
    • Bladder
      • Distensible, muscular sac
      • Reservoir for urine ( approx. capacity = 600mls )
      • Organ of excretion ( norm. voiding= 300mls)
      • Lies in pelvic cavity behind symphysis pubis
    • Urethra
      • Short, muscular tube
      • Urine from bladder to meatus and from the body
      • Female 4-6.5cm (1 ½ - 2 ½ in.) length
      • Male 20cms ( 8 in.)
        • Urinary and reproductive systems
    • Meatus
      • External opening of the urethra, male & female
    • The need to void is a conscious awareness
  • Life Cycle Changes
    • Infants & children
      • Unable to concentrate urine b/c kidneys are immature
      • Urine is light yellow
      • Void frequently
      • Voluntary control @ 24mos. when neuromuscular structures develop
    • Adult
      • 1500 – 1600 mls urine/24hrs
      • Concentrates urine – normal is amber colored
      • Nocturia
        • Not usually
        • Decreased renal blood flow during rest
        • Ability to concentrate urine
    • Elderly
      • Micturition impaired
      • mobility
      • Diseases, alzheimer’s, CVA
      • Physiological age related changes
        • Bladder loses muscle tone and capacity
        • Kidneys lose ability to concentrate urine
        • Bladder loses muscle strength
  • Common Problems
    • Urinary Retention
      • Accumulation of urine in the bladder
      • Inability to empty
      • Pressure, discomfort and tenderness
    • Residual Urine = urine retained in the bladder after voiding
    • Incontinence
      • Loss of voluntary control to void
        • Infection, nerve damage to bladder or brain, spinal cord injury, or aging process
        • Total incontinence = no control
        • Stress incontinence = sm. amts. Urine excreted involuntarily with coughing or laughing
    • At risk for skin breakdown related to acid urine next to skin.
    • Adult Diapers or Attends
    • Frequency & Urgency
    • Nocturia
    • Enuresis – involuntary discharge of urine
    • Nocturnal Enuresis
      • During sleep
      • Bed-wetting children 5yrs and older
    • Oliguria
      • 30mls/hr or 720 mls/24hrs
    • Renal anuria
      • cessation of urine production 100mls/24h
  • Promoting Healthy Urinary Elimination
    • Urinate as soon as the urge is felt
      • Avoids stasis and distention
      • Prevents urgency, infection, and incontinence
    • Drink about 2liters fluid/day
    • Limit Na, caffeine, and alcohol
    • For people with Nocturia
      • fld. Intake in the p.m.
      • caffiene and alcohol
      • Void before bedtime
    • For Women
      • Wipe perineum front to back
      • Void soon after intercourse
      • Wash hands
      • Pelvic – floor strengthening exercises (Kegel Exercises)
  • Client Education
    • S & S of infection
    • Fluid intake ( if no restrictions 2-5 L/day )
    • Perineal hygiene
    • Meds. & side effects on urination, color, and volume
  • Facilitating Micturition
    • Nursing Measures to promote voiding in people who are having difficulty:
      • Privacy and natural position
      • Providing commode or bathroom
      • Running water
      • Warm water to dangle fingers
      • Warm water over perineum ( measure if on In/Out )
    • Gently stroking inner thighs or pressure to symphysis pubis
    • Pain relief
    • Warmth to the bladder & perineum relaxes muscles & facilitates voiding. ( Sitz bath or warm tub )
    • If unsuccessful- urinary catheterization may be indicated
    • Promoting complete bladder emptying
    • Prevention of infection
      • Good perineal hygiene
      • Adequate fld. Intake
        • Dilutes urine & flushes urethra
      • Acidifying urine ( inhibits microorganisms)
        • Cranberry juice, whole grain breads, meats, eggs, prunes and plums.
  • Indwelling Catheter Care
    • Goal - prevent infection & maintain unobstructed flow of urine. Monitor for problems.
    • Perineal hygiene @ least 2x/day and prn
    • Do not advance catheter further into urethra during perineal care
  • Catheter Care
    • Fld intake (3L/day )
    • Handwashing and Gloves
    • Positioning
      • Urine bag
      • Tubing
  • Bowel Elimination
    • Function - excrete/eliminate waste products of digestion.
    • Maintaining normal bowel elimination is essential to health and efficient body functions.
  • GI System
    • Small Intestine
      • Absorption nutrients & electrolytes
      • 20 ft length, 1 in. diameter
      • 3 sections
        • Duodenum
        • Jejunum
        • Ileum
  • GI
    • Large Intestine
      • Absorbs H2O and electrolytes
      • Temporarily stores waste products
      • Main function is elimination
      • 5 – 6 ft. length, 6 – 7 cm. diameter
        • Cecum
        • Ascending colon ( Right side )
        • Transverse colon
        • Descending colon
  • Patterns through life cycle
    • Babies: 3 – 6 BM’s/day
    • Children:
      • Neuromuscular structures not developed until 15 – 18 mos.
      • Voluntary control 2 – 3 yrs.
    • Pregnant women prone to constipation
      • Pressure on abd. Organs
      • Iron supplements
    • Elderly prone to constipation
      • Slowing of peristalsis
  • Determinants affecting elimination
    • Dietary patterns & fld. Intake
      • 6 – 8 glasses H2O/day ( 1400- 2000mls )
        • fld. Liquifies stool
        • Dietary fiber stimulates peristalsis
        • Soft stool
  • Factors affecting elimination
    • Fiber ( undigestible residue ) provides bulk
      • Absorbs fluid
      • Increases stool mass
      • Bowel wall stretches
      • Peristalsis stimulated
      • Defecation results
  • Factors affecting elimination
    • Personal habits
      • Busy schedule, postpone BM, constipation
    • Activity & exercise
      • Immobile activity in colon
    • Medications
      • Laxatives
      • Narcotics with codiene
  • Factors affecting elimination
    • Emotions
      • Anxiety peristalsis & diarrhea
      • Depression
    • Pain
    • Surgery
      • Anaesthetic causes temporary cessation of peristalsis
      • Direct manipulation of the bowel stops peristalsis
  • Common Problems
    • Constipation – difficult passage of hard, dry stool; infrequent movements
    • Fecal Impaction – unrelieved constipation, feces wedged in rectum, no BM usually 3days, oozing of diarrheal stool develops
    • Diarrhea- # liquid stool
    • Flatulence – abd. Distention & pain
  • Common Problems
    • Incontinence – inability to control passage of stool
    • Hemorrhoids
      • Dilated engorged veins
      • Increased pressure when straining
      • Internal / external
      • Bleeding
    • Daily BM Not essential.
    •  2 / week a concern
    • Defecation pattern
    • BM, Stool, Feces, Defecate – all mean waste products expelled via the bowel
  • Promoting Healthy Bowel Elimination
    • Privacy
    • Squatting position
    • Bedpan position
    • Cathartics & laxatives
    • Anti- diarrheal agents
    • Enemas
    • disimpaction
    • Bowel routine
      • Daily time clock
      • Hot drinks
      • Stool softeners
      • Privavy
      • Position and abdominal pressure
      • Bearing down
  • Assissting with Elimination
    • Embarrassing & stressful
      • Usually urge to defecate 1hr. Pc
    • Bedpans
      • Metal or plastic
      • Regular or fracture pan
      • Cleanliness
    • Urinals
    • Commode
  • Procedure
    • Privacy- close door,
    • Side rail as needed
    • Recumbent with HOB
    • Tissue
    • Call bell
    • Leave alone if possible
    • Gloves
    • Clean genitals
  • Procedure
    • Remove pan and cover
    • In & Out
    • Specimens
    • Clean pan
    • Wash hands yours and client’s
    • Lower bed
    • Client comfort
  • Peri - Care
    • Cleaning of genitals , routine part of complete/ partial bed bath
    • Incontinence
  • Procedure for Peri Care
    • Regular patient
      • Simple explanation- layman’s terms
      • Privacy
      • Gloves
      • Dorsal recumbent position
      • Incontinent pad under buttocks
      • Warm soap and water
      • Female – separate labia
  • Procedure for Peri Care
    • Male – begin penile head move down along shaft, retract foreskin, rinse and dry.
  • Procedure for Peri Care
    • Catheter –
      • Q 8 hrs.
      • Clean perineum & 2in. Of catheter
        • No powders / lotions
        • Avoid advancing catheter
        • Keep urine drainage bag off floor but below level of bladder
        • Empty bag Q8 – 12hrs or when bag is full, remember to mark amt. Emptied on In/Out sheet
    • Avoid use of baby powder/ cornstarch
      • No medicinal purpose
      • Can form clumps or will cake in creases
      • Use vaseline/ zincoxide as skin barrier for incontinent clients
  • Suppository Administration
    • Check physician’s order, protocol
    • Left Lateral position
    • Gloves
    • Lubication
    • Hold with thumb and index finger
    • Insert with index finger (3 – 4”) never force
    • Deep breath = relaxes anal sphincter
    • Caution
      • Vagus nerve stimulation can cause heart rate to slow – avoid excess manipulation
  • Enema Administration
    • Main purpose
      • Promotion of defecation, stimulate peristalsis
      • The fluid breaks up fecal mass, stretches the rectal wall & initiates the defecation reflex
  • Types of Enemas
  • Cleansing Enemas
    • Tap Water
      • Hypotonic
      • Used only once
      • Electrolyte imbalance
        • Water toxicity
        • Circulatory overload ( concentration gradient)
    • Normal Saline
      • Used when more than one enema is needed
      • Safest
      • Isotonic
      • Large volume to distend bowel
    • Hypertonic Solution
      • Smaller volume of fluid
      • Draws from surrounding tissue into bowel to soften stool and stimulate peristalsis
      • Fleets – sodium phosphate
        • Low volume, concentrated solution
    • Soap suds
      • Less common
      • Soap irritates the bowel
      • 5 – 15 mls. Castile soap in 1000mls warm water
    • Oil Retention
      • Oil based solution
      • Lubricates the rectum and colon
      • Softens stool, easier to pass
      • Retain 1 –2 hrs if possible
      • Follow with cleansing enema
    • Medicated
      • Instill meds.
      • Rectal mucosa absorption
      • Ex. – Kayexalate to K (potassium). Absorbs K from the intestinal tract
  • Volumes for Enemas
    • Large Volume
      • 500 – 1000mls.
      • Container 12 – 18 in. above the bowel
      • Lg. Volume stimulates & causes evacuation of stool
    • Small Volume
      • 500 mls.
      • Container 12 in.above bowel
  • Volumes for Enemas
    • Pre packaged
      • Fleet 150mls
      • Microlax 5mls
      • Hypertonic solution
      • User friendly
      • Hold for 5min.
    • Oral Fleet
    • Prepackaged used more than large volume because:
      • Works
      • Less risk for electrolyte imbalance
      • Rapid administration
      • Less discomfort and distention
      • Convenient and quick
    • Physician’s order reads “ enemas to clear”
      • No more than 3 total given
      • Return solution will be highly colored but no solid stool
      • Isotonic solution (normal saline)
    • Excess enema use seriously depletes fluid and electrolytes
  • Procedure for Enema Administration
    • Confirm Dr’s order, prepare client, verbal consent, equipment, privacy
      • Left lateral position ( fld. Flows by gravity)
      • Drape, pad under buttocks
      • Warm solution- stimulates peristalsis
        • Hot sol’n burns mucosa
        • Cold sol’n causes cramping
  • Procedure for Enema Administration
    • Prime tube
    • Lubricate tip
    • Glove
    • Insert 7 – 10 cm.(3-4in) adult
      • Do not force
      • Deep breath
      • Guide toward umbilicus
  • Procedure for Enema Administration
    • Container at appropriate height
      • Lg. = 12 – 18in
      • Sm. = 12in
      • 1000mls takes ~ 10 min to instill
      • Higher the bag – greater the pressure
        • C/O discomfort, lower bag, slow infusion, stop, then start again
      • Remain side lying to retain 5 – 10 min. or as long as possible
  • Procedure for Enema Administration
    • Assist to bathroom or give bedpan
    • Evaluate results
    • Document
      • Type & volume of enema
      • Color, amount, consistency of fecal return
      • Hygienic measures for client
    • Wash Hands
  • Ostomy Care
    • Certain diseases require surgical interventions to create an opening into the abdominal wall for fecal and urinary elimination
    • Enterostomy – the surgical procedure performed to produce the artificial stoma.
  • Definitions
    • Ostomy = opening made to allow passage of urine or stool
      • Piece of intestine is brought out onto the client’s abd.
      • Lacks nerve endings
      • Doesn’t hurt to touch but has other implications
    • Stoma = mouth like opening in the abdominal wall to drain urine or stool
    • Effluent – drainage from stoma
    • Bowel ostomies
      • Cancer ( Ca)
      • Drain fecal material
      • Consistency depends on location
        • Higher up = more liquid
        • Greater risk skin irritation b/c concentration of digestive enzymes
    • Ileostomy
      • End of small intestine
      • By passes lg. Intestine = freq. Liquid stools
    • Colostomy
      • Large intestine
      • More solid stool
    • Ostomies may be permanent
      • More common
    • temporary
      • Rest the bowel
      • Crohn’s
  • Urinary Ostomies
    • Provide drainage of urine that bypasses the bladder = Urinary Diversion
    • Ureterostomy
      • Ureter to abd. Wall
      • Lt., Rt., Bilateral
  • Ileal Conduit
    • 6 – 8 in. ileum
    • 1 end for external opening
    • Other end closed off
    • Ureters implanted into this piece of bowel
    • Pouch
    • Urine will have shred of mucus b/c bowel still produces same
  • Concerns
    • Infection
      • Sterile ureters provide opening into system
    • Skin Breakdown
      • Continuous drainage
      • Moisture on skin
    • Replace urinary pouch q 2-3 days
  • Pouching an Enterostomy
    • Effluent ( drainage ) may begin immediately
    • Collects all effluent
    • Protects the skin
    • Stoma should be moist and reddish pink (same as other mucus membranes)
    • Flush to skin or bud-like protrusion
    • Black, purple, dry = inadequate circulation
  • Pouch with Skin Barrier
    • Comfortable fit
    • Cover skin surrounding stoma
    • Good seal
    • Post-op pouch should allow for visibility of stoma
  • Types of pouches and skin barriers
    • One Piece Pouching System
      • Skin barriers preattached, precut, custom fit
    • Two Piece System
      • Skin barrier with flange ( plastic ring)
      • Corresponding size pouch
    • Assess stoma
      • Measure correct size
      • Change q 3-7 days
      • Empty 1/3 to ½ full, expel flatus prn
  • Steps to Care for Ostomies
    • Supine position
    • Wash hands, glove
    • Remove pouch & skin barrier, push skin away from barrier
    • Cleanse peristomal skin gently with warm tap water and clean cloth
      • Do not scrub, Avoid soap ( residue- pouch won’t adher)
  • Steps to Care for Ostomies
    • Correct sizing
    • Cut opening 1/16 – 1/8 larger than stoma
    • Remove backing
    • Ileostomy- apply thin circle barrier paste around opening of pouch and allow to dry (if creases or bumps use barrier paste to even surface for pouch application)
  • Steps to Care for Ostomies
    • Pouch should point to client’s knees
    • Maintain gentle finger pressure around barrier for 1-2 min.
    • Picture frame flange with non allergic paper tape
    • Ostomy deodorant for pouch
    • Tub bath or shower
  • Steps to Care for Ostomies
    • Normal stoma oozes blood if rubbed
    • Actual bleeding into pouch is abnormal
    • Pouch covers are available
    • The client will be watching the nurse during ostomy care to gage reaction.
    • Be conscious of facial expression & nonverbal cues
  • Steps to Care for Ostomies
    • Education
    • Counseling
      • Body image
      • Self care
      • Fear of rejection
      • Sexual function
      • Powerlessness over bowel regulation