NurseReview.Org - Elimination Nursing Lecture

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

Personal habits
Busy schedule, postpone BM, constipation
Activity & exercise
Immobile activity in colon
Medications
Laxatives
Narcotics with codiene

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

Male – begin penile head move down along shaft, retract foreskin, rinse and dry.

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

Prime tube
Lubricate tip
Glove
Insert 7 – 10 cm.(3-4in) adult
Do not force
Deep breath
Guide toward umbilicus

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

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)

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)

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

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

Education
Counseling
Body image
Self care
Fear of rejection
Sexual function
Powerlessness over bowel regulation

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NurseReview.Org - Elimination Nursing Lecture

by Nurse ReviewDotOrg on Apr 15, 2008

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