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  • good ppt. can I get a copy at kujurmamta@yahoo.co.in
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  • helpful website that help others. This website has practice exams for various nursing classes as well as videos, presentations, notes, nclex help, and many other tools . Hope they help


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  • Characteristics of Normal Stool

    1. Color – varies from light to dark brown foods & medications may affect color
    2. Odor – aromatic, affected by ingested food and person’s bacterial flora
    3. Consistency – formed, soft, semi-solid; moist
    4. Frequency – varies with diet (about 100 to 400 g/day)
    5. Constituents – small amount of undigested roughage, sloughed dead bacteria and epithelial cells, fat, protein, dried constituents of digestive juices (bile pigments); inorganic matter (calcium, phosphates)

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    NurseReview.Org - Elimination Nursing Lecture NurseReview.Org - Elimination Nursing Lecture 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