“international health organizations and nursing organizations”

1. Concept of Elimination
Ms. SHAHINA BANO
Objectives
At the end of this unit, learners will be able to:
1. Define elimination pattern
2. Discuss common problems of elimination.
3. Identify nursing interventions for common problems of fecal elimination.
4. Discuss common problem of Urinary Elimination
5. Identify nursing intervention for common urinary problems
6. Describe factors that can alter urinary function
Discuss nursing process for a patient with altered elimination
Elimination
• The process of expelling or removing, especially of waste products from the body
Elimination patterns
• Elimination patterns describe the regulation, control, and removal of by-products and wastes in the body.
• The term usually refers to the movement of feces or urine from the body.
Main Focus of Elimination

2. Urinary Elimination
Urinary Elimination
Urinary elimination depends on the effective functioning of :
 The upper urinary tract’s kidneys and ureters
 The lower urinary tract’s urinary bladder, urethra, and pelvic floor

3. Urination
• The act of urinating—also called micturition
• Micturition, voiding, and urination all refer to the process of emptying the urinary bladder.
• This occurs when the adult bladder contains between 250 and 450 mL of urine.
• In children, a considerably smaller volume, 50 to 200 mL, stimulates these nerves
ALTERED URINE PRODUCTION
a) Polyuria (or diuresis) :
• Refers to the production of abnormally large amounts of urine
• Polyuria can follow excessive fluid intake, a condition known as Polydipsia, or may be associated with
diseases such as diabetes mellitus, diabetes insipidus, and chronic nephritis.
• Polyuria can cause excessive fluid loss, leading to intense thirst, dehydration, and weight loss.
b) Oliguria
 The terms oliguria are used to describe decreased urinary output.
 Oliguria is low urine output, usually less than 500 mL a day or 30 mL an hour for an adult.
c) Anuria
 Anuria refers to a lack of urine production
d)Urinary frequency
• Urinary frequency is voiding at frequent intervals, that is, more than four to six times per day.
• An increased intake of fluid causes some increase in the frequency of voiding.

4. – Conditions such as UTI, stress, and pregnancy can cause frequent voiding of small quantities (50
to 100 mL) of urine.
• Total fluid intake and output may be normal.
E)Nocturia
 Nocturia is voiding two or more times at night.
 Like frequency, it is usually expressed in terms of the number of times the person gets out of bed to void.
 For example, “nocturia × 4.
F)Urgency
 Urgency is the sudden, strong desire to void.
 There may or may not be a great deal of urine in the bladder, but the person feels a need to void
immediately.
g) Dysuria
• Dysuria means voiding that is either painful or difficult.
• Often clients will say they have to push to void or that burning accompanies or follows voiding.
• The burning may be described as severe, like a hot poker, or, like a sunburn.
h) Enuresis
• Enuresis is involuntary urination in children beyond the age when voluntary bladder control is normally
acquired, usually 4 or 5 years of age.
I)Urinary Incontinence
 Urinary incontinence (UI), or involuntary leakage of urine or loss of bladder control.
 It is a health symptom, not a disease.
Types of Urinary incontinence
The four main types of Urinary incontinence are:
1. Stress urinary incontinence
2. Urge urinary incontinence
3. Mixed urinary incontinence
4. Overflow incontinence
1)Stress Urinary Incontinence (SUI)
 Stress urinary incontinence (SUI) occurs because of weak pelvic floor muscles causing urine leakage with
such activities :

5. --laughing, coughing, sneezing, or any body movement that puts pressure on the bladder.
 SUI is not related to emotional stress but is “caused by increased pressure or ‘stress’ on the bladder as
well as anatomical changes to the urethra, and pelvic floor muscle weakness”
2. Urge Urinary Incontinence
• This type of incontinence is described as an urgent need to void and the inability to stop micturition
(passage of urine).
• The urine leakage can range from a few drops to soaking of undergarments.
• Urge incontinence is a major symptom of an overactive bladder
3) Mixed Urinary Incontinence
• Mixed incontinence is diagnosed when symptoms of both stress UI and urgency UI are present.
• It is very common among middle-age and older women
4) Overflow Incontinence
• This is “continuous involuntary leakage or dribbling of urine that occurs with incomplete bladder
emptying”.
• It can be seen in men with an enlarged prostate and clients with a neurologic disorder.
• An impaired neurologic function can interfere with the normal mechanisms of urine elimination, resulting
in a neurogenic bladder.
• The client with a neurogenic bladder does not perceive bladder fullness and is therefore unable to control
the urinary sphincters.
J) Urinary Retention
• When emptying of the bladder is impaired, urine accumulates and the bladder becomes overdistended, a
condition known as urinary retention.
• Common causes of urinary retention include prostatic hypertrophy (enlargement), surgery, and some
medications.
•
• Clients with urinary retention may experience overflow incontinence, eliminating 25 to 50 mL of urine at
frequent intervals.
• The bladder is firm and distended on palpation and may be displaced to one side of the midline
Factors Influencing Urinary Elimination

6. • Growth & Development
• Infants and children: Infants are born without urinary control.
Most will develop this between the ages of 2 and 5 years.
• After 50yrs: The excretory function of the kidney diminishes with age.
• Elderly adults: increased frequency because of , loss of muscle tone.
• Pregnancy
Psychosocial Factors
Privacy , Sufficient time, Appropriate position , Anxiety, stress
Fluid and Food Intake
• Increase fluid intake
• Caffeine increases urinary frequency
• alcohol, increase fluid output
• Fluids high in sodium can cause fluid retention
Medications
• Diuretics increase urine formation by preventing the reabsorption of water and electrolytes from the
tubules of the kidney into the bloodstream
• Certain drugs changes color of urine
Muscle tone
Regular exercise lead to strong muscle contraction and control of the external sphincter
Pathological Conditions
• Renal failure
• Diabetes Mellitus
• Urinary stone (calculus)
• Hypertrophy of the prostate gland
Nursing Assessment
• A complete assessment of a client’s urinary function includes the following:
 Nursing history

7.  Physical assessment of the genitourinary system, hydration status, and examination of
the urine
 Relating the data obtained to the results of any diagnostic tests and procedures
Subjective data
• Nursing History
– Normal voiding pattern and frequency, appearance of the urine and any recent changes
– Past or current problems with urination, the presence of an ostomy
• Assessment Interview
Voiding Pattern
 How many times do you urinate during a 24-hour period?
 Has this pattern changed recently?
 Do you need to get out of bed to void at night? How often?
Description of Urine And Any Changes
 How would you describe your urine in terms of color, clarity (clear, transparent, or cloudy), and odor
(faint or strong)?
Objective data
• Physical Assessment
– Palpation and percussion of the bladder ,percussion of kidney to detect tenderness.

8. – Inspection of urethral meatus of both male and female for swelling, discharge, and
inflammation.
Measuring Urinary Output:
• Normally, the kidneys produce urine at a rate of approximately 60 mL/h or about 1,500 mL/day
• Urine outputs below 30 mL/h may indicate low blood volume or kidney malfunction and must be reported
• Intake and output chart
• Ultrasound
Diagnostic Tests
• Urine D/R
• Urine culture
• 24 hours urine specimen
• Urea and creatinine
• Blood urea nitrogen (BUN).
NURSING DIAGNOSIS
• NANDA International includes two general diagnostic labels for urinary elimination:
 Impaired Urinary Elimination: dysfunction in urine elimination
 Readiness for Enhanced Urinary Elimination: a pattern of urinary functions for meeting
eliminatory needs, which can be strengthened.
• The more specific NANDA International nursing diagnoses related to urinary elimination include the
following:
 Functional Urinary Incontinence
 Overflow Urinary Incontinence
 Stress Urinary Incontinence
 Urge Urinary Incontinence
 Risk for Urge Urinary Incontinence
 Urinary Retention
 Risk for Infection
 Risk for Impaired Skin Integrity
 Risk for Deficient Fluid Volume or Excess Fluid Volume
Implementation
Maintaining Normal Urinary Elimination

9. • Promoting adequate fluid intake
• Maintaining normal voiding habits
• Assisting with toileting
Promoting Fluid Intake
• Increasing fluid intake increases urine production
• A normal daily intake averaging 1,500 mL for most adult clients.
• Clients who are at risk for UTI or urinary calculi (stones) should consume 2,000 to 3,000 mL of fluid daily.
• Dilute urine and frequent urination reduce the risk of UTI as well as stone formation.
Increased fluid intake may be contraindicated for some clients such as people with kidney failure or heart failure.
Managing Urinary Incontinence
• Continence training
• Pelvic muscle exercises
• Positive reinforcement
• Maintaining skin integrity
Urinary Incontinence:
• Assess the pattern of incontinence
• Schedule voiding every 1-2 hrs. and increase upto 3-4 hrs.
• Maintain fluid intake
• Decrease fluid intake before bedtime
• Provide perineal care after incontinence
• Use cotton undergarments
Urinary Retention:
• Encourage for adequate fluid intake
• Give sufficient time to void
• Provide appropriate position and privacy
• Pour warm water over the perineum
Intervention For Common Urinary Problems

10. • Respond as soon as possible to the urge to void
• Drink 8 to 10 glasses of water a day
• After urination, must wipe the area
• Maintain perineal-genital cleanliness
• Avoid foods and fluids that contain excessive sodium which can lead to fluid retention
• Empty the bladder completely at each voiding
• Obtain medical assistance if burning accompanies voiding or if the urine changes color, clarity, odor or
amount
Urine Dipstick
• A urine dipstick test is the quickest way to test urine.

11. • It involves dipping a specially treated paper strip into a sample of your urine.
• The results are usually available within 60-120 second

12. Fecal Elimination

13. Fecal Elimination
• Elimination of the waste products of digestion from the body is essential to health.
• The excreted waste products are referred to as feces or stool.
Defecation
• Defecation is the expulsion of feces from the anus and rectum.
• It is also called a bowel movement.
Fecal Elimination Problems
• Four common problems are related to fecal elimination:
• Constipation
• Diarrhea
• Bowel Incontinence
• Flatulence
Constipation
• Constipation may be defined as fewer than three bowel movements per week.
• This infers the passage of dry, hard stool or the passage of no stool.
• It occurs when the movement of feces through the large intestine is slow, thus allowing time for
additional reabsorption of fluid from the large intestine.
Fecal Impaction
• Fecal impaction is a mass or collection of hardened feces in the folds of the rectum.
• Impaction results from prolonged retention and accumulation of fecal material.
In severe impactions the feces accumulate and extend well up into the sigmoid colon and beyond

14. Digital evacuation or Surgery is required to remove the mass
Nursing Interventions for Constipation
• Increase daily fluid intake
• Instruct the client to drink hot liquids, warm water with a squirt of fresh lemon, and fruit juices, especially
prune juice.
• Include fiber in the diet, that is, foods such as raw fruit, bran products, and whole-grain cereals and bread.
• Relaxation
• Privacy
• Posture
• Exercise
Diarrhea
• Diarrhea refers to the passage of liquid feces and an increased frequency of defecation.
• It is the opposite of constipation and results from rapid movement of fecal contents through the large
intestine
Nursing Interventions For Diarrhea
• Drink at least 8 glasses of water per day to prevent dehydration
• Avoid alcohol, beverages with caffeine, and excessive cold fluid which aggravates the problem
• Ingest foods with sodium and potassium
• Limit foods containing insoluble fiber
• Limit fatty foods e.g. dairy food and packaged processed meat
• Use soft toilet tissue or cotton balls if the perennial area is irritated
• Discontinue medication or food that cause diarrhea
Nursing Interventions For Diarrhea
• Encourage oral intake (ORS)of fluids and bland food.
• Eating small amounts can be helpful because small amounts are more easily absorbed.
• Eat foods with sodium and potassium. Most foods contain sodium.
• Limit foods containing insoluble fiber, such as high-fiber whole-wheat and whole-grain breads and cereals,
and raw fruits and vegetables.

15. • clean and dry the perianal area after passing stool to prevent skin irritation and breakdown.
• Avoid spicy foods
• Give medication as per doctor’s orders (antispasmodic and antidiarrheal )
Bowel Incontinence
• Bowel incontinence, also called fecal incontinence, refers to the loss of voluntary ability to control fecal
and gaseous discharges through the anal sphincter
• Types:
• Partial incontinence
• Inability to control flatus or to prevent minor soiling
• Major incontinence
• Inability to control feces of normal consistency
• Causes
• Impaired functioning of the anal sphincter
• Neuromuscular disease
• Tumors of the external and internal sphincter muscle
• Note: Fecal incontinence is an emotional distressing problem leading to social isolation
• Treatment:
• Several surgical procedures are used e.g. repair of the sphincter, fecal diversion or colostomy.
Flatulence
Flatulence is the presence of excessive flatus in the intestines and leads to stretching and inflation of the intestines
(intestinal distention).
Flatus is the accumulation of gas in the GI tract.
Prevention For Flatulence
• Limit carbonated beverages, the use of drinking straws, and chewing gum—all of which increase the
ingestion of air.
• Avoid Gas-forming foods, such as cabbage, beans, onions, and cauliflower.
Nursing Interventions for common Problems
Promoting Regular Defecation

16. The nurse can help clients achieve regular defecation by attending to
(a) the provision of privacy
(b) timing
(c) nutrition and fluids
(d) Exercise
(e) positioning.
Administering Prescribed Medications
• Laxatives
• Suppositories
• Administering Enemas
• Antidiarrheal
• Antiflatulents.
Nursing Interventions for common Problems
Digital Removal of a Fecal Impaction
Digital removal involves breaking up the fecal mass digitally and removing it in portions.
Bowel Training Programs
• For clients who have chronic constipation, frequent impactions, or fecal incontinence, bowel training
programs may be helpful
• The program is based on factors within the client’s control and is designed to help the client establish
normal defecation.
• Such matters as food and fluid intake, exercise, and defecation habits are all considered.
References
• Berman, A., Frandsen, G., Snyder, S., Kozier, B., & Erb, G. L. (2016). Kozier and Erb's fundamentals of
nursing, volumes 1-3 (10th ed.).
Delaune, S. C. (2010). Fundamentals of nursing (4th ed.). Delmar Pub