Elimination needs of the patient

1. Elimination

2. Basic Principles
 Wash Hands & Wear Gloves
 Infection control, your protection & your
client’s protection
 Privacy
 Embarrassing
 Positions for urination
 Independence

3. 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

4. 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.

5. 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

6.  Ureters
 Connect kidneys to bladder
 10 -12 in length, ½ in diameter in adult
 Peristaltic waves
 Renal colic
 Micturition

7.  Bladder
 Distensible, muscular sac
 Reservoir for urine ( approx. capacity =
600mls )
 Organ of excretion ( norm. voiding= 300mls)
 Lies in pelvic cavity behind symphysis pubis

8.  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

9.  Meatus
 External opening of the urethra, male &
female
 The need to void is a conscious
awareness

10. 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

11.  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

12.  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

13. 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

14.  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

15.  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

16.  Renal anuria
 cessation of urine production 100mls/24h

17. 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

18.  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)

19. 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

20. Facilitating Micturition
 Nursing Measures to promote voiding in
people who are having difficulty:
1. Privacy and natural position
2. Providing commode or bathroom
3. Running water
4. Warm water to dangle fingers
5. Warm water over perineum ( measure if on
In/Out )

21. 6. Gently stroking inner thighs or pressure
to symphysis pubis
7. Pain relief
Warmth to the bladder & perineum relaxes
muscles & facilitates voiding. ( Sitz bath
or warm tub )
If unsuccessful- urinary catheterization
may be indicated

22.  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.

23. 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

24. Catheter Care
 Fld intake (3L/day )
 Handwashing and Gloves
 Positioning
 Urine bag
 Tubing

25. Bowel Elimination
 Function- excrete/eliminate waste
products of digestion.
 Maintaining normal bowel elimination is
essential to health and efficient body
functions.

26. GI System
 Small Intestine
 Absorption nutrients & electrolytes
 20 ft length, 1 in. diameter
 3 sections
 Duodenum
 Jejunum
 Ileum

27. 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

28. 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

29.  Elderly prone to constipation
 Slowing of peristalsis

30. Determinants affecting
elimination
 Dietary patterns & fld. Intake
 6 – 8 glasses H2O/day ( 1400- 2000mls )
 fld. Liquifies stool
 Dietary fiber stimulates peristalsis
 Soft stool

31. Factors affecting
elimination
 Fiber ( undigestible residue ) provides
bulk
 Absorbs fluid
 Increases stool mass
 Bowel wall stretches
 Peristalsis stimulated
 Defecation results

32. Factors affecting
elimination
 Personal habits
 Busy schedule, postpone BM, constipation
 Activity & exercise
 Immobile activity in colon
 Medications
 Laxatives
 Narcotics with codiene

33. Factors affecting
elimination
 Emotions
 Anxiety peristalsis & diarrhea
 Depression
 Pain
 Surgery
 Anaesthetic causes temporary cessation of
peristalsis
 Direct manipulation of the bowel stops
peristalsis

34. Common Problems
1. Constipation – difficult passage of hard,
dry stool; infrequent movements
2. Fecal Impaction – unrelieved
constipation, feces wedged in rectum,
no BM usually 3days, oozing of
diarrheal stool develops
3. Diarrhea- # liquid stool
4. Flatulence – abd. Distention & pain

35. Common Problems
 Incontinence – inability to control
passage of stool
 Hemorrhoids
 Dilated engorged veins
 Increased pressure when straining
 Internal / external
 Bleeding

36.  Daily BM Not essential.
  2 / week a concern
 Defecation pattern
 BM, Stool, Feces, Defecate – all mean
waste products expelled via the bowel

37. Promoting Healthy Bowel
Elimination
Privacy
Squatting position
Bedpan position
Cathartics & laxatives
Anti- diarrheal agents
Enemas
disimpaction

38. Bowel routine
Daily time clock
Hot drinks
Stool softeners
Privavy
Position and abdominal pressure
Bearing down

39. Assissting with
Elimination
 Embarrassing & stressful
 Usually urge to defecate 1hr. Pc
 Bedpans
 Metal or plastic
 Regular or fracture pan
 Cleanliness
 Urinals
 Commode

40. Procedure
 Privacy- close door,
 Side rail as needed
 Recumbent with HOB
 Tissue
 Call bell
 Leave alone if possible
 Gloves
 Clean genitals

41. Procedure
 Remove pan and cover
 In & Out
 Specimens
 Clean pan
 Wash hands yours and client’s
 Lower bed
 Client comfort

42. Peri - Care
 Cleaning of genitals , routine part of
complete/ partial bed bath
 Incontinence

43. 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

44. Procedure for Peri Care
 Male – begin penile head move down
along shaft, retract foreskin, rinse and
dry.

45. 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

46.  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

47. 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

48.  Caution
 Vagus nerve stimulation can cause heart
rate to slow – avoid excess manipulation

49. Enema Administration
 Main purpose
 Promotion of defecation, stimulate peristalsis
 The fluid breaks up fecal mass, stretches the
rectal wall & initiates the defecation reflex

50. Types of Enemas

51. Cleansing Enemas
 Tap Water
 Hypotonic
 Used only once
 Electrolyte imbalance
 Water toxicity
 Circulatory overload ( concentration gradient)

52.  Normal Saline
 Used when more than one enema is
needed
 Safest
 Isotonic
 Large volume to distend bowel

53.  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

54.  Soap suds
 Less common
 Soap irritates the bowel
 5 – 15 mls. Castile soap in 1000mls warm
water

55.  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

56.  Medicated
 Instill meds.
 Rectal mucosa absorption
 Ex. – Kayexalate to K (potassium).
Absorbs K from the intestinal tract

57. 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

58. Volumes for Enemas
 Pre packaged
 Fleet 150mls
 Microlax 5mls
 Hypertonic solution
 User friendly
 Hold for 5min.
 Oral Fleet

59.  Prepackaged used more than large
volume because:
 Works
 Less risk for electrolyte imbalance
 Rapid administration
 Less discomfort and distention
 Convenient and quick

60.  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

61. 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

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

63. 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

64. 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

65. Ostomy Care

66.  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.

67. 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

68.  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

69.  Ileostomy
 End of small intestine
 By passes lg. Intestine = freq. Liquid stools
 Colostomy
 Large intestine
 More solid stool

70.  Ostomies may be permanent
 More common
 temporary
 Rest the bowel
 Crohn’s

71. Urinary Ostomies
 Provide drainage of urine that bypasses
the bladder = Urinary Diversion
 Ureterostomy
 Ureter to abd. Wall
 Lt., Rt., Bilateral

72. 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

73. Concerns
 Infection
 Sterile ureters provide opening into system
 Skin Breakdown
 Continuous drainage
 Moisture on skin
 Replace urinary pouch q 2-3 days

74. 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

75. Pouch with Skin Barrier
 Comfortable fit
 Cover skin surrounding stoma
 Good seal
 Post-op pouch should allow for visibility
of stoma

76. 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

77. 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)

78. 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)

79. 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

80. 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

81. Steps to Care for
Ostomies
 Education
 Counseling
 Body image
 Self care
 Fear of rejection
 Sexual function
 Powerlessness over bowel regulation