elimination, nursing

1. Nursing Fundamentals Focus IX Elimination Needs

2. Objectives:Solid Describe the physiology of stool formation and the elimination process. List the common problems of bowel elimination. Discuss nursing responsibilities involved with each problem. Define and explain some of the basic but important measures to promote normal bowel elimination. Compare and contrast the different types of altered means of bowel elimination . Identify the procedures/technical skills and related nursing responsibilities. Identify the common diagnostic procedures related to the bowel elimination need and the associated nursing responsibilities

3. Objectives:Fluid Describe the normal micturition process mechanism. Discuss common conditions /situations responsible for a disruption in the normal micturition process. List the commonly recognizable signs (behaviors) indicating a disruption in urinary elimination. Compare and contrast the altered means of urinary elimination and explain the related procedures and nursing responsibilities. Report the basic but important nursing interventions to promote normal urinary elimination. Examine the common diagnostic procedures related to urinary elimination and the associated nursing responsibilities.

4. Bladder and Bowel Function Overview: The human body eliminates waste of metabolism through urine and stool. Normal function depends on these factors: - anatomic integrity - intact neurologic components for both voluntary and synergistic emptying - a predictable pattern of waste production - physical and mental ability and the psycho-social willingness to carry out toileting related tasks

5. Structures and Functions Related To Bowel Elimination Digestion http://www.medtropolis.com/VBody.asp Structures and Functions Related To Bowel Elimination

6. Structures and Functions Related To Bowel Elimination Amylase released Releases bile to duodenum HCL, Pepsin Intrinsic factor Mucus  CHYME Bolus with Ptyalin Nutrients, electrolytes, vitamins absorbed Absorption, secretion, protection, elimination Defecation process

7. Physiology of Defecation Peristaltic waves move the feces into the sigmoid colon and the rectum Sensory nerves in rectum are stimulated Individual becomes aware of need to defecate Feces move into the anal canal when the internal and external sphincter relax

8. External anal sphincter is relaxed voluntarily if timing is appropriate Expulsion of the feces assisted by contraction of the abdominal muscles and the diaphragm Moves the feces through the anal canal and expelled through anus Facilitated by thigh flexion and a sitting position

9. Lifestyle Personal habits Nutrition and fluid intake Physical activity Culture Norms of western culture Age Infancy Elders Factors Affecting Bowel Elimination

10. Factors Affecting Bowel Elimination Physiological factors Pregnancy Motor and or sensory disturbance Intestinal pathology Medications Surgery and anesthesia Psychosocial factors Anxiety Depression

11. Color Odor Consistency Frequency Amount Shape Constituents Characteristics of normal stool

12. Selected Fecal Elimination Problems Constipation Diarrhea Bowel incontinence Flatulence

13. CONSTIPATION A symptom not a disease Decreased frequency of defecation Hard, dry, formed stools Straining at stools Painful defecation Causes include: Insufficient fiber and fluid intake Insufficient activity Irregular habits

14. FECAL IMPACTION Mass or collection of hardened feces in folds of rectum that cannot be expelled Passage of liquid fecal seepage and no normal stool Causes usually: Poor defecation habits Results from unrelieved constipation Treatment Removed manually Must have physician order Monitor patient for Valsalva reaction

15. dIARRHEA Passage of liquid feces and increased frequency of defecation Spasmodic cramps, increased bowel sounds Fatigue, weakness, malaise, emaciation A symptom of disorders affecting digestion, absorption, and secretion of the GI tract. Major causes: Stress, medications, allergies, intolerance of food or fluids, disease of colon

16. FECAL INCONTINENCE Loss of voluntary ability to control fecal and gaseous discharges Generally associated with: Impaired functioning of anal sphincter or nerve supply Neuromuscular diseases Spinal trauma Tumor Nursing Considerations Incontinence can harm a clients body image Incontinence predisposes the skin to breakdown

17. fLATUENCE Excessive flatus in intestines Leads to stretching and inflation of intestines Can occur from variety of causes: Foods Abdominal surgery Narcotics

18. Assessment of Bowel Function History of bowel prior patterns usual time frequency of stool past reliance on aids Present status and pattern Time Characteristics of stool Medications that may affect bowel functioning sedatives diuretics antihistamines

19. Assessment of Bowel Function Infection , trauma, or stress may affect stool formation Physical Abdominal Assessment Inspection Auscultation Palpitation determine abdominal discomfort palpable obstruction would indicate need for rectal exam

20. Abdominal quadrants and organs

21. Abdominal quadrants and organs

22. Abdominal quadrants and organs

23. Abdomen Subjective Assessments: Any abdominal pain ? N/V? Appetite good? Last BM? Stool formed/loose?

24. ABDOMEN-Objective Assessment Normal soft non-tender non-distended normoactive bowel sounds in all 4 quadrants Normal bowel sounds 2-3 every 15sec or 10-30 every min

25. Abdomen – Abnormal Assessments Distended Rigid Tender Hypoactive bowel sounds (<10/min ) Hyperactive bowel sounds (>30/min ) Absence of bowel sounds Presence of mass Ascities Abnormal pulsations Tubes , drains, ostomies

26. Aids To Normal Bowel Elimination Fluid intake and fiber: Adequate fiber Adequate fluid intake Upright posture

27. Constipation Managing constipation: Diet 25 -35 G of fiber + WATER! Medications Laxatives cathartics Enemas high – cleanse entire colon low – cleanse rectum and sigmoid colon hypotonic and isotonic – immediate large colonic emptying hypertonic and mineral - fleets

28. Fecal Incontinence Assessment key factors: Is the problem correctable or manageable? What is the timeline or duration of situation? Any associated symptoms?

29. NANDA nursing diagnosis Bowel Incontinence Constipation Risk for Constipation Perceived Constipation Diarrhea

30. Related nursing diagnosis Risk for Deficient Fluid Volume Risk for Impaired Skin Integrity Low Self-esteem Disturbed Body Image Deficient Knowledge Bowel Training Ostomy Management Anxiety

31. Desired Outcomes Maintain or restore normal bowel elimination pattern Maintain or regain normal stool consistency Prevent associated risks such as fluid and electrolyte imbalance, skin breakdown, abdominal distention and pain

32. Nursing considerations Promoting regular defecations Teaching about medications Decreasing flatulence Administering enemas Digital removal of a fecal impaction (if agency policy permits) Instituting bowel training programs Applying a fecal incontinence pouch Ostomy management

33. Fecal elimination patterns Privacy Timing Nutrition and fluids Exercise Positioning

34. Altered means of bowel elimination

35. Altered means of bowel elimination Ileostomy

36. Altered means of bowel elimination Stoma Form- ation

37. Altered means of bowel elimination Stoma

38. Stoma Care for Clients with an Ostomy Normal stoma should appear red and may bleed slightly when touched Assess the peristomal skin for irritation each time the appliance is changed Treat any irritation or skin breakdown immediately Keep skin clean by washing off any excretion and drying thoroughly Protect skin, collect stool, and control odor with an ostomy appliance

39. Common tests Direct Visualization fiber optic endoscopic instruments introduced through the mouth or rectum to inspect integrity of mucosa blood vessels, and organs. UGI Endoscopy Colonoscopy http://www.swarminteractive.com/patient_ed_animations.html

40. Common tests Fecal specimens Ova and Parasites Guaiac testing Hidden (occult) blood

41. Urinary Elimination

42. http://www.youtube.com/watch?v=chhNaLi9P3E Urine Formation http://www.argosymedical.com/flash/urine_formation/landing.html Kidneys

43. Micturition The process of emptying the bladder Contraction of detrusor muscle Increases pressure on bladder to produce urge to urinate Pressure overcomes the internal sphincter Urine enters urethra Requires relaxation of external sphincter consciously relaxed or contracted Urinary Elimination

44. Normal Micturition Mechanism and Related Body Structures

45. Urine formation Nephron Functional unit of the kidney Urine is formed here Glomerulus Tuft of capillaries surrounded by Bowman’s capsule Fluids and solutes move across endothelium of the capillaries into the capsule Bowman’s Capsule Filtrate move from here into the tubule of the nephron

46. Daily fluid intake Urine produced = fluid consumed Need 6 to 8 glasses per day of WATER Activity External sphincter is part of pelvic floor muscle Tone needed to maintain voluntary control Personal Habits Relaxation Distractions Aids to Normal Urinary Elimination

47. Characteristics of normal urine: Color Clarity Odor Structures and Functions related to Fluid Elimination

48. Oliguria Diminished, scanty amount <30cc Anuria absence of urine Polyuria >1500 cc/24 hours consider intake Enuresis Altered Amount

49. Dysuria Painful urination: Frequency Hesitancy Urgency Common disruptions in urinary elimination

50. Urinary Tract Infection (UTI) Can occur anywhere in the urinary tract Cystitis Ureteritis Pyleonephritis More common in women than men Common disruptions in urinary elimination

51. Common disruptions in urinary elimination Urinary retention: Inability to pass part of the urine in bladder Common in older men with benign prostate Hyperplasia

52. Urinary obstruction Urolithiasis Stones calculi block or partially block kidney, Ureters, or bladder Obstruction from strictures, tumors, edema Common disruptions in urinary elimination

53. Urinary Incontinence : Failure of major smooth muscle strength of Detrusor muscle of the bladder, instability or obstruction. Incontinences divided into 4 types. Pt may have mixed pattern: Forms of Incontinence

54. Urge Incontinence Urgency following strong sense to void Decreased bladder capacity Alcohol or caffeine ingestion infection Stress Incontinence Small amts with laughing, sneezing, coughing Urgency, frequency Forms of Incontinence

55. Overflow Incontinence : Retention Functional Incontinence : Intact urinary and nervous system Change in environment Sensory, cognitive or mobility deficit Void before reaching bathroom Forms of Incontinence

56. Nursing ASSESSMENT of Urinary Incontinence: Confirm factors related to episodes Determine cognitive function and the ability of patient to participate interventions Make observations during caregiving regarding the amount and frequency of loss of urine and situations surrounding incontinent episodes Assess abdominal and suprapubic palpation for tenderness and fullness Determine hydration status and possibility of constipation Ask specific questions regarding situations that lead to urine loss Loss of urinary control

57. Altered means of urinary elimination Catheters urethral suprapubic condom

58. Foley Catheter

59. Foley Catheters

60. Foley http://www.youtube.com/watch?v=tynS0E4hBn0

61. Foley

62. Condom/Texas Catheter

63. Bedside Drainage bags

64. Suprapubic catheter

65. Altered means of urinary elimination Urinary diversion - surgical creations Ureterostomy - (transureterostomy) Bring Ureters to abdominal surface Uterosigmoidostomy Ilea conduit or loop Implant ureter into ileum Form stoma Form pouch Need occasional catheterization to empty Kock pouch

66. Ileal conduit

67. A neobladder

68. Nephrostomy tube

69. The Kock pouch—a continent urinary diversion

70. Common Tests BUN http://video.google.com/videoplay?docid=7519331476907982001&q=urinary+system&total=83&start=0&num=10&so=0&type=search&plindex=0 Creatinine Clearance Urinalysis

71. Common Tests Visualization procedures KUB An X-ray showing the kidney, ureter, and bladder. This is in reality a plain abdominal X-ray and includes other structures such as the diaphragm above and the pelvis below. http://trismus1.files.wordpress.com/2007/04/eg-kub_2_1withpaint.jpg Retrograde Pyleography CT scan