BOWEL and BLADDER ELIMINATION Introduction The elimination of waste from the bowel is essential body function.

Successful elimination in human beings depends on the individual having an intact and fully functional urinary tract, gastrointestinal tract and nervous system. Though variations of what is normal occurs in every human being must have. Furthermore, bladder and bowel functioning may be processes that are most often taken for granted, until problems occur. The purpose of this lecture is to explore the urinary and bowel elements elimination. And it will also provides an opportunity for students to undertake activities that will assist them in their understanding of some aspects of client specifically in the promotion of bowel and bladder elimination. Fecal Elimination Physiology of Defecation Defecation is the expulsion of feces from the rectum. It has an involuntary phase. When the feces enters the rectum, the local distension and the pressure gives rise to sensory impulses that initiate reflex impulses to the internal anal sphincter and to the muscle tissue of the sigmoid colon and the rectum. The sphincter relaxes and the muscle tissue contracts, moving the feces to the anal canal. The external anal canal sphincter is under voluntary and must also relax for evacuation of the rectum. Defecation may be facilitated voluntarily by contracting the abdominal muscles and by forceful expiration with glottis closed increase the abdominal pressure (Valsalva manuever). If the defecation reflex is ignored and the external sphincter is kept closed, the defecation desire soon wanes. Consequently, with repeated ignoring of the defecation reflex, local stimulation by distention and pressure is lost. Feces accumulate in the rectum and lower colon resulting to constipation. The fecal matter may take 24 to 48 hours to pass through the entire large intestine. Between 150 to 300 grams of feces is produced daily. The fecal matter consist of unabsorbed food residue, mucus digestive secretions (gastric, intestinal, pancreatic and liver), water and microorganisms. The feces consist of 75% water and 25% of solid. If feces are moved rapidly through the large intestine, less water is absorbed and the stool is liquid. If the movement of the feces and elimination are delayed, an excessive amount of water is absorbed and the stool becomes hard and dry. Normal Characteristics of the Stool Color: yellow or golden brown (due to the bile pigment derivative known as stercobilin fecal urobilinogen. Odor: aromatic upon defecation ( due to indole and scatole, which are products of fermentation and putrefraction in the large intestine. Amount: depend on the bulk of the food intake. Approximately 150 to 300 g per day. Consistency: soft, formed

Shape: cylindrical Frequency: Variable; usual range 1-2 per day to 1 every 2-3 days Alteration on the Characteristics of Stool 1. Acoholic Stool. Gray, pale or clay-colored stool due to absence of stercobilin caused by biliary obstruction. 2. Hematochezia. Passage of stool with bright red blood. It is due to lower gastrointestinal bleeding. 3. Melena. Passage of black, tarry stool due to upper GI bleeding. 4. Steatorrhea. Greasy, bulk, foul-smelling stool. It is due to presence of undigested fats like in hepatobiliary-pancreatic obstructions/disorders. Common Fecal Elimination Problems 1. Constipation Refers to the passage of small, dry, hard stools or the passage of no stool for period of time. Nursing Interventions to Prevent and Relieve Constipation 1. Adequate fluid intake, between 1,500 to 2,000 mls/day. This is the most effective measure to relieve constipation. 2. High fiber diet. To provide bulk to the stool. High fiber foods include fresh or cooked fruits and vegetables with their skin, whole grain fresh, breads and cereals, fruits and vegetable juices. 3. Establish regular pattern of defecation. For some people, ingestion of food or fluid first thing in the morning stimulates an urge to defecate. Over time, a pattern of bowel elimination every morning can be established and is considered a normal pattern for that person. Some people are ritualistic, using the same method to promote a regular pattern of bowel elimination, whereas others have no set pattern except to respond to the defecation urge wherever it occurs. 4. Respond immediately to the urge to defecate. The defecation reflex and the urge to defecate subside after a few minutes if the initial urge is ignored. The feces then, remain in the rectum until another mass colonic movement propels more stool into the rectum, which may not be for several hours or longer. 5. Minimize stress. Stress triggers the sympathetic nervous system, causing decreased peristalsis. 6. Adequate activity and exercise promote muscle tone and facilitate peristalsis. 7. Assume setting or semisquatting position. This position allows gravity to assist the elimination of feces and also makes it easier for the client to contract the abdominal and pelvic muscles, thereby applying external pressure to the large intestine and encouraging evacuation. 8. Administer laxatives as ordered. Laxatives stimulate peristalsis and promote defecation. Avoid overuse of laxatives because natural defecation reflexes are inhibited, rebound constipation occurs.

Types of Laxatives 1. Chemical Irritants. They provide chemical stimulation to intestinal wall, thereby increasing peristalsis. E.g., Dulcolax (Bisacodyl), castor oil, Senokot (Senna) 2. Stool Lubricants. They lubricate feces and facilitate the expulsion. E.g., mineral oil 3. Stool Softeners. They soften the stool and facilitates expulsion. E.g., Colace (Na decussate) 4. Bulk Formers. They increase the bulk of the feces, increasing mechanical pressure and distention of the intestine, thereby, increasing peristalsis. E.g., Metamucil (psyllium hydrophilic mucilloid) 5. Osmotic Agents. They attack fluids from the intestinal capiliaries to the stool. E.g., Milk of Magnesia (Magnesium Hydroxide) Duphalac (lactoluse) 2. Fecal Impaction Is the mass or collection of hardened, putty-like feces in the folds of the rectum. The stool is lodged or stuck in the rectum; the person is unable to voluntarily evacuate the stool. Assessment 1. Absence of bowel movement for 3 to 5 days. 2. Passage of liquid fecal seepage. 3. Hardened fecal mass is palpated during digital examination of the rectum. 4. Nonproductive desire to defecate and rectal pain. 5. anorexia, body malaise 6. Subjective feeling of abdominal fullness or bloating; apparent abdominal distention. 7. Nausea and vomiting. Nursing Interventions to Relieve Fecal Impaction 1. Manual extraction or fecal disimpaction as ordered. 2. increased fluid intake 3. Sufficient bulk in diet. 4. Adequate activity and exercise. 3. Diarrhea Refers to frequent evacuation of watery stools. It is associated with increased gastrointestinal motility, and a rapid passage of fecal contents through the lower gastrointestinal tract. Nursing Interventions to Relieve Diarrhea 1. Replace fluid and electrolyte losses. 2. Provide good perianal care. Diarrheal stool is oftentimes highly acidic. This causes anal soreness and irritation in the perianal area. 3. Promote rest. To reduce peristalsis. 4. Diet. Small amount of bland foods Low fiber diet BRAT (banana, rice am, apple, toast)

Avoid excessively hot or cold fluids (this are stimulants) Potassium-rich foods and fluids (e.g., banana, Gatorade) Antidiarrheal medications as ordered. CAUTION: Do not administer antidiarrheal at the start of diarrhea. Diarrhea is the bodys protective mechanism to rid itself of bacteria and toxins.

4. Flatulence Is the presence of excessive gas in the intestines,(also tympanities). This may be due to swallowed air, bacterial action in the large intestine and diffusion from blood. Common causes of Flatulence 1. Constipation 2. Medications that decreases intestinal motility (e.g.,Codeine, barbiturates) 3. Anxiety 4. Eating gas forming foods, e.g.; cabbage, onions, root crops, legumes 5. Rapid food or fluid ingestion 6. Improper use of drinking straw. 7. Excessive drinking of carbonated beverages 8. Gum chewing, candy sucking, smoking 9. Abdominal surgery. This causes decreased peristalsis Nursing Interventions to relieve Flatulence 1. 2. 3. 4. 5. 6. Avoid gas forming foods. Provide warm fluids to drink. To increase peristalsis Early ambulation among post operative clients Adequate activity and exercise. Limit carbonated beverages, use of drinking straws and chewing gum. Rectal tube insertion.

5. Fecal Incontinence Is the involuntary elimination of bowel contents; it is often associated with neurologic, mental or emotional impairments. Clients with cerebral cortex injury may be unable to perceived distended rectum, or are unable to initiate the motor response required to inhibit defecation voluntarily. People who have sustained sacral spinal cord injury experience impaired nerve supply to the rectum and anal sphincters to postpone defecation. Clients who are disoriented or confused may have lost the social inhibition that prevents immediate fecal evacuation. Diarrhea predisposes a person to fecal incontinence. Sometimes, the volume of feces is so large and the defecation urge so intense that the person cannot maintain sphincter contraction long enough to access toilet facilities and remove the necessary clothing

Nursing Diagnosis: Clients with Fecal Elimination Problems: 1. Constipation related to: a. Inadequate fiber in diet b. Immobility/inadequate physical activity c. Inadequate fluid intake d. Pain on defecation e. Change in routine (diet intake) f. Abuse of laxatives g. Delayed defecation when urge is present h. Use of prescribed constipating medication (narcotic analgesic, iron, antacid and anticholinergic) 2. Perceived constipation related to: a. Altered thought process b. Family health beliefs c. Knowledge deficit about normal processes 3. Diarrhea related to: a. Dietary alteration b. Stress/anxiety c. Inflammation/irritation of the bowel d. Drug side effects e. Spoiled food f. Tube feeding g. Allergy 4. Potential fluid volume deficit related to: a. Diarrhea b. Abnormal fluid loss through ostomy c. Potential impaired skin integrity related to: a. Prolonged diarrhea b. Bowel incontinence c. Bowel diversion ostomy

Urinary Elimination Anatomy and Physiology of the Urinary System The major role of the urinary system is to maintain homeostasis by maintaining body fluid composition and volume. The components of the urinary system are as follows: kidneys, ureters, urinary bladders and urethra. The Kidneys The kidneys are two bean-shaped organs located retroperitoneally at the level of the twelftg thoracic and third lumbar vertebra. The right kidney is slightly lower than the left kidney due to the presence of the liver on the right side of the abdomen. The kidneys are divided into renal cortex, medulla and pelvis. The medulla is composed of series of pyramids. Functional units of the kidneys are the nephrons. The nephrons is composed of glumerulus and the renal tubules.

The glumerulus is a turf of semi-permeable capiliaries, surrounded by the Bowmans capsule. The three regions of the renal tubules are as follows: proximal convoluted tubules, loop of Henle and the distal convoluted tubules. The primary function of the nephrons is formation of urine. About 1200 ml of blood flows to the kidneys per minute, which is 20-25% of the cardiac output. Through the formation of urine, the kidneys remove waste products from the body, regulate fluid volume, maintain electrolytes concentration, blood pressure and pH within the body. The glomerular filtration rate (GFR) is 125 ml/min. From this, the kidneys form 0.5 to 1 ml per minute, 60 mls per hour, approximately 1500 ml per day of urine.

The Ureters The ureters are two small tubes about 25 cm long. They transport urine from the renal pelvis to the urinary bladder. The ureters enters the urinary bladder obliquely and is guarded by ureterovesicular sphincter. These two factors prevent reflux of urine as the bladder contracts.

The Urinary Bladder The urinary bladder serves as reservoir for urine. It is composed of three layers of detrusor muscles. Contraction of the these muscle expels urine from the bladder. The bladder is guarded by internal urethral sphincter in the junction of its opening into the urethra. The trigone is triangular region in the floor of the bladder that is marked by the openings for the two ureters and the internal urethral orifice. The approximate maximum capacity of the bladder is 1000 ml of urine.

The Urethra The urethra is the passageway of the urine into the external environment. The internal urethral sphincter is an involuntary muscle, while the external urethral sphincter is a voluntary muscle. The female urethra is 1 to 2 inches while the male urethra is 5 to 6 inches up to 8 inches in length. The shorter urethra among females increase propensity to urinary tract infection.

Urine Formation Three steps of formation of urine by the kidneys are as follows: a. Glomerular filtration. Water and solutes move from the blood to the glomerular capsule. The fluid that enters the capsule is called glomerular filtrate. b. Tubular reabsorption. It is the movement of the substance from the filtrate in the kidney tubules into the blood in the peritubular capiliaries. Only 1% of the filtrate remains in the tubules and becomes urine.

Water and other substances that are useful to the body are reabsorbed. Water is reabsorbed by osmosis, while most solutes are reabsorbed by active transport. c. Tubular secretion. It is the transport of substances from the blood into the renal tubules. Potassium and hydrogen are primarily eliminated from the body. Ammonia, uric acid, some f=drug metabolites are likewise eliminated. Micturation It is the act of expelling urine from the bladder. Synonymous to urination or voiding The parasympathetic nervous system initiates voiding. Whereas, the sympathetic nervous system inhibits voiding. The micturation reflex is involuntary, but it can be inhibited by higher brain centers.

Normal Characteristics of the Urine Color Odor Transparency pH Specific gravity amber/straw aromatic-upon voiding Clear slightly acidic (range:4.6 -8 average of 6) 1.010-1.025 (this is measures by urinometer)

Problems in Urinary Elimination A. Altered Urine Composition RBC Hematoria WBC Pus Pyuria Bacteria Bacteriuria Urinary Tract Infection Albumin Albuminuria Protein Proteinuria Casta Cylindriuria Glucose Glycosuria Ketones Ketonuria Diabetic Ketoacidosis B. Altered Urine Production 1. Polyuria. The production of excessive amount of urine, such as a more than 100ml/hr or 2500 ml/day (also dieresis) 2. Oliguria. The production of decreased amount of urine, such as less than 30 ml/hr or less than 500 ml/24hrs 3. Anuria. The absence of production of urine by the kidneys such as a 0 to 10 ml/hr (also urinary suppression) C. Altered Urinary Frequency 1. Frequency. Voiding at frequent intervals 2. Nocturia. Increased frequency at night. 3. Urgency. The strong feeling that the person wants to void. There may or may not be great amount of urine in the bladder. 4. Dysuria. Voiding that is either painful or difficult. 5. Hesistancy. Difficulty in initiating voiding. 6. Enuresis. Repeated involuntary voiding beyond 4-5 years of age. 7. Pollakuria. Frequent, scanty urination 8. Urinary incontinence. a. Total incontinence. A continuous and unpredictable loss of urine.

b. Stress incontinence. The leakage of less than 50 ml of urine as a result of sudden increase in intra-abdominal pressure, e.g., when one coughs, sneezes, laughs or exerts physically c. Urge incontinence. Follows a sudden strong desire to urinate and leads to involuntary detrusor contraction. d. Functional incontinence. The involuntary unpredictable passage of urine. e. Reflex incontinence. Is an involuntary loss of urine occurring atb somewhat predictable intervals when specific bladder volume is reached. 9. Retention. The accumulation of urine in the bladder with associated inability of the bladder to empty itself. 250-450 ml of urine in the bladder triggers micturation reflex. Clinical Signs of Urinary Retention a. Discomfort in the pubic area b. Bladder distention (palpation & percussion) Smooth, firm, ovoid mass at the suprapubic area Mass arising out of the pelvis Dullness on percussion c. Inability to void or frequent voiding of small volumes (25-50 ml at a time) d. A disproportionately small amount of output in relation to fluid intake. e. Increasing restlessness and feeling of need to void Nursing Interventions to Induce Voiding 1. Provide privacy. This is the most effective nursing measure to induce voiding. 2. Provide fluids to drink 3. Assist the patient in the anatomical position of voiding 4. Serve clean, warm and dry bedpan (female), urinal (male) 5. Allow the patient to listen to the sound of running water 6. Dangle fingers in warm water 7. Promote relaxation 8. Provide adequate time for voiding 9. Perform Credes maneuver as ordered. This is done by applying pressure on the suprapubic area. 10. Administer cholinergics, e.g., Urecholine (Bethanecol) as ordered. 11. Last resort: Urinary catheterization. This is the last resort because it is one of the most common causes of nasocomial infection Nursing Diagnosis: Client with Urinary Elimination Problems A. Incontinence related to: Altered environment Sensory or cognitive deficit Mobility deficit Weak pelvic muscles and structural supports associated with age, surgery or multiple injuries. B. Urinary retention related to: Urethral blockage Medication C. Altered patterns of urinary elimination related to: Bladder infection Neurologenic disorder or injury Renal calculi Loss of perineal tissue tone Medication therapy D. Potential for infection related to: Indwelling urethral catheter Urinary retension

E. Potential for impaired skin integrity related to: Incontinence Urinary diversion ostomy F. Social isolation related to: Incontinence G. Self-Esteem disturbance related to: Incontinence H. Self-care deficit: Toileting related to: Functional incontinence I. Potential fluid volume deficit/volume excess related to: Impaired urinary function associated with a disease process J. Body image disturbance related to: Urinary diversion ostomy References:

Fundamentals of Nursing by Kozier Mastering Fundamentals of Nursing by Udan