Elimination

Basic Principles
Wash Hands & Wear Gloves
Infection control, your protection & your clients 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, 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 - 2 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, alzheimers, 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 Wipe perineum front to back Void soon after intercourse Wash hands Pelvic floor strengthening exercises (Kegel Exercises)

For Women

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:
1. 2. 3. 4. 5. Privacy and natural position Providing commode or bathroom Running water Warm water to dangle fingers Warm water over perineum ( measure if on In/Out )

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

 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 BMs/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
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

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 clients 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- laymans 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 physicians 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

 Physicians 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 Drs order, prepare client, verbal consent, equipment, privacy
Left lateral position ( fld. Flows by gravity) Drape, pad under buttocks Warm solution- stimulates peristalsis
Hot soln burns mucosa Cold soln 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 clients abd. Lacks nerve endings Doesnt 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 Crohns

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 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 wont 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 clients 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