Title: Elimination
1Elimination
2Basic Principles
- Wash Hands Wear Gloves
- Infection control, your protection your
clients protection - Privacy
- Embarrassing
- Positions for urination
- Independence
-
3Functions 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
4Goal 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.
5Overview 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
10Life Cycle Changes
- Infants children
- Unable to concentrate urine b/c kidneys are
immature - Urine is light yellow
- Void frequently
- Voluntary control _at_ 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, alzheimers, CVA
- Physiological age related changes
- Bladder loses muscle tone and capacity
- Kidneys lose ability to concentrate urine
- Bladder loses muscle strength
13Common 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
17Promoting 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)
19Client Education
- S S of infection
- Fluid intake ( if no restrictions 2-5 L/day )
- Perineal hygiene
- Meds. side effects on urination, color, and
volume
20Facilitating Micturition
- Nursing Measures to promote voiding in people who
are having difficulty - Privacy and natural position
- Providing commode or bathroom
- Running water
- Warm water to dangle fingers
- Warm water over perineum ( measure if on In/Out )
21- Gently stroking inner thighs or pressure to
symphysis pubis - 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.
23Indwelling Catheter Care
- Goal- prevent infection maintain unobstructed
flow of urine. Monitor for problems. - Perineal hygiene _at_ 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
25Bowel Elimination
- Function- excrete/eliminate waste products of
digestion. - Maintaining normal bowel elimination is essential
to health and efficient body functions.
26GI System
- Small Intestine
- Absorption nutrients electrolytes
- 20 ft length, 1 in. diameter
- 3 sections
- Duodenum
- Jejunum
- Ileum
27GI
- 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
28Patterns 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
29- Elderly prone to constipation
- Slowing of peristalsis
30Determinants affecting elimination
- Dietary patterns fld. Intake
- 6 8 glasses H2O/day ( 1400- 2000mls )
- fld. Liquifies stool
- Dietary fiber stimulates peristalsis
- Soft stool
31Factors affecting elimination
- Fiber ( undigestible residue ) provides bulk
- Absorbs fluid
- Increases stool mass
- Bowel wall stretches
- Peristalsis stimulated
- Defecation results
32Factors affecting elimination
- Personal habits
- Busy schedule, postpone BM, constipation
- Activity exercise
- Immobile activity in colon
- Medications
- Laxatives
- Narcotics with codiene
33Factors affecting elimination
- Emotions
- Anxiety peristalsis diarrhea
- Depression
- Pain
- Surgery
- Anaesthetic causes temporary cessation of
peristalsis - Direct manipulation of the bowel stops peristalsis
34Common Problems
- Constipation difficult passage of hard, dry
stool infrequent movements - Fecal Impaction unrelieved constipation, feces
wedged in rectum, no BM usually 3days, oozing of
diarrheal stool develops - Diarrhea- liquid stool
- Flatulence abd. Distention pain
35Common 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
37Promoting 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
39Assissting with Elimination
- Embarrassing stressful
- Usually urge to defecate 1hr. Pc
- Bedpans
- Metal or plastic
- Regular or fracture pan
- Cleanliness
- Urinals
- Commode
40Procedure
- Privacy- close door,
- Side rail as needed
- Recumbent with HOB
- Tissue
- Call bell
- Leave alone if possible
- Gloves
- Clean genitals
41Procedure
- Remove pan and cover
- In Out
- Specimens
- Clean pan
- Wash hands yours and clients
- Lower bed
- Client comfort
42Peri - Care
- Cleaning of genitals , routine part of complete/
partial bed bath - Incontinence
43Procedure 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
44Procedure for Peri Care
- Male begin penile head move down along shaft,
retract foreskin, rinse and dry.
45Procedure 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
47Suppository 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
48- Caution
- Vagus nerve stimulation can cause heart rate to
slow avoid excess manipulation
49Enema Administration
- Main purpose
- Promotion of defecation, stimulate peristalsis
- The fluid breaks up fecal mass, stretches the
rectal wall initiates the defecation reflex
50Types of Enemas
51Cleansing 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
57Volumes 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
58Volumes 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- 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
61Procedure 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
62Procedure for Enema Administration
- Prime tube
- Lubricate tip
- Glove
- Insert 7 10 cm.(3-4in) adult
- Do not force
- Deep breath
- Guide toward umbilicus
63Procedure 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
64Procedure 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
65Ostomy 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.
67Definitions
- 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
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
- Crohns
71Urinary Ostomies
- Provide drainage of urine that bypasses the
bladder Urinary Diversion - Ureterostomy
- Ureter to abd. Wall
- Lt., Rt., Bilateral
72Ileal 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
73Concerns
- Infection
- Sterile ureters provide opening into system
- Skin Breakdown
- Continuous drainage
- Moisture on skin
- Replace urinary pouch q 2-3 days
74Pouching 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
75Pouch with Skin Barrier
- Comfortable fit
- Cover skin surrounding stoma
- Good seal
- Post-op pouch should allow for visibility of stoma
76Types 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
77Steps 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)
78Steps 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)
79Steps 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
80Steps 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
81Steps to Care for Ostomies
- Education
- Counseling
- Body image
- Self care
- Fear of rejection
- Sexual function
- Powerlessness over bowel regulation