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Elimination

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Title: Elimination


1
Elimination
2
Basic Principles
  • Wash Hands Wear Gloves
  • Infection control, your protection your
    clients 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 _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

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
  • 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.

23
Indwelling 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

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 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

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 clients
  • 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- laymans 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 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

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
  • 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

61
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

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
    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

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 wont
    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 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

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
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