Elimination

• Defecation


  Expulsion of feces from the rectum
• Normal Characteristics of the Stool

  • Color: yellow or golden brown
  • Odor: aromatic upon defecation
  • Amount: 150 to 300 g per day
  • Consistency: soft, formed
  • Shape: cylindrical
  • Frequency: 1-2 per day, 1 every 2-3 days
• Acholic Stool


  • Gray, pale or clay-colored stool due to absence of stercobilin caused by biliary obstruction
• Hematochezia


  • Passage of stool with bright red blood due to lower gastrointestinal bleeding
• Melena


  • Passage of black, tarry stool due to upper GI bleeding
• Steatorrhea


  • Greasy, bulky, foul-smelling stool due to presence of undigested fats like in hepatobiliary-pancreatic obstructions/disorders
• Common Fecal Elimination


  • Constipation
  • Fecal Impaction
  • Diarrhea
  • Flatulence
  • Fecal Incontenence
• Constipation


  Passage of small, dry, hard stools or the passage of no stool for a period of time
• Nursing Interventions to Prevent and Relieve Constipation

  1. Adequate fluid intake

  2. High-fiber diet

  3. Establish regular pattern of defecation

  4. Respond immediately to the urge to defecate

  5. Minimize Stress

  6. Adequate activity and exercise

  7. Assume sitting or semisquatting position

  8. Administer laxatives as ordered
• Types of Laxatives


  • Chemical Irritants
  • Stool Lubricants
  • Stool Softeners
  • Bulk Formers
• Fecal Impaction


  Mass or collection of hardened, putty-like feces in the folds of the rectum
• Assessment of Fecal Impaction

  • Absence of bowel movement for 3 to 5 days
  • Passage of liquid fecal seepage
  • Hardened fecal mass palpated during digital examination
  • Nonproductive desire to defecate and rectal pain
  • Anorexia, body malaise
  • Abdominal fullness or bloating; apparent abdominal distention
  • Nausea and vomiting
• Nursing Intervention to Relieve Fecal Impaction


  1. Manual extraction or fecal disimpaction

  2. Increase fluid intake

  3. Sufficient bulk in diet

  4. Adequate activity and exercise
• Diarrhea


  Frequent evacuation of watery stools due to increased gastrointestinal motility and rapid passage of fecal contents
• Nursing Intervention to Relieve Diarrhea

  1. Replace fluid and electrolyte losses

  2. Provide good perineal care

  3. Promote rest

  4. Small amounts of bland, low fiber foods

  5. Avoid excessively hot or cold fluids

  6. Potassium-rich food and fluid

  7. Administer antidiarrheal medications
• Types of Antidiarrheal Medications

  • Demulcents
  • Absorbents
  • Astringents
• Flatulence


  Presence of excessive gas in the intestines
• Common Causes of Flatulence


  • Constipation
  • Medications that decrease intestinal motility
  • Anxiety
  • Eating gas-forming, rapid food or fluid ingestion
  • Improper use of drinking straw
  • Excessive drinking of carbonated beverages
  • Gum chewing, candy sucking, smoking
  • Abdominal surgery
• Nursing Interventions to Relieve Flatulence

  1. Avoid gas-forming foods

  2. Provide warm fluids to drink

  3. Early ambulation among postoperative clients

  4. Adequate activity and exercise

  5. Limit carbonated beverages, use of drinking straws and chewing gum

  6. Rectal tube insertion

  7. Carminative enema

  8. Administer cholinergics
• Fecal Incontenence


  Involuntary elimination of bowel contents due to neurologic, mental or emotional impairments
• Purposes of Administering Enemas

  • To relieve constipation and fecal impaction
  • To relieve flatulence
  • To administer medication
  • To evacuate feces in preparation for diagnostic procedure or surgery
• Types of Enemas


  • Cleansing Enema
  • Carminative Enema
  • Retention Enema
  • Return flow enema/Harris Flush/Colonic Irrigation
• Non-Retention Enema Solutions


  • Tap water
  • Soap suds
  • Normal Saline Solution
  • Hypertonic Solution/fleet enema
• Retention Enema Solutions


  • Carminative enema
  • Oil
• Nursing Interventions in Enema Administration

  1. Check the doctor's order

  2. Provide privacy

  3. Promote relaxation
• Non-Retention Enema


  1. Tap water (500-1000 mls)

  2. Sooap suds (20ml of castile soap 500-1000 ml of water)

  3. Normal Saline Solution (9 ml of NaCl to 1000 ml of water)

  4. Hypertonic Solution/fleet enema (90-120ml)
• Non-Retention Enema


  • Height of Solution 18 inches above the rectum
  • Temperature of Solution 115-125˚F on preparation
  • Time of retention 5-10 mins for better cleansing effect
• Retention Enema


  1. Carminative enema

  2. Oil (90-120 ml of mineral, olive or cottonseed oil)
• Retention Enema


  • Height of Solution 12 inches above the rectum
  • Temperature of Solution 105-110ºF on preparation
  • Time of retention 1-3 hours until desired therapeutic effect is obtained
• Nursing Interventions in Enema Administration

  1. Check the doctor's order

  2. Provide privacy

  3. Promote relaxation

  4. Position the client

  5. Lubricate 5cm (2 in) of the rectal tube

  6. Allow solution to flow through the connecting tubing and the rectal tube to expel air before insertion

  7. Insert 7-10 cm (3-4 in) of rectal tube gently in rotating motion

  8. Introduce solution slowly

  9. Change the position to distribute solution well in the colon

  10. Give the enema 3X

  11. Alternate hypotonic solution with isotonic solution

  12. If abdomical cramps occur, temporarily stop the flow of solution

  13. After introduction of the solution, press buttocks together

  14. Ask the client who is using the toilet not to flush it

  15. Do perianal care

  16. Make relevant documentation

  
• Siphoning an Enema


  1. Use water at 40ºC (105ºF)

  2. Client in right side-lying position

  3. Height of the enema container: 10cm (4 in) above the anus

  4. Quickly lower enema container after introduction of solution

  5. Note amount of fluid siphoned off as well as color, odor and presence of any feces or abnormal constituents
• Urinary Elimination


  The major role of the urinary system is to maintain homeostasis by maintaining body fluid composition and volume
• Components of the urinary system

  • Kidney
  • Ureters
  • Urinary bladder
  • Urethra

  
• Kidneys


  • Two bean-shaped organs located retroperitoneally at the level of the twelfth 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
  • Divided into renal cortex, medulla and pelvis
  • The medulla is composed of series of pyramids
  • The functional units of the kidneys are the nephrons
  • The nephron is composed of glomerulus and the renal tubules
  • The glomerulus is a tuft of semi-permeable capillaries, surrounded by the Bowman's 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 1,200 mls of blood flows to the kidney 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 electrolyte concentration, blood pressure and pH within the body
  • 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 1,500 mls per day of urine
• Ureters


  • Two small tubes about 25cm long
  • They transport urine from the renal pelvis to the urinary bladder
  • They enter the urinary bladder obliquely and is guarded by uretrovesicular sphincter

  
• Urinary Bladder


  • Serves as reservoir for urine
  • Composed of three layers of detrusor muscles
  • Contraction of these muscles expels urine from the bladder
  • Guarded by internal urethral sphincter in the junction of its opening into the urethra
  • The trigone is the 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 1,000 mls of urine

  
• Urethra


  • The passageway of urine into the external environment
  • The internal urethral sphincter is an involuntary muscle, while the external urethral sphincter is a voluntary muscle
  • Female urethra is 1 ½ to 2 ½ inches while the male urethra is 5 ½ to 6 ½ inches up to 8 inches in length

  
• Urine Formation


  1. Glomerular Filtration - water and solutes move from the blood to the glomerular capsule

  2. Tubular reabsorption - movement of the substances from the filtrate in the kidney tubules into the blood in the peritubular capillaries

  3. Tubular Secretion - transport of substances from the blood into the renal tubules
• Micturition


  Act of expelling urine from the bladder, also called urination or voiding
• Average Daily Urine Output by Age

  • 1-2 days: 15-60 ml
  • 3-10 days: 100-300 ml
  • 10 days – 2 months: 250-450 ml
  • 2 months – 1 year: 400- 500 ml
  • 1-3 years: 500-600 ml
  • 3-5 years: 600-700 ml
  • 5-8 years: 700-1,000 ml
  • 8-14 years: 800 – 1,400 ml
  • 14 years through adulthood: 1,500 ml
  • Older adulthood: 1,500 or less ml