ELIMINATION

• Urinary elimination


  The major role is to maintain homeostasis by maintaining body fluid composition and volume
• Micturition


  The act of expelling urine from the bladder (also called urination or voiding)
• Micturition process


  1. Urine collects in the bladder

  2. Pressure stimulates stretch receptors in bladder wall

  3. Parasympathetic nervous system initiates voiding

  4. Sympathetic nervous system inhibits voiding

  5. Micturition reflex is involuntary but can be inhibited by higher brain centers
• Factors affecting voiding


  • Developmental factors
  • Psychological factors
  • Fluid and food intake
  • Medications
  • Muscle tone
  • Pathologic conditions
  • Surgical and diagnostic procedures
• Normal urine characteristics


  • Amount in 24hrs: 1,200-1500 ml
  • Color: amber/straw
  • Odor: aromatic upon voiding
  • Transparency: Clear
  • pH: slightly acidic (ranges: 4.6-8; average of 8)
  • Specific gravity: 1.010-1.025
• Urine composition problems


  • RBC (Hematuria)
  • WBC (Pyuria)
  • Pus (Pyuria)
  • Bacteria (Bacteriuria)
  • Albumin (Albuminuria)
  • Protein (Proteinuria)
  • Casts (Cylindriuria)
  • Glucose (Glycosuria)
  • Ketones (Ketonuria)
• Altered urine production


  • Polyuria - excessive urine production
  • Oliguria - decreased urine production
  • Anuria - absence of urine production
• Altered urinary frequency


  • Frequency - voiding at frequent intervals
  • Nocturia - increased frequency at night
  • Urgency - strong feeling to void
  • Dysuria - painful or difficult voiding
  • Enuresis - involuntary voiding beyond 4-5 years
  • Pollakuria - frequent, scanty urination
• Types of urinary incontinence

  • Total urinary incontinence - continuous and unpredictable loss
  • Stress urinary incontinence - leakage with sudden increase in intra-abdominal pressure
  • Urge urinary incontinence - follows sudden strong desire to urinate
  • Functional incontinence - involuntary, unpredictable passage
  • Reflex incontinence - involuntary loss at predictable intervals
• Urinary retention


  Accumulation of urine in the bladder with inability to empty
• Clinical signs of urinary retention

  • Discomfort in pubic area
  • Bladder distention
  • Inability to void or frequent voiding of small volumes
  • Disproportionately small output vs fluid intake
  • Increasing restlessness and feeling of need to void
• Nursing interventions to induce voiding

  1. Provide privacy

  2. Provide fluids to drink

  3. Assist in voiding position

  4. Provide warm bedpan/urinal

  5. Allow listening to running water

  6. Dangle fingers in warm water

  7. Pour warm water over perineum

  8. Promote relaxation

  9. Provide adequate time

  10. Perform Crede's maneuver

  11. Administer cholinergics
• Urinary catheterization


  Introduction of a catheter into the urinary bladder
• Types of urinary catheterization

  • Single catheterization: straight/nelaton catheter
  • Retention catheterization: 2 way Foley catheter
  • Continuous bladder irrigation: 3 way Foley catheter
• Purposes of urinary catheterization

  • To relieve bladder distention
  • To instill medications
  • To irrigate the bladder
  • To measure hourly urine output
  • To obtain sterile urine specimen
  • To measure residual urine
  • To manage incontinence
  • To promote healing post-operatively
  • To empty bladder for procedures
• Equipment for catheterization


  • Sterile catheter of appropriate size
  • Catheterization kit (gloves, drapes, antiseptic, lubricant, specimen container)
• Defecation


  Expulsion of feces from the anus and rectum (also called bowel movement)
• Normal stool characteristics


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


  • Acholic stool - gray, pale or clay-colored
  • Hematochezia - bright red blood
  • Melena - black, tarry stool
  • Steatorrhea - greasy, bulky, foul smelling
• Constipation


  Passage of small, dry, hard stools or no stool for a period of time
• Nursing interventions for constipation

  • Adequate fluid intake
  • High fiber diet
  • Establish regular defecation pattern
  • Respond to urge to defecate
  • Minimize stress
  • Adequate activity and exercise
  • Assume sitting or semi-squatting position
  • Administer laxatives as ordered
• Types of laxatives


  • Chemical irritants
  • Stool lubricants
  • Bulk formers
  • Stool softeners
  • Osmotic agents
• Fecal impaction


  Mass or collection of hardened, putty-like feces in the rectum
• Nursing interventions for fecal impaction

  • Manual extraction or disimpaction
  • Increase fluid intake
  • Sufficient bulk in diet
  • Adequate activity and exercise
• Diarrhea


  Frequent evacuation of watery stools due to increased GI motility and rapid passage of fecal contents
• Nursing interventions for diarrhea

  • Replace fluid and electrolyte losses
  • Provide good perianal care
  • Promote rest to reduce peristalsis
  • Provide small, frequent meals
• Osmotic agents


  They attract fluids from the intestinal capillaries to the stool
• Osmotic agents


  • Milk of magnesia
  • Duphalac
• Fecal impaction


  The mass or collection of hardened, putty-like feces in the folds of the rectum. The stool lodged or stuck in the rectum, the person is unable to voluntarily evacuate the stool
• Nursing interventions to relieve fecal impaction

  1. Manual extraction or fecal disimpaction as ordered

  2. Increase fluid intake

  3. Sufficient bulk in diet

  4. Adequate activity and exercise
• Diarrhea


  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

  3. Promote rest to reduce peristalsis

  4. Diet: small amount of bland diet, low fiber diet, BRAT diet (banana, rice, apple, toast), avoid excessive hot or cold fluids

  5. Administer antidiarrheal medications as ordered
• Demulcents


  Mechanically coat the irritated bowel and act as protectives
• Absorbents


  Absorb gas or toxic substances from the bowel
• Astringents


  Shrink swollen or inflamed tissues in the bowel
• Do not administer antidiarrheal at the start of diarrhea
• Flatulence


  The presence of excessive gas in the intestines, this may be due to swallowed air, bacterial action in the large intestine and diffusion from blood
• Common causes of flatulence

  • Constipation
  • Codeine, barbiturates and other medications that decrease intestinal motility
  • Anxiety
  • Eating gas forming foods e.g. cabbage, legumes, root crops
  • Rapid food or fluid ingestion
  • Excessive drinking of carbonated beverages
  • Improper use of straw
  • Gum chewing, candy sucking, smoking
  • Abdominal surgery- causes decreased peristalsis
• Nursing interventions for flatulence

  1. Avoid gas forming foods

  2. Provide warm fluids to drink- increase peristalsis

  3. Adequate activity and exercise

  4. Limit carbonated beverages, use of straws and chewing gums

  5. Rectal tube insertion as ordered

  6. Carminative enema as ordered

  7. Administer cholinergics as ordered e.g. prostigmin
• Fecal incontinence


  The involuntary elimination of bowel contents; often associated with neurologic, mental, or emotional impairments due to dysfunction of the anal sphincter