Elimination

1. Elimination

2. Basic Principles • Wash Hands & Wear Gloves • Infection control, your protection & your client’s 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 @ 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, alzheimer’s, 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 @ 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 BM’s/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 • 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

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 client’s • 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- layman’s 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 physician’s 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