Chapter 37

1. Chapter 37 Urinary and Bowel Elimination

2. Physiology of Urinary Elimination • Urinary Elimination (voiding, urination) • The kidneys form the urine. • The ureters carry urine to the bladder. • The bladder acts as a reservoir for the urine. • The urethra is the passageway for the urine to exit the body. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

3. Physiology of Urinary Elimination • Continence in the Adult • Anatomic integrity of the urinary system • Nervous control of the detrusor muscle • Competent sphincter mechanism • Urinary Incontinence • Uncontrolled loss of urine • Abnormalities of one or more factors Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

4. Physiology of Urinary Elimination • Structures of the Upper Urinary Tract • Kidneys • Nephrons • Parenchyma • Hilus of kidney • Renal pelvis • Ureter Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

5. Physiology of Urinary Elimination • Both the renal pelvis and ureters consist primarily of smooth muscle. • Peristalsis (muscular contraction)moves urine from the upper to the lower urinary tract. • Occurs during the prolonged phases of bladder filling and storage. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

6. Physiology of Urinary Elimination • Structures of the Lower Urinary Tract • Bladder • Detrusor (smooth muscle bundles in the upper portion of the bladder) • Urethra (sphincter mechanism) • Pelvic muscles (slow-twitch fibers and fast-twitch fibers) Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

7. Physiology of Urinary Elimination • Nervous Control of the Detrusor Muscle • Central nervous system • Peripheral nervous system • Sympathetic nervous system • Parasympathetic nervous system • Micturition center Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

8. Physiology of Urinary Elimination • Urethral Sphincter Mechanism • Urethral compression • Bladder filling • Urinary storage • Urethral tension • Supportive structures Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

9. Physiology of Bowel Elimination • Continence • Consistency of the stool (fecal material) • Intestinal motility • Compliance and contractility of the rectum • Competence of the anal sphincters Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

10. Physiology of Bowel Elimination • Structures of the Gastrointestinal Tract (alimentary canal) Related to Bowel Elimination • Small intestine • Ileocecal valve • Large bowel (colon) • Ileocecal sphincter • Anal sphincter Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

11. Physiology of Bowel Elimination • Intestinal Motility and Rectal Accommodation • Rectal filling • Rectal contractions • Rectal accommodation • Postponement of defecation • Constipation Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

12. Physiology of Bowel Elimination • Anal Sphincter Mechanism • Internal and external sphincters • Striated muscle fibers • Sensory receptors Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

13. Factors Affecting Elimination • Age • Diet • Exercise • Medications Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

14. Common Alterations in Elimination • Urinary Elimination • Acute urinary incontinence • Chronic urinary incontinence Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

15. Common Alterations in Elimination • Stress Urinary Incontinence (SUI) • Uncontrolled loss of urine caused by physical exertion in the absence of a detrusor muscle contraction • Associated with urethral hypermobility or intrinsic sphincter deficiency Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

16. Common Alterations in Elimination • Urgency and Urge Urinary Incontinence (overactive bladder syndrome) • Involuntary leakage accompanied by urge to void • Functional Urinary Incontinence • Altered mobility, manual dexterity • Ability to access toilet • Cognitive changes Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

17. Common Alterations in Elimination • Extraurethral Incontinence • Uncontrolled loss of urine that exists when the sphincter mechanism has been bypassed Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

18. Common Alterations in Elimination • Urinary Retention • Bladder outlet obstruction • Deficient detrusor muscle Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

19. Alterations in Bowel Elimination • Constipation • Diarrhea • Fecal Incontinence Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

20. Bowel Retention • Constipation is infrequent and difficult passage of hardened stool. • Dietary factors, dehydration • Inadequate dietary bulk • Diverticular disease • Neuropathic conditions • Functional limitations Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

21. Bowel Retention • Fecal Impaction • Bolus of hardened stool • Further slows colonic transit time and passage of further fecal contents Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

22. Bowel Retention • Perceived constipation is influenced by psychological and emotional stress. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

23. Alterations in Bowel Elimination • Diarrhea is the passage of liquefied stool with increased frequency and consistency. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

24. Alterations in Bowel Elimination • Primary Causes of Diarrhea • Malabsorption syndromes • Inflammatory bowel disease • Short bowel syndrome • Side effects of drugs • Laxative or enema misuse • Infectious diarrhea is caused by a pathogen. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

25. Alterations in Bowel Elimination • Bowel (fecal) Incontinence • Dysfunction of the anal sphincter • Disorders of the delivery of stool to the rectum • disorders of rectal storage • Anatomic defects Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

26. Assessment • Health History • Elimination habits • Type of incontinence • Complicating factors • Bladder and bowel management strategies used by client Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

27. Assessment • Physical Examination • Mental status • Mobility and dexterity • Inspection of perineum for skin integrity • Inspection of vaginal vault • Pelvic support • Perineal sensation • Perianal area, digital rectal exam Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

28. Assessment • Diagnostic and Laboratory Data • Urinalysis • Stool culture • Defecography • Anorectal ultrasonography Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

29. Nursing Diagnoses • Impaired Urinary Elimination • Stress Urinary Incontinence • Reflex Urinary Incontinence • Urge Urinary Incontinence • Functional Urinary Incontinence • Urinary Retention Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

30. Nursing Diagnoses • Constipation • Perceived Constipation • Diarrhea • Bowel Incontinence Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

31. Other Nursing Diagnoses • Low Self-Esteem • Deficient Knowledge • Risk for Infection • Risk for Impaired Skin Integrity • Toileting Self-Care Deficit Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

32. Outcome Identification and Planning • Target outcomes center around restoring and maintaining regular elimination habits and preventing complications. Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

33. Implementation • Maintain Elimination Health • Fluid intake • Diet • Lifestyle and Prevention Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

34. Implementation • Lifestyle and Prevention • Alcohol and tobacco use • Stress management • Weight reduction • Elimination habits • Positioning Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

35. Implementation • Lifestyle and Prevention • Initiate pelvic muscle exercise regimen • Bladder training for urge incontinence • Management of urinary retention • Management of functional urinary incontinence • Suggest environmental modifications Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

36. Implementation • Lifestyle and Prevention • Initiate behavioral intentions • Monitor skin integrity Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

37. Implementation • Apply a Containment Device • Condom catheter • Incontinence and dribble pads • Rectal pouch and rectal tube • Initiate Diet and Fluid Therapy Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

38. Implementation • Administer Medications • Over the Counter (OTC) • Prescription Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

39. Implementation • Perform Catheterization • Intermittent Catheterization Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

40. Implementation • Administer Enemas • Cleanse the lower bowel • Assist in evacuation • Instill medication • Initiate Rectal Stimulation Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

41. Implementation • Various types of enema equipment and solutions Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

42. Implementation • Monitor Elimination Diversions • Urinary Diversions • Ileal conduit • Continent urinary diversion • Bowel Diversions • Ileostomy • Colostomy • Ileoanal reservoir Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

43. Implementation • Surgical Management • Bladder suspension • Artificial urinary sphincter device • Implanted devices • Surgical reconstruction • Surgical closure of fistulae and ectopia • Endoscopy, other procedures to alleviate obstruction or dyssynergia Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

44. Implemenation • Complementary Therapies • Holistic approach to effective elimination of waste products and toxins • Diuretics • Antimicrobials • Antiseptics • Stimulants and Cathartics Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.

45. Evaluation • Client’s level of maintenance or restoration of elimination patterns and return to an appropriate level of independence • Prevention of skin breakdown and infection • Client understanding of procedures and self-care Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc.