Elimination

Elimination Ella Yu

Elimination Bowel elimination Urinary elimination  Describe the physiology of elimination  Identify factors that influence the elimination  Identify common causes of the elimination problem  Implement nursing process to help the client with elimination problems

Bowel elimination Physiology of defecation  The colon in the adult is about 125 to 150 cm long  Cecum; ascending, transverse, descending colon; sigmoid colon; rectum and anus  Is a muscular tube lined with mucous membrane  Circular and longitudinal muscle fibres  Haustra

Bowel elimination Function of the colon:  Absorption of water and nutrients  Mucal protection of the intestinal wall   

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Bicarbonate ions Parasympathetic nerve stimulation e.g. emotion Protect the wall of large intestine from the fecal acids and bacterial activity, as an adherent for holding the fecal material together

Fecal elimination    

Ingested content over the previous 4 days ileocecal valve- 1500mL chyme 100mL of fluid is excreted in the feces Flatus- by-product of digestion of carbohydrates

Bowel elimination Movements of the colon:  Haustral churning  

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Colon peristalsis 

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Mixing and moving forward the content Absorption of the water Wavelike movement

Mass peristalsis  

Powerful muscle contraction After eating, only few times a day

Bowel elimination Rectum (10 to 15 cm)  Rectum folds extend vertically contains vein and artery  Haemorrhoids- distended vein Anal Canal (2.5 to 5 cm)  Internal and external sphincter  Internal sphicter: involuntary control innervated by autonomic nervous system  External sphincter: voluntarily control by the somatic nervous system

Defecation      

Expulsion the feces from the anus to rectum Bowel movement Several times per day to 2 or 3 times per week Sensory nerves of the rectum are stimulated Facilitate by thigh flexion and sitting position Repeated inhibition of the urge of defecate can result in the expansion of the rectum and loss of sensitivity→ constipation

Feces

Normal

Color

Adult: brown Infant: yellow

Consistency

Formed, soft, semisolid, moist

Shape

Cylindrical, 2.5 cm in diameter

Amount

100 – 400g /day

Odor

Affected by food and normal flora

Constituents

Undigested roughage, dead cells, fat ,protein and digestive juice

Flatus

7 to 10 L/ day

Factors that affect defecation 

Development      

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Diet   

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Newborn: meconium- black, tarry, odorless, sticky Infants: increase frequency Breastfeeding: yellow to golden feces Cow’s milk formula: dark yellow or tan stool Toddlers: daytime control- age 2½ Elders: constipation, the use of laxative high- fibre food, spicy foods Regular time, increase fluid intake (2L-3L/ day) Gas, laxative and constipation producing food

Activity Psychologic factors Defecation habits- gastrocolic reflex

Factors that affect defecation 

Medications     

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Diagnostic procedures Anesthsia and surgery Pathologic conditions 

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Morphin, codeine, tranquilizers, iron tablets- constipation Laxatives- stimulate bowel activity Aspirin- gastrointestinal bleeding Iron tablets- black stool, antacids- whitish discoloration Antibiotics- gray-green discoloration

Spinal cord injuries, head injuries, impaired mobility

pain

Fecal elimination problems 

Constipation  

Fewer than 3 bowel movements per week Fecal impaction Irregular Insufficient activity or intake motility Insufficient defecation fluid habits 

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Insufficient Change Lack in daily of fiber privacy routine intake

A mass or collection of hardened feces in the folds of the rectum results from prolonged retention and accumulation of fecal material. Requires oil retention enema, cleansing enema, suppositories, stool softener or manual removal (digital evacuation)

Causes???

Fecal elimination problems

Fecal elimination problems 

Diarrhoea 

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Bowel incontinence 

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Passage of liquid feces and an increased frequency of defecation Causes: psychologic stress, medication, allergy, food or fluid intolerance, diseases of the colon Maintain skin integrity Loss of voluntary ability to control fecal and gaseous discharges through the anal sphincter

Flatulence 

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Usually 7-10 L of flatus in the large intestine every 24 hours The gases include carbon dioxide, methane, hydrogen, oxygen and nitrogen

Fecal elimination problems 

Flatulence (excessive flatus) 

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Usually 7-10 L of flatus in the large intestine every 24 hours The gases include carbon dioxide, methane, hydrogen, oxygen and nitrogen Three sources: bacteria on chyme, swallowed air and gas diffuses between bloodstream and intestine belching

Bowel diversion ostomies

Colostomy: can be permanent or temporary

Promoting regular defecation  

The provision of privacy Timing  

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Nutrition and fluids    

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High fiber, adequate fluid Constipation: e.g. prune juice, fiber Diarrhoea: adequate fluid, avoid spicy Flatulence: limit carbonated beverages, chewing gum, gas forming foodcabbage, beans, onions

Exercise 

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Do not ignore the urge Adequate time for defecation

Tightened abdominal muscle and thigh muscle

Positioning   

Squatting position Commode bedpan

Medication 

Carthartics and laxative     

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Bulk- forming Emollien/ stool softener Stimulant/ irritant Lubricant Saline/ osmotic

Antidiarrheal medications Antiflatulent medications

Decreasing flatulence     

Avoiding gas-producing foods Exercise Moving in bed Ambulation Movement stimulates   

peristalsis the escape flatus reabsorption of gases in the intestinal capillaries

Enema  

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Enema is a solution introduced into the rectum and large intestine It distends the intestine and sometimes irritates the intestine mucosa, thereby increasing peristalsis and the excretion of feces and flatus Four groups: cleansing, carminative, retention and return-flow enemas

Enema 

Cleansing enema: remove feces 

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Hypertonic, hypotonic, isotonic, soapsuds solutions or oil (p.1242, table 46-4)

Carminative enema: expel flatus Retention enema: oil or medication into rectum and sigmoid colon and retained for a relatively long period (1-3 hours). For treating infection or soften the feces Return- flow enema: expel flatus. Alternating flow of 100 to 200 mL of fluid by five to six times Administering an enema

Digital removal of a fecal impaction 

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Breaking up the fecal mass digitally and removing it in portions Restriction!!! Contraindication e.g. cardiac arrhythmia. Using of the cleansing enema

Bowel training program 

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Determine the client’s usual bowel habits and factors that help and hinder normal defecation Design a plan:____________ Maintain the daily routine for 2 to 3 weeks:_________________ Provide feedback Offer encouragement

Urinary elimination physiology

Urinary elimination Bladder  An inner muscous layer  A connective tissue layer  Three layer of smooth muscledetrusor muscle  An outer serous layer

Urination     

Micturation Voiding Special nerve ending in the bladder wall- 250 to 450 mL of urine Voiding reflex center to spinal cordrelaxation of the internal sphincter Voluntary control of the external sphincter

Factors affecting voiding 

Developmental factors   

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Enuresis- involuntary passing of urine Nocturnal enuresis Nocturnal frequency

Psychosocial factors Fluid and food intake Medication: diuretics Muscle tone Pathologic condition: renal failure, prostate gland hypertrophy, renal stone Surgical and diagnostic procedure

Altered urine production 

Polyuria (diuresis) 

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Abnormally large amount of urine production by kidneys

Oliguria – low urine output Anuria- lack of urine production

Altered urinary elimination     

Frequency and nocturia: UTI, pregnancy Urgency Dysuria: painful voiding Enuresis Urinary incontinence: involuntary urination 

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Acute Vs chronic

Urinary retention Neurogenic bladder: does not perceive bladder fullness, unable to control the urinary sphincters. Bladder becomes flaccid, distended or spastic with incontinence

Assist client in urinary elimination    

Maintaining normal urinary elimination Preventing urinary tract infections Managing urinary incontinence Managing urinary retention 

Catherterization

Assist client in urinary elimination 

Maintaining normal urinary elimination 

Promoting fluid intake if not contraindicated   

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Normal daily intake averaging 1,500mL Diaphoresis, diarrhoea, vomitting require more intake Client who are at risk for UTI or urinary calculi should consume 2,000 to 3,000 mL Contraindication: kidney failure, heart failure

Maintaining normal voiding habits Assisting with toileting

Assist client in urinary elimination 

Maintaining normal urinary elimination 

Maintaining normal voiding habits 

Positioning   

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Relaxation    

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Privacy Sufficient time Read or listen to music Pour warm water to perineum, warm bath

Timing  

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Standing for male, squatting/ leaning slightly forward when sitting for female Bed-side commode Push over the pubic area

Do not delay when pateint have the urge At usual time of voiding

Bed-ridden client  

Warm the bedpan Fowler’s position, back support, flex the hip and knee

Assist client in urinary elimination 

Maintaining normal urinary elimination 

Assisting with toileting    

Prevent slip and fall injury Easy accesible call signal Handrails Bedside urinary equipment   

Urinal Bedpan commode

Assist client in urinary elimination    

Maintaining normal urinary elimination Preventing urinary tract infections Managing urinary incontinence Managing urinary retention

Assist client in urinary elimination 

Preventing urinary tract infection           

Prevalence: women> men Why? Common pathogen: escherichia coli Drink 8 glasses of water per day Practice frequent voiding Void immediately after intercourse Avoid use of harsh soap, bubble bath, powder or spray Take shower bath Avoid tight fitting pants Wear cotton clothes Wipe the perineal area from front to back

Assist client in urinary elimination    

Maintaining normal urinary elimination Preventing urinary tract infections Managing urinary incontinence Managing urinary retention

Assist client in urinary elimination 

Managing urinary incontinence     

Bladder training, habit training, prompted voiding Pelvic muscle exercise: Kegel exercises Maintain skin integrity Applying external urinary drainage devices medication

Assist client in urinary elimination    

Maintaining normal urinary elimination Preventing urinary tract infections Managing urinary incontinence Managing urinary retention

Assist client in urinary elimination 

Managing urinary retention  

Catheterization- aseptic technique Caring of the indwelling catheter     

Fluids Dietary measures Perineal care Changing the catheter and tubing Removing indwelling catheter