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 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

Fecal elimination
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Bowel elimination
Movements of the colon:  Haustral churning
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Mixing and moving forward the content Absorption of the water Wavelike movement Powerful muscle contraction After eating, only few times a day

Colon peristalsis

Mass peristalsis
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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
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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
Color Consistency Shape Amount Odor Constituents

Normal
Adult: brown Infant: yellow Formed, soft, semisolid, moist Cylindrical, 2.5 cm in diameter 100 – 400g /day Affected by food and normal flora Undigested roughage, dead cells, fat ,protein and digestive juice

Flatus

7 to 10 L/ day

Factors that affect defecation

Development
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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

Diet
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Activity Psychologic factors Defecation habits- gastrocolic reflex

Factors that affect defecation

Medications
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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

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Diagnostic procedures Anesthsia and surgery Pathologic conditions

Spinal cord injuries, head injuries, impaired mobility

pain

Fecal elimination problems

Constipation
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Fewer than 3 bowel movements per week Fecal impaction Irregular defecationintake Insufficient activity or motility Insufficient fluid habits

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)

Change in daily routine Insufficient of privacy Lack fiber intake

Causes???

Fecal elimination problems

Fecal elimination problems

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

Bowel incontinence

Flatulence
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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
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The provision of privacy Timing
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Do not ignore the urge Adequate time for defecation 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 Tightened abdominal muscle and thigh muscle Squatting position Commode bedpan

Nutrition and fluids
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Exercise

Positioning
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Medication

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

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Antidiarrheal medications Antiflatulent medications

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

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

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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
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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

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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)

Abnormally large amount of urine production by kidneys

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Oliguria – low urine output Anuria- lack of urine production

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

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
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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

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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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Standing for male, squatting/ leaning slightly forward when sitting for female Bed-side commode Push over the pubic area Privacy Sufficient time Read or listen to music Pour warm water to perineum, warm bath Do not delay when pateint have the urge At usual time of voiding Warm the bedpan Fowler’s position, back support, flex the hip and knee

Relaxation
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Timing
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Bed-ridden client
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Assist client in urinary elimination

Maintaining normal urinary elimination

Assisting with toileting
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Prevent slip and fall injury Easy accesible call signal Handrails Bedside urinary equipment
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Urinal Bedpan commode

Assist client in urinary elimination
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Maintaining normal urinary elimination Preventing urinary tract infections Managing urinary incontinence Managing urinary retention

Assist client in urinary elimination

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

Assist client in urinary elimination

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

Assist client in urinary elimination

Managing urinary retention
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Catheterization- aseptic technique Caring of the indwelling catheter
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Fluids Dietary measures Perineal care Changing the catheter and tubing Removing indwelling catheter

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