Elimination - Concepts

diseases that are under IBD

Ulcerative Colitis and Crohn’s Disease

IBD diagnosis age

any age, but usually between 15-30

ulcerative colitis

affects large intestine and involves only the mucosa and submucosa.

Spreads uniformly beginning at the rectum and spreading upward toward the cecum

ulcerative colitis risk factors

exact etiology unknown, genetic predisposition, Environmental conditions, sex, and age, defects in immune regulation

narcotics affect

slow intestinal activity and should be used with caution

narcotic bowel syndrome

chronic, intermittent, and cramping abdominal pain associated w/ effects of the narcotic analgesic wearing off. Patient then takes more to relieve pain, leading to cycle of chronic abdominal pain

Complications of ulcerative colitis

dehydration, hemorrhage, anemia, uncontrolled pain, narcotic bowel syndrome, peritonitis, colorectal cancer

ulcerative colitis diagnostics

guiac stool testing, labwork, colonoscopy, sigmoidoscopy, MRI, CT

ulcerative colitis clinical manifestations

left-lower quadrant abdominal pain and cramping, anorexia, fluid and electrolyte imbalances anemia, extraintestinal manifestations, friable appearing mucosa, 10-20+ liquid bloody stools/day, Tenesmus

ulcerative colitis treatment

Fluids, electrolyte replacement, meds, surgery cure w/ total colectomy

ulcerative colitis assessment

poor nutrition, weight loss, dehydration, assess for electrolyte imbalances, emotional, and physical distress, assess frequency, amount and characteristics of stools, vital signs

ulcerative colitis nursing interventions

providing the client w/ barrier cream, consult w/ nutritionist, psychosocial support, report abnormal v/s to provider, monitor weight, offer fluids, correct electrolyte imbalances

ulcerative colitis patient education

foods to avoid, avoid caffeine and ETOH, daily weights, eat high protein, high-calorie and low-fiber diet

what part of GI tract does crohn’s disease affect?

anywhere, from mouth to anus, more common in terminal ileum and colon, affects layers of bowel

difference between crohn’s disease and ulcerative colitis

crohn’s disease does not have a uniform pattern of lesions, it has skip lesions

Crohn’s Disease risk factors

genetic predisposition, tobacco abuse, sex and age

Crohn’s disease complications

strictures, anal fissures, fibrosis, scarring, intestinal obstruction, perforation, malnutrition, cancer of small bowel

Crohn’s disease diagnostics

capsule endoscopy, colonoscopy, sigmoidoscopy, CT scan, labwork, hemoccult stool study, urinalysis

Crohn’s disease clinical manifestations

Right-lower quadrant abdominal pain, cramping, anorexia, weight loss, fluid and electrolyte imbalances, anemia, extraintestinal manifestations

crohn’s disease treatment

no cure, frequent surgeries, meds

crohn’s disease assessment

poor nutrition, weight loss, dehydration, emotional, and physical distress, v/s

crohn’s disease nursing interventions

barrier cream, consult w/ nutritionist, psychosocial support, report abnormal v/s, monitor weight, correct electrolyte imbalances

crohn’s disease patient education

small and frequent meals, rest, adequate nutrition, daily weights, high-protein, high-calorie, low-fiber diet

celiac disease risk factors

family member w/ known disease, having dermatitis herpetiform, Type 1 diabetes

Celiac disease complications

malabsorption, malnutrition, anemia, osteopenia, osteoporosis

celiac disease diagnostics

endoscopy w/ small endoscopy, anti-tTg IgA, serum electrolytes, coagulation profile, liver function tests

clinical manifestations of celiac disease

fowl smelling light colored diarrhea that’s frothy, constipation, steatorrhea (fatty stools), weight loss, fatigue, weakness, anemia, dental enamel defects, infertility

celiac disease treatment

gluten free diet

assessment of celiac disease

perform thorough assessment of the abdomen, assess for diarrhea, flatulence, abdominal bloating, steatorrhea, weakness, fatigue, weight loss, for hypocalcemia, for orthostatic hypotension

celiac disease nursing interventions

monitor and replace serum electrolytes (potassium, calcium), monitor CBC, monitor intake and output, monitor characteristics of stool, refer client to a dietician

patient education of celiac disease

avoid tobacco and caffeine, increase water intake, maintain a nutritious and balanced diet that’s gluten free

Ileostomy

surgical opening into ileum, stools are continuous, frequent, and liquid to semi-liquid, can promote bowel rest for ulcerative colitis, ostomy bag with it

ileostomy and colostomy nursing assessment

Assess type and location of ostomy, the stoma that is moist and pink, skin integrity around stoma, output, and pain

ileostomy and colostomy nursing management

empty bag when 1/3-1/2 full or there is gas, assess for fluid and electrolyte imbalance, ensure proper fit

ileostomy and colostomy patient education

same as nursing management and assessment

colostomy

surgical opening into large intestine to drain stool, stools may be liquid, semi-formed, or formed contingent upon where stoma is located

common sites of colostomy

ascending, transverse, descending, and sigmoid colon

colostomy indication

provide bowel rest when portion of bowel must be removed due to ischemic injury

dysuria

painful or discomfort w/ urination, indicative of infection or obstruction

hematuria

presence of blood in urine, either gross or micro

cystitis

infection of lower urinary tract and bladder

chordee

bending or curvature of the penis

ureterolithiasis

calculi w/in ureters

nephrolithiasis

calculi w/in kidneys

nephrostomy

incontinent urinary diversion where tube is surgically attached from renal pelvis via a stoma to abdominal wall

ureterostomy

an incontinent urinary diversion where one or both ureters are attached via a stoma

hyrdroneprosis

excess fluid on kidney caused by a blockage of urinary flow somewhere in urinary tract

hypospadias

abnormal position of urethral meatus in boys

hydroureter

excess fluid w/in ureter caused by a blockage of urinary flow somewhere in urinary tract

urosepsis

life-threatening complication of a UTI that has gone to client’s bloodstream and systemic.

UTI risk factors

female clients, intercourse, prolonged use of urinary catheters, diabetes mellitus, alkaline urine, stool incontinence, residual urine, urinary stasis, urinary calculi, poor perineal hygiene

UTI clinical manifestations

cloudy, foul-smelling urine, hematuria, nausea, fever, dysuria, frequency, urgency, lower back pain, abdominal discomfort, and tenderness of bladder, feeling of inability to empty bladder, leukocytosis, confusion (older adult), falls (older adult), incontinence (older adult)

UTI diagnostics

• Urinalysis​

• Urine Culture & Sensitivity (usually collected only if urine comes back dirty on urinalysis)​

• CBC w/differential

Uti treatment

• Trimethoprim/sulfamethoxazole (BactrimDS), Ciprofloxacin (Cipro), and Nitrofurantoin (Macrobid) ​

• Uncomplicated UTI’s are treated empirically with 3 days of Abx (antibiotics)​

• Complicated UTI’s are treated longer, usually a 7-10 day course of Abx​

• Pyridium (phenazopyridine)​

• Surgery​

UTI Assessment

• Fever​

• Dysuria​

• Urinary frequency​

• Urinary urgency​

• Gross hematuria​

• Cloudy urine​

• Malodorous urine​

• Flank pain, abdominal discomfort, tenderness over bladder​

• Hypotension (Urosepsis)​

• Tachycardia (Urosepsis)​

UTI Interventions

• Administer antibiotics as prescribed​

• Avoid the use of indwelling catheters if at all possible​

• Encourage fluids PO​

• Administer IV fluids per MD order​

UTI Education

• Drink at least 2000-3000ml of fluid daily (unless otherwise restricted)​

• Urinate before & after intercourse​

• Properly conduct a clean-catch urine specimen​

• (Female clients) wipe the perineum from front to back only​

• Abstain from wearing tight clothing​

• Avoid holding urine for prolonged periods of time​

• Complete all antibiotics as prescribed​

Intermittent Foley Catheterization

• An intermittent or as-needed catheterization to empty the bladder​

• Done as a sterile technique (hospital)​

• Utilize 10 to 12Fr for females​

• Utilize a 12 to 14Fr for males​

• Use silicon or Teflon products for clients who have a latex allergy​

Indwelling Foley Catheterization

• Done as a sterile technique ​

• Utilize 10 to 12Fr for females​

• Utilize a 12 to 14Fr for males​

• Use silicon or Teflon products for clients who have a latex allergy​

• Are inserted at provider’s discretion ​

• Used to maintain strict I&O’s, during end-of-life care, traumatic injuries, for operative procedures, urinary obstruction relief, wound healing​

Catheter Associated UTIs

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• Conduct daily assessments of the need for the foley catheter and document the continued need​

• Use reminder systems targeting early removal of catheters​

• If appropriate, use external catheters on males​

• Consider intermittent catheterization instead of indwelling catheter insertion with the use of a portable ultrasound bladder scanner to check for residual amounts of urine​

• Seek early removal of all unnecessary urinary catheters and utilize alternative methods to drain the bladder ​

Kidney, Ureter, & Bladder (KUB)​

• Abdominal x-ray of the kidneys, ureters, and bladder (KUB) ​

• The patient maintains a supine position during the imaging​

• The size and anatomy of the renal and urinary system structures can be seen, as well as any masses, obstructions, and calculi within the kidneys and urinary tract. ​

urinary calculi diagnostics

• Noncontrast Computed Tomography​

( CT scan) is the diagnostic of choice ​

for urinary stones​

• A kidney, ureter, bladder (KUB) ​

• Ultrasound​

• Urinalysis​

urinary calculi treatment

• Trial of passage is the first-line treatment prior tosurgical intervention​

• Narcotics or opioid analgesics nonsteroidal anti-inflammatory drugs (NSAIDS)medicine along with ​

• Antiemetics are used during this trial of passage(ondansetron-Zofran, promethazine-Phenergan​

• Alpha-adrenergic blockers such as tamsulosin(Flomax), doxazosin (Cardura), and terazosin(Hytrin) can be used to relax the musculature of thelower ureter to aid in stone passage.​

• Abx such as gentamycin or cephalexin (Keflex) inthe event a UTI occurs d/t blockage of urine fromcalculi​

• Antispasmodics such as oxybutynin to alleviatepain by decreasing bladder spasms d/t calculi​

urinary calculi risk factors

• Male clients​

• Dehydration​

• Family history of gout​

• Diabetes Mellitus Type 2​

• malabsorption conditions such as Crohn’s disease ​

• dietary habits which include high sodium intake,high calcium intake ​

• Prior personal history of urinary calculi ​

• Prolonged use of urinary catheters *​

• Diabetes Mellitus​

• High Alkaline Acidic urine​

• Residual urine​

• Urinary Stasis​

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urinary calculi clinical manifestations

• Severe pain and discomfort​

• Cloudy, foul-smelling urine, hematuria​

• Nausea, vomiting, fever, dysuria, frequency,urgency​

• Leukocytosis (Condition of abnormally highWBC’s)​

• Flank pain​

• Pallor, diaphoresis​

• oliguria

Urinary calculi nurse role

• Encourage client to drink at least 2500-3000ml of fluid daily (unless otherwise restricted)​

• Administer opioid analgesics as ordered​

• Administer antiemetics as ordered​

• Administer alpha blockers as ordered​

• Strain urine and collect stone for analysis​

• Insert foley catheter if the client is unable to void​

triple lumen foley catheter

• Utilized primarily after surgery on the bladder or the prostate to wash away blood and blood clots​

• Utilized during continuous or intermittent bladder irrigation​​

• Remember to maintain the foley bag below the level of the bladder ​

Closed (continuous) bladder irrigation

• Irrigation solution is hung above the bladder​

• Irrigation fluid is instilled into the bladder through the irrigation port and drained through the catheter. ​

• Remember to maintain the foley drainage bag below the level of the bladder ​

open (manual) bladder irrigation

• Performed to maintain patency or remove a blockage of an indwelling urinary catheter​

• Used sterile technique to perform the irrigation​

• Irrigation solution per provider order and or hospital policy​

• Irrigation fluid is instilled into the bladder through the irrigation port and drained through the catheter or urine drainage port. ​

• Remember to maintain the foley drainage bag below the level of the bladder ​

ureterostomy

• This is an incontinent diversion where one or both ureters are attached via a stoma to the surface of the abdominal wall​

• A pouch is required to collect the urine ​​

• Most common type of urinary diversion​

Nephrostomy

• An incontinent type of urinary diversion ​

in which a tube exits from the renal pelvis ​

via a stoma to the surface of the ​

abdominal wall​

neobladder

using the ileum that attaches to ​

the ureters and urethra. By this approach, ​

it lets the client to maintain ​

continence by learning to void by straining ​

the abdominal muscles. ​

• Closely resembles normal urination​

Kock pouch (continent ileal bladder conduit)

• continent urinary diversion in which reservoir is formed from ileum. ​

• Contains a pouch​

• pouch is accessed and emptied by clean technique straight catheterization every 2-3 hr initially, then every 5-6hr once pouch expands to capacity​

Kock pouch nursing role

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• Consult the wound ostomy continence nurse (WOCN) to assist clients with incontinent diversions​

• Monitor stoma and peristomal skin for indications of skin integrity impairment​

Hypospadias/ Epispadias

• Unknown cause​

• Urinary meatus is inferior to its usual position​

• will NOT be circumcised at birth because the foreskin can be utilized in the repair ​

• may be unusual bending of the penis(chordee), which could later present problems with intercourse.​

• Young males with hypospadias may not be able to urinate standing, and there may be associated cryptorchidism (undescended testicle(s))

• Surgical repair is the only way to correct the condition.​

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hypospadias risk factors

unknown risk factors, possibly congenital in nature

hypospadias clinical manifestations

• Opening of the urethra below the tip on bottom side of the penis​

• Incomplete foreskin​

• Curvature of the penis during erection​

• Abnormal position of the scrotum in relation to the penis​

hypospadias diagnostics

• History and physical ​

• Radiography​

• Sonography​

hypospadias treatment

surgical repair, between ages 6-12 months

Hypospadias assessment

voiding dysfunction, chordee

Hypospadias intervention

offer support as necessary