Elimination

ELIMINATION

BOWEL OBSTRUCTION

Types of Bowel Obstruction

  • Mechanical Obstruction: Refers to a physical blockage in the intestine that prevents the passage of contents.

    • Causes include:

    • Adhesions

    • Tumors

    • Hernias

    • Fecal impactions

    • Strictures

    • Intussusception

    • Volvulus

    • Fibrosis

  • Nonmechanical Obstruction: No physical blockage; often results from motility issues.

    • Example: Paralytic ileus

Nursing Cues for Bowel Obstruction

  • Patient history:

    • History of gastrointestinal (GI) surgeries

    • History of intestinal tumors

    • Older age

  • Symptoms:

    • Nausea

    • Vomiting

    • Crampy abdominal pain

    • Loss of appetite

    • Constipation

    • No bowel movement or gas

    • Abdominal swelling

    • High-pitched bowel sounds

SMALL BOWEL OBSTRUCTION (SBO) vs LARGE BOWEL OBSTRUCTION (LBO)

  • SBO:

    • Pain: Localized/intermittent

    • Peristaltic waves may be visible in upper abdomen

    • Upper abdominal distention

    • Symptoms:

    • Nausea and profuse early vomiting

    • Obstipation (severe constipation)

    • Fluid and electrolyte imbalance

  • LBO:

    • Pain: Intermittent lower abdominal cramping

    • Lower abdominal distention

    • Symptoms:

    • Minimal or no vomiting

    • Obstipation or ribbon-like stools

    • Minimal fluid and electrolyte imbalance

Diagnostics for Bowel Obstruction

  1. Abdominal CT

  2. Colonoscopy

  3. X-ray

  4. Ultrasound

  5. Air or barium enema

Nursing Interventions for Bowel Obstruction

  1. Monitor vital signs

  2. Assess bowel sounds, abdominal distention, and flatus

  3. Trend fluids and electrolytes

  4. Insert NG tube for decompression

  5. Maintain oral care

  6. Keep patient NPO (nothing by mouth)

  7. Position patient in Semi-Fowler's position

  8. Administer analgesics as needed

  9. Initiate IV therapy for hydration

Surgical Interventions for Bowel Obstruction

  • Support Surgery:

    • Exploratory laparotomy

    • Laparoscopy

    • Colon resection

OSTOMIES

Definition of an Ostomy

  • A surgically created opening (stoma) in the abdominal wall to redirect elimination when the normal route is bypassed or removed.

  • Types:

    • Colostomy: End from the large intestine (colon), resulting in more formed stool.

    • Ileostomy: End from the small intestine (ileum), resulting in liquid stool that is highly caustic to the skin.

  • May be temporary or permanent depending on the indication.

  • Common indications include colorectal cancer, Crohn’s disease, ulcerative colitis, bowel obstruction, trauma, diverticulitis.

Colostomy vs Ileostomy

  • Colostomy:

    • Types: Ascending, transverse, descending, or sigmoid colon

    • Stool consistency: More solid/formed

    • Less risk of skin irritation

    • May be temporary or permanent

  • Ileostomy:

    • Location: Terminal ileum (right lower quadrant)

    • Stool consistency: Liquid to pasty; high risk for skin breakdown due to enzymatic content

    • High risk for fluid and electrolyte imbalance (monitor K+, Na+)

    • Stoma protrudes 2–3 cm above skin surface (spout)

    • Indications include Crohn’s disease and ulcerative colitis.

Types of Colostomies

  • Loop Colostomy:

    • A loop of colon brought through the abdominal wall, creating two openings on one stoma.

    • Usually temporary; used to divert stool away from distal injury or obstruction.

    • Proximal opening outputs stool; distal opening passes only mucus.

  • End (Closed) Colostomy:

    • The bowel is divided; proximal end becomes stoma while distal end is closed.

    • Single functioning opening for stool.

    • Can be permanent or temporary, depending on reanastomosis need.

  • Double-Barrel Colostomy:

    • Bowel fully divided; both ends are brought out as two separate stomas.

    • Proximal stoma outputs stool; distal stoma acts as mucus fistula.

    • Usually temporary and reversed once bowel issues resolve.

Stoma Assessment: Nursing Cues

  • Assess the Stoma:

    • Color: Should be beefy red/pink and moist; pallor or dusky color indicates ischemia.

    • Size: Stoma shrinks 4–6 weeks post-op; measure with each pouch change initially.

    • Height: Should protrude slightly above skin surface.

    • Peristomal skin: Should be intact, with no erythema or breakdown.

  • Assess the Output:

    • Note color, consistency, amount, and odor of output.

    • No output in the first 24–72 hours post-op is expected; report if absent beyond 72 hours.

    • Expected ileostomy output: 1,000–1,500 mL/day; trend intake and output closely.

    • Signs of complications such as prolapse or retraction of the stoma necessitate provider notification.

Ostomy Care: Pouching System

  1. Gather supplies:

    • Pouch system, ostomy scissors, skin barrier wafer, ostomy bag, stoma measuring guide, warm water, mild soap.

  2. Remove old pouch:

    • Push skin down while gently lifting barrier; empty pouch before removal.

  3. Clean the stoma and protect peristomal skin:

    • Use warm water and a gentle cloth; avoid soaps with lotion or oils; pat dry thoroughly.

  4. Measure and cut wafer:

    • Opening should be 1/8 inch larger than stoma; avoid leaving skin exposed.

  5. Apply new barrier and pouch:

    • Press firmly from stoma outward; hold with palm for 1–2 minutes for a secure seal.

  6. Empty pouch:

    • Empty when 1/3 to 1/2 full to prevent leakage and skin breakdown.

Patient Education: Living with an Ostomy

  • Pouch Care & Routine:

    • Change pouch every 3–7 days or when leaking; empty when 1/3 to 1/2 full.

    • Preferred to change in the morning before eating when output is lowest.

    • Avoid lotions, oils, or powders near the barrier to maintain adhesion.

    • Involve ostomy nurse (CWOCN) for ongoing support.

  • Diet, Fluids & When to Call:

    • For ileostomy, increase fluid intake to 2–3 liters/day; replace electrolytes.

    • Avoid gas-producing foods initially (e.g., beans, broccoli, carbonated drinks).

    • Chew foods thoroughly; introduce new foods one at a time.

    • Call provider for signs of complications (dark stoma, no output >6 hours, severe skin irritation, fever, abdominal pain).

Complications of Bowel Obstructions

  • Fluid/electrolyte imbalance leading to hypovolemia.

  • Risk of bacterial peritonitis (with or without perforation).

  • Possible bowel perforation.

  • Risk of sepsis.

  • Closed loop obstruction; strangulated obstruction may occur.

URINARY SYSTEM

Review Terms

  • Urinary Output: The excretion of urine produced by the kidneys and expelled from the body.

  • Micturition: The act of voiding (urination), controlled by the micturition reflex arc in the spinal cord and brain.

  • Anuria: Total urine output < 100 mL/24 hours. Indicates severe renal failure and requires immediate evaluation.

  • Oliguria: Urine output of 100–400 mL/24 hours. Indicates decreased output, an early sign of renal compromise, dehydration, or obstruction.

  • Polyuria: Urine output > 2,000 mL/24 hours. May indicate conditions such as diabetes insipidus (DI), diabetes mellitus (DM), hypercalcemia, or diuretic use.

  • Dysuria: Pain or burning sensation during urination, commonly associated with urinary tract infections (UTIs), urethritis, interstitial cystitis, or bladder inflammation.

Review Terms: Voiding Patterns

  • Frequency: Voiding often (hourly or more) in small amounts, typically associated with UTIs, BPH, or overactive bladder.

  • Hesitancy: Difficulty in initiating urine flow despite the urge to void. Common in conditions like BPH, urethral stricture, or neurogenic bladder.

  • Urgency: A sudden and intense need to void immediately, which may progress to urge incontinence if facilities are unavailable.

  • Nocturia: Awakening from sleep to urinate one or more times, related to BPH, congestive heart failure (CHF), diuretics, or normal aging.

  • Uremia: Systemic manifestations of end-stage renal failure, also known as uremic syndrome, arising from accumulated metabolic waste.

Anatomy and Physiology of the Renal/Urinary System

  • Organs Involved:

    • Left Kidney

    • Right Kidney

    • Ureters

    • Urinary bladder

    • Urethra

  • Key Structures of the Kidney:

    • Renal capsule

    • Nephrons (functional unit)

    • Minor and major calyces

    • Renal pelvis

    • Glomerulus and Bowman's capsule

    • Collecting ducts

Functions of the Kidneys

  • Maintain homeostasis by regulating electrolytes and fluids.

  • Excrete end products of metabolism.

  • Control acid-base balance and blood pressure.

  • Excrete bacterial toxins and secrete hormones like renin and erythropoietin.

Urinary Obstruction: Urolithiasis

  • Summary: Kidney stones cause obstruction in the urinary tract, interfering with normal urine flow.

    • Locations:

    • Renal pelvic stones

    • Upper ureteral stones

    • Calyceal stones.

Nursing Cues for Urinary Obstruction

  • Signs of dehydration

  • High urine acidity or alkalinity

  • Family history of urinary stones

  • Obesity and UTI signs

  • Hydronephrosis

  • Renal colic, oliguria, anuria, frequency, and dysuria

Calcium Oxalate Stones

  • Risk Factors: Increased intake of high oxalate foods, hard water, high sodium intake, excessive vitamin D, prolonged immobilization, and hyperparathyroidism.

Stone Formation: 5-Step Cascade

  1. Supersaturation: Urine becomes concentrated with calcium ions (Ca²⁺) and oxalate beyond solubility threshold.

  2. Nucleation: Formation of initial microscopic crystals due to organized lattice formation, inhibited by certain substances (e.g., citrate).

  3. Crystal Growth: Additional ions deposit onto crystal surfaces; rate driven by degree of supersaturation.

  4. Aggregation: Crystals bind together, often aided by urinary proteins, into larger masses.

  5. Retention: Crystal mass adheres to damaged tubular epithelium, continuing to grow and cause obstruction/pain.

Promoters vs. Inhibitors of Stone Formation

  • Promoters (Increase supersaturation):

    • Hypercalciuria, hyperoxaluria, low urine volume, and low urine pH.

  • Inhibitors (Keep solutes dissolved):

    • Citrate and magnesium which prevent nucleation and bind oxalate; high urine volume (>2 L/day) is crucial for reducing risk.

Nursing Interventions for Calcium Oxalate Stones

  • Encourage fluid intake to achieve urine output of >2 L/day.

  • Strain all urine to collect stone fragments for analysis.

  • Limit high-oxalate foods (spinach, nuts, chocolate) in the patient's diet.

  • Monitor intake and output; assess for hematuria, flank pain, dysuria, urinary frequency.

  • Administer pain medications and antispasmodics as needed; prepare for potential surgical interventions (ESWL, ureteroscopy).

Urinary Acid Stones

  • Causes: Excess dietary purines or a history of gout.

Nursing Interventions for Urinary Acid Stones

  • Assess family or personal history of stones.

  • Obtain dietary and fluid intake history.

  • Instruct to avoid purine-rich foods.

  • Increase oral hydration or IV hydration if necessary.

  • Trend hydration status through labs (H&H, electrolytes).

Nursing Interventions: Drug Therapy for Stones

  • Manage conditions of hypercalciuria and hyperoxaluria.

  • Administer medications for gout or hyperuricemia.

Lithotripsy for Kidney Stones

  • Extracorporeal Shock Wave Lithotripsy (ESWL): Uses sound waves or energy to fragment stones.

  • Procedure includes conscious sedation and continuous EKG monitoring.

  • Post-operative care: Monitor for bleeding, ensure adequate fluid intake, and assess for possible infections.

Surgical Interventions for Urolithiasis

  • Stenting: Placement of a small tube in the ureter to maintain urine flow.

  • Percutaneous Ureterolithotomy or Nephrolithotomy: Removal of stones in the kidney or ureter through the skin.

Benign Prostatic Hyperplasia (BPH)

  • Definition: Enlargement or hypertrophy of the prostate gland, leading to urinary obstruction.

Nursing Cues for BPH

  • Consider age, family history, race, and dietary factors.

  • Assess urinary patterns, including hesitancy, nocturia, weak stream, and blood in urine.

Symptoms of BPH (Mnemonic: "HI FUN")

  • Hesitancy

  • Intermittence

  • Frequency

  • Urgency

  • Nocturia

Nursing Interventions for BPH Management

  • Educate clients to avoid excessive liquid intake, especially at bedtime.

  • Limit caffeine and alcohol intake.

  • Support lab draws and diagnostic tests.

  • Prepare for digital rectal exam as needed.

Diagnostic and Lab Assessments for BPH

  • Tests Include:

    • Urinalysis

    • Complete blood count (CBC)

    • BUN/creatinine

    • Prostate-specific antigen (PSA) levels.

Pharmacology for BPH

  • Combination Therapy:

    1. Alpha 1-adrenergic antagonists to relax bladder neck muscles.

    2. 5-alpha reductase inhibitors to reduce prostate size.

Transurethral Resection of the Prostate (TURP)

  • Indications:

    • Urinary retention

    • History of UTIs due to residual urine

    • Hematuria

    • Hydronephrosis

    • Persistent pain with decreased urine flow.

Nursing Interventions Post-TURP

  • Monitor for signs of infection and pain every 2–4 hours.

  • Prevent immobility complications by encouraging out-of-bed activity.

  • Maintain Continuous Bladder Irrigation (CBI) and document output.

  • Watch for kinks or clots that could obstruct flow.

Urostomies

  • Definition: A surgically created stoma that allows urine to exit the body through the abdominal wall.

  • Common indications include bladder cancer, trauma, congenital abnormalities, or neurogenic bladder.

Ileal Conduit Urostomy

  • Details: A small segment of ileum is removed; ureters are connected to the ileum, which is brought out as a stoma with continuous urine drainage, and no urinary control is possible.

Location and Appearance of the Stoma for Urostomy

  • Typical location: Right lower quadrant.

  • Normal characteristics: Red or pink, moist, shiny, slightly protruding.

  • Abnormal findings (indicating possible ischemia): Pale, dusky, cyanotic, or black.

Urostomy Output Characteristics

  • Normal urine: Continuous, yellow, containing mucus.

  • Pouching System Components:

    • Skin barrier

    • Pouch

    • Drain valve

  • Key feature for urostomies: Anti-reflux valve to prevent urine backflow.

Nursing Assessment of a Urostomy

  • Assess the Stoma:

    • Observe for color, moisture, edema, bleeding; check peristomal skin for irritation, breakdown, and leakage.

  • Assess Urine Output:

    • Note color, amount, odor, and sediment; measure to maintain an adequate output.

Routine Nursing Care for Urostomy

  • Empty pouch when 1/3–1/2 full.

  • Encourage adequate hydration (2–3 L/day unless contraindicated).

Clinical Scenario Example: Case Study J.D.

  1. Day 1: 72-year-old male presents with severe abdominal pain, nausea, and vomiting.

    • Previous surgeries include appendectomy and cholecystectomy.

    • Vital Signs: BP 130/85, HR 100, RR 20, Temp 99.5°F

    • Abdominal examination shows distention and hypoactive bowel sounds.

    • Laboratory results indicate stress (WBC 12,000/mm³, BUN 25 mg/dL).

    • Diagnosis: SBO due to adhesions from previous surgeries.

  2. Day 2: Conservative management fails; surgical consult recommended for emergent exploratory laparotomy.

    • Indicates need for pre-operative preparation addressing the potential for a temporary or permanent ostomy after bowel resection.

  3. Post-operative Care: Successful laparotomy without ostomy; close monitoring of recovery and addressing dietary concerns for discharge planning.

  • Discharge education emphasized preventing recurrence and recognizing complications of bowel obstruction.