ELIMINATION

Elimination in Nursing

Elimination Objectives

• Explore nursing interventions to promote elimination.

  • Course Learning Outcomes (CLO): 1, 5

• Discuss factors that impact elimination.

  • Course Learning Outcomes (CLO): 2, 5

• Discuss the significance of intake and output findings.

  • Course Learning Outcomes (CLO): 4, 5

• Describe characteristics of normal urinary and bowel elimination including age-related changes in older adults.

  • Course Learning Outcomes (CLO): 5

• Evaluate results of diagnostic tests and procedures used to determine elimination function.

  • Course Learning Outcomes (CLO): 4, 5

Alterations in Function

• Importance of a fully functional urinary and gastrointestinal tract for maintaining health and proper elimination of waste.

• Alterations in elimination function need to be evaluated and addressed to assist clients in returning to their usual function or adapting to a new normal.

The Urinary Tract

• Primary Functions:

  • Eliminate waste and excess fluid from the body in the form of urine.

  • Regulate electrolyte levels.

  • Produce hormones essential for blood pressure regulation.

  • Develop red blood cells.

  • Maintain bone strength.

• Components of the Urinary System:

  • Kidneys: Filter blood and produce urine.

  • Ureters: Thin tubes that carry urine from the kidneys to the bladder.

  • Bladder: Stores urine until it is ready to be eliminated.

  • Urethra: The tube through which urine exits the body.

The Kidneys

• Characteristics of the kidneys:

  • Two bean-shaped organs situated below the ribcage, adjacent to the spine.

  • Average filtering capacity: 120 to 150 quarts of blood produces about 1 to 2 quarts of urine daily.

  • Urine is transported from the kidneys to the bladder via ureters, one from each kidney.

• Bladder Capacity:

  • Can hold up to 2 cups of urine, stretches based on urine presence.

Unwanted Urination

• Muscles Preventing Unwanted Urination:

  • Urethra: The passage for urine to exit.

  • Bladder Neck: Comprises the internal sphincter that helps control urine flow.

  • Pelvic Floor Muscles: Supports the bladder and urethra.

Antidiuretics and Diuretics

• Antidiuretics:

  • Reduce fluid loss by inhibiting urine production in the kidneys.

• Diuretics:

  • Promote urination by increasing urine production in the kidneys.

Types of Urinary Incontinence

• Stress Incontinence:

  • Caused by pressure on the bladder from coughing, sneezing, laughing, or physical activity.

• Urge Incontinence:

  • Sudden strong urge to urinate, leaking may occur before reaching the toilet.

• Reflex Incontinence:

  • Urinary leakage due to nerve damage.

• Overflow Incontinence:

  • Incomplete bladder emptying leading to overfilling and leakage.

• Functional Incontinence:

  • Physical inability to reach the toilet in time.

• Bedwetting (Nocturnal Enuresis):

  • Involuntary urination while asleep.

Urinary Retention

• Definition:

  • Inability of the bladder to fully empty.

• Symptoms:

  • Difficulty urinating, pain, abdominal distention, urinary frequency, urinary hesitancy, weak or slow urine stream, urinary leakage.

Diagnostic Tests for Urination

• Blood Tests:

  • BUN (Blood Urea Nitrogen), Creatinine, GFR (Glomerular Filtration Rate).

• Urinalysis Tests:

  • General analysis of urine for abnormalities.

• Urine Culture:

  • Identifies specific pathogens causing urinary infection.

• 24-Hour Urine Collection:

  • Total urine production over 24 hours to assess kidney function.

• Bladder Scan:

  • Ultrasound to check bladder volume.

• KUB X-ray:

  • X-ray of the Kidneys, Ureters, and Bladder.

• Kidney Ultrasound:

  • Imaging to assess kidney structure and blood flow.

• Cystography:

  • Radiographic imaging of the bladder using contrast.

• Intravenous Pyelogram (IVP):

  • X-ray imaging after intravenous injection of contrast.

The Gastrointestinal (GI) Tract

• Components:

  • Part of the digestive system including the liver, pancreas, gallbladder, and hollow organs extending from the mouth to the anus.

  • Comprises the mouth, esophagus, stomach, small intestine, large intestine, and anus.

• Epiglottis:

  • Prevents food and liquid from entering the airway during swallowing.

• Peristalsis:

  • Involuntary muscle contractions moving food down the GI tract.

Stomach and Small Intestine Function

• Stomach:

  • Mixing of food with digestive secretions occurs before being emptied into the small intestine.

• Small Intestine:

  • Continued mixing with digestive secretions from pancreas and liver.

  • Nutrient absorption occurs as peristalsis aids in food transport.

Large Intestine Function

• Process:

  • Liquid is absorbed from waste products forming stool.

  • Peristalsis helps move stool towards the anus for elimination.

Constipation

• Definition:

  • Fewer than three bowel movements in a week; stool production is slowed.

• Symptoms:

  • Hard, dry stools difficult to pass, sensation of incomplete emptying.

• Contributing Factors:

  • Low fiber diets, inadequate water intake.

Medications Affecting Constipation

• Categories of Medications:

  • Antacids: May slow gastric motility.

  • Anticholinergics and Antispasmodics: Can cause constipation by reducing gut movement.

  • Antiseizure Medications: Affect bowel function.

  • Calcium Channel Blockers: May slow down GI motility.

  • Diuretics: Encourage water loss, impacting stool consistency.

  • Iron Supplements: Can lead to constipation.

  • Anti-Parkinson's Medications: Can slow digestion.

  • Narcotics: Known to inhibit bowel motility.

  • Antidepressants: Can have side effects that affect GI movement.

Nursing Interventions for Constipation

• Interventions:

  • Increase Activity: Promote physical movement to stimulate bowel function.

  • Enhance Fluid and Fiber Intake: Encourage diet rich in fiber and adequate hydration.

  • Provide Privacy: Create a comfortable environment for bowel movements.

  • Assist with Positioning: Optimal positioning aids in effective elimination.

  • Administer Medications: To help manage constipation.

  • Administer Enemas: Various types, e.g., soapsuds, tap water, must be approached with caution.

  • Risks of Enemas:

  • Perforation of Bowel: Risk of injury to bowel.

  • Vagal Response: Can cause significant physiological responses.

Contraindications to Enemas

• Certain Conditions Include:

  • Rectal surgery.

  • Severe bleeding hemorrhoids.

  • Ulcerative colitis or Crohn’s disease.

  • Rectal fissure.

  • Rectal cancer.

  • High bleeding potential due to underlying disease or medication.

  • Specific heart conditions affecting perfusion.

Factors Contributing to Diarrhea

• Potential Causes:

  • Lactose Intolerance: Lack of enzymes to digest lactose leads to diarrhea.

  • Medication Side Effects: Some medications can increase bowel motility.

  • Anxiety and Stress: Emotional distress can provoke gastrointestinal upset.

  • Diverticulosis: Inflammation or infection can lead to diarrhea.

  • Inflammatory Processes: Conditions such as infections or chronic inflammation can affect bowel health.

  • Food Allergies: Reactions to certain foods can manifest as diarrhea.

Lab Tests for Causes of Diarrhea

• Blood Tests: For the presence of occult blood.

• Microbial Testing: Assess stool for parasitic or bacterial infections.

• Guaiac Test: Checks for hidden blood in the stool.

• Culture and Sensitivity: Identifies harmful microorganisms and their antibiotic susceptibilities.

• Ova and Parasite Test (O&P): Tests for parasitic infections.

Bowel Incontinence

• Definition:

  • The inability to control bowel movements leading to involuntary passage of stool.

• Management:

  • Frequent toileting and thorough perineal care needed to minimize skin irritation and preserve skin integrity full circle.

• Potential Consequences:

  • Fecal material can cause skin irritation and excoriation.

Bowel Elimination and Aging

• Consequences of Aging:

  • Diarrhea in older adults can result in severe fluid volume depletion.

  • Decreased peristalsis may cause constipation.

  • Issues such as improperly fitting dentures or lack of teeth can hinder intake and digestion.

  • Level of physical activity is typically decreased in older adults leading to gastrointestinal changes.

Alternative Bowel Elimination

• Surgical Interventions:

  • Patients may require bowel diversion surgeries, redirecting intestinal contents through an abdominal exit site.

• Types of Bowel Diversions:

  • Colostomy: Changes stool consistency based on the section of the colon involved.

  • Ileostomy: Involves the ileum and creates output that may be more liquid.

  • Kock Pouch or Continent Ostomy: A surgical procedure that allows for controlled elimination.

Measuring Input and Output

• Input:

  • Refers to liquid intake by the client including drinks, soups, popsicles, jello, and IV fluids/blood.

• Output:

  • Anything liquid coming out including urine, bleeding, sweat, liquid stool, drool.

• Measurement Unit:

  • All intake and output are measured in milliliters (mL).

• Calculation:

  • After 24 hours, total input and output are compared to assess fluid balance: if intake is higher (+ fluid) or output is higher (− fluid).

Example of Intake and Output Calculation

• Input Example Calculation:

  • Chicken broth: 8 oz; Three cups of water (8 oz each): 24 oz; Popsicle: 6 oz; IV fluid: 50 mL/hr for 8 hrs (400 mL).

  • Total input calculated as follows:

  • Convert ounces to milliliters: 38 oz total = 38 x 30 = 1140 mL + 400 mL (IV fluid) = 1540 mL.

• Output Example Calculation:

  • Voided: 300 mL + Voided: 400 mL + Vomiting: 100 mL x 2 (200 mL) + Ostomy drainage: 300 mL = 1200 mL.

• Net Fluid Calculation:

  • Overall fluid balance for the client: +340 mL (input more than output).

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