Elimination exemplars

Elimination Exemplars

  • Incontinence
  • Benign Prostatic Hypertrophy (BPH)
  • Urinary retention
  • Constipation
  • Diarrhea
  • Obstruction
  • Crohn’s Disease
  • Irritable Bowel Syndrome (IBS)
  • Chapter 46 Med surg book

Incontinence

  • Problems Associated:

    • Hygiene issues
    • Risk of urinary tract infections (UTIs)
    • Feelings of shame and embarrassment
    • Skin breakdown due to leakage

  • Signs and Symptoms (S&S):

    • Urgency (sudden and strong need to urinate)
    • Frequency of urination
    • Leakage of urine during activities such as coughing or sneezing (stress incontinence)
    • Complete inability to control urination (functional incontinence)

  • Nursing Care:

    • Cause of incontinence may influence care strategies.
    • Teach Kegel exercises to strengthen pelvic floor muscles.
    • Monitor the patient’s elimination patterns.
    • Set up a scheduled voiding plan.
    • Monitor and modify fluid intake (avoid large amounts during the evening).
    • Provide encouragement and praise to the patient for successes.
    • Implement dietary modifications to manage incontinence.
    • Ensure careful perineal care to prevent skin breakdown.
    • Modify the medication schedule or administration when necessary (antispasmodic medications).

Benign Prostatic Hyperplasia (BPH)

  • Obstruction Mechanism:

    • Enlargement of the prostate gland
    • The enlarged prostate compresses the urethra

  • Causes:

    • Urinary tract infections (UTI)
    • Prostatitis (inflammation of the prostate)
    • Urethral strictures
    • Prostate cancer

  • Diagnostics:

    • Digital Rectal Exam (DRE) to assess the prostate
    • Urinalysis to check for infection or abnormalities
    • Prostate-Specific Antigen (PSA) test for cancer detection

  • Symptoms:

    • Increased urinary frequency
    • Decreased urine output
    • Bladder distension
    • Urinary retention
    • Incontinence episodes
    • Discomfort in the pelvis
    • Risk of urinary infection (cystitis)

  • Nursing Care:

    • Educate the patient on maximizing bladder emptying by:
    • Voiding frequently
    • Leaning forward to help empty the bladder
    • Consuming smaller amounts of fluid to prevent overfilling
    • Limit intake of alcohol and caffeine.
    • Avoid cold and cough medications that could exacerbate urinary retention.
    • Instruct patients to contact their healthcare provider (PCP) if unable to void or experience lower abdominal discomfort, distention, fever, or chills.
    • Do not force catheterization; use a Coude catheter if needed and notify the RN or PCP if the catheter cannot be advanced.

  • Treatment Options:

    • Pharmacology:
    • Alpha blockers such as Tamsulosin
    • 5-alpha reductase inhibitors (e.g., Finasteride)
    • Surgery:
    • Most common procedure: Transurethral resection of the prostate (TURP)

  • Preoperative Care:

    • Teach about pain management and the surgical procedure

  • Postoperative Care:

    • Educate about managing bladder spasms and using antispasmodics (e.g., Oxybutynin chloride)
    • Monitor Continuous Bladder Irrigation (CBI):
    • Color should be pinkish-red in the first 24 hours, then light pink (like pink lemonade).
    • Frank red with clots is abnormal; notify RN and PCP.

  • Discharge Teaching:

    • Advise drinking 12-14 glasses of water daily
    • Avoid straining or strenuous activities for 3-4 weeks
    • Avoid sexual intercourse for 3-4 weeks
    • Report any large amounts of bright red blood.

Constipation

  • Problems Associated with Constipation:

    • Abdominal pain
    • Chronic constipation
    • Reduced appetite and inadequate nutrition
    • Risk of fecal impaction

  • Signs and Symptoms (S&S):

    • Bloated feeling
    • Distended abdomen
    • Hypoactive bowel sounds
    • Rectal fullness and pressure sensation
    • Inability to defecate or the passing of hard, dry stools
    • Possible rectal bleeding from straining
    • If fecal impaction occurs, liquid stools may leak around the obstruction

  • Nursing Care:

    • Encourage physical activity
    • Increase fluid intake and gradually increase dietary fiber
    • Assess for fecal impaction
    • Medications:
    • Prebiotics
    • Laxatives (oral or suppositories)
    • Enemas for severe cases
    • Monitor intake and output (I&O)
    • Soak the rectal area to relieve discomfort

Diarrhea

  • Problems Associated with Diarrhea:

    • Fluid and electrolyte loss
    • Impaired skin integrity
    • Risk of dehydration and malnutrition

  • Signs and Symptoms (S&S):

    • Frequent, watery stools (may contain mucus or blood)
    • Urgency and abdominal discomfort
    • Hyperactive bowel sounds
    • Possible fever (depends on the underlying cause)
    • Risk of hypokalemia (low potassium)
    • Risk of hyponatremia (low sodium)

  • Nursing Care:

    • Keep the patient NPO (nothing by mouth) and advance the diet slowly as symptoms improve
    • Provide frequent oral care
    • Administer antiemetics for nausea
    • Administer intravenous fluids and electrolyte replacement
    • Ensure timely cleaning and skin integrity management using barrier creams (e.g., zinc oxide, A&D ointment)
    • Monitor I&O closely
    • Document frequency, amount, and characteristics of stools
    • Manage care to promote patient rest

Obstruction: Kidney Stones

  • Problems Associated with Kidney Stones:

    • Urinary retention and blockage leading to kidney damage risks
    • Tearing and damage to ureters
    • Inflammation and infection potential
    • Severe pain due to blockage

  • Signs and Symptoms (S&S):

    • Symptoms vary with stone size and location
    • Sharp, severe flank pain and spasms
    • Urgency with reduced urine output
    • Possible nausea/vomiting, chills, fever
    • Hematuria (blood in urine)
    • KUB (Kidneys, Ureters, Bladder) imaging may reveal stones; IVP (Intravenous Pyelogram) may show obstruction

  • Treatment:

    • Lithotripsy to break stones down
    • Endoscopy for stone removal and possible placement of temporary stent

  • Nursing Care:

    • Pain management utilizing opioids and proper positioning
    • Monitor I&O; strain urine to catch stones
    • Monitor kidney function through blood urea nitrogen (BUN), creatinine levels, and electrolyte balance
    • Dietary teaching to:
    • Ensure adequate water intake
    • Encourage consumption of citrus juices to maintain acidic urine
    • Limit purines (found in organ meats and certain seafood) if uric acid stones are present or increase calcium as needed
    • Contact PCP if experiencing anuria (no urine output), severe pain, fever, or chills

Organ Failure: Kidney Failure

  • Problems Associated with Kidney Failure:

    • Fluid volume excess
    • Electrolyte imbalances
    • Anorexia and poor nutritional intake
    • Dietary restrictions
    • Anemia and fatigue
    • Impaired skin integrity and increased infection risk
    • Potential impact on multiple systems (as discussed in Med-surg texts regarding systemic complications)
    • Issues with isolation and body image concerns, leading to depression

  • Signs and Symptoms (S&S):

    • Increased blood pressure and weight
    • Decreased urine output
    • Puffy facial appearance
    • Pale skin color and pruritus (itching)
    • Elevated BUN and creatinine levels
    • Low glomerular filtration rate (GFR)
    • Low hemoglobin and hematocrit (H&H) levels
    • Possible need for dialysis (either hemodialysis or peritoneal dialysis)
    • Uremic frost (a crystalline deposit on the skin)

  • Nursing Care:

    • Monitor intake and output (I&O) closely
    • Provide dietary teaching to include fluid and protein restrictions and adjustments based on lab values
    • Ensure good skin care and mouth care
    • Potentially restrict visitors for infection control
    • Maintain excellent aseptic techniques to prevent infection
    • Evaluate sources of emotional support for the patient
    • Encourage expression of feelings and provide nonjudgmental support
    • Manage care effectively to promote rest and recovery
    • Important Monitoring:
    • Blood pressure, electrolytes, and mental status

Kidney Failure: Dialysis

  • Dialysis Overview:

    • Procedure for cleaning and filtering the blood due to kidney failure

  • Hemodialysis:

    • Uses a machine to filter blood outside the body
    • Requires vascular access (permanent access through fistula/graft)
    • Identifiable by the thrill (vibration felt) and bruit (sound heard)
    • Typically performed in a dialysis center
    • Quicker process compared to peritoneal dialysis

  • Peritoneal Dialysis:

    • Utilizes the peritoneum in the body to filter waste and fluids
    • Longer process than hemodialysis
    • Can be performed at home with patient education and training provided

Crohn’s Disease and Irritable Bowel Syndrome (IBS)

  • Crohn’s Disease:

    • Characterized by chronic inflammation of the bowel affecting various segments
    • Etiology is unknown; onset typically between adolescence and 60 years of age
    • Symptoms:
    • Right lower quadrant pain
    • Nausea/vomiting
    • Weight loss
    • Fever
    • Dehydration
    • Steatorrhea (fat in stool)
    • Anemia
    • Diagnostics:
    • Stool sample analysis
    • CT imaging
    • Colonoscopy (notable for cobblestone appearance or skip lesions)
    • Barium enema imaging
    • Treatment Approach:
    • Nursing care focuses on achieving remission
    • Monitor weight and encourage fluid intake of 2-3 L daily
    • Recommend low-residue, high-protein, high-calorie diet; limit dairy intake
    • Provide emotional support to the patient
    • Pharmacology:
      • Use of anti-inflammatory agents
      • Vitamin supplementation and B12 injections
      • Surgical intervention as necessary
      • NPO status for bowel rest with total parenteral nutrition (TPN) as indicated

  • Irritable Bowel Syndrome (IBS):

    • Characterized by spastic contractions of the bowel
    • Symptoms include abdominal pain, cramping, flatulence, bloating, and diarrhea
    • May have white or yellow mucus present in stool
    • No intestinal inflammation occurs in IBS
    • Diagnostic Criteria:
    • Diagnosis is based on Rome and Manning criteria
    • Triggers:
    • Specific foods can precipitate symptoms while bowel movements may provide relief