Elimination Day 1

Elimination Overview

• Elimination is the removal of waste products from the body through the skin, lungs, kidneys, and intestines via perspiration, expiration, urination, and defecation (Taylor et al., 2023).

Learning Objectives

• Anatomy and Physiology

  • Review the intestinal and renal systems.

• Altered Elimination

  • Discuss factors contributing to alteration in elimination status.

• Incontinence and Retention

  • Explain causes of urinary and fecal incontinence and retention.

• Risk Populations

  • Identify at-risk populations across the lifespan and the rationale for their risk.

• Nursing Interventions

  • Describe nursing interventions for altered elimination conditions such as constipation, incontinence, diarrhea, and retention.

• Diagnoses

  • Discuss relevant nursing diagnoses for normal and abnormal elimination status.

Urinary Elimination

• Renal System Anatomy

  • Kidneys filter entire blood volume for waste removal.

  • Nephrons are responsible for fluid balance and urine formation; they empty urine into the renal pelvis, transported by ureters to the bladder.

  • Detrusor muscle contracts, sphincter constricts to hold urine in the bladder.

  • Increasing pressure in the bladder triggers the need to urinate.

  • Urethra length: 20 cm in men, 4 cm in women; females are more prone to UTIs due to shorter urethra.

Act of Urination (Voiding)

• Begins as an involuntary reflex in infancy, develops into voluntary control.

• Normal volume triggers urge to void (>250mL), adults produce 1000-2000mL per day.

• Increased abdominal pressure (coughing, sneezing) can cause urinary incontinence.

Factors Affecting Urination

• Development - Children develop bladder control between ages 2-5; nocturnal enuresis typically subsides by age 6.

• Aging - Nocturia, decreased bladder muscle tone, urinary retention are common.

• Pregnancy - Increased abdominal pressure compresses the bladder; frequent need to urinate.

• Diet - High sodium intake can lead to decreased urination; diuretics increase urination.

• Pathologic Conditions - Conditions like UTIs, CKD, AKI, diabetes affect elimination.

• Medications - Nephrotoxic drugs and diuretics can alter urinary patterns.

Urinary Incontinence

• Involuntary leakage of urine with types:

  • Stress Incontinence - Leakage during exertion (sneezing, coughing) due to weakened pelvic floor—common in females after childbirth.

  • Urge Incontinence - Overactive bladder causing urgent need to void, can disrupt sleep.

  • Overflow Incontinence - Frequent leak of small amounts due to bladder overdistention or neurological disorders.

  • Functional Incontinence - Resulting from impairments or barriers to mobility and cognition.

Care & Management

• Behavioral Therapy - Kegel exercises for pelvic floor strength, fluid management.

• Pharmacologic Therapy - Medications like oxybutynin can help relax the bladder.

• Surgical - Options available to strengthen the urethra such as bladder sling.

Nursing Interventions

• Use absorbent pads, manage moisture, assess skin integrity, and educate patients on voiding schedules and irrigation management.

Urinary Retention

• Can lead to overflow incontinence, UTIs, skin breakdown.

• Causes - Includes advanced age, diabetes, anesthesia, prostate enlargement, infections, and medication effects.

Assessing for Urinary Retention

• Monitor urine output and bladder discomfort; use bladder scans when voiding patterns are irregular.

Urinary Diversions

• Surgical options to divert urine; can be continent or incontinent, necessitating diligent nursing assessments and interventions for ostomies.

Bowel Elimination

• GI Anatomy Review - Involves the esophagus, stomach, small and large intestine that contribute to digestion and absorption processes.

• Factors Affecting GI Control - Nervous system control (sympathetic vs. parasympathetic), the role of peristalsis, and the valsalva maneuver influence bowel movements.

Bowel Elimination Across the Lifespan

• Infants - Frequent, softer stools based on diet.

• Toddler - Achieve voluntary control around ages 2-3.

• Older Adults - Slowing peristalsis leading to increased constipation risk.

Nutrition Considerations

• High-fiber diet (whole grains, fruits, veggies) to prevent constipation.

• Adequate fluid intake recommended (2000mL/day as per patient need).

Alterations: Diarrhea

• Causes include chronic conditions, infections, and certain medications.

• Symptoms: at least 3 liquid stools per day, urgency, possible dehydration.

• Nursing interventions include fluid and electrolyte management and education on food safety.

Complications of Diarrhea

• Potential for fluid imbalance, dehydration, and skin breakdown from prolonged exposure.

C. diff and Nursing Management

• A significant infection caused by antibiotic disruption; requires strict isolation and careful management.

Alterations: Bowel Incontinence

• Involuntary stool passage due to various factors.

• Nursing interventions focus on protective skin care, toileting schedules, and management systems.

Alterations: Constipation

• Identified by dry, hard stool with a range of causes (dehydration, medications).

• Patient education focusing on diet, hydration, and physical activity is vital.

Complications of Constipation

• Includes fecal impaction, potential vagal response leading to hypotension, as well as hemorrhoids or rectal fissures.

Bowel Diversions

• Created for passing fecal matter; drainage and skin care are paramount for optimal outcomes in patients with ostomies.