elemination meds

Elimination Diagnostics and Medications Learning Objectives

• Describe how to collect a stool specimen for laboratory analysis.

• Identify appropriate nursing interventions when administering laxatives and antidiarrheals.

• Identify appropriate nursing interventions when administering enemas.

• Describe how to collect urine specimens.

• Identify appropriate nursing interventions when administering urinary medications.

Stool Specimens

Types of Stool Tests

• Fecal occult blood (guaiac) test: A test to check for hidden blood in the stool.

• Stool for culture, parasites, and ova:

  • Obtain using medical asepsis while wearing gloves.

  • Label the specimen and promptly transport it to the laboratory.

Stool Collection Instructions

Client Education

• First Void: Instruct clients to void first so that urine is not mixed with the stool sample.

• Defecation into Container: Advise defecating directly into the container rather than the toilet bowl.

• No Toilet Tissue: Caution against placing toilet tissue in the bedpan or specimen container.

• Avoiding Contaminants: Instruct to avoid contact with soaps, detergents, and disinfectants.

• Notification: Clients should notify the nurse when the specimen is available.

Laxatives

Docusate Sodium (Colace) - Lubricating Laxative

• Indications: Used for constipation; prophylactic for patients who should not strain (after surgery, myocardial infarction, or postpartum).

• Nursing Considerations:

  • Assess if the patient has adequate fluid intake, exercise, and dietary fiber.

• Patient Teaching:

  • Educate about dietary sources of fiber.

  • Advise to stop drug and notify the prescriber if severe cramping occurs.

  • Counse to avoid over-the-counter formulations over 7 days (without provider's knowledge) or when symptoms like abdominal pain, nausea, or vomiting arise.

Magnesium Citrate (Citrate of Magnesia) - Saline Laxative

• Indications: For short-term relief of constipation, prevention of straining, particularly for GI procedures.

• Nursing Considerations:

  • Assess for adequate fluid intake, exercise, and dietary fiber.

  • Monitor electrolyte levels during prolonged use.

  • Use cautiously in patients with sodium restrictions.

• Patient Teaching:

  • Teach about dietary sources of fiber, such as bran cereals, fresh fruits, and vegetables.

  • Caution about frequent or prolonged use due to the potential of dependence; this drug should be for short-term use only.

Enemas

Equipment for Administering an Enema

• Required Equipment:

  • Gloves

  • Lubricant

  • Absorbent waterproof pads

  • Bedpan, beside commode, or toilet

  • IV pole

  • Enema bag with tubing or prepackaged enema

• Solutions and Additives: Vary with the type of enema:

  • Tap Water or Hypotonic Solution: Stimulates evacuation; should never be repeated due to potential water toxicity.

  • Soapsuds: Pure castile soap in tap water or normal saline; acts as an irritant to promote bowel peristalsis.

  • Normal Saline: Considered safest due to equal osmotic pressure; volume stimulates peristalsis.

  • Low-Volume Hypertonic: Used for clients who cannot tolerate high-volume enemas; these are commercially prepared and should not be used on infants or dehydrated clients.

  • Oil Retention: Lubricates the rectum and colon for easier passage of stool.

  • Medicated Enema: Contains medications (such as antibiotics or anthelmintics) to be retained for a specific period (1-3 hours).

Preparing the Enema

• Perform hand hygiene.

• Prepare and warm the enema solution as indicated.

• Pour the solution into the enema bag, allowing it to fill the tubing, then close the clamp.

• Provide privacy and quick access to a commode or bedpan.

• Place absorbent pads under the client to protect the bed linens.

• Position the client on the left side with the right leg flexed forward (Sims position).

• Put on gloves and lubricate the rectal tube or nozzle.

Administering the Enema

• Slowly insert the rectal tube 3-4 inches (2-3 inches for children).

• With the bag level with the client’s hip, open the clamp.

• Raise the bag 12-18 inches above the anus, depending on the level of cleansing desired.

• If the client reports cramping or if fluid leaks around the tube at the anus, slow the flow of solution by lowering the container. Clamp the enema tubing for 30 seconds to reduce intestinal spasms if cramps occur.

• If using a prepackaged solution, insert the lubricated tip into the rectum and squeeze the container to instill all of the solution.

• Ask the client to retain the solution for the prescribed time, or until they can no longer retain it.

Post-Administration

• Discard the enema bag and tubing.

• Assist the client to the appropriate position to defecate.

• Remove gloves and perform hand hygiene.

• For clients with little or no sphincter control, administer the enema on a bedpan.

• Document the results and the client’s tolerance of the procedure.

Antidiarrheal Medications

Loperamide (Imodium)

• Indications: Short-term relief of diarrhea.

• Adverse Effects: Can include constipation, abdominal pain, flatulence, nausea, vomiting, dizziness, fatigue, headache, syncope, QT/QTc-interval prolongation, torsades de pointes, other ventricular arrhythmias, and cardiac arrest.

• Contraindications & Cautions:

  • Contraindicated in patients who must avoid constipation, those with bloody diarrhea, diarrhea with fever greater than 101°F (38°C), abdominal pain without diarrhea, acute ulcerative colitis, bacterial enterocolitis, or Clostridium difficile-associated diarrhea from broad-spectrum antibiotics.

  • Avoid higher-than-recommended dosages in adults and children aged 2 and above due to the risk of serious cardiac adverse reactions.

  • Use cautiously in patients with hepatic disease; extremes of caution used in children.

Urinary Laboratory Tests

Blood Tests to Assess Renal Function

• Blood Urea Nitrogen (BUN): Normal range is 6-24 mg/dL.

• Creatinine (blood or urine test):

  • Normal range for men: 0.7-1.3 mg/dL.

  • Normal range for women: 0.6-1.1 mg/dL.

• Glomerular Filtration Rate (GFR):

  • A GFR of 60 or higher is considered normal.

  • A GFR below 60 may indicate kidney disease.

  • A GFR of 15 or lower may indicate kidney failure.

Urinalysis and Urine Culture and Sensitivity (C&S)

• Collection Process:

  • Utilize specimen containers, labels, and soap/cleansing solutions accordingly.

  • Do not touch the inside of the container.

  • Ensure the specimen cannot be mixed with bowel movements.

  • Properly identify the client and label the specimen at the bedside.

  • Transport the specimen to the designated lab.

Types of Urine Specimen Collection

• Urinalysis: Conduct a random non-sterile specimen.

• Clean-Catch Midstream for C&S: After thorough cleansing of the urethral meatus, have the client void, stop, place the specimen container, and then resume voiding.

• Catheter Urine Specimen for C&S: Obtain a sterile specimen from a straight or indwelling catheter using surgical asepsis (sterile technique).

• Timed (24 Hour) Urine Specimens: Collect for 24 hours or other durations. Discard the first voiding and collect all other urine, refrigerrating, labeling, and transporting the specimen accordingly.

Straining Urine

• Indication for Straining: When nephrolithiasis (kidney stones) are suspected.

• Physical Description: Kidney stones may resemble grains of sand or small pieces of gravel.

• If any material remains in the strainer, it should be sent to the lab for analysis.

Nursing Considerations for Diuretics

• Assess patients for sulfa allergies, as some diuretics are sulfonamide derivatives.

• Monitor:

  • Blood pressure.

  • Weight, intake, and output.

  • Serum electrolyte levels.

  • Blood glucose levels (some agents may induce hyperglycemia).

• Regularly follow blood urea nitrogen and creatinine levels.

• Administer diuretics in the morning to prevent nocturia.

• Educate patients on the agents prescribed and review potential adverse effects.

Urinary Stimulants

Bethanechol (Urecholine)

• Class: Urinary stimulant/cholinergic.

• Indications: Used for urinary retention.

• Adverse Effects: Can include urinary urgency, abdominal discomfort, salivation, nausea, vomiting, diaphoresis, flushing, and bradycardia.

• Nursing Considerations:

  • Monitor for orthostatic hypotension.

  • Closely observe for adverse reactions indicating drug toxicity.

• Patient Teaching:

  • Instruct to take the drug on an empty stomach and at regular intervals.

  • Note that the drug usually takes effect in 30 to 90 minutes after administration.

Urinary Antispasmodics

Oxybutynin Chloride (Ditropan XL)

• Class: Urinary antispasmodic/anticholinergic.

• Indications: For overactive bladder.

• Adverse Effects: May cause drowsiness, dizziness, blurred vision, tachycardia, dry mouth, constipation, nausea, urinary hesitancy/retention, or decreased sweating.

• Nursing Considerations:

  • Monitor for anticholinergic effects.

  • Monitor episodes of incontinence and post-void residual.

  • Inquire about a history of glaucoma.

• Patient Teaching:

  • Advise reporting dysuria, palpitations, and constipation.

  • Caution against hazardous activities such as operating machinery or driving until CNS effects are known.

  • Warn against alcohol consumption.

  • Using the drug in very hot weather may lead to fever or heatstroke as it suppresses sweating.

Other Urinary Medications

• Classes/Types Include:

  • Antibiotics.

  • Bladder analgesics.

  • Tricyclic antidepressants.

  • Hormone replacement therapy.