Elimination

Elimination in Nursing Practice

Elimination Objectives

• Expand upon the concept of elimination as it applies to nursing practice.

• Recognize when an individual has problems with elimination.

• Provide appropriate nursing and collaborative interventions to optimize elimination.

• Employ elimination as a concept used to represent and organize many categories of information.

• Recognition of exemplars as sources of content knowledge related to elimination.

What is Elimination?

• Elimination refers to the physiological process of expelling waste products from the body, including substances eliminated through both bowel and urinary systems.

Vocabulary to Review

• Defecation: The act of expelling feces from the digestive tract through the anus.

• Micturition: The process of expelling urine from the bladder.

• Voiding: Another term for urination, which is the process of discharging urine.

• Continence: The ability to control bowel and bladder functions.

• Incontinence: The inability to control bowel or bladder function.

• Retention: Holding onto substances or fluids in the body, specifically refers to urine or stool.

Review of Anatomy and Physiology

Bowel Elimination

• Colon: The final part of the digestive system, responsible for the absorption of water and electrolytes, and the formation of stool.

• Rectum: The final section of the large intestine, leading to the anus, and where stool is stored prior to excretion.

• Anus: The opening at the end of the digestive tract through which stool is expelled.

• Peristalsis: The involuntary contractions of muscles that move food through the digestive tract.

• Sphincter: Circular muscles that maintain constriction of a natural orifice of the body and relax as appropriate.

• Gastrocolic Reflex: A physiological response that triggers peristalsis in the colon after food enters the stomach, leading to defecation.

Urinary Elimination

• Bladder: A hollow muscular organ that stores urine until it is expelled.

• Urethra: The tube that carries urine from the bladder to the outside of the body.

• Internal sphincter: A muscle that helps control the release of urine from the bladder automatically.

• External sphincter: A muscle under voluntary control that can be contracted to prevent urination.

Types of Incontinence

• Stress Incontinence: Leakage of urine during activities that increase abdominal pressure, such as sneezing or coughing.

• Urge Incontinence: An intense, sudden urge to urinate followed by involuntary leakage of urine.

• Overactive Bladder: A condition characterized by frequent urge to urinate and involuntary loss of urine.

• Functional Incontinence: Inability to reach the bathroom in time due to physical or cognitive limitations.

• Mixed Incontinence: A combination of stress and urge incontinence.

• Transient Incontinence: Temporary incontinence due to a reversible condition such as a urinary tract infection.

Risks Associated with Incontinence

• Skin breakdown (dermatitis) due to prolonged moisture.

• Changes in daily activities as individuals may avoid activities that could lead to accidents.

• Changes in social relationships due to stigma or anxiety associated with incontinence.

Opposite of Incontinence - Retention

Urinary Retention

• Condition where urine builds up in the bladder instead of being eliminated.

• May lead to backflow to the upper urinary tract, causing dilation of ureters and renal pelvis, potentially resulting in pyelonephritis and renal atrophy.

Bowel Retention

• Condition often caused by ignoring the urge to defecate, leading to decreased peristalsis and resulting in constipation.

• Can lead to fecal impaction, which is a severe condition requiring medical intervention.

• Vital signs can be affected by bearing down during bowel movements, notably heart rate.

Populations at Risk for Elimination Problems

• All individuals, regardless of age, gender, or race, are potentially at risk.

• Key populations at greatest risk include:

  • Children: Due to developmental stages and potential lack of toilet training.

  • Pregnant women: Due to hormonal changes and physical pressure on the bladder.

  • Older adults: Due to age-related physiological changes.

  • Individuals with altered mobility: Difficulty accessing bathrooms can hinder elimination.

  • Individuals with cognitive impairment: May struggle to recognize the need for elimination or reach the bathroom in time.

Assessment Methodology

• Assessment of elimination issues is heavily based on client history and physical examination.

Diagnostic Tests

• Laboratory Tests:

  • Urinalysis

  • Renal function tests

  • Cultures

  • Occult blood testing

• Pathology Tests: Determine underlying problems related to elimination.

• Radiographic Tests and Scans: Imaging studies used for diagnosis.

• Direct Observation Tests:

  • Colonoscopy: Allows direct visualization of the colon.

  • Sigmoidoscopy: Examines the rectum and lower colon.

  • Cystoscopy: Examines the bladder.

  • Uroscopy: Examines the urinary tract.

• Other Tests:

  • Bladder stress testing

  • Urine flow studies

Collaborative Interventions

• Treatment strategies depend on the underlying condition determining elimination problems.

Types of Interventions

• Pharmacologic Agents: These medications are used depending on the specific type of elimination issue.

  • Examples include:

  • Antibiotics: Effective against urinary tract infections.

  • Rifaximin: Often used for treating “traveler’s diarrhea”.

  • Diuretics: Promote urination.

  • Antispasmodics: Reduce spasms in bladder and bowel.

  • Antidiarrheal: E.g., Loperamide which decreases peristalsis and increases bulk of stool.

  • Psyllium: A fiber supplement; monitor for potential electrolyte imbalance.

  • Agents for constipation management: E.g., Lubiprostone (contraindicated in bowel obstructions) and Linaclotide (to be taken 30 mins before breakfast).

  • Analgesics: To manage pain associated with elimination issues.

Exemplar: Irritable Bowel Syndrome (IBS)

• IBS is classified as a non-inflammatory bowel disorder characterized by recurrent abdominal pain and altered bowel habits.

Etiology

• The etiology of IBS is uncertain but can be influenced by:

  • Environmental Factors: Certain foods like dairy or caffeine and infectious agents.

  • Immunological Factors: Involvement of cytokine genes.

  • Stress-Related Factors: Stress, anxiety, and depression can exacerbate symptoms.

Clinical Manifestations

• Symptoms of IBS can include:

  • Chronic diarrhea

  • Constipation

  • Bloating

  • Abdominal pain

• Diagnosis is based on the presence of these manifestations.

Risk Factors for IBS

• Common risk factors include:

  • Female gender

  • Stress

  • High caffeine intake

  • Alcohol consumption

  • Eating large meals with high fat content.

Assessment for IBS

• Symptoms to assess:

  • Cramping

  • Left Lower Quadrant (LLQ) abdominal pain

  • Nausea that may accompany meals

  • Anorexia

  • Abdominal bloating

  • Patterns of diarrhea and constipation

• Lab Tests: May include:

  • Complete Blood Count (CBC)

  • Serum Albumin

  • Erythrocyte Sedimentation Rate (ESR)

  • Occult blood testing for colon cancer screening

  • Hydrogen Breath Test

Nursing Interventions for IBS

• Recommendation includes:

  • Strategies to decrease stress in clients.

  • Instructing clients to limit irritating dietary agents:

  • Examples: caffeine, alcohol, gas-forming foods.

  • Encourage a diet high in fiber and fluids.

  • Keeping a food diary to track food intake and bowel patterns to identify triggers.

  • Importance of these strategies supports overall management of symptoms.

Conclusion

• The complexity of elimination in nursing requires understanding various factors, assessment methods, and collaborative interventions across patient populations. Proper education and intervention can lead to improved outcomes in patients suffering from elimination disorders.

Contact Information

• If you have any questions, please feel free to reach out via email at khendricks@newriver.edu