Elimination

Concept of Elimination

  • Reference Materials:
    • NURA 212 Lewis, pages 1111-1113; 1123-1125.
    • Giddens, Chapter 17.
    • Wong, pages 831, 846, 848-849.
    • Silvestri, Chapter 34, pages 430, 432-435, 442.

Objectives

  • Determine care needs and provide nursing care for clients with bladder and bowel elimination problems using the nursing process.
  • Analyze the effectiveness of nursing care for clients with bladder and bowel elimination problems through the nursing process and clinical reasoning.

Pediatric Elimination Disorders

  • Key Disorders:
    • Enuresis
    • Encopresis
    • Pyloric Stenosis
    • Hirschsprung's Disease
    • Intussusception
    • Volvulus

Enuresis (Bed-Wetting)

  • Definition:
    • Repeated voiding of urine into clothes or bed at least twice a week for at least 3 consecutive months in a child at least 5 years old.
  • Types:
    • Diurnal Enuresis: Wetting while awake.
    • Nocturnal Enuresis: Voiding during sleep.
    • Primary Enuresis: Occurs in children who have never been consistently dry through the night.
    • Secondary Enuresis: Resumption of wetting after at least 6 months of dryness.

Enuresis: Nursing Diagnosis

  • Situational low self-esteem related to bed-wetting or urinary incontinence.
  • Impaired social interaction related to bed-wetting or urinary incontinence.
  • Compromised family coping related to negative social stigma and increased laundry load.
  • Risk for impaired skin integrity related to prolonged contact with urine.

Enuresis Management

  • Prognosis: 95% of children will outgrow the condition by their teenage years.
  • Treatment Options:
    • Bedwetting alarm for nocturnal enuresis.
    • Pharmacologic therapy:
    • Desmopressin (DDAVP).
    • Imipramine (Tofranil), not indicated for children under 8-10 years old.
    • Note: High relapse rate when medications are stopped.
  • Behavioral Strategies:
    • Encourage bathroom visits at the urge.
    • Implement rewards for being dry (hugs, stickers, treats).
    • Avoid using diapers.
    • Encourage toilet use upon noticing signs of urgency (e.g., squatting, squirming).
    • Increase fluid intake during the day, restricting before bedtime.
    • Scheduled bathroom breaks every 1-2 hours during the day.

Encopresis: Fecal Incontinence

  • Definition:
    • Repeated passage of stool into inappropriate places (1x per month for 3 months).
    • Requires a chronological/mental age of at least 4 years.
  • Pathophysiology:
    • Creates a pain-retention-pain cycle wherein a child holds in stool due to pain, leading to stretched nerves and muscles, and hard stool buildup.

Encopresis Management

  • Bowel Cleansing:
    • Use MiraLAX initially; switch to other methods if unsuccessful.
  • Bowel Training Steps:
    1. Administer stool softeners/laxatives; MiraLAX (1 capful in 8 oz. of water daily).
    2. Implement a high-fiber diet (whole grains, fruits, vegetables).
    3. Encourage time on the toilet (10 minutes, twice daily after meals).
    4. Track success on a calendar.
  • Behavioral Modifications:
    • Adjustments in habits and practices to promote regularity.

Pyloric Stenosis

  • Description:
    • Condition in young infants obstructing food from entering the small intestine; classified as an outlet obstruction.
    • Potential complications include dehydration, metabolic alkalosis, and failure to thrive.
  • Signs:
    • Projectile vomiting post-feeding.
    • Persistent hunger despite vomiting.
    • Visible stomach contractions (peristalsis).
    • Signs of dehydration and constipation.
    • Possible olive-shaped abdominal mass.
  • Treatment:
    • Surgical intervention, specifically Pyloromyotomy.

Nursing Management for Pyloric Stenosis

  • Goals:
    • Maintain adequate nutrition and fluid intake.
    • IV fluids indicated for severe dehydration; for mild dehydration, use thickened formula in high Fowler’s position.
    • Manage profuse vomiting by stopping oral feeds and placing an NG tube before surgery.
    • Provide mouth care and promote skin integrity.

Intestinal Obstruction

  • Types:
    • Mechanical Obstruction:
    • Caused by physical blocks outside or inside the intestine (e.g., tumors, adhesions).
    • Non-mechanical Obstruction:
    • Caused by decreased or absent peristalsis, often due to neuromuscular disturbances.

Causes of Mechanical Obstruction

  • Adhesions (scar tissue).
  • Benign/malignant tumors.
  • Hernias and fecal impactions.
  • Strictures from Crohn’s disease or radiation therapy.
  • Intussusception and volvulus.

Symptoms of Small Bowel vs. Large Bowel Obstruction

  • Small Bowel Symptoms:
    • Wavelike abdominal pain (colicky).
    • Nausea and vomiting.
    • Decreased or absent stool output.
    • Signs of dehydration and abdominal distention.
  • Large Bowel Symptoms:
    • Constipation and altered stool shape.
    • Abdominal distention and cramping pain.

Etiology and Genetic Risk

  • Mechanical Obstruction Etiology:
    • Resulting from adhesions, tumors, and inflammatory bowel diseases like Crohn’s.
  • Non-mechanical Obstructions:
    • Postoperative ileus and bowel ischemia.

Complications of Intestinal Obstruction

  • Potential outcomes include:
    • Hypovolemia
    • Bacterial peritonitis (with or without perforation)
    • Septic shock
    • Life-threatening conditions require immediate intervention.

Assessment of Obstruction

  • Historical data regarding GI disorders or surgeries.
  • Bowel habits, last bowel movement (BM).
  • Pain location and severity assessment.
  • Abdomen assessment for distention and tenderness.
  • Bowel sounds: increasing pitches indicate obstruction; absent sounds indicate late-stage.
  • Symptoms of obstipation and other indications of total obstruction require keeping the patient NPO.

Nursing Management of Intestinal Obstruction

  • Goals:
    • Maintain nasogastric tube function and output measurement.
    • Monitor for signs of fluid and electrolyte imbalance.
    • Assess nutritional status and signs of resolution.

Key Nursing Interventions: Intestinal Obstruction

  • Monitor vital signs (risk for hypovolemia and sepsis).
  • Frequent abdominal assessments (for bowel sounds, distention, and flatus).
  • Fluid and electrolyte monitoring; strict input/output records.
  • Nasogastric tube management and pain control.
  • Maintain NPO status and advocate for necessary IV fluid replacement.

Nasogastric Tube Management

  • Proper placement must be confirmed radiologically.
  • Assess every 4 hours for:
    • Placement integrity
    • Patency
    • Output quality and quantity
  • Regularly assess nasal skin integrity and ensure the patient is in a semi-Fowler position to minimize aspiration risk.

Surgical Management of Small Bowel Obstruction

  • Indicated for complete obstruction scenarios.
  • Require preoperative IV fluids and electrolyte replacement.
  • Surgical procedures depend on the underlying cause (e.g., adhesions, hernia repair, tumor removal).

Surgical Management of Large Bowel Obstruction

  • Surgical resection to remove obstructive lesions.
  • Preoperative care involves education on minimally invasive or open procedures. Reconvene on ostomy implications as needed.
  • Postoperative care includes NG tube management until peristalsis returns.

Mechanical Obstruction: Intussusception vs. Volvulus

  • Intussusception: Telescoping of bowel segments.
  • Volvulus: Intestinal twisting (180 degrees).

Children: Intussusception

  • Emergency condition where part of the intestine telescopes into another segment, frequently following a viral infection.
  • Early treatment options include radiologist-guided pneumoenema; late treatment typically necessitates surgery.

Symptoms of Intussusception

  1. Vomiting (bilious nature).
  2. Abdominal pain:
    • Sudden, intermittent, and colicky.
    • Spells of crying and knee-to-chest positions may occur.
  3. Bloody stools (referred to as "currant jelly").
  4. A palpable sausage-shaped abdominal mass.

Children: Volvulus

  • Condition characterized by twisting of the intestine leading to obstruction and blood vessel compression, often requiring rapid medical intervention.
  • Commonly affected areas include the sigmoid colon and cecum.
  • Treatment options are sigmoidoscopy or colectomy, depending on severity.

Causes of Volvulus

  • Contributing factors include:
    • Adhesions
    • Anomalies in bowel rotation
    • Ingested foreign bodies
    • Diaphragmatic hernia
    • Other congenital conditions.
    • Risk factors such as chronic constipation, advanced age, and laxative abuse.

Bowel Obstruction History

  • Symptoms to be aware of:
    • Severe cramping pain
    • Bilious vomiting
    • Possible constipation or diarrhea.
  • Physical findings:
    • Distended abdomen
    • Tenderness on palpation
    • Observable peristaltic waves
    • Shock symptoms.

Disorders of the Large Intestine

Hirschsprung's Disease

  • Characterized by an absence of ganglion cells in the rectum, leading to megacolon effects.
  • Cardinal sign includes delayed or absent passage of meconium.
  • Diagnosis typically confirmed through rectal biopsy.
  • Targeted treatment involves removal of the affected bowel section.

Clinical Manifestations of Hirschsprung Disease

  • Newborn Period:
    • Failure to pass meconium in 24-48 hours.
    • Refusal to feed, bilious vomiting, abdominal distention.
  • Infancy:
    • Failure to thrive, constipation, intermittent diarrhea.
  • Childhood:
    • Ribbonlike, foul-smelling stools, abdominal distention, intermittent crying, and palpable fecal masses.

Diagnostic Evaluation for Hirschsprung Disease

  • Gather history focused on chronic constipation patterns.
  • Physical examinations suggest empty rectum, tight internal sphincter.
  • Diagnostic modalities include contrast enema and rectal biopsy.

Diverticular Disease

  • Diverticulosis:

    • Refers to the presence of diverticula, often impacting the sigmoid colon.
    • High intraluminal pressure leading to out-pouching in weak areas of the colonic wall.
    • Management includes prevention strategies focused on high fiber intake.

  • Diverticulitis:

    • Occurs when diverticula become inflamed; can lead to serious complications such as abscess formation or perforation.
    • Symptoms include LLQ pain, fever, N/V, abdominal tenderness.

Non-Surgical Management of Diverticulitis

  • Management Approaches:
    • Bowel rest (NPO) and clear diet initiation.
    • Broad-spectrum antibiotics (e.g., Metronidazole, Trimethoprim/Sulfamethoxazole).
    • Avoiding laxatives/enemas due to perforation risks.

Surgical Management of Diverticulitis

  • Required when complications manifest.
  • Possible approaches include colon resection with/without colostomy.
  • Post-operative care aligns with standard abdominal surgery protocols, monitoring for infection and ensuring effective pain management.

Nursing Interventions for Diverticulitis

  • Provide antibiotic therapy and maintain pain control.
  • Regularly check vital signs and stool characteristics.
  • Frequency assessment of abdominal condition and avoidance of activities elevate intra-abdominal pressure.
  • Transition to a high-fiber diet post-inflammation resolution to encourage bowel health.