Elimination

Nursing Definition:

Nurse [nurs] noun:
A patient, kind, caring, trained professional who focuses on the needs of others; a superhero.

Elimination Overview:

Elimination is a normal function of the body and is critical for maintaining nutritional status, hydration, and fluid and electrolyte balance.

As nurses, we must ask the following questions regarding elimination:

• When was your last BM?

• Any changes in elimination patterns (color, consistency, or odor)?

• Pain with elimination?

• Any medications that could affect elimination?

Abnormal Defecation Patterns

Diarrhea

• Abnormal frequency & consistency of bowel movements. Bowel sounds are hyperactive.

• Causes: Infections, medications, food intolerances.

• The nurse knows that Clostridium difficile (C. diff) is a bacterial infection that can lead to life-threatening inflammation of the colon. Most commonly affects hospitalized patients. Typically occurs after the use of what type of medications? Antibiotics.

• Treatment: Depends on the cause. Serious fluid & electrolyte losses can develop if left untreated.

Constipation

• Infrequent or difficult bowel movements (BM), fewer than three times per week. Can lead to protrusions or outpouching in the colon called diverticula.

• Can lead to diverticulitis or infection of these protrusions.

• Diverticulosis can also lead to hemorrhoids and anal fissures.

• Causes: Ignoring the urge to go, decreased fiber & fluid intake, sedentary lifestyle, medications, and stress.

• Treatment: Increase dietary fiber, fluids, and physical activity, and possibly use laxatives.

Elimination Overview

• Poop can kill! Elimination is a normal function of the body and critical to maintaining nutritional status, hydration, and fluid and electrolyte balance.

• As nurses, we must ask:

  • When was your last BM?

  • Any changes in elimination patterns (color, consistency, or odor)?

  • Any pain with elimination?

  • Any medications that could affect elimination?

Fecal Impaction

• Fecal Impaction: Hard fecal mass (stool blockage) in the rectum or colon that the patient is incapable of expelling.

  • Causes: Chronic constipation, ignoring the urge to go, dehydration.

  • Cardinal sign: Oozing of liquid stool, abdominal discomfort, nausea & vomiting.

  • Treatment: Manual disimpaction, enema, suppository, or digital disimpaction (done by healthcare professionals).

Paralytic Ileus

• Definition: Paralytic Ileus is caused post-operatively from anesthesia that causes peristalsis to slow or cease.

• Treatment: NG tube, ambulation, and monitoring bowel sounds.

Bowel Diversions

Colostomy

• A bowel diversion is surgically created when a portion of the colon (large intestine) or rectum is removed, and the remaining colon is brought through the abdominal wall.

• Ostomy: General term for a surgical opening.

• Stoma: Means "mouth" in Greek; an opening where the intestine is brought through the abdominal wall to form a stoma.

Ileostomy

• Ileostomies may be temporary or permanent and may involve the removal of all or part of the colon.

• Stools from an ileostomy are liquid and frequent, and drainage cannot be regulated.

• Drainage contains digestive enzymes, which can be damaging to skin.

Factors Affecting Bowel Elimination

• Diet:

  • Adults need 20 to 30 grams of fiber each day.

  • Cheese, pasta, eggs, and lean meats can cause constipation.

  • Poor fluid intake increases the risk of constipation.

  • Bran, prunes, figs, alcohol, and chocolate have a laxative effect.

• Physical Activity:

  • Regular physical activity promotes peristalsis and maintains the tone of pelvic muscles and the abdominal floor.

• Psychological Factors:

  • Personal Habits:

  • When the urge to defecate is habitually suppressed, it may be lost, leading to constipation and impaction.

• Posture:

  • Immobilized patients cannot effectively contract abdominal muscles, making defecation difficult.

• Pain:

  • Hemorrhoids, rectal surgery, and abdominal surgery will cause patients to suppress the urge to defecate to avoid pain.

• Surgery & Anesthesia:

  • Anesthesia blocks parasympathetic stimulation to the colon muscles and causes peristalsis to slow or cease.

  • The stoppage of peristalsis is called paralytic ileus, which can last 24-48 hours.

Types of Laxatives

1. Bulk-forming:

   • Absorbs water into the intestine, increasing bulk and distending the bowel to initiate bowel activity.

   • Example: Psyllium.

2. Emollient:

   • Allows more water & fat to be absorbed in the stool, softening it.

   • Example: Docusate sodium.

3. Hyperosmotic:

   • Increases fecal water content.

   • Example: PEG 3350, lactulose (also decreases blood ammonia levels).

   • Used before diagnostic tests.

4. Saline:

   • Draws water into the colon.

   • Example: Magnesium hydroxide, Milk of Magnesia.

5. Stimulant:

   • Stimulates nerves in the intestine to increase peristalsis.

   • Example: Senna.

   Risk: Dependency and dehydration.

Bowel Diversions (Urinary Diversions Included)

• Purpose:

  • An ostomy pouch effectively collects fecal material (effluent), while a urostomy collects urine.

  • Changing the ostomy pouch is critical to:

    • Maintain skin integrity.

    • Assess stoma healing and integrity:

      • A healthy stoma appears pink and moist.

      • An unhealthy stoma appears pale or necrotic.

    • Cleanse the stoma with warm water.

    • Prevent odors.

    • Promote comfort and maintain or increase self-esteem and dignity.

Lab Tests & Diagnostics

1. Fecal Occult Blood Test:

   • Detects hidden (occult) blood in the stool.

   • Collected stool is placed on a hemoccult card.

   • Requires the collection of three small stool samples, one day apart.

   • Teach patients to avoid certain foods (beets) and how to collect samples.

2. Upper GI Series (Barium Swallow):

   • Barium is swallowed, and an X-ray is taken to visualize the upper GI tract.

   • NPO 4-8 hours before the test.

   • Constipation is a major side effect.

   • Encourage extra fluids after the procedure.

3. Lower GI Series (Barium Enema):

   • Barium is inserted into the colon, and an X-ray is taken to visualize the lower GI tract.

   • Liquid diet two days before the test, clear liquids for 24 hours.

   • Laxative prior to the test.

4. Endoscopy (Esophagogastroduodenoscopy):

   • A fiberoptic endoscope with a camera is passed into the stomach.

   • NPO 8 hours before the test.

   • Check gag reflex post-procedure before allowing food or drink.

   • Biopsies can be taken.

5. Colonoscopy:

   • Clear liquid diet for 1-3 days, NPO several hours before the procedure.

   • A long colonoscope with a camera is inserted into the rectum.

   • Biopsies can be taken.

Administering an Enema

• Purpose:

  • Promotes bowel cleansing, relieves constipation, empties the bowel for diagnostic tests or surgery, and begins a bowel training program.

• Position: Patient should be in the left lateral (Sims') position.

• Documentation: Record the results, including the type of enema, amount of solution, characteristics of stool, and patient tolerance.

Urinary System and Catheterization

• Normal Urine Output:

  • Average adult passes 960 to 1920 mL of urine a day (approx. 50-60 mL/hour).

  • Safe practice alert: If less than 30 mL/hour, it may indicate kidney failure and should be reported to the patient's HCP immediately.

Urinary Terms

• Polyuria: More than 2000 mL of urine a day.

• Nocturia: Excessive urination at night. (Especially Men with BPH)

• Dysuria: Painful urination. (Women with UTI)

• Hematuria: Blood in the urine.

• Oliguria: More than 100 mL but less than 500 mL a day.

• Anuria: Less than 50 to 100 mL a day

When kidneys fail...

Dialysis is a medical technique used to remove waste products and excess fluids from the blood when the kidneys are no longer able to perform this function. It works by filtering fluids and molecules through an artificial semipermeable membrane via osmosis.

1. Hemodialysis:
   In this procedure, the patient’s blood is filtered externally through a machine. Blood is drawn from the body using vascular catheters and passed through the dialysis machine, where it is cleaned before returning to the body.

2. Peritoneal Dialysis:
   In this process, a dialysis solution is instilled into the patient's abdominal cavity through an external catheter. The peritoneal membrane acts as a natural filter to remove waste and fluid from the blood.

Safe Practice Alert:

• Careful monitoring of intake and output (I&O) is essential to ensure the patient’s fluid balance is properly managed. Accurate measurement and documentation are critical for patient safety during dialysis.

Urinary Diversions

A urinary diversion is a surgical procedure used to reroute the normal flow of urine due to damage or disease affecting the bladder, urethra, or distal ureters.

• Indications: Trauma, cancer, or disease involving the bladder or urinary tract.

• Types: Depending on the location of the damage, different methods may be used to create an alternative route for urine to exit the body, often involving a stoma.

Urinary Catheterization

Urinary catheterization involves the insertion of a tube (catheter) into the bladder to drain urine. Catheterization must be performed using aseptic (sterile) technique and sterile equipment, as recommended by the Centers for Disease Control (CDC), to prevent infections.

• Catheter Bag Placement: The catheter bag should be kept below the level of the bladder at all times to prevent the backflow of urine, which could lead to infections.

• Catheter Bag Emptying: The drainage bag should be emptied when it is 1/3 to 1/2 full, or as per facility guidelines, to prevent overflow and leakage.

Types of Urinary Catheters

1. Straight Catheter:
   A single-use catheter that is inserted into the bladder to drain urine and then removed immediately after the bladder is empty.

2. Double Lumen (Indwelling) Catheter:
   Commonly referred to as a Foley catheter, this type of catheter remains in the bladder for an extended period and has two lumens—one for draining urine and the other for inflating the balloon that keeps the catheter in place.

3. Triple Lumen Catheter:
   This catheter has three channels—one for urine drainage, one for inflating the balloon, and one for bladder irrigation, which is often required after bladder surgery or for patients with bladder clots.

4. Coude Catheter:
   A catheter with a curved tip is often used for male patients who have an enlarged prostate, which may make regular catheterization more difficult.

Alternatives to Indwelling Urinary Catheters

There are non-invasive options available for urinary management when indwelling catheters are not ideal:

• For Females: Devices such as external urinary collection systems or intermittent catheterization may be used to manage urinary output.

• For Males: External catheters, such as condom catheters, are often preferred as a less invasive option to manage urine drainage.

Elimination Vocabulary

Bowel Vocabulary (Chapter 40)

1. Bowel Incontinence:
   The involuntary loss of bowel control, leading to unintentional passage of stool.

2. Constipation:
   Difficulty in passing stools or infrequent bowel movements, typically fewer than three per week.

3. Diarrhea:
   Frequent, loose, or watery stools, often accompanied by abdominal cramping and urgency.

4. Impaction:
   A large, hard mass of stool that becomes stuck in the colon or rectum, often preventing normal bowel movements.

5. Flatulence:
   The presence of excess gas in the digestive system, leading to bloating, discomfort, and passing of gas.

6. Paralytic Ileus:
   A temporary cessation of peristalsis in the intestines, often following surgery, leading to bowel obstruction and lack of bowel sounds.

7. Stoma:
   An artificial opening created surgically in the abdominal wall through which part of the intestine (or urinary tract) is brought outside the body to allow waste to exit.

8. Colostomy:
   A surgical procedure in which a portion of the colon is brought through the abdominal wall to form a stoma, allowing stool to bypass the rectum.

9. Colonoscopy:
   A diagnostic procedure using a flexible camera (colonoscope) inserted into the rectum to visualize the colon and detect abnormalities.

10. Ileostomy:
    A surgical procedure in which the ileum (the final part of the small intestine) is brought through the abdominal wall to form a stoma. Stools are typically liquid or semi-liquid.

11. Melena:
    The passage of dark, tarry stools, indicating the presence of digested blood, usually from bleeding in the upper gastrointestinal tract.

12. Hematochezia:
    The presence of fresh, bright red blood in the stool, usually indicating bleeding from the lower gastrointestinal tract (such as the colon or rectum).

Urinary Vocabulary (Chapter 41)

1. Anuria:
   The absence of urine production or extremely low urine output, typically less than 100 mL per day.

2. Oliguria:
   A significantly reduced urine output, usually defined as producing more than 100 mL but less than 400 mL of urine per day.

3. Polyuria:
   Excessive urine output, typically more than 2000 mL per day, which may be associated with conditions like diabetes.

4. Nocturia:
   The need to wake up and urinate frequently during the night, which may be caused by various health conditions, including urinary tract infections or heart failure.

5. Dysuria:
   Painful or difficult urination, is often associated with urinary tract infections or inflammation.

6. Hematuria:
   The presence of blood in the urine, which may be visible (gross hematuria) or only detected under a microscope (microscopic hematuria).

7. Urinary Incontinence:
   The involuntary leakage of urine, which can result from weakened pelvic muscles, nerve damage, or other medical conditions.

8. Urostomy:
   A surgical procedure that creates a stoma for the urinary system, diverting urine away from the bladder when the bladder is not functioning properly.