Nr210 Alt Elim
NR210: Alterations in Elimination
Ray
1.
Factors that affect GI elimination
Defecation:
the expulsion of feces from the anus and rectum
Factors that facilitate defecation:
1.1
Age and development
A.
Young
Neuromuscular control
B.
Elderly
Decreased smooth muscle tone of colon:
Decreased abdominal muscle tone:
Decreased anal sphincter control:
1.2.
Diet
A.
B.
C.
D.
Bulk
Digestion of foods
Spicy foods
Eating schedules/routines
1.3.
Fluid intake
1.4.
Mobility/Immobility
A.
Activity
B.
Muscle tone/strength
1.5.
Psychological consideration
1.6.
Life-style considerations
A.
Early bowel training
B.
Availability of toilet facilities
C.
Embarrassment about odors
D.
Need for privacy
E.
Time management
1.7.
Medications
A.
Side effects
B.
1.8.
GI medications
laxatives, antidiarrheal medications,
stool softeners, enemas
Diagnostic procedures
A.
Preparing the pt for a diagnostic exam:
NPO status
"Bowel prep"
Nr210 Alt Elim
1.9.
B.
Barium studies
Anesthesia and surgery
A.
Parasympathetic stimulation
B.
Abdominal surgery
C.
Paralytic ileus
distended, painful abdomen, absent bowel sounds, nausea. Usually lasts
24 - 48 hours
1.10.
Pathologic conditions
A.
Altered sensory stimulation or sensation
spinal cord injury, head injury
B.
Impaired mobility/decreased physical strength
1.11.
Irritants
bacterial toxins, poisons
1.12.
2.
Pain
Common GI elimination problems
2.1.
Constipation
the passage of small, dry, hard stool
the passage of no stool for a period of time.
The slower the chyme moves through the colon, the more fluid is absorbed from the stool
and the harder and drier it becomes.
A.
B.
C.
Identify the client's normal bowel patterns
Defining characteristics of constipation
decreased frequency defecation, hard, dry stools, straining to defecate,
painful defecation, abdominal pain/cramps, rectal pressure or fullness,
headache, palpable fecal mass
Factors which contribute to the development of constipation
1.
Irregular defecation habits
2.
Overuse of laxatives
3.
Increased psycho logic stress (long term stress response)
4.
Inappropriate diet
5.
Insufficient fluid intake
6.
Age
7.
Disease processes
bowel obstruction, paralysis
Nr210 Alt Elim
D.
E.
F.
2.2.
Complications r/t constipation
Bowel obstruction, nausea, vomiting
Initiation of the vagal response
Fecal impaction
(the collection of hardened feces in the rectal folds)
s/s:
no stool, diarrhea, abnormal stools, pencil-like feces, palpation of
fecal mass
anorexia, distended abdomen, nausea, vomiting
treatment:
Mineral oil enema followed by soap suds enema
Digital removal of stool (Monitor vital signs
closely!)
Teach to prevent reoccurrence!
Hemorrhoids (see discussion below)
Treatment
A. Medications
laxatives and/or stool softeners
enemas
B.
Increase fluid intake
C.
Increase bulk in diet
D.
Increase activity
E.
Teach re: prevention
Prevention
A.
For the hospitalized pt
B.
Indications for prophylactic stool softener therapy
Diarrhea
the passage of liquid feces
frequent passage of unformed feces
A.
B.
C.
S/S:
(see above plus abdominal cramping, urgency, sometimes blood and
excessive mucus)
Treatment:
A.
Medications
B.
Maintain fluid intake
C.
Monitor for signs of dehydration,
fluid/electrolyte imbalances
D.
Preventive perianal skin care
Complications:
Alterations in fluid/electrolyte status
Alterations in skin integrity
Nr210 Alt Elim
2.3.
Bowel incontinence
The loss of voluntary control of gaseous and fecal discharges.
A.
Types
Partial
Major
B.
Causes:
Impaired neurological fx
diarrhea
C.
Social considerations:
2.4.
Flatulence
The presence of excessive air or gas in the GI tract.
A.
Etiology:
action of bacteria on large intestine chyme
swallowed air
gas that diffuses from the bloodstream into
the GI tract
B.
C.
2.5.
Postoperatively
(depending on the type of surgery, anesthetic agent used,
pre/postop dietary changes, patient's postoperative activity level)
Other: narcotics, constipation, meds that decrease GI motility, anxiety,
gas-forming foods
S/S:
GI distention, pain, abdominal cramping
Treatment:
Positioning of pt:
Decreased amt of swallowed air:
1.
2.
3.
4.
Nasogastric tube insertion
Hemorrhoids (piles)
Distended veins in the anal area. Can be internal or external.
A.
S/S:
asymptomatic, or pain, itching, burning, blood in the stool
B.
Etiology:
Chronic constipation, straining during defecation, pregnancy, obesity
C.
Treatment:
Astringents, stool softeners
Nr210 Alt Elim
3.
Nsg process for client with GI elimination alterations
3.1.
Assessment Data
Nsg Hx:
Pt's normal defecation patterns
Description of feces and any changes
Pt's description of fecal elimination problems
Pt's perception of factors influencing fecal
elimination
Physical Assessment:
Abdominal assessment
inspection, auscultation, percussion, palpation
Diagnostic Studies:
Anoscopy, proctoscopy, colonoscopy
Abdominal xrays
Stool specimens for C and S, blood, etc.
3.2.
Nursing diagnoses
Constipation r/t...
Bowel incontinence r/t....
Diarrhea r/t....
Potential fluid volume deficit r/t...
Potential alteration in skin integrity r/t...
3.3
Goals/Planning of pt care
Promote normal defecation patterns
Allow for privacy
Facilitate timing
Nutrition/fluids as indicated
to prevent/treat constipation
hot/warm liquids, fruit juices, prunes, raw fruit, bran cereal, whole-grain
cereals
to prevent/treat diarrhea
BRAT diet (bananas, rice, applesauce, tea/toast); encourage fluids
Maintain optimal activity level
Positioning
Administer prescribed meds and enemas
3.4.
Evaluation
Nr210 Alt Elim
4.
Factors that affect urinary elimination
The urinary output is dependent upon:
the amount of urine formed
the process of voiding.
Terms:
micturation, voiding, urination, "empty the bladder"
4.1.
Growth and development
A.
Young
Neuromuscular control
B.
Elderly
Frequent urination
Excessive urination at night
Increased risk of UTI
Some degree of urinary incontinence
(r/t decreased perineal muscle tone, UTI,
physical impairments, sensory/cognitive impairments)
4.2.
Psychosocial factors
privacy
"normal position":
4.3.
4.4
4.5.
men
women
sufficient time
running water
Fluid and food intake
A.
Substances which promote diuresis
alcohol, coffee, cola, tea
B.
Substances which promote fluid retention
Medications
Diuretic therapy
Muscle tone/mobility/immobility
4.6.
Pathologic conditions
endocrine alterations:
diabetes insipidus (urine formation)
vascular alterations:
renal failure (urine formation)
renal alterations:
decrease/increase urine formation;
could decrease urine excretion
Febrile conditions:
_____ urine formation and _____ urine concentration
Prostate disease:
decreases urine excretion
4.7.
Surgical/diagnostic procedures
Urinary catheterization, cystoscopy
Spinal anesthetics
Abdominal surgery
Nr210 Alt Elim
5.
Common urinary elimination problems.
A.
B.
Normal urine output
Voiding patterns
5.1.
Polyuria diuresis
The production of abnormally large amounts of urine by the kidneys.
A.
Etiology:
B.
Other S/S:
5.2.
Oliguria and anuria
Oliguria:
voiding scant/small amts of urine (100 - 500 ml/day)
anuria: voiding less than 100 ml per day.
Etiology:
5.3.
Frequency and nocturia
Frequency:
voiding at frequent intervals.
Nocturia:
frequency at night (that is not the result of increased fluid
intake).
Etiology:
5.4.
Urgency
The feeling that a person must void immediately.
Etiology:
5.5.
Dysuria
Burning on urination. Often associated with hesitancy.
Etiology:
5.6.
Enuresis
Repeated involuntary urination in children beyond the age when voluntary
bladder control is normally acquired (usu 4-5 years of age).
A.
Nocturnal enuresis:
Involuntary urination during sleep.
B.
5.7.
Diurnal Enureses:
Involuntary urination during the waking hours.
Urinary incontinence
5.7.1. Total incontinence:
Continuous and unpredictable loss of urine.
Nr210 Alt Elim
5.7.2.
5.8.
Stress incontinence:
The leakage of a small amount of urine (less than 50ml) as a
result of a sudden increase in intra-abdominal pressure.
5.7.3. Urge incontinence:
An individual who is unable to suppress the urge to void.
5.7.4. Functional incontinence:
Involuntary, unpredictable passage of urine.
5.7.5. Reflex incontinence:
An involuntary loss of urine which occurs at somewhat
predictable intervals.
5.7.6. Urinary retention with overflow:
Dribbling of urine which occurs when the bladder is greatly
distended with urine.
Neurogenic bladder:
Any voiding problems secondary to neurologic impairment or dysfunction.
5.9.
Urinary retention
The accumulation of urine in the bladder.
S/S:
discomfort in the pubic area
bladder distention
inability to void or the frequent voiding of small
amounts of urine (25 - 50 ml)
Intake is significantly greater than output.
increasing restlessness
Treatment:
6.
Nursing process for the client with
6.1.
urinary elimination alterations.
Assessment
A.
Nursing history
Determine normal voiding patterns
Description of urine
Description of urinary elimination alterations
Assess for factors which might influence urinary
elimination
Assess PO intake
Nr210 Alt Elim
B.
C.
Physical assessment
Palpation, percussion of bladder, kidneys
Evaluation of the I and O
Diagnostic studies:
Evaluation of the urine:
color, clarity, odor, specific gravity, glucose, ketones, blood, Ph
Review results of lab diagnostics
Blood urea nitrogen (BUN), Sodium (Na)
Creatine clearance
Urine C and S
Intravenous pyelogram (IVP), x-ray of kidneys,
ureters, bladder (KUB)
Nursing diagnoses
Incontinence r/t...
Altered patterns of urinary elimination r/t...
Alteration in body image r/t...
D.
Planning
Prevention of incontinence
Prevention of altered skin integrity
Manages incontinence sufficiently to maintain social function
E.
Implementing
Maintain normal/adequate fluid intake. (for optimal Urinary fx)
Normal: 1200-1500 ml per day
Immobilized client:
2000-3000 ml per day
Promote normal voiding habits.
Promote comfort and relaxation.
Caring for incontinent patients.
Caring for a patient with urinary retention.
6.5.
"Elim.210"
06/05 JR
Evaluation.