Elimination
Basic Principles
 Wash Hands & Wear Gloves
 Infection control, your protection & your
client’s protection
 Privacy
 Embarrassing
 Positions for urination
 Independence
Functions of Urinary
System
 Remove wastes from blood to form urine
 Remove nitrogenous waste products of
cellular metabolism
 Regulates fluid and electrolyte balance
The nephron = functional unit of the
kidney and forms the urine
Goal of Urinary System
 To maintain chemical homeostasis of the
blood.
 Filtration by the Nephrons
 H2O, glucose, amino acids, urea, creatinine,
major electrolytes
 Not normally large proteins or blood cells
 Proteinuria is a sign of glomerular injury
 Normal adult 24hr output = 1500-1600ml.
Overview of Urinary
System
 Kidneys
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Bean shaped organs
Either side of vertebral columns T12 – L3
Right kidney lower due to liver
Urine produced with filtration of blood
through nephrons
 Major role in fluid & electrolyte balance
 Ureters
 Connect kidneys to bladder
 10 -12 in length, ½ in diameter in adult
 Peristaltic waves
 Renal colic
 Micturition
 Bladder
 Distensible, muscular sac
 Reservoir for urine ( approx. capacity =
600mls )
 Organ of excretion ( norm. voiding= 300mls)
 Lies in pelvic cavity behind symphysis pubis
 Urethra
 Short, muscular tube
 Urine from bladder to meatus and from the
body
 Female 4-6.5cm (1 ½ - 2 ½ in.) length
 Male 20cms ( 8 in.)
 Urinary and reproductive systems
 Meatus
 External opening of the urethra, male &
female
 The need to void is a conscious
awareness
Life Cycle Changes
 Infants & children
 Unable to concentrate urine b/c kidneys are
immature
 Urine is light yellow
 Void frequently
 Voluntary control @ 24mos. when
neuromuscular structures develop
 Adult
 1500 – 1600 mls urine/24hrs
 Concentrates urine – normal is amber
colored
 Nocturia
 Not usually
 Decreased renal blood flow during rest
 Ability to concentrate urine
 Elderly
 Micturition impaired
 mobility
 Diseases, alzheimer’s, CVA
 Physiological age related changes
 Bladder loses muscle tone and capacity
 Kidneys lose ability to concentrate urine
 Bladder loses muscle strength
Common Problems
 Urinary Retention
 Accumulation of urine in the bladder
 Inability to empty
 Pressure, discomfort and tenderness
 Residual Urine = urine retained in the
bladder after voiding
 Incontinence
 Loss of voluntary control to void
 Infection, nerve damage to bladder or brain, spinal cord
injury, or aging process
 Total incontinence = no control
 Stress incontinence = sm. amts. Urine excreted
involuntarily with coughing or laughing
At risk for skin breakdown related to acid urine
next to skin.
Adult Diapers or Attends
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Frequency & Urgency
Nocturia
Enuresis – involuntary discharge of urine
Nocturnal Enuresis
 During sleep
 Bed-wetting children 5yrs and older
 Oliguria
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30mls/hr or 720 mls/24hrs
 Renal anuria
 cessation of urine production
100mls/24h
Promoting Healthy Urinary
Elimination
 Urinate as soon as the urge is felt
 Avoids stasis and distention
 Prevents urgency, infection, and
incontinence
 Drink about 2liters fluid/day
 Limit Na, caffeine, and alcohol
 For people with Nocturia
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fld. Intake in the p.m.
caffiene and alcohol
Void before bedtime
 For Women
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Wipe perineum front to back
Void soon after intercourse
Wash hands
Pelvic – floor strengthening exercises (Kegel
Exercises)
Client Education
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S & S of infection
Fluid intake ( if no restrictions 2-5 L/day )
Perineal hygiene
Meds. & side effects on urination, color,
and volume
Facilitating Micturition
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Nursing Measures to promote voiding in
people who are having difficulty:
1.
2.
3.
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5.
Privacy and natural position
Providing commode or bathroom
Running water
Warm water to dangle fingers
Warm water over perineum ( measure if on
In/Out )
6. Gently stroking inner thighs or pressure
to symphysis pubis
7. Pain relief
Warmth to the bladder & perineum relaxes
muscles & facilitates voiding. ( Sitz bath
or warm tub )
If unsuccessful- urinary catheterization
may be indicated
 Promoting complete bladder emptying
 Prevention of infection
 Good perineal hygiene
 Adequate fld. Intake
 Dilutes urine & flushes urethra
 Acidifying urine ( inhibits microorganisms)
 Cranberry juice, whole grain breads, meats,
eggs, prunes and plums.
Indwelling Catheter Care
 Goal- prevent infection & maintain
unobstructed flow of urine. Monitor
for problems.
 Perineal hygiene @ least 2x/day and
prn
 Do not advance catheter further into
urethra during perineal care
Catheter Care
 Fld intake (3L/day )
 Handwashing and Gloves
 Positioning
 Urine bag
 Tubing
Bowel Elimination
 Function- excrete/eliminate waste
products of digestion.
 Maintaining normal bowel elimination is
essential to health and efficient body
functions.
GI System
 Small Intestine
 Absorption nutrients & electrolytes
 20 ft length, 1 in. diameter
 3 sections
 Duodenum
 Jejunum
 Ileum
GI
 Large Intestine
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Absorbs H2O and electrolytes
Temporarily stores waste products
Main function is elimination
5 – 6 ft. length, 6 – 7 cm. diameter
 Cecum
 Ascending colon ( Right side )
 Transverse colon
 Descending colon
Patterns through life cycle
 Babies: 3 – 6 BM’s/day
 Children:
 Neuromuscular structures not developed
until 15 – 18 mos.
 Voluntary control 2 – 3 yrs.
 Pregnant women prone to constipation
 Pressure on abd. Organs
 Iron supplements
 Elderly prone to constipation
 Slowing of peristalsis
Determinants affecting
elimination
 Dietary patterns & fld. Intake
 6 – 8 glasses H2O/day ( 1400- 2000mls )
 fld.
Liquifies stool
 Dietary fiber stimulates peristalsis
 Soft stool
Factors affecting
elimination
 Fiber ( undigestible residue ) provides
bulk
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Absorbs fluid
Increases stool mass
Bowel wall stretches
Peristalsis stimulated
Defecation results
Factors affecting
elimination
 Personal habits
 Busy schedule, postpone BM, constipation
 Activity & exercise
 Immobile
activity in colon
 Medications
 Laxatives
 Narcotics with codiene
Factors affecting
elimination
 Emotions
 Anxiety
peristalsis & diarrhea
 Depression
 Pain
 Surgery
 Anaesthetic causes temporary cessation of
peristalsis
 Direct manipulation of the bowel stops
peristalsis
Common Problems
1. Constipation – difficult passage of hard,
dry stool; infrequent movements
2. Fecal Impaction – unrelieved
constipation, feces wedged in rectum,
no BM usually 3days, oozing of
diarrheal stool develops
3. Diarrhea- # liquid stool
4. Flatulence – abd. Distention & pain
Common Problems
 Incontinence – inability to control
passage of stool
 Hemorrhoids
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Dilated engorged veins
Increased pressure when straining
Internal / external
Bleeding
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Daily BM Not essential.
 2 / week a concern
Defecation pattern
BM, Stool, Feces, Defecate – all mean
waste products expelled via the bowel
Promoting Healthy Bowel
Elimination
Privacy
Squatting position
Bedpan position
Cathartics & laxatives
Anti- diarrheal agents
Enemas
disimpaction
Bowel routine
Daily time clock
Hot drinks
Stool softeners
Privavy
Position and abdominal pressure
Bearing down
Assissting with
Elimination
 Embarrassing & stressful
 Usually urge to defecate 1hr. Pc
 Bedpans
 Metal or plastic
 Regular or fracture pan
 Cleanliness
 Urinals
 Commode
Procedure
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Privacy- close door,
Side rail as needed
Recumbent with HOB
Tissue
Call bell
Leave alone if possible
Gloves
Clean genitals
Procedure
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Remove pan and cover
In & Out
Specimens
Clean pan
Wash hands yours and client’s
Lower bed
Client comfort
Peri - Care
 Cleaning of genitals , routine part of
complete/ partial bed bath
 Incontinence
Procedure for Peri Care
 Regular patient
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Simple explanation- layman’s terms
Privacy
Gloves
Dorsal recumbent position
Incontinent pad under buttocks
Warm soap and water
Female – separate labia
Procedure for Peri Care
 Male – begin penile head move down
along shaft, retract foreskin, rinse and
dry.
Procedure for Peri Care
 Catheter –
 Q 8 hrs.
 Clean perineum & 2in. Of catheter
 No powders / lotions
 Avoid advancing catheter
 Keep urine drainage bag off floor but below
level of bladder
 Empty bag Q8 – 12hrs or when bag is full,
remember to mark amt. Emptied on In/Out
sheet
 Avoid use of baby powder/ cornstarch
 No medicinal purpose
 Can form clumps or will cake in creases
 Use vaseline/ zincoxide as skin barrier for
incontinent clients
Suppository
Administration
Check physician’s order, protocol
Left Lateral position
Gloves
Lubication
Hold with thumb and index finger
Insert with index finger (3 – 4”) never
force
 Deep breath = relaxes anal sphincter
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 Caution
 Vagus nerve stimulation can cause heart
rate to slow – avoid excess manipulation
Enema Administration
 Main purpose
 Promotion of defecation, stimulate peristalsis
 The fluid breaks up fecal mass, stretches the
rectal wall & initiates the defecation reflex
Types of Enemas
Cleansing Enemas
 Tap Water
 Hypotonic
 Used only once
 Electrolyte imbalance
 Water toxicity
 Circulatory overload ( concentration gradient)
 Normal Saline
 Used when more than one enema is
needed
 Safest
 Isotonic
 Large volume to distend bowel
 Hypertonic Solution
 Smaller volume of fluid
 Draws from surrounding tissue into bowel to
soften stool and stimulate peristalsis
 Fleets – sodium phosphate
 Low volume, concentrated solution
 Soap suds
 Less common
 Soap irritates the bowel
 5 – 15 mls. Castile soap in 1000mls warm
water
 Oil Retention
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Oil based solution
Lubricates the rectum and colon
Softens stool, easier to pass
Retain 1 –2 hrs if possible
Follow with cleansing enema
 Medicated
 Instill meds.
 Rectal mucosa absorption
 Ex. – Kayexalate to K (potassium).
Absorbs K from the intestinal tract
Volumes for Enemas
 Large Volume
 500 – 1000mls.
 Container 12 – 18 in. above the bowel
 Lg. Volume stimulates & causes evacuation
of stool
 Small Volume
 500 mls.
 Container 12 in.above bowel
Volumes for Enemas
 Pre packaged
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Fleet 150mls
Microlax 5mls
Hypertonic solution
User friendly
Hold for 5min.
 Oral Fleet
 Prepackaged used more than large
volume because:
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Works
Less risk for electrolyte imbalance
Rapid administration
Less discomfort and distention
Convenient and quick
 Physician’s order reads “ enemas to
clear”
 No more than 3 total given
 Return solution will be highly colored but no
solid stool
 Isotonic solution (normal saline)
Excess enema use seriously depletes fluid
and electrolytes
Procedure for Enema
Administration
 Confirm Dr’s order, prepare client, verbal
consent, equipment, privacy
 Left lateral position ( fld. Flows by gravity)
 Drape, pad under buttocks
 Warm solution- stimulates peristalsis
 Hot sol’n burns mucosa
 Cold sol’n causes cramping
Procedure for Enema
Administration
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Prime tube
Lubricate tip
Glove
Insert 7 – 10 cm.(3-4in) adult
 Do not force
 Deep breath
 Guide toward umbilicus
Procedure for Enema
Administration
 Container at appropriate height
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Lg. = 12 – 18in
Sm. = 12in
1000mls takes ~ 10 min to instill
Higher the bag – greater the pressure
 C/O discomfort, lower bag, slow infusion,
stop, then start again
 Remain side lying to retain 5 – 10 min. or
as long as possible
Procedure for Enema
Administration
 Assist to bathroom or give bedpan
 Evaluate results
 Document
 Type & volume of enema
 Color, amount, consistency of fecal return
 Hygienic measures for client
 Wash Hands
Ostomy Care
 Certain diseases require surgical
interventions to create an opening into
the abdominal wall for fecal and urinary
elimination
 Enterostomy – the surgical procedure
performed to produce the artificial
stoma.
Definitions
 Ostomy = opening made to allow passage of
urine or stool
 Piece of intestine is brought out onto the client’s
abd.
 Lacks nerve endings
 Doesn’t hurt to touch but has other implications
 Stoma = mouth like opening in the abdominal
wall to drain urine or stool
 Effluent – drainage from stoma
 Bowel ostomies
 Cancer ( Ca)
 Drain fecal material
 Consistency depends on location
 Higher up = more liquid
 Greater risk skin irritation b/c concentration
of digestive enzymes
 Ileostomy
 End of small intestine
 By passes lg. Intestine = freq. Liquid stools
 Colostomy
 Large intestine
 More solid stool
 Ostomies may be permanent
 More common
 temporary
 Rest the bowel
 Crohn’s
Urinary Ostomies
 Provide drainage of urine that bypasses
the bladder = Urinary Diversion
 Ureterostomy
 Ureter to abd. Wall
 Lt., Rt., Bilateral
Ileal Conduit
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6 – 8 in. ileum
1 end for external opening
Other end closed off
Ureters implanted into this piece of bowel
Pouch
Urine will have shred of mucus b/c bowel
still produces same
Concerns
 Infection
 Sterile ureters provide opening into system
 Skin Breakdown
 Continuous drainage
 Moisture on skin
 Replace urinary pouch q 2-3 days
Pouching an Enterostomy
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Effluent ( drainage ) may begin immediately
Collects all effluent
Protects the skin
Stoma should be moist and reddish pink (same
as other mucus membranes)
 Flush to skin or bud-like protrusion
 Black, purple, dry = inadequate circulation
Pouch with Skin Barrier
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Comfortable fit
Cover skin surrounding stoma
Good seal
Post-op pouch should allow for visibility
of stoma
Types of pouches and skin
barriers
 One Piece Pouching System
 Skin barriers preattached, precut, custom fit
 Two Piece System
 Skin barrier with flange ( plastic ring)
 Corresponding size pouch
 Assess stoma
 Measure correct size
 Change q 3-7 days
 Empty 1/3 to ½ full, expel flatus prn
Steps to Care for
Ostomies
 Supine position
 Wash hands, glove
 Remove pouch & skin barrier, push skin
away from barrier
 Cleanse peristomal skin gently with warm
tap water and clean cloth
 Do not scrub, Avoid soap ( residue- pouch
won’t adher)
Steps to Care for
Ostomies
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Correct sizing
Cut opening 1/16 – 1/8 larger than stoma
Remove backing
Ileostomy- apply thin circle barrier paste
around opening of pouch and allow to dry
(if creases or bumps use barrier paste to
even surface for pouch application)
Steps to Care for
Ostomies
 Pouch should point to client’s knees
 Maintain gentle finger pressure around
barrier for 1-2 min.
 Picture frame flange with non allergic
paper tape
 Ostomy deodorant for pouch
 Tub bath or shower
Steps to Care for
Ostomies
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Normal stoma oozes blood if rubbed
Actual bleeding into pouch is abnormal
Pouch covers are available
The client will be watching the nurse
during ostomy care to gage reaction.
 Be conscious of facial expression &
nonverbal cues
Steps to Care for
Ostomies
 Education
 Counseling
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Body image
Self care
Fear of rejection
Sexual function
Powerlessness over bowel regulation