Elimination: Bowel & Urinary – Flashcards

Normal elimination of urinary wastes is a function that affects all body systems. Patients with alterations in urinary elimination may suffer emotionally from body image changes. It is important to know the reasons for urinary elimination problems, to find acceptable solutions, and to provide understanding of and sensitivity to all patients' needs.

Urinary elimination depends on the function of: *Kidneys *Ureters *Bladder *Urethra All organs of the urinary system must be intact and functional for successful removal of urinary wastes.

Remove waste from the blood to form Urine

Transport urinne from the kidneys to the bladder.

Holds urine until the urge to urinate develops.

Where urine leaves the body.

Growth and development Sociocultural factors Psychological factors Personal habits Fluid intake Pathological conditions Surgical procedures Medications Diagnostic examinations

Factors in children include physical development and readiness. Factors in older adults include decreased bladder capacity, increased bladder irritability and an increased frequency of bladder contractions during bladder filling. Older adults are at increased risk for urinary incontinence caused by chronic illnesses and problems with mobility, cognition, and manual dexterity.

will determine the degree of privacy needed for urination. Social expectations (e.g., school recesses, work breaks) can interfere with timely voiding.

Anxiety Stress Depression Anxiety and stress may increase voiding. Depression may decrease desire for urinary continence.

can influence the ability to adequately empty the bladder, such as... *need for privacy *adequate time to void,

(increased) increases urine production if fluids, electrolytes, and solutes are balanced. Alcohol decreases the release of antidiuretic hormones, which increases urine production. Fluids containing caffeine or other bladder irritants can cause bladder contractions, resulting in frequency, urgency, and incontinence.

affect urination. Diabetes mellitus, multiple sclerosis, and stroke can alter bladder contractility in addition to the ability to sense bladder filling. Arthritis, Parkinson's disease, dementia, and chronic pain syndromes can interfere with timely access to a toilet. Spinal cord injury or intervertebral disk disease (above S-1) can cause the loss of urine control due to bladder overactivity and impaired coordination between the contracting bladder and urinary sphincter. Prostatic enlargement can obstruct the bladder outlet causing urinary retention.

can cause local trauma during lower abdominal and pelvic surgery. This sometimes obstructs urine flow, requiring temporary use of an indwelling urinary catheter. Anesthetic agents and other agents given during surgery can decrease bladder contractility and/or sensation of bladder fullness causing urinary retention.

can influence urination. Some can change the color of urine. including... *Diuretics *Anticholinergics *Hypnotics *Sedatives

Cystoscopy: may cause localized trauma of the urethra resulting in transient (1- to 2-day) dysuria and hematuria. Catheterization creates a risk for infection.

*Urinary Retention *Urinary Tract Infections *Urinary Incontinence *Urinary Diversion

is the inability to partially or completely empty the bladder

are the most common health care-acquired infections; 80% of these infections result from the use of an indwelling urinary catheter. Burning during urination is known as dysuria as urine passes through inflamed tissues. An irritated bladder is known as cystitis.

is defined by the International Continence Society as the "involuntary loss of urine." The most common forms of UI are urge or urgency UI (strong desire to void associated with involuntary loss of urine) and stress UI (involuntary loss of urine associated with an increase in intraabdominal pressure such as with coughing or exercise). Stress UI is the result of weakness or injury to the urinary sphincter or pelvic floor muscles. Urgency UI is caused by involuntary contractions of the bladder that cause leakage of urine.

Some patients may have a urinary stoma to divert the flow of urine from the kidneys to an external source. This may be necessary because of trauma, cancer, radiation, fistula, or chronic cystitis.

The urinary tract is sterile. The use of infection control principles will help to prevent the spread of UTI.

Infants, children, and the elderly experience problems with urination. The young need to learn to recognize the need to urinate. The elderly need to deal with decreased functioning that accompanies aging. Weak abdominal and pelvic floor muscles impair the ability of the urinary sphincter to maintain tone. Immobility, muscle damage during vaginal delivery, and muscle atrophy or trauma contribute to problems with urination.

issues such as self-concept, culture, and sexuality may influence urination. Self-concept changes over one's life span and includes body image; self-esteem, roles, and identity. Incontinence can be devastating to self-image and self-esteem.

will often dictate gender specific roles when it comes to care of elimination issues. It may be inappropriate for a male to touch or even talk about elimination matters with a woman.

Integrated ___________________ from nursing and other disciplines.

Reflect on previous and personal ________________________ to help you determine a patient's elimination needs

is an important component of caring for a patient with urinary elimination problems. Approach patients with a confident attitude but at the same time remain open to the opinions of other clinicians

When you care for a patient with an alteration in urinary elimination it is important to apply standards of critical thinking. Use standards of care such as the HICPAC Guideline for the Prevention of Catheter-Associated Urinary Tract Infections or those developed by the Wound, Ostomy, Continence Nurses Society related to the care of incontinence related skin problems, ostomies, and incontinence.

*Nursing History *Physical Assessment *Assessment of Urine *Laboratory/Diagnostic Testing

*Pattern of urination *Symptoms of urinary alterations *Factors affecting voiding *Older adult considerations

*Kidneys - flank pain may occur with infection or inflammation *Bladder - distended bladder rises above symphysis pubis *External genitalia and urethral meatus - observe for discharge, inflammation, and lesions *Perineal skin - observe for erythema

*Intake and output *Characteristics of urine - color, clarity, and odor *Urine testing - specimen collection

*Urinalysis *Timed urine tests *Clean-catch midstream specimen *Urine culture and sensitivity *Diagnostic examinations

*Functional Urinary Incontinence *Reflex Urinary Incontinence *Stress Urinary Incontinence *Urge Urinary Incontinence *Risk for Urge Urinary Incontinence *Risk for Infection *Toileting Self-Care Deficit *Impaired Urinary Elimination *Readiness for Enhanced Urinary Elimination *Urinary Retention An important part of formulating nursing diagnoses is identifying the relevant causative or related factor. Specifying related factors for each diagnosis allows selection of individualized nursing interventions

Goals and outcomes: *Realistic and individualized A general goal is often normal urinary elimination, but sometimes the individual goal differs, depending on the problem. Consider the patient's home environment and normal elimination routines when planning therapies Setting priorities: *Physical and safety needs, patient expectations, and readiness to perform some self-care activities Collaborative care Patient, family, and specialists

*Patient Education *Promoting Normal Micturition (Contractions) *Promote Bladder Emptying *Prevention of Infection

plays an important part in the success of therapies. You can incorporate teaching when giving nursing care. Health promotion assists a patient in understanding and participating in self-care activities to preserve and protect healthy urinary system function.

Maintaining normal urinary elimination helps to prevent many urination problems. Integrating patients' habits into the care plan fosters normal voiding and helps prevent problems related to urination. A simple method of promoting normal micturition is maintaining adequate fluid intake.

by helping patients assume the normal position for voiding. Other measures that promote relaxation and the ability to void include sensory stimuli. *The sound of running water helps many patients void through the power of suggestion. *Stroking the inner aspect of the thigh stimulates sensory nerves and promotes the voiding reflex. *Pour warm water over the patient's perineum and create the sensation to urinate. If you need to measure urine output, first measure the volume of water that you pour over the perineal area. Encouraging patients to wait until urine stops flowing or to attempt to void again (double voiding) can improve bladder emptying.

Most important** Some strategic interventions include *Promoting adequate fluid intake *Perineal hygiene *Voiding at regular intervals. If the patient has a problem with urine leakage, hygiene should be especially stressed. Prolonged periods of urine wetness should be avoided.

*Catheterization *Urinary Diversions *Medications *Restorative Care

invasive procedure; can be intermittent or indwelling

incontinent or continent diversions

Life style changes Pelvic floor training Bladder retraining Toiling schedules Intermittent catheterization Skin care

*To evaluate your patient's care plan, use the expected outcomes developed during planning to determine whether interventions were effective. *This evaluation process is dynamic. Use information gathered to modify the plan of care to meet expected outcomes. Reinforce patient education and explore potential barriers when your patient has difficulty following a behavioral plan. *Your patient is the best source of evaluation of outcomes and responses to nursing care. Include patients during evaluation. Encourage patients to express in their own words if their preferences and needs were met. Make revisions based on your their feedback. Remember that urinary problems affect a patient physically, emotionally, psychologically, spiritually, and socially. You need to carefully evaluate a patient's self-image, social interactions, sexuality, and emotional status.

Evaluate whether the patient has met outcomes and goals. Help the patient redefine goals if necessary. Revise nursing interventions as indicated.

Check how the patient reports progress made.

Regular elimination of bowel waste products is essential for normal body functioning. Alterations in bowel elimination are often early signs or symptoms of problems within the gastrointestinal (GI) or other body systems. Because bowel function depends on the balance of several factors, elimination patterns and habits vary among individuals. Individuals of any age sometimes experience changes in intestinal elimination. These changes are often the result of illness, medications, diagnostic testing, or surgical intervention. These alterations respond to both preventive and supportive nursing care.

*Mouth *Esophagus *Stomach *Small Intestine *Large Intestine *Anus *Defecation

**mechanically and chemically breaks down nutrients into a usable size and form Digestion begins in the mouth and ends in the small intestine.

As food enters the upper esophagus, it passes through the upper esophageal sphincter, a circular muscle that prevents air from entering the esophagus and food from refluxing into the throat. The bolus of food travels down the esophagus and is pushed along by peristalsis, which propels it through the length of the GI tract

performs three tasks: *Storing the swallowed food and liquid *Mixing food with digestive juices *Regulated emptying of its contents into the small intestine

Movement within... *Occurring by peristalsis *Facilitates both digestion and absorption.

is divided into *Cecum *Ascending colon *Transverse colon *Descending colon *Sigmoid colon *Rectum. It is the primary organ of bowel elimination.

The body expels feces and flatus from the rectum through the anus

Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out.

*Constipation *Impaction *Diarrhea *Fecal Incontinence *Flatulence *Hemorrhoids

A symptom, not a disease!! fewer than three bowel movements per week, >25% of which are hard and require straining to evacuate is most often caused by changes in diet, medications, mobility, inflammation, environmental factors (such as unavailability of toilet facilities or lack of privacy), and lack of knowledge about regular bowel habits. It is not a physiological response to aging, but changes in mobility and co-morbidities make this condition more prevalent in the elderly. Intestinal motility slows, causing prolonged exposure of the fecal mass to the intestinal wall. Liquid from the feces continues to be absorbed, leaving stool hard and dry.

results from unrelieved constipation. The patient is unable to expel the hardened feces retained in the rectum. In severe impaction the hardened fecal mass extends up into the sigmoid colon.

is an increase in the number of stools and the passage of liquid, unformed stools. Common causes are *Infection Inflammation *Food intolerance. Intestinal contents pass too quickly through the small intestine and colon to allow for the usual absorption of fluid and nutrients. Dehydration leading to fluid and electrolyte and acid-base imbalances can result from diarrhea.

is the inability to control the passage of feces and gas from the anus. It may be a temporary or permanent condition. It may be caused by impairment of anal sphincter function or control.

(having accumulated gas) is one of the most common GI disorders. It refers to a sensation of bloating and abdominal distention accompanied by excess gas. When intestinal motility is reduced as a result of such things as medications, general anesthetics, abdominal surgery, or immobilization, flatulence may become severe, causing abdominal distention and sharp pain

are dilated, engorged veins in the lining of the rectum. Causative factors include increased venous pressure resulting from straining at defecation, pregnancy, and chronic illnesses such as congestive heart failure or chronic liver disease. Passage of hard stool causes hemorrhoid tissue to stretch and bleed.

Anatomy and physiology of the GI tract, the nature of pain, psychology, and cultural considerations

Previous patients with similar alterations and lifestyle habits affecting elimination.

Creativity, perseverance, and confidence *Use creativity when patients need adjustments in their diet and exercise planning. *Use perseverance when selecting effective diet therapies or finding the right medication regimen for patients with constipation or diarrhea. *Your confidence with moving and positioning the patient, managing ostomy care, and managing pain places the patient at ease and facilitates the recovery process.

Apply intellectual standards and applicable association guidelines The Association for Parenteral and Enteral Nutrition (ASPEN) has specific guidelines for nutritional support. The Wound, Ostomy and Continence Nurses Society (Goldberg et al., 2010) has specific standards for ostomy care.

*Health History *Physical Assessment *Laboratory Tests *Diagnostic Examinations *Patient Expectations

pattern of bowel elimination, characteristics of stool, specific routines, home management of constipation, presence of bowel diversion, changes in appetite, diet history, daily fluid intake, history of surgery or GI illnesses, medication history, emotional state, exercise history, pain history, patient mobility and dexterity.

conduct an examination of the oral cavity, abdomen, and external opening

fecal specimens and fecal occult blood test (FOBT)

direct visualization (endoscopy) or indirect visualization (barium swallow/enema, ultrasound imaging, computed tomography (CT) scan, and magnetic resonance imaging

anticipate the need for privacy and consider the patient's normal bowel pattern

*Disturbed Body Image *Bowel Incontinence *Constipation *Risk for Constipation *Diarrhea *Nausea *Dysfunctional Gastrointestinal *Motility *Deficient Knowledge (regarding nutrition) *Acute Pain *Toileting Self-Care Deficit Gather data from the nursing assessment, validate the data, and analyze clusters of defining characteristics to identify relevant nursing diagnoses. Reflecting on each of your data sources is necessary to determine the correct diagnosis. Defining characteristics identified during your assessment sometimes apply to more than one diagnosis; therefore be clinically skillful in determining patterns that reveal the diagnosis that best fits the patient's situation. A variety of nursing diagnoses are relevant for patients with altered bowel elimination. Some are shown on the slide. It is important to establish the correct "related to" factor for a diagnosis. For example, with the diagnosis of Constipation you distinguish between related factors of nutritional imbalance, exercise, medications, and emotional problems. Selection of the correct related factors for each diagnosis ensures that you implement the appropriate nursing interventions.

Goals and outcomes *Incorporate the patient's elimination routines and habits when possible Setting priorities *Work with the patient to establish priorities Collaborative care *Patient, family, community, and specialists

*Diet *Exercise *Timing &Privacy *Promotion of Normal Defecation Factors that normally promote bowel elimination are appropriate interventions for helping patients develop normal bowel habits. Teach your patients to try to develop a routine time for bowel evacuation. A good time is after a morning or evening meal when your patient does not feel rushed. Establishing a consistent time for bowel hygiene is just one practice to avoid constipation.

A well-balanced diet that includes several servings of fruits and vegetables and whole grain foods daily and an adequate fluid intake promotes normal bowel function.

An age-specific exercise program also helps patients maintain a healthy bowel pattern. Regular exercise such as walking, biking, or swimming 30 minutes daily promotes normal GI motility.

Teach patients to take time for defecation. To establish regular bowel habits, a patient needs to respond to the urge to defecate. Prompt response helps the patient reduce episodes of constipation. Defecation is most likely to occur after meals.

is often a concern for patients. Health care providers should knock before entering a patient's room. Privacy curtains should be used, especially for patients who reside in semiprivate rooms or shared living areas.

To help patients evacuate contents normally and without discomfort, recommend interventions that stimulate the defecation reflex or increase peristalsis. Helping the patient into an upright sitting position increases pressure on the rectum and facilitates use of intraabdominal muscles. Patients who have had surgery or have muscular weakness or mobility limitations benefit from the use of elevated toilet seats. With an elevated seat the patient exerts less effort to sit and stand.

*Bedpan *Medications *Nasogastric tube *Enemas *Digital removal of stool *Restorative care

*Laxatives *Cathartics *Antidiarrheal Agents

helps with gastric decompression

bowel training and ostomy care

Patient care Determine success in meeting expected outcomes and goals of care. Patient expectations Determine the patient's level of satisfaction with nursing care. Evaluate the effectiveness of nursing interventions for the patient with alterations in bowel elimination by determining success in meeting his or her expected outcomes and goals of care. Optimally the patient is to eliminate soft-formed stools regularly. In addition, he or she gains the information necessary to establish a normal elimination pattern. Evaluate success of the plan by having the patient describe his or her elimination pattern following therapy. Evaluate the character of the patient's stool. A return to a more normal, regular elimination pattern can take time. In patients with ostomies, assess the patient's emotional state with regard to the ostomy and provide support as needed. Using patient expectations identified during assessment, determine the patient's level of satisfaction with nursing care. Does the patient believe that you provided care respectfully, offering privacy and support when necessary? Is he or she satisfied with the elimination pattern established? Are stools easier to manage? Your goal for the patient with an ostomy is to achieve a realistic level of self-care and maintain or reinforce a healthy body image. When discussing these issues with the patient, determine if the patient's participation in care helped him or her accept the ostomy. Were expectations of the patient unrealistic? Did the patient feel like a partner in care? Learning about the patient's level of satisfaction with care goes a long way toward helping future patients.