Elimination

1. Elimination Urinary & Bowel Elimination Enemas Ostomy care

2. Principles of Elimination Observe infection control practices - wear gloves!! Approximate the normal as much as possible - sitting for female; standing to void, sitting to defecate for male May be embarrassing for the client - respect privacy, keep exposure to a minimum, straight-forward professional attitude, give them as much control as possible

3. Urinary Elimination Functions: 1) remove nitrogenous waste products of cellular metabolism, 2) regulate fluid & electrolyte balance Goal: maintain chemical homeostasis of the blood Urinary system is a sterile system Micturition, void, urinate - act of emptying the bladder

4. Urinary System Kidney - filters blood. Excess fluids, electrolytes, & wastes are filtered out & excreted as urine Ureter - tubes carrying urine from kidney to bladder Bladder - distensible, muscular sac, holds urine Urethra - short, muscular tube carries urine out of the body Urethral meatus - external opening

5. Factors affecting Urination Growth & development Disease conditions Sociocultural factors Psychological factors Muscle tone Fluid intake

6. Common Urination Problems Incontinence Frequency & urgency Nocturia Enuresis Oliguria Renal anuria Dysuria Urinary retention UTI

7. Promoting Healthy Voiding Urinate as soon as the urge is felt Drink 2L fluid daily Limit sodium, caffeine, & alcohol Limit fluids in the evening, void before retiring Women - wipe front to back, void after intercourse, Kegel exercises Wash hands before & after voiding

8. How to help those experiencing difficulty starting the stream of urine Provide privacy & natural position for voiding (female sitting, male standing) In the BR or on a commode rather than a bedpan Run water within their hearing Dangle their fingers in warm water Pour warm water over perineum (I&O) Provide pain relief

9. Urinary Catheterization When conservative measures fail & the client becomes uncomfortable, a urinary catheter may need to be inserted to drain the bladder

10. Bowel Elimination Function: to excrete/eliminate waste products of digestion Gastrointestinal system (GI) - a clean system, normally some microorganisms present Concerned with small & large intestine. Small intestine absorbs nutrients & electrolytes, large absorbs water & electrolytes

11. Food passed along the system by peristalsis - wavelike contractions & relaxation of smooth muscle Stool, feces, bowel movement (BM), & to defecate - waste products expelled

12. Factors Affecting Bowel Elimination Age Diet Fluid intake Physical activity Psychological factors Personal habits Position during defecation Pain Meds

13. Common Defecation Problems Constipation Fecal impaction Diarrhea Incontinence Hemorrhoids Daily BM not essential - <2x/week a concern

14. Promoting Healthy Bowel Elimination Defecate when the urge arises. Establish a routine Drink lots of fluids Eat a well-balanced diet, high fiber foods, fresh fruits & veggies Avoid gas forming foods Exercise Women - wipe front to back Wash hands after using the toilet

15. Enemas Main reason to promote defecation Instill fluid, breaks up fecal mass, stretches rectal wall, & initiates defecation reflex

16. Types of Enemas Tap water Normal saline Hypertonic solution Soap suds Oil retention Medicated

17. Enema Volumes Large volume - 500 -1000ml, hold 30cm above bowel Small volume - 500ml, hold 7.5cm above Pre-packaged - hypertonic solution (Fleet)

18. Pre-packaged used more than large volume because: Adequate to deal with constipation Does not cause electrolyte imbalance Can be given rapidly Less abdominal discomfort Convenient, no prep

19. �Enemas till clear� No more than 3 No solid stool present but solution returned may be slightly colored

20. Procedure for Giving an Enema L lateral position, drape, pad under buttocks Warm solution - hot will burn mucosa, cold will cause cramping Prime tubing Lubricate tip, gloves on Insert 7-10cm in adult, deep breath & let out slowly, guide towards umbilicus, do not force

21. Raise container to appropriate height - higher the can, greater the pressure 1000ml takes 10min c/o discomfort, lower can to slow the infusion, can stop & then start again Remain sidelying, retain 5min Assist to BR/bedpan/commode Do not flush, evaluate results

22. Suppository Local effect on GI system - promote defecation Systemic effect - relieve nausea or provide analgesia L lateral position, lubricate pointed end, gloves on, insert finger to assess for presence of stool, insert suppository & advance length of index finger, 10cm for adult, retain as long as possible Want suppository placement past internal sphincter & along rectal wall

23. Dulcolax vs Glycerine Suppositories Dulcoax (bisacodyl) is a stimulant laxative. Acts on the smooth muscle of the intestine to stimulate peristalsis. Position along rectal wall; results within 15-60 minutes. Glycerine is a hyperosmolar laxative that draws water from tissues into stool to stimulate evacuation. Results within 15-60min. Watch fluid & electrolyte status (local absorption of sodium & water in stool)

24. Removing Fecal Impactions When enema & suppository are unsuccessful, digital removal of stool is necessary Caution - stimulates vagus nerve & could slow heart rate Need Dr�s order & monitor client�s heart rate & for fatigue

25. Potential Laxative Side Effects Flatulence Diarrhea Abdominal discomfort & cramping Weakness Dependence

26. Ostomy Care Ostomy - opening made in abdominal wall to allow passage of stool/urine Stoma - piece of intestine brought out onto client�s abdomen. Is mucous membrane, appears red, smooth & moist Effluent - drainage from an ostomy

27. Bowel Ostomies Drain stool. Consistency of effluent depends on where the ostomy is located along the bowel. Higher up the bowel is more liquid stool, farther down the bowel is more solid, normal stool May be permanent (in case of Ca) or temporary (to allow bowel to rest & heal)

28. Types of Bowel Ostomies Ileostomy - end of small intestine, frequent liquid stool, bypasses large intestine, still contains digestive enzymes - watch for skin breakdown Colostomy - anywhere along the large intestine. Usually due to Ca, farther along, the more solid the stool. 3 types end loop double barrel

29. Urine Ostomies Drain urine Bypass the bladder, usually due to Ca May be incontinent (drains urine continually) or continent (insert a catheter periodically to drain urine) 3 types ileal conduit Indiana pouch urterostomy

30. Concerns with Urine Ostomies Infection - urinary system is a sterile system, opening of an stoma is a pathway into the system Skin breakdown - urine continually draining leaves moisture on the skin

31. When to Change the Pouch Note the condition of the existing bag for leaking or breakdown/melting of the skin barrier (stoma adhesive) Any client c/o�s of discomfort or burning around the stoma How much drainage in the pouch? - empty when no more than half full (weight may pull it off)

32. Changing the Pouch Not changed daily. Q2-3 days for urinary, q3-7 days for bowel Pouches may be disposable or reusable Inspect stoma & surrounding skin Wash with warm water & a cloth Measure the size of the stoma

33. Pouch opening should face down Snap on tightly, no holes in pouch for air to escape

34. Education & Counseling of Client�s with Ostomies Body image changes Self-care issues Fear of rejection Loss of normal sexual functioning Feeling powerless