1. Chapter 51 Elimination

2. Changes in Bowel or Bladder Habits
May be signs of illness
May cause illness

3. Elimination Urine Body’s liquid waste product
Urination, micturition, voiding
Passing urine from the body
Feces, stool
Body’s solid waste product
Defecation, bowel movement (BM)
Excretion of feces

4. Elimination To maintain homeostasis
Elimination of liquid and solid waste products is necessary.
Changes in bowel or bladder habits
May be signs of illness, or they may cause illness
Standard Precautions
Use gloves and other protective devices when coming in contact with any body secretion or drainage from the client.

5. Urinary Elimination *Urine amounts: about 1 mL/kg body weight/hour
Approx 500 to 2,400 mL of urine every 24 hours
*Minimum of 30 mls/hour
Urine output varies depending upon fluid intake AND
Amount excreted through
Respiration
Perspiration
Fluid in feces
Fluid output is usually about the same as fluid intake.

6. Urinary Elimination Output depends on
Fluid intake and kidney efficiency
Processes, such as respiration, perspiration
Salt intake and fluid contained in feces
Urge to void is triggered when about 250 ml’s of urine has collected in the bladder*
Edema (overhydration)
Excess of body fluid that collects in the tissues
Dehydration
Deficiency in body fluids

7. Characteristics of Urine
Color
Light yellow or amber
Overhydration
colorless
Dehydration
Dark amber/orange brown
Medications
Clarity
Odor
Volume
Specific gravity
Acidity
Abnormal components

8. Patterns of Urinary Elimination
Urinary frequency
Voiding more often than usual without an increase in total urine volume
Urgency
Desire or sensation of needing to void immediately
Dysuria
Painful or burning sensation when passing urine
Nocturia
Frequent or repeated voiding during the night

9. Patterns of Urinary Elimination, cont.
Enuresis
Involuntary voiding in bed (bedwetting)
Polyuria
Increase in the expected amount of urine a person excretes over a period of time
Oliguria
Decrease in the expected amount of urine a person excretes
Daily output less than about 500 mL

10. Patterns of Urinary Elimination, cont.
Anuria
Absence of urine excreted by the kidneys
<100 mL/d
Urinary retention
Inability to empty the bladder of urine
Stress incontinence
Caused by increased intra-abdominal pressure
Affects childbearing women, aging, loss of muscle tone, HORMONAL changes!
Incontinence
Involuntary loss of urine from the bladder

11. Patterns of Urinary Elimination
Urinary suppression
Oliguria
Anuria
Urinary retention
Distention
Retention overflow
Temporary urine retention

12. Urinary Tract Problems
Urinary tract infection
Urethritis: Inflammation of the urethra
Cystitis: Inflammation of the bladder
Nephritis and pyelonephritis: Inflammation of the kidneys
C/O urgency, frequency, dysuria, chills, abd. discomfort and flank pain
Client should void q. 2-3 hours to decrease urinary stasis
Nephritis, pyelonephritis
Inflammation of the kidneys
**Upper UTI affects kidneys, ureters
Lower UTI affects bladder and urethra

14. Urinary Tract Problems
Urinary Calculi
Calculi or stones formed from substances excreted by the body
May occur in the kidney or bladder
STRAIN urine

16. Characteristics of Feces
Color
Melena
Passage of dark-colored stools containing partially or fully digested blood in the stool or vomitus
Bright red blood (streaked inside or outside) indicates bleeding from hemorrhoids- rectal or anal bleeding

17. Characteristics of Feces, cont.
Consistency
Constipation
Difficult or infrequent and hardened bowel movements
Chronic may occur if a person ignores the impulse to empty the rectum on a regular basis*
Diarrhea
Abnormal frequency and fluidity of discharge from the bowels
Chronic diarrhea suggests chronic irritation of the colon, intestinal infection, food poisoning or a parasitic infection
Could indicate fecal impaction

18. Characteristics of Feces, cont.
Shape
Odor
Density
Steatorrhea
High fat content in stool*
Abnormal components
Fecal impaction
Accumulation of hardened stool or a putty-like stool in the rectum, cannot be expelled by client*
s/s-abdominal pain, hard abdomen, feeling of pressure*

19. Patterns of Bowel Elimination
Patterns of elimination are unique to each individual.
Nursing data collection
Frequency
Regularity
Client reported changes
If the person is symptom-free, bowel movements occurring less often are not a cause for concern.

21. Flatus Flatus: Intestinal gas
Flatulence: Condition of having intestinal gas
Most flatus is reabsorbed through the vasculature of the intestinal wall; some of it is expelled with defecation.
Abdominal signs and symptoms
Diminished or absent sounds indicate that the bowel is functioning improperly.

22. Description of Bowel Sounds
*Listen to peristalsis, bubbling, gurgling or clicking sounds that vary in intensity, frequency and pitch
*Auscultate
for 5 minutes

23. Assisting With Toileting
Helping the client to the bathroom
Giving and removing a bedpan or urinal
Bedpan
Fracture bedpan (fracture pan)
Urinal
Helping the client to use a commode

24. Helping the Client to Use a Commode

25. The Client Requiring a Urinary Catheter
Latex or vinyl tube that is inserted to remove urine
Straight catheter
Inserted, urine drained, catheter removed and discarded
Retention catheter (indwelling catheter)
Inserted, anchored in place, continuously drains urine from the bladder

26. The Client Requiring a Urinary Catheter, cont.
Foley catheter
Most frequently used
Two tube-like cavities called lumens
One lumen connected to balloon, inflated inside bladder, anchors catheter
Another lumen drains the urine.
Distal end attached to drainage bag

27. The Urinary Catheter Inserting the catheter **Sterile procedure
Collection bag must never be higher than level of client’s bladder
Crede’s manueuver*
Caring for the catheter
Ensure catheter is secure, tubing is not kinked
Measure amount of urine and empty bag regularly; observe flow
Tubing should go over the client’s leg when in bed
Do not let tubing hang below the level of the bag

28. Irrigating the Catheter
Ensures patency
Removes clots or debris
Usually requires physician’s order
Sterile procedure

29. Types of Catheters

30. External Catheter Systems
Condom catheter
Noninvasive approach to managing urinary incontinence in male clients
Drainage bag is similar or like the one used for a regular catheter
Once a day, disconnect the leg bag, wash in warm, soapy water, rinse and hang to dry, when dry, reattach to catheter

31. Bladder Retraining Kegel exercises
Exercises designed to increase sphincter tone by tightening, holding, and releasing the muscles of the pelvic floor and sphincter.
Used to decrease episodes of incontinence
Fluids
Exercise
Record I&O to ensure no urinary retention

32. Urinary Incontinence Male client
External catheter, external incontinence guard
Female client
Perineal pad or disposable incontinent brief
Bladder retraining
Plenty of fluids and exercise (Kegel exercises)
Catheter connected to closed drainage system
Self-catheterization

33. Urinary Retention Temporary retention After receiving anesthesia
When using the bedpan
Report if urinary retention continues, the bladder becomes distended, and the client is uncomfortable
Catheterization

34. Assisting With Bowel Elimination
Fecal retention
Short-term (constipation)
Long-term (fecal impaction or bowel obstruction)
Suppositories
Bullet-shaped, soft wax-like mass
Melts after administration releasing medication

35. Enemas
Introduction of a solution into the rectum and colon to stimulate peristalsis, thereby causing elimination of stool
Barium enema
Harris flush, or return-flow enema
May be habit forming

36. Types of Enemas Carminative enema
Cleansing enema (purgative enema)
Plain tap water (tap water enema: TWE) monitor for circulatory overload (increased BP and bounding pulse)*
Soap solution – soapsuds enema (SSE)
Fleet enema-hypertonic, pulls water from the colon tissue into intestinal lumen by osmosis, adds liquid to soften hard stools*
Carminative enema
Stimulates peristalsis to expel flatus
Anthelminthic enema
Emollient enema  
Oil retention enema 
*Retain for minutes 
Medicated enema  

37. Assisting With Bowel Elimination (cont’d)
Manual disimpaction or digital evacuation
If fecal impaction does not respond to an enema or if the client has paralysis
Stop procedure immediately if c/o pain, faintness, nausea, bleeding*
CONTRAINDICATED in cardiac clients!!
Bowel retraining
For the client who is unable to have a bowel movement naturally or is incontinent of stool
Use of rectal tube for expelling gas
Fecal incontinence pouch
Very frequent liquid stools

38. Nausea and Vomiting Nausea Unpleasant abdominal sensation
Vomiting or emesis
Involuntary action that expels stomach contents
Report if the client vomits intact medication tablets. Save the tablets for identification.
Have the client lie on the right side

39. Nausea and Vomiting, cont.
Projectile vomiting
Expelled with great force
Vomitus
Stomach contents
Assess
Particles
Color
Coffee ground indicates lower GI bleed
Odor
Consistency

40. In Practice: Giving a Cleansing Enema
See Nursing Procedure 51-4.
Key points:
Solution ranges between ml’s
Do not exceed 3 consecutive enemas!
Insert rectal tube 3-4 inches toward the umbilicus
Hold enema solution no more than 18” above anus

41. In Practice: Administering an Enema
See Nursing Care Guidelines 51-4
Key Points:
Enema temperature should not exceed 40.5 celsius or
105 F
Administer in Sims position, instruct the client to take a few short, panting breaths and relax while you are inserting the tube
C/o cramping, stop or slow solution
Administer solution slowly