Urinary & Fecal Elimination Nur 102 Faculty of Nursing

Urinary Elimination Process Of Urination Kidneys Ureters Urinary bladder Urethra

Urination Micturition, Voiding and Urination: Are all refer to the process of emptying the Urinary Bladder. Urine collects in the Bladder until Pressure stimulate the stretch receptors which occurs when bladder contain 250-450 ml of urine in adult & 50 -200ml in children Stretch receptors transmit impulse to the Voiding center in the spinal cord (2-4 Sacral Vertebrae). Causing internal sphincter to relax and stimulating the urge to voiding If the time and place are suitable the cerebral cortex relaxes the external Urethral sphincter muscle and micturation occur. The process of Urination is under voluntary and involuntary control.

Factors Affecting Voiding Developmental Factors (Age): Which affect the amount, frequency, Urine concentration (Kidney function) and control of Voiding. Psychological Factors: Privacy, normal position, sufficient time, and running water are enhancing the process of micturition. On the other hand other stressful condition may cause anxiety and muscle tension which diminish micturition.

3. Fluid and food intake: 4. Medication: such as Diuretics, BB or opioid (cause urinary retention) . 5. Muscle Tone: retention catheter continuously drain urine so prevent bladder from filling and emptying normally 6. Pathological Condition: Renal failure, and heart failure decreases the urine formation, kidney and Ureters stones may obstruct the urinary flow. Prostate enlargement. 7. Surgical and diagnostic procedures: such as cystoscopy, spinal anesthesia decrease the sensation for urination.

Problems in Urinary Elimination Altered Urine Production: Polyuria: or Diuresis is production of abnormally, large amounts of urine by the kidneys. Can cause excessive fluid loss, dehydration and weight loss. Associated with excessive fluid intake (polydipsia), DM, Diabetes insipidus, chronic nephritis.

Oliguria and Anuria: Decreases urine output. Oliguria: Urine less than 500 ml/day or less than 30 ml/hr, may occur due to ↓fluid intake, it indicate impaired blood flow to the kidney, RF Anuria: Lack of urine production less than 50 ml/day Dialysis: removing the fluid and molecules using artificial techniques (Hemodialysis and peritoneal dialysis).

II. Altered Urinary Elimination: Normal urine production but the problem is in the elimination: Frequency and Nocturia: Frequency voiding more than 4-6 times/day, due to increase intake, UTI, stress, and pregnancy Nocturia: is voiding 2 or more times at night Urgency: is the sudden strong desire to void. Due to stress or irritation of urethra, poor external sphincter control, and unstable bladder contraction.

Dysuria: painful or difficult voiding Dysuria: painful or difficult voiding. Due to stricture of the urethra, UTI, and injury to bladder and urethra. May cause (Urinary hesitancy) delay or difficulty in initiating voiding. Enuresis: is involuntary urination in children beyond the age when voluntary bladder control is normally acquired (4-5 yrs). Nocturnal enuresis: affect boys more than girls Diurnal (daytime): affect women and girls more frequently.

Urinary incontinence: or involuntary urination, it’s a symptoms not disease. Due to UTI, Urethritis, pregnancy, Hypercalcemia, Volume over load, restricted mobility, stool impaction, multiple vaginal birth and neurological disorders. Lead to Isolation, social withdrawal, and embarrassment. Urinary Retention: Inability to empty the bladder completely so the bladder become overdistended which cause poor contractility of the bladder. Due to Prostate hypertrophy, Surgeries, and some medications (antihistamine, anticholinargeic)

Neurogenic Bladder: impaired neurologic function of the bladder which affect the process of elimination. No awareness of bladder fullness, and unable to control the urinary sphincters. The bladder become flaccid and distended or spastic, with frequent involuntary urination, occur in spinal cord disease and brain tumor

Nursing Management Assessment: Normal urine compose of 96% water and 4% solutes Nursing History: Normal voiding pattern, frequency, appearance of the urine, any past or current urination problem. Physical assessment: tenderness, dullness over distended bladder, assess skin color, turgor, edema Assessing Urine: color (straw, amber, transparent), odor, sterility, acidity (4.5-8), specific gravity (1.010-1.025), glucose, ketone bodies, blood Measuring Urinary output Measuring Residual Urine: < 100 ml Diagnostic test: KFT, 24hrs creatinine clearance test, U/A routine and culture, specific gravity, Direct visualization (Cystoscopy), Ultrasound (KUB), and X rays.

Nursing Diagnosis Impaired Urinary Elimination: dysfunction in urine elimination Functional Urinary Incontinence Reflex Urinary incontinence Stress Urinary incontinence Urge urinary incontinence Urinary retention Associated Nursing Diagnosis: Risk for Infection Low Self-esteem Impaired skin integrity fluid volume deficit or excess, Knowledge deficit

Planning Goals: Maintain or restore a normal voiding pattern Regain normal urine output Prevent associated risk Perform toilet activities independently with or without assistive device objective: pt will be able to demonstrate kegel exercise during my shift pt will be able to show 24hr’s intake and output balance

Implementation Maintaining Normal Urinary elimination: I-1 Promote fluid intake: Give daily requirement of fluid (1500 ml/day) Increase fluid intake as required (hot weather, at risk for UTI, Calculi formation (2000-3500 ml/day) to increase urination Decrease fluid intake in case of RF, or HF to prevent edema. I-2 Maintain Normal Voiding Habits: Help the pt to adhere to normal voiding pattern as much as possible. I-3. Assisting with toileting:

II. Preventing Urinary Tract Infection: most common Nosocomial infection, mostly caused by bacteria from GIT. Greater in women than men Drink 8 glasses of water per day to flush bacteria Avoiding tight fitting pants that irritate urethra. Wear cotton rather than nylon underclothes to prevent moisture. Girls and women should always wipe the perineal from front to back In recurrent UTI, take always showers rather than baths Increase intake of vit C to increase urine acidity Practice frequency voiding Q 2-4 hr’s

III. Managing Urinary Incontinence: Continence (bladder) training program: Education of the client and support people. Bladder training: postpone voiding, resist or inhibit the sensation of urgency, and voiding according to a timetable rather than sensation to urge. Habit training: timed voiding or schedule regular intervals but no attempt to motivate the client to delay voiding if the urge occur (effective in children) Prompted Voiding: encouraging the client to try to use the toilet (prompting) and reminding the client when to void.

2. Pelvic Muscle Exercises: Tightening the perineal muscles by stopping urination mid stream. Contract perineal muscles any time and anywhere. Avoiding contraction of the buttocks and thigh muscles. 3. Maintaining Skin integrity: Wash perineal area with mild soap and rinse thoroughly with water, then dry Provide clean and dry clothes and bed linen Place draw sheet under the pt 4. Applying External Urinary Drainage Device: as condom

IV. Managing Urinary Retention: Cholinergic drug such as Urecholine to stimulate bladder contraction. Manual pressure on the bladder to promote bladder emptying (Crede’s maneuver) used in client with a flaccid bladder Urinary Catheterization: Can cause UTI, trauma for the urethra V. Urinary Diversions : Uretrostomy, nephrostomy Diversion: surgical rerouting of urine from kidney to site other than the bladder

Bowel elimination

Defecation ( bowel movement) Is the expulsion of feces from the anus & rectum The frequency varies from several times\day to 2or 3t\wk Expulsion of feces facilitated by the contraction of the abdominal muscle and the diaphragms (increase abdominal pressure), muscle of the pelvic floor ( moves the feces through the anal canal) normal defecation facilitated by: Thigh flexion (increase abd pressure) Sitting position (increase downward pressure on the rectum)

Feces 75% water, 25% solid Normal color of the feces is brown due to presence of urobilin and EC Adult forms 7-10L of flatus in large intestine every 24 hr Consistency may be semisolid, soft and moist The odor affected by ingested food and by normal flora (E.coli)

Factors Affecting Defecation Developmental stage Diet Activity Psychologic factors Defecation habits Medications Diagnostic procedures Anesthesia & surgery Pathologic conditions pain

Fecal Elimination Problems Constipation: - is infrequent and difficult passage of hardened stool. (box 46-1, page 1230). Occurs when the movement of feces through the large intestine is slow. Fewer than 3 BM/week It may cause problem to pt with heart and brain problems it increase intrathoracic pressure and intracranial pressure Causes: Low fiber intake Low fluid intake Insufficient activity or immobility Irregular defecation habit Lack of privacy Chronic use of laxatives and enemas Emotional disturbances (depression) Medications as iron salts, anti acid Neurological condition as stroke

Fecal Impaction: Is a mass or collection of hardened feces in the fold of the rectum, from prolonged retention and accumulation of fecal material Recognized by passage of liquid fecal seepage and no normal stool Assessed by digital examination (hardened mass will be palpable) Symptoms: frequent but nonproductive desire to defecate, rectal pain, anorexia, abd distention, N&V Causes: poor fecal habits and constipation, barium study Rx: oil retention enema, 2-4hrs later cleansing enema given, suppositories or stool softener given daily

Diarrhea: is the passage of liquefied stool with increased frequency, result from rapid movement of fecal content Associated with Abd cramps Bowel sound increase, irritation of the perineum may occur Results in fatigue, weakness, emaciation (extreme wt loss) Primary Causes of Diarrhea: Malabsorption syndromes (as crhon’s disease: type of inflammatory bowel ) Inflammatory bowel disease Side effects of drugs (AB) Anxiety

Bowel (fecal) Incontinence: loss of voluntary ability to control fecal and gaseous discharge through anal sphincter. Two types: Partial (inability to control flatus) or Major (inability to control feces or normal consistency). Associated with impaired function of the anal sphincter or its nerve supply ( spinal injury, tumors of the anal sphincter muscle) Can lead to social isolation Rx: sphincter repair or fecal diversion or colostomy.

Flatulence: is the presence of excessive flatus in the intestines and leads to stretching and inflation of the intestines sources: action of bacteria, swallowed air, and gas that diffuse between the bloodstream and the intestine. Result from: foods, abd surgeries, or narcotics Results in intestinal distension

Ostomies is an opening in the GI, urinary, or respiratory tract onto the skin Can be temporary or permanent Purpose of bowel Ostomies are to divert and drain fecal material Types: Gastrostomy: opening through abdomen to stomach Jejonostomy: opening to jejunum. Ileostomy: opening to small intestine (ileum) Colostomy: opening to colon Characteristics of fecal drainage depends on anatomical location of ostomy Liquid: gastrostomy, Ileostomy, ascending colon (odor) Mushy (soft): transverse colon, odorous Formed (twisted): descending colon, sigmiodostomy

Assessment Health History Physical Examination Elimination habits Type of incontinence Complicating factors Bladder and bowel management strategies used by client Physical Examination Mental status Mobility Inspection of perineum for skin integrity Perianal area, digital rectal exam

Inspect feces color, consistency, shape, amount, odor, presence of abnormal constituent Diagnostic studies: Stool culture Anorectal Ultrasonography Direct and indirect visualization (colonoscopy, Sigmoidoscopy)

Nursing Diagnoses Constipation related to immobility Risk for constipation Perceived Constipation Diarrhea related to ingestion of laxatives Bowel Incontinence related to disease process Risk for impaired skin integrity related to frequent defecation of fluid-like stool Risk for deficit fluid volume related to frequent defecation of fluid-like stool Low Self-Esteem related to presence of ostomy Deficient Knowledge regarding toileting care (appropriate diet) Risk for Infection Self-Care Deficit (Toileting)

Planning Maintain normal bowel elimination pattern Maintain or regain normal stool consistency Prevent associated risks as fluid & electrolyte imbalance, pain Objective: pt will be able to demonstrate respond to urge in the timely manner pt will be able to verbalize the importance of increase fluid intake to 3L\day

Implementation Promote regular defecation by: Maintain intake of 8glass of water \day Do not ignore the urge to defecate (timing) Avoid over use of laxatives Provide privacy for pt during defecation Limited carbonated beverage Encourage exercise Instruct the pt about proper positioning during defecation (leaning forward)

Instruct pt about diet to manage constipation and diarrhea Diet for constipation: increase fluid intake Consume hot liquid and fruit juice Include fiber in diet Diet for diarrhea: Increase fluid intake Eat small amount Avoid hot or cold fluids Avoid spicy and fiber diet Diet for Flatulence: Limit carbonated beverage Avoid use of straw and gum Avoid gas forming food (cabbage, onion, beans, cauliflower)

Use bed pan and commode for pt have difficulty seated themselves Teach about medication ( laxatives, antidiarrheal, antiflatulance) Administer (introduction of a solution into the rectum and large intestine to distend the intestine or irritate intestinal mucosa leading to increase peristalsis and facilitate feces and flatus discharge) Ostomy care ( cleaning and irrigation)