Chapter 37 Urinary and Bowel Elimination

37-2 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Physiology of Urinary Elimination  Urinary Elimination (voiding, urination) The kidneys form the urine. The ureters carry urine to the bladder. The bladder acts as a reservoir for the urine. The urethra is the passageway for the urine to exit the body.

37-3 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Physiology of Urinary Elimination  Continence in the Adult Anatomic integrity of the urinary system Nervous control of the detrusor muscle Competent sphincter mechanism  Urinary Incontinence Uncontrolled loss of urine Abnormalities of one or more factors

37-4 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Physiology of Urinary Elimination  Structures of the Upper Urinary Tract Kidneys Nephrons Parenchyma Hilus of kidney Renal pelvis Ureter

37-5 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Physiology of Urinary Elimination  Both the renal pelvis and ureters consist primarily of smooth muscle.  Peristalsis (muscular contraction) moves urine from the upper to the lower urinary tract.  Occurs during the prolonged phases of bladder filling and storage.

37-6 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Physiology of Urinary Elimination  Structures of the Lower Urinary Tract Bladder Detrusor (smooth muscle bundles in the upper portion of the bladder) Urethra (sphincter mechanism) Pelvic muscles (slow-twitch fibers and fast- twitch fibers)

37-7 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Physiology of Urinary Elimination  Nervous Control of the Detrusor Muscle Central nervous system Peripheral nervous system Sympathetic nervous system Parasympathetic nervous system Micturition center

37-8 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Physiology of Urinary Elimination  Urethral Sphincter Mechanism Urethral compression Bladder filling Urinary storage Urethral tension Supportive structures

37-9 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Physiology of Bowel Elimination  Continence Consistency of the stool (fecal material) Intestinal motility Compliance and contractility of the rectum Competence of the anal sphincters

37-10 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Physiology of Bowel Elimination  Structures of the Gastrointestinal Tract (alimentary canal) Related to Bowel Elimination Small intestine Ileocecal valve Large bowel (colon) Ileocecal sphincter Anal sphincter

37-11 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Physiology of Bowel Elimination  Intestinal Motility and Rectal Accommodation Rectal filling Rectal contractions Rectal accommodation Postponement of defecation Constipation

37-12 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Physiology of Bowel Elimination  Anal Sphincter Mechanism Internal and external sphincters Striated muscle fibers Sensory receptors

37-13 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Factors Affecting Elimination  Age  Diet  Exercise  Medications

37-14 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Common Alterations in Elimination  Urinary Elimination Acute urinary incontinence Chronic urinary incontinence

37-15 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Common Alterations in Elimination  Stress Urinary Incontinence (SUI) Uncontrolled loss of urine caused by physical exertion in the absence of a detrusor muscle contraction Associated with urethral hypermobility or intrinsic sphincter deficiency

37-16 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Common Alterations in Elimination  Urgency and Urge Urinary Incontinence (overactive bladder syndrome) Involuntary leakage accompanied by urge to void  Functional Urinary Incontinence Altered mobility, manual dexterity Ability to access toilet Cognitive changes

37-17 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Common Alterations in Elimination  Extraurethral Incontinence Uncontrolled loss of urine that exists when the sphincter mechanism has been bypassed

37-18 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Common Alterations in Elimination  Urinary Retention Bladder outlet obstruction Deficient detrusor muscle

37-19 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Alterations in Bowel Elimination  Constipation  Diarrhea  Fecal Incontinence

37-20 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Bowel Retention  Constipation is infrequent and difficult passage of hardened stool. Dietary factors, dehydration Inadequate dietary bulk Diverticular disease Neuropathic conditions Functional limitations

37-21 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Bowel Retention  Fecal Impaction Bolus of hardened stool Further slows colonic transit time and passage of further fecal contents

37-22 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Bowel Retention  Perceived constipation is influenced by psychological and emotional stress.

37-23 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Alterations in Bowel Elimination  Diarrhea is the passage of liquefied stool with increased frequency and consistency.

37-24 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Alterations in Bowel Elimination  Primary Causes of Diarrhea Malabsorption syndromes Inflammatory bowel disease Short bowel syndrome Side effects of drugs Laxative or enema misuse  Infectious diarrhea is caused by a pathogen.

37-25 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Alterations in Bowel Elimination  Bowel (fecal) Incontinence Dysfunction of the anal sphincter Disorders of the delivery of stool to the rectum disorders of rectal storage Anatomic defects

37-26 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Assessment  Health History Elimination habits Type of incontinence Complicating factors Bladder and bowel management strategies used by client

37-27 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Assessment  Physical Examination Mental status Mobility and dexterity Inspection of perineum for skin integrity Inspection of vaginal vault Pelvic support Perineal sensation Perianal area, digital rectal exam

37-28 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Assessment  Diagnostic and Laboratory Data Urinalysis Stool culture Defecography Anorectal ultrasonography

37-29 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Nursing Diagnoses  Impaired Urinary Elimination  Stress Urinary Incontinence  Reflex Urinary Incontinence  Urge Urinary Incontinence  Functional Urinary Incontinence  Urinary Retention

37-30 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Nursing Diagnoses  Constipation  Perceived Constipation  Diarrhea  Bowel Incontinence

37-31 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Other Nursing Diagnoses  Low Self-Esteem  Deficient Knowledge  Risk for Infection  Risk for Impaired Skin Integrity  Toileting Self-Care Deficit

37-32 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Outcome Identification and Planning  Target outcomes center around restoring and maintaining regular elimination habits and preventing complications.

37-33 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Implementation  Maintain Elimination Health Fluid intake Diet Lifestyle and Prevention

37-34 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Implementation  Lifestyle and Prevention Alcohol and tobacco use Stress management Weight reduction Elimination habits Positioning

37-35 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Implementation  Lifestyle and Prevention Initiate pelvic muscle exercise regimen Bladder training for urge incontinence Management of urinary retention Management of functional urinary incontinence Suggest environmental modifications

37-36 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Implementation  Lifestyle and Prevention Initiate behavioral intentions Monitor skin integrity

37-37 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Implementation  Apply a Containment Device Condom catheter Incontinence and dribble pads Rectal pouch and rectal tube  Initiate Diet and Fluid Therapy

37-38 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Implementation  Administer Medications Over the Counter (OTC) Prescription

37-39 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Implementation  Perform Catheterization  Intermittent Catheterization

37-40 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Implementation  Administer Enemas Cleanse the lower bowel Assist in evacuation Instill medication  Initiate Rectal Stimulation

37-41 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Implementation  Various types of enema equipment and solutions

37-42 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Implementation  Monitor Elimination Diversions Urinary Diversions -Ileal conduit -Continent urinary diversion Bowel Diversions -Ileostomy -Colostomy -Ileoanal reservoir

37-43 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Implementation  Surgical Management Bladder suspension Artificial urinary sphincter device Implanted devices Surgical reconstruction Surgical closure of fistulae and ectopia Endoscopy, other procedures to alleviate obstruction or dyssynergia

37-44 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Implemenation  Complementary Therapies Holistic approach to effective elimination of waste products and toxins -Diuretics -Antimicrobials -Antiseptics -Stimulants and Cathartics

37-45 Copyright 2004 by Delmar Learning, a division of Thomson Learning, Inc. Evaluation  Client’s level of maintenance or restoration of elimination patterns and return to an appropriate level of independence  Prevention of skin breakdown and infection  Client understanding of procedures and self-care