1. Urinary & Bowel Elimination Needs

2. Unit V: Urinary Elimination Kidneys – function to filter waste products from the blood Kidneys also produce essential regulatory substances – renin & erythropoietin 25% of cardiac output circulates through the kidneys each minute Nephron = filtration system; composed of: –Glomerulus Bowman’s capsule –Proximal covoluted tubule Distal tubule –Loop of Henle Collecting duct

3. Unit V: Urinary Elimination

4. Blood enters kidney via renal artery  Glomerulus filters water, glucose, amino acids, urea, creatinine & electrolytes  99% of filtrate is reabsorbed into the blood stream 1 % excreted into collecting duct as urine

5. Unit V: Urinary Elimination Urine leaves the nephron via the collecting ducts  renal pelvis  ureters (peristalsis)  bladder Urine leaving the kidneys is sterile unless a kidney infection or generalized sepsis is present Bladder functions as a hollow storage receptacle for urine Internal & external sphincters at base of bladder under voluntary control after child’s development progresses to walking.

6. Unit V: Urinary Elimination Urethra – tubular passage for urine from the bladder to the meatus Female urethra = 1.5 – 2.5 inches long Male urethra = 7 – 8 inches long Turbulent urine flow through urethra intended to wash away bacteria that migrate into urethra Women more susceptible to bladder infection due to shorter urethra length

7. Unit V: Female Urinary System

8. Unit V: Male Urinary System

9. Unit V: Urinary Elimination Process of Urination: Sensors in the cerebral cortex, thalamus, hypothalamus & brain stem Stretching of the bladder as it fills stimulates micturation center in sacral spinal cord detrusor muscle contracts Internal sphincter relaxes first conscious relaxation of external sphincter simultaneously with relaxation of the pelvic floor and contraction of the bladder

10. Unit V: Urinary Elimination How do clients manifest nursing needs related to urinary elimination? Which clients have problems meeting this basic elimination need?

11. Unit V: Urinary Elimination Oliguria – reduced urinary output Anuria – absence of urinary output Dysuria – pain or difficulty of urination Hematuria – blood in urine Polyuria – excessive urine output Diuresis – promotion of increased urine output

12. Unit V: Urinary Elimination Reflex bladder – damage to the spinal cord above the sacral region causes loss of voluntary control of urination; if the reflex pathway is intact, urination occurs reflexively rather than voluntarily – cord injury Disease states that affect muscle tone and control of abdominal & pelvic floor muscles impact urinary control – i.e. multiple sclerosis, ALS…

13. Unit V: Urinary Elimination Pre-renal conditions affecting urinary elimination: Decreased blood flow to the kidneys – such as from CHF, blood loss, dehydration – resulting in oliguria or anuria Damage to glomeruli or renal tubule also results in changes in renal efficiency – diabetes mellitus, transfusion reactions Obstruction of urine flow from the renal pelvis, ureters, bladder or urethra can occur – calculi, blood clots, scarring, tumors…urine backs up in kidney and causes (hydronephrosis) lasting damage to nephrons

14. Unit V: Urinary Elimination Mobility issues impact client ability to meet urinary elimination needs Arthritis, degenerative joint disease, surgery to lower extremities, back pain – may impair client’s ability to get to a toilet Cognitive impairments – dementia or Alzheimer’s – affect client’s ability to correctly perceive need to void and how to meet that need

15. Unit V: Urinary Elimination Renal failure & end-stage renal disease results from irreversible damage to glomerulus or tubules –Increase in BUN, fluid & electrolyte imbalances,  BP, headache, N&V, seizures, coma… Dialysis or kidney transplant applied to meet elimination need of renal failure client

16. Unit V: Urinary Elimination Sociocultural Factors – Cultural experiences influence when and where it is appropriate to urinate and how much privacy is/is not required Psychologic Factors – Anxiety and stress contribute to urinary frequency or urgency; some individuals unable to void in situations provoking stress or without sufficient privacy

17. Unit V: Urinary Elimination Muscle Tone factors – weak abdominal or pelvic floor muscles affect ability to control urination – incontinence Prolonged immobility Stretching of muscles from childbirth Muscle atrophy from menopause Trauma to muscles

18. Unit V: Urinary Elimination Fluid Balance Factors – kidneys try to maintain balance between fluids and electrolytes…. Increased fluid intake causes increased urine production Nocturia – increased urine production at night – occurs in clients whose renal blood flow or venous return is + affected by rest and lying down at night (think about night-time falls!!!)

19. Unit V: Urinary Elimination Nutritional factors – Foods & drinks that contain caffeine stimulate urine formation; alcohol inhibits the release of ADH resulting in increased water loss; high sodium foods may cause water retention Metabolic Factors – Basic metabolic body functions, breathing, digestion… account for insensible loss (500 – 1000 ml/day); conditions increasing metabolic rate increase fluid consumption (fever)

20. Unit V: Urinary Elimination Surgical influence on urinary elimination – G.A.S. causes release of ADH water reabsorption; &  aldosterone water & sodium retention NPO status reduces fluid intake Anesthetics & meds alter glomerular filtration rate reducing urinary output Effects of anesthetics & surgery affect mobility and ability to void

21. Unit V: Urinary Elimination Medications affecting urination – Diuretics – prevent reabsorption of water and some electrolytes – increase urine output Antihistamines & anticholinergics can contribute to urinary retention Some meds change urine color – pyridium, amitriptyline, levodopa

22. Unit V: Urinary Elimination Diagnostic exams for urinary function: BUN, Creatinine Urinalysis Urine culture IV Pyelogram Cystoscopy

23. Unit V: Urinary Elimination Urinary Retention – accumulation of urine in bladder from obstruction, urethral edema, trauma, childbirth – may result in 2000 – 3000 ml urine – causes bladder spasms & can result in nerve damage to bladder and sphincter Bladder assessed by palpation and catheterization for residual urine

24. Unit V: Urinary Elimination Urinary Tract Infections (UTI): most common nosocomial infection in US hospitals (catheterization or surgical instrumentation) – ranges from bladder infections to urosepsis – can become life-threatening – immobility contributes to development of UTI Pain, frequency, dysuria, hematuria, fever, chills, cloudy/foul-smelling urine, flank pain & tenderness, chills, malaise

25. Unit V: Urinary Elimination Urinary Incontinence – involuntary loss of urine on a continuous or intermittent basis Classifications = Stress, functional, overflow, reflex, urge incontinence Mobility problems, energy limitations, loss of manual dexterity contribute to incidence Frequent episodes of incontinence contributes to skin breakdown

26. Unit V: Urinary Elimination Urinary Diversions – the ureter is surgically created to drain urine through the abdominal wall (bladder cancer, radiation, trauma…) A collection device that adheres to the abdomen collects urine draining from the kidney Issues include skin breakdown at the stoma site, risk for infection, self- concept alterations…

27. Unit V: Urinary Elimination Infection Control & Hygiene: Many UTIs related to poor hand hygiene, inadequate or incorrect toileting hygiene, incorrect catheterization technique, inadequate catheter care Client teaching, frequent handwashing and strict aseptic technique for catheterization help control/prevent UTIs

28. Unit V: Urinary Elimination Sterile technique for catheter insertion, regular catheter care and securing catheter and drainage tubing to avoid urethral irritation help prevent development of UTIs with foley catheters

29. Unit V: Urinary Elimination Position changes, adequate fluid intake, ambulation also help to prevent UTI in Foley clients

30. Unit V: Urinary Elimination Growth & Development Factors – Toddler – 2-3 years – has beginning neurologic maturity to sense bladder fullness, hold bladder 2 hours – and to communicate need to urinate Prostate enlargement in late life may cause urinary retention

31. Unit V: Urinary Elimination Nursing History Pattern or urination Symptoms of alterations Factors affecting urination Physical Assessment Skin & mucous membranes Kidneys & bladder Urinary meatus Characteristics of urine

32. Unit V: Urinary Elimination Urine Collection for Testing: Midstream specimen Straight catheterized specimen Sterile collection from indwelling catheter

33. Unit V: Urinary Elimination Nursing Diagnoses: Incontinence… Risk for infection… Toileting self-care deficit… Impaired urinary elimination… Urinary retention…

34. Unit V: Urinary Elimination Related Nursing Diagnoses: Risk for impaired skin integrity… Risk for falls… Alteration in self-concept… Knowledge deficit… Pain…

35. Unit V: Urinary Elimination Nursing Interventions: To promote prevention of infection To promote normal voiding pattern & bladder control To promote + self concept To prevent skin breakdown & falls To educate client To promote comfort & well-being

36. Unit V: Urinary Elimination Bladder Training: Normal body position/posture to void Sound of running water Warm water over perineum Adequate fluid intake – no caffeine Regular attempts to void Privacy & screening Pelvic muscle exercises

37. Unit V: Urinary Elimination Self-catheterization: Needed after surgery causing swelling and inflammation of urinary tract – or CNS alterations affecting urinary function Usually performed as a clean rather than sterile process Females have to be taught to find meatus by touch rather than visualized

38. Unit V: Bowel Elimination Needs

39. GI System begins at the mouth esophagus stomach small intestine ileocecal valve colon rectum 

40. Unit V: Bowel Elimination Needs Colon = large intestine is 5-6 feet in length; consists of the cecum, the colon (ascending, transverse, descending and sigmoid) and rectum Colon = has 3 functions: absorption (water, Na, & Cl), secretion (of bicarbonate) and elimination of wastes

41. Unit V: Bowel Elimination Needs Factors Affecting Bowel Elimination: Age – neuromuscular control of bowel elimination not developed until age 2 or 3 years; older adults loose muscle tone in perineal floor and anal sphincter; aging causes slowing of nerve impulse to signal need for defecation Diet – regular eating patterns support regular bowel habits; fiber provides bulk to fecal material and stimulates peristalsis; some foods produce gas causing intestinal distention

42. Unit V: Bowel Elimination Needs Fluid Intake – reduced fluid intake may contribute to constipation; Ingestion of milk products slows peristalsis; adequate water & fruit juice promote normal bowel function

43. Unit V: Bowel Elimination Needs Factors Affecting Bowel Elimination: Physical Activity – physical activity promotes peristalsis; immobility can lead to loss of muscle tone, constipation, ileus, bowel obstruction… Psychological Factors – stress response may stimulate peristalsis and digestion diarrhea or gas; depression slows peristalsis and may promote constipation; strong link of psychological influences on ulcerative colitis and Crohn’s disease

44. Unit V: Bowel Elimination Needs Factors Affecting Bowel Elimination: Position during defecation – sitting or squatting aids increased intra-abdominal pressure and contraction of pelvic floor muscles. Hospitalization and imposed use of bedpans, or bedside commode may inhibit client’s bowel elimination Pain – surgery, hemorrhoids, rectal fistulas, etc. may make defecation painful – causing client to suppress urge constipation

45. Unit V: Bowel Elimination Needs Factors Affecting Bowel Elimination: Personal Habits – privacy, convenience, regular habits; gastrocholic reflex = response to defecate approx. 30 - 60 min. after meals.

46. Unit V: Bowel Elimination Needs Factors Affecting Bowel Elimination: Pregnancy – growing uterus exerts pressure on rectum, peristalsis slows in 3 rd trimester, constipation is common & may lead to development of hemorrhoids Surgery & Anesthesia – general anesthetics causes temporary cessation of peristalsis (which is why clients are NPO just before & after surgery)

47. Unit V: Bowel Elimination Needs Paralytic Ileus = peristalsis stops as a result of direct manipulation of bowel or exposure of the intestines to air during abdominal surgery and/or general anesthesia; may resolve in 24 – 48 hours – or may progress to intestinal infarction and necrosis – can be life-threatening!

48. Unit V: Bowel Elimination Needs Factors Affecting Bowel Elimination: Medications – laxatives & cathartics promote peristalsis & fluid retention in the bowel promoting defecation; opioid analgesics suppress peristalsis; medications to treat diarrhea primarily suppress peristalsis

49. Unit V: Bowel Elimination Needs Common Dx Tests: EGD Barium Swallow Colonoscopy Barium enema Xrays Stool Culture Hemoccult

50. Unit V: Bowel Elimination Needs Common Bowel Elimination Problems: Constipation Fecal Impaction Diarrhea Incontinence Flatulence Hemorrhoids

51. Unit V: Bowel Elimination Needs Bowel Diversions = surgical openings created to drain intestinal waste; performed in a response to a disease process – such as ulcerative colitis, colon cancer, trauma, etc. Stoma = opening in the abdominal wall Jejunostomy = jejunum brought to abdominal wall Ileostomy = ileum portion of intestine exists abdominal wall Colonostomy = large intestine brought to abdominal wall

52. Unit V: Bowel Elimination Needs Loop Colostomy – performed when closure & reversal of colostomy is anticipated – loop of bowel brought to surface of abdomen – plastic or metal rod holds loop at surface; opening in bowel drains feces

53. Unit V: Bowel Elimination Needs End Colostomy – A single proximal section of colon brought to abdominal wall to form a stoma – distal portion of colon & rectum is either removed or sewn closed

54. Unit V: Bowel Elimination Needs Nursing History: Usual elimination pattern Typical stool characteristics Routines included in normal elimination Diet history Hx of surgery or illness Use of enemas, laxatives, fiber supplements at home Changes in bowel habits Changes in appetite Presence & status of bowel diversions Daily fluid intake Medication history

55. Unit V: Bowel Elimination Needs Physical Assessment: Mouth – assess for factors affecting diet intake Abdomen – contour, shape, symmetry, skin color, masses, scars, peristaltic waves, distention, pain and bowel sounds Rectum – lesions, hemorrhoids, bleeding… Digital exam for impaction

56. Unit V: Bowel Elimination Needs Lab Tests: Stool specimens Fecal Occult Blood Amylase Alkaline Phosphatase CEA

57. Unit V: Bowel Elimination Needs The Colonoscopy – Outpatient procedure Client prep day before –Co-Lyte –Enemas Conscious sedation Monitoring post- sedation

58. Unit V: Bowel Elimination Needs Nursing Diagnoses: Bowel incontinence… Constipation… Risk for constipation… Diarrhea… Fluid imbalance… Nutritional imbalance… Pain…

59. Unit V: Bowel Elimination Needs Planning Nursing Care to: Support regular bowel habits… Correct fluid & electrolyte loss through diarrhea… Correct discomfort from constipation… Promote bowel control… Reduce/relieve pain… Correct nutritional deficiencies… Educate client about bowel health…

60. Unit V: Bowel Elimination Needs Nursing Interventions: Assess abdomen for changes in assessment Activity & exercise Stool softners or laxatives as Rx Encourage toileting at same time of day – 30 min after meals Provide privacy for toileting Monitor bowel movements for frequency & characteristics Provide fiber intake Position sitting upright if possible Fluid intake –Fruit juice –Water –Hot beverages

61. Unit V: Bowel Elimination Needs Nursing Interventions: Manual exam for impaction Manual removal of impaction Suppositories Stool softners Laxatives

62. Unit V: Bowel Elimination Needs Types of Enemas: Cleansing enemas –Soapsuds –Saline –Tap-water –3-H –Harris Flush Oil Retention Carmative Commercial preparations

63. Unit V: Bowel Elimination Needs Position client in left Sims’ position Wearing exam gloves, lubricate enema administration tip Insert 2-3” into rectum Initiate flow of solution with bag 18” above client’s hips Monitor client tolerance

64. Unit V: Bowel Elimination Needs