1. Urinary & Fecal Elimination
Nur 102
Faculty of Nursing

2. Urinary Elimination Process Of Urination Kidneys Ureters
Urinary bladder
Urethra

3. 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 ml of urine in adult & ml 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.

4. 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.

5. 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.

6. 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.

7. 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).

8. 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.

9. 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.

10. 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)

11. 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

12. 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 ( ), 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.

13. 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

14. 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

15. 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 ( 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:

16. 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

17. 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.

18. 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

19. 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

20. Bowel elimination

21. 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)

22. 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)

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

24. 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

25. 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

26. 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

27. 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.

28. 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

29. 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

30. 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

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

32. 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)

33. 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

34. 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)

35. 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)

36. 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)