Elimination

inability to produce urine

bacteria in the urine

a substance that causes evacuation of the bowel by softening stool and promoting peristalsis

a catheter which drains from a condom type devise that is worn over the penis, it is used on incontinent or comatose men who still have complete and spontaneous bladder emptying

• a symptom of improper diet, reduced fluid intake, lack of exercise, and the effect of certain medications
• can be identified by infrequent bowel movements, difficulty passing stool, excessive straining, inability to defecate at will and hard feces

an inflammation of the urinary bladder or ureters characterized by pain, urgency and frequent urination

the elimination of feces from the digestive tract through the rectum

sweating

• an increase in the number of stools and the passage of liquid, unformed feces
• BRAT diet: bananas, rice, apples, toast

an increase in urine formation

pain or burning during urination

incontinence of urine

waste products that reach the sigmoid portion of the colon

gas which has accumulated in the lumen of the bowel/GI tract causing distension

the number of repetitions in a fixed period

presence of sugar, specifically glucose in the urine

blood in the urine

dilated, engorged veins in the lining of the rectum

a collection of hardened feces wedged un the rectum, which cannot be expelled, results from unrelieved constipation

the inability to control urination or defecation

• presence of excessive ketone bodies in urine
• occurs as a result of uncontrolled diabetes, starvation or other metabolic condition in which fats are rapidly catabolized

a substance which causes an evacuation of the bowel by mild action

black tarry stool containing digested blood

the act of passing urine

excessive urination at night

blood that is not grossly apparent and appears from a nonspecific source with obscure S&S

• <400ml/24h
• diminished capacity to form urine

the rhythmic contraction of smooth muscle that forces food through the digestive tract

• excessive urination
• > 2000ml/24h

sweating

• the presence of large proteins in urine
• indication of glomerular injury

• the presence of WBC's in urine
• indication of UTI

• when urine is retained in the bladder after voiding
• occurs in OA bc the bladder does not contract effectively

• the ability of the digestive system to hold food or fluid
• inability to urinate or defecate

• the pressure of retained urine after voiding
• results in dribbling

• a circular band of muscle fibers that closes a natural opening in the body
• the external anal sphincter closes the anus

• greater than nl amount of fat in feces
• frothy foul smelling feces that floats

feces

a urinary bladder catheter inserted through the skin above the pubic symphysis

feeing or need to void urine immediatly

the spread of bacteria into the bloodstream and kidneys

evacuating urine from bladder

regular elimination of urinary and bowel waste is essential for normal body fx, alterations can be a early signs or symptoms of problems with the GI or GU system

• Anxiety causes a sense of urgency and increased frequency of urination bc it often prevents a person from urinating completely and as a result the urge to void returns shortly
• Longterm use of an indwelling catheter will cause muscle atrophy
• Increased fluid intake increases urinary output
• Diabetes Mellitus causes polyuria
• Narcotic Analgesics decreases urine output

RENAL SYSTEM:

Kidneys- reddish brown kidney shaped organs measuring approx 5"x3" that weighs about 12-150g; Waste products of metabolism that collect in the blood are filtered in the kidneys; the blood is filtered in the glomerular capillaries which are porous and permit filtration of water and substances such as glucose, amino acids, urea, creatinine and major electrolytes; only 1% of glomerular filtration is excreted as urine and the rest is reabsorbed into the plasma; nl urine output is 1500-1700ml/24h and the kidney produces renin and erythropoietin.

Ureters- urine enters the renal pelvis from collecting ducts where ureters join them to the bladder; they are lumens approx 10-12" long and approx 1/2" in diameter; urine drainage from the ureter to the bladder is normally sterile; peristaltic waves cause the urine to enter the bladder in spurts rather than steadily

Bladder- is a hollow, muscular organ that is both a reservoir for urine and the organ of secretion; when empty the bladder lies behind the pubic symphysis; in men it lies on the anterior wall of the rectum; in women in the anterior wall of the uterus and vagina; the bladder capacity is about 600ml and nl voiding is 200-300ml

Urethra- urine travels from the bladder through the urethra and passes outside the body through the urethral meatus; normally the turbulent flow of urine through the urethra washes it free of bacteria; in women the urethra is 1.5- 2.5" in length; in men the urethra is approx 8" in length

GI SYSTEM:

Mouth- digestion begins in the mouth where mechanical and chemical breakdown of nutrients occur (mastication); food is broken down so it can be swallowed; salivary secretions contain enzymes that initiate digestion of certain food elements; saliva softens the bolus of food for easier swallowing

Esophagus- food passes from the mouth through the esophagus to the stomach where it is now referred to as chyme

Small Intestine- during normal digestion, chyme leaves the stomach and enters the small intestine; it is a tube approx 1" in diameter and 20' long which contains 3 divisions, duodenum, jejunum and ileum; chyme mixes with digestive enzymes while traveling through the small intestine; it travels slowly to allow the absorption of nutrients and electrolytes; the enzymes (bile and amalyse) in the small intestine break down fats, protein and carbs into simple elements; nutrients are almost entirely absorbed by the duodenum and jejunum; the ileum absorbs certain vitamins, iron and bile salts

Large Intestine- large in diameter then the small intestine and is 5'-6' in length; it is divided into 3 parts, the cecum, colon and rectum; it is responsible for the absorption of water and primary organ for bowel elimination; unabsorbed chyme enters the cecum at the ileocecal valve where it travels through to the colon; as watery chyme enters the colon the water volume decreases as it moves along;the colon is divided into 4 parts, ascending, transverse, descending and sigmoid colon; 4 fx of the colon are absorption, protection, secretion and elimination; a large volume of water and significant amounts of Na and Cl are absorbed by the colon daily; the amt of water absorbed from chyme depends on the speed at which colonic contents move; alterations in colon fx can cause diarrhea, electrolyte imbalance or constipation; the colon eliminates waste products and gas

Rectum- waste products that reach the sigmoid colon are called feces; this is the final division of the GI tract; its normally empty of feces until defecation; when a fecal mass moves into the rectum, the walls distend and defecation begins

URINE:

Color- normal urine ranges from pale to amber, depending on its concentration; bleeding can cause it to look dark red if from the kidneys or ureters or bright red if from the bladder or urethra

Clarity- normal urine appears transparent at voiding; urine that stands in a container for several minutes appears cloudy; urine appears thick and cloudy as a result of bacteria

Odor- urine has a characteristic odor, the more concentrated the urine the stronger the odor; stagnant urine has an ammonia odor which is common for incontinent pt's; a sweet or fruity odor can indicate acetone as seen in diabetes mellitus or starvation

FECES:

Color- adults its brown; infants its yellow; abnormal is white, clay, black, tarry or red

Odor- pungent, affected by food type

Consistency- soft or formed

Frequency- daily or 2-3x a week

Amount- approx 150g/d

Shape- resembles the diameter of the rectum

*from the pt's description, the nurse determines whether the stool is watery or formed, soft or hard as well as the typical color

• URINALYSIS: a specimen of urine for lab testing; all are labeled with the pt's name, date and time of collection; the specimen should be examined within 2 hrs and it should be the first voided specimen in the morning to ensure uniform concentration of constituents
• STERILE SPECIMEN: a method of collecting urine for a culture by obtaining the specimen from an indwelling catheter or a sterile collection bag; clean the port with an antimicrobial swab and withdraw 3-5ml of urine via the syringe
• SPECIFIC GRAVITY: the weight or degree of concentration of a substance compared with an equal volume of distilled water; the concentration of dissolved substances in urine aids in the determination of a clients fluid balance; a specific gravity < 1.010 reflects an inability of the kidneys to concentrate urine or an insufficient secretion of ADH
• MEASURING URINE OUTPUT: I&O measures the pt's average daily intake of fluids; urine output can be measured in a marked drainage bag, a urimeter or a graduated measuring receptacle; an hourly output of <30ml for more than 2 hrs is cause for concern; high volumes >2000ml/d should be reported to an MD
• MIDSTREAM SPECIMEN: used to obtain a specimen relatively free of microorganisms growing in the lower urethra; used for C&S tests; the pt cleanses the external genitalia, begins to urinate allowing the initial urine to escape, then during the middle of the void they collect the specimen; the initial void cleanses the residual bacteria
• STOOL SPECIMEN: the nurse is responsible to ensure proper technique is used and the sample is put in the appropriate properly labeled container which is transported to the lab in a timely manner; medical asepsis should be used during during the collection of a stool sample; the nurse collects about 1" of formed stool or 15-30ml of diarrheal stool
• GUANIAC TEST: fecal occult blood test which measures for microscopic amounts of blood in the stool; helps to reveal visually undetectable blood

• URINARY RETENTION: is the marked accumulation of urine in the bladder as a result os the inability of the bladder to empty fully; urine continues to collect in the bladder, stretching its walls and causing feelings of pressure, discomfort, tenderness over the pubic symphysis restlessness and diaphoresis; in nl urination the bladder fills and receptors activate when a certain level of stretch has been reached; the micturition reflex occurs and the bladder empties; in urinary retention, the bladder becomes unable to respond to the micturition reflex and thus is unable to empty
• URINARY OVERFLOW: as bladder retention progresses, overflow may develop; pressure in the bladder builds to a point where the external urethral sphincter is unable to hold back urine; the sphincter temporarily opens to allow a small volume of urine (25-60ml) to escape; as urine exits the bladder pressure falls enough to allow the sphincter to regain control and close

• FUNCTIONAL: involuntary, unpredictable passage of urine in a pt with intact urinary and nervous system; can be caused by changes in the environment such as sensory, cognitive or mobility deficits
• OVERFLOW: see description above; can be caused by reaction to drugs, diabetes, fecal impaction or prostate enlargement
• REFLEX: involuntary loss of urine occurring at somewhat predictable intervals (large or small volume); can be caused by spinal cord dysfunction; the person is unaware of the full bladder and the need to void
• STRESS: leakage of small volumes of urine caused by a sudden increase in intraabdominal pressure; can be caused by coughing, laughing, sneezing or lifting with a full bladder
• URGE: involuntary passage of urine after a strong sense of urgency to void; can be caused by decreased bladder capacity, irritation to stretch receptors, infection or Etoh/caffeine ingestion

• Stimulation of the micturation reflex
• maintain elimination habits
• Maintain adequate fluid intake
• kegel excercises

• women void better sitting
• men void better standing
• leave the water running
• stroke the inner thigh
• place the hand in warm water
• warm the bedpan
• put warm water in the perineal area

• repetitive contractions of muscle groups to improve the strength of the pelvic floor muscles
• pt begins exercises while urinating and continues to practice during non-voiding times
• teach pt to tighten the urinary sphincter during urination to feel the sensations associated with urinary sphincter contraction (this stops the flow of urine), then hold the sphincter closed for 3-4 seconds 25-30 times 3-4 times a day for 6 mos

• good personal hygiene, cleansing the urethral meatus after each void and BM
• intake 2000-2500 ml of fluids to dilute the urine and promote regular micturation which flushes the urethra of microorganism
• acidifying urine inhibits the growth of microorganisms; meats, eggs, whole grain breads, cranberry juice and prunes increase urine acidity

• AGE: food passes quickly in infants and children; peristaltic action declines with age and esophageal emptying slows; older adults lose muscle tone in the perineal floor and anal sphincter
• INFECTION: duodenal ulcers can cause Helicobacter pylori
• DIET: the food we eat influences elimination; fiber provides bulk in fecal material, bulk forming foods absorb fluid thereby increasing stool mass; lactose intolerance causes diarrhea, gaseous distention and cramping
• FLUID INTAKE: an inadequate intake of fluid or disturbances resulting in loss of fluid affects the character of feces; reduced fluid intake slows the passage of food through the intestine and can result in the hardening of stool content
• PHYSICAL ACTIVITY: promotes peristalsis, immobilization depresses peristalsis
• PSYCHOLOGICAL FACTORS: if an individual becomes anxious, angry or afraid the stress response is initiated; the digestive process is accelerated and peristalsis is increased to provide nutrients needed for defense; side effects of increased peristalsis include diarrhea and gas
• POSITION DURING DEFECATION: squatting is the normal position, for the pt immobilized in bed defecation is often difficult; in the supine position it is impossible to contract the muscles used during defecation
• PAIN: normally defecation is painless, if a pt is in pain they are likely to suppress the urge to defecate to avoid pain
• PREGNANCY: the fetus exerts pressure on the rectum
• SURGERY & ANESTHESIA: causes temporary cessation of peristalsis

• voluntary contraction of abdominal muscles during forced expiration with a closed glottis
• it can cause changes in HR and rhythm and is contraindicated for pt's with heart problems or perineal sx
• it can be avoided by telling pt's to exhale during straining

• irregular bowel habits
• ignoring the urge to defecate
• low fiber diet high in animal fat
• low fluid intake slows peristalsis
• lengthy bed rest or lack of physical exercise
• heavy laxative use causes loss of normal defecation reflex
• medications
• bowel obstruction, paralytic ileus or diverticulitis
• neurologic conditions that block nerve impulses to the colon

• pt's with recent rectal, abdominal or gynecological sx
• pt's w a hx of cardiovascular disease
• those who have diseases causing elevated intra-ocular pressure (glaucoma) or increased intracranial pressure

• an inability to pass stool for several days despite to urge to defecate
• when a continuous oozing of diarrheal stool develops bc liquid is seeping around the impacted mass
• loss of appetite
• abdominal distention, cramping and rectal pain

• raw fruits
• cooked fruits
• greens
• raw vegetables
• whole grains

• fiber promotes bulk in fecal material
• bulk-forming food absorb fluids thereby increasing stool mass
• the bowel walls are stretched, increasing peristalsis and initiating the defecation reflex
• by stimulating peristalsis bulk foods pass quickly through the intestines, keeping the stool soft
• ingestion of a high fiber diet improves the likelihood of a normal elimination pattern if other factors are nl

• excess loss of colonic fluid can result in serious fluid and electrolyte or acid base imbalances
• the skin of the perineum and buttocks are exposed to irritating intestinal contents

• WHITE OR GRAY COLOR: indicates absence of bile
• BLACK OR TARRY (MELENA): iron ingestion or upper GI bleeding
• RED: lower GI bleeding or hemorrhoids
• LIQUID CONSISTENCY: moving quickly through the GI tract, diarrhea, reduced absorption
• NARROW/PENCIL SHAPE: obstruction, stenosis of the rectum

• Determination of the usual elimination pattern: frequency and time of day
• Routines associated with normal elimination: laxative use, reading a book
• Description of any recent changes in elimination: pt can best detect changes, very significant data
• Diet hx: determines the pt's preference
• Description of daily fluid intake: type and amount of fluid
• Hx of exercise: type and amount
• The use of artificial aides at home: enemas, laxatives or special foods that make them go
• Hx of surgery or illness to the GI tract: helps explain symptoms
• Presence and status of bowel diversion (ostomy): frequency of drainage and character of feces, appearance and condition of stoma, type of appliance used and method used to maintain ostomy's fx
• Medical hx: medications which may alter defecation or fecal characteristics
• Emotional state: stress?
• Social Hx: do they have their own bathroom? what are their living arrangements
• Mobility and dexterity: do they need assistance?

• understanding normal elimination
• attaining regular defecation habits
• understanding and maintaining proper fluid and food intake
• achieving a regular exercise program
• achieving comfort
• maintaining skin integrity
• maintaining self concept

• stimulate defecation reflex by assisting with squatting or proper position on bedpan
• affect the character of feces with laxatives, enemas or alterations in diet
• increase peristalsis with a high fiber diet

• give the pt the opportunity to discuss concerns or fears about their problem
• provide the pt and family with information to u/s and manage the elimination problem
• give positive feedback when the pt attempt self care measures
• help the pt to manage the condition but don't expect them to like it
• provide privacy during care
• show acceptance and understanding

• action inhibits GI motility and has a constipating effect
• indication is for pt's who have diarrhea
• nursing implications include assessing fluid and electrolyte status, assess GI fx and note mental status and any renal or hepatic dysfunction

• Metamucil
• acts by forming a gelatinous mass with water that adds bulk to the stool and stimulates peristalsis
• indicated for pt's as a prophylactic measure to prevent constipation or for short term treatment of constipation
• nursing implications include noting the reasons for the therapy, advise pt to add powder to 8oz of liquid and to wash it down with another glass of water or juice, advise pt to take exactly as directed and to ensure adequate fluid intake along with outer forms of fiber.

• colace
• acts by lowering surface tension of the feces and promoting penetration by water and fat to increase the softness of the stool
• indicated for pt's with constipation, megacolon or for pt's where straining to defecate should be avoided
• nursing implications include advising the pt to drink plenty of water, note reasons for therapy, may not take effect for 1-3 days