URINARY ELIMINATION Problems in Urinary elimination:
The major role is to maintain homeostasis by A. Altered Urine composition
maintaining body fluid composition and RBC Hematuria volume. WBC Urinary Tract Micturition- is the act of expelling urine from thebladder. ( also called urination or voiding). Pus Pyuria Infection Bacteria Bacteriuria - Refers to the process of emptying the urinary Albumin Albuminuria bladder. Urine collects in the bladder until Protein Proteinuria pressure stimulates special sensory nerve Casts Cylindriuria endings in the bladder wall called the stretch Glucose Glycosuria receptors. Ketones ketonuria Diabetic ketoacidosis The parasympathetic nervous system initiates voiding. Whereas, the sympathetic nervous B. Altered Urine Production: system inhibits voiding. The micturition reflex is 1. Polyuria – the production of excessive involuntary, but it can be inhibited by higher amount of urine, such as more than brain centers. 100ml/hr or 25,000 ml/ day ( also called diuresis) Factors affecting voiding: 2. Oliguria – the production of decreased 1. Developmental factors amount of urine, such as less than 30 a. infants- ml/hr or less than 500 ml/24 hours b. preschoolers 3. Anuria – the absence of production of c. school-age children urine by the kidneys such as 0 to 10 d. elders ml/hour ( also called urinary 2. Psychological factors- ex. Nurses-ignore the suppression urge to void until they are able to have a break C. Altered Urinary Frequency 3. Fluid and food intake- can change the color of 1. Frequency – voiding at frequent intervals that the urine is more than 4 to 6 times per day 4. Medications- diuretics- increase urine 2. Nocturia - increased frequency at night formation; may alter color of the urine 3. Urgency – the strong feeling that the person 5. Muscle tone- wants to void 6. Pathologic conditions-urinary stone- may 4. Dysuria – voiding that is either painful or obstruct a ureter, blocking urine flow from difficult kidney to the bladder 5. Enuresis – repeated involuntary voiding 7. Surgical and diagnostics procedures- beyond 4-5 years of age cystoscopy 6. Pollakuria – frequent, scanty urination Normal Characteristics of the Urine: 8. Urinary Incontinence: Amount in 24hrs: 1,200-1500 ml a. Total urinary incontinence- a Color: amber/straw continuous and unpredictable loss of Odor: aromatic upon voiding urine Transparency: Clear b. Stress urinary incontinence – the Ph: slightly acidic (ranges: 4.6-8; average of 8) leakage of less than 50 ml of urine as a Specific gravity: 1.010-1.025 (this is measured result of a sudden increase in intra- by urinometer abdominal pressure Glucose/ketone bodies (acetone)/blood: Not c. Urge urinary incontinence – follows a Present sudden strong desire to urinate and leads to involuntary detrusor contraction ( overactive bladder ( Bethanecol) as ordered syndrome) Last resort: Urinary catheterization . d. Functional incontinence – the This is the last resort because it is one involuntary unpredictable passage of of the most causes of nasocomial urine infection. It is the introduction of a e. Reflex incontinence – is an involuntary loss of catheter into the urinary bladder. urine occuring at some what predictable intervals when specific bladder volume is URINARY CATHETERIZATION reached. Single catheterization: straight /nelaton catheter 9. Urinary retention – the accumulation of urine Retention catheterization: 2 way Foley catheter in the bladder with associated inability of the Continuous Bladder irrigation( Cystoclysis): 3 bladder to empty itself way Foleys Catheter
- 250-450 ml of urine in the bladder triggers PURPOSES:
micturition reflex 1. To relieve bladder distention 2. To instill medications into the bladder. Clinical signs of urinary retention 3. To irrigate the bladder. Discomfort in the pubic area 4. To measure hourly urine output Bladder distention ( palpation and 5. To obtain a sterile urine specimen. percussion) 6. To measure residual urine. Residual urine - smooth, firm, ovoid mass at the suprapubic is the amount of urine retained in the bladder area after forceful voiding. - mass arising out of the pelvis 7. To manage incontinence when other - dullness on percussion measures have failed Inability to void or frequent voiding of 8. To promote healing of the genito-urinary small structures post-operatively. volumes ( 25-50 ml at a time) 9. To empty the bladder in preparation for Disproportionately small amount of diagnostic procedures and surgery. output in relation to fluid intake Increasing restlessness and feeling of Equipments for Catheterization: need to void Sterile catheter of appropriate size Nursing Interventions to induce Voiding: Sizes: adult - #14, #16 Provide privacy. This is the most children- #8 or #10 effective nursing measure to induce Catheterization kit: voiding. 1-2 pairs of sterile gloves Provide fluids to drink. sterile drapes Assist the patient in the anatomical antiseptic solution, cleansing balls, forceps, position of voiding. lubricant, sterile urine specimen container Serve clean, warm and dry bedpan (female) or urinal (male) BOWEL ELIMINATION Allow the patient to listen to the sound of running water • DEFECATION – is the expulsion of feces Dangle fingers in warm water. from the anus and rectum. It is also Pour warm water over the perineum. called the bowel movement. Promote relaxation Provide adequate time for voiding Normal characteristic of the stool: Perform Crede’s maneuver as ordered. Color: yellow or golden brown (due to the This is done by applying pressure on the bile pigment derivative known as the stercobilin suprapubic area. or fecal urobilinogen)
Administer cholinergics e.g. Urecholine Odor: aromatic upon defecation
Amount: depends on the bulk of the food Bulk Formers – they increase the bulk of the intake. Approximately 150-300 g per day feces, increasing mechanical pressure and Consistency: soft, formed distention of the intestine, thereby, increasing Shape: cylindrical peristalsis e.g. Metamucil Frequency: variable; usual range 1-2 per day to 1 every 2-3 days • Stool softeners – they soften the stool and facilitate its expulsion e. g. Colace Alterations on the Characteristic of Stool: • Osmotic agents – they attract fluids • Acholic stool – gray, pale or clay- from the intestinal capillaries to the colored stool due to absence of stool e.g. Milk of magnesia, Duphalac stercobilin caused by biliary obstruction 2. FECAL IMPACTION – is the mass or collection • Hematochezia – passage of stool with of hardened, putty-like feces in the folds of the bright red blood due to lower rectum. The stool lodged or stuck in the rectum, gastrointestinal bleeding the person is unable to voluntarily evacuate the stool • Melena – passage of black, tarry stool due to upper gastrointestinal bleeding Nursing interventions to relieve Fecal Impaction: • Steatorrhea – greasy, bulky, foul Manual extraction or fecal disimpaction smelling stool due to present of as ordered undigested fats like in hepatobiliary- Increase fluid intake pancreatic obstruction/disorder Sufficient bulk in diet Common Fecal Elimination Problems: Adequate activity and exercise
1. CONSTIPATION – refers to the passage 3. DIARRHEA – refers to frequent evacuation of
of small, dry, hard stools or the passage watery stools. It is associated with increased of no stool for a period of time. gastrointestinal motility, and a rapid passage of fecal contents through the lower • Nursing interventions to prevent and gastrointestinal tract relieve constipation: Adequate fluid intake Nursing interventions to relieve Diarrhea; High fiber diet to provide bulk to the Replace fluid and electrolyte losses stool Provide good perianal care. Diarrhea Establish regular pattern of defecation stool is often times highly acidic which Respond immediately to the urge to causes anal soreness and irritation in defecate the perianal care. Minimize stress To promote rest; to reduce peristalsis Adequate activity and exercise promote Diet: small amount of bland diet muscle tone and facilitate peristalsis Low fiber diet Assume sitting or semi-squatting BRAT diet (banana, rice am, apple, position toast Administer laxatives as ordered Avoid excessive hot or cold fluids, these are stimulants Types of laxatives: Potassium rich foods and fluid e.g. banana, gatorade Chemical irritants – they provide chemical Antidiarrheal mediations as ordered: stimulation to intestinal wall, thereby increasing perisitalsis, e.g. Dulcolax, castor oil,senakot • Demulcents – mechanically coat the irritated bowel and act as protectives Stool lubricants – they lubricate feces and facilitate the expulsion e.g. mineral oil • Absorbents – absorbs gas or toxic substances from the bowel • Astringents – shrink swollen or Enema – is a solution introduced into the inflamed tissues in the bowel rectum and large intestine. The action of the enema is to distend the intestine sometimes to CAUTION: Do not administer antidiarrheal at irritate the intestinal mucosa , thereby increase the start of diarrhea. peristalsis and excretion of feces and flatus. 4. FLATULENCE – is the presence of excessive TYPES: gas in the intestines, this may be due to 1. Cleansing enema swallowed air, bacterial action in the large 2. Carminative enema intestine and diffusion from blood 3. Retention enema Common causes of flatulence: 4. Return- flow enema • Constipation PURPOSES: • Codeine, barbiturates and other 1. To relieve constipation medications that decrease intestinal 2. To relieve flatulence motility 3. To administer medication • Anxiety 4. To evacuate feces in preparation for • Eating gas forming foods e.g. cabbage, diagnostic procedure or surgery legumes, root crops • Rapid food or fluid ingestion CONTRAINDICATION: • Excessive drinking of carbonated 1. Appendicitis beverages 2. Intestinal obstruction • Improper use of straw 3. Increase intracranial pressure • Gum chewing, candy sucking, smoking • Abdominal surgery- causes decreased TYPES peristalsis 1. Cleansing enema – intended to remove feces, stimulates peristalsis by irritating Nursing Interventions: the colon and rectum and or by • Avoid gas forming foods distending the intestine with the • Provide warm fluids to drink- increase volume of fluid introduced. It is given peristalsis chiefly to: • Adequate activity and exercise Prevent the escape of feces during • Limit carbonated beverages, use of surgery straws and chewing gums Prepare the intestine for certain • Rectal tube insertion as ordered. Place diagnostic tests such as x-ray or client in left lateral position. Insert 3-4 visualization test ( colonoscopy) inches of the lubricated rectal tube, Remove feces in instances of gently in rotating motion. Use rectal constipation and impaction. tube Fr. 22-30. Retain rectal tube for a maximum of 30 minutes Commonly used solutions: • Carminative enema as ordered Hypertonic – saline • administer cholinergics s ordered e.g. Hypertonic enema – fleet phosphate enema prostigmin Hypotonic – tap water Isotonic – normal saline 5. FECAL INCONTINENCE is the involuntary Soap suds –irritates mucosa, distends colon elimination of bowel contents; often associated Mineral oil – lubricates the feces and the with neurologic, mental, or emotional colonic mucosa impairments due to dysfunction of the anal Catminative enema sphincter e.g. spinal cord injury clients- impaired nerve supply to the rectum & A. High enema – is given to cleanse as sphincter much of the colon as possible , client should be in left lateral position to the ADMINISTERING ENEMAS: dorsal recumbent then to the right lateral so that the solution can follow NON-RETENTION ENEMA the large intestine; 1000 ml 0f solution Solutions used are as follows: o Tap water (500-1000 ml) B. low enema – is used to clean the o Soap suds ( 9 20 ml of castile soap in rectum and sigmoid colon only; client 500-1000 ml of water) maintains left lateral position during o Normal Saline solution ( 9 ml of NaCl to administration. 500ml of solution is 1000 ml of water) introduced o Hypertonic solution /fleet enema (90- The force of flow is governed by: 120 ml) Height of solution a. Height of solution container – 30 to 49 o 18 inches above the rectum cm (12 to 18 in) – the higher the faster Temperature of solution o 115°-125° F b. Size of the tubing- larger size, the faster Time of retention c. Viscosity of the fluid- thicker, slower o 5-10 minutes for better cleansing effect
d. Resistance of the rectum -+= slower RETENTION ENEMA
Solutions 2. Carminative enema – to expel flatus o Carminative enema - The solution instilled into the rectum o Oil (90-120 ml of mineral oil, olive oil or releases gas, which in turn distends the cottonseed oil) rectum and the colon thus stimulating Height of solution peristalsis. For an adult, 60-80 ml of o 12 inches above the rectum fluid is instilled Temperature of solution o 105˚-110˚ F 3. Retention enema – introduces oil or Time of retention medication into the rectum and sigmoid colon; o 1-3 hours until desired therapeutic oil is retained in 1-3 hours, acts to soften the effect is obtained feces and lubricates the rectum and anal canal, facilitate passage of feces GUIDELINES FOR ADMINISTERING ENEMA:
4. Return-flow enema – is used occasionally Suggested Maximum Volumes
used to expel flatus Infant 150 to 250 ml Toddler 250 to 350ml • Harris Flush/ Colonic Irrigation School –age 300 to 500 ml • 100-200 ml of fluid is introduced into Adolescent 500 to 750 ml and out of the large intestine to Adult 750 to 1000 ml stimulate peristalsis and to promote Suggested temperature of Solution expulsion of flatus Child 37.7 C (105 to 110 F) • The solution container is lowered so that the fluid backs out through the Adult 40-43 C ( 105 to 110 F) rectal tube into the container. Retention Enema 33 C ( 91 F ) • The inflow –outflow process is repeated Suggested Rectal Tube Size 5-6 times Infant/ Small Children 10 – 12 Fr • Replace the solution several times during the procedure as it becomes Child 12-18 Fr thick with feces Adult 22-30 Fr • May take 15-20 minutes to be effective Length of Insertion Infant 1-1.5 inches