Transcript Elimination Concept

Introduction
 To understand the concept of Elimination it is
necessary to
1. Define the Attributes or the normal process of
Elimination
2. Identify the Antecedents - what must exist for
normal Elimination to occur?
3. Define the Consequences (Outcomes)
Posititive = Normal function
Negative = Altered or Impaired Function
4. Determine Interrelated and Sub-concepts that work
together to promote normal elimination or that can
impair elimination if impaired
OBJECTIVES
 Define Elimination and key terms related to elimination
 Summarize the structure and physiological processes of the
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renal and GI system related to Elimination
Explain the concept of Elimination
Analyze conditions which place a patient at risk for
disruptions in Elimination.
Identify when Elimination disruptions are developing or
have developed.
Discuss exemplars of common Elimination disorders.
Apply the nursing process across the life span for
individuals experiencing disruptions in Elimination
Identify pharmacological interventions in caring for
individuals with alterations in urinary and bowel function
Elimination
 Definition
The excretion of waste products from
the kidneys and intestines.
 The Concept
The use of the nursing process to make
decisions about care of patients
experiencing alterations in elimination
Concept Key Terms
Basic
Anuria
Polyuria
Oliguria
Nocturia/frequency
Dysuria
Enuresis
Retention
glycosuria
crede maneuver
Constipation
Diarrhea
Incontinence
Impaction
Obstruction
Encopresis
Scope & Categories of Elimination
INTERELATED CONCEPTS
INTERELATED CONCEPTS of
ELIMINATION
 Nutrition
 Fluids and Electrolytes
 Mobility
 Cognition
 Coping
Sub-Concepts
Components of Elimination
 Physiological development & function
 Genetics, gender, age, congenital defects
 Bowel and bladder toileting habits,
culture
 Nutrition & fluids
 Medication
 Medical conditions
CRITICAL ATTRIBUTES & ANTECEDENTS
ASSOCIATED WITH ELIMINATION
CATEGORY
CRITICAL
ATTRIBUTES
ANTECEDENTS
Presence of urine
Urge to urinate
Passage of urine
Bladder elimination
Retention of urine
Feeling of fullness or
(normal)
Color of urine
possible contraction of
Frequency of urination
bladder
Amount of urine
Presence of stool/feces
Urge to defecate
Passage of stool
Bowel elimination
Form of stool
Possible intestinal
(normal)
Color of stool
cramping or feeling of
Giddens, J. (2013). Concepts for Nursing Practice (1st ed). Mosby. Retrieved from http://pageburstls.elsevier.com/books/978Frequency of stool passage
fullness in rectum
0323-08376-8/id/B9780323083768000142_t0010
Retention of stool
Urinary Elimination
Normal Physiological Process
 The Renal System
 Kidneys
 Primary
regulators of fluid, acid–base
balance
 Nephron – the functional unit of
kidney
 Ureters
 Bladder
 Urethra
Figure 9-5 Female and male urinary bladders and urethras, showing sphincter muscles.
Source: Custom Medical Stock Photo, Inc.
Urinary and Bowel Control
Normal Physiological Process
Retention
Incontinence
Pregnancy and Birth
 Urinary frequency
 Ureters elongate
 Postpartum
 Newborns
 GFR lower than adult
 Limited tubular reabsorption, excretion
 Patterns of voiding
 Appearance of urine
Physiological Development & Function
 Developmental factors
 Infants
 Output
 Frequency
 Control
 Preschoolers
 Independent toileting
 Modeling,
reminders
 Instruction for wiping
Physiological Development & Function
 School Age
 Kidneys double in size
 Elimination system matures
 Older Adults
● Excretory function diminishes but not
significantly below normal unless there is a
disease process
● At higher risk for medication toxicity
● Men –changes often caused by enlarged
prostate
● Changes in bladder supporting muscles
● Bladder capacity and emptying decreases
Physiological Development & Function
 Psychosocial factors
 Fluid and food intake
 Medications that cause urinary retention
Anticholinergics
 Antidepressants- Antipsychotics
 Antihistamines
 Antihypertensives
 Antiparkinsonism
 Beta-adrenergics blockers
 Opioids

Physiological Development & Function
●Muscle Tone
 Pathologic Conditions that cause
altered Urine Production
 Polyuria
 Anuria
 Oliguria
 Inadequate kidney function
Physiological Development & Function
 Altered urine production
 Polyuria
 Anuria
 Oliguria
 Inadequate kidney function
Consequences of Function
Positive
Homeostasis
Active Lifestyle
Positive socialization
Positive Self Esteem
Comfort
Therapeutic nutritional status
Consequences of Function
Negative
Constipation – Impaction
Urinary Retention
Incontinence of urine and/or feces
Diarrhea
Age related changes
Diagnostic Tests
 Routine urinalysis
 Urine culture
 Bladder scan
 Uroflowmetry
 IVP
 Renal arteriography or angiography
 Cystoscopy
 Renal ultrasound
 CT
 MRI
 Renal scan
 Kidney biopsy
Pharmacological Therapy
 Diuretics – Loop, thiazide , potassium
sparing , and miscellaneous
Increases urine production
 Anticholinergics –Oxybutynin (Ditropan XL)
Reduces frequency- urgency
 Cholinergics – Urecholine
Stimulates bladder contractions to facilitate
voiding
Nursing Process
 Assessment
Assessment interview
Health history
Physical assessment
Nursing skills
 Nursing diagnosis
 Expected Outcomes
 Planning – Implementation
 Evaluation
Urinary Elimination Exemplars
Benign Prostatic Hypertrophy
Urinary Incontinence
Urinary Retention
Benign Prostatic Hypertrophy
 An enlargement of the prostate gland
resulting from an increase in the number of
epithelial cells and stromal tissue.
 Most common problem in adult males
 50% men over the age of 50
 90% men over the age of 80
 About ¼ of the men require some sort of
treatment by the time they reach 80 y/o
Benign Prostatic Hypertrophy
Benign Prostatic Hypertrophy
Benign Prostatic Hypertrophy
Etiology/Pathophysiology
 Endocrine changes
 Excessive accumulation of
dihydroxytestosterone (principal intraprostatic
androgen)
 Stimulation by estrogen and growth hormone
 Develops in the inner part of the prostate
 Gradually compresses the urethra
 Leading to eventual partial or complete
obstruction
Benign Prostatic Hypertrophy
Risk Factors
 Family history
 Environment
 Diet
 Western men are more likely to develop
obstructive problems
 Obesity increases the risk
 Increased saturated fats in the diet
 Physical activity and moderate alcohol
consumption decrease the risk for BPH
Benign Prostatic Hypertrophy
Clinical Manifestations
(gradual onset)
 Irritative Symptoms
 Due to inflammation or
infection
 Frequency & Urgency
 Dysuria
 Bladder pain
 Nocturia
 Incontinence
 Obstructive Symptoms
 Due to retention
 Decrease in force of stream
of urine
 Difficulty initiating
urination
 Intermittency
 dribbling
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Benign Prostatic Hypertrophy
Complications of BPH
 Majority are from
 Hydronephrosis
urinary obstruction.
 Acute retention
 UTIs
 UTI & sepsis
 Residual urine
 Alkalinization of
residual urine=
stones in bladder
 Pyelonephritis and
bladder damage if
treatment for acute
urinary retention is
delayed.
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Benign Prostatic Hypertrophy
Diagnostic Tests
 History & physical
 *DRE (digital rectal examination)
 UA & culture to r/o infection
 Serum Creatinine to r/o renal insufficiency
 *PSA to r/o Prostate CA (^slight with BPH)
 *Transrectal US with Bx (trus)
 Cystourethroscopy
 Uroflowmetry & post void residual
Benign Prostatic Hypertrophy
Pharmacological Agents
 1.
5-alpha reductase inhibitors: finasteride
(Proscar)
 3-6 month improvement
 Suppress conversion of testosterone to
dihydroxytestosterone. (ED)
 2. Alpha adrenergic receptor blockers: alfuzosin
(UroXatral), doxazosin (Cardura), tamsulosin
(Flowmax).
 These drugs are also used for ^ BP
 3. Herbal Therapy: Saw Palmetto
 conflicting and contradictory research r/t it’s
effectiveness
Benign Prostatic Hypertrophy
Invasive Treatments are not first
treatment choice
 TURP (resectoscope thru the urethra)
 Transurethral resection of the prostate
 Expect blood in urine post-op
 Usually continuous irrigation via indwelling Foley
catheter post-op
 TUIP (small incision local anesthesia)
 Transurethral incision of the prostate
 Open Prostatectomy 2 approaches
 Retropubic & perineal
Minimally Invasive
Treatments out patient
 TUMT (probe 113 degrees F)
 Transurethral microwave therapy-cath 7 days
 TUNA (needle low wave radiofrequency)
 Transurethral needle ablation of the prostate
 Laser Prostatectomy (VLAP) visual laser ablation of
Prostate-vaporization(little to 0 bleeding, short recovery)
 TUVP
 Transurethral vaporization of the prostate
 Intraprosthetic urethral stents (poor surgical candidates)
 A positive factor re these procedures is that ED is rare and
retrograde ejaculation is rare except with VLAP & TUVP
(also with invasive TURP)
Benign Prostatic Hypertrophy
TURP pre-operative care
 Restore urinary drainage (urologist,
Coude’ or Filiform catheter)
 Antibiotics and high fluid intake 2-3
liters
 Concerns of sexual functioning
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TURP post-op care
(Expect blood clots 24-36 hoursFoley catheter 2-4 days)
 Watch for excessive bleeding, pain with bladder
spasms, urinary incontinence, and infection
 Triple lumen catheter for bladder irrigation
 Sterile NS continuous irrigation
 Input and output must match
 Peri care
 Avoid activities that increase abdominal pressuresitting or walking a long time, straining
 Sphincter tone- Kegels
 It may take weeks to gain control of urine , continence
can improve for up to 12 months.
Benign Prostatic Hypertrophy
TURP or open surgery
 Retropubic approach: no enemas, or
rectal temps, may insert lubricated
belladonna and opium suppository for
spasms.
 High fiber diet and stool softeners
Nursing Diagnosis
 Pain
 Risk for infection
 Fear r/t actual or potential sexual
dysfunction
 Ineffective management of therapeutic
regimen
 Urge incontinence
 Potential complication: Risk for hemorrhage
post-operatively
PLANNING
 Restoration of urinary drainage
 Treat UTI
 Explain planned procedures
 Explain implications for sexual function
and urinary control
Consequences of Malfunction
 Flatulence
 Eructation
 Distention
 Causes
 Bowel incontinence
 Impaction
 Bowel cancer
 Obstruction
Physiological Development & Function
 Developmental factors
Pregnancy
 Newborns and infants
 Meconium
 Consistency
 Frequency
 Toddlers
 Bowel control
 School-age children and adolescents
 Patterns vary
●
Implementation
 Independent Nursing Interventions
 Health promotion
Maintain or increase fluids (BPH or
surgery?)
 Avoid alcohol, caffeine, (diuretic effect)
cold/cough medications, sudafed(aadrenergic agonists)
 Urinate q 3-4 hours
 Teaching
 Kegel Exercises
 Emotional Support

Kegel Exercises
 Kegel exercises are easy to do and can be done anywhere
without anyone knowing.
 First, as you are sitting or lying down, try to contract the
muscles you would use to stop urinating. You should feel
your pelvic muscles squeezing your urethra and anus. If
your stomach or buttocks muscles tighten, you are not
exercising the right muscles.
 When you've found the right way to contract the pelvic
muscles, squeeze for 3 seconds and then relax for 3
seconds.
 Repeat this exercise 10 to 15 times per session. Try to do this
at least 3 times a day. Kegel exercises are only effective
when done regularly. The more you exercise, the more
likely it is that the exercises will help.
Implementation
 Dependent nursing interventions
 Medical Administration
 Pre-op and post-op care
 Bladder Irrigation (OPEN)
 Continuous Bladder Irrigation
 Interdependent Nursing interventions
 Health promotion
 Collaborative intra/interdisciplinary care
planning
Urinary Incontinence
 An involuntary, unpredictable passage of urine or
loss of bladder control
 A symptom ; not a disease
 Women represent 85% of the approximate 13
million Americans that suffer this condition
1. Women have a shorter urethra
2. The trauma to the pelvic floor s/p childbirth
3. Menopausal changes
Urinary Incontinence
Transient Urinary Incontinence
 Sudden arrival lasts 6 months or less, has reversible
causes – i.e.
1. Infection
2. Pharmaceuticals
3. Vaginitis
4. Urethritis
5. Confusion
 If the cause is reversed, UI can be reduced
Urinary Incontinence
Established or Chronic UI
 Functional UI
 Overflow UI

Reflex UI
 Stress UI
 Urge UI
 Risk for urge incontinence UI
Treatment
Kegel exercises
Surgery
Bladder Training
Goals for Urinary Elimination Problems
 Maintain or restore normal voiding patterns
 Regain normal urine output
 Prevent infection, skin breakdown, fluid & electrolyte
imbalance, lowered self esteem
 Perform toileting activities independently with or
without assistive devices
 Contain urine with the appropriate device, i.e.
catheter, ostomy appliance , or absorbent product
 Patient/family education and discharge planning
Berman, A., & Snyder, S. (2012). Kozier & erbs's fundamentals of nursing: Concepts, process,
and practice (9th ed.). Upper Saddle River , NJ: Pearson.
Nursing Management
 Nursing history and assessment interview
 Physical Assessment
1. Skin inspection
2. Abdominal – bladder assessment
3. Kidney assessment
 Nursing Diagnosis
 Planning
 Interventions
 Implementation
Urinary Retention
 Incomplete emptying or inability to completely empty
the bladder
Gastrointestinal Elimination
Normal Physiological Process
● The Gastrointestinal System
● Oral Cavity
● Esophagus
● Stomach
● Small Intestine
● Large Intestine
● Digestion
● Elimination
Bowel Elimination
 Normal presentation
 Terms used to describe:
feces
stool
defecation
 Frequency is highly individual
 Normal feces
 Flatus
 Bowel elimination and pregnancy
Bowel Elimination
Exemplars
Constipation
Paralytic Ileus
Bowel Obstruction
Diarrhea
Physiological Development & Function
What are the Implications for older adults for
the following?
 Constipation
 Gastrocolic
reflex
 Laxative use
 Diet
 Bulk and fiber
 Foods that affect bowel elimination
 Psychologic factors
Constipation
 Infrequent passage of hard stool
Treatment
Increase fluid and fiber intake
Increase activity level
Administer enema
May require laxative, stool softeners
Evaluate medication profile for GI side
effects
Clostridium difficile – C. diff
 C. difficile or C. diff, is a bacterium that can
cause symptoms ranging from diarrhea to
life-threatening inflammation of the colon.
 Most commonly affects older adults in
hospitals or long term care facilities after use
of antibiotics
 Studies show increasing rates of C. diff
among younger and healthy persons not on
antibiotics or exposure to healthcare
facilities
C. difficile
 Causes
 C. diff bacteria are found in the
environment – soil, air, water, human and
animal feces , processed meats
 Commonly associated with health care –
occurs in hospitals and other health care
facilities where a higher percentage of
persons are that carry the bacteria
 Passed in feces and spread to food, surfaces
and objects when hand hygiene is poor
C. difficile
 Antibiotic therapy can destroy normal
intestinal flora which increases growth of
C. difficile bacteria
 Once established C. difficile produces
toxins that attack the lining of the
intestine
 Toxins destroy cells and produces plaques
of inflammatory cells and decaying
cellular debris inside the colon = watery
diarrhea
C. difficile
 Symptoms
 Some carry the bacterium in their
intestines and can spread the infection
but not become sick themselves
 C. difficile symptoms usually develop
during or within a few months after a
course of antibiotics
C. difficile
 Mild to Moderate Infection Symptoms
 Watery diarrhea three or more times
daily for two or more days
 Mild abdominal cramping and
tenderness
 Severe Infection Symptoms
 Watery diarrhea 10-15 x daily
 Abdominal cramping & pain, may be
severe
C. difficile
 Fever
 Blood or pus in the stool
 Nausea
 Dehydration
 Loss of appetite
 Weight loss
 Swollen abdomen
 Kidney failure
 Increased WBC

C. difficile
 Diagnostic Studies
Stool Specimen
Enzyme Immunoassay
Polymerase chain reaction
Cell cytotoxicity assay
Flexible sigmoidoscopy
Colonoscopy
Imaging Tests - Abdominal xray-CT scan
C. difficile
 Treatment
 Antibiotics – stop the antibiotic that triggered
the infection when possible
 The standard treatment is another antibiotic to
keep C.difficile from growing and treat the
diarrhea and other complications
 Metronidazole (Flagyl) by mouth Vancomycin
(by mouth) - severe and recurrent cases
 Fidaxomicin (Dificid) effective and more
expensive than Flagyl or Vancomycin
C. difficile
 Complications
 Dehydration
 Kidney failure
 Toxic megacolon
 Bowel perforation
 Death
C. difficile
Surgery
 Removal of disease portion of the
bowel may be only option for patients
in severe pain, organ failure or
peritonitis
C. Difficile
 Recurrent infection occurs in up to 20% of
patients
 Risk increases with
1. Persons older than 65
2. Persons taking antibiotics for other
conditions during treatment for C.diff
3. Persons with sever underlying medical
condition such as chronic kidney failure,
IBD or chronic liver disease
C. difficle
 Treatment for recurrence
 Antibiotics (typically Vancomycin) – one or more
courses
 An antibiotic given once every few days (pulsed
regimen)
 Effectiveness of abx therapy for recurrence is about
60% but declines with each recurrence
 Fecal microbiota transplant (FMT) –
– FMT restores healthy intestinal bacteria by placing
another person’s stool in the affected patient’s colon
using a colonscope or NG tube.
 Probiotics – organisms such as bacteria and yeast
which help to restore balance to the intestinal tract
C. difficile
 Push fluids
 Balanced Nutrition
 Increase high complex dietary starches
( potatoes, noodles, rice, wheat , oatmeal) and
fruits (bananas) to decrease diarrhea
 Prevention
 Strict Infection Control
 a. Hand washing
 b. Contact Precautions
 c. Disinfect surfaces with bleach
 Patient/family teaching
Diarrhea
Passage of Liquid Stools
Major Causes
 Psychologic Stress
 Medications
 Antibiotics
 Iron
 Cathartics
 Allergy to food, fluid, drugs
 Intolerance of food or fluid
 Diseases of the colon
DIARRHEA
CLINICAL PRESENTATION
Small bowel diarrheas
 – large, loose stools
 – periumbilical or RLQ pain
Large bowel diarrheas
 – frequent, small, loose stools
 – crampy, LLQ pain or cramping
Diarrhea
Treatment
Increase fiber intake
Administer anti-diarrheal
medications
Assess for cause (medication, diet ,
bacterial infection?? )
Bowel Incontinence
Inability to control release of feces
Treatment
 Bowel Training
 Surgery may be indicated (repair of sphincter and fecal
diversion)
REFERENCES
Berman, A., & Snyder, S. (2012). Kozier & erbs's fundamentals of nursing:
Concepts, process, and practice (9th ed.). Upper Saddle River , NJ:
Pearson.
Ignativicius, D.D. and Workman, M. L. (2013) Medical-surgical nursing:
Patient-centered collaborative care, 7th ed. St. Louis, MO:
Elsevier/Saunders.
Lewis, S.L., Dirksen, S.R., & Heitkemper, M.M., Bucher, L., Camera, I.M.
(2011). Medical-surgical nursing: Assessment and management of
clinical problems (8th ed.). St. Louis, MO: Elsevier Mosby.
Lemone, P., Burke, K., & Bauldoff, G. (2011). Medical -surgical nursing:
Critical thinking in patient care (5th ed.). Upper Saddle River, NJ:
Pearson
REFERENCES
North, carolina concept-based learning editorial board. (2011). Nursing; A
concept -based approach to learning. Volume I . Upper Saddle River,
N,J,: Pearson.
Potter, P.A., Perry, A.G., Stockert, P.A., Hall, A.M. (2013) Fundamentals of
nursing, (8th ed.). St. Louis, MO: Elsevier/Mosby.