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Transcript
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 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 31 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. 32 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 37 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.
