Download NURS 130/131 Elimination

Nursing 122
Urinary Elimination
 Bowel Elimination
 Sexuality
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Urinary Elimination
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Anatomy and Physiology
Kidneys
Ureters
Bladder
Urethra
Factors affecting Micturition
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Developmental
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Food and fluid intake
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Psychological variables
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Activity and muscle tone
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Medications
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Pathologic conditions
Elimination-Urinary
Elimination is a basic need that has to
be met for all clients.
 It is one of the functional patterns of
special concern to nurses
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Nursing Process in Urinary
Elimination
Assessment: voiding pattern
 Physical exam of kidneys, urinary
meatus, bladder; skin integrity,
hydration, examine urine
– Terminology: anuria, dysuria,
glycosuria,nocturia,oliguria,polyuria,
proteinuria,pyuria,urgency
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Physical Exam
Right kidney at 12th rib, left kidney
higher-more difficult to palpate
 Bladder can rise to the umbilicus if
grossly distended
 Urine characteristics?
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Collecting Urine Specimens
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Routine urinalysis is not a sterile specimen
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For infants, may use a disposable collection
bag
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Clean catch
Collecting Urine Specimens
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From an indwelling catheter–
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Use the port on the tubing, not the bag;
Always wipe with antiseptic swab.
Use a sterile syringe to withdraw 3-10 mL
Tube may be clamped below port for up to 30
minutes to allow urine to accumulate .
24-hour specimens: Empty bladder then start
collection time. Voids at the end of 24 hours.
 Measuring output: measured in ml’s; use
gloves.
Urine Characteristics
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Color-usually pale yellow to amber
Odor-aromatic
– An ammonia smell is the result of
interaction with bacteria; may be sweet or
fetid
Appearance: clear not cloudy
pH- range 4.6-8.0, affected by diet
Specific gravity- measures concentration of
solids.
– Adult: 1.015-1.025
– Elderly: less concentrated with age
Urine Constituents
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Protein:
– 0-8 mg/dL (100 mL), random void
– 50-80 mg/ 24 hours (at rest)
– < 250 mg/24 hours (during exercise)
 White blood cells (WBC’s):
– 0-4 WBC per low power field
 Red blood cells (RBC’s):
– < or = to 2 RBC per low power field
 Abnormal: blood, bilirubin, glucose, ketones,
nitrites, WBC or RBC casts, crystals, and
bacteria.
Medical diagnostic procedures
Urodynamic studies
 Cystoscopy
 Intravenous pyelography
 Retrograde pyelography
 Renal ultrasound
 Computed tomography (CT) scans
 Renal biopsy
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Nursing Process:
Analysis and Nursing Diagnoses
Incontinence: functional, reflex, stress,
total, urge
 Urinary retention-acute , chronic
 Impaired urine elimination (frequency,
urgency, dysuria, nocturia)
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Nursing Process:
Outcome Identification and Planning
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The patient will:
– Produce urine output that almost equals
fluid intake
– Maintain fluid/electrolyte balance
– Empty bladder completely at 2-4 hour
intervals
– Report ease of voiding
– Maintain skin integrity
Nursing Process: Implementation
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Promote normal urination:
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Promote fluid intake:
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Strengthening muscle tone:
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Stimulating urination-manual bladder
compression, stroke inner thigh, run water
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Assist with toileting (toilet, bedpan, urinal,
commode)
Nursing Process: Implementation
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Preventing urinary tract infections (UTI):
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Drink 8-10 8-oz. glasses of water each day
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Dry perineum from front to back
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Drink fluids before sexual intercourse, void
immediately after
Shower rather than bathe
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Cotton crotch underclothing
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Drink cranberry juice
Nursing Process: Implementation
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Urinary Incontinence:
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Stress (coughing, sneezing, laughing),
Urge (urgency)
Mixed (stress and urge)
Overflow (signal to empty the bladder inactive or absent)
Functional (impairment of physical or cognitive functioning)
Management of urinary incontinence:
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Kegel exercises
Timed voiding
Appropriate use of prescribed medications
Catheters
Drip collectors
Absorbent products
Fluid intake- watch for sufficiency and caffeine
Catheterization
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Indwelling: Foley or retention:
– Double lumen or triple lumen (irrigation)
– Retention balloon, collecting container or
bag
 Intermittent: not continuous
– Single lumen, no retention balloon
– “Straight”
 Suprapubic- surgical incision, collecting device
Catheterization
Relieve urinary retention
 Obtain sterile urine specimen when not
possible by clean catch method
 Measure postvoid residual
 Emptying the bladder before, during and
after surgery
 Monitoring renal function of critically ill
patients
 Hazard: SEPSIS and TRAUMA
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Catheterization-Procedure
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Equipment: sterile disposable tray, sterile catheter
with 5-10 mL balloon
 Position: dorsal recumbent of side-lying
 In males, do not lubricate catheter, inject lubricant
into penis
 STERILE technique , after positioning and cleansing
patient
 Antiseptic solution
 Insertion: 2-3 inches in females, 6-8 inches in males
until urine flows
 Advance an additional 2-3 inches in females
 Inflate balloon with 5-10 mL sterile water
 Secure drainage bag tube to upper thigh females,
upper thigh or lower abdomen males.
 Attach drainage bag to bed frame (not siderail) below
level of bladder and never on floor; check for kinks or
compression on tubes.
Bladder Irrigation
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Purpose: to maintain patency
 First choice, natural irrigation through oral
and IV fluid intake
 Continuous bladder irrigation (CBI):
– Use a triple lumen catheter
– Use third port to instill irrigation fluid
Catheterization Removal and
Resumption of Urination
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Always completely deflate balloon before
removing an indwelling catheter (10 mL
syringe without a needle needed)
Monitor I&O for 24 hours after removal
Monitor for “Due to Void” (DTV): within 8
hours or less after removal(and repot if
necessary).
Leg bags may be used for ambulatory
patients with indwelling catheters
Condom catheters- latex, leave 1-2 inches
between penis and end of catheter, Velcro
strap
Urinary diversions
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ileal conduit: ureters diverted to ileum, with
surgically created opening on abdomen
(stoma). Requires external appliance for
continuous drainage. Usually permanent.
 Continent urostomy: internal reservoir
surgically created from small intestine,
requires regular catheterizations to
drain.
 Stoma care requires attention to skin , using
skin protectants.
Nursing Process: Evaluation
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Did the patient meet the goals?
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Support with patient data
Bowel Elimination
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Bowel elimination is a critical functionaffects fluid/electrolyte balance,
hydration, nutritional status, skin
integrity, comfort, self-concept.
Anatomy and Physiology
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Large intestine-ileocecal valve to anus:
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60 inches long
1-3 inches in diameter
Chyme (1500 mL per day), .
800-1000 mL of fluid absorbed in large intestine
daily.
– Ascending colon, hepatic flexure, transverse
colon, splenic flexure, descending colon, sigmoid
colon, rectum, anus.
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Parasympathetic system stimulates
movement, sympathetic system inhibits.
Anatomy and Physiology (cont.)
Peristalsis occurs every 3-12 minutes
daily, with mass peristaltic sweeps
occurring about 1 hour after eating.
 It may take 72 hours to excrete waste
from 1 meal.
 Normal range of frequency of bowel
movements is 2-3 per day to
2-3 per week.
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Factors affecting Bowel Elimination:
Developmental
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Infants pass stool with a frequency dictated
by type of food
– bottle fed, 1-2 stools/day
– breast fed up to 10 stools/day
– by 1 year, stabilizes to 1 per day
 Between 18-24 months of age the nerves
around the anal sphincter are fully developed.
 Bowel training accomplished by 30 months.
 Elders: vulnerable to constipation,
incontinence or diarrhea.
Factors Affecting Bowel Elimination
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Daily patterns- privacy, position
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Food/fluids: high fiber and 2-3L fluid per day optimal
– Food intolerances
– Constipation
– Laxative foods
– Gas producing foods
– Regular exercise
Factors affecting Bowel Elimination
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Stress:
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Pathologic conditions
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Medications
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Surgery
Nursing Process: Assessment
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History-Usual pattern of elimination
-Any aids used
-Any changes in stool
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Physical Assessment: Inspection, auscultation, then
palpation. Listen in all 4 quadrants .
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Describe, stool
Stool Specimen Collection
Use gloves, tongue blades, 1 inch
formed stool or 30 mL liquid stool is
sufficient. Send Immediately to lab or
refrigerate.
 Occult blood
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Diagnostic Studies
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Endoscopies-require consents and fasting or bowel
preparation
 Fluoroscopic and radiographic exams-may require
drinking contrast material, or bowel preparation
 Scheduling order:
1. Fecal occult blood testing
2. Abdominal ultrasound
3. Endoscopies may be done before Bariumrelated studies
4. Barium enema with abd. X-ray visualization
5. Barium swallow of upper gastrointestinal tract
with upper gastrointestinal X-ray visualization
Nursing Process:
Analysis and Diagnosing
Constipation- Actual or Risk for
 Diarrhea
 Bowel Incontinence
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Nursing process: Outcome
Identification and Planning
The patient will have a soft, formed
stool every 1-3 days without discomfort
 The patient will explain the relationship
between bowel elimination and dietary
intake, fluid intake, exercise
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Nursing Process: Implementation
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Promoting regular bowel habits
– Assist patient about 1 hour after meals
– Provide toilet, bedpan, commode in as close to
sitting position as possible
– Provide privacy
– Provide for 2-3L fluid/day
– Provide high fiber foods
– Ambulate or exercise abdomen/thigh exercises at
bedside.
Nursing Process: Implementation
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Preventing/treating constipation
– Teach about fiber/fluids
– Teach about laxatives:
• bulk-forming: may interfere with absorption
calcium, iron; expense
• emollient: may interfere with fat soluble vitamin
absorption
• lubricant: can be aspirated; can interfere with
fat soluble vitamin absorption
• stimulant: alters electrolyte transport, easily
abused, causes lazy bowel
• saline-osmotic: can produce dehydration
– Encourage increased physical activity
Nursing Process: Implementation
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Preventing/treating diarrhea
– Increase fluids to replace those lost (clear liquids)
– Assess cause and remove
– Be sure to rule-out impaction
– Special skin care to area around anus may include
creams
– Recommend fermented dairy intake to return
normal bowel flora (yogurt, Kefir)
– Teach food storage and preparation :avoid raw
eggs, undercooked meats, raw seafood,
pasteurized juices to small children, refrigerate all
dairy/meat after 2 hours at room temperature
– Administer anti-diarrhea medications
Nursing Process: Implementation
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Administering an enema
– Cleansing: water, saline, soap, hypertonic
– Retention: oil, carminative, medicated,
nutritive
– Return-flow-to expel flatus
Administering an enema
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Obtain appropriate equipment
Cleansing enema:
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750-1000 mL , warmed to 110 degrees
Administer over 5-10 minutes,
Patient positioning and privacy (left side)
Lubricate rectal tube and insert 3-4 inches
Clamp tube to stop flow if cramping occurs
Encourage holding solution for 5-15 minutes
Patient hygiene afterwards
Hypertonic solution : 70-130 mL. Administer
over 1-2 minutes. Do NOT warm. Left side
position.
 Oil retention: body temperature, hold for 30
minutes if possible.
Nursing Process: Implementation
Digital Disimpaction- side lying, one
finger well lubricated to manipulate stool
into smaller pieces and remove
 Caution: can slow heart rate (vagal
nerve stimulation results in bradycardia,
< 60 beats/ min in an adult)
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Nursing Process: Implementation
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Managing Bowel Incontinence
– Scheduled toileting, especially following
meals
– Skin care to perineal area
– Administer suppository or enema as
physician order
Nursing Process: Implementation
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Patients with bowel diversions: ileostomy,
colostomy. Stoma may be temporary or
permanent
– Appliances contain odors and are
preferred to dressings; emptied frequently
– Inspect stoma for color, bleeding
– Measure stoma: stabilizes within 8 weeks
– Maintain skin care to peri-stomal area
– I & O measurement
– Assist patient to learn self-care
– Change appliance : pouch, skin barrier
rings; empty pouch when 1/3-1/2 full
Nursing Process: Evaluation
Is there a change in defining
characteristics?
 Have goals been achieved?
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Sexuality
The degree to which a person
experiences male or femaleness,
physically, emotionally and mentally
Sexual Health
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“Integration of the somatic, emotional,
intellectual and social aspects of sexual
being in ways that are positively
enriching and enhance personality,
communication and love”
(World Health Organization)
Health Concerns related to Sexuality
Sexually transmitted infections
 Sexual dysfunction and effect on selfconcept
 Self care behaviors related to breasts
and testes, including mammograms,
pap smears, prostate exams
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Factors Affecting Individual’s
Sexuality
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Development
Culture
Religion
Ethics
Lifestyle
STI’s
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Childbearing
considerations
Sexual dysfunction
Diseases
Surgery
Spinal cord injury
Chronic pain
Mental illness
Medications
Sexual Expression
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Vaginal intercourse
Masturbation
Anal intercourse
Oral genital
stimulation
Celibacy
Alternative forms
 Voyeurism
 Sadism
 Masochism
 Sadomasochism
 Pedophilia
Sexual Dysfunctions
Female
Male
Erectile failure –
impotence
 Premature
ejaculation
 Retarded ejaculation
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Inhibited sexual
desire
 Dyspareunia – may
occur in men as
well.
 Vaginismus
 Vulvodynia
Sexual Orientation
 Heterosexual
 Homosexual
 Bisexual
 Transsexual
 Transvestite
Nursing Process in Sexual Health
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Assessment: questions related to
– menarche/menopause
– birth control
– births
– diseases
– dysfunction
– self care practices
– self concept
– physical assessment
Nursing Process:
Analysis and Diagnosing
Ineffective sexuality pattern
 Sexual dysfunction
 Rape-trauma syndrome
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Nursing Process:
Outcome Identification and Planning
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Examples include:
– Communication with significant others
– Responsible self examination care
practices
Nursing Process: Implementation
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Form a trusting relationship
Offer education regarding prevention of STI’s,
self exam procedures, birth control
Anticipatory guidance regarding possible
medication side effects
Plan for privacy with partner while
hospitalized
Provide a safe environment and counseling
following rape.
Teaching Self-examination
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Women: breasts monthly
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Men: testes monthly
Teaching Contraception
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Describe effectiveness, side effects and
complications for:
– Behavioral methods (temperature, cervical mucus,
calendar)
– Barrier methods: diaphragm, condom, cervical
cap, spermicide, vaginal sponge
– Hormonal methods: oral contraceptives, Norplant
(under skin), Implanon (under skin), Depo-Provera
(injected), transdermal contraceptive patch,
vaginal ring.
– Intrauterine devices
– Emergency contraception-morning after pill or
insert copper IUD
– Sterilization: surgical severing vas deferens or
fallopian tubes.
Nursing Process: Evaluation
Is there an increase in knowledge?
 Has there been a behavior change?
 Has there been an improvement in selfconcept or body-image?
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Sexual Harassment
Unwelcome behavior that is sexual or
gender-based in nature.
Two forms are:
1. Quid Pro Quo
2. Hostile environment
The End
Questions
Bethany Perry, RN, MS
HS 216
443-518-3158
[email protected]