Regents College Nursing
Study Guide Expanded Notes
Commonalities in Nursing Care: Area B
Study Guide Elimination
II. Elimination
A. Theoretical framework: basis for care
Elimination is looked at in two area, urinary elimination and
intestinal or bowel elimination. Most people have difficulty
discussing problems involving these two areas.
Elimination is a skill learned early, with bowel and bladder
control an important element of the early years. It marks a major
development level. When problems develop in these systems, people
are often very disturbed over the change. Loss constitutes a major
threat to the social and emotional well-being of people, raising fears
of loss of independence.
1. Principles related to normal elimination (e.g., anatomy
and physiology, microbiology)
Urinary Elimination
The urinary system excretes most of the nitrogen waste from
cellular metabolism. This system is also important in the fluid and
electrolyte balance of the body.
Kidneys, the ureters, the bladder, and urethra are, in
descending anatomical and functional order, the components of the
urinary tract. The kidneys are the functional portion of the tract,
with the others being conducting, storage and elimination elements.
The kidneys eliminates the waste products of cellular
metabolism, and controls the concentration of the various
components of the body fluids, especially the overall volume of
blood. Blood is circulated through the kidneys where the excess
water, acid, and other wastes are removed. In a series of steps, the
wastes and water are excreted through filtration and then selectively
reabsorbed to accomplish this process.
The nephron is the functional unit of the kidney. The kidneys can
function effectively even with much damage. Only one is needed.
Ureters are long connecting tubes between the kidney and the
bladder. The bladder functions to store urine until excretion. It can
hold 300 to 500 ml in the adult. With this amount of urine in the
bladder, the person becomes aware of the urge to void through
sensory impulses.
A spinal cord stretch reflex is initiated which, if no inhibiting
impulses are present, causes the bladder muscle walls to contract
and the internal sphincter to relax. Urination occurs.
Micturition is the voiding act. It is normally a voluntary action
after about three years of age. This voluntary control is obtained
through a second external sphincter muscle. It is located in men at
where the urethra enters that glans penis, about the middle of the
urethra.
The urethra conducts the urine from the bladder to the
external environment. It is about 3 to 5 cm in length for women, and
about 20 cm for men. The external opening is called the meatus.
The meatus opens just above the vagina in females, and at the
end of the glans penis in males. For males, the urethra function in the
reproductive system. The entire urinary tract is lined with mucous
membrane that is continuous form the pelvis of the kidney to the
meatus. No further excretion or reabsorption of fluid occurs below or
distal to the pelvis of the kidney.
In a given daily 24 hour period, the average person excretes
about 1000 to 1500 ml. of urine. The volume varies with the fluid
intake and losses through the other routes of sweating, respiration,
and feces. The body will conserve fluid and decrease urine
production, increasing the concentration, when faced with abnormal
losses as from vomiting, diarrhea, edema, and other blood volume
loss.
People usually void on rising for the morning, and then four to
six times through the day, ending the day with a voiding act for
retiring to sleep. During sleep, voiding does not usually have to occur
unless the fluid intake had been increased, especially just prior to
bed. Frequency and number of micturation events vary according to
individual patterns and activities.
Urine has a faintly aromatic odor when freshly voided, and
becomes stronger on standing. It is slightly acidic, a pH in the range
of 4.8 to 8.0, and becomes alkaline due to disintegration of the
constituents, with a cloudy sediment developing. Urine normally
contains creatinine, uric acid, urea, and a few white blood cells.
Urine is normally sterile, containing no bacteria. Urine also does
not normally have red blood cells, sugar, albumin (protein), acetone,
casts, pus, or calculi (stones).
Intestinal or Bowel Elimination
For excretion, the colon and the rectum are the principle
elements of the digestive tract. The more proximal elements are
involved with digestion and absorption. Chyme is delivered to the
colon. It is further processes, with water absorbed changing the
liquid product delivered into a semi solid and then a solid before
transporting it to the rectum for removal.
In the colon, sodium and chloride ions are absorbed with
potassium and bicarbonate ions excreted.
Food product is moved through the gastrointestinal tract by
peristalsis, wave like propulsions. Recall that peristalsis occurs
throughout the digestive tract, in the esophagus, stomach, and small
and large bowel. Reflex action propels it form one area to another,
with sphincters preventing back flow.
As the small intestine distends pushing up against the ileocecal
sphincter, the reflex is initiated, relaxing the sphincter allowing
product to pass into the large bowel. In the large intestine, peristalsis
is at infrequent intervals, with the mass being propelled along
through the distal portion of the intestine relaxing and the proximal
portion contracting. The colon delivers feces to the rectum, with the
rectal reflex being stimulated when the rectum is full and distended.
Although full and ready for excretion, the rectal reflex does not
have to be acted upon. Defecation is a voluntary action, with
accessory abdominal muscles sometimes used. The anal sphincter
relaxes, and the feces is expelled.
Feces is about 60 to 80 per cent water. Digestive residue of
undigested and unabsorbed foods compose the bulk of the feces.
Bacteria and their products, cellular debris and mucus sloughed off
the lining as well as material secreted into the intestines as lubricant
are also normally found in the feces.
One tenth to one third of the feces is bacteria, living and dead.
This bacteria normally lives in the colon, providing assistance to the
digestive process, including synthesis of some vitamins. The bacterial
colonies in the colon are referred to as the normal intestinal flora.
Minerals are primarily excreted through the feces. The brown
colour is a result of the bile salts, mainly urobilinogen. Calcium and
iron are notably excreted through the feces.
Stools are normally a soft solid cylindrical mass. Quantity of
feces varies with diet. Fiber increases bulk. A diet of mainly refined
products may only produce 100 to 200 gm. per day, but a high fiber
diet can double that to 300 to 400 gms. The higher fiber stool is also
moister and easier to pass. The normal number of bowel movements
per day also varies between three a day to one ever two to three
days.
When products are propelled to fast through the bowels, water
is not reabsorbed, and the resulting stools are watery and loose.
Delay in evacuation results in increased absorption, making the stools
hard and dry, being difficult to pass.
2. Common disturbances of intestinal elimination (e.g.,
constipation, diarrhea, impaction, flatulence,
incontinence)
The two main common disturbances are constipation and
diarrhea. Other problems often are included with either of these two
complaints.
Both of these bowel dysfunctions are symptoms of diseases or
problems. Treatment of the underlying problem is the treatment
modality.
Constipation
Delay in the evacuation of the bowels causes an increased
absorption of water, resulting in dry and hard feces. Constipation can
be caused by some medications, immobility and lack of exercise,
mechanical disturbances and obstructions, poor diet and decreased
fluid intake, and breakdown of the deification reflex.
Failure to defecate when needed and poor diet are two common
causes. School age children and shift workers are known for failing to
take the appropriate time to have a bowel movement, considering it
an interruption, resulting in delayed evacuation and increased water
absorption producing constipation. Increased consumption of fast
foods which are low in fiber, with increased fat consumption has
produced a diet may not produce the bulk needed for good
evacuation. The teenage years, and the elderly are particularly prone
to poor diet.
Definition
The number of bowel movements a day or a week is a
individualistic characteristic. There is no right number. For one, twice
a day may be normal, and for another, twice a week.
The dry and hard nature of feces is the defining characteristic.
It indicates increased time for absorption. Pain and particularly
tenesmus, the painful often unproductive straining associated with
constipation, may be present, as well as other symptoms.
Normal range is between a bowel movement every two to
three days, to two to three bowel movements a day. Two or less
bowel movements a week should be investigated.
Failure to Defecate
Defecation is voluntary. The rectal reflex is initiated by
presence of feces distending the rectal walls.
If defecation is resisted, the rectum adjusts to the distended
state. Increased absorption of water occurs. If repetitively done, the
normal conditioned reflex may be lost. Habits in childhood, and time
pressures for adults are main causes.
Bulk, Fiber and Fluids
Simply put, fluid liquefies stools. A normal intake of six to eight
daily glasses of fluid is important in maintaining soft stools.
Constipation can often be reduced or eliminated through ensuring an
adequate daily fluid intake.
Sufficient bulk is needed to distend the rectum to initiate the
defecation reflex. Bulk also increases overall distention of the bowel
walls all the way along, improving the peristalsis.
Fiber is the best way to increase bulk. This indigestible fiber
remains in the internal bowel tract. The fiber also draws water into
the stool, keeping it soft.
Diarrhea
Impaction
Flatulence
Incontinence
Hemorrhoids
Colostomy and Ileostomy (The Ostomies)
Parasitic Infections
3. Common disturbances of urinary elimination (e.g.,
incontinence, frequency, urgency, retention, suppression,
dysuria, polyuria)
Incontinence
Frequency
Urgency
Retention
Suppression
Dysuria
Polyuria
Enuresis
Urinary Tract Infections
Lower UTI
Upper UTI
4. Factors affecting intestinal and urinary elimination
a. Developmental level: infancy through senescence
b. Individual preferences and patterns (e.g., use of laxatives,
health habits)
c. Physical condition (e.g., immobility, decreased sphincter tone,
decreased abdominal muscle tone, colonic atony)
d. Ethnic and cultural considerations (e.g., fasting)
e. Socioeconomic factors (e.g., excess intake of refined
carbohydrates, decreased intake of fresh fruits and vegetables)
f. Environmental factors (e.g., access to sanitary facilities, privacy,
time schedule demands)
g. Psychological factors (e.g., hospitalization, loneliness, anxiety,
depression, stress)
5. Theoretical basis for interventions to promote
intestinal and urinary elimination
a. Physiological considerations (e.g., positioning exercise,
gastrocolic reflex)
b. Medications (e.g., stool softeners, cathartics, urinary tract
antiseptics and analgesics, antidiarrheal agents)
c. Catheterization (e.g., indwelling, external, straight)
d. Enemas (e.g., cleansing, carminative, retention)
e. Dietary modifications (e.g., after intake of fiber, establish
regular eating times, alter intake of fluids)
B. Nursing care related to theoretical framework
1. Assessment: gather and synthesize data about the
patient's elimination status in relation to the patient's
functional health patterns
a. Obtain the patient's elimination history (e.g., pattern of bowel
elimination [time of day and frequency], use of laxatives and
cathartics, anorexia, frequency of urination, dysuria)
b. Assess factors affecting elimination (see IIA4)
c. Obtain objective data (e.g., intake and output, color, and amount;
altered bowel sounds; bladder distention)
d. Review laboratory and other diagnostic data (e.g., specific
gravity, stool for guaiac, urinalysis, culture and sensitivity, stool
for ova and parasites)
e. Collect specimens
2. Analysis: identify the nursing diagnosis (patient
problem) and determine the expected outcomes (goals) of
patient care
a. Identify nursing diagnoses (e.g., constipation related to
decreased abdominal muscle tone associated with aging,
constipation related to immobility, urinary retention related to
loss of muscle tone, stress incontinence related to weak pelvic
muscles, high risk for urinary tract infection related to improper
perineal hygiene)
b. Set priorities and establish expected outcomes (patient-
centered goals) for care (e.g., patient will pass a soft, formed stool
at regular intervals; patient will remain free of infection; patient
will verbalize understanding of perineal floor exercises; patient
will wipe perineal area from front to back after urinating and
defecating)
3. Planning: formulate specific strategies to achieve the
expected outcomes
a. Incorporate factors affecting elimination in planning the
patient's care (e.g., for a patient with an indwelling catheter, for
an older adult on bed rest, for a patient with increased urine
specific gravity) (see IIA4)
b. Plan nursing measures on the basis of established priorities to
help the patient achieve the expected outcomes (e.g., discuss the
problems associated with the misuse of laxatives and enemas,
establish an elimination routine, encourage the patient to practice
perineal floor exercised q2h while awake)
4. Implementation: carry out nursing plans designed to
move the patient toward the expected outcomes
a. Ensure appropriate intake (e.g., encourage adequate intake of
fiber, provide daily fluid intake appropriate to the patient's
developmental level)
b. Ensure appropriate activity (e.g., encourage ambulation, provide
range-of-motion exercises)
c. Establish an environment conducive to elimination (e.g.,
decrease stress, provide proper positioning, ensure privacy)
d. Use nursing measures appropriate to particular elimination
needs (e.g., perform bladder catheterizations and irrigations,
insert rectal tube, administer enema, administer laxatives and
stool softeners, provide bladder and bowel retraining)
e. Provide information and instruction regarding toilet training for
their child, instruct the patient regarding hygiene and asepsis)
5. Evaluation: appraise the effectiveness of the nursing
intervention relative to the nursing diagnosis and the
expected outcomes
a. Record and report patient's response to nursing actions (e.g.,
relief of subjective symptoms, increased fluid intake, altered
consistency of stool, increase in volume of urine, adverse reactions
to treatments)
b. Reassess and revise patient's plan of care as necessary (e.g.,
change pattern of patient's fluid intake to control enuresis, use a
fracture pan rather than a regular bedpan, use a bedside
commode when it is difficult for the patient to reach the toilet)