1. NURSING FUNDAMENTALS FOCUS IX
Elimination Needs

2. OBJECTIVES:SOLID
 Describe the physiology of stool formation and the
elimination process.
 List the common problems of bowel elimination.
 Discuss nursing responsibilities involved with each
problem.
 Define and explain some of the basic but important
measures to promote normal bowel elimination.
 Compare and contrast the different types of altered
means of bowel elimination.
 Identify the procedures/technical skills and related
nursing responsibilities.
 Identify the common diagnostic procedures related to
the bowel elimination need and the associated
nursing responsibilities

3. OBJECTIVES:FLUID
 Describe the normal micturition process mechanism.
 Discuss common conditions /situations responsible for
a disruption in the normal micturition process.
 List the commonly recognizable signs (behaviors)
indicating a disruption in urinary elimination.
 Compare and contrast the altered means of urinary
elimination and explain the related procedures and
nursing responsibilities.
 Report the basic but important nursing interventions
to promote normal urinary elimination.
 Examine the common diagnostic procedures related to
urinary elimination and the associated nursing
responsibilities.

4. BLADDER AND BOWEL FUNCTION
Overview:
 The human body eliminates waste of metabolism
through urine and stool.
 Normal function depends on these factors:
- anatomic integrity
- intact neurologic components for both voluntary and
synergistic emptying
- a predictable pattern of waste production
- physical and mental ability and the psycho-social
willingness to carry out toileting related tasks

5. Structures and Functions Related To
Bowel Elimination
STRUCTURES AND FUNCTIONS
RELATED TO BOWEL ELIMINATION
DIGESTION
HTTP://WWW.MEDTROPOLIS.COM/VBODY.ASP

6. STRUCTURES AND FUNCTIONS RELATED TO
BOWEL ELIMINATION
Bolus with Ptyalin
HCL, Pepsin
Intrinsic factor
Mucus  CHYME
Releases bile to Amylase released
duodenum
Absorption, secretion, Nutrients, electrolytes,
protection, elimination vitamins absorbed
Defecation process

7. Physiology of Defecation
 Peristalticwaves move the feces into
the sigmoid colon and the rectum
 Sensory nerves in rectum are
stimulated
 Individual becomes aware of need to
defecate
 Feces move into the anal canal when
the internal and external sphincter relax

8.  External anal sphincter is relaxed
voluntarily if timing is appropriate
 Expulsion of the feces assisted by
contraction of the abdominal muscles
and the diaphragm
 Moves the feces through the anal canal
and expelled through anus
 Facilitated by thigh flexion and a sitting
position

9. FACTORS AFFECTING BOWEL
ELIMINATION
 Lifestyle
 Personal habits
 Nutrition and fluid intake
 Physical activity
 Culture
 Norms of western culture
 Age
 Infancy
 Elders

10. FACTORS AFFECTING BOWEL ELIMINATION
 Physiological factors
 Pregnancy
 Motor and or sensory disturbance
 Intestinal pathology
 Medications
 Surgery and anesthesia
 Psychosocial factors
 Anxiety
 Depression

11. CHARACTERISTICS OF NORMAL
STOOL
 Color
 Odor
 Consistency
 Frequency
 Amount
 Shape
 Constituents

12. SELECTED FECAL ELIMINATION
PROBLEMS
Constipation
Diarrhea
Bowel incontinence
Flatulence

13. CONSTIPATION
 A symptom not a disease
 Decreased frequency of defecation
 Hard, dry, formed stools
 Straining at stools
 Painful defecation
 Causes include:
 Insufficient fiber and fluid intake
 Insufficient activity
 Irregular habits

14. FECAL IMPACTION
 Mass or collection of hardened feces in folds
of rectum that cannot be expelled
 Passage of liquid fecal seepage and no
normal stool
 Causes usually:
 Poor defecation habits
 Results from unrelieved constipation
 Treatment
 Removed manually
 Must have physician order
 Monitor patient for Valsalva reaction

15. DIARRHEA
 Passage of liquid feces and
increased frequency of
defecation
 Spasmodic cramps, increased bowel sounds
 Fatigue, weakness, malaise, emaciation
 A symptom of disorders affecting digestion,
absorption, and secretion of the GI tract.
 Major causes:
 Stress, medications, allergies, intolerance of
food or fluids, disease of colon

16. FECAL INCONTINENCE
 Loss of voluntary ability to control fecal and
gaseous discharges
 Generally associated with:
 Impaired functioning of anal sphincter or nerve
supply
 Neuromuscular diseases
 Spinal trauma
 Tumor
 Nursing Considerations
 Incontinence can harm a clients body image
 Incontinence predisposes the skin to breakdown

17. FLATUENCE
 Excessive flatus in intestines
 Leads to stretching and inflation of
intestines
 Can occur from variety of causes:
Foods
Abdominal surgery
Narcotics

18. ASSESSMENT OF BOWEL FUNCTION
 History of bowel prior patterns
 usual time
 frequency of stool
 past reliance on aids
 Present status and pattern
 Time
 Characteristics of stool
 Medications that may affect bowel functioning
 sedatives
 diuretics
 antihistamines

19. ASSESSMENT OF BOWEL FUNCTION
 Infection, trauma, or stress may affect
stool formation
 Physical Abdominal Assessment
 Inspection
 Auscultation
 Palpitation
 determine abdominal discomfort
 palpable obstruction would indicate need for rectal
exam

20. ABDOMINAL QUADRANTS AND ORGANS

21. ABDOMINAL QUADRANTS AND ORGANS

22. ABDOMINAL QUADRANTS AND ORGANS

23. ABDOMEN
 Subjective Assessments:
 Any abdominal pain?
 N/V?
 Appetite good?
 Last BM?
 Stool formed/loose?

24. ABDOMEN-OBJECTIVE ASSESSMENT
 Normal
 soft
 non-tender
 non-distended
 normoactive bowel sounds in all 4 quadrants
 Normal bowel sounds
 2-3 every 15sec or 10-30 every min

25. ABDOMEN – ABNORMAL ASSESSMENTS
 Distended
 Rigid
 Tender
 Hypoactive bowel sounds (<10/min)
 Hyperactive bowel sounds (>30/min)
 Absence of bowel sounds
 Presence of mass
 Ascities
 Abnormal pulsations
 Tubes, drains, ostomies

26. AIDS TO NORMAL BOWEL ELIMINATION
 Fluid intake and fiber:
 Adequate fiber
 Adequate fluid intake
 Upright posture

27. CONSTIPATION
Managing constipation:
 Diet
 25 -35 G of fiber + WATER!
 Medications
 Laxatives
 cathartics
 Enemas
 high – cleanse entire colon
 low – cleanse rectum and sigmoid colon
 hypotonic and isotonic
 – immediate large colonic emptying
 hypertonic and mineral - fleets

28. FECAL INCONTINENCE
Assessment key factors:
 Is the problem correctable or manageable?
 What is the timeline or duration of
situation?
 Any associated symptoms?

29. NANDA NURSING DIAGNOSIS
 Bowel Incontinence
 Constipation
 Risk for Constipation
 Perceived Constipation
 Diarrhea

30. RELATED NURSING DIAGNOSIS
 Risk for Deficient Fluid Volume
 Risk for Impaired Skin Integrity
 Low Self-esteem
 Disturbed Body Image
 Deficient Knowledge
 Bowel Training
 Ostomy Management
 Anxiety

31. DESIRED OUTCOMES
 Maintain or restore normal bowel
elimination pattern
 Maintain or regain normal stool
consistency
 Prevent associated risks such as fluid
and electrolyte imbalance, skin
breakdown, abdominal distention and
pain

32. NURSING CONSIDERATIONS
 Promoting regular defecations
 Teaching about medications
 Decreasing flatulence
 Administering enemas
 Digital removal of a fecal impaction
 (if agency policy permits)
 Instituting bowel training programs
 Applying a fecal incontinence pouch
 Ostomy management

33. FECAL ELIMINATION PATTERNS
 Privacy
 Timing
 Nutrition and fluids
 Exercise
 Positioning

34. ALTERED MEANS OF BOWEL ELIMINATION

35. ALTERED MEANS OF BOWEL ELIMINATION
Ileostomy

36. ALTERED MEANS OF BOWEL
ELIMINATION
Stoma
Form-
ation

37. ALTERED MEANS OF BOWEL ELIMINATION
Stoma

38. STOMA CARE FOR CLIENTS WITH AN OSTOMY
 Normal stoma should appear red and may
bleed slightly when touched
 Assess the peristomal skin for irritation each
time the appliance is changed
 Treat any irritation or skin breakdown
immediately
 Keep skin clean by washing off any excretion
and drying thoroughly
 Protect skin, collect stool, and control odor
with an ostomy appliance

39. COMMON TESTS
 Direct Visualization
 fiber optic endoscopic instruments introduced through the
mouth or rectum to inspect integrity of mucosa blood vessels,
and organs.
 UGI Endoscopy
 Colonoscopy
http://www.swarminteractive.com/patient_ed_animations.html

40. COMMON TESTS
 Fecal specimens
 Ova and Parasites
 Guaiac testing
 Hidden (occult) blood

41. Urinary Elimination

42. KIDNEYS
http://www.youtube.com/watch?v=chhNaLi9P3E
Urine Formation
http://www.argosymedical.com/flash/urine_formation/landing.html

44. Urinary Elimination
 Micturition
 The process of emptying the bladder
 Contraction of detrusor muscle
 Increases pressure on bladder to produce urge to
urinate
 Pressure overcomes the internal sphincter
 Urine enters urethra
 Requires relaxation of external sphincter
consciously relaxed or contracted

45. NORMAL MICTURITION MECHANISM AND
RELATED BODY STRUCTURES

46. URINE FORMATION
 Nephron
 Functional unit of the kidney
 Urine is formed here
 Glomerulus
 Tuft of capillaries surrounded by Bowman’s capsule
 Fluids and solutes move across endothelium of the
capillaries into the capsule
 Bowman’s Capsule
 Filtrate move from here into the tubule of the nephron

47. Aids to Normal Urinary Elimination
 Daily fluid intake
 Urine produced = fluid consumed
 Need 6 to 8 glasses per day of WATER
 Activity
 External sphincter is part of pelvic floor muscle
 Tone needed to maintain voluntary control
 Personal Habits
 Relaxation
 Distractions

48. STRUCTURES AND FUNCTIONS RELATED
TO FLUID ELIMINATION
 Characteristics of normal urine:
 Color
 Clarity
 Odor

49. ALTERED AMOUNT
 Oliguria
 Diminished, scanty amount <30cc
 Anuria
 absence of urine
 Polyuria
 >1500 cc/24 hours
 consider intake
 Enuresis

50. COMMON DISRUPTIONS IN URINARY
ELIMINATION
 Dysuria
 Painful urination:
 Frequency
 Hesitancy
 Urgency

51. COMMON DISRUPTIONS IN URINARY
ELIMINATION
 Urinary Tract Infection (UTI)
 Can occur anywhere in the urinary tract
Cystitis
Ureteritis
Pyleonephritis
More common in women than
men

52. COMMON DISRUPTIONS IN URINARY
ELIMINATION
Urinary retention:
 Inability to pass part
of the urine in bladder
 Common in older men
with benign prostate
Hyperplasia

53. COMMON DISRUPTIONS IN URINARY
ELIMINATION
Urinary obstruction
Urolithiasis
- Stones calculi block or
partially block kidney,
Ureters, or bladder
- Obstruction from
strictures, tumors,
edema

54. FORMS OF INCONTINENCE
Urinary Incontinence:
Failure of major smooth muscle strength of
Detrusor muscle of the bladder, instability
or obstruction. Incontinences divided into 4
types. Pt may have mixed pattern:

55. FORMS OF INCONTINENCE
 Urge Incontinence
Urgency following strong sense to void
 Decreased bladder capacity
 Alcohol or caffeine ingestion
 infection
 Stress Incontinence
Small amts with laughing, sneezing, coughing
 Urgency, frequency

56. FORMS OF INCONTINENCE
 Overflow Incontinence:
Retention
 Functional Incontinence:
Intact urinary and nervous system
 Change in environment
 Sensory, cognitive or mobility deficit
 Void before reaching bathroom

57. LOSS OF URINARY CONTROL
Nursing ASSESSMENT of Urinary Incontinence:
 Confirm factors related to episodes
 Determine cognitive function and the ability of patient
to participate interventions
 Make observations during caregiving regarding the
amount and frequency of loss of urine and situations
surrounding incontinent episodes
 Assess abdominal and suprapubic palpation for
tenderness and fullness
 Determine hydration status and possibility of
constipation
 Ask specific questions regarding situations that lead to
urine loss

58. ALTERED MEANS OF URINARY
ELIMINATION
Catheters
 urethral
 suprapubic
 condom

59. FOLEY CATHETER

60. FOLEY CATHETERS

61. FOLEY
http://www.youtube.com/watch?v=tynS0E4hBn0

62. FOLEY

63. CONDOM/TEXAS CATHETER

64. BEDSIDE DRAINAGE BAGS

65. SUPRAPUBIC CATHETER

66. ALTERED MEANS OF URINARY ELIMINATION
Urinary diversion - surgical creations
 Ureterostomy -
(transureterostomy)
Bring Ureters to abdominal surface
 Uterosigmoidostomy
 Ilea conduit or loop
Implant ureter into ileum
 Form stoma
 Form pouch
 Need occasional catheterization to
empty
 Kock pouch

67. ILEAL CONDUIT

68. A NEOBLADDER

69. NEPHROSTOMY TUBE

70. THE KOCK POUCH—A CONTINENT URINARY
DIVERSION

71. COMMON TESTS
 BUN
 http://video.google.com/videoplay?docid=7519331476907982001&q=urinary+system&total=83&start=0&num=10&so=0&type
=search&plindex=0
 Creatinine Clearance
 Urinalysis

72. COMMON TESTS
Visualization procedures
 KUB
An X-ray showing the kidney, ureter, and bladder. This is in reality a plain abdominal X-ray
and
includes other structures such as the diaphragm above and the pelvis below.
http://trismus1.files.wordpress.com/2007/04/eg-kub_2_1withpaint.jpg
 Retrograde Pyleography
 CT scan