Elimination

Question 1

What is elimination?

Answer 1

The removal, clearance, or separation of matter. The excretion of waste products.

Question 2

How do we eliminate?

Answer 2

We eliminate through the skin (sweat), lungs, kidneys, and intestines.

Question 3

Where is elimination on the Maslow’s Hierarchy of Needs?

Answer 3

Physiological Needs (Air, water, food, shelter, sex, sleep, breathing)

Question 4

What is the main functional unit of the kidney? How many are there in a human body?

Answer 4

Nephron (If they are not working properly we have problems getting rid of waste and elimination and metabolic problems)
-Each kidney has 1Million of them
-Nephron has 2 parts: blood vessels and renal tubules

Question 5

What is perfusion and what kinds of problems can it cause for the kidneys?

Answer 5

Blood flow through out the body. Average of 1 L/min to the kidneys and functional nephrons. Hypertension, Diabetes, and other conditions can affect the perfusion of the kidneys.

Question 6

How does blood move through the kidneys?

Answer 6

Blood flows into your kidney through the renal artery. This large blood vessel branches into smaller and smaller blood vessels until the blood reaches the nephrons. In the nephron, your blood is filtered by the tiny blood vessels of the glomeruli and then flows out of your kidney through the renal vein. Unfiltered blood flows into your kidneys through the renal artery and filtered blood exits through your renal vein. The ureter(small tubes from kidney) carries urine from the kidney to your bladder, and out through the urethra to outside of the body.
*When people have bad stomach pain (kidney stones-jagged) normally are stuck in ureters.

Question 7

How much urine can our bladder hold?

Answer 7

300-500 ml in adult. Output is measured in ml.

Question 8

How do we control urine?

Answer 8

There is an internal/external sphincter that help us control the bladder flow. 1. The bladder contracts along with urethral sphincter and pelvic floor muscles relaxes signals micturition center. 2. The micturition center impulses in the brain responds to the urge to void or ignore it (making urination voluntary control). 3. When a person voids, the central nervous system sends a message to the micturition centers , the external sphincters relaxes and empties the bladder.

Question 9

Anatomy of Stomach

Answer 9

We take in food down the esophagus and it goes down to the stomach (acids/food broken down) and goes into the small intestine (longer small lumen-interior). Absorption is going in small intestine and goes into the large intestine (Pulls water and primary place for stool formation).

Question 10

What are the parts of the large intestine?

Answer 10

• The tail hanging off of the intestine is the appendix. Starting point of the large intestine is the Cecum, if it goes up it is called the (Ascending colon), if it goes across it is called the (Transverse colon), down is the (Descending colon), then the Sigmoid colon, and finally to the rectum.

Question 11

If peristalsis is to slow what happens?

Answer 11

Pulling to much fluid out and causes the stool to become hardened and too difficult to pass.

Question 12

Scope of Elimination

Answer 12

Range of things that can happen with elimination (normal/abnormal)

Question 13

Physiological changes that affect the overall health condition of elimination

Answer 13

Age- Children are typically 18 to 24 months of age before they are able to identify the urge to urinate and defecate. Toilet training by the parent or caregiver helps the child obtain conscious control of his or her bowel/bladder functions
*Pregnancy can affect elimination patterns because the fetus in the abdominal cavity affects both bowel and bladder function.
* In elderly the reduced tone of the internal and external sphincter as well as reduced neural impulses (reducing the sensation of bowel evacuation) can make the older adult more susceptible to constipation or incontinence.
*Comorbidities

Question 14

Babies Born

Answer 14

Normally have black stools (meconium)-Sterile stool clears with 2-3 days
* Yellow seedy stool -loose watery-breastfed baby
*diarrhea stool or more formed and brown -formula fed baby

Question 15

When do toddlers have more control over their bladder/bowel?

Answer 15

*18-24 months
*2-3 years old for bowel control
*If a toddler still couldn’t control their bladder at 30 months would not be concerning because some children development faster than others.

Question 16

Things that affect elimination

Answer 16

Growth factors, fluid intake, medications, and etc.

Question 17

Look at Box 46.1 and Page 1278 for Influences on Urinary/Bowel Elimination

Answer 17

Factors that Influence Bowel Elimination: Age, Diet, Fluid Intake, Physical Activity, Psychological Factors, Personal Habits, Position During Defecation, Pain, Pregnancy, and Surgery/Anesthesia

Question 18

Risk Factors for alterations in Urinary/Bowel Elimination

Answer 18

*Urinary-Age, Impaired Cognition (thinking), Kidney Failure, Impaired mobility, Trauma, Thirsty (people aren’t as thirsty), Females-Short urethra/Males (Retention), Pregnancy (urge to go in beginning/end of pregnancy)
*Bowel-Diet-High bulk fiber/foods/Water(Risks for constipation), Blockage(Impactation), Hemorrhoids, Immobility (Peristalsis slows down), IBS (Stomach problem), Pregnancy (Iron supplement), Debilitated-Can’t get to the bathroom

Question 19

Kinds of medications that can cause problems with bowel elimination

Answer 19

Opioids (Constipation/Urinary retention), Laxative-Patients can depend on them

Question 20

Neurological problems can affect bowel elimination how?

Answer 20

People who can’t control or strain down to have a bowel movement.

Question 21

Look over Box 46.2 Elimination with Older Adults

Answer 21

More of problems associated with aging

Question 22

Physical Assessment Urinary/Bowel Elimination) What is involved?

Answer 22

A focused assessment on urinary/bowel elimination. When was the last time they voided/eliminated? Can you describe it-brown, loose, hard/Color, Clarity, and amount for urine/Any pain and any recent changes

Question 23

Bowel Physical Assessment

Answer 23

Look/Listen/feel abdomen for any distention, sounds should be gurgling (diarrhea-Hyperactive), Absence-Hypoactive) Feel (Palpate) for any tenderness. Tell about your diet (What did you eat/Is it normal) What do you drink? How often?. Assess the stool (Black-old blood in stool), Red-Hemorrhoids/Constipation

Question 24

Urinary Physical Assessment

Answer 24

Is there any pain/burning, color/What is normal and is there any leakage. Look for color(straw-colored yellow), clarity(Clear), and the amount
*Darker, cloudy, dark yellow in the early morning hours/Drink more fluids it lightens up throughout the day
*Medications can change color

Question 25

Look at Figure 47.6 Bristol Stool Form Scale

Answer 25

*Type 1 Separate hand lumps like nuts (difficult to pass) Hard
*Type 2 Sausage shaped but lumpy
*Type 3 Like a sausage but with cracks on surface
*Type 4 Like a sausage or snake, smooth and soft
*Type 5 Soft blobs with clear-cut edges (passed easily)
*Type 6 Fluffy pieces with ragged edges, a mushy stool
*Type 7 Watery, no solid pieces (entirely liquid) Loose

Question 26

47.3 Nursing Assessment Questions Related to Bowel (Look at)

Question 27

What is urinary incontinence and continence?

Answer 27

The loss of control of either urine elimination. It can be minor or long term. Continence is the ability to control urine output.

Question 28

Types of Incontinence

Answer 28

*Stress Incontinence(Common type)- Weak Pelvic muscles (pregnant women with bigger babies)-Do Kegel exercises several times a day to strengthen pelvic area/older females-Leakage (cough, sneeze, and walking) Try to completely
*Urge Incontinence-Caused by bladder inflammation (Common type)/Sometimes during sleep *Medications can be given for this type, Put pt. on toileting schedule, keep skin clean & dry
*Overflow Incontinence-Associated with chronic retention-Can’t empty completely-Leaks out
*Transient Incontinence-Comes/Goes Treatable/Reversible-(UTI) Stress after surgery, scope done
*Functional Incontinence-Cognitive Impairment, Disabilities, Ability to not function
*Reflex Incontinence-Spinal Cord Damage
*Avoid caffeine with incontinence

Question 29

In Giddeons book look at Table 17.1/Fundamentals Table 46.1

Answer 29

Type of Incontinence
Stress-Leakage of small amounts of urine during physical movement (coughing, sneezing, exercising)
Urge-Leakage of large amounts of urine at unexpected times, including during sleep
Overactive bladder-Urinary frequency and urgency, with or without urge incontinence
Functional-Untimely urination because of physical disability, external obstacles, or cognitive problems that prevent person from reaching toilet
Overflow-Unexpected leakage of small amounts of urine because of full bladder
Mixed-Usually occurrence of stress and urge incontinence together
Transient-Leakage that occurs temporarily because of a situation that will pass (infection, taking a new medication, colds with coughing)

Question 30

Nursing management for patient with Incontinence
*Look at page 1253 2 paragraphs on Toileting schedule

Answer 30

Depends on degree and causes of incontinence
*Toileting Schedule -Depends on degree/cause
*Go to bathroom every 2 hours
*Mange Fluid Intake/Decrease Fluids at night
*Modifying the environment-Bedside Commode/Clear path to Bathroom
*Skin is most important -Want clean/dry, turning patient, and putting on a skin barrier to protect skin

Question 31

Safety for Incontinent patient

Answer 31

*Falls risk-Remind the cognitive patient to go to the bathroom.
*Watching new meds that affect the patient’s cognition (memory worse. *Teaching women about self care (stress incontinence)
*Remind patients to drink fluids because they can be less thirsty as they get older
*Older Men leaking/have enlarged prostate-pressure near urethra causing hard time to void/could have leakage

Question 32

How does patient incontinence affect them psychologically?

Answer 32

Affects their mindset. They may have a low self-esteem, lifestyle(pads everywhere I go)

Question 33

Bowel Incontinence

Answer 33

Leakage-C. Diffe, bowel trauma, surgery, pelvic floor muscles
*Check on Patients often
*1298-Bowel movement training (Feed at same time of the day) High fiber breakfast
*Give hot coffee, Hot apple juice, bathroom schedule

Question 34

What is urinary retention? Who is at risk?

Answer 34

Not emptying bladder (seen in older men-enlarged prostate) Puts pressure near urethra making a blockage
*Patients with UTI
*Surgery/Pain meds after-Opioids
*Immobile
*Pregnancy (last few weeks)

Question 35

What is used to see if patient has urinary retention?

Answer 35

*Bladder Scan (Post Void Residual)-After voided, if urine is still in there/how much
*In & out Cath-Voided later (Put in bladder and taken out) and get Little urine

Question 36

What helps with urinary retention?

Answer 36

Medicine-Antispasmodics, Anticholinergics

Question 37

How does a patient feel with urinary retention?

Answer 37

Restless, pain, diaphoresis, bladder still full even though I emptied it

Question 38

Look at Table 17.2 in Giddeons Risk Factors

Question 39

Urinary Incontinence

Answer 39

*Stress-Increase in intrabdominal pressure
*Urge-Urine lost during abrupt/strong desire to void
*Mixed-Symptoms of urge & Stress Incontinence
*Overflow-Over distention and overflow of bladder
*Functional-Caused by factors outside of the urinary tract
*Transient -Most often acute, treatable, and reversible
*Reflex-Spinal Cord Damage

Question 40

What is constipation?

Answer 40

It is a symptom and not a disease. If less than 3 times a week /Hyperactive-tender
*Causes-Lifestyle, meds, illness, physiological changes(aging), exercises
*Can be fixed with Fiber, Fluid & Activity

Question 41

Box 47. 1 Common Causes of Constipation

Answer 41

*Irregular bowel habits/ignoring the urge to defecate
*Chronic illnesses (Parkinson’s disease, MS, rheumatoid arthritis, Chronic bowel diseases, depression, eating disorders
*Low fiber diet high in animal fats (meats/carbohydrates), low fluid intake
*Stress (illness of a family member, death of a loved one, divorce)
*Physical inactivity
* Medications especially opioids
*Changes in life or routine(pregnancy, aging, and travel
*Neurological conditions that block nerve impulses to the colon (stroke, spinal cord injury, tumor)
*Chronic bowel dysfunction (colonic inertia, irritable bowel)

Question 42

Nurses Intervention for patients with constipation

Answer 42

Fluid Intake, High diet fiber, walking up and down hall, Bowel training schedule, Administration of meds

Question 43

Complications with constipation
*Box 47.10 Digital Removal of Stool

Answer 43

Impaction of rectum can lead to bowel obstruction in bowel, Septic, Straining (Bowel, Savor Maneuver)-Heart patients can have a decrease in HR and BP leading them to pass out, Hemorrhoids

Question 44

What is pica (Things pregnant women shouldn’t eat?

Answer 44

When people crave and chew substances that have no nutritional value, they such as corn starch, ice, clay, soil, or paper. It can cause constipation, and impaction.

Question 45

What is diarrhea and what causes it?

Answer 45

Increase in the number of stools and the passage of liquid, unformed feces. Food poisoning, dairy, spicy foods, medications, gastroenteritis (viral), disorders (IBS, Chron’s Disease)-How patient’s digest food?
*Too much of it leads to dehydration-Young and old are deceivable to it/Fraile and malnourished

Question 46

What is the most important thing for a patient with diarrhea that a nurse should be concerned about? What do you need to find out about the diarrhea?

Answer 46

*Skin care
*Find out reason behind-medications, any symptoms/Could they have something going on like gastroenteritis
*Protein foods (Brand muffin), fluids oral/IV

Question 47

Signs/symptoms consistent with dehydration
*Look at Box 47

Answer 47

Skin turgor, tenting, dry mucous membranes, dry skin, dizziness, thirsty, and decreased urine output
* Babies-dry skin, no tears, less wet diapers, soft spots (Fontanels)sunk in

Question 48

What is an occult blood test?

Answer 48

Test for seeing if there is blood in the stool, parasites causing it, screening for colon cancer
*Done in lab/bedside-Done 3 times on 3 separate occasions
*Guaic Test-Put little stool on card.

Question 49

Mediations for diarrhea

Answer 49

Antidiarrheal-Loperamide

Question 50

Medications for Constipation
* Table 47.2 List them
* Body can depend on them

Answer 50

*Emolient-Docusate Sodium (Colace)-Stool softener (Preventive)
*Osmotic-MiraLAX Milk of Magnesium (Harsher)
*Bulk forming (fiber)-Metamucil (Safest form)-Take with full cup of water (for reoccurance)
*Stimulant-Caster Oil, Dulcolax, XLAX(Harshest)

Question 51

Medications

Answer 51

*Cholinergic-Urinary Retention
*Alpha Adrenergic Blockers-Urinary Retention (Flomax)
*Muscarinic Blockers-Overactive bladder-Incontinence

Question 52

Different types of catheterization

Answer 52

*Intermittent (Straight)
*Indwelling
*External/Condom
*Suprapubic(Above pubic bone and surgery inserted into the bladder through skin)-Long term
Do catheter care while in (every 8 hours( with warm soap/water) or soiled-bowel movement) and discontinue when not needed anymore-decrease in fluids first 6-8 hours when they void, little stinging when first void

Question 53

Different types of Enemas

Answer 53

*Cleansing for colonoscopy or procedure (750-1000 ml & warm & soapy water (Castile soap)
-Tap Water
-Normal Saline
-Hypertonic (fleets)-Medicated found in Walmart (less volume)
-Soapsuds (Castile)
*Oil retention (oil substance)
*Carminative (Relieves gas)
*Medicated (kayexalate)-Potassium is to high

Question 54

NG Tube (Nose to stomach) Decompression of stomach

Answer 54

*Postoperatively or (obstruction of GI TRACT from tumors, trauma(peristalsis is absent)
*Small or large bore tubes (large used for decompression)
*Salem Sump (decompression)-NPO
-Water based lubricant around nare/nostril for comfort or moistened swab sticks-To keep mouth moist
*Oral care can be provided (brushing teeth & dont swallow toothpaste)
*Taped at nose/Replaced when dirty
*Place in Semi-Fowlers poistion

Question 55

Diagnostic Tests
*Clean Catch Urinalysis
*Urine Culture & Sensitivity
*Renal Function Test
*Bladder Scan
*Stool for Occult Blood
*Cystoscopy
*Colonoscopy

Answer 55

Clean Catch Urinalysis. Most common test. Screening for diagnostic fluid/electrolyte disturbances, urinary tract infections. *Skill 46.1
*Collect during normal voiding or from indwelling catheter or urinary diversion collection bag. Use a clean specimen. Some places use urine dip strip. Observe the color changes.
*Make sure you are using a sterile technique. Take all medications(antibiotics). Educate the patient to wash their hands before and after. Clean the area from front to back. Take all medications.

Urine Culture & Sensitivity-Determines the presence of bacteria and to which antibiotic the bacteria are sensitive.

Renal Function Test (24 hour urine)-Looking at function of kidneys and collecting urine for 24 hours. Urine is kept on ice and in dark container. Then it goes to the lab to tell kidney function (BUN & Creatine).

Bladder Scan-PVR (Post Void Residua) is done within 15 minutes to see if any residual is left after voiding.
*Guideline 46.11

Stool for occult blood- Done at beside/lab screening tool for colon cancer. Repeat 3 times on 3 separate occasions.
*Box 47.4

Cystoscopy (Scope with camera used to look into the urethra to bladder) Anesthesia is used. Looks for any abnormalities in specimen.
*Patient has to be NPO but we encourage fluids after.
*Urine may be pink tinged after due to an invasive procedure causing irritation.

Colonoscopy(Lower bowel-Looking for polyps) Depends on age-Screening for risk factors & family history, for colon cancer.
*Colon has to be cleaned before colonoscopy so they can see inside of intestine (24-48 hours before).
*Patient will have alot of gas after procedure.