Elimination

Ella Yu
Elimination
Bowel elimination
Urinary elimination
 Describe the physiology of elimination

 Identify factors that influence the elimination

 Identify common causes of the elimination

problem
 Implement nursing process to help the client with
elimination problems
Bowel elimination
Physiology of defecation
 The colon in the adult is about 125 to 150 cm
long
 Cecum; ascending, transverse, descending
colon; sigmoid colon; rectum and anus
 Is a muscular tube lined with mucous membrane
 Circular and longitudinal muscle fibres
 Haustra
Bowel elimination
Function of the colon:
 Absorption of water and nutrients
 Mucal protection of the intestinal wall
 Bicarbonate ions
 Parasympathetic nerve stimulation e.g. emotion
 Protect the wall of large intestine from the fecal acids and
bacterial activity, as an adherent for holding the fecal
material together
 Fecal elimination
 Ingested content over the previous 4 days
 ileocecal valve- 1500mL chyme
 100mL of fluid is excreted in the feces
 Flatus- by-product of digestion of carbohydrates
Bowel elimination
Movements of the colon:
 Haustral churning
 Mixing and moving forward the content
 Absorption of the water
 Colon peristalsis
 Wavelike movement
 Mass peristalsis
 Powerful muscle contraction
 After eating, only few times a day
Bowel elimination
Rectum (10 to 15 cm)
 Rectum folds extend vertically contains vein and
artery
 Haemorrhoids- distended vein
Anal Canal (2.5 to 5 cm)
 Internal and external sphincter
 Internal sphicter: involuntary control innervated by
autonomic nervous system
 External sphincter: voluntarily control by the somatic
nervous system
Defecation
 Expulsion the feces from the anus to
rectum
 Bowel movement
 Several times per day to 2 or 3 times per
week
 Sensory nerves of the rectum are stimulated
 Facilitate by thigh flexion and sitting position
 Repeated inhibition of the urge of defecate
can result in the expansion of the rectum
and loss of sensitivity→ constipation
 Feces Normal
Color Adult: brown
Infant: yellow
Consistency Formed, soft, semisolid,
moist
Shape Cylindrical, 2.5 cm in
diameter
Amount 100 – 400g /day
Odor Affected by food and
normal flora
Constituents Undigested roughage,
dead cells, fat ,protein and
digestive juice
Flatus 7 to 10 L/ day
Factors that affect defecation
 Development
 Newborn: meconium- black, tarry, odorless, sticky
 Infants: increase frequency
 Breastfeeding: yellow to golden feces
 Cow’s milk formula: dark yellow or tan stool
 Toddlers: daytime control- age 2½
 Elders: constipation, the use of laxative
 Diet
 high- fibre food, spicy foods
 Regular time, increase fluid intake (2L-3L/ day)
 Gas, laxative and constipation producing food
 Activity
 Psychologic factors
 Defecation habits- gastrocolic reflex
Factors that affect defecation
 Medications
 Morphin, codeine, tranquilizers, iron tablets- constipation
 Laxatives- stimulate bowel activity
 Aspirin- gastrointestinal bleeding
 Iron tablets- black stool, antacids- whitish discoloration
 Antibiotics- gray-green discoloration
 Diagnostic procedures
 Anesthsia and surgery
 Pathologic conditions
 Spinal cord injuries, head injuries, impaired mobility
 pain
Fecal elimination problems
 Constipation
 Fewer than 3 bowel movements per week
 Fecal impaction Irregular
Insufficient activity
Insufficient
defecation or intake
fluid motility
habits
Insufficient
Change Lack
in daily
of
fiber
privacy
routine
intake
 A mass or collection of hardened feces in the folds of
the rectum results from prolonged retention and
accumulation of fecal material.
 Requires oil retention enema, cleansing enema,
suppositories, stool softener or manual removal (digital
evacuation)
 Causes???
Fecal elimination problems
Fecal elimination problems
 Diarrhoea
 Passage of liquid feces and an increased frequency of
defecation
 Causes: psychologic stress, medication, allergy, food or
fluid intolerance, diseases of the colon
 Maintain skin integrity
 Bowel incontinence
 Loss of voluntary ability to control fecal and gaseous
discharges through the anal sphincter
 Flatulence
 Usually 7-10 L of flatus in the large intestine every 24
hours
 The gases include carbon dioxide, methane, hydrogen,
oxygen and nitrogen
Fecal elimination problems
 Flatulence (excessive flatus)
 Usually 7-10 L of flatus in the large
intestine every 24 hours
 The gases include carbon dioxide,
methane, hydrogen, oxygen and nitrogen
 Three sources: bacteria on chyme,
swallowed air and gas diffuses between
bloodstream and intestine
 belching
Bowel diversion ostomies

Colostomy: can be permanent or temporary

Promoting regular defecation
 The provision of privacy
 Timing
 Do not ignore the urge
 Adequate time for defecation
 Nutrition and fluids
 High fiber, adequate fluid
 Constipation: e.g. prune juice, fiber
 Diarrhoea: adequate fluid, avoid spicy
 Flatulence: limit carbonated beverages, chewing gum, gas forming food-
cabbage, beans, onions
 Exercise
 Tightened abdominal muscle and thigh muscle
 Positioning
 Squatting position
 Commode
 bedpan
Medication
 Carthartics and laxative
 Bulk- forming
 Emollien/ stool softener
 Stimulant/ irritant
 Lubricant
 Saline/ osmotic
 Antidiarrheal medications
 Antiflatulent medications
Decreasing flatulence

 Avoiding gas-producing foods

 Exercise
 Moving in bed
 Ambulation
 Movement stimulates
 peristalsis
 the escape flatus
 reabsorption of gases in the intestinal capillaries
Enema
 Enema is a solution introduced into the
rectum and large intestine
 It distends the intestine and
sometimes irritates the intestine
mucosa, thereby increasing peristalsis
and the excretion of feces and flatus
 Four groups: cleansing, carminative,
retention and return-flow enemas
Enema
 Cleansing enema: remove feces
 Hypertonic, hypotonic, isotonic, soapsuds solutions or oil
(p.1242, table 46-4)
 Carminative enema: expel flatus
 Retention enema: oil or medication into rectum and
sigmoid colon and retained for a relatively long
period (1-3 hours). For treating infection or soften
the feces
 Return- flow enema: expel flatus. Alternating flow of
100 to 200 mL of fluid by five to six times
 Administering an enema
Digital removal of a fecal
impaction
 Breaking up the fecal mass digitally
and removing it in portions
 Restriction!!!
 Contraindication e.g. cardiac
arrhythmia.
 Using of the cleansing enema
Bowel training program
 Determine the client’s usual bowel
habits and factors that help and hinder
normal defecation
 Design a plan:____________
 Maintain the daily routine for 2 to 3
weeks:_________________
 Provide feedback
 Offer encouragement
Urinary elimination physiology
Urinary elimination

Bladder
 An inner muscous layer

 A connective tissue layer

 Three layer of smooth muscle-

detrusor muscle
 An outer serous layer
Urination
 Micturation
 Voiding
 Special nerve ending in the bladder
wall- 250 to 450 mL of urine
 Voiding reflex center to spinal cord-
relaxation of the internal sphincter
 Voluntary control of the external
sphincter
Factors affecting voiding
 Developmental factors
 Enuresis- involuntary passing of urine
 Nocturnal enuresis
 Nocturnal frequency
 Psychosocial factors
 Fluid and food intake
 Medication: diuretics
 Muscle tone
 Pathologic condition: renal failure, prostate gland
hypertrophy, renal stone
 Surgical and diagnostic procedure
Altered urine production
 Polyuria (diuresis)
 Abnormally large amount of urine
production by kidneys
 Oliguria – low urine output
 Anuria- lack of urine production
Altered urinary elimination
 Frequency and nocturia: UTI, pregnancy
 Urgency
 Dysuria: painful voiding
 Enuresis
 Urinary incontinence: involuntary urination
 Acute Vs chronic
 Urinary retention
 Neurogenic bladder: does not perceive bladder
fullness, unable to control the urinary sphincters.
Bladder becomes flaccid, distended or spastic with
incontinence
Assist client in urinary
elimination
 Maintaining normal urinary elimination
 Preventing urinary tract infections
 Managing urinary incontinence
 Managing urinary retention
 Catherterization
Assist client in urinary
elimination
 Maintaining normal urinary elimination
 Promoting fluid intake if not contraindicated
 Normal daily intake averaging 1,500mL
 Diaphoresis, diarrhoea, vomitting require more intake
 Client who are at risk for UTI or urinary calculi should
consume 2,000 to 3,000 mL
 Contraindication: kidney failure, heart failure
 Maintaining normal voiding habits
 Assisting with toileting
Assist client in urinary
elimination
 Maintaining normal urinary elimination
 Maintaining normal voiding habits
 Positioning
 Standing for male, squatting/ leaning slightly forward when sitting for
female
 Bed-side commode
 Push over the pubic area
 Relaxation
 Privacy
 Sufficient time
 Read or listen to music
 Pour warm water to perineum, warm bath
 Timing
 Do not delay when pateint have the urge
 At usual time of voiding
 Bed-ridden client
 Warm the bedpan
 Fowler’s position, back support, flex the hip and knee
Assist client in urinary
elimination
 Maintaining normal urinary elimination
 Assisting with toileting
 Prevent slip and fall injury
 Easy accesible call signal
 Handrails
 Bedside urinary equipment
 Urinal
 Bedpan
 commode
Assist client in urinary
elimination
 Maintaining normal urinary elimination
 Preventing urinary tract infections
 Managing urinary incontinence
 Managing urinary retention
Assist client in urinary
elimination
 Preventing urinary tract infection
 Prevalence: women> men
 Why?
 Common pathogen: escherichia coli
 Drink 8 glasses of water per day
 Practice frequent voiding
 Void immediately after intercourse
 Avoid use of harsh soap, bubble bath, powder or spray
 Take shower bath
 Avoid tight fitting pants
 Wear cotton clothes
 Wipe the perineal area from front to back
Assist client in urinary
elimination
 Maintaining normal urinary elimination
 Preventing urinary tract infections
 Managing urinary incontinence
 Managing urinary retention
Assist client in urinary
elimination
 Managing urinary incontinence
 Bladder training, habit training, prompted voiding
 Pelvic muscle exercise: Kegel exercises
 Maintain skin integrity
 Applying external urinary drainage devices
 medication
Assist client in urinary
elimination
 Maintaining normal urinary elimination
 Preventing urinary tract infections
 Managing urinary incontinence
 Managing urinary retention
Assist client in urinary
elimination
 Managing urinary retention
 Catheterization- aseptic technique
 Caring of the indwelling catheter
 Fluids
 Dietary measures
 Perineal care
 Changing the catheter and tubing
 Removing indwelling catheter