BOWEL ELIMINATION
Bowel Elimination Part 1
Objectives
1. Explain the normal physiologic process of urination and defecation.
2. Identify common risk factors that lead to alterations in elimination.
3. Apply the nursing process in the prevention of common alterations in elimination.
4. Relate this concept to nutrition, fluid balance, cognition and mobility.
5. Identify the mechanism of action, indications, routes of administration, adverse effects, toxicity, and nursing implications (client education) of medications used in the treatment of constipation and diarrhea.
6. Compare and contrast the exemplars of constipation, diarrhea, urinary retention and bladder incontinence focusing on assessment, treatment modalities and evaluative outcomes.
7. Apply nursing process to nursing care related to elimination needs.
Anatomy & Physiology Gastrointestinal System
Mouth: Mechanical and chemical breakdown of food
Esophagus: Peristalsis moves food to the stomach
Stomach: Stores food & liquid; mixes food, liquid and digestive juices; empties into small intestines
Small intestine: facilitates digestion and absorption:
* Duodenum-chyme processed
* Jejunum- absorption of carbohydrates and protein
* Ileum- absorbs water, fats, and bile salts
Large Intestine: Primary organ of bowel elimination
* Cecum
* Colon
* Ascending
* Transverse
* Descending
* Sigmoid
* Rectum
* Aids in electrolyte balance
* Last step: defecation: poop/feces
Factors Influencing Bowel Elimination
* Diet and physical activity
* Psychological factors
* Personal habits
* Posture
* Pain
* Pregnancy
* Surgery and anesthesia
* Medications
* Diagnostic tests
Factors Influencing Bowel Elimination: Nutrition & Fluids
Fiber:
* Soluble: carrots, oranges, apples, beans
* Insoluble: whole wheat products, corn bran, vegetable
Both soluble and insoluble fiber aid defecation: water softens the stool and bulk assists peristalsis
* Daily fiber intake: 25g – 38g
* Daily fluid intake: 2,000 to 3,000 mL 2-3L
Foods that alter Gastrointestinal function
* Cause Gas: beans, cabbage family, cucumbers, dairy products, onions
* Cause Odor: beans, cabbage family, cheese, eggs, garlic, onions
* Thicken stool/Constipation: high-fiber foods, applesauce, bananas, bread, cheese, peanut butter
* Loosen stool/Laxative: beans, chocolate, coffee, prune or grape juice, raw fruits or vegetables,
Factors Influencing Bowel Elimination: Physical activity
* Exercise: muscle tone affects the activity of the intestinal musculature and the supporting muscles that aid in defecation
* Other factors that affect muscle tone:
* Immobility
* Neurological impairment
* Multiple pregnancies
Factors Influencing Bowel Elimination: Physiological
* Emotional stress: initiates a parasympathetic response that accelerates the digestive process. Peristalsis is increased. Nausea, diarrhea, and gaseous distention may occur.
* colitis
* Crohn’s disease
* ulcers
* irritable bowel syndrome
* Depression: may have decreased peristalsis, resulting in constipation
Factors Influencing Bowel Elimination: Personal Habits
* Regular pattern of sleeping and eating assists with a regular pattern of elimination
* Failing to respond to the urge to defecate can disrupt a person’s normal schedule and lead to constipation
* Sharing a bathroom/privacy concerns
* convenience of toileting facilities
* busy schedules
Factors Influencing Bowel Elimination:
* Posture: normal: squatting
* Pain (hemorrhoids, fissures, surgery)
* Pregnancy
Factors Influencing Bowel Elimination: Surgery
* Surgical procedures:
* Anesthesia
* Direct handling of bowel stops peristalsis
* Procedure involving the pelvis or perineum may affect defecation patterns
* Medications
* Bowel function can be altered temporality or permanently by surgical intervention
* Diagnostic procedures
Factors Influencing Bowel Elimination: Medications
* Laxatives
* Antidiarrheals
* Antibiotics alter normal bowel flora
* Anticholinergic drugs, opioid analgesics: depress peristalsis
* Drugs that contain iron may turn stools black
* Antacids may cause a white discoloration
Factors Influencing Bowel Elimination: Developmental
Infancy: Stomach is small and secretes a smaller amount of digestive enzymes. Rapid peristalsis propels food quickly through the GI tract, because the neuromuscular system is not well developed, the infant con not control defecation.
Adolescence: Bowel Elimination usually not a problem unless there is an underlying health problem
Factors that can affect elimination:
* May experience changes in bowel habits associated with rapid growth
* Irregular patterns of eating & sleeping
Older Adults: Vulnerability to GI disturbances increases:
* Increase prevalence of motor and neurological disturbances, Colon Cancer & Diverticulitis (outpouching in the intestinal wall)
* Dietary (fiber & water) and sleep patterns
* The amount of digestive enzymes in saliva and gastric acids in the stomach declines
* Muscle atrophy may decrease bowel control
Problems of Bowel Elimination
Constipation:less than 3 BM/week Slowed intestinal motility causing water to be absorbed, leaving feces hard and under lubricated
* Constipation can be a significant health problem due to increased pressure that occurs when straining.
Fecal Impaction: Results from unrelieved constipation. Lower intestinal obstruction
Common Causes: Constipation
* Medications: narcotics
* Diet
* Environmental factors
* Chronic illness: Rheumatoid Arthritis
* Bowel disease
* Neurological conditions: Spinal cord injury
* Organic Illnesses: Hypothyroidism: peristalsis slowed
Diarrhea: Rapid movement of fecal matter through the intestine, resulting in diminished absorption of water, nutrients, and electrolytes and producing abnormally frequent evacuation of watery stools.
* Concerns: Fluid and electrolyte imbalances & Skin breakdown
Problems of Bowel Elimination
Common Causes: Diarrhea
* Intestinal infections: Clostridium difficile
* Food-borne pathogens
* Food allergies or intolerances
* Inflammatory bowel diseases: Chrohn’s disease, colitis
* Surgical alterations: colon resection
Problems of Bowel Elimination
Bowel Incontinence: inability to voluntarily control the passage of feces and gas
Flatulence: gas, the presence of abnormal amounts of gas in the GI tract, causing abdominal distention and discomfort
* Belching: Upper GI
* Flatus: Lower GI farting
Hemorrhoids: dilated, engorged veins in the rectum from straining can result from constipation, pregnancy, chronic conditions
Bowel Elimination Part 2
Objectives
* Explain the normal physiologic process of urination and defecation.
* Identify common risk factors that lead to alterations in elimination.
* Apply the nursing process in the prevention of common alterations in elimination.
* Relate this concept to nutrition, fluid balance, cognition and mobility.
* Identify the mechanism of action, indications, routes of administration, adverse effects, toxicity, and nursing implications (client education) of medications used in the treatment of constipation and diarrhea.
* Compare and contrast the exemplars of constipation, diarrhea, urinary retention and bladder incontinence focusing on assessment, treatment modalities and evaluative outcomes.
* Apply nursing process to nursing care related to elimination needs.
Bowel Assessment: History
Determine usual pattern of bowel elimination
* frequency, time of day
Normal characteristic of stool
* Watery or formed; soft or hard; typical color
Specific routines followed to promote normal elimination
Use of laxatives or bowel elimination aids
Bowel Assessment: History
Inquire about dietary habits
* Normal dietary intake. Changes in dietary intake
* Normal fluid intake. Changes in fluid intake
* Changes in appetite. Recent weight gain or loss (unexpected)
Physical activity. Recent changes in physical activity
Surgery or illnesses affecting GI tract
Medication use
Bowel Assessment: Physical
Inspection
* Contour, symmetry, scars, distension, masses, stomas
Auscultation
* Note frequency (5-30/min) and character
Palpate
* Assess for areas of tenderness, guarding, palpable masses
Bowel Assessment: Physical
Inspect anus: Ulcers, inflammation, rashes, or excoriation
Assess patient’s mobility and strength: Can the patient toilet independently or do they need assistance?
Laboratory & Diagnostic Testing
Fecal Specimens/Stool Analysis
* Characteristics of feces
* Laboratory analysis of feces
Radiographic/indirect examination
* X-ray with or without contrast
* Ultrasound
* CT & MRI
* Colonic transit study
Direct visualization of bowel
Laboratory Testing
Stool Specimens
* Blood in the stool, ova and parasites (O&P) and stool culture
* Laboratory tests for blood, O&P and culture require a small sample of stool
Patient Teaching
* Specimens are collected in a clean dry bedpan or with a specimen container placed under the toilet seat
* Instruct the patient not to mix stool with water or urine
Laboratory Testing
Fecal occult blood test (FOBT) or guaiac test: colorectal screening tool
* Requires more than one positive result
* Need to assure that the patient is not ingesting food or medication that could create a false-positive result
* Food: red meat, (blood-containing foods) some raw vegetables (uncooked broccoli, turnip, radish)
* Medications: Vitamin C, NSAIDS (aspirin)
* Anticoagulant therapy-FOBT Screening
Diagnostic Testing
Endoscopy: Allows for direct visualization of the gastrointestinal tract.
* Upper endoscopy
* Sigmoidoscopy
* Colonoscopy
Patient Preparation
* Sigmoidoscopy: Use an enema to empty bowels, usually about 1 hour before the procedure. On the morning of the procedure, eat a light breakfast.
Diagnostic Testing
Patient Preparation: Colonoscopy
* Completely cleanse your intestines.
* Enemas, not eating solid foods for 2 or 3 days before the test, and taking laxatives.
* Drink plenty of clear liquids for 1 - 3 days before the test.
* Stop taking aspirin, ibuprofen, naproxen, or other blood-thinning medications for several days before the test.
* Stop taking iron pills or liquids a few weeks before the test
Nursing Diagnosis
* Bowel incontinence
* Constipation
* Perceived and risk for constipation
* Diarrhea
* Nausea
* Imbalanced nutrition
* Acute pain
* Toileting self-care deficit
* Disturbed body image
Planning: Client Outcomes
Bowel Incontinence
Chronic
* Client’s perianal skin will remain intact (time frame)
Temporary
* Client will have regular, complete bowel elimination daily (or every 2 days) on a commode or bedpan
* Client will have regulation of stool consistency (soft, formed stool) in the next two weeks
Implementation
Health promotion activities
* Diet
* Daily fiber intake: 25g – 38g
* Daily fluid intake: 2,000 to 3,000mL
* Exercise
* Promotes GI motility
* Timing and privacy
* Respond to the urge to defecate
Implementation: Acute Care
* Use of bedpan
* Medications to prevent constipation or manage diarrhea
* Administration of enemas
* Digital removal of stool
* Positioning patient on bedpan:
* Help position patient comfortably
* Head of bed should be raised 30-45 degrees
* Regular bedpan
* Fracture pan
Medications: Constipation
Bulking agents, such as bran or psyllium (found in Metamucil, for example) ease constipation by increasing the volume of stool and making it easier to pass.
* Drink plenty of water throughout the day
Stool softeners (such as Colace and Docusate Calcium) soften the stool, making it easier to pass.
Osmotic laxatives, such as Fleet Phospho-Soda, Milk of Magnesia, or Miralax, hold fluid in the intestine. They also draw fluids into the intestine, making the stool softer and easier to pass.
Stimulant laxatives (such as Correctol, Ex-Lax, and Senokot) make stool move faster through the intestines by irritating the lining of the intestines. Regular use of stimulant laxatives is not recommended.
Precautions
* Take any laxative or bulking agent with plenty of water or other liquids.
* Do not take laxatives regularly. They change the tone and feeling in the large intestine and may result in dependency on them to have a bowel movement. If you need help having regular bowel movements, use a bulking agent.
* Regular use of laxatives may change the body's ability to absorb vitamin D and calcium that can lead to weakened bones.
Medications: Antidiarrheal
Thicken the stool or decreasing intestinal peristalsis to slow the passage of feces
* Thickening mixtures (such as psyllium) absorb water. This helps bulk up the stool and make it more firm
* Antispasmodic antidiarrheal products such as Loperamide-Opiod (active ingredient in Imodium A-D) slow the intestine.
* Some products contain both thickening and antispasmodic ingredients.
Antidiarrheal precautions
* Use antidiarrheals if you have diarrhea for longer than 6 hours.
* Do not use if you have bloody diarrhea, a high fever, or other signs of serious illness
* Long-term use is not recommended. To avoid constipation, stop taking antidiarrheal medicines as soon as stools thicken.
Implementation: Acute Care
Enema: Installation of a preparation into the rectum and sigmoid colon to promote defecation.
* Cleansing: promote complete evacuation of the feces from the colon
* Tap water: Hypotonic
* Normal saline: safest solution, exerts the same osmotic pressure as fluids in the interstitial spaces around the colon.
* Fleet enema: Hypertonic
Digital removal of stool: Because of the risk factors associated with the procedure some institutions restrict nurse from digitally removing impactions
* Rectal manipulation causes irritation
* Risk of vagus nerve stimulation
Continuing and Restorative Care
Bowel Training
* Establishing a daily routine
* Time, patience and consistency
Care of Hemorrhoids
* Soft formed stool
* Prescribed topical medication
* Sitz bath
Maintenance of skin integrity
* Good perianal hygiene, use of barrier creams
Evaluation
Has the patient met the expected outcomes and goals of care?
* Establishment of a regular bowel elimination routine (regular soft-formed stool)
* Knowledge of dietary factors that promote healthy elimination?
Did nursing care meet the patient’s expectation?
URINARY:
Urinary Elimination Part 1
Learning Objectives
* Explain the normal physiologic process of urination and defecation.
* Identify common risk factors that lead to alterations in elimination.
* Apply the nursing process in the prevention of common alterations in elimination.
* Relate this concept to nutrition, fluid balance, cognition and mobility.
* Compare and contrast the exemplars of constipation, diarrhea, urinary retention and bladder incontinence focusing on assessment, treatment modalities and evaluative outcomes.
* Apply nursing process to nursing care related to elimination needs.
Urinary Elimination
Kidneys
Ureters
Bladder
Urethra
Bladder
* Can not be palpated when empty
* Can extend to the umbilicus when distended
Urethra
* External urethral sphincter – permits voluntary flow of urine
* Uretrhritis – inflammation
Act of Urination
* Brain structures influence bladder function.
* Voiding: Bladder contraction + Urethral sphincter and pelvic floor muscle relaxation
* Stretching of bladder wall signals the micturition center in the sacral spinal cord.
* Impulses from the micturition center in the brain respond to or ignore this urge, thus making urination under voluntary control.
* When a person is ready to void, the external sphincter relaxes, the micturition reflex stimulates the detrusor muscle to contract, and the bladder empties.
Factors affecting urinary elimination
* Developmental considerations
* Fluid and food intake
* Muscle tone
* Psychosocial factors
* Pathologic conditions
* Surgical and diagnostic procedures
* Medications
Developmental Considerations
* Children
* Infants
* Toilet training 2 to 5 years old, enuresis
* Effects of aging
* Nocturia
* Increased frequency
* Urine retention and stasis
* Voluntary control affected by physical problems
Disease Conditions Affecting Urination
* Diabetes mellitus and neuromuscular diseases such as multiple sclerosis
* Benign prostatic hyperplasia
* Cognitive impairments (e.g., Alzheimer’s)
* Diseases that slow or hinder physical activity
* Conditions that make it difficult to reach and use toilet facilities
* End-stage renal disease, uremic syndrome
* Medications
Effects of Medications on Urine Production and Elimination
* Diuretics
* Cholinergic medications
* Analgesics and tranquilizers
Medications Affecting Color of Urine
* Anticoagulants
* Diuretics
* Pyridium
* Elavil
* Levodopa
Medical Interventions Affecting Urination
* Surgical procedures
* Restriction of fluid intake lowers urine output.
* Stress causes fluid retention.
* Diagnostic examinations
* Restriction of fluid intake lowers urine output.
* Direct visualization causes localized trauma and edema; patients may have difficulty voiding.
Alterations in Urination
* Altered urine production
* Polyuria (diuresis): production of abnormally large amounts of urine
* Can cause excessive fluid loss → intense thirst, dehydration,
weight loss
* Polydipsia: extreme thirst
* Associated with polyuria
* Anuria: absence of urine production
* Oliguria: scant urine production
* May signal impending renal failure
Alterations in Urination
* Altered urine elimination
* Urinary frequency
* Nocturia: voiding at night
* Urgency: sudden strong desire to void
* Dysuria: painful or difficult voiding
* Urinary hesitancy
* Neurogenic bladder
* Does not perceive bladder fullness
* Unable to control urinary sphincters
Alterations in Urination
* Urinary incontinence: the involuntary leakage of urine
* Up to 50% of women, 5% of men < age 65
* 60% of men > age 60
* Related to treatment for enlarged prostate
* Urinary retention: inability to completely empty the bladder
* Less prevalent than incontinence
* More men than women
* Related to prostate enlargement
* Uncommon in women
Urinary Incontinence
UI Type
Etiology
Presentation
Treatment modalities
Urge
Irritation of bladder stretch receptors
Urinary urgency, frequency, nocturia, bladder contractures
Scheduled toileting, Diet, Medications, treatment of underlying causes
Stress
Weakened urethral sphincter, pelvic floor muscles.
Dribbling with coughing, laughing, sneezing. Increased intra-abdominal pressure
Kegel exercises, Vaginal pessary, Surgical intervention
Overflow (OAB)
Urinary retention
Discomfort, restlessness, diaphoresis
Catheterization
Functional
Other Illness or disability
Inability to get to the bathroom timely
Toileting programs, adaptive equipment
Reflex
Neuropathy; trauma
Constant flow of urine; lack of awareness
Management of skin; dignity
Types of Urinary Incontinence
* Transient: appears suddenly and lasts 6 months or less
* Mixed: urine loss with features of two or more types of incontinence
Urinary Elimination Part 2
Learning Objectives
* Explain the normal physiologic process of urination and defecation.
* Identify common risk factors that lead to alterations in elimination.
* Apply the nursing process in the prevention of common alterations in elimination.
* Relate this concept to nutrition, fluid balance, cognition and mobility.
* Compare and contrast the exemplars of constipation, diarrhea, urinary retention and bladder incontinence focusing on assessment, treatment modalities and evaluative outcomes.
* Apply nursing process to nursing care related to elimination needs.
Nursing Process
* Assessing data about voiding patterns, habits, past history of problems
* Physical examination of the bladder, if indicated, and urethral meatus; assessment of skin integrity and hydration; and examination of the urine
* Correlation of these findings with results of procedures and diagnostic tests
* Urinary Assessment: History
* Patterns
* Daily intake
* # of voiding episodes
* Volume
* Recent changes
* Symptoms
* Nocturia
* Frequency
* Urgency
* Dribbling
* Retention
* Hesitancy
* Polyuria
* Oliguria
* Dysuria
Physical Assessment
* Skin and mucosal membranes
* Assess hydration
* Kidneys
* Flank pain may occur with infection or inflammation
* Bladder
* Distended bladder rises above symphysis pubis.
* Urethral meatus
* Observe for discharge, inflammation, and lesions.
Assessment of Urine
* Intake and output
* Characteristics of urine
* Color
* Pale-straw to amber color
* Clarity
* Transparent unless pathology is present
* Odor
* Ammonia in nature
* Urine testing
* pH range 4.6 – 8.0
* Specific gravity 1.015-1.025
Urine Tests and Diagnostic Examinations
Urinalysis
Specific gravity
Culture
Noninvasive procedures
Invasive procedures
Nursing Diagnoses
* Urinary functioning as the problem
* Incontinence
* Pattern alteration
* Urinary retention
* Urinary functioning as the etiology
* Anxiety
* Caregiver role strain
* Risk for infection
Implementation
* Health promotion
* Patient education
* Promoting normal micturition
* Stimulating micturition reflex
* Maintaining elimination habits
* Maintaining adequate fluid intake
* Promoting complete bladder emptying
* Preventing infection
Implementation
* Acute care
* Maintaining elimination habits
* Allow time and provide privacy.
* Medications
* Parasympathetic stimulation of the detrusor muscle aids emptying.
* Cholinergic drugs increase bladder contraction and improve emptying.
* Catheterization
Implementation: Restorative Care
* Strengthening pelvic floor muscles
* Bladder retraining
* Habit training
* Self-catheterization
* Maintenance of skin integrity
* Promotion of comfort
Evaluation
* Evaluate whether the patient has met outcomes and goals.
* Check how the patient reports progress made.
* Help the patient redefine goals if necessary.
* Revise nursing interventions as indicated.