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Elimination. Basic Principles . Wash Hands & Wear Gloves Infection control, your protection & your client’s protection Privacy Embarrassing Positions for urination Independence. Functions of Urinary System. Remove wastes from blood to form urine

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basic principles
Basic Principles
  • Wash Hands & Wear Gloves
    • Infection control, your protection & your client’s protection
  • Privacy
    • Embarrassing
  • Positions for urination
    • Independence
functions of urinary system
Functions of Urinary System
  • Remove wastes from blood to form urine
  • Remove nitrogenous waste products of cellular metabolism
  • Regulates fluid and electrolyte balance

The nephron = functional unit of the kidney and forms the urine

goal of urinary system
Goal of Urinary System
  • To maintain chemical homeostasis of the blood.
    • Filtration by the Nephrons
      • H2O, glucose, amino acids, urea, creatinine, major electrolytes
      • Not normally large proteins or blood cells
        • Proteinuria is a sign of glomerular injury
  • Normal adult 24hr output = 1500-1600ml.
overview of urinary system
Overview of Urinary System
  • Kidneys
    • Bean shaped organs
    • Either side of vertebral columns T12 – L3
    • Right kidney lower due to liver
    • Urine produced with filtration of blood through nephrons
    • Major role in fluid & electrolyte balance
slide6
Ureters
    • Connect kidneys to bladder
    • 10 -12 in length, ½ in diameter in adult
    • Peristaltic waves
      • Renal colic
  • Micturition
slide7
Bladder
    • Distensible, muscular sac
    • Reservoir for urine ( approx. capacity = 600mls )
    • Organ of excretion ( norm. voiding= 300mls)
    • Lies in pelvic cavity behind symphysis pubis
slide8
Urethra
    • Short, muscular tube
    • Urine from bladder to meatus and from the body
    • Female 4-6.5cm (1 ½ - 2 ½ in.) length
    • Male 20cms ( 8 in.)
      • Urinary and reproductive systems
slide9
Meatus
    • External opening of the urethra, male & female
  • The need to void is a conscious awareness
life cycle changes
Life Cycle Changes
  • Infants & children
    • Unable to concentrate urine b/c kidneys are immature
    • Urine is light yellow
    • Void frequently
    • Voluntary control @ 24mos. when neuromuscular structures develop
slide11
Adult
    • 1500 – 1600 mls urine/24hrs
    • Concentrates urine – normal is amber colored
    • Nocturia
      • Not usually
      • Decreased renal blood flow during rest
      • Ability to concentrate urine
slide12
Elderly
    • Micturition impaired
    • mobility
    • Diseases, alzheimer’s, CVA
    • Physiological age related changes
      • Bladder loses muscle tone and capacity
      • Kidneys lose ability to concentrate urine
      • Bladder loses muscle strength
common problems
Common Problems
  • Urinary Retention
    • Accumulation of urine in the bladder
    • Inability to empty
    • Pressure, discomfort and tenderness
  • Residual Urine = urine retained in the bladder after voiding
slide14
Incontinence
    • Loss of voluntary control to void
      • Infection, nerve damage to bladder or brain, spinal cord injury, or aging process
      • Total incontinence = no control
      • Stress incontinence = sm. amts. Urine excreted involuntarily with coughing or laughing

At risk for skin breakdown related to acid urine next to skin.

Adult Diapers or Attends

slide15
Frequency & Urgency
  • Nocturia
  • Enuresis – involuntary discharge of urine
  • Nocturnal Enuresis
    • During sleep
    • Bed-wetting children 5yrs and older
  • Oliguria
    • 30mls/hr or 720 mls/24hrs
slide16
Renal anuria
    • cessation of urine production 100mls/24h
promoting healthy urinary elimination
Promoting Healthy Urinary Elimination
  • Urinate as soon as the urge is felt
    • Avoids stasis and distention
    • Prevents urgency, infection, and incontinence
  • Drink about 2liters fluid/day
  • Limit Na, caffeine, and alcohol
slide18
For people with Nocturia
    • fld. Intake in the p.m.
    • caffiene and alcohol
    • Void before bedtime
  • For Women
    • Wipe perineum front to back
    • Void soon after intercourse
    • Wash hands
    • Pelvic – floor strengthening exercises (Kegel Exercises)
client education
Client Education
  • S & S of infection
  • Fluid intake ( if no restrictions 2-5 L/day )
  • Perineal hygiene
  • Meds. & side effects on urination, color, and volume
facilitating micturition
Facilitating Micturition
  • Nursing Measures to promote voiding in people who are having difficulty:
    • Privacy and natural position
    • Providing commode or bathroom
    • Running water
    • Warm water to dangle fingers
    • Warm water over perineum ( measure if on In/Out )
slide21
Gently stroking inner thighs or pressure to symphysis pubis
  • Pain relief

Warmth to the bladder & perineum relaxes muscles & facilitates voiding. ( Sitz bath or warm tub )

If unsuccessful- urinary catheterization may be indicated

slide22
Promoting complete bladder emptying
  • Prevention of infection
    • Good perineal hygiene
    • Adequate fld. Intake
      • Dilutes urine & flushes urethra
    • Acidifying urine ( inhibits microorganisms)
      • Cranberry juice, whole grain breads, meats, eggs, prunes and plums.
indwelling catheter care
Indwelling Catheter Care
  • Goal- prevent infection & maintain unobstructed flow of urine. Monitor for problems.
  • Perineal hygiene @ least 2x/day and prn
  • Do not advance catheter further into urethra during perineal care
catheter care
Catheter Care
  • Fld intake (3L/day )
  • Handwashing and Gloves
  • Positioning
    • Urine bag
    • Tubing
bowel elimination
Bowel Elimination
  • Function- excrete/eliminate waste products of digestion.
  • Maintaining normal bowel elimination is essential to health and efficient body functions.
gi system
GI System
  • Small Intestine
    • Absorption nutrients & electrolytes
    • 20 ft length, 1 in. diameter
    • 3 sections
      • Duodenum
      • Jejunum
      • Ileum
slide27
GI
  • Large Intestine
    • Absorbs H2O and electrolytes
    • Temporarily stores waste products
    • Main function is elimination
    • 5 – 6 ft. length, 6 – 7 cm. diameter
      • Cecum
      • Ascending colon ( Right side )
      • Transverse colon
      • Descending colon
patterns through life cycle
Patterns through life cycle
  • Babies: 3 – 6 BM’s/day
  • Children:
    • Neuromuscular structures not developed until 15 – 18 mos.
    • Voluntary control 2 – 3 yrs.
  • Pregnant women prone to constipation
    • Pressure on abd. Organs
    • Iron supplements
slide29
Elderly prone to constipation
    • Slowing of peristalsis
determinants affecting elimination
Determinants affecting elimination
  • Dietary patterns & fld. Intake
    • 6 – 8 glasses H2O/day ( 1400- 2000mls )
      • fld. Liquifies stool
      • Dietary fiber stimulates peristalsis
      • Soft stool
factors affecting elimination
Factors affecting elimination
  • Fiber ( undigestible residue ) provides bulk
    • Absorbs fluid
    • Increases stool mass
    • Bowel wall stretches
    • Peristalsis stimulated
    • Defecation results
factors affecting elimination1
Factors affecting elimination
  • Personal habits
    • Busy schedule, postpone BM, constipation
  • Activity & exercise
    • Immobile activity in colon
  • Medications
    • Laxatives
    • Narcotics with codiene
factors affecting elimination2
Factors affecting elimination
  • Emotions
    • Anxiety peristalsis & diarrhea
    • Depression
  • Pain
  • Surgery
    • Anaesthetic causes temporary cessation of peristalsis
    • Direct manipulation of the bowel stops peristalsis
common problems1
Common Problems
  • Constipation – difficult passage of hard, dry stool; infrequent movements
  • Fecal Impaction – unrelieved constipation, feces wedged in rectum, no BM usually 3days, oozing of diarrheal stool develops
  • Diarrhea- # liquid stool
  • Flatulence – abd. Distention & pain
common problems2
Common Problems
  • Incontinence – inability to control passage of stool
  • Hemorrhoids
    • Dilated engorged veins
    • Increased pressure when straining
    • Internal / external
    • Bleeding
slide36
Daily BM Not essential.
  •  2 / week a concern
  • Defecation pattern
  • BM, Stool, Feces, Defecate – all mean waste products expelled via the bowel
promoting healthy bowel elimination
Promoting Healthy Bowel Elimination
  • Privacy
  • Squatting position
  • Bedpan position
  • Cathartics & laxatives
  • Anti- diarrheal agents
  • Enemas
  • disimpaction
slide38
Bowel routine
    • Daily time clock
    • Hot drinks
    • Stool softeners
    • Privavy
    • Position and abdominal pressure
    • Bearing down
assissting with elimination
Assissting with Elimination
  • Embarrassing & stressful
    • Usually urge to defecate 1hr. Pc
  • Bedpans
    • Metal or plastic
    • Regular or fracture pan
    • Cleanliness
  • Urinals
  • Commode
procedure
Procedure
  • Privacy- close door,
  • Side rail as needed
  • Recumbent with HOB
  • Tissue
  • Call bell
  • Leave alone if possible
  • Gloves
  • Clean genitals
procedure1
Procedure
  • Remove pan and cover
  • In & Out
  • Specimens
  • Clean pan
  • Wash hands yours and client’s
  • Lower bed
  • Client comfort
peri care
Peri - Care
  • Cleaning of genitals , routine part of complete/ partial bed bath
  • Incontinence
procedure for peri care
Procedure for Peri Care
  • Regular patient
    • Simple explanation- layman’s terms
    • Privacy
    • Gloves
    • Dorsal recumbent position
    • Incontinent pad under buttocks
    • Warm soap and water
    • Female – separate labia
procedure for peri care1
Procedure for Peri Care
  • Male – begin penile head move down along shaft, retract foreskin, rinse and dry.
procedure for peri care2
Procedure for Peri Care
  • Catheter –
    • Q 8 hrs.
    • Clean perineum & 2in. Of catheter
      • No powders / lotions
      • Avoid advancing catheter
      • Keep urine drainage bag off floor but below level of bladder
      • Empty bag Q8 – 12hrs or when bag is full, remember to mark amt. Emptied on In/Out sheet
slide46
Avoid use of baby powder/ cornstarch
    • No medicinal purpose
    • Can form clumps or will cake in creases
    • Use vaseline/ zincoxide as skin barrier for incontinent clients
suppository administration
Suppository Administration
  • Check physician’s order, protocol
  • Left Lateral position
  • Gloves
  • Lubication
  • Hold with thumb and index finger
  • Insert with index finger (3 – 4”) never force
  • Deep breath = relaxes anal sphincter
slide48
Caution
    • Vagus nerve stimulation can cause heart rate to slow – avoid excess manipulation
enema administration
Enema Administration
  • Main purpose
    • Promotion of defecation, stimulate peristalsis
    • The fluid breaks up fecal mass, stretches the rectal wall & initiates the defecation reflex
cleansing enemas
Cleansing Enemas
  • Tap Water
    • Hypotonic
    • Used only once
    • Electrolyte imbalance
      • Water toxicity
      • Circulatory overload ( concentration gradient)
slide52
Normal Saline
    • Used when more than one enema is needed
    • Safest
    • Isotonic
    • Large volume to distend bowel
slide53
Hypertonic Solution
    • Smaller volume of fluid
    • Draws from surrounding tissue into bowel to soften stool and stimulate peristalsis
    • Fleets – sodium phosphate
      • Low volume, concentrated solution
slide54
Soap suds
    • Less common
    • Soap irritates the bowel
    • 5 – 15 mls. Castile soap in 1000mls warm water
slide55
Oil Retention
    • Oil based solution
    • Lubricates the rectum and colon
    • Softens stool, easier to pass
    • Retain 1 –2 hrs if possible
    • Follow with cleansing enema
slide56
Medicated
    • Instill meds.
    • Rectal mucosa absorption
    • Ex. – Kayexalate to K (potassium). Absorbs K from the intestinal tract
volumes for enemas
Volumes for Enemas
  • Large Volume
    • 500 – 1000mls.
    • Container 12 – 18 in. above the bowel
    • Lg. Volume stimulates & causes evacuation of stool
  • Small Volume
    • 500 mls.
    • Container 12 in.above bowel
volumes for enemas1
Volumes for Enemas
  • Pre packaged
    • Fleet 150mls
    • Microlax 5mls
    • Hypertonic solution
    • User friendly
    • Hold for 5min.
  • Oral Fleet
slide59
Prepackaged used more than large volume because:
    • Works
    • Less risk for electrolyte imbalance
    • Rapid administration
    • Less discomfort and distention
    • Convenient and quick
slide60
Physician’s order reads “ enemas to clear”
    • No more than 3 total given
    • Return solution will be highly colored but no solid stool
    • Isotonic solution (normal saline)

Excess enema use seriously depletes fluid and electrolytes

procedure for enema administration
Procedure for Enema Administration
  • Confirm Dr’s order, prepare client, verbal consent, equipment, privacy
    • Left lateral position ( fld. Flows by gravity)
    • Drape, pad under buttocks
    • Warm solution- stimulates peristalsis
      • Hot sol’n burns mucosa
      • Cold sol’n causes cramping
procedure for enema administration1
Procedure for Enema Administration
  • Prime tube
  • Lubricate tip
  • Glove
  • Insert 7 – 10 cm.(3-4in) adult
    • Do not force
    • Deep breath
    • Guide toward umbilicus
procedure for enema administration2
Procedure for Enema Administration
  • Container at appropriate height
    • Lg. = 12 – 18in
    • Sm. = 12in
    • 1000mls takes ~ 10 min to instill
    • Higher the bag – greater the pressure
      • C/O discomfort, lower bag, slow infusion, stop, then start again
    • Remain side lying to retain 5 – 10 min. or as long as possible
procedure for enema administration3
Procedure for Enema Administration
  • Assist to bathroom or give bedpan
  • Evaluate results
  • Document
    • Type & volume of enema
    • Color, amount, consistency of fecal return
    • Hygienic measures for client
  • Wash Hands
slide66
Certain diseases require surgical interventions to create an opening into the abdominal wall for fecal and urinary elimination
  • Enterostomy – the surgical procedure performed to produce the artificial stoma.
definitions
Definitions
  • Ostomy = opening made to allow passage of urine or stool
    • Piece of intestine is brought out onto the client’s abd.
    • Lacks nerve endings
    • Doesn’t hurt to touch but has other implications
  • Stoma = mouth like opening in the abdominal wall to drain urine or stool
slide68
Effluent – drainage from stoma
  • Bowel ostomies
    • Cancer ( Ca)
    • Drain fecal material
    • Consistency depends on location
      • Higher up = more liquid
      • Greater risk skin irritation b/c concentration of digestive enzymes
slide69
Ileostomy
    • End of small intestine
    • By passes lg. Intestine = freq. Liquid stools
  • Colostomy
    • Large intestine
    • More solid stool
slide70
Ostomies may be permanent
    • More common
  • temporary
    • Rest the bowel
    • Crohn’s
urinary ostomies
Urinary Ostomies
  • Provide drainage of urine that bypasses the bladder = Urinary Diversion
  • Ureterostomy
    • Ureter to abd. Wall
    • Lt., Rt., Bilateral
ileal conduit
Ileal Conduit
  • 6 – 8 in. ileum
  • 1 end for external opening
  • Other end closed off
  • Ureters implanted into this piece of bowel
  • Pouch
  • Urine will have shred of mucus b/c bowel still produces same
concerns
Concerns
  • Infection
    • Sterile ureters provide opening into system
  • Skin Breakdown
    • Continuous drainage
    • Moisture on skin
  • Replace urinary pouch q 2-3 days
pouching an enterostomy
Pouching an Enterostomy
  • Effluent ( drainage ) may begin immediately
  • Collects all effluent
  • Protects the skin
  • Stoma should be moist and reddish pink (same as other mucus membranes)
  • Flush to skin or bud-like protrusion
  • Black, purple, dry = inadequate circulation
pouch with skin barrier
Pouch with Skin Barrier
  • Comfortable fit
  • Cover skin surrounding stoma
  • Good seal
  • Post-op pouch should allow for visibility of stoma
types of pouches and skin barriers
Types of pouches and skin barriers
  • One Piece Pouching System
    • Skin barriers preattached, precut, custom fit
  • Two Piece System
    • Skin barrier with flange ( plastic ring)
    • Corresponding size pouch
  • Assess stoma
    • Measure correct size
    • Change q 3-7 days
    • Empty 1/3 to ½ full, expel flatus prn
steps to care for ostomies
Steps to Care for Ostomies
  • Supine position
  • Wash hands, glove
  • Remove pouch & skin barrier, push skin away from barrier
  • Cleanse peristomal skin gently with warm tap water and clean cloth
    • Do not scrub, Avoid soap ( residue- pouch won’t adher)
steps to care for ostomies1
Steps to Care for Ostomies
  • Correct sizing
  • Cut opening 1/16 – 1/8 larger than stoma
  • Remove backing
  • Ileostomy- apply thin circle barrier paste around opening of pouch and allow to dry (if creases or bumps use barrier paste to even surface for pouch application)
steps to care for ostomies2
Steps to Care for Ostomies
  • Pouch should point to client’s knees
  • Maintain gentle finger pressure around barrier for 1-2 min.
  • Picture frame flange with non allergic paper tape
  • Ostomy deodorant for pouch
  • Tub bath or shower
steps to care for ostomies3
Steps to Care for Ostomies
  • Normal stoma oozes blood if rubbed
  • Actual bleeding into pouch is abnormal
  • Pouch covers are available
  • The client will be watching the nurse during ostomy care to gage reaction.
  • Be conscious of facial expression & nonverbal cues
steps to care for ostomies4
Steps to Care for Ostomies
  • Education
  • Counseling
    • Body image
    • Self care
    • Fear of rejection
    • Sexual function
    • Powerlessness over bowel regulation