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Monday, April 21, 2008

Elimination Nursing Lecture

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Elimination Nursing Lecture Slide Transcript
Slide 1: Elimination

Slide 2: Basic Principles  Wash Hands & Wear Gloves  Infection control, your protection & your client’s protection  Privacy  Embarrassing  Positions for urination  Independence

Slide 3: 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

Slide 4: 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.

Slide 5: 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

Slide 6:  Ureters  Connect kidneys to bladder  10 -12 in length, ½ in diameter in adult  Peristaltic waves  Renal colic  Micturition

Slide 7:  Bladder  Distensible, muscular sac  Reservoir for urine ( approx. capacity = 600mls )  Organ of excretion ( norm. voiding= 300mls)  Lies in pelvic cavity behind symphysis pubis

Slide 8:  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

Slide 9:  Meatus  External opening of the urethra, male & female  The need to void is a conscious awareness

Slide 10: 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

Slide 11:  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

Slide 12:  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

Slide 13: 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

Slide 14:  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

Slide 15:  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

Slide 16:  Renal anuria  cessation of urine production 100mls/24h

Slide 17: 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

Slide 18:  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)

Slide 19: 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

Slide 20: Facilitating Micturition  Nursing Measures to promote voiding in people who are having difficulty: 1. Privacy and natural position 2. Providing commode or bathroom 3. Running water 4. Warm water to dangle fingers 5. Warm water over perineum ( measure if on In/Out )

Slide 21: 1. Gently stroking inner thighs or pressure to symphysis pubis 2. Pain relief Warmth to the bladder & perineum relaxes muscles & facilitates voiding. ( Sitz bath or warm tub ) If unsuccessful- urinary catheterization may be indicated

Slide 22:  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.

Slide 23: 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

Slide 24: Catheter Care  Fld intake (3L/day )  Handwashing and Gloves  Positioning  Urine bag  Tubing

Slide 25: Bowel Elimination  Function- excrete/eliminate waste products of digestion.  Maintaining normal bowel elimination is essential to health and efficient body functions.

Slide 26: GI System  Small Intestine  Absorption nutrients & electrolytes  20 ft length, 1 in. diameter  3 sections  Duodenum  Jejunum  Ileum

Slide 27: 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

Slide 28: 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

Slide 29:  Elderly prone to constipation  Slowing of peristalsis

Slide 30: Determinants affecting elimination  Dietary patterns & fld. Intake  6 – 8 glasses H2O/day ( 1400- 2000mls )  fld. Liquifies stool  Dietary fiber stimulates peristalsis  Soft stool

Slide 31: Factors affecting elimination  Fiber ( undigestible residue ) provides bulk  Absorbs fluid  Increases stool mass  Bowel wall stretches  Peristalsis stimulated  Defecation results

Slide 32: Factors affecting elimination  Personal habits  Busy schedule, postpone BM, constipation  Activity & exercise  Immobile activity in colon  Medications  Laxatives  Narcotics with codiene

Slide 33: Factors affecting elimination  Emotions  Anxiety peristalsis & diarrhea  Depression  Pain  Surgery  Anaesthetic causes temporary cessation of peristalsis  Direct manipulation of the bowel stops peristalsis

Slide 34: Common Problems 1. Constipation – difficult passage of hard, dry stool; infrequent movements 2. Fecal Impaction – unrelieved constipation, feces wedged in rectum, no BM usually 3days, oozing of diarrheal stool develops 3. Diarrhea- # liquid stool 4. Flatulence – abd. Distention & pain

Slide 35: Common Problems  Incontinence – inability to control passage of stool  Hemorrhoids  Dilated engorged veins  Increased pressure when straining  Internal / external  Bleeding

Slide 36:  Daily BM Not essential.   2 / week a concern  Defecation pattern  BM, Stool, Feces, Defecate – all mean waste products expelled via the bowel

Slide 37: Promoting Healthy Bowel Elimination  Privacy  Squatting position  Bedpan position  Cathartics & laxatives  Anti- diarrheal agents  Enemas  disimpaction

Slide 38:  Bowel routine Daily time clock Hot drinks Stool softeners Privavy Position and abdominal pressure Bearing down

Slide 39: Assissting with Elimination  Embarrassing & stressful  Usually urge to defecate 1hr. Pc  Bedpans  Metal or plastic  Regular or fracture pan  Cleanliness  Urinals  Commode

Slide 40: Procedure  Privacy- close door,  Side rail as needed  Recumbent with HOB  Tissue  Call bell  Leave alone if possible  Gloves  Clean genitals

Slide 41: Procedure  Remove pan and cover  In & Out  Specimens  Clean pan  Wash hands yours and client’s  Lower bed  Client comfort

Slide 42: Peri - Care  Cleaning of genitals , routine part of complete/ partial bed bath  Incontinence

Slide 43: 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

Slide 44: Procedure for Peri Care  Male – begin penile head move down along shaft, retract foreskin, rinse and dry.

Slide 45: 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

Slide 46:  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

Slide 47: 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

Slide 48:  Caution  Vagus nerve stimulation can cause heart rate to slow – avoid excess manipulation

Slide 49: Enema Administration  Main purpose  Promotion of defecation, stimulate peristalsis  The fluid breaks up fecal mass, stretches the rectal wall & initiates the defecation reflex

Slide 50: Types of Enemas

Slide 51: Cleansing Enemas  Tap Water  Hypotonic  Used only once  Electrolyte imbalance  Water toxicity  Circulatory overload ( concentration gradient)

Slide 52:  Normal Saline  Used when more than one enema is needed  Safest  Isotonic  Large volume to distend bowel

Slide 53:  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

Slide 54:  Soap suds  Less common  Soap irritates the bowel  5 – 15 mls. Castile soap in 1000mls warm water

Slide 55:  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

Slide 56:  Medicated  Instill meds.  Rectal mucosa absorption  Ex. – Kayexalate to K (potassium). Absorbs K from the intestinal tract

Slide 57: 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

Slide 58: Volumes for Enemas  Pre packaged  Fleet 150mls  Microlax 5mls  Hypertonic solution  User friendly  Hold for 5min.  Oral Fleet

Slide 59:  Prepackaged used more than large volume because:  Works  Less risk for electrolyte imbalance  Rapid administration  Less discomfort and distention  Convenient and quick

Slide 60:  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

Slide 61: 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

Slide 62: Procedure for Enema Administration  Prime tube  Lubricate tip  Glove  Insert 7 – 10 cm.(3-4in) adult  Do not force  Deep breath  Guide toward umbilicus

Slide 63: 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

Slide 64: 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

Slide 65: Ostomy Care

Slide 66:  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.

Slide 67: 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

Slide 68:  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

Slide 69:  Ileostomy  End of small intestine  By passes lg. Intestine = freq. Liquid stools  Colostomy  Large intestine  More solid stool

Slide 70:  Ostomies may be permanent  More common  temporary  Rest the bowel  Crohn’s

Slide 71: Urinary Ostomies  Provide drainage of urine that bypasses the bladder = Urinary Diversion  Ureterostomy  Ureter to abd. Wall  Lt., Rt., Bilateral

Slide 72: 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

Slide 73: Concerns  Infection  Sterile ureters provide opening into system  Skin Breakdown  Continuous drainage  Moisture on skin  Replace urinary pouch q 2-3 days

Slide 74: 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

Slide 75: Pouch with Skin Barrier  Comfortable fit  Cover skin surrounding stoma  Good seal  Post-op pouch should allow for visibility of stoma

Slide 76: 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

Slide 77: 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)

Slide 78: 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)

Slide 79: 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

Slide 80: 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

Slide 81: Steps to Care for Ostomies  Education  Counseling  Body image  Self care  Fear of rejection  Sexual function  Powerlessness over bowel regulation





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