elimination

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Factors that
Influence
Urination

Factors
Affecting
Urinary
Output

Pathological
Conditions
Affecting
Urinary
Elimination
9

Promoting
Normal
Urination

1.Growth and development- ageing.

Enlargement of prostate, female prolapsed
bladder, weaker muscles. Decreased kidney
filtration. Cognitive ability, forget to use
bathroom. Incotent , mobility issues, nocturia
2.Cultural- man or women helping you to
bathroom
3. Psychological- uti, kidney stones.
4. Personal habits
5. Muscle tone
6 Fluid intake
7. Disease conditions- cardio, nervouse system,
neurogenic bladder
8. Surgical procedures- child birth
9. Medications- diuretics
10. Diagnostic examinations
HAPFABPUBES
Personal, sociocultural, & environmental
factors
Amount of Intake
Blood Pressure
Blood Volume
Hydration- becomes dehydrated decreased
output
Functional status of kidneys
Protective compensatory mechanisms
Urinary Retention
Surgery & anesthesia
Extra sodium- less fluid out put
Alcole- urinates more.
Infection or inflammation of GU tract- uti,
bladder infections
Renal calculi- block flow
Hypertrophy- excessive growth of the prostate
Neurogenic bladder- when person lacks control
due to injury to brain or spine. Symptoms are
from which part of brain or spine is affected.
Head trauma Parkinson's etc. brain impulse.
Cardiovascular and metabolic disordersdecreases blood flow
Stroke or spinal cord injury- lose bladder control
Systemic infection- causes kidneys to reabsorb
and retain water.
Mobility and communication problemsincontinence
Cognitive changes-altered perceptionsincontinence
Provide privacy
Assist with positioning
Facilitate toileting routines
Promote adequate fluids and nutrition
Assist with hygiene

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Assessment
:history..

History:
*Habits, patterns- learn their abilities,
trends, frequency is,
*Past medical history- surgeries,
pregnancy's, chronic diseases- diabetes,
uti
*Medications
*Environmental barriers- access to the
bathroom, equipment to use the bathroom
( toilet seat raised, bars, clothes)
*Sensory impairments: Velcro/Different
clothing
Presence of catheter or urinary diversion

Assessment:
Symptoms rt
urintaion
problems

UrgencyFrequency- excessive amount of times used

Dysuria
Polyuria
Oliguria
Anuria
Proteinuria
Nocturia - excessive urination at night
Hesitancy
Dribbling
Incontinence
Hematuria
Pyuria

Physical
Assessment

Distended bladder
----Palpate above symphyus pubis ,
midline
-----Palpation causes discomfort, urge to
void
Urinary meatus
Female: Dimple-like opening below
clitoris, above vagina
No drainage
Not inflamed, reddened, swollen, painful
Male: Tip of penis
No discharge, inflammation, pain
Other factors... Intake? Feels need to void,
pain?

assesment of
urine:Color,
clarity and odor.

Assessment of Urine
Color
Pale, straw colored to amber
Bleeding
Red: hematuria
Invisible (microscopic)
Drugs - changes how urine looks
Foods: beets, rhubarb, blackberriesred
Dark amber - very concentrated
Bilirubinyellow foam when shaken

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Color; what color

should it be and what
are abnormalties to
look for.

Pale, straw colored to amber

Bleeding
Red: hematuria
Invisible (microscopic)
Drugs - changes how urine looks
Foods: beets, rhubarb,
blackberriesred
Dark amber - very concentrated
Bilirubinyellow foam when
shaken

bilirubin

yellow foam when shaken

Clarity -examples of
different urine colors:

Transparent - normal
Cloudy - from standing, protein,
bacteria
Thick - sediment, bacteria

Odor of urinedifferent smells related

to what?

More concentrated - strong odor

Bacteria - ammonia odor
Fruity - ketosis- spilling over of
ketones into the urine ( fat break
down) in diabetic patiet

Assessment of Urine:
Urinalysis

- overall screening of urine. freshly

voided sample. helps to diagnosis
renal, hepatic and other diseases.

Specific gravity:

Part of urinalysis that compares

density of urine and water.
measures solutes in solution
Weight or degree of
concentration compared to equal
volume of H2O= 1.000
Measures ability of kidneys to
concentrate urine
Normal: 1.010 to 1.025
If very low, insufficient ADH (
adrenal function) or kidney
damage
If very high, can indicate
dehydration
uses a refrcatomete

Is it normal to have
protien in urine? what
does it indicate?

NO, May indicate diabetes, kidney

disease

Is glucose normally
found in urinalysis?

Not present unless glucose intake

is very high.

Ketons present?

no, unless excessive ASA

what do red blood cells

and white blood cells
indicate in urine?

white- infection
red- bledding

24 hour urine:

showing kidney ****etions

through out different time framesvoid first time then continue to
collect specimens therer on after
for 24 hours and save.
May need to ice specimenp0;

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Creatinine clearance

end product of skeletal

muscle metabolismbreaking down of these
muscles.

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Clean catch

uralysis and cultural

Cleanse genitalia before
voiding
o Collect sample midstream-initial flow may
contain organisms

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Culture and sensitivity test

o To determine presence of
infection
o Determines appropriate
antibiotics to use

Impaired urinary
elimination: what does this
mean/ plans and goals/
common problems . Risk
fors.....

means >>Urinary
incontinence: Functional,
Overflow, Reflex, Stress,
Total, Urge and Urinary
Retention

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Planning/Goal:
Client will resume his
normal urination pattern by
...
Client will respond to the
urge to void in a timely
manner by ...
Client will have a post void
residual volume of less than
150ml by
Client will perform toileting
activities independently by
....
common problems:
Decreased Urinary Output
Urinary Retention
Pain
Incontinence
Urinary Tract Infection
(UTI)
risk for :
Risk for infection (urinary
tract)
Risk for impaired skin
integrity
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signs and symptoms of

Decreased Urinary Output

Less than 30ml/hr oliguria

None - anuria

Normal uriniary output

1500-1600 mL per 24 hours

Should have hourly urine
output of about 60 mL/ hr.
no less then 30 ml per hour.

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what can cause decreased

urine output?

Surgery/manipulation/edema
Prostate enlargement
Recent indwelling catheter
(loss of bladder tone)
Indwelling catheter
blocked, tubing kinked
Renal calculi- kidney or
bladder stones
Position restrictions
Anesthesia
Medications (narcotics,
anticholinergics)

what to do if there is
decreased urinary output?

Palpate for bladder

distention
Observe intake
Notify provider

Urinary Retention;
retention with overflow

No urine output
Retention with overflow- not
able to empty but spills out
due to being full

Residual urine is what?

how is it diagnosed? what
symptoms are associated
with it?

the amount left in the bladder

immediately after voiding.
o Diagnosed by
catheterization or
ultrasound.- check to see
what's in the bladder.
Pain
Costovertebral Angle (CVA):
tenderness - kidney - flank
pain
Bladder distention
UTI
Spasms
Other

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Types of Incontinence- not

related to ageing other
factors. Diabetes, cigarette
smoke, obesity.

Functional
Overflow
Stress
Urge
Reflex
Total

Functional
incontinencewhat is it?
Related to?
interventions?

Inability of usually continent person to

reach toilet in time to avoid unintentional
loss of urine;;Involuntary, unpredictable
passage of urine.; Urinary and nervous
system intact.
Related to: physical impairment, external
obstetrical, immobility,pain and
communication problems.
Environmental Factors Sensory Impairment- communication
issues
Psychological Factors
Interventions:
Modify environment
Orientation cues
Clothing- easier
Raise toilet seat
Lighting
Call light
Schedule Voiding
Assess for UTI

Urinary
Incontinence:
Overflow
. what is it?
Related to and
interventions.

Voluntary or involuntary loss of small

amount of urine (20-30ml) from overdistended bladder.
Hypotonic or underactive detrusor.
Related to:
Drugs
Fecal impaction
Diabetes
Spinal cord injury
Prostate enlargement
Severe uterine prolapse
Interventions:
Intermittent catheterization
Surgery
Indwelling or condom catheter
Cred's method

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Urinary Incontinence:
Stress. what is it?
Related factors?
interventions?

Urinary Incontinence:
Total. what is it?
related to?
interventions

when coughing or sneezing- Loss

of less than 50cc of urine
occurring with increased
abdominal pressure
Related to:
Weakened pelvic
muscles/structural supports
Increased intra-abdominal
pressure
Over-distention
Interventions:
Pelvic floor strengthening
exercises (Kegel)
Schedule regular voiding to
reduce bladder pressure
Limit coffee/tea
Weight loss
Incontinence pads
Biofeedback training- electronic
device in bladder to see if
improving. Diary kept about
intake/output

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Continual and unpredictable

loss of urine
Neurological dysfunctionParkinson's, brain injury, ficial
formation.
Anatomic abnormalities such as
fistula

Urinary
Incontinence: Urge.
what is it? related
to? Interventions?

Involuntary passage of urine

occurring soon after a strong sense
of urgency to void
Commonly known as "overactive
bladder"
Related to:
Decreased bladder capacity
Medications (diuretics,
anticholinergic)
Irritation of bladder stretch
receptors
Interventions:
Voiding schedule (avoid overdistention)
Limit coffee/tea/ alcohol
Treat infections
Pelvic floor strengthening
Modify clothing- Velcro
Review use of anticholinergic
medications

Urinary
Incontinence:
Reflex? related to?
Interventions?

Involuntary loss of urine at

somewhat predictable intervals when
a specific bladder volume is reached
(large or small)
--Unawareness of bladder filling,
lack of urge, bladder spasm
Related to:
Tissue damage (radiation, radical
pelvic surgery) chronic bladder
infection
Neurological impairment
(paralysis)
Interventions:
Determine schedule for emptying
bladder
Self-catheterization or collection
devices
Urinary Tract Infections (UTIs)
Common nosocomial infection
Can spread to kidneys
(pyelonephritis) and bloodstream
(urosepsis)
Very uncomfortable
Can lead to chronic cystitis,
interstitial cystitis

urinary infection
contributors.

Residual urine
pH
Instrumentation
Contaminated hands
Poor perineal hygiene
Catheterization
Intercourse
Kinked catheter drainage tubing,
back flow of urine
Bubble bath

Interventions:
Schedule fluid intake
Schedule regular voiding times
Assess skin regularly and use
barrier creams
Use adult briefs
Intermittent catheterizationstraight cath, empty bladder with
cath when full.

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sings and symtoms of urinary

infection

Signs and Symptoms

Bladder
Pain, burning (dysuria)
Frequency, urgency
Hematuria
Cloudy urine
malaise
Kidneys - CVA
tenderness (flank pain)
Chills and fever

how to treat urinary

infections:

Medications
Antibiotics (oral for
cystitis, IV for
pyelonephritis)
Analgesics
Push fluids
Education to prevent
recurrence

how to prevent urinary

infection?

Drink eight 8 oz.

glasses water/day
Women:
Wear cotton briefs
Cleanse front to back
Void before and after
intercourse
Avoid bubble baths,
hygiene sprays, and
douches
Empty bladder every 2-3
hours while awake, avoid
voluntary retention
Maintain urine acidity
Avoid excess milk
products, sodium
bicarbonate
Learn symptoms,
prevention, report
promptly

why do we do intake output?

To determine fluid
balance

on who do we measure intake

and output?

Patients on IV Therapy
Postoperative patients
Acutely ill patients
At risk for urinary
retention
Just about everybody in
hospital
Burn patients

do we need a order to get

intake and output? If strict i
and o what should you do?

Do not need an order

Strict I&O - do not
estimate

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examples of intake?

Oral
IV
Enteral
Irrigations
Blood and blood
products
Anything on a
full liquid diet

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examples of output to record?

Urine
Vomitus
Drainage
Output from
tubes
Bile
Diarrhea
Anything
liquid that comes
out of the body

Caring for a Patient with an

Indwelling Catheter. your number
one goal and how to get there?

Prevent urinary
tract infection
Maintain closed
system
Maintain free
flow of urine
prevent back flow
Prevent
transmission of
infection
Promote normal
urine production
Maintain skin
and mucosal
integrity

Removing an indwelling catheter

...

Define medical terminology related to

urinary elimination.
Describe common urinary
alterations.
Assess urinary output.
Interpret the findings of a basic
routine urinalysis.
Differentiate the types of urinary
incontinence.
Provide care for a client with a Foley
catheter to prevent injury and
infection.
Describe strategies that promote
urination.
Identify strategies for bladder
retraining.
Assess, plan interventions and
evaluate the following alterations in
urinary elimination:
Urinary retention
Urinary incontinence
Urinary tract Infections

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Factors Affecting
Bowel Elimination

Development
Diet
Fiber, supplements, fluids
Activity
Psychological, personal, cultural
Habits
Medication
Antibiotics, iron, pain meds,
NSAIDS, ASA
Anesthesia and Surgery
Paralytic ileus
Pain, stress
Medical conditions
o Irritable Bowel Syndrome (IBS),
pregnancy, food allergies,
diverticulitis, colon cancer, infections

bowel assesment

Assessment
Normal Bowel Habits- how often
Changes in Pattern
Use of elimination aids
Risk Factors
Physical assessment: bowel sounds
(BS), abdomen

stool assesment,
what are we looking
for?

Old blood will be dark/blackish melena

Iron may cause black colored stools
Sometimes can see bright red blood
in stool
Stress ulcers in very ill people
Cancer or lesion in GI tract
Stool Assessment
White or clay colored - no bile - bile
gives stool its pigment
Pale with fat malabsorption
Mucus or bloody mucus
Worms

stool specimens;
are used to?

and P (ova -egg and parasites)

Culture and Sensitivity
Occult blood
o GUAIAC (Hemoccult) - test for
occult blood
o Order guaiac all stools or guaiac
stools x 3
o Screening for colon cancer

what can cause a

false posatuve in
stool specimen?

iron

what can cause a

false negative in
stool specimen?

vitamin c

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Diagnostic Tests

Direct Visualization Studies

Sigmoidoscopy
Colonoscopy
Indirect Visualization Studies
Flat plate of abdomen (radiologic
study)

Nursing
Diagnosis:
related to bowls

Bowel Incontinence
Constipation
Risk for constipation
Perceived constipation
Diarrhea
Social isolation- consistent diarrhea or
colostomy bag- body oder
Disturbed body image
Impaired skin integrity
Anxiety

Planning/Goals:
related to all bowl

o Client will maintain / restore normal

bowel elimination pattern by ...
o Client will maintain / regain normal
stool consistency by .....
o Prevent (associated risks)
o Fluid and electrolyte imbalance
o Skin breakdown

bowl objectives:

Define medical terminology related to

bowel elimination.
Identify factors affecting bowel
elimination.
State common causes of constipation.
Describe screening tests for occult blood.
Assess and plan care for a client with the
following bowel elimination alterations:
Constipation
Fecal impaction
Diarrhea
Bowel Incontinence
Describe common procedures used in
bowel training

Promoting
Normal
Defecation

Privacy
Positioning
Fluids and nutrition
Exercise

Constipation

Abnormal frequency of defecation

Abnormally hard stools
Both of the above
May be consequence of another
disorder
May be side effect of medications
Other causes
o Physical inactivity
o Stress
o Dietary changes
o Lack of fluids
o Failure to respond to defecation urge
o Overuse of laxatives

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constipation is high
among..

older adults

disease that can

promote
constipation:

o Diabetes
o Hypothyroidism
o Multiple sclerosis (MS)
o Parkinson's disease

medications that
may cause
constipation

Opiods.
Anticonvulsants .
Anticholinergic

Pathophysiology
related to
constipation

Decreased motility of colon

Retention of feces in lower colon or
rectum
Water reabsorbed and stool
becomes hard and dry
Chronic constipation
Leads to decreased muscle tone
Increased use of Valsalva's
maneuver (risks)
Hemorrhoids

what to asses for

constipation?

Assessment
Nature, severity, duration

treatment for
constipation?

Dietary and fluid modification

Increased activity
Regular toileting patterns
Fiber supplements and dietary fiber
Increases water content of stood
o Promotes colonic motility
(bacterial degradation)
Non-absorbable saccharides
(sorbitol, lactulose)
Laxatives, if needed (avoid use if
possible)
Stool softeners-effectiveness
(undocumented)
Monitor hospitalized patients as
exercise and eating patterns
disrupted
Record bowel movements
Initiate preventive bowel program
Patients on bed rest
Patients receiving opioids
Promote normal defecation

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Medications for Treatment of

Constipation

Bulk Formers
Metamucil (psyllium)
Citrucel
(methylcellulose)
Stool Softeners
Colace (docusate
sodium)
Surfak (docusate
calcium)
Lubricants
Mineral oil
Enemas
o Review the types of
enemas (Vol. 1, table 282, page 694) o Cleansing
o Retention
o Oil-retention
o Medication
o Return-Flow

Administering an Enema;
positions

Positioning-Left Sims
then dorsal recumbent and
right lateralfollows
colon
Controlling flow rate

During the enema, the client

begins to complain of pain.
The nurse notes blood in the
return fluid and rectal
bleeding. The nurse should:

1. Stop the instillation

Fecal imp action physical

sign, leads to what for
patient?

Rectum over distends

Cannot respond to
normal sensory
stimulation at/in the anus
Leads to cycle of
impaction, rebound
diarrhea, fecal
incontinence

fecal impaction often occurs

in, why>?

Often occurs in
institutionalized older
adults who may be
confused and immobile
and cannot/do not
respond to urge to defecate

sings and symptoms of fecal

imp action?

Anorexia- due to pain

Abdominal distention
and cramping
Rectal pain
Sudden onset of
continuous oozing of
diarrheal stool
Fecal mass palpated on
digital exam of rectum
o Digital Removal of Stool

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o Digital
Removal of
Stool

o For unresolved fecal impaction

o May need to break up and remove stool
manually
o Will need an order
May administer an oil-retention enema 30
minutes prior to procedure

Patient/Family
Education
Teach
relationship
between
constipation
and

Diet
Fluids
Activity
Stress
Encourage high-fiber diet
Limit highly refined foods
Drink 2000 ml of fluid daily, if allowed
Planned daily time for defecation
Avoid harsh laxatives, enemas

Diarrhea is...

Increase in frequency/number of stools

Liquid/ no form
Stool is going through the bowels quickly
and water is not absorbed
Count as output when you are doing I & O

Complications
of Diarrhea...

Danger of too much fluid loss - with severe

diarrhea patient develops fluid and
electrolyte imbalance and acid base
imbalances
Infants and older adults most at risk
Exposes skin to very irritating substances
which cause breakdown

Causes of
Diarrhea

Antibiotic Use
Infections e.g. C Diff
Enteral Nutrition- g tube, NG
Allergies
Food borne pathogens
Medication
Lactose Intolerance
Illnesses such as colitis
Interventions

Interventions
of diarrhea

Replace fluids
Medications to slow down peristalsisanti diarrhea
Treat infections
Clean skin right away and dry and apply
barrier cream
Fecal incontinence pouch

what is Fecal
Incontinence?

Involuntary release of stool

Etiology r/t
fecal
incontinence

Release of external or internal sphincters

Interruption of voluntary control of stool
in brain or spinal cord
Impaired sensation
Structural damage

Management of
Fecal
Incontinence

Correct underlying problem

Control of diarrhea
Treat impaction
Prevent constipation
Correct structural problems
Implement bowel training
Have client sit on toilet
Consistent timing
Familiar surroundings
Controlled dietary and fluid intake
Biofeedback

Patient/Family
Education on
fecal
incontinence

Fecal incontinence is one of the most

common reasons for nursing home
placement
Assess frequency of incontinence,
cognition, muscle control, awareness of
urge to defecate, relationship to meals
Teach about need for high-fiber diet and
2500 ml fluids/day
May use glycerin suppository to
stimulate defecation at a regular time
each day

Bowel Training..
how to?

Assists patient to have regular, soft,

formed stools
Bowel Training Program
Plan with patient/caregivers
Increase fiber while monitoring stool
consistency
Increase fluid intake to 8 glasses per
day
Provide uninterrupted time for
defecation
Provide privacy
Treat constipation with a plan
Evaluate and modify plan as needed

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Hemorrhoids

Dilated, engorged veins in rectal lining

May be internal or external
External
Visible extrusions of skin
May have purplish discoloration
May bleed
May be painful
Avoid constipation
Surgery sometimes necessary

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melena

Old blood will be dark/blackish -

what can cause

black colored
stools?

Iron may cause black colored stools

White or clay
colored means?

- no bile - bile gives stool its pigment

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