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Bowel and Urine Elimination
Bowel and Urine Elimination
Defecation
Defecation (bowel elimination) is the act of
expelling feces (stool) from the body. To do
so, all structures of the gastrointestinal
tract, especially the components of the large
intestine must function in a coordinated
manner (Fig. 31-1). In the large intestine, a
remarkable volume of water is removed from
Assessment of Bowel Elimination
the remnants of digestion, causing the
Elimination Patterns
bowel's contents to become a consolidated
Because various elimination patterns
mass of residue before being eliminated.
can be normal, it is essential to
determine the client's usual patterns,
including frequency of elimination,
effort required to expel stool, and
what elimination aids, if any, he or
she uses.
Stool Characteristics
Information that is particularly
diagnostic includes stool color, odor,
consistency, shape, and unusual
Fig. 31 - 1
components
Peristalsis means the rhythmic contractions
of intestinal smooth muscle that facilitate
defecation. Peristalsis moves fiber, water,
and nutritional wastes along the ascending,
transverse, descending, and sigmoid colon
toward the rectum. Peristalsis becomes even
more active during eating; this increased
peristaltic activity is termed the gastrocolic
reflex.
The gastrocolic reflex usually precedes
defecation .Its accelerated wavelike
movements, sometimes perceived as slight
abdominal cramping, propel stool forward,
Common Alterations in Bowel Elimination
packing it within the rectum .As the rectum
Constipation
distends, the person feels the urge to
Constipation is an elimination
defecate .Stool is eventually released when
problem characterized by dry, hard
the anal sphincters (ring-shaped bands of
stool that is difficult to pass.
muscles) relax. Performing the Valsalva
Various accompanying signs and
maneuver (closing the glottis and contracting
symptoms include the following:
the pelvic and abdominal muscles to increase
Complaints of abdominal
abdominal pressure) facilitates this process.
fullness or bloating
Several dietary, physical, social, and
Abdominal distention
emotional factors can influence the bowel's
Complaints of rectal fullness
mechanical function
or pressure
Pain on defecation
Decreased frequency of bowel
movements
Inability to pass stool
1
Changes in stool Some clients with an impaction pass liquid
characteristics such as oozing stool, which they may misinterpret as
liquid stool or hard small diarrhea.
stool
The incidence of constipation tends to be
high among those whose dietary habits lack Flatulence
adequate fiber(such as not eating sufficient Flatulence or flatus (excessive accumulation
raw fruits and vegetables, whole grains, of intestinal gas) results from swallowing air
seeds, and nuts .)Dietary fiber, which while eating or sluggish peristalsis. Another
becomes undigested cellulose, is important cause is the gas that forms as a byproduct
because it attracts water within the bowel, of bacterial fermentation in the bowel.
resulting in bulkier stool that is more quickly Vegetables such as cabbage, cucumbers, and
and easily eliminated. onions are commonly known for producing
Constipation is classified into one of four gas. Beans are other gas formers.
distinct types (primary, secondary, Diarrhea
iatrogenic, and pseudoconstipation), according Diarrhea is the urgent passage of watery
to the underlying cause. stool and commonly is accompanied by
Primary Constipation abdominal cramping. Simple diarrhea usually
Primary or simple constipation is well within begins suddenly and lasts for a short
the treatment domain of nurses. It results period. Other associated signs and symptoms
from lifestyle factors such as inactivity, include nausea and vomiting and blood or
inadequate intake of fiber, insufficient fluid mucus in the stools.
intake, or ignoring the urge to defecate. Usually diarrhea is a means of eliminating an
Secondary Constipation irritating substance such as tainted food or
Secondary constipation is a consequence of a intestinal pathogens .Diarrhea may also result
pathologic disorder such as a partial bowel from emotional stress, dietary indiscretions,
obstruction. It usually resolves when the laxative abuse, or bowel disorders.
primary cause is treated. Fecal Incontinence
Iatrogenic Constipation Fecal incontinence is the inability to control
Iatrogenic constipation occurs as a the elimination of stool.
consequence of other medical treatment. For Measures to Promote Bowel Elimination
example, prolonged use of narcotic analgesia Nurses commonly use two interventions—
tends to cause constipation. These and other inserting suppositories and administering
drugs slow peristalsis, delaying transit time. enemas—to promote elimination when it
The longer the stool remains in the colon, does not occur naturally or when the bowel
the drier it becomes, making it more must be cleansed for other purposes, such as
difficult to pass. preparation for surgery and endoscopic or x-
Pseudoconstipation ray examinations.
Pseudoconstipation, also referred to as Inserting a Rectal Suppository
perceived constipation, is a term used when Medications released from the suppository
clients believe themselves to be constipated can have local or systemic effects .Depending
even though they are not. on the drug, local effects may include
Fecal Impaction softening and lubricating dry stool, irritating
Fecal impaction occurs when a large, the wall of the rectum and anal canal to
hardened mass of stool interferes with stimulate smooth muscle contraction, and
defecation, making it impossible for the liberating carbon dioxide, thus increasing
client to pass feces voluntarily. Fecal rectal distention and the urge to defecate.
impactions result from unrelieved Administering an Enema
constipation, retained barium from an An enema introduces a solution into the
intestinal x-ray, dehydration, and weakness rectum Nurses give enemas to:
of abdominal muscles. Cleanse the lower bowel(most
common reason.)
2
Soften feces. Most persons with an ostomy, also called
Expel flatus. ostomates, wear an appliance (bag or
Soothe irritated mucous membranes. collection device over the stoma) to collect
Outline the colon during diagnostic x- stool. Depending on the type and location of
rays. the ostomy, client care may involve providing
Treat worm and parasite peristomal care, applying an appliance,
infestations. draining a continent ileostomy, and, for
Cleansing Enemas clients with a colostomy, administering
Cleansing enemas use different types of irrigations through the stoma.
solution to remove feces from the rectum
3
URINARY ELIMINATION • See box, Female and Male Urinary Bladder
and Urethras
Process of Urination Factors Affecting Voiding
• Depends on effective functioning of • Developmental factors (enuresis, nocturnal
– Upper urinary tract (kidneys, enuresis, nocturnal frequency)
ureters) • Psychosocial factors
– Lower urinary tract (bladder, • Fluid and food intake
urethra, pelvic floor) • Medications (especially diuretics)
– Cardiovascular system • Muscle tone
– Nervous system • Pathologic conditions
Urine Formation • Surgical and diagnostic procedures
• Nephron Altered Urine Production
– Functional unit of the kidney • Polyuria (diuresis), may follow polydipsia
– Urine is formed here • Oliguria
• Glomerulus • Anuria (requires dialysis)
– Tuft of capillaries surrounded by • Urinary frequency
Bowman’s capsule • Nocturia
– Fluids and solutes move across • Urgency
endothelium of capillaries into the • Dysuria, associated with urinary hesitancy
capsule • Enuresis
• Bowman’s capsule • Urinary incontinence
– Filtrate moves from here into the – Transient (acute)
tubule of the nephron – Established (chronic)
• Proximal convoluted tubule • Urinary retention
– Most of water and electrolytes • Neurogenic bladder
reabsorbed Assessing
• Loop of Henle • Nursing history
– Solutes such as glucose reabsorbed • Physical assessment and hydration status
– Other substances secreted • Examination of urine
• Distal convoluted tubule • Related data from diagnostic tests and
– Additional water and sodium procedures
reabsorbed here under control of
hormones Nursing History
• Formed urine then moves to: • Normal voiding patterns
– Calyces of the renal pelvis • Appearance of urine
– Ureters (valve prevents reflux) • Recent changes
– Bladder (detrusor muscle, trigone) • Past or current problems
Process of Micturition • Presence of ostomy
• Micturition = voiding = urination • Factors influencing elimination pattern
• Urine collects in bladder Physical Assessment
• Pressure stimulates special stretch receptors • Percussion of kidneys to detect tenderness
in bladder wall • Palpation and percussion of bladder
• Stretch receptors transmit impulses to • Inspection of urethral meatus for swelling,
spinal cord voiding reflex center discharge, inflammation
• Internal sphincter relaxes, stimulating urge • Inspect skin for color, texture, turgor, signs
to void of irritation, edema
• If appropriate, conscious portion of the brain Assessing Urine
relaxes external urethral sphincter muscle • 96% water; 4% solutes
• Urine is eliminated through urethra at the • Organic solutes include urea (chief solute),
meatus ammonia, creatinine, and uric acid
• Pelvic floor tone aids voluntary control
Female and Male Urinary Bladder and Urethras
4
• Inorganic solutes include sodium, chloride, • Maintaining normal urinary elimination
potassium sulfate, magnesium, and – Promoting fluid intake
phosphorus – Maintaining normal voiding habits
• Volume – Assisting with toileting
• Color, clarity • Preventing urinary tract infections
• Odor • Teaching to prevent UTIs
• Sterility – Drink eight 8-oz glasses of water per
• pH day
• Specific gravity – Practice frequent voiding (every 2 -
• Glucose 4 hours)
• Ketone bodies – Avoid harsh soaps, bubble baths,
• Blood powder or sprays in perineal area
• Measure urinary output – Avoid tight-fitting clothing
• Measure residual urine – Wear cotton, not nylon, underclothes
• Diagnostic tests – (Girls and women) - always wipe
– Blood urea nitrogen (BUN) perineal area from front to back
– Creatinine clearance following urination or defecation
Nursing Diagnoses – Take showers rather than baths if
• Impaired Urinary Elimination recurrent urinary infections are a
• Readiness for Enhanced Urinary Elimination problem)
• Functional Urinary Incontinence • Managing urinary incontinence
• Overflow Urinary Incontinence – Providing continence training (bladder
• Reflex Urinary Incontinence training, habit training, prompted
• Stress Urinary Incontinence voiding)
• Urge Urinary Incontinence – Pelvic muscle exercises
• Risk for Urge Urinary Incontinence – Maintaining skin integrity
• Urinary Retention – Applying external urinary drainage
Urinary Elimination May Become Etiology devices
• Risk for Infection • Managing urinary retention (flaccid bladder,
• Situational Low Self-Esteem Crede’s maneuver)
• Risk for Impaired Skin Integrity • Condom catheter preferred because less risk
• Toileting Self-Care Deficit of UTI
• Risk for Deficient Fluid Volume or Excess Catheterization and Infection
Fluid Volume • Insertion of urinary catheters is one of most
• Disturbed Body Image common causes of hospital-acquired
• Urinary Elimination May Become Etiology (nosocomial) infections
(cont'd) Implementing: Nursing Care for Clients with
• Deficient Knowledge Indwelling Catheters
• Risk for Caregiver Role Strain • Encourage large amounts of fluid intake
• Risk for Social Isolation • Provide foods that create acidic urine
Planning • Give routine perineal care; prevent
• Maintain or restore a normal voiding pattern contamination with feces in incontinent
• Regain normal urine output clients
• Prevent associated risks such as infection, • Change catheter and tubing when necessary
skin breakdown, fluid and electrolyte (sediment, impaired drainage)
imbalance, and lowered self-esteem • Maintain sterile closed-drainage system
• Perform toilet activities independently with • Remove catheter as soon as possible after
or without assistive devices purpose achieved
• Contain urine with the appropriate device, • Provide bladder retraining if needed
catheter, ostomy appliance, or absorbent • Follow good handwashing techniques
product Implementing: Ongoing Assessments of Clients with
Implementing Indwelling Catheters
5
• Ensure tubing is free of obstructions • Care includes
• Ensure there is no tension on catheter or – Regular assessment of urine, fluid
tubing intake, and comfort
• Ensure gravity drainage is maintained, with – Maintaining patent system
no loops in tubing below entry to drainage – Maintaining skin around site,
bag trimming pubic hair as needed
• Ensure system is well sealed or closed – Periodic clamping preparatory to
• Keep drainage receptacle below level of removal
client’s bladder Urinary Diversions
• Observe flow of urine q 2 - 3 hours • Incontinent
• Note color, odor, abnormal constituents – Ureterostomy
• If sediment is present, check more often – Nephrostomy
Implementing: Removing Indwelling Catheter – Vesicostomy
• Obtain receptacle for catheter; place client – Ileal conduit
in supine position; remove catheter-securing • Continent
device – Kock pouch
• Insert syringe into injection port and – Neobladder
withdraw fluid from balloon Implementing: Nursing Care for Clients with Urinary
• After all fluid removed, withdraw catheter Diversions
and place in receptacle • Assess intake and output
• Dry perineal area • Note any changes in urine color, odor, or
• Remove gloves clarity (mucus shreds are commonly seen in
• Measure and record amount of urine in urine of clients with ileal diversion)
drainage bag • Frequently assess condition of stoma and
• Document removal of catheter surrounding skin
• Provide urinal, commode, or collection device • Consult with wound ostomy continence nurse
• Monitor for first voiding and amount voided (WOCN) as needed
in first 8 hours; monitor I&O Evaluating
• Observe for dysfunctional voiding behaviors • Nurse collects data to evaluate the
Implementing: Teaching Clean Intermittent Self- effectiveness of nursing activities
Catheterization • If desired outcomes not achieved, explore
• Performed by clients with neurogenic bladder the reasons before modifying the care plan
dysfunction – Client perception and understanding,
• Clean or medical aseptic technique access to toilet, ability to manipulate
• Before teaching, establish clothing, Kegel exercises
– Client voiding pattern, volume – Review schedule for voiding, fluid
voided, fluid intake, residual amounts intake (including caffeine, etc.),
Implementing: Bladder Irrigations diuretics
• Bladder irrigation – Lighting, mobility aids, continence
– To wash out bladder aids
– To provide medication to bladder
lining
• Catheter irrigation
– To maintain or restore patency of
catheter
• Closed method preferred; open method
occasionally required but adds risk for
infection