Feca l E lim inat ion

• Physiology of Defecation
o Peristaltic waves move the feces into the sigmoid colon and the rectum
o Sensory nerves in rectum are stimulated
o Individual becomes aware of need to defecate
o Feces move into the anal canal when the internal and external sphincter relax
o External anal sphincter is relaxed voluntarily if timing is appropriate
o Expulsion of the feces assisted by contraction of the abdominal muscles and the diaphragm
o Moves the feces through the anal canal and expelled through anus
o Facilitated by thigh flexion and a sitting position

• Factors that influence fecal elimination

o Developmental stage
o Diet
o Fluid
o Activity
o Psychologic factors
o Defecation habits
o Medications
o Diagnostic procedures
o Anesthesia
o Surgery
o Pathologic conditions
o Pain
• Characteristics of Feces
o Color; brown (golden)
o Consistency
o Shape
o Amount
o Odor
o Constituents
• Selected fecal elimination problem
o Constipation
o Diarrhea
o Bowel incontinence
o Flatulence
• Constipation
o Decreased frequency of defecation
o Hard, dry, formed stool
o Straining at stools
o Painful defecation
o Causes include:
• Insufficient fiber and fluid intake
• Insufficient activity
• Irregular habits
• Fecal impaction
o Mass or collection of hardened feces in folds of rectum
o Passage of liquid fecal seepage and no normal stool
o Causes usually:
• Poor defecation habits
• Constipation
• Diarrhea
o Passage of liquid feces and increased frequency of defecation
o Spasmodic cramps, increased bowel sounds
o Fatigue, weakness, malaise, emaciation
 o Major causes:
• Stress, medication, allergies, intolerance of floor fluids, disease of colon
• Bowel incontinence
o Loss of voluntary ability to control fecal and gaseous discharges
o Generally associated with
• Impaired functioning of anal sphincter or nerve supply
• Neuromuscular diseases
• Spinal trauma
• Tumor
• Flatulence
o Excessive flatus in intestines
o Leads to stretching and inflation of intestines
o Can occur from variety of causes:
• Foods
• Abdominal surgery
• Narcotics
• Assessment of fecal elimination
o Nursing History
• Ascertains the client's normal pattern
• Description of usual feces
• Recent changes
• Past problems with elimination
• Presence of an ostomy
• Factors influencing elimination pattern
o Physical Examination
• Examination of the abdomen, rectum, and anus
• Auscultation precedes palpation because palpation alters peristalsis
• Inspection of feces for color, consistency, shape, amount, odor, abnormal constituents
• Review any data obtained from relevant diagnostic tests
o Review of data from any diagnostic tests
• Stool exam or fecalysis
• NANDA nursing Diagnosis
o Bowel incontinence
o Constipation
o Risk for constipation
o Perceived constipation
o Diarrhea
• Related Nursing Diagnosis
o Risk for deficient fluid volume
o Risk for impaired skin integrity
o Low self-esteem
o Disturbed body image
o Deficient knowledge (bowel training, ostomy management)
o Anxiety
• Desired outcomes
o Maintain or restore normal bowel elimination pattern
o Maintain or regain normal stool consistency
o Prevent associated risks such as fluid volume
• General nursing interventions
o Promoting reg. Defecation
o Teaching about medications
o Decreasing flatulence
o Administering enemas
• Measures to maintain normal fecal elimination pattern
o Privacy
o Timing
o Nutrition and fluids
o Exercise
o Positioning
• Common enema solution and actions
o Hypertonic (fleet phosphate)
• Draws water into colon
o Hypotonic (tap water)
• Distends the colon
• Stimulates peristalsis
• Softens feces
o Isotonic (physiologic saline)
• Distends the colon
• Stimulates peristalsis
• Soften feces
o Soapsuds (pure soap)
• Irritates mucosa
• Distends the colon
o Oil
• Lubricates feces and colonic mucosa
• Types of enemas
o Cleansing
• Prevent Escape of feces during surgery
• Prepare Intestines for certain diagnostic tests
• Removes feces in instances of constipation or impaction
o Carminative and return flow
• Used primarily to expel flatus
o Retention

• Stoma care for clients with an ostomy

o Normal stoma should appear red and may bleed slightly when touched
o Assess the peristomal skin for irritation each time the appliance is changed
o Treat any irritation or skin breakdown immediately
o Keep skin clean by washing off any excretion and drying thoroughly
o Protect skin, collect stool, and control odor with ostomy appliance

Ur inar y E li minat ion

• Process of urination
o Depends on the effective functioning of
• Upper Urinary Tract (kidneys, ureters)
• Lower Urinary Tract (bladder, urethra, pelvic floor)
• Cardiovascular system
• Nervous system
• Urine formation
o Proximal convoluted tubule
• Most of water and electrolytes are reabsorbed
o Loop of Henle
• Solutes such as glucose reabsorbed here
• Other substance secreted
o Distal convoluted tubule
 • Additional water and sodium reabsorbed here under control of hormones
o Formed urine then moves to:
• Calyces of the renal pelvis
• Ureters
• bladders
• Process of Micturition
o Urine collects in the bladder
o Pressure stimulates special stretch receptors in the bladder wall
o Stretch receptors transmit impulses to the spinal cord voiding reflex center
o Internal sphincter relaxes stimulating the urge to void
o If appropriate, the conscious portion of the brain relaxes the external urethral sphincter muscle
o Urine eliminated through the urethra
• Factors influencing urinary elimination
o Developmental factors
o Psychosocial factors
o Fluid and food intake
o Medication
o Muscle tone
o Pathologic conditions
o Surgical and diagnostic procedures
• Selected urinary problems
o Polyuria - urinates a lot of times
o Oliguria - urinates a bit, anuria - doesn't urinate at all
o Frequency or nocturia - urinating every night that disturbs sleeping
o Urgency - cant wait to urinate
o Dysuria - painful urination
o Enuresis - bed wetting
o Incontinence - urinated, can't control
o Retention - cant urinate, catheterize
o Neurogenic bladder
• Nursing assessment of urinary function
o Nursing History
• Normal voiding patterns - should urinate 2-4hours interval
• Appearance of urine
• Recent changes - in urine or in pattern
• Past or current problems
o Physical assessment
• Percussion of kidneys and bladder to detect tenderness
• Inspect urethral meatus for swelling, discharge, inflammation
• Skin color, texture, turgor, signs of irritation
• Edema
o Assessing urine
• Measuring urine output
• Measuring residual urine
• Diagnostic tests
 Blood urea nitrogen
 Creatinine
• Characteristics of normal urine
o 96% water and 4% solutes
o Organic solutes include urea, ammonia, creatinine, uric acid
o Inorganic solutes include sodium, chloride, potassium sulfate, magnesium, and phosphorus
• Characteristics of Urine
o Volume
 o Color, clarity
o Odor
o Sterility
o pH
o Specific gravity
o Glucose
o Ketone bodies
o Blood
• NANDA nursing diagnosis
o Impaired urinary elimination
o Functional urinary incontinence
o Reflex urinary incontinence - involuntary loss of urine
o Stress urinary incontinence - too much laughing may cause urge to urinate
o Total urinary incontinence - continuous and unpredictable passage
o Urge urinary incontinence
o Urinary retention
• Related nursing diagnosis
o Risk for infection
o Low self-esteem
o Risk for impaired skin integrity
o Self-care deficit
o Risk for deficient fluid volume or excess fluid volume
o Disturbed body image
o Deficient knowledge
o Risk for caregiver role strain
o Risk for social isolation
• Desired outcome
o Maintain or restore a normal voiding pattern
o Regain normal urine output
o Prevent associated risks such as infection, skin breakdown, fluid and electrolyte imbalance, and lowered self-esteem
o Perform toilet activities independently w/ or w/o assistive devices
o Contain urine w/ the appropriate device, catheter
• General nursing intervention
o Promote fluid intake
o Maintaining normal voiding pattern
o Assisting with toileting
o Preventing urinary tract infections
o Managing urinary incontinence
o Continence (bladder) training
o Pelvic muscle exercises
o Maintaining skin integrity
o Applying external urinary drainage devices
o Performing urinary catheterizations
o Performing bladder irrigations
• Preventing UTI
o Drink 8 glasses of water/day
o Practice frequent voiding (every 2-4 hours)
o Avoid use of harsh soaps, bubble bath, powder, or sprays in the perineal area
o Avoid tight fitting clothing
o Wear cotton rather than nylon undercloths
o Always wipe the perineal area from front to back following urination or defecation
o Take a shower rather than baths if recurrent UTI
• Nursing Care of client w/ an indwelling catheter
o Encourage large amounts of fluid intake
o Intake of foods that create acidic urine
o Perineal care
 o Change catheter and drainage system only when necessary
o Catheter only when necessary
o Maintain sterile closed-drainage system
o Remove catheter as soon as possible
o Follow good hand hygiene
o Prevent fecal contamination
• Interventions to maintain urinary flow through drainage system
o Ensure tubing free of obstructions
o Ensure tubing not clogged
o Ensure there is no tension on catheter or tubing
o Ensure gravity drainage maintained
o Ensure no loops in tubing below entry
o Keep drainage receptacle below level of client's bladder
o Ensure closed drainage system
o Observe flow of urine
o Input and output q2-3 hours
o Note color, odor and abnormal constituents
o If sediment present, check more frequently
• Nursing Care of Client w/ urinary diversion
o Assess I&O
o Note any changes in urine color, odor or clarity (mucous shreds are commonly seen in the urine of client with an ileal diversion)
o Frequent assess the condition of the stoma and the surrounding skin
o Consult with the wound ostomy continence nurse (WOCN)