Week 14 - Elimination

Treatment Options: BPH

"Watchful waiting" /Lifestyle changes Non-surgical treatment Drug therapy: ↓ size prostate or slow growth of prostate ◦Alpha blockers, such as doxazosin (Cardura) - relaxes smooth muscle ◦Androgen inhibitors such as finasteride (Proscar) - slower process Surgical treatment: TUNA or TURP Goals of treatment: improve urinary flow decrease symptoms delay or prevent progression of BPH

Transurethral Prostate Resection (TURP)

90% of all surgeries for BPH high-frequency electrical loop cuts tissue and seals blood vessels Continuous Bladder Irrigation (CBI) 1-3 days

Altered Structure and Function

Altered elimination: ◦Urinary retention ◦Loss of voluntary control of voiding Factors affecting the structure or function of the urinary system ◦Psychosocial factors ◦Food and fluid intake ◦Surgical and diagnostic procedures ◦Pathologic conditions (HTN, arteriosclerosis) Urinary tract infections •With the exception of developmental factors associated with age and pregnancy, altered urinary elimination is generally due to some degree of urinary retention or loss of voluntary control of voiding (ability to empty the bladder). •Psychosocial factors, food and fluid intake, surgical and diagnostic procedures, pathologic conditions such as hypertension and arteriosclerosis, and urinary tract infections (UTIs) all can affect the structure or function of the urinary system. •These factors alter the volume or characteristics of the urine produced or the effectiveness of excretion.

Anuria

Anuria, the failure of the kidneys to excrete urine, results from any process that limits effective blood flow through the kidneys. ◦Diagnosis of anuria is made when a catheter is passed into the bladder and no urine is present. ◦Inadequate flow or complete obstruction by anything (such as stones or tumors) that blocks both ureters and the bladder, or obstructs the urethra, can lead to an anuric state, resulting in acute or chronic renal failure. ◦Acute anuria is life threatening and requires emergent investigation to determine the cause. •As waste accumulates in acute anuria, the patient is at risk for coma or death.

Abnormal Urination Patterns

Anuria: failure to produce or excrete 50 to 100 mL of urine in 24 hours (•As waste accumulates in acute anuria, the patient is at risk for coma or death.) Oliguria: reduced volume: 100 to 400 mL in 24 hours Polyuria: excessive production and excretion of urine Nocturia: excessive urination at night Dysuria: painful urination Hematuria: blood in the urine Urinary incontinence = the inability to control urination Urinary retention: Inability to empty the bladder fullyAbnormal Urination Patterns •Abnormal patterns of urination fall into several categories related to failure of the kidneys to produce or excrete more than 50 to 100 mL of urine in 24 hours (anuria), a reduced volume of urine typically greater than 100 and less than 500 mL in 24 hours (oliguria), excessive production and excretion of urine (polyuria), excessive urination at night (nocturia), painful urination (dysuria), and blood in the urine (hematuria). •Urinary incontinence, the inability to control urination, is prevalent, particularly in women, and can greatly impact quality of life. Urinary retention is the inability to empty the bladder fully and is generally caused by an obstruction or neurologic disorder, enlarged prostate gland, or infection, among other factors.

Benign Prostatic Hyperplasia (BPH)

BPH is characterized by excessive cell growth of the prostate gland, a physiological change of aging. BPH cellular proliferation encroaches on the urethra and causes obstruction of flow of urine from the bladder.

bladder and urethra

Bladder and urethra ◦From the ureters, the urine flows slowly into the bladder, located below the umbilicus and above the symphysis pubis in the lower abdomen, for storage. ◦The bladder walls relax and expand to store urine, and contract and flatten to empty urine through the urethra. ◦Sphincter muscles at the base of the bladder help keep urine from leaking by closing tightly like a rubber band around the opening of the bladder. ◦The urethra transports urine from the bladder to outside the body for urine elimination and bladder emptying.

Laboratory Tests

Blood urea nitrogen (BUN) and creatinine- REVIEW ◦Blood levels of urea and creatinine are used to evaluate renal function. ◦Urea is the end product of protein metabolism and is measured as BUN. ◦BUN is a measure of the urea level in the blood. ◦Creatinine is a waste product that is produced in the blood as a byproduct of muscle metabolism. ◦The patient with kidney damage has decreased urinary creatinine but increased serum levels. BUN and creatinine are viewed in relationship to each other •Common laboratory tests to evaluate urinary function include measurement of blood urea nitrogen (BUN) and creatinine levels to determine kidney function, urinalysis, culture of urine to determine the cause of a UTI, and 24-hour urine collection to measure creatinine clearance. •Blood Urea Nitrogen and Creatinine •Urea is cleared by the kidney, and levels may be increased in the patient who is dehydrated or who has a disease that compromises the function of the kidney. •Normal values for BUN in the blood are 7 to 20 mg/dL. •Elevated levels may indicate kidney injury or disease as well as conditions such as diabetes, high blood pressure, blockage of the urinary tract, a high protein diet, severe burns, gastrointestinal bleeding, or conditions such as dehydration or heart failure, which impact blood flow. •Medications may also elevate BUN levels. Low BUN values may be caused by a low protein diet, malnutrition, liver damage, or drinking excessive amounts of liquids. No pretest preparation is required; however, medications, such as certain antibiotics, corticosteroids, and diuretics, may affect test results. •Creatinine is filtered along with other waste products from the blood by the kidney and eliminated in the urine. •It is made at a steady rate and is not affected by diet or by normal physical activities. •The amount of creatinine in the blood is directly related to muscle mass; generally men have higher creatinine levels than women. •Normal values of creatinine are 0.6 to 1.2 mg/dL for women and 0.8 to 1.4 mg/dL for men. •Sudden rises in BUN-to-creatinine ratios occur in acute kidney failure associated with shock, dehydration, or severe gastrointestinal bleeding. •Low BUN-to-creatinine ratios are seen in patients with low-protein diets, severe muscle injury, cirrhosis of the liver, or syndrome of inappropriate antidiuretic hormone (SIADH). Urinalysis ◦Assesses urine at a single point in time ◦Screens for UTI, kidney disease, other conditions •Urinalysis is an assessment of the urine at a single point in time. Urinalysis is a screening tool for UTI, kidney disease, and other conditions. •Single samples can be used to determine amounts of substances such as bacteria, glucose, white blood cells, red blood cells, or proteins. •Urinalysis samples are collected by having the patient void in a specimen cup, or samples may be taken via catheterization. Only small samples of urine (10-15 mL) are required for urinalysis testing. •Specific Gravity •Urinalysis for specific gravity monitors the balance of water and solutes (solid matter) in urine. •The higher the level of specific gravity, the more solid material is contained in the urine. •Fluid intake has a direct relationship to specific gravity. If large volumes of water are consumed, dilute urine is produced, which has a low specific gravity. Specific gravity associated with dehydration is high. • pH ◦pH: acid-base balance •The acid-base balance in the body is determined by pH, or the acidity or alkalinity of the urine. •Urine is normally slightly acidic, with an average pH of 6. Urine with a pH of 4 is very acidic. A pH of 7 is neutral, and a pH of 9 is very alkaline. •The pH is useful in determining the kidneys' response to acid-base imbalances. •In metabolic acidosis, the urine pH decreases as the kidneys excrete hydrogen ions; in metabolic alkalosis, pH of the urine increases. Maintaining a healthy pH helps prevent formation of kidney stones. • Urine for Protein ◦Protein: not normally in urine •Normally urine does not contain protein. Protein modules are generally too large to escape from the glomerulus capillaries into filtrate. •Protein in the urine may be associated with fever, hard exercise, pregnancy, and some diseases, such as kidney disease. •In conditions such as glomerulonephritis (inflammation of the glomerulus of the kidney), the membrane can become permeable and allow proteins to cross. •Glucose ◦Glucose: normal urine has little to no glucose Urine glucose is used to screen for diabetes and to assess glucose tolerance. •Glucose in the urine may be a sign of kidney damage or disease. Urine glucose levels are not an adequate measure of blood glucose levels. •In the uncontrolled diabetic patient, glucose may appear in the urine. •Ketones •The presence of ketones in the urine (ketonuria) indicates that fat has broken down for energy. Ketones are normally not passed in the urine. •Large amounts of ketones in the urine may indicate diabetic ketoacidosis. •A diet low in sugars and carbohydrates, prolonged fasting or starvation, and vomiting may cause ketone presence in the urine. •Microscopic Analysis ◦Urine is spun in a centrifuge and sediment settles at the bottom. The sediment is then spread on a slide and checked for RBCs or WBCs, casts, plugs, or crystals. •The presence of crystals in the urine may indicate that stones are present. Bacteria, yeast, and parasites are not normally present in urine and, when present, usually indicate infection. •UTI Suspicion •A leukocyte esterase test determines the level of white blood cells in the urine; elevated levels indicate presence of a UTI. UTI suspicion ◦Urine may be checked for nitrates. Nitrate levels elevate when bacteria are present. •Culture and Sensitivity •Urine culture and sensitivity tests are performed for diagnosis of a UTI. •If organisms grow in the culture, sensitivity testing is performed to determine the appropriate antibiotic for treatment. ◦Urine in the bladder is normally sterile; it does not contain bacteria or organisms. A 24-hour urine collection ◦Taken to determine the amount of creatinine cleared through the kidneys ◦Also used to measure levels of protein, hormones, minerals, and other chemical compounds in urine ◦Factors affecting accuracy ◦Not collecting part of the output ◦Continuing beyond 24 hours ◦Spilling the specimen ◦Inability to keep the specimen cool Ingestion of certain foods or medications. •Creatinine clearance, which measures how well creatinine is removed from the blood by the kidneys, provides information about kidney function. •Preparation is not required before initiating a 24-hour urine collection. •The time of the patient's first morning void is the best start time for the 24-hour specimen collection. •The first voided specimen is not saved; all urine produced after the first (discarded) specimen is saved in a special, opaque container and kept cool. •At the completion of the 24 hours, the first voided specimen of the second day (if the collection was started in the morning) is included in the specimen, and the container is transported to the laboratory for analysis. •Twenty-four-hour collections may be performed on an outpatient or inpatient basis. •

Urine Tests and Diagnostic Examinations

Blood urea nitrogen and creatinine Urinalysis: specific gravity, pH, protein, glucose, ketones, microscopic analysis Culture and sensitivity 24-hour urine collection Ultrasound Kidney, ureter, and bladder x-ray Intravenous pyelography Computed tomography Cystoscopy

collaboration and delegation

COLLABORATION AND DELEGATION •The patient with bowel elimination problems benefits from a multidisciplinary approach to care. •Patients who are about to undergo ostomy surgery and patients with new ostomy placement should have a consultation with a wound ostomy continence nurse, who is certified as an expert in the care of patients with wounds, ostomies, and incontinence. •Nutrition counseling helps in planning a diet to manage elimination issues. •Mental health professionals are consulted if issues such as anxiety and depression are affecting the patient's elimination patterns. •The primary care provider is consulted for prescriptions and diagnostic evaluation. •A patient with an ostomy in place learns self-care, and it is crucial that this is begun in the acute care settings. •Self-esteem and a positive body image are important to promote in an ostomy patient, and emotional support is needed preoperatively and postoperatively. •[Review the Collaboration and Delegation box.p 1061] •

The Most Common Renal Calculi Are:

Calcium stones Struvite (magnesium ammonium phosphate) uric acid stones Cystine stones Seventy-five percent of renal calculi consist of calcium; most are composed of calcium oxalate. According to one of the theories of formation of renal calculi, calcium phosphate, a normal compound from breakdown of bone, deposits onto an area of tubule cell membranes in the renal papilla, which is an area of kidney that empties into the minor calyx. The calcium phosphate compound collects layers of collagenous material and cellular debris. At this point, it is known as a Randall plaque. The Randall plaque is located within the subepithelial membrane. The plaque collects layers of crystalline elements and becomes a calculus. The calculus erodes through the urothelium of the renal pelvis to enter the ureter.

chyme, peristalsis

Chyme is thick fluid mass of partially digested food and gastric secretions that is passed from the stomach to the small intestine. Peristalsis is the wave of progressive contraction and relaxation of the walls of the intestine. This forces chyme into the large intestine through the ileocecal valve, which prevents regurgitation of chyme.

colonoscopy

Colonoscopy: Performed to visualize inflamed tissue, ulcers, and abnormal growths in the anus, rectum, and colon. ◦During the procedure, growths (polyps) or abnormal tissues may be removed (biopsy) and tested for cancer. •Diagnostic tests provide information about alterations in a patient's status that may not have been seen in lab test. •An upper GI series (barium swallow) is a radiologic test that defines the anatomy of the upper digestive tract to visualize the esophagus, stomach, and duodenum. •The lower GI series, also known as a barium enema, is comprised of x-rays of the rectum, colon, and the lower portion of the small intestine to assist in diagnosis of abnormal growths, ulcers, polyps, diverticuli, and colon cancer. •An esophagoscopy is an endoscopic procedure to view the inside of the esophagus. •A gastroscopy is a procedure to view the inside of the stomach. •A colonoscopy is used to look for early signs of colorectal cancer and to diagnose unexplained changes in bowel habits, abdominal pain, bleeding from the anus, and weight loss. •Biopsy of polyps or abnormal tissues and the treatments to stop bleeding are usually painless.

Assessment of Urine

Color: Range is pale yellow to amber ◦Food ◦Medication ◦Pathologic conditions Clarity: normally clear Odor: not very strong Amount: depends on fluid intake, dehydration, retention •Normal urine color ranges from pale yellow to amber. •Common causes of urine discoloration are medications, vitamins (such as vitamin B), food (such as asparagus or elderberries), and food dyes. Urine color may be altered by certain health problems. •Concentrated urine is darker in color (deep amber) and may result from dehydration, low fluid intake, or reduced urine production. Dilute urine ranges in color from clear to pale straw and results from excessive fluid intake or the inability of the kidneys to concentrate urine. •Red or pink urine may be associated with bleeding, strenuous exercise, urinary tract infection, enlarged prostate, kidney or bladder stones, kidney disease, or cancer. •Foods such as beets, blackberries, and rhubarb may discolor the urine pink or red; carrots and carrot juice may turn it orange. Brown or tea-colored urine is associated with consumption of fava beans and aloe. Asparagus consumption may result in blue-green urine. •Certain medications can affect the color of urine. Those including antimalarial drugs, laxatives, and metronidazole may cause the urine to turn brown or tea colored. Rifampin, warfarin, and phenazopyridine may turn the urine orange. Blue-green urine can be seen in patients receiving medications such as cimetidine, indomethacin, or promethazine. •Patients with hypercalcemia may have blue-green urine. Those with liver failure from hepatitis and cirrhosis may have brown to tea-colored urine. Dehydration can cause urine to range anywhere between dark yellow orange to tea color. •Urine is normally clear. Cloudy urine is indicative of bacteria, blood, sperm, crystals, or mucus. •Following bladder or kidney surgery, patients may excrete bloody urine containing clots. •These patients typically require irrigation of the bladder via a three-way catheter to prevent potential blockage. •Most urine does not smell very strong. Dehydration may increase the odor of urine as more waste is excreted in smaller volume. •Some diseases and foods cause a change in the odor of urine. •For example, uncontrolled diabetes can cause a sweet fruity odor, whereas infections can cause a vile odor. •The amount of urine that a patient eliminates can vary, depending on factors such as fluid intake, dehydration, and retention. •The normal urinary output is approximately equal to fluid intake. •Adult urinary output of approximately 60 mL/hr is considered normal. •Output of less than 30 mL/hr may indicate decreased renal perfusion and should be reported to the patient's PCP immediately.

NURSING DIAGNOSES FOR ISSUES RELATED TO BOWEL ELIMINATION

Constipation related to pain medication use, decreased fluid intake, and decreased mobility as evidenced by no stools for a few days, hypoactive bowel sounds, and a firm, tender abdomen. Diarrhea related to malabsorption as evidenced by bloating, cramping, and loose liquid stools. Bowel incontinence related to sphincter dysfunction as evidenced by constant dribbling of soft and liquid feces, inability to recognize the urge to defecate, and fecal staining of underclothing. Self-care deficit: Toileting related to impaired mobility as evidenced by need for assist of one for toileting and restriction of bedrest. Disturbed body image related to bowel diversion as evidenced by refusal to discuss descending colostomy and disinterest in learning about care of ostomy. •Upon completion of the nursing assessment of a patient's bowel function, data obtained may reveal a risk for, or actual, elimination problem. •Accurate assessment is crucial to identify defining characteristics of impaired elimination. •To determine the appropriate nursing diagnoses for the patient, the nurse clusters the data. •[Review the nursing diagnoses for issues related to bowel elimination.] •In addition, the patient may exhibit Risk for constipation or perceived constipation. Although not directly related to elimination, the patient with bowel elimination issues may have associated nursing diagnoses such as Risk for impaired skin integrity, Fluid volume deficit, and Pain

Abn bowel (continued)

Constipation: Infrequent or difficult bowel movements; fewer than three bowel movements per week. •Constipation is a common problem affecting the quality of life of many individuals. •Slowed intestinal peristalsis and infrequent bowel movements result in increased water absorption in the colon, leading to difficulty passing stool, excessive straining at defecation, the inability to defecate at will, hard feces, and rectal pain. •[some of the causes of constipation are irregular bowel habits, ignoring the urge to defecate, a diet low in fiber or high in animal fats, hemorrhoids, and low fluid intake.] •Straining during defecation can induce elevations in intraocular pressure, increased intracranial pressure, changes in the cardiac rhythms, and hemorrhoids. Valsalva maneuver: Occurs when a person's breath is held while bearing down •The Valsalva maneuver causes an extremely rapid rise in blood pressure, which is followed by a fall in arterial blood pressure. Impaction: Hard fecal mass in the rectum or colon that the patient is incapable of expelling. Impaction is the result of unresolved constipation. •Over time stool becomes wedged in the rectum, and the patient is unable to pass it. Flatulence: Production of a mixture of gases in the intestine; byproducts of digestion. In flatulence, a mixture of gases, known as flatus, is expelled from the mouth (belching) or the anus (passing of flatus). •Severe flatulence contributes to abdominal distention and severe sharp pain.

factors affecting urinary elimination

Developmental factors ◦Individual control of urination changes with age. •The infant has no urinary control, and the young child will not gain control until between ages 2 and 5 years. •Preschoolers may have the ability for independent toileting; however, accidents may occur, and enuresis may be an issue until approximately age 5 years. •By school age, the child's elimination patterns should be well established. •Nocturnal enuresis (bedwetting) is commonly seen in children until full bladder control is established and should not be considered a problem until after age 6 years. ◦Elderly patients are at risk for elimination problems secondary to age-related decreased function of the kidneys. •In the elderly, urgency and frequency are often reported as the muscles supporting the bladder weaken. •Retention of urine may lead to nocturia. •Prostate enlargement that causes narrowing of the urethra may impair the ability of male patients to completely empty the bladder. •Residual urine may predispose the elderly patient to bladder infections. Psychosocial factors ◦Many people consider urination to be a private matter and have established behaviors or habits that are associated with voiding. ◦Patients may voluntarily suppress the urge to void secondary to other circumstances. •Alterations in the patient's elimination patterns produce anxiety and contribute to an inability to relax the muscles necessary to initiate voiding. •Patients may voluntarily suppress the urge to void secondary to other circumstances, such as unavailability of toileting facilities. •These behaviors have been shown to increase the risk of incontinence and urinary tract infection. Food and fluid intake ◦Changes in a patient's eating or drinking pattern can disrupt normal urination. •Dehydration may lead to diminished urinary output. Excessive fluid intake may change color, odor, or quantity of urine produced. •Dietary changes, such as the intake of different food, can cause changes in the color or odor of the urine. •Medication ◦Medication may alter the production, formation, concentration, clarity, and color of urine. •Medications that affect the autonomic nervous system interfere with the urination process and cause urinary retention. •Blood pressure medications, specifically diuretics, change the ratio of water and electrolyte reabsorption within the kidneys and alter the concentration of urine. Muscle tone ◦Muscle tone plays a direct role in filling and emptying of the bladder. •Poor muscle tone affects the ability of the bladder to contract and expand completely. •Changes in the muscle tone of the pelvic floor can alter sphincter control, causing urine leakage. Surgical and diagnostic procedures ◦Surgical and diagnostic procedures alter the formation, concentration, color, and passage of urine. •Ability to pass urine is affected by swelling. •Postoperative bleeding transforms the color and quantity of the urine. •Anesthesia contributes to urine retention by decreasing awareness of the need to void. Pathologic conditions ◦Diseases of the kidneys reduce the production of urine. ◦Heart and circulatory disorders diminish blood flow to the kidneys and affect urine production. ◦Calculi may obstruct the ureter, blocking the flow of urine. •Dehydration causes water retention, resulting in decreased urinary output. •Some pathologic conditions can result in bladder removal. If so, urine will need to be diverted in order to exit the body. Urinary tract infections (UTIs) are the result of bacteria in the urine. UTI is the single most common hospital-acquired infection. ◦Females are more vulnerable than males, with the rate of occurrence gradually increasing with age. Why?? ◦People with an elevated risk for infection include those with any abnormality of the urinary tract that obstructs the flow of urine, those with catheters in place, those who have difficulty voiding, and the elderly with bladder control loss.

evaluation of goals and outcomes

Evaluation of the goals and outcomes for the patient with bowel elimination problems is important to achieve the desired outcomes. Whether the goals include a return to normal bowel function or maintaining existing function within the parameters of the patient's condition, it is important for the nurse to determine whether they have been met, and if not, why. •After an evaluation, if it is determined that the patient's goals have not been met, the nurse reviews the plan of care and considers revising interventions related to bowel elimination. •The patient's current food and fluid intake, medication use, activity level, and knowledge is reviewed to determine the effects on gastrointestinal function. •It is important to include the patient in the planning stage during changes in the plan of care. •The interim steps may need to be reevaluated and readjusted continuously.

xAssessment: Abdominal Examination

Explain the exam to the patient. Inspection Auscultation Percussion and palpation •After explaining to the patient what to expect during the abdominal assessment, the nurse should assess the general appearance of the abdomen for dry skin to help determine hydration status, and masses, indentations, and scars. •Inspect for color, contour, symmetry, and distension while the patient is in a supine position. •Normally, the abdomen is not distended, is symmetric and free of bruises, masses, and swelling. •A distended bladder may be visible in the suprapubic area. A bladder scan [figure on slide] can be conducted by the nurse with handheld ultrasound equipment to quickly determine the extent of urinary retention. •Abdominal distension may be seen in conditions such as polycystic kidney disease, pyelonephritis, ascites, and pregnancy. •Auscultate the left and right renal arteries to assess circulation sounds. Normally no sounds are heard. •Percussion and Palpation •Assessment by a PCP may include blunt or indirect percussion to further assess the kidneys. •The patient should feel no pain or tenderness with pressure or percussion. •Pain or discomfort during or after percussion is suggestive of kidney disease. •Percussion of the bladder determines location and degree of fullness. •Palpation of the bladder is conducted to determine symmetry, location, size, and sensation. •Light palpation should be performed over the lower abdomen. The abdomen should be soft and nondistended. •Deep palpation which can be done to outline the shape of the bladder is usually completed by the patient's primary care provider (PCP). •Using a bimanual technique, the PCP will attempt to palpate the kidneys, which are rarely palpable unless they are enlarged due to tumors, cysts, or hydronephrosis. •An enlarged palpable kidney could be painful for the patient.

fecal occult blood test

Fecal occult blood test: Measures for microscopic amounts of blood in the feces and can be a sign of a growth in the colon or rectum •Testing for the presence of blood in the feces is performed utilizing a fecal occult blood test. •[Refer to Skill 34-3, Stool Specimen Collection.] •[Review auscultation, palpation, and stool culture ordering.]

EVIDENCE-BASED PRACTICE Fiber and Bowel Health

Fiber in the diet has many benefits, including: •Normalization of bowel movements •Maintenance of bowel integrity and health •Lowering blood cholesterol levels •Helping control blood sugar levels •Aiding weight loss •Potentially helping to prevent colorectal cancer. •The nurse can help patients achieve regular bowel elimination by performing or assisting the client with techniques and habits that promote regular elimination. •Nursing measures to aid in bowel elimination include interventions for diarrhea, constipation, impaction, and incontinence, as well as those for patients with bowel diversions. •After assessing the pattern of the patient's elimination and determining the patient's perception of normal bowel elimination, encourage the establishment of a regular elimination pattern. •Every patient with elimination problems is weighed daily as an important indicator of fluid balance in the body. •Dementia, acute confusion, and mental retardation are risk factors for fecal incontinence; therefore, mental status is monitored closely. •Nurses should wash their hands frequently to greatly reduce the risk of diarrhea from a foodborne or communicable illness. •In general, a diet of high-fiber foods, with adequate fluid intake, is encouraged, although this diet may not be sufficient for the patient with alterations to normal elimination patterns. •[Review the Evidence-Based Practice box. p1057] •[Refer to Chapter 30, Nutrition, for more information on a high-fiber diet.]. •Encourage the patient to be out of bed as soon as possible after surgery or illnesses. •Exercises such as turning and changing positions in bed and passive or active range of motion exercises increase peristalsis and help prevent constipation. •Aerobic exercise raises respiratory and heart rates, which stimulates contraction of intestinal muscles. •Walking 10 to 15 minutes per day has been shown to increase digestive function. •The nurse assists patients in healthcare facilities achieve regular defecation by providing privacy and assisting in establishing a regular pattern of elimination. •Patients who are unable to walk to the bathroom or who are restricted to bed secondary to procedures, illness, injury, or surgery require the use of the bedpan for elimination. •[Review the Nursing Care Guideline for assisting a patient using a bedpan. ] •The bedside commode is a portable chair with a toilet seat and a receptacle beneath that can be emptied. •[Refer to Figure 40-7.] •It is used most often with adult patients who can get out of bed but have difficulty with ambulation. •Safety is a consideration when moving the patient to the commode.

BPH Signs and Symptoms

Frequency of urination Voids only small amounts of urine Urgency to urinate Incomplete emptying of the bladder Hesitancy of urination Decreased urine stream Susceptibility to lower urinary tract infection because of retained urine in the bladder, which provides a medium for bacterial growth.

Health Assessment Questions (Cont.)

Have you ever been diagnosed with kidney or bladder disease? Have you ever had surgery or trauma to the urinary system? Have you ever had a urinary tract or kidney infection? Do you have a family history of kidney disease or urinary problems? Do you have any physical problems that may affect the urinary tract, such as high blood pressure, diabetes, kidney stones, multiple sclerosis, Parkinson's disease, spinal cord injury, or stroke? If so, have you noticed or experienced any problems with urinary retention? Have you experienced changes in your normal urination pattern? If so, have they caused you embarrassment or anxiety, and for how long? Are you able to control when you urinate? Do you ever have to get up at night to urinate? Do you have difficulty starting or stopping your flow of urine?

hemorrhoids

Hemorrhoids are swollen and inflamed veins in the anus or lower rectum.

health assessment questions

History Have you ever been diagnosed with an abdominal disease such as cholecystitis, ulcers, diverticulitis, cholelithiasis, or cirrhosis? General Questions Have you experienced changes in diet or appetite recently? Describe your daily diet and fluid intake. Describe your bowel habits. Pregnant Patient Do you suffer from constipation, heartburn, or flatulence? Are you experiencing nausea and vomiting? Older Adult Do you experience constipation? If so how often? Are you ever incontinent of feces? Do you take laxatives? Which one? How often? •Gathering subjective and objective data for assessment of bowel elimination allows the nurse to identify patterns and abnormalities. •The assessment of the GI system includes: •A focused interview, including past and present health history; physical inspection of the abdomen; inspection of the feces; a focused diet history including chewing difficulties; medications; illnesses; and food intolerance. •While performing the bowel elimination assessment, the nurse considers the patient's physical, mental, and functional abilities, as well as the patient's environment and family and social support. •[Review the Health Assessment Questions box, which includes questions such as those shown on the slide p1053.]

Promoting Normal Urinary Patterns in a Health Care Facility

In the health care facility, there are often conflicts with a person's normal routine. Proper integration of the patient's habits into daily care will aid in preventing elimination issues. Safe Practice Alert! ◦Medications such as diuretics may cause frequency or urgency, potentially compromising patient safety risk. Instruct patients who are on falls precautions to ask for assistance prior to ambulation for toileting. •Generally, every patient in a health care facility experiences an alteration in the pattern of elimination. •Many people follow routines to promote voiding. For example, bed rest, medication use, prescribed medical therapies, and privacy issues can alter the patient's pattern.

Normal Structure and Function of the Urinary System - Kidneys

Kidneys ◦Major excretory organs of the body ◦Filter liquid waste from the blood ◦Balance salts and electrolytes in the blood ◦Regulate blood volume and pressure ◦Produce erythropoietin for red blood cell (RBC) formation ◦Synthesize vitamin D to help with calcium levels Maintains acid-base balance of extracellular fluid •The kidneys are the major excretory organs of the body. The two kidneys are located bilaterally below the ribs toward the middle of the back. •They filter liquid waste from the blood, balance salts and electrolytes in the blood, regulate blood volume and pressure, produce erythropoietin for RBC formation, synthesize vitamin D to help control calcium levels, and maintain the acid-base balance of the extracellular fluid.

Difference in the systems of elimination

Kidneys responsible for metabolic waste and other blood elements in the form of urine. GI tract responsible for digestive waste in the form of stool/feces

Nephrolithiasis

Nephrolithiasis is the formation of stones, also called calculi, in the kidney. Stones can travel down the ureter or bladder. Genetic susceptibility Dehydration Hypercalcemia; excessive calcium intake Hyperparathyroidism Gout Hyperuricemia Urinary tract infection; proteus Immobility

Oliguria

Oliguria is defined as reduced urine volume: ◦Less then 1mL/kg/h in an infant; ◦Less than 0.5 mL/kg/h in children ◦Less than 400 mL/day in adults A symptom of acute or chronic renal failure Revealed by monitoring urinary output Classified ◦Prerenal from reduced blood flow to kidneys ◦Renal from actual renal damage ◦Postrenal failure from obstruction of urine flow •Oliguria is a symptom of acute or chronic renal failure; it is classified as prerenal, renal, or postrenal failure. •Prerenal failure occurs as a result of reduction in blood flow to the kidneys. •Causes of prerenal failure include dehydration, vascular collapse and low cardiac output. •Renal failure is seen in patients with actual renal damage. •Structural issues with the kidneys, from primary glomerular diseases or vascular lesions, result in renal failure. •Postrenal failure is related to a mechanical or functional obstruction of the flow of urine. •Oliguria is most easily observed by the nurse through frequent monitoring of a patient's urinary output. •Signs and symptoms of oliguria vary according to the causes. •The patient may be breathless, pale, clammy, and cool with a low blood pressure; there may be signs of edema or anemia; changes in the heart rhythm, hepatomegaly, and hypertension may be present. •The management of oliguria includes treatment of any reversible causes. •If the intravascular volume is low, fluids should be administered for restoration. •Fluid balance should be monitored and maintained with electrolyte monitoring and correction. •Input and output should be recorded, along with daily weights. •Potassium retention is common in renal failure. •Potassium levels need to be monitored, and dialysis should start when serum potassium exceeds 6.5 meQ/L. •Potassium intake should be limited until urine flow is reestablished. •Dialysis may be required until the kidneys recover. •The overall goal of dialysis is to remove toxins and to maintain the fluid, electrolyte, and acid-base balance.

Factors Affecting Urinary Elimination

Pathologic and surgical conditions Privacy issues and embarrassment Medications Food and fluid intake Ambulatory ability Muscle tone The cause of enuresis, the involuntary passing of urine, may be structural or pathologic, although it may be related to nonurinary problems such as constipation, stress, and illness. •A person's ability to urinate is influenced by a variety of factors. •Pathologic and surgical conditions may affect the process of urination temporarily or permanently. •Factors ranging from privacy issues and embarrassment, to medications, food, fluid intake, ambulatory ability, and muscle tone influence the frequency of voiding, the amount of urine produced, the color and other characteristics of the urine, the time of voiding, and voluntary control over actual urination.

home care considerations for ostomy

Patient education in colostomy and ileostomy care: Family and significant others are included in ostomy teaching since this may facilitate the patient's readiness to learn. If the patient is apprehensive about touching or looking at the stoma, start slowly and encourage the patient's participation in care. Patients are given a teaching manual with step-by-step instructions, complete with illustrations, and supplemented with DVDs and access to websites. Evaluate the patient's home toileting facilities; note the location and availability. If the patient consumes gas-producing foods, it may be necessary to manually expel (belch) trapped air from the bag. In a private setting, the patient can undo the clasp on the flap of the bag and allow the air to be released from the bag. •A stoma may cause disturbed body image, especially if it is permanent. •Patients may perceive a stoma as invasive and disfiguring. •Patients should begin to assist the WOCN in caring for the ostomy as soon as possible. •Involvement in this process helps the patient build confidence and regain control. •Refer patients to colostomy support groups such as the United Ostomy Association or the National Foundation for Ileitis and Colitis.

How Does Hyperuricemia Occur?

Purines à breakdown into uric acid. Purines are derived from the DNA of animal cells or cancer cells. High purine levels in the bloodstream occur with high ingestion of meats or whenever there is high cellular breakdown as in chemotherapy treatment of malignancy. Also, high uric acid can be caused by gout, which is a metabolic disorder.

implementation and evaluation (continued)

Rectal suppository: Drug delivery system inserted into the rectum, where it dissolves for medication absorption by coming into contact with the rectal mucosa Enema: The introduction of solutions into the rectum and sigmoid colon via the anus ◦Cleansing enemas ◦Hypertonic ◦Isotonic ◦Oil retention enemas ◦Medication enemas ◦Carminative enemas ◦Return-flow enemas •Early ambulation after surgery or an illness stimulates peristalsis and helps maintain function. •For the patient experiencing bowel elimination problems, a return to previous level of function is the optimal goal. •In order to achieve that goal, additional assistance may be needed in the form of bowel training programs, elimination schedules, and medications. •Antidiarrheal medications are used to slow the motility of the intestine or promote the absorption of excess fluid in the intestine. •Cathartics and laxatives may be prescribed when a patient is unable to empty the bowel normally. •Laxative suppositories are more effective than their oral counterparts because of their stimulant effect on the rectal mucosa. •The nurse ensures that the rectal suppository is placed next to the mucosa and not in stool that is in the rectum. •Laxative suppositories work to soften the stool and distend the rectum. •[Refer to the Nursing Care Guideline: Medication Administration: Rectal, in Chapter 35, Medication Administration chapter, for more information on rectal suppository administration.] •With enemas, the increase in the volume of fluid rapidly distends the colon and irritates the intestinal mucosa lining, stimulating complete evacuation of the lower intestinal tract. •Common uses of enemas include relief of constipation, removal of impacted feces, emptying of the bowel prior to diagnostic tests or surgery, and beginning a program of bowel training. •Several types of enema solutions are used today. •[Review Table 40-2, Types of Enemas, for more specific information; see next slide.] •[Review Skill 40-1: Administering an Enema.]

Symptoms of Nephrolithiasis

Severe abdominal pain, flank pain around to groin; colicky pain caused by ureter spasms Hematuria Crystalluria Radiating pain down left side and into groin

ADPIE

Sharing evaluation findings with patients helps them recognize goal achievement and move closer to healthy urinary elimination patterns regardless of previous challenges. Prevention of kidney disease, urinary tract infections, and secondary complications such as skin breakdown related to incontinence is ongoing, whether the patient is in a health care facility or at home.

Complication of Nephrolithiasis Infection or Hydronephrosis

Stone can cause back pressure into the renal pelvis, a condition called hydronephrosis. Hydronephrosis occurs when edema and distention of the renal pelvis occurs. Prolonged hydronephrosis causes compression of the kidney tissue, ischemia, and irreversible kidney damage.

Treatment of Nephrolithiasis

Strain urine to catch stone Save stone for analysis High fluid intake to flush out stone of greater than 3 liters/day. Lithotripsy Surgery if no relief Dietary changes to keep urine acidic or alkaline, depending on stone composition

different kinds of incontinence

Stress incontinence: happens when physical movement or activity — such as coughing, laughing, sneezing, running or heavy lifting — puts pressure (stress) on your bladder, causing you to leak urine. Sphincter muscle that you keep closed, if you have intra-abd pressure, will put pressure on the sphincter and cause leakage Urge incontinence: occurs when you have a sudden urge to urinate. In urge incontinence, the urinary bladder contracts when it shouldn't, causing some urine to leak through the sphincter muscles holding the bladder closed. Overactive bladder: frequent and sudden urge to urinate that may be difficult to control. You may feel like you need to pass urine many times during the day and night, and may also experience unintentional loss of urine Functional incontinence: also known as disability associated urinary incontinence. It occurs when the person's bladder and/or bowel is working normally but they are unable to access the toilet. This may be due to a physical or a cognitive condition Mixed incontinence: typically a combination of stress and urge incontinence, it shares symptoms of both. You may have mixed incontinence if you experience the following symptoms: Urine leakage when you sneeze, cough, laugh, do jarring exercise, or lift something heavy Transient incontinence: refers to continence issues that can and do resolve when the condition that's causing it heals or is cured. What conditions cause Transient Incontinence? A weakened pelvic floor muscle. If you're able to exercise and strengthen the muscle then you will be able to regain control.

Kidney Stones

Struvite stones commonly cause staghorn calculi, which can fill the entire renal pelvis. They are often caused by proteus infection.

BPH Surgeries

Surgical treatment of BPH involves transurethral needle ablation (TUNA) or transurethral resection of the prostate (TURP). In both of these procedures, the obstructive prostatic tissue is excised so that the urethra can allow free flow of urine.

Nursing Process: ADPIE (Implementation and Evaluation)

The focus of each goal is directly related to the identified nursing diagnosis, which in turn determines what interventions are most appropriate for each patient. The nurse must focus on activities that will help the patient with compromised urinary elimination return to the normal state of function or to adapt to changes in the state of function. Ongoing assessment and follow-up are needed to assure quality in the care provided and to determine need for further nursing interventions. •The implementation phase of the nursing process involves interventions that assist the patient in achieving the goals, including, but not limited to, continence, complete emptying of the bladder, and self-care in toileting. •Nursing interventions to help patients achieve urinary continence and complete emptying of the bladder and independent toileting include promoting adequate fluid intake, teaching self-care activities, and assisting with voiding. •Collaborative interventions require the assistance of the PCP or other professionals, such as a physical therapist or nutritionist.

Prostate Gland

The prostate is a gland that sits below the urinary bladder and encircles the urethra. The prostate secretes an alkaline fluid that combines with seminal fluid to form the semen that promotes sperm motility. In addition, the prostate secretes prostate surface antigen (PSA), which can be used in the assessment of prostatic structure and function. The prostate gland naturally enlarges with age.

BPH Medication

The two primary drug classes used for BPH are alpha-blockers and 5-alpha-reductase inhibitors. Alpha-blocker drugs relax smooth muscles, especially in the bladder neck and prostate. Alpha-blockers help relieve BPH symptoms, but they do not reduce the size of the prostate. They can help improve urine flow and reduce the risk of bladder obstruction. A typical alpha-blocker is tamsulosin (FlomaxR). The 5-alpha-reductase (androgen) inhibitors are drugs that block the conversion of testosterone to dihydrotestosterone, the male hormone that stimulates the prostate. In addition to relieving symptoms, they increase urinary flow and help shrink the prostate. Patients have to take these drugs for up to 6 to 12 months to achieve full benefits. Finasteride (ProscarR) is an example of a 5-alpha-reductase inhibitor. The 5-alpha-reductase inhibitor drugs decrease PSA levels, which may mask the presence of prostate cancer. Women should not handle finasteride tablets when they are or may potentially be pregnant.

Normal Structure and Function of the Urinary System

The urinary system is responsible for absorption of nutrients and fluids from the body's intake. It controls the composition of blood by removing waste products known as urea and conserving useful substances. ◦Urea is produced when protein-rich foods are digested. The urinary system helps to control blood pressure and plays a crucial role in acid-base balance

Benign Prostatic Hyperplasia (BPH)

To physically assess the patient for BPH, the clinician performs a digital rectal examination (DRE). The posterior wall of the prostate can be palpated through the anterior wall of the rectal vault. On physical examination, the hyperplastic prostate is enlarged, smooth, firm, and nontender. A PSA blood test should be done to rule out prostate cancer. However, a diagnosis of prostate cancer cannot be based solely on PSA testing because the test has a high false positive rate. At age 50, men should begin having yearly examinations for BPH and prostate cancer, which include DRE and PSA testing.

ureters

Ureters ◦After exiting the kidneys, urine is carried to the bladder via narrow tubes called the ureters. ◦The ureter wall muscles continually tighten and relax, forcing urine downward. ◦If urine is retained in the kidney or backflows from the bladder toward the kidneys, the patient becomes susceptible to kidney infections.

Urinary retention

Urinary retention is the inability of the bladder to empty. It is caused by an obstruction in the urinary tract or by a neurologic disorder. Characteristics: ◦Difficulty starting a stream or emptying the bladder ◦Weak urine flow ◦Chronic or acute pain ◦Chronic = mild but constant discomfort •The patient with chronic urinary retention has difficulty starting a stream of urine or emptying the bladder. •When started, the urine flow is weak. •Chronic urinary retention causes mild but constant discomfort. ◦Acute = medical emergency •During episodes of acute urinary retention, the patient will be unable to urinate despite a full bladder. •A patient may express the need to urinate frequently and when finished still feel urge. •Dribbling may occur between trips to bathroom because the bladder is constantly full. •Acute urinary retention is a medical emergency requiring prompt action. •Conditions that contribute to urinary retention include vaginal childbirth; infections of the brain or spinal cord; diabetes; stroke; neurologic disorders; heavy metal poisoning; pelvic injury or trauma; prostate enlargement; infection; surgery; medications such as antihistamines, anticholenergics, antispasmodics, and tricyclic antidepressants; bladder stones; rectocele; cystocele; constipation; or stricture.

Urinary tract infections

Urinary tract infections (UTIs) are the result of bacteria in the urine. UTI is the single most common hospital-acquired infection. ◦Females are more vulnerable than males, with the rate of occurrence gradually increasing with age. Why?? ◦People with an elevated risk for infection include those with any abnormality of the urinary tract that obstructs the flow of urine, those with catheters in place, those who have difficulty voiding, and the elderly with bladder control loss. •Infection occurs when bacteria, usually Escherichia coli, from the digestive tract invade the urethra and multiply. •UTI results in more than 1 million hospital admissions per year in the United States alone. •UTI can occur in anyone. Up to 30% of women experience a symptomatic UTI in their lifetime. •The rate for women is believed to be elevated because the female urethra is significantly shorter than that of the male and is located near sources of bacteria from the anus and vagina. The shorter urethra also contributes to the risk of infection associated with sexual intercourse. •Diabetes or other diseases that suppress the immune system increase the risk of UTI.

urine formation

Urine is formed by tiny filtering units called nephrons, which are the functional unit of the kidney. ◦Each nephron consists of the renal corpuscle and a small tube called the renal tubule. ◦The renal corpuscle is comprised of a network of blood capillaries called the glomerulus, which is surrounded by Bowman capsule. ◦The renal tubule is comprised of the proximal tubule, the loop of Henle, and the distal convoluted tubule. Filtration initially occurs in the glomerulus as fluid moves across a membrane as the result of a pressure difference. Reabsorption occurs in the renal tubule as most of the filtrate moves back into the blood. At this point waste products, excess solutes, and small amounts of water are not reabsorbed but are secreted. As secretion takes place, urine is produced. Urea, water, and other waste substances form urine as they pass through the nephrons down the renal tubules.

loop colostomy

Usually performed in a medical emergency. Temporary large stomas constructed in the transverse colon. Surgeon pulls a loop of bowl onto the abdomen supported by a device such a a plastic rod, bridge, or rubber catheter temporarily placed under the bowel loop to keep it from slipping back. Two openings: proximal end drains stool, whereas the distal portion drains mucus. Within 7 to 10 days the surgeon removes the external supporting device

Urinary elimination interrelated concepts

acid-base balance fluid & electrolytes

ascending colostomy

done for right sided tumors Ascending colostomies are similar to ileostomies. • Drainage is liquid and cannot be regulated. • Ascending colostomies are relatively rare.

ileostomy

ileostomy is a surgically created opening in the small intestine •In an ileostomy, the intestine is brought through the abdominal wall to form a stoma. •Ileostomies may be temporary or permanent and may involve removal of all or part of the colon. •Stools from an ileostomy are frequent and liquid and drainage cannot be regulated. •Drainage contains digestive enzymes, which can be damaging to the skin; therefore, ileostomy patients wear an appliance continuously and take special precautions to prevent skin breakdown.

Descending Colostomy

increasingly solid feces • Sigmoid and descending colostomies are the most common type of ostomy surgeries. • The descending colostomy is located higher than the sigmoid colostomy. • Both produce solid fecal material. • Patients with descending or sigmoid colostomies may not need to wear an appliance at all times and odors can usually be controlled.

sigmoid colostomy

more formed stool • Sigmoid and descending colostomies are the most common type of ostomy surgeries. • The descending colostomy is located higher than the sigmoid colostomy. • Both produce solid fecal material. • Patients with descending or sigmoid colostomies may not need to wear an appliance at all times and odors can usually be controlled.

Transurethral microwave thermotherapy (TUMT)

special catheter delivers microwave energy to prostate causes high temperatures within the prostate without affecting adjacent structures heat kills prostate cells, so becomes smaller

Transverse Colostomy

transverse colon (usually temporary). ostomy return is firm, very foul odor, pouch is worn continuously A transverse colostomy is created in the transverse colon, resulting in one or two openings. • Transverse colostomies produce semi-formed liquid drainage as some liquid has been reabsorbed. • The patient usually has no control over the frequency of discharge, so appliances are in place at all times. • The double-barrel colostomy is performed when two ends of bowel are brought out onto the abdominal wall. • The procedure consists of two distinct stomas. • The proximal end is the functional stoma, and the distal end is the nonfunctional stoma. • The bowel between the double-barrel colostomy stomas is surgically severed.

assessment

•A comprehensive history identifying normal and abnormal patterns of bowel elimination and comparing them to the patient's perception of normal is a crucial step in identifying elimination issues. •Include any history of surgeries or illness affecting the GI tract. •Family history is evaluated for gastrointestinal cancer, Crohn's disease, and other GI disturbances with familial links. •Prior to inspecting the abdomen, inspect the patient's mouth, teeth, tongue, and gums for sores, dentition, and moisture. •The abdominal assessment is performed while the patient is in the supine position with a pillow behind the head and knees. •Auscultation begins in the right lower quadrant and proceeds through each of the remaining quadrants.

altered function of GI system

•Many hospitalized patients are either at risk or have some type of alteration in bowel elimination. •The changes may be due to physiologic issues, such as surgical alterations or disease processes, medication effects, or mobility issues. Diarrhea is an intestinal disorder that is characterized by an abnormal frequency and fluidity of fecal evacuations. Can be caused by C. diff. •Other causes include: food allergies or intolerances (lactose intolerance), hyperosmotic fluids, foods, antibiotics, cathartics or laxatives, communicable food borne pathogens, specific diseases of the colon (colitis, crohns, etc.) dumping syndrome (rapid emptying, common after gastric bypass ...see pg 1046) Clostridium difficile (C. difficile), often called "C. diff," is a bacterium that causes diarrhea. C. diff can lead to life-threatening inflammation of the colon Incontinence refers to the loss of ability to voluntarily control fecal and gaseous discharges through the anus. •Incontinence can have a profound impact on a patient's body image. In many cases, the patient is alert but unable to control defecation.

GI system function review

•The esophagus is a collapsible tube, connecting the pharynx to the stomach. •The primary function of the esophagus is to transport solids and liquids from the mouth, where digestion begins, into the stomach. •Food mixes in the stomach with digestive juices, causing the chemical and mechanical breakdown of food into chyme prior to entering the small intestine. •The small intestine is digestive and absorptive in function. •Intestinal juices and bile from the liver, gallbladder, and pancreas mix with the chyme for digestion and absorption of nutrients. •[Review the sections and functions of the small intestine. p1045] •The large intestine is the primary organ of bowel elimination. •[Review the sections and functions of the large intestine. P.1045-46] •Peristalsis forces chyme into the large intestine through the ileocecal valve, which prevents regurgitation of chyme.

Bedpan and Urinal

•The patient who is unable to ambulate to the bathroom may require the use of a bedpan or urinal. •For many patients, this can be an uncomfortable and embarrassing procedure. •Many patients require privacy and time to void. Pulling the bedside curtain closed, allowing for adequate time for the patient to void, and encouraging the patient to be in the most normal position possible on the bedpan will help to promote elimination. •The bedpan may be warmed prior to use since a cold bedpan can cause contraction of the perineal muscles and inhibit voiding. •The high-Fowler position increases the intraabdominal pressure and helps stimulate voiding, and flexion of the hip and knees simulate the normal position that a woman assumes. •A small pillow or rolled towel placed behind the patient's back will increase comfort. •A fracture bedpan is recommended for patients who must remain positioned at an angle less than 30 degrees. •Urinals are generally for male use, although urinals for use by women are available, but rarely used in the hospital setting.

GI system function review (more)

•The rectum has folds of tissue that temporarily hold fecal contents. •Each fold contains an artery and a vein that can become distended from pressure during straining. •This distention may result in the formation of a condition known as hemorrhoids. •The sensory nerves in the anal canal help to control bowel continence. •Feces and flatus are expelled from the GI tract through the anal canal and anus. •Frequency and amount of defecation varies among individuals, ranging from two or three times per week to several times per day. •When peristaltic waves move the waste into the rectum, the nerves in the rectum are stimulated so that the individual becomes aware of the need (urge) to defecate. •Feces can be hard and dry, formed, soft, or liquid; the characteristics of feces vary, depending on diet, illness, medications, and age.

paralytic ileus

◦Paralytic ileus is the stoppage of peristalsis. •Diet is a major factor the function of the GI system. •[understand the importance of a high-fiber diet and other diet factors.] •Regular physical activity promotes peristalsis and facilitates movement of chyme thorough the colon. •Psychological factors also affect the function of a person's GI system. •Anesthesia blocks parasympathetic stimulation to the muscles of the colon and cause peristalsis to slow or cease. •Paralytic ileus lasts 24 to 48 hours. •Some medications interfere directly or indirectly with bowel elimination. •Cathartics are strong laxatives that stimulate evacuation of the bowels by causing a change in GI transit time. •other relevant factors are: privacy concerns, convenience of toileting facilities, and busy schedules; an immobilized patient who is not able to effectively contract abdominal muscles, making defecation difficult; for pregnant women, as the fetus grows, pressure is exerted on the rectum, impairing passage of feces; diagnostic tests that require the patient to be placed on a restricted diet or given an enema.