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Roshdahl Ch 51 Elimination

Terms in this set (36)

Urine Documentation
color, clarity, odor, volume
Urine Output
approximately 500-2400 mL of urine every 24 hours
(1 mL urine per kg of body weight per hour)
Instruction on Bladder Control
drink plenty of fluids, get exercise,
keep record of I&O, practice Kegels
*reassure if incontinence occurs
Client Education on Urine Collection
-wash hands before & after collecting specimen
-clean genital area with soap, women wipe from
from to back, men use separate wipe for tip of penis
Incontinence
involuntary loss of urine from the bladder or inability to hold urine
Dysuria
pain or burning during urination
Frequency
voiding more often than usual without an increase in total urine volume
Polyuria
increase in expected amount of urine a person excretes over a period of time
Diarrhea
expulsion of loose, watery, unformed stools
Contributes to Diarrhea
irritation of colon, intestinal infection, food poisoning, parasitic infection
Constipation
hard, dry stools that are difficult to eliminate
Contributes to Constipation
low fluid intake, low fiber, ignoring the urge to defecate on a regular basis, immobility, anesthesia, & drying agents
Characteristics of Urine Elimination
color, clarity, odor, volume, any associated pain or discomfort
Characteristics of Stool Elimination
time, frequency, consistency, color, any associated pain
S/S Fecal Impaction
severe abdominal discomfort, a hard abdomen, a feeling of pressure, possibly diarrhea
Interventions to Help Clients Urinate
providing urinal or bedpan, safe access to a commode/toilet or catheter insertion
Foley Catheter Care
-cleanse meatus and the 1st 3-4" of exposed catheter b.i.d.
-using a mild soap wipe from the meatal opening outward
-ointments, powders and lotions are not recommended
-antimicrobial ointment may be recommended by agency policy
-never disconnect or irrigate without a doctors order
S/S Circulatory Overload
hypervolemia, headache, dyspnea, constriction of chest, coughing, cyanosis, JVD, pedal edema, increased BP, bounding pulse
Cleansing Enema
-soapsuds, tap water, or saline
-stimulates peristalsis through distention
and irritation of colon and rectum
Fleet Enema
-commercially prepared disposable enema
-uses hypertonic saline solution to draw water into
the bowel, irritate the bowel and stimulate peristalsis
Carminative Enema
stimulate peristalsis so that flatus is expelled
from the intestine, along with stool
Anthelmintic Enema
administered to destroy intestinal parasites
Emollient Enema
has small amounts of olive or cottonseed oil to protect or soothe the mucous membrane on the colon, must be retained
Oil Retention Enema
-lubricates the stool and intestinal mucosa making defecation easier
-contains a small amount of oil and is given in very small amounts because it must be retained to be effective
Medicated Enema
-provide medications that are absorbed through rectal mucosa
-combined with a small amount of oil or saline to reduce its irritating effect & to lessen clients desire to expel it
Harris Flush
-return flow or "in & out" enema
-a mild colonic irrigation that helps expel flatus
Manual Disimpaction - s/s distress
stop immediately if the client complains of pain, faintness or nausea or if you note any untoward effects, such as bleeding
Manual Disimpaction - Contraindication
clients with cardiac conditions, after reproductive surgery, abdominal repair, rectal surgery, colostomy, genitourinary surgery, clients receiving isotope therapy or perineal perfusion of anticancer drugs, pregnant women or clients who have a bleeding tendency
Bright Red Vomitus
indicates gastric or esophageal bleeding
"Coffee Ground" Material in Vomitus
indicates bleeding in the lower digestive tract
*may contain mucus or pus
Yellowish/Greenish Vomitus
bilious-indicates the presence of bile
Vomitus w/ Fecal Odor
has been forced back into the stomach from the intestine
Monitored in Frequent Vomiting
Vital signs, skin turgor & urine output for signs of dehydration
Enema Administration
check doctors order, check for allergies, check package for specific instructions, don ppe, make sure enema is room temp, have client lie in Sims position, place water proof pad under client, ensure privacy, lubricate tip, clear tube of air, carefully insert tip 3-4" toward umbilicus, give solution slowly, observe client for signs to slow or stop instillation, instruct client to retain enema as long as possible, assure safe access to bedpan, commode or toilet, offer hand hygiene to client after procedure, perform hand hygiene, assess effectiveness, document
Bladder Retraining
-observe & document emptying pattern
-assist with toileting immediately before the
documented times to establish a routine
-gradually increase the time between voiding
*Kegel exercises are often recommended
Kegel Exercises
alternate contracting and relaxing of the pelvic floor muscles to strengthen the muscles surrounding the urinary meatus and vagina
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