ELIMINASI Meliputi Informasi / riwayat pasien Pemeriksaan • Pola BAB, BAK

bacteriuriaconstipationdefecationdetrusor musclediarrheadysuriaextraurethral incontinencefecal incontinenceflatulencefunctional incontinencehematuriahemorrhoidsimpactioninstability incontinencenocturiaperistalsispyuriaspecific gravitystomastoolstress urinary incontinenceurge urinary incontinenceurinalysisurinary incontinenceurinary retentionvoiding

CTORSAFFECTING ELIMINATIONAgeA client’s age or developmental level will affect controlover urinary and bowel patterns. Infants initially lack apattern to their elimination. Control over bladder andbowel movements can begin as early as 18 months of age

DietAdequate fluid and fiber intake are critical factors to aclient’s urinary and bowel health. Inadequate fluidintake is a primary cause of constipation, as is ingestionof constipating foods such as certain dairy products.Diarrhea and flatulence (discharge of gas from the rectum)

are a direct result of foods ingested, and clientsneed to be educated as to which foods and fluids promotehealthy elimination and which foods may inhibit it.

ExerciseExercise enhances muscle tone, which leads to betterbladder and sphincter control. Peristalsis is also aidedby activity, thus promoting healthy bowel eliminationpatterns.

MedicationsMedications can have an impact on a client’s eliminationhealth and patterns and should be assessed during thehealth history interview. Cardiac clients, for instance, arecommonly prescribed diuretics, which increase urineproduction. Antidepressants and antihypertensives maylead to urinary retention.

COMMON ALTERATIONSIN ELIMINATIONUrinary EliminationUrinary incontinence and urinary retention are themost common causes of altered urinary elimination patterns.Urinary incontinence is the uncontrolled loss ofurine that constitutes a social or hygienic problem.Urinary retention is the inability to completely evacuateurine from the bladder during micturition. There aretwo primary types of urinary incontinence, acute andchronic. In addition, chronic urinary incontinence canbe subdivided into several distinctive types. Becauseeach has its own etiology and management, it is importantto determine the type of incontinence before subjectingthe client to the expense, potential risks, andrigors of a treatment program.Acute Urinary IncontinenceAcute urinary incontinence is a transient and reversibleloss of urine. It may occur during an acute illness orafter an injury. Common causes of acute urinary incontinenceinclude urinary tract infection, atrophic vaginitis,polyuria related to diabetes, acute confusion,immobility, and sedation. Medications that increase ordecrease bladder or urethral sphincter tone also maycontribute to acute incontinence.Chronic Urinary IncontinenceAcute incontinence is distinguished from established orchronic incontinence. There are four predominanttypes of chronic urine loss: stress urinary incontinence,instability incontinence, functional incontinence, andextraurethral incontinence.

TABLE 39-1Common Causes of Stress Urinary IncontinenceUrethral hypermobility Multiple vaginal deliveries• Forceps-assisted deliveries• Pelvic muscle denervation• Estrogen deficiency• Obesity (exacerbating factor)Intrinsic sphincter Iatrogenicdeficiency • Multiple bladder suspensions

(women)• Radical prostatectomy (men)• Transurethral resection of prostate(rare in men)• Y-V plasty surgery (both genders)Neuropathic• Lesion of lumbosacral spine• Cauda equina syndrome• Pelvic fracture

TABLE 39-2Common Causes of Instability IncontinenceUrge urinary Neuropathic (sensationsincontinence preserved)• Cerebrovascular accident• Brain tumor• Hydrocephalus• Organic brain syndrome (alsoassociated with functional urinaryincontinence)• Incomplete spinal lesions (whensensations of bladder filling arepreserved)Bladder inflammation• Bladder calculi• Bladder tumor (particularlycarcinoma in situ)• Cystitis (may exacerbatesubclinical instability)• Atrophic vaginitisSUI (39% of women with SUIexperience instability and urgeincontinence; cause ofrelationship unclear)Bladder outlet obstructionIdiopathic (may represent subtleneuropathy or other undiagnoseddisorder)Reflex incontinence Spinal lesions above neurologiclevel S-2• Complete cord injury• Transverse myelitis• Multiple sclerosis

Urinary RetentionUrinary retention is caused by two conditions: bladderoutlet obstruction and deficient detrusor muscle contractionstrength.TABLE 39-3Common Causes of Urinary RetentionBladder outlet Prostatic enlargementobstruction • Benign prostatic hyperplasia• Prostate cancer• ProstatitisBladder neck dyssynergia(dyssynergia of the smoothmuscle of the sphinctermechanism)Detrusor sphincter dyssynergia(typically indicates dyssynergiabetween detrusor and striatedmuscle of sphincter)

Urethral strictureUrethral tumor (rare)Deficient detrusor Transient conditionscontraction strength • Fecal impaction• Acute immobility• Side effects of drugs includinganticholinergics, tricyclicantidepressants• Side effect of recreational drugsincluding hallucinogens• Herpes zoster of sacraldermatomesEstablished conditions• Lesions of sacral spine• Cauda equina syndrome• Diabetes mellitus (late stages)• Tabes dorsalis• Poliomyelitis

Bowel EliminationMany diseases and conditions affect bowel function.Although many alterations in bowel elimination patternsmay be observed, this discussion is limited to threecommon alterations: constipation, diarrhea, and fecalincontinence.ConstipationColonic constipation is the infrequent and difficult passageof hardened stool. (Perceived constipation, influencedby psychological and emotional stress, is notincluded in this discussion.)Dietary factors may contribute to constipation.Dehydration causes drying of the stool as the bodyincreases the reabsorption of water and sodium fromthe bowel. Inadequate dietary bulk also dehydrates thestool. Diverticular disease, a common problem in theelderly, also reduces colonic transit, further increasingthe risk of constipation

ConstipationColonic constipation is the infrequent and difficult passageof hardened stool. (Perceived constipation, influencedby psychological and emotional stress, is notincluded in this discussion

DiarrheaDiarrhea is the passage of liquefied stool that, because ofits increased frequency and consistency, represents achange in the person’s bowel habits. The primary causesof diarrhea include infectious agents, malabsorption disorders,inflammatory bowel disease, short bowel syndrome,side effects of drugs, and laxative or enemamisuse.Fecal IncontinenceFecal incontinence is the involuntary loss of stool of sufficientmagnitude to create a social or hygienic problem.The primary mechanisms that predispose the adultto incontinence of stool are dysfunction of the analsphincter, disorders of the delivery of stool to the rectum,disorders of rectal storage, and anatomic defects.

ASSESSMENTHealth HistoryPhysical Examination

 • frekwensi karakter BAB, BAB terakhir• frekwensi, karakteristik ekskresi urin, kesulitan BAK, penyakit ginjal / liver• penggunaan laksative / diuretic• penggunaan alat Bantu ekskratory, missal : colostomy, ureterostomy• derajat berkeringat• tempat ekskratory lain missal; drain, Water Seal Drainage, NGT, muntah• hasil lab termasuk : urinalisis, feses, rutin, kultur feses, test fungsi ginjal, test fungsi liver, • OBGYN – catat adanya kelainan, mual, konstipasi, hemoroid, sering kencing, stress inkontinensiaPEDIATRIK – catat penggunaan popok atau rutinitas toileting, catat kata-kata khusus yg digunakan • Periksa jika ada indikasi, warna konsistensi, karakter, frekwensi dan kualitas feses dan urine• Periksa jika ada indikasi, warna, karakter dan kualitas output dari tempat ekskratori lain

• Pengkajian abdomen, termasuk suara usus, flatus, softnes, distensi, massa, hemoroid, drain atau alat Bantu pengumpulan lain 

Diagnostic and Laboratory DataWhen significant urinary or fecal elimination problemsare observed, further testing is needed to evaluatethe underlying cause of the condition and to determinetreatment options. When urinary incontinenceexists, a dipstick urinalysis is obtained and evaluatedfor nitrites, leukocytes, hemoglobin, glucose, and specificgravity. When nitrites or leukocytes are present, amicroscopic analysis is completed to determine thepresence of white blood cells in the urine (pyuria) andbacteria in the urine (bacteriuria). Urine culture andsensitivity testing are completed and the client istreated for a urinary tract infection. If glucose is notedin the urine, the patient may undergo further evaluationfor diabetes mellitus, or methods of glucose controlmay be reviewed and adjusted in the client withknown diabetes. If the specific gravity (weight of urinecompared with weight of distilled water) of the urine isabnormally low (below 1.010), the volume of fluidconsumed by the client over a 24-hour period is evaluatedfurther. Hematuria (blood in the urine) may benoted.

DOMAIN 3. ELIMINATION/EXCHANGE

CLASS 1 : URINARY SYSTEM 00016. Kerusakan eliminasi urine00023. Retensi urine00020. Inkontinensia urine fungsional00017. Inkontinensia urine stress

00019. Inkontinensia urine urgensi00018. Inkontinensia urine refleks00022. Risiko Inkontinensia urine urgensi00166. Kesiapan untuk meningkatkan eleminasi urine00176. Inkontinensia urine overflowCLASS 2 : GASTROINTESTINAL FUNGTION00014. Inkontinensia usus00013. Diare00011. Konstipasi00015. Risiko untuk konstipasi00012. Konstipasi dirasakan00196. Disfungsi motilitas gastrointertinal00197. Risiko disfungsi motilitas gastrointertinal