Fundamental of nursingFundamental of nursingUnit Eleven and TwelveUnit Eleven and Twelve

Objectives:Objectives:

Describe the function of the lower intestinal tract.Describe the function of the lower intestinal tract. Identify the factors that influence in the fecal Identify the factors that influence in the fecal

elimination and pattern of elimination.elimination and pattern of elimination. Distinguish normal from abnormal characteristics Distinguish normal from abnormal characteristics

o feces.o feces. Differentiate common fecal elimination problem.Differentiate common fecal elimination problem. Identify common causes and effect of fecal Identify common causes and effect of fecal

elimination problems.elimination problems. Relate common intervention to specific fecal Relate common intervention to specific fecal

problem problem

Cont Cont

Describe essential nursing care of patient with Describe essential nursing care of patient with ostomies. ostomies.

Describe the process of urination.Describe the process of urination. Identify factors that influence urinary elimination.Identify factors that influence urinary elimination. Describe diagnostic measure to assess kidney Describe diagnostic measure to assess kidney

function.function. Develop nursing diagnosis related to urinary Develop nursing diagnosis related to urinary

elimination elimination Describe nursing intervention to maintain normal Describe nursing intervention to maintain normal

urinary elimination.urinary elimination.

Anatomy of GITAnatomy of GIT

Physiology of defecation:Physiology of defecation:

The large intestine extend from the The large intestine extend from the ileocecal valve to the anus, is a muscular ileocecal valve to the anus, is a muscular tube lined with mucous membrane.tube lined with mucous membrane.

125 to 150 cm in length.125 to 150 cm in length.

Function of colon:Function of colon: Absorption of water and nutrient.( Na, Absorption of water and nutrient.( Na,

1500ml daily).1500ml daily). Protection of intestinal wall. (Acid, Protection of intestinal wall. (Acid,

adherence).adherence). Fecal elimination.Fecal elimination.

Flatus: is largely air and by product of digestion of Flatus: is largely air and by product of digestion of carbohydrate.carbohydrate.

Defecation: is the expulsion of feces from the anus Defecation: is the expulsion of feces from the anus and rectum. the frequency of defecation is highly and rectum. the frequency of defecation is highly individual vary from several time per day or three time individual vary from several time per day or three time per weeks.per weeks.

When feces move into sigmoid, the sensory nerves When feces move into sigmoid, the sensory nerves are stimulated. The expulsion of feces is result from are stimulated. The expulsion of feces is result from relaxation of internal and external sphincter and by relaxation of internal and external sphincter and by contraction of abdominal muscle and diaphragm contraction of abdominal muscle and diaphragm which increase abdominal pressure.which increase abdominal pressure.

Feces: normal feces are made of about Feces: normal feces are made of about 75% water and 25% solid material. if they 75% water and 25% solid material. if they feces propelled very quickly along the feces propelled very quickly along the large intestine there is not time for most large intestine there is not time for most water in the chyme to be absorbed and water in the chyme to be absorbed and feces will be more fluid.feces will be more fluid.

Feces: are normally brown, chiefly due to Feces: are normally brown, chiefly due to presence of sterocoblin and urobilin. presence of sterocoblin and urobilin. Which are derived from bilirubin and Which are derived from bilirubin and another factor effect of color is bacteriaanother factor effect of color is bacteria

Type of peristalsis movement Type of peristalsis movement

1 . Haustral movement.1 . Haustral movement. 2. peristalsis 2. peristalsis 3. mass peristalses 3. mass peristalses

Abnormal feces:Abnormal feces:

Clay or white color may indicate of absence of Clay or white color may indicate of absence of bile or bile obstruction.bile or bile obstruction.

Black, tarry stool may indicate of bleeding from Black, tarry stool may indicate of bleeding from upper gastrointestinal tract or drug.upper gastrointestinal tract or drug.

Red: may indicate of bleeding from lower Red: may indicate of bleeding from lower gastrointestinal tract.gastrointestinal tract.

Pale may indicated to mal absorption.Pale may indicated to mal absorption. Green may indicate intestinal infection.Green may indicate intestinal infection. Dry, hard: dehydration decreased intestinal Dry, hard: dehydration decreased intestinal

motility.motility. Pus: bacterial infection.Pus: bacterial infection.

Factor that effect of defecation:Factor that effect of defecation:

1.1. Development: infant, meconium is the first Development: infant, meconium is the first fecal material passed by the newborn, fecal material passed by the newborn, normally up to 24 hr after newborn. Its black, normally up to 24 hr after newborn. Its black, tarry, odorless which contains mucous.tarry, odorless which contains mucous.

2.2. Infant pass stool frequently often each after Infant pass stool frequently often each after feeding, because intestine immature. feeding, because intestine immature.

3.3. Toddlers, school age and adult.Toddlers, school age and adult.

4.4. Diet: sufficient bulk in the diet (cellulose, Diet: sufficient bulk in the diet (cellulose, fiber) is necessary to provide fecal bulk.fiber) is necessary to provide fecal bulk.

Cont Cont

5. Fluid: the reduce fluid intake may cause Harding of 5. Fluid: the reduce fluid intake may cause Harding of stool; healthy fecal elimination requires 2000 to stool; healthy fecal elimination requires 2000 to 3000ml/ day.3000ml/ day.

6. Activity: stimulate peristalsis, thus facilitating 6. Activity: stimulate peristalsis, thus facilitating movement of chyme along the colon.movement of chyme along the colon.

7. Psychological factor: some people who are anxious 7. Psychological factor: some people who are anxious or angry increased peristalsis activity and or angry increased peristalsis activity and subsequent diarrhea and other individual may subsequent diarrhea and other individual may cause constipation by depress peristalsis. cause constipation by depress peristalsis.

8. Defecation habit: early bowl training may establish 8. Defecation habit: early bowl training may establish habit of the defecation.habit of the defecation.

9. medication habit9. medication habit

Cont Cont

10. Pain.10. Pain.

11. Pathological condition: spinal cord injury 11. Pathological condition: spinal cord injury and head injury can decrease sensory and head injury can decrease sensory stimulation for defecation.stimulation for defecation.

Common fecal elimination Common fecal elimination problem:problem:

constipation:constipation: Is defined as three bowl movement per Is defined as three bowl movement per

week, this infers the passage of small, week, this infers the passage of small, dry, hard stool for period of time.dry, hard stool for period of time.

Characteristics for constipationCharacteristics for constipation::

Decreased frequency of defecation.Decreased frequency of defecation. Hard, dry stool.Hard, dry stool. Straining of stool, painful defecation.Straining of stool, painful defecation. Report rectal fullness.Report rectal fullness. Abdominal pain, cramps and distention.Abdominal pain, cramps and distention. Use laxatives.Use laxatives. Decreased appetite.Decreased appetite. Headache. Headache.

Causes factor contribute to Causes factor contribute to constipation:constipation: Insufficient fiber intake.Insufficient fiber intake. Insufficient activity or mobility.Insufficient activity or mobility. Insufficient fluid intake.Insufficient fluid intake. Irregular defecation habits.Irregular defecation habits. Chronic use laxatives.Chronic use laxatives. Emotional disturbance depression or mental Emotional disturbance depression or mental

confusion.confusion. Medication such as iron salts.Medication such as iron salts.

b) Fecal impaction:b) Fecal impaction: Fecal impaction is a mass or collection of Fecal impaction is a mass or collection of

hardened, puttylike feces in the folds of hardened, puttylike feces in the folds of the rectum. Impaction result from the rectum. Impaction result from prolonged retention and accumulation of prolonged retention and accumulation of the fecal material.the fecal material.

Sign and symptom:Sign and symptom:

Liquid production of the feces seep.Liquid production of the feces seep. Generalized feeling of illness.Generalized feeling of illness. Rectal pain.Rectal pain. Abdominal distention.Abdominal distention. Nausea and vomiting occur.Nausea and vomiting occur.

) Diarrhea: ) Diarrhea: Refers to the passage of liquid feces and Refers to the passage of liquid feces and

increased frequency of defecation. It result increased frequency of defecation. It result from rapid movement of fecal content from rapid movement of fecal content through the large intestine.through the large intestine.

Causes of diarrhea:Causes of diarrhea: Psychological stress ( anxiety).Psychological stress ( anxiety). Medication (antibiotic).Medication (antibiotic). Allergy of food.Allergy of food. Desease of the colon.Desease of the colon.

Bowl diversion ostomies:Bowl diversion ostomies: Ostomy: is an opening on the abdominal wall Ostomy: is an opening on the abdominal wall

for the elimination of feces or urine. for the elimination of feces or urine.

There are many types of ostomies:There are many types of ostomies: Gastrostomy: is an opening through the Gastrostomy: is an opening through the

abdominal wall in to the stomach.abdominal wall in to the stomach. Jejunostomy: is an opening through Jejunostomy: is an opening through

abdominal wall in to jejunum.abdominal wall in to jejunum. Ileostomy: is an opening in to the ileum.Ileostomy: is an opening in to the ileum. Colostomy: is an opening in the colon.Colostomy: is an opening in the colon.

Assessment:Assessment: Nursing history: Nursing history:

Defecation pattern, description of feces and any Defecation pattern, description of feces and any changes, fecal elimination problem, presence and changes, fecal elimination problem, presence and management of ostomies.management of ostomies.

Factor effecting elimination.Factor effecting elimination. Physical examinationPhysical examination: inspect for color, : inspect for color,

consistency, shape a mount odor and presence consistency, shape a mount odor and presence of abnormal constitute of abnormal constitute

Diagnostic studyDiagnostic study: direct visualization : direct visualization techniques, lapratory test, stool for occult blood.techniques, lapratory test, stool for occult blood.

Nurses need to give client the following Nurses need to give client the following instruction:instruction:

Defecate in a clean bedpan.Defecate in a clean bedpan. Don’t contaminate the specimen if Don’t contaminate the specimen if

possible by urine.possible by urine. Don’t replace the toileting paper in the Don’t replace the toileting paper in the

bedpan.bedpan. Notify the nurse after defecation.Notify the nurse after defecation.

Nursing diagnosisNursing diagnosis:: Bowl incontinence related to fecal impaction.Bowl incontinence related to fecal impaction. Constipation related to immobility.Constipation related to immobility. Risk for constipation insufficient fiber intake.Risk for constipation insufficient fiber intake. Diarrhea related to spoiled food.Diarrhea related to spoiled food. Risk for fluid volume deficit related to diarrhea.Risk for fluid volume deficit related to diarrhea. Risk for impaired skin integrity related to Risk for impaired skin integrity related to

colostomy.colostomy. Self esteem disturbances related to bowl Self esteem disturbances related to bowl

diversion.diversion.

Planning: Planning: Maintain normal bowl elimination pattern.Maintain normal bowl elimination pattern. Maintain normal stool consistency.Maintain normal stool consistency.

Implementation:Implementation: Promote regular defecation by:Promote regular defecation by: PrivacyPrivacy Timing. Timing. Nutrition: high fiber dietNutrition: high fiber diet Increase fluid intake to 2L per day.Increase fluid intake to 2L per day. Exercise Exercise Positioning: squatting position best facilities Positioning: squatting position best facilities

defecation. defecation.

Teaching about medication. Antidiarrhreal Teaching about medication. Antidiarrhreal medication or laxative medication.medication or laxative medication.

Administrating enema: is a solution introduced Administrating enema: is a solution introduced in the rectum and the large intestine.in the rectum and the large intestine.

Decreasing flatulus by avoid gas – producing Decreasing flatulus by avoid gas – producing food, exercise, moving in bed and ambulation.food, exercise, moving in bed and ambulation.

Bowel training program.Bowel training program. ostomy management by stoma color, size and ostomy management by stoma color, size and

shape, bleeding and amount and type of feces.shape, bleeding and amount and type of feces.

. Kidneys:. Kidneys: the paired kidneys are situated the paired kidneys are situated on either side of the spinal column, behind on either side of the spinal column, behind the peritoneal cavity.the peritoneal cavity.

Function of kidneys:Function of kidneys: urine formation by three process filtration, urine formation by three process filtration,

reabsorbtion and excretion.reabsorbtion and excretion. removes urea from bloodremoves urea from blood removes water and inorganic salts from bloodremoves water and inorganic salts from blood regulates blood acid/base by varying pH of urineregulates blood acid/base by varying pH of urine Production of vitamin DProduction of vitamin D

Synthesis of erythropoietin Synthesis of erythropoietin

b. Uretersb. Ureters:: The Ureters are from 25 to 30 cm long in the The Ureters are from 25 to 30 cm long in the

adult and 1.25cm in diameter.adult and 1.25cm in diameter. The lower end enters the bladder.The lower end enters the bladder. C. BladderC. Bladder: : Is a hollow, muscular organIs a hollow, muscular organ Functions as temporary reservoir urine storageFunctions as temporary reservoir urine storage Full bladder can contain 0.5 -1 Full bladder can contain 0.5 -1 liter of urine liter of urine

. Urethra: . Urethra: The Male Urethra The Male Urethra Extends from neck of urinary bladderExtends from neck of urinary bladder To tip of penis (18–20 cm) To tip of penis (18–20 cm) The Female UrethraThe Female Urethra Is very short (3–5 cm)Is very short (3–5 cm) Extends from bladder to vestibuleExtends from bladder to vestibule External urethral orifice is near anterior wall of External urethral orifice is near anterior wall of

vaginavagina

Urination: Urination: Micturation, voiding and urination all refer Micturation, voiding and urination all refer

to the process of emptying the urinary to the process of emptying the urinary bladder. urine collects in the bladder until bladder. urine collects in the bladder until the pressure stimulates special sensory the pressure stimulates special sensory nerve ending in the bladder wall called nerve ending in the bladder wall called stretch receptors.stretch receptors.

Alteration urine production:Alteration urine production: Polyuria: refer to the production of abnormally Polyuria: refer to the production of abnormally

large amount of urine by the kidneys.large amount of urine by the kidneys. Polydepsia: excessive fluid intake may be Polydepsia: excessive fluid intake may be

associated with diabetes.associated with diabetes. Diuresis: another term of production large Diuresis: another term of production large

amount of urine.amount of urine. Oliquria: is low urine output less than 500ml/ Oliquria: is low urine output less than 500ml/

day.day. Anuria: lack of urine production less than 30 ml / Anuria: lack of urine production less than 30 ml /

dayday

Altered urinary elimination:Altered urinary elimination: Frequency: is the voiding more than normal with frequent Frequency: is the voiding more than normal with frequent

intervals.intervals. Nocturia: is voiding two or three time at night.Nocturia: is voiding two or three time at night. Urgency: is the feeling of person must void.Urgency: is the feeling of person must void. Dysuria: means voiding that is either painful or difficulty.Dysuria: means voiding that is either painful or difficulty. Enuresis: is defined as involuntary urination.Enuresis: is defined as involuntary urination. Urinary incontinence: involuntary urination. Symptom not Urinary incontinence: involuntary urination. Symptom not

a disease.a disease. Urine retention: accumulation of urine in the bladder and Urine retention: accumulation of urine in the bladder and

become over distended become over distended

Assessment: Assessment: Nursing history:Nursing history: Voiding pattern, description of urine for Voiding pattern, description of urine for

any changing.any changing. Urinary elimination problem.Urinary elimination problem. Presence of urinary diversion.Presence of urinary diversion. 2. Physical assessment: inspection, 2. Physical assessment: inspection,

palpation, percussion and auscultation.palpation, percussion and auscultation.

Assessing urine:Assessing urine: Color: straw, transparent.Color: straw, transparent. Amount: 1200 – 1500ml/d.Amount: 1200 – 1500ml/d. Sterility: no microorganism present.Sterility: no microorganism present. Glucose: not present.Glucose: not present. Blood: not present.Blood: not present. Ketone bodies: not present.Ketone bodies: not present. Epithelial cell not present.Epithelial cell not present. Measuring urine output.Measuring urine output. Colleting urine specimen.Colleting urine specimen.

Nursing diagnosis:Nursing diagnosis: Altered urinary elimination related to Altered urinary elimination related to

bladder neck obstruction.bladder neck obstruction. Stress incontinence related to relaxation of Stress incontinence related to relaxation of

sphenicter. sphenicter. Risk for infection related to urinary Risk for infection related to urinary

retention.retention. Self esteem disturbances related to Self esteem disturbances related to

urinary incontinence.urinary incontinence.

Planning:Planning: Maintain normal voiding pattern.Maintain normal voiding pattern. Regain normal urine output.Regain normal urine output. Prevent infection.Prevent infection.

InterventionIntervention:: Maintaining normal urinary elimination:Maintaining normal urinary elimination: Promote fluid intake.Promote fluid intake. Maintain normal voiding habit.Maintain normal voiding habit. Assisting with toileting.Assisting with toileting. Preventing urinary tract infection:Preventing urinary tract infection: Increased fluid intake.Increased fluid intake. Practice frequent voiding process.Practice frequent voiding process. Avoid any harsh soap.Avoid any harsh soap. Girls should always wipe the perineal area from Girls should always wipe the perineal area from

front to back. front to back.