O. Elimination & Specimen Collection

8/9/2019 O. Elimination & Specimen Collection

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NIGHTINGALE INTERNATIONAL


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Assisting with Elimination

Elimination is the excretion of waste

products (skin, lungs, intestines and

kidneys) Urination

The act of emptying the urinary bladder

Defecation The act of eliminating the feces


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Allow a patient enough time for eliminationBe prompt to assist the patient

Provide Privacy, close curtain in bedroom

Bathroom doors must be closed

For those patients who cannot assume thenormal squat position, stool risers may be used,which requires less effort to stand or sit

Bedpan should be emptied immediately after

use, cleansed and stored properly. Urine must be recorded if patient is on I&O

monitoring.

Liquid stool is measured per facility protocol


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Types of Devices used for Elimination

Urinal Device used for collecting urine when patientis unable to get up to use the bathroom

Male urinal & Female urinal

Urine must be recorded if patient is on I&O monitoring.

Liquid stool is measured per facility protocol Bedpan -Device for receiving feces or urine from either

male or female.

High Back

Fracture pan Flat and smaller

Bedside commode Receptacle suitable for use as atoilet.

Bedpan should be emptied immediately after use,cleansed and stored properly.


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If male cannot use urinal by himself,nurse should provide assistance

Request patient to abduct legs to a slight

distanceHolding the urinal in the handle and directing

the urinal at an angle, place the urinal in

between the patients leg, making certain the

long , flat side which was the opposite of thehandle of the urinal is resting on the bed

Gently raise penis; place fully within the

urinal.


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Urine

comes from one ofits composition uricacid.

1000 2000 ml of urine

amount of daily bodyformation

Composition of urine

95% water

Salts andnitrogenous wastes


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Factors that

influence urine

amount production mental and physical

health

oral intake

blood pressure


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Normal Characteristics of Urine with

Elimination

Ranges from pale yellow, straw color to amber(depends on the concentration) yellow colorbecause of urochrome, a pigment resulting frombodys destruction of hemoglobin

Transparent at time of voidingHas characteristic of faintly aromatic odor, at roomtemperature it develops the odor of ammonia as aresult of breakdown of urea

Urine is slightly acidic, pH of 4.6 to 8.0

Healthy urine is sterile, but at room temperature itrapidly decomposes

Is negative of protein, glucose, ketone bodies,RBCs, WBCs & bacteria


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Urine Abnormalities

Erythrocytes Hematuria presence of erythrocytes in the urine

may indicate infection, tumors or kidney disease

Individuals with renal calculi (renal stones) may

have irritation and produce hematuria Ketone Bodies

Ketonuria/ ketone aciduria presence of ketones inurine.

Leukocytes

Presence of WBC in urine

Occurs when there is an infection in urinary tract


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Types of Incontinence

Urinary Incontinence Loss of voluntary

control over voiding

Cause of incontinence

Pressure in the bladderis too great

Sphincters are too weak

Stress

Inability to prevent

escape of small amountof urine during stresssuch as laughing,sneezing, lifting orsudden movement.

Urge incontinence Involuntary passage

of urine occurringsoon after a strongsense of urgency to

void Functional

incontinence

Inability of a usuallycontinent person toreach the toilet in timeto avoid unintentionalloss of urine.


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Types of incontinence

Reflex incontinence Involuntary loss of urine at somewhat

predictable intervals when a specific bladdervolume is reached

Total Incontinence State at which individual experiences a

continuous and unpredictable loss of urine.

Overflow Incontinence characterized by small frequent

voiding due to overfilling of the bladder or to abladder with pathologically decreased volume.


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Managing Incontinence

Teach exercises to strengthen muscles aroundexternal sphincter

Kegel exercises (pelvic floor exercises) involves

tightening of muscle around the vagina and anus

for several seconds. Done at least 10 times, 3 times a day.

Use of disposable under garment or incontinence

pads.

Persistent urge, stress or overflow incontinence mayrequire referral to urologist.


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Bladder training Effective with incontinence due to decreased

perception of bladder fullness or impaired voluntary

muscle control.

Provides cooperative patient to void at 1.5 to 2 hrinterval to achieve continence.

On schedule, pt need to ask if they are wet or dry,

checked for wetness, reminded or assisted to toilet.

Limiting fluids after evening meal minimizes theneed for voiding during the night.


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Credes Method for paralyzed patients withoverflow incontinence

Involves manual pressure over the lower abdomen

to express urine from the bladder at regular

intervals. Requires a measure of expertise toprevent injury to bladder.

Cleansing the skin thoroughly after each episode of

incontinence with warm soapy and drying it thoroughly

help prevent skin impairment

Urine and feces are highly irritating to the skin.

Skin that is continuously exposed become inflamed

and irritated.


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Avoid all negative verbal or nonverbal

expressions. Cleanse the perineum in a

professional, caring matter of fact manner. Under no circumstances should any patient

be reprimanded or humiliated (scolded) for

having an accident.


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Bowel Elimination

Factors Influences Bowel Elimination

Balanced diet

Including high-fiber foods

A daily fluid intake of 2000 to 3000 ml

Activity to promote peristalsis (rhythmic

contraction of the intestine that propel gastric

contents through the GI tract)


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Normal Stool Characteristics

Brown in color

Odor is affected by food types

Has soft formed consistency

Frequently ranges from once qd, to 2-3 x/week

Resembles the shape of the rectum

Contains undigested food, dead bacteria, fat, bile,

pigment, living cells, intestinal mucosa, and water.

Each patient has an individual pattern of defecation


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Promotion ofNormal patterns of Bowel

elimination

Establish routine time for defecation

Heeding the urge to defecate

Sitting on a commode or toilet

Having privacy

Respect patients embarrassment, provide

supportive nursing measure and allow as

much privacy as possible


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Physical Assessment Upon Admission

Assess patients abdomen

Determine any nursing diagnosis r/t alteration inbowel elimination including patterns and habits.

Be alert to habits that are detrimental to normal

bowel function. Long term use of laxatives and cathartics

(substances that produce bowel movements)

Causes the intestines to lose ability to respond to

presence of stool Chronic constipation.

Mineral oil cause reduce absorption of fatsoluble vitamins


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Common Alternatives in Bowel Elimination

Constipation A decrease in a persons normal frequency of

defecation accompanied by difficult or incompletepassage of stool or excessively hard stool

Fecal Impaction

Involve a presence of fecal mass too large or hard tobe passed voluntarily.

Either constipation or diarrhea suggests presence ofimpaction. Seepage of stool.

Diarrhea

Passage of fluid or unformed stool. Distention

State by which person is experiencing abdominaldistention related to unable to pass stool due toconstipation or fecal impaction


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Fecal Impaction

Fecal Impaction

Prolonged retention andaccumulation of feces inthe rectum

Feces are hard or putty likein consistency

Results when constipationis not relieved

More water is beingabsorbed from the alreadyhardened feces.

Liquid seeping from theanus is a sign of fecalimpaction. Liquid fecespass around the hardenedfecal mass in the rectum.


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Administering an Enema Enema is the instillation of

solution into the rectum orsigmoid colon.

PURPOSE: Promotion ofdefecation.

ACTION: the volume andtype of fluid installed canlubricate or break up thefecal mass, stretch the walland initiate defecationreflex.

Enema does not treat the

cause of irregularity orconstipation

Frequent enema disruptsnormal defecation reflexes,resulting in dependence onenema for elimination.


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Types of Enema Solution

Large Volume Enema

Cleansing enema promote complete evacuation offeces from the colon by infusion of large volume ofsolution.

Tap Water Enema

Use of tap water

Soap Suds Enema Use of prepared soap suds

Hypertonic

Prepackaged enema solution

Oil retention Lubricates rectum & colon, softens feces and

facilitates defecation.


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FlatulenceFlatulence Presence of air or gas in the intestinalPresence of air or gas in the intestinaltracttract

CauseCauseIntake of gasIntake of gas--producing liquids and food such asproducing liquids and food such ascarbonated beverages, cabbage or beans.carbonated beverages, cabbage or beans.Swallowed a lot of airSwallowed a lot of airDecreased peristalsis due to abdominal surgeryDecreased peristalsis due to abdominal surgerySome narcotic medicationsSome narcotic medicationsDecreased physical activity.Decreased physical activity.Constipation.Constipation.


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Signs and Symptoms of Flatulence

Distention or swelling of stomach Mild to moderated abdominal cramping

Pain

Management to promote peristalsisincludes

Walking

Rectal tube Presence of rectal tube stimulates

peristalsis and movement of flatus


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Nursing Diagnosis with UTI

Incontinence, functional Urinary-R/T Sensory Deficits

-R/T Cognitive Deficits

-R/T Mobility Deficits

Skin integrity, risk or impaired R/T presence ofurine

Self esteem, situational low R/T inability tocontrol passage of urine


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Incontinence, urge for R/T decrease bladdercapacity due to abdominal surgeries or

indwelling urinary catheter.

Incontinence, stress urinary R/T degenerativechange in pelvic muscles and structural supportassociated with increased age

Infection, risk for R/T inadequate personalhygiene

-R/T lack of knowledge of car of urinary


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Nursing Diagnosis for Altered Bowel

Elimination

Constipation

-R/T dehydration

-R/T decreased activity

-R/T postsurgical Ileus

-R/T inadequate dietary fiber intake

Pain, acute R/T bowel distention

Anxiety R/T bowel function


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Diagnostic Examination

It may be performed by a physician at the patientsbedside or in a specially equipped room fortherapeutic or diagnostic purposes.

The nurses knowledge and organization of thediagnostic procedure can be the keys to success.

Fundamental requirement to protect patients rights:

Informed consent: The patient must fullyunderstand what will be done during a test, surgery,or any medical procedure and must understand the

risks and implications before he or she can legallyconsent to it.


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Nurses Responsibilities

Reinforce physician's explanation of the procedure;

confirm that the patient comprehends it; and verify

that written consent is not always necessary for an

individual test; informed verbal consent may be

adequate.

Anticipate the needs of the physician and have

proper supplies ready.

Keep the patient adequately informed of procedural

details that could cause discomfort.

Assist the patient throughout the procedure


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Diagnostic Examination P

reparing theP

atient for DiagnosticExaminations

The nurse must be prepared to answerquestions for which the patient may needclarification.

The patient needs to know if Nothing can be taken by mouth (NPO) after

midnight

Breakfast will be held until the examination is

complete A special room or piece of equipment is required

for the test

Medication is needed before or during the test


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All patients admitted to a health care facilityhave at least one laboratory specimen collectedduring hospitalization.

Laboratory examination of specimens of urine,

stool, sputum, blood, and wound drainageprovides important information about bodyfunctioning and contributes to the assessmentof health status.

Laboratory test can facilitate the diagnosis ofhealth care problems, provide information aboutthe stage and activity of a disease process, andmeasure the response to therapy.


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Specimen Collection

Guidelines for Specimen Collection Consider the patients need and ability to

participate in specimen collection procedures.

Recognize that the collection of a specimen

may provoke anxiety, embarrassment, ordiscomfort.

Provide support for patients who are fearfulabout the results of a specimen examination.

Recognize that children require clearexplanation of procedures and that they needthe support of their parents or family member.

Obtain specimen in accordance with specificprerequisite conditions as


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Specimen Collection

Guidelines for Specimen Collection (continued)Wear gloves when collecting specimens of blood or

other body fluids.

Wash hands and other skin surfaces immediately

and thoroughly if contaminated with blood or bodyfluids; wash hands immediately after removing

gloves.

Collect specimens in appropriate containers, at the

correct time, and in the appropriate amount.

Properly label all specimens with the patients

identification; complete laboratory requisition form

as necessary.


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Specimen Collection

Guidelines for Specimen Collection (continued)

Most specimens are transported to the laboratory in aseparate outer plastic bag.

Deliver specimens to the laboratory within therecommended time or ensure that they are storedproperly for later transport.

Use aseptic technique in all collections to preventcontamination, which can cause inaccurate testresults.

Transport specimens under special conditions asrequired.

Enclose specimenin a plastic bag


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Specimen Collection Collecting a Midstream Urine Specimen

Midstream urine specimen Urine is collected after voiding is initiated (midstream)

and before voiding is completed.

This is the cleanest part of the voided specimen.

Several tests can be ordered on one sample of urine:

pH, protein, glucose, ketones, blood, and specificgravity.

Nurses responsibilities

Collect and label the urine sample.

Ensure safe delivery to the laboratory.

Assess the results.

Collecting a midstream urineCollecting a midstream urinespecimenspecimen


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Specimen Collection

COLLECTING 24 HR URINE COLLECTION PURPOSE: To test renal function and urine

composition (measurements of adenocortical

steroids, hormones, proteins, and creatinine

clearance)

Test must be performed accurately

Residual urine

This is urine left in the bladder after voiding.

The patient voids, and catheterization is performedwithin 10 minutes.

Residual urine is more than 50 ml of urine

remaining in the bladder.


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Specimen Collection

Collecting a Sterile UrineSpecimen

Two methods

Insert a straight

catheter into the urinarybladder and remove

urine.

Obtain a specimen from

the port of an indwellingcatheter using sterile

technique.


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Specimen Collection

Stool Specimen

Stool specimens are

collected and examined

for a variety of reasons.

Determine the

presence of infection,

bleeding, or

hemorrhage

Observe the amount,

color, consistency, and

presence of fats

Identify parasites, ova,

and bacteria


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Specimen Collection

Collecting a Stool Specimen (continued)The nurse collects the feces, labels thespecimen appropriately, and sends the specimen

and laboratory request to the laboratory.

Stool to be examined for parasites must be takento the laboratory immediately in order for the

parasites to be examined under the microscope

while still alive.

Stool specimen for ova and parasite (O&P)examination must be collected in an appropriate

container with a special solution.


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Specimen Collection

Determining the presence ofoccultDetermining the presence ofoccultblood in stoolblood in stool

Collecting a Stool SpecimenCollecting a Stool Specimen


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Collecting a Stool Specimen

Determining the

P

resence of OccultBlood in Stool (Guaiac)The presence of blood in body waste isabnormal.

Bright red blood indicates the blood is freshand that the site of bleeding is in the lowergastrointestinal tract.

Black, tarry feces indicates the presence ofold blood and that the site of bleeding is

higher in the GI tract.Occult indicates blood is present in the stoolbut cannot be seen without a microscope.

Hemocult test detects occult blood in feces.

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O. Elimination & Specimen Collection