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Urinary Elimination
Process of Urination
• Depends on effective functioning of
– Upper urinary tract (kidneys, ureters)
– Lower urinary tract (bladder, urethra, pelvic floor)
CV system
– CV system
– Nervous system
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Urine Formation
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Urine Formation
• Nephron
– Functional unit of the kidney
– Urine is formed here
• Glomerulus
– Tuft of capillaries surrounded by Bowman’s capsule
– Fluids and solutes move across endothelium of the
capillaries into the capsule
• Bowman’s Capsule
– Filtrate move from here into the tubule of the nephron
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Urine Formation
• Proximal convoluted tubule
– Most of water and electrolytes are reabsorbed
• Loop of Henle
– Solutes such as glucose reabsorbed here
– Other substances secreted
• Distal convoluted tubule
– Additional water and sodium reabsorbed here under control of
hormones
• Formed urine then moves to:
– Calyces of the renal pelvis
– Ureters
– Bladder
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Process of Micturition
• Urine collects in the bladder
• Pressure stimulates special stretch receptors in the
bladder wall
• Stretch receptors transmit impulses to the spinal
d idi fl
cord voiding reflex center
• Internal sphincter relaxes stimulating the urge to void
• If appropriate, the conscious portion of the brain
relaxes the external urethral sphincter muscle
• Urine eliminated through the urethra
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Factors Influencing Urinary Elimination
• Developmental factors
• Psychosocial factors
• Fluid and food intake
• Medications
• Muscle tone
• Pathologic conditions
• Surgical and diagnostic procedures
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Selected Urinary Problems
• Polyuria • Enuresis
• Oliguria, Anuria • Incontinence
• Frequency or Nocturia • Retention
• Urgency • Neurogenic Bladder
g
• Dysuria
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Nursing Assessment of
Urinary Function
• Nursing history
• Physical assessment of urinary system
• Hydration status
• Examination of urine
• Data from diagnostic tests and procedures
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Nursing History
• Normal voiding patterns
• Appearance of urine
• Recent changes
• Past or current problems
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Physical Assessment
• Percussion of kidneys and bladder to detect
tenderness
• Inspect urethral meatus for swelling,
discharge inflammation
discharge, inflammation
• Skin color, texture, turgor, signs of irritation
• Edema
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Assessing Urine
• Measuring urinary output
• Measuring residual urine
• Diagnostic Tests
– Blood urea nitrogen: urea end product of protein
metabolism, measured as BUN
– Creatinine clearance: uses 24 hour urine and
serum creatinine levels to determine glomerular
filtration rate sensitive indicator of renal
functioning
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Characteristics of
Normal Urine
• 96% water and 4% solutes
• Organic solutes include urea, ammonia,
creatinine, and uric acid
i l i l d di hl id
• Inorganic solutes include sodium, chloride,
potassium sulfate, magnesium, and
phosphorus
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Characteristics of Urine
– Volume
– Color, clarity
– Odor
– Sterility
– pH
– Specific gravity
– Glucose
– Ketone bodies
– Blood
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NANDA Nursing Diagnosis
• Impaired Urinary Elimination
• Functional Urinary Incontinence
• Reflex Urinary Incontinence
• Stress Urinary Incontinence
• Total Urinary Incontinence
• Urge Urinary Incontinence
• Urinary Retention
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Related Nursing Diagnosis
• Risk for Infection
• Low Self‐esteem
• Risk for Impaired Skin Integrity
• Self‐care Deficit
• Ri k f D fi i t Fl id V l E Fl id V l
Risk for Deficient Fluid Volume or Excess Fluid Volume
• Disturbed Body Image
• Deficient Knowledge
• Risk for Caregiver Role Strain
• Risk for Social Isolation
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Desired Outcomes
• Maintain or restore a normal voiding pattern
• Regain normal urine output
• Prevent associated risks such as infection, skin
breakdown, fluid and electrolyte imbalance, and
lowered self‐esteem
l d lf
• Perform toilet activities independently with or
without assistive devices
• Contain urine with the appropriate device, catheter,
ostomy appliance, or absorbent product
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General Nursing Interventions
• Promoting fluid intake
• Maintaining normal voiding patterns
• Assisting with toileting
• Preventing urinary tract infections
• Managing urinary incontinence
• Continence (bladder) training
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General Nursing Interventions
• Pelvic muscle exercises
• Maintaining skin integrity
• Applying external urinary drainage devices
• Performing urinary catheterizations
• Performing bladder irrigations
• Providing care for clients with indwelling
urinary catheters and urinary diversions
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Preventing Urinary Tract
Infections
• Drink eight oz of water per day
• Practice frequent voiding (every 2 to 4 hours)
• Avoid use of harsh soaps, bubble bath,
d i h i l
powder, or sprays in the perineal area
• Avoid tight‐fitting clothing
• Wear cotton rather than nylon underclothes
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Preventing Urinary Tract
Infections
• Always wipe the perineal area from front to
back following urination or defecation (girls
and women)
Take showers rather than baths if recurrent
• Take showers rather than baths if recurrent
urinary infections are a problem
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Nursing Care of Client with an Indwelling
Catheter
• Encourage large amounts of fluid intake
• Intake of foods that create acidic urine
• Perineal care
• Change catheter and drainage system only when
necessary
• Catheterize only when necessary
• Maintain sterile closed‐drainage system
• Remove catheter as soon as possible
• Follow good hand hygiene
• Prevent fecal contamination
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Interventions to Maintain Urinary
Flow Through Drainage System
• Ensure tubing free of obstructions
• Ensure tubing not clogged
• Ensure there is no tension on catheter or tubing
• Ensure gravity drainage maintained
• Ensure no loops in tubing below entry
Ensure no loops in tubing below entry
• Keep drainage receptacle below level of client’s bladder
• Ensure closed drainage system
• Observe flow of urine q. 2 to 3 hours
• Note color, odor, abnormal constituents
• If sediment present, check more frequently
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Nursing Care of Client with an Indwelling
Catheter
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Nursing Care of Client with
Urinary Diversion
• Assess intake and output
• Note any changes in urine color, odor, or
clarity (mucous shreds are commonly seen in
)
the urine of clients with an ileal diversion)
• Frequently assess the condition of the stoma
and surrounding skin
• Consult with the wound ostomy continence
nurse (WOCN)
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Scientific Knowledge Base:
Organs of Urinary Elimination
Kidneys Ureters
Remove waste from the Transport urine from the
blood to form urine kidneys to the bladder
Bladder Urethra
Reservoir for urine until the Urine travels from the
urge to urinate develops bladder and exits through
the urethral meatus
Acts of Urination
• Brain structure influences bladder
function.
– Cerebral cortex, thalamus, hypothalamus,
brain stem
brain stem
• Multiple factors influence urination.
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Diseases That Cause Irreversible Damage
• ESRD
– Irreversible damage to the kidney tissue
• Uremic syndrome
– Increase in nitrogenous wastes in the blood
• Renal replacement therapies
– Dialysis
– Organ transplant
Alterations in Urinary Elimination
Urinary retention Urinary tract
An accumulation of urine infections
due to the inability of the Result from catheterization
bladder to empty or procedure
Urinary incontinence Urinary diversions
Involuntary leakage of urine Diversion of urine to
external source
Nursing Knowledge Base
• Infection control and hygiene
• Growth and development
• Muscle tone
• Psychosocial considerations
• Cultural considerations
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Nursing Process and Alterations in Urinary
Function
• Assessment
– Nursing history
• Patterns of urination
Symptoms of urinary alterations
• Symptoms of urinary alterations
• Factors affecting urination
Physical Assessment
Skin and Mucosal Kidneys
Membranes Flank pain may occur with
Assess hydration infection or inflammation
Bladder Urethral Meatus
Distended bladder rises Observe for discharge,
above symphysis pubis inflammation, and lesions
Assessment of Urine
• Intake and output
• Color
– Pale‐straw to amber color
• Clarity
– Transparent unless pathology is present
• Odor
– Ammonia in nature
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Urine Tests and Diagnostic Examinations
• UA: Urinalysis
• Specific gravity
• C & S: culture
• 24 hour
• Creatinine/creatinine clearance
• IVP/CT scan/ultrasound
• cystoscopy
• Noninvasive examination
• Invasive examination
Implementation
• Catheterization
• Catheter insertion
• Catheter care
• Alternative to urethral catheterization
Evaluation
• Ascertain if client has met outcomes and
goals.
• Evaluate how the client reports progress
d
made.
• Help the client redefine goals if
necessary.
• Revise nursing interventions as
indicated.
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Need For
Bowel Elimination
Physiology of Defecation
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Physiology of Defecation
• Elimination of waste products of digestion from
body essential to health
• Excreted waste products called feces or stool
• Most wastes excreted in 48hrs of ingestion
•
• The waste products leaving the stomach thr small
intestine and passing thru ileocecal valve are
called chyme
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Terms
• Flatus: largely air and by products of digestion of
carbohydrates
• Peristalsis: wavelike movement produced by
circular and longitudinal muscle fibers of
intestinal wall
Hemorrhoids: veins become distended of rectum
• Hemorrhoids: veins become distended of rectum
or anal canal
• Defecation: expulsion of feces from anus and
rectum
• Feces: made up of 75% water and 25% solid
material
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Affect Defecation:
• Gastrocolic reflex: increased peristalsis of the
colon after food entered stomach
• Laxatives: stimulate bowel activity and assist fecal
elimination
• Anasthesia: cause normal colonic movements to
l fi i
cease or slow, surgery of intestines can cause
temporary cessation of intestinal movement
• Pts w/pain w/defecating will suppress the urge to
go
• Constipation: fewer than 3 bowel movements per
week
41
Physiology of Defecation
• Peristaltic waves move the feces into the
sigmoid colon and the rectum
• Sensory nerves in rectum are stimulated
di id l b f d d f
• Individual becomes aware of need to defecate
• Feces move into the anal canal when the
internal and external sphincter relax
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Physiology of Defecation
• External anal sphincter is relaxed voluntarily if
timing is appropriate
• Expulsion of the feces assisted by contraction
p g
of the abdominal muscles and the diaphragm
• Moves the feces through the anal canal and
expelled through anus
• Facilitated by thigh flexion and a sitting
position
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Factors that Influence
Fecal Elimination
• Developmental stage • Medications
• Diet • Diagnostic procedures
• Fluid • Anesthesia
• y
Activity • g y
Surgery
• Psychologic factors • Pathologic conditions
• Defecation habits • Pain
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Characteristics of Feces
• Color: brown, infant: yellow
• Consistency: formed, soft, moist
• Shape: cylinder contour of rectum
• Amount: varies w/ diet
• Odor: aromatic affected by ingestion of food
• Constituents: small amts of undigested
roughage, sloughed dead bacteria and
epitheal cells
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Fecal Elimination Problems
• Constipation: fewer than 3 bowel movements
week
• Fecal impaction: mass or collection of hardened
stool in folds of rectum
• Diarrhea: passage of liquid feces and increased
frequency
• Bowel incontinence or fecal incontinence: loss of
voluntary ability to control fecal and gaseous
discharges thru anal sphincter
• Flatulence: presence of excess flatus in intestines
leads to stretching and inflation
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Constipation
• Decreased frequency of defecation
• Hard, dry, formed stools
• Straining at stools
• Painful defecation
• Causes include:
– Insufficient fiber and fluid intake
– Insufficient activity
– Irregular habits
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Types of Laxatives
• Bulk forming: increases fluid or bulk in intestines‐
Metamucil
• Emollient/stool softener: softens, delays drying of
feces and allows fat and water to penetrate feces‐
Colace
Stimulant/irritant: stimulate nerve endings in wall
• S i l /i i i l di i ll
of intestine‐ducolox, senekot, castor oil
• Lubricant: lubricates feces‐mineral oil
• Saline/osmotic: draws water into intestine by
osmosis distends bowel‐fleet, magnesium sulfate
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Fecal Impaction
• Mass or collection of hardened feces in folds
of rectum
• Passage of liquid fecal seepage and no normal
stool
• Causes usually:
– Poor defecation habits
– Constipation
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Diarrhea
• Passage of liquid feces and increased frequency
of defecation
• Spasmodic cramps, increased bowel sounds
• Fatigue, weakness, malaise, emaciation
• Major causes:
– Stress, medications, allergies, intolerance of food or
fluids, disease of colon
– TX: 8 glasses water, sodium, potassium foods, soluble
fiber, avoid alcohol and caffeine, limit fats, clean area
well after going, D/C meds that cause diarrhea, if
weak, dizzy, and stool longer than 48hrs call MD
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Bowel Incontinence
• Loss of voluntary ability to control fecal and
gaseous discharges
• Generally associated with:
–I i d f ti i f l hi t
Impaired functioning of anal sphincter or nerve
supply
– Neuromuscular diseases
– Spinal trauma
– Tumor
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Flatulence
• Excessive flatus in intestines
• Leads to stretching and inflation of intestines
• Can occur from variety of causes:
– Foods
– Abdominal surgery
– Narcotics
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Assessment of
Fecal Elimination
• Nursing history
• Physical examination
• Review of data from any diagnostic tests
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Nursing History
• Ascertains the client’s normal pattern
• Description of usual feces
• Recent changes
• Past problems with elimination
• Presence of an ostomy
• Factors influencing elimination pattern
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Physical Examination
• Examination of the abdomen, rectum, and
anus
• Auscultation precedes palpation because
p p p
palpation alters peristalsis
• Inspection of feces for color, consistency,
shape, amount, odor, abnormal constituents
• Review any data obtained from relevant
diagnostic tests
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NANDA Nursing Diagnoses
• Bowel Incontinence
• Constipation
• Risk for Constipation
• Perceived Constipation
• Diarrhea
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Related Nursing Diagnosis
• Risk for Deficient Fluid Volume
• Risk for Impaired Skin Integrity
• Low Self‐esteem
• Disturbed Body Image
• Deficient Knowledge (Bowel Training, Ostomy
Management)
• Anxiety
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Desired Outcomes
• Maintain or restore normal bowel elimination
pattern
• Maintain or regain normal stool consistency
i d ik h fl id d
• Prevent associated risks such as fluid and
electrolyte imbalance, skin breakdown,
abdominal distention and pain
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General Nursing
Interventions
• Promoting regular defecations
• Teaching about medications
• Decreasing flatulence
• Administering enemas
• Digital removal of a fecal impaction (if agency policy
permits)
• Instituting bowel training programs
• Applying a fecal incontinence pouch
• Ostomy management
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Measures to Maintain Normal
Fecal Elimination Patterns
• Privacy
• Timing
• Nutrition and fluids
• Exercise
• Positioning
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Common Enema (solution given into
rectum) Solutions
and Actions
• Hypertonic (Fleet phosphate)
– Draws water into colon
• Hypotonic (tap water)
– Distends the colon
– Stimulates peristalsis
– Softens feces
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Common Enema Solutions
and Actions
• Isotonic (physiologic saline)
– Distends the colon
– Stimulates peristalsis
– Softens feces
• Soapsuds (pure soap)
– Irritate mucosa
– Distends the colon
• Oil
– Lubricates feces and colonic mucosa
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Enema Animation
Click here to view an animation on enemas.
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Types of Enemas
• Cleansing
– Prevents escape of feces during surgery
– Prepare intestines for certain diagnostic tests
– Removes feces in instances of constipation or impaction
• Carminative and return‐flow
– Used primarily to expel flatus
• Retention
– Introduces oil or medication into the rectum and sigmoid
colon
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Administering an Enema
Skill 49‐1
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Bowel Diversion Ostomies
• Ostomy: opening for GI, urinary, respiratory tract
onto the skin
• Gastrostomy: opening thru abdominal wall into
stomach
• Jejunostomy: open thru abd wall into jejunum
• Ileostomy: opens into ileum (small bowel)
• Colostomy: opens in colon (large bowel)
• Gastrostomy and jejunostomy generally placed to
provided feedings route
• Bowel ostomies is to divert or drain fecal material
(permanent or temporary )
• Stoma: the opening created in the abdominal
wall
66
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Factors in Potential Bowel Elimination
Problems
• Poor fluid intake
• Inability to eat high fiber foods
• Medications: antacids, hypertensive's,
i
narcotics
• Tube feeding can cause diarrhea
• Impaired mobility may have problem getting
to the bathroom
67
Stoma Care for Clients with
an Ostomy
• Normal stoma should appear red and may bleed
slightly when touched
• Assess the peristomal skin for irritation each time the
appliance is changed
Treat any irritation or skin breakdown immediately
• T i i i ki b kd i di l
• Keep skin clean by washing off any excretion and
drying thoroughly
• Protect skin, collect stool, and control odor with an
ostomy appliance
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Changing a Bowel Diversion
Ostomy Appliance: Skill 49‐2
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Changing a Bowel Diversion
Ostomy Appliance: Skill 49‐2
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Scientific Knowledge Base
Mouth Esophagus
Digestion begins with Peristalsis moves food into
mastication the stomach
Stomach Small intestine
Stores food; mixes food, Duodenum, jejunum, and
liquid and digestive juices; ileum
moves food into small
intestines
Large intestine Anus
The primary organ of bowel Expels feces and flatus
elimination from the rectum
Nursing Knowledge Base:
Factors Affecting Bowel Elimination
Age Diet and fluid intake
Physical activity Psychological factors
Personal habits Position during
defecation
Pregnancy Surgery and anesthesia
Medications, laxatives, Diagnostic tests
and cathartics
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Common Bowel Elimination Problems
Constipation Impaction
A symptom, not a disease Results from unrelieved
constipation
Diarrhea Incontinence
Associated with disorders Inability to control passage of
affecting digestion, absorption, feces and gas to the anus
and secretion in the GI tract
Flatulence Hemorrhoids
Accumulation of gas in the Dilated, engorged veins in the
intestines causing the walls to lining of the rectum
stretch
Bowel Diversions
• Temporary or permanent artificial
opening in the abdominal wall
– Stoma
Surgical opening in the ileum or colon
• S i l i i h il l
– Ileostomy or colonoscopy
• The standard bowel diversion creates a
stoma
Nursing Process and Bowel Elimination
• Assessment
– Nursing history
– Physical assessment
Laboratory tests
–L b
– Diagnostic examinations
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Assessment: Interview
• When do you usually have a bowel movement?
• Has this pattern changed recently
• Have you noticed change in color, texture, shape,
odor?
Any consitipation, diarrhea, flatulence,
• Any consitipation diarrhea flatulence
incontinence?
• What have you done to try to solvethe problem?
• Any natural aids?
• Fluids? Exercise?Stress?Medications?
76
Nursing Diagnosis and Planning
• The nursing assessment will help you to
select the appropriate nursing diagnosis.
• When planning goals and outcomes for
li t f t A f
your client, you can refer to Agency for
Health Care Policy and Research (AHCPR)
and Agency for Healthcare Research and
Quality (AHRQ).
Implementations
Acute Care
• Health promotion
• Regular exercise program
• Timing: don’t ignore urge to go
– Promotion of normal defecation
– Sitting position: squatting bet promotes
elimination, commode bedpan
– Positioning on bedpan
– Privacy
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Medications
• Cathartics and laxatives
– Bulk forming, emollient or wetting, saline,
stimulants, or lubricants
Antidiarrheal agents
• A tidi h l t
– Can be over the counter
– Can be opiates
Enemas
• Cleansing
• Tap water
• Normal saline
• Hypertonic solutions
• Soapsuds
• Oil retention
• Others: carminative and Kayexalate
Diagnostic testing
• FOBT
• O&P
• x‐ray
• endoscopy
• C&S
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Inserting and Maintaining a Nasogastric
Tube
• Purposes
– Decompression, enteral feeding,
compression, and lavage
Maintaining patency
• M i t i i t
Continuing and Restorative Care
• Care of ostomies
• Pouching ostomies
• Bowel training
• Skin integrity
Evaluation
• The fifth step in the nursing process.
• The effectiveness of care depends on
how successful the client is in achieving
l d t
goals and outcomes.
• Nursing interventions may be altered if
necessary.
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