Fundamentals Module 2C

Bowel Elimination: Fluid Intake and Patient Education

• Learning guides assist in exploring key concepts for course exams, ATI assessments, NCLEX, and nursing practice.
• Encourage clients to drink 1.5 to 2 liters (6–8 glasses) of water daily unless contraindicated due to conditions like heart or kidney failure; proper hydration softens stool, making it easier to pass.
• Dehydrating beverages like coffee, tea, and alcohol can contribute to constipation.
• Many factors such as surgery, immobility, medications, and therapeutic diets, can alter bowel function and affect bowel elimination.
• Bowel diversions may be necessary to allow fecal elimination to continue in various disease processes.
• Promote regular bowel elimination through adequate dietary fiber, fluid intake, and activity, such as walking 15 to 20 minutes daily if mobile or performing exercises in bed or chair.
• The amount of stool produced depends on the amount of food and liquid consumed.
• Bowel movement frequency varies significantly; passage of stool should not be difficult, and stool should be soft, not hard or liquid.

Normal Bowel Elimination

• Normal bowel movements range from three times a day to three times a week.
• A regular bowel routine, such as going to the bathroom at the same time daily, is important.
• Promptly responding to the urge to defecate prevents stool hardening.
• A fiber intake of 25–30g/day is recommended from fruits, vegetables, and whole grains to promote regular bowel movements.

Constipation Challenges: Assessment and Interventions

• Monitor for signs of impaction such as straining, abdominal discomfort, and small, hard stools.
• Assess for medication side effects, including those of opioids and anticholinergics.
• Increase fiber and water consumption unless contraindicated before more invasive interventions.
• Give bulk-forming products before stool softeners, stimulants, or suppositories.
• Enemas are a last resort for stimulating defecation.
• Encourage regular exercise.
• Physical activity stimulates peristalsis.
• Stool softeners or laxatives can be prescribed but avoid overuse to prevent dependency.
• Regular toileting habits and using a footstool promote a more natural position for defecation.

Diarrhea: Nursing Education

• Consumption of clear fluids, including water, broth, and electrolyte solutions, is preferred.
• The BRAT diet (bananas, rice, applesauce, and toast) can help firm up stools.
• Spicy foods, dairy, caffeine, and high-fat foods should be avoided until diarrhea resolves.
• Avoid alcohol, caffeine, dairy, foods high in fat, beverages that contain fructose, spicy foods, apples, peaches, pears, and products that contain sweeteners
• Gentle cleansing and barrier creams prevent skin breakdown.
• Protective undergarments can prevent embarrassment and discomfort.
• Dehydration and malabsorption can occur with persistent diarrhea resulting in life-threatening situations if severe.
• Symptoms requiring medical follow-up include a fever of 102°F or higher, diarrhea lasting longer than 2 days or six or more bowel movements a day, abdominal pain, or the presence of blood or black feces.
• Older adults and children with impaired immune systems should receive immediate medical care if symptoms are present.
• Check for signs of dehydration and encourage fluid intake to replace fluid loss.
• Suggest yogurt after diarrhea stops to help re-establish the intestinal balance of beneficial bacteria.
• Avoid bowel irritants, such as caffeinated beverages and alcohol.

Fecal Occult Blood Specimen: Client Education

• Avoid red meat, NSAIDs, and vitamin C supplements 72 hours before the test to prevent false results.
• Do not collect stool during menstruation or with active hemorrhoid bleeding.
• Provide the client with a stool collection kit and explain how to use it; follow instructions to place stool on the card.
• Collect samples from three different bowel movements for accuracy.
• Ensure the sample is properly sealed and stored as directed, usually refrigerated.
• A positive result likely indicates bleeding from the stomach or elsewhere in the digestive tract.

Mobility Impact on Bowel Elimination

• Physical activity stimulates peristalsis, aiding bowel movement.
• Walking or light exercise for at least 20–30 minutes per day is recommended.
• Bedridden clients should do range-of-motion exercises and be repositioned regularly to prevent constipation.
• Instruct clients to use a footstool while sitting on the toilet to improve rectal alignment and ease defecation.
• No or decreased mobility will slow bowel motility and peristalsis; increased walking or moving around will increase these.

Factors Impacting Bowel Elimination Patterns

• Infants have water and yellow-brown stools from breast milk versus pasty and brown stools from formula.
• Toddlers gain bowel control at 2-3 years old.
• Adolescents experience increased secretion of gastric acids and accelerated growth of the large intestine.
• Older adults experience decreased peristalsis and relaxation of sphincters.
• Fiber requirement is 25-38 g/day.
• Difficulty digesting foods, for example, lactose intolerance, can cause watery stools.
• Gas can be increased by certain foods like cabbage, cauliflower, and apples
• Laxative effects can come from figs and chocolate.
• Risk of constipation can be increased from consuming pasta, cheese, and eggs.
• Recommended fluid intake is 2.7 L/day for females and 3.7 L/day for males from fluid and food sources.
• Physical activity stimulates intestinal activity and increases skeletal muscle tone needed for defecation.
• Emotional distress increases peristalsis and exacerbates chronic conditions like colitis, Crohn’s, ulcers, and irritable bowel syndrome.
• Depression can lead to decreased peristaltic activity and constipation.
• Reluctance to use public toilets, false perception of the need for "one-a-day" bowel movements, and lack of privacy when hospitalized all affect bowel habits.
• Normal positioning includes squatting.
• Immobility can result in difficulty contracting gluteal muscles and defecating.
• Suppression of the urge to defecate can come from pain from hemorrhoids, fissures, and perianal surgery.
• Opioid use contributes to constipation.
• Growing fetus compromises intestinal space during pregnancy.
• Slower peristalsis and straining can increase the risk of hemorrhoids during pregnancy.
• Surgery causes temporary slowing of intestinal activity, needing auscultation bowel sounds before advancing diet.
• Laxatives soften stool, and cathartics promote peristalsis.
• Laxative overuse can cause a weakening of the bowel’s expected response to distention from feces, resulting in chronic constipation.

Fecal Impaction: Safety Considerations

• Stool becomes wedged in the rectum, possibly with diarrhea fluid leaking around it.
• Administer enemas, suppositories, or stool softeners as prescribed to promote relief.
• If necessary, manually remove fecal impactions that do not respond to other interventions with a gloved, lubricated finger for digital removal of stool.
• Loosen the stool around the edges and remove it in small pieces, allowing the client to rest as necessary.
• Avoid stimulating the vagus nerve when evacuating the rectum.
• Cease the procedure if the heart rate drops significantly or the heart rhythm changes.
• Monitor for signs of bowel perforation such as severe abdominal pain, distension, fever, and tachycardia.
• Hardened stools clump together, preventing bowel evacuation and leading to intestinal obstruction or rectal injury.

Urinary Elimination: Catheter Insertion and Specimen Collection

• Confirm prescription for indwelling catheter.
• Introduce yourself, perform hand hygiene, and verify client identification.
• Explain the procedure and determine whether the client has allergies.
• Place equipment on a stable surface and adjust the environment for convenience, ergonomics, and lighting.
• Assist the client to a position that accounts for their physical limitations.
• Apply clean gloves and perform perineal care, following with hand hygiene.
• Use sterile technique to prepare equipment and apply sterile gloves.
• Cleanse the meatus using sterile technique, then apply lubricant.
• Insert the catheter and advance it until urine appears in the drainage tube; then, advance approximately 2 inches more.
• Retract the foreskin if uncircumcised, then hold the penis just below the glans.
• Clean the meatus with sterile antiseptic using a circular motion at least three times, using one cotton swab or cotton ball each time.
• With the nondominant hand, hold the penis upward using slight tension.
• Once urine is noted in the drainage tube, advance all the way to the tubing bifurcation (catheter).
• Hold the catheter securely with the nondominant hand while inflating the catheter balloon.
• Gently pull back on the catheter until resistance is felt and replace the foreskin if the client is uncircumcised.
• Secure the catheter with a securement device, placing the collection device below the level of the bladder.
• Perform perineal care, dispose of equipment, and perform hand hygiene.
• Ensure that the client is safe and has the call light within reach.
• For clean-catch urine specimens, indications include urinalysis, culture and sensitivity, and signs of UTI.
• 30-60mL is required.
• Female clients should perform hand hygiene, spread the labia, cleanse the vulva from front to back, initiate the urine stream, pass the container into the urine stream, remove the container before urine flow ends, replace cap, and hand hygiene.
• Male clients should perform hand hygiene, retract the foreskin if uncircumcised, cleanse the urinary meatus, initiate the urine stream, pass the container into the urine stream, remove the container before urine flow ends, replace cap, and hand hygiene.
• Urine collection bags can be used for pediatric specimen collection of non-sterile urine.
• Culture and sensitivity is done with sterile intermittent catheterization.
• Label the specimen per policy, send it to the lab immediately, document collection, and report findings to the provider after specimen collection.

Urinary Catheter Insertion

• Indications include urinary tract obstruction, strict output monitoring in critically ill clients, perioperative, and hospice care.
• Women position themselves with knees bent, knees falling to the side.
• Perform hand hygiene and open a sterile kit, applying sterile gloves and a drape under the client’s buttocks.
• Lubricate the catheter tip and pour antiseptic solution over cotton balls or swab sticks.
• Use nondominant hand to spread the labia. Cleanse labia majora, labia minora, and urinary meatus, then use dominant hand to insert the catheter until urine return is visualized.
• Advance an additional 1-2 inches for an indwelling catheter.
• Hold the catheter in place and inflate the balloon, pulling back gently, then attach it to the client using a securement device.
• Straight catheters: When flow of urine ceases, slowly remove the catheter.
• Men position themselves supine.
• Perform hand hygiene and open a sterile kit while applying sterile gloves and a drape with an opening over the penis.
• Lubricate the catheter tip and pour antiseptic solution over cotton balls or swab sticks.
• Grasp the penis and retract the foreskin if present, cleansing in a circular motion from meatus to glans three times.
• Use the dominant hand to insert the catheter to bifurcation.
• Hold the catheter in place and inflate the balloon to gently pull the catheter back and return the foreskin over the flans if present.
• Attach a catheter to the thigh using a securement device.
• Straight catheters: When flow of urine ceases, slowly remove the catheter.

Urinary Incontinence

• Random bladder muscle contractions can be from central nervous system (CNS) dysfunction, spinal cord injury, bladder disorders, and bladder outlet obstruction.
• Clinical features include a strong, sudden urge to urinate resulting in urine leakage and leakage varying in frequency and amount.
• Incontinence commonly occurs at night.
• Nursing interventions include bladder retraining with urge suppression.
• Avoid bladder irritants like smoking, caffeine, and alcohol, and avoiding constipation
• Empty the bladder every 2 hours while awake.
• Pelvic floor muscle exercises like Kegels.
• Use absorbent products and weight loss.
• The use of antispasmodic medication like oxybutynin and tolterodine treat incontinence.
• A significant contributing factor to skin breakdown and falls, especially in older adults.

Urinary Retention

• Inability to empty the bladder completely results in a high postvoid residual volume.
• Urinary retention can be caused by urethral obstruction or bladder paresis.
• Urinary retention has associated factors like prostate enlargement, urethral trauma, anesthesia, neurologic conditions, and anticholinergics or opioids.
• Clinical features can be acute such as with surgery or chronic like benign prostatic hyperplasia.
• Lower abdominal pain, pressure, discomfort, straining to void, decreased urine output, overflow incontinence, and bladder firmness results in the feeling of incomplete bladder emptying.
• Complications include bladder distension and UTI, which can lead to pyelonephritis, sepsis, hydronephrosis, and skin breakdown.
• Nursing interventions promote spontaneous voiding, assisting the client to use the bathroom, beside commode, or urinal and to provide privacy.
• Run water and/or pout warm water over the perineum.
• Offer oral fluids and monitor intake and output.
• Perform a bladder scan to assess the volume of urine in the bladder, normal PVR is 50-75 mL, and consider intermittent urinary catheterization if indicated.

Urinary Tract Infection

• Bacterial infection of the urinary tract (cystitis) and/or upper urinary tract (pyelonephritis)
• Escherichia coli is the most common cause
• Diagnosis via clean-catch, midstream urine sample
• Risk factors include female sex, advanced age, bladder obstruction, diabetes mellitus, sexual intercourse, recurrent antibiotic use, and the presence of foreign objects.
• Clinical Features of cystitis include dysuria, urinary frequency and urgency, hematuria, and lower abdominal pain.
• Clinical Features of pyelonephritis include nausea and vomiting, fever, and flank pain.
• Confusion is common in older adults.
• Antibiotics are used in Pharmacological management like trimethoprim/sulfamethoxazole and ciprofloxacin.
• Antipyretic/analgesics, for example, acetaminophen, are antipyretics.
• Use antispasmodics in pharmacological management
• Client teaching includes increasing fluid intake, 2-3 L daily.
• Avoid bladder irritating foods and beverages, including caffeine, spicy foods, and alcohol.
• Practice Perineal hygiene, wiping front to back after voiding/defecating for females.
• Males should pull back uncircumcised foreskin when cleaning, and infants need prompt changing of wet diapers to keep the perineum dry and clean.
• Avoid scented soaps, bubble baths, and synthetic fabrics like nylon and spandex.
• Do not delay urination, empty the bladder before and after sex.

Urinary Incontinence: Risk Factors and Manifestations

• Urinary incontinence is the involuntary loss of urine, affecting millions worldwide.
• Urinary incontinence is common among older adults.
• Risk factors include pregnancy, obesity, menopause, neurological conditions, and physical disabilities.
• Urinary incontinence can lead to skin breakdown and frequent bladder infections.
• It can impact daily life with embarrassment, social withdrawal, and ineffective coping.
• Stress incontinence results in a loss of urine during activities like sneezing or lifting.
• Urge incontinence involves a strong urge to void, frequent urination, and nocturia.
• Reflex incontinence has sudden leakage without urge from neurological issues
• Overflow incontinence has leakage due to an overfilled bladder from urinary retention.
• Functional incontinence is when clients is unable to reach the toilet in time because of physical or cognitive impairments.
• Suggested interventions: lifestyle modifications (diet changes, fluid management), behavioral therapy (bladder training, scheduled voiding), Kegel exercises (strengthening pelvic muscles), medications (anticholinergics, beta-3 agonists, estrogen), devices (pessary, urethral inserts), and surgery for severe cases.
• For skin breakdown implement bladder training programs, keep skin clean and dry, assess manifestations, and apply protective barrier creams.
• For social isolation, assist with measures to conceal injury and provide emotional support.

Types of Incontinence: Etiology and Clinical Manifestations

• Stress incontinence is due to the relaxation of pelvic muscles/weakness of the urethra, which can be caused by extra pressure on the bladder from pregnancy, obesity, cystocele, or urethrocele, it is also caused due to weak pelvic floor muscles following childbirth or menopause and in males from alterations in the urethra following a prostatectomy.
• Clinical manifestations include loss of urine when sneezing, coughing, lifting and uncontrollable wetting.
• Urge incontinence results from a hypertonic/overactive detrusor muscle, bladder irritation from a UTI, or an overactive bladder.
  • Random bladder muscle contractions caused by:
    • CNS dysfunction with impaired bladder signals, leading to hyperactivity and spasticity.
    • Spinal cord injury causing impaired bladder signals, leading to hyperactivity and spasticity.
    • Bladder disorders.
    • Bladder outlet incontinence.
  • Clinical features: strong sudden urge to urinate resulting in urine leakage, which varies in frequency and amount and commonly occurs at night.
  • Nursing interventions: bladder retraining, avoid bladder irritants (smoking, caffeine, alcohol), avoid constipation, empty bladder every 2 hours while awake, Kegels, lose weight, use absorbent products, antispastic meds.
• CAUTI is an infection from a catheter.
  • Risks include the use of an indwelling catheter, increased dwell time of the catheter, opening the urinary drainage system, routine changes of an indwelling catheter, and irrigation of the indwelling catheter.
  • Older adults manifestations: new onset of increased confusion, recent falls, new onset incontinence, anorexia, fever, tachycardia, and hypotension.
  • Manifestations: urinary frequency, urgency, nocturia, flank pain, hematuria, cloudy/foul-smelling urine, and fever.
• Prevention includes the use of aseptic technique to prevent obstruction and backflow of urine, drainage tubing, and drainage bag; keep the catch bag below the bladder, peri care routinely, assess ongoing need for a catheter, drain the system before the bag is half full.
• Nocturia is when you wake up during the night to urinate, which can be caused high fluid intake before bed, bladder overactivity, underlying health conditions like diabetes/heart failure.
• Dysuria is difficult or painful urination, often from UTS, bladder infections, or irritation.
  • Pain or discomfort is clinical manifestation of dysuria

Urinary Disorders: Assessment

• Observe skin color for flushing or urine color, clarity, and odor, ask about urination frequency, urgency, burning, nocturia, lower abdominal, back, or flank pain, nausea, vomiting, temperature, length of symptoms, prior UTS, current and past treatments.
• Women should be asked about pregnancy and birth control use. All clients should be asked about chronic diseases, current medications, and allergies.
• Also check general health and vital signs and assess abdominal inspection, auscultate and percussion, palpate the abdomen, kidney assessment, and palpate the flank for tenderness and pain.
• Inspect the genitals and perianal area, check for swelling, discharge, inflammation, and signs of moisture or fecal exposure.
• Diagnosis include acute pain, impaired urinary elimination, lack of knowledge about UTIs, urinary retention, risk for fluid volume deficiency, fear.
• Clinical therapies that include lifestyle modifications for fluid and stress.
• Medication includes the use of antibiotics, behavioral, Kegel exercises, and bladder training. Surgeries include operative interventions for severe cases.
• Urine analysis checks for infection, blood, or other abnormalities, and imaging with ultrasound or CT scan identifies structural issues.

Nursing Actions for Urine Specimen Collections

• Urinalysis assesses for pyuria, bacteria, and blood cells. Needs provider's orders.
• In-depth information about a urine sample from blood to protein to white blood cells.
• Although ut can dteremine the presence of bacteria, it cannot determine the tyoe so it is often ordered with a culture and sensitivity.
• Obtain a midstream clean-catch specimen; if necessary, use straight catheterization with strict aseptic technique.
• Rapid tests use a nitrite dipstick and leukocyte esterase test to detect bacteria.
• A clean catch collects a urine sample that is free from contaminants.
• Instruct the patient to clean the genital area, start urinating, and then collect the midstream portion of the urine in a sterile container.
• Purpose of collecting a catheter-urine specimen is to obtain a sterile urine sample directly from the bladder.
• Get from the bag or straight form the catheter if first time.
• Use a catheter with strict aseptic technique; avoid catheterization to reduce infection.
• Purpose of Timed urine (24 hour) is to measure total volume and specific substances (e.g., creatinine, potassium).
• This involves collecting all urine produced in a 24-hour period in a special container, ensurING proper storage and labeling.
• Must avoid certain foods before the test and review meds, supplements, and vitamins.

Catheter Irrigation

• Continuous Bladder Irrigation (CBI) is used to prevent blood clots that can obstruct urinary output, especially after procedures like TURP (Transurethral Resection of the Prostate).
• Intermittent Irrigation is used when the urine is bloody or contains large blood clots, or when bladder spasms increase.
• Maintain the rate of flow of irrigating fluid to keep the urine output light pink or colorless, then regularly assess the catheter and drainage tubing when performing assessment
• Continuous Bladder Irrigation (CBI) - Monitor urinary output for color, consistency, and presence of blood clots and use sterile technique to gently irrigate the catheter with sterile irrigating solution until the obstruction is relieved or the urine is clear.
• This will require assessing and monitoring equal input and output of irrigating fluid.

Urinalysis Abnormalities

• Assess the urine color/clarity/smell, and compare to baseline
• If someone is exhibiting color changes (e.g., dark amber, red), expect dehydration and hematuria.
• Interventions include increasing fluid intake, monitoring for signs of bleeding, and notifying the healthcare provider.
• If someone exhibits cloudy urine, expect infection or presence of pus.
• Interventions include obtaining a urine culture, administering prescribed antibiotics, and educate on hygiene.
• If someone has a strong odor, expect infection and certain foods.
• Interventions include assessing for infection, dietary review, and increasing fluid intake.
• For someone exhibiting abnormal pH (e.g., very high or low), expect metabolic and/or respiratory conditions.
• Interventions include monitoring acid-base balance, reviewing medications, and making dietary modifications.
• If someone has high specific gravity, expect dehydration or glycosuria.
• Interventions include increasing fluid intake and monitoring blood glucose levels.
• Presence of protein would mean possible kidney disease/hypertension
• Interventions include dietary protein management
• Presence of Glucose comes with diabetes mellitus
• Interventions include Hypoglycemics, and dietary education.
• Elevated ketone levels is associated with Provide insulin therapy, ensure adequate nutrition when diabetic ketoacidosis and starvation is present
• Presence of blood implies there are trauma, infection, and stones
• Assess for injury, obtain urine culture, pain Management, increase fluid intake
• Presence of Bilirubin would mean some sort of liver desease
• To intervene, assess for jaundice, dietary Modifications, assess liver function
• If the Nitrites/Leukocyte findings are high then its very likely infection and antibiotics will manage that

Factors Affecting Urination

• Poor abdominal and pelvic muscle tone is one.
• Then acute and chronic disorders and spinal cord injuries, and age affect it with a common problem in older men being enlarged prostrates
• Pregnancy, high BMI and weight gain, and childbirth all affect urination and pelvic support
• Factors that interfere with mobility and dexterity also affects voiding function

Age

• Children typically achieve full bladder control by 4-5 years of age.
• Prostate enlargement in older adult males can cause urinary retention and urgency to which clients must take good care of themsselves
• For a clients post menopausal then the lack of estrogen affects perineal tone.
• Childbirth and gravity weaken the pelvic floor, putting clients at risk for prolapse of the bladder outlet, leading to stress incontinence, which clients can help manage with pelvic floor (kegel) exercises.

Older Adults

• Fewer nephrons and reduced bladder tone
• Increase the risk for UTIs since there is higher residual volume
• Increased nocturia since lower total bladder V
• Presence of chronic illnesses

Other Affecting factors

• The growing fetus affects urination
• 30 - 50 % is a major increase to workload on the kidneys
• Diet
• Increased sodium hurts urination and the increase in caffiene hurts urination
• Surgery and medications also play crucial roles to ensure that no adverse affects happens
• The hormone relaxin causes relaxation of the sphincter during pregnancy.

Nursing Assessment: Voiding Patterns

• How many times are you voiding per day ?
• Has this total daily balance recently changed ?
• Do yo need to void per night

Latex Allergies

• Make sure that the correct latex product and all associated products is identified
• Use non latex products as a primary method since it may harm
• Be sure to use powder free as powder just makes thing worse
• Never use oil based since that also hurts
• Monitor for all the main signs and report and educate the client on what exactly is up
• Use silicon or Teflon products for clients who have latex allergies.
• Use nitrile gloves.

Catheter Care

• Make sure to use Anaseptic technique and preform good maintenance to keep the risk of infections low
• Maintenence and insertion, use full length and avoid any damage to urethra and always keep it at a closed drainage
• Keep up with perineal care to avoid the chance of any bacteria increase
• Monitor 1-2 hours since its yellow or longer and be careful

IVP and key aspects

• The injection is to evaluate the structure and function of the kidneys.
• Contrast dyes that can cause adverse and sometimes fatal reactions
• Hydration of the client is the most important since it decreases damage
• Fasting before hand is very crucial.

I and Os

• A normal amount of fluids and solids
• A normal amount of excrement for people to keep everything working
• And remember that 400 minimum since thats a bare minimum to stay healthy.
• Monitor for any chronic complications and preform any and all necessary nursing implacations.
• <30/mL/hr for more than 2 hr should be reported to the provider because inadequate urinary output is a manifestation of urinary retention, hypovolemia, or impaired kidney function.
• Minimal output can cause bladder distention, overfilled and swollen kidneys causing injury to tissue, leading to a UTI and cause pyelonephritis, lead to the bloodstream, causing sepsis.
• Overflow incontinence can lead to skin breakdown very quickly.
• Use a hard plastic durometer or an indwelling catheter drainage bag.