Elimination (Nursing)

00:00 I'm Kristine Pfendt, and I'm here to talk to you today about the topic of elimination.

00:06 The elimination of waste products from the body is very important, but it is also something that is very private and personal to each one of us. There are four systems which are involved with the elimination process. The first one that we really don't think about a lot is the pulmonary system, or the lungs.

00:26 The second one is the integumentary system which is the skin that covers our body. The third one is the urinary system, which is primarily concerned with the kidneys and the bladder.

00:35 And the fourth system is the gastrointestinal or GI system which is made up of the small and large intestine. The process of inspiration is part of the respiratory function and it is involved with the intake of oxygen into the lungs where it's dispersed throughout the body through the circulatory system. The process of exhalation is where waste products, carbon dioxide, and other gasses along with water are exhaled. The integumentary system, which involves the skin which covers our entire body, assists with the process of elimination through perspiration or sweating. Perspiration is a way that the body maintains thermal regulation or maintains temperature.

01:24 When we perspire, we lose water, we lose the substance called lactate, we lose urea, and we lose small amounts of minerals. Water losses via the skin can range from a third of a liter within 24 hours to up to six liters, depending on the activity level of the person. So, normal water loss through the skin ranges from a third of a liter up to two liters. People who are more active can lose from two to four liters.

01:54 And those that are really active like runners or mountain climbers can lose up to six liters of water through perspiration in 24 hours.

02:04 The renal system filters waste products from the circulation of the blood via the kidneys. As the kidneys filter waste products, urine is passed through the ureters to the bladder where it is stored until the person is ready to urinate. The kidneys act as filter which removes metabolic waste products from the blood, and they play a key role in maintaining homeostasis of fluid and electrolyte balance throughout the body.

02:32 Urea combines with water to form urine which is stored in the bladder and excreted. Normal urine output ranges from 1200 to 1500 milliliters per day. Each time an adult urinates or voids, they eliminate between 200 and 500 ml per voiding.

02:54 Infants have a normal urine output of about 600 mls per day. And of course, this will differ with the age and the size of the child. For 24 hours should equal the fluid intake of the person in that same 24 hours. In other words, intake should equal output in 24 hours.

03:16 Anytime urine output falls below 30 ml per hour, there is a problem, either the kidneys are not functioning, there's not enough fluid in the patient's system or blood volume and kidney function are being compromised. The last system that I'm going to talk about is the gastrointestinal system. As food is taken in by the person into the stomach, the digestion process begins. And as it moves through the small intestine, additional water is added to help facilitate digestion and the reabsorption of nutrients. Once that process is completed, the food moves into the large intestine, I should say food in the form of waste products. The longer the waste products stay in the large intestine, the more of water is reabsorbed into the body. So the primary function of the large intestine is to reabsorb water, as well as facilitate the movement of waste products. Skin cleanliness and integrity are essential to preserving the patient's self-concept. If skin breakdown occurs in any of the areas around the elimination orifices, odor and bacteria will take place causing infection and skin breakdown. It is very important that as nurses, we are aware of this and that we use good hygiene methods to eliminate odor and to try to minimize any skin breakdown. Odors can make the patient very self-conscious as well as be offensive to caretakers who would tend to avoid the patient.

04:56 I want to address elimination across the age span. Children do not normally achieve voluntary urination and bowel elimination continence until about the age of three years. Some children may achieve it earlier and some children may be delayed in achieving it. In Europe, children are often potty trained by the age of two. But in the United States, potty training may not start until the age of three. It all depends on the development of the neurological system as it relates to elimination. But if a child has not achieved continence, meaning they cannot control urine or bowel, by the age of five to seven, it's very important that the nurse refer the parents and the child to a physician who specializes in urinary continence to determine whether or not there's a physiological problem. As we age, we lose muscle tone and strength. So, control of urination and bowel become a huge concern for the older population. No muscular signals may slow as a person ages, and oftentimes, the person may not realize that they have to go to the bathroom. They may struggle with continence, and as a result, their self-esteem may be impaired. No one wants to lose control of their bowel or bladder.

06:18 Falls are common as older people struggle to get to the bathroom on time.

06:25 Surgical diversions include ostomies which divert either the urinary flow or the elimination products from the GI system into pouches, which are worn on the outer skin of the patient. Collecting pouches are essential to collecting the products of elimination, but they can also become a source of great frustration for the patient. If the bag leaks or if it becomes very odorous, smelly, then the bag needs to be changed. And if leakage occurs, skin breakdown can occur second to that. So it's very important that we as nurses maintain good skin integrity through cleanliness and necessary changes of the bag as it's needed.

07:12 Older clients often lose the sense of thirst. So they become dehydrated very easily.

07:18 As nurses, we should encourage drinks of water or fluid intake of juices, etc, every two hours for a patient so that they can remain well-hydrated. The nurse that assists the client and family also in identifying potential hazards within the patient's room in the hospital or in the home setting in order to keep the patients safe as they try to go to the bathroom. We should be sure that we have good lighting, pick up any throw rugs that may be on the floor, and remove any potential hazards to falling such as electrical cords or telephone cords.

07:55 Patients often fall and fracture hips or other bones as they are trying to get to the bathroom. So good lighting is essential even at night. Sometimes in the elderly, we put absorbing pads or diapers on them, and this should be used as a last resort.

08:11 We should always try to encourage continence, self-continence of the patient before putting diapers on the patient. And it is never acceptable for a nurse to say to a client who says they need to go to the bathroom to quote just go in the diaper, because that discourages continence in the patient. I'd like to talk now about urinary catheters. Catheters have often historically been used as a way to maintain continence in patients. But we need to remember as nurses, that anytime a urinary catheter is introduced into the bladder, we also have the potential of introducing bacteria. So with urinary catheters, there is a 95% chance of infection over time. And if the infection becomes systemic in an older patient, they can succumb to septicemia. So, long-term catheters place the patient at risk for infection. And these would include suprapubic catheters as well.

09:11 So, once a patient has this type of catheter, they?re almost assured of getting a urinary tract infection. And patients often make repeated trips to the emergency room in septic states. One of the ways that nurses can help to minimize the incidents of urinary tract infections is to include fluids in the patient's daily regimen. Lots of water, cranberry juice, and those types of fluids are very important for flushing bacteria that may exist in the urinary tract system out of the patient's body. Bladder training should always be encouraged in patients regardless of their age. There is no reason that an older client has to lose self-control of urinary and bowel elimination. It is very important that we as nurses work with clients and their families to promote the integrity of the patient and promote self-esteem. Working together with bladder training or bowel training regimens can keep the patient independent as long as possible.