I'm Kristine Pfendt, and I'm here to talk to
you today about the topic of elimination.
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.
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.
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.
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.
And those that are really active like runners
or mountain climbers can lose up
to six liters of water through perspiration
in 24 hours.
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.
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.
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.
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
as well as be offensive to caretakers who
would tend to avoid the patient.
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.
Falls are common as older people struggle
to get to the bathroom
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
Older clients often lose the sense of thirst.
So they become dehydrated very easily.
As nurses, we should encourage drinks
of water or fluid intake of
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.
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.
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.
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.