208 Concept: Elimination; topics: Abdomen/GI, male/female genitourinary, anus, rectum and prostate Flashcards
Define elimination.
Broadly speaking, the term elimination refers to the removal, clearance, or separation of matter. From a human physiological perspective, the term elimination is defined as the excretion of waste products.
What is the scope of elimination?
Efficient elimination — Waste excretion —– Impaired elimination
What is elimination from the bowels called?
passage of stool
What is elimination from the urinary system called?
passage of urine
What are risk factors for persistent urinary incontinence?
Advanced age Female Menopause Multiparity Obesity Smoking Impaired mobility Trauma or surgery pelvic region Impaired cognitive, debilitated state Neurologic disorders (such as stroke, spinal injury, brain tumor)
What are risk factors for persistent fecal incontinence?
Advanced age Diarrhea Impaired mobility Impaired cognitive debilitated state Injury chronic condition affecting rectal neuropathway
What are risk factors for urine retention?
Advanced age Male Prostate enlargement, inflammation, or infection Pelvic organ prolapse Pelvic mass Pelvic trauma/surgery Medications (anticholinergics, sympathomimetics)
What are risk factors for fecal retention?
Advanced age Female Pregnancy Lower income Poorly educated Sedentary lifestyle Dehydration Chronic conditions (inflammatory bowel syndrome, depression) Medications (opioids, diuretics, antidepressants, aluminum-based antacids)
At what age are children typically potty trained?
2-3 years old
What organs would you find in the right upper quadrant?
- gallbladder
- liver
- ight kidney
- hepatic flexure
- duodenum
- head of pancreas
- parts of ascending and transverse colon
What organs would you find in the right lower quadrant?
- appendix
- cecum
- right ovary
- right ureter
- right spermatic cord
What organs would you find in the left lower quadrant?
- sigmoid
- left ovary
- left ureter
- left spermatic cord
What organs would you find in the left upper quadrant?
- stomach
- spleen
- body of pancreas
- left kidney
- parts of transverse and descending colon
What organs would you find in the midline?
- aorta (just left of midline)
- uterus (if enlarged)
- bladder (if distended)
In infants, how many arteries and veins are in the umbilical cord?
2 arteries and 1 vein
In infants, does the liver take up proportionately more or less space than in later life?
More
What developmental considerations are there for pregnant women?
- “morning sickness” - no definitively known cause but hormones are suspected
- Elevated progesterone relaxes muscles and can lead to increased heart burn
- constipation and increased venous pressure can lead to hemorrhoids
- bowel sounds are diminished
What developmental considerations are there for older adults?
- fat can accumulate on the belly
- salivation decreases leading to dry mouth
- esophageal emptying is delayed, so feeding older adult in supine position increases risk for aspiration
- gastric secretions decrease; absorption of medication can be impaired and may cause pernicious anemia (from impaired vitamin B12 absorption)
- more susceptible to dehydration
- liver decreases in size, though function remains normal
- renal function decreases
- increased gall stones
- risk for colorectal caner increases with age
What factors can lead to constipation in older adults?
- decreased mobility
- pathological conditions
- adverse medication effects
- poor dietary habits (inadequate intake of fluids and fiber)
- prolonged use of laxatives
- use of opiods or NSAIDS
What health history topics get covered in an abdomen assessment?
- Appetite
- Dysphagia
- Food intolerance
- Abdominal pain
- Nausea/vomiting
- Bowel habits
- Past abdominal history
- Medications
- Alcohol and tobacco
- Nutritional assessment
Define pyrosis.
Burning sensation in esophagus and stomach, caused by reflux of gastric acid.
Pain from internal organ characterized as dull, general, poorly localized
visceral pain
Pain characterized as sharp, precisely localized, aggravated by movement
parietal pain (inflammation of overlying peritoneum)
Pain resulting from a disorder in another site.
referred pain
What can cause hematemesis (blood in vomit)?
- stomach or duodenal ulcers
- esophageal varices
What might cause black and tarry stool?
- occult blood from gastrointestinal bleeding
What might cause black but non-tarry stool?
iron medications
What might cause grey stools?
hepatitis
what might cause red blood in stools?
- gastrointestinal bleeding
- localized bleeding around the anus (hemorrhoids)
What can cause peptic ulcer disease?
- frequent use of NSAIDS
- alcohol
- smoking
- H. pylori infections
Additional abdominal assessment Hx questions for infants and children.
- breastfeeding or formula
- table foods
- eating patterns
- non-food eating (termed pica)
- constipation
- abdominal pain
- overweight children
Additional abdominal assessment Hx questions for adolescents.
- schedule and content
- exercise
- underweights (awareness of anorexia nervosa and bulemia)
Additional abdominal assessment Hx questions for older adults.
- food access (risk for nutritional deficiency)
- emotional characteristics (alone or shared)
- Recall
- any trouble swallowing
- bowel movements
Measures that enhance abdominal wall relaxation.
- empty bladder ahead of examination
- keep room warm (prevents tensing of muscles)
- arms at sides
- warm the stethoscope
- keep fingernails short
- inquire about painful areas and examine last to prevent muscle guarding
- privacy; covering and draping
What might cause excessive belcing?
hiatal hernia
Why might your urine be the colour of syrup or brown ale?
- liver disease
- severe dehydration
Why might your urine be pink or reddish?
- beetroot, berries or rhubarb
- blood in urine (kidney disease, uti, tumour)
Why might your urine be orange?
- not drinking enough water
- liver or bile duct condition
- food dye
Why might your urine be blue or green?
- rare genetic disease
- bacterial infection
- dye in food or medication
What frequency of bowel movement constitutes constipation?
less than 3-4 BMs per week
What other reasons could stool be black besides blood or iron medication?
- muconium in newborns
- use of bismuth (pepto)
How many levels of the Bristol chart?
7
Describe the 7 levels of the Bristol chart.
1: Separate, hard lumps: very constipated
2: Lumpy and sausage like: slightly constipated
3. A sausage shape with cracks in the surface: normal
4. Like a smooth, soft sausage or snake: normal
5: Soft blobs with clear cut edges : lacking fiber
6: mushy consistency with ragged edges: inflammation
7: liquid consistency with no solid pieces: inflammation and diarrhea
Why beside hepatitis might your stool be white/pale/gray?
lack of bile, and some anti-diarrheal medications
Why might stool be green?
- spinach, kale
- too much bile
- not enough bilirubin
Why might stool be red?
- blood
- beets
- hemorrhoids
- GI bleeding
What is the normal rate of urine output?
30 - 40 mL per hour; about 240 mL per 8 hours, though that is still quite concentrated
What is the correct sequence for physical examination?
1) Inspection
2) Auscultation
3) Percussion
4) Palpation
What are the normal and abnormal contours of the abdomen that you might find?
Normal: Flat or rounded
Abnormal: Scaphoid or protuberant (except in toddlers and pregnant ladies)
What developmental considerations are there for infants and children? (across abdomen, urinary and genital)
- Umbilical cord shows on the abdomen
- Liver takes up more space in the abdomen
- Bladder is higher in the abdomen – between symphysis pubis and umbilicus
- Abdominal wall less muscular – organs easier to palpate
- Increased risk for dehydration with gastroenteritis due to small body weight. Signs of dehydration (changes in LOC, sunken eyes, tachycardia, tachypnea, & decreased skin turgor)
- Testes descend along the inguinal canal into the scrotum before birth
- Effects of maternal estrogen on the external genitalia of newborns – swollen labia
- Meconium – indicates anal patency
- Stool is passed by reflex – voluntary control doesn’t start until around 1 ½ - 2 years of age
What developmental considerations are there for adolescents? (across abdomen, urinary and genital)
Puberty changes – estrogen stimulates cell growth in the reproductive tract and there is development of secondary sex characteristics. First signs are breasts and pubic hair developments (8 ½ - 13).
Menarche -occurs over latter part of the sequence. Irregularity is common.
Prostate gland doubles in size at puberty
What developmental considerations are there for adults and older adults? (across abdomen, urinary and genital)
Older women - Fat accumulates in the suprapubic area (due to decreased estrogen)
Adipose tissue redistributed
Decreased salivation
Delayed esophageal emptying
Decreased gastric acid secretions – impaired or delayed absorption of medications
Increased risk for dehydration
Liver size decreases
Renal function decreases – increase risk of toxic medication effects
Increased constipation – decreased motility, decreased mobility, medication effects, dietary habits, decreased fluid intake.
Medications can affect sexual performance
Older women – changes in sexual function
Pregnancy – morning sickness (due to hormone changes), acid indigestion (due to esophageal reflux), constipation (due to decreased motility and increased water reabsorption from the colon), decreased bowel sounds (increased belly size displaces intestines)
Menopause due to decreased hormone levels; uterus shrinks and ovaries atrophy
Without sexual activity the vagina atrophies (becomes thinner, drier, itchy) – increased risk for bleeding and vaginitis.
Urinary incontinence is prevalent
Prostate gland enlarges during middle adult years - BPH is present in 10% of males by age 40. This gradually impedes urine output by obstructing the urethra. Also an increased risk of prostate cancer with aging.
What are signs of possible intestinal obstruction?
- markedly visible peristalsis combined with abdominal distension
True or false: if you hear a bruit while auscultating the abdomen, you should continue
False. You should stop and not palpate. Report findings immediately as it could be an aortic aneurysm and you may rupture it if you palpate it.
What quadrant should you start auscultation in?
Right lower quadrant; bowel sounds are normally present there
What is the frequency of normal bowel dounds?
5 - 30 times per minutes; don’t really need to count.
What is a “growling stomach” called and is it a normal finding?
borborymus - yes, normal
What is uncommon to hear in bowel sounds and how long should you listen to verify your finding?
no sounds: “silent abdomen”. Listen for 5 minutes before deciding they are absent.
What are developmental considerations for anus and rectum for newborns?
- meconium; 24 - 48 hours after birth indicates anal patency
- Passes stool by reflex - voluntary control by 1.5 to 2 years
What are developmental considerations for anus and rectum for adolescents?
- at puberty, prostate gland undergoes a very rapid increase to more than twice its prepubertal size
What is benign prostatic hypertrophy (BPH)?
The normal enlargement of the prostate throughout the man’s lifetime.
How often is usual screening for colorectal cancer (CRC) for those aged 50 to 74?
Every two years for stool tests and every 10 years fir flexible sigmoidoscopy.
What health history questions do you ask for anal, rectum and prostate assessment?
- Usual bowel routine
- change in bowel habits
- rectal bleeding or blood ins tool
- medications, including laxatives, stool softeners, and iron
- Rectal conditions such as pruritis, hemorrhoids or fissures
- Family history of polyps; inflammatory bowel disease; colon, rectal or prostate cancer
Self-care behaviours like a high fiber diet
What are the steps of the objective assessment for rectum, anus and prostate?
- Inspect anus and perianal area
- Inspect during Valsalva manoeuvre
- Palpate anal canal and rectum in all adults.
- Test stool for occult blood.
- Engage in teaching and health promotion.
What factors affect normal bowel elimination?
- diet (fiber and fluid are important)
- fluid intake ( 6- 8 glasses of non-caffeinated fluids daily; limit coffee and tea as it can irritate bowel and be dehydrating.
- physical activity
- personal bowel elimination habits
- privacy
