Elimination & med math

How stool is madeSlides content

• The epiglottis covers the airway when you swallow so food goes into the esophagus.
• Peristalsis starts in the esophagus and pushes food along the whole tract.
• Stomach: food mixes with digestive secretions, then empties slowly into the small intestine.
• Small intestine: the pancreas, liver and gallbladder add enzymes; most nutrients are absorbed here into the bloodstream.
• Large intestine: water is absorbed and stool forms from unused food, liquid and GI cells. Bacteria here make vitamin K (clotting and strong bones). The rectum stores stool until a bowel movement.
• Like urine, the amount of stool depends on how much a person eats and drinks. Frequency varies (several a day to every other day), but stool should be soft and formed.

Assessing bowel eliminationSlides content

Stool characteristics to assess: volume, color, odor, consistency and shape.

Abdominal exam order: inspect → auscultate → percuss → palpate. Listen before you touch, because touching can change bowel sounds.

Bristol Stool Chart

What affects bowel eliminationSlides content

The slides list diet, age, medications, physical activity and psychological factors (plus constipation and diarrhea themselves), and as risk factors age, mobility/motility, psychological stress (lack of privacy) and medications.

Constipation vs diarrheaSlides content

Medications

ComplicationsSlides content

Nursing care

1. Increase fiber and fluids
2. Bulk-forming product
3. Stool softener, stimulant or suppository
4. Enema (last resort)

Adults with diarrhea need follow-up for: fever 39° C (102.2° F) or higher, diarrhea longer than 2 days or 6+ stools a day, severe abdominal pain, black or bloody stool, vomiting that blocks drinking, a weak immune system, or signs of dehydration.

Bowel incontinence, gas & hemorrhoidsSlides content

Bowel (fecal) incontinence, also called accidental bowel leakage, is loss of control over stool or gas. Causes include diarrhea, impaction with liquid stool leaking around it, nerve damage (stroke, spinal cord injury, diabetes), weak sphincter muscles (childbirth, aging) and dementia. It raises the risk of skin breakdown, falls (rushing to the toilet) and embarrassment.

Skin care for incontinent clientsSlides content

• Clean after every episode with mild soap and water or a soap-free perineal cleanser; pat dry
• Alcohol-free moisturizer, then a barrier (zinc oxide, petrolatum, lanolin or a sealant), reapplied every time, even with briefs
• Inspect the buttocks, hips, genitals and perineum often for redness that doesn't blanch, blisters or open areas
• No alcohol-based products; reposition and change linens promptly

At a glanceSlides content

1. Assess distention, pain, nausea and vomiting
2. Notify the provider; expect a CT scan
3. NPO as prescribed
4. IV fluids and electrolytes
5. Prepare for an NG tube for decompression

Suspected bowel obstruction: action order

Stool specimen collectionSlides content

Use fresh stool, wear gloves (medical asepsis), and keep urine, toilet water and tissue out of the sample.

1. Place the collection container in the toilet
2. Have a bowel movement into it
3. Transfer stool to the test container with the spatula
4. Label the container
5. Place it in the return container and send it promptly

Stool culture at home: step order

Diagnostic tests of the GI systemSlides content

Colonoscopy and sigmoidoscopy prep: usually clear liquids and a bowel cleanser. Moderate (conscious) sedation means the client can't drive home.

Bedpans & commodesSlides content

• Place the upper end under the buttocks and the lower end under the upper thighs, with a waterproof pad underneath.
• Can't lift hips: roll to the side, place the pan, roll back. Fracture pan: head of bed at 30°.
• Sit the client up whenever possible; never leave a client lying flat on a regular bedpan.
• Privacy, call light in reach, bed low and locked, measure output, perianal skin care afterward.

EnemasSlides content

An enema instills solution into the rectum and sigmoid colon to stimulate peristalsis: to relieve constipation, expel gas, empty the bowel before a test or surgery, give a medication, or start bowel training. It's a clean, not sterile, procedure.

1. Warm the solution
2. Lubricate the tube
3. Slowly insert 7.5–10 cm (3–4 in)
4. Raise the bag 30–45 cm (12–18 in) above the anus
5. Ask the client to hold it as long as possible

• Cramping or leaking around the tube: lower the bag to slow the flow.
• Resistance: stop, have the client take a deep breath, and run in a little fluid. Never force it.
• Little or no sphincter control: give it with the client on a bedpan.
• Document the results and how the client tolerated it.

Large-volume enema for an adult: 750–1,000 mL. Cleansing enemas usually work within 10–15 minutes.

Laxatives & stool softenersSlides content

Laxatives work more slowly than enemas. Long-term use weakens the bowel's natural response and causes chronic constipation. They can complicate appendicitis or a bowel obstruction.

Rectal tube or fecal management system: protects the skin of clients with no bowel control, usually in the ICU (intensive care unit). Bowel training: a regular time each day (often after a meal), high fiber and fluids, sometimes laxatives.

Types of bowel diversionsSlides content

An ostomy is a surgical opening in the abdominal wall; the stoma is the end of bowel brought to the skin. Ostomies are temporary or permanent, for cancer, inflammatory bowel disease, trauma, obstruction or diverticular disease.

Assessing the stomaSlides content

• New stomas are swollen and shrink over the first weeks to months. Measure weekly for the first 8 weeks; cut-to-fit barriers are used for the first 6–8 weeks.
• Report right away: a pale, dark red, dusky, purple, brown or black stoma (blood supply), and no output with cramping and distention (blockage).
• The stoma has few nerve endings, so the client may not feel an injury. Inspect daily.
• Clean peristomal skin with warm water or a mild soap without moisturizers; dry completely. Alcohol, povidone-iodine and oil-based or moisturizing soaps keep the barrier from sticking.

Pouching systems

1. Hand hygiene, gloves; remove the pouch gently, one corner first, supporting the skin
2. Inspect the stoma and skin
3. Clean with warm water or mild soap; dry completely
4. Measure and trace; cut the barrier 1/16–1/8 in larger
5. Paste in creases if needed; apply the barrier and pouch; clamp
6. Dispose of the old pouch; remove gloves; hand hygiene

Empty the pouch when it's one-third to one-half full. Colostomy irrigation (warm water through the stoma on a schedule) suits a permanent descending or sigmoid colostomy in a client who had normal bowel habits. Refer fit, leak or skin problems to a WOC (wound, ostomy and continence) nurse.

Peristomal skin problems

Teach clients to call for: more abdominal or incision pain, fever or incision drainage, skin irritation that a well-fitted pouch doesn't fix, trouble getting a seal, a bulge (hernia), a narrowing stoma, separation of the stoma from the skin, cuts in the stoma, or a change in bowel habits.

Living with a colostomy or ileostomySlides content

NG tube for decompressionSlides content

• Why: removes gas and stomach contents for a bowel obstruction or ileus, relieving distention, nausea and vomiting and lowering aspiration risk. Decompression and feeding aren't done through the tube at the same time.
• Double-lumen (sump) tube: the blue pigtail is an air vent. Keep it above the stomach and never clamp it while the tube is on suction.
• Before inserting: high-Fowler's, agree on a distress signal, towel and basin, check the nares, water-soluble lubricant. No oral pain medication (suction removes it).
• Measure: tip of the nose → earlobe → xiphoid process, then add 10 cm for the stomach (your instructor's rule; ATI stops at the xiphoid).
• Placement: X-ray is the gold standard; gastric pH 5.5 or less supports it; the air "whoosh" test is unreliable.
• Report coffee-ground, dark or blood-streaked drainage right away.
• Delegate: measuring output, comfort and oral care. Insertion and maintenance stay with the nurse.

How urine is madeSlides content

Each kidney has about a million nephrons, the units that make urine.

• Kidneys: two bean-shaped organs below the ribcage beside the spine. They filter waste and toxins, balance fluids and electrolytes, help keep acid-base balance, and make hormones: renin (blood pressure), erythropoietin (red blood cells), and they activate vitamin D.
• Nephrons do the filtering, reabsorbing and excreting.
• Renin → angiotensin I → ACE (angiotensin-converting enzyme) → angiotensin II, which raises blood volume and pressure.
• ADH (antidiuretic hormone) from the posterior pituitary: high ADH = less urine, low ADH = more urine.
• One ureter from each kidney carries urine to the bladder, which stretches as it fills. Stretch receptors signal the brain; the sphincters relax and urine leaves through the urethra.
• Factors that influence urination: age, medical conditions, diet and exercise, medications, fluid intake, muscle tone, psychological factors.

Measuring output & termsSlides content

• Minimum expected output: 0.5 mL/kg/hr, about 30–40 mL/hr for adults.
• Measure in a graduated container: from a bedpan, commode, urinal, a "hat" in the toilet, or the urometer on a catheter bag.

What urine color tells youSlides content

• Light yellow and clear: normal
• Dark yellow or amber: concentrated, dehydration
• Brown or tea-colored: liver disease, bile pigments or medications
• Red: blood, or foods
• Foods: beets, blackberries, rhubarb (red); food dyes (blue or green); asparagus (green, stronger odor); aloe or fava beans (dark brown).
• Medications: phenazopyridine (orange-red), amitriptyline (green-blue), levodopa (dark), riboflavin (bright yellow).

Risk factors that alter urinationSlides content

The slides list age, diet, gender, psychological stress (lack of privacy) and medications (diuretics).

Diuretics increase urination by increasing urine production in the kidneys. Take them in the morning.

Types of urinary incontinenceSlides content

Risk factors: female anatomy, many pregnancies and vaginal births, aging, low estrogen, obesity, neurologic disorders, diabetes, dementia, immobility, and medications (diuretics, opioids, anticholinergics, sedatives). Incontinence raises the risk of falls, fractures, pressure injuries and depression.

Managing incontinenceSlides content

Urinary retentionSlides content

Retention: the bladder doesn't empty fully. More common in males (BPH, benign prostatic hyperplasia). Untreated, it leads to UTIs, bladder damage, hydronephrosis, kidney injury and overflow incontinence.

• Signs: trouble starting (hesitancy), weak stream, suprapubic discomfort, distention, frequency, dribbling
• Causes: enlarged prostate, bladder prolapse, outlet obstruction, nerve problems, medications (opioids, anticholinergics, antihistamines)
• Treatment: drain the bladder (catheter), then treat the cause
• Postoperative retention: more common after spinal or epidural anesthesia, long surgery, lots of IV fluid and opioids. Confirm with a bladder scan, catheterize, ambulate early, cut back opioids.
• Bladder scanning (portable ultrasound) shows bladder volume and residual urine and avoids unneeded catheters, lowering CAUTI risk.
• Intermittent catheterization: adjust frequency so each volume is 400 mL or less.
• BPH: age-related prostate growth (DHT, dihydrotestosterone) → frequency, urgency, nocturia, weak stream, retention. After a TURP (transurethral resection of the prostate), incontinence usually resolves in about 3 months.

Conditions that alter urinary eliminationSlides content

Stone risk factors: dehydration, BMI (body mass index) over 30, gout, high urine calcium, hyperparathyroidism, past or family history, recurrent UTIs, diuretics, calcium antacids. CKD (chronic kidney disease) risk factors: diabetes, hypertension, heart disease, family history, obesity, smoking.

Urine specimen collectionSlides content

• Female clean-catch: wash hands, cleanse the labial folds front to back, then the urethral opening with a second wipe. Male: cleanse the tip of the penis (retract the foreskin if uncircumcised).
• Collect a culture before antibiotics; get it to the lab within about 2 hours or refrigerate it.
• Label in front of the client with two identifiers; note menstruation. Postpone a 24-hour collection during menstruation.
• 24-hour urine: no toilet paper, stool or blood in the container. Missed a void? Restart.

Lab studies & diagnostic testsSlides content

• Dipstick (reagent strip): quick bedside check of pH, specific gravity, glucose, ketones, protein, blood, bilirubin, leukocyte esterase and nitrites.
• Urinalysis: needs an order; can show bacteria but not which kind.
• Culture and sensitivity (C&S): grows and identifies the bacteria (24–48 hr) and shows which antibiotics kill them; the gold standard for UTI.

Types of cathetersSlides content

• Catheterization needs a provider's order. Use sterile technique for straight and indwelling catheters; external catheters use clean technique.
• Sizes: females 10–12 Fr, males 12–14 Fr. Latex allergy: silicone or Teflon.
• Female client: ask the client to bear down to make the urethral opening easier to see.
• Inflate the balloon with sterile water.
• Assess allergies, mental status, voiding pattern, vital signs, skin and bladder distention before and after.

Drainage bags

• Keep the bag below the bladder, attached to the bed frame (not the side rail), never on the floor.
• Empty into a graduated container without touching the spout.
• Cover a bag on a wheelchair for dignity.

Catheter & perineal care

• Use soap and water, not antiseptics or alcohol. Clean the catheter starting at the meatus and moving away from the body (the first 4 in).
• Female: front to back, a clean part of the washcloth for each stroke. Male: upper thighs, then the meatus and glans down the shaft; replace the foreskin.
• Clean after every bowel movement. Keep a colleague present for confused or combative clients.
• Bladder fullness but little urine: check for kinks and sediment.
• Leaking around the catheter: bladder spasms, blockage (clots, kinks) or a balloon problem.
• Irrigation uses sterile technique; pain during bladder irrigation isn't expected; report it.

CAUTISlides content

CAUTI (catheter-associated urinary tract infection): while a catheter is in place or up to 48 hours after removal.

Signs: frequency, urgency, flank pain, hematuria, cloudy foul urine, fever. In older adults: new confusion, falls, incontinence, poor appetite.

TypesSlides content

Nursing care

• After urostomy surgery keep output at 30 mL/hr or more (prevents hydronephrosis). Stents may stay 10–21 days.
• Diversions made from bowel can cause electrolyte imbalance and metabolic acidosis.
• When changing a urostomy pouch, wick urine from the stoma with rolled gauze while the skin is prepared.
• Cut the barrier no more than about 1/8 in (3 mm) larger than the stoma; mild soap and water only.
• Drink about 2 L a day (continent reservoirs: flushes mucus; all diversions: prevents infection).
• No diet restrictions after a urostomy, but alcohol, asparagus, beans, cabbage, eggs, fish and onions can cause odor.
• Report: dusky, cyanotic or black stoma; can't pass a catheter or drain a continent pouch; fever, flank pain, cloudy foul urine, confusion.
• Consult a WOC nurse; support body image concerns.

The 24-hour clockSlides content

• a.m.: remove the colon and make it 4 digits: 5:30 a.m. → 0530.
• p.m.: add 12 to the hour: 5:30 p.m. → 1730.
• Midnight hour: 12:30 a.m. → 0030; midnight itself is 2400, and one minute after is 0001.
• Noon hour: just remove the colon: 12:10 p.m. → 1210.
• Back to 12-hour: subtract 1200 for afternoon times (1930 → 7:30 p.m.).

Metric & household equivalentsSlides content

• Base units: weight in kilograms (doses in mg or mcg), volume in liters (IV fluids in L or mL; liquid doses in mL), length in meters (height in cm).
• Bigger unit → smaller unit: multiply (move the decimal right). 5 mg = 5,000 mcg. Smaller → bigger: divide (move the decimal left). 5,000 mg = 5 g. Each step between g, mg and mcg is 3 decimal places.
• More household equivalents: 2 Tbsp = 1 oz, 1 pint = 480 mL (16 oz), 1 quart = 960 mL (32 oz).
• Pounds and kilograms: lb ÷ 2.2 = kg; kg × 2.2 = lb. The kilogram number is always the smaller one.
• Apothecary units (grains) are no longer used: they caused so many errors that The Joint Commission and ISMP (Institute for Safe Medication Practices) put them on the "Do Not Use" list.
• Teach clients to use a calibrated cup or oral syringe; kitchen spoons vary.
• Insulin, heparin and some vitamins are measured in units (always spelled out); potassium in milliequivalents (mEq).

AbbreviationsSlides content

The slide writes IM as "intermuscular"; the correct term is intramuscular (into the muscle). USP (U.S. Pharmacopeia) on a label means the drug meets standards for quality, potency and purity.

Rounding rulesSlides content

• Doses less than 1: round to the nearest hundredth (0.746 → 0.75; 0.743 → 0.74).
• Doses greater than 1: round to the nearest tenth (7.48 → 7.5; 7.43 → 7.4).
• Digit to the right is 5 or more: round up. Less than 5: drop it.
• Always a leading zero (0.5 mg); never a trailing zero (5 mg, not 5.0 mg).
• Facility rules can differ, especially for high-alert drugs.

Three ways to set up a doseSlides content

The slide's example

174 mg of amoxicillin/clavulanate ordered; available 125 mg/5 mL; round to the nearest whole number.

One more example, all three ways

Phenytoin 0.6 g ordered; available 300-mg capsules. First convert: 0.6 g = 600 mg.

Habits that prevent errors

• Read the whole problem first: what unit you're solving for, the desired dose, the dose you have, the quantity, and any time factor (such as every 12 hr).
• Write the unit labels (mg, mL, tablets) in every step.
• Pick one method and use it every time.
• Ask whether the answer makes sense; 25 tablets means recheck or have another nurse check.

Dosage by weight

1. Convert pounds to kilograms: divide by 2.2 (don't round yet)
2. Multiply kilograms by the prescribed mg/kg
3. Work out the volume or tablets from what's available
4. Round the final answer as directed

Example: 15 mg/kg for a client who weighs 176 lb → 176 ÷ 2.2 = 80 kg → 80 × 15 = 1,200 mg.