Topic 3: Elimination Complexities

Objectives:

1. Evaluate functions of systems related to elimination.

2. Explain the nurse’s role of supporting the patient’s psychological and emotional needs.

3. Recommend resources to assist in patient recovery.

Assignment 1

Discuss how elimination complexities can affect the lives of patients and their families. Discuss the nurse’s role in supporting the patient’s psychological, emotional, and spiritual needs. Provide an example integrating concepts from the “Statement on the Integration of Faith and Work” located in Class Resources.

 

Assignment 2

Discuss how functional health patterns help a nurse understand the current and past state of health for a patient. Using a condition or disease associated with an elimination complexity, provide an example. Include the possible pathophysiological causes of the condition or disease.

 

Assignment 3

Case Study: Mr. C

It is necessary for an RN-BSN-prepared nurse to demonstrate an enhanced understanding of the pathophysiological processes of disease, the clinical manifestations and treatment protocols, and how they affect clients across the life span.

Evaluate the Health History and Medical Information for Mr. C., presented below.

Based on this information, formulate a conclusion based on your evaluation, and complete the Critical Thinking Essay assignment, as instructed below.


Health History and Medical Information

Health History

Mr. C., a 32-year-old single male, is seeking information at the outpatient center regarding possible bariatric surgery for his obesity. He currently works at a catalog telephone center. He reports that he has always been heavy, even as a small child, gaining approximately 100 pounds in the last 2-3 years. Previous medical evaluations have not indicated any metabolic diseases, but he says he has sleep apnea and high blood pressure, which he tries to control by restricting dietary sodium. Mr. C. reports increasing shortness of breath with activity, swollen ankles, and pruritus over the last 6 months.

Objective Data:

1. Height: 68 inches; weight 134.5 kg

2.
BP: 172/98, HR 88, RR 26

3. 3+ pitting edema bilateral feet and ankles

4. Fasting blood glucose: 146 mg/dL

5. Total cholesterol: 250 mg/dL

6. Triglycerides: 312 mg/dL

7. HDL: 30 mg/dL

8. Serum creatinine 1.8 mg/dL

9. BUN 32 mg/dl


Critical Thinking Essay

In 750-1,000 words, critically evaluate Mr. C.’s potential diagnosis and intervention(s). Include the following:

1. Describe the subjective and objective clinical manifestations present in Mr. C.

2. Describe the potential health risks for obesity that are of concern for Mr. C. Explain whether bariatric surgery is an appropriate intervention.

3. Assess each of Mr. C.’s functional health patterns using the information given. Discuss at least five actual or potential problems you can identify from the functional health patterns and provide the rationale for each. (Functional health patterns include health-perception, health-management, nutritional, metabolic, elimination, activity-exercise, sleep-rest, cognitive-perceptual, self-perception/self-concept, role-relationship, sexuality/reproductive, coping-stress tolerance.)

4. Explain the stages of renal disease that leads to end-stage renal disease (ESRD). What factors contributed to Mr. C’s ESRD? 

5. Consider ESRD prevention and health promotion opportunities. Describe what type of patient education for ESRD should be provided to Mr. C. for prevention of future events, health restoration, and avoidance of deterioration of renal status.

6. Explain the type of resources available for ESRD patients for nonacute care and the type of multidisciplinary approach that would be beneficial for these patients. Include aspects such as devices, transportation, living conditions, return-to-employment issues.

You are required to cite a minimum of three sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and relevant to nursing practice.

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. 

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion. 

Rubric Criteria

Collapse All Rubric CriteriaCollapse All

Clinical Manifestations of Mr. C.

12 points

Criteria Description

Detail of subjective and objective clinical manifestations.

5. Target

12 points

Subjective and objective clinical manifestations are thorough.

Potential Health Risks for Obesity and Bariatric Surgery

12 points

Criteria Description

Discussion of the potential health risks for obesity and the appropriateness of bariatric surgery as an intervention.

5. Target

12 points

Discussion of the potential health risks for obesity and the appropriateness of bariatric surgery as an intervention are thorough.

Functional Health Patterns

18 points

Criteria Description

Discussion of at least five actual or potential problems identified from the functional health patterns assessment, and rationale for each.

5. Target

18 points

Discussion of at least five actual or potential problems identified from the functional health patterns assessment and rationale for each are thorough.

Staging and Contributing Factors of End-Stage Renal Disease (ESRD)

12 points

Criteria Description

Explanation of the stages of renal disease that lead to end-stage renal disease (ESRD), and what factors contributed to the patient’s ESRD.

5. Target

12 points

Explanation of the stages of renal disease that lead to end-stage renal disease (ESRD), and what factors contributed to the patient’s ESRD are thorough.

Health Promotion and Prevention Opportunities for ESRD

24 points

Criteria Description

Description of patient education for the prevention and health promotion opportunities for ESRD, including preventing future events, health restoration, and avoidance of deterioration of renal status.

5. Target

24 points

Description of patient education for the prevention and health promotion opportunities for ESRD, including preventing future events, health restoration, and avoidance of deterioration of renal status is thorough.

Resources for ESRD Patients for Nonacute Care and Multidisciplinary Approach

18 points

Criteria Description

Explanation of the types of resources available for ESRD patients for nonacute care, and the benefit of a multidisciplinary approach including aspects such as devices, transportation, living conditions, return-to-employment issues.

5. Target

18 points

Explanation of the types of resources available for ESRD patients for nonacute care, and the benefit of a multidisciplinary approach including aspects such as devices, transportation, living conditions, return-to-employment issues is thorough.

Thesis, Position, or Purpose

6 points

Criteria Description

Communicates reason for writing and demonstrates awareness of audience.

5. Target

6 points

The thesis, position, or purpose is clearly communicated throughout and clearly directed to a specific audience.

Development, Structure, and Conclusion

6 points

Criteria Description

Advances position or purpose throughout writing; conclusion aligns to and evolves from development.

5. Target

6 points

The thesis, position, or purpose is logically advanced throughout. The progression of ideas is coherent and unified. A clear and logical conclusion aligns to the development of the purpose.

Evidence

6 points

Criteria Description

Selects and integrates evidence to support and advance position/purpose; considers other perspectives.

5. Target

6 points

Specific and appropriate evidence is included. Relevant perspectives of others are clearly considered.

Mechanics of Writing

3.6 points

Criteria Description

Includes spelling, capitalization, punctuation, grammar, language use, sentence structure, etc.

5. Target

3.6 points

No mechanical errors are present. Appropriate language choice and sentence structure are used throughout.

Format/Documentation

2.4 points

Criteria Description

Uses appropriate style, such as APA, MLA, etc., for college, subject, and level; documents sources using citations, footnotes, references, bibliography, etc., appropriate to assignment and discipline.

5. Target

2.4 points

No errors in formatting or documentation are present.



Elimination ComplexitiesBy Stacey Whitney

Essential Questions

· What are the normal functions of the renal, pancreatic, hepatic, biliary, and gastrointestinal systems?

· What significant findings should the nurse look for when systems are not functioning normally?

· What factors should be considered when assisting the patient’s transition to independence?

· What resources are available to assist patients as they recover?

Introduction

The renal, pancreatic, hepatic, biliary, and gastrointestinal systems are complex structures of elimination that are necessary for the maintenance of a healthy body. Internal disease processes and factors outside of the body can influence the functioning and balance of these life-sustaining systems. There are many disease factors that can affect function, such as substance abuse, genetics, family history, and poor lifestyle choices. Age-related differences can significantly influence assessment findings. Psychosocial, cultural, and spiritual support can impact the patient’s transition to independence. In this chapter, health education for prevention of progression of disease and health restoration will be reviewed, and resources necessary to promote patient independence will be explored.

Pathophysiology

Normal Function

The kidneys filter the blood and directly affect every organ system. If kidney failure occurs without treatment, death will result. See Figures 3.1 and 3.2 for visualizations of the function and location of the kidneys.

Figure 3.1


Bodily Functions of the Kidney

Figure 3.2


Kidney Location in the Body

The nephron, or functional unit of the kidney, is a tubular structure that filters and forms urine (see Figure 3.3). There are approximately one million nephrons in each kidney. Two kidneys and ureters, a urinary bladder, and urethra compose the urologic system (see Figure 3.4).

Figure 3.3


Structure of Nephron

Figure 3.4


Urologic System

The gastrointestinal tract is composed of a continuous pathway that includes the mouth, esophagus, stomach, small intestine, large intestine, rectum, and anus (see Figures 3.5, 3.6, and 3.7). Accessory organs needed for the digestion process include the liver, gallbladder, and exocrine pancreas (see Figure 3.5). The gastrointestinal tract breaks down food by mechanical and chemical means so that absorption of nutrients may occur.

Figure 3.5


Structures and Accessory Organs of the Digestion System

Figure 3.6


Small Intestine

Figure 3.7


Large Intestine

Normal changes of the urinary system related to aging include a decrease of the kidney size and decreased elasticity or muscle tone of the ureter, bladder, and urethra, resulting in a weakening urinary sphincter, decreased bladder capacity, and retention of urine. Resulting symptoms can include stress incontinence, urinary frequency, dribbling of urine, urgency, and nocturia. Overactive bladder can occur as well, as an increase of bladder contractions are common with age. Gerontologic assessment findings may show a less palpable kidney with decreased creatinine clearance, and elevated serum creatinine and BUN. Drug excretions may be altered due to the decrease in kidney function, particularly the loop of Henle and renal tubules. The bladder may be palpable upon exam after urination if urinary retention has occurred. In males, prostate enlargement may cause urinary urgency, hesitancy, straining, frequency, retention, dribbling, and nocturia (Huether & McCance, 2012).

Normal changes of the gastrointestinal system related to aging include periodontal disease, and decreased salivary production, known as xerostomia, which can cause a dry mouth and difficulty swallowing. Aging adults often experience a decrease in the sense of taste and smell, resulting in a decreased appetite. Decreased food intake is often a concern for the aging adult. Motility of the gastrointestinal system seems to be affected with aging as well; resulting in decreased gastric emptying and constipation. A decreased production of stomach acid in aging adults may result in the decreased production of vitamin B12 and production of red blood cells causing anemia. Decreased liver size and gallstones are common. Decreases in sphincter control and production and secretion of digestive enzymes often occur (Huether & McCance, 2012). Table 3.1 identifies normal function of the renal, pancreatic, hepatic, biliary, and gastrointestinal systems.

Table 3.1


Normal Function of Systems

Renal

· Excrete waste products from the body.

· Extracellular fluid regulation.

· Blood pressure control related to fluid balance.

· Activate vitamin D.

· Control acid-base balance.

· Produce and secrete renin, which aids in blood pressure control.

· Produce and release erythropoietin, which stimulates the bone marrow to produce RBCs.

· Metabolize calcium.

Pancreatic

· Endocrine pancreas produces glucagon and insulin to aid the formation and cellular uptake of glucose.

· Exocrine pancreas secretes digestive enzymes that break down carbohydrates, proteins, and fats.

Hepatic

· Metabolic function, including metabolism of carbohydrates, protein, and fat; detoxification of harmful substances; and steroid metabolism.

· Bile production and secretion.

· Storage of glucose, fat soluble vitamins (A, D, E, K), water soluble vitamins (B1, B2, folic acid, cobalamin), fatty acids, amino acids, and minerals (iron and copper).

· Breakdown of RBCs, WBCs, and bacteria.

Biliary

· Concentrate and store bile.

Gastrointestinal

· Mechanical and chemical breakdown of food.

· Secretion of enzymes to aid in digestion.

1.
Salivary glands – Salivary amylase.

1.
Stomach – Pepsinogen, hydrochloric acid, lipase, intrinsic factor.

1.
Small intestine – Enterokinase, amylase, peptidases, aminopeptidase, maltase, sucrose, lactase, lipase.

1.
Pancreas – Trypsinogen, chymotrypsin, amylase, lipase.

1.
Liver/Gallbladder – Bile.

· Absorption of nutrients.

Abnormal Findings

The nurse should be aware of the disorders that may result from the renal, pancreatic, hepatic, biliary, and gastrointestinal systems (see Table 3.2).

Table 3.2


Common Disorders

Renal

Chronic or Acute Renal Failure

Renal Calculi

Acute Tubular Necrosis

Glomerulonephritis

Hydronephrosis

Prostatitis

Benign Prostatic Hyperplasia

Cancer

Pancreatic

Pancreatitis

Cancer

Hepatic

Jaundice

Hepatitis

Cirrhosis

Cancer

Biliary

Cholelithiasis

Gastrointestinal

GERD

Hernias

Gastritis

Peptic Ulcer Disease

GI Bleeding

Malabsorption Syndromes

Inflammatory Bowel Disease

Appendicitis

Crohn’s Disease

Cancer

In children, there are many alterations in renal and bladder function that can be present, such as congenital malformations, glomerulus or bladder disorders, incontinence, Wilms tumor, and injury to the kidney. Congenital malformations of the kidney and urinary tract occur in approximately 1 of 500 births (Song, 2011). Malformations can range from minor to severe. In children, approximately 45% of kidney malformations cause renal failure (Allen, 2018).

Children can experience disorders of the gastrointestinal tract that are congenital, causing structure and motility impairments, impairments in absorption and digestion of nutrients, enzyme deficiencies, malformations of organs and structures, inflammatory disorders, metabolic disorders, and infection. These impairments can hinder normal growth and development in children (McCance & Huether, 2014).

Kidney function is measured by the glomerular filtration rate (GFR),
 which is typically obtained by a 24-hour urine test. The GFR is defined as the volume of blood filtered by the glomerulus over 1 minute (Isaac, 2012). Symptoms of chronic renal failure often do not appear until more than 75% of glomerular filtration is lost, and symptoms worsen as the kidney function decreases. Renal failure affects all body systems and can cause hyperkalemia, hypervolemia, peripheral edema, anemia, hyperphosphatemia, hypocalcemia, azotemia, metabolic acidosis, and peripheral neuropathy (Lewis, Heitkemper, Dirksen, O’Brien, & Bucher, 2007).

Pancreatitis, or inflammation of the pancreas, can be chronic or acute. Many patients experience worsening epigastric pain near the umbilicus. Acute pancreatitis causes severe, persistent abdominal pain in the midepigastric region. The pain typically begins after eating or drinking a large meal, or after consuming alcohol. Pancreatitis causes elevated white blood cell counts, serum amylase, and lipase levels. Liver function tests are often elevated. An enlarged pancreas is often seen on CT or ultrasound, often with cysts. Treatment is aimed at decreasing pain, maintaining circulation and fluid volume, and decreasing pancreatic secretions (Sargent, 2006).

Cirrhosis
 of the liver, which is irreversible, causes the collapse of the liver’s structure. When the liver structure failure begins, jaundice, edema, ascites, and blood clotting disorders, along with metabolic disruption, develop (Fullwood & Purushothaman, 2014). Early signs and symptoms of cirrhosis include decreased appetite, nausea and vomiting, dull abdominal pain, jaundice, frequent bruising, constipation or diarrhea. Later signs can cause negative effects on several body systems, such as pulmonary edema, hypoxia, and mental changes (Huether & McCance 2014).

The best indicator of gallbladder dysfunction is the presence of fatty stools and serum amylase. Gallbladder obstruction produces elevated serum bilirubin, elevated urine urobilinogen levels, and an increase in fatty stools. Gallbladder inflammation can be noted with elevated serum leukocyte levels. Cholecystitis, which can be acute or chronic, causes the gallbladder to become inflamed, resulting in pain when stones are lodged in the cystic duct (Lewis et al., 2007).

Gastrointestinal disorders often exhibit similar signs and symptoms, such as pain, abdominal distention, fullness, bloating, dysphagia, indigestion, heartburn, weight loss, decreased appetite, diarrhea, constipation, bleeding, or mucus in stool. Disease processes along the GI tract can cause multiple metabolic effects, some of which may be life threatening.

Prevalent Problems

Chronic kidney disease is progressively irreversible and will result in loss of kidney function (see Figure 3.8 and Table 3.3). It typically develops slowly over months or years, and in stages. It is commonly caused by:

· chronic glomerulonephritis,

· polycystic kidney disorder,

· hypertension,

· nephrosclerosis,

· renal calculi,

· systemic lupus erythematosus,

· nephrotoxins,

· diabetic neuropathy,

· chronic kidney infections, and

· tuberculosis (McCance & Huether, 2014).

Figure 3.8


Stages of Chronic Kidney Disease

Note. Adapted from “Glomerular Filtration Rate (GFR)” in the 
A to Z Health Guide, by the National Kidney Foundation, 2018.

Acute renal failure that is caused by impaired blood flow to the kidneys, or volume depletion, is referred to as prerenal failure. Impaired blood flow decreases the glomerular filtration rate, causing increased tubular reabsorption of water and sodium (Yaklin, 2011). Prerenal failure can be caused by the following disorders:

· Severe vasoconstriction

· Eclampsia

· Disseminated intravascular coagulation (DIC)

· Vasculitis

· Malignant hypertension

· Peripheral vasodilation

· Antihypertensive drug treatment

· Sepsis

· Obstruction

· Arterial embolism

· Tumor

· Arterial thrombosis

· Venous thrombosis

· Hypovolemia

· Trauma

· Shock

· Hemorrhage

· Diuretics

· Dehydration

· Severe burns

· Cardiovascular abnormalities

· Myocardial infarction (MI)

· Heart arrhythmias

· Heart failure

· Cardiac tamponade

· Cardiogenic shock (Yaklin, 2011).

Damage to the kidneys referred to as intrinsic kidney injury is caused by structural damage to the glomerulus, renal tubules, or vessels, causing cell necrosis, or by infectious agents and toxins that cause inflammation and injury (Yaklin, 2011). The following disorders are the most common causes of intrinsic renal failure:

· Acute tubular necrosis caused by:

· Crush injury to the body

· Sepsis

· Reaction to blood product transfusions

· Nephrotoxins

· Radiographic contrast media

· Antibiotics such as gentamycin

· Heavy metals

· Anesthetics

· Acute interstitial nephritis caused by exposure to nephrotoxic drugs:

· Nonsteroidal anti-inflammatories

· Antibiotics

· Contrast-induced nephropathy occurs within 12-24 hours of a procedure using contrast. Risk factors include:

· Age >70

· Volume depletion

· Repeated contrast exposure

· Heart failure

· Diabetes mellitus

· Renal insufficiency (Yaklin, 2011; Isaac, 2012).

Damage to the kidneys referred to as postrenal kidney injury is caused by obstruction that increases the pressure within the kidney collection systems, decreasing the GFR, water and sodium reabsorption, and phosphaturia (Yaklin, 2011). The following disorders are the most common causes of
 postrenal failure:

· embolus,

· strictures,

· renal calculi,

· benign prostatic hypertrophy,

· malignancies, and

· pregnancy (Yaklin, 2011, p. 14).

Table 3.3


Systemic Effects of Acute Renal Failure and Signs to Watch For

Urinary

Respiratory

Hematologic

Cardiovascular

· Decreased Urine Output

· Oliguria

· Proteinuria

· Pulmonary Edema

· Kussmaul Respirations

· Pleural Effusion

· Dry Mucous Membranes

· Anemia

· Leukocytosis

· Volume Overload Resulting in Hypertension

· Dysrhythmias

· Pericardial Effusion

· Tachycardia

· Hypotension

· Decreased Cardiac Output

Gastrointestinal

Neurologic

Metabolic

· Nausea

· Vomiting

· Anorexia

· Bleeding

· Diarrhea

· Seizures

· Confusion

· Lethargy Progressing to Coma

· Increased BUN and Creatinine

· Increased Potassium

· Decreased Calcium, Sodium, Bicarbonate, and pH

· Increased Phosphorus

Note. Adapted from 
Understanding Pathophysiology (5th ed.), by S. E. Huether & K. L. McCance, 2012, St. Louis, MO: Elsevier Mosby, pp. 1486-1490.

Cirrhosis is a chronic liver disease that causes progressive destruction of hepatic cells. Liver cells attempt to regenerate, but fibrotic regeneration occurs causing a distortion of the hepatic architecture (Horne, 2011). The overgrowth of fibrous cells creates a distorted liver lobular structure that impairs blood flow.

Four types of cirrhosis include:

· alcoholic cirrhosis,

· postnecrotic cirrhosis,

· biliary cirrhosis, and

· cardiac cirrhosis.

Typically, there are no early signs and symptoms of cirrhosis. Typical gastrointestinal complaints are common, such as flatulence, dyspepsia, nausea/vomiting, loss of appetite, and change in bowel patterns. Abdominal pain in the upper right quadrant often occurs, and the liver is often palpable. Late symptoms resulting from liver failure include jaundice, spider angioma skin lesions, splenomegaly, thrombocytopenia, leukopenia, anemia; and blood clotting disorders often occur. Because of changes in the liver structure from fibrous cell formations, portal hypertension and esophageal and gastric varices often occur, along with ascites and peripheral edema. Ascites is the accumulation of fluid in the peritoneal cavity, a frequent complication of liver failure (Fullwood & Purushothaman, 2014).

Pancreatitis, or inflammation of the pancreas, is a rare and serious condition. Pancreatitis can be chronic or acute, potentially life-threatening, and is diagnosed in approximately 17 of 100,000 people in the United States (Brown, 2008).

Common causes of pancreatitis include:

· alcoholism (common in chronic pancreatitis),

· peptic ulcers,

· cholelithiasis or other obstructive disorders of the biliary tract,

· abdominal trauma,

· hyperlipidemia,

· can be drug induced,

· genetics, and

· cystic fibrosis.

Symptoms of pancreatitis include:

· epigastric and peri-umbilical pain that may radiate to the back is a classic symptom

· fever,

· shock,

· nausea/vomiting, and

· abdominal distension with small intestine ileus (Sargent, 2006).

Abnormal laboratory findings include elevated serum amylase and lipase. Elevated urinary amylase, hyperglycemia, hyperlipidemia, and hypocalcemia may also occur. Ultrasound and CT scans may be used to diagnose pancreatitis as well. Pancreatitis can recur, and each episode may further damage the cells of the pancreas related to production of insulin; therefore, diabetes may occur in patients with long-term pancreatitis (Hughes, 2004). The pancreas cannot be palpated because it lies beneath the stomach. Clinical signs and symptoms usually occur abruptly with sudden pain. If left untreated, renal failure, shock, sepsis, and multisystem organ failure may occur (Schlapman, 2001).

Check for Understanding

1. What are the components of the gastrointestinal tract that form a continuous pathway?

2. What accessory organs are needed to aid in digestion?

3. Identify normal changes in the gastrointestinal, renal, and urinary systems that are related to aging.

4. Identify disorders in the gastrointestinal, renal, and urinary systems that can be present in children.

Nursing Management

·

Nursing management should be provided in a holistic, individualized way. Patients with elimination complexities have specific nursing needs as well as individualized needs.

Nurses play a key role in the management of elimination complexities at initial presentation, during treatment, and upon discharge (Cunningham, Noble, Kadhum, Modhefer, & Walsh, 2016). For example, during initial presentation and treatment, critical care nurses are in an ideal position to identify risk factors and potentially nephrotoxic agents that pose a threat to patients’ renal function. Interventional studies including contrast pose risk for contrast-induced nephropathy. Procedures such as computed tomography, cardiac catheterization, and pacemaker implantations all include injection of contrast medium that is toxic to the kidneys (Isaac, 2012). The nephrotoxic effects of contrast medium can increase patient morbidity and mortality (Isaac, 2012). Nurses play an important role in assessing for and preventing renal insult by determining the patient’s baseline serum creatinine level, level of hydration, and nephrotoxic medications that may need to be adjusted. Postinterventional study serum creatinine levels should be monitored, along with patient teaching to report signs and symptoms of decreased renal function (Isaac, 2012).

Restoration of Function

·

The goal of nursing management in the care of patients with renal or gastrointestinal disorders is aimed toward restoration of function. Incorporation of nursing assessment, nursing diagnoses, planning, nursing implementation, and evaluation are all important steps in the process. Early identification of clinical manifestations of disease, utilization of collaborative care for treatment, and recognition of complications all play a major role in restoration of function of systems. Assessment of patients for predisposing and etiological factors that contribute to disease is of vital importance. Encouragement of patients to receive early treatment and interventions of identified disorders to prevent worsening of symptoms or recurrence of disease should be prioritized.

Important steps to promote restoration of function should be encouraged by the nurse during inpatient and outpatient care. Patients should comply with all prescribed regimens, including follow-up appointments, medications, therapies, dietary management, and activity restrictions. It is important for the patient and family to continue to educate themselves about the medical condition and disease processes. The nurse can provide credible sources for reading, such as websites, pamphlets, printed material, brochures, or books, and encourage questions at follow-up visits.

Transition to Independence

·

Nurses should be sensitive to the fact that many patients find the loss of independence during illness demoralizing. Patients’ right to refusal of nursing care or assistance should be respected and patients’ privacy and dignity must be maintained (Hughes, 2004).

The patient and family should be interviewed about the presence or history of illness and disease that may be related to renal or gastrointestinal disorders. Contributing factors that should be considered as patients transition to independence include, but are not limited to, genetic/family history of disease, history of alcohol use or abuse, obesity, smoking, hypertension, and recurrent kidney infections. Subjective data include past medical history, medications, and previous surgeries. Psychosocial, cultural, and spiritual considerations offer even greater insight into the patients’ state of health. Certain cultural health disparities related to renal and gastrointestinal disorders should not be overlooked. Many symptoms, such as incontinence, for example, may go underreported because it is considered a social hygiene problem in some cultures, causing embarrassment (Lewis et al., 2007). Kidney stones, cancer, and other disorders have higher incidence in certain cultures because of higher incidence of genetic conditions in certain ethnic groups.

Information regarding functional health patterns can offer the nurse significant insight into the current and past state of health of patients. Functional health patterns include:

· Health perception—values,

· Nutrition/metabolic pattern,

· Sleep/rest pattern,

· Elimination pattern,

· Activity/exercise pattern,

· Cognitive/perceptual pattern,

· Sensory/perception—self-concept pattern,

· Role relationship pattern,

· Sexuality/reproductive pattern, and

· Coping

·

Patients experiencing illness such as end-stage renal disease, liver disease, and pancreatitis face adversity, as their treatment options are limited. Many are considering dialysis to treat renal disease, transplantation, or death. Encouraging resiliency
 or “the capacity of individuals to successfully maintain or regain their mental health in the face of significant adversity or risk” (Stewart & Yuen, 2011, p. 199) can enhance the patients’ quality of life, which may be the most valuable nursing intervention that can be provided. Nurses have many opportunities to promote resilience, but the advantages of positive outcomes when intervening early in the process has proven beneficial. Stewart and Yuen (2011) related the following factors with resiliency:

· Social support;

· Coping skills, including spirituality;

· Psychological factors, including self-esteem, optimism, acceptance of illness, determination, and self-efficacy; and

· Factors related to physical illness, including adherence to treatment plan, quality of life, perception of illness, self-care, perception of pain, adherence to physical activity plan (Stewart & Yuen, 2011).

Nurses can encourage patients to improve or develop resiliency in the following ways:

· Offer care and support during the acute phase of illness and provide resources for support when discharged, such as support groups.

· Set high, but realistic, goals for recovery and independence.

· Offer opportunities for the patient to develop and increase meaningful connections with others, such as attending support groups after being discharged.

· Help the patient develop and maintain life skills and encourage physical and occupational therapy if prescribed.

· Set clear boundaries when necessary so that the patient always feels safe and not overwhelmed.

· Encourage patience with the healing process (Henderson, 2007; Ulrich, 2016).

Prevention and Health Promotion

·

Patient education is needed for prevention of future events, health restoration, avoidance of deterioration, and prevention of readmission. Providing patient education is an important part of transitioning the patient from acute or chronic illnesses to independence. In fact, lack of education can cause anxiety for some patients and their family members.

For example, a patient in acute renal failure has required multiple packed red blood cell transfusions to treat low hematocrit levels. The patient’s family is overly anxious seeing the transfusions, assumes the patient is losing blood, and worries that the patient’s condition must have worsened. When the nurse educates the patient and family that acute renal failure causes the lack of erythropoietin production, thus decreasing the body’s production of red blood cells, they begin to understand the need for the packed red blood cell transfusions, and the patient and family’s anxiety is resolved.

Educating patients and families throughout the disease process is good practice and may help to promote independence. The increased knowledge can assist patients and families in decision making related to their course of treatment. It is important to continue educating patients as they continue to recover by discussing causes of their disease and ways to prevent recurrence. Along with patient education, excellent communication skills are vital. The nurse should show empathy toward the patient and family and manage any anxieties in an empathetic and professional manner (Hughes, 2004).

Note: Table 3.4 is incorrect, and should say low protein diet instead of high protein diet. 

Table 3.4


Important Health Promotion Considerations

Nutrition/Intake

Patients often have orders for dietary restrictions such as:


Pancreatitis:

 Often NPO for acute cases or high carbohydrate diet to decrease the stimulation of the exocrine pancreas.


Renal Disease:
 Renal diet with potassium and sodium restrictions. Often a high protein diet. Fluid restrictions are often ordered.


Cirrhosis:
 High calorie and high carbohydrate diet. Fluid and sodium restriction are often ordered for patients with ascites or edema.


Cholecystitis/Cholelithiasis:
 Low fat diet to decrease stimulation of the gallbladder.

Exercise/Mobility

Consider activity as ordered at applicable levels of prevention.

Medications

Patient may need assistance obtaining and maintaining prescriptions to prevent future medical events.

Post-Transplant

Concerns

Monitor for infection.

Importance of taking medications exactly at prescribed times.

Immunologic considerations.

Emotional support and patient education are essential.

Patients and families often require assistance in obtaining tools and services that are necessary to maintain independence during the chronic stages of care. When orders for equipment and other resources are received from the primary care provider, the nurse may request assistance from other collaborative care partners, such as social services, durable medical equipment companies, home health, hospice, or pastoral care, to meet the patients’ needs. A few examples are listed in Table 3.5.

Table 3.5


Resources Necessary for Nonacute Care

Devices

Durable medical equipment, mobility equipment, oxygen, enteral feeding supplies, glucose monitoring system, peritoneal dialysis supplies.

Medications

Patient may need assistance obtaining and maintaining prescriptions to prevent future events.

Transportation

Dialysis treatment is often required multiple days per week, and assistance with transportation may be needed.

Living Conditions

Assistance with household activities may be needed. No smoking in homes with oxygen tanks.

Return to Employment Issues

Resources for rehabilitative time and modifications to previous workload may be needed. Fatigue may interfere with work performance.

Check for Understanding

1. What types of support processes are commonly available to patients with elimination complexities?

2. What is the goal of nursing management in the care of patients with renal or gastrointestinal disorders?

3. What contributing factors should the nurse consider as patients transition to independence?

4. What functional patterns exist that can provide the nurse insight into patients’ current and past state of health?

Reflective Summary

There are many disease processes that affect the complex structures of elimination that are necessary for sustaining life. Today, individuals live longer than they used to, so many opportunities exist for nurses to improve care by offering psychosocial, cultural, and spiritual support that can impact patients’ transition to independence. The key role that nurses offer in providing patients the resources necessary to promote independence, along with developing and encouraging resiliency, can increase patient quality of life. Educating patients regarding illness prevention, prevention of progression of disease, and health restoration has benefits for both patients and health professionals.

Key Terms

Ascites: Complication of liver failure causing accumulation of fluid in the peritoneal cavity.

Cholecystitis: Inflammation of the gallbladder that causes stone formation lodged in the cystic duct.

Chronic Kidney Disease: Progressively irreversible loss of kidney function.

Cirrhosis: Chronic liver disease that causes irreversible and progressive destruction of hepatic cells.

Glomerular Filtration Rate (GFR): Volume of blood filtered by the glomerulus over 1 minute; kidney function is measured by this.

Intrinsic Renal Failure: Damage to the kidneys caused by structural damage to the glomerulus, renal tubules, or vessels, causing cell necrosis, or by infectious agents and toxins that cause inflammation and injury.

Nephron: Functional unit of the kidney; tubular structure that filters and forms urine.

Pancreatitis: Inflammation of the pancreas can be chronic or acute.

Postrenal Failure: Damage to the kidneys caused by obstruction resulting in kidney injury from increased pressure within the kidney collection systems.

Prerenal Failure: Acute renal failure caused by impaired blood flow to the kidneys or volume depletion.

Resiliency: Positive adaptation to adversity.

Spirituality: Participation in organized religion, such as attending church, or nonreligious experiences such as personal reflection, yoga, or meditation.

References

Allen, R. C. (2016). Horseshoe kidney. Retrieved from www.medscape.com/article/441510-overview

Brown, A. (2008). Are health related outcomes in acute pancreatitis improving? An analysis of national trends in the U.S. from 1997 to 2003. 
Journal of the Pancreas
9(4), 408-414.

Cunningham, P., Noble, H., Kadhum, A., Modhefer, A., & Walsh, I. (2016). Kidney stones: Pathophysiology, diagnosis and management. 
British Journal of Nursing
25, 1112-1116.

Fullwood, D., & Purushothaman, A. (2014). Managing ascites in patients with chronic liver disease. 
Nursing Standard
28(23), 51-58.

Henderson, N. (2007). Hard-wired to bounce back. Retrieved from http://www.resiliency.com/free-articles-resources-hard-wired-to-bounce-back/

Horne, P. M. (2011). Managing complications in patients with cirrhosis and hepatocellular carcinoma. 
American Journal for Nurse Practitioners
15(1/2), 28-34.

Huether, S. E., & McCance, K. L. (2012). 
Understanding pathophysiology (5th ed.). St. Louis, MO: Elsevier Mosby.

Hughes, E. (2004). Understanding the care of patients with acute pancreatitis. 
Nursing Standard
18(18), 45-52.

Isaac, S. (2012). Contrast-induced nephropathy: Nursing implications. 
Critical Care Nurse
32(3), 41-48.

Lewis, S. L., Heitkemper, M. M., Dirksen, S. R., O’Brien, P. G., & Bucher, L. (2007). 
Medical-surgical nursing (9th ed.). St. Louis, MO: Mosby Elsevier.

McCance, K. L., & Huether, S. E. (2014). 
Pathophysiology: The biologic basis for disease in adults and children (7th ed.). St. Louis, MO: Elsevier Mosby.

Sargent, S. (2006). Pathophysiology, diagnosis, and management of acute pancreatitis. 
British Journal of Nursing
15, 999-1005.

Schlapman, N. (2001). Spotting acute pancreatitis. 
Registered Nurse
64(11), 55-59.

Song, Y. R. (2011). Genetics of congenital anomalies of the kidney and urinary tract. 
Pediatric Nephrology
26, 353-364.

Stewart, D. E., & Yuen, T. (2011). A systematic review: Review of resilience in the physically ill. 
Psychosomatics, 52(3), 199-209.

Ulrich, B. (2016). Promoting resilience among patients with end stage renal disease. 
Nephrology Nursing Journal
43(3), 189, 267.

Yaklin, K. M. (2011). Acute kidney injury: An overview of pathophysiology and treatments. 
Nephrology Nursing Journal
38(1), 13-30.

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Elimination ComplexitiesBy Stacey Whitney

Essential Questions

· What are the normal functions of the renal, pancreatic, hepatic, biliary, and gastrointestinal systems?

· What significant findings should the nurse look for when systems are not functioning normally?

· What factors should be considered when assisting the patient’s transition to independence?

· What resources are available to assist patients as they recover?

Introduction

The renal, pancreatic, hepatic, biliary, and gastrointestinal systems are complex structures of elimination that are necessary for the maintenance of a healthy body. Internal disease processes and factors outside of the body can influence the functioning and balance of these life-sustaining systems. There are many disease factors that can affect function, such as substance abuse, genetics, family history, and poor lifestyle choices. Age-related differences can significantly influence assessment findings. Psychosocial, cultural, and spiritual support can impact the patient’s transition to independence. In this chapter, health education for prevention of progression of disease and health restoration will be reviewed, and resources necessary to promote patient independence will be explored.

Pathophysiology

Normal Function

The kidneys filter the blood and directly affect every organ system. If kidney failure occurs without treatment, death will result. See Figures 3.1 and 3.2 for visualizations of the function and location of the kidneys.

Figure 3.1


Bodily Functions of the Kidney

Figure 3.2


Kidney Location in the Body

The nephron, or functional unit of the kidney, is a tubular structure that filters and forms urine (see Figure 3.3). There are approximately one million nephrons in each kidney. Two kidneys and ureters, a urinary bladder, and urethra compose the urologic system (see Figure 3.4).

Figure 3.3


Structure of Nephron

Figure 3.4


Urologic System

The gastrointestinal tract is composed of a continuous pathway that includes the mouth, esophagus, stomach, small intestine, large intestine, rectum, and anus (see Figures 3.5, 3.6, and 3.7). Accessory organs needed for the digestion process include the liver, gallbladder, and exocrine pancreas (see Figure 3.5). The gastrointestinal tract breaks down food by mechanical and chemical means so that absorption of nutrients may occur.

Figure 3.5


Structures and Accessory Organs of the Digestion System

Figure 3.6


Small Intestine

Figure 3.7


Large Intestine

Normal changes of the urinary system related to aging include a decrease of the kidney size and decreased elasticity or muscle tone of the ureter, bladder, and urethra, resulting in a weakening urinary sphincter, decreased bladder capacity, and retention of urine. Resulting symptoms can include stress incontinence, urinary frequency, dribbling of urine, urgency, and nocturia. Overactive bladder can occur as well, as an increase of bladder contractions are common with age. Gerontologic assessment findings may show a less palpable kidney with decreased creatinine clearance, and elevated serum creatinine and BUN. Drug excretions may be altered due to the decrease in kidney function, particularly the loop of Henle and renal tubules. The bladder may be palpable upon exam after urination if urinary retention has occurred. In males, prostate enlargement may cause urinary urgency, hesitancy, straining, frequency, retention, dribbling, and nocturia (Huether & McCance, 2012).

Normal changes of the gastrointestinal system related to aging include periodontal disease, and decreased salivary production, known as xerostomia, which can cause a dry mouth and difficulty swallowing. Aging adults often experience a decrease in the sense of taste and smell, resulting in a decreased appetite. Decreased food intake is often a concern for the aging adult. Motility of the gastrointestinal system seems to be affected with aging as well; resulting in decreased gastric emptying and constipation. A decreased production of stomach acid in aging adults may result in the decreased production of vitamin B12 and production of red blood cells causing anemia. Decreased liver size and gallstones are common. Decreases in sphincter control and production and secretion of digestive enzymes often occur (Huether & McCance, 2012). Table 3.1 identifies normal function of the renal, pancreatic, hepatic, biliary, and gastrointestinal systems.

Table 3.1


Normal Function of Systems

Renal

· Excrete waste products from the body.

· Extracellular fluid regulation.

· Blood pressure control related to fluid balance.

· Activate vitamin D.

· Control acid-base balance.

· Produce and secrete renin, which aids in blood pressure control.

· Produce and release erythropoietin, which stimulates the bone marrow to produce RBCs.

· Metabolize calcium.

Pancreatic

· Endocrine pancreas produces glucagon and insulin to aid the formation and cellular uptake of glucose.

· Exocrine pancreas secretes digestive enzymes that break down carbohydrates, proteins, and fats.

Hepatic

· Metabolic function, including metabolism of carbohydrates, protein, and fat; detoxification of harmful substances; and steroid metabolism.

· Bile production and secretion.

· Storage of glucose, fat soluble vitamins (A, D, E, K), water soluble vitamins (B1, B2, folic acid, cobalamin), fatty acids, amino acids, and minerals (iron and copper).

· Breakdown of RBCs, WBCs, and bacteria.

Biliary

· Concentrate and store bile.

Gastrointestinal

· Mechanical and chemical breakdown of food.

· Secretion of enzymes to aid in digestion.

1.
Salivary glands – Salivary amylase.

1.
Stomach – Pepsinogen, hydrochloric acid, lipase, intrinsic factor.

1.
Small intestine – Enterokinase, amylase, peptidases, aminopeptidase, maltase, sucrose, lactase, lipase.

1.
Pancreas – Trypsinogen, chymotrypsin, amylase, lipase.

1.
Liver/Gallbladder – Bile.

· Absorption of nutrients.

Abnormal Findings

The nurse should be aware of the disorders that may result from the renal, pancreatic, hepatic, biliary, and gastrointestinal systems (see Table 3.2).

Table 3.2


Common Disorders

Renal

Chronic or Acute Renal Failure

Renal Calculi

Acute Tubular Necrosis

Glomerulonephritis

Hydronephrosis

Prostatitis

Benign Prostatic Hyperplasia

Cancer

Pancreatic

Pancreatitis

Cancer

Hepatic

Jaundice

Hepatitis

Cirrhosis

Cancer

Biliary

Cholelithiasis

Gastrointestinal

GERD

Hernias

Gastritis

Peptic Ulcer Disease

GI Bleeding

Malabsorption Syndromes

Inflammatory Bowel Disease

Appendicitis

Crohn’s Disease

Cancer

In children, there are many alterations in renal and bladder function that can be present, such as congenital malformations, glomerulus or bladder disorders, incontinence, Wilms tumor, and injury to the kidney. Congenital malformations of the kidney and urinary tract occur in approximately 1 of 500 births (Song, 2011). Malformations can range from minor to severe. In children, approximately 45% of kidney malformations cause renal failure (Allen, 2018).

Children can experience disorders of the gastrointestinal tract that are congenital, causing structure and motility impairments, impairments in absorption and digestion of nutrients, enzyme deficiencies, malformations of organs and structures, inflammatory disorders, metabolic disorders, and infection. These impairments can hinder normal growth and development in children (McCance & Huether, 2014).

Kidney function is measured by the glomerular filtration rate (GFR),
 which is typically obtained by a 24-hour urine test. The GFR is defined as the volume of blood filtered by the glomerulus over 1 minute (Isaac, 2012). Symptoms of chronic renal failure often do not appear until more than 75% of glomerular filtration is lost, and symptoms worsen as the kidney function decreases. Renal failure affects all body systems and can cause hyperkalemia, hypervolemia, peripheral edema, anemia, hyperphosphatemia, hypocalcemia, azotemia, metabolic acidosis, and peripheral neuropathy (Lewis, Heitkemper, Dirksen, O’Brien, & Bucher, 2007).

Pancreatitis, or inflammation of the pancreas, can be chronic or acute. Many patients experience worsening epigastric pain near the umbilicus. Acute pancreatitis causes severe, persistent abdominal pain in the midepigastric region. The pain typically begins after eating or drinking a large meal, or after consuming alcohol. Pancreatitis causes elevated white blood cell counts, serum amylase, and lipase levels. Liver function tests are often elevated. An enlarged pancreas is often seen on CT or ultrasound, often with cysts. Treatment is aimed at decreasing pain, maintaining circulation and fluid volume, and decreasing pancreatic secretions (Sargent, 2006).

Cirrhosis
 of the liver, which is irreversible, causes the collapse of the liver’s structure. When the liver structure failure begins, jaundice, edema, ascites, and blood clotting disorders, along with metabolic disruption, develop (Fullwood & Purushothaman, 2014). Early signs and symptoms of cirrhosis include decreased appetite, nausea and vomiting, dull abdominal pain, jaundice, frequent bruising, constipation or diarrhea. Later signs can cause negative effects on several body systems, such as pulmonary edema, hypoxia, and mental changes (Huether & McCance 2014).

The best indicator of gallbladder dysfunction is the presence of fatty stools and serum amylase. Gallbladder obstruction produces elevated serum bilirubin, elevated urine urobilinogen levels, and an increase in fatty stools. Gallbladder inflammation can be noted with elevated serum leukocyte levels. Cholecystitis, which can be acute or chronic, causes the gallbladder to become inflamed, resulting in pain when stones are lodged in the cystic duct (Lewis et al., 2007).

Gastrointestinal disorders often exhibit similar signs and symptoms, such as pain, abdominal distention, fullness, bloating, dysphagia, indigestion, heartburn, weight loss, decreased appetite, diarrhea, constipation, bleeding, or mucus in stool. Disease processes along the GI tract can cause multiple metabolic effects, some of which may be life threatening.

Prevalent Problems

Chronic kidney disease is progressively irreversible and will result in loss of kidney function (see Figure 3.8 and Table 3.3). It typically develops slowly over months or years, and in stages. It is commonly caused by:

· chronic glomerulonephritis,

· polycystic kidney disorder,

· hypertension,

· nephrosclerosis,

· renal calculi,

· systemic lupus erythematosus,

· nephrotoxins,

· diabetic neuropathy,

· chronic kidney infections, and

· tuberculosis (McCance & Huether, 2014).

Figure 3.8


Stages of Chronic Kidney Disease

Note. Adapted from “Glomerular Filtration Rate (GFR)” in the 
A to Z Health Guide, by the National Kidney Foundation, 2018.

Acute renal failure that is caused by impaired blood flow to the kidneys, or volume depletion, is referred to as prerenal failure. Impaired blood flow decreases the glomerular filtration rate, causing increased tubular reabsorption of water and sodium (Yaklin, 2011). Prerenal failure can be caused by the following disorders:

· Severe vasoconstriction

· Eclampsia

· Disseminated intravascular coagulation (DIC)

· Vasculitis

· Malignant hypertension

· Peripheral vasodilation

· Antihypertensive drug treatment

· Sepsis

· Obstruction

· Arterial embolism

· Tumor

· Arterial thrombosis

· Venous thrombosis

· Hypovolemia

· Trauma

· Shock

· Hemorrhage

· Diuretics

· Dehydration

· Severe burns

· Cardiovascular abnormalities

· Myocardial infarction (MI)

· Heart arrhythmias

· Heart failure

· Cardiac tamponade

· Cardiogenic shock (Yaklin, 2011).

Damage to the kidneys referred to as intrinsic kidney injury is caused by structural damage to the glomerulus, renal tubules, or vessels, causing cell necrosis, or by infectious agents and toxins that cause inflammation and injury (Yaklin, 2011). The following disorders are the most common causes of intrinsic renal failure:

· Acute tubular necrosis caused by:

· Crush injury to the body

· Sepsis

· Reaction to blood product transfusions

· Nephrotoxins

· Radiographic contrast media

· Antibiotics such as gentamycin

· Heavy metals

· Anesthetics

· Acute interstitial nephritis caused by exposure to nephrotoxic drugs:

· Nonsteroidal anti-inflammatories

· Antibiotics

· Contrast-induced nephropathy occurs within 12-24 hours of a procedure using contrast. Risk factors include:

· Age >70

· Volume depletion

· Repeated contrast exposure

· Heart failure

· Diabetes mellitus

· Renal insufficiency (Yaklin, 2011; Isaac, 2012).

Damage to the kidneys referred to as postrenal kidney injury is caused by obstruction that increases the pressure within the kidney collection systems, decreasing the GFR, water and sodium reabsorption, and phosphaturia (Yaklin, 2011). The following disorders are the most common causes of
 postrenal failure:

· embolus,

· strictures,

· renal calculi,

· benign prostatic hypertrophy,

· malignancies, and

· pregnancy (Yaklin, 2011, p. 14).

Table 3.3


Systemic Effects of Acute Renal Failure and Signs to Watch For

Urinary

Respiratory

Hematologic

Cardiovascular

· Decreased Urine Output

· Oliguria

· Proteinuria

· Pulmonary Edema

· Kussmaul Respirations

· Pleural Effusion

· Dry Mucous Membranes

· Anemia

· Leukocytosis

· Volume Overload Resulting in Hypertension

· Dysrhythmias

· Pericardial Effusion

· Tachycardia

· Hypotension

· Decreased Cardiac Output

Gastrointestinal

Neurologic

Metabolic

· Nausea

· Vomiting

· Anorexia

· Bleeding

· Diarrhea

· Seizures

· Confusion

· Lethargy Progressing to Coma

· Increased BUN and Creatinine

· Increased Potassium

· Decreased Calcium, Sodium, Bicarbonate, and pH

· Increased Phosphorus

Note. Adapted from 
Understanding Pathophysiology (5th ed.), by S. E. Huether & K. L. McCance, 2012, St. Louis, MO: Elsevier Mosby, pp. 1486-1490.

Cirrhosis is a chronic liver disease that causes progressive destruction of hepatic cells. Liver cells attempt to regenerate, but fibrotic regeneration occurs causing a distortion of the hepatic architecture (Horne, 2011). The overgrowth of fibrous cells creates a distorted liver lobular structure that impairs blood flow.

Four types of cirrhosis include:

· alcoholic cirrhosis,

· postnecrotic cirrhosis,

· biliary cirrhosis, and

· cardiac cirrhosis.

Typically, there are no early signs and symptoms of cirrhosis. Typical gastrointestinal complaints are common, such as flatulence, dyspepsia, nausea/vomiting, loss of appetite, and change in bowel patterns. Abdominal pain in the upper right quadrant often occurs, and the liver is often palpable. Late symptoms resulting from liver failure include jaundice, spider angioma skin lesions, splenomegaly, thrombocytopenia, leukopenia, anemia; and blood clotting disorders often occur. Because of changes in the liver structure from fibrous cell formations, portal hypertension and esophageal and gastric varices often occur, along with ascites and peripheral edema. Ascites is the accumulation of fluid in the peritoneal cavity, a frequent complication of liver failure (Fullwood & Purushothaman, 2014).

Pancreatitis, or inflammation of the pancreas, is a rare and serious condition. Pancreatitis can be chronic or acute, potentially life-threatening, and is diagnosed in approximately 17 of 100,000 people in the United States (Brown, 2008).

Common causes of pancreatitis include:

· alcoholism (common in chronic pancreatitis),

· peptic ulcers,

· cholelithiasis or other obstructive disorders of the biliary tract,

· abdominal trauma,

· hyperlipidemia,

· can be drug induced,

· genetics, and

· cystic fibrosis.

Symptoms of pancreatitis include:

· epigastric and peri-umbilical pain that may radiate to the back is a classic symptom

· fever,

· shock,

· nausea/vomiting, and

· abdominal distension with small intestine ileus (Sargent, 2006).

Abnormal laboratory findings include elevated serum amylase and lipase. Elevated urinary amylase, hyperglycemia, hyperlipidemia, and hypocalcemia may also occur. Ultrasound and CT scans may be used to diagnose pancreatitis as well. Pancreatitis can recur, and each episode may further damage the cells of the pancreas related to production of insulin; therefore, diabetes may occur in patients with long-term pancreatitis (Hughes, 2004). The pancreas cannot be palpated because it lies beneath the stomach. Clinical signs and symptoms usually occur abruptly with sudden pain. If left untreated, renal failure, shock, sepsis, and multisystem organ failure may occur (Schlapman, 2001).

Check for Understanding

1. What are the components of the gastrointestinal tract that form a continuous pathway?

2. What accessory organs are needed to aid in digestion?

3. Identify normal changes in the gastrointestinal, renal, and urinary systems that are related to aging.

4. Identify disorders in the gastrointestinal, renal, and urinary systems that can be present in children.

Nursing Management

·

Nursing management should be provided in a holistic, individualized way. Patients with elimination complexities have specific nursing needs as well as individualized needs.

Nurses play a key role in the management of elimination complexities at initial presentation, during treatment, and upon discharge (Cunningham, Noble, Kadhum, Modhefer, & Walsh, 2016). For example, during initial presentation and treatment, critical care nurses are in an ideal position to identify risk factors and potentially nephrotoxic agents that pose a threat to patients’ renal function. Interventional studies including contrast pose risk for contrast-induced nephropathy. Procedures such as computed tomography, cardiac catheterization, and pacemaker implantations all include injection of contrast medium that is toxic to the kidneys (Isaac, 2012). The nephrotoxic effects of contrast medium can increase patient morbidity and mortality (Isaac, 2012). Nurses play an important role in assessing for and preventing renal insult by determining the patient’s baseline serum creatinine level, level of hydration, and nephrotoxic medications that may need to be adjusted. Postinterventional study serum creatinine levels should be monitored, along with patient teaching to report signs and symptoms of decreased renal function (Isaac, 2012).

Restoration of Function

·

The goal of nursing management in the care of patients with renal or gastrointestinal disorders is aimed toward restoration of function. Incorporation of nursing assessment, nursing diagnoses, planning, nursing implementation, and evaluation are all important steps in the process. Early identification of clinical manifestations of disease, utilization of collaborative care for treatment, and recognition of complications all play a major role in restoration of function of systems. Assessment of patients for predisposing and etiological factors that contribute to disease is of vital importance. Encouragement of patients to receive early treatment and interventions of identified disorders to prevent worsening of symptoms or recurrence of disease should be prioritized.

Important steps to promote restoration of function should be encouraged by the nurse during inpatient and outpatient care. Patients should comply with all prescribed regimens, including follow-up appointments, medications, therapies, dietary management, and activity restrictions. It is important for the patient and family to continue to educate themselves about the medical condition and disease processes. The nurse can provide credible sources for reading, such as websites, pamphlets, printed material, brochures, or books, and encourage questions at follow-up visits.

Transition to Independence

·

Nurses should be sensitive to the fact that many patients find the loss of independence during illness demoralizing. Patients’ right to refusal of nursing care or assistance should be respected and patients’ privacy and dignity must be maintained (Hughes, 2004).

The patient and family should be interviewed about the presence or history of illness and disease that may be related to renal or gastrointestinal disorders. Contributing factors that should be considered as patients transition to independence include, but are not limited to, genetic/family history of disease, history of alcohol use or abuse, obesity, smoking, hypertension, and recurrent kidney infections. Subjective data include past medical history, medications, and previous surgeries. Psychosocial, cultural, and spiritual considerations offer even greater insight into the patients’ state of health. Certain cultural health disparities related to renal and gastrointestinal disorders should not be overlooked. Many symptoms, such as incontinence, for example, may go underreported because it is considered a social hygiene problem in some cultures, causing embarrassment (Lewis et al., 2007). Kidney stones, cancer, and other disorders have higher incidence in certain cultures because of higher incidence of genetic conditions in certain ethnic groups.

Information regarding functional health patterns can offer the nurse significant insight into the current and past state of health of patients. Functional health patterns include:

· Health perception—values,

· Nutrition/metabolic pattern,

· Sleep/rest pattern,

· Elimination pattern,

· Activity/exercise pattern,

· Cognitive/perceptual pattern,

· Sensory/perception—self-concept pattern,

· Role relationship pattern,

· Sexuality/reproductive pattern, and

· Coping

·

Patients experiencing illness such as end-stage renal disease, liver disease, and pancreatitis face adversity, as their treatment options are limited. Many are considering dialysis to treat renal disease, transplantation, or death. Encouraging resiliency
 or “the capacity of individuals to successfully maintain or regain their mental health in the face of significant adversity or risk” (Stewart & Yuen, 2011, p. 199) can enhance the patients’ quality of life, which may be the most valuable nursing intervention that can be provided. Nurses have many opportunities to promote resilience, but the advantages of positive outcomes when intervening early in the process has proven beneficial. Stewart and Yuen (2011) related the following factors with resiliency:

· Social support;

· Coping skills, including spirituality;

· Psychological factors, including self-esteem, optimism, acceptance of illness, determination, and self-efficacy; and

· Factors related to physical illness, including adherence to treatment plan, quality of life, perception of illness, self-care, perception of pain, adherence to physical activity plan (Stewart & Yuen, 2011).

Nurses can encourage patients to improve or develop resiliency in the following ways:

· Offer care and support during the acute phase of illness and provide resources for support when discharged, such as support groups.

· Set high, but realistic, goals for recovery and independence.

· Offer opportunities for the patient to develop and increase meaningful connections with others, such as attending support groups after being discharged.

· Help the patient develop and maintain life skills and encourage physical and occupational therapy if prescribed.

· Set clear boundaries when necessary so that the patient always feels safe and not overwhelmed.

· Encourage patience with the healing process (Henderson, 2007; Ulrich, 2016).

Prevention and Health Promotion

·

Patient education is needed for prevention of future events, health restoration, avoidance of deterioration, and prevention of readmission. Providing patient education is an important part of transitioning the patient from acute or chronic illnesses to independence. In fact, lack of education can cause anxiety for some patients and their family members.

For example, a patient in acute renal failure has required multiple packed red blood cell transfusions to treat low hematocrit levels. The patient’s family is overly anxious seeing the transfusions, assumes the patient is losing blood, and worries that the patient’s condition must have worsened. When the nurse educates the patient and family that acute renal failure causes the lack of erythropoietin production, thus decreasing the body’s production of red blood cells, they begin to understand the need for the packed red blood cell transfusions, and the patient and family’s anxiety is resolved.

Educating patients and families throughout the disease process is good practice and may help to promote independence. The increased knowledge can assist patients and families in decision making related to their course of treatment. It is important to continue educating patients as they continue to recover by discussing causes of their disease and ways to prevent recurrence. Along with patient education, excellent communication skills are vital. The nurse should show empathy toward the patient and family and manage any anxieties in an empathetic and professional manner (Hughes, 2004).

Note: Table 3.4 is incorrect, and should say low protein diet instead of high protein diet. 

Table 3.4


Important Health Promotion Considerations

Nutrition/Intake

Patients often have orders for dietary restrictions such as:


Pancreatitis:

 Often NPO for acute cases or high carbohydrate diet to decrease the stimulation of the exocrine pancreas.


Renal Disease:
 Renal diet with potassium and sodium restrictions. Often a high protein diet. Fluid restrictions are often ordered.


Cirrhosis:
 High calorie and high carbohydrate diet. Fluid and sodium restriction are often ordered for patients with ascites or edema.


Cholecystitis/Cholelithiasis:
 Low fat diet to decrease stimulation of the gallbladder.

Exercise/Mobility

Consider activity as ordered at applicable levels of prevention.

Medications

Patient may need assistance obtaining and maintaining prescriptions to prevent future medical events.

Post-Transplant

Concerns

Monitor for infection.

Importance of taking medications exactly at prescribed times.

Immunologic considerations.

Emotional support and patient education are essential.

Patients and families often require assistance in obtaining tools and services that are necessary to maintain independence during the chronic stages of care. When orders for equipment and other resources are received from the primary care provider, the nurse may request assistance from other collaborative care partners, such as social services, durable medical equipment companies, home health, hospice, or pastoral care, to meet the patients’ needs. A few examples are listed in Table 3.5.

Table 3.5


Resources Necessary for Nonacute Care

Devices

Durable medical equipment, mobility equipment, oxygen, enteral feeding supplies, glucose monitoring system, peritoneal dialysis supplies.

Medications

Patient may need assistance obtaining and maintaining prescriptions to prevent future events.

Transportation

Dialysis treatment is often required multiple days per week, and assistance with transportation may be needed.

Living Conditions

Assistance with household activities may be needed. No smoking in homes with oxygen tanks.

Return to Employment Issues

Resources for rehabilitative time and modifications to previous workload may be needed. Fatigue may interfere with work performance.

Check for Understanding

1. What types of support processes are commonly available to patients with elimination complexities?

2. What is the goal of nursing management in the care of patients with renal or gastrointestinal disorders?

3. What contributing factors should the nurse consider as patients transition to independence?

4. What functional patterns exist that can provide the nurse insight into patients’ current and past state of health?

Reflective Summary

There are many disease processes that affect the complex structures of elimination that are necessary for sustaining life. Today, individuals live longer than they used to, so many opportunities exist for nurses to improve care by offering psychosocial, cultural, and spiritual support that can impact patients’ transition to independence. The key role that nurses offer in providing patients the resources necessary to promote independence, along with developing and encouraging resiliency, can increase patient quality of life. Educating patients regarding illness prevention, prevention of progression of disease, and health restoration has benefits for both patients and health professionals.

Key Terms

Ascites: Complication of liver failure causing accumulation of fluid in the peritoneal cavity.

Cholecystitis: Inflammation of the gallbladder that causes stone formation lodged in the cystic duct.

Chronic Kidney Disease: Progressively irreversible loss of kidney function.

Cirrhosis: Chronic liver disease that causes irreversible and progressive destruction of hepatic cells.

Glomerular Filtration Rate (GFR): Volume of blood filtered by the glomerulus over 1 minute; kidney function is measured by this.

Intrinsic Renal Failure: Damage to the kidneys caused by structural damage to the glomerulus, renal tubules, or vessels, causing cell necrosis, or by infectious agents and toxins that cause inflammation and injury.

Nephron: Functional unit of the kidney; tubular structure that filters and forms urine.

Pancreatitis: Inflammation of the pancreas can be chronic or acute.

Postrenal Failure: Damage to the kidneys caused by obstruction resulting in kidney injury from increased pressure within the kidney collection systems.

Prerenal Failure: Acute renal failure caused by impaired blood flow to the kidneys or volume depletion.

Resiliency: Positive adaptation to adversity.

Spirituality: Participation in organized religion, such as attending church, or nonreligious experiences such as personal reflection, yoga, or meditation.

References

Allen, R. C. (2016). Horseshoe kidney. Retrieved from www.medscape.com/article/441510-overview

Brown, A. (2008). Are health related outcomes in acute pancreatitis improving? An analysis of national trends in the U.S. from 1997 to 2003. 
Journal of the Pancreas
9(4), 408-414.

Cunningham, P., Noble, H., Kadhum, A., Modhefer, A., & Walsh, I. (2016). Kidney stones: Pathophysiology, diagnosis and management. 
British Journal of Nursing
25, 1112-1116.

Fullwood, D., & Purushothaman, A. (2014). Managing ascites in patients with chronic liver disease. 
Nursing Standard
28(23), 51-58.

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Horne, P. M. (2011). Managing complications in patients with cirrhosis and hepatocellular carcinoma. 
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Huether, S. E., & McCance, K. L. (2012). 
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Hughes, E. (2004). Understanding the care of patients with acute pancreatitis. 
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18(18), 45-52.

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Schlapman, N. (2001). Spotting acute pancreatitis. 
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Resources

1. Acute Kidney Failure

Read “Acute Kidney Failure,” located on the Mayo Clinic website.

https://www.mayoclinic.org/diseases-conditions/kidney-failure/symptoms-causes/syc-20369048

2. Chronic Kidney Disease (CKD) Symptoms and Causes

Read “Chronic Kidney Disease (CKD) Symptoms and Causes ,” located on the National Kidney Foundation website (2022).

https://www.kidney.org/atoz/content/about-chronic-kidney-disease

3. Kidney Failure (Symptoms, Signs, Stages, Causes, Treatment, and Life Expectancy)

Read “Kidney Failure (Symptoms, Signs, Stages, Causes, Treatment, and Life Expectancy),” by Wedro, located on the MedicineNet web

… Read More

https://www.medicinenet.com/kidney_failure/article.htm

4. Nephrotoxicity of Iodinated Contrast Media: From Pathophysiology to Prevention Strategies

Read” Nephrotoxicity of Iodinated Contrast Media: From Pathophysiology to Prevention Strategies,” by Faucon, Bobrie, and Clement,

… Read More

https://www-sciencedirect-com.lopes.idm.oclc.org/science/article/pii/S0720048X19300993


5. Optional- Ascites: A Common Problem in People With Cirrhosis

For additional information, the following is recommended:

“Ascites: A Common Problem in People With Cirrhosis,” by Chalasan

… Read More


https://gi.org/topics/ascites