4. Alterations affecting elimination
1. Urinary system
1. Physiological changes:
1. Relaxation of smooth muscle results in conditions that can persist 4-6 weeks after birth:
1. Dilatation of ureters.
2. Decreased bladder tone.
3. Increased potential for urinary stasis and infection (UTI).
2. Increased glomerular filtration rate (50%) during last two trimesters.
3. Increased renal plasma flow (25-50%) during first two trimesters; returns to near normal levels by end of last trimester.
4. Increased renal-tubular reabsorption rate - compensates for increased glomerular activity.
5. Glycosuria - reflects kidney’s inability to reabsorb all glucose filtered by glomeruli (may be normal or may indicate gestational diabetes; glycosuria always warrants further testing).
6. Increased renal clearance of urea and creatinine (creatinine clearance used as test of renal function during pregnancy).
7. Hormone - induced turgescence of bladder and pressure on bladder from gravid uterus.
2. Assessment:
1. Urinary frequency, first and third trimesters.
2. Nocturia.
3. Stress incontinence in third trimester.
3. Nursing care plan/implementation:
Goal: health teaching
1. Void with urge, to prevent bladder distention.
2. Learn signs and symptoms of UTI.
3. Decrease fluid intake in late evening.
4. Perform Kegel exercises to reduce incontinence.
2. Gastrointestinal system
1. Physiological changes:
1. General decrease in smooth-muscle tone and motility due to actions of progesterone.
2. Intestines: slowed peristalsis, increased water reabsorption in bowel.
3. Stomach
1. Gastric emptying time is delayed (e.g., 3 hr vs. 1 and ½ hr).
2. Gastric secretion of HCI and pepsin decreases.
3. Decreased motility delays emptying; increased acidity.

4. Cardiac sphincter relaxes.
5. Increasing size of uterus and displacement of intraabdominal organs.
6. Gallbladder: decreased emptying.
2. Assessment:
1. Nausea and vomiting in first trimester.
2. Constipation and flatulence.
3. Hemorrhoids.
4. Heartburn, reflux esophagitis, indigestion.
5. Hiatal hernia.
6. Epulis-edema and bleeding of gums.
7. Ptyalism-excessive salivation.
8. Jaundice.
9. Gallstones.
10. Pruritus due to increased retention of bile salts.
3. Nursing care plan/implementation:
Goal: health teaching
1. Nausea and vomiting
1. Avoid fatty food; increase carbohydrates.
2. Eat small, frequent meals.
3. Eat dry crackers in morning.
4. Decrease liquids with meals.
5. Avoid odors that predispose to nausea.
2. Constipation and flatulence
1. Increase fluids (6-8 glasses/day).
2. Maintain exercise regimen.
3. Add fiber to diet.
4. Avoid mineral oil laxatives.
5. Avoid gas-producing foods (e.g., beans, cabbage).
3. Heartburn and indigestion
1. Eliminate fatty or spicy foods.
2. Eat small, frequent meals (6/day).
3. Eat slowly.
4. Avoid gastric irritants (e.g., alcohol, coffee).
5. Perform “flying exercises.”
6. Avoid lying flat.
7. Take antacids without sodium or phosphorus.
8. Sip milk or eat yogurt if heartburn occurs.
9. Avoid sodium bicarbonate.
4. Hemorrhoids
1. Increase fluid and fiber intake.
2. Maintain exercise regimen.
3. Avoid constipation and straining to defecate.
4. Take warm sitz baths.
5. Apply witch hazel pads.
6. Elevate hips and legs frequently.
7. Use hemorrhoidal ointments only with advice of health care provider.