BOWEL AND

URINARY
ELIMINATION
URINARY ELIMINATION
 Functional Units of Kidneys:
 Glomerular filtration Rate:
(GFR): 125 mL/min
 Kidneys form 0.5 to 1 mL/min
= 60 mL/hr
 1500 mL/day of urine
Adult: 60 – 120 mL/hr;
720 – 1440 mL/day
Child: 300 – 1500 mL/day
URINARY ELIMINATION
NORMAL CHARACTERISTICS
OF URINE:
Color: amber/straw
Odor: aromatic – upon voiding
Transparency: clear
pH: slightly acidic
(4.6 – 8; average 6)
SG: 1.010 – 1.025
URINARY ELIMINATION
Altered Urine Production:
Polyuria:
 100 mL/hr or 2500 mL/day
Oliguria:
 < 30 mL/hr or < 500 mL/24 hr
Anuria:
 0 – 10 mL/hr
URINARY ELIMINATION
Altered Urinary Frequency:
1. Frequency
2. Nocturia
3. Urgency
4. Dysuria
5. Hesitancy
6. Enuresis
7. Pollakuria – frequent, scanty urination
8. Retention -
URINARY ELIMINATION
Altered Urinary Frequency:
9. Urinary Incontinence
a. Total – continuous, unpredictable
b. Stress – leakage of < 50 mL urine due to
intra- abdominal pressure
c. Urge – sudden, strong desire to urinate
d. Functional – involuntary, unpredictable
passage of urine
e. Reflex – involuntary loss but predictable
URINARY ELIMINATION
Nursing Interventions to Induce
Voiding:
1. Fluids
2. Listen to sound of running water
3. Dangle fingers to warm water
4. Crede’s Maneuver: applying pressure
to suprapubic area
5. Last resort: URINARY
CATHETERIZATION
URINARY ELIMINATION
URINARY CATHETERIZATION:
1. Single:
2. Retention:
3. Continous Bladder Irrigation
(Cystoclysis)
URINARY ELIMINATION
Considerations:
1. Invasive procedure
2. Strict Asepsis
3. Perineal Care
4. Size of catheter:
a. Male: Fr. 16- 18
b. Female: Fr. 12 – 14
5. Position: Male? Female?
URINARY ELIMINATION
6. Urinary Meatus:
a. Male:
b. Female:
7. Length of catheter insertion:
a. Male: 6 – 9 inches
b. Female: 3 – 4 inches
URINARY ELIMINATION
 Condom Catheter:
Considerations:
a. Proper way to apply condom
catheter:
b. Frequency of checking:
c. Frequency of changing:
d. Attach to where part of the body?
URINARY ELIMINATION
 Indwelling Catheter/Straight:
a. Where to insert:
b. For indwelling: how to anchor:
c. If inserted to vagina, what to
do:
COMPARISON:
CATHETERIZATION
GENDER MALE FEMALE
URETHRAL 6 – 9 inches 2 -3 inches
LENGTH
POSITION supine Dorsal
recumbent
GENITAL 90 degrees Retract
HANDLING
CLEANING circular Front –
METHOD back
ATTACH Lower Lower thigh
abdomen
 CATHETERIZATION REMINDERS:

 LEFT LEFT, RIGHT RIGHT. Left handed

nurse must stand on the left side of pt.
 GRASP CATHETER 2 – 3 INCHES
 As nurse INSERTS catheter – CLIENT
INHALES DEEPLY and EXHALES
 STERILE WATER IN BALLOON not NSS
 TEST BALLOON before catheter insertion
 IF URINE FLOWS, do not stop, INSERT 2
INCHES further into the bladder

WHAT TO DO WHEN A URINARY CATHETER

ACCIDENTALLY INSERTED TO VAGINA?
BOWEL ELIMINATION
Defecation – expulsion of feces from
the rectum
 Fecal matter may take 24 – 48
hours to pass through large
intestine
 150 – 300 gm of feces is produced
daily
 Composition of feces? : 75 % water
and 25 % solid
BOWEL ELIMINATION
Normal Characteristics of Stool:
Color: yellow or golden brown
“ What do you call the bile pigment
responsible for stool color?”
• Stercobilin/fecal urobilinogen
Odor: aromatic
Amount: 150 – 300 g/day
Consistency: soft, formed
Shape: cylindrical
Frequency: 1-2/day to 2 -3 days
BOWEL ELIMINATION
Alteration on Stool Characteristics
1. Acholic Stool: gray, pale, clay –
colored stool
2. Hematochezia: stool with bright
red blood
3. Melena: black tarry stool
4. Steatorrhea: greasy, bulky, foul
smelling stools
BOWEL ELIMINATION
Alteration on Stool Characteristics
 YELLOW DARK
= BREAST FED
 YELLOW PALE
= BOTTLE FED
 CURRANT JELLY
= INTUSSUSCEPTION
 RIBBON-LIKE
= HIRSCHPRUNG’S
BOWEL ELIMINATION
RECTAL TUBE INSERTION:
 INSERTED in the rectum to decrease
bloating and GI AIR.
 Lubricate 4 INCHES
 LATERAL position
 Insert towards the UMBILICUS
 4 INCHES
 FR. 22-30
 Release within 20 MINUTES.
 Monitor HEART CHANGES
BOWEL ELIMINATION
COLOSTOMY CARE:
 REMOVE OLD BAG WHEN 1/2 – ¾ FILLED.
 Press the SKIN gently
 DO NOT pull the BAG to prevent stoma
breakdown
 Cleanse the site with SOAP AND WATER.
 Stool is never STERILE, neither the procedure as
well
 Assess STOMA
 Bluish colored stomach means oxygenation
CONCERN.
 MEASURE AND CUT BAG
 Give extra 1/8 INCH LARGER ALLOWANCE.
 Place wafer and apply to pt
BOWEL ELIMINATION
Fecal Elimination Problems:
1. Constipation – passage of small, dry, hard
stools
Management:
1. Fluids
2. Fiber
3. Regular pattern of defecation
4. Respond immediately to urge to defecate
5. Minimize stress
6. Exercise
7. Laxatives as ordered
BOWEL ELIMINATION
2. Diarrhea – frequent evacuation of
stools
Management:
1. Replace F and E
2. Diet: BRAT
3. Avoid excessive hot or cold fluids
4. Antidiarrheal as ordered:
* BEST TIME TO ADMINISTER MEDS?
BOWEL ELIMINATION
3. Fecal Impaction
 mass or collection of hardened feces
in the folds of rectum
Management:
1. Manual extraction as ordered
2. Fluid intake
3. Bulk in diet
4. Activity and exercise
BOWEL ELIMINATION
4. Flatulence
 excessive gas in intestine
Management:
1. Avoid gas forming
2. Warm fluids to drinks
3. Early ambulation
4. Activity and exercise
5. Limit carbonated beverages
6. Rectal tube insertion (3-4 in) for 30
minutes; Position?
BOWEL ELIMINATION
5. Fecal Incontinence
 involuntary elimination of bowel
contents
ENEMA:
a. CLEANSING = FOR SURGERY
b. RETENTION = STOOL LURICATION
c. CARMINATIVE = FLATUS REMOVAL

PROCEDURE: 
 LEFT SIDE LYING FIRST
 LUBRICATE
 INSTRUCT TO DEEP BREATHE THRU MOUTH
 INSTRUCT TO HOLD DEFECATION AS MUCH AS
POSSIBLE IN CLEANSING ENEMA.
 CLAMP IF THERE IS ABDOMINAL CRAMPING
 ASSIST TO C.R.
 REFER TO H.N OR DR IF STOOL IS NOT YET CLEAR
AFTER 3 RETURNS.
BOWEL ELIMINATION
Administering Enema:
Types:
1. Cleansing – irritating the colon and
rectum
 Differentiate high and low enema
administration:
a. High enema: clean as much colon; 1000
mL of solution is introduced
b. Low enema: rectum and sigmoid colon
only
BOWEL ELIMINATION
2. Carminative enema – expel flatus;
60 – 180 mL introduced
3. Retention enema – oil is
introduced and retained 1-3 hours to
rectum and sigmoid
4. Return flow-enema/Harris flush
– to expel flatus; 300 -500 mL of
fluids is introduced into and out of
large intestine
BOWEL ELIMINATION
Non retention Enema
 Solution: tap water, soap suds
 height: 18 inches above rectum
 Temp: 115 – 225 F
 Time: 5 – 10 mins

Retention:
 Solution: carminative; oil
 height: 12 inches above rectum
 Temp: 105 – 110 F
 Time: 1 – 3 hours
BOWEL ELIMINATION
Enema Administration:
1. Position:
 Adult: left lateral
2. Lubricate
3. Length of insertion: 3 -4 in
4. High enema: change position; Low: remain
• INSTRUCTION TO CLIENT
AFTER DEFECATING?
ELIMINATION

Practice Test
1. To help maintain continence in a
patient who has urge incontinence, the
nurse should:
     A. toilet the patient every 4 hours
     B. toilet the patient immediately on
request
     C. encourage the patient to stay near
the bathroom
     D. ask the patient to limit fluid intake
in the evening
 TEST-TAKING TIP The word “urge” is the
significant clue in the stem. Option B is patient
centered. The word “every’ in Option A is a
specific determiner.
A. Toileting the patient every 2 hours is more
appropriate.
B. This supports continence because the person with
urge incontinence must immediately void or lose
control.
C. This promotes isolation and should be avoided.
D. Limiting fluid intake during the early evening and
night may be part of a toileting program to provide
uninterrupted sleep; however, it does not address
the patient’s need to urinate immediately when
feeling the urge to void.
 When administering a tap
water enema, the nurse
recognizes that its primary
purpose is to:
     A. minimize intestinal gas       
B. cleanse the bowel of stool
C. reduce abdominal
distension
D. decrease the loss of
electrolytes
TEST-TAKING TIP The words “tap water” are a
significant clue in the stem. The word “primary”
is the key word in the stern that sets a priority.
A. A Harris drip (Harris flush), not a tap water
enema, helps evacuate intestinal gas.
B. A tap water enema introduces a hypotonic fluid
into the intestinal tract; distention and pressure
against the intestinal mucosa increase peristalsis
and evacuation of stool.
C. This is a secondary gain because flatus and stool
are evacuated along with the enema solution.
D. A tap water enema would increase, not decrease,
the loss of electrolytes because it is a hypotonic
solution.
 The physician orders a 750-mL tap
water enema. To best promote acceptance
of the volume ordered, the nurse should:
       A. administer the fluid slowly and have the
patient take shallow breaths
     B. place the patient in the left lateral
position and slowly administer the fluid
       C. have the patient take shallow
breaths and keep the fluid at body
temperature
      D. keep the fluid at body temperature and
place the patient in the left lateral position
 TEST-TAKING TIP The word “best” is the word in the stem that sets a
priority. Four different interventions are offered as actions that help a patient
retain a 750-mL tap water enema. If you can identify one action that is based
on a scientific principle associated with tap water enema administration, you
can narrow the correct answer to two options. If you can identify one action
that is not based on a scientific principle associated with tap water enema
administration, you can delete two options from consideration.
A. Although the slow administration of enema fluid is appropriate, encouraging
shallow breaths, versus deep breaths, may con tribute to an increase in
intra-abdominal pressure, which can interfere with the retention of enema
fluid.
B. Both of these actions contribute to retention of enema fluid. In the left lateral
position, the sigmoid colon is below the rectum, facilitating the instillation of
fluid. The slow administration of enema fluid minimizes the probability of
intestinal spasm and premature evacuation of the enema fluid before a
therapeutic effect is achieved.
C. Encouraging shallow breaths and using a 98.6°F enema fluid interfere with
the instillation and retention of enema fluid. Encouraging deep breaths, not
shallow breaths, helps to prevent patients from holding their breath, which
increases intra-abdominal pressure; increased intra-abdominal pressure can
interfere with the instillation and retention of enema fluid. A water
temperature of 98.6°F is too cool and can contribute to intestinal muscle
spasm and discomfort.
D. Although placing the patient on the left side is appropriate, a water
temperature of 98.6°F is too cool and can contribute to intestinal muscle
spasm and discomfort. Enema water temperature should be between 105°
and 110°F because warm fluid promotes muscle relaxation and comfort.
 Which solution would be most
effective for a patient who is
unable to tolerate a large amount
of enema fluid?
     A. Hypertonic fluid        
B. Normal saline
C. Soapy water
D. Tap water
 TEST-TAKING TIP The word “most” in the stem sets a
priority.
A. A hypertonic enema solution uses only 120 to 180 mL of
solution. Hypertonic solutions expend osmotic pressure
that draws fluid out of the interstitial spaces; fluid pulled
into the colon and rectum distend the bowel, causing an
increase in peristalsis resulting in bowel evacuation.
B. A normal saline enema is isotonic and requires a
volume of 500 mL to 750 mL to be effective; the volume
of fluid, not its saline content, causes an evacuation of
the bowel.
C. A soapsuds enema requires a volume of 750 to 1000 mL
of fluid to result in an effective evacuation of the bowel.
D. A tap water enema usually requires a minimum of 750
mL of water.
 Which patient is at greatest
risk for developing
constipation?
   A. Toddler       
  B. Adolescent
C. Pregnant woman
D. Middle-age man
 TEST-TAKING TIP The word “greatest” is the key word
in the stem that sets a priority.
A. A toddler usually drinks adequate fluids, eats a regular
diet, and is very active; these activities contribute to
bowel elimination.
B. The adolescent usually eats more food than at earlier
stages and may complain of indigestion, not
constipation; indigestion is a response to increased
gastric acidity that occurs during adolescence.
C. The growing size of the fetus exerts pressure on the
rectum and bowel, which impinges on intestinal
functioning, contributing to constipation; the
decreased motility causes increased absorption of
water, promoting constipation.
D. As people advance through middle adulthood, they are
at risk for gaining weight, not developing constipation.
 When preparing a soapsuds
enema for an adult, how much
fluid should the nurse use to
effectively stimulate the bowel?
    A. 250 mL
    B. 500 mL
C. 700 mL
D. 900 mL
17. TEST-TAKING TIP Options A and D are opposites.
A. 250 mL is too little fluid; this is the recommended
amount for a toddler.
B. 500 mL is too little fluid; this is the recommended
amount for a large school-age child or small
adolescent.
C. 700 mL is too little fluid for an adult. 700 mL is the
recommended volume for an average-sized
adolescent.
D. The range of 750 to 1000 mL, with an average of
900 mL, is the suggested volume of soap suds
solution administered to an adult to stimulate
effective evacuation of the bowel. It pro vides
enough fluid to fill the bowel and apply pressure to
the intestinal mucosa, along with the irritating
action of soap on the mucosa, to stimulate
defecation.
 When administering an
enema, the nurse should
position the patient in the:
     A. dorsal recumbent position
B. right lateral position
C. back-lying position
D. left Sims’ position
 TEST-TAKING TIP Options A and C are equally
plausible. Options B and D are opposites.
A. This position would not use the natural curve
of the rectum and sigmoid colon to facilitate
instillation of the enema solution.
B. Same as A.
C. Same as A.
D. The left Sims’ position permits the solution to
flow downward via gravity along the natural
curve of the rectum and sigmoid colon,
promoting instillation and retention of the
solution.
 When voiding, the male
patient on bed rest should be
positioned in the
     A. supine position       
B. lateral position
C. contour position
D. standing position
 TEST-TAKING TIP Option D denies the patient’s
needs because standing is contraindicated. The
stem informs you that the patient is on “bed
rest.”
A. The supine position would not promote passage
of urine through the urinary tract via gravity.
B. The lateral position is the closest to the normal
standing position used by men to void; the hips
and knees are almost extended and the hands
can be used for self-care.
C. In the contour position, the hips and knees are
flexed and the perineal area is dependent in
relation to the knees, placing and using a urinal
in this position without spilling would be
difficult.
D. Standing is contraindicated because the patient
is not allowed out of bed.
 In the morning a patient has a loose watery
stool. To determine if the patient has
diarrhea, the nurse should ask:
      A. “What did you have for dinner last
night?”
     B. “Have you been drinking a lot of fluid
lately?”
      C. “When was the last time you had a
similar stool?”
      D. “Are you experiencing any abdominal
cramping?”
A. Although this answer may help determine
if food influenced the patient’s intestinal
elimination, it does not further assess
the presence of diarrhea.
B. Excessive fluid intake is excreted
through the kidneys, not the intestinal tract,
C. Diarrhea is the defecation of liquid feces
and increased frequency of defecation.
D. Champing is not specific to diarrhea; it
can also be associated with constipation
and intestinal obstruction.
 When administering a soapsuds
enema, the nurse understands that
the primary action of the soapsuds is
to:
     A. increase pressure in the
bowel
     B. distend the lumen of the
bowel
C. irritate the bowel mucosa
D. exert an osmotic effect
 TEST-TAKING TIP The word “primary” is the
key word in the stem that sets a priority.
Options A and B are equally plausible because
they are both related to the effects of the
volume of the enema solution, not the action of
soapsuds, on the intestinal mucosa.
A. This is the rationale for using a high volume of
fluid, not soapsuds.
B. Same as A.
C. Soap is an irritant that stimulates the intestinal
mucosa, precipitating peristalsis and the
eventual evacuation of stool.
D. This is the rationale for using a hypertonic
solution, not soapsuds.
 When does stress incontinence
occur?
     A. with a urinary tract infection
     B. in response to emotional strain
     C. as a result of increased intra-
abdominal pressure
     D. when a specific volume of
urine is in the bladder
A. Urinary tract infections often cause
frequency as a result of irritation of the
mucosal wall of the bladder, not stress
incontinence.
B. Emotional strain may cause frequency,
not stress incontinence.
C. When intra-abdominal pressure
increases, the person with stress
incontinence experiences urinary
dribbling, or an approximate loss of 50
mL of urine or less.
D. This occurs in reflex, not stress,
incontinence.
 The nurse understands that with a tap
water enema, the:
       A. volume of instilled water stimulates
peristalsis
      B. water can cause excessive interstitial
fluid loss
       C. surface tension of water is reduced by
soapsuds
      D. hypertonic nature of the water irritates
the intestinal mucosa
 TEST-TAKING TIP The words “tap water” modify
the word “enema.” This is the clue in the stem.
A. The large volume of instilled tap water distends
the colon, which in turn stimulates peristalsis; it
also softens feces.
B. Tap water is hypotonic which can cause water
intoxication and fluid and electrolyte imbalance,
not excessive interstitial fluid loss.
C. Soap is not added to a tap water enema.
Soapsuds enemas work by irritating the mucosa
and distending the colon, which ill turn
stimulates peristalsis.
D. A tap water enema is hypotonic, not hypertonic.
 What should the nurse assess
for when establishing the
patency of a urinary retention
catheter (Foley)?
     A. Color        
B. Clarity
C. Volume
D. Constituents
A. The color of urine would reflect urine
concentration or a reaction to a specific drug
or food, not catheter patency.
B. A cloudy urine would indicate the presence of
such products as red or white blood cells,
bacteria, prostatic fluid, or sperm. Clarity
would not indicate catheter patency.
C. If urine volume was minimal or nonexistent, it
would indicate that the catheter was
obstructed or the patient was not producing
urine in the kidneys.
D. Abnormal constituents of urine such as pus or
blood would indicate possible pathology, not
catheter patency.
 Which is the most common
psychologic concern of patient who
have a colostomy?
     A. Maintenance of skin
integrity       
B. Frequency of defecation
C. Ability to control odor
D. Consistency of feces
 TEST-TAKING TIP The word “most” modifies the
word “common” indicating a priority. The words
“psychologic concern” are the clue in the stem.
A. This is a physiologic, not a psychologic,
concern.
B. Same as A.
C. This is a major psychologic concern of people
with a colostomy, because the odor can be
offensive if not controlled.
D. Consistency is not as major a concern as
another factor. The consistency of feces varies
accord ing to the location of the stoma along the
intestinal tract.