4 Urinary and Bowel Elimination

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/strawOdor: aromatic – upon voidingTransparency: clearpH: slightly acidic

(4.6 – 8; average 6)SG: 1.010 – 1.025

URINARY ELIMINATION

Altered Urine Production:Polyuria: 100 mL/hr or 2500 mL/dayOliguria: < 30 mL/hr or < 500 mL/24 hrAnuria: 0 – 10 mL/hr

URINARY ELIMINATION

Altered Urinary Frequency:1. Frequency2. Nocturia3. Urgency4. Dysuria5. Hesitancy6. Enuresis7. Pollakuria – frequent, scanty urination8. Retention -

URINARY ELIMINATION

Altered Urinary Frequency:9. Urinary Incontinencea. Total – continuous, unpredictableb. Stress – leakage of < 50 mL urine due

to intra- abdominal pressurec. Urge – sudden, strong desire to urinated. Functional – involuntary, unpredictable

passage of urinee. Reflex – involuntary loss but

predictable

URINARY ELIMINATION

Nursing Interventions to Induce Voiding:

1. Fluids 2. Listen to sound of running water3. Dangle fingers to warm water4. Crede’s Maneuver: applying

pressure to suprapubic area5. Last resort: URINARY

CATHETERIZATION

URINARY ELIMINATION

URINARY CATHETERIZATION:1. Single:2. Retention:3. Continous Bladder Irrigation

(Cystoclysis)

URINARY ELIMINATION

Considerations:1. Invasive procedure2. Strict Asepsis3. Perineal Care4. Size of catheter:

a. Male: Fr. 16- 18b. 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 inchesb. 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 LENGTH

6 – 9 inches

2 -3 inches

POSITION supine Dorsal recumbent

GENITAL HANDLING

90 degrees Retract

CLEANING METHOD

circular Front – back

ATTACH Lower abdomen

Lower thigh

CATHETERIZATION REMINDERS:

LEFT LEFT, RIGHT RIGHT. Left handed nurse must stand on the left side of pt.

GRASP CATHETER 2 – 3 INCHESAs nurse INSERTS catheter – CLIENT

INHALES DEEPLY and EXHALESSTERILE WATER IN BALLOON not NSSTEST BALLOON before catheter insertionIF 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: aromaticAmount: 150 – 300 g/dayConsistency: soft, formedShape: cylindricalFrequency: 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 stool4. Steatorrhea: greasy, bulky,

foul smelling stools

BOWEL ELIMINATION

Alteration on Stool CharacteristicsYELLOW DARK

= BREAST FEDYELLOW PALE

= BOTTLE FEDCURRANT JELLY

= INTUSSUSCEPTIONRIBBON-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 ELIMINATIONCOLOSTOMY 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 stoolsManagement:1. Fluids2. Fiber3. Regular pattern of defecation4. Respond immediately to urge to

defecate5. Minimize stress6. Exercise7. Laxatives as ordered

BOWEL ELIMINATION

2. Diarrhea – frequent evacuation of stools

Management:1. Replace F and E2. Diet: BRAT3. Avoid excessive hot or cold fluids4. Antidiarrheal as ordered:* BEST TIME TO ADMINISTER

MEDS?

BOWEL ELIMINATION

3. Fecal Impaction mass or collection of hardened

feces in the folds of rectumManagement:1. Manual extraction as ordered2. Fluid intake3. Bulk in diet4. Activity and exercise

BOWEL ELIMINATION

4. Flatulence excessive gas in intestineManagement:1. Avoid gas forming2. Warm fluids to drinks3. Early ambulation4. Activity and exercise5. Limit carbonated beverages6. Rectal tube insertion (3-4 in) for 30

minutes; Position?

BOWEL ELIMINATION

5. Fecal Incontinence involuntary elimination of bowel

contents

ENEMA:a. CLEANSING = FOR SURGERYb. RETENTION = STOOL LURICATIONc. 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 introducedb. 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 ELIMINATIONNon retention Enema Solution: tap water, soap suds height: 18 inches above

rectumTemp: 115 – 225 F Time: 5 – 10 mins

Retention:Solution: carminative; oil height: 12 inches above

rectumTemp: 105 – 110 FTime: 1 – 3 hours

BOWEL ELIMINATION

Enema Administration:1. Position: Adult: left lateral2. Lubricate3. Length of insertion: 3 -4 in4. High enema: change position; Low:

remain• INSTRUCTION TO CLIENT

AFTER DEFECATING?

ELIMINATIONPractice 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 stoolC. reduce abdominal distensionD. 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 womanD. 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 mLD. 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 positionD. 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 positionD. 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 mucosaD. 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. ClarityC. 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

defecationC. Ability to control odorD. 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.