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Engage Fundamentals

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 Lesson 32
Elimination

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 Everyone needs to have a fully functional urinary and
gastrointestinal tract to maintain the proper elimination of bodily
waste and to remain healthy. Alterations in function need to be
evaluated and addressed so that clients can return to their usual
function or return to a new normal.

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The Urinary Tract ➢ Primary function is to eliminate waste
and excess fluid from the body in the
form of urine.
➢ Regulates levels of electrolytes,
produces hormones that are important
for blood pressure regulation,
develops red blood cells, and helps to
keep bones strong.
➢ Urine travels through the urinary
system or urinary tract, which consists
of the kidneys, ureters, bladder, and
urethra.

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 ➢ Two bean-shaped organs located
below the ribcage, each adjacent to the
spine.
The Kidneys ➢ On average, filter 120 to 150 quarts of
blood to produce about 1 to 2 quarts of
urine.
➢ From the kidneys, urine is transported
to the bladder by ureters, or thin tubes
of muscle. There is one ureter from
each kidney.
➢ Once urine reaches the bladder, it
begins to fill and stretch based on the
amount of urine present.
➢ Normally, a bladder can hold up to 2
cups of urine.
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Structure of the Urinary System

Kidneys
• Two bean-shaped organs 6 cm wide x 12 cm
long
• Located at level of L1 on either side of the
spine
• Each kidney contains approximately 1 million
nephrons

Nephrons
• Inside each nephron is a glomerulus consisting
of a cluster of capillaries surrounded by
Bowman’s capsule and a system of tubules
This Photo by Unknown Author is licensed under CC BY-SA-NC
• Nephrons are the working units of the kidney

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Structure of the Urinary System

Ureters
• Hollow tubes that carry urine from the
kidneys to the bladder
• Each ureter is 25 to 30 cm long

Bladder
• Hollow muscular organ located in lower
pelvis that stores urine

Urethra
• Carries urine from bladder to meatus; flow
This Photo by Unknown Author is controlled by urinary sphincter
licensed under CC BY-SA-NC
• Meatus—conducts urine to outside the
body

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 Urinary Elimination

• Normal Urinary • Factors Affecting

Elimination Normal Urination
• Infants void 5 to 40 times/day • Neurologic and muscle
• Preschool children may void every development
2 hours • Alterations in spinal cord integrity
• Adults void 5 to 10 times per day • Fluid volume intake
• Males void 300 to 500 mL • Fluid loss in perspiration
• Females void 250 mL • Vomiting
• Average output should be • Diarrhea
approximately 30 mL/hr • ADH secreted by the pituitary

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There are three sets of
muscles to prevent
unwanted urination:

1. The urethra
2. The bladder neck which
is composed of the
internal sphincter
3. The pelvic floor

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 Characteristics of Normal Urine

• Color
• Straw-colored or amber
• Clarity
• Transparent or only slightly
cloudy
• Odor
• Faintly like ammonia
• Specific gravity
• Normal range is 1.010 to 1.030
This Photo by Unknown Author is licensed under

• pH CC BY-NC-ND

• Slightly acid, ranging from 5.5 to

7.0
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 Alterations in Urinary Elimination Patterns
• Anuria
• Less than 100 mL of urine output in 24 hours
• Dysuria
• Painful or difficult urination; may be from infection or trauma
• Incontinence
• Nocturia
• When a person has to get up more than twice in the night to
void
• Oliguria
• Decreased urine output less than 400 mL in 24 hours
• Polyuria
Excessive urination (>1500ml in 24 hours)
• Cystitisi
• Inflammation of the bladder
• May be caused by irritation of highly concentrated urine,
pathogenic bacteria, injury, or instillation of an irritating
substance
• Symptoms: frequency, urgency, dysuria, burning, malaise, foul-
smelling urine, slight temperature elevation This Photo by Unknown Author is licensed under CC BY-NC-ND

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 Antidiuretics minimize fluid loss by preventing urine
production in the kidneys.

Diuretics increase urination by increasing urine production

in the kidneys.
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 Urine Specimens

• Normal voided specimen

• Send to the laboratory within 5 to 10 minutes
• Urine standing more than 15 minutes changes characteristics
• Midstream (clean-catch) specimen
• Specimen from an indwelling catheter
• Sterile catheterized specimen
• 24-hour specimen
• Strained specimen

This Photo by Unknown Author is licensed under CC BY

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Factors Interfering with
Urinary Elimination

Total loss of Disruption of the

Decreased kidney Blockage of the
kidney’s ability to bladder by tumor
profusion ureters
manufacture urine or trauma

Neurologic
Infection damage to the Prostate surgery
nerves

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Changes Occurring with Aging

Decrease in the number of functioning nephrons

Decrease in filtration rate

Decreased bladder tone—nocturia

Decreased bladder emptying, increased residual

Enlargement of prostate—urethral obstruction

Incontinence is not a normal part of aging

This Photo by Unknown Author is licensed under CC BY-NC

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 Factors Affecting Urinary Elimination

• Age • Poor abdominal and pelvic muscle

tone
• Pregnancy
• Acute and chronic disease
• Diet
• Spinal cord injury
• Immobility
• Psychosocial Factors
• Pain
• Surgical Procedures
• Medications

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 Urinary Assessment and Abnormalities

• Assessment • Abnormalities Found in

Urine
• Glycosuria
• Patients should be assessed for:
• Glucose in the urine
• Usual pattern of elimination
• Proteinuria
• Incidences of incontinence, • Protein in the urine
frequent urination
• Hematuria
• Burning on urination • Blood in the urine
• Sense of urgency • Pyuria
• Times of day for elimination • Pus in the urine
• Total daily fluid intake • Ketonuria
• Ketones in the urine

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 Types of ➢ Stress incontinence: coughing, sneezing,
laughing, or physical activity that increases
Urinary pressure on the bladder
Incontinence ➢ Urge incontinence: strong urge to urinate,
but leaking occurs before getting to the toilet
➢ Reflex incontinence: urinary leakage as a
result of nerve damage
➢ Overflow incontinence: incomplete bladder
emptying which results in the bladder
overfilling when full
➢ Functional incontinence: physical inability to
reach the toilet in time
➢ Bedwetting

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Types of Urinary Catheters / Catheterization

• Catheter types • Sterile equipment and aseptic

• Robinson technique
• Foley
• Suprapubic
• Coudé • Procedure for male and female
• Alcock
catheterization is similar
• de Pezzer • Variations in the positioning, draping,
and cleansing of the urinary meatus
• Malecot
• Condom

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 Urinary retention occurs when the bladder
is not able to fully empty.

Symptoms of urinary retention include the inability to urinate,

pain, abdominal distention, urinary frequency, urinary hesitancy,
weak or slow urine stream, and urinary leakage.
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 ➢ Caused by bacteria entering the urinary
Urinary Tract tract.
➢ More common in women than in men
Infections because women have a shorter urethra.
➢ If left untreated, may result in a kidney
infection called pyelonephritis.
➢ Risk factors include sexual activity,
menopause, urinary retention, urinary
obstruction, frequent urinary catheter use,
diabetes, or urinary tract abnormalities.
➢ Symptoms include burning or painful
urination and frequent urgency to urinate
despite not having a lot of urine to pass.

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 Kidney stones (also
called renal calculi,
nephrolithiasis, or
urolithiasis) are hard
formations of minerals
and salts that collect in
the kidneys.

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Urinary Diversion Care

• Necessary when the bladder is

removed or bypassed

• One or both ureters are implanted

into:
• The abdominal wall (urostomy)
• The bowel
• A pouch constructed from a
piece of bowel

• Skin care depends on the type of

diversion
This Photo by Unknown Author is licensed under CC BY-NC-ND

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The Gastrointestinal (GI) Tract
➢ Part of the digestive system, which is composed of
the liver, pancreas, gallbladder, and a series of
hallow organs that originate at the mouth and
terminate at the anus.
➢ The GI tract is made up of the mouth, esophagus,
stomach, small intestine, large intestine, and anus.
➢ In coordination, the GI tract works with the organs
of the digestive system to digest food and drink.
➢ A small flap, called the epiglottis, prevents food
and liquid from entering the airway and allows it to
continue into the esophagus.
➢ In the esophagus, peristalsis moves food
downward toward the stomach.
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The Gastrointestinal (GI) Tract (cont.)
➢ Once in the stomach, food and liquid mix with
digestive secretions before slowly being emptied
into the small intestine.
➢ In the small intestine, food and liquid continue to
mix with digestive secretions from the pancreas,
liver, and small intestine as peristalsis continues to
aid in the transport of food through the GI tract.
➢ Digested products continue into the large intestine.
➢ Once in the large intestine, liquid is absorbed from
the waste byproduct, and stool begins to form.
➢ Peristalsis continues to move the forming stool out
of the body through the anus during a bowel
movement.
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 Constipation
➢ Fewer than three bowel movements
in a week.
➢ A condition where the production of
stool is slowed.
➢ Can result in dry and hard to pass
bowel movements and give a
sensation of incomplete emptying or
passing of stool.
➢ Diets with too little fiber can be
constipating.
➢ Drinking too little water throughout
the day can contribute to
constipation.
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Initial Assessment

• Physical assessment
• Shape of the abdomen with the
patient supine Does patient have a bowel problem?
• Flat, distended Usual bowel pattern
• Auscultate for bowel sounds in all Any measures used to promote defecation?
four quadrants
Use of enemas or laxatives
• Percuss for presence of excessive
air/gas in the abdomen Usual eating habits and exercise

• Palpate for masses or tenderness Foods that produce diarrhea or constipation

Disorders that contribute to constipation or diarrhea

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Normal Stool and Abnormal Stool

Color: light to dark brown • Blood in the stool: most serious

abnormality
• Fresh red blood: bleeding in
Consistency: soft-formed in children and adults;
colon
consists of ¼ solids and ¾ water • Occult: upper GI bleed (black
stool called melena)
• Pale white or light gray stool:
Appearance: affected by diet and metabolism
absence of bile in the intestine
• Large amounts of mucus, fat, pus,
or parasites
Composition: solid materials consist of 70%
undigested roughage from carbohydrates, fat,
protein, and inorganic matter, and 30% dead
bacteria

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Factors Affecting Bowel Elimination Patterns

Physical
Age Diet Fluid Intake
Activity

Psychosocial Personal
Positioning Pain
Factors Habits

Surgery and
Pregnancy Medications
Anesthesia
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Effects of Aging on the Intestinal Tract

• Atrophy of the villi

• Decreased absorption of fats,

vitamin B12

• Decrease in motility

• Bowel habits should not change in

the normal healthy individual

This Photo by Unknown Author is licensed under CC BY-SA

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 Medications That Can Slow Gastric
Motility and Cause Constipation

➢ Antacids
➢ Anticholinergics and antispasmodics
➢ Antiseizure medications
➢ Calcium channel blockers
➢ Diuretics
➢ Iron supplements
➢ Anti-Parkinson’s disease
medications
➢ Narcotic pain medications
➢ Antidepressants

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Drugs Used for Constipation

• Stool softeners
• Colace, Surfak, Dialose
• Bulk-forming laxatives
• Fibercon, Metamucil, Citrucel
• Irritant/stimulant laxatives
• Dulcolax, Neolid, Ex-Lax, Correctol, Senokot
• Saline laxatives
• Citrate of magnesia, milk of magnesia, phospho-soda

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Hyperactive Bowel and Diarrhea

• Drugs
• Many antibiotics kill normal bowel Increase in peristalsis Usually results in diarrhea
bacteria, resulting in diarrhea
• Patients who experience diarrhea
from antibiotics should replace
normal flora by:
• Eating yogurt May be self-limiting Causes

• Drinking buttermilk
• Taking acidophilus (available
OTC) Inflammation of GI tract,
infectious diseases,
diseases such as:
• Diverticulitis
• Ulcerative colitis
• Crohn’s disease

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Medications Used to Control Diarrhea

Camphorated tincture of opium (paregoric)

Diphenoxylate hydrochloride with atropine sulfate

(Lomotil)
Loperamide hydrochloride (Imodium)

Difenoxin hydrochloride with atropine sulfate (Motofen)

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Diverticulosis is a condition in which small sacs or pouches
form in the colon. These sacs increase a client’s risk for
diverticulitis as a result of food becoming trapped.

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 Irritable bowel syndrome
(IBS) is a term used to describe
abdominal pain and changes to
bowel elimination patterns
which can include diarrhea
alone, constipation alone, or
can be classified as mixed: both
diarrhea and constipation.

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Ulcerative colitis (UC) is
a chronic disease that
causes inflammation and
ulcerations of the large
intestine or colon. Onset
is gradual and worsens
over time, but there can
be periods of remission
that can last weeks or
years.

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 Crohn’s disease is a chronic disease that commonly
causes inflammation of the small intestine, but it can also affect
any part of the GI tract. Like UC, Crohn’s disease worsens
over time but can have periods of remission.

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Fecal Incontinence

Lack of voluntary control Distressing condition

of fecal evacuation; Causes that causes a loss of
inability to retain feces dignity
• Illness • Feelings of being less of
• Cerebrovascular a person
accident • Loss of self-respect
• Traumatic injury • Embarrassed
• Neurogenic dysfunction • Anxiety or fear of losing
control

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Rectal Suppositories

Used to promote bowel movements

Glycerin and bisacodyl suppositories

Promote bowel evacuation

• Stimulate the inner surface of the rectum and

increasing the urge to defecate
This Photo by Unknown Author is licensed
under CC BY-SA
• Form gas that expands the rectum
• Melt into a lubricating material to coat the stool
for easier passage through the anal sphincter

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Enemas Type of Enemas

• Retention enema
Fluid introduced into rectum by means of a • Softens stool as oil is absorbed
tube
• Cleansing enema
Stimulate peristalsis or wash out waste • Stimulates peristalsis through distention
products and irritation of colon and rectum
• Distention reduction enema
• Relieves discomfort from flatus causing
Often given before a colonoscopy or an x-ray distention
• Medicated enema
Volume of typical cleansing enema • Solution with drugs to reduce bacteria
or remove potassium
• Infants: 20 to 150 mL • Disposable enema (small volume)
• Ages 3 to 5 years: 200 to 300 mL • Stimulates peristalsis by acting as
• School-age: 300 to 500 mL irritant
• Adults: 500 to 1000 mL

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Position For Giving Enema

• Amount & Temperature of Solution

• Disposable enema units

• Contain about 240 mL of solution
• May be given at room temperature,
but work best when slightly warmed
• Cleansing enema
• Adults is between 500 and 1000 mL;
smaller amounts are used for children

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Fecal Impaction

Means that the rectum and sigmoid colon become filled with
hardened fecal material

Most obvious sign is the absence of (or only a small amount

of) bowel movement for more than 3 days in a patient who
usually has a bowel movement more frequently
Occurs in patients who are very ill, are on bed rest, or are
confused

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 Bowel Training for Incontinence

• Principles for establishing regular bowel elimination

• Adequate diet
• Sufficient fluids
• Adequate exercise
• Sufficient rest
• Regular time for evacuation should be established
• All efforts must be made to provide patient with environment that is conducive
to evacuation
• May require digital stimulation to relax the anal sphincter
• Suppositories, stool softeners, and bulk laxatives used to assist in establishing
a normal, regular bowel pattern

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Bowel Ostomy Types of Ostomies

A diversion of intestinal contents from • Ileostomy

their normal path • Diversion of the small bowel
contents to a pouch or stoma;
effluent is liquid
Results in formation of an external
opening called a stoma • Colostomy
• Diversion of the colon
• Effluent may be liquid or solid
May be an internal tissue pouch with a depending on the site; may
valve opening require irrigation

Special procedures aid in effective,

controlled elimination through the
stoma
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 Type of Ostomies

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 Types of Ostomies

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 Ostomy Care

• Skin care
• Stoma and skin washed with mild
soap and water and patted dry
• Skin barrier paste is applied
• Applying an ostomy appliance
• Appliance is positioned with the stoma
protruding through the opening in the
center of the faceplate
• Irrigating a colostomy
• A solution is instilled into the colon via This Photo by Unknown Author is licensed
the stoma under CC BY

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 Alterations in urinary elimination are usually treatable or manageable.
Nurses can assist clients with making lifestyle changes, provide bladder
training, and instruct clients how to perform pelvic floor muscle exercises. There
is also urinary catheterization, which the client can do, if necessary.

Alterations in bowel elimination are usually treatable or manageable. Nurses

can assist the client with making lifestyle changes, provide bowel training, and
provide the client with agents to stimulate a bowel movement.
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