BACHELOR OF SCIENCE IN NURSING

OUTCOME BASED CLINICAL LEARNING 1

COURSE MODULE COURSE UNIT WEEK
1 2 13
ELIMINATION

 Read course and unit objectives

 Read study guide prior to class attendance
 Read required learning resources; refer to unit terminologies for jargons
 Proactively participate in classroom discussions
 Participate in weekly discussion board (Canvas)
 Answer and submit course unit tasks.

Laptop/Personal computer/Android phone

Stable internet connection

At the end of the course unit (CM), learners will be able to:

Cognitive:
1. To know and identify what is Elimination and the organs involved in the elimination process
2. To discuss the different alteration in elimination
3. To discuss the different factors that affects the elimination
4. To identify and determine the common procedure specifically to different elimination process,
the need and the associated nursing responsibilities
Affective:
1. Listen attentively during class discussions
2. Demonstrate tact and respect when challenging other people’s opinions and ideas
3. Accept comments and reactions of classmates on one’s opinions openly and graciously.
Psychomotor:
1. Participate actively during class discussions and group activities
2. Express opinion and thoughts in front of the class

Elimination
the process of excretion involves finding and removing waste materials or toxins produced by the body.

Normal function defends on these factors:

_ anatomic integrity
_ intact neurologic for both voluntary and synergistic emptying
_ predictable pattern of waste production
_ physical, mental ability and psycho-social capacity

Symptoms of toxins in the body

5 main organs involved in the elimination process

SKIN - is a vital organ that cover the entire outside of the body forming a protective barrier against
pathogens and injuries from the environment.

LAYERS OF THE SKIN

EPIDERMIS - is the top layer of the skin
DERMIS - is the second layer of the skin
HYPODERMIS - is a layer directly below the dermis and serves to connect the skin to the underlying
fascia of the bones and muscles

Skin Elimination
Acts as a supplemental filter to the kidneys for removing wastes or toxin and excess minerals in the
body
The skin throws all about 2pounds of toxic waste a day in the form of perspiration
Sweating or perspiration eliminates excess water and salts, small amount of urea
Dead skin cells are form of bodily waste that facilitate the growth of new epidermal cells.

LUNG
Pulmonary excretion is the primary route for the elimination of gases and some volatile compounds

Nasal cavity (nose) Trachea

Oral cavity (mouth) Bronchi
Pharynx Bronchioles
Larynx Alveoli

Lung elimination
Lung excrete carbon dioxide as you breathe out.
Respiratory system automatically perform vital process called gas exchange
Protection from microbes that entering body through mucus production and our body tends to
expectorate

LIVER
represents the human body’s primary filtration system, converting toxins into waste products,
cleaning the blood and metabolizing nutrients and medications to provide the body with some of
it’s most important proteins
Plays a largest role in the body in detoxification

DETOXIFICATION
the process of removing toxic substances.
1. To have a set of interventions aimed at managing acute intoxication and withdrawal.
 2. It denotes a clearing of toxins from the body of the client who is acutely intoxicated and/or
dependent on substances of abuse.
3. Seeks to minimize the physical harm by abuse or use substances.

Liver elimination

1. Uses enzymes and oxygen to burn toxins

2. Combines toxins with amino acids so they can remove from the liver through bile or urine

KIDNEY
Kidneys - clean waste products from the blood by making urine
Ureters - muscle in ureter walls tighten and relax to force urine down
and away from kidneys
Bladder - organ that stores the urine
Urethra – transport urine that stored in the bladder out of the body

URINARY ELIMINATION

Functional Units of Kidneys: NEPHRON

Glomerular filtration Rate: Men 100-130 mL/min
Women 90-120 mL/min
Kidneys filter about 1-2 quarts of urine per day from 120-150quartz of blood everyday
Normal range for 24hour urine volume is: 800-2000 ml/day
Kidneys formed 0.5 to 1 mL/min = 60 mL/hr.
Urine output less than 500ml in 24 hours or less than 30cc/hour indicates kidney problem
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

Altered Urine Production

Polyuria Urinary Frequency Enuresis Pollakiuria
Oliguria Urinary urgency Urinary retention
Anuria Dysuria Neurogenic bladder

URINARY INCONTINENCE
Total – continuous, unpredictable
Stress – leakage of < 50 mL urine due to intra- abdominal pressure
Urge – sudden, strong desire to urinate
Functional – involuntary, unpredictable passage of urine
Reflex – involuntary loss but predictable
Nursing Interventions to Induce Voiding:
Increase Fluid intake
Listen to sound of running water
Dangle fingers to warm water
Crede’ s Maneuver: applying pressure to suprapubic area
Last resort: URINARY CATHETERIZATION

URINARY CATHETERIZATION
Catheterization is the insertion of a catheter (lumen) into the bladder of the patient through the
urethra.
Purposes:
- To relieve discomfort due to bladder distention or provide gradual decompression of a distended
bladder
- To assess the amount of residual urine if the bladder empties incompletely
- To obtain urine specimen
- To empty the bladder completely prior to surgery
- To facilitate accurate measurement of urinary output for critically ill clients whose output needs to
be monitored hourly
- To provide for intermittent or continuous bladder drainage and irrigation
- To prevent urine from contacting an incision after perineal surgery
- To manage incontinence when other measures have failed

Types of Catheters

According to the number of lumen

1. Straight Catheter (Non-retention) – single lumen tube
2. Two-Way Catheter (Foley, Retention) – double lumen catheter
3. Three-Way Catheter – triple lumen catheter used in bladder irrigation
According to catheter material used

Plastic Catheters - can be used for short periods because of inflexibility; 1 week or less
Rubber Catheters - can be use for 2-3 weeks; assess client for latex allergy
Silicone Catheter - for long term use of 2-3 months; expensive
PVC Catheter - can be use for 4-6 weeks; soften at body temperature and more comfortable to use

CATHERIZATION COMPARISON
GENDER MALE FEMALE
URETHRAL LENGTH 6-9 inches 2-3 inches
POSITION SUPINE/ FROG LIKE DORSAL RECUMBENT
GENITAL HANDLING 90° RETRACT
CLEANING METHOD CIRCULAR FRONT BACK
ATTACHMENT LOWER ABDOMEN LOWER THIGH

CATHETERIZATION REMINDERS:
Left Left, Right Right, Left handed nurse must stand on the left side of pt.
Grasp catheter at least 2 – 3 inches
As nurse Inserts catheter – Client advise to inhale deeply and exhales
Sterile water in Balloon not NSS
Test the balloon before catheter insertion
If there is urine flows, do not stop, insert 2 inches further into the bladder
Considerations:
Invasive procedure
Strict Medical asepsis
Perineal Care
Size of catheter:
French 12-14 for male and female
French 16-20 if patient has mucous, blood clots
French 22 standard size for bladder irrigation and washout
French 6-10 use for children

Condom Catheter
Are designed for men whose bladder are able to drain urine, but who have trouble controlling when
it’s release or micturate
- Also called external catheter
Considerations:
Proper way to apply condom catheter
Frequency of checking
Frequency of changing

CYSTOCLYSIS
- or the bladder irrigation
- the process of flushing the bladder with normal saline continuously to prevent or treat clot
formation, allowing urine to flow freely and maintaining indwelling urinary catheter patency
- To prevent blood clot formation

TYPES OF IRRIGATING CYSTOCLYSIS

1. OPEN BLADDER IRRIGATING SYSTEM

- Also called the Manual Irrigating
- This is used when the bladder irrigations are required less frequency and there are no
blood clots or large mucous fragments
 2. CONTINUOUS BLADDER IRRIGATION SYSTEM
- Closed drainage system
- Involves instilling sterile irrigation solution into the bladder allowing the fluid to drain out.
- Using the 2-way irrigation system with triple lumen catheter, to remove loose tissues, clots
and mucous shreds from the bladder

Open bladder irrigation system Continuous bladder irrigation system

BOWEL ELIMINATION

Defecation – is the final act of digestion, by which the organism eliminates solid, semisolid
or liquid waste material from the digestive tract via the anus.
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

Factors that affects bowel elimination

ALTERATION ON STOOL CHARACTERISTICS

1. Acholic stool
2. Hematochezia
3. Melena
4. Steatorrhea
5. Yellow dark – breastfeeding
6. Yellow pale – bottle feeding
7. Currant jelly – intussusception
8. Ribbon like - Hirschsprung’s disease

Fecal Elimination Problems

1. Constipation- passage of small, dry and hard stool

- Management
Fluids
Fiber
Regular pattern of defecation
Respond immediately to urge to defecate
Minimize stress
Exercise
Laxatives as ordered

2. Diarrhea – frequent evacuation of stools

Management:
Replace F and E
Diet: BRAT diet
Avoid excessive hot or cold fluids
Antidiarrheal as ordered
* Best time to administer anti diarrheal meds

3.Fecal Impaction - mass or collection of hardened feces in the folds of rectum

Management:
Manual Disimpaction as ordered
Treatment option – laxatives, anal suppositories, water irrigation
Increased Fluid intake
Bulk in diet
Activity and exercise

4. Flatulence - excessive gas in intestine

Management:
Avoid gas forming
Warm fluids to drinks
Early ambulation
Activity and exercise
Limit carbonated beverages
Rectal tube insertion (2-4 in) for 30 minutes

5. Fecal Incontinence
- inability to control bowel movements causing stool to leak unexpectedly from the rectum.
- also called bowel incontinence
- range from occasional leakage of stool while passing gas to a complete loss of bowel control

Management:
1. Wearing absorbent pads
2. Diet changes
3. Bowel training
4. Pelvic floor muscle exercise
5. Biofeedback therapy
6. Sacral nerve stimulation
7. Prescribed medications

RECTAL TUBE INSERTION:

Inserted in the rectum to decrease bloating and decompression
Lubricate and insert 2-4 inches
Left Sim’s position
Insert towards the Umbilicus
FR. 22-30
Leave the tube in place for 20 minutes
Monitor heart changes.

ENEMA - is an injection of fluid into the lower bowel by way of the rectum
Types:
1. Cleansing – irritating the colon and rectum
Differentiate high and low enema administration:
a. High enema - clean as much colon and 1000 mL of solution is introduced
b. Low enema - rectum and sigmoid colon only
2. Carminative enema – expel flatus, 60–180 mL introduced of solution
3. Retention enema – introduced at low pressure and retained for 30 minutes to 3 hours before
being expelled.
4. Return flow-enema/Harris flush – to expel flatus and stimulate peristalsis; 100 -200 mL of
fluids is introduced into and out of large intestine
COLOSTOMY
- Is a surgical procedure that brings one end of the large intestine out through the abdominal
wall and create a stoma.
- A stoma is the opening in the skin where a pouch for collecting the feces is attached.

COLOSTOMY CARE:
Remove old bag when 1/2 – ¾ filled.
Do not pull the bag to prevent stoma breakdown
Protect the skin around the stoma
Cleanse the skin around the stoma with water.
Change the pouch system regularly
Assess STOMA and watch for sensitivities and allergies
Any discoloration should refer to the Doctor.
Use the right size of pouch and skin barrier opening

Polyuria - refers to the production of abnormally large amounts of urine by the kidneys
Oliguria - is a low urine output usually less than 500 ml/day.
Anuria - refers to a lack of urine production 0 – 10 mL/hr.
Urinary frequency- voiding at frequent intervals more than usual
Nocturia - voiding more than two times at night
Urinary urgency- feeling that a person must void immediately
Dysuria - voiding that is either painful or difficult
Enuresis - involuntary urination
Urinary retention - results from over distention of the bladder and urine accumulates
Neurogenic bladder - unperceived bladder fullness
Pollakiuria - is a benign idiopathic urinary frequency, it refers to frequent daytime urination in children
with no specific cause
Acholic stool - gray, pale, clay-colored stool
Hematochezia - stool with bright red blood
Melena - black tarry stool
Steatorrhea: greasy, bulky, foul smelling stools
Hinkle, Janice L. (2014) Brunner & Suddarth’s text book of Medical Surgical Nursing, 13 th. Philadelphia:
LippincottWilliams & Wilkins.617.0231 H592014
www.livescience.com
www.sciencedirect.com
www.healthlife.com
nursinglife.com
www.peoi.org
www.biologyonline.com
www.britannica.com
https;//en.m.wikipedia.org

1. GIVE AT LEAST 15 NURSING RESPONSIBILITIES FOR CLIENT WHO HAVE PROBLEM IN

ELIMINATION THAT INVOLVED THE 5 AFFECTED ORGANS (60 pts.)

2. FORMULATE AT LEAST ONE NCP (ADPIE) FOR CLIENT WITH URINARY RETENTION AND FECAL
IMPACTION (20 points for each ncp)

3. ANSWER MUTIPLE CHOICE QUESTIONS.