URINARY ELIMINATION Problems in Urinary elimination:

The major role is to maintain homeostasis by A. Altered Urine composition

maintaining body fluid composition and  RBC Hematuria
volume.  WBC Urinary
Tract
Micturition- is the act of expelling urine from
thebladder. ( also called urination or voiding).  Pus Pyuria Infection
 Bacteria Bacteriuria
- Refers to the process of emptying the urinary  Albumin Albuminuria
bladder. Urine collects in the bladder until  Protein Proteinuria
pressure stimulates special sensory nerve  Casts Cylindriuria
endings in the bladder wall called the stretch  Glucose Glycosuria
receptors.  Ketones ketonuria Diabetic
ketoacidosis
The parasympathetic nervous system initiates
voiding. Whereas, the sympathetic nervous B. Altered Urine Production:
system inhibits voiding. The micturition reflex is 1. Polyuria – the production of excessive
involuntary, but it can be inhibited by higher amount of urine, such as more than
brain centers. 100ml/hr or 25,000 ml/ day ( also called
diuresis)
Factors affecting voiding:
2. Oliguria – the production of decreased
1. Developmental factors amount of urine, such as less than 30
a. infants- ml/hr or less than 500 ml/24 hours
b. preschoolers 3. Anuria – the absence of production of
c. school-age children urine by the kidneys such as 0 to 10
d. elders ml/hour ( also called urinary
2. Psychological factors- ex. Nurses-ignore the suppression
urge to void until they are able to have a break
C. Altered Urinary Frequency
3. Fluid and food intake- can change the color of
1. Frequency – voiding at frequent intervals that
the urine
is more than 4 to 6 times per day
4. Medications- diuretics- increase urine
2. Nocturia - increased frequency at night
formation; may alter color of the urine
3. Urgency – the strong feeling that the person
5. Muscle tone-
wants to void
6. Pathologic conditions-urinary stone- may
4. Dysuria – voiding that is either painful or
obstruct a ureter, blocking urine flow from
difficult
kidney to the bladder
5. Enuresis – repeated involuntary voiding
7. Surgical and diagnostics procedures-
beyond 4-5 years of age
cystoscopy
6. Pollakuria – frequent, scanty urination
Normal Characteristics of the Urine: 8. Urinary Incontinence:
Amount in 24hrs: 1,200-1500 ml a. Total urinary incontinence- a
Color: amber/straw continuous and unpredictable loss of
Odor: aromatic upon voiding urine
Transparency: Clear b. Stress urinary incontinence – the
Ph: slightly acidic (ranges: 4.6-8; average of 8) leakage of less than 50 ml of urine as a
Specific gravity: 1.010-1.025 (this is measured result of a sudden increase in intra-
by urinometer abdominal pressure
Glucose/ketone bodies (acetone)/blood: Not c. Urge urinary incontinence – follows a
Present sudden strong desire to urinate and
leads to involuntary detrusor
 contraction ( overactive bladder
syndrome)
d. Functional incontinence – the
involuntary unpredictable passage of
urine
e. Reflex incontinence – is an involuntary loss of
urine occuring at some what predictable
intervals when specific bladder volume is
reached.
9. Urinary retention – the accumulation of urine
in the bladder with associated inability of the
bladder to empty itself
- 250-450 ml of urine in the bladder triggers
micturition reflex
Clinical signs of urinary retention
 Discomfort in the pubic area
 Bladder distention ( palpation and
percussion)
- smooth, firm, ovoid mass at the suprapubic
area
- mass arising out of the pelvis
- dullness on percussion
 Inability to void or frequent voiding of
small
volumes ( 25-50 ml at a time)
 Disproportionately small amount of
output in relation to fluid intake
 Increasing restlessness and feeling of
need to void
Nursing Interventions to induce Voiding:
 Provide privacy. This is the most
effective nursing measure to induce
voiding.
 Provide fluids to drink.
 Assist the patient in the anatomical
position of voiding.
 Serve clean, warm and dry bedpan
(female) or urinal (male)
 Allow the patient to listen to the sound
of running water
 Dangle fingers in warm water.
 Pour warm water over the perineum.
 Promote relaxation
 Provide adequate time for voiding
 Perform Crede’s maneuver as ordered.
This is done by applying pressure on the
suprapubic area.
 Administer cholinergics e.g. Urecholine
( Bethanecol) as ordered
 Last resort: Urinary catheterization .
This is the last resort because it is one
of the most causes of nasocomial
infection. It is the introduction of a
catheter into the urinary bladder.
URINARY CATHETERIZATION
Single catheterization: straight /nelaton
catheter
Retention catheterization: 2 way Foley catheter
Continuous Bladder irrigation( Cystoclysis): 3
way Foleys Catheter
PURPOSES:
1. To relieve bladder distention
2. To instill medications into the bladder.
3. To irrigate the bladder.
4. To measure hourly urine output
5. To obtain a sterile urine specimen.
6. To measure residual urine. Residual urine
is the amount of urine retained in the bladder
after forceful voiding.
7. To manage incontinence when other
measures have failed
8. To promote healing of the genito-urinary
structures post-operatively.
9. To empty the bladder in preparation for
diagnostic procedures and surgery.
Equipments for Catheterization:
 Sterile catheter of appropriate size
Sizes: adult - #14, #16
children- #8 or #10
 Catheterization kit:
1-2 pairs of sterile gloves
sterile drapes
antiseptic solution, cleansing balls, forceps,
lubricant, sterile urine specimen container
BOWEL ELIMINATION
• DEFECATION – is the expulsion of feces
from the anus and rectum. It is also
called the bowel movement.
Normal characteristic of the stool:
Color: yellow or golden brown (due to the
bile pigment derivative known as the stercobilin
or fecal urobilinogen)
Odor: aromatic upon defecation
 Amount: depends on the bulk of the food
intake. Approximately 150-300 g per day
Consistency: soft, formed
Shape: cylindrical
Frequency: variable; usual range 1-2 per day
to 1 every 2-3 days
Alterations on the Characteristic of Stool:
• Acholic stool – gray, pale or clay-
colored stool due to absence of
stercobilin caused by biliary obstruction
• Hematochezia – passage of stool with
bright red blood due to lower
gastrointestinal bleeding
• Melena – passage of black, tarry stool
due to upper gastrointestinal bleeding
• Steatorrhea – greasy, bulky, foul
smelling stool due to present of
undigested fats like in hepatobiliary-
pancreatic obstruction/disorder
Common Fecal Elimination Problems:
1. CONSTIPATION – refers to the passage
of small, dry, hard stools or the passage
of no stool for a period of time.
• Nursing interventions to prevent and
relieve constipation:
 Adequate fluid intake
 High fiber diet to provide bulk to the
stool
 Establish regular pattern of defecation
 Respond immediately to the urge to
defecate
 Minimize stress
 Adequate activity and exercise promote
muscle tone and facilitate peristalsis
 Assume sitting or semi-squatting
position
 Administer laxatives as ordered
Types of laxatives:
Chemical irritants – they provide chemical
stimulation to intestinal wall, thereby increasing
perisitalsis, e.g. Dulcolax, castor oil,senakot
Stool lubricants – they lubricate feces and
facilitate the expulsion e.g. mineral oil
Bulk Formers – they increase the bulk of the
feces, increasing mechanical pressure and
distention of the intestine, thereby, increasing
peristalsis e.g. Metamucil
• Stool softeners – they soften the stool
and facilitate its expulsion e. g. Colace
• Osmotic agents – they attract fluids
from the intestinal capillaries to the
stool e.g. Milk of magnesia, Duphalac
2. FECAL IMPACTION – is the mass or collection
of hardened, putty-like feces in the folds of the
rectum. The stool lodged or stuck in the rectum,
the person is unable to voluntarily evacuate the
stool
Nursing interventions to relieve Fecal
Impaction:
 Manual extraction or fecal disimpaction
as ordered
 Increase fluid intake
 Sufficient bulk in diet
 Adequate activity and exercise
3. DIARRHEA – refers to frequent evacuation of
watery stools. It is associated with increased
gastrointestinal motility, and a rapid passage of
fecal contents through the lower
gastrointestinal tract
Nursing interventions to relieve Diarrhea;
 Replace fluid and electrolyte losses
 Provide good perianal care. Diarrhea
stool is often times highly acidic which
causes anal soreness and irritation in
the perianal care.
 To promote rest; to reduce peristalsis
 Diet: small amount of bland diet
Low fiber diet
BRAT diet (banana, rice am, apple,
toast
Avoid excessive hot or cold fluids, these
are stimulants
Potassium rich foods and fluid e.g.
banana, gatorade
 Antidiarrheal mediations as ordered:
• Demulcents – mechanically coat the
irritated bowel and act as protectives
• Absorbents – absorbs gas or toxic
substances from the bowel
 • Astringents – shrink swollen or
inflamed tissues in the bowel
CAUTION: Do not administer antidiarrheal at
the start of diarrhea.
4. FLATULENCE – is the presence of excessive
gas in the intestines, this may be due to
swallowed air, bacterial action in the large
intestine and diffusion from blood
Common causes of flatulence:
• Constipation
• Codeine, barbiturates and other
medications that decrease intestinal
motility
• Anxiety
• Eating gas forming foods e.g. cabbage,
legumes, root crops
• Rapid food or fluid ingestion
• Excessive drinking of carbonated
beverages
• Improper use of straw
• Gum chewing, candy sucking, smoking
• Abdominal surgery- causes decreased
peristalsis
Nursing Interventions:
• Avoid gas forming foods
• Provide warm fluids to drink- increase
peristalsis
• Adequate activity and exercise
• Limit carbonated beverages, use of
straws and chewing gums
• Rectal tube insertion as ordered. Place
client in left lateral position. Insert 3-4
inches of the lubricated rectal tube,
gently in rotating motion. Use rectal
tube Fr. 22-30. Retain rectal tube for a
maximum of 30 minutes
• Carminative enema as ordered
• administer cholinergics s ordered e.g.
prostigmin
5. FECAL INCONTINENCE is the involuntary
elimination of bowel contents; often associated
with neurologic, mental, or emotional
impairments due to dysfunction of the anal
sphincter e.g. spinal cord injury clients-
impaired nerve supply to the rectum &
sphincter
ADMINISTERING ENEMAS:
Enema – is a solution introduced into the
rectum and large intestine. The action of the
enema is to distend the intestine sometimes to
irritate the intestinal mucosa , thereby increase
peristalsis and excretion of feces and flatus.
TYPES:
1. Cleansing enema
2. Carminative enema
3. Retention enema
4. Return- flow enema
PURPOSES:
1. To relieve constipation
2. To relieve flatulence
3. To administer medication
4. To evacuate feces in preparation for
diagnostic procedure or surgery
CONTRAINDICATION:
1. Appendicitis
2. Intestinal obstruction
3. Increase intracranial pressure
TYPES
1. Cleansing enema – intended to remove
feces, stimulates peristalsis by irritating
the colon and rectum and or by
distending the intestine with the
volume of fluid introduced. It is given
chiefly to:
 Prevent the escape of feces during
surgery
 Prepare the intestine for certain
diagnostic tests such as x-ray or
visualization test ( colonoscopy)
 Remove feces in instances of
constipation and impaction.
Commonly used solutions:
Hypertonic – saline
Hypertonic enema – fleet phosphate enema
Hypotonic – tap water
Isotonic – normal saline
Soap suds –irritates mucosa, distends colon
Mineral oil – lubricates the feces and the
colonic mucosa
Catminative enema
A. High enema – is given to cleanse as
much of the colon as possible , client
should be in left lateral position to the
dorsal recumbent then to the right
 lateral so that the solution can follow
the large intestine; 1000 ml 0f solution
B. low enema – is used to clean the
rectum and sigmoid colon only; client
maintains left lateral position during
administration. 500ml of solution is
introduced
The force of flow is governed by:
a. Height of solution container – 30 to 49
cm (12 to 18 in) – the higher the faster
b. Size of the tubing- larger size, the faster
c. Viscosity of the fluid- thicker, slower
NON-RETENTION ENEMA
 Solutions used are as follows:
o Tap water (500-1000 ml)
o Soap suds ( 9 20 ml of castile soap in
500-1000 ml of water)
o Normal Saline solution ( 9 ml of NaCl to
1000 ml of water)
o Hypertonic solution /fleet enema (90-
120 ml)
 Height of solution
o 18 inches above the rectum
 Temperature of solution
o 115°-125° F
 Time of retention
o 5-10 minutes for better cleansing effect

d. Resistance of the rectum -+= slower RETENTION ENEMA

 Solutions
2. Carminative enema – to expel flatus
o Carminative enema
- The solution instilled into the rectum o Oil (90-120 ml of mineral oil, olive oil or
releases gas, which in turn distends the cottonseed oil)
rectum and the colon thus stimulating  Height of solution
peristalsis. For an adult, 60-80 ml of o 12 inches above the rectum
fluid is instilled  Temperature of solution
o 105˚-110˚ F
3. Retention enema – introduces oil or  Time of retention
medication into the rectum and sigmoid colon; o 1-3 hours until desired therapeutic
oil is retained in 1-3 hours, acts to soften the effect is obtained
feces and lubricates the rectum and anal canal,
facilitate passage of feces GUIDELINES FOR ADMINISTERING ENEMA:

4. Return-flow enema – is used occasionally Suggested Maximum Volumes

used to expel flatus Infant 150 to 250 ml
Toddler 250 to 350ml
• Harris Flush/ Colonic Irrigation School –age 300 to 500 ml
• 100-200 ml of fluid is introduced into Adolescent 500 to 750 ml
and out of the large intestine to Adult 750 to 1000 ml
stimulate peristalsis and to promote Suggested temperature of Solution
expulsion of flatus
Child 37.7 C (105 to 110 F)
• The solution container is lowered so
that the fluid backs out through the Adult 40-43 C ( 105 to 110 F)
rectal tube into the container.
Retention Enema 33 C ( 91 F )
• The inflow –outflow process is repeated
Suggested Rectal Tube Size
5-6 times
Infant/ Small Children 10 – 12 Fr
• Replace the solution several times
during the procedure as it becomes Child 12-18 Fr
thick with feces
Adult 22-30 Fr
• May take 15-20 minutes to be effective
Length of Insertion
 Infant 1-1.5 inches

Child 2-3 inches

Adult 3-4 inches

Height of Enema Container

High Enema 18 inches

Low enema 12 inches

Infant 3 inches

Position for administration

Adult Left side lying (sim’s) position

with right knee flexed

Child Dorsal recumbent

Clients with Bedpan in comfortable dorsal

poor sphincter recumbent position

control