Elimination

Urinary Elimination Objectives

  • Identify factors that affect urinary elimination.

  • Identify common causes of urinary problems.

  • Describe the nursing assessment of urinary function.

  • Describe nursing interventions to:   
    - Maintain normal urinary elimination.  
    - Prevent urinary tract infection (UTI).   
    - Manage urinary incontinence.

Facts

  • 75% of all hospital-acquired urinary tract infections (UTI) are catheter-associated urinary tract infections (CAUTIs).

  • 95% of Intensive Care Unit (ICU) UTIs are linked to catheters (CDC, June 27, 2025).

Anatomy of the Urinary System

  • Kidneys

  • Ureters

  • Bladder

  • Urethra

  • Adrenal Gland

  • Diaphragm   - 10th rib   - 11th rib   - 12th rib

  • Hilum

  • Abdominal Aorta

  • Vena Cava

Male and Female Bladder Anatomy

  • Biological Male:   - Ureter, Bladder, Prostate Gland, Urethra.

  • Biological Female:   - Ureter, Uterus, Bladder, Urethra.

Normal Development

  • Nephrons can concentrate urine at 6 weeks.

  • Voluntary sphincter control is achieved by 18-24 months (1.5-2 years).

  • Full urinary control occurs between 2 to 5 years old.

  • Psychological factors influencing control: motivation, embarrassment, nervousness.

Factors Affecting Urination

Increasing Age

  • Decreased bladder muscle tone.

  • Decreased bladder contractility.

  • Inability to concentrate urine at night.

  • Joint stiffness or muscular debility.

  • Atrophied or weakened muscles.

  • Long periods of immobility leading to:   
    - Reduced capacity   
    - Urine retention or stasis   
    - Increased voiding at night   
    - Impaired mobility   
    - Incontinence   
    - Decreased emptying.

Changes with Age

  • Increased voiding frequency.

  • Partial emptying or nocturia.

  • Symptoms include:   
    - Urinary accidents   
    - Involuntary leakage   
    - Urinary stasis.

Pathologic Conditions

  • Acute Kidney Injury (AKI): sudden loss of kidney function.

  • Chronic Kidney Disease (CKD): slow degeneration of renal efficiency.

  • End-Stage Renal Disease (ESRD): kidneys can no longer excrete waste or balance fluids + electrolytes.

Factors Affecting Urine Output (UOP)

  • Food and Fluid Intake:   
    - Increased alcohol.   
    - Reduced fluids or dehydration.   
    - High sodium foods + beverages (e.g., asparagus, onions, red beets, caffeine).

  • Effects include:   
    - Increased urine output.   
    - Strong odor of urine.   
    - Discolored urine.

Medications Affecting Urine Elimination

  • Diuretics: (e.g., Lasix, spironolactone).

  • Anti-inflammatories: (e.g., Naproxen, Ibuprofen).

  • Antibiotics: can cause acute kidney injury if infused too rapidly.

Terms of Altered Urinary Output

  • Frequency: Increased urge to urinate.

  • Urgency: Strong, sudden need to urinate.

  • Dysuria: Painful urination.

  • Enuresis: Bed wetting.

  • Polyuria: Excessive urine production.

  • Neurogenic Bladder: Loss of normal bladder control.

  • Incontinence: Involuntary loss of urine.

  • Nocturia: Urination at night.

  • Urinary Retention: Inability to urinate fully.

  • Oliguria/Anuria: Low urine output or no urine output.

Assessing Urinary Elimination

  • History: Voiding patterns, changes, difficulties, nighttime voiding.

  • Physical Assessment: Tenderness, swelling, discharge, edema.

  • Urine Analysis:   - Amount, color, clarity, odor, pH (5-6), specific gravity (1.015 – 1.025).

  • Lab Tests: Blood urea nitrogen, creatinine, urine analysis, urine culture.

  • Bladder Scanner: To check for urine retention post-voiding.

  • Urinary Diversion: Assess for surgically created alternate urine excretion routes.

Describing Urine Output

Urine Color Chart

  • Light Yellow: Hydrated.

  • Yellow: Normal.

  • Dark Yellow: Dehydrated.

  • Amber/Brown/Red: Indicates severe dehydration or other conditions.

Collecting + Measuring Urine

  • Methods and Equipment:   
    - Bed pan   
    - Urinal   
    - Fracture Pan   
    - Urine hat   
    - Specimen cup   
    - Graduated Cylinder   
    - Indwelling catheter system   
    - External pouch or collection bag.

Urine Specimens

  • For Urinalysis (UA): Clean-catch (midstream) sample (3 - 5 mL).

  • For Urine Culture: Obtain sterile sample using a straight catheter or urinary diversion bag (only if new).

Urinary Diversions

  • Can lead to incontinence or be designed for continence.   
    - Types:     
    - Ureterostomy: Empties into an external bag.     
    - Nephrostomy: Renal function through an external bag.     
    - Ileal Conduit: Urinary diversion through ileum.     
    - Kock or Indiana Pouch: Diversion to ileum and cecum.     
    - Neobladder: Created from small intestine to function as bladder.

Suprapubic Catheter

  • Permanently or temporarily inserted into the bladder.

  • Requires sterile technique and careful care similar to Foley catheters.

Nursing Diagnoses for Urinary Issues

  • Impaired elimination.

  • Stress or urge incontinence.

  • Urine retention.

  • Risk for UTI or CAUTI.

  • Risk for impaired skin integrity.

  • Patient goals:   
    - Maintain normal voiding pattern.   
    - Improve urine control.   
    - Free from bladder discomfort.   
    - Remain free of UTI.   
    - Skin remains clean, dry, and intact.

Nursing Interventions for Urinary Function

  • Encourage adequate oral fluids (8 to 10 glasses/day).

  • Maintain privacy.

  • Provide assistance for normal elimination positions.

  • Use bedside commode if necessary.

Specific Interventions for Urinary Incontinence

  • Instruct pelvic floor exercises for stress and urge incontinence.

  • Apply an external catheter for females (e.g., Pure Wick).

  • Apply condom catheter for males (e.g., Primo Fit).

Preventing Urinary Tract Infection (UTI)

  • Drink 8-10 glasses of water daily.

  • Void every 2-4 hours to flush out bacteria.

  • Encourage showers over baths.

  • Dry female perineal area from front to back.

  • Avoid irritating sprays and tight synthetic underwear.

Preventing Catheter Associated UTI

  • Advise good hand hygiene.

  • Use indwelling catheters as a last resort.

  • Remove catheters ASAP after their need has ended.

  • Perform daily perineal care.

  • Ensure proper drainage position (gravity).

  • Check tubing for kinks or loops.

For Loss of Kidney Function

  • Arteriovenous (AV) Access: Surgically created connection for dialysis access - essential for blood waste removal.

BOWEL FUNCTION + ELIMINATION

Bowel Function + Elimination Objectives

  • Describe assessment of bowel function and elimination.

  • Identify measures to maintain normal bowel function.

  • Describe factors affecting bowel function.

  • Recognize common bowel elimination problems.

  • Develop nursing diagnoses and interventions for bowel problems.

Normal Feces Characteristics

  • Formed or semi-solid stool, primarily absorbed water.

  • Peristalsis: Contractions cause transit through the GI tract (24-28 hours).

Defecation Process

  • Intra-rectal pressure accumulates due to feces.

  • Internal sphincter relaxes reflexively.

  • External sphincter is voluntarily controlled to allow feces to exit.

Methods to Increase Intra-rectal Pressure

  1. Contracting abdominal wall muscles.

  2. Holding breath.

  3. Contracting diaphragm while closing glottis.

  4. Flexing thigh muscles.

  5. Seated position.

  6. Bearing down known as the Valsalva Maneuver.

Assessing Bowel Function

  • Bowel Pattern: Normal frequency, changes, difficulties.

  • Physical Examination: Color (brownish), consistency (soft, formed), shape, palpation, auscultation.

Factors Affecting Bowel Function and Elimination

  • Development/Age: Infants, toddlers, older adults affected by intake of fluids and fiber, GI motility.

  • Diet: Sufficient fluid and fiber to ensure normal function.

  • Psychological Factors: Chronic anxiety can impede normal elimination.

  • Habits: Routine and timing affect bowel habits.

Medications Impacting Bowel Function

  • Anticoagulants: Color changes in stool (pink, red, tarry black).

  • Opioids: Prolonged transit time leading to constipation.

  • Antacids: Can decrease motility and cause constipation.

  • Anticholinergics/Medications: Delay peristalsis, causing constipation.

Pathologic Conditions Impacting Bowel Function

  • Diverticulitis: Inflammation or bulging of colon pouches.

  • Malabsorption Syndromes: Improper nutrient absorption from intestines.

  • Colon Tumors: Physical obstructions or changes in bowel habits.

Elimination Issues in Bowel Function

  • Constipation: Difficulty passing stool or incomplete emptying.

  • Diarrhea: Increased BM frequency or watery stools.

  • Fecal Incontinence: Involuntary passing of stool or gas.

  • Fecal Impaction: Hardened mass in rectum.

Nursing Diagnoses and Goals for Bowel Function

  • Bowel incontinence, constipation, or diarrhea.

  • Goals:   
    - Restore normal bowel pattern.   
    - Maintain normal stool consistency.   
    - Prevent fluid and electrolyte imbalance, skin damage, and comfort.

Nursing Interventions for Bowel Function

  • Ensure privacy and comfort.

  • Offer options for positioning after meals.

  • Increase dietary fiber and fluid intake.

  • Promote mobility and physical activity.

Stool Collection Procedures

  • Have patient void before stool collection.

  • Utilize a collection hat or sterile containers.

  • Stool Culture: Obtain before starting antibiotics.

  • Occult Blood Testing: Evaluate for hidden blood in stool.

Bowel Diversions Types

A. Sigmoid colostomy
B. Descending colostomy
C. Transverse colostomy
D. Ascending colostomy
E. Ileostomy

Conditions Requiring Bowel Diversion

  • Crohn's Disease:

  • Colon Cancer:

  • Bowel Obstruction:

  • Diverticulitis:

  • Trauma:

Ostomy Drainage Characteristics

  • Ileostomy: Liquid with digestive enzymes; monitor skin.

  • Ascending Colostomy: Liquid; possible odors.

  • Transverse Colostomy: Malodorous, mushy drainage.

  • Descending Colostomy: More solid with controlled frequency.

Enema Administration Guidelines

  • Types of Enemas:   
    - Hypertonic (Fleets): Draws fluid into colon.   
    - Hypotonic (Tap Water): Stimulates peristalsis.   
    - Isotonic (Saline): Safest option.   
    - Oil Retention, Digital manipulation, Rectal suppository.

  • Position for Administering: Left lateral position promotes gravity flow.

  • Patient Instructions: Hold for prescribed time post-administration.

Diagnostic Tests for Bowel Health

  • EGD: Visualizes upper GI tract.

  • Colonoscopy: View lower intestines.

  • Barium Enema/X-rays: Assess large intestine.

  • Abdominal Ultrasound & MRI: Non-invasive imaging techniques to visualize organs.