After ingesting food and fluids, our body eliminates waste products through the urinary system and the gastrointestinal system. Nurses provide care for patients with commonly occuring elimination alterations, including urinary tract infections, urinary incontinence, urinary retention, constipation, diarrhea, and bowel incontinence. This chapter will provide an overview of these alterations and the associated nursing care.

1. Concept of Elimination
Ghaffar Ahmed
Lecturer INC

2. Bowel Elimination

3. Objectives
 Define elimination pattern.
 Discuss common problems of elimination.
 Identify nursing interventions for common problems of fecal
elimination.
 Discuss common problem of Urinary Elimination.
 Identify nursing intervention for common urinary problems.
 Describe factors that can alter urinary function.
 Discuss nursing process for a patient with altered elimination
pattern.

4. Anatomy of GI Tract
 Human GI system is composed of :
 Mouth
 Pharynx
 Larynx
 Esophagus
 Stomach Accessory Organs
 Small Intestine
 Large Intestine
 Anus

5. Elimination Pattern
 The ability to get rid of wastes from the body.
OR
 The expulsion of waste from body is known as elimination.
 Elimination patterns describe the regulation, control, and removal of
by products and wastes in the body. The term usually refers to the
movement of feces or urine and sweat from the body.

6. Bowel Elimination
 It is also known as defecation. Bowel elimination is a natural process
critical to human functioning in which body excretes waste products
of digestion. It is a essential component of the healthy body
functioning.
OR
 Defecation (Bowel Elimination) is the act of expelling feces (Stool)
from the body. To do so, all structures of the gastrointestinal tract,
especially the components of the large intestine must function in a
coordinated manner.

7. Bowel Elimination …. Cont
 Large intestine (Colon) is about 125-150cm long.
 It has seven parts:
 Cecum, ascending, transverse and descending, sigmoid
colon, rectum and anus
 The colon forms pouches called haustra (haustrum is
singular)
 The large intestine is a muscular tube lined with mucous
membrane
 The muscles are circular and longitudinal to facilitate
peristaltic movement.

8. Types of colon
 Haustral Churning involves back and forth movement of chyme within
the colon.
 Colon peristalsis is relatively sluggish movement of the chyme along
the colon.
 Mass peristalsis is powerful muscular movement along the colon.

9. Defecation Process
 Defecation is initiated by two reflexes.
 When feces enter the rectum, its distention gives signal to mesenteric
plexus to initiate peristaltic movement in the descending, sigmoid
colon, and the rectum.
 The internal sphincter in the anus relaxes and defecation occurs by
opening the external sphincter.

10. Characteristics of Feces
 Feces (Healthy People)
 Soft, Brown, moist and firmed.
 Distinct odor.
 Factors affecting the odor or appearance
 Certain foods.
 Medication.
 Illness or infection.

11. Abnormal Feces
 Black: Tarry stool may indicate of bleeding from upper
gastrointestinal tract or drug.
 Red: May indicate of bleeding from lower gastrointestinal tract.
 Pale: May indicate to mal absorption.
 Green: May indicate intestinal infection.
 Dry hard: Dehydration decreased intestinal motility.
 Pus: Bacterial infection.

12. Factors Promoting Elimination
 Stress free environment
 Ability to follow personal bowel habits, privacy
 High fiber diet
 Normal fluid intake (Fruit juice, warm liquid)
 Exercise (Walking)
 Ability to assume squatting position
 Properly administered laxatives

13. Factors Impaired Elimination
 Emotional anxiety
 Failure to heed defecation reflex
 Lack of time and privacy
 High carbohydrate, high fat diet
 Reduced fluid intake
 Immobility and inactivity
 Overuse of cathartics, narcotics analgesic
 Inability to squat because of immobility, musculoskeletal
deformity, pain during defecation

14. Alteration in Bowel Elimination
 Diarrhea: Liquid watery stool, deals with the consistency and
frequency
 Constipation: Less then 3 times / week or what ever is less then the
pt. regular pattern of elimination.
 Incontinence: inability to control fecal discharge through anal
sphincter. Involuntary passage of stool
 Fecal Impaction: Mass of hardened feces in rectum…. Recognized by
seepage
 Flatulence: Gas, Abdominal Distention and pain

15. Assessing Elimination Status
 Usual Pattern: How often, when changes in bowels: blood, mucus.
 Aids to eliminate: laxatives, Enemas.
 Current problems: food related, meds physical, emotional, Artificial
orifices, hemorrhoids ( Abnormally distended veins) colostomy

16. Physical Assessment
 Inspection: observe contour of abdomen and note visible peristalsis.
 Auscultation: listen for bowel sounds in all quadrants.
 Percussion: resonant or tympany over hollow organs… dullness over
intestinal obstructions.
 Palpation: feel for masses tenderness etc.

17. Nursing Diagnosis
 Bowel incontinence related to fecal impaction.
 Constipation related to immobility.
 Risk for constipation related to insufficient fiber intake.
 Diarrhea related to spoiled food.
 Risk for fluid volume deficit related to diarrhea.
 Risk for impaired skin integrity related to colectomy.
 Self esteem disturbances related to bowel diversion.

18. Nursing intervention to promote normal
bowel elimination
 Privacy
 Timing- patient should be encouraged to defecate when the urge to
defecate is recognized.
 Nutrition and fluids- high fiber food, 2000 cc fluids /day
 Exercise- Ambulation helps to stimulate normal motility, and
therefore should be encouraged in post surgical patient
 Positioning- comfortable position needed.
 Squatting position common. Assess need for elevated toilet
commode.

19. Nursing intervention for constipated patients
 Increase fluid intake. Instruct the patient to drink fruit juices
 Include fiber in diet with foods
 Administration of laxatives
 Administration of enema

20. Nursing intervention for patients with
diarrhea
 Encourage intake of fluids
 Eating small amount of bland foods
 Encourage the ingestion of food or fluids containing potassium since
diarrhea can lead great potassium loss.
 Avoid excessively hot or cold fluids and highly spicy foods and high
fiber food that can aggravate diarrhea.

21. Nursing Interventions for Fecal Incontinence
 Give balance meals.
 Note time of incontinence.
 Toilet pt 30-60min before ..usual time of incontinence.
 Begin bowel training program.

22. Nursing interventions for fecal impaction
 Teach / counseling / habit training.
 Diet (fiber, lactose, fructose).
 Reduce caffein intake.
 Anal hygiene / skin care.
 Digital removal of stool.

23. Nursing Interventions for Flatulence
 Decreasing flatulus by avoiding gas- producing food, exercise, moving
in bed and ambulation.
 Glycerin suppository

24. Interventions …….. Cont
 Cathartics/laxatives- drugs that induce emptying of the intestine.
Habitual use of laxatives lead to constipation and irregular frequency.
 Enemas: solution introduced into lower bowel by way of rectum for
the purpose of removing feces.
 Suppositories: bullet shaped substance inserted into the rectum
beyond the anal sphincter where it melts to aid in elimination.
 Digital removal: with prolonged retention of feces, fecal impaction
occurs preventing passage of normal stool. Liquid fecal seepage
around hard stool can occur. Oil retention enema is given prior to
digital removal to soften stool.

25. Urine Elimination

26. Anatomy of Renal System
Renal system of compose of
 2- kidneys
 2- ureters
 1- urinary bladder
 1- urethra

27. Structure o f kidney
 Kidneys are pairs of organ
 Shapes: bean shape
 Size: 11 cm long, 6cm wide, 3cm thick
 Weight: 150g
 Location: the kidney lie on the posterior abdominal wall, one on each
side of the vertebral column.
 Position: it is situated at T12-L3

28. Structure o f kidney ………. Cont
 Longitudinal section of the kidney shows following parts
 Capsule
 Cortex
 Medulla
 Hilum

29.  Urinary system consist of organs that produce and excrete urine from the
body.
 Urine contains waste: mostly excess water, salts and nitrogen compounds.
 Primary organs are the kidneys
 Normal adult bladder can store up to 5 liters.
 Also responsible for regulating blood volume and blood pressure
 Regulates electrolytes

30. Organs of the Urinary System
The component of urinary system include
 Kidneys
 Ureters
 Urinary bladder
 Urethra

31. Formation of Urine
 The formation of urine has 3 processes
 Filtration
 Reabsorption
 Tubular secretion
 Urine consists of 95% water and 5% solid substances.
 The need to urinate is usually felt at 300 -350 ml of urine in the
bladder.
 Typically 1000 – 1500 is voided daily.

32. Urination
 Micturition, voiding and urination all refer to the process of emptying
the urinary bladder.
 Stretch receptors- special sensory nerve endings in the bladder wall
that is stimulated when pressure is felt from the collection of urine.
 Adult: 250ml-450 ml of urine
 Children: 50-200 ml of urine

33. Factors Affecting Voiding
 Growth and development
 Psychosocial
 Fluid and food intake
 Medication
 Muscle tone and activity
 Pathologic conditions
 Surgical and diagnostic procedures

34. Common Urinary Elimination Problems
 Urinary retention
 Urinary tract infection
 Urinary incontinence

35. Altered Urinary Elimination
 Frequency: is the voiding more than normal with frequent intervals.
 Nocturia: is voiding two or three time at night.
 Urgency: Is the feeling of person must void.
 Dysuria: means voiding that is either painful or difficulty.
 Enuresis: is defined as involuntary urination.
 Urinary incontinence: involuntary urination. Symptom not a disease.
 Urine retention: accumulation of urine in the bladder and become over
distended.
 Hypospadias is a birth (Congenital) defect in which the opening of the
urethra is on the underside of the penis,.

36. Assessing Urinary Function
 Determine normal voiding pattern and frequency.
 Appearance of urine.
 Recent changes.
 Past or current problems with urination (burning, urgency etc).
 Presence of an ostomy.
 Factors influencing elimination pattern.

37. Assessment
 Nursing history.
 Voiding pattern, description of urine for any changing.
 Urinary elimination problems.
 Presence of urinary diversion.
 Physical assessment:
 Inspection
 Palpation
 Percussion
 Auscultation

38. Assessing Urine
 Color: Transparent
 Normal kidney produce urine at the rate of 40-60 ml/hr or 1500-2000
ml/day
 Sterility: no microorganism present.
 Glucose: not present
 Epithelial cell not present
 Measuring urine out put
 Collecting urine specimen

39. Nursing Diagnosis
 Altered urinary Elimination related to bladder neck obstruction.
 Stress incontinence related to relaxation of sphincter.
 Risk for infection related to urinary retention.
 Self esteem disturbances related to urinary incontinence.

40. Planning
 Maintain normal voiding pattern.
 Regain normal urine output.
 Prevent infection.
 Maintaining normal urinary elimination.
 Promote/increase fluid intake.
 Assisting with toileting.
 Prevent urinary tract infection.
 Practice frequent voiding process.
 Strengthening pelvic floor muscles.
 Manual bladder compression & kegal exercise

41. Managing Urinary Incontinence
 Bladder training: requires that the client postpone voiding, resist or
inhibit the sensation urgency, and void according to a time table
rather than according to the urge to void. The goal is to lengthen the
intervals between urination to correct the client’s habit of frequent
urination.
 Habit training: also referred to as timed voiding or scheduled
toileting. There is no attempt to motivate the client to delay voiding is
the urge occurs.
 Prompt voiding: supplements the habit training by encouraging the
client to use the toilet and reminding the client when to void

42. Managing Urinary Incontinence ……. Cont
 Pelvic muscle exercises (PME).
 Referred to as perineal muscle tightening or kegel’s exercise.
 Strengthen pubococcygeal muscles and can increase the incontinent.
female’s ability to start and stop the stream of urine.

43. Managing Urinary Incontinence ……. Cont
 Positive reinforcement.
 Maintaining skin integrity.
 Applying external urinary devices.

44. Managing Urinary Retention
 Urinary catheterization

46. Reference
Berma A, Snyde S. Fundamentals of Nursing. 9th ed. Tamil Nadu, India:
Kozier & Erb's; 2017.