BOWEL ELIMINATION  Anal canal – is bounded by an external

Physiology of Defecation and internal sphincter muscle.

 Feces or stool – the excreted waste  Internal sphincter – involuntarily
products controlled; autonomic nervous system
Large Intestine  External sphincter – voluntarily
 Extends from the ileococcal valve, which controlled; somatic nervous system
lies between the small and large
intestines, to the anus.
 In adults, the colon is about 125 to 150
(50 to 60 in.) long.
 It has seven parts: cecum, ascending,
transverse, and descending colons;
sigmoid colon; rectum; and anus
 The longitudinal muscles are shorter than
the colon and therefore cause the large
intestine to form pouches, or haustra.
 The main function of colon are absorption
of water and nutrients, the mucoid
protection of the intestinal wall, and fecal
Defecation
elimination.
 Defecation (bowel elimination) is the act
 The contents of the colon normally
of expelling feces (stool) from the body. It
represent foods ingested over the
is the expulsion of feces from the anus
previous 4 days, although most of the
and rectum. It is also called bowel
waste products are excreted within 48
movement. In the large intestine, a
hours of ingestion (the act of taking food)
remarkable volume of water is removed
 Chyme – the waste products leaving the from the remnants of digestion, causing
stomach through the small intestine and the bowel's contents to become a
then passing through the ileocecal valve consolidated mass of residue before being
 The ileocecal valve regulates the flow of eliminated.
chyme into the large intestine and  Normal defecation is facilitated by:
prevents backflow into the ileum o Thigh flexion, which increases the
 The colon acts to transport along its lumen pressure within the abdomen
the products of digestion, which are o A sitting position, which increases the
eliminated through the anal canal. These
downward pressure on the rectum
products are:
 Flatus – is largely air and the
byproducts of the digestion of
carbohydrates
Three types of movement occur in the
large intestine:
o Haustral churning – involves
movement of the chyme back and
forth within the haustra.
o Peristalsis – is wavelike
movement produced by the circular
and longitudinal muscle fibers off
the intestinal walls; it propels the
intestinal contents forward Feces
o Mass peristalsis – involves a  Normal feces are made of about 75%
wave of powerful muscular water and 25% solid materials.
contraction that moves over large  Soft but formed
areas of the colon.  Normally brown, due to presence of
 Feces stercobilin and urobilin, which are derived
from bilirubin (red pigment in bile)
 The action of microorganisms on the
chyme is also responsible for the odor of
feces
 Adult usually forms 7 to 10 L of flatus
(gas) in the large intestine every 24 hours
 Gases include CO2, methane, H20, O2,
and nitrogen
 Peristalsis means the rhythmic
contractions of intestinal smooth muscle
that facilitate defecation. Peristalsis moves
fiber, water, and nutritional wastes along
Rectum and Anal Canal the ascending, transverse, descending,
 Rectum – in an adult is usually 10 to 15 and sigmoid colon toward the rectum.
cm (4 to 6 in.) long, the most distal Peristalsis becomes even more active
portion, 2.5 to 5 cm (1 to 2 in.) during eating; this increased peristaltic
 Hemorrhoids – a condition when the activity is termed the gastrocolic reflex.
veins become distended, as can occur
with repeated pressure
1
  Laxatives – are medications that
stimulate bowel activity and so assist fecal
elimination
Diagnostic Procedures
 Certain diagnostic procedures, such as
visualization of the colon (colonoscopy or
sigmoidoscopy), the client is restricted
from ingesting food or fluid
Anesthesia and Surgery
 General anesthetics cause the normal
colonic movements to cease or slow by
blocking parasympathetic stimulation to
Factors That Affect Defecation the muscles of the colon
Development  Surgery that involves direct handling of
Newborns and Infants the intestines can cause temporary
 Meconium is the first fecal material cessation of intestinal movement. This
passed by the newborn, normally after 24 condition, called ileus, usually lasts 24 to
hours after birth. It is black, tarry, 48 hours.
odorless, ad sticky. Pathologic Conditions
 They pass stool frequently, often after  Spinal cord and head injuries decrease the
feeding sensory stimulation for defecation
 Breast fed = yellow to golden feces  Impaired mobility may limit the client’s
Formula = dark yellow or tan feces ability to respond to the urge to defecate
Toddlers and the client may experience
 Some control defecations start at 1 ½ to 2 constipation
years of age Pain
 A desire to control daytime bowel  Clients who experience discomfort when
movements and to use toilet generally defecating often suppress the urge to
starts when the child becomes aware of defecate to avoid the pain
(a) discomfort caused by soiled diaper, Assessment of Bowel Elimination
and (b) sensation that indicates the need  Elimination Patterns
for bowel movement  Because various elimination
School-Age Children and Adolescents patterns can be normal, it is
 Patterns of defecation vary in frequency, essential to determine the client's
quantity, and consistency usual patterns, including frequency
Elders of elimination, effort required to
 Constipation is the most common bowel- expel stool, and what elimination
management problem in elders due to aids, if any, he or she uses.
reduced activity levels, inadequate  Stool Characteristics
amounts of fluid, and fiber intake and  Information that is particularly
muscle weakness diagnostic includes stool color,
 Gastrolic refex – increased peristalsis of odor, consistency, shape, and
the colon after food has entered the unusual components
stomach
Diet
 Sufficient bulk (cellulose, fiber) in the diet
is necessary to provide fecal volume
 Irregular eating can also impair regular
defecation
 Spicy foods can produce diarrhea and
flatus
 Gas producing foods ie. cabbage, onions
 Laxative producing foods ie. bran, prunes
 Constipation producing foods ie. cheese,
pasta
Fluid
 Health fecal elimination usually requires a
daily fluid intake of 2,000 to 3,000 mL
Activity
 Activity stimulates peristalsis, this Fecal Elimination Problems
facilitating the movement of chyme along Constipation
the colon  Fewer than three bowel movements per
Psychologic Factors week.
 People who are anxious and angry  Passage of dry, hard stool or the passage
experience diarrhea, while people who are of no stool.
depressed experience constipation  The movement of feces through the large
Defecation Habits intestine is slow, thus allowing time for
 Early bowel training may establish the additional reabsorption of fluid from the
habit if defecating at a regular time large intestine
Medications  Difficult evacuation of stool, and increased
 Some drugs have side effects that can effort or straining of the voluntary muscles
interfere with normal elimination of defecation
2
  Factors that contribute to constipation:  Gastorostomies and jejunostomies are
 Insufficient fiber intake generally performed to provide an
 Insufficient fluid intake alternate feeding route.
 Insufficient activity or immobility  Bowel diversion ostomies are often
 Irregular defecation habits classified according to:
 Change in daily routine, etc  Their status as permanent or
 The Valsalva maneuver can present temporary
serious problems to people with heart  Their anatomic location
disease, brain injuries, or respiratory  The construction of stoma
disease. Holding the breath, while bearing  Stoma – the opening created in the
down, increases inthrathoracic pressure abdominal wall by the ostomy. Generally
and vagal tone, slowing the pulse rate red in color and moist
Fecal Impaction Measures to Promote Bowel Elimination
 Is a mass or collection of hardened feces  Nurses commonly use two interventions—
in the folds of the rectum. Impaction inserting suppositories and administering
results from prolonged retention and enemas—to promote elimination when it
accumulation of fecal material. does not occur naturally or when the
 Can be recognized by the passage of bowel must be cleansed for other
liquid fecal seepage (diarrhea) and no purposes, such as preparation for surgery
normal stool. and endoscopic or x-ray examinations.
Flatulence Inserting a Rectal Suppository
 Is the presence of excessive flatus in the  Medications released from the suppository
intestines and leads to stretching and can have local or systemic effects.
inflation of the intestines (intestinal Depending on the drug, local effects may
distention). include softening and lubricating dry stool,
 There are three primary sources of flatus: irritating the wall of the rectum and anal
 Action of bacteria on the chyme in the canal to stimulate smooth muscle
large intestine contraction, and liberating carbon dioxide,
 Swallowed air thus increasing rectal distention and the
 Gas that diffuses between in the urge to defecate.
bloodstream and intestine Administering an Enema
Diarrhea  An enema introduces a solution into the
 Refers to the passage of liquid feces and rectum Nurses give enemas to:
an increased frequency of defecation.  Cleanse the lower bowel(most
 Rapid passage of chyme reduces the time common reason).
available for the large intestine to  Soften feces.
reabsorb water and electrolytes  Expel flatus.
 With persistent diarrhea, irritation of the  Soothe irritated mucous
anal region extending to the perineum and membranes.
buttocks  Outline the colon during diagnostic
 Results to fatigue, weakness, malaise, and x-rays.
emaciation  Treat worm and parasite
Bowel Incontinence (Fecal Incontinence) infestations.
 The loss of voluntarily ability to control Cleansing Enemas
fecal and gaseous discharges through the  Cleansing enemas use different types of
anal sphincter solution to remove feces from the rectum
 Two types of bowel incontinence:
 Partial incontinence – the inability to
control flatus or to prevent minor soiling
 Major incontinence – the inability to
control feces of normal consistency
 Generally associated with impaired
functioning of the anal sphincter or its
nerve supply
 Several procedures are used for the
treatment of fecal incontinence which
includes repair of the sphincter and fecal
diversion or colostomy
Bowel Diversion Ostomes
 To divert and drain fecal material. Retention Enemas
 Ostomy – is an opening for the  A retention enema uses a solution held
gastrointestinal, urinary, or respiratory within the large intestine for a specified
tract onto the skin period, usually at least 30 minutes. Some
 Gastrostomy – is an opening through the retention enemas are not expelled at all.
abdominal wall into the stomach One type of retention enema is called an
because the fluid instilled is mineral,
 Jejunostomy – opens through the
cottonseed, or olive oil. Oils lubricate and
abdominal wall into the jejunum
soften the stool, so it can be expelled
 Ileostomy – opens into the ileum
more easily.
 Colostomy – opens into the colon Ostomy Care
 A client with an ostomy (surgically created
opening to the bowel or other structure;
3
 requires additional care for promoting
bowel elimination. Two examples of
intestinal ostomies are an ileostomy
(surgically created opening to the ileum)
and a colostomy (surgically created
opening to a portion of the colon;
Materials enter and exit through a stoma
(entrance to the opening).

 Most persons with an ostomy, also called

ostomates, wear an appliance (bag or
collection device over the stoma) to
collect stool. Depending on the type and
location of the ostomy, client care may
involve providing peristomal care,
applying an appliance, draining a
continent ileostomy, and, for clients with a
colostomy, administering irrigations
through the stoma.

Providing Peristomal Care

 Preventing skin breakdown is a major
challenge in ostomy care. Enzymes in
stool can quickly cause excoriation
(chemical injury of skin). Washing the
stoma and surrounding skin with mild soap
and water and patting it dry can preserve
skin integrity.
Nursing Implications
 Constipation
 Risk for Constipation
 Perceived Constipation
 Diarrhea
 Bowel Incontinence
 Toileting Self-Care Deficit
 Situational Low Self-Esteem

4
DEFINITION OF TERMS  fewer than 3 bowel movements per week
Main functions of the colon Impaction
 absorption of water and nutrients, mucoid  hardened stool in the folds of the rectum
protection of the intestinal wall, and fecal  will experience diarrhea and no normal
elimination stool
 Contents are usually food ingested over  the pt becomes anorexic, abdomen
the past 4 days, although most waste distended and rectal pain
products were excreted within 48 hours of  antihistamines and anticholinergics
ingestion. increase the risk
Chyme  older people might experience delirium
 Partially digested, semiliquid food mixed Bowel incontinence
with digestive enzymes and acids in the  inability to control defecation
stomach.  Partial: inability to control flatus or to
 Waste products from the stomach that prevent minor soiling
pass through the small intestine and then  Major: inability to control feces of normal
through the ileocecal valve. consistency
 1500 mL of chyme passes thru the colon Emollient of Surfactant: decussate calcium
daily and all but about 100 mL is (Surfak) and docusate sodium (Colace)
reabsorbed in the proximal half of the  softens fecal mass, doesnt stimulate
colon the rest is excreted in the feces. peristalsis, used for prevention of
Ileocecal valve constipation and to reduce strain
 Valve at the junction of the small and Iron supplements cause
large intestines. Prevents back flow into  constipation or diarrhea; black or tarry
the ileum of the small intestine. stool
Three types of movement in the colon Cathartics
 Haustral churning: movement of the  drugs that induce defecation; a laxative is
chyme back and forth within the haustra; mild in comparison
aids in the absorption of water Gastrostomy
 Peristalsis: propels the intestinal  creation of an artificial opening into the
contents forward; doesn't do much stomach
 Mass peristalsis: a wave of powerful Jejunostomy
muscular contraction that moves over  opens through the abdominal wall into the
large areas of the colon. Usually occurs jejunum
after eating and happens only a few times Ileostomy
a day.  opens into the ileum (small bowel)
Hemorrhoids Colostomy
 There are vertical folds in the rectum and  opens into the colon (large bowel)
each contains a vein and an artery. Stoma
 This condition occurs when the veins  the opening created in the abdominal wall
become distended, as can occur from by the ostomy
repeated pressure. Generally red and moist. Initially, slight
Newborns and infants feces bleeding may occur when the stoma is
 light yellow to golden feces if breast-fed; touched, this is normal.
dark yellow or tan stool if taking formula Pt doesn't feel the stoma because there
Meconium are no nerve endings.
 the first bowel movement of the newborn;
black, tarry, odorless, and sticky. Single stoma
Normal amount of feces  Created when one end of bowel is brought
 varies with diet (about 100-400 g/day) out through an opening onto the anterior
Gastrocolic reflex abdominal wall. This is referred to as an
 increased peristalsis of the colon after end or terminal colostomy because the
food has entered the stomach stoma is permanent.
Insoluble fibers
 promotes movement of material through Loop colostomy
digestive system and increases stool bulk.  a loop of bowel is brought out onto the
 whole wheat flour, nuts, and many veggies abdominal wall and supported by a plastic
Soluble fiber bridge. Has two openings: the proximal or
 fiber that dissolves in water to form a gel afferent end, which is active, and the
like material. Can help lower cholesterol distal or efferent end, which is inactive.
and glucose levels.  Usually an emergency procedure and is
 oats, peas, beans, apples, citrus fruits, often situated on the right transverse
carrots, barley, and psyllium colon.
Men ages 50 and younger daily fiber
 38 g Divided colostomy
Men ages 51 and older daily fiber  consists of two edges of bowel brought out
 30 g onto the abdomen but separated from
Women ages 50 and younger daily fiber each other. Proximal end is the colostomy,
 25 g the distal end is called a mucous fistula
Women ages 51 and older daily fiber because it continues to secrete mucus.
 21 g
Constipation

5
  Often used when spillage of feces into the  cleans as much of the colon as possible
distal end of the bowel needs to be  pt changes from the left lateral position to
avoided. the dorsal recumbent position and then to
the right lateral position.
Double-barreled colostomy  hang solution about 12 to 18 in above the
 the proximal and distal loops of bowel are rectum.
sutured together for about 10 cm (4 in) Low cleansing enema
and both ends are brought up onto the  cleanses only the rectum and sigmoid
abdominal wall colon. Pt maintains a left lateral position
Slipper bedpan or fracture pan  hang solution no higher than 12 in above
 bedpan that has a how back and is used the rectum.
for pts unable to raise their butts Carminative enema
 given to expel flatus
Suppositories  60 to 80 mL is instilled
 best results if inserted 30 mins before the Retention enema
pts usual defecation time or when the  introduces oil or medication into the
peristaltic action is greatest, such as after rectum and sigmoid colon. The liquid is
breakfast. retained for a long period (e.g., 1 to 3
Carminative hours)
 herbal oils known to act as agents that  oil, abx, anthelmintic
help expel gas from the stomach and Return flow enema (Harris flush)
intestines.  occasionally used to expel flatus.
Enema  Alternating flow of 100 to 200 mL of fluid
 a solution introduced into the rectum and into and out of the rectum and sigmoid
large intestine. The action is to distend the colon stimulates peristalsis. Repeated 5 or
intestine and sometimes to irritate it to 6 times until the flatus is expelled and
increase peristalsis and the excretion of abdominal distention is relieved.
feces and flatus. Fecal incontinence pouch
 should be 37.7 C (100F)  To collect and contain large volumes of
 cleansing, carminative, retention, and liquid fees, the nurse may place a fecal
return-flow enemas. incontinence collector pouch around the
Cleansing enema anal area
 intended to remove feces for surgery, x- In many agencies, the pouch is replacing
ray, impaction, etc. the traditional approach to this problem;
 Uses a variety of solutions that is, inserting a large Foley catheter
 can be described as high or low into the client's rectum and inflating the
Hypertonic enema solution balloon to keep it in place- a practice that
 90-120 mL of solution (sodium phosphate may damage the rectal sphincter and
[Fleet]) rectal mucosa. A rectal catheter also
 Draws water into the colon increases peristalsis and incontinence by
 5-10 min will take effect stimulating sensory nerve fibers in the
 Adverse: retention of solution rectum.
 Using more than one in 24 hours can be -change bag every 72 hours or sooner if
harmful. Be careful in renal failure pts. leakage
Hypotonic enema solution Colostomy irrigation
 500-1000 mL of tap water  For clients with a sigmoid or descending
 distends colon, stimulates peristalsis, and colostomy purpose is to distend the bowel
softens feces. as to stimulate peristalsis and evacuation
 15-20 mins  When done, need to be performed at the
 Adverse: fluid and electrolyte imbalance, same time each day
water intoxication.  300-500 mL of fluid
 Long-term irrigation puts client at risk for
Isotonic enema solution peristomal hernias, bowel perforation, and
 500-1000 mL of normal saline electrolyte imbalance
 distends colon, stimulates peristalsis, and
softens feces
 15-20 mins to take effect
 adverse: possible Na retention
Soapsuds enema solution
 500-1000 mL (3-5 mL soap to 1000 mL of
water)
 irritates mucosa, distends colon
 10-15 mins
 Adverse: irritates and may damage
mucosa.
Oil (mineral, olive, cottonseed) enema
solution
 90-120 mL
 lubes the feces and the colonic mucosa
 0.5-3 h
High cleansing enema
6
1. The nurse is presenting information at the community
health fair about normal defecation patterns across the 5. After having a transverse colostomy constructed for
lifespan. Which of the following factors would not be colon cancer, discharge planning for home care would
part of the discussion? include teaching about the ostomy appliance.
Diet Information appropriate for this intervention would
Fluid intake and output include:
Medications Instructing the client to report redness, swelling, fever,
Gender or pain at the site to the physician for evaluation of
infection
Gender Nothing can be done about the concerns of odor with
Rationale: There is no relationship noted between the appliance.
gender and defecation pattern. Diet, fluids, and Ordering appliances through the client's health care
medications all can affect amount, consistency, or provider
pattern of defecation. The appliance will not be needed when traveling.
Answer: Instructing the client to report redness,
2. The elderly population is known to use laxatives with swelling, fever, or pain at the site to the physician for
regularity. In advising an older adult practicing this evaluation of infection
habit, the nurse would identify all of the following Rationale: Signs and symptoms for monitoring infection
except: (Select all that apply.) at the ostomy site are a priority evaluation for clients
Consistent use of laxatives inhibits natural defecation with new ostomies. The remaining actions are not
reflexes, and is thought to cause rather that cure appropriate. There are supplies avaliable for clients to
constipation. help control odor that may be incurred because of the
Habitual use of laxatives eventually requires larger or ostomy. Although a prescription for ostomy supplies is
stronger doses because the effect is progressively needed, you can order the supplies from any medical
reduced. supplier. Dependent on the location and trainability of
Laxatives may interfere with fluid and electrolyte the ostomy, appliances are almost always worn
balance. throughout the day and when traveling.
Laxatives increase the absorption of certain vitamins.
6. At the local wellness fair, the nurse is asked to share
Answers: information on having healthy bowel life. Included in
Consistent use of laxatives inhibits natural defecation this area is the topic of having a healthy defecation.
reflexes, and is thought to cause rather that cure The nurse should include which of the following
constipation. information as appropriate action to follow?
Habitual use of laxatives eventually requires larger or
stronger doses because the effect is progressively Eliminating high-fiber foods in your diet
reduced. Defecating only once a day. Ignore any other urges.
Laxatives may interfere with fluid and electrolyte Establishing a regular exercise regimen
balance. Drinking four glasses of water a day
Rationale: Laxatives decrease the absorption of
vitamins. The remaining answer choices are true. Answer: Establishing a regular exercise regimen
Rationale: Exercise helps to stimulate muscle
3. The nurse encounters a 75-year-old in the emergency functioning and metabolic activity, thus promoting
department, with complaints of nausea, diarrhea, and healthy defecation. High-fiber foods are encouraged in
anorexia. He has been evaluated, and it is determined the diet of this client. Do not avoid the urge to
that he can be treated at home. In discussing the defecate, because this conditioned reflex tends to
guidelines of managing diarrhea, the nurse knows the weaken or is ultimately lost. Six to eight glasses of
client understands his care measures when he says: water are recommended to maintain fluid balance in
the body.
"I will drink two glasses of water a day to prevent
dehydration." 7. An 80-year-old client is in the emergency department.
"I will drink tea when I get home." The client complains of diarrhea and vomiting for the
"I will increase foods with fiber, like oatmeal." past two days. In assessing the client, it is noted that
"I will eat fried chicken for supper." his skin is dry and can be tented, he has lost eight
Answer: "I will increase foods with fiber, like oatmeal." pounds, and is itchy. Which NANDA diagnosis would be
most appropriate to use with this client in making his
Rationale: Increasing roughage (fiber) in the diet helps plan of care?
to add bulk to the stool. Eight glasses of water remains
the recommended fluid recommendation, although Risk for Deficient fluid volume related to prolonged
there is some disagreement. Beverages with caffeine, diarrhea and vomiting
like tea, and fatty foods like fried chicken aggravate Risk for fluid volume excess related to prolonged
diarrhea. diarrhea and vomiting
Risk for normal fluid volume related to prolonged
4. A client suffering with ulcerative colitis has discussed diarrhea and vomiting
the need for a temporary colostomy to rest the colon Risk for hidden fluid related to prolonged diarrhea and
and help the healing process. The colostomy will be vomiting
located in the descending colon. The type of stool that Risk for Deficient fluid volume related to prolonged
the client can expect from this stoma is: diarrhea and vomiting
Liquid that cannot be regulated
Malodorous and mushy drainage Rationale: This client is showing signs of dehydration.
Increasingly solid The first answer is the only appropriate answer.
Liquid fecal drainage
8. When using a rectal tube in helping a client expel
Answer: Increasingly solid flatulence, the most appropriate intervention to be
Rationale: Stool in the descending colon is often followed by the nurse is
formed, and the tissue can be trained for periodic
defecation. Liquid stool and malodorous stool that Have client in the supine position
cannot be controlled is found within the ascending Insert rectal tube, no lubrication needed
colon. Malodorous, mushy stool is noted in the Leave tube in for one hour
transverse colon. Output is always expected at some Encourage the client to assume various positions in
point in time from ostomies as evidence of their bed once the tube is inserted.
functioning.
7
 Encourage the client to assume various positions in 12. Which statement provides evidence that an older adult
bed once the tube is inserted. who is prone to constipation is in need of further
teaching?
Rationale: Varying the position from side-lying to
sitting to supine helps the client to expel flatus. The "I need to drink one and a half to two quarts of liquids
side-lying position is recommended for use during each day."
insertion. Lubrication of the tube helps to ease the "I need to take a laxative such as Milk of Magnesia if I
insertion process and prevent damage to the tissue. don't have a BM every day."
The tube should not be left in the client for more than "If my bowel pattern changes on its own, I should call
30 minutes, to avoid irritation to the rectal mucosa. you."
"Eating my meals at regular times is likely to result in
9. A client has had a stroke, and can no longer move her regular bowel movements."
bowels on her own accord. A bladder-training program "I need to take a laxative such as Milk of Magnesia if I
is to be established for her. Before beginning this don't have a BM every day."
program, the client and her family members must Rationale: The standard of practice in assisting older
understand what is involved with this care. Which of adults to maintain normal function of the
the following would be the most appropriate directions gastrointestinal tract is regular ingestion of a well-
or information to share? balanced diet, adequate fluid intake, and regular
exercise. If the bowel pattern is not regular with these
Maintain the daily routine for six weeks activities, this abnormality should be reported.
Only allow client to defecate once a day Stimulant laxatives can be very irritating and are not
Administer a cathartic suppository 30 minutes before the preferred treatment for occasional constipation in
the client's defection time to stimulate peristalsis older adults (option 2). In addition, a normal stool
Fluid intake, decreased fiber in diet, intake of hot pattern for an older adult may not be daily elimination.
drinks, and increased exercise all influence one's ability
to perform the action of defection on a regular basis. 13. A client is scheduled for a colonoscopy. The nurse will
provide information to the client about which type of
Administer a cathartic suppository 30 minutes before enema?
the client's defection time to stimulate peristalsis Oil retention
Rationale: The best results can be obtained by Return flow
inserting the suppository 30 minutes before the client's High, large volume
usual defecation time, or when the peristaltic action is Low, small volume
greatest. The daily routine in bowel training is Low, small volume
recommended to be 2-3 weeks. When the client Rationale: Small-volume enemas along with other
experiences the urge to defecate, assist the client to preparations are used to prepare the client for this
the toilet/commode/bedpan to defecate. Fluid intake, procedure. An oil retention enema is used to soften
increased fiber in the diet, intake of hot drinks, and hard stool (option 1). Return flow enemas help expel
increased exercise all influence one's ability to perform flatus (option 2). Because of the risk of loss of fluid and
the action of defecation on a regular basis. electrolytes, high, large-volume enemas are seldom
used (option 3).
10. The nurse has completed the administration of a
cleaning enema for a client being prepared for 14. The nurse is most likely to report which finding to the
intestinal surgery. Complete documentation by the primary care provider for a client who has an
nurse of this event includes all but which of the established colostomy?
following assessments? (Select all that apply.)
The stoma extends 1/2 in. above the abdomen.
Type of solution The skin under the appliance looks red briefly after
Length of time solution retained removing the appliance.
Relief of flatus and abdominal distention The stoma color is a deep red-purple.
Amount of return An ascending colostomy delivers liquid feces.
Type of solution The stoma color is a deep red-purple.
Rationale: An established stoma should be dark pink
Length of time solution retained like the color of the buccal mucosa and is slightly
Relief of flatus and abdominal distention raised above the abdomen. The skin under the
Rationale: Document color, odor, amount and appliance may remain pink/red for a while after the
consistency of feces, and the condition of the perineal adhesive is pulled off. Feces from an ascending ostomy
area. The remaining actions are also documented. are very liquid, less so from a transverse ostomy, and
more solid from a descending or sigmoid stoma.
11. Clients should be taught that repeatedly ignoring the
sensation of needing to defecate could result in which 15. Which goal is the most appropriate for clients with
of the following? diarrhea related to ingestion of an antibiotic for an
upper respiratory infection?
Constipation
Diarrhea The client will wear a medical alert bracelet for
Incontinence antibiotic allergy.
Hemorrhoids The client will return to his or her previous fecal
elimination pattern.
Constipation The client verbalizes the need to take an antidiarrheal
Rationale: Habitually ignoring the urge to defecate can medication prn.
lead to constipation through loss of the natural urge The client will increase intake of insoluble fiber such as
and the accumulation of feces. Diarrhea will not result grains, rice, and cereals.
—if anything, there is increased opportunity for water The client will return to his or her previous fecal
reabsorption because the stool remains in the colon, elimination pattern.
leading to firmer stool (option 2). Ignoring the urge Rationale: Once the cause of diarrhea has been
shows a strong voluntary sphincter, not a weak one identified and corrected, the client should return to his
that could result in incontinence (option 3). or her previous elimination pattern. This is not an
Hemorrhoids would occur only if severe drying out of example of an allergy to the antibiotic but a common
the stool occurs and, thus, repeated need to strain to consequence of overgrowth of bowel organisms not
pass stool (option 4). killed by the drug (option 1). Antidiarrheal medications
are usually prescribed according to the number of
stools, not routinely around the clock (option 3).
8
 Increasing intake of soluble fiber such as oatmeal or 19. A student nurse (SN) is assigned to care for a client
potatoes may help absorb excess liquid and decrease with a sigmoidostomy. The student will assess which
the diarrhea, but insoluble fiber will not (option 4). ostomy site?
Option 1
16. A client with a new stoma who has not had a bowel Option 2 Ascending Colon
movement since surgery last week reports feeling Option 3 Transverse Colon
nauseous. What is the appropriate nursing action? Option 4 Descending Colon
Prepare to irrigate the colostomy. Option 5 Sigmoid Colon
After assessing the stoma and surrounding skin, notify Option 5
the surgeon. Rationale: Option 5 is a sigmoidostomy site. Option 1 is
Assess bowel sounds and administer antiemetic. an ileostomy site, option 2 is ascending colostomy,
Administer a bulk-forming laxative, and encourage option 3 is transverse colostomy, and option 4 is
increased fluids and exercise. descending colostomy.
After assessing the stoma and surrounding skin, notify
the surgeon. 20. The nurse is working with a client whose main diet is
Rationale: The client has assessment findings rice, eggs, and lean meat. It is most important for the
consistent with complications of surgery. Option 1: nurse to teach the client which of the following things
Irrigating the stoma is a dependent nursing action, and about a diet high in these foods? [Hint]
is also intervention without appropriate assessment.
Option 3: Assessing the peristomal skin area is an This diet needs more fluid intake to move it through GI
independent action, but administering an antiemetic is tract.
an intervention without appropriate assessment. No additional fiber or bulk is needed, as this diet is rich
Antiemetics are generally ordered to treat immediate in it.
postoperative nausea, not several days postoperative. Eating this diet may result in the passage of watery
Option 4: stools.
Administering a bulk-forming laxative to a nauseated This diet may produce a significant amount of bloating
postoperative client is contraindicated. and flatus.
This diet needs more fluid intake to move it through GI
The nurse assesses a client's abdomen several days tract.
after abdominal surgery. It is firm, distended, and
painful to palpate. The client reports feeling "bloated." 21. The nurse is administering a medication containing iron
The nurse consults with the surgeon, who orders an to a client. The nurse does some teaching about the
enema. The nurse prepares to give what kind of iron medication. Which of the following statements will
enema? the nurse most need to make when instructing the
client about taking iron? [Hint]
Soapsuds
Retention "Diarrhea may result from taking iron supplements."
Return flow "Iron may cause your stools to appear black in color."
Oil retention "The urine may become brown when taking iron."
Return flow "You will need additional vitamin C when taking iron."
Rationale: This provides relief of postoperative flatus, "Iron may cause your stools to appear black in color."
stimulating bowel motility. Options 1, 2, and 4 manage
constipation and do not provide flatus relief. 22. You are going to have a client collect a stool sample for
a guaiac test, on three consecutive stools. In order to
17. Which of the following is most likely to validate that a avoid false positive results, you will instruct your client
client is experiencing intestinal bleeding? about the foods to eat and foods to avoid for a day or
two prior to the test. Which of the following meals
Large quantities of fat mixed with pale yellow liquid selected by the client would indicate they understood
stool your instructions? (Select ALL that apply)
Brown, formed stools
Semisoft tar-colored stools sirloin steak, a garden salad, and bread
Narrow, pencil-shaped stool fried chicken, mashed potatoes, and cake
Semisoft tar-colored stools fresh fruit salad bowl and cookies
Rationale: Blood in the upper GI tract is black and a hamburger and a bowl of chili
tarry. Option 1 can be a sign of malabsorption in an sirloin steak, a garden salad, and bread
infant, option 2 is normal stool, and option 4 is fried chicken, mashed potatoes, and cake
characteristic of an obstructive condition of the rectum.
False positive results can occur in a guaiac test if the
18. Which nursing diagnoses is/are most applicable to a client has recently ingested red meat, raw vegetables,
client with fecal incontinence? Select all that apply. fruits, especially radishes, turnips, horseradish, and
melons, or taken medications such as aspirin, iron
Bowel Incontinence preparations, and anticoagulants that irritate the
Risk for Deficient Fluid Volume gastric mucosa.
Disturbed Body Image
Social Isolation 23. Your assigned client, who has a history of heart
Risk for Impaired Skin Integrity disease, has a tendency to strain when having a bowel
Bowel Incontinence movement. You instruct the client not to strain for
which of the following reasons? [Hint]
Disturbed Body Image
Social Isolation It increases intrathoracic pressure.
Risk for Impaired Skin Integrity It can suddenly increase the blood pressure.
Rationale: Option 1 is the most appropriate. The client Straining reduces the amount of available oxygen.
is unable to decide when stool evacuation will occur. In The medial nerve is stimulated during straining.
option 3, client thoughts about self may be altered if It increases intrathoracic pressure.
unable to control stool evacuation. In option 4, client Straining during defecation uses the valsalva
may not feel as comfortable around others. In option 5, maneuver, which can present serious problems to
increased tissue contact with fecal material may result people with heart disease because it increases
in impairment. Option 2 is more appropriate for a client intrathoracic and intracranial pressures and lowers
with diarrhea. Incontinence is the inability to control heart rate.
feces of normal consistency.

9
24. You answer the call light of a hospitalized client who
states they are having a lot of flatulence and asks for a
carbonated drink with a straw. Which of the following
things would be best for you to do to help this client
reduce the amount of flatulence? [Hint]

Get the client a cola drink with a straw.

Offer the client some chewing gum.
Give the client a straw but offer a noncarbonated drink
Give the client a noncarbonated drink without a straw
Give the client a noncarbonated drink without a straw.

25. You are instructing a client in the clinic about

diphenoxylate (Lomotil), which the physician has just
ordered for diarrhea. Which of the following
instructions would be most important to give a client
who is on this medication? [Hint]

Take the medication with food.

Increase the dose until results are satisfactory.
Do not give to children under the age of 12.
Do not take before driving or using running machinery.
Do not take before driving or using running machinery.
Diphenonoxylate can cause drowsiness, so clients on
this medication should not use this medication prior to
driving or operating running machinery.

26. How high above the rectum should the nurse giving a
high-cleansing enema hold the enema solution? [Hint]

5 to 7 inches
8 to 9 inches
10 to 12 inches
14 to 16 inches
10 to 12 inches
During the high-cleansing enema, the solution
container is usually held 30 to 45 cm (12 to 18 inches)
above the rectum because the fluid is instilled further
to clean the entire bowel.

27. The colon's three main functions include which one of

the following in addition to that of fecal elimination?
[Hint]

to eliminate excess fluid

to excrete excess electrolytes with the fecal matter
excretion of a substance that sloughs off dead cells
to excrete mucus and protect the intestine from
bacteria
to excrete mucus and protect the intestine from
bacteria
The colon's main functions are the absorption of water
and electrolytes, the mucal protection of the intestinal
wall, and fecal elimination.

28. Which of the following factors would be most likely to

decrease the movement of chyme in the intestine?
[Hint]
depression
anxiety
exercise
anger
depression

29. When checking the stool of a client, you notice there is

a whitish discoloration and some white specks in the
stool. Which of the following medications do you
suspect the client is taking? [Hint]

Non-enteric coated aspirin

Antacids
New-generation cephalosporins
Antimalarials
Antiacids

10
 URINARY ELIMINATION Female and Male Urinary Bladder and
Urethras
Process of Urination
• Depends on effective functioning of
– Upper urinary tract (kidneys,
ureters)
– Lower urinary tract (bladder,
urethra, pelvic floor)
– Cardiovascular system
– Nervous system
Urine Formation
• Nephron
– Functional unit of the kidney
– Urine is formed here
• Glomerulus
– Tuft of capillaries surrounded by
Factors Affecting Voiding
Bowman’s capsule
• Developmental factors (enuresis,
– Fluids and solutes move across
nocturnal enuresis, nocturnal frequency)
endothelium of capillaries into the
 Infants
capsule
• Bowman’s capsule  Urine output: 250 to 500mL a day
– Filtrate moves from here into the  Colorless and odorless
tubule of the nephron  Kidneys are still immature, they
• Proximal convoluted tubule are unable to concentrate urine
– Most of water and electrolytes very effectively
reabsorbed  Preschoolers
• Loop of Henle  Is able to take responsibility for
– Solutes such as glucose reabsorbed independent toileting
– Other substances secreted  Accidents do occur and the child
• Distal convoluted tubule should never be punished for it
– Additional water and sodium  Teach girls on how to wipe from front
reabsorbed here under control of to back to prevent contamination of
hormones the urinary tract by feces
• Formed urine then moves to:  School-age children
– Calyces of the renal pelvis  Kidneys double in size between ages
– Ureters (valve prevents reflux) 5 to 10
– Bladder (detrusor muscle, trigone)  Child urinates six to eight times a
day
 Enuresis can be a problem for some
school-age children. About 10% of all
6 year olds experience difficulty
controlling their bladder
 Enuresis - the involuntary passing
of urine when control should be
established (about 5 years of age).
Process of Micturition  Some children also experience
• Micturition = voiding = urination nocturnal enuresis
• Urine collects in bladder
 Nocturnal enuresis (or bed
• Pressure stimulates special stretch
wetting) - is the involuntary passing
receptors in bladder wall
of urine during sleep.
• Stretch receptors transmit impulses to
 Elders
spinal cord voiding reflex center
 The excretory function of the kidney
• Internal sphincter relaxes, stimulating
diminishes with age, but usually not
urge to void
significantly below normal levels
• If appropriate, conscious portion of the
unless a disease process intervenes.
brain relaxes external urethral sphincter
 With age, the number of functioning
muscle
nephrons decreases to some decree,
• Urine is eliminated through urethra at the
impairing the kidney’s filtering
meatus
abilities.
• Pelvic floor tone aids voluntary control
 The capacity of the bladder and its
ability to completely empty diminish
with age. This explains the need for
elders to arise during the night to void
(nocturnal frequency) and the
retention of residual urine,
predisposing the elder to bladder
infection.
• Psychosocial factors
 Circumstances that do not allow for
the client’s accustomed conditions
may produce anxiety and muscle
tension.
11
  People may voluntarily suppress • Anuria (requires dialysis) – lack of urine
urination because of perceived time production
pressures • Dialysis – technique by which fluids and
• Fluid and food intake molecules pass through a semipermeable
 When the amount of fluid increases, membrane according to the rules of
the output normally increases osmosis
 Certain fluids ie. Alcohol increase fluid  Hemodialysis – the client’s blood flows
output by inhibiting the production of through vascular catheters, passes by
antidiuretic hormone, others ie. Food the dialysis solution in an external
or fluids high in sodium can cause fluid machine, and then returns to the
retention because water is retained client
 Some foods or fluids can change the  Peritoneal dialysis – the dialysis
color of urine solution is instilled into the abdominal
• Medications (especially diuretics) cavity through a catheter, allowed to
 Medications may affect the ANS, rest there while the fluid and
interfere with the normal urination molecules exchange, and then
process, and may cause retention removed through the catheter.
 Diuretics – increase urine formation by Altered Urinary Elimination
preventing the reabsorption of water • Urinary frequency – is voiding at frequent
and electrolytes from the tubules of the intervals, more than 4 to 6 times per day.
kidney into the bloodstream • Nocturia – is voiding two or more times at
• Muscle tone night
 Good muscle tone is important to • Urgency – is the sudden strong desire to
maintain the stretch and contractility of void
the detrusor muscle so the bladder can • Dysuria, associated with urinary hesitancy
fill adequately and empty completely – means voiding that is either painful or
 Pelvic muscle tone contributes to the difficult. It can accompany a stricture
ability to store and empty urine (decrease in caliber) of the urethra,
• Pathologic conditions urinary infections, and injury to the
bladder and urethra.
 Diseases of the kidney may affect the
• Enuresis – is the involuntary urination in
ability of the nephrons to produce urine.
children beyond the age when voluntary
 Renal failure – abnormal amounts of
bladder control is normally acquired,
protein or blood cells present in urine
usually 4 or 5 years of age.
 Heart failures, shock or hypertension
• Urinary incontinence - or involuntary
may affect blood flow to the kidneys
urination is a symptom, not a disease.
 Urinary stone – may obstruct ureter, – Transient (acute)
blocking urine flow from the kidney to – Established (chronic)
the bladder • Urinary retention – when emptying the
• Surgical and diagnostic procedures bladder is impaired, urine accumulates
 Some surgical and diagnostic and the bladder becomes over distended
procedures affect the passage of urine • Neurogenic bladder – the client does not
and the urine as well. perceive fullness and is unable to control
 Ex. Cystoscopy, surgical procedures, or the urinary sphincters.
spinal anesthetics Assessing
Urination • Nursing history
 Micronutrition, voiding, and urination • Physical assessment and hydration status
all refer to the process of emptying the • Examination of urine
urinary bladder. • Related data from diagnostic tests and
 Urine collects in the bladder until pressure procedures
stimulates special sensory nerve endings
in the bladder wall called stretch Nursing History
receptors. • Normal voiding patterns
 Adult bladder = 250 to 450 mL • Appearance of urine
Children = 50 to 200 mL • Recent changes
 The stretch receptors transmit impulses to • Past or current problems
the spinal cord, specifically to the voiding • Presence of ostomy
reflex center located at the level of the • Factors influencing elimination pattern
second to the fourth sacral vertebrae, Physical Assessment
causing the internal sphincter to relax and • Percussion of kidneys to detect
stimulating the urge to void. tenderness
Altered Urine Production • Palpation and percussion of bladder
• Polyuria (diuresis) – refers to the • Inspection of urethral meatus for swelling,
production of abnormally large amounts of discharge, inflammation
urine by the kidneys, often several liters • Inspect skin for color, texture, turgor,
more than the client’s usual daily output signs of irritation, edema
• Polydipsia – may be followed by polyuria; Assessing Urine
it is associated with diseases such as • 96% water; 4% solutes
diabetes mellitus, diabetes insipidus, and • Organic solutes include urea (chief solute),
chronic nephritis. ammonia, creatinine, and uric acid
• Oliguria – low urine output, less than • Inorganic solutes include sodium, chloride,
500mL a day or 30 mL an hour for an adult potassium sulfate, magnesium, and
phosphorus
12
 • Volume – Providing continence training
• Color, clarity (bladder training, habit training,
• Odor prompted voiding)
• Sterility – Pelvic muscle exercises
• pH – Maintaining skin integrity
• Specific gravity – Applying external urinary drainage
• Glucose devices
• Ketone bodies • Managing urinary retention (flaccid
• Blood bladder, Crede’s maneuver)
• Measure urinary output • Condom catheter preferred because less
• Measure residual urine risk of UTI
• Diagnostic tests
– Blood urea nitrogen (BUN) Catheterization and Infection
– Creatinine clearance • Insertion of urinary catheters is one of
Nursing Diagnoses most common causes of hospital-acquired
• Impaired Urinary Elimination (nosocomial) infections
• Readiness for Enhanced Urinary Implementing: Nursing Care for Clients with
Elimination Indwelling Catheters
• Functional Urinary Incontinence • Encourage large amounts of fluid intake
• Overflow Urinary Incontinence • Provide foods that create acidic urine
• Reflex Urinary Incontinence • Give routine perineal care; prevent
• Stress Urinary Incontinence contamination with feces in incontinent
• Urge Urinary Incontinence clients
• Risk for Urge Urinary Incontinence • Change catheter and tubing when
• Urinary Retention necessary (sediment, impaired drainage)
Urinary Elimination May Become Etiology • Maintain sterile closed-drainage system
• Risk for Infection • Remove catheter as soon as possible after
• Situational Low Self-Esteem purpose achieved
• Risk for Impaired Skin Integrity • Provide bladder retraining if needed
• Toileting Self-Care Deficit • Follow good handwashing techniques
• Risk for Deficient Fluid Volume or Excess Implementing: Ongoing Assessments of
Fluid Volume Clients with Indwelling Catheters
• Disturbed Body Image • Ensure tubing is free of obstructions
• Urinary Elimination May Become Etiology • Ensure there is no tension on catheter or
(cont'd) tubing
• Deficient Knowledge • Ensure gravity drainage is maintained,
• Risk for Caregiver Role Strain with no loops in tubing below entry to
• Risk for Social Isolation drainage bag
Planning • Ensure system is well sealed or closed
• Maintain or restore a normal voiding • Keep drainage receptacle below level of
pattern client’s bladder
• Regain normal urine output • Observe flow of urine q 2 - 3 hours
• Prevent associated risks such as infection, • Note color, odor, abnormal constituents
skin breakdown, fluid and electrolyte • If sediment is present, check more often
imbalance, and lowered self-esteem Implementing: Removing Indwelling
• Perform toilet activities independently Catheter
with or without assistive devices • Obtain receptacle for catheter; place client
• Contain urine with the appropriate device, in supine position; remove catheter-
catheter, ostomy appliance, or absorbent securing device
product • Insert syringe into injection port and
Implementing withdraw fluid from balloon
• Maintaining normal urinary elimination • After all fluid removed, withdraw catheter
– Promoting fluid intake and place in receptacle
– Maintaining normal voiding habits • Dry perineal area
– Assisting with toileting • Remove gloves
• Preventing urinary tract infections • Measure and record amount of urine in
• Teaching to prevent UTIs drainage bag
– Drink eight 8-oz glasses of water • Document removal of catheter
per day • Provide urinal, commode, or collection
– Practice frequent voiding (every 2 - device
4 hours) • Monitor for first voiding and amount
– Avoid harsh soaps, bubble baths, voided in first 8 hours; monitor I&O
powder or sprays in perineal area • Observe for dysfunctional voiding
– Avoid tight-fitting clothing behaviors
– Wear cotton, not nylon, Implementing: Teaching Clean Intermittent
underclothes Self-Catheterization
– (Girls and women) - always wipe • Performed by clients with neurogenic
perineal area from front to back bladder dysfunction
following urination or defecation • Clean or medical aseptic technique
– Take showers rather than baths if • Before teaching, establish
recurrent urinary infections are a – Client voiding pattern, volume
problem) voided, fluid intake, residual
• Managing urinary incontinence amounts
13
Implementing: Bladder Irrigations
• Bladder irrigation
– To wash out bladder
– To provide medication to bladder
lining
• Catheter irrigation
– To maintain or restore patency of
catheter
• Closed method preferred; open method
occasionally required but adds risk for
infection

Implementing: Suprapubic Catheter Care

• Inserted surgically through abdominal wall
above symphysis pubis
• Care includes
– Regular assessment of urine, fluid
intake, and comfort
– Maintaining patent system
– Maintaining skin around site,
trimming pubic hair as needed
– Periodic clamping preparatory to
removal
Urinary Diversions
• Incontinent
– Ureterostomy
– Nephrostomy
– Vesicostomy
– Ileal conduit
• Continent
– Kock pouch
– Neobladder
Implementing: Nursing Care for Clients with
Urinary Diversions
• Assess intake and output
• Note any changes in urine color, odor, or
clarity (mucus shreds are commonly seen
in urine of clients with ileal diversion)
• Frequently assess condition of stoma and
surrounding skin
• Consult with wound ostomy continence
nurse (WOCN) as needed
Evaluating
• Nurse collects data to evaluate the
effectiveness of nursing activities
• If desired outcomes not achieved, explore
the reasons before modifying the care
plan
– Client perception and
understanding, access to toilet,
ability to manipulate clothing,
Kegel exercises
– Review schedule for voiding, fluid
intake (including caffeine, etc.),
diuretics
– Lighting, mobility aids, continence
aids

14
DEFINITION OF TERMS List the three major factors to be explored
Nephron during a nursing history in regard to urinary
 Functional unit of the kidneys that forms elimination. (3)
the urine  Pattern of urination
Proteinuria  Symptoms of urinary alterations
 Presence of large proteins in the urine  Factors affecting urination
Erythropoietin Urgency
 Functions within the bone marrow to  Feeling of the need to void immediately
stimulate red blood cell production Dysuria
Renin  Painful or difficult urination
 Enzyme that converts angiotensinogen Frequency
into angiotension I  Due to increased fluid intake, pregnancy,
Micturition and diuretics
 Reflux of urine from the bladder into the Hesitancy
urethers  Caused by prostate enlargement, anxiety,
Renal calculus or urethral edema
 Kidney stone Polyuria
Reflex incontinence  Large amounts of urine voided
 Loss of voluntary control; micturition Oliguria
reflex pathway is intact  Diminished urinary output relative to
List source of the factors that influence intake
urination. (5) Nocturia
 Pathophysiological conditions (acute,  Nighttime voiding often caused by coffee
chronic) or alcohol
 Sociocultural factors Dribbling
 Psychological factors  May be caused by stress incontinence
 Fluid balance Incontinence
 Surgical and diagnostic procedures  Cause by loss of pelvic muscle tone, fecal
Explain the following alterations in urinary impaction, overactive bladder
elimination. Hematuria
Urinary diversion  Blood in the urine
 a surgical formation (temporary or Retention
permanent) that bypasses the bladder and  Accumulation of urine in the bladder with
has a stoma on the abdomen to drain the the inability to empty fully
urine Residual urine
Urinary retention  Greater than 100mL of urine remaining
 an accumulation of urine resulting from an after voiding
inability of the bladder to empty properly Identify the primary structures that the
Urinary tract infection (UTI) nurse would assess.
 Hospital-acquired UTIs result from  Skin and mucosal membranes, kidneys,
catheterization or surgical manipulation. bladder, urethral meatus
Escherichia coli is the most common Describe the following characteristics of
pathogen urine: Color
List the signs or symptoms of UTIs. (8)  Pale, straw-colored to amber-colored
 Dysuria depending on its concentration
 Fever Describe the following characteristics of
 Chills urine: Clarity
 Nausea  Appear transparent at voiding; becomes
 Vomiting and malaise more cloudy on standing in a container
 Cystitis Describe the following characteristics of
 Hematuria urine: Odor
 WBC's or bacteria in the urine  Has a characteristic odor; the more
Explain the following types of incontinence. concentrated the urine, the stronger the
Stress incontinence odor
 occurs when intrabdominal pressure Describe the following types of urine
exceeds urethral resistance specimens collected got testing
Urge incontinence  Collect during normal voiding from an
 sudden, involuntary contraction of the indwelling catheter or urinary diversion
muscles of the urinary bladder resulting in collection bag. Use a clean specimen cup.
the urge to urinate Describe the following types of urine
Ileal conduit specimens collected got testing: Clean-
 Ureters are implanted into the isolated voided or midstream
segment of ileum and used as a conduit  Use a sterile specimen cup.
for continuous drainage. The patient wears  For girl and women: After donning sterile
a stomal pouch continuously gloves, spread the labia with thumb and
Briefly describe the following urinary forefinger of the non-dominant hand.
diversions. Cleanse the area with a cotton ball or
Nephrostomy gauze, moving from front (above urethral
 A tube is placed directly into the renal orifice) to back (toward anus). Using a
pelvis to drain urine directly from one or fresh swab each time, repeat the front-to-
both of the kidneys back motion three times (begin with the

15
 center, then left side, then right side). If Abdominal radiography
agency policy indicates, rinse the area  Determines the size, shape, symmetry,
with sterile water and dry with dry cotton and location of kidneys.
ball or gauze. While continuing to hold the Intravenous pyelogram (IVP)
labia apart, have the patient initiate the  Views the collecting ducts and renal pelvis
urine tream. After the patient achieves a and outlines the ureters, bladder and
stream, pass the container into the stream urethra. A special intravenous injection
and collect 30 to 60 mL. Remove the (iodine based) that converts to a dye in
specimen container before the flow of urine is injected intravenously.
urine stops and before releasing the labia. Cystoscopy
The patient finishes voiding in a bedpan or  Direct visualization, specimen collection,
toilet. and treatment
 For boys and men: After donning sterile Computerized axial tomography (CT)
gloves , hold the penis with one hand, and  Obtains detailed images of structures
using circular motion and antiseptic swab, within a selected plane of the body. The
clean the end of the penis, moving from computer reconstructs cross-sectional
the center to the outside. In uncircumcised images and thus allows the health care
men, retract the foreskin before cleansing. provider to view pathologic conditions
If agency procedure indicates , rinse the such as tremors and obstructions.
area with sterile water and dry with cotton Ultrasonography
or gauze. After the patient has initiated  Renal ultrasonography identifies gross
the urine stream pass the specimen renal structures and structural
collection container into the stream and abnormalities of bladder of lower urinary
collect 30 to 60 mL. Remove the specimen tract. It can also be used to estimate the
container before the flow of urine stops volume of urine in the bladder.
and before releasing the penis . The List potential or actual nursing diagnoses
patient finishes voiding in a bedpan or related to urinary elimination:
toilet. o Urinary Incontinence (Functional, Stress,
Describe the following types of urine Urge)
specimens collected got testing: Sterile o Pain (Acute, Chronic)
 If the patient has an indwelling catheter, o Risk for Infection
collect a sterile specimen by using a septic o Self-Care Deficit, Toileting
technique through the pecial sampling o Impaired Skin Integrity
port (Figure 45-7, p. 1053) found on the o Impaired Urinary Elimination
side of the catheter. Clamp the tubing
o Urinary Retention
below the port, allowing fresh,
uncontaminated urine to collect in the List goals appropriate for a patient with a
tube. After the nurse wipes the port with urinary elimination problem:
o Normal Elimination
an antimicrobial swab, insert a sterile
o Patient will be able to independently use
syringe hub and withdraw at least 3 to 5
mL of urine (check agency policy). Using the toilet
sterile aseptic technique, transfer the o Decrease the number of pads by one to
urine to a sterile container. two within 8 weeks
Describe the following types of urine List measures that promote normal
specimens collected got testing: Timed micturition:
urine  Maintain elimination habits
 Time required may be 2-, 12-, or 24-hour  Maintain adequate fluid intake
collection . The timed period begins after  Promote complete bladder emptying
the patient urinates and ends with a final  Prevent infection
voiding at the end of the time period. The Intermittent Catheterizations
patient voids into a clean receptacle, and  Used to measure post void residual (PVR)
the urine is transferred to the special when a bladder scanner is not available or
collection container, which often contains as away to manage chronic urinary
special preservative . Each specimen must retention
be free of feces and toilet tissue. Missed Short- or Long-term indwelling
specimens make the whole collection Catheterizations
inaccurate. Check with agency policy and  Used to accurate monitoring of urinary
the laboratory for specific instructions. output, perioperative or postoperative
Urinalysis after urologic or GYN procedures, and
 will analyze values of pH, protein, glucose, when the bladder inadequately empties
ketones, blood, specific gravity and due to obstruction or neurological
microscopic values for RBCs, WBCs, condition.
bacteria, casts, and crystals. Perineal hygiene
Specific gravity  The nurse should perform personal
 measures concentration particles in the hygiene at least 3 times a day for a
urine. High specific gravity in the urine patient with an indwelling catheter with
reflects concentrated and low reflects soap and water.
diluted urine. Catheter care
Urine culture  Catheter care requires special care three
 performed on a sterile or clean voided times a day and after defecation.
sample of urine and can report bacterial Fluid intake
growth in 24-28 hours.

16
  Fluid intake should be 2000 to 2500 mL if for accidental pulling or tension on the
permitted. catheter. The advancement of the
Irrigations and installations catheter until flows and then inserting ¼
 To maintain the latency of indwelling inch more is not unique to the male
catheters, it may be necessary to irrigate patient.
or flush with sterile normal saline (NS). Which nursing intervention minimizes the
Blood, pus, or sediment can collect within risk for trauma and infection when applying
the tubing, resulting in the need to change an external/condom catheter?
the catheter.  Leave a gap of 3-5 inches between the tip
Suprapubic catheter of the penis and drainage tube
 A catheter is surgically placed through the  Shave the pubic area so that hair does
abdominal wall above the symphysis pubis not adhere
and into the urinary bladder.  Wash with soap and water prior to
External catheter applying the condom type catheter.
 A external catheter is suitable for  Apply tape to the condom sheath to keep
incontinent or comatose men who still it securely in place
have complete and spontaneous bladder  Wash with soap and water prior to
emptying. applying the condom type catheter.
Pelvic floor muscle training (PEMPT)  Hygiene minimizes skin irritation. There
 Improve the strength of pelvic muscles needs to be 2.5 to 5 cm (1 to 2 inches) of
and consist of repetitive contractions of space between tip of the glans penis and
muscle groups. They are effective in the end of the catheter. Excess space may
treating stress incontinence, overactive cause pooling of urine causing excessive
bladders, and mixed causes of urinary exposure to urine. Shaving the pubic area
incontinence. increases the risk for skin irritation. The
Bladder retraining condom should be secure but not tight.
 Used to reduce the voiding frequency and Application of tape is contraindicated
to increase the bladder capacity, because it could interfere with circulation
specifically for patients with the urge increasing risk for necrosis of the penis.
incontinence related to overactive What instructions should the nurse give the
bladder. NAP concerning a patient who has had an
Scheduled toileting indwelling urinary catheter removed that
 Benefits patients with functional day?
incontinence by improving voluntary  Limit oral fluid intake to avoid possible
control over urination. urinary incontinence.
Identify how the nurse would evaluate the  Expect patient complaints of suprapubic
effectiveness of the interventions used fullness and discomfort.
 A nurse would evaluate for change in the  Report the time and amount of first
patient's voiding pattern and continued voiding.
presence of urinary tract alterations.  Instruct patient to stay in bed and use a
When assessing a patient's first voided urinal or bedpan.
urine of the day, which finding should be  Report the time and amount of first
reported to the health care provider? voiding.
 Pale yellow urine  In order to adequately assess bladder
 Slightly cloudy urine function after a catheter is removed;
 Light pink urine voiding frequency and amount should be
 Dark amber urine monitored. Unless contraindicated, fluids
Light pink urine should be encouraged. To promote normal
 Light pink urine indicates the presence of micturition, patients should be placed in
blood in the urine, which is never a normal as normal a posture for voiding as
finding. First voided urine can normally be possible. Suprapubic tenderness and pain
slightly cloudy and darker in color. Pale are possible indicators of urinary retention
yellow urine indicates normal finding. and/or a UTI.
What is a critical step when inserting an A post-operative patient with a three-way
indwelling catheter into a male patient? indwelling urinary catheter and continuous
 Slowly inflate the catheter balloon with sterile bladder irrigation (CBI) complains of lower
saline. abdominal pain and distention. What should
 Secure the catheter drainage tubing to the be the nurse's initial intervention?
bed sheets  Increase the rate of the CBI
 Advance the catheter to the bifurcation of the  Assess the intake and output
drainage and balloon ports.  Decrease the rate of the CBI
 Advance the catheter until urine flows, then  Assess vital signs
insert ¼ inch more.  Assess the intake and output
 An appropriate first action would be to
Advance the catheter to the bifurcation of assess the patency of the drainage
the drainage and balloon ports. system. Urine output in the drainage bag
 Advancing the catheter to the bifurcation should be more than the volume of the
avoids inflating the catheter balloon in the irritant solution infused. If the system is
prostatic urethra causing trauma and pain. not draining urine and irritant, the irritant
Catheter balloons are never inflated with should be stopped immediately, the
saline. Securing the catheter drainage catheter may be occluded and the bladder
tubing to the bed sheets increases the risk distended.
17
An ambulatory elderly woman with What best describes measurement of post-void
dementia is incontinent of urine. She has residual (PVR)?
poor short term memory and has not been - Bladder scan the patient immediately after
seen toileting independently. What is the voiding.
best nursing intervention for this patient? - Catheterize the patient 30 minutes after
 Recommend she be evaluated for an OAB voiding.
medication. - Bladder scan the patient when they report a
 Start a scheduled toileting program. strong urge to void.
 Recommend she be evaluated for an - Catheterize the patient with a 16 Fr/10 mL
indwelling catheter. catheter
 Start a bladder retraining program - Bladder scan the patient immediately after
 Start a scheduled toileting program. voiding.
The first nursing intervention for any
patient with incontinence, who is able to A PVR or post void residual is the measurement of
toilet, is to assist them with toilet access. urine in the bladder within 15 minutes of normal
This patient is not cognitively intact so a voiding. It would not be a true measurement of
bladder retraining program is not PVR if the bladder was full, or if after 30 minutes
appropriate for her. It is not clear in this of voiding. A 16 Fr/10 mL catheter and would not
case that she has OAB and a catheter is be appropriate to use when catheterizing for PVR.
never a good solution for incontinence. What nursing intervention decreases the risk for
Which nursing assessment question would catheter associated urinary tract infection
best indicate that an incontinent man with a (CAUTI)?
history of prostate enlargement might not - Cleanse the urinary meatus 3-4 times daily with
be emptying his bladder adequately? antiseptic solution.
 Do you leak urine when you cough or - Hang the urinary drainage bag below the level
sneeze? with the bladder.
 Do you need help getting to the toilet? - Empty the urinary drainage bag daily.
 Do you dribble urine constantly? - Irrigate the urinary catheter with sterile water.
 Does it burn when you pass your urine? Hang the urinary drainage bag below the level
with the bladder
 Do you dribble urine constantly?
Incontinence characterized by constant
Evidenced based interventions shown to decrease
dribbling of urine is associated with
the risk for CAUTI include ensuring that there is a
incontinence associated with urinary
free flow of urine from the catheter to the
retention. . The other options point to
drainage bag.
stress incontinence, functional incontinence
There is no urine when a catheter is inserted into
or a UTI.
a female's urethra. What should the nurse do
Which of the following is the correct order for
next?
insertion of an indwelling catheter in a female
- Remove the catheter and start all over with a
patient?
new kit and catheter.
1. Insert and advance catheter.
- Leave the catheter there and start over with a
2. Lubricate catheter.
new catheter.
3. Inflate catheter balloon.
- Pull the catheter back and re-insert at a
4. Cleanse urethral meatus.
different angle.
5. Drape the patient with the sterile square and
- Ask the patient to bear down and insert the
fenestrated drapes.
catheter further.
6. When urine appears advance another 2.5 to 5
Leave the catheter there and start over with a
cm.
new catheter.
7. Prepare sterile field and supplies.
8. Gently pull catheter until resistance is felt.
The catheter may be in the vagina, leave the
9. Attach drainage tubing.
catheter in the vagina as landmark indicating
- 7, 5, 2, 1, 4, 6, 3, 8, 9
where not to insert, and insert another sterile
- 5, 7, 2, 4, 1, 6, 3, 8, 9
catheter. Pulling the catheter back and re-
- 5, 7, 1, 2, 4, 6, 3, 9, 8
inserting is poor technique increasing the risk for
- 5, 7, 2, 1, 4, 3, 6, 8, 9
CAUTI.
- 5, 7, 2, 4, 1, 6, 3, 8, 9
A patient is scheduled to have an intravenous
pyelogram (IVP) the next morning. Which nursing
The NAP reports to the nurse that a
measures should be implemented prior to the
patient's catheter drainage bag has been
test? (Select all that apply.)
empty for 4 hours. What is a priority
- Ask the patient about any allergies and
nursing intervention?
reactions.
- Implement the "as needed" order to irrigate the
- Instruct the patient that a full bladder is
catheter.
required for the test.
- Assess the catheter and drainage tubing for
- Instruct the patient to save all urine in a special
obvious occlusion.
container.
- Notify the health care provider immediately.
- Ensure that informed consent has been
- Assess the vital signs and intake and output
obtained.
record.
- Explain that the test includes instrumentation of
Assess the catheter and drainage tubing for
the urinary tract.
obvious occlusion.
- Ask the patient about any allergies and
The priority nursing intervention is to ensure that
reactions.
there is not an occlusion in the catheter or
- Ensure that informed consent has been
drainage tubing.
obtained.
18
An intravenous pyelogram (IVP) involves
intravenous injection of an iodine based contrast
media. Patients that have had a previous
hypersensitivity reaction to contrast media in the
past are at high risk for another reaction.
Informed consent is required. There is no need for
a full bladder such as with a pelvic ultrasound or
to save any urine for testing. There is no
instrumentation of the urinary tract such as with
a cystoscopy.
What should the nurse teach a young woman
with a history of urinary tract infections about UTI
prevention? (Select all that apply.)
- Keep the bowels regular.
- Limit water intake to 1-2 glasses a day
- Wear cotton underwear
- Cleanse the perineum from front to back.
- Practice pelvic muscle exercise (Kegel) daily.
- Keep the bowels regular.
- Wear cotton underwear
- Cleanse the perineum from front to back

All are interventions that lead to healthy bladder

habits. Adequate hydration will ensure that the
bladder is regularly flushed out and will help
prevent a UTI. Pelvic muscle exercises promote
pelvic health but not necessarily prevent UTI.
Which nursing interventions should the nurse
implement when removing an indwelling urinary
catheter in an adult patient? (Select all that
apply.)
- Attach a 3 mL syringe to the inflation port
- Allow the balloon to drain into the syringe by
gravity.
- Initiate a voiding record/bladder diary
- Pull catheter quickly
- Clamp the catheter prior to removal.
- Allow the balloon to drain into the syringe by
gravity.
- Initiate a voiding record/bladder diary

By allowing the balloon to drain by gravity the

development of creases or ridges in the balloon
may be avoided and thus minimize trauma to the
urethra during withdrawal. All patients who have
a catheter removed should have their voiding
monitored. The best way to do this is with a
voiding record or bladder diary. The size syringe
used to deflate the balloon is dictated by the size
of the balloon. In the adult patient balloon sizes
are either 10 mLs or 30 mLs. Catheters should be
pulled out slowly and smoothly. There is no
evidence to support clamping catheters prior to
removal.

19
1. If obstructed, which component of the urination physiological or
system would cause peristaltic waves? psychological condition exists.
a. Kidney
b. Ureters 5. The nurse knows that indwelling catheters are
c. Bladder placed before a cesarean because
d. Urethra a. The patient may void uncontrollably during the
ANS: B procedure.
b. A full bladder can cause the mother's heart rate to
Ureters drain urine from the kidneys into the bladder; if drop.
they become obstructed, peristaltic waves attempt to c. Spinal anesthetics can temporarily disable urethral
push the obstruction sphincters.
into the bladder. The kidney, bladder, and urethra do d. The patient will not interrupt the procedure by
not produce peristaltic waves. Obstruction of both asking to go to the bathroom.
bladder and urethra ANS: C
typically does not occur.
Spinal anesthetics may cause urinary retention due to
2. When reviewing laboratory results, the nurse should the inability to sense or carry out the need to void. The
immediately notify the health care provider about patient is more likely
which finding? to retain urine, rather than experience uncontrollable
a. Glomerular filtration rate of 20 mL/min voiding. With spinal anesthesia, the patient will not be
b. Urine output of 80 mL/hr able to ambulate during
c. pH of 6.4 the procedure. A full bladder has no impact on the
d. Protein level of 2 mg/100 mL pulse rate of the mother.
ANS: A
6. The nurse knows that urinary tract infection (UTI) is
Normal glomerular filtration rate should be around 125 the most common health care-associated infection
mL/min; a severe decrease in renal perfusion could because
indicate a a. Catheterization procedures are performed more
life-threatening problem such as shock or dehydration. frequently than indicated.
Normal urine output is 1000 to 2000 mL/day; an output b. Escherichia coli pathogens are transmitted during
of 30 mL/hr or less surgical or catheterization procedures.
for 2 or more hours would be cause for concern. The C.Perineal care is often neglected by nursing staff.
normal pH of urine is between 4.6 and 8.0. Protein up D.Bedpans and urinals are not stored properly and
to 8 mg/100 mL is transmit infection.
acceptable; however, values in excess of this could ANS: B
indicate renal disease.
E. coli is the leading pathogen causing UTIs; this
3. A patient is experiencing oliguria. Which action pathogen enters during procedures. Sterile technique
should the nurse perform first? is imperative to prevent the
a. Increase the patient's intravenous fluid rate. spread of infection. Frequent catheterizations can place
b. Encourage the patient to drink caffeinated a patient at high risk for UTI; however, infection is
beverages. caused by bacteria, not
c. Assess for bladder distention. by the procedure itself. Perineal care is important, and
d. Request an order for diuretics. buildup of bacteria can lead to infection, but this is not
ANS: C the greatest cause.
Bedpans and urinals may become bacteria ridden and
The nurse first should gather all assessment data to should be cleaned frequently. Bedpans and urinals are
determine the potential cause of oliguria. It could be not inserted into the
that the patient does not urinary tract, so they are unlikely to be the primary
have adequate intake, or it could be that the bladder cause of UTI.
sphincter is not functioning and the patient is retaining
water. Increasing fluids 7. An 86-year-old patient tells the nurse that she is
is effective if the patient does not have adequate experiencing uncontrollable leakage of urine. Which
intake, or if dehydration occurs. Caffeine can work as a nursing diagnosis should the nurse include in the
diuretic but is not helpful if patient's plan of care?
an underlying pathology is present. An order for a. Urinary retention
diuretics can be obtained if the patient was retaining b. Hesitancy
water, but this should not be c. Urgency
d. Urinary incontinence
4. A patient requests the nurse's assistance to the ANS: D
bedside commode and becomes frustrated when
unable to void in front of the nurse. The nurse Age-related changes such as loss of pelvic muscle tone
understands the patient's inability to void because: can cause involuntary loss of urine known as Urinary
a. Anxiety can make it difficult for abdominal and incontinence. Urinary
perineal muscles to relax enough retention is the inability to empty the bladder.
to void. Hesitancy occurs as difficulty initiating urination.
b. The patient does not recognize the physiological Urgency is the feeling of the need
signals that indicate a need to to void immediately.
void.
c. The patient is lonely, and calling the nurse in under 8. A patient has fallen several times in the past week
false pretenses is a way to get when attempting to get to the bathroom. The patient
attention. informs the nurse that he gets up 3 or 4 times a night
d. The patient is not drinking enough fluids to produce to urinate. Which recommendation by the nurse is
adequate urine output. most appropriate in correcting this urinary problem?
ANS: A a. Clear the path to the bathroom of all obstacles
before bed.
Attempting to void in the presence of another can b. Leave the bathroom light on to illuminate a pathway.
cause anxiety and tension in the muscles that make c. Limit fluid and caffeine intake before bed.
voiding difficult. The nurse d. Practice Kegel exercises to strengthen bladder
should give the patient privacy and adequate time if muscles.
appropriate. No evidence suggests that an underlying
20
ANS: C are often signs of
infection.
Reducing fluids, especially caffeine and alcohol, before
bedtime can reduce nocturia. Clearing a path to the 13. Which nursing diagnosis related to alternations in
restroom or illuminating urinary function in an older adult should be a nurse's
the path, or shortening the distance to the restroom, first priority?
may reduce falls but will not correct the urination a. Self-care deficit related to decreased mobility
problem. Kegel exercises are b. Risk of infection
useful if a patient is experiencing incontinence. c. Anxiety related to urinary frequency
d. Impaired self-esteem related to lack of
9. When caring for a patient with urinary retention, the independence
nurse would anticipate an order for ANS: B
a. Limited fluid intake.
b. A urinary catheter. Older adults often experience poor muscle tone, which
c. Diuretic medication. leads to an inability of the bladder to fully empty.
d. A renal angiogram. Residual urine greatly
ANS: B increases the risk of infection. Following Maslow's
hierarchy of needs, physical health risks should be
A urinary catheter would relieve urinary retention. addressed before
Reducing fluids would reduce the amount of urine emotional/cognitive risks such as anxiety and self-
produced but would not esteem. Decreased mobility can lead to self-care
alleviate the urine retention. Diuretic medication would deficit; the nurse's priority
increase urine production and may worsen the concern for this diagnosis would be infection, because
discomfort caused by urine the elderly person must rely on others for basic
retention. A renal angiogram is an inappropriate hygiene.
diagnostic test for urinary retention.
14. A patient asks about treatment for urge urinary
10. Upon palpation, the nurse notices that the bladder incontinence. The nurse's best response is to advise
is firm and distended; the patient expresses an urge to the patient to
urinate. The nurse should a. Perform pelvic floor exercises.
follow up by asking b. Drink cranberry juice.
a. "When was the last time you voided?" c. Avoid voiding frequently.
b. "Do you lose urine when you cough or sneeze?" d. Wear an adult diaper.
c. "Have you noticed any change in your urination ANS: A
patterns?"
d. "Do you have a fever or chills?" Poor muscle tone leads to an inability to control urine
ANS: A flow. The nurse should recommend pelvic muscle
strengthening exercises
To obtain an accurate assessment, the nurse should such as Kegel exercises; this solution best addresses
first determine the source of the discomfort. Urinary the patient's problem. Drinking cranberry juice is a
retention causes the bladder preventative measure for
to be firm and distended. Further assessment to urinary tract infection. The nurse should not encourage
determine the pathology of the condition can be the patient to reduce voiding; residual urine in the
performed later. Questions bladder increases the risk
concerning fever and chills, changing urination of infection. Wearing an adult diaper could be
patterns, and losing urine during coughing or sneezing considered if attempts to correct the root of the
focus on specific problem fail.
pathological conditions. DIF: Analyze
REF: 1056
11. Which of the following is the primary function of the OBJ: Identify nursing diagnoses appropriate for patients
kidney? with alterations in urinary elimination.
a. Metabolizing and excreting medications
b. Maintaining fluid and electrolyte balance 15. The nurse suspects that a urinary tract infection
c. Storing and excreting urine has progressed to cystitis when the patient complains
d. Filtering blood cells and proteins of which symptom?
ANS: B a. Dysuria
b. Flank pain
The main purpose of the kidney is to maintain fluid and c. Frequency
electrolyte balance by filtering waste products and d. Fever and chills
regulating pressures. The ANS: C
kidneys filter the byproducts of medication
metabolism. The bladder stores and excretes urine. Cystitis is inflammation of the bladder; associated
The kidneys help to maintain red symptoms include hematuria and urgency/frequency.
blood cell volume by producing erythropoietin. Dysuria is a common symptom of a lower urinary tract
infection. Flank pain, fever, and chills are all signs of
12. While receiving a shift report on a patient, the pyelonephritis.
nurse is informed that the patient has urinary
incontinence. Upon assessment, the nurse would 16. Which assessment question should the nurse ask if
expect to find stress incontinence is suspected?
a. An indwelling Foley catheter. a. "Does your bladder feel distended?"
b. Reddened irritated skin on the buttocks. b. "Do you empty your bladder completely when you
c. Tiny blood clots in the patient's urine. void?"
d. Foul-smelling discharge indicative of a UTI. c. "Do you experience urine leakage when you cough
ANS: B or sneeze?"
d. "Do your symptoms increase with consumption of
Urinary incontinence is uncontrolled urinary alcohol or caffeine?"
elimination; if the urine has prolonged contact with the ANS: C
skin, skin breakdown can
occur. An indwelling Foley catheter is a solution for Stress incontinence can be related to intra-abdominal
urine retention. Blood clots and foul-smelling discharge pressure causing urine leakage, as would happen
during coughing or sneezing.
21
Asking the patient about the fullness of his bladder medications. Painful urination indicates an alteration in
would rule out retention and overflow. An inability to urinary elimination.
void completely can refer
to urge incontinence. Physiological causes and 21. What signs and symptoms would the nurse expect
medications can effect elimination, but this is not to observe in a patient with excessive white blood cells
related to stress incontinence. present in the urine?
a. Fever and chills
17. When establishing a diagnosis of altered urinary b. Difficulty holding in urine
elimination, the nurse should first c. Increased blood pressure
a. Establish normal voiding patterns for the patient. d. Abnormal blood sugar
b. Encourage the patient to flush kidneys by drinking ANS: A
excessive fluids.
c. Monitor patients' voiding attempts by assisting them The presence of white blood cells in urine indicates a
with every attempt. urinary tract infection. Difficulty with urinary
d. Discuss causes and solutions to problems related to elimination indicates blockage
micturition. or renal damage. Increased blood pressure is
ANS: D associated with renal disease or damage and some
medications. Abnormal blood
The nurse should assess first to determine cause, then sugars would be seen in someone with ketones in the
should discuss and create goals with the patient, so urine, as this finding indicates diabetes.
nurse and patient can
work in tandem to normalize voiding. The nurse should 22. The nurse would anticipate an order for which
incorporate the patient's input into creating a plan of diagnostic test for a patient who has severe flank pain
care for the patient. and calcium phosphate crystals
Drinking excessive fluid will not help and may worsen
alterations in urinary elimination. The nurse does not revealed on urinalysis?
need to monitor every a. Renal ultrasound
void attempt by the patient; instead the nurse should b. Bladder scan
provide patient education. The nurse asks the patient c. KUB x-ray
about normal voiding d. Intravenous pyelogram
patterns, but establishing voiding patterns is a later ANS: D
intervention.
Flank pain and calcium phosphate crystals are
18. To obtain a clean-voided urine specimen for a associated with renal calculi. An intravenous
female patient, the nurse should teach the patient to pyelogram allows the provider to
a. Cleanse the urethral meatus from the area of most observe pathological problems such as obstruction of
contamination to least. the ureter. A renal ultrasound is performed to identify
b. Initiate the first part of the urine stream directly into gross structures. A
the collection cup. bladder scan measures the amount of urine in the
c. Hold the labia apart while voiding into the specimen bladder. A KUB x-ray shows size, shape, symmetry, and
cup. location of the kidneys.
d. Drink fluids 5 minutes before collecting the urine
specimen. 23. A nurse is caring for a patient who just underwent
ANS: C intravenous pyelography that revealed a renal calculus
obstructing the left ureter.
The patient should hold the labia apart to reduce
bacterial levels in the specimen. The urethral meatus What is the nurse's first priority in caring for this
should be cleansed from the patient?
area of least contamination to greatest contamination a. Turn the patient on the right side to alleviate
(or front-to-back). The initial steam flushes out pressure on the left kidney.
microorganisms in the urethra b. Encourage the patient to increase fluid intake to
and prevents bacterial transmission in the specimen. flush the obstruction.
Drink fluids 30 to 60 minutes before giving a specimen. c. Administer narcotic medications to alleviate pain.
19. When viewing a urine specimen under a d. Monitor the patient for fever, rash, and difficulty
microscope, what would the nurse expect to see in a breathing.
patient with a urinary tract infection? ANS: D
a. Bacteria
b. Casts Intravenous pyelography is performed by administering
c. Crystals iodine-based dye to view functionality of the urinary
d. Protein system. Many
ANS: A individuals are allergic to shellfish; therefore, the first
nursing priority is to assess the patient for an allergic
Bacteria indicate a urinary tract infection. Crystals reaction that could be
would be seen with renal stone formation. Casts life threatening. The nurse should then encourage the
indicate renal alterations. patient to drink fluids to flush dye resulting from the
Protein is not visible under a microscope and indicates procedure. Narcotics can
renal disease. be administered but are not the first priority. Turning
the patient on the side will not affect patient safety.
20. The nurse would expect the urine of a patient with
uncontrolled diabetes mellitus to be 24. Which statement by the patient about an upcoming
a. Cloudy. computed tomography (CT) scan indicates a need for
b. Discolored. further teaching?
c. Sweet smelling. a. "I'm allergic to shrimp, so I should monitor myself for
d. Painful. an allergic reaction."
ANS: C b. "I will complete my bowel prep program the night
before the scan."
Incomplete fat metabolism and buildup of ketones give c. "I will be anesthetized so that I lie perfectly still
urine a sweet or fruity odor. Cloudy urine may indicate during the procedure."
infection or renal d. "I will ask the technician to play music to ease my
failure. Discolored urine may result from various anxiety."

22
ANS: C 28. A nurse is caring for an 8-year-old patient who is
embarrassed about urinating in his bed at night. Which
Patients are not put under anesthesia for a CT scan; intervention should the
instead the nurse should educate patients about the
need to lie perfectly still and nurse suggest to reduce the frequency of this
about possible methods of overcoming feelings of occurrence?
claustrophobia. The other options are correct. Patients a. "Drink your nightly glass of milk earlier in the
need to be assessed for an evening."
allergy to shellfish if receiving contrast for the CT. b. "Set your alarm clock to wake you every 2 hours, so
Bowel cleansing is often performed before CT. you can get up to void."
Listening to music will help the c. "Line your bedding with plastic sheets to protect
patient relax and remain still during the examination. your mattress."
d. "Empty your bladder completely before going to
25. The nurse anticipates preparing a patient who is bed."
allergic to shellfish for an arteriogram by ANS: A
a. Obtaining baseline vital signs after the start of the
procedure. Nightly incontinence and nocturia are often resolved by
b. Monitoring the extremity for neurocirculatory limiting fluid intake 2 hours before bedtime. Setting the
function. alarm clock to
c. Keeping the patient on bed rest for the prescribed wake does not correct the physiological problem, nor
time. does lining the bedding with plastic sheets. Emptying
d. Administering an antihistamine medication to the the bladder may help
patient. with early nighttime urination, but will not affect urine
ANS: D produced throughout the night from late-night fluid
intake.
Before the procedure is begun, the nurse should assess
the patient for food and other allergies and should 29. Many individuals have difficulty voiding in a bedpan
administer an or urinal while lying in bed because they
antihistamine, because a contrast iodine-based dye is a. Are embarrassed that they will urinate on the
used for the procedure. Baseline vitals should be bedding.
obtained before the start of b. Would feel more comfortable assuming a normal
the procedure and frequently thereafter. The voiding position.
procedure site is monitored and the patient kept on c. Feel they are losing their independence by asking
bed rest after the procedure is the nursing staff to help.
complete. d. Are worried about acquiring a urinary tract infection.
ANS: B
26. A nurse anticipates urodynamic testing for a
patient with which symptom? Assuming a normal voiding position helps patients
a. Involuntary urine leakage relax and be able to void; lying in bed is not the typical
b. Severe flank pain position in which people
c. Presence of blood in urine void. Men usually are most comfortable when standing;
d. Dysuria women are more comfortable when sitting and
ANS: A squatting. Embarrassment at
using the bedpan and worrying about a urinary tract
Urodynamic testing evaluates the muscle function of infection are not related to the lying-in-bed position.
the bladder and is used to look for the cause of urinary Fear of loss of
incontinence. Severe independence is not related to use of the bedpan or
flank pain indicates renal calculi; CT scan or IVP would urinal.
be a more efficient diagnostic test. Blood indicates
trauma to the urethral 30. The nurse would anticipate inserting a Coudé
or bladder mucosa. Pain on elimination may warrant catheter for which patient?
cultures to check for infection. a. An 8-year-old male undergoing anesthesia for a
tonsillectomy
27. A patient is having difficulty voiding in a bedpan b. A 24-year-old female who is going into labor
but states that she feels her bladder is full. To c. A 56-year-old male admitted for bladder irrigation
stimulation micturition, which d. An 86-year-old female admitted for a urinary tract
infection.
nursing intervention should the nurse try first? ANS: C
a. Exiting the room and informing the patient that the
nurse will return in 30 minutes A Coudé catheter has a curved tip that is used for
to check on the patient's progress patients with enlarged prostates. This would be
b. Utilizing the power of suggestion by turning on the indicated for a middle-aged male
faucet and letting the water who needs bladder irrigation. Coudé catheters are not
run indicated for children or women.
c. Obtaining an order for a Foley catheter
d. Administering diuretic medication 31. The nurse knows that which indwelling catheter
ANS: B procedure places the patient at greatest risk for
acquiring a urinary tract infection?
To stimulate micturition, the nurse should attempt a. Emptying the drainage bag every 8 hours or when
noninvasive procedures first. Running warm water or half full
stroking the inner aspect of b. Kinking the catheter tubing to obtain a urine
the upper thigh promotes sensory perception that specimen
leads to urination. A patient should not be left alone on c. Placing the drainage bag on the side rail of the
a bedpan for 30 minutes patient's bed
because this could cause skin breakdown. d. Failing to secure the catheter tubing to the patient's
Catheterization places the patient at increased risk of thigh
infection and should not be the first ANS: C
intervention attempted. Diuretics are useful if the
patient is not producing urine, but they do not Placing the drainage bag on the side rail of the bed
stimulate micturition. could allow the bag to be raised above the level of the
bladder and urine to flow
23
back into the bladder. The urine in the drainage bag is REF: 1048
a medium for bacteria; allowing it to reenter the OBJ: Discuss nursing measures
bladder can cause infection.
The drainage bag should be emptied and output 35. An 86-year-old patient asks the nurse what lifestyle
recorded every 8 hours or when needed. Urine changes will reduce the chance of a urinary tract
specimens are obtained by infection. Which response is
temporarily kinking the tubing; a prolonged kink could accurate?
lead to bladder distention. Failure to secure the a. Urinary tract infections are unavoidable in the
catheter to the patient's thigh elderly because of a weakened
places the patient at risk for tissue injury from catheter immune system.
dislodgment. b. Decreasing fluid intake will decrease the amount of
urine with bacteria produced.
32. A nurse notifies the provider immediately if a c. Making sure to cleanse the perineal area from back
patient with an indwelling catheter to front after voiding will
a. Complains of discomfort upon insertion of the reduce the chance of infection.
catheter. d. Increasing consumption of acidic foods such as
b. Places the drainage bag higher than the waist while cranberry juice will reduce the
ambulating. chance of infection.
c. Has not collected any urine in the drainage bag for 2 ANS: D
hours.
d. Is incontinent of stool and contaminates the external Cranberry juice and other acidic foods decrease
portion of the catheter. adherence of bacteria to the bladder wall. Urinary tract
infections are avoidable in
ANS: C the elderly population with proper knowledge and
ANS: C hygiene. Perineal skin should be cleansed from front to
back to avoid spreading
If the patient has not produced urine in 2 hours, the fecal matter to the urethra. Increasing fluids will help to
physician needs to be notified immediately because flush bacteria, thus preventing them from residing in
this could indicate renal the bladder for
failure. Discomfort upon catheter insertion is prolonged periods of time.
unpleasant but unavoidable. The nurse is responsible
for maintaining the integrity of 36. A nurse is providing education to a patient being
the catheter by ensuring that the drainage bag is treated for a urinary tract infection. Which of the
below the patient's bladder. Stool left on the catheter following statements by the
can cause infection and patient indicates an understanding?
should be removed as soon as it is noticed. The nurse a. "Since I'm taking medication, I do not need to worry
should ensure that frequent perineal care is being about proper hygiene."
provided. b. "I should drink 15 to 20 glasses of fluid a day to help
flush the bacteria out."
33. The nurse would question an order to insert a c. "My medication may discolor my urine; this should
urinary catheter on which patient? resolve once the medication is
a. A 26-year-old patient with a recent spinal cord injury stopped."
at T2 d. "I should not have sexual intercourse until the
b. A 30-year-old patient requiring drug screening for infection has resolved."
employment ANS: C
c. A 40-year-old patient undergoing bladder repair
surgery Some anti-infective medications turn urine colors; this
d. An 86-year-old patient requiring monitoring of is normal and will dissipate as the medication leaves
urinary output for renal failure the system. Even if the
ANS: B patient is on medication, hygiene is important to
prevent spread or reinfection. Fluid intake should be
Urinary catheterization places the patient at increased increased to help flush out
risk for infection and should be performed only when bacteria; however, 15 to 20 glasses is too much.
necessary. Urine can be Sexual intercourse is allowed with a urinary tract
obtained via clean-catch technique for a drug infection, as long as good hygiene
screening or urinalysis. Spinal cord injury, surgery, and and safe practices are used.
renal failure with critical intake and output monitoring
are all appropriate reasons for catheterization. 37. To reduce patient discomfort during closed
catheter irrigation, the nurse should
34. When caring for a hospitalized patient with a a. Use room temperature irrigation solution.
urinary catheter, which nursing action best prevents b. Administer the solution as quickly as possible.
the patient from acquiring an infection? c. Allow the solution to sit in the bladder for at least 1
a. Inserting the catheter using strict clean technique hour.
b. Performing hand hygiene before and after providing d. Raise the bag of irrigation solution at least 12 inches
perineal care above the bladder.
c. Fully inflating the catheter's balloon according to the ANS: A
manufacturer's
recommendation Using cold solutions, instilling solutions too quickly, and
d. Disconnecting and replacing the catheter drainage prolonging filling of the bladder can cause discomfort
bag once per shift and cramping. To
ANS: B reduce this, ensure that the solution is at room
temperature, lower the solution bag so it instills slowly,
Hand hygiene helps prevent infection in patients with a and drain the bladder fully
urinary catheter. A catheter should be inserted in the after an ordered amount of time.
hospital setting using
sterile technique. Inflating the balloon fully prevents 38. Which observation by the nurse best indicates that
dislodgement and trauma, not infection. Disconnecting bladder irrigation for urinary retention has been
the drainage bag from effective?
the catheter creates a break in the system and an open a. Recording an output that is larger than the amount
portal of entry and increases risk of infection. instilled
DIF: Apply b. Presence of blood clots or sediment in the drainage
24
bag d. Bladder infection
c. Reduction in discomfort from bladder distention e. Presence of renal calculi
d. Visualizing clear urinary catheter tubing ANS: A, B, D
ANS: A
42. Catheter irrigation is used to flush and remove
Recording an output that is greater than what was blockage that may be impeding the catheter from
irrigated into the bladder shows progress that the properly draining the bladder.
bladder is draining urine. The Irrigation is used to remove blood clots in the bladder
other observations do not objectively measure the following surgery. For patients with bladder infection,
increase in urine output. an antibiotic irrigation
is often ordered. A ruptured catheter balloon will
39. The nurse anticipates urinary diversion from the involve extensive follow-up and possible surgery to
kidneys to a site other than the bladder for which remove the particles. Renal
patient? calculi obstruct the ureters and therefore the flow of
a. A 12-year-old female with severe abdominal trauma urine before it reaches the bladder.
b. A 24-year-old male with severe genital warts around 4. Which of the following symptoms are most closely
the urethra associated with uremic syndrome? (Select all that
c. A 50-year-old male with recent prostatectomy apply.)
d. A 75-year-old female with end-stage renal disease a. Fever
ANS: A b. Nausea and vomiting
c. Headache
Urinary diversion would be needed in a patient with d. Altered mental status
abdominal trauma who might have injury to the urinary e. Dysuria
system. Genital warts ANS: B, C, D
are not needed for urinary diversion. Patients with a
prostatectomy may require intermittent catheterization 43. Uremic syndrome is associated with end-stage
after the procedure. renal disease. Signs and symptoms include headache,
End-stage renal disease would not be affected by altered mental status, coma,
rerouting the flow of urine. seizures, nausea, vomiting, and pericarditis.
5. The nurse understands that peritoneal dialysis and
40. Which nursing actions are acceptable when hemodialysis use which processes to clean the
collecting a urine specimen? (Select all that apply.) patient's blood? (Select all that
a. Growing urine cultures for up to 12 hours apply.)
b. Labeling all specimens with date, time, and initials a. Gravity
c. Wearing gown, gloves, and mask for all specimen b. Osmosis
handling c. Diffusion
d. Allowing the patient adequate time and privacy to d. Filtration
void ANS: B, C
e. Squeezing urine from diapers into a urine specimen
cup 44. Osmosis and diffusion are the two processes used
f. Transporting specimens to the laboratory in a timely to clean the patient's blood in both types of dialysis. In
fashion peritoneal dialysis,
g. Placing a plastic bag over the child's urethra to catch osmosis and dialysis occur across the semi-permeable
urine peritoneal membrane. In hemodialysis, osmosis and
ANS: B, D, F, G dialysis occur through
the filter membrane on the artificial kidney. In
All specimens should be labeled appropriately and peritoneal dialysis, the dialysate flows by gravity out of
processed in a timely fashion. Allow patients time and the abdomen.Gravity has no
privacy to void. Children effect on cleansing of the blood. Filtration is the
may have difficulty voiding; attaching a plastic bag process that occurs in the glomerulus as blood flows
gives the child more time and freedom to void. Urine through the kidney.
cultures can take up to 48
hours to develop. Gown, gloves, and mask are not
necessary for specimen handling unless otherwise
indicated. Urine should not be
squeezed from diapers.
2. The nurse properly obtains a 24-hour urine specimen
collection by (Select all that apply.)
a. Asking the patient to void and to discard the first
sample.
b. Keeping the urine collection container on ice.
c. Withholding all patient medications for the day.
d. Asking the patient to notify the staff before and after
every void.
ANS: A, B

41. When obtaining a 24-hour urine specimen, it is

important to keep the urine in cool condition. The
patient should be asked to void
and to discard the urine before the procedure begins.
Medications do not need to be held unless indicated by
the provider. If
properly educated about the collection procedure, the
patient can maintain autonomy and perform the
procedure alone, taking care
to maintain the integrity of the solution.
3. Which of the following are indications for irrigating a
urinary catheter? (Select all that apply.)
a. Sediment occluding within the tubing
b. Blood clots in the bladder following surgery
c. Rupture of the catheter balloon
25