Chapter 13

Elimination
 Learning Objectives
At the end of this chapter, students will be able to:
• Define catheterization.
• Explain purpose of catheterization.
• Identify different types of catheters.
• Describe indication of catheterization.
• Demonstrate sterility technique through out the catheterization.
• Intervene the procedure for those in need of it with
understanding of both male and female catheterization.
• Define enema.
• List purposes of, enema
• Mention types of enema.
• Provide enema according to its purpose and need.
• Explain mechanism of action of fluids used for enema.
 ELIMINATION

Elimination patterns are essential to maintain health.

The urinary and gastrointestinal systems together
provide for the elimination of body wastes.
The urinary system filters and excretes urine from the
body, thereby maintaining fluid, electrolyte, and acid-
base balance.
 Normal bowel function provides for the regular
elimination of solid wastes.
 During periods of stress and illness, clients experience
alterations in elimination patterns.
 Urinary Catheterization
• Definition of catheterization: Is the
introduction of a tube (catheter) through the
urethra into the urinary bladder.
• Catheter: is a tube with a hole at the tip
• Is performed only when absolutely necessary
for fear of infection and trauma
• Note. Strictly a sterile procedure, i.e. the nurse
should always follow aseptic technique.
• Occasionally, an indwelling urethral or
suprapubic catheter may be used to provide
continuous drainage for reflex incontinence.
• An indwelling catheter may be inserted for an
acute episode of urinary retention or when
other strategies to manage retention are
ineffective. A catheter is chosen that
minimizes urethral irritation and maximizes
drainage from the bladder.
B. Three-Way Foley Catheter with Balloon
Inflated;
 Types of Catheter
• 1. Straight (plain or Robinson)
• 2. Retention (Foleys, indwelling)
• 1. Selecting an appropriate catheter:
• • May be made of
• ⇐ Plastic – for 1 week
• ⇐ Latex – 2-3 (rubber)
• ⇐ Silicon – for 2-3 month
• ⇐ Pelyvinylchloride (PVC) – 4-6 month
Select the type of material in accordance with the estimated length
of the catheterization period:
2. Determine appropriate catheter size
- are determined by diameter of lumen
- graded on French scale or number.
• Catheter size depends on the size of the urethral canal
• ⇐ # 8-10 Fr – children
• ⇐ # 14-16 Fr – female adults
• ⇐ # 18 Fr – adult male
3. Determine appropriate catheter length by the
clients gender
• For adult male – 40 cm catheter
• For adult females – 22 cm catheter
4. Select appropriate balloon size
• 5 ml – for adults
• 3 ml – for children
 Plain catheter
• Purpose
• To relieve discomfort due to bladder distention
• To assess the residual urine
• To obtain a urine specimen
• To empty the bladder prior to surgery
 Equipment

I. Sterile •Specimen bottle

• Kidney dish •Gloves
•Galipot II. Clean
•Gauze •Waste receiver
•Towel •Rubber sheet
•Solution •Flash light
•Lubricant •Measuring jug
•Catheter •Screen
Syringe
•Water
 Procedure
• Prepare the client and equipment for
perennial wash
• Position the patient – dorsal recumbent
(pillowscan be used to elevate the buttocks in
females).
• Drape the patient.
• Wash the perennial area with warm water and
soap
• Rinse and dry the area
• Prepare the equipment
• Create a sterile field
• Drop the client with a sterile drape
• Clean the area with antiseptic solution.
• Lubricate the insertion tip of the catheter (5-7
cm in)
• Expose the urinary meatus adequately by
retracting the tissue or the labia minora in an
upward direction – female
• Retract the fore skin of uncircumcised mal.
• Grasp the penis firmly behind the glans and
hold straighten the down ward curvature of
vertical it go to the body – male hole the
catheter 5 cm from the insertion tip
• Insert the catheter into the urethral orifice
• Insert 5 cm in females and 20 cm in males or until
urine comes
• Collect the urine – for specimen (about 30 ml)
• Pinch previous leakage
• Empty or drain the bladder and remove the
catheter
• For adults experiencing urinary retention an order
is needed on the amount to urine to be expelled
 Note
• If resistance is encountered during insertion,
do not force it – forceful pressure can cause
trauma.
• Ask the client to take deep breaths - relaxes
the external sphincter (slight resistance is
normal)
 Dorsal Recumbent

• Female - for a better view of the urinary meatus

and reduce
• the risk of catheter contaminate.
• Male- allows greater relaxation of the abdominal
and perennial
• muscles and permits easier insertion of the tube.
• Straight Catheter: is a single lumen tube with a
small eye or
• opening about (1.25 cm) from the insertion tip
 Indwelling catheter (Female & Male)
• Indwelling (Foley) Contains a second, smaller tube
through out its length on the inside
– this tube is connected to a balloon near the insertion tip.
• Purpose
• To manage incontinence
• To provide for intermittent or continuous bladder
drainage and irrigation
• To prevent urine from contacting an incision after
perineal surgery (prevent infection)
• To measure urine out put needs to be monitored hourly
 Procedure
• Explain the procedure to the patient
• Prepare the equipment like:
 Retention catheter
 Syringe
 Sterile water
 Tape
 Urine collection bag and tubing
• After catheter insertion, the balloon is inflated to hold the
catheter in place with in the bladder.
• ™ The out side end of the catheter is bifurcated i.e., it has two
openings, one to drain the urine, the other to inflate the
balloon.
• ™ The balloons are sized by the volume of fluid
or air used to inflate them 5 ml – 30 ml (15
commonly) indicated with the catheter size
18 Fr – 5 ml.
• Test the catheter balloon
• Follow steps as insertion straight catheter
• Insert the catheter an additional 2.5 – 5 cm (1-2
in) beyond the point at which urine began to
flow (the balloon of the catheter is located
behind the opening at the insertion tip) – this
ensures that the balloon is inflated inside the
bladder and not in the urethra (cause trauma)
• Inflate the balloon with the pre filled syringe
• Apply slight tension on the catheter until you
feel resistance: resistance indicates that the
catheter balloon is inflated appropriately and
that the catheter is well anchored in the
bladder
• Release the resistance
• Tape the catheter with tape to the inside of a
females thigh or to the thigh or a body of a
male client
⇐ Restricts the movement of the catheter and
irritation in the urethra when the client moves
⇐ When there is increased risk of penile scrotal
excoriation
• Establish effective drainage
• The bag should be off the floor – the emptying
spout does not become grossly contaminated
• Document pertinent data
Removal
• Withdraw the solution or air from the balloon
using a syringe
•And remove gently
 Condom Catheter
• The condom catheter is a device that
resembles a condom with a large-caliber
connector at its distal end. This is connected
to a drainage bag via a leg bag or bedside
container.
 Applying a Condom Catheter

• Equipment
• Bedpan (regular or fracture)
• Toilet paper
• Disposable gloves
• Washcloth and towel
• Condom Catheter
• Charting materials
 Procedure
1. Wash hands and apply gloves. Select an appropriate condom
catheter.
3. Cleanse the penile shaft. And Inspect the penile shaft for
excessive hair.
4. Stretch the shaft of the penis and unroll the condom to the base
of the penis .
5. Attach the condom to the drainage apparatus, either a leg bag or
bedside drainage bag.
6. Remove gloves and wash hands.
7. Remove and reapply the condom catheter every 24 to 48 hours,
or when leakage occurs.
8. Chart the procedure
 Bladder irrigation
Equipment
Three-way indwelling catheter
Irrigation solution
IV pole
Large drainage bag
Gloves
Wipes
 Procedure
1. Explain procedure and provide for privacy.
2. Obtain irrigation solution from pharmacy as
prescribed by the physician.
3. Hang solution (1–3 L) from IV pole
(depending on anticipated rate of irrigation)
using one-, two-, or three-port irrigation
tubing.
• 4. Connect the irrigation
infusion tubing to the
third irrigation port of
the three-way catheter;
refer to the product for
instructions and
identification of the
irrigation port.
5. Consult the physician concerning the rate of
irrigation; never slow the irrigation rate
because “pink urine” has been observed
unless directed by the physician or urologic
nurse specialist.
6. Regularly check the drainage container;
empty the bag when filled two-thirds or more.
 Cystostomy care
• Sometimes an incision is made into the
bladder (a suprapubic cystostomy) to provide
drainage.
• The cystostomy tube may be removed before
or after the urethral catheter is removed.
• Some urinary incontinence may occur after
catheter removal, and the patient is informed
that this is likely to subside in time.
• If a cystostomy catheter
is in place, it is taped to
the abdomen.
• The nurse explains the
purpose of the catheter
to the patient and
assures him that the
urge to void results from
the presence of the
catheter and from
bladder spasms.
 Administer Enemas
• Enema administration is a procedure used to introduce
fluid into the lower bowel. The purpose of an enema is
to cleanse the lower bowel, to assist in the evacuation
of stool or flatus, or to instill medication and for
diagnostic, barium enema.
• Enemas can be cleansing or retention depending on
their purpose. Large-volume enemas, which typically
contain500 to 1000 ml fluid, are administered to
cleanse the bowel. Small-volume enemas are used for
the purpose of evacuating stool or instilling medications
in the lower bowel.
• These are usually found as prepackaged
solutions, which contain 150 to 240 ml fluid.
Caution should be used when administering
large volume enemas, because fluid and
electrolyte imbalance can occur. This is related
to the volume, frequency, and type of solution
used.
 Administering cleansing Enema

• Purpose:- For constipation, cleansing enema

stimulates peristalsis and remove faces
• To prepare the patient for operation; mostly
for abdominal and pelvic operation
• For diagnostic test; before certain x-ray eg.
Barium enema
• For incontinent patient to keep the colon
empty
 Type of liquid used

• Tape water; usually prepared on large quantity

500-1500cc
• Soap solution; ca be made by dissolving small
amount of bland white soap in water. usually
prepared in large quantity 500 - 1000cc
depending on the age and condition of the
patient. The purpose of soap in water is to aid
in stimulating peristalsis by chemical irritation
to mucous membrane
• NB: too much soap can produce sever
irritation of mucus membrane of the colon
• Normal saline ; is a salt solution that is made
up by mixing one teaspoon of salt in a liter of
water.
• Epson salt ; 15gm to 120gm in 1000cc of water
 Equipment
• Enema bag
• Water-soluble lubricant
• Catheter checked for damage& rectal tip
• Clean gloves
• Rectal catheter
• Bedpan
• Towel and washcloth
• Charting material
 Procedure
1. Introduce yourself and explain procedure.
2. Prepare the solution, assure temperature
within range of 99° to 102°F by using a
thermometer or placing a few drops on your
wrist.
3. Wash hands and don
gloves.
4. Assist patient to left
side-lying position, with
right knee bent.
5. Hang bag of enema
solution 12 to 18 inches
above anus.
6. Lubricate 4 to 5 inches of catheter tip.
7. Place bedpan, commode, robe and slippers within easy reach.
8. Separate buttocks, insert catheter tip into anal opening, slowly
advance catheter
approximately 4 inches.
9. Slowly infuse solution via gravity flow; bag height may be
increased but not to exceed 18
inches above anal opening.
10. If client complains of increased pain or cramping, or if fluid is
not being retained, stop
procedure, wait a few minutes, then restart.
11. Clamp tubing when fluid finishes infusing;
remove catheter tip.
12. Assist client to bedpan, commode, or toilet.
13. Discard equipment in proper place. If equipment
is reusable, properly clean and store it.
14. Remove gloves and wash hands.
15. Instruct client to call for assistance when
finished eliminating, or if untoward feeling
occurs, such as lightheadedness or dizziness.
 Administering Retention Enema
• Purpose: - To supply the body with fluid
• To provide medication such as sedative
• To soften Impacted fecal matter
• Equipment
• Enema—small and mini-enemas come
• Lubricant & Disposable gloves
• Bedpan, commode, toilet
• Washcloth and towel
• Charting materials
• Bed protectors
 Procedure
1. Introduce yourself, explain procedure, close
door or curtain.
2. Place commode next to bed; have robe and
slippers available.
3. Wash hands and don gloves.
4. Lower head of bed to flat position.
5. Assist client to roll to left side-lying position
with right knee slightly bent.
6. Place bedpan slightly under buttocks.
7. Remove catheter tip guard; gently squeeze bottle until fluid drips
(for mini-enemas tip needs
to be punctured with needle or pin).
8. Lubricate catheter tip.
9. Separate buttocks and insert enema tip into anal opening; gently
squeeze contents into rectum.
10. Remove tip and assist to bedpan, commode, or toilet. Ask client
to retain fluid for as long as
possible, at least 30 minutes.
11. Dispose of contaminated material in proper receptacles.
12. Remove gloves and wash hands.
13. Assist client with cleaning if needed.
14. Chart the procedure
NB: - Most medicated retention enema must be preceded by
cleansing enema and patient
should rest for ½ hours before retention enema
A small catheter is used instead of rectal tube
If necessary, elevate foot of bed to help patient retain enema
Kind of solution used to supply body with fluid are plain water,
normal saline, glucose 5-15%, soda bicarbonate 2-5%
Olive oil 100- 200cc to be retained for 6- 8 hours is given for several
constipation. This should be followed by cleansing enema.
 Rectal wash out
• (SIPHONING AN ENEMA) (Colon irrigation or colonic flush)
• Also called enterolysis .It is the process of introducing large
amount of fluid into large bowel for flushing purpose and allow
return or wash out fluid
• PURPOSE
• To prepare the patient for x-ray exam and sigmoidoscopy
• To prepare the patient for rectum and color operation
• SOLUTION USED
• Normal saline
• Tap water
• Soda-bi-carbonate solution (to remove excess mucus) and other
 Amount of solution
• Five to six liters or until the wash out rectum fluid
becomes clear
• PROCEDURE
• Insert the tube like the cleansing enema
• The client lies on the bed with hips close to the side
of the bed.
• Open clamp& allow to run about 1,000 cc of fluid in
the bowel, then siphon back into bucket
• Carry on the procedure until the fluid return is clear
• NOTE:
• The procedure should not take > 2 hrs. Should
be finished 1 hr before exam or x-ray – to give
time for the large intestine to absorb the rest
of the fluid. Give cleansing enema ½ hr before
the rectal wash out. Allow the fluid to pass
slowly
• INSERTION OF FLATUS TUBE (PASSING A
FLATUS TUBE)
• PURPOSE
• To decrease flatulence (severe abdominal
distention), Before giving a retention enema
• PROCEDURE 1) Place the patient in left lateral
position, Lubricate the tube about 15 cm
• 2) Separate the rectum and insert 12-15 cm
in to the rectum and tape it.
• The end of the tube should reach the (tap H 2O)
solution in the bowel. The amount of air passed can be
seen bubbling through the solution.
• Leave the rectal tube in place for a period or no longer
than 20 – can affect the ability to voluntarily control
the sphincter if placement is prolong
 Passing Flatus tube
• Purpose
• For relief of abdominal distention due to abdominal gas
• Equipment: - Flatus tube, lubricant& glove
• Glass of plastic connector
• Tubbing about one meter
• Large bowel& basin for used mop
• Rubber and cotton draw sheet
• Container of gauze
• Receiver for used tube
 Procedure
• explain the procedure to the patient
• Wash your hands
• Position the patient (same as enema)
• Lubricate and insert the rectal tube 6-8cm into the rectum.
• Taped in place and put the free end of tube in large bowel of
water placed neer the patients buttock. A rectal tube is usually
left in place for ½ an hour
• Remove the tube and give necessary assistance for patient
• The approximate amount of flatus that was expelled is noted
• Record the observation
• Comfort the patient, care of equipment and wash your hands
 Colostomy irrigation
• Defn. : A colostomy is an operation in which an artificial
opening is made in to the colon
• It is done to permit a escape of faces when there is an
obstruction of the large bowel or known lesion such as cancer,
that will eventually cause an obstruction
• It also may be done to permit the healing of the bowel distal to
it
• It may be done as palliative measure in the treatment of an
obstruction cased by an inoperable growth of the colon r if the
rectum is removed to treat cancer
• It may be done to provide permanent means of bowel
evacuation
 Purpose of colostomy irrigation
• To encourage bowel motion in recently
established colostomy and to insure that the
opening is patent
• To relieve constipation in patient who have
difficulty in managing their colostomy
• To teach the patient how to establish regularity of
evacuation through the colostomy
• To reduce distention before closure of colostomy
 Equipment
• Irrigation can, Clamp glass connection & Rectal
catheter
• Solution as ordered usually normal saline about
500cc at a temperature of 400c
• Two large receivers
• Colostomy bag
• bucket and news paper
• IV stand
• Screen
Colostomy.
 Procedure

1. Explain the procedure to the patient and

wash your hands
2. Prepare the equipment and bring to bed side
3. Screen the bed and remove dressing
4. Put the patient in comfortable sitting position
with abdomen exposed
5. Place the rubber and cotton draw shit t
protect the bed
6. Fill the irrigating can with solution and elevate
the can about 50cm above bed expel air and
clamp
7. Place the bucket on the floor over the news
paper beside the bed
8. Place large receiver below the colostomy
9. Connect the oath with the tube with the
irrigation can and lubricate it
10) Insert the catheter 6 to 8 cm into the colon
11) Allow the solution to run in very slowly and remove the
catheter for the return flow
12) Repeat the same procedure until the colon is clearer
13) Give the patient clean abdominal pad to hold over
abdominal colostomy during expulsion of gas
14) With draw the tube and live large receiver as long as
necessary
15) Return to patient at intervals to give assistance if needed
16) Clean the area and apply Vaseline gauze dressing to prevent
irritation.
17) Comfort patient, care of equipment and chart the procedure
18) Wash your hands
 Changing a Colostomy Pouch

• Equipment
• Appropriate pouch
• Skin barrier
• Pouch clip or rubber band
• Skin paste
• Disposable gloves
• Soap and washcloth
• Warm water
 Procedure
1. Explain the procedure to client and provide for privacy.
Include caregivers in instruction if
indicated.
2. Assist client to a standing (preferable) or sitting position.
3. Wash hands and don gloves.
4. Remove the soiled pouch by gently pressing on the skin
while pulling the pouch.
5. Dispose of the pouch in a plastic bag after removing the
clip used to seal the pouch.
6. Cleanse the skin with soap and water.
7. Inspect the peristomal skin for redness, altered skin integrity,
or rashes; consult the enterostomal nurse if lesions of the
peristomal skin are observed.
8. Remove excessive hair with a safety razor or electric razor.
9. Inspect the pouch opening and ensure that it fits the stoma;
use a pouch pattern to customize the fit if indicated.
10. Apply a skin sealant or skin paste if indicated; apply skin
barrier.
11. Gently apply the pouch and press into place. Seal the
inferior opening with the clip or a rubber band.
12. Remove gloves and discard; wash hands.