CHAPTER 3: ELIMINATION OF GASTROINTESTINAL AND URINARY

OUTPUTS

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 Learning Objective
At completion of the unit the learner will be able to:
•Define enema.
• List purposes of gastric aspiration, lavage, enema and catheterization.
• Mention types of enema.
• Provide enema according to its purpose and need.
• Explain mechanism of action of fluids used for enema.
• Explain purpose of catheterization.
• Identify different types of catheters.
• Describe indication of catheterization.

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•Demonstrate sterility technique through out the catheterization.
• Intervene the procedure for those in need of it with understanding of both
male and female catheterization.
• Identify important precautions of the procedure.

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 Key Terminology
Anuria:- failure of the kidneys to produce urine.
Dysuria:- painful or difficult urination.
melena :- refers to black stools that occur as a result of gastrointestinal
bleeding
projectile vomiting:- is a type of severe vomiting in which stomach contents
can be forcefully propelled several feet away from you
Consitipation:- occurs when bowel movements become less frequent and
stools become difficult to pass
Enema:- involves inserting liquid or gas into the rectum, which is the lower part
of the large intestine.
Micturition:- the action of urinating.
urgency:- emergency
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Cystitis:- is inflammation of the bladder
fecal impaction:- is a large, hard mass of stool that gets stuck so badly in your colon
or rectum that you can't push it out
nocturia :- is a condition in which you wake up during the night because you have to
urinate. Causes can include high fluid intake,
urinary catheter:- a catheter is inserted into your bladder through your urethra
Defecation:- the discharge of feces from the body.
Flatus:- gas in or from the stomach or intestines, produced by swallowing air or by
bacterial fermentation
Oliguria:- as a urine output that is less than 1 mL/kg/h in infants, less than 0.5
mL/kg/h in children, and less than 400 mL daily in adults
urinary frequency:- s the need to urinate many times during the day, at night
(nocturia),

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Diarrhea:- is characterized by loose, watery stools or a frequent need to have a
bowel movement
incontinenece:- lack of voluntary control over urination or defecation.
polyuria:- make up to 15 liters per day.
urinary retention:- s a condition in which you cannot empty all the urine from
your bladder.
Voiding:- urination
Vomitus:- matter that has been vomited

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 I .Gastric Lavage
Definition
This is the irrigation or washing out of the stomach.
Purpose
1. To remove alcoholic, narcotic or any other poisoning, which has been
swallowed.
2. To clean the stomach before the operation
3. To relieve congestion, thereby stimulating peristalsis e.g. Pyloric stenosis
4. For diagnostic purposes

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 Gastric Lavage Using a Simple Rubber Tube
Equipment:
• Clean trolley.
• Bowel containing large esophageal tube in ice (cold water)
• Rubber tubing with screw or clip and glass connection
• Metal or plastic funnel
• Large Jug (5 litter)
• Solution as prescription/usually to care for acidic poisoning.
• We use sodium bicarbonate 1 teaspoon to 500 cc. of water at
a temperature of 37

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• Small jug to carry solution to the funnel
• Lubricant e.g. liquid paraffin
• Bowl for gauze swabs
• Cape or protective material to put around the patient chest
• Pail to receive returned fluid
• Mackintosh or paper to protect the floor beneath the pail
• Receiver for used esophageal tube
• Paper bag for waste material
• A tray for mouth wash after lavage

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 Procedure
1. Explain procedure to the pt and ask him/her to remove artificial dentures, If
any.
[Link] pt with cape or towel
[Link] bed linen by spreading the mackintosh on the accessible side of the
bed.
4. Place mackintosh or paper under the pail to protect the floor
5. Elevate head of the bed it pt is conscious and the condition permits
6. Measure the tube from the tip of the nose up to the ear lobe
7. Gently pass the tube over the tongue,
8. Ask patient to swallow while inserting the tube and allow to breath in
between swallowing.
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[Link] air bubbles, cough and cyanosis are noticed the tube is with drawn and
procedure commenced again.
10. After inserting, place funnel end in a basin of water to check if the tube is in
the air passage.
11. Fill the small pint measure and power gently until the funnel is empty, then
invert over the pail.
12. Take specimen. If required, and continue the process until the returned fluid
becomes clear and the prescribed solution has been used.
13. Remove tube gently and give mouth wash
14. Measure the amount of fluid returned and record
15. Report and abnormality e.g. blood stain or clots or pieces of the gut.
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N.B.
Record
• Time of treatment
• Amount & kind of solution used
• Nature of returned fluid
• Reaction of the patient during and after the procedure

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 2. GASTRIC ASPIRATION
Aspiration is to withdrawal of fluid or gas from a cavity by suction
Purpose
1. To prevent or relieve distention following an abdominal operation
2. In case of gastrointestinal obstruction, remove the stomach or gastric
contents
3. To keep the stomach empty before an emergency Abdominal operation is
done
4. To aspirate the stomach contents for diagnostic purposes

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 There are two type of gastric Aspiration
1. Intermittent method: - In this case, Aspiration is done as the condition
requires and as ordered.
2. Continues method: - Attached to a drainage bag
There are 2 ways of supplying suction
a. Simple suction by the use of a syringe
b. An electric suction machine
The continuous method is indicated when it is absolutely necessary
and desirable to keep the stomach and duodenum empty and at
rest.

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 Equipment
• Aspiration tube (Ryle's tube)
• Aspiration syringe if this method is used
• Gallipots with lubricant e.g. liquid paraffin or vaseline, to lubricate the
nostrils
• Gauze swabs in a bowl
• Sodium bicarbonate solution or saline to clean the nostrils
•Litmus paper
• Water in a galipot to test the right position of the tube in the stomach
• Two test tubes and laboratory forms of necessary

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• Saline or plain water in a galipot to be injected, in case the stomach content is
too thick to come out through the syringe.
• Rubber mackintosh and towel to protect the patient’s chest.
• Receiver for soiled swabs

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 Procedure
1. Explain the procedure to the patient, in order to gain her/his cooperation
2. Prop up in an upright position with the help of a backrest and pillow
3. Cleanse and lubricate the nostrils
4. Lubricate the Ryle's tube with water
5. Insert the tube as directed in nasal feeding and ask the patient to swallow as
the tube goes down.
6. Instruct the patient to open her or his mouth to make sure the tube is in the
stomach
7. After being sure that the tube is in the right position, inject about 15-20 cc. of
saline or water into the stomach.
8. Draw the plunger back to withdraw the fluid collect a specimen, If needed
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 N.B
1. Special care of the nose and mouth to prevent dryness should be
considered
2. Always measure the amount withdrawn accurately noting color, contents,
and smell
3. Record on the fluid chart properly
4. Report any change in patient condition regarding pulse, Temperature, B.P
fluid output.

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 3. Enema
• Enema: is the introduction of fluid into the rectum and sigmoid colon for
cleansing, therapeutic or diagnostic purposes.

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 Purpose
• For emptying – soap solution enema
• For diagnostic purposes (Barium enema)
• For introducing drug/substance (retention enema)

Solution used:
1. Normal saline
2. Soap solution – sol. Soap 1gm in 20 ml of H2O
3. Epsum salt 15 gm – 120 gm in 1,000 ml of H2O

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 Mechanisms of some solutions used in enema
1. Tap water: increase peristalsis by causing mechanical
• distension of the colon.
2. Normal saline solution
3. Soap solution: increases peristalsis due to the irritating effect of
• soap on the lumenal mucosa of the colon.
4. Epsum salt: The concentrated solution causes the flow of ECF
• (extracellular fluid) to the lumen causing mechanical
• distension resulting in increased peristalsis

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 Classified into:
Enemas are classified into two main categories:
1. Cleansing (evacuation) enema
2. Retention enema

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 1. Cleansing enema
Kinds:
1. High enema
• Is given to clean as much of the colon as possible
• The solution container should be 30-45 cm about the rectum
2. Low enema
• Is administered to clean the rectum and sigmoid colon only
guidelines
Enema for adults is usually given at 40-43 o c and for children at 37.7 o c
Hot – causes injury to the bowel mucous
Cold – uncomfortable and may trigger a spasm of the sphincter
muscles
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 the amount of solution to be administered depends on:
• Kind of enema
• The age of the person and
• the person’s ability to retain the solution
Age Amount
• 18 months:50-200 ml
• 18 mon-5 yrs. :200 -300 ml
• 5-12 yrs.:300 -500 ml
• 12 yrs. and older: 500 -1,000 ml

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The rectal tube should be appropriate: is measured in French scale
Age Size
• Infants/small child 10 -12 fr
• Toddler 14 -16 fr
• School age child 16 -18 fr
• Adults 22-30 fr

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 Purpose
• To stimulate peristalsis and remove feces or flatus (for constipation)
• To soften feces and lubricate the rectum and colon
• To clean the rectum and colon in preparation for an examination. E.g.
Colonoscopy
• To remove feces prior to a surgical procedure or a delivery
• For incontinent patients to keep the colon empty For diagnostic test
E.g. before certain x-ray exam – barium enema Before giving stool specimen
for certain parasites

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 Procedure
• inform the patient about the procedure
• Put bed side screen for privacy
• Attach rubber tube with enema can with nozzle and stop cock or clamp
• Place the patient in the lateral position with the Rt. leg flexed, for adequate
exposure of the anus (facilitates the flow of solution by gravity into the sigmoid
and descending color, which are on the side
• Fill the enema can which 1000 cc of solution for adults
• Lubricate about 5 cm of the rectal tube – facilities insertion through the
sphincter and minimizes trauma
• Hung the can = 45 cm from bed or 30 cm from patient on the stand

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• Place a piece of mackintosh under the bed
• Make the tube air free by releasing the clamp and allowing the fluid to run
down little to the bed pan and clamp open – prevents unnecessary distention
• Lift the upper buttock to visualize the answer
• Insert the tube
 7-10 cm in an adult smoothly and slowly
 5-7.5 cm in the child
 2.5-3.75 cm in an infant
• Raise the solution container and open the clamp to allow fluid to flow

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• Administer the fluid slowly if client complains of fullness or pain stop the flow
for 30” and restart the flow at a slower rate – decreases intestinal spasm and
premature ejection of the solution
• Do not allow all the fluid to go as there is a possibility of air entering the
rectum or when the client can not hold anymore and wants to defecate, close
the clamp and remove the rectal tube from the anus and offer the bed pan.
• Remove bed pan and clean the rectal tube
Note: if resistance is encountered at the internal sphincter, ask the clients to
take a deep breath, then run a small amount of solution (relaxes the internal
anus sphincter)

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 Retention Enema
 administration of solution to be retained in the rectum for a short or long
period
 Are enemas meant for various purposes in which the fluid usually medicine
is retained in rectum for a short or long periods – for local or general effects
E.g. oil retention enema, Antispasmodic enema
1. Principles:
• Is given slowly utilizing a rectal tube
• The amount of fluid is usually 150-200 cc
• Cleansing enema is given after the retention time is over
• Temperature of enema fluid is 37.4 c or body (Return flow Enema) Harris
fluid
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 Purpose
 To supply the body with fluid.
 To give medication E.g. stimulants – paraldehyde or antispasmodic.
 To soften impacted fecal matter. Other equipment is similar except that the
tube for retention enema is smaller in width.
Procedure
 Similar to the cleansing enema but the enema should be
 administered very slowly and always be preceded by passing a
 flatus tube

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 Note
1. Most medicated retention enema must be preceded by a cleansing enema.
A patient must rest for ½ hrs before giving a retention enema
2. Elevate the foot of the bed to help patient retain the enema
3. The amount of fluid is usually 150-200 cc
4. The temperature of enema fluid is 37.4 oc or at the body
5. Kinds of solution used to supply the body with fluid are plain H2O, normal
saline, glucose 5% soda bicarbonate 2-5% 6. Olive oil 100-200 cc to be
retained for 6-8 hrs is given for server constipation

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 Procedure
• Insert the tube like the cleansing enema
• The client lies on the bed with hips close to the side of the bed (client
assumes a right side-lying position for siphoning)
• Open the clamp and allow to run about 1,000 cc of fluid in the bowel, then
siphon back into the bucket
• Carry on the procedure until the fluid return is clear

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 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 washout
• Allow the fluid to pass slowly
Amount of solution
• 5-6 liters or until the washout rectum fluid becomes clear

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 6. Urinary Catheterization
Definition of catheterization: Is the introduction of a tube (catheter) through
the urethra into the urinary bladder
• 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

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Catheter: a tube with a hole at the tip
Types of Catheter
1. Straight (plain or Robinson)
2. Retention (Foleys, indwelling)
Selecting an appropriate catheter: May be made of
⇐ Plastic – for 1 week
⇐ Latex – 2-3 (rubber) days
⇐ Silicon – for 2-3 months
⇐ Polyvinylchloride (PVC) –4,6 days

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1. Select the type of material in accordance with the estimated length of the
catheterization period:
2. Determine the appropriate catheter size
- are determined by the diameter of the lumen
- graded on a French scale or number.
Catheter size depends on the size of the urethral canal
⇐ # 8-10 Fr – children
⇐ # 14-16 Fr – female adults is 4.67 mm
⇐ # 18 Fr – adult male is 5.94mm
NB. Fr= French Scale
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3. Determine appropriate catheter length by the client’s gender
• For adult males – 40 cm catheter
• For adult females – 22 cm catheter
4. Select the appropriate balloon size
5 ml – for adults
3 ml – for children

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 Catheterization Using a straight 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

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 I. Sterile
• Kidney dish
•Galipot
•Gauze
•Towel
•Solution
•Lubricant
•Catheter
•Syringe
•Water
•Specimen bottle
•Gloves
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 II. Clean
•Waste receiver
•Rubber sheet
•Flash light
•Measuring jug
•Screen

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 Procedure
• Prepare the client and equipment for perennial wash
• Position the patient – dorsal recumbent (pillows can 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 an antiseptic solution.
• Lubricate the insertion tip of the catheter (5-7 cm in)
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• Expose the urinary meatus adequately by retracting the tissue or the labia
minora in an upward direction – female
• Retract the foreskin of uncircumcised mal.
• Grasp the penis firmly behind the glans and hold straighten the downward
curvature vertically it goes to the body–male hole of 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 the specimen (about 30 ml)
• Pinch the previous leakage
• Empty or drain the bladder and remove the catheter
• For adults experiencing urinary retention an order is needed on the amount
of urine to be expelled
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 Note
• If resistance is encountered during insertion, do not force it – forceful
pressure can cause trauma. Ask the client to take deep breaths - relax the
external sphincter (slight resistance is normal)
Dorsal Recumbent
• Female - for a better view of the urinary meatus and to reduce the risk of
catheter contamination.
• Male- allows greater relaxation of the abdominal and perennial muscles and
permits easier insertion of the tube.
Straight Catheter: a single-lumen tube with a small eye or
• opening about (1.25 cm) from the insertion tip:

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 Inserting a Retention (Indwelling) Catheter
• Retention (Foley) Catheter. Contains a second, smaller tube throughout its
length on the inside this tube is connected to a balloon near the insertion
tip.

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 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 output needs to be monitored hourly

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 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
within the bladder. The outside end of the catheter is bifurcated i.e., it has two
openings, one to drain the urine, and the other to inflate the balloon.

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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 the steps to insert a 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 48
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Tape the catheter with tape to the inside of a females thigh or to the thigh or
body of a male client
 Restricts the movement of the catheter and irritation in the urethra when the
client moves
 When there is an 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

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 Removal the catheter
• Withdraw the solution or air from the balloon using a syringe and remove
gently

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