ELIMINATION

PATTERN
Revised by Kausar Ali
Objectives
By the end of the session the students will be able to:
1. Review the basic anatomy of digestive system
2. Define elimination pattern
3. Discuss common problem of bowel elimination
4. Identify nursing care for common problem of fecal elimination
5. Discuss common problems of urinary elimination
6. Identify nursing intervention for common urinary problems
7. Describe factors that can alter urinary function
8. Discuss nursing care for alterations in elimination pattern

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ELIMINATION PATTERN
• Elimination pattern refers to a person’s usual habits
and routines of getting rid of body wastes — mainly
urination (urine) and defecation (stool).
ELIMINATION PATTERN - in nursing
• How often the patient urinates and passes stool
• Characteristics (color, consistency, odor)
• Any difficulty (pain, constipation, incontinence,
diarrhea)
• Use of aids (catheters, laxatives, diapers)
Anatomy of Digestive System
Anatomy of GIT.
• Human GI system is composed of;
• Mouth
• Pharynx
• Esophagus
• Stomach accessory organs (Liver, Spleen, Pancreas)
• Small intestine
• Large intestine
• Anus

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Elimination Pattern
Elimination: The ability to get rid of wastes from the
body. OR
The expulsion of waste from body is known as
elimination.

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

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Bowel Elimination
Large intestine (colon) is about 125-150 cm long
It has seven parts: Cecum, ascending, transverse, and descending;
sigmoid colon, rectum, and anus.

The colon forms pouches called haustra (haustrum is singular)

The large intestine is a muscular tube lined with mucous membrane

The muscles are circular and longitudinal to facilitate peristaltic

movements.

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insta | [Link]
Types of Colon Movements
• Haustral Churning involves back and forth movement of
chyme within the colon.

• Colon Peristalsis is relatively sluggish movement of the

chyme along the colon.

• Mass Peristalsis is powerful muscular movement along

the colon

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Type of
Region of Colon Primary Function
Movement

Haustral Transverse / Mixing &

contractions descending etc. absorption

Propulsion of
Peristaltic waves Along colon
contents
Much of colon, Rapid bulk
Mass movements
sweeping toward transport, urge
/ HAPCs
rectum to defecate

Reflex / Meal‐ Entire colon after Trigger motility

induced eating after food intake

Maintain
Basal slow waves readiness &
Entire colon
/ tone overall motility
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 Defecation Process
Defecation is initiated by two reflexes.
When feces enter the rectum, its distention gives signal
to brain via mesenteric plexus to initiate peristaltic
movements in the descending, sigmoid colon, and the
rectum and abdominal contrations
The internal sphincter in the anus relaxes and defecation
occurs by opening the external sphincter.

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Characteristics of Feces
Feces (Healthy People):
• Soft, brown, moist, and firmed.
• Distinct odor.

Factors affecting the odor or appearance:

• Certain foods.
• Medications.
• Illness
• infection.
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Abnormal Feces
• Black: stool may indicate of bleeding from upper
gastrointestinal tract or drug.
• Red: may indicate of bleeding from lower
gastrointestinal tract.
• Pale: may indicated to mal absorption.
• Green: may indicate intestinal infection.
• Dry hard: dehydration decreased intestinal motility.
• Pus: bacterial infection.

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

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Factors Impairing Elimination
• Emotional anxiety
• Failure to heed defecation reflex (urgent need for passing
stool),
• lack of time and privacy
• High carbohydrate, high fat diet
• Reduced fluid intake
• Immobility and inactivity
• Overuse of cathartics (laxatives), narcotic analgesic
• Inability to squat because of immobility,
• musculoskeletal deformity = pain during defecation
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Alteration in Bowel Elimination
• Diarrhea: Liquid watery stools..deals with the
consistency and frequency
• Constipation : Less then 3 times/week or what ever
is less then the pt. Regular pattern of elimination
• Incontinence : Inability to control fecal discharge
thru anal sphincter. Involuntary passage of stool
• Fecal Impaction: large, hard mass of stool gets stuck
in the rectum and cannot be passed normally.
• Flatulence:- Gas, Abdominal Distention & Pain
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Assessing Elimination Status
Usual pattern: -How often, When
Changes in Bowels: Blood, Mucus
Aids to Eliminate: - Laxatives Enemas
Current Problems: Food Related, Meds
Physical, Emotional, Artificial Orifices,
Hemorrhoids (abnormally distended
veins)

Artificial Orifices
• Colostomy → opening from colon to abdomen for stool
• Urostomy → opening for urine if bladder isn’t used
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Physical Assessment
Inspection- Observe contour of abdomen and note
visible peristalsis
Auscultation- Listen for bowel sounds in all quadrants
Percussion- Resonant or tympany over hollow organs…
dullness over intestinal obstruction
Palpation- Feel for masses, tenderness etc

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Nursing Diagnosis
Bowel incontinence related to fecal impaction.
When a large, hard mass of stool gets stuck in the rectum (fecal
impaction), liquid stool from higher up in the bowel can leak around
the impaction → uncontrolled leakage = bowel incontinence.

Constipation related to immobility.

Risk for constipation related to insufficient fiber intake.
Diarrhea related to spoiled food.
Risk for fluid volume deficit related to diarrhea.
Risk for impaired skin integrity related to colostomy.
Self-Esteem Disturbance Related to Bowel Diversion (e.g., colostomy /
ileostomy)
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Nursing Interventions to Promote
Normal Bowel Elimination
• Privacy
• Timing- Patients should be encouraged to defecate when the
urge to defecate is recognized.
• Nutrition and fluids- High fiber foods, 2000cc fluids/day
• Exercise- Ambulation helps to stimulate normal motility, and
therefore should be encouraged in post-surgical patients.
• Positioning- Comfortable position needed. Squatting position
common.
• Assess need for elevated toilet.

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Nursing Interventions for Constipated
Patients

• Increase fluid intake. Instruct the patient to drink fruit

juices.

• Include fiber in the diet with foods.

• Administration of laxatives.

• Administration of Enema, or glycerin suppositories

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N. Interventions for Patients with
Diarrhea
• Encourage intake of fluids and food.
• Eating small amounts of bland foods.
• Encourage the ingestion of food or fluids containing
potassium, since diarrhea can lead to great potassium
losses.
• Avoid excessively hot or cold fluids and highly spiced
foods and high fiber foods that can aggravate diarrhea.

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Nursing Interventions for Fecal Incontinence
• Give balanced meals
• Note time and frequency of incontinence
• Assist patient to toilet at regular intervals (especially
after meals)
• Apply barrier creams to prevent dermatitis
• Keep skin dry to reduce infection risk
• Provide adequate hydration
• Avoid trigger foods (e.g., caffeine, spicy foods, artificial
sweeteners)
• Teach Kegel exercises if appropriate for Pelvic Floor
Muscle Strengthening
• Monitor for constipation
• Anti-diarrheals (e.g., loperamide) if loose stools
• Stool softeners or laxatives if constipation-related
• Review medications causing diarrhea
• Maintain privacy and dignity.
[Link] for Flatulence

• Decreasing flatulus by avoiding gas – producing food,

exercise, moving in bed and ambulation
• Glycerin Suppository (constipation)
• No Antacids
• Use PPIs

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Interventions
Cathartics/Laxatives - Drugs that induce emptying of the
interest. Habitual use of laxatives lead to constipation and irreg.
frequency. Only use for Prep. for procedures
Enemas- Solution introduced into the GI. Interest for the purpose
of removing feces.
Suppositories - bullet shaped substance inserted into the rectum
beyond the anal sphincter where it melts to aid in elimination.
Digital removal- with prolonged retention of feces, fecal
impaction occurs preventing passage of normal stool. Liquid fecal
seepage around hard stool can occur. Oil retention enema is
given prior to digital removal to soften stool.

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Digital Removal of Fecal Impaction
Digital removal means using your gloved,
lubricated fingers (usually the index finger) to
manually break up and remove the impacted stool
from the rectum.

When feces are retained in the rectum for a

prolonged period, fecal impaction can occur. This
hard mass of stool blocks the normal passage of
feces, and sometimes liquid stool may leak around
the impaction (fecal seepage).”

Before performing digital removal, an oil retention

enema is usually administered to help soften and
lubricate the stool, making the manual removal
process easier and less traumatic.
Urinary Elimination
Anatomy of Renal system

• The renal system is composed of;

• 2 kidneys

• 2 Ureters

• 1 urinary bladder

• 1 urethra

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Structure of kidney
• Kidneys are pairs of organ.
• Shape: Bean shaped
• Size: 11cm long, 6 cm wide, 3 cm thick
• Weight: 150g.
• Location: On either side of the vertebral
column, roughly between T12 and L3
vertebrae.
• Right kidney: Slightly lower than the left
because of the liver sitting above it.
• Left kidney: A bit higher, roughly between
T11–L2.

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Longitudinal section
of the kidney shows
following parts.

• Capsule
• Cortex.
• Medulla
• Hilum

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 Formation of urine
1. Glomerular Filtration
Water, salts, glucose,
amino acids, and waste
(like urea, creatinine) out of
the blood into Bowman’s
capsule.
2. Tubular Reabsorption
The proximal convoluted
tubule, loop of Henle, and
distal convoluted tubule
reabsorbs needed
substances.
3. distal convoluted tubule
and collecting duct
actively secrete extra
waste.
Formation of urine
The formation of urine happens in the nephrons — the functional
units of the kidneys — and it involves three main steps:

1. Glomerular Filtration
Blood pressure forces water, salts, glucose, amino acids, and
waste (like urea) out of the blood into Bowman’s capsule.
Large molecules (like proteins and blood cells) stay in the blood.
The fluid that enters Bowman’s capsule is called the filtrate.

2. Tubular Reabsorption
With the help of proximal convoluted tubule, loop of Henle, and
distal convoluted tubule body reabsorbs needed substances from
the filtrate back into the blood — like: Glucose, Amino acids,
Water, Sodium and other ions.
This is to retain useful materials and maintain water/electrolyte
balance.
3. Tubular Secretion
In the distal convoluted tubule and collecting duct
actively secrete extra waste (like hydrogen ions,
potassium, ammonia, and drugs) from the blood into
the filtrate to remove remaining waste and regulate
pH of blood (7.35 - 7.45).
The final fluid left in the collecting duct is urine,
which contains: Urea, Creatinine, Excess ions, Water
(varies depending on hydration).

This urine then travels:

Collecting ducts → Renal pelvis → Ureter → Bladder
→ Urethra → Out of body
• Urine consists of 95% water and 5% solid
substances.
• The need to urinate is usually felt at 300-350ml of
urine in the bladder.
• Normal fluid intake (daily): about 2–3 liters
(including water, food, and drinks).

• Normal urine output: about 1–2 liters per day.

The rest of the fluid is lost through: Sweat,
Breathing, Stool.

• NOTE:
Normal urine intake vs output is:
0.5ml/Kg/hr. → 1.5ml/Kg/hr.
Urination
• Micturation, voiding, and urination all refer to the
process of emptying the urinary bladder.
• Stretch receptors- special sensory nerve endings in the
bladder wall that is stimulated when pressure is felt
from the collection of urine – Adult: 250-450mL of urine
– Children: 50-200mL of urine

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Urine Routine Examination (R/E)

1. Physical
Examination
Normal Value /
Parameter Appearance

Color Pale yellow to amber

Appearance Clear

Specific Gravity 1.005 – 1.030

pH 4.6 – 8.0

Volume (if noted) ~1–2 liters/day

2. Chemical
Examination:
Normal Result
Parameter
Protein Nil / Negative

Glucose Nil / Negative

Ketone bodies Nil / Negative

Bilirubin Nil / Negative

Urobilinogen Normal

Blood Nil / Negative

Nitrite Negative

Leukocyte esterase Negative

3. Microscopic
Examination:
Normal Range
Parameter

Pus cells (WBCs) 0–5 /HPF

RBCs 0–2 /HPF

Epithelial cells Occasional

Casts Absent or occasional hyaline cast

Occasional (urates, phosphates,

Crystals
oxalates may be seen)

Bacteria Nil or few

Yeast Nil
Factors affecting voiding
• Growth and development
• Psychosocial factors
i. Anxiety or Stress - urinary retention
ii. urinary retention
iii. Depression - urinary retention or incontinence
iv. Fear or Pain - withhold urination
• Fluid and food intake
• Medications(Lasix, Atropine)
• Bladder Muscle tone
• Activity
• Pathologic conditions (UTI, BPH)
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Common Urinary Elimination Problems

Urinary retention
Urinary tract infections
Urinary incontinence

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 Urinary incontinence Types

• Stress Incontinence - Weak pelvic floor muscles,

Leakage with coughing, sneezing, laughing.

• Urge Incontinence - Overactive bladder (detrusor

overactivity), Sudden strong urge to void — can’t reach
toilet in time. Most elderly.

• Overflow Incontinence - Bladder doesn’t empty fully

due to BPH → overfills and leaks.

• Functional Incontinence - Physical or cognitive

impairment — can’t get to toilet in time or Forget
urination

• Reflex (Neurogenic) Incontinence - Spinal cord injury

or neurologic disease.
Altered Urinary Elimination
Frequency: Voiding more than normal frequency.
Nocturia: is voiding two or three time at night.
Urgency: is the feeling of person must void.
Dysuria: means voiding that is either painful.
Enuresis: is defined as involuntary urination.
Urinary incontinence: involuntary urination.
Urine retention: accumulation of urine in the bladder and
become over distended.
Hypospadias is a birth (congenital) defect in which the
opening of the urethra is on the underside of the penis
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Assessing Urinary Function
• Determine normal voiding pattern and frequency
• Appearance of urine
• Past or current problems with urination (burning,
urgency, Cannot empty your bladder).
• Presence of an ostomy for urinary diversion.
• Factors influencing elimination pattern (BPH,
Renal calculi, infections, meds).
• Physical assessment: inspection, palpation
• Review Labs and Radiology
i. Urine R/E report
ii. U/S of Pelvic (Kidneys, ureters, Bladder)
iii. U/S of Scrotum
Assess the Urine
[Link] R/E
[Link] Culture and Sensitivity

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

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PLANNING
• Maintain normal voiding pattern.
• Maintaining normal urinary elimination:
• Promote fluid intake = Regain normal urine output.
• Assisting with toileting.
• Preventing urinary tract infection:
• Increased fluid intake.
• Strengthening pelvic floor muscles via Manual
bladder compression & Kegal exercise
• Maintaining skin integrity
• Applying urinary devices
• Hygiene
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Managing Urinary Incontinence
• Bladder training - requires that the client postpone
voiding, resist or inhibit the sensation urgency, and void
according to a timetable rather than according to the
urge to void. The goal is to lengthen the intervals
between urination to correct the client’s habit of frequent
urination.
• Habit training - also referred to as timed voiding or
scheduled toileting. Not to attempt to motivate the client
to delay voiding when urge occurs.
• Prompt voiding - encouraging the client to use the toilet
and reminding the client when to void.
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Managing Urinary Incontinence
Pelvic Muscle Exercises (PME)
Referred to as perineal muscle tightening or Kegel’s
exercises
Streghthen pubococcygeal muscles and can increase
female’s ability to start and stop the stream of urine.

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References
1:Olowu WA, Niang A, Osafo C, Ashuntantang G, Arogundade
FA, Porter J, et al. lancet global health, 2016.
2:[Link] › Kidney Stones › News.
3:[Link]
[Link].
4: Porth, C., & Hannon, R. (2009). Porth pathophysiology.
Philadelphia, Pa.: Lippincott Williams & [Link]

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