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Textbook for Nursing Assistants
Chapter 21: Assisting With Urinary and
Bowel Elimination
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Assisting With Elimination
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Assisting With Elimination
• Some patients or residents may only need a steady arm
to lean on during their trip to the bathroom; others will
need more help
• The bathrooms in many health care facilities have special
features that make them easier for people with physical
disabilities to use
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Assisting with Elimination
• Modifications allow many
patients or residents to
use the toilet in the
bathroom with very little
assistance from a nursing
assistant
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Assisting with Elimination Elimination Equipment
• Some patients or residents may not be able to get out of
bed at all, or they may be too weak or ill to walk to the
bathroom. These people may need to use
– Bedside commodes
– Bedpans
– Urinals
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Elimination Equipment: Bedside Commodes
• The bedside commode consists of a chair
frame with a toilet seat and a removable
collection bucket
• For a person who is able to get out of bed but who is
not able to walk to the bathroom, a bedside commode
can make toileting easier
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Elimination Equipment: Bedpans
• A bedpan is used for elimination when a person is unable
to get out of bed at all
• A woman who cannot get out of bed uses a bedpan to
urinate and for bowel movements. A man who cannot get
out of bed uses a bedpan for bowel movements, and a
urinal to urinate
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Elimination Equipment :
Fracture Pans
• Arthritis can make using a bedpan very painful, as can
fractures of the back or legs
• In such cases, when using a bedpan is uncomfortable or
dangerous, a special bedpan called a fracture pan is used
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Elimination Equipment:
Fracture Pans
• The fracture pan, which is
wedge-shaped, is placed
underneath the person’s
buttocks with the thin
edge toward the person’s
back
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Fracture Pans and Bedpans:
Useful Tips
• Warm a metal bedpan before offering it to the patient or
resident by wrapping the bedpan in a warm towel, or
running warm water over the seat area and then drying it
before use
• Apply a small amount of powder to the rim of the bedpan
to make it easier to slide under the person
• Provide as much privacy as safely possible
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Fracture Pans and Bedpans:
Useful Tips
• If the person’s condition
allows, raise the head
of the bed to promote
a more natural elimination
position
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Elimination Equipment: Urinals
• A man uses a urinal to urinate
when he cannot get out of bed
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Elimination Equipment: Urinals
• To urinate, the man puts his penis in the opening of
the urinal
• If the man is very weak or disabled, you may need to
place his penis inside the opening of the urinal for him
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Difficulty With Normal Elimination
• A patient or a resident may have difficulty with
elimination, if elimination occurs under conditions that
are not as private as the person would like
• In a health care facility, people may share a bathroom or
use a bedpan while only being separated from other
people in the room by a curtain
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Difficulty With Normal Elimination
• Feelings of embarrassment and shame are made worse
when patients or residents accidentally soil themselves,
their bed linens, or their clothing with urine or feces. This
might be due to:
– The effects of medications
– Being in a strange place
– Reluctance to ask for help
– Physical or mental disabilities
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Promoting Normal Elimination
• Kindness, empathy, and a professional attitude can go a
long way toward easing the patient’s or resident’s
embarrassment
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Promoting Normal Elimination
• Being in a health care facility can change a person’s
normal elimination patterns, which can cause health
problems
• The most effective method of treating urinary and bowel
problems is to prevent them from happening in the first
place
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Promoting Normal Elimination
•
Encourage plenty of fluids, unless the doctor has ordered
against it
•
Answer call lights promptly
•
Encourage the person to call when he first feels the urge
to void
•
Offer people the chance to eliminate frequently
•
Provide for privacy and comfort
•
The sound of running water may help some people to
urinate
•
If a person is having difficulty moving his bowels, do not
rush the person
•
Regular exercise and foods containing insoluble fiber help
promote regular bowel movements
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Obtaining Urine and Stool Specimens
• The contents of a person’s urine or feces can provide a
doctor with clues about the person’s overall health status
• A nursing assistant may be asked to obtain a urine or
stool specimen (sample) for laboratory study
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Obtaining Urine and Stool Specimens
• Before collecting any specimen—of urine, feces, or any other
body fluid—ask yourself the following questions:
– Do I have the right person?
– Do I have the right laboratory requisition slip?
– What method is to be used to collect the specimen?
– Do I have the right type of specimen container?
– Is the specimen container properly labeled?
– What is the correct date and time?
– What storage and delivery method must I use?
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Obtaining Urine and Stool Specimens
• Always remember to wear gloves when assisting with
specimen collection and when handling the specimen
containerss
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Obtaining Urine and Stool Specimens:
Urinalysis
• Urinalysis, or examination of the urine under a microscope and
by chemical means, is a commonly used diagnostic tool in the
health care setting
• Substances found in urine during urinalysis can help doctors
diagnose kidney disease, certain metabolic diseases, and
infections
• To perform urinalysis, a urine specimen must be obtained
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Obtaining Urine Specimens: Routine Urinalysis
• For routine urinalysis, the person is asked to urinate
directly into the specimen cup, if possible. If difficult, the
person can urinate into a specimen collection device.
• The person must not have a bowel movement at the
same time the urine is being collected. Do not place toilet
paper in the collection device. Either of these actions will
change the urinalysis results.
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Obtaining Urine Specimens: Midstream
(“Clean Catch”) Urine Specimen
• This method of collecting urine prevents contamination of the
urine by the bacteria that normally live in and around the
urethra
• A midstream (“clean catch”) urine specimen is usually ordered
when the doctor suspects a urinary tract infection
• When a midstream (“clean catch”) urine specimen is
requested, the person is asked to clean the area around the
urethral opening with a special cleansing wipe
• The urine flow is started, then stopped, then started again
• The urine sample is collected from the restarted flow in a
sterile specimen cup
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Obtaining Urine Specimens: Testing
• A type of routine urine testing involves
dipping chemically treated paper strips
into a urine sample
• Chemicals on the paper react with certain substances that
may be found in the urine, causing the chemical blocks on
the paper to change color if these substances are present in
the urine
• The paper is then compared with a color chart that comes
with the strips
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Obtaining Stool Specimens
• Stool is analyzed for the presence of blood, pathogens (such as
parasites or bacteria), fat, and other things that are not
normally found in feces
• If a stool sample is needed, the person should be notified well
in advance so that the specimen can be collected when it
becomes available
• Ask the nurse if there are any particular collection methods
that should be used
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Obtaining Stool Specimens
• Stool can be collected in a bedpan, bedside commode, or
in a collection device placed into a regular toilet.
• The person must not urinate at the same time the stool
sample is being collected. Toilet paper must not be
placed in the collection device. Both of these actions will
change the test results.
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Urinary Elimination
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Urinary Elimination: Urinary System
• The urinary system consists of the kidneys,
urinary bladder, ureters, and urethra
• Blood is filtered by the kidneys, forming
urine
• The urine is stored in the urinary bladder
• As the bladder fills, we begin to feel the
urge to urinate
• Urine leaves the body through the
urethra
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Urinary Elimination: Expressions
• The process of passing urine from the body is known by
several terms, including:
– Urination
– Voiding
– Micturition
• Patients or residents will have their own terms for urinating,
such as “peeing” or “passing water”
• When talking about urination, use words that the person is
familiar with. This is especially important when talking with
children.
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Urinary Elimination: Color and Odor
• In healthy people, urine is
– Clear, without cloudiness or particles
– Pale yellow, straw-colored, or dark gold (amber) in
color, with a slight odor
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Urinary Elimination: Color and Odor
• Foods and drugs can affect the color and odor of urine
• When you are helping a patient or resident with
urination, observe the urine and report any abnormalities
to the nurse
• Urine with an unusual odor or appearance could be a sign
of illness or infection
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Urinary Elimination: Hematuria
• A slight red tinge to the urine may indicate hematuria, or
the presence of blood in the urine
• Sometimes hematuria is occult and must be detected
using urinalysis
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Factors Affecting Urinary Elimination
• Many factors influence a person’s urinary pattern, including
– The amount of fluids the person drinks
– The types of medications the person takes
– The person’s age
– The person’s lifelong elimination habits
• A nursing assistant soon becomes aware of the urinary pattern
that is normal for each person in her care
• This knowledge allows her to recognize any changes that
may occur
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Urination: Frequency and Nocturia
• Frequency is the term used to describe voiding that
occurs more often than usual
• Frequency is often accompanied by a feeling of urgency,
or the need to urinate immediately
• Nocturia is the need to get up more than once or twice
during the night to urinate, to the point where sleep is
disrupted
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Urination: Dysuria
• Dysuria is difficulty voiding that may or may not be
associated with pain
• Some people describe the discomfort they feel during
urination as a “burning” or “cramping” sensation
• Dysuria is often associated with bladder infections,
prostate problems, and some sexually transmitted
diseases (STDs)
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Measuring Urine Output
• In a person maintaining a good fluid balance, urine
output is neither too high nor too low. Complications
associated with urine output are:
– Oliguria (the state of voiding a very small amount of
urine over a given period of time)
– Polyuria (the state of excessive urine output)
– Anuria (the state of voiding less than 100 mL of urine
over the course of 24 hours)
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Measuring Urine Output
• People who have illnesses or take medications that may
alter their body’s ability to maintain a healthy fluid
balance will need to have their urine output measured
regularly
• Some people who are critically ill will have their urine
output measured and recorded every hour, but most
people in the health care setting have routine orders for
their urine output to be measured and recorded each
shift
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Measuring Urine Output: Process
• If a person uses a regular toilet, you will need to remind
the person:
– To void into a specimen collection device (“commode
hat”)
– To call you after he or she has finished voiding so that
you can measure and record the amount of urine
• Specimen collection devices, urinals, and the drainage bags
used with urinary catheters often have markings that make
measuring urine output easy
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Measuring Urine Output: Process
• Urine output can also be
measured by pouring
it into a graduate
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Measuring Urine Output: Process
• If the urine output of one of your residents or patients is being
monitored, you will need to keep a record of the amount of
urine passed at each voiding
• This can be done using an intake and output (I&O) flow sheet,
which has spaces to record the amount of each individual
voiding
• To obtain the end-of-shift amount, simply add the individual
amounts and record the total in the appropriate space
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Urinary Catheterization
• Urinary catheterization is done when a person is unable
to urinate using a toilet, bedpan, urinal, or bedside
commode
• A urinary catheter is a tube that is inserted into the
bladder through the urethra to allow the urine in the
bladder to drain out
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Urinary Catheterization: Situations When a
Urinary Catheter Is Used
• A urinary catheter is used in many different
situations:
–
A urinary catheter may be inserted to drain the
bladder before or during a surgical procedure,
during recovery from a
serious illness or injury, or to collect
urine for testing
–
A urinary catheter may be used for a person
who is incontinent of urine, if the person has
wounds
or pressure ulcers that would be made worse
by contact with urine
–
A urinary catheter is necessary when a person
is unable to urinate because of an obstruction
in the urethra
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Urinary Catheterization: Insertion of
Urinary Catheter
• Inserting a catheter is a procedure that requires sterile
technique because it involves putting a foreign object (that is,
the catheter) into a person’s body
• Inserting a urinary catheter is usually beyond the scope of
practice for a nursing assistant, although in some facilities,
nursing assistants are provided with additional training that
allows them to catheterize residents or patients
• Regardless of whether or not you are trained to actually insert
urinary catheters, caring for people who have urinary catheters
in place will almost certainly be a part of your daily duties
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Urinary Catheterization: Types of Urinary Catheters
• You will see many different types of urinary catheters in use
– A straight catheter, also known as a Robinson, Rob-Nel, or
Red Rubber catheter, is used when the catheter is to be
inserted and removed immediately
– An indwelling catheter, also known as a retention or Foley
catheter, is left inside the bladder to provide continuous
urine drainage
– A suprapubic catheter is a type of indwelling catheter. The
suprapubic catheter is inserted into the bladder through a
surgical incision made in the abdominal wall, right above
the pubic bone
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Catheters
Straight
Indwelling
Suprapubic
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Urinary Catheterization: Caring for a Person
With an Indwelling Urinary Catheter
• Indwelling urinary catheters are connected by a length of
tubing to a urine drainage bag
• The tubing is secured loosely to the person’s body near
the insertion site using a catheter strap or adhesive tape
• Securing the tubing to the person’s body prevents the
catheter from being accidentally pulled out during
repositioning
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Urinary Catheterization: Caring for a Person
With an Indwelling Urinary Catheter
• A little bit of slack is left in the tubing to prevent the
catheter from pulling against the bladder outlet and the
urethral opening
• The remaining length of tubing is then gently coiled and
secured to the bed linens using a plastic clip
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Urinary Catheterization: Caring for a Person
With an Indwelling Urinary Catheter
• Coiling the tubing prevents the tubing from becoming bent or
kinked, which would stop the free flow of urine into the
drainage bag. Coiling the tubing and securing it to the bed
linens also keeps the weight of the tubing from pulling against
the person’s body.
• The drainage bag is then secured to the bed frame or the back
of the person’s wheelchair, at a level lower than the person’s
bladder.
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Urinary Catheterization: Caring for a Person
With an Indwelling Urinary Catheter
• If the drainage bag and tubing are higher than the
person’s bladder, then gravity could cause old,
contaminated urine to run back down the tubing and into
the person’s bladder, causing an infection.
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Urinary Catheterization: Providing
Catheter Care
• Nursing assistants are usually responsible for providing
catheter care.
• Catheter care involves thorough cleaning of the perineal
area and the catheter tubing that extends outside of the
body, to prevent infection.
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Urinary Catheterization: Providing
Catheter Care
• Providing good catheter care is important because the
presence of the catheter in the urethra provides a pathway for
bacteria to travel up from the perineum into the bladder,
where they can cause infection.
• In addition, having a catheter in place eliminates the “flushing”
action of normal urination, which helps to remove bacteria
from the urinary tract naturally.
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Urinary Catheterization: Providing
Catheter Care
• Because bacteria can be introduced into the body both when a
urinary catheter is inserted and after it is in place, urinary tract
infections in catheterized people are one of the most common
nosocomial infections.
• In an effort to reduce the risk of nosocomial infection in people
who are catheterized, many facilities require catheter care to
be provided routinely.
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Urinary Catheterization: Emptying Urine
Drainage Bags
• Urine drainage bags are routinely emptied and the urine
measured at the end of each shift.
• Urine drainage bags should also be emptied if they are
full.
• Leg bags need to be emptied frequently because they are
smaller, and hold less urine.
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Urinary Catheterization: Preparing for
Removal of an Indwelling Catheter
• Use of an indwelling catheter can lead to temporary urinary
incontinence when the catheter is removed, because the lack of
activity can decrease the muscle tone of the bladder.
• To prepare the bladder for removal of the catheter, it is common to
clamp the tubing of the catheter for a period of time to allow the urine
to fill the bladder.
• The tubing is then unclamped and the urine is allowed to drain from
the bladder.
• The procedure is repeated over a period of time, with the time
intervals between clamping and emptying becoming increasingly
longer.
• Then the catheter is removed and the person is allowed to void
normally.
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Urinary Incontinence
• Urinary incontinence is the inability to hold one’s urine, or the
involuntary loss of urine from the bladder
• Urinary incontinence may be temporary or permanent
• Temporary urinary incontinence can occur as a result of bladder
infection, or after an indwelling catheter that has been in place for a
long time is removed
• Permanent urinary incontinence can be caused by many things,
including
–
Decreased muscle tone in the bladder or the muscles that
support the bladder, such as occurs after childbirth or from
obesity
–
Injuries or illnesses that affect the spinal cord, the brain, or the
nerves that control bladder function
–
Dementia
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Urinary Incontinence
• Urinary incontinence can be emotionally devastating for both the
incontinent person and the person’s caregivers
• For the person who is incontinent, having wet clothes or smelling like
urine can be very embarrassing. In addition, being incontinent of
urine places a person at risk for developing skin problems and for
falling
• For the caregiver, caring for a person who is incontinent of urine can
be frustrating and emotionally draining
• Because caring for an incontinent person can be so emotionally trying
and time consuming, incontinence is the factor that most often leads
family members to have a relative admitted to a long-term care
facility
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Urinary Incontinence: Types
• There are many types of urinary incontinence
–
Stress incontinence is the involuntary release of urine from
the bladder when the person coughs, sneezes, or exerts
herself
–
Urge incontinence is the involuntary release of urine right
after feeling a strong urge to void
–
Functional incontinence occurs in the absence of physical or
nervous system problems affecting the urinary tract
–
Overflow incontinence occurs when the bladder is too
full of urine
–
Reflex incontinence occurs when there is damage to the
nerves that enable the person to control urination
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Urinary Incontinence: Managing
Urinary Incontinence
• Products available to help manage urinary incontinence
include:
– Incontinence pads
– Incontinence briefs
– Condom catheters
• In addition, techniques such as bladder training may be used
to help a person overcome certain types of incontinence
• For some people, temporary or permanent catheterization may
be necessary to manage incontinence
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Urinary Incontinence: Managing Urinary
Incontinence - Incontinence Pads and Briefs
• Incontinence pads and briefs are specially made to absorb urine and
hold it away from the person’s skin
• Incontinence pads are placed inside the person’s underpants to
prevent wetting of the clothes and to draw the moisture away from
the person’s body
• For a person who is confined to bed, bed protectors are used to help
to keep the bed linens and mattress dry and to wick urine away from
the person’s skin
• Incontinence briefs tend to fit closely, which makes it difficult for air
to reach the skin. Switching between briefs and bed protectors helps
expose the skin to air at night
• A nursing assistant must make sure that these incontinence products
are changed frequently and that urine is cleaned from the skin
whenever the change occurs
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Urinary Incontinence - Managing Urinary
Incontinence - Condom Catheters
• A condom catheter consists
of a soft plastic or rubber
sheath, tubing, and a
collection bag for the urine.
The sheath is placed over the
penis and the collection bag
is attached to the leg.
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Urinary Incontinence: Managing Urinary
Incontinence - Condom Catheters
• The urine flows through the tubing into the collection bag,
allowing the man to urinate at will
• The condom must fit the penis and should be fastened securely
enough to prevent leaking, but not so snugly as to restrict
circulation
– Adhesive material on the inside of the condom allows for a
good seal
– Or, the condom is secured with elastic tape applied in a
spiral fashion to allow for changes in the size of the penis
• Use of a condom catheter requires good skin care. The penis
must be cleaned, and the condom apparatus changed, daily
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Urinary Incontinence: Managing Urinary
Incontinence - Bladder Training
• Bladder training is commonly used to help people re-learn how
to control their urinary elimination patterns
• For example, a person may be encouraged to use the bedpan,
urinal, or commode at scheduled times. Scheduling of
elimination helps promote regular emptying of the bladder
• The primary goal is for the person to be able to control
involuntary urination. If this is not possible, then the person
may still at least be able to get to the bathroom in time to
avoid accidents
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Bowel Elimination
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Bowel Elimination: Digestive System
• The digestive tract consists of
the mouth, esophagus, stomach,
small intestine, large intestine,
rectum, and anus
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Bowel Elimination: Digestive System
• The rectum is actually part of the large intestine, and together,
the large and small intestines are sometimes referred to as
“bowels”
• The food and fluids that we take in are broken down into
smaller pieces and mixed together in the stomach, forming a
partially digested food and fluid mixture known as chyme
• From the stomach, the chyme passes slowly into the small
intestine, where more digestion occurs and nutrients and fluid
are absorbed, and then into the large intestine
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Bowel Elimination: Digestive System
• Wave-like muscular movements, called peristalsis, move
the chyme through the intestines
• Finally, the chyme reaches the last part of the large
intestine, called the rectum
• At this point, all of the nutrients have been removed, and
what remains is a semi-solid waste material, called feces
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Bowel Elimination: Digestive System
• The presence of feces in the rectum stimulates the urge
to defecate, and the feces leave the body through the
anus
• Flatus (or gas) is a natural byproduct of digestion, just as
feces are
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Bowel Elimination: Color and Odor
• In healthy people, feces
– Are soft, brown, and moist
– Have a distinct odor
• Certain foods and medications can affect the color and odor
of feces
• When helping a patient or resident with defecation, observe
the feces and report any abnormalities to the nurse
• Feces with an unusual odor or appearance could be a sign of
illness or infection
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Factors Affecting Bowel Elimination
• The factors that influence a person’s bowel elimination pattern
include
– The amount of fluid the person drinks
– The type of food he or she eats
– The types of drugs the person takes
– The person’s age
– The person’s level of activity
• A nursing assistant soon becomes aware of the bowel
elimination pattern that is normal for each person in her care.
This knowledge allows her to recognize any changes that may
occur
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Problems With Bowel Elimination
• Problems with bowel elimination that are often seen in
the health care setting include
– Diarrhea
– Constipation
– Fecal impaction
– Flatulence
– Fecal (bowel) incontinence
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Problems With Bowel Elimination: Diarrhea
• Diarrhea is the passage of liquid, unformed stool
• Diarrhea may occur frequently and can be
accompanied by abdominal cramping
• If diarrhea is frequent or excessive, the loss of fluid
from the body can quickly cause dehydration,
especially in young or elderly people
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Problems With Bowel Elimination: Diarrhea
• When caring for a person with diarrhea
– Practice good infection control techniques
– Answer the call light quickly to provide access to the
toilet, commode, or bedpan
– Provide gentle, thorough skin care after each bowel
movement to prevent skin breakdown
– Make sure to record and report the frequency and
amount of each incident of diarrhea
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Problems With Bowel Elimination:
Constipation
• Constipation occurs when the feces remain in the
intestines for too long
• The delay allows too much fluid to be reabsorbed by the
intestines, resulting in hard, dry feces that are difficult to
pass
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Problems With Bowel Elimination:
Constipation
• Risk factors for developing constipation include
– Taking medications that slow peristalsis
– Not taking in enough dietary fiber or fluids
– Not getting enough exercise
– Delaying having a bowel movement
– Lack of privacy
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Problems With Bowel Elimination:
Constipation
• There are many things a nursing assistant can do to help
a patient or resident maintain normal bowel function and
prevent constipation
– Encouraging fiber-rich foods
– Encouraging plenty of fluids
– Assisting with exercise
– Ensuring privacy
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Problems With Bowel Elimination:
Constipation
• If a person is constipated and all other methods of promoting
normal bowel function have failed, a laxative, stool softener, or
fiber supplement may need to be used
– A laxative is a medication that chemically stimulates
peristalsis so that material inside the intestines moves
through at a faster pace
– Stool softeners help to keep fluid in the feces and are used
to help prevent constipation for some people
– Fiber supplements, in the form of tablets or drink
additives, can add bulk to the feces, causing it to hold
fluid, and preventing constipation
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Problems With Bowel Elimination:
Fecal Impaction
• A fecal impaction occurs when constipation is not relieved
• The feces build up in the rectum and become harder and
harder as more and more fluid is absorbed. Eventually, it
becomes almost impossible to pass the feces normally
• The impaction blocks the passage of normal stool, but liquid
stool may go around the impacted mass
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Problems With Bowel Elimination:
Fecal Impaction
• A person with an impaction is usually very uncomfortable
and may complain of abdominal or rectal pain or of liquid
feces “seeping” out of the anus
• The person’s abdomen may be swollen
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Problems With Bowel Elimination: Fecal Impaction
• If a person is thought to have a
fecal impaction, the nurse will
perform a digital examination
• During the digital examination, a
finger is inserted into the
person’s rectum to feel for the
impacted mass (digital means
“finger”)
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Problems With Bowel Elimination:
Fecal Impaction
• The impaction is removed by using the finger to break the
impacted feces apart and scoop it out of the rectum piece by piece
• The doctor may also order the use of an oil retention enema or
drugs to help remove the impaction
• Digital removal of a fecal impaction is very uncomfortable and
embarrassing for most patients and residents
• Many facilities require that a nurse remove an impaction, but your
assistance will be necessary
• If you are allowed to remove an impaction, make sure you have
been adequately trained for the procedure and that it is part of
your job description
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Problems With Bowel Elimination: Flatulence
• Flatulence is the presence of excessive amounts of flatus (gas) in
the intestines, causing abdominal distension (swelling) and
discomfort
• People have difficulty passing flatus because of a lack of activity or
a recent surgical procedure
• Getting out of bed and walking might be all that is needed to help
the person to expel the gas
• If walking is not allowed, positioning the person on her left side
may help
• If the flatulence cannot be relieved with these methods, a nurse
may insert a rectal tube to help the gas escape
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Problems With Bowel Elimination: Fecal
Incontinence
• Fecal (bowel) incontinence is the inability to hold one’s
feces, or the involuntary loss of feces from the bowel
• Like urinary incontinence, fecal incontinence can be
temporary or permanent
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Problems With Bowel Elimination: Fecal
Incontinence
• Temporary fecal incontinence may be due to
–
A severe case of diarrhea
–
An inability to get to the bathroom quickly enough
–
Failure to answer call lights promptly
• Diseases or injuries that affect the nervous system can also result
in temporary or permanent fecal incontinence
• A person who is unconscious will be incontinent of feces
• A person who has dementia will develop fecal incontinence as the
disease progresses
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Problems With Bowel Elimination:
Fecal Incontinence - Bowel Training
• Bowel training is very similar to bladder training and works to
promote regular, controlled bowel movements
• Offering the commode or bedpan at regular scheduled intervals
is a common method of bowel training
• Bowel training is often started by keeping track of when an
incontinent person usually has a bowel movement, then
making sure to provide the appropriate toilet facilities during
that time period
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Enemas
• An enema is the introduction of fluid into the large intestine by
way of the anus for the purpose of removing stool from the
rectum
• Enemas are used to
– Relieve constipation
– Relieve fecal impactions
– Empty the intestine of fecal material before surgery or
certain diagnostic tests
• Sometimes enemas are used as part of a bowel training
program
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Enemas: Types of Enemas
• Types of enemas used in the health care setting include
– Cleansing enemas
– Oil retention enemas
– Commercial enemas
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Enemas: Cleansing Enemas
• Cleansing enemas are primarily used to remove feces from the
lower large intestine
• Tap water enemas and saline (salt water) enemas help soften
the stool and stimulate peristalsis
• Soapsuds enemas consist of water and a small amount of a
very gentle soap called castile soap. The soap solution irritates
the lining of the bowel, stimulating peristalsis
• Enemas containing these solutions should not be given
repeatedly because the intestine can absorb the solution,
causing a fluid imbalance in the body
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Enemas: Oil Retention Enemas
• An oil retention enema contains mineral, olive, or
cottonseed oil
• The oil lubricates the inside of the intestine and any stool
that is present, making the stool easier to pass or
remove
• Oil retention enemas are useful for helping to remove
fecal impactions
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Enemas: Commercial Enemas
• Commercially prepared and packaged enemas usually
contain 120 mL of a solution that irritates the intestinal
mucosa to promote peristalsis
• Some commercial enemas contain a solution that is
absorbed into the stool to make it softer and easier to
pass
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Enemas: Administering Enemas
• Enemas are ordered by a doctor and usually given by a nurse
• Some facilities allow nursing assistants to administer enemas
after adequate training
• Nursing assistants must make sure that
– They follow proper procedure and the doctor’s orders
closely
– The solution is correct for the person
– The correct amount of solution is being administered
– The solution is at the proper temperature
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Enemas: Administering Enemas
• Enema solutions that are too cool can cause abdominal
cramping and pain, while solutions that are too hot can
cause serious injury and possibly even death
• When assisting with the administration of an enema,
make sure that a bed protector and bedpan are in place,
or that the path to the bathroom is clear
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Enemas: Administering Enemas
• An enema is given with the person on her left side in Sims’
position
• When a person is lying on her left side in Sims’ position, the
intestine is positioned to take the best advantage of gravity
• After the enema has been administered, the person is asked to
hold the solution in the bowel for the specified amount of time,
and then to expel the solution
• The doctor may order a cleansing enema to be administered “until
clear,” which means that enemas are to be given until the enema
return from the person does not contain any fecal material
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Enemas: Administering Enemas
• Ask the nurse how many enemas are allowed to be given
during a particular session
• To make the procedure easier for the person, keep the person
covered as much as possible and ensure that she has as much
privacy as possible
• Having the person take a few slow, deep breaths as the enema
tubing is inserted into the rectum may help to relax the person
and make insertion easier
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Rectal Suppositories
• A rectal suppository is a small, wax-like cone or oval that is
inserted into the anus
• The wax-like substance dissolves at body temperature,
stimulating peristalsis or lubricating and softening the stool
• Glycerin rectal suppositories are often used to help with bowel
elimination before resorting to an enema
• Some rectal suppositories also contain medication. These
should only be inserted by a nurse
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Stoma
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Stoma Care
• Regardless of the type of appliance used, certain principles
remain the same regarding the client care
• Points to remember include:
– Keeping the skin around the stoma clean and dry to
minimize irritation
– Attending to the client’s privacy and modesty
– Protecting the client and the client’s bed from fecal matter
– The wearing of proper personal protection equipment
– Proper disposal of fecal waster and used equipment
– Proper cleansing and drying of the stoma area
– Effective application of the appliance
– Appropriate documentation of the procedure
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Tell the Nurse
• Urine is cloudy or contain particles, has abnormal color,
or abnormal odor
• Patient c/o difficulty or pain when passing urine
• Patient c/o frequency, urgency, or both
• Patient needs to use bathroom more frequently than
usual during the night
• Patient is having incontinence accidents or more frequent
incontinence accidents
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Tell the Nurse- When caring for
catheterized patient
• Changes in color, clarity, or odor
• Failure of urine to flow freely through the tubing
• c/o pain and discomfort from catheter
• Redness, swelling or discharge from catheter site
• Leaking around catheter insertion site
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Tell the Nurse
• Patient has diarrhea or constipation
• Blood or mucus in the stool
• Stool is black or green
• Foul-smelling stool
• Painful defecation
• Bleeding at defecation
• Swollen abdomen or c/o of and pain
• Liquid feces “seeping” from the anus
• Excessive flatus or gas
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End of Presentation
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins