CHAPTER 16

Elimination Needs
 Understand and Understand the
describe the basics of nursing care provided
urinary elimination during various
and the factors which procedures.
affect it. Understand how
Elaborate alterations urinary elimination
in urinary elimination and bowel elimination
Learning Objectives and bowel elimination. is facilitated.
Understand and
describe the process of
bowel elimination and
the factors affecting it.
 Urinary Elimination Needs
 Review of Physiology of Urine
Elimination, Composition and
characteristics of urine
 Factors Influencing Urination
 Alteration in Urinary
Elimination (retention and
incontinence)
 Facilitating urine
CHAPTER elimination: assessment,
types, equipment,
procedures and special
OUTLINE considerations
 Providing urinal/bedpan
 Care of patients with
 Condom drainage
 Intermittent
Catheterization
 Indwelling Urinary
catheter and urinary
drainage
 Urinary diversions
 Bladder irrigation
Bowel Elimination Needs
 Review of the physiology of
bowel elimination, composition
and characteristics of faeces
 Factors affecting bowel
elimination
 Alteration in bowel elimination
 Facilitating bowel elimination:
assessment equipment,
procedures and special
considerations
 Passing of Flatus tube
 Enemas
 Suppository
 Sitz bath
 Bowel wash
 Digital Evacuation of
impacted feces
 Care of patients with Ostomies
(Bowel Diversion Procedures)
URINE
ELIMIN
ATION
NEEDS
 The function of the
urinary system is to
filter blood and create
REVIEW OF urine as a waste by-
PHYSIOLOGY product.
OF URINE
ELIMINATION Urination is the
process by which
the urinary bladder
is emptied.
ORGANS OF URINARY SYSTEM

Kidneys
Renal pelvis
Ureters
Bladder
Urethra
ORGANS OF URINARY SYSTEM
 KIDNEYS

• A pair of kidneys is located on each side of the spinal

column, and is retroperitoneal.
• Kidneys regulate the acid-base balance of the body.
• The functional unit of the kidney is the nephron. These
nephrons are responsible for filtering the blood and
removing body waste.
• Every minute, around 1.2 L of blood is filtered.
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KIDNEYS
 URETERS
The collecting ducts carry the urine from the kidneys
to the ureters by passing through the calyces and
pelvic floor.
The ureters end into the urinary bladder, where at the
junction, a flap-like structure of mucus acts as a valve.
This valve prevents the reflux of urine from the
bladder back to the ureters.
 URINARY BLADDER
The smooth muscles of
the urinary bladder are Trigone is a triangular area at
called the detrusor the base of the bladder and is
muscle. These muscles marked by the opening of the
allow the bladder to be ureter posteriorly and the
filled up with urine, by urethra anteriorly.
the action of expansion.
 URETHRA
The urethra is the extension of
the urinary bladder into the
urinary meatus. Hence, it acts
as a passage for the urine for
elimination.
 PELVIC FLOOR
The pelvic floor consists of muscles and
ligaments that are responsible for the
provision of support to the viscera of the
pelvis.
Through the pelvic floor passes the
vagina, urethra and rectum of a human.
 PROCESS OF URINARY
ELIMINATION
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PROCESS OF URINARY ELIMINATION
GLOMERULAR FILTRATION
• This is the first step of urine formation.
• This process is marked by the movement of
water and more solutes from blood plasma
through the walls of glomerular capillaries.
• These capillaries filter the substances and then
these substances are moved into the renal
tubule through the glomerular capsule.
 TUBULAR REABSORPTION

About 99% of the filtered water along with

certain useful solutes is reabsorbed by the tubule
cells.
These solutes and water return to the blood
through the vasa recta and peritubular capillaries.
 TUBULAR SECRETION
 Other materials such as wastes, drugs, ions, which are in excess are secreted by the
duct cells and renal tubules. This process is responsible for removing the
substances from the blood.
 These substances, as they are drained into calyces and renal pelvis, urine is formed
and is excreted.
 Urea is one of the major protein wastes that is excreted through urine. About 25–30
g of urea is produced daily. Other substances that must be excreted are creatinine,
phosphates, sulfates, and uric acid.
 BLADDER EMPTYING
The process of micturition is mediated by the
micturition reflex in the sympathetic and
parasympathetic nervous system.
Micturition occurs in a sequence of events.
 BLADDER EMPTYING
(EVENTS OF MICTURATION)
The bladder is stimulated and is contracted by the action of the efferent pelvic nerve,
which originates from S1 and S4 area.

As the bladder is contracted, the striated urethral sphincter is relaxed.

The urethral pressure is dropped, the detrusor muscle is contracted, the vesicle neck
and proximal urethra is opened.

Finally, the urine flows down. The muscarinic and cholinergic receptors are also
involved in this process.
COMPOSITION OF URINE

Urine is the liquid

waste of the human
body. Water constitutes
about 96% of the urine
in a healthy human
being. 1–2 Liters of
water is excreted as
urine every day.
COMPOSITION OF URINE
COMPOSITION OF URINE
CHARACTERISTICS OF URINE

Sterility Quantity

Density Composition

Characteristics

Specific
Color
gravity

pH Odor
Turbidity
 QUANTITY
• Around 1.4 L of urine is produced every day in an
adult human being.
• The whole quantity of urine is released in 6–8
micturition.
• However, the frequency may depend upon the
hydration status and individual health of a person.
• When the production of urine is altered, it may lead
to polyuria or oliguria. These conditions must be
noted and must draw medical attention.
ALTERATIONS IN URINE
PRODUCTION
 COMPOSITION
Urine contains 91–96% of water, and the rest
of it is constituted by solid inorganic and
organic compounds. These compounds can
be urea, proteins, phosphates, or sodium, etc.
 COLOR
The color of urine depends on various aspects including the hydration status of an
individual.
Colorless to amber; Pale yellow Normal urine
Dark yellow urine Dehydrated body; due to bilirubin or jaundice

Green urine Due to biliverdin

Orange urine Due to rifampicin
Presence of blood in urine Due to some bodily conditions; also known as
hematuria
Brown urine Due to hemochromatosis
Black or grey urine Due to melanin or homogentisic acid
 ODOR
o The presence of a strong odor in urine may indicate urinary tract
infections (UTI) because the urine of a healthy person doesn’t
have any odor.
o Mainly odor is due to ammonia.
o A sweetish and fruity smell indicates the presence of ketone
bodies, therefore urine and blood sugar must be assessed.
 TURBIDITY
Visible cloudiness appears in case the urine
is infected by bacteria, or if the salts are
crystallized. This is called turbidity.
 pH
The normal pH of urine of a healthy human
being ranges between 5.5 and 7, with the
average urine pH being 6.2.
 SPECIFIC GRAVITY
It is high when the patient has kidney
failure or gastric suction is done,
vomiting and UTI.
 DENSITY

The normal specific

density of human urine is
1.003–1.035.
STERILITY

Urine isn’t sterile even

inside the bladder.
Urine can remain
sterile until it reaches
the urethra.
FACTORS AFFECTING URINATION
FACTORS AFFECTING URINATION
FACTORS AFFECTING URINATION
 ALTERATION IN URINE
ELIMINATION
Urinary elimination is altered when the patient is not able to
pass the urine or control the urge to pass the urine.
Alteration in urine elimination

Urinary retention

Urinary incontinence
 URINARY RETENTION
• Urinary retention can be described as a situation when the
process of bladder emptying can be impaired, which leads
to the accumulation of urine inside the bladder.
• This results in the overdistension of the urinary bladder.
• As the overdistension worsens, the detrusor muscles
become poorly contractible, which results in the further
worsening of the urination process.
• The process of urination can be affected due to many
factors.
 CAUSES OF URINARY
RETENTION
• Retention of urine can be due to obstruction present in

Obstruction the urethra. The obstruction can be from inside or

outside, and can be due to various reasons such as the
enlargement of the prostate gland, etc.

Muscle bladder • Muscle bladder stimulation is decreased due to various

reasons such as paralysis, alcoholism, etc.
stimulation
• The muscle tone of the bladder is decreased or is absent
Decreased due to which the bladder cannot contract appropriately.
muscle tone As the bladder contractility is decreased or is absent, it
causes problems in micturition.
 CAUSES OF URINARY RETENSION

• The pressure imposed on the bladder due to pregnancy, any

Pressure imposed tumor or fecal impaction can lead to urinary retention.

• When a person doesn’t consume enough fluids, urinary

Fluid volume deficit retention may occur. As the intake is less, the urine
production is less, and the bladder takes time to fill.

• Retention can occur due to changes in lifestyles. Lack of

Lifestyle exercise, hospitalizations, change in home, etc can cause
retention.

• Certain medications suppress urine production and interfere

Medications with elimination.
ROLE OF THE NURSE WHILE CARING FOR
THE PATIENT WITH URINARY RETENTION
ROLE OF THE
NURSE
WHILE
CARING FOR
THE PATIENT
WITH
URINARY
RETENTION
 URINARY INCONTINENCE
• Urinary incontinence is a symptom, not a
disease.
• It is defined as the leakage of urine from the
urinary bladder, involuntarily.
• Urinary sphincters are unable to control the
urine passage and thus the urine leaks from
the bladder.
 Urinary
incontinence

Complete Partial
URINARY
INCONTINENCE
The bladder is not
The bladder is drained completely,
leaked and emptied and the urine just
completely. dribbles from the
bladder.
 • Old age: It is a common problem in
the older population.
• Unconsciousness
• Neurological conditions leading to
damage and inability to control
CAUSES OF • Perineal
INCONTINENCE muscle weakness can lead to
incontinence
• Incase of any tumors, such as prostate
enlargement, can cause incontinence
• Effects
of certain drugs that lead to
lowered voiding sensation.
TYPES OF INCONTINENCE
TYPES OF INCONTINENCE
ROLE OF NURSE
WHILE CARING
FOR THE PATIENT
WITH URINARY
INCONTINENCE
ROLE OF NURSE WHILE CARING FOR THE
PATIENT WITH URINARY INCONTINENCE
TYPES AND COLLECTION OF
URINE SPECIMEN

After blood, urine is

the most commonly
used specimen for
diagnostic testing,
monitoring of disease
status and detection
of drugs.
 TYPES OF URINE COLLECTION
METHODS

Random specimen

• Void at any time of the day or night and collect a portion of the urine in a clean container. It is not regarded as a specimen of
choice because of the potential for dilution of the specimen when collection occurs soon after the patient has consumed
fluids.

First-morning specimen

• It is taking the sample in the morning from the first urine of the patient. It is a choice for urinalysis and
microscopic analysis, since the urine is generally more concentrated.
 TYPES OF URINE COLLECTION
METHODS
• The patient voids the first portion of the urine stream
into the toilet. This significantly reduces the
opportunities for contaminants to enter the urine stream
during the collection of the clinical specimen. The
Midstream urine midstream is then collected into a clean container
after which the remaining urine is voided into the toilet.
specimen This method of collection can be conducted at any time
of day or night. This is recommended for
microbiological culture and antibiotic susceptibility
testing because of the reduced incidence of cellular and
microbial contamination.
TYPES OF URINE COLLECTION METHODS

Specimen from the catheter Suprapubic specimen

• Urine specimens can be
collected from catheters (e.g.,
Foley’s catheter) using a • Collection of the specimen by
syringe, followed by transfer
needle aspiration through the
to a specimen tube or cup.
abdominal wall into the
Alternatively, urine can be
bladder.
drawn directly from the
catheter to an evacuated tube
using an appropriate adaptor.
 All urine collection and/or transport containers
should be clean and free of particles or interfering
substances.
The collection and/or transport container should
have a secure lid and be leak-resistant.
Leak-resistant containers reduce specimen loss and
SPECIMEN healthcare worker exposure to the specimen while
TRANSPORT also protecting the specimen from contaminants.
It is a good practice to use containers that are made
GUIDELINES of break-resistant plastic, which is safer than glass.
The container material should not leach interfering
substances into the specimen.
Specimen containers should not be reused.
 z SPECIMEN TRANSPORT
GUIDELINES
 Take collection container that holds at least 50 mL, has a wide base and an opening of at least 4
cm. The wide base prevents spillage and a 4 cm opening is an adequate target for urine
collection.

 The 24-hour containers should hold up to 3 L.

 The containers should have secure closures to prevent specimen loss and to protect the
specimen from contaminants.

 Transport tubes should be compatible with automated systems and instruments used by the lab.

 National Committee for Clinical Laboratory Standards (NCCLS) recommends the use of an
amber-colored container for specimens being assayed for light-sensitive analytes, such as
urobilinogen and porphyrins. The colorant prevents the degradation of certain analytes.

 Proper labeling should be applied to the collection container or tubes.

URINE SPECIMEN HANDLING GUIDELINES

Labels include the patient’s name and identification on it.

Make sure that the information on the container label and the requisition match.

If the collection container is used for transport, the label should be placed on the container
and not on the lid, since the lid can be mistakenly placed on a different container.

Ensure that the labels used on the containers are adherent under refrigerated conditions.
 URINE SPECIMEN HANDLING
GUIDELINES
• Ensure that there is sufficient volume to fill the tubes and/or
perform the tests.
• Under filling or overfilling containers with preservatives
may affect specimen-to-additive ratios.
• Collection date and time should be included on the
specimen label. This will confirm that the collection was
done correctly.
• For timed specimens, verify start and stop times of
collection.
 SPECIAL CONSIDERATIONS FOR
COLLECTION OF URINE SPECIMEN
SPECIAL CONSIDERATIONS FOR COLLECTION OF
URINE SPECIMEN
 PROVIDING BEDPAN/URINAL

A bedpan or a urinal can be described as devices,

which are used by patients who are unable to get
FACILITATING out of bed to urinate or have a bowel movement.
URINARY The reason for using a bedpan can be any, such as
ELIMINATION an injury or disease, which makes people unable
to walk. A urinal is used by male patients to
urinate while the bedpan is used for bowel
movement. However, a female patient uses a
bedpan for both purposes.
PROVIDING BEDPAN/URINAL
 PROVIDING BEDPAN/URINAL
ARTICLES PROCEDURE
• A bedpan/Urinal Refer book (page no. 404)
• A basin containing
lukewarm water
• Towels
• Wash clothes
• Powder
• Mackintosh and towel
 CLEANING AFTER USING
BEDPAN/URINAL
• Clean patient’s buttocks and perineum with toilet paper.
• Clean the area with wet wipes or washcloth (wet).
• Soap and water can be used.
• Area is then dried.
• The nurse can then assess for any rash or lesions on the skin of the buttock
region due to any irritation or moisture. Report to the physician, if any.
• After the patient is done defecating, the patient can wash his/her hands.
• The bedpan is then taken to the toilet and the contents are emptied.
• Then, it is cleaned using soap and water and dried. Other disinfectants can be
used, as per institutional policies.
 NURSING CARE OF THE CLIENT
WITH CONDOM DRAINAGE

Condom drainage is a
method of managing
incontinence in male patients
in which a condom is used to
attach to a plastic drainage
tube and is rolled over the
penis. The tube, from the
other end, is connected to a
drainage bag.
NURSING CARE OF THE CLIENT
WITH CONDOM DRAINAGE
PURPOSES OF CONDOM
DRAINAGE
 APPLICATION OF CONDOM
DRAINAGE

• PROCEDURE
Refer book (page no. 405)
ROLE OF NURSE IN APPLICATION
OF CONDOM DRAINAGE
URINARY CATHETERIZATION

Urinary catheterization is a procedure,

where a catheter (hollow tube) is inserted
into the bladder to drain or collect urine.
TYPES OF URINARY CATHETERIZATION
Types
Intermittent

Indwelling

Suprapubic
INTERMITTENT CATHETERIZATION
Intermittent Catheterization is
defined as a procedure
performed medically in a
situation when a patient is in
medical need of
catheterization, but for a
shorter period of time.
The intermittent catheterization is
required for urinary bladder emptying.
It can be done easily by the patient
himself at home or by the nurse in
hospital settings. The major indication
for intermittent catheterization is
neurogenic bladder.
INTERMITTENT CATHETER
BENEFITS OF INTERMITTENT
CATHETERIZATION
 INTERMITTENT CATHETERIZATION

• PROCEDURE
Refer book (page no. 406)
INTERMITTENT CATHETERIZATION
CONSIDERATIONS
INDWELLING CATHETERIZATION
• An indwelling catheter, also called Foley’s catheter is
defined as a device, which helps in the drainage of the
urinary bladder.
• The catheter that is inserted inside is sterile in nature.
• The indwelling catheter consists of a catheter and a
balloon that retains the catheter inside the bladder.
• The catheter is connected to the collecting device such
as a drainage bag.
INDWELLING CATHETER
 PARTS OF FOLEY’S
CATHETER
Balloon inflation port It has an inscription of the
amount to be instilled in the
balloon.
Uro bag connector From this port urine will drain.
Balloon It keeps the catheter in place.
Distal end of catheter It is an opening at the tip and an
eye on the lateral surface.
SIZE OF THE FOLEY’S CATHETER
 PURPOSES OF INDWELLING
CATHETERIZATION
• For bladder emptying
• For collecting the sterile urine sample
• To relieve bladder distention
• To relieve urinary incontinence
 INDWELLING CATHETERIZATION

ARTICLES PROCEDURE
• Sterile dressing set (two bowls, Refer book (page no. 407)
artery forceps, thumb forceps,
sponge holder, cotton and gauze
piece, kidney tray)
• Sterile sheet (hole sheet)
• Antiseptic solution, saline
• Syringe for balloon inflation
• Foley’s catheter and Urobag
• Adhesive tape to secure the
catheter
 SUPRAPUBIC CATHETERIZATION
• It is the placement of a drainage tube into the urinary bladder
just above the pubic symphysis.
• This is typically performed for individuals who are unable to
drain their bladder via the urethra.
• Suprapubic catheterization offers an alternative means to drain
the urinary bladder when other methods are not clinically
feasible, undesirable or impossible.
 SUPRAPUBIC
CATHETERIZATION
 INDICATIONS FOR SUPRAPUBIC
CATHETERIZATION

• Urinary retention when urethral catheterization is not

feasible.
• When the urethra is damaged or injured.
• If the pelvic floor muscles are weakened, causing a
urethral catheter to fall out.
• After surgeries that involve the bladder, uterus, prostate,
or nearby organs.
 CONTRAINDICATIONS FOR SUPRAPUBIC
CATHETERIZATION
• Nondistended bladder and bladder malignancy.
• Active skin infection, coagulopathy, osteomyelitis
of the pubis.
COMPLICATIONS OF
SUPRAPUBIC
CATHETERIZATION
ROLE OF NURSE IN URINARY CATHETERIZATION
Hygiene
Diet Catheter changing

Fluid Intake-output

Role of nurse
 FLUID
The nurse has to encourage the patient for the intake of a good
amount of fluid orally. It is advisable to drink up to 3 L of
fluids every day for a patient with an indwelling catheter,
unless contradicted due to any disease condition. As the
patient’s intake is high, accordingly the output will also be
high. The urine thus helps to flush the bladder and urethra and
prevents infection due to urinary stasis. The flushing of the
bladder and urethra helps to remove any obstruction, if present.
 DIET
• To reduce the risk of urinary tract infection, the urine must
be acidic in nature. Also, acidic urine prevents the
formation of calculi.
• Intake of food products that promote the urine to turn acidic
must be promoted by the nurse.
• These items are eggs, meat, cranberry, plums, and prunes.
On the other hand, milk and milk products turn the urine
alkaline.
 HYGIENE
• Perineal care is advised. However, no specific cleaning is
required.
• Routine hygiene practices have to be followed by the
patients.
• The nurse can guide the family or the patient on how to
perform perineal and catheter care and if necessary, the
nurse can even assist them with the procedure.
 CATHETER CHANGING
The catheter or tubing is not changed regularly. If the
catheter and drainage system is impaired, or there is
some evidence of collection of certain salts in the form
of sediments in the tube, the catheter can be changed.
Regular insertion of a new catheter can injure the
perineum and promote the chances of infections.
 INPUT-OUTPUT

The nurse has to maintain the documentation

where the accurate input and output is
mentioned to assess the hydration status of the
patient and the urinary functions.
 REMOVAL OF THE
URINARY CATHETER
 REMOVAL OF THE
URINARY CATHETER
 BLADDER IRRIGATION
This
procedure is
Bladder
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functional.
 ARTICLES FOR
BLADDER IRRIGATION
 BLADDER IRRIGATION
PROCEDURE
Refer book (page no. 409)
BLADDER IRRIGATION
• Urinary diversion is defined as the process by which the urine flow is
diverted.
• It is a surgical procedure in which the urine is diverted and re-routed from
the kidneys and is directed to a body part other than the bladder.
• Through diversions, a new pathway is built for the urine to bypass and
thus, urine exits from a new site.
• This procedure is performed when the urinary tract or some part of the
urinary tract is diseased.
• For instance, if the bladder tumor requires cystectomy, urinary diversion
can be performed. Other malignant conditions of the bladder can require
this procedure.
INDICATIONS FOR URINARY DIVERSION
TYPES OF URINARY DIVERSIONS
Types

Incontinent

Continent
 INCONTINENT
In this type of diversion, an Ureterostomy
appliance from outside is
required for the urine to Nephrostomy
drain and contain since there
is no control on how the
urine passes. It is not Vesicostomy
essential that the urinary
bladder has to be removed. Ileal conduit
 TYPES OF INCONTINENT URINARY
DIVERSION
TYPE DESCRIPTION
Ureterostomy A small stoma is formed on the side of the
abdomen, where one or both the ureters are
connected to it directly. These stomas impair
urinary drainage and provide a port for the
entry of the microorganisms.
Nephrostomy Urine is diverted to the stomas from the
kidneys.
 TYPES OF INCONTINENT
URINARY DIVERSION
TYPE DESCRIPTION
Vesicostomy In this case, micturation from the urethra isn’t possible.
However, the bladder is not excised. Ureters remain attached to
the bladder and an opening happens to be attached with the
bladder wall through surgical manipulations.
Ileal conduit In this case, a small portion of the ileum is removed. The end of
the intestine is attached again. A pouch-like structure is formed
as the one end of the removed portion is sutured. A stoma is
created as the other end is brought out of the abdominal wall.
This is the most common kind of diversion performed, in which
the urine is drained through the ileal pouch.
 CONTINENT
• The continent diversion helps
the patient to control the Types of continent urinary diversion
urine flow.
• A reservoir for urine is Intermittent catheterization of the inner reservoir
(Kock pouch)
Straining during voiding
(Neobladder)
formed inside the body using
the part of the ileum. If a
patient has undergone this
procedure, there may be
certain problems due to body
image and sexuality.
However, these activities are
resumed shortly after the
procedure.
 KOCK POUCH
• In the ‘Kock’ pouch, small nipple valves are created as the tissue
is doubled backward in the reservoir, the junction where the
pouch and skin connect and the ureter and pouch connect.
• The valves fill up with the urine, which prevents the leakage and
reflux of urine.
• The pouch can be emptied by inserting a catheter by the patient
himself at a regular interval. In between the catheterization, the
stoma is covered using a small dressing for protection purpose.
This dressing also prevents the spoilage of cloths.
KOCK POUCH
 NEOBLADDER
• In neobladder, the original bladder is replaced with a
piece of ileum since the bladder could be diseased or
damaged beyond repair.
• This piece of ileum, acting as the bladder is then
sutured to the urethra and thus, the patient can void
easily with complete control over the voiding
process.
NEOBLADDER
ROLE OF NURSE IN MAINTENANCE
OF URINARY DIVERSION
 CARE OF
THE
PATIENT
BEFORE
AND AFTER
THE
URINARY
DIVERSION
 Perineal care involves
washing the external
genitalia and surrounding
PERINEAL with soap and water or
CARE with water alone or in
combination with any
commercially prepared
peri-wash.
INDICATIONS FOR PERINEAL
CARE
 PERINEAL CARE
PRELIMINARY ASSESSMENT PRELIMINARY ASSESSMENT

• Assess the condition of • Assess whether perineal care

perineal skin for any itching, should be done under an
irritation, ulcers, edema, aseptic technique or a clean
drainage, etc. technique.
• Assess the need and • Check the physician’s order for
frequency of perineal care. any specific instructions.
• Assess the patient’s ability • Assess the patient’s mental
for self-care. state to follow instructions.
ARTICLES FOR PERINEAL
CARE
 PREPARATION OF THE PATIENT
 Explain the procedure to the patient and provide privacy by screens and drapes.
 Remove all the articles that may interfere with the procedure, e.g., air cushion.
 Give extra pillows to raise the head.
 Roll the draw sheet to the opposite side to prevent soiling when bedpan is placed
under buttocks, over draw sheet.
 Offer bedpan. Keep the clean bedpan on the bed on your working side.
 Leave the patient for some time so that he/she may pass urine or stool if
necessary.
 Get the toilet tray and arrange the articles conveniently on the bedside table.
 PERINEAL CARE

PROCEDURE FOR PERINEAL CARE

Refer book (page no. 413)
 PERINEAL CARE
AFTER CARE
◦ Apply the medicine and pad if necessary.
◦ Remove the Mackintosh if an extra one is used.
◦ Change linen if necessary and straighten the bed clothes. Arrange the bed linen.
◦ Make the patient comfortable.
◦ Take the bedpan. Remove cotton swabs, and empty the contents into the toilet.
◦ Clean all the articles.
◦ Replace the articles.
BOWEL
ELIMIN
ATION
NEEDS
 REVIEW OF PHYSIOLOGY OF BOWEL
ELIMINATION

Feces or stool refers to the solid waste excreted from the

body. To maintain good health, this excretion is necessary.
The major nursing responsibilities in bowel excretion are
associated with the assessment of functions, their
maintenance of good health and managing any alterations,
if present.
 LARGE INTESTINE
The large intestine is the part of the digestive tract, which extends
from the ileocecal valve to the anus.
 LARGE
INTESTINE
The large intestine majorly absorbs
water and nutrients. It also
promotes fecal elimination. It
almost takes 48 hours to 4 days to
excrete the complete contents of
ingested food.
There is a formation of the pouch,
called haustra because the
longitudinal muscles are shorter than
the colon.
 CHYME
Chyme is the waste product that
moves through the small intestine
to the ileocecal valve. This valve is
responsible for regulating the flow
of chime and preventing backflow.
LARGE
Out of 1500 mL chyme that passes INTESTINE
into the large intestine, 100 mL is
reabsorbed in the proximal part of
the colon, daily. The fluid excreted
through feces is about 100 ml.
 LARGE INTESTINE
MUCUS
• The lining of the colon secretes mucus that acts as a protective
agent.
• The functions of mucus are:
Protects the walls of the large intestine from the acid present in feces.
Acts as an adherent as it holds the feces together.
Protects the lining of the intestine from microbes.
 LARGE INTESTINE
MOVEMENT OF WASTE
PRODUCT
 The waste products move from colon to anus
from where they can be eliminated eventually.
 Along with the feces, flatus; which is mainly
air and by-products of carbohydrate digestion,
is excreted.
MOVEMENTS OF WASTE PRODUCTS

Haustral • When the chyme is moved back and forth inside the haustra, the
movements are called haustral churning. This helps in the mixing of
contents and absorption of water. It also pushes the waste products
churning further into the next haustra.

•The movement produced by the muscle fibers of the

Peristalsis intestine is the peristalsis. It is wave-like in nature, which
pushes the waste products forward.

Mass •Mass peristalsis is the movement in which

the muscles of the colon contract powerfully.
peristalsis
 RECTUM AND ANAL CANAL
• Inadults, the rectum and anal canal are 10–15 and 2.5-5 cm
long, respectively.
• The rectum contains vertical folds, which further contain
veins and arteries. These folds are responsible for holding the
feces inside the rectum. If, due to pressure, these veins
become distended, hemorrhoids occur.
• The anal canal has sphincters, internal and external. These
sphincters are under involuntary and voluntary control,
respectively.
 DEFECATION
Defecation is also referred to as bowel
movement. It is the excretion and
expulsion process of feces from the
anus.
 PHYSIOLOGY OF DEFECATION

The external
The amount sphincter works
and frequency As the internal voluntarily. So, as
of defecation sphincter the person uses The feces
and defecated relaxes, the the bathroom or expulsion takes
waste depend feces move into bedpan, the place.
on an the anus. external
individual. sphincter relaxes
voluntarily.
 COMPOSITION OF NORMAL
FECES
 Normal feces of a healthy adult human being is
composed of various constituents, out of which the
majority of the portion is constituted by the water.
 Fecescontains up to 3/4th of water, that is around
75% of the feces is composed of water. The rest 1/4th
or 25% of the feces is solid waste.
 Feces also contain some amount of roughage, which
is undigested. It also contains unabsorbed food.
 COMPOSITION OF NORMAL
FECES
The mucus that lines the large intestine is excreted along with the
feces. There may also be the presence of some intestinal
secretions.
In addition to that, digestive juices such as bile and bile pigments
and salts are also present in the excreta.
The normal flora and bacteria such as Escherichia coli gets
excreted with the feces. Moreover, the dead epithelial cells also
constitute the feces.
CHARACTERISTICS OF NORMAL AND
ABNORMAL FECES
z
FACTORS AFFECTING BOWEL
ELIMINATION
z
FACTORS AFFECTING BOWEL
ELIMINATION
FACTORS AFFECTING BOWEL
ELIMINATION
 FACTORS
AFFECTING
BOWEL
ELIMINATION
 ALTERATION IN BOWEL
ELIMINATION

Constipation
Diarrhea
Bowel incontinence
Flatulence
 CONSTIPATION
• Constipation refers to a situation when a person passes stool
less than three times a week.
• The stool may move extremely slow or may remain inside the
large intestine for a longer period.
• The stool, if passed during the constipated stage, is very dry
and hard, because when the stool stays longer in the large
intestine, there is additional reabsorption of the water or fluids.
• During constipation, there is a feeling that the bowel is not
completely evacuated.
CHARACTERISTICS OF
CONSTIPATION
 CAUSES OF CONSTIPATION
Insufficient fiber
Diet
and roughage in
restrictions the diet

Any changes in
Insufficient
the defecation
 CAUSES OF
CONSTIPATION
Exploitation of drugs like
Emotional instability
morphine, codeine

Intake of caffeine containing

beverages in excess Natural aging process
COMPLICATIONS OF CONSTIPATION

Hemorrhoids

Fissures

Ulcers
 ROLE OF NURSE IN THE
MANAGEMENT OF CONSTIPATION
Health education

The nurse must provide health education to the client about constipation, its side effects and
further factors, which affect the bowel eliminations process.

Diet

If the diet is not sufficient, it may lead to constipation. Therefore, diet intake must be
adequate so as to avoid or manage constipation.
 Elimination Privacy
Roughage pattern • Providing privacy
and fiber • It is essential that to a patient while
• Foods containing a defecation defecating is of
ROLE OF roughage and pattern is utmost
fiber such as established to importance
NURSE IN THE vegetables and avoid because privacy
MANAGEMENT fruits should be constipation. helps to have a
bowel movement.
included in the Some people
OF diet. In addition form a pattern to Therefore, the
CONSTIPATION to this, a healthy defecate patient must be
left alone if
breakfast should immediately after
be included as a breakfast while provided with a
part of a healthy some defecate bedpan to spare
diet. immediately after him of the
waking up. embarrassment.
 ROLE OF NURSE IN THE
MANAGEMENT OF
CONSTIPATION

Emotional stability Position Physical activity

• For the purpose of
defecation, the squatting
• The patient position is the most • Exercises and physical
without
effective one since, in
anxiety or depression is activities help to
this position, intra-
likely to have a better improve the muscle tone
abdominal pressure can
bowel movement than of the abdomen and
be increased by the
otherwise. perineum.
client. This pressure is
necessary for the
expulsion of feces.
 • On average, an individual
must take 2-3 L of water
Fluid
every day. This can
intake prevent the feces from
ROLE OF
being dry and hard.
NURSE IN THE
MANAGEMENT
• Since laxatives are habit-
OF
CONSTIPATION forming drugs; these
should not be taken in
Laxatives
excess. The use of these
drugs should be
discouraged and avoided.
 DIARRHEA
 Diarrhea refers to a condition in which liquid and watery stools are
passed by an individual. In addition, the frequency of passage of stool
also increases.
 In case of diarrhea, the gut mobility is increased, which results in the
quick passage of the chyme. As the chyme passes rapidly, the large
intestine cannot reabsorb the water and electrolytes. Due to this, there is
an evident loss of water and electrolytes from the body.
 Diarrhea is definitive if the consistency of the feces is watery, and the
frequency of passage of stool is not much significant.
 It is accompanied with an increased urge to defecate. Along with
diarrhea, there may be some abdominal cramps, increased bowel sounds.
 CAUSES OF DIARRHEA
Enteritis Some microorganisms can cause intestinal infection as they damage the
mucus layer of the gut, e.g., amoebiasis, food poisoning, etc.
Emotional instability If the parasympathetic nervous system is stimulated excessively, gut
mobility is increased. Also, there is an increase in colon secretions. These
conditions result in psychogenic diarrhea.
Medications Certain medications such as antibiotics, iron medications, etc. are irritant
to the
gut resulting in diarrhea.
Mechanical reasons Due to some conditions such as bowel obstruction, tumors may cause
diarrhea.
Others Malabsorption syndrome, narcotic withdrawal, gluten intolerance.
 COMPLICATIONS OF DIARRHEA

If the diarrhea is persistent, there may be:

Anal irritation Fatigue Weakness Chances of dehydration

 ROLE OF NURSE IN THE
MANAGEMENT OF DIARRHEA
FECAL/BOWEL INCONTINENCE

It is defined as the loss of voluntary control

over the passage of the feces and gaseous
discharge from the anal sphincter. There may
be a specified time for the discharge or it may
occur anytime. Specified time may include
just after ingestion of meals.
 TYPES OF
FECAL
INCONTINENCE
 FECAL/BOWEL INCONTINENCE
Fecal incontinence is the result of There are some surgical
impaired sphincters or procedures, which can help to
impairment of nerve supply. correct fecal incontinence.
Conditions may include tumors, Through surgeries, sphincters
traumas to muscles and can be repaired.
sphincter,
any neuromuscular condition,
etc.
FLATULENCE

Flatulence or tympanites can be defined

as the condition in which gas is
accumulated in the GI tract. The
accumulation of gas is excessive. The
gas accumulated is called flatus. The
accumulated gas can result in the
distention of the abdomen.
CAUSES OF FLATULENCE
Causes

Excessively swallowed Bacterial action on the Diffused gas between

air chyme blood and intestine
 CAUSES OF FLATULENCE
• Result of anxiety, improperly drinking or eating food, smoking, chewing the
Excessively swallowed air
gum, etc.

• Due to the bacterial action, gas produced in the large intestine is eliminated
Bacterial action on the
through the anus. The gas-forming foods result in the accumulation of flatus
chyme
in the intestine. These foods are radish, carrot, onion, cabbage, etc.

Diffused gas between • There is evidence of the diffusion of gas from the bloodstream into the
blood and intestine intestine.
TYPE AND COLLECTION OF SPECIMEN
OF FECES

Fecal specimens are usually obtained for

microbiological examination to identify
pathogenic organisms that cause
gastrointestinal infections, such as
bacteria, viruses and parasites.
 INDICATIONS FOR COLLECTING A
FECAL SPECIMEN
• Investigate suspected infective diarrhea in patients who are
systematically unwell with symptoms of diarrhea, vomiting,
pain, weight loss and fever.
• Identify suspected parasites such as tapeworms.
• Investigate diarrhea associated with the use of antibiotics.
• Screen symptomatic contacts of patients with infection
associated with organisms such as Escherichia coli.
• Identify occult blood in the stool.
COLLECTING A FECAL SPECIMEN
■ A clean technique should be used to collect the
stool sample to avoid contamination, which may
result in inappropriate treatment.
■ Although contamination with urine should be
avoided where possible, fecal specimens can still
be processed by the laboratory if urine is present.
COLLECTING A FECAL SPECIMEN
ARTICLES PROCEDURE
• A clean bedpan or disposable Refer book (page no. 418)
receiver—ensure the
• bedpan is not contaminated with
detergent or disinfectant, which
may affect the results.
• Clean tray to carry equipment
• Sterile specimen pot with an
integral spoon
• Nonsterile gloves
• Apron
• Specimen form and specimen bag
 AFTER CARE
• Remove gloves and apron and dispose of them.
• Wash hands with soap and water.
• Examine the specimen and record the color, consistency and odor of the
stool as part of the nursing assessment.
• Label the sample and complete the microbiology form.
• Put the sample in a specimen bag.
• Send the sample to the laboratory as soon as possible.
• Document the procedure in the patient’s notes.
COLOR AND CONSISTENCY OF
FECES
FACILITATING BOWEL
ELIMINATION
PASSING OF FLATUS TUBE
Flatus is Refer
the
gaseous book
accumul (page
ation in
the
no.
intestine 418)
. To
relieve
Pr
the Descr ed
flatus
and iption e
FLATUS TUBE
 ENEMA

An enema can be
defined as the fluid
that is introduced
inside the rectum to
clean the lower
bowel, and/or to
insert any
medications.
 PURPOSES OF ENEMA

Treating constipation Softening of fecal matter

Administration of
Stimulate defecation
medications
 TYPES
OF
ENEMA
BEFORE
GIVING
ENEMA
 • Given to clean the bowel
EVACUANT • Patient holds it for 5 to 10
ENEMA minutes
(CLEANSING • Most suitable position – left
ENEMA) lateral position
• In case of high bowel enema,
knee-chest position may be
given.
 SIMPLE ENEMA
Main purposes • Stimulation of defecation
• Treatment of constipation

Other purposes • To relieve flatulence.

• Helps in relieving urinary retention.
• Before surgeries or X-ray, to clean the
bowel.
• For stimulation of the uterus and
initiating contractions.
In this enema, either soap water or normal saline can be used.
 MEDICATED ENEMA

The addition of some agent

is done in the water like
glycerine or oils.
 TYPES OF MEDICATED ENEMA
Oil Enema
• In case the patient is suffering from severe
constipation, oil enema can be provided to
soften the fecal matter.
• This enema is also given in post rectal
surgeries to facilitate the first bowel
movement, to avoid strain and injury.
• Oil enema has to be followed by soap and
water enema.
• Oils such as olive oil, sweet oil, and castor
oil along with olive oil in the proportion of
1:2 can be given.
• The solution has to be at least 115 mL and
can range up to 175 mL.
Purgative Enema
• Helps in increasing the intestinal motility
(contraction of the bowel) for active
evacuation of bowel contents
• This results in the irritation of the mucus
lining and stimulation of gut movements.
• To administer this enema, solutions such as
pure glycerin, glycerin along with water, or
glycerin along with castor oil can be given.
• There is a special classification of this
enema, called the 1-2-3 enema. In this
magnesium sulfate, glycerin and water are
used in the quantities of 30 mL, 60 mL, and
90 mL respectively.
 TYPES OF MEDICATED ENEMA
Astringent Enema Anthelmintic Enema
• In case the inner lining of the gut is • If there is a presence of worms inside
inflamed or is bleeding, this enema the intestine, this enema is given as a
helps in lessening mucus discharge, treatment.
contracting the blood vessels, and • Soap and water enema should
providing temporary relief from the precede this enema.
inflammation. • After cleansing the bowel with soap
• Alum, tannic acid, or 2% silver and water enema, the worms can
nitrate can be used in these enemas. come directly in contact with an
anthelmintic enema. A hypertonic
saline or quassia infusion can be used
for this enema.
 TYPES OF MEDICATED ENEMA
Carminative Enema or Antispasmodic Cold Enema
Enema
• This enema is used for the release of • When a patient suffers from high
gaseous contents of the abdomen body temperature, most probably
and thus helps in the relieving of hyperpyrexia, this enema is given.
distension. • This enema is also given if a patient
• For the administration of this enema, suffers from heat stroke. However,
solutions such as turpentine, Tr. this can lead to an extreme decrease
Asafoetida and milk and molasses in body temperature leading to
can be used. hypothermia.
RETENTION ENEMA

It is a type of enema that patient needs to hold for 30-minute or more. In case of a nutrient enema,
the nutrients shall be absorbed through the intestine then only the enema will be effective.
 TYPES OF RETENTION ENEMA

Stimulant Sedative Anesthetic

Enema Enema Enema
•Given to stimulate the •Drugs
•To induce sleep, such as
patient in case of shock,
collapse, or opium sedative drugs such avertin (150– 300
poisoning. as potassium bromide mg/kg body weight)
•Stimulating agents such or paraldehyde are are administered to
as black coffee or brandy given in the form of
can be given as retention
induce an anesthetic
enema.
enema. effect in a client.
 TYPES OF RETENTION ENEMA

Emollient Nutrient
Enema Enema
•A bland solution is introduced
in the rectum to assess if the
•In order to introduce
patient is having diarrhea and food, and fluids inside
for a soothing purpose. the body, a nutrient
•Starchy solutions are used for
the enema.
enema is administered.
TYPES OF ENEMA SOLUTIONS
TYPES OF ENEMA SOLUTIONS
TYPES OF ENEMA SOLUTIONS
 ADMINISTRATION OF ENEMA
(NURSING ASSESSMENT)
• Check for the diagnosis of the client.
• Look for the date of surgery, if performed or scheduled.
• Assess if the client is in sound mind to follow any instructions.
• Check the type of enema that has been ordered by the physician.
• See if the doctor has ordered to collect any sample or specimen.
• Examine the rectal area.
• See if any assistance is required, and if required, call a help.
• Gather all the articles required.
 ADMINISTRATION OF
ARTICLES ENEMA
A tray containing
Enema can Rectal tube Mackintosh

Towel Jelly or Vaseline Water

Paper bag Bed pan Specimen bottles if needed

Clean bedsheets IV stand Toileting tray

 ADMINISTRATION OF ENEMA
(PRE PROCEDURE PREPARATION)
ADMINISTRATION OF ENEMA
 ADMINISTRATION OF ENEMA

• Procedure for the administration of enema:

Refer to book (page no 422)
 ADMINISTRATION OF ENEMA
(AFTER CARE)
• The fluid should be retained inside the anal cavity for about 15–30
minutes.
• Provide bedpan when required. Assist the client in reaching the bathroom.
• Observe the client and the results of the enema.
• If the doctor has ordered for obtaining samples, collect them.
• Provide and assist the client in perineal care.
• Take all the articles and disinfect them. Store them in their appropriate
place.
• Wash hands and document the procedure.
SUPPOSITORIES
Suppositories are defined
as a form of medication,
solid in nature, which
melts or dissolves inside
the body due to the body’s
temperature.
 SUPPOSITORIES

The suppositories are inserted inside the body’s cavities, such as the
rectum, vagina, and urethra.

Since the suppositories are semisolid and meant to melt at room

temperature, they are stored in cool places, such as refrigerators. If not
kept inside the refrigerator, insertion becomes difficult.

There are several types of suppositories such as glycerine suppositories,

and Dulcolax suppositories.
ADMINISTRATION OF
SUPPOSITORIES

Procedure of administration
of suppositories:
Refer to book (page no 423)
 ADMINISTRATION OF SUPPOSITERIES
(POST-PROCEDURE NURSING
RESPONSIBILITY)
• It is the responsibility of the nurse to make the patient
comfortable after the procedure.
• Clean and tidy up the patient.
• Observe the patient.
• Document about the type of suppository, timing of insertion
and the effect of suppository, what is the timing of evacuation
of bowel.
•A
z
INSERTION OF SUPPOSITORY
 SITZ BATH (HIP BATH)
Sitz bath or hip bath is a procedure in which heat is applied to the
perineal or rectal area by soaking the client in warm or hot water.
The client is made to sit in a tub or a large basin and water is filled so
that it reaches up to the umbilicus of the client.
The temperature of the water is set up to 43-46°C.
The client is made to sit in the tub for about 15-30 minutes.
 SITZ
BATH
(HIP
BATH)
 OBJECTIVES OF SITZ BATH
• To relieve pain, inflammation, or congestion if the
patient is suffering from conditions such as
hemorrhoids, anal fissures, and post rectal surgeries.
• To induce menstruation.
• To induce urination in case of retention.
• To relieve muscular spasms.
• To provide comfort to the client.
INDICATIONS FOR SITZ BATH

Hemorrhoi Anal
ds fissures

Anal Episiotomy
CONTRAINDICATIONS FOR SITZ
BATH
Pregnancy

Menstruation

Renal inflammation
EQUIPMENT REQUIRED FOR SITZ BATH
EQUIPMENT EQUIPMENT
Tube half filled with water
Ice cap with cover

A pitcher of additional water

Patient’s clean cloths

Bath thermometer

Inflatable ring
Bath towel and blanket
 • Support patient’s lumbar back.
SPECIAL
• Observe the client closely and
CONSIDERATIONS check if the patient is feeling
FOR weak or dizzy.
SITZ • Don’t use warm water if there
BATH is a presence of congestion.
 PRE PROCEDURE FOR SITZ
BATH
• Take all the articles to the bathroom.
• Check water temperature. It shouldn’t be too hot.
• The rubber ring has to be placed inside the tub, at
the bottom. If the ring isn’t available, use a towel.
PROCEDURE FOR SITZ BATH

Procedure:
Refer to book (page no 424)
 DIGITAL EVACUATION OF
IMPACTED FECES
The digital evacuation of impacted feces is defined as the process in which the
fecal material is broken into portions digitally and then removed in portions.
This procedure, although useful, can have deleterious effects on the mucus
membrane of the gut as it can potentially injure the mucosa.
Before this procedure is initiated, it is suggested that an oil enema should be
given and the patient must hold it for 30 minutes.
After the digital evacuation is done, remaining fecal matter can be removed
using a cleansing enema or by using a suppository.
DIGITAL EVACUATION OF
IMPACTED FECES
 DIGITAL EVACUATION
OF FECES
 Procedure:
Refer to book (page no 425)
 Bowel wash is defined as the procedure in
which the colon is cleared off of fecal
matter using large volumes of solutions. It
is, basically, the washing of the colon.
BOWEL
WASH
 PURPOSES OF BOWEL
WASH
 It can be done pre- or post-surgery to perform any diagnostic procedure.
 To relieve inflammatory responses.
 To initiate peristaltic movements.
 For the removal of toxins from the gut.
 In case of fecal incontinence.
 Wash off the feces or gas present in the gut.
 For the treatment of any other medical condition.
 CONTRAINDICATIONS OF
BOWEL WASH

Contraindications Contraindications Contraindications

• Anal
• Infection • Damaged
fistula • Rectal sphincters
• Anal • Hemorrhoids
tumor
fissures
BOWEL WASH
 Tap or Normal Alum
cold water saline 1:100

Tannic Soda bicarb Boric solution

SOLUTIONS acid 1-2% 1-2%

USED FOR
BOWEL
WASH
ARTICLES REQUIRED FOR BOWEL
WASH
 BOWEL WASH
(PRE-PROCEDURE)
• Check if the patient has been ordered for the bowel wash.
• Assess the client’s general physical condition, along with the mental condition.
• See if there is any contraindication.
• Prepare all the articles before the procedure.
• Explain the procedure and the necessity of the procedure to the client.
• Using the curtains or screens, the client has to be provided with privacy.
• Gather all the articles near the bedside of the patient.
• Spread mackintosh and towel under the patient’s buttocks.
• Position the client in the left lateral position and remove any pillows if placed
under the head or back.
 BOWEL WASH
•Procedure for bowel wash:
Refer to book (page no 426)
• Discard all the rag pieces.
• Provide the patient with a
comfortable position. BOWEL WASH
(POST
• Offer the bedpan. PROCEDURE)
• Wash hands thoroughly.
• Document the procedure.
GASTRIC LAVAGE
 BOWEL DIVERSION PROCEDURES:
OSTOMIES
• An opening in either GI, urinary or respiratory
tract via skin layer is defined as an ostomy.
• It is an opening done surgically for the
treatment of various conditions.
• There are various types of ostomies depending
upon the part of the body where the stoma is
created.
 STOMA
“Stoma is defined as an opening in the skin through the
abdominal wall, made with surgical procedures.”
• For instance, if a stoma is created through the abdomen
into the stomach, it is called a gastrostomy. Likewise, if the
stoma opens into the jejunum of the intestine, it is called a
jejunostomy.
• If the stoma is created to open into the ileum or colon, they
are called ileostomy and colostomy respectively.
STOMA
 PURPOSE OF OSTOMY
• The basic purpose of the ostomies is the diversion of the
pathway of the fecal matter and helping it drain into some
other cavity. The conditions due to which diversion is
required can be:

Any disease
condition of bowel
Ulcerative
like Crohn’s disease colitis

Infarction of
CLASSIFICATION OF OSTOMY
Classification of ostomy
Based on anatomical Surgical construction of
Based on duration
location stoma
Temporary ostomy Single-barrel

Permanent ostomy Loop

Divided

Double-barrel
 Temporary ostomy is
constructed when the bowel
isn’t functional due to
BASED temporary reasons, such as an
injury.
ON
DURATION Permanent ostomy: If the
rectum or anus is damaged
permanently, their function is
carried forward by a
permanent ostomy.
BASED ON DURATION
 BASED ON ANATOMICAL
LOCATION

• The anatomical condition influences how

the fecal matter is managed.
• If the ostomy is created far inside the
bowel, the stool is more hard and solid.
• If the ostomy is created nearer to the large
intestine, the stool will be watery.
 TYPES
OF
OSTOMIES
SURGICAL CONSTRUCTION
OF STOMA
Single-barrel

• It is the stoma through which the end of the bowel is brought out. The opening is made into the abdominal
wall anteriorly and through this opening, the bowel is brought out. This is a permanent type of stoma.

Loop

• This stoma has two openings, out of which a loop of bowel is made to bring out through one
opening and it is supported by a plastic bridge. One end is active while the other is inactive.
SURGICAL CONSTRUCTION
OF STOMA
• In this stoma, two ends of the bowel are brought out, but they remain separated
Divided
from each other.

• In this, both ends are brought out through the abdominal wall and are sutured
Double-barrel
together.
SURGICAL CONSTRUCTION OF
STOMA
CHARACTERISTICS OF THE FECES
ACCORDING TO THE SITE OF
COLOSTOMY
CHARACTERISTICS OF THE FECES
ACCORDING TO THE SITE OF
COLOSTOMY
ROLE OF NURSE IN CARING FOR THE
PATIENT WITH OSTOMY
•Due to stoma, the surrounding skin may break and cause irritation to the

Skin care
client. Therefore, the nurses must help the client in maintaining dry skin.
The nurses must keep a check that the pouch isn’t leaking. If the pouch is
leaking, change it immediately. However, regular changing of the pouch
must be ensured to avoid leakage.

Psychologic •In case the ostomy is permanent, the client may feel ashamed and cannot
come to terms with the situation. Therefore, a nurse must provide
psychological support to the client and help him adjust to the ostomy. Assist

al support
the client and family members with ostomy care. Latest colostomy bags allow
the patient to socialize and provide a sense of freedom and independence.
 Educate the client
A person with an
about the
ostomy is given a
necessary details
low residual
z diet
at first. Gas ROLE OF NURSEonIN
howCARING
to manage FOR
the ostomy, the
forming food likeTHE PATIENT WITH OSTOMY
changing of the
cabbage, and meat
pouch, skin care,
products should
and prevention of
be avoided.
complications.

Nutritio Educatio
n n
ROLE OF NURSE IN CARING FOR THE
PATIENT WITH OSTOMY
Administer The pouch
any
medications
prescribed
may be
smelly and
therefore,
Od
by the
doctor.
Instruct the
Me the client
must take
measures
or
dic
such as

co
client that
the regular
consistency emptying of
the pouch,

ati
or color of
the stool
may change
due to
preventing
leakage, and
changing
ntr
ons
the pouch
certain
medications
.
whenever
necessary. ol
 COLOSTOMY CARE
(ARTICLES)
 A tray containing:
 Colostomy pouch
 Pouch valve
 Clean glove
 Draw sheet & mackintosh
 Basin with warm water
 Scissors

 Skin barrier cream/wipes

 Stethoscope

 Measurement plate
 COLOSTOMY CARE

•Procedure for colostomy care:

Refer to book (page no 429)
WARNING SIGNS FOR
COMPLICATIONS
Bleeding
Bleeding from the
from skin
stoma around the
stoma
Change in
size of Protrusion
stoma – /sinking in
edema/ of stoma
shrinking
COMPLICATIONS OF OSTOMY
 INDICATION OF EMPTYING THE
COLOSTOMY BAG

Remove the clip.

Bag is filled two-third Unfold the sleeve.
Empty the bag in the
Wash hands. toilet and reverse the
steps and secure it.
 INDICATION OF CHANGING
THE COLOSTOMY BAG
Disposable bag shall be
discarded once filled.

Reusable bags shall be changed

after when it is two-third full.
DIET INFLUENCE ON STOOL
 • Urination is the process by which the urinary bladder is
emptied, and it involves the kidneys, ureters, and bladder
for the elimination process.
• Urine is composed of majorly water, i.e., 96%. The rest
CHAPTER 4% are organic and inorganic compounds.
• There are various factors that affect the process of
FOCUS urination and due to which there are evident alterations in
the urination process. These alterations are retention and
POINTS incontinence.
• Nurses play a significant role in various procedures such
as providing a bedpan to a patient, inserting a catheter, or
condom drainage. They also take part in the procedures
such as bowel irrigation, or urinary diversions.
• Elimination of bowel contents takes place through the
digestive system after the important electrolytes and
water is reabsorbed in the large bowel.
 • 3/4th of feces is composed of water and 1/4th of it consists of
solid waste.
• There are a number of factors, which affect the elimination
process.
CHAPTER • Constipation is a condition in which the frequency of
defecation is reduced and the stool becomes hard and dry.
FOCUS This can be caused due to many reasons.
• Diarrhea is a condition in which an individual passes watery
POINTS stool. Also, the frequency is increased. This condition is
opposite to that of constipation.
• Flatulence is the accumulation of gaseous contents in the GI
tract.
• Nurses take part in the procedures which facilitate bowel
elimination. These procedures can be passing of flatus tube,
enema, suppositories, sitz bath, bowel wash, diversion
ostomies, or the digital evacuation of the feces.
“Textbook of Foundation of
Nursing" by Jyoti Kathwal