BNS Section 9: Elimination

Section Overview

Urinary and bowel elimination are fundamental physiological functions, and disruption of either — whether from illness, surgery, immobility, medication effects, or structural pathology — has significant consequences for patient comfort, dignity, nutritional status, wound healing, and overall recovery. Nurses are central to assessing elimination patterns, implementing supportive interventions, preventing complications, and educating patients about maintaining elimination health at home.

This section addresses both urinary and bowel elimination, including the technically complex and infection-sensitive procedure of urinary catheterization, evidence-based catheter-associated urinary tract infection (CAUTI) prevention, incontinence management, constipation and diarrhea prevention and care, enema administration, and introductory ostomy care.

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Learning Objectives

By the end of this section, students will be able to:

1. Insert and maintain an indwelling urinary catheter using sterile technique and adherence to CAUTI prevention evidence-based bundles. (Bloom’s: Apply)
2. Assess urine characteristics and recognize findings that require provider notification. (Bloom’s: Analyze)
3. Implement nursing strategies to manage urinary incontinence and promote continence in diverse adult patients. (Bloom’s: Apply)
4. Assess bowel elimination patterns and identify patients at risk for constipation, diarrhea, or ileus. (Bloom’s: Analyze)
5. Perform enema administration using correct technique and appropriate solution for the clinical indication. (Bloom’s: Apply)
6. Describe the principles of ostomy care including pouch application, peristomal skin assessment, and patient education. (Bloom’s: Understand)

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Urinary Elimination

Assessing Urine

Normal urine assessment findings guide clinical decision-making and serve as a baseline against which changes are compared.

Characteristic	Normal	Abnormal (Report to Provider)
Color	Pale yellow to amber	Dark amber (dehydration), red/pink (blood), bright orange (medications), cloudy
Clarity	Clear to slightly hazy	Turbid, cloudy, sediment-laden
Odor	Faint, characteristic	Foul, ammonia-like, sweet/fruity (hyperglycemia)
Volume (hourly)	≥ 0.5 mL/kg/hr (adults)	< 30 mL/hr (oliguria) or anuria
Specific gravity	1.005–1.030	> 1.030 (dehydration); < 1.005 (overhydration or renal concentrating defect)

Urinary Catheterization

An indwelling urinary catheter (Foley catheter) is placed into the bladder via the urethra to provide continuous urinary drainage. Because the catheter bypasses the body’s natural defense mechanisms, it creates a direct pathway for bacteria to enter the bladder — making CAUTI the most common healthcare-associated infection in the United States.

Indications for Indwelling Catheterization

• Accurate urine output monitoring in critically ill or hemodynamically unstable patients
• Urinary retention that does not respond to less invasive measures
• Management of urinary incontinence when skin integrity is severely compromised (e.g., Stage 3/4 pressure injury in the sacral region)
• Pre-operative, intra-operative, or post-operative care for select surgeries
• Palliative care comfort measures

An indwelling catheter should never be inserted for convenience, because the patient is confused or incontinent, or as a substitute for nursing care.

Catheter Insertion — Sterile Technique

1. Perform hand hygiene; explain the procedure and provide privacy
2. Open the catheter insertion kit using sterile technique; establish the sterile field
3. Don sterile gloves
4. Prepare the collection bag and tubing; inflate and deflate the balloon to test patency; lubricate the catheter tip generously with water-soluble lubricant
5. Cleanse the urethral meatus with antiseptic solution:
   • Female: Separate labia with non-dominant hand (which is now contaminated); cleanse with antiseptic swabs front to back — far labia, near labia, urethral meatus — using a separate swab for each stroke
   • Male: Retract the foreskin with non-dominant hand; cleanse in circular motion from the meatus outward using antiseptic; maintain retraction throughout insertion
6. Insert the catheter with the dominant (sterile) hand:
   • Female: Insert 2–3 inches until urine returns; advance 1 inch more, then inflate the balloon
   • Male: Insert 6–9 inches (advance through urethral resistance at the sphincter with slight downward penile traction); urine return confirms bladder placement; advance 1–2 more inches, then inflate
7. Inflate the balloon with the specified volume of sterile water (typically 10 mL); gently pull back to confirm the balloon is seated against the bladder neck
8. Secure catheter tubing to the inner thigh (female) or lower abdomen (male) with a securement device; position drainage bag below the level of the bladder at all times
9. Replace the foreskin in uncircumcised male patients to prevent paraphimosis

CAUTI Prevention Bundle

Evidence-Based Practice	Rationale
Insert only when clinically indicated; reassess need daily	Every catheter day adds 3–7% risk of infection
Use sterile technique for insertion	Prevents introduction of pathogens at time of insertion
Maintain a closed, unobstructed drainage system	Open systems dramatically increase contamination risk
Keep drainage bag below bladder level; never allow reflux	Prevents backflow of potentially contaminated urine
Secure catheter to prevent urethral traction	Reduces meatal trauma and pathogen migration
Perform perineal hygiene daily and after each bowel movement	Reduces perimeatal colonization
Remove catheter as soon as clinically appropriate	Reduces duration of infection risk exposure

NCLEX-Style Practice Question:

A nurse is caring for a patient with an indwelling Foley catheter. During assessment, the nurse notes that the drainage bag is positioned on the bed at the same level as the patient’s bladder. Which action should the nurse take first?

• A) Clamp the drainage tubing to prevent urine backflow
• B) Lower the drainage bag below the level of the bladder ✓
• C) Empty the drainage bag and reposition it at the correct height
• D) Notify the provider that the catheter is malfunctioning

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Urinary Incontinence

Urinary incontinence (UI) — the involuntary leakage of urine — affects up to 50% of hospitalized older adults and is a significant contributor to falls, pressure injuries, incontinence-associated dermatitis, and loss of dignity. Rather than managing UI with indwelling catheters (which carry CAUTI risk), nurses implement targeted nursing strategies based on the type of incontinence.

Type	Description	Nursing Intervention
Stress	Leakage with increased intra-abdominal pressure (coughing, sneezing, lifting)	Pelvic floor exercises (Kegel); scheduled voiding; avoid bladder irritants
Urge	Sudden, strong desire to void followed by leakage before reaching the toilet	Bladder training; timed voiding; avoid caffeine and alcohol
Functional	Continent bladder but inability to reach the toilet due to mobility or cognitive impairment	Timed toileting every 2 hours; bedside commode; assist to bathroom promptly
Overflow	Continuous dribbling from an overdistended, poorly emptying bladder	Intermittent catheterization; Credé maneuver with provider order
Mixed	Combination of stress and urge components	Combination of above strategies

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Bowel Elimination

Normal Bowel Elimination Patterns

Normal bowel function varies widely between individuals — from 3 times daily to once every 3 days. What is most important clinically is a change from the patient’s established baseline pattern. Nurses document frequency, consistency, color, and amount of stool using the Bristol Stool Form Scale (Types 1–2 = constipated; Types 3–4 = normal; Types 5–7 = diarrhea).

Constipation

Constipation is defined as fewer than three bowel movements per week, combined with straining, hard/lumpy stools, or the sensation of incomplete evacuation. In hospitalized patients, constipation results from immobility, opioid medications, inadequate fluid and fiber intake, environmental factors (lack of privacy), and altered routine.

Evidence-Based Prevention and Management:

• Encourage ambulation and mobility as soon as clinically appropriate
• Ensure adequate fluid intake (1.5–2 L/day unless contraindicated)
• Encourage dietary fiber when oral intake is permitted
• Provide privacy and an appropriate toileting position (knees higher than hips; use footstool)
• Administer stool softeners, bulk-forming agents, or osmotic laxatives as ordered
• Implement a bowel protocol for all patients receiving scheduled opioid medications

Diarrhea

Diarrhea (> 3 loose stools per day or a watery stool) disrupts fluid and electrolyte balance, causes perianal skin breakdown, and increases the risk of pressure injury and incontinence-associated dermatitis (IAD). Common causes in hospitalized patients include antibiotics (altered gut flora), Clostridioides difficile infection, enteral feeding osmolality, and medications containing sorbitol.

Key Assessment and Safety Actions:

• Send stool for C. difficile testing when diarrhea develops in a hospitalized patient receiving or recently completed antibiotics
• Implement contact precautions for suspected or confirmed C. difficile until diarrhea resolves (minimum 48 hours after last loose stool); use soap and water for hand hygiene
• Apply zinc oxide or other moisture barrier to perianal skin after each episode
• Monitor for dehydration and electrolyte imbalance (particularly potassium and sodium)

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Enema Administration

An enema is the instillation of a solution into the rectum and colon to stimulate peristalsis, soften stool, or cleanse the bowel prior to a procedure or surgery.

Types of Enemas

Type	Solution	Volume	Purpose
Cleansing (tap water or normal saline)	Tap water or 0.9% NaCl	750–1000 mL	Pre-procedure bowel prep; severe constipation
Hypertonic (Fleet / phosphate)	Sodium phosphate	118 mL (commercial)	Bowel preparation; constipation
Oil retention	Mineral oil	90–120 mL; retained 30–60 min	Soften impacted stool
Medicated (e.g., kayexalate)	Specific drug solution	Varies	Deliver medication rectally (e.g., for hyperkalemia)

Contraindications: Recent rectal or colorectal surgery, rectal bleeding, bowel obstruction, suspected appendicitis, severe hemorrhoids, or bowel perforation.

Enema Administration Technique (Key Steps)

1. Verify the order; assess for contraindications; provide privacy; position the patient in the left lateral (Sims’) position with right knee flexed
2. Warm the solution to body temperature (too hot risks mucosal burns; too cold causes cramping); fill the enema bag; expel air from tubing
3. Lubricate the rectal tip; insert gently 3–4 inches in adults, aiming toward the umbilicus; do not force
4. Raise the enema bag no higher than 12–18 inches above the rectum; administer slowly to reduce cramping
5. If the patient reports cramping, lower the bag or temporarily clamp the tubing; allow cramping to subside before continuing
6. Instruct the patient to retain the solution as long as possible (at least 5–10 minutes for cleansing enemas; per order for retention enemas) before expelling
7. Assist the patient to the bathroom or bedpan; assess the results and document

NCLEX-Style Practice Questions:

1. A nurse is preparing to administer a cleansing enema. In which position should the nurse place the patient?

   • A) High Fowler’s
   • B) Right lateral with left knee flexed
   • C) Left lateral (Sims’) with right knee flexed ✓
   • D) Prone with hips elevated on a pillow

2. A patient has not had a bowel movement in 4 days and reports straining without success. Which nursing intervention should be attempted first?

   • A) Administer a hypertonic phosphate enema
   • B) Request an order for a stool softener and increase fluid intake ✓
   • C) Perform a digital rectal examination and manually disimpact
   • D) Place the patient on NPO status until the bowel pattern resolves

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Ostomy Care: Introductory Principles

An ostomy is a surgically created opening (stoma) on the abdominal wall that diverts urine or stool when the normal elimination route is altered by disease, injury, or surgery. Common types include colostomy (large bowel diversion), ileostomy (small bowel diversion), and urostomy (urinary diversion). Ostomy care is an important component of BNS education, and students will develop more advanced skills in subsequent clinical courses.

Stoma Assessment

A healthy stoma should appear:

• Pink to brick-red in color (indicating adequate blood supply)
• Moist and shiny (like the inside of the mouth)
• Raised slightly above the skin surface or flush with the abdominal wall

Report immediately: pale, dusky, dark, or necrotic appearance (impaired circulation); retraction below skin level; prolapse; signs of mucocutaneous separation.

Peristomal Skin Assessment

The skin surrounding the stoma must remain intact, dry, and free from pouch adhesive irritation. Assess for:

• Erythema, maceration, or denudation
• Leakage under the wafer (most common cause of peristomal skin breakdown)
• Yeast (candidal) rash — requires antifungal powder under the skin barrier

Pouching System Basics

1. Empty the pouch when it is one-third to one-half full to prevent weight from breaking the adhesive seal
2. Measure the stoma diameter with each pouch change during the first 6–8 weeks post-operatively (stoma size decreases during healing); cut or select a pre-sized opening that fits within 1/8 inch of the stoma edge
3. Apply barrier paste or ring to fill any uneven skin contours before placing the wafer
4. Ensure the skin is clean and completely dry before applying the new pouch system
5. Apply gentle pressure over the entire wafer for 30–60 seconds after placement to ensure adhesion

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Standards Alignment

This section supports the following professional and regulatory frameworks:

• AACN Essentials D1, D2, D3, D9: Knowledge for nursing practice; person-centered care; population health
• NCLEX-NG CJMM: Recognize Cues (RC), Analyze Cues (AC), Prioritize Hypotheses (PH), Generate Solutions (GS), Take Action (TA)
• QSEN: Patient-Centered Care (PCC), Evidence-Based Practice (EBP), Safety (S), Quality Improvement (QI)
• CCNE Standards I, II: Professional identity; curriculum outcomes
• ACEN Standards 3, 4: Student outcomes; elimination and catheter care curriculum content