Post RN BSN Advanced Concepts in Nursing I – Unit VI Elimination Pattern Solved Answers
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| Elimination Pattern, Colostomy, Catheter and Enema Solved Answers | Post RN BSN ACN-I Use as a revision guide and verify with your course notes. |
Unit VI: Elimination Pattern
Course syllabus · Model exam answers
B.Sc NURSING (POST-RN), FIRST YEAR, SEMESTER-I
ADVANCED CONCEPTS IN NURSING I (ACN-I) – COURSE NO. 701
UNIT VI: ELIMINATION PATTERN
Syllabus topics: Elimination concept; anatomy and physiology of bladder and bowel elimination; terminology related to defecation and micturition; colostomy care; catheterization; enemas; bladder training; Kegel exercise; bowel training.
Q-1. Explain the concept of elimination. Why is it important and what factors affect it?
Elimination is the removal of waste products from the body: urine and stool (and, in the wider sense, sweat and exhaled gases). Urinary elimination removes metabolic waste and keeps fluid, electrolyte and acid–base balance; bowel elimination removes undigested food waste. In Gordon’s framework, the elimination pattern describes bowel, bladder and skin excretion, including regularity, control, and aids used.
| Factor | Effect on elimination |
|---|---|
| Age | Infants have no voluntary control; elderly have weaker muscles and reduced bladder capacity; constipation is common |
| Diet and fluids | Fibre and water soften stool; low fluid causes concentrated urine and constipation; caffeine and alcohol increase urine |
| Activity | Movement stimulates peristalsis; immobility causes constipation and urinary stasis |
| Psychological | Stress, anxiety, depression, privacy, embarrassment |
| Habits and culture | Toilet type, privacy, routine, toileting hygiene practices, timing |
| Medicines | Diuretics, opioids, iron, antacids, laxatives, anticholinergics |
| Disease and surgery | Diabetes, spinal cord injury, enlarged prostate, infection, abdominal surgery, anaesthesia |
| Pregnancy | Pressure on bladder and bowel |
| Pain | Haemorrhoids or fissures cause stool holding |
Q-2. Describe the anatomy and physiology of the urinary tract and the process of micturition.
| Structure | Function / key points |
|---|---|
| Kidneys | Filter blood in nephrons; form urine; regulate fluid, electrolytes, BP (renin) and red cell production (erythropoietin) |
| Ureters | Muscular tubes; peristalsis carries urine to bladder |
| Urinary bladder | Muscular reservoir (detrusor muscle); adult capacity about 400–600 mL; first urge at about 150–200 mL |
| Internal urethral sphincter | Involuntary (smooth muscle) |
| External urethral sphincter | Voluntary (skeletal muscle): gives control |
| Urethra | Female about 3–4 cm (short, so infections are more common); male about 18–20 cm, passes through prostate |
Micturition (voiding)
- Bladder fills; stretch receptors send signals to the sacral spinal cord (S2–S4) and brain.
- Urge to void is felt; the brain (pons and cortex) allows or delays voiding.
- Parasympathetic stimulation contracts the detrusor and relaxes the internal sphincter.
- When ready, the external sphincter relaxes voluntarily and urine passes out.
Normal urine: volume about 1–2 L (1500 mL) per day; pale yellow to amber; clear; slightly aromatic; pH about 4.6–8 (average 6); specific gravity about 1.010–1.025; no glucose, protein, blood or ketones.
Q-3. Describe the anatomy and physiology of bowel elimination and the defecation reflex.
| Part | Function |
|---|---|
| Mouth, stomach, small intestine | Digestion and absorption of most nutrients |
| Large intestine (about 1.5 m): caecum, colon (ascending, transverse, descending, sigmoid), rectum, anal canal | Absorbs water and electrolytes; forms and stores stool; bacteria make some vitamin K and gas |
| Internal anal sphincter | Involuntary |
| External anal sphincter | Voluntary: control of defecation |
Movements: peristalsis; segmentation (mixing); mass movements (1–3 times a day, often after meals: gastrocolic reflex), which push stool to the rectum.
Normal stool: frequency from about three per day to three per week (individual); soft, formed, brown (colour from bile pigments), about 100–200 g per day; odour from bacteria. Normal stool is mostly water, fibre, bacteria, dead cells and bile pigments.
Voluntary defecation is helped by sitting or squatting, the Valsalva manoeuvre (straining), and abdominal muscle contraction. Straining should be avoided in cardiac, eye and post-surgical clients.
Q-4. Define the terminology related to defecation and micturition.
| Urinary term | Meaning |
|---|---|
| Micturition / voiding | Passing urine |
| Polyuria | Large volume of urine (more than about 2.5–3 L/day), e.g. diabetes |
| Oliguria | Less than about 400 mL/day (about 30 mL/h or less than 0.5 mL/kg/h) |
| Anuria | Less than about 100 mL/day (almost none) |
| Dysuria | Painful or difficult urination |
| Frequency | Voiding more often than usual in small amounts |
| Urgency | Sudden strong need to void |
| Nocturia | Waking at night to void |
| Hesitancy | Delay in starting urine stream |
| Hematuria | Blood in urine |
| Pyuria | Pus in urine |
| Proteinuria / glycosuria | Protein / glucose in urine |
| Retention | Inability to empty the bladder |
| Residual urine | Urine left after voiding |
| Incontinence | Involuntary loss of urine (stress, urge, overflow, functional, total) |
| Enuresis | Bedwetting beyond the expected age (usually after 5 years) |
| Bowel term | Meaning |
|---|---|
| Defecation | Passing stool |
| Constipation | Infrequent, hard, difficult stool |
| Diarrhoea | Frequent loose or watery stool (three or more per day) |
| Impaction | Hard stool stuck in the rectum with liquid leakage around it (“overflow diarrhoea”) |
| Flatulence | Excess gas in the gut |
| Melaena | Black tarry stool from upper GI bleeding |
| Hematochezia | Bright red blood in stool |
| Steatorrhoea | Fatty, foul, floating stool |
| Tenesmus | Painful urge to pass stool without result |
| Faecal incontinence | Involuntary passage of stool |
| Haemorrhoids | Dilated veins in anal canal |
| Stoma | Surgical opening on the abdomen for waste (colostomy, ileostomy, urostomy) |
| Borborygmi | Rumbling gut sounds |
Q-5. Describe the assessment of bladder and bowel elimination.
- History: usual habits, changes, pain, medicines, diet, fluids, activity, surgery, toilet facilities.
- Observation: urine amount, colour, clarity, odour; stool shape (Bristol Stool Chart), colour, consistency, blood, mucus.
- Inspection and palpation: abdominal distension, tenderness, bowel sounds, bladder distension (suprapubic area), anal area, skin.
- Intake and output chart (I/O).
- Investigations: urinalysis, culture, serum creatinine, urea, stool test for occult blood or ova and parasites, ultrasound, endoscopy as ordered.
| Nursing diagnosis (NANDA-I examples) | Cause examples |
|---|---|
| Constipation | Low fibre, immobility, medicines |
| Diarrhea | Infection, medicines, enteral feeds |
| Bowel incontinence | Spinal injury, impaction, weak sphincter |
| Impaired urinary elimination; Urinary retention | Enlarged prostate, medicines, surgery |
| Stress / urge incontinence | Weak pelvic floor; bladder irritation |
| Risk for infection | Catheter |
Q-6. Describe the nursing care of clients with constipation, diarrhoea and faecal impaction.
| Problem | Nursing care |
|---|---|
| Constipation | Increase fibre (vegetables, fruit, whole grains, bran) and fluids; regular toilet routine; physical activity; privacy and comfortable position (squatting or foot stool); review medicines; laxatives only as ordered; avoid long straining |
| Diarrhoea | Oral rehydration solution (ORS) and fluids; replace fluid and electrolyte losses; continue feeding; hand washing and isolation if infectious; skin care around anus; antimotility drugs only as ordered; report blood, high fever, signs of dehydration (dry mouth, sunken eyes, low urine, poor skin turgor) |
| Faecal impaction | Doctor may order oil retention enema, then cleansing enema; digital removal by trained, authorized staff; prevent by fibre, fluids, activity; careful in cardiac clients because of vagal stimulation |
| Flatulence | Walk, avoid gas-forming foods, correct position, carminative enema or rectal tube as ordered |
Q-7. Describe the nursing care of clients with urinary retention and incontinence.
| Problem | Nursing care |
|---|---|
| Urinary retention | Assess bladder (suprapubic fullness); encourage normal position and privacy; run water, warm bath or pour warm water over perineum; adequate fluids; ambulation; catheterization if ordered; monitor I/O; treat cause |
| Stress incontinence | Pelvic floor (Kegel) exercises; weight loss; avoid caffeine; pads |
| Urge incontinence | Bladder training; scheduled toileting; limit caffeine and fluids at night; treat infection |
| Overflow incontinence | Treat obstruction; intermittent catheterization |
| Functional incontinence | Easy access to toilet; call bell; mobility aids; clothing easy to remove |
| All types | Skin care (wash, dry, barrier cream), change pads, odour control, respect dignity, avoid restricting fluids to “control” accidents |
Q-8. Define colostomy. Describe its types, indications and nursing care.
A colostomy is a surgical opening of the colon onto the abdominal wall so that stool leaves through a stoma into a pouch (appliance). It may be temporary or permanent.
| Type (site) | Stool |
|---|---|
| Ascending colostomy (right side) | Liquid, frequent, contains enzymes that irritate skin |
| Transverse colostomy (upper abdomen) | Pasty to soft; irregular |
| Descending colostomy (left side) | Semi-formed to formed; more predictable |
| Sigmoid colostomy (left lower) | Formed stool; most regular |
Indications: colorectal cancer, bowel obstruction, trauma, diverticulitis, inflammatory bowel disease, bowel perforation, anorectal malformation, protection of a bowel repair. Types of stoma construction: end, loop, double-barrel.
Normal stoma
Red or pink, moist, slightly raised, painless. Report immediately: stoma dusky, purple or black (poor blood supply), pale, dry, retracted or prolapsed, bleeding heavily, no output with distension, skin damage, or foul-smelling bloody discharge.
Nursing care
- Pre-operative: teach, mark stoma site with enterostomal therapist, emotional support, bowel preparation as ordered.
- Post-operative: observe stoma colour and output; protect the surrounding skin; the stoma passes gas first, stool in a few days.
- Changing the pouch: gather supplies; wash hands; empty the old pouch; gently remove it, pushing the skin from the adhesive; clean the skin with warm water and pat dry (no alcohol); measure the stoma and cut the barrier about 2–3 mm larger; apply skin barrier or paste if needed; fit the new pouch from bottom to top; press and hold for about a minute.
- Empty the pouch when one-third to half full; rinse and close; change the appliance every 3–7 days (depends on the type) or if it leaks.
- Skin care: look for redness, rash or leakage; use correct size; treat early.
- Diet: eat regularly, chew well, fluids; introduce new foods one at a time; avoid foods that cause gas or odour if troublesome; include fibre as advised.
- Irrigation (some descending or sigmoid colostomies) only after teaching; the doctor or stoma nurse decides.
- Psychosocial: body image, sexuality, clothing, travel, bathing, work, religious practices (e.g. cleanliness for prayer), support groups; involve family.
- Complications: necrosis, prolapse, retraction, parastomal hernia, stenosis, skin excoriation.
Nursing diagnoses: Disturbed body image; Impaired skin integrity (risk); Deficient knowledge; Risk for constipation or diarrhoea; Anxiety.
Q-9. Define urinary catheterization. State its indications, types and describe the procedure with nursing responsibilities.
Urinary catheterization is insertion of a sterile tube through the urethra into the bladder to drain urine. (In the syllabus this appears as “Cauterization”; see the note above.)
| Indications | Types |
|---|---|
| Acute urinary retention; relieving obstruction; accurate I/O in the critically ill; before and during surgery; bladder irrigation; collecting a sterile specimen if needed; neurogenic bladder; pressure injury healing in incontinence (only when other measures fail); end-of-life comfort | Intermittent (in-and-out, straight); indwelling (Foley) with balloon; suprapubic; condom (external) catheter for men; two-way and three-way (irrigation) catheters |
Catheter size is measured in French (Fr) units; typical adult sizes are about 14–16 Fr for women and 16–18 Fr for men; use the smallest suitable size (textbook values vary).
Procedure (female / male, sterile technique)
- Check the order and indication; explain; obtain consent; provide privacy.
- Wash hands; assemble sterile catheter set, gloves, antiseptic solution, lubricant, syringe and drainage bag, light.
- Position: women dorsal recumbent, knees flexed and apart (or Sims); men supine, legs slightly apart.
- Clean the perineum, open the sterile set without touching inside, put on sterile gloves, drape.
- Clean the urethral meatus (women: labia separated with the non-dominant hand, which is now contaminated; men: hold the penis behind the glans at 90°).
- Lubricate the catheter tip; ask the client to breathe slowly. Insert about 5–7.5 cm (2–3 inches) in women, and about 17–22.5 cm (7–9 inches) in men, until urine flows, then advance a little further.
- Inflate the balloon with the amount of sterile water stated on the catheter label; gently pull back to check it is held.
- Connect to the closed drainage bag; secure the catheter (thigh or abdomen); keep the bag below the bladder level, off the floor.
- Document: reason, size, time, amount and colour of urine, client response.
Do not force. If resistance is felt in a male, stop and call the doctor. Replace the foreskin after the procedure. Avoid draining more than the policy limit at once if the bladder is very full (follow orders).
Care of an indwelling catheter and CAUTI prevention
- Closed drainage system; do not disconnect unnecessarily.
- Perineal and meatal hygiene daily with soap and water.
- Keep the bag below bladder level; empty when about two-thirds full using a clean container for each client.
- Keep tubing free of kinks; no loops.
- Maintain fluids unless restricted; monitor urine colour, odour, volume and signs of infection (fever, cloudy urine, suprapubic pain).
- Review daily: remove as soon as not needed.
- Document I/O.
Complications: urinary tract infection (the commonest healthcare-associated infection), trauma, bladder spasm, stones, blockage, leakage.
Q-10. Define enema. Describe its types, indications, contraindications and the procedure.
An enema is the introduction of fluid into the rectum and colon to empty the bowel, soften stool, or give medicine.
| Type | Purpose | Examples |
|---|---|---|
| Cleansing (evacuant) | Remove stool before surgery or tests; for constipation or impaction | Tap water, normal saline, soap-suds (large volume); commercial hypertonic phosphate or small-volume enema |
| Retention | Soften stool (oil) or give medicine; fluid kept 30 min or more | Mineral or olive oil; medicated |
| Carminative | Expel flatus | Magnesium, glycerin and water as per hospital formula |
| Return flow (Harris flush) | Relieve flatulence | Alternate raising and lowering the container |
| Barium (radiology) | Imaging | Given in radiology |
Contraindications / caution: undiagnosed abdominal pain, suspected appendicitis, bowel obstruction or perforation, recent bowel or rectal surgery, recent myocardial infarction, severe hypertension, rectal bleeding or tumour, severe dehydration. Soap-suds and repeated enemas can damage the bowel; tap water repeated can disturb electrolytes (especially in children). Use only on a doctor’s order.
Procedure (large-volume cleansing enema, adult; values vary by textbook)
- Check order, explain, privacy, wash hands, gather supplies.
- Prepare the solution (adult about 500–1000 mL) at about 40.5–43°C (105–110°F); test on the inner wrist.
- Position left lateral (Sims) with the right knee flexed, so fluid flows by gravity along the descending colon; protect the bed.
- Hang the container about 30–45 cm (12–18 inches) above the anus (higher gives more pressure, causing pain).
- Lubricate the tube tip; clear air; separate the buttocks; ask the client to breathe slowly; insert about 7.5–10 cm (3–4 inches).
- Run the fluid slowly; if cramping occurs, clamp or lower the container and wait.
- Remove the tube; ask the client to hold the fluid as long as comfortable (5–15 minutes).
- Help to the toilet or commode or give a bedpan; call bell nearby.
- Record the result, clean, wash hands, and document.
For children use smaller volumes and age-specific protocols. Watch for pain, bleeding, dizziness, vagal response (slow pulse) and perforation signs.
Q-11. Describe bladder training: indications, methods and nursing role.
Bladder training is a behavioural programme to restore normal voiding patterns and control, by gradually increasing the interval between voids.
| Method | How it works |
|---|---|
| Scheduled (timed) voiding | Void at fixed times, e.g. every 2 hours while awake |
| Bladder retraining (delaying) | When the urge occurs, delay (relax, breathe, contract pelvic floor) and slowly lengthen the interval by 15–30 minutes each week toward 3–4 hours |
| Habit training | Based on the client’s own pattern |
| Prompted voiding | Caregiver asks and prompts every 2 hours (dementia) |
| Catheter clamping | Before catheter removal, used by some units (only as ordered) |
Indications: urge and stress incontinence, overactive bladder, after catheter removal, neurogenic bladder, enuresis in children.
Nursing role
- Assess with a 3-day bladder diary (times, amounts, leakage, fluids).
- Teach: drink adequate fluids (do not restrict), limit caffeine and alcohol, avoid last-minute rushing to the toilet, avoid “just in case” voiding.
- Pelvic floor (Kegel) exercises; weight control; treat constipation.
- Encourage; record progress; be patient; praise success; expect results in weeks.
- Provide privacy, easy access, suitable clothing.
Q-12. What are Kegel exercises? Describe the technique, benefits and precautions.
Kegel (pelvic floor muscle) exercises, named after Dr Arnold Kegel, strengthen the pubococcygeus (pelvic floor) muscles that support the bladder, uterus and rectum.
| Item | Details |
|---|---|
| Who benefits | Women with stress incontinence; after childbirth; pregnancy; menopause; men after prostate surgery; older adults with urgency |
| Find the muscles | Imagine stopping the passing of wind or tighten the muscles you would use to stop urine. Do not use repeated mid-stream stopping as an exercise (it can interfere with emptying) |
| Technique | Empty the bladder; contract the muscles and hold for about 3 to 5 seconds, then relax for equal time; build up to 10 seconds |
| Dose | About 10 repetitions, 3 times a day (or as advised by a physiotherapist); can be done sitting, standing or lying |
| Rules | Breathe normally; do not tighten the abdomen, buttocks or thighs; do not hold the breath |
| Results | Improvement usually in 4 to 12 weeks if done regularly |
| Precautions | Stop if pain occurs; seek medical help for persistent leakage; some conditions need specialist physiotherapy |
Benefits
- Reduces leakage, improves bladder control.
- Supports pregnancy and recovery after birth.
- May improve sexual function and prevent prolapse.
- Safe, cheap and can be done anywhere.
Q-13. Describe bowel training: aim, principles and nursing care.
Bowel training (bowel retraining or programme) establishes a regular time of evacuation in clients with constipation, faecal incontinence, spinal cord injury, stroke, dementia, or long-term immobility.
- Choose a regular time daily, usually 20–30 minutes after a meal (gastrocolic reflex), such as after breakfast.
- Take a warm drink in the morning; give fibre (25–30 g per day as tolerated) and adequate fluids (about 2 L unless restricted).
- Encourage exercise and abdominal massage in the direction of the colon.
- Provide privacy, sitting or squatting position, foot stool, allow enough time; do not rush.
- Use suppository, mini-enema or digital stimulation only if ordered, usually 15–30 minutes before the planned time; trained staff only.
- Avoid laxative dependence; stop habitual straining.
- Keep a bowel record (time, type, amount, accidents) and review.
- Manage skin and dignity; use incontinence pads only as safety.
- Be consistent for several weeks; progress may be slow.
For faecal incontinence also review diet, medicines, impaction (overflow), and pelvic-floor exercises.
Q-14. Solve the made-up cases on the elimination pattern.
Case 1. A 72-year-old woman, immobile after hip surgery, has not passed stool for 5 days, has hard small pieces, and is distended. Write the diagnosis, three interventions, and one thing to avoid.
Answer: Constipation (related to immobility, medicines, low fibre and fluids). Interventions: increase fluids and fibre as allowed, assist with a regular toilet routine and early mobility, give laxatives or an enema only as ordered. Avoid straining (cardiac and surgical risk) and do not give an enema without checking for obstruction.
Case 2. A man with a Foley catheter has cloudy foul urine, a temperature of 38.5°C and suprapubic pain. What do you do?
Answer: Suspect a catheter-associated urinary tract infection. Report promptly to the doctor; collect a urine specimen from the sampling port using aseptic technique for culture; check the need for the catheter and prepare for removal or replacement if ordered; encourage fluids if allowed; monitor temperature and vital signs; maintain a closed system; document.
Case 3. A new colostomy stoma appears dark purple the day after surgery. What is the nurse’s action?
Answer: Report to the surgeon immediately: this may mean poor blood supply (ischaemia). Keep the pouch clear to see the stoma, document colour, and prepare for review.
Case 4. A woman of 40 leaks urine when she coughs. What non-drug advice helps?
Answer: Stress incontinence: teach Kegel exercises (10 repetitions, three times daily), weight loss if overweight, limit caffeine, treat chronic cough or constipation, bladder diary, and refer if no improvement.
Q-15. Write the importance of this unit for a Post RN BSN nurse.
- Elimination problems are common in hospital and home care, and affect comfort, dignity and infection risk.
- Safe catheter, enema and stoma care prevents complications and healthcare-associated infection.
- Training programmes and teaching help clients to regain independence.
- Elimination is an important part of Gordon’s assessment.
Conclusion: Good elimination care combines accurate knowledge, safe technique and respect for the client’s privacy and dignity.
Suggested references (see the syllabus page for its own reading list): Gordon, M. Manual of Nursing Diagnosis (Functional Health Patterns; latest edition). Jones & Bartlett / Elsevier.
Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). NANDA International Nursing Diagnoses: Definitions and Classification (current edition). Thieme.
Potter, P. A., & Perry, A. G. Fundamentals of Nursing (latest edition). Elsevier.
Smeltzer, S. C., & Bare, B. G. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (latest edition). Lippincott.
Kozier, B., Erb, G., et al. Fundamentals of Nursing (latest edition). Pearson.
Source syllabus: Post RN BSN Nursing ACN-I Course (course syllabus) (original post dated April 12, 2019).
Series (Advanced Concepts in Nursing I, Course No. 701): Part 1: Unit I – Nursing Process and Diagnoses. Part 2: Unit II – Theoretical Frameworks. Part 3: Unit III – Functional Health Patterns. Part 4: Unit IV – Health Perception and Health Management. Part 5: Unit V – Nutritional-Metabolic Pattern. Part 6: Unit VI – Elimination Pattern. Part 7: Units VII–VIII – Activity-Exercise and Coping-Stress. Part 8: Units IX–X – Sleep-Rest and Sexuality-Reproduction. Part 9: Units XI–XII – Role Relationships and Pain. Part 10: Units XIII–XIV – Self-Perception and Values-Beliefs. Part 11: Clinical Objectives. Part 12: Learning Advanced Nursing Concepts – facts, skills, uses, benefits and hurdles.
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