6.4 Elimination

Elimination

Elimination is a basic need that affects comfort, dignity, and safety. The NCLEX-PN tests the numbers that trigger reporting, sterile-technique catheter principles, and the color changes that signal an emergency.

Urinary Elimination

Normal output: 1,500-2,000 mL/day, with a minimum of about 30 mL/hour in adults. Below that, escalate.

Normal urine is pale yellow to amber, clear, faintly aromatic, pH 4.5-8.0, specific gravity 1.010-1.025. Incontinence types: stress (leak with cough/sneeze), urge (sudden need), overflow (dribbling from a full bladder), functional (cannot reach the toilet), and mixed.

Urinary Catheter Care and CAUTI Prevention

Indwelling catheters are the top cause of healthcare-associated infection. To prevent catheter-associated urinary tract infection (CAUTI):

1. Maintain a closed drainage system at all times.
2. Keep the bag below bladder level and off the floor.
3. Secure tubing to the thigh to prevent traction; avoid dependent loops.
4. Empty when two-thirds full and at least every 8 hours.
5. Perform perineal care at least twice daily and after stool.
6. Advocate for early removal; duration is the biggest modifiable risk.

Do not routinely irrigate or change catheters on a fixed schedule. Worked example: a patient with a 5-day indwelling catheter develops fever 101.2 F, cloudy malodorous urine, suprapubic discomfort, and white blood cells 14,500/mm3 - the classic CAUTI picture. Check the tubing for kinks, confirm the bag is below the bladder, obtain a culture as ordered, and notify the RN.

Bowel Elimination

Normal frequency ranges from 3 times daily to 3 times weekly; normal stool is brown, soft, and formed.

Enema Administration

Position the patient in the left Sims' position so gravity follows the natural curve of the sigmoid colon. Lubricate the tip, insert 3-4 inches (1-1.5 inches in a child), and hang the bag 12-18 inches above the rectum so flow is gentle. Lower the bag or pause if cramping occurs, and encourage the patient to retain a cleansing enema 5-15 minutes.

Ostomy Care

A colostomy drains from the colon (stool firms as it moves distally); an ileostomy produces continuous liquid output and risks rapid dehydration and skin breakdown. Assess stoma color every time: a healthy stoma is pink to red, moist, and slightly raised. A dusky, purple, or black stoma signals ischemia and is an emergency to report at once. Empty the pouch when one-third to one-half full, size the barrier to the stoma, and protect peristomal skin from effluent.

Trap to avoid: a urine output of 25 mL/hour for 3 hours is oliguria and must be reported - do not chart it as adequate or simply push oral fluids without escalating.

Specimen Collection and Bladder Training

Elimination items frequently test specimen technique. A routine urinalysis uses a clean voided sample, but a clean-catch midstream specimen is needed for culture: cleanse the meatus front to back, begin the stream into the toilet, then catch the midstream portion in a sterile cup. A sterile specimen from an indwelling catheter is withdrawn from the sampling port with a syringe after clamping briefly, never from the drainage bag, because bag urine is contaminated and stagnant.

A 24-hour urine collection begins by discarding the first void, then saving every drop for the full period, often on ice; a single missed void invalidates the test and the collection restarts. For functional or urge incontinence, bladder training schedules voiding at fixed intervals, gradually lengthening them, while pelvic floor (Kegel) exercises strengthen the muscles that control stress incontinence. Prompted toileting every 2 hours helps the patient with cognitive impairment stay continent and protects skin.

Constipation, Diarrhea, and Skin Protection

Bowel problems carry real safety risks the exam expects you to manage. For constipation, the first-line, least invasive interventions are increased fluids, dietary fiber, and activity, with stool softeners or ordered laxatives added when those fail; a patient who has had no stool for several days and reports cramping may be developing fecal impaction, which can present paradoxically as small amounts of liquid stool leaking around the hardened mass. Digital removal of an impaction is performed only per facility policy because of the vagal-stimulation risk that can slow the heart rate, so monitor the pulse.

For diarrhea, the priorities are replacing fluids and electrolytes, identifying the cause such as a new tube feeding or Clostridioides difficile infection, and protecting perianal skin with thorough cleansing and a moisture-barrier cream. Frequent liquid stool quickly breaks down skin and can cause painful denudement, so prevention beats treatment. Always weigh dehydration risk in older adults and infants, who decompensate fastest from fluid loss.