3.3 Urinary and Bowel Elimination, Catheter Care, and Ostomy Management
Key Takeaways
- The single most effective measure against catheter-associated urinary tract infection is avoiding or removing the catheter; convenience, incontinence, and routine monitoring are not acceptable indications.
- Keep the urinary drainage bag below bladder level at all times and off the floor, maintain a closed system, and never lift the bag above the bladder during transfers.
- A urine output below 0.5 mL/kg/hour in an adult, or below 30 mL/hour, requires assessment for obstruction, hypovolaemia, and acute kidney injury before any assumption that the kidneys have failed.
- A healthy stoma is beefy red and moist; a dusky, purple, or black stoma indicates ischaemia and must be reported urgently, while the stoma itself has no nerve endings and is painless to touch.
- An ileostomy produces liquid to porridge-like output high in sodium and water, putting the patient at risk of dehydration and electrolyte loss; a sigmoid colostomy produces formed stool and can often be regulated by diet.
3.3 Urinary and Bowel Elimination, Catheter Care, and Ostomy Management
Elimination problems are quietly dangerous. A missed urinary retention becomes hydronephrosis; an unnecessary catheter becomes a bloodstream infection; an unrecognised ischaemic stoma becomes a return to theatre. This section covers the fundamentals-level skills the DHP blueprint expects and the safety judgements examiners test around them.
Normal Parameters and Urinary Retention
| Parameter | Normal adult value |
|---|---|
| Urine output | 0.5–1.5 mL/kg/hour; roughly 1,500 mL/24 hours |
| Oliguria | < 0.5 mL/kg/hour, or < 400 mL/24 hours |
| Anuria | < 100 mL/24 hours |
| Post-void residual | < 50 mL (< 100 mL in older adults) |
| Bladder capacity before urge | 300–500 mL |
| Specific gravity | 1.005–1.030 |
Acute urinary retention presents with suprapubic distension and discomfort, an urgent desire to void with little or no output, restlessness, and sometimes overflow incontinence — small frequent dribbles that a hurried assessment mistakes for normal voiding. The post-operative patient, the patient on opioids or anticholinergics, and the older man with prostatic hypertrophy are the classic candidates.
Assessment sequence: palpate and percuss the suprapubic area, then use a bladder scanner — a non-invasive ultrasound measurement — before considering catheterisation. Non-invasive measures come first where the situation allows: privacy, upright or standing position for men, running water, warm perineal water, and adequate analgesia. If catheterisation is required, intermittent straight catheterisation is preferred over an indwelling catheter wherever feasible.
Catheters and the CAUTI Bundle
Catheter-associated urinary tract infection is one of the most common healthcare-associated infections worldwide, and it is almost entirely a consequence of catheters that were never needed or were left in too long.
Appropriate indications: acute retention or bladder outlet obstruction; accurate output measurement in the critically ill; selected perioperative use; healing of sacral or perineal wounds in an incontinent patient; prolonged immobilisation for trauma; and comfort at end of life.
Not acceptable indications: staff or patient convenience, managing incontinence in a patient who can void, obtaining a urine specimen in a patient who can provide one, or routine monitoring outside critical care.
The prevention bundle:
- Insert only for an appropriate indication, and review the need daily with a documented plan to remove.
- Insert using sterile technique, sterile equipment, and adequate lubricant.
- Maintain a closed drainage system; never disconnect the tubing to obtain a specimen — aspirate from the sampling port after disinfection.
- Keep the bag below bladder level at all times and off the floor; empty into a clean, individual container before it is two-thirds full.
- Avoid dependent loops and kinks; secure the catheter to the thigh or abdomen to prevent traction on the urethra.
- Perform routine perineal hygiene with soap and water — antiseptic meatal cleaning does not reduce infection.
- Do not irrigate routinely, and do not change catheters on a fixed schedule in the absence of obstruction or infection.
Blocked catheter is an emergency in the patient with a spinal cord injury above T6 because bladder distension is a leading trigger of autonomic dysreflexia. If a catheter stops draining, first check for the simple causes — kinking, the bag above the bladder, constipation compressing the outflow — then assess for clot obstruction and escalate.
Bowel Elimination
Constipation is defined by difficulty and infrequency rather than a fixed number of days. Contributing factors that recur in exam stems are opioids, immobility, dehydration, low fibre intake, iron supplements, anticholinergics, and ignoring the urge to defecate.
Management is stepwise: fluid and fibre, mobility, a regular unhurried toileting routine timed to the gastrocolic reflex after breakfast, then laxatives. Know the classes:
| Class | Example | Onset | Key nursing point |
|---|---|---|---|
| Bulk-forming | Psyllium, ispaghula | 12–72 h | Must be taken with a full glass of water or it causes obstruction |
| Osmotic | Lactulose, polyethylene glycol | 24–48 h | Lactulose also lowers ammonia in hepatic encephalopathy |
| Stimulant | Senna, bisacodyl | 6–12 h | Avoid in suspected obstruction; do not crush enteric-coated bisacodyl |
| Stool softener | Docusate | 12–72 h | Prophylactic, not a rescue agent |
| Saline | Magnesium hydroxide | 0.5–3 h | Avoid in renal impairment — magnesium accumulates |
Faecal impaction may present paradoxically as liquid stool leaking around a hard mass, easily misread as diarrhoea. Recognise the pattern and assess rather than giving an antidiarrhoeal.
Enema administration. Position the adult in the left lateral (Sims') position so that gravity assists flow along the natural curve of the descending and sigmoid colon. Insert 7 to 10 cm in an adult, hang the solution no more than 30 to 45 cm above the anus, and instil slowly. Stop immediately for cramping, bleeding, or a vasovagal response. A cleansing enema is retained for 5 to 15 minutes; a retention enema is held far longer. Enemas are contraindicated with suspected bowel obstruction or perforation, recent rectal or prostate surgery, and — for phosphate preparations — in renal impairment and young children, because of severe phosphate absorption.
Clostridioides difficile diarrhoea deserves its own reminder: contact precautions, a private room, soap-and-water handwashing (alcohol does not kill spores), dedicated equipment, and sporicidal cleaning agents such as chlorine-based disinfectants.
Stoma Care
| Feature | Ileostomy | Transverse colostomy | Sigmoid colostomy | Urostomy (ileal conduit) |
|---|---|---|---|---|
| Output consistency | Liquid to porridge | Semi-formed | Formed | Urine with mucus |
| Output volume | 800–1,500 mL/day | Moderate | Low | Follows fluid intake |
| Enzyme content | High — very excoriating | Moderate | Low | Not applicable |
| Can be irrigated/regulated | No | No | Sometimes | No |
| Main risk | Dehydration, sodium loss, blockage | Skin excoriation | Constipation | UTI, stone formation |
| Pouch type | Drainable, emptied when one-third full | Drainable | Closed or drainable | Drainable with night bag |
Stoma assessment. A healthy stoma is beefy red to pink and moist, protrudes slightly, and has no sensation — it does not hurt when touched, and minor bleeding on cleaning is normal because the mucosa is highly vascular. Report urgently a stoma that is dusky, purple, or black (ischaemia), one that retracts below skin level, prolapses markedly, or is accompanied by no output plus distension and vomiting (obstruction).
Skin and appliance care. Measure the stoma each time during the first weeks because it shrinks as oedema resolves; the wafer opening should clear the stoma by only 2 to 3 mm. Empty a drainable pouch when it is one-third full, because a heavier pouch drags the seal loose. Change the appliance when output is least — for an ileostomy that usually means before a meal or first thing in the morning. Use warm water and a soft cloth, not soap containing oils or moisturisers, and avoid adhesive removers that leave residue.
Teaching points patients remember. Chew thoroughly and reintroduce high-fibre foods cautiously after an ileostomy — nuts, popcorn, sweetcorn, mushrooms, and citrus membranes are the usual blockage culprits. Odour is controlled by pouch filters and deodorants, and by moderating eggs, fish, onions, and garlic. For an ileostomy, maintain generous fluid and replace salt in hot weather, which matters particularly in Qatar's climate where insensible losses are high. Refer every new ostomy patient to a stoma care nurse, and address body image openly — psychosocial adjustment is part of the care plan, not an optional extra.
A nurse is transferring a patient with an indwelling urinary catheter from the bed to a wheelchair. Which action by a student nurse assisting with the transfer requires immediate correction?
A nurse assesses a patient on the second postoperative day following the formation of an ileostomy. The stoma is dark purple, cool to touch, and dry, and there has been no output for six hours. The patient reports no pain at the stoma. How should the nurse interpret and act on these findings?
An older adult who has had no bowel movement for five days is receiving loperamide because the nursing staff documented frequent small liquid stools. On assessment the nurse finds abdominal distension, a palpable mass in the left lower quadrant, and liquid brown staining on the incontinence pad. What is the nurse's priority action?