Elimination Assessment Tool

Subjective (Reports)

Usual bowel elimination pattern:________ Character of stool (e.g., hard, soft, liquid):________ 
Stool color (e.g., brown, black, yellow, clay colored, tarry):________
Last BM/Character of stool:________ Constipation (acute/chronic):________Diarrhea (acute/chronic):________ Bowel incontinence:________ History of bleeding:________ Hemorrhoids/fistula:________ Laxative use:_____________ How often:_____________ Enema/suppository:_____________ How often:_____________
Usual voiding pattern and character of urine:_______________________________________________________
Difficulty voiding:________ Urgency:________ Frequency:________ Retention:________ 
Bladder spasms:________
Pain/burning:_____________________________________________________________________
Urinary incontinence (type & time of day usually occurs):______________________________________________
History of kidney/bladder disease:______________________________________________________________________________________
Diuretic use:_____________________________________________ 
Other medications/herbals:_________________________________

Objective (Exhibits)
Abdomen (auscultation):________ Bowel sounds (location/type):________ Abdomen (palpation):________ Soft/firm:________ 
Tenderness/pain (quadrant location):________Distention:________ Palpable mass:________ Size/girth:________
CVA tenderness:_______________________________________________________________________________
Bladder palpable:_________________ Residual (per scan):_________________ 
Overflow voiding:__________________
Rectal sphincter tone (describe):_________________ Hemorrhoids/fistulas:_________________
Stool in rectum:_________________ Impaction:_________________ Occult blood:(+ or –):_________________
Presence/use of catheter or continence devices:________ 
Ostomy appliances (describe appliance and location):________