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NURSING PROCESS: THE PATIENT WITH ALTERED ELIMINATION PATTERNS
Urinary and bowel incontinence or constipation and impaction are problems that often occur in disabled patients. Incontinence curtails a person’s independence, causing embarrassment and iso-lation. It occurs in up to 15% of the community-based elderly population, and almost half of nursing home residents are bowel or bladder incontinent or both. In addition, constipation may be a problem for patients with disabilities. Complete and predictable evacuation of the bowel is the goal. If a bowel routine is not es-tablished, the person may experience abdominal distention; small, frequent oozing of stool; or impaction.
Urinary incontinence can be classified as urge, reflex, stress, func-tional, or total incontinence (AHCPR, 1996). Urge incontinence is involuntary elimination of urine associated with a strong per-ceived need to void. Reflex (neurogenic) incontinence is associ-ated with a spinal cord lesion that interrupts cerebral control, resulting in no sensory awareness of the need to void. Stress in-continence is associated with weakened perineal muscles that per-mit leakage of urine when intra-abdominal pressure is increased (eg, with coughing or sneezing). Functional incontinence refers to incontinence in patients with intact urinary physiology who experience mobility impairment, environmental barriers, or cog-nitive problems and are unable to reach and use the toilet before soiling themselves. Total incontinence occurs in patients who are unable to control excreta because of physiologic or psychological impairment; management of the excreta is the focus of nursing care. Urinary incontinence may result from multiple causes, in-cluding urinary tract infection, detrusor instability, bladder out-let obstruction or incompetence, neurologic impairment, bladder spasm or contracture, and inability to reach the toilet in time.
The health history is used to explore bladder and bowel func-tion, symptoms associated with dysfunction, physiologic risk fac-tors for elimination problems, perception of micturition and defecation cues, and functional toileting abilities. Previous and current fluid intake and voiding patterns may be helpful in de-signing the plan of nursing care. A record of times of voiding and amounts voided is kept for at least 48 hours. In addition, episodes of incontinence and associated activity (eg, coughing, sneezing, lifting), fluid intake time and amount, and medications are recorded. This record is analyzed and used to determine patterns and relationships of incontinence to other activities and factors.
The ability to get to the bathroom, manipulate clothing, and use the toilet are important functional factors that may be related to incontinence. Related cognitive functioning (perception of need to void, verbalization of need to void, and ability to learn to control urination) must also be assessed. In addition, the nurse reviews the results of the diagnostic studies (eg, urinalysis, uro-dynamic tests, postvoiding residual volumes). See the accompa-nying Gerontologic Considerations box for factors that affect the older adult.
Bowel incontinence and constipation may result from multi-ple causes, such as diminished or absent sphincter control, cog-nitive or perceptual impairment, neurogenic factors, diet, and immobility. The origin of the bowel problem must be determined.
The nurse assesses the patient’s normal bowel patterns, nutri-tional patterns, use of laxatives, gastrointestinal problems (eg, coli-tis), bowel sounds, anal reflex and tone, and functional abilities.The character and frequency of bowel movements are recorded and analyzed.
Based on the assessment data, major nursing diagnoses for the pa-tient may include the following:
• Impaired bowel elimination
• Impaired urinary elimination
The major goals of the patient may include control of urinary in-continence or urinary retention, control of bowel incontinence, and regular elimination patterns.
After the nature of the urinary incontinence has been identified, a nursing plan of care is developed based on analysis of the as-sessment data. Various approaches to promotion of urinary con-tinence have been designed. Most approaches attempt to condition the body to control urination or to minimize the occurrence of un-scheduled urination. Selection of the approach depends on the cause and type of the patient’s incontinence. For the program to be successful, the patient’s participation and desire to avoid in-continence episodes are crucial, and an optimistic attitude with positive feedback for even slight gains is essential for success. Ac-curate recording of intake and output and of the response to se-lected strategies is essential for evaluation.
At no time should the fluid intake be restricted to decrease the frequency of urination. Sufficient fluid intake (2000 to 3000 mL/day according to patient needs) must be ensured. To optimize the likelihood of voiding as scheduled, measured amounts of fluids may be administered about 30 minutes before voiding attempts. In addition, most of the fluids should be consumed be-fore evening to minimize the need to void frequently during the night.
The goal of bladder training is to restore the bladder to nor-mal function. Bladder training can be used with cognitively in-tact patients experiencing urge incontinence. A voiding and toileting schedule is formulated based on analysis of the assess-ment data. The schedule specifies times for the patient to try to empty the bladder using a bedpan, toilet, or commode. Privacy should be provided during voiding efforts. The interval between voiding times in the early phase of the bladder training period is short (90 to 120 minutes). The patient is encouraged not to void until the specified voiding time. Voiding success and episodes of incontinence are recorded. As the patient’s bladder capacity and control increase, the interval is lengthened. Usually, there is a tem-poral relationship between drinking, eating, exercising, and void-ing. The alert patient can participate in recording intake, activity, and voiding and can plan the schedule to achieve maximum con-tinence. Barrier-free access to the toilet and modification of cloth-ing can help the patient with functional incontinence to achieve self-care in toileting and continence.
Habit training is used to try to keep the patient dry by strict adherence to a toileting schedule and may be successful with stress, urge, or functional incontinence. In the case of a confused person, the caregiver takes the person to the toilet according to the schedule before involuntary voiding occurs. Simple cuing and consistency promote success. Periods of continence and success-ful voidings are positively reinforced.
Biofeedback is a system through which the patient learns con-sciously to contract excretory sphincters and control voiding cues. Cognitively intact patients who have stress or urge incontinence may gain bladder control through biofeedback.
Pelvic floor exercises (Kegel exercises) strengthen the pubo-coccygeus muscle. The patient is instructed to tighten pelvic floor muscles for 4 seconds ten times, and this is repeated four to six times a day. Stopping and starting the stream during urination is recommended to increase control. Daily practice is essential. These exercises are helpful for cognitively intact women who ex-perience stress incontinence.
Suprapubic tapping or stroking of the inner thigh may pro-duce voiding by stimulating the voiding reflex arc in patients with reflex incontinence. This method is not always effective, however, because of detrusor–sphincter dyssynergy. As the bladder reflex-ively contracts to expel urine, the bladder sphincter reflexively closes, producing a high residual urine volume and an increased incidence of urinary tract infection.
Intermittent self-catheterization is an appropriate alternative for managing reflex incontinence, urinary retention, and overflow incontinence due to an overdistended bladder. The emphasis of patient teaching is on regular emptying of the bladder rather than sterility. Disabled patients reuse and clean catheters with bleach or hydrogen peroxide solutions or soap and water and may use a micro-wave oven to sterilize catheters. Aseptic intermittent catheteriza-tion technique is required in health care institutions because of the potential for bladder infection from resistant organisms. Inter-mittent self-catheterization may be difficult for patients with lim-ited mobility, dexterity, or vision; however, family members can be taught the procedure.
Indwelling catheters are avoided if at all possible because of the high incidence of urinary tract infections with their use. Short-term use may be needed during treatment of severe skin break-down due to continued incontinence. Patients with disability who are unable to perform intermittent self-catheterization may elect to use a suprapubic catheter for long-term bladder manage-ment. Suprapubic catheters are easier to maintain than indwelling catheters. A fluid intake of 3000 mL/day must be encouraged.
External catheters (condom catheters) and leg bags to collect spontaneous voidings are useful for male patients with reflex or total incontinence. The appropriate design and size must be cho-sen for maximal success, and the patient or caregiver must be taught how to apply the condom catheter and how to provide daily hygiene, including skin inspection. Instruction on empty-ing the leg bag must also be provided, and modifications can be made for patients with limited hand dexterity. External collectiondevices for women do exist, but difficulties with fit have pre-cluded widespread use.
Incontinence pads (briefs) are used only as a last resort, be-cause they only manage rather than solve the incontinence prob-lem. Also, they have a negative psychological effect on the patient because many people think of them as diapers. Every effort should be made to reduce the incidence of incontinence episodes through the other methods that have been described. Inconti-nence pads may be useful at times for patients with stress or total incontinence to protect clothing, but they should be avoided when-ever possible. When incontinence pads are used, they should wick moisture away from the body to minimize contact of moisture and excreta with the skin. Wet incontinence pads must be changed promptly, the skin cleansed, and a moisture barrier applied to protect the skin.
The goals of a bowel training program are to develop regular bowel habits and to prevent uninhibited bowel elimination. Reg-ular, complete emptying of the lower bowel results in bowel con-tinence. A bowel-training program takes advantage of the patient’s natural reflexes. Regularity, timing, nutrition and fluids, exercise, and correct positioning promote predictable defecation.
The nurse records defecation time, character of stool, nutri-tional intake, cognitive abilities, and functional self-care toileting abilities for 5 to 7 days. Analysis of this record is helpful when de-signing a bowel program for the patient with fecal incontinence.
Consistency in implementing the plan is essential. A regular time for defecation is established, and attempts at evacuation should be made within 15 minutes of the designated time daily. Natural gastrocolic and duodenocolic reflexes occur about 30 minutes after a meal; therefore, after breakfast is one of the best times to plan for bowel evacuation. If the patient had a previously estab-lished habit pattern at a different time of day, however, it should be followed.
The anorectal reflex may be stimulated by rectal suppository (eg, glycerin) or by mechanical stimulation (eg, digital stimula-tion with a lubricated gloved finger or anal dilator). Mechanical stimulation should be used only in patients with disability who have no voluntary motor function and no sensation as a result of injuries above the sacral segments of the spinal cord, such as quadriplegic, high paraplegic, or severely brain-injured patients. The technique is not effective in patients who do not have an in-tact sacral reflex arc (eg, those with flaccid paralysis). Mechanical stimulation, suppository insertion, or both should be initiated about 30 minutes before the scheduled bowel elimination time, and the interval between stimulation and defecation is noted for subsequent modification of the bowel program. Once the bowel routine is well established, stimulation with a suppository may not be necessary.
The patient should assume the normal squatting position (knees higher than the hips) and be in a private bathroom for defecation if at all possible, although a padded commode chair or bedside toilet is an acceptable alternative. Seating time is lim-ited in patients who are at risk for skin breakdown. Bedpans should be avoided. A patient with disability who is unable to sit on a toilet should be positioned on the left side with legs flexed and the head of the bed elevated 30 to 45 degrees to increase intra-abdominal pressure. Protective padding is placed behind the buttocks. When possible, the patient is instructed to bear down and to contract the abdominal muscles. Massaging the ab-domen from right to left facilitates movement of feces in the lower tract.
The record of bowel elimination, character of stool, food and fluid intake, level of activity, bowel sounds, medications, and other assessment data are reviewed to develop the plan of care. Multiple approaches may be used to prevent constipation. The diet should be well balanced and should include adequate intake of high-fiber foods (vegetables, fruits, bran) to prevent hard stools and to stimulate peristalsis. Fluid intake should be between 2 and 3 L/day unless contraindicated. Prune juice or fig juice (120 mL) taken 30 minutes before a meal once daily is helpful to some cases when constipation is a problem. Physical activity and exercise are encouraged, as is self-care in toileting. The patient is encouraged to respond to the natural urge to defecate. Privacy during toileting is provided. Stool softeners, bulk-forming agents, mild stimulants, and suppositories may be prescribed to stimulate defecation and to prevent constipation.
Expected patient outcomes may include:
1. Demonstrates control of bowel and bladder function
a. Experiences no episodes of incontinence
b. Avoids constipation
c. Achieves independence in toileting
d. Expresses satisfaction in level of bowel and bladder control
2. Achieves urinary continence
a. Uses therapeutic approach appropriate to type of in-continence
b. Maintains adequate fluid intake
c. Washes and dries skin after episodes of incontinence
3. Achieves bowel continence
a. Participates in bowel program
b. Verbalizes need for regular time for bowel evacuation
c. Modifies diet to promote continence
d. Uses bowel stimulants as prescribed and needed
4. Experiences relief of constipation
a. Uses high-fiber diet, fluids, and exercise to promote defecation
b. Responds to urge to defecate
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