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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