Urinary
Elimination
Video
1
Elimination patterns are essential
to maintain health. The urinary and gastrointestinal systems together provide
for the elimination of body wastes. The urinary system filters and excretes
urine from the body, thereby maintaining fluid, electrolyte, and acid-base
balance. Normal bowel function provides for the regular elimination of solid
wastes. During periods of stress and illness, clients experience alterations in
elimination patterns. Nurses assess for changes, identify problems, and
intervene to assist clients with maintaining proper elimination patterns. The
nurse’s role encompasses teaching clients self-care
activities to promote independence and health.
PHYSIOLOGY OF ELIMINATION
The urinary system is composed
of the kidneys, ureters, bladder, and urethra. The
kidneys form the urine, the ureters carry urine to
the bladder, the bladder acts as a reservoir for the urine, and the urethra is
the passageway for the urine to exit the body.
The gastrointestinal tract is
composed of the stomach, small intestine, large intestine, and rectum. The
small intestine absorbs nutrients, the large intestine absorbs fluids and the
remaining nutrients, and the distal portion of the large intestine collects and
stores the remaining solid waste until elimination occurs.
Urinary Elimination
The physiological mechanisms
that govern urinary elimination are complex and not yet completely understood.
Continence in the adult requires anatomic integrity of the urinary system,
nervous control of the detrusor muscle, and a
competent sphincter mechanism. Urinary
incontinence occurs when abnormalities of one or more of these factors
causes an uncontrolled loss of urine that produces social, physiological, or
hygienic difficulties for the client.
Structures
of the Urinary Tract
The urinary system is
typically divided into upper and lower tracts. The upper urinary tract includes
the kidneys, renal pelves, and ureters;
the lower urinary tract includes the urinary bladder, urethra, and pelvic
muscles (Figure 39-1).
Upper Urinary Tract
The kidneys are a pair of
reddish brown, bean-shaped organs located in the retroperitoneal space,
adjacent to vertebral bones T-12 to L-2. The right kidney lies slightly lower
than the left because of the presence of the liver. The periphery of the kidney
contains approximately 1 million nephrons;
collectively this aspect of the organ is called the parenchyma. The hilus of the kidney (its convex surface) contains the renal
pelvis and the ureters, which connect the kidneys and
the bladder. The primary function of the kidney is to maintain internal
homeostasis through filtration of the blood and production of urine. In
addition, the kidney is an endocrine organ (producing erythropoietin, a hormone
that aids in the production of red blood cells), and it plays a role in vitamin
D synthesis. After production within the nephron,
urine passes through the calyceal system of the
kidneys into the renal pelvis. The renal pelvis is shaped like a funnel, holds
approximately 15 ml of urine, and serves as a temporary storage area for urine
before transport to the lower urinary tract. The ureter
is a long tube, shaped like an inverted S, that begins
at the renal pelvis, passes under the psoas muscle of
the back, and enters the pelvis near the sacroiliac junction. When entering the
pelvis, the ureters curve medially to end in the base
of the bladder. The union between bladder and ureter
is called the ureterovesical junction.
Both the renal pelvis and ureters consist primarily of smooth muscle, and they move
urine from the upper to the lower urinary tract by muscular contraction. This
process is called peristalsis, and it is similar to the peristaltic waves of
the gastrointestinal system used to digest food and produce fecal waste. The
process of peristalsis occurs during the prolonged phases of bladder filling
and storage, but it is temporarily interrupted during micturition.
Lower Urinary Tract
The bladder is a hollow,
muscular organ located in the pelvis. It has a fixed base and a distensile
upper portion composed of multiple bundles of smooth muscle. Collectively, the
smooth muscle bundles are called the detrusor muscle.
The urethra is a tube that is
a conduit for urinary elimination. The urethra differs significantly in women
and men. In women, the urethra exits the bladder base and travels at a 16°
angle to the external meatus located at the
vestibule. The female urethra is approximately 3.5 to
In men, the urethra is
approximately
The pelvic muscles connect the
anterior and posterior aspects of the bony pelvis, support the organs of the true
pelvis, and contribute to the urethral sphincter mechanism in both women and
men. The pelvic muscles contain primarily slow-twitch fibers that are
physiologically suited for prolonged periods of tone. In addition, fast-twitch
fibers within the pelvic muscles respond rapidly to sudden increases in
abdominal pressure, although they soon fatigue. Fibers from the pelvic muscles
surround the membranous urethra of the male and the proximal two-thirds of the
female urethra. In both sexes, the urethra pierces the muscular diaphragm of
the pelvic muscles.
Nervous
Control of the Detrusor Muscle
The detrusor
muscle, the smooth muscle of the bladder, is under indirect voluntary control,
allowing the continent adult to postpone urination until a “socially appropriate”
time and location for bladder evacuation is identified. Specific areas of the
brain, spinal cord, and peripheral nervous system modulate the reflex activity
of the detrusor muscle.
Central nervous control of the
bladder begins in several modulatory centers in the
brain. A neurologic lesion affecting one or more of these areas causes
hyperactive detrusor contractions and a loss of
bladder control. The primary areas in the brain that modulate the detrusor muscle are located in the frontal lobes, the thalamus,
hypothalamus, basal ganglia, and cerebellum.
The limbic system, which
controls many aspects of autonomic nervous function, also influences
continence. A micturition
center, located near the base of the brain, has two groups of neurons that mark
the origin of the urination (micturition), the
evacuation of urine from the bladder. In the infant, urinary elimination is
controlled entirely by the micturition center, which
evacuates the bladder when a specific “threshold” volume is reached or when the
bladder is stimulated in another way. In the adult, however, the micturition center is controlled by the multiple centers of
the brain, and urination usually occurs when the individual wishes to empty the
bladder.
Reticulospinal
tracts in the spinal cord transmit messages from the brain and brain stem to
the peripheral nerves of the bladder. Bladder filling and urinary storage are
promoted by excitation of the sympathetic nervous system via efferent,
sympathetic spinal nuclei at spinal segments T-10 to L-2. Excitation of these
neurons relaxes the detrusor muscle and contracts the
muscular elements of the sphincter mechanism. Urinary evacuation is
accomplished through the parasympathetic nervous system. Excitation of neurons
located at segments S-2 to S-4 causes voiding (urination) by contraction of the detrusor muscle and relaxation of muscular elements of the
sphincter mechanism.
Two peripheral nerves transmit
messages from the central nervous system to the detrusor
muscle. The pelvic plexus transmits parasympathetic impulses to the smooth
muscle of the detrusor. Nervous excitation of the
parasympathetic nerves causes release of a neurotransmitter, acetylcholine,
which produces contraction of detrusor muscle cells.
Other substances also affect contraction of the detrusor
muscle, but all act under the influence of the central nervous system.
The inferior hypogastric nerves provide the majority of sympathetic tone
to the bladder wall and sphincter mechanism. In the detrusor
muscle, excitation of
β-adrenergic receptors causes release of norepinephrine,
which inhibits detrusor muscle contraction. In
addition, stimulation of α-adrenergic (excitatory) receptors at the
bladder neck, proximal urethra, and in the prostatic urethra in men causes
contraction of muscular components of the sphincter mechanism, promoting
urethral closure and continence.
Urethral
Sphincter Mechanism
The urethral sphincter is
traditionally divided into two muscles, an internal (smooth muscle) and
external (striated) sphincter. Unfortunately, this schema leads to more
confusion than it addresses, and it should be discarded for a conceptualization
of the sphincter as a single mechanism, comprising elements of compression and
elements of tone, with essential supportive structures.
Urethral compression relies on
three components: urethral mucosa softness, mucous secretions, and a vascular
cushion. During bladder filling and urinary storage, the epithelium must fill
in the gaps of the collapsed (closed) urethral lumen, creating a watertight
seal through which no urine can escape. Coaptation
requires a pliable, soft, and nonscarred urethra,
with adequate mucous secretions to reduce surface tension and to fill in the
microscopic gaps left by the epithelium. These elements of compression are
supplemented by a rich network of vascular connections in the submucosal space. This vascular network promotes urethral
closure by nourishing the epithelium and mucous production cells and by serving
as a cushion for the transmission of force exerted by the muscular elements of
the sphincter mechanism. In women, all the elements of compression are directly
influenced by the presence of estrogens.
Elements of urethral tension
protect the individual from urinary leakage during physical exercise or
exertion. Smooth muscle bundles at the bladder neck and proximal urethra (and
prostatic urethra of the male) close the urethra during bladder filling and
urinary storage. The urethral wall also contains a set of highly specialized,
triple-innervated striated muscle fibers that form a rhabdosphincter.
It is crucial for maintaining continence during normal exertion. Striated
muscle fibers from the pelvic muscle surround the urethra and contribute to the
sphincter. These muscles are particularly needed when abdominal pressure changes
from sneezing, coughing, or lifting a heavy object.
The muscular elements of the
urethra rely on supportive structures to provide an optimal configuration
allowing them to contract and relax efficiently. Loss of support interferes
with efficient urethral sphincter function.
FACTORS AFFECTING ELIMINATION
Age
A client’s age or
developmental level will affect control over urinary and bowel patterns.
Infants initially lack a pattern to their elimination. Control over bladder and
bowel movements can begin as early as 18 months of agebut
is typically not mastered until age 4. Nighttime control usually takes longer
to achieve, and boys typically take longer to develop control over elimination
than girls.
Control of elimination is
generally constant throughout the adult years, with the exception of illness
and pregnancy stages, when temporary loss of control, urgency, and retention
may develop. With increasing age comes loss of muscle tone and therefore
bladder control; this is usually accompanied by the urge to void more
frequently.
Diet
Adequate fluid and fiber
intake are critical factors to a client’s urinary and bowel health. Inadequate
fluid intake is a primary cause of constipation, as is ingestion of
constipating foods such as certain dairy products. Diarrhea and flatulence (discharge of gas from the
rectum) are a direct result of foods ingested, and clients need to be educated
as to which foods and fluids promote healthy elimination and which foods may
inhibit it.
Exercise
Exercise enhances muscle tone,
which leads to better bladder and sphincter control. Peristalsis is also aided
by activity, thus promoting healthy bowel elimination patterns.
Medications
Medications can have an impact
on a client’s elimination health and patterns and should be assessed during the
health history interview. Cardiac clients, for instance, are commonly
prescribed diuretics, which increase urine production. Antidepressants and antihypertensives may lead to urinary retention. Some
over-the-counter (OTC) cold remedies, especially antihistamines, may also
result in urinary retention. Other OTC medications are designed specifically to
promote bowel elimination or to soften stools; the nurse needs to inquire about
all medications being taken in order to provide proper care for a client
experiencing alterations in elimination patterns.
COMMON ALTERATIONS IN ELIMINATION
Urinary Elimination
Urinary incontinence and urinary
retention are the most common causes of altered urinary elimination patterns.
Urinary incontinence is the uncontrolled loss of urine that constitutes a
social or hygienic problem. Urinary
retention is the inability to completely evacuate urine from the bladder
during micturition. There are two primary types of
urinary incontinence, acute and chronic. In addition, chronic urinary
incontinence can be subdivided into several distinctive types. Because each has
its own etiology and management, it is important to determine the type of
incontinence before subjecting the client to the expense, potential risks, and
rigors of a treatment program.
Acute
Urinary Incontinence
Acute urinary incontinence is
a transient and reversible loss of urine. It may occur during an acute illness
or after an injury. Common causes of acute urinary incontinence include urinary
tract infection, atrophic vaginitis, polyuria related to diabetes, acute confusion, immobility,
and sedation. Medications that increase or decrease bladder or urethral
sphincter tone also may contribute to acute incontinence.
Chronic
Urinary Incontinence
Acute incontinence is
distinguished from established or chronic incontinence. There are four
predominant types of chronic urine loss: stress urinary incontinence,
instability incontinence, functional incontinence, and extraurethral
incontinence.
Stress Urinary Incontinence
Stress urinary incontinence
(SUI) is the uncontrolled loss of urine caused by physical exertion in the
absence of a detrusor muscle contraction. SUI is
associated with urethral hypermobility or with
intrinsic sphincter deficiency. Urethral hypermobility
is the abnormal movement of the bladder base and urethra during physical
exertion. The relationship between urethral hypermobility
and SUI is not entirely understood, although several mechanisms have been
proposed. Descent of the urethra into the lower portion of the pelvis may cause
a loss of abdominal pressure transmission when compared with forces that affect
the bladder. In addition, muscular contraction is compromised in the hypermobile urethra.
Loss of the normal anatomical
relationships between the urethral sphincter and related structures also may
contribute to SUI by reducing the efficiency of the muscular elements of the
sphincter. The contribution of estrogen deficiency, which compromises the
elements of urethral coaptation in the woman, remains
unclear. Table 39-1 identifies common factors that contribute to SUI.
Intrinsic sphincter deficiency
is a disorder of the muscular components of the urethral sphincter. Sphincter
closure is compromised, and urinary leakage is often severe. Severe urine loss
caused by intrinsic sphincter deficiency is defined as Total Incontinence by
the North American Nursing Diagnosis Association (NANDA) system. Unlike
urethral hypermobility, which is a women’s health
concern, intrinsic sphincter deficiency occurs in both genders and is related
primarily to iatrogenic or neuropathic causes. Table 39-1 identifies common
causes of intrinsic sphincter deficiency. It is important to note that
intrinsic sphincter deficiency and urethral hypermobility
frequently coexist in women.
Instability Incontinence
Instability incontinence is
the loss of urine caused by a premature or hyperactive contraction of the detrusor. In the person with normal sensations of the lower
urinary tract, these unstable detrusor contractions
initially cause a precipitous desire to urinate,
followed by urinary leakage unless the opportunity to toilet is immediately
available. In those without sensations of bladder filling and impending
urination, the contraction is followed by urinary incontinence that is often
described as unpredictable. The NANDA classification schema divides this type
of incontinence into two forms: Urge
Incontinence and Reflex Incontinence. This distinction is clinically relevant
because reflex incontinence is commonly associated with detrusor
sphincter dyssynergia, an uncontrolled contraction of
striated muscle of the sphincter mechanism during micturition.
Dyssynergia, or a loss of coordination between the
bladder and sphincter mechanism, causes a functional obstruction of the bladder
outlet and urinary retention. Table 39-2 outlines common causes of instability
incontinence of urine.
Functional Incontinence
Functional incontinence is the
loss of urine caused by altered mobility, dexterity, access to the toilet, or
changes in mentation. Altered mobility and dexterity
produce incontinence when the individual is unable to reach the toilet within a
reasonable time after the onset of the urge to urinate. These conditions are
worsened in an unfamiliar environment, such as a hospital, where side rails are
raised on beds and sedatives are used to enhance sleep. Difficulty in reaching
the toilet due to environmental factors, such as stairs, poor lighting, toilet
height, narrow doors that are impassable to wheel-chairs or walkers, or other
conditions also produce functional incontinence when they render the person
unable to enter the bathroom with reasonable ease. Acute confusion or dementia
causes urinary incontinence when the signals to toilet become unclear.
Functional incontinence exists
as a separate entity from stress or instability urinary leakage. Nonetheless,
it is important to remember that functional limitations also exacerbate these
forms of urine loss. Functional incontinence related to dementia may be managed
by a prompted voiding technique. Prompted voiding is a technique of providing
the opportunity to toilet on the basis of an individualized urge response toileting
program (PURT) or using a routine schedule. A PURT program is based on
knowledge of the individual’s typical voiding pattern. The client’s voiding
pattern is assessed by the use of a specially designed device to monitor
urinary elimination patterns or by routine assessment of containment devices
for wetness. The client is then placed on a prompted voiding schedule requiring
the nurse or other caregiver to approach the client, offer the opportunity to
urinate, and assist with toileting. Voiding is praised, as is dryness during
the period before voiding.
PURT is limited to clients
with adequate cognitive awareness to respond to the prompted voiding and to
those with caregivers willing to comply with the demands of this ongoing
program. Prompted voiding programs also may be instituted using a more
arbitrary schedule for toileting, usually every 2 to 3 hours.
Extraurethral Incontinence
Extraurethral
incontinence is the uncontrolled loss of urine that exists when the sphincter
mechanism has been bypassed. According to the NANDA classification system, extraurethral leakage is termed Total Incontinence, although that term
is also applied to severe SUI. The three causes of extraurethral
incontinence are ectopia (a congenital defect in
which leaks occur from a source outside the urethra), a fistula (acquired
passage allowing urinary leakage), or a surgical bypass of the urinary bladder
(such as the ileal conduit). The severity of extraurethral incontinence varies from a dribbling leakage
superimposed on an otherwise normal voiding pattern to a continuous urine loss
that replaces any recognizable voiding pattern.
Urinary
Retention
Urinary retention is caused by
two conditions: bladder outlet obstruction and deficient detrusor
muscle contraction strength. Bladder outlet obstruction causes incomplete
bladder evacuation by blocking the outflow of urine through the sphincter
mechanism or the urethra. Deficient detrusor muscle
contraction strength occurs when contractions are insufficient to maintain
urethral opening long enough for complete emptying of the bladder’s contents.
Because the management of each condition is different, it is important to
differentiate between these disorders during evaluation. Table 39-3 describes
common causes of urinary retention.
ASSESSMENT
The nursing assessment of
elimination is based on a client interview, evaluation of an objective log or
record of urinary or fecal elimination patterns, focused physical examination,
and review of diagnostic laboratory data. When altered patterns of elimination
indicate a significant health problem, additional diagnostic information is
used to formulate a plan of care.
Health History
Because issues of elimination
may produce feelings of anxiety, guilt, or shame among clients, the interview must
be instigated by the nurse and conducted in a setting that provides adequate
privacy. Clients are asked to describe their usual elimination habits. Table
39-4 presents the typical questions asked when assessing urinary and fecal
elimination patterns.
When screening questions
concerning altered patterns of elimination reveal significant findings, the
interview should be expanded to include specific questions about the nature of
the elimination disorder. These questions explore the type of incontinence,
complicating factors, and bladder (Table 39-5) and bowel management strategies
currently used by the client.
Physical Examination
The physical examination for
elimination patterns focuses on functional issues associated with urinary or fecal
incontinence and assesses the perineal and perianal areas. Functional evaluation begins with the
interview and continues throughout the physical examination. Mental status can
be evaluated by listening to the client’s responses to questions and by observing
interactions with others. When mental assessment reveals changes from normal or
expected function, a more specific tool, such as the Mini-Mental Status
Examination may be administered.
Mobility and dexterity are
evaluated by observation or by asking the client to perform simple tasks.
Mobility may be evaluated by observing the client undress or move onto a table,
chair, or bed. Dexterity is assessed by observing the client remove clothing;
particular attention is paid to the manipulation of zippers, buttons,
shoestrings, and snaps.
The perineum is initially
inspected for skin integrity. Among clients with severe urinary leakage, the
characteristic odor of urine may be present, and the skin may show signs of a monilial rash (maculopapular, red
rash with satellite lesions) or an ammonia contact dermatitis (papular rash with saturated, macerated skin). Among
patients with severe fecal incontinence, the skin is frequently denuded, red,
and painful to touch, particularly if it has been exposed to liquid stool. The
integrity of the skin typically remains intact with mild to moderate fecal or
urinary incontinence, although a monilial rash may be
present. This monilial rash may involve the inner
aspect of the thighs, and it frequently extends throughout the skin surface
covered by a containment device.
The vaginal vault of the woman
is inspected for signs of atrophic vaginitis and for
bladder and urethral support. The atrophic vagina has a dry, thin, friable
mucosa with a loss of rugae (regular folds of tissue
observed in the normal vagina). It is tender to touch, pale, and cracks or
bleeds easily. The vaginal introitus and vault may be
quite small, and the client may be intolerant of even gentle efforts to distend
the vagina for examination. Atrophic vaginal changes are important to assess
because they are associated with SUI, irritative
voiding symptoms, and urge incontinence.
Pelvic support is assessed in
the woman because it is associated with pelvic muscle weakness. Loss of pelvic
muscle tone is associated with pelvic descent, increasing the risk of urethral hypermobility or intrinsic sphincter deficiency. Both can
lead to SUI or defects of the anal sphincter or rectocele,
causing chronic constipation and incomplete evacuation of stool with
defecation.
Paravaginal
support is assessed using a gloved hand or speculum. The posterior vaginal wall
is supported using either a Sims’ speculum or a gloved finger gently inserted
into the vagina. The woman is asked to cough or strain down, and movement of
the posterior vaginal wall is evaluated. Bulging of the anterior wall indicates
a cystocele or loss of support of the bladder base.
This maneuver is repeated, and the posterior vaginal wall is evaluated for the
presence of a rectocele. Uterine prolapse
is noted when the uterus or cervix migrates toward the vaginal introitus in response to physical exertion.
The sensations of the perineal area are assessed, using a small needle to
evaluate sharp versus dull stimuli and using two probes to determine one-
versus two-point discrimination. The bulbocavernosus
reflex (BCR) is evaluated by gently tapping on the clitoris while observing the
anal sphincter. A positive reflex will produce an anal “wink” or contraction of
the perianal muscle. A weaker response is assessed by
placing a gloved finger at the anus or by pelvic muscle electromyogram
using patch or needle electrodes. Loss of sensations or absence of the BCR
indicates neurologic damage associated with urinary incontinence or retention.
Careful inspection of the perianal area and a digital rectal examination are
particularly important for men and women. The cheeks of the buttocks should be
pulled apart and the anus and surrounding area visually inspected. The client
may be asked to bear down and the anus inspected for prolapse
or for gaping, indicating significant weakness of the anal sphincter. In both
genders, the anal sphincter is assessed for tone and symmetry. The gloved,
lubricated finger is gently inserted into the anal sphincter. The finger is
rotated 360° and the tone of the external sphincter is assessed. In addition,
the rectum is palpated for evidence of stool or the hardened, large mass of
feces characteristic of fecal impaction.
Hemorrhoids (perianal varicosities of the hemorrhoidal veins) may also be identified. The prostate is
examined for size, consistency, and induration when
urinary retention is suspected. Benign prostatic hyperplasia, a common cause of
urinary retention in older men, produces a uniform enlargement of the prostate.
In contrast, prostate cancer causes asymmetric enlargement or discrete, hard
nodules.
When altered patterns of
urinary or fecal elimination are suspected from the health history, a log or
diary should be completed. The simple bladder log is kept over a long period of
time to determine patterns of urinary elimination and patterns of incontinence.
A more detailed log allows the nurse to evaluate fluid intake, client responses
to prompted toileting, functional bladder capacity, and the estimated volume of
an incontinent episode.
Diagnostic and Laboratory Data
When significant urinary or
fecal elimination problems are observed, further testing is needed to evaluate
the underlying cause of the condition and to determine treatment options. When
urinary incontinence exists, a dipstick urinalysis is obtained and evaluated
for nitrites, leukocytes, hemoglobin, glucose, and specific gravity. When
nitrites or leukocytes are present, a microscopic analysis is completed to
determine the presence of white blood cells in the urine (pyuria)
and bacteria in the urine (bacteriuria). Urine
culture and sensitivity testing are completed and the client is treated for a
urinary tract infection. If glucose is noted in the urine, the patient may
undergo further evaluation for diabetes mellitus, or methods of glucose control
may be reviewed and adjusted in the client with known diabetes. If the specific
gravity (weight of urine compared with weight of distilled water) of the urine
is abnormally low (below 1.010), the volume of fluid consumed by the client over
a 24-hour period is evaluated further. Hematuria
(blood in the urine) may be noted.
More detailed diagnostic
testing of lower urinary tract function may be obtained in cases of complex
urinary retention or incontinence. Urodynamics is a
set of tests that measure bladder and surrounding abdominal pressures. Pressure
data are combined with electromyography of the pelvic muscles and urinary flow
rate to determine lower urinary tract function during bladder filling and micturition.
Laboratory tests also may be
obtained for select cases of fecal incontinence. A stool culture may be
analyzed for ova and parasites, electrolytes, or culture when dietary
intolerance or a gastrointestinal infection is thought to be causing diarrhea
and related incontinence. When anal sphincter weakness is suspected as a cause
of fecal incontinence, anorectal manometry
may be completed to further evaluate anal sphincter and rectal vault function.
When pelvic muscle weakness and descent are thought to cause fecal
incontinence, defecography (x-ray images of the
rectal vault and anal sphincter obtained during defecation) or anorectal ultrasonography may be
completed.
NURSING DIAGNOSIS
The following nursing
diagnoses are frequently encountered in clients experiencing changes in urinary
and bowel habits.
Impaired Urinary Elimination
Impaired Urinary Elimination
is the state in which the individual experiences a disturbance in urine
elimination. Defining characteristics include dysuria
(painful urination), frequency, hesitancy, incontinence, nocturia,
retention, and urgency. Altered urinary elimination patterns can result from
multiple causes, including anatomic obstruction, sensory motor impairment, and
urinary tract infection.
Stress Urinary Incontinence
Stress urinary incontinence is
the state in which an individual experiences a loss of urine less than 50 ml
occurring with increased abdominal pressure. Major characteristics include
reported or observed dribbling with increased abdominal pressure. Minor
characteristics may include urinary urgency and urinary frequency (more often
than every 2 hours). The client may also be experiencing related factors such
as degenerative changes in pelvic muscles and structural supports associated
with increased age, high intra-abdominal pressure (e.g., obesity, gravid
uterus), incompetent bladder outlet, overdistension between voidings,
or weak pelvic muscles and structural supports.
Reflex Urinary Incontinence
The state
in which an individual experiences an involuntary loss of urine, occurring at
somewhat predictable intervals when a specific bladder volume is reached, is
known as Reflex Urinary Incontinence. Major characteristics include no
awareness of bladder filling, no urge to void or feelings of bladder fullness,
and uninhibited bladder contraction or spasm at regular intervals.
Related factors include a
neurologic impairment (e.g., spinal cord lesion that interferes with conduction
of cerebral messages above the level of the reflex arc).
Urge Urinary Incontinence
Urge Urinary Incontinence is the
state in which an individual experiences involuntary passage of urine occurring
soon after a strong sense of urgency to void. Major characteristics include
urinary urgency, frequency (voiding more often than every 2 hours), and bladder
contracture or spasm. Minor characteristics include nocturia
(more than two times per night), voiding small amounts (less than 100 ml) or
large amounts (more than 550 ml), and inability to reach the toilet in time.
Urge incontinence may be related to decreased bladder capacity (e.g., history
of pelvic inflammatory disease, abdominal surgeries, indwelling urinary
catheter), irritation of bladder stretch receptors causing spasm (e.g., bladder
infection), alcohol, caffeine, increased fluids, increased urine concentration,
or overdistension of the bladder.
Functional Urinary Incontinence
The state in which an
individual experiences an involuntary, unpredictable passage of urine is called
Functional Urinary Incontinence. Major characteristics include urge to void or
bladder contractions sufficiently strong to result in loss of urine before
reaching an appropriate receptacle. Altered environment, sensory, cognitive, or
mobility deficits may contribute to functional incontinence.
Total Urinary Incontinence
Total Urinary Incontinence is
the state in which an individual experiences a continuous and unpredictable
loss of urine. Major characteristics include constant flow of urine occurring
at unpredictable times without distension, uninhibited bladder contractions or
spasms, unsuccessful incontinence refractory treatments, and nocturia. Related factors include neuropathy that prevents
transmission of the reflex that indicates bladder fullness, neurologic
dysfunction causing triggering of micturition at
unpredictable times, independent contraction of the detrusor
reflex owing to surgery, trauma, or disease that affects spinal cord nerves, or
anatomy (fistula).
Urinary Retention
The state in which the
individual experiences incomplete emptying of the bladder is known as Urinary Retention.
Major characteristics for urinary retention include bladder distension and
small, frequent voiding or absence of urine output. Minor characteristics
include sensation of bladder fullness, dribbling, residual urine, dysuria, and overflow incontinence. High urethral pressure
caused by weak detrusor, inhibition of reflex arc,
strong sphincter, and blockage are related factors for urinary retetion.
Other Diagnoses
Other nursing diagnoses that
may be important for clients experiencing alterations in elimination patterns include Situational
Low Self-Esteem, Deficient Knowledge,
Risk for Infection, Risk for Impaired Skin Integrity, and Toileting Self-Care
Deficit. Nursing diagnoses and the resulting plan of care need to be developed
to ensure delivery of thoughtful nursing care for both the physical and
psychosocial aspects of altered elimination patterns that may affect a client’s
well-being.
OUTCOME IDENTIFICATION AND PLANNING
The targeted outcomes for
clients with alterations in elimination patterns center around
restoring and maintaining regular elimination habits and preventing potential
associated complications such as infections and altered skin integrity.
Interventions to respond to the client’s physical needs relating to maintaining
skin health and fluid volume balance need to be developed, as well as
strategies to address the client’s psychosocial needs, such as countering
deficient knowledge, enhancing self-esteem, and reducing or controlling
anxiety. Client teaching is also a critical factor in planning care for clients
with urinary and fecal complications. The nurse’s role in educating clients
concerning proper diet and exercise regimens to maintain urinary and fecal
health is also an important aspect of planning care. When ostomies
are involved, clients and their families will need instruction and demonstration on
proper care and the warning signs of infection.
IMPLEMENTATION
Maintain Elimination Health
The nursing management of altered
patterns of urinary and bowel elimination begins with an understanding of the
principles for general bladder and bowel health and by primary prevention of
problems whenever feasible. All clients should be taught basic principles of
fluid intake and urinary output, regular bowel evacuation, stool consistency,
and altered patterns of elimination. The Client Teaching Checklists offer
suggestions for maintaining urinary and bowel elimination patterns.
Fluid
Intake
Clients should be taught to
drink an adequate volume of fluid each day. The recommended daily allowance
(RDA) for fluids is 30 ml/kg body weight, or roughly ½ oz/lb body
weight. In the average-sized adult, this equals 1500 to 2000 ml/d, although
obese and thin individuals will vary from this range. Manipulation of the
volume of fluid intake showed only a weak correlation with voluntary or
incontinent episodes in the classical research regarding elderly women (Wyman, Elswick, Ory, Wilson, & Fantl, 1991). A person who experiences altered patterns of
urinary elimination, particularly incontinence, is likely to reduce fluid
intake in an attempt to manage the problem. Many clients reason that curtailing
fluid intake will reduce urinary output and the risk of incontinence.
Unfortunately, it will not. Systematic
dehydration may increase rather than diminish the risk of urinary incontinence
by promoting bacteriuria and by concentrating the
urine, thereby enhancing its irritative properties
when stored in the bladder. Dehydration also causes the body to compensate for
a shortage of available fluids by reabsorbing fluids and sodium from the bowel,
causing drying of the stool and constipation.
Diet
Persons with urinary
incontinence or frequent urination associated with urgency should be taught to
recognize potential bladder irritants. Specific foods and beverages irritate
the bladder and produce frequent urination and bladder discomfort in certain
persons, while exerting relatively little effect among others. Foods or
substances that may irritate the bladder are:
·
Caffeinated beverages, carbonated
drinks, and acidic fluids (including coffee and tea)
· Aspartame,
particularly when added to a caffeinated or carbonated beverage
·
Citrus fruits or juices
·
Foods containing tomatoes or
tomato-based sauces
·
Chocolate
·
Greasy or spicy foods
Dietary fiber may prevent
constipation and increase the desire to defecate. The client is advised to
increase the amount of fiber-rich foods in the diet, including grains, fruits,
and vegetables (Table 39-6). Remind the client that dietary fiber should be
increased gradually; a sudden increase in fiber may produce bloating and
abdominal discomfort.
Lifestyle
and Prevention
For many clients, lifestyle
and habits affect normal elimination patterns. Individual, social, family, and
cultural variables play an important role in elimination. Proper nutrition,
adequate rest and sleep, and regular exercise help maintain healthy elimination
patterns. Clients with elimination problems can take measures to correct or
alter the problem by modifying their lifestyle.
Alcohol and Tobacco Use
Consumption of alcohol exerts
significant effects on the bladder. Alcohol suppresses antidiuretic
hormone (ADH) excretion by the hypothalamus, causing polyuria
and increasing the risk of urinary leakage. In addition, the sedative effects
of alcohol increase the risk of urinary incontinence, both while awake and
during sleep. Alcohol irritates the intestines and bowels, causing
inflammation. The irritant effect causes increased elimination of fluid in the
stool, resulting in diarrhea. With chronic use of alcohol,
inflammation results, causing enteritis or colitis.
Cigarette smoking also may
irritate the bladder. Cigarette smoke may increase the risk of SUI because of its
association with a chronic cough, and smoking is a significant risk factor for
the development of bladder cancer. Smoking stimulates the bowel through the
action of nicotine, present in tobacco, causing increased bowel tone and
motility. The result is diarrhea.
Stress Management
Managing stress promotes
healthy bowel and urinary elimination patterns. Acute and chronic stress affect both elimination systems. The bowel responds
by increasing activity when the parasympathetic nervous system is stimulated. However,
the longer lasting effect of norepinephrine causes
slowing of the gastrointestinal tract. In response to the effect of ADH, the
kidneys retain fluid. The effect of ADH in combination with the effect of norepinephrine and epinephrine elevates the blood pressure.
Using education and support, nurses can help clients manage stress.
Elimination
Habits
The client is urged to
establish a regular schedule of bowel elimination and to answer the desire to
defecate. In the normal individual, the desire to move the bowel is transient
and lost when avoided or ignored. Although occasional avoidance of the urge to
defecate is a useful tool for continence, routine avoidance may predispose the
client to constipation and reduce the efficiency of bowel evacuation. The urge
to defecate is typically greatest after a meal, and it may be enhanced by
dietary stimulants such as fiber or a caffeinated beverage or by light
exercise. In an unfamiliar setting, such as the hospital, it is important to
provide adequate privacy so that the client can heed the urge to defecate
without undue interruption or embarrassment.
Encourage the client to
establish a regular elimination pattern to prevent urinary incontinence. This
can be successfully accomplished by using techniques such as relaxation and
timing. The client, with the assistance of the nurse, establishes a voiding
schedule. Once the client has met the goal of staying continent for the
established time period, the interval between voiding can be lengthened. Within
the interval between urinations, the client can use relaxation exercises to
help manage the feelings of urgency.
Positioning
Positioning of the client
plays an important role in elimination. Sitting is the usual position for both
men and women for bowel elimination. Sitting is also the usual position for
women to urinate; standing is the position preferred by some men. Clients
unable to use the toilet require assistance in accomplishing elimination.
Devices such as the bedpan,
commode, or urinal can be substituted (Figures 39-5 and 39-6). Clients who use a bedpan need as comfortable
a setting as possible, therefore, after placement of the bedpan the head of the
bed should be elevated to a 45° angle, unless contraindicated. The nurse may
need to assist the client to cross the legs in order to create somewhat of a
sitting position. Male clients who are unable to stand should have the head of
the bed elevated to a 45° angle, unless contraindicated, while using the
urinal. Procedure 39-1 outlines the
steps in positioning and removing a bedpan.
Clients who are able to get
out of bed but are unable to ambulate to the toilet can use a bedside commode,
which resembles a toilet but is portable. Typically, the client is assisted to
stand and pivot to the commode from the bed.
Initiate Exercise Regimen
Regular exercise leads to good
muscle tone and body metabolism. Exercise also stimulates the bowels to move
regularly and leads to good urine production. Poor muscle tone can lead to
impaired bladder muscle contraction and poor urination control. Pelvic muscle
exercises are taught to manage SUI, and a strength
training program is begun using principles of exercise physiology. Clients are
taught to identify, isolate, and contract the pelvic muscles and to avoid
contraction of distant muscles groups such as the thigh or abdominal muscles.
Because clients frequently have difficulty isolating the pelvic muscles,
biofeedback may be helpful. The nurse teaches the client to perform a single
exercise that combines maximal strength and endurance. The client is asked to
perform a maximal strength contraction of the muscles “surrounding the urethra
and vagina or rectum” for a count of 10, or approximately 6 seconds, followed
by a rest period of equal length. The program begins with few contractions
(typically 10 or fewer), and the number of repetitions is increased to a
maximum of 35 to 50. The exercise regimen must be integrated into activities of
daily living for maximal effectiveness. Pelvic muscle exercises, particularly
when combined with biofeedback techniques, are typically taught by a specialty
practice or advanced practice nurse with specific education in the management
of the client with SUI.
Other management techniques
are administered by the advanced practice or specialty practice nurse. These
include transvaginal or transrectal
electrical stimulation and placement of a vaginal pessary
(a supportive device).
Inadequate tone in the
abdominal muscles, diaphragm, and the perineal
muscles can cause difficulty in defecating. If a client is suffering from
constipation, a regimen of walking or light recreational exercise should be
recommended to promote peristalsis and defecation.
Suggest Environmental Modifications
Functional incontinence is managed
by removing the barriers to toileting. The environment is manipulated to
maximize opportunities for toileting, to minimize the impact of poor mobility,
and to remove any environmental barriers. Clothing is carefully evaluated, and
buttons, zippers, and multiple layers of clothing are exchanged for items that
are simpler to remove. Mobility is maximized by selection of shoes with nonskid
soles, and Velcro straps are preferred over strings when dexterity is
compromised. The accompanying display describes the effectiveness of
environmental modifications in managing functional incontinence.
The nursing management of
fecal incontinence begins with measures to normalize stool consistency because
constipation and diarrhea increase the risk of incontinent episodes. The
environment is also manipulated to minimize functional limitations to bowel
elimination. Mobility is enhanced by assistive devices (canes, walkers) as
needed, and by altering seating and toilets to a height that allows optimal
ease when transferring.
Clothing is altered to
minimize the time required for removal in preparation for defecation.
Environmental barriers including poor lighting, narrow doorways, and slippery
flooring are removed, or portable toileting facilities are made available.
Initiate Behavioral Interventions
A scheduled defecation program
is used for clients with either a diminished ability to sense rectal distension
or altered cognition who are unable to adequately
respond to the presence of a bolus of stool in the rectum. The colon is
cleansed of any excess stool, using an oral laxative or enema. The diet is
altered to enhance the formation of a soft, solid stool, and supplemental bulk
is added if indicated. Patterns of bowel elimination are evaluated, and the
client is encouraged to defecate on this schedule if feasible. Otherwise, bowel
elimination is scheduled after either a meal or another stimulant, such as a
caffeinated beverage or a pharmacologic agent. The importance of heeding the
urge to defecate is emphasized, and the client with altered cognition is
prompted to defecate.
Clients with significant
sensory and motor deficits of the rectum and anus typically require a scheduled
defecation program combined with vigorous stimulation of defecation. Persons
with a paralyzing neurologic disorder have significant loss of anal sphincter
control, poor abdominal muscle control, and altered colonic mobility. As a
result, defecation must be scheduled and vigorously stimulated to avoid
impaction and fecal incontinence.
The colon is cleansed and
stool consistency is normalized at the outset of the program. A timetable for
bowel elimination is identified. Because of the need for an extensive process
for effective defecation, this program must consider the schedule of the client
and significant others, as well as premorbid
defecation patterns. The bowel is stimulated by a pharmacologic device, such as
bisacodyl or a mini-enema.
Behavioral interventions play
a primary role in the management of urge incontinence. Methods of biofeedback
are used to teach the client to perform either a “quick flick” maneuver or a
sustained contraction in response to an episode of precipitous urgency. The
quick flick is a rapid, maximal contraction of the pelvic muscles held for 3 to
4 seconds, and a sustained contraction is held for 6 to 10 seconds. The client
is instructed to stop, rather than rush to the bathroom, thus decreasing the
risk of falling. Several quick flicks or a sustained contraction are then
performed until the precipitous urge is controlled. At this point, the client
is instructed to proceed to the bathroom at a normal pace, but without further
delays.
Other techniques, including
electrical stimulation and more extensive biofeedback training, also may be
used for urge incontinence. These treatment programs are typically managed by
the advanced practice or specialty practice continence nurse.
The management of urinary
retention is influenced by the underlying cause and the severity of the
symptom. Mild urinary retention caused by poor detrusor
contractility or obstruction may be managed by timed voiding or by double
voiding. Timed voiding is a strategy to reduce overdistension
and loss of muscle tone in clients with diminished sensations of urinary
urgency.
The client is taught to
urinate at specific intervals, typically every 3 to 4 hours. Double voiding is
an attempt to increase the efficiency of urine evacuation by contracting the detrusor twice during micturition.
The client is taught to void, rest on the toilet for 2 to 5 minutes, and void
again.
Intermittent catheterization
is used for moderate to severe urinary retention, when the residual urine
volume is 50% or more of the total bladder capacity.
Intermittent
self-catheterization is taught using a clean technique. The client is taught to
wash his hands and to locate and catheterize the urethra using a water-based
soluble lubricant. Catheters may be cleaned and reused, and the client or
significant other may catheterize without applying sterile gloves.
Monitor Skin Integrity
Because problems with urinary
functioning may result in disturbances in hydration and excretion of body
wastes, the skin should be carefully assessed for color, texture, turgor, and the excretion of any wastes. The integrity of
the skin in the perineal area also should be
assessed. Problems with incontinence may result in severe excoriation.
The risk of altered skin
integrity is significant. The client is taught to regularly clean and
thoroughly dry the skin. Clients with fragile skin are advised to use a skin
cleanser; otherwise, use of soap and water is adequate. After cleansing, the
skin should be dried thoroughly. A hair dryer set on the low (cool) setting may
be recommended.
When monitoring a client with
diarrhea, the nurse should assess the perineal skin
for altered integrity. After each defecation, the skin
is routinely cleansed with tap water or a gentle cleanser specifically designed
for incontinence. Soap and water and abrasive cleaning techniques are avoided
because they increase discomfort and the risk of altered skin integrity. The
skin is then protected by application of a sealant or moisture barrier. Denuded
skin is first treated with a pectin-based powder, followed by a skin sealant or
moisture barrier.
Apply a Containment Device
Condom
Catheter
The condom catheter is a
device that resembles a condom with a large-caliber connector at its distal end
(Figure 39-9). This is connected to a drainage bag via a leg bag or bedside
container for urinary containment. Procedure 39-2 discusses the application of
a condom catheter.
Several types of condom
catheters are available. The ideal device adheres to the penile skin without
producing irritation and has sufficient elasticity to maintain its watertight
seal whether the penis is in an erect or a flaccid state. Because of the
potential for altered skin integrity, the condom catheter is reserved for
severe SUI.
Men without adequate upper
extremity dexterity may manage urine containment using a condom catheter.
The bladder outlet resistance
caused by detrusor sphincter dyssynergia
must be managed by pharmacotherapy or by transurethral or laser sphincterotomy. A special device, the Urolume,
also may be inserted. This device consists of a wire mesh that is inserted into
the urethra via a special cystoscopic device and
expanded at the membranous urethra. The wire mesh of the Urolume
gently holds the sphincter open, promoting urine evacuation and preventing the
deleterious effects of sphincter dyssynergia.
Incontinent
and Dribble Pads
Many women attempt to contain
urine with feminine hygiene pads. Although these pads effectively contain
menstrual flow, they are not designed for urine loss. As a result, they must be
changed frequently, and the risk of odor and soiling outer clothing is
enhanced. Women with mild SUI typically benefit from a small incontinent pad
that adheres to the undergarments. Unlike the feminine hygiene pad, the ideal
incontinent pad contains Superabsorbents® that
increase the product’s absorptive ability. Women with more severe SUI also may
use a device that adheres to the undergarments. However, larger pads that are
capable of absorbing up to 500 ml are recommended (Figure 39-10). Only women
with very severe leakage are advised to use an incontinent brief. It is
important to remember that containment devices are considered temporary, and
the ultimate goal is reduction or ablation of urinary leakage so that pads are
not needed.
Men with mild SUI may use a
“dribble pad,” a device that adheres to the undergarments and holds the penis
is a specially designed pouch. More absorptive pads or incontinent briefs are
reserved for severe cases. Two additional devices, the penile clamp and condom
catheter, are also used for men with SUI. The penile clamp is a constrictive
device that mechanically closes the pendulous urethra. The device is worn for a
brief period and removed to prevent ischemia to local tissues. Because of the
risk of necrosis and discomfort associated with the clamp, its use is limited.
The medical management of SUI
includes both OTC and prescription drugs. OTC medications such as Dexatrim without caffeine and Sudafed contain the α-adrenergic
agonists phenylpropanolamine and pseudoephedrine,
respectively, which increase urethral sphincter tone and relieve urinary
leakage. Nurses teach the client the specific purpose of these medications, and
they advise clients to ignore the dosage and scheduling recommendations on the
medication container. Instead, the client is taught to take the medication only
during waking hours rather than around theclock to
reduce the risk of associated insomnia. Potential side effects associated with
these medications, such as restlessness and hypertension, are discussed with
the client, and blood pressure is monitored regularly.
Stress urinary incontinence
also may be managed by
prescription medications including imipramine (Tofranil) and topical estrogens, often administered in
combination. The client is taught the dosage and administration of each of
these agents. Because imipramine has anticholinergic as well as α-adrenergic effects,
clients are advised of additional side effects including dry mouth, the
potential for constipation, and mydriasis. Women who
are placed on topical or systemic estrogens are advised to seek ongoing care
from their gynecologist, including routine vaginal examinations and Papanicolaou (Pap) smears.
Medications are often
prescribed for urge urinary incontinence. Anticholinergics
or antispasmodics relax detrusor muscle contractions
by blocking the action of acetylcholine, by a local anesthetic effect, or by a
direct effect on the detrusor muscle. Common agents,
their actions, and potential side effects are described in Table 39-7. None of
these agents will be effective unless the client is taught to adhere to a timed
voiding schedule and to identify and limit the intake of bladder irritants.
Several pharmacologic agents
may be used in the management of urinary retention. Finasteride,
a 5-α-reductase inhibitor, is used to reduce prostatic size and related
urinary retention. Men who take finasteride are
taught the dosage and administration of the drug and its potential side
effects, including impotence and loss of libido. Caregivers are cautioned to
refrain from handling the drug without gloves because transdermal
absorption and irritation of the skin have been reported.
Alpha-adrenergic blocking
agents also may be used to manage urinary retention caused by prostatic
hyperplasia, bladder neck dyssynergia, or detrusor striated sphincter dyssynergia.
Because of the risk of postural hypotension when the medication reaches a peak
plasma level, the client is taught to take these drugs before bedtime. Clients
are also taught to monitor for medication side effects, including postural
dizziness during waking hours, fatigue, and headache. The significance of
titrating the dosage of an α-blocking agent is
emphasized, and the client is reminded that the dosage must be retitrated if the medication is inadvertently stopped for a
period of more than 72 hours.
Perform Catheterization
Occasionally, an indwelling
urethral or suprapubic catheter may be used to
provide continuous drainage for reflex incontinence (Figure 39-13). An
indwelling catheter may be inserted for an acute episode of urinary retention
or when other strategies to manage retention are ineffective. A catheter is
chosen that minimizes urethral irritation and maximizes drainage from the
bladder.
A silicone or other
inert-material catheter is preferred over a Silastic
catheter coated with Teflon. A Lubricious-coated catheter (Bard Urological,
The use of a coudé catheter is indicated when intermittent
catheterization is needed. The coudé catheter works
much like the other catheters; however, a distinguishing feature is that the
tip of the catheter is more pointed and curved. The coudé
catheter does not have a balloon; therefore it cannot be used for a procedure
requiring an indwelling catheter. Procedures 39-3 and 39-4 discuss
catheterization. Procedures 39-5 and 39-6 discuss irrigation of catheters.
Intermittent
Self-Catheterization
Women with reflex incontinence
have more-limited options for management because no effective condom device has
been designed for women. Intermittent self-catheterization is chosen whenever
feasible. This option is typically used in combination with pharmacotherapy for
detrusor hyperreflexia.
Indwelling catheterization is used only when other means of bladder management
are not feasible.
Of the bladder management
programs available for the client with a spinal injury or multiple sclerosis
and reflex incontinence, intermittent self-catheterization is preferred when
feasible. The nurse teaches the client with adequate upper extremity dexterity
to perform self-catheterization, and the skill is also taught to significant
others. Pharmacotherapy, consisting of an anticholinergic
agent, imipramine, or (rarely) a calcium channel
blocker, is frequently required to control hyperreflexic
detrusor contractions.
Monitor Surgical Management
The surgical management for
SUI differs for urethral hypermobility as compared
with intrinsic sphincter deficiency. Urethral hypermobility
is managed by a bladder suspension designed to prevent descent of the bladder
base and urine loss during physical exertion. The selection of the procedure
depends on the severity of the incontinence and client and surgeon preference.
Clients with adequate urethral
support and intrinsic sphincter deficiency may be managed with a urethral
bulking agent, such as Contigen (Bard Urological,
An artificial urinary
sphincter device also may be used to manage intrinsic sphincter deficiency.
This mechanical device allows the client to mechanically inflate and deflate a
cuff that compresses underlying urethral tissues. Each of these procedures
requires specific nursing care and instruction. See a urologic nursing text for
a detailed discussion of the nursing care for urologic surgery. Surgery plays
only a limited role in the management of urge incontinence. Surgical procedures
designed to denervate the bladder (sever nerves
needed for contraction of the detrusor muscle) have
had little success because of significant complications, including fecal
incontinence and impotence among men. A surgically implanted device designed to
deliver electrical stimulation to the lower urinary tract has been approved for
use in the
Surgical reconstruction is
sometimes used in the long-term management of reflex incontinence. An
augmentation enterocystoplasty enlarges bladder
capacity and alleviates reflex incontinence by converting the hyperreflexic bladder into a large, atonic
bladder with improved storage ability. Unfortunately, the augmented bladder
rarely empties efficiently, and clients are advised that lifelong intermittent
self-catheterization will be necessary after augmentation surgery. A continent
or incontinent urinary diversion is occasionally used to manage urine
elimination in the patient with reflex incontinence. However, urinary diversion
is completed only when bladder function threatens the normal function of the
upper urinary tracts.
Fistulae and ectopia are managed by surgical closure whenever possible.
When surgery is not feasible, a fistula may be treated by careful application
of a sclerosing agent, such as tetracycline or doxycycline in suspension. The solution is applied monthly,
and a skin barrier is used on the area surrounding the fistula to prevent
scarring. The fistula that cannot be closed surgically or by sclerosing therapy must be managed by application of a
urinary containment device and a preventive skin program.
Surgery or endoscopic
procedures alleviate urinary retention caused by bladder outlet obstruction.
Transurethral resection of the prostate, open prostatectomy, VaporTrode, visual ablation of the prostate, and other
procedures are used to alleviate obstruction caused by benign prostatic
hyperplasia. Transurethral incision of the bladder neck or transurethral sphincterotomy may be used for bladder neck or striated
sphincter dyssynergia.
Complementary Therapies
“One of the
largest health problems in the western world is in the area of elimination”
(Barney, 1996, p. 57). When the body fails to eliminate
waste that is full of toxic substances, other systems are compromised and the
person becomes prone to illness. Herbalists view the role of the kidneys and
the intestines in a holistic manner. The proper function of any part of the
body is dependent on the effective elimination of waste products and toxins.
“Considering
the importance of the kidneys, it is not surprising that nature is abundant in
herbs that can aid their functions” (Hoffmann, 1998, p. 109).
Herbs that aid the functions of the urinary system are:
·
Diuretics: Dandelion root and leaf
and cleavers
· Antiseptics: bearberry, birch, boldo,
buchu, celery seed, couchgrass,
juniper, and yarrow
·
Antimicrobials: Echinacea and wild
indigo root
·
Demulcents: corn silk, couchgrass,
and marshmallow leaf
Herbs that possess other
properties may also be used, such as urinary astringents (beth
root, horsetail, and plantain tormentil), to treat
blood in the urine caused by minor problems, and to aid the healing of lesions,
and antilithics (gravel root, hydrangea, and stone
root), to prevent the formation of or aid in the removal of calculi (stones or
gravel) in the urinary system.
Both urinary and fecal
elimination are reliant upon sufficient amounts of fiber and fluids in the
diet. Poor nutrition is the most common cause of chronic constipation (Barney,
1996). The following herbs are helpful in relieving constipation: Cascara sagrada
bark, senna, ginger root, butternut root bark,
burdock root. Also, milk thistle, a cholagogue, may
be used to aid liver function and to enhance bile flow to soften stools.
Cascara sagrada
bark is an old Indian remedy to encourage peristalsis and tone relaxed muscles
of the digestive tract. Senna is the most widely used
stimulant laxative when compared to synthetic drugs (Barney, 1996). Cascara and
senna should be combined with aromatics and
carminatives such as licorice and ginger root to increase palatability and
reduce gripping. Ginger root aids in digestion and enhances bile flow from the
liver. Burdock root is a mild laxative and an effective diuretic; its cleansing
effect goes beyond its diuretic and laxative properties as it promotes
perspiration and strengthens the liver.
Psyllium
seed and flaxseed are also helpful for constipation. Psyllium
seed must be taken with a full glass of water.
Mineral oil should not be
taken on a regular basis because, if inhaled, it can damage the lungs, and it
reduces the absorption of fat-soluble vitamins (Balch & Balch, 1997).
EVALUATION
Evaluating the effectiveness
of the nursing interventions is an ongoing process. The client’s level of
maintenance or restoration of elimination patterns and return to an appropriate
level of independence are indicators of success. When evaluating these aspects,
it is important for the nurse to reassess how realistic the original identified
outcomes were, especially for goals that were not met, and to modify the target
outcomes accordingly.
Prevention of skin breakdown
and infection can also be used to determine the appropriateness of the plan of
care. Client understanding of procedures and self-care should be evaluated to
determine the effectiveness of teaching plans, and modifications should be made
to address deficiencies and ongoing learning needs. If support persons were
included in the teaching process, their understanding of skills and competence
with procedures should also be measured. If additional care or teaching is
deemed necessary, clients should be given referrals for community and other
resources to support their continuing learning needs.
Alternative
Urinary and Bowel Elimination Procedures
