Urinary Elimination

 

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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 nurses 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 5.5 cm long, and the distal third is histologically fused with the vaginal wall (Figure 39-1). The entire length of the urethra forms a sphincter mechanism with elements of compression and elements of tension.

In men, the urethra is approximately 23 cm long. It begins at the bladder base, pierces the anterior portion of the prostate, and turns to exit the body through the penis. The proximal third of the male urethra forms a sphincter mechanism comparable to the female urethra. The distal two-thirds is a conduit for the expulsion of urine or semen.

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 clients 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 clients 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 clients 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 womens 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 individuals typical voiding pattern. The clients 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 bladders 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 clients 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 clients 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 clients physical needs relating to maintaining skin health and fluid volume balance need to be developed, as well as strategies to address the clients 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 nurses 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 products 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, Covington, Georgia) also may be used because of its hydrophilic nature and its low friction coefficient. The client is provided with a drainage bag with adequate storage capacity for overnight use (typically 2000 ml) and a leg bag with nonlatex straps when indicated.

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, Covington, Georgia). This product is a glutaraldehyde cross-linked collagen that improves continence by enhancing compressive elements of the urethral sphincter mechanism. It is injected transurethrally, and local anesthesia with systemic sedation is often used in preference to general anesthesia. Women with a combination of urethral hypermobility and intrinsic sphincter deficiency may undergo a suburethral sling procedure, in which the proximal third of the urethra is supported with fascia or a synthetic material.

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 United States. Refer to a urologic nursing text for management of these clients. The management of reflex incontinence is complicated by the combination of urine leakage and urinary retention caused by detrusor sphincter dyssynergia. A bladder management program is chosen that both protects the upper urinary tracts from serious damage and maximizes continence.

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 clients 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