Bowel Elimination
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.
Bowel Elimination
The process of normal fecal elimination is not completely understood. Continence primarily relies on the consistency of the stool (fecal material), intestinal motility, compliance and contractility of the rectum, and competence of the anal sphincters.
Structures of the Gastrointestinal Tract
The gastrointestinal system (alimentary canal) begins at the mouth and ends at the anus. The small intestine in the adult is approximately
Substances that are well tolerated move through the bowel relatively slowly; foods or drugs that are toxic or irritable to the small bowel are evacuated rapidly. The small intestine joins the large bowel (colon) at the ileocecal valve. This valve works in conjunction with the ileocecal sphincter to control emptying of contents from the small intestine into the colon and to prevent regurgitation of digestive chime from the large to small bowel (Figure 39-2).
The colon is approximately 5 to
Intestinal Motility and Rectal Accommodation
Fecal continence relies on regular delivery of small boluses of stool that are stored in the rectum before elimination. The transit time from ingestion of food to passage of stool from the bowels varies. Typically, at least 80% of intake that is not absorbed by the body is excreted from the bowel within 5 days following ingestion. Transit time is significantly affected by the type of foods ingested, subsequent dietary intake, exercise, and stress-related factors.
Filling of the rectum causes a growing awareness of the presence of stool, which is stored until an appropriate opportunity for defecation (evacuation of stool from the rectum) is identified. In the continent individual, an initial awareness of stool in the rectum is identified at 150 ml. The desire to defecate is typically transient, diminishing as the rectum accommodates larger volumes of stool. When 400 ml or more of stool is collected in the rectum, this urge becomes strong, and the call to defecate becomes more persistent. Failure to heed the call to defecate may lead to overdistension of the rectum with hardening of the stool and subsequent constipation.
Anal Sphincter Mechanism
The anal sphincter is divided into two mechanisms, called the internal and external sphincters (Figure 39-3). An internal anal sphincter is primarily made up of smooth muscle bundles that are connected to the smooth muscle of the rectum. It begins in the distal portion of the rectum and extends approximately
The external sphincter is composed of striated muscle fibers that are divided into deep and superficial components. The deep portion of the external anal sphincter comprises muscle fibers that encircle the proximal aspect of the anal canal and attach to the symphysis pubis, forming a U shape. The superficial portion of the anal sphincter also encircles the anal canal, forming a U shape; however, it attaches to the coccyx and postanal plate rather than to the anterior aspect of the pelvis. Like the periurethral muscles, the striated component of the external anal sphincter contains both fast and slow-twitch fibers that allow sustained tone over a period of time before voluntary defecation.
Sensory receptors located at the proximal anal canal affect anal function. These specialized sensory receptors are able to “sample” fecal contents, allowing the individual to differentiate among solid stool, liquid stool, and gas.
Distension of the rectum causes a reflex inhibition of the internal anal sphincter and contraction of the external sphincter. The proximal anal sphincter then samples the contents of the rectum, and the individual perceives the desire to defecate. If the person postpones defecation, rectal accommodation occurs and the desire to defecate is postponed. If the desire to defecate is heeded, the person voluntarily relaxes the external anal sphincter and evacuates the bowel of feces.
The significance of rectal contractions during defecation remains unclear. Many persons strain to defecate, and abdominal force is readily transmitted to the rectum, creating an effective expulsive force. The continent individual is able to simultaneously increase abdominal pressure by straining and maintain external anal sphincter relaxation, allowing effective evacuation of feces from the bowel.
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
Bowel Elimination
Many diseases and conditions affect bowel function. Although many alterations in bowel elimination patterns may be observed, this discussion is limited to three common alterations: constipation, diarrhea, and fecal incontinence.
Constipation
Colonic constipation is the infrequent and difficult passage of hardened stool. (Perceived constipation, influenced by psychological and emotional stress, is not included in this discussion.) Dietary factors may contribute to constipation. Dehydration causes drying of the stool as the body increases the reabsorption of water and sodium from the bowel. Inadequate dietary bulk also dehydrates the stool. Diverticular disease, a common problem in the elderly, also reduces colonic transit, further increasing the risk of constipation.
Neuropathic conditions promote constipation by diminishing the efficiency of gastric motility. They also weaken the abdominal muscles, reducing the efficiency of straining and rectal evacuation. Lesions of the brain, such as cerebrovascular accident, and spinal disorders, disc problems, or spinal stenosis contribute to constipation by reducing mobility, weakening the abdominal muscles, and diminishing the motility of the smooth muscle of the colon and rectum. Functional limitations, particularly impaired mobility, predispose elderly clients to constipation; they perceive a diminished desire to defecate and have prolonged colonic transit time. Multiple medications, particularly narcotics, sedatives, anticholinergics, antidepressants, antiparkinsonian drugs, and iron, also contribute to constipation.
In women, mechanical factors may exacerbate constipation. A rectocele is the herniation of the rectum and surrounding tissues into the potential space of the vagina (Figure 39-4). A significant rectocele causes a mechanical obstruction to defecation and subsequent constipation. Both women and men may experience constipation because of incomplete control of the anal sphincter. In this case, failure of complete relaxation of the anal sphincter causes fecal retention, drying of stool, and constipation.
In severe cases, the hardened stool may consolidate into an impaction. This bolus of stool serves as a nidus for bacterial overgrowth and produces an obstruction that further slows colonic transit time and the passage of further fecal contents.
Diarrhea
Diarrhea is the passage of liquefied stool that, because of its increased frequency and consistency, represents a change in the person’s bowel habits. The primary causes of diarrhea include infectious agents, malabsorption disorders, inflammatory bowel disease, short bowel syndrome, side effects of drugs, and laxative or enema misuse.
Infectious diarrhea occurs when overgrowth of a pathogen produces osmotic diarrhea via toxins or reduced absorptive ability due to mucosal damage. Common pathogens include Clostridium difficile, enterotoxigenic Escherichia coli, Salmonella, Shigella, Entamoeba histolytica, and Giardia.
Malabsorption syndromes produce diarrhea when nonabsorbed substances in the diet create an osmotic imbalance and liquefaction of the stool. Lactose intolerance, sorbitol intolerance, and celiac sprue syndrome are examples of common malabsorption syndromes that predispose clients to diarrhea. Persons with inflammatory bowel disease or short bowel syndrome are predisposed toward diarrhea because of a reduced surface area for reabsorption.
Specific drugs may cause diarrhea as a side effect. Administration of multiple antimicrobial agents may indirectly predispose the client to diarrhea by promoting an overgrowth of C. difficile in the bowel. Cholinergic drugs increase motility and reduce reabsorption of water and electrolytes from the stool. Other drugs produce osmotic diarrhea, primarily because of the vehicle for delivery, which frequently contains sorbitol and a high osmolality.
Enteral feedings contain a relatively high osmolality that frequently predisposes the client to diarrhea. These formulas may contain lactose, which causes intolerance in some people. The risk of diarrhea is further enhanced in the critically ill who have highly catabolic states and decreased absorptive ability and among those receiving bolus administration of intravenous fluids.
The misuse of laxatives and enemas is frequentlyassociated with diarrhea among clients living at home. Overuse of saline cathartics may produce osmotic diarrhea, and the chronic misuse of laxatives may alter motility patterns and cause an osmotic shift in the bowel.
Secretory diarrhea occurs when the normal mechanisms that produce intestinal fluid are hyperactivated, causing excessive production and movement of food through the intestinal system. Zollinger-Ellison syndrome, pancreatic cholera, carcinoid syndrome, and villous adenoma may produce severe, chronic diarrhea.
Fecal Incontinence
Fecal incontinence is the involuntary loss of stool of sufficient magnitude to create a social or hygienic problem. The primary mechanisms that predispose the adult to incontinence of stool are dysfunction of the anal sphincter, disorders of the delivery of stool to the rectum, disorders of rectal storage, and anatomic defects.
A disorder of stool volume and consistency is typically not enough to produce fecal incontinence in the otherwise normal individual. Instead, the person is likely to perceive a precipitous urgency to defecate, an impulse that is heeded rapidly. However, if the volume of stool is sufficient and the storage capacity of the rectum is compromised, or sphincter function is suboptimal, fecal incontinence may result. When severe constipation leads to an impaction of stool, bacteria in the rectum overgrow, producing a liquefied medium. The toxins produced by this liquefied stool are likely to stimulate the bowel and may produce transient seepage of stool in the normally continent client.
Low compliance of the rectum also predisposes the client to fecal incontinence. In the normal individual, the rectum is able to accommodate 400 ml of feces at low pressure. However, clients with radiation proctitis, rectal wall fibrosis due to inflammatory disorders, infectious proctitis, chronic obstruction, or malignancies store lower volumes of stool at higher pressures. Low rectal compliance diminishes storage capacity and causes greater thaormal urgency to defecate when stool enters the rectum. When a large volume of stool enters the rectum rapidly, the urgency to defecate is likely to be overwhelming, and the risk of incontinence is significant.
Anal sphincter dysfunction is likely to cause incontinence when both the internal and external mechanisms are compromised. Neurologic lesions are the most common cause of anal sphincter dysfunction. Typically, the client is able to compensate for sphincter weakness, provided the rectum is presented with a normal delivery of solid stool. However, in the presence of diarrhea, significant fecal incontinence may occur.
Sensory disorders also predispose the client to fecal incontinence. Loss of the sensitive epithelium in the proximal anal canal interferes with the client’s ability to differentiate gas and solid and liquid contents in the rectum. In addition, loss of proprioception in the rectum disturbs the client’s ability to detect rectal fullness. These individuals are particularly prone to incontinence when a large bolus of stool enters the rectum rapidly or when an impaction occurs.
Anatomic disorders also may compromise sphincter function and predispose the individual to fecal incontinence. Among women, the most common risk factor is obstetric trauma. Vaginal deliveries, particularly those requiring the use of forceps and those complicated by third-degree tearing, are likely to damage the anal sphincter mechanism.
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.
Constipation
A state in which an individual experiences a change iormal bowel habits characterized by a decrease in frequency or passage of hard, dry stools is called Constipation. Defining characteristics include decreased activity level, frequency less than usual pattern, hardformed stools, palpable mass, reported feeling of pressure and fullness in rectum, and straining at stool.
Other possible characteristics include abdominal pain, appetite impairment, back pain, headache, interference with daily living, and use of laxatives. Related factors for constipation are still under development by NANDA; some possible considerations may be change in daily routine and less than adequate fluid and dietary intake.
Perceived Constipation
Perceived Constipation is the state in which an individual makes a self-diagnosis of constipation and ensures a daily bowel movement through abuse of laxatives, enemas, and suppositories. Major characteristics include expectation of daily bowel movement, with the resulting overuse of laxatives, enemas, and suppositories, and expected passage of stool at the same time every day. Related factors may include cultural or family health beliefs, faulty appraisal, or impaired thought processes.
Diarrhea
Diarrhea is the state in which an individual experiences a change iormal bowel habits characterized by the frequent passage of loose, fluid, unformed stools. Defining characteristics include abdominal pain, cramping, increased frequency, increased frequency of bowel sounds, loose or liquid stools, and urgency. Other possible characteristics include change in color of stools. Gastrointestinal, metabolic, nutritional, or endocrine disorders; infectious processes; tube feedings; fecal impaction; change in dietary intake; adverse affects of medications; and high stress levels may all contribute to diarrhea.
Bowel Incontinence
A state in which an individual experiences a change iormal bowel habits characterized by involuntary passage of stool is called Bowel Incontinence. Related factors may include gastrointestinal and neuromuscular disorders, colostomy, loss of rectal sphincter control, and impaired cognition.
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 bedpaeed 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
Rectal Pouch and Rectal Tube
Severe diarrhea may justify the use of a rectal pouch or rectal tube to contain leakage and to protect the surrounding skin. The rectal pouch is a drainable pouch attached to an adhesive skin barrier that conforms to the perianal region. The pouch is attached to the perianal area and any exposed skin surfaces are carefully protected with a skin sealant. Attachment to intact skin is relatively straightforward; however, application to denuded skin is difficult, and consultation with an enterostomal therapist or incontinence nurse specialist is recommended. The rectal tube is an alternative to the rectal pouch.
A larger catheter (30 French) is passed into the rectum and attached to a large bedside drainage bag. Although the rectal tube is effective for short-term use, its safety when used over longer periods of time is uncertain.
Initiate Diet and Fluid Therapy
It is important to remember that foods and beverages affect each client differently and that a very restrictive diet, designed to remove all potential irritants, is not reasonable for most clients. Therefore, nurses can teach the client to eliminate potential irritants one at a time and to judge the effects on patterns of voiding and urinary leakage.
Dietary fiber and fluid intake can be increased to promote the passage of soft, hydrated stool. The client who is unable or unwilling to obtain adequate fiber from the diet may be given a bulk laxative (such as Metamucil) or a bran mixture as a specific dietary supplement. The nurse should present options for taking this supplement, honoring the client’s preferences whenever feasible. Initially, 3 to
The initial management of diarrhea involves the removal of factors that predispose the individual to the condition and the maintenance of adequate fluid and electrolyte balance. The nurse collaborates with the client, physician, and dietitian to determine foods that contribute to diarrhea by malabsorption or inflammation of the gastrointestinal tract. These foods are then eliminated from the diet or given with a substance (such as Lactaid) that renders them tolerable to the client.
Persons with infectious diarrhea are given antimicrobials to destroy the pathogens that produce diarrhea.
Anti-inflammatory drugs are administered as directed for diarrhea caused by inflammatory disorders of the bowel (see the accompanying Nursing Checklist).
Bulking agents may be used for clients with watery diarrhea. These agents absorb water in the stool and improve the consistency of feces. Antidiarrheal drugs, including diphenoxylate and loperamide, may be administered to reduce intestinal motility and increase absorption of water from the stool. However, these drugs are contraindicated in patients with infectious diarrhea because the diminished motility would enhance overgrowth of pathogens in the gastrointestinal tract.
Clients who have significant diarrhea may experience mild to severe dehydration and electrolyte imbalances. Oral fluids are given as tolerated; beverages containing glucose and electrolytes are encouraged. In contrast, beverages that contain caffeine are avoided because they stimulate colonic motility. Individuals with severe fluid volume deficits and large-volume diarrhea may require intravenous fluid and electrolyte support until the diarrhea subsides.
Administer Medications
Constipation is initially managed by assisting the individual to pass hardened stool or by removing any impacted feces (see the accompanying Nursing Checklist). Bowel evacuation is encouraged by an oral laxative, such as psyllium, a bulk-forming agent.
Constipation resulting in an impaction requires mechanical disruption and removal, followed by a cleansing enema or an oral laxative. As an alternative, a pulsed irrigation enhanced evacuation (PIEE) system can be used to remove severe impaction. The PIEE uses gravity to deliver intermittent pulses of warmed saline to break up and remove hardened and impacting fecal material.
Administer Enemas
Enema administration is a procedure used to introduce fluid into the lower bowel. The purpose of an enema is to cleanse the lower bowel, to assist in the evacuation of stool or flatus, or to instill medication. Table 39-8 outlines four types of enemas, along with the solutions and the indications for use of each.
Enemas can be large or small depending on their purpose. Large-volume enemas, which typically contain 500 to 1000 ml fluid, are administered to cleanse the bowel. Small-volume enemas are used for the purpose of evacuating stool or instilling medications in the lower bowel. These are usually found as prepackaged solutions, which contain 150 to 240 ml fluid. Refer to Procedures 39-7 and 39-8 for guidelines on enema administration.
Caution should be used when administering large volume enemas, because fluid and electrolyte imbalance can occur. This is related to the volume, frequency, and type of solution used. Table 39-9 lists the types of enema solutions and their effects.
Initiate Rectal Stimulation
As an alternative to a scheduled defecation program, digital rectal stimulation may be used to regulate fecal elimination patterns. This process requires circular palpation of the anal sphincter and distal anus for 2 to 3 minutes. This process is repeated in 20 minutes if defecation does not occur. Deep breathing is encouraged during defecation because it drops the diaphragm and partially compensates for the client’s inability to effectively strain.
Persons with chronic fecal incontinence due to anal sphincter incompetence may be managed with biofeedback techniques. These techniques are typically taught by a specialty or advanced practice nurse with specific training in the field of gastrointestinal disorders and biofeedback techniques.
Monitor Elimination Diversions
Bowel Diversions
The fecal stream is diverted when tissue damage from trauma or inflammatioecessitates the temporary bypassing of a segment of bowel or when permanent resection of malignant or irreversibly damaged tissue is necessary. Several techniques are used to create a fecal diversion; some require a pouch to contain fecal contents, whereas others maintain continence. Continent diversions rely on catheterization of an abdominal stoma or evacuation of stool from a pouch reservoir reattached to the anal sphincter.
Virtually any portion of the large and small intestine can be diverted or used to form a fecal reservoir. Some diversions rely on a stoma (surgically created opening) for the evacuation of fecal contents. Stomas are primarily constructed in three ways. An end stoma is created by dividing the bowel and bringing the proximal segment to the abdominal wall. The end is rolled and attached to the skin of the abdomen, creating a red rosette of intestinal mucosa. A double-barrel stoma is constructed by dividing the bowel and bringing both the proximal and distal ends to the abdominal wall. The proximal end is used to evacuate stool. The distal stoma is typically referred to as a mucous fistula. The double-barrel stoma is designed for temporary diversion of the fecal stream. A loop stoma is created by opening the anterior aspect of the bowel either longitudinally or transversely. The resulting stoma has both proximal and distal openings that are separated by the posterior wall of the bowel loop. It is designed for temporary fecal diversion.
The fecal stream is diverted at the most distal point possible to maximize the absorption of food, fluid, and electrolytes and to preserve continence. The ileostomy (diversion of the bowel at the level of the ileum) is more uncommon than it was during earlier decades. A permanent ileostomy is typically reserved for clients with severe Crohn’s colitis, familial adenomatous polyposis, or chronic ulcerative colitis. A loop (temporary) ileostomy may be created as one stage in an ileoanal reservoir procedure or as a staged procedure for the relief of obstruction of the ascending colon.
The colostomy is created as a permanent or temporary fecal diversion (Figure 39-20). Among adults, it may be created in cases of severe diverticulitis or trauma.
The most common indication for a permanent colostomy among adults is an abdominoperineal resection for lower rectal cancer. A temporary colostomy may be created from the transverse colon or (rarely) from the cecum. The descending or sigmoid colon may be temporarily diverted because of radiation proctitis or low rectal carcinoma. Procedure 39-9 outlines steps for changing a colostomy pouch.
Continent diversions of the bowel may incorporate the anus and sphincter or may be constructed with an abdominal stoma. The ileoanal reservoir is created in a staged approach. In the first stage an abdominal colectomy is completed, followed by a rectal mucosectomy, creation of a J- or S-shaped pouch comprising anus and ileum, and a temporary end or loop ileostomy. In the second stage the temporary ileostomy is taken down and the ileoanal reservoir is reattached to the rectal stream.
The Kock continent ileostomy is performed as a single procedure. A colectomy and proctectomy are performed, and the distal
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.
