Chapter 16 Elimination

Question 1

Elimination

Answer 1

• Can be severe enough to interfere with ability to continue independent living and threaten body’s capacity to function and survive
• Can threaten a person’s independence and well-being
• Nurses are in a key position to implement evidence-based assessment and interventions to enhance continence and improve function, independence, and quality of life

Question 2

Age-Related Changes in the Renal and Urological System

Answer 2

Age-related loss of nephrons, kidney mass, and ability to concentrate urine generally lead to little change in the body’s ability to maintain adequate fluid homeostasis

Renal disease or urinary tract obstruction can amplify age-related decline in function

Urinary incontinence (UI) and frequency should never be considered a normal part of aging – However, It is often found r/t other issues.

Question 3

Urinary Incontinence

Answer 3

UI is a stigmatized, underreported, underdiagnosed, and undertreated condition that is not a normal part of aging

Individuals may not seek treatment because they may be embarrassed or think it is normal

UI is an important but yet neglected geriatric syndrome

Viewed as an inconvenience instead of a treatable condition

Nurses must take the lead in implementing approaches to continence promotion and public health education

Question 4

UI facts and figures

Answer 4

More common in women and peaks at menopause, and steady increase in aging men

More prevalent than diabetes and Alzheimer’s disease

More expensive than diabetes

Question 5

Risk factors

Answer 5

Dementia is a high-risk factor for UI because a person may not be able to find the bathroom or recognize the urge to void

Drugs that increase urine output, sedatives, tranquilizers, hypnotics that produce drowsiness, confusion, or limited mobility promote incontinence by dulling the transmission or desire to urinate

Question 6

Consequences of UI

Answer 6

Affects quality of life and has physical, psychosocial, and economic consequences

Associated with increased risk for falls, fractures, and hospitalization

Affects self-esteem and increases risk for depression, anxiety, dignity, autonomy, social isolation, skin breakdown, and sexual activity

Increases the risk for admission to the nursing home in those over 65 years of age

Question 7

Types of UI

Answer 7

Classified as either transient (acute) or established (chronic)

Transient has a sudden onset, present 6 months or less, and is usually caused by treatable factors, like urinary tract infection (UTI), delirium, constipation, stool impaction, or increased urine production

Established UI may have sudden or gradual onset and is categorized as: (1) stress, (2) urge, (3) overflow, (4) functional, (5) mixed

Question 8

Assessment

Answer 8

UI should routinely be addressed on the initial assessment

80% of incontinence can be cured or treated to minimize detrimental affects

Nurses play a key role in identification of UI

Assessment is multidimensional and includes continence patterns, alterations, and contributing factors

Question 9

Interventions

Answer 9

Treatment choices (Box 16-8)

• Lifestyle
• Environmental

Behavioral

• Scheduled voiding
• Pelvic floor muscle exercises
• Habit/bladder retraining
• Prompted voiding

Question 10

Barriers to implementation and continuation of toileting programs include

Answer 10

include inadequate staffing, lack of knowledge about UI and existing evidence-based protocols, and insufficient professional staff

Question 11

Urinary Catheters

Answer 11

Intermittent catheterization
Usually used for weak detrusor muscle, blockage of urethra, reflux incontinence

Indwelling catheter*
Long-term use increases risk of recurrent UTIs
Those with more care needs, cognitive impairment, and pressure injuries are at higher risk of catheter placement

External catheter
“Condom catheters” used for male patients

Question 12

Urinary Incontinence Management

Answer 12

Absorbent products
Protective undergarments or briefs

Pharmacological interventions
Not considered first-line treatment
Anticholinergics and antimuscarinics

Surgical interventions
Indicated for stress incontinence
Most common procedures colposuspension and “slings”

Nonsurgical devices
Intravaginal or intraurethral devices to relieve stress

Question 13

Urinary Tract Infections

Answer 13

Most common cause of bacterial sepsis in older adults and 10 times more common in women

Assessment and appropriate treatment of UTIs in older people, particularly in the nursing home, is complex

Persons may be cognitively impaired or do not present with classic symptoms

The diagnosis of symptomatic UTI is based on clinical features and laboratory evidence

Question 14

Bowel Elimination

Answer 14

*Bowel function is only slightly altered by physiological changes of aging, but can be a source of concern and potentially serious

Normal elimination should be easy passage of feces, without undue straining or a feeling of incomplete evacuation or defecation

Question 15

Constipation

Answer 15

Defined as the reduction in the frequency of stool or difficulty in formation or passage of stool

The Rome Criteria outlines operational definitions of constipation and guide to diagnosis

Associated with impaired quality of life, significant health care costs, large economic burden, and can lead to serious consequences
It is a symptom, not a disease

Question 16

Fecal impaction

Answer 16

More commonly seen in institutionalized older adults who require narcotic medications for chronic pain

Unrecognized, unattended, or neglected constipation eventually leads to fecal impaction

Removal of fecal impaction is at times worse than the misery of the condition

Management requires digital removal of the hard, compacted stool from the rectum with lubrication containing lidocaine jelly

Question 17

Assessment

Answer 17

It is important to obtain a bowel history including usual patterns, frequency, size, consistency, any changes, and occurrence of straining and hard stools

The precipitants and causes of constipation must be included in the evaluation

Question 18

Interventions

Answer 18

Nonpharmacological interventions
Physical activity
Positioning
Toileting regimen
Pharmacological interventions
Enemas
Alternative treatments

Question 19

Fecal incontinence

Answer 19

Involuntary loss of liquid or solid stool that is a social and hygienic problem

Higher prevalence rates are found in persons with diabetes, irritable bowel syndrome, stroke, multiple sclerosis, spinal cord injury

Also associated with UI

Devastating social ramifications for persons and families

Skin breakdown

Question 20

Assessment

Answer 20

The term accidental bowel leakage is preferred over fecal incontinence

Assessment should include complete client history as in UI and investigation into stool consistency and frequency, use of laxatives or enemas, surgical and obstetric history, medications, effects of incontinence on quality of life, focused physical examination with attention to the gastrointestinal system, and a bowel record

Question 21

Interventions

Answer 21

Environmental manipulations (accessible toilet)
Dietary alterations
Habit-training schedule
Pelvic floor muscle exercises
Improving transfer and ambulation ability
Sphincter training exercises
Biofeedback
Medications
Surgical intervention

Question 22

Which is a risk factor for UI?  
A. High caffeine intake 
B. Smoking 
C. Estrogen deficiency 
D. All of the above

Answer 22

D. All of the above

Question 23

Which persons have the highest risk for fecal incontinence?
A. Persons living in the community
B. Persons residing in nursing homes
C. Persons in the hospital 
D. Persons that are younger in age

Answer 23

B. Persons residing in nursing homes