Urinary & Bowel.pdf

1 Elimination Chapter 16 Copyright © 2020 by Elsevier, Inc. All rights reserved. 2 Elimination  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 wellbeing  Nurses are in a k...

1 Elimination Chapter 16 Copyright © 2020 by Elsevier, Inc. All rights reserved. 2 Elimination  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 wellbeing  Nurses are in a key position to implement evidence-based assessment and interventions to enhance continence and improve function, independence, and quality of life Copyright © 2020 by Elsevier, Inc. All rights reserved. 3 Age-Related Changes in the Renal and Urological System  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  See Box 16-1 for age-related changes Copyright © 2020 by Elsevier, Inc. All rights reserved. 4 Urinary Incontinence  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 Copyright © 2020 by Elsevier, Inc. All rights reserved. 5 Urinary Incontinence (Cont.) UI Facts and Figures  Public health problem affecting millions of adults worldwide  Over 25 million Americans live with bladder leaka  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 Copyright © 2020 by Elsevier, Inc. All rights reserved. 6 Urinary Incontinence (Cont.) Risk Factors  Many risk factors are associated with changes in aging  See Box 16-4: Risk factors for UI  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 Copyright © 2020 by Elsevier, Inc. All rights reserved. 7 Urinary Incontinence (Cont.) Consequences of UI  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  Psychosocial impact affects the person and his or her family caregivers Copyright © 2020 by Elsevier, Inc. All rights reserved. Urinary Incontinence Types of(Cont.) UI 8  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) urge, mixed, stress, (4) functional, (5) mixed **  See Table 16-1 Types & Symptoms of UI* Copyright © 2020 by Elsevier, Inc. All rights reserved. 9 Promoting Healthy Aging: Implications for Gerontological Nursing Assessment  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  See Boxes 16-6 & 16-7 for continence assessment Copyright © 2020 by Elsevier, Inc. All rights reserved. 10 Urinary Incontinence Interventions &/or Management (continued) Interventions  Treatment choices (Box 16-8)  Lifestyle  Environmental  Behavioral  Scheduled voiding  Pelvic floor muscle exercises Box 16-9  Habit/bladder retraining  Prompted voiding Box 16-10 Copyright © 2020 by Elsevier, Inc. All rights reserved. 11 Urinary Incontinence Management  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 Copyright © 2020 by Elsevier, Inc. All rights reserved. 12 Continence Programs in LTC Settings  Are required by Centers for Medicare and Medicaid regulations  Monitoring and documentation of continence status related to implemented continence care is a quality indicator in nursing homes  Barriers to implementation and continuation of toileting programs include inadequate staffing, lack of knowledge about UI and existing evidence-based protocols, and insufficient professional staff Copyright © 2020 by Elsevier, Inc. All rights reserved. 13 Urinary Tract Infections  Most common cause of bacterial sepsis (urosepsis) 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 (UA/C&S/CBC/BMP)  Tips for Best Practice Figure 16-11  Assessment Cues, VS, Treatment, Evaluation  Nursing Diagnosis and plan of care: Copyright © 2020 by Elsevier, Inc. All rights reserved. 14 Catheter Associated Urinary Tract Infections (CAUTI)  Persons who develop UTI with an indwelling catheter in place or within 48 hours of removal  Most common hospital-acquired infection worldwide  Implementation of evidence-based guidelines, catheter reminders, stop orders, nurse-initiated removal, and urinary catheter bundle can decrease CAUTIs in acute care  Box 16-11 Copyright © 2020 by Elsevier, Inc. All rights reserved. 15 Urinary Retention  Assessment CUES: voiding small amounts frequently  Possible causes: Bladder outlet obstruction, Deficient detrusor contraction; Men-BPH; Women-post-op after pelvic surgery for incontinence, side effect of epidural post-op  Assessment: percuss and palpate bladder for distention, pain and or use bladder scanner / ultrasound to check PVR  Interventions/Treatment: catheter see next slide, medications for BPH, surgery TURP or pelvic reconstruction  If Untreated, can lead to acute renal failure, Emergency  Nursing Diagnosis:  See Lewis (11 ed) medical-surgical textbook pgs:1050-1051 Copyright © 2020 by Elsevier, Inc. All rights reserved. 16 Urinary Catheters  Intermittent catheterization  Usually used for weak detrusor muscle, blockage of urethra, benign prostatic hyperplasia, reflux incontinence  Indwelling catheter  Long-term use increases risk of recurrent UTIs leading to urosepsis, urethral damage in men, urethritis, or fistula formation  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 Copyright © 2020 by Elsevier, Inc. All rights reserved. 17 Bowel Elimination  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  Normal consumption of food should be evacuated in 24-48 hours (72 occasionally)  What are some physiological changes? Box16-12 Copyright © 2020 by Elsevier, Inc. All rights reserved. 18 Bowel Elimination: Constipation  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 (Box 16-13)  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.  Why is it a problem in the elderly? Copyright © 2020 by Elsevier, Inc. All rights reserved. 19 Bowel Elimination: Constipation Fecal impaction  More commonly seen in institutionalized older adults who require narcotic medications for chronic pain and is reported in 40% of older adults admitted to the hospital  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 Copyright © 2020 by Elsevier, Inc. All rights reserved. 20 Promoting Healthy Aging: Implications for Gerontological Nursing Assessment  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  Decreased activity  Decreased oral water intake  Diet deficient in fruits and veggies  Assessment of constipation Copyright © 2020 by Elsevier, Inc. All rights reserved. 21 Bowel Elimination: Constipation Nonpharmacological Interventions  Diet/Fluids  Physical activity  Positioning  Toileting  Pharmacological interventions: Table 16-2 & Natural Laxative Recipes Box16-16  Enemas  Alternative treatments  Possible Nursing Diagnosis or problem Copyright © 2020 by Elsevier, Inc. All rights reserved. 22 Bowel Leakage/Fecal Incontinence  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 family Copyright © 2020 by Elsevier, Inc. All rights reserved. 23 Bowel Elimination: Fecal Incontinence aka “Accidental Bowel Leakage”  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 including antibiotics  lactose intolerance or recent food at restaurants  effects of incontinence on quality of life  focused physical examination with attention to the gastrointestinal system, and a bowel record Copyright © 2020 by Elsevier, Inc. All rights reserved. 24 Promoting Healthy Aging: Implications for Erotological Nursing (Cont.) Interventions for Accidental Bowel Leakage Box 16197Environmental manipulations (accessible toilet)  Diet alterations: BRAT  Habit-training schedule  Pelvic floor muscle exercises  Improving transfer and ambulation ability  Sphincter training exercises  Biofeedback  Medications  Surgical intervention  R/O Infection with stool culture Copyright © 2020 by Elsevier, Inc. All rights reserved. 25 Question 1 Which of the following are risk factors for UI? a. High caffeine intake b. Smoking c. Estrogen deficiency d. All of the above Copyright © 2020 by Elsevier, Inc. All rights reserved. 26 Question 2 What 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 Copyright © 2020 by Elsevier, Inc. All rights reserved. References 27  Touhy, T., & Jett, K. (2020). Ebersole and Hess’ Toward Healthy Aging Human Needs & Nursing Response. (9th ed.) St. Louis, MO: Elsevier.  Harding, M., Kwong,J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Lewis’s Medical-Surgical Nursing Assessment and Management of Clinical Problems. (11 ed.) St. Louis, MO: Elsevier.  Statement of Copyright and Fair Use The author of this PowerPoint believes that the following presentation contains copyrighted materials used under the Multimedia Guidelines and Fair Use exemptions of U.S. Copyright law applicable to educators and students. Further use is prohibited. If owners of images used in this presentation feel otherwise, please contact the author and they will be taken down if other amicable resolutions cannot be agreed upon. Copyright © 2020 by Elsevier, Inc. All rights reserved.