Chapter 12EliminationCopyright © 2018, Elsevier Inc. A.docx

Chapter 12
Elimination
Copyright © 2018, Elsevier Inc. All rights reserved.
The body must remove waste products of metabolism to sustain
healthy function
Bowel and bladder functions later in life contribute to the
independence of older adults
Nurses are in a key position to implement evidence-based
assessment and interventions to enhance continence and
improve function, independence, and quality of life for older
people
Concepts of Elimination
*
The involuntary loss of urine sufficient to be a problem Is an
underdiagnosed, underreported, and undertreated condition,
especially in older adultsTreatment is not sought because of
embarrassment, normal aging, or the older adult is uneducated
about treatment
Urinary Incontinence
*

Thought to be related toCognitive impairmentLimitations in
daily activitiesInstitutionalization Stroke, diabetes, obesity,
poor general health, certain medications, and comorbidities are
associated with urinary incontinence (UI)
Risk Factors for Urinary Incontinence
*
Increased risk of falls, fractures, hospitalization, and skin
breakdown Loss of dignity and autonomyIncreased feelings of
depression, anxiety, shame, and embarrassmentIncreased social
isolationSexual activity is avoidedLoss of independence and
self-confidence
Consequences of Urinary Incontinence
*
Incontinence is classified as Transient (acute) or
Sudden onset
Present for 6 months or less
Usually caused by treatable factors such as urinary tract
infections (UTIs) or deliriumEstablished (chronic)
Sudden or gradual onset
Includes stress; urge; urge, mixed, or stress UI with high
postvoid residual (PVR); functional UI; and mixed UI
Types of Urinary Incontinence
*

Continence must be routinely addressed in the initial assessment
of every older personNurses are expected to be able to collect
and organize data about urine control, report findings, and
implement evidence-based interventions
Implications for Gerontological Nursing and Healthy Aging
*
Multidimensional Determine if UI is transient or established,
determine type of UI, and identify possible causes Continence
care is a quality of care indicator for nursing homes; residents
should be assessed on admission and whenever there is a change
in cognition, physical ability, or urinary tract function
Assessment
*
BehavioralScheduled voidingBladder trainingPrompted
voidingPelvic floor muscle exercisesLifestyle
modificationsAbsorbent productsNonsurgical devices
Interventions
*
*

*
Pharmacologic treatmentAnticholinergic, antimuscarinic agents
may be indicated for urge UI and overactive bladder (OAB)
Have similar efficacy
Choice depends on drug effects, drug–drug and drug–disease
interactions, dosing frequency, titration range, and cost Beta3-
agonists (mirabegron) are a new class of medications for urge
UI and OAB Surgical treatmentColposuspension (Burch
operation)Slings
Interventions (Cont.)
*
Urinary cathetersIntermittent catheterization Indwelling
catheters
Not appropriate for long-term management (more than 30 days)
except in certain clinical conditions External catheters
Interventions (Cont.)
*
*

Most common cause of bacterial sepsis in older adults10 times
more common in women than in menMay be difficult to
detectOlder individuals do not report classic
symptomsCognitively impaired residents may not recall or
report symptoms
Urinary Tract Infection
*
UTIs that occur in a patient with an indwelling catheter or
within 48 hours of catheter removal Most common hospital-
acquired infection worldwide Incidence decreased by
implementing evidence-based guidelines, catheter reminders,
stop orders, nurse-initiated removal protocols, and a urinary
catheter bundle
Catheter-Associated Urinary Tract Infections (CAUTIs)
*
During a visit to the emergency department, a 92-year-old man
discloses that he dribbles when he urinates. Which of the
following would be a reason for this incontinence?
Diet
Old age
Laziness when urinating
Underlying cause, such as an infection
Question
*

D—Dribbling is a symptom of a UTI.
Answer
*
Can be a source of concern and a potentially serious problem,
especially for older persons who are functionally impaired
Normal elimination should be an easy passage of feces, without
undue straining or a feeling of incomplete evacuation or
defecation
Bowel Elimination
*
A reduction in the frequency of stool or difficulty in formation
or passage of stool One of the most common gastrointestinal
complaints encountered in clinical practice Associated with
impaired quality of life, significant health care costs, fecal
impaction, bowel obstruction, cognitive dysfunction, delirium,
falls, and increased morbidity and mortality
Constipation
*
*

Common in incapacitated and institutionalized older
peopleSymptoms include malaise, urinary retention, elevated
temperature, incontinence of bladder or bowel, alteration in
cognitive status, fissures, hemorrhoids, and intestinal
blockageTreat with oil-retention enemas and digital removal
Fecal Impaction
*
AssessPrecipitants and causes of constipationThorough bowel
historyPhysical assessment rules out systemic causesFood and
fluid intake Abdomen is examined for masses, distention,
tenderness, and bowel soundsRectal examination is performed
for painful anal disorders
*
Examine medications for constipation-producing effectsIncrease
fluid and fiber intakePromote exerciseEnvironmental
manipulationEstablish regularity of bowel evacuationCautiously
use laxativesUse enemas
Interventions
*
The involuntary loss of liquid or solid stool that is a social and

hygienic problem Often associated with UICan be transient or
persistentDevastating social affectsContributing factors include
damage to the pelvic floor, neurologic disorder, functional
impairment, immobility, and dementia
Fecal Incontinence
*
AssessmentObtain a complete history of UI; investigate stool
incontinence, surgical and obstetric history, and medicationsUse
of laxatives and enemasDigital examination is performed to
determine the presence of a massEffect on quality of life
*
Environmental manipulation (access to toilet)Diet
alterationsHabit-training schedulesImproved transfer and
ambulation abilitiesSphincter-training
exercisesBiofeedbackMedicationsSurgery to correct underlying
cause
Interventions
*
Which of the following interventions would the nurse include in
a bowel retraining program for a patient in an extended care
facility?
Administering a daily oil-retention enema

Limiting fluid intake at breakfast and lunch
Reducing the intake of high residue foods
Toileting the patient at the same time daily
Question
*
D—A critical part of a bowel retraining program is to establish
a regular time for bowel movements.
Answer
*
You and Claudia are nearing the end of your journey in this
course, and it is time to put those newly acquired skills to work.
For this paper, you will be required to create an academic paper
in APA format, demonstrating reflective thinking. Click here to
access the essay template for this assignment.
The elements below should be included in the essay.
· Include an APA-formatted title page (refer to the essay
template).
· Include an introduction. The introduction to your paper should
be one paragraph that states the overarching concept for your
paper. The introduction is the first paragraph of the paper in
which you will introduce readers to the three main topics in
your paper: career goals, learning strategies for success, and
time management. (This section should be a minimum of 50
words.)
· Describe your career goals. What were your career goals when
you first began this course? How have they changed? What
future courses will you take that will help you reach your goals?

What role will mentors play in your quest? (This section should
be a minimum of 150 words.)
. Make sure that you list the courses from your Degree
Advisement Plan (DAP) and how they will assist your future
career goals.
· Identify your learning style. What is your learning style? How
can awareness in this area impact your behaviors as a student?
What can you do to improve? How can your family help support
your study habits? (This section should be a minimum of 150
words.)
. Include a paraphrased statement from your course textbook
and/or a peer-reviewed article from the CSU Online Library to
support your learning style and study methods. Make certain to
include in-text citations.
. Remember to place the reference (for the textbook and/or the
peer-reviewed research article) in APA style on the references
page.
· Identify your time management techniques. When you first
began this course, how well did you manage your time? What
consumes most of your time on a daily basis now? Can
adjustments be made in this area? What new strategies will you
begin to incorporate in your educational experiences as well as
your work and home environments to best balance all of your
obligations? (This section should be a minimum of 150 words.)
· Provide a conclusion. The last paragraph should summarize
the body of your paper. It should reflect back to the
introduction and briefly state how you will approach career
goals, time management, and study methods. (This section
should be at least 50 words.)
· Include a references page.
. On a separate page, list the reference(s) for your paper. You
must use a minimum of one reference, which can be your
textbook.
. The heading “References” (or “Reference” if only one source
is used) should be centered at the top of the page.
. The references should be formatted according to the type of

source. In other words, a book is formatted in a certain way, and
an article is formatted in another way.
. List the references in alphabetical order according to the first
author’s last name. Apply double-spacing.
. Each reference should be formatted with a hanging
indentation.
Your paper must be a minimum of two pages in length. Make
certain to double space, use 12-point Times New Roman font,
and use one-inch margins for your paper.

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