In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of elimination in order to:
- Assess and manage client with an alteration in elimination (e.g., bowel, urinary)
- Perform irrigations (e.g., of bladder, ear, eye)
- Provide skin care to clients who are incontinent (e.g., wash frequently, barrier creams/ointments)
- Use alternative methods to promote voiding
- Evaluate whether the client's ability to eliminate is restored/maintained
Some of the commonly used terms relating to urinary elimination, also referred to as micturition, are:
Polyuria is an excessive amount of urine production in excess of 2.5 liters over a 24 hour period of time. Some clients may be affected with nocturnal polyuria only during the night time hours and others may be affected with polyuria throughout the course of the entire day.
Some frequently occurring causes of polyuria are the consumption of large amounts of fluids, the use of diuretic medications, renal disease, psychogenic polydipsia which is a psychiatric mental disorder causing excessive thirst, sickle cell, anemia diabetes mellitus and diabetes insipidus. Excessive and prolonged polyuria can lead to dehydration which can cause fluid and electrolyte imbalances in the client. The normal urinary output is about 2 liters per day.
Oliguria is a less than the normal amount of urinary output at less than 400 mLs over the course of 24 hours. The most commonly occurring causes of oliguria are impaired renal blood flow, renal disease, decreased fluid intake and dehydration, hypovolemic shock and other diseases and disorders associated with excessive bodily fluid losses, and an anatomical urinary stricture.
Anuria is a lack of the production of urine or a severely scant amount of urine less than 50 mLs in a 24-hour period of time.
Dysuria is painful burning upon urination. It often occurs as the result of a urinary tract infection and trauma.
Urinary incontinence is the involuntary leakage of urine and a loss of bladder control. The types of urinary incontinence include functional urinary incontinence, reflex urinary incontinence, stress urinary incontinence, urge urinary incontinence, and total urinary incontinence. The causes of urinary incontinence are numerous and they can include a neurological deficit, a lack of sphincter control musculature, and an overactive bladder.
Urinary retention is the accumulation of urine in the bladder because, for one reason or another, the patient is not able to effectively empty their bladder.
Urgency is defined as strong, sudden and relentless need to immediately urinate without delay.
Some of the commonly used terms relating to bowel elimination are:
Constipation is defined as less than three bowel movements per week. Under normal circumstances, clients should typically defecate from once a day to every 3 to 5 days. Some of the commonly occurring causes of constipation are immobility, a lack of fluid intake, some medications like opioid drugs, and impaired neurological functioning.
Diarrhea is a watery loose stool. Some of the causes of diarrhea are a gastrointestinal infection, some foods, stress, anxiety, some medications, malabsorption syndrome and a parasite infection. Technically, diarrhea is defined as three or more loose stools over a 24 hour period of time.
Fecal impaction is a collection of hardened stool in the rectum. Fecal impaction can occur from some medications and also secondary to constipation, among other causes.
Flatulence is the expulsion of often odorous gastrointestinal gas. Flatulence can result from some foods and medications.
Some of the factors that impact on urinary and fecal elimination and place patients at risk for impaired elimination include, in addition to the ones discussed immediately above, an altered level of hydration, advanced age, weak muscular tone, the age of the client, the presence of some physical disorders including anatomical structural disorders, and psychological factors.
For example, some medications can lead to the retention of fluids, increased urinary elimination, constipation and diarrhea; foods high in sodium can decrease urinary output and increase fluid retention; and excessive hydration can lead to polyuria.
Both genders can be adversely affected bowel and/or bladder incontinence secondary to impaired sphincter control; middle aged and older male adults can have urinary retention and urinary incontinence because of an enlarged prostate gland; and elderly females can have urinary stress incontinence as the result of their loss of pelvic muscle tone secondary to having vaginal deliveries of babies.
Age also impacts on bowel and bladder elimination and alterations. For example, urinary tract infections are the second most common infection among young children; neonates and infant male babies are the most commonly affected group along the life span with bowel and urinary tract obstructions and malformations; and older children who are females become more prone to urinary tract infections because of poor wiping techniques.
Bowel function and bowel elimination can also be affected by a variety of disorders including a paralytic ileus, an anatomical defect, infectious diarrhea, and other disorders such as ulcerative colitis and Crohn's disease. Urinary function and urinary excretion can be adversely impacted with a number of disorders such as an anatomical stricture defect, renal failure, hypertension, shock, vomiting, diarrhea, and other disorders.
The lack of privacy, the lack of sufficient time to void or defecate, the lack of psychological comfort, and the need to use unusual devices such as a bed pan and/or urinal can also impair normal urinary and bowel elimination for many people who are hospitalized.
After a complete client assessment of the client's bladder and bowel functioning, a number of interventions can be done, according to the client's identified needs.
Some of these interventions can include:
- Exercising to promote bowel function
- The elimination or addition of some foods and fluids. For example, a high fiber diet can promote normal bowel functioning without constipation.
- The elimination of a medication which is problematic
- Medications to promote urinary and/or bowel elimination
- Suppositories to promote bowel function
- Enemas to promote bowel function
- A fecal or urinary diversion such as a colostomy
- Urinary catheters for urinary retention
- Bowel and bladder training and management
The four types of enemas are a:
- Carminative Enema: Carminative enemas are used to relieve flatus or flatulence and to simulate peristalsis.
- Cleansing Enema: Cleansing enemas remove feces. These types of enemas are used to relieve constipation and also to cleanse the bowel of fecal material prior to some surgical procedures and to prep the bowel prior to some diagnostic tests like a screening and diagnostic colonoscopy examination when the visualization of the bowel without fecal contents is necessary.
- Retention Enema: This type of enema consists of an oil solution or a medication added solution that is administered and then retained and held by the client for an hour or more. A retention enema is used to administer a medication, to soften stool and to lubricate the rectum so that it is easier and more comfortable for the client to defecate.
- Return-Flow Enema: Return-flow enemas, similar to a carminative enema, are used to relieve flatus and stimulate peristalsis which is frequently a problem after a client has received anesthesia. The fluid is instilled into the rectum and sigmoid colon and, then, the enema bag is lowered so that the flatus and fluid returns back into the enema bag. The instillation and removal of this fluid is typically done five to six times and more often if necessary.
Urinary and Fecal Diversion
Fecal diversion colostomies can be either permanent or temporary. Colostomies are done to promote the healing of anastomoses, to relieve a bowel obstruction caused by a tumor, and to enable the elimination of fecal contents when the distal colon and rectum are removed.
There are different types of colostomies which are an ascending colostomy, a transverse colostomy, a descending colostomy and a sigmoid colostomy. The location of the stoma depends on the type of colostomy. For example, a sigmoid colostomy stoma is usually located on the lower left quadrant of the abdomen.
Some of the complications associated with a colostomy include infection, dehiscence, an ischemic ileostomy, a peristomal hernia, stoma stenosis, stomal retraction, a prolapsed stoma, necrosis, mucocutaneous separation, stomal trauma, peristomal skin damage as the result of leakage and parastomal hernias.
A urostomy is a urinary diversion; the types of urostomy are the ileal conduit, the neobladder, the Miami pouch, the Indiana pouch, and a nephrostomy.
Some complications of urinary diversion surgery include:
- Renal infections
- A urinary tract infection
- Urinary stones
- A vitamin B12 deficiency
- Nocturnal enuresis
- A distended bladder
- Changes in urinary pH
- Mucous plugs and ostomy clogs can be corrected with Marlen MucoSperse
Urinary pH changes, the formation of salts and stones, and infections can be prevented with ample oral intake of fluids. Patients should also be instructed to dissolve mucous plugs that are clogging the pouch by using Marlen MucoSperse.
Urinary catheters are a useful and necessary tool to prevent urinary leakage and control skin breakdown from the caustic nature of urine to skin tissue. That said, the decision to place the catheter must be strategic and the continued use of the indwelling catheter must be reviewed at least daily. Preventing catheter-associated urinary tract infections (CAUTI) not only improves patient outcomes, overall, but is essential in meeting many regulatory standards.
The care team should consider these key indicators as to when to place a urinary catheter such as urinary retention (use a bladder scanner to confirm), prolonged surgery, genitourinary surgery, presence of a sacral wound, pelvic or spine trauma, or hemodynamic instability. Once a urinary catheter is placed, staff should follow a urinary incontinence bundle to prevent urinary tract infections, which includes a purposeful review of whether the catheter is still indicated. A multidisciplinary approach to this review, including the use of electronic reminders, will keep CAUTIs to a minimum.
Once the urinary catheter is removed, the patient must be observed to urinate within 6 hours. If not, a bladder scanner can determine the volume of urine in the bladder and, if more than 400mls (or per organizational protocols), the nurse should utilize techniques to promote urination and, with a clinician's order, drain urine using a straight catheter. If the patient still has not voided in another 6 hours, and there is more than 400ml of urine in the bladder via scan, the nurse should contact the clinician for further orders.
Urinary Incontinence Bundle
Here are some examples of best practices for preventing catheter-associated urinary tract infections:
- Always choose the smallest diameter of the catheter and, when possible, use an antimicrobial product
- Apply and ensure there is a securement device to minimize friction of the catheter insertion site
- Maintain a closed system
- Ensure the flow of urine is not obstructed within the tubing
- Keep the drainage bag below the bladder
- Perform perineal care daily (at minimum)
- Review the appropriateness of continuing the catheter at least daily
Bowel and Bladder Management
In terms of generalities, bowel and bladder management are used for bowel and bladder incontinence and retention. Bowel retention is constipation in terms of bowel functioning and urinary retention in terms of bladder functioning.
Constipation is treated with interventions such as the promotion of exercise, a high fiber diet, ample fluids, suppositories and enemas.
Urinary retention can be prevented and managed with ample fluids, assistance with toileting, the administration of a cholinergic medication to stimulate bladder contractions and bladder emptying, Crede massage which is the application of manual pressure and a kneading kind of massage of the area over the bladder, and the use of an intermittent or continuous urinary catheterization to fully empty the bladder.
The use of a urinary catheter is the last resort because these catheters can relatively easily lead to a urinary tract infection which is a major infection concern in health care facilities. These and other infections such as one affecting a client who is intubated, are referred to as health care acquired infections, formerly known as nosocomial infections. When a urinary catheter is necessary as the last resort, this catheter should remain in place for the briefest period of time possible and scrupulous catheter care must be given to the catheter to prevent catheter associated urinary tract infections, referred to as CAUTI (Catheter associated urinary tract infections).
Urinary and bowel incontinence is managed, whenever possible, with an incontinence management program which is sometimes referred to as bladder or bowel training, prompted and timed voiding and evacuation and other techniques such as muscular exercises to strengthen the muscles on the floor of the pelvis as well as those for the urinary and bowel sphincters. For example, Kegel exercises, which are also done after a vaginal delivery of a baby, are often done to strengthen the muscles of the pelvic floor and the sphincter muscles to correct some causes of incontinence.
Clients who remain incontinent, despite preventive measures, can use protective briefs, and fecal incontinence pouches which are placed externally over the anus. Males, with urinary incontinence can also use a condom catheter, also referred to as a Texas catheter. Clients who are incontinent required scrupulous skin care to prevent complications associated with incontinence such as skin breakdown. Briefs and other devices are used to preserve the dignity of the client, particularly when the client is in a public space, and NOT a mechanism to save nursing staff's time. No client should ever be left in a condition with excrement or urine in their briefs. These clients must be promptly washed and dried to preserve the client's skin integrity and dignity.
Some of the nursing diagnoses appropriate for clients affected with, or potentially at risk for, a urinary and bowel dysfunction include:
- Bowel incontinence related to rectal urgency
- Bowel incontinence related to a neurological deficit that disables the client's ability to feel the urge to defecate
- Potential bowel and/or bladder incontinence related to poor pelvic floor muscle strength
- Impaired urinary elimination related to functional urinary incontinence
- Impaired urinary elimination related to reflex urinary incontinence
- Impaired urinary elimination related to stress urinary incontinence
- Impaired urinary elimination related to urge urinary incontinence
- At risk for an alteration in skin integrity related to bowel and/or bladder incontinence
- At risk for infection related to the presence of a urinary catheter
- Readiness for enhance urinary and/or bowel elimination
- Urinary retention related to benign prostatic hyperplasia (BPH)
- Urinary retention related to impaired detrusor musculature and the ability to contract
- Urinary retention related to cauda equine syndrome
- Urinary retention related to the side effect of a medication
- Urinary retention related to peripheral neuropathy
Nurses irrigate bodily orifices and therapeutic interventions such as the irrigation of the bladder, the ear, the eye and an ostomy. All of these irrigations are done using sterile technique, with the exception of a fecal diversion irrigation which uses clean technique. Additionally, a gown is donned to protect the nurse from sprays and splashes; protective masks or goggles when a spray or splash can be reasonably possible and gloves are used during these doctor ordered irrigations.
Bladder irrigations are done when a client has an indwelling urinary catheter that is blocked and not patent.
The procedure for bladder irrigation is as follows:
- Empty and measure the contents of the existing urinary drainage bag.
- Hang the irrigation solution on an IV pole above the level of the client to facilitate the flow of the irrigation solution using gravity.
- Prime the irrigating solution.
- Swab the irrigation port on the three way catheter and then connect the irrigation solution to this port.
- Open the clamp on the irrigation solution and allow the fluid to flow into the bladder at the ordered rate which is typically about 40 to 60 gtts per minute.
- The irrigation solution is allowed to remain in the bladder when the doctor has ordered a closed intermittent bladder irrigation.
- The irrigation solution is allowed to flow out of the bladder with a closed intermittent bladder irrigation by opening the urinary catheter clamp to allow the contents of the bladder to empty into the urinary drainage bag.
- Measure and document the volume of the irrigation solution that was used for the irrigation and also the volume of urinary catheter collection bag. The amount of urine produced as the result of the irrigation is calculated by subtracting the amount of irrigation solution instilled during the irrigation from the total volume that was collected in the urinary catheter drainage bag. For example, if the nurse instills 1200 mLs of irrigating solution into the bladder and the volume in the urinary drainage bag after this instillation of irrigating solution is 1400 mLs, the urinary output is 1400 – 1200 = 200 mLs in terms of urinary output.
Urinary Catheter Irrigations
Urinary catheter irrigations are done when a client has an indwelling urinary catheter that is blocked and not patent.
The procedure for bladder irrigation is as follows:
- Clamp the catheter between the injection port and the extension tubing.
- Clean the port with antiseptic wipes.
- Insert a syringe and slowly inject the irrigation solution.
- Remove the syringe and then finally
- Remove the clamp and permit the irrigation solution to drain into drainage bag.
Ear irrigations are done to cleanse the ears and also to irrigate the ears with an otic medication, according to the doctor's order. Ear irrigations and instillations are done with slightly warm solutions and these instillations and irrigations, including medications, are a little different for children less than three years of age and children and adults over three years of age because of anatomical differences.
The nurse will gently pull the pinna, or ear lobe, downwards and backwards for children less than three years of age because the ear canal is still directed upward, and the nurse will gently pull the pinna upwards and backwards for children older than three years of age and for adults.
The procedure for ear irrigation is as follows:
- Place the client on their side with the affected ear up in a comfortable position.
- Cleanse the pinna and the external ear canal with a cotton tipped applicator to remove extraneous debris and to prevent this debris from entering the inner ear during an instillation or irrigation.
- Pull the pinna downwards and backwards for children less than three years of age and upwards and backwards for clients over three years of age.
- Insert the syringe with the irrigation solution into the ear.
- Direct the flow of the solution towards the top of the ear and with gentle pressure.
- Place the client on their treated ear downward and over a basin to allow the irrigation solution to freely flow out of the ear.
Ear irrigations are done to cleanse the eyes, to remove debris and to instill optic medications and solutions.
The procedure for eye irrigations and instillations is as follows:
- Place the client in an upright and supine position or in a chair.
- Cleanse the eye lashes and the eye lids with a cotton ball.
- Advise the client to not blink during the process.
- While the client is looking upward towards the ceiling, gently apply or instill the ordered optic solution on to the lower conjunctival sac from the inner canthus of the eye to the outer canthus of the eye.
- Apply gently pressure to the client's closed eye for a minimum of 30 seconds to prevent the outward flow of the solution or medication.
Sigmoid and Descending Colostomy Irrigations
The purposes of a sigmoid and descending colostomy irrigation is to stimulate peristalsis and fecal emptying by introducing a fluid of about 300 to 1000 mLs into the ostomy using an irrigating cone or catheter.
These irrigations and instillation cannot be delegated to the unlicensed assistive personnel; these procedures are restricted to the scope of practice for only the licensed practical nurse or the registered nurse.
All incontinent clients must be continuously clean and dry. The use of briefs is done to maintain the client's dignity in social situations and to allow the staff to be able to clean and dry the client without having soiled bed linens; however, briefs are not used to allow the client to lie in their urine and feces without being care for by the nursing staff.
In addition to the frequent washing and drying of all skin exposed to feces and/or urine, there are some topical skin preparations that are helpful to the prevention of skin breakdown. These topical agents include:
- Solid Skin Barriers: Solid skin barriers are moldable skin barriers which can be shaped as a disk or strips; and they can consist of hydrocolloids, carboxymenthyl cellulose, gelatine, karaya, pectin, and a combination of one or more of these components. Some examples include Hollister's Flextend, and Premium Skin Barrier. Solid skin barriers are longer lasting but more expensive than the moisture barrier ointments and pastes described below.
- Moisture Barrier Ointments: Moisture barrier ointments like Lantiseptic Skin Protectant, Caloseptine Ointment, and Proshield Plus Skin are zinc oxide containing products that are used to prevent incontinence dermatitis. These products are reapplied after all episodes of incontinence and the washing of the affected areas.
- Moisture Barrier Pastes: Moisture barrier pastes like Remedy Calazime Protectant Paste and Ilex Skin Protectant Paste are thick topical skin preparations that permit the nurses' assessment of the underlying skin while protecting the skin from impaired skin integrity secondary to incontinence.
- Skin Sealants: Skin sealants, in contrast to moisture barrier pastes and ointments, last up to about 14 days after application. These products, including Film Wipe, Shield Skin, Bard Protective Barrier, and Convatec's Allkare, consist of a fast drying polymer transparent film that can be applied relatively simply with a wipe or a spray.
Urinary catheters are used to promote urinary elimination. These catheters come in various sizes which are referred to as French and the abbreviation "Fr". Children will have an 8 to 10 Fr., adult males will typically have a size 16 to 18 Fr, and adult females will typically use a 14 to 16 Fr. Latex urinary catheters are contraindicated when the client has a latex sensitivity or allergy. The insertion of a urinary catheter is a sterile procedure and one that CANNOT be delegated to an unlicensed assistive staff member. Only registered nurses and licensed practical nurses can insert a sterile urinary catheter.
The procedure for inserting a urinary catheter is as follows:
- Provide the client with privacy and explain the insertion procedure to the client to alleviate any anxiety and discomfort which is something that is frequently encountered because this procedure invades the client's intimate space.
- Position the client in a supine position with the thighs separated so that they do not interfere with this sterile procedure.
- Lubricate the lower section of the catheter with a sterile water soluble lubricant.
- Cover the surrounding area with a sterile drape.
- Clean the urinary meatus with an antiseptic solution using sterile technique. The male urinary meatus is cleansed using a circular pattern from the meatus and then outwards. The female urinary meatus is cleansed with an antiseptic solution beginning with the labia from the front to the back while holding the area open.
- Insert the urinary catheter into the urinary meatus.
- Advance the catheter about 3 cms past the point when urine appears in the urinary catheter tubing.
- Inflate the balloon for an indwelling catheter.
- Secure the catheter to the client's leg.
- Connect the urinary drainage bag to the tubing and maintain the level of the urinary drainage bag below the level of the client's abdomen to prevent any back flow of urine.
After placement, the urinary catheter needs care and maintenance. For example, the insertion site is washed with soap and water at least on a daily basis and every time the area becomes soiled with feces. The drainage bag must be maintained below the client's abdominal level, the urinary drainage bag should be emptied each shift and more often when necessary, and the tubing should be inspected to make sure that there is no kinking or twisting of the tubing because this will obstruct the free flow of urinary output that could back up into the bladder.
The interventions and treatments for urinary and bowel elimination problems are evaluated in terms of whether or not the client has maintained or restored elimination functioning. Some of the expected outcomes, or client goals, that are evaluated in terms of whether or not the client has achieved them can include:
- The client will be able to perceive and attend to voiding cues.
- The client will be free of any urgency, frequency and pain associated with voiding
- The client will have no more than 200 mLs of residual urine after voiding
- The client will free of any urinary tract infection secondary to the placement of an indwelling urinary catheter
- The client will be free of urinary incontinence after a prompted voiding and exercise program
- The client will demonstrate the correct procedure and technique for self intermittent catheterization
- The client will demonstrate the correct technique and procedure for colostomy irrigation
- The client will be free of fecal incontinence after a bowel training program
- The client will have normal bowel functioning
- The client will be free of diarrhea
- Assistive Devices
- Elimination (Currently here)
- Non Pharmacological Comfort Interventions
- Nutrition and Oral Hydration
- Personal Hygiene
- Rest and Sleep