elimination

Elimination and Impaired Elimination

Exemplar Cases

  • Urinary incontinence

  • Constipation

Student Learning Objectives

The following objectives are set for understanding the concept of elimination:

  1. Discuss the concept of elimination and impaired elimination.

  2. Distinguish age-related changes and urinary incontinence and constipation.

  3. Identify interventions to promote urinary continence and normal bowel function.

  4. Apply the CJMM to a case study with an older adult experiencing impaired urinary elimination and impaired bowel elimination.

SLO 1: Discuss the Concept of Elimination

Definitions

Elimination: The physiological process of removing waste from the body, encompassing both the formation of waste products and their subsequent excretion.

  • Continence: The purposeful control of urinary or fecal elimination.

  • Urinary Elimination: The process of urine passage through the urinary tract by means of the urinary sphincter and urethra (also known as micturition).

  • Bowel Elimination: The process of stool (feces) passage through the intestinal tract and expulsion through the intestinal smooth muscle (also known as defecation).

Scope of Elimination

  • Waste Formation: The physiological mechanisms responsible for creating waste materials in the body.

  • Efficient Excretion: The effective removal of waste products to maintain bodily homeostasis.

  • Impaired Elimination: Conditions adversely affecting the elimination process, leading to issues such as urinary incontinence and constipation.

Types of Impaired Elimination

Urinary Impairments

  • Oliguria: Urine output of 100-400 ml per day.

  • Anuria: Urine output of 0-100 ml per day.

  • Dysuria: Painful urination.

  • Polyuria: Urine output exceeding 3 liters per day.

  • Frequency: The need to urinate more frequently than normal volumes.

  • Urinary Hesitancy: Difficulty starting or maintaining a urine stream.

Bowel Impairments

  • Constipation: A condition where there is a difficulty in passing stool.

  • Fecal Impaction: Resulting from severe constipation, characterized by an inability to regularly pass stool, leading to a backup in the colon.

Anatomy of the Urinary System

Key Components

  • Right Kidney: Filters blood to produce urine.

  • Ureter: Transports urine from kidneys to bladder.

  • Urinary Bladder: Stores urine until eliminated.

  • Urethra: The duct through which urine is discharged.

  • Sphincters: Muscle structures that help maintain continence.
      - Internal Urethral Sphincter: Under involuntary control.
      - External Urethral Sphincter: Under voluntary control.

Lower Gastrointestinal Anatomy

  • Esophagus: Transports food to the stomach.

  • Liver: Produces bile to help digest fats.

  • Small Intestine: Continues digestion and nutrient absorption.

  • Colon: Absorbs water and forms feces.

  • Rectum: Final section of the bowel.

  • Anus: The opening at the end of the digestive tract.

Factors Affecting Bowel Elimination

  • The formation and elimination of feces depend on various factors, including:
      - Adequate fluid and nutrition
      - Sensory function
      - Oral health (e.g., xerostomia)
      - Propulsive waves in the gastrointestinal tract
      - Swallowing mechanisms
      - Bowel motility through the intestines

SLO 2: Age-Related Changes in Elimination

Urinary Changes

  1. Bladder Capacity: Decreases from 300-500 ml to 200-300 ml, leading to increased urinary frequency.

  2. Smooth Muscle Loss: In urethra, diminishing control over urinary elimination.

  3. Relaxation of Pelvic Floor: Diminishes external sphincter tone, affecting continence.

  4. Decreased Bladder Efficiency: Increased irritability and urgency, with incomplete emptying during urination.

Bowel Changes

  1. Smooth Muscle Atrophy: Leads to decreased motility in the colon.

  2. Reduced Mucous Secretions: Affects bowel movements.

  3. Diminished Sphincter Tone: Compromises bowel control.

  4. Decreased Nerve Response: Results in a diminished urge for evacuation.

Risk Factors Affecting Elimination

  • Myths about aging and incontinence that misdirect understanding.

  • Fluid intake and dietary factors.

  • Side effects of medications.

  • Functional impairments that limit access to toileting facilities.

  • Various pathological conditions including obesity, smoking, and neurological disorders.

SLO 3: Types of Urinary Incontinence and Constipation

Definition of Urinary Incontinence

  • Urinary Incontinence: "Disruption in the storage or emptying of the bladder with involuntary release of urine, usually associated with dysfunction of the external or internal urinary sphincters" (Giddens, p. 159).

  • It is referred to as "involuntary loss of urine and an important yet neglected geriatric syndrome" (Boscart et al., p.129).

Prevalence

  • Experienced by 12% of older adults over the age of 65.

  • Nonetheless, only a minority seek professional advice due to stigma and overly common perceptions, leading to underreporting and undertreatment.

  • 50% of adults report symptoms of urge incontinence, with 60-90% of long-term care residents reporting incontinence issues.

Types of Urinary Incontinence

Acute/Transient Urinary Incontinence

  • Definition: Recent or sudden onset of urinary incontinence, typically associated with:
      - Iatrogenic: related to medical treatment or procedures.
      - Infection
      - Delirium: Sudden onset of confusion and change in mental status.
      - Limited Mobility: Environmental factors.
      - Medications: That influence bladder control.
      - Constipation: Contributes to urinary incontinence as well.

Chronic Incontinence

  • Risk factors associated with chronic urinary incontinence include:
      1. Urge Incontinence: Involuntary loss of urine after feeling an urgent need to void, characterized by overactive bladder muscles;
      2. Stress Incontinence: Involuntary urine loss during activities that increase intra-abdominal pressure like coughing or sneezing, more common in women due to pelvic floor weaknesses;
      3. Functional Incontinence: Occurs as a result of environmental barriers or dependence on caregivers;
      4. Mixed Incontinence: Combination of stress and urge types.

Consequences of Urinary Incontinence

  • Renal Risks: Compromised kidney function over time.

  • Increased Infection Risk: Urinary tract infections and skin breakdown.

  • Altered Skin Integrity: Resulting from prolonged contact with urine.

  • Disturbed Sleep Patterns: Due to frequent need for urination.

  • Psychological Impacts: Feelings of shame and embarrassment often accompany incontinence.

SLO 4: Assessment and Interventions

Assessment of Urinary Incontinence

  • Sensitive Topics: Approach discussions about urinary incontinence with sensitivity due to social stigma.

  • Common Terminologies: Use terms that are less stigmatizing—accidents, leaking, etc.

Underlying Causes of Urinary Incontinence

Comprehensive Assessment Should Include:

  1. Health History

  2. Physical Assessment (Post Void Residual - PVR)

  3. Functional Assessment

  4. Mental and Cognitive Status Evaluation

  5. Medication Review

  6. Symptoms Review

  7. Environmental Assessment

Laboratory Tests to Determine Underlying Causes

  1. Urinalysis: Evaluate for infections or abnormalities.

  2. Blood Urea Nitrogen (BUN): Indicates kidney function.

  3. Creatinine: End product of muscle metabolism and an indicator of kidney function.

  4. Radiographic Tests: Such as X-rays or scans for structural abnormalities.

  5. Direct Observation Tests: Like colonoscopy or cystoscopy to visualize the condition.

  6. Urine Flow Studies: To assess function.

Interventions to Promote Continence

Tools and Techniques:

  1. Voiding Diary: Gold standard to record incontinence, patterns, and other related factors (pain, difficulty, etc.).

  2. Lifestyle Modifications:
       - Drinking adequate fluids, limiting caffeine and alcohol.
       - Scheduled voiding intervals to train bladder.
       - Behavior modification techniques to encourage continence.

  3. Pelvic Floor Muscle Exercises (PFME): Strengthening exercises to improve muscle control.

  4. Education and Referral: Teaching patients about urinary health, addressing misconceptions, and referring to specialists when necessary.

  5. Environmental Modifications: Optimize the ease of access to bathrooms and ensure physical assistance is available as needed.

Constipation and Fecal Impaction

Definitions

  • Constipation: A condition characterized by infrequent bowel movements, straining during BM, or a sense of incomplete evacuation.

  • Fecal Impaction: Severe constipation where stool becomes hard and cannot be expelled, leading sometimes to bowel incontinence.

Risk Factors for Constipation

  1. Hypotonic Colon Function: Age-related decline affecting bowel motility.

  2. Immobility: Contributes to slowed bowel transit.

  3. Cognitive Impairment: May hinder perception and response to bowel needs.

  4. Medication Effects: Certain medications can lead to constipation.

  5. Dietary Issues: Inadequate fiber and fluid intake impact bowel health.

Assessing Cues and Intervention Needs

Identifying Constipation Cues:

  • Symptoms such as: malaise, urinary or fecal incontinence, changes in mental status, straining, or physical discomfort.

  • Physical Exam: To evaluate for distension, tenderness, or the presence of masses.

Interventions for Treatment and Prevention

  1. Dietary Modifications: Increase fluid intake and dietary fiber.

  2. Exercise: Promote mobility to enhance bowel function.

  3. Scheduled Toileting: Encourage regular bowel habits.

  4. Medications: Use of laxatives appropriately—bulk-forming ones are generally safe.

  5. Monitor and Adjust: Regular tracking of dietary habits and bowel patterns to inform necessary interventions.

Inter-Relationships in Elimination

Interconnected Factors

  • Recognize that functional ability, cognition, mood, and mobility are critical for effective elimination.

  • Different components like nutrition and hydration directly influence stool formation and urinary elimination capabilities.

  • Fluid and Electrolyte Balance: Gastrointestinal and renal health are interrelated and impact elimination's efficiency.

Case Study Application

Case Profile: Mr. Fibre

  • Background: 90-year-old male in a personal care home, has osteoarthritis and congestive heart failure.

  • Medications: Includes pain management (Tylenol #3), diuretics (Lasix), and laxatives (Senakot).

  • Symptoms: Reports episodes of urinary incontinence, affecting his well-being.

  • Family Response: Daughter expresses concern over his newfound incontinence and its implications on his comfort and dignity.

Analyzing Cues

  1. Assess Mr. Fibre's mobility and its impact on his need to void.

  2. Review medication effects and adjust as necessary to mitigate incontinence.

  3. Evaluate his dietary fluid intake related to urinary frequency and urgency.

Recommended Interventions

  • Optimize fluid intake, assess and potentially limit caffeine, monitor medication effects, and improve access to bathroom facilities for ease of use.