Elimination Needs

Elimination Needs

Urinary Retention

• Urinary retention is the inability to partially or totally empty the bladder.
• If the bladder does not empty, it can be damaged or even rupture.
• Problems can result in urinary retention, such as:
  • The body does not send messages to the brain.
  • The brain does not receive messages.
  • There may be a blockage, such as an enlarged prostate.

Assisting Residents with Elimination Needs

• Assisting residents with elimination needs is a large part of the nursing assistant role.
• Assist residents with toileting needs every 2 hours, and more frequently when the resident requests or needs help.
• Levels of assistance:
  • Independent: Residents may only need reminders or supplies.
  • Limited Assistance: Help to the toilet and change incontinence products as needed.
  • Totally Dependent: Requires full care during toileting and changing incontinence garments; level of assistance is indicated on the resident's care plan.
• When helping the resident with elimination needs, check the integrity of the skin of the peri-area because it is at high risk for breakdown.
• Always report any red, excoriated, or open areas to the nurse promptly.

Urinary Elimination

• Urine is formed in the kidneys.
• It travels down the ureters to the bladder, where it is stored.
• When the bladder becomes full, the nerves in the bladder send a signal to the brain that it is time to void.
• Sphincters in the bladder open, allowing the urine to flow via the urethra out of the body.

Bowel Elimination

• Bowel movements occur at different times for different people.
• Some residents may be very regular and have a bowel movement once per day, others may not have a bowel movement for 3 days.
• When the resident has a bowel movement, it must be charted.
• If the resident has not had a bowel movement for 3 days, an oral laxative, such as milk of magnesia, is normally given.
• If it has been 4 days, a suppository is inserted. A suppository is a wax cone that is inserted directly into the rectum to help the resident have a bowel movement.
• If the resident has not had a bowel movement in 5 days, an enema is then administered.
• An enema is an injection of fluid into the rectum.
• The resident holds the fluid in the rectum as long as possible.
• Normally, an over-the-counter Fleet® enema is used.
• The bottle is soft plastic and prefilled with a small volume of fluid.
• The resident must always lie on their left side when receiving an enema.
• Oral laxative, suppository, and enema administration are all the responsibility of the nurse. The nursing assistant should report to the nurse if the intervention was effective or not.

Constipation

• Residents who have a slower digestion may be at risk for developing constipation.
• Constipation is defined as having to strain to have a bowel movement and having infrequent bowel movements.
• Generally, if a person has fewer than three bowel movements per week and experiences discomfort they are suffering from constipation.
• Some residents have a faster digestion and may be at risk for loose stools or diarrhea. These stools are usually very watery and happen more frequently.
• "Regular" stools are soft, formed, and do not cause pain when passing.
• Constipation and loose stools are outside of the normal limits and should be reported to the nurse to determine if the resident has constipation, regular stools, or diarrhea.
• Many healthcare organizations use the Bristol Stool Form Scale to chart the consistency of stool.

Table 8G.1 Stool Form Scale

• Type 1: Separate hard lumps
• Type 2: Lumpy, sausage-shaped
• Type 3: Sausage-shaped with crack on the surface
• Type 4: Smooth and soft, sausage- or snake-shaped
• Type 5: Soft pieces with clear-cut edges
• Type 6: Mushy, fluffy pieces with ragged edges
• Type 7: Liquid with no solid pieces

Incontinence

• Incontinence is the involuntary leakage or passing of urine from the bladder or feces from the rectum.
• Toileting the incontinent resident a minimum of every 2 hours is essential for maintaining skin integrity. Change the incontinence garment, cleanse the area, and apply barrier cream.
• Just because a resident is incontinent does not mean that they cannot void using a toilet.
  • At best, sitting on the toilet can help retrain the bowel and bladder.
  • At the minimum, it will decrease the amount of urine or stool on their skin.
• If the resident is physically able to sit on the toilet, you must help them do so.
• If the resident is not physically able to sit on the toilet, change the incontinence garment and complete peri-care at the bedside (Skill. 8G.1).
• Allow the resident to sit on the toilet for several minutes.
• If they have cognitive deficits, such as dementia or a traumatic brain injury, remind them that they are on the toilet and that they should void.
• Try running the faucet; the sound of water might encourage them to void.

Types of Incontinence Products

• Many different types and brands of incontinence products are available.
• Liners: A pad that is inserted into the underwear; Liners absorb drips and leaks and are often more comfortable and less embarrassing to wear than a brief.
• Briefs: Larger than liners; worn in place of underwear; Many sizes and styles are available. Some briefs pull on like underwear. They are stretchy at the top and conform to the resident's body. The sides can be pulled apart when the brief is soiled so that the briefs do not have to be pulled down the resident's legs. Other briefs have tabs on each side of the brief that fasten with adhesive or Velcro®.
• Barrier Cream: A barrier cream should be used on any resident who is incontinent; apply it after peri-care has been provided. The barrier cream should be applied to any area that is reddened or irritated. If no areas are reddened or irritated, apply barrier cream to the anal area and the buttocks to protect the skin from breakdown, moving in a front-to-back direction.

Ostomies

• When the rectum or colon is diseased or injured, a person may not be able to have a bowel movement via the rectum. In this case, an ostomy is created.
• A segment of the bowel is drawn outside the body in the abdominal area.
• The stool is diverted through the stoma and empties into a bag attached outside the body.
• A colostomy is made from the large intestine; an ileostomy is made from the small intestine.

Urostomy

• Sometimes the bladder may be diseased. A person may have cancer of the bladder, or the bladder may need to be removed due to trauma.
• If the bladder is no longer functioning, surgery is performed so that the person can get along without it. The surgical procedure results in a urostomy.
• To create a urostomy, the ureters are detached from the bladder and then attached to a segment of bowel. One end then extends outside of the abdominal wall, allowing urine to drain to the outside of the body.
• This creates a stoma: an opening that protrudes from the abdomen connecting an internal organ to the outside of the body.
• The stoma is usually pink or red in color and should be moist.
• The stoma is very delicate skin, but it sticks out a little bit so be careful to not disturb the tissues.
• The stoma does not have nerve endings so it will not hurt if you touch it.
• When caring for the resident, you must always monitor the stoma for abnormal symptoms.
• If the stoma is bleeding, shrinks, gets larger, narrows, is level with the skin, is dry, or turns a color other than pink or red, report this to the nurse immediately.
• The urine that flows through the stoma is then collected in a bag outside of the body.
• The bag is emptied once it becomes one third to one half full, and at the end of each shift.

Ostomy Bag

• It is the role of the nursing assistant to physically empty and clean the ostomy bag.

• Sometimes it is also the responsibility of the nursing assistant to completely change the ostomy appliance (which is the wafer that adheres to the resident's skin and the bag).

• Check your facility's protocol.

• The bag should be emptied when it is approximately half full, or when the resident requests.

• Chart this as a bowel movement at your end-of-shift charting.

• Clean the stoma and the surrounding area with adult wipes.

• Monitor the resident for abnormal signs and symptoms affecting the stoma as noted in the urostomy section.

• If the resident has a reusable bag, you must rinse out the bag after emptying it. Empty the rinse water into the toilet. Dry the bag and reattach it. Some residents do not reuse bags. In this case, simply detach the bag and throw it away.

Devices Used for Elimination

• Many implements are available to assist residents with their elimination needs.
• A bedpan is one of the more common pieces of equipment.
  • It is used for residents who are either bed bound or on strict bed rest, or who cannot physically sit up on a toilet or commode.
  • Or it is used at night so that the resident does not need to get out of bed.
  • Bedpans are stored in the bottom drawer of the chest of drawers or in the resident's bathroom.
• Types of bedpans:
  • Traditional
  • Fracture
• Most facilities use only fracture pans because they are smaller, easier to use, more comfortable for the resident, and more economical.
• If you are assisting a resident who has had a hip surgery, you must only use the fracture pan to reduce the risk of injury.

Commode

• Some people prefer to use a commode at the bedside rather than a bedpan.
• A commode is used for residents who can sit on a toilet but who may not be able to walk to the bathroom.
• Some commodes have wheels. The wheel locks need to be on at all times. Residents may self-transfer onto the commode, and unlocked brakes would be a safety hazard.
• If they are able, encourage the resident to wipe themself and use hand sanitizer if they cannot get to the sink to wash their hands.
• Empty the contents of the commode bucket into the toilet.
• Rinse the commode bucket and empty the rinse water into the toilet.
• Wipe the bucket out with adult or disinfectant wipes and replace it under the toilet seat of the commode.
• If the resident is on intake and output, place a commode hat, which is another measurement tool, under the toilet seat of the commode.

Urinal

• A urinal is an alternative to a bedpan or commode.
• It is used to collect only urine.
• Although urinals are available for both men and women, only the male urinal is commonplace.
• The urinal can also be used in lieu of a graduate to measure urine, since mL or cc hash marks are on its side.
• If the resident chooses to use a urinal, place a bed protector underneath them.
• If the resident uses the urinal independently, you may need to assist as needed.
• If the resident uses the urinal independently, reinforce to them the importance of not placing the urinal on the overbed table because its surface is a designated clean area.
• Teach the resident to hang the urinal on the side rail (either lowered or raised) if easily available, or place the urinal on paper towels on the chest of drawers if it is next to the bed.
• When the resident has finished using the urinal, empty the contents into the toilet.
• Fill the urinal with rinse water, and empty the rinse water into the toilet.
• Dry the urinal and place it in the bottom drawer of the chest of drawers or in the bathroom.
• If the resident is on intake and output, first measure the contents.
• No elimination equipment should ever be placed on the overbed table because its surface is a designated clean area.
• The hard rim of the urinal may irritate the penis; the contact of the skin of the scrotum and thighs with the plastic may be irritating as well.
• Wrap the urinal with a washcloth to keep the skin from meeting the plastic. Tuck the washcloth around and into the rim of the urinal to protect the penis; it will also catch any drips.

Commode Hat

• A commode hat is placed under the toilet seat of either a commode or a toilet to collect urine and/or stool.
• It is used for measuring output or for collecting a stool sample.
• It should not be used for collecting a urine sample.
• If you are only measuring urine output, place the hat in the front part of the commode.
• If you need only to collect a stool sample, place it in the back part of the commode.
• If you are using the commode hat for measuring urine and stool output, place one in the front and one in the back of the commode.
• Teach the resident to not place toilet paper into the commode hat if they are on intake and output.
• The toilet paper must be placed in a wastebasket to not skew the amount of urine and/or stool being measured.

External Female Urine Management System

• A newer product is an external female urine management system, sometimes called an external catheter.
• This type of system can help keep urine away from the skin and decrease the risks of infection associated with a typical catheter.
• It is used in hospitals and at home.
• The system consists of a urine collection container that sits in a base at the bedside, a tube, and a catheter.
• At the end of the tubing is an external catheter that is slightly flexible and rounded at the end, one side of which is gauze.
• It is important to perform peri-care and assess the skin integrity before each use of this product.
• Before positioning the device, turn the machine on at the base of the unit. Once on, it creates a gentle suction from the catheter to the container. This will wick the urine away from the resident's body.
• Next, with the resident lying on their back, ask the resident to open their legs. Assist as needed.
• With gloved hands, open the labia and gently place the catheter so that the gauze side is touching the labia and the top of the gauze is at the pubic bone.
• At this time, the resident can place their legs back to a comfortable position. The genitalia will serve to keep the catheter in place.
• To remove, ask the resident to open their legs, and while the suction is still on, gently pull the catheter directly away from the resident's body. Wait until the rest of the urine in the tubing is in the collection container before turning it off. Assess skin integrity and report anything outside of normal limits to the nurse promptly.
• The external catheter is single use only and can be used for up to 8 to 12 hours.
• If it becomes soiled with blood or feces, remove and throw away. Be sure to complete peri-care once more.
• The tubing and canister must be cleaned daily as per the manufacturer's recommendations and facility policy. The canister and tubing must be replaced every 60 days at a minimum.
• Do not use if the skin has any open areas, breakdown, or irritation. Combative or agitated residents should not use this product.
• Just like a typical catheter, a privacy sheath should be placed over the collection system. This system should not be used while the resident is being moved or transported, only while they are lying in bed.

Urinary Retention and Catheters

• Sometimes residents suffer from urinary retention.
• Urinary retention occurs when the resident still has urine in the bladder even after urinating or attempting to urinate. When this occurs, the resident may need to have a catheter placed.
• Catheters are the most common way a resident will acquire a urinary tract infection (UTI). It is important to limit the use of catheters when possible.
• When nursing assistants toilet residents every 2 hours, they are helping to reduce this risk because they are helping the residents to fully empty their bladders.
• Sometimes bladder scanners are used to help prevent Catheter-Associated Urinary Tract Infections (CAUTIs).
• Before deciding whether to use a catheter, the nurse may use information from a bladder scan. The bladder scanner is an ultrasound that determines how much urine is in the bladder.
• A bladder scanner is not invasive, so there is no risk of a UTI from using this. The scanner is a portable unit that can be used at the bedside.
• You may need to help the nurse complete this scan. If you receive training through your employer, you may be able to complete the bladder scan. The nurse will use this information to determine if a catheter should be used or not.

Digestive Tract Bleeding

• Bleeding can occur anywhere in the digestive tract.

• If bleeding occurs in the upper part of the digestive tract, such as in the stomach or the beginning of the intestine, the resident will have black, tarry stools. These are very sticky or pasty and may smell foul. The blood in these stools may be occult, or hidden.

• If the bleeding occurs lower in the digestive tract, there may be frank blood, meaning red, obvious blood.

• Many residents have hemorrhoids, which are large, distended veins found around and in the anus; they are a result of constipation and can be very painful.

• Sometimes hemorrhoids bleed frank blood. When wiping, pat, rather than rub, the area. Use adult wipes, if available, instead of toilet paper.

• Some residents that experience hemorrhoids may benefit from a sitz bath, which can relieve mild pain and swelling. A basin filled with warmer water sits over the toilet. As the resident sits on the toilet, the bottom is submerged in the water. A resident can sit this way for 10 to 15 minutes, up to two or three times per day, for relief.

• Update the nurse if there is any sign of frank or occult blood when toileting your resident; if so, do not flush the toilet because the nurse must assess the stool first.

• Get the nurse immediately if there is a large amount of frank blood in the toilet or if the resident is visibly bleeding from the rectum; that is a medical emergency.

• Occult Blood: Hidden blood

• Frank Blood: Red, obvious blood