Tools
Assisting Patients With Elimination
Definition/Introduction
Assisting patients with elimination is an essential aspect of the nurse's role and has important medical significance as well as psychosocial effects on the client's quality of life.[1] As the pattern of healthy bowel movements and urination vary in different patient groups, the management for each patient population may differ. Nurses need to assist with healthy elimination patterns to ensure patients are having regular soft bowel movements and adequate urination and to identify abnormal patterns such as flatulence, constipation, diarrhea, incontinence, fecal impaction, hemorrhoids as well as polyuria, anuria, and other abnormalities which can be signs of underlying medical conditions.
Issues of Concern
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Issues of Concern
While there are pharmacologic alternatives to assist with elimination issues, assistance by nurses is often required. For instance, in abdominal pain syndrome and constipation, studies show that abdominal massage appears to increase bowel function, but without the negative effects of laxatives.[2]
Conversely, certain medications can cause constipation, diarrhea, and hinder or exacerbate elimination. Opioids, NSAIDs, antibiotics, anticoagulants, can all induce constipation.[3] It is vital nurses know which patients are at risk for bowel and bladder disruption and monitor them for these issues.
The nursing team must provide strong supportive communication when assisting clients with elimination. A study found that the nurse's attitudes toward excretion-related nursing care strongly influenced the use of a toilet and physical functions of the elderly.[4] Patients may be reluctant to discuss their bowel and bladder problems due to embarrassment. It is vital that nurses maintain open communication and empathy with their clients and ask questions as well as physically assess patients for signs of bladder and bowel irregularities.[5][6]
Clinical Significance
Elimination issues may occur due to a variety of different medical conditions; for instance, post-surgical patients are at risk for ileus, congenital malformations in infants can cause bowel and bladder disruption, and cancer patients and the elderly can have altered elimination secondary to drugs and therapy.[7][8]
The inability to effectively eliminate waste products from the bowel and bladder may lead to serious medical conditions and can be a psychosocial factor contributing to decreased quality of living.[5] Special consideration is necessary for patients at risk for bowel and bladder dysfunction such as patients with decreased fiber or fluid intake, or those with decreased bulk in their diet, patients on bed rest, those with kidney, CNS, or heart disease, the elderly, infants and cancer patients.[6]
Nursing, Allied Health, and Interprofessional Team Interventions
Management may differ based on the diagnosis of the patient. For instance, a study found that enterally fed preterm infants would benefit from abdominal massage twice a day, whereas cancer patients with elimination issues may benefit from Sitz baths.[9][7][10]
Non-invasive interventions such as repositioning the patient, providing counseling in regards to a high fiber diet rich in prunes, stool softeners, removing drugs that may be causing gastrointestinal or genitourinary side effects, and abdominal massage can aid the patient in elimination. Additionally, more invasive interventions such as the use of suppositories, urinary catheters, enemas, bowel and bladder training, and management can also help clients who have failed initial interventions.[6]
Urinary catheterization for retention is possible with the use of ointments such as zinc oxide and topical agents to keep the skin protected. A recent meta-analysis found that periurethral cleaning with water before urinary catheterization is as effective as using anti-septic agents and does not increase the risk of UTI's.[11] Bladder, colostomy, and urinary catheter irrigations can also be performed to assist with elimination.[11]
Various enemas can also be used depending on the issue; cleansing enemas are used before procedures like colonoscopies to clean the colon of fecal material for optimal visualization, retention enemas may help lubricate the rectum and deliver medication, and lastly, return-flow enemas are often used after anesthesia to stimulate peristalsis.[12]
If less invasive techniques are unsuccessful, colostomies, or urostomies are options. However, given that these are invasive procedures, there is an increased risk of complications such as infections, B12 deficiency, dehiscence, and necrosis, and these patients require thorough monitoring.[13]
Invasive methods may lead to long term adverse outcomes. A study found that decreasing the use of the invasive practices routinely adopted in nursing homes (laxatives, enemas, rectal exploration) improved constipation in nursing home residents.[14] Thus, empathetic nursing care, counseling, and non-invasive methods are ideal for improving excretion issues.
Nursing, Allied Health, and Interprofessional Team Monitoring
Any patient without a bowel movement for several days requires assessment for constipation or small bowel obstruction. Nurses may assess bladder function by measuring the amount of residual urine. On average, adults urinate 30 mL each hour.[4]
Secondary complications of disrupted elimination such as delirium secondary to UTI’s, or a positive FOBT secondary to ulcers or hemorrhoids also need monitoring.[15]
It is also essential to monitor elimination to prevent the spread of hospital-acquired infections such as Clostridium difficile and to isolate the client and use hand hygiene and gown and glove precautions when assisting the patient.[16]
Thus, by following these methods and being knowledgeable about elimination and the complications associated with patient elimination, nurses can adequately assist with this fundamental aspect of patient care.
References
Coggrave M. Neurogenic continence. Part 3: Bowel management strategies. British journal of nursing (Mark Allen Publishing). 2008 Aug 14-Sep 10:17(15):962-8 [PubMed PMID: 18983017]
Lämås K, Lindholm L, Stenlund H, Engström B, Jacobsson C. Effects of abdominal massage in management of constipation--a randomized controlled trial. International journal of nursing studies. 2009 Jun:46(6):759-67. doi: 10.1016/j.ijnurstu.2009.01.007. Epub 2009 Feb 12 [PubMed PMID: 19217105]
Level 2 (mid-level) evidenceSharma A, Rao S. Constipation: Pathophysiology and Current Therapeutic Approaches. Handbook of experimental pharmacology. 2017:239():59-74. doi: 10.1007/164_2016_111. Epub [PubMed PMID: 28185025]
Tanaka K, Takeda K, Suyama K, Kooka A, Nakamura S. [Factors related to the urination methods of elderly people with incontinence who require at-home nursing care]. Nihon Ronen Igakkai zasshi. Japanese journal of geriatrics. 2016:53(2):133-42. doi: 10.3143/geriatrics.53.133. Epub [PubMed PMID: 27250220]
Cauley CE, Savitt LR, Weinstein M, Wakamatsu MM, Kunitake H, Ricciardi R, Staller K, Bordeianou L. A Quality-of-Life Comparison of Two Fecal Incontinence Phenotypes: Isolated Fecal Incontinence Versus Concurrent Fecal Incontinence With Constipation. Diseases of the colon and rectum. 2019 Jan:62(1):63-70. doi: 10.1097/DCR.0000000000001242. Epub [PubMed PMID: 30451749]
Level 2 (mid-level) evidencePellatt GC. Clinical skills: bowel elimination and management of complications. British journal of nursing (Mark Allen Publishing). 2007 Mar 22-Apr 11:16(6):351-5 [PubMed PMID: 17505389]
Wickham RJ. Managing Constipation in Adults With Cancer. Journal of the advanced practitioner in oncology. 2017 Mar:8(2):149-161 [PubMed PMID: 29900023]
Powell M, Rigby D. Management of bowel dysfunction: evacuation difficulties. Nursing standard (Royal College of Nursing (Great Britain) : 1987). 2000 Aug 9-15:14(47):47-51; quiz 53-4 [PubMed PMID: 11974378]
Tekgündüz KŞ, Gürol A, Apay SE, Caner I. Effect of abdomen massage for prevention of feeding intolerance in preterm infants. Italian journal of pediatrics. 2014 Nov 14:40():89. doi: 10.1186/s13052-014-0089-z. Epub 2014 Nov 14 [PubMed PMID: 25394549]
Level 1 (high-level) evidenceTseng YL, Lin SY, Tseng HC, Wang JY, Chiu JL, Weng KT. Stress and other factors associated with colorectal cancer outpatients with temporary colostomies. European journal of cancer care. 2019 Jul:28(4):e13054. doi: 10.1111/ecc.13054. Epub 2019 Apr 16 [PubMed PMID: 30993754]
Huang K, Liang J, Mo T, Zhou Y, Ying Y. Does periurethral cleaning with water prior to indwelling urinary catheterization increase the risk of urinary tract infections? A systematic review and meta-analysis. American journal of infection control. 2018 Dec:46(12):1400-1405. doi: 10.1016/j.ajic.2018.02.031. Epub 2018 May 31 [PubMed PMID: 29778430]
Level 1 (high-level) evidencePeate I. How to administer an enema. Nursing standard (Royal College of Nursing (Great Britain) : 1987). 2015 Dec 2:30(14):34-6. doi: 10.7748/ns.30.14.34.s43. Epub [PubMed PMID: 26639291]
de Oliveira AL, Boroni Moreira AP, Pereira Netto M, Gonçalves Leite IC. A Cross-sectional Study of Nutritional Status, Diet, and Dietary Restrictions Among Persons With an Ileostomy or Colostomy. Ostomy/wound management. 2018 May:64(5):18-29 [PubMed PMID: 29847308]
Level 2 (mid-level) evidencePalese A, Granzotto D, Broll MG, Carlesso N. From health organization-centred standardization work process to a personhood-centred care process in an Italian nursing home: effectiveness on bowel elimination model. International journal of older people nursing. 2010 Jun:5(2):179-87. doi: 10.1111/j.1748-3743.2010.00220.x. Epub 2010 Apr 20 [PubMed PMID: 20925719]
Kobayashi Y, Watabe H, Yamada A, Suzuki H, Hirata Y, Yamaji Y, Yoshida H, Koike K. Impact of fecal occult blood on obscure gastrointestinal bleeding: observational study. World journal of gastroenterology. 2015 Jan 7:21(1):326-32. doi: 10.3748/wjg.v21.i1.326. Epub [PubMed PMID: 25574108]
Level 2 (mid-level) evidenceRead ME, Olson AJ, Calderwood MS. Front-line education by infection preventionists helps reduce Clostridioides difficile infections. American journal of infection control. 2020 Feb:48(2):227-229. doi: 10.1016/j.ajic.2019.08.002. Epub 2019 Sep 9 [PubMed PMID: 31515098]