Elimination

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Here are some important points and most tested concepts in NCLEXRN about Elimination:

Assessment of bowel elimination: Assessment of bowel elimination is an important aspect of patient care. The nurse must assess the patient’s bowel movements, frequency, and consistency. The nurse must also assess the patient’s abdomen for any signs of distension, tenderness, or discomfort. In addition, the nurse should assess for any complaints of constipation, diarrhea, or fecal incontinence.
Urinary elimination: Assessment of urinary elimination is also an important aspect of patient care. The nurse must assess the patient’s urinary output, frequency, and color. The nurse should also assess the patient’s bladder for any signs of distension, tenderness, or discomfort. In addition, the nurse should assess for any complaints of urinary retention, urgency, or incontinence.
Types of urinary incontinence: There are four types of urinary incontinence that are commonly tested in the NCLEXRN. These include stress incontinence, urge incontinence, overflow incontinence, and functional incontinence.
Types of bowel incontinence: There are two types of bowel incontinence that are commonly tested in the NCLEXRN. These include fecal incontinence and flatulence incontinence.
Management of urinary incontinence: The management of urinary incontinence depends on the type of incontinence. Behavioral techniques such as bladder training and pelvic floor exercises are commonly used for stress incontinence. Medications such as anticholinergics are commonly used for urge incontinence. Surgery may be necessary for overflow incontinence.
Management of bowel incontinence: The management of bowel incontinence depends on the cause. Dietary changes and the use of stool softeners and laxatives may be necessary for fecal incontinence. Biofeedback training and pelvic floor exercises may also be helpful. For flatulence incontinence, the use of deodorizers and absorbent pads may be helpful.
Enemas and bowel preparation: Enemas and bowel preparation are commonly used to prepare the bowel for procedures such as colonoscopies and surgeries. The nurse must assess the patient’s bowel function before and after the procedure to ensure that the bowel has been adequately prepared.
Ostomy care: Ostomy care is an important aspect of patient care for patients who have had ostomy surgery. The nurse must assess the stoma and surrounding skin for any signs of irritation or infection. The nurse must also assess the patient’s bowel movements and output. In addition, the nurse must educate the patient on how to care for the ostomy and how to change the ostomy pouch.
Fluid and electrolyte balance: The nurse must monitor the patient’s fluid and electrolyte balance to ensure that the patient is adequately hydrated and that electrolyte levels are within normal limits. The nurse must also monitor the patient’s urine output and assess for any signs of dehydration or fluid overload.
Medications that affect elimination: The nurse must be aware of medications that can affect bowel and urinary elimination. These medications include diuretics, laxatives, and anticholinergics. The nurse must assess the patient’s elimination patterns and monitor for any adverse effects of these medications.

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, caused by various factors such as the use of diuretic medications, renal disease, psychogenic polydipsia, diabetes mellitus and diabetes insipidus.
Oliguria is a less than normal amount of urinary output, less than 400 mLs over the course of 24 hours, caused by impaired renal blood flow, renal disease, decreased fluid intake and dehydration, hypovolemic shock, and other diseases and disorders associated with excessive bodily fluid losses.
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, often occurring as the result of a urinary tract infection and trauma.
Urinary incontinence is the involuntary leakage of urine and a loss of bladder control, caused by various factors such as a neurological deficit, a lack of sphincter control musculature, and an overactive bladder.
Urinary retention is the accumulation of urine in the bladder because the patient is not able to effectively empty their bladder.
Urgency is defined as strong, sudden and relentless need to immediately urinate without delay.
Constipation is defined as less than three bowel movements per week, often caused by immobility, a lack of fluid intake, some medications like opioid drugs, and impaired neurological functioning.
Diarrhea is a watery loose stool, caused by various factors such as a gastrointestinal infection, some foods, stress, anxiety, some medications, malabsorption syndrome, and a parasite infection.
Fecal impaction is a collection of hardened stool in the rectum, caused by some medications and also secondary to constipation, among other causes.
Flatulence is the expulsion of often odorous gastrointestinal gas, resulting from some foods and medications.

Assessing and Managing the Client with an Alteration in Elimination

Assessing and managing a client with an alteration in elimination is an important topic frequently tested on the NCLEX RN exam. Nurses must have a good understanding of the pathophysiology of the urinary and gastrointestinal systems to identify and manage alterations in elimination. Assessment of the client should include obtaining a thorough health history, a focused physical examination, and diagnostic testing as indicated. Nurses must be able to identify signs and symptoms associated with alterations in elimination, such as dysuria, urgency, frequency, incontinence, constipation, and diarrhea. Management of the client may include non-pharmacological and pharmacological interventions depending on the underlying cause of the alteration in elimination. Nurses must educate clients about prevention and management strategies, such as diet modifications, fluid intake, exercise, and medication adherence. They must also be able to recognize complications associated with these alterations, such as dehydration, electrolyte imbalances, and infection.

Some of these interventions can include:

Positioning
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
Timing
Privacy
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

Enemas are used to relieve flatus, stimulate peristalsis, and remove feces. There are four types of enemas: carminative, cleansing, retention, and return-flow enemas.

Carminative enemas are used to relieve flatulence and stimulate peristalsis.
Cleansing enemas remove feces and are used to relieve constipation, prep the bowel for surgery, or diagnostic tests.
Retention enemas consist of an oil or medication solution that is retained by the client for an hour or more to administer medication, soften stool, and lubricate the rectum.
Return-flow enemas are used to relieve flatus and stimulate peristalsis after anesthesia by instilling fluid into the rectum and sigmoid colon and then removing it multiple times.

Urinary and Fecal Diversion

Fecal diversion colostomies are a medical procedure that can be either temporary or permanent. It is performed to promote healing of anastomoses, relieve bowel obstruction due to a tumor, or facilitate fecal content elimination when the distal colon and rectum are removed.

There are four types of colostomies, namely ascending colostomy, transverse colostomy, descending colostomy, and sigmoid colostomy. The location of the stoma depends on the type of colostomy. For example, the stoma for a sigmoid colostomy is usually located in the lower left quadrant of the abdomen.

Complications associated with colostomy include infection, dehiscence, ischemic ileostomy, peristomal hernia, stoma stenosis, stomal retraction, prolapsed stoma, necrosis, mucocutaneous separation, stomal trauma, peristomal skin damage due to leakage, and parastomal hernias.

Urostomy is a urinary diversion procedure. Different types of urostomy include ileal conduit, neobladder, Miami pouch, Indiana pouch, and 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 Catheterization

Urinary catheters are necessary to prevent urinary leakage and skin breakdown caused by urine, but their use should be strategic and reviewed daily to prevent catheter-associated urinary tract infections (CAUTI). Indicators for placing a urinary catheter include urinary retention confirmed by bladder scanning, prolonged surgery, genitourinary surgery, sacral or pelvic/spine trauma, or hemodynamic instability. After catheter placement, staff should follow a urinary incontinence bundle to prevent CAUTI and regularly review if the catheter is still necessary. Upon catheter removal, the patient should be observed to urinate within 6 hours. If not, a bladder scan can determine urine volume and techniques to promote urination or straight catheterization may be used per clinician’s order. If the patient still cannot void after 6 hours and has more than 400ml of urine in the bladder, 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

Bowel and bladder management techniques are used to address issues of incontinence and retention. Constipation and urinary retention can be managed with the use of interventions like exercise, dietary modifications, and medications. The use of urinary catheters should be avoided if possible to prevent infections, but if necessary, catheter care must be provided to avoid catheter-associated urinary tract infections (CAUTI). Incontinence management programs include timed voiding and evacuation, muscle exercises, and the use of protective devices like briefs and pouches. Scrupulous skin care is required to prevent complications associated with incontinence, and client dignity must be preserved at all times.

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

Evaluating Whether the Client’s Ability to Eliminate is Restored and Maintained

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

Overall, assessment and management of elimination are important aspects of patient care. Nurses must be knowledgeable about the types of incontinence, management strategies, enemas and ostomy care, fluid and electrolyte balance, and medications that affect elimination. These concepts are commonly tested on the NCLEXRN and it is important for nurses to be prepared to answer questions related to elimination.