Chapter 37

Urinary and Bowel Elimination

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Physiology of Urinary Elimination

Urinary Elimination (voiding, urination)• The kidneys form the urine.• The ureters carry urine to the bladder.• The bladder acts as a reservoir for the urine.• The urethra is the passageway for the urine

to exit the body.

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Physiology of Urinary Elimination

Continence in the Adult • Anatomic integrity of the urinary system• Nervous control of the detrusor muscle• Competent sphincter mechanism

Urinary Incontinence• Uncontrolled loss of urine • Abnormalities of one or more factors

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Physiology of Urinary Elimination

Structures of the Upper Urinary Tract• Kidneys • Nephrons• Parenchyma• Hilus of kidney• Renal pelvis• Ureter

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Physiology of Urinary Elimination

Both the renal pelvis and ureters consist primarily of smooth muscle.

Peristalsis (muscular contraction) moves urine from the upper to the lower urinary tract.

Occurs during the prolonged phases of bladder filling and storage.

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Physiology of Urinary Elimination

Structures of the Lower Urinary Tract• Bladder• Detrusor (smooth muscle bundles in the

upper portion of the bladder)• Urethra (sphincter mechanism)• Pelvic muscles (slow-twitch fibers and fast-

twitch fibers)

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Physiology of Urinary Elimination

Nervous Control of the Detrusor Muscle• Central nervous system• Peripheral nervous system• Sympathetic nervous system• Parasympathetic nervous system• Micturition center

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Physiology of Urinary Elimination

Urethral Sphincter Mechanism• Urethral compression• Bladder filling• Urinary storage• Urethral tension• Supportive structures

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Physiology of Bowel Elimination

Continence • Consistency of the stool (fecal material)• Intestinal motility• Compliance and contractility of the rectum • Competence of the anal sphincters

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Physiology of Bowel Elimination

Structures of the Gastrointestinal Tract (alimentary canal) Related to Bowel Elimination• Small intestine• Ileocecal valve• Large bowel (colon)• Ileocecal sphincter• Anal sphincter

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Physiology of Bowel Elimination

Intestinal Motility and Rectal Accommodation• Rectal filling • Rectal contractions• Rectal accommodation• Postponement of defecation• Constipation

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Physiology of Bowel Elimination

Anal Sphincter Mechanism• Internal and external sphincters• Striated muscle fibers• Sensory receptors

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Factors Affecting Elimination

Age Diet Exercise Medications

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Common Alterations in Elimination

Urinary Elimination• Acute urinary incontinence• Chronic urinary incontinence

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Common Alterations in Elimination

Stress Urinary Incontinence (SUI)• Uncontrolled loss of urine caused by

physical exertion in the absence of a detrusor muscle contraction

• Associated with urethral hypermobility or intrinsic sphincter deficiency

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Common Alterations in Elimination

Urgency and Urge Urinary Incontinence (overactive bladder syndrome)• Involuntary leakage accompanied by urge to

void

Functional Urinary Incontinence• Altered mobility, manual dexterity• Ability to access toilet• Cognitive changes

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Common Alterations in Elimination

Extraurethral Incontinence• Uncontrolled loss of urine that exists when

the sphincter mechanism has been bypassed

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Common Alterations in Elimination

Urinary Retention• Bladder outlet obstruction• Deficient detrusor muscle

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Alterations in Bowel Elimination

Constipation Diarrhea Fecal Incontinence

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Bowel Retention

Constipation is infrequent and difficult passage of hardened stool.• Dietary factors, dehydration• Inadequate dietary bulk• Diverticular disease• Neuropathic conditions• Functional limitations

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Bowel Retention

Fecal Impaction• Bolus of hardened stool• Further slows colonic transit time and

passage of further fecal contents

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Bowel Retention

Perceived constipation is influenced by psychological and emotional stress.

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Alterations in Bowel Elimination

Diarrhea is the passage of liquefied stool with increased frequency and consistency.

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Alterations in Bowel Elimination

Primary Causes of Diarrhea• Malabsorption syndromes• Inflammatory bowel disease• Short bowel syndrome• Side effects of drugs• Laxative or enema misuse

Infectious diarrhea is caused by a pathogen.

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Alterations in Bowel Elimination

Bowel (fecal) Incontinence• Dysfunction of the anal sphincter• Disorders of the delivery of stool to the

rectum• disorders of rectal storage• Anatomic defects

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Assessment

Health History• Elimination habits• Type of incontinence• Complicating factors• Bladder and bowel management strategies

used by client

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Assessment

Physical Examination• Mental status• Mobility and dexterity• Inspection of perineum for skin integrity• Inspection of vaginal vault • Pelvic support• Perineal sensation• Perianal area, digital rectal exam

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Assessment

Diagnostic and Laboratory Data• Urinalysis• Stool culture• Defecography• Anorectal ultrasonography

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Nursing Diagnoses

Impaired Urinary Elimination Stress Urinary Incontinence Reflex Urinary Incontinence Urge Urinary Incontinence Functional Urinary Incontinence Urinary Retention

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Nursing Diagnoses

Constipation Perceived Constipation Diarrhea Bowel Incontinence

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Other Nursing Diagnoses

Low Self-Esteem Deficient Knowledge Risk for Infection Risk for Impaired Skin Integrity Toileting Self-Care Deficit

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Outcome Identification and Planning

Target outcomes center around restoring and maintaining regular elimination habits and preventing complications.

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Implementation

Maintain Elimination Health• Fluid intake• Diet• Lifestyle and Prevention

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Implementation

Lifestyle and Prevention• Alcohol and tobacco use• Stress management• Weight reduction• Elimination habits• Positioning

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Implementation

Lifestyle and Prevention• Initiate pelvic muscle exercise regimen• Bladder training for urge incontinence• Management of urinary retention• Management of functional urinary

incontinence• Suggest environmental modifications

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Implementation

Lifestyle and Prevention • Initiate behavioral intentions• Monitor skin integrity

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Implementation

Apply a Containment Device• Condom catheter• Incontinence and dribble pads• Rectal pouch and rectal tube

Initiate Diet and Fluid Therapy

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Implementation

Administer Medications• Over the Counter (OTC)• Prescription

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Implementation

Perform Catheterization Intermittent Catheterization

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Implementation

Administer Enemas• Cleanse the lower bowel• Assist in evacuation• Instill medication

Initiate Rectal Stimulation

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Implementation

Various types of enema equipment and solutions

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Implementation

Monitor Elimination Diversions• Urinary Diversions

- Ileal conduit- Continent urinary diversion

• Bowel Diversions- Ileostomy- Colostomy- Ileoanal reservoir

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Implementation

Surgical Management• Bladder suspension• Artificial urinary sphincter device• Implanted devices• Surgical reconstruction• Surgical closure of fistulae and ectopia• Endoscopy, other procedures to alleviate

obstruction or dyssynergia

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Implemenation

Complementary Therapies• Holistic approach to effective elimination of

waste products and toxins- Diuretics- Antimicrobials- Antiseptics- Stimulants and Cathartics

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Evaluation

Client’s level of maintenance or restoration of elimination patterns and return to an appropriate level of independence

Prevention of skin breakdown and infection

Client understanding of procedures and self-care