Nursing management of altered
patterns of elimination
Nancy Ann Lewis, RN, MSN, CRRN
Nursing Supervisor
Harmarville Rehabilitation Center, Inc.
Pittsburgh, Pennsylvania
ALTERATION in bladder and bowel
A elimination is a concern for nurses in
all settings, including the home. Urinary
and bowel dysfunction are frequently
encountered when caring for the elderly.1
Urinary incontinence affects 5% to 15% of
the elderly living in the community, 40% in
the hospital, and over 50% in extended
care facilities.’ Resnick and Yalla’ report
that primary risk factors include neurologi-
cal impairment, immobility, and female
sex. Neither advanced age nor chronic uri-
nary tract infection are risk factors.
Incontinence can be emotionally and
financially costly to both the individual and
the caregiver. The incontinent individual is
often embarrassed and depressed by the
condition and may become socially isolated
for fear of having an &dquo;accident&dquo; in public.
Incontinence may be costly to the caregiver
in terms of time, laundry, supplies, and
treatment of resultant medical complica-
tions for cystitis, urinary sepsis, decubitus
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ulcers, skin irritation, and falls.~ But many
incontinent individuals can be helped with
active nursing or medical intervention, thus
decreasing the burden on home care
patients and their caregivers.
Urinary incontinence is not the result of
aging. It is caused
by decreased reserve
capabilities of the urinary system com-
pounded by medical complications. Aging
does cause a reduction in bladder capacity,
ability to postpone voiding, urethral and
bladder compliance, urethral closure pres-
sure, and flow rate. Yet there is
an increase
in uninhibited bladder contractions and
postvoid residual volumes.2 These changes
place the elderly in a precarious position
between control and incontinence. Any
additional medical or emotional change
may cause a shift to incontinence. Any new
episode or worsening of incontinence
should be evaluated for medical interven-
tion.
NEUROLOGICAL INNERVATION
The nurse must have a basic understand-
ing of the neurological components of elim-
35
36
ination. Neurological innervation of the
bladder and bowel are4Very similar. Neuro-
logical function involves cortical control,
ascending and descending pathways of the
spinal cord, the S2-4 spinal cord segments,
and the sensory and motor portions of the
reflex arc.3 Interruption of the nerve path-
way produces neurological dysfunction of
the bladder and bowel.4 Normal urination
is a complicated but coordinated function.
Filling of the bladder causes distention of
the detrusor muscle of the bladder wall,
which stimulates the stretch receptors and
transmits impulses via the pelvic nerve to
the S2-4 spinal cord segments and back via
the parasympathetic fibers of the same
nerve. This micturition reflex pathway
maintains the muscle tone of the bladder
and provides the sensory input for normal
bladder function. Cortical control provides
inhibition of the micturition reflex with
continual contraction of the external
sphincter and pelvic floor. Voluntary uri-
nation consists of contracting the detrusor
muscle to increase the intravesical pressure
and’opening the bladder neck to allow the
flow of urine by gravity.4
TYPES OF URINARY DYSFUNCTION
Urinaryincontinence may be identified
as transient or established. Resnick and
Yalla2 report that common causes of tran-
sient incontinence are delirium or con-
fused state, symptomatic urinary tract
infection, atrophic urethritis or vaginitis,
medications, psychological disorder (de-
pression), endocrine disorder (hypercal-
cemia or hyperglycemia), restricted mobili-
ty, or stool impaction. Identification and
treatment of the cause will improve the
incontinence.
Established incontinence occurs second-
ary to functional abnormalities of the
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detrusor muscle of the bladder, the bladder
outlet, or both. Urge incontinence is caused
by detrusor instability from neurological
disease or damage, carcinoma of the blad-
der, radiation damage, interstitial cystitis,
or outlet obstruction.5 The individual is
unable to inhibit bladder contractions and
to control urination.
Established stress incontinence is seen
more often in women as the result of relax-
ation of the pelvic floor muscle and
estrogen insufficiency. Stress incontinence
is uncommon in men but may be associated
with urinary tract infection, chronic
inflammation, papilloma, urologic surgery,
5
radiation damage, or neurological disease.s
The bladder outlet pressure is insufficient
to stop the flow of urine when abdominal
pressure is increased.
Reflex incontinence is the result of sen-
sory and motor disruption within the spinal
cord above the sacral cord segments. The
micturition reflex remains intact, causing
an automatic reflex emptying of the blad-
der as it fills. This is commonly seen as the
result of spinal cord injury from trauma or
disease.4
Overflow incontinence is the result of
inadequate detrusor contractions that are
unable to exceed the outlet pressure until a
high volume is reached. This may be the
result of detrusor inadequacy, bladder out-
let obstruction, or impaired sensation. The
client will experience high bladder volume
and residual urine.55
NURSING ASSESSMENT
Nursing assessment is the first step in
management of urinary dysfunction.
Nurses directly involved with patient care
should routinely assess and manage uri-
nary dysfunction. A change in the nursing
focus from comfort and custodial care to

rehabilitative efforts is required for the
client to reach optimal health status,6 espe-
cially if the client is to function well at
home. Nursing assessment includes a
detailed history, including everything that
may relate directly or indirectly to urinary
dysfunction. The client’s level of aware-
ness, mobility, and functional status must
be assessed. Is the client aware of the need
to go to the bathroom? Does the client have
time to get there? Is the client physically
able to get to the bathroom in time? The
client or caregiver should be asked to
describe the dysfunctional episode in terms
of onset (chronic or recent), frequency, time
of day, symptoms of urinary tract infection,
and sensation related to voiding.
Possible related medical conditions
should be reviewed, such as neurological
disease, acute illness, cancer, diabetes,
pelvic and lower urinary tract surgery, any
of which may affect urinary control. The
client’s prescription and over-the-counter
medications should be reviewed for those
that may affect the level of awareness or
the urinary system. The assessment should
conclude with a physical examination,
including special emphasis on abdominal
distention after voiding and rectal inspec-
tion for stool impaction. When appropriate,
a medical order for catheterization for
residual urine should be requested. A true
residual urine must be done within five
minutes of voiding. The amount of urine
voided and the residual volume can give
the nurse information on bladder capacity
and ability to empty the bladder. Identifica-
tion of a change in the client’s condition or
continued problems may require medical
follow-up.
BLADDER PROGRAMS
The nursing diagnosis and management
plan of the bladder program is based on the
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37
assessment. The client or caregiver should
be asked to document a daily bladder rec-
ord listing intake, attempts to void, amount
voided, and incontinency. The record will
be reviewed at the next visit, and the man-
agement program will be altered accord-
ingly. In addition to intermittent catheteri-
zation and indwelling catheter, three basic
toileting programs exist: scheduled toilet-
ing, habit training, and bladder retraining. 7
The client with a neurogenic bladder8
secondary to spinal cord injury requires a
bladder program with close urologic super-
vision and follow-up to prescribe the most
functional program while preserving renal
function. Males will generally develop
reflex voiding when the micturition reflex
is intact. Most will require external cathe-
ter drainage secondary to loss of sensation,
or physical ability, and lack of voluntary con-
trol. A client in total retention will need to
follow an intermittent catheterization pro-
gram. Since there is no adequate female
external catheter drainage system (many
are under development), females generally
will follow an intermittent catheterization
program, with medications as required to
promote urinary retention. An indwelling
catheter may be chosen if the client is
unable to follow an intermittent program.
An intermittent catheterization program
is based on balancing intake and the cathe-
terized output. The catheterized output
should not exceed 500 mL; higher volumes
overstretch the bladder muscle, compro-
mise circulation, and increase risk of uri-
nary tract infection and complications.8 A
routine intermittent catheterization pro-
gram regulates fluid intake to 150 mL to 200
mL every hour, with catheterization four to
five times a day. The premise behind clean
catheterization technique is simplifying the
procedure that the client follows the
so
program and keeps the bladder volume
38
low. The low volume permits adequate
circulation to the bladder wall, which
decreases the risk of urinary tract infec-
tion.
Indwelling catheters are no longer the
accepted form of treatment for urinary dys-
function. A client may require an indwell-
ing catheter during an acute illness, but the
catheter should be removed as soon as
possible. Long-term indwelling catheters
are appropriate for clients with urinary
retention that is not treatable by other
approaches; for clients with skin areas
worsened by frequent contact with urine;
for terminally ill clients as a means of
increasing comfort; and for incontinent
clients at high risk of skin breakdown sec-
ondary to malnutrition or steroid therapy.7
If a long-term indwelling catheter is used,
the recommended catheter is a silastic
catheter, size 14 F or 16 F, with a 5-mL
balloon (filled with 8 mL of sterile water).
Continued leakage around the catheter,
secondary to detrusor muscle activity, may
require medication to reduce bladder con-
tractions and not a larger catheter or bal-
loon,9 as has been used in the past.
Removal of an indwelling catheter or
frequent incontinency requires a bladder
management program to regain bladder
control. The type of program chosen is
based on the client’s level of awareness
and physical ability. Physical limitations
may require adjustments in the bathroom
to make the bathroom more accessible or
the use of a bedside commode.
Scheduled toileting7 is based on a fixed
The type of bladder management
program chosen is based on the
client’s level of awareness and
physical ability.
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schedule for toileting with techniques to
trigger voiding and to empty the bladder.
The caregiver needs to assist the client with
moderate to severe physical or cognitive
dysfunction to the bathroom every two
hours during the day and at least once at
night, adjusting the schedule as required.
The goal is to avoid incontinent episodes
with an acceptable schedule.
Habit training7 involves a flexible toilet-
ing schedule based on the client’s pattern
of incontinence. Review of the bladder
record for incontinent episodes is used to
determine the schedule. Both these tech-
niques include regulating the fluid intake
during the day and limiting fluids after
dinner. The goal is to keep the client, chair,
and bed dry.
Bladder retraining~ can be used for the
client with adequate cognitive function,
mobility, dexterity, and motivation for self-
care. The goal is restoration of a normal,
continent, voiding pattern. The client uses
progressive lengthening or shortening of
toileting intervals, regulated intake, trigger-
ing and emptying techniques, and intermit-
tent catheterization when required.
Stress incontinence may be reduced in
women through a self-help program of pel-
vic floor strengthening exercises (Kegel
exercises) and through medical treatment
for atrophic vaginitis. In the early 1950s
Kegel10 published information on the
improvement of stress incontinence with
pelvic floor exercises. The changing health
care system and interest in self-help
methods have renewed interest in Kegel
exercises. Kegel exercises have had many
variations, but research1o.11 continues to
demonstrate an improvement in stress
incontinence. The pubococcygeal muscle
forms the main support of the pelvic floor
and surrounds all the outlets of the pelvis:
urethra, vagina, and rectum. The pubococ-

cygeal muscle is often stretched and dam-
aged during childbirth and is known to
weaken in postmenopausal women. Weak-
ness of the pubococcygeal muscle reduces
the bladder outlet pressure enough to allow
increased abdominal pressure from cough-
ing, sneezing, or laughing to force urine
from the bladder. Active exercises to
increase the endurance of this muscle have
been shown to increase the bladder outlet
pressure and to prevent stress inconti-
nence.
Taylor and Henderson1o report that the
pubococcygeal muscle can be felt three
fourths of the way up the vagina and is
about the size of a pencil when contracted.
The muscle strength can be checked by
spreading the knees apart while voiding
and stopping the flow midstream with mus-
cle contraction. A muscle with good
strength should be able to stop the flow of
urine. The pubococcygeal muscle can be
exercised by tightening the perineum to
contract the muscle, holding the contrac-
tion to the count of ten, and then relaxing.
This exercise should be repeated 100 times
everyday.
ALTERATION OF BOWEL
ELIMINATION
Bowel dysfunction is encountered fre-
quently by all nurses. It can result from
acute alteration in life style caused by ill-
.
ness or a chronic condition. Nursing assess-
ment is required, since bowel dysfunction
can result from many causes.’ Patterns of
bowel dysfunction can be constipation;
diarrhea; uninhibited; neurogenic reflex;
or areflexic.8 The nursing assessment must
include a review of the premorbid and
current pattern, the frequency, the time of
day, and the facilitating factors. The
abdo-
men should be auscultated for bowel
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39
sounds and should be palpated for disten-
tion or mass. Diet should be reviewed for
fluid intake and adequate bulk and fiber.
Self-care activities and abilities should be
reviewed to determine whether commode
accessibility should be modified. Nursing
assessment may indicate the potential
cause of bowel dysfunction. Nursing inter-
vention includes management of the cur-
rent problem and a treatment plan to nor-
malize bowel dysfunction.
Constipation
Constipation may be related to poor fluid
intake, inadequate dietary bulk, decreased
physical activity, lack of privacy, medica-
tion, confusion, or chronic laxative use. The
client’s bowel program goal will be the
development of an effective bowel routine
to evacuate the bowel comfortably and
completely without the use of laxatives.
Adequate fluid intake is required for soft,
formed stool. Six 8-ounce glasses of fluid
should be consumed daily, excluding cof-
fee, tea, and grapefruit juice, which act as
diuretics.1
Fiber and bulk are necessary for ade-
quate peristalsis within the intestine. Fiber
is not digested and passes through the gas-
trointestinal (GIJ tract as bulk for peristal-
sis. High-fiber foods include whole-grain
bread, cereals, and fresh fruits and vegeta-
bles. Miller’s bran can be added to the
client’s normal breakfast to add fiber to the
die f.12 Miller’s bran or other high-fiber
foods should be added gradually until ade-
quate results are obtained. Prunes are high
in fiber, but prune juice acts as a catharsis,
not as bulk.
Decreased physical activity slows gastric
motility and muscle tone, adding to consti-
pation. The client should be encouraged to
perform as many self-care activities and as
much ambulation as possible. A 30-minute
40
walk everyday can be sufficient to improve
gastric motility. Limited physical mobility
may also limit bathroom accessibility. The
commode should be evaluated for accessi-
bility, safety, and comfort. Grab bars
elevated seat may be required, or a bedside
commode may be needed.
Medications should be reviewed for
those that may reduce gastric motility or
cause confusion. Chronic laxative use actu-
ally worsens constipation, rather than help-
ing it.’,12 The gastric motility slows for two
days to recover after laxative irritation.
Frequently the client is worried about lack
of bowel movement and takes the laxative
again before the gastric motility has recov-
ered, causing a laxative-abuse cycle. The
bowel program should be based on an ade-
quate intake of fluid, fiber, and bulk;
increased physical activity; and, reduced
laxative use.
Diarrhea
Diarrhea may be seen as the result of
bowel irritation from inflammatory bowel
disease or secondary to tube feedings, lac-
tose intolerance, bacterial or parasitic
infestation, medications, overuse of laxa-
tives, stress, anxiety, irritating foods, or
fecal impaction. Nursing assessment and
identification of potential causative factors
will determine the treatment plan.8 Hydra-
tion must be maintained while the diarrhea
is brought under control. Tube feedings
should be followed with sufficient water to
maintain hydration. Prescription medica-
tion may be given to decrease gastric motil-
ity. Restoration of normal bowel flora with
plain yogurt may be beneficial following
use of antibiotics.
Adjustment of the tube feeding regimen
may be required. Administration rate may
need to be decreased, the strength diluted,
or the product changed. Smaller, more fre-
quent feedings may help one client, while
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bolus feedings that mimic normal eating
patterns may help another. Consultation
with a nutritionist may be necessary when
altering a program.
or an
Uninhibited bowel
Uninhibited bowel elimination is related
to decreased cortical control over voluntary
defecation. This results from neurological
damage to the inhibitory/facilitory fibers of
the corticospinal tract secondary to cere-
brovascular accident (CVA), head injury,
brain tumor, multiple sclerosis, or Parkin-
son’s disease. An adequate bowel manage-
ment program will attain predictable, regu-
lar elimination without involuntary bowel
movements.8 Timing becomes a major fac-
tor for a predictable bowel pattern in addi-
tion to the previous factors of diet, fluid,
premorbid habits, activity, medications,
and bathroom accessibility.
Timing for a planned bowel movement is
based on following a trigger meal. Break-
fast is often used for this meal, since the
gastrocolic and duodenocolic reflexes are
strongest on an empty stomach. The peri-
stalsis created by these reflexes moves the
feces forward to the descending colon.
Gravity assists the peristalsis by moving the
formed feces into the rectum. The rectal
defecation reflex is triggered as the feces
enter the rectum. The loss of cortical inhibi-
tion allows the reflex to continue to empty
the rectum. 13
Suppositories may assist the establish-
ment of a regular pattern. The suppository
should be inserted prior to the trigger meal,
and the client should be placed on the
commode 15 minutes following the meal.
The use of suppositories should progress
from bisacodyl to glycerin to digital stimu-
lation.13 Digital stimulation is performed by
moving a gloved, lubricated finger in a
gentle, circular motion within the anal
sphincter. This motion relaxes the

sphincter and helps trigger the
defecation
reflex. Documentation on a bowel record
allows review and adjustment of the pro-
gram by the nurse.
Reflex neurogenic bowel
A reflex neurogenic bowel is caused by
injury to the spinal cord above the sacral
cord segments. A planned bowel program
is required for adequate elimination with-
out involuntary bowel movements. The
program is based the factors previously
on
discussed. The bowel program is planned
following a trigger meal. The client is
placed on the commode and a suppository
is used with digital stimulation to relax the
sphincter and to initiate the defecation
reflex. The program is started on an every-
other-day schedule and is adjusted for the
individual. 8
Areflexic neurogenic bowel
An areflexic neurogenic bowel is caused
by injury to the sacral spinal cord and loss
of the defecation reflex. This may result
from spina bifida, cauda equina injury,
intervertebral disc, or diabetic neuropa-
thies. The client experiences fecal inconti-
nence from sensory loss and flaccid exter-
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41
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history.
..*
Many clients with altered patterns of
elimination can be helped through nursing
intervention. A thorough knowledge base
and an understanding of bladder and
bowel elimination are required. A nursing
assessment is needed to gain insight and
understanding of the client’s bladder or
bowel problem, level of awareness, medi-
cal status, and physical abilities. The nurs-
ing intervention consists of a specific treat-
ment plan with education of the client and
caregiver, geared toward assisting the
client to function normally at home. Docu-
mentation on a bladder or bowel record
gives the nurse information to evaluate and
to individualize the plan. Control of blad-
der and bowel dysfunction builds self-
esteem for the client and allows active
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42

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