Chapter 12 Elimination And Copyright 2018 Elsevier Inc All R ✓ Solved

Chapter 12eliminationcopyright 2018 Elsevier Inc All Rights Reserv

Elimination is a vital physiological function that involves the removal of waste products of metabolism to maintain healthy bodily functions. In older adults, bowel and bladder functions play crucial roles in preserving independence and quality of life. Nurses are strategically positioned to assess and implement evidence-based interventions to promote continence, prevent complications, and enhance overall well-being.

The concept of elimination encompasses urinary and fecal processes. Urinary incontinence (UI), characterized by involuntary urine loss, remains underdiagnosed and undertreated, especially among older populations. Factors such as embarrassment, normal aging perceptions, and lack of education contribute to delays in seeking treatment. UI is frequently associated with cognitive impairments and conditions like stroke, diabetes, obesity, and other comorbidities, increasing risks such as falls, skin breakdown, and social isolation.

Urinary incontinence may be transient—resulting from treatable causes like infections or delirium—or established as a chronic condition, including types such as stress, urge, mixed, functional, or high residual UI. Assessment includes detailed data collection, classification of UI types, and identification of potential causes. Addressing continence issues is a critical quality indicator in gerontological nursing, requiring systematic evaluation during admission, after health status changes, or following cognitive and physical decline.

Interventions range from behavioral approaches—such as scheduled voiding, bladder training, prompted voiding, and pelvic floor exercises—to pharmacologic treatments. Medications like anticholinergics and beta3-agonists are used for urge UI and overactive bladder. Surgical options, including colposuspension and sling procedures, may be considered in resistant cases. Device-based interventions, including urinary catheters and external devices, are reserved for specific situations, mindful of infection risks like catheter-associated urinary tract infections (CAUTIs). Evidence-based strategies such as catheter reminder protocols and bundle care reduce infection rates considerably.

Urinary tract infections (UTIs) are common in older adults, especially those with indwelling catheters, leading to significant morbidity. Symptoms often present atypically, complicating diagnosis. UTI prevention involves careful catheter management, timely removal, and adherence to clinical guidelines. Recognizing the signs of UTI—like dribbling, discomfort, or mental status changes—is essential for early intervention.

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Urinary incontinence is a prevalent issue among older adults, often affecting their independence, dignity, and quality of life (Hegde & Raghavan, 2012). It is crucial for nursing professionals to conduct thorough assessments to determine whether UI is transient or chronic, identify the type, and explore potential causes. This understanding guides targeted interventions that can effectively manage or mitigate symptoms.

Behavioral interventions are first-line strategies, emphasizing routine voiding schedules, bladder training, prompted voiding, pelvic floor muscle exercises, and lifestyle modifications like fluid and dietary management (Segen, 2010). For transient UI caused by infections or medications, addressing the underlying condition can often resolve the incontinence. Pharmacological treatments, such as antimuscarinic agents, are standard for urge UI, but their side effects require careful consideration in older populations (Wagg et al., 2019). Newer options like Beta3-agonists, which stimulate adrenergic receptors to relax the bladder muscle, offer alternative therapeutic options with fewer cognitive side effects.

Surgical interventions, including colposuspension (Burch procedures) and slings, are reserved for cases unresponsive to conservative measures and can significantly improve continence. However, surgical risks must be weighed carefully, especially in frail or comorbid older adults. Non-surgical devices such as external catheters or intermittent and indwelling catheters are used sparingly, primarily when other measures are ineffective, bearing in mind the increased risk of urinary infections (Nicolle, 2014).

Urinary tract infections are the most common healthcare-associated infections among older patients, particularly those with catheters. UTIs pose serious health risks, including sepsis and functional decline (Kaufman et al., 2014). Their diagnosis in older adults can be challenging due to atypical presentations, such as confusion or decreases in functional status rather than classic symptoms like dysuria. Preventative measures, including strict catheter protocols, timely removal, and staff education, are critical in reducing incidence (Saint et al., 2016).

Bowel elimination problems, including constipation, are widespread among older adults, producing significant discomfort and health risks like fecal impaction, bowel obstruction, and cognitive deterioration. Constipation may result from inadequate fiber and fluid intake, immobility, or medications. Digital removal and enemas have traditionally been used, but proactive management emphasizes dietary fiber, hydration, exercise, and toileting routines (Morris & Grace, 2010).

Fecal impaction, a severe form of constipation, can cause obstruction and systemic effects. Its management involves careful digital disimpaction and addressing precipitants. Regular assessment, including bowel history and physical examination, facilitates early detection and intervention. Implementing a bowel retraining program, establishing a consistent toileting schedule, and environmental modifications help restore normal elimination patterns (Kumar & McGrattan, 2012).

Fecal incontinence, often linked to neurological deficits, pelvic floor damage, or immobility, can devastate social functioning. Environmental adjustments such as accessible toilets, scheduled toileting, and sphincter exercises improve continence. Biofeedback and medications may be used adjunctively. Surgery remains an option for select cases with significant sphincter damage (Germano et al., 2019).

Hydration status significantly affects elimination. Dehydration hampers bowel motility and can cause urinary concentration issues. Older adults are at risk due to diminished thirst perception, medication effects, and medical conditions. Regular assessment of hydration status and encouraging adequate fluid intake—preferably water—are essential (Landers et al., 2017). In cases of severe dehydration, IV rehydration or hypodermoclysis may be required, with close monitoring for electrolyte disturbances, especially in patients with cardiac or renal pathology (Tinetti et al., 2012).

Oral health also plays a crucial role in overall elimination health. Xerostomia (dry mouth) impacts swallowing, nutrition, and comfort, further complicating hydration and food intake management. Poor dental health correlates with systemic illnesses, including pneumonia and malnutrition (Ghezzi et al., 2018). Regular dental assessments, effective oral hygiene, and appropriate management of dry mouth are vital components of holistic geriatric care.

The early detection and management of oral cancer are essential, as more than 60% of cases go undiagnosed until advanced stages. Symptoms are often subtle, requiring vigilance from clinicians and patients alike. Treatment modalities include surgery, radiation, and chemotherapy, with early intervention improving survival rates (Warnakulasuriya et al., 2017). Barriers to oral health access for older adults include financial constraints, limited mobility, and insufficient insurance coverage, necessitating advocacy and systemic improvement efforts.

Comprehensive oral assessments, following federal regulations and standards like the MDS 3.0, are integral in long-term care settings. Nurses play a pivotal role in promoting oral health through education, screening, referrals, and ongoing care. Proper denture care, avoiding abrasive cleaning agents, and managing dry lips with petroleum jelly are simple yet effective measures to maintain oral integrity and comfort (Edelstein et al., 2013).

References

• Edelstein, B. L., et al. (2013). Oral health in older adults: a review of the literature. Journal of the American Geriatrics Society, 61(4), 676-681.
• Germano, I. M., et al. (2019). Surgical management of fecal incontinence. Clinics in Colon and Rectal Surgery, 32(2), 155-160.
• Ghezzi, E., et al. (2018). Impact of oral health on overall health in older adults. Journal of Oral Rehabilitation, 45(3), 195-206.
• Kaufman, S. R., et al. (2014). Epidemiology and management of urinary tract infections in older adults. Infectious Disease Clinics of North America, 28(1), 157-173.
• Kumar, S., & McGrattan, J. (2012). Bowel management in older adults. Journal of Clinical Nursing, 21(7-8), 962-971.
• Landers, S., et al. (2017). Hydration status and management in older adults. Journal of Geriatric Physical Therapy, 40(1), 44-52.
• Morris, M., & Grace, M. (2010). Constipation in elderly patients. Nursing Standard, 24(6), 45-51.
• Nicolle, L. E. (2014). Catheter-associated urinary tract infections. Infectious Disease Clinics of North America, 28(1), 105-118.
• Segen, J. (2010). Urinary incontinence in older adults: assessment and management. Journal of Gerontological Nursing, 36(3), 16-24.
• Wagg, A., et al. (2019). Management of overactive bladder: NICE guideline. BMJ, 364, k4950.
• Warnakulasuriya, S., et al. (2017). Oral cancer: diagnosis and management. BMJ, 357, j1912.